**Table 1.**

*Chemical composition of different by-products from agro-industrial processing.*

diets through supplementary concentrate can potentially enhance milk production and improve growth rate, body weight gain, and reproductive performance [50, 51].

There are further feedstuffs also valuable as an alternative feed for ruminants, such as palm fiber, chickpea, orange pulp, rapeseed meal, cottonseed meal, and palm kernel cake (PKC), which because of its nutritional content may be described as an energy food. In addition, palm kernel cake supplies protein and energy but is usually classified as a source of protein, which may vary from 10.1 to 16.6% (**Table 1**). This protein content of PKC is regarded as sufficient to meet the needs of most ruminants [52, 53]. Proteins are the principal constituents of the organs and muscles and are required by ruminants for metabolic functions [38, 54]. Palm kernel cake also contains a large amount of crude fiber (CF; 19.3%), dry matter ranging from 91.9 to 95.8%, ether extract (EE; 7.8 to 10.8%), ash (3.1 to 3.5%), neutral detergent fiber (NDF; 64.1 to 71.4%), acid detergent fiber (13.5 to 56.0%) (**Table 1**), nitrogen-free extract (NFE; 46.7 to 58.8%), total carbohydrates (78.7%), nonfibrous carbohydrates (NFCs) (7.31%), hemicellulose (HEM) (25.98%), and lignin (4.28%) [38, 55]. The metabolizable energy (ME) of palm kernel cake for ruminants is 2.5 to 2.6 Mcal kg−1, which is considered suitable for most ruminants [55].

Animals must be fed diets containing the earlier-mentioned essential nutrients for healthy growth and increased production. The ether extract is the main source of lipids which constitutes the principal component of sperm cells. It also stimulates cholesterol biosynthesis and testosterone secretion to sustain semen production in males [56]. Other fibrous components are sources of carbohydrates which are converted to acetic acids and used by the cows for energy and precursor of fat in milk [57]. It is also essential for animal health, since it is required by ruminants to support an appropriate rumen function and physiology [58].

#### **3.2 Dietary effects on reproductive performance of ruminant livestock**

The process of reproduction is aligned closely with the food supply. It is a coordinated function of many tissues, cell types, and regulatory systems which is possible only when animals are provided with sufficient quantities of dietary nutrients [59]. In tropical regions such as Africa, ruminants raised on smallholder farms face constraints of improper nutritional management, which may negatively affect their growth, health, and reproductive performance [60, 61]. For instance, puberty is usually delayed in grazing ruminants because grasslands in semiarid zones in the tropics do not provide enough protein and other nutrients, which leads to insufficient production of rumen microbial protein to support optimum growth rate [60]. Thus, nutrition plays a pivotal role in maintaining the body condition and reproductive efficiency of animals.

Nutrition consists of different nutrients such as protein, fat, carbohydrates, and micro-elements. Carbohydrates and proteins provide substrates for rumen fermentation, which results in the production of volatile fatty acids (VFAs). Ruminants utilize these VFAs as their main source of energy for maintenance, milk production, and reproductive performance. Malnutrition resulting from inadequate, excess, or imbalanced nutrient intake may lead to the loss of body weight. Low body condition delays the onset of puberty (up to 1 year in sheep and goats), reduces ovulation and lower conception rates, compromises embryonic and fetal survival, increases the postpartum interval to conception, interferes with normal ovarian cyclicity by decreasing gonadotropin secretion, increases the chances of infertility, and influences the rate of genetic progress [62, 63]. So, it seems to be clear that the initial reproductive events are sensitive to fluctuations in nutrient availability [61].

#### *Alternative Animal Feeding for Intensive Livestock Farming Systems and Their Impact… DOI: http://dx.doi.org/10.5772/intechopen.106061*

An inverse relationship between growth rate and age at puberty also exists in males. Low-quality feeding has been shown to delay puberty by about 5 months in bulls. The animals had poor testicular development and smaller ejaculates as compared to their normal counterparts. On the other hand, bulls kept on grazing plus concentrate feed showed a better growth rate than those on grazing only, with an earlier age at puberty and a greater scrotal circumference [60]. Even at maturity, the size of the testicles of underfed animals can be smaller [59] resulting in a lower sperm concentration in the semen. It has also been reported that the seminal vesicles contain less fructose and citric acid as well as smaller Leydig cells and seminiferous tubules and decreased testosterone levels under protein stress conditions [64]. Restriction of both protein and energy also prevented Merino lambs from reaching puberty in their first potential breeding season, with reduced testicular size and sperm quality in the ejaculate. Feed restriction also reduces libido in rams [60].

#### *3.2.1 Effect of coconut meal on goat reproductive performance*

To assess the effectiveness of coconut meal as an alternative feed and its effect on beef goats' reproductive performance, a study was conducted in Brazil in 2016. Fortyeight males with initial body weight ranging from 26.04 to 28.54 kg were assigned in a completely randomized design into four groups with 12 replicates each under a semi-intensive system. The animals were kept indoors during the night and moved to graze in the morning on a pasture composed of *Brachiaria decumbens (*nonlegume forage plant). In the afternoon, the animals were supplemented with a concentrate containing 0% of coconut meal (group 1), 15% of coconut meal (group 2), 30% of coconut meal (group 3), and 45% of coconut meal (group 4) (**Table 2**). Before feeding the animals, the nutritional composition of coconut meal, soybean bagasse, corn meal, and pasture was assessed for dry matter, ash, ether extract, crude protein, neutral detergent fiber, total carbohydrates, hemicellulose, and lignin, and the results are shown in **Table 3**. In our study, coconut meal was included in four different levels (0%, 15%, 30%, and 45% of coconut meal) as a source of fatty acids and protein as well as a substitute for soybean meal, which is one of the most expensive feedstuffs in animal feed. In addition, the levels of cornmeal were also reduced while increasing the level of coconut meal. The animals' body weight and testicular parameters were recorded every 15 days, and the semen was collected and assessed for volume, wave motion, progressive motility, sperm concentration, and sperm vigor according to the methodology suggested by CBRA [65]. In addition, the total number of sperm and the total number of viable spermatozoa were estimated according to the methodology described by Martin-Rillo [66].

Our results showed an increase in the scrotal circumference and testicular volume of goats fed with concentrates containing 30% and 45% of coconut meal (**Table 4**). This result suggests that concentrates with high amounts of coconut meal may be more effective than those with lower amounts in improving goat's testis. Also, the data in **Table 4** suggest that scrotal circumference and testicular volume may increase as the body weight of goat increases, indicating a positive relationship between nutrition and goats' testis size or reproductive efficiency. Males with a larger testis tend to produce more semen and offspring that reach puberty at an earlier age and release more ovules during each estrous period [68]. Oldham et al. [69] found that a 25% increase in testicular size led to an 81% increase in the production of spermatozoa. Also, Cameron et al. [70] found that an 86% increase in testicular size led to a 250% increase in the production of spermatozoa. The positive relation between testicular

#### **Table 2.**

*Level of coconut meal (treatments) in diet supplied to the goats.*

#### **Table 3.**

*Chemical composition of forage and feedstuffs used in concentrated feed for goats in 2016.*

biometric parameters and body weight concerning nutrition effects was also reported by Martinez et al. [71].

The diets with 30% and 45% of coconut meal showed higher levels of ether extract (**Table 5**) which is a saturated fatty acids source, such as lauric (C12:0), myristic (C14:0), palmitic (C16:0), and stearic (C18:0) acids and unsaturated fatty acids such as myristoleic (C14:1), palmitoleic (16,1), oleic (C18:1), and polyunsaturated fatty acids (PUFA) that include linoleic (C18:2) and linolenic (C18:3) acids, compared with other diets. So, it may be possible that the fatty acids in coconut meal may have increased the concentration of serum cholesterol which may lead to improved testosterone levels in goats. However, changing nutrition in small ruminants alters not only the total mass of testicular tissue but also the efficiency with which the spermatozoa are produced by that tissue [77].

It has been classically admitted that in both the mid and the long terms, variations in growth, testicle parameters, and fluctuations in live weight as a result of nutritional status affect also semen quality of ruminants, as nutrition appears to be the major modulator of sexual efficiency in small ruminants [71]. In our previous study with sheep managed under extensive range grazing conditions and fed with palm kernel cake as an


**Author details**

Jinyu Zhang\*, Gang Liu\* and Jun Sun\*

\*Address all correspondence to<EMAIL_ADDRESS><EMAIL_ADDRESS>and<EMAIL_ADDRESS>
State Key Laboratory for Mechanical Behavior of Materials, Xi'an Jiaotong University, Xi'an, PR China


**2.10. Management of endometrioma**

Endometriomas usually present as a pelvic mass arising from growth of ectopic endometrial tissue within the ovary. They typically contain thick brown tar-like fluid (hence the name "chocolate cyst"). Ultrasound is useful for supporting the clinical diagnosis of endometrioma. In case of infertility, the management of endometriomas is controversial. Many women with endometriosis can conceive naturally. For those who have difficulty, surgery often provides a "window of opportunity" during which the chances of conception increase the medical treatment alone usually is inadequate. The ultrasound-guided aspiration of the chocolatecolored fluid aspiration sometimes have serious consequences including post aspiration infection, pelvic adhesions, and ovarian abscess. Laparoscopic cystectomy is the gold standard, and preferred approach for the treatment of endometriosis and endometrioma. Surgical treatment is associated with a high recurrence rate and its employment for women undergoing assisted conception.. Excision of the entire cyst by laparoscopy or laparotomy appears to be the optimum treatment approach. Fenestration and ablation of the lining of an endometrioma is a less preferred option. Aspiration alone is ineffective. Laparoscopic drainage of endometriomas has the same disadvantages as ultrasound-guided aspiration. The recurrence rate is very high (80-90%). Fenestration and ablation is also less effective than excision, both in terms of improving fertility and for reducing pain. Laparoscopic cystectomy remains a first-line choice for the treatment of endometrioma. This consists of: opening the cyst, identifying the cyst wall and removing it from the ovarian cortex by traction and with grasping forceps. Surgery is not only the elimination of the endometrioma effectively but also to reconstruct the pelvic anatomy. The advantage of medical treatment has not been shown to be effective in controlling symptoms or improving fertility potential. After surgical treatment GnRH for a period of 12 weeks or dienogest (Visanne®, 2 mg) should be useful. Birth control pills have been shown to be ineffective in postoperative treatment of endometriomas. Recurrent ovarian surgery is not recommended.

It is generally accepted, that patients with endometriosis have lower success rates with IVF than patients without endometriosis. Several investigations have been occurring to improve the pregnancy rates following treatment with IVF in patients with endometrioma.

### **2.11. Adhesions - laparoscopic adhesiolysis**

Adhesions are bands of scar tissue that connect normally separated pelvic structures. Postoperative adhesions occur in 60% to 90% of patients undergoing major gynecologic surgery. Pelvic adhesions (scars) develop as a normal tissue response to inflammation, which occurs whenever the tissue is damaged.  Pelvic adhesions impair fertility by disrupting normal tubalovarian relationships. Postoperative adhesions are squeal of impaired fibrinolysis of the fibrin and cellular exudates after peritoneal injury. Both microsurgical and laparoscopic techniques are used to treat pelvic adhesions. Additional studies also indicate the benefit of adhesiolysis in treating infertility. The most important factors which suppress fibrinolytic activity and promote adhesion formation are:

6 Enhancing Success of Assisted Reproduction

(resulting in oocyte phagocytosis)

modulators, TNF-α inhibitors, - Ultrasound-guided aspiration

**2.10. Management of endometrioma**

up to 6- 9 months after surgery.

**2.9. Endoscopic techniques in endometriosis**

infertility. Some of the options for treatment to conceive include:

Infertility and pelvic pain in its various forms are the main expressions of endometriosis. The fallopian tubes and ovaries may adhere to the lining of the pelvis or to each other, restricting their movement. Another factor which cause infertility with Endometriosis, may be the over-production of prostaglandins. No laboratory findings are particularly helpful in making or confirming a diagnosis of endometriosis. Treatment of endometriosis, medical or surgical, is directed at ameliorating the symptoms and severity of the pelvic pain and

Surgery may include lysis of adhesions, restoration of normal anatomy and ablation of all endometriotic implants, cystectomy or resection of endometriomas and in extreme cases even the removal of the ovaries and the uterus. During laparoscopy can remove endometrial growths, scar tissue, and adhesions caused by the endometriosis. This is not a really cure, and endometriosis may return later. However, some women will have increased fertility for

Endometriomas usually present as a pelvic mass arising from growth of ectopic endometrial tissue within the ovary. They typically contain thick brown tar-like fluid (hence the name "chocolate cyst"). Ultrasound is useful for supporting the clinical diagnosis of endometrioma. In case of infertility, the management of endometriomas is controversial. Many women with endometriosis can conceive naturally. For those who have difficulty, surgery often provides a "window of opportunity" during which the chances of conception increase the medical treatment alone usually is inadequate. The ultrasound-guided aspiration of the chocolatecolored fluid aspiration sometimes have serious consequences including post aspiration infection, pelvic adhesions, and ovarian abscess. Laparoscopic cystectomy is the gold standard, and preferred approach for the treatment of endometriosis and endometrioma.

	- Surgical glove powder
	- Delayed postoperative mobilization of patient

Causes of pelvic adhesions

The incidence and severity of adhesions

Prevention of adhesions in surgery

With an optimal surgical technique intending to minimize mesothelial injury, peritoneal trauma is inevitable. laparoscopy leads to less adhesion formation compared to open surgery.

The Role of Endoscopy in Management of Infertility 9

The most common intraoperative complication is injury to the bowel. With dense adhesions, this risk increases. Other intraoperative complications may include bleeding and injury to adjacent organs such as the gallbladder, spleen, ovaries, especially when working next to

Uterine fibroids are the most common pelvic tumor, occurring in about 70% of women by age 45. However, many fibroids are small and asymptomatic. About 25% of white and 50% of black women have symptomatic fibroids. Fibroids are benign tumors of the muscle of the uterus most myomas do not cause clinical symptoms and do not require intervention. Based on location the various types of myoma are subserous, intramural and submucous fibroid. Most frequently, they develop in the myometrial wall and can lead to uterine distortion. Common problems associated with myomas are pelvic, abdominal, or back discomfort; urinary bladder irritability; abnormal uterine bleeding; bowel dysfunction; infertility; and pregnancy loss and/or complications. Myomas can cause infertility are mechanical interference with implantation, sperm and embryo transport, focal endometrial vascular and endocrine disturbances, endometrial inflammation, and abnormal uterine contractility. During the past few years, there have been a number of studies advancing the knowledge about the efficacy and safety of treatments of myomas, including medical and minimally invasive therapies. Laparoscopic myomectomy was first described by Semm and Metler in 1980 for subserosal fibroid there is an increasing trend for minimal access surgery for treatment of uterine myomas. Laparoscopic myomectomy is a very recent advance in the field of gynaecological surgery. Laparoscopic myomectomy has provided minimal invasive alternative to laparotomy with advantage of faster recovery and less postoperative adhesions. Laparoscopic myomectomy (LM) is an effective technique that is associated with the development of operative laparoscopic equipment and surgical techniques. The size does not matter for performance of a myomectomy laparoscopically. Laparoscopic myomectomy has evolved into a safe, efficient, and cost effective approach for the treatment of intramural, subserosal, and pedunculated fibroids. Criteria for myomectomy for surgical intervention, supported by the American College of Obstetricians and Gynecologists

(ACOG) and American society for reproductive medicine (ASRM) are:

otherwise asymptomatic;

Steps of operation: subserosal myomas

Before myomectomy, Hysteroscopy is performed in most patients at the outset of the

procedure, than all pelvic structures and the abdominal cavity are inspected

**2.14. Complications**

these organs-

**3. Myomectomy**

The most commonly used agents for preventing postoperative adhesions:


*4.3. UPR Regulation by MITOL*

In addition to the basic role of MITOL in unstressed conditions, recent evidence has implied that MITOL serves as a unique signaling regulator in several specific conditions. We recently identified a novel substrate, IRE1 α, for MITOL at the MCS between the ER and mitochondria [76]. IRE1 α is an ER membrane-integrated protein that possesses bifunctional activity as a kinase and endoribonuclease. The luminal domain of IRE1 α contributes to monitoring the stress level of the ER by sensing the emergence of unfolded proteins. Meanwhile, the cytosolic domain of IRE1 α, containing both catalytic domains, contributes to signal transduction from the ER to outside it in order to recover from ER damage during ER stress conditions. The ubiquitination of IRE1 α by MITOL determines the persistence of IRE1 α activation upon ER stress (Figure 4B). MITOL-catalyzed ubiquitination of IRE1 α is accompanied by binding to the mediator BIM for a smaller state of (or less stable) IRE1 α oligomerization, allowing the catalytic activation of IRE1 α only for the short term. This regulation of IRE1 α is pivotal with regard to termination of the UPR after the recovery of ER homeostasis. Unresolved IRE1 α activation indeed triggers an alternative outcome of IRE1 α signaling, namely, cell death. Importantly, severe ER stress attenuates the ubiquitination levels of IRE1 α by MITOL via unclear mechanisms. Therefore, the unlimited IRE1 α oligomerization and activation promote the induction of cell death during severe and irremediable ER stress. Taking these findings together, MITOL prevents the signal switching of IRE1 α from cell survival to cell death via direct ubiquitination of IRE1 α at the MCS between the ER and mitochondria. The ER network accumulates severe abnormalities, both functional and morphological, during irremediable ER stress. Thus, it might be reasonable to set the monitoring system, related to the signal switch of the UPR, outside the ER, such as on the mitochondrial surface. Several mitochondrial molecules therefore hold therapeutic potential in diseases initiated or aggravated by ER stress, not only mitochondrial stress.


**7. Conclusions**

Cervical disc arthroplasty has been one of the most closely scrutinized surgical procedures in the last decade. Short-term prospective clinical studies show cervical disc arthroplasty to be at least the equivalent of ACDF for degenerative pathology. There is some evidence that cervical disc arthroplasty may play a role in diminishing adjacent segment disease. However, the long-term efficacy and safety of cervical disc arthroplasty await further clinical studies.

### **8. References**

Cervical Disc Arthroplasty 513

[24] Huang RC, Girardi FP, Cammisa FP et al. (2003) The implications of constraint in

[25] Hilibrand AS, Carlson GD, Palumbo MA, et al. (1999) Radiculopathy and myelopathy

[26] Mehren, Suchomel et al. (2006) Heterotopic ossification in total cervical artificial disc

[27] Leung C, Casey et al. (2005) Clinical significance of Heterotopic ossification in cervical

[28] McAfee, Cunningham et al. (2003) Classification of Heterotopic ossification (HO) in artificial disk replacement. *Journal of Spinal Disorders and Techniques* 16: 384-9 [29] Mummaneni et al. Clinical and radiographic analysis of cervical disc arthroplasty

[30] Murrey et al. (2009) Results of the prospective, randomized, controlled Food and Drug

[31] Peng CW, Yue WM, Abdul B et al. (2011) Intermediate results of the Prestige LP

[32] Pospiech J, Stolke D, Wilke HJ et al. (1999) Intradiscal pressure recordings in the

[33] Phillips FM, Allen TR, Regen JJ, et al. (2009) Cervical disc replacement in patients with

[34] Pimenta L, McAfee PC, Cappuccino A, et al. (2007) Superiority of multilevel cervical

[35] Penning L. (1978) Normal movements of the cervical spine. *Am J Roentgenol,* 130: 317-

[36] Raposo J, Darden BV. (publication pending) Biomechanics of cervical disc arthroplasty.

[37] Riew KD, Buchowski JM, Sasso R, Zdeblick T, Metcalf NH, Anderson PA. (2008)

[38] Robinson R, Smith G. (1955): Anterolateral cervical disc removal and interbody fusion

[39] Sola S, Hebecker R, Knoop M et al. (2005 suppl) Bryan cervical disc prosthesis- three

[40] Tumialan LM and Gluf, Wm. (2011) Progressive vertebral body osteolysis after cervical

myelopathy. *Journal of Bone and Joint-A*, Vol. 90: pp 2354-2364

years follow-up. *European Spine Journal,* 14:38

arthroplasty. *Spine,* 36(14):973-8

for cervical disc syndrome. *Bull. John Hopkins Hospital,* 96:223-224

symptomatic cervical disc disease. *Spine Journal*, Vol. 9, pp 275-286

417

discussion 763

(6) 556-565

326

Wilkins

*Bone and Joint Surgery Am*, 81: 519-528

replacement. *Spine,* 31(24) 2802-2806

*Neurosurgery –Spine*, Vol. 6, pp 198-209

year follow-up. *Spine,* 36 (2): E 105-111

cervical spine. *Neurosurgery*, 44: 379-384.

prostheses. *Spine,* 32 (12) 1337-1344

lumbar total disc replacement. *Journal of Spinal Disorders and Techniques,* 16(4): 412-

at segments adjacent to the site of a previous anterior cervical arthrodesis. *Journal of*

disc replacement: a prospective multi-center clinical trial. *Neurosurgery,* 57:759-631

compared with allograft fusion: A randomized controlled trial*. Journal of*

Administration Investigational Device Exemption Study of the ProDisc-C total disc replacement versus anterior discectomy and fusion for the treatment of one level

cervical disc replacement: clinical and radiological analysis with minimum two-

and without previous adjacent level fusion surgery: A prospective study. *Spine,* 34

arthroplasty outcomes versus single level outcomes: 229 consecutive PCM

*The Cervical Spine, 5th Edition*. Editor Edward Benzel, Lippincott, Williams and

Cervical disc arthroplasty compared with arthrodesis for the treatment of

[8] Cloward RD. (1961) Treatment of acute fractures and fracture dislocations of cervical

[9] Cummins BH, Robertson JT, Gill SS. (1998) Surgical experience with an implanted

[10] Delamarter RB, Pradhan BB. (2004) Indications for cervical spine prostheses, early

[11] Delamarter RB, Murrey D, Janssen MI et al. (2010) Results of 24 months from the

[12] DiAngelo DJ, Robertson JT, Metcalf NH et al. (2003) Biomechanical testing of an

[13] Dmitriev AE, Cunningham BW, Hu N et al. (2005) Adjacent level intradiscal pressure

[14] Dvorak J, Panjabi MM, Grob D et al. (1993) Clinical validation of functional flexion/extension radiographs of the cervical spine. *Spine,* 18:120-127 [15] Dvorak J, Panjabi MM, Novotny JE et al. (1991) In vivo flexion/extension of the normal

[16] Eck JC, Humphreys SC, Lim T, et al. (2002) Biomechanical study on the effect of

[17] Goffin J, VanLoo J, VanCalenbergh F et al. (2010) A clinical analysis of 4-6 year follow-

[18] Goffin J, Geusens E, Vantomme N, et al. (2004) Long-term follow-up after

[19] Goffin J, Casey A, Kehr P, et al. (2002) Preliminary clinical experience with the Bryan

[20] Goffin J, Van Loon J, VanCalenbergh F, et al. (1995) Long-term results after anterior

[22] Gore DR, Sepic SB. (1984) Anterior cervical fusion for degenerated or protruded discs:

[23] Heller JG, Sasso RC, Papadopoulos SM, Anderson PA, Fessler RG et al. (2009)

the cervical spine. *Journal of Spinal Disorders and Techniques,* 8: 500-508 [21] Gore DR, Sepic SB. (1998) Anterior discectomy and fusion for painful cervical disc

A review of one hundred forty-six patients. *Spine,* 9:667-71

decompression and fusion. *Spine,* 34(2) 101- 107

artificial cervical joint. *Journal of Neurosurgery,* 88: 943-948

experiences with ProDisc-C in the USA. *Spine Art*, 1:7-9

and continued access patients. *SAS Journal,* 4: 122-128

human cadaveric model. *Spine,* 30: 1165-1172

cervical spine. *Journal of Orthop Res,* 9: 828-834

cervical disc prosthesis. *Neurosurgery*, 51(3) 840-845.

209

*Tech,* 16(4): 314-323

*Spine,* 27: 2431-2434

17(2) 79-85

2047-2051

J *Neurosurgery Spine,* 12 (3) 261-9

spine by vertebral body fusion: a report of cases. *Journal of Neurosurgery*, 118: 205-

prospective, randomized, multicenter investigation device exemption trial of ProDisc-C versus anterior cervical discectomy and fusion with 4-year follow-up

artificial cervical joint and an anterior cervical plate. *Journal of Spinal Disorders and*

and segmental kinematics following a cervical total disc arthroplasty: An in vitro

cervical spine fusion on adjacent level intradiscal pressure and segment motion.

up results after cervical disc replacement using the Bryan Cervical Disc Prosthesis.

interbody fusion of the cervical spine. *Journal of Spinal Disorders and Techniques,*

cervical fusion and osteosynthetic stabilization for fractures and/or dislocation of

disease: a report of 50 patients with an average follow-up of 21 years. *Spine,* 23:

Comparison of Bryan Cervical Disc Arthroplasty with anterior cervical

**24**

*USA*

**Lumbar Spinal Arthroplasty:**

*Chicago Back Institute, Swedish Covenant Hospital, N. Francisco, Chicago, IL*

Lumbar spinal arthroplasty was first reported in clinical settings more than 10 years ago by Griffith et al 1. This early experience was acquired with the first lumbar artificial disc, the CHARITÉ I, in patients with degenerative disc disease. Since that time, a randomized controlled trial comparing arthroplasty with the CHARITÉ Artificial Disc vs. anterior lumbar interbody fusion with the BAK Cage and iliac crest bone was completed. Multiple other lumbar arthroplasty devices have been developed subsequent to the CHARITÉ and

Unlike other spinal medical devices, lumbar discs are required by the Food and Drug Administration to complete randomized controlled trials (RCT) prior to market approval in the United States. As a result, lumbar arthroplasty devices have undergone more scrutiny and clinical evaluation than any other spinal medical devices. Specifically, a new device, the ProDisc-L, was granted FDA approval in 2006 and was described in a recent peer-review publication2. In addition, the Maverick Total Disc Arthroplasty System (Medtronic Sofamor Danek), Kineflex Lumbar Disc (SpinalMotion), and FlexiCore Intervertebral Disc (SpineCore/Stryker) lumbar discs have both completed their randomized enrollments and

All these ongoing and completed randomized clinical trials have generated a large body of evidence on the safety and efficacy of arthroplasty for lumbar spine in clinical applications

The safety and efficacy of arthroplasty are not the only parameters discussed in the >60 clinical papers published over the last 6 years. In fact, significant insights were developed in the impact of arthroplasty on sagittal alignment and motion, possible adverse events and reoperation, as well as optimal patient selection and indication. Surgical technique and health economics papers have also been generated in an effort to fully understand the clinical and societal impact of this new technology. This review paper is aimed at providing

A search was conducted on the OVID and COCHRANE Library database to collect all clinical data relevant to spinal arthroplasty. Specifically, the following keywords were used:

**1. Introduction**

are undergoing or completing clinical trials.

and, in many cases, in Level-1 publications.

**2. Materials and methods**

are currently in continued access (non-randomized) mode.

an overview of all the existing clinical data related to spinal arthroplasty.

**Clinical Experience**

Fred H. Geisler

[41] Yi S, Kim KN, Yang MS, et al. (2010) Difference in occurrence of Heterotopic ossification according to prosthesis type in the cervical artificial disc replacement. *Spine,* 35(16):1556-1561


# **COVID-19 Outbreak and Beyond Psychological and Behavioral Responses and Future Perspectives**

Edited by Paolo Roma, Merylin Monaro, Cristina Mazza

Printed Edition of the Special Issue Published in *International Journal of Environmental Research and Public Health*

www.mdpi.com/journal/ijerph


**6. Possible diagnostic markers**

68 Aneurysm

13].

aneurysm [14, 15].

development of AAA [16].

MMP-12 [8].

Nishimura *et al.* also observed a significant correlation of the expression of MMP-2 and

The degeneration of collagen and elastin leading to the development of aneurysms is a multifactorial process. Various factors may take part in the stimulation of both cells constituting the arterial wall and cells infiltrating it to produce MMPs. Aortic wall is subjected to cyclic stretching because of pulsative blood flow which is a normal physiological condition. AAA is often accompanied by an intraluminal thrombus. It causes that some cells within the aneurysm may be subjected to hypoxia. Experimental study of Oya *et al*. revealed that macrophages cultured in conditions subjected to cyclic stretching under normoxia and hypoxia which simulated the pulsative blood flow and hypoxia due to thrombus presented an increased MMP-9 production. These macrophages produced interleukin-8 (IL-8) and tumor necrosis factor-α (TNF-α) leading to increased apoptosis of vascular smooth muscle cells. Hypoxia was also demonstrated to augment the expression of MMP-1, MT-1 MMP, MMP-2, MMP-7 and MMP-9 in SMC derived from human aorta [12,

Nowadays many scientists focus their research on finding new factors which may augment the secretion of metalloproteinases by the cells present in aneurysms. Experimental studies confirmed that stenosis resulting in a turbulent blood flow can be the next factor increasing expression of MMP-2 and MMP-9 within abdominal aortic aneurysm. Interesting results were obtained by Stolle *et al*. Mice exposed to cigarette smoke and angiotensin II treatment had increased the incidence of AAA and higher gene expression of MMP-2, MMP-3, MMP-8, MMP-9 and MMP-12 in aorta and increased proteolytic activity of two most investigated metalloproteinaes, MMP-2 and MMP-9. Although each of this two factors alone induced minor changes, their combination accelerated the pathologic process. Exposure of the arterial wall to an increased concentration of angiotensin II represents conditions that may be observed in patients with arterial hypertension. This experiment demonstrates that coexistance of arterial hypertension and smoking augments the risk of a development of

Studies of Zhang *et al*. demonstrated that human AAA tissues had elevated levels of advanced glycation end products (AGEs) and their receptor (RAGE). In experimental model this group of researchers observed that AGEs induce the production of MMP-9 by macrophages. An increased serum concentration of AGEs accompanies poorly controlled diabetes mellitus. These results indicate that such patients may be at a greater risk of a

Abdominal aortic aneurysm is characterized not only by the destruction of its structural integrity of the extracellular matrix protein and inflammatory infiltrate but also by intensive neovascularisation. These new blood vessels developing inside the arterial wall in a place of growing aneurysm are the next source of metalloproteinases degrading ECM. Immature neovessels express MMP-1, MMP-2, MMP-3, MMP-7, MMP-8, MMP-9 and

MMP-9 and between each of these metalloproteinases and TIMP-1 [6].

The results of scientific researches discussed so far concern the evaluation of either expression or activity of MMPs in the tissue obtained from aneurysms in humans or experimental animals. These measurements have the scientific importance but cannot serve as a diagnostic marker. A growing interest is focused on finding circulating predictors of risk of the development of aneurysm or plasma markers of existing, yet undiagnosed aneurysm. Plasma levels of MMPs are of great interest. MMP-2 and MMP-9 are the candidates for such markers. Polish researchers observed significantly higher plasma concentration of MMP-9 in patients with AAA and thin intraluminal thrombus than in patients with abdominal aortic aneurysm and thick thrombus. Hellenthal *et al.* points out that plasma level of MMP-9 may serve as a marker discriminating patients with and without endoleak within AAA [18-20].

Several polymorphisms of metalloproteinases have been discovered. Their role in the development of AAA is being studied. The polymorphisms of MMP-2 (1306C/T), MMP-3 (5A/6A) and MMP-13 (77A/G) may contribute to the pathogenesis of AAA. The studies of circulating markers of aneurysms give promising results but further research is still required [21].


*Advances and Applications in Deep Learning*

[50] Denisov P, Vu NT, Font MF. Unsupervised domain adaptation by adversarial learning for robust speech recognition. InSpeech Communication; 13th ITG-Symposium 2018 Oct 10 (pp. 1–5). VDE.

[51] Purushotham S, Carvalho W, Nilanon T, Liu Y. Variational recurrent adversarial deep domain adaptation.

[52] Tonutti M, Ruffaldi E, Cattaneo A, Avizzano CA. Robust and subjectindependent driving manoeuvre anticipation through Domain-Adversarial Recurrent Neural Networks. Robotics and Autonomous Systems. 2019 May 1;115:162–73.

[53] Chen C, Miao Y, Lu CX, Xie L, Blunsom P, Markham A, Trigoni N. Motiontransformer: Transferring neural inertial tracking between domains. InProceedings of the AAAI Conference on Artificial Intelligence 2019 Jul 17 (Vol. 33, pp. 8009–8016).

**63**

Section 2

Future Trends of Deep

Learning

Section 2