Comparison of the effectiveness of interferon in chronic myeloproliferative disorders.
\\n\\n
These books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\\n\\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\\n\\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
\\n\\n\\n\\n\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
IntechOpen and Knowledge Unlatched formed a partnership to support researchers working in engineering sciences by enabling an easier approach to publishing Open Access content. Using the Knowledge Unlatched crowdfunding model to raise the publishing costs through libraries around the world, Open Access Publishing Fee (OAPF) was not required from the authors.
\n\nInitially, the partnership supported engineering research, but it soon grew to include physical and life sciences, attracting more researchers to the advantages of Open Access publishing.
\n\n\n\nThese books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\n\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\n\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
\n\n\n\n\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"6929",leadTitle:null,fullTitle:"Active Learning - Beyond the Future",title:"Active Learning",subtitle:"Beyond the Future",reviewType:"peer-reviewed",abstract:"Active learning is now a form of learning that accompanies the knowledge evolution that challenges the learner to promote it, but also encourages him to investigate and become emotionally involved in the task. The great key to obtaining this behavior successfully depends, therefore, on the subject's involvement and ability to undertake, so that active learning becomes emotional entrepreneurial learning that generates new ideas and new forms of knowledge. From memorization, we move on to inquiry, from questioning to constructive participation, from hypostasis to problem-solving, from generalization to critical thinking. When we look at this book, we see real examples, concrete, and senses, from the most important act of human nature: learning!",isbn:"978-1-83962-244-1",printIsbn:"978-1-83962-243-4",pdfIsbn:"978-1-83962-245-8",doi:"10.5772/intechopen.73460",price:119,priceEur:129,priceUsd:155,slug:"active-learning-beyond-the-future",numberOfPages:162,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"fe54807c3ff7c1b500127e814988f5e2",bookSignature:"Sílvio Manuel Brito",publishedDate:"October 2nd 2019",coverURL:"https://cdn.intechopen.com/books/images_new/6929.jpg",numberOfDownloads:13777,numberOfWosCitations:4,numberOfCrossrefCitations:32,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:42,numberOfDimensionsCitationsByBook:0,hasAltmetrics:1,numberOfTotalCitations:78,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 26th 2018",dateEndSecondStepPublish:"May 17th 2018",dateEndThirdStepPublish:"July 16th 2018",dateEndFourthStepPublish:"October 4th 2018",dateEndFifthStepPublish:"December 3rd 2018",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"170935",title:"Ph.D.",name:"Sílvio Manuel",middleName:"Da Rocha",surname:"Brito",slug:"silvio-manuel-brito",fullName:"Sílvio Manuel Brito",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS9HrQAK/Profile_Picture_2022-04-25T07:50:04.png",biography:"Sílvio Brito obtained a degree in Human Resources Management and Work Psychology from the Higher Institute of Languages and Administration (ISLA), Portugal. He has a master\\'s degree in Management (Organizational Behaviour) from Lusíada University, Portugal, and a PhD in Psychology from the University of Extremadura, Spain. He is a scientific editor and reviewer for several journals and books. He is also a member of several societies, including the Portuguese Society of Psychology, National Association of Evolutionary and Educational Psychology of Childhood, Adolescence, Elderly and People with Disabilities (NAEEPCAEPD), Psyche-EX Research Centre of the University of Extremadura, and the University of Salamanca Chair of Entrepreneurs Scientific Committee. He is also vice president of the Association for Training, Research, and Development of Entrepreneurship.\n\nAlso, he is a Senior teacher and scientific projects and internships manager at the Human Resources and Organizational Behaviour Department of Management at the School of Polytechnic, Institute of Tomar.",institutionString:"Instituto Politécnico de Tomar",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"Instituto Politécnico de Tomar",institutionURL:null,country:{name:"Portugal"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"265",title:"Education",slug:"social-sciences-education"}],chapters:[{id:"65975",title:"Introductory Chapter: Active Learning—Beyond the Future",doi:"10.5772/intechopen.84758",slug:"introductory-chapter-active-learning-beyond-the-future",totalDownloads:1114,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:null,signatures:"Sílvio Manuel da Rocha Brito",downloadPdfUrl:"/chapter/pdf-download/65975",previewPdfUrl:"/chapter/pdf-preview/65975",authors:[{id:"170935",title:"Ph.D.",name:"Sílvio Manuel",surname:"Brito",slug:"silvio-manuel-brito",fullName:"Sílvio Manuel Brito"}],corrections:null},{id:"63962",title:"Human Active Learning",doi:"10.5772/intechopen.81371",slug:"human-active-learning",totalDownloads:1030,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Active machine learning (AML) is a popular research area in machine learning. It allows selection of the most informative instances in training data of the domain for manual labeling. AML aims to produce a highly accurate classifier using as few labeled instances as possible, thereby minimizing the cost of obtaining labeled data. As machines can learn from experience like humans do, using AML for human category learning may help human learning become more efficient and hence reduce the cost of teaching. This chapter is a review of recent research literature concerning the use of AML technique to enhance human learning and teaching. There are a few studies on the applications of AML to the human category learning domain. The most interesting study was by Castro et al., which showed that humans learn faster with better performance when they can actively select the informative instances from a pool of unlabeled data instead of random sampling. Although AML can facilitate object categorization for humans, there are still many challenges and questions that need to be addressed in the use of AML for modeling human categorization. In this chapter, we will discuss some of these challenges.",signatures:"Akram M. Radwan",downloadPdfUrl:"/chapter/pdf-download/63962",previewPdfUrl:"/chapter/pdf-preview/63962",authors:[{id:"257723",title:"Ph.D.",name:"Akram",surname:"Radwan",slug:"akram-radwan",fullName:"Akram Radwan"}],corrections:null},{id:"63456",title:"Empowering Learners Using Active Learning in Higher Education Institutions",doi:"10.5772/intechopen.80838",slug:"empowering-learners-using-active-learning-in-higher-education-institutions",totalDownloads:1083,totalCrossrefCites:2,totalDimensionsCites:5,hasAltmetrics:0,abstract:"Higher education institutions are expected to produce skillful, problem solver, and competent graduates. This becomes possible when the instructors are using the appropriate teaching methodology and the learners are active and empowered in the teaching-learning process. In relation to this, constructivism theory emphasized that the learner is the center of the learning and the instructors playing an advising and facilitating role. In the teaching-learning process, when the learners are empowered using the appropriate teaching methodology, they feel a sense of confidence, capability, competence, and self-esteem, enabling them to meet life’s challenges more effectively. Therefore, a shift in theory (education theory) to a more student-centered approach using active learning is recommended because this approach has its own role to make the students creative and competent in their study. Thus, this chapter of a book tried to address the contribution of active learning in the empowerment of learners in higher education institutions.",signatures:"Abatihun Alehegn Sewagegn and Boitumelo M. Diale",downloadPdfUrl:"/chapter/pdf-download/63456",previewPdfUrl:"/chapter/pdf-preview/63456",authors:[{id:"257798",title:"Dr.",name:"Abatihun Alehegn",surname:"Sewagegn",slug:"abatihun-alehegn-sewagegn",fullName:"Abatihun Alehegn Sewagegn"},{id:"259191",title:"Dr.",name:"Boitumelo",surname:"Diale",slug:"boitumelo-diale",fullName:"Boitumelo Diale"}],corrections:null},{id:"63363",title:"The New Movement of Active Learning in Japanese Higher Education: The Analysis of Active Learning Case in Japanese Graduate Programs",doi:"10.5772/intechopen.80836",slug:"the-new-movement-of-active-learning-in-japanese-higher-education-the-analysis-of-active-learning-cas",totalDownloads:1227,totalCrossrefCites:3,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Currently, active learning becomes the major concern for Japanese higher education institutions. In this chapter, active learning is defined that students study with clear purposes and are engaged in learning proactively. As a result, active learning brings some learning outcomes. Many previous studies have shown that the learning outcomes of students are strongly associated with the quality of pedagogy and student experience. Such pedagogy often includes active learning methods, and it is often expected that active learning methods are strongly associated with proactive learning of students. Such active learning methods have been introduced in the Japanese graduate programs so called leading graduate programs. In this chapter, after examining the theory and effectiveness of active learning, we will examine the practice of active learning methods introduced in leading graduate program of University of Tsukuba. That program is unique and interdisciplinary programs, which will lead to learning outcomes sought in the new knowledge-based society.",signatures:"Aki Yamada and Reiko Yamada",downloadPdfUrl:"/chapter/pdf-download/63363",previewPdfUrl:"/chapter/pdf-preview/63363",authors:[{id:"257359",title:"Dr.",name:"Reiko",surname:"Yamada",slug:"reiko-yamada",fullName:"Reiko Yamada"},{id:"257361",title:"Dr.",name:"Aki",surname:"Yamada",slug:"aki-yamada",fullName:"Aki Yamada"}],corrections:null},{id:"63639",title:"Cooperative Learning: The Foundation for Active Learning",doi:"10.5772/intechopen.81086",slug:"cooperative-learning-the-foundation-for-active-learning",totalDownloads:3501,totalCrossrefCites:19,totalDimensionsCites:25,hasAltmetrics:1,abstract:"The role of instructors is evolving from the presenter of information to the designer of active learning processes, environments, and experiences that maximize student engagement. The more active a lesson, the more students tend to engage intellectually and emotionally in the learning activities. Cooperative learning is the foundation on which many of the active learning procedures are based. Cooperative learning is the instructional use of small groups so that students work together to maximize their own and each other’s learning. Most of the active learning procedures, such as problem-based learning, team-learning, collaborative learning, and PALS, require that students work cooperatively in small groups to achieve joint learning goals. Cooperative learning is based on two theories: Structure-Process-Outcome theory and Social Interdependence theory. Four types of cooperative learning have been derived: formal cooperative learning, informal cooperative learning, cooperative base groups, and constructive controversy. There is considerable research confirming the effectiveness of cooperative learning. To be cooperative, however, five basic elements must be structured into the situation: positive interdependence, individual accountability, promotive interaction, social skills, and group processing.",signatures:"David W. Johnson and Roger T. Johnson",downloadPdfUrl:"/chapter/pdf-download/63639",previewPdfUrl:"/chapter/pdf-preview/63639",authors:[{id:"259976",title:"Dr.",name:"David",surname:"Johnson",slug:"david-johnson",fullName:"David Johnson"},{id:"263004",title:"Dr.",name:"Roger",surname:"Johnson",slug:"roger-johnson",fullName:"Roger Johnson"}],corrections:null},{id:"66545",title:"Dictionary Learning-Based Speech Enhancement",doi:"10.5772/intechopen.85308",slug:"dictionary-learning-based-speech-enhancement",totalDownloads:954,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"This chapter presents an overview of dictionary learning-based speech enhancement methods. Specifically, we review the existing algorithms that employ sparse representation (SR), nonnegative matrix factorization (NMF), and their variations applying for speech enhancement. We emphasize that there are two stages in a speech enhancement system, namely learning dictionary and enhancement. The two scenarios of learning dictionary process, offline and online, are discussed carefully as well. We finally present some evaluation methods and suggest the future lines of work.",signatures:"Viet-Hang Duong, Manh-Quan Bui and Jia-Ching Wang",downloadPdfUrl:"/chapter/pdf-download/66545",previewPdfUrl:"/chapter/pdf-preview/66545",authors:[{id:"268463",title:"Prof.",name:"Wang",surname:"Jai-Ching",slug:"wang-jai-ching",fullName:"Wang Jai-Ching"}],corrections:null},{id:"64546",title:"Innovative Approach for Renewing Instructional Design Applied in the Context of e-Learning",doi:"10.5772/intechopen.82246",slug:"innovative-approach-for-renewing-instructional-design-applied-in-the-context-of-e-learning",totalDownloads:818,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"This research aims to present an overview of an innovative approach for renewing instructional design by offering new form of research in e-learning design. Instructional innovations need to stand back and review the design of innovative components for e-learning system. We postulate in this chapter that the design of learning devices requires the design of complex multifaceted object which supports adaptive learning and lets learners bring into play their knowledge in order to carry out the prescribed tasks. Our approach is centred on the design of this complex object called pedagogical instrument, whose molecules are the smallest collection of the components retaining the properties of that material (according to the teaching intentions). The goal that we have set ourselves is to create the first specification of the micro-instructional engineering design. This specification aims at micro pedagogical technology which needs various types of competencies; our discussion implies that instructional innovation is better likely to succeed if it takes into account the actors, the constraints and the standards required to describe the tools allowing the integration of ICT.",signatures:"Sofiane Aouag and Hedjazi Djalal",downloadPdfUrl:"/chapter/pdf-download/64546",previewPdfUrl:"/chapter/pdf-preview/64546",authors:[{id:"259602",title:"Dr.",name:"Sofiane",surname:"Aouag",slug:"sofiane-aouag",fullName:"Sofiane Aouag"},{id:"259604",title:"Dr.",name:"Hedjazi",surname:"Djalal",slug:"hedjazi-djalal",fullName:"Hedjazi Djalal"}],corrections:null},{id:"63436",title:"Strategies for Digital Creative Pedagogies in Today’s Education",doi:"10.5772/intechopen.80695",slug:"strategies-for-digital-creative-pedagogies-in-today-s-education",totalDownloads:1747,totalCrossrefCites:3,totalDimensionsCites:3,hasAltmetrics:1,abstract:"Creativity and digital technologies are considered to be central for success and development in the current society, becoming crucial educational objectives worldwide. Nevertheless, education often fails to keep pace with creative and digital economies; this is mainly because teachers are not prepared for adopting pedagogical strategies that foster creativity or for fully exploiting the educational potential of digital technologies. Based on the seminal theories of creativity, we propose an innovative framework for applying creative teaching practices mediated by digital technologies: in the light of constructivist and constructionist approaches, we suggest a series of digital tools which are particularly suitable to the emergence of creativity, i.e. manipulative technologies, educational robotics and game design and coding. Furthermore, we shape the concept of digital creative pedagogies (DCP) and establish a set of characteristic components of teaching practices which contribute to the development of students’ creativity. Drawing on a substantial body of research, the chapter intends to embed educational creativity in the digital culture.",signatures:"Mario Barajas, Frédérique Frossard and Anna Trifonova",downloadPdfUrl:"/chapter/pdf-download/63436",previewPdfUrl:"/chapter/pdf-preview/63436",authors:[{id:"257879",title:"Prof.",name:"Mario",surname:"Barajas",slug:"mario-barajas",fullName:"Mario Barajas"},{id:"268386",title:"Dr.",name:"Frédérique",surname:"Frossard",slug:"frederique-frossard",fullName:"Frédérique Frossard"},{id:"268388",title:"Dr.",name:"Anna",surname:"Trifonova",slug:"anna-trifonova",fullName:"Anna Trifonova"}],corrections:null},{id:"63836",title:"Social and Ethical Dilemmas in Working with School Counselors in Secondary Schools for Students with Learning Disabilities",doi:"10.5772/intechopen.81160",slug:"social-and-ethical-dilemmas-in-working-with-school-counselors-in-secondary-schools-for-students-with",totalDownloads:1409,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"We examined the differences in the way school counselors handle social and moral dilemmas in secondary schools for children with learning disabilities. This study compared educational counselors with open approaches to counselors with more conservative approaches to social and moral dilemmas. The study raised two questions. (1) How do school counselors with more open pedagogical approaches handle social and moral dilemmas? (2) How do school counselors with more conservative pedagogical approaches handle social and moral dilemmas? The participants were 15 school counselors in secondary schools who worked with students with learning disabilities. We asked the counselors to describe a dilemma that they had experienced in the course of their work. The findings show that we can divide school counselors into two groups based on the way they handle dilemmas: a more open group and a more conservative group. The results of our study will enable us to improve the training programs for school counselors and provide more effective treatment approaches to solve social and moral dilemmas school counselors encounter.",signatures:"Saied Bishara",downloadPdfUrl:"/chapter/pdf-download/63836",previewPdfUrl:"/chapter/pdf-preview/63836",authors:[{id:"257952",title:"Dr.",name:"Saied",surname:"Bishara",slug:"saied-bishara",fullName:"Saied Bishara"}],corrections:null},{id:"62982",title:"Women Entrepreneurs as Employers",doi:"10.5772/intechopen.80309",slug:"women-entrepreneurs-as-employers",totalDownloads:897,totalCrossrefCites:4,totalDimensionsCites:4,hasAltmetrics:0,abstract:"This study is the first empirical research that focuses only on successful female entrepreneurs in North Cyprus to identify their motivational factors, personality traits and challenges shown and faced by them. To accomplish this objective, an in-depth analysis of 10 female entrepreneurs employing at least 5 staff is used. Results indicate that pull factors are the key motivational drives of successful female entrepreneurs. Self-determination and an achievement-oriented mind set together with honesty and reliability in business life are found to be their main personality traits. The level of risk especially due to the Cyprus conflict and difficulties in accessing funding are found to be the key constraints on these successful female entrepreneurs.",signatures:"Emete Toros and Mehmet Altinay",downloadPdfUrl:"/chapter/pdf-download/62982",previewPdfUrl:"/chapter/pdf-preview/62982",authors:[{id:"261142",title:"Ph.D.",name:"Emete",surname:"Toros",slug:"emete-toros",fullName:"Emete Toros"},{id:"261144",title:"Prof.",name:"Mehmet",surname:"Altinay",slug:"mehmet-altinay",fullName:"Mehmet Altinay"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"6389",title:"Entrepreneurship",subtitle:"Trends and Challenges",isOpenForSubmission:!1,hash:"f30626e6cc598d69d90838d24db873b8",slug:"entrepreneurship-trends-and-challenges",bookSignature:"Sílvio Manuel Brito",coverURL:"https://cdn.intechopen.com/books/images_new/6389.jpg",editedByType:"Edited 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\r\n\tVirtual Instrumentation revolutionized the engineer's and scientists’ activities in the field of measurements, monitoring, and testing. The main programing environment used for virtual instrument implementation in LabVIEW was developed by NI company. A very important aspect of education and engineering development is to use the right tool. In the current development, PCs and embedded systems are on a large scale use. Therefore, the programming of these could be a challenge for non-programming specialists. LabVIEW offers a solution for developing and implementing complex applications even for non-programming specialists. The LabVIEW libraries and add-ons offered by NI or the community allow educators and engineers to cover domains that otherwise would not be tangible for them. This book aims to collect original works and reviews concerning subjects such as correct technique programming approaches, simulation and modeling, systems control, remote control, IoT and IIoT, renewable energy, artificial intelligence, and combining LabVIEW with other programming languages.
\r\n\t
Confocal laser scanning microscopy (CLSM) combined with the broad range of new fluorescent probes, has become an indispensable tool in basic and applied research within a variety of areas. Extending CLSM to multiphoton microscopy (MPM) and nonlinear optical microscopy (NLOM) opens further possibilities. MPM can be used to increase the penetration into the sample, and is thus ideal for thick samples and
CLSM is widely used to image cells
Two-photon excitation arises from the simultaneous absorption of two photons and requires a high photon density. The excitation is thus intrinsically confocal and no pinhole in front of the detector is required. To obtain a sufficient number of photons in the focal volume, high power, pulsed femtosecond IR lasers are used. The absorption cross section depends on the square of the excitation intensity, and absorption occurs only in the focal volume [2], [3]. Thus, no absorption or photo-bleaching occurs above or below the focal plane, as illustrated in Figure 1. The reduced absorption of photons through the tissue and the use of IR excitation light which is less scattered than visible light, is responsible for the possibility of imaging deeper into the thick sample. Furthermore, the detection of emitted photons can be more efficient than in CLSM as no pinhole is needed in front of the detector and thereby more scattered photons can reach the photomultiplier tubes. 3D imaging of thick specimens, based on 3D reconstruction of 2D optical slices, is superb in MPM compared to CLSM, as no bleaching occurs outside the focal plane. 3D imaging several hundred µm into the sample is regularly reported and imaging down to 1 mm in brain tissue has been achieved [1] - [4]. Most fluorescent organic dyes, quantum dots, and reporter proteins can be excited in a two-photon process, although the absorption spectra are very different from single photon excitation spectra [5]. The excitation is followed by emission of photons from the same excited state as after single photon excitation, thus the emitted fluorescence has the same spectrum in the two cases.
Schematic illustration of the difference between one- and two-photon absorption. On the left is two-photon absorption which only occurs in the small focal volume. On the right, the one-photon absorption occurs above and below the focal plane.
The pulsed IR laser can be used for SHG, another non-linear process. SHG requires that the second order optical susceptibility is non-zero, thus occurring only in non-centrosymmetric molecules [6]. Two photons combine their energy and emit a photon with exactly twice the energy of the two incoming photons, or equivalently, at half the wavelength [7]. The interaction is illustrated in the Jablonski diagram in Figure 2. Thus, placing a narrow bandpass filter at half the wavelength of the excitation light in front of the detector, the SHG signal is easily detected. It should be emphasized that in the SHG process no energy is lost and SHG does not involve an excited state, as opposed to the two-photon excitation fluorescence where some of the incoming energy is lost during relaxation of the excited state. Consequently, SHG does not involve excitation of molecules and no phototoxicity occurs. The SHG signal is polarization sensitive and its intensity depends on the angle between the fibres and the polarization of the excitation light. Therefore, polarization sensitivity studies of SHG from tissues can provide information on the fibre organization. Furthermore, the SHG signal is anisotropic and can be detected in both the forward and backscattered direction. The SHG signal in the forward direction is generally dominating, but if the size of the scattering structures along the optical axis is less than the wavelength, the intensity of the backscattered signal will be equal or even larger than the forward signal [8].
Jablonski diagram illustrating several nonlinear processes. SHG: Two photons are converted to a single photon with twice the energy, corresponding to half the wavelength. TPEF: Two photons are absorbed simultaneously to excite a molecular energy state which can emits fluorescene as if excited by a single molecule. CARS: Three beams interact with a vibrational mode to emit photons at slightly longer wavelengths. SRS: Two beams interact with a vibrational level to transfer energy from one beam to the other.
A major advantage of SHG is that no exogenous labeling of the sample is needed. This label-free technique can be used to image materials with a non-centrosymmetric molecular organization. Examples of such molecules are protein fibres such as collagen, microtubules and actomyosin, as well as cellulose. Combining SHG, two photon excitation fluorescence (TPEF) and conventional CLSM makes it possible to obtain information in the same sample of various molecular and structural constituents (see applications below).
A recent addition to the family of nonlinear optical microscopy is coherent anti-Stokes Raman scattering (CARS) and stimulated Raman scattering (SRS) microscopy [9], [10]. These techniques allow for imaging contrast based on molecular vibrational states, similar to information derived from spontaneous Raman spectroscopy. These methods are slightly more technically complex as two pulsed lasers, temporally and spatially overlapped, must be employed. In CARS, the detection is at a different wavelength than the excitation lasers, so filter-based detection is used. For SRS, the signal is actually a decrease or increase in the laser light intensity so detection of the weak signal in the presence of the laser noise is challenging. A technique called modulation transfer is used where one of the laser beams is modulated and a corresponding modulation in the signal is detected using a lock-in amplifier. CARS and SRS are mainly used for imaging lipids which give a very strong signal, but recent work have shown the potential for imaging other biologically relevant molecules,
Structural fibres are abundant in nature. They provide support for the cells to develop complex organs. Not only do the fibres provide mechanical support, but they are also modifiers for cellular behaviour. They control the diffusion of signalling molecules and act as signalling molecules themselves, for example through mechanobiological transduction.
NLOM is especially useful when imaging structural fibres in biological thick samples. The thicker 3D volumes generated will facilitate the subsequent analysis of 3D structural information. Also, being able to perform optical sectioning through thicker sections than in CLSM, fewer serial sections have to be cut mechanically, which reduces workload and potential for sectioning artefacts. When using traditional fluorophores for providing imaging contrast, the main advantage of nonlinear microscopy is the reduced out-of-focus bleaching and the availability of non-descanned detection.
However, the main advantage of NLOM for imaging structural properties lies in the possibility of using endogenous signals from the molecule in question to generate contrast in the image. This is highly advantageous as there are limitations in quantitation caused by uneven labelling or fading of the fluorescence. Furthermore, since the signal is generated from the molecule itself, and not some fluorescent molecule attached to it, a range of optical signals (polarization, spectral, lifetime) can be used to extract even sub-resolution information about the molecule. For example, SHG has been used to measure the helical pitch angle of myosin and collagen with a high degree of accuracy [12]. Fortunately, nature has also provided bright nonlinear endogenous signals from several highly relevant structural molecules, e.g. collagen [7] with SHG, elastin [13] with TPEF and cellulose [11] with CARS.
Collagen is the most abundant protein in the extracellular matrix (ECM) in animals. Collagen forms fibres with high tensile strength and thus accounts for much of the mechanical strength of tissue. Collagen exists in many different varieties but the main common feature is a polypeptide with repeating sequences of three amino acids. Typically, every third amino acid is glycine. The repeating sequence can thus be described as gly-X-Y where the amino acids in the X and Y positions vary. Three of these polypeptides then form a triple stranded helix to create a collagen molecule. Various combinations of the three strands yields different collagen types which are denoted by roman numerals (I,II, III etc.). Some of these types have a molecular structure which causes them to aggregate into even larger structures called collagen fibrils (~20-500 nm in diameter), and the fibrils form fibre collagens (e.g. type I and II) (~500-3000 nm in diameter). Due to their semi-crystalline ordering and non-centrosymmetric structure of the collagen molecule, these fibrils are efficient emitters of SHG. In addition to the SHG intensity, the full tensor nature of the second order susceptibility and the ratio of forward to backscattered light may be used to extract sub-resolution information about the molecules. Several works have illustrated how the orientation of the collagen molecules can be determined from a single pixel and how the forward/backward scattering ratio can be used to determine the size and sub-resolution structure of collagen fibrils [8].
Elastin fibres are aggregates of monomers of the elastin molecule, which are covalently bound through cross-links. These cross-links are very flexible so that the polymer can stretch quite significantly without breaking, thus giving rise to the elasticity of tissue. Elastin has a strong TPEF (probably linked to the molecular cross-links). Elastin is found in many important organs e.g. skin, arteries and some types of cartilage. Imaging of elastin fibres is especially striking in elastic arteries where such imaging has been used for biomechanical applications and atherosclerosis research [13].
Cellulose is the main component of the cell wall of green plants. In vascular plants, cellulose is a major component of the structural fibres that provide mechanical stability and are responsible for transporting water and nutrients. Cellulose, lignin and hemicellulose are the major components of wood fibres, or tracheids. The cellulose molecules form the elementary fibrils, which have been reported to be the structural unit of natural cellulose, with a diameter of 3.5 nm [14] - [16]. The cellulosic components of a wood fibre wall structure are the cellulose molecule, the elementary fibril, the microfibril, the macrofibril and the lamellar membrane [15]. The mentioned cellulosic constituents compose various layers of the fibre wall structure, including the primary wall (P) and secondary walls (S1, S2 and S3) [17].
For nonlinear microscopy one typically wants to cut samples which are much thicker than samples used for conventional histology. This is to take advantage of the 3D imaging capability of the techniques. We have successfully cut fixed and embedded sections of breast tissue with a rotary vibratome up to 100 microns. The challenge with thicker samples is to remove all the paraffin, but we found that this is usually not a problem if slightly longer incubation for removal of paraffin is used.
For samples which are not embedded, a vibratome is good choice for cutting sections of desired thickness. Here the challenge is on the other end of the scale, that is, creating thin samples. We have found that sections down to 40 microns of unfixed and unembedded cartilage are easily cut. Thinner samples are not necessary, as imaging down to 40 micron is straightforward and typically thicker sections can be cut. A vibratome requires a certain rigidity of the sample, but we have found that cartilage is an ideal sample to cut with this technique.
Cryosections are also possible. There is some concern that the freezing procedure might cause structural changes but this depends heavily on the structure that is to be imaged. For example, cryosections of collagen fibres in cartilage have been shown to be well preserved. This might also be the case for other structural fibres due to their inherent mechanical strength [30]. For other, more delicate structures (e.g. cell structures), preparation artefacts and lost morphology might be a concern.
Of course, in addition to the endogenous signal, tissues might also be stained with various fluorochromes to access the distribution of other molecules of interest. For thick sections, the additional stain penetration is an issue. This is highly dependent on the size of the staining molecule and the type of tissue. For fixed and embedded samples from breast tissue we have been able to stain nuclei with DAPI down to about 50 micron, yielding striking images of the cellular distribution relative to the collagen network imaged with SHG (Figure 3).
Breast cancer tissue imaged with SHG (red) to visualize collagen structure and TPEF (green) of DAPI stained cells. The collagen structure may serve as a prognostic marker for the degree of malignancy.
Since one of the main advantages of NLOM is the 3D imaging capability, enhancing this feature is often desirable. This leads to the concept of optical clearing. By substituting the water in the tissue with some other compound which has a refractive index comparable to cells and the collagen fibres, the scattering is greatly reduced. We have seen up to a two-fold increase in the penetration depth, based on this technique (typically 50 % increase) (see Figure 4). A useful compound is glycerol. It is nontoxic and has little interaction with the samples. Furthermore, the refractive index of glycerol can be tuned by using various mixing ratios of water and glycerol, to optimize the effect of the clearing.
The organization of structural fibres has a wide variety of effects on the biology of the components it supports. The primary property is structural,
To be able to incorporate these parameters into mathematical models for biological systems, quantitative data needs to be derived from the images. Several image analysis methods have been developed for this purpose and a few of the most common ones are presented in this chapter.
Change in penetration depth due to optical clearing. Mean SHG signal in an image frame as a function of depth for uncleared sample (solid line) and cleared with 70% glycerol (dashed line)
The linear arrangement of fibres in many types of structures and the resulting periodicity of the fibres in the direction perpendicular to the fibres immediately leads to the idea of using the Fourier transform of the image to determine the direction of the fibres (Figure 5) [19] - [21]. Even though the idea is simple, aligned fibres rarely yields a perfectly sinusoidal signals and significant processing is necessary to extract the desired information.
The one dimensional discrete Fourier transform
where
Left) SHG image of collagen fibres from chicken cartilage. Pseudocolours have been applied for better visualization. Right) The corresponding Fourier transform of the SHG image.
The most common way to interpret Fourier transform images is to assume that the frequency components are distributed on an ellipse (or ellipsoid in three dimensions). The long axis is perpendicular to the direction of the fibre, which corresponds to strong frequency components (periodicity) in this direction. Again, it must be noted that an ellipse is not the resulting frequency pattern of a specific ordered fibre distribution (as seen in Figure 5, right), but rather represents some of the inherent variability of the systems which are analyzed. There are several methods for fitting an ellipsoid to data. See for example [34].
To avoid aliasing in the image due to edge effects, it is important to add a windowing function to the image. The edge effect can be seen in Figure 5 (right), as straight lines through the center of the image. These are however easily removed by a windowing function. Several options are possible, with the Blackman-Harris function and the Hann window being popular candidates [19].
Also, as can be seen in Figure 5 (right) the pure Fourier image is quite noisy, and there is a lot of signal which is not relevant to the structure of interest. Before extracting the directional information it is often necessary to filter the data to get a good result. Typically, a band pass filter can be employed which lets through the frequencies associated with the fibrils. The approach removes random high frequency components and low frequency components which represent slow variations in intensity across the image. The frequency limits of the band pass filter must be determined from the size of the structures of interest. An example can be found in [34].
Due to the linearity of sums (or integrals for the continuous case) used in the Fourier transform, the extension of the one dimensional transform to two, three and higher dimensions is trivial. Hence, the 3D image volumes generated by CLSM and NLOM may be analyzed by the 3D Fourier transform. An important point to keep in mind when analyzing 3D volumes with the Fourier transform, is that the point spread function of the microscope is not equal in all three directions. This will cause an elongation of signals in the z-direction, thereby reducing the higher order frequency components in this direction. This must be taken into account when trying to extract quantitative information.
During the years several methods for characterization texture have been developed, including autocorrelation, Fourier transform, gradient analysis and quadtree decomposition. Gradient analysis is an interesting approach, as this technique can be applied for estimating the orientation of fibrous structure,
SHG image of collagen fibres analyzed with gradient techniques. Ellipses have been superimposed to exemplify the local direction of the fibres.
A relatively simple approach for quantification of structural orientation has been implemented in the SurfCharJ plugin for ImageJ [26]. The plugin plots the frequency of azimuthal angles for estimating the preferred orientation of a given structure. In addition, an estimation of the structural orientation based on the mean resultant vector is provided [27].
A distance transform converts a binary image to a grey level image, where all pixels have a value corresponding to the distance to the nearest feature pixel [28]. The lateral size of fibrous structures can thus be estimated, provided that the previous segmentation is adequate (Figure 7). Some common metrics for estimating the distance between pixels are the City-block (Eq. 2), Chessboard (Eq. 3) and Euclidean distance (Eq. 4):
where
A distance transform can be efficiently applied for estimating the thickness of collagen and cellulose fibres, as exemplified in Figure 7.
SHG image of collagen fibres. The distance transform map exemplifies the approximate lateral dimensions of the fibres. The calibration and scale bars are given in micrometers.
Optimizing a nonlinear optical system is demanding, especially for more complex techniques like SRS and CARS. We will in this section address a few points, which must be considered. To improve the generated signal, the first step is to maximize the photon density, while keeping the average power constant. As the femtosecond laser pulses undergo significant dispersion as they propagate through the optics of the microscope, pre-chirping the laser pulse is necessary to achieve a transform limited pulse. The most recent generation of Ti:Sapphire lasers have such a system integrated.
The next thing to consider is the objective, which should have a high numerical aperture (NA). High NA usually means large magnification which is typically a disadvantage, as a large field of view is also desirable. The latest high-end objectives can achieve about 20-25x magnification with a NA of around unity. The objective should also have good transmission and achromaticity in the NIR spectra region. Another important point to consider, especially when imaging in deep tissue, is that there might be significant spherical aberration. Therefore a correction collar might be useful.
Often the excitation light wavelength is governed by the fluorophore used. However, if the application allows a choice (e.g. with SHG), longer wavelengths are scattered less and will result in deeper penetration depths [29]. It should also be kept in mind that many molecules, especially structural ones which have a preferred orientation, have a highly polarization dependent response [6]. To avoid bias in the images due to this effect, circularly polarized excitation should be used or ideally a variable polarization of the laser beam and an analyzer on the detection side. This polarization dependence can also be used to derive additional information, as already explained.
Collagen, ubiquitous in the vertebrate body, has been imaged in a host of different tissues using SHG. Several proof-of-principle studies exist, but there are few that actually have used the signals to derive clinical, biological or quantitative data. However, as the instrumentation becomes more user-friendly and wide spread, we will likely see an even further increase in the use of NLOM for more clinical and biological applications. We will here present a few model systems where nonlinear and confocal microscopy can provide relevant structural information.
Cartilage consists of a highly hydrated (70% water) proteoglycan gel, which is reinforced with collagen fibres, primarily type II collagen (Figure 8). The tissue provides both distribution of load across the joint surface, and a low friction surface for joint articulation. Degradation and traumatic injuries to cartilage are major health challenges, especially with an increasingly old and obese population. Osteoarthritis (OA), characterized by a degradation of the collagen matrix is one such disease. The development of OA is linked both to biological and biomechanical causes, and there is interplay between these effects. To understand the biological effects, the biomechanical effects of OA must be understood. The biomechanics is tightly connected to the collagen matrix which not only imparts tensile strength to the tissue, but also affects diffusion and fluid flow, which affects the biomechanical response. SHG, being able to characterize the collagen structure in great detail, is an ideal tool for generating high fidelity structural input parameters for biomechanical models.
Collagen and chondrocytes in the transitional layer of cartilage imaged with SHG (red) and TPEF (green), respectively.
SHG from cartilage was first described by Yeh et al. which imaged canine cartilage and showed that several structural features could be discerned [31]. Mansfield used polarization sensitive SHG to derive directional information from the cartilage [32], [33]. We have taken a different approach and used Fourier transforms of images where individual fibrils are resolved to extract 3D structural information. As a model tissue, we use excised cartilage from chicken. These samples were sectioned in 100 μm sections using a vibratome, placed on objective slides and subsequently imaged. We have shown that this information can be directly employed in biomechanical models to improve the fidelity of such models. This has been applied to assess how the tissue responds to mechanical loading and how the mechanical properties are altered as the tissue undergoes pathological changes [34].
Atherosclerosis is a disease characterized by an inflammatory process where monocytes are recruited to the vessel and differentiated into macrophages (Figure 9). As the diseases progress, a necrotic core of lipids and cellular debris develops, which is covered by a collagenous cap holding the pathological tissue, called a plaque. It is believed that a large part of heart attacks are caused by the rupture of these plaques which exposes the blood stream to the thrombogenic substances in the plaque and causes an occlusion of the artery. Plaques, which are prone to rupture, are denoted vulnerable plaques.
Collagen and elastin in arterial wessel imaged with SHG (red) and TPEF (green), respectively
There are several highly important molecules related to atherosclerosis, which can be imaged label-free using NLOM. Firstly, the collagenous cap of the atherosclerotic plaques are easily imaged with SHG. The cap is a very important structure as it is really the mechanical degradation (through the degradation of collagen by matrix metalloproteinases) of this cap, which ultimately leads to the disruption. The elastic fibres of the media are readily imaged using TPEF. As the plaque remodels and develops, smooth muscle cells are recruited through the media and any disruption or increased permeability may be monitored using TPEF. Using samples from human autopsies, we have studied how different plaque structures can be characterized using NLOM [17]. In this study, unprepared samples were placed on a cover glass and imaged from the lumen side. Hence, similar data could potentially be extracted using an
In cancer therapy, encapsulation of drugs into nanoparticles is a promising strategy to enhance the accumulation of the drugs in tumor tissue and reduce the exposure to healthy tissue (Figure 10). This is due to the leaky blood vessels in tumor tissue, allowing the extravasation of nanoparticles from the blood vessels to the ECM, whereas the nanoparticles are constrained to the vessel in normal tissue. However, a major obstacle for successful delivery of drugs and nanoparticles to cells is the poor penetration through the ECM. The ECM consists of a network of the structural protein collagen embedded in a gel of hydrophilic glycosaminoglycans. Both the hydrophilic gel and the collagen network represent a hindrance for delivery of nanoparticles. To study the barrier represented by the collagen network, imaging of the collagen by the SHG signal gives valuable information to improve drug delivery [36], [37]. Especially intravital microscopy of tumors growing in dorsal window chambers on the back of athymic mice combined with SHG provides a valuable tool to image collagen fibres
Being the most abundant organic polymer on Earth, cellulose generates a wide range of research worldwide. Additionally, cellulose is exploited industrially, including various applications,
Recently, cellulose nanofibrils from wood have been proposed as a major component of cryo-gels for wound healing applications. Cryo-gels based on cellulose are macro-porous and have wall structures composed of nano-sized fibrils (Figure 11) [47]. Due to this multi-dimensionality, proper characterization of porous cellulose nanofibril structures is demanding. Considering the limitations with respect to resolution, and provided an adequate preparation of the sample, the walls of cellulose macro-porous structures can be visualized. Two-photon fluorescence microscopy may be used for this purpose by staining the cellulose with for example calcofluor white. The 3D capabilities provided by nonlinear microscopy can provide enhanced understanding of the water retaining properties of cryo-gels, which is most important (Figure 12). CARS has also been used for imaging cellulose fibres and using polarization sensitive measurements, sub-resolution about molecular orientation may be derived [11]. This label-free imaging technique is thus expected to be useful for characterizing samples, which are meant for future use (quality assurance) as well as for monitoring the development of nanofibrils as they are processed using various chemical pre-treatments [48].
Tumor tissue growing in a dorsal window chamber. Collagen visualized by SHG (green), blood vessels (red) and nanoparticles (blue).
A) Elastic cryo-gel prepared from cross-linked cellulose nanofibrills. B) The macro-porous structure is exemplified. C) The nanofibrils are visualized. Reproduced from [
Three-dimensional rendering of a macro-porous cellulose structure in a wet state, observed from different angles. The sample was stained with Calcofluor White (CFW) before imaging.
Structural fibres are ubiquitous in biology were they play a wide array of roles. They provide support to the cells to develop complex organs. Not only do the fibres provide mechanical support but they are also modifiers of cellular behaviour, as they control the diffusion of signalling molecules and act as signalling molecules themselves, for example through mechanobiological transduction. The structural fibres included in this book chapter are cellulose and collagen fibres, from plant and animal tissue, respectively. We have in this chapter shown that nonlinear optical microscopy is an important extension of basic CLSM providing both label-free and three dimensional imaging. Adequate image acquisition and relevant image analysis techniques widen the possibilities for structural characterization. The ability to adequately characterize structural fibres thus expands our understanding of biological processes, which can be most important in medical applications.
Chronic myeloproliferative disorders are a group of clonal diseases of the stem cell. It is a group of several diseases with some common features. They derive from a multipotential hematopoietic stem cell. A clone of neoplastic cells in all these neoplams is characterized by a lower proliferative activity than that of acute myeloproliferative diseases. In each of these diseases, leukocytosis, thrombocythemia, and polyglobulia may appear at some stage, depending on the diagnosis [1, 2].
The research on interferon has been going on since the 1950s [3]. Then, the attention was paid to its influence on the immune system. It has been noted that it can exert an antiproliferative effect by stimulating cells of the immune system [4]. In 1987, a publication by Ludwig et al. was published, which reported the effectiveness of interferon alpha in the treatment of chronic myeloproliferative disorders [5].
More and more new studies have been showing the effectiveness of interferon alpha in reducing the number of platelets, reducing the need for phlebotomies in patients with polycythemia vera and also in reducing the number of leukocytes. Moreover, interferon reduced the symptoms of myeloproliferative disorders such as redness and itching of the skin. Additionally, it turned out to be effective in reducing the size of the spleen.
Further studies on the assessment of remission using molecular-level response assessments indicate that the interferon action in chronic myeloproliferation diseases targets cells from the mutant clone with no effect on normal bone marrow cells [6].
Over the years, interferon alpha-2a and interferon alpha-2b have been introduced into the treatment of chronic myeloproliferation, followed by their pegylated forms. The introduction of pegylated forms allowed for a reduction in the number of side effects and less frequent administration of the drug to patients. In recent years, monopegylated interferon alpha-2b has been used to further increase the interval between drug administrations while maintaining its antiproliferative efficacy.
The exact mechanism of action of interferon alpha in the treatment of chronic myeloproliferative disease is still not fully understood, but it has an impact on JAK2 (Janus Kinase) signal transducers and activates the STAT signal pathway (Janus Kinase/SignalTransducer and Activator of Transcription).
Interferon alpha binds to IFNAR1 and IFNAR2c, which are type I interferon receptors. Interferon alpha has an impact on JAK2(Janus Kinase) signal transducers and activates the STAT signal pathway. The disturbances in this signaling pathway are observed in chronic myeloproliferative disorders [7].
Interferon inhibits the JAK-STAT signaling pathway by directly inhibiting the action of thrombopoietin in this pathway [8].
So far, three driver mutations have been described in the course of chronic myeloproliferative diseases that affect the functioning of the JAK-STAT pathway.
JAK2 kinase and JAK1, JAK3, and TYK2 kinases belong to the family of non-receptor tyrosine kinases. They are involved in the intracellular signal transduction of the JAK-STAT pathway. It is a system of intracellular proteins used by growth factors and cytokines to express genes that regulate cell activation, proliferation, and differentiation. The mechanism of JAK activation is based on the autophosphorylation of tyrosine residues that occurs after ligand binds to the receptor. JAK2 kinase transmits signals from the hematopoietic cytokine receptors of the myeloid lineage (erythropoietin, granulocyte-colony stimulating factor thrombopoietin, and lymphoid lineage [9].
A somatic G/T point mutation in exon 14 of the JAK2 kinase gene converts valine to phenylalanine at position 617 (V617F) in the JAK2 pseudokinase domain, which allows constitutive, ligand-independent activation of the receptor to trigger a proliferative signal [10].
Mutation of the MPL gene, which encodes the receptor for thrombopoietin, increases the sensitivity of magekaryocytes to the action of thrombopoietin, which stimulates their proliferation [11].
Malfunction of calreticulin as a result of mutation of the CARL gene leads to the activation of the MPL-JAK/STAT signaling pathway, which is independent of the ligand, as calreticulin is responsible, for the proper formation of the MPL receptor. Consequently, there is a clonal proliferation of hematopoietic stem cells [12].
Below, we provide an overview of some clinical studies on the efficacy of interferon in chronic myeloproliferative disorders.
Polycythemia vera (PV) is characterized by an increase in the number of erythrocytes in the peripheral blood.
Polycythemia vera is caused by a clonal mutation in the multipotential hematopoietic stem cell of the bone marrow. The mutation leads to an uncontrolled proliferation of the mutated cell clone, independent of erythropoietin and other regulatory factors. As the mutation takes place at an early stage of hematopoiesis, an increase of the number of erythrocytes as well as of leukocytes and platelets is observed in the peripheral blood. The cause of proliferation in PV independent from external factors is a mutation in the Janus 2 (JAK2) tyrosine kinase gene. The V617F point mutation in the JAK2 gene is responsible for about 96% mutation, and in the remaining cases the mutation arises in exon 12. Both mutations lead to constitutive activation of the JAK-STAT signaling pathway [13].
As a result of the uncontrolled proliferation, blood viscosity increases, which generates symptoms such as headaches and dizziness, visual disturbances, or erythromelalgia. As the number of all hematopoietic cells, including the granulocytes ones, increases, the difficult to control symptoms of their hyperdegranulation may appear, among which gastric ulcer or skin itching is often observed. During the disease progression, the spleen and liver become enlarged.
The most common complication of the disease is episodes of thrombosis, especially arterial one. During the course of the disease, it can also evolve into myelofibrosis or acute myeloid leukemia.
The treatment of PV is aimed at preventing thromboembolic complications, relieving the general symptoms, the appearance of hepatosplenomegaly as well as preventing its progression.
Each patient should receive an antiplatelet drug chronically, and usually acetylsalicylic acid is the choice. Most often, the treatment is started with phlebotomy in order to rapidly lower the hematocrit level. If cytoreductive therapy is necessary, the drugs of first choice are hydroxycarbamide and interferon [2].
However, the research on the mechanism of the action of interferons is still ongoing. In vitro studies with CD34+ cells from peripheral blood of patients diagnosed with polycythemia vera showed that interferon inhibits clonal changed cells selectively. It was found that interferon alpha-2b and pegylated interferon alpha-2a reduce the percentage of cells with JAK2 V617F mutation by about 40%. Pegylated interferon alpha-2a works by activating mitogen-activated protein kinase P38. It affects CD34+ cells of patients with polycythemia vera by increasing the rate of their apoptosis [6].
A case of a patient with PV with a confirmed chromosomal translocation t(6;8) treated with interferon alpha-2b, which resulted in a reduction of the clone with translocation by 50% from the baseline value, was also described [14].
In 2019, the results of a phase II multicenter study were published, which aimed at assessing the effectiveness of recombinant pegylated interferon alpha-2a in cases of refractory to previously hydroxycarbamide therapy. The study included 65 patients with essential thrombocythemia (ET) and 50 patients with polycythemia vera. All patients had previously been treated with hydroxycarbamide and showed resistance to this drug or its intolerance.
The assessment of the response was performed after 12 months of treatment. Overall response rate to interferon was higher in patients diagnosed with ET than in patients with polycythemia vera. In essential thrombocythemia, the percentage of achieved complete remissions was 43 and 26% of partial remissions. The remission rate in ET patients was higher if calreticulin CALR gene mutation was present. Patients with polycythemia vera achieved complete remission in 22% of cases and partial remission in 38% of cases.
Treatment-related side effects that follow to discontinuation of treatment were reported in almost 14% of patients [15].
The duration of response to treatment with pegylated interferon alpha-2a and the assessment of its safety in long-term use in patients with chronic myeloproliferative disorders was the goal of a phase II of the single-center study. Forty-three adult patients with polycythemia vera and 40 patients with essential thrombocythemia were enrolled in the study. The complete hematological response was defined as a decrease in hemoglobin concentration below 15.0 g/l, without phlebotomies, a resolution of splenomegaly, and no thrombotic episodes in the case of PV, and for essential thrombocythemia—a decrease platelet count below 440,000/μl and two other conditions as above. The assessment of the hematological response was performed every 3–6 months. The median follow-up was 83 months.
The hematological response was obtained in 80% of cases for the entire group. In patients with polycythemia vera, 77% of patients achieved a complete response (CR) while 7% a partial response (PR). The duration of response averaged 65 months for CR and 35 months for PR. In the group of patients diagnosed with essential thrombocythemia, CR was achieved in 73% and PR in 3%. The durance of CR was 58 months and PR was 25 months.
The molecular response for the entire group was achieved in 63% of cases.
The overall analysis showed that the duration of hematological remission and its achievement with pegylated interferon alpha-2a treatment is not affected neither by baseline disease characteristics nor JAK2 allele burden and disease molecular status. There was also no effect on age, sex, or the presence of splenomegaly.
During the course of the study, 22% of patients discontinued the treatment, because of toxicity. Toxicity was the greatest at the beginning of treatment. The starting dose was 450 μg per week and was gradually tapered off.
Thus, on the basis of the above observations, the researchers established that pegylated interferon alpha-2a may give long-term hematological and molecular remissions [16].
The assessment of pegylated interferon alpha-2a in group of patients diagnosed with polycythemia vera only was performed. The evaluation was carried out on a group of 27 patients. Interferon decreased the JAK2 V617F allele burden in 89% of cases. In three patients who were JAK2 homozygous at baseline, after the interferon alpha-2a treatment wild-type of JAK2 reappeared. The reduction of the JAK2 allele burden was estimated from 49% to an average 27%, and additional in one patient the mutant JAK2 allele was not detectable after treatment. It can therefore be postulated that the action of pegylated interferon alpha-2a is directed to cells of the polycythemia vera clone [17].
In 2005, the results of treatment by pegylated interferon alpha-2b of 21 patients diagnosed with polycythemia vera and 21 patients diagnosed with essential thrombocythemia were published. In the case of polycythemia vera in 14 patients, PRV-1 gene mutation was initially detected. In 36% of cases, PRV-1 expression normalized after treatment with pegylated interferon alpha-2b. For the entire group of 42 patients, the remission assessment showed that complete remission was achieved in 69% cases after 6 months of treatment. However, only in 19 patients remission was still maintained 2 years after the start of the study. Pegylated interferon alpha-2b was equally effective in patients with PV and ET. The use and the type of prior therapy did not affect the achievement of remission [18].
Another study with enrolled only PV patients included 136 patients. They were divided into two arms. One group received interferon alpha-2b and the other group received hydroxycarbamide. Interferon dosage was administered in 3 million units three times a week for 2 years and then 5 million units two times a week. Hydroxycarbamide was administered at a dose between 15 and 20 mg/kg/day.
In the group of patients treated with interferon, a significantly lower percentage of patients developed erythromelalgia (9.4%) and distal parasthesia (14%) compared with the group treated with hydroxycarbamide, for whom these percentages were respectively: 29 and 37.5%. Interferon alpha-2b was found to be more effective in inducing a molecular response, which was achieved in 54.7% of cases, in comparison with hydroxycarbamide—19.4% of cases, despite the fact that the percentage of achieved general hematological responses did not differ between the groups and amounted about 70%. The 5-year progression free period in the interferon group was achieved in a higher percentage (66%) than in the hydroxycarbamide group (46.7%) [19].
The most recent form of interferon approved by the
Thanks to these changes to the structure of the molecule, it was possible to achieve a significant increase in its half-life. Ropeginterferon can be administered subcutaneously to patients every 14 days. The clinical trials conducted so far have assessed the ropeginterferon dose from 50 micrograms to a maximum dose of 500 microgams administered as standard every 2 weeks. The possible dose change in case of side effects includes not only the reduction of the drug dose itself, but also the extension of the interval between doses. The extension of the dosing interval up to 4 weeks was assessed.
Ropeginterforn was approved in 2019 by the EMA for the use in patients diagnosed with polycythemia vera without splenomegaly, as monotherapy.
Ropeginterferon, like the previous forms of interferons used in treatment, is contraindicated in patients with severe mental disorders, such as severe depression. It is also a contraindication in patients with noncompensatory standard treatment of disorders of the thyroid gland as well as severe forms of autoimmune diseases. The safety profile of ropeginterferon is similar to that of other forms of alpha interferons. The most common side effects are flu-like symptoms [20].
Ropeginterferon has been shown to exhibit in vitro activity against JAK2-mutant cells. The activity of ropeginterferon against JAK2-positive cells is similar to that of other forms of interferons used actually for standard therapy. Ropeginterferon has an inhibitory effect on erythroid progenitor cells with a mutant JAK2 gene. At the same time, it has almost no effect on progenitor cells without the mutated allele (JAK2-wile-type) and normal CD34+ cells. A gradual decrease of JAK2-positive cells was observed in patients with PV during ropeginterferon treatment. The examination was performed after 6 and 12 months of treatment. In comparison, the reduction in the percentage of JAK2 positive cells in patients treated with hydroxycarbamide was significantly lower.
These results may suggest that ropeginterferon may cause elimination of the mutant clone, but further prospective clinical trials are needed to confirm this theory. The evaluation was performed on a group of patients enrolled in the PROUD-PV study who were treated in France [21].
In 2017, a multicenter study was opened in Italy. The study was of the second phase. In total, 127 patients with polycythemia vera were included in the study. All patients enrolled on the study had low-risk PV. The clinical trial consisted of two arms. Patients received phlebotomies and low-dose aspirin in one arm and ropeginterferon in the other arm. The aim of the study was to achieve a hematocrit of 45% or lower without any evidence of disease progression. Ropeginterferon was administered every 2 weeks at a constant dose of 100 μg.
The response to the treatment was assessed after 12 months. The reduction of hematocrit to the assumed level was achieved in significantly higher percentage of patients in the ropeginterferon group than of patients who received only phlebotomies and aspirin. In addition, none of the patients treated with ropeginterferon experienced disease progression during the course of the study, while among those treated with phlebotomies, 8% of patients progressed.
Grade 4 or 5 adverse events were not observed in patients treated with ropeginterferon, and the incidence of remaining adverse event (AE) was small and comparable in both arms. The most common side effects in the ropeginterferon group were flu-like symptoms and neutropenia; however, the third-grade neutropenia was the most common (8% of cases) [22].
One of the most important clinical studies on the use of ropeginterferon was the PROUD-PV study and its continuation: the CONTINUATION-PV study. These were three-phase, multicenter studies. The aim of the study was to compare the effectiveness of ropeginterferon in relation to hydroxycarbamide. The study included adult patients diagnosed with polycythemia vera treated with hydroxycarbamide for less than 3 years and no cytoreductive treatment at all. In total, 257 patients received this treatment. The patients were divided into two groups: those receiving ropeginterferon or the other being given hydroxycarbamide.
During the PROUD-study, drug doses were increased until the hematocrit was achieved below 45% without the use of phlebotomies, and the normalization of the number of leukocytes and platelets was reached.
The PROUD-PV study lasted 12 months. After this time, the patients continued the treatment under the CONTINUATION-PV study for further 36 months. After the final analysis performed in the 12th month at the end of PROUD study, it was found that the hematological response rates did not differ between the ropeginterferon and hydroxycarbamide treatment groups. These were consecutively 43% in the ropeginterferon arm and 46% in the control arm.
However, after analyzing the CONTINUATION- PV study, it turned out that after 36 months of treatment, the rates of hematological responses begin to prevail in the group of patients receiving ropeginterferon, 53% versus 38% in the control group. Thus, from the above data, it can be seen that the response rate to ropeginterferon increases with the duration of treatment [23].
Another analysis of patients participating in the PROUD and CONTINUATION studies was based on the assessment of treatment results after 24 months, dividing patients into two groups according to age (under and over 60 years).
The initial comparison of both groups of patients showed that older patients had a more aggressive course of the disease. Patients over 60 years of age had a higher percentage of cells with a mutant JAK2 allele. They experienced both general symptoms and some complications, such as thrombosis, more frequently. Both patients under 60 years of age and over 60 years of age in the ropeginterferon arm had a higher rate of molecular response, namely 77.1 and 58.7% compared with the HU remission: 33.3 and 36.1%, respectively. Significantly higher reductions in the JAK2 allele were observed in both groups of patients after ropeginterferon treatment: it was 54.8% for younger patients and 35.1% for elderly patients. For comparison, this difference in the group of patients treated with HU was 4.5 and 18.4%, respectively.
What is more, the age did not affect the frequency of ropeginterferon side effects. In addition, the incidence of adverse ropeginterferon disorders was similar to that observed in the hydroxycarbamide group [24].
Essential thrombocythemia is a clonal growth of multipotential stem cells in the bone marrow. The consequence of this is increased proliferation of megakaryocytes in the bone marrow and an increase in the number of platelets in the peripheral blood. The level of platelets above 450,000/μl is considered a diagnostic criterion.
Essential thrombocythemia may progress over time to a more aggressive form of myeloproliferation, i.e., myelofibrosis. The disease can also evolve into acute myeloid leukemia or myelodysplastic syndrome, both with very poor prognosis. Thromboembolic complications are serious, and they concern over 20% of patients. Thrombosis occurs in the artery and venous area. Moreover, in patients with a very high platelet count, above 1,000,000/μl, bleeding may occur as a result of secondary von Willebrand syndrome [1, 2].
The treatment of ET is primarily aimed to prevent thrombotic complications.
In low-risk patients, only acetylsalicylic acid is used. In cases of high-risk patients, hydroxycarbamide is the first-line drug for most patients. Anagrelide and interferon are commonly used as second-line drugs.
Due to the possible effects of hydroxycarbamide of cytogenetic changes in the bone marrow cells after long-lasting usage, some experts recommend the use of interferon in younger patients in the first line. Interferon is also used as the drug of choice in patients planning a pregnancy [25].
The efficacy of pegylated interferon alpha-2a was assessed on the basis of the group of 39 patients with essential thrombocythemia and 40 patients with polycythemia vera.
Of the overall group, 81% of patients were previously treated prior to the study entry. The patients received pegylated interferon alpha-2a in a dose of 90 μg once a week. The dose of 450 μg was associated with a high percentage of intolerance.
In patients with essential thrombocythemia, the complete remission was achieved in 76%, while the overall hematological response rate brought 81%. Moreover, the molecular remission was achieved in 38%, in 14% of cases, JAK2 transcript became not detectable.
Patients diagnosed with polycythemia vera achieved 70% complete hematological remission and 80% general hematological response to treatment. JAK2 transcript was undetectable in 6% of patients. Molecular remission was achieved in 54% of cases.
Pegylated interferon alpha-2a at the dose of 90 μg per week was very well tolerated. In total, 20% of patients experienced a grade of 3 or 4 of adverse reaction, which was neutropenia. In addition, an increase in liver function tests was observed. Grade 4 of AE was not observed among patients who started the treatment with 90 μg/week while grade 3 neutropenia was an adverse event in only 7% of cases [26].
The effect of interferon alpha-2b treatment in patients with ET and PV was investigated. The study was prospective. Some of the results concerning the group of patients with polycythemia vera are presented in the subsection on polycythemia vera. In total, 123 patients with diagnosed essential thrombocythemia participated in the study. All of them received interferon alpha-2b. The patients were divided into two groups depending on the presence of the JAK2 V617F mutation. The enrolled patients were between 18 and 65 years of age. The treatment they received was, sequentially, interferon alpha-2b in the dose of 3 million units three times a week for the first 2 years, after which time the dose was changed into a maintenance dose, which amounted to 5 million units two times a week.
The analysis showed that the patients with the JAK2 V617F mutation present in a higher percentage achieved an overall hematological response as well as a complete hematological response. The overall hematological response was achieved in 83% of patients with JAK2 mutation, and the complete hematological remission was achieved in 23 cases. In the group of ET patients without the JAK2 V617F mutation, overall hematological response was achieved in 61.4%, while the complete hematological remission was achieved in 12 patients. The 5-year progression-free survival was obtained in 75.9% in the JAKV617F group and only in 47.6% without the mutation.
A significant proportion of patients experienced mild side effects. Grade 3 and 4 of adverse events were severe, most of them being a fever. The isolated cases of elevated liver tests and nausea have also been reported [19].
Pegylated interferon alpha-2b in patients with essential thrombocythemia who were previously treated with hydroxycarbamide, anagrelide, and other forms of interferon alpha, however, due to the lack of efficacy or toxicity, the patients required a change of treatment, was assessed. Pegylated interferon alpha-2b turned out to be effective in these cases. It led to the complete hematological remission in 91% of patients after 2 months of therapy, and in 100% of patients after 4 months. However, merely 11 patients participated in the study. Also only two patients required treatment discontinuation due to the side effects such as depression and general fatigue grade 3 [27].
In case of pregnant patients, interferon is currently considered the only safe cytoreductive drug. Over the years, several analyses of the results of interferon treatment during pregnancy have been carried out.
The assessment of 34 pregnancies in 23 women diagnosed with ET was performed retrospectively. All the pregnancies included in the analysis were of high risk. This high risk was associated with a high platelet count above 1,500,000/μl, a history of thrombotic episode, severe microcirculation disorders, or a history of major hemorrhage.
It turned out that the use of interferon allowed the birth of an alive child in 73.5% of cases. There was no difference in efficacy between the basic and pegylated forms of interferon alpha. In pregnancies without interferon treatment, the percentage of live births was only 60%. Moreover, it was not found if the presence of the JAK2 V617F mutation had any influence on the course of pregnancy [28].
An analysis of the course of pregnancy in patients with ET was assessed in Italy. Data from 17 centers were taken into account. Data from 122 pregnancies were collected from 92 women. In patients diagnosed with essential thrombocythemia, the risk of the spontaneous loss of pregnancy is about 2.5 times higher than among the general population. In the contrary to the study quoted above, it was found that the presence of the JAK2 mutation increases the risk of pregnancy loss. The proportion of live births in patients exposed to interferon during pregnancy was 95%, compared with 71.6% in the group of patients not treated with interferon.
The multivariate analysis also showed that the use of acetylsalicylic acid during pregnancy had no effect on the live birth rate of patients with ET [29].
Whatever its form, interferon is the drug of first choice in pregnancy. Hydroxycarbamide and anagrelide should be withdrawn for about 6 months, and at least for 3 months, before the planned conception. Experts recommend the use of interferon in high-risk pregnancies [30]. A Japanese analysis of 10 consecutive pregnancies in ET patients showed 100% live births in patients who received interferon [31].
In myelofibrosis (MF), monoclonal megakaryocytes produce cytokines that stimulate the proliferation of normal, non-neoplastic fibroblasts and stimulate angiogenesis. The consequence of this is the gradual fibrosis of the bone marrow, impaired hematopoiesis in the bone marrow, and the formation of extramedullary location mainly in the sites of fetal hematopoiesis, i.e., in the spleen and the liver.
The production of various cytokines by neoplastic megakaryocytes leads to the proliferation of normal, noncancerous fibroblasts as well as to increased angiogenesis.
Progressive bone marrow fibrosis leads to worsening anemia and thrombocytopenia. On the other hand, the production of proinflammatory cytokines by megakaryoblasts leads to the general symptoms such as weight loss, fever, joint pain, night sweats, and consequently, progressive worsening of general condition.
The prognosis for myelofibrosis is poor. In about 20% of patients, myelofibrosis evolves into acute myeloid leukemia with poor prognosis.
Currently, the only effective method of treatment that gives a chance to prolong the life is allogeneic bone marrow transplantation. However, this method is only available to younger patients.
The goal of treatment of patients who have not been qualified for allotranspalntation is to reduce the symptoms and to improve the patient’s quality of life. In case of leukocytosis cytoreducing drugs, such as hydroxycarbamide, melphalan, or cladribine can be used. They cause a reduction in the number of leukocytes and may, to some extent, inhibit splenomegaly. Interferon alpha has been used successfully for the treatment of myelofibrosis for many years. The results of its effectiveness will be presented below [2].
Currently, the JAK2 inhibitor ruxolitinib is approved for the treatment of myelofibrosis with enlarged spleen in intermediate and high-risk patients. Ruxolitinib reduces the size of the spleen, reduces general symptoms, and improves the quality of life; however, it does not prolong the overall survival of patients [32].
In 2015, the results of a retrospective study were published to compare the histological parameters of the bone marrow before and after interferon treatment. Twelve patients diagnosed with primary myelofibrosis as well as post-PV MF and post-ET MF were enrolled in the study. Patients were treated with pegylated recombinant interferon alpha-2a or recombinant interferon alpha-2b in standard doses. The time of treatment was from 1 to 10 years. Some patients had previously been treated with hydroxycarbamide or anagrelide. In all cases, karyotype was normal. The prognostic factor of Dynamic International Prognostic Scoring System (DIPSS) was assessed at the beginning as well as during the treatment.
Bone marrow cellularity decreased in cases with increased bone marrow cellularity before the treatment. After the interferon treatment, a reduction in the degree of bone marrow fibrosis was found. The parameters, such as the density of naked nuclei and the density of megakaryocytes in the bone marrow, also improved.
It proves that if the JAK2 V617F mutation had been present, DIPSS was decreased after interferon treatment. This relationship was not observed in patients without the JAK2 V617F mutation. The improvement in peripheral blood morphological parameters and the overall clinical improvement correlated with the improvement in the assessed histological parameters of the bone marrow.
Before the initiation of interferon, seven patients had splenomegaly. During the treatment with interferon, the complete resolution of splenomegaly was achieved in 17% of patients (two cases), and its size decreased in 25% (three cases). A good clinical response was achieved in 83% during interferon therapy. There was no significant difference in response between the two types of interferon used [33].
A prospective study was also conducted in patients with low and intermediate-1 risk group myelofibrosis. Seventeen patients were enrolled. Patients received interferon alpha-2b (0.5–3 milion units/three times a week) or pegylated interferon alpha-2a (45–90 μg/week). The duration of therapy was on average 3.3 years.
Most of the patients responded to the treatment. Partial remission was found in seven patients and complete remission in two patients. Moreover, in four cases, the disease was stabilized and in one case the clinical improvement was achieved. Three patients did not respond to treatment at all and progressed to myelofibrosis. Additionally, the assessment in reducing spleen size was performed. At baseline, 15 patients have splenomegaly, nine of them achieved the compete regression of spleen size [34].
However, the efficacy of interferon in the treatment of myelofibrosis appears to be limited only to a less advanced form, when the bone marrow still has an adequate percentage of normal hemopoiesis and the marrow stroma is not significantly fibrotic. In more advanced stages, interferon was not shown to have any significant effect on the regression of the fibrosis process [35].
In 2020, the results of the COMBI study were published. That was a two-phase, multicenter, single-arm study that investigated the efficacy and safety of the combination of ruxolitinib and pegylated interferon alpha. Thirty-two patients with PV and 18 patients with primary and secondary myelofibrosis participated in the study. The patients were at age 18 and older. Remission was achieved in 44% of myelofibrosis cases, including 28% (5 patients) of complete remission. In patients with PV, the results were slightly worse: 31% of remissions, including 9% of complete remissions. Patients received pegylated interferon alpha-2a (45 μg/week) or pegylated interferon alpha-2b (35 μg/week) in low doses and ruxolitinib in doses of 5–20 mg twice a day.
For the entire group of patients (with PV and MF), the initial JAK2 allele burden was 47% at baseline, and after 2 years of treatment with interferon and ruxolitinib, it decreased to 12%.
The treatment toxicity was low. The highest incidence of side effects occurred at initiation of therapy. It was mostly anemia and thrombocytopenia.
The observations from the COMBI study show that, for the combination of interferon in lower doses with ruxolitinib, it may be effective and well tolerated even in the group of patients who had intolerance to interferon used as the only drug in higher doses. The combined treatment improved the bone marrow in terms of fibrosis and its cellularity. It also allowed to improve the value of peripheral blood counts [36].
It is currently known that some of the additional mutations are associated with a worse prognosis in patients with myelorpoliferation, including patients with myelofibrosis. Some of these mutations have been identified as high-risk molecular mutations. These are ASXL1, EZH2, IDH1/2, or SRSF2. Earlier studies have shown their association with a more aggressive course of the disease, worse prognosis, and shorter survival of patients, as well as a poorer response to treatment. Due to their importance, they have been included in the diagnostic criteria of myelofibrosis [37].
It is also known that the presence of driver mutations, i.e., JAK2, CALR, and MPL or triple negativity, may affect the course of myeloproliferation, including the incidence of thromboembolic complications.
The assessment of the influence of driver mutations and a panel of selected additional mutations on the effectiveness of interferon treatment in patients with myelofibrosis was performed on a group of 30 patients. Only the patients with low- and intermediate-1-risk were enrolled in the study. The treatment with pegylated interferon alpha-2a or interferon alpha-2b resulted in a complete remission in two patients and partial remission in nine patients. The disease progressed in three cases. One patient relapsed and four died. The remaining patients achieved a clinical improvement or disease stabilization. In the studied group, it was not found if the effectiveness of interferon treatment was influenced by the lack of driver mutations. Among the group of four patients with additional mutations, two died and one had disease progression. It was a mutation of ASXL1 and SRSF2. The treatment with interferon in patients without additional molecular mutations in the early stages of the disease may prevent further progression of the disease [38].
The side effects of interferon in the group of patients with myelofibrosis are similar to those occurring after the treatment of other chronic myeloproliferative diseases. The most frequently described are hematological toxicity- anemia and thrombocytopenia, less often is the appearance of leukopenia. Hematological toxicity usually resolves with dose reduction or extension of the dose interval. The most frequently nonhematological toxicity was fatigue, muscle pain, weakness, and depression symptoms. All symptoms are usually mild and do not exceed grade 2 [38].
However, the use of interferon in the treatment of myelofibrosis has not been recommended as a standard therapy. Interferon is still being evaluated in clinical trials, or it is used in selected patients as a nonstandard therapy in this diagnosis.
Mastocytosis is characterized by an excessive proliferation of abnormal mast cells and their accumulation in various organs.
The basis for the development of mastocytosis is ligand-independent activation of the KIT receptor, resulting from mutations in the KIT proto-oncogene. The KIT receptor is a trans membrane receptor with tyrosine kinase’s activity. Its activation stimulates the proliferation of mast cells. That excessive numbers of mast cells infiltrate tissues and organs and release mediators such as histamine, interleukine-6, tryptase, heparin, and others, which are responsible for the appearance of symptoms typical of mastocytosis. In addition, the infiltration of tissues for mast cells itself causes damage to the affected organs.
The prognosis of mastocytosis depends on the type of the disease. In the case of cutaneous mastocytosis (CM), in the majority of cases prognosis is good and the disease does not shorten the patient’s life, but in aggressive systemic mastocytosis (ASM), the average follow-up is about 40 months. Mast cell leukemia has a poor prognosis with a median follow-up of approximately 1 year.
Systemic mastocytosis usually requires the implementation of cytoreductive therapy. The first line of therapy is interferon alone or its combination with corticosteroids. In aggressive systemic mastocytosis, the first line in addition to interferon 2-CdA can be used. An effective drug turned out to be midostaurin in the case of the present KIT mutation. In patients without the KIT D816V mutation, treatment with imatinib may be effective. In the case of mast cell leukemia, multidrug chemotherapy is most often required, as in acute leukemias, followed by bone marrow transplantation [39].
Systemic mastocytosis requiring treatment is a rare disease, this is why the studies available in the literature evaluating various therapies concern mostly small groups of patients.
In 2002, the French authors presented their experiences on the use of interferon in patients with systemic mastocytosis. They included 20 patients. The patients received interferon alpha-2b in gradually increased doses.
The patients were assessed after 6 months. In cases in which bone marrow was infiltrated for mast cells at baseline, it still remained infiltrated after 6 months of treatment.
However, the responses were obtained in terms of symptoms related to mast cell degranulation. Partial remission was achieved in 35% of patients and minor remission in 30%. It concerns mainly skin lesions and vascular congestion. Moreover, the assessment of the histamine level in the plasma revealed a decrease of it in patients who previously presented symptoms related to the degranulation of mast cells, such as gastrointestinal disorders and flushing.
A high percentage of side effects were found during treatment. They concerned 35% of patients. Depression and cytopenia were most frequent ones [40].
Another analysis was a report of five patients with systemic mastocytosis treated with interferon and prednisolone. All patients received interferon alpha-2b in a dose of 3 million units three times a week and four patients additionally received prednisolone. Four patients responded to interferon treatment at varying degrees. One patient, who at baseline had bone marrow involvement by mast cells in above 10%, progressed to mast cell leukemia. In two patients, the symptoms C resolved completely and in one of them they partially disappeared. In one case, stabilizing disease was achieved [41].
In 2009, a retrospective analysis of patients treated with cytoreductive therapy due to mastocytosis was published. The authors collected data from 108 patients treated at the Mayo Clinic. This analysis allowed for the comparison of the efficacy of four drugs used in systemic mastocytosis. There were interferon alpha alone or in the combination with prednisone—among 40 patients, hydroxycarbamide—among 26 ones, imatinib—among 22 persons, and 2-chlorodeoxyadenosine (2-CdA)—among 22 patients.
After dividing the patients into three additional groups on the basis of the type of mastocytosis—indolent systemic mastocytosis, aggressive systemic mastocytosis, and systemic mastocytosis associated with another clonal hematological nonmast cell lineage disease (SM-AHNMD)—the effectiveness of each of type of therapy was assessed.
The highest response rates in indolent and aggressive mastocytosis were achieved with interferon treatment. They were 60% of the responses in both groups, and in the SM-AHNMD group of patients, the percentage was also one of the highest and amounted to 45%. The second most effective drug was 2-CdA. The response rates were 56% for indolent MS, 50% for aggressive MS, and 55% for SM-AHNMD. The patients treated with imatinib achieved response in 14, 50, and 9% by following groups, respectively. In contrast, patients with indolent and aggressive systemic mastocytosis did not respond to hydroxycarbamide treatment at all. The response rate in both groups was 0%. However, patients with MS associated with another clonal hematological nonmast cell lineage disease achieved 21% response to hydroxycarbamide. Additionally, it was found that only interferon relieved symptoms caused by the release of inflammatory mediators by mast cells.
The additional analysis showed no influence of the TET 2 mutation on the response to treatment [42].
In the literature, there are also single cases of mastocytosis presenting trials of nonstandard treatment. That is description of a patient with systemic mastocytosis with mast cell bone marrow involvement. Mutation of c-kit Asp816Val was present. Patient progressed despite treatment with dasatinib and 2-chlorodeoxyadenosine. The patient developed symptoms related to the degranulation of mast cells and increased ascites.
The patient was treated with pranlukast, which is an anti-leukotriene receptor antagonist due to an asthma episode. The rate of ascites growth decreased significantly after one administration. The patient required paracentesis every 10 days and not every 3 days, as before starting to take the drug. After 15 days of treatment with pranlukast, the patient received interferon alpha, which resulted in complete regression of ascites, resolution of pancytopenia, and complete disappearance of the c-kit mutation clone. The infiltration of mast cells in the bone marrow significantly decreased [43].
Interferon alpha was also effective in a patient with systemic mastocytosis associated with myelodysplastic syndrome with the c-kit D816V mutation, which was refractory to imatinib treatment [44].
Interferon alpha also proved to be effective in the treatment of osteoporotic lesions appearing in the course of mastocytosis.
The series of 10 cases with resolved mastocytosis and osteoporosis-related fractures was presented in 2011. The patients received interferon alpha in a dose of 1.5 million units three times a week as well as pamindronic acid. The patients were treated for an average of 60 months. For the first 2 years, pamindronate was given at a dose of 1 mg/kg every month, and then every 3 months.
During the course of the study, no patient had a new-bone fracture. The level of alkaline phosphatase decreased by 25% in relation to the value before treatment and tryptase by 34%. Bone density increased during treated with interferon and pamindronate. The increase was on average 12% in the spine bones and 1.9% in the hip bones. At the same time, there was no increase in the density of the hip bone and a minimal increase in the density of the spine in patients treated with pamindronate alone.
The results of this observation suggest that it is beneficial to add low doses of interferon alpha to pamindronate treatment in terms of bone density increase [45].
That experiences show that interferon used in systemic mastocytosis significantly improves the quality of life of patients by inhibiting the symptoms caused by degranulation of mast cells. They prevent bone fractures and, in some patients, they cause remission of bone marrow infiltration by mast cells.
Chronic neutrophilic leukemia (CNL) is a very rare disease. It is characterized by the clonal proliferation of mature neutrophils.
The diagnostic criteria proposed by the World Health Organization (WHO) comprise leukocyte counts above 25,000/μl (including more than 80% of rod and segmented
Physical examination often shows enlargement of the liver and spleen, moreover, patients complain on weight loss and weakness [1].
The prognosis varies. The average survival time for patients with CNL is less than 2 years.
Only few descriptions of chronic neutrophilic leukemia are available in the literature, and these are mostly single case reports.
Because it is an extremely rare disease, there are no established and generally accepted treatment standards. In most cases, patients are given hydroxycarbamide or interferon. Patients who are eligible for a bone marrow transplant may benefit from this treatment. Bone marrow allotransplantation remains the only method that gives a chance for a significant extension of life.
The German authors presented a series of 14 cases of chronic neutrophilic leukemia. The group of patients consisted of eight women and six men. The average age was 64.7 years. From the entire group of patients, longer survival was achieved only in three cases. One of these patients was treated with interferon alpha and achieved hematological remission, the other underwent bone marrow allotransplantation from a family donor, and the third one was treated with hydroxycarbamide and transfusions as needed. The follow-up period of the patient after allogeneic matched related donor transplantation (allo-MRD) was 73 months, and for the patient after interferon treatment it was 41 months.
The remaining patients died within 2 years of diagnosis. Six patients, the largest group, died due to intracranial bleeding, three patients died because of leukemia cell tissue infiltration, one patient because of the disease transformation into leukemia, and one patient because of pneumonia [46].
It can be seen from these experiences that treatment with interferon alpha can significantly extend the survival time of patients.
The case of a 40-year-old woman diagnosed with chronic neutrophilic leukemia is presented by Yassin and coauthors. Initially, the patient had almost 41,000 leukocytes in the peripheral blood. In a physical examination, splenomegaly and hepatomegaly were not present. Patient received pegylated interferon alpha-2a. The initially dose was 50 μg once a week for the first 2 weeks, then the dose was increased to 135 μg weekly for 6 weeks, and then the dose interval was extended to another 2 weeks. As a result of the treatment, the general condition of the patient improved and the parameters of peripheral blood counts were normalized [47].
Another case report presented in the literature describes a 41-year-old woman diagnosed with CNL accompanied by focal segmental glomerulosclerosis (FSGS). The patient had increasing leukocytosis for several months. On the admission to the hospital, leukocytosis was 94,000/μl. Moreover, the number of platelets in the morphology exceeded 1,000,000/μl. More than a year earlier, the patient had splenectomy due to splenomegaly and spleen infraction.
Additionally, JAK2 V617F mutation was found. Some authors suggest that the presence of JAK2 mutation may be associated with longer survival in CNL.
The patient received hydroxycarbamide for 3 months and reduction in the number of leukocytes was achieved. After this time, interferon alpha-2b was added to hydroxycarbamide. As a result, focal segmental glomerulosclerosis disappeared and the renal tests improved [48].
Another case of chronic neutrophilic leukemia with a JAK2 gene mutation concerns a 53-year-old man. The patient’s baseline leukocytosis was 33,500/μl, including the neutrophil count of 29,700/μl. The patient also had splenomegaly.
The treatment with interferon alpha-2b at a dose of 3 million units every other day was started. After a month of treatment, the number of leukocytes was reduced to less than 10,000/μl. Then the patient was treated chronically with interferon alpha-2b in doses of 3 million units every 2 weeks. As a result of the therapy, the number of leukocytes remains between 8 and 10,000/μl. The patient remains in general good condition [49].
A series of two CNL cases are also shown. The first patient was a 70-year-old woman with stable leukocytosis of about 35,000/μl and the remaining morphology parameters in normal range. The patient was only observed for 5 years until hepasplenomegaly progressed rapidly. Then, interferon alpha-2b was included. Due to the treatment, the rapid regression of hepatosplenomegaly was achieved.
The second case is a 68-year-old woman with baseline leukocytosis of almost 14,000/μl. In this case, the treatment with hydroxycarbamide was started immediately. However, no improvement was achieved. After 6 weeks of HU treatment, interferon alpha-2b 3 million units 3 times a week was implemented and leukocytosis decreased. Due to the interferon treatment, the disease stabilized for a long time. Because the patient experienced an adverse reaction, a severe flu-like syndrome, interferon was discontinued. After interferon withdrawal, the disease progressed gradually and the treatment attempts by busulfan and 6-mercaptopurine were unsuccessful. Therefore, interferon was readministered and the disease went into remission. Interferon treatment was continued at a reduced dose. The disease regression was achieved again.
Additionally, the patient showed an improvement in the function of granulocytes in terms of phagocytosis and an improvement in neutral killer (NK) cell function after treatment with interferon [50].
The above examples show that interferon alpha is effective in the treatment of chronic neutrophilic leukemia. The side effects are rare and can be managed with dose reductions. Moreover, in these cases, interferon is also effective in a reduced dose. Disease remission or regression can be achieved without typical of CNL complications, such as intracranial bleeding.
Interferon has been used in the past to treat chronic myeloid leukemia. The treatment with tyrosine kinase inhibitors is now a standard practice. However, in a small number of patients, they are ineffective or exhibit unmanageable toxicity. Therefore, the attempts are underway to use interferon in combination with TKI in lower doses, which is to ensure the enhancement of the antiproliferative effect while reducing the toxicity.
There are ongoing attempts to use ropeginterferon in patients diagnosed with chronic myeloid leukemia, in whom treatment with imatinib alone has not led to deep molecular response (DMR). The first phase study was conducted in a small group of patients with chronic myeloid leukemia. The patients in first chronic phase treated with imatinib who did not achieve DMR, but in complete hematologic remission and complete cytogenetic remission, were included in the study. Patients have been treated with imatinib for at least 18 months. Twelve patients were enrolled in the study, and they completed the study according to the protocol. These patients received additional ropeginterferon to imatinib and four achieved DMR. Low toxicity was observed during the treatment. Among the hematological toxicities, neutropenia was the most common. There was no nonhematological toxicity with a degree higher than 1/2 during the treatment. Moreover, it has been found that better effects and fewer side effects are obtained when ropeginterferon is administered for a longer time, but in lower doses. The comparison of the effectiveness of interferon in chronic myeloproliferative disorders based on selected articles is presented in Table 1 [51].
Source | Type of trial | Interferon | Diagnosis | No. | Prior treatment status | Response rate |
---|---|---|---|---|---|---|
Yacoubet al. [15] | Phase II, multicenter | Pegylated IFN alfa-2a | PV | 50 | Resistance to HU or HU intolerance | CR:22% PR:38% |
ET | 65 | CR:43% PR:26% | ||||
Masarova et al. [16] | Phase II, single-center | Pegylated IFN alfa-2a | PV | 43 | Untreated or previously treated with cytoreductive therapy | CR:77% PR:7% |
ET | 40 | CR:73% PR:3% | ||||
Samuelsson et al. [18] | Phase II | Pegylated IFN alfa-2b | PV | 21 | Untreated or previously treated with cytoreductive therapy | CR: 69% for the entire group |
ET | 21 | |||||
Huang BT et al. [19] | Open label, multicenter | IFN alfa-2b | PV | 136 | Untreated or previously treated with cytoreductive therapy | OHR:70% Molecular response:54.7% |
ET | 123 | OHR (JAK2+ patients):83% CHR:23 cases OHR (JAK2-patients): 61.4% CHR:12 cases | ||||
Gisslinger et al. [23] | phase III, multicenter | Ropeginterferon | PV | 257 | Previously treated | OHR:53% |
Quintás-Cardama et al. [26] | phase II | Pegylated IFN alfa-2a | PV | 40 | Untreated or previously treated with cytoreductive therapy | OHR:80% CR:70% Molecular remission:54% |
ET | 39 | OHR:81% CR:76% Molecular remission:38% | ||||
Sørensen et al. [36] | Phase III, multicenter, COMBI | Pegylated IFN alfa-2a with ruxolitinib or Pegylated IFN alfa-2b with ruxolitinib | PV | 32 | Untreated or previously treated with cytoreductive therapy | OHR:44% CR:28% |
MF | 18 | OHR:31% CR:9% | ||||
Casassus et al. [40] | Open label, multicenter | IFN alpha-2b | Mastocytosis | 20 | Untreated and previously treated | PR:35% Minor remission: 30% |
Comparison of the effectiveness of interferon in chronic myeloproliferative disorders.
PV: polycythemia vera; ET: essential thrombocythemia; MF: myelofibrosis; HU: hydroxycarbamide/hydroxyurea; CR: complete remission; PR: partial remission; and OHR: overall hematological response.
Interferon alpha appears to be an effective and safe drug in the most type of chronic myeloproliferative disorders. Nowadays, all forms of its using have similar effectiveness. Interferon alpha can be effective even in cases of resistance for first-line treatment. Trial research is currently underway to combine it with some new drugs, such as ruxolitinib, and to add it to the already well-established therapy, it is a promising option for patients with refractory disease.
From time to time, new forms of interferon, such as ropeginterferon, are introduced, which gives hope for better effectiveness, better safety profile, and greater comfort in its use for patients who have to be treated for many years. In the case of the use of interferons alpha in the treatment of chronic myeloproliferative diseases, there are still opportunities to extend its use and to study its combination with newly introduced drugs.
This is a brief overview of the main steps involved in publishing with IntechOpen Compacts, Monographs and Edited Books. Once you submit your proposal you will be appointed a Author Service Manager who will be your single point of contact and lead you through all the described steps below.
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Stress is any adverse environmental condition that hampers proper growth of plant. Abiotic stress creates adverse effect on multiple procedures of morphology, biochemistry and physiology that are directly connected with growth and yield of plant. Abiotic stress are quantitative trait hence genes linked to these traits can be identified and used to select desirable alleles responsible for tolerance in plant. Plants can initiate a number of molecular, cellular and physiological modifications to react to and adapt to abiotic stress. Crop productivity is significantly affected by drought, salinity and cold. Abiotic stress reduce water availability to plant roots by increasing water soluble salts in soil and plants suffer from increased osmotic pressure outside the root. Physiological changes include lowering of leaf osmotic potential, water potential and relative water content, creation of nutritional imbalance, enhancing relative stress injury or one or more combination of these factors. Morphological and biochemical changes include changes in root and shoot length, number of leaves, secondary metabolite (glycine betaine, proline, MDA, abscisic acid) accumulation in plant, source and sink ratio. Proposed chapter will concentrate on enhancing plant response to abiotic stress and contemporary breeding application to increasing stress tolerance.",book:{id:"9345",slug:"sustainable-crop-production",title:"Sustainable Crop Production",fullTitle:"Sustainable Crop Production"},signatures:"Summy Yadav, Payal Modi, Akanksha Dave, Akdasbanu Vijapura, Disha Patel and Mohini Patel",authors:[{id:"186963",title:"Dr.",name:"Summy",middleName:null,surname:"Yadav",slug:"summy-yadav",fullName:"Summy Yadav"},{id:"308004",title:"Ms.",name:"Payal",middleName:null,surname:"Modi",slug:"payal-modi",fullName:"Payal Modi"},{id:"308005",title:"Ms.",name:"Akanksha",middleName:null,surname:"Dave",slug:"akanksha-dave",fullName:"Akanksha Dave"},{id:"308006",title:"Ms.",name:"Akdasbanu",middleName:null,surname:"Vijapara",slug:"akdasbanu-vijapara",fullName:"Akdasbanu Vijapara"},{id:"308007",title:"Ms.",name:"Disha",middleName:null,surname:"Patel",slug:"disha-patel",fullName:"Disha Patel"},{id:"308008",title:"Ms.",name:"Mohini",middleName:null,surname:"Patel",slug:"mohini-patel",fullName:"Mohini Patel"}]},{id:"45540",doi:"10.5772/56621",title:"Genes and QTLs for Rice Grain Quality Improvement",slug:"genes-and-qtls-for-rice-grain-quality-improvement",totalDownloads:3768,totalCrossrefCites:21,totalDimensionsCites:49,abstract:null,book:{id:"3554",slug:"rice-germplasm-genetics-and-improvement",title:"Rice",fullTitle:"Rice - Germplasm, Genetics and Improvement"},signatures:"Jinsong Bao",authors:[{id:"52135",title:"Dr.",name:"Jinsong",middleName:null,surname:"Bao",slug:"jinsong-bao",fullName:"Jinsong Bao"}]}],mostDownloadedChaptersLast30Days:[{id:"70658",title:"Factors Affecting Yield of Crops",slug:"factors-affecting-yield-of-crops",totalDownloads:4150,totalCrossrefCites:31,totalDimensionsCites:45,abstract:"A good understanding of dynamics involved in food production is critical for the improvement of food security. It has been demonstrated that an increase in crop yields significantly reduces poverty. Yield, the mass of harvest crop product in a specific area, is influenced by several factors. These factors are grouped in three basic categories known as technological (agricultural practices, managerial decision, etc.), biological (diseases, insects, pests, weeds) and environmental (climatic condition, soil fertility, topography, water quality, etc.). These factors account for yield differences from one region to another worldwide. The current chapter will discuss each of these three basic factors as well as providing some recommendations for overcoming them. In addition, it will provide the importance of climate-smart agriculture in the increase of crop yields while facilitating the achievement of crop production in safe environment. This goes in line with the second goal of 2030 Agenda for Sustainable Development of United Nations in transforming our world formulated as end hunger, achieve food security, improve nutrition and promote sustainable agriculture.",book:{id:"8153",slug:"agronomy-climate-change-food-security",title:"Agronomy",fullTitle:"Agronomy - Climate Change & Food Security"},signatures:"Tandzi Ngoune Liliane and Mutengwa Shelton Charles",authors:[{id:"313819",title:"Dr.",name:"Liliane",middleName:null,surname:"Tandzi",slug:"liliane-tandzi",fullName:"Liliane Tandzi"},{id:"314316",title:"Prof.",name:"Charles Shelton",middleName:null,surname:"Mutengwa",slug:"charles-shelton-mutengwa",fullName:"Charles Shelton Mutengwa"}]},{id:"40178",title:"Molecular Markers and Marker-Assisted Breeding in Plants",slug:"molecular-markers-and-marker-assisted-breeding-in-plants",totalDownloads:23130,totalCrossrefCites:85,totalDimensionsCites:153,abstract:null,book:{id:"3060",slug:"plant-breeding-from-laboratories-to-fields",title:"Plant Breeding from Laboratories to Fields",fullTitle:"Plant Breeding from Laboratories to Fields"},signatures:"Guo-Liang Jiang",authors:[{id:"158810",title:"Dr.",name:"Guo-Liang",middleName:null,surname:"Jiang",slug:"guo-liang-jiang",fullName:"Guo-Liang Jiang"}]},{id:"60074",title:"Pollen Germination in vitro",slug:"pollen-germination-in-vitro",totalDownloads:2812,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"Pollen germination in vitro is a reliable method to test the pollen viability. It also addresses many basic questions in sexual reproduction and particularly useful in wide hybridization. Many pollen germination medium ranging from simple sugars to complex one having vitamins, growth regulators, etc. in addition to various minerals have been standardized to germinate pollen artificially. The different media, successful pollen germination methods, procedures from pollen germination studies with wheat, rye, brinjal, pigeonpea and its wild relatives are discussed.",book:{id:"6659",slug:"pollination-in-plants",title:"Pollination in Plants",fullTitle:"Pollination in Plants"},signatures:"Jayaprakash P",authors:[{id:"235465",title:"Dr.",name:"Jayaprakash",middleName:null,surname:"P",slug:"jayaprakash-p",fullName:"Jayaprakash P"}]},{id:"62376",title:"Genotype × Environment Interaction: A Prerequisite for Tomato Variety Development",slug:"genotype-environment-interaction-a-prerequisite-for-tomato-variety-development",totalDownloads:2339,totalCrossrefCites:2,totalDimensionsCites:7,abstract:"Tomato (Solanum lycopersicum L.) is the second most important vegetable crop in the world due to its high level of nutrition particularly in vitamins and antioxidants. It is grown in several ecologies of the world due to its adaptability and ease of cultivation. Besides field conditions, tomatoes are grown in controlled environments which range from hydroponics and simple high tunnel structures to highly automated screen houses in advanced countries. However, the yield and quality of the fruits are highly influenced by the environment. This results in unpredictable performances in different growing environments in terms of quality, a phenomenon known as genotype by environment (G × E) interaction which confounds selection efficiency. Various approaches are employed by plant breeders to evaluate and address the challenges posed by genotype by environment interaction. This chapter discusses various field and controlled environments for growing tomatoes and the effect of these environments on the performance of the crop. The various types of genotype × environment interactions and their effect of the tomato plant are discussed. 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Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. 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She has more than fifteen years of teaching and research experience. She has published more than 550 scientific publications/communications, including 15 books, 50 book chapters, 100 original research papers, 380 research communications in national and international conferences, and 12 patents. She is a member of the editorial board of five journals and acts as a reviewer for several national and international journals. 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Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). He leads the working group of experts representing Brazil in the Global Partnership on Artificial Intelligence (GPAI), on the theme \"AI and the Pandemic Response\".",institutionString:"Manufacturing and Technology Integrated Campus – SENAI CIMATEC",institution:null},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:'"Politechnica" University Timişoara',institution:null},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"414880",title:"Dr.",name:"Maryam",middleName:null,surname:"Vatankhah",slug:"maryam-vatankhah",fullName:"Maryam Vatankhah",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Borough of Manhattan Community College",country:{name:"United States of America"}}},{id:"414879",title:"Prof.",name:"Mohammad-Reza",middleName:null,surname:"Akbarzadeh-Totonchi",slug:"mohammad-reza-akbarzadeh-totonchi",fullName:"Mohammad-Reza Akbarzadeh-Totonchi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Ferdowsi University of Mashhad",country:{name:"Iran"}}},{id:"414878",title:"Prof.",name:"Reza",middleName:null,surname:"Fazel-Rezai",slug:"reza-fazel-rezai",fullName:"Reza Fazel-Rezai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"American Public University System",country:{name:"United States of America"}}},{id:"426586",title:"Dr.",name:"Oladunni A.",middleName:null,surname:"Daramola",slug:"oladunni-a.-daramola",fullName:"Oladunni A. Daramola",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Federal University of Technology",country:{name:"Nigeria"}}},{id:"357014",title:"Prof.",name:"Leon",middleName:null,surname:"Bobrowski",slug:"leon-bobrowski",fullName:"Leon Bobrowski",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Bialystok University of Technology",country:{name:"Poland"}}},{id:"302698",title:"Dr.",name:"Yao",middleName:null,surname:"Shan",slug:"yao-shan",fullName:"Yao Shan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Dalian University of Technology",country:{name:"China"}}},{id:"354126",title:"Dr.",name:"Setiawan",middleName:null,surname:"Hadi",slug:"setiawan-hadi",fullName:"Setiawan Hadi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Padjadjaran University",country:{name:"Indonesia"}}},{id:"125911",title:"Prof.",name:"Jia-Ching",middleName:null,surname:"Wang",slug:"jia-ching-wang",fullName:"Jia-Ching Wang",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"National Central University",country:{name:"Taiwan"}}},{id:"332603",title:"Prof.",name:"Kumar S.",middleName:null,surname:"Ray",slug:"kumar-s.-ray",fullName:"Kumar S. Ray",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Statistical Institute",country:{name:"India"}}},{id:"415409",title:"Prof.",name:"Maghsoud",middleName:null,surname:"Amiri",slug:"maghsoud-amiri",fullName:"Maghsoud Amiri",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Allameh Tabataba'i University",country:{name:"Iran"}}},{id:"357085",title:"Mr.",name:"P. Mohan",middleName:null,surname:"Anand",slug:"p.-mohan-anand",fullName:"P. Mohan Anand",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"356696",title:"Ph.D. Student",name:"P.V.",middleName:null,surname:"Sai Charan",slug:"p.v.-sai-charan",fullName:"P.V. Sai Charan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}},{id:"357086",title:"Prof.",name:"Sandeep K.",middleName:null,surname:"Shukla",slug:"sandeep-k.-shukla",fullName:"Sandeep K. Shukla",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Indian Institute of Technology Kanpur",country:{name:"India"}}}]}},subseries:{item:{id:"17",type:"subseries",title:"Metabolism",keywords:"Biomolecules Metabolism, Energy Metabolism, Metabolic Pathways, Key Metabolic Enzymes, Metabolic Adaptation",scope:"Metabolism is frequently defined in biochemistry textbooks as the overall process that allows living systems to acquire and use the free energy they need for their vital functions or the chemical processes that occur within a living organism to maintain life. Behind these definitions are hidden all the aspects of normal and pathological functioning of all processes that the topic ‘Metabolism’ will cover within the Biochemistry Series. Thus all studies on metabolism will be considered for publication.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11413,editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",slug:"yannis-karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",biography:"Yannis Karamanos, born in Greece in 1953, completed his pre-graduate studies at the Université Pierre et Marie Curie, Paris, then his Masters and Doctoral degree at the Université de Lille (1983). He was associate professor at the University of Limoges (1987) before becoming full professor of biochemistry at the Université d’Artois (1996). He worked on the structure-function relationships of glycoconjugates and his main project was the investigations on the biological roles of the de-N-glycosylation enzymes (Endo-N-acetyl-β-D-glucosaminidase and peptide-N4-(N-acetyl-β-glucosaminyl) asparagine amidase). From 2002 he contributes to the understanding of the Blood-brain barrier functioning using proteomics approaches. He has published more than 70 papers. 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