Modified Glasgow coma scale for infants and children.
\r\n\t
",isbn:"978-1-80356-363-3",printIsbn:"978-1-80356-362-6",pdfIsbn:"978-1-80356-364-0",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,hash:"969d1c6315b04584c2f011e03dad69c2",bookSignature:"Dr. Mansoor Zoveidavianpoor",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11929.jpg",keywords:"Drilling Performance, Drilling Tools, Well Design, Drilling Procedure, Rotary Drilling, Directional Drilling, Measuring-While-Drilling, Smart Well Technology, Environment Protection, Geothermal Drilling, Sustainable Drilling Fluids, Carbon Sequestration",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 18th 2022",dateEndSecondStepPublish:"March 18th 2022",dateEndThirdStepPublish:"May 17th 2022",dateEndFourthStepPublish:"August 5th 2022",dateEndFifthStepPublish:"October 4th 2022",remainingDaysToSecondStep:"2 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Dr. Zoveidavianpoor has over 18 years of multidisciplinary oil and gas experience, built upon his technical, operational, and management roles in the industry and academia. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"66640",title:"Reduction of Myopia Burden and Progression",doi:"10.5772/intechopen.85715",slug:"reduction-of-myopia-burden-and-progression",body:'\nMyopia is a refractive condition of the eye that has globally affected 1.89 billion people worldwide, and projected to affect 2.56 billion people by the year 2020 [1]. Over the past few decades, the prevalence of myopia in Asia has increased dramatically affecting as much as 80–90% of the pediatric Asian population, and 25–50% of the American and European population [2].
\nRefractive development in early ocular growth is an intricate and continuous process. At birth, there is a high prevalence of large refractive errors in newborn infants due to mismatch between the axial length and the focal length of its optics [3, 4, 5]. As the newborn matures, the eye develops in size and refracting power in a rapid fashion to attain an ideal refractive state in early childhood. This physiological process is known as emmetropization [5, 6, 7]. Coordination between axial length and optical components will allow for the images of distal objects to focus on the retina, rather than in front or behind it [5]. Interruption of this homeostatic process of ocular growth results in the development of refractive error. The disorder manifests in early childhood and progresses at an average of 0.5D every year until stabilizing during adolescence [8, 9, 10].
\nIt was once considered a mere refractive error, but myopia is now often associated with a multitude of ocular diseases such as retinal detachment, glaucoma, cataract and chorioretinal abnormalities [11]. Therefore, in recent years, the focus of myopia research has been on halting the progression to decrease the risk of associated future ocular diseases.
\nThis chapter focuses on the mechanics of the various treatment methods including optical, pharmacological and surgical strategies, for precise control of myopia. The goal of such treatment methods is to reduce both personal and societal burden, as well as prevent disease progression such as worsening refractions, axial length and overall ocular health.
\nWhile potential optical strategies are investigated for adequate myopia control, the visual outcomes of Single Vision Lenses (SVLs) are used as control for efficacy comparison. Single vision lenses (SVLs) have universally been utilized by ophthalmologists and optometrists for correction of refractive error. With periodic monitoring, the spectacle prescription is often adjusted to correct the increasing refractive error. The growth of the eye is regulated by visual signals, which are manipulated and controlled by the power of the spectacle lens [5]. By regulating the refractive error of the cornea and the axial length of the eye, SVLs emulate the eye’s innate process of emmetropization by allowing the eye to focus the rays on the retina [5, 12].
\nWhile visual outcomes are improved, SVLs do not interrupt the myopia progression or axial length elongation. Though clinically insignificant, evidence from animal studies suggest compensatory eye growth in spectacle induced emmetropization [13, 14]. Since SVLs alter the refractive error but does not reduce progression or axial elongation, studies have investigated on alternate optical correction methods, such as under-correction of refractive error.
\nAnimal studies have postulated that under-correction of the refractive error reduces the mean change in refractive error, in comparison to fully-corrected SVLs. Hence, some clinicians advocate for under-corrected SVLs in an attempt to reduce the axial growth and prevent further myopia progression. It is theorized that modest under-correction of SVLs by 0.5–0.75D reduces the accommodative stimulus and consequently the blur drive for near work accommodation [15, 16]. However, studies have demonstrated contradicting results.
\nThe pilot randomized study performed by Chung et al. compared the effects of under correction versus full correction on Hong Kong Chinese children. The study demonstrated that myopia progression was slightly greater in patients with under-correction in comparison to full correction, with 0.5 and 0.35D, respectively [17]. Similar results were obtained by study conducted by Adler et al., which showed 0.66 versus 0.55D for patients with under-correction and full correction, respectively [18]. Both studies concluded that myopic defocus through under-correction slightly increased the rate of myopia progression. While SVLs attend to the refractive error and vision complaints of the child, it does not have a protective role on the health and growth of the eye.
\nAs an alternative to SVLs, multifocal lenses have gained popularity for use in slowing or halting the progression of myopia and axial elongation of the eye. It is believed that these lenses decrease the rate of myopia progression by reducing accommodation effort and hyperopic defocus. A relatively newer version of the multifocal lenses is Progressive Addition Lenses (PALs). The Correction of Myopia Evaluation Trial (COMET) study is the largest double randomized, double masked clinical trial that evaluates the effect of PALs versus SVLs on the progression of myopia in children. Although clinically insignificant, the study revealed decreased mean increase of myopia in children treated with PALs, compared to children with SVLs [13, 19].
\nA similar study conducted by Hasebe et al. investigated the effects of PALs versus SVLs on slowing the progression of myopia using a crossover design, which switches the spectacle type at the half of the study. At the end of this 3-year study period, progression was less in the group wearing PALs first than the group with SVLs first. The study concludes that early intervention with PALs is more effective that SVLs in controlling myopia, slowing progression and halting axial elongation of the eye [20]. Several other statistically significant, but clinically insignificant, studies have explored the use of PALs compared to SVLs for slowing the progression of myopia [21, 22, 23]. With more large population and long duration studies, the studies can achieve statistical and clinical significance in preventing myopia progression and axial elongation.
\nMyovision lenses appear similar to SVLs, but they are a newer design of spectacles that correct central and side vision that are experimented on many myopic Asian pediatric populations. The mechanism of these spectacles is to reduce the peripheral hyperopia and prevent myopia progression. These lenses resemble SVLs in appearance, are comfortable to wear and easy to adapt to the young population [24]. Similar studies with MyoVision lenses on Japanese children, which reveal an insignificant difference between the effect of MyoVision lenses and SVL wearers on spherical equivalent refraction and axial elongation of the eye [25].
\nAt this early stage of exploration, the efficacy of MyoVision lenses are not yet fully understood or proven. With additional studies that can reduce peripheral hyperopic defocus more effectively, there is more potential for reduction of myopia progression and axial elongation.
\nMajority of the myopic population advocate for contact lenses are from the adult population, as it produces cosmetic benefits in addition to functional improvement of the vision and their quality of life. However, contact lenses, such as rigid gas permeable contact lens, have also been utilized in the pediatric population to retard myopia progression and decrease axial elongation.
\nRigid gas permeable contact lenses have been shown to retard myopia progression in studies such as, The Contact Lens and Myopia Progression (CLAMP), which explored the progression of myopia in rigid gas permeable contact lens wearers versus soft lens controls. The CLAMP study reported that in 2 years the myopia progression was less in rigid gas permeable wearers (−1.56 ± 0.95D) than in soft contact lens wearers (−2.19 ± 0.89D) [11, 26]. Numerous other studies have demonstrated that the provisional decrease in myopia progression in rigid gas permeable contact lens wearers in comparison to other treatment groups, was a consequence of flattening of the cornea, and not the axial length of the eye [26, 27, 28].
\nSoft bifocal contact lens has demonstrated slowing of myopia progression by reducing the accommodation effort and halting axial elongation [29]. These lenses are designed with power for distance in the center and additional power in the periphery, or inversely, which corrects central myopia and reduces relative peripheral hyperopia. A study conducted by Walline et al. compared the effects of soft multifocal contact lenses with single vision lenses, and reported that the average myopic progression at 2 years was 0.41 ± 0.03D for the single-vision contact lens wearers and 0.29 ± 0.03D for the soft multifocal contact lens wearers [29]. While the study produced statistically significant results, it was clinically insignificant.
\nUsing a contralateral eye study design, Anstice et al. demonstrated that the eye wearing soft bifocal contact lens have a slower axial elongation in comparison to the eye wearing soft single vision contact lens. However, this was not clinically significant [30].
\nThere is much potential for soft bifocal contact lenses to reduce myopic progression and axial elongation, which can be achieved with future large-scale studies that explore the mechanism of myopic control through reduced accommodation effort and studies that compare the effectiveness of soft bifocal contact lens with other modes of optical control of myopia.
\nOrthokeratology is a technique used in the reduction of myopia by flattening the cornea by the rigid orthokeratology contact lenses. The pattern of lens wear in this correction technique allows for the correction of myopia for short periods of time. The lenses are worn overnight to temporarily alter the corneal shape by corneal thinning, are removed during the day when the visual acuity would be improved temporarily [31]. The Berkeley Orthokeratology study demonstrated a significantly greater reduction of myopia in orthokeratology contact lens wearers, in comparison to a control group. However, the study was not clinically significant [9, 32].
\nThe Longitudinal Orthokeratology Research in Children study was explored the effects of Orthokeratology contact lenses worn for 2 years on children in Hong Kong. At the study end, the there was a significant difference in the axial length between the lens wearers and the control group, 0.29 and 0.54 mm, respectively. The study was not clinically significant, represents the need for large scale studies to achieve clinical and statistical significance [31, 33].
\nWith additional studies that can reduce peripheral hyperopic defocus more effectively, there is more potential for reduction of myopia progression and axial elongation.
\nAtropine is a non-selective muscarinic antagonist that has been the most effective in slowing the progression of myopia. One theory for the mechanism of atropine is the role of scleral remodeling in myopia and axial elongation. The expression of the muscarinic receptors (mAChRs) results in the proliferation of fibroblasts in the scleral collagenous matrix, which promotes scleral remodeling and ultimately axial elongation [34]. Some axial elongation induced morphological scleral changes include lamellar arrangement of collagen fibers in myopic eyes rather than the tight interwoven collagen fibers in emmetropic eyes, the reduction in fibril diameter, a dispersed range of fibril diameters, and an increased number of abnormal fibrils represent are representations [35, 36]. It is theorized that atropine receptor blockage interrupts scleral fibroblast proliferation and consequential axial elongation of the eye. Although the mechanism of atropine remains obscure, there are several working theories on the action and effect of this drug on myopia progression and axial elongation.
\nThe Atropine in the Treatment of Myopia (ATOM) study was conducted from 1999 to 2004, which explored the effect of atropine 1% instilled nightly in children in Singapore for 2 years. The study contained two phases: a 2-year treatment phase and a 1-year washout phase. At the end of the 2-year study period, there was a 77% reduction in myopia progression with an unaltered axial length, compared to the control [37, 38]. The study was originally conducted in Asia but was adopted by other countries due to its encouraging results [39, 40, 41, 42, 43]. Following a successful 2-year treatment phase, the patients displayed rebound phenomenon in the 1-year washout phase. During this phase, there was an increase in both refractive error and axial length [37, 38]. The instillation of topical atropine was generally tolerated with some short- and long-term side effects. Short-term side effects are red eyes, photophobia, dilatation, increased intraocular pressure and glaucoma, and long-term side effects include retinal vascular diseases and cataract formation [37, 38]. The ATOM study was proved highly effective in reducing the rate of axial elongation and myopia progression, but was associated with such expected side effects.
\nFollowing the ATOM1 study was a 5-year clinical trial, which investigates low-dose atropine on reducing the progression of myopia, and subsequently decreasing the side effects. ATOM2 participants were randomly assigned to receive 0.5, 0.1 or 0.01% concentration of atropine for 24 months, followed by a 1-year washout phase. The results of ATOM2 study reveals that 0.01% is a viable concentration for reducing myopia progression and increasing the safety profile [44, 45].
\nWhile both ATOM and ATOM2 studies display efficacy in reducing myopia progression, both studies reveal a dose-dependent rebound phenomenon during the washout period. More recently, The Low-Concentration Atropine for Myopia Progression (LAMP) study was conducted to evaluate the efficacy and safety of low concentrations of atropine eye drops including 0.05, 0.025 and 0.01% compared to a placebo. The LAMP study revealed that all three low concentrations of atropine reduce myopia without a discernable adverse effect on the visual quality of life, and 0.05% was the most effective in controlling the spherical equivalent progression and the axial elongation over the 1-year study period [46]. Numerous studies have compared the effect of atropine to other optical strategies, such as single vision lenses, multifocal lenses, rigid gas permeable contact lenses, and orthokeratology [47, 48, 49].
\nCombination studies have explored the effects of atropine and an optical correction for greater myopia control. Shih et al. demonstrated that multifocal lens wearers treated with 0.5% atropine have a greater reduction of axial elongation and myopia progression, compared to placebo group [50]. Atropine eye drops for the treatment of myopia control has gained wide popularity in Asian countries, and more recently it has been adopted by the Western countries as well. With further investigation and modification to the treatment regimen that evades rebound phenomenon, atropine has the potential to be the conventional treatment of myopia.
\nPirenzepine is a selective M1 muscarinic receptor antagonist with a similar mechanism as atropine in halting myopia progression and axial elongation. A study conducted by Siatkowski et al. developed a 2% pirenzepine gel that displayed great efficacy in reduction of refractive error compared to the placebo group. Additionally, the average axial length increase at 1 year was 0.19 mm for patients in pirenzepine treatment group compared to 0.23 mm for those in the placebo group. While the results are statistically significant, they are clinically insignificant [51]. The adverse events in patients treated with pirenzepine were mild to moderately severe and included mydriasis, erythema of eyelids and ocular itching [9, 51, 52]. Overall, the study displayed good safety and efficacy for use in myopia control. Future studies are warranted to compare the efficacy and safety of pirenzepine and atropine in slowing the progression of myopia and axial elongation. Atropine eye drops for the treatment of myopia control has gained wide popularity in Asian countries, and more recently it has been adopted by the Western countries as well. With further investigation and modification to the treatment regimen that evades rebound phenomenon, atropine has the potential to be the conventional treatment of myopia.
\nAnti-hypoxic drugs such as salidroside and formononetin have shown anti-hypoxic effects to treat scleral hypoxia in myopia [53, 54]. Scleral hypoxia, which is induced by Hypoxia-Inducible Factor-1α (HIF-1), triggers a signaling cascade for myofibroblast trans-differentiation leading to scleral extracellular collagenous matrix remodeling in progressing myopia [55]. Formononetin is known decrease HIF-1α, vascular endothelial growth factor (VEGF) and prolyl hydroxylase domain-2 (PHD-2), which are protective in hypoxia-induced retinal neovascularization [54]. Salidroside is protective against for hypoxia-induced cardiac apoptosis and pulmonary hypertension [56, 57].
\nIn animal models with experimentally induced myopia, anti-hypoxic drugs down-regulated HIF-1α expression and the phosphorylation levels of eIF2α and mTOR to inhibit the development of form deprivation myopia, without affecting the normal ocular growth in guinea pigs [55]. Due to encouraging results in animal models, the use of anti-hypoxic drugs shows great potential for treatment of myopia in human eyes.
\nSurgeons have recently advocated for surgical intervention to halt the progression of myopia, axial elongation and weakening of the posterior sclera. Macular buckle surgery or posterior reinforcement (PSR) surgery is proven to be effective in reinforcing the weakened posterior sclera. A scleral buckle is used to apply direct mechanical force onto the posterior pole, which slows the axial elongation. Shen et al. documented significantly higher Best-Corrected Visual Acuity (BCVA) and lower refractive error in the group who underwent macular buckle surgery compared to the control group [58]. Additionally, patients who underwent PSR surgery have a shorter mean axial length and lower mean refractive error than the control group [59, 60].
\nMacular buckling surgery has also been used myopic macular hole with retinal detachment and posterior staphyloma, which displayed high reattachment rates and improved visual acuity [61, 62]. Recent studies have experimented with different buckle materials, shapes, techniques and other modifications for the best correction of myopia and its complications [63, 64, 65]. With more advanced techniques and modifications, the surgical technique can be utilized as conventional treatment of myopia to reduce myopia progression and axial elongation.
\nThe global prevalence of myopia is in an increasing trend, with estimates of myopia and high myopia affecting nearly 5 billion and 1 billion people, respectively, in 2050 [1]. As a major public health concern, it is essential to develop interventions that sufficiently delay or stop the progression of myopia. Of the above discussed treatments, all have shown to reduce the progression of myopia, but atropine has been the most popular and effective in reducing progression and axial elongation. Despite the expected side effects, its rebound phenomenon and its obscure mechanism, atropine has achieved global popularity. With changes in lifestyle, health education, government and other health systems, the importance and acceptance of myopia control will significantly diminish number of people affected. Additionally, the implementation of a conventional, safe and effective intervention for myopia control will significantly reduce the personal, societal and economic burden, and decrease the disease progression and the risk of future myopia-induced ocular complications.
\nThere are no financial conflicts of interest.
Poisoning is a relatively common medical emergency worldwide and raises particular problems of diagnosis and treatment especially in children, regardless of the path the toxic enters the body (ingestion, inhalation, injection, or skin absorption). This age group is the most vulnerable population with the highest risk of accidental intoxications that can be partially prevented [1]. It is a common cause of presentation in the ED and the PICU. Early identification of the clinical characteristics of patients with acute intoxication and rapid initiation of therapy in these services can help reduce the mortality of intoxicated patients [2, 3]. These departments have the ability to continuously monitor vital parameters, use the most advanced medical technology and the most appropriate treatment. Usually, admission to PICU is by ED or by transfer from another hospital [4]. Often, a poisoned patient will be brought into intensive care not for treatment, but for continuous surveillance and monitoring in order to minimize mortality. On the other hand, care in these units has a very high cost. It is therefore recommended that the admission of poisoning cases in intensive care should take into account the efficient use of resources without compromising patient care [5]. The percentage of children with acute poisoning in PICU ranges from 8% [6] to 11.7% [2]. In the United States in 2014, 2336 intoxicated patients admitted to intensive care units needed ventilatory support, 509 received vasopressors, and 127 needed hemodialysis [4].
There are several studies that attempt to establish criteria for admission to intensive care in patients based on severity scores (APACHE II/III, PRISM II/III, SAPS II, Glasgow etc.). These included patients with various medical and surgical conditions, but few can be validated using such scoring systems in poisoned patients [7, 8, 9]. Until more specific poisoning factors are established, it is thought that experience and proper clinical judgment can predict which patients will receive intensive care. The presence of certain abnormal symptoms or abnormal test results may require monitoring and/or treatment in PICU regardless of the suspected toxic. This approach is more consistent with the principle of “treating the patient and not the poison” [5]. It should be kept in mind that an initially asymptomatic poisoned patient may worsen later. Poisoned children and adolescents should be directed to the nearest intensive care unit that has pediatric critical care practitioners and equipment appropriate to pediatric age.
Acute respiratory failure characterized by one or more of the following [4]:
Need for ventilatory support or emergency tracheostomy.
Marked respiratory compromise as indicated by:
FR <20 or >60 for children <1 year and <12 or >60 for children >1 year.
SpO2 <92% when O2 is administrated by mask or tracheostomy.
PaO2 <80 mm Hg at 100% O2 administrated by mask.
Rapidly progressive deterioration in respiratory status.
Respiratory acidosis with PaCO2 > 60 mmHg and pH < 7.25.
Airway obstruction, apnea, anaphylaxis.
Hemodynamic instability or circulatory insufficiency characterized by one or more of the following:
Shock as indicated by capillary refill time >4 s, distal or proximal nonpalpable pulse, systolic TA < lower age limit or TA < mean 50 mmHg (<40 mmHg in newborn), metabolic acidosis with < pH 7.25, base deficit >10 or serum bicarbonate <10 mEq/l, need for invasive hemodynamic monitoring.
Cardiac instability and arrhythmia, necessity of continuous perfusion or vasoactive substances, ECG ischemic changes, congestive heart failure, and vascular volume instability.
Neurological instability manifested by one or more of the following:
Neurological damage with one or more of the following: Glasgow score <10, severe irritability, hallucinations, and change of posture.
Intracranial bleeding, increased intracranial pressure, seizures, or delirium.
Severe metabolic disorders: serum Na <125 mmol/l or >160 mmol/l, serum K <3 mmol/l or >6.5 mmol/l, glucose <30 mg/dl or >400 mg/dl, ionic calcium <0.8 mEq/l, base deficit >−10.
Other patients at risk of organ failure or system failure.
Toxic exposed patients in which none of the above are present but:
Within a few hours, one of the above criteria is expected.
Suicide patient that cannot be monitored in other unit care.
The main concern in the management of a patient with acute intoxication in PICU is the support of the vital functions. The general measures in a poisoned patient do not differ significantly from those required in a patient admitted to PICU with similar symptoms and a comparable level of severity but with pathology [4]. These critically intoxicated patients should be rapidly recognized by the clinician and evaluated for appropriate therapy. Continuous follow-up of vital functions, neurological status, blood volume, and heart rate makes possible early detection of poisoning worsening signs requiring rapid intervention to prevent complications [5]. Advanced medical technology in PICU offers a number of invasive and noninvasive options that can trigger an early warning of rapid deterioration or provide feedback about the response to treatment. For example, monitoring hemodynamic parameters are valuable for managing poisoned patients with hypotension, volume depletion, or respiratory failure from acute lung injury (ALI). Most importantly, clinicians need to recognize that no monitoring device improves clinical outcome unless is completed by a treatment.
Some antidotes and specific therapies are initiated in ED and continued in PICU, which is the most appropriate place to administer or continue treatment. In addition to conventional therapies, PICU’s medical practitioners also know how to deal with situations that do not look like treatment protocols. For example, high doses of atropine, like hundreds of milligrams, can be used to treat organophosphate insecticides [5, 10]. Sometimes the antidote has less effect than the toxin. For example, opioid-intoxicated coma patients responding to naloxone are rapidly recovering. But these patients should be closely monitored for rejoining their coma, and in this situation, the antidote should be repeated. A surveillance period of at least 2 h after the last dose of naloxone is required to assert that the risk of recurrence of toxicity has passed [11].
Pulse oximetry is the recommended method to detect the presence of hypoxemia and to guide the administration of oxygen. Gasometry is a more accurate method for highlighting hypoxemia [4].
Acute respiratory failure is a common condition for children with various intoxications to come into the PICU. Respiratory failure occurs due to central hypoventilation, central nervous system depression, by the poisoning of central nervous system depressants (barbiturates, opiates, alcohol, and tranquilizers), intoxication with organophosphate compounds, alkaloids, and atropine. Respiratory muscular paralysis is another mechanism encountered in hemlock poisoning (
As for the diagnosis of acute toxic respiratory insufficiency, in the initial phase, the signs and symptoms of background intoxication are highlighted. Once the respiratory failure has occurred, its symptoms, which are generally circumscribed to the pathophysiological mechanisms involved, become evident. In acute respiratory failure (ARF) from CNS disorders, consciousness status can be abolished and respiratory movements diminished in amplitude and frequency. The symptoms of ARF by affecting the resilient muscles are dominated by generalized muscular asthenia and dyspnea, and in the ARF by pulmonary damage, the tachypnea is more common. The clinical signs associated with hypercapnia and hypoxia in comatose patients are psychomotor agitation, dyspnea, and cyanosis [4]. However, the severity of cyanosis does not adequately reflect the severity of respiratory insufficiency. Increased intracranial pressure due to cerebral vasodilatation may result in cerebral edema, causing headache, obtundation, and even coma.
Blood gas analysis may reveal respiratory acidosis (pH < 7.35 and PaCO2 > 45 mmHg), which can be partially compensated by lowering the alkaline reserve and, in the absence of oxygen therapy, decreasing PaCO₂. A serious form of acute respiratory failure is acute respiratory distress syndrome (ARDS) manifested by bilateral pulmonary infiltration on radiography, PaO2/FiO2 ratio (partial oxygen pressure in arterial blood/oxygen fraction in the inspired air) below 200 mmHg and hemodynamic parameters within normal limits [12].
Corticosteroids and antibiotics may be used for the prophylactic purposes. Corticosteroids have been used for many toxic inhalational injuries. The prophylactic treatment of patients with inhalation injury with antibiotics has a empirical support [14, 15]. Essential therapy aims to ensure adequate blood oxygenation. Ensuring the ventilatory support should be seen in dynamics. Thus, ventilatory support begins with the least invasive supportive methods and progresses to the most aggressive techniques; you must minimize risks such as pneumothorax [16]. Oxygen supplementation is indicated for patients with suspected or confirmed respiratory failure.
Approximately 10% of children admitted to the PICU for poisoning may require endotracheal intubation [6]. After the decision for mechanical ventilation has been made, the route needs to be selected. Some experts prefer oral intubation because it allows the use of a larger endotracheal tube—usually 8 mm or more in adults—than nasal intubation [17]. A wide range of equipment is necessary to allow for a wide range of patient size. A selection of both straight and curved blades should be available. Capnography should be available to assist the endotracheal tube placement in the airway.
The goal of mechanical ventilation is to provide a sufficient exchange of oxygen and carbon dioxide and the metabolic needs of a patient to be accomplished with minimum adverse effects [4]. The purpose of mechanical ventilation is not always to achieve the normal blood gas concentration. Given the predisposition to hypoventilation and the risk of acute pulmonary edema, the mechanical ventilation of patients intoxicated with salicylates requires a lot of attention [18, 19]. High-frequency ventilation and ECMO should be considered to treat some severe intoxications, but there are limited reports on their use in pediatric toxicology [4, 20].
Noninvasive ventilation refers to providing the ventilation support without an invasive artificial path (intubation or tracheostomy probe). Patient selection is made taking into account noninvasive ventilation indications and contraindications as well as predictive factors of success or failure. Before starting noninvasive ventilation, a plan should be established to be applied if therapy fails. Noninvasive ventilation can be done with either portable CPAP or BiPAP devices that can also be used for home ventilation with either intensive ventilation or portable ventilation. One of the common causes of failure of noninvasive ventilation is the large air loss around to the ventilation mask [21].
These are often the most prevalent symptoms in accidental or voluntary poisonings. Acute voluntary poisonings often involve psychotropic drugs (anxiolytic-hypnotic, antidepressant, antipsychotic, etc.) or ethanol, whose central toxic target is the central nervous system. If the alteration of consciousness is a frequent complication of poisoning, mortality directly attributable to neurological impairment is small compared to other etiologies (traumatic, vascular, etc.). Alteration of consciousness is most often due to a functional and reversible nature. It results from an interaction with one or more essential neurotransmitters (gamma-acidobutyric acid, serotonin, dopamine, etc.). However, lesional damage remains possible in case of exposure to a toxicant that prevents oxygen cellular use (e.g., carbon monoxide), when late detection or cardiopulmonary resuscitation complications cause anoxic or ischemic brain injury and ultimately neurovascular lesions [4, 22].
This is one of the most common pediatric emergencies. Its most serious form, coma, is one of the most critical situations faced by a doctor. Child coma occurs on an immature and fragile brain. In all cases of coma under the age of 7 years (including accidental poisoning), there is a risk that child’s natural development achievements process will be compromised because the damage to the nervous system occurs during the full development process [23, 24]. The central nervous system (CNS), due to its rich lipid content and abundant vascularization is frequently the target organ for many toxic and nontoxic drugs. In intoxications, coma may occur due to direct toxic effects, metabolic abnormalities, or toxic-induced anoxia [25, 26].
The frequency of toxic coma varies in different studies, from 5% [26] to 28.9% [27]. In a recent prospective observational study, they accounted for 11.5% of all nontraumatic coma [28].
The toxic etiology of a coma must be raised in any patient who presents a severe deterioration of consciousness, without another obvious cause. In the absence of seizures, the patient often progresses to coma passing through the stages of lethargy, confusion, and stupor. A carefully conducted anamnesis, taken from the caregivers, can sometimes indicate a poisoning. The child’s age can provide important information. Small children are prone to accidental poisoning, and in this situation, questioning the caregivers about toxic substances found in the house may be useful. Adolescents tend to experience alcohol, psychoactive substances, or recreational drugs. In the absence of an obvious history, toxicological exams need to be conducted in serum and urine [29, 30].
The physical examination can also provide clues about a possible intoxication. Thus, a careful examination of the teguments may reveal signs of venous punctures suggesting a drug self-injection, including heroin. Sclero-tegumentary jaundice may be highlighted, suggesting a hepatic failure of a toxic cause that has evolved into a coma. Epistaxis may exist in snorting cocaine. The presence of head lesions should alert the doctor about the possibility of a possible simultaneous cranial trauma [31]. The vital signs are also important for orientation toward a toxic etiology. For example, benzodiazepines and opiates often cause respiratory depression. Amphetamines and cocaine can cause hypertension and tachyarrhythmias. Drugs that affect the autonomic nervous system may induce hyperthermia, vasoconstriction or vasodilatation, and heart rhythm disorders [32].
Neurological examination is very important for the diagnosis (Figure 1). Evaluation of the coma is important in unconscious patients (Table 1). The general characteristics of toxic coma are the absence of meningeal signs and neurological focal signs, unless hypoglycemia is involved. During neurological examination, the plantar, deep tendon reflex, and muscle tone must be examined. Depending on the changes found, one of the following three syndromes can be outlined: pyramidal, extrapyramidal, or myorelaxation, which may indicate the toxins involved in inducing coma.
Neurological examination of the patient with toxic coma [
Area assessed | Infant | Children | Score |
---|---|---|---|
Eyeopening | Open spontaneously | Open spontaneously | 4 |
Open in response to verbal stimuli | Open in response to verbal stimuli | 3 | |
Open in response to pain only | Open in response to pain only | 2 | |
No response | No response | 1 | |
Verbalresponse | Coos and babbles | Oriented, appropriate | 5 |
Verbal response | Confused | 4 | |
Cries in response to pain | Inappropriate words | 3 | |
Moans in response to pain | Incomprehensible words or nonspecific sounds | 2 | |
No response | No response | 1 | |
Motor response | Moves spontaneously and purposefully | Obeys commands | 6 |
Withdraws to touch | Localizes painful stimulus | 5 | |
Withdraws in response to pain | Withdraws in response to pain | 4 | |
Responds to pain with decorticate posturing (abnormal flexion) | Responds to pain with decorticate posturing (abnormal flexion) | 3 | |
Responds to pain with decerebrate posturing (abnormal extension) | Responds to pain with decerebrate posturing (abnormal extension) | 2 | |
No response | No response | 1 |
Modified Glasgow coma scale for infants and children.
Eye exams are essential for the toxic etiology. The type of coma associated with pupillary response may also suggest the toxin responsible for the coma appearance [33, 34, 35] (Figure 1). Periodic movement type “ping-pong” has been described in poisoning with monoamine oxidase inhibitors [34]. Hyperthermia is part of the anticholinergic syndrome; when associated with neurological disorders and toxic ingestion is not evident, then it is necessary to search for a
Useful investigations into a toxic coma are mainly in serum determinations and much less often in neuroimaging investigations. Any metabolic acidosis in a toxic coma requires further investigation. The presence of low anionic gap suggests lithium or bromine intoxication. Highlighting an osmolar gap usually indicates a poisoning with ethanol, isopropanol, methanol, or ethylene glycol. Pure respiratory acidosis is consistent with hypoventilation, possibly a sign of poisoning with hypnotic sedatives or opioids. Although urinary toxicological tests may sometimes be useful in a toxic coma, the results are often false positive or false negative [24, 25].
Dosage of serum concentrations of some drugs is of great help, if available. Other useful investigations are the dosage of serum cholinesterases and carboxyhemoglobin. Coma caused by tricyclic antidepressants poisoning may be accompanied by electrocardiographic abnormalities (dysrhythmia) and seizures [38].
The main life threat in toxic coma is the alteration of respiratory function. Therefore, maintaining airway permeability and ensuring effective breathing are a priority, because providing the O2 requirement of the brain is essential. In any suspicion of hypoxia or CO intoxication, O2 should be administered [32]. Not every child in a toxic coma should be intubated. It is estimated that orotracheal intubation is required in about 20% of toxic coma. The main indications are coma with alteration of swallow reflexes, acute respiratory failure unresponsive to O2 administration, severe circulatory insufficiency or toxic comas associated with severe symptoms, refractory to pharmacological treatment (convulsions, hyperthermia) [33].
Glycemia should be measured as a matter of urgency, and if there is hypoglycemia, this must be quickly rectified. Activated charcoal gastrointestinal decontamination can sometimes provide benefits, if done early. Gastric lavage can be performed if the patient has the respiratory tract protected by endotracheal tube. If the toxic is adsorbed on the activated charcoal, it can be administered by nasogastric tube. There is a lot of attention needed when administered to non-intubated patients. Hemodynamic instability induced by toxic shock, which may be hypovolemic, distributive, or cardiogenic, requires vascular filling with saline or Ringer’s solution, injected quickly and possibly vasopressor medication. Any detected heart rhythm disorders and hypertension or hypotension need to be corrected. Simultaneously with the stabilization measures, the antidote will be administered according to the protocols in toxic-induced coma [25].
In comas of unknown etiology, the concept of “coma cocktail” containing dextrose, oxygen, naloxone, and thiamine (vitamin B1) was proposed. But indications and efficiency were controversial.
Currently, in toxic comas, precise indications for flumazenil and naloxone are used. Flumazenil acts by a competitive mechanism at the benzodiazepine receptor level, canceling the sedation effects of benzodiazepines within 1–2 min of administration. In the case of children, we start with a dose of 0.01 mg/kg intravenously, which can be repeated 1–2 min to a total dose of 0.05 mg/kg maximum 1 mg. It is effective in toxic-induced coma by zolpidem and zopiclone. If in a calm coma of undetermined etiology, there is no patient awakening after the administration of flumazenil referred to dose, the diagnosis of intoxication with benzodiazepines is infirmed [39]. Naloxone is a pure opioid antagonist, which acts by competitive antagonism at μ receptors to determine the reversibility of respiratory depression, hypotension, and miotic within 2 min. For children >3 years, the indicated dose is 0.01–0.1 mg/kg. If the desired effect is obtained, it may be repeated two times at an interval of 5 min; the dose may reach 10 mg. Regardless of the way of administration (intravenous, subcutaneous, intramuscular, endotracheal intubation probe, or inhalation), the effect is similar. The lack of response within 15 min after administration requires looking for another coma cause [4, 5].
Extrarenal epuration may sometimes have indications in coma due to alcohol intoxications (ethylene glycol, isopropyl alcohol, and methanol), salicylates, theophylline, lithium, valproic acid, carbamazepine, or carbamates [40].
The prognosis of toxic coma is generally better than that of anoxic coma. For example, in sedative poisoning, mortality is below 1%. The following neurological signs provide a poor prognosis for recovery from toxic coma: absence of corneal reflexes after day 1, absence of eye opening response on day 3, loss of pupillary reflexes (up to 1 week), lack of oculovestibular response, abnormal skeletal muscle tonus, the absence of spontaneous eye movement, the isoelectric pathway on the electroencephalogram [25].
Some toxic may cause prolonged coma (>100 h) with intermittent agitation periods known as cyclic coma: barbiturates, carbamazepine, clonazepam, ethchlorvynol, glutethimide, meprobamate, olanzapine, quetiapine. Short-term memory alteration and postcoma amnesia are possible, secondary to neuron damage in the pyramidal system at the hippocampus level in CO intoxication [25, 38].
Convulsions are common in situations when the toxic involved affects the central nervous system. In the context of poisoning, seizures are often a sign of severity [41]. From the clinical point of view, toxic-induced convulsions can occur with or without warning signs (e.g., aura) or mental state alteration. Most toxic-induced seizures are generalized, tonic–clonic (“grand mal”). Epileptic status is defined as a continuous convulsive activity lasting more than 30 min or more convulsive episodes between which consciousness is not completely regained [4, 5, 42]. Patients with preexisting epileptogenic focal conditions may experience focal seizures [42].
Table 2 presents the etiology of toxic seizures.
Class | Example(s) | Class | Example(s) |
---|---|---|---|
Pharmaceuticals | Nonpharmaceuticals | ||
Analgesics | Meperidine/normeperidine, propoxyphene, pentazocine, salicylate, tramadol | Alcohols | Methanol, ethanol (withdrawal) |
Anesthetics | Local anesthetics | Antiseptic/preservatives | Ethylene oxide, phenol |
Anticonvulsants | Carbamazepine | Biologic toxins | |
Antidepressants | Tricyclic (amitriptilina/ nortriptyline), amoxapine, bupropion, selective serotonin reuptake inhibitors (citalopram), venlafaxine | Marine animals, mushrooms, plants | Domoic acid [shellfish (blue mussels)], monomethylhydrazine ( |
Antihistamines | Diphenhydramine, doxylamine, tripelennamine | Gases (naturally and/or anthropogenically occurring) | Carbon monoxide, hydrogen sulfide, cyanide |
Antimicrobials | Antibacterials (selected penicillins, cephalosporins, carbapenems, fluoroquinolones), antimalarials (chloroquine), tuberculostatics (isoniazid) | Metals/organometallics | Alkyl mercurials (dimethylmercury), arsenic, lead, thallium, tetraethyl lead, organotins (trimethyltin) |
Antineoplastics | Alkylating agents (busulfan, chlorambucil) | Metal hydrides | Pentaborane, phosphine |
Antipsychotics | Clozapine, loxapine | Pesticides | |
Antiasthmatic | Theophylline | Fungicides/herbicides | Dinitrophenol, diquat, glufosinate |
Cardiovascular drug | Propranolol, quinidine | Insecticides | Organochlorines (DDT, lindane), organophosphates (parathion), pyrethroids (type II), sulfuryl fluoride, alkylhalides (methyl bromide) |
Cholinergics | Pilocarpine, bethanechol | Molluscicides | Metaldehyde |
Muscle relaxants | Baclofen, orphenadrine | Rodenticides | Strychnine, zinc, or aluminum phosphide |
Nonsteroidal anti-inflammatory drug | Mefenamic acid, phenylbutazone | ||
Psychostimulant/anorectics | Amphetamine, caffeine, cocaine, methamphetamine, 3,4-methylenedioxymethamphetamine, synthetic cannabinoids | ||
Vitamins/supplements | Vitamin A, ferrous sulfate |
Proconvulsant agents (adapted after Hanson [44]).
Seizure control in PICU is a fundamental problem in the management of a poisoned child. Convulsions associated with toxic ingestion are sometimes difficult to control, being recurrent or persistent leading to status epileptics. This is associated with an increase in oxygen in the brain level. The imbalance between supply and demand can lead to cerebral ischemia. That is why an aggressive management of toxic seizures is critical to preventing brain damage. The first priority in managing seizure crises is to provide airway permeability and oxygen therapy to ensure delivery of oxygen to the brain. Evaluation and correction of electrolyte disturbances and hypoglycemia should also be promptly performed [4, 43]. The first therapeutic line for toxic-induced convulsions is represented by benzodiazepines (diazepam, lorazepam, or midazolam). Lorazepam and diazepam exhibit a similar clinical response time (until termination of seizure activity) [41, 42]. However, after treatment with lorazepam, the rate of seizure recurrence appears to be lower [44]. Also, according to some studies, lorazepam has been shown to have a longer duration of action of the anticonvulsant effect (12–24 h vs. 15–30 min) and is therefore the preferred choice of some clinicians [42]. The preferred route of administration of benzodiazepines is intravenous. Table 3 lists the doses of benzodiazepines that can be used in toxic-induced convulsions in children and adolescents.
Benzodiazepine | Pediatric dose |
---|---|
Lorazepam | 0.05–0.1 mg/kg iv (maximum 4 mg/dose). It can be repeated at 10–15 min if necessary. Maximum dose: 8 mg/12 h |
Diazepam | <5 years: 0.2–0.5 mg/kg iv every 2–5 min up to a maximum total dose of 5 mg. >5 years: 1–2 mg iv every 2–5 min up to a maximum total dose of 10 mg. |
Midazolam | >2 months: 0.15 mg/kg iv bolus, followed by a continuous infusion of 1 μg/kg/min, titrating the dose every 5 min until seizure control. Mean dose: 2–3 μg/kg/min. |
Posology of benzodiazepines in seizures in childhood (adapted after Blais and Dubé [41]).
In the absence of response to benzodiazepines, phenobarbital or valproic acid may be effective for crises control. Phenytoin is less effective in the treatment of induced seizures [42]. If seizures do not stop at the referred medication, it is necessary to induce coma with sodium thiopental or propofol. To induce a coma, sodium thiopental is administered as a bolus of 3 mg/kg, which is repeated after 2 min, followed by maintenance with 1–15 mg/kg/h. For propofol, the dose is 1–5 mg/kg bolus (repeatable) followed by continuous infusion up to a maximum of 5 mg/kg/h [45]. A special category of seizure, which does not respond to traditional therapy, is that of isoniazid intoxication. In this case, the crises result from exhaustion of pyridoxine (vitamin B6) and respond only to its administration [4]. In case of intoxication with isoniazid, the vitamin B6 posology is 1 gram per gram of ingested isoniazid (maximum 5 grams). This dose will be given slowly within 10 min, or until seizures cease. If the seizures stop during administration, the remaining dose will be given within the next 4 h. If the dose of isoniazid is unknown, 70 mg/kg iv (maximum 5 g) should be administered in the same manner. The initial dose may be repeated once seizures relapse. Pyridoxine is also anticonvulsant therapy of choice in intoxication with gyromitra mushrooms in the dose of 25 mg/kg iv in 10 min and can be repeated in case of seizure recurrence [41].
These are a serious complication of some poisoning, requiring prompt monitoring and treatment. Assessing a poisoned child at risk of cardiovascular disease requires a detailed physical exam. In addition to cardiac volume and output evaluation, a series of laboratory tests must be performed: blood gases, electrolyte dosing, blood sugar, transaminases, and azote retention tests. In some cases, the serum level of the toxic substance can also be determined, which helps to assess the severity of intoxication and to support the therapeutic decision. Additional care management such as blood pressure measurement, electrocardiography, and echocardiography can also be useful to guide therapy in case of a poisoning accompanied by cardiovascular instability. Identification of a certain toxic can simplify the treatment through specific intervention. If the poison is unknown, the initial resuscitation consists in administration of intravenous fluids to maintain a proper intravascular volume [4, 5]. Rapid administration of 20 ml/kg bolus isotonic fluids, usually crystalloid (normal saline or Ringer’s lactate) over 10–15 min, is used to restore intravascular volume. Additional fluid bolus may be required depending on the reassessment of intravascular volume [46]. However, the intravascular volume should be corrected cautiously, because too vigorous expansion may lead to fluid retention, liver enlargement, signs of pulmonary edema, jugular vein distension, or cardiomegaly, without improvement of vital signs and tissue perfusion. Positively inotropic agents are required in such patients. The cardiovascular disorders, which are present at the time, determine which inotropic agents and vasopressor drugs to choose.
Arrhythmia is a frequent complication in cardiovascular drug poisoning. Dysrhythmia may occur by direct affecting of the electrical conduction system of the heart, by changing the electrical membrane potential across the myocardial cell, or by indirect disturbance of the electrical conduction system through the nervous system or due to electrolytic and metabolic disorders, which affect the electrical activity of the heart.
Bradyarrhythmias occur due to some toxic substances, which decrease the central nervous system influx or the chronotropic activity of the conduction system. Agents that can induce bradyarrhythmias are tricyclic antidepressants, α2-adrenergic agonists, β-adrenergic blockers, calcium channel blockers, cholinomimetics, digoxin, sedative hypnotics, organophosphorus and carbamates, plants containing cardiac glycosides, opioids, cocaine, organophosphorus, and carbamates [47].
Bradyarrhythmia due to ingestion of unknown toxic substance is managed with supportive treatment. Atropine or positive inotropic agents, such as epinephrine, are used to correct bradyarrhythmia. When the toxic agent is known, the aim of the therapy is to antagonize the toxic effects (e.g., calcium chloride is used to treat calcium channel blockers intoxication). Literature data showed that in poisoning with β-blocker, calcium channel blocker, and tricyclic antidepressant, glucagon may be used, given its positive inotropic and chronotropic effects. Glucagon dose in children is 0.03–0.15 mg/kg in 1–2 min bolus, followed by 0.07 mg/kg/h infusion or by repeated boluses in 5–10 min, as needed [48]. Other therapies that may be used in severe β-blocker and calcium channel blocker poisoning are hyperinsulinemia—euglycemia (HIE) and intravenous fat emulsion (IFE) [49]. In bradycardia mediated by vagal reflex, atropine is the treatment of choice. For unresponsive sinus bradycardia, as well as for junctional or ventricular bradyarrhythmias, isoproterenol may be used. Specific therapy should also be used (calcium in calcium channel blockers intoxication; digoxin antibodies in digoxin poisoning). Sodium bicarbonate is beneficial in tricyclic antidepressant poisoning. Concomitant correction of electrolyte disturbances, hypoxia, and acidosis is mandatory because they may contribute to failure of pacing stimulus to depolarize cardiac cells [47]. In severe cases of bradyarrhythmia or heart block unresponsive to pharmacological therapy, direct transthoracic pacing may be necessary.
Tachyarrhythmias are common in poisonings. They are classified as wide-complex and narrow-complex rhythm (Tables 4 and 5).
Poisoning-induced narrow-complex tachyarrhythmias.
Antiarrhythmics (type Ia, Ic, III), antihistamines, arsenic, cardiac glycosides, cyclic antidepressants, carbamazepine, chloral hydrate |
Poisoning-induced wide-complex tachyarrhythmias.
Electrocardiogram (ECG) in narrow-complex tachyarrhythmias shows sinus tachycardia or supraventricular tachycardia (normal conduction).
Specific therapies include antidotes depending on xenobiotic. Treatment imposes corrections of hypotension, hypoxia, or electrolyte abnormalities and administration of esmolol or other short-acting beta-blocker for intractable tachycardia in the absence of hypotension or other signs of myocardial depression [4, 47].
ECG in wide-complex tachyarrhythmias may show ventricular tachycardia (VT) monomorphic or polymorphic, ventricular fibrillation (VF), ECG signs preceding VF/VT, supraventricular tachyarrhythmias, prominent R wave lead AVR, rightward deviation of QRS axis, and QT prolongation [47].
Correction of possible hydroelectrolytic and acido-basic imbalance is required in treatment of toxic ventricular tachycardia. In monomorphic ventricular tachycardia, if the patient’s condition is stable and there is no hemodynamic instability, chemical cardioversion with amiodarone 5 mg/kg iv, or procainamide 15 mg/kg iv or lidocaine 1 mg/kg bolus is first attempted. In wide QRS complex tachycardias, adenosine is not useful. If the chemical cardioversion has results, the drug will be administered by continuous intravenous infusion to avoid relapses. The IV infusion time will be decided along with the pediatric cardiologist. If the chemical cardioversion is ineffective, synchronized biphasic electrical cardioversion with 0.5–1 J/kg is needed [47, 50]. In polymorphic ventricular tachycardia with hemodynamic instability, the treatment is based on electrical cardioversion associated with magnesium. If magnesium sulfate is ineffective or bradyarrhythmias occur, isoproterenol IV may be useful. Hypokalemia can exacerbate ventricular tachycardia, and therefore, potassium supplementation is required even in patients with normal potassium at the time of determination.
Bidirectional ventricular tachycardia is a hallmark of severe digitalis toxicity, and immediate specific antidote treatment with FAB antibodies must be started. This type of ventricular tachycardia may occur in aconite poisoning too [51, 52].
Torsades de pointes (TdP) is a specific type of polymorphic ventricular tachycardia exhibiting a characteristic morphology on the electrocardiogram, in which the QRS complexes “twist” around the isoelectric line. This is a major toxin-induced arrhythmia, which may degenerate into ventricular fibrillation and sudden death [53, 54]. In this situation, the corrections of electrolyte disorders, bradycardia, acidosis, low blood pressure, and hypoxia are needed. If poisoning involves a drug with Na+ channel blocking properties (e.g., tricyclic antiarrhythmic drugs, cocaine, class IA and IC antiarrhythmic drugs, or antipsychotic drugs), sodium bicarbonate may be used to reduce the degree of sodium channel blockade by increasing extracellular sodium [55]. The treatment of choice in torsade de pointes is magnesium sulfate. The pediatric dose is 25–50 mg/kg iv. If a poisoned patient does not respond to the abovementioned therapeutic measures, intravenous lipid emulsion therapy should be considered if the drug has lipophilic properties. A last therapeutic alternative is arteriovenous extracorporeal membrane oxygenation (ECMO) [47, 55].
The Extracorporeal Treatments in Poisoning (EXTRIP) Workgroup is a group of international experts spanning disciplines of nephrology, toxicology, pediatrics, emergency medicine, critical care, and clinical pharmacologists that has been reviewing the evidence in the literature and provide recommendations for the use of extracorporeal treatments in poisonings. To date, EXTRIP has published systematic reviews on the role of extracorporeal treatment (ECTR) for poisoning from acetaminophen, barbiturates, carbamazepine, digoxin, lithium, metformin, methanol, salicylates, thallium, theophylline, tricyclic antidepressants, and valproic acid [56]. Waste treatment methods are numerous, and techniques and/or equipment continuously evolve. It mainly involves hemodialysis, hemoperfusion, hemofiltration, and albumin dialysis [57].
Hemodialysis is the technique of removing toxins from the blood using a diffusion gradient through a semipermeable membrane. To be dialyzable, poisons must meet the following conditions: hydrosolubility, low molecular weight, apparent low volume of distribution, low protein binding, and low endogenous clearance [5]. It may be necessary in the following situations: severe poisoning with salicylates, accompanied by important mental disorders, in some phenobarbital intoxications, ethylene glycol, lithium, and theophylline [4, 6].
Possible complications of hemodialysis are hypotension, hypoxemia, bleeding, embolism, and cardiac rhythm disorders [4].
The hemoperfusion column can be considered as an extracorporeal clearance organ, increasing the overall clearance of the body. Its efficacy is superior to hemodialysis or hemofiltration. It has been proposed in serious poisonings with theophylline, carbamazepine, and cardiotoxic (membrane stabilizers, inhibitors calculation, and meprobamate) that do not quickly respond well to symptomatic treatment led. Its indication should be taken into account very early and in intoxications with some toxic lesions such as colchicine or paraquat [57]. Complications of hemoperfusion can be thrombocytopenia (30%), leukopenia (10%), hypocalcemia, hypoglycemia, reduction of fibrinogen, and hypothermia. The future lies in hemoperfusion devices coated with drug-specific antibodies or the antidote of the toxin instead of activated charcoal [58].
Hemofiltration and hemodiafiltration have similar properties as hemodialysis regarding the distribution volume and protein-binding percentage. Water-like substances move out of the plasma through the membrane, and this fluid is replaced with isotonic fluids. The rate of removal of the toxin is influenced by the degree of protein binding and the ultrafiltration (UF) and the sieving coefficient, which is the ability of the solute to cross a membrane by convection. Although this makes high-efficiency convective techniques suitable for poisoning, reports of their use in poisoned patients remain limited due to their higher technical requirements and lesser availability [58, 59].
The most developed and most commonly used hepatic dialysis systems are the molecular adsorbent recirculation (MARS) and fractional plasma separation and absorption (Prometheus).
MARS is a hemodialysis technique that combines the selective removal of albumin-bound toxins with the removal of water-soluble toxins. The MARS system uses a 20% human albumin solution as a dialyzate and a semipermeable membrane as a dialyzer.
The albumin acquires an increased ability to bind toxins through contact with membrane’s polymers. Through the membrane, the patient’s blood comes into contact with the albumin solution, and the albumin-related toxins cross the membrane and enter the dialyzate, the transfer being made in the sense of the existing concentration gradient between the blood compartment and the albumin solution. After detoxification, the albumin solution is recirculated, coming into contact with the patient’s blood again [60, 61, 62]. Several small randomized controlled trials and case control studies in adults showed significant improvement, both in morbidity and mortality, in patients treated with MARS. However, there are little data on the use of MARS in the children [63].
It consists of a bloodstream where two filters perform a purification of water-soluble toxins and then a fractional separation of plasma, so that cellular components and macromolecules are separated by albumin and by low-molecular-weight solvents. Then, the autologous albumin solution crosses a neutral resin filter, which has an increased affinity for bile acids, aromatic amino acids, and phenols, and also an anion exchange resin filter that removes unconjugated bilirubin [64, 65, 66].
These techniques were initially used in hepatology. Subsequently, they were also used for the treatment of acute poisonings with or without liver failure, especially the MARS technique. The aim is to remove albumin-related toxic substances. There are several reports regarding the use of these purification techniques in high liver toxicity mushrooms poisoning as
ECMO is a special technique for maintaining pulmonary and cardiac function through an extracorporeal circulation pump. The purpose of this method is to provide a good oxygenation support and remove the excess of CO₂. It is an exceptional therapy proposed for serious poisonings, especially those that are complicated with respiratory distress syndrome or cardiogenic shock refractor on conventional therapy [68]. ECMO is difficult and should only be done in experienced centers as it carries significant risks. It is a method that requires systemic anticoagulation. The main possible complications are bleeding, systemic infection, and thromboembolic accidents [4, 68]. If the ECMO indication has been established, this therapy should be initiated as soon as possible, before irreversible cerebral or visceral anoxic lesions [68, 69].
Despite the best efforts of the care team, it is not possible to save every child with poisoning. Particularly, in cases where there was significant hypoxic–ischemic central nervous system injury, patient may progress to brain death [70]. Because poisoning is not a sign of organ donation, these patients can be a potential donor source [71]. Toxicological risk assessment should be rigorously conducted in the sense that the transmission of intoxication to the recipient should be avoided. Some toxic substances accumulate in the liver, heart, or lung and could theoretically be released from these grafts after transplantation. These risks, however, should not be exaggerated. They can be diminished by knowledge of kinetics and toxics in target organs. Taking risks is more important for heart or kidney transplantation, organs that are more susceptible to anoxic-ischemic damage [4, 5, 6]. Since severe depression of the central nervous system induced by some toxic can mimic brain death, it is important to allow sufficient time, depending on the pharmacology of the toxic substance, until the plasma concentration decreases to an acceptable level. To declare cerebral death, the following are necessary [4, 72, 73]:
clinical criteria: deep, dormant coma, absence of brain stem reflexes, absence of spontaneous breathing;
biological criteria:
mandatory: flat track on the EEG, apnea test, atropine test;
optional: cerebral angiography (stroke), transcranial echo-Doppler, scintigraphy, etc.
The conditions for declaring brain death vary according to the country’s legislation. Basically, the patient’s examination should be performed by two physicians: neurologist or neurosurgeon and anesthetist. In children, the intervals between examinations must be 24 h for the child aged 2 months to 1 year and at least 12 h over 1 year [74].
Complications of poisonings during childhood may enforce hospitalization to PICU and may contribute to lowering the survival rate. Supporting vital functions is the main objective of the management of a poisoned patient admitted in PICU.
None.
As an Open Access publisher, IntechOpen is dedicated to maintaining the highest ethical standards and principles in publishing. In addition, IntechOpen promotes the highest standards of integrity and ethical behavior in scientific research and peer-review. To maintain these principles IntechOpen has developed basic guidelines to facilitate the avoidance of Conflicts of Interest.
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\\n\\nPolicy last updated: 2016-06-09
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\n\nA Conflict of Interest is a situation in which a person's professional judgment may be influenced by a range of factors, including financial gain, material interest, or some other personal or professional interest. For IntechOpen as a publisher, it is essential that all possible Conflicts of Interest are avoided. Each contributor, whether an Author, Editor, or Reviewer, who suspects they may have a Conflict of Interest, is obliged to declare that concern in order to make the publisher and the readership aware of any potential influence on the work being undertaken.
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\n\nEditors can also have Conflicts of Interest. Editors are expected to maintain the highest standards of conduct, which are outlined in our Best Practice Guidelines (templates for Best Practice Guidelines). Among other obligations, it is essential that Editors make transparent declarations of any possible Conflicts of Interest that they might have.
\n\nAvoidance Measures for Academic Editors of Conflicts of Interest:
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\n\nCONFLICT OF INTEREST - REVIEWER
\n\nAll Reviewers are required to declare possible Conflicts of Interest at the beginning of the evaluation process. If a Reviewer feels he or she might have any material, financial or any other conflict of interest with regards to the manuscript being reviewed, he or she is required to declare such concern and, if necessary, request exclusion from any further involvement in the evaluation process. A Reviewer's potential Conflicts of Interest are declared in the review report and presented to the Academic Editor, who then assesses whether or not the declared potential or actual Conflicts of Interest had, or could be perceived to have had, any significant impact on the review itself.
\n\nEXAMPLES OF CONFLICTS OF INTEREST:
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\n\nNON-FINANCIAL
\n\nAuthors are required to declare all potentially relevant non-financial, financial and material Conflicts of Interest that may have had an influence on their scientific work.
\n\nAcademic Editors and Reviewers are required to declare any non-financial, financial and material Conflicts of Interest that could influence their fair and balanced evaluation of manuscripts. If such conflict exists with regards to a submitted manuscript, Academic Editors and Reviewers should exclude themselves from handling it.
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Radiotherapy and Nuclear Medicine Technology has always been my aspiration and my life. As years passed I accumulated a tremendous amount of skills and knowledge in Radiotherapy and Nuclear Medicine, Conventional Radiology, Radiation Protection, Bioinformatics Technology, PACS, Image processing, clinically and lecturing that will enable me to provide a valuable service to the community as a Researcher and Consultant in this field. My method of translating this into day to day in clinical practice is non-exhaustible and my habit of exchanging knowledge and expertise with others in those fields is the code and secret of success.",institutionString:null,institution:{name:"Majmaah University",country:{name:"Saudi Arabia"}}},{id:"313277",title:"Dr.",name:"Bartłomiej",middleName:null,surname:"Płaczek",slug:"bartlomiej-placzek",fullName:"Bartłomiej Płaczek",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/313277/images/system/313277.jpg",biography:"Bartłomiej Płaczek, MSc (2002), Ph.D. (2005), Habilitation (2016), is a professor at the University of Silesia, Institute of Computer Science, Poland, and an expert from the National Centre for Research and Development. His research interests include sensor networks, smart sensors, intelligent systems, and image processing with applications in healthcare and medicine. He is the author or co-author of more than seventy papers in peer-reviewed journals and conferences as well as the co-author of several books. He serves as a reviewer for many scientific journals, international conferences, and research foundations. Since 2010, Dr. Placzek has been a reviewer of grants and projects (including EU projects) in the field of information technologies.",institutionString:"University of Silesia",institution:{name:"University of Silesia",country:{name:"Poland"}}},{id:"35000",title:"Prof.",name:"Ulrich H.P",middleName:"H.P.",surname:"Fischer",slug:"ulrich-h.p-fischer",fullName:"Ulrich H.P Fischer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/35000/images/3052_n.jpg",biography:"Academic and Professional Background\nUlrich H. P. has Diploma and PhD degrees in Physics from the Free University Berlin, Germany. He has been working on research positions in the Heinrich-Hertz-Institute in Germany. Several international research projects has been performed with European partners from France, Netherlands, Norway and the UK. He is currently Professor of Communications Systems at the Harz University of Applied Sciences, Germany.\n\nPublications and Publishing\nHe has edited one book, a special interest book about ‘Optoelectronic Packaging’ (VDE, Berlin, Germany), and has published over 100 papers and is owner of several international patents for WDM over POF key elements.\n\nKey Research and Consulting Interests\nUlrich’s research activity has always been related to Spectroscopy and Optical Communications Technology. Specific current interests include the validation of complex instruments, and the application of VR technology to the development and testing of measurement systems. He has been reviewer for several publications of the Optical Society of America\\'s including Photonics Technology Letters and Applied Optics.\n\nPersonal Interests\nThese include motor cycling in a very relaxed manner and performing martial arts.",institutionString:null,institution:{name:"Charité",country:{name:"Germany"}}},{id:"341622",title:"Ph.D.",name:"Eduardo",middleName:null,surname:"Rojas Alvarez",slug:"eduardo-rojas-alvarez",fullName:"Eduardo Rojas Alvarez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/341622/images/15892_n.jpg",biography:null,institutionString:null,institution:{name:"University of Cuenca",country:{name:"Ecuador"}}},{id:"215610",title:"Prof.",name:"Muhammad",middleName:null,surname:"Sarfraz",slug:"muhammad-sarfraz",fullName:"Muhammad Sarfraz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/215610/images/system/215610.jpeg",biography:"Muhammad Sarfraz is a professor in the Department of Information Science, Kuwait University, Kuwait. His research interests include optimization, computer graphics, computer vision, image processing, machine learning, pattern recognition, soft computing, data science, and intelligent systems. Prof. Sarfraz has been a keynote/invited speaker at various platforms around the globe. He has advised/supervised more than 110 students for their MSc and Ph.D. theses. He has published more than 400 publications as books, journal articles, and conference papers. He has authored and/or edited around seventy books. Prof. Sarfraz is a member of various professional societies. He is a chair and member of international advisory committees and organizing committees of numerous international conferences. He is also an editor and editor in chief for various international journals.",institutionString:"Kuwait University",institution:{name:"Kuwait University",country:{name:"Kuwait"}}},{id:"32650",title:"Prof.",name:"Lukas",middleName:"Willem",surname:"Snyman",slug:"lukas-snyman",fullName:"Lukas Snyman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/32650/images/4136_n.jpg",biography:"Lukas Willem Snyman received his basic education at primary and high schools in South Africa, Eastern Cape. He enrolled at today's Nelson Metropolitan University and graduated from this university with a BSc in Physics and Mathematics, B.Sc Honors in Physics, MSc in Semiconductor Physics, and a Ph.D. in Semiconductor Physics in 1987. After his studies, he chose an academic career and devoted his energy to the teaching of physics to first, second, and third-year students. After positions as a lecturer at the University of Port Elizabeth, he accepted a position as Associate Professor at the University of Pretoria, South Africa.\r\n\r\nIn 1992, he motivates the concept of 'television and computer-based education” as means to reach large student numbers with only the best of teaching expertise and publishes an article on the concept in the SA Journal of Higher Education of 1993 (and later in 2003). The University of Pretoria subsequently approved a series of test projects on the concept with outreach to Mamelodi and Eerste Rust in 1993. In 1994, the University established a 'Unit for Telematic Education ' as a support section for multiple faculties at the University of Pretoria. In subsequent years, the concept of 'telematic education” subsequently becomes well established in academic circles in South Africa, grew in popularity, and is adopted by many universities and colleges throughout South Africa as a medium of enhancing education and training, as a method to reaching out to far out communities, and as a means to enhance study from the home environment.\r\n\r\nProfessor Snyman in subsequent years pursued research in semiconductor physics, semiconductor devices, microelectronics, and optoelectronics.\r\n\r\nIn 2000 he joined the TUT as a full professor. Here served for a period as head of the Department of Electronic Engineering. Here he makes contributions to solar energy development, microwave and optoelectronic device development, silicon photonics, as well as contributions to new mobile telecommunication systems and network planning in SA.\r\n\r\nCurrently, he teaches electronics and telecommunications at the TUT to audiences ranging from first-year students to Ph.D. level.\r\n\r\nFor his research in the field of 'Silicon Photonics” since 1990, he has published (as author and co-author) about thirty internationally reviewed articles in scientific journals, contributed to more than forty international conferences, about 25 South African provisional patents (as inventor and co-inventor), 8 PCT international patent applications until now. Of these, two USA patents applications, two European Patents, two Korean patents, and ten SA patents have been granted. A further 4 USA patents, 5 European patents, 3 Korean patents, 3 Chinese patents, and 3 Japanese patents are currently under consideration.\r\n\r\nRecently he has also published an extensive scholarly chapter in an internet open access book on 'Integrating Microphotonic Systems and MOEMS into standard Silicon CMOS Integrated circuitry”.\r\n\r\nFurthermore, Professor Snyman recently steered a new initiative at the TUT by introducing a 'Laboratory for Innovative Electronic Systems ' at the Department of Electrical Engineering. The model of this laboratory or center is to primarily combine outputs as achieved by high-level research with lower-level system development and entrepreneurship in a technical university environment. Students are allocated to projects at different levels with PhDs and Master students allocated to the generation of new knowledge and new technologies, while students at the diploma and Baccalaureus level are allocated to electronic systems development with a direct and a near application for application in industry or the commercial and public sectors in South Africa.\r\n\r\nProfessor Snyman received the WIRSAM Award of 1983 and the WIRSAM Award in 1985 in South Africa for best research papers by a young scientist at two international conferences on electron microscopy in South Africa. He subsequently received the SA Microelectronics Award for the best dissertation emanating from studies executed at a South African university in the field of Physics and Microelectronics in South Africa in 1987. In October of 2011, Professor Snyman received the prestigious Institutional Award for 'Innovator of the Year” for 2010 at the Tshwane University of Technology, South Africa. This award was based on the number of patents recognized and granted by local and international institutions as well as for his contributions concerning innovation at the TUT.",institutionString:null,institution:{name:"University of South Africa",country:{name:"South Africa"}}},{id:"317279",title:"Mr.",name:"Ali",middleName:"Usama",surname:"Syed",slug:"ali-syed",fullName:"Ali Syed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/317279/images/16024_n.png",biography:"A creative, talented, and innovative young professional who is dedicated, well organized, and capable research fellow with two years of experience in graduate-level research, published in engineering journals and book, with related expertise in Bio-robotics, equally passionate about the aesthetics of the mechanical and electronic system, obtained expertise in the use of MS Office, MATLAB, SolidWorks, LabVIEW, Proteus, Fusion 360, having a grasp on python, C++ and assembly language, possess proven ability in acquiring research grants, previous appointments with social and educational societies with experience in administration, current affiliations with IEEE and Web of Science, a confident presenter at conferences and teacher in classrooms, able to explain complex information to audiences of all levels.",institutionString:null,institution:{name:"Air University",country:{name:"Pakistan"}}},{id:"75526",title:"Ph.D.",name:"Zihni Onur",middleName:null,surname:"Uygun",slug:"zihni-onur-uygun",fullName:"Zihni Onur Uygun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/75526/images/12_n.jpg",biography:"My undergraduate education and my Master of Science educations at Ege University and at Çanakkale Onsekiz Mart University have given me a firm foundation in Biochemistry, Analytical Chemistry, Biosensors, Bioelectronics, Physical Chemistry and Medicine. After obtaining my degree as a MSc in analytical chemistry, I started working as a research assistant in Ege University Medical Faculty in 2014. In parallel, I enrolled to the MSc program at the Department of Medical Biochemistry at Ege University to gain deeper knowledge on medical and biochemical sciences as well as clinical chemistry in 2014. In my PhD I deeply researched on biosensors and bioelectronics and finished in 2020. Now I have eleven SCI-Expanded Index published papers, 6 international book chapters, referee assignments for different SCIE journals, one international patent pending, several international awards, projects and bursaries. In parallel to my research assistant position at Ege University Medical Faculty, Department of Medical Biochemistry, in April 2016, I also founded a Start-Up Company (Denosens Biotechnology LTD) by the support of The Scientific and Technological Research Council of Turkey. Currently, I am also working as a CEO in Denosens Biotechnology. The main purposes of the company, which carries out R&D as a research center, are to develop new generation biosensors and sensors for both point-of-care diagnostics; such as glucose, lactate, cholesterol and cancer biomarker detections. My specific experimental and instrumental skills are Biochemistry, Biosensor, Analytical Chemistry, Electrochemistry, Mobile phone based point-of-care diagnostic device, POCTs and Patient interface designs, HPLC, Tandem Mass Spectrometry, Spectrophotometry, ELISA.",institutionString:null,institution:{name:"Ege University",country:{name:"Turkey"}}},{id:"246502",title:"Dr.",name:"Jaya T.",middleName:"T",surname:"Varkey",slug:"jaya-t.-varkey",fullName:"Jaya T. Varkey",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/246502/images/11160_n.jpg",biography:"Jaya T. Varkey, PhD, graduated with a degree in Chemistry from Cochin University of Science and Technology, Kerala, India. She obtained a PhD in Chemistry from the School of Chemical Sciences, Mahatma Gandhi University, Kerala, India, and completed a post-doctoral fellowship at the University of Minnesota, USA. She is a research guide at Mahatma Gandhi University and Associate Professor in Chemistry, St. Teresa’s College, Kochi, Kerala, India.\nDr. Varkey received a National Young Scientist award from the Indian Science Congress (1995), a UGC Research award (2016–2018), an Indian National Science Academy (INSA) Visiting Scientist award (2018–2019), and a Best Innovative Faculty award from the All India Association for Christian Higher Education (AIACHE) (2019). She Hashas received the Sr. Mary Cecil prize for best research paper three times. She was also awarded a start-up to develop a tea bag water filter. \nDr. Varkey has published two international books and twenty-seven international journal publications. She is an editorial board member for five international journals.",institutionString:"St. Teresa’s College",institution:null},{id:"250668",title:"Dr.",name:"Ali",middleName:null,surname:"Nabipour Chakoli",slug:"ali-nabipour-chakoli",fullName:"Ali Nabipour Chakoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/250668/images/system/250668.jpg",biography:"Academic Qualification:\r\n•\tPhD in Materials Physics and Chemistry, From: Sep. 2006, to: Sep. 2010, School of Materials Science and Engineering, Harbin Institute of Technology, Thesis: Structure and Shape Memory Effect of Functionalized MWCNTs/poly (L-lactide-co-ε-caprolactone) Nanocomposites. Supervisor: Prof. Wei Cai,\r\n•\tM.Sc in Applied Physics, From: 1996, to: 1998, Faculty of Physics & Nuclear Science, Amirkabir Uni. of Technology, Tehran, Iran, Thesis: Determination of Boron in Micro alloy Steels with solid state nuclear track detectors by neutron induced auto radiography, Supervisors: Dr. M. Hosseini Ashrafi and Dr. A. Hosseini.\r\n•\tB.Sc. in Applied Physics, From: 1991, to: 1996, Faculty of Physics & Nuclear Science, Amirkabir Uni. of Technology, Tehran, Iran, Thesis: Design of shielding for Am-Be neutron sources for In Vivo neutron activation analysis, Supervisor: Dr. M. Hosseini Ashrafi.\r\n\r\nResearch Experiences:\r\n1.\tNanomaterials, Carbon Nanotubes, Graphene: Synthesis, Functionalization and Characterization,\r\n2.\tMWCNTs/Polymer Composites: Fabrication and Characterization, \r\n3.\tShape Memory Polymers, Biodegradable Polymers, ORC, Collagen,\r\n4.\tMaterials Analysis and Characterizations: TEM, SEM, XPS, FT-IR, Raman, DSC, DMA, TGA, XRD, GPC, Fluoroscopy, \r\n5.\tInteraction of Radiation with Mater, Nuclear Safety and Security, NDT(RT),\r\n6.\tRadiation Detectors, Calibration (SSDL),\r\n7.\tCompleted IAEA e-learning Courses:\r\nNuclear Security (15 Modules),\r\nNuclear Safety:\r\nTSA 2: Regulatory Protection in Occupational Exposure,\r\nTips & Tricks: Radiation Protection in Radiography,\r\nSafety and Quality in Radiotherapy,\r\nCourse on Sealed Radioactive Sources,\r\nCourse on Fundamentals of Environmental Remediation,\r\nCourse on Planning for Environmental Remediation,\r\nKnowledge Management Orientation Course,\r\nFood Irradiation - Technology, Applications and Good Practices,\r\nEmployment:\r\nFrom 2010 to now: Academic staff, Nuclear Science and Technology Research Institute, Kargar Shomali, Tehran, Iran, P.O. Box: 14395-836.\r\nFrom 1997 to 2006: Expert of Materials Analysis and Characterization. Research Center of Agriculture and Medicine. Rajaeeshahr, Karaj, Iran, P. O. Box: 31585-498.",institutionString:"Atomic Energy Organization of Iran",institution:{name:"Atomic Energy Organization of Iran",country:{name:"Iran"}}},{id:"248279",title:"Dr.",name:"Monika",middleName:"Elzbieta",surname:"Machoy",slug:"monika-machoy",fullName:"Monika Machoy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/248279/images/system/248279.jpeg",biography:"Monika Elżbieta Machoy, MD, graduated with distinction from the Faculty of Medicine and Dentistry at the Pomeranian Medical University in 2009, defended her PhD thesis with summa cum laude in 2016 and is currently employed as a researcher at the Department of Orthodontics of the Pomeranian Medical University. She expanded her professional knowledge during a one-year scholarship program at the Ernst Moritz Arndt University in Greifswald, Germany and during a three-year internship at the Technical University in Dresden, Germany. She has been a speaker at numerous orthodontic conferences, among others, American Association of Orthodontics, European Orthodontic Symposium and numerous conferences of the Polish Orthodontic Society. She conducts research focusing on the effect of orthodontic treatment on dental and periodontal tissues and the causes of pain in orthodontic patients.",institutionString:"Pomeranian Medical University",institution:{name:"Pomeranian Medical University",country:{name:"Poland"}}},{id:"252743",title:"Prof.",name:"Aswini",middleName:"Kumar",surname:"Kar",slug:"aswini-kar",fullName:"Aswini Kar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252743/images/10381_n.jpg",biography:"uploaded in cv",institutionString:null,institution:{name:"KIIT University",country:{name:"India"}}},{id:"204256",title:"Dr.",name:"Anil",middleName:"Kumar",surname:"Kumar Sahu",slug:"anil-kumar-sahu",fullName:"Anil Kumar Sahu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204256/images/14201_n.jpg",biography:"I have nearly 11 years of research and teaching experience. I have done my master degree from University Institute of Pharmacy, Pt. Ravi Shankar Shukla University, Raipur, Chhattisgarh India. I have published 16 review and research articles in international and national journals and published 4 chapters in IntechOpen, the world’s leading publisher of Open access books. I have presented many papers at national and international conferences. I have received research award from Indian Drug Manufacturers Association in year 2015. My research interest extends from novel lymphatic drug delivery systems, oral delivery system for herbal bioactive to formulation optimization.",institutionString:null,institution:{name:"Chhattisgarh Swami Vivekanand Technical University",country:{name:"India"}}},{id:"253468",title:"Dr.",name:"Mariusz",middleName:null,surname:"Marzec",slug:"mariusz-marzec",fullName:"Mariusz Marzec",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/253468/images/system/253468.png",biography:"An assistant professor at Department of Biomedical Computer Systems, at Institute of Computer Science, Silesian University in Katowice. Scientific interests: computer analysis and processing of images, biomedical images, databases and programming languages. He is an author and co-author of scientific publications covering analysis and processing of biomedical images and development of database systems.",institutionString:"University of Silesia",institution:null},{id:"212432",title:"Prof.",name:"Hadi",middleName:null,surname:"Mohammadi",slug:"hadi-mohammadi",fullName:"Hadi Mohammadi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/212432/images/system/212432.jpeg",biography:"Dr. Hadi Mohammadi is a biomedical engineer with hands-on experience in the design and development of many engineering structures and medical devices through various projects that he has been involved in over the past twenty years. Dr. Mohammadi received his BSc. and MSc. degrees in Mechanical Engineering from Sharif University of Technology, Tehran, Iran, and his PhD. degree in Biomedical Engineering (biomaterials) from the University of Western Ontario. He was a postdoctoral trainee for almost four years at University of Calgary and Harvard Medical School. He is an industry innovator having created the technology to produce lifelike synthetic platforms that can be used for the simulation of almost all cardiovascular reconstructive surgeries. He’s been heavily involved in the design and development of cardiovascular devices and technology for the past 10 years. He is currently an Assistant Professor with the University of British Colombia, Canada.",institutionString:"University of British Columbia",institution:{name:"University of British Columbia",country:{name:"Canada"}}},{id:"254463",title:"Prof.",name:"Haisheng",middleName:null,surname:"Yang",slug:"haisheng-yang",fullName:"Haisheng Yang",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/254463/images/system/254463.jpeg",biography:"Haisheng Yang, Ph.D., Professor and Director of the Department of Biomedical Engineering, College of Life Science and Bioengineering, Beijing University of Technology. He received his Ph.D. degree in Mechanics/Biomechanics from Harbin Institute of Technology (jointly with University of California, Berkeley). Afterwards, he worked as a Postdoctoral Research Associate in the Purdue Musculoskeletal Biology and Mechanics Lab at the Department of Basic Medical Sciences, Purdue University, USA. He also conducted research in the Research Centre of Shriners Hospitals for Children-Canada at McGill University, Canada. Dr. Yang has over 10 years research experience in orthopaedic biomechanics and mechanobiology of bone adaptation and regeneration. He earned an award from Beijing Overseas Talents Aggregation program in 2017 and serves as Beijing Distinguished Professor.",institutionString:"Beijing University of Technology",institution:null},{id:"255757",title:"Dr.",name:"Igor",middleName:"Victorovich",surname:"Lakhno",slug:"igor-lakhno",fullName:"Igor Lakhno",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255757/images/system/255757.jpg",biography:"Lakhno Igor Victorovich was born in 1971 in Kharkiv (Ukraine). \nMD – 1994, Kharkiv National Medical Univesity.\nOb&Gyn; – 1997, master courses in Kharkiv Medical Academy of Postgraduate Education.\nPhD – 1999, Kharkiv National Medical Univesity.\nDSc – 2019, PL Shupik National Academy of Postgraduate Education \nLakhno Igor has been graduated from an international training courses on reproductive medicine and family planning held in Debrecen University (Hungary) in 1997. Since 1998 Lakhno Igor has worked as an associate professor of the department of obstetrics and gynecology of VN Karazin National University and an associate professor of the perinatology, obstetrics and gynecology department of Kharkiv Medical Academy of Postgraduate Education. Since June 2019 he’s a professor of the department of obstetrics and gynecology of VN Karazin National University and a professor of the perinatology, obstetrics and gynecology department of Kharkiv Medical Academy of Postgraduate Education . He’s an author of about 200 printed works and there are 17 of them in Scopus or Web of Science databases. Lakhno Igor is a rewiever of Journal of Obstetrics and Gynaecology (Taylor and Francis), Informatics in Medicine Unlocked (Elsevier), The Journal of Obstetrics and Gynecology Research (Wiley), Endocrine, Metabolic & Immune Disorders-Drug Targets (Bentham Open), The Open Biomedical Engineering Journal (Bentham Open), etc. He’s defended a dissertation for DSc degree \\'Pre-eclampsia: prediction, prevention and treatment”. Lakhno Igor has participated as a speaker in several international conferences and congresses (International Conference on Biological Oscillations April 10th-14th 2016, Lancaster, UK, The 9th conference of the European Study Group on Cardiovascular Oscillations). His main scientific interests: obstetrics, women’s health, fetal medicine, cardiovascular medicine.",institutionString:"V.N. Karazin Kharkiv National University",institution:{name:"Kharkiv Medical Academy of Postgraduate Education",country:{name:"Ukraine"}}},{id:"89721",title:"Dr.",name:"Mehmet",middleName:"Cuneyt",surname:"Ozmen",slug:"mehmet-ozmen",fullName:"Mehmet Ozmen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/89721/images/7289_n.jpg",biography:null,institutionString:null,institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"243698",title:"M.D.",name:"Xiaogang",middleName:null,surname:"Wang",slug:"xiaogang-wang",fullName:"Xiaogang Wang",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/243698/images/system/243698.png",biography:"Dr. Xiaogang Wang, a faculty member of Shanxi Eye Hospital specializing in the treatment of cataract and retinal disease and a tutor for postgraduate students of Shanxi Medical University, worked in the COOL Lab as an international visiting scholar under the supervision of Dr. David Huang and Yali Jia from October 2012 through November 2013. Dr. Wang earned an MD from Shanxi Medical University and a Ph.D. from Shanghai Jiao Tong University. Dr. Wang was awarded two research project grants focused on multimodal optical coherence tomography imaging and deep learning in cataract and retinal disease, from the National Natural Science Foundation of China. He has published around 30 peer-reviewed journal papers and four book chapters and co-edited one book.",institutionString:"Shanxi Eye Hospital",institution:{name:"Shanxi Eye Hospital",country:{name:"China"}}},{id:"242893",title:"Ph.D. Student",name:"Joaquim",middleName:null,surname:"De Moura",slug:"joaquim-de-moura",fullName:"Joaquim De Moura",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/242893/images/7133_n.jpg",biography:"Joaquim de Moura received his degree in Computer Engineering in 2014 from the University of A Coruña (Spain). In 2016, he received his M.Sc degree in Computer Engineering from the same university. He is currently pursuing his Ph.D degree in Computer Science in a collaborative project between ophthalmology centers in Galicia and the University of A Coruña. His research interests include computer vision, machine learning algorithms and analysis and medical imaging processing of various kinds.",institutionString:null,institution:{name:"University of A Coruña",country:{name:"Spain"}}},{id:"267434",title:"Dr.",name:"Rohit",middleName:null,surname:"Raja",slug:"rohit-raja",fullName:"Rohit Raja",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRZkkQAG/Profile_Picture_2022-05-09T12:55:18.jpg",biography:null,institutionString:null,institution:null},{id:"294334",title:"B.Sc.",name:"Marc",middleName:null,surname:"Bruggeman",slug:"marc-bruggeman",fullName:"Marc Bruggeman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/294334/images/8242_n.jpg",biography:"Chemical engineer graduate, with a passion for material science and specific interest in polymers - their near infinite applications intrigue me. \n\nI plan to continue my scientific career in the field of polymeric biomaterials as I am fascinated by intelligent, bioactive and biomimetic materials for use in both consumer and medical applications.",institutionString:null,institution:null},{id:"244950",title:"Dr.",name:"Salvatore",middleName:null,surname:"Di Lauro",slug:"salvatore-di-lauro",fullName:"Salvatore Di Lauro",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0030O00002bSF1HQAW/ProfilePicture%202021-12-20%2014%3A54%3A14.482",biography:"Name:\n\tSALVATORE DI LAURO\nAddress:\n\tHospital Clínico Universitario Valladolid\nAvda Ramón y Cajal 3\n47005, Valladolid\nSpain\nPhone number: \nFax\nE-mail:\n\t+34 983420000 ext 292\n+34 983420084\nsadilauro@live.it\nDate and place of Birth:\nID Number\nMedical Licence \nLanguages\t09-05-1985. Villaricca (Italy)\n\nY1281863H\n474707061\nItalian (native language)\nSpanish (read, written, spoken)\nEnglish (read, written, spoken)\nPortuguese (read, spoken)\nFrench (read)\n\t\t\nCurrent position (title and company)\tDate (Year)\nVitreo-Retinal consultant in ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl. National Health System.\nVitreo-Retinal consultant in ophthalmology. Instituto Oftalmologico Recoletas. Red Hospitalaria Recoletas. Private practise.\t2017-today\n\n2019-today\n\t\n\t\nEducation (High school, university and postgraduate training > 3 months)\tDate (Year)\nDegree in Medicine and Surgery. University of Neaples 'Federico II”\nResident in Opthalmology. Hospital Clinico Universitario Valladolid\nMaster in Vitreo-Retina. IOBA. University of Valladolid\nFellow of the European Board of Ophthalmology. Paris\nMaster in Research in Ophthalmology. University of Valladolid\t2003-2009\n2012-2016\n2016-2017\n2016\n2012-2013\n\t\nEmployments (company and positions)\tDate (Year)\nResident in Ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl.\nFellow in Vitreo-Retina. IOBA. University of Valladolid\nVitreo-Retinal consultant in ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl. National Health System.\nVitreo-Retinal consultant in ophthalmology. Instituto Oftalmologico Recoletas. Red Hospitalaria Recoletas. \n\t2012-2016\n2016-2017\n2017-today\n\n2019-Today\n\n\n\t\nClinical Research Experience (tasks and role)\tDate (Year)\nAssociated investigator\n\n' FIS PI20/00740: DESARROLLO DE UNA CALCULADORA DE RIESGO DE\nAPARICION DE RETINOPATIA DIABETICA BASADA EN TECNICAS DE IMAGEN MULTIMODAL EN PACIENTES DIABETICOS TIPO 1. Grant by: Ministerio de Ciencia e Innovacion \n\n' (BIO/VA23/14) Estudio clínico multicéntrico y prospectivo para validar dos\nbiomarcadores ubicados en los genes p53 y MDM2 en la predicción de los resultados funcionales de la cirugía del desprendimiento de retina regmatógeno. Grant by: Gerencia Regional de Salud de la Junta de Castilla y León.\n' Estudio multicéntrico, aleatorizado, con enmascaramiento doble, en 2 grupos\nparalelos y de 52 semanas de duración para comparar la eficacia, seguridad e inmunogenicidad de SOK583A1 respecto a Eylea® en pacientes con degeneración macular neovascular asociada a la edad' (CSOK583A12301; N.EUDRA: 2019-004838-41; FASE III). Grant by Hexal AG\n\n' Estudio de fase III, aleatorizado, doble ciego, con grupos paralelos, multicéntrico para comparar la eficacia y la seguridad de QL1205 frente a Lucentis® en pacientes con degeneración macular neovascular asociada a la edad. (EUDRACT: 2018-004486-13). Grant by Qilu Pharmaceutical Co\n\n' Estudio NEUTON: Ensayo clinico en fase IV para evaluar la eficacia de aflibercept en pacientes Naive con Edema MacUlar secundario a Oclusion de Vena CenTral de la Retina (OVCR) en regimen de tratamientO iNdividualizado Treat and Extend (TAE)”, (2014-000975-21). Grant by Fundacion Retinaplus\n\n' Evaluación de la seguridad y bioactividad de anillos de tensión capsular en conejo. Proyecto Procusens. Grant by AJL, S.A.\n\n'Estudio epidemiológico, prospectivo, multicéntrico y abierto\\npara valorar la frecuencia de la conjuntivitis adenovírica diagnosticada mediante el test AdenoPlus®\\nTest en pacientes enfermos de conjuntivitis aguda”\\n. National, multicenter study. Grant by: NICOX.\n\nEuropean multicentric trial: 'Evaluation of clinical outcomes following the use of Systane Hydration in patients with dry eye”. Study Phase 4. Grant by: Alcon Labs'\n\nVLPs Injection and Activation in a Rabbit Model of Uveal Melanoma. Grant by Aura Bioscience\n\nUpdating and characterization of a rabbit model of uveal melanoma. Grant by Aura Bioscience\n\nEnsayo clínico en fase IV para evaluar las variantes genéticas de la vía del VEGF como biomarcadores de eficacia del tratamiento con aflibercept en pacientes con degeneración macular asociada a la edad (DMAE) neovascular. Estudio BIOIMAGE. IMO-AFLI-2013-01\n\nEstudio In-Eye:Ensayo clínico en fase IV, abierto, aleatorizado, de 2 brazos,\nmulticçentrico y de 12 meses de duración, para evaluar la eficacia y seguridad de un régimen de PRN flexible individualizado de 'esperar y extender' versus un régimen PRN según criterios de estabilización mediante evaluaciones mensuales de inyecciones intravítreas de ranibizumab 0,5 mg en pacientes naive con neovascularización coriodea secunaria a la degeneración macular relacionada con la edad. CP: CRFB002AES03T\n\nTREND: Estudio Fase IIIb multicéntrico, randomizado, de 12 meses de\nseguimiento con evaluador de la agudeza visual enmascarado, para evaluar la eficacia y la seguridad de ranibizumab 0.5mg en un régimen de tratar y extender comparado con un régimen mensual, en pacientes con degeneración macular neovascular asociada a la edad. CP: CRFB002A2411 Código Eudra CT:\n2013-002626-23\n\n\n\nPublications\t\n\n2021\n\n\n\n\n2015\n\n\n\n\n2021\n\n\n\n\n\n2021\n\n\n\n\n2015\n\n\n\n\n2015\n\n\n2014\n\n\n\n\n2015-16\n\n\n\n2015\n\n\n2014\n\n\n2014\n\n\n\n\n2014\n\n\n\n\n\n\n\n2014\n\nJose Carlos Pastor; Jimena Rojas; Salvador Pastor-Idoate; Salvatore Di Lauro; Lucia Gonzalez-Buendia; Santiago Delgado-Tirado. Proliferative vitreoretinopathy: A new concept of disease pathogenesis and practical\nconsequences. Progress in Retinal and Eye Research. 51, pp. 125 - 155. 03/2016. DOI: 10.1016/j.preteyeres.2015.07.005\n\n\nLabrador-Velandia S; Alonso-Alonso ML; Di Lauro S; García-Gutierrez MT; Srivastava GK; Pastor JC; Fernandez-Bueno I. Mesenchymal stem cells provide paracrine neuroprotective resources that delay degeneration of co-cultured organotypic neuroretinal cultures.Experimental Eye Research. 185, 17/05/2019. DOI: 10.1016/j.exer.2019.05.011\n\nSalvatore Di Lauro; Maria Teresa Garcia Gutierrez; Ivan Fernandez Bueno. Quantification of pigment epithelium-derived factor (PEDF) in an ex vivo coculture of retinal pigment epithelium cells and neuroretina.\nJournal of Allbiosolution. 2019. ISSN 2605-3535\n\nSonia Labrador Velandia; Salvatore Di Lauro; Alonso-Alonso ML; Tabera Bartolomé S; Srivastava GK; Pastor JC; Fernandez-Bueno I. Biocompatibility of intravitreal injection of human mesenchymal stem cells in immunocompetent rabbits. Graefe's archive for clinical and experimental ophthalmology. 256 - 1, pp. 125 - 134. 01/2018. DOI: 10.1007/s00417-017-3842-3\n\n\nSalvatore Di Lauro, David Rodriguez-Crespo, Manuel J Gayoso, Maria T Garcia-Gutierrez, J Carlos Pastor, Girish K Srivastava, Ivan Fernandez-Bueno. A novel coculture model of porcine central neuroretina explants and retinal pigment epithelium cells. Molecular Vision. 2016 - 22, pp. 243 - 253. 01/2016.\n\nSalvatore Di Lauro. Classifications for Proliferative Vitreoretinopathy ({PVR}): An Analysis of Their Use in Publications over the Last 15 Years. Journal of Ophthalmology. 2016, pp. 1 - 6. 01/2016. DOI: 10.1155/2016/7807596\n\nSalvatore Di Lauro; Rosa Maria Coco; Rosa Maria Sanabria; Enrique Rodriguez de la Rua; Jose Carlos Pastor. Loss of Visual Acuity after Successful Surgery for Macula-On Rhegmatogenous Retinal Detachment in a Prospective Multicentre Study. Journal of Ophthalmology. 2015:821864, 2015. DOI: 10.1155/2015/821864\n\nIvan Fernandez-Bueno; Salvatore Di Lauro; Ivan Alvarez; Jose Carlos Lopez; Maria Teresa Garcia-Gutierrez; Itziar Fernandez; Eva Larra; Jose Carlos Pastor. Safety and Biocompatibility of a New High-Density Polyethylene-Based\nSpherical Integrated Porous Orbital Implant: An Experimental Study in Rabbits. Journal of Ophthalmology. 2015:904096, 2015. DOI: 10.1155/2015/904096\n\nPastor JC; Pastor-Idoate S; Rodríguez-Hernandez I; Rojas J; Fernandez I; Gonzalez-Buendia L; Di Lauro S; Gonzalez-Sarmiento R. Genetics of PVR and RD. Ophthalmologica. 232 - Suppl 1, pp. 28 - 29. 2014\n\nRodriguez-Crespo D; Di Lauro S; Singh AK; Garcia-Gutierrez MT; Garrosa M; Pastor JC; Fernandez-Bueno I; Srivastava GK. Triple-layered mixed co-culture model of RPE cells with neuroretina for evaluating the neuroprotective effects of adipose-MSCs. Cell Tissue Res. 358 - 3, pp. 705 - 716. 2014.\nDOI: 10.1007/s00441-014-1987-5\n\nCarlo De Werra; Salvatore Condurro; Salvatore Tramontano; Mario Perone; Ivana Donzelli; Salvatore Di Lauro; Massimo Di Giuseppe; Rosa Di Micco; Annalisa Pascariello; Antonio Pastore; Giorgio Diamantis; Giuseppe Galloro. Hydatid disease of the liver: thirty years of surgical experience.Chirurgia italiana. 59 - 5, pp. 611 - 636.\n(Italia): 2007. ISSN 0009-4773\n\nChapters in books\n\t\n' Salvador Pastor Idoate; Salvatore Di Lauro; Jose Carlos Pastor Jimeno. PVR: Pathogenesis, Histopathology and Classification. Proliferative Vitreoretinopathy with Small Gauge Vitrectomy. Springer, 2018. ISBN 978-3-319-78445-8\nDOI: 10.1007/978-3-319-78446-5_2. \n\n' Salvatore Di Lauro; Maria Isabel Lopez Galvez. Quistes vítreos en una mujer joven. Problemas diagnósticos en patología retinocoroidea. Sociedad Española de Retina-Vitreo. 2018.\n\n' Salvatore Di Lauro; Salvador Pastor Idoate; Jose Carlos Pastor Jimeno. iOCT in PVR management. OCT Applications in Opthalmology. pp. 1 - 8. INTECH, 2018. DOI: 10.5772/intechopen.78774.\n\n' Rosa Coco Martin; Salvatore Di Lauro; Salvador Pastor Idoate; Jose Carlos Pastor. amponadores, manipuladores y tinciones en la cirugía del traumatismo ocular.Trauma Ocular. Ponencia de la SEO 2018..\n\n' LOPEZ GALVEZ; DI LAURO; CRESPO. OCT angiografia y complicaciones retinianas de la diabetes. PONENCIA SEO 2021, CAPITULO 20. (España): 2021.\n\n' Múltiples desprendimientos neurosensoriales bilaterales en paciente joven. Enfermedades Degenerativas De Retina Y Coroides. SERV 04/2016. \n' González-Buendía L; Di Lauro S; Pastor-Idoate S; Pastor Jimeno JC. Vitreorretinopatía proliferante (VRP) e inflamación: LA INFLAMACIÓN in «INMUNOMODULADORES Y ANTIINFLAMATORIOS: MÁS ALLÁ DE LOS CORTICOIDES. RELACION DE PONENCIAS DE LA SOCIEDAD ESPAÑOLA DE OFTALMOLOGIA. 10/2014.",institutionString:null,institution:null},{id:"265335",title:"Mr.",name:"Stefan",middleName:"Radnev",surname:"Stefanov",slug:"stefan-stefanov",fullName:"Stefan Stefanov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/265335/images/7562_n.jpg",biography:null,institutionString:null,institution:null},{id:"318905",title:"Prof.",name:"Elvis",middleName:"Kwason",surname:"Tiburu",slug:"elvis-tiburu",fullName:"Elvis Tiburu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Ghana",country:{name:"Ghana"}}},{id:"336193",title:"Dr.",name:"Abdullah",middleName:null,surname:"Alamoudi",slug:"abdullah-alamoudi",fullName:"Abdullah Alamoudi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Majmaah University",country:{name:"Saudi Arabia"}}},{id:"318657",title:"MSc.",name:"Isabell",middleName:null,surname:"Steuding",slug:"isabell-steuding",fullName:"Isabell Steuding",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Harz University of Applied Sciences",country:{name:"Germany"}}},{id:"318656",title:"BSc.",name:"Peter",middleName:null,surname:"Kußmann",slug:"peter-kussmann",fullName:"Peter Kußmann",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Harz University of Applied Sciences",country:{name:"Germany"}}},{id:"338222",title:"Mrs.",name:"María José",middleName:null,surname:"Lucía Mudas",slug:"maria-jose-lucia-mudas",fullName:"María José Lucía Mudas",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Carlos III University of Madrid",country:{name:"Spain"}}},{id:"147824",title:"Mr.",name:"Pablo",middleName:null,surname:"Revuelta Sanz",slug:"pablo-revuelta-sanz",fullName:"Pablo Revuelta Sanz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Carlos III University of Madrid",country:{name:"Spain"}}}]}},subseries:{item:{id:"39",type:"subseries",title:"Environmental Resilience and Management",keywords:"Anthropic effects, Overexploitation, Biodiversity loss, Degradation, Inadequate Management, SDGs adequate practices",scope:"\r\n\tThe environment is subject to severe anthropic effects. Among them are those associated with pollution, resource extraction and overexploitation, loss of biodiversity, soil degradation, disorderly land occupation and planning, and many others. These anthropic effects could potentially be caused by any inadequate management of the environment. However, ecosystems have a resilience that makes them react to disturbances which mitigate the negative effects. It is critical to understand how ecosystems, natural and anthropized, including urban environments, respond to actions that have a negative influence and how they are managed. It is also important to establish when the limits marked by the resilience and the breaking point are achieved and when no return is possible. The main focus for the chapters is to cover the subjects such as understanding how the environment resilience works, the mechanisms involved, and how to manage them in order to improve our interactions with the environment and promote the use of adequate management practices such as those outlined in the United Nations’ Sustainable Development Goals.
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His work is reflected in more than 230 communications presented in national and international conferences and congresses, 29 invited lectures from universities, associations and government agencies. Prof. Navarro-Pedreño is also a director of the Ph.D. Program Environment and Sustainability (2012-present) and a member of several societies among which are the Spanish Society of Soil Science, International Union of Soil Sciences, European Society for Soil Conservation, DessertNet and the Spanish Royal Society of Chemistry.",institutionString:"Miguel Hernández University of Elche, Spain",institution:null},editorTwo:null,editorThree:null,series:{id:"25",title:"Environmental Sciences",doi:"10.5772/intechopen.100362",issn:"2754-6713"},editorialBoard:[{id:"177015",title:"Prof.",name:"Elke Jurandy",middleName:null,surname:"Bran Nogueira Cardoso",slug:"elke-jurandy-bran-nogueira-cardoso",fullName:"Elke Jurandy Bran Nogueira Cardoso",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRGxzQAG/Profile_Picture_2022-03-25T08:32:33.jpg",institutionString:"Universidade de São Paulo, 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