Classification and the criteria of ototoxic substances based on occupational exposure limits.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
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Each step of such activities produces various types of agricultural waste that include crop residue, on-farm livestock and fisheries waste, forest waste, agro-industrial waste, etc. Currently, handling and managing agricultural waste is a challenging task worldwide, especially in the context of environmental pollution control and sustainable agriculture. Thus, efficient management in terms of reuse, recycling, and reduction of agricultural waste is principally needed not only for the green economy but also for farmers' profitability. This would also contribute to minimizing environmental pollution, greenhouse gas emissions, and climate change to meet the 2030 UN-SDGs. Therefore, this book aims to address agricultural waste production and management in the multidimensional aspects of crop residue, biodegradables, biomass, composting and vermiculture, agricultural waste economics, air pollution, environmental safety, waste management, and handling, on-farm waste reuse, and agricultural waste value addition. Authors are encouraged to submit original research, reviews, modeling and simulation, case studies, and recent progress and scenarios in the above-mentioned subject areas.
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The presence of venous and renal anomalies can create technical difficulties during aortoiliac surgery, and the patients are most likely to suffer severe bleeding, thus the surgeon must be alert to detect these anomalies and to treat them correctly to avoid severe injuries.
The most frequent anomalies than can complicate abdominal aortic aneurysms (AAA) repair are:
Major venous anomalies:
Renal vein anomalies:
Retroaortic left renal vein type I or II.
Circumaortic left renal vein.
Inferior cava vein anomalies:
Left-sided inferior vena cava or cava vein transposition
Double inferior vena cava: type I, II or III, right double cava.
Marsupial cava or preaortic iliac venous confluence.
Preureteral inferior vena cava, retrocaval ureter or circumcaval ureter.
Inferior vena cava malposition, anterior or posterior.
Agenesis of inferior vena cava.
Genitourinary anomalies:
Fusion anomalies:
Horseshoe kidney: frequently fusion of inferior poles, exceptionally fusion of superior polo with inferior polo, or fusion of both superior poles.
Pancake kidney, lump kidney or pelvic horseshoe kidney: fusion of both poles.
Position anomalies, renal ectopia:
Congenital pelvic kidneys:
Unilateral or bilateral pelvic kidneys.
Crossed kidney with fusion.
Crossed kidney without fusion.
Unilateral crossed kidney with contralateral agenesic kidney.
Bilaterally crossed kidneys.
Acquired pelvis kidneys (renal transplant).
Multiple renal arteries, veins or ureters.
Congenital venous abnormalities in the retroperitoneal space are relatively infrequent and, under normal circumstances, asymptomatic, but have clinical importance in aortoiliac surgery. These anomalies have a low prevalence, the type I retroaortic left renal vein (LRV), with an incidence of 0.3–0.9% joining the inferior vena cava (IVC) in orthotopic position; the type II LRV that joins the IVC lower, at L4–L5 has an incidence of 0.4–0.9%; circumaortic LRV (0.5–1.4%); duplication of IVC (0.2–3%) and left-sided IVC (0.2–0.5%) (Aljabri et al., 2001; Bass et al., 2000).
The prevalence of marsupial cava in humans cannot be predicted, but it is probably very rare because only sporadic cases are described in literature, and studies of inferior cava anomalies do not even cite.
Retrocaval ureter is reported to be in 0,06-0,017% of autopsy materials. The incidence is greater in males than in females, with a ratio of 2,8:1 (Uthappa et al., 2002).
Agenesis of the IVC has an incidence of 0.0005% to 1% in the general population (Simon et al., 2006).
Horseshoe kidney is a renal fusion anomaly estimated to be present in 0,25-0,6% of the population. It is twice as common in males as in females, while abdominal aortic aneurysm (AAA) occurs in 2% of the elderly. Horseshoe kidney associated with AAA is rare: it is found in only 0.12% of the patients that undergo AAA repair (Eze, et al., 1998;\n\t\t\t\t\tMakita et al., 2009; Yamamoto et al., 2006).
The pancake kidney also called fused pelvic kidney, is rare respect to other forms of ectopia, and its incidence cannot be estimated from the literature (Eckes & Lawrence, 1997; Krohn et al., 1999).
The incidence of congenital pelvic kidney has been estimated to be in 0,3%, due to an absence of migration of metanephros, and is the most frequent kidney ectopia. Crossed renal ectopia is an uncommon genitourinary anomaly, detected in 1 of 7000 autopsies. (Krohn et al., 1999; Marone et al., 2008 ; Morales & Greenberg, 2009 ; Sebe et al., 2004 ; Yano et al., 2003).
The prevalence of abdominal aortic aneurysm in patients with renal transplant is 1.01 to 6.7%.
Multiple renal arteries are relatively frequent (15 to 30%), the incidence of a single additional renal artery is 23,2% and is more common on the left side (27,6%) and in males (33,1%) (Natsis et al., 2010).
IVC results of a complex embryological process between the sixth and tenth weeks of gestation. Three pairs of primitive veins: postcardinal, subcardinal and supracardinal veins, appear in this order and form the four segments of the adult IVC: hepatic, suprarenal, renal and infrarenal (Fig.1).
The postcardinal veins appear first on the posterior aspect of the embryo. These veins regress, except for the distal aspects which became the iliac bifurcation. The subcardinal veins then appear anterior and medial to the postcardinal veins. The right subcardinal vein remains to form the suprarenal inferior vena cava, while the left subcardinal vein completely regresses. Subsequently, the supracardinal veins appear dorsally to the subcardinal veins. The left supracardinal vein then regresses, and the right supracardinal vein forms the infrarenal inferior vena cava (Minniti & Procacci 2002).
Embryologic derivation of the inferior vena cava from 6-8 weeks of gestation (A) to the adult (B). IVC: inferior vena cava, LRV: left renal vein.
The most frequent anomalies are detected in the renal and infrarenal IVC, and there are some types of variants.
The vein crosses the aorta in posterior face instead of the anterior face like normally. There are two types (Karkos et al., 2001; Kraus et al., 2003):
In the
In the
In the circumaortic LRV, both the preaortic and retroaortic limb of the venous collar persists. There is a periaortic venous ring like in the embryonic state (Karkos et al., 2001) (Fig. 2C).
Transposition or left-sided IVC develops from the persistence of the left instead of the right supracardinal vein, which occurs in the normal evolution. The left-sided infrarenal IVC typically joins the LRV, before it crosses the aorta to form a normal right-sided suprarenal IVC. Probably it could be subclassified in
Left renal vein anomalies. A, Retroaortic left renal vein type I. B, Retroaortic left renal vein type II. C, Circumaortic left renal vein
Inferior vena cava (IVC) anomalies. A, Transposition or left-sided IVC. B, Left-sided IVC (incomplete). C, Duplication of the IVC. D, Double IVC (incomplete). E, Right-sided double IVC.
In the double IVC, both left and right supracardinal veins persist. The renal segment of the IVC develops from the right suprasubcardinal and postsubcardinal anastomoses, and the infrarenal segment develops from the right supracardinal vein. Persistence of both supracardinal veins results in duplication of the IVC. (Palit & Deb, 2002).
The left iliac vein ascends as duplicated left IVC and usually drains into the left renal vein, which then crosses anterior to the aorta and joins the right IVC in a normal fashion,
It is possible that the left IVC does not drains into the left renal vein, but after receiving the left renal vein it continues with a major preaortic trunk that travels obliquely and empties into the right IVC,
Type I or major duplication: comprises two bilaterally symmetrical trunks and a preaortic trunk of the same caliber.
Type II or minor duplication: comprises two bilaterally symmetrical trunks, but smaller than the preaortic trunk.
Type III or asymmetric duplication: comprises small left IVC, larger right IVC and even larger preaortic trunk.
In the
In the double right IVC the left iliac vein crosses the midline behind or in front the aorta and ascends as double IVC, then joining at the renal level (Fig. 3E). There is a ventral-dorsal relationship between the two vessels. The right gonadal vein drains into the ventral vessel in majority of cases and into the IVC between the renal venous confluence and the confluence of the two vessels in other cases. (Nagashima et al., 2006; Tagliafico et al., 2007).
At fifth week embryo, three paired veins are roughly symmetrical (posterocardinal, supracardinal and sucardinal). At eighth week, a complex venous plexus appears in the lumbar region, with consolidation of various anastomoses between posterocardinal and supracardinal veins and with further development of circumumbilicous venous rings, which surround the future common iliac arteries on each side. By the tenth week, the ventral portion of the venous rings normally disappears. The persistence of a ventral anastomosis between interposterocardinal and supracardinal veins and the regression of the dorsal venous pathways gives rise to the preaortic common iliac veins confluence later on in fetal life (Natsis et al., 2003).
In this rare anomaly the normally right-sided inferior vena cava arise from an iliac vein confluence located anteriorly to the right common iliac artery and the aortic bifurcation rather than posteriorly (Fig. 4A) (Shindo et al., 1999).
Inferior vena cava (IVC) anomalies. A, Marsupial cava or preaortic venous confluence. B, Retrocaval ureter or pre-ureteric IVC. C, Transcaval ureter or periureteral venous ring. D Agenesis of infrarenal IVC.
Because such an anterior position of IVC is typical in most marsupials, as stated by McClure and Huntington in 1929, compared with the posterior position present in placental mammalians, it is used the term “marsupial cava” (Schiavetta et al., 1998).
The embryological significance of the retrocaval ureter is, strictly speaking, an anomaly affecting the IVC and not the ureter. In embryology, the IVC normally develops from a plexus of fetal veins. The posterior cardinal and subcardinal veins lie ventrally, and the supracardinal veins lie dorsally. The left supracardinal veins and the lumbar portion of the right posterior cardinal vein atrophy and the subcardinal veins become the internal gonadal veins. A definitive right-sided IVC forms from the right supracardinal vein. If the postcardinal vein in the lumbar portion fails to atrophy and becomes the right-side IVC, the ureter is trapped dorsally to it. This occurs because the right postcardinal vein is positioned ventral to ureter in the definitive inferior vena cava, so the developing right ureter courses behind to the IVC.
Retrocaval ureter almost invariably involves the right side. In this uncommon venous anomaly the right ureter courses posterior to the IVC and partially encircles it. Right ureter’s courses wings medially over pedicle of L3/4, passes behind the IVC, then exits anteriorly between IVC and aorta returning to its normal position, and produces varying degrees of proximal hydroureteronephrosis (Fig. 4B).
Bateson and Atkinson distinguished two types of retrocaval ureter according to the radiological appearance and site of ureteral narrowing (Uthappa et al., 2002; Shindo et al., 1999):
Occasionally exits the
There has been described malposition of the inferior vena cava, anteriorly to an AAA or posterior at it. (Chauduri, 2011).
Agenesis of the IVC is often used to describe three different entities (Ruggeri el al., 2001):
The renal system is developed from three structures that follow in time: pronephros, mesonephros and metanephros. The embryologic kidneys ascend cranially and receive blood from multiple arteries of common iliac arteries and media sacra artery; the renal artery is formed later in the third month. If the migration does not happen it gives the pelvic kidney, and if a fusion occurs, gives the horseshoe kidney.
The normally separate left and right metanephric blastemas fuse prior to migration and rotation, resulting in a fused mass. During the development of the kidney, if the metannephric masses come into contact or fuse and their normal medial rotation is interrupted, the anomalous
There is a fusion at inferior poles of the kidneys at the midline in 90% of cases, with the majority of each kidney lying on its own side of the spine. The isthmus connecting the lower poles contains usually functional parenchyma but may be a fibrous band and is located anterior to the aorta and IVC and posterior to the inferior mesenteric artery. The renal pelvis is usually rotated anteriorly and ureters arise anteriorly or laterally, because the horseshoe kidney, similarly to the pelvic kidney cannot rotate (Fig. 5A).
Renal fusion anomalies. A, Horseshoe kidney. B, Vascularization of horseshoe kidney: type I, II, III, IV and V. C, Pancake kidney.
The blood supply to the horseshoe kidney can be quite variable, especially in the isthmus and lower poles. The abnormalities of blood supply have been reported in 60% to 74% of patients with horseshoe kidneys and frequently the isthmus and lower poles frequently have their own accessory renal artery from the aorta or iliac arteries. (Makita et al., 2009)
Different classifications exit for variable arterial blood supply in horseshoe kidney, like that proposed by Eisendrath (Fig. 5B) (Ruppert et al., 2004):
Type I: one renal artery for each side of the horseshoe kidney, 20% of cases.
Type II: one renal artery for each side with an aortic branch to the isthmus, 30%.
Type III: two arteries for each side and one renal isthmus artery, 15%.
Type IV: two arteries for each side with one or more arising from iliac arteries, including the isthmus branch, 15%.
Type V: multiple renal arteries originating from the aorta and mesenteric and iliac arteries, 20%.
Anatomically, the blood supply to the horseshoe kidney is controlled segmentally by the accessory arteries, and the collateral blood flow between the segments is minimum. The occurrence of the renal ischemia was as high as 74% and is recommended reconstructing the accessory artery whenever its diameter is 2 mm or more. (Makita et al., 2009).
The renal vein anatomy is normal, with two renal veins each from left and right portions of the horseshoe kidney draining into the cava in a standard position.
Although the embryologic development of pancake kidney has not been fully elucidated, it is thought that it arrests in the early stages of rotation and migration. The renal blastemas are completely fused at 4-8 week embryos, and consequently fails to migrate in a cephalic direction, leaving it in a pelvic location that is usually at or below the aortic bifurcation. (Eze et al., 1998).
As its name implies, there is complete fusion of renal parenchyma without the presence of an isthmus giving an irregularly lobulated kidney, which is nearly circular in outline. The kidney is normally located at the level of the aortic bifurcation and gives rise to two collecting systems from his anterior surface that join the bladder in the normal anatomic position. Various cases from literature report two, three or four renal arteries that supply the kidney from the aorta, the right or the left common iliac arteries. The only assumption one should make is that the renal blood supply will be variable in number and position of renal arteries and can often involve the distal aorta and iliac arteries. The venous drainage systems could be variable to the iliac vein and proximal vena cava (Fig. 5C). (Eze et al., 1998).
A pelvic kidney occurs when the blastema in the 5 to 7 week embryo inexplicably fails to ascend normally.
By definition, a pelvic kidney is located under a flat level between the two iliac crests. Left pelvic kidneys are more common than right ones. Adding variety to the anatomy is the fact that the pelvic kidney does not rotate medially, so its hilium is ventrally located. There is usually a normal short ureter entering the bladder on the ipsilateral side (Sebe et al., 2004).
It is possible to affirm than in pelvic position, the renal arteries are multiple in the most cases, much more frequent than in orthotopic position, where is evaluated a 30%. Whenever is a single renal artery (49% of cases), it origins systematically from the aortic bifurcation. When the renal arteries are double, in 40% cases, a branch is originated from aortic bifurcation, and the second branch can emanate from the ipsilateral or the contralateral common iliac artery or from internal iliac artery. In case of three or four arteries (11% of cases), a branch comes from aortic bifurcation and the others branches from iliac axis ipsi and contralateral. Rarely, blood supply is guaranteed by feeding arteries originating from inferior mesenteric arteries. In definitive, if there are multiple renal arteries (in more than 50% of cases), one of the branches origin systematically from aortic bifurcation, and the other branches comes from ipsilateral iliac axis and more rare from contralateral iliac axis. The venous vascularization of pelvic kidneys is never described. The pelvic renal veins are multiples and small caliber. They drain in the IVC and in ipsilateral common iliac vein (Fig. B) (Marone et al., 2008; Sebe et al., 2004).
The
The corpse kidney is situated in the pelvis, with anastomosis in iliac arteries and veins (Fig. 6C).
Pelvic kidney. A, Congenital pelvic kidney. B, Vascularization of congenital pelvic kidney: one, two or three arteries. C, Acquired pelvic kidney (renal transplant).
Causes may involve faulty development of the ureteric buds, vascular obstruction to the ascent of the kidneys, and environmental factors.
The ectopic kidney crosses the midline and lies contralateral to its normal position, and usually is fused to the normal kidney, so is called crossed fused ectopia. The ureter of the ectopic kidney crosses the midline to enter the bladder at its normal position. This type of kidney is most often malrotated (ventral helium) and situated below the normal kidney. The anomaly is more common in male patients, and frequently involves the left kidney.
The blood supply to the kidneys is from the aorta or the iliac arteries, and the number of renal arteries varies. Venous drainage may also be abnormal, but because venous structures are not involved in aortic surgery, there have been no reports regarding this. This anomaly can be classified into four types (Fig. 7):
Crossed renal ectopia. A, Solitary crossed kidney. B, Crossed kidney without or C, with fusion. D, Bilaterally crossed kidney.
Renal arteries are derived from the embryonic mesonephric arteries. Regression of these arteries results in persistence of single mesonephric artery and formation of a single renal artery. Displasia of the mesonepric arteries gives rise to
The polar renal arteries are common, and usually of a small calibre, irrigating only a renal pole; double renal arteries is less frequent. Multiple renal veins can occur, but is less important because are not directly implied in aortic surgery.
These anomalies are asymptomatic usually. If there is a case with AAA ruptured into a
Several cases report of thromboembolic events occurring in patient with
The
The i
Recent reports confirm that
Although about 1/3 of
The presence of a
In case of
Since computed tomography (CT) is routinely performed for the elective repair of AAA, usually these anatomical anomalies like
In emergency surgery for a ruptured AAA, diagnosed by ultrasound alone, venous anomalies may be injured during surgery resulting in serious bleeding. In case of a ruptured AAA a CT could be useful to detect venous and renal anomalies and to avoid severe injuries.
Radiologically, the presence of
Characteristic computed tomography findings of
The knowledge of variations like
The CT and the MRI are the most efficacious and least invasive method of confirm diagnosis of
Retrograde pyelogram or iv urogram may show marked dilatation of the right pelvicalyceal system and proximal ureter to the level of transverse process of L3 vertebra. In addition there is medial deviation of the ureter at the point of transition with the characteristic “S” shape. The distal few centimeters of the right ureter are of normal caliber.
Ultrasonography demonstrates the anatomy of the retrocaval ureter and is useful in follow-up patients for hydronephrosis, parenchymal atrophy, and nephrolithiasis. (Mahmood et al., 2005)
In
The collateral circulation may simulate a paraspinal mass. The dilated azygous vein may be misinterpreted as a mediastinal mass on chest radiography, an the dilated collaterals in the abdomen could misinterpret as a enlarged pericaval lymph nodes in a CT abdominal, presumed a retroperitoneal lymphoma.
Left renal vein (LRV) anomalies CT. A, Retroaortic left renal vein type I. B, Retroaortic LRV type II. C, Circumaortic LRV.
Inferior vena cava (IVC) anomalies CT and arteriography. A, Left IVC. B, Posterior IVC. C, Agenesis of IVC.
Preoperative knowledge of renal blood supply is of paramount importance to the vascular surgeon when working with anomalous kidneys. Abdominal aortic and iliac aneurysms are frequently repaired without routine preoperative angiographic examination; however, the presence of renal ectopia, often discovered by ultrasonographic or computed tomographic scanning, is a specific indication for preoperative angiographic examination.
With helical CT, adequate preoperative diagnosis of abdominal aortic aneurysm accompanied by
Renal scintigraphic scanning may also demonstrate whether the isthmus contains functioning tissue.
Computed tomography and magnetic resonance angiography allow providing information about both aortoiliac aneurysm anatomy and
Duplex ultrasonography provide hemodynamic information such as alterations of peak systolic velocity that can occur in cases of severe kinking or dislocation of congenital pelvic kidney renal arteries in cases of huge associated aorto-iliac aneurysms.
Retrograde pyelography may provide further information about the path of the ureters and preoperative placement of ureteral catheter can enable the identification of an anomalous ureter.
There is renovascular hypertension in some cases, until 32%, but is difficult to diagnose in this cases with captopril isotopic gammagraphy. In hypertensive patients, preoperative base-line and captopril radionuclide renographic study may reveal the renovascular nature of the hypertension. It is possible that preoperatively hypertensive patients had postoperative captopril-renogram and serum creatinine levels returned to normal and were discharged without blood pressure medication (Hanif et al., 2005, Marone et al., 2008).
In
Genitourinary anomalies. A, Horseshoe kidney. B, Renal transplant.
Exposure of the proximal aorta and performing the proximal graft anastomosis is the major technical problem associated with anomalies of the renal vein or IVC; an adequate control of the aneurysm neck can be achieved through a midline transperitoneal approach minimizing the retroaortic dissection and avoiding to encircle the aorta. Unlike other authors, we do not believe a left retroperitoneal approach is necessary. Clamping the aorta is feasible above or below a retroaortic LRV type I. (Shindo et al., 2000).
During the control of the patient’s lumbar arteries from within the open sac of the aneurysm, there is a risk of damage especially in the case of retroaortic LRV type II. The vein can be damaged with the posterior stitches, resulting in severe bleeding or in the formation of a graft- LRV fistula. To avoid this, whenever possible, is better applying lumbar artery clips outside the AAA with visual control.
Sometimes it is necessary to ligate the normal LRV to control aneurysm’s neck. Whenever LRV ligating is necessary, it should be performed close to the IVC in order to preserve the gonadal and adrenal veins that normally empty into the LRV, and thus maintain the left venous renal draining.
There has been described ruptured AAA with fistula to the retroaortic left renal vein, resolved with open surgery. Furthermore, the proximity of the arteriovenous fistula to the renal arteries increased the risk of endoleak type I because it influenced the sealing and fixation zone of the stent graft even more. (Gabrielli et al., 2010).
Some authors prefer a left retroperitoneal approach in case of a left-sided IVC, which may be safer when preparing the perirenal aorta. A transperitoneal approach with division of the aberrant IVC as it crosses the aorta with subsequent anastomosis also has been suggested. Nevertheless, an adequate control of the aneurysmal neck can be achieved through a midline transperitoneal approach with sufficient cava mobilization (Fig. 11). There has been described an AAA with horseshoe kidney and left-sided inferior vena cava, resolved with open surgery (Evers et al., 2007; Giglia & Thompson 2004; Radermecker et al., 2008).
Surgery image, left inferior vena cava and aortobifemoral bypass.
It has been suggested that the transperitoneal approach rather than retroperitoneal one should be adopted for patients with an abdominal aortic aneurysm and concomitant double IVC (Ng & Ng 2009). (Nagashima et al., 2006).
During elective surgery for AAA, the presence of this rare anomaly can be managed with little additional risk through the use of a long midline incision and transperitoneal route. With a careful blunt dissection of the right common iliac artery bifurcation, it is possible to gain distal control without mobilizing the caval confluence, which results strictly adherent to aorta. On the contrary, this anomaly is very troublesome if the distal aorta and right common iliac artery are approached retroperitoneally from the patient’s right side (Schiavetta et al., 1998).
During emergency surgery, the priority of gaining quick control of the aorta and the iliac arteries through the retroperitoneal hematoma may lead to injury to major venous structures, excessive hemorrhage, and subsequent death. The inflammatory AAA poses another problem since an abdominal vein could be buried in the fibrosis, the preoperative mapping is important.
The retrocaval ureter can be inadvertently injured or ligated during aortoiliac surgery. Therefore, it is useful to identify such anomaly preoperatively. Ureteral stent (double J) may be helpful for stenting and drainage avoiding urine leakage and urosepsis.
Conservative treatment is necessary to those patients who have mild hydronephrosis without obvious symptoms, infection, worsening renal function, or stone formation. Ureteroureteral reanastomosis anterior to the vena cava with resection of the retrocaval segment is the widely favorite standard treatment; this reanastomosis can be done without resection of the retrocaval segment Laparoscopic or retroperioneoscopic ureterolisis and reconstruction of retrocaval ureter become popular in recent years with satisfactory success rate (Nagraj et al., 2006; Li et al., 2010).
Again is important identify these alteration of normal position of the vena cava due to not injury it during aortic surgery. With careful technique it could not be a problem.
The agenesic or hipoplasic cava vein difficult AAA dissection due the big collaterals with risk of haemorrhage. In the postoperative period may led deep venous thrombosis.
Patients with these venous anomalies, inflammatory AAA as well as elderly patients are at particularly high risk and could be candidates for endovascular procedures.
Horseshoe kidneys pose more technical difficulties because they limit access to the distal aorta and besides they are usually supplied by multiple renal arteries arising from the aorta, the AAA itself, or the iliac arteries. Although the retroperitoneal approach is recommended, the majority of authors describe the transperitoneal approach for most routine cases involving horseshoe kidney and abdominal aortic aneurysm. A retroperitoneal approach can need an adjunctive right iliac incision to facilitate clamping and manipulation of a right iliac aneurysm. The isthmus of the horseshoe kidney should not be divided unless it is thin and atrophic. Rather, the aortic graft usually can be tunneled beneath the kidney if the aorta is approached anteriorly. After resection of the isthmus, however, there are possibilities of hemorrhage, of formation of a hematoma in the retroperitoneum, or of vascular prosthesis infection associated with urine leakage (Makita et al., 2009; Yamamoto et al., 2006).
Cold perfusion is useful for renal preservation during temporary ischemia. Care must be taken, however, to revascularize the major arteries by reimplantation. Preoperative arteriography facilitates identification of these branches, but careful intraoperative dissection and inspection are required to avoid injury. Ligation of a small accessory artery diverging from an aneurysm did not affect postoperative renal functions. An accessory artery with a diameter of more than 2 mm requires reconstruction (Makita et al., 2009; Stroosma et al., 2001).
In the emergency setting the transperitoneal approach, less frequent re-anastomosis of renal arteries arising from the aneurysm, and more frequent separation of the renal isthmus were preferred to a retroperitoneal approach without separation of the isthmus, since the need for rapid vascular control lowered the threshold for division of the renal arteries and isthmus. (Stroosma et al., 2001).
In pluripathologic patients there are a high surgical risk and could be candidates for endovascular procedures. Endovascular aortic repair (EVAR) is feasible despite predictable technical difficulties (angulated neck, iliac aneurysm and occlusion) and the possibility or renal impairment. In patients with ruptured AAA and horseshoe kidney the EVAR treatment should be strongly considered (Chauduri, 2011; Saadi et al., 2008).
In presence of blood supply type I and II, according to Eisendrath, EVAR is preferable to open aneurysm repair in any patient in whom EVAR is technically feasible, if renal retention values are normal. Non predominant accessory renal artery less than 3 mm in diameter providing the isthmus with blood can be covered without any problems. In the case of dominant accessory renal artery greater than 3 mm in diameter, we recommend diagnostic use of selective angiography to determine what proportion of the horseshoe kidney and how much parenchyma is supplied by the accessory renal artery. When a blood supply types III and IV exist, it must be decided on the basis of each case whether EVAR is feasible. In our view, type V cannot be repaired with EVAR (Galiñanes et al., 2011; Radermercker et al., 2004; Ruppert et al., 2004).
The presence of a large, relatively fixed renal mass impairs anterior transperitoneal access to the pelvic vessels, thus can be a successful repair via retroperitoneal procedures. The retroperitoneal approach, avoids the renal isthmus, collecting system, and venous anomalies. In addition, it provides direct access to the abdominal aorta, the hypogastric arteries, and its branches. The pancake kidney has no isthmus, and therefore dissection and retraction is the only means of exposure, with dissection of the kidney and gentle retraction the exposure was adequate without endangering the kidney, its blood supply and collecting system. Division of the parenchyma of the pancake kidney presents potential problems such as postoperative urinary leakage, renal vascular compromise, and eventual renal failure. If the aneurysm extends into the iliac arteries, aneurysmectomy poses a significant threat to renal salvage since complete mobilization of the pancake kidney is required with the attendant risk of vascular or parenchymal injury (Krohn et al., 1999).
Anomalous renal masses invariably have aberrant vasculature including abnormal venous drainage. Exanguinating hemorrhage can occur with inadverted venous injury, but this can be avoided by careful dissection around the pancake kidney. Renal blood must be preserved, as the sacrifice of any renal artery can result in renal necrosis and loss of renal function. In other cases, the renal arteries may arise from the aneurysm itself requiring reimplantation or bypass grafting or may be temporarily occluded to perform the aneurysm repair. The renal warm ischemia time and period of increased cardiac afterload were shortened by first performing the iliac artery anastomosis (Eze et al., 1998).
A variety of techniques are available that can be used to minimize the ischemic injury to the renal parenchyma:
Mannitol has been shown to be an affective scavenger of oxygen derived free radicals through its inhibition of thromboxane synthesis. It has been recommended as a standard precaution before aortic cross clamping in patient undergoing aneurysmectomy also with forced diuresis with furosemide. Low-dose dopamine has also been used for its renal protective effects. Dopamine is used intraoperatively and postoperatively to maximize renal vasodilatation. (Krohn et al., 1999)
The renal parenchyma can be preserved with the use of in situ cold perfusion (4ºC) with lactated Ringer’s or Collin’s solution. To further diminish the effects of ischemia and reperfusion, selective renal perfusion techniques can also be used during aortic cross- clamping in specific cases, including the use of a variety of shunts and temporary bypass (Eckes & Lawrence, 1997).
In the majority of patients with a congenital pelvic kidney who underwent open repair developed significant, albeit largely transient, rises in creatinine value. Typically, this initial rise of creatinine levels is followed by a complete or near complete recovery which is consistent with that natural history of acute tubular necrosis (ATN). A preprocedure elevation of creatinine likely puts the patient at a higher risk for clinically apparent ATN postprocedure because of diminished functional renal reserve. (Bui et al., 2007).
In spite of all techniques for protection the pelvic kidney during aorta reconstruction ATN is common after surgery and tends to resolve within two weeks. Whether an episode of transient ATN shortens transplanted kidney life span is unknown, but we think is prudent to take reasonable steps to minimize ATN without adding complications to the procedure.
The risk factors currently associated with postoperative ATN include (1) the pelvic kidney constituting all functioning renal mass (congenital solitary pelvic kidney, renal transplant); (2) more than two anastomoses required to revascularize the kidney (e. g., reimplantation or bypass of the pelvic renal artery); (3) an elevated creatinine preoperatively; (4) poor collaterals such as occluded lumbars, inferior mesenteric artery, or internal iliac arteries or a measured aortic sac backpressure of <35 mm Hg; and (5) estimated aortic cross-clamp time for more than 50 min. (Bui et al., 2007).
Different mechanisms may plausibly be involved in renal function impairment, mainly related to malperfusion of congenital pelvic kidney such as aneurysm distal embolization, kinking of the renal artery, hemodynamic effects of abnormal pulsatility, and in the case of large lesions, due to depression of the renal parenchyma, renal veins, and the ureter and/or ureteropelvic junction. (Marone et al., 2008)
Renal function is more susceptible to ischemia in patients undergoing elective AAA repair who have transplanted kidneys than in patients with ectopic congenital pelvic kidneys. Except for patients with congenital solitary pelvic kidney, good results with congenital pelvic kidney should be expected as these patients had a normal kidney above the AAA that was not at risk of ischemic injury. Without the advantage of pre and postoperative nuclear renal isotope scans to assess excretion and flow, it is difficult to assess the degree of acute tubular necrosis in the congenital pelvic kidney in a patient with normal contralateral kidney.
Unlike a transplanted pelvic kidney, the congenital pelvic kidney may have a single renal artery, but their origin may be displaced to the distal aorta or even iliac arteries; or may has multiple renal arteries, one which may originate from the diseased distal aorta, requiring reimplantation. In cases of iliac aneurysm, it may be needed to reimplant the renal artery. If during aortic cross-clamping an ischemic discoloration of a segment of the kidney is observed that indicates the lack of a collateral vascular supply and the necessity of reimplanting the artery that supply that segment (Bui et al., 2007).
In case of renovascular hypertension refractory at treatment with an atrophic pelvic kidney it could be needed a nephrectomy for better hypertension control with less drugs (Sebe et al., 2004).
Because of the presence of congenital pelvic kidney, the renal function may be affected by intraoperative renal ischemia after aortic aneurysm repair and several methods of renal protection to prevent renal ischemic injury have been previously reported. These methods of renal preservation, also used during abdominal aneurysmectomy in renal transplant patients, can be divided in various groups: pharmacological systemic renal protection, in situ perfusion with hypothermic crystalloid solution, use of a temporary shunt and double proximal clamping technique, the use of perfusion with pump oxygenator or ex vivo perfusion are abandonee. In appropiate candidates, EVAR may be considered.
Systemic renal protection. The expansion of plasmatic volume with preoperatory hydration and the intraoperatory administration of furosemide and mannitol or dopamine to obtain forced diuresis before cross-clamping, reduce the risk of kidney loss, or acute tubular necrosis. These methods are safe and effective and can represent a good choice if associated to a fast aortic reconstruction.
In situ cooling techniques. To preserve renal function during supra-renal clamping for a longer time (60 to 90 min), it is possible to use selective infusions of bolus of cold (4ºC) lactate Ringer’s solution that can be repeated every 20 minutes or continuously infused to reduce the temperature of the kidney to 15-18ºC. Some authors added 6-methylprednisolone and mannitol to this solution. Topical cooling kidney packing with ice slush is a complementary action in these cases. (Marone et al., 2008).
Temporary shunts. Temporary bypasses or shunts are performed from the axillary or subclavian artery or from the abdominal aorta above the aneurysm, or less frequently from the left atrial cavity or ascending aorta to the iliac or femoral vessels. A temporary extra-anatomic shunt maintains renal perfusion when conventional AAA repair is required. A shunt with partial extracorporeal circulation and pulsatile cold blood perfusion needs systemic anticoagulation; a shunt with centrifugal pump or a Gott shunt (heparin coated) does not need anticoagulation. However, all these procedures entail possible intimal arterial dissection or embolization and may increase the risk of haemorrhagic or infectious complications (Hanif et al., 2005; Maeda et al., 2009; Martin-Conejero et al., 2003).
Clamping and anastomoses techniques. The double proximal clamping technique, described by Lacombe offers a potential sufficient protection for medium time (less than 60 min) using backflow by lumbar, inferior mesenteric, and iliac arteries during completion of proximal aortic anastomosis. This technique involves completely dividing the aortic neck proximally between two clamps. The aortic back pressure after aortic cross-clamping is between 35 and 60 mm Hg, and experimentally, a renal blood flow under a low arterial pressure of only 25 mm Hg is adequate for organ survival (Lacombe, 1991, 2008)
Once the proximal anastomosis is complete, the sac can be opened and the distal anastomosis is performed while the pelvic kidney is perfused by retrograde flow from the ipsilateral internal and femoral arteries. The absence of a valid collateral circulation and the presence of a short proximal neck limit the use of this alternative. Some authors have pointed out that having two clamps together makes the proximal anastomosis more difficult. This technique has been modified by Hollis et al. to use a vascular stapler to avoid the distal clamp. The short proximal aortic neck may require placing the distal clamp across the proximal aneurysm sac. This compression of the sac could potentially lead to significant embolization. (Bui et al., 2007).
When using a bifurcated graft, performing the distal before the proximal anastomosis is another described technique for limiting clamp time. By taking the graft limb ipsilateral to the pelvic kidney and anastomosing it distal to the kidney on the external iliac artery, this anastomosis can be done without interrupting the normal aortoiliac flow to the pelvic kidney. Warm kidney ischemic time is then limited to the time it takes to do the proximal aortic anastomosis only.
5. Extracorporeal pump. Finally, another technical approach to this pathology is the renal perfusion using a femoral vein to femoral artery bypass using extracorporeal oxygenation. This method offers a reliable protection but requires a perfusionist, a pump-oxygenation, and a groin incision for retrograde cannulation of the femoral artery and vein. The technique of
In suitable aneurysm candidates, the use of an endovascular graft can also be considered for treatment in patients with congenital pelvic kidneys. Endovascular repair obviates the need for renal protection as warm ischemic time is limited to ballooned graft placement. This is also especially attractive for high-risk patients with multiple comorbidities who otherwise may not tolerate open repair. Contrast load and excessive manipulation of the donor artery in renal allograft patients, however, need to be minimized in order to achieve optimal outcomes. However, there is a risk of vascular damage at the graft anastomotic site, so, if implant dislocation occurs, graft thrombosis may happen (Bui et al., 2007; Bertoni et al., 2010; Morales et al., 2009)
The decision to implant a bifurcated or an aorto-uni-iliac device depends on the anatomical characteristics of the aneurysm. The bifurcated stent graft maintains in-line flow to the renal transplant. The larger delivery system for the main body of the graft can be inserted
In conclusion, to preserve renal function during open repair, various methods have been previously reported, but no procedure has been clearly considered the therapeutic gold standard. The congenital pelvic kidney is associated with a normal and functional contralateral kidney, so protective measures need not to be drastic. In our experience, the forced intraoperative diuresis with mannitol and furosemide and the main pelvic kidneys arteries selective perfusion with hypothermic lactate ringer solution, associated to a fast surgical technique, have proven to be safe and effective. (Marone et al., 2008).
A ureteral stent can be placed preoperatively to prevent ureter intraoperative injury as a marker of the abnormal ureter. This shows that the ureter crosses the midline, and enters the bladder at its normal anatomic location. (Yano et al.,2003).
The incidence of acute renal failure after aortic surgery in renal transplant patients has ranged from 1 to 8% in elective cases, and in patients with mild or moderate degree of renal dysfunction the morbidity rates are higher than in patients with normal renal function. Given the lack of collateralization of renal allograft, they are more susceptible to ischemic injury than congenital pelvic kidneys (Favi et al., 2005).
The aortic clamp during AAA repair may cause ischemia of the renal graft and diverse procedures have been performed to preserve the function of the transplanted organ. These methods are similar like described in congenital pelvic kidney. Successful surgical repair of AAA in patients with a transplanted kidney has been reported without any form of renal transplant protection, with judicious clamping and rapid anastomosis, although the warm ischemia time of the allograft should not take longer than 60 min. This option could be made difficult by the possibility of finding a very diseased calcific or malacious aortic wall due to dialysis and immunosuppressive therapy (Skelly et al., 2002).
Standard open surgery without adjunctive shunts or bypasses remains a viable treatment option for these patients. Renal ischemia during aortic cross-clamping can be effectively reduced by cold graft perfusion and local hypothermia. In addition, the potential risk of atheromatous embolization to the transplanted kidney is less than for other temporary procedures of shunt or bypass. The endovascular technique may be used for patients who meet the anatomical criteria for endovascular repair and are at high risk for a conventional operation (Ailawadi et al., 2003; Khanmoradi et al., 2004; Karkos et al., 2006; Kokotsakis et al., 2009). The fever before EVAR in a kidney transplant patient is not always synonymous with infection; it may be a postimplantation syndrome. (Regidor et al., 2009).
It has been described an aortoiliac aneurysm resection and reconstruction with allograft together with simultaneous kidney transplantation as a one-stage procedure with good results. Also it has been described an aortic stent-graft explantation in a kidney transplant recipient (Hughes et al., 2009; Matia et al., 2008, 2009).
Accessory renal arteries can also be found during careful dissection of the aorta, usually arising more anteriorly than the normal lateral renal artery orifices. Those that are sufficiently large to supply distinct areas of renal parenchyma should be reimplanted onto the aortic graft if they arise from the AAA. This is facilitated by excising a surrounding collar (Carrel patch) of associated aortic wall along with the orifice.
Although uncommon, anatomical anomalies may lead to difficult situations and life-threatening bleeding. A preoperative CT is useful in the patients undergoing an AAA repair. Familiarity with these anomalies and safe operative technique is needed to avoid fatal complications. Endovascular techniques play an important role in AAA cases with venous and genitourinary anomalies if the patient has serious comorbidities and has adequate anatomical conditions in neck and iliac arteries.
To Carol, Celia and Miguel, for their patient and understanding.
Occupational noise exposure is very common around the world. Up to 25% of workers are exposed to workplace noise above 85 dB(A) (weighted decibel relative to human ear) [1]. Noise-induced hearing loss (NIHL) is the second most common cause of hearing loss after age-related hearing loss (ARHL) and 16% of adult hearing loss is estimated to be caused by workplace noise [2]. In addition, one-third of workers exposed to noise showed audiometric evidence of NIHL, with 16% experiencing material hearing loss [3, 4].
The prevalence of NIHL is increasing worldwide. Prevalence in Korea is also increasing, especially over the past 20 years. Cases of accepted compensation for NIHL are more rapidly rising from 2016 than the cases for audiometric diagnosis (Figure 1).
Prevalence of noise-induced hearing loss (D1) and compensated cases in Korea by year (1991 to 2018). Prevalence of noise-induced hearing loss (D1) (in blue bars) and cases for compensation (in red line) have increased from 1991 to 2018. Diagnostic criteria of NIHL in Korea requires hearing loss more than 30 dB on average threshold across 0.5 kHz, 1 kHz, and 2 kHz and more than 50 dB at 4 kHz. If the average threshold exceeds 40 dB, decision for compensation could be made. The compensated cases for NIHL were increasing more sharply since 2016, whereas the diagnosed cases were increasing more steadily.
Hearing loss is associated with cognitive decline and depression, and now accepted as a risk factor for dementia [5]. Noise from by daily life (subways, electric tools) or hobby (music concerts, sports viewing, hunting, etc.) can also contribute to hearing loss.
There are jobs where hearing is very important due to the nature of work itself or safety concerns. Hearing loss reduces speech recognition ability in the noisy environment and hearing protection devices (HPDs) also hampers speech recognition in noise. When hearing impaired workers wear a HDPs, their difficulty increases in hearing warning signals. There was association between the severity of hearing loss and the risk of work-related injury requiring hospitalization [6]. Even in the workplace where hearing is less important, hearing loss is a major cause of stress-related sick leave [7]. Economic impact of NIHL on social burden includes lost productivity, absenteeism, reduced income and tax revenues, welfare payment and compensation, special education, vocational rehabilitation programs, and health care [8].
The purpose of this review is to have a comprehensive overview of NIHL including pathophysiology, diagnosis, prevention, and to understand the recently emerging topics on noise-induced cochlear synaptopathy.
Noise-induced hearing loss is a complex disease caused by the interaction of genetic and environmental factors. It is usually caused by chronic loud noise exposure but also could be caused by transient or repetitive acoustic trauma of very high intensity, resulting in greater damage [9]. The total energy level of noise causing NIHL is determined by the intensity of the noise and the total exposure time. The noise at the same total energy level will cause the same amount of cochlear damage [10].
The inner ear damage caused by noise is divided into temporary threshold shift (TTS) and permanent threshold shift (PTS) depending on the duration of the hearing loss. Hearing loss recovers within 24–48 hours in TTS, while it is irreversible in PTS. Mechanisms of TTS and PTS are considered to be different. Animal study showed that TTS in early life can accelerates age-related hearing loss (ARHL) [11]. However, long-term impact of TTS in human ear is lacking. Pathology of noise induced damage is the loss of outer hair cells leading to threshold elevations and poorer frequency discrimination. Main threshold shift occurs at an half octave higher than the frequency of loud noise, with the largest damage at 4 kHz and the smallest at 0.5 kHz [12]. Susceptibility around 4 kHz is associated with the mechanical properties of the middle ear and resonance frequency of external auditory canal [13].
Mechanism of cochlear pathology can be categorized into mechanical and metabolic [12]. Metabolic damage is a major mechanism of NIHL from chronic exposure to noise. Characteristic finding is loss of hair cells as a result of increased free radicals such as reactive oxygen species (ROS) and reactive nitrogen species within cochlear hair cells [14]. Damage starts in outer hair cells in row 2 and 3 of most vulnerable area to noise, possibly as a result of necrosis [15]. Noise releases ROS from mitochondria into cytoplasm of hair cells via release of Ca2+. Cytoplasmic ROS leads to production of pro-inflammatory cytokines and pro-apoptotic factors, finally to apoptosis of hair cells. Free radicals can persist for 7–10 days after cessation of noise exposure, which could induce progressive cochlear damage [16]. Noise-induced ischemia and reperfusion also increase the generation of ROS [14]. Lipid peroxidation induced by ROS acts as a toxic substance, causing apoptosis [15].
When the noise is extremely loud over 130 dB SPL, mechanical damage could occur via excessive vibrations of the delicate cochlear structures. Breaking or fusion of stererocilia of hair cells are most specific morphopathology. Noise could damage other cochlear structures; damage to cochlear vasculature, loss of fibrocytes, rupture of attachments of stereocilia tips to the tectorial membrane, distension or rupture of tip links, damage to pillar cells, and rupture of dendrites [14]. Noise could crumple pillar cell, decreasing length of the OHC, and detaching stereocilia from tectorial membrane in reversible way, which is understood as a mechanism of TTS [17].
Recent hot topic on noise-induced damage on auditory system is cochlear synaptopathy. Until recently, noise that does not cause threshold shift was considered safe. However, recent animal experiments have shown that noise exposure that does not cause hair cell loss may damage ribbon synapse between inner hair cell and spiral ganglion neuron [11]. Cochlear inner hair cells (IHCs) are important as mechano-electrical transducer of auditory information. Receptor potential generated by IHCs releases the neurotransmitter at the synaptic end, while outer hair cells work as cochlear amplifier via process of electromotility which increases the vibration of basilar membrane. Synaptic ribbon is specialized electron-dense structure, which is anchored to pre-synaptic membrane only nanometers apart. It contains large pool of “readily releasable” vesicles to finely vary synaptic output continuously in sensory organ of hearing and vision [18]. Thus, damage of ribbon synapse between IHCs and spiral neurons results in improper conveyance of neural information to auditory nerve fiber. Noise causes damage of presynaptic ribbons and postsynaptic nerve terminals showing various degree of swelling. The mechanism of damage for postsynaptic terminal is glutamate-mediated excitotoxicity, while mechanism of ribbon loss is unclear [19]. In cochlear synaptopathy, hearing threshold is normal because OHC is undamaged, but the amplitude of auditory nerve activity decreases as a result of silenced auditory nerve fibers [20].
Auditory nerve fibers (ANFs) could be functionally categorized by their spontaneous rate (SR). High-SR ANFs respond to sound at threshold level, whereas low-SR ANFs react to loud sound, follow rapid amplitude changes of acoustic signal, and are considered to have an important role in the hearing in noisy environment due to their larger dynamic range. Low-SR ANF appears to be damaged selectively after noise exposure [20]. Because it causes functional hearing loss without threshold change, it is also called “noise-induced hidden hearing loss”. Cochlear synaptopathy could be permanent and lead to a degenerative death of the spiral ganglion neuron [21]. The results of human studies on cochlear synaptopathy are controversial. If the cochlear synaptopathy is confirmed in human subjects, the conventional belief that noise would be safe if it does not cause a threshold shift should be changed [19].
Severity of cochlear damage after noise exposure varies among individuals. Genetic factors would account for the different susceptibility up to 50% [22]. In animal study, genetic deficits leading to ARHL predispose the inner ear to NIHL [23]. Single Nucleotide Polymorphism (SNP) is the most common site of genomic mutations. It is estimated that the SNP of K+ recycling gene and heat shock protein (HSP) gene in the inner ear is associated with the sensitivity of NIHL [24, 25].
ISO 1999:2013 model assesses the risk of NIHL with age, gender in addition to intensity of exposed noise and exposure time in years [26]. The prevalence of NIHL is higher in male than in female and racial difference exists with lower prevalence in darker pigmentation [27]. Increasing age, smoking, poor diet, lack of exercise, comorbidity such as diabetes, cardiovascular disease may increase risk of NIHL [28]. Sufficient nutrition helps to preserve high frequency hearing [29].
The prevalence of hearing loss among noise-exposed workers is various across industries and occupations. Noise exposure is common in industries of mining, construction, manufacturing, forestry, utilities, repair and maintenance, and transportation sectors [2]. Sixty-one percent of the mining workers, 51% of the construction workers, and 47% of the manufacturing workers are exposed to noise [1]. Among workers of the above industry sectors, 20 ~ 25% have a material hearing impairment [30]. In Korea, NIHL was most common in the workers of manufacturing sector, followed by construction sector (Figure 2).
Prevalence of noise-induced hearing loss (D1) according to Korean standard industrial classification. A total of 12,822 cases were diagnosed as NIHL in 2018 in Korea. Among them, NIHL was most commonly reported in manufacturing sector with 9,455 cases, followed by construction, mining, transportation, and business facility management and business support services sectors.
Audiometric evidence of NIHL is characteristic notch or bulge between 3 kHz and 6 kHz, mostly worst at 4 kHz, with preserved hearing at 8 kHz and lower frequencies [31]. Notch deepens and widens with continued noise exposure, eventually involving lower frequencies. Hearing aggravates in the first 10–15 years of noise exposure, and then process slows down [17]. The maximum hearing loss from NIHL has been accepted not to exceed 75 dB at higher frequencies and 40 dB at lower frequencies [32]. However, it could reach 80 dB or worse in 2.6% of construction industry engineers [33]. Notch could be observed in 19.9% of persons without history of loud noise exposure, so audiometric notch does not necessarily mean NIHL [3].
Unlike NIHL, the ARHL accelerates over time. Hearing loss in ARHL starts at 8 kHz or higher frequencies and expands to lower frequencies. When NIHL and ARHL coexist, the notch widens and looks like a bulge [34]. As the combined ARHL progresses with advanced age, noise notch may be rarely observed [35]. Sometimes medicolegal opinion is sought about which factor contributes more on the etiology of hearing loss between noise and age. It is impossible to distinguish the allocation of each factor in aged persons.
Hearing in noise may be compromised probably due to cochlear synaptopathy. To quantify damage from noise exposure, speech recognition in quiet and noise is also recommended [21]. Otoacoustic emission (OAE) can be used as an earlier test before PTA deficit is evident [36]. But recent studies showed that OAE was not more sensitive than PTA in assessing hearing loss caused by long-term exposure to noise [37]. Possibility of middle ear acoustic reflex as a diagnosis of cochlear synaptopathy was also suggested [38].
Noise-induced hearing loss is typically bilateral because noise affects both ears symmetrically. However, it could be asymmetric. Prevalence of asymmetric hearing gap larger than 15 dB in general population is 1% while those of NIHL were reported as 4.7–36% [35]. Left ear was more affected, especially in male [39, 40]. Lateral difference was most prominent in 3–6 kHz [41]. The firefighters and public safety workers may no longer be able to carry their duties because asymmetric hearing disturbs to distinguish sound direction and causes work-related risk [42].
There are two theories about mechanism of lateral asymmetry. One is head shadowing effect that makes noise level affecting each ear unequal [43]. Another is that left ear is more susceptible to noise damage for physiological reasons. It involves a less sensitive acoustic reflex in left side and a stronger protective auditory efferent system of the right olivocochlear bundle [44, 45].
MRI scan should be performed to rule out vestibular schwannoma in asymmetric hearing loss. Medicolegal decision of asymmetric NIHL is quite unconvincing. According to Robinson’s criteria, if there is no evidence of NIHL in the better ear, patients can be declined compensation [45]. Whereas, Fernandes et al. insisted that comment should be made on the causation as being noise-induced, if there is no other cause to explain the asymmetry [46].
The prevalence of tinnitus among noise-exposed workers is 24%, which is much higher than that of the general population [47]. Tinnitus is bilateral in majority of workers exposed to noise, however, some of them complains of unilateral symptom, more commonly in left ear [48]. Tinnitus degrades quality of life in workers and distracts military personnel during military operation [49]. Although association of noise and hyperacusis have rarely been studied, pop and rock musicians were at high risk for the development of hyperacusis [50].
Besides hearing loss, noise can induce vestibular dysfunction through the damage to sacculocolic reflex pathway or damage to vestibular hair cell [51, 52]. The relationship between NIHL and abnormal vestibular evoked myogenic potentials (VEMPs) was reported in human study [53]. Noise exposure reduced the stereocilia bundle density of the vestibular end organ and reduces the firing rate of the anterior semicircular canal (ASCC) without significant change of the vestibular-ocular reflex, suggesting possibility of “hidden vestibular loss” [52]. Abnormal electronystagmography (ENoG) was more common in the asymmetrical NIHL group than in symmetrical NIHL [54].
Noise regulation is the best option to prevent NIHL. Current noise regulations are based on the intensity of chronic continuous noise rather than impulsive acoustic trauma. Degree of exposure is calculated as registered in individual reporting or hearing protection programs [30]. Noise of intensity below 80 dB (A) (weighted decibel relative to human ear) reduces the risk of NIHL [55]. Daily permissible exposure limit (PEL) and exchange rate should be set to run hearing conservation program. Many countries legislate PEL at 85 dB(A) for an 8-hour workday. Some countries loosely permit up to 90 dB(A). Exchange rate defines the 3–5 dB increase in noise intensity with which exposure time should be halved to protect hearing. Exchange rate of 5 dB appears to be more accurate than 3 dB [56]. For example, 4 hours of exposure to 90 dB(A) is as hazardous as 8 hours of exposure to 85 dB(A). Number of workplaces of which noise exceeds PEL of 85 dB(A) for an 8-hour workday has been decreasing in Korea. It reduced from 20.2% of total workplaces in 2014 to 15.3% in 2018 (Figure 3). For impulse noise, 140 dB is generally set as the upper limit [57].
Korean workplaces of which noise exceeded permissible exposure limit (2014 to 2018). Percentage of Korean workplaces of which noise exceeded permissible exposure limit was 21% until 2010 but is gradually decreasing. In the second half of 2018, it was 15.3% showing the lowest rate for the past 5 years.
Hearing protection devices (HPDs), including earmuffs and earplug, are secondary level personal protection. Most workplace noise can be attenuated to a safe level by reducing noise by 5–10 dB, and this goal can be achieved when if HPDs are worn properly and continuously [30]. However, many workers do not wear HPDs for enough time and the effect is cut in half if workers remove HPDs for only 30 minutes of an 8-hour workday [58]. Therefore, it is efficient, when selecting HPDs, to focus on consistency of use than noise reduction rate of HPDs [59]. Individual fit-test system for earplugs is more feasible for field use and could effectively prevent hearing deterioration [60]. Earmuffs can reduce noise more consistently than earplug, and 3D print earmuffs made from light materials such as acrylonitrile butadiene styrene/clay nanocomposites was helpful in reducing weight of earmuffs and would probably increase comfort [61]. Hearing conservation program in elementary school are potentially effective way to know the risks of noise exposure early in life, leading to behavioral changes such as noise reduction and HPDs [62].
It is important to reduce the “know-do” gap between knowledge accumulated to prevent NIHL and actual implementation at workplace. This requires frequent communication meetings for noise control, assigning staff to provide daily program support, noise hazard identification, selection of HPDs, and providing inexpensive sound level meters or sound measuring apps [30].
We suggest that hearing conservation program should include administrative or engineering controls to reduce sound levels. Workplace noise should be monitored using either a wearable sound level meter or a dosimeter to determine if noise exposure level is at or above 85 dB(A). If the workplace noise exceeds an 85 dB(A) for an 8-hour workday, exposed employees should be enrolled in a hearing conservation program (HCP) and audiometric test should be conducted annually by audiologist to check if the standard threshold shift occurs. Employees enrolled in HCP should be offered HPDs and take mandatory training program annually about effects of noise on hearing, purpose and value of HPDs and hearing test. Managers or supervisors must attend training sessions and should keep the record of all hearing tests, noise surveys, and training records.
There is no practical medication to prevent NIHL from chronic noise exposure. Most drugs have been studied either on an experimental level or on an animal study basis.
The noise exposure increases the immune and inflammatory factors in the cochlea. Steroids are the only approved medicine in treating sudden hearing loss. Animal study showed that steroids before and after the exposure to acoustic trauma were effective through control of the inflammatory response [63, 64]. It is estimated that intratympanic steroid injection would be effective in protecting outer hair cell efferent terminal synapse, and intraperitoneal steroid injection would be effective in protecting organ of Corti and stria vascularis [65]. In human studies, combined systemic & intratympanic steroid administration was more effective than systemic steroid only [66]. Long-term administration of steroid is inadequate due to its possible side effects.
Free oxygen radicals and oxidant stress are important pathological mechanisms of NIHL. N-acetylcysteine (NAC) is an antioxidant and is known to reduce noise-induced ototoxicity in animal study. There was no significant differences of overall hearing loss in military population between NAC group and placebo group [67].
Neurotropin-3 (NT3) and Brain derived neurotrophic factor (BDNF) are known to be important factors in the generation and maintenance of cochlear hair cell ribbon synapse [68, 69]. Animal study demonstrated a reduction in synaptopathy and a restoration of hearing immediately after strong noise exposure [70] but human data is lacking.
Noise-induced hearing loss is drawing more attention than ever before. Besides hearing loss, noise can also compromise the vestibular function. Recently, evidence on noise-induced cochlear synaptopathy is accumulating. Exposure to noise in short duration or less intense noise may result in functional hearing loss without threshold change on audiogram. So far, prevention is the best option, but we expect that continuous research on NIHL will open up the possibility for treating drug ototoxicity and ARHL as well.
Chemicals such as organic solvents, metals and asphyxiants are known for their neurotoxic effects on both the central and peripheral nervous systems. These agents could injure the sensory cells and peripheral nerve endings of the cochlea [71].
Over the past 3 decades, several studies investigated the relationship between occupational exposure to chemical substances and hearing loss for humans [72]. According to the score combining human and animal data, lead (and its inorganic salts) as an only inorganic substance and the organic chemicals including toluene, styrene, and trichloroethylene were ranked as “ototoxic”. Other candidate substances classified as “possibly ototoxic” are nitriles (acrylonitrile, 3-butenenitrile), carbohydrates (n-hexane, p-xylene, and ethylbenzene), hydrogen cyanide, carbon monoxide, carbon disulfide, and mercury, germanium, and tin. Recently, a classification criteria on ototoxic substances was delivered by the Nordic Expert Group (NEG). The NEG chose a quantitative approach, meticulously comparing the “no observed” or “lowest observed” effect levels with occupational exposure limits from various countries. This information can be useful for the management of toxic substances and prevention of hearing loss (Table 1) [73].
Classification | Criteria | Ototoxic substances |
---|---|---|
Category 1 | Human data indicate auditory effects below or near the existing OELs. There are also robust animal data supporting an effect on hearing resulting from exposure | toluene, styrene, carbon monoxide, carbon disulfide, lead and mercury |
Category 2 | Human data are lacking, whereas animal data indicate an auditory effect below or near the existing OELs. | p-xylene, ethylbenzene, and hydrogen cyanide |
Category 3 | Human data are poor or lacking. Animal data indicate an auditory effect well above the existing OELs. | Other substance |
Classification and the criteria of ototoxic substances based on occupational exposure limits.
OEL: occupational exposure limits.
Until now, regarding regulatory problem, the interaction with noise has not been investigated in a satisfactory way. Although it is very difficult to combine all of the data to arrive at solid conclusions, this does not exclude the possibility of other chemical substances can worsen hearing losses due to noise.
In workplace, one of the most common kinds of exposure is solvents mixture. The most prevalent exposures seem to happen in industries where workers have contacts with paints, thinners, lacquers and printing inks [74]. In Korea, organic solvents have the second highest excess rate among harmful factors in workplaces. The exceeded rate of the occupational exposure limit maintained a similar level of 0.4 to 0.7% for the last five years from 2014 to 2018 (Figure 4). Although the ototoxic effects of organic solvents have been widely studied, there is no consensus about the correlation between the solvents exposure level and the resultant hearing loss.
Korean workplaces of which organic solvents exceeded permissible exposure limit (2014 to 2018).
In occupational condition, the ototoxicity of organic solvents is more difficult to prove. Because the workplace concentration of chemicals is much lower than that used in animal studies, and the workers are usually exposed to a mixture of solvents with widely varying compositions and concentrations, it is difficult to assess the effect of a single substance. Furthermore, in industrial settings, exposure to chemicals often coexists with an elevated level of noise, which makes it difficult to distinguish the solvent effect from the noise-induced hearing loss [22].
Recently, Hormozi et al. reported dose–response relationship between organic solvents mixture exposure and risk of hearing loss from a meta-analysis [72]. The results showed a statistically significant dose–response relationship between the occupational exposure level (Exposure Index, EI), duration of exposure or number of solvents and the risk of developing hearing loss (Table 2).
Variable | Reports (n) | OR (95% CI)† | p |
---|---|---|---|
Duration of exposure | 0.001 | ||
< 5 years | 4 | 1.01 (0.92–1.10) | |
5–10 years | 3 | 1.57 (1.27–1.93) | |
> 10 years | 7 | 3.36 (2.36–4.79) | |
Exposure index (EI)‡ | 0.049 | ||
< 0.5 | 3 | 1.37 (0.75–2.48) | |
0.5–0.99 | 3 | 3.25 (1.88–5.62) | |
≥ 1 | 7 | 4.51 (3.46–5.90) | |
Solvents | 0.045 | ||
2–5 | 7 | 1.62 (1.07–2.44) | |
6–8 | 4 | 4.22 (2.72–6.56) |
Dose–response relationship between organic solvents mixture exposure and risk of hearing loss*.
Hearing loss: average hearing threshold greater than 25 dB in at least one ear (250–8000 Hz).
Reference group: not exposed to either noise or solvents mixture.
EI: the sum of the mean time-weighted exposures to each solvent was divided by its occupational exposure limit (American Conference of Governmental Industrial Hygienists threshold limit value, ACGIH TLV).
Cited from THE RISK OF HEARING LOSS ASSOCIATED WITH OCCUPATIONAL EXPOSURE TO ORGANIC SOLVENTS MIXTURE WITH AND WITHOUT CONCURRENT NOISE EXPOSURE: A SYSTEMATIC REVIEW AND META-ANALYSIS. International Journal of Occupational Medicine and Environmental Health 2017;30(4):521–535 https://doi.org/10.13075/ijomeh.1896.01024.
Long-term exposure to organic solvents has been shown to cause irreversible hearing impairment damaging the cochlear hair cells as the first target [75]. The mechanism of acute injury would be the direct action of solvents on the cells of the organ of Corti, resulting in disorganization of their membranous structures, whereas chronic ototoxic effects may be explained by the formation of chemically and biologically reactive intermediates [76].
The ototoxicity mechanisms with strong evidence were described in Table 3. These solvents adversely affect both peripheral and central auditory system. For example, toluene may enhance inhibitory synaptic responses as CNS depressants, also can inhibit the middle-ear acoustic reflex (cholinergic efferent system). This would make inner ear more susceptible to co-exposure even to a noise intensity below permissible limit value [77].
Chemicals | Targets and impacts | Mechanism | Points to consider |
---|---|---|---|
Aromatic solvents | Target: Central nervous system, cochlear hair cell Impact: Enhancement in inhibitory synaptic responses, affecting middle-ear acoustic reflex. | In case of acute effect, direct action on the cells of the organ of Corti. In case of chronic effect, formation of intermediates such as reactive oxygen species. Cause K+ flow dysfunction. Outer hair cell toxicity due to K+ massive efflux and tunnel accumulation. | Prolonged exposure causes irreversible hearing impairment. Affect the middle-ear acoustic reflex, which partially explain the synergistic effects of co-exposure to noise and aromatic solvents. |
Nitriles | Target: cochlear hair cell, spiral ganglion cells Impact: Reduces high-frequency hearing sensitivity and enhances noise-induced hearing impairment. | Induce loss of inner ear hair cells and spiral ganglion cells. In the case of acrylonitrile, the risk of oxidative damage to the inner ear is increased due to damage to the cellular antioxidant defense mechanisms. | Permanent hearing damage may occur due to combined exposure with noise. |
Halogenated hydrocarbons | Target: Outer hair cell | In the case of polychlorinated biphenyls (PCB), it is assumed to have a direct effect on outer hair cells. | Presumed to be a sequelae of thyroid disease caused by halogenated hydrocarbons. |
Trichloroethylene | Target: Cochlear sensory hair cell, spiral ganglion cells, auditory nerve pathways | Unknown, but dose dependent hearing loss | Hearing loss tends to occur only at high level of exposure. |
Summary for impacts and mechanisms of ototoxic chemicals in workplace exposure.
Śliwinska-Kowalska (2007) summarized a risk/odds ratio of organic solvent-induced hearing loss, compared to non-exposed population, as followings. 1) No excess risk was found for workers exposed to solvent mixture when: the exposure history was short (up to 4 years), or the exposure level was very low (current exposure ranged from few to 18 ppm for toluene, to few ppm for xylene and other solvents, and the exposure index was <1). 2) Excess risk was found for workers exposed to solvent mixture when: the exposure level was moderate (toluene exposure ranged from 25 to 70 ppm, xylene exposure 25–40 ppm, and exposure index from 0.3–1.53), or the workers were exposed to high solvent concentrations and noise (the mean lifetime exposure to xylene was 696 ppm, to toluene 203 ppm, and the mean exposure index was 6.3) [72]. Risk/odds ratios of hearing loss due to exposure to organic solvent mixture were ranged 1.4 to 5.0, while the ratio of populations co-exposed to noise and solvents were 1.7 to 8.25 [78].
Previous experiments on ototraumatic substances in animals have confirmed the synergistic adverse effects of combined exposure to noise and solvents on hearing [79, 80]. In the case of combined exposure to noise and organic solvents, depending on the parameters and characteristics associated to the noise (such as intensity and impulsiveness) and solvent (such as concentration), they might interactively affect each other.
From the animal studies, the increase in auditory brainstem response (ABR) latencies after exposure by inhalation of more than two solvents observed an additive effect rather than a synergistic or antagonistic interaction. Results of these studies imply that the mechanism of ototoxicity for these solvents may be similar. However, rats simultaneously exposed to both toluene and noise induced a more severe hearing loss than the summated hearing loss obtained from an equivalent exposure level to each agent alone [77].
From the human studies, exposure to a mixture of solvents may damage the inner ear to a much greater extent than noise exposure. The relative risk for hearing loss in workers exposed to solvents was greater (RR = 9.6) in comparison to workers exposed only to noise (RR = 4.2). Hearing loss associated with styrene significantly increased in high frequency (8–16 kHz) and mid-audiometric frequency of 2 kHz [22]. Sliwinska-Kowalska et al. (2003) found a positive linear relationship between average working life exposure to styrene concentrations and hearing thresholds at 6 and 8 kHz. The possible synergism of combined exposure to solvents and noise on hearing has not been consistently identified in human studies. Some researchers have failed to find a synergistic effect between these agents on hearing [22].
Although it is difficult to derive a dose–response relationship between the solvent concentration and the hearing outcome, the risk of hearing loss increase with the longer duration of employment and accompanying noise in workers exposed to organic solvent [72].
Although there is no consensus on the lowest OELs for solvents in relation to their effect on the auditory organ, the current standards for solvent-exposed populations seem to be inadequate. Since organic solvents have detrimental effects both on the peripheral and central parts of the auditory pathway, pure-tone audiogram might be insufficient to monitor their ototoxicity [78].
From previous studies, researchers have found some useful tests for the evidence of adverse effects on the central auditory system in workers exposed to mixture of solvents: 1) dichotic listening: useful tool in the assessment of solvent-exposed workers, particularly in those who have had intermediate levels of exposure; 2) electrophysiological techniques (ABR): increase of the absolute latencies and inter-peak latencies (IPL) between waves of the ABR (I-III IPL; I-V IPL; III-V IPL) or prolonged P300 (a long latency auditory evoked potential); 3) otoacoustic emissions (OAEs): gradual deterioration of hearing threshold before audiometric change; 4) comprehensive battery of behavioral central auditory function assessment procedures: solvent-exposed participants presented with poorer results adjusted for age and hearing thresholds in comparison to non-exposed subjects [77]. These tests can be conjugated to evaluate possible adverse effects of solvents on the auditory system.
So far, the robust evidence confirms that the effects of ototoxic substances on auditory function can be aggravated by noise, which is supported by data from epidemiologic studies on human workers.
In real world, the exposure to solvent mixtures is various in terms of levels and composition. Numerous study groups reported an association between low to moderate exposure to solvent mixtures and hearing disorders. However, occupational legislation does not take environmental chemicals hazardous to hearing into consideration. Thus, there may be numerous workers with unmet needs concerning hearing conservation.
Here we are going to make some necessary suggestions for occupational health professionals and the workforce. Health care provider should be aware of the risks related to ototoxic substances. Employers and workers should be advised accordingly. Risk management measures aimed at reducing exposure to noise and ototoxic substances, especially co-existence of them, should be encouraged. In occupational health-screening activities, ototoxicity should be included. Appropriate diagnostic tools should be developed for early detections of chemically induced hearing impairment. Suitable scientific investigations into ototoxic properties of substance and combined effects with noise should be encouraged by well-designed studies.
Occupational noise exposure has been well-known as the most deleterious factor to hearing loss, however, the impact of chemical-induced hearing loss on workers should not be underestimated [81]. Industry-based initiatives should include the identification of populations at risk and the delivery of tailored hearing conservation program accordingly to noise and chemical-exposed workers regarding their exposure levels.
The authors declare no conflict of interest.
I would like to thank the members of the Department of Occupational and Environmental Medicine, Ulsan University Hospital. A Ram Kim, Daeyun Kim, Sunghee Lee, Jisoo Kim, and Hanjoon Kim, also Jinhee Bang, member of Environmental health center have contributed directly or indirectly to this chapter. We have shared information and ideas. Moreover, they have made suggestions and comments.
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The sources related to thyroid surgery show that the success of the neck masses with the surgical intervention was limited until the second half of the nineteenth century. Among the names leading the development of thyroid surgery in contemporary times are Emil Theodor Kocher, Theodor Billroth, William James Mayo, and William Stewart Halsted. 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Completed the Course Medical Mycology, the Centraalbureau voor Schimmelcultures (CBS), Fungal Biodiversity Centre, Netherlands (2006). International Union of Microbiological Societies (IUMS) Fellow, and International Emerging Infectious Diseases (IEID) Fellow, Centers for Diseases Control and Prevention (CDC), Atlanta, USA. Diploma of Dermatological Scientist, Japanese Society for Investigative Dermatology. Ph.D. of Juntendo University, Japan. Bachelor’s and Master’s degree, Medicine, West China University of Medical Sciences. Chair of Sichuan Medical Association Dermatology Committee. General Secretary of The 19th Annual Meeting of Chinese Society of Dermatology and the Asia Pacific Society for Medical Mycology (2013). In charge of the Annual Medical Mycology Course over 20-years authorized by National Continue Medical Education Committee of China. Member of the board of directors of the Asia-Pacific Society for Medical Mycology (APSMM). Associate editor of Mycopathologia. 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He is currently a rated researcher by the National Research Foundation of South Africa at category C2. He has published widely in the field of infectious diseases and has overseen several MSc’s and PhDs. His research activities mostly cover topics on infectious diseases from epidemiology to control. His particular interest lies in the study of intestinal protozoan parasites and opportunistic infections among HIV patients as well as the potential impact of childhood diarrhoea on growth and child development. He also conducts research on water-borne diseases and water quality and is involved in the evaluation of point-of-use water treatment technologies using silver and copper nanoparticles in collaboration with the University of Virginia, USA. 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His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",institutionURL:null,country:{name:"India"}}},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:58,paginationItems:[{id:"81961",title:"Antioxidants as an Adjuncts to Periodontal Therapy",doi:"10.5772/intechopen.105016",signatures:"Sura Dakhil Jassim and Ali Abbas Abdulkareem",slug:"antioxidants-as-an-adjuncts-to-periodontal-therapy",totalDownloads:3,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Dental Trauma",coverURL:"https://cdn.intechopen.com/books/images_new/11567.jpg",subseries:{id:"2",title:"Prosthodontics and Implant Dentistry"}}},{id:"82357",title:"Caries Management Aided by Fluorescence-Based Devices",doi:"10.5772/intechopen.105567",signatures:"Atena Galuscan, Daniela Jumanca and Aurora Doris Fratila",slug:"caries-management-aided-by-fluorescence-based-devices",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Dental Caries - The Selection of Restoration Methods and Restorative Materials",coverURL:"https://cdn.intechopen.com/books/images_new/11565.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"81894",title:"Diet and Nutrition and Their Relationship with Early Childhood Dental Caries",doi:"10.5772/intechopen.105123",signatures:"Luanna Gonçalves Ferreira, Giuliana de Campos Chaves Lamarque and Francisco Wanderley Garcia Paula-Silva",slug:"diet-and-nutrition-and-their-relationship-with-early-childhood-dental-caries",totalDownloads:11,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Dental Caries - The Selection of Restoration Methods and Restorative Materials",coverURL:"https://cdn.intechopen.com/books/images_new/11565.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"81595",title:"Prosthetic Concepts in Dental Implantology",doi:"10.5772/intechopen.104725",signatures:"Ivica Pelivan",slug:"prosthetic-concepts-in-dental-implantology",totalDownloads:27,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Current Concepts in Dental Implantology - From Science to Clinical Research",coverURL:"https://cdn.intechopen.com/books/images_new/10808.jpg",subseries:{id:"2",title:"Prosthodontics and Implant Dentistry"}}}]},overviewPagePublishedBooks:{paginationCount:8,paginationItems:[{type:"book",id:"6668",title:"Dental Caries",subtitle:"Diagnosis, Prevention and Management",coverURL:"https://cdn.intechopen.com/books/images_new/6668.jpg",slug:"dental-caries-diagnosis-prevention-and-management",publishedDate:"September 19th 2018",editedByType:"Edited by",bookSignature:"Zühre Akarslan",hash:"b0f7667770a391f772726c3013c1b9ba",volumeInSeries:1,fullTitle:"Dental Caries - Diagnosis, Prevention and Management",editors:[{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",institutionURL:null,country:{name:"Turkey"}}}]},{type:"book",id:"7139",title:"Current Approaches in Orthodontics",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7139.jpg",slug:"current-approaches-in-orthodontics",publishedDate:"April 10th 2019",editedByType:"Edited by",bookSignature:"Belma Işık Aslan and Fatma Deniz Uzuner",hash:"2c77384eeb748cf05a898d65b9dcb48a",volumeInSeries:2,fullTitle:"Current Approaches in Orthodontics",editors:[{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null}]},{type:"book",id:"7572",title:"Trauma in Dentistry",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7572.jpg",slug:"trauma-in-dentistry",publishedDate:"July 3rd 2019",editedByType:"Edited by",bookSignature:"Serdar Gözler",hash:"7cb94732cfb315f8d1e70ebf500eb8a9",volumeInSeries:3,fullTitle:"Trauma in Dentistry",editors:[{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",institutionURL:null,country:{name:"Turkey"}}}]},{type:"book",id:"7060",title:"Gingival Disease",subtitle:"A Professional Approach for Treatment and Prevention",coverURL:"https://cdn.intechopen.com/books/images_new/7060.jpg",slug:"gingival-disease-a-professional-approach-for-treatment-and-prevention",publishedDate:"October 23rd 2019",editedByType:"Edited by",bookSignature:"Alaa Eddin Omar Al Ostwani",hash:"b81d39988cba3a3cf746c1616912cf41",volumeInSeries:4,fullTitle:"Gingival Disease - A Professional Approach for Treatment and Prevention",editors:[{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. 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He also obtained an MSc in Molecular and Genetic Medicine, and a Ph.D. in Clinical Immunology and Human Genetics from the University of Sheffield, UK. He also completed a short-term fellowship in Pediatric Clinical Immunology and Bone Marrow Transplantation at Newcastle General Hospital, England. Dr. Rezaei is a Full Professor of Immunology and Vice Dean of International Affairs and Research, at the School of Medicine, Tehran University of Medical Sciences, and the co-founder and head of the Research Center for Immunodeficiencies. He is also the founding president of the Universal Scientific Education and Research Network (USERN). Dr. Rezaei has directed more than 100 research projects and has designed and participated in several international collaborative projects. He is an editor, editorial assistant, or editorial board member of more than forty international journals. He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. 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His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. 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Voyich",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Montana State University",country:{name:"United States of America"}}},{id:"330412",title:"Dr.",name:"Muhammad",middleName:null,surname:"Farhab",slug:"muhammad-farhab",fullName:"Muhammad Farhab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"349495",title:"Dr.",name:"Muhammad",middleName:null,surname:"Ijaz",slug:"muhammad-ijaz",fullName:"Muhammad Ijaz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Veterinary and Animal Sciences",country:{name:"Pakistan"}}}]}},subseries:{item:{id:"95",type:"subseries",title:"Urban Planning and Environmental Management",keywords:"Circular economy, Contingency planning and response to disasters, Ecosystem services, Integrated urban water management, Nature-based solutions, Sustainable urban development, Urban green spaces",scope:"