\r\n\tBacteriology is subdivision of microbiology which deals with morphology, ecology and biotechnology of bacteria that found in different environmental niches - either inside living organisms, or free living in soil, marine and fresh water. It is also connected to medicine concerning spoilage of foods and bacterial associated diseases (pathogenic bacteriology). On the other hand, good use of friendly bacteria gives protection from other bad microbes causing serious illness. These beneficial bacteria promote absorption of nutrients and aid in healthy digestion.
\r\n\r\n\tBacteria are key players in bioremediation.They can play a significant role in the mitigation or removal of contaminants in the environment, both organic and inorganic.
\r\n\r\n\tIn natural environment, bacteria produce nanoparticles as part of their metabolism. Bacteria grab target ions from their environment and then turn the metal ions into the element metal through enzymes generated by the cell activities.The biosynthesized nanoparticles have been used in a variety of applications including drug carriers for targeted delivery, cancer treatment, gene therapy and DNA analysis, antibacterial agents, biosensors and magnetic resonance imaging (MRI).
\r\n\r\n\tThis book intends to provide the reader with a comprehensive overview of bacterial science and it's applications in different disciplines.
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She received her BSc in Microbiology, MSc and Ph.D. in Marine Microbiology from Faculty of Science, Alexandria University in 1998, 2003 and 2008, respectively. She had 25 published papers in local and international peer-reviewed journals and 2 abstracts conference proceedings in the field of marine and microbial biotechnology. She worked as an Assistant Professor at Faculty of Science and Humanities studies, Shaqra University, Saudi Arabia, from 2010 -2012 where she conducted lectures on General Microbiology, Bacteriology and Pollution. She is a member of numerous local societies and serves as an editorial board of the International Journal of Scientific and Technology Research, International Archive of Medicine, Lawarence Press, International Journal of Natural Resource Ecology and Management. She was also selected as a member at Who\\'s Who in the World for inclusion in the forthcoming 31st Edition 2014. 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1. Introduction
\n
The backdrop to this chapter was the development and implementation of the concept of “self-help friendliness” (SHF) in Germany. This process started in 2004 and has good chances and prerequisites to be continued in the coming years. The idea behind is based on a number of expert opinions, surveys and well-documented model projects. Parallel to this practice-oriented developmental research, from 2008 to 2011, a research project with the title “Self-Help Friendliness as a Quality Concept” was carried out. The project was funded by the German Federal Ministry of Education and Research (BMBF) as part of a larger project in the BMBF’s research framework program “Chronic Diseases and Patient Centeredness”.
\n
This chapter deals first with the role of SHF as one of the main elements in patient centeredness as well as its role in the overall German healthcare context. Thereafter, we concentrate on looking at the research and practical experiences gathered with the idea of SHF as well as outlining the present state of the concept’s implementation in healthcare facilities.
\n
\n\n
2. Patient centeredness as a guiding concept
\n
Providing a precise definition of and an approach to the concept of patient centeredness is challenging. Patient centeredness is no longer just a matter of treating patients in a “humane” manner; the concept has become very complex because of the fact that patients today are also evaluators, controllers, critics and active contributors to the development and regulation of the healthcare system.
\n
This abandons any simple understanding of patient centeredness. However, until today the German Medical Association as one of the most important players in the German healthcare sector reduces patients’ roles to more or less inactive recipients and beneficiaries. Their guideline on quality management in hospitals can be seen as an example how the term “patient centeredness” can be narrowed down to a number of unidirectional features of professionals towards patients, but not vice versa:
\n
“waiting times during admission to the hospital,
receiving proper information during the doctor’s visit,
extent of care provided by nursing personnel,
waiting times during X-rays, endoscopic examinations, laboratory exams, etc.
handling of privacy concerns,
wake-up and bedtime hours,
contacts with social services,
number and types of leisure programs,
hygienic measures,
guidance in the hospital, access to the parking lots and other means of assisting patients and visitors who enter the hospital” ([1] p. 45).
\n
No doubt–all of these points are important. Nevertheless, the guideline gives the impression that the managers of health facilities knew in advance of how their organizations work and how their offers should be structured to ensure patient centeredness–and thus that they require no input on the part of the patients: “Patients trigger the demand for orientation, and the personnel takes the proper action” [2].
\n
Even in differentiated and focused papers on patient centeredness in Germany, the contribution of the active patient in the concept of patient centeredness remains at least vague or is even completely absent (e.g., [3–5]).
\n
A contemporary understanding of patient centeredness, however, demands just such active participation. Patient centeredness ought to balance the informational asymmetry between professional staff and patients and promote equitable interactions. It is not just a matter of sharing knowledge; also, the responsibility for therapy and diagnosis has to be distributed ensuring a reciprocal process to replace the former domination of the physician’s perspective. This in turn demands great sovereignty and responsibility on the part of the patient [6]–not only on the microlevel of healthcare provision. It is a transforming perspective from the patient “who is cared for” to the patient who is an “active participant,” and an active “creator of the treatment process” [7], and indeed of the entire provision of health and social services [8].
\n
In 1995, the PubMed/Ovid MEDLINE system introduced the Medical Subject Heading (MeSH) term, “patient-centered care”, defined as “design of patient care wherein institutional resources and personnel are organized around patients rather than around specialized departments” [9]. In 2001, the Institute of Medicine defined “patient centeredness” as: “health care that establishes a partnership among practitioners, patients and their families (…) to ensure that decisions respect patients’ wants, needs and preferences and that patients have the education and support they require to make decisions and participate in their own care” ([10], p. 7). In his conclusion, Blum [11] summarized the concept of “patient-centered care” with the key-terms integration, information, communication and participation. Self-help-oriented patient centeredness corresponds to this modern definition by focusing on the cooperation of self-help organizations with professional services.
\n
The International Alliance of Patients’ Organizations (IAPO) did a systematic study to determine what patient centeredness looks like around the world [12]. Not surprisingly, they found many and manifold different definitions, which, however, have despite of their diversity very similar core statements. The definition supported by the IAPO is comparable to that of the Institute of Medicine [10]. In a declaration on patient-centered health care derived from that overview ([12], p. 29), the following five principles are given:
\n
respect
choice and empowerment
patient involvement in health policy
access and support
information
\n
This understanding of patient centeredness is clearly reminiscent of the term “health literacy” propagated by the World Health Organization [13] as “the cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health”. In this sense, patient centeredness is a continual companion in the endeavor to increase the health literacy of all citizens in general and patients in particular.
\n
The concept of SHF runs parallel to the approaches put forward by the IAPO and the WHO. One of our original propositions is that the implementation of modern approaches to patient centeredness demands cooperation with self-help groups (see [14–16]). This thought is present in the newer secondary literature on patient centeredness, but does not play a prominent role in the light of the many other aspects of patient centeredness. Unfortunately, the various potentials for implementing self-help in patient centeredness have to date not been fully realized but often reduced to individual functions. Here, some German examples:
\n
classifying the complaints of self-help organizations as “patient feedback” ([177], pp. 62–63),
regarding them as “complementary services” or as “complementary efforts” ([18], p. 25),
relaying information on self-help groups during discharge procedures ([18], p. 19),
“Using experiences of self-help” by allowing “persons concerned to assist in disseminating information to patients” ([17], p. 66),
cooperation subsequent to hospitalization [18].
\n
These forms of cooperation are oriented towards the short definition of patient centeredness as the “adjustment of available services and operating procedures to the presumed interests and needs of patients” [18].
\n
More recently, the idea of participative (or shared) decision-making has played a major role. This thrust exists primarily in the individual doctor-patient relationship on the microlevel, from the patient vantage point as “co-production,” and in the interactive process of decision-making [19]. In fact, however, there are a number of recent programmatic articles proposing a broader and more diverse understanding of cooperation. Some of the early demands and present opinions are reflected in the following research papers:
\n
Patients as “an important resource in the fight against ignorance, quality defects and waste in the healthcare system” [20].
Quality is a utilitarian approach–meaning participation, i.e., “patients and insured persons are involved in decision-making processes at all levels through their position as users” ([21], p. 78).
“We must give consumers of the healthcare system a voice and enable a dialog between them, the providers and the political system” ([22], p. 25).
“Support for organized self-help is an area of activity that serves to strengthen citizen and patient centeredness” ([16], p. 24).
The goal is to use the “collective competence” of self-help to influence new directions taken by caretaking structures and procedures, and generally to strengthen the skills of patients ([5], p. 1120).
“Human relations should include and support all forms of self-help” ([17], p. 72).
\n
The last quote refers to “patient-centered quality management” [17], which holds the promise of becoming a context for including cooperation with self-help groups in a less random way than offered by previous well-meaning but weak contacts.
\n
The first important document that brought patient centeredness into the mainstream as a goal of continual quality management was an application developed in 1996 during the Conference of Health Ministers of the Federal States of Germany [23]; later found in the concordant application with the National Expert Council in Health Care [24]. At that meeting, “goals for a common quality strategy in the healthcare system” were adopted, the first goal being “systematic patient centeredness in the healthcare system”.
\n
The document clearly shows that concepts concerning patient centeredness and patient participation in the healthcare system are closely related with quality assurance strategies. To date, this has been realized to a greater extent for the macrolevel of the healthcare system [16] than for the mesolevel of individual institutions such as hospitals and physicians’ offices ([25], p. 19).
\n
Implementing a comprehensive plan for patient centeredness is greatly dependent on how sound the systems for quality management and quality assurance have been established. Groene et al. [26] did a Europe-wide study of hospitals concerning the relationship between patient centeredness and the presence of quality management: patient centeredness was more broadly implemented in hospitals with an extensive quality management.
\n
Good quality management on its own, however, does not necessarily guarantee an implementation of patient centeredness–neither is it a predictor of systematic cooperation with self-help organizations. In addition to quality management, “proper overall conditions are necessary that allow those professionals working in the healthcare system to take patients into due consideration, in particular, by focusing on their wishes and preferences,” as was formulated in the conclusion of the “Report on Citizen and Patient Centeredness in the Healthcare System” ([16], p. 26).
\n
This short overview of the German situation serves to point up deficits and to provide suggestions on establishing cooperations with self-help groups. In our opinion, the concept of “self-help friendliness of healthcare services” comprises quite a number of advantages for patients and healthcare providers and should be integrated in a modern understanding of patient centeredness. During the course of implementation in Germany, some important milestones have been achieved:
\n
The basic principles of cooperation with organized self-help groups were systematically reduced to a manageable list of just seven quality criteria.
Specific criteria were adapted to the individual areas of healthcare (inpatient, outpatient, public health, rehabilitation).
The criteria for all areas were jointly formulated by healthcare professionals–predominantly those, who are responsible for quality management–representatives of self-help organizations, and professional staff of the self-help clearinghouses. The criteria represent the interests and needs of both the collective group of patients and their self-help representatives and professionals in the respective positions.
Implementation was tested in all areas, systematic approaches were developed, and the concepts and experiences derived from these attempts were put at the disposal of all facilities involved (www.selbsthilfefreundlichkeit.de).
The quality criteria comprise three main dimensions: (1) a coordinated cooperation based on information and support for the self-help groups; (2) the dimension of participation through information exchange, participation in the further education of staff, as well as participation in bodies such as quality circles and ethics committees; (3) the long-term assurance of communication and cooperation (sustainability). The completeness and applicability of these criteria were evaluated in a number of surveys and with various groups of participants [27, 28].
The consistent application of these criteria leads to an overall increase in the systematic participation of organized self-help on the mesolevel. The participation of patients is generally accepted, but to date has not been realized in reforms of the healthcare system.
Overall, this approach highlights previously neglected aspects of patient centeredness and cooperation with patient lobby groups. It demonstrates ways in which these aspects can be solidly integrated into quality management, both at the level of individual facilities and on the system level.
\n
As the advantages of SHF discussed in this section are rather abstract so far, we will strive to present the relevant aspects in clearer and concreter terms. The next section systematically focuses on the relationship between the three main programmatic terms patient centeredness, SHF and patient participation.
\n
\n\n
3. On the relationship between patient centeredness, self-help friendliness and patient participation
\n
Patient centeredness, SHF and patient participation are concepts with rather fuzzy borders. Presently, there are no agreed-upon scientific definitions. At least, the fact that these three terms represent the key concepts for creating healthcare that is tailored to patient needs and requirements, and thus likely also suited to ensure economic effectiveness, is globally accepted [29–38]. Internationally, there are a number of different approaches, methods and regulatory instruments for integrating patient participation into healthcare systems [39–43].
\n
In Germany, the development and implementation of these concepts has gone hand in hand with the overall rise of the self-help movement and for some time has been subsumed under the catchword “Self-Help Friendliness”. The only other similar country in this regard is Austria, which established a similarly important role for self-help within its healthcare system [44, 45]. Three factors in particular can explain the present development in Germany: First, there is a well-established landscape of self-help organizations and up to 100,000 self-help groups with around 3–3.5 million members. Second, this development has been supported systematically for several decades now [46], especially, by Para. 20 h of the Social Security Code, Book V, which requires that the statutory health-insurances companies pay EUR 1.05 per insured person to promote self-help, which sums up to around 73 million EUR. (This amount is changed every year to reflect cost-of-living increases). Third, since 2004, the German government has adopted a policy whereby patients (including for the most part the representatives of self-help organizations) are increasingly being included in the future planning of the healthcare system at the macrolevel.
\n
Yet systematic cooperation between physicians and self-help groups as a way to increase patient participation as well as the quality of healthcare provided has barely been addressed in the international research literature. For this reason, we must rely on the ongoing discussion in Germany to determine the relations among the various different concepts.
\n
It is helpful to differentiate between a broader and a narrow employment of the term patient centeredness. As mentioned at the outset, patient centeredness basically comprises everything that is carried out or improved upon within a healthcare facility to affect patient care. In accordance with the popular slogan “The Patient Is the Focus of Our Concerns,” patient centeredness becomes nearly synonymous for comprehensive quality management.
\n
The narrow understanding regards everything that directly concerns cooperation with patients and their welfare as belonging to patient centeredness. The broad understanding also includes the two components that make up this concept: “internal” and “external” patient centeredness [47]. Internal patient centeredness reflects all interventions that deal with the structures and processes occurring within a hospital which serve the well-being of the patient; external patient centeredness concerns everything that is in direct contact with patients and occurs in cooperation with the patient. This understanding of patient centeredness may also be seen as the invitation directed towards the patients to participate in the processes of professional caretaking.
\n
The participation of the patients may be further divided up into different levels of intensity. Participation may reflect only “joint knowledge” (strengthening one aspect of health literacy), to “having a say” (participation in the relevant boards and committees) or up to “codetermination” (participation in the decision-making process and active voting rights in boards and committees).
\n
All three basic concepts–patient centeredness, participation and SHF–are employed on all three levels: physician–patient interaction (microlevel), the institutional level of the individual facility (mesolevel) and on the system level of the entire healthcare system (macrolevel).
\n
This chapter is concerned mainly with the mesolevel and the associated question: How can we create and anchor more SHF (and thus greater patient centeredness and participation) in the facilities of the healthcare system? We used an instrument from our research project to measure “self-help-related patient centeredness.” This concept comprises two components: (1) strengthening individual self-help competences (How intensively does the hospital support individual patients by informing, enabling and including them in caretaking processes?); (2) strengthening collective self-help efforts (How intensively does the hospital cooperate with self-help groups in accordance with quality criteria?).
\n
Within the context of this volume on patient-centered medicine, we barely touch on the microlevel and the macrolevel. Rather, our focus lies clearly on the collective patient centeredness on the mesolevel, that is, initiating cooperation between local health facilities and collective self-organized patient groups. SHF is considered one special aspect of the quality dimension “patient centeredness.” SHF is only shortly discussed by us on the macrolevel, in particular when we are concerned with SHF in quality management systems (in this context: the so-called accreditation systems) and in the coordination of SHF at the national level (“Network Self-Help Friendliness and Patient Centeredness in the Healthcare System” [48]).
\n
\n\n
4. Developing the approach
\n
The development of self-help friendliness did neither follow a “master-plan” nor a rigorously designed intervention concept. The process should rather be considered as a complex participative research program, which has been described in a recent publication more comprehensively [49]. The development comprised a number of empirical surveys and practice-oriented demonstration projects. All these projects were conducted between 2004 and 2013 (see Table 1 [49]). Their methods differed considerably: most often qualitative (expert interviews and focus groups) and quantitative surveys were combined. As a guiding principle, patient representatives contributed in several stages of the research. Due to the participative approach, we proceeded only step by step. The core elements of self-help friendliness became continuously clearer by discussing the relevant quality criteria in the various sectors of health services. The implementation in one sector inspired and facilitated the process in the following ones. There was a steering group of professional self-help supporters, social scientists and staff from both sickness funds and healthcare providers, who looked for funding and decided on how to proceed. One milestone was the foundation of a network on SHF in 2009 (see Section 6.3). In its first years, the network consisted primarily of actors who had made major contributions to the support of self-help groups (SHGs) in various contexts and had promoted their recognition in practice and politics of healthcare provision. They favored a more systematic approach to sustainable collaboration between SHGs and healthcare professionals and were willing to find and/or to provide resources for implementing SHF. Particularly, healthcare insurance companies funded a number of both model projects and research. The steering group of healthcare insurance representatives and a professional self-help supporter have been the driving force for further development till today. They are supported by a “federal coordination office” funded by a consortium of four sickness funds [48].
\n
\n\n\nStudy area (year) | \nType of study | \nSample | \nMain results | \n
\n\n\n\nHospital, part 1 (2004/2005) | \nExplorative survey | \n30 SHO, 20 SH clearing houses | \nParticipative development of criteria | \n
\n\nHospital, part 2 (2004–2006) | \nModel project, implementation study | \n2 hospitals in Hamburg | \nTesting and final formulation of 8 criteria; 2 hospitals awarded “quality seal” | \n
\n\nHospital, part 3 (2008–2010) | \nModel project, implementation study | \n31 hospitals in NRW, 17 finishing the process | \nProcess pattern and guidelines for becoming self-help friendly; 17 hospitals awarded distinction | \n
\n\nPublic health service (2009–2011) | \nDelphi method, interactive identification and approval of quality criteria | \n16 public health departments | \n10 quality criteria approved by workshop of public health doctors at their annual conference 2011 | \n
\n\nAmbulatory care (2009–2011) | \nModel project, implementation study | \n9 practices, individual MDs from 8 specialties | \n6 criteria approved and introduced into quality management manual for doctors in NRW | \n
\n\nRehabilitation (2010–2013) | \nModel project, implementation study prepared by focus group of 14 SHR | \n2 rehabilitation hospitals | \n5 criteria successfully tested; 2 hospitals awarded distinction; introduction in one national accreditation system planned | \n
\n\n
Table 1.
Major studies and steps in the development of SHF [49].
Abbreviations: SHO, self-help organization; SH, self-help; SHR, self-help representative.
\n
\n
4.1. Development of self-help friendliness in hospital care
\n
The concept of SHF stems from two sources. The first is a former survey of 345 contact persons out of 658 SHGs in Hamburg. As a main result of this research, it became clear that most SHGs were not satisfied with the care they have received. Consequently, they wanted changes both in the attitudes of their healthcare providers and in the running of healthcare institutions. These results were interpreted as a plea for intensified communication and collaboration between SHGs and professional staff in health services. Self-help friendliness was the most systematic approach to reach this goal.
\n
The other source and stimulus for this approach were the annual “self-help forums”, a sort of workshop of SHG members and medical doctors of all specialties. They are regularly organized by the Medical Chamber of Hamburg in collaboration with the local clearinghouse for SHGs. In the course of a discussion about shortcomings of hospital care, the idea of “self-help friendly hospitals” arose. It was appealing to both parties, doctors and self-help members. In 2003, this term resulted the first time in a formal cooperation statement between the Federation of Hamburg State Hospitals and SHGs. At the same time, the idea came up to initiate and to evaluate the implementation of the approach in some pilot hospitals. The funds for an explorative study and the process evaluation of the model project were granted in autumn 2004 from the Federal Association of Company Health Insurance Funds (BKK BV).
\n
The explorative study started in 2005: A questionnaire was sent to self-help organizations and self-help clearinghouses with extensive experience in cooperation with healthcare providers, SHGs and SHOs, and patient representatives. About 30 organizations and 20 self-help clearinghouses administered the questionnaire. They responded to questions concerning their wishes and expectations and assessed several statements on quality criteria that had come up so far in the self-help forums. These assessments provided a first quantitative picture of what was important for self-help groups and, hence, what they would prefer to be implemented. This was the first basis for the identification and formulation of those quality criteria that were adopted in the end.
\n
A steering group of the model project decided for the relevant criteria. The group comprised a project leader (a former self-help supporter with know-how in quality management), three hospital quality managers, two employees of the local clearinghouse and four members of SHGs. Staff members of the Hamburgian Institute of Medical Sociology accompanied the process as consultants. Eight criteria for good collaboration between hospitals and SHGs were developed [49]:
\n
The hospital offers rooms, infrastructure and possibilities for public relations.
Patients of the hospital are personally informed about self-help on a regular basis.
The hospital supports public relations of the SHG.
The hospital appoints a staff member as a contact person for self-help.
Staff and SHG members meet regularly for information exchange.
SHGs are involved in further education/training of staff.
SHGs are involved in quality (control) circles and ethics committees.
The collaboration is formally agreed on and the activities will be documented.
\n
Most of the criteria address the support of SHGs by the hospital; criteria 5–7 aim at a permanent and regular involvement of SHGs in the health service quality.
\n
The implementation of self-help criteria was achieved in two hospitals in a process of nearly two years. Thus, the “reality-test” of the quality criteria was passed successfully. As a reward (and as an incentive for their further engagement), the two hospitals were awarded a “Quality Seal for Self-Help Friendliness” in 2006, based on an external audit. Eight members of SHGs, who had been trained for this task, played a major role in the on-site Visitation. The quality criteria were published in their final version as a brochure guiding and encouraging both hospital staff and self-help advocates in other places to do the same.
\n
The process as a whole, however, had to face several delays due to lack of funding. Finally, the welfare organization “Der PARITÄTISCHE North Rhine-Westphalia” provided resources for the next development project from 2008 to 2010. This model project had the aim to develop a standard for the consecutive steps of implementing the quality criteria in hospitals, which resulted in nine steps of becoming “self-help friendly” [49]:
\n
The agency for SHF (or a self-help clearinghouse) contacts and informs the hospitals.
First consultation of the agency takes place in the hospital.
The agency contracts the hospital and mediates contacts with self-help clearinghouses.
The staff of the self-help clearinghouses counsel hospital staff and mediates SHGs.
The hospital and SHGs collaborate in a quality circle.
Measures to fulfill the quality criteria are put into practice and are part of the internal quality management system.
The hospital applies for a certificate (optional).
The quality report of the hospital is signed by representatives of SHGs.
Certification (formally documented distinction) is awarded and can be used in public relations of the hospital.
\n
Thirty-one hospitals in North RhineWestphalia (NRW) made use of the offered supportive consultations. Seventeen finished the implementation of SHF with a distinction in the form of a certificate. The capacities of the experienced facilitator for becoming self-help friendly (a half-time social worker), however, turned out to be overstrained: She did not have the resources and capacities to meet the total amount of requests for support, which means that probably more than the mentioned 17 hospitals might have finished the process if more resources were available.
\n
The projects in Hamburg and in NRW produced decisive findings and downloadable guidance for other hospitals interested in becoming self-help friendly (www.selbsthilfefreundlichkeit.de). There were, however, some problems that obviously had to be conceived of as obstacles for further spreading the approach: For example, providing additional staff for consultations, as it was carried out in the model project during the implementation process, was too expensive. Consequently, the approach was changed in the sense, that near-by clearinghouses get a small amount of funding in order to compensate them for their additional workload. A formal quality seal after an external audit, which in the first project had seemed the most appropriate way to give an award, required too many resources, too, both human and (ultimately) financial: The expenditure of time was enormous, not only for the hospitals but also for the self-help representatives. Presently, healthcare services can gain an award of the network “Self-Help Friendliness and Patient Centeredness”. Prerequisites are (i) a certification by patient representatives that at least one measure for each quality criterion was put into practice and (ii) the inclusion of the SHF quality criteria in the internal quality management system. These two simple requirements are easy to fulfill, and additionally guarantee that no advertising of SHF claims can be made without the consent of the collaborating SHGs.
\n
\n
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4.2. Development of self-help friendliness in other areas of the health services
\n
After successful implementation in the hospital area, the program was started in the other healthcare sectors: public health, practices and rehabilitation services.
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The process in the area of public health did not correspondent to the general pattern because the ten quality criteria stem from an interactive process with professionals from 16 public health departments of local health authorities. Unfortunately, we do not have exact data on the degree of local self-help engagement.
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The next project started to develop equivalent criteria for ambulatory care. The ten existing recommendations for cooperation and the eight quality criteria for inpatient care can be seen as the starting point for developing criteria for outpatient care in an interactive process of all relevant players. They produced a consensus document with six criteria that was accepted by the Association of Statutory Health Insurance Physicians Westphalia-Lippe. These criteria are quite similar in substance to those in the hospital sector.
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Nine practices (doctors with their staff) participated in the process: general practice, gynecology and obstetrics, internal medicine, urology, ophthalmology, orthopedics, ENT medicine and pediatrics. At the end of the process, in which the medical and lay persons jointly developed measures to put the quality criteria into practice, the implementation of the criteria was formally documented in a report which was signed by both parties. The practices were subsequently awarded as being self-help friendly. Current endeavors are underway to build doctors’ networks (instead of single practices) as partners in this process.
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The way in hospitals for rehabilitation was similar to the hospital sector. It started with a team on quality assurance of an umbrella organization of rehabilitation institutions. In December 2011, the preliminary SHF criteria were discussed with 14 self-help representatives in a workshop. Result were five quality criteria which were tested in a pilot project with two rehabilitation hospitals. The participating SHGs in the project were: the Interest Group of Contergan Victims, the Federal Osteoporosis Association, the German Multiple Sclerosis Society and a local SHG of stroke patients. Finally, the successful implementation of SHF was proved by self-help representatives and led to a distinction for the hospitals involved.
\n
\n
\n\n
5. Research limitations and transferability to other countries
\n
It is not possible to discuss in detail the research limitations of all the mentioned pilot projects and studies. But, we would like to highlight some basic problems, both of which have been discussed in a previous medical sociological publication [50].
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One of the most important features of the different studies is their participative and explorative nature. This has obviously some disadvantages: Despite all attempts to gather information as systematically as possible, and to reflect all aspects of the development, implementation, testing and evaluating of SHF, the results are not representative, neither for all healthcare professionals nor for all self-help representatives. Participants are usually highly motivated, therefore the results are emphasizing much more the positive factors rather than potentially negative ones. All generalization of these experiences and results is only adequate in comparable contexts with healthcare institutions which are open towards SHF and patient centeredness.
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The very essential issue whether SHF is feasible at all in healthcare institutions can be answered positively. This implies that SHF criteria have been integrated into the quality management system of healthcare institutions and thus have become sustainable.
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However, another question is the transferability to other countries. Though there are many other types of collaboration with patients [51], we only know about comparable approaches in Austria. This seems to be grounded in similarities both in the hospital sector and in the policies to promote and integrate self-help associations. Firstly, of course, due to the common language, which makes it much easier to adopt ideas and concepts, and secondly because of a regular exchange between Austrian and German members of relevant advisory boards. Regarding to the first German pilot project in Hamburg, similar initiatives of SHF have been put into practice in about 40 Austrian hospitals [44]. This confirms the transferability in comparable contexts.
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\n\n
6. Discussion and conclusion
\n
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6.1. Advantages of the concept
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Cooperativeness is a necessary but not sufficient prerequisite for better involvement of civil society organizations into quality improvement of healthcare services. The SHF concept and its implementation offer some incentives, such as the formal acknowledgement, either as a “seal” for promotion and corporate identity or as a quality certificate in the framework of a quality management audit [52].
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The additional practical support by counselors from the agency for SHF and the involved clearinghouses on self-help assist hospital staff and SHG members to find practical solutions for systematic implementation of collaboration. The open concept of patient centeredness and the “romantic vision” of a doctor-patient partnership turn into a measurable task. This intensifies the pressure to produce a positive result: Failing is visible and may be embarrassing.
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Further advantages are several (positive) side effects which are coming up for both partners [50]:
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If a hospital decides for the SHF approach, this has to be communicated to patients. This leads to an overall reflection of questions like: ’What is self-help at all?’, ’Is self-help beneficial or can it bear risks?’, ’Can I recommend it to my patients and, if so, how shall I communicate it to them?’
If SHGs decide for the approach, they will have to fulfill additional roles, and the “voluntary”-aspect of their work may become subordinated. Other questions arise: ’How do we define our (new) roles?’, ’How do we make sure that we are complementary to professional staff and are not regarded as a substitute?’, ’How do we deal with dissatisfaction or conflicts between hospital patients and hospital staff?’ etc.
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In the whole, we can summarize that the discussion about and reflection of the topic “SHF” helps …
\n
to inform healthcare professionals about the role, chances and possibilities of self-help and specifically their integration in professional care,
\n
to clarify the roles and responsibilities of healthcare staff and members of SHGs,
to better understand the viewpoints and needs of their counterparts,
\n
to learn new facets of the relevant indication and their implications for coping, self-management and consequences in daily life.
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These are all relevant aspects of (collective) patient centeredness which can measurably increase the quality of care in terms of health outcomes [53], better functional status, less infections, shorter hospital stay and higher compliance in joint replacements [54], or significantly reduced decubitus rates and other treatment-related complications [55]. Hospitals and quality managers like the effect that patient centeredness even can reduce the costs and thus increases the financial benefit [31].
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There is some evidence that SHF is a solution to the lack of sustainable cooperation and a way to enhance quality standards in patient-centered care. There are signs that this results in better patients’ health outcomes. Nevertheless, there is a strong plausibility that healthcare institutions will re-adapt their procedures to patients’ needs and thereby improve patient satisfaction, self-management, coping and health literacy. Forster and Rojatz ([44], p. 50–51) scientifically accompanied the SHF-implementation process in Austria with a qualitative study design. They found some reasons why the approach is appreciated and accepted. Positive effects were mainly seen in the quality of cooperation with patients, better visibility and acknowledgement of SHGs, as well as an increasing patient centeredness in hospitals. Interestingly, the interviewed experts did not see any disadvantages. A qualitative study in Germany found strong agreement of both professional staff and SHG-members that SHF would enhance quality in care [56].
\n
\n
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6.2. Shortcomings of the concept
\n
We should not ignore that the voluntary engagement of SHG members can be rather limited due to their health conditions or even may stop suddenly because of decompensation or acute episodes of their illness [57]. Furthermore, healthcare organizations or legal committees require more and different skills beyond the “mere patient role”. Just being a patient who is only describing his or her experience, but not reflecting the wider circumstances and the impact on healthcare providers, institutions, regulations and legislation, may not be sufficient for the concerted development of common strategies [58]. Finally, the motives of the different stakeholders addressing SHGs can be very different. SHGs seem increasingly to be a target of other actors in the health policy arena, like healthcare insurers or especially the pharmaceutical industry [59], but also scientists, predominantly in the area of medical research.
\n
The study with 625 moderators of physicians’ quality circles showed that doctors considered a possible relief of their workload as one of the strongest incentives [60]. However, there is a high probability that professionals like to establish patient groups as auxiliaries [61] rather than equal partners. Several scientists have expressed their concerns about such kinds of “misuse” and identity changes of patient groups; they argue professionals would offer collaboration but in fact try to get “control” of SHGs [62] or to achieve “colonization” [63–65].
\n
Rabeharisoa\'s “partnership model” [61] should hinder misuse and legitimate SHGs to adjust any aberrations from SHF as it is meant by its proponents, if this concept is truly understood and adequately put into practice. However, also here, the above described risk remains: Professionals might take personal advantage of SHGs or could try to co-opt them.
\n
\n
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6.3. Future development in Germany
\n
The SHF approach is focusing at one global aim, which is to reach quality improvements in health care by promoting both individual and specifically collective patient centeredness. While at the macro level patient representatives and other stakeholders in the healthcare system mostly negotiate legal and administrative quality issues, SHF at the mesolevel deals significantly more with daily routines and practical issues in treatment and care. One crucial requirement can be seen in positive attitudes and mindsets of professional staff towards SHGs, which is not a matter of course, as still today some reservation against SHGs exists. Thus, SHF is also a continuous change management process.
\n
The German Network “Self-help Friendliness and Patient Centeredness” promotes a nationwide cooperation between healthcare professionals and SHGs by developing and circulating training materials, implementing agencies for the support of SHGs, running pilot projects, and integrating self-help-friendly criteria into quality management and accreditation measures (www.selbsthilfefreundlichkeit.de). This network helps to tackle critical and non-desirable developments at an early stage, and it can deal with new ways and opportunities for dissemination. These are reaching from appropriate incentive structures to demonstration projects aiming at the implementation of patient centeredness and/or SHF in institutions [36, 39, 43].
\n
The German network has grown steadily since its start in 2009. In April 2016, the network consisted of 118 active members, 42 of them were local self-help clearinghouses, 13 were sent by self-help organizations, 29 were coming from hospitals, and 16 from rehabilitation hospitals. Twenty-one general hospitals and 5 rehabilitation centers are currently distinguished as self-help friendly healthcare institutions. In each case, the list contains the names of the collaborating SHGs (about 9, on average; [66]). If we keep in mind that active dissemination is still in the beginning, these figures look promising.
\n
\n
\n
6.4. Potential and barriers for international transfer and dissemination
\n
Patient involvement and participation in health care and the ways and methods to integrate them in health policies vary in different countries. Despite comparable aims and principles in general, it is still difficult to compare these developments cross-nationally due to diverse and permanently transforming national healthcare systems [67]. At least for the Western World, we meanwhile can assert that there is a common agreement for the need of patient centeredness and patient involvement. We can also state that the reluctance and resistance of healthcare professionals against patients and SHGs, which has often been observed and discussed in the past [68], has more or less overcome. Nevertheless, it is still quite challenging to transfer models of good practice from one country to the other, not only because of the different healthcare systems themselves, but also because of different developments in health-related civil society organizations and in support systems for patients and/or SHGs.
\n
The self-help support system in Germany is rather unique. No other country in the world provides such manifold professional support for patients and SHGs at regional levels. Three hundred clearinghouses and -offices for self-help are serving for around 100,000 SHGs, and several hundred further community-based information centers provide information and counseling for citizens and patients in consumer protection, care, legal affairs and patients’ rights, etc. However, as research on self-help and patient involvement and the debates in these areas are usually held, written and published in German language, the German situation remains widely unknown in other countries except the German speaking like Austria or parts of Switzerland.
\n
The characteristics of the German healthcare system with its integrated self-help support system have certainly promoted patient involvement and participation. The German Network “Self-help Friendliness and Patient Centeredness in the Healthcare System”, initiated by stakeholders from all relevant healthcare areas, was an important and necessary measure for the development of systematic cooperation between healthcare providers and SHGs at the mesolevel [48].
\n
The SHF-concept may possibly sound rather specific and seems strongly being influenced by the German legislations and circumstances. Nevertheless, there are some similarities with other approaches in other countries aiming at patient centeredness, at least concerning the individual (patient) level of patient centeredness rather than the collective (SHG) level. A study by Luxford et al. [35], for example, has recently investigated organizational barriers and facilitators towards patient-centered care in eight healthcare institutions in the USA. They conducted 40 qualitative interviews with healthcare professionals and stakeholders and shaped out nine key facilitators very similar to the quality criteria for SHF. Methods and measures may be different, but it seems obvious that change management towards patient participation, patient centeredness, public involvement or SHF needs participative approaches integrating patients and patient representatives–or specifically: self-help representatives–if a satisfactory cooperation between patients and professional healthcare staff is to be achieved. The German examples demonstrate that self-help and patient groups play an important role in further development of partnerships between patients and healthcare professionals and thus for improvements in the quality of healthcare services.
\n
\n
\n\n',keywords:"self-help friendliness, self-help groups, patient centeredness, patient involvement, patient associations, healthcare institutions, healthcare research",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/52869.pdf",chapterXML:"https://mts.intechopen.com/source/xml/52869.xml",downloadPdfUrl:"/chapter/pdf-download/52869",previewPdfUrl:"/chapter/pdf-preview/52869",totalDownloads:649,totalViews:268,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,dateSubmitted:"May 3rd 2016",dateReviewed:"October 5th 2016",datePrePublished:null,datePublished:"April 12th 2017",dateFinished:null,readingETA:"0",abstract:"Collaboration between laypersons and professionals is closely linked to the concept of patient centeredness. Patient centeredness means meeting the needs of individual patients as well as reacting to patients’ demands on the collective level. The support of self-help groups and their integration into healthcare institutions represent a major policy approach to fulfilling this requirement. Here, we first deal with the concept of patient centeredness in general, and the understanding of concept and use in Germany. We also provide a short definition of self-help friendliness (SHF) and discuss the success achieved in implementing it in Germany so far. We then clarify the closely related concepts of patient centeredness, patient participation and patient involvement SHF is seen as a strategy for increasing both patient centeredness and patient participation in healthcare services. We subsequently describe the involvement of self-help groups and patient associations in a series of empirical studies and practice-oriented projects carried out between 2004 and 2013. The last section contains a general discussion of the SHF approach as a means of systematically increasing sustainable patient centeredness and patient participation in healthcare services. Finally, we address the chances for future development in Germany and the transferability of SHF to other countries.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/52869",risUrl:"/chapter/ris/52869",book:{slug:"patient-centered-medicine"},signatures:"Alf Trojan, Christopher Kofahl and Stefan Nickel",authors:[{id:"190672",title:"Dr.",name:"Stefan",middleName:null,surname:"Nickel",fullName:"Stefan Nickel",slug:"stefan-nickel",email:"nickel@uke.de",position:null,institution:{name:"University of Hamburg",institutionURL:null,country:{name:"Germany"}}},{id:"191200",title:"Dr.",name:"Christopher",middleName:null,surname:"Kofahl",fullName:"Christopher Kofahl",slug:"christopher-kofahl",email:"kofahl@uke.de",position:null,institution:null},{id:"191201",title:"Prof.",name:"Alf",middleName:null,surname:"Trojan",fullName:"Alf Trojan",slug:"alf-trojan",email:"trojan@uke.de",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Patient centeredness as a guiding concept",level:"1"},{id:"sec_3",title:"3. On the relationship between patient centeredness, self-help friendliness and patient participation",level:"1"},{id:"sec_4",title:"4. Developing the approach",level:"1"},{id:"sec_4_2",title:"4.1. Development of self-help friendliness in hospital care",level:"2"},{id:"sec_5_2",title:"4.2. Development of self-help friendliness in other areas of the health services",level:"2"},{id:"sec_7",title:"5. Research limitations and transferability to other countries",level:"1"},{id:"sec_8",title:"6. Discussion and conclusion",level:"1"},{id:"sec_8_2",title:"6.1. Advantages of the concept",level:"2"},{id:"sec_9_2",title:"6.2. Shortcomings of the concept",level:"2"},{id:"sec_10_2",title:"6.3. Future development in Germany",level:"2"},{id:"sec_11_2",title:"6.4. Potential and barriers for international transfer and dissemination",level:"2"}],chapterReferences:[{id:"B1",body:'[\nBundesärztekammer [German Medical Association], editor. Leitfaden: Qualitätsmanagement im deutschen Krankenhaus [Guidline: Qualiy Management in German Hospitals]. 3rd ed. München: Zuckschwerdt; 2001\n]'},{id:"B2",body:'[\nBleses H. Patientenorientierung als Qualitätsmerkmal [online-dissertation]. Berlin: Humboldt-Universität. http://edoc.hu-berlin.de/dissertationen/bleses-helma-2005-01-24/html/index.html\n]'},{id:"B3",body:'[\nStratmeyer P. Das Patientenorientierte Krankenhaus. Eine Einführung in das System Krankenhaus und die Perspektiven für die Kooperation zwischen Pflege und Medizin [The patient-centered hospital]. Weinheim, München: Juventa; 2002\n]'},{id:"B4",body:'[\nHoefert HW, Härter M, editors. Patientenorientierung im Krankenhaus [Patient-centeredness in Hospital]. Göttingen: Hogrefe-Verlag; 2010\n]'},{id:"B5",body:'[\nWeis J et al. 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Baden-Baden: Nomos (Bundestagsdrucksache 14/5660, -5661, -6871); 2012\n]'},{id:"B25",body:'[\nGerlinger T. Nutzerorientierung im Gesundheitswesen – Probleme und Perspektiven [User Involvement in Healthcare – Problems and Prospects]. In Mozygemba K et al., editors. Nutzerorientierung - ein Fremdwort in der Gesundheitssicherung? Bern: Huber; 2009. pp. 17–29\n]'},{id:"B26",body:'[\nGroene O et al. Is patient-centredness in European hospitals related to existing quality improvement strategies? Analysis of a cross-sectional survey (MARQuIS study). Quality & Safety in Health Care. 2009;18(Suppl I):i44–i50\n]'},{id:"B27",body:'[\nTrojan A, Nickel S. Integration von Selbsthilfefreundlichkeit in das Gesundheitswesen – Entwicklungen und Perspektiven [Integration of self-help associations into the health services system–developments and perspectives]. Das Gesundheitswesen. 2011;73(2):67–72\n]'},{id:"B28",body:'[\nBobzien M, Trojan A. Selbsthilfefreundlichkeit” als Element patientenorientierter Rehabilitation – Ergebnisse eines Modellversuchs [Self-help friendliness as an element of patient-centered rehabilitation–Results of a pilot project]. Rehabilitation. 2015;54:1–7. doi:10.1055/s-0034-1398515\n]'},{id:"B29",body:'[\nAkrich M, Nunes J, Paterson F, Reharisoa V. The Dynamics of Patient Organizations in Europe. Paris: Collection Sciences Sociales; 2008\n]'},{id:"B30",body:'[\nAllsop J, Jones K, Baggott R. Health consumer groups in the UK: a new social movement? Sociology of Health and Illness. 2004;26(6):737–756\n]'},{id:"B31",body:'[\nCharmel PA, Frampton SB. Building the business care for patient-centered care. Healthcare Financial Management. 2008;62(3):80–85\n]'},{id:"B32",body:'[\nConklin A, Morris ZS, Nolte E. Involving the Public in Healthcare Policy. An Update of the Research Evidence and Proposed Evaluation Framework. Santa Monica: RAND Corporation; 2010\n]'},{id:"B33",body:'[\nEngelhardt HD, Trojan A, Nickel S. Leistungen von Selbsthilfegruppen und deren ökonomische Bewertung [Performance of self-help groups and their economic evaluation]. Bundesgesundheitsblatt: Selbsthilfe. 2009;52:64–70\n]'},{id:"B34",body:'[\nLewin S et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database of Systematic Reviews. 2001;(4):CD003267 doi:10.1002/14651858.CD003267\n]'},{id:"B35",body:'[\nLuxford K, Safran DG, Delbanco T. Promoting patient-centred care: a qualitative study of facilitators and barriers in healthcare organizations with a reputation for improving the patient experience. International Journal for Quality in Health Care. 2011;23(5):510–515\n]'},{id:"B36",body:'[\nShaller D. Patient-Centered Care: What Does It Take? New York: The Commonwealth Fund; 2007\n]'},{id:"B37",body:'[\nTaylor K. Paternalism, Participation and Partnership–The Evolution of Patient-centeredness in the Consultation. Patient Education and Counselling. 2009;74(2):150–155\n]'},{id:"B38",body:'[\nEpstein RM, Fiscella K, Lesser CS, Stange KC. Why the nation needs a policy push on patient-centered health care. Health Affairs. 2010;29(8):1489–1495\n]'},{id:"B39",body:'[\nBitton A, Martin C, Landon BE. A nationwide survey of patient-centered medical home demonstration projects. Journal of General Internal Medicine. 2010;25(6):584–592\n]'},{id:"B40",body:'[\nBox G. Patient participation groups: the national picture. Quality in Primary Care. 2009;17(4):291–297\n]'},{id:"B41",body:'[\nCanadian Health Services Research Foundation. CHSRF Patient Engagement Project–PEP. http://cahspr.ca/en/funding-opportunity/chsrf-patient-engagement-project-%E2%80%93-pep [Accessed: 5th March 2011]\n]'},{id:"B42",body:'[\nBovenkamp HM van de, Trappenburg MJ, Grit KJ. Patient participation in collective healthcare decision making: the Dutch model. Health Expectations. 2010;13(1):73–85\n]'},{id:"B43",body:'[\nScrivens E. Widening the scope of accreditation–issues and challenges in community and primary care. International Journal for Quality in Health Care. 1998;10(3):191–197\n]'},{id:"B44",body:'[\nForster R, Rojatz D. Selbsthilfegruppen als Partner der Gesundheitsförderung im Krankenhaus. Eine Analyse am Beispiel krankenhausbezogener Kooperationsprojekte [Self-help Groups as Partners für Health Promotion in Hospitals]. Institut für Soziologie, Universität Wien. Forschungsbericht; 2011\n]'},{id:"B45",body:'[\nForster R, Braunegger-Kallinger G, Krajic K. Selbsthilfeorganisationen als “Stimme der Patienten”: Erfahrungen und Herausforderungen von Interessenvertretung und Beteiligung [Self-help Organizations as “Voice of Patients”]. In: Meggeneder O, editor. Selbsthilfe im Wandel der Zeit. Frankfurt/Main: Mabuse; 2011. pp. 9–39\n]'},{id:"B46",body:'[\nGeene R, Huber E, Hundertmark-Mayser J, Möller-Bock B, Thiel W. Entwicklung, Situation, und Perspektiven der Selbsthilfe-Unterstützung in Deutschland [Development, Situation and Perspective of Self-help Support in Germany]. Bundesgesundheitsblatt – Gesundheitsforschung – Gesundheitsschutz. 2009;52:11–20\n]'},{id:"B47",body:'[\nKörner M, Ehrhardt H, Steger AK. Interne und externe Patientenorientierung in der medizinischen Rehabilitation [Internal and External Patient-centeredness in the Medical Rehabilitation]. Public Health Forum. 2011;19(70):21–22\n]'},{id:"B48",body:'[\nhttp://www.selbsthilfefreundlichkeit.de [Accessed: 2016-07-06]\n]'},{id:"B49",body:'[\nNickel S, Kofahl C, Trojan A. Involving self-help groups in health care institutions: the patients’ contribution to and their view of “self-help friendliness” as an approach to implement quality criteria of sustainable cooperation. Health Expectations. 2016. doi:10.1111/hex.12455 (March 2016)\n]'},{id:"B50",body:'[\nKofahl C, Trojan A, Knesebeck Ovd, Nickel S. Self-help friendliness: a German approach for strengthening the cooperation between self-help groups and health care professionals. Social Science and Medicine. 2014;123:217–225\n]'},{id:"B51",body:'[\nKeizer B, Bless R. Pilot Study on the Position of Health Consumer and Patients’ Organisations in Seven EU Countries. Den Hague: ZonMw; 2010\n]'},{id:"B52",body:'[\nTrojan A, Werner S, Bobzien M, Nickel S. Integration von Selbsthilfezusamenschlüssen in das Qualitätsmanagement im amulanten und stationären Versorgungsbereich [Integration of self-help associations into the quality management of outpatient and inpatient health care]. Bundesgesundheitsblatt: Gesundheitsforschung – Gesundheitsschutz. 2009;52:47–54\n]'},{id:"B53",body:'[\nMeterko M, Wright S, Lin H, Lowy E, Cleary PD. Mortality among patients with acute myocardial infarction: the influences of patient-centered care and evidence-based medicine. Health Services Research. 2010;45(5):1188–1204\n]'},{id:"B54",body:'[\nDi Gioia AM. The AHRQ Innovation Exchange: Patient - and Family-centered Care Initiative Is Associated with High Patient Satisfaction and Positive Outcomes for Total Joint Replacement Patients. Rockville: Agency for Health Care Research and Quality; 2008\n]'},{id:"B55",body:'[\nIsaac T, Zaslavsky AM, Cleary PD, Landon BE. The relationship between patients\' perception of care and measures of hospital quality and safety. Health Services Research. 2010;45(4):1024–1040\n]'},{id:"B56",body:'[\nSchumann M. Die Institutionelle Verankerung von Selbsthilfe im Krankenhaus. Fördernde und hemmende Rahmenbedingungen aus Sicht der beteiligten Akteure [The Institutional Entrenchment of Self-Help in Hospitals. Facilitating Factors and Barriers from the Stakeholders’ View]. MH Hannover: Magisterarbeit Public Health; 2011\n]'},{id:"B57",body:'[\nMatzat J. Selp-help/mutual aid in Germany–a 30 year perspective of a participant observer. International Journal of Self-Help and Self Care. 2006–2007;5:279–294\n]'},{id:"B58",body:'[\nBerger B, Gerlach A, Groth S, Sladek U, Ebner K, Mühlhauser I, Steckelberg A. Competence training in evidence-based medicine for patients, patient counsellors, consumer representatives and health care professionals in Austria: a feasibility study. Zeitschrift für Evidenz, Fortbildung und Qualität im Gesundheitswesen. 2013;107(1):44–52\n]'},{id:"B59",body:'[\nNAKOS, editor. Transparenz und Unabhängigkeit der Selbsthilfe [Transparency and Independence of Self-help]. Wahrung der Selbstbestimmung und Vermeidung von Interessenkonflikten. Berlin: NAKOS Konzepte und Praxis 6; 2012\n]'},{id:"B60",body:'[\nNickel S, Trojan A, Kofahl C. Increasing patient centredness in outpatient care through closer collaboration with patient groups? An exploratory study on the views of health care professionals working in quality management for office-based physicians in Germany. Health Policy. 2012;107(2):249–257.\n]'},{id:"B61",body:'[\nRabeharisoa V. The struggle against neuromuscular diseases in France and the emergence of the partnership model of patient organisation. Social Science & Medicine. 2003;57:2127–2136\n]'},{id:"B62",body:'[\nBorkman T. Groups at the turning point: emerging egalitarian alliances with the formal health care system? American Journal Community Psychology. 1990;18(2):321–32\n]'},{id:"B63",body:'[\nKelleher D. Self-help groups and their relationship to medicine. In: Kelleher D, Gabe J, Williams J, editors. Challenging Medicine. London: Routledge; 2006. pp. 104–121\n]'},{id:"B64",body:'[\nO’Donovan O. Corporate colonization of health activism? Irish healthadvocacy organizations’ modes of engagement with pharmaceutical corporations. International Journal of Health Services. 2007;37(4):711–733\n]'},{id:"B65",body:'[\nMarent B, Forster R, Nowak P. Conceptualizing lay participation in professional health care organizations. Administration and Society. 2015;47(7):827-850. doi:10.1177/0095399713489829\n]'},{id:"B66",body:'[\nhttp://www.selbsthilfefreundlichkeit.de/selbsthilfe/content/wie_wir_auszeichnen/ausgezeichnete_kliniken/index_ger.html [Accessed: 2016-07-06]\n]'},{id:"B67",body:'[\nBurau V. Transforming health policy and services: challenges for comparative research. Current Sociology. 2012;60(4):569–578\n]'},{id:"B68",body:'[\nMoeller ML. History, concept and position of self-help groups in Germany. Group Analysis. 1999;32(2):181–194\n]'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Alf Trojan",address:null,affiliation:'- Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
'},{corresp:null,contributorFullName:"Christopher Kofahl",address:null,affiliation:'- Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
'},{corresp:"yes",contributorFullName:"Stefan Nickel",address:"nickel@uke.de",affiliation:'- Institute of Medical Sociology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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1. Introduction
\n
\n
1.1 Definition and incidence
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Acute pancreatitis (AP) refers to the sudden inflammation of the pancreas, and it may be confined to the pancreas, or more life-threatening, affecting all organs and systems [1–5]. Recurrence is experienced in 15–30% of patients, and 5–25% can develop chronic pancreatitis. It progresses mildly in 80% of patients and resolves with treatment, but in cases of severe AP, complications such as organ failure and pancreatic necrosis may develop, with mortality of around 30% recorded in this group [2, 4, 5]. AP is an acute gastrointestinal disease that requires hospitalization, and is the most common cause of admission to the emergency room worldwide [1, 6, 7]. Hospital admissions for AP in the United States are in the region of 270,000/year, with a mortality rate of 30% in severe cases. Death is due to systemic inflammatory response syndrome (SIRS) and organ failure in the first two weeks, while death after two weeks can be attributed to sepsis and complications [3, 6, 8, 9].
\n
\n
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1.2 Etiology
\n
Gallstones are the most common etiology of AP, being responsible for 40–70% of AP cases [10–12]. The ease at which small gallstones can pass into the bile duct make AP more common in this patient group [13]. Although alcohol is commonly blamed as the second most common cause, the link between alcohol and AP is unclear, as AP is seen in only a small number of alcoholics [2, 14, 15]. Recent studies have suggested that alcohol increases the oxidative metabolism in the acinar cells of the pancreas, thereby causing mitochondrial dysfunction and cell death. This increases also the production of acetaldehyde in the pancreatic stellate cells, and increases circulating lipopolysaccharide and tumor necrosis factor alpha (TNFα), leading to fibrosis in the pancreas [16, 17]. Alcohol has also been reported to increase the viscosity of pancreatic juice and to cause ductal obstructions. That said, it has also been suggested that genetic factors play a role in the development of AP,based on the low incidence of AP in people with chronic alcohol consumption [2, 15, 18]. Other causes have been identified as Hypertriglyceridemia (HTR), and diabetes, hypothyroidism, pregnancy and obesity that cause HTR [1]. Patients with a body mass index (BMI) >35 are at risk of both HTR and AP, while those with serum triglyceride levels >1000 mg/dl are at greater risk [19–21]. Following endoscopic retrograde cholangiopancreatography (ERCP) performed by inexperienced practitioners, patients with Sphincter of Oddi dysfunctions may develop AP following ERCP due to difficult cannulation [22].
\n
AP can also occur due to drugs at a rate of 0.1–0.5% [2, 23–25]. Many drugs have been identified that cause acute pancreatitis. Drugs cause AP by different mechanisms. While some drugs cause direct toxicity to the pancreas (eg, diuretics, sulfonamides), some drugs cause acute pancreatitis by causing an immunological reaction (eg, 6-mercaptopurine, amino salicylates, sulfonamides). Diuretics and azothiopurine cause direct ischemia, while hormones such as steroids and estrogen cause vascular thrombosis or ischemic pancreatitis by decreasing the viskosity of the pancreatic juice. Toxic metabolites of drugs such as valproic acid and tetracycline may accumulate in the pancreas and cause pancreatitis [2, 26, 27].
\n
AP cases have been reported associated with such infectious diseases as Mumps, Coxsackievirus, Hepatitis B, Cytomegalovirus, Varicella-Zoster, herpes simplex and human immunodeficiency virus (HIV) among the viruses; with Mycoplasma, Legionella, Leptospira and Salmonella among the bacteria; with Aspergillus among the fungi; and with Toxoplasma and Cryptosporidium among the parasites [2, 27, 28] . There have been reports of cases of AP with the recent SARS-CoV-2 infection at the heart of the current global pandemic [29, 30]. In a review of current literature, AP was found to be detected in 17% of patients hospitalized due to Covid-19 [29]. Although tests for specific infectious agents are not generally recommended in AP patients, Covid-19 infection should also be kept in mind in AP cases during the pandemic [30].
\n
Concerning other rare causes, pancreatic injury following trauma is an extremely rare condition due to its retroperitoneal nature. Pancreatic duct injuries may occur due to blunt or penetrating traumas [31], while AP may occur due to gallbladder sludge, tumors, autoimmune pancreatitis, hypercalcemia, anatomical and physiological anomalies (pancreatic divisum, biliary cysts, pancreaticobiliary malunion, large juxta-ampullary diverticula, annular pancreas and Sphincter of Oddi dysfunction), and vasculitis [27, 32–36]. Ischemic AP can also be seen after major cardiovascular operations [27, 37, 38]. Patients with an unknown etiology after history-taking, physical examination, laboratory tests, imaging methods and advanced tests are classified as idiopathic. In the event of recurrent AP attacks in this patient group and AP at a young age, genetic factors should be investigated [27, 39].
\n
\n
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1.3 Pathogenesis
\n
As its main mechanism, AP blockades the secretion of enzymes while the synthesis of enzymes continues [2, 40]. Under normal conditions, trypsinogen is produced in the pancreas and secreted into the duodenum where it is converted into protease trypsin, but in cases where secretion is blocked, trypsin continues to be produced in pancreatic acinar cells. While activation continues, elimination is inhibited, and the active trypsin damages the vascular endothelium, interstitium and acinar cells [2, 40, 41]. As a result, autodigestion begins in the pancreas,and ischemia occurs at a tissue level in the pancreas due to the vasoconstriction and stasis of the capillary vessels. The activation of granulocytes and macrophages in response to these events causes a release of proinflammatory cytokines (tumor necrosis factor, interleukins 1, 6 and 8), arachidonic acid metabolites (prostaglandins, platelet activating factor and leukotrienes), proteolytic and lipolytic enzymes, and reactive oxygen metabolites [2, 27, 42, 43]. All of these factors together cause damage to the pancreatic tissue. In general, the inflammation is locally self-limiting, buton occasions, inflammatory agents may cause a systemic response, leading to the damage and failure of distant organs. This, in turn, may result in Acute Respiratory Distress Syndrome (ARDS), pleural effusion, acute renal failure, shock, and even death [2, 27, 44, 45].
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\n
\n\n
2. Clinical features
\n
Patients withAP present to the emergency room with sudden and severe abdominal pain that usually starts in the epigastric region. In patients with gallstones, the pain spreads to the right upper quadrant and is more sharply limited. In 50% of patients, the pain spreads to the back, and is felt around the entire abdomen, like a belt. Nausea and vomiting may accompany,and in rare cases there may be pain on the left side of the abdomen [2, 46, 48–50].
\n
Physical examination findings can vary, depending on the severity of AP and any accompanying diseases. Initial findings typically include mild or generalized tenderness upon abdominal palpation, distension and diminished bowel sounds. In cases of obstruction due to gallstones, jaundice may be observed, while in severe AP, fever, hypotension, tachycardia, tachypnea and hypoxemia may be observed. In cases of pancreatic necrosis, ecchymotic lesions can be seen in the periumbilical region (Cullen’s sign) or on the flanks (Gray Turner’s sign) [2, 27, 51, 52].
\n
\n\n
3. Diagnosis
\n
Diagnosis is established based on the presence of two of three criteria: 1) Presence of clinical findings consistent with AP, 2) serum lipase or amylase levels three times greater than normal, and 3) characteristic findings of AP on imaging [2, 27, 47–49].
\n
\n
3.1 Laboratory
\n
In AP, enzymes pass from the basolateral membrane to the interstitial area, and then on to the systemic circulation due to the blockade of the secretion ofpancreatic enzymes, while the synthesis of enzymes continues, resulting in increased levels of pancreatic enzymes in the blood.
\n
At the onset of AP, serum amylase starts to increase within 6–12 hours, peaks at 48 hours, and returns to normal within 3–5 days, although no increase in amylase levels will be observed in alcohol-induced pancreatitis and AP due to hypertriglyceridemia. Sensitivity and specificity in diagnosis are 67–83% and 85–98%, respectively [2, 27, 49, 53, 54]. Elevated amylase levels may also be seen in non-pancreatic diseases, such as renal failure, salivary gland diseases, acute appendicitis, cholecystitis, perforations, intestinal obstructions or intestinal ischemia, and gynecological diseases. For these reasons, amylase alone is not sufficient for a diagnosis of AP [2, 49, 50]. The increase in serum lipase levels in AP is more specific. Following the onset of symptoms, the levels begin to increase within 8–10 hours, peak at 24 hours, return to normal within 8–14 days, with a sensitivity of 82–100% [2, 49, 53, 55], and may increase in alcohol-induced AP and AP due to hypertriglyceridemia. It is useful in delayed patients who present 24 hours after the onset of pain [49, 55, 56]. Aside from amylase-lipase, liver and kidney tests,a complete blood count should also be made in AP, as this will allow the assessment of the patient’s clinical condition, the early identification of complications and the detection of organ failure, and will aid in a therapeutic evaluation. An alanine aminotransferase (ALT) liver function test value in excess of 150 U/L indicates gallstones [2, 47, 48]. There are also specific tests for AP that are not routinely used. Among the enzymes with early elevation are trypsinogen-activating peptide, urinary and serum trypsinogen and trypsin, phospholipase, carboxypeptidase, carboxyl ester lipase, colipase and pancreatic isoamylase [57–59], and an increase is also observed in inflammatory mediators such as C-reactive protein (CRP), interleukin IL-6, IL-8, IL-10, tumor necrosis factor (TNF) and PMN elastase. The elevation of inflammatory mediators is usually proportional to the severity of AP. A CRP level above 150 mg/dl within the first 48 hours has been associated with severe AP [60, 61].
\n
\n
\n
3.2 Imaging
\n
Imaging can aid in determining the etiology of AP, or complications due to AP. Abdominal and chest radiographs may reveal appearances of pleural effusion, atelectasis and ileus accompanying AP. Radiographs should be evaluated to rule out other causes of abdominal pain. Abdominal ultrasound should be performed on every patient with suspected AP, and USG can detect findings that support AP, if present, such as gallstones, obstructions in the common bile duct, intraabdominal free fluid and diffuse enlarged and hypoechoic appearance in the pancreas, as well as peripancreatic fluid, necrosis and abscesses. A normal USG cannot exclude AP [2, 27, 47–49, 62], while Contrast-Enhanced Computed Tomography (CECT) has a sensitivity of 90% in the diagnosis of AP. However, AP is not routinely recommended for diagnosis, since it is mild and uncomplicated in most patients [2, 47–49], but may be recommended in cases where other causes of acute abdomen cannot be excluded, or for patients who show no improvement within 48–72 hours [49, 63, 64].
\n
Among the patients considered for CECT, MRI is recommended rather that CECT for those with renal failure, pregnant patients and those with allergies to IV contrast agents [49, 63].
\n
Serum triglyceride levels must be examined in patients with normal test results, but with a strong suspicion of AP, in those with pancreatic tumors aged over 40 years, in the presence of genetic factors in patients under the age of 30 and in recurrent AP cases [39, 49].
\n
\n
\n
3.3 Differential diagnosis
\n
Other diseases that may cause abdominal pain should be excluded in a differential diagnosis.In particular, peptic ulcer disease, choledocholithiasis, cholangitis, biliary obstruction, cholecystitis, perforated viscus, intestinal obstruction, mesenteric ischemia and hepatitis should be considered in differential diagnosis due to their clinical similarities to AP [2, 27] .
\n
\n
\n\n
4. Initial management
\n
AP can be classified into two groups as mild AP, in which patients have no accompanying organ failure, and recover and can be orally fed within 48 hours; and severe AP, which is accompanied by organ failure and a lack of response to treatment. Most patients with severe AP have not suffered organ failure at the time of admission to emergency room, and so may be evaluated as mild AP,but deteriorate rapidly due to inadequate hydration and inadequate treatment. As such, the severity of the disease should be determined along at the time of diagnosis in the emergency room, and treatment should be planned accordingly [47–49, 65].
\n
According to the Atlanta classification, severe AP is characterized by resistant/persistent organ failure with no improvement within 48 hours, although in the absence of organ failure, the presence of local complications alone is an indicator of severe AP [66]. Patients who develop transient organ failure alongside local complications are classified as moderately severe AP (Table 1). The Atlanta classification evaluates the presence of organ failure based on Marshall’s organ failure criteria. Accordingly, the presence of shock (systolic BP <90 mmHg), pulmonary failure (PaO2 < 60 mmHg), renal failure (creatinine >2 despite adequate hydration), and/or the presence of gastrointestinal bleeding (>500 ml blood loss within 24 hours) should be evaluated as organ failure [47, 49, 67].
\n
\n\n\n\n\n\nMild AP | \nModerately AP | \nSevere AP | \n
\n\n\n\nAbsence of local complications | \nLocal complications Peripancreatic fluid collection Pancreatic or peripancreatic necrosis(sterile or infected) Gastric outlet disfunction Splenic or portal vein thrombosis Colonic necrosis AND/OR | \nPersistent organ failure > 48 h GI bleeding (>500 cc/24 hr) Shock – SBP < 90 mmHg PaO 2 < 60% Creatinine >2 mg/d | \n
\n\nAbsence of organ failure | \nTransient organ failure < 48 h | \n | \n
\n\n | \nGI bleeding (>500 cc/24 hr) Shock – SBP < 90 mmHg PaO 2 < 60% Creatinine >2 mg/d | \n | \n
\n\n
Table 1.
Atlanta classification 2015.
\n
Besides the Atlanta classification, several scoring systems have been proposed for the determination of the severity in AP. These include Ranson’s criteria,Acute Physiology and Chronic Health Examination-II, modified Glasgow score, Bedside Index for Severity in Acute Pancreatitis and the Balthazar CT Severity Index,none of which has been shown to be superior to any other, and they have only limited use in the emergency room, as they rely on too many parameters, and some give results only after 48 hours [68, 69]. The assessment of the patient in the emergency department is of utmost importance, with patient-related risk factors such as age, weight, comorbidities and vital signs as well as laboratory findings all being evaluated together (Table 2) [47, 48, 56, 65].
\n
\n\n\n\n\n\n\nPatient characteristics | \nThe systemic inflammatory response syndrome (SIRS) | \nLaboratory findings | \nRadiology findings | \n
\n\n\n\nAge > 55 years Obesity (BMI >30 kg/m2) Altered mental status Comorbid disease | \npulse >90 beats/min respirations >20/min or PaCO2 > 32 mmHg temperature > 38°C or < 36°C WBC count >12,000 or < 4,000 cells/mm3 or > 10% immature neutrophils (bands) | \nBUN >20 mg/dl Rising BUN HCT >44% Rising HCT Elevated creatinine | \nPleural effusions Pulmonary infiltrates Multiple or extensive extrapancreatic collections | \n
\n\n
Table 2.
Initial assessment for risk of severe AP.
\n
\n\n
5. Treatment
\n
\n
5.1 Fluid replacement
\n
The initial approach to AP involves aggressive fluid therapy, pain management and nutritional support. In AP, there is a large amount of fluid deficit due to losses from vomiting, reduced oral intake, passage of fluid into the third space, respiration and sweating. If the patient has no additional cardiovascular or renal disease, fluid replacement should be initiated at 5–10 ml/kg/hour. For patients presenting with evidence of hypovolemia and shock, 3 ml/kg of fluid should be given for 8–12 hours following a fluid bolus of 20 ml/kg in 30 minutes, with isotonic normal saline preferred as the fluid [47–49, 70–72]. A prospective study found hydration with Ringer’s lactate solution to be more beneficial, although Ringer’s lactate solution has been shown to activate trypsin in acinar cells, thereby making the patient more susceptible to injury due to its low pH. With normal saline, there is a risk of developing non-anion gap metabolic acidosis, and patients should be monitored accordingly during fluid replacement [2, 72]. An assessment should be made after 6, 24 and 48 hours to as certain whether the fluid administered is sufficient. With adequate hydration, the heart rate should drop below 120/min, mean arterial pressure (MAP) should be maintained between 65 and 85, and hematocrit (HCT) should be 35–44%. If the BUN value is initially high, a decrease upon hydration is an indicator of adequate hydration. Changes in blood urea nitrogen (BUN) values within the first 24 hours are particularly important [27, 48, 49, 73]. If the BUN values continue to be high, or increase even further, acute tubular necrosis or resistant volume deficit should be suspected [27, 47, 48, 65, 75]. Another parameter that should be monitored during hydration is hematocrit. Continued hemoconcentration for more than 24 hours suggests the development of necrotizing pancreatitis, and so the patient’s urine output, BUN and HCT values should be closely monitored. The development of severe pancreatitis should be considered in patients who do not respond to aggressive hydration for 6–12 hours [47–49].
\n
\n
\n
5.2 Pain management
\n
Adequate hydration and the resolution of hypovolemia relieve ischemic pain secondary to hemoconcentration. Nevertheless, opioid analgesics are recommended for rapid pain management. Fentanyl can be used safely, especially in patients with kidney failure, in which intravenous (IV) fentanyl of 20–50 microgram is administered slowly over 10 minutes. Meperidine can be used as an alternative to morphine due to the spasm effect of morphine on the Sphincter of Oddi [2, 27, 76, 77].
\n
\n
\n
5.3 Monitoring
\n
AP patients should be followed closely for 24 hours, with continued monitoring of blood pressure, temperature, pulse, oxygen saturation and urine output. Blood tests should be monitored for hematocrit, BUN and electrolytes (calcium, magnesium), and blood glucose should be maintained between 180 and 200 mg/dl [2, 27, 47]. Intensive care follow-up is required for patients whose vital signs and laboratory values are unstable and / or continue (Table 3) [47].
\n
\n\n\n\n\n\nVital signs | \nLaboratuary findings | \nPatient condition | \n
\n\n\n\npulse <40 or > 150 beats/min; systolic arterial pressure < 80 mmHg (<10.7 kPa) or mean arterial pressure < 60 or diastolic arterial pressure > 120 mmHg respiratory rate > 35 breaths/min; | \nserum sodium <110 mmol/l or > 170 mmol/l; serum potassium<2.0 mmol/l or > 7.0 mmol/l; paO2 < 50 mmHg pH < 7.1 or > 7.7; serum glucose >800 mg/dl (>44.4 mmol/L); mmol/L); serum calcium >15 mg/dl (>3.75 | \ncoma. Furthermore, a patient with severe acute pancreatitis as defined by the revised Atlanta Classification (i.e. persistent organ failure) | \n
\n\n
Table 3.
Assessment for intensive care.
\n
\n
\n
5.4 Nutrition
\n
It is no longer recommended to stop oral intake until the AP has fully resolved and the enzymes have returned to normal limits in order to put the pancreas at rest. Patients ceasing oral intake may develop atrophy in the mucosa of gastrointestinal tract [27, 47–49, 78, 79], and so oral feeding should be initiated in patients without nausea, vomiting or ileus and with relieved pain, as soon as they can tolerate [47–49, 79–81]. Liquid, light and low-fat foods should be given at first [82]. In cases of severe AP, enteral feeding may be initiated in patients who are still unable to tolerate oral feeding after 5 days, and in those with complications. For enteral nutrition, a nasojejunal or nasogastric tube should be used for feeding. A nasogastric tube insertion may be easy, but there is a risk of aspiration, while a nasojejunal tube requires an operation. Depending on the conditions, both methods can help provide effective nutrition [49, 48, 82]. If the goal of enteral nutrition is not achieved within 48–72 hours, or if the patient cannot tolerate, parenteral nutrition should be initiated [80, 81, 83].
\n
\n
\n
5.5 Antibiotics
\n
20% of patients develop extrapancreatic infections that may be cholangitis, catheter infection, urinary tract infection or pneumonia. Prophylactic ABs, even if severe, are not routinely recommended in AP without an unidentified focus of infection or presence of infection. ABs for infective necrosis prophylaxis are not recommended, even for patients with sterile necrosis [2, 27, 47–49, 65, 84, 85].
\n
\n
\n\n
6. Management of complicatıons
\n
If, during the follow-up of moderately severe or severe AP patients, signs of sepsis appear, no improvement occurs within 72 hours or the condition deteriorates gradually, then complications should be suspected and a CECT should be performed.
\n
\n
6.1 Local complications
\n
\n
6.1.1 Acute peripancreatic fluid collection
\n
Acute peripancreatic fluid collection occurs early, and has no specific wall. It resorbs spontaneously [27, 49, 117].
\n
\n
\n
6.1.2 Necrotizing pancreatitis
\n
Necrotizing pancreatitis can involve both the pancreas and peripancreatic tissues. A variable amount of fluid and necrotic tissue may develop within the necrosis,and is known as Acute Necrotic Collection (ANC) when a clear wall cannot be defined, and as Wall-off Necrosis (WON) when there is a mature, encapsulated and well-defined wall. WON is a pancreatic pseudocyst that occurs around 4 weeks after an AP attack, and that has a noticeable wall, for which drainage may be required. In either case, the necrotic area may be sterile or infected, and the type of treatment is determined based on the presence or absence of infection [84, 86–88].
\n
\n
6.1.2.1 Infected necrosis
\n
Infection should be suspected in patients with pancreatic or extrapancreatic necrosis upon clinical deterioration or a lack of improvement within 7–10 days of hospitalization. Infectious agents are usually of intestinal origin (such as Escherichia coli, Pseudomonas, Klebsiella and Enterococcus), and may be suspected with the emergence of clinical signs of infection in patients and the presence of gas around the pancreas on imaging [89, 90]. Empirical AB may be initiated in these patients, with ABs that can penetrate the pancreas well (carbapenem alone; or quinolone, ceftazidime, or cefepime combined with an anaerobic agent such as metronidazole)being recommended [27, 48, 49]. Fine needle aspiration (FNA) or sampling is not recommended in such patients. Necrosectomy may be scheduled for patients who show no improvement, but should be delayed as much as possible, since many patients respond well to AB therapy [49, 90–92]. Antibiotic therapy should have been completed 4 weeks prior to a decision of necrosectomy. For the necrestomy, endoscopic or invasive percutaneous procedures should be tried first, and if these fail, surgery should be scheduled [47–49, 91–93].
\n
\n
\n
6.1.2.2 Sterile necrosis
\n
In patients with necrotizing pancreatitis, sterile necrotizing pancreatitis should be suspected when there is no improvement despite treatment, and no clear clinical or imaging findings of infection. In such cases, FNA sampling is indicated, and if the collected material is sterile, there is no need to continue the ABs. Even ABs cannot prevent sterile necrosis from turning into infected necrosis [47, 48, 94]. In sterile necrosis in the absence of any sign of infection, interventions will be required in the following cases:
Continued obstruction of the gastric outlet, intestine or bile ducts, caused by mass effects after 4–8 weeks following the onset of acute pancreatitis.
Persistant symptoms (e.g. abdominal pain, nausea, vomiting, anorexia or weight loss) identified more than eight weeks following the onset of acute pancreatitis.
Disconnected duct syndrome (full transection of the pancreatic duct) with persistent symptomatic collections with necrosis (e.g., pain, obstruction) more than 8 weeks following the onset of acute pancreatitis.
\n\n
Aside from these, CT and FNA should be repeated 5–7 days later in patients with sterile necrosis detected by CECT and FNA, but with signs of systemic toxicity [49, 47].
\n
The much rarer complications include peripancreatic vascular complications, splanchnic vein thrombosis, abdominal compartment syndrome and pseudoaneurysm. Furthermore, patients may risk developing diabetes in the following periods [27, 47, 95].
\n
\n
\n
\n
\n
6.2 Systemic complications
\n
Respiratuar insufficiency includes pneumonia, atelectasis, and ARDS. Renal complications are prerenal azotemia, hypotansion and acute tubuler necrosis. Shock is caused by third space losses, vomiting and interstitial edema. Hypo-hyperglicemia, coagulation disorders, fat necrosis and pancreatic encphalophaty are other rare systemic complications of AP [27].
\n
\n
\n\n
7. Management of predisposing underlying conditions
\n
\n
7.1 Nonsurgical management
\n
The detection and treatment of the underlying diseases that cause AP are as important as AP itself. Most gallstones that pass into the common bile duct advance to the intestines, and are excreted with feces. However, stones that cause obstructions to the pancreatic duct and/or biliary ducts may result in severe AP and/or cholangitis. ERCP is recommended within the first 24 hours for AP patients with stones detected as causing an obstruction. The removal of stones by via a sphincterotomy with ERCP prevents both severe AP and the cholangitis and future development of biliary AP. ERCP should be performed within the first 24 hours in AP patients due to gallstones accompanied by acute cholangitis. A papillotomy, or the surgical removal of stones, with ERCP reduces the severity of AP [47, 49, 96–98]. It has been reported that mortality decreases with early ERCP in patients with no cholangitis, with biliary duct obstructions, and with elevated liver function test scores. That said, it is unnecessary to perform ERCP within the first 24 hours on patients with no increase in liver function tests, with therapeutic ERCP recommended for such patients before or during the cholecystectomy. It is recommended that EUS and MRCP be performed prior to ERCP in patients without cholangitis or jaundice, but with suspected choledocholithiasis, pregnant women and patients on whom ERCP cannot be performed anatomically [47–49, 65, 99].
\n
\n
\n
7.2 Surgıcal managment
\n
The removal of stones through the use of ERCP in patients without cholangitis can prevent the development of AP in the future, but it cannot prevent the development of biliary colic or cholecystitis. Accordingly, cholecystectomy is recommended prior to discharge in patients with mild AP and with gallstones [47–49, 65, 100–103]. Preoperative MRCP or EUS, or intraoperative cholangiography may be carried out for the selection of patients with common bile duct stones who need to be treated through an operative bile duct exploration or endoscopic sphincterotomy during a cholecystectomy [47, 49, 99]. A cholecystectomy may be avoided in ineligible elderly patients (>80 years of age), particularly if a sphincterotomy has already been performed [47, 49, 96, 97]. A cholecystectomy should be performed in patients with gallbladder sludge and AP. In patients with necrotizing biliary AP, cholecystectomies should be delayed until the active inflammation subsides and fluid collections have resolved or stabilized. If collection takes longer than 6 weeks to resolve, the cholecystectomy should be delayed until it can be performed safely [47–49, 65]. Asymptomatic pseudocysts and pancreatic and/or extrapancreatic necrosis require no surgical intervention, regardless of the size, location and/or extension. In asymptomatic patients with infected necrosis, surgical, radiological and/or endoscopic drainage should be delayed for more than 4 weeks to allow for the liquefaction of the content and the development of a fibrous wall around the necrosis (WON). Minimally invasive necrosectomy methods are preferred in symptomatic patients with infected necrosis [47–49, 84, 87]. Percutaneous drainage and/or endoscopic drainage/debridement are minimally invasive alternatives to open surgery [104].
\n
Percutaneous CT-guided catheter drainage:The procedure is performed under local anesthesia. Depending on the size and location of the necrosis, the catheter is placed under CT guidance. Irrigation with saline every several days after insertion [105, 106]. Although percutaneous catheter drainage was used for patients who are too unstable to undergo surgical debridement, approximately one third to one half of patients can be managed with this method alone [106, 107] The only disadvantage of this method is the risk of persistent pancreatico-cutaneous fistula [108].
\n
Endoscopic debridement:It is performed via transgastric or transduedonal [104, 105, 109]. Cystenterostomy is created using wire-guided balloon dilators. Mechanical debridement is performed using snares, baskets, and stone retrieval balloons. Following this, a stent is placed in the cavity. The flow of necrotic contents into the stomach or duodenum is provided. [109]. Minimally invasive operative approaches are preferred to open surgical necrosectomy and given lower morbidity [110].
\n
\n
\n\n
8. Conclusion
\n
Although new guidelines have been published, there are several knowledge gaps identified in the initial management of the AP. Risk stratification of patients with AP is important to ensure the appropriate level of care. Therefore, there is a need to develop fast, easy and practical systems that can be used in the emergency room. There is also a need to define targeted therapies in AP. Future research will enable prevention of relapse, chronicity, and cancer development, improvement of quality of life and reduction of mortality.
\n
\nAcknowledgments
\n
No funding support.
\n
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"acute pancreatitis, complications, diagnosis, emergency, management",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/75048.pdf",chapterXML:"https://mts.intechopen.com/source/xml/75048.xml",downloadPdfUrl:"/chapter/pdf-download/75048",previewPdfUrl:"/chapter/pdf-preview/75048",totalDownloads:36,totalViews:0,totalCrossrefCites:0,dateSubmitted:"October 7th 2020",dateReviewed:"January 13th 2021",datePrePublished:"February 3rd 2021",datePublished:null,dateFinished:"February 2nd 2021",readingETA:"0",abstract:"Acute pancreatitis (AP) is the sudden inflammation of the pancreas, and it may be confined to the pancreas, or more life-threatening, affecting all organs and systems. AP is a common gastrointestinal condition Worldwide and is associated with cost to the health care system. It progresses mildly in 80% of patients and resolves with treatment, but in cases of severe AP, with mortality of around 30% recorded. In this section, we will discuss the first management of the AP in the emergency department. Because this is the period when management decisions can change the course of the disease and the length of stay in the hospital. In the management AP, approaches regarding the utility and timing of antibiotics, the timing and type of nutritional support, endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy approaches are constantly being updated. Treatment is mainly related to the severity of the disease. With early diagnosis and treatment, most of the patients can be discharged, and the development of complications and mortality can be reduced. Therefore, emergency management is important in acute pancreatitis.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/75048",risUrl:"/chapter/ris/75048",signatures:"Rezan Karaali and Firdes Topal",book:{id:"10318",title:"Pancreatitis",subtitle:null,fullTitle:"Pancreatitis",slug:null,publishedDate:null,bookSignature:"Prof. Qiang Yan",coverURL:"https://cdn.intechopen.com/books/images_new/10318.jpg",licenceType:"CC BY 3.0",editedByType:null,editors:[{id:"247970",title:"Prof.",name:"Qiang",middleName:null,surname:"Yan",slug:"qiang-yan",fullName:"Qiang Yan"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_1_2",title:"1.1 Definition and incidence",level:"2"},{id:"sec_2_2",title:"1.2 Etiology",level:"2"},{id:"sec_3_2",title:"1.3 Pathogenesis",level:"2"},{id:"sec_5",title:"2. Clinical features",level:"1"},{id:"sec_6",title:"3. Diagnosis",level:"1"},{id:"sec_6_2",title:"3.1 Laboratory",level:"2"},{id:"sec_7_2",title:"3.2 Imaging",level:"2"},{id:"sec_8_2",title:"3.3 Differential diagnosis",level:"2"},{id:"sec_10",title:"4. Initial management",level:"1"},{id:"sec_11",title:"5. Treatment",level:"1"},{id:"sec_11_2",title:"5.1 Fluid replacement",level:"2"},{id:"sec_12_2",title:"5.2 Pain management",level:"2"},{id:"sec_13_2",title:"5.3 Monitoring",level:"2"},{id:"sec_14_2",title:"5.4 Nutrition",level:"2"},{id:"sec_15_2",title:"5.5 Antibiotics",level:"2"},{id:"sec_17",title:"6. Management of complicatıons",level:"1"},{id:"sec_17_2",title:"6.1 Local complications",level:"2"},{id:"sec_17_3",title:"6.1.1 Acute peripancreatic fluid collection",level:"3"},{id:"sec_18_3",title:"6.1.2 Necrotizing pancreatitis",level:"3"},{id:"sec_18_4",title:"6.1.2.1 Infected necrosis",level:"4"},{id:"sec_19_4",title:"6.1.2.2 Sterile necrosis",level:"4"},{id:"sec_22_2",title:"6.2 Systemic complications",level:"2"},{id:"sec_24",title:"7. Management of predisposing underlying conditions",level:"1"},{id:"sec_24_2",title:"7.1 Nonsurgical management",level:"2"},{id:"sec_25_2",title:"7.2 Surgıcal managment",level:"2"},{id:"sec_27",title:"8. Conclusion",level:"1"},{id:"sec_28",title:"Acknowledgments",level:"1"},{id:"sec_31",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'[\nGarg SK, Sarvepalli S, Campbell JP, Obaitan I, Singh D, Bazerbahi F et al. Incidence, admission rates and predictors and economic burden of adult emergency visits for acute pancreatitis data from the national emergency department sample 2006 to 2012. J Clin Gastroenterol 2019;53(3):220-225. https://doi.org/10.1097/MCG.0000000000001030.\n]'},{id:"B2",body:'[\nBesinger B, Stehman CR. Pancreatitis and Cholecystitis In Tintinalli JE, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM. editors. Tintinalli’s Emergency Medicine A Comprehensive Study Guide 8th ed. Mc Graw-Hill Education; 2016. p: 517-521 ISBN: 978-0-07-180913-9.\n]'},{id:"B3",body:'[\nSingh VK, Bollen TL, Wu BU, et al: An assessment of the severity of interstitial pancreatitis. Clinical Gastroenterol Hepatol 2011;9(12):1098-103. https://doi.org/ 10.1016/j.cgh.2011.08.026\n]'},{id:"B4",body:'[\nLankisch PG, Breuer N, Bruns A, et al: Natural history of acute pancreatitis: a long-term population-based study. Am J Gastroenterol 2009;104(11):2797-805. https://doi.org/10.1038/ajg.2009.405.\n]'},{id:"B5",body:'[\nYadav D, O’Connell M, Papachristou GI: Natural history following the first attack of acute pancreatitis. Am J Gastroenterol 2012;107(7):1096-103. doi: 10.1038/ajg.2012.126.\n]'},{id:"B6",body:'[\nPeery AE, Dellon ES, Lund J et al. Burden of gastrointestinal diseases in the United States 2012 Update. Gastroenterology 2012;143:1179-87. https://doi.org/10.1053/j.gastro.2012.08.002.\n]'},{id:"B7",body:'[\nFagenholz PJ, Fernandez-del Castillo C, Harris NS et al. Direct medical costs of acute pancreatitis hospitalizations in the United States. Pancreas 2007;35:302-7. https://doi.org/ 10.1097/MPA.0b013e3180cac24b.\n]'},{id:"B8",body:'[\n\nGloor B, Müller CA, Worni M, et al. Late mortality in patients with severe acute pancreatitis. Br J Surg 2001; 88:975. https://doi.org/10.1046/j.0007-1323.2001.01813.x\n\n]'},{id:"B9",body:'[\n\nMutinga M, Rosenbluth A, Tenner SM, et al. Does mortality occur early or late in acute pancreatitis? Int J Pancreatol 2000;28:91. https://doi.org/ 10.1385/IJGC:28:2:091.\n]'},{id:"B10",body:'[\nCheon YK, Cho KB, Watkins JL, et al: Frequency and severity of post-ERCP pancreatitis correlated with extent of pancreatic ductal opacification. Gastrointest Endosc 2007;65(3):385-93. https://doi.org/ 10.1016/j.gie.2006.10.021.\n]'},{id:"B11",body:'[\nGullo I, Migliori M, Olah A et al. Acute pancreatitis in five European countries: etiology and mortality. 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Ann Surg 2007;245(5):674-83. https://doi.org/10.1097/01.sla.0000250414.09255.84.\n]'},{id:"B95",body:'[\nDas S, Singh PP, Phillips A, et al. Newly diagnosed diabetes mellitus after acute pancreatitis: A systematic review and meta-analysis. Gut 2014;63(5):818-31. https://doi.org/10.1136/gutjnl-2013-305062.\n]'},{id:"B96",body:'[\nSchepers NJ, Hallensleben NDL, Besselink MG, et al. Urgent endoscopic retrograde cholangiopancreatography with sphincterotomy versus conservative treatment in predicted severe acute gallstone pancreatitis (APEC): a multicentre randomised controlled trial. Lancet 202018;396(10245):167-176. https://doi.org/10.1016/S0140-6736(20)30539-0.\n]'},{id:"B97",body:'[\nTse F, Yuan Y. Early routine endoscopic retrograde cholangiopancreatography strategy versus early conservative management strategy in acute gallstone pancreatitis. Cochrane Database Syst Rev 2012;(5):CD009779. https://doi.org/ 10.1002/14651858.CD009779.pub2.\n]'},{id:"B98",body:'[\nMoretti A, Papi C, Aratari A et al. Is early endoscopic retrograde\ncholangiopancreatography useful in the management of acute biliary\npancreatitis? A meta-analysis of randomized controlled trials. Dig Liver\nDis2008;40(5):379-385. https://doi.org/10.1016/j.dld.2007.12.001\n\n]'},{id:"B99",body:'[\nArguedas MR, Dupont AW, Wilcox CM. Where do ERCP, endoscopic\nultrasound, magnetic resonance cholangiopancreatography, and intraoperative cholangiography ft in the management of acute biliary pancreatitis? A decision analysis model. Am J Gastroenterol 2001;96(10):2892-2899. https://doi.org/10.1016/S0002-9270(01)02806-4\n\n]'},{id:"B100",body:'[\nLarson SD, Nealson WH, Evers BM. Management of gallstone pancreatitis. Adv Surg 2006;40:265-84. https://doi.org/10.1016/j.yasu.2006.06.005.\n]'},{id:"B101",body:'[\n\nAboulian A, Chan T, Yaghoubian A, et al. Early cholecystectomy safely decreases hospital stay in patients with mild gallstone pancreatitis: a randomized prospective study. Ann Surg 2010; 251:615. 2010;251(4):615-9. https://doi.org/ 10.1097/SLA.0b013e3181c38f1f.\n]'},{id:"B102",body:'[\nFalor AE, de Virgilio C, Stabile BE, et al. Early laparoscopic cholecystectomy for mild\ngallstone pancreatitis. Arch Surg 2012;147(11):1031-5. https://doi.org/10.1001/archsurg.2012.1473.\n]'},{id:"B103",body:'[\nTrna J, Vege SS, Pribramska V, et al: Lack of significant liver enzyme elevation andgallstones and/or sludge on ultrasound on day 1 of acute pancreatitis isassociatedwithrecurrence after cholecystectomy: a population-based study. Surgery 2012;151(2):199-205. https://doi.org/10.1016/j.surg.2011.07.017.\n]'},{id:"B104",body:'[\n\nNavaneethan U, Vege SS, Chari ST, Baron TH. Minimally invasive techniques in pancreatic necrosis. Pancreas 2009;38(8):867-75. https://doi.org/ 10.1097/MPA.0b013e3181b3b237.\n]'},{id:"B105",body:'[\n\nPapachristou GI, Takahashi N, Chahal P, et al. Peroral endoscopic drainage/debridement of walled-off pancreatic necrosis. Ann Surg 2007; 2007;245(6):943-51. https://doi.org/10.1097/01.sla.0000254366.19366.69.\n]'},{id:"B106",body:'[\n\nTraverso LW, Kozarek RA. Pancreatic necrosectomy: definitions and technique. J Gastrointest Surg 2005;9(3):436-9. https://doi.org/ 10.1016/j.gassur.2004.05.013.\n]'},{id:"B107",body:'[\n\nMortelé KJ, Girshman J, Szejnfeld D, et al. CT-guided percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J Roentgenol 2009;192(1):110-6. https://doi.org/10.2214/AJR.08.1116.\n]'},{id:"B108",body:'[\n\nGluck M, Ross A, Irani S, et al. Dual modality drainage for symptomatic walled-off pancreatic necrosis reduces length of hospitalization, radiological procedures, and number of endoscopies compared to standard percutaneous drainage. J Gastrointest Surg 2012;16(2):248-56; discussion 256-7. https://doi.org/ 10.1007/s11605-011-1759-4.\n]'},{id:"B109",body:'[\n\nBradley EL 3rd, Howard TJ, van Sonnenberg E, Fotoohi M. Intervention in necrotizing pancreatitis: an evidence-based review of surgical and percutaneous alternatives. J Gastrointest Surg 2008;12(4):634-9. https://doi.org/ 10.1007/s11605-007-0445-z.\n]'},{id:"B110",body:'[\n\nBaronTH, DiMaio CJ , Wang\ufeff AY, et al. American Gastroenterological Association Clinical Practice Update: Management of Pancreatic Necrosis Gastroenterology 2020;158(1):67-75.e1. https://doi.org/ 10.1053/j.gastro.2019.07.064.\n]'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Rezan Karaali",address:"rezantahtaci@hotmail.com",affiliation:'- Emergency Department, Izmir Katip Celebi University Atatürk Training and Research Hospital, Turkey
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In recent years, more than a dozen shafts, some almost 700 m deep, have been sunk in Poland using various methods of water hazard elimination. The vast majority of shafts that pass through aquifer formations have been sunk using artificial rock freezing, waterproof tubing, and concrete lining. Generally, this system has proven to be very effective. However, there have been cases of complications during sinking, including occasional flooding. This paper presents two cases of highly problematic flooding in shaft sunk using the freezing method, both leading to considerable construction delays and a significant increase in shaft sinking costs. The first case involved water inflow into the bottom section of the R-XI shaft at KGHM with rocks near the melting point of ice. In the other case, problems occurred passing through an Albian layer in the S. 1.3 shaft sunk for the Lubelski Węgiel Bogdanka S.A. mining corporation, where the freezing process was carried out while it was necessary to heat the rocks in the upper part of the shaft to protect the final lining from damage.",signatures:"Piotr Czaja, Paweł Kamiński and Artur Dyczko",authors:[{id:"318919",title:"Ph.D.",name:"Paweł",surname:"Kamiński",fullName:"Paweł Kamiński",slug:"pawel-kaminski",email:"pkamin@agh.edu.pl"},{id:"323409",title:"Prof.",name:"Piotr",surname:"Czaja",fullName:"Piotr Czaja",slug:"piotr-czaja",email:"czajap@agh.edu.pl"},{id:"323410",title:"Dr.",name:"Artur",surname:"Dyczko",fullName:"Artur Dyczko",slug:"artur-dyczko",email:"arturdyczko@min-pan.krakow.pl"}],book:{title:"Mining Techniques",slug:"mining-techniques-past-present-and-future",productType:{id:"1",title:"Edited Volume"}}}],collaborators:[{id:"200229",title:"Dr.",name:"Yıldırım İsmail",surname:"Tosun",slug:"yildirim-ismail-tosun",fullName:"Yıldırım İsmail Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/200229/images/4972_n.jpg",biography:"Asst.Prof Dr.Yıldırım İsmail Tosun\n\nDr. Tosun became a Member of Mining Eng. 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Dept. of Şırnak University in Şırnak, Turkey. \nDr. Tosun deals with coal processing, utilization of coal, iron ores, processing iron industrial wastes, environmental waste processes, clean energy technologies, utilization fly ash and stack gases, nano technology for industrial production.",institutionString:null,institution:{name:"Şırnak University",institutionURL:null,country:{name:"Turkey"}}},{id:"243537",title:"Prof.",name:"Lizete",surname:"Stumpf",slug:"lizete-stumpf",fullName:"Lizete Stumpf",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Universidade Federal de Pelotas",institutionURL:null,country:{name:"Brazil"}}},{id:"250106",title:"Prof.",name:"Luiz Fernando Spinelli",surname:"Pinto",slug:"luiz-fernando-spinelli-pinto",fullName:"Luiz Fernando Spinelli Pinto",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Universidade Federal de Pelotas",institutionURL:null,country:{name:"Brazil"}}},{id:"312528",title:"Mr.",name:"Xiaohan",surname:"Yang",slug:"xiaohan-yang",fullName:"Xiaohan Yang",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"University of Wollongong",institutionURL:null,country:{name:"Australia"}}},{id:"312567",title:"Prof.",name:"Vladimír",surname:"Sedlák",slug:"vladimir-sedlak",fullName:"Vladimír Sedlák",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"313182",title:"Prof.",name:"Rami",surname:"Alrawashdeh",slug:"rami-alrawashdeh",fullName:"Rami Alrawashdeh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"Al-Hussein Bin Talal University",institutionURL:null,country:{name:"Jordan"}}},{id:"313522",title:"Dr.",name:"Awwad",surname:"Altiti",slug:"awwad-altiti",fullName:"Awwad Altiti",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Al-Hussein Bin Talal University",institutionURL:null,country:{name:"Jordan"}}},{id:"313523",title:"Prof.",name:"Hani",surname:"Alnawafleh",slug:"hani-alnawafleh",fullName:"Hani Alnawafleh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Al-Hussein Bin Talal University",institutionURL:null,country:{name:"Jordan"}}},{id:"318919",title:"Ph.D.",name:"Paweł",surname:"Kamiński",slug:"pawel-kaminski",fullName:"Paweł Kamiński",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/no_image.jpg",biography:null,institutionString:null,institution:{name:"AGH University of Science and Technology",institutionURL:null,country:{name:"Poland"}}},{id:"323410",title:"Dr.",name:"Artur",surname:"Dyczko",slug:"artur-dyczko",fullName:"Artur Dyczko",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Mineral and Energy Economy Research Institute of the Polish Academy of Sciences",institutionURL:null,country:{name:"Poland"}}}]},generic:{page:{slug:"open-access-funding-funders-list",title:"List of Funders by Country",intro:"If your research is financed through any of the below-mentioned funders, please consult their Open Access policies or grant ‘terms and conditions’ to explore ways to cover your publication costs (also accessible by clicking on the link in their title).
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