Time requirement for recovery of gas phase after door opening
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\n'}],latestNews:[{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"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"1758",leadTitle:null,fullTitle:"Otolaryngology",title:"Otolaryngology",subtitle:null,reviewType:"peer-reviewed",abstract:'This book emphasizes on different aspects of otolaryngology - the medical sciences of diagnosis and treatment of ENT disorders. 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They are computing systems inspired by the biological neural networks that constitute animal brains. Neural networks are widely used in different industries, from eCommerce to vehicle building. The most frequent example of the artificial neural network application is personalizing the purchaser’s experience in e-Commerce. For instance, Amazon, AliExpress, and other eCommerce platforms use AI to show the related and recommended products. There are various types of neural networks being used, including Convolutional neural networks, Recurrent neural networks, and Long and short terms memory networks. Such neural networks could be applied in various applications such as image recognition, facial recognition, speech recognition, language translation, audio generation, and time-series prediction. This book reviews the past development, new perspectives, and application of such neural networks. It could provide a great understanding of the current state of neural networks and work out the frameworks for developing neural networks in the future.
",isbn:"978-1-83768-222-5",printIsbn:"978-1-83769-994-0",pdfIsbn:"978-1-83768-223-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"e57ff97a39cfc6fe68a1ac62b503dbe9",bookSignature:"Dr. Chi Leung Patrick Hui",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11448.jpg",keywords:"Supervised Learning, Unsupervised Learning, Reinforcement Learning, Neural Networks, ANN, CNN, RNN, LSTM, Image Recognition, Text Recognition, Language Translation, Voice Generation",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 6th 2022",dateEndSecondStepPublish:"June 3rd 2022",dateEndThirdStepPublish:"August 2nd 2022",dateEndFourthStepPublish:"October 21st 2022",dateEndFifthStepPublish:"December 20th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"a month",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"A pioneering researcher in artificial intelligence, machine learning, and deep learning, and holder of four registered patents: ‘’Thermosensitive poloxamer hydrogel for atopic dermatitis treatment”, “Development Method of Making Double Layers maturation of human monocyte-derived dendritic cells,” “Intelligent Monitoring System and Method on Diaper,” and “RFID Passive Tags Anti-counterfeiting System” of Chinese Herbal Medicine onto Cotton Fabric. 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In the last several decades, efforts have been mainly focused on the sub-culturing of established cell lines and on optimizing culture conditions, including selection of appropriate culture medium, in order to achieve rapid cell growth. The conventional CO2 incubator only provides minimum requirements for keeping cells alive in a culture environment; pH and temperature are held at 7.4 and 37°C, respectively, and sub-saturated humidity is maintained to avoid evaporative condensation of the culture medium. To avoid contamination of the culture medium from aerosol bacteria, the conventional clean bench removes particles from the working atmosphere by continuous displacement of ambient air that passes through a high-efficiency particle (HEPA) filter, whereas the medium exposed to ambient air quickly discharges dissolved CO2. In vivo, the pH of blood is strictly maintained at ~ pH 7.4 by means of physiological buffer systems, whereas the pH of culture medium mainly depends on a sodium bicarbonate/CO2 buffer, which is adjusted to a pH of 7.4 in an atmosphere of 5% CO2; the pKa is 6.1, and the buffering capacity at pH 7.4 is very weak. The pH and temperature are generally uniform in almost all organs, tissues, and cells in living mammals; however, the dissolved oxygen or oxygen partial pressure (PO2) in various organs and tissues is generally much lower than that in the ambient air (159 mmHg); it decreases to 100 mmHg and 25 mmHg or less in arterial blood and in the periphery, respectively. Although oxygen is essential to produce ATP through the tricarboxylic acid cycle, it is quite toxic at high concentrations [1-3]. Tissues and cells in body fluids are protected from reactive oxygen species (ROS) by multiple physiological anti-oxidant systems, whereas those in artificial culture medium lack an extracellular protective system and are exposed to highlevels of O2. Numerous studies have cited a variety of harmful effects of ROS, such as lipid and protein peroxidation as well as membrane and DNA damage [4-8]. Although lower PO2 implies lower production of ROS, it also implies hypoxia that can damage various cellular functions [9, 10]. The recent advances in tissue engineering focus on clinical applications of cultured cells in regenerative medicine. When primary cells and stem cells are retrieved from human tissue, their original physicochemical environments and metabolic features are quite different from each other. Moreover, induction of differentiation stimulates changes in gene expression over a time course, which may affect cellular metabolism. The above-mentioned point of view suggests that ranges in cell viability, in terms of PO2 and tolerance for ROS (which need to be controlled for normal proliferation and prevention of malignant transformation), may be quite narrow for primary cells in comparison to cell lines. The stringent control of oxygen during bioprocessing is undoubtedly important; however, the exact influence of PO2 and ROS is not completely understood because past experimental data have been obtained by using conventional culture apparatuses or their improved models. Although the performance of apparatuses has already been proven by sub-culturing of established cell lines, they have not been designed for stringent control of oxygen throughout the culture period. Every time the incubator door is opened, the O2 environment is quickly lost and requires a long time to recover. To clarify the net influence of PO2 and ROS, it is essential to develop advanced equipment that can provide a stringent control of oxygen around the pericellular environment throughout the culture period.
In the past 30 years, researchers have made significant progress in the field of clinical reproductive medicine through assisted reproductive technology (ART). In 1978, the first human baby was born through in vitro fertilization-embryo transfer. To date, more than a million children have already been born with the help of ART. Fertilization through intra-cytoplasmic sperm injection (ICSI) [11] is becoming increasingly popular, and it now accounts for more than half of clinical ART cases worldwide. ART is the first example of large-scale clinical application of regenerative medicine to cultured human stem cells, which involves in vitro fertilization of gametes (primary stem cells) and subsequent culture of early embryos up to the blastocyst stage, followed by transfer into the uterus. Some recent cohort studies could not deny the possibility of birth defects in babies who were delivered as a consequence of ART [12-14], although ART is recognized as an elementary clinical regenerative medicine that makes use of native stem cells. We point out two major issues in this regard: one is quality control of the gametes, and the other is quality assurance of the culture environments. It is well known that human ejaculate contains a heterogeneous sperm population that possesses a variety of abnormalities. ICSI is a technique mainly used in male infertility, which occurs as a result of dysfunction of spermatogenesis and is accompanied by various functional deteriorations in the sperm. Nuclear damage to human sperm, in particular, DNA fragmentation as a consequence of double-strand breaks, has attracted attention. If a sperm with damaged DNA is incorporated into the embryonic genome, it may lead to sperm-derived chromosomal aberrations [15], which may in turn result in higher miscarriage rates [16] and an increased risk of pregnancy loss [17]. The resultant aberrations can also be potentially inherited through the germ line by future generations [18-20]. Several studies have reported that the rate of DNA-damaged sperm increases in infertile men with poor semen quality, who are the primary candidates for ICSI [21]. Although the techniques in clinical ICSI are well established, the sperm is selected merely based on motility and gross morphology, as observed under a microscope, and there are no validated methods to address and assure sperm nuclear DNA integrity.
There is a concern about higher malformations resulting from ICSI cycles, due to the possibility of iatrogenic transmission of genetic abnormalities to the offspring [14, 22, 23]. Studies comparing ART cycles and natural births suggest that infants conceived by IVF ⁄ ICSI techniques have three times a risk of a congenital heart defect [24] as well as a higher risk of autosomal and gonosomal aneuploidies [25]. It still remains unclear whether culture environments provided by conventional culture apparatus or their improved models have been responsible for the results of various cohort analyses. In general, we have to consider the heterogeneity of the cell population at the start of culture as well as some transformation during the culture. The lumen of the fallopian tube, where the oocyte fertilizes with the sperm, shows very low PO2[26], contrary to the endometrium at the implantation phase, which shows thickening with increased blood flow; thus, the implanting blastocyst is exposed to higher PO2.During this one-week trip in the oviduct, the embryo undergoes early development in a PO2 gradient. To determine optimal physicochemical environment for primary and stem cells, including the embryo, one has to pay attention to complicated cross-interactions between the atmosphere, especially PO2, and the composition of culture medium: ATP production is influenced by peri- and intra-cellular PO2 as well as energy sources in the medium. Even if PO2 is kept low during cell culture, the handling of cells in a clean bench is critical, while temperature, PO2, and pH of the medium are dramatically changed. Tolerances to such parameters varies quite differently among cell types. For example, some neuronal cells have a low threshold for oxygen toxicity, and exposure of these cells to ambient air in a clean bench induces apoptosis [3]. Such cells have to be treated in an enclosed space filled with low-oxygen gas mixtures. In contrast, some cells can readily induce apoptosis under low PO2 conditions [9]. It is well-known that long-term subculture of cell lines induces some genetic transformations. Some researchers [27-31] have proposed that this phenotypic variability might originate from epigenetic alterations, and the methylation profiles of stem cell lines are fundamentally changed during subculture, thus complicating their use in basic and clinical research. Several reports have also discussed the epigenetics of early development [32] and the genetic and epigenetic features of children delivered through ICSI [33]. Kohoda et al. suggested that ICSI induces transcriptome perturbation [34]. To ensure the reliability of clinical embryo cultures, or in general terms, clinical cell cultures, as a premise for human implantation, we have to recognize the complicated cross-interactions of gas phase with composition of the culture medium, cell features, and their heterogeneity with regard to genetic and epigenetic regulation. Numerous reports have emphasized that reducing PO2 during in vitro cultures increases the proportion of blastocyst formation in mice [35-37], hamsters [38], sheep [39], and cattle [40]. Other studies found no clear effect in mice [41]. As mentioned above, PO2 and ROS might be essential parameters at least in early embryogenesis [42]. The discrepancies in the results of the above-mentioned studies may be partially explained by differences in culture hardware as well as culture methods: for example, oxygen tension in droplets of medium under oil will be 1ess than those without an oil overlay [43]. Adding EDTA to culture medium increased the proportions of mouse [41, 44] and cattle [40] embryos that developed to blastocysts. Chelating transition metals such as zinc, iron, and copper may prevent chemical reactions that generate harmful oxygen radicals [45]. Because oviductal oxygen tension is less than atmospheric levels [26], mammalian embryos may be protected from oxidative stress in vivo in part by a relatively low oxygen tension in the oviduct [46]. The influence of low PO2 and hypoxic culture conditions on some cellular functions has also been studied in somatic cells. When BeWo cells, an in vitro model of human trophoblasts, were cultured in 2% O2, reverse-transcriptase polymerase chain reaction (RT-PCR) indicated increased transcription of the organic cation transporter (OCTN2) gene compared to that observed under 20% O2 [47]. Hirao et al. ([48] observed that MC3T3-E1 cells and calvariae from 4-day-old mice cultured in 5% or 20% O2 conditions showed osteoblastic differentiation and subsequent transformation to osteocytes, which was promoted by low PO2. The importance of a lower PO2 environment was a cited factor; however, excessively low PO2 are also important to consider for cellular growth, differentiation, gene expression, phenotype manipulation, epigenetics, and moreover, for survival. We consider it essential to determine the narrow range between hyperoxia and hypoxia, but not to overestimate the benefit of lower PO2.
As will be described later (Figs. 7 and 8), established cell lines that adapt to 5.0% CO2-air often tolerate prolonged changes in pH and PO2. In contrast, clinical cultures of primary and stem cells used for human transplantation demands rigorous duplication of in vivo environments because it is of prime importance for maintaining normality or to minimize phenotypic changes within the cells. We have previously established an individual cell culture system that emphasizes the precise control of oxygen concentration and quick recovery from disturbances (Figs. 1 and 2) [49]. As shown in Fig. 1, the culture bath has an aluminum block with 16 wells for heat storage, and the block and inner space are kept at 37.0 °C by a temperature sensor. The apparatus is first used as a multivariate screening system for the simultaneous determination of the narrow range between hyperoxia and hypoxia and for designing the optimal formula corresponding to the gas phase. This system can provide up to 16 types of different premixed gases into each capsule individually. The commonly used infrared CO2 sensor and the Galvanic current O2 sensor devices have sufficient sensitivity and undergo scheduled calibrations to maintain accuracy assurance. When a small amount of gas is infused for fine control of the gas phase, static diffusion causes an inhomogeneous gas concentration in the chamber, and the display values are often similar to those around the sensors. We therefore used pre-mixed gases and a small capsule for precise control of O2 concentration. Pure O2, CO2, and N2 gases were mixed according to their weight base molar ratios and compressed in the gas canister.. The following gases were used for cell culture experiments: 2.0% O2, 5.0% CO2, and 93% N2 as an example of hypoxic culture. For purging the capsule, 5.0% CO2 and 95% N2 were used. The gas compositions were measured using gas chromatography, according to the pre-shipment review.
Individual cell culture apparatus
5.0% CO2-air circulation clean bench
The degree of cleanliness of air was defined by a “cleanliness class”, which is specified by the number of particles of a size 0.5 μm or over in one cubic feet of air. For instance, a cleanliness class of 100 is interpreted as less than 100 particles in one cubic feet of air. The simultaneous measurements of particle size and number were performed using a light-scattering particle counter. The intake air stream was first passed through a high-intensity laser beam. As a result, the particles in the sample caused light scattering, and their numbers and intensities were detected. Room air often shows a cleanliness class of 106–105, and the aim of a conventional clean bench is to provide a low-dust environment below a cleanliness class of 102. The cell handling is, however, performed in ambient air, allowing temperature decrease, dissolution of O2, and pH change by removal of CO2. We newly developed the 5.0% CO2-air circulation clean benches with or without a built-in microscope (Fig. 2). The bench top was covered with an acrylic chamber to prevent leakage of the ambient atmosphere, with the set-up resembling an infant incubator. Pure CO2 was infused with the aid of a gas sensor control to maintain 5.0% CO2-air. The bench top and the ambient temperature were kept at 37°C and 30°C–34°C by temperature control (Fig. 2). In addition, a small chamber was set on the bench top, so that if cells could not tolerate 5.0% CO2-air for more than a few minutes, they were isolated in the chamber, and the humidified culture gas was supplied. If the bench top was contaminated with some infectious material such as body fluid, it was merely wiped off. In the newly developed system, a cover shield was placed on the bench top, and a disposable clear film was set and discarded at each operation (Fig. 3). Although the conventional clean bench filtered fresh air only once, the newly developed system circulated the enclosed 5.0% CO2-air through a HEPA filter every 24 sec. Before starting the filtration process, the cleanliness class was found to be 105; however, a cleanliness class of 1 was readily achieved by repeated filtration within 5 min (Fig. 4). Furthermore, particles within the size range of 0.3 µm–0.5 µm were reduced to less than 100 within 5 min.
Disposable cover film on bench top
Change in cleanliness class after starting filters
The conventional CO2 incubator has a structural problem when it comes to achieving a stable hypoxic environment. As summarized in Table 1, whenever the door is opened, a large amount of ambient air intrudes, and the reduced CO2 can be readily recovered by infusion of pure gas; however, it took more than 30 min to exclude O2 by flushing with N2. Thus, we developed a disposable small capsule to control the gas phase, especially for hypoxic tissue culture (Fig. 5). A 500-ml plastic capsule containing 220 ml of the gas buffer solution (20 mM H, 25 mM NaHCO3, and 0.05% Phenol Red) was used as the CO2 incubator. First, it was equilibrated by ventilation of the pre-mixed culture gas (10 ml/min) for at least overnight. Following gas equilibration, the pH was adjusted to 7.4 ± 0.05, and the O2 concentration was measured using a Galvanic current O2 sensor. Coexistence of a large amount of gas buffer solution, which serves the same function as the culture medium in terms of gas equilibration, stabilizes the physicochemical environment by functioning as a heat storage and gas pool. Inflow of air when the cap is opened should be excluded as soon as possible. To achieve this, the anoxic purging gas (5.0% CO2 and 95% N2) was flushed (500 ml/min) just after closing the cap. As a consequence, the oxygen level returned to 2.0% within 4 min, after which the gas supply was changed automatically to culture gas, which was infused (10 ml/min) continuously to maintain positive pressure (Fig. 6). If the gas purging process was omitted, it took 120 min until recovery, despite the inner space volume being only 280 ml (Fig. 6). This fact suggested that the void volume of the culture capsule should be minimized as much as possible, and coexistence of the gas buffer enhance the stability of the gas phase in the culture environment. In this system, gas control through a CO2 sensor was not necessary, and we also did not need to consider the improper gas control caused by sensor deterioration. Gas equilibration of each capsule was roughly estimated by checking the color of phenol red in the gas buffer (Fig. 5), and the precision control of the culture environment was monitored by measuring the temperature and pH of the gas buffer. Although simultaneous culturing of multiple tissues is usually possible in a single CO2 incubator, the present method allows the culturing of individual tissues in disposable capsules. The system also has additional advantages in that it allows easy and error-free identification of dishes and avoids disturbances in culture conditions when the door of the unit is opened.
Use of disposable capsules for individual cultures with precise control of oxygen concentration and quick recovery from disturbances in culture conditions
Effect of gas purging on O2 concentration recovery in capsule
Period of open door (sec) | 0 | 10 | 20 | 30 |
CO2 (%) Time require for recovery (min) | 5.0% - | 5.4% 2 | 5.4% 2 | 5.3% 2 |
O2 (%) Time require for recovery (min) | 2.1% - | 13.7% 30 | 18.4 34 | 18.2% 35 |
Time requirement for recovery of gas phase after door opening
The most common cultureware or vessels are sterile, disposable, and specially treated with polystyrene plastic. The cultureware includes petri dishes, multiwell plates, microtiter plates, roller bottles, and screw-cap flasks. All cultureware is equipped with lids or caps to prevent contamination from aerosol bacteria, and these culture vessels are designed to stack. Handling of culture media in conventional or in 5.0% CO2-air circulation clean benches caused dissolution of oxygen in the media. After the lid was mounted on the culture dish or the cap of the flask was loosely closed, ambient air or 5.0% CO2-air remained in the inner space of the cultureware. We placed an O2 sensor on the lid of a culture dish (90 mm diameter, 10 mm height) or on the body of a culture flask (250 ml) to measure the ventilation velocity between the outer and inner spaces of the cultureware. As shown in Fig. 7, when the lid is held in the normal position and placed in the culture gas containing 2.0% O2, it took more than 40 min for equilibration, despite the inner space volume being only about 60 ml. When the lid was held over the spacers (2 mm and 7 mm in height), the time for equilibration was again shortened to 20 min. If the cells demand a faster velocity of ventilation, a lid made out of gas-permeable materials should be used, or cultureware without lids should be used. A flask with a screw cap has a larger void volume than that of a dish, and, hence, more reliable results were obtained using a flask. The cap of the flask was opened in ambient air and closed loosely. When the flask was placed in the culture-gas environment, the ventilation velocity was found to be extremely low, and it took more than 20 h to attain equilibration (Fig. 8-A). Moreover, the same duration was required for gas leakage, which served as a reversal process (Fig. 8-B). We examined purging of ambient air with anoxic gas in the same manner as described in Fig. 6. A needle was inserted in the cap as a gas injection port, and the flask was capped loosely (Fig. 8). The flushing (500 ml/min) of anoxic gas obviously accelerated the ventilation, and the oxygen level returned to 2.0% within 4 min (Fig. 8-C). This result suggested that the conventional use of a flask with a loose cap, which is subsequently placed in the CO2 incubator, is unfavorable for primary and stem cells, which were intolerant to prolonged changes in pH and PO2. An air-tight plastic vessel often suffers from gas leakage through the sealant of wide open-mouthed containers as well as due to the gas permeability of materials. After the cap was closed, the gas phase was recovered by flushing (Fig. 6), and a minimum amount of culture gas (10 ml/min) was supplied constantly (Fig. 9-A) or intermittently (Fig. 9-B) in order to maintain positive pressure. The constant supply of culture gas held PO2 steady, whereas the intermittent supply caused narrow, wave-like changes due to gas leakage, although their margins of fluctuation were not so much different from each other. The intermittent supply saved gas consumption. The computer-assisted programmable system allowed greater flexibility to evaluate optimum environmental settings. Fig. 10 shows a time-course model of switching of the gas phase with intermittent gas supply.
Effect of gap between lid and culture dish on ventilation velocity
Ventilation velocity of loose cap flask and effects of purging with anoxic gas
Time-course changes in O2 concentration during constant and intermittent gas supply
A model of computer-assisted programmable intermittent gas supply
The 16 capsules placed in the culture bath (Figs. 1 and 5) were used as a multivariate assessment system to determine the optimal formula corresponding to the narrow range between hyperoxia and hypoxia. Fig. 11 presents the model usage to optimize the combination of three parameters, namely the four premixed gases with 0% to 6.0% O2 and the dosage of two constituents. For example, the capsule at the right edge/bottom line the combination of the constituent α, dose 4 and the constituent β, dose 5/6.0% O2. The formula of widely used media (for example, RPMI and MEM) has been established more than half of a century ago; at that time, the multifaceted pharmacological actions and the concept of genotoxicity of some constituents had not yet been established. Amino acids are often added as supplements in the media, some of which serve as the most abundant neurotransmitters in the brain. Amino acids are responsible for almost all rapid signaling between neurons. For example, glutamate is used as a nitrogen source to promote the syntheses of proteins and nucleic acids, and it is the major excitatory neurotransmitter that is distributed in all regions of the brain ([50]. Inadequate dosing causes glutamate-induced excitotoxicity ([51]. Extracellular ATP ([52], while the decomposed species, adenosine [53], is responsible for calcium channel regulation. It is very important to evaluate whether target cells are pharmacologically sensitive to some of the constituents as well as to impurities and their degraded agents. Moreover, it is important to note that the term “sensitive” includes genotoxicity.
Multivariate assessment of environmental settings
To date faster proliferation has often been associated with the optimum culture environment, we have to investigate minutely whether this enhanced proliferation is not caused by genetic transformation or malignant changes or not. The present review dealt with “cell handling and culture under controlled oxygen concentration”. The precision control of oxygen to determine the narrow range between hyperoxia and hypoxia is likely to play an important role in ensuring the safety of cell cultures, especially for primary and stem cells.
About 7% of the population >65 years suffer from a painful heel, even though younger people are often affected, too [1]. The most common cause of this symptom is the so‐called “plantar fasciitis” [2]. This term is widely used, although “plantar fasciopathy” or “plantar fasciosis” would be a better description to point out the degenerative nature of the disease. However, as more than 1100 citations in Pubmed quote “plantar fasciitis” (in comparison with only 50), we will use the traditional term in the following.
Plantar fasciitis has been associated with obesity, with acute or chronic work overload, or with work on hard surfaces [2, 3]. It seems that physiological degeneration of the fascia at the calcaneal insertion exacerbates due to repetitive microtraumas caused by vertical compression [4]. This causes inflammatory tissue reactions. As a result, the fascia is thickened with an associated fluid collection to 4.0 mm and more in ultrasonography [5]. Furthermore, this inflammation may trigger bone formation, the so‐called “plantar heel spur.” This process has been studied intensively by Kumai and Benjamin [6]. They proposed three stages of spur growth: “(a) an initial formation of cartilage cell clusters and fissures at the plantar fascia enthesis; (b) thickening of the subchondral bone plate at the enthesis as small spurs form; and (c) development of vertically oriented trabeculae buttressing the proximal end of larger spurs” [6]. The first description of this spur formation and correlation with the clinical symptoms was carried out by Plettner in 1900 [7]. However, not every heel spur is associated with heel pain, as these spurs are found in 11–16% of the normal asymptomatic population [4]. On the other hand, some patients with painful plantar fasciitis do not have a radiographic confirmation of a spur formation.
A similar mechanism (although caused by longitudinal traction and not by vertical compression) of bone formation has been described at the insertion of the Achilles tendon [8].
According to the American clinical practice guidelines from 2010, diagnosis is established by the typical anamnesis and the characteristic localizations of tenderness. Still, weight‐bearing radiographs are also recommended [9].
Single doses of external beam radiotherapy (EBRT) in the range of 0.3–1 Gy are called “low dose EBRT” (LD‐EBRT). These single fractions are applied two or three times a week until a total dose of about 3–6 Gy is reached. Such radiotherapeutic concepts are used for diverse nonmalignant conditions, e.g., osteoarthrosis, tendinopathy, epicondylitis, or bursitis. A comprehensive review of the historical developments in LD‐EBRT for benign diseases is given by Trott [10].
In contrast, EBRT in oncology is characterized by much higher single and total doses. “Normofractionation” describes single doses of 1.8–2 Gy, applied about five times a week. To treat breast cancer, the total doses of about 62 Gy are necessary, in prostate cancer even more than 72 Gy. From a radiobiological point of view, these high cumulative doses are used to induce DNA double strand breaks. Due to errors in a repair mechanism (nonhomologous end joining), dicentric chromosomes can occur. These can result in unfinished mitoses, the so‐called “mitotic catastrophe,” the main mechanism to reduce clonogenic survival in tumor cells [11]. High doses of EBRT induce local inflammation and tissue reactions.
The much lower doses of LD‐EBRT act via different mechanisms. In the last two decades, several anti‐inflammatory effects have been discovered, contrary to the effects of the above‐mentioned high EBRT doses.
Furthermore, doses between 0.1 and 0.5 Gy reduced the adhesion of PBMC significantly to endothelial cells (ECs)
A third mechanism was the suppression of nitric oxide (NO) production in activated macrophages by LD‐EBRT between 0.3 and 1.25 Gy [18]. As the expression of inducible nitric oxide synthases (iNOS) proteins was not altered, the LD‐EBRT seemed to act at the translational or posttranslational level. Furthermore, a dose of 0.5 Gy significantly reduced oxidative burst and superoxide production of stimulated macrophages [19]. A diminished release of reactive oxygen species (ROS) can also contribute to the anti‐inflammatory effects of LD‐EBRT.
Taken together, all of these pathways and mechanisms showed a similar dose dependence with a maximum effect between 0.3 and 0.7 Gy regarding a discontinuous dose‐effect relation [20].
There are several
Since 1937 [21] for decades, large retrospective studies on the efficacy of LD‐EBRT in calcaneodynia have been published (overview in 22). In 1970, one negative randomized trial was reported and heavily criticized but had not been repeated [23]. Starting in the 1980s, patients were systematically clinically examined and interrogated in a structured manner to try to control for diverse risk factors and to compare the efficacy of different fractionation schemes and total doses [24].
It took until the past decade to perform and report prospectively randomized trials to proof the efficacy of LD‐EBRT and to identify the optimal dose fractionation schedule. In the following, we report the design and the results of these trials. Table 1 gives a short overview of the studied dose concepts and the results. Due to methodological reasons, we will describe the studies not following their publications dates, but according to a systematic order.
Since the publication of the first randomized trial on LD-EBRT in 1970, the efficacy of LD‐EBRT was questioned [23]. Goldie et al. randomized 399 patients, however, only nine patients suffered from calcaneodynia. This is why these results cannot be extrapolated to LD‐EBRT of a painful heel spur. Furthermore, endpoints were not clearly defined, and therapy was started in an acute stage of the disease [25].
The landmark study to prove the efficacy of LD‐EBRT was performed by the German cooperative group on the radiotherapy for benign diseases (GCGBD) under the responsibility of Niewald et al. [26]. A very low dose EBRT (6 × 0.1 Gy applied twice a week up to a total dose of 0.6 Gy) was randomized to a standard dose LD‐EBRT (6 × 1 Gy twice a week up to a total dose of 6 Gy). In the case of an unfavorable response after 3 months, the patient was offered a second treatment series (“reirradiation”) applying a standard dose. The dosage of the experimental arm was chosen to examine if very low doses are effective at all. Second, it acted as a placebo irradiation, as a sham irradiation was regarded unethical. LD‐EBRT was applied using a linear accelerator (4‐ to 6‐MV photons) using lateral parallel opposing fields.
Inclusion criteria were tenderness of the calcaneus with a limitation of the painless walking distance and duration of the symptoms for more than 6 months. Furthermore, a radiological proof of a heel spur was required, and the patients had to be least 40 years of age. Patients with previous traumata to the foot, rheumatic or vascular diseases, lymphatic edema, pregnancy, or breastfeeding were excluded. Concomitant therapy with oral analgesics was not limited. However, local injections with steroids during the study period were not permitted.
Initially, 200 patients were planned [27] to detect a difference of 10% in the quality of life (QOL) sum score (SF‐12) [28] and calcaneodynia sum score (CS) [29] (Table 2) with a power of 80% and an error probability of 5%. Furthermore, the visual analogue scale (VAS) to evaluate pain intensity was used. However, after randomization of 66 patients and interim analysis of 62 patients (4 had to be excluded due to a withdrawal of informed consent or violation of the inclusion criteria), the differences in efficacy between the two treatment arms were so pronounced, that the trial was closed early.
Author | Year | N | Standard arm | Experimental arm | Results | Conclusions |
---|---|---|---|---|---|---|
2012 | 66 | 6 × 1 Gy twice a week | 6 × 0.1 Gy | 3 months: VAS/CS/SF12 sig. better with standard | 1. Dose‐response relationship | |
1 year: less second treatment series with standard | 2. Proof of therapeutic effect of LD‐EBRT | |||||
2007 | 130 | 6 × 1 Gy twice a week | 6 × 0.5 Gy | 6 months: CS no sig. differences | 6 × 0.5 Gy as standard fractionation | |
2014 | 457 | 6 × 1 Gy twice a week | 6 × 0.5 Gy | 6 weeks, 2.5 years: VAS/CS no sig. differences | 6 × 0.5 Gy as standard confirmed | |
2015 | 127 | 6 × 1 Gy twice a week | 12 × 0.5 Gy thrice a week | 3 months: VAS/CS/SF12 no sig. differences | Efficacy not increased with 12 × 0.5 Gy standard still 6 × 0.5 Gy |
Summary of contemporary randomized trials on LD‐EBRT of painful heel spurs: tested schedules, results, and conclusions.
Criteria | Extent of symptoms/alteration | Points |
---|---|---|
S = Pain at | 6 / 4 / 2 / 0 | |
(total: 30%) | N = Pain during D = Pain during R = Pain at I = Pain at none = 6 ; slight = 4 ; moderate = 2 ; severe = 0 points ⇨ | 6 / 4 / 2 / 0 6 / 4 / 2 / 0 6 / 4 / 2 / 0 6 / 4 / 2 / 0 |
per single criterion | ||
(total: 15%) | None Orthopedic shoe, insoles, heel cushion One cane or crutch Two canes or crutches ⇨ | 15 10 5 0 |
(total: 20%) | No limitation, maximum professional strain possible Slight limitation, normal professional work possible Moderate limitation, reduced professional activity Severe limitation, daily professional work impossible ⇨ | 20 10 5 0 |
(total: 15%) | No limitation of daily and leisure activities and sports Slightly limitation/reduced leisure activities and sports Moderate limitation/no leisure activities and sports Complete limitation of any daily and leisure activities ⇨ | 15 10 5 0 |
(total: 20%) | No limp, normal walking is possible without a limitation Slightly altered, limp after walking Moderately altered, limp after walking Severely altered, normal walking is impossible ⇨ | 20 10 5 0 |
The mean age of patients was 54 years in the standard dose group and 58 years in the 6 × 0.1 Gy group. Sixty‐one patients had a plantar, one patient a dorsal heel spur. In mean, patients in the standard dose group suffered for 15.3 months before the start of LD‐EBRT, in the 6 × 0.1 Gy group for 18.8 months. Twenty‐one patients had symptoms on both sides. In 28 patients the pain irradiated into the calf, only in 18 patients it was localized to the sole of the foot. Two patients had received surgery for LD‐EBRT.
Three months after therapy VAS values, CS‐ and QOL‐scores were significantly better after the standard dose in comparison with the very low dose treatment arm. The higher pain relief resulted in a better QOL. Twelve months after therapy about 64% of the patients after 6 × 0.1 Gy had to receive a second treatment series due to insufficient treatment results, in comparison with only 17% of the patients in the standard dose treatment group. As the second series was applied with a standard dose (6 × 1 Gy), patients in the 6 × 0.1 Gy group who were reirradiated showed equally favorable results compared with those in the standard‐dose group who did not receive a second course [26]. This is why the second treatment series in this clinical setting acted as a “salvage therapy.” Another interesting finding was that patients with a good response already at 3 months remained stable or even improved at 12 months. Furthermore, this underlines the long‐lasting efficacy of LD‐EBRT.
Acute side effects or long‐term toxicity did not occur.
In conclusion, this randomized trial established a dose‐response‐relationship of the analgesic effect of LD‐EBRT, thus providing a clinical and methodological proof of the efficacy of 6 × 1 Gy LD‐EBRT on the clinical course of painful heel spurs. The early termination of the study was justified due the interim analysis showing significant differences in the clinical outcome between both treatment arms. Still, the trial was not blinded, so both the patients and the staff were aware of the received dose. With modern linear accelerators, a complete blinding of the staff is nearly impossible. The only option would be a shame irradiation with closed collimator jaws, reducing the dose to the unavoidable “leakage” radiation. A much easier and straight forward way was used in the above‐mentioned study by application of a minimal physical dose with 0.1 Gy. Another critical point might be that only half of the patients were examined 12 months after therapy (
Another potential confounder not only in this study but also in all other published prospective and retrospective case series might be that a lot of the patients had received diverse and other conservative therapies before being referred to LD‐EBRT. An interaction between one of these other treatments and LD‐EBRT cannot be ruled out due to methodological reasons. This reflects clinical reality. Still, an interaction between one of these therapies and LD‐EBRT is rather unlikely and counter‐intuitive, as patients were referred to LD‐EBRT after the clinical failure of all the other conservative treatments.
Two randomized studies investigated the efficacy of 0.5 Gy single dose in comparison to 1 Gy.
The first trial was conducted by Heyd et al. [30]. They randomized 130 patients between 6 × 0.5 Gy twice weekly (low dose) and 6 × 1 Gy (standard dose). A linear accelerator was used, applying a single field technique.
Inclusion criteria were clinical signs of a painful heel spur, radiological evidence of spur formation, patient age ≥30 years and a relapse after previous conservative treatments, in patients >45 years LD‐EBRT could be used as the primary treatment. Endpoints of the study were changes in the “original” calcaneodynia score [31], that was documented before LD‐EBRT, at the end of the course, and 6 weeks and 6 months afterward.
One hundred and thirty patients were randomized. Mean age was 58.4 years. A 102 patients suffered from a plantar, one patient from a dorsal, and 27 patients from combined spurs. In mean, patients had been suffering from symptoms for 9.8 months. The symptoms had been present in 58 patients for less than 6 months, in 72 patients for a longer time. In 7 heels LD‐EBRT was the first therapeutic approach.
At the end of LD‐EBRT, 66% in the low dose group vs. 59% in the standard dose experienced an improvement in symptoms, 6 weeks later 80 vs. 85%. At this time point, 1.5% in each group reported an increase in symptoms, 19 vs. 14% no change. No statistically significant differences were noted. In case of insufficient treatment results patients were offered a second EBRT series. Thus 26 vs. 37% were treated a second time. Six weeks after that, 71 vs. 79% of these patients reported a further improvement. Six months after LD‐EBRT 88% of the patients in both groups had an amelioration of their symptoms, the remaining patients reported no change. During the EBRT series a slight increase in pain was reported by 26 vs. 29% of the patients. No other acute or late toxicity occurred.
In conclusion, 6 × 0.5 Gy twice weekly was as effective as 6 × 1 Gy.
These results were confirmed by a second randomized trial [32, 33]. Ott et al. randomized 457 patients between 6 × 0.5 Gy (low dose) and 6 × 1 Gy (standard dose). In contrast to the above‐cited “Heyd‐study” [30] an X‐ray unit (orthovoltage) and not linear accelerators was used. Patients received a single field (6 × 8 cm on the plantar calcaneus) with 150 kV, 15 mA, 1 mm Cu‐filter, with source‐to‐skin distance (SSD) of 40 cm. Six weeks after the LD‐EBRT a second series was offered to patients with an insufficient response. The endpoint was pain reduction. CS score and VAS values were measured before and at the end of LD‐EBRT (early response), 6 weeks (delayed), and 2.5 years (long‐term) afterward.
With a median follow‐up of 32 months the mean VAS values before treatment, for early, delayed, and long‐term response for the 0.5 and 1.0 Gy groups were 65.5 ± 22.1 and 64.0 ± 20.5 (
Taken together, the above‐mentioned studies proofed an equivalent clinical efficacy of 6 × 0.5 Gy in comparison to 6 × 1 Gy, thus defining a new clinical treatment standard with six times 0.5 Gy twice weekly as the minimum effective dose.
Before proofing 0.5 Gy as the new standard single dose, another randomized study tried to increase efficacy in reaching the “old” cumulative dose of 6 Gy with a single dose of 0.5 Gy. Niewald et al. randomized between 6 × 1 Gy twice a week (old “standard dose”) and 12 × 0.5 Gy three times a week (“experimental dose”) [25]. The aim was not just to get comparable results, but to further improve the analgesic effects. Linear accelerators (6 MV photons) applying a lateral opposing field technique were used.
Inclusion and exclusion criteria were quite similar to the ones used in the landmark study [26]: Clinical evidence of a painful heel spur, and duration of the symptoms for more than 6 months; radiological proof of a spur formation; age at least 40 years; Karnofsky‐Index at least 70%. Patients with previous radiotherapy or previous trauma to the foot, rheumatic or vascular diseases, lymphatic edema, pregnancy, breastfeeding, or severe psychiatric disorders were excluded. Concomitant therapy with analgesics was allowed. However, patients receiving surgery or shock wave therapy after randomization were excluded.
Endpoints were the SF‐12 sum score, the CS sum score (Table 2), and VAS. Follow‐up was scheduled every 6 weeks for 1 year.
Two‐hundred and forty patients were calculated to detect a difference of 15% in the VAS and CS score, with a power of 80%, and an error probability of 5%. After randomization of 127 patients and an interim analysis of 107 patients, the study was closed early, as the intended increase in analgesic efficacy by the experimental treatment was very unlikely to be achieved.
The mean age of the patients in the standard group was 56.1 Gy in comparison with 58.1 Gy in the experimental group. The mean duration of symptoms before initiation of LD‐EBRT was 17 vs. 16 months. In 98% of the standard group and 93% of the experimental group a plantar spur was treated, in 2 and 7% a combined (plantar and dorsal) spur.
Results after 3 months have been issued so far [25], longer follow‐up has yet to be published. After 3 months, there were no significant differences neither in the VAS (standard 42.3 vs. experimental 44.4) nor the CS sum score (28 vs. 28.4) nor in the QOL (SF‐12) scores. Although longer follow‐up has to be awaited, a further increase in the analgesic effect by applying 12 × 0.5 Gy three times a week is unlikely. This is why this fractionation schedule is currently not recommended, as it does not follow the “as low as reasonable achievable” principle of radiation protection.
Further reduced single doses in LD‐EBRT (with the exception of 0.1 Gy [26]) have never been tested in a prospectively randomized clinical trial. In radiotherapy of degenerative joint disorders, single doses of about 0.3–0.4 Gy were established by von Pannewitz in the late 1920s and published in 1933 and 1970 [34, 35]. However, two studies on calcaneodynia have raised serious concerns on single doses as low as 0.3 Gy.
Seegenschmiedt et al. analyzed treatment efficacy in 141 patients (170 irradiated heels), who were treated from 1984–1994 with X‐ray units (250 kV/200 kV, 20 mA, 40 cm SSD), applying a single field of 6 × 8 cm [24]. Seventy‐two heels received 12 Gy with 6 × 1 Gy (three times a week) –6 weeks break – 6 × 1 Gy (group A), 50 heels were treated with 10 × 0.3 Gy every day (group B1), and 38 heels 10 × 0.5 Gy every day (group B2). The endpoint was the value of a semiquantitative pain score 3 months and in mean 4 years after LD‐EBRT.
The median age of patients was 55 years in group A and 59 years in group B1/B2. The mean duration of symptoms before LD‐EBRT was 8 months, in one‐third, the symptoms persisted for more than 6 months.
Complete pain remission was achieved in 68–71% of the patients without significant differences between the treatment groups. However, there were differences in the clinical course of patients with partial remission of the symptoms: The best results in these patients were achieved during longer follow‐up in group B1 (10 × 0.5 Gy), followed by group A (6 × 1–6 × 1 Gy), followed by group B2 (10 × 0.3 Gy). The latter group showed a significantly worse amelioration of symptoms than the other groups.
A reduced efficacy was also reported in another retrospective case series, comprising 673 heels treated with a single dose of 0.3 Gy three times weekly up to 1.5 Gy (X‐ray) [36]. In case of insufficient treatment results the patients were offered a second course. After the first treatment, only 13% reported CR, nearly all patients had undergone a second LD‐EBRT.
Taken together, to the best of our current knowledge a single dose of 0.5 Gy is standard of care and should only be modified in controlled clinical trials.
In Table 3 selected contemporary randomized trials and patient series are shown broken down into several factors that might be correlated with treatment efficacy. For a better overview, we did not differentiate between univariate and multivariate analyses. We did not try to collect all ever published data.
Duration of symptoms before start of LD‐EBRT has been shown to be correlated with treatment efficacy in numerous studies.
Muecke et al. analyzed in a retrospective multicenter study 502 patients [22]. Duration of symptoms ≤6 months was associated with 76% treatment success vs. 44% after a history >6 months. Also Seegenschmiedt et al. found in their large collectives a correlation between the duration of heel pain and treatment outcome [24]. A significant influence of duration of symptoms before LD‐EBRT was also reported in 73 heels by Schneider et al. [37]. With a history of 3–6 months, the VAS value was reduced by 85%, 28 months after LD‐EBRT in comparison with a reduction of 58% with a history > 6 months. Similar results were obtained by Hermann et al. in 285 heels comparing <12 month history of pain vs. >12 months [38].
In contrary, another study could not confirm these results [30].
To the best of our knowledge, in no study, an influence of gender on treatment outcome has been confirmed [22, 24, 30, 38, 39]. In contrast to radiotherapy for oncological indications with high doses, efficacy and tolerability of LD‐EBRT seems to be the same concerning gender.
Several studies described a correlation between older age and better treatment results, at least 6 weeks after LD‐EBRT [37]. Age somewhat over 50 years seems to be important: >50 years [40], > 53 [38], or > 58 [22]. For a possible explanation see Section 2.3.7.
However, other studies found no influence of this patient characteristic on treatment outcome [24, 30, 39].
A very precise registration of changes in pain intensity (VAS) was done by Schneider at al. [37]. Sixty‐two patients (73 treated heels) were prospectively scored every week during LD‐EBRT, at the end of therapy, 6 weeks, 28 months, and 40 months later. Additionally, subjective mechanical heel stress during LD‐EBRT was estimated. A linear accelerator (10 MV) was used, applying one single field with a size of 12 × 17 cm. Patients were treated twice a week to a total dose of 5 Gy, with increasing single fraction doses (0.25 – 0.25 – 0.5 – 1 – 1 – 1 – 1 Gy). Mean patient age was 54 years, and all had a radiologically proven plantar spurn, mean symptom duration before LD‐EBRT was 6.5 months. Nearly all patients had received other conservative therapies before LD‐EBRT with insufficient results.
Interestingly, VAS scores decreased continuously during LD‐EBRT: before treatment the mean value was 6.3 ± 1.5, after the first week of LD‐EBRT 6.2 ± 1.8, after the second week 5.5 ± 2 (
In standard schedules with fixed single doses a slight increase in pain during the treatment series was reported by 26% (during 6 × 0.5 Gy) vs. 29% (6 × 1 Gy) of the patients [30]. Unfortunately, a possible correlation of this phenomenon with definite treatment results was not investigated.
Without further quantification, another study (6 × 1 vs. 6 × 0.1 Gy) stated, that this initial increase in symptoms “had no influence on the final pain relief 3 and 12 months after treatment” [26]. Older studies postulated a temporary reduction of the pH value in the irradiated tissues at the beginning of the treatment series, without consequences for the long‐term efficacy of LD‐EBRT [41].
This is contrasted by observations of LD‐EBRT in peritendinitis humeroscapularis [42]. In 73 patients (86 shoulders) initial increase of pain during the treatment course was significantly associated with a good response.
Muecke et al. analyzed in a retrospective multicenter study the influence of different treatment techniques in 502 patients [22]. Treatment failure was defined as pain persistence after LD‐EBRT and recurrence of pain during follow‐up. Treatment with MV (6–10 MV) was a significant prognostic factor for pain relief in multivariate analysis, as MV was associated with an eight‐year event‐free probability of 68 vs. 61% after X‐ray beams (175 kV). There are two possible explanations for this finding: besides the possibility of a random result, the authors postulate a more homogenous dose distribution with MV treatment in comparison with KV [22].
Schneider et al. reported an efficacy of just one‐third after a second LD‐EBRT course (so‐called “re‐irradiation”) in comparison with the effects of the first course [37]. Out of 73 heels treated with 5 Gy LD‐EBRT 18 heels received reirradiation due to insufficient treatment response. However, pain reduction measured by means of changes in VAS shortly after the second course and during long‐term follow‐up was significantly diminished in comparison with the efficacy of the first course (about 30% reduction in pain at the last evaluation vs. 86%).
Similar results were obtained in the large retrospective series (502 patients) by Muecke et al. [22]. Treatment failure was significantly associated with the number of treatment series: eight‐year event‐free probability was about 70% after the first course in comparison with just about 30% after reirradiation.
A systematic study on the efficacy of a reirradiation has been published by Hautmann et al. [43]. Eighty‐three patients (101 heels) with insufficient response to the first course or recurrent pain afterward due to plantar fasciitis (83 heels), or achillodynia (28 heels) received a second LD‐EBRT course in median 10 weeks (range 4 weeks to 63 months) after the first LD‐EBRT. About 75% of the patients were treated with 6 × 1 Gy, the others 6 × 0.5 Gy. The pain was assessed using the numeric rating scale (NRS) before and at the end of LD‐EBRT, 6, and 12 weeks, and 6, 12, and 24 months thereafter.
Before reirradiation NRS values were 6 (interquartile range 5–8), at the end of LD‐EBRT 5 (2–6), 6 weeks later 2 (1–4), at 12 weeks 1 (0–3), at 6 months 0 (0–2), at 12 and 24 months 0 (0–1). Interestingly, not only the patients with recurrent pain after the first course but also patients with insufficient responses to the first course experienced a profound and long‐lasting amelioration of their symptoms after the second course.
This is why a second treatment course should be recommended in case of insufficient efficacy of the first course.
A significant correlation between avoidance of heel stress during LD‐EBRT and efficacy of LD‐EBRT 6 weeks after therapy was reported by Schneider et al. in 73 heels [37]. With a Pearson\'s correlation coefficient of -0.467 (
An intuitive explanation is given by the authors [37]: As patient age was associated with positive treatment results, too, they proposed that older patients are often retired, thus being able to take more care of their heels.
Interestingly, all randomized trials required the radiological proof of a heel spur before including patients into the studies. Furthermore, most of the prospective and retrospective series warranted such an objective sign. However, as a substantial part of the patients suffers from plantar heel pain without having developed a heel spur, LD‐EBRT should be effective in these patients, too.
Hermann et al. analyzed treatment efficacy in 250 patients (285 heels), who received LD‐EBRT predominantly with 6 × 1 Gy [38]. In this series, 33% of the treated heels were without radiological evidence of a spur. In 185 patients a spur was confirmed with a mean length of 6.5 mm (range 0.6–25 mm). Patients without evidence of a plantar heel spur had a significantly higher chance of CR after LD‐EBRT (43 vs. 35%). Furthermore, the length of the spurs correlated directly with treatment outcome. Spurs >6.5 mm had just a 30% chance of experiencing CR in comparison with shorter ones. No statistical differences were found between treatment results of heels without spurs and those with spurs ≤6.5 mm.
Miszczyk et al. reported on 327 patients (623 LD‐EBRT series) mostly treated with X‐ray (180 kV, usually 1mm Cu filters) with single doses of 1.5 Gy (range 1–3 Gy) up to a total dose between 9 and 12 Gy (range 1–45 Gy) [39]. Mean spur size was 9 mm (range 1–30 mm). With a mean follow‐up of 74 months, no correlation between spur size and duration of pain relief was found. Analysis concerning spur length and treatment outcome in itself were unfortunately not reported.
Multivariate logistic regression enables the identification of factors independently predicting treatment outcome. By combining these factors, models can be calculated, that predict treatment outcome with a high probability. An example from the study of Hermann et al. is given in Table 4: in 285 heels treated with 6 × 1 Gy/6 × 0.5 Gy the influences of the patient characteristics age, spur length, and duration of symptoms before LD-EBRT alone and in combination were calculated [38]. The best results were obtained for patients > 53 years, spur length <6 mm, and a duration of symptoms <12 months with a probability for CR of 55% (CI 36–73%) and PR of 38% (CI 22–58%). Without these characteristics, the chance for CR was just 18% (CI 9–33%), for PR 31% (17–48%).
Study (citation) | [30] | [26] | [24] | [37] | [39] | [22] | [38] | [40] | [83] |
---|---|---|---|---|---|---|---|---|---|
Rand | Rand | Prospect | Prospect | Retrospect | Retrospect | Retrospect | Retrospect | Retrospect | |
130 | 66 | 170 | 73 | 623 | 502 | 285 | 161 | 7947 | |
MV | MV | KV | MV | KV | MV, KV | MV | KV | MV, KV | |
calcaneus | calcaneus | calcaneus | entire dorsal and middle foot | insertion of plantar fascia | calcaneus | calcaneus vs. insertion of calcaneus | calcaneus | entire dorsal foot vs. calcaneus vs. insertion of plantar fascia | |
6 × 1 vs. 6 × 0.5 Gy | 6 × 1 Gy vs. 6 × 0.1 Gy | 12, 3, 5 Gy | 5 Gy (increasing single dose) | 1.5 (1–3) up to 9–12 Gy (1–45) | 5–10 × 0.5–1 Gy | 6 × 1 Gy6 × 0.5 Gy | 6 × 1 Gy | 0.3–1.5 Gy; 2–3x weekly 2.5–18.76 Gy | |
History of symptoms | 0 | n.i. | + | + | 0 | + | + | + | + |
Gender | 0 | n.i. | 0 | n.i. | 0 | 0 | 0 | n.i. | n.i. |
Patient\'s age | 0 | n.i. | 0 | + | 0 | + | + | + | n.i. |
Initial worsening of pain during LD‐EBRT | n.i. | n.i. | n.i. | n.i. | n.i. | n.i. | n.i. | n.i. | n.i. |
MV vs. KV | n.i. | n.i. | n.i. | n.i. | n.i. | + | n.i. | n.i. | 0 |
Number of therapy series | n.i. | n.i. | n.i. | + | n.i. | + | n.i. | n.i. | + |
Heel stress during LD‐EBRT | n.i. | 0 | n.i. | + | n.i. | n.i. | n.i. | n.i. | n.i. |
Factors associated with treatment efficacy in contemporary studies.
Patient\'s age >53 | No spur or spur ≤6.5 mm | Duration of symptoms <12 months | Probability of | ||
---|---|---|---|---|---|
No change | Partial remission | Complete remission | |||
1 | 1 | 1 | 0.07 (0.03–0.14) | 0.38 (0.22–0.58) | 0.55 (0.36–0.73) |
1 | 1 | 0 | 0.13 (0.07–0.28) | 0.37 (0.21–0.57) | 0.50 (0.30–0.70) |
1 | 0 | 1 | 0.15 (0.06–0.24) | 0.53 (0.33–0.72) | 0.32 (0.17–0.53) |
1 | 0 | 0 | 0.25 (0.13–0.45) | 0.48 (0.27–0.69) | 0.27 (0.13–0.48) |
0 | 1 | 1 | 0.17 (0.10–0.31) | 0.33 (0.19–0.50) | 0.50 (0.33–0.66) |
0 | 1 | 0 | 0.34 (0.20–0.53) | 0.40 (0.24–0.59) | 0.26 (0.13–0.45) |
0 | 0 | 1 | 0.30 (0.20–0.46) | 0.29 (0.18–0.43) | 0.41 (0.27–0.56) |
0 | 0 | 0 | 0.51 (0.35–0.69) | 0.31 (0.17–0.48) | 0.18 (0.09–0.33) |
Probabilities (95%‐CI) for NC, PR and CR calculated by polytomous logistic regression in dependence of the risk factors age, spur length, and duration of symptoms before LD‐EBRT according to Hermann et al. in a collective of 285 heels treated with 6 × 1/6 × 0.5 Gy (taken from [38]).
In modern radiotherapeutic departments, X‐ray sources are less and less available. This is why nowadays most patients are treated with linear accelerators, which were initially developed for the treatment of oncological diseases. However, these machines can be used in the treatment of benign diseases without any modifications or problems. Due to the high efforts in physical, technical, and organizational quality assurances for the operation of an accelerator or an X-ray source, the concentration on accelerators and their use for all indications is recommended.
For irradiation of the heel, the patient has to be placed on the treatment couch with the feet toward the gantry of the accelerator (so‐called “feet first”). Two different patient positions are widely used. He can be placed in supine position, with the irradiated leg is stretched out, while the other leg is angled. Another option is to place the patient in a lateral decubitus position on the side of the involved heel. Again, the symptomatic leg is stretched, while the contralateral leg is bent, with a cushion placed beneath the knee. Using X‐rays, the ipsilateral knee is bent by 90% and the foot is positioned on the treatment table. One anterior‐posterior (AP) beam is usually applied in this technique.
For the treatment itself, there are also two different options. Irradiation may be given as a single stationary field (SSD 100cm by convention). Alternatively, parallel opposing fields from 0° and 180° gantry position (in decubitus position) or lateral opposing fields (90° and 270° in supine position) are also applicable but take a little bit longer in daily clinical practice. The hypothetical advantage of using two opposing fields is a uniform dose distribution in the entire beam path in the calcaneus (Figure 1). However, there has never been a clinical proof, whether this theoretical assumption translates into any clinical advantage for the patient. When applying opposing fields, the dose is specified according to the ICRU 50 report, normally in the center of the calcaneus.
Dose distribution of two different treatment techniques generated in a treatment planning system (XIO®). In A and B just one single 6 MV photon field (8 × 8 cm) is applied, while C and D shows the dose distribution with two opposing fields from 0 and 180°. In the upper row, the so‐called “beams eye views” are given, while in the lower row the respective dose distributions on an axial CT scan directly at the calcaneal insertion are shown. Note the more uniform dose distribution with opposing fields. The 95% isodose is given as a green line (2.85 Gy). This dose encompasses larger parts of the calcaneal bone in D (opposing fields) than in B (single field). More information is given in Section 2.4.
A third option is the so‐called “plantar field” with the patient lying in prone position. A single field is positioned directly over the plantar insertion/calcaneus, potentially with rotations of the patient table and the gantry to compensate for inclinations of the patients surface in the irradiated field. However, this technique is regarded problematic when using linear accelerators due to the dose build‐up effect in the critical tissue depth. This problem is illustrated in Figure 2: photons with 6 MV reach just the half of the prescribed dose at the skin level, 100% is reached at 1.5 cm tissue depth. This would result in an insufficient dose in the critical structures (plantar fascia and heel spur). To overcome this problem, a silicone flap of about 1 cm diameter must be positioned on the skin before radiation.
Depth curves of different megavoltage energies. Blue 6 MV photons, red 15 MV photons. At the surface of the body/skin (depth 0 mm), only half (or even less with 15 MV) of the prescribed dose is applied. By physical interactions between photons and the tissue/water, there is a steep increase in dose. A 100% is reached at 1.5 cm depth with 6 MV and at about 3 cm depth with 15 MV. KV‐radiation reaches the maximum dose directly under the surface/skin (not shown). More information is given in Section 2.4.
Patients are often sent to the radiotherapist after a long unsuccessful history of diverse conservative treatments. The reason for this is a widespread fear among general practitioners that LD‐EBRT might be associated with severe side effects and risks. These fears are not substantiated, as reactions of the nerves or vessels require much higher doses than used for LD‐EBRT. For example, a dose of 45 Gy in normofractionated oncological therapy is considered to be safe for the spinal cord and therefore daily clinical practice [44]. Peripheral nerves are even more radioresistant. Acute or chronic side‐effects have never been reported in all contemporary studies on LD‐EBRT.
Acute side effects are negligible, as very low doses of ionizing radiation (in comparison with oncological treatments) are applied to a distal extremity. The total dose of LD‐EBRT with 3 or 6 Gy is far too low to cause any acute or late reactions on the skin overlaying the calcaneus. During normofractionated EBRT (single doses of 1.8–2 Gy, treatment on 5 days a week) erythema and mild edema develop at about 30 Gy [45]. Hyperpigmentation occurs at about 45 Gy, moist epitheliolyses at about 50 Gy. A 50–60 Gy might cause telangiectasias years after the therapy. This is why there is no report on acute treatment side effects in LD‐EBRT until now to the best of our knowledge.
About one‐third of the patients might experience a slight increase in pain during LD‐EBRT. In the randomized trial by Heydt et al. this phenomenon was seen in 26% (during 6 × 0.5 Gy) vs. 29% (6 × 1 Gy) [30]. It does not seem to be correlated with treatment outcome; further detailed information is given in Section 2.3.4.
The dose scattered to the male gonads is somewhat higher than to the ovaries. Jansen et al. calculated for 6 × 0.5 Gy about 1.5 mSv received by the testes and 0.75 mSv to the ovaries [46]. Comparable results have repeatedly been measured in the past [47, 48].
Taken together, the dose received by the gonads is insignificant. As the distal extremity is irradiated, scattered dose to the gonads is comparable to normal diagnostic radiological imaging [49]. The hereditary effects of these doses are very small and very likely negligible [46].
Although spermatogonial cells are very radiosensitive, a single dose of at least 100 mSv is needed to induce a temporary failure of spermatogenesis [50]. A single dose of 1000 mSv (equivalent to 1 Gy photon irradiation) results in an azoospermia for 9–18 months [51]. Interestingly, fractionated doses harm these cells even more. A temporary oligospermia is reported after receiving several fractions up to a cumulative dose of 160 mSv [52]. An azoospermia lasting for 14–22 months has been reported for fractionated doses of 620–860 mSv [53]. The actually during LD‐EBRT received testicular dose is about 100 times smaller than the lowest dose causing temporary changes in testicular tissues.
The dose to the testicles can be further reduced by utilizing a special testicular shielding. However, clinically meaningful dose reductions have been only measured in MV treatment of subdiaphragmatic/pelvine lymphatic regions or tumors [54, 55].
The mean lethal dose for human oocytes has been estimated at 2 Gy (2000 mSv) [56]. Permanent ovarian failure after radiotherapy is age dependent: in perimenopausal women, a dose of 6 Gy is sufficient [57], while in younger women up to 20 Gy are tolerated. The dose scattered to the ovaries during LD‐EBRT for calcaneodynia cannot cause such sequelae (0.75 mSv).
Naturally, pregnancy has to be excluded in all premenopausal women before beginning with LD‐EBRT, to avoid any risk to the fetus.
So far, no studies with long‐term observation periods have been published, describing a case of malignancy induced by LD‐EBRT for calcaneodynia. However, induction of malignancies is a stochastic effect of ionizing radiation. This means that there is no threshold dose—in contrast for example to the above‐mentioned reactions of the skin. A photon can accidentally trigger a mutation, which in turn leads to tumor formation many years later. The higher the radiation dose, the higher the probability of such an event occurring.
The best available data on tumor induction of full dose EBRT in oncology has been collected in patients treated with breast cancer. Almost 11,000 patients have been followed for over 20 years. The risk of a radiation‐induced tumor was approx. 1% per decade after radiotherapy [58].
To estimate the risk associated with much lower doses of LD‐EBRT, mathematical models on the basis of epidemiological long‐term observations of atomic bomb victims have been developed by the ICRP [59].
Jansen et al. applied the ICRP model on LD‐EBRT of a painful heel spur [46]. Assumed was a single field entering at the foot sole with a size of 8 × 10 cm, 200 kV photons, SSD 40 cm. For an LD‐EBRT series with 6 × 1 Gy the average attributable lifetime risk for induction of a fatal tumor was calculated to be about 0.5 in a thousand patients. An important risk factor for radiogenic‐induced cancer is the patient\'s age by the time the radiation exposure occurs. The risk is already reduced in the 3rd decade of the patient\'s life, it starts to decrease steadily from the age of 40 [60]. Applying these calculations, the estimated lifetime risk per one thousand patients for a fatal tumor accounts for the age of 25 0.6 (male)/0.8 (female), for the age of 50 0.2/0.3, for the age of 75 0.07/0.1 [46].
However, it must be critically noted that this mathematical model was developed for radiation protection and relates to the exposure of complete organ systems with approx. 1 Gy. Therefore, other groups argue that a significantly lower risk of radiogenic cancer induction— approx. ten times less—should be adopted [49, 61]. Furthermore, taken the new standard scheme with 6 × 0.5 Gy into account, these risks are additionally halved.
This risk (max. 1/1000, very likely much lower) must be seen in relation to the tumor risk of the not additionally radiotherapeutical‐treated population. In 2008, the lifetime risk of a man in Germany to suffer from cancer was 50.7% (25.9% to die from malignancy), in women 42.8% and 20.2% respectively [62].
By limiting the application of LD‐EBRT treatment to patients > 30 years of age, an exposure of the juvenile “relatively higher risk” patient population is avoided.
Traditionally target volume definition has been quite large. Field sizes of 12 × 17cm were treated, including the entire dorsal and middle foot, and not just the calcaneus [37, 82] (Figure 3A).
Field definitions in LD‐EBRT of a painful plantar heel spur/fasciitis. (A) traditional field definition including the entire dorsal and middle foot. (B) In randomized trials and large prospective series commonly used field definition encompassing the entire calcaneus, including insertion of the plantar fascia and the Achilles tendon. (C) Proposed small field definition for localized painful plantar fasciitis/plantar spur, encompassing only the painful area with 2 cm margins extending into the neighboring areas (calcaneus, fascia, fat pad).
In the recent randomized trials and prospective observational studies target volume definition was more restricted and confined to the calcaneus (Figure 3B). “The target volume consisted of the calcaneus and the region of the plantar aponeurosis” [26]. “The ventral margin is corresponding to the ventral surface of the calcaneus, the plantar and dorsal margins are surrounding the soft‐tissue border, and the cranial margin is below the ankle” [30]. “Target volume is the calcaneus, normally with a field size of 6 cm × 8 cm” [32]. “The calcaneus and the plantar aponeurosis were included in the target volume” [25].
In a German national survey 2001 on LD‐EBRT of painful heel spurs the target volume definition “large” (dorsal and middle foot) vs. “small” (entire calcaneus) was not correlated with treatment outcome [83]. Consequently, very large field definitions should be regarded as obsolete.
However, as the pathophysiological cause of calcaneodynia is thought to be a localized inflammatory process (see Section 1), it is questionable, whether the entire calcaneus has to be irradiated (as long as there are not a plantar as well as a painful dorsal spurs). There are some clinical data that support a further restriction of target volume definition.
Field sizes have been given in the study by Miszczyk et al. on 327 patients treated with X‐ray beams [39]. Target volume was “… the insertion of the plantar fascia with a calcaneal spur and a reasonable margin. The field size varied from 27 to 150 cm2 (mean 47 cm2).” However, although not explicitly stated, no correlation was found between field size and duration of pain relief after LD‐EBRT. Treatment efficacy in itself was apparently not investigated.
In the above‐mentioned series of 285 heels Hermann et al. analyzed treatment efficacy in dependence of field sizes, too [38]. The mean field size was 74 cm2. No correlation between field size (smaller vs. larger than 74 cm2) with treatment efficacy was found. Further analyses of small fields (< 6 × 6 cm), medium‐sized fields (36–64 cm2) and larger fields revealed no significant differences.
This is why it seems to suffice to encompass the painful region with 2 cm margins extending into the neighboring areas (calcaneus, fascia, fat pad; Figure 3C). However, this recommendation is deducted from pathophysiological considerations and the above‐mentioned case series. A randomized trial is necessary to proof clinical equivalence of a field definition “entire calcaneus” (Figure 3B) vs. “insertion of the plantar fascia” (Figure 3C).
The optimal fractionation schedule has not been elucidated yet. All randomized trial used twice weekly treatments. Only one experimental arm was scheduled three times a week [25]. In a National Survey in Germany with 146 answering institutions, about 45% applied two fractions and 37.5% three fractions weekly [83].
Interestingly, in the landmark study by von Pannewitz a fractionation schedule of only once per week was established [34]. Until now, there is no proof of a higher efficacy applying LD‐EBRT twice or three times per week.
In radiotherapy of another benign disease (endocrine orbitopathy) a 1 Gy per week over 20 weeks schedule was more effective than the standard schedules (10 × 2 Gy or 10 × 1 Gy every working day) [84]. Although other immunological mechanisms cause endocrine orbitopathy in comparison with plantar fasciitis, there is sufficient clinical evidence to test in a randomized trial different fractionation schedules (twice a week vs. once a week, possibly thrice a week).
Other therapies than LD‐EBRT have been applied in painful heel spur. In the following, just a rough overview can be given.
Different kinds of insoles and foot orthoses have been developed. The goal was to reduce plantar contact pressure and to distribute the pressure uniformly over the whole rearfoot [63]. Magnetic insoles do not seem to provide additional benefit [64]. As a short‐term treatment, low‐Dye taping techniques are often used. However, in a randomized trial only a modest improvement in ‘first‐step’ pain was seen in comparison with sham‐intervention [65].
Manual stretching is often recommended. A systematic review of six studies found only statistically significant differences in comparison with the control in one study combining calf muscle and plantar fascia stretches [66].
Several trials have investigated acupuncture. A systematic review from 2010 showed (limited) evidence for the effectiveness [67]. A randomized trial published in 2014 recruited 84 patients [68]. The authors concluded, that “dry needling provided statistically significant reductions in plantar heel pain, but the magnitude of this effect should be considered against the frequency of minor transitory adverse events.”
Ultrasound therapy has led to questionable results [69], but a randomized trial on cryo‐ultrasound with about 100 patients published in 2014 showed good effectiveness [70].
Low‐level laser light (635 nm), given twice a week for a total of six applications, reduced in a randomized trial VAS scores significantly after 8 weeks in comparison with placebo [71]. However, the study comprised of just 69 patients; other similar studies have not been reported so far.
Extracorporeal shock waves are widely applied. Three metaanalyses comprising at least five randomized trials found significant short‐term pain relief and improved functional outcomes for this therapeutic option [72–74]. Another study compared the analgesic efficacy of ultrasound and shock wave therapy in 47 patients [75]. The results suggested that the shock wave therapy had greater analgesic efficacy.
Another basic approach is the oral administration of nonsteroidal anti‐inflammatory drugs (NSAID) to achieve a symptomatic relief. Injections into the painful area are also recommended. A recent review summarized ten randomized trials on corticosteroid injections into the plantar fascia [76]. A significant effect of the steroids on the pain has been shown. However, it was usually short‐term, lasting 4–12 weeks in duration. No advantage of ultrasound‐guided injection techniques in comparison with palpation guidance was found, and no superiority of one type of corticosteroid over another was seen. A longer lasting pain relief has been suggested by a small randomized trial of botulinum toxin injections [77]. Another option is the injection of autologous platelet‐rich plasma. A recent review identified three randomized trials, all showing promising results [78]. However, a very small trial challenged this method of plasma preparation, as the same clinical effectivity was observed after the injection of whole blood [79].
Different surgical approaches have been developed. Releases of the plantar fascia are done, in some studies combined with a spur resection [80]. Due to a probably faster recovery after surgery with comparable functional results endoscopic procedures are recommended nowadays [81]. Surgery is usually indicated after failure of conservative therapies as the ultimate “salvage‐therapy.”
There is only a limited amount of studies randomizing patients between LD‐EBRT and the above‐mentioned alternative therapies.
Canyilmaz et al. randomized 123 patients between LD‐EBRT (6 × 1 Gy, three times a week) and 1 ml injection of 40 mg methylprednisolone and 0.5 ml 60 mg 1% lidocaine under the guidance of palpation [85]. After 3 and 6 months, VAS values and CS‐scores were compared between both groups. After 3 months, the results in the radiotherapy arm were significantly superior compared with those after injections.
To corroborate these findings, similar studies should be conducted. Furthermore, more studies randomizing LD‐EBRT against other therapies (e.g. extracorporeal shock waves) are needed. A minimum size of 50 patients per treatment arm should be assured to gain more statistically relevant results. Recruiting patients without prior excessive other therapies for these studies would be optimal.
The goal must be an evidence‐based algorithm defining the therapeutic sequence of the different conservative treatment modalities for plantar fasciitis.
LD‐EBRT for painful plantar fasciitis/heel spur is an effective and safe treatment option for patients over 30 years of age and after exclusion of pregnancy. A fractionation of 6 × 0.5 Gy twice weekly up to a total dose of 3 Gy is currently recommended. In the case of an insufficient response a second course can be offered to the patient.
Randomized trials on target volume definition and further optimization of LD‐EBRT fractionation are currently in the process of planning. Further trials to compare the different conservative therapies for plantar fasciitis with each other are necessary to allow the development of an evidence‐based treatment algorithm.
This chapter is dedicated to Professor Gisela Hermann‐Brennecke on the occasion of her 70th birthday.
AP | anterior‐posterior |
CI | confidence interval |
CR | complete remission |
CS | Calcaneodynia score |
Cu | chemical element symbol for copper |
EC | endothelial cells |
GCG‐BD | German Cooperative Group on Radiotherapy for Benign Diseases |
Gy | Gray |
ICRP | International Commission on Radiological Protection |
IL | interleukin |
iNOS | inducible nitric oxide synthases |
KV | kilovoltage |
LD‐EBRT | low dose external beam radiotherapy |
mA | milliampere |
mRNA | messenger ribonuclein acid |
mSv | milliSievert |
MV | megavoltage |
NC | no change |
NF‐κB | nuclear factor kappa B |
NO | nitric oxide |
NSAID | non‐steroidal anti‐inflammatory drug |
PBMC | peripheral blood mononuclear cells |
PR | partial remission |
QOL | quality of life |
ROS | reactive oxygen species |
SSD | skin‐to‐source distance |
TGF‐β1 | transforming growth factor β1 |
VAS | visual analogue scale |
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\\n"}]'},components:[{type:"htmlEditorComponent",content:'At IntechOpen, the majority of OAPFs are paid by an Author’s institution or funding agency - Institutions (73%) vs. Authors (23%).
\n\nThe first step in obtaining funds for your Open Access publication begins with your institution or library. IntechOpen’s publishing standards align with most institutional funding programs. Our advice is to petition your institution for help in financing your Open Access publication.
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\n\nPlease consult our Open Access Funding page to explore some of these funding opportunities and learn more about how you could finance your IntechOpen publication. Keep in mind that this list is not definitive, and while we are constantly updating and informing our Authors of new funding opportunities, we recommend that you always check with your institution first.
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Some systems are highly affected by a small fraction of influential nodes. Number of fast and efficient spreaders in a network is much less compared to the number of ordinary members. Information about the influential spreaders is significant in the planning for the control of propagation of critical pieces of information in a social or information network. Identifying important members who act as the fastest and efficient spreaders is the focal theme of a large number of research papers. Researchers have identified approximately 10 different methods for this purpose. Degree centrality, closeness centrality, betweenness centrality, k‐core decomposition, mixed degree decomposition, improved k‐shell decomposition, etc., are some of these methods. In this expository article, we review all previous works done in the field of identifying potential spreaders in a network.",book:{id:"5842",slug:"graph-theory-advanced-algorithms-and-applications",title:"Graph Theory",fullTitle:"Graph Theory - Advanced Algorithms and Applications"},signatures:"Reji Kumar Karunakaran, Shibu Manuel and Edamana Narayanan\nSatheesh",authors:[{id:"200190",title:"Dr.",name:"Reji Kumar",middleName:null,surname:"Karunakaran",slug:"reji-kumar-karunakaran",fullName:"Reji Kumar Karunakaran"},{id:"200193",title:"Mr.",name:"Manuel",middleName:null,surname:"Shibu",slug:"manuel-shibu",fullName:"Manuel Shibu"},{id:"200194",title:"Dr.",name:"E N",middleName:null,surname:"Satheesh",slug:"e-n-satheesh",fullName:"E N Satheesh"}]},{id:"55541",doi:"10.5772/intechopen.68703",title:"Modeling Rooted in‐Trees by Finite p‐Groups",slug:"modeling-rooted-in-trees-by-finite-p-groups",totalDownloads:1138,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Graph theoretic foundations for a kind of infinite rooted in-trees T(R)=(V,E) with root R, weighted vertices v ∈ V, and weighted directed edges e∈E⊂V×V are described. Vertex degrees deg(v) are always finite but the trees contain infinite paths (vi)i≥0. A concrete group theoretic model of the rooted in-trees T(R) is introduced by representing vertices by isomorphism classes of finite p-groups G, for a fixed prime p, and directed edges by epimorphisms π: G → πG of finite p-groups with characteristic kernels ker(π). The weight of a vertex G is realized by its nuclear rank n(G) and the weight of a directed edge π is realized by its step size s(π)=logp(#ker(π)). These invariants are essential for understanding the phenomenon of multifurcation. Pattern recognition methods are used for finding finite subgraphs which repeat indefinitely. Several periodicities admit the reduction of the complete infinite graph to finite patterns. The proof is based on infinite limit groups and successive group extensions. It is underpinned by several explicit algorithms. As a final application, it is shown that fork topologies, arising from repeated multifurcations, provide a convenient description of complex navigation paths through the trees, which are of the greatest importance for recent progress in determining p-class field towers of algebraic number fields.",book:{id:"5842",slug:"graph-theory-advanced-algorithms-and-applications",title:"Graph Theory",fullTitle:"Graph Theory - Advanced Algorithms and Applications"},signatures:"Daniel C. Mayer",authors:[{id:"198580",title:"Dr.",name:"Daniel C.",middleName:null,surname:"Mayer",slug:"daniel-c.-mayer",fullName:"Daniel C. Mayer"}]},{id:"57771",doi:"10.5772/intechopen.71774",title:"Governance Modeling: Dimensionality and Conjugacy",slug:"governance-modeling-dimensionality-and-conjugacy",totalDownloads:1324,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"The Q-analysis governance approach and the use of simplicial complexes—type of hypergraph—allow to introduce the formal concepts of dimension and conjugacy between the network of entities involved in governance (typically organizations) and the networks of those attributes taken into account (e.g. their competences), which offer a specific angle of analysis. The different sources of existing data (e.g. textual corpora) to feed the analysis of governance—environmental in particular—are mentioned, their reliability is briefly discussed and the required pre-processing steps are identified in the perspective of evidence-based analyses. Various indices are constructed and evaluated to characterize the context of governance as a whole, at mesoscale, or locally, i.e. at the level of each of the entities and each of the attributes considered. The analysis of ideal-type stylizing boundary cases provides useful references to the analysis of concrete systems of governance and to the interpretation of their empirically observed properties. The use of this governance modeling approach is illustrated by the analysis of a health-environment governance system in Southeast Asia, in the context of a One Health approach.",book:{id:"5842",slug:"graph-theory-advanced-algorithms-and-applications",title:"Graph Theory",fullTitle:"Graph Theory - Advanced Algorithms and Applications"},signatures:"Pierre Mazzega, Claire Lajaunie and Etienne Fieux",authors:[{id:"220099",title:"Dr.",name:"Pierre",middleName:null,surname:"Mazzega",slug:"pierre-mazzega",fullName:"Pierre Mazzega"},{id:"220102",title:"Dr.",name:"Claire",middleName:null,surname:"Lajaunie",slug:"claire-lajaunie",fullName:"Claire Lajaunie"},{id:"220103",title:"Prof.",name:"Etienne",middleName:null,surname:"Fieux",slug:"etienne-fieux",fullName:"Etienne Fieux"}]},{id:"57940",doi:"10.5772/intechopen.72145",title:"Graph-Based Decision Making in Industry",slug:"graph-based-decision-making-in-industry",totalDownloads:1693,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Decision-making in industry can be focused on different types of problems. Classification and prediction of decision problems can be solved with the use of a decision tree, which is a graph-based method of machine learning. In the presented approach, attribute-value system and quality function deployment (QFD) were used for decision problem analysis and training dataset preparation. A decision tree was applied for generating decision rules.",book:{id:"5842",slug:"graph-theory-advanced-algorithms-and-applications",title:"Graph Theory",fullTitle:"Graph Theory - Advanced Algorithms and Applications"},signatures:"Izabela Kutschenreiter-Praszkiewicz",authors:[{id:"218951",title:"Associate Prof.",name:"Izabela",middleName:null,surname:"Kutschenreiter-Praszkiewicz",slug:"izabela-kutschenreiter-praszkiewicz",fullName:"Izabela Kutschenreiter-Praszkiewicz"}]},{id:"72140",doi:"10.5772/intechopen.91972",title:"Comparative Study of Algorithms Metaheuristics Based Applied to the Solution of the Capacitated Vehicle Routing Problem",slug:"comparative-study-of-algorithms-metaheuristics-based-applied-to-the-solution-of-the-capacitated-vehi",totalDownloads:653,totalCrossrefCites:0,totalDimensionsCites:2,abstract:"This chapter presents the best-known heuristics and metaheuristics that are applied to solve the capacitated vehicle routing problem (CVRP), which is the generalization of the TSP, in which the nodes are visited by more than one route. To find out which algorithm obtains better results, there are 30 test instances used, which are grouped into 3 sets of problems according to the position of the nodes. The study begins with an economic impact analysis of the transportation sector in companies, which represents up to 20% of the final cost of the product. This case study focuses on the CVRP for its acronym capacitated vehicle routing problem, analyzing the best-known heuristics such as Clarke & Wright and sweep, and the algorithms GRASP and simulated annealing metaheuristics based.",book:{id:"8241",slug:"novel-trends-in-the-traveling-salesman-problem",title:"Novel Trends in the Traveling Salesman Problem",fullTitle:"Novel Trends in the Traveling Salesman Problem"},signatures:"Fernando Francisco Sandoya Sánchez, Carmen Andrea Letamendi Lazo and Fanny Yamel Sanabria Quiñónez",authors:[{id:"155426",title:"Ph.D.",name:"Fernando",middleName:"Francisco",surname:"Sandoya",slug:"fernando-sandoya",fullName:"Fernando Sandoya"},{id:"313162",title:"M.Sc.",name:"Carmen",middleName:null,surname:"Letamendi",slug:"carmen-letamendi",fullName:"Carmen Letamendi"},{id:"319376",title:"Dr.",name:"Fanny",middleName:null,surname:"Sanabria",slug:"fanny-sanabria",fullName:"Fanny Sanabria"}]}],mostDownloadedChaptersLast30Days:[{id:"71899",title:"Moments of Catalan Triangle Numbers",slug:"moments-of-catalan-triangle-numbers",totalDownloads:542,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"In this chapter, we consider the Catalan numbers, \n\n\nC\nn\n\n=\n\n1\n\nn\n+\n1\n\n\n\n\n\n\n2\nn\n\n\n\n\nn\n\n\n\n\n\n, and two of their generalizations, Catalan triangle numbers, \n\n\nB\n\nn\n,\nk\n\n\n\n and \n\n\nA\n\nn\n,\nk\n\n\n\n, for \n\nn\n,\nk\n∈\nN\n\n. They are combinatorial numbers and present interesting properties as recursive formulae, generating functions and combinatorial interpretations. We treat the moments of these Catalan triangle numbers, i.e., with the following sums: \n\n\n∑\n\nk\n=\n1\n\nn\n\n\nk\nm\n\n\nB\n\nn\n,\nk\n\nj\n\n,\n\n∑\n\nk\n=\n1\n\n\nn\n+\n1\n\n\n\n\n\n2\nk\n−\n1\n\n\nm\n\n\nA\n\nn\n,\nk\n\nj\n\n,\n\n for \n\nj\n,\nn\n∈\nN\n\n and \n\nm\n∈\nN\n∪\n\n0\n\n\n. We present their closed expressions for some values of \n\nm\n\n and \n\nj\n\n. Alternating sums are also considered for particular powers. Other famous integer sequences are studied in Section 3, and its connection with Catalan triangle numbers are given in Section 4. Finally we conjecture some properties of divisibility of moments and alternating sums of powers in the last section.",book:{id:"8142",slug:"number-theory-and-its-applications",title:"Number Theory and Its Applications",fullTitle:"Number Theory and Its Applications"},signatures:"Pedro J. Miana and Natalia Romero",authors:null},{id:"55642",title:"Monophonic Distance in Graphs",slug:"monophonic-distance-in-graphs",totalDownloads:1534,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"For any two vertices u and v in a connected graph G, a u − v path is a monophonic path if it contains no chords, and the monophonic distance dm(u, v) is the length of a longest u − v monophonic path in G. For any vertex v in G, the monophonic eccentricity of v is em(v) = max {dm(u, v) : u ∈ V}. The subgraph induced by the vertices of G having minimum monophonic eccentricity is the monophonic center of G, and it is proved that every graph is the monophonic center of some graph. Also it is proved that the monophonic center of every connected graph G lies in some block of G. With regard to convexity, this monophonic distance is the basis of some detour monophonic parameters such as detour monophonic number, upper detour monophonic number, forcing detour monophonic number, etc. The concept of detour monophonic sets and detour monophonic numbers by fixing a vertex of a graph would be introduced and discussed. Various interesting results based on these parameters are also discussed in this chapter.",book:{id:"5842",slug:"graph-theory-advanced-algorithms-and-applications",title:"Graph Theory",fullTitle:"Graph Theory - Advanced Algorithms and Applications"},signatures:"P. Titus and A.P. Santhakumaran",authors:[{id:"198301",title:"Dr.",name:"P.",middleName:null,surname:"Titus",slug:"p.-titus",fullName:"P. Titus"},{id:"199035",title:"Prof.",name:"A. P.",middleName:null,surname:"Santhakumaran",slug:"a.-p.-santhakumaran",fullName:"A. P. Santhakumaran"}]},{id:"71501",title:"Accelerating DNA Computing via PLP-qPCR Answer Read out to Solve Traveling Salesman Problems",slug:"accelerating-dna-computing-via-plp-qpcr-answer-read-out-to-solve-traveling-salesman-problems",totalDownloads:783,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"An asymmetric, fully-connected 8-city traveling salesman problem (TSP) was solved by DNA computing using the ordered node pair abundance (ONPA) approach through the use of pair ligation probe quantitative real time polymerase chain reaction (PLP-qPCR). The validity of using ONPA to derive the optimal answer was confirmed by in silico computing using a reverse-engineering method to reconstruct the complete tours in the feasible answer set from the measured ONPA. The high specificity of the sequence-tagged hybridization, and ligation that results from the use of PLPs significantly increased the accuracy of answer determination in DNA computing. When combined with the high throughput efficiency of qPCR, the time required to identify the optimal answer to the TSP was reduced from days to 25 min.",book:{id:"8241",slug:"novel-trends-in-the-traveling-salesman-problem",title:"Novel Trends in the Traveling Salesman Problem",fullTitle:"Novel Trends in the Traveling Salesman Problem"},signatures:"Fusheng Xiong, Michael Kuby and Wayne D. Frasch",authors:[{id:"14757",title:"Prof.",name:"Wayne",middleName:null,surname:"Frasch",slug:"wayne-frasch",fullName:"Wayne Frasch"},{id:"317054",title:"Prof.",name:"Michael",middleName:null,surname:"Kuby",slug:"michael-kuby",fullName:"Michael Kuby"},{id:"317055",title:"Dr.",name:"Fusheng",middleName:null,surname:"Xiong",slug:"fusheng-xiong",fullName:"Fusheng Xiong"}]},{id:"72027",title:"Identification of Eigen-Frequencies and Mode-Shapes of Beams with Continuous Distribution of Mass and Elasticity and for Various Conditions at Supports",slug:"identification-of-eigen-frequencies-and-mode-shapes-of-beams-with-continuous-distribution-of-mass-an",totalDownloads:904,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"In the present article, an equivalent three degrees of freedom (DoF) system of two different cases of inverted pendulums is presented for each separated case. The first case of inverted pendulum refers to an amphi-hinge pendulum that possesses distributed mass and stiffness along its height, while the second case of inverted pendulum refers to an inverted pendulum with distributed mass and stiffness along its height. These vertical pendulums have infinity number of degree of freedoms. Based on the free vibration of the above-mentioned pendulums according to partial differential equation, a mathematically equivalent three-degree of freedom system is given for each case, where its equivalent mass matrix is analytically formulated with reference on specific mass locations along the pendulum height. Using the three DoF model, the first three fundamental frequencies of the real pendulum can be identified with very good accuracy. Furthermore, taking account the 3 × 3 mass matrix, it is possible to estimate the possible pendulum damages using a known technique of identification mode-shapes via records of response accelerations. Moreover, the way of instrumentation with a local network by three accelerometers is given via the above-mentioned three degrees of freedom.",book:{id:"8142",slug:"number-theory-and-its-applications",title:"Number Theory and Its Applications",fullTitle:"Number Theory and Its Applications"},signatures:"Triantafyllos K. Makarios",authors:[{id:"69418",title:"Prof.",name:"Triantafyllos",middleName:"Konstantinos",surname:"Makarios",slug:"triantafyllos-makarios",fullName:"Triantafyllos Makarios"}]},{id:"57940",title:"Graph-Based Decision Making in Industry",slug:"graph-based-decision-making-in-industry",totalDownloads:1693,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Decision-making in industry can be focused on different types of problems. Classification and prediction of decision problems can be solved with the use of a decision tree, which is a graph-based method of machine learning. In the presented approach, attribute-value system and quality function deployment (QFD) were used for decision problem analysis and training dataset preparation. A decision tree was applied for generating decision rules.",book:{id:"5842",slug:"graph-theory-advanced-algorithms-and-applications",title:"Graph Theory",fullTitle:"Graph Theory - Advanced Algorithms and Applications"},signatures:"Izabela Kutschenreiter-Praszkiewicz",authors:[{id:"218951",title:"Associate Prof.",name:"Izabela",middleName:null,surname:"Kutschenreiter-Praszkiewicz",slug:"izabela-kutschenreiter-praszkiewicz",fullName:"Izabela Kutschenreiter-Praszkiewicz"}]}],onlineFirstChaptersFilter:{topicId:"1399",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:106,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403",scope:"Artificial Intelligence (AI) is a rapidly developing multidisciplinary research area that aims to solve increasingly complex problems. In today's highly integrated world, AI promises to become a robust and powerful means for obtaining solutions to previously unsolvable problems. This Series is intended for researchers and students alike interested in this fascinating field and its many applications.",coverUrl:"https://cdn.intechopen.com/series/covers/14.jpg",latestPublicationDate:"June 11th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:9,editor:{id:"218714",title:"Prof.",name:"Andries",middleName:null,surname:"Engelbrecht",slug:"andries-engelbrecht",fullName:"Andries Engelbrecht",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRNR8QAO/Profile_Picture_1622640468300",biography:"Andries Engelbrecht received the Masters and PhD degrees in Computer Science from the University of Stellenbosch, South Africa, in 1994 and 1999 respectively. He is currently appointed as the Voigt Chair in Data Science in the Department of Industrial Engineering, with a joint appointment as Professor in the Computer Science Division, Stellenbosch University. Prior to his appointment at Stellenbosch University, he has been at the University of Pretoria, Department of Computer Science (1998-2018), where he was appointed as South Africa Research Chair in Artifical Intelligence (2007-2018), the head of the Department of Computer Science (2008-2017), and Director of the Institute for Big Data and Data Science (2017-2018). In addition to a number of research articles, he has written two books, Computational Intelligence: An Introduction and Fundamentals of Computational Swarm Intelligence.",institutionString:null,institution:{name:"Stellenbosch University",institutionURL:null,country:{name:"South Africa"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:6,paginationItems:[{id:"22",title:"Applied Intelligence",coverUrl:"https://cdn.intechopen.com/series_topics/covers/22.jpg",isOpenForSubmission:!0,editor:{id:"27170",title:"Prof.",name:"Carlos",middleName:"M.",surname:"Travieso-Gonzalez",slug:"carlos-travieso-gonzalez",fullName:"Carlos Travieso-Gonzalez",profilePictureURL:"https://mts.intechopen.com/storage/users/27170/images/system/27170.jpeg",biography:"Carlos M. Travieso-González received his MSc degree in Telecommunication Engineering at Polytechnic University of Catalonia (UPC), Spain in 1997, and his Ph.D. degree in 2002 at the University of Las Palmas de Gran Canaria (ULPGC-Spain). He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. He won the “Catedra Telefonica” Awards in Modality of Knowledge Transfer, 2017, 2018, and 2019 editions, and awards in Modality of COVID Research in 2020.\n\nPublic References:\nResearcher ID http://www.researcherid.com/rid/N-5967-2014\nORCID https://orcid.org/0000-0002-4621-2768 \nScopus Author ID https://www.scopus.com/authid/detail.uri?authorId=6602376272\nScholar Google https://scholar.google.es/citations?user=G1ks9nIAAAAJ&hl=en \nResearchGate https://www.researchgate.net/profile/Carlos_Travieso",institutionString:null,institution:{name:"University of Las Palmas de Gran Canaria",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"23",title:"Computational Neuroscience",coverUrl:"https://cdn.intechopen.com/series_topics/covers/23.jpg",isOpenForSubmission:!0,editor:{id:"14004",title:"Dr.",name:"Magnus",middleName:null,surname:"Johnsson",slug:"magnus-johnsson",fullName:"Magnus Johnsson",profilePictureURL:"https://mts.intechopen.com/storage/users/14004/images/system/14004.png",biography:"Dr Magnus Johnsson is a cross-disciplinary scientist, lecturer, scientific editor and AI/machine learning consultant from Sweden. \n\nHe is currently at Malmö University in Sweden, but also held positions at Lund University in Sweden and at Moscow Engineering Physics Institute. \nHe holds editorial positions at several international scientific journals and has served as a scientific editor for books and special journal issues. \nHis research interests are wide and include, but are not limited to, autonomous systems, computer modeling, artificial neural networks, artificial intelligence, cognitive neuroscience, cognitive robotics, cognitive architectures, cognitive aids and the philosophy of mind. \n\nDr. Johnsson has experience from working in the industry and he has a keen interest in the application of neural networks and artificial intelligence to fields like industry, finance, and medicine. \n\nWeb page: www.magnusjohnsson.se",institutionString:null,institution:{name:"Malmö University",institutionURL:null,country:{name:"Sweden"}}},editorTwo:null,editorThree:null},{id:"24",title:"Computer Vision",coverUrl:"https://cdn.intechopen.com/series_topics/covers/24.jpg",isOpenForSubmission:!0,editor:{id:"294154",title:"Prof.",name:"George",middleName:null,surname:"Papakostas",slug:"george-papakostas",fullName:"George Papakostas",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002hYaGbQAK/Profile_Picture_1624519712088",biography:"George A. Papakostas has received a diploma in Electrical and Computer Engineering in 1999 and the M.Sc. and Ph.D. degrees in Electrical and Computer Engineering in 2002 and 2007, respectively, from the Democritus University of Thrace (DUTH), Greece. Dr. Papakostas serves as a Tenured Full Professor at the Department of Computer Science, International Hellenic University, Greece. Dr. Papakostas has 10 years of experience in large-scale systems design as a senior software engineer and technical manager, and 20 years of research experience in the field of Artificial Intelligence. Currently, he is the Head of the “Visual Computing” division of HUman-MAchines INteraction Laboratory (HUMAIN-Lab) and the Director of the MPhil program “Advanced Technologies in Informatics and Computers” hosted by the Department of Computer Science, International Hellenic University. He has (co)authored more than 150 publications in indexed journals, international conferences and book chapters, 1 book (in Greek), 3 edited books, and 5 journal special issues. His publications have more than 2100 citations with h-index 27 (GoogleScholar). His research interests include computer/machine vision, machine learning, pattern recognition, computational intelligence. \nDr. Papakostas served as a reviewer in numerous journals, as a program\ncommittee member in international conferences and he is a member of the IAENG, MIR Labs, EUCogIII, INSTICC and the Technical Chamber of Greece (TEE).",institutionString:null,institution:{name:"International Hellenic University",institutionURL:null,country:{name:"Greece"}}},editorTwo:null,editorThree:null},{id:"25",title:"Evolutionary Computation",coverUrl:"https://cdn.intechopen.com/series_topics/covers/25.jpg",isOpenForSubmission:!0,editor:{id:"136112",title:"Dr.",name:"Sebastian",middleName:null,surname:"Ventura Soto",slug:"sebastian-ventura-soto",fullName:"Sebastian Ventura Soto",profilePictureURL:"https://mts.intechopen.com/storage/users/136112/images/system/136112.png",biography:"Sebastian Ventura is a Spanish researcher, a full professor with the Department of Computer Science and Numerical Analysis, University of Córdoba. Dr Ventura also holds the positions of Affiliated Professor at Virginia Commonwealth University (Richmond, USA) and Distinguished Adjunct Professor at King Abdulaziz University (Jeddah, Saudi Arabia). Additionally, he is deputy director of the Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI) and heads the Knowledge Discovery and Intelligent Systems Research Laboratory. He has published more than ten books and over 300 articles in journals and scientific conferences. Currently, his work has received over 18,000 citations according to Google Scholar, including more than 2200 citations in 2020. In the last five years, he has published more than 60 papers in international journals indexed in the JCR (around 70% of them belonging to first quartile journals) and he has edited some Springer books “Supervised Descriptive Pattern Mining” (2018), “Multiple Instance Learning - Foundations and Algorithms” (2016), and “Pattern Mining with Evolutionary Algorithms” (2016). He has also been involved in more than 20 research projects supported by the Spanish and Andalusian governments and the European Union. He currently belongs to the editorial board of PeerJ Computer Science, Information Fusion and Engineering Applications of Artificial Intelligence journals, being also associate editor of Applied Computational Intelligence and Soft Computing and IEEE Transactions on Cybernetics. Finally, he is editor-in-chief of Progress in Artificial Intelligence. He is a Senior Member of the IEEE Computer, the IEEE Computational Intelligence, and the IEEE Systems, Man, and Cybernetics Societies, and the Association of Computing Machinery (ACM). Finally, his main research interests include data science, computational intelligence, and their applications.",institutionString:null,institution:{name:"University of Córdoba",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"26",title:"Machine Learning and Data Mining",coverUrl:"https://cdn.intechopen.com/series_topics/covers/26.jpg",isOpenForSubmission:!0,editor:{id:"24555",title:"Dr.",name:"Marco Antonio",middleName:null,surname:"Aceves Fernandez",slug:"marco-antonio-aceves-fernandez",fullName:"Marco Antonio Aceves Fernandez",profilePictureURL:"https://mts.intechopen.com/storage/users/24555/images/system/24555.jpg",biography:"Dr. Marco Antonio Aceves Fernandez obtained his B.Sc. (Eng.) in Telematics from the Universidad de Colima, Mexico. 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