Incidence of postoperative hemorrhage in gynecological surgery.*
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"1826",leadTitle:null,fullTitle:"Physical Therapy Perspectives in the 21st Century - Challenges and Possibilities",title:"Physical Therapy Perspectives in the 21st Century",subtitle:"Challenges and Possibilities",reviewType:"peer-reviewed",abstract:"This book contains new information on physical therapy research and clinical approaches that are being undertaken into numerous medical conditions; biomechanical and musculoskeletal conditions as well as the effects of psychological factors, body awareness and relaxation techniques; specific and specialist exercises for the treatment of scoliosis and spinal deformities in infants and adolescents; new thermal agents are being introduced and different types of physical therapy interventions are being introduced for the elderly both in the home and clinical setting. 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In the near future, Dr. Saltikov hopes to further her research into the perspectives and views of scoliosis patients and healthcare professionals who work with them to help scoliosis patients manage their own conditions.",institutionString:"Teesside University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"Teesside University",institutionURL:null,country:{name:"United Kingdom"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"103697",title:"Dr.",name:"Berta",middleName:null,surname:"Paz-Lourido",slug:"berta-paz-lourido",fullName:"Berta Paz-Lourido",profilePictureURL:"https://mts.intechopen.com/storage/users/103697/images/5375_n.jpg",biography:"Dr Berta Paz Lourido qualified as Physical Therapist in Spain in 1995. She is also Bachelor in Pedagogy, Post-graduated Degree in Manual Therapy, Post-graduated Degree in Cooperation and International Development. 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Or
In metallurgy, heavy metals are defined on the basis of densities, and in Physics, it is defined on the basis of atomic number while in chemistry on the basis of chemical behaviour. In biochemistry, heavy metals are defined whether it is Lewis’s acid (electron pair acceptor) performance of the ions in the aqueous solutions [1].
Some examples of heavy metals are iron (Fe), copper (Cu), tin (Sn), and other elements metals such as silver (Ag), gold (Au), and platinum which are precious; these were the earliest known metals. Other heavy metals are moreover essential nutrient, for example, iron, cobalt, and zinc some comparatively less dangerous such as ruthenium, silver, and indium; but can be toxic in the larger amounts or in their definite form [2]. Then a number of the certain heavy metals which are such as cadmium, mercury, and lead are highly poisonous.
Heavy metals contamination can be observed in soil, water (rivers), air (atmosphere), etc. The composition and physical properties and chemical structure of each of the heavy metals are different. No doubt that the heavy metals are toxic as well as hazardous. They have harmful effects. Heavy metals are needed to be handled with care. Some heavy metals tend to be less reactive, whereas some are very reactive. These are thought to be toxic or highly destructive to the environment. Heavy metals mortify air, water, and soil quality and consequently cause health issues in plants, animals, people, etc. Some toxic elements are also regarded as beneficial, but only in small quantities for human health. These elements are vanadium, manganese, cupper, iron, zinc, strontium, selenium, molybdenum etc. The deficiency of these metals is harmful and may increase susceptibility to heavy metal poisoning. Chronic level ingestion of heavy metals toxic or heavy metals has dangerous effects on human body, and the impacts are observable only after several years of exposure [2].
According to their toxicity to living organisms, the heavy metals are arranged in the following order: Hg > Cu > Zn > Ni > Pb > Cd > Cr > Sn > Fe > Mn > Al [3].
Heavy metals are less reactive than the other lighter metals.
Heavy metals are relatively scarce in the Earth crust, means concentration of heavy metals are less.
Heavy metals have usually higher density than the light metals.
These metals are quite hard whereas soft metals are easy and tend to cut easily.
Thermal expansively of heavy metals is lower than the light metals.
Melting point of heavy metals varies from low to high whereas light metals have low melting point.
Tensile strength of heavy metals is mostly higher.
Heavy metals are less abundant in earth crust.
These are extremely insoluble in sulphides.
These are generally insoluble in hydroxides.
Heavy metals form coloured solutions in water.
Complexes of heavy metals are mostly coloured.
Heavy metals are the micronutrients, required in small concentrations whereas light metals are the macronutrients required in larger concentrations.
If heavy metals are toxic, they are useful or beneficial also. Its regular uses depend on the general characteristics of heavy metals such as electrical conductivity and reflectivity or some other general characteristics such as its density, its strength, and its durability. Other uses depend on the quality of the particular element, such as their biological role as nutrients or poisons or some other specific atomic properties. Some examples of the atomic properties include partially filled d or f orbital that enables the formation of coloured complexes. Other uses are in sport, mechanical engineering, military ordnance, and nuclear science, which take the advantage of their relatively high density. In mechanical engineering heavy metals are used as ballast in boats, aeroplanes, and other motor vehicles or in balance weights on wheels and gyroscope and propellers and centrifugal clutches, in situation requiring maximum weight in minimum space. In military ordnance, tungsten and uranium are used in armour plating and armour piercing projectiles, as well as in nuclear weapons to increase the efficiency. Also, denser materials absorbs more radioactive emissions than the lighter ones, so heavy metals are useful for radiation shielding and to focus radiation beams in linear accelerators and radiotherapy applications [3].
Soil is an essential constituent of an ecosystem. Soil has the absorbing and emitting capabilities, which is vulnerable to contamination by a wide variety of sources. The continuous development of the urbanisation leads to constructions, agriculture farming, cemetery, and traffic emission. Soil, where we live, where we do our agriculture, is not safe from these metals. Heavy metals reached into the soils as from the parent materials (lithosphere) and from different human activities. There are some factors which affects the presence and division of the these metals in the earth; they are the composition of the parent rocks, the extent of weathering and the chemical, physical and, biological features of the soil, and it also depends on the climatic conditions. Human activities are the major cause and are gradually increasing day by day which results in the deterioration of environment [4].
These metals in soil reach through many sources which include atmospheric deposition, improper disposal of the industrial solid and liquid waste, mining activities, sewage, and using of pesticide and fertilisers. These metals in the environment are released mainly from the gas, dirt, and dust produced by the transportation, energy, metallurgy, and during building. Heavy metal basically reaches into the air in the form of aerosol and finally deposit in the soil through natural sedimentation and rainfall process.
Automobile transport causes some serious heavy metal contamination. Also, heavy metals are brought into soil by irrigative sewage, sanitary sewage, chemical waste water, and industrial mining. Industries release a lot of harmful chemical which are directly released to river or an open area. Also, people nowadays use a lot of fertilisers, pesticides, for agricultural purposes. The long-term extreme application has resulted in the degradation of the soil. Heavy metals are the largely reported pollutant inside the fertilisers. Phosphoric fertilisers generally contain high amount of toxic heavy metals, whereas nitrogen and potash fertilisers contain considerably low amount of heavy metals.
An increased concentration of certain elements is found particularly in vegetables grown in the nearby of industrial plants and busy roads, as well as in crops exposed to municipal and agricultural wastewater [4]. This may result in disrupted balance of these elements, and in turn significantly affect their bioavailability and interaction with other food ingredients as well as other metals. Different branches of industry as well as road traffic have a significant impact on the environmental pollution with the heavy metals such as the following chrome from metallurgical, paint, and tanning industries, nickel mainly from the steel industries and burning of coal and liquid fuel, cadmium from metal smelters, while along reads another sources of contamination with this element may be grease used in motor vehicles and lead from paints industries, metallurgical, and glass industries. The main sources of lead contamination in soils, air, and plants are the exhaust gases releasing from [4].
Microbial activity and the enzymatic activity gradually decrease because of heavy metals. Microbial activities are inhibited. Different metals in soil have different effects on it. Low concentration of heavy metals indicates high microbial activity and growth and thus high microbial biomass and high quantity of the metals in the soil indicates very low microbial growth and thus results in low microbial biomass. A significant role in process of organic matter decomposition and nutrient cycling are played by the enzymes. So due to excess heavy metals in soil reduces its enzymatic activity. These degrade the quality and quantity of the soil which are not good for fertilisation. The soil loses its fertility and it is completely degraded. So, the degraded soil is of no use; it will only be considered as barren land.
Heavy metals in soil mean heavy metals in plants too. The prime reaction of plants is production of reactive oxygen species (ROS) on the exposure to high level of heavy metals. Through soil it reaches the plants and water. In water, heavy metals reach not only through water but from the environment too. The aerosol particles are present in the atmosphere; these reach the water, soil, from soil to plants and water. These all are related, and all are affected by one another. And high concentration of heavy metals in soil means high concentrations in environment and the surrounding which is a global threat. The heavy metals they are not easy to remove but they get incorporated easily. Exposure to heavy metals is toxic is a serious problem the motor vehicles [5].
The risk of heavy metal presence in vegetables cultivated near old industrial areas is significant. Industrial and municipal sewage is also an important source of heavy metals. Also, wastewater irrigation is an important approach for irrigation in agriculture which is treated biologically. Wastewater irrigation has changed physical and chemical properties of the soil and led to the heavy metals’ uptake by plants, mostly vegetables as vegetables are grown mostly. And vegetables grown in such soils has high amount of heavy metals accumulated in them. Also, concentration of heavy metals in the soil also depends on amount of fertilisers and pesticides being used in the soil. The higher we use fertilisers and pesticides in the soil for the plants to grow better and to protect them from the insects and the weeds the higher the chemicals will reach the soil and will be absorbed by the plants or vegetable being grown in that particular soil. So, the amount of fertilisers and pesticides doses also influence the amount of heavy metals in the soil. Also, some other sources of heavy metals are used as plant protectors’ products. The dynamics of the heavy metals in the soil and their uptake by plants depend on the soil properties, which play a key role in the bioavailability of these metals. The level and amounts of these heavy metals accumulation in plants depends on among others, soil types, pH, humidity, and micronutrients content as well as the time of crop harvesting. Among these, the acidic pH is considered to be the most important factor influencing the increased in absorption of heavy metals by vegetation. Whereas in alkaline soils, a risk of heavy metal leaching and their bioavailability to plants are lower and the presence of organic matter can inhibit metals uptake from the soil solution. By changing these following soil properties that determine metal solubility in the soil, heavy metals are transferred in its solid phase. Metal mobility and bioavailability may be influenced by addition of organic and inorganic matter [6].
A basic treatment restricting metal mobility is soil de-acidification by liming. Some studies revealed that phosphate stabilises Pb by reducing its availability in the soil. But this effect depends on the soil type. The addition of phosphate increases soil permeability, thus contributing to arsenic migration deeper into soil profile and entering groundwater. Adding materials which are rich in organic compounds such as compost, tree bark, sawdust, or granulated or powdered lignite, are generally recommended to reduce mortality and bioavailability of metals. Some studies also show that regular addition of organic matter in large quantities may inhibit metal uptake from the soil solution. Also, organic matter stabilises trace elements in the soil, and addition of compost may lead to increase in accumulation of metals in cultivated plants. Other studies show that lead and arsenic levels in vegetables were strongly correlated with a total content of these meals in the soil, and not with organic matter content in the soil or a level of compost addition. Some researchers also proved that the soil age also plays a crucial role in modulation of metal bioavailability in plants. Higher content of heavy metals is found in old flat wetlands due to long term discharges of municipal and industrial wastewater. Some analysis shows that bed rock is a source of Fe and Mn, while copper, zinc, cadmium, chromium, nickel, and lead are of anthropogenic origin. After comparing wet ditches and reclaimed wetlands, levels of some heavy metals such as lead, cadmium, and zinc are found in excess or in higher amount in wetlands because the wetlands are richer in mangrove soils. Apart from the soil factors which influence the presence and concentration of heavy metals in soil absorption of metals differ in different types of soils and plants. An important variation in metal concentrations was also seen being depending on the location in plant tissue, species also on the varieties of the same species. Such as concentrations of nickel, chromium, and cadmium were highest in plants roots, while leaves have highest level of lead accumulation. There are differences in the concentrations of heavy metals in edible parts of different plants and vegetables and concentration also varies. Cadmium and zinc are accumulated to a higher extent in lettuce and spinach, and lead was highly accumulated in lettuce and onions. Also, vegetables of the same species accumulated different amount and concentration of the heavy metals depending on the cultivar [6].
Heavy metals concentration is higher than in potato, carrot, tomato, kohlrabi, and green bean seeds. After some studies, it is concluded that edible parts have highest heavy metal concentration in leafy vegetables, lower in root vegetables, and minimum or lowest in fruit vegetables. Root vegetables in plants are particularly susceptible to cadmium accumulation. Uptake of cadmium is extremely easy, both by the root and the leaves system, generally in proportion to its concentration in the environment, despite of the soil properties. However, acidic soil is considered to be most important factor influencing its increased phyto assimilation. Cadmium is characterised by a high bioaccumulation index up to 10 and its content in plants is commonly directly proportional to its content in the soil [7].
Cultivation of vegetables in regions is characterised by high density of the industrial and factorial, or nearby the busy roads like has traffic 24 hours result in significant contamination of crops with heavy metals. On the other hands, irrigation of agricultural fields with the wastewater results in the considerable contamination with the heavy metals and thereby to the accumulation of metals in vegetables cultured there. It is also important to maintain rational approach to fertilising and the use of plants protection products because they also increase accumulation of these metals in plants. They should be used in a reasonable amount so that could be beneficial for the plants or vegetables as well as the soil. Also if the concentration of heavy metals in the soil and the plants are in limit, they could be taken care off or if they reach into the body of any human being through plants or vegetables; they are in little amount or they can be cured but if once the concentration of heavy metals exceeds its reasonable limit, they then become very difficult to be cure and also causes difficulties in identifying. Leafy vegetables and root vegetables have the metals that have the greatest ability to accumulate the heavy metals absorb from the soil. Therefore, they should not be grown in such types of soil or the soil should be experimented or it should be examined properly before growing of the vegetables. Or they should not be grown at all. Once the plants or animals or human being are contaminated with the heavy metals, it is very difficult to cure them. Some causes damage to the internal organs like damage to the respiratory system, cardiovascular system, excretory system, neuromuscular system, and some other causes damage to the functioning of brain activity, heart, lungs, and kidney activity. In extreme cases, it can lead to paralysis or even death. So, one must take care of themselves. As soil is not the only one factor or way through which heavy metals reach the human body in fact there are many other ways such as through water, through air, and many other ways [7].
Soil contaminated with zinc due to fertilisers, urban compost, emission from municipal waste incinerators, and other anthropogenic activities. Also, zinc is as essential nutrient for living organisms while cadmium is non-essential and potentially toxic for higher plants, animals, and also for the humans. Excess concentration of zinc leads to phytotoxicity, limits in its growth of both roots and shoots, senescence, chlorosis in younger leaves, and later extends to older leaves. Copper is a micronutrient for plants and its role is in CO2 assimilation and ATP synthesis. It reaches to soil through industrial activities and human activities like mining and smelting of Cu containing ores. Excess of Cu in soil leads to growth of plants and its reduction. Mercury reaches the soil mainly in the solid phase through adsorption. It accumulates in the higher aquatic plants. It induces physiological disorder. Chromium is heavy metal and is a serious threat for the environment contamination of soil. Its toxicity is seen in many plants. Its toxicity leads to alterations in the growth of roots, stems, and leaves, deleterious effects on the plants physiological process such as photosynthesis, water relations, and mineral nutrition. Cobalt, this naturally occurs in the earth crust as cobaltite, erythrite, and smaltite. Excess of Ni2+ in soil causes various physiological alterations and diverse toxicity symptoms such as chlorosis and necrosis according to different species, shows impairment of nutrient balance, and resulted in disorder of cell membrane functions. Other symptoms are changes in water balance, etc. Lead accumulations are gradually decreasing in the plants and the nearby highway and roads as when the law came up with using of lead-free petrol. Properties of soil include its texture, capability to absorb water, Ph value, and ion exchange capacity. Lead, mercury, and chromium are usually tightly fixed in soils, and cadmium and zinc are readily absorbed by the plant roots. The heavy metals are absorbed by the plants through soil. These metals are absorbed by plants roots and get accumulated in the softer tissue of plants. These metals are not metabolised by the tissues, so it gets accumulated. From plants, it reaches human body. Human being consumes the plants containing the heavy metals, and the metabolization in humans too is not proper and thus it gets accumulated there. This further becomes toxic for the human and they face the consequences in form of the diseases.
Plants uptake the heavy metals that are present in soluble components in soil solution or those which can be easily solubilised. Some heavy metals are essential for the plants for their growth and upkeep, but in excess amount, these metals become toxic for the plants and even for the humans too. Plants growing in the soils containing heavy metals show reduction in growth, yield, and performance too. Growth reduction because of changes in physiological and biological process in plants growing on heavy metals polluted soil is seen. Continued growth in the size of plants leads to decrease in the yields which eventually lead to food insecurity. Soil properties affect metal availability in many ways. Like pH is the main factor affecting metal availability in soil. Other factors like density and type of charge in soil colloids the degree of complexation with ligands and the soils relative surface area.
Heavy metals reach the soil through the air\\atmosphere and absorb by the roots of the plants and get accumulated in the softer tissues of plants. Plants experience oxidative stress on exposure to the heavy metal that finally leads to the cellular damage. Also, plants accumulate metal ions that destroy the cellular ionic homeostasis. To overcome the hazardous effects of heavy metal exposure and their accumulation, plants have developed detoxification method. These mechanisms are mainly based on chelation and sub cellular compartmentalisation [8].
Heavy metals reach human body through intake of plants containing it. Heavy metals turn out to be venomous, when not metabolised via the body and thus they accumulate or gather in the softer tissues. Chronic level ingestion of heavy metals toxic or heavy metals has hazardous effects on human body, and the impacts are noticeable only after several years of exposure. Heavy metals enter plants, animals, and human tissue through air (inhalation), diet (humans consuming both plants and animals or animal consuming plants and in turn humans consuming animals). These metals not only cause hazardous effects to humans only but are harmful for soil too. Toxic metals are a threat for both terrestrial and aquatic ecosystem. Heavy metals contaminate water bodies, soils, and sediments, after releasing from both natural or anthropogenic or human activities. Heavy metals are importunate, so they accumulate or deposit in the ground waters. Contamination also occurs when these metals are released into air through volcanic activities and from different industrial emission which ultimately return to the land.
Cadmium toxicity has been identified in the liver, brain, kidney, lungs, placenta, and bones. It causes muscular weakness, vomiting, abdominal cramps, and nausea. In Japan, Itai-Itai diseases brought dangers of cadmium into attention. Zinc is considered nontoxic, however, if taken in excess amount causes vomiting, impairment of growth, diarrhoea, bloody urine, reproductive issues, liver and kidney failure and anaemia. Cupper, exposure to high levels causes hepatic and renal damage, severe gastrointestinal irritation, skin irritation, etc. Heavy metals are detected in soil with some specific instruments like Atomic Absorption Spectroscopy (AAS), Inductively Coupled Plasma (ICP), Inductively Coupled Plasma-Mass Spectroscopy (ICP-MS), and X-ray Fluorescence and Spectroscopy are used. Among all these instruments, atomic absorption spectroscopy gives the precise quantitative determination. The research basically focuses on the study to find out the presence of heavy metal, and quantity or amount of heavy metals or what the heavy metals are [9].
Soil is like the fingerprint because as there are different patterns of fingerprint, the same way soil has its unique characteristics and properties that serve as its identification. Soils can be used as a profitable proof to establish the link between the suspect and the crime scene. Soil is a common blend of chemical, biological, and physical properties. If any heavy metals detected in soil, then it is used to geo-tag any particular location. Atomic Absorption Spectroscopy (AAS) is an apparatus for identification of the metals from the sample (soil, blood, serum, etc.) While investigating a various crimes, soils from different regions like sites of rivers, urban regions, industrial regions, and institutional regions etc. are used. Suppose we found a soil sample from the crime scene, it was sent further to laboratories tor its analysis. Whatever the result is like present of any heavy metals or ay normal or general metals will help to geo tag the location. By tallying both the question soil samples and the reference soil samples conclusions can be drawn [10, 11].
Water pollution includes contamination in liquid forms. Water pollution is of both marine pollution and river pollution. Industrial, factorial and consumer waste, fertilisers and pesticides, and acid rain which fall in the soils and finally reache these heavy metals into streams, rivers, lakes, and ground water. Heavy metals tend to bio accumulate and thus they are dangerous. It is well said that because of water, life exists in biosphere. And water is a universal solvent. Various inorganic chemicals and organic chemicals are dissolved in water, and the environment impurities are also dissolved in water. Both aquatic ecosystems be it fresh water or marine all are affected because of pollution. Water contamination is a serious environmental issue and which has direct impact on animals, plants, and human beings. Heavy metals are tremendously lethal to aquatic life even at small concentrations. Histopathological modification in the tissues of aquatic organisms such as fish, insects, and other aquatic life are seen because of the toxicity of the water. As these metals do not decompose, they accumulate in the soft tissues of the aquatic animals as well as in plants too. Contamination by heavy metals from many other various sources is major threat to the water and its organism. One source is effluents which released from the factories and industries [12].
Environmental pollution from dangerous metals and minerals can appear from natural as well as human activities sources. Natural sources such as leakage from rocks into water, volcanic action, forest fires, etc. With quick industrialisation and changing in lifestyle supply of environment pollution has increased. Chromium through mining and industrial coolants; lead through lead acid batteries, E-wastes, and bangle industry; mercury through fluorescent lamps, hospital waste, and electrical appliances; arsenic through natural process, fuel, and thermal power plants; copper and nickel through mining and electroplating; cadmium is released through waste batteries, e-waste, paints sludge, incinerators, and fuel combustions; zinc through smelting and electroplating [13].
It releases toxic substances which are harmful for the aquatic life. Heavy metals tend to bio accumulate and thus they are dangerous for all the living organisms. Bio accumulates mean to boost concentration of any chemical in any living organism eventually. Increase in water pollution leads to release of toxic substance, pathogenic germs which requires more oxygen to decompose, for radioactivity, etc. Example: Eutrophication is a condition in which lack of oxygen in a water body is seen which is caused by unnecessary algae growth since it has enrichments of pollutants. It kills all the aquatic plants, small fishes (which in turn feds on the aquatic plants), large fishes (which feeds on the small fishes), and the human beings. And finally degrade the environment. The quality of water everywhere is degrading day by day. It is becoming less suitable for any work, and for drinking purpose, it is completely unfit. But still some people have no choice, they filter the water and then they consume it. And the animals, they have no idea whether is suitable for drinking purpose or not, and after grazing, they come to the river, ponds, or small lakes to drink water. Along with the water, they take the toxic metals in them. And slowly this toxic metal affects their system and makes them ill and finally leads to their death [13].
Animals graze on the plants which are contaminated with the heavy metals and then gulp the same water. The marine lives that breed in heavy metals contaminated water; both such metals form a mass in their tissue and milk. In short, every single living organism is dependent on each other for their survival. And when humans consume these plants and animals, they eat the toxic substances along with them. Specific metals have specific toxicity. And toxicity also depends on the concentration of the metals consumed. Cadmium is poisonous at a low level [10]. In humans, it leads to renal dysfunction, bone defects, osteoporosis, increases blood pressure, and myocardial dysfunctions. Lead is very harmful and mostly captivated by ingestion with food and water and through inhalation. One of the serious effects is teratogenic effect. Poisoning of lead also causes cessation of the production of haemoglobin, kidney dysfunction, and unceasing damage to central nervous system. Zinc has same effects as lead. Its excessive concentration causes improper growth and reproduction, diarrhoea, bloody urine, vomiting, kidney failure, and anaemia. Mercury is toxic as it causes spontaneous abortion, gastric intestinal disorder, etc. Many health-related issues occur because of protein deficiency including reduction of chondroblastic or osteoblastic activity. In this condition, normal growth and formation of bones and cartilage gets manipulated, which finally results in irreparable body deformities in the growing child and in adults. Fishes are an important and staple food in the coastal regions of many parts of India. Hence, it is very important to know the correct amount of heavy metals present in the coastal amounts to protest both the aquatic and terrestrial life. Terrestrial life suffers damage to liver, kidney, heart, and body joints. The liver and kidney produce metallothioneins causing toxicity which is very hazardous for the human life [14]. In Figure 1, there is presentation of bioaccumulation and biomagnification.
Bioaccumulation and bio magnification [
Heavy metals are continuously being released in aquatic environment from natural and anthropogenic activities such as industrial, factories and domestic sewage discharges, mining, farming, electronic waste, anthropic accidents, etc., and metals are easily dissolved in water and are subsequently absorbed by the aquatic organisms such as small and large fishes and invertebrate, including a wide range of biological effects from being important or essential to being lethal. In spite of the fact that some metals are essential at low concentration, at higher concentration, they could be inducing toxic and lethargic effects in organisms, disturbing its growth, metabolism or reproduction [16].
Micronutrients are such as copper, zinc, ferric, manganese, cobalt, molybdenum, chromium and selenium, and macronutrients such as calcium, magnesium, sodium, phosphorous and sulphur. Apart from the essential elements, the non-essential elements such as lead, cadmium, nickel, arsenic, and mercury show its toxic effects at a very low concentration. High levels of metals in the surrounding could be hazardous for the functioning of the natural ecosystem and human health, due to their toxic effects, long persistence, bio accumulative properties, and bio magnifications in the food chain. Due to the possibility that the aquatic biota can accumulate various chemicals, are used to measure the effects of metals on aquatic organism as an essential indicator of water quality [17].
The organic chemical can be metabolised by the organisms easily, but the majority of metals cannot be easily metabolised because of its non-biodegradability. Once they get introduced in the aquatic environment, the metals get redistributed throughout the water column, gets accumulated in sediments, or consumed by biota. Metal residues in contaminated habitats have the ability to bio accumulate in aquatic environment like aquatic flora and fauna, which in turn gets consumed by the human beings or animals as food and enters the human food chain and finally results into health problems. Metal accumulation in sediments occurs through the process of precipitation of certain compounds. Some factors that control the bioavailability of metals are such as size or age, sediments, suspended matter and metal speciation, physical and chemical factors such as temperature, salinity, pH, ionic strength, concentration of the dissolved organic carbon, etc. [18].
The metals are up taken from the permeable epidermis if metals are in dissolved forms or through food ingestion if metals are in particulate forms. The ingestion uptake mainly depends on many factors. The suspended solid particles accumulate the insoluble metal compounds but under certain conditions, the metals reach the interstitial water being dissolved.
Toxic metals are a threat for both terrestrial and aquatic ecosystem. Heavy metals contaminate water bodies, air, soils, and sediments, after releasing from natural or anthropogenic or human activities. Heavy metals are unrelenting or indestructible, so they both accumulate or deposit in the ground waters. Heavy metals reach water through the industrial, factorial, and consumer waste, through fertilisers and pesticides and also the from acid rain falling down in the earth which releases the heavy metals in the lakes, rivers, streams, and ground water. The release of factories and industrial effluents or waste is the chief source of water pollution as they are released directly into the rivers without being treated, which is a major threat to the aquatic life. Pollution of the rivers and water is a global problem because of its perseverance, bioaccumulation, and biomagnifications in the food chains and toxicity of the heavy metals. Atmosphere pollution is mainly in the gaseous state of the heavy metals and dust emitted by the transport, energy, metallurgy, and during building. Heavy metal principally goes in the atmosphere in the form of atomizer and gets deposited in the soil in the course of the natural sedimentation and rainfall process. Automobile transport causes some serious heavy metal contamination. Also, heavy metal is brought into soil by irrigative sewage, sanitary sewage, chemical wastewater, and industrial mining. Industries release a lot of harmful chemical which are directly released to river or an open area. Also, people nowadays use a lot of fertilisers and pesticides, for agricultural purposes. Factories and industrial outlets in the form of smoke, automobiles emissions and release of variety of compounds and chemical are followed by increase by man’s some unwanted pollutants, which are serious threats and problem risking for the environment and for the man himself. Lead, mercury, and cadmium are the common air pollutants.
From the description of heavy metals, it can be concluded that these are toxic for all living beings. But the difference is in its concentration. If the concentration is low, the toxicity is also low but if it is high, it could be fatal. Heavy metals are present everywhere. These are present in soil, deposited in water, and present in the atmosphere too. These pollute the environment as well as human’s life. Through soil, it is absorbed by plants further by the herbivorous animals which in turn are eaten by the carnivorous animals as well as by the humans. These metals do not go off easily from the plants and animals instead it gets accumulated in the soft tissues of plants and animals and further reaches to humans. The heavy metals which are in the water degrade the quality of water and makes it unfit for drinking for all the living beings and even for other purposes. It is a threat for the aquatic life. Because of this, the amount of dissolve oxygen decreases and thus the life which are under aquatic do not get sufficient oxygen to breathe, which could lead to death of the fishes, aquatic insects, animals, and plants. Heavy metals are present in the atmosphere in the form of aerosols, air, etc. which directly goes into our lungs and then slowly to all our body parts through breathing. These heavy metals reached into the environment through the anthropogenic activities or human activities. By the industrial effluents, discharge of industrial and hospital waste directly into water without being treated, similarly the sewages are also released unto water without being treated, through vehicular emission.
We should control our activities and start thinking about the future. Already a lot of damage has been done to the environment and now it is time to take preventive measures. That includes a forestation, sewage waste should be treated before releasing into rivers, non-biodegradable waste should not be dumped here and there, instead recycle it and then again use it, heavy and radioactive metals should be properly incinerated.
Considered the second most commonly performed operation after cesarean section worldwide, hysterectomy may be classified as abdominal (laparotomy, laparoscopy, or robotic assistance) and vaginal (via an incision through the superior part of the vagina).
The most common indications for hysterectomy are benign conditions such as uterine fibroids, endometriosis, genital prolapse, pelvic pain, heavy menstrual bleeding, but the technique is also used for gynecological malignancy (usually ovarian, uterine, or cervical) and risk-reducing surgery (in cases of BRCA 1 or 2 mutations or Lynch syndrome) [1, 2, 3, 4].
Actually, there are three types of hysterectomy—total hysterectomy (the uterus and cervix are removed), subtotal or partial hysterectomy (the uterus is removed, but the cervix is left in place), and total hysterectomy with bilateral salpingo-oophorectomy (uterus, fallopian tubes, ovaries, and cervix are removed) [1, 2, 3, 4]. The term radical hysterectomy (removal of the uterus, cervix, parametrium, vaginal cuff, and fallopian tubes) is used to describe a wide range of procedures universally applicable to cervical cancer. However, the degree of radicality clearly depends on preoperative estimation of tumor location, surgical margins and the risk of occult lymphatic spread. Moreover, the ovaries may or may not be removed according to the patient age [1, 2, 3, 4]. In addition, supracervical hysterectomy is sometimes preferred to diminish the intraoperative complications and surgical times, as well as to limit the possibility of lower urinary tract issues and maintain normal sexual function [1, 2, 3, 4].
The best route for hysterectomy is multifactorial, depending not only on the surgeon’s skills and patient safety (minimally invasive procedures as vaginal, laparoscopic, laparoscopic-assisted, and robotic-assisted hysterectomies) but also on economic reasons [1, 2, 3, 4].
Hemorrhage after hysterectomy is recognized as an occasional life-threatening complication in modern gynecological surgery, assuming appropriate medical and surgical management [2, 3, 4, 5, 6, 7, 8, 9].
Classified as “reactionary” (postoperative bleeding within the first 24 hours following surgery) and secondary (bleeding occurring in the interval 3–22 days after surgery), unexpected hemorrhage may arise regardless of the route or subtype of hysterectomy [5, 6, 9]. Early recognition and prompt intervention (reoperation or arterial embolization) to arrest bleeding are essential strategies for the suitable outcome of the patient [2, 3, 4, 5, 6, 7, 8, 9, 10].
While the role of risk factors for “reactionary” hemorrhage is emerging and critical for a correct assessment of the patient, operative laparoscopy is still ideal to treat hemorrhage after vaginal hysterectomy, laparoscopic hysterectomy, laparoscopic-assisted vaginal hysterectomy, and laparotomy being necessary only in selected cases [2, 3, 4, 6, 9].
Secondary hemorrhage presents with varying degrees of severity and tends to be more common after laparoscopic hysterectomy, especially total laparoscopic hysterectomy than after the other hysterectomy approaches [5, 9]. Factors potentially responsible are vaginal vault infection, vault hematoma, a poor surgical technique including excessive thermal injury by electrocoagulation, and early resumption of physical activity, large uterus size, excessive use of an energy source for the uterine artery, and culdotomy [2, 3, 4, 5, 7, 9, 10].
Ultimately, the management of secondary hemorrhage is challenging and involves diverse approaches based on the exact cause of bleeding, comprising vaginal packing with or without vault suturing, laparoscopic coagulation of the uterine artery if the source of bleeding could not be identified vaginally or arterial embolization [6, 9, 10].
Because of elective gynecologic surgery, we encourage selective patients to donate their own blood before surgery [6, 11]. Several definitions are actually used:
autologous blood transfusion, when is done with the patient’s own blood; blood is stored and can be transfused during surgery;
homologous transfusion or transfusion from another woman;
parachute pack or umbrella pack is a useful tool for pelvic bleeding after pelvic exenteration;
peanut dissector; this tool is indicated for blunt pressure dissection of small places;
total blood volume; estimated blood volume of total body weight is 8% or 4.5–5.0 liters in the average women. When intraoperative blood loss exceeds 15% of the blood volume, blood transfusion must be taken into consideration in combating hypovolemic shock. About 15% of an adult blood volume can be calculated by amplification a patient’s weight in kg 10 times. The usual method of performing abdominal hysterectomy involved the use of clamps or forceps on vessels.
The present chapter will give an overview on different aspects of bleeding after hysterectomy such as incidence rate, risk factors, mechanisms, and management techniques aiming to expand our knowledge and skills in recognizing and treating this unexpected potentially serious complication. Furthermore, we intend to offer a guide toward standardizing treatment practice across bleeding issues following hysterectomy considering clear recommendations and algorithms.
Postoperative hemorrhage represents a significant potential complication of contemporary gynecological surgery. Despite normal hemostasis, appropriate/suitable surgical technique and close monitoring, postoperative bleeding may occur, leading to the different clinical and operative scenarios and challenging even the most experienced operative team [2, 3, 4, 9, 11, 12].
Based on their timing to surgery, two main subtypes of postoperative hemorrhage are actually recognized [5, 6, 7, 8, 9]:
Although the incidence of postoperative hemorrhage basically varies according to surgery, the difference between abdominal, laparoscopic, and vaginal hysterectomy remains statistically insignificant [5, 6, 7]. Indeed, some authors postulate that postoperative bleeding occurs more frequently after abdominal and laparoscopic than after vaginal hysterectomy, but overall, the incidence of hemorrhagic events after a hysterectomy varies from 0.2 to 3.1%, irrespective of surgical route [5, 6, 7, 8, 10, 13, 14].
On the other hand, the true frequency of delayed bleeding complications is still unknown, although the consequences can be particularly significant in women undergoing outpatient surgery [5, 6, 7, 8, 10, 13, 14]. Paul et al. reported an overall cumulative incidence of secondary hemorrhage after a total laparoscopic hysterectomy of 1.3% [5]. Although secondary hemorrhage is rare, it is more often reported after total laparoscopic hysterectomy than after other hysterectomy approaches [5, 6, 7, 8, 10, 13, 14].
Table 1 summarizes data on the incidence of postoperative hemorrhage reported by several authors.
Authors | Type of study, no of cases | Incidence postoperative hemorrhage |
---|---|---|
Makinen et al. [15] |
|
|
Wilke et al. [13] |
|
|
Holub and Jabor [7] |
|
|
Erian et al. [6] | 719 patients between November 1990 and March 2007: 476 VH, 243 LH |
|
Paul et al. [5] |
|
|
Incidence of postoperative hemorrhage in gynecological surgery.*
AH, abdominal hysterectomy; LH, laparoscopic hysterectomy; VH, vaginal hysterectomy; L-AVH, laparoscopic-assisted vaginal hysterectomy.
Hemorrhage is responsible for about half of the postoperative complications following gynecological surgery, ranging from persistent venous oozing to massive blood loss from injury to retroperitoneal vessels [5, 6, 7, 12, 13].
Main bleeding sites comprise the anterior abdominal wall (both the suprapubic and the umbilical incision), the vaginal cuff (after laparoscopic hysterectomy and laparoscopic-assisted vaginal hysterectomy), and intraabdominal bleeding. Abdominal wall vessel injury occurs with increasing frequency, as the practice of laparoscopic surgery becomes wider and trocars become sharper [2, 3, 4, 7, 9].
The source of bleeding in secondary hemorrhage can be the uterine vessels or descending cervical/vaginal vessels; occasionally, uterine artery pseudoaneurysm can cause delayed heavy vaginal bleeding after laparoscopic hysterectomy [2, 3, 4, 7, 9]; additionally, the technique of vaginal vault closure may also contribute to the occurrence of secondary hemorrhage [5, 9].
Postoperative hemorrhage can result from failure to control vascular injury during surgery. Accurate clamp placement, gentle handling of tissues, and the accuracy of dissection are all important and contribute to maximum efficiency with minimum blood loss and minimum tissue damage when abdominal hysterectomy is performed [9].
The electrosurgical instrument can be used for a precise incision of the abdominal wall with minimal tissue injury. By holding the electrode close to the tissue or touching the metal clamp and pressing the coagulation button, superficial coagulation can be achieved [2, 3, 4, 9].
Intra- and post-operative bleeding generally develops in younger women or those with a more vascular pelvis who underwent a hysterectomy, especially laparoscopic hysterectomy in the presence of fibroids [6, 16].
Possible rationales for secondary hemorrhage comprise a bleeding vessel missed at the end of the procedure, effects of pneumoperitoneum, Trendelenburg position, low intraoperative pressure, wearing off the effect of vasopressin, subacute infection, postoperative analgesia, as well as bleeding disorders [2, 3, 4, 5, 7, 9].
Other potential factors accounting for delayed postsurgical bleeding are vaginal vault infection, vault hematoma, poor surgical technique with excessive thermal injury by electrocoagulation, and early resumption of physical activity [5, 7, 9]. A large-sized uterus, high vascularity, large-sized vessels, excessive use of an energy source for the uterine artery, and culdotomy also play a role in this hemorrhagic event [5, 7, 9].
Most of the complications during or after hysterectomy are preventable or treatable. Other complications may exist as medical conditions before hysterectomy but are worsened during surgery, especially if not managed as part of holistic woman’s care.
Complications after surgery include [2, 3, 4, 9, 12]:
In Romania, the mortality rate following a hysterectomy is very low.
Contemporary management of surgical interventions includes postoperative bleeding and the possibility of blood transfusion with risks of HIV transmission (in 1.9 million cases), the transmission of hepatitis B (one in every 180.000 cases), or a febrile reaction to transfusion (1% cases) [2]. Most experts recommend acute normovolemic hemodilution and cell salvage in women undergoing hysterectomy section who will not accept blood products.
Hypovolemic shock can occur after major bleeding as a direct result of uncontrolled hemorrhage. Depending on the total blood volume lost, hypovolemic shock may be divided into four classes: I (< 75 mL or 15%), II (750–1500 mL, or 15–30%), III (1500–2000 mL or 30–40%) and IV (>2000 mL or > 40%) [6].
The clinical manifestations of class I hypovolemia are not measurable and compensatory mechanisms restore plasma volume within a day. In class II hypovolemia, tachycardia is the most frequent clinical finding as a result of inadequate circulatory volume. The distinction between class I and II hypovolemic shock is made by recording blood pressure and pulse in the standing, sitting, or reclining position. Postural hypotension is observed as result of cardiac failure. Compensatory mechanisms begin to fail with the class III hypovolemic shock. This results in an increase in the arterial and venous oxygen difference with classic signs including worked tachycardia, tachypnea, oliguria, and cold skin. With the class IV hypovolemic shock, a patient’s survival depends on rapid transfusion of blood and immediate surgical intervention before cardiovascular collapse and death or organ system failure.
After initial resuscitative measures are instituted, it is highly recommended for patients to be carried out in a critical care unit. Use of sympathomimetic agents after sufficient hydration and vasodilator is normally preferred in the management of patients with hemorrhagic shock who have arterial pressure higher than 70 mm Hg.
Once restoration of the intravascular volume has been completed, it is important to reassess the patient’s response to blood transfusion when managing women with severe blood loss, especially in those patients who have pulmonary edema, myocardial infarction, or congestive heart failure [12].
Transfusion for patients with hemoglobin of 8–10 mg/dL is no longer recommended.
When major surgery is anticipated and transfusion is massive, platelets in addition to packed cell transfusion are required. It is recommended that cryoprecipitate be reserved for patients with deficiencies in von Willebrand factor, factor VIII, and fibrinogen factor XIII.
Recognized as an uncommon complication of hysterectomy, postoperative hemorrhage represents a true challenge in routine practice [8]; irrespective of the procedure, a close follow-up of the patient in a high-dependency unit is indicated in order to exclude recurrence of bleeding [6, 7].
The key to successful management is timely intervention meaning prompt diagnosis, urgent resuscitation if necessary and rapid decision for either arterial embolization or reoperation according to the severity of bleeding and the hemodynamic stability of the patient. Both techniques are highly effective to control bleeding; nevertheless, if the patient is hemodynamically unstable or of the interval since surgery is under 24 hours suggesting rapid hemorrhage, the emergency return to the operating theater to arrest the bleeding is preferred [6, 7, 9].
Current options for managing hemorrhage include [6, 7, 9]:
every patient should be carefully monitored postoperatively for signs of bleeding (hypotension, tachycardia, tachypnea, abdominal distension);
ultrasound can confirm intraperitoneal bleeding; more ways to determine intraabdominal hemorrhage include abdominal and pelvic CT scan; a routine coagulation profile should be done immediately for the patient with a rapid pulse, low blood pressure, and/or low urine output. The surgeon must take charge of the problem and execute the technical steps necessary to treat hemorrhagic shock in the operating room. Intraperitoneal bleeding can be hidden by incisional pain and analgesic medications. Despite adequate dissection, a small vessel may bleed or the suture may cut through tissue. Skeletonized vessels and small sutures should be used for significantly reducing the incidence of postoperative hemorrhage. Venous bleeding can be more life-threatening than arterial hemorrhage which can be clearly seen and controlled with fast small sutures or clamps.
the presence of unexpected drop in hematocrit or hemoglobin postoperatively.
A simplified algorithm to describe steps after gynecological surgery and potential post-surgery bleeding is provided in Figure 1.
A simplified algorithm of post-surgery bleeding approach.
A closer look at the holistic management of postoperative blood should also underpin the following [9]:
to assess blood value and coagulation mechanisms;
to identify changes in the coagulation components, and to initiate replacement therapy in order to achieve adequate hemostasis. In assessing the patient’s coagulation status, it is very important to avoid such a situation known as the trauma triad of death consisting of—hypothermia, metabolic acidosis, and coagulopathy. In some patients with benign disease, blood transfusion is rarely indicated. Experience has shown that blood transfusion may be significant in women with malignant disease;
to establish the therapeutic strategy by measuring the level of prothrombin time < 14 sec, activated partial thromboplastin time (aptt) < 40 sec, fibrinogen >100 mg/dL, platelets >80 × 103 mL.
In hemodynamically unstable women (rapid pulse, falling blood pressure, with or without renal impairment) or if the bleeding occurs shortly in post-surgery (the so-called reactionary hemorrhage), it is desirable to return to the operating room [5, 6, 7, 8, 9].
A preoperative abdominal and pelvic ultrasound or CT scan is routinely required to visualize the source of bleeding as being intra- or retro-peritoneal, as well as adequate local examination without or under anesthesia. Moreover, the operative procedure should be mentally revised to identify any potential bleeding issue [9].
Surgical revision for postoperative bleeding may be performed transvaginally, laparoscopically, or both [5, 6, 7, 8, 9, 13, 14].
Postoperative hemorrhage from the vaginal vault recurrently originates from the vaginal artery in the lateral vaginal fornix or from one of its branches, since the lateral vaginal angle which includes the vaginal artery may not be accurately protected or turn into disligated [9, 13, 14]. Excessive vaginal bleeding needs to be objectively measured; since the vagina is a distensible organ, clots obstructing the vaginal introitus may lead to a large amount of blood accumulating and distending the vagina, subsequently covering the true significance of hemorrhage [9, 13, 14]. Vaginal bleeding can be controlled by clamping and ligating the bleeding point as well as by delayed-absorbable transfixion suturing of the vaginal mucosa and paravaginal tissue [9, 13, 14]. If such techniques are not enough or bleeding vessels have retracted, other tactics should be intended [8].
When no noticeable vaginal source, bleeding after abdominal or vaginal hysterectomy is traditionally treated by laparotomy or laparoscopy [7, 9]. While laparotomy is recommended in cases of intraperitoneal bleeding or unsuccessful conservative transvaginal treatment, operative laparoscopy is clearly indicated if the source of bleeding cannot be identified by the means of vaginal examination and/or if an intraabdominal bleeding source is suspected [7, 9, 13].
Post-surgery bleeding requires laparotomy in two situations.
Firstly, if the surgical hemostasis cannot be achieved transvaginally, laparotomy may be necessary [9].
Secondly, if the patient underwent an abdominal hysterectomy, the incision should be reopened, succeeding the following steps (i) clots and blood evacuation from the abdomen and pelvic area; (ii) searching of the potential bleeding sites, commencing with the most expected places; (iii) ligating, suturing, or clipping of the identified bleeding sites; (iv) verifying the ureteral integrity as high risk of ureteral damage during reoperation; and (v) closing second time after a completely dry abdomen and pelvis [9].
The laparoscopic approach to postoperative bleeding following laparoscopic hysterectomy, vaginal hysterectomy, or laparoscopic-assisted vaginal hysterectomy is an attractive alternative to the abdominal surgical approach in the majority of patients [6, 7, 9, 13]. The procedure can be used to adequately evaluate the pelvis and the abdominal wall, which is occasionally the source of hemorrhage after laparoscopic hysterectomy. Moreover, whether the bleeding is from the abdominal wall, the surgical pedicles, or the vaginal cuff, it can be managed laparoscopically [8, 9]. Evidently, hemostasis can be more easily obtained in laparoscopic surgery because of magnification, close inspection, routine use of suction irrigation, and bipolar coagulation [7, 9]. Besides, bipolar coagulation, a Foley catheter introduced in the port-site bleeding, or a collagen-fibrin agent can be used to achieve local hemostasis during laparoscopy [7, 9].
Following laparoscopic irrigation/suction using Ringer’s solution to clear the operative field, a combination of laparoscopic suturing using absorbable suture material and laparoscopic bipolar coagulation is commonly recommended [6, 8, 9]. Also, electrosurgery is effective in controlling bleeding during laparoscopic surgery. Furthermore, different forms of fibrin adhesive are tested in gynecologic open surgery in order to stop oozing hemorrhages after primary hemostatic treatment with a high efficacy rate (98%) [6]. Holub and Kliment reported successful treatment of hemorrhage from damaged tissue near important pelvic structures using the laparoscope to apply collagen fleece combined with fibrin glue [7, 17].
To avoid further risk of injury to the abdominal wall and to improve the recovery time from surgery,
Conversely, if the patient is reasonably stable and there is not abrupt early bleeding (based on the volume of blood in the abdomen or retroperitoneal space as estimated by ultrasound and the time from surgery), it seems realistic to try to identify the bleeding artery and embolize it by transcatheter interventional radiological techniques [2, 3, 4, 9, 10].
Arterial embolization remains an important minimally invasive option for the management of delayed postoperative hemorrhage [2, 3, 4, 8, 9, 18]. Transcatheter arterial embolization has been shown to be an effective tool for the management of postoperative hemorrhage after gynecologic laparoscopy, but also after abdominal and vaginal hysterectomy [8, 9]. Selective angiographic arterial embolization is a quite simple and safe procedure with a clinical success rate up to 90% in routine practice and usually a low complication rate less than 10%, including a mild postembolization syndrome with pain, fever, high leucocyte count related to vascular thrombosis and tissue necrosis [8, 9]. Bladder necrosis, vesicovaginal fistula, neuropathies as well as renal toxicity are uncommon, isolated side effects [9].
Arterial embolization technique comprises the following main steps—(i) identification of the site of bleeding by angiofluoroscopy if more than 2–3 mL/min bleeding rate; (ii) percutaneous catheterization of the femoral artery or, uncommonly, brachial artery under local anesthesia with retrograde direct access to the hypogastric artery; (iii) canulation of the hypogastric artery or specific collateral vessel if appropriate; (iv) injection of the embolization material under angiographic observation (metal coins, autologous clot, small pieces of gelfoam, small silastic spheres, subcutaneous tissue, or other hemostatic materials; (v) repeat angiography to demonstrate the occlusion of the bleeding vessel; (vi) remove of the catheter followed by careful monitoring for further bleeding [8, 9, 10].
Although second surgery is often the initial choice for postoperative hemorrhage, for a patient who is hemodynamically stable but is experiencing postoperative hemorrhage, transcatheter arterial embolization is a welcome alternative to a second surgery [8, 9]. However, if rapid access to interventional radiology is not available or if transcatheter arterial embolization is unsuccessful, laparoscopy can still be considered [8, 9]. Besides, a potential advantage of surgical management of postoperative hemorrhage over transcatheter arterial embolization is the ability to evacuate the hemoperitoneum, which may decrease postoperative pain, the risk of infection, and the risk of ileus [8, 9].
It is typical to expect some bleeding after hysterectomy in the 6–8 weeks following the procedure; the discharge may be red, brown, or pink. Bleeding should steadily decrease in the days and weeks following the surgery and should never be excessive at any point of recovery [18]. The exception is menstruation in women who have undergone a subtotal hysterectomy [18, 19]. In case of bleeding after hysterectomy, it is more likely to be of some pathologic cause instead of menstruation which needs to be ruled out [19].
However, a sudden and significant increase in bleeding during recovery should be considered abnormal. Points of concern comprise but are not limited to—bright red vaginal bleeding (indicating active bleed), temperature over 100.4°F, severe nausea or vomiting, increasing pelvic pain, a local complication such as redness, swelling, or drainage at the incision site as well as difficulty in urinating or pain with urination suggesting either an infection or a neurogenic bladder [18].
Delayed vaginal hemorrhage after laparoscopic supracervical hysterectomy usually requires emergent reoperation. Several studies have described continued cyclical bleeding from the cervical stump after supracervical hysterectomy in 0–25% of cases [20].
Effective interventions addressing hemorrhage after hysterectomy are needed to reduce women’s mortality worldwide.
Prior to hysterectomy, these women should be offered specific counseling and have a prospective plan for the management of their disease, developed by gynecologists of how their condition and hysterectomy interact. Prehysterectomy counseling services starting for all women planning this surgical intervention are a key part of hospital services and should be an integral part of the local health services network. They could be provided by general practitioners or specialist clinicians or surgeons, all of whom should be suitably trained or may require different management or specialized services before hysterectomy. There are special circumstances as congenital or acquired coagulation disorders that should be considered to evaluate by a thorough history and lab tests.
Professional interpretation services for women who do not speak English.
It is not clear how much the specific medical terminology is conveyed to the patient. Healthcare providers have to invest in technology, security, specialists, and translators to ensure healthcare becomes world-class. Medical tourism is growing each year. Romania provides the highest quality healthcare at the lowest price. Also, the cost of hysterectomy in Romania is lower than the same treatment in UK or UE. In developed countries as the USA, UE countries or Canada patients have to wait a long time for major surgeries. The cost involved in treating a patient depends upon factors like—type of hysterectomy needed, hospital and physician selected for it, and duration of staying.
Communication and referrals among professionals.
Good communication among professionals is essential. Referral between specialties involved should be rapid. They can use a variety of communication methods including—mobile phone, email, fax, Whatsapp, Instagram, Tik Tok, Facebook, etc. In many cases, junior trainees in the front line did not have proper support and need to have clear guidelines about when to seek senior help.
Women with serious medical conditions
They require immediate and appropriate multidisciplinary specialist care; women will require referral to tertiary or specialist medical centers for their preexisting medical or mental conditions before hysterectomy. Conditions that require prehysterectomy counseling and advice include—epilepsy, diabetes, asthma, congenital or known acquired cardiac disease, autoimmune disorders, renal and liver disease, obesity (BMI > 30), severe mental illness, or psychiatric conditions that require a change of medication, HIV infection. Women with potential serious underlying preexisting medical on mental health conditions should be immediately referred to appropriate specialist centers of expertise as soon as their symptoms develop.
Clinical training
All clinical staff must undertake regular training for the identification and management of serious disease conditions or potential emergencies or signs and symptoms of potentially life-threatening conditions, circulatory failure, severe hypertension or major hemorrhage, pyrexia >38°C, tachycardia >100 bpm, breathlessness. The local clinicians may be excellent at the management of severely ill women but must also accept written, documented, and audited courses. There should be a well-trained team of doctors for recording and charting investigations performed, obtaining quick results, ensuring that abnormal results are followed up promptly and have resulted in a better outcome.
Identifying and managing very sick women with critical illness before, during or after hysterectomy
In very acute situations, a team approach can be very healthful. The management of patients with an acute severe illness with circulatory failure, arterial hypertension, and major hemorrhage requires a team approach and help from the anesthetic and critical care services. There are some healthcare professionals who failed to manage crisis situations outside their immediate area of expertise; therefore, it is crucial to recognize their limitations and to know when and whom to call for another opinion once the patient was admitted to the hospital.
Coagulation factors, hematocrit, serum calcium, glucose, and electrolytes could be assessed every 120 minutes or after 10 U of transfusion; these lab tests are very helpful for the diagnosis of postoperative bleeding.
RCOG guidelines of the responsibilities of the consultant on call should be followed.
Bilateral hypogastric artery ligation can reduce blood loss to a minimum during hysterectomy [9].
Hypotensive anesthesia is also a safe and effective technique in reducing the circulation to the operative field [9].
Serious incident and women death reporting
Health professionals, senior or junior, must recognize an act on the signs and symptoms of potentially life-threatening conditions.
The evaluation of such a report must include clinicians from relevant disciplines (including anesthetics) who were not involved with the deaths. This report is recommended to be a requirement in the future.
The identification and act on women’s death should be reviewed as a serious incident and disseminated to all health professionals, junior or senior. Women’s deaths are generally underreported because of incorrect classification of cause.
Fatal hemorrhage can result from laceration of the external iliac vein or the hypogastric vein where they join together which are at risk of injury when the surgeon dissects between the distal common iliac artery, the psoas muscle, and the area of lumbosacral nerve trunks [9]. These vessels cannot be clamped and ligated with clips or sutures [9].
Dissection around the aorta and vena cava done with inadequate exposure performed in order to remove lymph nodes around them can result in serious hemorrhage. Bleeding usually can be avoided by placing a finger over the laceration and a vascular needle is used to close the laceration from side to side. The same technique may be used for common and external iliac veins [9].
Also, bleeding can occur by dissecting pararectal space and presacral space as well as obturator fossa [9].
Pathology
Patient death autopsy must be improved and require more expertise.
In Romania, the number of women death after hysterectomy (death rate) is very small and many of the autopsies reviewed were considered adequate. When an autopsy is needed, the body can be taken to another area for more expert examination. Despite evaluation by many examiners in the different specialties, the final diagnosis could not be resolved because of inadequate clinical data, poor autopsy quality, or the unmanageable nature of some death.
The lack of routine observation in the postoperative period or a failure to appreciate blood loss or recognition of abnormal vital signs such as oxygen saturation and respiratory rate can lead to death after hysterectomy. The patient should be evaluated before hysterectomy for risk factors and the medical conditions of the women should be diagnosed by a careful history and lab tests in order to decrease the possibility of hemorrhage.
The risks of blood transfusion, the transmission of HIV or hepatitis B should be discussed before surgical procedure.
The peace of surgical intervention should be governed by good exposure of the tissue, accuracy of dissection, and clamping or suturing the vessels in a precise manner. The skills and experiences of the surgeon without wasting time with unnecessary hesitation or indecision will reduce the risk of uncontrolled hemorrhage after a hysterectomy.
The surgeon should control the life-threatening hemorrhage by judgment, knowledge, and technical skills. The patient’s medical history for vital signs, blood loss volume, and levels of coagulation factors will determine how quickly blood transfusion is initiated. Careful postoperative clinical evaluation of the patient by the surgeon and surgical team with abdominal or pelvic ultrasound or CT scanning will help to prevent or minimize significant blood loss after hysterectomy and localize the site of bleeding.
No funding was received for this chapter.
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In the current study, removal of heavy metal ions from water/wastewater and the use of response surface methodology (RSM) for experimental optimization were examined thoroughly. The objective of this work was to summarize the removal of heavy metal ions from water/wastewater using various chemical techniques and to emphasize the superiority of RSM in these studies.",book:{id:"9407",slug:"biochemical-toxicology-heavy-metals-and-nanomaterials",title:"Biochemical Toxicology",fullTitle:"Biochemical Toxicology - Heavy Metals and Nanomaterials"},signatures:"Muharrem Ince and Olcay Kaplan Ince",authors:[{id:"258431",title:"Prof.",name:"Muharrem",middleName:null,surname:"Ince",slug:"muharrem-ince",fullName:"Muharrem Ince"},{id:"266549",title:"Dr.",name:"Olcay",middleName:null,surname:"Kaplan Ince",slug:"olcay-kaplan-ince",fullName:"Olcay Kaplan Ince"}]},{id:"67269",doi:"10.5772/intechopen.86213",title:"Polycyclic Aromatic Hydrocarbons (PAHs) and Their Influence to Some Aquatic Species",slug:"polycyclic-aromatic-hydrocarbons-pahs-and-their-influence-to-some-aquatic-species",totalDownloads:1256,totalCrossrefCites:7,totalDimensionsCites:17,abstract:"Polycyclic aromatic hydrocarbons (PAHs) are ubiquitous environmental pollutants generated primarily during the incomplete combustion of organic materials (e.g., coal, oil, petrol, and wood). Many PAHs have toxic, mutagenic, and/or carcinogenic functions. PAHs are highly lipid soluble which lead to a fast absorption by the gastrointestinal tract of marine mammals. They are immediately distributed in a vast variety of tissues with a notable tendency for localization in body fat. Metabolism of PAHs is obtained via the cytochrome P450-mediated mixed function oxidase system with oxidation or hydroxylation as the first step. PAHs are environmental contaminants that pose significant risk to health of fish. The effect of PAHs on fish is a topic of rising attention in a lot of countries. Different studies using the bile metabolites separated by high-performance liquid chromatography with fluorescence detection were presented. The aim is to compare the levels of PAH metabolites in fish from different areas and fish species. The major metabolite present in all fish was 1-hydroxypyrene. The data confirm the importance of 1-hydroxypyrene as the key PAH metabolite in fish bile and suggest that the European eel is an ideal species for monitoring PAHs.",book:{id:"9407",slug:"biochemical-toxicology-heavy-metals-and-nanomaterials",title:"Biochemical Toxicology",fullTitle:"Biochemical Toxicology - Heavy Metals and Nanomaterials"},signatures:"Ayoub Baali and Ahmed Yahyaoui",authors:[{id:"288629",title:"Ph.D.",name:"Ayoub",middleName:null,surname:"Baali",slug:"ayoub-baali",fullName:"Ayoub Baali"},{id:"293206",title:"Prof.",name:"Ahmed",middleName:null,surname:"Yahyaoui",slug:"ahmed-yahyaoui",fullName:"Ahmed Yahyaoui"}]},{id:"66089",doi:"10.5772/intechopen.85159",title:"Water Resource Pollution by Herbicide Residues",slug:"water-resource-pollution-by-herbicide-residues",totalDownloads:1294,totalCrossrefCites:7,totalDimensionsCites:11,abstract:"Herbicides are frequently used in the chemical control of weeds in various crops in Brazil and worldwide, so they are more frequently detected outside the application areas, contributing to the risk of environmental contamination. The importance of knowledge of the physicochemical properties of the environment and the pesticide used in the agricultural area is in order to understand its effects on terrestrial and aquatic ecosystems and the search for the prevention of future bioaccumulation potentials (bioconcentration and/or biomagnification) of molecules of pesticides in living nontarget organisms, minimizing their negative effects on the environment. The understanding of analytical techniques for measuring the quality of water resources as well as techniques for the remediation of contaminated water is essential to minimize the possible impacts caused by the application of pesticides to the environment.",book:{id:"9407",slug:"biochemical-toxicology-heavy-metals-and-nanomaterials",title:"Biochemical Toxicology",fullTitle:"Biochemical Toxicology - Heavy Metals and Nanomaterials"},signatures:"Kassio Ferreira Mendes, Ana Paula Justiniano Régo, Vanessa Takeshita and Valdemar Luiz Tornisielo",authors:[{id:"162791",title:"Prof.",name:"Valdemar",middleName:null,surname:"Tornisielo",slug:"valdemar-tornisielo",fullName:"Valdemar Tornisielo"},{id:"197720",title:"Ph.D.",name:"Kassio",middleName:null,surname:"Ferreira Mendes",slug:"kassio-ferreira-mendes",fullName:"Kassio Ferreira Mendes"},{id:"258779",title:"Dr.",name:"Ana Paula",middleName:null,surname:"Justiniano Régo",slug:"ana-paula-justiniano-rego",fullName:"Ana Paula Justiniano Régo"},{id:"277330",title:"MSc.",name:"Vanessa",middleName:null,surname:"Takeshita",slug:"vanessa-takeshita",fullName:"Vanessa Takeshita"}]},{id:"70500",doi:"10.5772/intechopen.89601",title:"Challenges for Assessing Toxicity of Nanomaterials",slug:"challenges-for-assessing-toxicity-of-nanomaterials",totalDownloads:1129,totalCrossrefCites:4,totalDimensionsCites:11,abstract:"On the development of nano-world, nanotechnology provides enormous opportunities in daily routine products and further future sustainable innovations. The nanotechnology extends its benefits to various fields such as engineering, medical, biological, environmental, and communication. However, the exponential growth of nanomaterials production would lead to severe complications related to their hazardous effects to the human health and environment. Moreover, negative impact of nanomaterials toxicity on human health is one of the significant issues on exhausting nano-products. The most vulnerable situation is associated with the use of nanomaterials in the biomedical application. The several efforts have been ongoing to study the nanotoxicity and its interaction with the biomolecules. Nevertheless, it is hard to assess and validate the nanotoxicity in a biological system. This chapter aims to study the challenges in determining the toxicity of nanomaterials. The toxicity assessment and hurdles in determining the impact on biological systems are epoch making. In-vitro, in-vivo, and in-silico studies are summarized in this chapter in assessing the toxicity of engineered nanomaterials. The different approaches of toxicity assessment have their difficulties faced by researchers while characterizing nanomaterials in powder form, solution-based, and interacting with biological systems. The assessment tools and characterization techniques play a vital role in overcoming the challenges, while the cytotoxic assays involve nanoparticle shape, morphology, and size consideration.",book:{id:"9407",slug:"biochemical-toxicology-heavy-metals-and-nanomaterials",title:"Biochemical Toxicology",fullTitle:"Biochemical Toxicology - Heavy Metals and Nanomaterials"},signatures:"Akanksha Gupta, Sanjay Kumar and Vinod Kumar",authors:[{id:"309802",title:"Dr.",name:"Vinod",middleName:null,surname:"Kumar",slug:"vinod-kumar",fullName:"Vinod Kumar"},{id:"311316",title:"Dr.",name:"Akanksha",middleName:null,surname:"Gupta",slug:"akanksha-gupta",fullName:"Akanksha Gupta"},{id:"311317",title:"Mr.",name:"Sanjay",middleName:null,surname:"Kumar",slug:"sanjay-kumar",fullName:"Sanjay Kumar"}]},{id:"69211",doi:"10.5772/intechopen.89299",title:"Formaldehyde Advantages and Disadvantages: Usage Areas and Harmful Effects on Human Beings",slug:"formaldehyde-advantages-and-disadvantages-usage-areas-and-harmful-effects-on-human-beings",totalDownloads:1330,totalCrossrefCites:0,totalDimensionsCites:7,abstract:"Formaldehyde, a simple but important member of aldehydes, is highly reactive due to its strong electrophilic properties. It is a colorless, pungent, low molecular weight poisonous gas that can rapidly pass into gaseous phase at room temperature, can burn, and can dissolve very well in water. Formaldehyde, which is found in the natural structure of the organism, is used in many places from industrial areas to household materials and from the production of coatings in dentistry to the determination of cadavers in laboratories. In addition to having such a wide range of uses, it has harmful effects on human health as it can react spontaneously with various cellular elements. In this review, which is based on various sources, detailed information about the definition, properties, usage areas, and harmful effects of formaldehyde will be given.",book:{id:"9407",slug:"biochemical-toxicology-heavy-metals-and-nanomaterials",title:"Biochemical Toxicology",fullTitle:"Biochemical Toxicology - Heavy Metals and Nanomaterials"},signatures:"Nuriye Tuna Subasi",authors:[{id:"279801",title:"Dr.",name:"Nuriye Tuna",middleName:null,surname:"Subaşı",slug:"nuriye-tuna-subasi",fullName:"Nuriye Tuna Subaşı"}]}],mostDownloadedChaptersLast30Days:[{id:"68822",title:"Heavy Metal Removal Techniques Using Response Surface Methodology: Water/Wastewater Treatment",slug:"heavy-metal-removal-techniques-using-response-surface-methodology-water-wastewater-treatment",totalDownloads:2218,totalCrossrefCites:10,totalDimensionsCites:19,abstract:"Advanced water/wastewater treatment techniques including ion exchange separation, filtration separation, and adsorption are essential in the removal of nonbiodegradable toxic wastes from water. 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The boron and nitrogen atoms are linked via strong B-N covalent bonds and form interlocking hexagonal rings. h-BN is used in different areas due to its interesting physical and chemical properties, e.g., in electronics as an insulator and in ceramics, resins, plastics, and paints. Therefore, boron nitride (BN) is also a popular inorganic compound in cosmetic industry (the highest BN concentration up to 25% can be found in eye shadow formulation). It is also widely used in dental cement production (for dental and orthodontic applications). Boron nitride seems to be suitable for biomedical applications; therefore, the cytotoxicity in vitro and in vivo observations of h-BN nanoplates and novel few-layered h-BN-based nanocomposites are still needed. The short-time studies confirm their low cytotoxicity and suggest that BN can be used as a novel drug delivery system; however, medical application needs additional verification in long-term studies.",book:{id:"9407",slug:"biochemical-toxicology-heavy-metals-and-nanomaterials",title:"Biochemical Toxicology",fullTitle:"Biochemical Toxicology - Heavy Metals and Nanomaterials"},signatures:"Magdalena Jedrzejczak-Silicka, Martyna Trukawka, Katarzyna Piotrowska and Ewa Mijowska",authors:[{id:"186478",title:"Dr.",name:"Magdalena",middleName:null,surname:"Jedrzejczak-Silicka",slug:"magdalena-jedrzejczak-silicka",fullName:"Magdalena Jedrzejczak-Silicka"},{id:"231014",title:"Prof.",name:"Ewa",middleName:null,surname:"Mijowska",slug:"ewa-mijowska",fullName:"Ewa Mijowska"},{id:"312078",title:"MSc.",name:"Martyna",middleName:null,surname:"Trukawka",slug:"martyna-trukawka",fullName:"Martyna Trukawka"},{id:"312079",title:"Dr.",name:"Katarzyna",middleName:null,surname:"Piotrowska",slug:"katarzyna-piotrowska",fullName:"Katarzyna Piotrowska"}]},{id:"69211",title:"Formaldehyde Advantages and Disadvantages: Usage Areas and Harmful Effects on Human Beings",slug:"formaldehyde-advantages-and-disadvantages-usage-areas-and-harmful-effects-on-human-beings",totalDownloads:1329,totalCrossrefCites:0,totalDimensionsCites:7,abstract:"Formaldehyde, a simple but important member of aldehydes, is highly reactive due to its strong electrophilic properties. It is a colorless, pungent, low molecular weight poisonous gas that can rapidly pass into gaseous phase at room temperature, can burn, and can dissolve very well in water. Formaldehyde, which is found in the natural structure of the organism, is used in many places from industrial areas to household materials and from the production of coatings in dentistry to the determination of cadavers in laboratories. In addition to having such a wide range of uses, it has harmful effects on human health as it can react spontaneously with various cellular elements. 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Venom contains zootoxins which is a highly modified saliva that is either injected via fangs during a bite or spitted. The modified parotid gland, encapsulated in a muscular sheath, present on each side of the head, below and behind the eye, have large alveoli which temporarily stores the secreted venom and later conveyed by a duct to tubular fangs through which venom is injected. Venoms are complex mixtures of more than 20 different compounds, mostly proteins and polypeptides, including proteins, enzymes and substances with lethal toxicity which are either neurotoxic or haemotoxic in action and exert effects on nervous/muscular impulses and blood components. 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Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). He leads the working group of experts representing Brazil in the Global Partnership on Artificial Intelligence (GPAI), on the theme \"AI and the Pandemic Response\".",institutionString:"Manufacturing and Technology Integrated Campus – SENAI CIMATEC",institution:null},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:'"Politechnica" University Timişoara',institution:null},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"414880",title:"Dr.",name:"Maryam",middleName:null,surname:"Vatankhah",slug:"maryam-vatankhah",fullName:"Maryam Vatankhah",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Borough of Manhattan Community College",country:{name:"United States of America"}}},{id:"414879",title:"Prof.",name:"Mohammad-Reza",middleName:null,surname:"Akbarzadeh-Totonchi",slug:"mohammad-reza-akbarzadeh-totonchi",fullName:"Mohammad-Reza Akbarzadeh-Totonchi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ferdowsi University of Mashhad",country:{name:"Iran"}}},{id:"414878",title:"Prof.",name:"Reza",middleName:null,surname:"Fazel-Rezai",slug:"reza-fazel-rezai",fullName:"Reza Fazel-Rezai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"American Public University System",country:{name:"United States of America"}}},{id:"426586",title:"Dr.",name:"Oladunni A.",middleName:null,surname:"Daramola",slug:"oladunni-a.-daramola",fullName:"Oladunni A. Daramola",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Federal University of Technology",country:{name:"Nigeria"}}},{id:"357014",title:"Prof.",name:"Leon",middleName:null,surname:"Bobrowski",slug:"leon-bobrowski",fullName:"Leon Bobrowski",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Bialystok University of Technology",country:{name:"Poland"}}},{id:"302698",title:"Dr.",name:"Yao",middleName:null,surname:"Shan",slug:"yao-shan",fullName:"Yao Shan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Dalian University of Technology",country:{name:"China"}}},{id:"354126",title:"Dr.",name:"Setiawan",middleName:null,surname:"Hadi",slug:"setiawan-hadi",fullName:"Setiawan Hadi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Padjadjaran University",country:{name:"Indonesia"}}},{id:"125911",title:"Prof.",name:"Jia-Ching",middleName:null,surname:"Wang",slug:"jia-ching-wang",fullName:"Jia-Ching Wang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Central University",country:{name:"Taiwan"}}},{id:"332603",title:"Prof.",name:"Kumar S.",middleName:null,surname:"Ray",slug:"kumar-s.-ray",fullName:"Kumar S. Ray",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Statistical Institute",country:{name:"India"}}},{id:"415409",title:"Prof.",name:"Maghsoud",middleName:null,surname:"Amiri",slug:"maghsoud-amiri",fullName:"Maghsoud Amiri",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Allameh Tabataba'i University",country:{name:"Iran"}}},{id:"357085",title:"Mr.",name:"P. Mohan",middleName:null,surname:"Anand",slug:"p.-mohan-anand",fullName:"P. Mohan Anand",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356696",title:"Ph.D. Student",name:"P.V.",middleName:null,surname:"Sai Charan",slug:"p.v.-sai-charan",fullName:"P.V. Sai Charan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"357086",title:"Prof.",name:"Sandeep K.",middleName:null,surname:"Shukla",slug:"sandeep-k.-shukla",fullName:"Sandeep K. Shukla",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}}]}},subseries:{item:{id:"25",type:"subseries",title:"Evolutionary Computation",keywords:"Genetic Algorithms, Genetic Programming, Evolutionary Programming, Evolution Strategies, Hybrid Algorithms, Bioinspired Metaheuristics, Ant Colony Optimization, Evolutionary Learning, Hyperparameter Optimization",scope:"Evolutionary computing is a paradigm that has grown dramatically in recent years. This group of bio-inspired metaheuristics solves multiple optimization problems by applying the metaphor of natural selection. It so far has solved problems such as resource allocation, routing, schedule planning, and engineering design. Moreover, in the field of machine learning, evolutionary computation has carved out a significant niche both in the generation of learning models and in the automatic design and optimization of hyperparameters in deep learning models. This collection aims to include quality volumes on various topics related to evolutionary algorithms and, alternatively, other metaheuristics of interest inspired by nature. For example, some of the issues of interest could be the following: Advances in evolutionary computation (Genetic algorithms, Genetic programming, Bio-inspired metaheuristics, Hybrid metaheuristics, Parallel ECs); Applications of evolutionary algorithms (Machine learning and Data Mining with EAs, Search-Based Software Engineering, Scheduling, and Planning Applications, Smart Transport Applications, Applications to Games, Image Analysis, Signal Processing and Pattern Recognition, Applications to Sustainability).",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",hasOnlineFirst:!1,hasPublishedBooks:!0,annualVolume:11421,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. Dr Ventura also holds the positions of Affiliated Professor at Virginia Commonwealth University (Richmond, USA) and Distinguished Adjunct Professor at King Abdulaziz University (Jeddah, Saudi Arabia). Additionally, he is deputy director of the Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI) and heads the Knowledge Discovery and Intelligent Systems Research Laboratory. He has published more than ten books and over 300 articles in journals and scientific conferences. Currently, his work has received over 18,000 citations according to Google Scholar, including more than 2200 citations in 2020. In the last five years, he has published more than 60 papers in international journals indexed in the JCR (around 70% of them belonging to first quartile journals) and he has edited some Springer books “Supervised Descriptive Pattern Mining” (2018), “Multiple Instance Learning - Foundations and Algorithms” (2016), and “Pattern Mining with Evolutionary Algorithms” (2016). He has also been involved in more than 20 research projects supported by the Spanish and Andalusian governments and the European Union. He currently belongs to the editorial board of PeerJ Computer Science, Information Fusion and Engineering Applications of Artificial Intelligence journals, being also associate editor of Applied Computational Intelligence and Soft Computing and IEEE Transactions on Cybernetics. Finally, he is editor-in-chief of Progress in Artificial Intelligence. He is a Senior Member of the IEEE Computer, the IEEE Computational Intelligence, and the IEEE Systems, Man, and Cybernetics Societies, and the Association of Computing Machinery (ACM). Finally, his main research interests include data science, computational intelligence, and their applications.",institutionString:null,institution:{name:"University of Córdoba",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null,series:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403"},editorialBoard:[{id:"111683",title:"Prof.",name:"Elmer P.",middleName:"P.",surname:"Dadios",slug:"elmer-p.-dadios",fullName:"Elmer P. Dadios",profilePictureURL:"https://mts.intechopen.com/storage/users/111683/images/system/111683.jpg",institutionString:"De La Salle University",institution:{name:"De La Salle University",institutionURL:null,country:{name:"Philippines"}}},{id:"106873",title:"Prof.",name:"Hongwei",middleName:null,surname:"Ge",slug:"hongwei-ge",fullName:"Hongwei Ge",profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institutionString:null,institution:{name:"Dalian University of Technology",institutionURL:null,country:{name:"China"}}},{id:"171056",title:"Dr.",name:"Sotirios",middleName:null,surname:"Goudos",slug:"sotirios-goudos",fullName:"Sotirios Goudos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS9IuQAK/Profile_Picture_1622623673666",institutionString:null,institution:{name:"Aristotle University of Thessaloniki",institutionURL:null,country:{name:"Greece"}}},{id:"15895",title:"Assistant Prof.",name:"Takashi",middleName:null,surname:"Kuremoto",slug:"takashi-kuremoto",fullName:"Takashi Kuremoto",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLrqQAG/Profile_Picture_1625656196038",institutionString:null,institution:{name:"Nippon Institute of Technology",institutionURL:null,country:{name:"Japan"}}},{id:"125844",title:"Prof.",name:"Wellington",middleName:"Pinheiro Dos",surname:"Santos",slug:"wellington-santos",fullName:"Wellington Santos",profilePictureURL:"https://mts.intechopen.com/storage/users/125844/images/4878_n.jpg",institutionString:null,institution:{name:"Federal University of Pernambuco",institutionURL:null,country:{name:"Brazil"}}}]},onlineFirstChapters:{paginationCount:0,paginationItems:[]},publishedBooks:{paginationCount:5,paginationItems:[{type:"book",id:"8737",title:"Rabies Virus at the Beginning of 21st 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