Description of institutional variables.
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"5470",leadTitle:null,fullTitle:"Child and Adolescent Mental Health",title:"Child and Adolescent Mental Health",subtitle:null,reviewType:"peer-reviewed",abstract:"In the present volume, we collected state-of-the-art chapters on diagnosis, treatment, and social implications. The first section describes diagnostic processes. It describes a reevaluation of projective techniques, a new clinical tool in psychotraumatology, the foundations of the framing technique, and an overview on integrative approaches. The second section focuses on new developments in the field with special emphasis on culture-specific contexts. From parenting of adolescents in India to the influence of poverty on mental health issues in Mexico, as well as the use of marijuana and Internet addiction, some of the most important fields are highlighted. The third section concentrates on therapy. It shows how to react to bullying and reviews the use of antidepressants in children and adolescents.",isbn:"978-953-51-3190-8",printIsbn:"978-953-51-3189-2",pdfIsbn:"978-953-51-4832-6",doi:"10.5772/63037",price:119,priceEur:129,priceUsd:155,slug:"child-and-adolescent-mental-health",numberOfPages:218,isOpenForSubmission:!1,isInWos:1,isInBkci:!1,hash:"4c9efb06aad3521aa0be6f7135b5fe22",bookSignature:"Martin H. Maurer",publishedDate:"May 24th 2017",coverURL:"https://cdn.intechopen.com/books/images_new/5470.jpg",numberOfDownloads:20757,numberOfWosCitations:9,numberOfCrossrefCitations:12,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:22,numberOfDimensionsCitationsByBook:1,hasAltmetrics:1,numberOfTotalCitations:43,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 20th 2016",dateEndSecondStepPublish:"May 11th 2016",dateEndThirdStepPublish:"August 15th 2016",dateEndFourthStepPublish:"November 13th 2016",dateEndFifthStepPublish:"December 13th 2016",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"95060",title:"Prof.",name:"Martin Henrik",middleName:"H.",surname:"Maurer",slug:"martin-henrik-maurer",fullName:"Martin Henrik Maurer",profilePictureURL:"https://mts.intechopen.com/storage/users/95060/images/system/95060.jpeg",biography:"Martin H. Maurer graduated from medical school at the University of Heidelberg, Germany, and McGill University, Montréal, Canada, in 1999 – receiving his MD in 1999. As a post-doctoral fellow in 2003 at the Johns Hopkins University, Baltimore, Md., USA, he concentrated on neurological diseases and was appointed Assistant Professor of Physiology in 2005 and Associate Professor of Physiology in 2007 at the University of Heidelberg. From 2007-08, he was a research group leader in the biotech industry. In 2009-10, he did clinical work in pediatrics, and from 2011 until present in child and adolescent psychiatry. He is now at the Mariaberg Hospital for Child and Adolescent Psychiatry in Gammertingen, Germany, and at a private practice in Stuttgart, Germany. He is Editor-in-Chief of the scientific journal The Application of Clinical Genetics.",institutionString:"Heidelberg University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Heidelberg University",institutionURL:null,country:{name:"Germany"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1054",title:"Neurobiology",slug:"mental-and-behavioural-disorders-and-diseases-of-the-nervous-system-neurobiology"}],chapters:[{id:"54469",title:"Draw, Write, Speak, Play: The Role of Projection in Diagnosis and Therapy of Children and Adolescents",doi:"10.5772/67578",slug:"draw-write-speak-play-the-role-of-projection-in-diagnosis-and-therapy-of-children-and-adolescents",totalDownloads:3637,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"In this chapter, I will (1) review the concept and function of projective mechanisms on a psychodynamic basis. In this section, I will outline the relation of projection to the unconscious, its use in innerpsychic dynamics, and the underlying mechanisms for its use in psychotherapy like creativity, imagination, and symbolization; (2) give an overview over the use of projective methods for testing and diagnosis in the psychological sciences; and (3) exemplify the use of projective methods in diagnostics and psychotherapy of children and adolescents. I will present current methods based on drawing, verbally describing and imaginating, and playing arts, focusing on sand play therapy and miniature figure play.",signatures:"Martin H. Maurer",downloadPdfUrl:"/chapter/pdf-download/54469",previewPdfUrl:"/chapter/pdf-preview/54469",authors:[{id:"95060",title:"Prof.",name:"Martin Henrik",surname:"Maurer",slug:"martin-henrik-maurer",fullName:"Martin Henrik Maurer"}],corrections:null},{id:"54625",title:"A Qualitative Tool for Detecting and Approaching Psychological Trauma in Children Victims of the 2009 Italian Earthquake",doi:"10.5772/67364",slug:"a-qualitative-tool-for-detecting-and-approaching-psychological-trauma-in-children-victims-of-the-200",totalDownloads:1313,totalCrossrefCites:2,totalDimensionsCites:2,hasAltmetrics:0,abstract:"Expressive therapies are considered effective intervention modalities with children who have experienced traumatic events such as natural disasters. Particularly, drawing consent to trauma affected children to convey the complexity of traumatic feelings by giving them a shape and a sense. But the efficacy of art therapies with children exposed to natural disasters, has not been research proved. This chapter present an exploratory and pilot study on the use of the specific technique “Test de trois dessins: avant, pendant et avenir” (Three Pictures Test: Past, Present, and Future), which may accomplish the double function of diagnostic instrument, for detecting the presence of psychological trauma, and therapeutic technique, for facilitating recovery from psychological distress, with children exposed to natural disasters. The graphic tool has been employed with children victims of the Italian earthquake which affected the region of Abruzzi, on the 6th April 2009. The case studies analysis illustrates the efficacy of the test in both detecting the presence and the extent of the psychological trauma, and in enhancing the trauma recovery process. Further researches need to be done in order to validate the use of the “Three Pictures Test: Past, Present, and Future” as a validated technique with children experiencing disasters.",signatures:"Francesca Giordano",downloadPdfUrl:"/chapter/pdf-download/54625",previewPdfUrl:"/chapter/pdf-preview/54625",authors:[{id:"190360",title:"Dr.",name:"Francesca",surname:"Giordano",slug:"francesca-giordano",fullName:"Francesca Giordano"}],corrections:null},{id:"54044",title:"Can Frames Make Change? Using Communications Science to Translate the Science of Child Mental Health",doi:"10.5772/67340",slug:"can-frames-make-change-using-communications-science-to-translate-the-science-of-child-mental-health",totalDownloads:1344,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:1,abstract:"Mental illness in children is on the rise in the United States, but research shows that the American public does not understand the science of child mental health—what it is and what supports and disrupts it. To build public understanding of child mental health and support for the systemic solutions needed to promote it, the FrameWorks Institute developed a “core story”—a master narrative—that advocates and experts in the field can use to communicate about the issue more effectively. This research is built on interviews with experts and members of the public, cognitive analyses of frames commonly used in media stories about the issue, and surveys of frame elements such as values and metaphors. Findings show that two values—Prosperity and Ingenuity—lifted support for policies related to child mental health. The Levelness Explanatory Metaphor, which compares child mental health to the levelness of a table, is also effective.",signatures:"Nat Kendall‐Taylor and Allison Stevens",downloadPdfUrl:"/chapter/pdf-download/54044",previewPdfUrl:"/chapter/pdf-preview/54044",authors:[{id:"190986",title:"Ms.",name:"Allison",surname:"Stevens",slug:"allison-stevens",fullName:"Allison Stevens"},{id:"191393",title:"Dr.",name:"Nat",surname:"Kendall-Taylor",slug:"nat-kendall-taylor",fullName:"Nat Kendall-Taylor"}],corrections:null},{id:"54165",title:"Integrative Approach to Child and Adolescent Mental Health",doi:"10.5772/67556",slug:"integrative-approach-to-child-and-adolescent-mental-health",totalDownloads:1347,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The prevalence of mental disorders between children and adolescents is 10–20% worldwide. Research has shown that most mental disorders begin at childhood and adolescence. Neurodevelopmental disorders are classified by which the development of the central nervous system is disturbed and are associated with varying degrees of consequences in one’s mental, emotional, physical, and economic states. Recently, research in mental health, neurobiology, and early childhood development supported the case for early intervention and prevention. The causes of mental disorders in children and adolescents are not currently known, but research suggests that a combination of factors that include heredity, biology, psychological trauma, spiritual well-being, and environmental stress might be involved. There are many factors that play into child and adolescent mental health and disorders; therefore, individualized, personalized, and integrative approaches are necessary in therapeutic interventions and prevention. Thus, by ensuring that the needed mental health care competencies are made available in each primary health care team and by assuring fully integrated mental health and other types of health care, primary health care teams would best provide early, efficient, effective, and optimal recovery-based care.",signatures:"Seungpil Jung",downloadPdfUrl:"/chapter/pdf-download/54165",previewPdfUrl:"/chapter/pdf-preview/54165",authors:[{id:"189654",title:"Dr.",name:"Seungpil",surname:"Jung",slug:"seungpil-jung",fullName:"Seungpil Jung"},{id:"195108",title:"Prof.",name:"Keun-Mi",surname:"Lee",slug:"keun-mi-lee",fullName:"Keun-Mi Lee"}],corrections:null},{id:"53127",title:"Parenting Adolescents in India: A Cultural Perspective",doi:"10.5772/66451",slug:"parenting-adolescents-in-india-a-cultural-perspective",totalDownloads:2020,totalCrossrefCites:5,totalDimensionsCites:9,hasAltmetrics:1,abstract:"Contemporary parenting has witnessed a multitude of adaptations over the past decade across various cultural settings. Adolescent attachment patterns with parents have been explored in varying cultural contexts. These attachment patterns have been extensively studied in the light of adolescence as a turbulent phase of development. This chapter offers a systematic review of the cultural factors influencing parenting, with a theoretical analysis specific to adolescents within the Indian context. Based on the exploration of these cultural influences on parenting, the chapter further explores the relevance of mindfulness-based approaches within the Indian culture, with an applicability of a model of mindful parenting specifically with adolescents in India. The conceptualization of mindfulness-based approaches stems from both Eastern and Western cultures, which have significant influences on parenting of adolescents. The components of mindful parenting have shown applicability within the dynamic context of parental-adolescent attachment patterns, especially considering the culture-specific concept of interdependence in a collectivistic culture like India. Such findings have potential implications for the formulation of parenting strategies toward the future of adolescent mental health in the country.",signatures:"Roshni Sondhi",downloadPdfUrl:"/chapter/pdf-download/53127",previewPdfUrl:"/chapter/pdf-preview/53127",authors:[{id:"190983",title:"Ms.",name:"Roshni",surname:"Sondhi",slug:"roshni-sondhi",fullName:"Roshni Sondhi"}],corrections:null},{id:"52578",title:"Poverty and Mental Health Outcomes in Mexican Adolescents",doi:"10.5772/65513",slug:"poverty-and-mental-health-outcomes-in-mexican-adolescents",totalDownloads:1494,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"The purpose of this chapter is to analyze the adaptive and resilience processes in adolescents from different marginalizing communities. The theoretical and empirical foundations of the ecological‐transactional perspective of adolescent development as a framework for understanding the adaptive processes and resilience in contextual adversity is reviewed, with the recognition of risk and protective factors at multiple levels and ecological settings. Under this perspective, the authors provide data supporting the predictive role of stressful life events, coping, and family functioning in adaptive and nonadaptive outcomes in adolescents living in diverse contexts of high‐risk communities in Mexico City. These findings may contribute to early intervention programs based on empirical evidence with adolescents and families living in disadvantages communities in schools and in clinical settings.",signatures:"Blanca Estela Barcelata‐Eguiarte and Maria Elena Márquez‐Caraveo",downloadPdfUrl:"/chapter/pdf-download/52578",previewPdfUrl:"/chapter/pdf-preview/52578",authors:[{id:"191559",title:"Ph.D.",name:"Blanca",surname:"Barcelata-Eguiarte",slug:"blanca-barcelata-eguiarte",fullName:"Blanca Barcelata-Eguiarte"},{id:"194280",title:"Dr.",name:"Maria Elena",surname:"Márquez-Caraveo",slug:"maria-elena-marquez-caraveo",fullName:"Maria Elena Márquez-Caraveo"}],corrections:null},{id:"52182",title:"Marijuana, Experience of Temporality, and School Performance from a Qualitative and Quantitative Approach",doi:"10.5772/65058",slug:"marijuana-experience-of-temporality-and-school-performance-from-a-qualitative-and-quantitative-appro",totalDownloads:1182,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The study aims at knowing how low marijuana doses affect cognitive ability in postprimary students. The objective of the quantitative research was to analyze the results of neuropsychological and Neuro-SPECT tests comparing schoolchildren who smoke marijuana with those who do not, with emphasis on the effects on cognitive functions involved in learning. We wanted to assess the effects on the cerebral function of marijuana-only users. It was a comparative study based on the total sample of 565 school adolescents coming from four schools in the metropolitan area of Santiago, Chile. All were interviewed in order to select a sample that was stratified by sex, class and consumption of marijuana. The following two groups were made: 40 marijuana-only users and 40 nonusers. We took as a reference a study performed by the authors in 2007, in which the correlation between the consumption of marijuana and effects on cognitive functions involved in scholastic learning were established. The findings show statistically significant differences in the following areas: subgenual bilateral hypoperfusion, more marked on the left side (Brodmann area 25), frontal bilateral hypoperfusion (Brodmann’s areas 10 and 32), front cingulate gyrushypoperfusion (Brodmann area 24) and hypoperfusion of Brodmann area 36 that projects to the hippocampus. The results are highly matched with the neuropsychological tests given in the sense that, like with the 2007 study, significant differences are found between the two groups as far as the tests measuring cognitive functions are concerned. A qualitative research: we wanted to investigate the experience of time in high school students who regularly smoke marijuana, given that this substance has effects on the prefrontal lobe and on the hippocampus, brain areas related to the ability to plan tasks (executive function) and to memory. Moreover, adolescence is a delicate stage in regard to planning of the future. At the same time, the idea was to understand and make use of the concepts of temporariness and anticipation, which as a general rule will be handled only by philosophical theories. Our guiding principle is the ability to “anticipate oneself,” proposed by Sutter, a phenomenological psychiatrist. Data were analyzed from the autobiographies of the students through the hermeneutical phenomenological method developed by Lindseth, based on Ricoeur. Results allow answering the question of the study about the temporary experiencing of the young abusive marijuana consumer. The results showed poverty in the temporary dimensions referring to the past and the future, while in the report, it is more developed in the present moment. They appear detained in a more childish stage, in which the present predominates, and the future seemed not to be united with the past, which impresses as if it were “avoided.” What has been (past) does not link with what is wanted to be, so, elements of the past have no relation with future project.",signatures:"Anneliese Dörr, Sandra Viani and María Elena Gorostegui",downloadPdfUrl:"/chapter/pdf-download/52182",previewPdfUrl:"/chapter/pdf-preview/52182",authors:[{id:"190982",title:"Dr.",name:"Anneliese",surname:"Dörr",slug:"anneliese-dorr",fullName:"Anneliese Dörr"},{id:"193752",title:"Prof.",name:"Maria Elena",surname:"Gorostegui",slug:"maria-elena-gorostegui",fullName:"Maria Elena Gorostegui"}],corrections:null},{id:"53535",title:"Internet Addiction Disorder",doi:"10.5772/66966",slug:"internet-addiction-disorder",totalDownloads:3523,totalCrossrefCites:1,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Internet addiction (IA) was introduced as a new disorder in mid-1990s. Since then, there is growing concern about the addictive nature of the Internet. This chapter is a comprehensive review of published seminal, research and review papers, meta-analyses and book chapters/books on IA in adolescents. The conceptualization of IA, epidemiology, phenomenology, screening, diagnoses, treatment and prevention are discussed with relevant references. The concept of IA is at fetal level with no consensus on definition, norms or clinical criteria. Asian countries such as China and South Korea are affected most. A multination meta-analysis estimated an overall prevalence of 6% for IA. Most of the research identifies IA in gaming, gambling, social networking and cybersex. A few assessment tools have been used with no comparability or cultural sensitivity. Diagnostic criteria are proposed based on those used for substance abuse and pathological gambling. The treatments are mainly psychological with a lot of emphasis on cognitive behavior therapy. The Internet is a very versatile and useful tool for children and adolescents, and it is not advisable to ban it totally. The review highlights education of them on sensible Internet use and supports inclusion of IA in international disease classifications.",signatures:"Pabasari Ginige",downloadPdfUrl:"/chapter/pdf-download/53535",previewPdfUrl:"/chapter/pdf-preview/53535",authors:[{id:"190433",title:"Dr.",name:"Pabasari",surname:"Ginige",slug:"pabasari-ginige",fullName:"Pabasari Ginige"}],corrections:null},{id:"53391",title:"Peer Bullying in Schools: A Cognitive Behavioral Intervention Program",doi:"10.5772/66701",slug:"peer-bullying-in-schools-a-cognitive-behavioral-intervention-program",totalDownloads:3684,totalCrossrefCites:1,totalDimensionsCites:4,hasAltmetrics:1,abstract:"Students face few problems in schools. Some of these conflicts may be defined with the bullying concept. The concept of bullying is defined as “to repetitively expose a student/students to negative effects of another student or students.” “Negative effects” includes students getting disturbed as well as getting hurt from the same kind of negative behavior; it also may be done by attempting to hurt someone, deliberately harming someone verbally or physically. Bullying behavior should include an “inequivalent power” between opponents and this needs to be “permanent” and “intentional.” Bullying at school affects lots of students around the schools who witness bullying behavior in different dimensions; thus, it is an important problem that needs to be prevented. While some of the studies encompass interventions toward the whole school system, some studies were conducted by determining separate groups and working on those. In this paper, first, some whole school approach–based prevention programs and the effectiveness of these programs and then intervention programs for groups, which are provided to reduce and intervene bullying, will be explained. Second, cognitive behavioral therapy and its use in preventing bullying will be briefly explained. Finally, the context of a cognitive‐behavioral based peer bullying intervention program.",signatures:"Füsun Gökkaya",downloadPdfUrl:"/chapter/pdf-download/53391",previewPdfUrl:"/chapter/pdf-preview/53391",authors:[{id:"191465",title:"Dr.",name:"Füsun",surname:"Gökkaya",slug:"fusun-gokkaya",fullName:"Füsun Gökkaya"}],corrections:null},{id:"55336",title:"Use of Antidepressants in Children and Adolescents",doi:"10.5772/intechopen.68994",slug:"use-of-antidepressants-in-children-and-adolescents",totalDownloads:1214,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Depression is a serious disorder that can cause significant problems in mood, thinking, and behavior at home, in school, and with peers. It is estimated that major depressive disorder (MDD) affects about 5% of adolescents. Research has shown that, as in adults, depression in children and adolescents is treatable. Certain antidepressant medications, called selective serotonin reuptake inhibitors (SSRIs), can be beneficial to children and adolescents with MDD. Certain types of psychological therapies also have been shown to be effective. However, our knowledge of antidepressant treatments in youth, though growing substantially, is limited compared to what we know about treating depression in adults. The U.S. Food and Drug Administration (FDA) issued a public warning in October 2004 about an increased risk of suicidal thoughts or behavior (suicidality) in children and adolescents treated with SSRI antidepressant medications. However, SSRI medications are considered to have an improvement over older antidepressant medications and they have been shown to be safe and effective for adults. In this chapter we provide an updated and well-documented review of the current scientific evidence on this topic.",signatures:"Isabel Hernández-Otero, Carlos Gómez Sánchez-Lafuente and\nCecilia Hernández González",downloadPdfUrl:"/chapter/pdf-download/55336",previewPdfUrl:"/chapter/pdf-preview/55336",authors:[{id:"190837",title:"Dr.",name:"Isabel",surname:"Hernandez-Otero",slug:"isabel-hernandez-otero",fullName:"Isabel Hernandez-Otero"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"543",title:"Amyotrophic Lateral Sclerosis",subtitle:null,isOpenForSubmission:!1,hash:"1a986185a49802e1e3beaf6cdc6dde8d",slug:"amyotrophic-lateral-sclerosis",bookSignature:"Martin H. 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\r\n\tIn recent years, there has been considerable interest in rheology because of its multifunctional applicability in totally diverse fields that range from food and cosmetics to enhanced oil recovery from deep seas. Advanced electronics and signal processing has made it possible to detect very small changes in the microstructure systems subject to stress and strain and at different temperatures. Combining rheological findings with simultaneous microscopic imaging provides deep insights into the molecular interactions between various components in the mixture. Such information is of crucial importance while designing a product, may it be an engine lubricant or yogurt.
\r\n\r\n\tThis book attempts to provide to its readers, both the expert and the beginner, whether from academia or industry, a comprehensive and compact overview of rheology and its applications across different disciplines like foods and pharmaceuticals, lubricants, and paints. It is for this purpose that we will cover the fundamental aspects of rheology before going to advanced topics and applications in subsequent chapters, and we will specifically avoid mathematical derivations so that readers from non-mathematical backgrounds may seamlessly follow through the content.
",isbn:null,printIsbn:null,pdfIsbn:null,doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,hash:"095d5991269fb83f32687922efdc9fa9",bookSignature:"Dr. Ashim Kumar Dutta",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11829.jpg",keywords:"Viscosity, Stress-Strain Relationship, Polymer Melts, Polyelectrolytes, Emulsions, Pickering Emulsions, Gels, Sensorial-Rheology Correlation, Mouth Feel –Rheology Correlation, Edible Polymers and Surfactants, Enhanced Oil Recovery, Lubricants",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 6th 2022",dateEndSecondStepPublish:"June 3rd 2022",dateEndThirdStepPublish:"August 2nd 2022",dateEndFourthStepPublish:"October 21st 2022",dateEndFifthStepPublish:"December 20th 2022",remainingDaysToSecondStep:"10 days",secondStepPassed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"Dr. Dutta presently works as the vice president (R&D) of India Glycols Limited, one of the largest surfactant manufacturers in South East Asia. Earlier, he had worked with Unilever as a senior researcher and product development manager and with United Phosphorus Limited and Indofil as their R&D global head of formulations. He has authored/co-authored 36 articles in international journals and is the holder of 21 patents.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"277477",title:"Dr.",name:"Ashim",middleName:"Kumar",surname:"Dutta",slug:"ashim-dutta",fullName:"Ashim Dutta",profilePictureURL:"https://mts.intechopen.com/storage/users/277477/images/system/277477.jpg",biography:"Dr. Ashim Kumar Dutta presently works as the vice president (R&D) with India Glycols Limited, one of the largest manufacturers of Green Surfactants in South East Asia. Earlier, he had worked with Unilever as a senior researcher and product development manager in their Home and Personal Care Category, with United Phosphorus Limited and Indofil as their global head for agrochemical formulations. He has authored/co-authored 36 articles in international journals and 19 patents. He received his Ph.D in physical chemistry from Indian Association for the Cultivation of Science (IACS) – a premiere research institute in India in 1993. Dr. Dutta has worked on various international post-doctoral fellowships in Japan, Canada and USA. His research interests include supramolecular assemblies, ultrathin nanostructured films, nanoparticles, novel surfactants, surfactant-polymer interactions, bio-membranes and spectroscopy of Langmuir-Blodgett films, tribology and rheology of complex systems.",institutionString:"India Glycols Limited",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"1",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"14",title:"Materials Science",slug:"materials-science"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"347258",firstName:"Marica",lastName:"Novakovic",middleName:null,title:"Ms.",imageUrl:"//cdnintech.com/web/frontend/www/assets/author.svg",email:"marica@intechopen.com",biography:null}},relatedBooks:[{type:"book",id:"6320",title:"Advances in Glass Science and Technology",subtitle:null,isOpenForSubmission:!1,hash:"6d0a32a0cf9806bccd04101a8b6e1b95",slug:"advances-in-glass-science-and-technology",bookSignature:"Vincenzo M. 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In adults, the primary pathology is isolated coronary atherosclerotic disease, which is exceedingly rare in pediatrics, and valvular disease. The indications, techniques, and interventions performed in pediatrics are different. There are a wide range of therapeutic procedures performed in the pediatric cardiac catheterization lab including device closure of septal defects, balloon angioplasty of stenotic lesions and valvuloplasty of stenotic valves, stenting for vascular stenosis, embolization and device closure of vessels, and even percutaneous pulmonary valve implantation. A complete assessment of the patient is important as well as evaluating and determining the best sedation, vascular access, and potential interventions.
\nAt its most basic, cardiac catheterization is the evaluation and manipulation of the heart and related vessels by catheters placed through peripheral vessels. Most commonly, access is now obtained by the femoral artery and vein using a modified Seldinger technique, which involves placing a sheath and catheter over a wire. Alternative sites include the carotid and jugular, axillary, radial, subclavian, transhepatic, and even umbilical vessels in neonates. Anytime a catheter, wire, or sheath sits in a blood vessel, primarily an artery, there is a risk of occlusion, thromboembolism, and stroke. To prevent this, heparin is routinely administered throughout a catheterization case. Knowledge of basic technique and case-specific complications will help the practitioner in the management of these patients.
\nTraditionally, cardiac catheterization was the primary tool in the diagnosis and evaluation of congenital heart disease. Before the emergence of echocardiograms, clinical suspicion of congenital heart disease required a cardiac catheterization for definitive diagnosis, possible intervention, and pre-surgical planning. Cardiac catheterization can provide information such as angiographic images by fluoroscopic imaging during contrast injection, pressure measurements, oxygen blood saturations, and estimations of cardiac output and pulmonary vascular resistance. Pressure measurements are taken by way of a fluid-filled pressure transducer attached to a catheter with end-holes that are passed through various vessels and structures in the heart (Figure 1). The transducer produces cardiac pressure waveforms that are interpreted by the interventionalist (Figure 2). This is especially important in the evaluation of stenosis, diastolic dysfunction, and pulmonary vascular resistance.
\nVarious cardiac catheters. (A) A thermodilution catheter used to calculate cardiac output. (B) A Berman catheter with an inflatable balloon and side holes is a multiuse catheter. (C) A pigtail multiuse catheter. The multiple side holes allow for angiography of arterial vessels.
Normal intracardiac pressure tracings in a 10 year old patient. (A) A simultaneous pressure tracing of the right ventricle (red) and the femoral artery (green). (B) Pressure tracing of the left ventricle.
In each chamber of the heart, blood can be aspirated through a catheter and a blood oxygen saturation measured. These data can then be used to estimate a patient’s cardiac output and ratio of pulmonary blood flow to systemic blood flow (Qp:Qs). In 1870, Adolph Fick described a method for calculating blood flow which was refined and is now known as the Fick Method [1]. Basically, he explained that the release of a substance (in this case, oxygen consumption) in an organ is the product of blood flow across that organ and the concentration difference of a substance (oxygen content difference) proximal and distal to the organ. In other words:
\nOxygen consumption is often estimated based on normal values in older children and adults. Oxygen content difference is primarily the product of the change in hemoglobin saturation and the oxygen carrying capacity of hemoglobin (1.36).
\nUsing this principle, one can estimate the blood flow through any organ by knowing the oxygen blood saturations proximal and distal to the organ and the hemoglobin concentration of blood. In this way, sampling blood in the systemic veins proximal to the heart and blood in the aorta, distal to the heart, can estimate cardiac output. Similarly, sampling blood in the pulmonary arteries and pulmonary veins can estimate pulmonary blood flow.
\nResistance calculations are then based on Ohm’s law of electromagnetism. Georg Ohm was a German born scientist who in 1827 described that the electric current through a conductor is directly proportional to the potential voltage difference divided by the resistance. Modified for body fluid dynamics and a quick variation, it simply states that:
\nOhm’s law is used to calculate the pulmonary vascular resistance (PVR). The change in pressure across the lungs is estimated by the difference between the left atrial pressure and pulmonary artery pressure in a normal heart. The pulmonary blood flow is estimated by the Fick principle. PVR is an important measure in the diagnosis and management of pulmonary hypertension and pre-surgical planning.
\nThe majority of pediatric cardiac catheterization interventions include balloons, stents, and various devices. The equipment and tools of an interventional cardiologist varies based on experience level and new technological innovations. Attached to a specialized balloon catheter, an inflatable and deflectable balloon is essential in the treatment of stenosis and the deployment of stents. There are a variety of different types of balloons that range in size, shape, and compliance. These specialized balloon catheters have end holes to inflate balloons with contrast solution so they are easily visible on fluoroscopy. Using a specialized device known as a gauge, the balloons are inflated, deflated, and removed from the patient. This is useful in the treatment of vessel stenosis and valve dilation. Balloon interventions carry lesion specific risks described in the subsequent sections of this chapter.
\nThe first intravascular stent use in children was first described in the late 1980s. Indications include those stenotic lesions that are unresponsive to balloon dilation or recur frequently. Additionally, covered stents are using in treating significant tears or aneurysms. Each stent has its own set of characteristics including their size, strength, and “shortening” ability (Figure 3). Stents are metal or plastic mesh tubes that are loaded over balloon catheters and expandable inside a vessel. Covered stents have a surgical fabric-coating that creates a contained tube that is expandable similar to bare stents. Finally, there are a number of devices used to embolize or close vessels and treat septal defects that are described in the following respective sections.
\nA and B are two different kinds of bare metal stents used in pediatrics. Notice the interconnected mesh wiring and “tube” like shape.
The ductus arteriosus is an embryological vessel that connects the systemic and pulmonary circulation and serves to bypass the neonatal lungs. The vessel connects the pulmonary artery to the aortic arch. The patent ductus arteriosus (PDA) is a persistence of the ductus arteriosus after birth. The PDA is useful in cyanotic congenital heart diseases and is kept open until surgical palliation in many cases. This is described further in the chapter on cyanotic congenital heart disease. In the absence of a cyanotic heart lesion, the isolated PDA allows for a portion of oxygenated blood from the left side of the heart to flow back towards the lungs. Isolated PDA accounts for 10% of all congenital heart disease and is unlikely to close naturally in term infants [2]. Long term complications can include congestive heart failure, infective endocarditis, and pulmonary hypertension.
\nThe first closure of the PDA was done by Gross and Hubbard in 1939. The first transcatheter closure of the PDA was performed by Portsmann et al. in 1967 and since then, there have been many developments in the closure of the PDA. Until recently, transcatheter closure of the PDA was not performed in infants less than 5–10 kg, but is now performed in infants as small as 600 g in some centers. Further innovation and experience in this procedure will result in a non-invasive, effective alternative to surgical PDA ligation in nearly all patients.
\nIn older patients, the indications for closure of the PDA are well defined. Patients who have signs of left ventricular overload due to the left to right shunting of the PDA should be evaluated for cardiac catheterization closure. A long-standing PDA can lead to congestive left sided heart failure and Eisenmenger’s syndrome similar to a ventricular septal defect. The indications for closure in neonates is more controversial. There is currently inadequate data for or against the closure of the PDA in young infants [3], but a general consensus is that transcatheter closure of the PDA in symptomatic infants at 2–3 weeks of age is both safe and effective. Alternatives include surgical ligation and medical closure with a non-steroidal anti-inflammatory drug such as indomethacin or acetaminophen. However, pharmacological treatment of the PDA is effective primarily in premature infants, and has an effective closure rate of around 68% [4].
\nAlthough the procedure is sometimes performed under only echocardiographic guidance and occasionally in the neonatal intensive care unit, we recommend fluoroscopy guidance in the cardiac catheterization lab. Traditionally, both femoral venous and arterial access is obtained. Arterial access is used as a guide for the distal end of the ductus. Recent technique innovation requires only femoral venous access and placement of an esophageal temperature probe. The probe acts as a landmark for the distal end of the ductus. The ductus is engaged by traversing a catheter through the pulmonary artery, ductus, and into the descending aorta.
\nFirst, an angiogram is performed to obtain measurements and describe the morphology of the PDA. A PDA with a pulmonary end diameter of less than 2.5 mm can occasionally be closed by coil embolization. These are spring wire coils enmeshed with polyester fibers and delivered through a catheter. The coil occludes the vessel by creating a wire and fabric framework that clots. In most PDAs, an occlusion device is used. A guidewire is used as an anchor and an occlusion device is loaded through a catheter into the PDA. There are various devices used for PDA closure including vascular plugs and two-disk duct occluders similar to atrial septal device occluders. The diameter of the device should be at least the measured diameter of the ductus. Ideally, the device is situated entirely in the ductus arteriosus with no protrusion in either the pulmonary artery or the aorta. Once the device is in position, echocardiography is used to verify no residual shunting, and no obstruction to either the descending aorta or the branch pulmonary arteries. Once this is verified, the device is deployed (Figures 4
Echocardiographic images of a PDA closure in a 4 week old premature infant who could not be extubated due to pulmonary edema. (A) Two-dimensional (2D) image of the aorta and the PDA as marked. (B) Color Doppler of the aorta and PDA showing opposite flow in each vessel. There is left to right shunting in the PDA. (C and D) After closure with a device, the PDA is no longer visualized by 2D or color Doppler.
Angiographic images of a PDA closure in a 4 year old patient who presented with left atrial and left ventricular dilation. (A) Contrast injection of the PDA through a pigtail catheter located in the aorta through a retrograde arterial course. (B) Contrast injection angiogram after closure of the duct with visualization of the PDA device. There is no visible stenosis of the aorta.
Angiograms of a PDA closure in an 800 g 28 week gestation infant who was unable to wean from ventilatory support. There was no arterial access in this patient. (A) An angiogram performed shows a large PDA similar in morphology to most premature infant ducts. (B) After closure with a microvascular plug device, there is no residual flow through the duct and the left pulmonary artery is unobstructed.
The major complications of the procedure acutely are obstruction of the aorta or branch pulmonary arteries and embolization of the device. The rate of embolization ranges from 1 to 3% and is nearly always retrievable by catheterization without surgical intervention. Loss of distal pulses and vascular injury has been shown to occur in around 20% of premature infants who had arterial access [5]. Infants also suffer an entity known as post ligation cardiac syndrome. Six to twelve hours after ligation, these patients suffer a transient low cardiac output state occasionally requiring additional inotropic support. Reported rates are as high as 50% [6].
\nAtrial septal defects (ASD) are holes between the right and left atrium of the heart. Their presence is noted in nearly half of all congenital defects and is important for preserved cardiac output and adequate mixing in a variety of critical congenital heart disease as described in the section on atrial septostomy [7]. Ostium secundum defects are the result of an embryological defect in the septum primum. They are the most common type of ASD with nearly 75% fitting their description. Other types of ASDs include sinus venosus, coronary sinus, or ostium primum defects. Isolated atrial septal defects are typically asymptomatic in infants as the shunting across them is insignificant in early life. Eventually, patients may become symptomatic with frequent respiratory infections, though most are diagnosed due to the presence of a persistent murmur heard by a primary care practitioner and subsequent echocardiogram. Right ventricular and atrial dilation may be present along with a classic fixed split S2 heart sound on auscultation [8].
\nThe first successful surgical closure of an ASD was performed in 1949. It was not until 1972 that the first transcatheter closure of ASDs were performed in animal studies [9]. The first human patient to undergo transcatheter device closure of an ASD was a 17 year old girl in 1975 using a Rashkind foam-covered, six-ribbed device [10]. Since that time, there have been numerous occlusion device revisions and innovations. Since the early 2000s, overall results from transcatheter atrial septal defect device closure have achieved results comparable if not exceeded those of surgical closure [11].
\nAs stated before, patients with atrial septal defects rarely have clinically relevant symptoms. Ostium secundum defects are the only type of ASD amenable to device closure. In general, atrial septal defects should be closed in patients with right cardiac chamber enlargement with or without symptoms, a paradoxical embolism, or exercise related cyanosis. Patients who have severe pulmonary arterial hypertension unresponsive to vasodilator therapy, intracardiac thrombus, or a contraindication to antiplatelet agents should not undergo transcatheter closure. Additionally, defects must measure 36 mm or less, have adequate rims, and be located a safe distance from adjacent structures. Those that do not meet these criteria should undergo evaluation for surgical closure.
\nAll patients should have standard catheterization precautions with general anesthesia, antibiotic prophylaxis, and anti-coagulation with heparin. In particular, patients undergoing this procedure should be started on aspirin before the procedure or be bridged with heparin. A transesophageal echocardiogram (TEE) is typically done simultaneously with the cardiac catheterization to ensure good positioning of the device and no residual defect or obstruction of other valves. Femoral venous percutaneous access is preferred. Arterial access is optional in these cases.
\nInitially, associated abnormalities including pulmonary venous abnormalities or associated atrial septal defects should be evaluated by TEE. Pressure and flow measurements are first obtained using a Berman or multiuse catheter. The defect is then crossed by a catheter and a wire is positioned in the left upper pulmonary vein through the defect to serve as an anchor. As the septal defects often stretch and are not symmetrical, balloon sizing is regularly performed. A balloon stretched and sized ASD is usually 30% larger than the measured TEE dimension prior to intervention. Balloon sizing also allows for temporary occlusion of the ASD to determine its hemodynamic effects on the heart and whether the patient will tolerate closure. Once this is done, a device is advanced through a sheath to the defect. Most popular devices consist of a two disk system [Gore Helex Septal Occluder (HSO) (W.L. Gore, Flagstaff, AZ) and Amplatzer septal occluder (ASO) (AGA Medical, Golden Valley, MN)]. The distal disk is deployed in the left atrium and pulled back until it is snug against the atrial septum. The proximal disk is then deployed and the device is released (Figures 7 and 8). Post procedure repeat chest films and echocardiograms over the next 24 hours are important to verify secure device positioning [12].
\nDevice closure of an ASD in a 10 y/o asymptomatic patient found to have moderate right atrial and right ventricular dilation. (A) The right atrium is moderately dilated due to a large ostium secundum atrial defect. (B) Color flow demonstrated all left to right shunt (blue color flow in the image). (C) Color Doppler after deployment of a two disk Amplatzer septal occluder shows no residual left to right shunting and complete closure of the ASD.
Fluoroscopic images of different deployed ASD closure devices. (A) Amplatzer septal occluder post deployment along with its delivery sheath. ASD closures are typically done under transesophageal echocardiographic guidance. (B) Cardioform septal occluder.
Reported severe complications in one study was as high as 7%, which is less than that of surgical closure [13]. During deployment of an occlusion device, components rotate and then return to their inherent shape. Device embolization is an unlikely complication but serious complication that occurs in the first 24–48 hours of the procedure. Erosion of a device into the adjacent anterosuperior wall or aorta is 0.1% in the US [14]. Incidence of device-associated thrombus is 1.2% and primarily occurs within the first month of the procedure. For this reason, patients are typically placed on a regimen of aspirin and clopidogrel for 3–6 months. Arrhythmias, primarily atrial fibrillation can occur with any manipulation and scarring of the atrium. The post-procedure incidence of atrial fibrillation is 6% [15]. Additionally, endocarditis prophylaxis is recommended for 6 months after device closure [12].
\nBalloon atrial septostomy, otherwise known as the Rashkind intervention, was described nearly 50 years ago as a life-saving emergent procedure required in particular congenital heart disease. Rashkind first described a transvenous approach for an atrial septostomy in patients with transposition of the great arteries in the early 1960s. The procedure itself involves either widening an existing restrictive atrial level communication (Figure 9), or perforating the septum to manufacture a communication. Although the procedure is emergent, it can be planned even before birth based on fetal echocardiography. The primary purpose of an atrial septostomy is to enhance atrial mixing, decompressing the left atrium in a left sided obstructive lesion, or augmenting cardiac output in a right sided obstructed lesion. Primary congenital heart diseases that may require a balloon atrial septostomy include single ventricle physiology such as hypoplastic left heart syndrome and tricuspid atresia, transposition of the great arteries without a ventricular septal defect, and total anomalous pulmonary venous return.
\nTransthoracic echocardiogram of a term newborn infant with D-transposition of the great vessels and a restrictive atrial septum. (A) 2D image of the restrictive atrial septal defect with bowing of the atrial septum. (B) There is nearly absent color Doppler signal across the defect representing scarce blood flow across the defect.
The procedure can be performed in either the intensive care unit or a cardiac catheterization laboratory, the latter being preferred. In some centers, the infants are delivered in the cardiac catheterization lab to avoid any desaturation and cerebral hypoxia from delay. Access may someones be possible through the neonatal umbilical vein. If there are venous duct tortuosities, access through a femoral venous approach is required. Transthoracic echocardiographic guidance is highly recommended. Newborns are too small for a transesophageal echocardiogram. The patient should be anticoagulated with heparin and receive antibiotic prophylaxis at birth.
\nThe procedure begins with advancing a balloon catheter into the right atrium and into the left atrium through the restrictive septum. In some cases, congenital heart disease such as hypoplastic left heart syndrome can have a thick atrial septum without any communication. In this case, a transseptal puncture needle or radiofrequency wire perforation may be required. Once the balloon is in the left atrium, it is inflated and, with a quick short movement, is passed back to the right atrium where it is deflated (Figure 10). This procedure is repeated several times and the presence of an atrial shunt is confirmed by echocardiography (Figure 11). In rare cases, a stent can be placed in the interatrial communication for a long-lasting result [16].
\nFluoroscopy of a balloon atrial septostomy in the same patient. (A) The balloon is inflated while positioned in the left atrium with the catheter through the restrictive atrial septal defect. (B) In a swift motion, the inflated balloon is pulled back to the right atrium to dilate the atrial septal defect. This process is repeated a number of times.
Post atrial septostomy echocardiogram of the same patient. (A) The atrial septal defect has now been dilated. (B) Color Doppler reveals unobstructed left to right shunting across the newly widened defect.
Balloon atrial septostomy is a life-saving emergent procedure with rare complications. Rupture of the balloon with embolization of the fragments can occur and require retrieval [17]. Traumatic complications including damage or rupture of the atrial appendage, mitral valve, or pulmonary veins can occur. Stroke has been reported, but recent studies have shown no increase odds of brain injury in patients who undergo a balloon atrial septostomy [18]. The most common complications include transient cardiac arrhythmias that require rapid treatment but generally resolve [16].
\nCoarctation of the aorta involves narrowing of various segments of the aorta. This often results in pathologic obstruction of systemic blood flow. Coarctation is the fourth most common congenital heart defect. It comprises of 7% of all congenital heart disease and affects ~0.04% of live births. Males are twice as likely to have coarctation compared to girls [19]. The more severe the narrowing, the more symptomatic a child will be, and the earlier the problem will be noticed. In some cases, coarctation is noted in infancy. In others, however, it may not be noted until school-age or adolescence. Symptoms may include diminished blood pressures in the lower extremities, diminished pulses in the lower extremities, and signs of left sided heart failure including poor feeding, poor weight gain, and cool extremities. In severe cases of coarctation of the aorta, babies may present with hypoxia [20].
\nInitially, transcatheter balloon angioplasty was introduced in the 1980s as an adjunctive treatment to recurrent coarctation of the aorta following surgical therapy. Both treatments had flaws including re-coarctation of the aorta, residual hypertension, dissection of the aorta, and other aortic wall damage including aneurysm formation [21, 22]. To reduce complications and limitations, balloon-expandable stent therapy was introduced as a novel treatment for congenital heart diseases including coarctation of the aorta in the early 1990s [23]. Since that time, stent therapy has become widely accepted in children and adults for native and re-coarctation of the aorta [24].
\nThe primary indication for repair in an older patient is an upper to lower-extremity systolic gradient of greater than 20 mmHg and/or the presence of symptoms including claudication and headaches. Of note, accurate blood pressure measurements are of the utmost importance. Ideally, three consecutive measurements in each extremity is required. Additional criteria include a diameter to diameter ratio of less than 0.6 between the narrowest portion of the coarctation of the abdominal aorta [25]. Cardiac balloon angioplasty and stent placement is rarely performed in small infants presenting with coarctation as rapid growth of the infant results in function coarctation from small stents.
\nAll patients should have standard catheterization precautions with general anesthesia, antibiotic prophylaxis, and anti-coagulation with heparin. The procedure occurs with a retrograde transfemoral approach by accessing both the femoral artery and vein. Care is taken to access the artery as proximal as possible and to avoid access past the bifurcation of the femoral artery. This ensures access to a large diameter vessel as larger stents require larger sheaths that can increase the risk of vascular compromise of the respective limb.
\nAll patients undergo a complete right and left-heart catheterization as well as a detailed angiogram of the aorta using one of many various angiographic catheters such as a pigtail or multitrack catheter. Rotational angiography can provide additional imaging details of the aorta. Evaluating each branching vessel and its relationship to the coarctation segment is essential. Typically, a stiffer guidewire is positioned across the area of stenosis in preparation for stent placement.
\nExperience of the interventional cardiologist is of the utmost importance when choosing a stent. Typically, the diameter of the stent should not exceed the abdominal aorta diameter. Additionally, the ratio of the stent diameter to the narrowest coarctation segment should be less than 3.5 [26]. Once the stent is chosen, it is loaded over a balloon-in-balloon catheter. The inner balloon allows repositioning after partial deployment of the stent. Successful treatment is defined as a residual gradient less than 10 mmHg and post intervention vessel caliber of greater than 80% of the normal adjacent aortic segment (Figure 12). Per the revised 2015 Bethesda guidelines, patients who have intravascular stent placement should avoid contact sports for 3–6 months post procedure. Patients often require continued anti-hypertensive medications. They require antiplatelet therapy and endocarditis prophylaxis for up to 6 months post procedure [26].
\nThree-dimensional reconstruction of a rotational angiogram in an 8-year-old boy with severe coarctation of the aorta who underwent stent placement. (A) There is discrete stenosis at the aortic isthmus. A stent loaded balloon catheter can be seen across the narrow portion and into the ascending aorta. (B) Resolution of the angiographic coarctation with placement of a bare metal stent.
Outcomes are generally excellent in the acute and long-term setting. Persistent hypertension is noted in up to 23% of patients requiring continued anti-hypertensive medication. Aortic wall complications are rare but can be severe and lead to cardiovascular compromise. These include dissection and rupture. In a cohort of 565 procedures, there was a 1.6% rate of aortic wall pathology especially in patients who underwent pre-stent angioplasty, balloon angioplasty ratio > 3.5, and age greater than 40 years [27].
\nAortic aneurysm is a complication in 5–9%. Most are small and do not require procedural re-intervention, but those that are progressive or large can be treated with placement of a covered stent [27, 28]. Cerebrovascular accidents are exceedingly rare with a rate of less than 1% [29].
\nVarious studies have compared outcomes between surgical repair, balloon angioplasty, and stent placement as treatments for coarctation of the aorta. A study by Forbes et al. compared intravascular stent placement, balloon angioplasty, and surgical repair in a cohort of 350 patients and found that stent patients had fewer acute complications though at intermediation follow up there was no significant difference in persistent hypertension. There was a significantly higher ratio of the post intervention coarctation are to the adjacent descending aorta and a lower rate of aortic wall injury in the patients with intravascular stents compared to those with balloon angioplasty and surgical repair [25].
\nThe aortic valve is a semilunar valve that connects the left ventricle to the aorta in the normal heart. The major difference between the aortic valve and pulmonary valve is the typical absence of an infundibular septum. Aortic stenosis occurs with obstruction below the valve (subvalvar), at the valve (valvar), and above the valve into the left ventricular outflow tract (supravalvar). Aortic stenosis accounts for 3–8% of all congenital heart disease. Valvar stenosis is the most common comprising of 75% of aortic stenosis. Of note, this is typically associated with either a bicuspid valve where two of the 3 cusps are fused, or a unicuspid valve where all three cusps are fused. Aortic stenosis is also associated with various other congenital heart defects as well as genetic syndrome such as Williams syndrome. Symptoms of aortic stenosis are similar to those of any left ventricular outflow tract obstruction including chest pain or syncope with exercise and dyspnea on exertion. There may also be respiratory distress in infants caused by pulmonary edema, though this is typically absent in children and adults [30].
\nAs with most other valvular disease, diagnosis is primarily made by an echocardiogram which is ordered based on clinical suspicion. Echocardiogram can demonstrate the morphology of the valve and characterize the location and degree of obstruction using both continuous wave and pulse wave Doppler, and color Doppler. Untreated aortic stenosis carries with it a 4% risk of endocarditis and a 5% risk of sudden death.
\nAortic stenosis with less than a transvalvar gradient of 50 mmHg is typically well tolerated. Aortic stenosis is a progressive disease with between 21 and 41% of these patients progressing to severe aortic stenosis defined as a gradient of greater than 50 mmHg. There is an associated 1% per patient-year risk of sudden death in these patients. Balloon aortic valvuloplasty is typically the first line treatment for patients with valvar aortic stenosis with a pressure gradient of greater than 50 mmHg and minimal aortic regurgitation. In patients with subvalvar and supravalvar stenosis, balloon angioplasty is typically not effective. Surgical repair by resection of the areas of stenosis is primarily the treatment for subvalvar and supravalvar stenosis.
\nMost patients should have standard catheterization precautions with general anesthesia, antibiotic prophylaxis, and anti-coagulation with heparin. In some cases outside of the neonatal period, the procedure can be performed under conscious sedation. The procedure occurs with a retrograde transfemoral approach by accessing both the femoral artery and vein. Care is taken to access the artery as proximal as possible and to avoid access past the bifurcation of the femoral artery.
\nThis ensures access to a large diameter vessel as larger sheaths that can increase the risk of vascular compromise of the respective limb.
\nAll patients undergo a complete right and left-heart catheterization as well as a detailed angiogram of the aorta and aortic valve. The most important measurement in a transvalvar gradient that can be obtained by a pullback measurement with a catheter, or simultaneous measurements in the aorta and left ventricle using either a trans-atrial-septal approach (in the presence of an ASD or PFO) or an additional arterial access point. The balloon size chosen should be 80–90% of the annulus size to reduce the risk of significant aortic regurgitation. Once the procedure is complete, the gradient is remeasured. Typically, a successful angioplasty results in reducing the gradient by half without a significant increase in aortic regurgitation (Figure 13).
\nAortic balloon valvuloplasty in a 14 year old patient with moderate aortic valve stenosis and dizziness. (A) There is moderate stenosis at the level of the aortic valve. A pigtail catheter rests in the left ventricle retrograde from the aorta. (B) During balloon angioplasty of the valve, a “waist” is seen at the area of stenosis. (C) Post valvuloplasty there is no evidence of residual stenosis or aortic regurgitation.
The most common complications with balloon aortic valvuloplasty are aortic regurgitation and injury to the peripherally accessed vessel. Significant aortic regurgitation occurs in approximately 10% of all aortic valve balloon dilations which is comparable to rates in surgical valvotomy. Oversizing of the aortic balloon to be greater than the size of the aortic valve annulus is a primary risk factor. In patients with balloon ratios greater than 1.0 (I.E. a balloon larger than the diameter of the aortic valve annulus), at least moderate aortic regurgitation is seen in 25% of patients. Vascular injury is less common with improvement in techniques and availability of monitoring equipment [31]. Re-intervention is common and is reportedly required in up to 50% of patients. Typically, each subsequent intervention carries a higher risk of complications. The incidence of moderate aortic regurgitation in repeat dilations is at least 25% [32].
\nThe pulmonary valve is a semilunar valve that connects the right ventricle to the pulmonary artery in a normal heart. Pulmonary stenosis is primarily a sequelae of congenital heart disease but can be acquired due to surgical or transcatheter interventions. Stenosis can occur at the level of pulmonary valve, above the pulmonary valve, or below the pulmonary valve. Valvular stenosis is the most common, accounting for up to 90% of cases [33]. It is often an isolated finding, but can be associated with congenital heart lesions, most notably tetralogy of Fallot. It is also associated with genetic conditions such as DiGeorge syndrome and 22q11 deletion, Williams syndrome, Alagille syndrome, congenital rubella, and Noonan’s syndrome. Noonan syndrome is particularly important as it results in dysplastic, thickened pulmonary valve leaflets that typically do not respond well to catheter-based balloon valvuloplasty. Patients with tetralogy of Fallot are more likely to have a component of sub-valvar and infundibular stenosis [34].
\nPatients with mild isolated pulmonary stenosis are typically asymptomatic and the stenosis rarely progresses rapidly. Symptoms are associated with the resulting decrease in cardiac output from stenosis. These include dyspnea on exertion, fatigue, and right ventricular hypertrophy, right ventricular diastolic and systolic dysfunction. Patients with severe pulmonary stenosis in the neonatal or early childhood can present with cyanosis in the setting of a intracardiac shunt such as an atrial septal defect.
\nDiagnoses by echocardiogram is the gold standard. Two-dimensional and three-dimensional echocardiography can evaluate the morphology of the stenosis and pulmonary valve, and evaluate the function and size of the right ventricle. Continuous and pulse wave Doppler can help determine pressure gradients and color Doppler can help quantify and resultant pulmonary regurgitation. In some cases, MRI can accurately assess the degree of regurgitation, flow across the valve, and measure right ventricular size [35].
\nThe three main treatment modalities for pulmonary valve stenosis are balloon pulmonary valvuloplasty, surgical valvotomy, and pulmonary valve replacement, either by surgery or cardiac catheterization. The first balloon valvuloplasty of the pulmonary valve was done in 1979 and is by far the procedure of choice. Valvuloplasty is generally safe and effective in greater than 90% of patients [36].
\nBalloon pulmonary valvuloplasty is indicated for asymptomatic patients with a domed valve morphology, a peak gradient by echocardiography of greater than 60 mmHg, and up to moderate pulmonary regurgitation. Symptomatic patients are treated with an echocardiographic gradient of greater than 50 mmHg and less than moderate pulmonary regurgitation. Immediate effects of balloon valvuloplasty include improved longitudinal right ventricular motion, reduced dyssynchrony in pediatric patients, reduction of tricuspid regurgitation, and improvement in the pulmonary valve gradient. Patients with supravalvar and subvalvar pulmonary stenosis may undergo balloon valvuloplasty but is often less effective, primarily in patients with Noonan syndrome.
\nAll patients should have standard catheterization precautions with general anesthesia, antibiotic prophylaxis, and anti-coagulation with heparin. Percutaneous femoral venous access is the preferred entry site for balloon pulmonary valvuloplasty. The procedure begins with pressure measurements of the right ventricular and pulmonary artery using a Berman or other multipurpose catheter. Pulmonary valve are can be calculated using the Gorlin formula. Simultaneous recording of the right ventricle and femoral artery pressure is done to assess severity of the obstruction. If the right ventricular systolic pressure is greater than 75% of the systemic systolic pressure, there is significant pulmonary valve obstruction. Angiography is an important tool in confirming the site of stenosis in addition to obtaining accurate measurements of the pulmonary valve annulus [37].
\nA guidewire is positioned in the distal left pulmonary or right pulmonary artery. In infants, the wire may be positioned in the descending aorta through the patent ductus arteriosus. The purpose of the wire is to guide the balloon catheter and increase its stability. A number of different balloon catheters are available and are often chosen based on availability and experience of the interventional cardiologist. The diameter of the balloon should be 1.2–1.4 times the size of the pulmonary valve annulus with a recommended ratio of 1.2–1.25 [38]. In cases of a dysplastic pulmonary valve, as is typically found in Noonan’s syndrome, a ratio of 1.4–1.5 may be used [39]. Successful balloon valvuloplasty is defined as a residual gradient of less than 30 mmHg. Patients with successful valvuloplasty may return to competitive sports 3–6 months post procedure (Figures 14 and 15).
\nColor Doppler transthoracic echocardiogram of a 2 year old patient with trisomy 21 and pulmonary stenosis who underwent balloon pulmonic valvuloplasty. (A) There is flow acceleration (blue and red color speckling) across the pulmonary valve indicating valvar stenosis. (B) Post balloon pulmonic valvuloplasty there is no flow acceleration or signs of obstruction.
Fluoroscopic images of the above patient during a balloon pulmonic valvuloplasty. (A) There is a thickened and stenotic pulmonary valve typical of patients with Noonan syndrome. (B) During balloon valvuloplasty a “waist” at the area of stenosis is seen.
Severe complications are rare occurring in 0.6% of cases and mortality in 0.2% [40]. A major complication is transient but severe right ventricular outflow tract obstruction (sometimes known as a “suicide right ventricle”) that can occur immediately after valvuloplasty. Long standing or severe pulmonary stenosis results in right ventricular hypertrophy. When the stenosis is resolved and the systolic right ventricular pressure drops, the hypertrophy results in acute narrowing of the outflow chamber and must be treated with fluid resuscitation and beta blockade [41].
\nThe most common long term side effect is pulmonary regurgitation and recurrent pulmonary stenosis [42]. One study found that 60% of patients followed for 10 years after pulmonary valvuloplasty had at least moderate pulmonary regurgitation. However, pulmonary regurgitation was well tolerated in the majority of patients. Only 5% had right ventricular dysfunction and 3% required intervention [43]. The lower the balloon:annulus ratio, the less risk of significant pulmonary regurgitation. The Long term impact of chronic pulmonary regurgitation from pulmonary valvuloplasty is not well studied. Surrogate data from pulmonary regurgitation secondary to surgical valvotomy or valvectomy suggests that right ventricular function begins to deteriorate after the first several decades [44].
\nRestenosis occurs in up to 25% of patients who undergo valvuloplasty defined as a peak gradient of >36 mmHg in 1–2 years post procedure. Around 15% of patients who have restenosis will require re-intervention with either surgery or repeat balloon pulmonary valvuloplasty. Risk factors for recurrent stenosis include a dysplastic valve, small annulus, high initial gradient, and a small balloon:annulus ratio defined as less than 1.2 [45].
\nForeign Direct Investments (hereinafter: FDI) has been largely found to positively affect economic growth in transition economies. Increases in FDI have been associated with productivity and export growth of local companies via knowledge spillovers and complementary effects on domestic investment. The impact of FDI on economic growth seems, however, conditional on the level of human capital and absorptive capacity of a host economy. Determinants of FDI in transition economies have been intensely researched highlighting the importance of traditional factors, institutions and policy choices in determining locational decisions of multinational corporations (MNCs). Although informal institutions and cultural factors have increasingly been characterised as important factors that off-set for the underdeveloped institutional capacity of transition economies, the impact of cultural ties on FDI remains fairly under researched. Informal economic structures and cultural similarities emanate trust and enable strong business ties across borders. How important are these factors in explaining differences in FDI flows among transition economies is the principal question investigated in this research.
Culture, in a broader sense, means a pattern of behaviour based on values and beliefs that develops over time in a particular society. While culture in a narrower sense represents the way of life of a social group, i.e. a society that includes language, tradition, knowledge, customs, laws, art and other tangible and intangible features of social life that are passed down through generations, cultural is of course subject to change. Culture includes a set of values and attitudes of a homogeneous group of people that are passed down from generation to generation, and these patterns of behaviour change rather slowly.
The importance of cultural factors has been increasingly emphasised in the FDI literature. In particular, the impact of cultural distance between home and host countries has found to be significant in number of studies investigating the role of culture in explaining FDI flows. However, few studies concentrated on the transition economies of Central and Eastern Europe. These countries are viewed as specific in terms of both scope of economic and institutional transformation, and specific (common) legacies of socialism. We contribute to recent literature on FDI in transition economies, by analysing the significance of broad set of institutional and cultural indicators ought to influence MNC decisions on where to invest. A special reference is given to the discussion on the relationship between formal and informal institutions, assumed to be predominantly depicted in cultural dimensions of a specific country. In addition, the relevance of specific Hofstede cultural dimension to foreign firms is brought to the fore. Having said this, the hypothesis tested imply ‘favourable cultural context’ that is, specific cultural characteristics that are assumed to be preferred by foreign firms. We posit somewhat universal aspects of culture related to Hofstede cultural dimensions that constitute favourable cultural environment to foreign firms. Furthermore, we make use of the gravity model and the panel data framework to examine the importance of relative differences between home and host country characteristics in explaining bilateral FDI stock. The gravity-panel empirical framework allows us to draw important and detailed conclusions with respect to the relative importance of formal institutions vs. cultural aspects to foreign firms. Our dataset includes 10 source countries (i.e. major trading partners) and 8 home countries (transition economies of Central Eastern and South East Europe for which the cultural indicators were available).
This paper is structured as follows. Next we elaborate on basic theoretical propositions underpinning the mechanism of institutional and cultural influence on FDI, with special reference to empirical work on the matter. In discussion theoretical and empirical issues, we present the conceptual framework for the empirical strategy used in this analysis discussing number of important issues including interplay between culture institutions and FDI, definitions and measurement issues, and research hypothesis. The third section relates to the empirical analysis where detailed description of the model, data and variables and methodology employed is provided and followed by the interpretation of the empirical results. The conclusion follows.
Institutional environment often encompasses political systems, policy making and policy enforcing institutional structures which determine economic structures at the national and sub-national levels. It includes institutional setting that provides formal rules of the game and sets forth the incentives to economic/societal agents as well as informal norms, set of beliefs, systems of values, customs considered also an important feature of the institutional environment of a given country. Different scholars perceive differently the relative importance of these various components, including the role played by formal and informal rules and conventions as well as the importance of and role played by organisations, encompassing both economic and social agents of various sorts.
They are competing theoretical perceptions and different values attached to institutions and organisations in the contemporary literature [1, 2, 3]. Generally, institutions are perceived as frames or rules of the game while organisations are defined as social agents constituting and carrying these rules [2]. Importantly, the relationship between institutions and organisations is not a straight forward one. There is a general consensus among scholars that institutions principally evolve in response to market- related imperfections, and as such, institutions are considered a mechanism to enhance efficiency associated with economic transactions. However, whether institutions evolve primarily in response to changes in values, perception and attitudes embodied in organisations (i.e. various social agents) including theirs’ perceived inefficiencies in functioning of the market, or whether institutional development can be viewed as principally exogenous process where norms dominantly govern actions of social agents is still a debated issue [1, 2, 3]. Relate to this is a question whether institutional development is constrained by organisations’ preferences and capacities? Arguably the answer to these questions depends on how we perceive institutions and how do we value the relative importance of institutions
The theoretical conceptualisation of institutions has mostly favoured the stream of literature which views institutions as frames or rules of the game which both guide and constrain actions of social agents i.e. organisations of various sorts including political and economic agents that make up societies. This stream of literature suggests the dichotomy between institutions and organisations. Accordingly institutions reveal formal and informal rules and conventions which set the structures within which, and upon which societal agents act [1, 2]. More precisely, the dichotomy in the words of [2] implies a clear conceptual distinction between institutions and organisations as follows; institutions define ‘the rules’ of the game and organisations are ‘the players’ by whom the game is played. Similarly, [4] suggests that institutions provide the set of rules defining frames within which organisations act. This is where the importance of cultural dimensions become crucial in understanding the institutional performance and in particular the differences in economic performance among countries amid similar institutional development and/or quality of institutions.
In this respect, ‘good’ institutions are only necessary but not sufficient condition to promote successful change within a society and/or to achieve desired societal goals. This view implies that although institutions evolve in response to market failures encompassing various forms of imperfections related to economics transactions and exchange they evolve in particular socio-historical context, and in accordance with prevailing preferences, norms and ethics of organisations that embody, interpret and influence the institutional conditions i.e. the specific (endogenous) rule setting [5]. These endogenous norms and values of a society have been embedded in what we call informal institutional structures of the economy. Put differently, formal institutions are embodied in culture, and culture matters for understanding the link between formal and informal institutional setting of individual countries [2, 6, 7]. The culture of a society determines informal behavioural patterns of economic agents, and by that the quality and the efficiency of formal institutions. This is to say that institutions, e.g. the relevance of formal rules, adherence to formal principles and legal provisions rests within organisation and agencies that is with people who implement those rules. This stream of literature, which identifies culture as important aspect of formal institutions, may help us disentangle the relationship between formal and informal institutions, and, in particular, may help us comprehend how societies with similar quality of formal institutions have divergent economic outcomes.
As pointed by [8], it is possible that societies with identical institutional setting perform differently assuming that societal agents are not ‘passive’ but influence and determine the outcomes of any particular institutional structure in relation to their competences and preferences as well as in relation to what is called informal institutions. The latter include rather endogenous institutional features or their evolution such as norms, social ethics, prevalence of (old) institutional legacies, initial institutional conditions, institutional and individual’s values and competences. This would imply that it does not suffice to develop ‘quality’ institutions in the form of extensive and desirable legislative and institutional infrastructures, or ‘optimal’ set of rules, but also necessary organisational capabilities that affect policy impacts and subsequent institutional change. Institutional development should be perceived as a long-term process of societal change, a one that certainly involves the development of ‘better’ or ‘improved’ conventions but importantly the process that rests on the commitment and competences of prevailing human and organisations kinds involved in those processes.1
Here it is important to emphasise that theoretic perspective of institutions matters for: (i) our understanding of the evolutionary dynamics of institutional development and change; ii) the importance of informal institutional structures and their link with formal institutions; as well as iii) the way we measure institutions in our empirical analysis. As pointed by [8]: “
The comparison of transition institutional reform, particularly the evidence revealing contrasting experiences and institutional performance across countries, however, led to doubts and seriously questioned the conventional wisdom of straightforward transplantation of practices of developed market economies [9, 10, 11]. Contrary to what has been expected, the years of transition saw institutional building and reform as exceptionally challenging and complex. The initial years of transition witnessed the remarkable differences in institutional progress among transition economies (EBRD, 2001). Empirical evidence point to the highly intrinsic and endogenous nature of institutional development including the varying institutional performance among transition economies [9, 10, 11, 12]. Transition economies were faced with the necessity to reform their economic and institutional structures on a large scale moving from centrally planned to free market economic system and resource allocation. The conventional economic wisdom implied that former centrally planned economies needed to develop institutions which underpin free market transactions and well functioning of the markets as quickly as possible. The importance of institutional environment conducive to rapid market development has been put high on the transition reform agenda. The initial institutional development in transition economy context reflected the establishment of institutions fundamental to free-market economies including setting proper incentives through policies of macroeconomic-stability, price liberalisation, denationalisation and privatisation, as well as through institutions underpinning effective financial sector reform and private sector growth. The prevailing conceptualisation of institutions at the time envisaged that institutions are somewhat easily transferable, exogenously created whereby institutions are built following best practices elsewhere [13]. However, over the course of transition, growing empirical evidence on the matter of institutional change in transition suggested that the important historical, political and social factors have played a role. The empirical studies pointed to the interrelatedness and interdependence between institutions and diverse political, cultural and economic contexts of a given country [8]. Among others, the initial institutional conditions and institution-related legacies, as well as cultural dimensions largely influenced the pace and character of institutional development in transition economies (see [11, 14]).
Despite these efforts, we do have a limited understanding of the processes and lack meaningful explanation on the diverging pattern of institutional development among countries including TEs. Analysing relationship between formal and informal institutions may help disentangle differences in institutional performance among transition economies. Such analysis is fairly constrained by number of difficulties including conceptualisation of the relationship, as well as data limitations and number of measurement issues related to informal institutions of the economy. We believe that indicators of cultural dimensions may help comprehend at least some aspect of this complex relationship. In view of this, we argue, that it is important to study institutions in an integrated framework, and point to the relevance of cultural factors.
In this paper, an attempt is made to illuminate the importance of formal institutions relative to the distinctive cultural features of a society in comprehending differences in FDI flows across transition economies. We use a narrow-definition of institutions and focus on institutions revealing principally formal rules specifically related to FDI such as the rule of law and corruption. Relying on previous empirical work, we emphasise the importance of corruption [15, 16, 17, 18], regulatory and governance indicators [19, 20, 21], as well as legal indicators in our empirical analysis. We identify institutional variables to be included in the model based on these results, and include three institutional variables (Corruption, Good governance and Rule of Law and Efficiency). Since we investigate the impact of institutional factors on FDI in transition economies, we do not use Political stability variable amid low variation in the data, and relatively similar Political stability index across CEE transition economies. In the light of the forgoing discussion, however, we acknowledge that by the way we measure institutional dimension in this analysis we possibly do not account for complex informal social structures (including social ethics and norms, preferences and capabilities of organisations) which may well influence the outcomes of institutional environment in a given country. This is why we include cultural indicators (Hofstende Cultural Dimensions) in the analysis in order to account for important aspects of both institutional and cultural behaviour of individual (host) countries that may influence FDI flows in transition economies.
While there is considerable number of studies analysing the impact of formal institutions on FDI, very little empirical research has been done on the importance of culture, and cultural factors in determining FDI. Furthermore, we study the impact of institutional and cultural factors on FDI in an integrated framework, where we assess the relative importance of formal institutions vs. cultural factors.
Informal institutions are often considered important determinant of FDI since they could compensate for the deficiencies associated with underperforming or poor quality formal institutions. Despite this, they are often overlooked in the FDI literature whereby the emphasis is given to the quality of formal institutions per se. The rationale behind is that while formal institutions ensure efficiency of foreign operations in a new environment, informal institutions mostly favour local economic agents. Local agents are assumed to have better access to political and local facilities and processes. Given this, reliance on informal institutions in ensuring efficient economic transactions is least favoured by MNCs. A study by [22, 23] have shown that institutional development in transition economies has had an impact on foreign investors’ strategic decisions, arguably their entry modes, whereby quality of formal institutions seems of greater importance for establishing wholly owned ventures. The study by [22] reveals evidence that quality of institutions does seem to impact type of ownership related to FDI, where poor institutional development is more likely to result in network- types of FDI (i.e. joint-ventures, contracts). This is why the FDI literature mostly emphasise the relevance of formal institutions as locational advantage as reliance on informal institutions tend to increase transaction costs of foreign investors relative to domestic agents. The cultural features seem to have been disregarded as important factors which influence the way in which markets develop and evolve.
Notwithstanding this, in this paper we argue that cultural dimension is important determinant of FDI, in the sense that culture ‘shape’ formal institutions (see for instance [24]). Cultural dimensions of a society depict ways in which ‘nations’ tend to understand the rules and norms of social behaviour. The role played by formal institution(s) within a society and their relative importance
Overall, we strongly believe that the essential question on the matter of culture-institutions-FDI nexus, is to what extent ‘formal institutions’ and the why we measure them, reflect society’s adherence to formal rules, as opposed to society’s ‘modus operandi’ e.g. collective actions, practices, behaviours that may contradict formal codes of conduct? Here it is worthwhile mentioning the theory of ‘institutional stickiness’ which firmly explains the relationship between culture and institutions [25]. The authors posit that formal institutions are stuck to what they call
Therefore, relying solely on formal institutions, and formal institutional indicators of one country, including various legal indicators that are of specific interest to FDI, when analysing the importance of formal institutions, may be associated with ambiguities and uncertain ‘policy’ implications. This is not to say that formal institutions are of less importance, but it is at least important to acknowledge that ‘good’ institutions are embodied in culture. These societal values, attitudes and norms evolve overtime and reinforce formal institutions [25, 26]. This means that overtime, cultural changes influence acceptance of formal institutions as values of a society in general, and society at large adheres to these formal ‘rules of the game’. Along the lines of these theoretical propositions, [6] investigates both direct and indirect effect of culture on FDI, and finds that culture impact FDI indirectly through its impact on formal institutions, as well as directly. The indirect impact of culture on FDI is mediated via formal institutions, which confines the hypothesis that culture ‘shape formal institutions’. Essentially, the impact of cultural factors is found to be more important than the impact of formal institutions. Similarly, a recent study by [27] finds significant and greater effect of cultural factors (embeddedness vs. autonomy; hierarchy vs. egalitarianism, mastery vs. harmony) than formal institutions in cross-country regressions. Both studies render support to the theoretical propositions underlying the importance of cultural factors in comprehending role played by formal institutions, as well as that distinctive features of national cultures influence FDI flows.
Culture seems to reveal hidden behavioural patterns that underpin societal prosperity, including society relation to and the perception of responsibility, ethics and trust. The idea that these norms affect companies’ efficiency and growth prospects cannot be dismissed. On the contrary, these factors should be perceived as important determinants of FDI that not only minimise transaction costs, but also enhance productivity potential of foreign affiliates, and/or simply create an environment conducive to business growth. Such an environment is perceived as friendly and or familiar market from MNC perspective. What kind of information MNC search for when deciding about new investment site is important? Do managers look at formal institutional indices, or have other sources of knowledge and information that reveal ‘true’ that is prevailing aspects of social relations, ethics and norms? Studying the impact of formal institutions on FDI, in an integrated framework in which we control for cultural factors, along with traditional FDI determinants, becomes of crucial importance.
In what follows we discuss in greater detail the relevance of culture in international business and briefly review past empirical research on the role of culture in attracting FDI.
According to the literature cultural dimension can influence foreign direct investments in two ways. First theoretical proposition suggest that more culturally diverse societies tend to be perceived as favourable cultural environment by MNC, while the second theoretical proposition implies that foreign investors prefer to invest in cultures similar to their own. These two distinct theoretical perspectives imply first that more culturally diverse societies positively impact foreign direct investments, and second that lower cultural distance between home and host countries positively affects FDI. As for the former, culturally diverse countries reflect on more open and welcoming societies that are viewed positively by foreign companies. As for the latter cultural difference between home and host countries is often associated with high transaction cost arising from uncertainty and lower FDI.
Alesina [28] argues that high level of ethnic, linguistic and religious diversity requires well functioning governments and as such is positively associated with FDI. Additionally, more culturally diverse society is more tolerable and less reluctant to foreigners, which is perceived positively by MNCs. A number of research investigate the impact of religious factors including religion diversity and pluralism [29, 30] religious similarity [31, 32] and religious groups [31, 33] on FDI and find that religion does influence FDI. Accordingly, religious pluralism is found to be positivelly associated with FDI and thus more important compared to religious similarity, while a study by [31] finds positive relationship between all monotheistic religious groups (Catholic, Protestant and Orthodox Christian) and FDI, but for Islam. According to the results of their study, significantly negative relationship is thus suggested between Buddhism and FDI. No doubt, the results of their study suggest that MNCs are not indifferent to culture, broadly represented by diverse religious groups, and that only certain religious groups are positively associated with FDI. However, the empirical evidence on the matter is scarce and far from uniform to draw any sensible conclusions.
In this paper we, however, argue that, while religious believes may influence attitudes toward free market, competition or foreign investors, it may be fairly misleading to associate specific attitudes and values to individual religious groups per se, based on our assumptions, generalisation and even pre-assumptions about religious constituencies of individual nations. This tendency to assign specific societal attributes to certain religious groups such as is the case of the La Porta et al. study [34], which prescribe and impose ‘low institutional quality, institutional inefficiency, political and economic instability, high level of corruption and tax invasion etc.’, to reside and prevail within the so called ‘hierarchical religious’ such as Catholicism, Orthodox Christianity and Islam is rather forged, deceptive and ambiguous.
Certainly, a genuine and reasonable approach to study religious aspects of cultural dimension and its relationship to FDI and/or economic growth need be based on attitudes toward certain economic concepts and principles, as well as on values assigned to those, including wealth and growth, competition-rivalry and struggle, market openness and foreign investors. In case, significant differences assigned to those concepts, could be associated with specific religious believes or related value-systems, then we could sensibly argue of the prevailing religiously rooted ‘cultural’ differences. This is to say, that we need to investigate the link between religious beliefs and values assigned to aforementioned economic concepts. How differently are these concepts perceived and valued by different religious groups need be the principal question investigated, and not something a priori assumed and assigned to specific religious groups. In line with this reasoning, for instance, Guiso, Sapienza and Zingales [33] conclude that Catholics and Protestants are more positively associated with attitudes favouring market-efficiency and economic growth, while Muslims are found to be negatively associated with competition. Last but not lease, if we consider far-reaching cultural differencies existing within supposedly homogenous religious groups across different nations, such as is the case of Islamic countries (Malasya vs. Tukey vs. Saudi Arabia vs. Iran), or cultural differences across supposedly Catholic states such as is the case of Ireland vs. Poland vs. (South) Italy, we clearly face the measurement problem that may bias the results. This could partly explain why number of studies including [34] failed to find significant impact of religious groups per se on either economic growth or FDI. The notable exception is the aforementioned study by Lucke and Eichler [31].
Overall, in this paper we argue that analysis of cultural influence on FDI, that measure cultural diversity via dichotomous variables depicting religious group(s) fails to sensibly reflect on the important cultural dimensions that are of relevance when studying the link between culture and FDI. This is to say, that it is fairly improper (invalidate) to a priori assign that certain religious groups are indifferent to economic growth or adversely oriented toward foreigners, unless we truly conceptualise and measure links between prevailing religious beliefs and some ‘relevant’ economic categories or attitudes. Most studies investigating the link between religious groups and FDI fall short of addressing this issue. We first need to conceptualise on, and empirically establish the link between certain believes and attitudes including individual aspirations for growth, attitudes toward risk and competition, attitudes toward other groups/individuals and specific religious groups, as suggested by Guiso et al. study [33], before we examine the relationship between supposedly distinct religious groups and FDI or economic growth.
The empirical evidence on the matter is far from consistent and far from its mature phase. In light of this discussion, we argue that although religion constitute important cultural dimension of a society, it may well be inappropriate and misleading to include religious group(s) as dummy variables in regression equations to estimate the effect of culture on FDI. In contrast, considering religious diversity or similarity across nations may reflect on cultural distance that could be associated with costs of transition to new business or cultural environment. Most empirical studies have, in fact, followed this line of reasoning where, cultural similarity is considered important,
Kogut and Singh [35], posit that foreign investors prefer investing in countries culturally similar to their own. Sharing similar attitudes and values implies better knowledge of the local market, customers and business practices. Greater cultural differences between the host country and the source country lead to higher costs of doing business in another culture, such as the cost of obtaining information or the cost of searching to discover the specifics of the local bureaucracy [31]. This theoretical proposition has dominated the research on culture and FDI. Most empirical studies analyse the impact of cultural distance per se on FDI, and hypothesise that cultural similarity between home and host countries positively affects FDI flows.
Accordingly, the principal question investigated by researcher refers to the effect of ‘cultural distance’ on FDI. Siegel and Licht [35] in their analysis using instrumental variables (social factionalization, dominant religion, 19th century war experience, previous communist rule) measure how cultural distance in terms of egalitarianism vs. hierarchy affects FDI flows. The analysis is based on a 2005 Schwartz study [36]. The results obtained explain that the egalitarian distance has a negative and statistically significant impact on FDI flows. Similarly, [35] conduct a comprehensive analysis on the impact of cultural distance on FDI. They rely on ‘egalitarianism vs. hierarchy’ dimension of culture developed by Schwarz [36] and argue that the greater the distance between culture of origin and destination country the greater the difficulty in interacting with stakeholders in the host country. The results of their study confirm the negative and significant impact of cultural distance on FDI. Moreover, [31] study suggest that foreign investors from developed countries are negatively affected by greater ‘cultural distance’ when investing in developing and transition economies. Lee, Shenkar, and Li [37] come to similar conclusions when it comes to the impact of cultural distance measured by Kogut and Singh index on inward FDI in South Korea.
Number of empirical studies uses cultural proximity as determinant of FDI, relaying on common language, common history (e.g. colonial legacy, socialist past), and common border as cultural proxies. Most studies find significant and positive impact of cultural proximity along geographical distance on FDI [32, 38]. Lopez-Duarte and Vidal-Suarez [39] analyse how language distance affects the choice between greenfield investments and acquisitions when investing in other countries. 383 foreign direct investments from Spain in 44 different countries in the period 1989–2003 were analysed. The authors find strong support for the role of language distance as the main factor causing transaction costs. The results suggest that investors avoid acquisitions as a way of investing in countries characterised by high language distance. Bandelj [40] analysed the cultural connections (presence of a national minority) between investors and recipients of investments (hosts). It measures how the presence of national minorities affects the movement of FDI between pairs of countries. Bilateral flows of 11 Central and Eastern European countries (recipients of investments) and 27 investor countries were analysed. The author came to the conclusion that cultural ties that have historically been formed due to the presence of national minorities of the host country in the investor country, and vice versa, positively and statistically significantly affect FDI flows between the two countries.
Although, the results of majority of studies on cultural distance and FDI support the hypothesis that greater cultural distance negatively affects FDI, and that cultural proximity plays important role in attracting FDI, studies by Voyer and Beamish [41], Grosse and Trevino [42] find that cultural distance does not exert significant negative impact on FDI, and that cultural distance does not seem to influence FDI flows. Tang [43] reports mixed results on the impact of all cultural distance variables (four Hofstede cultural indicators) on FDI and concludes that ‘cultural difference does not always imply cultural conflict’. In similar vein, Barkema, Bell, and Pennings [44] (following [45]) argue that the risks arising from cultural differences can be overcome because investors can learn over time how to deal with those differences. According to them, experienced investors, both from developed and developing countries, ultimately do not consider cultural differences a significant obstacle.
Analysing the impact of cultural distance on foreign direct investment has, however, proven to be quite complex resulting in inconclusive and even contradictory empirical evidence. Part of the reason can be attributed to the fact that authors use different measures of culture from which they construct cultural distance variable, rendering support to the need to understand the mechanism underpinning the influence of ‘cultural distance’ on FDI. Moreover, the problem of measurement of cultural distance variable has been investigated by van Hoorn and Maseland [46]. The authors analyse the implications of using ‘cultural distance’ variable, defined as a difference between home and host country scores of one or more cultural dimensions, on robustness of the empirical results obtained. They conclude that one cannot compare the impact of this ‘cultural distance variable’ on FDI for different countries of origin. Following the conclusions emanating from their study, Kapas and Czegledi [47] construct a ‘cultural distance’ variable taking into account the problem of ‘the mixed impact of cultural distance and the culture in the host country’ when constructing cultural distance variable. Essentially, the results of their study suggest that the impact of culture measured in levels on FDI is greater than the impact of ‘cultural distance’ variables. The results of their study along the van Hoorn and Maseland [46] study clearly suggest the possible bias effect of earlier studies analysing the impact of ‘cultural distance’ on FDI.
In light of this discussion and in view of the important insights arising from the previous empirical work, in this study we analyse the impact of culture on FDI in transition economies while highlighting the following:
The importance of cultural features of host economy that are independent of culture of the origin country, that is of specific values that could be attributed to individual national cultures as ‘core’ to comprehending the cultural influences on FDI
The importance of analysing the impact of institutional and cultural factors in an integrated empirical framework in which we take control of both institutional and cultural factors and examine their relative importance on FDI
In view of the possible biases associated with the ‘cultural distance variable’ constructed by subcontracting the origin form destination country cultural scores, we refrain from using ‘cultural distance’ variable in our empirical analysis. On the contrary, we postulate the importance of specific and intrinsic cultural features that reflect on deep cultural traits and different cultural models, developed by Hofstede [48, 49] to be important determinant of FDI. In what follows, we discuss the relevance of Hofstede cultural factors as determinants of FDI inflows. The impact of these factors has been fairly under-researched in transition economy context.
We postulated earlier that culture is important aspect of informal institutions. As such culture is associated with way formal institutions function, their quality and efficiency. Apart from this, local culture is associated with ‘social risk’ of investment and transition to a new market embedded in social relations. Risks associated with cross-border business go beyond economic analysis and economic risks. The social characteristics are important determinant of FDI in that they influence operational and the external environment of business, influencing business success factors in the long run. Social characteristics depicted in cultural dimensions of a society are considered important to the internationalisation process ([50] as companies do not perform their businesses in isolation from other firms and/or networks of firms [51] nor do they construct their internal capabilities in isolation. Local work ethics, values and attitudes affect business performance of foreign companies through social relations of the workforce. All economic activities are ‘submerged in social relations’ [52]. Social characteristics and relations are embedded in cultural dimensions of a society.
Research on culture attempted to define important elements and dimensions of national culture relating to both conscious and unconscious set of beliefs, values and norms that reflect general attitudes and preferences of a society. Hofstede study and the model of national culture presents a systematic and pioneering work on the matter, that had a major influence on understanding cultural differences among nations [52]. Hofstede introduced four cultural dimensions of a society, namely Power Distance (PDI); Masculinity (MAS); Individualism (IDV); and Uncertainty Avoidance (UAI). The fifth cultural dimension, Long term orientation (LTO) was later developed and added as additional variable by Hofstede and Bond (1988). Further research on cultural dimension and its measurement resulted in the development of the Globe cultural dimensions (Global Leadership and Organisational Behaviour Effectivness, Kogut and Singh’s Index of cultural distance [53] and Schwarz Value Survey [36]. The literature has critically assessed various aspects of these cultural indices, including the Hofstede work on culture and cultural dimensions [54, 55, 56]. Most of criticism is related to the problem of time invariant nature of cultural indices including Hofstende cultural dimensions, and lack of genuine (socio) anthropological aspect of culture. In this research we follow arguments presented in [57] on the rationale of using Hofstede cultural indicators encompassing discussion related to the i) the benefits of using separate indices rather than aggregate cultural distance indices developed by Korgut and Singh (see [57]); ii) the stability of cultural values over time and the empirical evidence pointing to no significant variation of Hofstede indices over time; iii) the benefits of using Hofstede cultural dimensions over other indices that have been originally developed using Hofstede cultural dimensions such as is the case of the Globe indices or Kogut and Singh’s Index. Thus, Hofstede [58] argues that the Globe index is deficient amid its complexity and, as such is less useful in empirical analysis, while Shenkar [59] points that we lose important information relying on aggregate cultural index i.e. Kogut and Singh’s Index. In what follows we present the five Hofstede cultural dimensions, brifly review the empirical literature using Hofstede indicators and present the hypothesis.
The first cultural dimension is Power Distance. This cultural dimension uncovers general perception of social inequality predominantly related to power concentration and social status [60].
This dimension represents the degree to which less powerful members of society within their institutions (family, school, etc.) expect and accept that power is unequally distributed. People are not equal by nature and inequality is present in every profession, but this fact is experienced in different ways. The distance of power actually shows how society faces inequalities. And the main issue that this index deals with is how society solves inequalities among people. People in societies that have a greater degree of power distance accept a hierarchical order in which everyone has their place and do not require further explanations. In these societies, independence is a feature of a small group of people, and others depend on them. On the other hand, in societies with a low degree of power distance, people try to equalise the distribution of power and look for explanations for the unequal distribution of power. There is interdependence between people, and subordinates perceive orders as ordinary people, and superiors are available to subordinates [61].
This cultural dimension uncovers general perception of social inequality predominantly related to power concentration and social status (Ferraro, 2002). Having said this, it’s worth emphasising that it indicates ‘the degree to which members of an organisation or society expect and agree that power should be unequally shared’ [62]. Applied to a firm level, it could be fairly assumed that the lower the index the higher the demand from workers within an organisation for more equally distribution of power (wealth) and higher the demand for ‘justification for’ and ‘rationale behind’ certain decisions or actions on a company level. All of these could lead to potential conflict between the workers and their superiors. Dispute and conflict(s) may arise from supposedly higher intolerance toward specific hierarchical structure of power, injustice or inequalities. Members of such society (workers within companies) prefer more horizontal organisational structure. On the other side, workers within societies with high power distance indices may be assumed to be: i) more submissive to ‘formal power structure’ and associated social distances; ii) to have lower levels of self-esteem associated with conflict-avoidance, (positive) affirmation and obedience. All of these lead to higher tolerance of: improper communication, improper job appraisal, overtime and unpaid work, and high tolerance of wage gaps that may be persistent within particular organisation. In light of this discussion it is firmly difficult to hypothesise what are the preferred cultural features by multinational companies seeking investments abroad. Whether a particular MNC prefer societies with high or lower Power distance depend on host of factors including company culture, organisational structure and motive of investment. As for the latter, we argue clearly that internationalisation of production activities through FDI seeking natural resource and/or cost-efficiency is concerned with, or values, work ethics that has a respect for ‘social hierarchical distance’. On this ground it seems plausible to argue that MNC seeking to access resources or to reduce production costs prefer societies with higher Power Distance. Given the specific context of our research the positive relationship between PDI and FDI could be assumed. However, from theoretical perspective, we do acknowledge that the sign of the relationship could go both ways.
H1:
Societies in which the degree of individualism is higher compared to collectivism value the efforts of the individual more than the collective and team results. Collectivism, on the other side represents a firmer social framework in which individuals can expect their extended family or some other group to care for them in exchange for unquestioning loyalty. Individualism, on the other hand, uncover preference that everyone is responsible only for themselves, the emphasis is on individualism and the ideal is leadership, belonging to an organisation is optional, the identity of the individual is based on his personal characteristics. Collectivism emphasises the organisation, the ideal is group membership, belonging to an organisation is a matter of morality, the identity of an individual is based on his belonging to the collective [52].
In view of this, in this research, we posit that more individualistic societies have positive attitudes toward competition and rivalry, with individuals being more determined and oriented toward self-interests, self-promotion and struggle for achievement. The individualistic society is thus characterised with proactive individuals, who strive to achieve their goals based on their individual efforts, and are less relying on social-framework. In view of this, we argue that individualist societies embody values and attitudes conducive to economic growth and efficiency, and are more likely to and/or that they willingly engage in ‘competitive (social) struggle’ that underpins productivity growth. Hence, the positive relationship between IDV and FDI is anticipated.
H2:
These dimensions do not describe a person’s gender but character in humans. Societies ruled by masculinity indicate that society has propensities for heroism, assertiveness, authority, success, and material rewards for success. Society as a whole is more competitive, money and material goods are important, successful and independent people are respected, and people are valued according to the material goods they own. The opposite of masculinity is femininity which signifies modesty and a propensity for agreement. Also, indulgence and consensus are considered women’s values, as well as caring for the weaker, and people in society are more focused on quality of life [52].
According to [63], apparently, more masculine societies uncover cultural models that value material goods and material rewards for success, as opposed to quality of life and merits associated with common good that present attitudes of more feminine societies. Having said this, it could be reasonably expected that more Masculine societies are characterised by individuals and leaders who are competitiveness driven and who manage business operations by objectives. Such leaders are less sensitive to social or employee issues, they are decisive and act in isolation. On the other hand, leaders and managers of organisations of more feminine societies prefer consensus over aggressiveness. In view of this, it could be reasonably assumed that more masculine societies are more competitive societies, assumed to be societal attributes that foster better economic performance in general framework of a capitalist society. Notwithstanding this, it could be argued, that masculine culture traits embodied in an individual managers are not always preferred by MNCs. In case MNC’s organisational culture rests on assertiveness and collective affirmation, and in case company values organisational capabilities as opposed to self-affirmation of individual employees, more feminine model of culture may be preferred. In light of this discussion, we assume that more masculine societies could be both positively and negatively related to FDI.
H3:
This dimension expresses the degree to which members of society feel fear or discomfort from an unfamiliar situation. This index is often misinterpreted as risk aversion. Risk avoidance is a characteristic of the individual, while uncertainty avoidance is a feature of society. The basic question this index deals with is: should we try to control the future or just let it happen? We have societies that are actively dealing with the future, i.e. they have inherent control, and societies where events are out of control (fatalism). Countries with high DACI exhibit “rigid” behaviours and are intolerant of unusual behaviours and ideas. Such nations prefer strict and precise rules of conduct in society, regulations and guidelines to minimise uncertainty. People in such societies feel more comfortable when there is a clear structure and when society is well organised. On the other hand, countries where the DACI is low reflect a more relaxed attitude in which practice is more important than rules. In such societies there is aversion to any rules and norms. But if aversion is “moderate,” then it’s mostly societies that are more creative and flexible. People in such societies use common sense when making decisions and rely less on prescribed rules [52].
Overall, it could be said that societies with high uncertainty avoidance are characterised with high emotional resistance to change and may feel anxious about the future [60]. It could be reasonable assumed then, that these societies are reluctant to working in unfamiliar (uncertain) environment linked to foreign companies, and may be resistant to changes in organisational structure, or any changes in business conduct. As for the former, they can present additional obstacles to foreign companies, and may thus result in “discrimination by the government, consumers, and suppliers” [64]. As for the latter feature, it is probably least preferred by international business, amid the dynamics of changes of microeconomic determinants of global industry competitiveness and the constantly changing international business environment. Bearing this in mind, we hypothesise that uncertainty avoidance exhibit a negative influence on FDI.
H4: UAI
A society from a long-term oriented environment cultivates virtues that are future-oriented - perseverance, thrift, while societies from a short-term oriented environment cultivate virtues that are related to the past and present - respect for tradition and fulfilment of social obligations. Societies that have a low LTO index generally prefer to maintain traditions and norms that have been respected in the past, while social changes are viewed with suspicion. On the other hand, societies with a high LTO have a somewhat more pragmatic approach: they encourage savings and innovation in education as a way to prepare society for the future [52]. As far as the latter characteristic is concerned it could be argued that MNCs prefer societies with long-term, rather than short-term orientation.
H:5 LTO
Holmes et al. and Mac-Dermott and Mornah conducted research on how collectivism and future orientation affect the movement of inward FDI [65, 66]. Data from the Global Leadership project and the effectiveness of organisational behaviour (House et al., 2002) were used. The analysis was conducted on 50 countries (21 from Europe, 15 from Asia, 9 from North, South and Central America, 3 from Africa, 2 from Australia) for a period of nine years. They came to the conclusion that the greater presence of collectivism in society negatively affects the attraction of FDI, and that societies that are future-oriented promote capital investment of domestic entities. Bezpaliukh (2016) using Hofstede’s dimensions in his paper analyzes how cultural factors, primarily concentration of power, avoidance of uncertainty, and language influence the attraction of DSI. The analysis covers post-Soviet bloc countries (Estonia, the Czech Republic, Poland, Slovakia and Hungary) and the results suggest that a higher degree of uncertainty avoidance, a lower concentration of power and a common language have a positive effect on FDI inflows.
Bhardwaj, Dietz, and Beamish analysed how cultural factors, more precisely the avoidance of uncertainty and trust, influence the choice of locations of foreign companies [67]. They concluded that foreign companies prefer to invest in countries that have a higher degree of uncertainty avoidance and a high level of trust. Steigner, Riedy, and Bauman examined the impact of Hofstede’s cultural dimensions on DSI flows. [68]. They came to the conclusion through OLS regression that countries with civil law and countries with customary law prefer to invest in different countries and sectors. Hofstede’s cultural dimensions are also analysed by Goraieb [69]. They conducted an MRQAP analysis on the example of 45 countries and came to the conclusion that firms avoid investing in countries that differ from theirs in terms of the presence of a high degree of uncertainty. Also, firms prefer to invest in countries that are similar to theirs in terms of power concentration. What these four studies have in common is that they all use Hofstede’s cultural factors.
We will also use Hofstede indices in this study. Most research focus on specific factors such as collectivism and future orientation or avoidance of uncertainty and trust [65, 67]. We contribute to the literature on foreign direct investment by testing the widest possible set of cultural dimensions that can influence the investment decisions of foreign companies in a particular country. Unlike previous research, we include 8 transition economies as host countries. The analysis includes also the four countries of Southeast Europe (Albania, Bulgaria, Croatia and Serbia) that have not been previously investigated. Using a bilateral econometric framweork on FDI stock gives us the opportunity to question in more detail the importance of cultural and institutional factors in explaining differencies in FDI.
In order to analyse the impact of institutional and cultural determinants on FDI, we pursue a panel data analysis. The empirical analysis covers four South East European countries (Albania, Bulgaria, Croatia and Serbia) and five Central and Eastern European countries (Estonia, the Czech Republic, Poland, Slovakia and Hungary) in the period from 2000 to 2018, containing information on FDI and host country characteristics. Each observation point in our dataset reveals FDI flows between home country “i” (ten major trading partners) and host country “j” in the period under observation. We develop a baseline specification of the following form:
Where
lnFDIijt denotes log FDI stock between home i and host countries j in period t;
lnGDPit denotes log of gross domestic product of home country i in the period t;
lnGDPjt denotes log of gross domestic product of home country i in the period t;
DISTijt denotes log distance between capital cities of host and home countries;
INFLjt denotes the inflation rate of the host country j in the period t;
TradeOjt denotes exports and imports share in GDP of the country
WAGEjt denotes relative unit labour cost of the host country j in the period t;
Country denotes country dummy variables used to control for time-invariant country specific effects;
Time denotes year dummy variables used to control for time specific effect; and.
εit —random error (structure eit determined by the Fixed Effect (FE) model).
We then investigate which particular features of institutional quality are important determinant of FDI flows in transition economy context while incorporating three individual institutional indicators in equations of the form:
where INSTjt represents institutional quality indicators developed by the World Bank including Government Effectiveness (GovEffjt), Control of Corruption (Corruptjt) and Rule of Law (R_Lawjt).
As noted earlier, the purpose of this empirical analysis is to examine whether cultural effects play an important role in explaining differences in bilateral foreign direct investment flows in the context of transition countries. With this in mind and in line with the previously reviewed empirical literature, we further expand the analysis and include cultural distance variables in our model. Using Hofstede’s cultural dimensions, we decide to utilise the gravity equation to analyse the impact of individualism (IDV), power distance (PDI), uncertainty avoidance (UAI), masculinity (MAS) and long-term orientation (LTO) on FDI. More specifically, we have:
In this research, we use FDI as our dependent variable which is the log of stock FDI between home and host countries in EUR. According to Christie (2003), looking at the stock level has the advantage of stripping out the business cycle and any other ‘time anomalies’. In addition, another reason for this choice is related to the functional form of the gravity equation because FDI inflows can be nil or even negative, which is something that the gravity equation cannot account for. The source of data for this variable is Database on FDI published by The Vienna Institute for International Economic Studies (WIIW).
According to North (1990), good institutions influence economic activities through various channels, such as reducing transaction and production costs. Moreover, quality institutions help reduce operating costs, which increases profitability. Foreign investors are reluctant to invest in a risky and unconvincing environment and prefer locations that offer the best economic and institutional environment. Lucas (1993) suggests that in transition economies, institutional factors play an important role in attracting foreign investment compared to purely economic factors.
In order to estimate the impact of institutional determinants on FDI, we employ three indices developed by Kaufmann, Kraay, and Mastruzzi including government effectiveness, rule of law and control of corruption [70]. Each governance index ranges from −2.5 to +2.5, with higher scores corresponding to better governance outcomes. Government effectiveness (GovEff) assesses the soundness of the host country’s policies and the efficiency of the administration that implements them. Rule of law (Rule) measures the confidence of agents in the rules of society, including the quality of contract enforcement, property rights and the effectiveness of the judiciary. Control of corruption (CCorr) measures corruption among public and private officials and the extent of bribery. The source of data for these variables is the World Bank. A detailed description of each institutional variable used in this analysis is given in Table 1.
Variable | Description |
---|---|
Government Effectiveness (GovEff) | “Government effectiveness captures perceptions of the quality of public services, the quality of the civil service and the degree of its independence from political pressures, the quality of policy formulation and implementation, and the credibility of the government’s commitment to such policies.” |
Rule of Law (RoL) | “Rule of law captures perceptions of the extent to which agents have confidence in and abide by the rules of society, and in particular the quality of contract enforcement, property rights, the police, and the courts, as well as the likelihood of crime and violence.” |
Control of Corruption (CCorr) | “Control of corruption captures perceptions of the extent to which public power is exercised for private gain, including both petty and grand forms of corruption, as well as “capture” of the state by elites and private interests.” |
Our variable of interest is the cultural variable. Our measure of cultural variable is based on the scores developed by Geert Hofstede, which reflect country averages of individuals’ attitude toward power, uncertainty, individualism etc. A detailed description of each cultural variable according to Hofstede (2018) used in this analysis is given in Table 2.
Variable | Description |
---|---|
Power Distance (PDI) | “This dimension expresses the degree to which the less powerful members of a society accept and expect that power is distributed unequally. The fundamental issue here is how a society handles inequalities among people. People in societies exhibiting a large degree of Power Distance accept a hierarchical order in which everybody has a place, and which needs no further justification. In societies with low Power Distance, people strive to equalise the distribution of power and demand justification for inequalities of power.” |
Individualism (IDV) | “The high side of this dimension, called Individualism, can be defined as a preference for a loosely-knit social framework in which individuals are expected to take care of only themselves and their immediate families. Its opposite, Collectivism, represents a preference for a tightly-knit framework in society in which individuals can expect their relatives or members of a particular ingroup to look after them in exchange for unquestioning loyalty. A society’s position on this dimension is reflected in whether people’s self-image is defined in terms of ‘I’ or ‘we’.” |
Masculinity (MAS) | “The Masculinity side of this dimension represents a preference in society for achievement, heroism, assertiveness, and material rewards for success. Society at large is more competitive. Its opposite, Femininity, stands for a preference for cooperation, modesty, caring for the weak and quality of life. Society at large is more consensus-oriented. In the business context Masculinity versus Femininity is sometimes also related to as ‘tough versus tender’ cultures.” |
Uncertainty Avoidance (UAI) | “The Uncertainty Avoidance dimension expresses the degree to which the members of a society feel uncomfortable with uncertainty and ambiguity. The fundamental issue here is how a society deals with the fact that the future can never be known: should we try to control the future or just let it happen? Countries exhibiting strong Uncertainty Avoidance maintain rigid codes of belief and behaviour, and are intolerant of unorthodox behaviour and ideas. Weak Uncertainty Avoidance societies maintain a more relaxed attitude in which practice counts more than principles.” |
Long Term Orientation (LTO) | “Every society has to maintain some links with its own past while dealing with the challenges of the present and the future. Societies prioritise these two existential goals differently. Societies who score low on this dimension, for example, prefer to maintain time-honoured traditions and norms while viewing societal change with suspicion. Those with a culture which scores high, on the other hand, take a more pragmatic approach: they encourage thrift and efforts in modern education as a way to prepare for the future. In the business context, this dimension is referred to as “(short-term) normative versus (long-term) pragmatic” (PRA). In the academic environment, the terminology Monumentalism versus Flexhumility is sometimes also used.” |
Indulgence (IND) | “Indulgence stands for a society that allows relatively free gratification of basic and natural human drives related to enjoying life and having fun. Restraint stands for a society that suppresses gratification of needs and regulates it by means of strict social norms.” |
In our sample, the scores for the cultural variables can take values between 0 and 100, with a higher value indicating that power distance, individualism, masculinity, uncertainty avoidance and long-term orientation are more firmly entrenched in a nation’s culture. The source of data for this variable is Hofstede [71].
Further, we incorporate a set of control variables. In our model we include information on gross domestic product of home and host country (GDPi and GDPj), distance (DIS), labour cost (LC) and inflation rate (INF), which proved to be significant in a number of previous empirical studies on FDI determinants.
As stipulated by the gravity model, both home and host countries’ market size are important determinants of FDI. The market size of the home country is a proxy for the economic power of the source country. The host country GDP serves as a proxy for the host country market size and thus the potential market for the investor’s products. We expect the coefficients of both GDP variables to be positive. The source of data for this variable is The Vienna Institute for International Economic Studies (WIIW).
Distance in this research pertains to geographic distance and serves as a proxy for all possible transportation and operating costs (see [72, 73]). The rationale behind including geographic distance to explain FDI is the greater cost of obtaining relevant information as well as the difficulties in managing affiliates in distant regions. The distance in this paper represents the geographical distance between the capital cities of home and host country in km. The source of data for this variable is CEPII database.
Furthermore, the prevailing factors for attracting FDI, besides market size and access to host market, certainly include the costs of the input factor. Previous empirical studies show that labour costs have a significant impact on FDI and play a crucial role in labour-intensive industries, as lower labour costs attract more investment. Studies suggest a double effect of labour costs. Numerous studies show that labour costs have a negative impact on foreign direct investment inflows, which is in line with the findings of Bevan and Estrin [74]. On the other hand, certain authors found that labour costs have a negative but statistically insignificant impact on FDI [75]. In our analysis unit labour cost is measured as average gross monthly wages. The source of data for this variable is UNECE.
We incorporate inflation rate as a control variable in our model. Inflation rate is often used as a proxy for macroeconomic stability in general. Political and macroeconomic stability along with transparency of legal regulations, such as land acquisition and repatriation of profits, can be important when making investment decisions [76]. The lack of macroeconomic stability creates a high degree of uncertainty for investment projects. Successful implementation of economic reforms in transition countries can be a good sign for potential investors to invest, given that stable macroeconomic performance implies lower investment risk. Thus, the lower the average inflation rate is in the host country, the more foreign investment will be attracted to the country [77]. We expect that foreign investment, ceteris paribus, will be attracted to countries with lower inflation rates. Source for this variable is IMF database.
Finally, we incorporate openness as a control variable in our model. Previous empirical results show that the openness of the economy is positively and statistically related to attracting foreign direct investment. Mphigalale states in its research that the openness of the economy contributes to attracting foreign direct investment in transition countries, but this must be complemented by appropriate macroeconomic policies [78]. The openness of the economy is the sum of exports and imports of goods and services measured by gross domestic product (Table 3). The source of data for this variable is the World Bank. Descriptive statistics for each variable are presented in Table 3 while the correlation matrix is in Appendix 1.
Variable | Obs | Mean | Std. Dev. | Min | Max |
---|---|---|---|---|---|
lnFDI | 1112 | 9.02 | 0.43 | 6.80 | 10.69 |
lnGDPhost | 1197 | 24.72 | 1.16 | 21.97 | 27.09 |
lnGDPhome | 1197 | 27.24 | 1.40 | 23.73 | 29.01 |
Distance | 1197 | 949.92 | 468.34 | 59.61 | 2126.43 |
Inflation | 1197 | 4.09 | 8.96 | −2 | 112 |
Trade oppeness | 1197 | 111.92 | 36.34 | 24.17 | 192.34 |
lnWage | 1064 | 6.55 | 0.63 | 4.24 | 7.33 |
IDV | 1216 | 49.75 | 17.61 | 25 | 80 |
PDI | 1216 | 68 | 19.49 | 40 | 104 |
UAI | 1216 | 77.12 | 13.93 | 51 | 93 |
MAS | 1216 | 59 | 25.72 | 30 | 110 |
LTO | 1216 | 25 | 6.76 | 15 | 33 |
GovEff | 1224 | 0.46 | 0.48 | −0.84 | 1.16 |
RoL | 1224 | 0.32 | 0.60 | −1.27 | 1.37 |
CCorr | 1224 | 0.17 | 0.51 | −1.17 | 1.30 |
Descriptive statistics.
In order to account for the panel structure of the data, we use bilateral fixed effects (FE) and random effects (RE) estimations. To choose between the FE and RE estimator, the Hausman (1978) test statistics are computed. The results of Hausman test showed that the model should be set as fixed effect model. This type of model is basically an Ordinary Least Squares (OLS) regression that includes a dummy variable for each country to account for country-specific effects (LSDV model). The OLS method is optimal if error processes have the same variance (homoscedasticity) and all of the error processes are independent of each other. According to Plümper et al. [79] panel data typically display contemporaneous correlation across units (i.e. large errors for country i at time t will often be associated with large errors for country j at time t), unit level heteroskedasity (i.e. variances of the error processes differ from country to country) and serial correlation (i.e. errors for each country show temporal dependence) making inference from standard errors produced by LSDV incorrect.
In order to test for possible serial correlation, we employ the Wooldridge (2002) test which indicates the presence of serial correlation in the panel data. In addition, the Breusch and Pagan test and Pasaran CD (cross-sectional dependence) test indicate a significant presence of heteroscedasticity and cross-sectional dependence/contemporaneous correlation. To avoid these problems, we follow Beck and Katz’s recommended procedure, using OLS with panel-corrected standard errors (PCSE), a method widely used in empirical research that assumes by default that the disturbances are heteroskedastic and contemporaneously correlated across panels [79, 80]. This estimation approache is the suitable method to test our hypotheses with the available data and provides efficient and robust outcomes, suitable for formulating accurate conclusions. We note that we do not make use the alternative the Generalised method of moments estimator due it is not feasible for our data set (see [81]).
Tables 4 and 5 report the results of the econometric analysis of the model specifications presented above. Specifically, the table reports OLS fixed effect panel data estimates with panel-corrected standard errors. We first estimate Eqs. (1) using three individual subdimensions of institutional development singly due to the problem of multicollinearity between the individual institutional variables.
Model 1 | Model 2 | Model 3 | |
---|---|---|---|
GDP home | 0.103*** (0.000) | 0.103*** (0.000) | 0.103*** (0.000) |
GDP host | 0.580*** (0.000) | 0.605*** (0.000) | −0.646*** (0.000) |
Distance | −0.000*** (0.000) | −0.000*** (0.000) | −0.000*** (0.000) |
Inflation | −0.001 (0.139) | −0.001 (0.140) | 0.001 (0.153) |
Trade openness | 0.001** (0.009) | 0.001** (0.005) | 0.001** (0.000) |
Wage | −0.607*** (0.000) | −0.601*** (0.000) | −0.583*** (0.000) |
Gov. Effectiveness | 0.050 (0.452) | ||
Control of Corruption | 0.007 (0.888) | ||
Rule of Law | −0.051 (0.369) |
Regression results: FDI and institutions (OLS with PCSE).
Statistical significance at the 10 percent level.
Statistical significance at the 5 percent level.
Statistical significance at the 1 per- cent level.
Notes: All the regressions include a constant, country and time dummies (not reported in the Table 4).
Model 4 | |
---|---|
GDP home | 0.109*** (0.000) |
GDP host | 0.281*** (0.000) |
Distance | −0.000*** (0.000) |
Inflation | −0.001** (0.038) |
Trade Openness | 0.000 (0.537) |
Wage | −0.293*** (0.000) |
Power distance (PDI) | 0.006*** (0.000) |
Individualism (IDV) | 0.012*** (0.000) |
Masculinity (MAS) | −0.008*** (0.000) |
Uncertainty avoidance (UAI) | −0.005*** (0.000) |
Long-term orientation (LTO) | 0.003*** (0.016) |
Regression results: FDI and culture (OLS with PCSE).
Statistical significance at the 10 percent level.
Statistical significance at the 5 percent level.
Statistical significance at the 1 per- cent level.
Notes: All the regressions include a constant, country and time dummies (not reported in the Table 5).
The “traditional” gravity variables in all specifications are proved to behave as expected. Both host and host countries’ economic size, proxied by GDP levels, are important determinants of FDI. The distance variable is also found to have significant implications for FDI flows which is in line with the gravity model hypothesis and previous empirical findings.
We find that labour costs adversely affect FDI flows. The coefficient on labour cost is negative and significant at 1% level. The coefficient of Trade openness is positive and significant at 5%, whereas the inflation rate is not suggested to influence FDI flows. This result may be explained by the observation that we are no longer in the early years of the transition process and all transition countries from the sample are characterised with relatively stable macroeconomic environment.
When it comes to institutions, the most important conclusion resulting from our analysis suggests that institutional variables do not exhibit significant influence on FDI flows in transition countries. The results obtained in this analysis are consistent with those obtained by Lucke and Eichler who study the impact of institutions and cultural factors in an integrated empirical framework [31]. Noteworthy is that institutional variables remain insignificant even when including lagged values, and the results are robust to different model specifications (i.e. manufacturing value added, productivity levels and differentials, population).
Regarding cultural determinants of bilateral FDI, Table 4 reports the results based on the Hofstede cultural frameworkandsummarizestheresults for thecoefficientson fivecultural indicatorsincludingindividualism (IDV), power distance (PDI), uncertainty avoidance (UAI), masculinity (MAS) and long-term orientation (LTO).
We find that higher levels of individualism, power distance and long-term orientation in the host countries have significant impact on the FDI. Meanwhile, thecoefficients on uncertainty avoidance andmasculinity are negative andsignificant as expected. Thus, theresults render support to the a priori postulated hypothesis.
Foreign Direct Investments has been largely found to positively affect economic growth in transition economies. Increases in FDI have been associated with productivity and export growth of local companies via knowledge spillovers and complementary effects on domestic investment. The impact of FDI on economic growth seems, however, conditional on the level of human capital and absorptive capacity of a host economy. Determinants of FDI in transition economies have been intensely researched highlighting the importance of traditional factors, institutions and policy choices in determining locational decisions of multinational corporations. Although informal institutions and cultural factors have increasingly been characterised as important factors that off-set for the underdeveloped institutional capacity of transition economies, the impact of cultural ties on FDI remains fairly under researched. Informal economic structures and cultural similarities emanate trust and enable strong business ties across borders. How important are these factors in explaining differences in FDI flows among transition economies is the principal question investigated in this research.
The cultural features seem to have been disregarded as important factors which influence the way in which markets develop and evolve. Homogenous cultures tend to understand the rules and norms of social behaviour in which firms operate and construct their capabilities. These tacit aspects of market, reflected in diverse cultural features of a society, shape and model the behaviour of local economic agents. As such, these are also likely to influence MNC’s decisions on where to invest. They seem to reveal hidden behavioural patterns that underpin societal prosperity, such as responsibility, ethics and trust. The idea that these norms affect companies’ efficiency and growth prospects cannot be dismissed. On the contrary, these factors should be perceived as important determinants of FDI that not only minimise transaction costs, but also enhance productivity potential of foreign affiliates, and/or simply create an environment conducive to business growth. Such an environment is perceived as friendly and or familiar market from MNC perspective.
We rely on gravity econometric framework and examine the impact of cultural factors on FDI using bilateral FDI flows between home (i.e. major trading partners) 8 transition economies, depicted as host countries, in the period 2000–2018. We study this relationship in an integrated framework considering principal gravity forces, traditional FDI determinants, policy and institutional factors.
In this research we provide strong and robust evidence that cultural factors, depicted in Hofmann cultural indices, influence MNCs’ locational decisions. Other things held constant, specific cultural features seem more important than formal institutions, which seems at odds with standard neoclassical propositions, and shed some new light on the way we understand international business transactions.
Having said this, here we do not intend to generalise our findings, since we examine the relative importance of cultural factors measured in levels, and assigned to certain cultural values, in attracting FDI in the specific context of transition economies. However, we do pay attention to the relative importance of formal institutions in explaining differences in bilateral FDI stock between selected transition economies considered as host economies in our analysis. The fact that institutional factors have not proven to exert significant influence on FDI in our analysis does not imply that formal institutions are not important or of lesser importance. We, however, believe that more work on the matter of interplay between culture and formal institutions in comprehending differences in inward FDI flows is needed. Future research should focus on disentangling the impact of institutions possibly conditional on some important, intrinsic cultural values. The nature of our dataset inhibits further investigation of the possible interplay, suggested by the Du et al. study [82].
| logFDI logGDP∼t logGDP∼e DISTANCE INFL TradeO logWag∼t GovEff R_Law Corrupt PDI
-------------+---------------------------------------------------------------------
logFDI | 1.0000
logGDPhost | 0.5809 1.0000
logGDPhome | 0.2727 0.0411 1.0000
DISTANCE | -0.1890 -0.3242 0.3486 1.0000
INFL | -0.1338 -0.2630 -0.0591 -0.0050 1.0000
TradeO | 0.0560 0.0196 0.0746 0.0290 -0.2563 1.0000
logWagehost | 0.2710 0.4907 0.1298 -0.1621 -0.4883 0.4015 1.0000
GovEff | 0.1631 0.2069 0.0350 0.0064 -0.3580 0.5840 0.5953 1.0000
R_Law | 0.2140 0.2824 0.0441 0.1055 -0.3268 0.5579 0.5404 0.9373 1.0000
Corrupt | 0.0770 0.0669 0.0362 0.2775 -0.2848 0.4105 0.4304 0.8394 0.8946 1.0000
PDI | -0.0495 0.0364 -0.0221 -0.3175 0.0878 -0.1498 -0.1013 -0.3901 -0.5724 -0.5897 1.0000
IDV | 0.2657 0.3912 0.0003 0.0082 -0.1425 0.5403 0.3158 0.6734 0.7871 0.6845 -0.5641
MAS | 0.2096 0.4224 -0.0236 -0.3800 -0.0569 0.4921 0.1989 0.2574 0.1797 0.0102 0.4222
UAI | 0.1929 0.3534 -0.0150 -0.0454 0.1184 -0.6783 -0.2291 -0.6100 -0.4481 -0.4224 -0.1482
IVR | 0.2433 0.4877 -0.0453 -0.6144 0.0221 -0.2467 0.2786 -0.0731 -0.1599 -0.2871 0.2971
| IDV MAS UAI IVR
-------------+-------------------------------
IDV | 1.0000
MAS | 0.4786 1.0000
UAI | -0.2121 -0.3567 1.0000
IVR | 0.0659 0.4164 0.3032 1.0000
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Tzallas, Markos G. Tsipouras, Dimitrios G. Tsalikakis, Evaggelos C. Karvounis, Loukas Astrakas, Spiros Konitsiotis and Margaret Tzaphlidou",authors:[{id:"5886",title:"Dr.",name:"Alexandros",middleName:"T.",surname:"Tzallas",slug:"alexandros-tzallas",fullName:"Alexandros Tzallas"},{id:"94709",title:"Dr.",name:"Markos",middleName:null,surname:"Tsipouras",slug:"markos-tsipouras",fullName:"Markos Tsipouras"},{id:"94710",title:"Dr.",name:"Dimitrios",middleName:null,surname:"Tsalikakis",slug:"dimitrios-tsalikakis",fullName:"Dimitrios Tsalikakis"},{id:"94712",title:"Dr.",name:"Loukas",middleName:null,surname:"Astrakas",slug:"loukas-astrakas",fullName:"Loukas Astrakas"},{id:"94714",title:"Dr.",name:"Spiros",middleName:null,surname:"Konitsiotis",slug:"spiros-konitsiotis",fullName:"Spiros Konitsiotis"},{id:"94873",title:"Prof.",name:"Margarita",middleName:null,surname:"Tzaphlidou",slug:"margarita-tzaphlidou",fullName:"Margarita Tzaphlidou"},{id:"128137",title:"Dr.",name:"Evaggelos",middleName:null,surname:"Karvounis",slug:"evaggelos-karvounis",fullName:"Evaggelos Karvounis"}]},{id:"26608",doi:"10.5772/28363",title:"Sex Differences in PTSD",slug:"sex-differences-in-ptsd",totalDownloads:5154,totalCrossrefCites:14,totalDimensionsCites:41,abstract:null,book:{id:"773",slug:"post-traumatic-stress-disorders-in-a-global-context",title:"Post Traumatic Stress Disorders in a Global Context",fullTitle:"Post Traumatic Stress Disorders in a Global Context"},signatures:"Dorte Christiansen and Ask Elklit",authors:[{id:"73642",title:"Prof.",name:"Ask",middleName:null,surname:"Elklit",slug:"ask-elklit",fullName:"Ask Elklit"},{id:"113525",title:"MSc.",name:"Dorte",middleName:null,surname:"M. Christiansen",slug:"dorte-m.-christiansen",fullName:"Dorte M. Christiansen"}]},{id:"51342",doi:"10.5772/63824",title:"Autoimmune Processes in Multiple Sclerosis: Production of Harmful Catalytic Antibodies Associated with Significant Changes in the Hematopoietic Stem Cell Differentiation and Proliferation",slug:"autoimmune-processes-in-multiple-sclerosis-production-of-harmful-catalytic-antibodies-associated-wit",totalDownloads:1344,totalCrossrefCites:6,totalDimensionsCites:32,abstract:"Multiple sclerosis (MS) is a chronic demyelinating disease of the central nervous system. MS pathogenesis is not clear. Destruction of myelin by inflammation caused by autoimmune reactions has been proposed. Interestingly, healthy humans usually do not develop abzymes (Abzs). It was shown that DNase and MBP-hydrolyzing Abzs are easily detectable at the beginning of autoimmune diseases (ADs) including MS, when concentrations of antibodies to autoantigens are not yet significantly increased and correspond to levels in healthy donors. In addition, the relative enzymatic activity of antibodies from cerebrospinal fluid (CSF) is ~50-fold higher than that from the sera of the same MS patients. Experimental autoimmune encephalomyelitis (EAE) in C57BL/6 mice, a model mimicking relevant aspects of human MS was used. During development of spontaneous and MOG35-55-induced EAE in C57BL/6 mice, a specific reorganization of the immune system of mice was observed. It leads to a condition which was associated with the generation of catalytically active IgGs-hydrolyzing DNA, myelin basic protein (MBP), and MOG. Production of Abzs was associated with increased proteinuria, leading changes in differentiation of mice bone marrow hematopoietic stem cells (HSCs) and an increase in proliferation of lymphocytes in bone marrow, spleen, and thymus as well as a significant suppression of cell apoptosis in these organs. Treatment of control non-autoimmune CBA mice with MOG led to the different differentiation and proliferation of HSCs comparing with EAE C57BL/6 mice. The treatment of EAE mice with cuprizone inducing demyelination lead to a significant decrease in the size of the brain corpus callosum, but do not significantly change the differentiation profile of HSCs differentiation when compared with untreated mice. It indicates that cuprizone treatment is associated with demyelination, but not autoimmune reactivity. The possible differences in immune system reorganizations during preclinical phases of the disease, acute and late EAE, leading to production of different autoantibodies and Abzs as well other changes are discussed.",book:{id:"5156",slug:"trending-topics-in-multiple-sclerosis",title:"Trending Topics in Multiple Sclerosis",fullTitle:"Trending Topics in Multiple Sclerosis"},signatures:"Georgy A. Nevinsky",authors:[{id:"47119",title:"Dr.",name:"Georgy",middleName:null,surname:"Nevinsky",slug:"georgy-nevinsky",fullName:"Georgy Nevinsky"}]},{id:"20033",doi:"10.5772/18507",title:"Parenting Stress in Mothers and Fathers of Children with Autism Spectrum Disorders",slug:"parenting-stress-in-mothers-and-fathers-of-children-with-autism-spectrum-disorders",totalDownloads:18739,totalCrossrefCites:16,totalDimensionsCites:30,abstract:null,book:{id:"463",slug:"a-comprehensive-book-on-autism-spectrum-disorders",title:"A Comprehensive Book on Autism Spectrum Disorders",fullTitle:"A Comprehensive Book on Autism Spectrum Disorders"},signatures:"Ewa Pisula",authors:[{id:"31714",title:"Prof.",name:"Ewa",middleName:null,surname:"Pisula",slug:"ewa-pisula",fullName:"Ewa Pisula"}]}],mostDownloadedChaptersLast30Days:[{id:"62216",title:"Subtypes of Psychotic-Like Experiences and Their Significance for Mental Health",slug:"subtypes-of-psychotic-like-experiences-and-their-significance-for-mental-health",totalDownloads:3157,totalCrossrefCites:2,totalDimensionsCites:4,abstract:"More recently, the interest in studying subclinical psychosis has increased, as it might provide critical information regarding mechanisms that are implicated in the exacerbation of subclinical symptoms and the maintenance of mental health. However, psychosis research has tended to focus on clinical outcomes and not to differentiate between subtypes of psychotic-like experiences (PLE) that might differ regarding their psychopathological significance. Importantly, this might have obscured a more accurate picture of the complex structure of psychosis and the significance of particular risk and protective factors. Notably, while studies point toward a continuity of psychotic experiences and accompanying factors across the general population, there is evidence indicating that some PLE in healthy individuals might also be associated with a weaker expression of other subclinical symptoms, increased well-being and even resilience to some degree. Importantly, such findings might have implications on strategies in psychosis prevention and therapy, early detection, as well as the construction of continuum models of psychosis. The present chapter aims at drawing together findings that necessitate a more differentiated view and assessment of PLE. It intends to provoke new questions that might offer starting points for future investigations, such as longitudinal studies investigating the interplay of subclinical symptoms.",book:{id:"7117",slug:"psychosis-biopsychosocial-and-relational-perspectives",title:"Psychosis",fullTitle:"Psychosis - Biopsychosocial and Relational Perspectives"},signatures:"Lui Unterrassner",authors:[{id:"245870",title:"Ph.D. Student",name:"Lui",middleName:null,surname:"Unterrassner",slug:"lui-unterrassner",fullName:"Lui Unterrassner"}]},{id:"18334",title:"Challenges and Opportunities in Diagnosis and Management of Generalized Anxiety Disorder in Primary Care",slug:"challenges-and-opportunities-in-diagnosis-and-management-of-generalized-anxiety-disorder-in-primary-",totalDownloads:3824,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"236",slug:"anxiety-and-related-disorders",title:"Anxiety and Related Disorders",fullTitle:"Anxiety and Related Disorders"},signatures:"Mehtap Kartal",authors:[{id:"33369",title:"Dr.",name:"Mehtap",middleName:null,surname:"Kartal",slug:"mehtap-kartal",fullName:"Mehtap Kartal"}]},{id:"67627",title:"Borderline Personality Disorder and Childhood Trauma: The Posited Mechanisms of Symptoms Expression",slug:"borderline-personality-disorder-and-childhood-trauma-the-posited-mechanisms-of-symptoms-expression",totalDownloads:1193,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Traumatic events are reported in a large percentage of the population, however, only in some individuals it will lead to a diagnosable trauma-related disorder. Borderline personality disorder (BPD) is deemed to be a form of acute reaction to childhood trauma. Therein experiences of childhood abuse and neglect take on an important etiological role, generating severely disorganized attachment relationships, which in turn affect the development of emotional regulation systems, and significantly inhibit the development of mentalization and metacognitive skills. Furthermore, the last decade has seen important contribution of neuroscientific research in shedding light on the neurobiological correlates of traumatic experiences. A wealth of scientific literature links the onset of BPD to the combination between genetic and environmental factors (G×E), in particular between biological vulnerabilities and the exposure to traumatic experiences during childhood. Although no research can predict with certainty which trauma will translate into symptoms, there are indications as to who is more at risk of developing a trauma-related disorder. Herein we describe the psychological and epigenetic mechanisms affected by childhood trauma and altered in BPD patients.",book:{id:"7834",slug:"psychological-trauma",title:"Psychological Trauma",fullTitle:"Psychological Trauma"},signatures:"Maria Uscinska, Nicolo’ Gagliano, Andrea Polla Mattiot and Silvio Bellino",authors:[{id:"285336",title:"Dr.",name:"Maria",middleName:null,surname:"Uscinska",slug:"maria-uscinska",fullName:"Maria Uscinska"},{id:"288179",title:"Dr.",name:"Andrea",middleName:null,surname:"Polla Mattiot",slug:"andrea-polla-mattiot",fullName:"Andrea Polla Mattiot"},{id:"302735",title:"Dr.",name:"Nicolo'",middleName:null,surname:"Gagliano",slug:"nicolo'-gagliano",fullName:"Nicolo' Gagliano"}]},{id:"69569",title:"Introductory Chapter: Psychological Trauma",slug:"introductory-chapter-psychological-trauma",totalDownloads:899,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"7834",slug:"psychological-trauma",title:"Psychological Trauma",fullTitle:"Psychological Trauma"},signatures:"Ana Starcevic",authors:[{id:"182584",title:"Dr.",name:"Ana",middleName:null,surname:"Starcevic",slug:"ana-starcevic",fullName:"Ana Starcevic"}]},{id:"71936",title:"Feeding and Eating Disorders",slug:"feeding-and-eating-disorders",totalDownloads:2116,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"Eating disorders, which are well known as a substantial mental health problem in society, have been reclassified as feeding and eating disorders in DSM-5 and also in the 11th revision of ICD. The new classification includes binge eating disorder and avoidant-restrictive food intake disorder (ARFID), in addition to anorexia and bulimia nervosa. They are considered serious disorders, with high morbidity and mortality risks, that affect the young community in particular. Current research shows increases in all genders and age groups. Various genetic and biologic factors, an insecure personality type, impulsive traits, dysfunctional emotion regulation, and society’s ideal of slimness have been found to play a role in the development of these disorders. A dual approach with focus on the symptom and the underlying problems is needed for all types of eating disorders throughout the psychotherapeutic interventions. Assessing comorbid psychiatric and medical symptoms is extremely important. Further research and new directions of treatment are needed with regard to the expanded classifications.",book:{id:"9489",slug:"neurological-and-mental-disorders",title:"Neurological and Mental Disorders",fullTitle:"Neurological and Mental Disorders"},signatures:"Bianca Suciu and Cătălina-Angela Crișan",authors:null}],onlineFirstChaptersFilter:{topicId:"187",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"80949",title:"The Cerebral Venous System: New Pathophysiological Theories and Diseases Related to Veins Occlusion",slug:"the-cerebral-venous-system-new-pathophysiological-theories-and-diseases-related-to-veins-occlusion",totalDownloads:44,totalDimensionsCites:0,doi:"10.5772/intechopen.102351",abstract:"Cerebral physiology and pathology are still frequently missing a comprehensive explanation and a complete description, but new data and hypothesis are emerging on a daily basis. Particularly, comprehension of the cerebral venous system’s functions and functioning has undergone through the last decades a deep and extended change. Depiction of the perivascular spaces and the mechanisms of glymphatic system has given light about venous system pivotal role in the genesis of different pathologies such as multiple sclerosis, hydrocephalus, cerebral hemorrhages, and strokes. After a key point discussion about embryology, physiology, and anatomy of the cerebral venous system, an overview is provided on the main pathologies, both well-known and newly described ones, in which cerebral veins act a major pathogenic role.",book:{id:"11371",title:"Cerebral Circulation - Updates on Models, Diagnostics and Treatments of Related Diseases",coverURL:"https://cdn.intechopen.com/books/images_new/11371.jpg"},signatures:"Giorgio Mantovani and Alba Scerrati"},{id:"80939",title:"Diagnosis and Treatment of Ophthalmology Related Cerebral Arterial Circulation Diseases: A 3D Animated Encyclopedia",slug:"diagnosis-and-treatment-of-ophthalmology-related-cerebral-arterial-circulation-diseases-a-3d-animate",totalDownloads:23,totalDimensionsCites:0,doi:"10.5772/intechopen.102846",abstract:"Cerebral circulation is the flow of blood through a group of arteries and veins which supply the brain. There are various diseases related to ophthalmology, due to pathologies in the cerebral arterial system. Arteries inside the skull can be blocked by plaque or disease, which in turn triggers a series of events leading to various cranial nerve palsies, visual fields defects, retinal diseases, etc. The highlights of this chapter are the novel three-dimensional (3D) animative videos created by us, to simplify various cerebral arterial circulation diseases and their diagnostic concepts for neophytes. 3D animative videos can aid learning and help in the cognitive concept building of these complex pathologies.",book:{id:"11371",title:"Cerebral Circulation - Updates on Models, Diagnostics and Treatments of Related Diseases",coverURL:"https://cdn.intechopen.com/books/images_new/11371.jpg"},signatures:"Prasanna Venkatesh Ramesh, Shruthy Vaishali Ramesh, Prajnya Ray, Aji Kunnath Devadas, Tensingh Joshua, Anugraha Balamurugan, Meena Kumari Ramesh and Ramesh Rajasekaran"},{id:"80456",title:"Cerebrospinal Venous Obstruction: Anatomy, Clinical Presentation, Diagnosis, and Treatment of Chronic Infective Cerebrospinal Venulitis",slug:"cerebrospinal-venous-obstruction-anatomy-clinical-presentation-diagnosis-and-treatment-of-chronic-in",totalDownloads:89,totalDimensionsCites:0,doi:"10.5772/intechopen.102685",abstract:"This review chapter describes the normal anatomy and function of the cerebrospinal venous system, ultrasound diagnosis of obstructions in the system, and the clinical implications and treatment of chronic cerebrospinal venous obstruction (CCSVO) associated with chronic persistent Chlamydophila pneumoniae (Cpn) infection. The normal patterns of flow in the cerebrospinal venous system are described and guidelines for the interpretation of the extracranial duplex ultrasound (ECDU) examination of the neck veins are presented. An infective cause of CCSVO is proposed and relevant pathology tests necessary for a diagnosis of chronic persistent Cpn venulitis are discussed. A treatment protocol for Cpn chronic venulitis is described and recommended. The progress of the patient with CCSVO can then be followed and monitored by using the ECDU and relevant pathology tests after 3 and 6 months. CCSVO is a relatively common condition encountered in chronic diseases of unknown etiology and is often neglected by medical practitioners when managing patients with symptoms of brain fog, chronic headaches, and fatigue. Objective diagnostic and treatment protocols are required to make further progress with these conditions.",book:{id:"11371",title:"Cerebral Circulation - Updates on Models, Diagnostics and Treatments of Related Diseases",coverURL:"https://cdn.intechopen.com/books/images_new/11371.jpg"},signatures:"Paul K. Thibault"},{id:"80543",title:"Measurement of Cerebral Circulation in Human",slug:"measurement-of-cerebral-circulation-in-human",totalDownloads:54,totalDimensionsCites:0,doi:"10.5772/intechopen.102383",abstract:"In this chapter, we review state-of-the-art non-invasive techniques to monitor and study cerebral circulation in humans. The measurement methods can be divided into two categories: direct and indirect methods. Direct methods are mostly based on using contrast agents delivered to blood circulation. Clinically used direct methods include single-photon emission computed tomography (SPECT), positron emission tomography (PET), magnetic resonance imaging (MRI) with contrast agents, xenon computed tomography (CT), and arterial spin labeling (ASL) MRI. Indirect techniques are based on measuring physiological parameters reflecting cerebral perfusion. The most commonly used indirect methods are near-infrared spectroscopy (NIRS), transcranial Doppler ultrasound (TCD), and phase-contrast MRI. In recent years, few more techniques have been intensively developed, such as diffuse correlation spectroscopy (DCS) and microwave-based techniques, which are still emerging as methods for cerebral circulation monitoring. In addition, methods combining different modalities are discussed and, as a summary, the presented techniques and their benefits for cerebral circulation will be compared.",book:{id:"11371",title:"Cerebral Circulation - Updates on Models, Diagnostics and Treatments of Related Diseases",coverURL:"https://cdn.intechopen.com/books/images_new/11371.jpg"},signatures:"Sadegh Moradi, Hany Ferdinando, Aleksandra Zienkiewicz, Mariella Särestöniemi and Teemu Myllylä"},{id:"80306",title:"Cerebral Arterial Circulation: 3D Augmented Reality Models and 3D Printed Puzzle Models",slug:"cerebral-arterial-circulation-3d-augmented-reality-models-and-3d-printed-puzzle-models",totalDownloads:81,totalDimensionsCites:0,doi:"10.5772/intechopen.102510",abstract:"The field of augmented reality (AR) and three-dimensional (3D) printing are rapidly growing with many new potential applications in medical education and pedagogy. 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