Attributes of physical examination, measurements, routine blood tests and non-adherent attributes.
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
\n'}],latestNews:[{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"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"8794",leadTitle:null,fullTitle:"Leading Community Based Changes in the Culture of Health in the US - Experiences in Developing the Team and Impacting the Community",title:"Leading Community Based Changes in the Culture of Health in the US",subtitle:"Experiences in Developing the Team and Impacting the Community",reviewType:"peer-reviewed",abstract:"Advancing health equity calls for a new kind of leader and a new approach to leadership development. Clinical Scholars and Culture of Health Leaders are mid-career leadership development programs supporting the emergence of collaborative and systemic approaches, bringing teams of leaders together with others in the community to work toward the common goal of lessening health disparities. In each chapter of this book, the authors share how they tackled seemingly intractable issues, making headway through applying the principles of adaptive leadership in unbounded systems to create not only outcomes but also impacts on health disparities and, in some cases, sustainable and scalable applications. In this volume, you will learn how Clinical Scholars and Culture of Health Leaders programs curated and measured the successful learning and development of these dedicated health-equity advocates.",isbn:"978-1-80355-153-1",printIsbn:"978-1-80355-155-5",pdfIsbn:"978-1-80355-154-8",doi:"10.5772/intechopen.80243",price:139,priceEur:155,priceUsd:179,slug:"leading-community-based-changes-in-the-culture-of-health-in-the-us-experiences-in-developing-the-team-and-impacting-the-community",numberOfPages:316,isOpenForSubmission:!1,isInWos:1,isInBkci:!1,hash:"5044f7244f5d99791ec13482f276a075",bookSignature:"Claudia S. P. Fernandez and Giselle Corbie-Smith",publishedDate:"September 8th 2021",coverURL:"https://cdn.intechopen.com/books/images_new/8794.jpg",numberOfDownloads:2842,numberOfWosCitations:2,numberOfCrossrefCitations:2,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:3,numberOfDimensionsCitationsByBook:1,hasAltmetrics:1,numberOfTotalCitations:7,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"July 11th 2018",dateEndSecondStepPublish:"August 1st 2018",dateEndThirdStepPublish:"September 30th 2018",dateEndFourthStepPublish:"December 19th 2018",dateEndFifthStepPublish:"February 17th 2019",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",middleName:null,surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez",profilePictureURL:"https://mts.intechopen.com/storage/users/89429/images/system/89429.png",biography:"Claudia S. Plaisted Fernandez, DrPH, MS, RD, LDN, is an associate professor in the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. She is the co‐author of It‐Factor Leadership: Become a Better Leader in 13 Steps. Dr. Fernandez has extensive experience developing custom executive education programs that focus on personal leadership development, innovation, and business skills for senior, middle, and frontline managers and leaders. As a licensed and registered dietitian, she has a particular interest in leadership in healthcare systems and high‐performing healthcare and public health teams. Since 2006, she has directed the American College of Obstetricians and Gynecologists Robert C. Cefalo ACOG National Leadership Institute. Since 2005 she has served as the director of the Leadership Core of the Food Systems Leadership Institute, which was ranked number 2 in the country for open enrollment/continuing education in leadership by Leadership Excellence in 2016. In 2015 she was named the Co‐Principal Investigator of the Clinical Scholars Fellowship for the Robert Wood Johnson Foundation’s Advancing Change Leadership initiative. She has co‐created and/or led several other leadership institutes, including the Managing in Turbulent Times: The Kellogg Fellowship for Emerging Leaders in Public Health Program (a minority leadership development program), the Southeast Public Health Leadership Institute, and Leadership Novant for the Novant Healthcare system. As an executive coach, Dr. Fernandez incorporates a wide array of leadership and psychological assessment tools and simulations and she is a trained hypnotherapist and stress management specialist with twenty years of experience counseling clients. Her programs offer values‐based coaching, appreciative inquiry, and engaged learning. Dr. Fernandez earned her BS from Miami University of Ohio in 1986 and her MS from Boston University in 1988. She then pursued further education in psychology and counseling at the Harvard University Extension School and at the University of North Carolina at Chapel Hill, where she earned her doctorate in leadership studies in 2003 through the Public Health Leadership Department and Health Policy and Administration. Dr. Fernandez worked in the Harvard Medical School-affiliated hospital system for more than five years before joining the Duke Center for Living in 1992. In 1997 she accepted a faculty position with UNC and subsequently worked at the North Carolina Institute for Public Health. In 2007 she joined the faculty in the Department of Maternal and Child Health at the renowned UNC Gillings School of Global Public Health.",institutionString:"The University of North Carolina at Chapel Hill",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"17",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of North Carolina at Chapel Hill",institutionURL:null,country:{name:"United States of America"}}}],equalEditorOne:{id:"419433",title:"Dr.",name:"Giselle",middleName:null,surname:"Corbie-Smith",slug:"giselle-corbie-smith",fullName:"Giselle Corbie-Smith",profilePictureURL:"https://mts.intechopen.com/storage/users/419433/images/system/419433.jpg",biography:"Giselle Corbie-Smith, MD, MSc, is Kenan Distinguished Professor, Departments of Social Medicine and Medicine, Director of the UNC Center for Health Equity Research at the University of North Carolina at Chapel Hill, and Associate Provost for UNC Rural. Internationally recognized for her scholarly work and expertise in community-engaged and patient-oriented research, Dr. Corbie-Smith has empirically studied methodological, ethical, and practical issues relating to studying racial disparities in health. Dr. Corbie-Smith has served as the Principal Investigator of several community-based participatory research projects focused on disease risk reduction among rural racial and ethnic minorities. These projects have included funding through the National Heart Lung and Blood Institute, the Robert Wood Johnson Foundation (RWJF), the National Center for Minority Health and Health Disparities, the National Institute of Nursing Research, Greenwall Foundation, and the National Human Genome Research Institute. Dr. Corbie-Smith is accomplished in drawing communities, faculty, and healthcare providers into working partnerships in clinical and translational research. This engagement ultimately transforms the way that academic investigators and community members interact while boosting public trust in research. She has also shown a deep commitment to working in North Carolina by bringing research to communities, involving community members as partners in research, and improving the health of minority populations and underserved areas. In 2013 she established the UNC Center for Health Equity Research (CHER) to bring together collaborative multidisciplinary teams of scholars, trainees, and community members to improve North Carolina communities’ health through a shared commitment to innovation, collaboration, and health equity. Dr. Corbie-Smith is also the Co-Principal Investigator for RWJF’s Advancing Change Leadership Clinical Scholars Program, which provides intensive learning, collaboration, networking, and leadership development to seasoned clinicians to create a community of practitioners promoting health equity across the country. She served as President of the Society of General Internal Medicine (SGIM) in 2018–2019. In 2018 she was elected to the National Academy of Medicine. In 2019 Dr. Corbie-Smith created and is the current host of A Different Kind of Leader, a podcast that captures insights from diverse leaders so that organizations are in a stronger position to grow, innovate, and meet the challenges of our day. Dr. Corbie-Smith earned her MD from the Albert Einstein College of Medicine, NY, and MSc in Clinical Research from Emory University, Georgia.",institutionString:"The University of North Carolina at Chapel Hill",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of North Carolina at Chapel Hill",institutionURL:null,country:{name:"United States of America"}}},equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"200",title:"Public Health",slug:"medicine-public-health"}],chapters:[{id:"77137",title:"Introductory Chapter: A New Approach to Developing Leadership for Cross-Sector, Community-Based Change",doi:"10.5772/intechopen.98448",slug:"introductory-chapter-a-new-approach-to-developing-leadership-for-cross-sector-community-based-change",totalDownloads:332,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:null,signatures:"Claudia S.P. Fernandez and Giselle Corbie-Smith",downloadPdfUrl:"/chapter/pdf-download/77137",previewPdfUrl:"/chapter/pdf-preview/77137",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"419433",title:"Dr.",name:"Giselle",surname:"Corbie-Smith",slug:"giselle-corbie-smith",fullName:"Giselle Corbie-Smith"}],corrections:null},{id:"77439",title:"Clinical Scholars: Effective Approaches to Leadership Development",doi:"10.5772/intechopen.98449",slug:"clinical-scholars-effective-approaches-to-leadership-development",totalDownloads:168,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"The Clinical Scholars (CS) National Leadership Institute (CSNLI) equips interprofessional teams of health care professionals through equity-centered leadership training, preparing them to be change leaders working to advance health equity in communities across the US and its territories. At the time of this writing, four cohorts consisting of 131 Fellows from 14 different disciplines, participating in 36 different teams of two to five members are working on “Wicked Problem Impact Projects”, an implementation science-based approach to action learning projects. This chapter reports on the design of the 3-year CS experience, the onsite and distance-based training support, and the subsequent learning responses of 98 participants, 30 of whom had completed the 3-year training (Cohort 1), 34 of whom had completed 2-years of the training (Cohort 2), and 34 who had completed 1-year of the training (Cohort 3). The training program is guided by 25 competencies that weave leadership and equity throughout, which are divided into four families: Personal, Interpersonal, Organizational, and Community & Systems. Learning outcomes indicated that Fellows are highly satisfied, with all participants rating their experience at 6.10-6.77 on a 7-point scale across all sessions, all years. Retrospective pre-and post-tests assessed learning gains on the competencies, indicating statistically significant changes from baseline to midpoint in participant knowledge, attitude, use, and self-efficacy in each of the 25 competencies and large and significant gains by competency family. The Clinical Scholars Program presents an in-depth, longitudinal, state-of-the-art approach to promoting the cultivation and development of a large and sophisticated set of skills that intentionally integrate leadership competencies with a focus on health equity. Taken together, these outcomes show how a logical and structured process, using widely available tools, can contribute to both learning and implementation of skills that lead to real world impacts in communities. Given the results reported at the close of their Clinical Scholars experience, the data suggest that investing in robust, intensive leadership development of interprofessional teams is a smart decision for impacting the culture of health in communities nationwide.",signatures:"Claudia S.P. Fernandez, Giselle Corbie-Smith, Melissa Green, Kathleen Brandert, Cheryl Noble and Gaurav Dave",downloadPdfUrl:"/chapter/pdf-download/77439",previewPdfUrl:"/chapter/pdf-preview/77439",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"419720",title:"Dr.",name:"Giselle",surname:"Corbie-Smith",slug:"giselle-corbie-smith",fullName:"Giselle Corbie-Smith"},{id:"419721",title:"Dr.",name:"Melissa",surname:"Green",slug:"melissa-green",fullName:"Melissa Green"},{id:"419722",title:"Dr.",name:"Kathleen",surname:"Brandert",slug:"kathleen-brandert",fullName:"Kathleen Brandert"},{id:"419723",title:"Dr.",name:"Cheryl",surname:"Noble",slug:"cheryl-noble",fullName:"Cheryl Noble"},{id:"419724",title:"Dr.",name:"Gaurav",surname:"Dave",slug:"gaurav-dave",fullName:"Gaurav Dave"}],corrections:null},{id:"77329",title:"Clinical Scholars: Making Equity, Diversity and Inclusion Learning an Integral Part of Leadership Development",doi:"10.5772/intechopen.98450",slug:"clinical-scholars-making-equity-diversity-and-inclusion-learning-an-integral-part-of-leadership-deve",totalDownloads:205,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"The plethora of persistent and pervasive health inequities in the United States is a Wicked Problem which threatens the health and wellbeing of all people. To dismantle them is no easy task, and requires a health care workforce practiced in leadership skill sets embracing a deep focus on areas of equity, diversity and inclusion (EDI). This chapter describes how the core competencies and curriculum of the Clinical Scholars Program have been designed to offer this set of skills. To start, the program’s foundational set of 25 competencies cover four domains (Personal, Interpersonal, Organizational, and Community & Systems) and include both more traditional leadership competencies as well as contemporary competencies focused on equity, diversity, and inclusion. The curriculum takes the set of 25 leadership and EDI competencies and breaks them down into learning sessions where participants listen, practice, and apply the ideas, behaviors, and mindsets. The leadership core and the EDI core of the curriculum exist both in tandem and in unison to provide the full Clinical Scholars experience. At times, sessions focus on one core or the other, and at times, both leadership and EDI are present in the learning of a session. Example learning sessions for each core and the weaving of the cores together are provided. Four challenges to creating an equity-centered leadership program are identified: 1. The personalized nature of the journey of self-development; 2. Shifting Mindsets and Skill Sets; 3. Piloting an evidence-based curriculum on EDI; and 4. Maintaining engagement with participants over time and across distance. A set of top recommendations for weaving EDI and Leadership learning are also offered. The chapter details the importance of meaningfully focusing on EDI when tackling modern, wicked problems.",signatures:"Kathleen Brandert, Giselle Corbie-Smith, Rachel Berthiaume, Melissa Green and Claudia S.P. Fernandez",downloadPdfUrl:"/chapter/pdf-download/77329",previewPdfUrl:"/chapter/pdf-preview/77329",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"419756",title:"Dr.",name:"Kathleen",surname:"Brandert",slug:"kathleen-brandert",fullName:"Kathleen Brandert"},{id:"419757",title:"Dr.",name:"Giselle",surname:"Corbie-Smith",slug:"giselle-corbie-smith",fullName:"Giselle Corbie-Smith"},{id:"419758",title:"Dr.",name:"Rachel",surname:"Berthiaume",slug:"rachel-berthiaume",fullName:"Rachel Berthiaume"},{id:"419759",title:"Dr.",name:"Melissa",surname:"Green",slug:"melissa-green",fullName:"Melissa Green"}],corrections:null},{id:"77272",title:"Clinical Scholars: Using Program Evaluation to Inform Leadership Development",doi:"10.5772/intechopen.98451",slug:"clinical-scholars-using-program-evaluation-to-inform-leadership-development",totalDownloads:202,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"Leadership development programs are notoriously difficult to evaluate, and when evaluations are attempted, they often do not go beyond measuring low-level, short-term outcomes of the impacts experienced by participants. Many leadership development programs do not systematically assess changes that are catalyzed within the organizations, communities and systems in which participants lead. To address these challenges, evaluators of the Clinical Scholars National Leadership Institute (CNLI) have designed a comprehensive, mixed-methods evaluation approach to determine the effectiveness of the training and explore the impacts of participants in the spheres in which they lead. Guided by Michael Patton’s Developmental Evaluation approach and framed by Kirkpatrick’s Training Evaluation Model, the CSNLI evaluation collects data on multiple levels to provide a robust picture of the multiple outcomes of the program. The approach focuses on individual participant outcomes, by measuring competency changes over time and exploring how participants use the competencies gained through the training in their work. Social network analysis is utilized to measure the development and expansion of participants’ networks and collaboration within the teams, cohorts, and across sectors and disciplines throughout their time in the CSNLI. The Most Significant Change methodology and semi-structured alumni interviews are used to measure impacts participants identify as occurring as a result of their participation. Finally, Concept Mapping is implemented to explore how Fellows make meaning of the foundational concepts and values of the CSNLI. The outcome and impact evaluation activities employed by the CSNLI, in combination with quality improvement-focused process evaluation, support innovation and excellence in the provision of a health equity-grounded leadership development program.",signatures:"Gaurav Dave, Cheryl Noble, Caroline Chandler, Giselle Corbie-Smith and Claudia S.P. Fernandez",downloadPdfUrl:"/chapter/pdf-download/77272",previewPdfUrl:"/chapter/pdf-preview/77272",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"419783",title:"Dr.",name:"Gaurav",surname:"Dave",slug:"gaurav-dave",fullName:"Gaurav Dave"},{id:"419784",title:"Dr.",name:"Cheryl",surname:"Noble",slug:"cheryl-noble",fullName:"Cheryl Noble"},{id:"419785",title:"Dr.",name:"Caroline",surname:"Chandler",slug:"caroline-chandler",fullName:"Caroline Chandler"},{id:"419786",title:"Dr.",name:"Giselle",surname:"Corbie-Smith",slug:"giselle-corbie-smith",fullName:"Giselle Corbie-Smith"}],corrections:null},{id:"77693",title:"Culture of Health Leaders: Building a Diverse Network to Advance Health Equity",doi:"10.5772/intechopen.98452",slug:"culture-of-health-leaders-building-a-diverse-network-to-advance-health-equity",totalDownloads:175,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The Culture of Health Leaders Program takes a holistic approach to leadership development, having participants work through a three-year process centered around four Areas of Mastery (self, relationships, environment, and change). Applying an equity lens to their leadership style and systems-level change work, a focus on the inner world, and network activation are some of the unique approaches the program uses that have resulted in advancing equitable leadership and a culture of health around the country. Use of rapid cycle learning and participant-led activities has allowed program staff to build upon lessons learned and adapt to participant needs in order to evolve the programming and participant experience since its inception in 2016.",signatures:"Natalie S. Burke, Gail C. Christopher, Tara S. Hacker, Jeffrey Moy and Andrea Williams",downloadPdfUrl:"/chapter/pdf-download/77693",previewPdfUrl:"/chapter/pdf-preview/77693",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"419764",title:"Dr.",name:"Natalie S.",surname:"Burke",slug:"natalie-s.-burke",fullName:"Natalie S. Burke"},{id:"419765",title:"Dr.",name:"Gail C.",surname:"Christopher",slug:"gail-c.-christopher",fullName:"Gail C. Christopher"},{id:"419766",title:"Dr.",name:"Tara S.",surname:"Hacker",slug:"tara-s.-hacker",fullName:"Tara S. Hacker"},{id:"419767",title:"Dr.",name:"Jeffrey",surname:"Moy",slug:"jeffrey-moy",fullName:"Jeffrey Moy"},{id:"419768",title:"Dr.",name:"Andrea",surname:"Williams",slug:"andrea-williams",fullName:"Andrea Williams"}],corrections:null},{id:"77220",title:"From Margins to Mainstream: Creating a Rural-Based Center of Excellence in Transgender Health for Upstate, New York",doi:"10.5772/intechopen.98453",slug:"from-margins-to-mainstream-creating-a-rural-based-center-of-excellence-in-transgender-health-for-ups",totalDownloads:177,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:1,abstract:"Transgender people face many barriers to healthcare, especially in rural America. The work to decrease barriers to care and address health care disparities for this population meets criteria for a wicked problem, each of which is unique and has no clear solution. The barriers are related to the individual and society and are both formal and informal. The definition for a Center of Excellence in healthcare is loose, but these organizations aspire to serve as specialized programs that offer comprehensive, interdisciplinary expertise and resources within a medical field to improve patient outcomes. With funding and leadership training from the Robert Wood Johnson Clinical Scholars program, a group of medical and mental health clinicians worked for three years with the goal of creating a Rural-Based Center of Excellence in Transgender Health embedded within a family practice to approach the wicked problem of transgender healthcare in their region. The goals of the center were six pronged: the provision of competent and affirming medical, surgical and mental health services, training for healthcare professional students, medical-legal advocacy and patient-centered research. The team created a strategic plan, with five strategic directions, including 1) developing infrastructure and organizational capacity, 2) expanding awareness, knowledge and skills, 3) fulfilling staffing needs, 4) ensuring gender-affirming care, and 5) advancing evidence-based care. I describe our work to bring transgender health from the margins to the mainstream for our region through implementation of this strategic plan.",signatures:"Carolyn Wolf-Gould",downloadPdfUrl:"/chapter/pdf-download/77220",previewPdfUrl:"/chapter/pdf-preview/77220",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"419770",title:"Dr.",name:"Carolyn",surname:"Wolf-Gould",slug:"carolyn-wolf-gould",fullName:"Carolyn Wolf-Gould"}],corrections:null},{id:"77144",title:"Building a Dental Home Network for Children with Special Health Care Needs",doi:"10.5772/intechopen.98455",slug:"building-a-dental-home-network-for-children-with-special-health-care-needs",totalDownloads:170,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"Children with special health care needs (SHCNs) live in all communities. They present with a diverse group of diagnoses including complex chronic conditions and diseases; physical, developmental, and intellectual disabilities; sensory, behavioral, emotional, psychiatric, and social disorders; cleft and craniofacial congenital disabilities, anomalies, and syndromes; and inherited conditions causing abnormal growth, development, and health of the oral tissues, the teeth, the jaws, and the craniofacial skeleton. Tooth decay, gum disease, dental injuries, tooth misalignment, oral infections, and other oral abnormalities are commonly seen or reported in the health history of children with SHCNs. Nationally, dental and oral health care ranks as the second most common unmet health need, according to the most recent National Survey of Children with Special Health Care Needs. The State of Minnesota does not have enough dental professionals prepared to meet the demand for care. As a result, children with SHCNs either go untreated or receive inadequate services resulting in treatment delays, the need for additional appointments, poor management of oral pain and dysfunction, adverse dental treatment outcomes and/or a lack of appropriate referrals to needed specialists. Research suggests children with SHCNs are best served when assigned to dental homes where all aspects of their oral health care are delivered in a comprehensive, interdisciplinary, and family-centered way under the direction of knowledgeable, experienced dental professionals working collaboratively with an array of allied health, medical professionals, and community partners. An interdisciplinary team consisting of a pediatric dentist, pediatric physician, and speech-language pathology innovator collaborated to advance current and future dental providers’ knowledge and comfort in providing care for children with SHCNs and was accepted into the Clinical Scholars program. Their interdisciplinary collaborative team project was named MinnieMouths and included the following six methods or critical endeavors to ensure success: 1. Development of a project ECHO site focused on advancing care for children with SHCNs. 2. Creation of a 28-participant web-based professional network of current dental, community health liaisons, family navigators, and medical health providers. 3. Establishment of a 32-participant web-based interface of dental and medical students and residents, including new-to-practice dental providers. 4. Launching an annual conference focused on advancing oral health care for children with SHCN. 5. Build a toolkit aimed at allowing dentists and future leadership teams to launch dental home networks focused on children with SHCN. 6. Building a Dental Homes Network Field Guide for Providers who attended our first in-person conference. Findings from the MinnieMouths project suggest that development of peer networks to advance dental homes for children with SHCNs has merit. Network participants gained skills in collaborating with a range of health care providers, understanding the complexities of working within and among health and dental care systems to coordinate care, and the need to better understand and advocate for a more robust medical and dental reimbursement program when launching dental homes for children with SHCN.",signatures:"Mark DeRuiter, Jeffrey Karp and Peter Scal",downloadPdfUrl:"/chapter/pdf-download/77144",previewPdfUrl:"/chapter/pdf-preview/77144",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"419772",title:"Dr.",name:"Mark",surname:"DeRuiter",slug:"mark-deruiter",fullName:"Mark DeRuiter"},{id:"419773",title:"Dr.",name:"Jeffrey",surname:"Karp",slug:"jeffrey-karp",fullName:"Jeffrey Karp"},{id:"419774",title:"Dr.",name:"Peter",surname:"Scal",slug:"peter-scal",fullName:"Peter Scal"}],corrections:null},{id:"77173",title:"Oral Health in Communities and Neighborhoods (OHICAN) Pilot Project: The Burden of Poor Oral Health",doi:"10.5772/intechopen.98456",slug:"oral-health-in-communities-and-neighborhoods-ohican-pilot-project-the-burden-of-poor-oral-health",totalDownloads:144,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"Poor oral health afflicts many low-income and other vulnerable populations. Lack of access to oral health can lead to unnecessary tooth decay, periodontal disease, pain, and the advancement of oral cancer. The absence of preventive care often leads to unnecessary and expensive visits to hospital-based emergency departments to address the pain of dental disease but not the causal conditions. The consequences on inequitable access to dental care are significant for individuals, families and communities. The OHICAN pilot project looked to address the lack of equitable access to care by creating new points of access, training medical providers to perform oral exams and apply fluoride when indicated, thus increasing the oral health workforce, utilizing technology to bridge clinical practice, education, training and research, educating stakeholders to allow dental hygienists to provide preventive care under general supervision, and creating business models that will assist others who seek to create a dental home for those they serve. Social, political and economic forces all contribute to varying degrees in terms of equity in healthcare. The work of OHICAN was designed to create a blueprint for potential solutions to these issues in order to foster oral health equity. Changes to improve access to dental care can take place in a relatively short period of time when all who care and are impacted by this continued unmet oral health need work together.",signatures:"Charles E. Moore, Hope Bussenius and David Reznik",downloadPdfUrl:"/chapter/pdf-download/77173",previewPdfUrl:"/chapter/pdf-preview/77173",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"419775",title:"Dr.",name:"Charles E.",surname:"Moore",slug:"charles-e.-moore",fullName:"Charles E. Moore"},{id:"419776",title:"Dr.",name:"Hope",surname:"Bussenius",slug:"hope-bussenius",fullName:"Hope Bussenius"},{id:"419777",title:"Dr.",name:"David",surname:"Reznik",slug:"david-reznik",fullName:"David Reznik"}],corrections:null},{id:"77330",title:"underdog DREAMS: Improving Long-Term Quality of Life Outcomes for Florida’s Foster Youth and Families",doi:"10.5772/intechopen.98457",slug:"underdog-dreams-improving-long-term-quality-of-life-outcomes-for-florida-s-foster-youth-and-families",totalDownloads:150,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Children and youth in the foster care system face significant and continuing barriers to both physical and mental health, including lack of a medical home, disruptions in primary care providers, frequent moves to new homes, excessive caseloads for oversight providers, and at times continuing exposure to the risk factors that are considered Adverse Childhood Experiences (ACEs). The underdog DREAMS project sought to alter the course of the foster youth experience via a tri-part model that focused on clinical, research, and advocacy interventions for foster youth and the development of the workforce that supports them through training on the impacts of trauma and poverty.",signatures:"Annette Bell, Slyving Bourdeau, Asha Davis, Amanda Stanec and Derrick Stephens",downloadPdfUrl:"/chapter/pdf-download/77330",previewPdfUrl:"/chapter/pdf-preview/77330",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"419778",title:"Dr.",name:"Annette",surname:"Bell",slug:"annette-bell",fullName:"Annette Bell"},{id:"419779",title:"Dr.",name:"Slyving",surname:"Bordeau",slug:"slyving-bordeau",fullName:"Slyving Bordeau"},{id:"419780",title:"Dr.",name:"Asha",surname:"Davis",slug:"asha-davis",fullName:"Asha Davis"},{id:"419781",title:"Dr.",name:"Amanda",surname:"Stanec",slug:"amanda-stanec",fullName:"Amanda Stanec"},{id:"419782",title:"Dr.",name:"Derrick",surname:"Stephens",slug:"derrick-stephens",fullName:"Derrick Stephens"}],corrections:null},{id:"77160",title:"Creating a Culture of Mental Health in Filipino Immigrant Communities through Community Partnerships",doi:"10.5772/intechopen.98458",slug:"creating-a-culture-of-mental-health-in-filipino-immigrant-communities-through-community-partnerships",totalDownloads:225,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"One out of five children in the United States has a mental, emotional, or behavioral health diagnosis. Behavioral health issues cost America $247 billion per year and those with mental health disorders have poorer health and shorter lives. Evidence-based parenting interventions provided in childhood have proven to be effective in helping parents to prevent disruptive, oppositional and defiant behaviors, anxiety and depressive symptoms, tobacco, alcohol, and drug misuse, aggression, delinquency, and violence. Yet, few parents participate in such programs, especially hard-to-reach, underserved minority and immigrant populations. The Robert Wood Johnson Foundation has identified a culture of health action framework that mobilizes individuals, communities, and organizations in order to examine ways to improve systems of prevention, invest in building the evidence base for such systems, and provide evidence-based information to decision makers. The overarching goal of this effort was to create a culture of mental health among Filipinos, a large, yet understudied immigrant community that is affected by alarming mental health disparities, including high rates of adolescent suicide ideation and attempts. Our impact project focused on increasing the reach of the Incredible Years® because maximizing the participation of high-risk, hard-to-engage populations may be one of the most important ways to increase the population-level impact of evidence-based parenting programs. If the approach succeeded with Filipinos, comparable strategies could be used to effectively reach other underserved populations in the U.S., many of whom are reluctant to seek behavioral health services. In this chapter we discuss 1) the state of the literature on the topic of Filipino adolescent mental health disparities; 2) our wicked problem and the impact project aimed at ameliorating this issue; 3) how our team formed and implemented our impact project; 4) outcomes and results of our efforts; 5) challenges we faced and how they were overcome; 6) the leadership and health equity skills that were most helpful in addressing our problem; and 7) a toolkit that could assist other communities addressing youth mental health and prevention of suicide and depression.",signatures:"Aviril Sepulveda, Dean M. Coffey, Jed David, Horacio Lopez, Kamil Bantol and Joyce R. Javier",downloadPdfUrl:"/chapter/pdf-download/77160",previewPdfUrl:"/chapter/pdf-preview/77160",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"419725",title:"Dr.",name:"Aviril",surname:"Sepulveda",slug:"aviril-sepulveda",fullName:"Aviril Sepulveda"},{id:"419726",title:"Dr.",name:"Dean M.",surname:"Coffey",slug:"dean-m.-coffey",fullName:"Dean M. Coffey"},{id:"419727",title:"Dr.",name:"Jed",surname:"David",slug:"jed-david",fullName:"Jed David"},{id:"419728",title:"Dr.",name:"Horacio",surname:"Lopez",slug:"horacio-lopez",fullName:"Horacio Lopez"},{id:"419729",title:"Dr.",name:"Joyce R.",surname:"Javier",slug:"joyce-r.-javier",fullName:"Joyce R. Javier"},{id:"421593",title:"Dr.",name:"Kamil",surname:"Bantol",slug:"kamil-bantol",fullName:"Kamil Bantol"}],corrections:null},{id:"77161",title:"Addressing the Under-Representation of African American Public Health Researchers: The Flint Youth Public Health Academy",doi:"10.5772/intechopen.98459",slug:"addressing-the-under-representation-of-african-american-public-health-researchers-the-flint-youth-pu",totalDownloads:143,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"In order to meet the health needs of a culturally diverse population, the United States public health workforce must become ethnically diversified to provide culturally competent care. The underrepresentation of minority, specifically African American public health professionals may be a contributing factor to the high rates of preventable health disparities in the African American community. Studies have shown that racial/ethnic communities bear the highest disparities across multiple health outcomes. African Americans, when compared with European Americans, suffer the greatest rates of health disparities, thus providing the justification to increase minority public health professionals. In addition, studies suggest that minorities are more likely to seek medical and health services from individuals of the same ethnicity. This will assist in decreasing language and comprehension barriers and increase the cultural competence of the health providers who serve populations from their ethnic/cultural origin. This chapter will highlight a 2014 study designed to explore and identify motivators for African Americans to choose public health as a career. African American public health professionals and graduate students were engaged to discuss their career and educational trajectories and motivators for career choice. Using qualitative research methods, this study was guided by the following research question: what are the motivating factors to engage African Americans into careers in public health? The study was approved by the Walden University Institutional Review Board and was conducted in 2014. The results of this study have served as the blueprint for the creation of the Flint Public Health Youth Academy (FPHYA). Coincidently the 2014 study was wrapping up at the genesis of the Flint Water Crisis (FWC). The FWC impacted residents of all ages in Flint. Specifically, the youth of Flint were exposed to lead (a neuro-toxin) and other contaminants through the water system which impacted them physically and cognitively. National media outlets disseminated headlines across the world that Flint youth would have behavioral (aggression) issues and struggle academically as a result of their exposure to lead. The FPHYA was designed to provide positive messages to and about Flint youth. It is an introduction to careers in public health, medicine, and research for Flint Youth. It creates a space for Flint youth to work through their lived experience of the FWC while learning the important role public health and research plays in recovering from an environmental public health crisis. More importantly, it is a pathway to public health careers providing didactic sessions, local mentors and internships.",signatures:"Kent Key",downloadPdfUrl:"/chapter/pdf-download/77161",previewPdfUrl:"/chapter/pdf-preview/77161",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"419752",title:"Dr.",name:"Kent",surname:"Key",slug:"kent-key",fullName:"Kent Key"}],corrections:null},{id:"77129",title:"Violence: A Prescription of Hope for a Vulnerable Population",doi:"10.5772/intechopen.98460",slug:"violence-a-prescription-of-hope-for-a-vulnerable-population",totalDownloads:123,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"Violence is a preventable disease that has long term effects on health. In the United States, violence has become an epidemic that disproportionately affects the African American community. Risk factors that contribute to the perpetration of youth violence include a combination of individual, relationship, community, and societal factors. Individual risk factors include a personal history of victimization of violence, high emotional stress, and exposure to violence and conflict. Family risk factors include low parental education, low income, poor family functioning and low parental involvement. Community risk factors include diminished economic opportunities, high concentration of poor residents, and socially disorganized neighborhoods – all of which are prevalent in communities with high rates of violence. Preventive strategies aimed at reducing violence need to be collaborative and community based. This multi-city project, A Prescription of Hope, aims to educate community members from Illinois and Missouri on the long- term effects of exposure to violence. The target population for Missouri is Ferguson, a small community with an approximate population of 21,035 (2017); however, it is recognized nationally for the demonstrations and unrest that erupted after the August 9, 2014 shooting death of 18-year-old Michael Brown. Worldwide, an estimated 200,000 homicides occur each year among youth aged 10–29 years, accounting for 43% of all homicide annually.",signatures:"Tonita Smith, Edith Amponsah and Lia Garman",downloadPdfUrl:"/chapter/pdf-download/77129",previewPdfUrl:"/chapter/pdf-preview/77129",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"421101",title:"Dr.",name:"Tonita",surname:"Smith",slug:"tonita-smith",fullName:"Tonita Smith"},{id:"421102",title:"Dr.",name:"Edith",surname:"Amponsah",slug:"edith-amponsah",fullName:"Edith Amponsah"},{id:"421103",title:"Dr.",name:"Lia",surname:"Garman",slug:"lia-garman",fullName:"Lia Garman"}],corrections:null},{id:"77243",title:"The MHISTREET: Barbershop Embedded Education Initiative",doi:"10.5772/intechopen.98461",slug:"the-mhistreet-barbershop-embedded-education-initiative",totalDownloads:161,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"The United States (US) is in the midst of a mental health crisis. More than one in four (26.2%) adults experience a diagnosable mental health disorder each year, and 46% of the population will do so in their lifetime. Collectively, mental health disorders are a leading cause of disability and account for one-third of all years lived with disability and premature mortality. Black Americans constitute about 12% of the US population, but they make up more than 18% of the population affected by mental disorders. Black men are 30% more likely than non-Hispanic white men to report having a mental illness but are less likely to receive proper diagnosis and treatment. Black adults are 20% more likely to report serious psychological distress than white adults. Despite this, many Black people do not seek mental health care for various reasons. Causes of higher morbidity and non-care seeking behavior in Black people and Black men in particular include racism, discrimination, stigma, and distrust of the healthcare system. Across the District of Columbia (DC), Black Americans are twice as likely as other ethnicities to report a serious mental disorder, especially if they live in poverty and did not complete high school. In the project service area of Ward 8 in Southeast DC, 92% of the population is Black, 30.7% live in poverty, and only 85% of the population age 25+ completed high school. Evidence shows common mental health disorders are distributed according to a gradient of economic disadvantage across society; the poor and disadvantaged suffer disproportionately from common mental health disorders. In Southeast DC, this negative impact on mental health is compounded by the geographic concentration of underemployment, lack of economic opportunity, poverty, and underutilization of mental health services. Improving mental health literacy is a non-systemic intervention shown to increase mental health care-seeking behaviors. Mental health literacy is the knowledge of, attitude about, and behavior toward mental health issues and mental health services. The goal of the Mental Health Improvement through Study, Teaching, Rebranding, Embedded Education, and Technology or (MHISTREET) initiative is to improve mental health in Black men through embedded education in non-traditional spaces such as barbershops.",signatures:"Nnemdi Kamanu Elias, Alfred Larbi, Kevin Washington and Erin Athey",downloadPdfUrl:"/chapter/pdf-download/77243",previewPdfUrl:"/chapter/pdf-preview/77243",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"}],corrections:null},{id:"77322",title:"Somewhere to Go: Implementing Medication-Based Treatment for Opioid Use Disorders in Rural Maryland and beyond",doi:"10.5772/intechopen.98462",slug:"somewhere-to-go-implementing-medication-based-treatment-for-opioid-use-disorders-in-rural-maryland-a",totalDownloads:129,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Treatment for opioid use disorders is highly effective yet unavailable in many rural areas. “Somewhere to Go: Ensuring Access to Medication-Assisted Treatment in Rural Maryland” is a Robert Wood Johnson Funded Clinical Scholars project intended to expand the use of tele-health medication-based treatment for opioid use disorders services directly to rural areas in need. We demonstrated that a University-based substance use treatment team can successfully collaborate with a geographically distant rural substance use treatment clinic to provide medication-based treatment for opioid use disorders using a HIPPA compliant telehealth strategy. We provide an overview of the implementation strategies our team used to expand overall access in different locales throughout the State of Maryland and beyond. We describe implementation results of a tele-health medication-based treatment program for opioid use disorders that focuses on implementation successes and how to identify and overcome implementation challenges and barriers. Implementation of a telemedicine approach can be challenging, but careful consideration and forethought can map a successful path to program development, operation and sustainability.",signatures:"Seth Himelhoch, Marion Currens, Jewell Benford and Eric Weintraub",downloadPdfUrl:"/chapter/pdf-download/77322",previewPdfUrl:"/chapter/pdf-preview/77322",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"},{id:"421104",title:"Dr.",name:"Seth",surname:"Himelhoch",slug:"seth-himelhoch",fullName:"Seth Himelhoch"},{id:"421105",title:"Dr.",name:"Marion",surname:"Currens",slug:"marion-currens",fullName:"Marion Currens"},{id:"421106",title:"Dr.",name:"Jewell",surname:"Benford",slug:"jewell-benford",fullName:"Jewell Benford"},{id:"421107",title:"Dr.",name:"Eric",surname:"Weintraub",slug:"eric-weintraub",fullName:"Eric Weintraub"}],corrections:null},{id:"77358",title:"Transforming Opioid Addictions Care in New Mexico: Combining Medication Treatment with Patient Autonomy, Civic Engagement and Integrative Healing",doi:"10.5772/intechopen.98463",slug:"transforming-opioid-addictions-care-in-new-mexico-combining-medication-treatment-with-patient-autono",totalDownloads:170,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Opioid addiction is a complex issue. New Mexico has historically experienced some of the highest rates of deaths from opioid overdose, and opioid addictions have affected generations of New Mexicans -- starting many years before the more recent national crisis. Treatment approaches to opioid and other addictions are fraught with paternalism, stigma, surveillance, criminalization, shaming, racism, discrimination, and issues with access to care. Current treatment paradigms fail to take into account the social and economic factors of people, community, and context. New paradigms embracing a broader, more-just contextualization of addictions, along with evidence-based treatment approaches are needed to transform medicine’s historic role in the “war on drugs”. The Strong Roots/Raices Fuertes program was developed by two community clinics, Casa de Salud and Centro Sávila, in Albuquerque, New Mexico. The program evolved from a desire to to acknowledge and right historical harms that the medical-industrial complex has caused; to provide rapid access to dignified, life-saving, evidence-based holistic treatment for opioid addictions in a community setting; and to build a model of care that transforms the biomedical model into one of solidarity with community and collective care. Five key concepts underpin the program design: 1) Harm Reduction, Autonomy, and Agency; 2) Healing-Centered Engagement; 3) Language and Cultural Humility; 4) Transforming Health Systems Design; 5) Workforce Diversity and Pipeline Training. The program’s core components include conventional approaches such as low-barrier access buprenorphine (suboxone®) to medication treatment, primary care, case management, syringe exchange, and counseling/therapy in addition to more community-rooted and integrative healing modalities such as healing circles, acupuncture, massage, reiki, ear acudetox, and civic engagement. In sharing the values, lessons learned, and tools from our work in the Strong Roots/Raices Fuertes program, we hope to inspire and encourage others wishing to develop new systems of care for people dealing with addiction issues.",signatures:"Anjali Taneja and William Wagner",downloadPdfUrl:"/chapter/pdf-download/77358",previewPdfUrl:"/chapter/pdf-preview/77358",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. Fernandez"}],corrections:null},{id:"77116",title:"Beautiful Ruin: Creating Healthfields",doi:"10.5772/intechopen.98464",slug:"beautiful-ruin-creating-healthfields",totalDownloads:171,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"Multiple programs promote redevelopment of land reuse sites, which are environmentally impacted or potentially contaminated sites. Historically, such programs have focused primarily on economic development. However, public health is an important consideration to address not only sustainable redevelopment but also health inequity and disparities. The Agency for Toxic Substances and Disease Registry’s (ATSDR) Land Reuse Health Program is a special program to promote broad public health improvements through safe land reuse and redevelopment. Land reuse sites are virtually in every community in the U.S. and are a global problem. Brownfields are the greatest number of land reuse sites. With estimates of over 450,000 land reuse sites across the U.S., most communities suffer the burden of blight and contamination associated with these sites. ATSDR promotes and practices Healthfields Redevelopment: The safe reuse of environmentally distressed land to reduce exposures to contaminants and to improve overall health in the community. In this chapter, I highlight Navajo Nation Healthfields activities using ATSDR’s 5-step Land Reuse Strategy to Safely Reuse Land and Improve Health (5-step Land Reuse Model) and describe some of ATSDR’s Healthfields projects and related tools and resources for communities to create their own Healthfields practice.",signatures:"Laurel Berman",downloadPdfUrl:"/chapter/pdf-download/77116",previewPdfUrl:"/chapter/pdf-preview/77116",authors:[{id:"89429",title:"Dr.",name:"Claudia S.P.",surname:"Fernandez",slug:"claudia-s.p.-fernandez",fullName:"Claudia S.P. 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\r\n\tThe scope of this book encompasses theory and applications of differential equations of various types. Differential equations are extremely important, especially nowadays since they are known as a fundamental way of modeling dynamical systems and, thus, their properties such as stability, instability, periodic and chaotic behaviors which are extremely important when studying dynamical systems. The applications have been growing in numbers and include autonomous vehicles (with examples being driverless cars and satellites), robotics, medical surgery, precision agriculture, and smart buildings, to name a few. The complexity and techniques of analyzing behaviors of differential equations depend on whether they are ordinary, linear or nonlinear, infinite-dimensional or stochastic, etc. Another important topic is how to control differential equations to achieve particular properties that they do not possess without any control action. The control designs heavily depend on the type of differential equations as well as different constraints imposed on the control variables as well as on the information available to the controllers.
",isbn:"978-1-80355-943-8",printIsbn:"978-1-80355-942-1",pdfIsbn:"978-1-80355-944-5",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,hash:"f23ece47540382b74ca6bfb40ad8a638",bookSignature:"Prof. Dusan Stipanovic",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11149.jpg",keywords:"Pursuit Evasion Games, Nash Equilibria, Multi-Agent Systems, Stability Theory, Infinite Dimensional Systems, Differential Games, Stochastic Processes, Probability Theory, Ito Integrals, Properties, Stability, Control",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"November 12th 2021",dateEndSecondStepPublish:"December 10th 2021",dateEndThirdStepPublish:"February 8th 2022",dateEndFourthStepPublish:"April 29th 2022",dateEndFifthStepPublish:"June 28th 2022",remainingDaysToSecondStep:"5 months",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:"Dr. Dusan Stipanovic's expertise is in stability and control of differential equations, differential games, and he is a recipient of the 2017 Friedrich Wilhelm Bessel Research Award in the area of mathematics (control theory and calculus of variations). He is a visiting professor in various universities in Serbia (Belgrade and Novi Sad), China, Germany, and the USA (University of California at Berkeley). Currently, he is an Associate Editor for the Journal of Optimization Theory and Applications.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"318375",title:"Prof.",name:"Dusan",middleName:null,surname:"Stipanovic",slug:"dusan-stipanovic",fullName:"Dusan Stipanovic",profilePictureURL:"https://mts.intechopen.com/storage/users/318375/images/system/318375.jpg",biography:"Professor Dusan Stipanovic received his B.S. degree in electrical engineering from the University of Belgrade, Belgrade, Serbia in 1994, and the M.S.E.E. and Ph.D. degrees in electrical engineering from Santa Clara University, Santa Clara, California in 1996 and 2000, respectively. Dr. Stipanovic had been an Adjunct Lecturer and Research Associate with the Department of Electrical Engineering at Santa Clara University (1998-2001), and a Research Associate in Professor Claire Tomlin’s Hybrid Systems Laboratory of the Department of Aeronautics and Astronautics at Stanford University (2001-2004). In 2004, he joined the University of Illinois at Urbana-Champaign where he is now Professor in the Controls Group of the Coordinated Science Laboratory and Department of Industrial and Enterprise Systems Engineering. He is a visiting Professor in the School of Electrical Engineering of the University of Belgrade in Serbia, School of Computer Science and Technology or the University of Science and Technology in Hefei, China, Technical School of the University of Novi Sad in Serbia, and in the Robotics and Telematics Department at the University of Würzburg in Germany. He also held visiting faculty positions in the EECS Department at the University of California at Berkeley. His research interests include decentralized control and estimation, stability theory, optimal control, and dynamic games with applications in control of autonomous vehicles, precision agriculture, circuits, and medical robotics. Dr. Stipanovic served as an Associate Editor on the Editorial Boards of the IEEE Transactions on Circuits and Systems I and II. 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South Africa has the highest prevalence of people with hypertension (between 42% and 54%) compared with the eastern (15%) and western (25%) parts of Southern Africa. Sadly, the condition of these patients is still not controlled even while on treatment [1]. A recommendation of this study is that a regionally tailored intervention is implemented to prevent disastrous consequences relating to hypertension mortality and morbidity. While hypertension is a chronic, lifelong condition that needs regular and continued follow-up care, it also requires skilled health care providers who are supported by the treatment guidelines of the National Department of Health (NDoH), South Africa.
Approximately 17-million patients diagnosed with hypertension, a chronic, non-communicable and preventable disease, visit South PHC clinics for consultation. Hypertensive patients are initially encouraged to follow lifestyle modifications to promote control and management of the disease as part of its non-treatment management. Thereafter, if condition remains uncontrolled, hypertensive patients are informed to use daily treatment for the rest of their lives [2]. The NDoH of South Africa recommends that health professionals who are practicing in PHC clinics provide health education to enhance compliance with the management and control of hypertension [3].
Before 2006 parallel guidelines were developed by the Southern African Hypertension Society and the South African Department of Health, but the 2006 guideline is the combination task of the two bodies [4]. The guideline outlines dissimilar broad steps that health professionals should adhere on to achieve controlled blood pressure effectively, beginning from the patient risk screening/profiling, the measurements and investigations, the classification and complete treatment of hypertensive patients with or without co-morbidities, to their repeat and continuous plan [5]. A research conducted in Pretoria (Tshwane) on adherence to the hypertension guidelines among private practitioners and PHC physicians found that overall adherence to the hypertension practice guidelines used by generalists in private practice was 55%, while among PHC doctors in public-service, it was 56.4% [6].
Although two guidelines, Adult Primary Care (APC)/ Standard Treatment Guidelines (STG) and Essential Medicines List (EML), are available for use in PHC facilities when consulting patients with hypertension, the challenge is whether these guidelines are adhered to or not. To this end, the study sought to assess adherence or non-adherence to these guidelines and to describe the follow-up care received by patients in the Tshwane district of the Gauteng province, South Africa.
As far as the workshop on Diabetes Mellitus was concerned, the former Deputy Minister of Health in South Africa Dr. Joe Phaahla reported concerns about the quality of records in some clinics during auditing of patients’ records. Hypertensive patients’ medical history was recorded in two sentences, for example
Detailed history, physical examination and interpretation of investigations should form an integral part of the routine care of patients with hypertension. Regarding measurements, it is important to ensure that PHC nurses who take blood pressure measurements have adequate initial training and their performance periodically reviewed. Equipment for measuring blood pressure must be correctly checked, serviced and adequately recalibrated according to the companies’ instructors’ manuals. When checking blood pressure, PHC nurses in the clinics should calm the setting and provide a relaxed, temperate atmosphere, with the patients quiet and seated, and arms outstretched and supported. Use of a correct machine for the patient’s arm is important [9]. A community-based study to estimate the prevalence of hypertension and its associated factors in municipalities of Kathmandu, Nepal [10], found that factors associated with hypertension were smoking, Body Mass Index (BMI), alcohol use, poor physical activity and diabetes.
The guidelines [9] emphasise the importance of the following lifestyle modifications:
Administer continuous lifestyle advice to patients
Promote a healthy diet and regular exercise
Offer guidance and written or audiovisual materials to promote lifestyle changes
Encourage reduced alcohol consumption
Discourage excessive consumption of coffee and other caffeine-rich products
Encourage patients to keep their dietary sodium intake low
Offer advice and help smokers to stop smoking
Inform patients about support groups such as local initiatives, health care teams or patient organisations that provide support and promote life-style change [9].
In South Africa, the following lifestyle modification is also recommended [11]:
Educate patients about adequate dietary fibre intake (fruits, vegetables and unrefined carbohydrate).
The research is quantitative because it sought to measure the phenomenon by attaching numerical values to express quantity [12]. The observation was carried out in the PHC facilities whereby entries of patients’ files were evaluated. Perusal of patients’ files and documentation using checklist was also done. Furthermore, quantitative research is described as a formal, objective, systematic methodology to describe variables, to test relationships, and to examine cause and effect [13]. However, for this study, only the former is applicable. The patients whose files were perused had experienced an event that is a “follow-up consultation for hypertension”. Moreover, the patients were mostly pensioners and depending on old age grant and even the unemployed ones without the medical aids. They resided around the townships and villages of Tshwane.
The study setting was guided by the research questions and the type of data that were required to answer the following questions [14].
How is the follow-up care received by patients with hypertension at PHC facilities in the Tshwane district?
What is the adherence or non-adherence to the National Guidelines by nurses about hypertension follow-up care?
A multi-site approach was used whereby ten different PHC facilities were selected. Using multiple sites offers a larger and more diverse sample [12], which improves external validity. Both provincial and municipal facilities were included. Data collection took place at two community health centres (CHCs) and eight clinics. The total number of PHC facilities was ten. The real-life settings were natural, and uncontrolled; the researcher did not attempt to manipulate them in any way.
The units of analysis were the files of male and female patients above 30-years old, who were diagnosed with hypertension at PHC facilities in the Tshwane district of Gauteng Province. As recommended [12], this was the entire aggregation of cases in which the researcher was interested.
Ten of the 74 PHC facilities in the Tshwane district were randomly selected from the list on the National Health Research Database (NHRD). All clinics in the Tshwane district appear on the NHRD. The names of the facilities were written on pieces of paper that were placed in a bowl, and jumbled. From this, the first facility was chosen. The names were jumbled again, and the second facility was chosen. The process was repeated until all ten facilities had been chosen. According to the monthly statistics, at the time of the study, an average of 300 hypertensive patients were seen in each of the ten facilities per month. Hence, a proportional sample of ten files was conveniently chosen per facility.
The pilot study was done a month prior data collection when the research instrument was tested with ten files which were not utilised in the actual study. This was done to check if it could yield required information. The instrument was then revised and refined after the statistician checked it for validity and reliability.
Reliability of an instrument is a major criterion for assessing quality [12]. It is defined as the consistency and accuracy with which an instrument measures what is intended to measure. When used on repeated trials, an instrument with high reliability will produce the similar results [15]. To determine usefulness reliability of the instrument, the researchers utilised South African NDoH hypertension management guidelines. The guidelines support for a consistent standard of care across all PHC facilities in the country. Thus, the measuring instrument was considered reliable because it entailed attributes that are nationally recommended as the standard of care that hypertensive patients should receive during their follow-up visits.
Content validity was proofed by aligning concepts with the hypertension management guidelines of the country’s NDoH. Prior the actual real research study was conducted, a clinic that was excluded in the final study sample was piloted to test the data collection process. Inputs from clinicians were used to amend the data collection tool where necessary. Piloting was conducted between the first two months of the year 2018.
The ethics approval certificate (HSHDC/839/2018) was granted by the University of South Africa (UNISA).
Data were collected by auditing the files of patients who were consulted for hypertension follow-up using a checklist. A checklist itemises task descriptions in one column and provides a space besides each item to check off items that are done or not done [16]. The checklist contains activities that must be performed on a follow-up visit for hypertension according to the National Guidelines, the APC and the EML. The checklist was distributed by the researcher herself at the chosen PHC facilities. Some amendments and modifications were made to the checklist following the pilot study. Data were collected over a period of two months (June and July 2018), and all 100 checklists were completed.
The managers of the selected PHC clinics were contacted in advance to inform them of the data collection date. Ten files were chosen per PHC clinic, and from these, the data were gathered. Files were physically collected from the filing room with the help of the administrative staff of the PHC facility. The researchers examined each file to check that it belonged to hypertensive adult patient, who was non-diabetic and not pregnant in order to adhere with the inclusion criteria. Once ten files that adhered with the criteria were found, the data gathering started. All 54 questions on the checklist were ticked/not ticked in accordance with either attribute was recorded or not recorded.
Data were coded and checked for correctness before being entered into a Microsoft Excel codebook. The data were analysed according to the following steps:
the last year in which patient was seen at the clinic;
characteristics of the sample;
patient’s history
physical examination;
vital signs;
side room investigations;
routine blood tests;
life style assessment;
management of the patients; and
knowledge and skills of health worker.
Table 1 below indicates whether the attributes listed were assessed, as evidenced by records.
Frequencies | Percentages (%) | |
---|---|---|
Dyspnoea | ||
Yes | 1 | 1.0 |
No | 0 | 0.0 |
Not recorded | 98 | 98.0 |
Missing/Incomplete | 1 | 1.0 |
Jugular venous pressure | ||
Yes | 1 | 1.0 |
No | 0 | 0.0 |
Not recorded | 99 | 99.0 |
Apex beat recorded | ||
Yes | 0 | 0.0 |
No | 0 | 0.0 |
Not recorded | 100 | 100.0 |
Oedema | ||
Yes | 64 | 64.0 |
No | 0 | 0.0 |
Not recorded | 36 | 36.0 |
Crepitations | ||
Yes | 17 | 17.0 |
No | 0 | 0.0 |
Not recorded | 83 | 83.0 |
Heart sounds | ||
Yes | 53 | 53.0 |
No | 0 | 0.0 |
Not recorded | 47 | 47.0 |
Cyanosis | ||
Yes | 28 | 28.0 |
No | 0 | 0.0 |
Not recorded | 72 | 72.0 |
Clubbing | ||
Yes | 28 | 28.0 |
No | 0 | 0.0 |
Not recorded | 72 | 72.0 |
Blood pressure | ||
Yes | 100 | 100.0 |
No | 0 | 0.0 |
Not recorded | 0 | 0.0 |
Pulse rate, rhythm and character | ||
Pulse rate | ||
Yes | 96 | 96.0 |
No | 0 | 0.0 |
Not recorded | 4 | 4.0 |
Pulse rhythm | ||
Yes | 0 | 0.0 |
No | 0 | 0.0 |
Not recorded | 100 | 100 |
Pulse volume | ||
Yes | 0 | 0.0 |
No | 0 | 0.0 |
Not recorded | 100 | 100. |
Waist circumference recorded | ||
Yes | 0 | |
No | 0 | 0.0 |
Not recorded | 100 | 100.0 |
Blood glucose measured | ||
Yes | 23 | 23.0 |
No | 77 | 77.0 |
Urine tests | ||
Yes | 32 | 32.0 |
No | 0 | 0.0 |
Not recorded | 68 | 68.0 |
Eye test done or recorded | ||
Yes | 0 | 0.0 |
No | 0 | 0.0 |
Not recorded | 100 | 100.0 |
eGFR | ||
Yes | 70 | 70.0 |
No | 0 | 0.0 |
Not recorded | 30 | 30.0 |
Cholesterol | ||
Yes | 66 | 66.0 |
No | 0 | 0 |
Not recorded | 34 | 34.0 |
Yes | 2 | 2.0 |
No | 8 | 8.0 |
Not recorded | 90 | 90.0 |
Alcohol use | ||
Yes | 1 | 1.0 |
No | 8 | 8.0 |
Not recorded | 91 | 91.0 |
Exercise | ||
Yes | 1 | 1.0 |
No | 0 | 0.0 |
Not recorded | 99 | 99.0 |
Salt reduction | ||
Yes | 0 | 0.0 |
No | 0 | 0.0 |
Not recorded | 100 | 100.0 |
Fat reduction | ||
Yes | 0 | 0.0 |
No | 0 | 0.0 |
Not recorded | 100 | 100.0 |
Dyspnoea | 99.0 | 1.0 |
Jugular venous pressure | 99.0 | 1.0 |
Apex beat recorded | 100.0 | 0.0 |
Crepitations | 83.0 | 17.0 |
No. of pillows used | 100.0 | 0.0 |
Cyanosis | 72.0 | 28.0 |
Clubbing | 72.0 | 28.0 |
Chest pain recorded | 100.0 | 0.0 |
Walk/climb | 100.0 | 0.0 |
Pulse rhythm | 100.0 | 0.0 |
Pulse volume | 100.0 | 0.0 |
BMI | 82.0 | 18.0 |
Waist circumference recorded | 100.0 | 0.0 |
Blood glucose measured | 77.0 | 23.0 |
Urine tests | 68.0 | 32.0 |
Eye test done or recorded | 100.0 | 0.0 |
Smoking | 98.0 | 2.0 |
Alcohol Use | 99.0 | 1.0 |
Exercise | 99.0 | 1.0 |
Salt reduction | 100.0 | 0.0 |
Fat reduction | 100.0 | 0.0 |
Adherence to medication recorded | 100.0 | 0.0 |
Side effects of treatment | 100.0 | 0.0 |
Heart sounds recorded | 47.0 | 53.0 |
Attributes of physical examination, measurements, routine blood tests and non-adherent attributes.
Antihypertensive drugs are mainly prescribed to reduce blood pressure and the complications associated with the disease. According to a study conducted among South African adult residents of Mkhondo Municipality, clinical guidelines recommend the use of multiple drugs to control blood pressure effectively and reduce the possibility of hypertension related complications [17]. The authors of this study determined that a high prevalence of uncontrolled hypertension was noted irrespective of the number of drugs and the combinations administered [17]. A plausible explanation could be non-adherence to treatment by patients. Hence, it is important for clinicians to follow evidence-based guidelines in prescribing antihypertensive drugs for patients. According to a registry-based observational study in two municipalities in Cuba on assessment of hypertension management and control [18], it found that almost half of the patients receiving treatment were taking two or more antihypertensive drugs. Figure 1 below indicates the commonly used antihypertensive medications at PHC facilities in the Tshwane district of Gauteng Province, South Africa as hydrochlorothiazide, enalapril and amlodipine.
Commonly used antihypertensive medications.
In this study, the determination of adherence and non-adherence was done by dichotomizing whether or not nurses complied with clinical guidelines in providing healthcare services regarding hypertension follow-up care. Binary counts showing whether or not nurses made records in compliance with clinical guidelines were done using frequency statistics tables in SPSS. Based on clinical guidelines, adherence was affirmed present if at least 60% of sample records showed that nurses made records in line with guidelines. Conversely, non-adherence was affirmed if less than 60% of sample records showed that nurses made records as per the guidelines. The at least 60% threshold affirming adherence was derived from clinical guidelines. This study’s results on nurses’ adherence and non-adherence to guidelines are as follows:
Moving onwards, the test for presence of significant association between compliance by nurses to clinical guidelines (adherence and non-adherence) and categories of attributes (physical examination, physical measurements, life-style modification, routine blood tests, and history) was done using the chi-square test at 5 percent level of significance. The Pearson chi-square value = 11.654 (p-value = 0.020) and Cramer’s V score = 0.634 (p-value = 0.020) indicate presence of statistically significant and strong association between compliance outcome (adherence and non-adherence) and category of attributes. The results confirm existence of significant difference between adherence and non-adherence proportions at 5 percent level.
The authors of the study conducted in Mkhondo Municipality [17] assert that the high prevalence of uncontrolled hypertension can possibly be attributed to obesity, lack of physical activity and dyslipidaemia. Moreover, the prevalence of uncontrolled hypertension and its association with low HDL-C, inadequate physical activity and obesity were reported [17].
Figure 2 below shows percentages of adherent and non-adherent attributes for this study.
Adherent and non-adherent attributes.
The aim of the study was to evaluate the follow-up care received by patients with hypertension at PHC facilities in the Tshwane district. The study found a significant percentage (93.4%) of non-adherence to hypertension guidelines among consulting nurses at selected PHC facilities. Based on the results of this study, some professional nurses could not interpret the danger related to an elevated eGFR or cholesterol. Where the BMI was measured, it was not interpreted so that interventions could be implemented. In the follow-up visit, there was total misunderstanding of lifestyle modification and how it must be implemented in the management of hypertension. It was clear that PHC facilities require greater assistance and support from the employer, the NDoH of South Africa, to enable PHC nurses in the Tshwane district to adopt more follow-up care of hypertensive patients. Furthermore, in order to assist, guide and motivate the nurses to become active partners in their care, in-service trainings, resources and equipment are needed. There should be a remediation programme for professional nurses who have been trained but are found to be non-adherent to the guidelines. In a study conducted in Kinshasa, Congo, in which knowledge of consulting nurse’s was assessed, 84% of the nurses reported to have received training [19]. The results suggest that training alone may not be enough, but continuous support and remedial actions may be necessary [19].
In addition, nurses of PHC facilities need to be supported by policy and organisational change. The results of the study [19] also supported the earlier observation made by the researcher in the research problem that chronic services are regarded as fast track and sometimes very incompetent nurses are allocated to these services since they are regarded as predominantly treatment collection with no specialised skills required. In accordance with other similar studies, most of the files of hypertensive patients that were audited for this study were found to be demonstrating positive and negative strengths regarding the follow-up care received by patients with hypertension.
A study conducted in Brazil by [16] on the association between follow-up care in health services and adherence to antihypertensive medication indicated that the level of therapeutic adherence in different populations of hypertensive patients is frequently investigated, given the severity of the problem. The adherence identified in the population was high (63%), possibly influenced by the characteristics of the participants, who had cardiovascular disease associated with arterial hypertension and, consequently, needed and sought health care more frequently. The findings indicate that higher consultation attendance has a statistically significant relationship with better medication adherence. This reinforces the notion that accessibility and frequent use of health services significantly affects the health conditions of hypertensive patients with associated cardiovascular disease [16].
Furthermore, the significance of follow-up care in clinics was analysed in relation to the level of therapeutic adherence and the prevalence of acute events [20, 21]. Patients who did not seek emergency services in the last two years had better adherence rates (p = 0.04). Since acute episodes usually lead to the introduction of new drugs in the treatment protocol of hypertensive patients, the lower adherence of the group that sought emergency services may be related to the problem in adapting to combination therapy, which demands post-discharge follow-up [20, 21].
In the study conducted in Brazil [16], the authors sought to advance knowledge concerning the correlation between health services and medication adherence when investigating attendance of hypertensive patients’ at nursing consultations, since these are mainly focused on health education [16]. Regardless of the fact that the respondents had a greater number of medical appointments than nursing consultations, drug adherence was better among those who attended nursing consultations more frequently (p = 0.022). In addition, the study indicated the number of consultations necessary to improve the therapeutic adherence of hypertension patients [16].
Repeated nursing follow-up does not necessarily result in increased therapeutic adherence, and can increase health care costs [22]. The practice revealed by the present chapter of 4 to 6 nursing consultations per annum is the preferred level of nursing follow-ups, to attain better levels of antihypertensive treatment adherence. It was also observed that hypertensive patients who attended medical and nursing consultations or who had received health orientations in the last 6 months presented greater therapeutic adherence, with a statistically significant correlation (p = 0.013). PHC professionals have a high capability and meaningful opportunity to impact the improvement of patients’ treatment adherence, through the support of guidelines and care during visits, home visits, health talk actions and tracking of non-adherent behaviours [23].
Regarding the view of impact of follow-ups in PHC services on therapeutic adherence of hypertensive patients, directed public policies are necessary to enhance this level of attention, and bring it closer to the population. Also meriting consideration is the social capital of the Brazilian population, which assists people overcome obstacles regarding the accessibility and utilisation of clinics by giving information and treatment support. For hypertensive patients, involvement into social health networks encourages them to look for specialised health care, although the decision to take part in treatment follow-up must be from the patients themselves [24]. However, treatment adherence will definitely be influenced by participation in social health networks and presence of follow-up visits in the clinics.
The results of this chapter are valid in the specific context of the Tshwane district and cannot be generalised to the entire Gauteng province or to the whole country.
The objectives of the study were to describe the follow-up care received by patients with hypertension at PHC facilities in the Tshwane district and to determine nurses’ adherence or non-adherence to the guidelines regarding hypertension follow-up care. The conclusion drawn is that follow-up care obtained by hypertensive patients in PHC facilities in the Tshwane district was found to be insufficient, and demonstrated by a trend of non-adherence to the guidelines. This showed a considerable lack of knowledge and practice in the treatment of hypertension in PHC clinics.
It is recommended that unskilled professional nurses should not be allocated to hypertension follow-up care or to a chronic section. Even if guidelines are available, they will yield better results if they are used by professional nurses who understand consultation skills such as history taking, physical examination and interpretation of investigations.
Thanks, are extended to the Tshwane district of Gauteng province, South Africa for granting permission to conducting the study and for providing support. The authors further thank the managers of the selected PHC facilities and their clerical staff for their support.
The authors declare that there are no competing interests regarding the writing of this chapter.
M.J.M., the author of the chapter, conducted the research.
D.S.K.H., the study supervisor, assisted in writing the chapter.
The study was self-funded.
The expressed ideas pertaining to the chapter are of authors and do not indicate the policy or position of any associations with them.
Data sharing is inapplicable to this book chapter since no new data were formulated or interpreted.
A variety of congenital and acquired pathologies results in pulmonary valve (PV) disease that necessitates intervention. The types of this intervention depend on the main pathology with transcatheter options such as balloon valvuloplasty and transcatheter pulmonary valve implantation gaining popularity in the current era, especially in the congenital settings to delay the need for a sternotomy or repeat surgery. Surgical options include open valvotomy for congenital pulmonary valve stenosis and pulmonary valve repair or replacement for many other pathologies. Several replacement options are available currently such as homografts, bioprostheses, and mechanical prostheses with long-term data. Other novel techniques such as intra-operative reconstruction of pulmonary valve leaflets using autologous or bovine pericardium and creation of hand-made valved conduits are being used but no long-term data are available for these techniques.
The focus of this chapter will be on discussing the several surgical options that are currently used to repair or replace the pulmonary valve and the different surgical approaches that are being used with reviewing the literature regarding outcomes. Discussion of the various pathologies involving the pulmonary valve, or the right ventricular outflow tract, is beyond the scope of this chapter.
Congenital
Primary
Pulmonary stenosis
Pulmonary atresia
Secondary to surgical treatment of congenital lesions
Pulmonary regurgitation after tetralogy of Fallot repair
Homograft dysfunctions:
Following Ross procedure
Homografts used for reconstruction of the right ventricular outflow tract (RVOT):
Pulmonary atresia
Complex forms of tetralogy of Fallot
Truncus arteriosus
Acquired
Carcinoid heart disease
Endocarditis
Pulmonary artery aneurysms
Tumors
Rheumatic heart disease
Although transcatheter pulmonary balloon valvuloplasty is becoming a gold standard for isolated congenital pulmonary valve stenosis, surgical (open) pulmonary valvotomy may be required in some cases that are most commonly associated with pulmonary annular hypoplasia (Figure 1). The advantage of the open technique is the ability to relief the right ventricular outflow tract (RVOT) obstruction in a controlled fashion
Intraoperative photo in an infant with isolated congenital pulmonary valve stenosis and hypoplastic pulmonary annulus. Notice the classic bicuspid pulmonary valve with fused commissures. RV: right ventricle; PA: pulmonary artery.
Pulmonary valve repair is possible in selected congenital or acquired cases of pulmonary regurgitation. In the patients who underwent repair of tetralogy of Fallot (TOF)
Although most valve procedures performed annually involve the aortic and/or mitral valves, the need for pulmonary valve replacement (PVR) is increasing due to the increase in patients with congenital heart disease who survive to adulthood. Because of the improved postoperative care and long-term survival of children undergoing repair of congenital heart defects, it is reasonable to predict that the problem of young adults who have developed sequelae of pulmonary regurgitation after repair of tetralogy of Fallot or neonatal/infant interventions for pulmonary stenosis or atresia will be seen with increasing frequency. In general, most authors recommend the use of bioprostheses or homografts for PVR in children and young adults [3].
A wide variety of materials have been utilized for PVR and or reconstruction of the RVOT. The most commonly used materials include autologous or bovine pericardium, bioprosthetic (bovine or porcine) or mechanical valves, Dacron conduits/grafts, bovine jugular veins, and homograft (aortic and pulmonary).
The autologous pericardium has been used for decades to create aortic and/or pulmonary valve leaflets (one or more) and more recently has been used to create three-leaflet aortic valves
More recently, the same procedure has been used to create three-leaflet pulmonary valves for PVR (Figures 2A–F and 3). Limited literatures are available for the Ozaki outcome in the pulmonary position and the majority of these are case reports using autologous pericardium [6] or bovine pericardium [7]. This was used in the setting of pulmonary artery aneurysm [8], endocarditis, and free pulmonary regurgitation after previous pulmonary valvotomy. We have utilized the Ozaki templates to create three leaflet pulmonary valves for an infant who was born with congenital pulmonary stenosis and hypoplastic annulus and in another child who underwent late repair of tetralogy of Fallot with pulmonary stenosis.
Intraoperative photos demonstrating the Ozaki technique for reconstruction of a new pulmonary valve using the autologous pericardium. (A) A large sheet of the anterior pericardium is harvested once the sternotomy is performed, (B) the pericardium is then mounted on the plate provided with the Ozaki set and is treated with glutaraldehyde 0.6% for 3 minutes, (C) the main pulmonary artery and the right ventricular outflow tract are opened longitudinally and remnants of the pulmonary valve leaflets are resected and the Ozaki sizers are used to determine the size of the future pericardial leaflets and to mark the suture lines and determine the location of the commissures, (D) the pericardial leaflets are marked using the Ozaki template, (E) the leaflets are cut with scissors, and (F) suturing is begun with running polypropylene along the marked lines in the right ventricular outflow tract. RV: right ventricle.
Intraoperative photos showing the rest of the steps for the Ozaki reconstruction of the pulmonary valve. (A) Pericardial leaflets are sewn in with running polypropylene sutures, and (B) two leaflets along the posterior native annulus and the anterior leaflet is sewn to the undersurface of the pericardial patch (asterisk) that is used to augment the right ventricular outflow tract and the main pulmonary artery. RV: right ventricle.
Valved conduits used during the repair of a variety of congenital heart defects, most commonly tetralogy of Fallot with pulmonary atresia, truncus arteriosus, and Rastelli procedure for (corrected) transposition of the great arteries with pulmonary outflow tract obstruction. These conduits include homografts (aortic/pulmonary/femoral vein), xenografts (bovine jugular vein), and synthetic (Dacron conduit, expanded polytetrafluoroethylene [e-PTFE]). Several factors affect the choice of any of these valved conduits such as the age of the patient, the original pathology, previous procedure/conduit used, and availability.
Homografts continued to remain the most commonly used conduits for RVOT reconstruction. A variety of these homografts have been used including aortic, pulmonary (Figure 4), and more recently valved femoral veins. The advantages include its availability in smaller sizes and the lack of the rigidity associated with other prostheses, which make them suitable conduits for neonates, infants, and small children. Downsides include long-term calcifications, cost, and limited availability in many countries. We reserve the use of homografts for infants and small children due to the absence of suitable size prostheses in this age and for those with endocarditis as well.
Intraoperative photo for a patient who underwent a Ross procedure with a pulmonary homograft used to establish the right ventricular-to-pulmonary arterial confluence continuity. RV: right ventricle, Ao: ascending aorta, PA: pulmonary artery homograft, RA: right atrium.
Handmade expanded e-PTFE valves have been used with good results for RVOT reconstruction. The main advantages of these handmade conduits are related to their availability and lack of calcifications or immunological reactions, which may have the potential to prolong the longevity of these conduits. Current data do not show the inferiority of these conduits to homografts or bovine jugular veins. In fact, they have good biocompatibility and there was no evidence of calcifications in excised e-PTFE valves [9]. We personally do not have experience with this technique.
The vast majority of children and young adults who require PVR receive a biological valve. These prostheses carry the advantage of good durability in the pulmonary position and avoidance of long-term anticoagulation.
While bioprostheses are the most commonly used prostheses for PVR, the need for repeat operation is inevitable in children and young adults with congenital heart disease and mechanical prostheses may be considered in selected clinical scenarios to minimize the risks involved with repeat operations. The operative risk of mortality increases from 2% at the first repeat sternotomy compared with 4.7% at a fourth sternotomy [10]. Furthermore, Morishita and colleagues demonstrated a fourth time sternotomy to be a predictor of resternotomy-related injury (hazard ratio, 4.31) [11].
Most of those who are considered for mechanical PVR had a congenital diagnosis and underwent multiple previous sternotomies in the past (Figure 5). Although mechanical prostheses are durable, the need for higher-level anticoagulation carries its own risks, but recent reports suggest that with proper anticoagulation and careful monitoring, the risk of prosthetic thrombosis or dysfunction is low.
Computed tomography scan in a patient who underwent multiple previous sternotomies for an initial Rastelli procedure with subsequent multiple pulmonary conduits changes and has a bileaflet mechanical prosthesis in the pulmonary position (white circle).
The issue of the performance of a mechanical prosthesis in the pulmonary position remains a matter of debate as there are no precise criteria for the selection of patients in whom this prosthesis would be well suited. We believe the ideal patient for mechanical PVR is the patient who underwent multiple previous sternotomies and/or requires anticoagulation for another reason such as a left-sided mechanical prosthesis. This patient population includes those with repaired truncus arteriosus, prior Ross procedure, and occasionally repaired tetralogy of Fallot. Other indications may include those who demonstrated poor durability of bioprostheses.
In every case where a mechanical prosthesis is considered, the ultimate treatment decision is individualized after weighing the risks of reoperation if a bioprosthesis is chosen, with the potential bleeding/thrombotic risks if a mechanical prosthesis is chosen.
Associated defects that commonly need to be addressed at the time of PVR include tricuspid valve repair, patch pulmonary arterioplasties, closure of residual shunts, and arrhythmia surgery.
Preoperative transthoracic echocardiography (TTE), computed tomography (CT) scan, or magnetic resonance imaging (MRI) are routinely performed. Cross-sectional imaging is helpful to determine the relationship of mediastinal structures especially the aorta and/or extracardiac conduits to the sternum and in assessing the pulmonary arterial anatomy. Coronary artery evaluation may be needed in certain circumstances to rule out obstructive coronary artery disease or coronary anomalies especially ones that may change the surgical plan regarding the PVR technique. Hemodynamic data from cardiac catheterization may be needed to complement other studies when there is uncertainty about the anatomy or ventricular function.
Intraoperative transesophageal echocardiography (TEE) is routinely performed before and after cardiopulmonary bypass with or without intraoperative direct pressure measurement across the right ventricular outflow tract.
Primary or repeat sternotomy has been the most commonly used approach. Technical aspects of repeat sternotomy with or without peripheral cannulation have been discussed previously [12].
Left posterolateral thoracotomy has been used as an alternate to sternotomy/repeat sternotomy for PVR [13]. With the patient in the modified right lateral decubitus position, the chest is usually entered through the left fourth/fifth intercostal space. Normothermic cardiopulmonary bypass is established
We have utilized left anterior minithoracotomy as an alternative approach to sternotomy for PVR in selected patients who required isolated PVR and in the absence of intracardiac shunts. This approach carries the advantage of being less invasive with rapid recovery, but careful patient selection is required. It is not advisable in the presence of previous pulmonary conduits, but it can be useful in cases where hostile mediastinum is encountered after multiple previous surgeries or in the presence of a large aorta in close proximity to the sternum, which increases the risk of repeat sternotomy.
We have previously published our technique that can be used in both primary and reoperative settings [14] (Figures 6A–F and 7A and B). In summary, the patient is positioned supine, prepped, and draped as for standard median sternotomy. A 6-cm horizontal incision is performed through the left third or fourth intercostal space. In primary operative settings, the left lung is gently retracted to expose the pericardium, which is then incised anterior to the left phrenic nerve to expose the RVOT and the main pulmonary artery. In re-operative settings, the left lung is usually adherent to the RVOT and/or the previously placed transannular patch if the pericardium was not closed after the first procedure and will need to be dissected off the main pulmonary artery and RVOT.
Intraoperative photos demonstrating the technical steps for pulmonary valve replacement
Intraoperative photos showing the remaining steps in pulmonary valve replacement
Cardiopulmonary bypass is established
Our experience with this technique is in its early phase, but we have performed the procedure in 6 patients (the youngest at age 13 years; 4 with previous tetralogy of Fallot repair). The procedure was feasible, with no conversion to open sternotomy in any. There was no early or late mortality. One patient developed a femoral artery pseudoaneurysm during follow-up due to percutaneous cannulation and required late repair. The length of stay averaged 2 days [15]. We believe that weight more than 30 kg is necessary for satisfactory groin vessel cannulation.
Basics of primary or repeat sternotomy are followed. Sternal re-entry can be challenging, especially in the presence of a right-sided pathology (e.g., pulmonary hypertension, enlarged right heart structures, or extracardiac conduit). We prefer the oscillating saw for repeat sternotomy, although a craniotome can also be used.
The decision to expose the femoral vessels versus cannulating them and initiating cardiopulmonary bypass to facilitate sternotomy is individualized and is dependent on the experience of the surgeon. Groin cannulation can be performed
The procedure can be performed with aortic and a single-venous cannulation at normothermia in the absence of concomitant cardiac pathology that needs concomitant repair. It is commonly performed on the beating heart without cardioplegic arrest in the absence of intracardiac shunts. However, a short period of aortic cross-clamping and cardioplegia may be needed in challenging cases where heavily calcified or scarred RVOT patches or conduits are present to allow safe decalcification and adequate debridement before removing the cross-clamp and completing the PVR or the new conduit placement on a beating heart.
The basic principle of the technique in harvesting the autologous pericardium and creating the leaflets and sewing them is similar to the Ozaki technique described for aortic valve replacement.
However, there are important anatomical differences between the aortic and pulmonary roots that required modification of the technique to facilitate exposure and leaflet placement. Three possible ways to apply this technique for pulmonary valve reconstruction are as follows:
If the pulmonary artery and root are adequate, the main pulmonary artery can be completely transected, and the leaflets are sized with the appropriate Ozaki sizers and suture lines are marked at the native pulmonary annulus in a similar fashion to the aortic procedure. The leaflets are then sewn in a similar fashion to the aortic technique; then, the pulmonary artery continuity is re-established.
A second strategy is to build a valved conduit with pericardial leaflets sewn inside a Dacron graft on the back table; then, the conduit is implanted in a similar fashion to a standard pulmonary conduit.
More commonly, the patient is presented with a hypoplastic pulmonary annulus that needs to be enlarged. A longitudinal pulmonary arteriotomy is performed, and the two posterior leaflets are created along the pulmonary annulus/RVOT. The RVOT is enlarged with a pericardial patch in a way similar to the transannular patch technique. This patch is extended up to the future sinotubular junction, and the third leaflet is then sewn to the pericardial patch and the commissures are created followed by completing the augmentation of the main pulmonary artery with the remainder of the patch.
The most common scenario occurs with a dilated right ventricular outflow tract from the previous repair of tetralogy of Fallot with a transannular patch (Figure 8A–D). In the setting, the patch is opened longitudinally and stay sutures are placed on both sides. Most commonly, the incision is extended proximally into the RVOT and distally into the proximal left main branch pulmonary artery. Pathological/remnant pulmonary valve cusps are resected if present. An appropriately sized bovine pericardial patch (our preference) is then chosen and sewn distally to the proximal left main branch pulmonary artery. It is not uncommon that concomitant branch pulmonary arterioplasty is needed in these cases. The patch is sewn in with running polypropylene sutures till the proposed level of the new pulmonary prosthesis is reached.
Intraoperative photos showing the most commonly used technique for pulmonary valve replacement. (A) A longitudinal incision is created along the main pulmonary artery and is extended proximally into the right ventricular outflow tract and distally usually to the proximal left main pulmonary artery. A large pericardial patch is then sued to augment the main pulmonary artery is extended down to the level of the future prosthesis, (B) the prosthesis is secured with a running polypropylene suture along the posterior annulus, (C) the anterior portion of the sewing ring is then secured to the undersurface of the pericardial patch, (D) the remainder of the patch is trimmed and used to complete the right ventricular outflow tract reconstruction. RV: right ventricle.
An appropriately sized prosthesis (biological/mechanical) is chosen and is secured along the native pulmonary annulus posteriorly with running polypropylene suture (interrupted sutures with or without pledgets may be used sometimes based on the tissue quality). It is critical to avoid deep sutures along the pulmonary annulus due to the close proximity of the left main coronary artery. In fact, in some situations, it is better to place the prosthesis more distally (between the native pulmonary annulus and the pulmonary artery bifurcation) to avoid compromising the left coronary artery. The anterior portion of the sewing ring of the prosthesis is then secured to the undersurface of the patch with a running suture. It is important to carefully think about the orientation of the prosthesis before securing it to the undersurface of the patch and especially when it is a biological one due to its larger profile that can create a higher gradient across its path if not oriented properly. The prosthesis should be tilted posteriorly toward the pulmonary bifurcation. Also, it is important to have some redundancy in the pericardial patch proximal and distal to the prosthesis to ensure no gradient is created due to a tight patch. This completes the prosthesis securement in the outflow tract. The rest of the bovine pericardial patch is then trimmed and sewn to the RVOT to complete its reconstruction.
If the main pulmonary artery/outflow tract is dilated or in the presence of a pulmonary artery aneurysm, our technique is different. A transverse pulmonary arteriotomy is created, and a running or interrupted suture technique is used to secure the prosthesis similar to a standard aortic valve replacement. The pulmonary arteriotomy is then closed with a running polypropylene suture.
This is commonly used to replace a failed or dysfunctional conduit that was placed in a previous operation as a part of the initial repair of congenital heart defects such as tetralogy of Fallot with pulmonary atresia, truncus arteriosus, and post-Ross and Rastelli procedures.
It is critical to keep in mind the location of the left main coronary artery (posterior) and the left anterior descending coronary artery (lateral) in relation to the conduit especially when anatomical details are unclear in the setting of repeat operations. The conduit itself while in most cases is located to the left of the sternum, and in certain congenital heart defects, it may be immediately behind the sternum, or in the midline such as cases of the previous repair of truncus arteriosus. This may require modification of the surgical technique during reoperation or initiation of cardiopulmonary bypass
We have used different techniques in these situations depending on the quality of the previous conduit and the degree of calcification present:
A longitudinal incision is placed in the anterior aspect of the conduit, while its posterior wall is kept intact, which minimizes injury to the left main coronary artery. After adequate debridement and decalcification, the new prosthesis is placed with a roof of pericardial patch similar to the technique described in the case of the transannular patch.
If the previous conduit was a Dacron conduit, it can be dissected from the external fibrous peel and excised. It is important to minimize dissection of the floor and preserve the thick fibrous peel to allow sturdy suture placement.
The position of the new prosthesis is critically important. In general, we place the prosthesis distally toward the pulmonary confluence, which minimizes potential compression of the left main coronary artery. Alternatively, the prosthesis can be placed more proximally near the level of the native pulmonary annulus.
In some scenarios, the old conduit can be completely excised, and, in these cases, there is a lack of continuity between the RVOT and the pulmonary confluence. We then create a new valved conduit using a biological/mechanical prosthesis inside a Dacron tube graft (Figure 9), which is then sewn proximally and distally to the RVOT and the pulmonary arterial confluence respectably.
Intraoperative photo showing a surgically created pulmonary conduit by placing a bioprosthesis inside a Dacron tube graft which is sewn proximally and distally to the right ventricular outflow tract and the pulmonary arterial confluence respectively. RV: right ventricle, D: Dacron tube graft, P: pulmonary bioprosthesis.
Regarding mechanical prostheses, it is important not to oversize them even if there is enough room to place a large prosthesis. Having a mild gradient across the prosthesis (10-15 mmHg) and a higher velocity facilitate leaflet mobility in a more effective way. When the prosthesis is oversized and the gradient is quite low (<5 mmHg), then only one disk may open properly, while the other is poorly moving, which increases the risk of thrombosis.
Finally, the heart is adequately de-aired and cardiopulmonary bypass is discontinued. Post-procedure TEE is performed, and direct pressure measurements of the right ventricular and pulmonary arterial pressures are obtained.
Dacron conduits create thick intimal peel that requires explantation at the time of repeat operations. Homografts and bovine jugular veins show variable degrees of durability, but early degeneration and calcifications are sometimes inevitable (Figure 10). Added to this is their limited availability in many countries.
Preoperative CT scan showing calcified bovine jugular vein graft in patient who underwent repeat sternotomy for pulmonary conduit replacement.
A multicenter study in Japan included 794 patients (aged 14 days to 56.8 years old) in which e-PTFE valves were used for RVOT reconstruction at 52 Japanese institutes had a mean follow-up of 3.6 years (maximum 10 years) [16]. The e-PTFE was in the form of fan-shaped valved conduits and patches with bulging sinuses. The freedom from reoperation at 10 years was 95.4% in patients with conduits and 92.3% in those with patches. No or mild pulmonary regurgitation was present in 95 and 79.6% of those with conduits and those with patches, respectively.
In general, there are conflicting reports in the literature regarding the durability of various prostheses in the pulmonary position. Bando et al. observed that 94% of homografts have good function after 5 years; however, almost 25% had evidence of moderate-to-severe calcifications (Figure 11A and B) [17].
Preoperative images of a patient who had previous aortic homograft placed in the right ventricular outflow tract for repair of tetralogy of Fallot with pulmonary atresia. (A) Chest X ray showing extensive and complete calcifications of the homograft pulmonary conduit (white circle), (B) which is confirmed by preoperative cardiac catheterization (multiple white arrows). Notice the close proximity of the pulmonary conduit to the back of the sternum.
Regarding bioprosthetic conduits, a failure rate of 15% of 3 years was observed in the study by Cleveland et al. and calculated that 55% would have avoided a reoperation at 5 years [18].
In the study by Batlivala et al., the authors compared bioprostheses and homograft conduits in the pulmonary position [19]. This included 254 patients aged 10–21 years old. The median follow-up was 4.4 years. Freedom from valvar dysfunction was 72% ± 4% at 5 years and 48% ± 8% at 10 years. Freedom from RVOT re-interventions was 90% ± 3%, and 67% ± 5% at 5 and 10 years, respectively. No differences were present between bioprosthesis and homografts.
In a study from Mayo Clinic, 59 patients underwent mechanical PVR between 1965 and 2013, and no valve thrombosis was observed in the settings of adequate anticoagulation with Warfarin. The maximum follow-up in this study extended to 20 years with no reoperations related to pannus formation, paravalvular leak, endocarditis, valve thrombosis, or prosthetic dysfunction.
The range of reported thrombosis for a mechanical PVR varies from 25 to 80% [20]. These thrombotic complications were reported with bileaflet mechanical prostheses, and none was reported in those with a tilting-disk prosthesis, although literature on this topic is spared in general. The reported complication rate of a bileaflet prosthesis in the pulmonary position has been about 35%. The majority of these thrombotic events were observed in those who were not adequately anticoagulated with Warfarin. Taken together, the frequency of thrombosis if the patient was not maintained on Warfarin was 41% (15 of 37 prostheses failed); however, if the patient is adequately anticoagulated, the rate of thrombosis dropped to 3.5% [21, 22]. These observations are seen also in the series reported by Freling et al., which spanned 26 years and included 66 patients [23]. Actuarial freedom from reoperation was 96% at 5 years and 89% at 10 years.
A meta-analysis of 299 patients from 19 observational studies by Dunne et al. documented nonstructural deterioration and valve thrombosis rates of 1.5 and 2.2%, respectively [24]. Redo surgery was needed in 0.9%, and thrombolysis was used in 0.5%. This is the largest analysis to date and confirms the low incidence of valve dysfunction and thrombosis for mechanical prostheses in the pulmonary position.
The pulmonary valve can be affected by a variety of congenital and acquired diseases. Although repair or preservation of the pulmonary valve may be possible in certain cases, replacement is usually required whether in primary or reoperative settings based on the original, pathology affecting the pulmonary valve/RVOT.
Surgical approaches can be through (repeat) sternotomy, left posterolateral thoracotomy, or minimally invasive left anterior minithoracotomy.
Several options are available for the replacement of the pulmonary valve with or without reconstruction of the RVOT. The most commonly used options include homografts and bioprosthetic or mechanical valves. While our first choice as a prosthesis for PVR is a biological valve that facilitates subsequent transcatheter interventions (Figure 12), the deciding factor between any of these options depends on the patient’s clinical profile especially age, original pathology/indication, prosthesis availability, and future expectations for this patient and therefore, it should be individualized. Other novel strategies such as handmade e-PTFE conduits and autologous pericardial leaflet reconstruction may be considered.
Melody transcatheter valve is they most commonly used transcatheter option after failed pulmonary bioprostheses and homografts.
Although some of these conduits have long-term data in terms of durability and freedom from reintervention, literatures are limited regarding other techniques and the bottom line is we do not have the ideal pulmonary valve/conduit yet.
The author (S.M.S) is a consultant for Cryolife and Stryker.
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This technique is called power over fiber (PoF). Besides the advantages of optical fiber (immunity to electromagnetic interferences and electrical insulation), the employment of a PoF scheme can eliminate the energy supplied by metallic cable and batteries located at remote sites, improving the reliability and the security of the system. Smart grid is a green field where PoF can be applied. Experts see smart grid as the output to a new technological level seeks to incorporate extensively technologies for sensing, monitoring, information technology, and telecommunications for the best performance electrical network. On the other hand, in telecommunications, PoF can be used in applications, such as remote antennas and extenders for passive optical networks (PONs). PoF can make them virtually passives. 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Although a considerable number of theoretical proposals already exist in this field, the most common used network simulators do not implement the latest wireless network standards and, consequently, they do not offer the possibility to emulate scenarios in which SAS or massive MIMO systems are employed. This aspect heavily affects the quality of the network performance analysis with regard to the next generation wireless communication systems. To overcome this issue, it is possible, for example, to extend the default features offered by one of the most used network simulators such as Omnet++ which provides a very complete suite of network protocols and patterns that can be adapted in order to support the latest antenna array systems. The main goal of the present chapter is to illustrate the improvements accomplished in this field allowing to enhance the basic functionalities of the Omnet++ simulator by implementing the most modern antenna array technologies.",book:{id:"6844",slug:"array-pattern-optimization",title:"Array Pattern Optimization",fullTitle:"Array Pattern Optimization"},signatures:"Vincenzo Inzillo, Floriano De Rango, Luigi Zampogna and Alfonso A. Quintana",authors:null},{id:"52919",title:"Waveform Design Considerations for 5G Wireless Networks",slug:"waveform-design-considerations-for-5g-wireless-networks",totalDownloads:3399,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"In this chapter, we first introduce new requirements of 5G wireless network and its differences from past generations. The question “Why do we need new waveforms?” is answered in these respects. In the following sections, time‐frequency (TF) lattice structure, pulse shaping, and multicarrier schemes are discussed in detail. TF lattice structures give information about TF localization of the pulse shape of employed filters. The structures are examined for multicarrier, single‐carrier, time‐division, and frequency‐division multiplexing schemes, comparatively. Dispersion on time and frequency response of these filters may cause interference among symbols and carriers. Thus, effects of different pulse shapes, their corresponding transceiver structures, and trade‐offs are given. Finally, performance evaluations of the selected waveform structures for 5G wireless communication systems are discussed.",book:{id:"5480",slug:"towards-5g-wireless-networks-a-physical-layer-perspective",title:"Towards 5G Wireless Networks",fullTitle:"Towards 5G Wireless Networks - A Physical Layer Perspective"},signatures:"Evren Çatak and Lütfiye Durak‐Ata",authors:[{id:"19414",title:"Prof.",name:"Lutfiye",middleName:null,surname:"Durak-Ata",slug:"lutfiye-durak-ata",fullName:"Lutfiye Durak-Ata"},{id:"189749",title:"M.Sc.",name:"Evren",middleName:null,surname:"Çatak",slug:"evren-catak",fullName:"Evren Çatak"}]},{id:"54645",title:"Power‐Over‐Fiber Applications for Telecommunications and for Electric Utilities",slug:"power-over-fiber-applications-for-telecommunications-and-for-electric-utilities",totalDownloads:2566,totalCrossrefCites:11,totalDimensionsCites:19,abstract:"Beyond telecommunications, optical fibers can also transport optical energy to powering electric or electronic devices remotely. This technique is called power over fiber (PoF). Besides the advantages of optical fiber (immunity to electromagnetic interferences and electrical insulation), the employment of a PoF scheme can eliminate the energy supplied by metallic cable and batteries located at remote sites, improving the reliability and the security of the system. Smart grid is a green field where PoF can be applied. Experts see smart grid as the output to a new technological level seeks to incorporate extensively technologies for sensing, monitoring, information technology, and telecommunications for the best performance electrical network. On the other hand, in telecommunications, PoF can be used in applications, such as remote antennas and extenders for passive optical networks (PONs). PoF can make them virtually passives. 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