Comparison of the effectiveness of interferon in chronic myeloproliferative disorders.
\r\n\tThe present book intends to provide to the reader a comprehensive overview of the state of art in empathy studies, embracing the different theoretical points of view and illustrating the advanced research such as the application of new technologies to promote perspective-taking. The critical aspects and the future directions of the study on empathy will also be presented.
",isbn:"978-1-80356-612-2",printIsbn:"978-1-80356-611-5",pdfIsbn:"978-1-80356-613-9",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"4c1042dfe15aa9cea6019524c4cbff38",bookSignature:"Ph.D. Sara Ventura",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11443.jpg",keywords:"Theoretical Model, Skill, Perspective Taking, Training Programs, Practical Implications, Advanced Research, Future Directions, Virtual Reality, Augmented Reality, New Trends, Assistive Technology",numberOfDownloads:21,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 1st 2022",dateEndSecondStepPublish:"June 8th 2022",dateEndThirdStepPublish:"August 7th 2022",dateEndFourthStepPublish:"October 26th 2022",dateEndFifthStepPublish:"December 25th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"Passionate researcher in the application of new technologies to psychological treatments, neuro-rehabilitation, human behavior, and the evolution of the human-computer interaction. In 2017 Dr. Ventura won a competitive grant (Santiago Grisolia) at the University of Valencia at LABPSITEC group, where she was awarded her Ph.D. degree, supervised by Prof. Rosa Baños at the University of Valencia, and co-directed by Prof. Giuseppe Riva of the Catholic University of Milan.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"227763",title:"Ph.D.",name:"Sara",middleName:null,surname:"Ventura",slug:"sara-ventura",fullName:"Sara Ventura",profilePictureURL:"https://mts.intechopen.com/storage/users/227763/images/system/227763.jpg",biography:"Sara Ventura gained a B.Sc in Psychology at the University of Padua (Italy) in 2013 and an M.Sc. in Ergonomic Psychology at the Catholic University of Milan (Italy) in 2015. In 2016, she carried out a postgraduate training at Universidad Nacional Autónoma de Mexico (Mexico) at the Ciberpsychology lab, working on a rehabilitation protocol for people with acquired brain injury through Virtual Reality. In 2020, Sara gained the Ph.D. in Clinical Psychology at University of Valencia (Spain) working with the LabPsitec group and focusing her research on the study of embodiment and empathy with the support of Virtual Reality. Actually, she is working both with Alma Mater Studiorum – University of Bologna (Italy), and the University of Valencia (Spain) on the fields of embodiment, stroke rehabilitation, empathy and patient care. Her research interests mainly focus on the adoption of new technologies, particularly Virtual/Augmented Reality and Artificial Intelligence for the psycho-social wellbeing with clinical and non-clinical populations, the study of human-computer interaction, and the user experience. She is the author of several scientific papers and various presentations at national and international conferences.",institutionString:"University of Valencia",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Valencia",institutionURL:null,country:{name:"Spain"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"21",title:"Psychology",slug:"psychology"}],chapters:[{id:"82719",title:"Empathy as a High-Performance Competency",slug:"empathy-as-a-high-performance-competency",totalDownloads:14,totalCrossrefCites:0,authors:[null]},{id:"82771",title:"Making Sense of a Biochemistry Learning Process and Teacher’s Empathy: Computer-Supported Collaborative Learning Using Emoji Symbols",slug:"making-sense-of-a-biochemistry-learning-process-and-teacher-s-empathy-computer-supported-collaborati",totalDownloads:0,totalCrossrefCites:null,authors:[null]},{id:"82888",title:"From Empathy to the Aggression–Compassion Continuum",slug:"from-empathy-to-the-aggression-compassion-continuum",totalDownloads:8,totalCrossrefCites:0,authors:[{id:"191531",title:"Dr.",name:"Neil E.",surname:"Grunberg",slug:"neil-e.-grunberg",fullName:"Neil E. 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C has four valence electrons, with three of these electrons participating in σ-bonding with its closest neighbors, creating a honeycomb structure. [1] The fourth of these valence electrons occupies an orbital perpendicular to the one-dimensional (1D) sheet creating delocalized π-bonding, as shown in Figure 1, which allows for the creation of a two-dimensional electron gas (2DEG) with high mobility within the sheets. [1, 2]
Graphene geometry, bonding, and a related band diagram [
The delocalization of the π-bonding electrons allows for the graphene sheets to have high mobility, up to 15,000–200,000 cm2/Vs, limited by interactions with the substrate, any contaminant particles, or from itself during bilayer growth. [1, 3–7] This makes cleanliness, grain size, and substrate interference very important issues for growing and using graphene for high mobility and ultrafast applications.
In this review, we are going to focus on the important electrical properties of graphene; however, we should mention some of its other properties for completeness. Due to the 2D nature of a graphene crystal, a single flake will exhibit a large breaking strength of ≈40 N/m due to the absence of slip planes associating the fracture strength of graphene with the strong bonding of c–c in a hex ring. [8] The isolation of electrons from phonons also contributes to the high room temperature thermal conductivity of ≈5,000 W/mK. [9] Along with its high breaking strength graphene is also very pliable with a Young’s modulus ≈1.0 TPa and an elastic strain of up to 20%. [8] These values were partially expected on the basis of previous studies of carbon nanotubes and graphite; although the higher values observed in graphene can be attributed to the crystal defects in samples obtained by micromechanical cleavage.
There are even more intriguing material characteristics of graphene such as shrinkage with increasing
For electronic applications the structure of graphene creates a semi-metal with a direct Fermi-Dirac band structure, as shown in Figure 1, having charge carriers interacting as Dirac Fermions (with zero-effective mass) that allows for ballistic transport of up to a micron at room temperature. [13– 15] The Fermi-Dirac cone as shown in Figure 1c, however, is modified either by the addition of multiple layers as shown in Figure 2iii, the addition of two layers and doping from contaminant particles (metal or polymer particles lying on the surface) shown in 2iv, or contaminants doping a single layer as shown in Figure 2ii. [16] The contaminant-induced doping would move the Fermi level either up or down, the Dirac cone causing a rounding of the k states resulting in a decrease in the mobility of the current carriers (electron or holes). [16] This, along with the thickness restriction for graphene, creates large resistance and chemical inertness, unless chemically doped and functionalized, making its use for pure conductive applications less attractive. [16, 17]
(i) Diagram showing the Dirac Fermi cone; (ii) the modification of the k states by chemical or geometry restrictive doping; (iii) the modification of the k states by bilayer graphene; (iv) and finally, the modification of the k states in doped bilayer graphene. [
For applications such as the channel in a field effect transistor, graphene provides an interesting solution since it can be doped electrostatically and has extremely high mobility allowing for quick response. [18] The replacement of Si by graphene for logic gates might be considered due to the high potential switching speed; however, the absence of a band gap means that a relatively large band gap would have to be induced through a variety of doping or other symmetry breaking mechanisms. [18] The absence of a band gap in graphene limits voltage and power gains that is achieved through operation of a device in the saturation regime, along with having a low Ion/Ioff ratio. [16] To overcome this, several doping strategies as shown in Figure 3 have been proposed and tested including: electrostatic doping, chemical doping, and stress or geometry restricted doping by breaking the graphene periodicity (and band properties). [18]
Diagram showing multiple mechanisms for inducing a band gap in graphene [
The induction of a band gap has been attempted by multiple groups creating transistors with low on/off ratio and high mobility with a tradeoff between on/off ratio and mobility possible through graphene functionalization techniques.[1] This makes graphene more desirable for applications that require fast response times, but not necessarily big on/off ratios such as RF electronics and IR detectors.
Since graphene’s performance is very susceptible to contamination and structural defects (such as folds, grain boundaries, and pin holes) from processing or the transfer process, a review of graphene growth techniques should be done to determine the benefits and drawbacks of each. [1] Due to the sensitivity of graphene, the growth method must be chosen with the required quality, processing, scale, and device architecture in mind, making exfoliation good for small test structures but inadequate for a repeatable semiconductor targeted process. As shown in Figure 4 there are five major pathways for creating graphene sheets: exfoliation from bulk graphite, unzipping through etching a carbon nanotube, growth from sublimation and reconstruction of carbon from a carbide surface, epitaxial growth from a carbide forming catalyst layer by utilizing condensation during cooling, and the epitaxial growth utilizing a non-carbide forming catalyst layer.
Fabrication schemes for the large scale synthesis of graphene sheets [
As of 2014, exfoliation methods produced graphene with the lowest number of defects and the highest electron mobility by the pioneers of graphene, Novoselov and Geim, using the adhesive tape method to isolate graphene from graphite.[1, 13, 20] The most common exfoliation method utilizes an adhesive tape to pull graphene films off a graphite crystal, which are subsequently thinned down by further strips of tape and finally rubbed against the desired substrate. This rather crude method creates a random array of single and double layer graphene flakes on the desired substrate that has been a key driver for investigating the many properties of graphene. Since graphene is susceptible to creating folds during this process, it cannot be produced with high accuracy and repeatability, so other mechanical and chemical exfoliation processes have been investigated. To address the difficulties of the scotch tape method, one group tried to exfoliate graphene from highly ordered pyrolytic graphite (HOPG) utilizing a sharp single-crystal diamond wedge penetrating into the graphite source to exfoliate layers. [21] This method has problems with defect initiation through shear stress and the reliable placement of the graphene flakes after exfoliation.
The other main exfoliation method is to utilize liquid-based techniques to create a dispersion of graphene or graphene oxide flakes that are drop-casted or ink-jet-printed, and in the case of graphene oxide subsequently reduced. Liquid exfoliation can be accomplished through the use of solvents or ionic liquids with similar surface tension to graphene, which when sonicated exfoliate the bulk graphite into graphene sheets that can be subsequently centrifuged to create a supernatant and dispersed. [22–25] Probably the oldest known method for producing graphene is through the production of graphite oxide using Hummers’ method, sonicating to create a dispersion and then reduction of the graphene oxide either through the introduction of hydrazine at elevated temperature or through the introduction of a quick burst of energy introduced either through a light burst as shown in Figure 5 (flash or laser) or a temperature spike. [21, 26, 27]
Reduction of graphene oxide using a LightScribe laser writing system ion, a standard DVD writer [
One of the more interesting liquid exfoliation methods utilizes sonicating graphite at the interface of two immiscible liquids, most notably heptane and water, producing macro-scale graphene films. [29] The graphene sheets are adsorbed to the high energy interface between the heptane and the water, where they are kept from restacking. [29] The graphene remains at the interface and the solvents may then be evaporated isolating the graphene flakes. [29]
Straightforward mechanical exfoliation methods have been able to produce high-quality graphene flakes that have been very beneficial for the investigation of the amazing characteristics of graphene, while liquid exfoliation (and reduction) methods have been utilized for the production of transparent conducting oxides, conductive inks, and electrodes for Li-ion batteries and super capacitors. Mechanical exfoliation, however, cannot be reliably scaled up to provide the reliable placement and large area high-quality graphene sheets desired for transistor and device applications.
As shown in Figure 6, graphene can be created by cutting open carbon nanotubes. [7] In one such method, multi-walled carbon nanotubes are cut open in a solution by action of potassium permanganate and sulfuric acid. [30] In another method, graphene nanoribbons were produced by plasma etching of nanotubes partly embedded in a polymer film. [30] This method is useful for producing nanoribbons of graphene that induces a band gap in graphene through geometry breaking, which will be discussed in Section 3. However, the placement of the nanotubes on an integratable chip has been problematic, and thus this method once again is only good for the production of test structures to probe graphene characteristics.
Image showing the unzipping of a carbon nanotube to produce graphene sheets [
Heating silicon carbide (SiC) or other carbide materials (TaC, NbCm ZrC, HfC, TiC) to high temperatures (>1,100°C) under low pressures (~10-6 torr) boils off the Si (from either the Si face or underlying Si from the C face) and reconstructs the C into a single layer graphene film, although multi-layer graphene has been produced through this approach as well. [19, 32] This process produces epitaxial graphene with dimensions dependent upon the size of the wafer.
Bonding of graphene at a SiC step edge [
The particular face of the SiC used for graphene formation, silicon- or carbon-terminated, highly influences the thickness, mobility, and carrier density of the resulting graphene, with the best results coming from a step edge in SiC that produces “floating” graphene attached to the SiC on the top and the bottom of the step edge as shown in Figure 7. [33] There has also been some work utilizing Ni and Cu bilayers to catalyze the production of graphene from SiC achieving growth at higher pressures and lower temperature. [34] The benefit of using graphene produced from SiC is that SiC is easily integratable with microelectronics processing technologies. The SiC is not desired for most electronics applications, making it desirable to transfer the graphene from its SiC substrate to a more standard substrate such as Si. The sublimation of graphene from SiC also creates a Si2O3 insulating under layer that could assist with the transfer process. Under high temperatures, a large variety of intercalant species can also be placed between the graphene and SiC layer that can potentially help with the exfoliation or the electrical modification/isolation. [19] Under normal conditions, the graphene SiC interface forms a Schottky contact; however, it has been shown that the oxide can be transformed to a nitrogen underlayer through a thermal annealing process in a nitride atmosphere modifying the electronic characteristics between the two. [35]
Graphene growth utilizing a carbonaceous source material (such as methane introduced through a CVD process) differs from material to material with the carbon solubility in the metal and the growth conditions determining the deposition mechanism as shown by the phase diagrams in Figure 8. [7] For carbide producing metallic substrates (such as Ni), graphene growth occurs through a precipitation process during cooling from the carbide. [7] The solubility of C in the metal (Ni for example) is higher at higher temperatures, and thus during the furnace cooling phase carbon diffuses out of its Ni host. [7] The process of forming graphene on Ni has the fundamental limitation that single and few layered graphene is obtained over few to tens of micron regions and not homogeneously over the entire substrate. [7] The lack of control over the number of layers is attributed to the difference in out-diffusion of C from the grains and the grain boundaries of Ni creating non-homogeneous growth conditions.
The phase diagram for a carbide creating catalyst (Fe) and a non-carbide creating catalyst (Cu) [
Epitaxy refers to the deposition of a crystalline overlayer on a crystalline substrate, where there is registry between the two. In some cases, epitaxial graphene layers are coupled to surfaces weakly enough (by Van der Waals forces) to retain the 2D electronic band structure of isolated graphene. [31, 32] It is commonly accepted that the production of graphene through the surface absorption of carbon on a non-carbide producing metal (such as Cu or Ir) is an epitaxial process due to the registry between the underlying Cu (or Ir) crystal structure and the graphene layer.
Exceptional high-quality single layer graphene growth over large areas have been recently achieved on polycrystalline copper foils.[7] The growth on Cu or Ir is simple and straightforward due to the metallic substrates not having a stable carbide material, thus the decomposition of C is only reliant upon the grain orientation. [36] For example, Cu is an FCC lattice with three dominant grain orientations Cu(100), Cu(110), and Cu(111) along with high index facets which are made up of combinations of low index facets. [36] Cu(100), Cu(110), and Cu (111) have cubic, rectangular, and hexagonal geometries making the Cu(111) grain orientation able to support epitaxial growth. [36] Thus, grain growth on Cu(111) grains tend to be monolayered graphene sheets while Cu(100) and Cu(110) geometries prevent C diffusion causing compact multilayered C islands to form with higher index facets replicating the performance of the lower index grains. [36]
Despite the ability for Cu and other metal substrates to grow high-quality graphene flakes for device applications, graphene has to first be transferred onto a semiconducting or insulating substrate when using this growth method. [37] The transference process usually involves spinning on a polymer, etching off the catalyst metal layer, then transferring the graphene onto the desired substrate by placing it on the substrate, and finally etching off the substrate. [37] Both of these processes can produce contaminants on the graphene layer, reducing the mobility by adding scattering centers in the sheet. [1] Groups have been working on ways to reliably reduce these contamination effects; one group has utilized Ti sputtering along with a Ti etch to remove any remaining Cu, while another group has shown that by first spinning on a lift off resist before a normal polymer backing layer produces a much cleaner graphene layer. [38, 39] High-quality graphene has also been shown to be grown between a GaN and Ni interface where the Ni can be peeled off and the graphene layer is left on the GaN substrate. [40]
Due to the chemical nature of the graphene with its zero band gap, mobility related to the delocalization of the π-bonding orbitals, and lattice periodicity, the doping of graphene can be achieved either through the breaking of lattice periodicity or the electrostatic confinement of the delocalized pz orbitals. [19] There have been several mechanisms proposed and tested that have been effective in shifting the Fermi energy to either p- or n-type regions of the band structure and the creation of p-n junctions at the interface. [19] It should be noted that by breaking the lattice symmetry, the electronic states and band edges are modified as shown in Figure 2, decreasing the mobility. With chemical functionalization, scattering is introduced into the graphene flakes, also decreasing the mobility.
Image showing trapped charges at graphene oxide interfaces [
Since graphene is a self-contained sheet with no real interface layer, it should be noted that process integration with oxide dielectrics as shown in Figure 9 can be difficult due to trapped impurities at the interface in terms of creating floating gates for voltage-controlled variable gate transistors. [41] This effect is relevant for device applications of graphene films. It should also be noted that the introduction of trap centers and doping sites through contamination will degrade the continuity of the 2DEG at the trap or dopant site, causing electron and hole pooling to occur. [16, 17, 42]
Electrostatic doping as shown in Figure 10 can be controlled through a variety of methods; some use floating gates with oxide buffer layers and others use direct gate contacts to locally modify the Fermi level allowing for the voltage-controlled operation of the graphene device. [43] Most electrostatic gating is accomplished through a horizontal device architecture to preserve the mobility of graphene for ultrafast devices. With both direct and indirect contact, electrostatic gating can be accomplished by utilizing metals with two different work functions; polymers with different end groups as shown in Figure 11; and finally, layered materials with different opposing band gaps with the higher band gap being the acceptor and the lower being the donor as shown in Figure 12. [19] Metals with dissimilar work functions are normally integrated into a horizontal device with many different combinations to choose from. [44, 45] The amount of gap opening is defined by the difference between the two metal work functions and the induced electric field decreasing down the length of the sheet making the contact placement critical. [44, 45]
Diagram showing charge injection and Fermi modification of a graphene Schottky contact [
Diagram showing the doping of graphene utilizing different polymer end groups [
For polymers, the use of different functional groups can electrostatically dope a horizontal graphene sheet with an isolated amine group (isolated nitrogen atom as in nitric acid) n-doping the graphene sheet while fluorine is well known as a good electron acceptor so a polymer containing an isolated fluorine end group p-dopes the polymer as shown in Figure 11. [18] For the polymer electrostatic doping technique, similar atomic dopants are utilized for the chemical doping regime with atoms lower than group V providing n-type doping and elements higher than group V creating p-type dopants (this will create environmental sensitivity within an exposed graphene sheet due to the oxygen and hydroxide adatoms p-doping the graphene). [18, 46]
Diagram showing the stacking of multiple Van der Waals materials in order to create unique and tunable electrical properties [
Finally, for electrostatic doping, the utilization of other 2D materials as shown in Figure 12 can be used by vertical device integration with either a homojunction-based device or a heterojunction-based device. For a homojunction-based device, graphene is utilized in a double layer with electrostatic doping coming from a layer above one graphene sheet with a lower band gap (such as tungsten diselenide WSe2) and one below the other graphene sheet with a higher band gap (such as molybdenum disulfide MoS2) creating an electric field between the two 2D materials with different band gaps and electrostatically doping the graphene as shown in Figure 12. [48] Since the electrostatic potential outside a sheet with a band gap will only induce a shift in the Fermi energy for graphene, a heterojunction can be formed between the junction of the 2D materials with a tuning of the upper and lower contacts required. [48] The use of 2D stacked devices is interesting but it should be remembered that many of these layers have not been shown to be readily deposited on top of the other, requiring transfer techniques that can induce defects, transfer contaminants, and have alignment issues between the lattices creating different properties across the lattice due to misalignment as shown in Figure 13. [47, 49]
Image showing that the misalignment of 2D materials can electrically isolate the two sheets by separating the Dirac cones [
It has been shown that a twist angle between two graphene sheets above 2° electrically isolates the two graphene sheets from one another except at certain twist angles as shown in Figure 13. [49] Most 2D materials have also been shown to have intrinsic doping due to vacancies and edge defects that create more problems for device integration. [49] It should be noted that the mobilities in graphene on boron nitride (BN) substrates have been measured up to 140,000 cm2/Vs, which is very close to completely suspended graphene grown from a SiC step edge, showing the validity of using 2D heterostructures for device integration and isolation. [32, 42]
As mentioned briefly in the electrostatic doping section, chemical dopants can be utilized to modify the electrical characteristics of graphene, modifying the Fermi energy to create p- or n-type doping as shown in Figure 14. [19, 46] The chemical doping mechanism of graphene works by having the dopant bond either ionically or covalently to the delocalized pz orbital. [46] The covalent bonding of a dopant with graphene occurs through modification of the delocalized pz orbitals to electrostatically hold an adatom onto the surface, which modifies the band structure by binding the electrons in the pz orbitals, thus creating a required energy (a band gap) for conduction. [46] The chemical dopant can be ionically bonded to a single carbon atom by breaking a c–c bond and attaching to that bonding spot, which breaks the graphene symmetry introducing a scattering defect and a band gap opening. [46, 51] The amount of surface adatoms is reliant upon the dopant and the type of bonding with ionic bonding and larger electronegativity being able to obtain a stronger bond, higher dopant concentration, and higher band gap shifting. [46] However, it should be noted that the higher the doping, the more scattering and the lower the mobility, leading chemical doping to be typically done on vertical devices with a small cross section and thus small diffusion length. [19, 46]
The functionalization scheme of graphene utilizing a H2 plasma [
The final way to dope graphene is by breaking the lattice periodicity of graphene as shown in Figure 15. [19, 53] This can be done by reducing the size of a graphene sheet in one direction so that the Fermi levels from the periodic boundary conditions are refined, providing doping through a quantum confinement effect. [53] Quantum confinement occurs when the material dimensions are below the Bohr radius, which for graphene is at 10 nm. [13, 53] This has been shown to be accomplished through the patterning of graphene into ribbons with one dimension restricted to under 10 nm, thus opening a gap of 2.5–3.0 eV in theory and 0.5 eV experimentally. [19, 53] Graphene with a size in either x or y under 10 nm is known as a graphene nanoribbon and it suffers, like many other graphene synthesis techniques, from a lack of a reliable production technique. [53] Traditional semiconductor line definition techniques cannot reliably get a line definition below 20 nm, with large problems creating lines with acceptable line edge roughness. For graphene nanoribbons, the resistance induced through scattering from the line edge roughness is coupled with a lack of graphene conformality, not knowing whether the line definition will create “zig-zag” or “arm-chair” end terminations that provide different conductivity values. [19, 53] The difference between “zig-zag” and “arm-chair” end terminations is shown in Figure 16 and the difference in conductivities between the two create a discrepancy when designing a device utilizing multiple nanoribbons or multiple devices utilizing a graphene nanoribbon. [54]
Different defined graphene sheet edge states and the associated band diagrams showing opening according to edge definitions [
A picture showing the difference between zig-zag and armchair graphene end terminations [
The induced line edge roughness produces many scattering defect reducing the lattice periodicity, obliterating the induced band gap, and decreasing the mobility ultimately limiting the usefulness of graphene nanoribbon formation. [16, 19] Thus, to achieve useful devices from geometry restricted graphene, a reliable method of patterning graphene with low line edge roughness and uniform width must be developed.
There has been an interest in looking at graphene for nanoelectronics applications due to its high intrinsic mobility allowing for greater switching speed. [18] The main problem with the integration of graphene into three-terminal devices is the lack of a high Ion/Ioff current, which for regular metal oxide semiconductor field effect transistors (MOSFETs) is on the order of 104–107, while for most graphene devices is on the order of 10. [16, 55] This makes graphene-based devices more attractive for the replacement of RF-based devices that are currently dominated by high electron mobility transistors (HEMT) that require a Ion/Ioff ratio of around 30. [16, 55] In addition to this, RF electronics require current saturation to obtain voltage and power gains of around 30, which for graphene means the creation of a band gap through one of the doping mechanisms described above. [16] Saturation current is normally attained through the saturation of charge carrier velocity; however, due to the high mobility of the graphene layer the velocity saturation is unattainable without going to extremely high source drain voltage. [16] Therefore, saturation must be obtained through current pinchoff effects and voltage gain as shown in Figure 17, which can be created in graphene through band gap formation. [16] Even with the formation of a band gap, graphene does not exhibit a saturation current at zero doping due to the Fermi-Dirac cone shape, but the band gap does allow the creation of current pinchoff due to electrical band gap modulation via the source and drain contacts. With this background, we are going to address in the subsequent section several issues that hinder the integration of graphene into FETs that can be utilized for RF applications and review the state-of-the-art technology in terms of GFETs for RF electronics.
Diagram showing current pinchoff in a Si MOSFET.
Graphene normally has a grain size of several to tens of microns with the desire to use a single grain as the channel material to avoid scattering at grain edges (also a factor in current MOSFET structures that is why single crystalline Si is used as a substrate). [16] This creates many of the short channel effects commonly seen in MOSFETS such as drain induced barrier lowering, surface scattering, velocity saturation, impact ionization, and hot-electron effects. [16] Specifically for graphene, drain-induced barrier lowering, surface scattering, and hot electron effects are all in play. Surface scattering is due to the intrinsic susceptibility of graphene to surface contamination and scattering sites, while the hot electron and barrier lowering effects affect graphene due to the pinchoff formation needed to have the large Ion/Ioff ratio required for typical electronics applications and to create large enough voltage and power gains for RF applications.
Graphene is a self-contained electronic sheet showing no classical band bending interactions when coupled to a metallic contact as shown in Figure 18. This creates an abrupt transition in the vacuum level, creating a barrier that any carrier would have to tunnel through, creating charge buildup at the band edges and large contact resistances. [56]
Classical band diagrams for a metal-silicon interface, a metal-metal interface, and a metal graphene interface.
In conjunction to this challenge is the relative inertness of a graphene sheet, making good electrical contacts difficult to realize and mainly occurring at grain edges. [56] This creates a situation where the bulk of the contact sits over the graphene electrostatically doping it, while also trying to realize good adhesion creating a search for a metals with good adhesion to graphene along with the correct Fermi level. [56] To achieve this goal, a double or triple metal stack is commonly used with an oxygen scavenger interfacing the graphene (normally Ti), followed by one or a couple of Fermi level contacts (Au, Pd, Ni). [56] The metallic doping effect, however, can be utilized for some interesting devices such as one using asymmetric contacts to create an internal electric field making an IR detector through the photothermoelectric effect, or using large gap superconducting contacts to confine electrons and holes in a graphene sheet to enhance bolometric response. [45, 57]
As stated in Section 1 and Section 3, graphene is a self-contained layer without any dangling bonds, thus adhesion and interfaces with graphene are a challenge. Multiple groups have been experimenting with different types of oxides with either an aluminum deposition and oxidation or a nitrogen dioxide surface pretreatment prior to a hafnium oxide, silicon dioxide, or aluminum oxide deposition. [58] The dielectric which seems to work the best (but has not yet been implemented in a complementary metal oxide semiconductor (CMOS) fabrication process) is another 2D self-contained dielectric BN with which graphene has shown mobilities of 140,000 cm2/Vs, which is very close to completely suspended graphene grown from a SiC step edge, demonstrating low interaction and good isolation between the two substrates. [42]
To overcome some of the short channel issues and problems with graphene integration into common process flows, a wafer bonding type of integration has been suggested as shown in Figure 19. [59] This allows for the separation of the drain and gate contacts, which reduces coupling and alleviates some of the issues with drain induced barrier lowering. [60]
Wafer bonding with subsequent source drain contact deposition [
Gate coupling is a significant issue with graphene FETs due to the large gate voltages needed to create sufficient barriers for high Ion/Ioff ratios, the metallic characteristic of the graphene layer, the thin gate oxide needed to ensure good gate control and reduced gate potential for smaller electrical field propagation, and finally the dielectric breakdown strength. [60] All of these needs show that a thin high-k gate with opposing gate and source drain contact geometry is desired as shown in Figure 19.
Graphene devices have a very thin cross section where the active electric field can affect one another. It has been shown that by using tapered contacts as shown in Figure 20, the amount of source drain coupling is reduced due to electric field reduction. [60] This is especially effective if utilizing a back gate design as shown later in Figure 21, or a large gate that could overlap the source and drain contacts on the opposing side of the devices channel. [55, 60]
Tapered contacts used on opposing sides of the gate to reduce [
In order to create a device that allows for the opening of a band gap required for current saturation and appropriate voltage and current gains, several device geometries have been proposed. [16, 55] The main mechanisms for increasing graphene performance in FETs is to increase gate coupling with graphene layer and to optimize the graphene dielectric interface to reduce scattering and make the conduction and valence states continuous. [16]
One possible device geometry shown in Figure 21 utilizes a bilayer graphene channel with a large backgate voltage to induce an electric field of 1.7 V/nm that opens a band gap in bilayer graphene of 80 meV with the Mexican hat shape shown in Figure 2iv. [16, 55] The band gap creates a saturation current due to pinchoff at the drain contact resulting in a voltage gain of 35, which is relevant for RF electronics.
Diagram of a B-bilayer graphene FET with back contact to create a pinchoff region and voltage gain [
This mechanism works much better for bilayer graphene than monolayer graphene as bilayer graphene more easily forms a pinchoff region. To demonstrate this, the amount of voltage gain in such a graphene FET is graphed as contour plots with voltage gain axis on the right hand side of the graph as shown in Figure 22. [55]
Contour maps of voltage gain in a single layer and bilayer graphene channel with modification of back gate voltage [
Current designs for graphene FETs are shown in Figure 23, with the back gated design commonly used to overcome any doping in the graphene channel due to substrate, atmospheric, or dielectric effects. [16] The back gate and top gate design are the most common since these allow for the shifting of the Dirac point to zero through an induced electric field and proper gate modulation. [16]
Image showing the most common designs for GFETs [
Utilizing a three-terminal top gate design of CVD graphene grown on a SiC substrate, one group was able to achieve a 350 GHz cutoff frequency, utilizing a channel length of 40 nm as shown in Figure 24. [61]
Image showing the threshold frequency versus gate length for the device architectures shown on the left, the epitaxial graphene is on the SiC substrate, and the frequency shows a 1/L dependence [
This group showed that the threshold frequency has a 1/L dependence, where L is the channel length of the graphene FET. This has been modeled and pushed to the limit with an understanding that graphene might be able to break the 1THz limit that InGaAs and SiGe HEMTs can’t break. [62] One group theoretically tuned all of the parasitic capacitances that would limit the graphene channel mobility; this includes removing Schottky interactions at the source and drain contacts, removal of any trapped states in the oxide, ignoring any electron/hole pooling effects, and having the gate voltage perfectly coupled to channel potential, allowing for a GFET that operates at 1.5 THz. [62] This GFET is optimized to have zero gain due to the current saturation in the 50 nm channel. [62] By allowing for current saturation in the GFET, a voltage gain can be engineered in the graphene channel; however, this would deteriorate the operating frequency of the GFET as shown in Figure 25. [62]
An image showing the threshold frequency for each possible gain in a GFET for systems with different amounts of tuning of parasitic resistance; the blue line has no parasitic resistance [
One of the interesting applications for graphene is its use in EO devices and lasers. Graphene can absorb wavelengths from the visible to the mid-IR with wavelength modulation enabled through electrostatic gating. [63–67] The electrostatic gating interacts with light either by modulating the band gap width up to a certain wavelength working as an absorption modulating element, or it modifies the graphene surface plasmon modes that interact with light. [63–67] The last example is how graphene was utilized for mode locking a laser. [63–67] The problem with utilizing graphene for pure optical devices is due to its inherent thinness only absorbing 2.3% of the incident light per monolayer. [63–67] This makes it more desirable to integrate graphene with other electro-optical components such as photonic cavities or plasmonic waveguides with an example shown in Figure 26. [63–67]
Integration of a tunable graphene capacitor with an EO modulator [
The EO modulator pictured in Figure 26 was created through the coupling of Si plasmonic nanocavities to a tunable graphene capacitor made from stacked layers of graphene and BN dielectric film. [63] The top and bottom graphene layers are electrostatically doped differently from one another with varying voltages for optical modulation of absorbed light. [63] The modulator worked up to 1.2 GHz frequency, which was limited by the RC time constant of the capacitor. [63]
Although on its own graphene is not practical for use as a waveguide or modulator, it can be combined with already active materials to increase the performance of such devices.
IR detectors can be separated into two separate categories: thermal-based IR detection and photon-based detection. [68] In thermal-based detectors, the incident IR radiation is absorbed, raising the temperature of the material. [68] The raised temperature affects some temperature-dependent property of the material; for pyrometers this is a change in electrical polarization, while for bolometers, this is a change in materials resistance. [68] Another more recent study utilized the photothermoelectric effect in graphene to create a net electric field due to electron diffusion into dissimilar metal contacts. [45] Photon-based detectors utilize band gap-based detection with the arriving photon being absorbed and utilized to promote electron hole pairs to create a photocurrent. [68] The photon-based detectors can be tuned to certain wavelengths by creating a quantum well structure. [68] Photon-based IR absorbers are characterized by having fast absorption response, but usually require cooling due to thermal effects, while thermal-based IR detectors have high responsivity over a large wavelength and can be utilized at room temperature but normally have slow absorption response. [68] This is where utilizing a graphene-based sensing element is attractive due to the high mobility with little temperature sensitivity making it ideal for IR detectors. [2]
Several groups have attempted to integrate graphene into IR detectors. The groups have tried both photon- and the thermal-based absorption methods. [45, 69–74] For photon-based absorption methods, the main focus has been the opening of a band gap through geometric modification. [45, 69] One group utilized bilayer graphene to open a small band gap that is sensitive to thermalization requiring cooling to 5 K for operation. [69]
The utilization of graphene nanoribbons to open a small band gap that is enhanced through the use of p- and n-type graphene contacts [
Another group utilized an array of aligned graphene nanoribbons as shown in Figure 27 to open up a small band gap that has significant difficulties in fabrication and noise properties from the nanoribbon edges. [45] Groups that have tried thermal-based IR detectors seem to have created more novelty, with one group utilizing multiple vertically aligned graphene flakes, while another group utilized a resonant structure of two graphene sheets separated by a dielectric to tune the photon wavelength of absorption as shown in Figure 28. Finally, another group utilized the photothermoelectric effect as shown in Figure 29 to induce an electric current in graphene due to electric gating or dissimilar metal contacts. [45, 70, 71] The bolometer utilizing vertically aligned graphene sheets used distance-based tunneling between sheets for the bolometric effect, which is sensitive to contamination between sheets and alignment of the graphene flakes making reproduction difficult. [71]
Phonon resonance-based IR detector [
The resonance-based IR detector shown in Figure 28 utilizes the phonon resonance of two separate graphene sheets separated by a dielectric allowing for the tuning of wavelength detection based upon separation distance, but the fabrication is difficult requiring pristine graphene and no trapped states in the oxide that would both modify the resonant frequency and could possibly contaminate the detector out of detection range. [70]
Image of a detector based upon the photothermoelectric effect [
The photothermoelectric effect detector shown in Figure 29 is relatively straight forward with contamination only affecting the speed of the detector and the noise only susceptible to trap states of the insulating oxide that the graphene is transferred onto. [45]
We have shown graphene to have many amazing properties due to its unique bonding and subsequently band gap characteristics, having electronic carriers act as “massless” Dirac-Fermions. The material characteristics of graphene are anisotropic, having phenomenal characteristic within a single sheet and diminished material characteristics between sheet with increasing sheet number and grain boundaries. This restricts the applications of graphene to technology that is consistent with miniaturization such as microelectronics. Therefore the integration of graphene into several electronic device applications was reviewed.
Graphene has the highest mobilities values measured in a material at room temperature making integration into fast response time devices such as a HEMT for RF applications. It has been shown that although the integration of graphene is challenging due to mobility degradation due to surface contamination in the graphene and trapped states in the oxide dielectric, a graphene RF detector with an overall response frequency of 300 Ghz was achieved utilizing a three-terminal design on a SiC substrate with a channel length of 40 nm.
Graphene use in optical devices is limited due to the absorption of 2.3% of incident light per layer making graphene’s use for optical devices a tradeoff between getting enough layer for good optical absorption and modulation versus restricting number of layers for fast carrier propagation. On its own, graphene is not practical for use as a waveguide or modulator but when it is combined with already active materials, it increases the performance of such devices thus an EO modulator utilizing a stacked graphene-BN capacitor along with a Si microcavity array displays the ability to modulate light at a rate of 1.2 GHz.
Graphene for IR detectors has shown some promising results utilizing graphene in thermal-based detection regimes since photon-based absorption regimes all require inducing a band gap, adding complexity and reliability issues. The unique thermal-based properties of graphene either in a traditional bolometric type of device or one based upon current produced from the photoelectric effect allowed for the creation of a graphene IR detector with sensitivity to a 2.5 THz (119µm) laser.
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.
Our journals are currently in their launching issue. They will be applied to all relevant indexes as soon as they are eligible. These include (but are not limited to): Web of Science, Scopus, PubMed, MEDLINE, Database of Open Access Journals (DOAJ), Google Scholar and Inspec.
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Dr. Kasenga is married to Grace and blessed with three children, a son and two daughters: Happy, Lettice and Sungani.",institutionString:"Malawi Adventist University",institution:{name:"Malawi Adventist University",institutionURL:null,country:{name:"Malawi"}}}]}]},openForSubmissionBooks:{paginationCount:2,paginationItems:[{id:"12086",title:"Cattle Diseases - Molecular and Biochemical Approach",coverURL:"https://cdn.intechopen.com/books/images_new/12086.jpg",hash:"afdbf57e32d996556a94528c06623cf3",secondStepPassed:!0,currentStepOfPublishingProcess:3,submissionDeadline:"July 5th 2022",isOpenForSubmission:!0,editors:[{id:"219081",title:"Dr.",name:"Abdulsamed",surname:"Kükürt",slug:"abdulsamed-kukurt",fullName:"Abdulsamed Kükürt"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{id:"11579",title:"Animal Welfare - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11579.jpg",hash:"12e4f41264cbe99028655e5463fa941a",secondStepPassed:!0,currentStepOfPublishingProcess:3,submissionDeadline:"July 8th 2022",isOpenForSubmission:!0,editors:[{id:"51520",title:"Dr.",name:"Shao-Wen",surname:"Hung",slug:"shao-wen-hung",fullName:"Shao-Wen Hung"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null}]},onlineFirstChapters:{paginationCount:9,paginationItems:[{id:"82936",title:"Soil Degradation Processes Linked to Long-Term Forest-Type Damage",doi:"10.5772/intechopen.106390",signatures:"Pavel Samec, Aleš Kučera and Gabriela Tomášová",slug:"soil-degradation-processes-linked-to-long-term-forest-type-damage",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Forest Degradation Under Global Change",coverURL:"https://cdn.intechopen.com/books/images_new/11457.jpg",subseries:{id:"94",title:"Climate Change and Environmental Sustainability"}}},{id:"82777",title:"Sustainability and Social Investment: Community Microhydropower Systems in the Dominican Republic",doi:"10.5772/intechopen.105995",signatures:"Michela Izzo, Alberto Sánchez and Rafael Fonseca",slug:"sustainability-and-social-investment-community-microhydropower-systems-in-the-dominican-republic",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Globalization and Sustainability - Recent Advances, New Perspectives and Emerging Issues",coverURL:"https://cdn.intechopen.com/books/images_new/11476.jpg",subseries:{id:"91",title:"Sustainable Economy and Fair Society"}}},{id:"82387",title:"Kept Promises? 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He was elected a Yangtze River Scholars Distinguished Professor in 2013, a member of the International Statistical Institute (ISI) in 2016, a member of the board of the International Chinese Statistical Association (ICSA) in 2018, and a fellow of the Institute of Mathematical Statistics (IMS) in 2021. He received the ICSA Outstanding Service Award in 2018 and the National Science Foundation for Distinguished Young Scholars of China in 2012. He serves as a member of the editorial board of Statistics and Its Interface and Journal of Systems Science and Complexity. He is also a field editor for Communications in Mathematics and Statistics. His research interests include biostatistics, empirical likelihood, missing data analysis, variable selection, high-dimensional data analysis, Bayesian statistics, and data science. He has published more than 190 research papers and authored five books.",institutionString:"Yunnan University",institution:{name:"Yunnan University",country:{name:"China"}}},{id:"1177",title:"Prof.",name:"António",middleName:"J. R.",surname:"José Ribeiro Neves",slug:"antonio-jose-ribeiro-neves",fullName:"António José Ribeiro Neves",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1177/images/system/1177.jpg",biography:"Prof. António J. R. Neves received a Ph.D. in Electrical Engineering from the University of Aveiro, Portugal, in 2007. Since 2002, he has been a researcher at the Institute of Electronics and Informatics Engineering of Aveiro. Since 2007, he has been an assistant professor in the Department of Electronics, Telecommunications, and Informatics, University of Aveiro. He is the director of the undergraduate course on Electrical and Computers Engineering and the vice-director of the master’s degree in Electronics and Telecommunications Engineering. He is an IEEE Senior Member and a member of several other research organizations worldwide. His main research interests are computer vision, intelligent systems, robotics, and image and video processing. He has participated in or coordinated several research projects and received more than thirty-five awards. He has 161 publications to his credit, including books, book chapters, journal articles, and conference papers. He has vast experience as a reviewer of several journals and conferences. As a professor, Dr. Neves has supervised several Ph.D. and master’s students and was involved in more than twenty-five different courses.",institutionString:null,institution:{name:"University of Aveiro",country:{name:"Portugal"}}},{id:"11317",title:"Dr.",name:"Francisco",middleName:null,surname:"Javier Gallegos-Funes",slug:"francisco-javier-gallegos-funes",fullName:"Francisco Javier Gallegos-Funes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/11317/images/system/11317.png",biography:"Francisco J. Gallegos-Funes received his Ph.D. in Communications and Electronics from the Instituto Politécnico Nacional de México (National Polytechnic Institute of Mexico) in 2003. He is currently an associate professor in the Escuela Superior de Ingeniería Mecánica y Eléctrica (Mechanical and Electrical Engineering Higher School) at the same institute. His areas of scientific interest are signal and image processing, filtering, steganography, segmentation, pattern recognition, biomedical signal processing, sensors, and real-time applications.",institutionString:"Instituto Politécnico Nacional",institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"428449",title:"Dr.",name:"Ronaldo",middleName:null,surname:"Ferreira",slug:"ronaldo-ferreira",fullName:"Ronaldo Ferreira",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/428449/images/21449_n.png",biography:null,institutionString:null,institution:{name:"University of Aveiro",country:{name:"Portugal"}}},{id:"165328",title:"Dr.",name:"Vahid",middleName:null,surname:"Asadpour",slug:"vahid-asadpour",fullName:"Vahid Asadpour",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/165328/images/system/165328.jpg",biography:"Vahid Asadpour, MS, Ph.D., is currently with the Department of Research and Evaluation, Kaiser Permanente Southern California. He has both an MS and Ph.D. in Biomedical Engineering. He was previously a research scientist at the University of California Los Angeles (UCLA) and visiting professor and researcher at the University of North Dakota. He is currently working in artificial intelligence and its applications in medical signal processing. In addition, he is using digital signal processing in medical imaging and speech processing. Dr. Asadpour has developed brain-computer interfacing algorithms and has published books, book chapters, and several journal and conference papers in this field and other areas of intelligent signal processing. He has also designed medical devices, including a laser Doppler monitoring system.",institutionString:"Kaiser Permanente Southern California",institution:null},{id:"169608",title:"Prof.",name:"Marian",middleName:null,surname:"Găiceanu",slug:"marian-gaiceanu",fullName:"Marian Găiceanu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/169608/images/system/169608.png",biography:"Prof. Dr. Marian Gaiceanu graduated from the Naval and Electrical Engineering Faculty, Dunarea de Jos University of Galati, Romania, in 1997. He received a Ph.D. (Magna Cum Laude) in Electrical Engineering in 2002. Since 2017, Dr. Gaiceanu has been a Ph.D. supervisor for students in Electrical Engineering. He has been employed at Dunarea de Jos University of Galati since 1996, where he is currently a professor. Dr. Gaiceanu is a member of the National Council for Attesting Titles, Diplomas and Certificates, an expert of the Executive Agency for Higher Education, Research Funding, and a member of the Senate of the Dunarea de Jos University of Galati. He has been the head of the Integrated Energy Conversion Systems and Advanced Control of Complex Processes Research Center, Romania, since 2016. He has conducted several projects in power converter systems for electrical drives, power quality, PEM and SOFC fuel cell power converters for utilities, electric vehicles, and marine applications with the Department of Regulation and Control, SIEI S.pA. (2002–2004) and the Polytechnic University of Turin, Italy (2002–2004, 2006–2007). He is a member of the Institute of Electrical and Electronics Engineers (IEEE) and cofounder-member of the IEEE Power Electronics Romanian Chapter. He is a guest editor at Energies and an academic book editor for IntechOpen. He is also a member of the editorial boards of the Journal of Electrical Engineering, Electronics, Control and Computer Science and Sustainability. Dr. Gaiceanu has been General Chairman of the IEEE International Symposium on Electrical and Electronics Engineering in the last six editions.",institutionString:'"Dunarea de Jos" University of Galati',institution:{name:'"Dunarea de Jos" University of Galati',country:{name:"Romania"}}},{id:"4519",title:"Prof.",name:"Jaydip",middleName:null,surname:"Sen",slug:"jaydip-sen",fullName:"Jaydip Sen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/4519/images/system/4519.jpeg",biography:"Jaydip Sen is associated with Praxis Business School, Kolkata, India, as a professor in the Department of Data Science. His research areas include security and privacy issues in computing and communication, intrusion detection systems, machine learning, deep learning, and artificial intelligence in the financial domain. He has more than 200 publications in reputed international journals, refereed conference proceedings, and 20 book chapters in books published by internationally renowned publishing houses, such as Springer, CRC press, IGI Global, etc. Currently, he is serving on the editorial board of the prestigious journal Frontiers in Communications and Networks and in the technical program committees of a number of high-ranked international conferences organized by the IEEE, USA, and the ACM, USA. He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:{name:"Association for Computing Machinery",country:{name:"United States of America"}}},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. 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:"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:"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. 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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:null,institution:null},{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. 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The area covers many techniques that offer solutions to emerging problems in robotics and enterprise-level software systems. Collaborative intelligence is highly and effectively achieved with multi-agent systems. Areas of application include swarms of robots, flocks of UAVs, collaborative software management. Given the level of technological enhancements, the popularity of machine learning in use has opened a new chapter in multi-agent studies alongside the practical challenges and long-lasting collaboration issues in the field. It has increased the urgency and the need for further studies in this field. We welcome chapters presenting research on the many applications of multi-agent studies including, but not limited to, the following key areas: machine learning for multi-agent systems; modeling swarms robots and flocks of UAVs with multi-agent systems; decision science and multi-agent systems; software engineering for and with multi-agent systems; tools and technologies of multi-agent systems.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/27.jpg",hasOnlineFirst:!0,hasPublishedBooks:!1,annualVolume:11423,editor:{id:"148497",title:"Dr.",name:"Mehmet",middleName:"Emin",surname:"Aydin",slug:"mehmet-aydin",fullName:"Mehmet Aydin",profilePictureURL:"https://mts.intechopen.com/storage/users/148497/images/system/148497.jpg",biography:"Dr. Mehmet Emin Aydin is a Senior Lecturer with the Department of Computer Science and Creative Technology, the University of the West of England, Bristol, UK. His research interests include swarm intelligence, parallel and distributed metaheuristics, machine learning, intelligent agents and multi-agent systems, resource planning, scheduling and optimization, combinatorial optimization. Dr. Aydin is currently a Fellow of Higher Education Academy, UK, a member of EPSRC College, a senior member of IEEE and a senior member of ACM. In addition to being a member of advisory committees of many international conferences, he is an Editorial Board Member of various peer-reviewed international journals. 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