**1. Introduction**

118 Sustainable Forest Management – Case Studies

Cruz, P., Honeyman, P., & Caballero, C. (2005). Propuesta metodológica de ordenación

Davis, L. S., & Johnson, K. N. (1987). *Forest management*. McGraw-Hill, ISBN 634-928-000-

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FAO. (2005). *State of the world's forests 2005*, Food and Agriculture Organization of the United

Gonzáles, J. M., Piqué, M., & Vericat, P. (2006). *Manual de ordenación por rodales*. Gestión multifuncional de los espacios forestales. Norprint, ISBN 84-690-3133-3, Barcelona Hernando, A., Tejera, R., Velázques, J., & Ñuñez, M.V. (2010). Quantitatively defining the

Irvine, R.J., Fiorini, S., Yearley, S., McLeod, J. E., Turner, A., Armstrong, H., White, P. C. L., &

ITTO. (1990). ITTO guidelines for the sustainable management of natural tropical forests. *Technical Series 5*. International Tropical Timber Organization, Yokohama, Japan. Lund, H. Gyde. (2009). *What is a degraded forest?* White paper prepared for FAO. Retrieved

Mc Evoy, T. J. (2004). *Positive impact forestry: a sustainable approach to managing woodlands*.

MMA. (2008). Instrução Normativa nº 6, de 23 de setembro de 2008. Reconhece espécies da

Oliveira, Y. M. M. de. (2000). Investigation of remote sensing for assessing and monitoring

Putz, F. E., & Pinard, M. A. (1993). Reduced-impact logging as a carbon-offset method. *Cons.*

Rivera, H. (2007). Ordenamento territorial de áreas florestais utilizando avaliação multicritério

Rosot, M. A. D. (2007). Manejo florestal de uso múltiplo: uma alternativa contra a extinção

Rosot, M. A. D., Oliveira, Y. M. M. de, Rivera, H., Cruz, P. & Mattos, P.P. (2006). Desarrollo

Smith, W. B., Miles, P. D., Perry, C. H. & Pugh, S. A. (2009). *Forest resources of the United*

flora brasileira ameaçadas de extinção e revoga a Portaria Normativa Ibama no 37- N, de 3 de abril de 1992. Diário Oficial [da República Federativa do Brasil], Brasília

the Araucaria Forest region of Brazil. Thesis (Doctor of Philosophy). Department of

apoiada por geoprocessamento, fitossociologia e análise multivariada. Curitiba. Thesis (MSc). Department of Forest Engeneering. Universidade Federal do Paraná, Curitiba Rivera, H., Rudloff, A. & Cruz, P. (2002). *Plan de Ordenación de la Reserva Nacional Valdivia*.

da floresta com Araucária? *Pesquisa Florestal Brasileira*, Colombo, n. 55, pp. 75-85,

de un modelo de plan de manejo para áreas protegidas en bosques con araucaria en el sur de Brasil, *Proceedings of IUFRO Second LatinAmerican Congress*. La Serena,

*States, 2007*. WO GTR-78. USDA Forest Service, Washington Office, Washington, D.C., USA. Retrieved from http://www.fs.fed.us/nrs/pubs/gtr/gtr\_wo78.pdf

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conservation status of Natura 2000 forest habitats and improving management options for enhancing biodiversity. *Biodiversity and Conservation*, Vol.19, No. 8, pp.

Van Der Wal, R. (2009). Can managers inform models? Integrating local knowledge into models of red deer habitat use. *J. of Appl. Ecol*., 46, 2, pp. 344–352, ISSN 0021-8901

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In many forests, timber harvesting is displacing natural disturbance (e.g., wildfire, wind, insects and disease) as the major agent of ecosystem disturbance. There is a growing concern over the impacts of intensive timber harvesting on the long-term site productivity (Nambiar et al., 1990; Nambiar and Sands, 1993; Johnson, 1994). The significant yield decline of Chinese fir (*Cunninghamia lanceolata* [Lamb] Hook) in southern China (Yu, 1988; Sheng and Xue, 1992) and of radiata pine (*Pinus radiata* D. Don) in southeastern Australia (Keeves, 1966; Squire, 1983) and New Zealand (Whyte, 1973) after several forest-harvest rotations exemplifies this concern, and the issue has gained renewed attention as interest has grown in forest certification, biodiversity, protection, forest carbon management and sustainability. A key issue in the discussion of sustainability is the comparability in ecological impacts between timber harvesting and natural disturbance (e.g., wildfire, insects, and disease). Much of the focus in this discussion has been on the characteristics that clear-cutting and natural disturbance have in common (Hammond, 1991; Keenan and Kimmins, 1993). However, the debate has frequently been frustrated by the lack of an adequate description of the range of ecological effects of both natural disturbance and forest harvesting. A variety of recent initiatives in forest policy in both the United States and Canada have emphasized natural disturbance processes and their structural consequences as models of forest management (Lertzman et al., 1997). However, implementing this approach is often limited by our incomplete understanding of natural disturbance regimes (Lertzman and Fall, 1998; Perera and Buse, 2004). Many studies have demonstrated importance of wildfire disturbance in forest ecosystems (Attiwill, 1994; Lertzman and Fall, 1998). If natural disturbance is fundamental to the development of forest ecosystems, then our management of natural areas should be based on an understanding of disturbance processes (Attiwill, 1994; Poff et al., 1997; Richter et al., 1997; Andison, 2000; Johnson et al., 2003)). This also highlights that ecological impacts of harvesting must be evaluated within a broad disturbance context. In the British Columbia (BC) interior forest ecosystems that are described as having a

natural disturbance type maintained by frequent stand-initiating fires, forest managers are

Sustainable Forest Management in a Disturbance

pine but can cause severe losses of volume production.

**3. Methods**

**3.1 Field investigation**

between SOH and WTH sites.

Context: A Case Study of Canadian Sub-Boreal Forests 121

Wildfire is a common, natural disturbance which cycles this type of forest about every 100 - 125 years (mean fire return interval in the SBPS Zone, J. Parminter, Ministry of Forests, Victoria, British Columbia). Other natural disturbance agents such as mountain pine beetles (*Dendroctonus ponderosae* Hopk) and dwarf mistletoe (*Arceuthobium americanum* Nutt) are common in the study area. The former can cause extensive tree mortality, and much of the harvesting in the study area was in stands where some (about 5-25%) of the dominant trees had been killed by mountain pine beetles. Dwarf mistletoe does not usually kill lodgepole

There are two types of timber harvesting including stem-only harvesting (SOH) and wholetree harvesting (WTH) applied in lodgepole pine forests in the central interior of British Columbia. WTH removes most of the above-ground woody biomass including crown materials while SOH removes most of the above-ground woody biomass but leaves crown materials on the site. Concern has focused on the ecological impacts of the removal of nutrient-rich crown materials, and in WTH such removal may result in considerably more

A combination of field investigation with ecosystem modeling was used for this study. The purpose of the field survey is to quantify the differences immediately following wildfire disturbance and harvesting, while the ecosystem modeling is to evaluate the long-term implication of those differences in site productivity. The ecosystem model FORECAST, or its forerunner FORCYTE, has been used as a management evaluation tool in several types of forest ecosystems (Sachs and Sollins, 1986; Kellomäki and Seppälä, 1987; Wang et al., 1995; Wei and Kimmins, 1995; Morris et al., 1997; Wei et al., 2000; Seely et al., 2002; Welham et al., 2002). The model was specifically designed to examine the impacts of different management strategies or natural disturbance regimes on long-term site productivity. A brief description of the FORECAST model approach is presented in the next section; details are found in

WD in this study includes CWD and fine woody debris (FWD). We define CWD as woody stems 2.5 cm diameter and FWD as woody stems < 2.5 cm diameter. We investigated FWD as well as CWD as the former should account for the major difference in WD loading

Thirteen plots (five for WTH and four each for wildfire disturbance and SOH) with records of the time of disturbance were located, interspersed across the study area. Most selected plots were harvested or burned within less than 20 years ago, with an exception of the plot burned in 1961. It was not possible to locate more fire-killed plots because no records are available for the fires occurred 30 years ago, and because recent fire protection in the area

The line intersect sampling method was employed to quantify WD volume (McRae et al., 1979). This involves 3 lines (each 30 m in length) laid out in an equilateral triangle. The triangular layout is used to minimize bias in situations where the logs are not randomly

site nutrient depletion. For this study, we included both harvesting methods.

Kimmins (1993); Seely et al., (1999); and Kimmins et al., (1999).

**3.1.1 Measurements of mass of above-ground WD**

has limited the number of fire disturbances.

particularly interested in understanding natural wildfire disturbances in order to maintain the ecological patterns and functions of these forests (Parminter, 1998; Kimmins, 2000; Wei et al. 2003). In these areas, wildfire disturbance is part of natural ecosystem processes, and its functions are, from a long-term perspective, part of natural variability. Lodgepole pine forest (*Pinus contorta ssp. latifolia* Engelm. ex S. Wats.) is a major type of forests in the central interior of BC, and concerns have been expressed over potential impacts of intensive timber harvesting on long-term site productivity (Kimmins, 1993; Wei et al., 1997).

Both timber harvesting and wildfire disturbances can vary substantially in size, intensity, severity, frequency and internal heterogeneity, greatly complicating comparisons of the effects of different disturbance types. The differences relate to differences in forest type, topography, timing of the disturbance, local management methods, and management objectives (Lertzman and Fall, 1998; Parminter, 1998). From a nutrient perspective, a major difference between timber harvesting and wildfire disturbance is the biomass of woody debris (WD) left in the ecosystem, and the quantity of nutrients removed.

WD, particularly coarse woody debris (CWD), has been shown to be an important structural and functional element in many forested ecosystems (Lambert et al., 1980; Sollins, 1982; Harmon et al., 1986; Spies et al., 1988). It provides a key habitat component (especially large logs) for many forms of wildlife (Reynolds et al. 1992). Studies by Harvey et al. (1981) and Harvey et al. (1987) showed that organic materials, especially humus and buried residue in the advanced stage of decay, are excellent sites for the formation of ectomycorrhizal root tips. Graham et al. (1994) used ecotomycorrhizal activity as a primary indicator of a healthy forest soil. Further, CWD may play a significant role in long-term nutrient cycling; it can be an important site for asymbiotic nitrogen fixation, and it acts as a source of slow nutrient release during its long period of decay.

This paper summarizes a series of our research and publications in lodgepole pine forests in the sub-boreal regions of British Columbia, Canada. The objectives of this study are: (1) to quantify the difference in the mass and nutrients of woody debris remaining immediately following harvesting and wildfire disturbances; (2) to evaluate long-term implications of those differences in site productivity; and (3) to determine the management strategies for achieving sustainability of long-term site productivity in lodgepole pine forests in the BC interior.


Author details

Lucía Hilario Pérez1 \*, Marta Covadonga Mora Aguilar2 , Nicolás Montés Sánchez1 and Antonio Falcó Montesinos1

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\*Address all correspondence to<EMAIL_ADDRESS>
1 Departamento Matemáticas, Físicas y Ciencias Tecnológicas, Universidad Cardenal Herrera-CEU, CEU Universities, Alfara del Patriarca, Spain

2 Department of Mechanical Engineering and Construction, Universitat Jaume I, Castellón, Spain


**1. Introduction**

Preeclampsia complicates 3%–5% of all pregnancies and remains one of the leading causes of maternal and perinatal morbidity and mortality [1]. In particular, pregnancies complicated by early onset preeclampsia (prior to 34 weeks gestation) are associated with a 20-fold increase in maternal death [2] and considerably increased rates of maternal and perinatal morbidities [3]. As such,

the management of early onset preeclampsia continues to pose significant challenges to obstetricians attempting to balance maternal risks with fetal benefits of prolonging pregnancy.

Although not fully understood, the pathophysiology of preeclampsia is generally agreed to originate with poor placentation [4]. Inadequate trophoblast invasion and failure of maternal spiral arterial remodeling leads to impaired placental development, including exposure to chronic progressive ischaemia–reperfusion injury characterized by evidence of excessive oxidative stress. In turn, this induces excessive placental release of anti-angiogenic factors such as soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng), coupled with inflammatory cytokines including tumour necrosis factor-α (TNF-α) and activin A [5–8]. These various factors target the maternal vasculature and contribute significantly to the widespread maternal vascular dysfunction, which is often associated with oxidative injury [9–12]. Dysfunctional cells of the vasculature are characterized by increased endothelial cell permeability, altered distribution of endothelial junctional proteins, and reduced endothelium-dependent relaxation [13,14].

Antimalarials, such as hydroxychloroquine, were first formally used as a treatment for cutaneous lupus in 1894. Following the observation in the 1940s that they had improved rheumatoid arthritis, they became a popular therapy in rheumatic diseases [15]. However, research has only recently unraveled some of the mechanisms of hydroxychloroquine's therapeutic effect, as observed by Wallace et al. 2012 [16]. Hydroxychloroquine is classified as C under the U.S. Food and Drug Administration pregnancy category because it crosses the placenta but has not been reported to cause any teratogenic effects to the fetus [17,18]. It has both anti-inflammatory and immunomodulatory properties [19–21], and is widely used in autoimmune disorders such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), and Sjogren's syndrome. The exact mechanisms by which hydroxychloroquine improves the activity of these disorders are still not fully understood. However, in women with SLE, it has been shown to decrease circulating levels of pro-inflammatory cytokines IL-6, IL-8, and TNF-α [22], as well as IL-17 and IL-22, which are cytokines produced by helper T cells [23]. Recently, in a female mouse model of SLE, it was reported that hydroxychloroquine decreased endothelial oxidative stress by reducing Nicotinanamide adenine dinucleotide phosphate (NADPH) oxidase activity, which led to improved endothelial function, lower blood pressure, and a reduction in proteinuria [24].

In preeclampsia, NADPH oxidase-dependent oxidative stress is one of the pathways underlying the maternal endothelial dysfunction [12]. Accordingly, we hypothesize that hydroxychloroquine may confer beneficial effects in women diagnosed with preeclampsia by reducing placental production of potentially deleterious mediators, thus improving the overall maternal endothelial homeostasis.


**4. Why grasslands development needed?**

Grasslands development occupies a pivotal position keeping in view the fact that these are located in regions wherein their rainfall is insufficient to effectively support the growth of trees to form a rain trees forest, but not so scarce to form a desert. Thus, it may be inferred that grasslands often serve as a transition zone between deserts and forests. These serve as one of the prime ecosystems and cover over one-third of the terrestrial surface worldwide. Extensively managed grasslands have emerged as one of the most secure habitats to ensure plant biodiversity. The need for their development even becomes more important as grasslands in conjunction with different rangelands contribute significantly to boost livestock productivity through the provision of cost-effective and nutritious forage abundantly and that too throughout the year owing to grasses diversity containing perennial grass species. Another aspect emphasizes the pertinence of grasslands development as

#### *Introductory Chapter: Grasslands Development - Green Ecological Economy and Ecosystem… DOI: http://dx.doi.org/10.5772/intechopen.105345*

grasslands (both natural and semi-natural grasslands) play a vital role in the provision of life-sustaining livelihood to people by providing animal feed. Developing grasslands has become mandatory, keeping in view the rapidly increasing supply needs for animal products owing to skyrocketing human population. In addition, gradually hiking consumption patterns and demand for livestock products (milk, meat, wool, etc.) on per capita basis has made it necessary to increase the conversion of natural grasslands into improved grasslands. It should be kept in mind that competition and land-use patterns are predicted to multiply considerably by 2050, which may be accentuated by the recent scenario of climate change. This scenario increased the intense focus on sustainable food production for ensuring food security through alteration of agricultural sciences research approaches and policymaking at state, regional, and global levels. Grasslands development can be achieved by putting into use the sustainable intensification concept, in terms of increasing the productivity of grasslands in order to supplement the production potential of croplands. However, up till now, the role of improved grasslands through biologically viable improvement and development has been direly neglected and thus compromising the food security of many tropical grassland regions of Africa and Asia [11–14].

The developed grasslands might be of unprecedented pertinence due to having very high conservation value and the potential to support sustainable food production. The co-development of grasslands adjacent with various types of rangelands, including shrubland and savannas can contribute significantly in ensuring the survival and food security of the surrounding population. Grassland development has to be initiated by keeping in view their local importance in terms of ensuring and maintaining the species biodiversity as well as food production. In addition, these also influence a variety of ecological processes at the local landscape (pollination), regional level (water regulation and recreation activities), and global scales (climate regulation) which necessitate their development in an integrated manner without disruption of prevalent ecosystems. Grasslands provide feed base to grazing livestock for producing high-quality food products, and in return get organic manures, a source of pollination and planting material transportation through natural means along with the provision of leather for human utilization for various purposes. In addition, grassland development can potentially provide vital services and roles such as water catchments, reserves of biodiversity, and fulfilling cultural as well as recreational needs. More importantly, grassland development has the potential to increase their capacity to serve as a carbon sink for alleviating the emissions of greenhouse gases which have contributed heavily to global warming and climate change. Inevitably, grasslands development might invoke plenty of challenges, but those have to be confronted and tackled through target-oriented and collaborative research and policymaking in a coherent manner.


**1. Introduction**

Cervix uteri is a metabolic active organ, a "gate keeper" in normal pregnancy, an early information prime source about spontaneous preterm birth (sPTB) risks [1], besides other two pathological conditions – preterm/premature membrane rupture (PROM), preterm contractions with which cervical insufficiency/incompetence interlinks in the "Preterm Labor Syndrome" [2], which replaced an earlier five ways acting in cascade/separately: uterine cervical support structures compromise acting alone/associated to the myometrial and membranes over-distension, to decidual hemorrhage, to intrauterine infection/inflammation or to precocious endocrine fetal activation (from maternal or fetal stress) [3]. Vink and Feltovich [4] proposed a new paradigm/concept that sPTB three essential elements (cervical remodeling, myometrium activation-preterm labor, decidua-preterm membrane rupture/hemorrhage) are inextricably intertwined, all lead to each other. These factors are considered as a possible "phenotype" for sPTB [4, 5], such as those that start with premature activation of fetal membranes leading to PROM vs. myometrium premature activation leading to preterm labor vs. premature cervical remodeling leading to cervical failure, but 25% of sPTB are not associated to any phenotype [5].

Prematurity rate has not declined over the past 40 years, or a small decline was followed by a new increase, and despite significant medical and management strategies advances, it has a continuous slow rise, with high offspring morbidity and mortality, affecting 14.8 million babies annually worldwide [6]. Management with actual opportunities of assessment and medical/surgical procedures—elective, urgent, and/ or emergency, consuming a substantial portion of the health budget [7, 8] is the aim of modern obstetrics/perinatal medicine societies, being imperative to improve medical understanding of normal/abnormal reproductive tissue structure and function, and how these tissues interact at cellular and biochemical level, and to act accordingly. This chapter focuses on cervix uteri involvement for sPTB prediction and prevention/ delay through cervical abnormal remodeling identification by non-invasive novel approach imaging techniques.


**2. Methodology**

The scientific approach in the development of the TMSMM (refer to Figure 1), resembles the procedure suggested in [17]. This procedure takes into account the iterative nature of the maturity model development process, as well as the need to combine theoretical and empirical research as recommended by other respected scholars of maturity models [6, 9, 18, 19].

researchers from the literature, was used to revise key design features, as well as the maturity

The Telemedicine Service Maturity Model: A Framework for the…

http://dx.doi.org/10.5772/56116

221

Upon finalization of the conceptual model, a top-down approach was followed to develop the descriptive model [6]: An overarching maturity scale was defined, after which domain-specific maturity scales were developed in alignment with these. A first iteration of TMSMM descrip‐ tors was defined, using as inputs firstly, the insights gained in the development of the conceptual model and secondly, frameworks and theories for the management and evaluation

The conceptual TMSMM is shown in Figure 2, which also provides a framework for the

of telemedicine services. The descriptors were refined, based on stakeholder input.

**3. The Telemedicine Service Maturity Model (TMSMM)**

model itself [21-23].

remainder of this chapter.

**Figure 2.** Conceptual model of the TMSMM

**Figure 1.** Scientific approach to the development of the TMSMM

The conceptual telemedicine service maturity model (TMSMM) was developed by following an iterative process involving telemedicine practitioners from five different South African provincial departments of health (DoH). The involvement of these stakeholders in the process, ensured the contribution of their domain knowledge for solution creation and in turn, contributed to the validity of the model. As a consequence, greater user acceptance was achieved [20].

Between June 2011 and December 2011, a series of workshops was held throughout South Africa. Representatives included healthcare workers (e.g. specialists, radiologists, radiogra‐ phers and nurses), as well as persons responsible for the development, implementation and maintenance of hospital information and communication technology (ICT).

The first day of these workshops was aimed at educating representatives about current stateof-the-art telemedicine. The second day of each workshop was an interactive session in which groups of delegates engaged with the maturity model. At the end of each session, workshop delegates were asked to reflect upon and provide feedback on the effectiveness of the maturity model in terms of its characteristics. This feedback, together with the thoughts of other researchers from the literature, was used to revise key design features, as well as the maturity model itself [21-23].

Upon finalization of the conceptual model, a top-down approach was followed to develop the descriptive model [6]: An overarching maturity scale was defined, after which domain-specific maturity scales were developed in alignment with these. A first iteration of TMSMM descrip‐ tors was defined, using as inputs firstly, the insights gained in the development of the conceptual model and secondly, frameworks and theories for the management and evaluation of telemedicine services. The descriptors were refined, based on stakeholder input.


**Author details**

Jailson Fulgencio de Moura and Salvatore Siciliano *National School of Public Health - ENSP; Oswaldo Cruz Foundation – FIOCRUZ, Brazil*

Emily Moraes Roges, Roberta Laine de Souza and Dalia dos Prazeres Rodrigues *National Reference Laboratory for Bacterial Enteroinfections – LRNEB; Oswaldo Cruz Institute – IOC; Oswaldo Cruz Foundation – FIOCRUZ, Brazil*


*Edited by Bernardo Llamas Moya and Juan Pous*

Sustainability should be a key component of every process, safeguarding resources and reserves for future generations. This book shows how a responsible use of resources is possible, offering valid technological alternatives to fight climate change. We offer current technologies and valid methods for a wide range of activities: teaching, investigation, work, business and even daily life. We encourage all our readers to join us and become part of the solution to climate change, rather than the problem. After reading this book, we are certain that you will find justified reasons to start your own personal and social awareness campaign in favour of these effective technologies against climate change.

ISBN 978-953-51-2273-9

Greenhouse Gases

Photo by curraheeshutter / iStock


**10. Case study successful implementation**

#### **10.1 Case study: successful integration of sustainable practices in a cotton chain**

The textile and clothing (T&C) business plays a crucial role in people's daily lives, and the products it produces are regarded as the second-most important thing that people desire. The sector has grown significantly and achieved great success over the past few decades, making it one of the most significant but also most polluting worldwide industries [80]. Significant environmental and social effects are caused by its magnitude, diversity of processes, and intricate worldwide production networks. Three natural fibers have been used by humans for at least 5000 years each: flax, wool, and cotton.

Today, 48% of all textiles are made from cotton. Only 27% of cotton is grown in rain-fed conditions globally, with irrigated fields accounting for the majority (73%). According to [81], irrigated cotton has an average output of 845 kg per hectare, and rain-fed cotton has an average yield of 391 kg per hectare. 75% of the total global production of cotton is produced by the six biggest cotton-producing nations (China, USA, India, Pakistan, Uzbekistan, and Turkey). Over the past 40 years, the contemporary cotton business has made substantial environmental progress, but it is not letting up.

Researchers and scientists work to create innovative techniques that will enable cotton to be grown, processed and manufactured more effectively and with less environmental impact. The cotton industry will be able to fulfill the demands for productivity and profit while identifying and implementing innovative technologies and practices without sacrificing the ability of future generations to meet their own needs.

#### **10.2 Collaboration among stakeholders**

Businesses began signing up for these certification programs to expand their market share and take advantage of fresh opportunities and trends. At the same time, these programs give companies the chance to have more control over their supply chains, ensuring safety and quality requirements while lowering manufacturing costs [82]. Positive side effects of certification included improved reputation and confidence among consumers and other stakeholders.

According to Bolwig *et al*. [83], certification schemes and the methods employed to implement them determine the extent to which these desired beneficial results are realized. In order to enhance the environmental and social circumstances of production operations in developing nations, sustainable chain governance systems have emerged as a result of collaboration between various market and non-market players [84].

## **10.3 Training**

Training farmers helps them become more productive, more able to meet the quality standards demanded by international supply chains, and more capable of producing food.


**2. Definition**

Deciding on the role of pregnancy in the development of melanoma is important, as more women are planning a pregnancy from 30 to 40 years, and an increase in the number of melanoma diagnoses during fetal growth is expected [3, 4]. Currently, the term "melanoma associated with pregnancy" is used, implying the inclusion of all clinical observations of the diagnosis of melanoma during pregnancy and in the first 2 years after delivery [5].

### **2.1 Diagnosis prior to pregnancy**

Few studies have addressed the impact on prognosis when melanoma is diagnosed before a woman becomes pregnant, but based upon the available data, there does not appear to be an effect on prognosis. In a large Swedish retrospective cohort study [6], 966 women who had pregnancies after a diagnosis of a primary

**57**

*Melanoma and Pregnancy: Risks, Current, and Forecast DOI: http://dx.doi.org/10.5772/intechopen.86928*

**2.2 Diagnosis during pregnancy**

**2.3 Diagnosis postpartum**

**3. Classification**

frequent dermatology examinations during pregnancy [7].

melanoma were compared with 4567 women who did not become pregnant after diagnosis. After adjustment for Breslow depth, tumor site, Clark level, and age, pregnancy did not significantly affect survival (HR 0.58, 95% CI 0.32–1.05). For patients with a history of melanoma and multiple dysplastic nevi, we suggest more

Most of the multiple small controlled studies and large population-based cohort studies [6] do not show a negative influence of pregnancy on survival [2]. In a review of 10 case-control studies that included 185 women diagnosed with melanoma during pregnancy and 5348 women of the same childbearing age who were diagnosed with melanoma but were not pregnant, pregnancy did not have an impact on survival and did not increase the risk of a second melanoma [8]. The higher the parity and the younger the age of the mother at her first delivery, the lower the risk of melanoma. Thus, the authors concluded that there was no reason for physicians to recommend deferral of subsequent pregnancies in women who have been diagnosed with a stage I melanoma during a previous pregnancy [1]. A controversial study is a single-institution study that compared 41 women diagnosed with PAM with a control group of women of childbearing age who were not pregnant within 1 year of diagnosis [9]. PAM was defined as melanoma diagnosis either during pregnancy or within 1 year after delivery. After adjustment for stage, age, and location, the PAM group showed a five-, seven-, and ninefold increase in mortality, metastasis, and recurrence, respectively, when compared with controls.

Multiple large population-based cohort studies [3, 10] and one small controlled study have generally found no influence on prognosis when melanoma is diagnosed up to 5 years following delivery, except for one study that observed an enhanced risk of death from melanoma in the first year postpartum, which may be due to delayed diagnosis during pregnancy. A large retrospective English study that linked data from a national cancer registry and hospital discharge data evaluated patients diagnosed with melanoma up to 5 years postpartum [10]. There was a significant increased death rate in the first year after delivery (HR 1.92, 95% CI 1.32–2.79) but not in the four subsequent years postpartum. Another study found a lower incidence of melanoma diagnosed during pregnancy than expected compared with the first 6 months postpartum [2]. The spike in melanoma diagnosis and death in the

The eighth edition of the American Joint Committee on Cancer (AJCC) tumor, node, and metastasis (TNM) staging system is based upon an evaluation of the primary tumor, the regional lymph nodes and lymphatic drainage, and the presence or absence of distant metastases. The information from TNM staging is then combined to classify patients into AJCC prognostic stage groups. There are four major growth patterns of melanoma: lentigo maligna, nodular, superficial spreading, and acral lentiginous. In an observational study of close to 120,000 patients with melanoma, nodular melanoma was an independent risk factor for death, after controlling for thickness, ulceration, and stage [11]. Nevertheless, the eighth edition of the American Joint Committee on Cancer tumor, node, and metastasis staging system,

early postpartum period may be caused by a delay in diagnosis.

melanoma were compared with 4567 women who did not become pregnant after diagnosis. After adjustment for Breslow depth, tumor site, Clark level, and age, pregnancy did not significantly affect survival (HR 0.58, 95% CI 0.32–1.05). For patients with a history of melanoma and multiple dysplastic nevi, we suggest more frequent dermatology examinations during pregnancy [7].

## **2.2 Diagnosis during pregnancy**

*Cutaneous Melanoma*

the following:

**2. Definition**

prognosis of women diagnosed with melanoma during pregnancy. Initial concerns about pregnancy's impact on prognosis in women diagnosed with melanoma date back to case reports from the 1950s. These reports suggested that pregnancy might lead to transformation of nevi into melanomas, increase the growth rate of existing melanomas, and cause localized melanomas to metastasize [4]. Subsequently, multiple observations seemed to support the argument that melanoma is a hormonally responsive malignancy: changes in skin pigmentation during pregnancy, detection of hormone receptors on some melanomas using older technology, a higher incidence of melanoma after puberty, and relative immunosuppression during pregnancy. The management of women diagnosed with melanoma during pregnancy is likewise controversial, particularly concerning sentinel lymph node biopsy (SLNB) and decisions about the management of the patient with nodal or metastatic disease [5]. Multiple studies have looked at the relationship between pregnancy and cutaneous melanoma. Factors limiting the interpretation of the literature include

• Many of the case series prior to the 1980s did not account for the most important prognostic factors, such as depth of tumor or stage of disease. Subsequently, there have been a number of small case-control studies and large population-based cohort studies. While the case-control studies have the advantage of including important prognostic factors, the small numbers of patients included are an important limitation. Conversely, the larger cohort

• Some of the larger studies do not distinguish between diagnosis of melanoma during pregnancy and diagnosis during the postpartum period. Such studies refer to these patients as having pregnancy-associated melanoma (PAM). The definition of PAM varies in different studies and ranges from diagnosis during

• There is significant variability in the techniques and quality of the statistical analysis of the data between studies and in the presence of age-matched nonpregnant control groups, as well as a lack of consideration of important confounding factors, including but not limited to age, anatomic site of lesion, sun exposure or season at time of diagnosis, depth of the melanoma, the absence or presence of

Deciding on the role of pregnancy in the development of melanoma is important, as more women are planning a pregnancy from 30 to 40 years, and an increase in the number of melanoma diagnoses during fetal growth is expected [3, 4]. Currently, the term "melanoma associated with pregnancy" is used, implying the inclusion of all clinical observations of the diagnosis of melanoma during preg-

Few studies have addressed the impact on prognosis when melanoma is diagnosed before a woman becomes pregnant, but based upon the available data, there does not appear to be an effect on prognosis. In a large Swedish retrospective cohort study [6], 966 women who had pregnancies after a diagnosis of a primary

[2].

ulceration, and the presence as well as number of mitoses per mm2

studies lack complete data on staging and Breslow depth.

pregnancy to diagnosis up to 5 years after delivery [6].

nancy and in the first 2 years after delivery [5].

**2.1 Diagnosis prior to pregnancy**

**56**

Most of the multiple small controlled studies and large population-based cohort studies [6] do not show a negative influence of pregnancy on survival [2]. In a review of 10 case-control studies that included 185 women diagnosed with melanoma during pregnancy and 5348 women of the same childbearing age who were diagnosed with melanoma but were not pregnant, pregnancy did not have an impact on survival and did not increase the risk of a second melanoma [8]. The higher the parity and the younger the age of the mother at her first delivery, the lower the risk of melanoma. Thus, the authors concluded that there was no reason for physicians to recommend deferral of subsequent pregnancies in women who have been diagnosed with a stage I melanoma during a previous pregnancy [1]. A controversial study is a single-institution study that compared 41 women diagnosed with PAM with a control group of women of childbearing age who were not pregnant within 1 year of diagnosis [9]. PAM was defined as melanoma diagnosis either during pregnancy or within 1 year after delivery. After adjustment for stage, age, and location, the PAM group showed a five-, seven-, and ninefold increase in mortality, metastasis, and recurrence, respectively, when compared with controls.

### **2.3 Diagnosis postpartum**

Multiple large population-based cohort studies [3, 10] and one small controlled study have generally found no influence on prognosis when melanoma is diagnosed up to 5 years following delivery, except for one study that observed an enhanced risk of death from melanoma in the first year postpartum, which may be due to delayed diagnosis during pregnancy. A large retrospective English study that linked data from a national cancer registry and hospital discharge data evaluated patients diagnosed with melanoma up to 5 years postpartum [10]. There was a significant increased death rate in the first year after delivery (HR 1.92, 95% CI 1.32–2.79) but not in the four subsequent years postpartum. Another study found a lower incidence of melanoma diagnosed during pregnancy than expected compared with the first 6 months postpartum [2]. The spike in melanoma diagnosis and death in the early postpartum period may be caused by a delay in diagnosis.


**1. Introduction**

The World Health Organization (WHO) made it a human right for everybody to have access to emergency care and it is an ethical obligation for governments to provide this service for the whole population [1]. It is an instinct for human beings to search better living place for themselves and family. There are several criteria to consider regarding the suitability of a place or city to live in. One important indicator is quality of life in general and an essential part of it is accessibility to high quality healthcare services. Part of quality assessment of healthcare in modern medicine is the time factor and easy access to healthcare services especially in emergency situations, such as serious traumatic injuries, myocardial infarction, stroke, infection …etc. Putting such system in place relies on an infrastructure which encompasses the provision to the general public of an emergency services contact number managed by a call center. The emergency medical dispatchers answering the calls should ideally have oversight of the status and location of the response vehicles around the caller so they can send the required help in the shortest amount of time as possible [2]. The expectation of the caller is to then be attended to by a team of well-trained professionals

coming in a vehicle equipped to deal with a wide range of medical emergencies. If transportation of the patient is needed, the next requirement is to have local and appropriately resourced facilities that can provide emergency and potentially definitive care. There are many factors to account for, a multitude of potential stakeholders, and several health delivery system models to consider for the provision of emergency care. This chapter will discuss access to emergency care and relate to our experience of working in the State of Qatar, a country which has been developing very fast since the beginning of the 21st century across several sectors, including healthcare [3].


**4. Therapeutic modalities in treating pathogenic angiogenesis in AD**

Angiogenesis, as stated by the studies mentioned in this chapter, can be viewed as that stage in AD pathology where all the different pathways (hypoperfusion, BBB dysfunction, inflam‐ mation) merge, leading to the AD pathology. Observations showing increased cerebrovascular permeability prior to the appearance of the hallmarks of AD, sprout a novel paradigm for integrating vascular remodelling (angiogenesis) with the pathophysiology of the disease. Targeting this integral step in the pathophysiology of AD and developing a novel therapeutic intervention using anti‐angiogenic drugs can help to alleviate the global societal burden of AD.

## **4.1. Anti‐angiogenics: small molecule tyrosine kinase inhibitors**

Anti‐angiogenics, including small molecule tyrosine kinase inhibitors have been tested and approved as anti‐cancer therapeutics and have shown to maintain normal vascular [75–77]. Sunitinib is a broad spectrum tyrosine kinase inhibitor. This is known to inhibit the phosphor‐ ylation of multiple receptor tyrosine kinases and is a potent inhibitor of VEGF as well as platelet‐derived growth factor (PDGF‐β). Currently, it is in use for gastrointestinal stromal tumours, renal cell cancer and pancreatic cancer. Sunitinib was shown to decrease the amyloid burden and reverse cognitive decline in AD model mice, suggesting that if we target angio‐ genesis, we can revert the increase in the accumulation of Aβ and abate the cognitive decline associated with AD [76].

## **4.2. Biologics and small molecule VEGFR inhibitors**

We now know that VEGF is the prime and central component of pathological blood vessel formation. There are biologics and small molecules that specifically target the ligand or its receptor. This specific‐targeted therapy could prove more efficient and less deleterious due to avoidance of unwanted 'off target' effects. A potential therapeutic is Bexarotene, a retinoid X receptor agonist, is shown to facilitate Aβ clearance via activation of apolipoprotein (APOE) expression and promoting microglial phagocytosis [78]. Bexarotene counteracts VEGF‐ mediated angiogenesis by decreasing blood vessel density and reversing cognitive deficits in AD mice [78].

These are examples of some of the therapeutic routes that could target angiogenesis; however, understanding the molecular mechanism behind angiogenesis causing eventual AD pathology is of utmost importance in order to look for safe and effective novel therapeutics for AD and other vascular diseases.

## **5. Concluding remarks**

As the Western world ages, AD represents an ailment that will place a significant burden on all the aspects of society. This burden, primarily placed on family caregivers, has been estimated to cost billions in lost productivity and healthcare costs (both direct and indirect). Currently, there is a lack of understanding regarding the cause(s) of the disease that translates into a lack of viable treatments or cures. Over the years, limited progress has been made with regards to the clinical translation of the popular amyloid hypothesis for treating AD and hence new thinking towards AD pathogenesis is required. Vascular risk factors and neurovascular dysfunction associated with hypotension, hypertension, cholesterol levels, type II diabetes mellitus, smoking, oxidative stress and iron overload have been found to play integral roles in the pathogenesis of stroke and AD. Observations showing increased cerebrovascular permeability prior to the appearance of the hallmarks of AD, sprout a novel paradigm for integrating vascular remodelling (angiogenesis) with the pathophysiology of the disease. Taking this into account, research focused on understanding the molecular mechanism behind the pathophysiology of angiogenesis leading to AD pathology will mediate in developing novel therapeutic interventions targeting this pathological blood vessel formation help to alleviate the global societal burden of AD.


*2.3. SMZ Degradation*

One batch experiment was first conducted with a fixed amount of SMZ (5 μM) with GO ranging from 10 mg/L to 50 mg/L. Dark control experiments were also conducted under the same conditions. To investigate the effects of solution chemistry factors on the photochemical transformation, another three sets of experiments were also performed with 5 μM SMZ and 30 mg/L GO. The pH effect experiments were conducted with the solution pH ranging from 3.0 to 9.0, which was adjusted with 0.1 M HCl or NaOH. Ionic strength and species effect experiments were performed in the presence of 0–600 mM NaCl or 0–30 mM Na2SO4. In addition, the photochemical transformation of SMZ was tested in the presence of humic acid (HA) in the range of 0–10 mg/L. All the above experiments were performed in triplicate. During the experiments, 3 mL of solution was sampled at determined time intervals and filtered with 0.22 μm nylon membranes to remove GO. Then, SMZ was analyzed at a determination wavelength of 270 nm by high-performance liquid chromatography (HPLC, Shimadzu LC-20AT, Tokyo, Japan) with a UV detector using a C18 column (25 cm × 4.6 mm, 5 μm). The mobile phase was acetonitrile/0.05 M acetic acid (30:70, *v:v*) with a flow rate of 1 mL/min. The injection volume was 10 μL, and the column temperature was maintained at 40 ◦C.


*Boolean Chaos Robust to Distinct Discrete Physical Implementation*

This subsection presents three different physical implementations of the Boolean chaos oscillators. The dynamics are affected by physical constraints and hardware differences. This may lead to time-delay variations where the boolean chaos displays. Therefore, the BCO-1 and BCO-2 are constructed with three different electronic devices (i) commercial-off-the-shelf logic gates (introduced previously), (ii) a GAL, and (iii) an FPGA. The experiments in Figure 3 demonstrate the robust generation of Boolean chaos. From the circuit conception, the implementations show the chaotic behavior source is the degradation effect [32]. In addition, there are no additional procedures to calculate the delay paths to achieve chaotic oscillations.

The implementation considers all cases of Tables 1 and 2, but for the sake of simplicity, the Table 3 displays only the examples where the largest Lyapunov exponent is higher. In particular, case 1 for both BCOs is of particular interest because they do not need extra time-delays for generating chaos. More specifically, we use the GAL22V10 for realizing both BCOs, as given in Figure 3b. The programming of the GAL was performed with VHDL language. Figure 4b,e,h give the experimental results for the cases 1, 3, and 7 of BCO-1; while Figure 5b,e shows the results for cases 1 and 5 of BCO-2. For FPGA implementation, the Spartan 6 was employed (Figure 3c). The experimental

results are shown in Figure 4c,f,i for cases 1, 3, 7 in Table 1, respectively. Figure 5c,f display the output signal for cases 1 and 5 in Table 2, respectively.

The measurements exhibit a 100 ns of time and a 2V of voltage grid per square. For all the three presented implementations, the output voltages (Figures 4 and 5) show the cumbersome temporal oscillations without evident periodicity. This continuous-time evolution can be identified as Boolean chaos. To verify the chaotic behavior, we compute the largest Lyapunov exponent for each implemented case of the corresponding technology, as shown in Figure 6. Table 3 also shows that the Lyapunov exponents for the three physical implementations have a similar value. This behavior suggests the Boolean chaos of proposed BCOs is robust to the distinct physical implementations changing the technology.

**Figure 6.** The divergence ln*d*(*s*) to determine the largest Lyapunov exponent of the attractor for cases in Table 3 from each discrete physical implementation (Logic gates, GAL, FPGA).

It is worth to noting that, although the intrinsic time-delays of the logic XOR and XNOR gates change among the physical realizations, Case-1 for both BCOs continues generating chaotic behavior. In agreement with Lemma 4, the fact that there is Boolean chaos, for various implementations without extra time-delays in the feedback links, demonstrates that the proposed BCOs are not overly sensitive to heterogeneous intrinsic time-delays.


**2. Single Detoxification Treatments Used in Solid Foods and Feeds**

In this section, we summarize the chemical, physical, and biological treatments applied separately, their effect on the reduction rates of different mycotoxins, and the quality of the treated materials.


**About the Editor**

#### **Diego Copetti**

Diego Copetti is a researcher at the National Research Council of Italy, Water Research Institute (CNR-IRSA), whose research interests mainly include lake ecology. He is interested in how these environments respond to local (e.g., nutrient loads) and global (e.g., climate change) forcings. During his research career, he used both experimental and modelling approaches. He is interested in the water cycle in urban agglomerations as well as the impact that they have on surface aquatic ecosystems. He likes photography and the study of history and philosophy of science.