\\n\\n
IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\\n\\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\\n\\nLaunching 2021
\\n\\nArtificial Intelligence, ISSN 2633-1403
\\n\\nVeterinary Medicine and Science, ISSN 2632-0517
\\n\\nBiochemistry, ISSN 2632-0983
\\n\\nBiomedical Engineering, ISSN 2631-5343
\\n\\nInfectious Diseases, ISSN 2631-6188
\\n\\nPhysiology (Coming Soon)
\\n\\nDentistry (Coming Soon)
\\n\\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\\n\\nNote: Edited in October 2021
\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/132"}},components:[{type:"htmlEditorComponent",content:'With the desire to make book publishing more relevant for the digital age and offer innovative Open Access publishing options, we are thrilled to announce the launch of our new publishing format: IntechOpen Book Series.
\n\nDesigned to cover fast-moving research fields in rapidly expanding areas, our Book Series feature a Topic structure allowing us to present the most relevant sub-disciplines. Book Series are headed by Series Editors, and a team of Topic Editors supported by international Editorial Board members. Topics are always open for submissions, with an Annual Volume published each calendar year.
\n\nAfter a robust peer-review process, accepted works are published quickly, thanks to Online First, ensuring research is made available to the scientific community without delay.
\n\nOur innovative Book Series format brings you:
\n\nIntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\n\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\n\nLaunching 2021
\n\nArtificial Intelligence, ISSN 2633-1403
\n\nVeterinary Medicine and Science, ISSN 2632-0517
\n\nBiochemistry, ISSN 2632-0983
\n\nBiomedical Engineering, ISSN 2631-5343
\n\nInfectious Diseases, ISSN 2631-6188
\n\nPhysiology (Coming Soon)
\n\nDentistry (Coming Soon)
\n\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\n\nNote: Edited in October 2021
\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"3837",leadTitle:null,fullTitle:"Geochronology - Methods and Case Studies",title:"Geochronology",subtitle:"Methods and Case Studies",reviewType:"peer-reviewed",abstract:"Chronology is the backbone of history, and there is a wise saying stating there is no history without a chronology. 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Therefore, the book should be of basic interest both for scientists in their practical in field and laboratory, as well as for general educational purpose.",isbn:null,printIsbn:"978-953-51-1643-1",pdfIsbn:"978-953-51-5051-0",doi:"10.5772/57041",price:119,priceEur:129,priceUsd:155,slug:"geochronology-methods-and-case-studies",numberOfPages:206,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"2b1836bafece610b56c6334e338be74c",bookSignature:"Nils-Axel Morner",publishedDate:"July 25th 2014",coverURL:"https://cdn.intechopen.com/books/images_new/3837.jpg",numberOfDownloads:14331,numberOfWosCitations:36,numberOfCrossrefCitations:6,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:27,numberOfDimensionsCitationsByBook:0,hasAltmetrics:1,numberOfTotalCitations:69,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"June 15th 2013",dateEndSecondStepPublish:"July 8th 2013",dateEndThirdStepPublish:"December 16th 2013",dateEndFourthStepPublish:"January 8th 2014",dateEndFifthStepPublish:"April 1st 2014",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"15619",title:"Dr.",name:"Nils-Axel",middleName:null,surname:"Morner",slug:"nils-axel-morner",fullName:"Nils-Axel Morner",profilePictureURL:"https://mts.intechopen.com/storage/users/15619/images/1648_n.jpg",biography:"Nils-Axel Mörner took his PhD in Quaternary Geology at Stockholm University in 1969. 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This includes lesions such as melasma, sun-induced lentigo, café-au-lait macules, moles, and malignant melanoma. In the second category “congenital hypopigmented disorders”, diseases such as albinism, piebaldism, hypomelanosis of Ito, and tuberous sclerosis are placed. The third topic is “common and acquired disorders of hypopigmentation”, where diseases such as vitiligo, tinea versicolor, and tinea alba are discussed. The fourth topic is the “treatment of hyper- and hypopigmented disorders”. Types of treatment include sunscreens, hydroquinone, skin peels, retinoids, azelaic acid, laser and IPL therapy, skin surgery, and depigmentation therapy.
\r\n\tThe fifth topic is “complications and drug side effects in the treatment of pigmentation disorders”. These include drug allergies, hyper- and hypopigmentation, persistent skin depigmentation, scars, skin burns, and the potential for skin cancer and skin lymphoma. The last topic is called “coping and support along with skin pigmentation diseases”. Increase the quality of life, psychotherapy, team therapy, and asking for understanding and support from family members.
Anesthesia is one of the important components of gastrointestinal endoscopic (GIE) procedures. The aim of anesthesia for these procedures is to improve patient’s comfort and endoscopic practice as well as patient and endoscopist satisfaction. The requirement for anesthesia is dependent on the type and duration of endoscopy, experience of endoscopist, and patient’s physical status. The anesthetic regimens for GIE procedures are quite different. Several guidelines from American Society of Anesthesiologists (ASA) [1] and American Academy of Pediatrics [2] are established. Appropriate pre-anesthetic assessment, anesthetic drugs used, monitoring practices and post-anesthesia care for anesthesia in GIE procedures are essential.
All patients scheduled to receive anesthesia/sedation should have a history and appropriate physical examination. Several risk factors including history of obstructive sleep apnea, alcohol or drug abuse, and history of adverse reaction to previous anesthesia/sedation are investigated. The patient physical status should be classified according to the ASA. The pregnancy test is recommended in women of childbearing age [3]. Consequently, written consent should be obtained. An anesthesia consultation should be done in high-risk patients including patients with respiratory or hemodynamic instability, obstructive sleep apnea, and high-risk airway management, as well as patients with ASA physical status >III and history of anesthesia-related adverse events.
Cardiorespiratory-related adverse events are a leading cause of morbidity and mortality associated with GIE procedures. Continuous monitoring of anesthetized patients is very important for safety. The physicians need to monitor the patients’ status throughout the procedure. Clinical observations including pattern of respiration, skin or mucosa color, and level or depth of anesthesia are continuously observed.
Pulse oximetry is a noninvasive device for continuous measurement of arterial oxygen saturation. Because clinical observation alone is inaccurate in the detection of hypoxemia, pulse oximetry has become a standard of care during GIE procedures. Oxygen saturation levels under 90% must be treated. However, pulse oximetry and oxygen supplementation do not diminish the severity or incidence of cardiorespiratory complications. In addition, oxygen desaturation is relatively a late sign [4].
Moreover, pulse oximetry and clinical observation cannot detect the development of hypercapnea. Capnography has been utilized to permit the safe titration of propofol by a qualified gastroenterologist during invasive procedures such as endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS).
Blood pressure and heart rate are important parameters of cardiovascular monitoring. The alterations of blood pressure are mediated by the depressive effects of anesthetic agents. Baseline hemodynamic parameters also provide useful information of the effects of various medical conditions. Generally, blood pressure and heart rate will be documented before anesthesia, and at least 5 min for deep sedation and general anesthesia, as well as every 15 min for mild and moderate sedation. Blood pressure is more likely to predict increasing and decreasing doses of anesthetic drugs.
The use of electrocardiography (ECG) was aimed to detect cardiac arrhythmias in high-risk patients undergoing anesthesia. However, the use of ECG during GIE procedure remains controversial [6]. American Society for Gastrointestinal Endoscopy (ASGE) and ASA practice guidelines recommend the use of ECG during GIE anesthesia in patients with significant cardiovascular diseases or arrhythmias. However, ECG is not recommended for routine use of ECG in patients with ASA physical status I or II [1, 4, 7].
Other monitors such as invasive arterial blood pressure, central venous pressure (CVP), and pulmonary arterial catheterization (PAC) are infrequently used during GIE anesthesia. However, these invasive monitors should be used in some high-risk patients including patients with severe hemodynamic instabilities and patients with shock.
The depth of anesthesia cannot be reliably judged by clinical assessments alone. Currently, the Bispectral (BIS) index has been reported to be more accurate in measurement of the depth of anesthesia. The BIS scale ranges from 0 to 100 (0, no cortical activity or coma; 40-60, unconscious; 70-90, varying levels of conscious sedation; 100, fully awake). In the past, BIS monitor was used to assess the patient consciousness during general anesthesia [4, 8]. To date, its use has subsequently expanded into the procedural sedation technique. However, the use of BIS during GIE procedures remains a controversial issue.
The usefulness of BIS monitoring for GIE procedure was confirmed by the study of Bower and colleagues. This study showed the correlation of BIS index and the Observer’s Assessment of Alertness/Sedation (OAA/S) scale for sedation during GIE procedures. It also suggested that a bispectral index near 82 corresponded with acceptable sedation level for GIE procedure [9]. Al-Sammak and coworkers compared BIS with clinical assessment for sedation during ERCP procedure in pediatric patients. The duration of sedation, recovery period, patient satisfaction, and total dose of sedative agents in the BIS group were better than in the clinical assessment group. This study demonstrated that BIS might be a valuable monitor for safe level of sedation and endoscopist’s satisfaction during ERCP [10]. Another study also showed that BIS monitoring guided to a decrease in the propofol dose for sedation in ERCP procedures. Mean BIS values throughout the procedure and during the maintenance period of sedation were 61.68 ± 7.5 and 53.73 ± 8.67, respectively [11].
In contrast, several reports demonstrated that BIS index had low accuracy for detecting deep sedation and it was not helpful for titrating propofol to an adequate depth of sedation level. For example, Chen and Rex evaluated the utility of BIS as a monitoring device for nurse-administered propofol sedation (NAPS) during colonoscopic procedure. The study showed the mean time required to accomplish BIS values ≤60 was significantly longer than the mean time required to achieve an Observer’s Assessment of Alertness/Sedation score of 1 (deep sedation). Additionally, there was also a lag time between the time required from the last dose of propofol and the time returned to baseline. The authors concluded that BIS index was not a useful device in titrating propofol to an adequate depth of sedation level [12].
Drake and coworkers also confirmed that BIS did not lead to the reduction in mean propofol dose or recovery time when used for sedation in colonoscopy [13]. Moreover, an observational study also showed that BIS index had a low accuracy for detecting deep sedation because of an overlap of scores across the sedation levels. Further improvements in BIS are needed to differentiate deep from moderate sedation for GIE procedures [14].
NarcotrendTM accomplishes a computerized analysis of the raw EEG. A statistical algorithm is used for analysis, resulting in a six-stage classification from A (awake) to F (general anesthesia/coma) and 14 substages [4, 15]. Wehrmann and colleagues evaluated 80 patients who underwent ERCP procedures by using EEG monitoring and clinical assessment for sedation. Their study demonstrated that mean propofol dose, decrease in blood pressure, and recovery time in the EEG monitoring group were significantly lower than in the clinical assessment group. The authors confirmed that EEG monitoring permitted more effective titration of propofol dosage for sedation during ERCP procedures and was associated with more rapidly patient recovery [16].
My previous study used the NarcotrendTM to guide the depth of sedation for ERCP procedure. NarcotrendTM monitoring was an effective tool for maintenance of the depth of sedation level in this procedure [17]. The other study compared the clinical efficacy of NarcotrendTM monitoring and clinical assessment used to provide deep sedation in patients who underwent ERCP procedure. In the study, Modified Observer’s Assessment of Alertness/Sedation scale 1 or 2 and the NarcotrendTM index 47-56 to 57-64 were maintained during the procedure. All endoscopies were completed successfully. Both NarcotrendTM and clinical-assessment-guided propofol deep sedation were equally safe and effective as well as demonstrated comparable propofol dose and recovery time. However, the NarcotrendTM-guided sedation showed lower hemodynamic changes and fewer complications compared with the clinical-assessment-guided sedation [18].
Esophagogastroduodenoscopy (EGD) is commonly performed by using topical pharyngeal anesthesia. Topical lidocaine is normally used as pretreatment for pharyngeal anesthesia. My previous study evaluated the clinical efficacy of topical viscous lidocaine solution and lidocaine spray when each was used as a single agent for unsedated EGD [19]. All patients were randomized into the viscous lidocaine (V) group (n = 930) or the lidocaine spray (S) group (n = 934). The results showed the procedure was successfully completed in 868 patients from group V and 931 patients from group S. Patient’s and endoscopist’s satisfaction, pain score, patient tolerance, and ease of intubation in group S were significantly better than those in group V. Additionally, adverse events in group S also occurred significantly lower than group V. This study demonstrated that the use of topical lidocaine spray was shown to be a better form of pharyngeal anesthesia than viscous lidocaine solution in unsedated EGD procedure [19].
Consequently, the use of posterior lingual lidocaine swab can apply for EGD procedure. Soweid and colleagues evaluated the effect of posterior lingual lidocaine swab in 80 patients who underwent diagnostic EGD procedures on patient tolerance, the ease of performance of EGD procedure, and to determine if such use would decrease the need for intravenous sedation [20]. The result of their study demonstrated that patients in the lidocaine swab group tolerated the procedure better than those in the lidocaine spray group. The procedural difficulty and the need of intravenous sedation in the lidocaine swab group were lower than in the lidocaine spray group. Additionally, the patients and the endoscopists in the lidocaine swab group were more satisfied than in the lidocaine spray group. They suggested the use of posterior lingual lidocaine swab for EGD procedure because of patient comfort and tolerance, endoscopist satisfaction, and reduction of the need for intravenous sedation.
Ramirez and coworkers also compared the effect of glossopharyngeal nerve block and topical anesthetic agent for EGD procedure [21]. The aim of the study was to evaluate the sedation, tolerance to the procedure, hemodynamic stability, and the adverse events. They performed a clinical trial in a total of 100 patients who underwent EGD procedures. All patients in both arms also received intravenous midazolam. The procedures were reported without discomfort in 48 patients (88%) in the glossopharyngeal nerve block group and 32 patients (64%) in the topical anesthetic group. There were no significant differences in the incidence of nausea and retching in both groups. The study confirmed that the use of glossopharyngeal nerve block provided greater patient comfort and tolerance as well as also diminished the need for sedation in EGD patients [21].
Sedation for GIE procedure can be safely and effectively performed with a multidrug regimen utilizing anesthesiologist or nonanesthetic personnel with appropriate monitoring. Currently, sedation practices for GIE procedures vary widely. The need for sedation is decided by the type of endoscopy, duration of procedure, degree of endoscopic difficulty, patient physical status, and physician’s preferences. However, the sedation regimen for GIE procedures is still varied. Benzodiazepines and opioids are commonly used by nonanesthetic personnel. In contrast, propofol in combination with opioids and/or benzodiazepines is usually used by anesthetic personnel.
The choice of anesthetic technique for GIE procedure depends on the patient and the type of procedure. General anesthesia is commonly utilized in patients with ASA physical status >III and patients with cardiorespiratory instability, as well as in long duration and complicated procedures. Traditionally, tracheal intubation is also performed when general anesthesia is used. An anesthesiologist usually uses balanced anesthesia technique including opioid, inhalation agent, and neuromuscular blocking drug. The majority of these anesthetic agents have short-acting and short-duration properties.
Target-controlled infusion (TCI) is a computer-controlled open-loop administration of anesthetic drugs. A continuous infusion technique uses a pharmacokinetic model to predict the patient plasma and effect site concentrations from the infusion design and allows the anesthesiologist to target a selected concentration. The device computes the appropriate infusion system to accomplish this concentration [22]. The TCI rapidly attains and maintains a predefined plasma or effect site concentration of the anesthetic drug. An appropriate target concentration for achieving the desired clinical endpoint is selected. The TCI delivery system performs better than the manual system. Presently, TCI devices for propofol administration are approved in several countries.
Mazanikov and colleagues compared TCI (initial targeted effect-site concentration 2 mcg/mL) with patient-controlled sedation (PCS) (single bolus 1 mL, lockout time set at zero) in 82 patients who underwent elective ERCP procedures. Alfentanil was supplemented if needed. All procedures were performed successfully. Mean consumption of propofol and the recovery time in the TCI group was significantly greater than in the PCS group. However, mean consumption of alfentanil in both groups was comparable. The authors concluded that there were no benefits of TCI over PCS for propofol administration in ERCP procedures [23].
Because of interindividual variability, new techniques of administration for sedation have been developed. Patient-controlled sedation (PCS) devices deliver a predefined bolus of intravenous drug during a defined time with or without a lockout interval. A prospective, randomized, controlled study compared the use of PCS with propofol and remifentanil and the anesthesiologist-administered propofol sedation for 80 elective ERCP patients. Sedation level was assessed every 5 min by using Ramsay and Gillham sedation scores. All ERCP patients were completely successful except two patients in the PCS group. Mean level of sedation and total propofol consumption in the PCS group were significantly lower than in the anesthesiologist-administered propofol group. However, patient and endoscopist satisfaction were equally high in both groups. The study confirmed that PCS with propofol and remifentanil was a safe and well-accepted sedation technique for ERCP patients [24].
Moreover, the use of PCS with propofol and remifentanil has been compared with fentanyl and midazolam for sedation in patients who underwent colonoscopy by Mandel and colleagues [25]. Their study demonstrated that time to sedation and the recovery time in the PCS with the propofol and remifentanil group were significantly shorter than in the PCS with the fentanyl and midazolam group. However, the perceptions of patients, nurses and endoscopists were comparable between the two groups.
Procedural sedation in cirrhotic patients is challenged. Titration of sedative and analgesic drugs is needed for an optimal sedation level. The use of PCS for sedation in these patients is an alternative technique. Although, dexmedetomidine is suggested for procedural sedation and reported effective for alcohol withdrawal, the efficacy of dexmedetomidine as a sole anesthetic agent is controversial. Mazanikov and coworkers evaluated 50 patients with chronic alcoholism scheduled for elective ERCP procedures. All patients in the PCS with propofol and alfentanil group were successfully sedated, and in 19 of 25 (76%) patients in the dexmedetomidine group. They also suggested that a loading dose of dexmedetomidine 1 mcg/kg over 10 min, followed by continuous intravenous infusion 0.7 mcg/kg/h was insufficient for the ERCP procedure. In addition, dexmedetomidine was also related with prolonged recovery [26].
The use of propofol for sedation in GIE procedures may allow for better quality of sedation and faster recovery. Computer-assisted personalized sedation system (CAPS) is based on the patient response to stimulation and physiologic profiles. It presents an attractive means of delivering safe and effective doses of propofol. The closed-loop target-controlled system or continuous EEG recordings are used to assess the degree of sedation. Patient-controlled platforms may also be used. These devices may help physicians titrating propofol administration and controlling the physiological functions [27].
The SEDASYS System is a CAPS integrating propofol delivery with patient monitoring to allow physicians to safely administer propofol. The efficacy and safety of this system for sedation during GIE procedures was evaluated and compared with the combination of benzodiazepine and opioid in 1000 adult patients with ASA physical status class I-III. All patients were sedated in mild to moderate depth of sedation level. The study demonstrated that SEDASYS system was safe and effective for sedation during EGD and colonoscopic procedures. Additionally, patient and physician satisfaction as well as recovery time in the SEDASYS group were significantly better than patients in the combination of benzodiazepine and opioid group [28].
The use of inadequate sedative agents results in over and under depth of sedation. The use of CAPS for administration of propofol by nonanesthetic personnel achieving mild to moderate sedation in patients who underwent GIE procedures was evaluated by Pambianco and coworkers [29]. This study showed that propofol administration in mild or moderate sedation level by nonanesthetic personnel used with CAPS system in patients who underwent EGD and colonoscopic procedures was safe and effective. Moreover, low propofol dosage and short recovery time were noted.
Closed-loop administration of anesthesia systems can provide anesthesia automatically and its effect feedback controlled. This system contains a central system, a target control device such as syringe pump, vaporizer, and other drug delivery systems [30]. Currently, there are several closed-loop administration systems for neuromuscular blockade, depth of anesthesia, and pain control during decreased levels of consciousness. In addition, McSleepy is also a closed-loop control system that displays the patient’s depth of consciousness, muscular movement during surgery, and the level of pain [30].
Teleanesthesia is the use of telemedicine technology in anesthetic management including preoperative assessment at distance, video consultation, and performing anesthesia in remote locations where experienced anesthesiologists are not always present [30, 31]. The impact of telemedicine pre-anesthesia evaluation on periprocedural processes was confirmed by Applegate II and colleagues. Their study demonstrated that telemedicine pre-anesthesia evaluation offered patients time- and cost-saving benefits without more surgical delay. Moreover, telemedicine and in-person assessments were comparable, with high patient and physician satisfaction [32].
Generally, lidocaine is the most common local anesthetic agent used for GIE procedure. The viscous lidocaine solution and lidocaine spray are usually performed for upper GIE procedure. In addition, lidocaine gel or jelly is frequently employed for lower GIE procedure. Recently, lidocaine lozenge has been tried to use for EGD procedure. Mogensen and colleagues evaluated the effect and acceptance of a lidocaine lozenge compared with a lidocaine viscous oral solution as pharyngeal anesthesia before EGD [33]. The 110 adult patients were randomized to receive either 100 mg lidocaine as a lozenge or 5 mL lidocaine viscous solution 2%. Supplemental intravenous midazolam was administered if needed. They concluded that the lozenge could reduce gag reflex and patients’ discomfort, and improved patients’ acceptance during the procedure. In addition, the lozenge form had also a good taste [33]. Another study of the lidocaine lozenge used for pharyngeal anesthesia in EGD procedure has been reported by Tumminakatte and Nagaraj [34]. The authors compared the efficacy, safety, and patient comfort for the lidocaine lozenge and lidocaine viscous as a single agent before EGD procedure. This study showed that lidocaine lozenge was effective and safe for pharyngeal anesthesia before EGD procedure. It was relatively better than lidocaine viscous in terms of lesser discomfort and procedural difficulty as well as increased tolerability of the EGD procedure [34].
Moreover, topical bupivacaine could be used as pretreatment for pharyngeal anesthesia in unsedated EGD. The effect of a bupivacaine lozenge as pharyngeal anesthesia and a lidocaine spray before EGD was assessed by Salale and coworkers [35]. Ninety-nine adult patients were randomized to receive either a bupivacaine lozenge or lidocaine spray. Patient discomfort and the acceptance of gag reflex during EGD procedures were evaluated. The results showed that patient discomfort and gag reflex during procedure in the bupivacaine lozenge group were significantly lower than the lidocaine spray group. The authors also suggested that bupivacaine lozenge for topical pharyngeal anesthesia before an unsedated EGD procedure verified to be a superior option as compared with lidocaine spray [35].
Chan and colleagues studied the effectiveness of 10% lidocaine pump spray plus plain Strepsils and Strepsils anesthetic lozenge plus distilled water spray for EGD procedure in terms of patient tolerance, taste of anesthetic agent, intensity of numbness, amount of cough or gag, and the degree of discomfort at esophageal intubation. They concluded that topical lidocaine spray was superior to the flavored anesthetic lozenge as a topical pharyngeal anesthesia in unsedated EGD procedure [36]. Furthermore, the safety and efficacy of a lidocaine lollipop as single-agent anesthesia for EGD has been evaluated by Ayoub and coworkers [37]. The main outcome variables of the study were the success rate and safety of local anesthesia by using lidocaine lollipop in addition to the need for intravenous sedation. Their study showed that lidocaine lollipop, a favorable form of pharyngeal anesthesia, was safe and well tolerated for EGD procedure.
Midazolam is one of the most common drugs used for sedation during GIE procedures. It is a rapid-onset, short duration of action, and water-soluble benzodiazepine with anxiolytic, amnesic, sedative, muscle relaxant, and anticonvulsant properties. These actions are due to the effect of binding to gamma-amino butyric acid receptors in the central nervous system. Midazolam has few adverse effects. Respiratory depression is the most important adverse effect and is synergistic when used in combination with opioids. The standard dose in adult patients is 0.015-0.06 mg/kg [38].
Fentanyl is a potent synthetic opioid and also commonly used for GIE procedures. It has a rapid onset, short duration of action, and lack of direct myocardial depressant effects. The onset of action is 30–60 s, and the duration of action is 30–45 min. Generally, the dose for GIE procedure is usually 1–2 mcg/kg, with a maximum dose of 100–150 mcg in adult healthy patients. Because of its analgesic effect, fentanyl is commonly used for therapeutic GIE procedures. Of late, the combination of fentanyl and midazolam is an accepted regimen with a safety profile [39-41]. However, fentanyl can cause respiratory depression including apnea as well as nausea and vomiting. It can reduce the heart rate.
Remifentanil is a fentanyl analog with a methyl ester group and is hydrolyzed by plasma and tissue esterases. Its metabolism is not affected by genetics, age, hepatic failure, and renal failure. Its action is rapid. The use of remifentanil for sedation in GIE procedures is not entirely recognized. Remifentanil is generally performed by using the continuous infusion technique. The TCI of remifentanil is another preference. The combination of propofol and remifentanil for sedation in GIE procedures is usually used. The study of Abu-Shahwan and Mack demonstrated the efficacy and safety of a combination of propofol and remifentanil for deep sedation in children who underwent GIE procedures [42]. In their study, anesthesia was induced with sevoflurane and nitrous oxide in oxygen, and was maintained with infusion of propofol and remifentanil. All GIE procedures were successfully completed with no complications. However, this combination of propofol and remifentanil demonstrated the reduction of heart rate, blood pressure, and respiratory rate.
Remifentanil in TCI appears to be a satisfactory drug for sedation in GIE procedures. However, propofol in TCI for GIE procedures demonstrates better sedation than remifentanil in TCI. This issue was confirmed by Munoz and colleagues [43]. They compared remifentanil and propofol in TCI for sedation in 69 patients during GIE procedures. The authors concluded that propofol in TCI for sedation in patients who underwent GIE procedures seemed to be an adequate agent. Additionally, propofol in TCI created less adverse effects and higher patient satisfaction than remifentanil in TCI.
Remimazolam is a rapidly acting intravenous sedative drug. It combines the properties of midazolam and remifentanil. Additionally, its tendency to cause apnea is very low. Remimazolam has potential to be used as a sedative drug in the intensive care unit and as a novel agent for procedural sedation [44, 45]. Recently, remimazolam was evaluated for sedation in patients who underwent upper GIE procedures by Rogers and McDowell. This clinical trial demonstrated that the time to recovery from sedation of remimazolam was faster and more reliable than midazolam [46]. Moreover, Worthington and colleagues assessed the feasibility of remimazolam for sedation during colonoscopy and reversing the sedative effects of remimazolam with flumazenil in 15 healthy volunteers. The sedation for colonoscopy was successfully completed in more than 70% of subjects. In addition, all subjects rapidly reversed with flumazenil and also rapidly recovered within 10 min. No serious adverse events were observed [47].
Propofol has sedative, hypnotic, and anesthetic properties. However, it does not have analgesic effects. Propofol rapidly crosses the blood–brain barrier. The onset of action is 30–60 s. Dose reduction is needed in patients with cardiac dysfunction and in elderly patients. However, the dose reduction of propofol in patients with moderately severe liver disease or renal failure is not required. Propofol potentiates the effects of analgesic and sedative drugs. The advantage of propofol has been demonstrated for therapeutic GIE procedures and not for diagnostic GIE procedures.
Propofol in combination with opioid or benzodiazepine can cause significant cardiovascular depression and may result in a deeper than expected depth of sedation because of its narrow therapeutic window. Pain at the injection site is the most frequent local complication. Several methods for propofol delivery have been used for GIE procedures. Generally, propofol is administered intravenously as a repeated bolus injection, continuous infusion, or a mixture of both. Currently, the nonanesthesiologist-administered propofol is a controversial issue and also varies among countries.
Generally, propofol is usually used for various GIE procedures. A previous study confirmed that sedation with propofol alone or propofol combined with fentanyl or midazolam in children was safe and effective. However, the use of propofol alone provides lesser sedation and ease of endoscopy than the use of propofol in combination with fentanyl or midazolam [48]. In Siriraj GI Endoscopy Center, the combination of propofol, fentanyl, and/or midazolam was usually used for GIE procedures even in pediatric patients. Moreover, our previous studies also demonstrated the clinical effectiveness of an anesthesiologist-administered sedation outside of the operating room for pediatric GIE procedures. Although, all sedation-related complications were relatively high, all of these complications were transient and easily treated [39, 40, 49, 50]. In terms of procedure-related complications, propofol-based sedation does not increase the rate of colonoscopic perforation [51].
For invasive GIE procedures, propofol-based sedation for ERCP and percutaneous endoscopic gastrostomy procedures in sick and elderly patients by anesthetic personnel with appropriate monitoring was also safe and effective without any serious complications [52-54]. The safety of propofol sedation for EUS with fine needle aspiration procedure was confirmed by Pagano and coworkers [55]. The complication rates for propofol deep sedation and meperidine/midazolam administered for moderate sedation were not significantly different. Furthermore, propofol combined with fentanyl and midazolam is frequently used for GIE procedures including EUS and small bowel enteroscopy [56-60].
Several guidelines do not recommend the use of propofol for routine GIE procedures. The safety and efficacy of propofol administered by registered nurses has been reported in a case series including 2000 patients undergoing elective EGD and/or colonoscopy [61]. Another study demonstrated that trained nurse-administered propofol for GIE sedation in patients with ASA class I, II, and III was safe and effective. The anesthetic support was assisted in 11 patients (0.4%) [62].
Similar to qualified nurses, the gastroenterologist can administer propofol effectively. Several guidelines recommend that gastroenterologist-administered propofol should be used to sedate patients only at mild or moderate sedation levels. Additionally, the patients must have ASA physical status not more than III. The study of Vargo and colleagues confirmed that gastroenterologist-administered propofol for elective ERCP and EUS procedures resulted in the reduction of propofol dosage and the improvement of recovery activity as well as the rapid detection of respiratory depression. This study also demonstrated that gastroenterologist-administered propofol should be a cost-effective sedation technique [63].
Propofol is commonly used by anesthesiologists for anesthesia in GIE procedures. To date, the use of propofol is still controversial. Propofol can be used by well-trained registered nurses or physicians in some countries. However, in developing countries, propofol-based sedation is performed by anesthesiologists or anesthetic nurses. Berzin and coworkers accomplished a cohort study of sedation-related adverse events, patient- and procedure-related risk factors associated with sedation, as well as endoscopist and patient satisfaction with anesthesiologist-administered sedation in 528 patients who underwent ERCP procedures. The study confirmed that anesthesiologist-administered sedation for ERCP patients was safe and effective. Cardiorespiratory-related adverse events were generally minimal [64].
Fospropofol is a water-soluble prodrug of propofol that is currently approved for sedation for diagnostic and therapeutic procedures. It is characterized by a smooth and predictable rise and decline rapidly observed following intravenous administration. It does not cause pain on intravenous injection, but it has been associated with paresthesia in the perineal and perianal area. However, fospropofol causes dose-dependent hypotension, respiratory depression, and apnea. Generally, a standard of fospropofol sedation is 6.5 mg/kg. In high-risk and elderly patients, a lower dose should be administered. Bergese and coworkers compared the efficacy and safety of fospropofol in a dose of 4.875 mg/kg and 6.5 mg/kg for sedation in high-risk elderly patients who underwent colonoscopy. This study showed that fospropofol in a dose of 4.875 mg/kg for sedation in high-risk elderly patients who underwent colonoscopy was not a clinically significant advantage. Fospropofol in a dose of 6.5 mg/kg was recommended in the elderly, obese, and high-risk patients when used for moderate sedation [65].
Ketofol is the combination of ketamine and propofol in various concentrations. It isan agent of choice for a variety of GIE procedures. Ketamine, a neuroleptic anesthetic agent, works on thalamocortical and limbic N-methyl-D-aspartate receptors. Ketamine stimulates the cardiorespiratory system. A direct effect increases cardiac output, arterial blood pressure, heart rate, and central venous pressures [66]. In contrast, propofol has antiemetic, anxiolytic, hypnotic, and anesthetic properties. Additionally, propofol has a short recovery time without an increase of cardiorespiratory side effects. As a result, the combination of these two drugs has several benefits because of hemodynamic stability, lack of respiratory depression, good recovery and post-procedural analgesia. The safety and efficacy of ketofol as a sedoanalgesic agent are dependent on the dose and the ratio of the mixture [67].
Ketofol is also commonly used for sedation during GIE procedures. My previous study evaluated the clinical efficacy of the ketofol and propofol alone when each regimen is used as sedative agents for colonoscopic procedure. A 194 patients were randomized into two groups; 97 patients in group PK received propofol and ketamine and 97 patients in group P received propofol and normal saline for sedation. All patients were premedicated with 0.02–0.03 mg/kg of midazolam. All colonoscopic procedures were completely successful. There were no significant differences in patient tolerance, hemodynamic parameters, recovery activity, patient and endoscopist satisfaction, as well as the sedation-related adverse events between the two groups. In addition, these adverse events were transient and mild in degree [68].
Dexmedetomidine is a specific central alpha-2 adrenoreceptor agonist with sedative and analgesic properties. Dexmedetomidine has no effect at the GABA receptor, and is not associated with significant respiratory depression. The patients can be sedated but are able to be awakened to full consciousness easily. It induces a biphasic blood pressure response: high doses cause hypertension, and lower doses cause hypotension and bradycardia. The other disadvantages of dexmedetomidine include a slow onset and longer duration of action [42].
To date, the role of dexmedetomidine for GIE procedures is not entirely established and remains a controversial issue. Samson and colleagues compared the sedation efficacy and the hemodynamic effects of dexmedetomidine, midazolam, and propofol in 90 patients with ASA physical status I or II, who underwent elective diagnostic upper GIE procedures. The results demonstrated that endoscopist satisfaction level, recovery, and the hemodynamic stability in the dexmedetomidine group were significantly better than in the midazolam and the propofol groups [69]. However, dexmedetomidine alone is less effective than the combination of propofol and fentanyl for moderate sedation during ERCP procedure [70]. Most of the patients needed supplementary analgesic and sedative drugs to accomplish the depth of sedation level. However, these findings do not allow us to conclude that propofol alone is better than dexmedetomidine alone, because the conclusion was established for propofol combined with fentanyl. Moreover, dexmedetomidine was associated with higher hemodynamic instability and a prolonged recovery phase [70].
Ketamine is a dissociative anesthetic agent and works on thalamocortical and limbic N-methyl-D-aspartate (NMDA) receptors. Its actions are described by catalepsy in which eyes remain open and there is slow nystagmic gaze while corneal and light reflexes remain intact. Direct effects increase cardiac output, blood pressure, heart rate as well as pulmonary arterial and central venous pressures, which stimulates the cardiorespiratory system. However, ketamine produces unpleasant psychological effects including hallucinations, nightmares, and emergence reactions. Dexmedetomidine is a specific central alpha-2 adrenergic agonist that decreases central presynaptic catecholamine release. It has no effect at the GABA receptor, and is not associated with significant respiratory depression. Its properties of sedation, anxiolysis, and analgesia together with its beneficial pharmacokinetics make it a valuable adjunct for procedural and intensive care sedation [66].
The use of ketodex for GIE procedures was reported by Goyal and colleagues [71]. They used a bolus dose of ketamine 2 mg/kg and dexmedetomidine 1 mcg/kg for upper GIE procedures in pediatric patients. The results of the study showed that blood pressure, heart rate, and oxygen saturation did not change significantly from the baseline. The airway interventions were not used. In addition, there were also no laryngospasm and postprocedural shivering. The delirium score was lower than 4 in all patients except for two cases. This case series supported the use of ketodex was safe and clinically effective for upper GIE procedure in pediatric patients [71].
Cisatracurium, an isomer of atracurium, is about three times more potent than atracurium and less tendency to release histamine than atracurium. It experiences spontaneous degradation at physiological pH and temperature by Hofmann elimination. Liver disease does not appear to have an effect on cisatracurium. Pharmacokinetics and pharmacodynamics of cisatracurium in normal adult and liver transplant patients do not show clinically significant differences in the recovery profiles [72]. Because of its beneficial properties, cisatracurium is a muscle relaxant drug of choice for tracheal intubation and maintenance during general anesthesia in GIE procedures [50, 59].
Rocuronium is a steroidal nondepolarizing neuromuscular blocking drug and has a rapid onset of action. It is a muscle relaxant drug of choice for tracheal intubation and maintenance during general anesthesia in GIE procedures [50, 59, 73]. Rocuronium has emerged as an alternative to succinylcholine for facilitating rapid tracheal intubation in full stomach patients. It is predominantly useful as a relaxant agent for tracheal intubation in patients at risk of hyperkalemia and patients with known or suspected increased intracranial or intraocular pressure. However, rocuronium may be used cautiously in patients with impaired liver function [74].
Naloxone is a pure mu-opioid antagonist with a high affinity for the receptor. It can reverse both the analgesic and respiratory effects of opioids [4, 42]. The standard dosage of intravenous naloxone is 1–2 mcg/kg with a maximum dose of 0.1 mg/kg and up to 2 mg. However, naloxone has a short duration of action and one dose typically only lasts for 30–45 min. Patients should be monitored for at least 2 h after the last dose of naloxone. The adverse reactions of naloxone include reversal of opioid withdrawal, nausea/vomiting, hypertension, tachycardia, pulmonary edema, and cardiac dysrhythmias.
Flumazenil is a benzodiazepine antagonist. It is a highly specific benzodiazepine receptor antagonist and can safely reverse the sedative and respiratory effects caused by benzodiazepines. The adult dose is 0.01 mg/kg and up to 1 mg. Its duration of action is just about 1 h. However, this effect is reversible. Importantly, the patients should be observed for at least 2 h after the administration of flumazenil [4, 42]. The adverse reactions of flumazenil consist of sweating, flushing, nausea/vomiting, hiccup, agitation, abnormal vision, paresthesia, and seizure.
Sugammadex is a selective relaxant binding drug that quickly reverses the effects of aminosteroid neuromuscular blocking agents such as rocuronium and vecuronium. It was successfully used to reverse rocuronium-induced neuromuscular block in patients where neostigmine was insufficient. Dogan and colleagues investigated the efficacy of sugammadex after unsatisfactory decurarization following neostigmine administration. This study was performed on 14 patients who experienced inadequate decurarization (TOF < 0.9) with neostigmine after general anesthesia. A dose of 2 mg/kg of sugammadex was used. The result confirmed that sugammadex was successfully performed to reverse rocuronium-induced neuromuscular block in patients where neostigmine was insufficient [75]. The capability to reverse a rocuronium-induced neuromuscular block at any stage and possibly to improve patients’ safety might make sugammadex a very attractive drug for the use in day-case anesthesia.
Another study compared the efficacy of sugammadex and neostigmine for the reversal of vecuronium-induced neuromuscular blockade in elective surgical patients [76]. All patients, ASA physical status I-III obtained a dose of 0.1 mg/kg vecuronium for tracheal intubation and maintenance dose of 0.02–0.03 mg/kg if needed. Neuromuscular blockade was monitored by using acceleromyography. At the end of surgery, patients were randomized to receive either sugammadex 2 mg/kg or neostigmine 50 mcg/kg and glycopyrrolate 10 mcg/kg. The study showed that mean recovery times to a TOF ratio of 0.8 and 0.7 in the sugammadex group were significantly shorter than in the neostigmine group. No serious adverse events were noted. The authors concluded that sugammadex presented significantly quicker reversal of vecuronium-induced neuromuscular blockade compared with neostigmine [76].
Sevoflurane is an inhalation agent with ideal properties for deep sedation during GIE procedures in pediatric patients. In addition, it is commonly used for balanced general anesthesia. A retrospective study reviewed data from children receiving sevoflurane inhalation administered by an anesthesiologist via laryngeal insufflation to attain deep sedation for outpatient GIE procedures. All patients were adequately sedated with sevoflurane, and no intravenous line was needed. Time to awakening, discharge, and complication rate in the sevoflurane group were significantly lower than in the combination of midazolam, fentanyl, and ketamine, as well as in the propofol alone groups. This report suggested that deep sedation with sevoflurane insufflation for pediatric outpatient GIE procedure is as safe as conventional sedation techniques [77].
Consequently, Meretoja and colleagues compared anesthesia with sevoflurane or halothane for bronchoscopy or gastroscopy, or both in 120 infants and children. All pediatric patients were assigned to receive either 7% sevoflurane or 3% halothane in 66% nitrous oxide in oxygen for induction of anesthesia. Induction time and psychomotor recovery as well as the incidence of nausea/vomiting and cardiac arrhythmia in the sevoflurane group were significantly lower than in the halothane group. This study confirmed that the use of sevoflurane was better than the use of halothane for bronchoscopy and gastroscopy procedures in pediatric patients [78].
Desflurane is an ether inhalational anesthetic agent. It offers the advantage of precise control over depth of anesthesia along with a rapid, predictable, and clear-headed recovery with minimal postoperative adverse events. It also has advantages when used in extremes of age and in obese patients. Desflurane is generally used for the maintenance of balanced general anesthesia because of its rapid recovery. Currently, the use of desflurane may increase the direct costs of anesthetic care [79]. However, no significant differences were demonstrated between desflurane and sevoflurane in the late recovery period.
Blood pressure, heart rate, respiratory rate, oxygen saturation, and level of consciousness are monitored and documented at least every 15 min or less, for a minimum of 30 min after the last dose of sedation drug. These parameters should be monitored and noted in the recovery period. Moreover, the patients should be monitored for at least 2 h after the last dose of a reversal drug. All patients will be discharged from the recovery room once the discharge criteria are completed. Generally, the majority of sedated patients would complete an acceptable score on or before 1 h after GIE procedure. Most delays after satisfactory scores were due to nonmedical causes [80]. In ambulatory cases, the presence of an escort must be confirmed, and the patients should not drive for at least 24 h.
GIE procedure requires some forms of anesthesia. To date, sedation for GIE procedure can be effectively and safely performed by anesthesiologist or nonanesthetic personnel with appropriate patient selection and monitoring. The new anesthetic drugs and monitoring equipments for safety and efficacy are available. However, pre-anesthetic evaluation and preparation, anesthetic drugs used, monitoring practices and post-anesthesia management are still essential for the anesthesia innovations in GIE procedures.
The role of the HR professional has changed dramatically along with the workforce and economy, and that evolution will continue as machines and technology replace tasks once performed by humans. Tomorrow’s HR leaders will need to be bigger, broader thinkers, and they will have to be tech-savvy and nimble enough to deal with an increasingly agile and restless workforce [1]. As organisations push on into the future and adapt to new realities, HR leaders should stay abreast of changes to prepare for the future world of work [2]. In order to progress towards a new understanding of workforce management within future organisations, it is essential to shed light on the different HR competencies that will be needed, future workspace, engagement, employment relations and resilience. It is important that HR academics, HR leaders and management take note that although engagement and employment relations are dated, it will still need to be addressed in the future, especially due to the man–machine connection, remote working and other future world of work challenges.
The role of the HR manager has changed dramatically along with the workforce and economy, and that evolution will continue as machines and technology replace tasks once performed by humans [2]. New technologies are here to stay, so companies need to understand and prepare for how it’s already changing the relationships within the workplace. Once there is this understanding, HR can then build a plan that ensures relationships will be shaped and supported in ways that help organisations and employees now and in the future [3].
As business strategies and teams grow more agile to keep pace with recurring change in companies, HR technology must adapt as well, including providing employees with more user-friendly and efficient experiences. HR leaders should therefore revise their priorities for 2021 and onwards. Future workspace should inspire workers to communicate, collaborate, solve problems, deepen engagement and spur productivity. The implications for HR is to equip leaders to manage remote teams over the long haul, preserve the company culture with a more distributed workforce and engage workers in a cost-constrained environment. According to [4], resilient HR should support with the business transformation.
Schultz [2] found that HR leaders should have the necessary competencies to be able to make a strategic contribution, to engage properly and to add value to ensure peaceful employment relations. Schultz [2] also found that innovation, business acumen, leadership, analytics and metrics and personal characteristics such as self-efficacy, honesty, openness, agility, flexibility and adaptability are of the essence. Leveraging HR Analytics to drive all people-related decisions is an essential future HR competency [5]. HR needs to start developing core business acumen rather than standardised HR capabilities. Fundamental business drivers like economic growth, capital markets, changing customer behaviour, competition and global business trends must be clearly understood by HR leaders [6].
McCartney et al. [7] found six distinct competencies required by HR analysts including consulting, technical knowledge, data fluency and data analysis, HR and business acumen, research and discovery and storytelling and communication. With the advent of new communication platforms and digital tools, the topic of the development of communicative competencies received a new round of interest from researchers [8]. HR should promote open dialogue and instal direct communication channels between all levels within an organisation to help keep leadership informed of employee concerns [9].
Schultz [10] found that foresight and being adaptable are essential HR competencies. Numerical data such as metrics focuses on outputs and analytics focuses on the combination of data that are part of metrics [11]. To be competitive, it is essential that HR leaders have the ability to meet the needs and future needs of line management in the workplace [12]. In order to ensure successful human and machine collaboration, HR leaders must understand analytics and automation to improve productivity and decision-making [13]. The current explosion of HR technology is far from over. On the contrary, there is hardly any HR function left that does not have an impressive range of software and tools designed to automate and digitise its processes. As automation and digitalisation continue to reshape job roles and skill needs, HR and learning groups will need to create increasingly agile and effective reskilling strategies for workers [14].
HR can navigate this new landscape by taking advantage of the advancement in technology – most notably by utilising AI and big data to open up opportunities for strategic value creation [15]. Technological agility will therefore be a key differentiator for HR’s value add to business outcome [5]. There could be a more dramatic, revolutionary impact in the business environment and on workforce management from AI and technological advancements in the near future. The world is still in the early phases of the Fourth Industrial Revolution, thus many areas remain unpredictable and uncontrollable. Functional HR competencies alone will not enable successful HR careers. Specialist skills will be required to fast track HR career opportunities and career growth [5]. Within the overall HR skill sets, future-oriented capabilities will take prominence. Functional changes in HR operations are freeing up HR professionals for more strategic work. This is also enabling the emergence of new roles such as workforce analytics professional, robot trainer, virtual culture architect, data, talent and AI integrator and cyber ecosystem designer [15].
The question arises: Is HR open in their communication? Feedback from internal and external clients by means of interviews, surveys and other relevant methods will add value to ensure open communication of HR on various platforms.
Self-reflection and feedback from superiors, subordinates and peers on one’s own self-efficacy, honesty, openness, agility, flexibility and adaptability are therefore needed to improve oneself.
In order for HR business leaders and academics to be well-developed in terms of their business acumen, they must obtain knowledge to understand business operations and functions, comprehend how HRM practices contribute to core business functions, and understand the organisation’s external environment.
Courses and training about HR analytics need to be successfully completed in order to ensure a full understanding and execution of this competency.
HR leaders need to obtain the necessary software and tools to ensure that their practitioners are able to successfully meet the needs of their internal and external clients.
HR leaders, HR practitioners and HR academics need to ensure that they have the ability to utilise all kinds of relevant technology and to have technological agility to be prepared for remote working, AI, career growth and other challenges in the future world of work.
The modern workplace is almost unrecognisable from ten years ago. The 9–5 has been replaced with remote working, and corner offices and rigid banks of desks have made way for flexible multi-purpose spaces. The importance of workspace design and spatial features has recently been emphasised in corporate business literature, but the volume of literature on this topic available from peer-reviewed journals is still limited [12]. We are heading towards a future where more employees are working from home, and increasingly reliant on a digital workplace that can fit their needs.
The recent health crisis has made this clear. Re-establishing organisational culture will become a top priority for HR departments as organisations look to adopt more flexible working arrangements. Pre-COVID, many organisations used lunchrooms, office collaboration spaces, and conference rooms to promote idea sharing and organic conversations across titles and departments. Companies are now finding virtual colleague relationships are starting to polarise into common roles and sectors [16]. There will likely be a major shift towards hybrid working models that capitalise on the benefits of both remote and office working [9].
Managers as well as HR leaders should constantly plan and shape how their organisation can improve future workspace so that it is beneficial for the business and the employees [17]. The future workspace should support agile working of employees and manager [18]. De [19] emphasise the importance of involving end-users in planning and designing their workspace. Advancement in future workspace, technology, robotics and artificial intelligence (AI) suggests new work design. Programs for skilling up for new jobs and for developing interfaces between human and machines must be rapid, flexible and tailored to maximise the potential value created by human and machines [20]. To plan the future workspace, it is recommended that HR managers involve line management and other stakeholders such as IT and other relevant staff members [21].
An employee’s office, home, a third places such as a coffee shop can be seen as workspaces [22]. De Paoli and Ropo [19] state that is important to be innovative when planning workspace. Innovation is what agile is all about [23]. Agile is a framework and a working mind-set which helps respond to changing requirements. The concept of agile working revolves around empowering staff to work where, when and how they choose, to ensure they perform at their best. As organisations look to accelerate the pace of remote working in the foreseeable future, it is essential that to make a conscious effort to preserve their core values and emphasise building a workplace that puts people at the forefront of every decision [9]. With less visibility on employees, leaders and managers have to determine how to both monitor and measure productivity.HR leaders need to reassess and modify metrics for what performance looks like due to the new remote working in many companies [16]. New workspaces seem to be accompanying new challenges for HR and management.
In the past, HR was not always part of workspace planning but in the future world of work, this will be a requirement for HR leaders.
This new challenge needs to get the necessary attention and HR should therefore discuss this topic with top management, line management and the workers to create an awareness of their future role in planning workspace.
Traditional thinking about workspace will be challenged and HR should therefore be a change agent in this regard.
HR leaders need to embark on improving their knowledge about workspace to best accommodate future work.
Humans have a basic need for belonging and connection. This fact will be even more so in the future world of work due to technology and man–machine challenges. A lack of interpersonal relationships can negatively impact our health, our ability to adjust, and overall well-being. These truths extend to the workplace. Employees want and need to build relationships at work. Personal connections with managers, leaders, coworkers, and customers lead to increased employee engagement and performance [24]. Gallup [25] defines an engaged employee as “those who are involved in, enthusiastic about, and committed to their work and workplace”. Engagement in the workplace has evolved considerably over the last decade. From remote work privileges to flexible hours, many of the benefits that were once viewed as benefits are now an expectation for the working world [26].
The HR leaders should engage with the line manger to improve overall performance [27]. Employee engagement can be a critical tool in helping organisations to respond rapidly to moving business environments, as well as playing a key role in growth and sustainability [28]. Traumatic events such as the Covid-19 pandemic has taught us the importance of embracing our humanity, including the need for compassion in the workplace. It is therefore important to acknowledge that we are all going through challenges, some shared and some unique, that benefit from others’ empathy [29]. Cleveland et al. [30] found that the importance of infusing HR with a psychological concern for human dignity results in respect for humanity at work, as well as advocacy for employees and their communities.
Schultz [10] found that meaningful engagement is essential and not mere engaging for the sake of engaging. This can be ascribed to the fact that managers and HR leaders will have to invest in people and guide them into discovering purpose and making a difference in the future workplace [10]. This is of utmost importance in order to ensure productivity in the future world of work. When it comes to measuring and tracking engagement, most companies still evaluate engagement on an annual, or longer, basis using traditional survey techniques [31]. While these practices have provided a wealth of insight into the dimensions and impact of engagement, it is time to rethink how we are measuring engagement and, more importantly, how the same digital tools can be applied towards improving the productivity, retention, and satisfaction of the workforce. The employee engagement is positively correlated to level of leadership engagement and top management should therefore have a vision and commitment [32].
Technology alone cannot drive employee engagement. Technology does not create a safe space for culture. It does other things, like support connection, communication and collaboration [33]. It is therefore the role of the HR leader to drive engagement and support to management in order to ensure appropriate engagement. To create a more engaged, worker-focused organisation, you need to align around a common, unified vision that clearly explains the problem and the way you want to solve it [33]. It looks like there could be a shift from engagement to experience, and employees will expect a truly personalised employee journey, from first point of contact right through to their continued employment [28].
Dash [5] proposes ongoing employee surveys to sustain and engage employee participation in building the organisation’s desired digital culture. PWC [9] agrees by stating that focusing on employee engagement through pulse and satisfaction surveys is a great way to gauge their experience and ideas, and get their recommendations on how best to transition to the new normal. PWC [9] also states that by introducing diversity, equality, and inclusion policies and programmes will help support organisational culture and create an environment that promotes trust, unity, empathy, and engagement. In the future, the concept of engagement, which gauges passion, commitment, and effort, will give way to employee experience, which is the journey that an employee takes in an organisation [6].
There seems to be a perception among HR scholars and HR leaders that engagement is dated and will not need attention in the future. According to the above literature review, it is clear that engagement will be an ongoing practice in the future world of work.
The reason for this ongoing practice is due to various human needs such as well-being, trust and support due to various future personal and work challenges that will need to be addressed.
Unfortunately, engagement is time-consuming and therefore needs deliberate planning to ensure continuous informal and formal meetings and conversations with management, workers and other relevant stakeholders.
One of the biggest lingering questions is about how future relationships will look as technology keeps coming into the workplace. How will relationships evolve as robots, automation, and artificial intelligence become more common in the workplace? How do workers feel about these changes? Although workers may feel better about technology in the workplace, there is concerns about how automation, robots, and AI will affect work and employment relations [3]. There has been less discussion on what happens to the jobs and experiences of workers in flexible employment relationships (e.g. temporary agency work and other forms of subcontracted labor, as well as new forms of working, such as in the gig economy) [34]. Gig workers can be classified into crowd workers, who are completing and delivering tasks online—location independent, and work-on-demand workers, who are completing and delivering tasks offline—location-dependent (although it is location dependent the work is not inevitably performed on-site and hence still shows location flexibility) [34].
Digital transformation and the reorganisation of the firm have given rise to new forms of work that diverge significantly from the standard employment relationship [35]. The fourth industrial revolution does not only bring change to future world of work but such change comes with significant threats and opportunities to the relationship between employment relations stakeholders [36]. Employment relations is a dynamic matter and therefore needs constant attention to ensure harmony and productivity [12]. When employers, employees and trade unions or other employee representatives work together in a relationship of mutual trust, difficulties can be discussed and sorted out before they become problems, productivity and profitability can be increased with greater rewards for the workforce [37]. The key to this advantage is partnership and this partnership can be a positive force for generating ideas, reacting quickly and making optimum use of the skill and knowledge of workforce and management alike [37].
How workers engage in new forms of employment relations can be very challenging for employers [38]. Briken [39] raise a concern that the digitalisation of workspaces may influence the relations between the employer and employee. HR will need to help assess which tasks throughout the organisation can be automated and then reskill those whose jobs are affected by automation [1]. This may have an effect on employment relations. Any successful business requires trusted relationships. However, traditional ways of growing and nurturing networks —conferences, coffee meetups, and more—are not options in many workplaces these days, at least at the beginning of this year. HR must assist with the adapting to new ways of facilitating relationships and creating cohesive teams in less-than-ideal circumstances [29].
As in the case of engagement, employment relations will also still need to be focused on in the future as a result of various challenges.
The complexity of employment relations due to challenges such as digitalisation, automation and gig workers, necessitates a rethinking of this HR responsibility.
Mutual trust and productivity between management, workers, trade unions and other employee representatives need to be facilitated by HR leaders. This can be done by establishing platforms where open communication between these stakeholders are possible and reliable.
There are all kinds of adversity and trauma in life. The response to trauma may include shattered beliefs about the self, others, and the future [40]. HR leaders should be resilient in order to have the ability to withstand adversity, bounce back, and grow despite life’s downturns. Schultz [10] found that resilience is an important ingredient to ensure a successful future workplace. Flexibility, adaptability, and perseverance can help people tap into their resilience by changing certain thoughts and behaviours [41]. It was also found that enough sleep, eating well, exercising, and social support can assist to being resilient [42].
The involvement of automation processes and the use of robots in the fourth industrial revolution have necessitated management to rethink and improve issues related to human resources (HR) to ensure organisational performance [43]. Nurturing resilience as a core value and building HR processes that support resilience through encouraging career path shifts, job sculpting and job crafting opportunities are of utmost importance [5].
[4] mentions the four phases of the Covid-19 pandemic:
React: figure out what’s going on.
Respond: take immediate actions to reduce harm or help teams.
Return: come back to a new work environment or back to the office.
Transform: redesign jobs, services, and customer offerings for the new world.
Bersin [4] also refers to the Big Reset in HR which indicates that HR must move from being responsive (efficient) to resilient (adaptive). As business strategies continue to evolve, organisations will need to take deliberate action to prioritise resilience and not just focus on efficiency if they want to succeed in their strategic ambitions [44]. Resilient HR refers to HR being cross-trained, highly collaborative, distributed, coordinated and agile. Hybrid workforce models can increase agility and resilience, drive competitive differentiation and save money [45]. Hybrid workforce planning is a deliberate design that enables employees to flow through various work sites — from remote solo locations and microsites of small populations to traditional concentrated facilities (offices, factories, retail, etc.) [45]. In such a hybrid workforce, managers will need to trust in the goals they have set — and trust employees to work productively against those goals, regardless of location. Employees on the other hand will need to be flexible and comfortable moving between various work environments when the need arises [45]. Coletta [46] accentuates that a shift from managing the employee experience to managing the life experience of the employees, employees’ flexibility over “when” they work, recruiting that will be increasingly automated, mental health support that will become the norm, as well as the distributing of the Covid-19 vaccine should be addressed as part of future HR. These are clear examples of how important resilience is going to be in future work in order to deal with such various burning issues.
A survey to obtain a snapshot and conducting focus groups to obtain detailed information of the current resilience climate within the organisation will assist HR leaders and HR academics to better investigate, prepare and upskill management, workers and HR themselves.
The above types of investigations are of utmost importance because a lack of resilience, organisations will not be able to thrive in the future world of work. HR leaders therefore need to develop a strategy or an approach to best fit the development of resilience of HR, management and workers.
Mentoring, coaching and training are examples of effective methods to improve one’s resilience.
Due to the pandemic’s effect on the economy, organisations were quickly forced to transform and adapt to the new normal in order to survive. It is vital that HR evolves and transforms across every element of the HR lifecycle to meet a new set of organisational needs. The pandemic is not just a public health crisis – it’s also an economic transformation where products, services, customer experiences, and physical work locations may change. While new technologies can help immeasurably when viewed as a tool to contribute to well thought-out change, organisational objectives and priorities, that alone will not be enough. Resilient HR means that HR professionals and leaders, are set up to quickly enable this transformation – not only helping people come back to work, but also helping the company transform in the fastest, most positive way. HR leaders should therefore develop a strategy that encompasses the enhancement of their own HR competencies, future workspace, engagement, employment relations and resilience. The execution of the strategy will assist to strategically position and prepare the organisation to effectively deal with future work challenges and developments.
A range of avenues for future research can therefore be identified. First, research could be broadened to obtain more insight into the future of HR. Second, case studies can be conducted to investigate the views of public and private sector managers regarding their future expectations of their HR managers. Third, future research should also suggest a study using statistical methods to determine the relationships between HR competencies, future workspace, engagement, employment relations and resilience.
In conclusion, it is essential that HR must go beyond the here and now in order to properly prepare for the future world of work.
This chapter drew on research funded by the National Research Foundation (NRF) of South Africa (reference number TTK150621119893) as well as by the Tshwane University of Technology (TUT) in South Africa. This funding is gratefully acknowledged.
The author declares no conflict of interest.
A word of gratitude is expressed towards Christiaan Schultz whom assisted with the technical editing of the references in this chapter.
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by",editors:[{id:"233998",title:"Ph.D.",name:"Sara",middleName:null,surname:"Palermo",slug:"sara-palermo",fullName:"Sara Palermo"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:66,seriesByTopicCollection:[],seriesByTopicTotal:0,mostCitedChapters:[{id:"58070",doi:"10.5772/intechopen.72427",title:"MRI Medical Image Denoising by Fundamental Filters",slug:"mri-medical-image-denoising-by-fundamental-filters",totalDownloads:2618,totalCrossrefCites:20,totalDimensionsCites:32,abstract:"Nowadays Medical imaging technique Magnetic Resonance Imaging (MRI) plays an important role in medical setting to form high standard images contained in the human brain. MRI is commonly used once treating brain, prostate cancers, ankle and foot. The Magnetic Resonance Imaging (MRI) images are usually liable to suffer from noises such as Gaussian noise, salt and pepper noise and speckle noise. So getting of brain image with accuracy is very extremely task. An accurate brain image is very necessary for further diagnosis process. During this chapter, a median filter algorithm will be modified. Gaussian noise and Salt and pepper noise will be added to MRI image. A proposed Median filter (MF), Adaptive Median filter (AMF) and Adaptive Wiener filter (AWF) will be implemented. The filters will be used to remove the additive noises present in the MRI images. The noise density will be added gradually to MRI image to compare performance of the filters evaluation. The performance of these filters will be compared exploitation the applied mathematics parameter Peak Signal-to-Noise Ratio (PSNR).",book:{id:"6144",slug:"high-resolution-neuroimaging-basic-physical-principles-and-clinical-applications",title:"High-Resolution Neuroimaging",fullTitle:"High-Resolution Neuroimaging - Basic Physical Principles and Clinical Applications"},signatures:"Hanafy M. Ali",authors:[{id:"213318",title:"Dr.",name:"Hanafy",middleName:"M.",surname:"Ali",slug:"hanafy-ali",fullName:"Hanafy Ali"}]},{id:"46296",doi:"10.5772/57398",title:"Physiological Role of Amyloid Beta in Neural Cells: The Cellular Trophic Activity",slug:"physiological-role-of-amyloid-beta-in-neural-cells-the-cellular-trophic-activity",totalDownloads:5952,totalCrossrefCites:19,totalDimensionsCites:32,abstract:null,book:{id:"3846",slug:"neurochemistry",title:"Neurochemistry",fullTitle:"Neurochemistry"},signatures:"M. del C. Cárdenas-Aguayo, M. del C. Silva-Lucero, M. Cortes-Ortiz,\nB. Jiménez-Ramos, L. Gómez-Virgilio, G. Ramírez-Rodríguez, E. Vera-\nArroyo, R. Fiorentino-Pérez, U. García, J. Luna-Muñoz and M.A.\nMeraz-Ríos",authors:[{id:"42225",title:"Dr.",name:"Jose",middleName:null,surname:"Luna-Muñoz",slug:"jose-luna-munoz",fullName:"Jose Luna-Muñoz"},{id:"114746",title:"Dr.",name:"Marco",middleName:null,surname:"Meraz-Ríos",slug:"marco-meraz-rios",fullName:"Marco Meraz-Ríos"},{id:"169616",title:"Dr.",name:"Maria del Carmen",middleName:null,surname:"Cardenas-Aguayo",slug:"maria-del-carmen-cardenas-aguayo",fullName:"Maria del Carmen Cardenas-Aguayo"},{id:"169857",title:"Dr.",name:"Maria del Carmen",middleName:null,surname:"Silva-Lucero",slug:"maria-del-carmen-silva-lucero",fullName:"Maria del Carmen Silva-Lucero"},{id:"169858",title:"Dr.",name:"Maribel",middleName:null,surname:"Cortes-Ortiz",slug:"maribel-cortes-ortiz",fullName:"Maribel Cortes-Ortiz"},{id:"169859",title:"Dr.",name:"Berenice",middleName:null,surname:"Jimenez-Ramos",slug:"berenice-jimenez-ramos",fullName:"Berenice Jimenez-Ramos"},{id:"169860",title:"Dr.",name:"Laura",middleName:null,surname:"Gomez-Virgilio",slug:"laura-gomez-virgilio",fullName:"Laura Gomez-Virgilio"},{id:"169861",title:"Dr.",name:"Gerardo",middleName:null,surname:"Ramirez-Rodriguez",slug:"gerardo-ramirez-rodriguez",fullName:"Gerardo Ramirez-Rodriguez"},{id:"169862",title:"Dr.",name:"Eduardo",middleName:null,surname:"Vera-Arroyo",slug:"eduardo-vera-arroyo",fullName:"Eduardo Vera-Arroyo"},{id:"169863",title:"Dr.",name:"Rosana Sofia",middleName:null,surname:"Fiorentino-Perez",slug:"rosana-sofia-fiorentino-perez",fullName:"Rosana Sofia Fiorentino-Perez"},{id:"169864",title:"Dr.",name:"Ubaldo",middleName:null,surname:"Garcia",slug:"ubaldo-garcia",fullName:"Ubaldo Garcia"}]},{id:"41589",doi:"10.5772/50323",title:"The Role of the Amygdala in Anxiety Disorders",slug:"the-role-of-the-amygdala-in-anxiety-disorders",totalDownloads:9758,totalCrossrefCites:4,totalDimensionsCites:28,abstract:null,book:{id:"2599",slug:"the-amygdala-a-discrete-multitasking-manager",title:"The Amygdala",fullTitle:"The Amygdala - A Discrete Multitasking Manager"},signatures:"Gina L. Forster, Andrew M. Novick, Jamie L. Scholl and Michael J. Watt",authors:[{id:"145620",title:"Dr.",name:"Gina",middleName:null,surname:"Forster",slug:"gina-forster",fullName:"Gina Forster"},{id:"146553",title:"BSc.",name:"Andrew",middleName:null,surname:"Novick",slug:"andrew-novick",fullName:"Andrew Novick"},{id:"146554",title:"MSc.",name:"Jamie",middleName:null,surname:"Scholl",slug:"jamie-scholl",fullName:"Jamie Scholl"},{id:"146555",title:"Dr.",name:"Michael",middleName:null,surname:"Watt",slug:"michael-watt",fullName:"Michael Watt"}]},{id:"26258",doi:"10.5772/28300",title:"Excitotoxicity and Oxidative Stress in Acute Ischemic Stroke",slug:"excitotoxicity-and-oxidative-stress-in-acute-ischemic-stroke",totalDownloads:7207,totalCrossrefCites:6,totalDimensionsCites:27,abstract:null,book:{id:"931",slug:"acute-ischemic-stroke",title:"Acute Ischemic Stroke",fullTitle:"Acute Ischemic Stroke"},signatures:"Ramón Rama Bretón and Julio César García Rodríguez",authors:[{id:"73430",title:"Prof.",name:"Ramon",middleName:null,surname:"Rama",slug:"ramon-rama",fullName:"Ramon Rama"},{id:"124643",title:"Prof.",name:"Julio Cesar",middleName:null,surname:"García",slug:"julio-cesar-garcia",fullName:"Julio Cesar García"}]},{id:"62072",doi:"10.5772/intechopen.78695",title:"Brain-Computer Interface and Motor Imagery Training: The Role of Visual Feedback and Embodiment",slug:"brain-computer-interface-and-motor-imagery-training-the-role-of-visual-feedback-and-embodiment",totalDownloads:1477,totalCrossrefCites:13,totalDimensionsCites:25,abstract:"Controlling a brain-computer interface (BCI) is a difficult task that requires extensive training. Particularly in the case of motor imagery BCIs, users may need several training sessions before they learn how to generate desired brain activity and reach an acceptable performance. A typical training protocol for such BCIs includes execution of a motor imagery task by the user, followed by presentation of an extending bar or a moving object on a computer screen. In this chapter, we discuss the importance of a visual feedback that resembles human actions, the effect of human factors such as confidence and motivation, and the role of embodiment in the learning process of a motor imagery task. Our results from a series of experiments in which users BCI-operated a humanlike android robot confirm that realistic visual feedback can induce a sense of embodiment, which promotes a significant learning of the motor imagery task in a short amount of time. We review the impact of humanlike visual feedback in optimized modulation of brain activity by the BCI users.",book:{id:"6610",slug:"evolving-bci-therapy-engaging-brain-state-dynamics",title:"Evolving BCI Therapy",fullTitle:"Evolving BCI Therapy - Engaging Brain State Dynamics"},signatures:"Maryam Alimardani, Shuichi Nishio and Hiroshi Ishiguro",authors:[{id:"11981",title:"Prof.",name:"Hiroshi",middleName:null,surname:"Ishiguro",slug:"hiroshi-ishiguro",fullName:"Hiroshi Ishiguro"},{id:"231131",title:"Dr.",name:"Maryam",middleName:null,surname:"Alimardani",slug:"maryam-alimardani",fullName:"Maryam Alimardani"},{id:"231134",title:"Dr.",name:"Shuichi",middleName:null,surname:"Nishio",slug:"shuichi-nishio",fullName:"Shuichi Nishio"}]}],mostDownloadedChaptersLast30Days:[{id:"29764",title:"Underlying Causes of Paresthesia",slug:"underlying-causes-of-paresthesia",totalDownloads:193348,totalCrossrefCites:3,totalDimensionsCites:7,abstract:null,book:{id:"1069",slug:"paresthesia",title:"Paresthesia",fullTitle:"Paresthesia"},signatures:"Mahdi Sharif-Alhoseini, Vafa Rahimi-Movaghar and Alexander R. Vaccaro",authors:[{id:"91165",title:"Prof.",name:"Vafa",middleName:null,surname:"Rahimi-Movaghar",slug:"vafa-rahimi-movaghar",fullName:"Vafa Rahimi-Movaghar"}]},{id:"63258",title:"Anatomy and Function of the Hypothalamus",slug:"anatomy-and-function-of-the-hypothalamus",totalDownloads:4632,totalCrossrefCites:6,totalDimensionsCites:12,abstract:"The hypothalamus is a small but important area of the brain formed by various nucleus and nervous fibers. Through its neuronal connections, it is involved in many complex functions of the organism such as vegetative system control, homeostasis of the organism, thermoregulation, and also in adjusting the emotional behavior. The hypothalamus is involved in different daily activities like eating or drinking, in the control of the body’s temperature and energy maintenance, and in the process of memorizing. It also modulates the endocrine system through its connections with the pituitary gland. Precise anatomical description along with a correct characterization of the component structures is essential for understanding its functions.",book:{id:"6331",slug:"hypothalamus-in-health-and-diseases",title:"Hypothalamus in Health and Diseases",fullTitle:"Hypothalamus in Health and Diseases"},signatures:"Miana Gabriela Pop, Carmen Crivii and Iulian Opincariu",authors:null},{id:"57103",title:"GABA and Glutamate: Their Transmitter Role in the CNS and Pancreatic Islets",slug:"gaba-and-glutamate-their-transmitter-role-in-the-cns-and-pancreatic-islets",totalDownloads:3565,totalCrossrefCites:4,totalDimensionsCites:10,abstract:"Glutamate and gamma-aminobutyric acid (GABA) are the major neurotransmitters in the mammalian brain. Inhibitory GABA and excitatory glutamate work together to control many processes, including the brain’s overall level of excitation. The contributions of GABA and glutamate in extra-neuronal signaling are by far less widely recognized. In this chapter, we first discuss the role of both neurotransmitters during development, emphasizing the importance of the shift from excitatory to inhibitory GABAergic neurotransmission. The second part summarizes the biosynthesis and role of GABA and glutamate in neurotransmission in the mature brain, and major neurological disorders associated with glutamate and GABA receptors and GABA release mechanisms. The final part focuses on extra-neuronal glutamatergic and GABAergic signaling in pancreatic islets of Langerhans, and possible associations with type 1 diabetes mellitus.",book:{id:"6237",slug:"gaba-and-glutamate-new-developments-in-neurotransmission-research",title:"GABA And Glutamate",fullTitle:"GABA And Glutamate - New Developments In Neurotransmission Research"},signatures:"Christiane S. Hampe, Hiroshi Mitoma and Mario Manto",authors:[{id:"210220",title:"Prof.",name:"Christiane",middleName:null,surname:"Hampe",slug:"christiane-hampe",fullName:"Christiane Hampe"},{id:"210485",title:"Prof.",name:"Mario",middleName:null,surname:"Manto",slug:"mario-manto",fullName:"Mario Manto"},{id:"210486",title:"Prof.",name:"Hiroshi",middleName:null,surname:"Mitoma",slug:"hiroshi-mitoma",fullName:"Hiroshi Mitoma"}]},{id:"35802",title:"Cross-Cultural/Linguistic Differences in the Prevalence of Developmental Dyslexia and the Hypothesis of Granularity and Transparency",slug:"cross-cultural-linguistic-differences-in-the-prevalence-of-developmental-dyslexia-and-the-hypothesis",totalDownloads:3622,totalCrossrefCites:2,totalDimensionsCites:7,abstract:null,book:{id:"673",slug:"dyslexia-a-comprehensive-and-international-approach",title:"Dyslexia",fullTitle:"Dyslexia - A Comprehensive and International Approach"},signatures:"Taeko N. Wydell",authors:[{id:"87489",title:"Prof.",name:"Taeko",middleName:"N.",surname:"Wydell",slug:"taeko-wydell",fullName:"Taeko Wydell"}]},{id:"58597",title:"Testosterone and Erectile Function: A Review of Evidence from Basic Research",slug:"testosterone-and-erectile-function-a-review-of-evidence-from-basic-research",totalDownloads:1370,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"Androgens are essential for male physical activity and normal erectile function. Hence, age-related testosterone deficiency, known as late-onset hypogonadism (LOH), is considered a risk factor for erectile dysfunction (ED). This chapter summarizes relevant basic research reports examining the effects of testosterone on erectile function. Testosterone affects several organs and is especially active on the erectile tissue. The mechanism of testosterone deficiency effects on erectile function and the results of testosterone replacement therapy (TRT) have been well studied. Testosterone affects nitric oxide (NO) production and phosphodiesterase type 5 (PDE-5) expression in the corpus cavernosum through molecular pathways, preserves smooth muscle contractility by regulating both contraction and relaxation, and maintains the structure of the corpus cavernosum. Interestingly, testosterone deficiency has relationship to neurological diseases, which leads to ED. Testosterone replacement therapy is widely used to treat patients with testosterone deficiency; however, this treatment might also induce some problems. Basic research suggests that PDE-5 inhibitors, L-citrulline, and/or resveratrol therapy might be effective therapeutic options for testosterone deficiency-induced ED. Future research should confirm these findings through more specific experiments using molecular tools and may shed more light on endocrine-related ED and its possible treatments.",book:{id:"5994",slug:"sex-hormones-in-neurodegenerative-processes-and-diseases",title:"Sex Hormones in Neurodegenerative Processes and Diseases",fullTitle:"Sex Hormones in Neurodegenerative Processes and Diseases"},signatures:"Tomoya Kataoka and Kazunori Kimura",authors:[{id:"219042",title:"Ph.D.",name:"Tomoya",middleName:null,surname:"Kataoka",slug:"tomoya-kataoka",fullName:"Tomoya Kataoka"},{id:"229066",title:"Prof.",name:"Kazunori",middleName:null,surname:"Kimura",slug:"kazunori-kimura",fullName:"Kazunori Kimura"}]}],onlineFirstChaptersFilter:{topicId:"18",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"82953",title:"Early Visual Areas are Activated during Object Recognition in Emerging Images",slug:"early-visual-areas-are-activated-during-object-recognition-in-emerging-images",totalDownloads:4,totalDimensionsCites:0,doi:"10.5772/intechopen.105756",abstract:"Human observers can reliably segment visual input and recognise objects. However, the underlying processes happen so quickly that they normally cannot be captured with fMRI. We used Emerging Images (EI), which contains a hidden object and extends the process of recognition, to investigate the involvement of early visual areas (V1, V2 and V3) and lateral occipital complex (LOC) in object recognition. The early visual areas were located with a retinotopy scan and the LOC with a localiser. The participants (N=8) then viewed an EI, followed by the hidden object’s silhouette (disambiguation), and then, the EI was repeated. BOLD responses before and after disambiguation were compared. The retinotopy parameters were used to back-project the BOLD response onto the visual field, creating spatially detailed maps of the activity change. V1 and V2 (but not V3) showed stronger response after disambiguation, while there was no difference in the LOC. The back-projections revealed no distinct pattern or changes in activity on object location, indicating that the activity in V1 and V2 is not specific for voxels corresponding to the object location. We found no difference before and after disambiguation in the LOC, which may be repetition suppression counteracting the effect of recognition.",book:{id:"11374",title:"Sensory Nervous System - Computational Neuroimaging Investigations of Topographical Organization in Human Sensory Cortex",coverURL:"https://cdn.intechopen.com/books/images_new/11374.jpg"},signatures:"Marleen Bakker, Hinke N. Halbertsma, Nicolás Gravel, Remco Renken, Frans W. Cornelissen and Barbara Nordhjem"},{id:"82931",title:"Neuroinflammation in Traumatic Brain Injury",slug:"neuroinflammation-in-traumatic-brain-injury",totalDownloads:4,totalDimensionsCites:0,doi:"10.5772/intechopen.105178",abstract:"Neuroinflammation following traumatic brain injury (TBI) is an important cause of secondary brain injury that perpetuates the duration and scope of disease after initial impact. This chapter discusses the pathophysiology of acute and chronic neuroinflammation, providing insight into factors that influence the acute clinical course and later functional outcomes. Secondary injury due to neuroinflammation is described by mechanisms of action such as ischemia, neuroexcitotoxicity, oxidative stress, and glymphatic and lymphatic dysfunction. Neurodegenerative sequelae of inflammation, including chronic traumatic encephalopathy, which are important to understand for clinical practice, are detailed by disease type. Prominent research topics of TBI animal models and biomarkers of traumatic neuroinflammation are outlined to provide insight into the advances in TBI research. We then discuss current clinical treatments in TBI and their implications in preventing inflammation. To complete the chapter, recent research models, novel biomarkers, and future research directions aimed at mitigating TBI will be described and will highlight novel therapeutic targets. Understanding the pathophysiology and contributors of neuroinflammation after TBI will aid in future development of prophylaxis strategies, as well as more tailored management and treatment algorithms. This topic chapter is important to both clinicians and basic and translational scientists, with the goal of improving patient outcomes in this common disease.",book:{id:"11367",title:"Traumatic Brain Injury",coverURL:"https://cdn.intechopen.com/books/images_new/11367.jpg"},signatures:"Grace Y. Kuo, Fawaz Philip Tarzi, Stan Louie and Roy A. Poblete"},{id:"82876",title:"Oxygen Tissue Levels as an Effectively Modifiable Factor in Alzheimer’s Disease Improvement",slug:"oxygen-tissue-levels-as-an-effectively-modifiable-factor-in-alzheimer-s-disease-improvement",totalDownloads:9,totalDimensionsCites:0,doi:"10.5772/intechopen.106331",abstract:"Despite the advance in biochemistry, there are two substantial errors that have remained for at least two centuries. One is that oxygen from the atmosphere passes through the lungs and reaches the bloodstream, which distributes it throughout the body. Another major mistake is the belief that such oxygen is used by the cell to obtain energy, by combining it with glucose. Since the late nineteenth century, it began to be published that the gas exchange in the lungs cannot be explained by diffusion. Even Christian Bohr suggested that it looked like a cellular secretion. But despite experimental evidence to the contrary and based only on theoretical models, the dogma that our body takes the oxygen it contains inside from the air around it has been perpetuated to this day. The oxygen levels contained in the human body are high, close to 99%, and the atmosphere only contains between 19 and 21%. The hypothesis that there is a supposed oxygen concentrating mechanism has not been experimentally proven to date, after almost two centuries. The mistaken belief, even among neurologists, that our body takes oxygen from the atmosphere is widespread, even though there is no experimental basis to support it, just theoretical models. Our finding that the human body can take oxygen from the water it contains, not from the air around it, like plants, comes to mark a before and after in biology in general, and the CNS is no exception. Therefore, establishing the true origin of the oxygen present within our body and brain will allow us to better understand the physio pathogenesis of neurodegenerative diseases.",book:{id:"11637",title:"Neuropsychology of Dementia",coverURL:"https://cdn.intechopen.com/books/images_new/11637.jpg"},signatures:"Arturo Solís Herrera"},{id:"82859",title:"Impact of Hypoxia on Astrocyte Induced Pathogenesis",slug:"impact-of-hypoxia-on-astrocyte-induced-pathogenesis",totalDownloads:6,totalDimensionsCites:0,doi:"10.5772/intechopen.106263",abstract:"Astrocytes are the most abundant cells of the central nervous system. These cells are of diverse types based on their function and structure. Astrocyte activation is linked mainly with microbial infections, but long-term activation can lead to neurological impairment. Astrocytes play a significant role in neuro-inflammation by activating pro-inflammatory pathways. Activation of interleukins and cytokines causes neuroinflammation resulting in many neurodegenerative disorders such as stroke, growth of tumours, and Alzheimer’s. Inflammation of the brain hinders neural circulation and compromises blood flow by affecting the blood–brain barrier. So the oxygen concentration is lowered, causing brain hypoxia. Hypoxia leads to the activation of nuclear factor kappa B (NFkB) and hypoxia-inducible factors (HIF), which aggravates the inflammatory state of the brain. Hypoxia evoked changes in the blood–brain barrier, further complicating astrocyte-induced pathogenesis.",book:{id:"10744",title:"Astrocytes in Brain Communication and Disease",coverURL:"https://cdn.intechopen.com/books/images_new/10744.jpg"},signatures:"Farwa Munir, Nida Islam, Muhammad Hassan Nasir, Zainab Anis, Shahar Bano, Shahzaib Naeem, Atif Amin Baig and Zaineb Sohail"},{id:"82839",title:"Neurophysiology of Emotions",slug:"neurophysiology-of-emotions",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.106043",abstract:"Emotions are automatic and primary patterns of purposeful cognitive-behavioral organizations. They have three main functions: coordination, signaling, and information. First, emotions coordinate organs and tissues, thus predisposing the body to peculiar responses. Scholars have not reached a consensus on the plausibility of emotion-specific response patterns yet. Despite the limitations, data support the hypothesis of specific response patterns for distinct subtypes of emotions. Second, emotional episodes signal the current state of the individual. Humans display their state with verbal behaviors, nonverbal actions (e.g., facial movements), and neurovegetative signals. Third, emotions inform the brain for interpretative and evaluative purposes. Emotional experiences include mental representations of arousal, relations, and situations. Every emotional episode begins with exposure to stimuli with distinctive features (i.e., elicitor). These inputs can arise from learning, expressions, empathy, and be inherited, or rely on limited aspects of the environment (i.e., sign stimuli). The existence of the latter ones in humans is unclear; however, emotions influence several processes, such as perception, attention, learning, memory, decision-making, attitudes, and mental schemes. Overall, the literature suggests the nonlinearity of the emotional process. Each section outlines the neurophysiological basis of elements of emotion.",book:{id:"11742",title:"Neurophysiology",coverURL:"https://cdn.intechopen.com/books/images_new/11742.jpg"},signatures:"Maurizio Oggiano"},{id:"82172",title:"Neuroimaging in Common Neurological Diseases Treated by Anticoagulants",slug:"neuroimaging-in-common-neurological-diseases-treated-by-anticoagulants",totalDownloads:7,totalDimensionsCites:0,doi:"10.5772/intechopen.105128",abstract:"Stroke imaging/Cerebral Venous sinus thrombosis/Arterial dissecting disease in Head and Neck regions/Neurocomplication of anticoagulation therapy. Nowsday, anticoagulant drugs are common drugs used in daily practice for patients in neurology clinic. Anticoagulant treatment used for treated symptomatic patients as well as for prophylaxis therapy in asymptomatic patients. 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