\\n\\n
IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\\n\\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\\n\\nLaunching 2021
\\n\\nArtificial Intelligence, ISSN 2633-1403
\\n\\nVeterinary Medicine and Science, ISSN 2632-0517
\\n\\nBiochemistry, ISSN 2632-0983
\\n\\nBiomedical Engineering, ISSN 2631-5343
\\n\\nInfectious Diseases, ISSN 2631-6188
\\n\\nPhysiology (Coming Soon)
\\n\\nDentistry (Coming Soon)
\\n\\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\\n\\nNote: Edited in October 2021
\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/132"}},components:[{type:"htmlEditorComponent",content:'With the desire to make book publishing more relevant for the digital age and offer innovative Open Access publishing options, we are thrilled to announce the launch of our new publishing format: IntechOpen Book Series.
\n\nDesigned to cover fast-moving research fields in rapidly expanding areas, our Book Series feature a Topic structure allowing us to present the most relevant sub-disciplines. Book Series are headed by Series Editors, and a team of Topic Editors supported by international Editorial Board members. Topics are always open for submissions, with an Annual Volume published each calendar year.
\n\nAfter a robust peer-review process, accepted works are published quickly, thanks to Online First, ensuring research is made available to the scientific community without delay.
\n\nOur innovative Book Series format brings you:
\n\nIntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\n\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\n\nLaunching 2021
\n\nArtificial Intelligence, ISSN 2633-1403
\n\nVeterinary Medicine and Science, ISSN 2632-0517
\n\nBiochemistry, ISSN 2632-0983
\n\nBiomedical Engineering, ISSN 2631-5343
\n\nInfectious Diseases, ISSN 2631-6188
\n\nPhysiology (Coming Soon)
\n\nDentistry (Coming Soon)
\n\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\n\nNote: Edited in October 2021
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Formerly he was with the Technical \nUniversity of Denmark, Lyngby and the University of Southern Denmark, Sonderborg . Dr. Karakehayov received the Ph.D. and D. Sc. degree in computer science from the \nTechnical University of Sofia, Bulgaria. He is a senior member of the IEEE Computer \nSociety and Computer Society Distinguish Visitors Program Speaker. He authored six \nbooks in the field of embedded systems and holds eight patents. His research field \nincludes low-power design for embedded systems, low-power and secure routing for \nwireless sensor networks. 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Smallholder farmers in tropical Africa generally have severe financial constraints and need high returns to justify an investment, often >100% within a year [1]. Risk needs to be low given the vulnerability of their livelihoods to failed investments. Fertilizer use can have a high probability of high profit with well-informed crop-nutrient-rate choices but also with efficient input supply, favorable credit terms, subsidies, and efficient marketing of the commodity produced [2, 3, 4]. The objective of this chapter was to explore four issues affecting the profit potential of fertilizer use by financially constrained smallholder farmers: (1) the choice of fertilizer use options with the greatest potential return on investment, (2) the choice of N source and management of soil acidification, (3) the use of tailored fertilizer blends as alternatives to common straight fertilizers, and (4) the alternative nontraditional products for managing soil productivity. The implications for farm profitability are fundamental to the discussion of these issues.
Smallholder cropping systems are typically diverse, and each crop or intercrop has some level of profit potential for each nutrient that might be applied [2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13]. Crop-nutrient response functions typically have a diminishing profit-to-cost ratio as the nutrient rate approaches the agronomic optimum. A financially constrained farmer maximizes net returns through optimized choice of crop-nutrient-rate options (Figure 1; [4]). In contrast, when fertilizer use is not financially constrained, the profit-oriented farmer targets to apply at the rate at which net returns per hectare are maximized. Fertilizer use decisions can be made by integrating crop-nutrient response functions using linear optimization through computer-based and simple paper decision tools that have been developed for 73 recommendation domains across 15 nations of tropical Africa by the project Optimizing Fertilizer Recommendations in Africa [2, 3, 14].
Net returns in Kenyan shillings (KSh) to investment in nutrient application vary with crop-nutrient-rate choices, exemplified for Central Kenya with fertilizer use costs and on farm commodity values typical in 2016 [
Supply of nitrogen to cropland typically contributes to soil acidification whether the N is supplied through fertilizer, organic materials, biological fixation of atmospheric N, or wet and dry deposition of atmospheric NH4-N [15]. Soil acidification also occurs with NH4+ uptake by plants with subsequent release of cations, mostly H+. Soil acidification is greater if NO3−-N is leached from the soil rather than recovered by plants. Soil acidification associated with N sources can be slowed by avoiding excessive application of N and leaching of NO3−-N and by the use of less acidifying but more costly NO3−-N fertilizers [16]. Very often, it is most economical to use relatively less expensive but more acidifying NH4+-N fertilizers and occasionally amend the soil with lime application rather than using less acidifying fertilizers.
Soil acidification concerns are important in Kenya, for example, especially in some high elevation and high yield potential areas (Figure 2). The promoted N fertilizer for these areas is calcium ammonium nitrate (CAN) rather than urea. The chemical composition of CAN varies, but CAN of 27% N contains about 13.5% each of NH4+-N and NO3−-N, and calcium carbonate or calcium-magnesium carbonate (dolomite) may be added to give the fertilizer about 20% calcium carbonate equivalent (CCE). The acidification effect of ammonium nitrate and urea is 3.65 kg CCE for each kg of N applied. If the CCE of CAN is neutralized in the soil, it reduces the net acidification effect of CAN-N by about 22% to about 2.85 kg CCE kg−1 N. Therefore, urea is about 28% more acidifying per kg of N compared with CAN. Calcium is supplied by CAN but cannot be credited with economic value to farmers if the yield response to CA is not profitable.
Soil pH distribution across Kenya determined using AfSIS data.
The farm-level 2015 costs in western Kenya were 1.3 US$ kg−1 for urea-N, 2.0 $ kg−1 for CAN-N, and 0.17 $ kg−1 for effective CCE of lime. The retail cost of fertilizer N plus lime to neutralize the N effect on soil acidity was $1.30 + 0.166 × $3.65 = $1.91 kg−1 for urea-N and $2.00 + 0.166 * $2.85 = $2.47 kg−1 for CAN-N and 30% more costly for the CAN compared with urea option. The CAN compared with the urea option remains less profitable at these fertilizer prices if the cost for effective CEC of lime is <0.90 $ kg−1 (Figure 3).
Comparison of the retail costs of N supply using urea and calcium ammonium nitrate, plus the cost of agricultural lime for neutralizing the fertilizer acidification effects (US$), based on common fertilizer and lime costs in Kenya in 2016.
Blended and compound fertilizers are mixtures of common or straight fertilizers. Blended fertilizers are mixtures of common fertilizers which are distinguishable in the mix. Compound fertilizers are formulated by re-granulating the component common fertilizers to have some of each fertilizer in each granule. Hereafter, blended and compound fertilizers are referred to as blends. Common fertilizers often used in dry blends include urea, triple super phosphate (TSP), diammonium phosphate (DAP), and potassium chloride (KCl).
The flexibility in nutrient application with common fertilizers is often important for profit optimization. For example, cereal yield response to N followed by P often has more profit potential than the application of K, secondary nutrients, and micronutrients. The application of several nutrients in a blend can result in increased yield compared to the application of fewer nutrients with the farmer’s chosen combination of common fertilizers such as for wheat and maize production in Rwanda, but the profit potential is more often greater with common fertilizers [5, 7, 12, 17]. Blending adds to the cost of nutrient supply, and blends often contain one or more nutrients that have low or no profit potential for the farmer. For example, maize (
The acidifying effect of blends depends on their ingredients. Common fertilizers that are generally available on the world market at very competitive prices and with relatively high nutrient content are commonly used to produce blends. The nutrient contents of blends need to be reported, but the constituent fertilizers commonly do not need to be reported. However, a dry NPK blend is expected to contain urea, DAP or mono-ammonium phosphate, and KCl or potassium sulfate. Applying basic algebra for a 17-17-17, for example, it could be composed of 22.5, 37.0, 28.3, and 12.2% of urea, DAP, KCl, and bulking material, respectively, but it could not be 37.0, 37.0, and 28.3% of urea, TSP, and KCl as these total to >100%. The soil acidification effect of the blend depends on the constituent fertilizers. The acidification effect of the urea-DAP-KCl blend could be only slightly reduced by replacing some of the DAP with TSP since TSP is a non-acidifying P source for acid soils or using lime as the 12.2% of bulk material. Therefore, a fertilizer user should not expect a fertilizer blend to be a much less acidifying means for nutrient application compared with judicious application of common fertilizers.
Soil test values vary considerably within and across smallholder farming operations with soil texture, depth, and pH generally stronger determinants of crop yield and yield response to nutrients than are soil test results for nutrient availability [20, 21]. However, the probability of maize yield response to N and P is high for agricultural soils not having severe edaphic and other abiotic and biotic constraints. Of 727 N and 672 P yield response functions determined from field maize trials in tropical Africa, yield increases were >0.1 Mg ha−1 for 87% of the N functions and 69% of the P functions [18].
Interpretation of soil test results for the estimation of the probability and magnitude of profitable yield response to applied nutrients is generally weak globally for most secondary and micronutrients, with Zn being a possible exception, even where nutrient management is strongly based on field research results. Soil test information has a low or negligible predictive value for crop yield response to applied nutrients in tropical Africa [19]. Soil S tests have been less indicative of crop yield response to S than the use of soil organic matter content and soil texture [22, 23]. Situation-specific interpretations of soil test results for micronutrients have been useful but are unconfirmed for extensive use across geographic and climatic conditions [24]. Hot water extraction of B has been useful in predicting alfalfa yield response to B, but prediction is improved by consideration of soil texture [25]. Different nutrient extraction procedures for soil tests require different interpretations. Mehlich-3 extraction [26] is increasingly used for good reasons but does not correlate well with DTPA extraction for most micronutrients with
Interpretation of soil test results in terms of probability of profitable yield response to an applied nutrient can be expected to be weak in tropical Africa because crop yield and yield response to inputs in the tropics typically encounter numerous unmitigated constraints that are periodically more constraining than a nutrient deficiency [31, 32]. Each of these constraints not only limits yield but also crop yield response to attempts to mitigate another constraint and ability to predict response. Wendt and Rijpma [33] did not find a relationship between soil test information and crop yield response to applied S, Zn, and B in Malawi for individual fields. Kaizzi et al. [34, 35] did not find a soil test relationship for maize and sorghum yield response to N, P, and K in Uganda. In the analysis of >1100 cases of crop yield response linked to soil test information, Mehlich-3 extracted P and K accounted for <1% of the variation in yield response to application of these nutrients [19]. With more research, interpretation of soil test results for tropical Africa is expected to improve, but soil test results do not provide a practical basis for the tailoring of fertilizer blends in tropical Africa at this time.
The greatest profit/cost potential is likely to be with the application of one or two most limiting nutrients, often N and P for non-legumes and P or P plus another nutrient for legumes [5, 7, 12, 17]. Positive synergistic effects of applying the two most limiting nutrients occur infrequently but tend to account for relatively little yield response compared with the additive effects of individual nutrients e.g., [6, 8, 9, 10, 11, 17, 34, 35, 36, 37]. Therefore the highest profit/cost ratio can generally be achieved by at least partly alleviating the most limiting nutrient deficiency constraint followed by the second most limiting deficiency.
Farmer profit from fertilizer use may be maximized in some situations through the use of relatively more costly blends compared with common fertilizers such as cited above for wheat and maize in Rwanda [5, 17]. The blends may then at least partly meet the needs for those two most limiting nutrients as well, commonly applied near planting time. Blends should not contain nutrients with inadequately verified yield response unless the added cost to the farmer is minimal as any money that a financially constrained farmer uses for relatively costly fertilizer implies less money available for common fertilizers that may have higher profit potential.
Small bottles of nutrients or other solutions or suspensions are commonly sold in agricultural input shops in Africa with claims that use of small amounts can substitute partly or fully for fertilizer. The price per small bottle, even with a wide profit margin, compared to the price of a 50-kg bag of fertilizer is small, but the nutrient quantity is also very small, and the cost per kg of nutrient may be extremely high. These may contain micronutrients, often as low solubility oxides and carbonates, but the form and solubility are usually not specified. Some such products are sometimes vaguely referred to as bio-fertilizers and bio-stimulants and are mostly unregulated. These may have claims of increased crop growth, yield, or tolerance to insect pests, diseases, or drought or more efficient nutrient cycling. The Compendium of Research Reports on Use of Non-Traditional Materials for Crop Production [38] addresses a fraction of such products that have been marketed in the USA, most of which are no longer available or occur under a different name. Others have been found to be effective for specific situations and have an enduring history of use. No such compendium exists for tropical Africa.
Bio-fertilizers may contain microbes or microbial metabolites claimed to fix atmospheric N, convert insoluble P into soluble forms, or stimulate plant growth. Some products such as
Bio-stimulates often are of unknown contents but often contain hormones or humic acid. Hormone application can be effective for specific crops in specific situations, but use across a broad spectrum of production situations is unlikely to be effective for well-adapted crop varieties grown on at least moderately good agricultural soil. Humic acid is important to plant growth but is already abundant in soil. A soil of 3% organic matter may have 1–1.5 Mg ha−1 of humic acid in the surface 20-cm soil depth, and adding humic acid at a few kg ha−1 has a low probability of increasing yield [35].
Fertilizer use is essential for wide-scale sustainable improvement of crop productivity in tropical Africa even though smallholder farmers commonly are severely constrained financially. They require high profit/cost ratios of their investments, with acceptable risk, to gradually reduce the limitations of poverty. Fertilizer use can be highly profitable with good crop-nutrient-rate choices made in consideration of the farmer’s financial and agronomic context. Maximizing the profit/cost ratio usually requires adequate access to common fertilizers. Soil acidification is a concern and is a partly an unavoidable consequence of N supply to crops. The most cost-effective means for management of soil acidification often involve avoiding excessive N application and the use of slightly more acidifying but less costly common NH4+-N fertilizers coupled with lime use compared with NO3−-N fertilizers and less lime use. The feasibility of tailored blends has been addressed in consideration of the cost of nutrient supply, the need for flexibility in fertilizer use for maximization of farmer profit, and the weakness of tailoring blends based on soil test results in tropical Africa. However, justification for blends for exceptions such as for wheat and maize in Rwanda should not restrict the supply of common fertilizers. Farmers need to be aware that unregulated products sold in small bottles or packets very often fail to provide the claimed benefits. Fertilizer use, sometimes with timely lime application, can be highly profitable with modest risk if based on good crop-nutrient-rate choices, with adequate fertilizer supply and avoidance of products with unconfirmed claims.
CAN | calcium ammonium nitrate |
CCE | calcium carbonate equivalent |
DAP | diammonium phosphate |
DTPA | diethylenetriaminepentaacetic acid |
TSP | triple super phosphate |
Anal fistulas, especially complex anal fistulas, still present a challenge for surgeons because of their high recurrence rate, possible postoperative risk of fecal incontinence and also the fact that nowadays we still do not have a standardized procedure of choice for treatment.
An anal fistula is defined as an abnormal communication between perianal skin and anal canal, filled with granulation and fibrotic tissue that supports chronic inflammation, disabling spontaneous healing. Most fistulas are of cryptoglandular etiology, but can also be associated with inflammatory bowel disease (Mb Crohn), malignancies, trauma, pelvic sepsis or diverticulitis. Incidence of the disease is about 10 cases per 100,000 individuals with a male to female ratio of 2:1 [1, 2].
In the past, various classifications for anal fistulas were proposed. One of the most widespread classifications was Parks’ classification which classified fistulas according to their correlation with anal sphincter complex and divided fistulas into intersphincteric, transsphincteric, suprasphincteric and extrasphincteric [3].
Surgeons noticed, using traditional surgical techniques such as fistulotomy, fistulectomy or cutting seton, frequent continence disturbance following operations, especially in cases when fistula tract passed through deeper parts of sphincter complex and internal fistula opening was positioned more proximally in the anal canal.
To simplify classification and to prevent possible postoperative continence disturbance, colorectal surgeons nowadays mostly use simple classification which divides fistulas into two groups: simple and complex, according to the relation of the proportion of the anal sphincter mechanism they pass through. The classification that distinguishes simple and complex anal fistulas helps the surgeon to avoid using traditional techniques to prevent possible continence disturbance, but does not help in the decision which operative technique is best to use in the treatment of complex fistulas. Classification by Garg is extrapolated from multiple clinical scenarios and presents a better correlation with an actual patient case (Figure 1).
Garg classification of anal fistulas (with permission of Dr. Pankaj Garg).
Simple anal fistulas have only one tract that crosses less than 30% of the anal sphincter complex and can be treated by fistulotomy or fistulectomy with very low postoperative continence disturbance incidence and high healing rate.
All other fistulas are classified as complex. These fistulas cross the anal sphincter at a point that encompasses more than 30% of the external anal sphincter. They can have multiple tracts. Complex fistulas also include those about inflamatory bowel disease (IBD), those which are anteriorly positioned in female patients or those which are recurrent. If those fistulas are treated with fistulotomy or some other traditional technique, it can result in some type of postoperative fecal incontinence. The average rate of continence disturbance, such as flatus or liquid stool leakage following fistulotomy, was observed in 20–25% cases and up to 12% cases after cutting seton treatment [4, 5]. This effect on continence has resulted in traditional surgical techniques being less favorable for complex anal fistulas treatment and the incentive to use minimally invasive sphincter sparing techniques is increasing.
In anal fistula treatment, it is important to apply an appropriate surgical approach to obtain the best postoperative results such as high primary healing rate, low postoperative pain, low risk for any type of fecal incontinence, low recurrence rate and to subsequently increase postoperative patient’s life quality.
To delve into the intricacies of anal fistulas, one must first understand hypotheses that currently exist. The most widespread hypothesis is the cryptoglandular one which states that infected or inflamed anal glands are the cause of anal abscess and fistula [6]. This could be due to the ascending inflammation originating in the anal canal or blockage of discharge. Over almost 150 years, much research was done to find out exact relationship between anal glands and anal fistula, and while some researchers found them to correlate, others weren’t even able to prove the existence of anal glands or found them to be very variable at best [7]. Nevertheless, this is the predominant theory that surgeons adhere to throughout the modern surgery era, and anal glands seem to be the likely culprit. Despite this, etiology remains uncertain or unknown, but the inflammatory process seems to play a crucial role.
From the anatomical standpoint, it was stated by Parks that anal fistula is the chronic manifestation of anal abscess that is an acute condition. Fistula forms as a consequence of the medio-lateral spread of infection that subsequently may perforate the anal sphincter complex and extend to the perianal skin, thus forming a fistula [3]. More recently, Garg has shown that intersphincteric space plays a major role in anal fistula pathology, stating that almost all complex fistulas have some degree of intersphincteric involvement and that fistula in closed intersphincteric space acts like an abscess and must be treated accordingly [8, 9].
Molecular analyses of an anal fistula are scarce. One study has shown abundant expression of pro-inflammatory cytokine IL-1b in 93 % of the cryptoglandular anal fistulas, along with increased levels of cytokines IL-8, IL-12p40 and TNF-α in anal fistulas [10]. IL-1, especially IL-1β are strong pro-inflammatory cytokines that can be stimulated by other cytokines, microbial products and even IL-1β by auto stimulation, which can play a role in the recurrence or persistence of anal fistula. Tozer et al. showed immunological differences between cryptoglandular and Crohn’s disease-associated fistula [11]. While those are undoubtedly valuable findings that advance our understanding of anal fistula pathology, they still don’t change anything in our management of this problem.
To achieve best results, accomplish a higher primary healing rate, prevent recurrence and risk of postoperative continence disturbance, it is essential to identify the entire course of fistula tract including infected anal gland in intersphincteric space, main and possible secondary tracts. In that way, one can decide which surgical option is best for the patient.
After performing DRE, additional usage of the metal probe with insertion through fistula canal should be done to identify which type of fistula patient has so one can decide which surgical option should be performed. In case of pain, this can be performed under anesthesia (EUA: examination under anesthesia) [12]. In the case of a simple anal fistula, it is usually sufficient to examine as mentioned above, but in cases of a complex anal fistula in most cases, additional diagnostic methods should be done.
Some diagnostic methods that have previously been used to verify the course of fistula tracts, have since been abandoned. One of these techniques is X-ray fistulography. This technique is not performed anymore because it does not show the correlation of the fistula tract to the anal sphincter complex, so in that way, surgeon does not know which type of anal fistula the patient has [13].
Possible options to verify the correlation of the fistula tract with anal sphincter complex are: CT fistulography, endoanal ultrasound (EUS) and MRI fistulography.
CT fistulography can be more accurate in cases associated with acute inflammations and abscesses, but it somewhat deficient in cases of mature anal fistula.
Endoanal ultrasound (EUS) is a very good option to verify fistula tract correlation with sphincter complex and possible secondary branches but it is a highly operator-dependent technique [14, 15, 16].
For now, the golden standard for anal fistula diagnosis and classification is magnetic resonance imaging (MRI). MRI helps not only to accurately demonstrate disease extension but also to predict prognosis, make therapy decisions and can be used in some cases in follow-up periods especially in the patient suffering from Crohn´s disease or recurrent fistula (Figure 2) [16, 17, 18, 19, 20, 21].
MR fistulography clearly shows horseshoe fistula on axial view.
One other possibility in the verification of main fistula tract and possible secondary branches is using fistuloscope during the diagnostic phase of VAAFT procedure (video-assisted anal fistula treatment) but the technique can also be considered as operator-dependent [22]. VAAFT procedure will be discussed later in this chapter.
It is stated that the ideal treatment for anal fistula lies on two principles. The first is the eradication of sepsis and promotion of fistula tract healing, and the second is preserving the sphincter complex and continence mechanism [23]. With simple fistulas, this can be achieved by laying open the fistulous tract with high healing rates and with no significant continence disturbance [24]. While simple fistulas have simple treatment solutions, the concept of treatment for complex fistulas is somewhat different, and while the above-mentioned principle holds, certain aspects should be explained.
Colorectal surgeons’ postulate that internal fistula openings should always be identified and closed. This was shown in a meta-analysis by Mei et al. with class I evidence for significant association between anal fistula recurrence and failure to identify and close internal fistula opening. The same meta-analysis also showed the connection between horseshoe fistula extensions and recurrence [25]. Both of these problems could be solved by applying video-assisted approach in treatment. This covers the first principle.
To achieve the second principle in complex anal fistula, sphincter preserving techniques should be used to address the anal continence problem. Currently, no study compares lay open techniques and sphincter preserving techniques for complex anal fistula treatment but other studies have shown that, in this case, lay open techniques have an unacceptably high incidence of continence disturbance, up to 25% [4]. Meanwhile, sphincter preserving techniques for complex fistulas, with the possible exception of rectal advancement flap, have shown to have no or only minor continence disturbances in up to 1.7% patients [26].
A somewhat different approach, arising from analysis of modern sphincter preserving techniques, to the ideal treatment of anal fistulas was described by Garg. He hypothesized that in order to successfully heal anal fistula, we should bear in mind three principles:
Intersphincteric fistula tract acts like an abscess in closed intersphincteric space.
Second principle follows the first: intersphincteric fistula must be drained and continuous drainage should be ensured.
Healing occurs progressively until interrupted irreversibly by a collection [9].
This may be the reason why most sphincter preserving treatment methods still do not have healing results comparable to lay open techniques.
When talking about traditional techniques in anal fistula treatment we refer to fistulotomy, fistulectomy or techniques with seton placement in the anal fistula canal. Even since Hippocrates, there have been advices and different references on how one should treat anal fistula [27]. Traditional techniques were used in the treatment of anal fistula during history, before the development of sphincter preserving techniques.
Fistulotomy as the oldest, simplest and most widely performed procedure in anal fistula treatment has its benefits and drawbacks. This procedure, with its synonym “lay open technique,” is quite a simple procedure in which the surgeon, after insertion of the metal probe, cuts (or lays open) the whole of fistula tract from the internal fistula opening which is located in the anal canal to the external opening situated on the perianal skin. Following this, the surgeon performs curettement of granulation tissue from the fistula tract remnant making, in a sense, an acute wound that should heal by secondary intention. Some surgeons perform additional marsupialization of wound edges the following fistulotomy to reduce postoperative bleeding and to speed up wound healing (Figure 3) [28].
Fistulotomy with marsupialization (shown by red arrows).
In this way, crucial postulates in anal fistula treatment are satisfied, except the preservation of anal sphincter complex to a lesser degree. Even though this procedure has a success rate of more than 90%, it is also associated with some type of postoperative continence disturbance in cases when the fistula tract crosses through deeper parts of the anal sphincter complex and when the internal fistula opening is placed more proximally in the anal canal. The incontinence rate following these procedures vary given the heterogeneity of anal fistulas, but can be up to 28% [4, 29].
In recent times, according to Garg’s classification, this technique should be only reserved for treatment of type 1 and 2 anal fistulae without risk of continence disturbance, meaning low intersphincteric and low transsphincteric fistula (simple anal fistula) [30].
Fistulectomy is performed by excising the whole of fistula tract, removing in that way the whole fistula tract from external fistula opening to internal fistula opening, without preservation of anal sphincter complex. In a meta-analysis that included 565 patients comparing fistulectomy and fistulotomy for low anal fistulas, there has been no conclusive evidence as to which procedure is better in simple anal fistula treatment [31].
Failure of treatment with fistulotomy of fistulectomy and recurrence is associated with inappropriate selection of patients with high anal fistulas or those with multiple tracts.
The seton placement technique distinguishes between “cutting” and “loose” seton.
Cutting seton technique is nowadays almost abandoned but was used to convert high anal fistula to low one which was later treated by lay open technique. Seton was made of unabsorbable material, placed through the anal fistula canal and then tightened enabling in that way slow cutting of the sphincter mechanism leaving behind a scar. The idea behind the technique was that it would prevent anal sphincter muscle to split and, in that way, to prevent serious problems with continence disturbance. It was proven however, that this technique has a high incidence of continence disturbance with high morbidity and recurrence rates [5].
When talking about the role of loose seton the situation is somewhat different. Loose seton should be placed through the fistula tract without tightening, helping in that way to reduce sepsis and to mature the fistula tract. This would be the first stage in resolving of anal fistula problem. Many surgeons advocate loose seton placement as an important step of rectal advancement flap procedure or LIFT (ligation of intersphincteric fistula tract) prior to that operation, even though there has not been clear clinical evidence [32, 33]. Seton placement before fistulotomy with sphincter reconstruction has shown its benefits in fistula treatment, namely in converting high transsphincteric to low transsphincteric fistula and also in the acute abscess stage before this procedure to reduce the risk of breakdown of sphincter repair [34].
As mentioned earlier, the high risk of postoperative continence disturbance after treatment of complex anal fistulas with traditional techniques, have led to the need for the development of new techniques, which would be dubbed “sphincter preserving techniques.” The main characteristic of such techniques is that they prevent or greatly reduce any possibility of postoperative fecal incontinence. Various sphincter preserving techniques were introduced in clinical practice in the last 10–15 years. Among these are laser treatment procedure (FiLaC®: fistula laser closure), fibrin glue treatment, anal fistula plug, VAAFT procedure (video-assisted anal fistula treatment), LIFT procedure (ligation of intersphincteric fistula tract), anal fistula treatment with platelet cells (PRP: platelet rich plasma), RAF (rectal advancement flap) and others. [22, 33, 35, 36, 37, 38, 39, 40, 41, 42].
Some sphincter preserving techniques weren’t broadly accepted given high cost, high recurrence rates or inability to reproduce similar results in other centers. Of above-mentioned sphincter preserving techniques, several gained wider acceptance, such as LIFT, VAAFT, and RAF technique.
Ligation of intersphincteric fistula tract (LIFT) is a sphincter preserving technique first performed and published by Rojanasakul [39]. This technique satisfies all goals of anal fistula treatment such as the closure of internal fistula opening, removal of infected intersphincteric fistula tract (anal gland) and eradication of remaining fistula tract. It is reserved for the treatment of complex transsphincteric anal fistulas. After identification of fistula tract using metal, probe surgeon makes a curvilinear incision on the anocutaneous border entering intersphincteric space and performs preparation of intersphincteric part of anal fistula, followed by removal of the intersphincteric portion of the fistula. Closure of remaining defect of anal fistula on internal and external anal sphincter muscle then follows. Curettement of remaining fistula tract from external fistula opening to external anal sphincter muscle should be performed. Intersphincteric space is then reconstructed and the perianal wound sutured.
According to the two available meta-analyses, this procedure gives an overall success rate of 76.4 and 78 % respectively, with a low complication rate 5.5–13.9%. The most common complication was wound dehiscence, and others were bleeding, infection, hematoma, anal discharge. Only a low grade of postoperative fecal incontinence in 1.4% of patents was recorded (Figure 4) [33, 43].
LIFT procedure: identification of fistula tract in the intersphincteric plane; red arrow showing fistula tract.
This technique is easily reproducible without the necessity of investment in potentially expensive equipment. In case of dehiscence of intersphincteric space loose seton can be inserted through the intersphincteric wound, thus making conversion of transsphincteric fistula in intersphincteric one, which can be afterward treated by fistulotomy without fear of continence disturbance.
Video-assisted anal fistula treatment (VAAFT) procedure is the only technique that enables visualization and operation of anal fistula from within fistula tract, using specially designed equipment. This sphincter preserving technique was developed by Meinero who described short and long-term results [22].
Using a special instrument (fistuloscope), the surgeon visualizes the fistula tract from inside, which helps to identify possible secondary branches of the fistula tract, abscess cavities and later destroys all chronic granulation tissue in the fistula tract making in that way an acute wound which should heal by secondary intention. The important part of this technique is also to identify the internal fistula opening inside the anal canal and to close it securely (Figures 5–9).
Intraoperative view of the fistula tract through fistuloscope.
Fulguration of the fistulous tract.
View of the debris after fulguration.
Postoperative view after VAAFT for complex horseshoe fistula.
Healed wounds in the same patient.
Many surgeons worldwide accepted this technique in their everyday practice for the treatment of complex anal fistulas [22, 38, 44, 45, 46].
The main indication for this technique is the treatment of complex anal fistulas, especially cases with multiple secondary branches which are deep in the ischioanal fossa and are not easily reached. Also, VAAFT has its benefits in treatment of patients who have anal fistula associated with Crohn’s disease, helping to ameliorate symptoms associated with chronic anal fistula such as pain and soiling, thus significantly increasing patient’s quality of life [44, 47]. VAAFT technique is comparable with other sphincter preserving techniques to healing and patient satisfaction. Diminished postoperative pain, earlier recovery after surgery and smaller postoperative perianal wounds allows for earlier return to normal activities [48].
In case of failure, this technique can be repeated because there is no risk for any continence disturbance following this procedure. The proposed mechanism whereby repeated procedures have an incremental effect is the conversion of complex fistula with multiple tracts into a more manageable, low or simple fistula, which can be called conversion of the fistula. [38]
VAAFT technique has been proven to be a safe procedure, associated with good functional outcomes and a very low incidence of complications [22, 44, 45], which was shown in a published meta-analysis [46]. It showed a recurrence rate ranging from 7.5 to 33.3% with a weighted mean recurrence rate of 17.7%. Recurrence rates varied significantly depending on the method of internal fistula opening closure (mattress suture, stapler, rectal advancement flap). No affection of anal continence was documented.
This technique is one of the oldest techniques which were and still are reserved for the treatment of complex anal fistulas especially in cases with large internal fistula opening. When discussing this technique, we can’t talk about the “pure” sphincter preserving technique because flap should be performed by dissection of anorectal mucosa and adjacent internal anal sphincter muscle, so in that way, internal anal sphincter muscle does not stay intact.
When doing this procedure surgeon should identify and excise the internal fistula opening in the anal canal. Then the U-shaped or rhomboid flap with a wider base side should be performed by dissecting anorectal mucosa and adjacent internal anal sphincter muscle. Curettement and irrigation of the whole fistula tract should be performed, followed by suture of a defect in sphincter complex left by earlier fistula tract. The site is then a covered by previously prepared flap and sutured. Even though much research has been made about optimal flap thickness, researchers found that there was a statistically higher rate of primary healing in cases with thicker flaps, but also have noticed a higher rate of mild postoperative continence disturbance which was more severe than the thicker flap was (Figure 10) [41, 49, 50].
Formed rectal advancement flap.
There have been many publications and several systematic reviews and meta-analyses on this technique where the effectiveness was shown to be 60–80%, but the same cases also reported some degree of postoperative fecal disturbance [42, 50, 51].
Factors that could affect healing after flap procedure are obesity and smoking, so patients should be advised to quit smoking and to try to reduce their weight prior to flap operation [52, 53, 54]. To increase the effectiveness of this technique one should perform bigger rhomboid or U-shape flaps using the minimally invasive approach, avoiding tissue trauma made by surgical cautery, avoiding excessive grasping as well as the too big strain of suture line.
As mentioned earlier in this chapter, there is no universal approach for anal fistula treatment. Some other possible solutions may be hybrid sphincter preserving techniques, fistulotomy with primary sphincter reconstruction, TROPIS (trans anal opening of the intersphincteric space) and use of autologous platelet rich plasma in anal fistula treatment.
Hybrid sphincter preserving techniques are combinations of two or more sphincter preserving techniques in a single procedure to increase healing rates and achieving better results.
Several reports exist with different combinations of techniques with authors trying to achieve higher healing rates, but the majority of reports are on a single institution basis or case reports with a small number of patients.
A combination of VAAFT and LIFT techniques was performed with intention of secure closure of internal fistula opening from intersphincteric space and additional exploration and eradication of remaining fistula tract from external fistula opening with identification of possible secondary branches using fistuloscope [55, 56]. VAAFT was also used in different combinations with other sphincter preserving techniques such as FiLaC® procedure and with RAF procedure in cases with large internal fistula opening [38, 44, 57].
The combination of LIFT technique with the insertion of a bioprosthetic graft in intersphincteric space was also described in a study that included 31 patients, where the success rate was 94% in a one-year follow-up period [58]. Another study combined LIFT and human acellular dermal matrix as a bioprosthetic plug with a reported success rate of 95% on a 21-patient sample [59]. Rectal advancement flap with the injection of porcine dermal collagen implant through the external opening was combined in a study which included 24 patients with a success rate of 82.5% in a 14-month follow-up period [60].
It was to be expected that surgeons started to combine two or more sphincter preserving techniques to achieve better results, but until evidence is found that one technique, or combination of techniques, has significantly better results over the others, they should be tailored individually depending on patient’s case.
This approach in the treatment of anal fistulas has the same operative philosophy as fistulotomy or fistulectomy, but is reserved for higher fistulas. In this procedure surgeon after eradication of the fistula tract and possible secondary fistula branches to prevent recurrences, makes additional anal sphincter reconstruction to try to eliminate the possibility of postoperative fecal incontinence. Ratto et al. reported a 93.2% overall success rate with a low morbidity rate using this approach. Overall postoperative fecal incontinence was 12.4% mainly post-defecation soiling, without significant changes in anorectal manometry parameters [61]. Voon et al. reported their experience in using this technique and had good outcomes with a very low rate of continence disturbance in follow-up period [34]. Even though this technique has been implemented in guidelines for anal fistula treatment by several surgical societies, it wasn’t accepted worldwide as the standardized procedure [62]. In case of abscess formation as the initial presentation, it is crucial to place seton drainage to give enough time for maturing of the fistula and to prevent continence disturbance following fistulotomy.
This technique was described and published by Garg, who used this approach in the treatment of high complex anal fistulas with a high primary healing rate and very low incidence of morbidities [8]. It is well known that high intersphincteric parts of anal fistula and abscesses are difficult to reach through intersphincteric approach or probing from external fistula opening, as well as that they are usually branching.
TROPIS approach also satisfies golden principles in the treatment of anal fistula such as identification and resolving internal fistula opening problem, as well as intersphincteric fistula tract with the accompanying anal gland, and also eradication of remaining fistulous tract by curettement.
The procedure is done by laying open intersphincteric space through internal anal with preservation of external sphincter. The external tracts in the ischioanal fossa should be curetted and the intersphincteric space is left open for secondary healing. In the initial prospective cohort which included 61 patients, the success rate was 84.6% with no significant changes with continence. The study included patients with high transsphincteric (anterior and posterior) and high intersphincteric type of fistula [8].
TROPIS procedure is an excellent approach for posterior high transsphincteric type and high intersphincteric type of anal fistula, especially if transsphincteric fistula is located at the puborectalis level. However, combination with drainage (preoperative seton placement and postoperative drain placement in remaining tract from external fistula opening), curettement or excision of external tracts is necessary to reduce recurrences.
Autologous platelet rich plasma (APRP) is nowadays used in various fields of medicine such as orthopedics, plastic surgery, dental medicine, but also in the treatment of anal fistula in the last decade. APRP is platelet concentration derived from centrifuged full blood after removal of red blood cells. Such prepared plasma is a rich source of various growth factors implicated in regeneration and tissue healing [63, 64].
The procedure consists of curettement of fistula tract and closure of internal fistula opening with an additional injection of previously prepared platelet rich autologous blood sample [65]. The majority of publications combined mucosal advancement flap with APRP injection [65, 66, 67]. Several publications reported an average healing rate from 60 to 90% [40, 66, 67, 68]. The drawbacks of mentioned publications were that they had a relatively small number of patients enrolled and still no meta-analyses exist on the subject. No problem with any type of postoperative fecal incontinence was reported. This is still considered to be a somewhat experimental procedure and is not widely used. The platelet separation procedure requires special equipment that is often only available in larger institutions. Also cost per patient exceeds that of the other techniques, which is why this technique needs more solid evidence for a patient benefit before it can be considered to become one of the mainstream sphincters preserving treatments.
We can say that fistulas associated with Crohn’s disease present a special entity in the treatment of anal fistulas. This kind of fistula presents a huge challenge for surgeons despite numerous surgical possibilities and technical advancements in recent years. Symptoms associated with Crohn’s anal fistula include purulent drainage, severe pain, possible continence disturbance which all can lead to a significant reduction in quality of life. These kinds of fistulas are often recurrent and hard to treat. The incidence of anal fistulas in patients with Crohn’s disease is 5 to 40% and is more common in patients who have a higher severity of colorectal inflammation [69, 70, 71].
Even though numerous surgical techniques have been described for the treatment of this kind of anal fistulas, the choice of which technique is best often depends on the anatomy, presence of local inflammation, type of fistula, and surgeon’s experience (Figure 11) [72, 73, 74].
Perianal form of Crohn’s disease in female patient: multiple treatment methods combined (fistulotomy with marsupialization, seton placement, VAAFT).
Many management proposals have been published, but all had higher reports of postoperative complications such as continence disturbance, infection and high recurrence rate compared to the same type of fistulas not associated with Crohn’s disease. Currently, numerous novel surgical sphincters preserving techniques are being studied to less invasively induce fistula healing while maintaining fecal continence. When we discuss surgical treatment of complex anal fistulas in Crohn’s disease, the goal should be to ameliorate symptoms associated with this kind of fistulas and to improve patients’ quality of life. Although, various endoscopic and surgical techniques exist, there is no gold-standard treatment strategy for patients with perianal fistulas [44, 47, 75, 76].
Treatment of Crohn’s disease-associated anal fistula should always be multidisciplinary including surgeons, radiologists and gastroenterologists with the use of antibiotics, immunosuppressors and anti-inflammatory agents [77, 78, 79, 80, 81].
General principles in the treatment of this condition are underlined here, but the treatment of an anal form of Crohn’s disease is a complex topic, requiring a chapter on its own.
The problem of anal continence presents a big obstacle when trying to treat anal fistula. It is of paramount importance to avoid any continence disturbances which in itself presents a hurdle to implementing more successful but invasive procedures regarding the anal sphincter mechanism. The solution might lie in a relatively new paradigm that puts intersphincteric space as a likely culprit to fistula recurrence or nonhealing, and subsequent shift in surgical approach. These new approaches still require multicentric verifications to be implemented as a mainstream treatment option.
Overall, novel approaches in anal fistula treatment, while not entirely successful in all of the patients, offer a significant increase in patients’ quality of life, and allow for repeated surgical procedures if the initial operation fails at no expense on the anal sphincter.
While various researchers made different molecular research on anal fistula that increased our understanding of fundamental pathologic mechanisms, still no findings translate into clinical practice in the sense that they made any difference on already existing surgical approaches.
The most widespread classification of fistulas are somewhat inadequate and do not transfer well to clinical situations. Parks classification may describe the relation of the anal fistula to anal sphincter muscles but does not distinguish between simple and complex fistulas. St. James University Hospital classification also doesn’t seem relatable to the clinical situations in the era of sphincter preserving techniques. A possible solution to this may be Garg classification that still needs confirmatory commentaries from other colorectal surgeons and proctologists.
Anal fistulas in Crohn’s disease present a different challenge. With current surgical solutions, we cannot hope to cure the condition but rather to ameliorate symptoms. Medical therapy in combination with surgical solutions can significantly reduce the severity of the disease and even hope to eradicate it completely.
The anal fistula condition remains a daunting task for the surgeon and a strenuous malady for the patient. Even though recent years brought advancements in the form of sphincter preserving techniques, which greatly improved treatment options, still no golden standard for anal fistula treatment exists. This problem still seems unlikely to resolve given the heterogeneity of pathology unless a radically different approach or breakthrough isn’t achieved.
IntechOpen - where academia and industry create content with global impact
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Therefore, this chapter makes a literature review of the most important general aspects of endogenous antioxidant systems, which will provide another point of view from which to approach the study and treatment of many chronic degenerative diseases, such as diabetes, hypertension, and Parkinson.",book:{id:"5407",slug:"a-master-regulator-of-oxidative-stress-the-transcription-factor-nrf2",title:"The Transcription Factor Nrf2",fullTitle:"A Master Regulator of Oxidative Stress - The Transcription Factor Nrf2"},signatures:"Tomás Alejandro Fregoso Aguilar, Brenda Carolina Hernández\nNavarro and Jorge Alberto Mendoza Pérez",authors:[{id:"154732",title:"Dr.",name:"Jorge A.",middleName:null,surname:"Mendoza-Pérez",slug:"jorge-a.-mendoza-perez",fullName:"Jorge A. Mendoza-Pérez"},{id:"154908",title:"Dr.",name:"Tomás A.",middleName:null,surname:"Fregoso-Aguilar",slug:"tomas-a.-fregoso-aguilar",fullName:"Tomás A. 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Furthermore, we discuss how reactive oxygen species influence cellular metabolism and how this affects antioxidant function. We also discuss how NRF2 reprograms cellular metabolism to support the antioxidant response and how this functions to funnel metabolic intermediates into antioxidant pathways. This chapter concludes by exploring how these factors may contribute to both normal physiology and disease.",book:{id:"5407",slug:"a-master-regulator-of-oxidative-stress-the-transcription-factor-nrf2",title:"The Transcription Factor Nrf2",fullTitle:"A Master Regulator of Oxidative Stress - The Transcription Factor Nrf2"},signatures:"Ting-Yu Lin, Lewis C. Cantley and Gina M. 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Mainly, the versatile techniques of ultra−/high-performance liquid chromatography (UPLC/HPLC) are in use for the analysis of assay and organic impurities/related substances/degradation products of a drug substance or drug product or intermediate or raw material of pharmaceuticals. A suitable analytical method is developed only after evaluating the major and critical separation parameters of chromatography (examples for UPLC/HPLC are selection of diluent, wavelength, detector, stationary phase, column temperature, flow rate, solvent system, elution mode, and injection volume, etc.). The analytical method development is a process of proving the developed analytical method is suitable for its intended use for the quantitative estimation of the targeted analyte present in pharmaceutical drugs. And it mostly plays a vital role in the development and manufacture of pharmaceuticals drugs.",book:{id:"8912",slug:"biochemical-analysis-tools-methods-for-bio-molecules-studies",title:"Biochemical Analysis Tools",fullTitle:"Biochemical Analysis Tools - Methods for Bio-Molecules Studies"},signatures:"Narasimha S. Lakka and Chandrasekar Kuppan",authors:[{id:"304950",title:"Prof.",name:"Chandrasekar",middleName:null,surname:"Kuppan",slug:"chandrasekar-kuppan",fullName:"Chandrasekar Kuppan"},{id:"309984",title:"Mr.",name:"Narasimha S",middleName:null,surname:"Lakka",slug:"narasimha-s-lakka",fullName:"Narasimha S Lakka"}]},{id:"72074",title:"The Chemistry Behind Plant DNA Isolation Protocols",slug:"the-chemistry-behind-plant-dna-isolation-protocols",totalDownloads:3691,totalCrossrefCites:3,totalDimensionsCites:5,abstract:"Various plant species are biochemically heterogeneous in nature, a single deoxyribose nucleic acid (DNA) isolation protocol may not be suitable. There have been continuous modification and standardization in DNA isolation protocols. Most of the plant DNA isolation protocols used today are modified versions of hexadecyltrimethyl-ammonium bromide (CTAB) extraction procedure. Modification is usually performed in the concentration of chemicals used during the extraction procedure according to the plant species and plant part used. Thus, understanding the role of each chemical (viz. CTAB, NaCl, PVP, ethanol, and isopropanol) used during the DNA extraction procedure will benefit to set or modify protocols for more precisions. 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Heshmati",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/313921/images/system/313921.jpg",biography:"Dr. Hassan Massoud Heshmati is an endocrinologist with 46 years of experience in clinical research in academia (university-affiliated hospitals, Paris, France; Mayo Foundation, Rochester, MN, USA) and pharmaceutical companies (Sanofi, Malvern, PA, USA; Essentialis, Carlsbad, CA, USA; Gelesis, Boston, MA, USA). His research activity focuses on pituitary tumors, hyperthyroidism, thyroid cancers, osteoporosis, diabetes, and obesity. He has extensive knowledge in the development of anti-obesity products. Dr. Heshmati is the author of 299 abstracts, chapters, and articles related to endocrinology and metabolism. He is currently a consultant at Endocrinology Metabolism Consulting, LLC, Anthem, AZ, USA.",institutionString:"Endocrinology Metabolism Consulting, LLC",institution:null},{id:"76477",title:"Prof.",name:"Mirza",middleName:null,surname:"Hasanuzzaman",slug:"mirza-hasanuzzaman",fullName:"Mirza Hasanuzzaman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/76477/images/system/76477.png",biography:"Dr. Mirza Hasanuzzaman is a Professor of Agronomy at Sher-e-Bangla Agricultural University, Bangladesh. He received his Ph.D. in Plant Stress Physiology and Antioxidant Metabolism from Ehime University, Japan, with a scholarship from the Japanese Government (MEXT). Later, he completed his postdoctoral research at the Center of Molecular Biosciences, University of the Ryukyus, Japan, as a recipient of the Japan Society for the Promotion of Science (JSPS) postdoctoral fellowship. He was also the recipient of the Australian Government Endeavour Research Fellowship for postdoctoral research as an adjunct senior researcher at the University of Tasmania, Australia. Dr. Hasanuzzaman’s current work is focused on the physiological and molecular mechanisms of environmental stress tolerance. Dr. Hasanuzzaman has published more than 150 articles in peer-reviewed journals. He has edited ten books and written more than forty book chapters on important aspects of plant physiology, plant stress tolerance, and crop production. According to Scopus, Dr. Hasanuzzaman’s publications have received more than 10,500 citations with an h-index of 53. He has been named a Highly Cited Researcher by Clarivate. He is an editor and reviewer for more than fifty peer-reviewed international journals and was a recipient of the “Publons Peer Review Award” in 2017, 2018, and 2019. He has been honored by different authorities for his outstanding performance in various fields like research and education, and he has received the World Academy of Science Young Scientist Award (2014) and the University Grants Commission (UGC) Award 2018. He is a fellow of the Bangladesh Academy of Sciences (BAS) and the Royal Society of Biology.",institutionString:"Sher-e-Bangla Agricultural University",institution:{name:"Sher-e-Bangla Agricultural University",country:{name:"Bangladesh"}}},{id:"187859",title:"Prof.",name:"Kusal",middleName:"K.",surname:"Das",slug:"kusal-das",fullName:"Kusal Das",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSBDeQAO/Profile_Picture_1623411145568",biography:"Kusal K. Das is a Distinguished Chair Professor of Physiology, Shri B. M. Patil Medical College and Director, Centre for Advanced Medical Research (CAMR), BLDE (Deemed to be University), Vijayapur, Karnataka, India. Dr. Das did his M.S. and Ph.D. in Human Physiology from the University of Calcutta, Kolkata. His area of research is focused on understanding of molecular mechanisms of heavy metal activated low oxygen sensing pathways in vascular pathophysiology. He has invented a new method of estimation of serum vitamin E. His expertise in critical experimental protocols on vascular functions in experimental animals was well documented by his quality of publications. He was a Visiting Professor of Medicine at University of Leeds, United Kingdom (2014-2016) and Tulane University, New Orleans, USA (2017). For his immense contribution in medical research Ministry of Science and Technology, Government of India conferred him 'G.P. Chatterjee Memorial Research Prize-2019” and he is also the recipient of 'Dr.Raja Ramanna State Scientist Award 2015” by Government of Karnataka. He is a Fellow of the Royal Society of Biology (FRSB), London and Honorary Fellow of Karnataka Science and Technology Academy, Department of Science and Technology, Government of Karnataka.",institutionString:"BLDE (Deemed to be University), India",institution:null},{id:"243660",title:"Dr.",name:"Mallanagouda Shivanagouda",middleName:null,surname:"Biradar",slug:"mallanagouda-shivanagouda-biradar",fullName:"Mallanagouda Shivanagouda Biradar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/243660/images/system/243660.jpeg",biography:"M. S. Biradar is Vice Chancellor and Professor of Medicine of\nBLDE (Deemed to be University), Vijayapura, Karnataka, India.\nHe obtained his MD with a gold medal in General Medicine and\nhas devoted himself to medical teaching, research, and administrations. He has also immensely contributed to medical research\non vascular medicine, which is reflected by his numerous publications including books and book chapters. Professor Biradar was\nalso Visiting Professor at Tulane University School of Medicine, New Orleans, USA.",institutionString:"BLDE (Deemed to be University)",institution:{name:"BLDE University",country:{name:"India"}}},{id:"289796",title:"Dr.",name:"Swastika",middleName:null,surname:"Das",slug:"swastika-das",fullName:"Swastika Das",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/289796/images/system/289796.jpeg",biography:"Swastika N. Das is Professor of Chemistry at the V. P. Dr. P. G.\nHalakatti College of Engineering and Technology, BLDE (Deemed\nto be University), Vijayapura, Karnataka, India. She obtained an\nMSc, MPhil, and PhD in Chemistry from Sambalpur University,\nOdisha, India. Her areas of research interest are medicinal chemistry, chemical kinetics, and free radical chemistry. She is a member\nof the investigators who invented a new modified method of estimation of serum vitamin E. She has authored numerous publications including book\nchapters and is a mentor of doctoral curriculum at her university.",institutionString:"BLDEA’s V.P.Dr.P.G.Halakatti College of Engineering & Technology",institution:{name:"BLDE University",country:{name:"India"}}},{id:"248459",title:"Dr.",name:"Akikazu",middleName:null,surname:"Takada",slug:"akikazu-takada",fullName:"Akikazu Takada",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/248459/images/system/248459.png",biography:"Akikazu Takada was born in Japan, 1935. After graduation from\nKeio University School of Medicine and finishing his post-graduate studies, he worked at Roswell Park Memorial Institute NY,\nUSA. He then took a professorship at Hamamatsu University\nSchool of Medicine. In thrombosis studies, he found the SK\npotentiator that enhances plasminogen activation by streptokinase. He is very much interested in simultaneous measurements\nof fatty acids, amino acids, and tryptophan degradation products. By using fatty\nacid analyses, he indicated that plasma levels of trans-fatty acids of old men were\nfar higher in the US than Japanese men. . He also showed that eicosapentaenoic acid\n(EPA) and docosahexaenoic acid (DHA) levels are higher, and arachidonic acid\nlevels are lower in Japanese than US people. By using simultaneous LC/MS analyses\nof plasma levels of tryptophan metabolites, he recently found that plasma levels of\nserotonin, kynurenine, or 5-HIAA were higher in patients of mono- and bipolar\ndepression, which are significantly different from observations reported before. In\nview of recent reports that plasma tryptophan metabolites are mainly produced by\nmicrobiota. He is now working on the relationships between microbiota and depression or autism.",institutionString:"Hamamatsu University School of Medicine",institution:{name:"Hamamatsu University School of Medicine",country:{name:"Japan"}}},{id:"137240",title:"Prof.",name:"Mohammed",middleName:null,surname:"Khalid",slug:"mohammed-khalid",fullName:"Mohammed Khalid",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/137240/images/system/137240.png",biography:"Mohammed Khalid received his B.S. in Chemistry in July 2000, and his Ph.D. in Physical Chemistry in 2007 from the University of Khartoum, Sudan. In 2009 he joined the Dr. Ron Clarke research group at the School of Chemistry, Faculty of Science, University of Sydney, Australia as a postdoctoral fellow where he worked on the Interaction of ATP with the phosphoenzyme of the Na+, K+-ATPase, and Dual mechanisms of allosteric acceleration of the Na+, K+-ATPase by ATP. He then worked as Assistant Professor at the Department of Chemistry, University of Khartoum, and in 2014 was promoted to Associate Professor ranking. In 2011 he joined the staff of the Chemistry Department at Taif University, Saudi Arabia, where he is currently active as an Assistant Professor. His research interests include:\r\n(1) P-type ATPase Enzyme Kinetics and Mechanisms; (2) Kinetics and Mechanism of Redox Reactions; (3) Autocatalytic reactions; (4) Computational enzyme kinetics; (5) Allosteric acceleration of P-type ATPases by ATP; (6) Exploring of allosteric sites of ATPases and interaction of ATP with ATPases located in the cell membranes.",institutionString:"Taif University",institution:{name:"Taif University",country:{name:"Saudi Arabia"}}},{id:"63810",title:"Prof.",name:"Jorge",middleName:null,surname:"Morales-Montor",slug:"jorge-morales-montor",fullName:"Jorge Morales-Montor",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/63810/images/system/63810.png",biography:"Dr. Jorge Morales-Montor was recognized with the Lola and Igo Flisser PUIS Award for best graduate thesis at the national level in the field of parasitology. He received a fellowship from the Fogarty Foundation to perform postdoctoral research stay at the University of Georgia. He has 153 journal articles to his credit. He has also edited several books and published more than fifty-five book chapters. He is a member of the Mexican Academy of Sciences, Latin American Academy of Sciences, and the National Academy of Medicine. He has received more than thirty-five awards and has supervised numerous bachelor’s, master’s, and Ph.D. students. Dr. Morales-Montor is the past president of the Mexican Society of Parasitology.",institutionString:"National Autonomous University of Mexico",institution:{name:"National Autonomous University of Mexico",country:{name:"Mexico"}}},{id:"217215",title:"Dr.",name:"Palash",middleName:null,surname:"Mandal",slug:"palash-mandal",fullName:"Palash Mandal",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/217215/images/system/217215.jpeg",biography:null,institutionString:"Charusat University",institution:null},{id:"49739",title:"Dr.",name:"Leszek",middleName:null,surname:"Szablewski",slug:"leszek-szablewski",fullName:"Leszek Szablewski",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49739/images/system/49739.jpg",biography:"Leszek Szablewski is a professor of medical sciences. He received his M.S. in the Faculty of Biology from the University of Warsaw and his PhD degree from the Institute of Experimental Biology Polish Academy of Sciences. He habilitated in the Medical University of Warsaw, and he obtained his degree of Professor from the President of Poland. Professor Szablewski is the Head of Chair and Department of General Biology and Parasitology, Medical University of Warsaw. Professor Szablewski has published over 80 peer-reviewed papers in journals such as Journal of Alzheimer’s Disease, Biochim. Biophys. Acta Reviews of Cancer, Biol. Chem., J. Biomed. Sci., and Diabetes/Metabol. Res. Rev, Endocrine. He is the author of two books and four book chapters. He has edited four books, written 15 scripts for students, is the ad hoc reviewer of over 30 peer-reviewed journals, and editorial member of peer-reviewed journals. Prof. Szablewski’s research focuses on cell physiology, genetics, and pathophysiology. He works on the damage caused by lack of glucose homeostasis and changes in the expression and/or function of glucose transporters due to various diseases. He has given lectures, seminars, and exercises for students at the Medical University.",institutionString:"Medical University of Warsaw",institution:{name:"Medical University of Warsaw",country:{name:"Poland"}}},{id:"173123",title:"Dr.",name:"Maitham",middleName:null,surname:"Khajah",slug:"maitham-khajah",fullName:"Maitham Khajah",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/173123/images/system/173123.jpeg",biography:"Dr. Maitham A. Khajah received his degree in Pharmacy from Faculty of Pharmacy, Kuwait University, in 2003 and obtained his PhD degree in December 2009 from the University of Calgary, Canada (Gastrointestinal Science and Immunology). Since January 2010 he has been assistant professor in Kuwait University, Faculty of Pharmacy, Department of Pharmacology and Therapeutics. His research interest are molecular targets for the treatment of inflammatory bowel disease (IBD) and the mechanisms responsible for immune cell chemotaxis. He cosupervised many students for the MSc Molecular Biology Program, College of Graduate Studies, Kuwait University. Ever since joining Kuwait University in 2010, he got various grants as PI and Co-I. He was awarded the Best Young Researcher Award by Kuwait University, Research Sector, for the Year 2013–2014. He was a member in the organizing committee for three conferences organized by Kuwait University, Faculty of Pharmacy, as cochair and a member in the scientific committee (the 3rd, 4th, and 5th Kuwait International Pharmacy Conference).",institutionString:"Kuwait University",institution:{name:"Kuwait University",country:{name:"Kuwait"}}},{id:"195136",title:"Dr.",name:"Aya",middleName:null,surname:"Adel",slug:"aya-adel",fullName:"Aya Adel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/195136/images/system/195136.jpg",biography:"Dr. Adel works as an Assistant Lecturer in the unit of Phoniatrics, Department of Otolaryngology, Ain Shams University in Cairo, Egypt. Dr. Adel is especially interested in joint attention and its impairment in autism spectrum disorder",institutionString:"Ain Shams University",institution:{name:"Ain Shams University",country:{name:"Egypt"}}},{id:"94911",title:"Dr.",name:"Boulenouar",middleName:null,surname:"Mesraoua",slug:"boulenouar-mesraoua",fullName:"Boulenouar Mesraoua",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94911/images/system/94911.png",biography:"Dr Boulenouar Mesraoua is the Associate Professor of Clinical Neurology at Weill Cornell Medical College-Qatar and a Consultant Neurologist at Hamad Medical Corporation at the Neuroscience Department; He graduated as a Medical Doctor from the University of Oran, Algeria; he then moved to Belgium, the City of Liege, for a Residency in Internal Medicine and Neurology at Liege University; after getting the Belgian Board of Neurology (with high marks), he went to the National Hospital for Nervous Diseases, Queen Square, London, United Kingdom for a fellowship in Clinical Neurophysiology, under Pr Willison ; Dr Mesraoua had also further training in Epilepsy and Continuous EEG Monitoring for two years (from 2001-2003) in the Neurophysiology department of Zurich University, Switzerland, under late Pr Hans Gregor Wieser ,an internationally known epileptologist expert. \n\nDr B. Mesraoua is the Director of the Neurology Fellowship Program at the Neurology Section and an active member of the newly created Comprehensive Epilepsy Program at Hamad General Hospital, Doha, Qatar; he is also Assistant Director of the Residency Program at the Qatar Medical School. \nDr B. Mesraoua's main interests are Epilepsy, Multiple Sclerosis, and Clinical Neurology; He is the Chairman and the Organizer of the well known Qatar Epilepsy Symposium, he is running yearly for the past 14 years and which is considered a landmark in the Gulf region; He has also started last year , together with other epileptologists from Qatar, the region and elsewhere, a yearly International Epilepsy School Course, which was attended by many neurologists from the Area.\n\nInternationally, Dr Mesraoua is an active and elected member of the Commission on Eastern Mediterranean Region (EMR ) , a regional branch of the International League Against Epilepsy (ILAE), where he represents the Middle East and North Africa(MENA ) and where he holds the position of chief of the Epilepsy Epidemiology Section; Dr Mesraoua is a member of the American Academy of Neurology, the Europeen Academy of Neurology and the American Epilepsy Society.\n\nDr Mesraoua's main objectives are to encourage frequent gathering of the epileptologists/neurologists from the MENA region and the rest of the world, promote Epilepsy Teaching in the MENA Region, and encourage multicenter studies involving neurologists and epileptologists in the MENA region, particularly epilepsy epidemiological studies. \n\nDr. Mesraoua is the recipient of two research Grants, as the Lead Principal Investigator (750.000 USD and 250.000 USD) from the Qatar National Research Fund (QNRF) and the Hamad Hospital Internal Research Grant (IRGC), on the following topics : “Continuous EEG Monitoring in the ICU “ and on “Alpha-lactoalbumin , proof of concept in the treatment of epilepsy” .Dr Mesraoua is a reviewer for the journal \"seizures\" (Europeen Epilepsy Journal ) as well as dove journals ; Dr Mesraoua is the author and co-author of many peer reviewed publications and four book chapters in the field of Epilepsy and Clinical Neurology",institutionString:"Weill Cornell Medical College in Qatar",institution:{name:"Weill Cornell Medical College in Qatar",country:{name:"Qatar"}}},{id:"282429",title:"Prof.",name:"Covanis",middleName:null,surname:"Athanasios",slug:"covanis-athanasios",fullName:"Covanis Athanasios",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/282429/images/system/282429.jpg",biography:null,institutionString:"Neurology-Neurophysiology Department of the Children Hospital Agia Sophia",institution:null},{id:"190980",title:"Prof.",name:"Marwa",middleName:null,surname:"Mahmoud Saleh",slug:"marwa-mahmoud-saleh",fullName:"Marwa Mahmoud Saleh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/190980/images/system/190980.jpg",biography:"Professor Marwa Mahmoud Saleh is a doctor of medicine and currently works in the unit of Phoniatrics, Department of Otolaryngology, Ain Shams University in Cairo, Egypt. She got her doctoral degree in 1991 and her doctoral thesis was accomplished in the University of Iowa, United States. Her publications covered a multitude of topics as videokymography, cochlear implants, stuttering, and dysphagia. She has lectured Egyptian phonology for many years. Her recent research interest is joint attention in autism.",institutionString:"Ain Shams University",institution:{name:"Ain Shams University",country:{name:"Egypt"}}},{id:"259190",title:"Dr.",name:"Syed Ali Raza",middleName:null,surname:"Naqvi",slug:"syed-ali-raza-naqvi",fullName:"Syed Ali Raza Naqvi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259190/images/system/259190.png",biography:"Dr. Naqvi is a radioanalytical chemist and is working as an associate professor of analytical chemistry in the Department of Chemistry, Government College University, Faisalabad, Pakistan. Advance separation techniques, nuclear analytical techniques and radiopharmaceutical analysis are the main courses that he is teaching to graduate and post-graduate students. In the research area, he is focusing on the development of organic- and biomolecule-based radiopharmaceuticals for diagnosis and therapy of infectious and cancerous diseases. Under the supervision of Dr. Naqvi, three students have completed their Ph.D. degrees and 41 students have completed their MS degrees. He has completed three research projects and is currently working on 2 projects entitled “Radiolabeling of fluoroquinolone derivatives for the diagnosis of deep-seated bacterial infections” and “Radiolabeled minigastrin peptides for diagnosis and therapy of NETs”. He has published about 100 research articles in international reputed journals and 7 book chapters. Pakistan Institute of Nuclear Science & Technology (PINSTECH) Islamabad, Punjab Institute of Nuclear Medicine (PINM), Faisalabad and Institute of Nuclear Medicine and Radiology (INOR) Abbottabad are the main collaborating institutes.",institutionString:"Government College University",institution:{name:"Government College University, Faisalabad",country:{name:"Pakistan"}}},{id:"58390",title:"Dr.",name:"Gyula",middleName:null,surname:"Mozsik",slug:"gyula-mozsik",fullName:"Gyula Mozsik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/58390/images/system/58390.png",biography:"Gyula Mózsik MD, Ph.D., ScD (med), is an emeritus professor of Medicine at the First Department of Medicine, Univesity of Pécs, Hungary. He was head of this department from 1993 to 2003. His specializations are medicine, gastroenterology, clinical pharmacology, clinical nutrition, and dietetics. His research fields are biochemical pharmacological examinations in the human gastrointestinal (GI) mucosa, mechanisms of retinoids, drugs, capsaicin-sensitive afferent nerves, and innovative pharmacological, pharmaceutical, and nutritional (dietary) research in humans. He has published about 360 peer-reviewed papers, 197 book chapters, 692 abstracts, 19 monographs, and has edited 37 books. He has given about 1120 regular and review lectures. He has organized thirty-eight national and international congresses and symposia. He is the founder of the International Conference on Ulcer Research (ICUR); International Union of Pharmacology, Gastrointestinal Section (IUPHAR-GI); Brain-Gut Society symposiums, and gastrointestinal cytoprotective symposiums. He received the Andre Robert Award from IUPHAR-GI in 2014. Fifteen of his students have been appointed as full professors in Egypt, Cuba, and Hungary.",institutionString:"University of Pécs",institution:{name:"University of Pecs",country:{name:"Hungary"}}},{id:"277367",title:"M.Sc.",name:"Daniel",middleName:"Martin",surname:"Márquez López",slug:"daniel-marquez-lopez",fullName:"Daniel Márquez López",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/277367/images/7909_n.jpg",biography:"Msc Daniel Martin Márquez López has a bachelor degree in Industrial Chemical Engineering, a Master of science degree in the same área and he is a PhD candidate for the Instituto Politécnico Nacional. His Works are realted to the Green chemistry field, biolubricants, biodiesel, transesterification reactions for biodiesel production and the manipulation of oils for therapeutic purposes.",institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"196544",title:"Prof.",name:"Angel",middleName:null,surname:"Catala",slug:"angel-catala",fullName:"Angel Catala",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/196544/images/system/196544.jpg",biography:"Angel Catalá studied chemistry at Universidad Nacional de La Plata, Argentina, where he received a Ph.D. in Chemistry (Biological Branch) in 1965. From 1964 to 1974, he worked as an Assistant in Biochemistry at the School of Medicine at the same university. From 1974 to 1976, he was a fellow of the National Institutes of Health (NIH) at the University of Connecticut, Health Center, USA. From 1985 to 2004, he served as a Full Professor of Biochemistry at the Universidad Nacional de La Plata. He is a member of the National Research Council (CONICET), Argentina, and the Argentine Society for Biochemistry and Molecular Biology (SAIB). His laboratory has been interested for many years in the lipid peroxidation of biological membranes from various tissues and different species. Dr. Catalá has directed twelve doctoral theses, published more than 100 papers in peer-reviewed journals, several chapters in books, and edited twelve books. He received awards at the 40th International Conference Biochemistry of Lipids 1999 in Dijon, France. He is the winner of the Bimbo Pan-American Nutrition, Food Science and Technology Award 2006 and 2012, South America, Human Nutrition, Professional Category. In 2006, he won the Bernardo Houssay award in pharmacology, in recognition of his meritorious works of research. Dr. Catalá belongs to the editorial board of several journals including Journal of Lipids; International Review of Biophysical Chemistry; Frontiers in Membrane Physiology and Biophysics; World Journal of Experimental Medicine and Biochemistry Research International; World Journal of Biological Chemistry, Diabetes, and the Pancreas; International Journal of Chronic Diseases & Therapy; and International Journal of Nutrition. He is the co-editor of The Open Biology Journal and associate editor for Oxidative Medicine and Cellular Longevity.",institutionString:"Universidad Nacional de La Plata",institution:{name:"National University of La Plata",country:{name:"Argentina"}}},{id:"186585",title:"Dr.",name:"Francisco Javier",middleName:null,surname:"Martin-Romero",slug:"francisco-javier-martin-romero",fullName:"Francisco Javier Martin-Romero",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSB3HQAW/Profile_Picture_1631258137641",biography:"Francisco Javier Martín-Romero (Javier) is a Professor of Biochemistry and Molecular Biology at the University of Extremadura, Spain. He is also a group leader at the Biomarkers Institute of Molecular Pathology. Javier received his Ph.D. in 1998 in Biochemistry and Biophysics. At the National Cancer Institute (National Institute of Health, Bethesda, MD) he worked as a research associate on the molecular biology of selenium and its role in health and disease. After postdoctoral collaborations with Carlos Gutierrez-Merino (University of Extremadura, Spain) and Dario Alessi (University of Dundee, UK), he established his own laboratory in 2008. The interest of Javier's lab is the study of cell signaling with a special focus on Ca2+ signaling, and how Ca2+ transport modulates the cytoskeleton, migration, differentiation, cell death, etc. He is especially interested in the study of Ca2+ channels, and the role of STIM1 in the initiation of pathological events.",institutionString:null,institution:{name:"University of Extremadura",country:{name:"Spain"}}},{id:"198499",title:"Dr.",name:"Daniel",middleName:null,surname:"Glossman-Mitnik",slug:"daniel-glossman-mitnik",fullName:"Daniel Glossman-Mitnik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/198499/images/system/198499.jpeg",biography:"Dr. Daniel Glossman-Mitnik is currently a Titular Researcher at the Centro de Investigación en Materiales Avanzados (CIMAV), Chihuahua, Mexico, as well as a National Researcher of Level III at the Consejo Nacional de Ciencia y Tecnología, México. His research interest focuses on computational chemistry and molecular modeling of diverse systems of pharmacological, food, and alternative energy interests by resorting to DFT and Conceptual DFT. He has authored a coauthored more than 270 peer-reviewed papers, 32 book chapters, and 4 edited books. He has delivered speeches at many international and domestic conferences. He serves as a reviewer for more than eighty international journals, books, and research proposals as well as an editor for special issues of renowned scientific journals.",institutionString:null,institution:null},{id:"217323",title:"Prof.",name:"Guang-Jer",middleName:null,surname:"Wu",slug:"guang-jer-wu",fullName:"Guang-Jer Wu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/217323/images/8027_n.jpg",biography:null,institutionString:null,institution:null},{id:"148546",title:"Dr.",name:"Norma Francenia",middleName:null,surname:"Santos-Sánchez",slug:"norma-francenia-santos-sanchez",fullName:"Norma Francenia Santos-Sánchez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/148546/images/4640_n.jpg",biography:null,institutionString:null,institution:null},{id:"272889",title:"Dr.",name:"Narendra",middleName:null,surname:"Maddu",slug:"narendra-maddu",fullName:"Narendra Maddu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272889/images/10758_n.jpg",biography:null,institutionString:null,institution:null},{id:"242491",title:"Prof.",name:"Angelica",middleName:null,surname:"Rueda",slug:"angelica-rueda",fullName:"Angelica Rueda",position:"Investigador Cinvestav 3B",profilePictureURL:"https://mts.intechopen.com/storage/users/242491/images/6765_n.jpg",biography:null,institutionString:null,institution:null},{id:"88631",title:"Dr.",name:"Ivan",middleName:null,surname:"Petyaev",slug:"ivan-petyaev",fullName:"Ivan Petyaev",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Lycotec (United Kingdom)",country:{name:"United Kingdom"}}},{id:"428313",title:"Dr.",name:"Sambangi",middleName:null,surname:"Pratyusha",slug:"sambangi-pratyusha",fullName:"Sambangi Pratyusha",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"CGIAR",country:{name:"France"}}},{id:"423869",title:"Ms.",name:"Smita",middleName:null,surname:"Rai",slug:"smita-rai",fullName:"Smita Rai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Integral University",country:{name:"India"}}},{id:"424024",title:"Prof.",name:"Swati",middleName:null,surname:"Sharma",slug:"swati-sharma",fullName:"Swati Sharma",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Integral University",country:{name:"India"}}},{id:"439112",title:"MSc.",name:"Touseef",middleName:null,surname:"Fatima",slug:"touseef-fatima",fullName:"Touseef Fatima",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Integral University",country:{name:"India"}}}]}},subseries:{item:{id:"2",type:"subseries",title:"Prosthodontics and Implant Dentistry",keywords:"Osseointegration, Hard tissue, Peri-implant soft tissue, Restorative materials, Prosthesis design, Prosthesis, Patient satisfaction, Rehabilitation",scope:"