Terminology
\r\n\t
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Saxena",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/12104.jpg",keywords:"Viral Outbreak, Viral Epidemic, Viral Pandemic, Disease Outbreak Detection, COVID-19, Nipah, Ebola, MERS, Pathogenesis, Host-Pathogen Interaction, Immunity, Antiviral",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 25th 2022",dateEndSecondStepPublish:"June 22nd 2022",dateEndThirdStepPublish:"August 21st 2022",dateEndFourthStepPublish:"November 9th 2022",dateEndFifthStepPublish:"January 8th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"9 days",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Prof. Dr. Shailendra K. has received many awards and honors in India and abroad, including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various prestigious international societies/academies, including the Royal College of Pathologists, United Kingdom; Royal Society of MedProf. He is the vice dean and Professor at King George\\'s Medical University, Lucknow.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"14",totalChapterViews:"0",totalEditedBooks:"9",institution:{name:"King George's Medical University",institutionURL:null,country:{name:"India"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"441704",firstName:"Ana",lastName:"Javor",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/441704/images/20009_n.jpg",email:"ana.j@intechopen.com",biography:"As an Author Service Manager, my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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It is not surprising that there are many enthusiastic claims. Haplotypes, by any of many definitions, offer opportunities to understand the inheritance of polymorphic traits and their regulation. The most useful are markers of extensive complex polymorphic sequences of evolutionary significance even when the functional components, whether coding or noncoding, are yet to be elaborated.
Substantial advances became possible with the elucidation of genomic structure and function more than 20 years ago and long before recent advances in sequencing technology [1] and bioinformatics [2]. It became clear that haplotypes,
This chapter evaluates some competing strategies and illustrates the power now available through NGS.
A review of current literature reveals a staggering collection of terms synonymous with haplotypes, as listed in Table 1.
Ancestral haplotypes Conserved extended haplotypes Linkage groups Linkage disequilibrium haplotypes Hapmaps Haplogroup Haplobanks Haploblocks Haplotype block | \n\t\t
Terminology
Even if it were possible to define the various neologisms, it seems certain that confusion will remain until there is recognition of the conceptual background.
We introduced the term
To yet further confound matters, increasingly, the term
Several other aspects are clear.
Linkage groups relate to closely linked loci but do not define haplotypes.
Linkage disequilibrium is affected by relative frequencies and therefore fails to detect rare haplotypes.
Trios can be misleading since the coverage of the family is limited.
Haplobanks. The Tokunaga group has established some important principles with the intention of establishing haplotype-matched pluripotential stem cell banks [6]. Unfortunately, and amazingly, there is now uncertainty as to how to define the haplotypes. For example, a recent paper urges international collaboration to avoid fragmentation [7]. It would be wise to avoid neologisms and such redefinitions without clarity of meaning.
In the presequencing era, there was a clear understanding of what was meant by the term
The implications were apparent at least 50 years ago: a specific allele A1 at locus A is inherited together with a specific allele B1 at an adjacent, “closely linked” locus B [9]. The fact that these two alleles segregated together through multiple generations was unexpected and lead to controversy but, in retrospect, clearly implied that
The two alleles were encoded on the same chromosome, whether paternal or maternal.
The two loci were closely linked.
Recombination was rare.
The two loci arose by duplication.
Duplication is associated with polymorphism.
The repeated cosegregation of alleles came to be known as a haplotype: from άπλφούς = single [9].
It is worth emphasizing that it was the cosegregation as haplotypes through “phased” multigenerational families (rather than “unphased” populations) which foretold the later demonstration that there was a continuous haplospecific sequence. It is also pertinent, with the benefit of hindsight and in view of recent confusion, that the haplotypes, defined in one family, occurred in other families of similar remote ancestry raising the radical possibility of conservation beyond that expected from close linkage alone. In other words, recombination is patchy and does not necessarily disperse the components of duplications, even after thousands of meioses. The issue of linkage disequilibrium and the limits of LD mapping are considered below.
The implications of haplotypes, as listed above, became even clearer as the HLA A and HLA B locus alleles and then HLA DR alleles were defined during the 1970s. However, in this case, the loci were widely separated. Over time, it became clear that each of the A-B and B-DR haplotypes were some 800 kb in length. Patently, close linkage could not explain these haplotypes; either there was selection for
Through their studies of diseases, the Alper–Yunis group discovered that the B-DR haplotypes contained specific alleles at duplicated loci which had no structural or functional relevance to HLA (i.e. complement and 21 hydroxylase loci) but which happen to be located within the major histocompatibility complex [10–16]. Thus,
The importance of discovery through disease was illustrated at a meeting held in 1982 [3, 4]. As shown in Table 2, it was disease associations which allowed the initial discovery of ancestral haplotypes; note, these three disease-associated haplotypes could have only been discovered through their associations. Two share DR3 and two share B18 but the frequencies differ. Thus, the three haplotypes cannot be detected by linkage disequilibrium.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
8.1 | \n\t\t\t1 | \n\t\t\t7 | \n\t\t\t8 | \n\t\t\tS | \n\t\t\tC | \n\t\t\tQ0 | \n\t\t\t1 | \n\t\t\t3 | \n\t\t\tMG, SLE, IDDM | \n\t\t
18.2 | \n\t\t\t– | \n\t\t\t– | \n\t\t\t18 | \n\t\t\tF1 | \n\t\t\tC | \n\t\t\t3 | \n\t\t\tQ0 | \n\t\t\t3 | \n\t\t\tIDDM | \n\t\t
18.1 | \n\t\t\t25 | \n\t\t\t– | \n\t\t\t18 | \n\t\t\tS | \n\t\t\tQ0 | \n\t\t\t4 | \n\t\t\t2 | \n\t\t\t2 | \n\t\t\tC2 deficiency | \n\t\t
MHC haplotypes and disease associations
MG = myasthenia gravis, SLE = systemic lupus erythematosus, IDDM = insulin-dependent (type 1) diabetes mellitus.
Adapted from ref. [4]
Once the numerous other ancestral haplotypes were defined, multigenerational family studies identified cosegregating combinations of multiple alleles at separated loci, i.e. haplotypes stretching over nearly 2 Mb from HLA A to DR. A haplotype was defined by the alleles “inherited
When haplotypes defined in one family were compared with those identified in apparently unrelated families, sharing was immediately apparent. There were specific combinations of alleles at all the numerous unrelated loci as these were defined and typed. However, and increasingly relevant today, as summarized in refs. [3, 4, 17, 18]:
The combinations observed are
Many haplotypes are rare combinations of frequent alleles at some loci but rare alleles at other loci.
Very few alleles are entirely haplospecific.
Haplotype frequencies are often less than 1%.
The same haplotypes are found in multiple, apparently unrelated, families.
Many of these nonrandom combinations are associated with a disease (such as systemic lupus erythematosus) or function (such as TNF production).
With a few dramatic exceptions (such as 21 hydroxylase and C2 deficiency carried by what we now call the 47.1 and 18.1 ancestral haplotypes), the individual alleles do not explain the haplospecific effects on disease and function.
Penetrance is low. That is to say, the haplotypes are
Recombination is rare and difficult to demonstrate even within multigenerational families with the potential to confirm a meiotic recombinant. Nevertheless, over the life of an ancestral haplotype—say 10, 000 meioses—there have been recombinations which have resulted in shuffling between ancestral haplotypes [18, 19].
Historic recombinations of AH 8.1. The HLA-B8 allele is carried by one ancestral haplotype marked by A1, Cw7, B8, BfS, C4AQ0, C4B1, DR3. All the haplotypes in data set 1 carrying HLA-B8 are represented. These haplotypes have been sorted so that haplotypes that carry all alleles of 8.1 from HLA-A to DR are shown at the top of the figure, followed by haplotypes that extend from HLA-B to DR. Telomeric recombinants are shown at the bottom. The boxed areas represent those portions of the 8.1 ancestral haplotype that are carried by unrelated B8-containing haplotypes. Vertical lines approximately indicate the region where historical recombination has occurred.
Some of these points are illustrated in Figure 1. It can be seen that subjects with B8 can be listed to show conservation but also historic recombinations between HLA A and B, between C4B and DR, and between HLA B and Bf.
By the mid-1990s, and long before the rediscoveries of the 2000s [2], such analyses led to the conclusion that there are polymorphic frozen blocks (PFB), as illustrated in Figure 2.
Ancestral haplotypes and polymorphic frozen blocks within the human major histocompatibility complex. Each ancestral haplotype has its own unique DNA sequence which includes single nucleotide polymorphisms (SNPs), copy number variations, segmental duplications, insertion and deletion events (indels) including retroviral and retroviral-like elements (RLEs). The full length is approximately 4 Mb. Higher degrees of diversity indicated by shading define polymorphic frozen blocks (PFB). Recombination occurs far more frequently between, rather than within, these blocks. Mutations within blocks are effectively suppressed. Adapted from refs. [
PFB throughout the genome are the latter-day equivalents of loci. Sequences which define ancestral haplotypes are the equivalent of alleles. The diversity is multifactorial with contributions from reiterative speciation as follows [17]:
Retroviral integration
Duplication
Indels
Polymorphism
These elements all contribute to the haplospecificity of the sequence of ancestral haplotypes as shown in Figure 3. Similar distribution of diversity has been found by many others [5, 17, 19, 20, 23, 24]. The same patterns are also found in primates [25].
Sequence diversity is packaged as polymorphic frozen blocks (PFB). SNPs and indel occur in similar locations within PFB. (a) The SNP profile after removing indels. Peaks higher than 20 SNPs per 1000 nucleotides are truncated. (b) The location of indels. Peaks higher than six indels per 1000 nucleotides are truncated. (c) The position of indels greater than 100 nucleotides.
Here, we illustrate the potential of sequence analysis, if designed to identify conserved, extended, ancestral haplotypes. The utility depends very largely on the concept behind the analysis. However, it also depends upon the genomic region actually sequenced and whether it is possible to interpret the patterns in the context of the heterogeneous architecture of the genome. Within PFB, there will be a multitude of alternative sequences to compare. In the genome between these blocks, there is much less diversity with long stretches of monomorphic sequence. Thus, the recent fashion for identifying homozygosity [27, 28], without regard to diversity, shifts the focus to less informative regions of the genome. Of course, by way of explanation for the fashion, homozygosity within PFB is much more difficult to find; the most common ancestral haplotypes with frequencies of 0.1 will be homozygous in only 1% of the general population. Until high-throughput NGS became available, it was necessary to examine disease panels or consanguineous families.
The conceptual background is summarised in the following figures which contrast two approaches.
Some of the implications are illustrated in Figures 4 and 5.
Importance of clustering functional genes. Colours represent loci and numbers represent alleles at those loci. On the left is the basis of the infinitesimal model used in population genetics. Loci are biallelic and can be homozygous or heterozygous. Free recombination occurs between loci and alleles segregate independently. On the right, loci are within polymorphic frozen blocks (PFB), shown by alignment of loci. Alleles within PFB segregate
Modern haplotypes are derived from the deep past—they are ancestral haplotypes.
By 1987, it was clearly established that each ancestral haplotype has a specific content of genomic features such as duplications and indels. These too are actively conserved and can themselves be used as signatures for haplotypes of hundreds of kilobases and even megabases. These observations were very difficult to explain in terms of any form of neo-Darwinism, natural selection, random errors or population genetics as taught then and today. Rather, we realised, the genome is not actually homogeneous but partitioned into protected quanta or PFB [17, 22, 26, 29].
By 1992, there was sufficient sequencing to confirm the earlier prediction that each ancestral haplotype is actually a frozen sequence.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
\n\t\t\t\t | \n\t\t\t(TC)12(TG)6(TC)14(TG)3(TC)12\n\t\t\t | \n\t\t\t94 | \n\t\t\tTA (TC)18 TT (TC) 9\n\t\t\t | \n\t\t\t58 | \n\t\t
\n\t\t\t\t | \n\t\t\t(TC)14\n\t\t\t | \n\t\t\t28 | \n\t\t\tDeleted | \n\t\t\t\n\t\t |
\n\t\t\t\t | \n\t\t\t(TC)28\n\t\t\t | \n\t\t\t56 | \n\t\t\t(TC)15 TG (TC)6 TG (TC)8 TG (TC)5\n\t\t\t | \n\t\t\t96 | \n\t\t
\n\t\t\t\t | \n\t\t\t(TC)12(TG)6(TC)14(TG)3(TC)12\n\t\t\t | \n\t\t\t94 | \n\t\t\t(TC)14 TG (TC)6 TG (TC)8 TG (TC)5\n\t\t\t | \n\t\t\t94 | \n\t\t
Haplospecific geometric elements. Ancestral haplotypes have specific sequence signatures at each of the duplicons. Note in 18.2, the duplication did not occur or has been deleted.
Adapted from ref. [30].
We now know that examples of the 8.1 ancestral haplotype are almost identical over megabases [31, 32].
We illustrate the differences between different haplotype sequences in Figure 6. It can be seen that there are certain sites where haplotypes differ. Importantly, haplospecificity is conferred by the whole sequence rather than single nucleotide polymorphisms. For example, reading from left to right, 8.1 and 18.2 differ in T/G but not A/G, etc. Note also that some of the differences are due to indels. Of critical importance is accurate, unmolested sequencing over kilobases, as is now possible through NGS. It is clear, however, that assembly is hazardous especially in areas of duplication and polymorphism. Note also, that there is no justification for regarding
The number of differences depends on which haplotypes are compared (see Table 4). Two of the most common Caucasian haplotypes, 8.1 and 7.1, differ by a hundred positions, representing approximately 1% nucleotide diversity. The most different haplotypes are 18.2 and 7.1, having 2.5% nucleotide diversity. Interestingly, these haplotypes are different functionally; 18.2 permits insulin-dependent diabetes mellitus whereas 7.1 is protective.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
\n\t\t\t\t | \n\t\t\t0 | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t\t | \n\t\t |
\n\t\t\t\t | \n\t\t\t187 | \n\t\t\t0 | \n\t\t\t\n\t\t\t | \n\t\t\t | \n\t\t |
\n\t\t\t\t | \n\t\t\t249 | \n\t\t\t221 | \n\t\t\t0 | \n\t\t\t\n\t\t\t | \n\t\t |
\n\t\t\t\t | \n\t\t\t73 | \n\t\t\t154 | \n\t\t\t227 | \n\t\t\t0 | \n\t\t\t\n\t\t |
\n\t\t\t\t | \n\t\t\t224 | \n\t\t\t219 | \n\t\t\t101 | \n\t\t\t204 | \n\t\t\t0 | \n\t\t
\n\t\t\t\t | \n\t\t\t184 | \n\t\t\t130 | \n\t\t\t250 | \n\t\t\t137 | \n\t\t\t245 | \n\t\t
Pairwise differences between haplotypes. Total differences between each pair of haplotypes in the 9277 bp region at HLA-B.
Alignment of 9 kb sequence at HLA-B. Sequences of 6 individuals with homozygous ancestral haplotypes were downloaded from UCSC browser [
The degree of conservation of each ancestral haplotype is truly remarkable. For example, Smith et al. [32] found variation at only 11 of 3, 600, 000 positions between HLA-A and DR. Similar findings have been reported by others, including Aly et al. [31], see Figure 7. Mutation and recombination must be suppressed.
Figure 7 illustrates the importance of interpreting nucleotide diversity according to the block structure of the genome. Thus, conservation in the intervening, essentially monomorphic regions, is of minor interest, whereas differences within PFB allow the discovery of evolution, function and disease susceptibility.
Remarkable conservation within 8.1 haplotypes. A total of 656 SNPs spanning 4.8 Mb in the MHC region are depicted. The lower frequency allele (row) for each SNP along each haplotype column is highlighted in yellow. The top group depicts SNP results from 8.1 AH haplotypes (
The inescapable conclusion is that some parts of the genome have
The challenge in terms of sequence analysis is to compile a sufficient matrix to be able to recognize each haplotype and its extent. Assume access to multigenerational families with accurate, truly phased but unmolested raw sequences of at least 100, 000 bases:
Clustering of these by independent criteria relating to as many as hundreds of distinct ancestral haplotypes.
Alignments which take account of haplospecific duplicons, indels and retroviral-like elements (RLE).
Functional information to address biological and disease significance.
Given NGS, this approach is now feasible, even if daunting.
Importantly, those regions which are complex because of duplications and indels should be included rather than “corrected” based on the assumption that there is a single reference or “wild” sequence. Some examples are shown in Figure 6.
In designing better algorithms [36], the strategy for comparative analysis will be crucial. In many polymorphic regions, the density of differences can be as high as 1 per 10 bases when different haplotypes are compared but as low as 0 if the haplotypes are the same. It follows that analysis without haplotype assignment will be misleading.
The best clue to the location of these blocks is segmental duplication [17, 37].
Segmental duplications in MHC alpha block. (a) Gene families and retroelements PERB 11, HLA, HCGIV, AD-3, HERV-16, PERB3 are duplicated to form an ordered pattern within the alpha block of the MHC, indicating that a segment containing multiple genes and retroelements has been duplicated to give 10 duplicons. Full-length duplicons consist of PERB11, HLA, HCGIV, 1AD3, HERV-16 (P5) and PERB3 genes. HLA-80, HLA-A, HIA-K, HLA-16, HLA-90 and HLA-F duplicons lack PERB11 gene. f = fragment, 1 = LTR only, d = discontinuous. ψ = pseudogene. A, B and C represent subgroups of duplicons with greater similarity. (b) A dot plot of the 319 kb genomic sequence encompassing the alpha block was compared against itself. The oblique lines in the plot represent duplications whereas the dots represent retroelements. Lines connect regions of the dotplot to the appropriate duplicons. The primers shown amplify products of different lengths in each duplication. Sequence from GenBank accession number AF055066. Adapted from ref. [
To characterize the PFB, it is helpful to amplify haplospecific geometric elements [30], see also Table 3. Essentially, this approach reveals duplications as seen in Figure 8. McLure developed the approach to find PFB throughout the genome [36]. Paralogous regions are also helpful as shown in Figure 9.
Paralogous locations of MHC genes. MHC genes are found on four chromosomes: 1, 9, 19 as well as chromosome 6. The arrangements of genes in each of the paralogous groups can be largely explained by duplication with and without inversion events. The genes common to chromosomes 6 and 9 are shown.
Once identified, we recommend tracking the polymorphism through panels of multigenerational families as illustrated in Figure 10. Although the region is over 10 megabases, recombination was not found. The different haplotypes in the three breeds must have been conserved for at least hundreds of generations and mark differences in function such as the melting point of fat [37].
Tracing segregation through three generation families. The alleles at MRIP, now known as myosin phosphatase Rho-interacting protein, are used to designate haplotypes within the 5.5 Mb region of bovine chromosome 19 from SREBF1 to TCAP. Within this region, there are many genes involved in muscle development, growth and fatty acid synthesis. For further details, see Williamson et al. [
Since it is known that PFB can be mapped by plotting diversity measurements (see Figure 3), we asked whether it would be possible to use data from the 1000 Genomes Project [39] in the same way.
Earlier work was based on haplotypes defined in multigenerational families. Initially, sequences of haplotypes were determined from Sanger sequencing of homozygous cell lines. In contrast, variations in 1000 genomes are determined from NGS for heterozygous and unrelated individuals. The phasing is an estimate based on ideas inherent in population genetics. It is known that the approach is a risky approximation. For example, artefactual “switch-overs” between haplotypes are misleading [40]. Since the reads tend to be short, such as just hundreds of bases, assembly can be fraught. There is a risk of missing complex polymorphisms and underestimating the number of ancestral haplotypes. Given these problems, we plotted several indices related to the 1000 genomes. The intention was to identify any similarities with the distribution as shown in Figure 3.
Unexpectedly, Figure 11 shows a remarkable correspondence between the classical measurements and our extraction from the 1000 Genomes database. The exception around 31.4 Mb was missed by the NGS reanalysis presumably because it is a region which is rich in complex iterative sequences, as shown in Figure 12.
Regions of high sequence diversity within 1000 genomes are similar to previously identified PFB. Imputed haplotypes in the 600 kb region surrounding HLA-B from 553 individuals were downloaded from the 1000 Genomes browser [
Complex iterative element. Dotplot of a 10 kb region in the MHC between MICA and MICB showing a complex iterative element. Gaudieri [
These results are very encouraging in that the advantages of NGS can be coupled with identification of genomic architecture and therefore targeting of the most informative regions. The similarity, by simply counting the base differences per 10 kb, can be refined and applied to the whole genome. The plot of number of “haplotypes” is also promising, although clearly not indicative of the number of ancestral haplotypes.
Since there are numerous ancestral haplotypes within a PFB, it is essential to compare as many sequences as possible. An example is shown in Figure 6.
It can be seen that
Only a minority of sites are informative and these must be selected from the remainder.
Kilobases need to be examined and reduced 10- to 100-fold, retaining the informative sites.
Different haplotypes are defined by specific combinations of bases at those informative sites.
Very few single nucleotide polymorphisms are specific for a particular ancestral haplotype. On the contrary, specific combinations may be best defined by comparison with a library of reference sequences.
Indels are important: alignments can be misleading.
Thus, although the identification of each of the many haplotype remains challenging, the overall patterns of informative sites are helpful in screening for PFB and for localising haplospecific sequences.
In analysing NGS databases, we recommend:
Screening for PFB.
Alignment based on the ability to detect multiple, and even hundreds of ancestral haplotypes.
Analysis must recognise that haplospecificity is confirmed by many characteristics including RLE, indels, copy number and complex iterative sequences.
Analysis may be facilitated by examining paralogous regions which help to define interactions, including epistasis.
Validation of results by showing segregation in multigenerational family studies.
Confirming biological significance by demonstrating permissive or
Although the term malnutrition has a meaning that includes the condition of being overweight, according to Early Career Faculty The European Society for Clinical Nutrition and Metabolism (ESPEN), it is defined as physical changes in body composition as a result of clinically significant malnutrition, as well as body functions and clinical outcomes [1, 2]. As a result of malnutrition mentioned here, it causes changes in body composition (decrease in fat free mass [FFM] and body cell mass [BCM]) that affect the physical and mental functions of the person and the healing process from diseases. In clinical practice, in addition to the decrease in food supply, increased catabolism in the body after trauma and inflammatory diseases also causes malnutrition. An important point here is that while malnutrition caused by inadequate food intake is easier to correct, the negative energy and nitrogen balance in the catabolic phase of diseases cannot be reversed even with large amounts of food intake. Replacing the lost tissues is only possible by controlling the inflammation [3, 4]. For these reasons, when evaluating the risk of malnutrition in individuals, static measurements such as body mass index (BMI) and anthropometry are evaluated together with simple bedside measurements of disease severity and body functions (e.g., evaluation of mood, hand-wringing dynamometer, measurement of peak expiratory flow) [5]. According to this information, the definition of malnutrition is a combination of both excessive and insufficient nutrition and inflammatory activity, and it is defined as a subacute or chronic nutritional disorder that causes changes in body composition and loss of functions [6]. Both definitions can be considered valid and should probably be used together because it is important for a definition to have a therapeutic feature to guide the clinician to select patients who would benefit from nutritional therapy. The process of identifying patients with nutritional problems begins with a rapid screening and continues with a detailed evaluation of those found to be at risk [7].
To diagnose an individual as being malnourished, two or more criteria of those need to be fullfilled: i) low energy intake, ii) weight loss, iii) loss of muscle mass, iv) loss of subcutaneous fat, v) fluid accumulation, and vi) hand grip [8]. Malnutrition is reported to be related with cognitive functioning in the elderly [9]. In addition, it is used to predict morbidity and mortality rate after surgical operations in critical elderly cases [10]. Also, it was shown that malnutrition increased the risk of readmission in hospitilized elderly patients [11].
The phenomenon of malnutrition in the elderly is more complex than that in the young ones and is a determinant of developing morbidity and mortality. It has been associated with adverse health conditions such as prolonged hospital stay, reduced quality of life, delays in wound healing, infection, and decreased functional capacity in these individuals. The prevalence of malnutrition was reported as 5–10% in the elderly living at home, as 30–60% in elderly residents of nursing homes, and as 35–65% in the elderly that have been hospitilized [12]. Considering that the daily energy requirement of people in this age group is 30 kcal/kg on average (in the absence of any stress situation under normal conditions), 50–60% of this energy should be planned to come from carbohydrates, 30% from fat, and 20% from proteins. While the daily protein requirement of a normal adult is 0.8–1.0 g/kg, the need is 1.0–1.2 g/kg per day under normal conditions, since muscle mass loss occurs in the elderly due to various reasons (sarcopenia) [13].
In cases of clinical diseases (such as infection, sepsis, cancer, etc.) that put the person in the acute catobolic process, the need for protein increases, and it can reach up to 1.5–2.0 g/kg per day. Vegetable proteins can be preferred as a protein source, but it is important to prefer animal proteins as they are limited in terms of both content and the presence of essential amino acids. Since most of the daily energy requirement is provided by carbohydrates, when its amount in the diet is reduced, it will cause fat and protein breakdown, which will lead to weight loss and sarcopenia. The omega-3 fatty acids in the dietary fat are important because of their anti-inflammatory character and positive effects on the cardiovascular system. On the other hand, it also has appetite-stimulating properties. Foods containing omega-3 fatty acids are fish, green vegetables, nuts, and walnuts. Adequate daily water consumption is also very important in old age. When this need is not met, it causes serious problems [13].
Dehydration and secondary medical emergencies to dehydration are responsible for a significant portion of hospitalizations in the elderly (e.g., acute renal failure, falls, arrhythmias, heart failure, electrolyte imbalance, etc.). The daily water requirement in the elderly is roughly 1 ml per kcal of daily energy requirement and is 30 ml per kg with another simple calculation. Another important nutrient is fiber (pulp). The first of the physiological changes that occur in the gastrointestinal system with aging is a decrease in movements. This problem can be partially solved by increasing the amount of fiber in the diet. On the other hand, dietary fiber plays an important role in blood sugar regulation. Therefore, the daily diet of the elderly should contain at least 25 g of fiber. 37–40% of the elderly cannot be fed at a level to meet the daily energy requirement, two out of three elderly people skip a meal, and this situation has been described as "anorexia of aging" in recent years [13]. In the old age, the mortality rate increases by 9–38% within 1–2.5 years following the onset of weight loss for any reason [14]. In addition to the decrease in oral food intake, daily growth hormone secretion decreases by 29–70% with age, which leads to sarcopenia [15]. In the frail elderly, different factors can occur at the same time and affect food intake by interacting with each other, and in the process of food intake and digestion, imbalances, weight loss, and loss of function may occur in the acute and chronic periods; in other words, malnutrition may occur. In Table 1, possible causes for inadequate food intake and malnutrition are listed under four subunits: somatic, psychological, functional, and social [7].
Somatic state | Chronic diseases (eg: cancer, diabetes, chronic obstructive pulmonary disease, cardiovascular diseases)
|
Psychological state | Stress
|
Functional status |
|
Socioeconomic status | Not having sufficient financial means to reach food
|
Causes of inadequate food intake in the elderly.
An increase in the incidence of depression, stool incontinence, loss of cognitive function, and physical dependence has been detected, especially in those with malnutrition [16]. There has been a significant increase in the incidence of other geriatric syndromes in the elderly with malnutrition. The risk of malnutrition was found to be associated with the levels of depression, hematocrit, fasting plasma glucose, albumin, erythrocyte sedimentation rate, instrumental activities of daily living, patient addiction, and bone mineral density [16, 17]. There has been a significant increase in the incidence of other geriatric syndromes in the elderly with malnutrition [16]. Although the effect of malnutrition on our country\'s economy is not fully known, it can be estimated that its negative effects are very high. It is known that such problems and costs will increase with the increase in the elderly group and chronic diseases in the aging world and in our country. The results of multicenter nutrition and health research conducted at the national level in the elderly show that there is an inadequacy in the consumption of energy, protein, vitamins A, B1 and B2, niacin and vitamin C, and minerals such as iron, calcium, and zinc, both at home and in the elderly living in nursing homes. Although the incidence of folate and vitamin B12 insufficiency in the elderly is not known in the whole population, it is known that insufficiency of these two vitamins in older ages is an important cause of cardiovascular diseases [7].
In a study, the malnutrition rate was found as 5.8% in the elderly living in the community, as 13.8% in those living in nursing homes, and as 38.7% in those hospitalized. There was a significant relationship between malnutrition and dementia and sarcopenia. In that study, mini-nutritional assessment (MNA) is recommended for the evaluation of the nutritional status of the geriatric age group [13]. In the ESPEN recommendations published in 2002, it is recommended that all individuals over the age of 65 should be screened routinely in terms of nutrition. Similar recommendations are included in all ESPEN guidelines published in the following years [17]. In the framework of the decision taken by the European Parliament in 2007, obesity and malnutrition were accepted as the most important public health problem, and the issue was included in the official political agenda of the European Union in 2008. The year 2009 has been declared the year of fight against malnutrition by ESPEN. Based on all these data, the nutritional status of elderly individuals living in the community and hospitalized in clinics should be screened, and a treatment plan should be developed by making detailed evaluations in risky individuals [2, 7].
Hunger has important effects on the function and structure of organs. Loss rates of various organs have been demonstrated in a study conducted on autopsy of patients who died from manure [18]. According to the findings of that study, the heart and liver lost about 30% of their weight, while the spleen, kidney, and pancreas were also affected. In that study, 32 healthy men who underwent partial fasting for 24 weeks each lost 25% of their baseline body weight. Fat mass decreased to 30% of baseline, and FFM to 82% of baseline. Clinical observations have shown that the loss in FFM is greatest in skeletal muscle. In response to stress, muscle proteins are both precursors of gluconeogenesis and amino acid precursors for protein synthesis required for immune response and repair. This muscle wasting may be one reason why debilitated people have a higher risk of developing complications during acute illness or after surgery [2, 7, 19].
In adults, hunger causes anxiety and depression, which may be due to specific micro and macronutrient deficiencies. Several large-scale epidemiological studies have shown a relationship between diet quality and the frequency of cognitive impairment. Subclinical deficiencies of vitamins C, E, B12, B6, and folate, and changes in calcium, magnesium, and phosphate have been identified as nutritional-related risk factors for impaired brain functions [20].
Malnutrition causes a decrease in muscle strength and endurance. With a lack of food, muscle function decreases before any change in muscle mass occurs, then worsens as the amount of cells decreases. Conversely, through its effects on cell function, function improves by 10–20% in the first few days of refeeding. Then, over a period of weeks, the muscle mass is restored and gradually returns to normal. In addition to muscle wasting, inflammatory activity all reduces muscle strength, endurance, and mobility. Muscle strength is a combined measure of muscle mass and inflammatory activity and is therefore a useful risk factor for quality of life and ability to cope with trauma and disease. The hand-grip dynamometer, which measures voluntary muscle strength, is a useful clinical tool for nutritional assessment and has been found to be correlated with surgical outcomes and clinical improvement [6].
Prolonged and severe malnutrition causes cardiac muscle wasting with decreased cardiac output, bradycardia, and hypotension. The reduction in heart volume, 40% of which is due to the reduction in heart muscle, is proportional to body weight loss. Decreased ventricular volume may explain the remaining 60%. In severely depleted patients, exercise tolerance is impaired and peripheral circulatory failure may also develop. Specific deficiencies such as vitamin B1 may lead to heart failure (wet beriberi), and mineral and electrolyte disturbances may lead to cardiac arrhythmias [21].
It has been reported that malnutrition causes significant changes in renal hemodynamics with a decrease in renal plasma flow and glomerular filtration rate, as well as a decrease in the capacity of concentrating urine and removing acid load. The capacity to remove excess water and salt load is also reduced, and the extravascular fluid volume makes up a larger-than-normal body part. Together with other malnutrition-related changes, these cause “hunger edema” [5].
Protein loss of more than 20% affects the structure and function of respiratory muscles. This is accompanied by a decrease in diaphragmatic muscle mass, maximal voluntary ventilation, and respiratory muscle strength. Impaired neural respiratory power also affects ventilation. Exhausted individuals have impaired response to hypoxia and hypercapnia, altered respiratory pattern, and morphological changes in the pulmonary parenchyma. It is quite difficult to separate the patients from the ventilator. Bronchopneumonia is common in such patients, resulting in hypoventilation, inability to cough effectively, and impaired resistance to spreading microbes [5].
The most prominent effect of acute and chronic food starvation in the small intestine is a decrease in the absorption surface area. Impaired absorption of lipids, disaccharides, and glucose has been demonstrated in severely depleted patients. There is also a decrease in the production of gastric, pancreatic, and biliary secretions, which also contribute to malabsorption. As a result of these changes, severely malnourished patients often suffer diarrhea that is added to the malnutrition, and a vicious cycle begins. Changes in the bacterial flora or significant intestinal infections add to malabsorption and diarrhea. All gastrointestinal changes associated with malnutrition lead to inflammation and impaired intestinal barrier function. In chronic cases, this leads to liver steatosis or worse, steatohepatitis [5].
Severe weight loss impairs the thermogenic response to fasting and cold, and fasting for more than 48 hours reduces vasoconstrictive responses. These changes predispose to mild hypothermia with important clinical consequences. A decrease of only 1–2°C in core body temperature leads to impaired cognitive functions, incoordination, confusion, and muscle weakness, which tends to decline, especially in the elderly. In cases of severe famine, the fever response is lost, and there may be no fever even in the presence of life-threatening infection. Loss of thermoregulation returns after refeeding [5].
Malnutrition itself affects nearly all immune response systems, but particularly impairs cellular immunity and resistance to infection. As a result of decreased immunity, susceptibility to infections increases, and the ability to cope with trauma and infection decreases. Annually, people with a BMI below 18.5 kg/m2 tend to be sick more days than most people with a BMI above 18.5 kg/m2 [21].
Malnutrition, and especially in the last period, low food intake, delays wound healing in surgical patients. Low body mass index, low body weight, and decreased food intake have been shown as independent risk factors for the development of pressure ulcers. An adequate diet improves wound healing in a week. There is evidence that nutritional support reduces the incidence of pressure ulcer development and that patients receiving high protein supplementation tend to have better healing of pressure ulcers [22].
Good nutrition improves quality of life, food itself not only provides sensory and psychological satisfaction, but also depends on it for mental and physical well-being. The consequences of malnutrition include progressive physical, mental, and social disability, and an increased propensity for diseases and their worsening [5].
Before making a diagnosis of malnutrition, risk groups should be screened. Screening tests are used for this. With these tests, people to be investigated for the diagnosis of manutrition are determined [5].
A good screening method should be simple to implement quickly and easily by practitioners, as well as have criteria such as predictive validity, content validity, and reliability, and should provide a correct orientation for diagnosis. For this purpose, many malnutrition screening methods have been developed recently. These methods include questions about weight, recent weight loss, if any, and food intake. At the same time, weight, height, net measurements, and BMI calculation are used in these methods [23, 24].
Malnutrition Screening Tool (MST) and Short Nutritional Assessment Questionnaire (SNAQ) can be given as examples of short, easily applicable screening methods that can be used in malnutrition screening. Some screening methods, on the other hand, are considered as an evaluation method, not a screening method, since they include inquiries such as clinical status, physical examination, disease severity, and food amount. Subjective Global Assessment (SGA) is one of these assessment methods. SGA has been used as a screening method for more than 20 years and is used as a reference in the development of new methods. Nutritional Risk Screening (NRS2002) supported by ESPEN and Malnutrition Universal Screening Tool (MUST) developed by British Association for Parenteral and Enteral Nutrition (BAPEN) are other screening methods widely used in Europe. Simple training is needed for the use of SGA, NRS-2002, and MUST [23, 24]. Some of these screening methods are more suitable for different patient categories. For example, NRS-2002 or MUST, SNAQ , or MST is more suitable methods for hospitalized adult patients. For community surveys, it has proven its MUST value. For the elderly in the hospital or community, MNA and its short form MNA-SF are suitable [25]. The patients whose malnutrition will be evaluated with screening tests are determined and the evaluation phase is started.
Nutritional evaluation is a more detailed and time-consuming evaluation process by dietitians, nurses, or doctors experienced in clinical nutrition of patients who are determined to be in the risk group in nutritional screening. Thus, an approach plan can be created that includes continuous monitoring and an appropriate treatment approach.
Malnutrition assessment should include the following principles:
Nutrient balance measurement
Body composition measurement
Inflammatory activity measurement
Body functions measurement
All potential factors that may cause malnutrition should be identified, and the course of the patient\'s condition should be predicted. Weight loss, food intake, appetite status, fluid balance, gastrointestinal symptoms, fever, various food losses, medical and drug use history should be evaluated. Detailed and accurate information about food intake is critical for the assessment of nutritional status. A dietary history should include qualitative as well as quantitative aspects to assess energy, protein, and micronutrient intake, as well as to estimate whether there is improvement or deterioration in the patient\'s nutritional status by comparison with predicted requirements. Making a good quality assessment is time-consuming and requires the specific experience of trained personnel. Evaluation of the diet in the last 24 hours reveals the current situation, while questioning the dietary history gives an idea for longer periods. Food diaries are indicative of individual intake, but to be fully reliable the questioner must ask additional questions. This type of query is only meaningful when used for the target population. Fluid balance is an intrinsic part of nutritional assessment. Physical examination should be performed to detect dehydration and edema. For this purpose, fluid balance records should be kept and blood creatinine, urea, and electrolyte levels should be measured when clinical indications are available [5]. Although it is not very common in daily practice, the energy requirement can best be determined by indirect calorimetry. There are many equations for estimating the energy requirement, but most of them deviate significantly from the actual values determined by indirect calorimetry. Isolated deficiencies can be determined by laboratory tests. Examples of these are minerals (i.e., K, Ca, Mg, Zn, Fe), vitamins, and trace elements [26].
Body weight, height, and calculated BMI are key measurements that should always be determined. Other anthropometric measurements, although easy, have not been popular. Anthropometric techniques measuring body compartments (fat free mass [FFM], fat mass [FM], skinfold thickness [TSFT], mid-arm muscle circumference [MAMC]) have been used in many studies. They may be useful in conditions where weight is difficult (i.e., elderly people with a fractured femur) [26].
The status of malnutrition should be determined not only by anamnesis, physical examination, and bedside measurements such as fever, pulse, and blood pressure, but also by laboratory tests such as hemoglobin, complete blood count, serum albumin, and c-reactive protein, which show the severity of inflammation [22].
Physical dysfunction related to malnutrition can be measured at the bedside with simple measurements that can identify the initial condition and allow monitoring. Evaluation of skeletal muscle function is important as it is sensitive to changes in muscle mass and food intake. Improvements in muscle strength occur within 2–3 days of starting nutritional support, but are not accompanied by an increase in muscle mass. Conversely, with total starvation, decreases in muscle strength begin within a few days. Muscle functions can be evaluated qualitatively by anamnesis and examination, as well as reductions in daily living activities and strength of handshake. The simplest quantitative measurement is with a handheld dynamometer, which correlates very well with clinical outcomes in surgical patients. Changes in respiratory muscle strength can be assessed by serial FEV1 measurements, bearing in mind that of course this also reflects changes in airway resistance. Evaluation of cognitive functions is not common. Malnourished patients exhibit a reversible deterioration in cognitive functions and mood. Using a valid mental scoring technique such as profile of mood states (POMS) or Mini-Mental State Examination (MMSE), mood swings should be scored and changes with treatment should be recorded [27, 28].
This measurement shows anatomical changes related to changes in body malnutrition status.
Changes in body weight in the short term reflect fluid balance and are the most important measure of fluid balance. Long-term changes in body weight, on the other hand, may reflect net changes in true tissue mass, but do not provide information about compositional changes. Involuntary weight loss in the last 3–6 months is considered mild if it is less than 5%, and if it is more than 10–15%, it is considered as an indicator of a severe nutritional change. Even if significant body weight has been lost in the past year, this does not reflect malnutrition if the lost body weight has recently been regained. However, if the loss of body weight continues, the clinician should investigate the reasons for this. Measured body weight is an important variable in calculating metabolic rate, nutritional requirement, and drug doses. Compared with indirect calorimetry, it is more accurate to use ideal body weight for calculations in overweight or underweight individuals, even though the metabolic rate estimates obtained with the equations may show deviations of up to 28%. Weight divided by ideal weight gives “percent of ideal body weight.” Reference tables are available for individuals of the same age and sex, giving the ideal weight specific to the North American population. Ideal weights are determined by American health insurance companies on the basis of minimum health expenses [5, 18].
It is another measure to evaluate malnutrition. It is expressed according to the formula below. Although it has a narrow normal range, it offers a wide range that allows comparison in both sexes and age groups.
BMI = Weight (kg)/(Height X Height) (mxm)
The result obtained is interpreted according to the following values:
30< obese
25–30 overweight
20–25 normal
18–20 possible malnutrition
23.5< indicates adequate nutritional status.
If the BMI is less than 12 in men and 10 in women, survival is rare. If the body mass index is below 20, mortality increases. As a result of osteoporosis in the elderly, this range is increased with a decrease in height, and a BMI lower than 22 indicates malnutrition. If the patient has recently complained of involuntary weight loss, this is associated with malnutrition, even if the BMI is obese or even within the normal range. Estimated height can be calculated by adjusting age and knee height measurements according to gender in patients, elderly and frail people, or in cases of scoliosis or kyphosis and when height measurement cannot be performed [5].
Mid-upper arm circumference (MUAC) is measured from the midpoint of the acromion and olecranon prominence using a tape measure. This measurement process is very easy and the margin of error is very small. It is a useful measurement method that replaces weight measurement in situations where weight measurement is impossible. Low measurement values correlate well with mortality, morbidity, and response to nutritional support. It has been determined that MUAC is a better predictor of mortality than BMI in the elderly population. The value obtained as a result of the upper middle arm circumference measurement; it reflects the sum of tissue, bone, muscle, fluid, and fat mass. However, useful correlations of muscle and fat mass can be obtained when triceps is used together with the measurement of skinfold thickness [5].
It provides the drawing of force frequency curves as a result of direct measurement of contraction, relaxation, and force by electrical stimulation of the adductor pollicis muscle. It can detect early changes with starvation and refeeding [5].
Besides measuring airway resistance, FEV1 reflects the strength of respiratory muscles. Expiratory and inspiratory force against resistance can also be measured. Hill demonstrated a strong correlation between respiratory function and total body proteins after a rapid loss of 20% in body proteins [5].
Severe protein energy malnutrition results in impairment of all factors such as cellular immunity, phagocyte function, complement system, secretory IgA, antibody concentrations, and cytokine production. Deficiency of some nutrients (e.g., zinc, selenium, iron, and vitamins A, C, E, B6) also alters the immune response. In the presence of malnutrition, leukocyte functions, antibody secretion, and complement levels may also be impaired [7, 29].
Although a good indicator of surgical risk and a good reflection of disease severity, it does not reflect malnutrition, contrary to popular belief. Delays in normalization of serum albumin during acute illness may be affected by energy and protein intake. Serum albumin is mainly affected by distribution and dilution. This is due to the increased rate of albumin escape from the circulation in relation to the cytokine response to injury and the dilution resulting from the increase in extravascular volume. Albumin has a long metabolic half-life of 18 days, the metabolic effects on its concentration take time to appear. In fact, the normal outflow of albumin from the circulation and its return through the lymphatics is approximately 10 times the synthesis rate [5, 7].
Proteins with shorter half-lives are affected by distribution and dilution, such as transthyretin (2 days) and transferrin (7 days) albumin. Transthyretin more accurately reflects recent food intake, but is not a good indicator of nutritional status. Therefore, these parameters are rarely included in a complete nutritional assessment [5, 7].
Liver enzyme tests, creatinine, urea and electrolyte levels, calcium, phosphate, and magnesium levels should be measured routinely and recorded regularly. It is useful to know the zinc, selenium, and iron levels in the diagnosis of gastrointestinal diseases. C-reactive protein is useful for assessing acute inflammatory activity, but is not reliable for chronic inflammation or recovery from acute inflammation [5, 7].
Urinary excretion of creatinine reflects muscle mass. Urinary excretion of creatinine is high in weight lifters with a large muscle mass and low in malnourished patients. The creatinine excretion in 24 hours is used to calculate the creatinine height index (CHI).
This formula is used to reflect muscle mass. If the deficit in muscle mass is 5–15%, it is mild, if it is between 15 and 30%, it is moderate, and if it is more than 30%, it indicates a severe nutritional deterioration.
Nitrogen balance is one of the most frequently used research methods in clinical practice, which always overestimates the intake and underestimates the losses from urine, faeces, and wounds. For total nitrogen, the Kjeldahl technique is better than inferring from urine urea. Under normal conditions, urea contains 80% of urinary nitrogen, but this ratio varies with malnutrition and disease. Nevertheless, large changes in urinary urea excretion are useful in demonstrating changes in net protein catabolism and are a simple method to apply in intensive care. Decreased protein turnover with fasting is characterized by low serum urea concentration if patients are well hydrated [5, 7].
It is absolutely essential that the data obtained by monitoring at the beginning and maintenance of nutritional support be recorded in a digital environment or on paper and be easily accessible for control when necessary. Thus, absolute values or trends can be easily monitored and decisions can be made quickly when necessary. In order to better reflect the clinical situation, the correlation or combination of various parameters paves the way for more effective predictions [5].
Today, there are many tools available for screening and diagnosing malnutrition. To prevent misuse, it is important to know how they were developed and for which specific patient population and department of care they were evaluated. The methods used in screening and diagnosis are important in recognizing the disease with malnutrition, finding the underlying causes of malnutrition, and evaluating the consequences of malnutrition [30, 31]. Screening instruments are short, time-consuming, easy for the patient, and often do not require the expertise of the personnel performing these tasks. Screening tools often indicate only malnutrition. For patients at risk, it is necessary to learn more about the cause, severity, and pattern of malnutrition (such as protein-energy malnutrition, vitamins, and minerals) [32, 33].
The tests used in the diagnosis of malnutrition give an opinion about the severity and type of malnutrition and the underlying factors. Diagnostic tools are more complex in shape than screening tools, take more time, and require more experienced personnel. The results of the laboratory and/or clinical research may form part of this evaluation [33, 34].
The most commonly used assessment tool specifically for malnutrition in the elderly is the Mini Nutritional Assessment test (MNA) [1, 32]. Subjective global assessment is another test that is accepted as a basis by the social security institution and is frequently and widely used in the screening and diagnosis of malnutrition. Comprehensive geriatric assessment is a method that ensures that many problems of an elderly person are evaluated and followed up as effectively as possible. Comprehensive Geriatric Evaluation is put into practice in order to obtain a full-fledged result in terms of the geriatric patient\'s condition. Thus, the patient is evaluated in terms of somatic, psychological, social, and functional aspects, and an integral treatment plan is created for the patient to manage himself and improve his quality of life [35, 36]. Malnutrition is a geriatric syndrome and must be included in a comprehensive geriatric evaluation. Comprehensive geriatric evaluation also evaluates the relationship of malnutrition with other somatic, psychological, social, and functional conditions. MNA is recommended in the evaluation of malnutrition in the elderly. MNA is a valid method for detecting malnutrition in clinical as well as outpatients. The MNA is also a valid tool for evaluating the results of nutritional support treatments. MNA is accepted as a valid measurement tool for detecting malnutrition in geriatric patients, as well as a valid tool for predetermining the risk of malnutrition. ESPEN recommends MNA as an examination tool for the elderly [32, 37]. It is a tool that must be used in SGA and has practical benefits.
The MNA begins with six screening questions (questions A-F1/F2), which are MNA-Short form (MNA-SF) with a maximum of 14 points. These questions relate to the patient\'s food intake, weight loss, mobility, psychological stress or acute illness, depression or memory problems, and determination of BMI. If BMI cannot be measured, it has been proven that the use of calf circumference may be appropriate [38]. If a score of less than 12 points is obtained as a result of this questioning, it is recommended to continue with the other questions (questions G-S). These questions are related to residence status, medication use, presence of pressure sores or skin inflammation, eating meals and protein and fluid intake, patient\'s own opinion according to nutrition and health status, and some extra anthropometric measurements [32, 37]. This will be the final MNA-score: <17 means malnutrition, 17–23.5 means malnutrition risk, and >23.5 indicates adequate nutritional status. Fill in the ”Examination” section of the form. If the total score is 11 or less, proceed to the questions under the “Research” section to determine the score for the Nutritional Malnutrition Indicator. The administration of MNA-SF takes less than 5 minutes, while the administration of full MNA requires 10–15 minutes. SGA is also a very useful and frequently applied test. In the current situation, it is frequently used in diagnosis. However, it includes subjectivity in practice. SGA is one of the easy and practical methods in determining the nutritional status of individuals. It is one of the tests required to be specified when a report is issued for the reimbursement of malnutrition products. It includes evaluation criteria such as the patient\'s history (weight loss, change in food intake, gastrointestinal symptoms, and functional status), physical tests (muscle mass, subcutaneous fat, sacral and foot edema, ascites). Does not include SGA lab data. It is thought that adding this information to the test will not affect the performance of the test in detecting malnutrition. It has been reported that the weight index is the main factor affecting the subjective evaluation. The feature of this screening test is that it can be used in the elderly population. In long-term care, it has been found to be a useful assessment tool in identifying the elderly at high risk for complications associated with changes in nutritional levels (major infections, pressure sores, and mortality) [38, 39, 40, 41].
Malnutrition Universal Screening Tool (MUST) [20], Short Nutritional Assessment Questionnaire (SNAQ) [42], Nutritional Risk Screening (NRS2002) [19]
Mini Nutritional Assessment Test Short Form (MNA-SF) [25, 32], Subjective Global Assessment (SGA).
In addition, using anthropometric measurements other than BMI will provide additional contributions in detecting malnutrition and the underlying causes of malnutrition [43].
Comprehensive geriatric assessment consists of the following sections:
Medical history
Family interview
Functional anamnesis
Social history
Physical examination
Clinical measuring instruments
Laboratory research
History is a standard part of Comprehensive Geriatric Evaluation. In anamnesis; decreased appetite, decreased sense of smell or taste, weight loss, nausea, vomiting, diarrhea, chewing and swallowing problems should be questioned. However, indicators of malnutrition can be found in all parts of the comprehensive geriatric assessment. Being in need of care in the functional history is a risk factor for malnutrition. In the social anamnesis, living alone or not having a caregiver who takes care of the needs of the elderly is known as a risk for malnutrition. In the physical examination, information about the nutritional status can be obtained by determining the clinical evaluation of the patient\'s nutrition and hydration status (weak, cachectic, dry axilla and mouth), height, weight, and BMI. By looking at muscle mass (atrophy, sarcopenia) and muscle strength, information about the symptoms and possible consequences of malnutrition can be obtained. Based on the results of the comprehensive geriatric assessment and MNA, the patient\'s problem list should include data on malnutrition problem or risk in malnutrition. At the same time, the most important factors that reveal the problem of malnutrition from both results will be seen. These factors may be, for example, reduced self-care and malnutrition due to moderate to severe dementia. In such a case, a nutrition plan should be drawn and followed during the patient\'s hospitalization or discharge. The treatment plan is aimed at adequate food intake on the one hand and treating the factors that cause it, on the other. For example, when such a patient goes home after being discharged from the hospital, he should be kept under control while taking his meals, and the meals given to him should be enriched with energy and nutrients, and he should be weighed and checked on a weekly basis during the home care period. However, many of the elderly patients do not know exactly how much weight loss occurs, it is not always possible to measure weight in polyclinic conditions, or it is not possible to measure the weight of bedridden patients. In such cases, the use of other acceptable anthropometric measurements such as calf measurement, skinfold thickness measurement instead of weight and body mass index will facilitate the work of doctors, patients, and patient relatives, especially in order to provide easier nutrition products for patients. It would be appropriate to define these measurements in the national health network system and include them in the scope of reimbursement [30, 43].
Nutritional support treatment should be planned for patients with malnutrition or risk of malnutrition as a result of screening and evaluation.
This can be done in two ways:
First of all, in those who can take oral food, a diet is arranged in line with the daily calorie needs by consulting the diet unit of the clinic. Considering the patient\'s preferences is the determinant of success; but unfortunately, since a rich diet kitchen is not possible in our hospitals today, adequate support cannot be provided in this way.
The second way is supportive treatment with enteral and/or parenteral nutrition products.
Enteral nutrition is essential in this treatment modality, but this is not always sufficient or possible, so it is sometimes supplemented with parenteral nutrition therapy. Enteral nutrition routes are oral enteral, nasoenteral, and enterocutaneous routes. Nasogastric or nasointestinal feeding tube can be used for the nasoenteral route. Silicone or polyurethane tubes should be preferred. Enterocutaneous routes are percutaneous endoscopic gastrostomy (PEG) and percutaneous endoscopic jejunostomy (PEJ). Sometimes the jejunum can be reached through a tube extended from the PEG (PEG-J). In the geriatric part of the enteral nutrition guide published by ESPEN in 2006, it is emphasized that oral nutritional support should be provided as much as possible in the frail elderly during the selection of the nutrition route. In the presence of neurological dysphagia, it is recommended to choose one of the enteral nutrition routes, choose products with fiber content, and give products with high protein content in the presence of pressure sores. It was emphasized that oral or tube feeding therapy should be given in patients with early and moderate dementia, and tube feeding should not be preferred in patients with advanced dementia. It is also recommended not to apply tube feeding in terminal stage cancer patients. PEG is recommended for patients who require long-term tube feeding (>4 weeks) [30]. After choosing the nutritional route, the daily energy requirement should be calculated, and then the amount of support to be given daily should be calculated by considering the oral food intake. The daily energy requirement can be found by adding the basal energy requirement, the activity factor, and the stress factor. We use practical formulas to calculate basal energy requirement. The most accurate way is to measure with an indirect calorimeter. The use of formulas saves time and is cost-effective and must be within ±10% standard deviation from actual measurements. The most commonly used formula is the Harris-Benedict formula. Calculation is made using weight, height, and age. After the basal energy requirement is found, the stress factor is determined by looking at the clinical disease and clinical findings and added to the basal energy requirement [44].
After calculating the daily energy requirement, two ways can be used to calculate the current deficit:
In the first, the patient is advised to list what they eat and the daily calorie intake is calculated from this list.
The other way is to question the ratio of the amount of food consumed today compared with the past. It is asked whether it consumes half of it compared with before, and then it is not satisfied with it, and it is questioned in more detail whether it is less or more. A ratio that can be obtained from here will approximately show the amount of energy it receives over the daily energy requirement. After calculating the daily calorie deficit, daily protein needs and water needs should be calculated. In addition, in the presence of special conditions (diabetes, cancer, sepsis, chronic kidney failure, congestive heart failure, etc.), appropriate nutrient ratios should be determined. Fibers gain importance in the maintenance of gastrointestinal system motility in elderly patients, and fiber should be added to the diet. During enteral nutrition, it is important to choose the appropriate product according to the clinical situation. Under normal conditions, standard products with different flavors are preferred, and special products are used in unusual cases. Standard products usually contain 1 kcal per 1 ml. They have moderate osmolarity and good tolerability. Nutrient ratios are at the levels of carbohydrate 50%, fat 30%, and protein 20%. They contain essential nutrients as well as vitamins and trace elements. Diabetic products contain less carbohydrate and molecules with lower glycemic indexes such as fructose, isomaltose, and maltodextrin are chosen. High-energy products are preferred in patients who need fluid restriction (1 ml=1.5–2 kcal). For this reason, their osmolarity is also high, tolerability is more difficult. Protein content is higher in protein-rich products. There are various soluble or insoluble fibers in fiber-rich products. While these fibers contribute to motility on the one hand, they also create a prebiotic effect. When tolerance cannot be achieved in others, products with low osmolarity may be preferred. Their osmolarity varies between 240 and 300 mosm/l. There are products developed for use in cancer cachexia and inflammatory diseases and containing various immunonutrition products (glutamine, arginine, RNA, eicosapentaenoic acid (EPA)). There are data showing that they are especially beneficial in cancer cachexia, they are appetizing. While glutamine stands out in terms of gastrointestinal system tolerability, antioxidant properties and anti-inflammatory contribution on the immune system, arginine in wound healing and EPA in increasing appetite gain importance. In various diseases in which intestinal absorption is affected, products containing semi-elementary and elementary molecules can be preferred. For example, medium-chain fatty acids (MCTs) are absorbed from the intestine, while they do not need lipoprotein lipase and are absorbed directly from the mucosa without the need for micelles and reach the liver by mixing directly with the portal system. It can be especially useful in conditions such as short bowel syndrome, inflammatory bowel disease, and cholestasis. Recently, support products consisting of combinations of arginine, glutamine, leucine, and its 52 metabolite hydroxy methyl butyrate (HMB), which are known to be effective in the healing of pressure sores, have taken their place in the market. In particular, HMB not only triggers collagen synthesis and protein synthesis, but also stops protein degradation, and is 200 times more potent than leucine, of which it is a metabolite. After calculating the daily energy deficit and choosing the appropriate enteral nutrition product, the first thing to do is how quickly this product should be given or how long it takes to reach the target volume. Because reaching the target quickly may cause complications such as tolerance disorders, vomiting, diarrhea, and aspiration. Generally, the recommended target amount is to be reached in 7–10 days. The preference of oral enteral products in low-volume boxes is positive in terms of patient compliance. Aroma differences arise between societies. While fruity flavors are preferred more in Turkish society, vanilla and coffee can be tolerated better in Western societies. Products produced for tube support therapy should not be given orally. Nausea, vomiting, and diarrhea are the most common symptoms during treatment. For nausea and vomiting, treatment should not be stopped immediately, products that accelerate gastric emptying time and increase intestinal motility can be used. On the other hand, the amount of product may be reduced for a while or a different product may be tried. When diarrhea occurs, first of all, the presence of infection should be investigated by stool analysis. In some cases, treatments that suppress bowel movements can be given (such as loperamide in short bowel syndrome). Since the risk of aspiration will increase in the elderly and those with neurological diseases, gastric residual determination should be made, especially in tube feds. In the presence of 200 cc or more residue, the amount or speed of outgoing product should be reduced, or the product should be changed in the same way or supportive treatments should be added. During bolus applications during tube feeding, 25–50 cc of water should be given in front of and behind the product, and during infusion therapy, the outgoing product should be stopped at regular intervals and water should be given again. The same is true with PEG. In patients fed from the jejunum, hypo-osmolar products or water should not be given directly. Bolus administration should not be done. Only infusion therapy can be given. In all cases, the patient\'s head should be kept at a height of 30–400 meters. In cases where enteral nutrition is not possible or insufficient, parenteral therapy should be applied. There are two types; peripherally administered and centrally administered. The main difference between the products applied in both ways is the calories and fat they contain in unit volume. While there is 0.6–0.7 kcal in ml of products administered centrally, there is 1 kcal in ml of products administered via central route. Fats are molecules suitable for central administration. They are found in peripherally applied products at low rates. The standard oil used in parenteral products is soybean oil. Over time, olive-oil-based products, mixtures containing medium-chain fatty acids, and mixtures containing fish oil have been introduced to the market. Mixtures containing fish oil stand out with their high EPA content and their anti-inflammatory effects are known. Again, while an anti-inflammatory effect is observed in products containing olive oil, it has been reported in some articles that it can prevent fatty liver [44].
Cancer usually occurs with advanced age. One of the most important reasons for weight loss in cancer patients is a decrease in food intake. Many factors cause this: Loss of appetite (tumor burden, treatment, depression), early satiety (gastrointestinal tract), other GI symptoms (nausea, vomiting), odynophagia (mocositis, fungal/viral esophagitis), dry mouth, dysphagia, chewing difficulty in reaching food as a result of a decrease in daily life activities, pain, and deterioration in quality of life. Poor oral hygiene, loss of teeth, space-occupying lesion, especially in tumors related to the gastrointestinal system, and due to the treatment that occurs or is used in the course of the disease (radiotherapy acute/chronic effect, chemotherapy-mucositis) loss of appetite can be seen as a result of side effects [44]. It causes some changes in carbohydrate, lipid, and protein metabolism. With the decrease in insulin sensitivity, impaired glucose tolerance develops, gluconeogenesis increases, and serum lactate level rises. Lipolysis increases and serum triglyceride levels increase and lipoprotein lipase activity may decrease. Negative nitrogen balance occurs as a result of excessive protein degradation. Proteolysis triggering factor and lipid mobilizing factor released by tumor cells cause excessive muscle destruction and lipolysis in the hypercatabolic process, and cytokines (TNF-alpha, IL-1, IL-6) oversynthesized by the body contribute to this [45]. 54 A correlation was found between IL-6 level and disease stage, acute phase response, and malnutrition status in patients with lung cancer [46]. A relationship was found between TNF- alpha, reduced oxygen products, reduced glutathione and vitamin E levels, and the development of anorexia-cachexia syndrome [47]. Circulating TNF levels were found to be higher, and serum albumin and IGF-1 levels were found to be lower in those with weight loss of >10% [48]. A relationship was found between anorexia-cachexia syndrome and parathormone-related peptide (PTHrP) levels, and it was understood that weight loss stopped and weight gain occurred when PTHrP was neutralized [49]. The ESPEN guideline states that “the nutritional status of cancer patients should be evaluated at frequent intervals and supportive treatment should be started early when deficiency is detected.” There is no routine enteral nutritional support during chemotherapy and/or radiotherapy. Enteral nutrition should be started to make up the difference between the need and the calories taken from the diet, and 1.2–2.0 g/kg/day protein support should be provided during the treatment. It has been stated that there is no clear data that standard products can be given, immunonutrition products and antioxidant vitamins increase survival. In cases where enteral nutrition is not possible or insufficient, parenteral nutrition should be given [50].
Neurological diseases known to cause malnutrition include Alzheimer\'s disease, Parkinson\'s disease, myastania gravis, cerebrovascular accident, multiple sclerosis, and amyotrophic lateral sclerosis. Severe dysphagia may occur in the course of these diseases. The most important causes of malnutrition developing in the course of neurological diseases are depression, impaired self-care, difficulty in swallowing, and drugs. The result is muscle atrophy (extremity/respiratory), pressure sores, falls, osteoporosis, infection risk, and reduced survival. In the presence of cerebrovascular accident, malnutrition is diagnosed in 15% of patients at the time of admission, 22–35% in the second week, and in 50% of the patients during follow-up. In the presence of swallowing dysfunction, the risk of food aspiration increases and may result in death. It may be undesirable to give oral food before the first 48 hours of consciousness change. In a study comparing nasogastric catheter vs. PEG application in patients with dysphagia as a result of acute stroke, mortality rates increased nearly five times in those fed with nasogastric feding tube [51]. Before the tube is inserted, the patient should be evaluated in detail and the indication for long-term supportive treatment should be discussed. In this case, 55 PEG (percutaneous endoscopic gastrostomy) should be inserted instead of the tube. In theory, tube enteral nutrition should be used for a maximum of 6 weeks, and PEG should be preferred in cases exceeding this. On the other hand, malnutrition causes pressure ulcer development. In the ESPEN guideline, enteral nutrition is recommended for those with severe neurological dysphagia, oral nutritional support therapy, or tube feeding is recommended for patients with early-middle stage dementia, and tube feeding is not recommended for advanced dementia. Supportive therapy with high protein content regresses pressure sores. It is stated that PEG should be inserted instead of long-term tube feeding [52].
Efficacy should be considered during enteral or parenteral nutrition therapy. Apart from the improvement in general condition, weight gain, increase in serum proteins, and decrease in acute phase response are good indicators of treatment success. Close monitoring of potential side effects is important for treatment success. Especially in cachectic patients who have lost weight for a long time, rapid supportive treatment may cause serious metabolic complications. “Re-feeding syndrome” in which one or more of the conditions such as severe electrolyte imbalances, osmolarity changes, arrhythmias, overload, dehydration, acute kidney failure, sudden death, hyperglycemia, hypoglycemia can be seen together can be fatal. The most important way to prevent this is to reach the target calorie requirement slowly, especially in cachectic patients, this time can be much longer. “Re-feeding syndrome” is more common in such patients, especially during parenteral nutrition. In the follow-up, daily blood glucose monitoring, 2–3 times a week electrolyte, Blood Urea Nitrogen, creatinine monitoring (especially potassium, phosphorus and magnesium) are recommended. Trace element and vitamin support should not be forgotten during parenteral therapy. Thiamine deficiency is common in prolonged fasting. It can cause serious neurological disorders (i.e., Beri-beri) [44].
These Terms and Conditions outline the rules and regulations pertaining to the use of IntechOpen’s website www.intechopen.com and all the subdomains owned by IntechOpen located at 5 Princes Gate Court, London, SW7 2QJ, United Kingdom.
',metaTitle:"Terms and Conditions",metaDescription:"These terms and conditions outline the rules and regulations for the use of IntechOpen Website at https://intechopen.com and all its subdomains owned by Intech Limited located at 7th floor, 10 Lower Thames Street, London, EC3R 6AF, UK.",metaKeywords:null,canonicalURL:"/page/terms-and-conditions",contentRaw:'[{"type":"htmlEditorComponent","content":"By accessing the website at www.intechopen.com you are agreeing to be bound by these Terms of Service, all applicable laws and regulations, and agree that you are responsible for compliance with any applicable local laws. Use and/or access to this site is based on full agreement and compliance of these Terms. All materials contained on this website are protected by applicable copyright and trademark laws.
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\\n"}]'},components:[{type:"htmlEditorComponent",content:'By accessing the website at www.intechopen.com you are agreeing to be bound by these Terms of Service, all applicable laws and regulations, and agree that you are responsible for compliance with any applicable local laws. Use and/or access to this site is based on full agreement and compliance of these Terms. All materials contained on this website are protected by applicable copyright and trademark laws.
\n\nThe following terminology applies to these Terms and Conditions, Privacy Statement, Disclaimer Notice, and any or all Agreements:
\n\n“Client”, “Customer”, “You” and “Your” refers to you, the person accessing this website and accepting the Company’s Terms and Conditions;
\n\n“The Company”, “Ourselves”, “We”, “Our” and “Us”, refers to our Company, IntechOpen;
\n\n“Party”, “Parties”, or “Us”, refers to both the Client and ourselves, or either the Client or ourselves.
\n\nAll Terms refer to the offer, acceptance, and consideration of payment necessary to provide assistance to the Client in the most appropriate manner, whether by formal meetings of a fixed duration, or by any other agreed means, for the express purpose of meeting the Client’s needs in respect of provision of the Company’s stated services/products, and in accordance with, and subject to, the prevailing laws of the United Kingdom.
\n\nAny use of the above terminology, or other words in the singular, plural, capitalization and/or he/she or they, are taken as interchangeable.
\n\nUnless otherwise stated, IntechOpen and/or its licensors own the intellectual property rights for all materials on www.intechopen.com. All intellectual property rights are reserved. You may view, download, share, link and print pages from www.intechopen.com for your own personal use, subject to the restrictions set out in these Terms and Conditions.
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. 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Graphene, one-atom thick, exhibits a unique chemical structure and outstanding electronic, optical, thermal, and mechanical properties that made it compelling for various engineering applications. Graphene and graphene-based materials are promising candidates for fabricating state-of-the-art nano-scale sensors and biosensors. They featured with good conductivity and large specific surface area thereby; graphene-based sensors/biosensors performed well with good accuracy, rapidness, high sensitivity and selectivity, low detection limits, and long-term stability. They are ideally used as gas sensors, electrochemical sensors for heavy metal ions, immunosensors and dihydronicotinamide dinucleotide NADH, DNA, catecholamine neurotransmitters, paracetamol, glucose, H2O2, hemoglobin, and myoglobin biosensors. This chapter reviews the applications of graphene in nanotechnology since it came to the field particularly in sensing and biosensing applications. It updates the reader with the scientific progress of the current use of graphene as sensors and biosensors. There is still much room for the scientific research and application development of graphene-based theory, materials, and devices. Despite the vast amount of research already conducted on graphene for various applications, the field is still growing and many questions remain to be answered.",book:{id:"4624",slug:"biosensors-micro-and-nanoscale-applications",title:"Biosensors",fullTitle:"Biosensors - Micro and Nanoscale Applications"},signatures:"Nada F. Atta, Ahmed Galal and Ekram H. El-Ads",authors:[{id:"30072",title:"Prof.",name:"Nada",middleName:null,surname:"F. Atta",slug:"nada-f.-atta",fullName:"Nada F. 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Here, we present the general concept and the classification of biosensors, their advantages and drawbacks, the main strategies in electrochemical biosensor technology and the materials used in electrochemical sensors, such as electrodes and supporting substrates, materials for improved sensitivity and selectivity, materials for bioreceptor immobilization, and biological recognition elements. Various nanomaterials, such as carbon-based materials (carbon nanotubes, graphene, carbon nanoparticles), inorganic and organic nanoparticles (magnetic and metal nanoparticles, nanosized clays), conductive and insulating polymers (nanosized and nanostructured polymers, molecularly imprinted polymers), and hybrid materials, etc., have been successfully applied for the enhancement of the electroanalytical performance of biosensors and for the immobilization of biorecognition elements. Among these, due to their unique physiochemical features, carbon-based materials, such as carbon nanotubes and graphenes, have received special attention in recent years, and examples of surface functionalization using various types of nanoparticles are presented. The future trends in sensor research activities and areas of development that are expected to have an impact in biosensor performance, like immobilization techniques, nanotechnology, miniaturization and multisensor array determinations, are also examined.",book:{id:"4624",slug:"biosensors-micro-and-nanoscale-applications",title:"Biosensors",fullTitle:"Biosensors - Micro and Nanoscale Applications"},signatures:"Robert Săndulescu, Mihaela Tertiş, Cecilia Cristea and Ede Bodoki",authors:[{id:"28983",title:"Prof.",name:"Robert",middleName:"Valentin",surname:"Sandulescu",slug:"robert-sandulescu",fullName:"Robert Sandulescu"}]}],mostDownloadedChaptersLast30Days:[{id:"48359",title:"Immunosensors",slug:"immunosensors",totalDownloads:3084,totalCrossrefCites:7,totalDimensionsCites:21,abstract:"Immunosensors are solid-state devices in which the immunochemical reaction is coupled to a transducer. They form one of the most important classes of affinity biosensors based on the specific recognition of antigens by antibodies to form a stable complex, in a similar way to immunoassay. Depending on the type of transducer there are four types of immunosensor: electrochemical, optical, microgravimetric and thermometric. The most commonly used bioelements for the development of electrochemical immunosensors are antibodies (Ab), followed by aptamers (Apt) and, in the last five years, microRNA (miRNA). In order to perform an early diagnosis, a method that is able to measure peptides and proteins directly in a sample, without any sample pre-treatment or any separation, is preferred. This direct detection can be performed with methods making use of the specific interaction of proteins with Ab, Apt and miRNA. The recent developments made in the immunosensor field, regarding the incorporation of nanomaterials for increased sensitivity, multiplexing or microfluidic-based devices, may have potential for promising use in industry and clinical analysis. Some examples of assays for several commercially available biomarkers will be presented. The main application fields, beside biomedical analysis, are drug abuse control, food analysis and environmental analysis.",book:{id:"4624",slug:"biosensors-micro-and-nanoscale-applications",title:"Biosensors",fullTitle:"Biosensors - Micro and Nanoscale Applications"},signatures:"Cecilia Cristea, Anca Florea, Mihaela Tertiș and Robert Săndulescu",authors:[{id:"28983",title:"Prof.",name:"Robert",middleName:"Valentin",surname:"Sandulescu",slug:"robert-sandulescu",fullName:"Robert Sandulescu"}]},{id:"48575",title:"Impedimetric Sensors for Bacteria Detection",slug:"impedimetric-sensors-for-bacteria-detection",totalDownloads:3676,totalCrossrefCites:6,totalDimensionsCites:20,abstract:"The application of electrochemical biosensors based on impedance detection has grown during the past years due to their high sensitivity and rapid response, making this technique extremely useful to detect biological interactions with biosensor platforms. This chapter is focused on the use of electrochemical impedance spectroscopy (EIS) for bacterial detection in two ways. On one hand, bacteria presence may be determined by the detection of metabolites produced by bacterial growth involving the media conductivity changes. On the other hand, faster and more selective bacterial detection may be achieved by the immobilization of bacteria on a sensor surface using biorecognition elements (antibodies, antimicrobial peptides, aptamers, etc.) and registering changes produced in the charge transfer resistance (faradic process) or interfacial impedance (nonfaradic process). Here we discuss different types of impedimetric biosensors for microbiological applications, making stress on their most important parameters, such as detection limits, detection times, selectivity, and sensitivity. The aim of the paper was to give a critical review of recent publications in the field and mark the future trends.",book:{id:"4624",slug:"biosensors-micro-and-nanoscale-applications",title:"Biosensors",fullTitle:"Biosensors - Micro and Nanoscale Applications"},signatures:"Sergi Brosel-Oliu, Naroa Uria, Natalia Abramova and Andrey Bratov",authors:[{id:"174122",title:"Dr.",name:"Andrey",middleName:null,surname:"Bratov",slug:"andrey-bratov",fullName:"Andrey Bratov"},{id:"175939",title:"MSc.",name:"Sergi",middleName:null,surname:"Brosel-Oliu",slug:"sergi-brosel-oliu",fullName:"Sergi Brosel-Oliu"},{id:"175940",title:"Dr.",name:"Naroa",middleName:null,surname:"Uria",slug:"naroa-uria",fullName:"Naroa Uria"},{id:"175941",title:"Dr.",name:"Natalia",middleName:null,surname:"Abramova",slug:"natalia-abramova",fullName:"Natalia Abramova"}]},{id:"48322",title:"New Materials for the Construction of Electrochemical Biosensors",slug:"new-materials-for-the-construction-of-electrochemical-biosensors",totalDownloads:3522,totalCrossrefCites:10,totalDimensionsCites:31,abstract:"The development of electrochemical sensors has attracted great interest due to these sensors’ high sensitivity and selectivity. Here, we present the general concept and the classification of biosensors, their advantages and drawbacks, the main strategies in electrochemical biosensor technology and the materials used in electrochemical sensors, such as electrodes and supporting substrates, materials for improved sensitivity and selectivity, materials for bioreceptor immobilization, and biological recognition elements. Various nanomaterials, such as carbon-based materials (carbon nanotubes, graphene, carbon nanoparticles), inorganic and organic nanoparticles (magnetic and metal nanoparticles, nanosized clays), conductive and insulating polymers (nanosized and nanostructured polymers, molecularly imprinted polymers), and hybrid materials, etc., have been successfully applied for the enhancement of the electroanalytical performance of biosensors and for the immobilization of biorecognition elements. Among these, due to their unique physiochemical features, carbon-based materials, such as carbon nanotubes and graphenes, have received special attention in recent years, and examples of surface functionalization using various types of nanoparticles are presented. The future trends in sensor research activities and areas of development that are expected to have an impact in biosensor performance, like immobilization techniques, nanotechnology, miniaturization and multisensor array determinations, are also examined.",book:{id:"4624",slug:"biosensors-micro-and-nanoscale-applications",title:"Biosensors",fullTitle:"Biosensors - Micro and Nanoscale Applications"},signatures:"Robert Săndulescu, Mihaela Tertiş, Cecilia Cristea and Ede Bodoki",authors:[{id:"28983",title:"Prof.",name:"Robert",middleName:"Valentin",surname:"Sandulescu",slug:"robert-sandulescu",fullName:"Robert Sandulescu"}]},{id:"36883",title:"Polysaccharide-Based Nanoparticles for Controlled Release Formulations",slug:"polysaccharide-based-nanoparticles-for-controlled-release-formulations",totalDownloads:5120,totalCrossrefCites:6,totalDimensionsCites:24,abstract:null,book:{id:"2259",slug:"the-delivery-of-nanoparticles",title:"The Delivery of Nanoparticles",fullTitle:"The Delivery of Nanoparticles"},signatures:"A. Martínez, A. Fernández, E. Pérez, M. Benito, J.M. Teijón and M.D. Blanco",authors:[{id:"98943",title:"Dr.",name:"Maria Dolores",middleName:null,surname:"Blanco",slug:"maria-dolores-blanco",fullName:"Maria Dolores Blanco"}]},{id:"36882",title:"Nanoparticles Based on Modified Polysaccharides",slug:"nanoparticles-based-on-modified-polysaccharides",totalDownloads:7872,totalCrossrefCites:17,totalDimensionsCites:47,abstract:null,book:{id:"2259",slug:"the-delivery-of-nanoparticles",title:"The Delivery of Nanoparticles",fullTitle:"The Delivery of Nanoparticles"},signatures:"Hassan Namazi, Farzaneh Fathi and Abolfazl Heydari",authors:[{id:"101658",title:"Prof.",name:"Hassan",middleName:null,surname:"Namazi",slug:"hassan-namazi",fullName:"Hassan Namazi"}]}],onlineFirstChaptersFilter:{topicId:"1166",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:106,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}},{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}}]},series:{item:{id:"13",title:"Veterinary Medicine and Science",doi:"10.5772/intechopen.73681",issn:"2632-0517",scope:"Paralleling similar advances in the medical field, astounding advances occurred in Veterinary Medicine and Science in recent decades. These advances have helped foster better support for animal health, more humane animal production, and a better understanding of the physiology of endangered species to improve the assisted reproductive technologies or the pathogenesis of certain diseases, where animals can be used as models for human diseases (like cancer, degenerative diseases or fertility), and even as a guarantee of public health. Bridging Human, Animal, and Environmental health, the holistic and integrative “One Health” concept intimately associates the developments within those fields, projecting its advancements into practice. This book series aims to tackle various animal-related medicine and sciences fields, providing thematic volumes consisting of high-quality significant research directed to researchers and postgraduates. It aims to give us a glimpse into the new accomplishments in the Veterinary Medicine and Science field. By addressing hot topics in veterinary sciences, we aim to gather authoritative texts within each issue of this series, providing in-depth overviews and analysis for graduates, academics, and practitioners and foreseeing a deeper understanding of the subject. Forthcoming texts, written and edited by experienced researchers from both industry and academia, will also discuss scientific challenges faced today in Veterinary Medicine and Science. In brief, we hope that books in this series will provide accessible references for those interested or working in this field and encourage learning in a range of different topics.",coverUrl:"https://cdn.intechopen.com/series/covers/13.jpg",latestPublicationDate:"June 29th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:11,editor:{id:"38652",title:"Prof.",name:"Rita",middleName:null,surname:"Payan-Carreira",slug:"rita-payan-carreira",fullName:"Rita Payan-Carreira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRiFPQA0/Profile_Picture_1614601496313",biography:"Rita Payan Carreira earned her Veterinary Degree from the Faculty of Veterinary Medicine in Lisbon, Portugal, in 1985. She obtained her Ph.D. in Veterinary Sciences from the University of Trás-os-Montes e Alto Douro, Portugal. After almost 32 years of teaching at the University of Trás-os-Montes and Alto Douro, she recently moved to the University of Évora, Department of Veterinary Medicine, where she teaches in the field of Animal Reproduction and Clinics. Her primary research areas include the molecular markers of the endometrial cycle and the embryo–maternal interaction, including oxidative stress and the reproductive physiology and disorders of sexual development, besides the molecular determinants of male and female fertility. She often supervises students preparing their master's or doctoral theses. She is also a frequent referee for various journals.",institutionString:null,institution:{name:"University of Évora",institutionURL:null,country:{name:"Portugal"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:3,paginationItems:[{id:"19",title:"Animal Science",coverUrl:"https://cdn.intechopen.com/series_topics/covers/19.jpg",isOpenForSubmission:!0,editor:{id:"259298",title:"Dr.",name:"Edward",middleName:null,surname:"Narayan",slug:"edward-narayan",fullName:"Edward Narayan",profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",biography:"Dr. Edward Narayan graduated with Ph.D. degree in Biology from the University of the South Pacific and pioneered non-invasive reproductive and stress endocrinology tools for amphibians - the novel development and validation of non-invasive enzyme immunoassays for the evaluation of reproductive hormonal cycle and stress hormone responses to environmental stressors. \nDr. Narayan leads the Stress Lab (Comparative Physiology and Endocrinology) at the University of Queensland. A dynamic career research platform which is based on the thematic areas of comparative vertebrate physiology, stress endocrinology, reproductive endocrinology, animal health and welfare, and conservation biology. \nEdward has supervised 40 research students and published over 60 peer reviewed research.",institutionString:null,institution:{name:"University of Queensland",institutionURL:null,country:{name:"Australia"}}},editorTwo:null,editorThree:null},{id:"20",title:"Animal Nutrition",coverUrl:"https://cdn.intechopen.com/series_topics/covers/20.jpg",isOpenForSubmission:!0,editor:{id:"175967",title:"Dr.",name:"Manuel",middleName:null,surname:"Gonzalez Ronquillo",slug:"manuel-gonzalez-ronquillo",fullName:"Manuel Gonzalez Ronquillo",profilePictureURL:"https://mts.intechopen.com/storage/users/175967/images/system/175967.png",biography:"Dr. Manuel González Ronquillo obtained his doctorate degree from the University of Zaragoza, Spain, in 2001. He is a research professor at the Faculty of Veterinary Medicine and Animal Husbandry, Autonomous University of the State of Mexico. He is also a level-2 researcher. He received a Fulbright-Garcia Robles fellowship for a postdoctoral stay at the US Dairy Forage Research Center, Madison, Wisconsin, USA in 2008–2009. He received grants from Alianza del Pacifico for a stay at the University of Magallanes, Chile, in 2014, and from Consejo Nacional de Ciencia y Tecnología (CONACyT) to work in the Food and Agriculture Organization’s Animal Production and Health Division (AGA), Rome, Italy, in 2014–2015. He has collaborated with researchers from different countries and published ninety-eight journal articles. He teaches various degree courses in zootechnics, sheep production, and agricultural sciences and natural resources.\n\nDr. Ronquillo’s research focuses on the evaluation of sustainable animal diets (StAnD), using native resources of the region, decreasing carbon footprint, and applying meta-analysis and mathematical models for a better understanding of animal production.",institutionString:null,institution:{name:"Universidad Autónoma del Estado de México",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null},{id:"28",title:"Animal Reproductive Biology and Technology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/28.jpg",isOpenForSubmission:!0,editor:{id:"177225",title:"Prof.",name:"Rosa Maria Lino Neto",middleName:null,surname:"Pereira",slug:"rosa-maria-lino-neto-pereira",fullName:"Rosa Maria Lino Neto Pereira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS9wkQAC/Profile_Picture_1624519982291",biography:"Rosa Maria Lino Neto Pereira (DVM, MsC, PhD and) is currently a researcher at the Genetic Resources and Biotechnology Unit of the National Institute of Agrarian and Veterinarian Research (INIAV, Portugal). She is the head of the Reproduction and Embryology Laboratories and was lecturer of Reproduction and Reproductive Biotechnologies at Veterinary Medicine Faculty. She has over 25 years of experience working in reproductive biology and biotechnology areas with a special emphasis on embryo and gamete cryopreservation, for research and animal genetic resources conservation, leading research projects with several peer-reviewed papers. Rosa Pereira is member of the ERFP-FAO Ex situ Working Group and of the Management Commission of the Portuguese Animal Germplasm Bank.",institutionString:"The National Institute for Agricultural and Veterinary Research. Portugal",institution:null},editorTwo:null,editorThree:null}]},overviewPageOFChapters:{paginationCount:14,paginationItems:[{id:"82457",title:"Canine Hearing Management",doi:"10.5772/intechopen.105515",signatures:"Peter M. Skip Scheifele, Devan Marshall, Stephen Lee, Paul Reid, Thomas McCreery and David Byrne",slug:"canine-hearing-management",totalDownloads:1,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Recent Advances in Canine Medicine",coverURL:"https://cdn.intechopen.com/books/images_new/11580.jpg",subseries:{id:"19",title:"Animal Science"}}},{id:"82285",title:"Parvovirus Vectors: The Future of Gene Therapy",doi:"10.5772/intechopen.105085",signatures:"Megha Gupta",slug:"parvovirus-vectors-the-future-of-gene-therapy",totalDownloads:5,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Recent Advances in Canine Medicine",coverURL:"https://cdn.intechopen.com/books/images_new/11580.jpg",subseries:{id:"19",title:"Animal Science"}}},{id:"81793",title:"Canine parvovirus-2: An Emerging Threat to Young Pets",doi:"10.5772/intechopen.104846",signatures:"Mithilesh Singh, Rajendran Manikandan, Ujjwal Kumar De, Vishal Chander, Babul Rudra Paul, Saravanan Ramakrishnan and Darshini Maramreddy",slug:"canine-parvovirus-2-an-emerging-threat-to-young-pets",totalDownloads:17,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Recent Advances in Canine Medicine",coverURL:"https://cdn.intechopen.com/books/images_new/11580.jpg",subseries:{id:"19",title:"Animal Science"}}},{id:"81271",title:"The Diversity of Parvovirus Telomeres",doi:"10.5772/intechopen.102684",signatures:"Marianne Laugel, Emilie Lecomte, Eduard Ayuso, Oumeya Adjali, Mathieu Mével and Magalie Penaud-Budloo",slug:"the-diversity-of-parvovirus-telomeres",totalDownloads:38,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Recent Advances in Canine Medicine",coverURL:"https://cdn.intechopen.com/books/images_new/11580.jpg",subseries:{id:"19",title:"Animal Science"}}}]},overviewPagePublishedBooks:{paginationCount:11,paginationItems:[{type:"book",id:"7233",title:"New Insights into Theriogenology",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7233.jpg",slug:"new-insights-into-theriogenology",publishedDate:"December 5th 2018",editedByType:"Edited by",bookSignature:"Rita Payan-Carreira",hash:"74f4147e3fb214dd050e5edd3aaf53bc",volumeInSeries:1,fullTitle:"New Insights into Theriogenology",editors:[{id:"38652",title:"Prof.",name:"Rita",middleName:null,surname:"Payan-Carreira",slug:"rita-payan-carreira",fullName:"Rita Payan-Carreira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRiFPQA0/Profile_Picture_1614601496313",biography:"Rita Payan Carreira earned her Veterinary Degree from the Faculty of Veterinary Medicine in Lisbon, Portugal, in 1985. She obtained her Ph.D. in Veterinary Sciences from the University of Trás-os-Montes e Alto Douro, Portugal. After almost 32 years of teaching at the University of Trás-os-Montes and Alto Douro, she recently moved to the University of Évora, Department of Veterinary Medicine, where she teaches in the field of Animal Reproduction and Clinics. Her primary research areas include the molecular markers of the endometrial cycle and the embryo–maternal interaction, including oxidative stress and the reproductive physiology and disorders of sexual development, besides the molecular determinants of male and female fertility. She often supervises students preparing their master's or doctoral theses. She is also a frequent referee for various journals.",institutionString:null,institution:{name:"University of Évora",institutionURL:null,country:{name:"Portugal"}}}]},{type:"book",id:"7144",title:"Veterinary Anatomy and Physiology",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7144.jpg",slug:"veterinary-anatomy-and-physiology",publishedDate:"March 13th 2019",editedByType:"Edited by",bookSignature:"Catrin Sian Rutland and Valentina Kubale",hash:"75cdacb570e0e6d15a5f6e69640d87c9",volumeInSeries:2,fullTitle:"Veterinary Anatomy and Physiology",editors:[{id:"202192",title:"Dr.",name:"Catrin",middleName:null,surname:"Rutland",slug:"catrin-rutland",fullName:"Catrin Rutland",profilePictureURL:"https://mts.intechopen.com/storage/users/202192/images/system/202192.png",biography:"Catrin Rutland is an Associate Professor of Anatomy and Developmental Genetics at the University of Nottingham, UK. She obtained a BSc from the University of Derby, England, a master’s degree from Technische Universität München, Germany, and a Ph.D. from the University of Nottingham. She undertook a post-doctoral research fellowship in the School of Medicine before accepting tenure in Veterinary Medicine and Science. Dr. Rutland also obtained an MMedSci (Medical Education) and a Postgraduate Certificate in Higher Education (PGCHE). She is the author of more than sixty peer-reviewed journal articles, twelve books/book chapters, and more than 100 research abstracts in cardiovascular biology and oncology. She is a board member of the European Association of Veterinary Anatomists, Fellow of the Anatomical Society, and Senior Fellow of the Higher Education Academy. Dr. Rutland has also written popular science books for the public. https://orcid.org/0000-0002-2009-4898. www.nottingham.ac.uk/vet/people/catrin.rutland",institutionString:null,institution:{name:"University of Nottingham",institutionURL:null,country:{name:"United Kingdom"}}}]},{type:"book",id:"8524",title:"Lactation in Farm Animals",subtitle:"Biology, Physiological Basis, Nutritional Requirements, and Modelization",coverURL:"https://cdn.intechopen.com/books/images_new/8524.jpg",slug:"lactation-in-farm-animals-biology-physiological-basis-nutritional-requirements-and-modelization",publishedDate:"January 22nd 2020",editedByType:"Edited by",bookSignature:"Naceur M'Hamdi",hash:"2aa2a9a0ec13040bbf0455e34625504e",volumeInSeries:3,fullTitle:"Lactation in Farm Animals - Biology, Physiological Basis, Nutritional Requirements, and Modelization",editors:[{id:"73376",title:"Dr.",name:"Naceur",middleName:null,surname:"M'Hamdi",slug:"naceur-m'hamdi",fullName:"Naceur M'Hamdi",profilePictureURL:"https://mts.intechopen.com/storage/users/73376/images/system/73376.jpg",biography:"Naceur M’HAMDI is Associate Professor at the National Agronomic Institute of Tunisia, University of Carthage. He is also Member of the Laboratory of genetic, animal and feed resource and member of Animal science Department of INAT. He graduated from Higher School of Agriculture of Mateur, University of Carthage, in 2002 and completed his masters in 2006. Dr. M’HAMDI completed his PhD thesis in Genetic welfare indicators of dairy cattle at Higher Institute of Agronomy of Chott-Meriem, University of Sousse, in 2011. He worked as assistant Professor of Genetic, biostatistics and animal biotechnology at INAT since 2013.",institutionString:null,institution:null}]},{type:"book",id:"8460",title:"Reproductive Biology and Technology in Animals",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/8460.jpg",slug:"reproductive-biology-and-technology-in-animals",publishedDate:"April 15th 2020",editedByType:"Edited by",bookSignature:"Juan Carlos Gardón Poggi and Katy Satué Ambrojo",hash:"32ef5fe73998dd723d308225d756fa1e",volumeInSeries:4,fullTitle:"Reproductive Biology and Technology in Animals",editors:[{id:"251314",title:"Dr.",name:"Juan Carlos",middleName:null,surname:"Gardón",slug:"juan-carlos-gardon",fullName:"Juan Carlos Gardón",profilePictureURL:"https://mts.intechopen.com/storage/users/251314/images/system/251314.jpeg",biography:"Juan Carlos Gardón Poggi received University degree from the Faculty of Agrarian Science in Argentina, in 1983. Also he received Masters Degree and PhD from Córdoba University, Spain. He is currently a Professor at the Catholic University of Valencia San Vicente Mártir, at the Department of Medicine and Animal Surgery. He teaches diverse courses in the field of Animal Reproduction and he is the Director of the Veterinary Farm. He also participates in academic postgraduate activities at the Veterinary Faculty of Murcia University, Spain. His research areas include animal physiology, physiology and biotechnology of reproduction either in males or females, the study of gametes under in vitro conditions and the use of ultrasound as a complement to physiological studies and development of applied biotechnologies. 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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419588",title:"Ph.D.",name:"Sergio",middleName:"Alexandre",surname:"Gehrke",slug:"sergio-gehrke",fullName:"Sergio Gehrke",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038WgMKQA0/Profile_Picture_2022-06-02T11:44:20.jpg",biography:"Dr. Sergio Alexandre Gehrke is a doctorate holder in two fields. The first is a Ph.D. in Cellular and Molecular Biology from the Pontificia Catholic University, Porto Alegre, Brazil, in 2010 and the other is an International Ph.D. in Bioengineering from the Universidad Miguel Hernandez, Elche/Alicante, Spain, obtained in 2020. In 2018, he completed a postdoctoral fellowship in Materials Engineering in the NUCLEMAT of the Pontificia Catholic University, Porto Alegre, Brazil. He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Univeristy of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:null},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:null},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. Her knowledge of English is at an advanced level.",institutionString:null,institution:null},{id:"332914",title:"Dr.",name:"Muhammad Saad",middleName:null,surname:"Shaikh",slug:"muhammad-saad-shaikh",fullName:"Muhammad Saad Shaikh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jinnah Sindh Medical University",country:{name:"Pakistan"}}},{id:"315775",title:"Dr.",name:"Feng",middleName:null,surname:"Luo",slug:"feng-luo",fullName:"Feng Luo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sichuan University",country:{name:"China"}}},{id:"423519",title:"Dr.",name:"Sizakele",middleName:null,surname:"Ngwenya",slug:"sizakele-ngwenya",fullName:"Sizakele Ngwenya",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419270",title:"Dr.",name:"Ann",middleName:null,surname:"Chianchitlert",slug:"ann-chianchitlert",fullName:"Ann Chianchitlert",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419271",title:"Dr.",name:"Diane",middleName:null,surname:"Selvido",slug:"diane-selvido",fullName:"Diane Selvido",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"419272",title:"Dr.",name:"Irin",middleName:null,surname:"Sirisoontorn",slug:"irin-sirisoontorn",fullName:"Irin Sirisoontorn",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Walailak University",country:{name:"Thailand"}}},{id:"355660",title:"Dr.",name:"Anitha",middleName:null,surname:"Mani",slug:"anitha-mani",fullName:"Anitha Mani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"355612",title:"Dr.",name:"Janani",middleName:null,surname:"Karthikeyan",slug:"janani-karthikeyan",fullName:"Janani Karthikeyan",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"334400",title:"Dr.",name:"Suvetha",middleName:null,surname:"Siva",slug:"suvetha-siva",fullName:"Suvetha Siva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}}]}},subseries:{item:{id:"1",type:"subseries",title:"Oral Health",keywords:"Oral health, Dental care, Diagnosis, Diagnostic imaging, Early diagnosis, Oral cancer, Conservative treatment, Epidemiology, Comprehensive dental care, Complementary therapies, Holistic health",scope:"\r\n This topic aims to provide a comprehensive overview of the latest trends in Oral Health based on recent scientific evidence. Subjects will include an overview of oral diseases and infections, systemic diseases affecting the oral cavity, prevention, diagnosis, treatment, epidemiology, as well as current clinical recommendations for the management of oral, dental, and periodontal diseases.
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