\r\n\tOver the past few decades, there has been a rationalization for better classification of dystonia and paying more attention to understanding the different causes of dystonic movements from the advanced study of genetics, neurophysiology, and functional imaging in various forms of dystonia.
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1. Introduction
Recurrent pneumothorax which is associated with menstruation is named as “catamenial pneumothorax” (CPX). It was first reported by Maurer et al. [1] and was presented to be a form of ectopic endometriosis and the term CPX was stated by Lillington et al. [2].
“Catamenial” is a name from Greek meaning “monthly.” CPX is most commonly associated with endometriosis, but other etiological mechanisms of this disease exist [3, 4, 5, 6].
In the literature, CPX is defined to be a recurrent pneumothorax occurring up to 24 h before or within 72 h after the onset of menstruation [4, 6], and on the other hand, not necessarily appearing every month [7]. Symptoms and signs of CPX are mostly unspecific so much clinical suspicion has to be maintained [8]. CPX is a rare entity; however, regarding literature, about one-third of all surgically treated cases of pneumothorax in women are diagnosed to be CPX [9, 10, 11, 12].
Therefore, thoracic endometriosis should always be suspected in reproductive-age woman who suffer chest pain from spontaneous pneumothorax.
Thoracic endometriosis syndrome may be associated with other causes than pelvic endometriosis. In the first 24–48 h of menstruation, symptoms begin to appear and are usually seen on the right side of the chest. In 90% of the patients, chest pain is the most common symptom, and in one-third of the patients, shortness of breath is rarely seen, but hemoptysis is also added to the clinical picture [13]. In the light of these findings, the diagnosis of the disease is made clinically.
From 3 to 6% of spontaneous pneumothorax cases are catamenial pneumothorax, about one-third of all surgically treated cases of pneumothorax in affected women.
The mean age of onset is reported to be 32–35 years [3, 4, 12, 14, 15, 16, 17]. CPX may also develop as late as at 39 years of age [18, 19]. CPX occurs most often (85–95%) unilaterally, usually occurring on the right side of the chest, but there are cases on which pneumothorax also occurs on the left side or bilaterally [11, 15, 16, 17, 18, 19, 20, 21].
2. Incidence
CPX is generally considered to be a rare entity, and there is an incidence less than 3–6% among women who suffer from spontaneous pneumothorax. Such a low incidence rate may be a result of decreased disease awareness and underdiagnosis [4, 8, 9, 10, 19, 22, 23, 24, 25, 26, 27, 28, 29].
Yet, the incidence of catamenial pneumothorax was much higher among women at reproductive age who were referred for surgical treatment because of recurrent spontaneous pneumothorax, ranging between 18 and 33% [9, 10, 11, 12, 22].
In a recent study [24, 29, 30], 156 premenopausal women who underwent surgery for spontaneous pneumothorax were reviewed retrospectively, and 31.4% (49/156) of the patients were classified as CPX.
In a retrospective study, Alifano et al. reported thoracic endometriosis in 13 out of 35 (37%) patients who underwent reoperation for recurrent spontaneous pneumothorax [29]. Catamenial pneumothorax was the initial diagnosis in eight cases and idiopathic pneumothorax in four cases [29]. Under/misdiagnosis of thoracic endometriosis can be referred to several causes, including decreased disease awareness, incomplete scanning for the lesions, variations in the size, appearance, and number of the lesions [24, 30].
3. Etiology
The etiopathology of catamenial pneumothorax remains unclear, but there are some theories explaining the etiopathogenesis of catamenial pneumothorax. These theories include physiological, migrational, microembolic-metastatic, and the diaphragmatic theory of air passage [17] (Table 1).
Physiological hypothesis
High levels of circulating prostaglandin F2 during menstrual cycle cause vasoconstriction, and this induces alveolar rupture and pneumothorax.
Metastatic or lymphovascular microembolization hypothesis
Endometrial tissue spreads through the venous and/or the lymphatic system to the lungs, and subsequent catamenial necrosis of endometrial parenchymal site adjacent to visceral pleura causes pneumothorax
Transgenital-transdiaphragmatic passage of air hypothesis
Absence of cervical mucus during menstruation provides air passage from the vagina to the uterus, through the cervix. Then air enters the peritoneal cavity straight through the fallopian tubes and reaches to the pleural space by diaphragmatic defects.
Migration hypothesis
Following catamenial necrosis of this diaphragmatic endometrial implants results in diaphragmatic perforations. Endometrial tissue then passes through this diaphragmatic perforation and spreads into the thoracic cavity. Ectopic endometrial tissue implants to the visceral pleura and following catamenial necrosis of this tissue causes rupture of the underlying alveoli, and pneumothorax occurs.
Table 1.
The etiopathology of catamenial pneumothorax remains unclear, but there are some theories explaining the etiopathogenesis of catamenial pneumothorax.
These theories include physiological, migrational, microembolic-metastatic, and the diaphragmatic theory of air passage.
According to the physiologic hypothesis, high levels of circulating prostaglandin F2 during menstrual cycle cause vasoconstriction and this induces alveolar rupture and pneumothorax. Pulmonary bullae blebs may be more sensitive to ruptures during hormonal changes. There are no pathognomonic lesions in such cases and this issue supports the physiologic theory [4, 7, 8, 24, 31].
In metastatic or lymphovascular microembolization theory, endometrial tissue spread through the venous and/or the lymphatic system to the lungs, and subsequent catamenial necrosis of endometrial parenchymal site adjacent to visceral pleura causes pneumothorax. If parenchymal endometrial focus is located centrally, hemoptysis may be present as a symptom [3, 4, 7, 8, 22, 24, 30, 31, 32]. Endometrial tissue can be detected in the lung parenchyma, at knee, in the brain, and in the eye. This supports the metastatic theory [12].
According to the transgenital-transdiaphragmatic passage of air theory, absence of cervical mucus during menstruation provides air passage from the vagina to the uterus, through the cervix. Then, air enters the peritoneal cavity straight through the fallopian tubes and reaches to the pleural space by diaphragmatic defects [4, 7, 8, 22, 24, 31]. This passage is facilitated by the difference in atmospheric pressures between pleural space and peritoneal space since the atmospheric pressure in the pleural cavity is less than the pressure in the peritoneal cavity.
There are few reports in the literature regarding transgenital-transdiaphragmatic passage of air theory. There are rare cases reporting simultaneous [33, 34] or undulating episodes CPX and pneumoperitoneum [35], and also case reports defining radiologic findings of small diaphragmatic defects associated with ipsilateral CPX [21]. But repeated episodes of pneumothorax after hysterectomy, fallopian tube ligation, and diaphragmatic resection provide evidence that all the CPX cases can be explained by this theory [7, 24, 29, 36].
Migration theory is based on retrograde menstruation which causes in pelvic seeding of endometrial tissue and migration of this tissue to the subdiaphragmatic sites through the peritoneal fluid flow. Endometrial tissue is mostly implanted to the right hemidiaphragm because peritoneal circulation prefers a clockwise flow through the right paracolic gutter to right hemidiaphragm and the liver facilitates flow with its piston-like activity. Catamenial necrosis of this diaphragmatic endometrial implants results in diaphragmatic perforations. Endometrial tissue then passes through this diaphragmatic perforation and spreads into the thoracic cavity. Ectopic endometrial tissue implants to the visceral pleura and following catamenial necrosis of this tissue cause rupture of the underlying alveoli, and pneumothorax occurs [3, 4, 7, 8, 22, 24, 30, 31]. Endometrial diaphragmatic implants exist along with diaphragmatic perforations [37], and endometrial tissue can be seen at the edges of the diaphragmatic perforations in many cases of CPX [22]; these findings may support the migration theory in the etiopathology of catamenial pneumothorax.
4. Clinical manifestations and diagnosis
The typical clinical manifestations of CPX include spontaneous pneumothorax with or before menses presented with pain, dyspnea, and cough. Scapular and thoracic pain may also be present before or during menstruation. There may also be a history of previous episodes of spontaneous pneumothorax, history of previous uterine surgery, primary or secondary infertility or uterine scratching, pelvic endometriosis diagnosis, and history of catamenial hemoptysis or catamenial hemothorax [30].
Medical history and occurrence of typical symptoms are crucial for the diagnosis of catamenial pneumothorax, and these findings should be systematically investigated [11]. Although existence of these findings creates high suspicion on catamenial pneumothorax, their absence does not exclude a diagnosis of catamenial pneumothorax [24, 30].
Intermittent presentations out of menstrual bleeding time should not exclude the diagnosis of noncatamenial endometriosis-associated pneumothorax even in the absence of symptoms and pelvic endometriosis [9, 24, 38].
The clinical course of CPX is usually mild or moderate, but sometimes be life-threatening. Widespread thoracic endometriosis after previous operations is reported in the literature as case reports [39]. A young woman who experienced an episode of life-threatening hemopneumothorax who has been treated by urgent tube thoracostomy and thoracotomy was reported by Morcos et al. [39]. Lung wedge resection, parietal pleurectomy, and partial diaphragmatic excision have also been performed in this case.
Patients with CPX are reported to have a mean age of 35 (range 15–54) years at presentation [40].
Catamenial pneumothorax can also have very rare presentations in the literature. Simultaneous occurrence of pneumoperitoneum and catamenial pneumothorax [33, 34], catamenial pneumoperitoneum mimicking acute abdomen in a woman with multiple episodes of pneumothorax [35], pneumothorax, and pneumoperitoneum in a patient with spontaneous diaphragmatic rupture has been reported in the literature [41].
Medical history is the main pathway on the way to the diagnosis of CPX. Synchronicity of the clinical course with menses is the main character of the disease, but on the other hand intraoperative visual inspection and appropriate histological examination of the pathognomonic lesions are crucial for the diagnosis of endometriosis-related pneumothorax. The surgeon needs to be vigilant because it can easily be missed if not cautious [7, 24, 29, 42].
5. Imaging diagnostic criteria
Chest radiogram, computed tomography, and magnetic resonance imaging are the imaging modalities that can be used for the diagnosis of catamenial pneumothorax. Although there are no disease-specific diagnostic criteria, pneumothorax is usually right sided. On the other hand, left-sided or bilateral cases are present. Air-fluid leveling may also occur at chest radiogram, in some cases. Hemopneumothorax may also be a part of clinical course [24, 30]. Loculated fluids can be seen in cases with the history of previous surgery [39].
Only in a few number of cases, small diaphragmatic defects can be detected with careful examination of chest radiogram, which refers to diaphragmatic perforations. Also when a right-sided pneumothorax with a round opacity on the right hemidiaphragm occurs, liver protrusion into a large diaphragm defect is suspected [21, 43]. This type of partial intrathoracic liver herniation at the right hemidiaphragm on chest radiogram and CT [24, 44] has been reported in the literature. There are also reports in the literature regarding diaphragmatic masses on CT [23] and pleural masses on MRI that refers to endometrial implants [45].
CT findings of hemoptysis are nonspecific; they may differ from a focal ground-glass opacity to consolidation because of alveolar filling, similarly in hemoptysis caused by other disease [46]. Especially in nondependent lung parenchyma, these findings facilitate the location of the site of bleeding. In the early period of the disease, endobronchial clots may be present, which cause atelectasis in some cases. There are also reports revealing band-like opacities referring to linear fibrosis sites, which result from chronic hemorrhage [46].
MRI is another imaging modality that can be used for confirming thoracic endometriosis in some cases. CT has some disadvantages especially in spatial resolution, but MRI has high-contrast resolution and can better characterize hemorrhagic lesions. Representation of diaphragmatic or pleural implants with MRI can help to clarify the diagnosis and management of the patient with catamenial pneumothorax [46].
MRI may also be useful for patients with catamenial hydropneumothorax; small pleural endometriomas characterized by the presence of small cystic hyperintense lesions can be revealed by MRI images of visceral or parietal pleura [46].
Coexisting pneumothorax and pneumoperitoneum are other findings that can be seen on radiography and computed tomography [33, 34].
6. Tumor antigens
Increased levels of cancer antigen 125 have been associated with endometriosis. It is not considered a specific marker, but it can play a role in early diagnosis of endometriosis-related pneumothorax [47, 48].
7. Characteristic findings of catamenial pneumothorax
Characteristic lesions of the catamenial pneumothorax include single or multiple diaphragmatic spots, perforations, nodules, and visceral or parietal pleural spots and nodules. Pericardial nodules have also been reported in some cases.
These lesions have not been found in all patients with catamenial pneumothorax, but they have been revealed in some cases with noncatamenial pneumothorax. Detection of endometrial tissue is not mandatory in these lesions. On the other hand, endometrial tissue has usually been found in diaphragmatic and pleural nodules, but it is rarely detected at the edges of the diaphragmatic perforations [30].
Visceral and parietal pleural lesions are less frequently detected than diaphragmatic defects, spots, and nodules.
7.1 Diaphragmatic lesions
The diaphragmatic lesions usually located at the centrum tendineum and can be single or multiple. They usually settle adjacent to nodules. They can be outlined as perforations, fenestrations, holes, stomata, and pores [24, 30, 49] (Figure 1a and b).
Figure 1.
(a) and (b) Thoracoscopic view of diaphragmatic endometriosis. Fenestrations can be seen on the surface of the diaphragm (arrows). (c) The liver is visible after surgical resection. (d) Sutured diaphragm after endometriosis resection. Images are used with the permission of Demetrio Larrain [49].
They can be tiny holes measuring 1–3 millimeters in diameter [7, 50], or larger defects measuring up to 10 mm [4, 18] or more than 10 mm [8] or represent as undetected holes proven only by diagnostic pneumoperitoneum [42].
Diaphragmatic defects are usually found close to coexisting nodules or spots, and endometrial tissue is sporadically found at the edges of the defects [4, 9, 11, 22]. This situation supports the theory claiming that the diaphragmatic defects represent the breakdown of endometrial implants during menstrual cycle [22, 24].
There are also case reports of larger lacerations that accompany with intrathoracic liver protrusion, but these presentations are very rare.
A patient with catamenial pneumothorax on the right hemithorax was reported by Pryshchepau et al. Liver of the patient was protruded through a large diaphragmatic defect [44].
Visouli et al. also reported five cases of catamenial pneumothorax [24], which contains a case very similar regarding liver protrusion, and they have recommended that these findings should be included in the characteristic findings of catamenial and thoracic endometriosis-related pneumothorax, although this presentation is very rare [24].
Catamenial pneumothorax with a huge diaphragmatic laceration and partial intrathoracic liver herniation was reported by Bobbio et al. [43], and Makhija et al. [51] reported a patient with multiple diaphragmatic fenestrations. The largest lesion was reported to have a diameter of 10 cm.
Spontaneous rupture of the right hemidiaphragm and intrathoracic liver herniation was also reported in the literature [41]. Pneumothorax and pneumoperitoneum was detected in a patient with a history of premenstrual periscapular pain. At the edge of the diaphragmatic defect, a nodule looking like an endometrial implant was found in that patient. Histological examination of the nodule revealed endometriosis with hemosiderin-loaded macrophages. This case is considered as endometriosis-related, but the histological criteria set by the authors was not appropriate [9, 11]. Additionally, previously mentioned cases of large diaphragmatic defects were considered to be limited diaphragmatic ruptures and stated that endometriosis was responsible for these ruptures [43, 44].
7.2 Thoracic lesions
Endometrial tissue is usually detected on histopathological examination of the spots or nodules accompanying catamenial pneumothorax so these lesions are considered to be endometrial implants. Diaphragm, visceral, and parietal pleura are the common sites for location. Pericardial implants were also reported by Fonseca et al. [52]. The lesions may be single or multiple and may have varying size. They may have different presentations in color as brown, purple, red, violet, blueberry, black, white, grayish, and grayish-purple [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 51].
Diaphragmatic and thoracic lesions may be present in all cases, but on the other hand, only one or more of them can be seen either [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 39, 53, 54].
In some cases of catamenial pneumothorax, characteristic findings may be absent and blebs and bullae may be the only pathological findings. In some cases, no characteristic thoracic findings may be detected [7, 12, 20, 22, 23, 24].
Detection of characteristic lesions during thoracotomy or thoracoscopy depends on thorough and deliberate examination of the thorax, including the diaphragm. This also depends on the stage of the disease and catamenial behavior of the disease and longer-term variation [22, 24, 30, 42].
8. Surgical treatment of catamenial pneumothorax
Surgical treatment is the gold standard in treatment of catamenial pneumothorax, not only for its better results but less recurrences after treatment as well. Surgery has better results compared with medical treatment [1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20].
Korom et al. [7] reviewed 195 cases of CPX among 229 cases and reported that 154 cases (78%) were treated surgically. Among surgically treated patients, diaphragmatic repair (38%), pleurodesis (81%), and lung wedge resection (20%) were performed.
There is common consensus in the literature that the appropriate approach to CPX has to be minimally invasive so video-assisted thoracoscopic surgery (VATS) is the choice of treatment. VATS not only provides magnification but complete visualization of diaphragm as well [23].
Video-assisted thoracoscopic surgery (VATS) has been mainly in use since 2000 in the treatment of thoracic diseases with several advantages over conventional thoracotomy. Incision may be extended when extensive diaphragmatic repair is required, and also a muscle-sparing thoracotomy may offer better access in such cases. Thoracotomy may be an option especially in recurrent interventions or in reoperations [4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30].
The lung examination for bullae, bleb, and air leakage is very important, but the diaphragm should also be carefully examined for fenestrations and spots or nodules. In addition, it is critical to examine the parietal pleura, lung, and pericardium in terms of spots and nodules.
Bagan et al. recommended the use of surgical treatment during menstruation. Thus, they stated that endometriotic lesions may be better visualized during menstrual period [22]. Slasky et al. used the pneumoperitoneum method to reveal unseen diaphragmatic fenestrations [42]. Identification of the lesions within the thorax is made easier by the magnification provided by VATS [4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30]. The tissue samples from these lesions make it easy to diagnose thoracic endometriosis [10].
Resection of all visible lesions such as bullae or bleb and also resection of endometriosis-induced thoracic lesions have been recommended by Alifano et al. Limited wedge resection of the diseased lung tissue, limited parietal pleurectomy, and partial diaphragmatic resection were suggested surgical techniques for the elimination of intrathoracic lesions [4].
Excision and wedge resection of bullae and blebs [7, 12, 23, 30], along with pleurodesis or pleurectomy, has been mainly performed in the literature [7, 8, 12, 23, 30, 47]. Pleurodesis was found to be the most common intervention [29]. The majority of pleurodesis performed was mechanical pleurodesis (abrasion or pleurectomy), which has been found to be more successful in comparison to chemical pleurodesis [6].
Addressing the diaphragmatic pathology is of paramount importance. Diaphragmatic plication and/or resection of the diseased area have been reported [7, 12, 23, 24, 30, 49] (Figure 1c and d).
Recurrence is the most common complication of CPX, and there are reported recurrence rates of 20–40% [4, 7, 41, 51]. Alifano et al. suggested that diaphragmatic resection with removal of endometrial implants is the preferred method compared to single diaphragmatic plication because plication has an disadvantage of leaving endometrial implants untreated [29, 38]. Still, recurrences may develop even after diaphragmatic resection [29].
Fewer recurrences after diaphragmatic coverage with a polyglactin mesh were reported by Bagan et al. To prevent recurrences, they suggested a systematic diaphragmatic covering, including the normal appearance of diaphragms, treating ocular defects, strengthening the diaphragm, and inducing adhesions to the lung [7].
There are also reports on diaphragmatic coverage with a polyglactin or polypropylene mesh [8], a polytetrafluoroethylene (PTFE) mesh [15], or a bovine pericardial patch [24], which has been reported with good mid-term results.
9. Medical treatment
Hormonal treatment has a supplementary role in the treatment of catamenial pneumothorax. With the administration of hormonal therapy, it is possible to prevent recurrences of catamenial pneumothorax.
A multidisciplinary approach is mandatory for the management of the disease and administration of gonadotrophin-releasing hormone (GnRH) analogue, which results in the lack of menses, and is suggested for all patients with proven catamenial pneumothorax in the early postoperative period for 6–12 months [4, 7, 8, 22, 24, 30, 48]. Patients without documented catamenial character or histologically proven thoracic endometriosis may also benefit from hormonal treatment even in the presence of characteristic lesions [24, 30].
Woman’s plans concerning pregnancy are very crucial, when deciding whether to start hormonal therapy or not. In such therapies, oral contraceptive pills (estrogen-progestogen) are usually used which induce menses every 28 days or they are used continuously without inducing menses. These pills also include progestogens, and they may be administered orally, intramuscularly, or in intrauterine way. There are also several medications, which are currently in use. Medical treatment is recommended in patients when catamenial pneumothorax is associated with endometriosis [17].
The aim of early GnRH analogue delivery is to prevent cyclic hormonal changes and to suppress the activity of the ectopic endometrium until effective pleurodesis occurs, because time is needed for the formation of effective pleural adhesions [38].
Hormonal treatment is advised for longer periods especially after reoperations for catamenial pneumothorax.
Proven ineffectiveness of the therapy or significant side effects of the drugs are the contraindications of hormonal therapy [29].
There is an accepted surgical algorithm and treatment in catamenial pneumothorax [55], which is described in Figure 2 in detail.
Figure 2.
Accepted surgical algorithm and treatment in catamenial pneumothorax.
10. Results of treatment
Practically, surgery for catamenial pneumothorax has very low mortality and morbidity. Recurrence is the most common complication of CPX, and there are reported recurrence rates of 20–40% [4, 7, 41, 53].
High recurrence rates are much higher than surgically treated idiopathic pneumothorax [8, 9, 10, 22, 23, 24, 29].
A low recurrence rate (8.3%), at a mean follow-up of 45.8 months, was reported by Attaran et al., by video thoracoscopic abrasion and pleurectomy, diaphragmatic repair and PTFE mesh coverage for the repair of diaphragmatic defects, and a routine postoperative hormonal treatment [55].
Also Alifano et al. reported that the highest postoperative recurrence rate in 114 women who were operated due to recurrent spontaneous pneumothorax was in the catamenial pneumothorax group (32%), and this was followed by a noncatamenial endometriosis-associated pneumothorax group (27%). They also reported a recurrence rate of 5.3%, at a mean of 32.7 months of follow-up, in patients with noncatamenial nonendometriosis-associated pneumothorax [32].
Young women with pneumothorax, especially in the perimenstrual period, should be suspected of catamenial pneumothorax. Failure occurs most frequently when recurrent catamenial pneumothorax occurs.
The lesions of the parietal and visceral pleura should be carefully examined and removed during surgery. Diaphragm reconstruction is required every time when fenestrations are detected in diaphragm.
Hormonal therapy is also recommended because it facilitates the effectiveness of the surgical results.
Multidisciplinary approach with early postoperative hormonal treatment, which deals with all thoracic pathologies including disease awareness, early diagnosis, diaphragmatic repair, and surgical management of the main chronic systemic disease, may eventually lead to a reduction in the rate of recurrence of catamenial pneumothorax [3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 23, 24, 30, 32].
Treatment of women of childbearing age is different from men of the same age group. CPX should be excluded in the cohort of women, especially when the pneumothorax is repeated. Full examination of the diaphragm should be part of the operation. Surgeons who perform VATS should be experienced to resect and repair diaphragms with fenestrations and endometrial deposits, including keyhole laying down of synthetic mesh.
Conflict of interest
There is no conflict of interest.
Thanks
We would like to thank Dr. Demetrio Larraín who kindly gave us permission to use his images in our chapter.
\n',keywords:"pneumothorax, menstruation, catamenial, surgery",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/65079.pdf",chapterXML:"https://mts.intechopen.com/source/xml/65079.xml",downloadPdfUrl:"/chapter/pdf-download/65079",previewPdfUrl:"/chapter/pdf-preview/65079",totalDownloads:1113,totalViews:0,totalCrossrefCites:1,totalDimensionsCites:1,totalAltmetricsMentions:0,impactScore:1,impactScorePercentile:75,impactScoreQuartile:3,hasAltmetrics:0,dateSubmitted:"July 23rd 2018",dateReviewed:"November 15th 2018",datePrePublished:"December 31st 2018",datePublished:"December 11th 2019",dateFinished:"January 7th 2019",readingETA:"0",abstract:"Catamenial pneumothorax is a rare condition in which spontaneous pneumothorax is recurrent. The incidence of catamenial pneumothorax has been underestimated for a few number of reasons. Recently, the etiology of catamenial pneumothorax has been more accurately diagnosed because of increased awareness and interest in the disease. Common and effective use of VATS technique contributed to better understanding of the disease. The management of the disease is difficult because of high recurrence rate. Operative and nonoperative interventions should be practiced more to prevent recurrences. Hormonal therapy should be added to treatment in selected cases. In this chapter, we will discuss all aspects of catamenial pneumothorax from diagnosis to treatment.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/65079",risUrl:"/chapter/ris/65079",book:{id:"7093",slug:"pneumothorax"},signatures:"Sezai Celik and Ezel Erşen",authors:[{id:"268979",title:"Prof.",name:"Sezai",middleName:null,surname:"Celik",fullName:"Sezai Celik",slug:"sezai-celik",email:"siyamie@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"279787",title:"Dr.",name:"Ezel",middleName:null,surname:"Erşen",fullName:"Ezel Erşen",slug:"ezel-ersen",email:"ezel.ersen@istanbul.edu.tr",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Incidence",level:"1"},{id:"sec_3",title:"3. Etiology",level:"1"},{id:"sec_4",title:"4. Clinical manifestations and diagnosis",level:"1"},{id:"sec_5",title:"5. Imaging diagnostic criteria",level:"1"},{id:"sec_6",title:"6. Tumor antigens",level:"1"},{id:"sec_7",title:"7. Characteristic findings of catamenial pneumothorax",level:"1"},{id:"sec_7_2",title:"7.1 Diaphragmatic lesions",level:"2"},{id:"sec_8_2",title:"7.2 Thoracic lesions",level:"2"},{id:"sec_10",title:"8. Surgical treatment of catamenial pneumothorax",level:"1"},{id:"sec_11",title:"9. Medical treatment",level:"1"},{id:"sec_12",title:"10. Results of treatment",level:"1"},{id:"sec_13",title:"11. Conclusions",level:"1"},{id:"sec_17",title:"Conflict of interest",level:"1"},{id:"sec_14",title:"Thanks",level:"1"}],chapterReferences:[{id:"B1",body:'Maurer ER, Schaal JA, Mendez FL Jr. Chronic recurring spontaneous pneumothorax due to endometriosis of the diaphragm. JAMA. 1958;168:2013-2014'},{id:"B2",body:'Lillington GA, Mitchell SP, Wood GA. Catamenial pneumothorax. 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Gynecologic evaluation of catamenial pneumothorax associated with endometriosis. Journal of Minimally Invasive Gynecology. 2010;17:593-599'},{id:"B54",body:'Kronauer CM. Images in clinical medicine. Catamenial pneumothorax. The New England Journal of Medicine. 2006;355:e9'},{id:"B55",body:'Baysungur V, Tezel C, Okur E, Yilmaz B. Recurrent pneumothorax diagnosed as catamenial after videothoracoscopic examination of the pleural cavity. Surgical Laparoscopy, Endoscopy & Percutaneous Techniques. 2011;21:e81-ee3'},{id:"B56",body:'Mikroulis DA, Didilis VN, Konstantinou F, et al. Catamenial pneumothorax. The Thoracic and Cardiovascular Surgeon. 2008;56:374-375'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Sezai Celik",address:"siyamie@gmail.com",affiliation:'
Department of Thoracic Surgery, Avicenna Hospitals, Turkey
Cerrahpasa Medical Faculty, Department of Thoracic Surgery, Istanbul University - Cerrahpasa, Turkey
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1. Introduction
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Nocturnal enuresis (NE) is a common disease that pediatricians often encounter. It is defined as an intermittent involuntary micturition during sleep in children over 5 years of age with at least two episodes per week and duration of more than 3 months [1]. Basically, NE is divided into non-monosymptomatic nocturnal enuresis (NMNE) and monosymptomatic nocturnal enuresis (MNE) according to whether there are daytime lower urinary tract symptoms. On the other hand, it is also classified into primary nocturnal enuresis (PNE) and secondary nocturnal enuresis (SNE) according to whether or not the duration of dry days is less than 6 months [1]. Secondary NE requires clinicians to identify and evaluate the diseases which NE is secondary to and treat them first. In PNE, NMNE usually means that children have more complex bladder dysfunction or other potential pathology and need to be referred to a specialist for further diagnosis and treatment. Although some children with MNE can be self-healing and the prevalence gradually decrease with age [2], most treatments for NE cannot achieve high cure rates and may cause high relapse rates. This may result from the complexity and uncertainty of the etiology of NE and the use of inappropriate treatment.
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2. Epidemiology
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According to Jain et al.’s review, the prevalence of MNE varies from 3.8 to 18.9% in different countries [2]. The risk factors related to NE reported in different studies include constipation, positive family history, obstructive respiratory disorder, deep sleep, corporal punishment at school, urinary tract infection, etc. [3, 4, 5, 6]. However, the effect of each factor on NE varies from study to study, and no universal conclusion is drawn. The results from different studies may be contradictory. For example, a few researches reported that the prevalence of NE was significantly higher in boys than the one in girls [3, 7], while other studies draw the opposite conclusion that girls’ prevalence is higher [8]. The potential reasons for the contradiction of results in different studies performed in different countries may be related to the difference in diagnostic criteria followed by each survey, sample size, sampling method, questionnaire design, and cultural background in different regions. According to Wen’s survey about NE in Chinese children, the overall prevalence was 4.07%, which is much lower than counterparts in other countries [9]. In it, Dr. Wen reported that Chinese parents would wake their children to void once they found children’s dysphoria due to the fullness of the bladder. Besides, he also found that Chinese parents were more likely to withdraw the diaper for their children as early as possible, which is believed to be helpful for the children to build normal urination habits. Similar to the mechanism of alarm therapy, these actions may have a positive effect to promote the establishment of reflex between bladder filling feeling and urination. It is important to analyze epidemiological data, which may help us to understand the importance of the children and their parents’ behavior and other complex physiological, pathological, and social psychological elements involved in the prevalence of NE.
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3. Clinical diagnosis and treatment algorithm
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There are a few diagnosis and treatment algorithms of NE proposed by the International Children’s Continence Society (ICCS), the International Continence Society (ICS), and some other literatures with similarities and differences. In this part, the algorithm of the ICCS’s practical consensus guideline is introduced and modified.
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NE has many possible causes: genetic factors, renal physiological factors, deficiency of antidiuretic hormone (ADH, vasopressin) leading to nocturnal polyuria, bladder dysfunction, arousal disorder, maturation delay, circadian rhythm disorder, etc. Moreover, many associated diseases such as obstructive sleep-disordered breathing, constipation, fecal incontinence, attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD), obesity, psychological problems, etc. can also be seen in children with NE. These associated diseases should be identified in the clinical evaluation and be treated first. For children without those conditions, the increase in nocturnal urine production and nighttime bladder capacity reduction are the two main prototypes. To provide an outline in the diagnosis and management of NE, we build an algorithm after summarizing available guidelines. Figure 1 is the clinical diagnosis and treatment algorithm adapted from the guideline of Walle et al [10]:
Clinical management tool is a medical history and symptoms collection form (see [10]).
Voiding diary (bladder diary) is not necessary.
After MNE is diagnosed, the 2012 guideline recommends directly the alarm and desmopressin treatment options. John Michael’s review in 2014 recommends 6 weeks of urotherapy first and then evaluating the child to decide whether to take alarm or desmopressin [11].
EBC: expected bladder capacity, calculated as {30 + (age in years × 30)} in milliliters.
MVV: maximum voided volume, the largest urine volume of 24 h (see part bladder diary for details).
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4. Treatment
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4.1 Urotherapy
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According to the 2006 ICCS’s standardized terminology of lower urinary tract (LUT) function, urotherapy is defined as a nonsurgical and nonpharmacological treatment for LUT dysfunction [1]. It includes standard therapy which means the therapy is noninterventional and has specific interventions.
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4.1.1 Standard therapy
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The standard therapy usually has these components as below:
Health education. Health education refers to providing parents basic information about normal LUT function and the causes, risk factors, different treatments, and their implementation of MNE [1]. The clinicians should emphasize that the condition is common and can be healed by itself and that parents should have a positive attitude instead of thinking enuresis as a shame because this helps children to establish their motivation for active participation and reduce damage to their self-esteem, which is the key to treatment [12].
Lifestyle advice. Develop healthy drinking and eating habits: avoid foods or beverages that have a diuretic effect, such as theophylline or caffeine; eat early in the evening, with less oil and less salt; and no more water or food and fruit rich in fluid at least 2 h before going to bed. These all avoid excessive nighttime fluids in body which may lead to overmuch urine production during the night. However, for children with MNE, fluid restriction may have a risk of reducing bladder capacity resulting in a decrease in the ratio of bladder capacity to nocturnal urine output, and so nocturnal enuresis increases [13]. Therefore, adequate fluid intake during the day is important, especially during the morning and early afternoon hours [14]. It is also good for cultivating the child’s feeling of bladder fullness. Moreover, a research indicates that holding exercises can increase the maximum voided volume of children with MNE, so it is better not to be active after dinner [15].
Developing regular voiding and bowel habits. As the ICCS recommended, children should develop a good habit of regular urination during the day and schedule to urinate before going to bed and in the early morning after waking up. The daily routine of micturition should be comprised of once in the morning, at least twice during school hours, and once each after school, at dinner, and before going to bed, with totally less than seven urinations during daytime [14]. Besides, parents should instruct the child to use a comfortable voiding posture to relax the pelvic floor muscles—and that means sitting on the toilet safely with the bottom and feet supported. Constipation is a common concomitant disease in children with NE, especially with NMNE. It is recommended to eat more foods rich in dietary fiber and develop regular bowel movements every day, best after breakfast. Based on current evidence, medication can be used to soften children’s stools if necessary [14].
Voiding diary or bladder diary (VD or BD). According to the 2012 ICCS’s practical consensus guidelines for MNE’s management [10], BD is recommended to assess the children’s voiding habit, especially for the families in which parents are unclear about children’s voiding history. The most important function of BD is to evaluate the bladder capacity of children through daytime diary and to assess the presence of nocturnal polyuria (NP) through nighttime diary. It is also helpful to distinguish NMNE through finding out daytime polyuria, stress urinary incontinence, urgency urinary incontinence, etc. A daytime diary should include at least fluid intake time, urination time, fluid intake volume, urination volume, and the occurrence of urinary incontinence and exclude the first urination after getting up in the morning. The recording time should be at least 3–4 consecutive days. Children attending school can choose to record two consecutive weekends [10]. In daytime diary, the most important thing that requires clinicians’ attention is the largest urinated volume which can indicate the child’s bladder capacity. It can be determined if the bladder capacity is reduced or increased when the maximum voided volume is <65% or >130% expected bladder capacity (EBC’s calculation formula is shown in Figure 1). The nighttime diary should include at least urination time (if the child gets up to the toilet), urination volume, diaper weight overnight, first urination volume after getting up in the morning, dry night or not (there is any enuresis or not), and whether there is bowel movement that day. The recording time should be at least seven consecutive nights [10]. What the nighttime diary can tell the clinicians is the child’s amount of urine produced at night by adding first urination after getting up in the morning, the nighttime diaper weight, and nocturnal urination volume to the toilet. If the total nighttime urine output exceeds 130% EBC, it is determined as nighttime polyuria (NP). Through analyzing individual BD, children with MNE can be classified into one of the four subtypes as shown in Figure 1. Then the corresponding treatment could be determined. In addition, by calculating a child’s body surface area, we can find whether the 24-h urine volume >2 L/m2, which means the child has polyuria; by observing a child’s water taking, we can know if the child has polydipsia which is considered as a predictor of diabetes or kidney disease. It is worth noting that children with these conditions are not suitable to take desmopressin.
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Figure 1.
Nocturnal enuresis algorithm (modified from Walle, 2012).
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4.1.2 Specific interventions
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Specific interventions comprise behavioral modification and nonbehavioral strategies including pelvic muscle floor training, biofeedback, electrical stimulation, etc. [1]. And the behavioral interventions can also be divided into simple and complex strategies based on whether it is a single action or they are composite interventions [16] (Table 1).
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4.1.2.1 Simple behavioral interventions
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Most of the simple behavioral interventions were initially presented in some early literatures, because the effects of first-line treatment on NE had not yet been determined at the time. They are often used in clinical treatment, but the efficacy is controversial since it lacks high-quality evidence. A systematic review about the efficacy and safety of simple behavioral interventions for NE has been published in the Cochrane Library. Unfortunately, only limited evidence is available. For most interventions only a single clinical trial was included, and therefore the data cannot be combined for meta-analysis except for the comparison between bladder training and alarm [16]. Furthermore, some other important limitations about the clinical trials were discussed in this review: for children with NE included in the trials, MNE and NMNE were not further distinguished; most trials had methodological deficiencies, and more than half of the trials reporting continuous outcomes did not report SDs; the trials’ sample size was small, risk of bias was high, and the confidence interval was too wide; since there is a lack of long-term follow-up after the end of treatment, no data were available to assess the long-term efficacy of the interventions [16]. The following is a summary of this review’s conclusion which needs to be cautiously referenced.
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In the simple behavioral interventions referring to reward systems, lifting or waking the children, bladder training, and fluid restriction (cleanliness training was not reviewed), though all of them were more effective statistically than the control group, none of them had a better effect than others at the end of the treatment. When compared with alarm or different drugs, they were usually less effective except for bladder training which has no significant difference with drugs [16]. In terms of safety, adverse events were not reported in the included trials.
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Bladder training is a behavioral therapy aiming to increase bladder capacity and strengthen the control of bladder in children. According to the review, bladder training seemed to be superior to the nonactive movements group in gaining less mean wet nights at the end of the treatment. However, there was no difference in the number of children who did not achieve 14 dry nights [16]. Another prospective trial further revealed that the basic bladder training’s effects mostly were pronounced after the third month of treatment for the MNE children who did not receive any previous treatment. Therefore, for children who are not strongly willing to accept behavioral interventions, early administration of alarm or desmopressin is necessary [17]. But it seems to have good efficacy in children with NMNE [18].
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Lifting without password is a controversial intervention because it allows the children to urinate while asleep, but it is useless to reduce the occurrence of nocturnal enuresis [19]. Being consistent with the conclusions of this review, a study also showed that the lifting without password group had a significantly higher proportion in the number of dry children than the control group and was even superior to lifting with password group and rewards group. In terms of long-term effect, both lifting groups had more dry children than the two other groups during 3 years follow-up [20].
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4.1.2.2 Complex behavioral interventions
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Dry bed training (DBT) is the oldest complex behavioral interventions with a multicomponent package of nighttime waking schedule, cleanliness training, reinforcement techniques, and other interventions. It has different versions and a few adapted versions with some components removed [21]. Full-spectrum home training (FSHT) is a combination with alarm, cleanliness training, and retention control training in the daytime. To maximize the effect, the FSHT needs to be overlearned (giving extra fluids at bedtime after successfully becoming dry). Specific implementation steps of DBT and FSHT have been described by Brown and Glazener [22, 23]. In a Cochrane review of NE, complex behavioral interventions were compared with control, alarm, and other complex behavioral interventions. Moreover, complex behavioral interventions removing alarm were compared with control, alarm, and complex behavioral interventions supplemented by alarm. The conclusions were that DBT or FSHT was better than control in efficacy and relapse rate and marginally superior to alarm alone. Either complex behavioral interventions removing alarm or control intervention was inferior to alarm alone or complex behavioral interventions supplemented by alarm. There is no evidence for the comparison between complex behavioral interventions removing alarm and control. Additionally, adverse events were not described by the trials [23]. Unfortunately, the included studies in the systematic review have some limitations including small scale, small quantity, and poor quality. Besides, it has to be mentioned that the interventions are heavy burdens on families.
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Alarm and reward system are the components of arousal therapy/training, which was reported to have a high efficacy and low relapse rate in an early literature [24]. However, they have not been recommended by the guideline [10] because there is not enough clinical evidence, which is similar to FSHT [25].
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4.1.2.3 Nonbehavioral interventions
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Biofeedback therapy and electrical stimulation therapy were originally used to treat voiding dysfunction, and now they have been tried to treat refractory MNE or PNE with a reported good efficacy. Dr. Hoekx and his colleagues prospectively evaluated the effect of bladder biofeedback in 21 boys and 3 girls (mean age 10.4 years). After treatment 17/24 patients showed good response that means they achieved totally dry. During the 60-month follow-up, 4 patients were lost, 15 were dry at night, and 4 continued bed-wetting. The proportion of children with small bladder capacity in responders is much less than the one in non-responders [26]. In a randomized clinical trial published in 2015, 54 children with PNE were included and randomly divided into interferential (IF) electrical stimulation group and control group. A responding rate was reported as 55.5 and 22% in the IF and control group at the 1-year follow-up (P = 0.01), respectively. In terms of the mean number of dry nights per week and the mean improvement score, the IF group was superior compared to control group. Additionally, no adverse events were reported [27]. In another trial, children with refractory MNE were randomly assigned to intra-anal biofeedback with behavioral therapy, electrical stimulation with behavioral therapy, and pelvic floor muscle training groups. The trial stated a total efficacy of three groups in the outcomes and that intra-anal ES group was superior to BF training group. But in these three outcomes, the method to assess nighttime bladder capacity with morning first urine volume is not accurate [28]. In short, there is no adequate clinical evidence to determine the therapeutic effectiveness of these NE treatments (Table 2).
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Simple behavioral Interventions
Reward systems
Lifting or waking the children at night to urinate1
Including bladder biofeedback and intra-anal biofeedback
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4.2 Alarm
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Alarm therapy, also known as enuretic alarm devices (EADs) or enuresis alarm treatment (EA), is a kind of therapy with sufficient evidence which shows a higher response rate and a superior long-time success than the control or other therapies. Although its relapse rate is still a little high, the addition of overlearning and dry bed training or avoiding penalties can reduce the rate by nearly half [29]. In terms of different types of alarms, there was no enough evidence to draw conclusions, neither did the comparison between alarm and other behavioral therapies [29]. Two other Cochrane reviews revealed that alarm had better effects than simple behavioral interventions, but not when compared with complex behavioral therapies [16, 23]. Some researchers believed the effect of alarm might be weakened if only the parents were waked by the alarm instead of the children. A result from Tsuji’s study showed whether the parents or children themselves are waked by the alarm or the effectiveness of alarm is equal [30]. Apos E. et al.’s study published in 2018 stated excellent effects of alarm therapy for MNE, NMNE, PNE, and SNE children using alarm therapy and especially for NMNE children [31]. The ICCS guideline also recommended that the alarm should be considered as the therapeutic option for every child. Furthermore, those children who have motivated parents should be given a priority [14].
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It has to be mentioned that alarm does not have an immediate effect. Normally, it often needs to take a period of time to achieve the expected efficacy. The appropriate course recommended by the ICCS is 2–3 months until children achieve 14 consecutive dry nights or the effect is not good [14]. Similarly, the ICS’s recommendation is to evaluate the efficacy of alarm after at least 6–8 weeks [12]. It also states that the efficacy will increase with treatment duration; however, the ideal course of alarm has not been introduced [12]. In one study, a total of 455 children with PMNE were randomly divided into three groups and received 3, 4, and 5 months of uninterrupted alarm treatment, respectively. The results showed that children with 16–20 weeks’ treatment had better curative effect [32]. Unfortunately, this study did not observe the effect with a longer follow-up. So we cannot conclude if the longer treatment can further increase the effect of alarm. In another study, NE children who were ineffective after 3 months’ alarm treatment were randomized into two groups to receive a repeat alarm treatment for ≥3 months without interval and with an interval of more than 6 months, separately. The success rate in the latter group was significantly higher than the former, which means repeat alarm therapy with at least one interval may reawaken children’s response [33]. Despite the small sample size, this study may provide new ideas for children who have no response to alarm treatment.
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The possible mechanism of alarm therapy may be a gradual establishment of a conditioned reflex between bladder filling and waking. Evidence showed that it could increase the prepulse inhibition (PPI), similar to the effect of desamino-arginine vasopressin (dDAVP), which suggested that the alarm could also promote the maturation of the reflex control of NE [34]. In addition, a study reported that children’s daytime functional bladder capacity increased markedly after treatment with alarm [35]. Therefore, the efficacy of alarm on children with NE may be achieved through multiple effects.
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4.3 Desmopressin
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Desmopressin is an arginine vasopressin analog that enhances the reabsorption of water by the distal convoluted tubules and collecting ducts of the kidney and inhibits the secretion of aldosterone. Schulz-Juergensen et al.’s study published in 2007 showed that 1-desamino-8-d-arginine vasopressin (dDAVP) could make PMNE children’s PPI upregulate to the age-related normal level. The authors offered a different explanation about dDAVP that it not only had a role in the kidney but also acted as a central neurotransmitter which has a positive effect on the delayed maturation of NE children’s micturition reflex [36]. According to the results of this study, desmopressin has the ability to cure a substantial group of children with NE in theory. However, it is more complicated in practice with problems of how to choose the potential suitable children for desmopressin therapy. Moreover, what is the appropriate dose and course of treatment are also big issues. To assess the effect of desmopressin, a number of studies have been performed. Evidence showed that it could significantly reduce bed-wetting by 1–2 nights per week during the treatment, but there is no difference in wet nights per week compared with the placebo group. Additionally, when comparing with alarm therapy, lower effectiveness and higher subsequent relapse rate were reported in the desmopressin group according to a Cochrane review [37].
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In general, children with nocturnal polyuria are suitable for desmopressin therapy. Basically, we can identify this subtype of MNE using the bladder diary. However, there is an evidence showing that children with NE may not present continuous nocturnal polyuria. Nocturnal urine production increases significantly on wet nights than the dry nights. Children without abnormal increase in nocturnal urine production do not respond to desmopressin [38]. This study revealed the polyuria characteristics for a subgroup of NE children and confirmed the efficacy of desmopressin for these children. Furthermore, some other studies also showed that desmopressin was not effective in children with low functional bladder capacity [39] and those with abnormal bladder volume and wall thickness (BVWT) [40], indicating that desmopressin’s clinical use should carefully identify children with potential bladder dysfunction.
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Referring to appropriate dose of desmopressin, there is an insufficient evidence to determine whether higher dose is more effective or not [37]. The recommended safe dose is 0.2–0.4 mg for tablets and 120–240 μg for melt formulation [14]. There is no enough evidence to state what is the appropriate course of treatment. Because of high relapse rate after treatment, it is advised to gradually reduce the drug dose instead of stopping it directly at the time of getting a complete response. For long-term safety, desmopressin is proven to be safe enough to use for several years. Water intoxication with hyponatremia is only a severe adverse event that needs to be concerned. Fluid restriction of 200 ml or less for the whole night is advised with desmopressin treatment [14]. Moreover, nasal spray reports more hyponatremia than oral formulations [41].
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4.4 Pharmacotherapy (other than desmopressin)
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Anticholinergic drugs are widely used for the management of NE since they can bind to choline receptors and produce antagonistic activity against acetylcholine and consequently relieve detrusor overactivity. They can be classified into M and N receptor blockers according to their selectivity for different receptors. M receptor blockers, also called as antimuscarinics, are more commonly used to treat NE. Generally, M receptors consist of five different subtypes, including M1, M2, M3, M4, and M5. Of those, M2 and M3 subtypes are mainly distributed in the bladder wall, and M3 has an upregulated expression in patients with overactive bladder. Therefore, the therapeutic mechanism of antimuscarinics is to inhibit the bladder M receptor, relax the detrusor, and consequently expand the bladder capacity. The mechanism determines that antimuscarinic drugs should be mainly used in treatment of NE children who are suffering from latent bladder smooth muscle spasm, detrusor overactivity, or decreased functional bladder capacity. This kind of children usually has daytime symptoms of lower urinary tract and is classified as NMNE. However, some children diagnosed as MNE are also suitable for anticholinergic drug therapy because they have only nighttime detrusor overactivity or mild urinary tract symptoms during daytime. For children who do not respond to alarm or desmopressin therapy, anticholinergic agents are usually a kind of therapeutic option. The clinical application of anticholinergic drugs should focus on how to identify the children with indications through bladder diary and other diagnostic techniques. Studies to evaluate the efficacy of anticholinergic drugs and their combination with alarm or desmopressin on these children should be conducted as well.
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Differing from anticholinergic drugs, the mechanism of tricyclic drugs in the treatment of NE is still unclear. The possible mechanism includes inhibiting rapid eye movement sleep to promote sleep arousal and stimulating antidiuretic hormone secretion. A Cochrane review showed that tricyclic drugs could reduce about one wet night per week, but most children relapsed after treatment which is similar to desmopressin and inferior to alarm [42]. In addition, most tricyclic drugs may cause serious side effects such as cardiotoxicity, so they are only used for the treatment of refractory or therapy-resistant NE. An exception is reboxetine. Neveus and his colleagues attempted to treat children with therapy-resistant NE using reboxetine, and they found that 59% of the patients reached a full response after 4 weeks of treatment. Moreover, during treatment, no significant cardiac toxicity was reported [43]. Lundmark et al. used reboxetine to treat therapy-resistant NE children and also achieved good results without significant cardiac adverse events [44]. Therefore, reboxetine may be a good therapeutic option instead of imipramine, but its effectiveness and safety need more clinical studies to prove.
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4.5 Complementary and alternative approaches
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Although a large amount of evidence has shown the effectiveness of conventional treatment including alarm and pharmacotherapy on NE [31, 45], these approaches cannot meet all the needs of the children and their parents. It is reported that as high as 30% of families discontinue the treatment of alarm on their own reason [46]. On the other hand, the side effects related to medications bother both children and their family members. Therefore, a number of parents are more likely to seek help from complementary and alternative medicine for their children. Being outside of conventional medicine, complementary and alternative medicine includes a series of medical approaches, such as acupuncture, herbal therapy, and massage. Recently, an increasing evidence has shown the efficacy of complementary and alternative medicine on management of NE.
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4.5.1 Acupuncture
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Acupuncture, as a component of traditional Chinese medicine, has been used to manage a number of chronic diseases. Even though acupuncture originates in China, its efficacy on various urological diseases has been recognized in industrial world [47]. A number of studies have demonstrated the effectiveness of acupuncture in treatment of NE. In a single-arm trial, Bjorkstrom et al. [48] showed that an 8-week treatment with 20 sessions of acupuncture decreased the episodes of NE and the sleep arousal threshold significantly in 65 and 50% of children, respectively, at the follow-up of 6 months. Another study further revealed that acupuncture might increase the nocturnal bladder capacity significantly in responders [49]. To assess the effect of acupuncture on NE, several systematic reviews were conducted. As presented in a part of Cochrane systematic review [50], Glazener et al. showed that acupuncture might result in a more significant improvement for children with NE than sham intervention. Moreover, acupuncture seemed to have a lower failure rate than combination therapy with meclofenoxate, oryzanol, and thiamine. Six years later, the updated Cochrane systematic review [50] demonstrated the same result. Another systematic review showed that acupuncture in conjunction with other treatment could reduce the number of NE more significantly than other treatment alone [51]. It needs to be mentioned that some methodological limitations have to be taken into consideration when we analyze the evidence. These systematic reviews included the nonrandomized and quasi-randomized studies besides randomized controlled trials, which may weaken the level of evidence. To provide the high quality of evidence, a recent published systematic review excluded nonrandomized and quasi-randomized trials and showed that acupuncture might be more effective in management of NE than sham procedure or drug treatment [52]. However, some studies with the intervention of acupoint injection were included in the systematic review, which may make the results controversial. As is known, acupuncture only provides physical effect, while both physical and chemical effects are involved in acupoint injection.
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To further provide evidence, we designed and conducted a systematic review. After performing a comprehensive search of medical literature, including Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CBM, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform, on February 22, 2019, a total of 238 randomized controlled trials were reviewed, and 10 of them with 953 randomized participants (441 in acupuncture group and 412 in control group) were included. We found that compared with the other treatment, acupuncture resulted in significantly higher complete response rate [OR = 2.41, 95%CI (1.41, 4.93) P = 0.002], so did the significance when compared with conventional drug, sham procedure, and herbal therapy, respectively. Moreover, although acupuncture did not reduce the average number of NE in comparison with other treatment, a significant decrease was found when compared to the sham intervention [MD = −1.49, 95%CI (−2.26, −0.72) P = 0.0002]. In terms of adverse events, there was no significant difference between acupuncture and other treatment [OR = 0.62, 95%CI (0.04, 8.72) P = 0.72]. Based on our results, acupuncture may have a better effect in management of NE, when compared to conventional drug, sham procedure, and herbal therapy, respectively.
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The potential mechanism of acupuncture’s effectiveness in managing NE might be the regulation on bladder function and secretion of antidiuretic hormone. A study assessed the effect of acupuncture on urodynamic parameters in children with NE and found acupuncture could suppress the detrusor overactivity [53]. On the other hand, an animal experiment showed that acupuncture could downregulate the concentration of arginine vasopressin in the hypothalamic paraventricular nucleus and upregulate the concentration of arginine vasopressin in the hypothalamic supraoptic nucleus, periaqueductal gray, caudate nucleus, and nucleus raphe magnus [54], which may cause an antidiuretic effect.
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4.5.2 Herbal therapy
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Herbal therapy is an important component of traditional medicine. About 3500 years ago, Papyrus Ebers described that cypress, juniper berries, and beer might be used to treat NE, which is the earliest record for the treatment of NE. Although there is lack of enough evidence, some herbs, such as St John’s wort (Hypericum perforatum), infusions of horsetail, or corn silk (Zea mays), are considered to be helpful to regulate bladder function [55]. Hosein et al. performed a double-blind randomized controlled trial to evaluate the effectiveness of chamomile oil in treating NE, in which 80 patients were allocated to receive chamomile oil or placebo. After 2 weeks treatment, the patients’ mean wet night frequency in chamomile oil group decreased from 8.2 to 5.6 nights/2 weeks, while no significant difference was found in placebo group [56]. We hope more clinical trials can provide more evidence for the efficacy of herbal therapy in future.
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4.5.3 Massage and chiropractic
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Both massage and chiropractic are a kind of manipulative therapy acting on the body with appropriate pressure. The former focuses on the relaxation of muscle, while the latter centers on the regulation of spinal articulations. They can be the therapeutic options for NE since their effectiveness has been reported. An early study attempted to treat five children with NE using massage which pressed the acupoint located in the creases between the first and the second and the third phalanx of the 5th finger. After an average of 20 sessions of therapy, two children achieved complete recovery, and one got partial recovery [57]. In another study, Yuksek et al. performed an efficacy comparison of massage with oxybutynin. After 6 months treatment, 83.3% of patients in massage group experienced a significant improvement, which is better than 58.3% in oxybutynin group [58].
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In a case series study, 171 children with NE were treated by chiropractic. After 2 weeks treatment, the median episodes of NE decreased from 7.0 per week at baseline to 5.6 per week and further dropped to 4.0 per week at the end of treatment [59]. Another finding of the study is that the more severe symptoms children had, the less benefit they got from the treatment, which means those with mild to moderate NE might be suitable for chiropractic. Reed et al. designed and conducted a 10-week controlled clinical trial, in which children with NE received chiropractic or sham intervention. After the treatment, a significant reduction was observed in children’s mean wet night frequency (from 9.1 to 6.7 nights/2 weeks) in chiropractic group. By contrast, the counterpart in sham intervention group did not change markedly (12.1 vs 12.2 nights/2 weeks) [60]. Van Poecke and his colleague found that the resolution rate within 1 year in children who received chiropractic was about 66.6% after analyzing the data of 33 patient records [61].
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5. New about diagnostic and treatment
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Enuretic bladder capacity is a big issue discussed in some recent research. Researchers are more likely to use the reduction in maximum voiding volume (MVV) on bladder diary to determine the decreased nocturnal bladder capacity (NBC). However, it might be unreasonable because a study found the enuretic bladder capacity of enuresis children was significantly less than their daytime functional bladder capacity (FBC), while healthy children’s NBC was the same as FBC [62]. Kim et al.’s study also showed that the proportion of NE children with small NBC and small MVV was quite different. The accuracy using decreased MVV to identify small NBC is only medium to low [63]. Another study performed by Borg et al. measured the difference in diaper weight between the early part and the later part of the night, as the enuretic bladder capacity, in MNE children with normal MVV, and found that 82% of children had less bladder capacity than MVV during enuresis, even less than 65% of expected bladder capacity [64]. These studies indicate that although small MVV can be used to determine the reduction of FBC, it cannot assess accurately NBC or enuretic bladder capacity. If pediatricians manage MNE children with normal MVV with desmopressin following the ICCS guidelines, these children may still experience nocturnal enuresis due to a mismatch between bladder capacity and urine volume at night. Therefore, a new method for assessing NBC and enuretic bladder capacity needs to be explored.
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Barroso et al. assessed the efficacy of a new device, which is the combination of alarm and electrical stimulation to the pelvic floor muscles, for NE. This device presented an advantage that helps children to achieve no wet beds during the period of treatment. On the one hand, pelvic floor muscle contraction induced by electrical stimulus may cause an increased urethral closure pressure, which allows children to keep dry during nighttime. On the other hand, alarm would also be triggered by the humidity sensor, and children would be waked to void [65]. This device needs more trials to determine its effectiveness and safety. Additionally, there was an intelligent autonomous alarm using ultrasound and smartphone ML techniques raised in 2019. It could monitor the bladder and trigger before the voiding desire. It also has the advantage to achieve totally dry bed during treatment [66].
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6. Conclusions
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Standard therapy should be applied to every child when he first visits the clinic. Then clinicians follow the diagnosis algorithm to distinguish MNE from NMNE and determine which subtype the child is. According to the ICCS’s guideline [10], MNE children with normal nocturnal urine volume (normal or reduced MVV) should choose the alarm therapy. It is believed as the most effective single-therapy with the lower recurrence rate and has efficacy for most types of MNE, even NMNE. The addition of overlearning can reduce the relapse rate of alarm. Therefore, it is necessary to perform overlearning after the success of the alarm treatment. Complex behavioral therapies supplemented by alarm are more effective than alarm and can reduce the recurrence rate. It can be advised to families with better motivation and seeking for better efficacy. Desmopressin should be used for the treatment of MNE children with polyuria (normal or reduced MVV). To avoid relapse, the drug can be taken for a long time and then gradually reduced.
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The guideline recommended small MVV and NP children to use combination therapy of alarm and desmopressin [10]. The addition of alarm can increase the long-term efficacy of desmopressin [37]. However, combination therapy seems not to reduce the number of children who do not achieve 14 consecutive dry nights compared with alarm alone [29], indicating that patients who do not have full response to these two therapies may be mostly overlapped.
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For refractory NE, clinicians should reassess children’s potential physiological malformations and neurogenic bladder diseases using MRI, urodynamics, cystoscopy, urography, etc. if necessary. After first-line treatment failure, children with detrusor overactivity or decreasing functional bladder capacity can choose anticholinergic drugs. Other children can choose tricyclic drugs, biofeedback therapy, electrical stimulation interventions, acupuncture, massage and so on, or a combination of first-line therapy and second-line therapy.
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In summary, after meticulous diagnosis and assessment and appropriate treatment with sufficient evidence, most MNE children can get a great relief or even cure.
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\n',keywords:"nocturnal enuresis, alarm, desmopressin, behavioral interventions, acupuncture",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/69092.pdf",chapterXML:"https://mts.intechopen.com/source/xml/69092.xml",downloadPdfUrl:"/chapter/pdf-download/69092",previewPdfUrl:"/chapter/pdf-preview/69092",totalDownloads:803,totalViews:0,totalCrossrefCites:0,dateSubmitted:"December 6th 2018",dateReviewed:"August 9th 2019",datePrePublished:"October 15th 2019",datePublished:"April 22nd 2020",dateFinished:"September 16th 2019",readingETA:"0",abstract:"Nocturnal enuresis is a condition with complex etiology affecting plenty of children and families. Even though multifarious clinical trials and studies have been designed and completed, some inconclusive results on nocturnal enuresis confuse clinicians. This article aims to provide useful information for clinicians by summarizing the existing evidence on nocturnal enuresis and discussing the effectiveness and safety of different treatments. Nocturnal enuresis mainly results from the disorders related to central nervous system, which may cause nocturnal polyuria, nighttime bladder capacity decline, arousal disorder, and various accompanying diseases. We discussed the efficacy and safety of different treatments for monosymptomatic nocturnal enuresis, including standard therapies, simple behavioral interventions, complex behavioral interventions, alarm therapy, desmopressin and other drugs, biofeedback therapy, electrical stimulation, acupuncture, Chinese herbal medicine, massage, and so on. Alarm is still the most effective single therapy with lower relapse rate. Desmopressin has efficacy mainly in children with nocturnal polyuria. Children with detrusor overactivity or decreasing functional bladder capacity can choose anticholinergics. Additionally, tricyclic drugs, biofeedback therapy, electrical stimulation, acupuncture, massage, and so on are therapeutic options for children with nocturnal enuresis.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/69092",risUrl:"/chapter/ris/69092",signatures:"Bingying Zhou, Jianxin Lu, Peiqi Shi and Yifang An",book:{id:"7957",type:"book",title:"Lower Urinary Tract Dysfunction",subtitle:"From Evidence to Clinical Practice",fullTitle:"Lower Urinary Tract Dysfunction - From Evidence to Clinical Practice",slug:"lower-urinary-tract-dysfunction-from-evidence-to-clinical-practice",publishedDate:"April 22nd 2020",bookSignature:"Ran Pang",coverURL:"https://cdn.intechopen.com/books/images_new/7957.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-78984-725-3",printIsbn:"978-1-78984-724-6",pdfIsbn:"978-1-78984-171-8",isAvailableForWebshopOrdering:!0,editors:[{id:"186524",title:"Prof.",name:"Ran",middleName:null,surname:"Pang",slug:"ran-pang",fullName:"Ran Pang"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"288655",title:"Dr.",name:"Bingying",middleName:null,surname:"Zhou",fullName:"Bingying Zhou",slug:"bingying-zhou",email:"zhou1173538131@163.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"290124",title:"Prof.",name:"Jianxin",middleName:null,surname:"Lu",fullName:"Jianxin Lu",slug:"jianxin-lu",email:"13501392760@163.com",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bUyIEQA0/Profile_Picture_1644508966663",institution:{name:"Guang’anmen Hospital",institutionURL:null,country:{name:"China"}}},{id:"290125",title:"Dr.",name:"Peiqi",middleName:null,surname:"Shi",fullName:"Peiqi Shi",slug:"peiqi-shi",email:"18770036538@163.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"290126",title:"Dr.",name:"Yifang",middleName:null,surname:"An",fullName:"Yifang An",slug:"yifang-an",email:"790562976@qq.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Epidemiology",level:"1"},{id:"sec_3",title:"3. Clinical diagnosis and treatment algorithm",level:"1"},{id:"sec_4",title:"4. Treatment",level:"1"},{id:"sec_4_2",title:"4.1 Urotherapy",level:"2"},{id:"sec_4_3",title:"4.1.1 Standard therapy",level:"3"},{id:"sec_5_3",title:"Table 1.",level:"3"},{id:"sec_5_4",title:"4.1.2.1 Simple behavioral interventions",level:"4"},{id:"sec_6_4",title:"4.1.2.2 Complex behavioral interventions",level:"4"},{id:"sec_7_4",title:"Table 1.",level:"4"},{id:"sec_10_2",title:"4.2 Alarm",level:"2"},{id:"sec_11_2",title:"4.3 Desmopressin",level:"2"},{id:"sec_12_2",title:"4.4 Pharmacotherapy (other than desmopressin)",level:"2"},{id:"sec_13_2",title:"4.5 Complementary and alternative approaches",level:"2"},{id:"sec_13_3",title:"4.5.1 Acupuncture",level:"3"},{id:"sec_14_3",title:"4.5.2 Herbal therapy",level:"3"},{id:"sec_15_3",title:"4.5.3 Massage and chiropractic",level:"3"},{id:"sec_18",title:"5. New about diagnostic and treatment",level:"1"},{id:"sec_19",title:"6. Conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'Austin PF, Bauer SB, Bower W, et al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the Standardization Committee of the International Children’s Continence Society. Journal of Urology. 2014;6:1863-1865.e13. DOI: 10.1016/j.juro.2014.01.110'},{id:"B2",body:'Jain S, Bhatt GC. Advances in the management of primary monosymptomatic nocturnal enuresis in children. Paediatrics and International Child Health. 2016;36(1):7-14'},{id:"B3",body:'Bakhtiar K, Pournia Y, Ebrahimzadeh F, et al. Prevalence of nocturnal enuresis and its associated factors in primary school and preschool children of khorramabad in 2013. International Journal of Pediatrics. 2014:120686-120686'},{id:"B4",body:'Mejias SG, Ramphul K. Nocturnal enuresis in children from Santo Domingo, Dominican Republic: A questionnaire study of prevalence and risk factors. BMJ Paediatrics Open. 2018;2(1):e000311'},{id:"B5",body:'Hamed A, Yousf F, Hussein MM. Prevalence of nocturnal enuresis and related risk factors in school-age children in Egypt: An epidemiological study. World Journal of Urology. 2017;35(3):459-465'},{id:"B6",body:'Sarici H, Telli O, Ozgur BC, et al. Prevalence of nocturnal enuresis and its influence on quality of life in school-aged children. Journal of Pediatric Urology. 2016;12(3):159.e1-159.e6. DOI: 10.1016/j.jpurol.2015.11.011'},{id:"B7",body:'Gür E, Turhan P, Can G, et al. Enuresis: Prevalence, risk factors and urinary pathology among school children in Istanbul, Turkey. Pediatrics International: Official Journal of the Japan Pediatric Society. 2004;46(1):58-63'},{id:"B8",body:'Jarvelin M, Vikevainentervonen L, Moilanen I, et al. Enuresis in Seven‐Year‐Old Children. Acta Paediatrica. 1988;77(1):148-153'},{id:"B9",body:'Wen JG, Wang QW, Chen Y, et al. An epidemiological study of primary nocturnal enuresis in Chinese children and adolescents. European Urology. 2006;49(6):1107-1113'},{id:"B10",body:'Walle JV, Rittig S, Bauer S, et al. Practical consensus guidelines for the management of enuresis. European Journal of Pediatrics. 2012;171(6):971-983'},{id:"B11",body:'Dibianco JM, Morley C, Alomar O. Nocturnal enuresis: A topic review and institution experience. Avicenna Journal of Medicine. 2014;4:77'},{id:"B12",body:'Tekgul S, Nijman R, Hoebeke P, Canning D, Bower W, von Gontard A. Diagnosis and management of urinary incontinence in childhood.Report from the 4th International Consultation on Incontinence. Plymouth, UK: Health Publication Ltd; 2009. pp. 701-792'},{id:"B13",body:'Sorotzkin B. Nocturnal enuresis: Current perspectives. Clinical Psychology Review. 1984;4(3):293-315'},{id:"B14",body:'Neveus T, Eggert P, Evans J, et al. Evaluation of and treatment for monosymptomatic enuresis: A standardization document from the international children’s continence society. The Journal of Urology. 2010;183(2):441-447'},{id:"B15",body:'Van Hoeck KJ, Bael A, Van Dessel E, et al. Do holding exercises or antimuscarinics increase maximum voided volume in monosymptomatic nocturnal enuresis? A randomized controlled trial in children. The Journal of Urology. 2007;178(5):2132-2136. DOI: 10.1016/j.juro.2007.07.051'},{id:"B16",body:'Caldwell PHY, Nankivell G, Sureshkumar P. Simple behavioural interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews. 2013;(7):CD003637. DOI: 10.1002/14651858.CD003637.pub3'},{id:"B17",body:'Tkaczyk M, Maternik M, Krakowska A, et al. Evaluation of the effect of 3-month bladder basic advice in children with monosymptomatic nocturnal enuresis. Journal of Pediatric Urology. 2017;13(6):615.e1-615.e6. DOI: 10.1016/j.jpurol.2017.03.039'},{id:"B18",body:'Kroll P, Zachwieja J. The system of management nocturnal enuresis based on functional classification. Przeglaṃd Lekarski. 2006;63:229-232'},{id:"B19",body:'Butler RJ, Redfern EJ, Holland P. Children’s notions about enuresis and the implications for treatment. Scandinavian Journal of Urology and Nephrology. Supplementum. 1994;163:39-47'},{id:"B20",body:'van Dommelen P, Kamphuis M, van Leerdam FJ, et al. The short- and long-term effects of simple behavioral interventions for nocturnal enuresis in young children: A randomized controlled trial. The Journal of Pediatrics. 2009;154(5):662-666. DOI: 10.1016/j.jpeds.2008.12.001'},{id:"B21",body:'Hofmeester I, Kollen BJ, Steffens MG, et al. Predictors for a positive outcome of adapted clinical dry bed training in adolescents and adults with enuresis. Neurourology and Urodynamics. 2016;35(8):1006-1010. DOI: 10.1002/nau.22869'},{id:"B22",body:'Brown ML, Pope AW, Brown EJ. Treatment of primary nocturnal enuresis in children: A review. Child: Care, Health and Development. 2011;37(2):153-160. DOI: 10.1111/j.1365-2214.2010.01146.x'},{id:"B23",body:'Glazener CMA, Evans JHC, Peto RE. Complex behavioural and educational interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews. 2004;(1):CD004668. DOI: 10.1002/14651858.CD004668'},{id:"B24",body:'van Londen A, van Londen-Barentsen MW, van Son MJ, et al. Arousal training for children suffering from nocturnal enuresis: A 2 1/2 year follow-up. Behaviour Research and Therapy. 1993;31(6):613-615'},{id:"B25",body:'Van Kampen M, Bogaert G, Feys H, et al. High initial efficacy of full-spectrum therapy for nocturnal enuresis in children and adolescents. BJU International. 2002;90(1):84-87'},{id:"B26",body:'Hoekx L, Vermandel A, Wyndaele JJ. Functional bladder capacity after bladder biofeedback predicts long-term outcome in children with nocturnal enuresis. Scandinavian Journal of Urology and Nephrology. 2003;37(2):120-123. DOI: 10.1080/00365590310008848'},{id:"B27",body:'Kajbafzadeh AM, Sharifi-Rad L, Mozafarpour S, et al. Efficacy of transcutaneous interferential electrical stimulation in treatment of children with primary nocturnal enuresis: A randomized clinical trial. Pediatric Nephrology. 2015;30(7):1139-1145. DOI: 10.1007/s00467-014-3039-5'},{id:"B28",body:'Abd El-Moghny SM, El-Din MS, El Shemy SA. Effectiveness of intra-anal biofeedback and electrical stimulation in the treatment of children with refractory monosymptomatic nocturnal enuresis: A comparative randomized controlled trial. International Neurourology Journal. 2018;22(4):295-304. DOI: 10.5213/inj.1836142.071'},{id:"B29",body:'Glazener CMA, Evans JHC, Peto RE. Alarm interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews. 2005;(2):CD002911. DOI: 10.1002/14651858.CD002911.pub2'},{id:"B30",body:'Tsuji S, Suruda C, Kimata T, et al. The effect of family assistance to wake children with monosymptomatic enuresis in alarm therapy: A pilot study. The Journal of Urology. 2018;199(4):1056-1060. DOI: 10.1016/j.juro.2017.11.072'},{id:"B31",body:'Apos E, Schuster S, Reece J, et al. Enuresis management in children: Retrospective clinical audit of 2861 cases treated with practitioner-assisted bell-and-pad alarm. Journal of Pediatrics. 2018;193:211-216. DOI: 10.1016/j.jpeds.2017.09.086'},{id:"B32",body:'Kosilov KV, Geltser BI, Loparev SA, et al. The optimal duration of alarm therapy use in children with primary monosymptomatic nocturnal enuresis. Journal of Pediatric Urology. 2018;14(5):447.e1-447.e6. DOI: 10.1016/j.jpurol.2018.03.021'},{id:"B33",body:'Hyuga T, Nakamura S, Kawai S, et al. Evaluation of the effectiveness of a short-term treatment and repeat treatment of nocturnal enuresis using an enuresis alarm. Urology. 2017;105:153-156. DOI: 10.1016/j.urology.2017.01.005'},{id:"B34",body:'Schulz-Juergensen S, Langguth A, Eggert P. Effect of alarm therapy on conditioning of central reflex control in nocturnal enuresis: Pilot study on changes in prepulse inhibition (PPI). Pediatric Nephrology. 2014;29(7):1209-1213. DOI: 10.1007/s00467-014-2756-0'},{id:"B35",body:'Hvistendahl GM, Kamperis K, Rawashdeh YF, et al. The effect of alarm treatment on the functional bladder capacity in children with monosymptomatic nocturnal enuresis. Journal of Urology. 2004;6(Pt 2):2611-2614'},{id:"B36",body:'Schulz-Juergensen S, Rieger M, Schaefer J, et al. Effect of 1-desamino-8-d-arginine vasopressin on prepulse inhibition of startle supports a central etiology of primary monosymptomatic enuresis. The Journal of Pediatrics. 2007;151(6):571-574. DOI: 10.1016/j.jpeds.2007.05.024'},{id:"B37",body:'Glazener CMA, Evans JHC. Desmopressin for nocturnal enuresis in children. Cochrane Database of Systematic Reviews. 2002;(3):CD002112. DOI: 10.1002/14651858.CD002112'},{id:"B38",body:'Rittig S, Schaumburg H, Schmidt F, et al. Long-term home studies of water balance in patients with nocturnal enuresis. Scandinavian Journal of Urology and Nephrology. 1997;183:25-26; discussion 26-7'},{id:"B39",body:'Hamano S, Yamanishi T, Igarashi T, et al. Functional bladder capacity as predictor of response to desmopressin and retention control training in monosymptomatic nocturnal enuresis. European Urology. 2000;37(6):718-722. DOI: 10.1159/000020224'},{id:"B40",body:'Yeung CK, Sreedhar B, Leung VT, et al. Ultrasound bladder measurements in patients with primary nocturnal enuresis: A urodynamic and treatment outcome correlation. Journal of Urology. 2004;6(Pt 2):2589-2594'},{id:"B41",body:'Wolfish NM, Barkin J, Gorodzinsky F, et al. The Canadian enuresis study and evaluation—Short- and long-term safety and efficacy of an oral desmopressin preparation. Scandinavian Journal of Urology and Nephrology. 2003;37(1):22-27. DOI: 10.1080/00365590310008631'},{id:"B42",body:'Caldwell PHY, Sureshkumar P, Wong WCF. Tricyclic and related drugs for nocturnal enuresis in children. Cochrane Database of Systematic Reviews. 2016;(1):CD002117. DOI: 10.1002/14651858.CD002117.pub2'},{id:"B43",body:'Neveus T. Reboxetine in therapy-resistant enuresis: Results and pathogenetic implications. Scandinavian Journal of Urology and Nephrology. 2006;40(1):31-34. DOI: 10.1080/00365590500407803'},{id:"B44",body:'Lundmark E, Stenberg A, Hagglof B, et al. Reboxetine in therapy-resistant enuresis: A randomized placebo-controlled study. Journal of Pediatric Urology. 2016;12(6):397.e1-397.e5. DOI: 10.1016/j.jpurol.2016.04.048'},{id:"B45",body:'Kwak KW, Lee YS, Park KH, et al. Efficacy of desmopressin and enuresis alarm as first and second line treatment for primary monosymptomatic nocturnal enuresis: Prospective randomized crossover study. Journal of Urology. 2010;184(6):2521-2526. DOI: 10.1016/j.juro.2010.08.041'},{id:"B46",body:'Butler RJ, Holland P, Gasson S, et al. Exploring potential mechanisms in alarm treatment for primary nocturnal enuresis. Scandinavian Journal of Urology and Nephrology. 2007;41(5):407-413. DOI: 10.1080/00365590701571506'},{id:"B47",body:'Tempest H, Reynard J, Bryant RJ, et al. Acupuncture in urological practice—A survey of urologists in England. Complementary Therapies in Medicine. 2011;19(1):27-31. DOI: 10.1016/j.ctim.2010.10.001'},{id:"B48",body:'Bjorkstrom G, Hellstrom AL, Andersson S. Electro-acupuncture in the treatment of children with monosymptomatic nocturnal enuresis. Scandinavian Journal of Urology and Nephrology. 2000;34(1):21-26'},{id:"B49",body:'Honjo H, Kawauchi A, Ukimura O, et al. Treatment of monosymptomatic nocturnal enuresis by acupuncture: A preliminary study. International Journal of Urology. 2002;9(12):672-676'},{id:"B50",body:'Huang T, Shu X, Huang YS, et al. Complementary and miscellaneous interventions for nocturnal enuresis in children. Cochrane Database of Systematic Reviews. 2011;(12):CD005230. DOI: 10.1002/14651858.CD005230.pub2'},{id:"B51",body:'Bower WF, Diao M, Tang JL, et al. Acupuncture for nocturnal enuresis in children: A systematic review and exploration of rationale. Neurourology and Urodynamics. 2005;24(3):267-272. DOI: 10.1002/nau.20108'},{id:"B52",body:'Lv ZT, Song W, Wu J, et al. Efficacy of acupuncture in children with nocturnal enuresis: A systematic review and meta-analysis of randomized controlled trials. Evidence-based Complementary and Alternative Medicine. 2015;2015:320701. DOI: 10.1155/2015/320701'},{id:"B53",body:'Minni B, Capozza N, Creti G, et al. Bladder instability and enuresis treated by acupuncture and electro-therapeutics: Early urodynamic observations. Acupuncture & Electro-Therapeutics Research. 1990;151(1):19-25'},{id:"B54",body:'Yang J, Yang Y, Wang CH, et al. Effect of arginine vasopressin on acupuncture analgesia in the rat. Peptides. 2009;302(2):241-247. DOI: 10.1016/j.peptides.2008.10.013'},{id:"B55",body:'Culbert TP, Banez GA. Wetting the bed: Integrative approaches to nocturnal enuresis. Explore (New York, N.Y.). 2008;4(3):215-220. DOI: 10.1016/j.explore.2008.02.014'},{id:"B56",body:'Sharifi H, Minaie MB, Qasemzadeh MJ, et al. Topical use of Matricaria recutita L (chamomile) oil in the treatment of monosymptomatic enuresis in children: A double-blind randomized controlled trial. Journal Evidence-Based Complementary and Alternative Medicine. 2017;22(1):12-17. DOI: 10.1177/2156587215608989'},{id:"B57",body:'Bartocci C, Lucentini M. Acupuncture and micro-massage in the treatment of idiopathic nocturnal enuresis. Minerva Medica. 1981;72(33):2237'},{id:"B58",body:'Yuksek MS, Erdem AF, Atalay C, et al. Acupressure versus oxybutinin in the treatment of enuresis. Journal of International Medical Research. 2003;31(6):552-556. DOI: 10.1177/147323000303100611'},{id:"B59",body:'Leboeuf C, Brown P, Herman A, et al. Chiropractic care of children with nocturnal enuresis: A prospective outcome study. Journal of Manipulative and Physiological Therapeutics. 1991;14(2):110-115'},{id:"B60",body:'Reed WR, Beavers S, Reddy SK, et al. Chiropractic management of primary nocturnal enuresis. Journal of Manipulative and Physiological Therapeutics. 1994;17(9):596-600'},{id:"B61",body:'van Poecke AJ, Cunliffe C. Chiropractic treatment for primary nocturnal enuresis: A case series of 33 consecutive patients. Journal of Manipulative and Physiological Therapeutics. 2009;32(8):675-681. DOI: 10.1016/j.jmpt.2009.08.019'},{id:"B62",body:'Kawauchi A, Tanaka Y, Naito Y, et al. Bladder capacity at the time of enuresis. Urology. 2003;61(5):1016-1018'},{id:"B63",body:'Kim JM, Park JW, Lee CS. Evaluation of nocturnal bladder capacity and nocturnal urine volume in nocturnal enuresis. Journal of Pediatric Urology. 2014;10(3):559-563. DOI: 10.1016/j.jpurol.2013.11.020'},{id:"B64",body:'Borg B, Kamperis K, Olsen LH, et al. Evidence of reduced bladder capacity during nighttime in children with monosymptomatic nocturnal enuresis. Journal of Pediatric Urology. 2018;14(2):160.e1-160.e6. DOI: 10.1016/j.jpurol.2017.09.021'},{id:"B65",body:'Barroso U Jr, Lordelo P, Teles A, et al. New device and new concept for treating nocturnal enuresis: Preliminary results of a phase one study. Journal of Pediatric Urology. 2014;10(6):1273-1276. DOI: 10.1016/j.jpurol.2014.06.023'},{id:"B66",body:'Kuru K, Ansell D, Jones M, et al. Feasibility study of intelligent autonomous determination of the bladder voiding need to treat bedwetting using ultrasound and smartphone ML techniques: Intelligent autonomous treatment of bedwetting. Medical & Biological Engineering & Computing. 2019;57(5):1079-1097. DOI: 10.1007/s11517-018-1942-9'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Bingying Zhou",address:"zhou1173538131@163.com",affiliation:'
Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
Guang’anmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
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Tailor-made service: choose between online only or online and print editions of your Compact
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+560,000 visitors per month guarantees high visibility and opportunities for international content sharing
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You retain copyright to your work
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Wide dissemination and distribution to scientific databases and university libraries
\n\t
Competitive pricing with funding opportunities
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Castro",authors:[{id:"107041",title:"Dr.",name:"Maite A",middleName:null,surname:"Castro",slug:"maite-a-castro",fullName:"Maite A Castro"},{id:"109692",title:"Mr.",name:"Felipe A",middleName:null,surname:"Beltran",slug:"felipe-a-beltran",fullName:"Felipe A Beltran"},{id:"109695",title:"Mr.",name:"Aníbal",middleName:"I.",surname:"Acuña",slug:"anibal-acuna",fullName:"Aníbal Acuña"},{id:"109696",title:"Ms.",name:"Maria Paz",middleName:null,surname:"Miro",slug:"maria-paz-miro",fullName:"Maria Paz Miro"}]},{id:"54565",doi:"10.5772/67828",title:"The Role of the Amygdala in Regulating the Hypothalamic-Pituitary-Adrenal Axis",slug:"the-role-of-the-amygdala-in-regulating-the-hypothalamic-pituitary-adrenal-axis",totalDownloads:3554,totalCrossrefCites:6,totalDimensionsCites:9,abstract:"We investigated the regulatory role of the amygdala upon the function of the hypothalamic-pituitary-adrenal (HPA) axis as measured by median eminence corticotrophin releasing hormone (CRH) content and serum levels of adrenocorticotrophic hormone (ACTH) and corticosterone. Our findings showed that (1) lesions of the central amygdala inhibited the HPA axis responses to a variety of stressful stimuli. (2) Depletion of norepinephrine or serotonin in the amygdala and hypothalamus and local injections of norepinephrine and serotonin receptor antagonists into the central amygdala inhibited the HPA axis responses to neural stress. Norepinephrine and serotonin agonists injected into the amygdala caused an increase in HPA axis activity. The activation of the amygdala facilitated the in vivo release of serotonin from the paraventricular nucleus following electrical stimulation of the brainstem raphe nuclei. (3) Electrical stimulation of the amygdala impaired the glucocorticoid negative feedback action following neural stressful stimuli probably via a decrease in hippocampal corticosteroid receptors.",book:{id:"5485",slug:"the-amygdala-where-emotions-shape-perception-learning-and-memories",title:"The Amygdala",fullTitle:"The Amygdala - Where Emotions Shape Perception, Learning and Memories"},signatures:"Joseph Weidenfeld and Haim Ovadia",authors:[{id:"190851",title:"Ph.D.",name:"Haim",middleName:null,surname:"Ovadia",slug:"haim-ovadia",fullName:"Haim Ovadia"},{id:"192823",title:"Prof.",name:"Joseph",middleName:null,surname:"Weidenfeld",slug:"joseph-weidenfeld",fullName:"Joseph Weidenfeld"}]},{id:"32393",doi:"10.5772/34852",title:"The Neurochemical Anatomy of Trigeminal Primary Afferent Neurons",slug:"the-neurochemical-anatomy-of-trigeminal-primary-afferent-neurons",totalDownloads:4712,totalCrossrefCites:0,totalDimensionsCites:9,abstract:null,book:{id:"1592",slug:"neuroscience-dealing-with-frontiers",title:"Neuroscience",fullTitle:"Neuroscience - Dealing With Frontiers"},signatures:"Nikolai E. Lazarov",authors:[{id:"101891",title:"Prof.",name:"Nikolai",middleName:null,surname:"Lazarov",slug:"nikolai-lazarov",fullName:"Nikolai Lazarov"}]},{id:"54301",doi:"10.5772/67585",title:"Revisiting the Role of the Amygdala in Posttraumatic Stress Disorder",slug:"revisiting-the-role-of-the-amygdala-in-posttraumatic-stress-disorder",totalDownloads:2172,totalCrossrefCites:2,totalDimensionsCites:8,abstract:"Over the past 20 years, the reactivity of amygdala to emotive stimuli has been explored by emerging neuroimaging techniques in an effort to understand the role of amygdala in the pathophysiology of posttraumatic stress disorder (PTSD). A fear neurocircuitry model, whereby the amygdala is hyperactive due to poor top-down control from the anterior cingulate and ventromedial prefrontal cortices, has been supported by numerous experimental studies and meta-analyses. However, this model has not always been upheld by experimental data and clinical observations. In particular, many neuroimaging studies find that the amygdala fails to activate in response to negative stimuli in individuals with PTSD. Several technical and design issues may explain disparate results regarding amygdala reactivity in PTSD. However, biological and symptom-based factors emerge as possible mediators of amygdala function in PTSD, leading to the conclusion that symptoms of emotional disengagement and dissociation are associated with amygdala hyporeactivity, and symptoms of hypervigilance/hyperarousal and problems with fear conditioning and extinction are reflected by amygdala hyperactivity. Therefore, treatment of PTSD should take into account the nature of amygdala dysfunction in the individual to optimize treatment outcomes.",book:{id:"5485",slug:"the-amygdala-where-emotions-shape-perception-learning-and-memories",title:"The Amygdala",fullTitle:"The Amygdala - Where Emotions Shape Perception, Learning and Memories"},signatures:"Gina L. Forster, Raluca M. Simons and Lee A. Baugh",authors:[{id:"145620",title:"Dr.",name:"Gina",middleName:null,surname:"Forster",slug:"gina-forster",fullName:"Gina Forster"},{id:"195109",title:"Dr.",name:"Raluca",middleName:null,surname:"Simons",slug:"raluca-simons",fullName:"Raluca Simons"},{id:"195110",title:"Dr.",name:"Lee",middleName:null,surname:"Baugh",slug:"lee-baugh",fullName:"Lee Baugh"}]},{id:"55211",doi:"10.5772/intechopen.68618",title:"The Amygdala and Anxiety",slug:"the-amygdala-and-anxiety",totalDownloads:2984,totalCrossrefCites:4,totalDimensionsCites:8,abstract:"The amygdala has a central role in anxiety responses to stressful and arousing situations. Pharmacological and lesion studies of the basolateral, central, and medial subdivisions of the amygdala have shown that their activation induces anxiogenic effects, while their inactivation produces anxiolytic effects. Many neurotransmitters and stress mediators acting at these amygdalar nuclei can modulate the behavioral expression of anxiety. These mediators may be released from different brain regions in response to different types of stressors. The amygdala is in close relationship with several brain regions within the brain circuitry that orchestrates the expression of anxiety. Recent developments in optogenetics have begun to unveil details on how these areas interact.",book:{id:"5485",slug:"the-amygdala-where-emotions-shape-perception-learning-and-memories",title:"The Amygdala",fullTitle:"The Amygdala - Where Emotions Shape Perception, Learning and Memories"},signatures:"Sergio Linsambarth, Rodrigo Moraga-Amaro, Daisy Quintana-\nDonoso, Sebastian Rojas and Jimmy Stehberg",authors:[{id:"144923",title:"Dr.",name:"Jimmy",middleName:null,surname:"Stehberg",slug:"jimmy-stehberg",fullName:"Jimmy Stehberg"},{id:"194182",title:"Ph.D. Student",name:"Rodrigo",middleName:null,surname:"Moraga-Amaro",slug:"rodrigo-moraga-amaro",fullName:"Rodrigo Moraga-Amaro"},{id:"194183",title:"M.Sc.",name:"Sergio",middleName:null,surname:"Linsambarth",slug:"sergio-linsambarth",fullName:"Sergio Linsambarth"}]}],mostDownloadedChaptersLast30Days:[{id:"54675",title:"The Key Role of the Amygdala in Stress",slug:"the-key-role-of-the-amygdala-in-stress",totalDownloads:2939,totalCrossrefCites:3,totalDimensionsCites:4,abstract:"Several data highlighted that stress exposure is strongly associated with several psychiatric disorders. The amygdala, an area of the brain that contributes to emotional processing, has a pivotal role in psychiatric disorders and it has been demonstrated to be highly responsive to stressful events. Here we will review evidences indicating how the amygdala changes its functionality following exposure to stress and how this contributes to the onset of anxiety disorders.",book:{id:"5485",slug:"the-amygdala-where-emotions-shape-perception-learning-and-memories",title:"The Amygdala",fullTitle:"The Amygdala - Where Emotions Shape Perception, Learning and Memories"},signatures:"Diego Andolina and Antonella Borreca",authors:[{id:"190318",title:"Dr.",name:"Diego",middleName:null,surname:"Andolina",slug:"diego-andolina",fullName:"Diego Andolina"},{id:"192832",title:"Dr.",name:"Antonella",middleName:null,surname:"Borreca",slug:"antonella-borreca",fullName:"Antonella Borreca"}]},{id:"55211",title:"The Amygdala and Anxiety",slug:"the-amygdala-and-anxiety",totalDownloads:2984,totalCrossrefCites:4,totalDimensionsCites:8,abstract:"The amygdala has a central role in anxiety responses to stressful and arousing situations. Pharmacological and lesion studies of the basolateral, central, and medial subdivisions of the amygdala have shown that their activation induces anxiogenic effects, while their inactivation produces anxiolytic effects. Many neurotransmitters and stress mediators acting at these amygdalar nuclei can modulate the behavioral expression of anxiety. These mediators may be released from different brain regions in response to different types of stressors. The amygdala is in close relationship with several brain regions within the brain circuitry that orchestrates the expression of anxiety. Recent developments in optogenetics have begun to unveil details on how these areas interact.",book:{id:"5485",slug:"the-amygdala-where-emotions-shape-perception-learning-and-memories",title:"The Amygdala",fullTitle:"The Amygdala - Where Emotions Shape Perception, Learning and Memories"},signatures:"Sergio Linsambarth, Rodrigo Moraga-Amaro, Daisy Quintana-\nDonoso, Sebastian Rojas and Jimmy Stehberg",authors:[{id:"144923",title:"Dr.",name:"Jimmy",middleName:null,surname:"Stehberg",slug:"jimmy-stehberg",fullName:"Jimmy Stehberg"},{id:"194182",title:"Ph.D. Student",name:"Rodrigo",middleName:null,surname:"Moraga-Amaro",slug:"rodrigo-moraga-amaro",fullName:"Rodrigo Moraga-Amaro"},{id:"194183",title:"M.Sc.",name:"Sergio",middleName:null,surname:"Linsambarth",slug:"sergio-linsambarth",fullName:"Sergio Linsambarth"}]},{id:"32387",title:"The Mystery of P2X7 Ionotropic Receptor: From a Small Conductance Channel to a Large Conductance Channel",slug:"the-mystery-of-p2x7-receptor-from-a-small-channel-to-a-big-pore",totalDownloads:2418,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"1592",slug:"neuroscience-dealing-with-frontiers",title:"Neuroscience",fullTitle:"Neuroscience - Dealing With Frontiers"},signatures:"R.X. Faria, L.G.B. Ferreira and L.A. Alves",authors:[{id:"76663",title:"Prof.",name:"Luiz A.",middleName:null,surname:"Alves",slug:"luiz-a.-alves",fullName:"Luiz A. Alves"},{id:"76674",title:"Mr.",name:"Leonardo",middleName:null,surname:"Braga",slug:"leonardo-braga",fullName:"Leonardo Braga"},{id:"79615",title:"Dr.",name:"Robson",middleName:null,surname:"Faria",slug:"robson-faria",fullName:"Robson Faria"}]},{id:"32399",title:"Brain Energy Metabolism in Health and Disease",slug:"brain-energy-metabolism-in-health-and-disease",totalDownloads:9132,totalCrossrefCites:1,totalDimensionsCites:10,abstract:null,book:{id:"1592",slug:"neuroscience-dealing-with-frontiers",title:"Neuroscience",fullTitle:"Neuroscience - Dealing With Frontiers"},signatures:"Felipe A. Beltrán, Aníbal I. Acuña, María Paz Miró and Maite A. Castro",authors:[{id:"107041",title:"Dr.",name:"Maite A",middleName:null,surname:"Castro",slug:"maite-a-castro",fullName:"Maite A Castro"},{id:"109692",title:"Mr.",name:"Felipe A",middleName:null,surname:"Beltran",slug:"felipe-a-beltran",fullName:"Felipe A Beltran"},{id:"109695",title:"Mr.",name:"Aníbal",middleName:"I.",surname:"Acuña",slug:"anibal-acuna",fullName:"Aníbal Acuña"},{id:"109696",title:"Ms.",name:"Maria Paz",middleName:null,surname:"Miro",slug:"maria-paz-miro",fullName:"Maria Paz Miro"}]},{id:"54509",title:"The Contribution of the Amygdala to Reward-Related Learning and Extinction",slug:"the-contribution-of-the-amygdala-to-reward-related-learning-and-extinction",totalDownloads:1742,totalCrossrefCites:3,totalDimensionsCites:3,abstract:"There has been substantial research into the role of the amygdala in fear conditioning and extinction of conditioned fear. The role of the amygdala in appetitive conditioning is relatively less explored. Here, we will review research into the role of the amygdala in reward‐related learning. Research to date suggests that the basolateral and central amygdala are responsible for learning about distinct aspects of a reinforcing event. For example, the basolateral amygdala is essential for distinguishing and choosing between specific rewards based on the specific‐sensory properties of those rewards as well as updating the relative value of specific rewarding events. In contrast, the central amygdala is involved in encoding reinforcement more generally and for regulating motivational influences on responding. We will also review what is known about the role of the amygdala in extinction of reward‐related behaviours and highlight areas for future research.",book:{id:"5485",slug:"the-amygdala-where-emotions-shape-perception-learning-and-memories",title:"The Amygdala",fullTitle:"The Amygdala - Where Emotions Shape Perception, Learning and Memories"},signatures:"Rose Chesworth and Laura Corbit",authors:[{id:"193670",title:"Dr.",name:"Laura",middleName:null,surname:"Corbit",slug:"laura-corbit",fullName:"Laura Corbit"},{id:"194020",title:"Dr.",name:"Rose",middleName:null,surname:"Chesworth",slug:"rose-chesworth",fullName:"Rose Chesworth"}]}],onlineFirstChaptersFilter:{topicId:"1176",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:106,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"24",title:"Sustainable Development",doi:"10.5772/intechopen.100361",issn:null,scope:"
\r\n\tTransforming our World: the 2030 Agenda for Sustainable Development endorsed by United Nations and 193 Member States, came into effect on Jan 1, 2016, to guide decision making and actions to the year 2030 and beyond. Central to this Agenda are 17 Goals, 169 associated targets and over 230 indicators that are reviewed annually. The vision envisaged in the implementation of the SDGs is centered on the five Ps: People, Planet, Prosperity, Peace and Partnership. This call for renewed focused efforts ensure we have a safe and healthy planet for current and future generations.
\r\n
\r\n\t
\r\n
\r\n\tThis Series focuses on covering research and applied research involving the five Ps through the following topics:
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\r\n\t1. Sustainable Economy and Fair Society that relates to SDG 1 on No Poverty, SDG 2 on Zero Hunger, SDG 8 on Decent Work and Economic Growth, SDG 10 on Reduced Inequalities, SDG 12 on Responsible Consumption and Production, and SDG 17 Partnership for the Goals
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\r\n\t2. Health and Wellbeing focusing on SDG 3 on Good Health and Wellbeing and SDG 6 on Clean Water and Sanitation
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\r\n\t3. Inclusivity and Social Equality involving SDG 4 on Quality Education, SDG 5 on Gender Equality, and SDG 16 on Peace, Justice and Strong Institutions
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\r\n\t4. Climate Change and Environmental Sustainability comprising SDG 13 on Climate Action, SDG 14 on Life Below Water, and SDG 15 on Life on Land
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\r\n\t5. Urban Planning and Environmental Management embracing SDG 7 on Affordable Clean Energy, SDG 9 on Industry, Innovation and Infrastructure, and SDG 11 on Sustainable Cities and Communities.
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\r\n\tThe series also seeks to support the use of cross cutting SDGs, as many of the goals listed above, targets and indicators are all interconnected to impact our lives and the decisions we make on a daily basis, making them impossible to tie to a single topic.
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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419588",title:"Ph.D.",name:"Sergio",middleName:"Alexandre",surname:"Gehrke",slug:"sergio-gehrke",fullName:"Sergio Gehrke",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038WgMKQA0/Profile_Picture_2022-06-02T11:44:20.jpg",biography:"Dr. Sergio Alexandre Gehrke is a doctorate holder in two fields. The first is a Ph.D. in Cellular and Molecular Biology from the Pontificia Catholic University, Porto Alegre, Brazil, in 2010 and the other is an International Ph.D. in Bioengineering from the Universidad Miguel Hernandez, Elche/Alicante, Spain, obtained in 2020. In 2018, he completed a postdoctoral fellowship in Materials Engineering in the NUCLEMAT of the Pontificia Catholic University, Porto Alegre, Brazil. He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Univeristy of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:null},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:null},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. Her knowledge of English is at an advanced level.",institutionString:null,institution:null},{id:"332914",title:"Dr.",name:"Muhammad Saad",middleName:null,surname:"Shaikh",slug:"muhammad-saad-shaikh",fullName:"Muhammad Saad Shaikh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jinnah Sindh Medical University",country:{name:"Pakistan"}}},{id:"315775",title:"Dr.",name:"Feng",middleName:null,surname:"Luo",slug:"feng-luo",fullName:"Feng Luo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sichuan University",country:{name:"China"}}},{id:"423519",title:"Dr.",name:"Sizakele",middleName:null,surname:"Ngwenya",slug:"sizakele-ngwenya",fullName:"Sizakele Ngwenya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419270",title:"Dr.",name:"Ann",middleName:null,surname:"Chianchitlert",slug:"ann-chianchitlert",fullName:"Ann Chianchitlert",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419271",title:"Dr.",name:"Diane",middleName:null,surname:"Selvido",slug:"diane-selvido",fullName:"Diane Selvido",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419272",title:"Dr.",name:"Irin",middleName:null,surname:"Sirisoontorn",slug:"irin-sirisoontorn",fullName:"Irin Sirisoontorn",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"355660",title:"Dr.",name:"Anitha",middleName:null,surname:"Mani",slug:"anitha-mani",fullName:"Anitha Mani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"355612",title:"Dr.",name:"Janani",middleName:null,surname:"Karthikeyan",slug:"janani-karthikeyan",fullName:"Janani Karthikeyan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"334400",title:"Dr.",name:"Suvetha",middleName:null,surname:"Siva",slug:"suvetha-siva",fullName:"Suvetha Siva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}}]}},subseries:{item:{id:"9",type:"subseries",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering",scope:"The Biotechnology - Biosensors, Biomaterials and Tissue Engineering topic within the Biomedical Engineering Series aims to rapidly publish contributions on all aspects of biotechnology, biosensors, biomaterial and tissue engineering. 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