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.
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This 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.
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To 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.
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.
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Initially, 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\n
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\n
This 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\n
To 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.
\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"5995",leadTitle:null,fullTitle:"Mediterranean Identities - Environment, Society, Culture",title:"Mediterranean Identities",subtitle:"Environment, Society, Culture",reviewType:"peer-reviewed",abstract:"What is the Mediterranean? The perception of the Mediterranean leans equally on the nature, culture, history, lifestyle, and landscape. To approach the question of identity, it seems that we have to give importance to all of these. There is no Mediterranean identity, but Mediterranean identities. Mediterranean is not about the homogeneity and uniformity, but about the unity that comes from diversities, contacts, and interconnections. The book tends to embrace the environment, society, and culture of the Mediterranean in their multiple and unique interconnections over the millennia, contributing to the better understanding of the essential human-environmental interrelations. The choice of 17 chapters of the book, written by a number of prominent scholars, clearly shows the necessity of the interdisciplinary approach to the Mediterranean identity issues. The book stresses the most serious concerns of the Mediterranean today - threats to biodiversity, risks, and hazards - mostly the increasing wildfires and finally depletion of traditional Mediterranean practices and landscapes, as constituent parts of the Mediterranean heritage.",isbn:"978-953-51-3586-9",printIsbn:"978-953-51-3585-2",pdfIsbn:"978-953-51-4612-4",doi:"10.5772/66587",price:139,priceEur:155,priceUsd:179,slug:"mediterranean-identities-environment-society-culture",numberOfPages:428,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"5254b511e85984b9457a09ddc2758a1c",bookSignature:"Borna Fuerst-Bjelis",publishedDate:"November 8th 2017",coverURL:"https://cdn.intechopen.com/books/images_new/5995.jpg",numberOfDownloads:27852,numberOfWosCitations:61,numberOfCrossrefCitations:53,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:107,numberOfDimensionsCitationsByBook:1,hasAltmetrics:1,numberOfTotalCitations:221,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 21st 2016",dateEndSecondStepPublish:"December 12th 2016",dateEndThirdStepPublish:"March 10th 2017",dateEndFourthStepPublish:"June 8th 2017",dateEndFifthStepPublish:"August 7th 2017",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"138475",title:"Prof.",name:"Borna",middleName:null,surname:"Fuerst-Bjeliš",slug:"borna-fuerst-bjelis",fullName:"Borna Fuerst-Bjeliš",profilePictureURL:"https://mts.intechopen.com/storage/users/138475/images/6374_n.jpg",biography:"Borna Fuerst-Bjeliš is a senior scientist and full time professor at the University of Zagreb, Croatia. She was awarded by the Federico Grisogono award for the scientific achievement and outstanding contribution to the development of geography in Croatia. \nHer field of expertise is environmental history and landscape change, spatially focused mainly on Mediterranean karst area, including the development of methodologies of research (historical cartography), borderland areas, spatial perceptions, and spatial (regional) identities. \nShe is the coauthor of the book Historical Geography of Croatia (University of Split, Croatia) and the editor of the Croatian editions of What is Environmental History by D. Hughes (Disput) and The Global Environmental History by I. G. Simmons (Disput).\nShe is the member of a number of international and national scientific organizations. Currently, she is the vice-president of the European Society for Environmental History and a member of the Steering Committee of the Specialty Commission of the International Geographical Union on Marginalization, Globalization, and Regional and Local Responses.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of Zagreb",institutionURL:null,country:{name:"Croatia"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"868",title:"Environment and Society",slug:"environment-and-society"}],chapters:[{id:"55745",title:"The Mediterranean: The Asian and African Roots of the Cradle of Civilization",doi:"10.5772/intechopen.69363",slug:"the-mediterranean-the-asian-and-african-roots-of-the-cradle-of-civilization",totalDownloads:2799,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"In Antiquity, the regions encompassed by the Mediterranean Sea were extremely fertile allowing rapid prosperity. This wealth combined with the easy communication between banks contributed to a rich and successful transmission of knowledge, especially during the 1st millennium BC, which turned the Great Sea the core of Ancient History. Later, the Mediterranean civilization was acknowledged as the fundamental political, cultural, artistic and religious substratum for the construction of the so-called Western world. Yet, it was in Egypt and Mesopotamia, during the 4th and 3rd millennia BC that many of these foundations were first set. The Ancient Mediterranean world was not just influenced by its African and Asian neighbours but was in fact defined by a profound communion, at all levels, between these different regions. In the twenty-first century, however, many European countries still insist in portraying themselves as direct heirs of the combined Greco-Roman and Judeo-Christian traditions, disregarding their African and Asian roots. As a result of this flawed self-perception, a gap between Europe, Africa and Asia came to be, bearing deep consequences to the present. With this contribution, we aim to reclaim the importance of these other legacies to the construction of the cradle of the civilization.",signatures:"Helena Trindade Lopes and Isabel Almeida",downloadPdfUrl:"/chapter/pdf-download/55745",previewPdfUrl:"/chapter/pdf-preview/55745",authors:[{id:"202246",title:"Prof.",name:"Helena",surname:"Trindade Lopes",slug:"helena-trindade-lopes",fullName:"Helena Trindade Lopes"},{id:"203967",title:"Prof.",name:"Isabel",surname:"Almeida",slug:"isabel-almeida",fullName:"Isabel Almeida"}],corrections:null},{id:"55949",title:"A Living Force of Continuity in a Declining Mediterranean: The Hospitaller Order of St John in Early Modern Times",doi:"10.5772/intechopen.69376",slug:"a-living-force-of-continuity-in-a-declining-mediterranean-the-hospitaller-order-of-st-john-in-early-",totalDownloads:1300,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The paper discusses two interrelated themes. From 1530 to 1798, the Order of St John, an international institution of the Church, played a significant role from its conventual base on central Mediterranean Malta—one that nourished a strong element of historical continuity within the wider context of a declining Mediterranean. This it did through its traditional twofold raison d’être—as a religious, charitable and Hospitaller Order with great expertise in medical knowledge and practice, and as a military institution whose traditional crusading zeal against Islam kept the ‘clash of civilisations’ alive. That is the first theme. The second theme concerns the concept of a declining Ottoman Empire and a declining Mediterranean. The paper argues against the idea that the collective impact of the great siege of Malta (1565) and the battle of Lepanto (1571) had marked the initial stage in the decline of the Ottoman Empire. It also claims that the decline of the sixteenth‐century Mediterranean needs revisiting. It was only a partial change for the worse. The great geographical discoveries succeeded in robbing the Middle Sea of its primacy in international economy and exchange but in the long term failed to uproot most of its other characteristic features.",signatures:"Victor Mallia‐Milanes",downloadPdfUrl:"/chapter/pdf-download/55949",previewPdfUrl:"/chapter/pdf-preview/55949",authors:[{id:"202919",title:"Prof.",name:"Victor",surname:"Mallia-Milanes",slug:"victor-mallia-milanes",fullName:"Victor Mallia-Milanes"}],corrections:null},{id:"57227",title:"Nutrient Cycling in the Mediterranean Sea: The Key to Understanding How the Unique Marine Ecosystem Functions and Responds to Anthropogenic Pressures",doi:"10.5772/intechopen.70878",slug:"nutrient-cycling-in-the-mediterranean-sea-the-key-to-understanding-how-the-unique-marine-ecosystem-f",totalDownloads:1691,totalCrossrefCites:5,totalDimensionsCites:15,hasAltmetrics:1,abstract:"The Mediterranean Sea is a marine desert: although it receives large nutrient inputs from a rapidly growing coastal population, its offshore waters exhibit extremely low biological productivity. Here, we use a mass balance modelling approach to analyse the sources and fate of the two main nutrients that support marine biomass production: phosphorus (P) and nitrogen (N). Surprisingly, the main source of P and N to the Mediterranean Sea is North Atlantic surface water entering through the Strait of Gibraltar, not emissions from surrounding land. The low biological productivity of the Mediterranean Sea is linked to the switch from less bioavailable nutrients entering the basin to highly bioavailable nutrients leaving it although similar amounts of total P and N enter and leave the Mediterranean Sea. This unique feature is a direct consequence of its unusual anti-estuarine circulation. An important environmental implication of the anti-estuarine circulation is that it efficiently removes excess anthropogenic nutrients entering the Mediterranean Sea, thus protecting offshore waters against eutrophication contrary to other semi-enclosed marine basins. In a similar vein, the “self-cleaning” nature of the Mediterranean Sea may prevent severe oxygen depletion of Mediterranean deep waters should ongoing climate warming lead to a weakening of the thermohaline circulation.",signatures:"Helen R. Powley, Philippe Van Cappellen and Michael D. Krom",downloadPdfUrl:"/chapter/pdf-download/57227",previewPdfUrl:"/chapter/pdf-preview/57227",authors:[{id:"203160",title:"Prof.",name:"Michael",surname:"Krom",slug:"michael-krom",fullName:"Michael Krom"},{id:"203427",title:"Ms.",name:"Helen",surname:"Powley",slug:"helen-powley",fullName:"Helen Powley"},{id:"203428",title:"Prof.",name:"Phillippe",surname:"Van Cappellen",slug:"phillippe-van-cappellen",fullName:"Phillippe Van Cappellen"}],corrections:null},{id:"55878",title:"How Landscapes Make Science: Italian National Narrative, The Great Mediterranean, and Giuseppe Sergi’s Biological Myth",doi:"10.5772/intechopen.69186",slug:"how-landscapes-make-science-italian-national-narrative-the-great-mediterranean-and-giuseppe-sergi-s-",totalDownloads:1200,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"The perception and representation of landscape are not natural facts but are cultural constructions of human agents. In this chapter, I aim at deconstructing the role of pre-classical archaeology of Eastern Mediterranean in the process of Italian nation building between the nineteenth and the twentieth centuries. In particular, I focus on how a substantial group of Italian intellectuals deployed archeological discoveries to construct the Mediterranean as a representational space, which eventually served as a platform for their nationalistic political discourses. To this end, I discuss the spreading of these new conceptions in the Italian cultural debate at large. A prominent figure in this debate was Giuseppe Sergi. By reconstructing his views on the connections between national identity and biology, I demonstrate the considerable performative effect of the Mediterranean as a symbolic space and source of meaning on Italian culture. Furthermore, I argue that this new role of the Mediterranean resulted from a negotiation between the archaeological discovery of pre-classical past and the political aspirations of those scholars who opposed Italian foreign and interior politics of the period.",signatures:"Fedra A. Pizzato",downloadPdfUrl:"/chapter/pdf-download/55878",previewPdfUrl:"/chapter/pdf-preview/55878",authors:[{id:"203769",title:"Dr.",name:"Fedra Alessandra",surname:"Pizzato",slug:"fedra-alessandra-pizzato",fullName:"Fedra Alessandra Pizzato"}],corrections:null},{id:"55867",title:"The Marine Biodiversity of the Mediterranean Sea in a Changing Climate: The Impact of Biological Invasions",doi:"10.5772/intechopen.69214",slug:"the-marine-biodiversity-of-the-mediterranean-sea-in-a-changing-climate-the-impact-of-biological-inva",totalDownloads:2374,totalCrossrefCites:12,totalDimensionsCites:22,hasAltmetrics:1,abstract:"The Mediterranean Sea, one of the most complex marine ecosystems, is inhabited by a rich and diverse biota which is disproportionate to its dimensions. It is currently affected by different pressures, mainly driven by human activities such as climate change and bioinvasions. This Sea, also due to its geographic position (wedged between the temperate climate of central Europe and the arid climate of northern Africa), seems to be one of the regions most susceptible to global climate change. The increased rates of introduction and spread of marine alien species may represent a supplementary stress factor to Mediterranean marine native biota already challenged by climatic abnormalities. The Suez Canal is considered to be the main vector of introduction of non‐indigenous marine species into the Mediterranean Sea. Due to the dramatically accelerating rate of such introductions and due to the sheer magnitude of shipping traffic, the Mediterranean Sea may be considered as a true hotspot of marine bioinvasions. The complexity of interactions between native and invasive species and the associated resulting impacts make environmental management of such an issue particularly difficult. A collaboration between researchers, resource management agencies and policy makers is called for to bolster the effectiveness of invasive species management procedures.",signatures:"Anna M. Mannino, Paolo Balistreri and Alan Deidun",downloadPdfUrl:"/chapter/pdf-download/55867",previewPdfUrl:"/chapter/pdf-preview/55867",authors:[{id:"202075",title:"Prof.",name:"Alan",surname:"Deidun",slug:"alan-deidun",fullName:"Alan Deidun"},{id:"203773",title:"Dr.",name:"Anna Maria",surname:"Mannino",slug:"anna-maria-mannino",fullName:"Anna Maria Mannino"},{id:"203777",title:"Dr.",name:"Paolo",surname:"Balistreri",slug:"paolo-balistreri",fullName:"Paolo Balistreri"}],corrections:null},{id:"55411",title:"Biodiversity in Central Mediterranean Sea",doi:"10.5772/intechopen.68942",slug:"biodiversity-in-central-mediterranean-sea",totalDownloads:1471,totalCrossrefCites:1,totalDimensionsCites:5,hasAltmetrics:0,abstract:"The Central Mediterranean Sea is an area that connects the western and the eastern Mediterranean Sea where migratory fluxes of marine organisms are very peculiar. The high biodiversity of these areas is owed to particular hydrological and geomorphological characteristics (Messina Strait and Sicily Channel). The morphology of the Strait of Messina resembles a funnel with the narrow end to the North and the largest one to the South, and its underwater profile can be compared to a mountain whose opposite sides have markedly different slopes. The great biodiversity that characterizes this ecosystem is linked to the particular hydrology of the area. The Sicily Channel (or Strait of Sicily) is a wide water body located between southern Sicily and northern African coasts and represents the transition between the Western (WMED) and the Eastern (EMED) basins of the Mediterranean Sea. Morphologically, the Strait of Sicily belongs to the continental shelf with some other sub‐units, as basins, seamounts and ‘banks’. The bottoms are generally irregular and canyons are present. Mediterranean Sea has been divided into different biogeographic districts that present great variability in water parameters and biocenosis too. This chapter resumes the main physical, chemical and biological properties of the Central Mediterranean Sea.",signatures:"Nunziacarla Spanò and Emilio De Domenico",downloadPdfUrl:"/chapter/pdf-download/55411",previewPdfUrl:"/chapter/pdf-preview/55411",authors:[{id:"203028",title:"Dr.",name:"Nunziacarla",surname:"Spanó",slug:"nunziacarla-spano",fullName:"Nunziacarla Spanó"},{id:"203064",title:"Prof.",name:"Emilio",surname:"De Domenico",slug:"emilio-de-domenico",fullName:"Emilio De Domenico"}],corrections:null},{id:"57009",title:"Deep-Sea Biodiversity in the Aegean Sea",doi:"10.5772/intechopen.70492",slug:"deep-sea-biodiversity-in-the-aegean-sea",totalDownloads:1743,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The present chapter aims to describe macrofauna in the Aegean deep waters. The review is based mainly on the studies of deep waters below 200 m. A total of 386 species are included on the present checklist belonging to 9 phyla. Among these species, Porifera has 9 species, Cnidaria 4, Brachiopoda 3, Bryozoa 1, Polychaeta 34, Mollusca 92, Arthropoda 86, Echinodermata 30 and Pisces 127 species.",signatures:"Onur Gönülal and Cem Dalyan",downloadPdfUrl:"/chapter/pdf-download/57009",previewPdfUrl:"/chapter/pdf-preview/57009",authors:[{id:"204258",title:"Dr.",name:"Onur",surname:"Gönülal",slug:"onur-gonulal",fullName:"Onur Gönülal"},{id:"213770",title:"Dr.",name:"Cem",surname:"Dalyan",slug:"cem-dalyan",fullName:"Cem Dalyan"}],corrections:null},{id:"55575",title:"Exotic Plant Species in the Mediterranean Biome: A Reflection of Cultural and Historical Relationships",doi:"10.5772/intechopen.69185",slug:"exotic-plant-species-in-the-mediterranean-biome-a-reflection-of-cultural-and-historical-relationship",totalDownloads:1190,totalCrossrefCites:5,totalDimensionsCites:6,hasAltmetrics:0,abstract:"The Mediterranean basin was the world’s cradle of agriculture and the first human civilisation. In the Neolithic age, the agrarian culture expanded throughout the Mediterranean basin from the East to the West. Later, an expansion of agrarian culture and trade occurred, associated with the European colonialism, giving rise to a great plant exchange among Mediterranean‐type regions. Despite being a biodiversity hotspot, the Mediterranean biome has been subjected to several anthropic impacts, such as alteration of land‐use and cross‐introductions of exotic species. The millenary anthropic modification of the landscape occurred in the Mediterranean basin gave rise to the formation of seminatural systems in which plants co‐evolved with anthropogenic activities over a long time. Thus, species that originated in the Mediterranean basin might have developed a key role in other agro‐silvo‐pastoral systems along the whole Mediterranean biome. Research is biased towards highlighting the negative impact of exotic species on the ecosystems. To defy the traditional belief, outstanding recent literature focused on the positive effects of exotics on native communities was reviewed. Exotic species seem to have a key role in Mediterranean‐type seminatural systems, as evidences of tolerance and facilitation processes were found. Exotic species that have co‐evolved with human practices over millennia seem to enhance biodiversity in the Mediterranean biome.",signatures:"Irene Martín‐Forés",downloadPdfUrl:"/chapter/pdf-download/55575",previewPdfUrl:"/chapter/pdf-preview/55575",authors:[{id:"202770",title:"Dr.",name:"Irene",surname:"Martín-Forés",slug:"irene-martin-fores",fullName:"Irene Martín-Forés"}],corrections:null},{id:"57251",title:"Amphibians and Reptiles of the Mediterranean Basin",doi:"10.5772/intechopen.70357",slug:"amphibians-and-reptiles-of-the-mediterranean-basin",totalDownloads:1906,totalCrossrefCites:1,totalDimensionsCites:3,hasAltmetrics:0,abstract:"The Mediterranean basin is one of the most geologically, biologically, and culturally complex region and the only case of a large sea surrounded by three continents. The chapter is focused on a diversity of Mediterranean amphibians and reptiles, discussing major threats to the species and its conservation status. There are 117 amphibians, of which 80 (68%) are endemic and 398 reptiles, of which 216 (54%) are endemic distributed throughout the Basin. While the species diversity increases in the north and west for amphibians, the reptile diversity increases from north to south and from west to east direction. Amphibians are almost twice as threatened (29%) as reptiles (14%). Habitat loss and degradation, pollution, invasive/alien species, unsustainable use, and persecution are major threats to the species. The important conservation actions should be directed to sustainable management measures and legal protection of endangered species and their habitats, all for the future of Mediterranean biodiversity.",signatures:"Kerim Çiçek and Oğzukan Cumhuriyet",downloadPdfUrl:"/chapter/pdf-download/57251",previewPdfUrl:"/chapter/pdf-preview/57251",authors:[{id:"202126",title:"Dr.",name:"Kerim",surname:"Çiçek",slug:"kerim-cicek",fullName:"Kerim Çiçek"},{id:"209030",title:"Mr.",name:"Oğuzkan",surname:"Cumhuriyet",slug:"oguzkan-cumhuriyet",fullName:"Oğuzkan Cumhuriyet"}],corrections:null},{id:"56566",title:"Vulnerability of Soil and Water in Mediterranean Agro-Forestry Systems",doi:"10.5772/intechopen.70094",slug:"vulnerability-of-soil-and-water-in-mediterranean-agro-forestry-systems",totalDownloads:1120,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"The study watershed is located within the Idanha Irrigation Scheme, Portugal. A hydrological and water quality station was installed at the outlet of the catchment. The AnnAGNPS model was applied in this study, and afterwards it was calibrated and validated to the conditions in the study catchment. The antecedent soil moisture conditions play an important role for rapid runoff and flash flooding. Relative Water Supply (RWS) is always bellow the unity value and sometimes below the value 0.5. Sometimes in very dry years, like the year 2004-2005 (302 mm), a runoff coefficient is equal to 0.40. Spatial distribution of runoff was primarily influenced by topography and soil management, which is common in Mediterranean agricultural systems, namely in grain crop systems such as oats and wheat. The simulation of spatial distribution of nitrate load shows a dependence of the spatial distribution of runoff, due to its high solubility. Spatial distribution of soil erosion by water indicates that the process does not depend directly on the runoff distribution in the catchment. Therefore, soil erosion is greatly influenced by deficient land cover whenever erosivity of rainfall is strong. Phosphorus losses were less than nitrate losses, due to their lower water solubility and mobility in soil.",signatures:"António Canatário Duarte",downloadPdfUrl:"/chapter/pdf-download/56566",previewPdfUrl:"/chapter/pdf-preview/56566",authors:[{id:"202913",title:"Prof.",name:"António",surname:"Canatário Duarte",slug:"antonio-canatario-duarte",fullName:"António Canatário Duarte"}],corrections:null},{id:"55350",title:"Resilience of Mediterranean Forests to Climate Change",doi:"10.5772/intechopen.68943",slug:"resilience-of-mediterranean-forests-to-climate-change",totalDownloads:1360,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"In the Mediterranean region, forests play a key role in the welfare of urban and rural peoples, by providing highly appreciated marketed goods as well as high value but nonmarket services. Anthropogenic climate change entails a significant impact on Mediterranean forests, such as the reduced species diversity, high density, pest, and diseases. In this chapter, we present the achievements of the project LIFE ResilForMed (Resilience of Mediterranean Forests to climate change), as Sicilian responds on adaptation and mitigation to climate change: (i) map of Sensitivity Forest Areas to desertification of the Sicilian region; (ii) list of bird indicators showing sensitivity to desertification in Sicily; (iii) set of resilience indicators aimed to assess the resilience of Mediterranean forests to climate changes; (iv) list of sporadic and endemic tree species of Sicilian forests; (v) development of optimal management models suitable to improve or consolidate the resilience of forest and preforest ecosystems. This work is at the forefront of developing knowhow and transferable best management practices that may help Mediterranean forests to adapt to climate change and thereby, safeguard their multifunctional benefits for future generations.",signatures:"Sferlazza Sebastiano, Maetzke Federico Guglielmo, Miozzo\nMarcello and La Mela Veca Donato Salvatore",downloadPdfUrl:"/chapter/pdf-download/55350",previewPdfUrl:"/chapter/pdf-preview/55350",authors:[{id:"203554",title:"Dr.",name:"Sebastiano",surname:"Sferlazza",slug:"sebastiano-sferlazza",fullName:"Sebastiano Sferlazza"},{id:"203555",title:"Prof.",name:"Federico Guglielmo",surname:"Maetzke",slug:"federico-guglielmo-maetzke",fullName:"Federico Guglielmo Maetzke"},{id:"203556",title:"Dr.",name:"Donato Salvatore",surname:"La Mela Veca",slug:"donato-salvatore-la-mela-veca",fullName:"Donato Salvatore La Mela Veca"},{id:"203557",title:"Dr.",name:"Marcello",surname:"Miozzo",slug:"marcello-miozzo",fullName:"Marcello Miozzo"}],corrections:null},{id:"55076",title:"Drought-Forest Fire Relationships",doi:"10.5772/intechopen.68487",slug:"drought-forest-fire-relationships",totalDownloads:1259,totalCrossrefCites:2,totalDimensionsCites:4,hasAltmetrics:0,abstract:"This study was carried out to determine the methods that bear the most realistic results in predicting the number of fires and burned area under the climate conditions in future. Different indices and statistical methods were used in predicting the burned area and the number of fires. With this aim, in addition to the indices used in estimating the climate, Machine Learning and multivariate adaptive regression spline (MARS) models are also used in predicting these factors. According to the results obtained in several studies, the relationship between the drought and fire indices burned area and the number of fires changes from region to region. While better results are obtained in predicting the burned area and the number of fires via the drought indices being used in this study and the MARS models that the combinations of these indices use, it is seen that a 30–39% success was achieved for predicting the amount of burned area via Machine Learning methods (Kernel Nearest Neighbor (kNN), Recursive Partitioning and Regression Trees (RPART), Support Vector Machine (SVM) and RF), and this success ranges widely from 8 to 41% in terms of the number of fires. RPART, of these four algorithms, performed the best in fire prediction, but kNN was the worst.",signatures:"Tuğrul Varol, Mertol Ertuğrul and Halil Barış Özel",downloadPdfUrl:"/chapter/pdf-download/55076",previewPdfUrl:"/chapter/pdf-preview/55076",authors:[{id:"187966",title:"Dr.",name:"Halil Barış",surname:"Özel",slug:"halil-baris-ozel",fullName:"Halil Barış Özel"},{id:"203381",title:"Dr.",name:"Tugrul",surname:"Varol",slug:"tugrul-varol",fullName:"Tugrul Varol"},{id:"203760",title:"Dr.",name:"Mertol",surname:"Ertuğrul",slug:"mertol-ertugrul",fullName:"Mertol Ertuğrul"}],corrections:null},{id:"55996",title:"The Fire in the Mediterranean Region: A Case Study of Forest Fires in Portugal",doi:"10.5772/intechopen.69410",slug:"the-fire-in-the-mediterranean-region-a-case-study-of-forest-fires-in-portugal",totalDownloads:2101,totalCrossrefCites:8,totalDimensionsCites:19,hasAltmetrics:1,abstract:"Forest fires are a common disturbance in many forest systems in the world and in particular in the Mediterranean region. Their origins can be either natural or anthropogenic. The effects in regard to the time trends, vegetation, and soil will be reflected in the species distribution, forest composition, and soil potential productivity. In general, it can be said that the larger the fire and the shorter the time between two consecutive occurrences, the higher the probability to originate shifts in vegetation and soil degradation. In the Mediterranean region, the number of fire ignitions does not reflect the burnt area due to the occurrence of very large fires. The latter occur in a very small proportion of the number of ignitions, but result in very large burnt areas. Also there seems to be an increasing trend toward larger fires in the Mediterranean region due mainly to climatic and land use changes. This case study highlights the importance of vegetation regrowth a short time after the fire to maintain both forest systems and soil conservation.",signatures:"Ana Cristina Gonçalves and Adélia M.O. Sousa",downloadPdfUrl:"/chapter/pdf-download/55996",previewPdfUrl:"/chapter/pdf-preview/55996",authors:[{id:"187880",title:"Prof.",name:"Adélia",surname:"Sousa",slug:"adelia-sousa",fullName:"Adélia Sousa"},{id:"194484",title:"Prof.",name:"Ana Cristina",surname:"Gonçalves",slug:"ana-cristina-goncalves",fullName:"Ana Cristina Gonçalves"}],corrections:null},{id:"55484",title:"A Common Approach to Foster Prevention and Recovery of Forest Fires in Mediterranean Europe",doi:"10.5772/intechopen.68948",slug:"a-common-approach-to-foster-prevention-and-recovery-of-forest-fires-in-mediterranean-europe",totalDownloads:1619,totalCrossrefCites:4,totalDimensionsCites:6,hasAltmetrics:0,abstract:"Most countries of Mediterranean Europe are strongly affected by forest fires, with major socio-economic and environmental impacts that can spread over several regions and countries. A transnational approach allows creating synergies regarding resource sharing and problem-solving strategies. The access to high quality and up-to-date information is critical to improve fire hazard mitigation measures and promote comparable appraisals between different regions. Several collaborative initiatives have been implemented in Europe to foster research and service development, focusing on common issues amongst countries. The PREFER project was one of these initiatives, with the purpose of contributing to protect human communities and forests from fire hazard, by providing cartographic products through the implementation of a new systematic framework. The participation of end users, such as civil protection organizations and forest services, covering the Euro-Mediterranean region, was crucial to ensure the operational application of the mapping products. Fuel classification, daily fire hazard indices, vulnerability assessment and damage severity levels were some of the mapping applications developed for several test areas in Mediterranean Europe. This chapter illustrates the potential enhancements for forest fire management offered by this framework, bearing in mind the benefits of applying shared and harmonized approaches for common issues.",signatures:"Sandra Oliveira, Giovanni Laneve, Lorenzo Fusilli, Georgios\nEftychidis, Adélia Nunes, Luciano Lourenço and Ana Sebastián-\nLópez",downloadPdfUrl:"/chapter/pdf-download/55484",previewPdfUrl:"/chapter/pdf-preview/55484",authors:[{id:"152339",title:"Prof.",name:"Luciano",surname:"Lourenço",slug:"luciano-lourenco",fullName:"Luciano Lourenço"},{id:"203745",title:"Dr.",name:"Sandra",surname:"Oliveira",slug:"sandra-oliveira",fullName:"Sandra Oliveira"},{id:"204131",title:"Prof.",name:"Giovanni",surname:"Laneve",slug:"giovanni-laneve",fullName:"Giovanni Laneve"},{id:"204132",title:"Dr.",name:"Lorenzo",surname:"Fusilli",slug:"lorenzo-fusilli",fullName:"Lorenzo Fusilli"},{id:"204133",title:"Mr.",name:"Georgios",surname:"Eftychidis",slug:"georgios-eftychidis",fullName:"Georgios Eftychidis"},{id:"204135",title:"Prof.",name:"Adélia",surname:"Nunes",slug:"adelia-nunes",fullName:"Adélia Nunes"},{id:"204136",title:"Dr.",name:"Ana",surname:"Sebastián-López",slug:"ana-sebastian-lopez",fullName:"Ana Sebastián-López"}],corrections:null},{id:"55705",title:"Climate and Urban Morphology in the City of Barcelona: The Role of Vegetation",doi:"10.5772/intechopen.69125",slug:"climate-and-urban-morphology-in-the-city-of-barcelona-the-role-of-vegetation",totalDownloads:1389,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Urban morphology defines many characteristics of a city, such as its urban quality, density, and free spaces layout with its vegetation, microclimate, and thermal comfort. All these variables have in common the element of urban space, which is where users develop themselves, making it an element of value. As the city evolves, environmental conditions of the area also change. One example is the urban heat island (UHI) effect. The UHI is defined as the accumulation of heat produced by the urban surfaces emitted to the environment, affecting the urban structure and the thermal comfort of users. As discomfort increases, urban public spaces lose their appeal and may be turned into deserted areas. One of the reasons is the lack of vegetation, particularly arboreal species, which protect these spaces from the solar incidence. In this regard, the questions arise as to how urban morphology affects the incidence of solar radiation in the urban canyon, and how vegetation and its characteristics influence climatic comfort. To develop these concepts, three introductory sections are addressed: the city of Barcelona, Barcelona climate, and urban morphology. Where the main variables are solar radiation, urban canyon, orientation, and the role that vegetation plays as a protection.",signatures:"Gilkauris Rojas-Cortorreal, Francesc Navés Viñas, Julio Peña, Jaime\nRoset and Carlos López-Ordóñez",downloadPdfUrl:"/chapter/pdf-download/55705",previewPdfUrl:"/chapter/pdf-preview/55705",authors:[{id:"203823",title:"Ph.D.",name:"Gilkauris",surname:"Rojas",slug:"gilkauris-rojas",fullName:"Gilkauris Rojas"},{id:"203826",title:"Dr.",name:"Francesc",surname:"Navés Viñas",slug:"francesc-naves-vinas",fullName:"Francesc Navés Viñas"},{id:"203827",title:"Prof.",name:"Julio",surname:"Peña",slug:"julio-pena",fullName:"Julio Peña"},{id:"203828",title:"Dr.",name:"Jaime",surname:"Roset Calzada",slug:"jaime-roset-calzada",fullName:"Jaime Roset Calzada"},{id:"203829",title:"Ph.D. Student",name:"Carlos",surname:"López Ordóñez",slug:"carlos-lopez-ordonez",fullName:"Carlos López Ordóñez"}],corrections:null},{id:"55480",title:"Wheat: A Crop in the Bottom of the Mediterranean Diet Pyramid",doi:"10.5772/intechopen.69184",slug:"wheat-a-crop-in-the-bottom-of-the-mediterranean-diet-pyramid",totalDownloads:1800,totalCrossrefCites:10,totalDimensionsCites:17,hasAltmetrics:0,abstract:"Wheat currently provides 18% of the daily intake of calories and 20% of proteins for humans. Since its domestication in the Fertile Crescent, wheat has been the basic staple food of the major civilizations of Europe, West Asia and North Africa. The wheat-growing area within the Mediterranean Basin represents 27% of the arable land, and the region represents 60% of the world’s growing area for durum wheat, the species used for pasta manufacturing. Many changes have occurred from the low-productive plants cultivated in prehistoric times to the modern varieties that are now grown, which offer high productivity and quality standards. During the migration process of ancient forms of wheat from the east to the west of the Mediterranean Basin, both natural and human selections occurred, resulting in the development of local landraces characterized by their huge genetic diversity and their documented resilience to abiotic stresses. Wheat breeding activities conducted in the Mediterranean Basin during the twentieth century resulted in large genetic gains in yield and quality. New wheat varieties to be grown in the Mediterranean Basin will need to be resilient to climate change because more frequent episodes of higher temperatures and water scarcity are to be expected.",signatures:"Conxita Royo, Jose Miguel Soriano and Fanny Alvaro",downloadPdfUrl:"/chapter/pdf-download/55480",previewPdfUrl:"/chapter/pdf-preview/55480",authors:[{id:"29324",title:"Dr.",name:"Conxita",surname:"Royo",slug:"conxita-royo",fullName:"Conxita Royo"},{id:"203525",title:"Dr.",name:"Jose Miguel",surname:"Soriano",slug:"jose-miguel-soriano",fullName:"Jose Miguel Soriano"},{id:"203526",title:"Dr.",name:"Fanny",surname:"Alvaro",slug:"fanny-alvaro",fullName:"Fanny Alvaro"}],corrections:null},{id:"55474",title:"Mediterranean Diet beyond the Mediterranean Basin: Chronic Disease Prevention and Treatment",doi:"10.5772/intechopen.68937",slug:"mediterranean-diet-beyond-the-mediterranean-basin-chronic-disease-prevention-and-treatment",totalDownloads:1533,totalCrossrefCites:0,totalDimensionsCites:2,hasAltmetrics:1,abstract:"The Mediterranean diet (MedDiet) is considered one of the healthiest dietary patterns. Current scientific evidence supports that this dietary pattern is associated with lower prevalence and incidence of a number of chronic diseases, such as cardiovascular disease, diabetes, cancer, and age-related cognitive decline as well as reduced overall mortality. The Mediterranean diet includes a wide variety of foods that are eaten in moderation and enjoyed in a positive social environment. It is characterized by a high intake of fruits and vegetables, whole grains, legumes, nuts, fish and seafood, white meats, olive oil, herbs, and spices paired with moderate consumption of fermented dairy products and wine and low intake of red meat, butter, and sugar. The generic term “Mediterranean diet” was coined in the Seven Countries Study led by Ancel Keys in the 1950s. Yet, in spite of its name, this dietary pattern and its benefits are not confined exclusively to the Mediterranean Basin. Among other world regions, Central Chile exhibits climate, agriculture, and culinary traditions similar to various Mediterranean countries. It is therefore essential to increase awareness about the Mediterranean-like richness of both produce and culinary culture beyond the Mediterranean Basin. Active promotion of this dietary pattern may offer health benefits and improve the quality of life in many populations worldwide.",signatures:"Guadalupe Echeverría, Catalina Dussaillant, Emma McGee, Inés\nUrquiaga, Nicolás Velasco and Attilio Rigotti",downloadPdfUrl:"/chapter/pdf-download/55474",previewPdfUrl:"/chapter/pdf-preview/55474",authors:[{id:"203824",title:"Dr.",name:"Attilio",surname:"Rigotti",slug:"attilio-rigotti",fullName:"Attilio Rigotti"},{id:"206454",title:"MSc.",name:"Guadalupe",surname:"Echeverría",slug:"guadalupe-echeverria",fullName:"Guadalupe Echeverría"},{id:"206455",title:"Dr.",name:"Catalina",surname:"Dussaillant",slug:"catalina-dussaillant",fullName:"Catalina Dussaillant"},{id:"206456",title:"BSc.",name:"Emma",surname:"McGee",slug:"emma-mcgee",fullName:"Emma McGee"},{id:"206457",title:"Dr.",name:"Inés",surname:"Urquiaga",slug:"ines-urquiaga",fullName:"Inés Urquiaga"},{id:"206458",title:"Dr.",name:"Nicolás",surname:"Velasco",slug:"nicolas-velasco",fullName:"Nicolás Velasco"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. 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1. Introduction
\n
The first successful transplant was performed by Starzl in 1967, on a 1-year-old child with hepatoma [13–15]. The patient survived for over 12 months dying from recurrence of the liver tumor. Throughout the next 15 years, liver transplants (LTs) were performed rarely in a very few centers, with survival rates of only 20‒30%. However, the quality of life in pediatric liver transplant (PLT) patients was so good as to support these forerunners to persevere in their efforts and to continue to refine and improve techniques and postoperative care [5].
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By March 1980, the liver trials with cyclosporine began in Denver. Twelve patients entered the study between March and September 1980; 11 patients lived for 1 year or longer [2,16]. In 1983, a National Consensus Conference on Liver Transplantation was held in the United States, which became a landmark in the liver transplantation history. This event concluded that liver transplant had advanced from an experimental stage to that of a procedure with a widespread application for patients dying of liver failure. The number of transplants performed both in the United States and elsewhere has grown since then. The number of liver transplant (LT) continues to grow to date as an increasing number of indications for liver replacement are identified [5].
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Liver transplantation is the treatment of choice for pediatric liver diseases causing acute liver failure or progressing to end-stage liver disease (ESLD). These include congenital hepatitis, hepatocellular carcinoma, biliary atresia, Wilson’s disease (WD), progressive familial intrahepatic cholestasis, and other metabolic syndromes involving injury to the liver [17]. Pediatric acute liver failure (PALF) is a complex, rapidly progressive clinical syndrome that is the final common pathway for many disparate conditions, some known and others yet to be identified. PALF accounts for 10‒15% of pediatric liver transplants performed in the United States annually [18–20].
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The foremost factor limiting expansion of orthotopic liver transplant (OLT) is donor availability. In small children, scarcity of size-appropriate grafts imposes a significant barrier to PLT. At present, waiting list mortality rate for children less than 6 years of age is four times greater than for children of ages 11–17 years [21]. Living-donor liver transplantation (LDLT) has been developed to address the disparity between the number candidates for transplant and the reduced number of available organs for LT [22].
\n
\n
2. Indications
\n
Various diseases that are indications for LT in pediatric patients can be classified into cholestatic disorders, metabolic liver diseases causing liver cirrhosis, metabolic liver diseases without liver cirrhosis, acute liver failure, acute and chronic hepatitis, and liver tumors. The most common indication of PLT is biliary atresia, approximately 40% of the pediatric candidates [1]. The indications are listed in Table 1.
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2.1. Biliary atresia
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Biliary atresia (BA) is a disease of unknown etiology in which there is obstruction or destruction of the biliary tree [6]. It occurs in approximately 1 of every 15,000 live births [24]. Early diagnosis and palliative surgery—Kasai portoenterostomy are the corner stone for the treatment of BA. In this procedure, the biliary tree is excised to expose biliary channels, and a Roux-n-Y loop is fashioned for drainage. The procedure is only successful if there is restoration of biliary flow under 6 month of age and is conditional to the age when the operation is performed, the skill of the surgeon, and the degree of fibrosis at operation [25]. BA is the main indication for PLT worldwide and accounts for 76% transplants in children younger than 2 years; 80% of children who have a successful operation do not require transplantation before adolescence [6,23,25].
In several cases, the child needs LT in the first year of life due to the aggressive evolution of the disease leads to cirrhosis accompanied with severe malnutrition. Consequently, technical difficulties related to the limited dimensions of the anatomic structures are faced [26]. Hypoplasia, with or without portal vein thrombosis are relatively frequent in the course of BA. These features are related to a higher incidence of portal vein complications [27]. Previous portoenterostomy procedures cause intra-abdominal adhesions increasing the morbidity due to intraoperative bleeding and eventual bowel perforation. Previous reports have indicated that BA patients display lower survivals than children undergoing LT for other hepatic diseases [26,28,29].
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Infants with suspected BA should be evaluated as rapidly as possible because the success of the surgical intervention (hepatoportoenterostomy, the Kasai procedure) diminishes progressively with older age at surgery [30]. The evaluation process involves a series of serologic, laboratory, urine, and imaging tests. The order of diagnostic tests is prioritized based on testing for treatable diseases first, such as biliary obstruction, infections, and some metabolic diseases.
\n
Evaluation of biliary anatomy begins with an ultrasound. The main utility of the ultrasound is to exclude other anatomic causes of cholestasis (i.e., choledochal cyst). In infants with BA, the gallbladder is usually either absent or irregular in shape. When a detailed ultrasonographic protocol is used, additional features can be identified to support the diagnosis of biliary atresia, including abnormal gallbladder size and shape, the “triangular cord” sign, gallbladder contractility, and absence of the common bile duct [31–34]. The triangular cord sign is a triangular echogenic density seen just above the porta hepatis on US scan. Its presence is highly suggestive of biliary atresia [35]. Patency of the extrahepatic biliary tree can be further assessed by hepatobiliary scintigraphy.
\n
The liver biopsy is important for mainly two reasons: to identify histologic changes consistent with obstruction that warrant surgical exploration and to differentiate BA from other causes of intrahepatic cholestasis, which would not need surgical exploration. Biopsy findings that indicate another etiology include bile duct paucity (Alagille syndrome), periodic acid-Schiff (PAS) positive diastase resistant granules (consistent with alpha-one antitrypsin deficiency), or giant cell hepatitis without proliferation of ducts. Characteristic histologic features of BA include expanded portal tracts with bile duct proliferation, portal tract edema, fibrosis and inflammation, and canalicular and bile duct bile plugs. The earliest histological changes associated with BA may be relatively nonspecific, and biopsies done too early may result in a false negative [36].
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Histologic findings alone cannot help to distinguish BA from other causes of obstruction, such as choledochal cyst or external compression. Therefore, any evidence of obstruction mandates imaging exploration and a definitive cholangiogram. The intraoperative cholangiogram is the gold standard in the diagnosis of BA. It is essential that patency be investigated both proximally into the liver and distally into the bowel to determine whether BA is present. If the intraoperative cholangiogram demonstrates biliary obstruction (i.e., if the contrast does not fill the biliary tree or reach the intestine), the surgeon should perform a hepatoportoenterostomy (Kasai HPE) at that time [37].
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An increase in the number of long-term survivors of biliary atresia has been observed. Nevertheless, the disease is still one of the most challenging problems in the field of pediatric surgery because of progressive fibrosis, portal hypertension, and liver cirrhosis [17]. Kasai portoenterostomy (KPE) may play a role in gaining time for liver transplantation [17,38]. Shinkai et al. [39] showed improvement of post-KPE survival rate with almost 90% for 5 years and nearly 80% for 10 years in patients who were operated on in the 1980s. Still, despite early success with portoenterostomy, a few long-term survivals will present manifestations of portal hypertension, such as esophageal and/or gastric varices, and hypersplenism. Cholangitis and/or hepatic failure caused by progressive ongoing cirrhosis may also occur in patients with long follow-up after KPE. The main cause of comorbidity among long-term survivals of biliary atresia is portal hypertension. Despite the improvement in the long-term survival rate after KPE in biliary atresia, two-thirds of patients who survived over 10 years suffer from various complications including portal hypertension, cholangitis, intrahepatic cyst, and intestinal obstruction in spite of successful KPE. Approximately one-third of these patients will not present any problem. Meticulous follow-up is required since some manifestations of on-going liver cirrhosis will present and therefore planning for liver transplantation is necessary [40].
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2.2. Inherited metabolic liver disease
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2.2.1. Acute liver failure in inherited metabolic liver disease patients
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Metabolic diseases account for at least 10% of acute liver failure cases in North America and Europe [19,41]. While some conditions, such as mitochondrial disease, may present at any age, many metabolic conditions presenting as liver failure segregate within age groups. Metabolic conditions affecting infants in the first few months of life include galactosemia, tyrosinemia, Niemann-Pick type C, mitochondrial hepatopathies, and urea cycle defects [42]. In older infants and young children up to 5 years of age presenting with acute liver failure, metabolic diseases are sometimes identified [18], such as mitochondrial hepatopathies, hereditary fructose intolerance (HFI), argininosuccinate synthetase deficiency (citrullinemia type 1), and ornithine transcarbamylase deficiency. In older children and adolescents, Wilson’s disease and mitochondrial disease (fatty acid oxidation defects) may cause acute liver failure [43].
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2.2.2. Alpha 1 antitrypsin deficiency
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Alpha 1 antitrypsin (AAT) deficiency is the most common form of inherited metabolic liver disease in childhood in Europe. Although 50‒70% of children develop persistent liver disease progressing to cirrhosis, only 20‒30% require transplantation in childhood or adolescence [44,45].
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The presentation of alpha 1 antitrypsin deficiency can include neonatal cholestasis. The frequency of AAT deficiency in infants with neonatal cholestasis ranges from 1 to 10% in different series [46,47]. AAT is an antiprotease and the natural inhibitor of the serine proteases released by activated neutrophils [48]. The “deficiency” state is actually an accumulation of abnormal protein within the endoplasmic reticulum resulting in liver injury in a subset of patients by unclear mechanism [49].
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2.2.3. Alagille’s syndrome
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This autosomal dominant condition has an incidence of 1 case per 100,000 live births. It is a multisystem disorder with cardiac, facial, renal, ocular, and skeletal abnormalities. The condition is caused by mutations in the Jagged 1 gene (JAG1), which encodes a ligand of Notch 1 [50]. The main clinical issues are cholestasis, malnutrition, and cardiac or renal disease [6]. Cholestatic liver disease is of variable severity and may stabilize by school age. It is managed conservatively, with treatment for pruritus and malabsorption as needed. Portoenterostomy (Kasai procedure) is not beneficial and is not recommended [51]. End-stage liver disease develops in approximately 20% of affected children and is amenable to liver transplantation [43,52].
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2.2.4. Tyrosinemia type I
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Tyrosinemia type I, also known as Hepatorenal tyrosinemia [43], is an autosomal recessive disorder caused by a defect of fumaryl acetoacetase (FAA). There is a lifetime risk of developing hepatocellular carcinoma (HCC) [53]. Clinical features are heterogeneous, even within the same family. Young infants present with cholestasis and coagulopathy, which is often disproportionate to the apparent degree of liver disease. Older infants and children may present with chronic liver disease, with or without cholestasis, and painful crises, mimicking porphyria [44]. Management is with a phenylalanine and tyrosine-restricted diet and nitisone, which prevents the formation of toxic metabolites and allows normal growth and development [55]. The long-term outcome has significantly improved with nitisone therapy and transplantation is now only indicated in those adolescents who do not respond to nitisone, or develop HCC [6,54]. Affected individuals have increased urinary excretion of succinylacetone and markedly elevated blood tyrosine concentration [44].
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2.2.5. Cystic fibrosis
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Cystic fibrosis (CF) occurs in 1 in every 3000 live births worldwide [55].
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The gene defect is an abnormality in the cystic fibrosis transmembrane conductance regulator (CFTR) located on chromosome 7q31. It is a multiorgan disease mainly affecting the lungs and pancreas [6]. The cystic fibrosis transmembrane conductance regulator is located on the apical surface of the biliary epithelium, explaining some of the biliary tract disease seen in patients with cystic fibrosis [56]. Neonatal cholestasis is an uncommon presentation of cystic fibrosis, occurring in fewer than 5% of patients with CF. In affected infants, jaundice and hepatomegaly slowly resolve. Infants with CF are more likely to present with meconium ileus or steatorrhea with failure to thrive [43]. Cystic fibrosis-associated liver disease (CFLD) occurs in 27‒35% of patients and usually presents before the age of 18 years [60]. Cirrhosis and portal hypertension occurs in 5‒10% of patients during the first decade of life and present with complications in adolescence or early adult life [57]. The indications for LT include malnutrition unresponsive to nutritional support, intractable portal hypertension, and hepatic dysfunction. It is essential that transplantation be carried out before pulmonary disease becomes irreversible [58].
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2.2.6. Wilson’s disease
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Wilson’s disease is the most common metabolic condition associated with PALF in children over 5 years of age [18]. It is an autosomal recessive disorder with an incidence of 1 case per 30,000 live births. The defective gene is on chromosome 13 and encodes a copper transporting P-type adenosinetriphosphatase (ATPase) (ATP7B) [59]. Clinical features in adolescence include hepatic dysfunction (40%) fulminant hepatitis, chronic hepatitis or cirrhosis, and psychiatric symptoms (35%). Neurologic symptoms may be nonspecific, but deteriorating school performance, abnormal behavior, lack of coordination, and dysarthria are common. Renal tubular abnormalities, renal calculi, and hemolytic anemia are associated features [60,61].
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The presence of a Coombs-negative hemolytic anemia, marked hyperbilirubinemia, low serum ceruloplasmin, and a normal or subnormal low serum alkaline phosphatase should prompt consideration of WD, but confirming the diagnosis remains a challenge [62]. LT is indicated for those with advanced liver disease (Wilson’s score > 6), fulminant liver failure, or progressive hepatic disease despite therapy [60,61].
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2.2.7. Other inborn errors of metabolism
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LT is indicated for those metabolic disorders secondary to hepatic enzyme deficiencies that lead to severe extrahepatic disease such as kernicterus in Crigler-Najjar type I and systemic oxalosis in primary oxaluria. Selection and timing of transplantation depends on the quality of life on medical management and the mortality and morbidity of the primary disease compared with the risks of transplantation [23]. Crigler-Najjar type I is an autosomal recessive condition caused by a deficiency of bilirubin uridine diphosphate glucuronosyltransferase (UDPGT) [63]. Most children require transplantation in early childhood, but those with milder forms may manage with phototherapy into adolescence. Primary hyperoxaluria is a defect of glyoxylate metabolism characterized by the overproduction of oxalate, which is deposited as calcium oxalate in various organs including the kidney [64]. Ideally, liver replacement should be prior to the development of irreversible renal failure. If this is not possible, liver and kidney replacement may be required simultaneously [65]. Children with milder phenotypes will not require intervention until adolescence [6].
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2.3. Liver tumors
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2.3.1. Hepatoblastoma
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The most common primary liver tumor in children is hepatoblastoma (HB), accounting for two-thirds of all malignant liver neoplasms in the pediatric population [66]. Neoadjuvant chemotherapy and surgical resection followed by adjuvant chemotherapy is the treatment of choice for patients with HB. When HB shows to be unresectable or unresponsive to chemotherapy, combination of chemotherapy and liver transplantation is an attractive alternative [67]. The United States Surveillance, Epidemiology, and End Results (SEER) from 2002 to 2008 showed an incidence in HB of 10.5 cases/million in children under 1 year of age and 5.2 cases/million in children 1‒4 years of age [68]. Histologically, HB cells resemble embryonic liver cells and the incidence is highest at birth suggesting that the process is initiated during gestation [69].
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Liver transplantation has resulted in long-term disease-free survival in up to 80% of children with large solitary, and especially multifocal, hepatoblastomas invading all four sectors of the liver [70]. While “extreme” resection of tumors without liver transplant will avoid the need for long-term immunosuppressive therapy, hazardous attempts at partial hepatectomy in children with major venous involvement or with extensive multifocal tumors should be discouraged [71–75]. Only in centers that have a facility for liver transplant extensive hepatic surgery in children should be carried out. In these centers, surgical expertise, as well as willingness to embark on more radical surgery with a transplant “safety net” is likely to be greater [75]. In a review of the United Network for Organ Sharing database in the United States concerning liver transplantation in 135 children transplanted for unresectable or recurrent HB (1987–2004), the 1-, 5-, and 10-year survival was 79, 69, and 66%, respectively [76]. The latest European Liver Transplant Registry (ELTR) report, including 129 patients transplanted for HB, has shown a 1- and 5-year survival of 100 and 74%, respectively [77,78].
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The only absolute contraindication for liver transplantation is the persistence of viable extrahepatic tumor deposit after chemotherapy, not amenable to surgical resection. When macroscopic venous invasion occurs (portal vein, hepatic veins, and vena cava), liver resection can be carried on if complete resection of the invaded venous structures is feasible. “En-bloc” and reconstruction should be performed whenever there is evidence or suspicion of invasion of the retrohepatic vena cava. Patients with lung metastases at presentation should not be excluded from liver transplantation if the metastases clear completely after chemotherapy and/or surgical resection. Liver transplant can only be performed after complete eradication of metastatic lesions, by chemotherapy and surgical resection, of any suspicious remnant after chemotherapy [79]. Rescue liver transplantation, after an incomplete partial hepatectomy or when intrahepatic relapse occurs, may be a relative contraindication because of the disappointing results observed in the SIOPEL-l study and in the reported world experience [77].
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2.3.2. Hepatocellular carcinoma
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Unlike the adult population, the frequency of HCC in the pediatric population is low; therefore, the experience in the application of liver transplantation in the pediatric population for HCC is limited [80–83]. Experience with liver transplantation in children with unresectable HCC is somewhat limited but results have significantly improved over the recent years. The Milan criteria—no more than three tumors, each not more than 3 cm in size, or a single tumor, not more than 5 cm in diameter, and no evidence of extrahepatic disease or vascular invasion is commonly used to determine which patients benefit the most with LT [84]. Recently, it has been suggested that the present cut-off for tumor size might be expanded to 6.5 cm or 7 cm, in an otherwise normal liver [89, 90]. Data suggesting that Milan criteria can appropriately identify children with a low-risk tumor recurrence of after transplantation is not yet available. The Milan criteria are derivative from experience treating adult patients with cirrhosis, whereas HCC in children usually is not associated with cirrhosis. The role of OLT in noncirrhotic liver is unknown due to lack of prospective trial in children. Furthermore, there are differences in biology of HCC in adults and in children [85]. The different molecular findings include mutation of c-met gene in children; lower levels of glycin D1 (regulatory protein of G1 phase cycle) expression in children; and higher incidence of loss of heterozygosity on chromosomal arm, 13q, in children [85]. In patients whose disease is confined to the liver, the use of liver transplantation is indicated.
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2.4. Acute Liver Failure
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Viral hepatitis A and B are the most common causes of acute liver failure in the developing world [86,87]. However, in the United Kingdom and United States, indeterminate hepatitis is the most common cause and has the worst prognosis for spontaneous recovery [18]. The main indications for LT for acute liver failure in adolescence are drug induced, infectious hepatitis, or metabolic disease (e.g., Wilson’s disease) [18,88]. Many different drugs cause acute liver failure, including antibiotics, antituberculosis therapy, antiepileptic therapy, and acetaminophen poisoning [89]. Adolescents have a lower incidence of liver failure with acetaminophen overdose than adults, possibly because of the effect of hepatic maturation and glutathione production [90]. Transplantation is more likely to be required if the overdose was taken with another drug (e.g., lysergic acid diethylamide [LSD], ecstasy) or with alcohol [91]. Persistent coagulopathy (INR > 4), metabolic acidosis (pH < 7.3), an elevated creatinine (>300 mmol/l), and rapid progression to hepatic coma grade III are indicatives for liver transplant. Cerebral edema may persist despite evidence of hepatic regeneration and recovery and influence postoperative recovery.
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Once the diagnosis of liver disease is made, the most important assessment is to determine the severity of the liver disease and its projected outcome. Patients with evidence of end-stage liver disease, including variceal hemorrhage, intractable ascites, hepatorenal syndrome, recurrent infection, and portosystemic encephalopathy, are candidates for immediate listing for transplantation. Selected patients with well-compensated Child’s A cirrhosis and isolated variceal bleeding benefit from surgical portosystemic shunting. The success of transplantation in patients with sequel of end-stage liver disease has also heralded an increasing willingness to apply transplantation in patients with life-disabling complications of liver disease consequent to severe metabolic consequences of chronic liver disease [92].
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Thus, the indications for PLT are significantly different to indications in adult LT recipients. In the past, PLT was only performed in curative intent. Nowadays, if life expectancy and/or quality of life can be significantly improved, PLT is also performed. Children diagnosed with metabolic liver diseases not resulting in liver cirrhosis, the indication for LT has to be cautiously evaluated. LT should be performed when the disease can either be cured or if extrahepatic manifestations can be significantly improved [1].
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3. Contraindications for transplantation
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The few contraindications include severe systemic sepsis—particularly fungal sepsis, at the time of operation; malignant hepatic tumors with extrahepatic spread; severe extrahepatic disease that is not reversible following LT (e.g., severe cardiopulmonary disease for which corrective surgery is not possible), or severe structural brain damage [23].
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4. Preoperative management
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When transplantation was still perceived as experimental, potential candidates were referred to very late in their course of end-stage liver disease. Generally, the patient was a child with biliary atresia with several prior surgical procedures, who was extremely malnourished, with stigmata of fat-soluble vitamin deficiency, bleeding diathesis, uncontrolled portal hypertension, and massive ascites. One could not imagine a poorer candidate for major surgery. Unfortunately, this is still reality in many centers [2].
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Correct preparation before transplantation requires a multidisciplinary approach. The use of new milk formulas specially developed for cholestatic children, parenteral nutrition, may be necessary to correct the nutrition deficit [93]. Gastrointestinal bleeding from esophageal varices should be prevented with sclerotherapy [93], variceal banding [94], and transjugular intrahepatic portosystemic shunt in older children [95]. The remarkable enhancement in the outcomes of liver transplantation, including children, has encouraged an earlier referral, allowing a more elective approach toward liver transplantation [2].
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Immunizations should be administered to solid organ transplant candidates as early as possible in the transplant evaluation in order to optimize immune responses and provide immunity to pathogens against which there is only a live vaccine (measles, mumps, rubella, varicella, and zoster). Standard age-appropriate vaccines, as well as vaccines indicated for immunocompromised hosts (e.g., pneumococcal vaccines in adults), should be administered 2‒6 months following transplantation, once maintenance immunosuppression levels have been attained. Inactivated vaccines are generally considered to be safe following solid organ transplantation [96].
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Live vaccines (measles, mumps, rubella, varicella, zoster, and intranasal influenza vaccine) are not recommended in the majority of solid organ transplant recipients. An exception is varicella-nonimmune pediatric renal or liver transplant recipients who are receiving minimal or no immunosuppression and who have had no recent allograft rejection; such individuals may receive the varicella vaccine [96].
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The measles, mumps, and rubella vaccine is considered safe in household contacts of solid organ transplant recipients. We suggest administering the varicella vaccine to nonimmune household contacts. The zoster vaccine should be administered to household contacts when indicated. Vaccinees who develop a rash should avoid contact with transplant recipients for the duration of the rash [1].
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In biliary atresia patients, which is the most frequent indication, a sequential strategy with a single attempt at surgical correction, Roux-en-Y portoenterostomy as described by Kasai [97], followed by liver transplantation, when it fails, is consensus by pediatric surgeons [104]. At present, most infants who do not achieve remission following portoenterostomy are referred to and transplanted under the age of 1 year. Malatack et al. [98] proposed a score to choose the timing of transplantation for children with chronic liver failure. Though such a score can be beneficial, it is suggested that liver transplantation should be performed as soon as an appropriate donor is found, even for children in stable condition, at least when the indication is straightforward at any age of the child.
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Due to better understanding of the pathophysiology and/or increased of clinical experience, many contraindications accepted in the past are not presently valid. An example is hepatopulmonary syndrome, which can associate with any type of chronic liver disease. Room air PaO2 level lower than 60 mmHg has been described to be associated with prohibitive mortality after liver transplant [99]. Differently, regardless of the severity of the syndrome, others have shown complete reversion of hepatopulmonary syndrome after LT [107].
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4.1. Psychological preparation
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A skilled multidisciplinary team, including a psychologist, is essential for counseling and preparation of the patient and his/hers family. Young people need to be involved in the decision making wherever possible, and previous experience of illness, knowledge about their condition and treatment, previous/current adherence to prescribed medical regimens, and self-management behaviors need to be explored. Parents and appropriate relatives must be fully informed of the necessity for LT in their child and of the risks, complications, and the long-term implications of the operation. Particularly, careful counseling is necessary for parents and children being considered for transplantation because of extrahepatic disease due to an inborn error of metabolism. As these young people are not dying from liver disease, they may find it difficult to accept the risks and complications and the necessity for compliance with long-term immunosuppression [6].
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4.2. Psychosocial evaluation of live organ donors
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Adequate psychosocial evaluation includes assessment of the motivation for donating, decision making and informed consent process, donor-recipient relationship, adequacy of both financial and social support, behavioral and psychological health, and substance use history. A complete assessment of a potential living donor should also address obstacles such as impression management and explicit deception. It should also include ethical aspects, such as the right to donate, donor autonomy, freedom from coercion, and “reasonable” risks to donors. The Transplantation Society Ethics Committee emphasizes that is essential when considering living organ donation, that the well-being of donors, including survival, quality of life, and psychological and social well-being, outweighs the risks to the donor-recipient pair, which include death and medical, psychological, and social morbidities [100]. Like to the psychosocial evaluation of the recipient, the attention should be on the interaction of risk versus protective factors for each donor [109]. Although recent research identifies the needs for standard criteria [101], live organ donor evaluations should be viewed within both individual and contextual frameworks [22].
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5. Surgical techniques
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Liver transplantation has gained from the knowledge of anesthesiologists handling babies with serious conditions. The pediatric anesthesiologist is an essential member of the team. As in any long operation, exact correction of blood loss, continual monitoring of electrolytes and blood gases, correct identification and treatment of bleeding diathesis, and maintenance of body temperature and diuresis are fundamental. Alongside a correct comprehension of all the surgical techniques, good tactics and technical expertise, proper attention by the surgeon to hemostasis is essential. Although limitation of graft ischemia time is important, the patient will be better off at the end of surgery if the operative field is dry and the small bowel has been preserved from damage during the tedious dissection of tight adhesions, rather than been rushed through surgery by a hurried surgeon [2].
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Figure 1.
Examples of surgical techniques for orthotopic liver transplantation.
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Prior the development of the technique of liver splitting, PLT was dependent on donors with similar age or size. In the early 1980s, Christoph Broelsch and Henri Bismuth were the first applying the technique of reduced-size LT in children [102,103]. Rudolf Pichlmayr performed the first split LT offering one cadaveric liver to two recipients in 1988 [104]. However, pediatric deceased donors as well as organs suitable for split LT remain rare. The numbers of PLTs performed significantly exceed the number of available pediatric organ donors [1,105].
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LT in children is comparable to adult LT (piggy back or conventional technique) when full size grafts are transplanted. Partial liver grafts can be obtained either by splitting a cadaveric donor organ or by living-donor liver donation. When liver-splitting technique is used, the anatomical determination of the eight liver segments first described by Couinaud [106,107] in 1957 is essential. Figure 1 depicts the surgical options for OLT.
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The splitting procedure can be performed as anatomical splitting, dividing the liver at Cantlie’s line, and splitting along the falciform ligament [117]. When the left lateral segment divided, the technique is much easier to perform than the true right/left lobe split procedure. Additionally, the left lateral segment is preferentially used in PLT. It is the smallest part of the liver when compared to the extended right, the anatomical left, or the right liver lobe.
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In small infants, even the left lateral segment of the liver often is too large and techniques to cut down left lateral lobes may be used to prevent graft-size mismatching and the so-called “large-for-size” syndrome [108]. Not rarely, primary closure of the abdominal wall after PLT is not feasible and should not be enforced in order to avoid increase in intra-abdominal pressure. Excessive increase in intra-abdominal pressure may compromise graft perfusion. In such occasions, abdominal wall closure is performed in stages during the first week post-transplant or accomplished by using mesh grafts. This allows for a continuous recovery of the graft from reperfusion injury and edema [109].
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5.1. Auxiliary transplantation
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Auxiliary partial orthotopic LT (APOLT) is an alternative technique for LT in patients with acute liver failure or in children with metabolic liver diseases without primary hepatocellular dysfunction or cirrhosis. In this technique, a partial graft is implanted without entirely removing the native liver. Gubernatis et al. reported the first successful case in a patient with acute liver failure. After her recovery, the native liver has regenerated and immunosuppressive treatment could be withdrawn [110,111].
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In patients with metabolic diseases, APOLT may provide sufficient liver mass to correct the hepatic metabolic function. If the graft fails, the patient’s native liver is still present to secure general liver function [112]. When APOLT is performed in acute fulminant liver failure, the immunosuppressive therapy can be stopped if the native liver recuperates, resulting in an atrophy of the transplanted liver [113].
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5.2. Living-donor liver donation
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After successful implementation of split-liver LT in PLT, this technique leads to the first living-donor liver transplant (LDLT). In 1989, the first series of LDLT in pediatric recipients was performed in Chicago [114], after the pioneer work of Raia et al. [115] in Brazil. As of today, LDLT is an established procedure and the main form of LT due to scarcity of deceased donor organs in most East-Asian countries [116]. In western countries and especially in the UNOS area, use of living-donor organs for LT is less frequent and within UNOS constantly <5% of LT over the last years [117]. Within the European Transplant Network, rates of LDLT in PLT are steadily increasing.
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Retrospective analyses have shown favorable or equal results as compared to PLT after deceased donor liver transplant (DDLT) [118–126]. When performing LDLT the scenery include an optimal healthy donor, minimal ischemic time, elective surgery, and timing of transplantation according to the recipients’ need. This is particularly pertinent for pediatric patients. During a waiting time for PLT, the underlying disease can complicate and psychosocial long-term morbidity may develop pediatric patient. It has been shown that long-term outcome after PLT significantly correlates with the severity of morbidity at PLT. In a early publication, significant independent predictors of survival after OLT in children with end-stage liver disease were bilirubin (p=0.0024), lower weight (p=0.034), and albumin (p=0.039). Post-transplantation survival rates was statistically significant difference at 1 year (57% vs. 90.5%) and 4 years (49% vs. 90.5%) after OLT(p=0.0001), when one or more of these risk factors - bilirubin >340 μmol/L, lower weight <−2.2 and albumin < 33 g/L, were presente [127]. LDLT offers the possibility and advantage of optimal timing of the transplant procedure before severe morbidity develops.
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Living-donor livers recipients have a shorter waiting time when compared to recipients of organs from deceased donors. This reflects in a reduction of waiting list mortality. Nevertheless, live donors are not deprived of risk. Also to considerer is the fact that LDLT is surgically more challenging than whole organ transplantation. Donor major complications, exceeding Clavien’s classification grade II, were described in up to 44% after right-lobe LDLT with a mortality risk up to 0.8% [128–130]. Donors of right liver lobe experience operating procedures with longer duration, have significant longer hospital stay and require more blood transfusions [131,132]. For PLT, in most cases, the left lateral segment donation is sufficient. The complication rates after full left lobe or left lateral lobectomy are significantly lower than right lobe donation [133–135]. In order to decrease morbidity and mortality after liver donation, a thorough evaluation of the potential donor is essential to detect and exclude potential increased medical risk factors for the otherwise healthy donor.
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5.3. Living related donor liver transplantation in children
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5.3.1. Surgical technique
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The donor procedure is performed first, except when recipient’s diagnosis is malignant liver tumor. The recipient surgery usually starts immediately after the quality of the graft is assured to minimize the cold ischemia time. Left lateral hepatectomy is performed without clamping of the portal triad. The vessels were divided after completion of the parenchymal transection. The whole hilum is dissected and the left hepatic artery is identified. Subsequently, dissection is confined to the left branch of the portal vein and to the left hepatic artery. Minimal dissection was performed around the left hepatic duct to avoid damaging its blood supply. At bench surgery, the graft is perfused with preservation solution.
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The liver implantation technique consists of the anastomosis of the left hepatic vein to the native inferior vena cava. This anastomosis can be performed by direct suturing of the donor hepatic veins to the recipient hepatic veins; by a triangular anastomosis after creating a wide triangular orifice in the recipient inferior vena cava at the confluence of all of the hepatic veins; or a wide longitudinal anastomosis in the anterior wall of the inferior vena cava. Subsequently, the portal vein is anastomosed to the trunk of the recipient’s portal vein in an end-to-end technique [136].
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The liver graft is reperfused after conclusion of the portal vein anastomosis. For the reconstruction of the artery, microsurgical techniques are necessary. The graft hepatic artery is anastomosed to one of the stumps of the main branches or to the trunk of the proper hepatic artery of the recipient in end-to-end fashion using 9-0 or 10-0 prolene sutures. The arterial anastomosis should be performed using microsurgery techniques under surgical microscope (magnification, 8×) or surgical loupes (magnification, 6×), depending on the size of the arteries. Biliary reconstruction is achieved by a Roux-en-Y hepaticojejunostomy. Occasionally, an end-to-end duct anastomosis can be performed [136].
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6. Post-transplant care
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Immediately after the transplant, the patient is usually ventilated in intensive care for 24-48 h. Graft function is assessed with coagulation studies, blood sugar and acid-base balance, and liver function tests. Initially in the post-operative period, high transaminase levels are usually observed that progressively fall during the first few postoperative days. A rapid reduction of jaundice is an indication of a well-functioning graft.
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When abnormal liver function tests are detected, a specific protocol of investigations to determine the cause is necessary. In patients with a t-tube, a cholangiogram will demonstrate patency of the biliary tree. In patients without a t-tube, an ultrasound of the liver can exclude biliary obstruction and demonstrate patency of the portal vein and hepatic artery. In the suspicion of a thrombotic event, angiography should be performed to confirm it. The gold standard for diagnosing a rejection episode is needle biopsy. Liver biopsy should be carried out subsequently. Other diagnoses such as preservation injury or viral hepatitis in the graft can also be diagnosed. For confirmation of viral infections, specific antibody tests usually are necessary [5].
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7. Immunossupression
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As in adult LT, the introduction of calcineurin inhibitors (CNI) in the early 1980s gave way to long-term survival also for pediatric transplant recipients and until today remains the backbone of immunosuppression practices [1,3,137]. The most popular immunosuppression drugs combination comprises low doses of prednisolone, mycophenolate, and tacrolimus. Despite the high effectiveness of these medications in controling the imune response, rejection is a reality in the majority of liver transplant recipients which can be controlled with the intensification of the steroid dose. Higher doses of immunosuppression are usually associated with a lower incidence of rejection. On the other hand, at the same time, a higher infection rate with considerable morbidity and even morality appears. Moreover, each of the agents has specific toxic effects [5]. Observations made by several groups indicate that after liver transplantation in children require more immunosuppression than adults, with a higher incidence of steroid sensitive and steroid-resistant acute rejection episodes [137].
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The period of highest risk for immunologic reactions between graft and host usually is in the early post-transplant phase. Consequently, higher dose of immunosuppression is required during this period. Most protocols include induction therapy, usually interleukin-2 receptor antibodies especially in the pediatric transplant population (Basiliximab® and Daclizumab®), in association with corticosteroids and calcineurin inhibitors (cyclosporine A and tacrolimus) as maintenance therapy [138–143]. In the pediatric transplantation community, the use of other mono- or polyclonal antibodies—monoclonal anti-CD3 antibody preparations (OKT3) and rabbit or equine antithymocyte globulin, for induction therapy has not been adopted. These potent agents can cause undesired short—and uncertain long-term effects on the developing organism and immune system [144]. Several reports showed that the lower doses of immunosuppression can be used based on the individual needs, particularly in pediatric cases which can, in long-term, improve the quality of life of these patients minimizing undesired side effects [145–148].
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Common side effects of immunosuppressants include diabetes, deficiency of growth, hypertension, nephrotoxicity, hyperlipidemia, neurologic alterations, hypertrichosis, and bone marrow suppression. Ideal levels of immunosuppression are hard to obtain due to great differences between individuals as well as within the same individual over time. Multiple combination protocols, such as mycophenolate-mofetil and mammalian target of rapamycin inhibitors (sirolimus and everolimus), with and without CNIs have been introduced for maintenance therapy also in pediatric solid organ transplant based on increasing data to safety aspects in the use of different immunosuppressant drugs in the adult population [149–156].
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It is well established that long-term immunosuppression increases the risk of infectious and malignant complications. Other side effects, such as nephrotoxicity, disturbances of the lipid profile, arterial hypertension, and cardiovascular disease, are also of concern. These side effects can jeopardize both quality of life and life expectancy. Especially in pediatric liver recipients whose survival can be expected to be more than a few decades; consequently prevention of these side effects is a major objective. The reduction of the global immunosuppression in the first months after the procedure, concerning the total amount of steroids and the target blood levels of calcineurin inhibitors, is the main goal. The use of tacrolimus has allowed complete withdrawal of steroids within the first posttransplant year in most patients, which has been proved to be beneficial. New protocols, specifically designed for children to test new immunosuppressive compounds as well as tolerance inducing strategies, have been more easily introduced [2].
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Although immunosuppression drugs is still recommended after liver transplantation, several studies have shown that particularly patients who are transplanted in the early years or receive a parental living liver donation could develop an evident degree of immune tolerance concerning the graft. Single center experiences demonstrate that patients who were withdrawn from immunosuppression because of medical reasons (such as renal insufficiency) or due to noncompliance suggest that around 20% of liver transplant patients develop operationally tolerance regarding the graft [157–162]. Another more aggressive approach to induce immune tolerance in solid organ transplantation is to combine solid organ transplantation with hematopoietic stem cell transplantation from the same donor [1,163–165].
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Complete freedom from immunosuppression or significant withdrawal of immunosuppression is possible in long-surviving recipients of liver allografts [159,166,167]. The drug weaning protocol established for pediatric liver transplant patients at the University of Pittsburgh includes long-term survivors who are medically compliant and have normal liver function without recent acute rejection episodes within the past 2 years. Drug withdrawal was begun at a mean time of 6 years after liver transplantation. The baseline immunosuppressant of tacrolimus or cyclosporine was weaned at 2-month to 3-month intervals as long as hepatocellular enzyme tests remained stable. Liver injury tests of aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyltransferase (GGTP), and bilirubin are monitored weekly after changes in drug dosage. Tacrolimus or cyclosporine levels are not used in monitoring because baseline levels in this patient population are frequently low or undetectable. Liver biopsy is done for sustained alterations in liver tests. Forty percent (17 of 43) of the patients were off immunosuppression, with a mean time from weaning of 1.7 years. No patient or graft loss has occurred. Rejection has occurred in 14% of patients (6 of 43), being mild in two patients and mild to moderate in four patients, prompting switch to tacrolimus from cyclosporine-based immunosuppression. Pediatric patients have the greatest potential benefit from the significant dosage reductions or complete drug withdrawal that can be potentially realized [2].
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However, it is not without risk and it must be done with great care because no marker is available to identify the patients who have developed graft acceptance operational tolerance [168]. Three main objectives should be pursued in PLT regarding immunosuppression: (1) reduction and individualization of immunosuppression in order to diminish long-term side effects; (2) maintenance of long-term allograft function; and (3) monitor and induce tolerance through the development of specific protocols, as well as identify operationally tolerant and nontolerant patients [1].
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8. Adherence
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Nonadherence to the medical regimen is part of the risk-taking spectrum of behavior [77], and approximately 33‒50% of adolescents with a chronic illness are nonadherent in some way with their treatment protocol [169]. There is a clear association between medication nonadherence and unfavorable transplant outcome.
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Several studies investigate the role of different factors predisposing to medication nonadherence [170]. In a recent study, 75% of post-LT adolescents were nonadherent and reported poorer health perceptions, lower self-esteem, more limitations in social and school activities, and poorer mental health than those who were adherent [171]. Factors such as history of substance abuse, previous psychiatric problems, older age, female gender, and living in a one-parent household have been associated with poorer adherence [172,173].
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Nonadherence to medication is associated with increased medical complications and higher rates of rejection and graft loss [174–176]. In addition, other aspects of nonadherence include clinic nonattendance, missing routine blood tests, and inconsistent timing of medications. The desire to be like their friends can result in nonadherence to different aspects of the treatment regimen. The monitoring and management of nonadherence can be challenging, necessitating a nonjudgmental approach, with a focus on individual adherence plans, improved education, behavioral strategies to encourage self-management and self-motivation and a recognition of the role of treatment burden for patients, and their families [6,177].
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9. Complication
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The main causes of graft loss in the first week include primary nonfunction (PNF), hepatic artery or portal vein thrombosis, systemic sepsis, and multiorgan failure (<10%). Other significant early complications are acute (50%) or chronic rejection (10%), biliary leaks/strictures (5–25%), viral infections (especially cytomegalovirus (CMV) and Epstein Barr virus), and acute kidney injury and fluid imbalance [7–12]. The most frequent complications are listed in Table 2.
Intraoperative bleeding in PLT is commonly less of a problem than in adults, even though the majority of the children will have had previous surgery on the liver. This can be explained by the fact that portal hypertension as measured by portal vein pressure is less severe in the child than in the adult, possibly consequence of more effective collateral vessel formation [5].
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Thrombosis of the hepatic artery is a major concern in PLT with rates varying from 10 to 25%. This ischemia, when occurring in the early posttransplant period, produces either acute graft failure or biliary tree infarction with bile leakage and intra- or extrahepatic abscess formation [5]. Early hepatic artery thrombosis (HAT) is the most common form of vascular complication and is the main cause of graft loss in pediatric living-related liver transplantation (LRLT) [178]. Early diagnosis and treatment can prevent biliary tract and parenchymal damage [179]. Bekker et al reported an incidence for early HAT in pediatric LT of 8.3% compared to 2.9% in adults. [180]. Hepatic artery stenosis and thrombosis can result in allograft ischemia, which is associated with high mortality and morbidity rate. Arterial complications are frequently diagnosed first by Doppler ultrasound followed by CT angiogram or angiography. Doppler ultrasound showed a sensitivity of 100%, a specificity of 99.5%, a PPV of 95% and NPV of 100%, and overall accuracy of 99.5% in early diagnosis of HAS [179]. According to the interval between LT and development of thrombosis, HAT can be divided into early (within 4 weeks) and late. Usually, early HAT may be the result of technical problems and can have dramatic presentation [181]. Due to the fact that early HAT has a higher mortality comparing to late HAT, intervention is required as urgent procedure [182]. Late HAT is usually due to ischemic or immunologic injuries. Patients with late symptomatic HAT can be initially treated with biliary stent placement and/or endovascular interventions [181].
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Positive CMV antibody in donor and negative CMV recipients has been shown to be associated with late HAT [183–186]. Some authors also suggest that perioperative hypercoagulable state as the possible underlying cause for hepatic artery thrombosis [180–187]. Although urgent retransplantation is considered the main therapy for early HAT, endovascular interventions, including PTA, intra-arterial thrombolysis (IAT), and stent placement, may be alternative treatments.
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Venous complications after PLT include caval/hepatic vein and portal problems. Clinical manifestations of portal vein stenosis (PVS) include ascites, anemia, splenomegaly, and gastrointestinal bleeding [188–191]. Platelet counts may be below normal limit in pediatric patients with PVS due to hypersplenism [192]. The incidence of portal vein complications is usually higher in pediatric recipients than in adults. Smaller portal vein diameter, size disparity between donor’s and recipient’s portal vein, and short pedicle of the donor’s portal vein are risk factors for portal vein complications [193–196].
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Clinically hepatic vein obstruction (HVO) is analogous to Budd-Chiari syndrome [197]. HVO is a general term reflecting any obstruction of the hepatic veins caused by either compression and twisting of the anastomosis. It can be caused by graft regeneration or by intimal hyperplasia and fibrosis at the anastomotic sites [198]. Risk factors related to portal vein complications include technical problems, young age, body weight <6 kg, the recipient’s portal vein size <5 mm, graft rotation, previous splenectomy, simultaneous thrombectomy for pre-existing PVT, and use of venous conduits for portal vein reconstruction [9,193,199–204]. Cold ischemia time longer than 12 h can also be a impose risk for developing venous problems. Portal vein stenosis is mostly associated with cryopreserved vein for portal conduits. Portal vein hypoplasia is one of the main risk factors for developing vascular complications in pediatric recipients of LT, particularly when biliary atresia is the indication for LT [205,206]. Suzuki et al. [207] reported a portal vein diameter of <3.5 mm to be the single most sensitive and specific predictor of portal vein stenosis.
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Endovascular interventions are less invasive treatment for post-LT vascular complications particularly in pediatric patients. In cases of post-LT HVO, percutaneous endovascular treatment with balloon dilation and/or stent placement can be used as a safe treatment with high success rate. Complications, such as ascites, renal failure, lower limb edema, and splenomegaly, can be resolved after endovascular interventions [208]. Simultaneous obstruction of HV and IVC can also be treated with endovascular interventions. However, isolated HV stenosis is better treated with balloon-expandable stent treatment than with balloon dilation [209].
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Although balloon dilation is an effective and relatively safe procedure for treatment of portal vein stenosis, 28–50% of these patients may develop recurrent PVS [210–213]. Previous reports suggest stent placement and repeated balloon dilation as solutions for this problem [212,213]. Sanada et al. [202] showed combined anticoagulant therapy using LMW heparin, warfarin, and aspirin can significantly lower the risk of recurrent PVS [214].
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9.1. Biliary complications
\n
The presentation of biliary complications is quite variable. The diagnosis biliary leakages (BL) usually are straightforward and presents early in the posttransplant period. Biliary stenosis (BS) has a more indolent progression and usually is diagnosed later. BS demands a high index of suspicion because in the initial phases the clinical picture can be confused with rejection, infection and primary disease recurrence [215].
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Early complications, occurring within 30 days of the transplant, usually are consequence of technical problems. These include handling and harvesting of the graft, preservation injuries, surgical technique of biliary reconstruction, or even vascular insufficiency [216]. Late complications, occurring after 90 days posttransplant, are classified into anastomotic (AS) and nonanastomotic strictures (NAS). NAS are associated to the use of ABO-incompatible grafts, preservation injury, opportunistic infections, recurrent hepatitis, ductopenic rejection, recurrent primary sclerosing cholangitis (PSC), stones or casts, posttransplant lymphoproliferative disorder or other tumors [216].
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Long cold ischemia time, hepatic artery thrombosis (HAT), CMV infection, and chronic rejection constitute risk factors for biliary anastomotic complications (leaks and strictures). Also, tissue hypoxia at level of the anastomosis, secondary to hepatopulmonary syndrome, can increase the frequency of biliary complications after liver transplantation [217]. Multiple bile ducts, requiring reconstruction or more than one biliary anastomosis is an independent risk factor for the development of biliary complications with a higher incidence of biliary complications when compared with a single duct (21% versus 9%, respectively) [218].
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Treatment strategies are based on the type and severity of the complication and the biliary reconstruction technique applied, duct-to-duct anastomosis or hepaticojejunostomy. Nonoperative management is the first-line approach, and success can be achieved in 70‒90% of all BS cases [219–222]. A novel magnetic compression anastomosis has been recently described. Transmural compression with two magnets causes gradual ischemic necrosis, thus creating a new anastomosis between the dilated duct and small intestine or bile duct. This technique has been applied in only few cases, and further experience is necessary before it has broader indications [215,223,224].
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The majority of patients will experience at least one episode of acute rejection. However, usually it is treated increasing the steroid. Small bile ducts destruction shown on biopsy is typical finding of chronic rejection. This type of rejection is not reversible by increasing immunosuppression. Repeated biopsy with histological confirmation is necessary to establish this diagnosis. When chronic rejection occurs, the only treatment is retransplantation [5].
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Immunosuppressed patients have a higher risk for infection complications. Common bacterial infections, usually in the respiratory and biliary tracts, opportunistic infections are a potential problem. The commonest of these are cytomegalovirus and fungal infections. Donor and recipient CMV status matching of both graft and blood products can minimize CMV infections [5].
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When CMV-negative patient receives a CMV-positive graft, prophylactic treatment with acyclovir has been shown to be effective in minimizing the severity of any resulting CMV infection. Fungal infections are not rare after liver transplant, since the majority of children with chronic liver disease are heavily colonized with candida. Limited use of broad-spectrum antibiotics and oral antibiotic prophylaxis may reduce the incidence and severity of fungal sepsis. Pneumocystis infection is an additional risk in these patients. Any of these infections is associated with a high mortality. Prophylaxis with oral cotrimoxazole is nearly always effective for these risks [5].
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Another rare complication of LDLT in pediatrics is the graft rotation. Previous studies showed that the graft rotation can lead to venous outflow obstruction and suggested stabilization of the graft to avoid this complication [225,226]. Several surgical factors might have an important role in preventing vascular thrombosis, especially in the transplantation of live donor or split liver allografts. Adequate inflow in the donor vessels is also important to reduce vascular complications. The use of interposition grafts (arteries or veins) is stimulate in the case of small-caliber vessels or a fibrotic and small portal vein, common observed in children with biliary atresia [224].
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Oversized grafts are prone to compression after abdominal wall closure, which may compromise the flow in the afferent hepatic vessels increasing the risk for thrombosis. Delayed abdominal wall closure is recommended in these situations, avoiding tight wound closure, and consequently avoiding augmented intra-abdominal pressure. Administration of antiplatelet agents early in posttransplant, such as aspirin, has been advocated to prevent HAT [227,228].
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10. Conclusion
\n
In conclusion, LT in the pediatric setting is technically challenging due to the reduced size of the vasculature and biliary tree. Discrepancies in portal vein and hepatic arterial diameter between the donor and recipient are expected. Despite technical evolution of pediatric liver transplantation, vascular complications are still a significant cause of allograft loss, reflecting in increase of postoperative morbidity and mortality. Arterial complications are more common, occur early in the postoperative period, and are associated with high rates of graft loss and patient mortality. On the other hand, venous complications are less frequent usually occurring in the late postoperative period with no significant effect on graft loss or mortality rates. Important strategies for reduction of mortality, morbidity, and the need for retransplantation include detection and mitigation of risk factors, avoidance of technical complications, and protocols for prompt detection of vascular complications.
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\n\n',keywords:"organ transplant, liver transplant, pediatric liver disease",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/51467.pdf",chapterXML:"https://mts.intechopen.com/source/xml/51467.xml",downloadPdfUrl:"/chapter/pdf-download/51467",previewPdfUrl:"/chapter/pdf-preview/51467",totalDownloads:2176,totalViews:645,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:0,introChapter:null,impactScore:0,impactScorePercentile:6,impactScoreQuartile:1,hasAltmetrics:0,dateSubmitted:"October 21st 2015",dateReviewed:"April 5th 2016",datePrePublished:null,datePublished:"September 7th 2016",dateFinished:"June 29th 2016",readingETA:"0",abstract:"Liver transplantation (LT) has become standard management of pediatric liver diseases that lead to acute liver failure or can progress to end-stage liver disease (ESLD). Indications for LT in pediatric patients can be classified into cholestatic disorders, metabolic liver diseases causing liver cirrhosis, metabolic liver diseases without liver cirrhosis, acute liver failure, acute and chronic hepatitis, and liver tumors. The most common indication of PLT is biliary atresia. Generally, the patient is a child with biliary atresia with several prior surgical procedures, extremely malnourished, with stigmata of fat-soluble vitamin deficiency, bleeding diathesis, uncontrolled portal hypertension and massive ascites. Before the technique of liver splitting, pediatric patients were dependent on donors with similar age or size. Partial liver grafts can be obtained either by splitting a cadaveric donor organ or by living-donor liver donation. Living donor liver recipients have a shorter waiting time. The majority of centers employ a regime of' triple therapy with prednisolone, mycophenolate and tacrolimus. LT in the pediatric setting is technically challenging due to the reduced size of the vasculature and biliary tree. Strategies for identification and mitigation of risk factors, prevention of technical complications, and protocols for early detection of vascular complications may reduce mortality, morbidity.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/51467",risUrl:"/chapter/ris/51467",book:{id:"5155",slug:"frontiers-in-transplantology"},signatures:"Julio Cesar Wiederkehr, Barbara de Aguiar Wiederkehr and\nHenrique de Aguiar Wiederkehr",authors:[{id:"179953",title:"Prof.",name:"Julio",middleName:"Cesar",surname:"Wiederkehr",fullName:"Julio Wiederkehr",slug:"julio-wiederkehr",email:"julio.wieder@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Federal University of Paraná",institutionURL:null,country:{name:"Brazil"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Indications",level:"1"},{id:"sec_2_2",title:"2.1. Biliary atresia",level:"2"},{id:"sec_3_2",title:"2.2. Inherited metabolic liver disease",level:"2"},{id:"sec_3_3",title:"2.2.1. Acute liver failure in inherited metabolic liver disease patients",level:"3"},{id:"sec_4_3",title:"2.2.2. Alpha 1 antitrypsin deficiency",level:"3"},{id:"sec_5_3",title:"2.2.3. Alagille’s syndrome",level:"3"},{id:"sec_6_3",title:"2.2.4. Tyrosinemia type I",level:"3"},{id:"sec_7_3",title:"2.2.5. Cystic fibrosis",level:"3"},{id:"sec_8_3",title:"2.2.6. Wilson’s disease",level:"3"},{id:"sec_9_3",title:"2.2.7. Other inborn errors of metabolism",level:"3"},{id:"sec_11_2",title:"2.3. Liver tumors",level:"2"},{id:"sec_11_3",title:"2.3.1. Hepatoblastoma",level:"3"},{id:"sec_12_3",title:"2.3.2. Hepatocellular carcinoma",level:"3"},{id:"sec_14_2",title:"2.4. Acute Liver Failure",level:"2"},{id:"sec_16",title:"3. Contraindications for transplantation",level:"1"},{id:"sec_17",title:"4. Preoperative management",level:"1"},{id:"sec_17_2",title:"4.1. Psychological preparation",level:"2"},{id:"sec_18_2",title:"4.2. Psychosocial evaluation of live organ donors",level:"2"},{id:"sec_20",title:"5. Surgical techniques",level:"1"},{id:"sec_20_2",title:"5.1. Auxiliary transplantation",level:"2"},{id:"sec_21_2",title:"5.2. Living-donor liver donation",level:"2"},{id:"sec_22_2",title:"5.3. Living related donor liver transplantation in children",level:"2"},{id:"sec_22_3",title:"5.3.1. Surgical technique",level:"3"},{id:"sec_25",title:"6. Post-transplant care",level:"1"},{id:"sec_26",title:"7. Immunossupression",level:"1"},{id:"sec_27",title:"8. Adherence",level:"1"},{id:"sec_28",title:"9. Complication",level:"1"},{id:"sec_28_2",title:"9.1. Biliary complications",level:"2"},{id:"sec_30",title:"10. Conclusion",level:"1"}],chapterReferences:[{id:"B1",body:'Hackl C. Current developments in pediatric liver transplantation. World J Hepatol. 2015;7(11):1509.'},{id:"B2",body:'Otte JB. 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Current state of the art in management of vascular complications after pediatric liver transplantation. Pediatr Transplant. 2015;19(1):18–26. http://doi.org/10.1111/petr.12407.'},{id:"B215",body:'Feier FH, da Fonseca EA, Seda-Neto J, Chapchap P. Biliary complications after pediatric liver transplantation: risk factors, diagnosis and management. World J Hepatol. 2015;7(18):2162–2170. http://doi.org/10.4254/wjh.v7.i18.2162.'},{id:"B216",body:'Ostroff JW. Management of biliary complications in the liver transplant patient. Gastroenterol Hepatol (N Y). 2010;6:264‒272 [PMID: 20567581].'},{id:"B217",body:'Gupta S, Castel H, Rao RV, Picard M, Lilly L, Faughnan ME, Pomier-Layrargues G. Improved survival after liver transplantation in patients with hepatopulmonary syndrome. Am J Transplant. 2010;10:354‒363 [PMID: 19775311, doi:10.1111/j.1600-6143.2 009.02822.x].'},{id:"B218",body:'Salvalaggio PR, Whitington PF, Alonso EM, Superina RA. Presence of multiple bile ducts in the liver graft increases the incidence of biliary complications in pediatric liver transplantation. Liver Transplant. 2005;11:161‒166 [PMID: 15666393, doi:10.1002/ lt.20288].'},{id:"B219",body:'Kling K, Lau H, Colombani P. Biliary complications of living related pediatric liver transplant patients. Pediatr Transplant. 2004;8:178‒184 [PMID: 15049799, doi:10.1046/j.1399-3046.2003.001 27.x].'},{id:"B220",body:'Feier FH, Chapchap P, Pugliese R, da Fonseca EA, Carnevale FC, Moreira AM, Zurstrassen C, Santos AC, Miura IK, Baggio V, Porta A, Guimarães T, Cândido H, Benavides M, Godoy A, Leite KM, Porta G, Kondo M, Seda-Neto J. Diagnosis and management of biliary complications in pediatric living donor liver transplant recipients. Liver Transplant. 2014;20:882‒892 [PMID: 24760734, doi:10.1002/lt.23896].'},{id:"B221",body:'Anderson CD, Turmelle YP, Darcy M, Shepherd RW, Weymann A, Nadler M, Guelker S, Chapman WC, Lowell JA. Biliary strictures in pediatric liver transplant recipients—early diagnosis and treatment results in excellent graft outcomes. Pediatr Transplant. 2010;14:358‒363 [PMID: 20003138, doi:10.1111/j.1399-3046.2 009.01246.x].'},{id:"B222",body:'Miraglia R, Maruzzelli L, Caruso S, Riva S, Spada M, Luca A, Gridelli B. Percutaneous management of biliary strictures after pediatric liver transplantation. Cardiovasc Intervent Radiol. 2008;31:993‒998 [PMID: 18574628, doi:10.1007/s00270-008-9378-5].'},{id:"B223",body:'Marubashi S, Nagano H, Yamanouchi E, Kobayashi S, Eguchi H, Takeda Y, Tanemura M, Maeda N, Tomoda K, Hikita H, Tsutsui S, Doki Y, Mori M. Salvage cystic duct anastomosis using a magnetic compression technique for incomplete bile duct reconstruction in living donor liver transplantation. Liver Transplant. 2010;16:33‒37 [PMID: 20035518, doi:10.1002/lt.21934].'},{id:"B224",body:'Muraoka N, Uematsu H, Yamanouchi E, Kinoshita K, Takeda T, Ihara N, Matsunami H, Itoh H. Yamanouchi magnetic compression anastomosis for bilioenteric anastomotic stricture after living-donor liver transplantation. J Vasc Interv Radiol. 2005;16:1263‒1267 [PMID: 16151070, doi:10.1097/01.RVI.0000173280.56442.9E].'},{id:"B225",body:'Wakiya T, Sanada Y, Mizuta K, et al. A comparison of open surgery and endovascular intervention for hepatic artery complications after pediatric liver transplantation. Transplant Proc. 2013 45:323–329.'},{id:"B226",body:'Funaki B, Rosenblum J D, Leef J A, et al. Percutaneous treatment of portal venous stenosis in children and adolescents with segmental hepatic transplants: long-term results. Radiology. 2000;215:147–151.'},{id:"B227",body:'Hashikura Y, Kawasaki S, Okumura N, et al. Prevention of hepatic artery thrombosis in pediatric liver transplantation. Transplantation. 1995:10:1109–1112.'},{id:"B228",body:'Shay R, Taber D, Pilch N, et al. Early aspirin therapy may reduce hepatic artery thrombosis in liver transplantation. Transplant Proc. 2013;45:330–334.'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Julio Cesar Wiederkehr",address:"julio.wieder@gmail.com",affiliation:'
Professor of Surgery, Federal University of Parana, Chief, Division of Liver Transplantation Hospital Pequeno Principe, Curitiba, Brazil
Resident in Gastrointestinal Surgery, Evangelic University Hospital of Curitiba, Curitiba, Brazil
'},{corresp:null,contributorFullName:"Barbara de Aguiar Wiederkehr",address:null,affiliation:'
Resident in Gastrointestinal Surgery, Evangelic University Hospital of Curitiba, Curitiba, Brazil
Resident in Gastrointestinal Surgery, Evangelic University Hospital of Curitiba, Curitiba, Brazil
'},{corresp:null,contributorFullName:"Henrique de Aguiar Wiederkehr",address:null,affiliation:'
Resident in Gastrointestinal Surgery, Evangelic University Hospital of Curitiba, Curitiba, Brazil
Resident in General Surgery Evangelic University Hospital of Curitiba, Curitiba, Brazil
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\n\t\t\t
1. Introduction
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Various home robots like sweeping robots and pet robots have been developed, commercialized and now are studied for use in cooperative housework (Kobayashi & Yamada, 2005). In the near future, cooperative work of a human and a robot will be one of the most promising applications of Human-Robot Interaction research in factory, office and home. Thus interaction design between ordinary people and a robot must be very significant as well as building an intelligent robot itself. In such cooperative housework, a robot often needs users’ help when they encounter difficulties that they cannot overcome by themselves. We can easily imagine many situations like that. For example, a sweeping robot can not move heavy and complexly structured obstacles, such as chairs and tables, which prevent it from doing its job and needs users’ help to remove them (Figure 1). A problem is how to enable a robot to inform its help requests to a user in cooperative work. Although we recognize that this is a quite important and practical issue for realizing cooperative work of a human user and a robot, a few studies have been done thus far in Human-Robot Interaction. In this chapter, we propose a novel method to make a mobile robot to express its internal state (called robot’s mind) to request users’ help, implement a concrete expression
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Figure 1.
A robot which needs user’s help.
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on a real mobile robot and conduct experiments with participants to evaluate the effectiveness.
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In traditional user interface design, some studies have proposed design for electric home appliances. Norman (Norman, 1988) addressed the use of affordance (Gibson, 1979) in artifact design. Also Suchman (Suchman, 1987) studied behavior patterns of users. Users\' reaction to computers (Reeves & Nass, 1996) (Katagiri & Takeuchi, 2000) is important to consider as designing artifacts. Yamauchi et al. studied function imagery of auditory signals (Yamaguchi & Iwamiya, 2005), and JIS (Japanese Industrial Standards) provides guidelines for auditory signals in consumer products for elderly people (JIS, 2002). These studies and guidelines deal with interfaces for artifacts that users operate directly themselves. These methods and guidelines assume use of an artifact directly through user control: an approach that may not necessarily work well for home robots that conduct tasks directly themselves. Robot-oriented design approaches are thus needed for home robots.
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As mentioned earlier, our proposal for making a mobile robot to express its mind assumes cooperative work in which the robot needs to notify a user how to operate it and move objects blocking its operation: a trinomial relationship among the user, robot, and object. In a psychology field, the theory of mind (TOM) (Baron-Cohen, 1995) deals with such trinomial relationships. Following TOM, we term a robot\'s internal state mind, defined as its own motives, intents, or purposes and goals of behavior. We take weak AI (Searle, 1980) position: a robot can be made to act as if they had a mind.
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Mental expression is designed verbally or nonverbally. If we use verbal expression, for example, we can make a robot to say “Please help me by moving this obstacle.” In many similar situations in which an obstacle prevents a robot from moving, the robot may simply repeat the same speech because it cannot recognize what the obstacle is. A robot neither say “Please remove this chair” nor “Please remove this dust box”. Speech conveys a unique meaning, and such repetition irritates users. Hence we study nonverbal methods such as buzzers, blinking lights, and movement, which convey ambiguous information that users can interpret as they like based on the given situation.
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We consider that the motion-based approach feasibly and effectively conveys the robot\'s mind in an obstacle-removal task. Movement is designed based on motion overlap (MO) that enable a robot to move in a way that the user narrows down possible responses and acts appropriately. In an obstacle-removal task, we had the robot move back and forth in front of an obstacle, and conducted experiments compared MO to other nonverbal approaches. Experimental results showed that MO has potential in the design of robots for the home.
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We assume that a mobile robot has a cylindrical body and expresses its mind through movement. This has advantages for developers in that a robot needs no component such as a display or a speech synthesizer, but it is difficult for the robot to express its mind in a humanly understandable manner. Below, we give an overview of studies on how a robot can express its mind nonverbally with human-like and nonhuman-like bodies.
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Hadaly-2 (Hashimoto et al., 2002), Nakata\'s dancing robot (Nakata et al., 2002), Kobayashi\'s face robot (Kobayashi et al., 2003), Breazeal\'s Kismet (Breazeal, 2002), Kozima\'s Infanoid (Kozima & Yano, 2001), Robovie-III (Miyashita & Ishiguro, 2003), and Cog (Brooks et al., 1999) utilized human-like robots that easily express themselves nonverbally in a human understandable manner. The robot we are interested in, however, is nonhuman-like in shape, only having wheels for moving. We designed wheel movement to enable the robot to express its mind.
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Ono et al. (Ono et al., 2000) studied how a mobile robot\'s familiarity influenced a user\'s understanding of what was on its mind. Before their experiments, participants were asked to grow a life-like virtual agent on a PC, and the agent was moved to the robot\'s display after the keeping. This keeping makes the robot quite familiar to a user, and they experimentally show that the familiarity made a user’s accuracy of recognising robot’s noisy utterance quite better. Matsumaru et al. (Matsumaru et al., 2005) developed a mobile robot that expresses its direction of movement with a laser pointer or animated eye. Komatsu (Komatsu, 2005) reported that users could infer the attitude of a machine through its beeps. Those require extra components in contrast with our proposal. The orca-like robot (Nakata et al., 1998), seal-like Paro (Wada et al., 2004)(Shibata et al., 2004), and limbless Muu (Okada et al., 2000) are efforts of familiarizing users with robots. Our study differs from these, however, in that we assume actual cooperative work between the user and robot, such as cooperative sweeping.
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\n\t\t
\n\t\t\t
2. Expression of robot mind
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The obstacle-removal task in which we have the robot express itself in front of an obstacle and how the robot conveys what is on its mind are explained below.
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2.1. Obstacle-removal task
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The situation involves a sweeping robot can not remove an obstacle, such as a chair and a dust box, that asks a user to remove it so that it can sweep the floor area where the obstacle occupied (Figure 1). Such an obstacle-removal task serves as a general testbed for our work because it occurs frequently in cooperative tasks between a user and a robot. To execute this task, the robot needs to inform its problem to the user and ask for help. This task has been used in research on cooperative sweeping (Kobayashi & Yamada, 2005).
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Obstacle-removal tasks generally accompany other robot tasks. Obstacle avoidance is essential to mobile robots such as tour guides (Burgard et al., 1998). Obstacles may be avoided by having the robot (1) avoid an obstacle autonomously, (2) remove the obstacle autonomously, or (3) get user to remove the obstacle. It is difficult for a robot to remove an obstacle autonomously because it first must decide whether it may touch the object. In practical situations, the robot avoids an obstacle either by autonomous avoidance or having a user remove it.
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2.2. Motion overlap
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Our design, motion overlap, starts when movement routinely done by a user is programmed into a robot. A user observing the robot\'s movement will find an analogy to human action and easily interprets the state of mind. We consider the overlap between human and robot’s movement causes an overlap between the minds of the user and the robot (Figure 2).
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A human is neither a natural light emitter nor expresses his/her intention easily using nonverbal sounds. They do, however, move expressively when executing tasks. We therefore presume that a user can understand a robot\'s mind as naturally as another person\'s mind if robot movement overlaps recognizable human movement. This human understanding has been studied and reported in TOM.
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As described before, nonverbal communication has alternative modalities: a robot can make a struggling movement, sound a buzzer, or blink a light. We assume movement to be better for an obstacle-removal task for the following reasons.
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Figure 2.
Motion overlap.
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\n\t\t\t\t\t\t\tFeasibility: Since a robot needs to move for achieving tasks, so a motion-based approach requires no additional component such as a LED or a speaker. The additional nonverbal components make a robot quite more complicated and expensive.
\n\t\t\t\t\t\t\tVariation: The motion-based approach enables us to design informational movement to suit different tasks. The variety of movements is far larger than that of sounds or light signals of other nonverbal methods.
\n\t\t\t\t\t\t\tLess stress: Other nonverbal methods, particularly sound, may force a user to strong attention at a robot, causing more stress than movement. The motion-based approach avoids distracting or invasive interruption of a user who notices the movement and chooses whether or not to respond.
\n\t\t\t\t\t\t\tEffectiveness: Motion-based information is intuitively more effective than other nonverbal approaches because interesting movement attracts a user to a robot without stress.
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While feasibility, variety, and stress minimization of motion-based information are obviously valid, we need to verify effectiveness needs to be verified experimentally.
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2.3. Implementing MO on a mobile robot
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We designed robot\'s movements which a user can easily understand by imagining what a human may do when he/she faces with an obstacle-removal task. Imagine that you see a person who has baggage and hesitates nervously in front of a closed door. Almost all the human observers would immediately identify the problem that the person needs help to open the door. This is a typical situation in TOM. Using similar hesitation movement could enable a robot to inform a user that it needs help.
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A study on human actions in doing tasks (Suzuki & Sakai, 2001) defines hesitation as movement that suddenly stops and either changes into other movement or is suspended: a definition that our back and forth movement fits (Figure 3). Seeing a robot moves back and forward in a short time in front of an obstacle should be easy for a user because a human acts similarly when they are in the same trouble.
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Figure 3.
Back and forth motion.
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We could have tested other movement such as turning to the left and right, however back and forth movement keeps the robot from swerving from its trajectory to achieve a task. It is also easily applicable to other hardware such as manipulators. Back and forth movement is thus appropriate for an obstacle-removal task in efficiency of movement and range of application.
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3. Experiments
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We conducted experiments to verify the effectiveness of our motion-based approach in an obstacle-removal task, comparing the motion-based approach to two other nonverbal approaches.
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3.1. Environments and a robot
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\n\t\t\t\t\tFigure 4 shows the flat experimental environment (400mm X 300mm) surrounded by a wall and containing two obstacles (white paper cups). It simulated an ordinary human work space such as a desktop. Obstacles corresponded to penholders, remote controllers, etc., and are easily moved by participants. We used a small mobile robot, KheperaII (Figure 5), which has eight infrared proximity and ambient light sensors with up to a 100mm range, a Motorola 68331 (25 MHz) processor, 512K bytes of RAM, 512K bytes of flash ROM, and two DC brushed servomotors with incremental encoders. Its C program runs on RAM.
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3.2. Robot’s expressions
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Participants observed the robot as it swept the floor in the experimental environment. The robot used ambiguous nonverbal expressions enabling participants to interpret them based on the situation. We designed three types of signals to inform the robot\'s mind to sweep the area under an obstacle or the wish for wanting user’s help to remove the obstacle. It expressed by itself using one of the three following types of signals:
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Figure 4.
An experimental environment.
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Figure 5.
KheperaII.
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\n\t\t\t\t\t\t\tLED: The robot\'s red LED (6 mm in diameter) blinks based on ISO 4982:1981 (automobile flasher pattern). The robot turns the light on and off based on the signal pattern in Fig. 6, repeating the pattern twice every 0.4 second.
\n\t\t\t\t\t\t\tBuzzer: The robot beeps using a buzzer that made a sound with 3 kHz and 6 kHz peaks. The sound pattern was based on JIS:S0013 (auditory signals of consumer products intended for attracting immediate attention). As with the LED, the robot beeps at “on” and ceases at “off” (Fig. 6).
\n\t\t\t\t\t\t\tBack and forth motion: The robot moves back and forward, 10 mm back and 10 mm forth based on “on” and “off” (Fig. 6).
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Figure 6.
Pattern of Behavior.
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The LED, buzzer, and movement used the same “on” and “off” intervals. The robot stopped sweeping and performed each when it encountered an obstacle or wall, then turned left or right and moved ahead. If the robot senses an obstacle on its right (left), it makes a 120 degree turn to the left (right), repeating these actions during experiments. Note that the robot did not actually sweep up dust.
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3.3. Methods
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Participants were instructed that the robot represented a sweeping robot, even though it actually did not sweep. They were to imagine that the robot was cleaning the floor. They could move or touch anything in the environment, and were told to help the robot if it needed it.
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Each participant conducted three trials and observed the robot moved back and forth, blinked its lights, or sounded its buzzer. The order of expressions provided to participants was random. A trial finished after the robot\'s third encounter with obstacles, or when the participant removed an obstacle. The participants were informed no information and interpretation about the robot\'s movement, blinking, or sounding.
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\n\t\t\t\t\tFigure 7 details experimental settings that include the robot\'s initial locations and those of objects. At the start of each experiment, the robot moved ahead, stopped in front of a wall, expressed its mind, and turned right toward obstacle A. Figure 8 shows a series of snapshots in which a participant had interaction with a mobile robot doing back and forth. The participant sat on the chair and helped the robot on the desk.
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The participants numbered 17: 11 men and six women aged 21-44 including 10 university students and seven employees. We confirmed that they had no experience in interacting with robots before.
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Figure 7.
Derailed experimental setup.
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Figure 8.
MO experiments.
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3.4. Evaluation
\n\t\t\t\t
We used the criterion that fewer expressions were better because this would help participants understand easily what was on the robot\'s mind. The robot expressed itself whenever it encountered a wall or an obstacle. We counted the number of participants who moved the object just after the robot\'s first encounter with the object. We considered using other measurement such as the period from the beginning of the experiment to when the participant moved an obstacle, however this was difficult because the time at which the robot reached the first obstacle was different in each trial. Slippage of the robot\'s wheels changed its trajectory.
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3.5. Results
\n\t\t\t\t
\n\t\t\t\t\tTable 1 shows participants and behavior in the experiments. The terms with asterisks are trials in which a participant removed an obstacle. Eight of 17 participants (47%) did not move any obstacle in any experimental condition. Table 2 shows ratios of participants moving the obstacle under each condition. The ratios increased with the number of trial. This appeared more clearly under the MO condition.
\n\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
ID
\n\t\t\t\t\t\t\t
Age
\n\t\t\t\t\t\t\t
Gender
\n\t\t\t\t\t\t\t
Trial-1
\n\t\t\t\t\t\t\t
Trial-2
\n\t\t\t\t\t\t\t
Trial-3
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
1
\n\t\t\t\t\t\t\t
25
\n\t\t\t\t\t\t\t
M
\n\t\t\t\t\t\t\t
LED*
\n\t\t\t\t\t\t\t
Buzzer*
\n\t\t\t\t\t\t\t
MO*
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
2
\n\t\t\t\t\t\t\t
30
\n\t\t\t\t\t\t\t
M
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t\t
MO
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
3
\n\t\t\t\t\t\t\t
24
\n\t\t\t\t\t\t\t
M
\n\t\t\t\t\t\t\t
MO
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
4
\n\t\t\t\t\t\t\t
25
\n\t\t\t\t\t\t\t
M
\n\t\t\t\t\t\t\t
LED*
\n\t\t\t\t\t\t\t
MO*
\n\t\t\t\t\t\t\t
Buzzer*
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
5
\n\t\t\t\t\t\t\t
23
\n\t\t\t\t\t\t\t
M
\n\t\t\t\t\t\t\t
Buzzer*
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t\t
MO*
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
6
\n\t\t\t\t\t\t\t
43
\n\t\t\t\t\t\t\t
F
\n\t\t\t\t\t\t\t
MO
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
7
\n\t\t\t\t\t\t\t
27
\n\t\t\t\t\t\t\t
M
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t\t
MO*
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\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
8
\n\t\t\t\t\t\t\t
29
\n\t\t\t\t\t\t\t
F
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t\t
MO*
\n\t\t\t\t\t\t\t
Buzzer*
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
9
\n\t\t\t\t\t\t\t
44
\n\t\t\t\t\t\t\t
F
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t\t
MO*
\n\t\t\t\t\t\t\t
LED*
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
10
\n\t\t\t\t\t\t\t
26
\n\t\t\t\t\t\t\t
F
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t\t
MO*
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
11
\n\t\t\t\t\t\t\t
29
\n\t\t\t\t\t\t\t
F
\n\t\t\t\t\t\t\t
MO
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
12
\n\t\t\t\t\t\t\t
27
\n\t\t\t\t\t\t\t
M
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t\t
MO*
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
13
\n\t\t\t\t\t\t\t
36
\n\t\t\t\t\t\t\t
M
\n\t\t\t\t\t\t\t
MO
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
14
\n\t\t\t\t\t\t\t
27
\n\t\t\t\t\t\t\t
M
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t\t
MO
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
15
\n\t\t\t\t\t\t\t
26
\n\t\t\t\t\t\t\t
M
\n\t\t\t\t\t\t\t
Buzzer*
\n\t\t\t\t\t\t\t
MO*
\n\t\t\t\t\t\t\t
LED*
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
16
\n\t\t\t\t\t\t\t
26
\n\t\t\t\t\t\t\t
M
\n\t\t\t\t\t\t\t
MO
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t
17
\n\t\t\t\t\t\t\t
21
\n\t\t\t\t\t\t\t
F
\n\t\t\t\t\t\t\t
LED
\n\t\t\t\t\t\t\t
Buzzer
\n\t\t\t\t\t\t\t
MO
\n\t\t\t\t\t\t
\n\t\t\t\t\t
Table 1.
Participant behaviors.
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Table 2.
Expressions and trials.
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\n\t\t\t\t\tFigure 9 shows ratios of participants who moved the obstacle immediately after the robot\'s first encounter with it. More participants responded to MO than to either the buzzer or light. We
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Figure 9.
Ratios of participants who moved an object.
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statistically analyzed the differences in ratios among the three methods. The result of the statistical test (Cochran\'s Q test) showed significant differences among methods (Q = 7.0, df = 2.0, p<.05). We conducted a multiple comparison test, Holm\'s test, and obtained 10% level differences between MO-LED (Q = 5.0, df = 1.0, p = 0.0253, \' = 0.0345, \' is the modified significant level by Holm\'s test) and MO-buzzer (Q = 4.0, df = 1.0, p = 0.0455, \' = 0.0513), indicating that MO is as effective or more effective than the other two methods.
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In the questionnaire on experiments (Table 3), most participants said they noticed the robot\'s action. Table 4 shows results of the questionnaire. We asked participants why they moved the object. The purpose of our design policy corresponds to question (1). More people responded positively to question (1) for the cases of the buzzer and MO. MO achieved our objective because it caused the most participants to move the object.
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4. Discussion
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We discuss the effectiveness and application of MO based on experimental results.
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4.1. Effectiveness of MO
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We avoided using loud sounds or bright lights because they are not appropriate for a home robot. We confirmed that participants correctly noticed the robot\'s expression. Results of the questionnaires in Table 3 show that the expressions we designed were appropriate for experiments.
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Table 3.
The number of participants who noticed the robot’s expression.
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MO is not effective in any situation because Table 2 suggests the existence of a combination effect. Although the participants experienced MO in previous experiments, only 40% of them moved the obstacle in the LED-Trial3 and Buzzer-Trial3 conditions. In the MO-Trial1 condition, no participants moved the obstacle. Further study of the combination effect is thus important.
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We used specific lighting and sound patterns for expressing the robot\'s mind, however the effects of other patterns are not known. For example, a different frequency, complex sound pattern may help a user to understand the robot\'s mind more easily. The expressive patterns we investigated through these experiments were just a small part of huge candidates. A more organized investigation on light and sound is thus necessary to find the optimal pattern. Our results show that conventional methods are not sufficient and that MO shows promise.
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Questionnaire results (Table 4) show that many participants felt that the robot “wanted” them to move the obstacle or moved it depending on the situation. The “wanted” response reflects anthropomorphization of the robot. The “depending on the situation” response may indicate that they identified with the robot\'s problem. As Reeves & Nass (Reeves & Nass, 1996) and Katagiri & Takeuchi (Katagiri & Takeuchi, 2000) have noted participants exhibiting interpersonal action with a robot would not report the appropriate reason, so questionnaire results are not conclusive. However MO may encourage users to anthropomorphize robots.
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Table 4.
Results of the questionnaire.
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\n\t\t\t\t\tTable 4 compares MO and the buzzer, which received different numbers of responses. Although fewer participants moved the obstacle after the buzzer than after MO, the buzzer had more responses in the questionnaires. The buzzer might offer highly ambiguous information in the experiments. The relationship between the degrees of ambiguity and expression is an important issue in designing robot behavior.
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4.2. Coverage of MO
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Results for MO were more promising results than for other nonverbal methods, however are these results general? Results directly support the generality of obstacle-removal tasks. We consider that an obstacle-removal task is a common subtask in human-robot cooperation. For other tasks without obstacle-removal, we may need to design another type of MO-based informative movement. The applicable scope for MO is thus an issue for future study.
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Morris\'s study of human behavior suggests the applicability of MO (Morris, 1977). Morris states that human beings sometimes move preliminarily before taking action, and these preliminary movements indicate what they will do. A person gripping the arms of a chair during a conversation may be trying to end the conversation but does not wish to be rude in doing so. Such behavior is called an intention movement and two movements with their own rhythm, such as left-and-right rhythmic movements on a pivot chair, are called alternating intention movement. Human beings easily grasp each other\'s intent in daily life. We can consider the back and forth movement to be a form of alternating intention movement meaning that the robot wants to move forward but cannot do so. Participants in our experiments may have interpreted the robot\'s mind by implicitly considering its movements as alternating intention movement. Although the LED and buzzer rhythmically expressed itself, they may have been less effective than MO. Participants may not have considered them as intention movement because they were not preliminary movement --- sounding and blinking were not related to previous movement, moving forward.
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If alternating intention movement works well in enabling a robot to inform a user about its mind, the robot will be able to express itself with other simple rhythmic movements, e.g., the simple left and right movements to encourage the user to help it when it loses the way. Rhythmic movement is hardware-independent and easily implemented. We believe that alternating intention movement is an important element in MO applications, and we plan to study this and evaluate its effectiveness. A general implementation for expressing robot\'s mind can be established through such investigations. The combination of nonverbal and verbal information is important for robot expression, and we plan to study ways to combine different expression to speed up interaction between users and robots.
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4.3. Designing manual-free machines
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A user needs to read the manuals of their machines or want to use them more conveniently. However, reading manuals imposes workload on the user. It would be better for a user to discover a robot\'s functions naturally, without reading a manual. The results of our experiments show that motion-based expression enables a user to understand the robot’s mind easily. We thus consider motion-based expression to be useful for making manual-free machines, and we currently devising a procedure for users to discover robot\'s functions naturally.
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The procedure is composed of three steps: (1) expression of the robot\'s mind, (2) responsive action of its user, and (3) reaction of the robot. The robot\'s functions are “discovered\'\' when the user causality links his/her actions with the robot\'s actions. Our experiments show that the motion-based approach satisfies step (1) and (2) and helps humans to discover such causality relations.
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5. Conclusion
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We have proposed a motion-based approach for nonverbally informing a user of a robot\'s state of mind. Possible nonverbal approaches include movement, sound, and lights. The design we proposed, called motion overlap, enabled a robot to express human-like behavior in communicating with users.
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We devised a general obstacle-removal task based on motion overlap for cooperation between a user and a robot, having the robot move back and forth to show the user that it wants an obstacle to be removed.
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We conducted experiments to verify the effectiveness of motion overlap in the obstacleremoval task, comparing motion overlap to sound and lights. Experimental results showed that motion overlap encouraged most users to help the robot.
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The motion-based approach will effectively express robot\'s mind in an obstacle-removal task and contribute to design of home robots. Our next step in this motion overlap is to combine different expressions to speed up interaction between users and robots, and to investigate other intentional movement as extension of motion overlap.
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\n\t\n',keywords:null,chapterPDFUrl:"https://cdn.intechopen.com/pdfs/6444.pdf",chapterXML:"https://mts.intechopen.com/source/xml/6444.xml",downloadPdfUrl:"/chapter/pdf-download/6444",previewPdfUrl:"/chapter/pdf-preview/6444",totalDownloads:1845,totalViews:133,totalCrossrefCites:0,dateSubmitted:null,dateReviewed:null,datePrePublished:null,datePublished:"December 1st 2009",dateFinished:null,readingETA:"0",abstract:null,reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/6444",risUrl:"/chapter/ris/6444",signatures:"Kazuki Kobayashi and Seiji Yamada",book:{id:"3376",type:"book",title:"Advances in Human-Robot Interaction",subtitle:null,fullTitle:"Advances in Human-Robot Interaction",slug:"advances-in-human-robot-interaction",publishedDate:"December 1st 2009",bookSignature:"Vladimir A. Kulyukin",coverURL:"https://cdn.intechopen.com/books/images_new/3376.jpg",licenceType:"CC BY-NC-SA 3.0",editedByType:"Edited by",isbn:null,printIsbn:"978-953-307-020-9",pdfIsbn:"978-953-51-5844-8",isAvailableForWebshopOrdering:!0,editors:[{id:"134137",title:"Prof.",name:"Vladimir",middleName:null,surname:"Kulyukin",slug:"vladimir-kulyukin",fullName:"Vladimir Kulyukin"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Expression of robot mind",level:"1"},{id:"sec_2_2",title:"2.1. Obstacle-removal task",level:"2"},{id:"sec_3_2",title:"2.2. Motion overlap",level:"2"},{id:"sec_4_2",title:"2.3. Implementing MO on a mobile robot",level:"2"},{id:"sec_6",title:"3. Experiments",level:"1"},{id:"sec_6_2",title:"3.1. Environments and a robot",level:"2"},{id:"sec_7_2",title:"3.2. Robot’s expressions",level:"2"},{id:"sec_8_2",title:"3.3. Methods",level:"2"},{id:"sec_9_2",title:"3.4. Evaluation",level:"2"},{id:"sec_10_2",title:"3.5. Results",level:"2"},{id:"sec_12",title:"4. Discussion",level:"1"},{id:"sec_12_2",title:"4.1. Effectiveness of MO",level:"2"},{id:"sec_13_2",title:"4.2. Coverage of MO",level:"2"},{id:"sec_14_2",title:"4.3. Designing manual-free machines",level:"2"},{id:"sec_16",title:"5. 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'}],corrections:null},book:{id:"3376",type:"book",title:"Advances in Human-Robot Interaction",subtitle:null,fullTitle:"Advances in Human-Robot Interaction",slug:"advances-in-human-robot-interaction",publishedDate:"December 1st 2009",bookSignature:"Vladimir A. Kulyukin",coverURL:"https://cdn.intechopen.com/books/images_new/3376.jpg",licenceType:"CC BY-NC-SA 3.0",editedByType:"Edited by",isbn:null,printIsbn:"978-953-307-020-9",pdfIsbn:"978-953-51-5844-8",isAvailableForWebshopOrdering:!0,editors:[{id:"134137",title:"Prof.",name:"Vladimir",middleName:null,surname:"Kulyukin",slug:"vladimir-kulyukin",fullName:"Vladimir Kulyukin"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},profile:{item:{id:"303832",title:"MSc.",name:"Nefeli",middleName:null,surname:"Lamprinou",email:"lamprinou@ceid.upatras.gr",fullName:"Nefeli Lamprinou",slug:"nefeli-lamprinou",position:null,biography:null,institutionString:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",totalCites:0,totalChapterViews:"0",outsideEditionCount:0,totalAuthoredChapters:"1",totalEditedBooks:"0",personalWebsiteURL:null,twitterURL:null,linkedinURL:null,institution:null},booksEdited:[],chaptersAuthored:[{id:"69335",title:"From Pillars to AI Technology-Based Forest Fire Protection Systems",slug:"from-pillars-to-ai-technology-based-forest-fire-protection-systems",abstract:"The importance of forest environment in the perspective of the biodiversity as well as from the economic resources which forests enclose, is more than evident. Any threat posed to this critical component of the environment should be identified and attacked through the use of the most efficient available technological means. Early warning and immediate response to a fire event are critical in avoiding great environmental damages. Fire risk assessment, reliable detection and localization of fire as well as motion planning, constitute the most vital ingredients of a fire protection system. In this chapter, we review the evolution of the forest fire protection systems and emphasize on open issues and the improvements that can be achieved using artificial intelligence technology. We start our tour from the pillars which were for a long time period, the only possible method to oversee the forest fires. Then, we will proceed to the exploration of early AI systems and will end-up with nowadays systems that might receive multimodal data from satellites, optical and thermal sensors, smart phones and UAVs and use techniques that cover the spectrum from early signal processing algorithms to latest deep learning-based ones to achieving the ultimate goal.",signatures:"Nikos Aspragathos, Eleftherios Dogkas, Pavlos Konstantinidis, Panagiotis Koutmos, Nefeli Lamprinou, Vassilis C. Moulianitis, Georgios Paterakis, Emmanouil Ζ. Psarakis, Evangelos Sartinas, Konstantinos Souflas, Georgios Thanellas, Georgios Tsiourlis, Nikitas Xanthopoulos and Panteleimon Xofis",authors:[{id:"93308",title:"Dr.",name:"Nikos",surname:"Aspragathos",fullName:"Nikos Aspragathos",slug:"nikos-aspragathos",email:"asprag@mech.upatras.gr"},{id:"290554",title:"Prof.",name:"Emmanouil",surname:"Psarakis",fullName:"Emmanouil Psarakis",slug:"emmanouil-psarakis",email:"psarakis@ceid.upatras.gr"},{id:"291501",title:"Prof.",name:"Panagiotis",surname:"Koutmos",fullName:"Panagiotis Koutmos",slug:"panagiotis-koutmos",email:"koutmos@mech.upatras.gr"},{id:"291502",title:"Prof.",name:"Vasileios",surname:"Moulianitis",fullName:"Vasileios Moulianitis",slug:"vasileios-moulianitis",email:"moulian@mech.upatras.gr"},{id:"291503",title:"Dr.",name:"Georgios",surname:"Tsiourlis",fullName:"Georgios Tsiourlis",slug:"georgios-tsiourlis",email:"gmtsiou@fri.gr"},{id:"303830",title:"MSc.",name:"Eleftherios",surname:"Dogkas",fullName:"Eleftherios Dogkas",slug:"eleftherios-dogkas",email:"lefterisdogas@gmail.com"},{id:"303831",title:"Dr.",name:"Pavlos",surname:"Konstantinidis",fullName:"Pavlos Konstantinidis",slug:"pavlos-konstantinidis",email:"pavkon@fri.gr"},{id:"303832",title:"MSc.",name:"Nefeli",surname:"Lamprinou",fullName:"Nefeli Lamprinou",slug:"nefeli-lamprinou",email:"lamprinou@ceid.upatras.gr"},{id:"303833",title:"MSc.",name:"Georgios",surname:"Paterakis",fullName:"Georgios Paterakis",slug:"georgios-paterakis",email:"paterakis.gio@gmail.com"},{id:"303834",title:"MSc.",name:"Evangelos",surname:"Sartinas",fullName:"Evangelos Sartinas",slug:"evangelos-sartinas",email:"sartinas@ceid.upatras.gr"},{id:"303835",title:"Dr.",name:"Konstantinos",surname:"Souflas",fullName:"Konstantinos Souflas",slug:"konstantinos-souflas",email:"souflaskonstantinos@gmail.com"},{id:"303836",title:"Dr.",name:"Georgios",surname:"Thanellas",fullName:"Georgios Thanellas",slug:"georgios-thanellas",email:"gthanellas@upatras.gr"},{id:"303838",title:"MSc.",name:"Nikitas",surname:"Xanthopoulos",fullName:"Nikitas Xanthopoulos",slug:"nikitas-xanthopoulos",email:"nxanthopou@ceid.upatras.gr"},{id:"303839",title:"Prof.",name:"Panteleimon",surname:"Xofis",fullName:"Panteleimon Xofis",slug:"panteleimon-xofis",email:"xofis@fri.gr"}],book:{id:"9384",title:"Intelligent System and Computing",slug:"intelligent-system-and-computing",productType:{id:"1",title:"Edited Volume"}}}],collaborators:[{id:"93308",title:"Dr.",name:"Nikos",surname:"Aspragathos",slug:"nikos-aspragathos",fullName:"Nikos Aspragathos",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Patras",institutionURL:null,country:{name:"Greece"}}},{id:"151722",title:"Dr.",name:"Fadi",surname:"Alnaimat",slug:"fadi-alnaimat",fullName:"Fadi Alnaimat",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/151722/images/12710_n.jpg",biography:"Dr. Fadi Alnaimat is serving as an assistant professor in the Mechanical Engineering Department at the United Arab Emirates University (UAEU) since 2016. Dr. Alnaimat has extensive experience in thermal fluid sciences, heat transfer, desalination, microfluidic and microchannels, CFD, concentrated solar energy harvesting and storage. Prior to joining UAEU, Dr. Alnaimat has held several research and academic positions at Khalifa University in UAE as a research and teaching associate in 2015-2016, and a lecturer at the Hashemite University in 2014. Dr. Alnaimat has industrial experience as he served as a Lead Simulation Engineer at Andritz Inc, USA in 2012-2014. Immediately, after receiving his Ph.D., Dr. Alnaimat has worked at the University of Florida for about 1.5 years as a Technical Manager for the UF Industrial Assessment Center, (Department of Energy) and served as a teaching lecturer at the Nuclear Engineering department in 2011-2012.",institutionString:null,institution:{name:"United Arab Emirates University",institutionURL:null,country:{name:"United Arab Emirates"}}},{id:"245338",title:"Dr.",name:"Bobby",surname:"Mathew",slug:"bobby-mathew",fullName:"Bobby Mathew",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"United Arab Emirates University",institutionURL:null,country:{name:"United Arab Emirates"}}},{id:"290554",title:"Prof.",name:"Emmanouil",surname:"Psarakis",slug:"emmanouil-psarakis",fullName:"Emmanouil Psarakis",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Patras",institutionURL:null,country:{name:"Greece"}}},{id:"291501",title:"Prof.",name:"Panagiotis",surname:"Koutmos",slug:"panagiotis-koutmos",fullName:"Panagiotis Koutmos",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Patras",institutionURL:null,country:{name:"Greece"}}},{id:"307726",title:"MSc.",name:"Mohammed",surname:"Ziauddin",slug:"mohammed-ziauddin",fullName:"Mohammed Ziauddin",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"United Arab Emirates University",institutionURL:null,country:{name:"United Arab Emirates"}}},{id:"308920",title:"Prof.",name:"Orken",surname:"Mamyrbayev",slug:"orken-mamyrbayev",fullName:"Orken Mamyrbayev",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"308925",title:"MSc.",name:"Nurbapa",surname:"Mekebayev",slug:"nurbapa-mekebayev",fullName:"Nurbapa Mekebayev",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"308927",title:"MSc.",name:"Mussa",surname:"Turdalyuly",slug:"mussa-turdalyuly",fullName:"Mussa Turdalyuly",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"308928",title:"Dr.",name:"Nurzhamal",surname:"Oshanova",slug:"nurzhamal-oshanova",fullName:"Nurzhamal Oshanova",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null}]},generic:{page:{slug:"content-alerts",title:"Content alerts",intro:"
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr.",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Rheinmetall (Germany)",country:{name:"Germany"}}},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. His current research interests are in the fields of intelligent control and robotics.",institutionString:null,institution:{name:"Technical University of Sofia",country:{name:"Bulgaria"}}},{id:"585",title:"Prof.",name:"Munir",middleName:null,surname:"Merdan",slug:"munir-merdan",fullName:"Munir Merdan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/585/images/system/585.jpg",biography:"Munir Merdan received the M.Sc. degree in mechanical engineering from the Technical University of Sarajevo, Bosnia and Herzegovina, in 2001, and the Ph.D. degree in electrical engineering from the Vienna University of Technology, Vienna, Austria, in 2009.Since 2005, he has been at the Automation and Control Institute, Vienna University of Technology, where he is currently a Senior Researcher. His research interests include the application of agent technology for achieving agile control in the manufacturing environment.",institutionString:null,institution:null},{id:"605",title:"Prof",name:"Dil",middleName:null,surname:"Hussain",slug:"dil-hussain",fullName:"Dil Hussain",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/605/images/system/605.jpg",biography:"Dr. Dil Muhammad Akbar Hussain is a professor of Electronics Engineering & Computer Science at the Department of Energy Technology, Aalborg University Denmark. Professor Akbar has a Master degree in Digital Electronics from Govt. College University, Lahore Pakistan and a P-hD degree in Control Engineering from the School of Engineering and Applied Sciences, University of Sussex United Kingdom. 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. He has contributed in stochastic estimation of control area especially, in the Multiple Target Tracking and Interactive Multiple Model (IMM) research, Ball & Beam Control Problem, Robotics, Levitation Control. He has contributed in developing Algorithms for Fingerprint Matching, Computer Vision and Face Recognition. He has been supervising Pattern Recognition, Formal Languages and Distributed Processing projects for several years. He has reviewed many books on Management, Computer Science. Currently, he is an active and permanent reviewer for many international conferences and symposia and the program committee member for many international conferences.\nIn teaching he has taught the core computer science subjects like, Digital Design, Real Time Embedded System Programming, Operating Systems, Software Engineering, Data Structures, Databases, Compiler Construction. In the Engineering side, Digital Signal Processing, Computer Architecture, Electronics Devices, Digital Filtering and Engineering Management.\nApart from his Academic Interest and activities he loves sport especially, Cricket, Football, Snooker and Squash. He plays cricket for Esbjerg city in the second division team as an opener wicket keeper batsman. 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Consequently, knowledge of exoplanets is considerably more limited than Solar System planets. This chapter reviews the essential characteristics of Solar System planets and associated data derived from a variety of observational approaches. Exoplanet characteristics and their comparison to Solar System planets are provided as well as general detection methods and planned probes to gather additional data.",book:{id:"10210",slug:"solar-system-planets-and-exoplanets",title:"Solar System Planets and Exoplanets",fullTitle:"Solar System Planets and Exoplanets"},signatures:"Joseph Bevelacqua",authors:[{id:"115462",title:"Dr.",name:"Joseph",middleName:"John",surname:"Bevelacqua",slug:"joseph-bevelacqua",fullName:"Joseph Bevelacqua"}]},{id:"65725",title:"On the Deviation of the Lunar Center of Mass to the East: Two Possible Mechanisms Based on Evolution of the Orbit and Rounding Off the Shape of the Moon",slug:"on-the-deviation-of-the-lunar-center-of-mass-to-the-east-two-possible-mechanisms-based-on-evolution-",totalDownloads:1029,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"It is known that the Moon’s center of mass (COM) does not coincide with the geometric center of figure (COF) and the line “COF/COM” is not directed to the center of the Earth, but deviates from it to the South-East. Here, we discuss two mechanisms to explain the deviation of the lunar COM to the East from the mean direction to Earth. The first mechanism considers the secular evolution of the Moon’s orbit, using the effect of the preferred orientation of the satellite with synchronous rotation to the second (empty) orbital focus. It is established that only the scenario with an increase in the orbital eccentricity e leads to the required displacement of the lunar COM to the East. It is important that high-precision calculations confirm an increase e in our era. In order to fully explain the shift of the lunar COM to the East, a second mechanism was developed that takes into account the influence of tidal changes in the shape of the Moon at its gradual removal from the Earth. The second mechanism predicts that the elongation of the lunar figure in the early era was significant. As a result, it was found that the Moon could have been formed in the annular zone at a distance of 3–4 radii of the modern Earth.",book:{id:"8444",slug:"lunar-science",title:"Lunar Science",fullTitle:"Lunar Science"},signatures:"Boris P. Kondratyev",authors:[{id:"277909",title:"Prof.",name:"Boris",middleName:"Petrovich",surname:"Kondratyev",slug:"boris-kondratyev",fullName:"Boris Kondratyev"}]},{id:"68357",title:"Solar System Exploration Augmented by In Situ Resource Utilization: System Analyses, Vehicles, and Moon Bases for Saturn Exploration",slug:"solar-system-exploration-augmented-by-in-situ-resource-utilization-system-analyses-vehicles-and-moon",totalDownloads:859,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Human and robotic missions to Saturn are presented and analyzed with a range of propulsion options. Historical studies of space exploration, planetary spacecraft and astronomy, in situ resource utilization (ISRU), and industrialization all point to the vastness of natural resources in the solar system. Advanced propulsion is benefitted from these resources in many ways. While advanced propulsion systems were proposed in these historical studies, further investigation of nuclear options using high-power nuclear electric and nuclear pulse propulsion as well as advanced chemical propulsion can significantly enhance these scenarios. Updated analyses based on these historical visions are presented. At Saturn, nuclear pulse propulsion with alternate propellant feed systems and Saturn moon exploration with chemical propulsion and nuclear electric propulsion options are discussed. Issues with using in situ resource utilization on Saturn’s moons are discussed. At Saturn, the best locations for exploration and the use of the moons as central locations for Saturn moon exploration are assessed. Environmental issues on Titan’s surface may present extreme challenges for some ISRU processes. In-space bases for moon-orbiting propellant processing and ground-based processing will be assessed.",book:{id:"7338",slug:"planetology-future-explorations",title:"Planetology",fullTitle:"Planetology - Future Explorations"},signatures:"Bryan Palaszewski",authors:[{id:"279275",title:"M.Sc.",name:"Bryan",middleName:null,surname:"Palaszewski",slug:"bryan-palaszewski",fullName:"Bryan Palaszewski"}]},{id:"65534",title:"Solar System Exploration Augmented by In Situ Resource Utilization: Lunar Base Issues",slug:"solar-system-exploration-augmented-by-in-situ-resource-utilization-lunar-base-issues",totalDownloads:1134,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Creating a presence and an industrial capability on the Moon is essential for the development of humankind. There are many historical study results that have identified and quantified the lunar resources and analyzed the methods of obtaining and employing those resources. The idea of finding, obtaining, and using these materials is called in situ resource utilization (ISRU). The ISRU research and development efforts have led to new ideas in rocket propulsion. Applications in chemical propulsion, nuclear electric propulsion, and many other propulsion systems will be critical in making the initial lunar base and future lunar industries more sustainable and will lead to brilliant futures for humanity.",book:{id:"8444",slug:"lunar-science",title:"Lunar Science",fullTitle:"Lunar Science"},signatures:"Bryan Palaszewski",authors:[{id:"279275",title:"M.Sc.",name:"Bryan",middleName:null,surname:"Palaszewski",slug:"bryan-palaszewski",fullName:"Bryan Palaszewski"}]},{id:"32533",title:"Measuring the Isotopic Composition of Solar Wind Noble Gases",slug:"measuring-the-isotopic-composition-of-solar-wind-noble-gases",totalDownloads:2789,totalCrossrefCites:6,totalDimensionsCites:9,abstract:null,book:{id:"1617",slug:"exploring-the-solar-wind",title:"Exploring the Solar Wind",fullTitle:"Exploring the Solar Wind"},signatures:"Alex Meshik, Charles Hohenberg, Olga Pravdivtseva and Donald Burnett",authors:[{id:"114740",title:"Prof.",name:"Alexander",middleName:null,surname:"Meshik",slug:"alexander-meshik",fullName:"Alexander Meshik"},{id:"115300",title:"Prof.",name:"Donald",middleName:null,surname:"Burnett",slug:"donald-burnett",fullName:"Donald Burnett"},{id:"115301",title:"Prof.",name:"Charles",middleName:null,surname:"Hohenberg",slug:"charles-hohenberg",fullName:"Charles Hohenberg"},{id:"115302",title:"Dr.",name:"Olga",middleName:null,surname:"Pravdivtseva",slug:"olga-pravdivtseva",fullName:"Olga Pravdivtseva"}]}],onlineFirstChaptersFilter:{topicId:"98",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"82332",title:"Access to Space, Access to the Moon – Two Sides of the Same Coin?",slug:"access-to-space-access-to-the-moon-two-sides-of-the-same-coin-",totalDownloads:13,totalDimensionsCites:0,doi:"10.5772/intechopen.105175",abstract:"The dynamics of human expansion towards space are going through Earth external layers, orbital space and the Moon. With its low gravity, slingshot effect relative to Earth, on-site resources and relative proximity to Earth in the solar system, the renewed space race is effectively returning first to the Moon. A psychological bridge to enlarge our civilization with a permanent bridge to our natural satellite. The development of this Earth-Moon system, requires enormous amount of finances, energy, science, technology, but over all, opportunities. This chapter deals with the efforts and the mental changes that may eventually result from all of these changes.",book:{id:"10955",title:"Lunar Science - Habitat and Humans",coverURL:"https://cdn.intechopen.com/books/images_new/10955.jpg"},signatures:"Yann-Henri Chemin"},{id:"81141",title:"Modeling Radiation Damage in Materials Relevant for Exploration and Settlement on the Moon",slug:"modeling-radiation-damage-in-materials-relevant-for-exploration-and-settlement-on-the-moon",totalDownloads:32,totalDimensionsCites:0,doi:"10.5772/intechopen.102808",abstract:"Understanding the effect of radiation on materials is fundamental for space exploration. Energetic charged particles impacting materials create electronic excitations, atomic displacements, and nuclear fragmentation. Monte Carlo particle transport simulations are the most common approach for modeling radiation damage in materials. However, radiation damage is a multiscale problem, both in time and in length, an aspect treated by the Monte Carlo simulations only to a limited extent. In this chapter, after introducing the Monte Carlo particle transport method, we present a multiscale approach to study different stages of radiation damage which allows for the synergy between the electronic and nuclear effects induced in materials. We focus on cumulative displacement effects induced by radiation below the regime of hadronic interactions. We then discuss selected studies of radiation damage in materials of importance and potential use for the exploration and settlement on the Moon, ranging from semiconductors to alloys and from polymers to the natural regolith. Additionally, we overview some of the novel materials with outstanding properties, such as low weight, increased radiation resistance, and self-healing capabilities with a potential to reduce mission costs and improve prospects for extended human exploration of extraterrestrial bodies.",book:{id:"10955",title:"Lunar Science - Habitat and Humans",coverURL:"https://cdn.intechopen.com/books/images_new/10955.jpg"},signatures:"Natalia E. Koval, Bin Gu, Daniel Muñoz-Santiburcio and Fabiana Da Pieve"},{id:"80241",title:"The Evolution of the Moon’s Orbit Over 100 Million Years and Prospects for the Research in the Moon",slug:"the-evolution-of-the-moon-s-orbit-over-100-million-years-and-prospects-for-the-research-in-the-moon",totalDownloads:65,totalDimensionsCites:0,doi:"10.5772/intechopen.102392",abstract:"As a result of solving the problem of interaction of Solar-system bodies, data on the evolution of the Moon’s orbit were obtained. These data were used as the basis for the development of a mathematical model for the Moon representing its motion over an interval of 100 million years. A program of exploration of the Moon with the aim of creating a permanent base on it is outlined. Such a base is intended for exploring the Earth, the Sun, and outer space.",book:{id:"10955",title:"Lunar Science - Habitat and Humans",coverURL:"https://cdn.intechopen.com/books/images_new/10955.jpg"},signatures:"Joseph J. Smulsky"},{id:"80217",title:"Educational and Scientific Analog Space Missions",slug:"educational-and-scientific-analog-space-missions",totalDownloads:88,totalDimensionsCites:0,doi:"10.5772/intechopen.101392",abstract:"Analog space missions in Poland include international scientific, technological, and business projects designed and realized by a private research company Analog Astronaut Training Center Ltd. (AATC) devoted to the future Moon and Mars exploration. Growing experience in educational aspect of the training as well as continuous development of the habitat and its professional space science laboratory equipment correspond to increased interest of educational organizations, universities, and individual students. We serve unique practical platform for space engineering, space master, and even space doctoral theses. In addition to a wide range of training courses offered for future astronauts, for example, diving, skydiving, rocket workshops, and stratospheric missions, AATC provides a private laboratory to simulate the space environment. It carries out scientific experiments focused on biology and space medicine, as well as addressing several multidisciplinary issues related to the Moon and Mars exploration, including space mining. The main goal of each our analog simulation is to get publishable results, what means that our analog astronauts obtain not only certification of completion of the training but also ability to continue studies and to perform it individually. This chapter summarizes methodology used by us, didactic tools, and obtained results for both educational and scientific analog simulations.",book:{id:"10955",title:"Lunar Science - Habitat and Humans",coverURL:"https://cdn.intechopen.com/books/images_new/10955.jpg"},signatures:"Agata Maria Kołodziejczyk and M. Harasymczuk"},{id:"79544",title:"Regolith and Radiation: The Cosmic Battle",slug:"regolith-and-radiation-the-cosmic-battle",totalDownloads:127,totalDimensionsCites:0,doi:"10.5772/intechopen.101437",abstract:"This chapter discusses regolith utilization in habitat construction mainly from the point of view of radiation protection of humans on missions of long duration. It also considers other key properties such as structural robustness, thermal insulation, and micrometeoroid protection that all have to be considered in parallel when proposing regolith-based solutions. The biological hazards of radiation exposure on the Moon are presented and put in the context of lunar exploration-type missions and current astronaut career dose limits. These factors guide the research in radiation protection done with lunar regolith simulants, which are used in research and development activities on Earth due to the reduced accessibility of returned lunar samples. The ways in which regolith can be used in construction influence its protective properties. Areal density, which plays a key role in the radiation shielding capacity of a given material, can be optimized through different regolith processing techniques. At the same time, density will also affect other important properties of the construction, e.g. thermal insulation. 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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:"24",title:"Sustainable Development",doi:"10.5772/intechopen.100361",issn:"2753-6580",scope:"
\r\n\tTransforming our World: the 2030 Agenda for Sustainable Development endorsed by United Nations and 193 Member States, came into effect on Jan 1, 2016, to guide decision making and actions to the year 2030 and beyond. Central to this Agenda are 17 Goals, 169 associated targets and over 230 indicators that are reviewed annually. The vision envisaged in the implementation of the SDGs is centered on the five Ps: People, Planet, Prosperity, Peace and Partnership. This call for renewed focused efforts ensure we have a safe and healthy planet for current and future generations.
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\r\n\tThis Series focuses on covering research and applied research involving the five Ps through the following topics:
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\r\n\t1. Sustainable Economy and Fair Society that relates to SDG 1 on No Poverty, SDG 2 on Zero Hunger, SDG 8 on Decent Work and Economic Growth, SDG 10 on Reduced Inequalities, SDG 12 on Responsible Consumption and Production, and SDG 17 Partnership for the Goals
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\r\n\t2. Health and Wellbeing focusing on SDG 3 on Good Health and Wellbeing and SDG 6 on Clean Water and Sanitation
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\r\n\t3. Inclusivity and Social Equality involving SDG 4 on Quality Education, SDG 5 on Gender Equality, and SDG 16 on Peace, Justice and Strong Institutions
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\r\n\t4. Climate Change and Environmental Sustainability comprising SDG 13 on Climate Action, SDG 14 on Life Below Water, and SDG 15 on Life on Land
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\r\n\t5. Urban Planning and Environmental Management embracing SDG 7 on Affordable Clean Energy, SDG 9 on Industry, Innovation and Infrastructure, and SDG 11 on Sustainable Cities and Communities.
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\r\n\tThe series also seeks to support the use of cross cutting SDGs, as many of the goals listed above, targets and indicators are all interconnected to impact our lives and the decisions we make on a daily basis, making them impossible to tie to a single topic.
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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419588",title:"Ph.D.",name:"Sergio",middleName:"Alexandre",surname:"Gehrke",slug:"sergio-gehrke",fullName:"Sergio Gehrke",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038WgMKQA0/Profile_Picture_2022-06-02T11:44:20.jpg",biography:"Dr. Sergio Alexandre Gehrke is a doctorate holder in two fields. The first is a Ph.D. in Cellular and Molecular Biology from the Pontificia Catholic University, Porto Alegre, Brazil, in 2010 and the other is an International Ph.D. in Bioengineering from the Universidad Miguel Hernandez, Elche/Alicante, Spain, obtained in 2020. In 2018, he completed a postdoctoral fellowship in Materials Engineering in the NUCLEMAT of the Pontificia Catholic University, Porto Alegre, Brazil. He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\r\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\r\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Orthodontist, Assoc Prof in the Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. Her knowledge of English is at an advanced level.",institutionString:null,institution:null},{id:"332914",title:"Dr.",name:"Muhammad Saad",middleName:null,surname:"Shaikh",slug:"muhammad-saad-shaikh",fullName:"Muhammad Saad Shaikh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jinnah Sindh Medical University",country:{name:"Pakistan"}}},{id:"315775",title:"Dr.",name:"Feng",middleName:null,surname:"Luo",slug:"feng-luo",fullName:"Feng Luo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sichuan University",country:{name:"China"}}},{id:"344229",title:"Dr.",name:"Sankeshan",middleName:null,surname:"Padayachee",slug:"sankeshan-padayachee",fullName:"Sankeshan Padayachee",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"315727",title:"Ms.",name:"Kelebogile A.",middleName:null,surname:"Mothupi",slug:"kelebogile-a.-mothupi",fullName:"Kelebogile A. 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Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",annualVolume:11405,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"35539",title:"Dr.",name:"Cecilia",middleName:null,surname:"Cristea",fullName:"Cecilia Cristea",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYQ65QAG/Profile_Picture_1621007741527",institutionString:null,institution:{name:"Iuliu Hațieganu University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"40735",title:"Dr.",name:"Gil",middleName:"Alberto Batista",surname:"Gonçalves",fullName:"Gil Gonçalves",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYRLGQA4/Profile_Picture_1628492612759",institutionString:null,institution:{name:"University of Aveiro",institutionURL:null,country:{name:"Portugal"}}},{id:"211725",title:"Associate Prof.",name:"Johann F.",middleName:null,surname:"Osma",fullName:"Johann F. 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