\\n\\n
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"9976",leadTitle:null,fullTitle:"Fuzzy Systems - Theory and Applications",title:"Fuzzy Systems",subtitle:"Theory and Applications",reviewType:"peer-reviewed",abstract:"This book presents some recent specialized works of theoretical study in the domain of fuzzy systems. Over eight sections and fifteen chapters, the volume addresses fuzzy systems concepts and promotes them in practical applications in the following thematic areas: fuzzy mathematics, decision making, clustering, adaptive neural fuzzy inference systems, control systems, process monitoring, green infrastructure, and medicine. The studies published in the book develop new theoretical concepts that improve the properties and performances of fuzzy systems. This book is a useful resource for specialists, engineers, professors, and students.",isbn:"978-1-83962-292-2",printIsbn:"978-1-83962-291-5",pdfIsbn:"978-1-83962-293-9",doi:"10.5772/intechopen.87799",price:119,priceEur:129,priceUsd:155,slug:"fuzzy-systems-theory-and-applications",numberOfPages:280,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"5c4c0d41cf25d2e8fda944450ac46d95",bookSignature:"Constantin Volosencu",publishedDate:"January 12th 2022",coverURL:"https://cdn.intechopen.com/books/images_new/9976.jpg",numberOfDownloads:2772,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:1,numberOfDimensionsCitationsByBook:0,hasAltmetrics:0,numberOfTotalCitations:1,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"June 4th 2020",dateEndSecondStepPublish:"September 10th 2020",dateEndThirdStepPublish:"November 9th 2020",dateEndFourthStepPublish:"January 28th 2021",dateEndFifthStepPublish:"March 29th 2021",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6,7",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:"Polytechnic University of Timişoara",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"5",totalChapterViews:"0",totalEditedBooks:"12",institution:{name:"Polytechnic University of Timişoara",institutionURL:null,country:{name:"Romania"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"721",title:"Fuzzy Control Systems",slug:"fuzzy-control-systems"}],chapters:[{id:"74023",title:"Existence, Uniqueness and Approximate Solutions of Fuzzy Fractional Differential Equations",doi:"10.5772/intechopen.94000",slug:"existence-uniqueness-and-approximate-solutions-of-fuzzy-fractional-differential-equations",totalDownloads:361,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"In this paper, the Cauchy problem of fuzzy fractional differential equations Tγut=Ftut, ut0=u0, with fuzzy conformable fractional derivative (γ-differentiability, where γ∈01) are introduced. We study the existence and uniqueness of solutions and approximate solutions for the fuzzy-valued mappings of a real variable, we prove some results by applying the embedding theorem, and the properties of the fuzzy solution are investigated and developed. Also, we show the relation between a solution and its approximate solutions to the fuzzy fractional differential equations of order γ.",signatures:"Atimad Harir, Said Melliani and Lalla Saadia Chadli",downloadPdfUrl:"/chapter/pdf-download/74023",previewPdfUrl:"/chapter/pdf-preview/74023",authors:[{id:"325545",title:"Dr.",name:"Atimad",surname:"Harir",slug:"atimad-harir",fullName:"Atimad Harir"},{id:"329831",title:"Prof.",name:"Said",surname:"Melliani",slug:"said-melliani",fullName:"Said Melliani"},{id:"329832",title:"Prof.",name:"Lalla Saadia",surname:"Chadli",slug:"lalla-saadia-chadli",fullName:"Lalla Saadia Chadli"}],corrections:null},{id:"75232",title:"(α, β)−Pythagorean Fuzzy Numbers Descriptor Systems",doi:"10.5772/intechopen.95007",slug:"-pythagorean-fuzzy-numbers-descriptor-systems",totalDownloads:85,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"By using pythagorean fuzzy sets and T-S fuzzy descriptor systems, the new (α, β)-pythagorean fuzzy descriptor systems are proposed in this paper. Their definition is given firstly, and the stability of this kind of systems is studied, the relation of (α, β)-pythagorean fuzzy descriptor systems and T-S fuzzy descriptor systems is discussed. The (α, β)-pythagorean fuzzy controller and the stability of (α, β)-pythagorean fuzzy descriptor systems are deeply researched. The (α, β)-pythagorean fuzzy descriptor systems can be better used to solve the problems of actual nonlinear control. The (α, β)-pythagorean fuzzy descriptor systems will be a new research direction, and will become a universal method to solve practical problems. Finally, an example is given to illustrate effectiveness of the proposed method.",signatures:"Chuan-qiang Fan, Wei-he Xie and Feng Liu",downloadPdfUrl:"/chapter/pdf-download/75232",previewPdfUrl:"/chapter/pdf-preview/75232",authors:[{id:"323276",title:"Mr.",name:"Feng",surname:"Liu",slug:"feng-liu",fullName:"Feng Liu"}],corrections:null},{id:"74040",title:"A Study of Fuzzy Sequence Spaces",doi:"10.5772/intechopen.94202",slug:"a-study-of-fuzzy-sequence-spaces",totalDownloads:85,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The purpose of this chapter is to introduce and study some new ideal convergence sequence spaces FSJθT, FS0JθT and FS∞JθT on a fuzzy real number F defined by a compact operator T. We investigate algebraic properties like linearity, solidness and monotinicity with some important examples. Further, we also analyze closedness of the subspace and inclusion relations on the said spaces.",signatures:"Vakeel A. Khan, Mobeen Ahmad and Masood Alam",downloadPdfUrl:"/chapter/pdf-download/74040",previewPdfUrl:"/chapter/pdf-preview/74040",authors:[{id:"276104",title:"Dr.",name:"Vakeel A.",surname:"Khan",slug:"vakeel-a.-khan",fullName:"Vakeel A. Khan"},{id:"276129",title:"Mr.",name:"Mobeen",surname:"Ahmad",slug:"mobeen-ahmad",fullName:"Mobeen Ahmad"},{id:"326484",title:"Dr.",name:"Masood",surname:"Alam",slug:"masood-alam",fullName:"Masood Alam"}],corrections:null},{id:"75035",title:"Towards a Fuzzy Context Logic",doi:"10.5772/intechopen.95624",slug:"towards-a-fuzzy-context-logic",totalDownloads:168,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"A key step towards trustworthy, reliable and explainable, AI is bridging the gap between the quantitative domain of sensor-actuator systems and the qualitative domain of intelligent systems reasoning. Fuzzy logic is a well-known formalism suitable for aiming at this gap, featuring a quantitative mechanism that at the same time adheres to logical principles. Context logic is a two-layered logical language originally aimed at pervasive computing systems for reasoning about and within context, i.e., changing logical environments. Both logical languages are linguistically motivated. This chapter uncovers the close connection between the two logical languages presenting two new results. First, a proof is presented that context logic with a lattice semantics can be understood as an extension of fuzzy logic. Second, a fuzzification for context logic is proposed. The resulting language, which can be understood as a two-layered fuzzy logic or as a fuzzified context logic, expands both fields in a novel manner.",signatures:"Hedda Schmidtke",downloadPdfUrl:"/chapter/pdf-download/75035",previewPdfUrl:"/chapter/pdf-preview/75035",authors:[{id:"330903",title:"Dr.",name:"Hedda",surname:"Schmidtke",slug:"hedda-schmidtke",fullName:"Hedda Schmidtke"}],corrections:null},{id:"76552",title:"Modified Expression to Evaluate the Correlation Coefficient of Dual Hesitant Fuzzy Sets and Its Application to Multi-Attribute Decision Making",doi:"10.5772/intechopen.96474",slug:"modified-expression-to-evaluate-the-correlation-coefficient-of-dual-hesitant-fuzzy-sets-and-its-appl",totalDownloads:239,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The main objective of this paper is to understand all the existing correlation coefficients (CoCfs) to determine the relation and dependency between two variables of the fuzzy sets and its extensions for solving decision-making (DM) problems. To study the weighted CoCfs between two variables the environment chosen here is dual hesitant fuzzy set (DHFS) which is a generalization of a fuzzy set which considers the hesitant value of both the membership and non-membership elements of a set. Although there exists CoCfs for DHFS but a detailed mathematical analysis suggests that there exists some shortcomings in the existing CoCfs for DHFS. Thus, an attempt has been made to properly understand the root cause of the posed limitation in the weighted CoCfs for DHFS and hence, modified weighted CoCfs for DHFS has been proposed for solving DHFS multi-attribute decision making (MADM) problems i.e., DM problems in which rating value of each alternative over each criterion is represented by a DHFS in the real-life. Also, to validate the proposed expressions of weighted CoCfs for solving DHFS MADM problems, an existing real-life problem is evaluated and a systematic comparison of the solution is presented for clarification.",signatures:"Akanksha Singh",downloadPdfUrl:"/chapter/pdf-download/76552",previewPdfUrl:"/chapter/pdf-preview/76552",authors:[{id:"323223",title:"Ph.D. Student",name:"Akanksha",surname:"Singh",slug:"akanksha-singh",fullName:"Akanksha Singh"}],corrections:null},{id:"76054",title:"Evaluating the Organizational Hierarchy Using the IFSAW and TOPSIS Techniques",doi:"10.5772/intechopen.95979",slug:"evaluating-the-organizational-hierarchy-using-the-ifsaw-and-topsis-techniques",totalDownloads:159,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Performance evaluations in organizations are viewed as ideal instruments for evaluating and rewarding the employee’s performance. While much emphasis is laid onto the administering of the evaluation techniques, not much thought has been laid out on assessing the contributions of each hierarchical level. Moreover the manifold decision making criteria can also impact the measurement of pertinent contributions because of their ambivalent characteristics. In such a scenario, intuitionistic fuzzy multi-criteria decision making can help strategists and policy makers to arrive at more or less accurate decisions. This paper restricts itself to six decision making criteria and adopts the intuitionistic fuzzy simple additive weighting (IFSAW) method and TOPSIS method to evaluate and rank the employee cadres. The results obtained were compared and both the methods revealed that the middle management displayed impeccable performance standards over their other counterparts.",signatures:"Mahuya Deb",downloadPdfUrl:"/chapter/pdf-download/76054",previewPdfUrl:"/chapter/pdf-preview/76054",authors:[{id:"333037",title:"Dr.",name:"Mahuya",surname:"Deb",slug:"mahuya-deb",fullName:"Mahuya Deb"}],corrections:null},{id:"75699",title:"Data Clustering for Fuzzyfier Value Derivation",doi:"10.5772/intechopen.96385",slug:"data-clustering-for-fuzzyfier-value-derivation",totalDownloads:292,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The fuzzifier value m is improving significant factor for achieving the accuracy of data. Therefore, in this chapter, various clustering method is introduced with the definition of important values for clustering. To adaptively calculate the appropriate purge value of the gap type −2 fuzzy c-means, two fuzzy values m1 and m2 are provided by extracting information from individual data points using a histogram scheme. Most of the clustering in this chapter automatically obtains determination of m1 and m2 values that depended on existent repeated experiments. Also, in order to increase efficiency on deriving valid fuzzifier value, we introduce the Interval type-2 possibilistic fuzzy C-means (IT2PFCM), as one of advanced fuzzy clustering method to classify a fixed pattern. In Efficient IT2PFCM method, proper fuzzifier values for each data is obtained from an algorithm including histogram analysis and Gaussian Curve Fitting method. Using the extracted information form fuzzifier values, two modified fuzzifier value m1 and m2 are determined. These updated fuzzifier values are used to calculated the new membership values. Determining these updated values improve not only the clustering accuracy rate of the measured sensor data, but also can be used without additional procedure such as data labeling. It is also efficient at monitoring numerous sensors, managing and verifying sensor data obtained in real time such as smart cities.",signatures:"JaeHyuk Cho",downloadPdfUrl:"/chapter/pdf-download/75699",previewPdfUrl:"/chapter/pdf-preview/75699",authors:[{id:"329648",title:"Prof.",name:"JaeHyuk",surname:"Cho",slug:"jaehyuk-cho",fullName:"JaeHyuk Cho"}],corrections:null},{id:"75248",title:"Compensatory Adaptive Neural Fuzzy Inference System",doi:"10.5772/intechopen.96050",slug:"compensatory-adaptive-neural-fuzzy-inference-system",totalDownloads:117,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The traditional approach to fuzzy design is based on knowledge acquired by expert operators formulated into rules. However, operators may not be able to translate their knowledge and experience into a fuzzy logic controller. In addition, most adaptive fuzzy controllers present difficulties in determining appropriate fuzzy rules and appropriate membership functions. This chapter presents adaptive neural-fuzzy controller equipped with compensatory fuzzy control in order to adjust membership functions, and as well to optimize the adaptive reasoning by using a compensatory learning algorithm. An analysis of stability and transparency based on a passivity framework is carried out. The resulting controllers are implemented on a two degree of freedom robotic system. The simulation results obtained show a fairly high accuracy in terms of position and velocity tracking, what highlights the effectiveness of the proposed controllers.",signatures:"Rabah Mellah, Hocine Khati, Hand Talem and Said Guermah",downloadPdfUrl:"/chapter/pdf-download/75248",previewPdfUrl:"/chapter/pdf-preview/75248",authors:[{id:"198671",title:"Dr.",name:"Rabah",surname:"Mellah",slug:"rabah-mellah",fullName:"Rabah Mellah"},{id:"346622",title:"Dr.",name:"Hocine",surname:"Khati",slug:"hocine-khati",fullName:"Hocine Khati"},{id:"346623",title:"Dr.",name:"Hand",surname:"Talem",slug:"hand-talem",fullName:"Hand Talem"},{id:"346624",title:"Dr.",name:"Said",surname:"Guermah",slug:"said-guermah",fullName:"Said Guermah"}],corrections:null},{id:"77324",title:"Fuzzy Logic Expert System for Health Condition Assessment of Power Transformers",doi:"10.5772/intechopen.98663",slug:"fuzzy-logic-expert-system-for-health-condition-assessment-of-power-transformers",totalDownloads:152,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"In the present chapter, a new fuzzy logic (FL) model is proposed to evaluate the overall health index (OHI) of power transformers. The most significant attributes such as dissolved gases, acidity, 2-furfuraldehyde, water content, breakdown voltage and dissipation factor that influence the health condition of transformers solid and liquid insulations are considered. These attributes are further divided into three different sets. Based on these sets, three different sub fuzzy models i.e. F1, F2 and F3 are designed in order to reduce the possible combinations of fuzzy rules. It results in reducing the complexity issues of the proposed OHI model. In addition, consideration of all significant testing parameters makes the model more reliable and accurate. Further, the proposed fuzzy model helps in initiating appropriate and early action on faulty conditions of the transformers. Conventional fuzzy logic models generally utilize large number of inputs and more number of rules in a single fuzzy model. It makes the models complex and inaccurate. Such shortcomings of existing conventional models are successfully overcame by the present proposed model. Furthermore, the results obtained from the proposed model are compared with the results obtained from expert model proposed by Abu-Elanien et al. This comparison ensures the reliability of the proposed method. Also, it is envisioned that the proposed model can be easily implemented by both the experienced and the inexperienced utility managers.",signatures:"Teruvai Manoj and Chilaka Ranga",downloadPdfUrl:"/chapter/pdf-download/77324",previewPdfUrl:"/chapter/pdf-preview/77324",authors:[{id:"333002",title:"Assistant Prof.",name:"Chilaka",surname:"Ranga",slug:"chilaka-ranga",fullName:"Chilaka Ranga"},{id:"417271",title:"Mr.",name:"Teruvai",surname:"Manoj",slug:"teruvai-manoj",fullName:"Teruvai Manoj"}],corrections:null},{id:"78533",title:"Health Monitoring of an Aircraft Fuel System Using Artificial Intelligence Techniques",doi:"10.5772/intechopen.99665",slug:"health-monitoring-of-an-aircraft-fuel-system-using-artificial-intelligence-techniques",totalDownloads:183,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Aircraft is a non-linear complex system and is need of regular monitoring. Integrated Vehicle Health Management (IVHM) is a process of health management paradigm, which involves system parameter monitoring, assessment of current, future conditions through diagnostic and prognostic approaches by providing required maintenance activities. Deployment of diagnostic, prognostic and health management processes enable to improve the system reliability and reduces the operating cost of the aircraft. Health monitoring and management plays a vibrant role in safe operation and maintenance of aircraft. Soft computing methodologies such as Artificial Neural Networks (ANN) and Adaptive Neuro-Fuzzy Inference System (ANFIS) are used to estimate the health status of fuel system by developing model of a typical pump feed, twin-engine, four-tank small aircraft fuel system using Simulink in the laboratory environment. The controller is designed to generate the signals of the fuel tanks based on the fuel requirement of the engine. The ANFIS based management system helps to detect the faults existing in the fuel system and diagnose those faults using the expert’s logical rules. During a fault ailment, the controller’s performance is evaluated. The efficacy of this intelligent controller is verified with the present fuel control system and ANN controller.",signatures:"Vijaylakshmi S. Jigajinni",downloadPdfUrl:"/chapter/pdf-download/78533",previewPdfUrl:"/chapter/pdf-preview/78533",authors:[{id:"329476",title:"Dr.",name:"Vijaylakshmi S.",surname:"Jigajinni",slug:"vijaylakshmi-s.-jigajinni",fullName:"Vijaylakshmi S. Jigajinni"}],corrections:null},{id:"75445",title:"Fuzzy Logic Control with PSO Tuning",doi:"10.5772/intechopen.96297",slug:"fuzzy-logic-control-with-pso-tuning",totalDownloads:166,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Several applications of artificial intelligence in the area of control of dynamic systems have proven to be an efficient tool for process improvement. In this context, control systems based on fuzzy logic - Fuzzy Logic Control (FLC) are part of a series of advances in the areas of control systems. Fuzzy control is based on natural language and therefore has the ability to make approximations closer to the real nature of the problems. The use of metaheuristic algorithms such as the particle swarm optimization (PSO) allows it to provide adequate adjustments to the fuzzy controller in an optimized manner. This technique allows to adjust the FLC in a simple way according to the performance desired by the designer, without the need for a long time of conventional tests.",signatures:"Jeydson Lopes da Silva",downloadPdfUrl:"/chapter/pdf-download/75445",previewPdfUrl:"/chapter/pdf-preview/75445",authors:[{id:"329341",title:"Dr.",name:"Jeydson Lopes",surname:"Da Silva",slug:"jeydson-lopes-da-silva",fullName:"Jeydson Lopes Da Silva"}],corrections:null},{id:"76854",title:"Functioning Fuzzy Logic in Optimizing the Solar Systems Work",doi:"10.5772/intechopen.97107",slug:"functioning-fuzzy-logic-in-optimizing-the-solar-systems-work",totalDownloads:106,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Fuzzy logic has been used in many fields, either to control a specific movement, improve the productivity of a machine, or monitor the work of an electrical or mechanical system or the like. In this chapter, we will discuss what are the basic factors that must be taken to use the fuzzy logic in the aforementioned matters in general, and then focus on its employment in the field of renewable energy. Three main axes for renewable energy are solar panels, a wind turbine and finally, solar collectors. The key to working and the basis of the static system is the mechanism for selecting the inputs that directly affect the output in addition to the methods and activation functions of the fuzzy logic.",signatures:"Daoud Raid, Ahmed Omer and Al-khashab Yaareb",downloadPdfUrl:"/chapter/pdf-download/76854",previewPdfUrl:"/chapter/pdf-preview/76854",authors:[{id:"286415",title:"Prof.",name:"Ahmed",surname:"Omer",slug:"ahmed-omer",fullName:"Ahmed Omer"},{id:"329474",title:"M.Sc.",name:"Daoud",surname:"Raid",slug:"daoud-raid",fullName:"Daoud Raid"},{id:"342060",title:"Dr.",name:"Al-khashab",surname:"Yaareb",slug:"al-khashab-yaareb",fullName:"Al-khashab Yaareb"}],corrections:null},{id:"75188",title:"Location Selection for Smog Towers Using Zadeh’s Z-Numbers Integrated with WASPAS",doi:"10.5772/intechopen.95906",slug:"location-selection-for-smog-towers-using-zadeh-s-z-numbers-integrated-with-waspas",totalDownloads:256,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Fuzzy sets have been extensively researched and results have been developed based on the extensions of fuzzy sets. In this chapter, fuzzy sets and its extensions are discussed. Z-numbers along with weighted sum product assessment method is used to obtain a feasible solution to the location selection problem for installation of smog towers in a densely populated locality. The degrees of freedom namely degree of membership, degree of non-membership and the degree of hesitancy have been expressed as Zadeh’s Z-number with probability quotient for the degrees. Further, ranking of the alternatives based on Z-numbers and WASPAS to allocate smog towers to residential areas stricken by air pollution.",signatures:"Janani Bharatraj",downloadPdfUrl:"/chapter/pdf-download/75188",previewPdfUrl:"/chapter/pdf-preview/75188",authors:[{id:"280068",title:"Dr.",name:"Janani",surname:"Bharatraj",slug:"janani-bharatraj",fullName:"Janani Bharatraj"}],corrections:null},{id:"75189",title:"Fuzzy Modeling of Urban Water Supply Crisis",doi:"10.5772/intechopen.95882",slug:"fuzzy-modeling-of-urban-water-supply-crisis",totalDownloads:211,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The chaotic growth of cities results in numerous problems related to public health and urban environment. One of these problems is the urban water supply system crisis. This research aims to develop a mathematical model for urban water supply crises (UWC) able to deal with the ambiguity of the real available data. The applied methodology comprises the following steps: (i) identifying the influencing factors in UWC; (ii) proposing a conceptual model for the description of UWC; (iii) collecting and simulating the necessary and available data; (iv) optimizing the conceptual model parameters; and (v) verifying the proposed model performance. The results indicate that there are many influencing factors in UWC. The model developed comprises two parts or two sub-models. The first sub-model explains water consumption, and the second sub-model explains water availability. In the first sub-model, the functions are related to the factors that influence water consumption. In the second sub-model, the functions are related to the factors that influence the availability of water. This research also aims to analyze the possibility of applying Fuzzy Logic to deal with the ambiguity of real data. It was concluded that, with the proposed model, the UWC was modeled appropriately. The model proposed can help to predict the impact of actions such as reducing losses, reducing pressure on the water supply network and intermittent supply on the intensity of water crisis cases in cities.",signatures:"Welitom Ttatom Pereira da Silva and Marco Antonio Almeida de Souza",downloadPdfUrl:"/chapter/pdf-download/75189",previewPdfUrl:"/chapter/pdf-preview/75189",authors:[{id:"252827",title:"Dr.",name:"Marco Antonio",surname:"Almeida de Souza",slug:"marco-antonio-almeida-de-souza",fullName:"Marco Antonio Almeida de Souza"},{id:"330069",title:"Prof.",name:"Welitom Ttatom",surname:"Pereira da Silva",slug:"welitom-ttatom-pereira-da-silva",fullName:"Welitom Ttatom Pereira da Silva"}],corrections:null},{id:"74830",title:"Fuzzy Multi-Attribute Decision Making (FMADM) Application on Decision Support Systems (SPK) to Diagnose a Type of Disease",doi:"10.5772/intechopen.94614",slug:"fuzzy-multi-attribute-decision-making-fmadm-application-on-decision-support-systems-spk-to-diagnose-",totalDownloads:192,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Fuzzy logic is widely applied to daily life with various methods. One method is fuzzy multi-attribute decision making (FMADM). FMADM is able to select the best alternative from a number of alternatives. In FMADM there is a supporting method so that the results obtained are accurate and optimal, namely the classic MADM method. One method in classic MADM is the Simple Additive Weighting (SAW) method. The SAW method is precisely used to minimize diagnostic errors, but if a decision support system is made, the SAW method still requires a further development method, one of which is the FMADM method with its development. The purposes of this study are to describe the steps of SAW method and the development of FDM in theory, implement SAW method and the development of FDM to diagnose a type of disease and implement it in a decision support system using GUI matlab. The completion step of those two methods is through two stages, the first one will go through FMADM stage with SAW, which is weighted sum, then the output will be used as input to the FDM method based on total integral values. The result of this study is proven by patient experienced initial symptoms of high fever at a temperature of 39.5° C - 40° C, very much spots appear in rumple leed test (> 50 petheciae), bleeding gums, rarely got nausea and headache, as well as diarrhea. Accuracy for the decision support system using MAPE was obtained 93% so that the decision support system with FMADM method to diagnose the disease was feasible to use.",signatures:"Sugiyarto Surono and Mustika Sari",downloadPdfUrl:"/chapter/pdf-download/74830",previewPdfUrl:"/chapter/pdf-preview/74830",authors:[{id:"323266",title:"Mr.",name:"Sugiyarto",surname:"Surono",slug:"sugiyarto-surono",fullName:"Sugiyarto Surono"},{id:"323269",title:"Ms.",name:"Mustika",surname:"Sari",slug:"mustika-sari",fullName:"Mustika Sari"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"2020",title:"New Technologies",subtitle:"Trends, Innovations and Research",isOpenForSubmission:!1,hash:"170d84903f390df23023d0623d8577d3",slug:"new-technologies-trends-innovations-and-research",bookSignature:"Constantin 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\r\n\tSchiff base (imine -N=CH-) is one of a popular group of organic compounds prepared from primary amines and aldehyde. Not only as organic compounds but also as ligands for metal complexes, a number of studies have been carried out so far. In this context, this book aims to record a wider range of interdisciplinary content on Schiff base compounds, with an emphasis on the latest advances. This book will aim to compile research results, commentary, reviews, etc., that have dealt with preparation, spectroscopy, crystallography, (asymmetric) synthetic roles, physical properties (magnets, optics, and so on), computational chemistry, and/or theoretical chemistry and their discussions. The book will also intend to focus on Schiff base and its strong connection from organic chemistry to biochemistry or polymer materials chemistry.
",isbn:"978-1-80355-679-6",printIsbn:"978-1-80355-678-9",pdfIsbn:"978-1-80355-680-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"ce51efbe2cae97ca3199350ef6c498ec",bookSignature:"Dr. Takashiro Akitsu",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/12078.jpg",keywords:"Schiff Base, Imine, Azomethine, Synthesis, Characterization, Crystal Structure, Chirality, Liquid Crystals, Polymers or Biopolymers, Metal Complex, Salen-Type Ligand, Computational Chemistry",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 20th 2022",dateEndSecondStepPublish:"July 21st 2022",dateEndThirdStepPublish:"September 19th 2022",dateEndFourthStepPublish:"December 8th 2022",dateEndFifthStepPublish:"February 6th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"25 days",secondStepPassed:!1,areRegistrationsClosed:!1,currentStepOfPublishingProcess:2,editedByType:null,kuFlag:!1,biosketch:"A professor from the University of Science, Japan, has published 220 articles and book chapters. 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Also, heteroaromatic compounds are always of great importance for chemists and the identification and confirmation of highly potent and selective bioactive molecules is a decisive step both in academic and pharmaceutical research.
Heterocyclic compounds with a pyrrole cycle are significant both in materials and in medicinal chemistry [1]. Indoles and indolizines (heterocyclic aromatic compounds structurally and chemically isomeric with indoles) are important classes of N-fused heterocyclic compounds due to their interesting biological and optical properties. Although their chemistry is a well-established subject for researchers, they continue to attract much attention due to their diverse biological properties. Also, the correlation between indoles and indolizines has prompted speculation that indolizine analogs of biologically important indoles could conceivably have potent physiological activities [2].
Indoles and their derivatives are well-known as an important class of heterocyclic compounds, their core being a near-ubiquitous component of biologically active natural products, widespread in different species of plants, animals, and marine organisms. The indole is also well-known as one of the most important scaffolds for drug discovery, capable of serving as ligand for a diverse array of receptors and it has been a major focus of research [3]. Indole derivatives have the unique property of mimicking the structure of peptides and to bind reversibly to enzymes and exhibit significant physiological and pharmacological, industrial, and synthetic applications such as beneficial estrogen metabolism promoter in humans, anticarcinogenic properties, inhibitors of human prostate cancer cells, and free radical scavenging activities [1, 4]. The indole scaffold is widely used in antiviral drugs and reverse-transcriptase inhibitors, drugs used to treat HIV infection or AIDS, and in some cases hepatitis B. Meanwhile, a number of bis (indolyl) alkanes have received considerable attention because of their occurrence in bioactive metabolites of terrestrial and marine origin [5].
Indolizine is the core structure of many of the naturally occurring alkaloids such as swainsonine (a potent inhibitor of Golgi alpha-mannosidase II, an immunomodulator and a potential chemotherapy drug), monomorine (might be used to lure ants to their doom), gephyrotoxin (muscarinic antagonist), and lamellarins (HIV-1 integrase inhibition and antibiotic activity) [6].
The indolizine synthetic derivatives also deserve special attention because of their pharmacological properties such as antibacterial, anti-inflammatory, antiviral and antileishmanial, analgesic and antitumor, antioxidant activities, aromatase inhibition, calcium entry blocking, histamine H3 receptor antagonist, and physicochemical properties such as strong fluorescence [6, 7].
Different strategies for generating diverse collections of small molecules with indole and indolizine moieties have been developed. They can be synthesized by means of classical and nonclassical pathways.
The development of simple, convenient, and an eco-friendly approach for the synthesis of these biologically important compounds is still in demand. For example, the very useful and green concept of a “click” reaction is a facile, selective, high-yield reaction under mild water-tolerant conditions with little or no by-products [8]. Cascade annulation reactions lead also to the formation of polycyclic fused six- and seven-membered heterocycles with indole and indolizine core [9].
Microwave irradiation, sonication, and solvent-free are green chemistry techniques that have been used for a variety of applications including organic synthesis. Microwaves and ultrasounds have been used as synthetic techniques for obtaining indole and indolizine derivatives in high-yield, higher reaction rate. The simplicity of the reactions using these techniques, the elimination of toxic solvents, and the synthesis carried out in a very short time period are particularly useful for the creation of diverse chemical compounds of “drug-like” molecules for biological screening [10].
Multicomponent reactions (MCRs) or tandem reactions have developed as a powerful tool for delivering the molecular diversity needed for the synthesis of interesting heterocyclic scaffolds, to efficiently construct a variety of intermediates possessing an indolyl or indolizyl subunit and are particularly attractive especially if they start from simple molecules [11].
The present study discusses the versatile nature of indole/ indolizine derivatives, new green methods for their synthesis, their possible mechanism of action, and also provides information about current/future prospects of the topics and different indole/indolizine derivatives in pharmaceutical/clinical trials.
Indole derivatives are, perhaps, the most studied nitrogen heterocyclic systems because of interesting biological properties that received particular interest due to the reserpine alkaloid, one of the first drugs used for the treatment of central nervous system (CNS) disorders. Different substituted indoles are particularly important in pharmaceutical chemistry being capable to bind many receptors with high affinity exhibiting various pharmacological activities. Therefore, it is important to explore new synthetic reactions and evaluate various properties of indole derivatives.
To obtain biologically relevant N-hydroxyindoles, a prudent step would be to synthesize O-protected hydroxyindoles, to avoid their dimerization into kabutanes. Such were the premises of one study, presenting the annulation of nitrosoarenes with various alkylating and acylating agents, able to afford the desired compounds with excellent regioselectivity [4].
The synthesis of 3,3-dimethyl-2-amide indoles could be achieved through the I2/DMSO promoted oxidative amidation reaction between 1,2,3,3-tetramethyl-3H-indolium iodide and secondary amines with moderate yields (Figure 1) [12].
Synthesis of 3,3-dimethyl-2-amide indoles: mechanism [
Using a method involving four steps, 2-indole-3-yl-thiochroman-4-ones could be obtained (Figure 2), according to Song et al. In the final step, the Michael addition reaction of thiochromone and indole, an ionic liquid is used, to increase the yield, with the added advantage that it could be reused three times without a decrease of efficiency [13].
Synthesis of 2-indole-3-yl-thiocroman-4-ones derivatives [
Polyvinylsulfonic acid, a biodegradable and recyclable polymeric acid rarely used in organic transformations, could be used as a Bronsted acid catalyst in the synthesis of bis (indolyl) methane [14]. Another pathway to obtain this compound would be to employ a reusable resin, Indion Ina 225H, as catalyst of the substitution reaction between indoles and aldehydes (Figure 3), reportedly attaining excellent yields in short reaction times [15].
Synthesis of bis(indolyl) methane using a reusable resin, Indion Ina 225H [
Various carbonyl compounds, including ketones could also be building blocks for the much desired bis(indolyl)methanes, using catalytic amounts of iodine in the presence of sodium dodecylsulfate in aqueous solution above its critical micellar concentration and the protocol was also extended to afford 3-substituted indolyl ketones (Figures 4 and 5) [3].
Synthesis of bis(indolyl)methanes, using catalytic amounts of iodine in the presence of sodium dodecylsulfate [
Iodine-catalyzed formation of bis(indolyl) methane from indole and aldehyde under aqueous micelar conditions [
The indolizine core has found numerous applications in the synthesis of biologically active compounds. Partially or completely reduced indolizine analogs are widely used in the synthesis of indolizidine alkaloids and related unnatural products. Among many other pharmacological uses, polycyclic analogs of indolizine, for example, have found a broad application as heterocyclic analogs of indene in the synthesis of ligands for transition metal complexes. Although many methods have been developed for their synthesis, they are generally time-consuming or require the use of stoichiometric amounts of organometallic reagents, Lewis acids, expensive catalysts or potentially toxic solvents, which limits their economical applications. Accordingly, development of alternative catalytic methods for construction of these important heterocyclic cores is necessary [9].
The mechanism of obtaining condensed five-membered ring systems via 1,3-dipolar cycloadditions implies the reaction of a dipole, in this case an N-ylide generated in situ from a cycloimmonium halide and a base or another deprotonating agent followed by its addition to a dipolarophile, olefinic, or acetylenic [7].
N-ylides could be generated employing 1,2-epoxybutane as both solvent and deprotonation agent, or by using triethylamine in DCM, with ethyl propiolate or DMAD as dipolarophiles, or again coupling the ylide with acrylonitrile and using TPCD for the aromatization step, all methods with similar medium to good yields (Figure 6) [7]. Moderate yields, up to 22%, are reported when reacting DMAD with N-ylides generated from pyridinium salts and K2CO3, using catalytic amounts of dicyclohexyl-18-crown-6 [16]. In another study, 20 substituted indolizines were obtained in just 30 min at room temperature, employing electron-deficient alkynes, in the presence of K2CO3 in DMF, with yields as high as 77% [17].
Synthesis of the new 7,8,9,10-tetrahydropyrrolo[2,1-a]isoquinolines [
The solvent could have a great impact on the reaction mechanism, as one study demonstrates, using substituted ethenes (E-1,2-di(alkylsulfonyl)-1,2-dichloroethene) as dipolarophiles (Figure 7). In aprotic solvents, the reaction takes place as a 1,3-dipolar cycloaddition, with yields between 62 and 75% for the six indolizines obtained, but in protic solvents an addition–elimination reaction intervenes, leading to the competitive formation of furans, with indolizine yields as low as 9% [18].
The reactions of pyridinium ylides with ethenes in EtOH [
One-pot reactions imply obtaining the product in a single step, by adding all the necessary reagents in the same reaction medium, without having to isolate and purify any precursors of the desired product. This type of procedure offers advantages such as swiftness, the preparation of complex compounds from readily available material, simplification of workup and atom economy.
Mishra et al. present a method to obtain 1-aminoindolizines from aldehydes, secondary amines, and terminal alkynes, in a one-pot reaction (Figure 8). After testing several solvents and metal catalysts, the best results are obtained with CuCl in PEG, synthesizing 15 substituted indolizines with yields exceeding 70%, after 3–4 h reaction time [19].
One-pot multicomponent synthesis of 1-aminoindolizines [
Substituted 3-aminoindolizines could be obtained via one-pot multistep reactions, from 2-pyridine carboxyaldehide and various nitriles, after 3 h reaction in toluene at 105°C, by adding 1.1 eq of Hantzsch ester as a hydride transfer agent and catalytic amounts of piperidinium acetate [20].
The synthesis of 2-acetyl-3-(phenylamino)indolizine-1-carboxamides could also be achieived in a single step (Figure 9), by combining pyridine-2-carbaldehyde, acetoacetanilide and isocyanides in toluene at reflux, with yields around 90% for the four compounds obtained [21].
Synthesis of 2-acetyl-3-(phenylamino)indolizine-1-carboxamides via a three-component condensation [
A four-component tandem reaction is proposed by Zhenjun et al., by treating pyridine (or quinoline) with phenacyl bromides (or bromoacetophenones), ethyl glyoxalate, and Na2CO3 in refluxing acetonitrile. The resulting polysubstituted indolizines are obtained after 16 h of reaction time in moderate-to-good yields [22].
Seventeen polysubstituted indolizines could be obtained via a one-pot sequential addition-cyclodehydration-dehydrocyanation from of 2-(1H-pyrrol-1-yl) nitriles with α,β-unsaturated carbonyl compounds (Figure 10) [23].
One-pot addition-cyclodehydration-dehydrocyanation of 2-(1H-pyrrol-1-yl) nitriles with α,β-unsaturated carbonyl compounds [
The indolizine core could be accessible starting from pyrrole, with strategies involving intramolecular aldol cyclization or domino Knoevenagel condensation, shown in Figure 11 [24].
Possible synthetic approaches to indolizines [
Another [3+3] annulation approach employs allyl bromides derived from Morita-Baylis-Hilman adducts (Figure 12), with the conclusion that electron withdrawing groups, as substituents at the aromatic ring, contribute to successful ring closure and result in accordingly substituted indolizines [25].
Design of new [3+3] annulation route to indolizines [
Novel 2-acyl-6-aryl substituted indolizines were obtained starting from 4-acyl-pyrrole-2-carbaldehyde and α, β-unsaturated esters, in the presence of K2CO3 in DMF, with yields between 42 and 68% after 8–12 h at 50°C [26].
Another possibility would be to perform a tandem oxidative C-H functionalization and 5-endo-dig cyclization, starting from 2-substituted pyridines and alkynes (Figure 13), which could be achieved with good yields using an Ag2CO3 reusable catalyst [27].
Silver-mediated oxidative C-H functionalization to synthesize indolizines [
Substituted pyridines and acetophenones lead to the formation of 1,2,3-triarylindolizines with moderate-to-excellent yields, promoted by I2/DMSO at 100°C, the proposed mechanism for this reaction is presented in Figure 14 [28].
Formation of 1,2,3-triarylindolizines. Proposed reaction pathway [
During the synthesis of N-heterocycles there are many problems of health and safety in addition to the environmental problems caused by their use and disposition as waste. Green methods are a route towards increasing the efficiency of indoles and indolizines synthesis, and stride to use less toxic solvents, to reduce the stages of the synthetic routes and minimize waste as far as practically possible for sustainable development.
A potential method to make synthetic chemistry more environment-friendly would be to reuse catalysts, such as ion-exchanging resins. Amberlite-IRA 402 (OH) could be employed as the ylide-forming base in the reaction between phenacyl pyridinium, quinolinium and isoquinolinium salts and alkynes (Figure 15) [29].
Synthesis of indolizines and pyrrolo [1,2-a] quinolines using alkynes [
Unconventional activation techniques, such as microwave irradiation, not only lead to shorter reaction times but generally increase the purity of the desired compound. One study presents the synthesis of 8 indolizine derivatives in an aqueous medium that were obtained in good yields after 1 min of irradiation at 300W [30].
Biocatalysis could be employed to aid the formation of indolizine derivatives in an aqueous medium, as seen in Figure 16. Ultrasound activation was compared to conventional heating, affording 7,7′-bis-indolizines with similar yields in much shorter reaction times [31].
Synthesis of bisindolizines by biocatalytic reaction [
The Oxone-induced oxidation of indole-3-carbaldehydes and 5-halogenated analogs could lead to the formation of tryptanthrin derivatives (Figure 17), a highly functionalized biologically active natural product, at room temperature [32]. The phthalazine moiety could also be accessible with green methods, employing catalytic amounts of L-proline, with good yields and less than 2 h reaction time [33].
Tryptanthrin derivative [
The reaction between indole and formaldeyde could produce high yields of hemiaminals, with the added value of mild conditions, such as room temperature and an aqueous medium, in the presence of TBAF [34].
The most eco-friendly approach when it comes to solvent choices would be not to employ any solvents. Analogs of 3-alkylindole, for example, could be prepared in solvent-free conditions, using MgO nanoparticles as catalyst [35]. Bis(indol-3-yl)methanes could be synthesized in solvent-free grinding conditions, employing a reusable catalyst, phosphate-impregnated titania, obtaining yields as high as 93% [36].
Synthesis of highly functionalized indolylpyrans [
Unconventional activation techniques could also be used for indole functionalization. Within 10 min, including reaction and purification time, 3-pyranyl indole derivatives could be obtained with good yields, through one-pot microwave-assisted reactions, with InCl3 as catalyst (Figure 18) [37]. Indolyl chalcones could be prepared from indole-3-carboxaldehyde and heteroaryl active methyl compounds under conventional heating, but the yield was much improved and reaction time was drastically reduced (from more than 9 h to less than 15 min) when microwave irradiation was introduced [38]. Ultrasounds aid the selective formation of 11 3-selanylindole derivatives with good yields, proving superior to conventional heating and microwave irradiation for this synthesis [39].
Both indoles and indolizines could be functionalized via alkylation with enamides under mild conditions (Figures 19 and 20), using FeCl3, in short reaction times with good yields [2].
Iron-catalyzed alkylation of indoles with enamides [
Iron-catalyzed alkylation of indolizines with enamides [
The Friedel-Crafts alkylation of indoles could also be performed in water, as presented in Figure 21, with yields as high as 97% in the presence of Keggin heteropoly acids, solid super-acid catalysts [40].
Friedel-Crafts alkylation of indole [
A novel approach presents the previously inaccessible regioselective formation of substituted pyrido[2,3-b]indolizine-10-carbonitriles, via a cascade transformation of α,β-unsaturated carbonyl compounds with a dimer of 1-(cyanomethyl) pyridinium chloride, in ethanol/water in the presence of sodium acetate [41].
As we have seen so far, interesting pathways have been proposed for the synthesis of indoles and indolizines. Many of these molecules have subsequently been involved in tests to assess their biological activity. Natural compounds with these moieties have also attracted interest, not just as extracts, but as targets for total/semisynthesis or as frameworks for compound libraries. Next, we shall review some of the extremely diverse pharmaceutical applications of these derivatives, ranging from fluorescence probes, to antiviral, to anticancer molecules currently in clinical trials.
Lead by Cialis, there are seven indole-containing commercial drugs in the Top-200 Best Selling Drugs by US Retail Sales in 2012. Examples of indole derivatives marketed as antiviral drugs, for example, are Arbidol (a broad-spectrum antiviral with anti-influenza and immunomodulating effects) and Delavirine (a non-nucleoside reverse transcriptase inhibitor) [42].
Bisindoles, such as hamacanthin A, isolated from marine sponges (
Natural indoles [
Some of the many studies published in this field have resulted in the elucidation of some of the mechanisms of their bioactivity. The influence of I3C, for example, on lung cancer cells, has been attributed to apoptosis via Fas activation and caspase-8 pathways and also cell-cycle arrest at the G0/G1 phase, and it was also shown that cancer preventive effects of I3C were mediated via modulation of the phosphatidylinositol-3-kinase (PI3K)/Akt signaling pathway [44]. I3C was also shown to induce the expression of phase I and II enzymes by the binding of the aryl hydrocarbon receptor (AhR) (Figure 23) [45].
Biological activity pathways of indoles [
DIM has been found to increase bone mass by supressing osteoclastic bone resorption, in physiological and pathological conditions [46]. DIM could also help prevent heart failure, as one study indicates the compound improves myocardial energy metabolism imbalance via AMPKα signaling [47].
Strychnine and brucine are well known for their toxic effect that manifests in the form of hypertension and violent convulsions. Brucine is also a proposed anticancer drug candidate, as it inhibits VEGF-induced cell proliferation, reducing p-VEGFR2 kinase activity and inhibiting neovascularization in vivo [48].
Other indole alkaloids, isolated from marine sources, such as coscinamides, dragmacidin D, topsentins, or even fungal sources, such as asterriquinone, have exibited antiviral (anti-HIV), antimicrobial, antitumor activity, along with the inhibition of serine–threonine protein phosphatases or ascites hepatoma AH13, for example [49]. Such compounds, isolated from the
Indole alkaloids – strychnine, brucine, asterriquinone, physostigmine, and rivastigmine[
With methods of extraction developing since the 1960s, with many efforts concentrating on the efficiency and environmental impact of the process, terpenoid indole alkaloids and their pharmacological properties continue to attract attention as some of them are already marketed as anticancer, antihypertensive, or hypoglycemic agents, for example [52]. Some monoterpene indole alkaloids are in high demand, such as vinblastine (
Indole alkaloids – vinblastine and camptothecin [
A novel class of indole-2-carboxylate derivatives was designed starting from the structure of pyrroloquinoline quinone, with two compounds (Figure 26) emerging as more potent antiproliferants than the reference drugs, compounds that induced PARP cleavage and increased ROS generation dose-dependence [55].
Indole-2-carboxylate derivatives [
Protein tyrosine phosphatases (PTP) are a novel, mostly untapped family of therapeutic targets, with implications in oncology (SHP2), autoimmunity (Lyp) or diabetes (PTP1B). X-ray crystal structural analysis has been performed on PTP-inhibitor complexes, revealing bicyclic benzofuran and indole-based salicylic acids as useful first steps toward the development of more potent inhibitors (Figure 27) [56].
PTP-inhibitor [
Novel galantamine derivatives with indole moiety have exhibited an activity against acetylcholinesterase up to 95 times higher than the parent compound, with one promising lead binding in a region close to the peripheral anionic site of the enzyme, where the Ω-loop of amyloid beta peptide adheres [57].
Coronary heart disease, prevalent in industrialized regions, comes hand-in-hand with high levels of LDL-C (”bad cholesterol”) and low levels of HDL-C (”good cholesterol”), treated mostly with statins, inhibitors of HMG-CoA reductase with dose-limiting hepato- and myotoxicity. However, the screening of a small indole chalcone fibrates library (Figure 28) has revealed three compounds with a more potent hypolipidemic effect than the standard drug, fenofibrate, coupled with high inhibition percentages of superoxide anions, hydroxyl radicals, and microsomal lipid-peroxidation [58].
Indole chalcone fibrates [
Beneficial effects on lipid and also glucose metabolism were also reported concerning 1-(4-chlorobenzoyl)-5-hydroxy-2-methyl-3-indoleacetitic acid (GY3), which increased glucose consumption and decreased lipid accumulation through AMPK activation in hepG2 cells, with obvious implications in metabolic syndrome, type 2 diabetes, and nonalcoholic fatty liver disease [59].
Some indole derivatives also show promising antimicrobial activity. Five out of 24 bisindolylmethane Schiff base derivatives synthesized were found to specifically inhibit
Natural products derived from the indolizine core, such as castanospermine, swainsonine, or tylophorine, polyhydroxylated indolizidine alkaloids, have attracted much attention, struggles toward total synthesis, or analog design issues. Their biological properties range from the antiviral to the anticancer realm, with promising effects on autoimmune diseases [60].
Indolizidine alkaloids [
For example, castanospermine glycoside analogs inhibit breast cancer cells MCF-7 and MDA-MB-231, inducing cell cycle arrest and apoptosis without impact on normal cell proliferation [61]. Some 5α-substituted swainsonine analogs successfully inhibit Golgi alpha-mannosidase II, a key enzyme in the N-glycosylation pathway and a potential target for cancer chemotherapy, without much loss of activity by comparison with the parent compound [62]. Tylophorine was shown to inhibit VEGFR2 tyrosine kinase activity and its downstream signaling pathways, neovascularization, tumor angiogenesis and tumor growth, molecular docking simulations indicating that it could form hydrogen bonds and have aromatic interactions within the ATP-binding region of the VEGFR2 kinase unit [63].
In the indolizine nucleus, the six-membered ring suffers from low electron density, with a subsequent charge buildup in the five-membered ring, resulting in a large dipole moment and fluorescence properties. The influence of the substituents goes a long way into predicting a blue or red-shifted fluorescence; for example, the C-2 position could carry a lot of weight [26].
The 10π conjugated planar electronic structure, exhibiting strong fluorescence properties, can be useful for DNA interaction studies. Such is the case of some indolizinylpyridinium derivatives, found to interact similarly to ethidium bromide, binding in the minor groove, but having its fluorescence partially quenched [64].
Switchable biosensors could be designed starting from Seoul-Fluor (Figure 30), an indolizine scaffold with three positions for different radicals: R1 and R2 substituents affect electronic perturbation; R3 could be a functional handle for bioconjugation, thus creating a versatile platform with tuneable emission wavelength and controllable quantum yield [65].
Indolizine biosensor: Seoul-Fluor [
Many indolizine derivatives have been proven to be worthy therapeutic agents, with a number of them undergoing clinical trials, notably five anticancer molecules that inhibit topoisomerase [66]. As is the case of photophysical properties, the substituents of the indolizine core can be tailored to suit the bioactivity requirements.
Following a SAR study, 49 indolizine derivatives were obtained and tested as potential HIV-1 infectivity factor inhibitors, one of which was found to exhibit an IC50 value of 11 µM [67].
A feature that makes indolizine derivatives attractive is the design possibilities. The facile replacement of substituents could lead to more in-depth perception toward their effect upon desired bioactivity, solubility, or other properties sought [66].
Two new classes of indolizines fused with phenantroline skeletons were designed and synthesized, obtaining compounds with a coplanar structure, potentially able to interact with DNA through an intercalation mechanism, compounds that also possess good solubility in microbiological medium. Furthermore, one of the compounds exhibit, under aerobic conditions, activity against
Indolizines fused with phenantroline skeletons active against M. tuberculosis and breast cancer [
During rational design efforts, concentrated on the identification of potential farnesyltransferase inhibitors (implications with respect to oncogenic Ras proteins), the replacement of the triazole unit with the indolizine nucleus resulted in IC50s in the low micromolar range. The substituents’ influence on bioactivity and pharmacokinetic parameters was also investigated [69].
Rational design could be pushed even further, employing 3D-QSAR studies to yield pharmacophore models, as is the case for 15-lipoxygenase inhibitory activity. For this purpose, 47 indolizines with anti-15-LOX activity were used to obtain a statistically significant model [70].
The similarity of the two heterocycles has motivated researchers since 1967, when Harrell and Doerge postulated that indolizine analogs of bioactive indoles could possess similar or improved potency [66]. Such an endeavor was attempted with the synthesis of l-(2-aminoethyl)-3-benzyl-7-methoxy-2-methylindolizine, an analog of indole derivative benanserin, the replacement of indole with indolizine proving to have no effect on anti-acetylcholinesterase activity but diminished the antihistamine and anti-5-hydroxytryptamine activity [66].
Ramatroban, 3-((3R)-3-{[(4-fluorophenyl)sulfonyl]amino}-1,2,3,4-tetrahydro-9H-carbazol-9-yl)propanoic acid, is a well-known prostaglandin D2 inhibitor and thromboxane receptor antagonist. Researchers from Merck and Amira have presented numerous ramatroban analogs with the indole moiety replaced with indolizine and aza-indole, both proving potential during SAR studies. Among them, a 4-aza-indole derivative (Figure 32) inhibited hCRTH2 with an IC of 6 nM and was active in a murine OVA-induced lung inflammation model [71-74].
Tricyclic CRTH2 antagonist [
LE 300 is a selective antagonist for dopamine D1/D5 and serotonin 5-HT (2A) receptors, bearing an azecine ring fused to an indole ring on one side and a benzene moiety on the other side. New analogs of this compound were prepared, namely pyrrolo[2,3-g]indolizine, pyrrolo[3,2-a]quinolizine rings and their corresponding dimethylpyrrolo[2,3-d]azonine, and dimethylpyrrolo[2,3-d]azecine [75]. The study concludes that the indolizine and quinolizine derivatives show no activity concerning the receptors analyzed, while their azonine and azecine counterparts exhibited only weak antagonistic effects for serotonin and histamine receptors, remaining nonresponsive toward the four dopamine receptors tested.
Secretory phospholipases A2 (sPLA2s) is successfully inhibited by substituted indole and indolizine derivatives, as previously reported by Lilly and Shinogi researchers, with compounds like indoxam and Me-indoxam exhibiting favorable pharmacokinetic profiles [76-79]. Oslund et al. have prepared a set of benzo-fused analogs, among which they identified a compound that was the first reported potent inhibitor of groups IID and IIF sPLA2s and the most generally potent sPLA2 inhibitor reported to date (Figure 33) [80].
Substituted indole, indolizine, and benzo-fused indole inhibitors against human and mouse sPLA2 [
James et al. have prepared a series of indole and indolizine-glyoxylamides (Figure 34) and subsequently tested the compounds’ cytotoxicity against cancer cell lines, identifying high antiproliferative activities, even in the case of multidrug-resistant phenotypes. After searching among numerous cores, with the goal to replace indole, the researchers synthesized a novel class of cancer agents with an indolizine core, with a lead compound that proved effective against multidrug-resistant cell lines such as MES-SA/DX5 and HL60/TX1000, resistant to treatment with Taxol [81].
Indole- and Indolizine-glyoxylamide derivatives [
Considering the growing interest for biologically active compounds, we believe that in the future the search for novel indole and indolizine derivatives will result in the emergence of new synthesis pathways and new and unexplored biologically active derivatives with pyrrole moieties.
Taking into account the importance of anticancer drugs, like vinblastine, irinotecan, topotecan, or camptothecin, the development of biologically active derivatives of new natural lead compounds containing indole and indolizine nucleus might be helpful in the design and development of novel and more potent anticancer drugs, antiviral agents, intercalating agents.
With the remarkable number of approved indole-containing drugs as well as the importance of the indolizine moiety, it can be easily concluded that indole and indolizine derivatives offer perspectives on how pyrrole scaffolds might be exploited in the future as bioactive molecules against a broad range of diseases.
This work was supported by a grant of the Romanian National Authority for Scientific Research, CNCS – UEFISCDI, project number PN-II-ID-PCE-2011-3-0226
Periodontitis is a noncommunicable infectious disease associated with an important inflammatory component affecting around 50% of the population worldwide and with a prevalence of its severe forms of 11.2% [1]. The Global Burden of Diseases, Injuries, and Risk Factors Study (2017) reported periodontitis as the sixth most prevalent chronic human disease [2].
Periodontitis is characterized by loss of connective tissue attachment that is normally located at the tooth neck (cementoenamel junction) as well as by alveolar bone destruction. Periodontitis is accompanied by the transformation of the shallow gingival sulcus into a deep periodontal pocket and a marked apical diffusion of the dysbiotic subgingival biofilm [3]. In generalized severe periodontitis, the surface area of the epithelial lining of the periodontal pockets is enormous and could favor the direct contact of subgingival bacteria with gingival connective tissue through focal ulcerated areas. Moreover, epithelial ulcerations constitute biological entries for the systemic dissemination of subgingival Gram-negative bacteria and local products eliciting different general biological responses [3, 4].
There is important evidence suggesting periodontitis as a biologically plausible risk factor for the development of other chronic, systemic, inflammatory conditions such as diabetes mellitus, cardiovascular disease (CVD), and adverse pregnancy outcomes [5]. Relationships between periodontitis and chronic obstructive pulmonary disease, rheumatoid arthritis, metabolic syndrome, obesity, cancers, and chronic renal disease have also been reported [6]. An inverse influence of systemic conditions on periodontal status has also been described [7]. Current epidemiological evidence sustains that periodontitis induces an increased risk for future atherosclerotic CVD [8].
The term CVD refers to atherosclerotic conditions such as coronary heart disease, cerebrovascular disease and peripheral vascular disease representing a leading cause of death, impairments, and quality of life alterations [8]. CVDs are the most prevalent noncommunicable diseases globally due to the increasingly aging population as well as to profound alterations of diets and lifestyles. Eurostat, the statistical office of the European Union, reported that in 2016 in UE 1.68 million deaths were resulting from diseases of the circulatory system, which was equivalent to 37.1% of all deaths—considerably higher than the second most prevalent cause of death, cancer (malignant neoplasms 25.8%). They accounted for 50–60% of all deaths in the Baltic Member States and Romania and 65.8% of all deaths in Bulgaria. By contrast, less than one-quarter of all deaths in Denmark (22.6%), France (24.3% 2016 data) and the Netherlands (25.0%) were caused by diseases of the circulatory system [9].
Periodontitis has a negative impact on cardiovascular outcomes. Also, periodontal treatment has been associated with potential risks and complications in patients on anti-thrombotic therapy which must be considered in clinical practice [8].
Due to significant advancement and the accumulation of new evidence on periodontitis-CVD relationships as well as to the major medical, economic and social burden represented by both periodontitis and CVD, this chapter aims to review existing epidemiological and pathogenetic links related to this topic as wells to highlight the impact of the periodontitis-CVD associative relationships on clinical practice and to provide some clinical recommendations for both periodontists and cardiologists on this topic.
A highly organized subgingival microbial community is involved in the transition from a periodontal health condition to a dysbiotic pathogenic status namely periodontitis characterized by a complex shift of the microbiota composition, abundance, and arrangement [10, 11]. Three members of the subgingival consortium included in the “Red complex” have been constantly identified in the subgingival microbiota of periodontitis patients are:
A paradox remarqued by the specialists is that dysbiotic microbiota requires inflammation to sustain their nutrition in the context in which localized inflammatory reaction developed by the host is a normal function addressed to reestablish local homeostasis through inhibiting bacterial development [11]. The behavior of
A low proportion of
Upregulation of many virulence genes of
Microbiota within the subgingival biofilm is a complex highly dynamic architectural arrangement of bacteria rather than a random static positioning of the microbial cells next to each other. Within the biofilm, biochemical interaction, signaling, and genetic exchanges between bacteria take place. Facultative aerobes within subgingival biofilms can sequester oxygen and create anaerobic niches that favor the expansion of anaerobic protobionts and thus the transition toward dysbiosis [11]. The bacterial load in periodontal pockets is exponentially greater compared to the flora of the sulcus at the expense of the dominant species rather than due to the replacement of early colonizers [16]. Four distinct layers have been described in the subgingival biofilm from periodontitis patients. The basal layer of the subgingival biofilm, located in the proximity of the tooth surface, is formed by
Atherosclerosis is a chronic, vascular inflammatory condition being a major cause of CVD. In atherosclerosis, the deposition of lipids in the artery walls results in plaque build-up. Its progression results in the reduction of blood flow and consecutive ischemia of organs and tissues and promotes clot formation [21]. The American Heart Association pointed out the relationships between periodontitis and CVD although causality remains unproven [22, 23].
A wide range of studies has investigated the causal relationships between periodontitis and CVD which have resulted in two essential hypotheses explaining this link. One hypothesis sustains the role of systemically disseminated periodontopathogens and of their by-products to induce atheroma formation through the infection of blood vessels [24]. Disseminated bacteria and their products including lipopolysaccharide (LPS) challenge the immune system inducing systemic inflammatory reactions [3].
Several data communicated over time have reported the ability of bacteria from subgingival plaque to migrate and localize to vascular walls and atheromatous plaques. Recent information provided by a systematic review and a meta-analysis showed that the DNA of periodontopathogens was present in atheromatous plaque samples from patients with myocardial infarction [25]. However, less than 5% of patients receiving surgery for atherosclerotic vascular disease presented bacterial DNA in isolated samples which were not statistically significantly different from patients receiving surgeries for rheumatic heart disease [26].
The second hypothesis considers that longstanding periodontal inflammation overlaps with existing chronic systemic inflammation through the dissemination of locally abundantly produced molecules (pro-inflammatory cytokines, chemokines, and gingiva-derived C-reactive protein CRP) promoting atherosclerosis development and CVD [24, 27].
Moreover, a recent emerging hypothesis considers that periodontopathogens and periodontal inflammation promote modifications in oral and gut microbiome which in turn may influence the evolution of both periodontitis and atherosclerosis [24].
In periodontitis patients, the processing of antigenic structures by the liver induces a systemic acute phase response associated with an increased plasma CRP [3]. Periodontitis patients have statistically significantly higher high sensitivity CRP plasma values compared to periodontally healthy subjects amounting to 1.56 mg/L. This difference is biologically relevant since it could drive patients into the high CRP risk category (>3 mg/L) [28]. IgG antibodies against specific periodontal bacteria were associated with all-cause and CVD mortality [29].
A vascular endothelial activation is a central event for atherosclerosis development and a connecting link to periodontitis [30]. Circulating bacterial LPS, outer membrane vesicles and fimbriae, as well as inflammatory cytokines induce the up-regulation of cell-surface receptors and the expression of adhesion molecules on the vascular endothelium, which recruit peripheral blood monocytes at the surface of the activated endothelium. On the other hand, antibodies targeting specific bacterial proteins behave as auto-antibodies through “molecular mimicry” and induce damage of the vascular endothelium [31]. Monocytes follow a chemoattractant gradient and migrate into the sub-endothelial space, become tissular macrophages, capture oxidized low-density lipoprotein cholesterol (LDL) and develop into foam cells. Apoptosis of the latter favor the accumulation of lipids in the sub-endothelial space forming the atheromatous plaques, which become coated by a fibrous shelter and promote platelet adhesion. Apoptosis of endothelial cell exposes the fibrous cap which in association with the enzymatic destruction of the extracellular matrix induce plaque rupture, exposure of pro-thrombotic plaque components, and subsequent thrombus formation that leads to vascular occlusion and CVD related events (myocardial infarction or stroke) [3].
Periodontitis patients have increased platelet recruitment and platelet hyperactivation as sustained by the augmented plasma concentration of platelet factor 4 (PF4) [32, 33]. Moreover, periodontitis has been frequently accompanied by a prothrombotic state. In patients with mild, moderate, or severe periodontitis D-dimer values were found to be increased by 1.62-fold, 2.06-fold and 2.54-fold, respectively than in healthy patients [34].
Although, the relationship between periodontitis and CVD has long been the subject of debate in the scientific literature, the existence of a moderate association between periodontitis and CVD was firstly reported by a systematic review in 2003 [35]. Since then, many other systematic reviews and meta-analyses highlighted this idea. Periodontitis patients had 19%, 15% and 14% increased risk of developing CVD, respectively [36, 37, 38].
Individuals with active periodontitis had a nearly 2–2.5-fold higher risk of developing acute myocardial infarction than those without the disease [39, 40].
A positive association between both severe and moderate periodontitis and acute myocardial infarction exists, which suggests a relationship between periodontitis severity and CVD [41].
A significant association was found between calcified carotid artery atheroma and the presence of periodontitis both in acute myocardial infarction (OR, 1.51; 95% CI, 1.09–2.10) and controls (OR, 1.70; 95% CI, 1.22–2.38) [42]. Periodontitis was associated with a 45% higher risk of acute myocardial infarction (OR, 1.45; 95% CI, 1.10–1.91), whilst patients with both periodontitis and calcified carotid artery atheromas had a 75% higher risk for acute myocardial infarction then those without these conditions [42].
An increased CVD burden in patients with significant periodontal destruction had been suggested in different studies. Data from the Oral Infections and Vascular Disease Epidemiology (INVEST) study showed that the number of missing teeth was significantly associated with carotid artery plaque after adjustment for CVD risk factors [43]. Moreover, the Periodontitis and Its Relation to Coronary Artery Disease (PAROKRANK) study reported an increased risk of myocardial infarction in patients with periodontitis (odds ratio of 1.28, 95% confidence interval (CI) 1.03–1.6) after adjustment for some behavioral, social and medical risk factors. The radiographic bone loss was used to quantify periodontal destruction [44]. However, concerns have been raised in relation to the difficulty to control for all possible confounders and the possibility that periodontitis could still be a surrogate for other risk factors not highlighted by these studies [45].
Periodontitis may also represent a risk factor for stroke, especially in ischemic events. However, new studies with a robust design are necessary for a reliable conclusion [46].
Hypertension is considered a major risk factor of CVD. Periodontitis has emerged as a new contributor to the complete cardiovascular risk profile of CVD.
The associative relationships between periodontitis and hypertension are important in the context of the high prevalence rates of both diseases that induce important medical and social burden. Besides the fact that periodontitis and hypertension share a group of common risk factors (older age, smoking, low socioeconomic and education status, genetics) an independent association between the two diseases has been reported.
The data provided by prospective and retrospective studies reported a higher prevalence of hypertension in patients with periodontal disease ranging from 7 to 77% as compared with patients without periodontitis with prevalence rates ranging from 4 to 70% [47]. Periodontitis patients had 4.5 mmHg higher systolic and 2.0 mmHg higher diastolic blood pressure than non-periodontitis patients [47]; the systolic component of the blood pressure seemed to be more influenced by periodontitis than the diastolic one [48].
Two meta-analyses provided information sustaining the association between periodontitis and hypertension [47, 49]. The heterogeneity of case definitions of both hypertension and periodontitis prevented the drawing of firm conclusions regarding this topic. The association between the two diseases is open to future analyses of data provided by clinical trials using uniform case definitions for periodontitis and hypertension.
The activity of periodontitis monitored through local inflammation index (bleeding on probing) seems also to play an important role in the complex interplay between periodontal disease and hypertension. Data from the Third US National Health and Nutrition Examination Survey (NHANES III) informed that local gingival inflammation (bleeding on probing) was significantly associated with increased systolic blood pressure (2.6 mmHg higher values compared with noninflamed situations) and increased risk of uncontrolled blood pressure after multivariate adjustments of a large make-up of influencing factors including systemic inflammatory diseases as well as behavioral and social factors [50]. Moreover, data from observational studies reported that even for patients on intensive antihypertensive treatment periodontitis was associated with an increased risk of uncontrolled hypertension [48].
The genetic background has been involved in the development of both periodontitis and hypertension at least partially by the modulation of immune-inflammatory reactions that sustain a proinflammatory milieu [48].
The high-salt diet is a common trigger for hypertension, but data has also shown to alter the microbiome and impair immune systems through salt-induced hyperglucocorticoidism [51, 52].
It was proven that oral health among vulnerable populations, such as pregnant women is an important determinant regarding the pregnancy outcome. Numerous epidemiological studies have demonstrated an increased risk of adverse pregnancy outcome (APO), including preterm birth, low birthweight and pregnancy-induced hypertension or pre-eclampsia (PE) as well as gestational diabetes (GDM), related to periodontal disease [53]. Therefore, maintaining optimal maternal oral hygiene is regarded as a mandatory standard of care for perinatal medicine [54].
The reported prevalence of periodontitis, during the time period of pregnancy, varies between 10 and 74% and it is highly dependent on the economical level and health policies of each country [55].
Two pathogenic mechanisms described the potential effect of periodontal diseases on pregnancy outcomes. On the one hand, the periodontal bacteria could induce bacteremia and a seeding of the feto-placental unit. On the other hand, inflammatory mediators such as interleukin-1 (IL-1), IL-6, IL-8, tumor necrosis factor-α (TNF-α) or prostaglandin E2 (PGE2), secreted by the subgingival inflammatory site are carried to the feto-placental unit, where an inflammatory response will develop [53].
The influence of the gingival bacterial microbiome on APO is confirmed by the new data that revealed the presence of a unique bacterial load even of the placentar tissue. Gram-positive as well as Gram-negative intracellular bacteria were identified in the basal plate of the human placenta [56]. Moreover, due to metagenomic technology, it was shown that placental microbiome profiles are more related to the oral microbiome than other microbiomes in the human body, such as the gut, nares, skin and urogenital tract [57].
The feto-maternal unit is exposed to oral bacteria during bacteriemia episodes caused by daily oral activities (e.g., tooth brushing and flossing) and dental treatments (e.g., scaling and root planing). Katz et al. identified the presence of
The relationship between hypertensive disorders (including both pregnancy pre-existing hypertension and pregnancy-induced hypertension, also called preeclampsia) and periodontitis was mostly explained in relation to the systemic inflammatory response due to maternal infection. In severe cases of periodontitis, the inflammatory mediators (alarmins) and cytokines found in the gingival mucosa, including IL-1β, IL-6, TNF-α and PGE2, entered systemic circulation and affect the feto-placental unit and myometrium [53].
The adequate invasion of the extravillous trophoblast in the vascular layer of spiral uterine arteries will determine appropriate feto-maternal perfusion. In vitro models showed the local interaction between the placental tissue (human trophoblast cell lines) and periodontal pathogens, bacterial components, or inflammatory mediators. According to the data, the inflammatory milieu may suppress the media layer invasion process, leading to an important vascular remodeling. Eventually, that will trigger the development of pregnancy-induced hypertension or will aggravate the chronic vascular changes in pregnant women with preexisting hypertension. This will further cause placental insufficiency, the physiopathological final step to the development of fetal distress in utero [61].
Non-surgical treatment of periodontitis refers to subgingival instrumentation of periodontally affected teeth and addresses the polymicrobial aetiologic factor from the subgingival areas. Full-mouth subgingival instrumentation performed within 24 hours has been proposed to prevent the dissemination of bacteria from non-instrumented pockets to the previously treated areas [62]. It is also worth mentioning that in severe generalized periodontitis, due to the mobilization of a huge mass of bacteria from the periodontal pockets, the full-mouth instrumentation could trigger an acute systemic inflammatory response associated with transient endothelial dysfunction [63]. Delivering subgingival instrumentation conventionally in several short sessions could overcome the systemic response and the theoretical short-term risk of developing a vascular event [64].
Data from observational studies observed no effect or just a minimal elevated risk of “
However, nowadays conclusions on this topic sustain that no association between “
The perioperative bleeding risk depends on the extent and invasiveness of the periodontal therapeutic approach. A low bleeding risk has been mentioned for most periodontal interventions such as subgingival instrumentation, conventional surgeries (debridement flaps and regenerative or resective interventions), dental implants placement, or tooth extraction [8]. The bleeding associated with these interventions could be controlled through local haemostatic measures. On the other hand, a moderate bleeding risk is considered for autogenous bone augmentation procedures including block bone harvesting and sinus floor elevation or interventions associated with secondary intention healing such as free gingival graft placement [71, 72]. The frequencies for low and moderate bleeding associated with periodontal therapies have been reported to be less than 1% and between 2 and 5%, respectively [8].
Single antiplatelet therapy such as acetylsalicylic acid (aspirin), clopidogrel, ticlopidine or ticagrelor did not increased the frequency of bleeding events as compared with control patients [73, 74].
Dual antiplatelet therapy usually using the combination of aspirin and clopidogrel may induce a certain risk for post-operative bleeding, which may be managed with local haemostatic approaches [75, 76].
The discontinuation of single or dual antiplatelet therapy before any kind of periodontal approach including dental implant placement is not recommended by current evidence [8].
“Current American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, European Society of Cardiology, American College of Chest Physicians Evidence-Based Clinical Practice (AHA/ACC/SCAI/ACS/ADA/ESC/ACCP) guidelines on perioperative management of antithrombotic therapy do not suggest discontinuation of anti-platelet therapy for low bleeding risk procedures” [77, 78, 79].
No increased risk of bleeding has been associated with oral vitamin K antagonist-anticoagulant therapy (warfarine, cumarine) in patients receiving dental extraction, minor dental procedures or dental implant placement when compared to patients discontinuing anticoagulant therapy [80, 81]. However, in comparison with non-vitamin K patients, a higher post-operative bleeding risk in patients continuing vitamin K antagonist-anticoagulant therapy and suffering from minor or higher-risk dental procedures have been reported, although post-operative bleeding could be effectively controlled with local haemostatic agents [80, 82, 83].
As for novel/direct anticoagulants such as apixaban, rivaroxaban, betrixaban, edoxaban, and dabigatran, it seems that the interruption of these drugs is not necessary for most dental-periodontal therapies, due to a low incidence of bleeding events associated with these drugs and which can be successfully managed with local haemostatic measures [84, 85, 86]. As a positive advancement in the field, a neutralizing agent (idarucizumab) has been developed for dabigatran. However, a higher incidence of delayed bleeding (2 days and later) has been reported in patients not discontinuing novel/direct anticoagulants in comparison with healthy persons [87]. Although, it has been widely used in the past, especially in the era of anti-vitamin K anticoagulants, the low molecular weight heparins (LMWH) bridging strategy should be avoided in patients treated with novel oral anticoagulants (NOAC) as it increases the risk of bleeding, with no benefit on the risk of cardioembolic events. It is reserved for patients with mechanical valve prostheses at high thrombotic risk [88].
However, in CVD patients receiving complex antithrombotic medication a strict communication with cardiologist is mandatory.
Patients with medium or severe generalized periodontitis without known CVD should [8]:
be advised that periodontitis induces a higher risk of CVD and its acute events (myocardial infarction and stroke)
actively manage all their CV risk factors such as smoking, lack of exercise, excess weight and blood pressure, lipid, and glucose profile
receive intensive periodontal therapy and tailored oral hygiene education and regimen
receive a strict scheduled periodontal maintenance
be referred to the cardiologist for CVD screening if CVD risk factors are present.
Patients with periodontitis and CVD should:
be informed that they may be at higher risk for CVD complications
receive active periodontal treatment and tailored oral hygiene education and regimen
be included in periodontitis regular maintenance and secondary preventive regimes.
People with CVD should:
be referred by the cardiologist to the periodontist for a thorough full-mouth oral examination and screening
receive a tailored oral hygiene education and regimen
be placed on a preventive care regime if no periodontitis is diagnosed and monitored regularly (at least once a year) for changes in periodontal status
be managed as for point b) if periodontitis is diagnosed.
Subgingival instrumentation in periodontitis patients with CVD should be provided preferably in several 30- to 45-minute sessions to reduce the putative acute systemic inflammation.
In patients with CVD, surgical periodontal and implant therapy when indicated should be provided similarly as in patients without CVD.
In hypertensive patients, high blood pressure above 180/100 indicates to postpone periodontal surgical procedures until stabilization of blood pressure.
In patients with antiplatelet and anticoagulant therapy
The periodontist should not modify the patient’s antiplatelet and anticoagulant medication to perform periodontal and implant surgeries which are associated with a low to medium risk of bleeding.
A consultation with the cardiologist is advised when doubts are raised.
Local management of bleeding complications should be considered such as: oxidized cellulose, absorbable gelatine sponges, sutures, tranexamic acid mouthwashes, compressive gauze soaked in tranexamic acid.
It has been suggested to discontinue vitamin K antagonist-antithrombotic therapy if the Internationalized Normalized Ratio (INR) ≤ 4 for low or medium bleeding risk surgeries, but the decision should be considered in consensus with the cardiologist. For INR ≥ 3.5 the advice of the responsible specialist is mandatory [8, 89].
For non-vitamin K novel and direct anticoagulant (NOAC/DOAC) and when low bleeding risk periodontal approaches are scheduled, the anticoagulant therapy should not be discontinued [8, 71, 72]. Periodontal procedures should be undertaken within 18–24 hours after the last intake (depending on a renal function assessment for the medication in question) after which medication intake should be resumed after 6 hours following treatment.
In higher thrombotic and ischaemic risk patients (i.e., chronic atrial fibrillation or after an acute myocardial infarction or recent coronary stenting) receiving combined antiplatelet and anticoagulant therapies,
Patients under
Patients with a risk of endocarditis should be premedicated with antibiotics following current guidelines (such as the European or the American guidelines).
People with CVD who have extensive tooth loss should be encouraged to pursue dental rehabilitation to restore adequate mastication for proper nutrition.
Diet counseling including low salt consumption could be beneficial for the management of both periodontitis and hypertension.
CVD including hypertension could benefit from periodontitis primary and secondary prevention.
Cardiologists should know that periodontitis is a highly prevalent disease that has potentially negative influences on CVD development and complications as well as that efficient periodontal treatment may positively impact CV status.
For patients already diagnosed with periodontitis, the cardiologist must ensure that the disease has been effectively treated.
The cardiologist should assist the periodontist in the management of patients under antithrombotic therapy before the periodontal surgery, to avoid risks of bleeding or ischaemic events.
Patients with CVD should know that:
periodontitis is a chronic infectious disease having the potential to worsen their systemic condition
periodontitis is treatable in most cases but requires lifelong personal management and professional supervision
left untreated periodontitis leads to further bone destruction and finally to tooth loss
periodontitis is a “silent” disease so regular dental-periodontal check-ups are advised
periodontitis treatment has a positive impact on CVD and reduces the risk of CV events
an annual oral check-up is recommended even in the absence of periodontitis.
Periodontitis patients are important co-therapists and without their sustained daily involvement, periodontitis resolution is not possible.
Patients with CVD and periodontitis, like all the other individuals, must efficiently clean the teeth based on the dental practitioner/periodontist personalized advice. The following oral care recommendations should be practiced:
Tooth brushing twice a day with an electric or a manual toothbrush is recommended; however, electric toothbrushes seem to be more efficient than manual toothbrushes in a personalized local hygiene routine.
Cleaning the areas between teeth using auxiliary oral hygiene aids is mandatory since using only conventional toothbrushing is not sufficient for complete plaque removal. Interdental brushes, carefully calibrated to fit the size of the interdental spaces should be used. Dental floss is an interdental cleaning option that can be used whenever the gums fill in the interdental spaces.
Periodontitis has been considered a risk factor for CVD, although no causal relationship has been demonstrated to this point. Two potential biological mechanisms (periodontal bacteria and endotoxins systemic dissemination and release of inflammatory molecules from the affected periodontal sites into the blood stream) have been described to link periodontitis and atherosclerosis-induced CVD. Periodontitis may increase the risk for hypertension as well as for acute CV events—myocardial infarction and stroke. In pregnant women, periodontitis may trigger adverse pregnancy outcomes and may worsen the chronic vascular changes in relation with pre-existing hypertension, which carries high maternal and fetal health risks. Periodontal screening in specialized medical care settings should be a component of the management of CVD. Periodontologists, cardiologists, and patients should be informed on the potentially negative influences of periodontitis on CVD development and its complications as well as on the positive impact of periodontitis treatment on CV status. All adjustments in antithrombotic treatment in periodontitis-CVD patients must be discussed and agreed upon with the responsible cardiologist.
The authors declare no conflict of interest.
We would like to thank Mr. Josip Knapic for his understanding and support.
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On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. 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He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}},{id:"338856",title:"Mrs.",name:"Nur Alvira",middleName:null,surname:"Pascawati",slug:"nur-alvira-pascawati",fullName:"Nur Alvira Pascawati",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universitas Respati Yogyakarta",country:{name:"Indonesia"}}},{id:"441116",title:"Dr.",name:"Jovanka M.",middleName:null,surname:"Voyich",slug:"jovanka-m.-voyich",fullName:"Jovanka M. Voyich",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Montana State University",country:{name:"United States of America"}}},{id:"330412",title:"Dr.",name:"Muhammad",middleName:null,surname:"Farhab",slug:"muhammad-farhab",fullName:"Muhammad Farhab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"349495",title:"Dr.",name:"Muhammad",middleName:null,surname:"Ijaz",slug:"muhammad-ijaz",fullName:"Muhammad Ijaz",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Veterinary and Animal Sciences",country:{name:"Pakistan"}}}]}},subseries:{item:{id:"12",type:"subseries",title:"Human Physiology",keywords:"Anatomy, Cells, Organs, Systems, Homeostasis, Functions",scope:"Human physiology is the scientific exploration of the various functions (physical, biochemical, and mechanical properties) of humans, their organs, and their constituent cells. The endocrine and nervous systems play important roles in maintaining homeostasis in the human body. Integration, which is the biological basis of physiology, is achieved through communication between the many overlapping functions of the human body's systems, which takes place through electrical and chemical means. Much of the basis of our knowledge of human physiology has been provided by animal experiments. Because of the close relationship between structure and function, studies in human physiology and anatomy seek to understand the mechanisms that help the human body function. The series on human physiology deals with the various mechanisms of interaction between the various organs, nerves, and cells in the human body.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/12.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11408,editor:{id:"195829",title:"Prof.",name:"Kunihiro",middleName:null,surname:"Sakuma",slug:"kunihiro-sakuma",fullName:"Kunihiro Sakuma",profilePictureURL:"https://mts.intechopen.com/storage/users/195829/images/system/195829.jpg",biography:"Professor Kunihiro Sakuma, Ph.D., currently works in the Institute for Liberal Arts at the Tokyo Institute of Technology. He is a physiologist working in the field of skeletal muscle. He was awarded his sports science diploma in 1995 by the University of Tsukuba and began his scientific work at the Department of Physiology, Aichi Human Service Center, focusing on the molecular mechanism of congenital muscular dystrophy and normal muscle regeneration. His interest later turned to the molecular mechanism and attenuating strategy of sarcopenia (age-related muscle atrophy). His opinion is to attenuate sarcopenia by improving autophagic defects using nutrient- and pharmaceutical-based treatments.",institutionString:null,institution:{name:"Tokyo Institute of Technology",institutionURL:null,country:{name:"Japan"}}},editorTwo:{id:"331519",title:"Dr.",name:"Kotomi",middleName:null,surname:"Sakai",slug:"kotomi-sakai",fullName:"Kotomi Sakai",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000031QtFXQA0/Profile_Picture_1637053227318",biography:"Senior researcher Kotomi Sakai, Ph.D., MPH, works at the Research Organization of Science and Technology in Ritsumeikan University. She is a researcher in the geriatric rehabilitation and public health field. She received Ph.D. from Nihon University and MPH from St.Luke’s International University. 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