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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"6444",leadTitle:null,fullTitle:"New Insights into Bayesian Inference",title:"New Insights into Bayesian Inference",subtitle:null,reviewType:"peer-reviewed",abstract:"This book is an introduction to the mathematical analysis of Bayesian decision-making when the state of the problem is unknown but further data about it can be obtained. The objective of such analysis is to determine the optimal decision or solution that is logically consistent with the preferences of the decision-maker, that can be analyzed using numerical utilities or criteria with the probabilities assigned to the possible state of the problem, such that these probabilities are updated by gathering new information.",isbn:"978-1-78923-093-2",printIsbn:"978-1-78923-092-5",pdfIsbn:"978-1-83881-474-8",doi:"10.5772/intechopen.70722",price:119,priceEur:129,priceUsd:155,slug:"new-insights-into-bayesian-inference",numberOfPages:140,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"8a6c48ec7bdf923a126816fdbbb24274",bookSignature:"Mohammad Saber Fallah Nezhad",publishedDate:"May 2nd 2018",coverURL:"https://cdn.intechopen.com/books/images_new/6444.jpg",numberOfDownloads:7824,numberOfWosCitations:2,numberOfCrossrefCitations:3,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:6,numberOfDimensionsCitationsByBook:0,hasAltmetrics:0,numberOfTotalCitations:11,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"December 5th 2016",dateEndSecondStepPublish:"December 19th 2016",dateEndThirdStepPublish:"October 9th 2017",dateEndFourthStepPublish:"November 6th 2017",dateEndFifthStepPublish:"January 8th 2018",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"150393",title:"Dr.",name:"Mohammad Saber Fallah",middleName:null,surname:"Nezhad",slug:"mohammad-saber-fallah-nezhad",fullName:"Mohammad Saber Fallah Nezhad",profilePictureURL:"https://mts.intechopen.com/storage/users/150393/images/system/150393.jpg",biography:"Mohammad Saber Fallah Nezhad is Associate Professor at Yazd University, Iran. He received his B.S., M.S. and Ph.D. degrees, all in Industrial Engineering from Sharif University of Technology, Tehran, Iran. Also he has been a visiting researcher in Karlsruhe University, Germany. He has published more than 60 research papers in national and international journals and is author of five books. Also, he has been awarded a Silver medal in 16th National Mathematics Olympiad in Iran and he has been ranked 1st in the graduate national university comprehensive exam in System Management in Iran. He has been ranked 47th among all high school graduates in Iran. His areas of interest include: reliability, quality control, quality engineering and operations research.",institutionString:"Yazd University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"Yazd University",institutionURL:null,country:{name:"Iran"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"163",title:"Applied Mathematics",slug:"applied-mathematics"}],chapters:[{id:"59747",title:"Introductory Chapter: Bayesian Thinking",doi:"10.5772/intechopen.75053",slug:"introductory-chapter-bayesian-thinking",totalDownloads:1061,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:null,signatures:"Mohammad Saber Fallah Nezhad",downloadPdfUrl:"/chapter/pdf-download/59747",previewPdfUrl:"/chapter/pdf-preview/59747",authors:[{id:"150393",title:"Dr.",name:"Mohammad Saber Fallah",surname:"Nezhad",slug:"mohammad-saber-fallah-nezhad",fullName:"Mohammad Saber Fallah Nezhad"}],corrections:null},{id:"58830",title:"Bayesian Modeling Approaches for Temporal Dynamics in RNA-seq Data",doi:"10.5772/intechopen.73062",slug:"bayesian-modeling-approaches-for-temporal-dynamics-in-rna-seq-data",totalDownloads:1085,totalCrossrefCites:1,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Analysis of differential expression has been a central role to address the variety of biological questions in the manner to characterize abnormal patterns of cellular and molecular functions for last decades. To date, identification of differentially expressed genes and isoforms has been more intensively focused on temporal dynamics over a series of time points. Bayesian strategies have been successfully employed to uncover the complexity of biological interest with the methodological and analytical perspectives for the various platforms of high-throughput data, for instance, methods in differential expression analysis and network modules in transcriptome data, peak-callers in ChipSeq data, target prediction in microRNA data and meta-methods between different platforms. In this chapter, we will discuss how our methodological works based on Bayesian models address important questions to arise in the architecture of temporal dynamics in RNA-seq data.",signatures:"Sunghee Oh and Seongho Song",downloadPdfUrl:"/chapter/pdf-download/58830",previewPdfUrl:"/chapter/pdf-preview/58830",authors:[{id:"219334",title:"Dr.",name:"Sunghee",surname:"Oh",slug:"sunghee-oh",fullName:"Sunghee Oh"},{id:"220707",title:"Dr.",name:"Seongho",surname:"Song",slug:"seongho-song",fullName:"Seongho Song"}],corrections:null},{id:"58443",title:"Bayesian Analysis for Hidden Markov Factor Analysis Models",doi:"10.5772/intechopen.72837",slug:"bayesian-analysis-for-hidden-markov-factor-analysis-models",totalDownloads:1146,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The purpose of this chapter is to provide an introduction to Bayesian approach within a general framework and develop a Bayesian procedure for analyzing multivariate longitudinal data within the hidden Markov factor analysis framework.",signatures:"Yemao Xia, Xiaoqian Zeng and Niansheng Tang",downloadPdfUrl:"/chapter/pdf-download/58443",previewPdfUrl:"/chapter/pdf-preview/58443",authors:[{id:"219552",title:"Dr.",name:"Yemao",surname:"Xia",slug:"yemao-xia",fullName:"Yemao Xia"},{id:"221831",title:"Prof.",name:"Niansheng",surname:"Tang",slug:"niansheng-tang",fullName:"Niansheng Tang"}],corrections:null},{id:"59889",title:"Dynamic Process Model Parameter Estimation by Global System Analysis",doi:"10.5772/intechopen.74635",slug:"dynamic-process-model-parameter-estimation-by-global-system-analysis",totalDownloads:1394,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Global system analysis (GSA) was applied to parameter estimation of dynamic process models. First, the posterior distribution of the model parameters was estimated by quasi-Monte Carlo (QMC) simulations or uncertainty analysis. The expected variance of the estimated parameters by GSA was in general smaller than those were obtained by local search for the maximum likelihood. Second, sensitivity analysis was performed as an alternative application of GSA for the same mathematical models and testing data. The total effect index should serve as a quantitative measure of the robustness of each estimated parameter. Two process models were studied to demonstrate effectiveness of the proposed methodology based on GSA: a bio-reactor and a catalytic reactor. Parallelised computation allowed for sampling as many as 500,000 combinations of the model parameters in reasonable amount of time.",signatures:"Shigeru Kashiwaya",downloadPdfUrl:"/chapter/pdf-download/59889",previewPdfUrl:"/chapter/pdf-preview/59889",authors:[{id:"219664",title:"Mr.",name:"Shigeru",surname:"Kashiwaya",slug:"shigeru-kashiwaya",fullName:"Shigeru Kashiwaya"}],corrections:null},{id:"58908",title:"Preventing Disparities: Bayesian and Frequentist Methods for Assessing Fairness in Machine-Learning Decision-Support Models",doi:"10.5772/intechopen.73176",slug:"preventing-disparities-bayesian-and-frequentist-methods-for-assessing-fairness-in-machine-learning-d",totalDownloads:1134,totalCrossrefCites:2,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Machine-learning (ML) methods are finding increasing application to guide human decision-making in many fields. Such guidance can have important consequences, including treatments and outcomes in health care. Recently, growing attention has focused on the potential that machine-learning might automatically learn unjust or discriminatory, but unrecognized or undisclosed, patterns that are manifested in available observational data and the human processes that gave rise to them, and thereby inadvertently perpetuating and propagating injustices that are embodied in the historical data. We applied two frequentist methods that have long been utilized in the courts and elsewhere for the purpose of ascertaining fairness (Cochran-Mantel-Haenszel test and beta regression) and one Bayesian method (Bayesian Model Averaging). These methods revealed that our ML model for guiding physicians’ prescribing discharge beta-blocker medication for post-coronary artery bypass patients do not manifest significant untoward race-associated disparity. The methods also showed that our ML model for directing repeat performance of MRI imaging in children with medulloblastoma did manifest racial disparities that are likely associated with ethnic differences in informed consent and desire for information in the context of serious malignancies. The relevance of these methods to ascertaining and assuring fairness in other ML-based decision-support model-development and -curation contexts is discussed.",signatures:"Douglas S. McNair",downloadPdfUrl:"/chapter/pdf-download/58908",previewPdfUrl:"/chapter/pdf-preview/58908",authors:[{id:"219757",title:"Dr.",name:"Douglas",surname:"McNair",slug:"douglas-mcnair",fullName:"Douglas McNair"}],corrections:null},{id:"60456",title:"Using Bayesian Inference to Investigate the Influence of Environmental Factors on a Phytoplasma Disease",doi:"10.5772/intechopen.74637",slug:"using-bayesian-inference-to-investigate-the-influence-of-environmental-factors-on-a-phytoplasma-dise",totalDownloads:1027,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Phytoplasma diseases cause major economic damage on crops worldwide. To draw inferences from such a system, joint estimation of dependencies and high flexibility in the model structure are required. Using Bayesian inference, the aim of this chapter was to infer the apple proliferation (AP) disease epidemiology in South Tyrol, Italy. The data consisted of (1) presence/absence of the AP vector Cacopsylla picta collected in 44 orchards in 2014; (2) prevalence of the AP pathogen “Candidatus Phytoplasma mali” in the vector population; and (3) AP symptomatic trees visually assessed in 2015. Generalized linear mixed models evaluated in a Bayesian framework were used to test species-environment relationships. The model results indicated that the occurrence of the AP vector and symptomatic plants are positively influenced by elevation and temperature and negatively by management. Vector and pathogen predictions in the disease symptoms model correlated negatively or not at all with the prevalence of AP symptoms occurrence. In conclusion, the model results suggest that the presence/absence of the AP vector alone may not be the only cause for disease occurrence. Considering factors such as phytoplasma transmission via root-bridges and specific management strategies, may help to improve inference and finally to optimize the existing pest management.",signatures:"Bernd Panassiti",downloadPdfUrl:"/chapter/pdf-download/60456",previewPdfUrl:"/chapter/pdf-preview/60456",authors:[{id:"222892",title:"Dr.",name:"Bernd",surname:"Panassiti",slug:"bernd-panassiti",fullName:"Bernd Panassiti"}],corrections:null},{id:"60169",title:"A Bayesian Hau-Kashyap Approach for Hepatitis Disease Detection",doi:"10.5772/intechopen.74638",slug:"a-bayesian-hau-kashyap-approach-for-hepatitis-disease-detection",totalDownloads:978,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"World Health Organization reported that viral hepatitis affects 400 million people globally. Every year, 610 million people are newly infected. In this research, we integrate a Bayesian theory and Hau-Kashyap approach for detecting hepatitis and displaying the result of calculation process. The basic idea of the Bayesian theory is using the known prior probability and conditional probability density parameter based on the Bayes theorem to calculate the corresponding posterior probability and then obtain the posterior probability to infer and make decisions. Bayesian methods combine present knowledge, prior probabilities, with additional knowledge derived from new data, the likelihood function. Hau-Kashyap presented an alternative Dempster-Shafer combination rule, and the alternative combination rule is that with the use of this alternative rule, the intersection conflict is put into the union. In this chapter, we get basic possibility assignment value from Bayesian probability. 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\r\n\tUpdates in Volcanology - Linking active volcanism and the geological record is a new venture to call contributions in the broad field of volcano science to showcase the recent achievement in understanding volcanic processes from the source to surface perspective. This book is particularly open to contributions that aim to present new research results that link modern volcanism to volcanic successions preserved in the geological record. Modern and active volcanoes operate through very diverse geological processes directly and can be observed and recorded. The eruptive products as a result of these complex geological phenomena ultimately accumulate in pyroclastic successions that preserve key information on the process that created them. However, over time and through diagenetic processes this information became more and more hidden and/or difficult to link to the primarily volcanic processes that created them. In this book, we welcome contributions intended to unlock this issue from various time and spatial scales. In recent years we experienced a large number of various volcanic eruptions, many of them leaving behind tephra deposits quickly vanishing. These examples potentially demonstrate well the need to identify useful proxies volcano geology can use and associate with real volcanic phenomena. As these recent volcanic eruptions also showed the need for updated volcano monitoring techniques that can be deployed and the gathered data utilized in near-real-time predictions of the course of the volcanic events. We also learned that the significant interest from global and local communities in volcanic eruptions can trigger valuable citizen science activity as well as provide a push to develop workable geoconservation strategies in volcanic terrains in concert with understanding the volcanic geodiversity and geoeducation aspects commonly provide the base of geopark establishments.
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Andreev",coverURL:"https://cdn.intechopen.com/books/images_new/1476.jpg",editedByType:"Edited by",editors:[{id:"62570",title:"Prof.",name:"Anatoly",surname:"Andreev",slug:"anatoly-andreev",fullName:"Anatoly Andreev"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},onlineFirst:{chapter:{type:"chapter",id:"73292",title:"Clinical Applications of Strain Imaging in Aortic Valve Disease",doi:"10.5772/intechopen.93341",slug:"clinical-applications-of-strain-imaging-in-aortic-valve-disease",body:'As the population grows older, the prevalence of aortic valve disease, particularly aortic stenosis, is swelling, making it currently, the most prevalent form of valvular heart disease [1, 2, 3]. Surgery and percutaneous interventions of the aortic valve are frequently needed in patients with severe symptomatic aortic valve disease, the timing for these procedures’ conditional on a comprehensive evaluation of the dysfunctional aortic valve and the resultant repercussions on the rest of the heart, particularly the left ventricle (LV). Parameters used to predict favorable/unfavorable results from aortic valve surgery or intervention include LV ejection fraction (EF), presence and severity of left ventricular hypertrophy (LVH), LV end-systolic volume (LVESV), degree of leaflet calcification, and trans-aortic valve gradients. Because of the LV deformation indices potential to detect subclinical LV dysfunction, they are being used with increasing frequency in the management of patients with aortic valve disease [4] and advancing the timing for aortic valve surgery or intervention, before the LV is irreversibly damaged.
Our objective with this chapter is to describe the use of strain imaging, particularly global longitudinal strain in the assessment of cardiac function in patients with aortic valve disease. We review the current clinical applications of strain analysis in patients with aortic valve disease, highlighting strengths and weaknesses and emphasizing normal and abnormal findings in aortic stenosis (AS) aortic regurgitation (AR) and mixed aortic valve disease (ASAR); we summarize unresolved issues, potential future research priorities, and recommended indications for incorporating this technique into the clinical practice of patients with aortic valve disease.
Strain is defined as the fractional change in length of a myocardial segment relative to its baseline length, it is expressed as a percentage. Strain rate is the temporal derivative of strain, providing information on the speed at which the deformation occurs. Echocardiography, because of its dynamic nature, is ideally suited for the evaluation of cardiac mechanics through the application of deformation indices [5, 6]. Two echocardiographic techniques have dominated the clinical and research arena of deformation echocardiography: (1) tissue Doppler imaging, and (2) speckle tracking imaging. Both techniques lend to the derivation of multiple parameters of myocardial function. Tissue Doppler Imaging (TDI) was the first method used to measure myocardial deformation by echocardiography. The method is well validated and has been shown to provide valuable data in a wide range of conditions. Tissue Doppler is currently used mainly for evaluation of diastolic LV function, its use in aortic valve disease will not be discussed in this chapter. Speckle tracking, mainly through the use of global longitudinal strain (GLS), is increasingly used to identify subclinical myocardial dysfunction in patients with valvular heart disease and to identify optimal timing for surgery or intervention and prognosticate outcomes after surgery/intervention, and is the main focus of this review.
Aortic stenosis inflicts progressive pressure overload on the LV with compensatory concentric hypertrophy (Figure 1). Initially, the increased wall thickness and conservation of normal LV chamber dimensions offsets the increased LV pressure, maintaining a normal ejection fraction. If the aortic stenosis is not corrected it will inexorably lead to reduced myocardial perfusion, and eventual fibrosis with consequent drop in ejection fraction. It is well recognized that LV GLS is superior to LVEF in detecting perturbations in myocardial function. Compared with normal controls, severe aortic stenosis patients have impaired strain in all three layers of the LV myocardium. LV strain analysis in aortic stenosis has been evaluated in different settings as noted in the following sections.
Severe aortic stenosis: global longitudinal strain (GLS) in a patient with severe aortic stenosis with an aortic valve area (AVA) of 1.1 cm2 maximal velocity (AV V2) of 3.9 m/s and a mean gradient of 48 mm Hg. Left ventricular end-diastolic and end-systolic volumes (EDV, ESV) are normal as well as the LV ejection fraction (EF). The GLS is normal at −20% indicating absence of any LV dysfunction.
Measuring LV ejection fraction is crucial in the management of patients with asymptomatic severe aortic stenosis (AS). According to the current American Heart Association/American College of Cardiology and European Society of Cardiology guidelines there is a Class I indication (Level of Evidence: B) to perform aortic valve intervention in asymptomatic patients with severe AS when the LVEF becomes <50% [7, 8]. Predictors of poor outcome in aortic stenosis include advanced age, significant leaflet calcification, rapid disease progression and decreased left ventricular (LV) ejection fraction (EF). Patients can develop impaired LVEF due to afterload mismatch or from true depression of myocardial contractility due to myocardial fibrosis. Myocardial fibrosis occurs early in the natural history of aortic stenosis, affecting diastolic and systolic function and offering a substrate for ventricular arrhythmias, playing a role in the progression to heart failure and sudden cardiac death. These observations indicate that current echocardiographic assessment of LV function by measuring only the LVEF is insufficient and that new parameters detecting subtle myocardial impairment are needed to improve risk stratification and predict outcomes in patients with AS.
Several studies have defined the added value of global longitudinal strain over LVEF to characterize and prognosticate the clinical evolution of patients with aortic stenosis:
There is growing evidence suggesting the prognostic role of global longitudinal strain (GLS), in asymptomatic patients with AS. The American Society of Echocardiography (ASE) on cardiac chamber quantification acknowledged the incremental value of LV GLS over traditional LVEF measurements, and recommended its clinical use in patients [9].
Conventional measures of LVEF can be preserved until end-stage disease due to the compensatory development of concentric hypertrophy, and thus lacks accuracy in identifying subtle changes in myocardial contractility [2].
Subclinical myocardial dysfunction with impaired LV GLS is frequently seen in patients with severe AS with preserved LVEF and no symptoms. Left ventricular global longitudinal strain deteriorates over time and impaired LV GLS at baseline is associated with an increased risk for progression to the symptomatic stage and the need for aortic valve surgery or intervention [10].
A relationship between aortic stenosis severity and alterations in LV deformation indices has been demonstrated in the following studies:
Strain and strain rate parameters relate to LV function and aortic stenosis severity. Further, they appear to be superior to tissue velocity and conventional echocardiography in detecting subtle changes in myocardial function after AVR before LV mass and LV function show improvement [11].
Despite unchanged LVEF, GLS gradually decreased as severity of AS increases. GLS measured by 2D-speckle tracking imaging might be useful to assess subtle changes in LV function in AS patients [12].
LV strain analysis has been demonstrated to provide prognostic information in patients with aortic stenosis:
A recent met analysis, including 1067 asymptomatic patients, with AS and preserved LVEF, showed that LVGLS is strongly associated with mortality, with >2.5-fold increase in risk of death in patients with impaired LVGLS (−14.7% or less) [13].
GLS detects subclinical dysfunction and has incremental prognostic value over traditional risk markers including hemodynamic severity, symptom class, and LVEF in patients with AS. Incorporation of GLS into risk models can improve the identification of the optimal timing for AV replacement [14].
Kusunose et al. [15] demonstrated on 395 patients that Longitudinal strain (LS) is independently associated with death in patients with AS and preserved LVEF, in addition they made the point that the flow/gradient pattern should also be considered as an important parameter. In the management of AS patients the use apical 4 chamber LS should be considered a new parameter of evaluation of LV function and prognosis [16].
LV GLS is independently associated with all-cause mortality in AS patients. It can further risk stratify severe AS patients and may influence the optimal timing of aortic valve replacement [2].
GLS is an independent predictor of all-cause mortality in severe AS, irrespective of their type of treatment. GLS <9.7% indicates a significantly higher 1- and 5-year mortality in non-AVR patients. Therefore, GLS should be regularly assessed for enhanced risk stratification and clinical decision-making [17].
In normal LVEF patients with significant aortic stenosis, brain natriuretic peptide (BNP) and LV-GLS provide incremental prognostic information over established predictors, suggesting that both play a synergistic role in defining outcomes [18].
A drop in LVGLS in bicuspid aortic valve (BAV) with preserved LVEF is not infrequent and was independently associated with increased risk of events (mainly aortic valve replacement events), as found by Kong et al. [19] in 513 patients (68% men; mean age 44 ± 18 years) with BAV and preserved LVEF (>50%).
Subclinical coronary artery disease is common in moderate and severe aortic stenosis, and should be suspected when regional longitudinal dysfunction is predominant in the apical and mid ventricular segments [20].
Sublayer strain analysis may add additional information in the characterization of LV function in patients with aortic stenosis. The following studies address this issue:
In severe AS, longitudinal strain impairment affects all three myocardial layers but is more noticeable in the endocardial layer. This becomes more manifest in the advanced phases of the disease when symptoms appear [21].
Bilayer strain ratio (subendocardial and subepicardial) can reliably differentiate patients with varying degrees of AS severity and is a sensitive marker of LV function. These findings suggest that the evaluation of subendocardial and subepicardial radial strain might be a novel method for assessing LV mechanics in patients with AS [22].
Medically treated patients with AS have worsening of GLS despite preserved LVEF, first appearing in the subendocardial layer. Global circumferential strain (GCS) becomes progressively impaired in moderate and severe AS. Improvement in LV strain after AVR is seen earlier with GLS than with GCS [23].
There is differential impairment in LV systolic strain in all three cardiac axes in patients with AS. Left ventricular longitudinal strain impairment is proportional to AS severity. Subendocardial longitudinal strain correlates better with AS severity than subepicardial longitudinal strain while correlations between circumferential and radial strain and AS severity are weak [24].
Compared with normal controls, severe aortic stenosis patients have impaired strain in all three layers of the LV myocardium [25].
Several studies have characterized the LV deformation indices in patients with low gradient aortic stenosis:
GLS is depressed in patients with paradoxic low flow (PLF) AS. This implies that subclinical myocardial dysfunction may be more prominent in PLF AS compared with normal-flow AS and suggests the possible diagnostic and prognostic value of two-dimensional global strain in identifying PLF AS [26].
In patients with low flow-low gradient aortic stenosis, 2-dimensional strain parameters are strong predictors of outcome. Peak longitudinal strain rate may add incremental prognostic value beyond what is obtained from N-terminal pro-B-type natriuretic peptide and peak stress left ventricular ejection fraction [27].
Sato et al. [28] demonstrated in 204 patients that longitudinal LV function is severely impaired in patients with paradoxical low-flow, low-gradient (LFLPG) AS and they have a poor prognosis. GLS could stratify the high-risk group for future adverse outcomes.
Patients with paradoxical low-flow severe aortic stenosis (PLF-AS) reportedly have higher left ventricular hydraulic load and more systolic strain dysfunction than patients with normal-flow aortic stenosis. Holmes et al. [29] investigated the relationship of systolic loading and strain to PLF-AS in 120 patients. Patients with PLF-AS were found to have more valvular load, lower energy loss coefficient, more arterial load and increased systemic vascular resistance and more total hydraulic load. They concluded that Increased hydraulic load, from more severe valvular stenosis and increased vascular resistance, and longitudinal strain impairment are associated with PLF-AS and their interplay is likely fundamental to its pathophysiology.
Dahou et al. [30] examined the impact of left ventricular (LV) global longitudinal strain (GLS) measured at rest and at dobutamine stress echocardiography on the outcome of 202 patients with low LV ejection fraction and low-gradient aortic stenosis. GLS was found to be independently associated with mortality in patients with low LV ejection fraction, low-gradient aortic stenosis. Stress GLS measured during dobutamine stress echocardiography provided incremental prognostic value beyond GLS measured at rest in these patients. Hence, these authors concluded that measurement of GLS at rest and during dobutamine stress echocardiography may be helpful to enhance risk stratification in low LV ejection fraction, low-gradient aortic stenosis.
In patients with LF-LG AS and low LVEF, reduced right ventricular longitudinal strain (RVLS) was found by Dahou et al. [31] to be independently associated with increased risk of mortality. Furthermore, stress RVLS provided incremental prognostic value beyond that obtained from rest RVLS. Thus, RVLS measurement at rest and with dobutamine stress may be helpful to enhance risk stratification in this high-risk population.
The added effect of hypertension in deformation indices abnormalities has been defined in the following studies:
Hypertension has significant negative effect on LV mechanics in patients with aortic stenosis. Blood pressure is associated with deterioration of LV global longitudinal and circumferential strains in aortic stenosis patients independently of clinical and demographic characteristics [32].
In AS, both the AS severity and concomitant hypertension attenuate radial tissue Doppler imaging strain in the inferior LV wall. The subendocardial radial strain is mainly influenced by AS severity, while midmyocardial radial strain is attenuated by both hypertension and AS severity [33].
The contributions of LV strain analysis in the surgical or interventional management of patients with aortic stenosis has been extensively documented. The following statements summarize the conclusions of several studies addressing the use of strain imaging as it relates to valve replacement or intervention in patients with aortic stenosis.
LV longitudinal systolic strain is depressed despite preserved LV ejection fraction and fractional shortening in AS. A significant association exists among natriuretic peptides, myocardial longitudinal contractility, and the degree of symptoms. Reverse LV remodeling after aortic valve replacement with regression of myocardial hypertrophy results in improvement of LV longitudinal myocardial strain and decrease of Nt-pro-BNP plasma levels. LV strain analysis has the potential to identify patients with asymptomatic AS who might benefit from earlier surgical intervention to preserve overall LV function [34].
In patients with symptomatic severe aortic stenosis undergoing aortic valve replacement, reduced GLS (Particularly in the setting of normal LVEF) provides important prognostic information beyond standard risk factors [35].
Shortly after balloon valvuloplasty for severe congenital AS, there is an improvement in systolic myocardial deformation. However, two-dimensional speckle-tracking echocardiographic parameters do not return to normal at 3-year follow-up. These abnormalities in systolic deformation cannot be fully attributed to residual stenosis or aortic regurgitation [36].
Marcus et al. [36] showed in 37 children that shortly after balloon valvuloplasty for severe congenital AS, there is an improvement in systolic myocardial deformation. However, two-dimensional speckle tracking echocardiography parameters do not return to normal at 3-year follow-up. These abnormalities in systolic deformation cannot be fully attributed to residual stenosis or aortic regurgitation.
Kafa et al. [37] evaluated 208 patients that underwent AVR for severe AS, measuring GLS pre and 12–24 months post AVR and found that in patients with severe aortic stenosis, approximately 20% of patients who survived more than 1 year after aortic valve replacement had an abnormal LV-GLS value on postoperative echocardiography, despite a preserved postoperative LVEF and demonstrable left ventricular mass regression. This finding was independently associated with adverse events, concluding that appropriately timed aortic valve replacement relieves left ventricular wall stress and prevents a decline in LVEF.
In asymptomatic/minimally symptomatic patients with severe bioprosthetic AS undergoing redo aortic valve replacement (AVR), baseline LV-GLS provides incremental prognostic value over established predictors and could potentially aid in surgical timing and risk stratification [38].
AVR reverses LA abnormalities and regains normal atrial function, a behavior which is directly related to the severity of preoperative LV outflow tract obstruction. Early identification of LA size enlargement and functional disturbances might contribute to better patient’s recruitment for AVR [39].
Speckle echocardiography analysis of left atrial (LA) myocardial deformation is considered a promising tool for the evaluation of LA subclinical dysfunction in patients undergoing AVR, giving a potentially better risk stratification for the occurrence of postoperative atrial fibrillation [40].
Gelsomino et al. [41] explored the influence of global longitudinal strain measured with two-dimensional speckle-tracking echocardiography on left ventricular mass regression (LVMR) in 83 patients with pure aortic stenosis (AS) and normal left ventricular function undergoing aortic valve replacement (AVR) and found that global longitudinal strain accurately predicts LV mass regression in patients with pure AS undergoing AVR.
In summary LV GLS can detect subclinical myocardial dysfunction in patients with severe aortic stenosis, and progressively worsens with increasing aortic stenosis severity. Impaired LV GLS is independently associated with increased mortality in high-gradient aortic stenosis, in low-flow, low-gradient severe aortic stenosis with preserved LVEF, and in low-flow, low-gradient severe aortic stenosis with reduced LVEF. Strain analysis of specific myocardial sublayers may add value to the evaluation of strain in aortic stenosis. Coronary artery disease and hypertension produce additional variables in strain analysis that need to be considered. Finally, there is increasing support for the use of strain imaging to determine the need and timing for aortic valve surgery or intervention in patients with aortic stenosis.
In contrast to aortic stenosis, aortic regurgitation (AR) generates LV volume overload with progressive LV dilatation, initially with preservation of LVEF and wall thickness (eccentric LV hypertrophy), but eventually with the development of LV systolic dysfunction expressed by a drop in LVEF (Figure 2). Several studies have described the value of strain imaging in the management of patients with aortic regurgitation. The results and conclusion statement of these studies are summarized in the following paragraphs:
In patient with AR, LV strain analysis can detect early subclinical myocardial dysfunction before the development of impaired LVEF. Using tissue Doppler imaging, Marciniak et al. [42] demonstrated that patients with severe AR had significant impairment of LV longitudinal strain, in contrast to patients with moderate AR where there was no difference with controls.
Smedsrud et al. [43] evaluated 47 AR patients and 31 controls with Longitudinal peak systolic strain rate and found they were significantly decreased in the patient’s population (P < 0.001). Global longitudinal peak systolic strain rate was also significantly decreased in aortic stenosis and regurgitation compared to the control group (−1 ± 0.5, −0.9 ± 0.3, and −1.6 ± 0.3, P = 0.001). As far as the comparison between patients with aortic stenosis and aortic regurgitation, neither global strain rate nor strain rate for each wall was found to be different. They concluded that there was reduced global longitudinal strain in patients with chronic AR with preserved LV ejection fractions. Global longitudinal strain might therefore disclose incipient myocardial dysfunction with a consequent potential for improved timing of aortic valve surgery.
Di Salvo et al. [44] evaluated 26 young patients (3-16 years) with asymptomatic AR and found LV average longitudinal strain to be significantly reduced in patients with progressive AR compared to those with stable AR (−17.8 ± 3.9% vs. −22.7 ± 2.7%, p = 0.001). On multivariate analysis, the only significant risk factor for progressive AR was average LV longitudinal strain (p = 0.04, cut-off value > −19.5%, sensitivity 77.8%, specificity 94.1%, area under the curve 0.889). These authors concluded that two-dimensional strain imaging can discriminate young asymptomatic patients with progressive AR. This could allow young patients with AR to have a better definition of surgical timing before the occurrence of irreversible myocardial damage.
Kaneko et al. [45] evaluated 36 chronic AR patients undergoing surgical correction and found, with the use of speckle-tracking strain imaging, that LV subendocardial dysfunction was present in patients with chronic severe AR and preserved EF, this improved after surgical correction.
Park et al. [46] evaluated 60 patients with chronic AR with LV global strain rate on apical four chamber image (GS-4CH). During 64 months follow-up duration, 16 patients (26.7%) were deceased and 38 patients (63.3%) underwent aortic valve replacement (AVR). Deceased group had lower longitudinal strain (−12.05 ± 3.72% vs. -15.66 ± 4.35%, p = 0.005). On multivariate analysis by cox proportional hazard model adjusting for age, sex, body surface area, history of atrial fibrillation, blood urea nitrogen, LV dilatation, LV ejection fraction and AVR, decreased GS-4CH proved to be an independent predictor of mortality in patients with chronic AR (hazard ratio 1.313, 95% confidence interval 1.010–1.706, p = 0.042). They concluded that GS-4CH may be a useful predictor of mortality in patient with chronic AR.
Alashi et al. [47] evaluated 1063 patients with asymptomatic severe chronic AR and preserved LVEF to examine the prognostic utility of left ventricular (LV) global longitudinal strain (GLS). A significantly higher proportion (log-rank p = 0.01) of patients with LV-GLS worse than median (−19.5%) died versus those with an LV-GLS better than median [86 of 513 (17%) vs. 60 of 550 (11%)]. The risk of death at 5 years significantly increased with an LV-GLS of worse than −19%. They concluded that in asymptomatic patients with ≥III+ chronic AR and preserved LVEF, worsening LV-GLS was associated with longer term mortality, providing incremental prognostic value and improved reclassification.
Alashi et al. [48] evaluated 865 patients with ≥3+ chronic AR and preserved LVEF undergoing AV surgery, a baseline LV-GLS value worse than −19% was associated with reduced survival. In a subgroup of patients who returned for 3- and 12-month postoperative follow-up examinations, persistently impaired LV-GLS was associated with increased mortality.
Severe aortic regurgitation: this patient had severe aortic regurgitation with normal LV end-diastolic and end-systolic volumes (EDV, ESV) and preserved systolic function as estimated by a normal LV ejection fraction (EF) of 68%; however, there is already evidence of insipient LV dysfunction as demonstrated by a mild drop in global longitudinal strain at −14%.
In summary, in patients with severe AR LV strain analysis detects early subclinical myocardial. Dysfunction before there is a drop in LVEF. This provides the potential for improving AVR/intervention timing. In addition GLS may be a useful predictor of mortality in AR patients by providing incremental prognostic value and improved reclassification. Finally, persistently impaired LVGLS in AR is associated with increased mortality.
Very little information has been published on the use of strain imaging in the management of patients with mixed aortic valve disease (Figure 3). The next paragraph summarizes the findings and conclusions in one study:
Longitudinal LV function is reduced in both pressure and volume overload, and both of this overload patterns are equally harmful to the ventricle. Gorgulu et al. [49] evaluated a total of 27 subjects with mixed aortic valve disease (53 ± 15 years). Fifteen healthy subjects (mean age 50 ± 6 years) were enrolled as the control group. Longitudinal peak systolic strain rate values of each segment derived from analysis of a total of 804 segments were significantly decreased in this patient population (P < 0.001). Global longitudinal peak systolic strain rate was also significantly decreased in aortic stenosis and regurgitation compared to the control group (−1 ± 0.5, −0.9 ± 0.3, and −1.6 ± 0.3, P = 0.001). As far as the comparison between patients with aortic stenosis and aortic regurgitation, neither global strain rate nor strain rate for each myocardial segment was found to be different.
Severe aortic stenosis and regurgitation: this example illustrates the presence of severe LV dysfunction as demonstrated by a marked drop of GLS to −6% despite a borderline drop of LV ejection fraction to 50%. The combination of severe aortic stenosis and regurgitation likely produces significant volume and pressure overload of the LV with significant LV dysfunction that is unmasked by strain analysis.
Although strain analysis is been used with increasing frequency for the evaluation of cardiac function, there are still issues with reproducibility of deformation analysis data, particularly when different echocardiography machines or analysis software is used. Until this issue is resolved the current recommendation is to use the same machine and software when obtaining comparative studies.
The fidelity of the strain data sets is dependent on the quality of the echocardiographic data, unfortunately endocardial contrast enhancing agents cannot be used during strain analysis, therefore strain analysis sometimes has to be obtained with substandard images. The current recommendation is not to report strain values if the echocardiographic images are of poor quality. Hopefully work-around solutions will be found to permit strain analysis with endocardial enhancement agents use.
The current literature supports actionable interventions according to fairly well-defined values of decreased LV ejection fraction, this is not as developed on the characterization of LV dysfunction according to levels of decreased strain values.
Although the literature on strain is fairly robust in aortic stenosis, it is only moderately developed in aortic regurgitation and almost not existent in mixed aortic valve disease.
Despite some of the shortcomings of strain analysis in aortic valve disease we have reviewed, we feel the added value this technique provides, justifies its use in the day to day imaging management of patients with diseases of the aortic valve. Our practice and recommendation is to characterize and sequentially follow global longitudinal strain in patients with moderate and severe aortic stenosis and/or moderate and severe aortic regurgitation. In asymptomatic patients with severe AS or AR and normal EF, the presence of an abnormal GLS should alert the clinician for the need of closer follow up or possibly aortic valve replacement/intervention.
The following studies highlight areas of study with high potential for development in the area of strain analysis in patients with aortic valve disease.
Broch et al. [50] studied, 31 patients with moderate to severe AR, 15 elite endurance athletes, and 17 healthy control subjects using three-dimensional speckle-tracking echocardiography. Global circumferential strain (GCS), global longitudinal strain (GLS), end-systolic circumferential wall stress (ESSc), end-systolic meridional wall stress (ESSm), and the wall stress ratio (ESSc/ESSm) were measured. LV end-diastolic volumes were similar in athletes and patients with AR and significantly larger than in healthy control subjects. Values of GLS in control subjects, athletes, and patients with AR were −18.8 ± 1.9%, −17.3 ± 2.0%, and −16.4± 2.0%, respectively (control subjects vs. athletes and patients, P < .05), whereas values of GCS were −16.9 ± 2.0%, −15.5 ± 1.9%, and −17.9 ± 2.6%, respectively (athletes vs. control subjects and patients, P < .01). The authors concluded that in compensated AR, relatively high GCS compensates for reduced GLS in a manner consistent with the preserved ejection fractions observed in these patients.
Uncovering post-exercise myocardial dysfunction in patients with asymptomatic AS with preserved left ventricular function can aid in risk assessment of these patients [51].
Left ventricular myocardial strain gradient using a novel multi-layer transthoracic echocardiography technique positively correlates with severity of aortic stenosis [23].
Early diastolic strain rate in relation to systolic and diastolic function and prognosis in aortic stenosis [52].
Preoperative left atrial strain predicts postoperative atrial fibrillation in patients undergoing aortic valve replacement for aortic stenosis [40].
Deformation imaging, particularly in the form of global longitudinal strain, has evolved as a powerful tool in the evaluation of ventricular function in patients with aortic valve disease. GLS is particularly suited to detect subclinical LV dysfunction, before a drop in LV ejection fraction, providing the opportunity to intervene earlier to prevent serious and permanent LV dysfunction. The role of GLS in the management of aortic stenosis is quite robust, illuminating nuances of LV dysfunction in aortic valve disease such as impact in severity of AS, prognosis, timing for surgery and interventions, low gradient aortic stenosis and presence of associated coronary artery disease, among others. Similar added value has been demonstrated in the application of GLS in the detection of subclinical LV dysfunction in patients with aortic regurgitation. Very little information exists in the use of GLS in patients with mixed aortic valve disease providing an opportunity for future research in this important group of patients with aortic valve disease.
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Rodriguez-Morales",hash:"61c627da05b2ace83056d11357bdf361",volumeInSeries:3,fullTitle:"Current Topics in Neglected Tropical Diseases",editors:[{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"7064",title:"Current Perspectives in Human Papillomavirus",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7064.jpg",slug:"current-perspectives-in-human-papillomavirus",publishedDate:"May 2nd 2019",editedByType:"Edited by",bookSignature:"Shailendra K. 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Saxena",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",institutionURL:null,country:{name:"India"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null}]},subseriesFiltersForPublishedBooks:[{group:"subseries",caption:"Bacterial Infectious Diseases",value:3,count:2},{group:"subseries",caption:"Parasitic Infectious Diseases",value:5,count:4},{group:"subseries",caption:"Viral Infectious Diseases",value:6,count:7}],publicationYearFilters:[{group:"publicationYear",caption:"2022",value:2022,count:2},{group:"publicationYear",caption:"2021",value:2021,count:4},{group:"publicationYear",caption:"2020",value:2020,count:3},{group:"publicationYear",caption:"2019",value:2019,count:3},{group:"publicationYear",caption:"2018",value:2018,count:1}],authors:{paginationCount:302,paginationItems:[{id:"280338",title:"Dr.",name:"Yutaka",middleName:null,surname:"Tsutsumi",slug:"yutaka-tsutsumi",fullName:"Yutaka Tsutsumi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/280338/images/7961_n.jpg",biography:null,institutionString:null,institution:{name:"Fujita Health University",country:{name:"Japan"}}},{id:"116250",title:"Dr.",name:"Nima",middleName:null,surname:"Rezaei",slug:"nima-rezaei",fullName:"Nima Rezaei",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/116250/images/system/116250.jpg",biography:"Professor Nima Rezaei obtained an MD from Tehran University of Medical Sciences, Iran. He also obtained an MSc in Molecular and Genetic Medicine, and a Ph.D. in Clinical Immunology and Human Genetics from the University of Sheffield, UK. He also completed a short-term fellowship in Pediatric Clinical Immunology and Bone Marrow Transplantation at Newcastle General Hospital, England. Dr. Rezaei is a Full Professor of Immunology and Vice Dean of International Affairs and Research, at the School of Medicine, Tehran University of Medical Sciences, and the co-founder and head of the Research Center for Immunodeficiencies. He is also the founding president of the Universal Scientific Education and Research Network (USERN). Dr. Rezaei has directed more than 100 research projects and has designed and participated in several international collaborative projects. He is an editor, editorial assistant, or editorial board member of more than forty international journals. He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. 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