\r\n\tIt has been established that energy/nutrient depletion, calcium flux injury, or oxidative stress disrupt endoplasmic reticulum homeostasis and even induce accumulation of misfolded/unfolded proteins leading to endoplasmic reticulum stress. Under endoplasmic reticulum stress conditions, an adaptive mechanism of coordinated signaling pathways, defined unfolded protein response (UPR), is activated to return the endoplasmic reticulum to its healthy functioning state. The aging causes a decrease of the protective adaptive response of the UPR and an increase of the pro-apoptotic pathway together with endoplasmic reticulum ultrastructural injury. Controlling endoplasmic reticulum stress response, maintaining the appropriate endoplasmic reticulum ultrastructure and homeostasis, and retaining mitochondria interplay are crucial aspects for cellular health.
\r\n
\r\n\tThis book presents a comprehensive overview of endoplasmic reticulum, including, but not limited to, endoplasmic reticulum ultrastructural anatomy, MAMs, endoplasmic reticulum stress, and their implication in health and diseases. Additionally, identifying perturbations in the endoplasmic reticulum stress response could lead to early detection of age-related disease and may help develop therapeutic approaches.
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\n
1. Introduction
\n
This chapter will focus upon social work practice with single and non-resident fathers. Its primary aim is to explore how practice can be more inclusive, supportive and collaborative, positioning single and non-resident fathers in social work assessments and processes as potential protectors and resources for their children. We are both undertaking research with these respective service user groups and elements of our research will be incorporated within the chapter. We have chosen to focus upon both groups within a single chapter because in our discussions, we have identified numerous themes that appear mutually relevant. This introductory section will provide a brief overview of key ideas.
\n
This chapter is located within wider discourses that propose societal assumptions about the feminised role of caring and lone parenthood exclude fathers and place responsibility for children primarily on mothers. Also within wider debates about the current nature of children and families, social work in the UK and indeed abroad, where practice is typically framed within an increasingly unequal society and increasingly bureaucratic and authoritarian systems.
\n
Despite an epochal change in the discourse in wider society, where fathers are now being more actively and emotionally involved in the care and nurture of their children [1, 2, 3], research studies have found that this is not necessarily reflected in social work practice. It has been suggested that a gendered discourse exists within social work [4, 5, 6] which places the care of children as the sole responsibility of mothers. This can not only lead to the oppression of mothers through the scrutiny of social workers [7] and blame being placed on their shoulders for family difficulties, neglect and abuse [8, 9], but also fathers becoming ‘secondary clients’ [10] or invisible where:
\n\n
“This invisibility exists whether or not the fathers are deemed as risks or as assets to their families.” ([11], p. 25)
\n\n
It can be argued that social work literature predominantly constructs fathers as a problem, through over emphasis upon their negative characteristics and behaviours [12, 13], creating stereotypes of fathers as uncommitted and unwilling to change [4, 7, 9, 12, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 100]. This poses challenges for the profession, as single and non-resident fathers can act as important figures for children and their well-being, and need to be assessed as resources as well as potential risks comprehensively and fairly. Few parents fall simply into a good or bad category.
\n
The authors conducted systematic literature reviews into social work with single and non-resident fathers to explore what the literature says about their experiences with social work. These employed established methods of formulating questions, inclusion and exclusion criteria and a search strategy, followed by quality appraisal and data analysis [24, 25]. Quality appraisal was used to ascertain the credibility, relevance and trustworthiness of the included studies and thematic analysis was the chosen method for data analysis. The analyses focused on rich depictions of the data sets, as these are under-researched areas, with limited available research [26]. Interviews were also conducted with non-resident fathers to gain their views directly.
\n
It is clear that there exists a dearth of social work research that explores the experiences of single or non-resident fathers with social work. This reflects the international research on fathers and social work involvement in general [16], where studies have failed to explicitly look from the perspective of the father [23, 27, 100] or actually recruited them as study participants [28]. Instead studies have tended to use the mother as the source of information [29] or considered parents together rather than distinguishing between them [100]. When fathers have been included as an individual entity, the numbers involved have usually been small [19].
\n
Single fathers are under-researched in social work, which aligns with their relative invisibility in practice and welfare debates. The current limited scope of research into social work practice with single fathers suggests that social workers do not genuinely or comprehensively understand their needs and do not effectively engage with them. The research that has been undertaken has not effectively considered the array of social influences on single fathers’ capacities to parent or effectively explored how, mutually influencing micro-level identities and interactions need to be linked with macro-level conditions and inequalities to analyse and understand the experiences of single fathers.
\n
Within this chapter, key theoretical concepts of non-hegemonic masculinities, borderwork [30, 31, 32] and Quick and Scott’s [33] ideas on emotional regimes within social work will be explained and used to examine social work with single and non-resident fathers. A variety of theoretical frameworks have been used to examine fatherhood, notably feminist theory, sociobiological theory and psychodynamic perspectives [4, 7]. Most social work research into fathers adopts a feminist framework (e.g. [13, 29, 34]). However, a feminist framework can be considered to develop only partial understanding of practice with single and non-resident fathers, with its central focus on the omnipotence and domination of men in our society. As a result, it is likely that this theory struggles to fully explain the experiences of single and non-resident fathers, given the likelihood that, in many contexts, they can be considered to hold non-hegemonic masculinities within our societies [35, 36].
\n
Both single and non-resident fatherhood raise challenges for socially constructed gendered norms, hegemonic masculinity and how children and families social work is practiced. It can be understood that both endeavours influence men’s senses of moral and social identity and engender significant social and emotional meanings for them [37], as well as others.
\n
So, let us now briefly think about working definitions of single and non-resident fathers and their prevalence in UK society.
\n
\n
\n
2. Definitions and statistics
\n
Single fatherhood is not a straightforward term and has not been clearly defined within the literature. Any definition can be used in different ways by different individuals, dependent on the context in which it is being used. Duncan and Edwards [38] define lone parent families as those ‘where a parent lives with his/her dependent children, without a spouse/partner, either on their own or in multi-unit households’ (p. 3). The official UK government definition of a lone parent, according to the Office for National Statistics (ONS) [39], is ‘a parent with a dependent child living in a household with no other people (whether related to that dependent child or not)’ (p. 5).
\n
Building upon these definitions, for the purposes of the author’s research and this chapter, single fathers will be understood as: ‘Fathers acting as the primary caregivers for their child(ren) through sole or joint care arrangements with no wife or partner living with them’. This definition is open to debate and, indeed, improvement.
\n
According to the Office for National Statistics (ONS), of the 2.9 million lone parent families in the UK in 2016, 1.9 million had dependent children, with 10% of those with dependent children headed by single fathers. This equates to 190,000 families headed by single fathers in the UK [39].
\n
Similar to single fatherhood, non-resident fatherhood is a difficult term to define in the literature. As stated, it is estimated that of the total number of lone parents with the primary care for their children in the UK, 90% are mothers [40, 41]. This suggests that a large number of fathers live apart from, and do not have primary care responsibilities for, their children.
\n
Studies have found that the experiences of becoming, and living as, a non-resident father can be ambiguous, complex and multifaceted [42, 43, 44, 45, 46] Therefore, with single fatherhood, it is challenging to find a term that encapsulates the profusion of these father-child relationships. Within the research literature, terms such as non-custodial, non-habitual, non-residential or “live-away fathers” ([42], p. 13) are often used. Within the UK, a standard legal definition can be found under legislation pertaining to financial maintenance for the child:
\n\n
A parent who does not have his or her child living with them. A parent is a non-resident parent (or absent parent) under the statutory child maintenance services, if both of the following apply:
The parent is not living in the same household as the child.
The child has his home with a person who is, in relation to him, a person with care.
\n\n
(Section 3(2), Child Support Act 1991.)
\n\n
Non-resident fathers experience nonstandard paternal biographies [47]. These can vary greatly and include them having never lived with their child, not knowing of the child’s existence, living with the child, being married or cohabiting. Efforts have been made in the UK in the last 20 years to create equal post-separation/divorce parenting through gender neutral legislation and policy. However, for the majority of parents and children going through separation and divorce the gendered model of parenting is adopted, with a resident mother and a non-resident father [48, 49]. Fathers are habitually elected as non-resident by default due to both parents adhering to the assumption that this is what will happen [49, 50]. Accordingly, following separation or divorce, both parents can be recalcitrant to change:
\n\n
“…gendered patterns of caring become fault-lines for the reorganization of parental roles and responsibilities following separation or divorce”. ([37], p. 421)
\n\n
This chapter will now move on to discuss the influential social and political contexts for single and non-resident fathers.
\n
\n
\n
3. The wider contexts for single and non-resident fatherhood
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Single and non-resident fathering do not take place in vacuums, rather within the wider contexts of parenthood, government policies and societal attitudes. If we consider child care within the wider notion of care, whether paid care or care for relatives, care has been a “woman-specific concept” ([51], p. 17) for a long time, with women perpetually performing the majority of this care work. There are a number of different perspectives that seek to explain this phenomenon. For example, it is argued that it has been socially constructed in both the private and public sphere of society as archetypically feminine, whereas others support the essentialist conception of women’s natural disposition towards care work and caring [52].
\n
A number of authors identify that the child welfare system in Britain mirrors the wider dominant societal discourses on parenting that are primarily predicated on traditional family and gendered parenting roles [18, 53, 54, 55]. Within these, childcare is constructed as “women’s work” ([56], p. 64) and mothers are subsequently viewed as more able and natural caregivers [57, 58]. Fathers are then positioned in a supporting role, as the secondary parent [59], and often the breadwinner for the family [13, 30, 60].
\n
Having stated this, there is evidence that societal norms are progressing towards greater appreciation of father engagement [11]. With studies identifying fathers populating a more positive range of roles in wider society [17], such as involved [3], reflexive [61, 62], deliberate [63], intimate [1] and caring [64]. Having said this, it has been argued that the behaviours of fathers are out of step with the emerging representations and discourses of increased involvement of fathers in the care of their children. This has been termed ‘lagged adaptation’ [3].
\n
Single fathers are of course single parents and the perception that single parents ‘always take and don’t give back to the state’ is so routinely suggested that it can be considered normative [65]. Based on this thinking, all single parents can be understood to be marginalised and stigmatised to varying degrees. Doucet [30, 31, 32] has eloquently articulated some of the links between shame, stigma and the imposition of social and community norms on masculinity and parenting, which will be discussed in more detail below. Smith [36], in his research into househusbands, argued powerfully that ‘To summarise, the men in this study encountered the gendered order in all its force at the level of experience…the gender order affected them in a way that challenged the legitimacy of their transgressive form of life’ (p. 156). In other words, they were excluded and stigmatised based on their statuses as househusbands and as different or other.
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When considering wider contexts, it is also important to consider how inclusive social work research is for single and non-resident fathers. Shapiro and Krysik [66] found that within social work journals, only 7.26% of family-related articles considered fathers. Social work research has tended to use the terms parents and families as proxies for mothers [9, 22, 67], mirroring very similar issues in policy and practice.
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Single fathers remain largely invisible within the social work research literature. For his systematic literature review, Haworth [68] found only seven relevant studies that discussed social work with single fathers, some of them only vary briefly. Of these seven studies, only three were concentrated on social work. None of the studies were UK based, but from countries with different cultural, legal and political contexts [69]. This includes Sweden, Australia, Canada, USA and Israel. The findings of the papers identified within Haworth’s systematic literature review suggest similar marginalisation and invisibility of single fathers in social work practice.
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On the theme of social work practice, it is important to consider the wider debates about the nature and direction of children and families social work. In the UK, a variety of scholars have argued that practice is framed within an increasingly unequal society and increasingly bureaucratic and authoritarian systems [70, 71, 72]. Furthermore, child protection systems and practice have become increasingly punitive, intensely focussed upon risk to the exclusion of support and wider sociopolitical forces [73, 74, 75, 76].
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The current debates questioning whether practice is supportive and protective, or punitive and repressive, clearly provide an important context for practice with single and non-resident fathers. They bring into sharp focus whether practitioners challenge or amplify socially and institutionally generated harms and disadvantage, and challenge or amplify exclusion and stigma for single and non-resident fathers.
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Prior to examining this in greater detail, we need to outline the legal contexts for single and non-resident fatherhood and our key theoretical frameworks.
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4. The legal context
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Having discussed the legal contexts, it is time to explore key theoretical frameworks for developing understanding of social work with single and non-resident fathers.
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5. Key theoretical frameworks
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As discussed above, the authors view a feminist framework as only providing a partial understanding of social work with single and non-resident fathers. So the subsequent question has to be which theoretical frameworks can be useful to aid our understating?
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Conceptions of masculinity are key to understanding social work with all fathers. Discourses in society and within services of the welfare state, including social work, promote specific masculinities and femininities [60]. Social work can be understood to frequently engage in a risk narrative around masculinity, with men often viewed as a risk to children, partners and the wider community [18]. Furthermore, binary ideas of fathers as ‘deserving’ or ‘undeserving’, ‘good’ or ‘bad’ can invade practice [77].
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So how do these narratives fit with the focus of this chapter? Well, both single and non-resident fathers can be understood to possess non-hegemonic masculinities. Hegemonic masculinity serves to legitimise men’s dominance in society through subordination of women and other men. It enforces the idea that to be a ‘real man’, we must show traits such as authority, aggressiveness, strength, and competitiveness. Non-hegemonic masculinities on the other hand can be viewed in society as subordinate to their hegemonic counterpart [35, 78]. Hegemonic masculinities can be understood to be constructed through shaming and controlling these non-hegemonic masculinities [79].
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Through such discourses, single and non-resident fathers can be viewed as deviant and outsiders as men and as carers for their children. This may then be amplified by further intersectionality of disadvantage through race, sexuality or class, for example. Fathers as primary carers subvert hegemonic masculinity and can then be victims of socially constructed gender ideologies that challenge their legitimacy and posit motherhood as preeminent [36]. However, it is not this simple or binary. Masculinity, like femininity, can be understood as fluid, revealing opportunities for being redefined in line with societal changes, individual experiences [80] and less stigmatising narratives. This leaves opportunities for all social workers, which will be discussed later in this chapter.
\n
Such opportunities for positive engagement and change can be perhaps be better understood through the concepts of borderwork and border crossing. Thorne [81] conceived the idea of borderwork. This vital concept has been briefly discussed in relation to social work by Featherstone [13], but more significantly explored and developed within the field of sociology by Doucet in Canada, notably in her excellent book ‘Do Men Mother?’ Doucet [30, 31, 32] has written about men as primary caregivers and explored the socially constructed gendered norms of parenting and masculinity. She describes borderwork as ‘spaces and times where intense gender differences are intensely perceived and experienced’ ([32], p. 42). Meanwhile, she conceives border crossing as times where gender boundaries and barriers are deactivated and the gender divide can be successfully crossed.
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Single and non-resident fathers cross gender borders and enter female-dominated spaces when accessing a variety of statutory and non-statutory services. This includes health visiting services, children’s centres and social work support. Furthermore, they enter female-dominated spaces when accessing the school playground or engaging in discussions about employment and caring responsibilities.
\n
Borderwork and border crossing offer possibilities for exploring and better understanding the experiences of single and non-resident fathers when they interact with social work. For these fathers, engaging with social work and female-dominated spaces and services can involve moving between equality and difference, and between stereotypically masculine and female roles. As will be seen below, single fathers can find social work to be excluding and stigmatising. In social work, we therefore need to appreciate how we can support successful border crossing. This requires, amongst other things, social acceptance and challenging stereotypical suspicions of men as primary caregivers [31].
\n
A significant challenge that appears to exist within social work practice with fathers, and indeed parents in general, involves a disconnect between how social workers perceive and understand the emotional reactions of parents during involvement with social workers. Baum and Negbi [82], in their study in Israel, interviewed 15 fathers whose children had been removed into care. They found that the fathers experienced intense feelings of grief and loss. However, they suggest that as result of the social workers not engaging with the fathers, or lacking the skills in working with them, in practice these feelings were underestimated or dismissed. Similarly Hojer [83] in her Swedish study of parents who had children in foster care, found that despite experiencing strong feelings of loss, grief and guilt, these were not always recognised by social workers.
\n
Paradoxically, the study found that when parents did demonstrate an emotional reaction, such as an emotional outburst and/or emotionally loaded language, they were often seen as undesired or inadequate reactions to a situation, and subsequently “interpreted as additional evidence of ‘bad parenting’ in the assessment process” ([83], p. 121) Similarly Smithers [84] observed that social workers held stereotypical or limited expectations of fathers exercising emotional depth, as he suggests:
\n\n
“If the emotional depth and complexity of the men is met with a blind eye and a deaf ear then it is little wonder that the one of frustration, which can be interpreted as aggression, thus fitting a stereotypical view of a problematic male client….” ([84], p. 22)
\n\n
In New Zealand, Quick and Scott [33] explored the experiences of parents and social workers where children had been removed into care as a result of parental mental health or addiction. Their study found that not only did the parents (including fathers) experience grief and loss, but also intense stigma of being involved with social workers. As a result, many of the parents expressed hostile emotions and resistance towards child-protection services, and this was viewed negatively by the social workers as non-cooperative and lacking self-control. Quick and Scott suggest that child protection services create an emotional regime where they can dictate and manage what they perceive as acceptable emotional responses. They recommend that social workers should not view such responses as negative, but instead see resistance, at least in some cases, as a sign of emotional resilience and strength.
\n
Prior to discussing themes of social work engagement and assessment, we must acknowledge that there is a clear absence of systematic information about social work practice with single and non-resident fathers that leaves a significant gap in our knowledge base. As there has been negligible empirical research into this area, practitioners have little research evidence to inform their practice, leading to few examples of lessons being applied in practice. In some ways, it appears a negative cycle has therefore been established, where research is not informing practice and practice is not informing research.
\n
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6. Social work engagement
\n
Research has consistently found that barriers exist to social workers engaging and working with fathers in meaningful ways. [5, 6, 13], despite the exclusion of fathers potentially increasing the risks of abuse [85, 86] and research indicating that the involvement of fathers can be considered beneficial for children and their development in a variety of ways [78, 87].
\n
With specific regard to non-resident fathers, there is the need for social workers to engage with the non-resident parent as soon as concerns are raised about the care afforded to the children, in order to ascertain levels of contact and type(s) of relationships with the children and ex-partner. Non-resident fathers can be used as a resource and source of protection for their children in such cases, and if necessary as an alternative permanent placement for the children should the children need to be removed into care. With the advent and growth of technology in our globalised world, virtual parenting and contact need to be considered. Virtual contact can provide increased contact opportunities and minimise distance when parents relocate, but can limit valuable face-to-face time and raise issues around supervision of contact [88].
\n
It has been found in the UK that non-resident fathers often only hear second hand or belatedly that the local authority were involved with their children [29]. For example, the catalyst for the seminal study by the Family Rights Group into father’s engagement with social services was prompted by:
\n\n
\n“…the increasing numbers of calls its advice service was receiving from non-resident fathers and paternal relatives. Some of these callers had only heard late in the day that their child had been taken in to care.”\n
\n\n
It is understood and accepted by the authors that a number of non-resident fathers are a risk to their children through their violence and abuse, and both authors have experienced working with these fathers through their own social work practice. However, it can be argued that risks should be assessed in the present and not based purely on priori risk and behaviour. It is at this stage that the father can fairly and effectively be deemed as either unsuitable or as a support and resource for his children.
\n
A study in Australia by Zazoni et al. [100] found that in contrast to the negative stereotypes, the fathers were typically committed and involved parents, who went to great lengths to work on previous behaviour and cease abusing substances. They stated that:
\n\n
“This study highlights the importance of child welfare workers engaging with and accurately assessing fathers without preconceived assumptions, as it is possible that some fathers are viable placement options for at-risk children.” ([100], p. 1)
\n\n
The adoption of preconceived assumptions by social workers in their involvement with fathers was also found in the seminal study of Ferguson and Hogan [18]. They interviewed professionals, mothers, children and 20 fathers who were involved with social services. The fathers were seen in the study as vulnerable, due in part to their status of living outside the family home, with varying levels of contact with their children. One of the main findings of the study was how powerful the role of dangerous, or ‘toxic’ (p. 51) masculinities, were in practice, influencing engagement and professional judgements of men as fathers. The toxicity of the masculinities were based upon questionable past or present behaviours and physical appearance;
\n\n
“Some men were excluded from being worked with and seen as possible caring fathers simply on the basis of their appearance and perceived lifestyles, such as men who had tattoos, bulked up physiques, skinheads and who did hard physical prone work such as bouncing or ‘security’”. ([18], p. 8)
\n\n
Several studies have found that fathers struggle to prove that they are ‘good enough’ to be entrusted by social workers to care for children [18, 20, 21, 22, 23, 28, 100]. A study by Dominelli et al. [17] found that the ‘good dad, bad dad’ binary ([89], p. 21) dominated and framed social work practice.
\n\n
“Stories uncovered by this study reveal that although the ‘good dad - ‘bad dad’ binary frames fathers’ relationships with social workers, these are difficult and complicated because social workers do not completely trust fathers to care for children”. (p. 364)
\n\n
Practice consequently focusses mostly on mothers, with the burden of care, responsibility and blame for family difficulties placed firmly on their shoulders [8, 18, 29, 90]. This poses a problematic and unfavourable context for social work engagement with single and non-resident fathers.
\n
Haworth’s [68] systematic literature review identified two predominant themes on social work with single fathers. Firstly, social workers’ misunderstanding and stereotyping single fathers; secondly social workers are not effectively engaging with or effectively supporting single fathers. The literature portrays that social workers struggle to genuinely or comprehensively understand the needs of single fathers, rather tending to stereotype along heteronormative and gendered lines. For instance, Kullberg [91] in his study found that support offered to single fathers and mothers tended to follow traditional gender lines, with social workers suggesting support for single fathers to return to work whereas focussing on support for social support networks for single mothers.
\n
Social work engagement is dependent upon a variety of micro and macro social contexts and these practice issues align with community and societal attitudes and assumptions about caring being a female endeavour, as well as an inability to recognise single fathers as a unique group with unique experiences. Engagement issues raise questions about social work’s role as an apparatus of states that continue to be predicated on archaic gendered norms as well as raising difficult questions about our profession’s continuing captivation with psychological theories, which place women as primary carers and focus on mothers, much less so fathers, in primary caring roles.
\n
Social work is practised at the interface between the public and the private and thus contributes to gender identity discourses [53]. Therefore, as Scourfield [4, 7] suggests, gendered identities are constructed in practice and within practice encounters. Single fatherhood raises challenges for such socially constructed gendered identities. It is therefore important that we are mindful that societal assumptions about the feminised role of caring and lone parenthood can still dominate social work [13, 60], excluding single and non-resident fathers in the process. These processes and narratives can stigmatise such fathers in the context of their ‘non-masculine’ relationships with their children and as part of a welfare state still predicated on traditional family norms. Certainly, Haworth’s [68] paper identified that the research literature portrays that single fathers experience challenging systems and practices when engaging with social work and can experience social work as alienating and unattentive to their holistic needs.
\n
Social work is a female-majority profession [60, 92, 93, 94] and the gendered identities of practitioners influence engagement with fathers [4, 7]. Single and non-resident fathers can be positioned as lone males within predominantly female professional networks, feeling misjudged and marginalised within these contexts. However, issues with engagement should not turn into a blame game and the words of Brandon et al. [8] ring true in this sense. They state that: “…the longstanding issue of ‘father engagement’ is better understood as an interactive two-directional process, rather than a ‘problem’ with either men or social workers” (p. 3).
\n
It is here that we should return to ideas of borderwork and border crossing. Doucet [31] describes that borderwork can engender conflict and intense feelings, while involving gender boundaries that can be strong and rigid. Single and non-resident fathers engage in crossing such boundaries through interactions with our social work profession, when the stakes can be very high. It is critical that we are aware that these fathers, experiencing stigma and perceived moral judgements, may find it extremely difficult to successfully engage in both border crossing and with us as social workers. They may portray protest masculinities where they present as a threat or risk or disengage [4, 7] and further alienate themselves from support from which they may benefit.
\n
Or they may try to conform to socially acceptable identities and present as especially sensitive to rejection when interacting with our profession. Such rejection will clearly be exacerbated by any fixed or immovable gender borders being erected by practitioners. Ferguson and Hogan [18] define fathers as those involved with child protection as ‘vulnerable fathers’ (p. 3), with such vulnerability incorporating issues from relationship problems to poverty and social exclusion. This vulnerability may then be amplified or diminished by further intersectionality of advantage/disadvantage through race or sexuality for example. Each single father and their family will therefore likely have different experiences of society, culture and social work engagement.
\n
Borderwork involves confusion, identity management and feeling othered. Border crossing requires value-based social work high on acceptance, empathy and unconditional positive regard. It is for us as social workers to show sensitivity to these dynamics, as well as to the complexity of single and non-resident fathers’ identities, and adjust how we support engagement accordingly.
\n
Having explored the issues and challenges in social work engaging with single and non-resident fathers, it is important to note that within the research literature, there are a few examples of more inclusive practice that can potentially be built upon and certainly need to be recognised and appreciated. These include professionals discussing single fathers taking responsibility for the care of their children and challenging negative stereotypical views held by foster carers towards single fathers. Such practice examples convey some hope and demonstrate that empathetic and sensitive practice is achievable. Within these examples, practitioners demonstrated acknowledgement and acceptance of single fathers’ distinctive needs and looked to genuinely engage and support.
\n
Before proceeding to highlight our ideas for father-inclusive practice, inclusive of collaborative and supportive ways of working that promote self-aware and expressive masculinities, we need to discuss social work assessments.
\n
\n
\n
7. Social work assessment
\n
Assessment is central to children and families social work. As Brown and Turney [95] state ‘Good assessment is key to effective intervention and better outcomes for children. Without it, practice is likely to lack focus and a clear sense of purpose; at worst, poor assessment may result in a vulnerable child’s needs being overlooked or misunderstood, with serious consequences for their well-being’ (p. 4). However, it must be recognised that too much emphasis on assessment as the all and end all, or simply a series of bureaucratic processes, is not conducive to child or family-centred practice [96].
\n
Kullberg [91, 97] conducted two studies in Sweden that analysed responses from a random sample of 880 Swedish social workers to a gender-comparative vignette presenting a single father and single mother facing very similar problems. These found that social workers assessed the single father as having more serious problems and yet less deserving of support. Further, social workers were more likely to assess the single father as more responsible for his own situation and less likely to conclude that he had taken sufficient steps to address the presenting issues. Despite the single father and single mother facing almost identical issues, the social workers recommended less support measures for him and assessed the single mother as in greater need of support. Kullberg [91] asserts that his findings suggest that single fathers were viewed as less deserving of help from the welfare state than single mothers.
\n
These types of findings suggest that the attitudes and narratives of social workers towards single fathers can be based on common gender stereotypes and that they intentionally or unintentionally can alienate single fathers from suitable social work support. Within his studies, the social workers, according to Kullberg [91], ‘assessed the two sexes according to different standards’ (p. 381), and such findings convey that social workers can struggle to understand single fathers’ strengths and needs. However, our practice and assessments do not need to mirror such issues and practice shortcomings.
\n
It is vital to ask searching questions within social work and our assessments. For single and non-resident fathers, we need to ask if there are specific parenting styles evident and whether we in social work recognise and acknowledge these parenting styles in assessments and indeed interventions. Again, returning to ideas of borderwork and border crossing, whether we are assessing single fathers through maternal lenses and female-centred practices [32], reinforcing the othering and potential rejection that constitute aspects of borderwork.
\n
Doucet [31] suggests that fathers acting as primary carers tend to show different types of nurture, for example through more playfulness. Further, that they engage in more physical activities with their children, with more inherent risks. It needs to be considered whether in our currently risk averse professional context assessments capture these styles of care. Certainly, from the literature reviewed, social workers’ assessments and views tended to reflect gendered and heteronormative assumptions about men and caring. If assessments do not, the question needs to be asked as to how single fathers’ narratives can be heard and social work can develop more inclusive ways of understanding how they care and nurture and avoid judging against maternal standards.
\n
This resonates with Brandon et al.’s [8] recommendation that a differentiated approach should be adopted in policy and practice to better understand motherhood and fatherhood and design services accordingly. Our assessments need to explore the mutually influencing micro-level identities and interactions with macro-level conditions and inequalities to analyse and understand the experiences of single and non-resident fathers. Based on the literature reviewed, there is clear concern that their choices and chances are limited through borders and barriers being constructed within social work and beyond that shape their needs and how services respond to these.
\n
However, we have choices as autonomous social workers, so we need to reflect upon how we can work collaboratively with single and non-resident fathers.
\n
\n
\n
8. How can practice become more inclusive and supportive?
\n
Although this chapter has to an extent explored the barriers and challenges to social workers engaging with fathers, perhaps a good starting point is to reframe the issue to one of mutual responsibility. It must be stated clearly that some men do not see themselves in the role of carer and/or avoid interacting with social workers [27]. Therefore, as Brandon et al. [8] suggest:
\n\n
“…the longstanding issue of ‘father engagement’ is better understood as an interactive, two-directional process, rather than a ‘problem’ with either men or social workers.” (p. 120)
\n\n
Father-inclusive practice for single and non-resident fathers should be multi-faceted and focussed on practical support, genuine collaboration and the promotion of more expressive and self-aware masculinities [13, 18]. Furthermore, to provide flexibility around working times and locations and support fathers within wider family contexts [29]. It is only then that the conditions for successful border crossing can be supported, where single and non-resident fathers can, as Doucet [31] articulates, ‘challenge the oppositional structure of traditional gender arrangements around parenting’ (p. 201).
\n
Such changes need to be systemic, requiring structural, cultural and individual changes, including challenging widespread gender stereotypes and assumptions. Support needs to encourage social acceptance, while accepting and respecting difference. For single fathers, this should incorporate recognition as a unique group with unique paternal identities. Ethics of solidarity and minimising otherness, through the medium of relationships, should play significant roles in practice. Such practice requires organisations that encourage critical reflection, inclusive practice and specific training about engaging fathers [18].
\n
For changes in practice to be sustained and developed further, there arguably needs to be an increased presence of single and non-resident fathers in social work qualifying programmes and training to raise awareness of their strengths, needs and experiences. Research by Malm et al. [98] found that practitioners who received specific training in working with fathers were more likely to identify and engage with fathers in practice. Specific knowledge about working with single and non-resident fathers could be valuable for all involved.
\n
Inclusive and gender-sensitive social work with single and non-resident fathers should appreciate the roles of borderwork and stigma in life chances and engagement with services, while being alert to gender theorising [4, 7]. But at the same time, recognising patriarchal privilege while engaging with the gender complexities and challenges to masculinity posed by such fatherhood forms. Support to these fathers can then start to act as a bridge to more comfortable and stress-free engagement with female-dominated professional networks of support, parenting communities and community/societal networks.
\n
These are simply initial ideas. There remain many unanswered questions about how to empower practitioners and single and non-resident fathers to work in collaborative and compassionate ways to promote social change.
\n
\n
\n
9. Conclusion
\n
This chapter has argued that there is a clear absence of systematic knowledge about social work practice with single and non-resident fathers to draw any clear conclusions about their experiences with children and families social work, the nature and quality of practice or whether practice is inclusive and supportive. We have suggested that that there is little knowledge about support and services offered to single and non-resident fathers and that we currently cannot learn much about social work practice with single fathers from the limited range of published research.
\n
However, the limited current literature portrays that practice tends to exclude both groups of fathers. The themes identified in this chapter include that social workers can struggle to understand and identify the needs of these fathers and struggle to effectively engage with them. Concepts of borderwork and emotional regimes have been utilised to explore these issues in greater depth. Marginalisation and exclusion from children and families social work can be reasonably understood to produce injustice, missed opportunities and lack of support for single and non-resident fathers.
\n
The themes identified in this chapter reaffirm the influence of socially constructed gendered norms and welfare discourses on fathers’ experiences and social work practice itself. As with us all, the identities of single and non-resident fathers are constructed and reconstructed in social, moral and cultural contexts and interactions [99].
\n
This chapter has started to reveal the myriad complex issues around single and non-resident fatherhood and their relationships with social work. It is clear that social work needs a fuller evidence base to understand how best to engage with and support single and non-resident fathers. From such as base, models of practice and organisational cultures can be promoted that engage these fathers while ensuring the best interests of children remain paramount. Such changes need to embrace fathers’ own perspectives. As Zanoni et al. [100] state, practice with fathers is only likely to improve if their perspectives are paid attention to.
\n
\n
Acknowledgments
\n
Both authors would like to thank their employing universities. For Simon Haworth this is the University of Birmingham; for Lee Sobo-Allen this is the Leeds Beckett University.
\n
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"single fathers, non-resident fathers, social work practice, borderwork, assessment, engagement",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/70948.pdf",chapterXML:"https://mts.intechopen.com/source/xml/70948.xml",downloadPdfUrl:"/chapter/pdf-download/70948",previewPdfUrl:"/chapter/pdf-preview/70948",totalDownloads:863,totalViews:0,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:31,impactScore:0,impactScorePercentile:48,impactScoreQuartile:2,hasAltmetrics:1,dateSubmitted:"May 13th 2019",dateReviewed:"November 25th 2019",datePrePublished:"February 26th 2020",datePublished:"July 15th 2020",dateFinished:"January 30th 2020",readingETA:"0",abstract:"This chapter is focused upon social work with single and non-resident fathers. There is a dearth of social work research that explores the experiences of single or non-resident fathers’ with social work, so this chapter starts to explore how we can work more sensitively and collaboratively with both groups. Both single and non-resident fatherhood raise challenges for socially constructed gendered norms, hegemonic masculinity and how children and families social work is practiced. Concepts of borderwork and the emotional regime are applied to develop understanding of these fathers’ experiences with social work and how practice can change. The chapter is located within wider discourses about the feminised role of caring and increasingly bureaucratic and authoritarian social work systems. Key practice features of assessment and engagement are discussed and suggestions for developing and improving practice are tentatively made.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/70948",risUrl:"/chapter/ris/70948",book:{id:"6942",slug:"global-social-work-cutting-edge-issues-and-critical-reflections"},signatures:"Simon Haworth and Lee Sobo-Allen",authors:[{id:"304991",title:"Mr.",name:"Simon",middleName:null,surname:"Haworth",fullName:"Simon Haworth",slug:"simon-haworth",email:"s.p.c.haworth@bham.ac.uk",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. Definitions and statistics",level:"1"},{id:"sec_3",title:"3. The wider contexts for single and non-resident fatherhood",level:"1"},{id:"sec_4",title:"4. The legal context",level:"1"},{id:"sec_5",title:"5. Key theoretical frameworks",level:"1"},{id:"sec_6",title:"6. Social work engagement",level:"1"},{id:"sec_7",title:"7. Social work assessment",level:"1"},{id:"sec_8",title:"8. How can practice become more inclusive and supportive?",level:"1"},{id:"sec_9",title:"9. Conclusion",level:"1"},{id:"sec_10",title:"Acknowledgments",level:"1"},{id:"sec_13",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'\nDermott E. The ‘Intimate Father’: Defining Paternal Involvement. 28/11/2003 ed. 2003. Sociological Research Online. Available from: http://www.socresonline.org.uk/8/4/dermott.html\n\n'},{id:"B2",body:'\nDermott E. Initimate Fatherhood: A Sociological Analysis. Abingdon: Routledge; 2008\n'},{id:"B3",body:'\nMiller T. Making Sense of Fatherhood. Cambridge: Cambridge University Press; 2011\n'},{id:"B4",body:'\nScourfield J. Constructing men in child protection work. Men and Masculinities. 2001;4(1):70-89\n'},{id:"B5",body:'\nScourfield J. The challenge of engaging fathers in the child protection process. 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York: Joseph Rowntree Foundation; 2007\n'},{id:"B48",body:'\nBlackwell A, Dawe F. Non-resident Parental Contact. London: Office for National Statistics; 2003\n'},{id:"B49",body:'\nKielty S. Similarities and differences in the experiences of non-resident mothers and non-resident fathers. International Journal of Law, Policy and the Family. 2006;20(1)\n'},{id:"B50",body:'\nBradshaw J, Stimson C, Skinner C, Williams J. Non resident fathers in Britain. In: Mcrae S, editor. Changing Britain: Families and Hosueholds in the 1990\'s. Oxford: OUP; 1999\n'},{id:"B51",body:'\nScambor E, Bergman N, Wojnicka K, Belghiti-Mahut S, Hearn J, Holter OG, et al. Men and gender equality: European insights. Men and Masculinities. 2014;17:552-577\n'},{id:"B52",body:'\nElliott K. Caring masculinities: Theorizing an emerging concept. Men and Masculinities. 2015;19:240-259\n'},{id:"B53",body:'\nChristie A. Negotiating the uncomfortable intersections between gender and professional identities in social work. Critical Social Policy. 2006;26(2):390-411\n'},{id:"B54",body:'\nDaly M, Rake K. Gender and the Welfare State: Care, Work and Welfare in Europe and the USA. Cambridge: Polity Press; 2003\n'},{id:"B55",body:'\nPascall G. Gender Equality in the Welfare State? Bristol: Policy Press; 2012\n'},{id:"B56",body:'\nHolland S. Child and Family Assessment in Social Work Practice. London: Sage Publications; 2004\n'},{id:"B57",body:'\nBuckley H. Child Protection Work: Beyond the Rhetoric. London: Jessica Kingsley Publications; 2003\n'},{id:"B58",body:'\nParker K, Livingston G. 6 Facts About American Fathers. 2017. Available from: www.pewresearch.org [Accessed: 14 March 2019]\n'},{id:"B59",body:'\nDufour S, Lavergne C, Larrivee M-C, Troeme N. Who are these parents involved in child neglect? A differential analysis by parent gender and family structure. Children and Youth Services Review. 2008;30:141-156\n'},{id:"B60",body:'\nChristie A. Gendered discourses of welfare, men and social work. In: Christie A, editor. Men and Social Work Theories and Practices. Basingstoke: Palgrave; 2001. pp. 7-34\n'},{id:"B61",body:'\nWilliams S. What is fatherhood? Searching for the reflexive father. Sociology. 2008;42:487-502\n'},{id:"B62",body:'\nWestering A. Reflexive fatherhood in everyday life: The case of Denmark. Families, Relationships and Societes. 2015;4:209-223\n'},{id:"B63",body:'\nIves J. Theorising the ‘deliberative father’: Compromise, progress and striving to do fatherhood well. Families, Relationships and Societies. 2015;4:281-294\n'},{id:"B64",body:'\nJohansson T, Klinth R. Caring fathers: The ideology of gender equality and masculine positions. Men and Masculinities. 2008;11:42-62\n'},{id:"B65",body:'\nGarner S. Home truths: The white working class and the racialization of social housing. In: Sveinsson K, editor. Who Cares About the White Working Class. London: Runnymede Trust; 2009. pp. 45-50\n'},{id:"B66",body:'\nShapiro A, Krysik J. Finding fathers in social work research and practice. Journal of Social Work Values and Ethics. 2010;7(1):1-9\n'},{id:"B67",body:'\nRisley-Curtiss C, Heffernan K. Gender biases in child welfare. Affilia. 2003;18(4):395-410\n'},{id:"B68",body:'\nHaworth S. A systematic review of research on social work practice with single fathers. Practice: Social work in Action. 2019;31(5):329-347. Available from: https://www.tandfonline.com/doi/full/10.1080/09503153.2019.1575955\n\n'},{id:"B69",body:'\nGreen B. Understanding and Researching Professional Practice. Rotterdam: Sense Publishers; 2009\n'},{id:"B70",body:'\nBywaters P et al. The Relationship between Poverty, Child Abuse and Neglect: An Evidence Review. Joseph Rowntree Foundation: York; 2016\n'},{id:"B71",body:'\nMorris K, Featherstone B, White S. Re-Imagining Child Protection Towards Humane Social Work with Families. Bristol: Policy Press; 2014\n'},{id:"B72",body:'\nWarner J. The Emotional Politics of Social Work and Child Protection. Bristol: Policy Press; 2015\n'},{id:"B73",body:'\nGupta A, Featherstone B, Morris K, White S. Protecting Children: A Social Model. Bristol: Policy Press; 2018\n'},{id:"B74",body:'\nCummins I. Poverty, Inequality and Social Work the Impact of Neoliberalism and Austerity Politics on Welfare Provision. Bristol: Policy Press; 2018\n'},{id:"B75",body:'\nKrumer-Nevo M. Four scenes and an epilogue. Qualitative Social Work. 2009;8(3):305-320\n'},{id:"B76",body:'\nRogowski S. Social work with children and families: Challenges and possibilities in the neo-liberal world. British Journal of Social Work. 2012;42:921-940\n'},{id:"B77",body:'\nBowl R. Men and community care. In: Christie A, editor. Men and Social Work Theories and Practices. Basingstoke: Palgrave; 2001. pp. 109-125\n'},{id:"B78",body:'\nHauari H, Hollingworth K. Understanding Fathering Masculinity, Diversity and Change. York: Joseph Rowntree Foundation; 2009\n'},{id:"B79",body:'\nRenold E. Other’ boys: Negotiating non-hegemonic masculinities in the primary school. Gender and Education. 2007;16(2):247-265\n'},{id:"B80",body:'\nMarsiglio W. Fatherhood Contemporary Theory, Research and Social Policy. London: Sage; 1999\n'},{id:"B81",body:'\nThorne B. Gender Play: Girls and Boys in School. Buckingham: Open University Press; 1993\n'},{id:"B82",body:'\nBaum N, Negbi I. Children removed from home by court order: Fathers’ disenfranchised grief and reclamation of paternal functions. Children and Youth Services Review. 2013;35:1679-1686\n'},{id:"B83",body:'\nHojer I. Parents with children in Foster care—How do Thwy perceive their contact with social workers? Practice: Social Work in Action. 2011;23:111-123\n'},{id:"B84",body:'\nSmithers N. Listening to Fathers—Men’s Experience of Child Protection in Central Scotland. Edinburgh: University of Edinburgh; 2012\n'},{id:"B85",body:'\nDouglas E. Child Maltreatment Fatalities in the United States: Four Decades of Policy, Program and Professional Responses. Dordrecht, The Netherlands: Springer; 2017\n'},{id:"B86",body:'\nKlevens J, Leeb R. Child maltreatment fatalities in children under 5: Findings from the National Violence Death Reporting System. Child Abuse & Neglect. 2010;34(4):262-266\n'},{id:"B87",body:'\nJones K. Assessing the impact of father-absence from a psychoanalytic perspective. Psychoanalytic Social Work. 2008;14(1):43-58\n'},{id:"B88",body:'\nSaini M et al. Parenting online: An exploration of virtual parenting time in the context of separation and divorce. Journal of Child Custody. 2013;10(2):120-140\n'},{id:"B89",body:'\nPleck E. Two dimensions of fatherhood: A history of the good dad-bad dad complex. In: Lamb M, editor. The Role of the Father in Child Development. 4th ed. New York: Wiley & Sons; 2004\n'},{id:"B90",body:'\nFeatherstone B et al. They are just good people…generally good people: Perspectives of young men on relationships with social care workers in the UK. Children & Society. 2017;31:331-341\n'},{id:"B91",body:'\nKullberg C. Differences in the seriousness of problems and deservingness of help: Swedish social workers’ assessments of single mothers and fathers’. British Journal of Social Work. 2005;35:373-386\n'},{id:"B92",body:'\nCree V. Men and masculinities in social work education. In: Christie A, editor. Men and Social Work Theories and Practices. Basingstoke: Palgrave; 2001. pp. 147-163\n'},{id:"B93",body:'\nPayne M. What Is Professional Social Work? Bristol: Policy Press; 2006\n'},{id:"B94",body:'\nSchaub J. Making sense of men’s experiences and progression through social work programmes. University of Bath; 2017. [unpublished PhD thesis]\n'},{id:"B95",body:'\nBrown L, Turney D. Analysis and Critical Thinking in Assessment. 2nd ed. Research in Practice: Dartington; 2014\n'},{id:"B96",body:'\nMunro E. The Munro Review of Child Protection: Final Report: A Childcentred System. The Stationery Office: Norwich; 2011\n'},{id:"B97",body:'\nKullberg C. Work and social support: Social workers’ assessments of male and female clients’ problems and needs. Journal of Women and Social Work. 2004;19(2):199-210\n'},{id:"B98",body:'\nMalm K, Murray J, Geen R. What about Dads? Child Welfare Agencies’ Efforts to Identify, Locate and Involve Non-resident Fathers. Department of Health and Human Services: Washington; 2006\n'},{id:"B99",body:'\nFinch J, Mason J. Negotiating Family Responsibilities. London: Routledge; 1993\n'},{id:"B100",body:'\nZanoni L et al. Fathers as ‘core business’ in child welfare practice and research. Children & Youth Services Review. 2012;35:1055-1070\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Simon Haworth",address:"s.p.c.haworth@bham.ac.uk",affiliation:'
School of Social Policy, University of Birmingham, UK
School of Health and Community Studies, Leeds Beckett University, UK
'}],corrections:null},book:{id:"6942",type:"book",title:"Global Social Work",subtitle:"Cutting Edge Issues and Critical Reflections",fullTitle:"Global Social Work - Cutting Edge Issues and Critical Reflections",slug:"global-social-work-cutting-edge-issues-and-critical-reflections",publishedDate:"July 15th 2020",bookSignature:"Bala Raju Nikku",coverURL:"https://cdn.intechopen.com/books/images_new/6942.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83880-475-6",printIsbn:"978-1-83880-474-9",pdfIsbn:"978-1-78985-210-3",reviewType:"peer-reviewed",numberOfWosCitations:2,isAvailableForWebshopOrdering:!0,editors:[{id:"263576",title:"Dr.",name:"Bala",middleName:null,surname:"Nikku",slug:"bala-nikku",fullName:"Bala Nikku"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"23"}],productType:{id:"1",title:"Edited 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Nikku"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}],publishedBooksByAuthor:[{type:"book",id:"6942",title:"Global Social Work",subtitle:"Cutting Edge Issues and Critical Reflections",isOpenForSubmission:!1,hash:"222c8a66edfc7a4a6537af7565bcb3de",slug:"global-social-work-cutting-edge-issues-and-critical-reflections",bookSignature:"Bala Raju Nikku",coverURL:"https://cdn.intechopen.com/books/images_new/6942.jpg",editedByType:"Edited by",editors:[{id:"263576",title:"Dr.",name:"Bala",surname:"Nikku",slug:"bala-nikku",fullName:"Bala Nikku"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},onlineFirst:{chapter:{type:"chapter",id:"78585",title:"Chest Tubes",doi:"10.5772/intechopen.100047",slug:"chest-tubes",body:'
1. Introduction
Insertion of intercostal drainage (ICD) tube is a common procedure that is required to drain the abnormal intrapleural collection. As the name implies, it is insertion of a tube through the intercostal space to facilitate the drainage of abnormal collection in the pleural cavity. The procedure is also known as tube thoracostomy and thoracostomy drainage. The earliest reports of thoracic drainage dates back to 5th century BC [1, 2].
The aim of thoracostomy drainage is to:
Remove fluid and air from pleural cavity as promptly as possible.
Prevent drained air and fluid from returning to pleural cavity.
Restore negative pressure in pleural cavity to help re-expand the lung.
Although, the procedure has been in practice since long, there is still no consensus in the management of chest tubes and there remains great variability in practice. The procedure of inserting a chest tube is simple, definitive in treating a majority of thoracic pathologies and may be life-saving in certain situations. However, improperly placed chest tubes and poor post-procedural care may increase the morbidity and is associated with complications in up to 40% of patients [3, 4]. It is therefore imperative that all clinicians should be well versed with this simple yet life-saving procedure.
In this chapter, we will discuss various aspects of intercostal drainage including the prerequisites, technique of insertion, post-procedural care, complications and common pitfalls in the management of chest tubes in the light of the recent advances and updates.
2. Characteristics of an ideal thoracostomy tube
An ideal thoracostomy tube should:
Allow collected air and fluid to drain out from the chest.
Contain a one-way valve to prevent air and fluid from returning back into the chest.
Allow maintenance of negative intra-pleural pressure (the normal intrapleural pressure is −3 mmHg that decreases further on inspiration).
Have provision for applying higher negative pressure to help in expanding the lung.
Allow accurate measurement of drained fluid and air.
3. Indications for inserting chest tube
Tube thoracostomy is required to drain any abnormal collection in the pleural cavity, that includes:
Air: Pneumothorax
Fluid: Pleural effusion
Blood: Hemothorax
Pus: Empyema
Chyle: Chylothorax
Prophylactically following cardio-thoracic surgery to drain post-operative collection of air, fluid or blood
4. Commercially available chest tubes
The modern, commercially available chest tubes are soft and pliable that are either made up of Polyvinyl chloride (PVC) or silicone (Figure 1).
Figure 1.
Intercostal drainage tube (chest tube).
The red rubber or malecot tube drains (Figure 2) are sometimes used as thoracostomy tubes mostly in resource constraint settings because of their low-cost, however their use is not advisable as they are difficult to retain, get kinked easily, wither rapidly and at times may break.
Figure 2.
Malecot (red rubber) tube drain.
Chest tubes come in various sizes from 6 French gauge (F) to 40 F. Larger the size of the tube, greater is its diameter. One F is equal to 0.033 cm. To know the diameter of the tube from the F size, one need to multiply F size by a factor of 0.033, so a chest tube of size 24 F will have an internal diameter of approximately 0.8 cm.
Some chest tubes are available with metallic trocar that has a pointed end (Figure 3).
Figure 3.
Chest tube with metallic trocar.
These are meant to insert in intercostal space after making a small skin incision, without dissecting the intercostal muscles. Although, this makes the procedure fast, there is a higher risk of injury to the intrathoracic organs and as such use of chest tubes with trocars should be discouraged [3, 5, 6]. Most of the chest tubes are open from one end while the other end is sealed. There are side holes or eyes on the tube and the markings are printed on it. There also is a radiopaque line all along the length of the tube that helps in identifying the position of the chest tube on X-ray (Figures 1 and 4).
Figure 4.
Radiopaque line in the chest tube visible on x-ray (arrow).
5. Before inserting the chest tube- the preparation
5.1 Consent
Insertion of ICD tube is a surgical procedure and like any other surgery, a written informed consent is required prior to the procedure. Consent may not be possible in cases where the patient requires urgent tube thoracostomy as a lifesaving measure and when he/ she is unconscious, unattended or is in extremis.
5.2 Preparing the trolley: Equipment required
Following instruments and equipment are required for inserting the chest tube. One must ensure the availability of all necessary equipment beforehand to avoid any difficulty during the procedure.
5 ml syringe with a suitable local anesthetic. Preferably 2% lidocaine with adrenaline.
Sponge holding forceps
Bowl with solution for painting
Number 11 surgical blade with handle
Sheets for draping
A pair of medium sized curved artery forceps
An appropriately sized chest tube: See the section on ‘selecting the size of chest tube.
Silk No.1 suture on cutting needle
Needle holder
A pair of tooth forceps
Prepared underwater seal bottle or bag.
Gauze pieces
Adhesive tape for dressing
5.3 Selecting the size of chest tube
The chest tubes are available in various sizes ranging from 6 F to 40 F. There is a general understanding that large-bore tubes are required to drain fluid and small-bore tubes are sufficient to drain air. There have been numerous studies on this issue, however there is no conclusive scientific data to support this idea. Large-bore tubes have been related to higher incidence of pain and patient discomfort without any significant advantage in draining the intra-pleural fluid. In various studies, small-bore tubes have been found to be equally effective to drain pleural effusion and hemothorax [7, 8, 9, 10, 11]. This has generated wider interest in use of small-bore tubes for thoracostomy. Conventionally, for most of the clinical conditions requiring tube thoracostomy a 24–32 F chest tube is inserted, depending on the expected underlying pathology, however tubes smaller than 24 F may be sufficient to drain pneumothorax.
5.4 Preparing the under-water seal
The reservoirs for collecting the pleural drainage are available either in the form of bags or single or multiple chambered plastic bottles (Figure 5A and B).
Figure 5.
A: Two chambered plastic bottle and B: ICD bag.
In both of these reservoirs, there are markings for calculation of effluent. In addition, there is also a marking for ‘initial fluid level’. Before connecting the reservoir to the chest tube, a sterile fluid like normal saline should be filled till this mark. As the chest tube is connected with the tube in the reservoir that remains below the ‘initial fluid level’, the air from the environment cannot gain access to the pleural cavity, however the intrapleural collection may egress easily into the reservoir, thus it functions as a one-way valve or ‘under water seal’.
5.5 Local anesthesia: type, amount and technique
Any suitable local anesthetic is appropriate for the procedure. Plain Lidocaine 2% solution and Lidocaine 2% with adrenaline are commonly used drugs for ICD insertion. A volume of nearly 5 ml is sufficient to anesthetize the local site. Local anesthesia may not be required where the patient is obtunded or unconscious and ICD insertion is required urgently.
6. Inserting the chest tube
The step by step procedure is demonstrated in the video supplemented with this article.
Inserting Intercostal drainage tube: step by step.
6.1 Position of the patient
Although the ICD can be inserted while the patient is sitting, leaning forward with the forearms resting over a stool, the supine position is less cumbersome and more comfortable for both patient and the doctor. In addition, the patient may not be able to sit for the procedure due to the underlying clinical condition. We prefer to insert ICD tube in supine position. The patient lies on the table close to the edge with arm abducted over the head if possible.
6.2 Identifying landmarks
The ideal site of inserting ICD is 4th or 5th intercostal space just anterior to the mid axillary line. One may calculate the desired intercostal space by considering sternal angle as landmark. The rib attached to the level of sternal angle is the second rib, subsequent ribs can be counted while palpating the chest wall distally and laterally. There is an alternative way of counting the ribs and the intercostal spaces which is quick and is particularly helpful in obese patients and in presence of subcutaneous emphysema. The level of the nipple in males and inframammary crease in females can be taken as a reference point- a line drawn from this point laterally to a point where it intersects the mid-axillary line is marked and the site for insertion of the chest tube is just anterior to this.
In case, the chest tube is being inserted prophylactically during thoracic surgery, the site of insertion is selected under vision in appropriate intercostal space.
6.3 Steps of the procedure
A wide area around the predetermined site of ICD insertion is painted with a suitable antimicrobial solution (Chlorhexidine or Povidone-iodine) and is draped. If the patient is awake and conscious, 5 ml of local anesthetic solution (preferably 2% lidocaine with adrenaline) is infiltrated in the overlying skin, intercostal muscles and pleura at the site of ICD insertion. Before injecting the local anesthetic, one should ensure that the needle is not in a blood vessel by pulling the plunger of the syringe back. For the adequate effect of local anesthesia, it is prudent to wait for at least 2 minutes before making the incision.
An incision measuring nearly 1.5–2 cms is made by a number 11 surgical blade at the predetermined site of ICD insertion along the long axis of the rib in the intercostal space just over the upper border of the lower rib. This is done to prevent injury to the neurovascular bundle that runs along the lower border of the ribs.
Using a medium sized curved hemostatic clamp, the subcutaneous tissues and inter-costal muscles are dissected bluntly till the parietal pleura is reached. By the tip of the closed hemostatic clamp, gentle pressure is then applied till there is a feeling of ‘give way’ which marks the entry into the pleural cavity. The entry into the pleural cavity is also confirmed by the escape of intra-pleural collection like air, fluid or blood (as the case may be). One should be careful enough not to apply undue force while puncturing the pleura as this may cause injury to lungs or mediastinal structures. The jaws of the hemostatic clamp are then opened while withdrawing the instrument to increase the size of the thoracostomy wide enough to allow the entry of index finger. This should be followed by ‘finger thoracostomy’. The index finger is inserted through the thoracostomy site to explore the pleural cavity for presence of any pleuro-pulmonary adhesions. In case they are present, adhesiolysis is performed to create space inside the pleural cavity for the chest tube. This step is important as attempts to insert a chest tube without ensuring space between the lung and the chest wall may injure the lung, cause air leak from the damaged lung parenchyma and such improperly placed tube may fail to drain the intra-pleural collection.
Following finger thoracostomy and ensuring safe space inside the pleural cavity to accommodate the chest tube, an adequately sized chest tube is then taken. The tip of the tube from the open end (the end that should lie inside the thoracic cavity) is held with the tip of the hemostatic clamp and the rest of the tube is held parallel to the instrument. The tube is introduced inside the pleural cavity, the instrument is then released and the tube is inserted gradually by guiding it to lie posteriorly and superiorly by using the same instrument aided by the index finger of the opposite hand to the point till the last eye (hole) on the chest tube is at least 5 cms inside the pleural cavity (this can be confirmed by looking at the markings over the chest tube). The limit to which the ICD tube needs to be put in depends on the build of the patient. In a patient with an average built a length till 8–12 cms inside the chest is sufficient.
The tube is then clamped by using an artery forceps (hemostatic clamp) close to its distal (closed) end. The end of the chest tube is now cut and is connected with the tubing of the underwater seal using the connector provided with the chest tube. The length of the tube of under-water seal apparatus should not be unduly long as the fluid column in the tube will provide resistance to the egress of intrapleural collection compromising the drainage. A good rule is not to allow any loop in the draining tube between the connector and the tubing of the reservoir.
The chest tube is then fixed by silk suture no.1. For better fixity, it should be anchored on either side. While fixing, one must ensure to take deep bites through the soft tissues close to the tube. Fixing the tube by taking superficial bites (including skin only) may leave potential space around the tube at the site of entry in the intercostal space which may lead to subcutaneous emphysema in cases of pneumothorax and may increase morbidity. Some clinicians prefer purse string suture for fixation of the tube but that leaves an ugly scar following removal of the chest tube and as such is not necessary. A dressing is now applied at the ICD site and the tube may then firmly be reinforced at the site by using adhesive tapes. This completes the procedure.
The free drainage of the collected material from the pleural cavity and the movement of the column of the fluid in the tube confirms the adequate position of the chest tube. The chest should now be auscultated, improvement in the breath sounds suggests success of the procedure. A chest X-ray is then performed for confirmation of proper positioning of the tube radiologically.
Some authors advocate creation of an oblique passage or ‘tunnel’ in the chest wall to insert the tube, primarily to decrease the incidence of recurrent pneumothorax following removal of the chest tube [12]. In this technique incision is made one intercostal space below the pre-determined site of thoracostomy, the skin and soft tissues of the chest wall are then bluntly dissected to reach the site of thoracostomy thereby creating a curved passage through the chest wall for introduction of the chest tube. This requires additional time at the expense of no added advantage and therefore is not required.
7. Post-procedural care
7.1 Nursing the patient with chest tube
Utmost care should be exercised while nursing a patient with chest tube. The reservoir should remain below the level of the chest at all times. Raising the reservoir above the chest level may result in passage of the fluid from the reservoir back into the pleural cavity. While turning or shifting the patient, one must ensure that the tube is not held or entangled in the patient’s bed. This may result in accidental displacement or dismantling of the tube. The outlet of the reservoir should remain open at all times especially in patients with pneumothorax or air leak. The closed outlet of the reservoir may lead to failure of decompression of pneumothorax leading to development of life-threatening tension pneumothorax. For the same reason, the tube should not be clamped at any time except while changing the fluid in the reservoir, collecting a sample of effluent or while planning to remove the chest tube. The patient should be closely monitored during this period.
The patient should be motivated for active physiotherapy and incentive spirometry (Figure 6).
Figure 6.
Patient performing incentive spirometry.
This aids in faster resolution of pleural collection and thereby early removal of the ICD tube. In case, the patient is unable to do active physiotherapy, passive physiotherapy should be performed. All efforts must be made to ambulate the patient early. The chest tube must be secured carefully while patient mobilizes and the drainage bag (reservoir) should be kept well below the thoracostomy site.
The ICD site should be carefully examined every day for signs of local infection like peri-tubal inflammation or tenderness. The dressing needs to be changed in case it is soaked. Extreme care must be taken while dressing the ICD site lest the tube is displaced or dismantled. The patient should be clinically monitored every day and the volume of drained fluid should be charted carefully in the patient’s record. The reservoir should be emptied once it is full up to 3/4 of its capacity. A new reservoir with prepared under water seal or disposable reservoir (in case of digital chest tube drainage systems) is kept ready while changing the reservoir. In resource constraint settings the same reservoir may be reused. It is important to follow universal precautions while changing the reservoir. The chest tube is clamped and the filled reservoir is disconnected from the tube, the new reservoir is then connected or fluid is filled up to the ‘initial water level’ mark (or till the outlet tube is at least 2 cms below the water level) in case one contemplates to use the same reservoir. Once the reservoir is reattached, the tube is unclamped. It is important to prepare the equipment beforehand while changing the reservoir to keep the time of occlusion of the chest tube to minimum possible.
The practice of performing daily x-ray has been questioned by many authors and it is suggested that this may not be required if there is pleura to pleura apposition in the post-procedure x-ray and the patient is improving clinically [13].
7.2 Use of analgesics and antibiotics
Appropriate oral or parenteral analgesics are administered depending on the underlying condition for which tube thoracostomy was necessitated. There has been much debate on the use of antibiotics following tube thoracostomy. There is no evidence to support the routine use of prophylactic antibiotic therapy following the procedure [14, 15]. However, the antibiotics may be needed for other associated causes for which tube thoracostomy was performed like in empyema thoracis or in a patient of trauma with soft tissue injuries.
7.3 Use of suction
The use of controlled suction (−10 to −15 cm saline) to the outlet of the reservoir may help in faster resolution of intrapleural collection and promote early pleura to pleura approximation. This is most useful following pulmonary resections and may decrease the incidence of persistent post-operative space problems. In our practice, we apply overnight suction in patients undergoing pulmonary resection surgery (except following pneumonectomy). At times, the application of suction may result in pleural pain, the amount of suction should be decreased in such situations. In case of increased air leak on application of suction, the suction may be decreased or avoided altogether.
7.4 What to do in case the tube is blocked?
Blockage of thoracostomy tube is not uncommon and occur frequently in hemothorax. Careful observation of the ICD tube and the ensuring drainage of the fluid are paramount to detect this complication early. If appropriate measures are taken in time, the possibility of maintaining the tube patency are high.
Various manipulations can be performed to restore the patency of blocked ICD tube. These include tapping, milking and stripping of the tube. These measures are successful only with partial blockage of the tube and should not be performed routinely to prevent blockage. There is theoretical possibility of generation of high intrapleural pressures with stripping and milking. Some authors have raised concern that this may cause pulmonary injury, however we have not observed any clinically significant adverse effects of these procedures. The practice of flushing the blocked tube by instilling sterile solutions should be discouraged as this may increase the chances of introducing infection from outside with resultant increase in the incidence of empyema. Some clinicians have used novel methods like using a fogarty balloon catheter to unblock the chest tube [16] or use of advanced systems to either prevent clot formation inside the tube [17] or wipe the inside of tube to unblock it [18].
7.5 How to collect a sample from the chest tube
A loop is formed in the ICD tube and the intrapleural fluid is allowed to accumulate in this loop. The tube is then clamped proximal to this collected fluid. With all aseptic measures the external surface of the ICD tube near its connection with the tubing of the reservoir is cleaned with alcohol based antiseptic solution. The tube is then disconnected from this end and the sample is collected in a sterile container. The ICD tube is then reconnected with the reservoir tube and is unclamped.
8. Removing the chest tube: when and how?
There are no fixed or universally agreed criteria that applies to all patients for guiding removal of the thoracostomy tube. There is great heterogeneity in practice, however the rule of thumb is that the chest tube should be removed once it has served its purpose. If the patient is clinically well, there is no more air leak than on forced expiration, no expanding subcutaneous emphysema, no blood, pus or chyle in the effluent and the volume of the fluid being drained is less than 250 ml, the tube can be safely removed. In case of residual space following pulmonary resection with persistent low volume air leak (no more than on forced expiration) beyond day 5, the chest tube may be clamped for up to 24 hours and a repeat x-ray is performed. The patient should be closely monitored during this period for tachypnoea or dyspnea. In case the patient remains asymptomatic and the pneumothorax does not worsen, the chest tube may be removed. The same may be done in case of persistent non-expanding effusion. This practice however, carries the risk of serious side effects if the patient monitoring following clamping of the tube is not diligent. The use of digital chest tube drainage devices might obviate this risk. The chest tube may be safely removed if the air leak is <40 ml/ min over 24 hours [19]. Alternatively, in patients with prolonged air leak (beyond day 5), a Heimlich valve may be applied to the chest tube and the patient may be followed on outpatient basis with a plan to remove the tube later allowing more opportunity for the residual lung to expand. We have recently proposed a protocol for removal of chest tubes following thoracic surgery that have enabled us to decrease the chest tube indwelling time [20].
In some specialties like Colorectal and Gynecological Surgery, the Enhanced Recovery After Surgery (ERAS) protocol has been well established. This has recently been proposed for patients undergoing oncological major lung resection surgery too. The guidelines suggest that chest tubes may safely be removed with a non-chylous fluid output of up to 450 ml/ day in absence of air leak or minimal air leak detected by the digital chest tube drainage systems [21].
The view is equally divided regarding removal of the chest tube during end-inspiration or end-expiration [22, 23]. In a Randomized Controlled Trial by Bell RL et al., there was no significant difference between the complications following removal of the chest tube at either the height of inspiration or expiration and both methods were considered safe [23]. The incidence of recurrent pneumothorax is likely to be multifactorial and correlates poorly to the method of chest tube removal alone [23, 24]. We prefer to remove the chest tube by a swift motion followed immediately by sealing of the thoracostomy wound by appropriate dressing material irrespective of the phase of respiration.
9. Complications
The complications of tube thoracostomy may be divided into 3 phases:
During insertion of the tube:
Hemorrhage from the ICD site
Injury to the lung and the mediastinal structures
Misplacement of the tube
During the indwelling time of the chest tube:
Displacement or dislodgement of the tube
Subcutaneous emphysema
Kinking
Blockage
Fracture of the tube
Empyema thoracis
Wound infection
Re-expansion pulmonary edema
Following removal of the tube
Recurrent pneumothorax or pleural effusion
Thoracostomy site pain
Hemorrhage from the ICD site may be avoided by carefully siting the thoracostomy incision on the upper border of the lower rib in the desired intercostal space. This avoids the damage to the neurovascular bundle that runs along the lower border of the rib. All aseptic measures should be taken while inserting the chest tube and later while handling the tube during the post procedural care to prevent wound infection and empyema. Care should be exercised while nursing and mobilizing the patient with chest tube to prevent accidental displacement or dislodgement of the tube.
To prevent re-expansion pulmonary edema, the pleural cavity should be gradually decompressed. Sudden evacuation of more than one liter of fluid from the thoracic cavity should be avoided. It is desirable to monitor the intrapleural pressure while draining large amount of fluid from the pleural cavity. The intrapleural pressure should not be allowed to fall below −20 cm saline at any point of time.
10. Common pitfalls in chest tube management
A pitfall is different from complication and is defined as a hidden or unsuspected danger or difficulty that may lead to adverse events. The awareness of a pitfall and preparation to act swiftly in such eventuality may help in averting the complication arising from it. Following are the common pitfalls in ICD tube management:
Missed diagnosis: ICD tube placed in a patient with large diaphragmatic hernia suspecting it to be a loculated pneumothorax. A careful history and diligent look at the x-ray will avoid this pitfall (Figure 7A and B).
Placement of ICD on wrong side: One should confirm the side with pathology before putting the chest tube. The history of the patient, clinical notes and the radiological findings should be correlated to correctly identify the side of pathology.
A large thoracostomy incision may result in potential space around the chest tube. This coupled with fixation of the tube by superficial skin suturing results in development of a closed plane in the subcutaneous tissues. Peri-tubal air leak in this situation may lead to massive surgical emphysema with attended morbidity and mortality.
Avoiding digital exploration of the pleural cavity may result in injury to pulmonary parenchyma in addition to improper positioning and kinking of the tube (Figure 8).
One must perform ‘finger thoracostomy’ before inserting the chest tube to avoid this from happening.
Use of tubes with trocar and applying undue force while gaining entry to the pleural cavity may result in injury to various thoracic, mediastinal or intra-abdominal organs.
Poor placement result in a tube that may be:
Too in: may impinge on to the mediastinal structures (Figure 9A and B).
Too out: the eye (hole) of the tube may lie in the subcutaneous tissues with resultant subcutaneous emphysema (Figure 10).
Mispositioned or kinked resulting in poor drainage (Figures 11–14).
Poor fixation of the chest tube may result in accidental displacement or dislodgement (Figure 11). The chest tube should be anchored properly with number 1 silk suture. An additional suture from the opposite side improves the fixation and decreases the chances of this mishap.
Improper filling of the reservoir (under water seal) with sterile solution so that the outlet tube is not beneath the water column may result in pneumothorax.
Raising the reservoir above the level of the chest may result in drainage of the collected material back into the thoracic cavity. The reservoir should remain below the chest level of the patient at all times.
Clamping the tube while shifting or mobilizing the patient may result in tension pneumothorax. The outlet of the reservoir should be kept open at all times to prevent this.
Figure 7.
A: Left sided diaphragmatic hernia with large gastric shadow. B: Chest tube inserted in a patient of diaphragmatic hernia misdiagnosed as hydropneumothorax.
Figure 8.
A kinked chest tube.
Figure 9.
A & B: Chest tube impinging on mediastinal structures.
Figure 10.
Eye of chest tube in subcutaneous tissues with subcutaneous emphysema.
Figure 11.
Chest tube (arrow) about to come out.
Figure 12.
Chest tube lying outside the chest wall.
Figure 13.
Mispositioned tube over the diaphragm (arrow).
Figure 14.
Mispositioned tube lying in abdomen (arrow).
11. Advances in chest tube drainage systems
With the advancement in technology, newer equipment has become available that may help in decreasing some of the complications associated with the tube thoracostomy, make the assessment of drainage more objective and accurate thus helping in better management of ICD tubes. Some of the advancement in the recent times are:
Devices for better fixation of the chest tubes: Some devices are available that claim better fixation of the chest tubes [25], others have been tested on animal models and may soon become available [26].
Digital chest tube drainage systems: This has been perhaps the most significant advancement that is now the part of most modern thoracic surgery units (Figure 15).
Figure 15.
A patient being managed on digital chest tube drainage system following thoracotomy.
The use of these drainage systems has been associated with improved decision-making regarding chest tube management, decrease complications, improved quality of life and reduce the hospital stay [27, 28, 29] These are light weight, portable system with a disposable reservoir that may be replaced once full. The main advantages of this system are:
It does not require an ‘underwater seal’ thus eliminating the risk of accidental pneumothorax and passage of drained material from the reservoir back to the chest.
It allows accurate measurement of drained fluid and air over time and thus helps in assessment of the trend of drainage (Figure 16A & B).
Figure 16.
A & B: Objective depiction of air and fluid drainage and trend of drainage in digital chest tube drainage system.
This may help the clinician in making decision for removal of chest tube more objective and accurately.
Continuous controlled suction may be applied to the chest tube that remains constant irrespective of the position of the drainage system.
The patient may easily carry the device while ambulation without the risk of changes in pressure effecting drainage or accidental drainage of the collected material back in chest.
Chest tube systems with inbuilt mechanism to keep the inside of the tube clean to prevent clogging [16, 18].
Motion activated systems for prevention of clot formation inside the chest tube: This system uses motion-activated energy (vibration) primarily to prevent early adhesion of clots within the internal chest tube surface and thus maintains the patency of the chest tube [17].
12. Conclusion
Insertion of ICD is a common, simple yet lifesaving procedure. All clinicians should be well versed with the appropriate technique of inserting the thoracostomy tube and various aspects of its management. Although simple, it is associated with high rate of complications that primarily occur due to improper technique of insertion or poor post-procedural care. Awareness of these factors will make the procedure safer with improved outcome.
Conflict of interest
There are no conflicts of interest.
\n',keywords:"Chest tube, Tube thoracostomy, intercostal drainage tube, ICD tube, Thoracentesis, Thoracostomy drainage",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/78585.pdf",chapterXML:"https://mts.intechopen.com/source/xml/78585.xml",downloadPdfUrl:"/chapter/pdf-download/78585",previewPdfUrl:"/chapter/pdf-preview/78585",totalDownloads:126,totalViews:0,totalCrossrefCites:0,dateSubmitted:"April 9th 2021",dateReviewed:"August 22nd 2021",datePrePublished:"September 14th 2021",datePublished:null,dateFinished:"September 14th 2021",readingETA:"0",abstract:"Insertion of intercostal drainage (ICD) tube is one of the commonest surgical procedure that is life saving in certain circumstances. Although the procedure is being used for long, yet there is no consensus in its management. The procedure is simple to perform but the incidence of the complications, which primarily occur due to improper positioning of the tube and poor post-procedural care, is as high as 40%. It is therefore essential that all clinicians should be familiar with this simple, common and lifesaving procedure. This chapter provides a comprehensive overview of various aspects of intercostal drainage including the prerequisites, technique of insertion, post-procedural care, complications and common pitfalls in the management of chest tubes in the light of the recent advances and updates.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/78585",risUrl:"/chapter/ris/78585",signatures:"Mohit Kumar Joshi",book:{id:"11045",type:"book",title:"Pleura - a Surgical Perspective",subtitle:null,fullTitle:"Pleura - a Surgical Perspective",slug:null,publishedDate:null,bookSignature:"Dr. Alberto Sandri",coverURL:"https://cdn.intechopen.com/books/images_new/11045.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-83969-693-0",printIsbn:"978-1-83969-692-3",pdfIsbn:"978-1-83969-694-7",isAvailableForWebshopOrdering:!0,editors:[{id:"50811",title:"Dr.",name:"Alberto",middleName:null,surname:"Sandri",slug:"alberto-sandri",fullName:"Alberto Sandri"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. 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J Medieval Military History.2010;8:119-130.'},{id:"B2",body:'Christopoulou-Aletra H, Papvramidou N. “Empyemas” of the thoracic cavity in the Hippocratic corpus. Ann Thorac Surg 2008;85:1132-1134.'},{id:"B3",body:'Kesieme EB, Dongo A, Ezemba N, Irekpita E, Jebbin N, Kesieme C. Tube thoracostomy: complications and its management. Pulm Med. 2012;2012:256878. doi: 10.1155/2012/256878. Epub 2011. PMID: 22028963; PMCID: PMC3195434.'},{id:"B4",body:'Hernandez MC, El Khatib M, Prokop L, Zielinski MD, Aho JM. Complications in tube thoracostomy: Systematic review and meta-analysis. J Trauma Acute Care Surg. 2018;85(2):410-416. doi: 10.1097/TA.0000000000001840. PMID: 29443856; PMCID: PMC6081248.'},{id:"B5",body:'Ortner CM, Ruetzler K, Schaumann N, Lorenz V, Schellongowski P, Schuster E, Salem RM, Frass M. Evaluation of performance of two different chest tubes with either a sharp or a blunt tip for thoracostomy in 100 human cadavers. Scand J Trauma Resusc Emerg Med. 2012;20:10. doi: 10.1186/1757-7241-20-10. PMID: 22300972; PMCID: PMC3395864.: chest drain insertion with trocars is associated with a 6-14% operator-related complication rate'},{id:"B6",body:'John M, Razi S, Sainathan S, Stavropoulos C. Is the trocar technique for tube thoracostomy safe in the current era? Interact Cardiovasc Thorac Surg. 2014;19(1):125-128. doi: 10.1093/icvts/ivu071. Epub 2014 Mar 19. PMID: 24648468.'},{id:"B7",body:'Light RW. Pleural controversy: optimal chest tube size for drainage. Respirology. 2011;16(2):244-248. doi: 10.1111/j.1440-1843.2010.01913.x. PMID: 21166742.'},{id:"B8",body:'Fysh ET, Smith NA, Lee YC. Optimal chest drain size: the rise of the small-bore pleural catheter. Semin Respir Crit Care Med. 2010;31(6):760-768. doi: 10.1055/s-0030-1269836. Epub 2011 Jan 6. PMID: 21213208.'},{id:"B9",body:'Inaba K, Lustenberger T, Recinos G, Georgiou C, Velmahos GC, Brown C, Salim A, Demetriades D, Rhee P. Does size matter? 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In this context, this chapter presents key subjects while implementing a quality management system at materials science laboratories and some considerations on strategies for effectively implementing such systems.",book:{id:"5486",slug:"quality-control-and-assurance-an-ancient-greek-term-re-mastered",title:"Quality Control and Assurance",fullTitle:"Quality Control and Assurance - An Ancient Greek Term Re-Mastered"},signatures:"Rodrigo S. Neves, Daniel P. Da Silva, Carlos E. C. Galhardo, Erlon H.\nM. Ferreira, Rafael M. Trommer and Jailton C. Damasceno",authors:[{id:"20571",title:"Prof.",name:"Erlon H.",middleName:null,surname:"Martins Ferreira",slug:"erlon-h.-martins-ferreira",fullName:"Erlon H. 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The quality practices or quality management systems adopted by industries will further evolve due to the changes of quality concepts as time goes by. This chapter discusses the change of quality concepts and the related revolution of quality management systems in the past century. The quality concepts were gradually changed from the achievement of quality standards, satisfaction of customer needs, and expectations to customer delight. Since merely satisfying customers is not enough to ensure customer loyalty, the enterprises gradually focus on customers’ emotional responses and their delight in order to pursue their loyalty. The emotion of “delight” is composed of “joy” and “surprise,” which can be achieved as the customers’ latent requirements are satisfied. Thus, the concept of “customer delight” and the means to provide the innovative quality so as to meet the unsatisfied customers’ latent needs are elaborated on. Finally, a framework of innovation creation is developed that is based on the mining of customer's latent requirements. This outline will manifest the essential elements of the related operation steps.",book:{id:"5486",slug:"quality-control-and-assurance-an-ancient-greek-term-re-mastered",title:"Quality Control and Assurance",fullTitle:"Quality Control and Assurance - An Ancient Greek Term Re-Mastered"},signatures:"Ching-Chow Yang",authors:[{id:"11862",title:"Prof.",name:"Ching-Chow",middleName:null,surname:"Yang",slug:"ching-chow-yang",fullName:"Ching-Chow Yang"}]},{id:"62915",title:"Advanced Methods of PID Controller Tuning for Specified Performance",slug:"advanced-methods-of-pid-controller-tuning-for-specified-performance",totalDownloads:3439,totalCrossrefCites:10,totalDimensionsCites:16,abstract:"This chapter provides a concise survey, classification and historical perspective of practice-oriented methods for designing proportional-integral-derivative (PID) controllers and autotuners showing the persistent demand for PID tuning algorithms that integrate performance requirements into the tuning algorithm. The proposed frequency-domain PID controller design method guarantees closed-loop performance in terms of commonly used time-domain specifications. One of its major benefits is universal applicability for both slow and fast-controlled plants with unknown mathematical model. Special charts called B-parabolas were developed as a practical design tool that enables consistent and systematic shaping of the closed-loop step response with regard to specified performance and dynamics of the uncertain controlled plant.",book:{id:"6323",slug:"pid-control-for-industrial-processes",title:"PID Control for Industrial Processes",fullTitle:"PID Control for Industrial Processes"},signatures:"Štefan Bucz and Alena Kozáková",authors:[{id:"21933",title:"Ms.",name:"Alena",middleName:null,surname:"Kozakova",slug:"alena-kozakova",fullName:"Alena Kozakova"},{id:"213658",title:"Dr.",name:"Štefan",middleName:null,surname:"Bucz",slug:"stefan-bucz",fullName:"Štefan Bucz"}]},{id:"75699",title:"Data Clustering for Fuzzyfier Value Derivation",slug:"data-clustering-for-fuzzyfier-value-derivation",totalDownloads:279,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The fuzzifier value m is improving significant factor for achieving the accuracy of data. Therefore, in this chapter, various clustering method is introduced with the definition of important values for clustering. To adaptively calculate the appropriate purge value of the gap type −2 fuzzy c-means, two fuzzy values m1 and m2 are provided by extracting information from individual data points using a histogram scheme. Most of the clustering in this chapter automatically obtains determination of m1 and m2 values that depended on existent repeated experiments. Also, in order to increase efficiency on deriving valid fuzzifier value, we introduce the Interval type-2 possibilistic fuzzy C-means (IT2PFCM), as one of advanced fuzzy clustering method to classify a fixed pattern. In Efficient IT2PFCM method, proper fuzzifier values for each data is obtained from an algorithm including histogram analysis and Gaussian Curve Fitting method. Using the extracted information form fuzzifier values, two modified fuzzifier value m1 and m2 are determined. 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He\nreceived a short-term scholarship to carry out his post-doctoral\nstudies abroad, from Japan International Cooperation Agency\n(JICA), in coordination with the Egyptian government. Dr.\nShalaby speaks fluent English and his native Arabic. He has 77\ninternationally published research papers, has attended 15 international conferences, and has contributed to 18 international books and chapters.\nDr. Shalaby works as a reviewer on over one hundred international journals and is\non the editorial board of more than twenty-five international journals. He is a member of seven international specialized scientific societies, besides his local one, and\nhe has won seven prizes.",institutionString:"Cairo University",institution:{name:"Cairo University",institutionURL:null,country:{name:"Egypt"}}}]}]},openForSubmissionBooks:{},onlineFirstChapters:{},subseriesFiltersForOFChapters:[],publishedBooks:{},subseriesFiltersForPublishedBooks:[],publicationYearFilters:[],authors:{paginationCount:617,paginationItems:[{id:"158492",title:"Prof.",name:"Yusuf",middleName:null,surname:"Tutar",slug:"yusuf-tutar",fullName:"Yusuf Tutar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/158492/images/system/158492.jpeg",biography:"Prof. Dr. Yusuf Tutar conducts his research at the Hamidiye Faculty of Pharmacy, Department of Basic Pharmaceutical Sciences, Division of Biochemistry, University of Health Sciences, Turkey. He is also a faculty member in the Molecular Oncology Program. He obtained his MSc and Ph.D. at Oregon State University and Texas Tech University, respectively. He pursued his postdoctoral studies at Rutgers University Medical School and the National Institutes of Health (NIH/NIDDK), USA. His research focuses on biochemistry, biophysics, genetics, molecular biology, and molecular medicine with specialization in the fields of drug design, protein structure-function, protein folding, prions, microRNA, pseudogenes, molecular cancer, epigenetics, metabolites, proteomics, genomics, protein expression, and characterization by spectroscopic and calorimetric methods.",institutionString:"University of Health Sciences",institution:null},{id:"180528",title:"Dr.",name:"Hiroyuki",middleName:null,surname:"Kagechika",slug:"hiroyuki-kagechika",fullName:"Hiroyuki Kagechika",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180528/images/system/180528.jpg",biography:"Hiroyuki Kagechika received his bachelor’s degree and Ph.D. in Pharmaceutical Sciences from the University of Tokyo, Japan, where he served as an associate professor until 2004. 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He has developed various compounds including a drug for acute promyelocytic leukemia.",institutionString:"Tokyo Medical and Dental University",institution:{name:"Tokyo Medical and Dental University",country:{name:"Japan"}}},{id:"40482",title:null,name:"Rizwan",middleName:null,surname:"Ahmad",slug:"rizwan-ahmad",fullName:"Rizwan Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/40482/images/system/40482.jpeg",biography:"Dr. Rizwan Ahmad is a University Professor and Coordinator, Quality and Development, College of Medicine, Imam Abdulrahman bin Faisal University, Saudi Arabia. Previously, he was Associate Professor of Human Function, Oman Medical College, Oman, and SBS University, Dehradun. Dr. Ahmad completed his education at Aligarh Muslim University, Aligarh. He has published several articles in peer-reviewed journals, chapters, and edited books. His area of specialization is free radical biochemistry and autoimmune diseases.",institutionString:"Imam Abdulrahman Bin Faisal University",institution:{name:"Imam Abdulrahman Bin Faisal University",country:{name:"Saudi Arabia"}}},{id:"41865",title:"Prof.",name:"Farid A.",middleName:null,surname:"Badria",slug:"farid-a.-badria",fullName:"Farid A. Badria",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41865/images/system/41865.jpg",biography:"Farid A. Badria, Ph.D., is the recipient of several awards, including The World Academy of Sciences (TWAS) Prize for Public Understanding of Science; the World Intellectual Property Organization (WIPO) Gold Medal for best invention; Outstanding Arab Scholar, Kuwait; and the Khwarizmi International Award, Iran. He has 250 publications, 12 books, 20 patents, and several marketed pharmaceutical products to his credit. He continues to lead research projects on developing new therapies for liver, skin disorders, and cancer. Dr. Badria was listed among the world’s top 2% of scientists in medicinal and biomolecular chemistry in 2019 and 2020. He is a member of the Arab Development Fund, Kuwait; International Cell Research Organization–United Nations Educational, Scientific and Cultural Organization (ICRO–UNESCO), Chile; and UNESCO Biotechnology France",institutionString:"Mansoura University",institution:{name:"Mansoura University",country:{name:"Egypt"}}},{id:"329385",title:"Dr.",name:"Rajesh K.",middleName:"Kumar",surname:"Singh",slug:"rajesh-k.-singh",fullName:"Rajesh K. Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329385/images/system/329385.png",biography:"Dr. Singh received a BPharm (2003) and MPharm (2005) from Panjab University, Chandigarh, India, and a Ph.D. (2013) from Punjab Technical University (PTU), Jalandhar, India. He has more than sixteen years of teaching experience and has supervised numerous postgraduate and Ph.D. students. He has to his credit more than seventy papers in SCI- and SCOPUS-indexed journals, fifty-five conference proceedings, four books, six Best Paper Awards, and five projects from different government agencies. He is currently an editorial board member of eight international journals and a reviewer for more than fifty scientific journals. He received Top Reviewer and Excellent Peer Reviewer Awards from Publons in 2016 and 2017, respectively. He is also on the panel of The International Reviewer for reviewing research proposals for grants from the Royal Society. He also serves as a Publons Academy mentor and Bentham brand ambassador.",institutionString:"Punjab Technical University",institution:{name:"Punjab Technical University",country:{name:"India"}}},{id:"142388",title:"Dr.",name:"Thiago",middleName:"Gomes",surname:"Gomes Heck",slug:"thiago-gomes-heck",fullName:"Thiago Gomes Heck",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/142388/images/7259_n.jpg",biography:null,institutionString:null,institution:{name:"Universidade Regional do Noroeste do Estado do Rio Grande do Sul",country:{name:"Brazil"}}},{id:"336273",title:"Assistant Prof.",name:"Janja",middleName:null,surname:"Zupan",slug:"janja-zupan",fullName:"Janja Zupan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/336273/images/14853_n.jpeg",biography:"Janja Zupan graduated in 2005 at the Department of Clinical Biochemistry (superviser prof. dr. Janja Marc) in the field of genetics of osteoporosis. Since November 2009 she is working as a Teaching Assistant at the Faculty of Pharmacy, Department of Clinical Biochemistry. In 2011 she completed part of her research and PhD work at Institute of Genetics and Molecular Medicine, University of Edinburgh. She finished her PhD entitled The influence of the proinflammatory cytokines on the RANK/RANKL/OPG in bone tissue of osteoporotic and osteoarthritic patients in 2012. From 2014-2016 she worked at the Institute of Biomedical Sciences, University of Aberdeen as a postdoctoral research fellow on UK Arthritis research project where she gained knowledge in mesenchymal stem cells and regenerative medicine. She returned back to University of Ljubljana, Faculty of Pharmacy in 2016. She is currently leading project entitled Mesenchymal stem cells-the keepers of tissue endogenous regenerative capacity facing up to aging of the musculoskeletal system funded by Slovenian Research Agency.",institutionString:null,institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"357453",title:"Dr.",name:"Radheshyam",middleName:null,surname:"Maurya",slug:"radheshyam-maurya",fullName:"Radheshyam Maurya",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/357453/images/16535_n.jpg",biography:null,institutionString:null,institution:{name:"University of Hyderabad",country:{name:"India"}}},{id:"311457",title:"Dr.",name:"Júlia",middleName:null,surname:"Scherer Santos",slug:"julia-scherer-santos",fullName:"Júlia Scherer Santos",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311457/images/system/311457.jpg",biography:"Dr. Júlia Scherer Santos works in the areas of cosmetology, nanotechnology, pharmaceutical technology, beauty, and aesthetics. Dr. Santos also has experience as a professor of graduate courses. Graduated in Pharmacy, specialization in Cosmetology and Cosmeceuticals applied to aesthetics, specialization in Aesthetic and Cosmetic Health, and a doctorate in Pharmaceutical Nanotechnology. Teaching experience in Pharmacy and Aesthetics and Cosmetics courses. She works mainly on the following subjects: nanotechnology, cosmetology, pharmaceutical technology, aesthetics.",institutionString:"Universidade Federal de Juiz de Fora",institution:{name:"Universidade Federal de Juiz de Fora",country:{name:"Brazil"}}},{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",slug:"abdulsamed-kukurt",fullName:"Abdulsamed Kükürt",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRNVJQA4/Profile_Picture_2022-03-07T13:23:04.png",biography:"Dr. Kükürt graduated from Uludağ University in Turkey. He started his academic career as a Research Assistant in the Department of Biochemistry at Kafkas University. In 2019, he completed his Ph.D. program in the Department of Biochemistry at the Institute of Health Sciences. He is currently working at the Department of Biochemistry, Kafkas University. He has 27 published research articles in academic journals, 11 book chapters, and 37 papers. He took part in 10 academic projects. He served as a reviewer for many articles. He still serves as a member of the review board in many academic journals.",institutionString:null,institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"178366",title:"Associate Prof.",name:"Volkan",middleName:null,surname:"Gelen",slug:"volkan-gelen",fullName:"Volkan Gelen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178366/images/system/178366.jpg",biography:"Volkan Gelen is a Physiology specialist who received his veterinary degree from Kafkas University in 2011. Between 2011-2015, he worked as an assistant at Atatürk University, Faculty of Veterinary Medicine, Department of Physiology. In 2016, he joined Kafkas University, Faculty of Veterinary Medicine, Department of Physiology as an assistant professor. Dr. Gelen has been engaged in various academic activities at Kafkas University since 2016. There he completed 5 projects and has 3 ongoing projects. He has 60 articles published in scientific journals and 20 poster presentations in scientific congresses. His research interests include physiology, endocrine system, cancer, diabetes, cardiovascular system diseases, and isolated organ bath system studies.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"418963",title:"Dr.",name:"Augustine Ododo",middleName:"Augustine",surname:"Osagie",slug:"augustine-ododo-osagie",fullName:"Augustine Ododo Osagie",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/418963/images/16900_n.jpg",biography:"Born into the family of Osagie, a prince of the Benin Kingdom. I am currently an academic in the Department of Medical Biochemistry, University of Benin. Part of the duties are to teach undergraduate students and conduct academic research.",institutionString:null,institution:{name:"University of Benin",country:{name:"Nigeria"}}},{id:"192992",title:"Prof.",name:"Shagufta",middleName:null,surname:"Perveen",slug:"shagufta-perveen",fullName:"Shagufta Perveen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192992/images/system/192992.png",biography:"Prof. Shagufta Perveen is a Distinguish Professor in the Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia. Dr. Perveen has acted as the principal investigator of major research projects funded by the research unit of King Saud University. She has more than ninety original research papers in peer-reviewed journals of international repute to her credit. She is a fellow member of the Royal Society of Chemistry UK and the American Chemical Society of the United States.",institutionString:"King Saud University",institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"49848",title:"Dr.",name:"Wen-Long",middleName:null,surname:"Hu",slug:"wen-long-hu",fullName:"Wen-Long Hu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49848/images/system/49848.jpg",biography:"Wen-Long Hu is Chief of the Division of Acupuncture, Department of Chinese Medicine at Kaohsiung Chang Gung Memorial Hospital, as well as an adjunct associate professor at Fooyin University and Kaohsiung Medical University. Wen-Long is President of Taiwan Traditional Chinese Medicine Medical Association. He has 28 years of experience in clinical practice in laser acupuncture therapy and 34 years in acupuncture. He is an invited speaker for lectures and workshops in laser acupuncture at many symposiums held by medical associations. He owns the patent for herbal preparation and producing, and for the supercritical fluid-treated needle. Dr. Hu has published three books, 12 book chapters, and more than 30 papers in reputed journals, besides serving as an editorial board member of repute.",institutionString:"Kaohsiung Chang Gung Memorial Hospital",institution:{name:"Kaohsiung Chang Gung Memorial Hospital",country:{name:"Taiwan"}}},{id:"298472",title:"Prof.",name:"Andrey V.",middleName:null,surname:"Grechko",slug:"andrey-v.-grechko",fullName:"Andrey V. Grechko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/298472/images/system/298472.png",biography:"Andrey Vyacheslavovich Grechko, Ph.D., Professor, is a Corresponding Member of the Russian Academy of Sciences. He graduated from the Semashko Moscow Medical Institute (Semashko National Research Institute of Public Health) with a degree in Medicine (1998), the Clinical Department of Dermatovenerology (2000), and received a second higher education in Psychology (2009). Professor A.V. Grechko held the position of Сhief Physician of the Central Clinical Hospital in Moscow. He worked as a professor at the faculty and was engaged in scientific research at the Medical University. Starting in 2013, he has been the initiator of the creation of the Federal Scientific and Clinical Center for Intensive Care and Rehabilitology, Moscow, Russian Federation, where he also serves as Director since 2015. He has many years of experience in research and teaching in various fields of medicine, is an author/co-author of more than 200 scientific publications, 13 patents, 15 medical books/chapters, including Chapter in Book «Metabolomics», IntechOpen, 2020 «Metabolomic Discovery of Microbiota Dysfunction as the Cause of Pathology».",institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"199461",title:"Prof.",name:"Natalia V.",middleName:null,surname:"Beloborodova",slug:"natalia-v.-beloborodova",fullName:"Natalia V. Beloborodova",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/199461/images/system/199461.jpg",biography:'Natalia Vladimirovna Beloborodova was educated at the Pirogov Russian National Research Medical University, with a degree in pediatrics in 1980, a Ph.D. in 1987, and a specialization in Clinical Microbiology from First Moscow State Medical University in 2004. She has been a Professor since 1996. Currently, she is the Head of the Laboratory of Metabolism, a division of the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation. N.V. Beloborodova has many years of clinical experience in the field of intensive care and surgery. She studies infectious complications and sepsis. She initiated a series of interdisciplinary clinical and experimental studies based on the concept of integrating human metabolism and its microbiota. Her scientific achievements are widely known: she is the recipient of the Marie E. Coates Award \\"Best lecturer-scientist\\" Gustafsson Fund, Karolinska Institutes, Stockholm, Sweden, and the International Sepsis Forum Award, Pasteur Institute, Paris, France (2014), etc. Professor N.V. Beloborodova wrote 210 papers, five books, 10 chapters and has edited four books.',institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"354260",title:"Ph.D.",name:"Tércio Elyan",middleName:"Azevedo",surname:"Azevedo Martins",slug:"tercio-elyan-azevedo-martins",fullName:"Tércio Elyan Azevedo Martins",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/354260/images/16241_n.jpg",biography:"Graduated in Pharmacy from the Federal University of Ceará with the modality in Industrial Pharmacy, Specialist in Production and Control of Medicines from the University of São Paulo (USP), Master in Pharmaceuticals and Medicines from the University of São Paulo (USP) and Doctor of Science in the program of Pharmaceuticals and Medicines by the University of São Paulo. Professor at Universidade Paulista (UNIP) in the areas of chemistry, cosmetology and trichology. Assistant Coordinator of the Higher Course in Aesthetic and Cosmetic Technology at Universidade Paulista Campus Chácara Santo Antônio. Experience in the Pharmacy area, with emphasis on Pharmacotechnics, Pharmaceutical Technology, Research and Development of Cosmetics, acting mainly on topics such as cosmetology, antioxidant activity, aesthetics, photoprotection, cyclodextrin and thermal analysis.",institutionString:null,institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"334285",title:"Ph.D. Student",name:"Sameer",middleName:"Kumar",surname:"Jagirdar",slug:"sameer-jagirdar",fullName:"Sameer Jagirdar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334285/images/14691_n.jpg",biography:"I\\'m a graduate student at the center for biosystems science and engineering at the Indian Institute of Science, Bangalore, India. I am interested in studying host-pathogen interactions at the biomaterial interface.",institutionString:null,institution:{name:"Indian Institute of Science Bangalore",country:{name:"India"}}},{id:"329795",title:"Dr.",name:"Mohd Aftab",middleName:"Aftab",surname:"Siddiqui",slug:"mohd-aftab-siddiqui",fullName:"Mohd Aftab Siddiqui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329795/images/15648_n.jpg",biography:"Dr. Mohd Aftab Siddiqui is currently working as Assistant Professor in the Faculty of Pharmacy, Integral University, Lucknow for the last 6 years. He has completed his Doctor in Philosophy (Pharmacology) in 2020 from Integral University, Lucknow. He completed his Bachelor in Pharmacy in 2013 and Master in Pharmacy (Pharmacology) in 2015 from Integral University, Lucknow. He is the gold medalist in Bachelor and Master degree. He qualified GPAT -2013, GPAT -2014, and GPAT 2015. His area of research is Pharmacological screening of herbal drugs/ natural products in liver and cardiac diseases. He has guided many M. Pharm. research projects. He has many national and international publications.",institutionString:"Integral University",institution:null},{id:"255360",title:"Dr.",name:"Usama",middleName:null,surname:"Ahmad",slug:"usama-ahmad",fullName:"Usama Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255360/images/system/255360.png",biography:"Dr. Usama Ahmad holds a specialization in Pharmaceutics from Amity University, Lucknow, India. He received his Ph.D. degree from Integral University. Currently, he’s working as an Assistant Professor of Pharmaceutics in the Faculty of Pharmacy, Integral University. From 2013 to 2014 he worked on a research project funded by SERB-DST, Government of India. He has a rich publication record with more than 32 original articles published in reputed journals, 3 edited books, 5 book chapters, and a number of scientific articles published in ‘Ingredients South Asia Magazine’ and ‘QualPharma Magazine’. He is a member of the American Association for Cancer Research, International Association for the Study of Lung Cancer, and the British Society for Nanomedicine. Dr. Ahmad’s research focus is on the development of nanoformulations to facilitate the delivery of drugs that aim to provide practical solutions to current healthcare problems.",institutionString:"Integral University",institution:{name:"Integral University",country:{name:"India"}}},{id:"30568",title:"Prof.",name:"Madhu",middleName:null,surname:"Khullar",slug:"madhu-khullar",fullName:"Madhu Khullar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/30568/images/system/30568.jpg",biography:"Dr. Madhu Khullar is a Professor of Experimental Medicine and Biotechnology at the Post Graduate Institute of Medical Education and Research, Chandigarh, India. She completed her Post Doctorate in hypertension research at the Henry Ford Hospital, Detroit, USA in 1985. She is an editor and reviewer of several international journals, and a fellow and member of several cardiovascular research societies. Dr. Khullar has a keen research interest in genetics of hypertension, and is currently studying pharmacogenetics of hypertension.",institutionString:"Post Graduate Institute of Medical Education and Research",institution:{name:"Post Graduate Institute of Medical Education and Research",country:{name:"India"}}},{id:"223233",title:"Prof.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/223233/images/system/223233.png",biography:"Xianquan Zhan received his MD and Ph.D. in Preventive Medicine at West China University of Medical Sciences. He received his post-doctoral training in oncology and cancer proteomics at the Central South University, China, and the University of Tennessee Health Science Center (UTHSC), USA. He worked at UTHSC and the Cleveland Clinic in 2001–2012 and achieved the rank of associate professor at UTHSC. Currently, he is a full professor at Central South University and Shandong First Medical University, and an advisor to MS/PhD students and postdoctoral fellows. He is also a fellow of the Royal Society of Medicine and European Association for Predictive Preventive Personalized Medicine (EPMA), a national representative of EPMA, and a member of the American Society of Clinical Oncology (ASCO) and the American Association for the Advancement of Sciences (AAAS). He is also the editor in chief of International Journal of Chronic Diseases & Therapy, an associate editor of EPMA Journal, Frontiers in Endocrinology, and BMC Medical Genomics, and a guest editor of Mass Spectrometry Reviews, Frontiers in Endocrinology, EPMA Journal, and Oxidative Medicine and Cellular Longevity. He has published more than 148 articles, 28 book chapters, 6 books, and 2 US patents in the field of clinical proteomics and biomarkers.",institutionString:"Shandong First Medical University",institution:{name:"Affiliated Hospital of Shandong Academy of Medical Sciences",country:{name:"China"}}},{id:"297507",title:"Dr.",name:"Charles",middleName:"Elias",surname:"Assmann",slug:"charles-assmann",fullName:"Charles Assmann",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/297507/images/system/297507.jpg",biography:"Charles Elias Assmann is a biologist from Federal University of Santa Maria (UFSM, Brazil), who spent some time abroad at the Ludwig-Maximilians-Universität München (LMU, Germany). He has Masters Degree in Biochemistry (UFSM), and is currently a PhD student at Biochemistry at the Department of Biochemistry and Molecular Biology of the UFSM. His areas of expertise include: Biochemistry, Molecular Biology, Enzymology, Genetics and Toxicology. He is currently working on the following subjects: Aluminium toxicity, Neuroinflammation, Oxidative stress and Purinergic system. Since 2011 he has presented more than 80 abstracts in scientific proceedings of national and international meetings. Since 2014, he has published more than 20 peer reviewed papers (including 4 reviews, 3 in Portuguese) and 2 book chapters. He has also been a reviewer of international journals and ad hoc reviewer of scientific committees from Brazilian Universities.",institutionString:"Universidade Federal de Santa Maria",institution:{name:"Universidade Federal de Santa Maria",country:{name:"Brazil"}}},{id:"217850",title:"Dr.",name:"Margarete Dulce",middleName:null,surname:"Bagatini",slug:"margarete-dulce-bagatini",fullName:"Margarete Dulce Bagatini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/217850/images/system/217850.jpeg",biography:"Dr. Margarete Dulce Bagatini is an associate professor at the Federal University of Fronteira Sul/Brazil. She has a degree in Pharmacy and a PhD in Biological Sciences: Toxicological Biochemistry. She is a member of the UFFS Research Advisory Committee\nand a member of the Biovitta Research Institute. She is currently:\nthe leader of the research group: Biological and Clinical Studies\nin Human Pathologies, professor of postgraduate program in\nBiochemistry at UFSC and postgraduate program in Science and Food Technology at\nUFFS. She has experience in the area of pharmacy and clinical analysis, acting mainly\non the following topics: oxidative stress, the purinergic system and human pathologies, being a reviewer of several international journals and books.",institutionString:"Universidade Federal da Fronteira Sul",institution:{name:"Universidade Federal da Fronteira Sul",country:{name:"Brazil"}}},{id:"226275",title:"Ph.D.",name:"Metin",middleName:null,surname:"Budak",slug:"metin-budak",fullName:"Metin Budak",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226275/images/system/226275.jfif",biography:"Metin Budak, MSc, PhD is an Assistant Professor at Trakya University, Faculty of Medicine. He has been Head of the Molecular Research Lab at Prof. Mirko Tos Ear and Hearing Research Center since 2018. His specializations are biophysics, epigenetics, genetics, and methylation mechanisms. He has published around 25 peer-reviewed papers, 2 book chapters, and 28 abstracts. He is a member of the Clinical Research Ethics Committee and Quantification and Consideration Committee of Medicine Faculty. His research area is the role of methylation during gene transcription, chromatin packages DNA within the cell and DNA repair, replication, recombination, and gene transcription. His research focuses on how the cell overcomes chromatin structure and methylation to allow access to the underlying DNA and enable normal cellular function.",institutionString:"Trakya University",institution:{name:"Trakya University",country:{name:"Turkey"}}},{id:"243049",title:"Dr.",name:"Anca",middleName:null,surname:"Pantea Stoian",slug:"anca-pantea-stoian",fullName:"Anca Pantea Stoian",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/243049/images/system/243049.jpg",biography:"Anca Pantea Stoian is a specialist in diabetes, nutrition, and metabolic diseases as well as health food hygiene. She also has competency in general ultrasonography.\n\nShe is an associate professor in the Diabetes, Nutrition and Metabolic Diseases Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. She has been chief of the Hygiene Department, Faculty of Dentistry, at the same university since 2019. Her interests include micro and macrovascular complications in diabetes and new therapies. Her research activities focus on nutritional intervention in chronic pathology, as well as cardio-renal-metabolic risk assessment, and diabetes in cancer. She is currently engaged in developing new therapies and technological tools for screening, prevention, and patient education in diabetes. \n\nShe is a member of the European Association for the Study of Diabetes, Cardiometabolic Academy, CEDA, Romanian Society of Diabetes, Nutrition and Metabolic Diseases, Romanian Diabetes Federation, and Association for Renal Metabolic and Nutrition studies. She has authored or co-authored 160 papers in national and international peer-reviewed journals.",institutionString:null,institution:{name:"Carol Davila University of Medicine and Pharmacy",country:{name:"Romania"}}},{id:"279792",title:"Dr.",name:"João",middleName:null,surname:"Cotas",slug:"joao-cotas",fullName:"João Cotas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/279792/images/system/279792.jpg",biography:"Graduate and master in Biology from the University of Coimbra.\n\nI am a research fellow at the Macroalgae Laboratory Unit, in the MARE-UC – Marine and Environmental Sciences Centre of the University of Coimbra. My principal function is the collection, extraction and purification of macroalgae compounds, chemical and bioactive characterization of the compounds and algae extracts and development of new methodologies in marine biotechnology area. \nI am associated in two projects: one consists on discovery of natural compounds for oncobiology. The other project is the about the natural compounds/products for agricultural area.\n\nPublications:\nCotas, J.; Figueirinha, A.; Pereira, L.; Batista, T. 2018. An analysis of the effects of salinity on Fucus ceranoides (Ochrophyta, Phaeophyceae), in the Mondego River (Portugal). Journal of Oceanology and Limnology. in press. DOI: 10.1007/s00343-019-8111-3",institutionString:"Faculty of Sciences and Technology of University of Coimbra",institution:null},{id:"279788",title:"Dr.",name:"Leonel",middleName:null,surname:"Pereira",slug:"leonel-pereira",fullName:"Leonel Pereira",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/279788/images/system/279788.jpg",biography:"Leonel Pereira has an undergraduate degree in Biology, a Ph.D. in Biology (specialty in Cell Biology), and a Habilitation degree in Biosciences (specialization in Biotechnology) from the Faculty of Science and Technology, University of Coimbra, Portugal, where he is currently a professor. In addition to teaching at this university, he is an integrated researcher at the Marine and Environmental Sciences Center (MARE), Portugal. His interests include marine biodiversity (algae), marine biotechnology (algae bioactive compounds), and marine ecology (environmental assessment). Since 2008, he has been the author and editor of the electronic publication MACOI – Portuguese Seaweeds Website (www.seaweeds.uc.pt). He is also a member of the editorial boards of several scientific journals. Dr. Pereira has edited or authored more than 20 books, 100 journal articles, and 45 book chapters. He has given more than 100 lectures and oral communications at various national and international scientific events. He is the coordinator of several national and international research projects. In 1998, he received the Francisco de Holanda Award (Honorable Mention) and, more recently, the Mar Rei D. Carlos award (18th edition). He is also a winner of the 2016 CHOICE Award for an outstanding academic title for his book Edible Seaweeds of the World. In 2020, Dr. Pereira received an Honorable Mention for the Impact of International Publications from the Web of Science",institutionString:"University of Coimbra",institution:{name:"University of Coimbra",country:{name:"Portugal"}}},{id:"61946",title:"Dr.",name:"Carol",middleName:null,surname:"Bernstein",slug:"carol-bernstein",fullName:"Carol Bernstein",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/61946/images/system/61946.jpg",biography:"Carol Bernstein received her PhD in Genetics from the University of California (Davis). She was a faculty member at the University of Arizona College of Medicine for 43 years, retiring in 2011. Her research interests focus on DNA damage and its underlying role in sex, aging and in the early steps of initiation and progression to cancer. In her research, she had used organisms including bacteriophage T4, Neurospora crassa, Schizosaccharomyces pombe and mice, as well as human cells and tissues. She authored or co-authored more than 140 scientific publications, including articles in major peer reviewed journals, book chapters, invited reviews and one book.",institutionString:"University of Arizona",institution:{name:"University of Arizona",country:{name:"United States of America"}}},{id:"182258",title:"Dr.",name:"Ademar",middleName:"Pereira",surname:"Serra",slug:"ademar-serra",fullName:"Ademar Serra",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/182258/images/system/182258.jpeg",biography:"Dr. Serra studied Agronomy on Universidade Federal de Mato Grosso do Sul (UFMS) (2005). He received master degree in Agronomy, Crop Science (Soil fertility and plant nutrition) (2007) by Universidade Federal da Grande Dourados (UFGD), and PhD in agronomy (Soil fertility and plant nutrition) (2011) from Universidade Federal da Grande Dourados / Escola Superior de Agricultura Luiz de Queiroz (UFGD/ESALQ-USP). Dr. Serra is currently working at Brazilian Agricultural Research Corporation (EMBRAPA). His research focus is on mineral nutrition of plants, crop science and soil science. Dr. Serra\\'s current projects are soil organic matter, soil phosphorus fractions, compositional nutrient diagnosis (CND) and isometric log ratio (ilr) transformation in compositional data analysis.",institutionString:"Brazilian Agricultural Research Corporation",institution:{name:"Brazilian Agricultural Research Corporation",country:{name:"Brazil"}}}]}},subseries:{item:{id:"12",type:"subseries",title:"Human Physiology",keywords:"Anatomy, Cells, Organs, Systems, Homeostasis, Functions",scope:"Human physiology is the scientific exploration of the various functions (physical, biochemical, and mechanical properties) of humans, their organs, and their constituent cells. The endocrine and nervous systems play important roles in maintaining homeostasis in the human body. Integration, which is the biological basis of physiology, is achieved through communication between the many overlapping functions of the human body's systems, which takes place through electrical and chemical means. 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