Comparisons of demographic data of patients with suicide attempts from height.
In 1837 Schönlein described a clinical triad manifested as purpuric rash, arthralgias/arthritis, and renal involvement; 1 year later, Henoch related the association of rash, abdominal pain (with bloody diarrhea), and proteinuria; the clinical association of these symptoms was diagnosed as Henoch-Schönlein purpura.
\nThe term Henoch-Schönlein purpura was replaced with immunoglobulin A vasculitis (IgA vasculitis), by the 2012 revised Chapel Hill International Consensus Conference for Nomenclature of Vasculitides [1], based on IgA1-dominant immune deposits affecting small vessels and typically involving the skin, joints, gastrointestinal tract, and kidney.
\nHenoch-Schönlein purpura (HSP) is a small-vessel vasculitis, characterized by a generalized vascular involvement, usually involving the small vessels of the skin, the gastrointestinal (GI) tract, the kidneys, and the joints; it is an acute IgA-mediated disorder that rarely may affect the lungs and the central nervous system (CNS) [2]. IgA vasculitis is a multi-system disorder characterized by palpable purpura, arthritis, glomerulonephritis, and gastrointestinal manifestations and is the most common form of systemic vasculitis for children (90% of cases occur in the pediatric patients) [3].
\nAlthough a lot of algorithm diagnoses were proposed (The American College of Rheumatology, Michel’s criteria, Chapel Hill Consensus Conference, etc.) [1], the diagnostic criteria remain the one published in 2006 [4], revised by the European League Against Rheumatism/Pediatric Rheumatology International Trial Organization/Pediatric Rheumatology European Society (EULAR/PRINTO/PRES); the mandatory criterion is palpable purpura in association with at least one of the following: diffuse abdominal pain, arthritis or arthralgia, renal involvement (hematuria and/or proteinuria), and IgA deposition in biopsy specimen (skin, intestinal tract) [5].
\nDifferential diagnosis includes many diseases with systemic manifestations (cutaneous, articular, gastrointestinal, renal) such as Crohn’s disease (no palpable purpura or gastrointestinal bleeding), IgA nephropathy (no palpable purpura), and hypersensitivity vasculitis (absence of IgA deposition) [4].
\nIgA vasculitis is the most common vasculitis for children; it is usually seen in children between 3 and 10 years old (the age peak is 5–7 years) and very rarely in adults [3, 4]. The annual incidence varies greatly, from 13 to 20/100,000 for children to 0.8–1.8/100,000 for adults [6, 7, 8]. Demographic data showed that males are more frequently affected (male-to-female ratio varies from 1.2:1 to 1.8:1) [3, 9].
\nThe diagnosis is more commonly established in winter and spring and rarely in summer [7, 8], and this aspect may be explained by the association of this disease with infection factors, while approximately 50% of IgA cases are preceded by an upper respiratory tract infection [10].
\nClinical features and severity of the disease also differ by aging, being more severe in adults than in children [10].
\nIgA vasculitis is a small-vessel vasculitis syndrome involving the small vessels of the skin, gastrointestinal tract, kidneys, and joints, consisting of palpable purpura, arthralgia, and gastrointestinal and renal manifestations.
\nThe etiology is still unknown, but precipitating factors such as drug intake and/or upper respiratory tract infections have been associated with the disease development [11]. Although a variety of infectious and chemical triggers are recognized, the underlying cause remains unknown.
\nIn approximately two-thirds of the cases, typical symptoms occur after 7–14 days from an upper respiratory tract infection (previous epidemiological studies have found a seasonal variation of incidence in IgA vasculitis, with more cases occurring in autumn and winter related with upper respiratory tract infection) [4, 11].
\nOther cases of IgA vasculitis have been associated with several viral infections or vaccinations, foods, drugs, hematological malignancies, and tumors [4].
\nHenoch-Schönlein purpura (HSP) is mediated by type III hypersensitivity with deposition of IgA immune complex in the walls of vessels.
\nHistologically, this disease is characterized by leukocytoclastic vasculitis accompanied by IgA immune complexes within affected organs (deposition of IgA and C3 in small-vessel walls, polymorphonuclear leukocyte infiltration around/in small blood vessels, and leukocytoclasia) [11]. The biopsy of the purpuric lesions showed the involvement of small vessels (primarily postcapillary venules) within the papillary dermis and that the predominant cell types within the inflammatory infiltrate are neutrophils and monocytes [12].
\nAlthough the pathogenesis of the disease remains unknown, several authors confirmed the implication of abnormal glycosylation of the hinge region of IgA1, elevated levels of IgA anticardiolipin antibodies, and increased levels of transforming growth factor (TGF)-beta in patients with Ig A vasculitis [12, 13].
\nThe diagnosis is often a clinical one (based on the classic symptoms and signs); since there is no disease-specific laboratory abnormality, no specific test available was able to establish the diagnosis.
\nIgA vasculitis typically has a prodrome (headache, anorexia, fever); after that, a lot of symptoms may develop: rash (especially involving the legs), abdominal pain and vomiting, joint pain (especially involving the knees and ankles), subcutaneous edema, scrotal edema, etc.
\nThe classic tetrad symptoms are rash, arthralgia/arthritis, abdominal pain, and renal manifestations. The clinical diagnosis is easily made in the presence of all these symptoms but may be omitted when the clinical picture is incomplete; in the absence of the classic purpuric rash, the diagnosis of Ig A vasculitis may not be obvious [14, 15].
\nPurpura and joint pain are usually the main symptoms on admission, but the symptoms may develop over the course of some days to weeks and may vary in their order of presentation.
\nThe major clinical manifestations are the following:
Purpura—the appearing symptom in approximately 75% of patients, usually preceding other symptoms
Arthralgia/arthritis—50–75% of cases
Abdominal pain—colicky pain in 50% of cases and gastrointestinal bleeding in 20–30% of cases
The skin lesions are the earliest and most common appearance of the disease in the majority of patients (70%) and include palpable nonthrombocytopenic purpura which evolves from erythema to papules and then to non-blanching palpable purpura with petechiae and ecchymosis (Figure 1). The rash is the hallmark of the disease and typically appears in crops, with new crops appearing in waves (eruptions usually last an average of 3 weeks).
\nPalpable purpura on both ankles.
The typical rash is symmetrically distributed and located primarily in gravity-/pressure-dependent areas, such as the feet, ankles, and lower legs in adults; in the case of children, the buttocks, face, trunk, and upper extremities are more affected [19]. In child patients purpura gradually disappears (it can recur and become chronic), but in adults, it may be necrotic or hemorrhagic in 1/3 of cases, and cutaneous exacerbations may be seen for 6 months or longer [20, 21].
\nArthralgia or arthritis is present in 2/3 of cases of patients; joint complaints are uncommon as the first symptom, but it is the appearing complaint in approximately 25% of children [21]. The articular manifestations are seen more often in adults than in children; typically involve the hips, knees, and ankles (less commonly the upper extremities); and are symmetrical (as skin lesions) in distribution [4]. The joint involvement is usually transient or migratory, typically oligoarticular and non-deforming. A prominent periarticular swelling and tenderness are usual, without joint effusion, erythema, or warmth. The most frequent symptom is arthralgia, while arthritis is very rare; joint effusions are exceptional [20].
\nRenal involvement is found in 40–85% of patients (more prevalent in older children and adults), ranging from microscopic hematuria to progressive glomerulonephritis, and is the most serious complication of Ig A vasculitis [17, 20]. The most common presentation is hematuria (with/without red blood casts) and mild proteinuria; proteinuria without hematuria is very rare. Renal manifestations usually develop within 4 weeks and never precede the onset of skin lesions. The risk of renal failure is rare in children [22] but may be present in about 30% of adult cases, especially in patients with nephrotic and nephritic syndromes [4]. Nephrotic-range proteinuria, elevated serum creatinine, hypertension, and the coexistence of hematuria and proteinuria are associated with an increased risk of renal failure; 2–5% of patients with renal involvement come to an end-stage renal failure [12, 17].
\nGastrointestinal involvement occurs in 50–75% of adult patients—abdominal pain and bloody diarrhea may precede the typical purpuric rash [15, 23]. The digestive symptoms are often present in patients with IgA vasculitis, and although less commonly found in adults, they are more severe and often atypical. The gastrointestinal symptoms vary in intensity, and prudent laparotomy is required to exclude an acute abdominal condition. Gastrointestinal manifestations range from mild (nausea, vomiting, abdominal pain, paralytic ileus) to severe findings (gastrointestinal bleeding, intussusception, bowel ischemia with secondary necrosis, bowel perforation).
\nGastrointestinal symptoms are often the most debilitating manifestations of the disease, and they are much more common in younger patients than in elders [23, 24].
\nThe gastrointestinal manifestations may precede the onset of IgA vasculitis or may develop later in the course of the disease. Typically, gastrointestinal symptoms develop within 8 days from the rash appearance, although longer periods (weeks, even months) have been described. In 10–15% of cases, the gastrointestinal symptoms occur before cutaneous manifestation, making the differential diagnosis of other causes of acute abdomen more difficult [24]. Rarely, gastrointestinal symptoms may appear with no cutaneous purpura at any time [25, 26].
\nAbdominal pain is the most common gastrointestinal symptom, manifested by colicky pain worsened by food (similar to bowel angina), localized to the epigastric and periumbilical regions. The pain is attributed to the involvement of the splanchnic circulation (mesenteric vasculitis) with bowel ischemia and edema of the gastrointestinal tract [4, 23, 27]. Abdominal pain associated with IgAV is caused by submucosal hemorrhage and edema.
\nAbdominal pain is often associated with diarrhea with gross or occult blood, nausea, vomiting, constipation, and gastrointestinal bleeding (hematemesis or melena).
\nIn most cases, on clinical examination, the abdomen is tender and slightly distended; rarely, it may resemble and be confused with an acute abdomen requiring surgery evaluation (suspicion of perforation, intussusception). Some of these cases, suggesting an acute abdomen, are leading to emergency computed tomography (CT) or unnecessary surgery [4, 23]. Sometimes, particularly in young patients, intense abdominal pain may suggest acute appendicitis, especially when the skin rash is absent. Even in the presence of rash (suggestive in a clinical context for Ig A vasculitis) in front of intense abdominal pain, the differential diagnosis of abdominal pain and the exclusion of acute surgical abdomen are mandatory; more, the IgA vasculitis rash may be a nonspecific erythematous or urticarial exanthem or limited to lesions on the buttocks or lower extremities early in the disease course.
\nGastrointestinal bleeding is another symptom, with an incidence varying between 17.6 and 51% [23]. In most cases, the bleeding is occult (detected as positive stool occult blood); when manifested, the main symptom is melena rather than hematemesis or hematochezia, because the intestinal lesions are usually localized in the small bowel and colon. Gastrointestinal bleeding is usually mild; in rare cases it may be severe, requiring blood transfusion or surgical treatment, even leading to death [4, 23].
\nOther rare gastrointestinal manifestations, such as esophageal ulcer, pancreatitis, pseudomembranous colitis, gall bladder involvement, intestinal perforation, and ischemic vasculitis may occur [23].
\nIntussusception is the most common gastrointestinal complication of IgA vasculitis. Edema and hemorrhage can act as a pathological lead point, contributing to the development of intussusception. Intussusception is limited to the small bowel in approximately 60% of cases, in contrast to idiopathic intussusception, which is typically ileocolic. The overall incidence of this complication of IgA vasculitis varies between 2.3 and 3.5%, although some retrospective series reported an incidence of only 0.4 to 0.6% [9, 17]. Children with severe gastrointestinal pain and/or requiring hospitalization are at greater risk.
\nUpper gastrointestinal endoscopy (UGD) is mandatory in patients with gastrointestinal bleeding. UGD is helpful in the diagnosis of IgA vasculitis, especially when gastrointestinal symptoms develop prior to the cutaneous lesions.
\nThe most important part of upper gastrointestinal tract is involved in the second part of the duodenum with endoscopic features including diffuse mucosal redness, petechiae, severe erosive duodenitis, hemorrhagic lesion, and ulcers [28] (Figure 2). Purpuric lesions may be seen on an endoscopy, commonly in the descending duodenum, stomach, and colon.
\nEndoscopic appearance of the second part of duodenum: multiple erosions, diffuse redness, submucosal hemorrhage, and small ulcerations.
The spectrum of upper endoscopic findings is based upon the severity of the vasculitis; usually, irregular, ulcerating, nodular lesions or hematoma-like protrusions are characteristic of IgA vasculitis in the duodenum. The stomach and colon are often involved as well, but the duodenal bulb is rarely affected; the absence of bulbar lesions is important to exclude the cause of the peptic disease hemorrhage [29]. The biopsies of gastrointestinal lesions are commonly performed in patients with or without suspected IgA vasculitis in order to rule out infection, inflammatory bowel disease, and less commonly, vasculitis. In general, vasculitis is not commonly observed in GI biopsies, and the spectrum of findings includes neutrophilic infiltrate within the small bowel and colon, with the duodenum most commonly affected. While the clinical and histologic findings may mimic early inflammatory bowel disease, the presence of predominant small bowel involvement, especially erosive duodenitis, should raise suspicion for IgA vasculitis. Biopsies should be obtained before steroid therapy is initiated, if possible [30].
\nResolution of duodenal lesions is spectacular, in accordance with the remission of inflammatory disorders [31] (Figure 3).
\nEndoscopic appearance of the second part of duodenum remission.
Colonoscopy: erythema of the mucosa, petechiae, and ulcers are the most common findings [32].
\nComputed tomography (CT) imaging: the hallmarks of IgA vasculitis are multifocal symmetric, circumferential, regular wall thickening and engorgement of mesenteric vessels. Associated findings include free intraperitoneal fluid, ileus of the affected loop, vascular engorgement in the adjoining mesentery, and nonspecific lymphadenopathy [24]. The target sign is not specific; it can be seen in many other conditions such as ischemic bowel disease, inflammatory bowel disease, infectious enterocolitis, radiation enteritis, etc. [19].
\nIn some selected cases, CT angiography can be used to visualize the site of the arterial or venous occlusion; however, a normal angiogram does not rule out the possibility of mesenteric ischemia [3]. Mesenteric vascular engorgement and skip areas are also seen in Crohn’s disease, but terminal ileal involvement, stricture, fistula, and abscess would favor Crohn’s disease over other conditions [12, 33].
\nThe diagnosis of IgA vasculitis (HSP) is usually based upon clinical manifestations of the disease, and in patients with an incomplete/unusual presentation, biopsy of the affected organ (e.g., skin or kidney) demonstrating predominantly IgA deposition supports the diagnosis. Although gastrointestinal involvement is frequent, the diagnosis of IgA vasculitis may be difficult when gastrointestinal manifestations occur alone or precede the characteristic skin purpura.
\nFalls from height cause significant death and disability worldwide, due to the severe traumatic load inflicted on their victims [1, 2, 3, 4]. According to the WHO, the yearly mortality due to suicide worldwide is approximately 800,000 people. What is more important is the fact that it affects mainly young people, suicide being the primary cause of death in the age group of 25–34 years [5]. The mean incidence of suicides across Europe in 2013 was of 11.7 deaths per 100,000 people. Low rates, under 8 deaths per 100,000 inhabitants were recorded in Italy, Malta, Cyprus and the United Kingdom. The lowest incidence was observed in Greece (4.8 cases per 100,000 people) [6]. There was a lag between the beginning of the economic crisis in Europe, and the manifestation of its effects on the Greek population. These became evident 3 or 4 years later, in the form of a reduction of household income and an increase in the rate of unemployment [7, 8, 9].
Causes for this mechanism of injury include both accidental falls and deliberate suicide attempts [10]. The latter constitutes a major social problem, with implications for the entire society, but particularly for the affected family. The psychological profile of people committing suicide is complex and unique for each case [11]. Thus, identifying contributing factors that may lead to suicide and establishing strategies for the safekeeping of mental health in communities are of paramount importance.
The type of injuries incurred after a fall constitute a unique pattern of blunt trauma, with a characteristic distribution of damage (multiple lesions in a variety of body areas) [1, 12, 13]. The most common form of trauma are fractures, followed by other areas, such as the head, the thorax, the abdomen as well as the retroperitoneum, being injured by varied degrees [14]. The quantity and the quality of traumatic load absorbed depend on factors like the height from which the fall occurred, the part of the patient’s body that had the first impact, the surface where the impact occurred and the victim’s age, taking into account the associated comorbidity, and reduced physiologic reserve that advanced age implies [15, 16, 17]. Anticipation and prediction of the exact areas being injured are not possible, because of the multitude of factors involved, and the exact unpredictability of the fall’s kinematic [18, 19].
As aforementioned, one can infer that the differential diagnosis of falls from height from other types of blunt trauma (for example, a road-traffic-collision with expulsion of the occupants from the vehicle) is difficult. Thus, a high index of suspicion must be maintained concerning the initial cause in cases of polytrauma in victims with an unknown history [20]. An array of papers have dealt with injury-related deaths in general, while others have differentiated between unintentional and intentional injury-related deaths [21, 22, 23, 24]. There are few studies though that have looked into patients with intentional or unintentional injuries, due to a fall from height, at a single centre [13, 25].
As noted by research in the past, self-harm due to a fall is a rare phenomenon, being responsible for 4–7% of deaths from suicide in the developed world [26, 27, 28, 29]. On the other hand, studies have shown that psychiatric disorders are a frequent finding in patients suffering trauma [30, 31, 32]. Nevertheless, the connection between mental disorders and specific injury patterns has not been adequately described. Furthermore, the elucidation of patterns of injury incurred after accidental falls and after intentional suicide jumps, might be of help to forensic pathologists while investigating the circumstances of a death after a fall from height.
From January 1990 to October 2012, 64 patients (15 males and 49 females) were studied as a result of falls from height. Fall from height ≥ 3 m is classified as high energy trauma in accordance to ATLS guidelines [33]. The mean patient age was 34 years (range 16–65 years). These 64 cases comprised our series and, for comparison, were divided into those without mental disorders (n = 32, group I) and those with mental disorders (n = 32, group II). Group II cases were further stratified according to their psychiatric diagnosis.
The principles of Advanced Trauma Life Support were followed in the management of all patients. Basic laboratory screening included haemoglobin level, prothrombin time, type and crossmatch and arterial blood gas analysis. Data collected included age, gender, associated trauma, injury severity score (ISS), Glasgow Coma Scale (GCS), haemodynamic status (systolic blood pressure less than 90 mm Hg on arrival), length of intensive care unit (ICU) and hospital stay.
Also, the following trauma variables were analysed: specific intracranial injuries (epidural, subdural and subarachnoid haemorrhage and brain contusion), spinal injuries (cervical, thoracic and lumbar spine), thoracic injuries, specific intra-abdominal injuries (liver, spleen, kidney, and hollow viscus) and specific fractures (pelvis, femur and tibia). The diagnosis of mental disorder was ascertained by psychiatric specialists using the criteria of the International Classification of Disease Ninth Version Clinical Modification (ICD-9CM).
The mean height of fall was 5.4 m (range, 3–25 m). The patients were separated in two groups: group I, without mental disorders (n = 32), and group II, with mental disorders (n = 32). The demographic data, including age, gender, height of fall, ISS, GCS, initial shock (SBP <90 mm Hg), hospital stay (days), ICU stay (days) and deaths are summarized in Table 1. The mean hospital stay was 29 days (range 19–45) and the mean ICU stay was 9 (range, 5–13) (Table 1).
Data | Patients |
---|---|
Age | 35 (18–65) |
Gender (M:F) | 15:49 |
ISS | 20 (12–58) |
GCS | 9 (6–13) |
Haemodynamic status-SBP <90 mmHg | 34 |
Hospital stay (days) | 29 (19–45) |
ICU stay (days) | 9 (5–13) |
Deaths | 13 |
Comparisons of demographic data of patients with suicide attempts from height.
Concerning their background psychiatric disorder in group II, the diagnosis was schizophrenia in 32 patients, depression in 12, drugs or alcohol abuse in 3, personality disorder in one, manic depression in one, another psychiatric condition in one and 14 cases without a specific diagnosis (generally marital or work related).
Patients due to suicide attempts from height comprised of 15 males and 49 females with a mean of age 35 years (range: 18–65 years). Of those, 16 were single, 14 were married and 2 were divorced. Thirty-three patients were employed, 6 were housewives, 7 were unemployed, 3 were students/pupils and 15 had various occupations. As far as religion was concerned, 48 were Christian Orthodox, one Roman Catholic, one Jewish, one Muslim and 13 of other religions.
Regarding their family status: 20 had children, 6 had only their parents, 3 had only their spouse, 2 had a step family, 2 had parents who were divorced, 6 had parents and/or siblings, one had both parents and children and 24 had no family at all.
The falls had occurred from a roof or balcony in 39 cases, from a window in 12, from a bridge in 7 and inside the house in 6. The mean injury severity score (ISS) was 20 (range 12–58) for all victims of fall. Sixteen patients arrived at the emergency department in shock. The most common body region having sustained severe trauma were the fractured extremities and/or spine, followed by the chest, the head and the abdomen for both groups (Table 2).
Fall from | Patients |
---|---|
Roof/balcony | 39 |
Window | 12 |
Bridge | 7 |
Inside the house | 6 |
Associated injuries | |
Abdominal trauma | 4 |
Thoracic trauma | 32 |
Head injuries | 16 |
Extremity fractures | 199 |
Spinal fractures | 32 |
Location where the fall occurred and associated injuries.
Head injuries were revealed by CT scan in 16 patients. The mean GCS was 9 (range 6–13) for both groups. The most common intracranial injury was brain contusion and subarachnoid haemorrhage, followed by subdural hematoma and epidural hematoma. The incidence of subarachnoid haemorrhage in the suicide group was significantly higher than in the accidental group.
Associated abdominal injuries were present in 4 patients. The most common injury was liver laceration, followed by kidney and spleen laceration. One died with an operative finding of a large central retroperitoneal haematoma due to a vena cava rupture. In the remaining 3 patients, ultrasonography showed minimal intraperitoneal blood and these patients were not operated on. Thoracic injuries were present in 32 patients. The most common of these were rib fractures—26 cases. Twelve of these patients had a haemopneumothorax and 6 had a sternum fracture. Conservative treatment with assisted ventilation was necessary in these cases (Table 3).
Patients | |
Skull, thorax and upper extremities | |
Skull | 16 (25%) |
Shoulder | 4 (6.2%) |
Scapula | 6 (9.3%) |
Sternum | 6 (9.3%) |
Ribs | 26 (40.6%) |
Humerus | 8 (12.5%) |
Elbow joint | 8 (12.5%) |
Distal radius | 7 (10.9%) |
Hand | 4 (6.2%) |
Spinal fractures | 32 (50%) |
Pelvis | 27 (42.1%) |
Lower extremities | |
Acetabulum | 9 (14%) |
Femoral neck | 38 (59.3%) |
Femur | 18 (28.1%) |
Knee joint | 17 (26.5%) |
Tibia | 19 (29.6%) |
Ankle joint | 36 (56.2%) |
Calcaneum | 34 (53.1%) |
The distribution of fractures in percentage across body region for the two groups of patients.
Upper extremity fractures were found in 37 patients, while pelvic and lower extremity fractures were found in 198 cases. Spinal fractures were noted in 32 patients. As far as the level of injury was concerned, in 16 cases, it was in the lumbar level, in 9 cases in the cervical, in 5 cases in thoracic and in 2 cases the sacral vertebrae were concerned. Regarding the neurologic deficit, in 23 cases, the injury was incomplete (14 with ASIA C and 9 with ASIA D), and in 9 cases, it was complete (4 with ASIA A and 5 with ASIA B). Further details with our data of 32 patients with spinal cord injury as a result of deliberate self-harm have been published previously [34]. It seems that the neurological complications of spinal injuries were correlated with the increase of the height from which the fall occurred.
Patients with psychiatric disorders were more frequently shocked on arrival at the emergency department than those in the accidental group, the most common reason for death being head injury. Fatalities were more common when patients fell from greater heights (over 4 m), or when their head hit a hard surface, such as concrete.
The final causes of inpatients’ death were: head injury in 8 cases, multiple organ failure in 3 cases, pneumonia in one case and cardiac complications in another one. The majority of patients who died of organ failure had sustained significant head injury. In one case, death occurred after a second suicide attempt 2 years later.
Each patient underwent a psychiatric evaluation by a consulting psychiatrist as soon as his condition and cooperation permitted. The assessment comprised of an interview. Regarding the type of treatment for the spinal fracture—dislocations, instrumentation devices included titanium rods, transpedicular screws, sacral bars and bone grafting in all patients. No new suicide attempt was recorded during the hospital stay.
All patients were discharged from hospital approximately 6–8 weeks after the operation with a custom-made thermoplastic thoracolumbar or lumbosacral orthosis for another 8 weeks and instructions for physical therapy and rehabilitation programs. The mean follow-up was 6 years (12 months to 10 years range). At follow-up, 27 patients were available for evaluation due to the death of 5 patients, 1–3 years post initial injury, because of suicide in one case (patient 7 of group II) and medical complications in 4 cases [renal failure in 3 cases (patients 8, 14 and 30 in group II) and pneumonia in one (patient 21)]. In the remaining patients, new unsuccessful attempts were recorded in 2 cases (7%) due to psychiatric disorders, 1–3 years after the first attempt (patients 10 and 24). All survivors received psychiatric follow-up. The overall mortality was significantly higher in those patients who fell from more than 10 m.
Suicides and suicide attempts constitute a major concern for public health services, with implications for both families and society [35]. Trauma incurred due to falls from height poses a great burden on health services due to its severity. This is particularly important if we take into account the fact that this is a largely preventable mechanism of injury. Prior knowledge of the possible traumatic patterns incurred after a fall from height can prove helpful in the initial evaluation of this group of patients. From an epidemiologic point of view, trauma due to falls may occur across all age groups, but it is the two extremes, the very young and elderly, which are particularly susceptible to it [36].
In this study, we have considered two groups of patients. Group I represented patients with no mental disorders and group II with mental disorders. It is quite difficult to identify someone who is prone to committing suicide. In addition, the observed number of suicides and suicide attempts being committed at a younger age (i.e. adolescence) has been a cause of concern worldwide and particularly in Europe [37]. The male-female ratio of suicide attempts varies across age groups. Thus, in the younger age group (15–24 years old), it is 1:1.9; and in the middle age group (45–54 years old) it is 1:1.7. This ratio further decreases for those older than 55 years to 1:1.4 [38]. In this study, the male-female ratio was 1:3. The female sex was associated with an increased likelihood of death due to a higher amount of energy involved in their attempted fall.
According to other studies [39, 40], young males tend to repeat suicide attempts more frequently than females and the methods used by them lead to an increased mortality. A suicide attempt in the past is a red flag for a possible attempt in the future; so, there is a strong correlation between suicide attempts and deaths from suicide both regionally and nationally, and particularly in young males [41]. Also, there is a strong correlation between repeated attempts and completed suicide, especially in the group of males who have used a violent method [42, 43].
The study by Dickson et al. had the aim of establishing a correlation between mortality and various factors, such as the patients’ injury severity score (ISS), the height from which the fall took place, the patient’s intention and the body regions that were injured. In addition, the height of the fall strongly correlated with the patient’s ISS and was an important predictor of mortality [44]. Head and/or chest injuries, if due to a fall from height, were strongly associated with an increased incidence of death. According to the authors, this mechanism of injury should be a triage priority when tasking ambulances. In addition, the best way of treating these injuries is their prevention. No other significant predictors of mortality were found in this study.
In the case series by Kent and Pearce, 282 suicide attempts were studied, 13 of which were completed. Of those, 8 happened at home, all patients were older than 49 years; and in 7 out of 8 deaths, ladders were implicated [45]. The retrospective study by Petratos et al. analysed in detail the musculoskeletal traumatic pattern resulting from falls from height, and focused particularly on the correlation between specific fracture patterns and the height from which the fall happened, as well as on the causation of the fall (suicide attempt vs. accident). According to their findings, with an increase in the height from which the fall occurred, the frequency of limb, thoracic and pelvic fractures also increased. Such a correlation was not evident for head injuries. Nevertheless, the anatomical regions having sustained fractures (including the cranium) varied in accordance with the height of the fall. Thus, we can infer a mechanism of injury that is varying proportionately to the height of the fall. There was no significant difference between the patients who attempted suicide and those who fell by accident as far as the number of fractures incurred or the regions having been injured were concerned. Nevertheless, with regard to our results that have been published previously, patients who attempted suicide had a significantly greater number of bilateral lower limb fractures than their accidental fall counterpart. In addition, logistic regression analysis shows a significant correlation between the cause of the fall and the presence of lower limb fractures. According to the authors, further research is necessary in order to establish a correlation between incurred traumatic pattern, the height of the fall and the patient’s intention [46].
Choi et al. in his recent study attempted to differentiate the characteristics of traumatic pattern between intentional and non-intentional falls [47]. In addition, he attempted to determine prognostic factors for suicide attempt-related injury and promote adequate measures for the prevention and management of such injuries. In this study, 8992 patients with an accidental fall (non-intentional group) and 144 patients who committed a suicide attempt (intentional group) were included. Falls from a height greater than 4 metres were more frequently encountered in the intentional group. Death prior to patient’s arrival in the accident and emergency department occurred in 54.9% of the cases of suicide attempt. Patients within the intentional group, having sustained increased traumatic load, had fallen from higher, were older and were more likely to be of lower educational level (high-school graduates, instead of college). Due to the fact that injuries sustained after an intentional fall were more likely to have a reserved outcome, the authors highlighted the importance of prevention. Such measures include telephone support and counselling lines, the installation of signs advising against suicide in high risk areas for an intentional fall, such as bridges, along with suggestions for government-coordinated programs aiming for the education of the public and the improvement of social conditions generally and the support of the community and family in particular.
The reasons behind a suicide attempt are multifactorial, hard to quantify and unique in every case. Nevertheless, the study of multiple suicide attempts puts into evidence some risk factors that would lead to such a decision. These are common across all age groups and include: the presence of mental illness, either currently or in the past, a history of alcohol or drug dependence, as well as the presence of depression [10]. Epidemiologically, one out of five persons who have attempted suicide will try once more within a year, and 10% of them will succeed in the end. Drug ingestion is the most common mechanism for a suicide attempt. Violent mechanisms such as hanging, falls from height and use of weapons are not common [48]. The persons who have attempted suicide by falling from height usually become polytrauma patients. The types of injuries incurred are two: deceleration injuries due to inertial phenomena, usually at viscera with vascular pedicles, and direct impact injuries [49].
The severity of fractures incurred will depend on factors like the area over which the impact is applied [50]. The smaller the area of spread of the impact, the greater the local load. Therefore, patients landing on their legs tend to suffer more severe injuries than those who have landed on their flanks, or prone, or supine [51]. Patients due to accidental falls mostly suffered spinal fractures and upper extremities fractures in an attempt to protect themselves. Patients due to suicidal high falls attempts suffered mostly of lower limb fractures, pelvis, spinal fractures and head injuries. Distal radius and hand was the most common affected region in upper extremities in patients with non-intentional falls, in an attempt to protect mainly the head and grab something stable to prevent further fall. In patients with intentional falls, kinetic energy is absorbed mainly by the lower limbs, pelvis, spine and head, leading to characteristic fracture patterns [52]. The most common cause for death is head injury [51, 53, 54] and this is accordance to our results. Turk and Tsokos reviewed 68 medicolegal autopsy cases (22 females, 46 males, age range 13–89 years) of fatal falls from height from 1997 to 2001 [55]. The cause of instant death was head trauma in 24 (35%), internal blood loss in 9 (13%) and polytrauma in 30 (44%) cases. Other causes of death, when the individuals survived the trauma for a longer period, included septic multiple organ dysfunction syndrome and pulmonary embolism. In general, suicides were from greater heights than accidents (mean height 22.7 m for suicides and 10.8 m for accidents, respectively). Strikingly, severe head injuries predominantly occurred in falls from heights below 10 m (84%) and above 25 m (90%). Head trauma was the cause of death in 11 of the 19 cases that were from 9 m or less (58%). Of all cases, 51 (75%) died within a few minutes. A survival time of several hours up to 1 day was observed in 8 cases. Nine patients survived for several days (up to 16 days). Five of them fell from heights below 10 m. Patients with intentional fall from height have a higher early mortality than patients due to accidental fall from height [56].
The easiest way to underline the suspicion that the mode is suicide is if a suicide note is found at the jumping site; this is, however, closer to being the exception than the rule. Analysing the distance of the body from the site of descent may sometimes also help us determine the manner of death. The distance of the body from the site of descent includes the falling height and the horizontal distance. The falling height in suicide was statistically higher than that in accident [57, 58]. For similar heights, Wischhusen et al. have demonstrated that in passive falls, the horizontal distance is usually farther than jumps [59]. From a mechanical point of view, during a fall from height, potential (dynamic) energy is converted into kinetic and this leads to fractures upon impact. Another important factor of the severity of injuries is the height of fall, as the kinetic energy is increasing due to acceleration during the fall and is maximum at the time of impact [60]. In suicide falls, kinetic energy is absorbed mainly by the lower limbs, pelvis and spine, leading to characteristic fracture patterns. In accidental falls, patients most probably extend their arms and flex their hips, which lead to a damping effect that protects the spine [61]. Hence, the most important determinant of survival after a free fall is the position of the body at the time of impact [49]. There were only 3 patients (cases 1, 22 and 31) in group II who have sustained solely upper extremity fractures. The most common body position at the time of impact is with the patient standing and landing with the lower extremities first. This usually leads to calcaneal or pilon fractures, as well as thoracolumbar fractures. If the impact takes place with the patient seated, then higher thoracic or cervical injuries are more likely to happen, which are associated with a higher rate of mortality. Finally, an unpredictable fracture pattern takes place when the victim suffers multiple secondary impacts, in various postures, after bouncing from the primary impact. The amount of injury incurred will depend on the rate of dissipation and absorption of energy, through the patient’s body.
According to the paper by Teh et al., there is a difference to the traumatic pattern incurred by jumpers compared to fallers [13]. Namely, the jumpers tend to impact their dominant lower limb first, as well as sustaining right sided thoracic injuries in the process. We did not confirm the above-mentioned findings in our study. The severity of spinal cord injuries was more important in the suicide than the accidental group [52]. This was in accordance with studies performed in the past, which also showed the early neurologic involvement in such cases. As far as prognosis of spinal cord injury is concerned, complete injuries will be unaltered both in level and extent in a year’s time. On the other hand, incomplete injuries may show signs of improvement for a period of 2 years after the impact [62]. Our results regarding prognosis for ambulation in ASIA A patients and for functionality in ASIA C patients are in accordance with current knowledge [63].
Anderson et al. performed a retrospective study, regarding the rehabilitation outcome of patients with spinal cord injury, as a result of deliberate self-harm (DSH) [29]. According to them, spinal fractures in the DSH group were mainly the result of falls from height. Underlying causes were revealed, such as psychiatric disorders and substance abuse, necessitating formal psychiatric review. There was no difference in short-term rehabilitation results between the DSH and accidental spinal cord injury group. In addition, DSH seemed to impact the length of stay only in patients with a spinal fracture, but without cord injury.
According to the literature, there are three studies on the subject of acute spinal cord injury following a suicide attempt that stand apart. The first is by Stanford et al. In his paper, 56 cases were followed over a period of 30 years (1970–2000). Fifty five cases were due to a fall from height and one open injury, through the use of a gun. Follow-up of 8 years on average was available for 47 cases (84%). The vertebral levels most frequently injured were C5 and L1. About 23 patients suffered from a complete spinal cord injury and 32 had a severe traumatic load (ISS > 15). The psychiatric background of these patients included personality disorder in 27, schizophrenia in 16, depression in 14 and substance abuse/dependence in 20. Of these patients, 4 were successful in subsequent suicide attempts [28].
The following two studies on this subject are from the UK [26] and Denmark [27]. Both of those are observational and retrospective, with a long follow-up. According to the latter, there is an increasing incidence of suicide attempts and associated spinal cord injury from 1965 to 1987. Approximately one third of the patients who attempted suicide suffered from schizophrenia. According to other papers [64, 65], schizophrenia is strongly correlated with falls from height (from bridges in particular). There were 7 patients in our study who have sustained a fall from a bridge. Damage control surgery principles are followed initially for the treatment of life-threatening injuries and for both limb and spinal trauma [66]. The primary goals of fracture fixation are timely mobilization and safe transfer to psychiatric services. Conservative treatment measures are not usually recommended for this group of patients.
Our findings are in accordance with relevant bibliography [67, 68], regarding the psychiatric background of patients who attempt suicide by falling from height. The spectrum of conditions encountered encompasses bipolar disorder, substance dependence and abuse, personality disorder and schizophrenia.
From an epidemiological point of view, schizophrenia is encountered in 5–10% of cases of suicide attempt. These patients may have well planned their suicide or even suffered from an active self-harm ideation. From the above-mentioned, we gather that management of these patients from a trauma point of view must take into consideration their psychiatric needs. The latter may cause significant disturbance in the delivery of medical care [69]. Most of the patients in this study had a positive response following adequate psychiatric intervention. Hence, we gather that prevention and early identification of persons at risk for a suicide attempt with the use of appropriate screening tools by health care professionals are invaluable.
Education of medical and nursing staff regarding the demands and particularities of care of this population, suffering from both spinal cord injury and psychiatric disorders, cannot be overemphasized. Regular follow-up with multidisciplinary team input and future research are necessary for the provision of high-quality care to this population.
According to the literature, it has been difficult to obtain comparable international data on suicide attempts, owing to disparities in definitions, survey designs and study methods, because the combination of free falls and mental disorders produces a unique group of patients. It has been our experience that psychiatric conditions, and especially the suicidal risk, should be evaluated and treated as early as possible during the orthopaedic or surgical hospitalization. Management requires both psychopharmacological therapy and psychotherapy. It has to be directed towards the achievement of symptomatic relief and, if possible, towards the remission of the primary psychiatric disorder.
The management of these patients in the orthopaedic or surgical ward is difficult, because of restlessness, non-cooperation of the patient and the problem of staff inexperienced in handling the psychiatric patient. When prolonged orthopaedic and rehabilitation management are necessary, it is suggested that the patient be transferred to a psychiatric hospital while continuing the necessary orthopaedic treatment. The outcome data provide critical information concerning those individuals who have attempted suicide and suggests future methods for the identification of suicidal factors.
The authors declare that they have no conflicts of interest.
You have been successfully unsubscribed.
",metaTitle:"Unsubscribe Successful",metaDescription:"You have been successfully unsubscribed.",metaKeywords:null,canonicalURL:"/page/unsubscribe-successful",contentRaw:'[{"type":"htmlEditorComponent","content":""}]'},components:[{type:"htmlEditorComponent",content:""}]},successStories:{items:[]},authorsAndEditors:{filterParams:{sort:"featured,name"},profiles:[{id:"6700",title:"Dr.",name:"Abbass A.",middleName:null,surname:"Hashim",slug:"abbass-a.-hashim",fullName:"Abbass A. Hashim",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/6700/images/1864_n.jpg",biography:"Currently I am carrying out research in several areas of interest, mainly covering work on chemical and bio-sensors, semiconductor thin film device fabrication and characterisation.\nAt the moment I have very strong interest in radiation environmental pollution and bacteriology treatment. The teams of researchers are working very hard to bring novel results in this field. I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. I have served as the editor for many books, been a member of the editorial board in science journals, have published many papers and hold many patents.",institutionString:null,institution:{name:"Sheffield Hallam University",country:{name:"United Kingdom"}}},{id:"54525",title:"Prof.",name:"Abdul Latif",middleName:null,surname:"Ahmad",slug:"abdul-latif-ahmad",fullName:"Abdul Latif Ahmad",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"20567",title:"Prof.",name:"Ado",middleName:null,surname:"Jorio",slug:"ado-jorio",fullName:"Ado Jorio",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidade Federal de Minas Gerais",country:{name:"Brazil"}}},{id:"47940",title:"Dr.",name:"Alberto",middleName:null,surname:"Mantovani",slug:"alberto-mantovani",fullName:"Alberto Mantovani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"12392",title:"Mr.",name:"Alex",middleName:null,surname:"Lazinica",slug:"alex-lazinica",fullName:"Alex Lazinica",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/12392/images/7282_n.png",biography:"Alex Lazinica is the founder and CEO of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. Today his focus is on defining the growth and development strategy for the company.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"19816",title:"Prof.",name:"Alexander",middleName:null,surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/19816/images/1607_n.jpg",biography:"Alexander I. Kokorin: born: 1947, Moscow; DSc., PhD; Principal Research Fellow (Research Professor) of Department of Kinetics and Catalysis, N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow.\r\nArea of research interests: physical chemistry of complex-organized molecular and nanosized systems, including polymer-metal complexes; the surface of doped oxide semiconductors. He is an expert in structural, absorptive, catalytic and photocatalytic properties, in structural organization and dynamic features of ionic liquids, in magnetic interactions between paramagnetic centers. The author or co-author of 3 books, over 200 articles and reviews in scientific journals and books. He is an actual member of the International EPR/ESR Society, European Society on Quantum Solar Energy Conversion, Moscow House of Scientists, of the Board of Moscow Physical Society.",institutionString:null,institution:{name:"Semenov Institute of Chemical Physics",country:{name:"Russia"}}},{id:"62389",title:"PhD.",name:"Ali Demir",middleName:null,surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62389/images/3413_n.jpg",biography:"Dr. Ali Demir Sezer has a Ph.D. from Pharmaceutical Biotechnology at the Faculty of Pharmacy, University of Marmara (Turkey). He is the member of many Pharmaceutical Associations and acts as a reviewer of scientific journals and European projects under different research areas such as: drug delivery systems, nanotechnology and pharmaceutical biotechnology. Dr. Sezer is the author of many scientific publications in peer-reviewed journals and poster communications. Focus of his research activity is drug delivery, physico-chemical characterization and biological evaluation of biopolymers micro and nanoparticles as modified drug delivery system, and colloidal drug carriers (liposomes, nanoparticles etc.).",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"61051",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"100762",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"St David's Medical Center",country:{name:"United States of America"}}},{id:"107416",title:"Dr.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Texas Cardiac Arrhythmia",country:{name:"United States of America"}}},{id:"64434",title:"Dr.",name:"Angkoon",middleName:null,surname:"Phinyomark",slug:"angkoon-phinyomark",fullName:"Angkoon Phinyomark",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/64434/images/2619_n.jpg",biography:"My name is Angkoon Phinyomark. I received a B.Eng. degree in Computer Engineering with First Class Honors in 2008 from Prince of Songkla University, Songkhla, Thailand, where I received a Ph.D. degree in Electrical Engineering. My research interests are primarily in the area of biomedical signal processing and classification notably EMG (electromyography signal), EOG (electrooculography signal), and EEG (electroencephalography signal), image analysis notably breast cancer analysis and optical coherence tomography, and rehabilitation engineering. I became a student member of IEEE in 2008. During October 2011-March 2012, I had worked at School of Computer Science and Electronic Engineering, University of Essex, Colchester, Essex, United Kingdom. In addition, during a B.Eng. I had been a visiting research student at Faculty of Computer Science, University of Murcia, Murcia, Spain for three months.\n\nI have published over 40 papers during 5 years in refereed journals, books, and conference proceedings in the areas of electro-physiological signals processing and classification, notably EMG and EOG signals, fractal analysis, wavelet analysis, texture analysis, feature extraction and machine learning algorithms, and assistive and rehabilitative devices. I have several computer programming language certificates, i.e. Sun Certified Programmer for the Java 2 Platform 1.4 (SCJP), Microsoft Certified Professional Developer, Web Developer (MCPD), Microsoft Certified Technology Specialist, .NET Framework 2.0 Web (MCTS). I am a Reviewer for several refereed journals and international conferences, such as IEEE Transactions on Biomedical Engineering, IEEE Transactions on Industrial Electronics, Optic Letters, Measurement Science Review, and also a member of the International Advisory Committee for 2012 IEEE Business Engineering and Industrial Applications and 2012 IEEE Symposium on Business, Engineering and Industrial Applications.",institutionString:null,institution:{name:"Joseph Fourier University",country:{name:"France"}}},{id:"55578",title:"Dr.",name:"Antonio",middleName:null,surname:"Jurado-Navas",slug:"antonio-jurado-navas",fullName:"Antonio Jurado-Navas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/55578/images/4574_n.png",biography:"Antonio Jurado-Navas received the M.S. degree (2002) and the Ph.D. degree (2009) in Telecommunication Engineering, both from the University of Málaga (Spain). He first worked as a consultant at Vodafone-Spain. From 2004 to 2011, he was a Research Assistant with the Communications Engineering Department at the University of Málaga. In 2011, he became an Assistant Professor in the same department. From 2012 to 2015, he was with Ericsson Spain, where he was working on geo-location\ntools for third generation mobile networks. Since 2015, he is a Marie-Curie fellow at the Denmark Technical University. His current research interests include the areas of mobile communication systems and channel modeling in addition to atmospheric optical communications, adaptive optics and statistics",institutionString:null,institution:{name:"University of Malaga",country:{name:"Spain"}}}],filtersByRegion:[{group:"region",caption:"North America",value:1,count:5703},{group:"region",caption:"Middle and South America",value:2,count:5174},{group:"region",caption:"Africa",value:3,count:1690},{group:"region",caption:"Asia",value:4,count:10246},{group:"region",caption:"Australia and Oceania",value:5,count:889},{group:"region",caption:"Europe",value:6,count:15653}],offset:12,limit:12,total:117317},chapterEmbeded:{data:{}},editorApplication:{success:null,errors:{}},ofsBooks:{filterParams:{topicId:"17"},books:[],filtersByTopic:[{group:"topic",caption:"Agricultural and Biological Sciences",value:5,count:9},{group:"topic",caption:"Biochemistry, Genetics and Molecular Biology",value:6,count:14},{group:"topic",caption:"Business, Management and Economics",value:7,count:2},{group:"topic",caption:"Chemistry",value:8,count:6},{group:"topic",caption:"Computer and Information Science",value:9,count:10},{group:"topic",caption:"Earth and Planetary Sciences",value:10,count:4},{group:"topic",caption:"Engineering",value:11,count:16},{group:"topic",caption:"Environmental Sciences",value:12,count:2},{group:"topic",caption:"Immunology and Microbiology",value:13,count:4},{group:"topic",caption:"Materials Science",value:14,count:5},{group:"topic",caption:"Mathematics",value:15,count:1},{group:"topic",caption:"Medicine",value:16,count:57},{group:"topic",caption:"Neuroscience",value:18,count:1},{group:"topic",caption:"Pharmacology, Toxicology and Pharmaceutical Science",value:19,count:5},{group:"topic",caption:"Physics",value:20,count:2},{group:"topic",caption:"Psychology",value:21,count:3},{group:"topic",caption:"Robotics",value:22,count:1},{group:"topic",caption:"Social Sciences",value:23,count:3},{group:"topic",caption:"Technology",value:24,count:1},{group:"topic",caption:"Veterinary Medicine and Science",value:25,count:2}],offset:12,limit:12,total:0},popularBooks:{featuredBooks:[{type:"book",id:"7802",title:"Modern Slavery and Human Trafficking",subtitle:null,isOpenForSubmission:!1,hash:"587a0b7fb765f31cc98de33c6c07c2e0",slug:"modern-slavery-and-human-trafficking",bookSignature:"Jane Reeves",coverURL:"https://cdn.intechopen.com/books/images_new/7802.jpg",editors:[{id:"211328",title:"Prof.",name:"Jane",middleName:null,surname:"Reeves",slug:"jane-reeves",fullName:"Jane Reeves"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9961",title:"Data Mining",subtitle:"Methods, Applications and Systems",isOpenForSubmission:!1,hash:"ed79fb6364f2caf464079f94a0387146",slug:"data-mining-methods-applications-and-systems",bookSignature:"Derya Birant",coverURL:"https://cdn.intechopen.com/books/images_new/9961.jpg",editors:[{id:"15609",title:"Dr.",name:"Derya",middleName:null,surname:"Birant",slug:"derya-birant",fullName:"Derya Birant"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8545",title:"Animal Reproduction in Veterinary Medicine",subtitle:null,isOpenForSubmission:!1,hash:"13aaddf5fdbbc78387e77a7da2388bf6",slug:"animal-reproduction-in-veterinary-medicine",bookSignature:"Faruk Aral, Rita Payan-Carreira and Miguel Quaresma",coverURL:"https://cdn.intechopen.com/books/images_new/8545.jpg",editors:[{id:"25600",title:"Prof.",name:"Faruk",middleName:null,surname:"Aral",slug:"faruk-aral",fullName:"Faruk Aral"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9157",title:"Neurodegenerative Diseases",subtitle:"Molecular Mechanisms and Current Therapeutic Approaches",isOpenForSubmission:!1,hash:"bc8be577966ef88735677d7e1e92ed28",slug:"neurodegenerative-diseases-molecular-mechanisms-and-current-therapeutic-approaches",bookSignature:"Nagehan Ersoy Tunalı",coverURL:"https://cdn.intechopen.com/books/images_new/9157.jpg",editors:[{id:"82778",title:"Ph.D.",name:"Nagehan",middleName:null,surname:"Ersoy Tunalı",slug:"nagehan-ersoy-tunali",fullName:"Nagehan Ersoy Tunalı"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8686",title:"Direct Torque Control Strategies of Electrical Machines",subtitle:null,isOpenForSubmission:!1,hash:"b6ad22b14db2b8450228545d3d4f6b1a",slug:"direct-torque-control-strategies-of-electrical-machines",bookSignature:"Fatma Ben Salem",coverURL:"https://cdn.intechopen.com/books/images_new/8686.jpg",editors:[{id:"295623",title:"Associate Prof.",name:"Fatma",middleName:null,surname:"Ben Salem",slug:"fatma-ben-salem",fullName:"Fatma Ben Salem"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7434",title:"Molecular Biotechnology",subtitle:null,isOpenForSubmission:!1,hash:"eceede809920e1ec7ecadd4691ede2ec",slug:"molecular-biotechnology",bookSignature:"Sergey Sedykh",coverURL:"https://cdn.intechopen.com/books/images_new/7434.jpg",editors:[{id:"178316",title:"Ph.D.",name:"Sergey",middleName:null,surname:"Sedykh",slug:"sergey-sedykh",fullName:"Sergey Sedykh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9208",title:"Welding",subtitle:"Modern Topics",isOpenForSubmission:!1,hash:"7d6be076ccf3a3f8bd2ca52d86d4506b",slug:"welding-modern-topics",bookSignature:"Sadek Crisóstomo Absi Alfaro, Wojciech Borek and Błażej Tomiczek",coverURL:"https://cdn.intechopen.com/books/images_new/9208.jpg",editors:[{id:"65292",title:"Prof.",name:"Sadek Crisostomo Absi",middleName:"C. Absi",surname:"Alfaro",slug:"sadek-crisostomo-absi-alfaro",fullName:"Sadek Crisostomo Absi Alfaro"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7831",title:"Sustainability in Urban Planning and Design",subtitle:null,isOpenForSubmission:!1,hash:"c924420492c8c2c9751e178d025f4066",slug:"sustainability-in-urban-planning-and-design",bookSignature:"Amjad Almusaed, Asaad Almssad and Linh Truong - Hong",coverURL:"https://cdn.intechopen.com/books/images_new/7831.jpg",editors:[{id:"110471",title:"Dr.",name:"Amjad",middleName:"Zaki",surname:"Almusaed",slug:"amjad-almusaed",fullName:"Amjad Almusaed"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9343",title:"Trace Metals in the Environment",subtitle:"New Approaches and Recent Advances",isOpenForSubmission:!1,hash:"ae07e345bc2ce1ebbda9f70c5cd12141",slug:"trace-metals-in-the-environment-new-approaches-and-recent-advances",bookSignature:"Mario Alfonso Murillo-Tovar, Hugo Saldarriaga-Noreña and Agnieszka Saeid",coverURL:"https://cdn.intechopen.com/books/images_new/9343.jpg",editors:[{id:"255959",title:"Dr.",name:"Mario Alfonso",middleName:null,surname:"Murillo-Tovar",slug:"mario-alfonso-murillo-tovar",fullName:"Mario Alfonso Murillo-Tovar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9139",title:"Topics in Primary Care Medicine",subtitle:null,isOpenForSubmission:!1,hash:"ea774a4d4c1179da92a782e0ae9cde92",slug:"topics-in-primary-care-medicine",bookSignature:"Thomas F. Heston",coverURL:"https://cdn.intechopen.com/books/images_new/9139.jpg",editors:[{id:"217926",title:"Dr.",name:"Thomas F.",middleName:null,surname:"Heston",slug:"thomas-f.-heston",fullName:"Thomas F. Heston"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9839",title:"Outdoor Recreation",subtitle:"Physiological and Psychological Effects on Health",isOpenForSubmission:!1,hash:"5f5a0d64267e32567daffa5b0c6a6972",slug:"outdoor-recreation-physiological-and-psychological-effects-on-health",bookSignature:"Hilde G. Nielsen",coverURL:"https://cdn.intechopen.com/books/images_new/9839.jpg",editors:[{id:"158692",title:"Ph.D.",name:"Hilde G.",middleName:null,surname:"Nielsen",slug:"hilde-g.-nielsen",fullName:"Hilde G. Nielsen"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8697",title:"Virtual Reality and Its Application in Education",subtitle:null,isOpenForSubmission:!1,hash:"ee01b5e387ba0062c6b0d1e9227bda05",slug:"virtual-reality-and-its-application-in-education",bookSignature:"Dragan Cvetković",coverURL:"https://cdn.intechopen.com/books/images_new/8697.jpg",editors:[{id:"101330",title:"Dr.",name:"Dragan",middleName:"Mladen",surname:"Cvetković",slug:"dragan-cvetkovic",fullName:"Dragan Cvetković"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],offset:12,limit:12,total:5146},hotBookTopics:{hotBooks:[],offset:0,limit:12,total:null},publish:{},publishingProposal:{success:null,errors:{}},books:{featuredBooks:[{type:"book",id:"7802",title:"Modern Slavery and Human Trafficking",subtitle:null,isOpenForSubmission:!1,hash:"587a0b7fb765f31cc98de33c6c07c2e0",slug:"modern-slavery-and-human-trafficking",bookSignature:"Jane Reeves",coverURL:"https://cdn.intechopen.com/books/images_new/7802.jpg",editors:[{id:"211328",title:"Prof.",name:"Jane",middleName:null,surname:"Reeves",slug:"jane-reeves",fullName:"Jane Reeves"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9961",title:"Data Mining",subtitle:"Methods, Applications and Systems",isOpenForSubmission:!1,hash:"ed79fb6364f2caf464079f94a0387146",slug:"data-mining-methods-applications-and-systems",bookSignature:"Derya Birant",coverURL:"https://cdn.intechopen.com/books/images_new/9961.jpg",editors:[{id:"15609",title:"Dr.",name:"Derya",middleName:null,surname:"Birant",slug:"derya-birant",fullName:"Derya Birant"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8545",title:"Animal Reproduction in Veterinary Medicine",subtitle:null,isOpenForSubmission:!1,hash:"13aaddf5fdbbc78387e77a7da2388bf6",slug:"animal-reproduction-in-veterinary-medicine",bookSignature:"Faruk Aral, Rita Payan-Carreira and Miguel Quaresma",coverURL:"https://cdn.intechopen.com/books/images_new/8545.jpg",editors:[{id:"25600",title:"Prof.",name:"Faruk",middleName:null,surname:"Aral",slug:"faruk-aral",fullName:"Faruk Aral"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9157",title:"Neurodegenerative Diseases",subtitle:"Molecular Mechanisms and Current Therapeutic Approaches",isOpenForSubmission:!1,hash:"bc8be577966ef88735677d7e1e92ed28",slug:"neurodegenerative-diseases-molecular-mechanisms-and-current-therapeutic-approaches",bookSignature:"Nagehan Ersoy Tunalı",coverURL:"https://cdn.intechopen.com/books/images_new/9157.jpg",editors:[{id:"82778",title:"Ph.D.",name:"Nagehan",middleName:null,surname:"Ersoy Tunalı",slug:"nagehan-ersoy-tunali",fullName:"Nagehan Ersoy Tunalı"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8686",title:"Direct Torque Control Strategies of Electrical Machines",subtitle:null,isOpenForSubmission:!1,hash:"b6ad22b14db2b8450228545d3d4f6b1a",slug:"direct-torque-control-strategies-of-electrical-machines",bookSignature:"Fatma Ben Salem",coverURL:"https://cdn.intechopen.com/books/images_new/8686.jpg",editors:[{id:"295623",title:"Associate Prof.",name:"Fatma",middleName:null,surname:"Ben Salem",slug:"fatma-ben-salem",fullName:"Fatma Ben Salem"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7434",title:"Molecular Biotechnology",subtitle:null,isOpenForSubmission:!1,hash:"eceede809920e1ec7ecadd4691ede2ec",slug:"molecular-biotechnology",bookSignature:"Sergey Sedykh",coverURL:"https://cdn.intechopen.com/books/images_new/7434.jpg",editors:[{id:"178316",title:"Ph.D.",name:"Sergey",middleName:null,surname:"Sedykh",slug:"sergey-sedykh",fullName:"Sergey Sedykh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9208",title:"Welding",subtitle:"Modern Topics",isOpenForSubmission:!1,hash:"7d6be076ccf3a3f8bd2ca52d86d4506b",slug:"welding-modern-topics",bookSignature:"Sadek Crisóstomo Absi Alfaro, Wojciech Borek and Błażej Tomiczek",coverURL:"https://cdn.intechopen.com/books/images_new/9208.jpg",editors:[{id:"65292",title:"Prof.",name:"Sadek Crisostomo Absi",middleName:"C. Absi",surname:"Alfaro",slug:"sadek-crisostomo-absi-alfaro",fullName:"Sadek Crisostomo Absi Alfaro"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7831",title:"Sustainability in Urban Planning and Design",subtitle:null,isOpenForSubmission:!1,hash:"c924420492c8c2c9751e178d025f4066",slug:"sustainability-in-urban-planning-and-design",bookSignature:"Amjad Almusaed, Asaad Almssad and Linh Truong - Hong",coverURL:"https://cdn.intechopen.com/books/images_new/7831.jpg",editors:[{id:"110471",title:"Dr.",name:"Amjad",middleName:"Zaki",surname:"Almusaed",slug:"amjad-almusaed",fullName:"Amjad Almusaed"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9343",title:"Trace Metals in the Environment",subtitle:"New Approaches and Recent Advances",isOpenForSubmission:!1,hash:"ae07e345bc2ce1ebbda9f70c5cd12141",slug:"trace-metals-in-the-environment-new-approaches-and-recent-advances",bookSignature:"Mario Alfonso Murillo-Tovar, Hugo Saldarriaga-Noreña and Agnieszka Saeid",coverURL:"https://cdn.intechopen.com/books/images_new/9343.jpg",editors:[{id:"255959",title:"Dr.",name:"Mario Alfonso",middleName:null,surname:"Murillo-Tovar",slug:"mario-alfonso-murillo-tovar",fullName:"Mario Alfonso Murillo-Tovar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9139",title:"Topics in Primary Care Medicine",subtitle:null,isOpenForSubmission:!1,hash:"ea774a4d4c1179da92a782e0ae9cde92",slug:"topics-in-primary-care-medicine",bookSignature:"Thomas F. Heston",coverURL:"https://cdn.intechopen.com/books/images_new/9139.jpg",editors:[{id:"217926",title:"Dr.",name:"Thomas F.",middleName:null,surname:"Heston",slug:"thomas-f.-heston",fullName:"Thomas F. Heston"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],latestBooks:[{type:"book",id:"7434",title:"Molecular Biotechnology",subtitle:null,isOpenForSubmission:!1,hash:"eceede809920e1ec7ecadd4691ede2ec",slug:"molecular-biotechnology",bookSignature:"Sergey Sedykh",coverURL:"https://cdn.intechopen.com/books/images_new/7434.jpg",editedByType:"Edited by",editors:[{id:"178316",title:"Ph.D.",name:"Sergey",middleName:null,surname:"Sedykh",slug:"sergey-sedykh",fullName:"Sergey Sedykh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8545",title:"Animal Reproduction in Veterinary Medicine",subtitle:null,isOpenForSubmission:!1,hash:"13aaddf5fdbbc78387e77a7da2388bf6",slug:"animal-reproduction-in-veterinary-medicine",bookSignature:"Faruk Aral, Rita Payan-Carreira and Miguel Quaresma",coverURL:"https://cdn.intechopen.com/books/images_new/8545.jpg",editedByType:"Edited by",editors:[{id:"25600",title:"Prof.",name:"Faruk",middleName:null,surname:"Aral",slug:"faruk-aral",fullName:"Faruk Aral"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9569",title:"Methods in Molecular Medicine",subtitle:null,isOpenForSubmission:!1,hash:"691d3f3c4ac25a8093414e9b270d2843",slug:"methods-in-molecular-medicine",bookSignature:"Yusuf Tutar",coverURL:"https://cdn.intechopen.com/books/images_new/9569.jpg",editedByType:"Edited by",editors:[{id:"158492",title:"Prof.",name:"Yusuf",middleName:null,surname:"Tutar",slug:"yusuf-tutar",fullName:"Yusuf Tutar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9839",title:"Outdoor Recreation",subtitle:"Physiological and Psychological Effects on Health",isOpenForSubmission:!1,hash:"5f5a0d64267e32567daffa5b0c6a6972",slug:"outdoor-recreation-physiological-and-psychological-effects-on-health",bookSignature:"Hilde G. Nielsen",coverURL:"https://cdn.intechopen.com/books/images_new/9839.jpg",editedByType:"Edited by",editors:[{id:"158692",title:"Ph.D.",name:"Hilde G.",middleName:null,surname:"Nielsen",slug:"hilde-g.-nielsen",fullName:"Hilde G. Nielsen"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7802",title:"Modern Slavery and Human Trafficking",subtitle:null,isOpenForSubmission:!1,hash:"587a0b7fb765f31cc98de33c6c07c2e0",slug:"modern-slavery-and-human-trafficking",bookSignature:"Jane Reeves",coverURL:"https://cdn.intechopen.com/books/images_new/7802.jpg",editedByType:"Edited by",editors:[{id:"211328",title:"Prof.",name:"Jane",middleName:null,surname:"Reeves",slug:"jane-reeves",fullName:"Jane Reeves"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8063",title:"Food Security in Africa",subtitle:null,isOpenForSubmission:!1,hash:"8cbf3d662b104d19db2efc9d59249efc",slug:"food-security-in-africa",bookSignature:"Barakat Mahmoud",coverURL:"https://cdn.intechopen.com/books/images_new/8063.jpg",editedByType:"Edited by",editors:[{id:"92016",title:"Dr.",name:"Barakat",middleName:null,surname:"Mahmoud",slug:"barakat-mahmoud",fullName:"Barakat Mahmoud"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"10118",title:"Plant Stress Physiology",subtitle:null,isOpenForSubmission:!1,hash:"c68b09d2d2634fc719ae3b9a64a27839",slug:"plant-stress-physiology",bookSignature:"Akbar Hossain",coverURL:"https://cdn.intechopen.com/books/images_new/10118.jpg",editedByType:"Edited by",editors:[{id:"280755",title:"Dr.",name:"Akbar",middleName:null,surname:"Hossain",slug:"akbar-hossain",fullName:"Akbar Hossain"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9157",title:"Neurodegenerative Diseases",subtitle:"Molecular Mechanisms and Current Therapeutic Approaches",isOpenForSubmission:!1,hash:"bc8be577966ef88735677d7e1e92ed28",slug:"neurodegenerative-diseases-molecular-mechanisms-and-current-therapeutic-approaches",bookSignature:"Nagehan Ersoy Tunalı",coverURL:"https://cdn.intechopen.com/books/images_new/9157.jpg",editedByType:"Edited by",editors:[{id:"82778",title:"Ph.D.",name:"Nagehan",middleName:null,surname:"Ersoy Tunalı",slug:"nagehan-ersoy-tunali",fullName:"Nagehan Ersoy Tunalı"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9961",title:"Data Mining",subtitle:"Methods, Applications and Systems",isOpenForSubmission:!1,hash:"ed79fb6364f2caf464079f94a0387146",slug:"data-mining-methods-applications-and-systems",bookSignature:"Derya Birant",coverURL:"https://cdn.intechopen.com/books/images_new/9961.jpg",editedByType:"Edited by",editors:[{id:"15609",title:"Dr.",name:"Derya",middleName:null,surname:"Birant",slug:"derya-birant",fullName:"Derya Birant"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8686",title:"Direct Torque Control Strategies of Electrical Machines",subtitle:null,isOpenForSubmission:!1,hash:"b6ad22b14db2b8450228545d3d4f6b1a",slug:"direct-torque-control-strategies-of-electrical-machines",bookSignature:"Fatma Ben Salem",coverURL:"https://cdn.intechopen.com/books/images_new/8686.jpg",editedByType:"Edited by",editors:[{id:"295623",title:"Associate Prof.",name:"Fatma",middleName:null,surname:"Ben Salem",slug:"fatma-ben-salem",fullName:"Fatma Ben Salem"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},subject:{topic:{id:"270",title:"Humanities",slug:"humanities",parent:{title:"Social Sciences",slug:"social-sciences"},numberOfBooks:3,numberOfAuthorsAndEditors:49,numberOfWosCitations:16,numberOfCrossrefCitations:8,numberOfDimensionsCitations:32,videoUrl:null,fallbackUrl:null,description:null},booksByTopicFilter:{topicSlug:"humanities",sort:"-publishedDate",limit:12,offset:0},booksByTopicCollection:[{type:"book",id:"6944",title:"Heritage",subtitle:null,isOpenForSubmission:!1,hash:"80ee36ba67b1fe4ff971074f7ddc4d00",slug:"heritage",bookSignature:"Daniela Turcanu-Carutiu",coverURL:"https://cdn.intechopen.com/books/images_new/6944.jpg",editedByType:"Edited by",editors:[{id:"176482",title:"Prof.",name:"Daniela",middleName:null,surname:"Turcanu-Carutiu",slug:"daniela-turcanu-carutiu",fullName:"Daniela Turcanu-Carutiu"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6169",title:"Culture and Identity",subtitle:null,isOpenForSubmission:!1,hash:"925cd8ebef5226a2fc3b36d060a27ecb",slug:"culture-and-identity",bookSignature:"Wilfred Isak April",coverURL:"https://cdn.intechopen.com/books/images_new/6169.jpg",editedByType:"Edited by",editors:[{id:"110034",title:"Dr.",name:"Wilfred",middleName:"Isak",surname:"April",slug:"wilfred-april",fullName:"Wilfred April"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2301",title:"Social Sciences and Cultural Studies",subtitle:"Issues of Language, Public Opinion, Education and Welfare",isOpenForSubmission:!1,hash:"d8b131a7ee5b8a5b952c49dc19c0cfe5",slug:"social-sciences-and-cultural-studies-issues-of-language-public-opinion-education-and-welfare",bookSignature:"Asuncion Lopez-Varela",coverURL:"https://cdn.intechopen.com/books/images_new/2301.jpg",editedByType:"Edited by",editors:[{id:"111237",title:"Dr.",name:"Asunción",middleName:null,surname:"Lopez-Varela Azcárate",slug:"asuncion-lopez-varela-azcarate",fullName:"Asunción Lopez-Varela Azcárate"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],booksByTopicTotal:3,mostCitedChapters:[{id:"39104",doi:"10.5772/37095",title:"Stress Management for Medical Students: A Systematic Review",slug:"stress-management-for-medical-students-a-systematic-review",totalDownloads:6086,totalCrossrefCites:2,totalDimensionsCites:15,book:{slug:"social-sciences-and-cultural-studies-issues-of-language-public-opinion-education-and-welfare",title:"Social Sciences and Cultural Studies",fullTitle:"Social Sciences and Cultural Studies - Issues of Language, Public Opinion, Education and Welfare"},signatures:"Muhamad Saiful Bahri Yusoff and Ab Rahman Esa",authors:[{id:"111238",title:"Dr.",name:"Muhamad Saiful Bahri",middleName:null,surname:"Yusoff",slug:"muhamad-saiful-bahri-yusoff",fullName:"Muhamad Saiful Bahri Yusoff"},{id:"121385",title:"Prof.",name:"Ab Rahman",middleName:null,surname:"Esa",slug:"ab-rahman-esa",fullName:"Ab Rahman Esa"}]},{id:"39097",doi:"10.5772/38617",title:"International Higher Education Rankings at a Glance: How to Valorise the Research in Social Sciences and Humanities?",slug:"international-higher-education-rankings-at-a-glance-how-to-valorise-the-research-in-social-scien",totalDownloads:1474,totalCrossrefCites:0,totalDimensionsCites:5,book:{slug:"social-sciences-and-cultural-studies-issues-of-language-public-opinion-education-and-welfare",title:"Social Sciences and Cultural Studies",fullTitle:"Social Sciences and Cultural Studies - Issues of Language, Public Opinion, Education and Welfare"},signatures:"José M. Gómez-Sancho and Carmen Pérez-Esparrells",authors:[{id:"118304",title:"Dr.",name:"Jose María",middleName:null,surname:"Gomez-Sancho",slug:"jose-maria-gomez-sancho",fullName:"Jose María Gomez-Sancho"},{id:"118305",title:"Dr.",name:"Carmen",middleName:null,surname:"Pérez-Esparrells",slug:"carmen-perez-esparrells",fullName:"Carmen Pérez-Esparrells"}]},{id:"59704",doi:"10.5772/intechopen.74411",title:"Popular Religions and Multiple Modernities: A Non-Western Perspective",slug:"popular-religions-and-multiple-modernities-a-non-western-perspective",totalDownloads:560,totalCrossrefCites:1,totalDimensionsCites:2,book:{slug:"culture-and-identity",title:"Culture and Identity",fullTitle:"Culture and Identity"},signatures:"Cristian Parker",authors:[{id:"207097",title:"Dr.",name:"Cristián",middleName:null,surname:"Parker",slug:"cristian-parker",fullName:"Cristián Parker"}]}],mostDownloadedChaptersLast30Days:[{id:"71421",title:"Cultural Heritage of a Three Centuries Old Wooden Church",slug:"cultural-heritage-of-a-three-centuries-old-wooden-church",totalDownloads:205,totalCrossrefCites:1,totalDimensionsCites:1,book:{slug:"heritage",title:"Heritage",fullTitle:"Heritage"},signatures:"Patricia Săsăran, Ancuța Țenter and Lorelay-Diana Jianu",authors:null},{id:"70968",title:"Public Governance and Cultural Heritage: Exploring the Links between Culture and Social Indicators with the Principal Component Analysis",slug:"public-governance-and-cultural-heritage-exploring-the-links-between-culture-and-social-indicators-wi",totalDownloads:206,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"heritage",title:"Heritage",fullTitle:"Heritage"},signatures:"Ionela Munteanu Florea, Marioara Mirea and Cosmin Susu",authors:null},{id:"72415",title:"China’s Use of Public Diplomacy in the United States: From World War II to the Twenty-First Century",slug:"china-s-use-of-public-diplomacy-in-the-united-states-from-world-war-ii-to-the-twenty-first-century",totalDownloads:197,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"heritage",title:"Heritage",fullTitle:"Heritage"},signatures:"Sally Burt",authors:null},{id:"73006",title:"Ideological Interaction Theory in Critical Discourse Analysis",slug:"ideological-interaction-theory-in-critical-discourse-analysis",totalDownloads:201,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"heritage",title:"Heritage",fullTitle:"Heritage"},signatures:"Yadu Prasad Gyawali",authors:null},{id:"39083",title:"Western and Eastern Ur-Topias: Communities and Nostalgia",slug:"western-and-eastern-ur-topias-communities-and-nostalgia",totalDownloads:1579,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"social-sciences-and-cultural-studies-issues-of-language-public-opinion-education-and-welfare",title:"Social Sciences and Cultural Studies",fullTitle:"Social Sciences and Cultural Studies - Issues of Language, Public Opinion, Education and Welfare"},signatures:"Anjan Sen and Asun López-Varela",authors:[{id:"111237",title:"Dr.",name:"Asunción",middleName:null,surname:"Lopez-Varela Azcárate",slug:"asuncion-lopez-varela-azcarate",fullName:"Asunción Lopez-Varela Azcárate"}]},{id:"71441",title:"Cultural Heritage Objects of Southern Benin: Plant Dyes and Exudates Used in Their Confection",slug:"cultural-heritage-objects-of-southern-benin-plant-dyes-and-exudates-used-in-their-confection",totalDownloads:173,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"heritage",title:"Heritage",fullTitle:"Heritage"},signatures:"Louis Fagbohoun and Cathy Vieillescazes",authors:null},{id:"39090",title:"Cyberfeminist Theories and the Benefits of Teaching Cyberfeminist Literature",slug:"cyberfeminist-theories-and-the-benefits-of-teaching-cyberfeminist-literature",totalDownloads:2317,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"social-sciences-and-cultural-studies-issues-of-language-public-opinion-education-and-welfare",title:"Social Sciences and Cultural Studies",fullTitle:"Social Sciences and Cultural Studies - Issues of Language, Public Opinion, Education and Welfare"},signatures:"Maya Zalbidea Paniagua",authors:[{id:"146627",title:"Prof.",name:"Maya",middleName:null,surname:"Zalbidea",slug:"maya-zalbidea",fullName:"Maya Zalbidea"}]},{id:"72358",title:"Technical - Experimental Methods Used in Artworks’ Expertise",slug:"technical-experimental-methods-used-in-artworks-expertise",totalDownloads:211,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"heritage",title:"Heritage",fullTitle:"Heritage"},signatures:"Verginica Schröder, Daniela Turcanu-Carutiu, Adina Honcea, Rodica-Mariana Ion, Sorin Grigore and Loreley-Dana Jianu",authors:null},{id:"71819",title:"Significance in African Heritage",slug:"significance-in-african-heritage",totalDownloads:154,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"heritage",title:"Heritage",fullTitle:"Heritage"},signatures:"Herman Ogoti Kiriama and Edith Nyangara Onkoba",authors:null},{id:"72251",title:"Public Diplomacy: Functions, Functional Boundaries and Measurement Methods",slug:"public-diplomacy-functions-functional-boundaries-and-measurement-methods",totalDownloads:179,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"heritage",title:"Heritage",fullTitle:"Heritage"},signatures:"Cao Wei",authors:null}],onlineFirstChaptersFilter:{topicSlug:"humanities",limit:3,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[{type:"book",id:"10176",title:"Microgrids and Local Energy Systems",subtitle:null,isOpenForSubmission:!0,hash:"c32b4a5351a88f263074b0d0ca813a9c",slug:null,bookSignature:"Prof. Nick Jenkins",coverURL:"https://cdn.intechopen.com/books/images_new/10176.jpg",editedByType:null,editors:[{id:"55219",title:"Prof.",name:"Nick",middleName:null,surname:"Jenkins",slug:"nick-jenkins",fullName:"Nick Jenkins"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],offset:8,limit:8,total:1},route:{name:"profile.detail",path:"/profiles/71490/andreu-andrio-balado",hash:"",query:{},params:{id:"71490",slug:"andreu-andrio-balado"},fullPath:"/profiles/71490/andreu-andrio-balado",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()