Overview and outcomes of Biatrial vs. Bicaval for orthotopic heart transplantation.
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This was one of the most significant accomplishments in history, allowing to save the life of several patients with end-stage heart disease in the last 50 years. This remarkable surgical innovation was the result of constant work, diligent research, creativity and innovative perception. During the early 1900s, Alexis Carrel, the father of vascular and transplant surgery who was awarded the Nobel Prize in Physiology or Medicine in 1912, and Charles Guthrie, professor of Physiology and Pharmacology at Washington University, performed the first heterotopic heart transplant [1]. Subsequently, other American surgeons, including Mann [2] at Mayo Clinic in 1933 and Marcus [3] at Chicago Medical School two decades later, pursued the experimentation and proposed new techniques for heterotopic heart transplantation. At the same time, on the other side of the world, Vladimir Demikhov at M.V. Lomonosov Moscow State University gave a considerable contribution to this experimental specialty, performing the first combined heart-lung transplant and also the first orthotopic transplant in dogs without the use of hypothermia and pump-oxygenator support. His technique consisted of end-to-side anastomoses between the corresponding thoracic
The introduction of hypothermia and cardiopulmonary bypass in the early 1950s had a decisive impact on heart transplantation research.
In the late 1950s, Shumway and Lower at Stanford University achieved brilliant results experimenting on dogs [5]. They used a simple and effective surgical technique, called “Shumway” or biatrial technique (BA), where the anterior part of donor’s left and right atria was incised and anastomosed to the posterior wall of the recipient’s atria. This became the standard heart transplant surgical technique until the 1990s. These two pioneers also introduced two innovative methods that allowed to prolong survival times: the use of isotonic saline solution at 4°C to preserve the donor’s heart and the use of cardiopulmonary bypass to support the transplanted heart [6].
Based on these promising premises, Shumway begun to think about human heart transplant.
This research recalled the attention of the international scientific community, in particular of Christiaan Barnard, a young South African surgeon with a good reputation in open heart surgery who developed almost an obsession for heart transplantation. In August 1966, he spent 4 months in Lower’s laboratory learning the principles of Shumway’s research.
At his return to South Africa, on December 3, 1967, he performed the first heart transplant [7]. The donor was Denise Darvall, a 25-year-old woman who had a severe brain injury and was certified brain dead by the neurosurgeons. The recipient was Luois Washkansky, a 53-year-old man with severe heart failure; he died 17 days later due to pneumonia [8].
On December 6, 1967, Adrian Kantrowitz, another pioneer in this field, performed the first pediatric heart transplantation at Maimonides Hospital of New York. The donor was an anencephalic baby and the recipient was an 18-day-old child with Ebstein anomaly. Unfortunately, the young patient died after 6 hours [9].
One month later, on January 6, 1968, Shumway and his team performed the first human heart transplant in the United States. The patient died of gastrointestinal bleeding on the 15th postoperative day.
During the next year, 102 heart transplants were performed around the world, with only 40% survival at 1 year [7]. These poor results were the reason why the most important cardiovascular surgery centers abandoned the procedure.
After these first attempts, heart surgeons realized that specific suppression of the recipient’s immune system was required for long-term graft survival. After the introduction of percutaneous transvenous endomyocardial biopsy in 1973, that improved the diagnosis of acute and chronic rejection, and the discovery of cyclosporine A in 1976, a powerful immunosuppressor, better results in terms of survival were achieved, therefore a greater number of procedures was performed [6].
While the “Shumway technique” remained the standard for more than 20 years worldwide, in the early 1990s, some surgeons proposed new effective surgical techniques trying to improve hemodynamic results and late survival [10]. Despite the technical evolution, in the last 50 years, despite the improvement in pharmacological treatment of end-stage heart failure, cardiac transplantation has remained the only treatment (along with left ventricle assistance devices (LVAD) implantation as destination therapy) capable of improving the long-term survival [11, 12]. The standard BA technique, based on the description of Cass and Brock [13] and Lower and Shumway [5] for orthotopic heart transplantation (OHT), was adopted worldwide for many years due to its simplicity and reproducibility. This technique requires, to some extent, the excision of the posterior part of the donor’s left atrium and the incision of the right atrium from the inferior vena cava toward the right atrial appendage to avoid injuries to the sino-atrial node. The atrial anastomoses can be performed easily, reducing from 8 possible single-vessel anastomoses for complete transplantation to 4 (Figure 1).
A schema of the Biatrial technique for orthotopic cardiac transplantation is shown. In the left (A), after cardiectomy, the double atrial cuff is distinguishable, with the interatrial septum with the foramen. In the right, (B) the right atrial cuff suture is represented.
However, several studies have demonstrated that the drawback of this technique consists in enlarged, figure-of-eight configured right and left atria without a physiological geometry between the donor and the recipient’s atria [14]. This non physiological geometry can lead to (i) higher incidence of mitral and tricuspid valve incompetence, (ii) rhythm disturbances [14] and (iii) tendency of thrombus formation and septal aneurysm [15]. Because of these problems, some authors, as Sir Magdi Yacoub, Banner and Dreyfus some time later [16, 17, 18] proposed a more anatomical surgical technique with complete excision of the recipient’s atria and direct anastomoses to the left pulmonary veins, right pulmonary veins, inferior venae cavae (IVC), and superior venae cavae (SVC). No technical complications occurred, but the benefit of this procedure on clinical outcome had to be demonstrated, at least in the 1990s.
Sievers and co-workers [19] in 1991, and the Wythenshawe group [20] in 1993, introduced into clinical practice the bicaval transplantation technique (BC), characterized by two arterial, one left atrial, and two caval anastomoses, leaving the right atrium intact and leaving only a small posterior part of recipient’s left atrial tissue between the pulmonary veins (Figure 2). Potential shortcomings of the BC technique include the marginally prolonged ischemic transplantation time, which is likely of no clinical relevance, as well as some sort of stenosis at the level of the venous anastomoses. Both problems, however, can be neutralized by refined surgical techniques.
The schema of the Bicaval technique has been designed. In the left side (A), both cavas and the left atrial cuff are prepared after cardiectomy, while in the right side (B) the final result with both superior and inferior vena cava sutures.
During the 1990s, many single center reports, with variable potency and sample size have been published, comparing both techniques from different points of view and outcomes, like postoperative mortality, length of operation in terms of ischemic organ time, length of hospital stay, need for permanent pace maker, echocardiographic findings, exercise capacity and long-term survival.
Remarkable is the paper of Sun et al. [21] with a total of 615 enrolled patients. Among them, 322 were transplanted using the BC technique and 293 using the BA technique. There was no statistically significant difference in terms of early mortality (within 30 post-operative days) between the two groups (3.4% in the BC group vs. 4.8% in the BA group, p 0.5). The average follow-up period was 4.0 ± 3.0 years (ranging from 1 to 11 years). There was no significant difference between groups (3.8 ± 3.5 years in Group 1, 3.8 ± 3.8 years in Group 2). Survival rates at 1, 5 and 10 years were 93, 89 and 87% in the BC group and 89, 82 and 80% in the BA group, respectively. Long-term survival differed significantly between the two groups and the cumulative proportion of survival was significantly higher in the BC group than in the BA group (p 0.05). In the univariate regression analysis, several echocardiographic parameters, such as left atrial diameter, mitral regurgitation, tricuspid regurgitation, left ventricular ejection fraction, right ventricular ejection fraction and surgical techniques, were predictors of long-term survival. Both mitral and tricuspid regurgitation were weakly associated with mortality. There were significant correlations between left and right ventricular ejection fraction and surgical techniques with mortality outcome. Using a multivariate model of analysis, left and right ventricular ejection fraction remained significant risk factors for mortality. When adjusted for left and right ventricular ejection fraction, the surgical techniques (BC vs. BA) significantly influenced mortality outcome in the multivariate analysis. Any significant difference in the incidence of mitral regurgitation between BC and BA transplant patients was demonstrated. However, tricuspid valve regurgitation was much more common in the BA group than in the BC group. They concluded that the BC technique helps to decrease atrial size and tricuspid regurgitation, and better preserves right and left heart function, resulting in improved long-term survival after heart transplantation compared with the BA technique.
Other authors have demonstrated that the BC technique leads to an increased parasympathetic reinnervation compared with the standard technique, which might be of clinical relevance because an increase in blood pressure control, by larger reflex changes in heart rate, might improve adaptation to various stimuli and to physical exercise [22].
However the best way to reach some conclusion is by analyzing papers with the strongest evidences. Relevant among these, two multicenter studies from the UNOS database and other two meta-analysis (see Table 1).
Author/year | Institution | Study Type | Patients | TVR | PM Insertion | Mortality | Survival |
---|---|---|---|---|---|---|---|
Wartig et al. 2014 [30] | Sahlgrenska University Hospital, Gothenburg, Sweden | Retrospective Cohort Study | BA: 221 BC: 226 | BA: BC: | NA | 48 (9.9%) | |
Davies et al. 2010 [23] | Columbia University, New York, USA | Retrospective Review UNOS database | BA: 11.919 (59.3%) BC: 7.661 (38.1%) Total: 519 (2.6%) | NA | BA: 576 (5.1%) BC: 146 (2.0%) Total: 11 (1.9%) | BA: 8.9% BC: 7.6% Total: 9.5% | BA: BC: |
Weiss et al. 2008 [24] | Johns Hopkins Medical Institution, Baltimore, USA | Retrospective Review UNOS database | BA: 6.724 BC: 5.207 | NA | BA: 343 (5.3%) BC: 103 (2.0%) | BA: BC: | BA: BC: |
Locali et al. 2008 [28] | Universidade Federal São Paulo, Brazil | Meta-analysis | BA: 914 BC: 872 | BA: 310/685 (45.2%) BC: 184/593 (31%) | NA | BA: 102/547 (18.6%) BC: 64/585 (10.9%) | NA |
Schnoor et al. 2007 [10] | Medical University Schleswig-Holstein, Luebeck, Germany | Meta-analysis | BA: 1.803 BC: 1.968 | BA: 153/261 (58.6%) BC: 61/211 (28.9%) | NA | BA: 18/110 (16.4%) BC: 9/118 (7.6%) | NA |
Overview and outcomes of Biatrial vs. Bicaval for orthotopic heart transplantation.
BA: biatrial; BC: bicaval; NA: not analyzed; PM: pace-maker; TVR: tricuspid valve repair; *= p< .01.
Davies et al. [23] recently reported from the UNOS data base an analysis of 20,999 transplantations performed on adult patients with no congenital heart disease between 1997 and 2007, including the type of anastomosis performed. Patients were stratified accordingly to the atrial anastomosis technique: standard BA (atrial group, n. 11,919 [59.3%]), BC (caval group, n. 7661 [38.1%]), or total orthotopic (total group, n. 519 [2.6%]). First of all, until 2003, the BA technique was used more frequently than the BC one, while the number of total transplantation decreased. In 2006, more than 34% of the cases of cardiac transplantation were performed with the “standard” or BA technique. The percentage of transplantations performed with the BC technique was higher at higher-volume transplant centers.
Regarding the outcomes, the need for permanent pacemaker was increased in patients in the atrial group (n. 576, 5.1%) requiring a PPM before discharge more often (odds ratio [vs. the caval group], 2.6; 95% CI, 2.2–3.1) than the caval group (n. 146, 2.0%) or the total group (n. 11, 1.9%; odds ratio [vs. the caval group], 1.0, 95% CI, 0.6–1.7). Multivariate predictors of the need for PPM implantation included BA anastomosis (odds ratio, 3.1; 95% CI, 2.5–3.9), donor age of 60–69 years (odds ratio, 2.9; 95% CI, 1.5–5.3), donor age of 50–59 years (odds ratio, 2.0; 95% CI, 1.6–2.5), donor age of 40–49 years (odds ratio, 1.3; 95% CI, 1.0–1.6), recipient inotropic support at transplantation (odds ratio, 1.5; 95% CI, 1.2–1.7), donor history of hypertension (odds ratio, 1.2; 95% CI, 1.0–1.4), and transplantation year (odds ratio, 1.04; 95% CI 1.01–1.07 [per year]); use of T4 before organ retrieval (odds ratio, 0.8; 95% CI, 0.6–0.9) was protective.
In terms of hospital length of stay, patients in the atrial group had longer posttransplantation stay (21.1 days) than those in the caval group (19.3 days, P < 0.0001).
In univariate analysis atrial group patients had a higher incidence of postoperative death (8.9%; odds ratio, 1.17; 95% CI, 1.05–1.30) than those in the caval group (7.6%; odds ratio, 0.83; 95% CI, 0.75–0.93); postoperative mortality in the total group (9.5%; odds ratio, 1.14; 95% CI, 0.86–1.53) was not significantly different from the one seen in either of the other groups. However, the logistic regression model predicting postoperative death did not include the type of anastomosis.
Also in the long-term outcomes, the need for PPM implantation was significantly higher among patients in the atrial group, (P < 0.0001): at 2 years, 8.6% required a pacemaker versus only 5.4% in the BC group and 4.0% in the total group. Multivariate predictors of the interval time between transplantation and PPM insertion included other factors, like recipient age (odds ratio, 1.006; 95% CI, 1.001–1.012 [per year]), transfusions between listing and transplantation (odds ratio, 1.2; 95% CI, 1.0–1.4), donor age of 50 to 59 years (odds ratio, 1.6; 95% CI, 1.3–2.0), donor’s age of 60 to 69 years (odds ratio, 2.2; 95% CI, 1.3–3.7), transplantation year (odds ratio, 1.25; 95% CI, 1.21–1.28 [per year]), and BA anastomosis (odds ratio, 2.5; 95% CI, 2.2–2.9); ventricular assistance device at transplantation was protective in this model (odds ratio, 0.7; 95% CI, 0.6–0.9). There was a small but significant difference in long-term survival between the atrial and caval groups in univariate analysis (survival at 1 year, 85.6 vs. 87.1%; at 5 years, 72.2 vs. 73.5%; at 10 years, 51.1 vs. 57.4%; P < 0.0168). Multivariate Cox proportional hazards regression analysis confirmed the decreased survival among patients in the atrial group (hazard ratio, 1.11; 95% CI, 1.04–1.19). There was no difference in graft survival, renal failure-free survival, and transplant coronary atherosclerosis–free survival, based on anastomotic technique.
Three years before the UNOS analysis from Davies et al. [23], Weiss et al. [24] conducted a retrospective review of the UNOS database from January 1999 to December 2005. A total of 14,418 patients underwent first-time OHT during this period. After exclusion of patients aged less than 18 years (n. 1831) and more than 80 years (n. 2), orthotopic total transplants (n. 482), heterotopic transplants (n. 4) and those without data on transplant technique (n. 139), the final study population was 11,931. Of these, 5207 (43%) received the BC anastomotic technique, with follow-up through September 2006. Almost 10,000 patient less than the population analyzed by Davies et al. [23]. Weiss et al. concluded that there was no difference in survival between BC and BA techniques when modeled with long-term follow-up and adjusted for confounding variables. Although the mortality rates were higher for the BA group at 30 days and 1, 3 and 5 years, this represents unadjusted mortality, which disappears in both the logistic regression and proportional hazards model for all time-points. Comparing both studies, we can conclude that probably the results obtained by Davies et al., due to the sample size and the interval period, are complementary to those obtained in the previous Weiss’ UNOS analysis, giving more conclusive information. Also the BC technique gives the advantage of decreasing both the need of PPM and the post-operative mortality, but also influences positively the long term survival.
Regarding two relevant meta-analysis, the first one, published by Schnoor et al. [10] in 2007, provides evidences that the expected theoretic advantages of BC transplantation, in comparison with the standard technique, have come true in clinical practice. The meta-analysis included 23 retrospective and 16 prospective studies. In prospective trials, a reduction in right atrial pressure was found. The absolute difference in right atrial pressure is probably of no clinical relevance at rest but it probably could be on exertion. It has been suggested that the patients with BC heart transplant may have superior exercise performance in comparison with BA heart transplant. An attempt to solve this dilemma has been done in 2011 by Czer et al. [25]: he did not found any significant difference in the exercise capacity between patients with BA versus BC techniques for orthotopic heart transplantation. Other factors such as cardiac denervation and immunosuppressive drug effect, or physical deconditioning, may be more important determinants of subnormal exercise capacity after heart transplantation. Nevertheless, the reduction in morbidity and postoperative complications and the simplicity in the BC technique suggest that the BC heart transplantation offers advantages when compared to the standard BA technique.
Another study by Aleksic et al. demonstrated that the BC technique improves resting hemodynamics in patients with high preoperative pulmonary vascular resistance as highlighted by higher cardiac output and index with lower right atrial pressures. Further studies by Aleksic et al. showed that the BC technique improved hemodynamics during episodes of cellular rejection (grade 1B-1R or greater) and during antibody-mediated rejection [26, 27].
Other conclusions from the Schnoor meta-analysis confirmed the outcomes of other single center results, like a higher rate of sinus rhythm after transplantation in the BC group, as well as the significantly reduced rate of tricuspid valve regurgitation, the prevention of contraction abnormalities by the acute atrial enlargement with the standard technique, and the asynchrony of recipient and donor atrial innervation, improving hemodynamic effects after BC transplantation. The enlargement and distension of the atria typical of the standard technique might not only induce an impairment of the electrical impulse initiation and conduction, triggering arrhythmias, but also promote atrial thrombus formation, most likely avoided using the BC technique.
Another relevant meta-analysis is the one conducted by the Brazilian group from San Paolo. Fagionato et al. [28] aimed at increasing the statistical power of the evidences supporting the new techniques against the BA transplantation, thus adding significance to the results of Schnoor et al. They demonstrated many advantages of the BC technique on the BA one: first of all, the ischemia time in the BC group, even when longer, as found in some studies, is compensated by a better cardiac performance with the new techniques, since adequate ventricular filling is dependent on a satisfactory atrial function. Furthermore, the incidence of atrial arrhythmias was lower in the group undergoing BC transplantation, like in Schnoor’s study. This can be explained by the preservation of the sino-atrial node integrity. Modifications in the atrial geometry predispose to atrial arrhythmias, as well as increased internal pressure, since these events prolong the electrical conduction time. The severity of the newly developed arrhythmias is known to be also related and proportional to the severity of the rejection. Fagionato’s results show no differences between the transplantation techniques in terms of rejection, concluding that the episodes of atrial arrhythmias are mainly due to greater deformity and atrial pressure. In this context, the rejection episodes can also be related to the degree of tricuspid valve regurgitation. In 2002, Aziz et al. [29] showed that individuals with moderate or severe tricuspid regurgitation have a higher number and intensity of rejection events. On the other hand, the progression of cardiac cellular rejection may be accompanied by oedema and papillary muscle dysfunction, or trigger asymmetrical right ventricular contractility, thus leading to tricuspid valve regurgitation. Additionally, the high hydrophilic property of the valve leaflets glycosaminoglycans leads to increased oncotic pressure in the extracellular matrix during cellular rejection, thus causing oedema and precluding adequate function. In this regard, there is another outstanding study conducted from the Swedish group of Wartig et al. [30] that demonstrated in a pretty huge population the impact of the transplantation techniques on the tricuspid function, as well as its impact on survival. Tricuspid valve regurgitation after cardiac transplantation has been argued to be related to the number of biopsies (although this has been found to be contradictory), to the altered geometry of the right atrial anastomosis in the BA technique, to the preoperative recipient’s pulmonary vascular resistance, to the ischemic time of the donor’s heart, to the donor-recipient size mismatch, to the mismatch between the donor’s heart and a large pericardial cavity of the recipient, or to the presence of TR already in the donor. Wartig et al. revised retrospectively their population of transplanted patient since 1984, comparing both cohorts of 221 patients receiving BA technique and 226 receiving BC technique. They observed first that the incidence of early significant TR after HTx was more common after the BA technique than after the BC technique. Furthermore, they demonstrated with a multivariate logistic regression analysis that the BA technique was the only significant predictor of early moderate to severe TR (odds ratio [OR], 2.70; 95% confidence interval [CI], 1.68–4.32; p 0.001). More interestingly, they found that moderate and severe TR at discharge was associated with impaired long-term survival. Moreover, it has been previously shown that the degree of TR is related not only to degree of symptoms and right-sided heart pressures but also to progressive renal dysfunction. When stratifying for technique, we found more patients with significant TR in the BA group at early and also 5-year follow-up, compared to the BC group; however, there was no difference at 10 year of follow-up between groups. The explanation might be that patients in the BA group with significant TR died before 10-year follow-up.
A good option to palliate the high incidence of tricuspid regurgitation is that patients undergoing HTx should have a prophylactic tricuspid valve annuloplasty [31, 32]. This may be a good option using the BA technique is used, but when the BC technique is used, prophylactic tricuspid annuloplasty not only becomes cumbersome intraoperatively, but also unnecessary because none or mild TR appears to be the case in approximately 80% of patients.
In light of these facts, the superiority of the BC technique demonstrated in many scientific relevant papers is undebatable. For this reason, some Authors postulated that the BA transplantation technique should no longer be considered the gold standard for transplantation, and should only be used in selected cases. Thus, today there is no more room for questioning whether there are advantages of the BC or total techniques over the BA technique, but it is legitimate to research possible advantages of one technique over the other, providing the patients with the best treatment.
Rectal cancer is currently a real public health problem, being the second most common type of cancer in women and the third most common type of cancer in men. Surgical treatment with curative intent (rectal resection with total mesorectal excision - TME) is the only therapeutic possibility that can ensure the healing of these patients [1].
In recent decades, the prognosis of these patients has significantly improved following the introduction in clinical practice of neoadjuvant radio chemotherapy, both to improve the life expectancy and to reduce the incidence of local recurrence. In this regard, studies show that in 15–27% of patients with rectal cancer, neoadjuvant radio-chemotherapy has caused a significant decrease in the size of tumors [2]. Therefore, a particularly important role in clinical practice is the response identification to neoadjuvant therapy in these patients. At the same time, a particularly important role in the prognosis of patients, in addition to the response to neoadjuvant radio chemotherapy, is the surgery itself and especially the achievement of a total mesorectal excision (TME) as accurate as possible and obtaining negative surgical resection margins [3, 4].
In recent years, abdominal and pelvic magnetic resonance imaging (MRI) has established itself as a gold standard method in the evaluation of patients with rectal cancer because of its crucial role in identifying non-responsive patients to neodjuvant radio chemotherapy [5, 6]. However, a particularly important role in the preoperative and postoperative clinical evaluation of these patients is played by accurate images of the anatomical structures of the pelvis, rectal tumor and their relationship with the surrounding anatomical structures [7].
In this sense, the most used MRI sequence in the preoperative evaluation of these patients for visualization of the rectum, tumor, and its relationship with surrounding tissues is High-spatial-resolution T2-weighted imaging [7]. On the other hand, one of the major advantages of rectal MRI scanning in T2 sequences is that 3 layers of the rectal wall can be differentiated. The inner layer is represented by the mucosa and submucosa, the middle layer is represented by the muscularis propria, and the outer layer is represented by the mesorectal fat. This allows for a much more accurate understanding of tumor invasion of the rectal wall and surrounding structures compared to other imaging studies [8, 9].
One of the disadvantages of MRI is the rather long time required to perform this investigation and therefore it is recommended that patients be positioned in a supine position for maximum comfort. But despite this inconvenience the benefit of this imaging method is major [10]. Current studies debate the optimal MRI resolution in the evaluation of patients with rectal cancer (1.5 T or 3 T). While 3 T cameras provide much better spatial resolution, they also have a higher susceptibility to artifacts during diffusion-weighted imaging (DWI) [10, 11, 12].
Newer studies have shown that MRI can identify patients who are at increased risk of local recurrence. In this sense, it has been shown that patients with tumors that invade only the rectal mucosa have a good long-term prognosis, while patients with invasion of the mesorectal fascia and pelvic organs in the vicinity of the rectum have a particularly high risk of recurrence [13, 14, 15]. In this respect MRI has a special utility for the detection of extramural tumor invasion as well as mucin deposits at this level [16]. On the other hand, more and more studies have shown that, in the case of superficial rectal tumors, EUS (endorectal ultrasound) has a special value in the identification of tumors and invasion of surrounding structures, while EUS is less useful in the case of tumors that penetrate the mesorectal fascia, respectively the anatomical structures in the vicinity of the rectum [17, 18].
Regarding the technique of performing MRI in these patients, in order to obtain good quality anatomical images, most authors recommend that the scan plane be perpendicular to the rectal wall at the level of the tumor with a slice thickness of maximum 3 mm. The sections are made in coronal, sagittal and axial plane [19]. On the other hand, there are debates in the literature regarding the use of intravenous contrast in these patients. Most authors do not recommend the routine use of intravenous contrast [16]. However, there are authors who consider that the use of gadolinum contrast increases the accuracy of detecting transmural tumor invasion as well as vascular invasion [9, 20, 21].
There is further controversy in regards to patient preparation for MRI. Some authors recommend the administration of spasmolytic drugs prior to imaging studies especially in patients with upper rectal tumors and if 3 T devices are used. Other authors recommend that the use of diffusion-weighted MRI be preceded by endorectal filling. But in these cases, dilation of the rectum can affect the measurement of the distance between the mesorectal fascia and the tumor [22, 23]. To eliminate this inconvenience, some authors recommend that a maximum of 60 ml of gel be used for endorectal filling [24].
One of the major advantages of performing MRI in patients with rectal cancer is that it is possible to accurately identify both the circumferential invasion of the tumor in the rectal mucosa and its transmural invasion. This fact is especially important because newer studies have shown that one of the main factors that can lead to local recurrence is incomplete resection, especially in the lateral aspect of the resection specimen [25]. At the same time, pelvic MRI has the ability to accurately detect the macroscopic type of rectal tumor (polypoid, ulcerative) and the presence or absence of mucin at this level [9].
When performing rectal MRI in T2 sequences, the rectal mucosa appears hypointense, the submucosa hyperintense, and the muscularis propria appears as a circumferential hypersignal. Precise identification of the layers of the rectal wall thus allows a precise location of the tumor at the level of the rectal wall [26]. According to the TNM classification of rectal cancer, in stage T1, the tumor is limited to the mucosa and submucosa, in stage T2, the tumor does not extend beyond the muscularis propria, in stage T3, the tumor exceeds muscularis propria and in stage T4, the tumor extends beyond the rectal wall [19] (Figure 1).
MRI image, axial view, the tumor invades the mesorectal fascia.
If the tumor invades the mesorectal fat it is considered to be stage T3 and if it invades the peritoneum of the pelvic cavity, it is interpreted as stage T4. The invasion of intersphincter space is considered a T3 stage. and the invasion of the external anal sphincter is considered a T4 stage [27, 28, 29] (Figure 2).
MRI image, sagital view – tumor recurrence invasive in the bladder and prostate.
A limiting factor in these cases is the existence of fibrous tissue in the rectal wall or in the tissues around the tumor. The existence of fibrosis at this level can make it difficult properly stage the patient, especially by over staging [30]. In this respect, there are studies in the literature which have shown that it is sometimes difficult to differentiate by MRI, peritumoral fibrosis from residual tumor deposits, especially in patients who have undergone neoadjuvant radiochemotherapy. Therefore, most authors in the literature recommend that, in patients who have undergone neo-adjuvant radio-chemotherapy, MRI examination should be performed by physicians experienced in this type of pathology [31].
Further MRI findings regard the relationship of the tumor with the anal sphincter as well as the distance between the tumor and the anocutaneous line. Tumors located less than 6 cm are considered low rectal tumors, tumors whose lower edge is located 7–11 cm from the ano-cutaneous line are considered medium rectal tumors, and tumors whose lower limit is located more than 11 cm from the ano-cutaneous line are considered superior rectal tumors [29]. The precise location of the tumor and its relationship to the anal sphincters are particularly important in determining the type of surgery to be performed in these patients (abdomino-perianal resection, abdominal resection) and the extent of the surgery to be performed.
Given the importance of precise localization of the rectal tumor relative to the anocutaneous line in determining the subsequent therapeutic decision in these patients, there are many studies that have investigated the specificity and sensitivity of MRI compared to colonoscopy in establishing the exact distance between the lower edge of the tumor and ano-cutaneous line.
In this regard, there are studies that have shown that MRI cannot rule out performing colonoscopy in these patients, especially because of the fact that colonoscopy offers the possibility of collecting biopsies for histopathological examination. But in many cases the assessment of the distance between the lower edge of the rectal tumor and the anocutaneous line during colonoscopy is subjective, both due to local anatomical details and the experience of the person performing colonoscopy, so many authors conclude that pelvic MRI it is much more useful in establishing the distance between the lower edge of the tumor and the ano-cutaneous line [32, 33, 34, 35].
In patients with rectal cancer, a particularly important factor that determines their long-term prognosis, both in terms of the occurrence of local recurrence and survival is represented by extramural vascular invasion (EMT). Recent studies have shown that, T2-weighted MRI was able to identify EMT in 80–90% of cases. EMT is manifested by the existence of morphological changes in the blood vessels adjacent to the tumor [29, 36, 37, 38].
Another particularly important prognostic factor that can be identified in these patients using MRI and is represented by the distance between the tumor margin and the mesorectal fascia. Thus, it has been shown that in patients in whom the distance between the rectal tumor and the mesorectal fascia is less than 1 mm, the risk of local recurrence is approximately 22%; if the distance is greater than 1 mm, the risk of local recurrence is only 5% [39, 40]. Regarding the assessment of the distance between the tumor edge and the mesorectal fascia, a factor that may limit the effectiveness of MRI is the existence of a low layer of mesorectal fat between the anterior wall of the rectum and the seminal vesicles in men, respectively the posterior wall of the vagina in women. In these cases, it has been shown that MRI sensitivity and specificity may be affected [41].
Regarding the accuracy of MRI, in the correct evaluation of the T descriptor of the TNM classification of rectal cancer, a very important role is played by the experience of the radiologist performing the investigation [42, 43]. Thus, population studies have shown that the sensitivity of MRI in the correct evaluation of the T descriptor varies between 29 and 57% and the specificity varies between 50 and 83% [43, 44, 45, 46, 47]. These results are due, in part, to the experience of the examining physician and, on the other hand, to the difficulty of differentiating in some cases a stage T1 tumor from a stage T2 tumor. In some cases, the desmoplastic reaction of the tumor makes a tumor look like T3 stage on MRI when in fact, following surgical specimen examining the surgical resection piece is actually a T2 stage [48].
Last but not least, the knowledge of local anatomical details, of the relations of the rectal tumor formation with the surrounding structures, allows the surgical team an adequate programming of the resection surgery, thus diminishing the possible intraoperative surprises regarding local invasion of the rectal tumor. In this way, the morbidity and postoperative mortality of these patients can be significantly reduced.
The existence of loco-regional lymph node metastases at the time of diagnosis is a poor prognostic factor in patients with rectal cancer, the first lymph nodes affected being those located in the mesorectum. In the case of rectal cancer, loco-regional lymph nodes are considered to be the obturator lymph nodes, internal iliac lymph nodes and the ones located in the mesorectum [49, 50, 51]. Therefore, the correct assessment of the existence of lymph node metastases in patients with rectal cancer is of particular importance in the preoperative assessment of these patients, the experience of the examining physician having a particularly important role in these cases [52, 53] (Figure 3).
Adjacent lymph nodes in mesorectal fat up to 4 mm in size. 4 mm extramesorectal lymph node.
It is often difficult to assess the status of loco-regional lymph nodes using MRI and it has been found that in about 25% of cases loco-regional lymphadenopathy which were considered as lymph node metastases were not confirmed positive on the histology report [54, 55]. However, some studies have shown that the use of high-resolution T2-weighted sequences can improve the sensitivity and specificity of MRI in the detection of lymph node metastases. These results are due to the fact that, especially in the case of patients undergoing neo-adjuvant radiochemotherapy, local fibrosis makes it difficult to correctly assess the status of loco-regional lymph nodes [56, 57, 58].
A much debated topic in the literature is the diagnostic criteria for lymph node metastases based on MRI examination. Thus, there are authors who consider that lymph node adenopathy with a diameter larger than 5 mm represents malignant lymphadenopathy, and those with a diameter below 5 mm are benign [59]. On the other hand, other authors consider that the most faithful sign of suspicion for malignancy is represented by the fact that the diameter of the loco-regional lymph nodes decreases in size or increases in size after the practice of neo-adjuvant radio-chemotherapy [60, 61]. On the other hand, other authors consider as criteria for malignancy of the lymph nodes, based on MRI examination, the existence of extracapsular invasion or enlargement of the lymph nodes located on the walls of the pelvic cavity (extramesorectal), or changes in their morphology (presence or absence of heterogeneity) [62, 63].
However, the specificity of the diagnosis of malignant lymphadenopathy with MRI is around 70%, mainly due to fibrotic changes or mucinous degeneration of these lymph nodes, these results being due also to the fact that there are studies that have shown the existence of fibrotic changes also in case of benign lymphatic nodules [64]. There are also studies in the literature that recommend the practice of MRI with dynamic contrast-enhanced, in patients with rectal cancer, in order to increase the accuracy of MRI diagnosis of lymph node involvement. In the case of the administration of dynamic contrast, it is considered that, usually, the malignant lymph nodes, when examined in T2 sequences, have edges in hypersignal, and their center presents hyposignal [65].
Recently, the importance of MRI in the preoperative evaluation of rectal cancer patients has increased greatly despite the abdominal CT examination, especially due to the fact that diffusion-weighted MRI is much more effective in detecting small liver metastases compared to abdominal CT imaging [66]. There are also studies in the literature that have shown that the sensitivity and specificity of MRI in the detection of liver metastases is superior even to PET-CT [67, 68]. Therefore, there are authors who recommend performing a whole body MRI, in patients with rectal cancer [69]. On the other hand, the sensitivity and specificity of the detection of pulmonary metastases, in patients with rectal cancer, is lower in the case of MRI compared with chest CT scan [70].
Recently, in order to detect the existence of distant metastases, in patients with rectal cancer, PET-MRI is increasingly used. This method eliminates the lower sensitivity and specificity of MRI in the detection of lung metastases and brings in addition the increased sensitivity and specificity of MRI for the detection of liver metastases, compared to abdominal CT scan [71].
The prognosis of patients with rectal cancer has significantly improved, in recent years, on the one hand by introducing the neo-adjuvant radiochemotherapy in their treatment, as well as by improving imaging methods that allow a more accurate preoperative staging of these patients [72, 73]. Thus, it has been shown that the introduction of neo-adjuvant radiochemotherapy in patients with advanced loco-regional forms of rectal cancer has led to an improvement in their survival, decreased the risk of local recurrence and, in some cases, has even been recorded a complete pathological response, improving as well the postoperative morbidity and mortality of these patients. Also, for these patients it was found a better compliance to postoperative radio-chemotherapy [74, 75, 76].
With the initiation of neo-adjuvant radio-chemotherapy of particular clinical importance is the identification of patients with no response to this therapy, with incomplete clinical response or with a complete clinical response (the absence of residual tumor, the absence of neoplastic lymph nodes in the mesorectum). The identification of these groups of patients is very important given the principles of personalized medicine. It is also of crucial importance to identify patients who do not respond to radiochemotherapy, in which case it is beneficial for them to initiate the surgical treatment as soon as possible [77, 78, 79, 80].
In this regard, in recent years there are authors who, in rectal cancer patients with neo-adjuvant radiochemotherapy to whom a complete clinical response is recorded, recommend either the practice of a resection surgery with preservation of the rectum or only the clinical follow-up of these patients, without the indication of a surgical treatment. In these situations, a complete clinical response is recorded in approximately 24% of cases [80, 81]. Some authors have shown that the usual MRI techniques (T2 weighted) cannot always correctly assess the clinical response to neo-adjuvant radiochemotherapy, recommending in these cases the use of functional MRI techniques (dynamic contrast-enhanced MRI - DCE-MRI and diffusion- weighted imaging - DWI). These techniques have the advantage of providing much more accurate information about the existence of the residual tumor.
In this sense, in the case of the use of DWI-MRI, the so-called diffusion coefficient that evaluates the diffusion capacity of water at the tissue level is particularly important in evaluating the tumor response to neo-adjuvant radiochemotherapy. This coefficient is inversely proportional to tissue cellularity. Usually, viable tumor cells prevent the diffusion of water to the tissues, while necrotic tumor cells allow the diffusion of water at this level [82, 83]. The diffusion coefficient is also particularly useful in differentiating viable tumor tissue from inflamed areas, respectively necrosis areas. Thus, some authors consider that the value of this coefficient has predictive value in terms of response to neo-adjuvant radiochemotherapy of these patients [84].
DCE-MRI can provide important information about the vascularization of the tumor, the permeability of these vessels, as well as about the structure of the extracellular space. Also, this method has the possibility to identify the areas of hypoxia as well as the intensity of the microvascularization at the level of the tumor formation, both from a quantitative and a qualitative point of view. In this regard, there are studies in the literature that have shown that the existence of increased vascular permeability in the tumor before initiating neo-adjuvant radiochemotherapy is associated with a good therapeutic response, in these cases. Other authors have also shown that the existence of mucin at the level of the tumor formation is associated with a poor therapeutic response in these cases [84, 85, 86, 87].
The major advantages of using MRI in evaluating the clinical response to neo-adjuvant radiochemotherapy are represented on the one hand by highlighting the morphological changes that occur at the level of the rectal tumor (size, vascularity, structure) as well as the changes that occur in the pelvic lymph nodes. The limiting factor that may influence the accuracy of the method in these cases is the occurrence of local fibrosis after radiotherapy or post irradiation proctitis [88].
Local recurrence occurs in approximately 30% of patients operated for rectal cancer. Early identification of local recurrence in these patients is of particular importance both for the therapeutic management of these patients as well as for their long-term prognosis [89]. Local recurrence is characterized by the appearance of a tumor formation at the level of the anastomosis, at the level of the operating bed or at the level of the pelvic lymph nodes. At the time of local recurrence, only about 20% of these patients are still suitable for surgical treatment [90].
Although currently the most used imaging method in postoperative follow-up of patients with operated rectal cancer is abdomino-pelvic CT scan, recently there are more and more studies in the literature that recommend performing abdominal-pelvic MRI in these patients. Those who promote this method are based on the fact that in the detection of pelvic neoplasms, the specificity and sensitivity of pelvic MRI in differentiating areas of fibrosis from tumor recurrence is much higher than pelvic CT scan [91, 92]. At the same time, it has been shown that, in the case of small liver metastases, abdominal MRI has a better detection rate compared to abdominal CT. Also, another argument for the utility of pelvic MRI in these cases is given by the fact that, compared to the pelvic CT, MRI offers a much better spatial resolution, and can also provide functional information (tissue diffusion, local vascularization) [93]. Recent studies have shown that when using diffusion-weighted MRI (DWI-MRI) there is the possibility of identifying tumor recurrence, in these cases, faster than when using conventional MRI techniques or when using abdominal CT [94, 95].
The pelvic MRI examination has a special utility both in the preoperative evaluation of the patients with rectal cancer and in the postoperative follow-up of these patients. Nowadays, this method represent the “gold standard” imagistic method in the evaluation of these patients.
Supporting women in scientific research and encouraging more women to pursue careers in STEM fields has been an issue on the global agenda for many years. But there is still much to be done. And IntechOpen wants to help.
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\n\nWe aim to publish 100 books in our Women in Science program over the next three years. We are looking for books written, edited, or co-edited by women. Contributing chapters by men are welcome. As always, the quality of the research we publish is paramount.
\n\nAll project proposals go through a two-stage peer review process and are selected based on the following criteria:
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\n\nInterested? If you have an idea for an edited volume or a monograph, we’d love to hear from you! Contact Ana Pantar at book.idea@intechopen.com.
\n\n“My scientific path has given me the opportunity to work with colleagues all over Europe, including Germany, France, and Norway. Editing the book Graph Theory: Advanced Algorithms and Applications with IntechOpen emphasized for me the importance of providing valuable, Open Access literature to our scientific colleagues around the world. So I am highly enthusiastic about the Women in Science book collection, which will highlight the outstanding accomplishments of women scientists and encourage others to walk the challenging path to becoming a recognized scientist." Beril Sirmacek, TU Delft, The Netherlands
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Ashkenazi, E. Mentovich, D. Cvikel, O. Barkai, A. Aronson and Y. 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In this chapter, we have presented a brief comprehensive survey of cultural heritage using augmented reality systems. This survey describes the main objectives and characteristics of marker-less augmented reality systems through presenting up-to-date research results in this area. We describe the marker-less technologies in the area of AR, indoor marker-less AR, outdoor marker-less AR, real-time solutions to the tracking problem, real-time registration, cultural heritage in AR, 3D remonstration techniques, as well as presenting the problems in each research.",book:{id:"7699",slug:"advanced-methods-and-new-materials-for-cultural-heritage-preservation",title:"Advanced Methods and New Materials for Cultural Heritage Preservation",fullTitle:"Advanced Methods and New Materials for Cultural Heritage Preservation"},signatures:"Hoshang Kolivand, Abdennour El Rhalibi, Mostafa Tajdini, Sarmad Abdulazeez\nand Pisit Praiwattana",authors:[{id:"151219",title:"Prof.",name:"Abdennour",middleName:null,surname:"El Rhalibi",slug:"abdennour-el-rhalibi",fullName:"Abdennour El Rhalibi"},{id:"225824",title:"Dr.",name:"Hoshang",middleName:null,surname:"Kolivand",slug:"hoshang-kolivand",fullName:"Hoshang Kolivand"},{id:"256916",title:"Dr.",name:"Sarmad",middleName:null,surname:"Abdulazeez",slug:"sarmad-abdulazeez",fullName:"Sarmad Abdulazeez"},{id:"256917",title:"Dr.",name:"Pisit",middleName:null,surname:"Praiwattana",slug:"pisit-praiwattana",fullName:"Pisit Praiwattana"},{id:"289071",title:"Dr.",name:"Mostafa",middleName:null,surname:"Tajdini",slug:"mostafa-tajdini",fullName:"Mostafa Tajdini"}]},{id:"36570",doi:"10.5772/45619",title:"Archaeological Geophysics - From Basics to New Perspectives",slug:"archaeological-geophysics-from-basics-to-new-perspectives",totalDownloads:6563,totalCrossrefCites:4,totalDimensionsCites:8,abstract:null,book:{id:"1999",slug:"archaeology-new-approaches-in-theory-and-techniques",title:"Archaeology",fullTitle:"Archaeology, New Approaches in Theory and Techniques"},signatures:"Roger Sala, Ekhine Garcia and Robert Tamba",authors:[{id:"131865",title:"Dr.",name:"Roger",middleName:null,surname:"Sala",slug:"roger-sala",fullName:"Roger Sala"}]},{id:"36574",doi:"10.5772/37679",title:"The Study of Shell Object Manufacturing Techniques from the Perspective of Experimental Archaeology and Work Traces",slug:"the-study-of-shell-object-manufacturing-techniques-from-the-perspective-of-experimental-archaeology-",totalDownloads:3119,totalCrossrefCites:1,totalDimensionsCites:5,abstract:null,book:{id:"1999",slug:"archaeology-new-approaches-in-theory-and-techniques",title:"Archaeology",fullTitle:"Archaeology, New Approaches in Theory and Techniques"},signatures:"Adrián Velázquez-Castro",authors:[{id:"113840",title:"Dr.",name:"Adrian",middleName:null,surname:"Velazquez",slug:"adrian-velazquez",fullName:"Adrian Velazquez"}]},{id:"70612",doi:"10.5772/intechopen.89154",title:"The Technological Diversity of Lithic Industries in Eastern South America during the Late Pleistocene-Holocene Transition",slug:"the-technological-diversity-of-lithic-industries-in-eastern-south-america-during-the-late-pleistocen",totalDownloads:684,totalCrossrefCites:1,totalDimensionsCites:4,abstract:"Brazilian archaeological literature has insisted for decades upon associating hunter-gatherer sites dated to the Pleistocene–Holocene transition either to the Itaparica tradition, if located in central or northeastern Brazil, or to the Umbu tradition and Humaitá tradition, if located in southern Brazil, Uruguay, or any other adjacent part of Paraguay and Argentina. These associations have been based almost entirely on the presence or absence of lesmas and “projectile points,” regardless of their morphological and technological features. In the Uruguayan archaeological literature, three other cultures are recognised: Fell industry, Catalanense industry, and Tigre tradition, all in the Uruguayan region. However, the last 10 years of systematic studies on the lithic assemblages from these sites have shown that Paleoindian societies from Eastern South America are more culturally diverse than expected and that previously defined archaeological cultures present several issues in their definition, suggesting that many of these “traditions” are not valid and should no longer be used. Instead, new lithic industries and archaeological cultures should be defined only when cultural patterns are observable through systematic analyses.",book:{id:"9251",slug:"pleistocene-archaeology-migration-technology-and-adaptation",title:"Pleistocene Archaeology",fullTitle:"Pleistocene Archaeology - Migration, Technology, and Adaptation"},signatures:"João Carlos Moreno De Sousa",authors:[{id:"303361",title:"Dr.",name:"João Carlos",middleName:null,surname:"Moreno De Sousa",slug:"joao-carlos-moreno-de-sousa",fullName:"João Carlos Moreno De Sousa"}]}],mostDownloadedChaptersLast30Days:[{id:"36570",title:"Archaeological Geophysics - From Basics to New Perspectives",slug:"archaeological-geophysics-from-basics-to-new-perspectives",totalDownloads:6552,totalCrossrefCites:4,totalDimensionsCites:8,abstract:null,book:{id:"1999",slug:"archaeology-new-approaches-in-theory-and-techniques",title:"Archaeology",fullTitle:"Archaeology, New Approaches in Theory and Techniques"},signatures:"Roger Sala, Ekhine Garcia and Robert Tamba",authors:[{id:"131865",title:"Dr.",name:"Roger",middleName:null,surname:"Sala",slug:"roger-sala",fullName:"Roger Sala"}]},{id:"36576",title:"Homage to Marcel Proust - Aspects of Dissemination and Didactic in a Museum and a Science Centre: Science Communication Visions for the Third Generation Museums",slug:"generations-of-ancient-history-dissemination-towards-the-public-at-the-university-museum-in-trondhei",totalDownloads:2644,totalCrossrefCites:1,totalDimensionsCites:1,abstract:null,book:{id:"1999",slug:"archaeology-new-approaches-in-theory-and-techniques",title:"Archaeology",fullTitle:"Archaeology, New Approaches in Theory and Techniques"},signatures:"Kistian Overskaug",authors:[{id:"117119",title:"Dr.",name:"Kristian",middleName:null,surname:"Overskaug",slug:"kristian-overskaug",fullName:"Kristian Overskaug"}]},{id:"63772",title:"Cultural Heritage in Marker-Less Augmented Reality: A Survey",slug:"cultural-heritage-in-marker-less-augmented-reality-a-survey",totalDownloads:1628,totalCrossrefCites:6,totalDimensionsCites:9,abstract:"Augmented reality (AR) is considered as one of the most significant technologies in the field of computer graphics and is utilised in many applications. In this chapter, we have presented a brief comprehensive survey of cultural heritage using augmented reality systems. This survey describes the main objectives and characteristics of marker-less augmented reality systems through presenting up-to-date research results in this area. We describe the marker-less technologies in the area of AR, indoor marker-less AR, outdoor marker-less AR, real-time solutions to the tracking problem, real-time registration, cultural heritage in AR, 3D remonstration techniques, as well as presenting the problems in each research.",book:{id:"7699",slug:"advanced-methods-and-new-materials-for-cultural-heritage-preservation",title:"Advanced Methods and New Materials for Cultural Heritage Preservation",fullTitle:"Advanced Methods and New Materials for Cultural Heritage Preservation"},signatures:"Hoshang Kolivand, Abdennour El Rhalibi, Mostafa Tajdini, Sarmad Abdulazeez\nand Pisit Praiwattana",authors:[{id:"151219",title:"Prof.",name:"Abdennour",middleName:null,surname:"El Rhalibi",slug:"abdennour-el-rhalibi",fullName:"Abdennour El Rhalibi"},{id:"225824",title:"Dr.",name:"Hoshang",middleName:null,surname:"Kolivand",slug:"hoshang-kolivand",fullName:"Hoshang Kolivand"},{id:"256916",title:"Dr.",name:"Sarmad",middleName:null,surname:"Abdulazeez",slug:"sarmad-abdulazeez",fullName:"Sarmad Abdulazeez"},{id:"256917",title:"Dr.",name:"Pisit",middleName:null,surname:"Praiwattana",slug:"pisit-praiwattana",fullName:"Pisit Praiwattana"},{id:"289071",title:"Dr.",name:"Mostafa",middleName:null,surname:"Tajdini",slug:"mostafa-tajdini",fullName:"Mostafa Tajdini"}]},{id:"73769",title:"Human Evolution in the Center of the Old World: An Updated Review of the South Asian Paleolithic",slug:"human-evolution-in-the-center-of-the-old-world-an-updated-review-of-the-south-asian-paleolithic",totalDownloads:847,totalCrossrefCites:0,totalDimensionsCites:1,abstract:"The Indian Subcontinent was an important geographic region for faunal and hominin evolution in Asia. While the Oldowan as the earliest technocomplex continues to be elusive, the oldest Acheulean is dated to ~1.5 Ma and the early Middle Paleolithic is ~385 ka (from the same site). New Late Pleistocene dates have been reported for the Middle Paleolithic which continues up to 38 Ka in southern India. The Upper Paleolithic remains ambiguous and requires critically multidisciplinary investigations. The microlithic evidence appears to spread rapidly across the subcontinent soon after its emergence at ~48 Ka (though its origin is debated) and continues into the Iron Age. The timeline of the initial arrival of Homo sapiens continues to be debated based on the archaeology (advanced Middle Paleolithic vs. microlithic) and genetic studies on indigenous groups. Other issues that need consideration are: interactions between archaics and arriving moderns, the marginal occurrence of symbolic behavior, the absolute dating of rock art and the potential role of hominins in specific animal extinctions and ecological marginalization. The region does not appear to have been a corridor for dispersals towards Southeast Asia (although gene flow may have occurred). Instead, once various prehistoric technologies appeared in the Subcontinent, they possibly followed complex trajectories within relative isolation.",book:{id:"9251",slug:"pleistocene-archaeology-migration-technology-and-adaptation",title:"Pleistocene Archaeology",fullTitle:"Pleistocene Archaeology - Migration, Technology, and Adaptation"},signatures:"Parth R. Chauhan",authors:[{id:"307040",title:"Dr.",name:"Parth",middleName:null,surname:"Chauhan",slug:"parth-chauhan",fullName:"Parth Chauhan"}]},{id:"73386",title:"Island Migration, Resource Use, and Lithic Technology by Anatomically Modern Humans in Wallacea",slug:"island-migration-resource-use-and-lithic-technology-by-anatomically-modern-humans-in-wallacea",totalDownloads:725,totalCrossrefCites:1,totalDimensionsCites:3,abstract:"Island migration and adaptation including both marine and terrestrial resource use and technological development by anatomically modern humans (AMH) are among the most significant issues for Pleistocene archaeology in Southeast Asia and Oceania, and directly related to the behavioral and technological advancements by AMH. This paper discusses such cases in the Wallacean islands, located between the past Sundaland and the Sahul continent during the Pleistocene. The Pleistocene open sea gaps between the Wallacean islands and both landmasses are very likely the major factor for the relative scarcity of animal species originating from Asia and Oceania and the high diversity of endemic species in Wallacea. They were also a barrier for hominin migration into the Wallacean islands and Sahul continent. We summarize three recent excavation results on the Talaud Islands, Sulawesi Island and Mindoro Island in Wallacea region and discuss the evidence and timeline for migrations of early modern humans into the Wallacean islands and their adaptation to island environments during the Pleistocene.",book:{id:"9251",slug:"pleistocene-archaeology-migration-technology-and-adaptation",title:"Pleistocene Archaeology",fullTitle:"Pleistocene Archaeology - Migration, Technology, and Adaptation"},signatures:"Rintaro Ono, Alfred Pawlik and Riczar Fuentes",authors:[{id:"177123",title:"Dr.",name:"Rintaro",middleName:null,surname:"Ono",slug:"rintaro-ono",fullName:"Rintaro Ono"},{id:"300616",title:"Dr.",name:"Alfred",middleName:null,surname:"Pawlik",slug:"alfred-pawlik",fullName:"Alfred Pawlik"},{id:"330591",title:"Dr.",name:"Riczar",middleName:null,surname:"Fuentes",slug:"riczar-fuentes",fullName:"Riczar Fuentes"}]}],onlineFirstChaptersFilter:{topicId:"263",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:98,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:287,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:10,numberOfPublishedChapters:103,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"13",title:"Veterinary Medicine and Science",doi:"10.5772/intechopen.73681",issn:"2632-0517",scope:"Paralleling similar advances in the medical field, astounding advances occurred in Veterinary Medicine and Science in recent decades. 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By addressing hot topics in veterinary sciences, we aim to gather authoritative texts within each issue of this series, providing in-depth overviews and analysis for graduates, academics, and practitioners and foreseeing a deeper understanding of the subject. Forthcoming texts, written and edited by experienced researchers from both industry and academia, will also discuss scientific challenges faced today in Veterinary Medicine and Science. 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A dynamic career research platform which is based on the thematic areas of comparative vertebrate physiology, stress endocrinology, reproductive endocrinology, animal health and welfare, and conservation biology. \nEdward has supervised 40 research students and published over 60 peer reviewed research.",institutionString:null,institution:{name:"University of Queensland",institutionURL:null,country:{name:"Australia"}}},editorTwo:null,editorThree:null},{id:"20",title:"Animal Nutrition",coverUrl:"https://cdn.intechopen.com/series_topics/covers/20.jpg",isOpenForSubmission:!0,editor:{id:"175967",title:"Dr.",name:"Manuel",middleName:null,surname:"Gonzalez Ronquillo",slug:"manuel-gonzalez-ronquillo",fullName:"Manuel Gonzalez Ronquillo",profilePictureURL:"https://mts.intechopen.com/storage/users/175967/images/system/175967.png",biography:"Dr. Manuel González Ronquillo obtained his doctorate degree from the University of Zaragoza, Spain, in 2001. 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He teaches various degree courses in zootechnics, sheep production, and agricultural sciences and natural resources.\n\nDr. Ronquillo’s research focuses on the evaluation of sustainable animal diets (StAnD), using native resources of the region, decreasing carbon footprint, and applying meta-analysis and mathematical models for a better understanding of animal production.",institutionString:null,institution:{name:"Universidad Autónoma del Estado de México",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null},{id:"28",title:"Animal Reproductive Biology and Technology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/28.jpg",isOpenForSubmission:!0,editor:{id:"177225",title:"Prof.",name:"Rosa Maria Lino Neto",middleName:null,surname:"Pereira",slug:"rosa-maria-lino-neto-pereira",fullName:"Rosa Maria Lino Neto Pereira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS9wkQAC/Profile_Picture_1624519982291",biography:"Rosa Maria Lino Neto Pereira (DVM, MsC, PhD and) is currently a researcher at the Genetic Resources and Biotechnology Unit of the National Institute of Agrarian and Veterinarian Research (INIAV, Portugal). 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He is also Member of the Laboratory of genetic, animal and feed resource and member of Animal science Department of INAT. He graduated from Higher School of Agriculture of Mateur, University of Carthage, in 2002 and completed his masters in 2006. Dr. M’HAMDI completed his PhD thesis in Genetic welfare indicators of dairy cattle at Higher Institute of Agronomy of Chott-Meriem, University of Sousse, in 2011. He worked as assistant Professor of Genetic, biostatistics and animal biotechnology at INAT since 2013.",institutionString:null,institution:null}]},{type:"book",id:"8460",title:"Reproductive Biology and Technology in Animals",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/8460.jpg",slug:"reproductive-biology-and-technology-in-animals",publishedDate:"April 15th 2020",editedByType:"Edited by",bookSignature:"Juan Carlos Gardón Poggi and Katy Satué Ambrojo",hash:"32ef5fe73998dd723d308225d756fa1e",volumeInSeries:4,fullTitle:"Reproductive Biology and Technology in Animals",editors:[{id:"251314",title:"Dr.",name:"Juan Carlos",middleName:null,surname:"Gardón",slug:"juan-carlos-gardon",fullName:"Juan Carlos Gardón",profilePictureURL:"https://mts.intechopen.com/storage/users/251314/images/system/251314.jpeg",biography:"Juan Carlos Gardón Poggi received University degree from the Faculty of Agrarian Science in Argentina, in 1983. Also he received Masters Degree and PhD from Córdoba University, Spain. He is currently a Professor at the Catholic University of Valencia San Vicente Mártir, at the Department of Medicine and Animal Surgery. He teaches diverse courses in the field of Animal Reproduction and he is the Director of the Veterinary Farm. He also participates in academic postgraduate activities at the Veterinary Faculty of Murcia University, Spain. His research areas include animal physiology, physiology and biotechnology of reproduction either in males or females, the study of gametes under in vitro conditions and the use of ultrasound as a complement to physiological studies and development of applied biotechnologies. 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He has both an MS and Ph.D. in Biomedical Engineering. He was previously a research scientist at the University of California Los Angeles (UCLA) and visiting professor and researcher at the University of North Dakota. He is currently working in artificial intelligence and its applications in medical signal processing. In addition, he is using digital signal processing in medical imaging and speech processing. Dr. Asadpour has developed brain-computer interfacing algorithms and has published books, book chapters, and several journal and conference papers in this field and other areas of intelligent signal processing. He has also designed medical devices, including a laser Doppler monitoring system.",institutionString:"Kaiser Permanente Southern California",institution:null},{id:"169608",title:"Prof.",name:"Marian",middleName:null,surname:"Găiceanu",slug:"marian-gaiceanu",fullName:"Marian Găiceanu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/169608/images/system/169608.png",biography:"Prof. Dr. Marian Gaiceanu graduated from the Naval and Electrical Engineering Faculty, Dunarea de Jos University of Galati, Romania, in 1997. He received a Ph.D. (Magna Cum Laude) in Electrical Engineering in 2002. Since 2017, Dr. Gaiceanu has been a Ph.D. supervisor for students in Electrical Engineering. He has been employed at Dunarea de Jos University of Galati since 1996, where he is currently a professor. Dr. Gaiceanu is a member of the National Council for Attesting Titles, Diplomas and Certificates, an expert of the Executive Agency for Higher Education, Research Funding, and a member of the Senate of the Dunarea de Jos University of Galati. He has been the head of the Integrated Energy Conversion Systems and Advanced Control of Complex Processes Research Center, Romania, since 2016. He has conducted several projects in power converter systems for electrical drives, power quality, PEM and SOFC fuel cell power converters for utilities, electric vehicles, and marine applications with the Department of Regulation and Control, SIEI S.pA. (2002–2004) and the Polytechnic University of Turin, Italy (2002–2004, 2006–2007). He is a member of the Institute of Electrical and Electronics Engineers (IEEE) and cofounder-member of the IEEE Power Electronics Romanian Chapter. He is a guest editor at Energies and an academic book editor for IntechOpen. He is also a member of the editorial boards of the Journal of Electrical Engineering, Electronics, Control and Computer Science and Sustainability. Dr. Gaiceanu has been General Chairman of the IEEE International Symposium on Electrical and Electronics Engineering in the last six editions.",institutionString:'"Dunarea de Jos" University of Galati',institution:{name:'"Dunarea de Jos" University of Galati',country:{name:"Romania"}}},{id:"4519",title:"Prof.",name:"Jaydip",middleName:null,surname:"Sen",slug:"jaydip-sen",fullName:"Jaydip Sen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/4519/images/system/4519.jpeg",biography:"Jaydip Sen is associated with Praxis Business School, Kolkata, India, as a professor in the Department of Data Science. His research areas include security and privacy issues in computing and communication, intrusion detection systems, machine learning, deep learning, and artificial intelligence in the financial domain. He has more than 200 publications in reputed international journals, refereed conference proceedings, and 20 book chapters in books published by internationally renowned publishing houses, such as Springer, CRC press, IGI Global, etc. Currently, he is serving on the editorial board of the prestigious journal Frontiers in Communications and Networks and in the technical program committees of a number of high-ranked international conferences organized by the IEEE, USA, and the ACM, USA. He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:null},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:"Polytechnic University of Timişoara",institution:{name:"Polytechnic University of Timişoara",country:{name:"Romania"}}},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:null},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"414880",title:"Dr.",name:"Maryam",middleName:null,surname:"Vatankhah",slug:"maryam-vatankhah",fullName:"Maryam Vatankhah",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Borough of Manhattan Community College",country:{name:"United States of America"}}},{id:"414879",title:"Prof.",name:"Mohammad-Reza",middleName:null,surname:"Akbarzadeh-Totonchi",slug:"mohammad-reza-akbarzadeh-totonchi",fullName:"Mohammad-Reza Akbarzadeh-Totonchi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ferdowsi University of Mashhad",country:{name:"Iran"}}},{id:"414878",title:"Prof.",name:"Reza",middleName:null,surname:"Fazel-Rezai",slug:"reza-fazel-rezai",fullName:"Reza Fazel-Rezai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"American Public University System",country:{name:"United States of America"}}},{id:"302698",title:"Dr.",name:"Yao",middleName:null,surname:"Shan",slug:"yao-shan",fullName:"Yao Shan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Dalian University of Technology",country:{name:"China"}}},{id:"125911",title:"Prof.",name:"Jia-Ching",middleName:null,surname:"Wang",slug:"jia-ching-wang",fullName:"Jia-Ching Wang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Central University",country:{name:"Taiwan"}}},{id:"357085",title:"Mr.",name:"P. Mohan",middleName:null,surname:"Anand",slug:"p.-mohan-anand",fullName:"P. Mohan Anand",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356696",title:"Ph.D. Student",name:"P.V.",middleName:null,surname:"Sai Charan",slug:"p.v.-sai-charan",fullName:"P.V. Sai Charan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"357086",title:"Prof.",name:"Sandeep K.",middleName:null,surname:"Shukla",slug:"sandeep-k.-shukla",fullName:"Sandeep K. Shukla",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356823",title:"MSc.",name:"Seonghee",middleName:null,surname:"Min",slug:"seonghee-min",fullName:"Seonghee Min",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Daegu University",country:{name:"Korea, South"}}},{id:"353307",title:"Prof.",name:"Yoosoo",middleName:null,surname:"Oh",slug:"yoosoo-oh",fullName:"Yoosoo Oh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:"Yoosoo Oh received his Bachelor's degree in the Department of Electronics and Engineering from Kyungpook National University in 2002. He obtained his Master’s degree in the Department of Information and Communications from Gwangju Institute of Science and Technology (GIST) in 2003. In 2010, he received his Ph.D. degree in the School of Information and Mechatronics from GIST. In the meantime, he was an executed team leader at Culture Technology Institute, GIST, 2010-2012. In 2011, he worked at Lancaster University, the UK as a visiting scholar. In September 2012, he joined Daegu University, where he is currently an associate professor in the School of ICT Conver, Daegu University. Also, he served as the Board of Directors of KSIIS since 2019, and HCI Korea since 2016. From 2017~2019, he worked as a center director of the Mixed Reality Convergence Research Center at Daegu University. From 2015-2017, He worked as a director in the Enterprise Supporting Office of LINC Project Group, Daegu University. His research interests include Activity Fusion & Reasoning, Machine Learning, Context-aware Middleware, Human-Computer Interaction, etc.",institutionString:null,institution:{name:"Daegu Gyeongbuk Institute of Science and Technology",country:{name:"Korea, South"}}},{id:"262719",title:"Dr.",name:"Esma",middleName:null,surname:"Ergüner Özkoç",slug:"esma-erguner-ozkoc",fullName:"Esma Ergüner Özkoç",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Başkent University",country:{name:"Turkey"}}},{id:"346530",title:"Dr.",name:"Ibrahim",middleName:null,surname:"Kaya",slug:"ibrahim-kaya",fullName:"Ibrahim Kaya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"419199",title:"Dr.",name:"Qun",middleName:null,surname:"Yang",slug:"qun-yang",fullName:"Qun Yang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Auckland",country:{name:"New Zealand"}}},{id:"351158",title:"Prof.",name:"David W.",middleName:null,surname:"Anderson",slug:"david-w.-anderson",fullName:"David W. Anderson",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Calgary",country:{name:"Canada"}}}]}},subseries:{item:{id:"92",type:"subseries",title:"Health and Wellbeing",keywords:"Ecology, Ecological, Nature, Health, Wellbeing, Health production",scope:"\r\n\tSustainable approaches to health and wellbeing in our COVID 19 recovery needs to focus on ecological approaches that prioritize our relationships with each other, and include engagement with nature, the arts and our heritage. This will ensure that we discover ways to live in our world that allows us and other beings to flourish. We can no longer rely on medicalized approaches to health that wait for people to become ill before attempting to treat them. We need to live in harmony with nature and rediscover the beauty and balance in our everyday lives and surroundings, which contribute to our well-being and that of all other creatures on the planet. This topic will provide insights and knowledge into how to achieve this change in health care that is based on ecologically sustainable practices.
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