Medications commonly used for atrial fibrillation
\\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
\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:"7132",leadTitle:null,fullTitle:"Complications of Pregnancy",title:"Complications of Pregnancy",subtitle:null,reviewType:"peer-reviewed",abstract:"Complications of pregnancy are health issues that are caused by pregnancy itself. These can happen during or after delivery (obstetric labor complications or puerperal disorders). Complications can be classified as mild, severe, immediate, or long-term health problems. Complications of pregnancy can cause maternal morbidity and mortality. The most common causes of maternal mortality are maternal bleeding, maternal sepsis, hypertensive diseases, obstructed labor, and pregnancy with the consequence of abortion, which includes miscarriage, ectopic pregnancy, and medical abortion.Heath problems can develop during pregnancy, which may be directly related to the pregnancy itself or nonobstetric disorders, such as pregnancy complicated by medical diseases. One of the main complications is obstetric abnormalities that increase the risk of morbidity or mortality for the pregnant woman and her fetus. High-risk pregnancy is an indicator of a maternal complication during pregnancy.",isbn:"978-1-83880-489-3",printIsbn:"978-1-83880-488-6",pdfIsbn:"978-1-83881-045-0",doi:"10.5772/intechopen.73930",price:119,priceEur:129,priceUsd:155,slug:"complications-of-pregnancy",numberOfPages:132,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"d2bdac8e99a71feab10bd0b9e1063bb9",bookSignature:"Hassan Abduljabbar",publishedDate:"June 12th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/7132.jpg",numberOfDownloads:8533,numberOfWosCitations:1,numberOfCrossrefCitations:6,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:13,numberOfDimensionsCitationsByBook:1,hasAltmetrics:1,numberOfTotalCitations:20,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 14th 2018",dateEndSecondStepPublish:"August 28th 2018",dateEndThirdStepPublish:"October 27th 2018",dateEndFourthStepPublish:"January 15th 2019",dateEndFifthStepPublish:"March 16th 2019",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"68175",title:"Prof.",name:"Hassan",middleName:"S",surname:"Abduljabbar",slug:"hassan-abduljabbar",fullName:"Hassan Abduljabbar",profilePictureURL:"https://mts.intechopen.com/storage/users/68175/images/system/68175.png",biography:"Hassan S. Abduljabbar, MD, FRCSC, American Board Diplomate, is a professor at the College of Medicine, King Abdulaziz\nUniversity, Saudi Arabia. He is also the president of the Saudi Society of Obstetrics and Gynecology and the Federation of Arab\nGynecology Obstetric Societies (FAGOS). He is a referee for\nmany international scientific journals. He is also an examiner for\ngraduate degrees as well as for the Saudi and Arab board exams.\nDr. Abduljabbar has published more than fifty articles and edited three books.",institutionString:"Dr. Erfan & Bagedo General Hospital",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"7",institution:{name:"King Abdulaziz University",institutionURL:null,country:{name:"Saudi Arabia"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"189",title:"Obstetrics and Gynecology",slug:"obstetrics-and-gynecology"}],chapters:[{id:"64142",title:"Placental Abnormalities",doi:"10.5772/intechopen.81579",slug:"placental-abnormalities",totalDownloads:1531,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"A detailed discussion of normal placental development and physiology is beyond the scope of this chapter and is discussed in other chapters. Instead, this chapter will focus on an overview of congenital placental abnormalities and the obstetrical complications that can arise. The goal of this chapter is to delineate the real-world implications of placental abnormalities and provide the reader with a basis for understanding the other chapters that will delve into microbiology, genomics, immunohistochemistry, and biochemistry of the placenta. The focus of this chapter will be on the developmental anomalies and this chapter will not discuss acquired anomalies (e.g., chorioamnionitis, amnion nodosum, metastatic tumors, and umbilical cord true knots). As the intention of this chapter is to focus on the etiopathogenesis of abnormal placentation, it is not intended to instruct the medical management of the described conditions, and therefore the discussions of management will be brief. The information provided is intended for general knowledge only and is not intended for use in diagnosing or treating a health problem or disease without consultation with a qualified healthcare provider. This chapter is not a substitute for professional medical advice, or treatment for specific medical conditions.",signatures:"Alexander L. Juusela",downloadPdfUrl:"/chapter/pdf-download/64142",previewPdfUrl:"/chapter/pdf-preview/64142",authors:[{id:"251181",title:"M.D.",name:"Alexander",surname:"Juusela",slug:"alexander-juusela",fullName:"Alexander Juusela"}],corrections:null},{id:"65996",title:"Miscarriage and Maternal Health",doi:"10.5772/intechopen.82117",slug:"miscarriage-and-maternal-health",totalDownloads:1107,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Miscarriage also known as spontaneous abortion is the termination of pregnancy before the age of fetal viability or expulsion of fetus or embryo weighing less than 500g. It occurs naturally without any human intervention and complicates about 15–20% pregnancies globally. The age of fetal viability varies from country to country depending on the level of technological development and fetal salvage rate. The age of fetal viability in Norway is 16 weeks, in Australia its 20 weeks, 24 weeks in the UK, 26 weeks in Spain and Italy while in Nigeria the age of fetal viability is 28 weeks of gestation. Causes of miscarriage include morphologic/genetic/chromosomal abnormalities, immunological and endocrine factors, structural uterine anomalies, cervical incompetence, maternal infections and toxins. It is classified into threatened miscarriage, inevitable miscarriage, incomplete miscarriage, septic miscarriage, missed miscarriage and complete miscarriage. Miscarriage has profound and tremendous psychologic and emotional effects on mothers before or during subsequent gestations. Every effort must be made to show understanding and empathy.",signatures:"John D. Ojule and Rosemary N. Ogu",downloadPdfUrl:"/chapter/pdf-download/65996",previewPdfUrl:"/chapter/pdf-preview/65996",authors:[{id:"213063",title:"Prof.",name:"Rosemary",surname:"Ogu",slug:"rosemary-ogu",fullName:"Rosemary Ogu"},{id:"262641",title:"Dr.",name:"John",surname:"Ojule",slug:"john-ojule",fullName:"John Ojule"}],corrections:null},{id:"65047",title:"Assessment of Fetal Gestational Age in the First Trimester in Normal and Abnormal Pregnancies: Which Sonographic Parameter to Use?",doi:"10.5772/intechopen.82746",slug:"assessment-of-fetal-gestational-age-in-the-first-trimester-in-normal-and-abnormal-pregnancies-which-",totalDownloads:957,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"To compare the correlation of various fetal ultrasound parameters to foot length, crown-rump length, and gestational age by date to determine the best estimate at 10–14 completed weeks’ gestation and to provide ratios of fetal parameters for assessment of fetal abnormalities in the first trimester. 35 routine obstetric scans were performed at 10–14 completed weeks’ gestation for fetal parameters and ratios. The fetal crown-rump length (CRL), biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) showed a linear correlation with the estimated gestational age by date (GA), crown-rump length (CRL), and foot length (FT) (p < 0.001), with the least correlation observed with GA and highest with FT. A combination of BPD, HC, AC, and FL correlated best with FT and then CRL and GA (R2 = 0.881, 0.795, and 0.685, respectively, p < 0.001). With the addition of CRL, R2 was 0.859. The ratio of FL/AC and FL/FT to FT, CRL, GA, BPD, and HC increases in an inverse relationship at 10–14 completed weeks’ gestation. The combination of BPD, HC, AC, and FL provides a better estimation of gestational age than (and hence may replace) CRL or GA at 10–14 weeks’ gestation.",signatures:"Hong Soo Wong",downloadPdfUrl:"/chapter/pdf-download/65047",previewPdfUrl:"/chapter/pdf-preview/65047",authors:[{id:"271674",title:"Dr.",name:"Hong Soo",surname:"Wong",slug:"hong-soo-wong",fullName:"Hong Soo Wong"}],corrections:null},{id:"64950",title:"Undernutrition during Pregnancy",doi:"10.5772/intechopen.82727",slug:"undernutrition-during-pregnancy",totalDownloads:1615,totalCrossrefCites:1,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Experience in being pregnant is exciting but is very challenging. The term “undernutrition,” as used in this chapter, focuses more on inadequate intake of energy and nutrients to meet the desired outcome of a healthy mother and her baby. Evidence shows that women with undernutrition before and during pregnancy have increased risk of metabolic disorders (i.e., gestational diabetes mellitus) and are at increased risk of complications during labor and birth. To date, nutritional therapies promoting healthier pregnancies fall into the following two major categories: (1) management of gestational weight gain and (2) the prevention or treatment of nutrient deficiencies related to pregnancy. A literature search on PubMed, the Cochrane library, Google scholar, and Cumulative Index of Nursing and Allied Health Literature was conducted to identify the relevant nutritional therapies. As a result, this chapter will analyze and discuss gestational weight gain and its effect on the health of women and her baby. The chapter briefly proposes evidence-based nutritional therapy for gestational diabetes as well as gestational common nutrient imbalance, such as vitamin D, folic acid, and omega-3 docosahexaenoic acid deficiency. The recommendations, in this chapter, would be a partial answer for these problems in Asia.",signatures:"Hoang Anh Nguyen",downloadPdfUrl:"/chapter/pdf-download/64950",previewPdfUrl:"/chapter/pdf-preview/64950",authors:[{id:"277012",title:"M.Sc.",name:"Anh Hoang",surname:"Nguyen",slug:"anh-hoang-nguyen",fullName:"Anh Hoang Nguyen"}],corrections:null},{id:"65356",title:"Hydrops Fetalis",doi:"10.5772/intechopen.83443",slug:"hydrops-fetalis",totalDownloads:1214,totalCrossrefCites:0,totalDimensionsCites:2,hasAltmetrics:0,abstract:"The abnormal accumulation of fluid in two or more fetal space and in some cases is associated with placental edema and polyhydramnios. This can be seen in all trimesters. It is classified as immune and nonimmune fetal hydrops. Immune hydrops fetalis-rhesus alloimmunization and other blood group antibodies cause hemolytic disease of the newborn. Nonimmune hydrops fetalis can be largely divided as fetal, maternal, placental and idiopathic. Pathophysiology, investigations, treatment and counseling are outlined.",signatures:"Renuka Sekar",downloadPdfUrl:"/chapter/pdf-download/65356",previewPdfUrl:"/chapter/pdf-preview/65356",authors:[{id:"270919",title:"Dr.",name:"Renuka",surname:"Sekar",slug:"renuka-sekar",fullName:"Renuka Sekar"}],corrections:null},{id:"66384",title:"Maternal and Fetal Complications Due to Decreased Nitric Oxide Synthesis during Gestation",doi:"10.5772/intechopen.85383",slug:"maternal-and-fetal-complications-due-to-decreased-nitric-oxide-synthesis-during-gestation",totalDownloads:1015,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Nitric oxide (NO) is synthesized from L-arginine by the constitutive NO synthase in vascular endothelial cells and plays an important role in the regulation of blood pressure and coronary vasomotion. Normal pregnancy is associated with major adaptations in maternal cardiovascular function, which help the woman to accommodate the growing fetus. The vascular endothelium is stimulated during pregnancy to release increased amounts of NO, and the abnormality in the L-arginine NO pathway may play a role in the etiology of preeclampsia. The objective of this study is to discuss the importance of nitric oxide during gestation and the maternal and fetal complications associated with decreased NO synthesis during this period. Maternal arterial hypertension due to inhibition of nitric oxide synthesis during pregnancy impairs fetal development, mainly the reduction of the wall/lumen ratio of the cardiac and renal microvasculature as well as the reduction in the number of nephrons. These changes may contribute to the development of hypertension. Despite these findings, more studies are needed to understand the programming of fetal development, and the intrauterine environmental factors. influence this process.",signatures:"Sonia Jurado, Kaelly Saraiva, Cauane Marceliano, Vanessa Souza and Izabela Vieira",downloadPdfUrl:"/chapter/pdf-download/66384",previewPdfUrl:"/chapter/pdf-preview/66384",authors:[{id:"270974",title:"Ph.D.",name:"Sonia",surname:"Jurado",slug:"sonia-jurado",fullName:"Sonia Jurado"},{id:"272785",title:"Dr.",name:"Kaelly",surname:"Saraiva",slug:"kaelly-saraiva",fullName:"Kaelly Saraiva"},{id:"284172",title:"BSc.",name:"Cauane",surname:"Marceliano",slug:"cauane-marceliano",fullName:"Cauane Marceliano"},{id:"284174",title:"BSc.",name:"Vanessa",surname:"Souza",slug:"vanessa-souza",fullName:"Vanessa Souza"},{id:"284176",title:"BSc.",name:"Izabela",surname:"Vieira",slug:"izabela-vieira",fullName:"Izabela Vieira"}],corrections:null},{id:"66744",title:"Alloimmunization and Role of HLA in Pregnancy",doi:"10.5772/intechopen.84211",slug:"alloimmunization-and-role-of-hla-in-pregnancy",totalDownloads:1099,totalCrossrefCites:4,totalDimensionsCites:6,hasAltmetrics:1,abstract:"Alloimmunization also known as isoimmunization, during pregnancy is the production of IgG antibodies by the mother against the paternally inherited antigens (IPA) in the foetus/newborn. The alloimmunization during pregnancy leads to various alloimmune disorders, such as, haemolytic disease of the foetus and newborn (HDFN), neonatal alloimmune neutropenia (NAN) and foetal and neonatal alloimmune thrombocytopenia (FNAIT) due to the production of maternal alloantibodies against the red blood cell antigen, neutrophils and platelets cell antigens, respectively. Recent studies suggest that maternal anti-HLA class I alloantibodies may also be the cause of FNAIT in addition to antibodies against platelet antigens. On the contrary, studies have also suggested that HLA-C, a classical HLA class I molecule, and HLA-G, a nonclassical HLA molecule, play an important role in placentation and modulation of the maternal immune system during pregnancy, respectively, and thereby leading to acceptance of the semi allogeneic fetus. So far most of the studies have discussed alloimmunization in pregnancy relating to Rh antigen. Thus, in this chapter an attempt has been made to discuss alloimmunization in pregnancy caused because of maternal alloantibody against HLA antigen and its role in immune modulation during pregnancy.",signatures:"Meenakshi Singh, Jyoti Rajak, Shalaka Kadam and Sunil B. Rajadhyaksha",downloadPdfUrl:"/chapter/pdf-download/66744",previewPdfUrl:"/chapter/pdf-preview/66744",authors:[{id:"267032",title:"Dr.",name:"Meenakshi",surname:"Singh",slug:"meenakshi-singh",fullName:"Meenakshi Singh"},{id:"268554",title:"Ms.",name:"Jyoti",surname:"Rajak",slug:"jyoti-rajak",fullName:"Jyoti Rajak"},{id:"268555",title:"Ms.",name:"Shalaka",surname:"Kadam",slug:"shalaka-kadam",fullName:"Shalaka Kadam"},{id:"280190",title:"Dr.",name:"Sunil",surname:"Rajadhyaksha",slug:"sunil-rajadhyaksha",fullName:"Sunil Rajadhyaksha"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"10485",title:"Fibroids",subtitle:null,isOpenForSubmission:!1,hash:"64ad14b1aba83e47fb100fa63e21533e",slug:"fibroids",bookSignature:"Hassan Abduljabbar",coverURL:"https://cdn.intechopen.com/books/images_new/10485.jpg",editedByType:"Edited by",editors:[{id:"68175",title:"Prof.",name:"Hassan",surname:"Abduljabbar",slug:"hassan-abduljabbar",fullName:"Hassan Abduljabbar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7969",title:"Leiomyoma",subtitle:null,isOpenForSubmission:!1,hash:"659a9fef0f90168b2184c86af85d3a42",slug:"leiomyoma",bookSignature:"Hassan Abduljabbar",coverURL:"https://cdn.intechopen.com/books/images_new/7969.jpg",editedByType:"Edited by",editors:[{id:"68175",title:"Prof.",name:"Hassan",surname:"Abduljabbar",slug:"hassan-abduljabbar",fullName:"Hassan Abduljabbar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2013",title:"Steroids",subtitle:"Clinical Aspect",isOpenForSubmission:!1,hash:"31dfd32a77f71bc348d7922af48b8e62",slug:"steroids-clinical-aspect",bookSignature:"Hassan Abduljabbar",coverURL:"https://cdn.intechopen.com/books/images_new/2013.jpg",editedByType:"Edited by",editors:[{id:"68175",title:"Prof.",name:"Hassan",surname:"Abduljabbar",slug:"hassan-abduljabbar",fullName:"Hassan Abduljabbar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"814",title:"Steroids",subtitle:"Basic Science",isOpenForSubmission:!1,hash:"74304f5d822f8f45d4b48a0e00ebd375",slug:"steroids-basic-science",bookSignature:"Hassan Abduljabbar",coverURL:"https://cdn.intechopen.com/books/images_new/814.jpg",editedByType:"Edited by",editors:[{id:"68175",title:"Prof.",name:"Hassan",surname:"Abduljabbar",slug:"hassan-abduljabbar",fullName:"Hassan Abduljabbar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5937",title:"Obstetrics",subtitle:null,isOpenForSubmission:!1,hash:"092197b1191815505a23e7dd1c9edde6",slug:"obstetrics",bookSignature:"Hassan Salah Abduljabbar",coverURL:"https://cdn.intechopen.com/books/images_new/5937.jpg",editedByType:"Edited by",editors:[{id:"68175",title:"Prof.",name:"Hassan",surname:"Abduljabbar",slug:"hassan-abduljabbar",fullName:"Hassan Abduljabbar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10721",title:"Preeclampsia",subtitle:null,isOpenForSubmission:!1,hash:"eb38592b7a656d02dd6b28c34e43de32",slug:"preeclampsia",bookSignature:"Hassan Abduljabbar",coverURL:"https://cdn.intechopen.com/books/images_new/10721.jpg",editedByType:"Edited by",editors:[{id:"68175",title:"Prof.",name:"Hassan",surname:"Abduljabbar",slug:"hassan-abduljabbar",fullName:"Hassan Abduljabbar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6191",title:"Selected Topics in Breastfeeding",subtitle:null,isOpenForSubmission:!1,hash:"3334b831761ffa52e78de6fc681e33b3",slug:"selected-topics-in-breastfeeding",bookSignature:"R. 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Although most of these arrhythmias are transient and have a benign course, it may prolong intensive care and hospital stay, and in rare instances, it may lead to mortality. Postoperative arrhythmias (POAs) include atrial tachyarrhythmias (ATs) and to a lesser extent ventricular arrhythmias (VAs) and bradyarrhythmias [1]. The incidence of POAs has not changed despite improvements in anesthetic and surgical techniques, and evidence suggests that its incidence may be increasing [2].
\nThe clinical significance of each arrhythmia depends on several factors that include underlying cardiac function, patient’s comorbidities, arrhythmia duration, and ventricular response rate. So, POAs could be tolerated in some patients and a source of morbidity and mortality in others, depending on the interaction between these factors [1, 3]. Rapid ventricular rates with tachycardia can cause diastolic and later on systolic dysfunction, reduce cardiac output, and result in hypotension or myocardial ischemia [4, 5]. Bradydysrhythmias, particularly with the loss of atrial function, may have a remarkable influence on patients with systolic or diastolic ventricular dysfunction [6].
\nArrhythmia management starts preoperatively with optimization of the patient’s condition and controlling patient’s risk factors. Intraoperatively, it includes careful attention to hemodynamic changes during surgery and uses appropriate anesthesia. Postoperatively, it includes correction of temporary and correctable predisposing factors, as well as specific therapy for the arrhythmia itself [7]. The POAs treatment urgency and management options are determined by the clinical presentation of the arrhythmia [7]. Self-terminating arrhythmias without overt cardiac disease often need no therapy. However, arrhythmias with hemodynamic instability, especially in patients with critical stress conditions like systemic infections or persistent pericardial effusion need urgent intervention to restore a stable clinical status [7].
\nThe aim of this chapter is to review post-CABG arrhythmias pathophysiology and management.
\nThe primary function of CABG is to reestablish perfusion to ischemic myocardium with utilizing autologous arteries and veins. This may be achieved by using different surgical techniques. The POAs pathophysiology, incidence, and clinical course may vary depending on the surgical techniques used. Initially, cardiac surgeries were performed on a beating heart, but with the development of cardiopulmonary bypass (CPB) machine and cardioplegia, most CABG surgeries were performed on a pump. However, interest in off-pump coronary artery bypass (OPCAB) surgery had revived in the 1990s [8]. Reported potential benefits of OPCAB include lower end-organ damage with less cerebrovascular accidents (CVA), fewer cognitive deficits, renal failure, less psychomotor defects, reduced systemic inflammation, and lower transfusion rates [9]. However, variable outcomes have been reported in studies comparing these strategies [9]. Minimally invasive surgery without use of CPB and through smaller incisions- and robotic-assisted approaches have also been developed [9]. This method is most often used for left internal mammary artery (LIMA) to left anterior descending artery (LAD) grafts. Additional benefits may also include reduced operative time, reduced recovery time, decreased the need for blood transfusion, less time under anesthesia, reduced duration of ICU stay, less pain, and an estimated 40% savings over conventional CABG [10].
\nThe development of POAs is related to factors that influence the atrial and ventricular myocardium. These primarily include: a previous
Several perioperative risk factors have been implicated in atrial and ventricular susceptibility to POAs, but their relative role is still uncertain. Risk factors for POAs may be classified into patient- and surgery-related factors [7].
\nVarious patient-related risk factors have been described to cause POAs. These include:
\nIncreasing age is associated with age-related structural and electrophysiological changes that may lead to postoperative atrial tachyarrhythmias in the elderly. Old age has been demonstrated to be correlated with the development of POAs [2, 3, 12–14].
\nPatients with underlying structural heart disease are at higher risk of developing POAs compared to patients with a normal heart. Structural heart disease in the atria and ventricles provides a substrate for arrhythmia via abnormal automaticity, triggered activity, or reentry. Cardiac surgery patients often have the substrate of atrial enlargement and elevation of atrial pressures may function as a substrate for atrial arrhythmias. It is well known that large atrial size and fibrosis supports propagation of atrial reentrant circuits and helps in maintaining atrial fibrillation (AF). Similarly, patients with ventricular dysfunction, ventricular dilation, or fibrosis are at higher risk of having ventricular arrhythmias [4]. Other important risk factors for POAs include previous history of arrhythmias (e.g., AF), cardiac surgery, and POAs. Also, severe right coronary artery stenosis [15], sinus nodal or atrioventricular nodal branch disease [13, 16, 17], and mitral valvular disease (particularly rheumatic mitral stenosis) have been reported as risk factors for POAs. The preoperative brain natriuretic peptide plasma concentration is another predictor of POAs [18].
\nCardiac surgery may lead to POAs via multiple surgery-related mechanisms and risk factors that include:
\nCardiac surgery provokes a vigorous inflammatory response due to a variety of metabolic, endocrine, and immune changes known as the “stress response,” which has important clinical implications [21, 22] (Figure 1). Surgical trauma, blood loss or transfusion, hypothermia, and CPB are nonspecific activators of the inflammatory response [18, 19]. Surgical trauma may contribute to a higher degree of the inflammatory response compared to CPB [23]. These effects predispose to atrial and ventricular arrhythmias in the early postoperative period. Inflammatory mechanisms have been proposed for the development of postoperative AF (POAF) as its incidence peaks at early postoperative days. Inflammation may be related to the development of clinically aberrant or silent pericarditis. Unfortunately, clinical criteria, such as fever, pleuritic chest pain, pericardial rubs, and electrocardiogram changes correlate poorly with postoperative pericarditis and supraventricular arrhythmias [7]. However, patients with pericardial effusion in one study had a higher incidence of supraventricular arrhythmias (63% compared with 11% in patients without effusions) [24].
\nPathophysiologic changes in response to cardiopulmonary bypass and the extracorporeal circulation. ROS, reactive oxygen species; SIRS, systemic inflammatory response syndrome (from Ref. [
Atrial and ventricular hemodynamic changes during CABG predispose to POAs. The risk factors for POAs include atrial changes at the time of cardiac surgery, such as acute atrial trauma from cannulation, enlargement, hypertension, and ischemia [7]. Postoperative pulmonary edema and postoperative pleural effusion requiring thoracentesis have also been described as possible risk factors [25]. Hemodynamic changes might trigger focal arrhythmias [7]. It is possible that atrial stretch, hypertension, pressure and volume shifts, and heightened catecholamine states can trigger AF foci from the pulmonary veins [26].
\nThe coronary blood flow is interrupted during CABG surgery and CPB, and the heart is put under circulatory arrest. This interruption of coronary blood flow causes ischemia-reperfusion injury that is exacerbated by adverse neutrophil-mediated myocardial inflammation and injury [27–29]. Atrial and ventricular ischemia or infarction triggers POAs [30]. Myocardial focal ischemia may occur due to endogenous or exogenous catecholamines, hypoxemia, hypercarbia, acid-base imbalances, drug effects, and mechanical factors. CPB, cross-clamp times, type of cardioplegia, and CABG surgical technique are also critical in determining ischemic injury. The incidence of AF has been demonstrated to be lower after OPCAB than conventional CABG. OPCAB is also associated with a lesser degree of inflammation [21].
\nBeta-blocker withdrawal has been associated with an increased rate of postoperative supraventricular arrhythmias [31]. In contrary, some studies showed that preoperative digoxin use is a risk factor for POAs [2, 32], but not in the others [33]. Intravenous inotropic agents may be associated with POAs in some patients. The reported primary arrhythmias are sinus tachycardia (ST) and premature ventricular beats (PVCs), although other supraventricular (SVT) or ventricular arrhythmias (VT) have been reported. Clinically significant proarrhythmic effects with these agents appear to occur rarely. At conventional doses, intravenous inotropic agents are relatively safe concerning proarrhythmic effects. Inotropic agents increase sinoatrial node automaticity and decrease atrioventricular (AV) nodal conduction time [34, 35]. Dobutamine use has been reported to induce ventricular ectopic activity in 3–15% of patients [34]. Dopamine is more likely to be associated with a dose-related ST or AF [34]. Finally, short-term intravenous administration of the phosphodiesterase inhibitors amrinone and milrinone has been reported to cause PVCs and short runs of VT in up to 17% of patients [34]. Amiodarone and sotalol are useful and can be considered appropriate alternatives in high-risk patients [36]. Patients who need urgent CABG may benefit from intravenous and oral amiodarone combination in addition to beta-blockers. Although corticosteroids are associated with risk, it may be considered in selected CABG patients [36].
\nHypokalemia leads to alteration of the electrophysiologic properties of cardiac myocytes with an increase in the action potential duration (increase in phase-3 depolarization), enhanced automaticity (increased slope of diastolic depolarization), and decreased conduction velocity [37]. These changes may provoke POAs [37]. Preoperative serum potassium levels of <3.5 mmol/L have a significant association with perioperative arrhythmias in patients undergoing elective CABG surgery [37].This association might be particularly evident in the atria, where changes in inward-rectifier potassium currents are supposed to act as profibrillatory mechanisms [38]. However, hypokalemia is more likely to be associated with VAs [38]. Moreover, it is worth noting that arrhythmogenesis is often multifactorial. Catecholamine release increases cellular potassium uptake and thus decreases serum potassium levels [39]. Serum potassium levels greater than 5.5 mmol/L appear to be associated with the development of POAF and atrial flutter (AFL) [37]. The role of magnesium remains controversial. The low serum magnesium levels—which is frequently seen after cardiac surgery—correlate with an increased incidence of POAs [7]. However, magnesium supplementation has produced conflicting results. Magnesium supplementation should be considered in all patients with hypomagnesemia [40–41].
\nThe human epicardial fat pads (FPs) contain parasympathetic ganglia [42]. There are two posterior FPs with the first one located in the superior vena caval-atrial junction and contains postganglionic fibers that lead to the sinoatrial (SA) node. The second FP is located at the pulmonary vein-left atrium and contains postganglionic fibers that lead to the atrioventricular (AV) node [43–45]. The anterior epicardial FP located in the aortopulmonary window that is routinely dissected and removed in CABG because it is located where the aortic cross-clamp is typically placed. Preservation of the human anterior epicardial FP during CABG decreases the incidence of POAF in one study [46], but not in another more recent study [47].
\nAF is the most common complication seen after CABG surgery. The incidence of POAF is approximately 30% after isolated CABG, 40% after valve replacements or repair, and about 50% after combined CABG and valve surgeries [2, 48–51]. The incidence of POAF increases with older age [2, 52, 53].
\nThe diagnosis of POAF is confirmed based on the telemetry and 12-lead electrocardiogram (ECG) recordings with an abrupt change in heart rate and rhythm, and loss of P waves [16, 54]. Atrial electrograms obtained from temporary atrial epicardial pacing wires that are often routinely placed at the time of cardiac surgery can be helpful in confirming the diagnosis of AF, AFL, and other forms of supraventricular tachycardia (SVTs) [54].
\nPOAF usually occurs within 2–4 days after cardiac surgery, with a peak incidence on the second postoperative day [12, 55]. In POAF patients without a prior history of atrial arrhythmias, AF is usually self-limited. About 15–30% of POAF convert to sinus rhythm within 2 h and up to 80% within 24 h [56, 57]. The mean duration of AF in one report was 11–12 h [57], and >90% of the patients were in sinus rhythm 6–8 weeks after surgery [57, 58]. In another study, only 2 out of 112 patients who had paroxysmal AF after CABG were still in AF at 6 weeks [59].
\nAlthough POAF is often self-limiting, its clinical effects depend on ventricular rate, ventricular function, arrhythmia duration, symptoms, hemodynamic stability, and risk of thromboembolism. [60]. POAF is associated with increased postoperative thromboembolic risk and stroke [25, 60–62]. In a series of 4507 patients, the incidence of stroke was significantly higher in those who developed POAF (3.3 versus 1.4%) [2]. Patient’s underlying comorbidities, such as older age, previous cerebrovascular disease (CVA), the presence of a carotid bruit, peripheral vascular disease (PVD), and CPB time, have an important role in the development of in-hospital stroke [63–65]. In a review of 2972 patients undergoing CABG and/or valve surgery, POAF was associated with late onset stroke only if accompanied by a low cardiac output syndrome (3.9 versus 1.9%) [66]. Besides, POAF development is associated with a prolonged length of hospitalization [2, 25, 54]. The POAF is associated with an additional 2–4 days hospital stay after CABG surgery with an additional cost [54]. However, this effect seems to be less prominent with current cardiac surgical care [67]. Additionally, POAF may result in hemodynamic compromise [68], ventricular dysrhythmias [2], and iatrogenic complications associated with therapeutic interventions [53]. POAF may result in increased in-hospital and long-term mortality in a subset of patients [3, 60]. In a retrospective study of 6475 patients undergoing CABG at a single institution: 994 patients (15%) developed POAF. Higher in-hospital (7.4 versus 3.4%) and 4-year mortality (26 versus 13%) was noted in POAF patients but also with more comorbidities (i.e., older age, hypertension, and left ventricular hypertrophy) [60].
\nThe management of POAF should include the strategy for prevention and treatment of POAF when it develops. PAOF management starts with the optimization of medical comorbidities, if possible (e.g., hypoxia), and the correction of underlying electrolyte disturbances (e.g., potassium and magnesium abnormalities) [53]. POAF is treated similarly to AF in nonsurgical patients by rhythm control via pharmacological or electrical approach or heart rate control, and appropriate antithrombotic therapy.
\nIn the atrial fibrillation follow-up investigation of rhythm management (AFFIRM) trial, the rate control versus rhythm control in nonsurgical patients with AF was studied and found that the use of rhythm control had no survival advantage, and it was associated with more frequent hospitalizations and adverse drug effects [69]. However, some studies involving patients with AF after cardiac surgery have suggested that rhythm control may offer advantages over rate control. This is still controversial and the evidence is inconclusive [11, 70–72].
\nTreatment strategies of POAF aim to reduce symptoms, limit adverse hemodynamic effects, decrease the length of hospital stay, prevent readmissions, and improve survival [73]. The rhythm control strategy has the advantage of a rapid conversion to sinus rhythm, which restores atrial activity, functional capacity, and might reduce thromboembolic. The rate control strategy has the advantage of avoiding the potential adverse effects of antiarrhythmic drugs and complications associated with cardioversion [73]. In a recent trial, there was no difference in hospital admissions during a 60-day follow-up, with randomizing POAF patients to either rhythm control therapy with amiodarone or rate control [73]. As a result, the main aim of rhythm control therapy in POAF patients should be to improve AF-related symptoms. In asymptomatic patients and those with acceptable symptoms, rate control or deferred cardioversion preceded by anticoagulation is a reasonable approach [73].
\nIn the following paragraph, rate control and rhythm control options will be discussed briefly.
\n(A) Rate control strategy: the rate control may be achieved by using beta-blockers, nondihydropyridine calcium channel blockers, digoxin, or a combination of these medications. Beta-blocker agents are the drug of choice, particularly for ischemic heart disease patients, because of the increased adrenergic stress in the postoperative period [53, 73, 74]. However, beta-blockers might be poorly tolerated or relatively contraindicated in patients with known bronchial asthma or bronchospastic lung diseases, active congestive heart failure, or AV conduction block [53]. The nondihydropyridine calcium channel blocker agents represent an alternative AV nodal blocking agent. Digoxin is less effective when the adrenergic tone is as high as in the postoperative period, but it may be used in patients with congestive heart failure. Amiodarone is another agent that can be used as it has been reported to be effective in controlling heart rate. Also, intravenous amiodarone administration has been associated with improved hemodynamic status [75, 76]. For further information about drugs used in AF rate control see Table 1.
\nDrug | \nRoute of admintration and doses | \nSide effects sects | \nRemarks | \n
---|---|---|---|
Oral 25–100 mg QD | \nBradycardia, hypotension, fatigue, depression, negative inotropy, bronchospasm, AVB | \nDecrease dose if CrCl <35 | \n|
Oral 2.5–10 mg QD | \nAs above | \nGood choice for HF patients | \n|
Oral 3.125–25 mg BID | \nAs above | \nGood choice for HF patients | \n|
I.V. 500 mcg/kg bolus over 1 min, then 50–300 mcg/kg/min | \nAs above | \nOnly IV Higher rate of hypotension | \n|
IV 2.5–5.0 mg bolus over 2 min; up to 3 doses Oral 25–100 mg BID | \nAs above | \n\n | |
Oral 50–400 mg QD | \nAs above | \nGood choice for HF patients | \n|
Oral 10 (usual initial adult dose 40 mg)–240 mg QD | \nAs above | \nDosage adjustments based on CrCl | \n|
IV 1 mg over 1 min, up to 3 doses at 2-min intervals Oral 10–40 mg up to 160–320 mg/day divided in BID to QID doses 80–160 to 320 mg QD (ER) | \nAs above | \n\n | |
IV 0.25 mg/kg bolus over 5 min followed by 0.05–0.15 mg/kg/h continuous infusion Oral 30 mg TID/QID up to 480 mg/day 120–360 to 480 mg Q D (ER) | \nBradycardia, hypotension, ankle swelling, exacerbation of HF, AVB | \nDo not use in HF Drug interaction via CYP3A4 including digoxin and warfarin | \n|
IV 5–10 mg (0.075–0.15 mg/kg) over bolus at least 2 min; may give an additional 10 mg (0.15 mg/kg) after 30 min if no response, then 0.005 mg/kg/min infusion Oral 80–120 mg TID up to 480 mg/day 180–480 mg QD or 240 BID (ER) | \nBradycardia, AVB, hypotension, constipation, exacerbation of HF | \nAs diltiazem | \n|
IV 0.25 mg IV with repeat dosing to a maximum of 1.5 mg over 24 h Oral 0.125–0.25 mg QD | \nBradycardia, AVB, nausea, vomiting, visual disturbance | \nNarrow therapeutic window Adjust for renal failure Drug interactions via p-glycoprotein | \n|
IV 150 mg over 10 min, followed by 1 mg/min continuous IV infusion for 6 h, then 0.5 mg/min continuous infusion for 18 h Oral 400–800 mg/day PO in divided doses for 2–4 weeks to a total load of up to 10 g, then 100–200 mg QD | \nBradycardia, hypotension, AV block, QTc prolongation, phlebitis on chronic use: Ocular, pulmonary, hepatic, hematological, neurological complications | \nMonitor thyroid, liver and lung functions | \n
Medications commonly used for atrial fibrillation
AVB, atrioventricular block; CrCl, creatinine clearance; BID, twice daily; h, hour; ER, extended release; HF, heart failure; IV, intravenous; mg milligram; min, minute; QD, once daily; QID, 4 times a day; QTc, correct QT interval; TID, 3 times a day.
(B) Rhythm control: the rhythm control could be archived by using a direct current cardioversion (electrical cardioversion) or antiarrhythmic drugs (pharmacological cardioversion). Electrical cardioversion is indicated on an urgent basis in hemodynamically unstable patients, acute heart failure, or myocardial ischemia. Also, it may be used electively to restore sinus rhythm when a pharmacologic attempt has failed to resume a sinus rhythm [53]. Rhythm control with antiarrhythmic medications is preferred in symptomatic patients despite rate control trial, or when the control of ventricular response is hard to achieve. Amiodarone [77–79] or vernakalant [79, 80] have been efficient in converting POAF to sinus rhythm. Other antiarrhythmic medications that may be used include procainamide [80], ibutilide [81], and sotalol [82]. With ibutilide use, electrolyte imbalance should be corrected to avoid polymorphic ventricular tachycardia [82]. For further information about drugs used in AF rhythm control see Table 2.
\nIR 100–200 mg q 6 h ER 200–400 mg q 12 h | \nHF Prolonged QT interval Prostatism Glaucoma | \nMetabolized by CYP3A4: caution with inhibitors (e.g., verapamil, diltiazem, ketoconazole, macrolide antibiotics, protease inhibitors, grapefruit juice) and inducers (e.g., phenytoin, phenobarbital, rifampin) Avoid other QT interval prolonging drugs | \n|
MD 1–4 mg/min | \nHF Prolonged QT interval May cause hypotension, myopathies, blood dyscrasias, and SLE-like syndrome | \nDrug of choice for WPW with AF Avoid other QT interval prolonging drugs Adjust for renal failure | \n|
IR 200–300 mg q 6–8 h up to 600 mg q 6 h ER 324 mg–648 mg q 8–12 h | \nProlonged QT interval Diarrhea Bradycardia, AV block, bundle-branch block, digitalis toxicity | \nInhibits CYP2D6: ⇧ concentrations of metoprolol, tricyclic antidepressants, antipsychotics; ⇩ efficacy of codeine Inhibits P-glycoprotein:⇧ digoxin concentration | \n|
LD 200 (wt < 70 kg)–300 mg (wt > 70 kg), MD 50–200 mg BID max. 400 mg/day | \nSinus or AV node dysfunction HF CAD Atrial flutter Brugada syndrome Renal or liver disease May cause blurred vision | \nMetabolized by CYP2D6 (inhibitors include quinidine, fluoxetine, tricyclics; also genetically absent in 7–10% of population) and renal excretion (dual impairment can ⇧⇧ plasma concentration) Decrease dose if CrCl < 35 | \n|
IR: 150–300 mg q 8 h ER: 225–425 mg q 12 h (Oral LD 450 mg (wt < 70 kg)–600 mg (wt > 70 kg), MD 450–900 mg/d divided into q 8 h (IR), or 12 h (ER)) | \nSinus or AV node dysfunction or Infranodal conduction disease HF CAD Atrial flutter Brugada syndrome Liver disease Asthma may cause dysgeusia | \nMetabolized by CYP2D6 (inhibitors include quinidine, fluoxetine, tricyclics; also genetically absent in 7–10% of population)—poor metabolizers have ⇧beta blockade Inhibits P-glycoprotein: ⇧digoxin concentration Inhibits CYP2C9: ⇧warfarin concentration (⇧INR 25%) Decrease dose in hepatic failure | \n|
Sinus or AV node dysfunction Infranodal conduction disease Lung disease Prolonged QT interval | \nInhibits most CYPs to cause drug interaction: ⇧concentrations of warfarin (⇧INR between 0–200%), statins, many other drugs Inhibits P-glycoprotein: ⇧digoxin concentration | \n||
Bradycardia HF Liver disease Thyriod disease pulmonary fibrosis Prolonged QT interval | \nMetabolized by CYP3A: caution with inhibitors (e.g., verapamil, diltiazem, ketoconazole, macrolide antibiotics, protease inhibitors, grapefruit juice) and inducers (e.g., phenytoin, phenobarbital, rifampin) Inhibits CYP3A, CYP2D6, P-glycoprotein: ⇧concentrations of some statins, digoxin, beta blockers, sirolimus, tacrolimus Avoid in long-standing persistent or permanent AF and HF | \n||
Decrease MD if QTc increased by >15% of >500 ms 2–3 h after dose or consider discontinuing it | \nProlonged QT interval and torsades de pointes Renal disease Hypokalemia hypomagnesaemia AV block, bradycardia, sick sinus syndrome | \nAdjust dose for renal function, body size, and age (avoid if CrCl < 20) Drug interactions via CYP3A4: CI to use with verapamil, cimetidine, ketoconazole, trimethoprim, prochlorperazine, HCTZ, and megestrol Discontinue amiodarone at least 3 m before initiation Avoid other QT interval prolonging drugs | \n|
once if necessary (if weight <60 kg, use 0.01 mg/kg) | \nProlonged QT interval and torsade de pointes hypotension CAD HF | \nMointor K and mg level | \n|
Prolonged QT interval Sinus or AV nodal dysfunction HF | \nRenal excretion: CI if Cr Cl <40 decrease dose if CrCl 40–60 Risk of torsade de pointes ( do not initiate sotalol therapy if the baseline QTc is longer than 450 ms. If the QT interval prolongs to 500 ms or greater, the dose must be reduced, the duration of the infusion prolonged or the drug discontinued) Avoid other QT interval prolonging drugs correct hypokalemia/hypomagnesemia | \n
Medications commonly used for atrial fibrillation Rythm Control with its dosage and major pharmacokinetic and drug interactions.
ACC AF [74]; JACC [53]. AF, atrial fibrillation; AV, atrioventricular; BID, twice daily; CAD, coronary artery disease; CI, contraindicated; CrCl, creatinine clearance; ER, extended release; h, hour; HCTZ, hydrochlorothiazide; HF, heart failure; IL, immediate release; IV, intravenous; LD, loading dose; INR, international normalized ratio; MD, maintenance dose; min, minute; max, maximum; SLE, systemic lupus erythematosus; Q, every; QD, once daily; wt, weight. http://www.pdr.net/
POAF is associated with poor short- and long-term outcomes, including high rates of early and late stroke, and late mortality as mentioned earlier. However, the indication and timing of anticoagulation in POAF patients should take into consideration the risk of postoperative bleeding. Oral anticoagulation at discharge has been associated with a reduced long-term mortality in patients with POAF [83] but without evidence from controlled trials [75]. POAF that persists for longer than 48 h should be anticoagulated with warfarin or nonvitamin K antagonist oral anticoagulants (NOACs). The NOACs are available for the treatment of nonvalvular AF. NOACs have been found to be as efficacious or even superior to warfarin in the prevention of stroke in nonvalvular AF patients with high risk of thromboembolism, with similar to lower rates of major bleeding, and also lower rates of intracranial hemorrhage [84].
\nBeta-blockers are effective in reducing POAF and SVTs. Propranolol uses reduced POAF incidence from 31.7% in the control group to 16.3% in the treatment group [85]. In the majority of beta-blocker studies, it is administered postoperatively [86]. Amiodarone reduced the incidence of POAF and hospital stay compared to beta-blocker therapy in several meta-analyses [86–89]. Prophylactic administration of sotalol may be considered for patients at risk of developing AF after cardiac surgery [76, 90, 91]. Also, administration of colchicine postoperatively may reduce POAF [75, 92]. Statin use preoperatively did not prevent POAF in a prospective controlled trial [93], despite that initial reports from meta-analyses were encouraging [94–96].
\nOther therapies for the prevention of POAF have been studied in small trials, but have not demonstrated clear beneficial effects [76]. These include angiotensin converting enzyme inhibitors (ACEIs) [97], magnesium [85, 98, 99], n-3 polyunsaturated fatty acids [100–108], corticosteroids [109–111], and posterior pericardiectomy [112]. Conflicting results have also been reported for acetylcysteine [113], and sodium nitroprusside [114].
\nNonpharmacologic therapy with atrial pacing has been tested in various studies [7]. One meta-analysis showed a significant reduction in POAF with atrial pacing (OR 0.57, 95% CI 0.38–0.84) [67], and most [115–117] but not all [118, 119] published studies showed benefit with this therapy. Besides, there are conflicting findings as to the relative value of the different types of atrial pacing [115, 116].
\nUnlike POAF, POAFL after CABG is not well studied. In a single-center study with 80 consecutive patients who underwent CABG with no previous history of AFL, 16 patients (20%) had documented POAFL. Ten of these patients showed temporary AFLs that were curable without radiofrequency catheter ablation (RFCA), and 37.5% of the patients with POAFL (i.e., 7.5% of the patients after CABG) showed sustained or repeated AFL with subjective symptoms [120]. In another study that looked at ATs late after open heart surgery, it was found that cavotricuspid isthmus (CTI)-dependent AFL was the most common. Atypical AFL becomes progressively more widespread with more extensive atriotomy [121]. AFL and ATs that developed late after cardiac surgery are believed to be due to scars created by incisions applied to the right and/or left atrium either for establishing extracorporeal circulation or access to intracardiac structures (coronary sinus, interatrial or interventricular septum, atrioventricular valves, etc.) [122]. The scars created by these incisions play a significant role in the development of ATs, months or years after surgery [123, 124].
\nAFL in the early postoperative period is managed as POAF with rate control or rhythm control and anticoagulation based on arrhythmia duration and patient risk factors. On long-term catheter ablation of AFL is an effective, safe, and potentially curative procedure.
\nSinus tachycardia (ST) represents an appropriate autonomic response to a physiological stress. The upper limit of normal rate for sinus tachycardia is calculated from the formula (220 bpm minus age) [125]. Inappropriate ST may be seen in some patients, especially with young age, but it is rare and should be considered a diagnosis of exclusion [125]. The term ‘SVT’ refers to paroxysmal tachyarrhythmias that require atrial or AV nodal tissue, or both, for their initiation and maintenance [126]. It is typical of a sudden or paroxysmal onset and includes AV nodal reentrant tachycardias (AVNRT), AV reentrant tachycardias (AVRT), and atrial tachycardias. The overall incidence of perioperative arrhythmias in noncardiac surgery varies from 16 to 62% with intermittent ECG monitoring and up to 89% with continuous Holter monitoring [127]. It is more likely to be supraventricular than ventricular in origin [127]. In small study, the incidence of persistent SVT in noncardiac surgery patients was 2% during surgery and 6% in the postoperative period [128].
\n12-lead ECG and rhythm strips during tachycardia are diagnostic and may give an impression about the most likely diagnosis. Although ST is usually easy to diagnose on 12-lead ECG, the presence of first-degree AV block, which is not uncommon after cardiac surgery, may give ECG appearance that mimics SVT due to P wave merge with T wave (P wave hidden within T wave). ECG features of ATs including SVTs are shown in Table 3.
\nDifferential diagnosis of atrial tachyarrhythmias.
ATs occur most frequently 2–3 days postsurgery and are likely related to sympathetic stimulation associated with an inflammatory response [129]. Patients with known SVT may have an exacerbation of their tachycardia in the perioperative period. However, SVT may be diagnosed for the first time in the perioperative period [2, 7, 130, 131]. SVT is often associated with a high sympathetic tone, but other precipitants may contribute to its occurrence. The clinical symptoms, time of onset, and natural course of ATs are identical in patients with cardiac, thoracic, or other surgery.
\nThe prognosis of perioperative SVTs is good, but it may be associated with increased hospital stay [128].
\nThe SVT management, in general, depends on the hemodynamic status of the patient. If the patient with SVT is hemodynamically unstable, synchronized cardioversion is recommended for acute termination of the tachycardia when vagal maneuvers or adenosine is ineffective or not feasible [132]. Before initiating specific drug therapy for acute SVT in hemodynamically stable patients, it is important to assess and correct possible precipitating factors such as respiratory failure or electrolyte imbalance. SVT may respond to vagal maneuver if the patient can do it. Adenosine might be used if there is no contraindication. SVT also responds to rate control drugs such as beta-blockers (e.g., esmolol, metoprolol, bisoprolol) or nondihydropyridine calcium channel antagonists (e.g., diltiazem, verapamil). Intravenous (IV) digoxin, IV amiodarone, adenosine, IV or oral beta-blockers, diltiazem, and verapamil are potentially harmful in acute treatment in patients with pre-excited AF (AF in patients with Wolff-Parkinson-White (WPW) syndrome) [133]. Of note, atrial tachycardia unifocal or multifocal usually respond to rate control drugs but are not amenable to direct current cardioversion. Cardiac electrophysiology study with catheter ablation is an effective long-term management for recurrent SVT.
\nThe postoperative ventricular tachyarrhythmias (POVTAs) range from isolated PVC to VT or ventricular fibrillation (VF).
\nIsolated PVCs including nonsustained ventricular tachycardia (NSVT) are seen in about 50% of patients during and after cardiac surgery [134]. PVCs can be related to electrolyte or other metabolic imbalances [7].
\nPVCs may be seen on continuous telemetric monitoring and 12-lead ECG, however, careful evaluation of the ECG tracing is needed to be distinguished from atrial ectopy with aberrant ventricular conduction [7].
\nPatients with postoperative PVCs may be asymptomatic or may have palpitations with a skipped beat, or dizziness. It is rarely associated with hemodynamic instability.
\nPatients with isolated and noncomplicated PVCs postoperatively do not exhibit increased risk of malignant VAs [135, 136]. On the contrary, frequent PVCs (>30 per hour) may reduce ventricular function and therefore have an adverse impact on the short-term outcome. There was no significant difference in mortality in patients with versus patients without frequent postoperative PVCs and NSVT (8 versus 5%), at an average follow-up of 3 years, in a study including 185 postoperative patients [137]. However, in another study of 126 patients with postoperative PVCs, it was shown that patients with left ventricular ejection fraction (LVEF) of <40% had a 75% mortality rate and 33% incidence of sudden death at an average follow-up of 15 months, whereas none of the patients with preserved left ventricular function had sudden death [135]. Thus, PVCs are not related to mortality with good LV function, and long-term outcome after cardiac surgery seems to be closely related to the left ventricular function.
\nCorrection of any reversible cause of ventricular arrhythmias should be performed. Hemodynamically stable and asymptomatic PVCs do not usually need treatment with antiarrhythmic therapy on short or long-term. Lidocaine has been used with a successful result in reducing hemodynamically significant or symptomatic PVCs, but without improving mortality. Empirical use of class I antiarrhythmic drugs for suppression of frequent and/or complex PVCs had no beneficial effects on mortality rate and may be harmful as shown in several studies in another setting [138, 139]. Additionally, overdrive pacing, using either atrial or atrioventricular sequential pacing, has been used without significant results [138, 139]. Patients with asymptomatic NSVT after cardiac surgery and preserved LVEF generally have a favorable long-term prognosis and do not require invasive workup with an electrophysiology study. The use of implantable cardioverter defibrillators (ICDs) has shown no benefits in improving prognosis in this population [140].
\nSustained VT and VF rarely occur after cardiac surgery with an incidence of 0.4–1.7% in most of the studies [138, 141], but an incidence of 3.1% has been reported [142]. Furthermore, it is life threatening and affects outcome [134, 143].
\nPathophysiology of POAs, in general, was disused in item 2. Coronary artery disease (CAD) leads to a broad spectrum of changes and may trigger arrhythmia mechanisms via enhanced automaticity, triggered activity, and reentry. While myocardial infarction (MI) related scar constitutes the clinical model of reentry [144], focal activation due to abnormal automaticity is the primary mechanism involved in the VT during acute ischemia [145]. Early and delayed after depolarization result from focal discharge by calcium overload and triggered activity is another likely mechanism of VT initiation in ischemia, but this needs to be proven experimentally thus far [146, 147]. Acute ischemia activates the adenosine triphosphate-sensitive potassium (K-ATP) channels, causing an increase in extracellular potassium along with acidosis and hypoxia in the cardiac muscle. As a result of the minor increases in extracellular potassium depolarize the myocardiocyte’s resting membrane potential, which can increase tissue excitability in early phases of ischemia [145]. The mechanism underlying the VT associated with healed or healing MI is reentry in more than 95% of cases [144].
\nComplex ventricular arrhythmias (VAs) are associated with multiple risk factors [7]. Based on clinical studies, the conditions associated with VAs after cardiac surgery may include: increased age, female gender, presence of unstable angina, congestive cardiac failure, hemodynamic instability, preoperative use of inotropes, preoperative use of IABP, emergency surgery, electrolyte disturbances, hypoxia, hypovolemia, myocardial ischemia/infarction, acute graft closure, reperfusion after cessation of CPB, and inotropes antiarrhythmic drugs use, on-pump surgery, and PVD [134, 135, 141, 143, 148].
\nIn addition to a clinical history and a physical exam, the general evaluation of a patient with CAD and suspected or documented VAs includes performing a 12-lead ECG and an echocardiogram. Telemetry monitoring with careful evaluation of VAs initiation and termination is very helpful. Based on ECG criteria, wide complex tachycardias (WCT) may be either ventricular or SVT with aberrancy. However, in patients with structural heart disease like prior infarction, the diagnosis is mostly VT. If feasible, a 12-lead ECG and atrial electrograms through temporary epicardial wires placed at the time of cardiac surgery should be obtained. The presence of AV dissociation strongly suggests VT [138]. Although the ECG diagnosis of a WCT is challenging, it is important to remember that VT is the cause in at least 80% of cases [149].
\nClinical presentation of patients post cardiac surgery with VTs is variable. The hemodynamic state of these patients depends mainly on the rate of the tachyarrhythmia and the left ventricular function. Therefore, some patients may be asymptomatic. Other patients with VT may complain of palpitations, dyspnea, or chest discomfort as their main symptoms. VTs may present with syncope and sudden cardiac death as a result of hemodynamic compromise. Incessant VT, even if it is hemodynamically stable, can lead to hemodynamic deterioration and heart failure [150, 151].
\nThe prognosis is correlated with the type of arrhythmia and the type and degree of structural heart disease [7]. As mentioned earlier, PVCs and NSVT generally have no impact on the outcome. However, patients with sustained VAs have poorer short- and long-term prognosis.
\nPOVAs predicts higher in-hospital mortality (21.7–31.5%) compared with (1.4–2.9%) in control [134, 143, 148]. In one study, POVAs was associated with increased long-term mortality over a mean follow-up of 3.5 years. Patients with POVAs had a high risk of death in the POVAs group during the first 6 postsurgical months (6-month survival of POVAs 59.8 versus 93.8% for POVAs free group). This difference in survival persisted over time [148].
\nAsymptomatic PVCs and hemodynamically stable short runs of NSVT do not need specific intervention, and the correction of any reversible cause of VAs is generally sufficient. Postoperative sustained VAs treatment follows the ICD indications used in other clinical settings [150, 152]. However, the postoperative patients require close attention to the identification and treatment of reversible causes of arrhythmia like electrolyte or other metabolic disturbances, myocardial ischemia, or mechanical complications of surgery [7]. Sustained VAs should be promptly cardioverted either by drugs infusion or electrically based on hemodynamic stability. Hemodynamically stable sustained VTs may be initially treated with antiarrhythmic drugs infusion.
\nIt includes antiarrhythmic medication use and standard medical therapy. The most commonly used antiarrhythmic agents include:
\n- Amiodarone: IV amiodarone is frequently used as a first-line treatment for VAs as it is better tolerated in patients with low ejection fraction than the other antiarrhythmic drugs. The recommended starting dose of Cordarone I.V. is 1000 mg over the first 24 h of therapy. It is usually delivered by bolus infusion of 150 mg over 10–15 min, followed by 1 mg/min for 6 h, then 0.5 mg/min infusion for 18 h. The alternative dose would be 300 mg over 1 h then infusion at 50 mg/h. Additional 150 mg blouses may be given but frequent boluses during the first 24 h should be limited due to the risk of hepatic toxicity [153].
\n- Lidocaine: it is generally a good choice if ischemia is suspected. Lidocaine is administered as a bolus of 0.75–1.5 mg/kg, followed by an IV infusion of 1–4 mg/min (the maximal dose is 3 mg/kg/h). In elderly patient and patients with congestive heart failure or hepatic dysfunction, the lidocaine dose should be reduced [153].
\n- Procainamide: it is often a second line drug, and it is given as loading dose of 15–18 mg/kg administered as a slow infusion over 25–30 min or 100 mg/dose. The infusion rate should not exceed 50 mg/min. The loading dose may be repeated every 5 min as needed to a total dose of 1 g. However, it should be stopped if hypotension occurs, or QRS complex widens by 50% of its original width. This is followed by a maintenance dose of 1–4 mg/min by continuous infusion. The procainamide maintenance infusion should be reduced by 1/3 in patients with moderate renal or cardiac impairment and by 2/3 in patients with severe renal or cardiac impairment [153].
\nStandard medical therapy includes beta-blockers, and ACEIs drugs have been demonstrated to improve long-term survival particularly in patients with left ventricular dysfunction.
\n- Overdrive pacing: in patients with slower VTs who have ventricular epicardial wires, overdrive pacing may be performed. Electrical cardioversion/defibrillation should be easily available because of the possibility of acceleration of the VT or degeneration to VF [154].
\n- Electrical cardioversion/defibrillation: in patients with cardiac arrest, basic life support (BLS) and advanced cardiovascular life support (ACLS) should be followed. Electrical defibrillation should be performed for VF, pulseless VT, and hemodynamically unstable VT. Electrical cardioversion may be used for stable sustained VT as the first choice or for those who do not respond to antiarrhythmic medications. The recommended energy with current biphasic defibrillators ranges from 150 to 200 Joules. Sedation with short-acting agents should precede cardioversion in awake patients [154].
\n- Emergency mechanical support: in postoperative patients who are not responding to standard resuscitation maneuvers, initiation of emergency CPB in the intensive care unit may be considered. In one study, CPB use in a postoperative cardiac arrest was associated with a 56% long-term survival rate with a 22% incidence of soft tissue infections and no mediastinitis [154].
\n- Implantable cardioverter-defibrillator (ICD) therapy:
\nIn the absence of a reversible cause of sustained VT or cardiac arrest after CABG, long-term management may include electrophysiology study and eventually an ICD implantation. Patients with NSVT, prior MI, and left ventricular dysfunction (LVEF <40%) may be considered for electrophysiology testing and implantation of an ICD if a sustained ventricular arrhythmia is induced [152, 155]. Multicenter automatic defibrillator implantation trial (MADIT) study [152] excluded subjects within 2 months after CABG and 3 months after percutaneous transluminal coronary angioplasty (PTCA), and MADIT-II study [156] excluded subjects within 3 months after revascularization. Conversely, early revascularization was permitted in MUSTT (Multicenter Unsustained Tachycardia Trial) study [155], which enrolled subjects at least 4 days after revascularization, and sudden cardiac death in heart failure trial (SCD-HeFT) study [157] made no specific exclusion on the timing of revascularization. However, in SCD-HeFT, the median time from CABG to enrollment was 3.1 years, and from PCI to enrollment was 2.3 years. Therefore, ICD implantation within 90 days of coronary revascularization for patients who otherwise meet ICD implant criteria for primary prevention of sudden cardiac death (SCD) is not addressed in the published device-based therapy guidelines. Revascularization has significant time-dependent benefits. In fact, MADIT-II study showed that the efficacy of ICD therapy in patients with ischemic left ventricular dysfunction is time dependent, with a significant life-saving benefit in patients receiving device implantation more than 6 months after coronary revascularization (CR). The lack of ICD benefit early after CR may be related to a relatively small risk of SCD during this period [158]. Although, sudden cardiac arrest (SCA) has a higher incidence in patients with reduced LVEF in the months after acute MI and/or following revascularization [159, 160]. The two randomized controlled trials, defibrillator in acute myocardial infarction (DINAMIT) and immediate risk stratification improves survival (IRIS), showed that early ICD implantation does not reduce mortality [161, 162]. In both of those trials, there was a reduction in arrhythmic death, which was counteracted by a concomitant increase in death due to other causes [163]. Similarly, the coronary artery bypass graft (CABG)-patch trial [164] examined ICD implantation at the time of elective CABG surgery showed a small decrease in arrhythmic death, but no benefit for overall mortality in patients with preoperative LVEF ≤35%. However, one should keep in mind that the epicardial ICDs tested in this trial differed significantly from the current transvenous endocardial ICD systems. A retrospective study evaluating ICD implantation within 3 months of cardiac surgery suggested the benefit of ICD implantation for secondary prevention. In this study, 164 patients were with ICD implantation within 3 months of cardiac surgery; 93 of these patients had an ICD for sustained pre or postoperative VT or VF requiring resuscitation. During the mean follow-up of 49 months; the primary endpoint was total mortality (TM) and/or appropriate ICD therapy (ICD-T), and secondary endpoints are the TM and ICD-T, and individual end points of TM and ICD-T were observed in 52 (56%), 35 (38%), and 28 (30%) patients, respectively, with 55% of TM, and 23% of ICD-T occurring within 2 years of implant [165].
\nOverall, ICD for
- they are previously qualified for primary prevention of SCD or
\n- revascularization is unlikely to result in an improvement in LVEF to level >35% [166].
\nICD for
- previously satisfied criteria for ICD implantation if they have abnormal left ventricular function or
\n- SCD is unlikely related to myocardial ischemia/injury and have normal left ventricular function [166].
\nICD implantation
An alternative approach for primary prevention of SCD in patients with ischemic cardiomyopathy and low LVEF undergoing revascularization would be the use the wearable cardioverter-defibrillator vest during the 3 months waiting period after revascularization until LVEF is reassessed and design made about permanent ICD implantation [163].
\n- Ventricular tachycardia ablation:
\nThere are no studies of VT ablation in POVAs situation. In patients with extensive structural abnormalities, especially those with prior MI, multiple morphologies of VT might develop. Therefore, VT ablation does not eliminate the need for ICD and/or antiarrhythmic therapy. VT episodes might occur in up 0–60% of patients who have received an ICD for secondary prevention and in 2.5–12% of patients with ICD implanted for primary prevention [167]. Because antiarrhythmic drugs do not eliminate the risk of VAs, VT catheter ablation may be needed to reduce the frequency of VT episodes, especially patients with incessant VT or frequent ICD therapy [149]. Ablation is usually indicated in cases of recurrent, monomorphic VT arising from a specific substrate that can be targeted by mapping techniques.
\nBradyarrhythmias (BAs) are common after cardiac surgery, but it mostly consists of transient episodes of low ventricular heart rate. The conduction defects post cardiac surgery include sinus node dysfunction, partial and complete bundle branch blocks, and various degrees of atrioventricular (AV) block. The right bundle branch block (RBBB) was the most frequently noted abnormality [168]. Bradyarrhythmias may decrease cardiac output in patients with relatively fixed stroke volumes. The risk of developing conduction disturbances after CABG or valvular surgery leading to permanent pacemaker (PPM) implantation is about 0.4–1.1% of patients after isolated CABG and 3–6% after heart valve operations [169–171]. It seems that in the current surgical era that the incidence of postoperative PPM implantation has decreased due to improvements in surgical techniques, technological innovations and enhanced understanding of the mechanisms of injury [172]. However, some studies have shown an increased incidence of PPM implantation after cardiac surgery after the year 2000 [173].
\nConduction disorders after cardiac surgery are explained by one of the following two mechanisms: (1) direct trauma to the conduction system in operative procedures in proximity to the sinoatrial or AV nodes or the His bundle; or (2) ischemic injury to the conduction system due to extensive coronary artery disease might compromise myocardial protection during intraoperative cardioplegic arrest [174].
\nThe risk factors for POBAs may be classified as preoperative, operative, and postoperative factors. Preoperative risk factors include age >75 years, the use of rate lowering cardiac medications (e.g., beta-blockers, calcium channel blockers, digoxin, and antiarrhythmic drugs), the presence of conduction system disease preoperatively, right bundle branch block (RBBB) or left bundle branch block (LBBB), first-degree AV block or left anterior fascicular block (LAFB) [169–171, 175–178].
\nOperative risk factors include myocardial ischemia, inadequate cardiac protection during surgery, and direct surgical injury to conduction system, prolonged CPB time and cross-clamp time, and reoperation [171, 172, 174, 179, 180].
\nPostoperative risk factors include postoperative conduction disturbances and high-grade AV block [174, 175, 181].
\nTemporary electrical pacing may be required in symptomatic bradycardias. It is common practice nowadays to place temporary epicardial atrial and ventricular pacing wires placed at the time of surgery to facilitate temporary pacing when needed. In some cases, as mentioned above, the conduction defect does not revert, and permanent pacing may be necessary. Chronotropic medications, such as theophylline or aminophylline, have been used for sinus bradycardia after transplantation to improve SSS [182] or high-grade AVB [183] and may decrease the need for permanent pacing but its long-term effect is not encouraging.
\nThe challenge with POBAs is often to determine when to implant the PPM as the sinus node function or AV conduction may recover in some patients. Recovery of conduction system is common with long-term follow-up. Only 30–40% of patients with a permanent pacemaker due to sinus node disease remain pacemaker dependent. However, the rate of recovery is less in patients with postoperative AVB, as 65–100% of patients with complete heart block, remain pacemaker dependent. Currently, the usual practice is to implant a PPM if postoperative symptomatic complete AVB or severe sinus node dysfunction persists longer than 5–7 days [184]. PPM implantation may be considered earlier if the underlying intrinsic rhythm is absent or temporary pacing leads fail.
\nArrhythmias are common after CABG. Although tachyarrhythmias are frequent, they are usually transient and have a benign course. POAF represents the most frequently observed ATs. VAs are less common but have an adverse impact on the short and long-term outcome. POTAs management includes optimization of the patient’s condition, controlling patient’s risk factors, and careful attention to hemodynamic changes during surgery with using appropriate anesthesia. Postoperatively, it is important to correct reversible arrhythmia predisposing factors, followed by specific therapy based on the arrhythmia type and its hemodynamic effect.
\nOn the other hand, bradyarrhythmias are also frequently observed after cardiac surgery. However, most of the conduction disturbances are transient and recovered spontaneously. PPM implantation may be required in patients with persistent symptomatic bradycardia due to sick sinus syndrome or second degree type 2, third degree, or high-grade AV block.
\nOne of the most striking characteristics of human beings is the diversities. Different ways of being, thinking and existing, different needs, world views, ethical positions mark the relationships between people. In this sense, interpersonal conflicts are understood as tension that involves different interests or positions, are inherent to human relationships, and are present in various social organizations, among them, the school.
The school as microcosms of society brings together different views of the world, different ways of being, thinking, and living, thus becoming a space for representing social differences and being a place where different conflicts occur daily. Dealing with this situation type requires learning and that is why teachers need training in conflict management so that they can correctly manage the classroom conflicts and educate also your students for conflict management.
Recognizing that the school is an organization that brings together social diversity and adopting as an assumption that interpersonal conflicts are inherent to human relationships, we define the school conflicts as this chapter theme. In this sense, this chapter addresses school conflicts with a focus on classroom conflicts in the teacher-student relationship. In the first part, a brief reference is made to the conflict. This is followed by a review of the bibliography on school/classroom conflict causes.
Due to its intrinsic characteristics, school is a favorable medium for conflict situations development. So, the conflict in the education system can be seen from the dialectic between the macrostructure of the education system, the general policies oriented towards it, and the management processes that prevail in each school [1].
The conflict presents formative possibilities, since the perception of the differences existing between people/or groups and their needs, values, ideas, and different ways of living are essential to a democratic society [2]. In this sense, it is important to enhance positive conflict characteristics and reduce the negative ones. So, the difficulty in resolving conflicts is largely due to the difficulties existing between those involved in the conflict to be able to communicate effectively. Therefore, the constructive and educational potential of conflicts depends largely on the skills of those involved. Thus, knowing how to communicate, and respecting the rights of others and existing differences are essential for conflicts to revert to social and human development benefits.
The concern with improving coexistence in schools, centred on the conflict variable, is addressed in different studies, whose objectives mark both understanding the school conflict [3, 4, 5, 6], as well as preventing its occurrence [7]. Since it is impossible to eliminate school conflicts, it is essential and urgent to reduce their intensity, duration, and severity, so that the teaching and learning process is not harmed. In this sense, this chapter addresses also the strategies used to manage classroom conflict, and some examples of programs that work these skills on teachers and students.
The conflict is defined and classified from different perspectives, and its definition can differ, in context, process, intervention, and study areas [1, 8]. Conflict is a phenomenon of incompatibility between individuals or groups with irreconcilable ends and/or values between them, considering it a social process [1]. For this author, four elements are present and must be addressed in all conflicts: the causes that give rise to it; the conflict protagonists; the process and the way the protagonists face the conflict; and the context in which it occurs. In turn, Chrispino [9] understands conflict as to any divergent opinion or a different way of seeing or interpreting an event, that is, the conflict originates in the difference of interests, desires, aspirations, or positions between individuals. He adds that conflicts can arise from difficulties in communication and assertiveness.
In this way, we can say that there is a conflict when two or more people interact with each other and perceive incompatible differences, or threats to their resources, needs, or values and when they respond according to what was perceived, then the ideal conditions for conflict are created. The conflict intensity, duration, or severity can then increase or decrease depending on the strategies used to resolve it. Regardless of the different conflict definitions, there is no conflict if the individuals involved are not aware of its existence. This conclusion is consensual to the majority of the definition proposals and to the attempts to conceptualize the conflict found in the specialized literature.
In addition to different conflict definitions, there are also different proposals for classifying it. Concerning the different conflict classification [8, 10, 11] the emphasis is placed on the theoretical proposals of [8, 11]. Conflicts can be classified into five different types: structural, value, relationship, interest, and data [11]. In structural conflicts, causes are associated with unequal control situations, possession or resource distribution, unequal power, and authority, geographical, physical, or environmental factors that prevent cooperation and time pressures. In value conflicts, it highlights situations of opposing ideas or behaviors, different ways of life, ideology, or religion. Relationship conflicts are caused by strong emotions, misperceptions or stereotypes, inadequate or deficient communication, and negative and/or repetitive behaviors. The causes of interest conflicts are perceived or real competition over fundamental interests (content), procedural interests, and psychological interests. Finally, about data conflicts, [11] highlights the lack of information or wrong information, different points of view on what is important, different data interpretations, and different assessment procedures.
In turn, Torrego [8] presents a typology that seems to reflect the type of school conflicts: relationship-communication conflicts; interest/needs conflicts; and preferences, values, and beliefs conflicts. As for the relationship-communication conflicts, it cannot be said that there is a concrete cause that justifies their appearance, however, it appears as a result of the relationship deterioration itself. As such, aggressions, struggles, offenses, defamations, rumors, humiliations, misunderstandings are part of this type of conflict, but also perception conflicts, because, despite the conflict reality being only one, this fact does not invalidate that those involved have their view of it. Interest or needs conflicts usually occur when one party considers that it will only be able to satisfy its needs/interests if the other gives in to theirs. This conflict type can include those that stem from disagreement about how to perform jobs or tasks and those that result from the need felt by one of the parties to own or be coerced into giving in: objects, time, space, or any type of appeal. Finally, preferences, values, and beliefs conflicts result when these systems are discordant or viewed as such by those involved in the conflict. However, this conflict type can be resolved if the parties identify higher values common to both.
It is important to say that the conflict constructive paradigm indicates that the conflict has positive and negative aspects, advantages, and disadvantages. This new model is opposed to the classic model and indicates that moderate levels of conflict are perceived as positive [12]. The conflict effects are positive, when they are well managed, to establish more cooperative relations and seek to reach an integrated solution, for the benefit of those involved in the conflict [10]. In any organization, the existence of low levels of conflict leaves the organization vulnerable to stagnation, to making impoverished decisions, even to the lack of effectiveness; on the other hand, having too much conflict leads the organization directly into chaos.
Given the above, we can say that conflicts are inherent to human relationships since human beings are characterized by diversity. The school, by bringing together people from different social groups with different values and worldviews, becomes a locus for conflicts.
The school is a society microsystem, in which are reflected constant changes. Thus, one of the most important school functions is to prepare students, teachers, and parents to live and overcome the difficulties of a world full of rapid changes and interpersonal conflicts, contributing to the development process of each individual. For being a society microsystem and bringing together different ways of life, thinking, feeling, relationship, constitutes a space conducive to interpersonal conflicts.
School conflict is defined as the disagreement between individuals or groups regarding ideas, interests, principles, and values within the school community, perceiving the parties their interests as excluded, although they may not be [13], being that the most frequent school conflicts occur in the relations between student–student and between student-teacher [14].
Conflicts in the school can be classified according to their causes and those involved. For Martinez [15], the conflicts between teachers are mainly caused by lack of communication, personal interests, previous conflicts, issues of power, or political and ideological differences. This author indicates that conflicts between students and teachers, as they happen due to the lack of understanding of the teacher’s explanation, due to arbitrary grades and divergence in the evaluation criteria, lack of didactic material, discrimination, disinterest in the study material, and because the students are ears. In turn, conflicts between students can arise due to misunderstandings, fights, the rivalry between groups, discrimination, bullying, use of spaces and assets, dating, sexual harassment, loss or damage of school assets, diverse elections, travel, and parties. Conflicts between parents, teachers, and administrators can arise due to aggressions that occurred between students and between teachers, due to the loss of work material, problems in the school canteen or similar, lack of teachers, lack of pedagogical assistance by teachers, evaluation, approval and disapproval criteria, failure to meet bureaucratic and administrative requirements of management [15].
From the literature review, it is possible to infer and highlight the different causes pointed to the school conflict. Participating teachers in the Göksoy and Argon [16] study indicate as causes for school conflict: the communication failures, personal, political/ideological, and organizational causes.
With a very similar rating, Jares [1] indicates four main causes: ideological-scientific, related to different pedagogical, ideological, and organizational options, and the type of school culture or cultures that coexist; power causes, related to organization control, professional promotion, access to resources and decision making; causes of structure, related to the ambiguity of objectives and functions, organizational fragility, organizational and variable contexts; and personal and interpersonal causes, related to self-esteem, security, professional dissatisfaction, and communication. Also, Burguet [17] points out as possible causes for the school conflict in the school’s organizational structure.
In this sequence, and given the increase in school conflicts, Ibarra [18] recognizes as school conflict causes: the increase in compulsory schooling, the increase in the number of students per class, teachers perceive a progressive decline in their authority about students, and students are less likely to comply with certain rules and limits, which results in conflict situations. Regarding the increase in compulsory education, this leads to a greater number of unmotivated and undisciplined students, which implies an increase in school conflict. Likewise, the increase in the number of students per class, without increasing the facilities or associated conditions, increases the conflict occurrence, because of their negative changes in the physical and psychological environment, in overcrowded classrooms, with a lack of space for practical and collaborative activities.
In addressing interpersonal relationships in schools cannot neglect family background. When dealing with interpersonal relationships in the school context, it is necessary to take into account the family reality of each student, since the family interpersonal relationships have a strong connection with the school conflict [19]. Distinguished authors indicate that school conflict situations often have their genesis at the family level [17, 20] since they are the most deprived families, where alcoholism, domestic violence, and unemployment problems occur, being that all these violence and incivilities manifestations that arise in the students’ lives are transported to school. Burguet [17] points the dismissal of families as educational agents. This author highlights the overprotection with a sense of guilt for not dedicating more time to children, the experience of fatherhood as a “burden” of those who educate in aggressiveness, and the criticisms of parents, and society itself, to teachers, instigates conflicts. In other words, the role of the family often does not seem to offer a good foundation in the education of young people, which is reflected in their behavior in the processes of interaction at school. As Berkowitz [20] indicates, many of the interaction problems originate in the family, and the student reproduces the behaviors he learns with his parents.
It should be noted that the context experienced by the Covid-19 pandemic has a greater impact on students from poorer families. The situation of these most vulnerable students was a problem whose dimension grew with online classes, as they encountered immense barriers and lack of support for quality education during confinement. Thus, students who before the pandemic were unmotivated and presented conflicting behaviors at school should be the target of more support during this pandemic phase, to minimize the conflicting behaviors. It should also be noted that although family-school relationships are extremely important for students’ learning and development, family participation in school is not always satisfactory.
So, the family and the school must go together to contribute to the conflict becoming part of a process of growth, acceptance of the other, and accountability. Learning to deal with school conflicts positively is essential for the development of healthy relationships.
Another cause of school conflicts is pointed to society and the values it conveys, Burguet [17] points to the example of social communication, which encourages violence through violent programs, broadcasting news with prejudiced and conflicting messages. All of these situations enhance the conflicting attitudes of children and young people, which are reflected in school behaviors.
The school builds a social interface favorable to involvement, where conflicts proliferate in the educational process complexity, being common and daily in classes. Thus, in the classroom different types of conflict occur, being a challenge for most teachers to know how to face, manage, and resolve these conflicts [7].
Teachers often perceive conflicts as indiscipline, violence, disrespect, and like all situations threatening his authority, and inexperienced and experienced teachers emphasize the teacher-student conflict as a frequent situation in difficult classes [21]. In this context, Silva and Flores [19] refer to the negative effect that these situations have on attainment and student motivation, so it is urgent to find solutions to avoid or mitigate such effects.
The classroom coexistence problems are mainly related to social and pedagogical changes [22]. In this sequence, there are several conflict situations that teachers can face during classes. Some of those indicated by the teachers are, namely: the student’s presence that did not focus on activities; students with serious learning and communication difficulties; students groups who do classroom not work and maintain an aggressive and provocative attitude; students with destructive attitudes towards school material, theirs and/or colleagues, as well as aggressive and violent attitudes towards colleagues and teachers; apathetic students, who do not show classes enthusiasm; and in extreme situations, students who take and display instruments in the class that can be used as weapons, in an attitude of defiance to the teacher [23].
Given the increase in the classroom conflicts, multiple causes, which include a combination of external and internal factors in the school environment, are indicated, such as the increase in compulsory education, the increase in students per class, the progressive decline in the teacher’s authority about students, and students are less likely to comply with rules and limits, which results in conflict [18]. The increase in the year of schooling also leads to greater difficulties in living and learning in the classroom, and older age student’s groups consider themselves inserted in an educational system that sometimes does not respond to their needs and some of them consider not be essential to your life. So, the increase in compulsory education leads to a greater number of dissatisfied, unmotivated, and undisciplined students. Likewise, the increase in students per class, without increasing the facilities or associated conditions, negatively affects the psychological environment in overcrowded classrooms, with a lack of space for practical and collaborative activities. In turn, the progressive decline in teacher authority in relation to students and students are less likely to comply with certain rules and limits, results in conflicts in the classroom.
Conflicts in the teacher-student relationship are recurrent in the classroom, and [17] indicates as causes generating conflict, not only concerning the expectations of the teacher-student but also the student towards the teacher. In this sequence, the authors highlight the following problems that cause conflict: discipline problems, adaptation to individual differences problems, and evaluation problems.
As for discipline problems, these are the result of provocation and contempt of the student towards the teacher, or the teacher towards the student, to exercise their authority. In turn, problems of adaptation to individual differences are related to heterogeneous behaviors and diminished personal relationships. As for the problems related to the evaluation, result mainly from the personal rhythms of each student and teacher.
Students’ undisciplined classroom behavior can lead to conflicts that divert the teacher’s attention to issues that blur him from his teaching function [19]. In this context, Pérez-de-Guzmán et al. [7] indicate disinterest, mainly academic, as the main source of classroom conflict, also mentioning that one of the conflicts that persist and continues to be common is the lack of study habits and the carrying out work, leading to a negative attitude during class. Also, the mandatory stay in the classroom, away from the interests and expectations of some students, is recurrent as a conflict cause.
There are many and diverse classroom conflict situations that disturb the class dynamics. And in situations where the conflict remains latent, the result of the diversity of class interests, if the teacher does not create a good environment, acting positively about communication, the use of legitimate authority, and the conflict management, he will see conflicts increase exponentially within the classes [24]. Thus, regardless of the classroom conflicts type, if they are not managed, they accumulate, which makes them more cohesive and complicated, triggering negative feelings in those involved, and negatively affecting the educational quality [24].
The causes of the aforementioned conflicts are linked to personal issues and interpersonal relationships. And, most of these conflicts reveal an undisciplined character and increase daily in the class context. In this way, the teacher in the absence of solid guidelines can develop discontent, insecurity, and dissatisfaction that are reflected in his conflict face performance. Another aspect to be highlighted is that related to the power or lack of it that, increasingly, the teacher presents, and that reveals itself in discontent. In short, there is a gap in society, between the values it promotes and demands the school and the lack of credibility that is given to the teacher, questioned before the disapproval of parents and society itself, which instigates an even greater student’s conflict, in classes.
Conflict can inspire innovations and creative strategies in addressing challenging issues, as well as improving work, results, and encouraging organizations to achieve higher levels of quality and achievement. In this context, Göksoy and Argon [16] argue that school conflicts have positive and negative impacts on psychological, social, and organizational results.
Negative psychological impacts include discomfort, insecurity, insignificance feelings, sadness, resentment, frustration, and stress. In turn, at the social level, results of hostility, intolerance, and violence are present [16]. As for the negative results within the institutions, the author highlights the existence of a tense environment, weakened cooperation, communication failures, poor performance, and an undisciplined environment. Inevitably, in this way, there is a decrease in education quality.
The conflicts traditional and negative view has implications for the training of students, as the current discourse in many schools is about how to avoid conflicts since their educational potential is sometimes not perceived by the school community. This discourse conceives the conflict by the violent consequences that result from its non-management.
Conflict is recognized as an engine of social development and its effects are positive when the conflict is managed well. Thus, about the positive impacts arising from the school conflict, these have various levels of benefits [16]. At a personal level, the conflict allows learning to be related to the perception of errors, and to develop new ideas. On the other hand, at the social level, it enables the reinforcement of communication, respect for others, and enhances commitment. Regarding the benefits at the organizational level, it makes it possible to understand problems, seek and develop new solutions, and develop a democratic and enriching environment in the school. Thus, conflicts can contribute to the construction of broader visions of certain situations and, at the same time, guarantee rights and opportunities for all, regardless of interpersonal differences.
Teachers’ perceptions of conflict indicate that they focus mainly on the conflicts’ negative aspects [6, 25]. It is noteworthy that the methods most used at school, face of students conflicting behaviors, include warning, disapproval, summoning guardians, and in some cases, student suspension. Methodologies that provoke negative feelings and, later, originate new undesirable behaviors, being applied without taking into account the needs, personal conflicts, problems, and students expectations [26]. As indicated by Torrecilla et al. [22] if the teacher is not an effective conflict manager, he will project this lack of skill, resulting in negative learning for students.
As noted earlier, classroom conflict is an unavoidable reality. Thus, being inevitable, adequate strategies are needed to resolve it so that the conflict potential advantages are taken advantage of and its harmful effects are minimized or canceled out. Conflict management strategies are understood as the behavior types that are adopted in the conflict context, that is, they are basic strategies to manage a situation in which the parties consider their interests to be incompatible.
It is important to note that the choice between different conflict management strategies depends on the conflict level and the various situations that must be managed effectively [27], that is, to manage conflict functionally, it is important to recognize that one strategy may be more appropriate than another, depending on the conflict situation, being considered appropriate if its use leads to the effective formulation or resolution of the conflict [27]. So, strategies refer to specific patterns of behavior that are adopted in conflict situations. Following this approach, Rahim and Bonoma [28] established five conflict management strategies using two dimensions “self-concern” and “others concern”. They are different strategies for conflict management and correspond to the attitudes to confront and conflict resolutions.
These five strategies for conflict management are [27]: (a) Avoiding: when conflicted parties show low levels of concern for others’ interests and a low level of concern for oneself. Strategy characterized by a low degree of assertiveness and a low degree of cooperation, where neither its interests nor those of its opponents are satisfied; (b) Dominating: reflecting the attempt to satisfy one’s interests without consideration of the interests of the other. Characterized by a high assertiveness and lack of cooperation, in which the acquisition of objectives is viewed with supremacy over the interests of the other party. Furthermore, it is often considered an aggressive strategy; (c) Obliging: tends to be adopted by those individuals who attempt to play down the differences and emphasizes commonalities to satisfy the concerns of the other party. Represents a conflict management strategy where the cooperation is high, and assertiveness is low; (d) Integrating: individuals who use this strategy manage conflicts directly and cooperatively, seeking to solve in collaboration with the other, is a strategy connected with problem-solving. The use of this involves openness, exchanging information, looking for alternatives, and examination of differences to reach an effective solution for everyone involved in the conflict. Is a strategy useful for effectively dealing with complex problems; and (e) Compromising: represents the attempt to satisfy, moderately and partially, the interests of all those involved in the conflict, and shares commonalities with all of the other four strategies. Is a strategy that requires compromise and assignment. Compromising is an intermediate strategy on assertiveness and cooperation, which implies a compromise in the search for an acceptable intermediate position for everyone involved in the conflict.
Among the variables that influence the choice of different conflict management strategies, the teachers’ emotional intelligence stands out. Valente and Lourenço [24] conclude that teachers who tend to have higher levels of emotional intelligence use more integration and commitment strategies, for conflict management in the classroom, and fewer strategies of consent, avoidance, and domination. Too, the findings of Aliasgari and Farzadnia [29] indicate that teachers prefer the integrating strategy over the other conflict management strategy. So, in the presence of classroom conflict, the teacher proposes alternatives, applies open lines of communication, makes concessions, accepts responsibility, maximizes similarities, and minimizes existing differences between self and student [24]. Therefore, the integrating strategy is connected with classroom problem-solving, the use of this strategy involves openness and exchanging information, being the ideal strategy in dealing with complex classroom problems [24]. When applying a commitment strategy, the teacher’s objective is an intermediate solution for conflict management, for this, he knows how to reduce differences with the student suggests an exchange of proposals with the student, and provides a quick solution to conflicts in the classroom [24]. This is an intermediate strategy on assertiveness and cooperation, which implies a compromise in the search for an acceptable intermediate position for everyone involved in the conflict [27]. In this way, teachers’ emotional intelligence allows for better conflict management, which supports the development of interpersonal relationships in the classroom and enables a favorable environment for teaching and learning.
So, conflicts involve, in addition to interpersonal skills such as availability for dialog, emotional intelligence skills, which require the perception and recognition of the affective dimension, and the feelings of those involved. In this sense, we can say that the evolution of interpersonal relationships has not kept pace with scientific and technological developments. We were not educated to know how to interpret the language of emotions, just as we did not learn to solve conflict situations. We do not learn to perceive and manage emotions. Thus, the emotions that emerge from conflicts must be the target of attention and discussion, so that teachers and students are aware of their emotions and know how to deal with them.
The concern with improving coexistence in schools, namely about conflict, is mentioned in several studies, whose objectives refer to the understanding of school conflicts, as well as preventing their occurrence through programs aimed at teachers and students [4, 5]. Thus, the school community must develop effective skills for conflict management, increasing self-awareness, and understanding of conflict through formal education sessions.
The manage conflict ability is not innate, so it must be learned through educational interventions. There are different programs that work these skills in the educational context, of which they stand: Recognizing, Understanding, Labeling, Expressing, Regulating (RULER), Social and Emotional Learning (SEL), and the Collaborative for Academic, Social and Emotional Learning (CASEL).
RULER program was created based on the emotional intelligence Mayer-Salovey’s model [30]. This training program focuses on emotional intelligence development and involving the students, parents, teachers, and the entire educational community [31]. RULER focuses on learning skills that deal with issues of interpersonal conflict and teach strategies for emotional regulation. Empirical evidence regarding the effectiveness of RULER programs indicates that they enhance students’ academic performance, improve the quality of learning environments, improve teacher-student relationships and reduce student behavior problems, being a success in reducing violence and abusive classroom behavior [32].
The SEL was developed with the aim of preventing school violence and includes five areas of interconnected skills (self-knowledge, social awareness, self-management and organization, responsible problem solving, and relationship management). Teaching these skills is vital to deal with behavioral, academic, disciplinary, and safety problems, promoting self-awareness, managing emotions, and acquiring skills such as empathy, the ability to perceive different perspectives and points of view, respect for diversity, and the ability to make the right decisions [33]. SEL programs refer to processes of developing socio-emotional competencies, which depend on the individual’s ability to recognize, understand, and manage emotions. These skills are the main building blocks for other outcomes that SEL programs include, such as the ability to persist in the face of challenges, stress management, the ability to develop healthy relationships, build trust in others, and to thrive both in the academic context, as in personal and social life. In a study carried out on more than 213 SEL programs, it was concluded that a school that successfully applies a quality curriculum of the SEL program can achieve behavioral improvements and a positive increase in the results of assessments [34].
CASEL program was created with the aim of establishing social and emotional education in a school context and making it a reality in today’s education. Its purpose is to apply high-quality, evidence-based SEL programs, from pre-school to secondary education [35]. The results of this program reveal significant changes in the socio-emotional capacities, social interactions, and academic results of the students who attended these programs. Among the results, it should be noted that students show greater communication skills, are more collaborative in teamwork, and more resistant to challenges and difficulties [36].
The school is a space for socialization par excellence and, precisely, due to the variety of styles, cultures, and values, it becomes an environment rich in conflicts. Conflict, commonly seen as something negative, destructive, and generating violence, is, in fact, extremely necessary for individual evolution. It should be noted that the conflict itself does not generate violence; this comes when there is a lack of peaceful solutions to conflict resolution, when there is no conflict constructive management.
Among the conflict management methodologies used in the school, the following stand out: arbitration, conciliation, negotiation, and mediation. School arbitration is a dialog process that takes place between the involved in the conflict with the presence of a third party that determines the conflict resolution based on the benefits of the parties with their authority and knowledge [37]. The school conciliation is a dialog process carried out between the involved in the conflict, with the support of a conciliator, who helps them decide, based on their interests and needs. This may present proposals for solutions that the parties can accept or not. The decision-making power belongs to the parties, even if the solution comes from the conciliator [37]. In turn, the school negotiation is a dialog process focused on conflict resolution between the involved in the conflict, which either meet face to face to work together unassisted to conflict resolution. Negotiation is one of the most used conflict management mechanisms in the classroom. The school mediation, this is a dialog process carried out between the parties in conflict, assisted by a third party, the mediator, who should not influence the conflict resolution, acting as a communication facilitator. Inserted in a socio-constructivist paradigm, it is considered not only as of the most current and flexible instrument for peaceful conflict resolution at the educational level, and promote a new culture for conflict management. Arising not only to solve school problems, but equally as a feasible way for creative conflict modification [38].
A more detailed approach to school negotiation is presented as it is considered the most appropriate method for resolving classroom conflicts, in teacher-student relationships. Negotiation includes a set of behavioral skills that teachers must master. It is essentially a well-structured process and based on some tacit behavior, being understood as a process of communicative interaction in which two parties seek to resolve a conflict of interest, use dialog, and progress gradually through mutual concessions. The negotiation process implies several skills, which stand out, effective communication, considered the main tool of the negotiation process.
Effective communication is essential to the school conflicts negotiation, as it enhances: the fear decrease of being rejected, the anxiety reduction produced in the struggle for acceptance and recognition, a greater predisposition to listen to the other and recognize their positive aspects, a strengthening of self-esteem, an increase in the degree of security, and a decrease in defensive-offensive behavior [39].
Concerning the negotiation phases, although there is no consensus on the definition of the negotiation stages, there are at least three that are classically identified [40]: definition of the content and limits of the negotiation (exploratory stage), with the manifestation of antagonism, facing individuals the “dilemma of trust” and the “dilemma of honesty”; negotiation dynamics (dynamic and tactical stage), with manifestations of concession flexibility, systematically assisting proposals and counter-proposals, constituting the central moment of the negotiation process; and, the resolution and agreements stage, this more integrative, brief, and intense phase, almost always implies tension and uncertainty.
These phases testify to the transformation that the negotiations must undergo and must respond to the three negotiation objectives, namely: identification of differences between the parties, making joint decisions, and building a commitment to resolve the conflict.
It should be noted that during a conflict negotiation, it is also important to highlight the importance of [39]:
Empathy: the pillar of good communication and the connection between teacher and student, which allows one to understand each other’s feelings and motivations;
Assertiveness: being able to expose your point of view, emotions, or opinions without provoking a defensive attitude, through a self-affirmative phrase that tells students what to think without blaming you, not putting you as an opponent. Being assertive requires understanding limitations to do another. The teacher when negotiating a conflict must establish his position and build self-confidence thus limiting abuse situations without attacking students;
Active listening: a tool is useful to obtain more information, corroborating data so that the student knows that he was heard. When we listen actively, we are asking, paraphrasing, asking for clarification, defining, and contextualizing. Some ways of they appear can be by echo, repetition of what the other said, reformulation, expressing in words what was understood, resolving points or questions, summarizing and ordering information or reflection of the feeling, an expression of what we perceive of the other; and
Feedback: the teacher must support and encourage positive behavior, correcting the inappropriate ones. To put feedback into practice, it is necessary to let the student know what the teacher feels and what he thinks.
That way, thinking of the joint construction of solutions to the conflict, through the correct use of empathy, assertiveness, active listening, and feedback can make those involved in the conflict evaluate their actions and rethink their attitudes, discovering ways to solve the problems, trying to maintain respect and balance. Knowing how to listen, evaluate, rethink with everyone involved in the conflict, creating the habit of dialog. Because when those involved in the conflict participate in the construction of possible actions for solutions, relationships can be restored, and the conflict constructively resolved. Therefore, classroom conflicts when managed constructively contribute to the preservation of interpersonal bonds and promote the socio-emotional skills of involved, since it makes possible to develop skills to know how to see reality from the perspective of the other, knowing how to cooperate, and also learn that conflict is an opportunity for growth and maturation.
As seen, although conflicts have negative impacts in general, the constructive and destructive consequences of conflict depend on the management skills of the individuals who experience it [25]. Effective conflict management strategies minimize the conflict negative impacts and enhance the positive ones, helping to improve interpersonal relationships and job satisfaction at school.
In general, teachers and the school ignore the importance of conflicts in the integral development of the student and training as autonomous citizens. In this way, most schools do not conceive of conflict resolution as an integral part of the curriculum, emphasizing only the contents of the curricular subjects. They leave aside interpersonal relationships, homogenizing the training of students without promoting the development of problem and conflict management skills. Thus, for the educational potential of the conflict to be truly used in the school context, it is necessary that the community, and especially teachers and management bodies, recognize the conflict possibilities. Constructive management of school conflicts is important and necessary for new generations to learn to live with social differences.
In this sequence, educational action is required, intentionally aimed at conflict management as an element inherent to the human condition and indispensable to democratic societies. Therefore, the formative potential of the conflict depends on the strategies used to resolve the conflict and the management that takes place. The way to conflict management, in turn, depends on how those involved experience the conflict. Therefore, the negative view of the conflict and the lack of perception of its educational potential can prevent those involved from developing essential skills such as respect for diversity, respect for the rights of others, and availability for dialog.
Pérez-de-Guzmán et al. [7] indicate that training in conflict management, generates very positive results in all members of the educational community, verifying a reduction in the interpersonal conflict between teacher-student. Also, Massabni [41] defends the urgency to prepare teachers to face professional conflicts; otherwise, we will have a generation of teachers able to succumb to the pressure that the profession is going through, to accept the reduction of their action, their status, and to share their commitments with other professionals, who take away the property of regulating their work. It is necessary to support teachers and provide them with tools to develop their ways of managing conflicts.
By making conflicts the subject of reflection and explaining the professional context in which teachers work is, in the opinion of [41], the commitment of the different higher education institutions that form them. It is important to work not only on the training of future teachers but also on training in the active teachers in conflict management, small or large, which inevitably emerge in the teacher-student relationship, throughout their professional life. Also, the Freire et al. [42] results support the importance of professional development opportunities with a focus on facilitating the relationship of teachers with students with perceived challenging behavior.
The school is an institution that reproduces a microcosm of society, bringing together diverse identities. This context with diverse personalities, rules, and values is full of conflicts, problems, and differences between the different actors that make up the school (students, teachers, staff, and parents). Thus, the school system, in addition to involving a range of people, with different characteristics, includes a significant number of continuous and complex interactions, depending on the stages of development of each one. So, school is a place where individuals with different characteristics, backgrounds, experiences, and personalities live together daily. Among so many differences, naturally, divergences of the most diverse species arise. It is essential, then, the proper management of conflicts that may arise so that harmony and respect are present in the school of the main causes presented for the school conflict, we highlight family problems. Being the family the main student emotional support, it becomes the life model of this. In this way, unstable and weakened family relationships directly affect the behavior of your children, behaviors that these after reproduced in the school social relationships. The families of the most deprived students are considered less functional. They do not contribute to the growth of positive feelings, they do not carry out good communication between family members, nor do they assist in healthily making decisions that are, based on the exchange of ideas together instead of imposition. In this sequence, students from more dysfunctional families need school increased support to learn and develop interpersonal skills. Thus, family and school must go together to contribute to the conflict becoming part of a process of growth, acceptance of the other, and accountability. Learning to deal with conflicts positively is essential for the development of healthy relationships.
The school, by bringing together people from different social groups with different values and worldviews, becomes a locus for conflicts. Thus, the conflict must be understood as a reality inherent to the educational context, and the school, as responsible for the education of values and skills for living together must be differently prepared to deal with the conflicts that occur in it.
Conflicts of various types have always been present in the classroom, and the causes that originate them are of great importance, as they allow a better conflict understanding and, consequently, a more correct intervention to its management. It should be noted that personal harmony and the development of attitudes that promote understanding, dialog, and tolerance are indispensable for negotiating conflicts in the teacher-student relationship. The way to intervene in classroom conflicts is essential in education, not only in terms of content, but also as a series of vital procedures in interpersonal relationships. As Lapponi [39] points out, for conflicts correct negotiation with the student, it is necessary to communicate effectively, cooperate, decide responsibly, and so teach to resolve conflicts.
Ending school conflict is impossible, since they are intrinsic to the human being, being an integral part of their development and the interpersonal relationships they experience daily. Learning to live with school conflict requires creating attitudes of openness, interest in differences, and respect for diversity, teaching how to recognize injustice, taking measures to overcome it, resolving differences constructively, and moving from conflict situations to reconciliations. So, it is essential that the initial and continuous training of teachers encompasses conflict management, providing them with tools so that they can resolve the conflicts they experience in the classroom.
In summary, it is important to conflict face and resolve it with skills to manage it properly and constructively, establishing cooperative relationships, and producing integrative solutions. Harmony and appreciation should coexist in a classroom environment and conflict should not interfere, negatively, in the teaching and learning process.
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Conventional methods for the removal of metal ions such as chemical precipitation and membrane filtration are extremely expensive when treating large amounts of water, inefficient at low concentrations of metal (incomplete metal removal) and generate large quantities of sludge and other toxic products that require careful disposal. Biosorption and bioaccumulation are ecofriendly alternatives. These alternative methods have advantages over conventional methods. Abundant natural materials like microbial biomass, agro-wastes, and industrial byproducts have been suggested as potential biosorbents for heavy metal removal due to the presence of metal-binding functional groups. Biosorption is influenced by various process parameters such as pH, temperature, initial concentration of the metal ions, biosorbent dose, and speed of agitation. Also, the biomass can be modified by physical and chemical treatment before use. The process can be made economical by regenerating and reusing the biosorbent after removing the heavy metals. Various bioreactors can be used in biosorption for the removal of metal ions from large volumes of water or effluents. The recent developments and the future scope for biosorption as a wastewater treatment option are discussed.",book:{id:"6137",slug:"biosorption",title:"Biosorption",fullTitle:"Biosorption"},signatures:"Sri Lakshmi Ramya Krishna Kanamarlapudi, Vinay Kumar\nChintalpudi and Sudhamani Muddada",authors:[{id:"238433",title:"Associate Prof.",name:"Sudhamani",middleName:null,surname:"Muddada",slug:"sudhamani-muddada",fullName:"Sudhamani Muddada"},{id:"244937",title:"Mrs.",name:"S L Ramyakrishna",middleName:null,surname:"Kanamarlapudi",slug:"s-l-ramyakrishna-kanamarlapudi",fullName:"S L Ramyakrishna Kanamarlapudi"},{id:"244938",title:"Mr.",name:"Vinay Kumar",middleName:null,surname:"Chintalpudi",slug:"vinay-kumar-chintalpudi",fullName:"Vinay Kumar Chintalpudi"}]},{id:"53211",doi:"10.5772/66416",title:"Biofloc Technology (BFT): A Tool for Water Quality Management in Aquaculture",slug:"biofloc-technology-bft-a-tool-for-water-quality-management-in-aquaculture",totalDownloads:16954,totalCrossrefCites:64,totalDimensionsCites:147,abstract:"Biofloc technology (BFT) is considered the new “blue revolution” in aquaculture. Such technique is based on in situ microorganism production which plays three major roles: (i) maintenance of water quality, by the uptake of nitrogen compounds generating in situ microbial protein; (ii) nutrition, increasing culture feasibility by reducing feed conversion ratio (FCR) and a decrease of feed costs; and (iii) competition with pathogens. The aggregates (bioflocs) are a rich protein-lipid natural source of food available in situ 24 hours per day due to a complex interaction between organic matter, physical substrate, and large range of microorganisms. This natural productivity plays an important role recycling nutrients and maintaining the water quality. 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So, air and water can potentially become polluted everywhere. Little is known about changes in pollution rates. The increase in water-related diseases provides a real assessment of the degree of pollution in the environment. This chapter summarizes water quality parameters from an ecological perspective not only for humans but also for other living things. According to its quality, water can be classified into four types. Those four water quality types are discussed through an extensive review of their important common attributes including physical, chemical, and biological parameters. These water quality parameters are reviewed in terms of definition, sources, impacts, effects, and measuring methods.",book:{id:"7718",slug:"water-quality-science-assessments-and-policy",title:"Water Quality",fullTitle:"Water Quality - Science, Assessments and Policy"},signatures:"Nayla Hassan Omer",authors:null},{id:"58138",title:"Water Pollution: Effects, Prevention, and Climatic Impact",slug:"water-pollution-effects-prevention-and-climatic-impact",totalDownloads:21554,totalCrossrefCites:18,totalDimensionsCites:38,abstract:"The stress on our water environment as a result of increased industrialization, which aids urbanization, is becoming very high thus reducing the availability of clean water. Polluted water is of great concern to the aquatic organism, plants, humans, and climate and indeed alters the ecosystem. The preservation of our water environment, which is embedded in sustainable development, must be well driven by all sectors. While effective wastewater treatment has the tendency of salvaging the water environment, integration of environmental policies into the actor firms core objectives coupled with continuous periodical enlightenment on the present and future consequences of environmental/water pollution will greatly assist in conserving the water environment.",book:{id:"6157",slug:"water-challenges-of-an-urbanizing-world",title:"Water Challenges of an Urbanizing World",fullTitle:"Water Challenges of an Urbanizing World"},signatures:"Inyinbor Adejumoke A., Adebesin Babatunde O., Oluyori Abimbola\nP., Adelani-Akande Tabitha A., Dada Adewumi O. and Oreofe Toyin\nA.",authors:[{id:"101570",title:"MSc.",name:"Babatunde Olufemi",middleName:null,surname:"Adebesin",slug:"babatunde-olufemi-adebesin",fullName:"Babatunde Olufemi Adebesin"},{id:"187738",title:"Dr.",name:"Adejumoke",middleName:"Abosede",surname:"Inyinbor",slug:"adejumoke-inyinbor",fullName:"Adejumoke Inyinbor"},{id:"188818",title:"Dr.",name:"Abimbola",middleName:null,surname:"Oluyori",slug:"abimbola-oluyori",fullName:"Abimbola Oluyori"},{id:"188819",title:"Mrs.",name:"Tabitha",middleName:null,surname:"Adelani-Akande",slug:"tabitha-adelani-akande",fullName:"Tabitha Adelani-Akande"},{id:"208501",title:"Dr.",name:"Adewumi",middleName:null,surname:"Dada",slug:"adewumi-dada",fullName:"Adewumi Dada"},{id:"208502",title:"Ms.",name:"Toyin",middleName:null,surname:"Oreofe",slug:"toyin-oreofe",fullName:"Toyin Oreofe"}]},{id:"45422",title:"Urban Waterfront Regenerations",slug:"urban-waterfront-regenerations",totalDownloads:14203,totalCrossrefCites:4,totalDimensionsCites:12,abstract:null,book:{id:"3560",slug:"advances-in-landscape-architecture",title:"Advances in Landscape Architecture",fullTitle:"Advances in Landscape Architecture"},signatures:"Umut Pekin Timur",authors:[{id:"165480",title:"Dr.",name:"Umut",middleName:null,surname:"Pekin Timur",slug:"umut-pekin-timur",fullName:"Umut Pekin Timur"}]},{id:"24941",title:"Tsunami in Makran Region and Its Effect on the Persian Gulf",slug:"tsunami-in-makran-region-and-its-effect-on-the-persian-gulf",totalDownloads:7575,totalCrossrefCites:4,totalDimensionsCites:7,abstract:null,book:{id:"406",slug:"tsunami-a-growing-disaster",title:"Tsunami",fullTitle:"Tsunami - A Growing Disaster"},signatures:"Mohammad Mokhtari",authors:[{id:"52451",title:"Dr.",name:"Mohammad",middleName:null,surname:"Mokhtari",slug:"mohammad-mokhtari",fullName:"Mohammad Mokhtari"}]},{id:"66307",title:"Bio-hydrogen and Methane Production from Lignocellulosic Materials",slug:"bio-hydrogen-and-methane-production-from-lignocellulosic-materials",totalDownloads:2953,totalCrossrefCites:6,totalDimensionsCites:8,abstract:"This chapter covers the information on bio-hydrogen and methane production from lignocellulosic materials. Pretreatment methods of lignocellulosic materials and the factors affecting bio-hydrogen production, both dark- and photo-fermentation, and methane production are addressed. Last but not least, the processes for bio-hydrogen and methane production from lignocellulosic materials are discussed.",book:{id:"7608",slug:"biomass-for-bioenergy-recent-trends-and-future-challenges",title:"Biomass for Bioenergy",fullTitle:"Biomass for Bioenergy - Recent Trends and Future Challenges"},signatures:"Apilak Salakkam, Pensri Plangklang, Sureewan Sittijunda, Mallika Boonmee Kongkeitkajorn, Siriporn Lunprom and Alissara Reungsang",authors:null}],onlineFirstChaptersFilter:{topicId:"12",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"82465",title:"Agroforestry: An Approach for Sustainability and Climate Mitigation",slug:"agroforestry-an-approach-for-sustainability-and-climate-mitigation",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.105406",abstract:"Agroforestry Systems (AFS), or the association of trees with crops (or animals), is a strategy for land management and use that allows production within the sustainable development: (a) environmentally (production environmentally harmonic); (b) technically (integrating existing resources on the farm); (c) economically (increase in production), and (d) socially (equality of duties and opportunities, quality of life of the family group). As an intentional integration of trees or shrubs with crop and animal production, this practice makes environmental, economic, and social benefits to farmers. Given that there is a set of definitions, rather than a single definition of Agroforestry (AF) and AFS, it is justified to explore the historical evolution and the minimum coincidences of criteria to define them and apply them in the recovery of degraded areas. Knowing how to classify AFS allows us to indicate which type or group of AFS is suitable for a particular area with its characteristics. The greatest benefit that AFS can bring to degraded or sloping areas lies in their ability to combine soil conservation with productive functions. In other words, AF is arborizing agriculture and animal production to obtain more benefits including climate change adaptation and mitigation by ecosystem services.",book:{id:"11663",title:"Vegetation Dynamics, Changing Ecosystems and Human Responsibility",coverURL:"https://cdn.intechopen.com/books/images_new/11663.jpg"},signatures:"Ricardo O. Russo"},{id:"82754",title:"Impact of Revegetation on Ecological Restoration of a Constructed Soil in a Coal Mining in Southern Brazil",slug:"impact-of-revegetation-on-ecological-restoration-of-a-constructed-soil-in-a-coal-mining-in-southern-",totalDownloads:3,totalDimensionsCites:0,doi:"10.5772/intechopen.105895",abstract:"The main problems in the constructed soils are the generation of acid mine drainage promoted by the presence of coal debris in the overburden layer and the compaction of the topsoil promoted by the machine traffic when the material used in the overburden cover is more clayey. This book chapter aimed to show an overview of the impact of more than a decade of revegetation with different perennial grasses on the chemical, physical, and biological quality of constructed soil after coal mining. The study was carried out in a coal mining area, located in southern Brazil. The soil was constructed in early 2003 and the perennial grasses, Hemarthria altissima; Paspalum notatum cv. Pensacola; Cynodon dactylon cv Tifton; and Urochloa brizantha; were implanted in November/December 2003. In 11.5, 17.6 and 18 years of revegetation soil samples were collected and the chemical, physical, and biological attributes were determined. Our results show that liming is an important practice in the restoration of these strongly anthropized soils because this positively impacts the plants’ development, facilitating the roots system expansion. Biological attributes such as soil fauna and the microorganism’s population are the attributes that possibly takes longer to establish itself in these areas.",book:{id:"11663",title:"Vegetation Dynamics, Changing Ecosystems and Human Responsibility",coverURL:"https://cdn.intechopen.com/books/images_new/11663.jpg"},signatures:"Lizete Stumpf, Maria Bertaso De Garcia Fernandez, Pablo Miguel, Luiz Fernando Spinelli Pinto, Ryan Noremberg Schubert, Luís Carlos Iuñes de Oliveira Filho, Tania Hipolito Montiel, Lucas Da Silva Barbosa, Jeferson Diego Leidemer and Thábata Barbosa Duarte"},{id:"82936",title:"Soil Degradation Processes Linked to Long-Term Forest-Type Damage",slug:"soil-degradation-processes-linked-to-long-term-forest-type-damage",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.106390",abstract:"Forest degradation impairs ability of the whole landscape adaptation to environmental change. The impacts of forest degradation on landscape are caused by a self-organization decline. At the present time, the self-organization decline was largely due to nitrogen deposition and deforestation which exacerbated impacts of climate change. Nevertheless, forest degradation processes are either reversible or irreversible. Irreversible forest degradation begins with soil damage. In this paper, we present processes of forest soil degradation in relation to vulnerability of regulation adaptability on global environmental change. The regulatory forest capabilities were indicated through soil organic matter sequestration dynamics. We devided the degradation processes into quantitative and qualitative damages of physical or chemical soil properties. Quantitative soil degradation includes irreversible loss of an earth’s body after claim, erosion or desertification, while qualitative degradation consists of predominantly reversible consequences after soil disintegration, leaching, acidification, salinization and intoxication. As a result of deforestation, the forest soil vulnerability is spreading through quantitative degradation replacing hitherto predominantly qualitative changes under continuous vegetation cover. Increasing needs to natural resources using and accompanying waste pollution destroy soil self-organization through biodiversity loss, simplification in functional links among living forms and substance losses from ecosystem. We concluded that subsequent irreversible changes in ecosystem self-organization cause a change of biome potential natural vegetation and the land usability decrease.",book:{id:"11457",title:"Forest Degradation Under Global Change",coverURL:"https://cdn.intechopen.com/books/images_new/11457.jpg"},signatures:"Pavel Samec, Aleš Kučera and Gabriela Tomášová"},{id:"82828",title:"Vegetation and Avifauna Distribution in the Serengeti National Park",slug:"vegetation-and-avifauna-distribution-in-the-serengeti-national-park",totalDownloads:6,totalDimensionsCites:0,doi:"10.5772/intechopen.106165",abstract:"In order to examine the bird species changes within different vegetation structures, the variations were compared between Commiphora-dominated vegetations with those of Vachellia tortilis and Vachellia robusta-dominated vegetations, and also compared the birds of grassland with those of Vachellia drepanolobium and Vachellia seyal-dominated vegetations. This study was conducted between February 2010 and April 2012. A total of 40 plots of 100 m × 100 m were established. Nonparametric Mann-Whitney U-test was used to examine differences in bird species between vegetations. Species richness estimates were obtained using the Species Diversity and Richness. A total of 171 bird species representing 103 genera, 12 orders, and 54 families were recorded. We found differences in bird species distribution whereby V. tortilis has higher bird species richness (102 species), abundance, and diversity when compared with Commiphora with 66 species and V. robusta with 59 species. These results suggest that variations in bird species abundance, diversity, and distribution could be attributed to differences in the structural diversity of vegetation. Therefore it is important to maintain different types of vegetation by keeping the frequency of fire to a minimum and prescribed fire should be employed and encouraged to control wildfire and so maintain a diversity of vegetation and birds community.",book:{id:"11663",title:"Vegetation Dynamics, Changing Ecosystems and Human Responsibility",coverURL:"https://cdn.intechopen.com/books/images_new/11663.jpg"},signatures:"Ally K. Nkwabi and Pius Y. Kavana"},{id:"82808",title:"Climate Change and Anthropogenic Impacts on the Ecosystem of the Transgressive Mud Coastal Region of Bight of Benin, Nigeria",slug:"climate-change-and-anthropogenic-impacts-on-the-ecosystem-of-the-transgressive-mud-coastal-region-of",totalDownloads:8,totalDimensionsCites:0,doi:"10.5772/intechopen.105760",abstract:"The transgressive mud coastal area of Bight of Benin is a muddy coastal complex that lies east of the Barrier/lagoon coast and stretches to the Benin River in the northwestern flank of the Niger Delta Nigeria. It constitutes a fragile buffer zone between the tranquil waters of the swamps and the menacing waves of the Atlantic Ocean. Extensive breaching of this narrow coastal plain results in massive incursion of the sea into the inland swamps with serious implications for national security and the economy. Climate change impacts from the results of meteorological information of the regions shows a gradual degradation in the past 30 years. Temperature, rainfall and humidity increase annually depict climate change, resulting from uncontrolled exploitation of natural resources is rapidly pushing the region towards ecological disasters. The ecosystem is very unique being the only transgressive mud coastal area of the Gulf of Guinea. The chapter describes the geomorphology, tidal hydrology, relief/drainage, topography, climate/meteorology, vegetation, economic characteristics, anthropogenic activities and their impacts on the ecosystem.",book:{id:"11663",title:"Vegetation Dynamics, Changing Ecosystems and Human Responsibility",coverURL:"https://cdn.intechopen.com/books/images_new/11663.jpg"},signatures:"Patrick O. Ayeku"},{id:"82697",title:"Analyzing the Evolution of Land-Use Changes Related to Vegetation, in the Galicia Region, Spain: From 1990 to 2018",slug:"analyzing-the-evolution-of-land-use-changes-related-to-vegetation-in-the-galicia-region-spain-from-1",totalDownloads:6,totalDimensionsCites:0,doi:"10.5772/intechopen.106015",abstract:"Considering the complex dynamics, patterns, and particularities that the Galicia region present—e.g., the fragility, shown to achieve sustainable development and growth—a study that analyzes the Land-Use related to the vegetation of this region is seen as pivotal to identifying barriers and opportunities for long-term sustainable development. Using GIS (Geographic Information Systems), the present chapter enables us to identify the dynamics and patterns of the evolution of the Land-Use Changes related to vegetation in the Galicia Region from 1990 to 2018 (years 1990, 2000, 2012, and 2018 using CORINE (Coordination of Information on the Environment) data). This study permits us to reinforce that the Land-Use Changes related to vegetation in the Galicia Region have undergone multiple changes—marked by increasing and decreasing periods. Also, can be considered a surveying baseline for the comparative analysis of similar works for different Land-Use Changes related to vegetation trends in Europe or worldwide. Land-Use Changes related to vegetation studies are reliable tools to evaluate the human activities and footprint of proposed strategies and policies in a territory. This chapter also enables us to understand that the main actors should design development policies to protect, preserve and conserve these incomparable landscapes, environments, ecosystems, and the region as a whole.",book:{id:"11663",title:"Vegetation Dynamics, Changing Ecosystems and Human Responsibility",coverURL:"https://cdn.intechopen.com/books/images_new/11663.jpg"},signatures:"Sérgio Lousada and José Manuel Naranjo Gómez"}],onlineFirstChaptersTotal:77},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:330,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:9,numberOfPublishedChapters:139,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:122,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:112,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:21,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"7",title:"Biomedical Engineering",doi:"10.5772/intechopen.71985",issn:"2631-5343",scope:"Biomedical Engineering is one of the fastest-growing interdisciplinary branches of science and industry. The combination of electronics and computer science with biology and medicine has improved patient diagnosis, reduced rehabilitation time, and helped to facilitate a better quality of life. Nowadays, all medical imaging devices, medical instruments, or new laboratory techniques result from the cooperation of specialists in various fields. The series of Biomedical Engineering books covers such areas of knowledge as chemistry, physics, electronics, medicine, and biology. 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Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:3,paginationItems:[{id:"7",title:"Bioinformatics and Medical Informatics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",isOpenForSubmission:!0,editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",slug:"slawomir-wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",biography:"Professor Sławomir Wilczyński, Head of the Chair of Department of Basic Biomedical Sciences, Faculty of Pharmaceutical Sciences, Medical University of Silesia in Katowice, Poland. His research interests are focused on modern imaging methods used in medicine and pharmacy, including in particular hyperspectral imaging, dynamic thermovision analysis, high-resolution ultrasound, as well as other techniques such as EPR, NMR and hemispheric directional reflectance. Author of over 100 scientific works, patents and industrial designs. Expert of the Polish National Center for Research and Development, Member of the Investment Committee in the Bridge Alfa NCBiR program, expert of the Polish Ministry of Funds and Regional Policy, Polish Medical Research Agency. Editor-in-chief of the journal in the field of aesthetic medicine and dermatology - Aesthetica.",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null},{id:"8",title:"Bioinspired Technology and Biomechanics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",isOpenForSubmission:!0,editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",slug:"adriano-andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",biography:"Dr. Adriano de Oliveira Andrade graduated in Electrical Engineering at the Federal University of Goiás (Brazil) in 1997. He received his MSc and PhD in Biomedical Engineering respectively from the Federal University of Uberlândia (UFU, Brazil) in 2000 and from the University of Reading (UK) in 2005. He completed a one-year Post-Doctoral Fellowship awarded by the DFAIT (Foreign Affairs and International Trade Canada) at the Institute of Biomedical Engineering of the University of New Brunswick (Canada) in 2010. Currently, he is Professor in the Faculty of Electrical Engineering (UFU). He has authored and co-authored more than 200 peer-reviewed publications in Biomedical Engineering. He has been a researcher of The National Council for Scientific and Technological Development (CNPq-Brazil) since 2009. He has served as an ad-hoc consultant for CNPq, CAPES (Coordination for the Improvement of Higher Education Personnel), FINEP (Brazilian Innovation Agency), and other funding bodies on several occasions. He was the Secretary of the Brazilian Society of Biomedical Engineering (SBEB) from 2015 to 2016, President of SBEB (2017-2018) and Vice-President of SBEB (2019-2020). He was the head of the undergraduate program in Biomedical Engineering of the Federal University of Uberlândia (2015 - June/2019) and the head of the Centre for Innovation and Technology Assessment in Health (NIATS/UFU) since 2010. He is the head of the Postgraduate Program in Biomedical Engineering (UFU, July/2019 - to date). He was the secretary of the Parkinson's Disease Association of Uberlândia (2018-2019). Dr. Andrade's primary area of research is focused towards getting information from the neuromuscular system to understand its strategies of organization, adaptation and controlling in the context of motor neuron diseases. His research interests include Biomedical Signal Processing and Modelling, Assistive Technology, Rehabilitation Engineering, Neuroengineering and Parkinson's Disease.",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",isOpenForSubmission:!0,editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",slug:"luis-villarreal-gomez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",biography:"Dr. Luis Villarreal is a research professor from the Facultad de Ciencias de la Ingeniería y Tecnología, Universidad Autónoma de Baja California, Tijuana, Baja California, México. 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