New classification combining covert and overt HE.
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\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:"4503",leadTitle:null,fullTitle:"Selected Topics in Applications of Quantum Mechanics",title:"Selected Topics in Applications of Quantum Mechanics",subtitle:null,reviewType:"peer-reviewed",abstract:"This book has two sections. 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He received his BSc from the Ferdowsi University of Mashad, MSc from the Tehran University and PhD from the Indian Institute of Technology Bombay-Mumbai India in experimental nuclear physics. He occupied the faculty member position in August 1991 and continued his duties as a professor in the Department of Nuclear Physics, Faculty of Basic Sciences - University of Mazandaran, Iran since. He has published more than 100 papers in ISI journals, mostly in Physical Review C, European physical journal A, International journal of modern physics A, Journal of physics G. 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Peanut (
Their bloom grow on the ground, then is fertilized and dried, the stalk extends longitudinally and this ovary is forced underground. The pod holding those seed matures underneath the surface. On maturity, inner lining of the pod darkens, and the seed coat changes from white to reddish‐brown. The entire plant, including most of the roots, is removed from the soil during harvesting [3].
As aflatoxin‐producing
Poor agricultural practice and post‐harvest treatments of peanuts can lead to an infection by mould fungus
The contamination of food and feed materials with aflatoxins, which have toxic, carcinogenic and mutagenic activity, causes important health problems and economic losses [7]. Among these, aflatoxin B1 (AFB1) is the most naturally occurring compound of toxigenic isolates of
Toxigenic fungi and aflatoxin contamination in peanuts start at farm level, and contamination occurs in both pre‐ and post‐harvest periods. Lavkor et al. [9] reported that the levels of aflatoxins detected in 74.5% raw peanut samples were in the range of 0.3–1333.42 μg/kg [9]. Williams [10] referred to a study close by African markets indicating that more than 40% of the commodities found there exceed reasonable aflatoxin levels and expected more than 4.5 billion individuals in developing nations are at danger because of uncontrolled or ineffectively control input of aflatoxins [10].
It is recognised that high aflatoxin levels in the circulation system discourage the safe framework, accordingly encouraging tumour and HIV and hindering the development of kids. A cross‐sectional review led in Ghana and referred by Williams et al. [11] demonstrates that invulnerable frameworks of as of late HIV‐contaminated individuals are fundamentally adjusted if they have above‐middle levels of regular exposures to aflatoxins [11]. Alluding to another study, Dr. Williams notes, “Individuals with a high aflatoxin biomarker status in the Gambia and Ghana will probably have dynamic jungle fever”. In 2014, the Global Forum for Innovations in Agriculture (GFIA) assembled an abnormal state meeting in Abu Dhabi, UAE, on reforming worldwide agribusiness through developments. Straight to the point Rijsberman, the CEO of the CGIAR Consortium, in his report in view of a Benin study about on the post‐weaning introduction to aflatoxin, presumes that aflatoxins have debilitated development in kids and are costing African agriculturists over $450 million USD every year in lost exports [12]. As indicated by Oladale [13], research has shown that aflatoxins can lead to cause infertility, premature births, and postponement of egg production in birds and sudden calamity in egg generation effectively in ovulation birds. Furthermore, loss of flavour, skin staining and even yellowish colouring on skin can be observed in fish [13]. Kooprasertying et al. [14] found that roasted and ground peanuts and raw samples were contaminated with AFs at 100% and 80%, respectively. They determined the high amounts of AFs in peanuts as 362 ng g−1, which means the highest concentration of AFS in peanuts (68. 22 ng g−1). It has been reported and emphasised by researcher that the average intake of AFs was 0.49, 0.40 and 2.13 ng/kg bw/day for raw, roasted and ground peanuts, correspondingly. In addition, the potential risk for cancer was estimated at 0.01–0.12 cancer/year/100,000 persons. According to the results of the research, the researchers suggest that the current situation of aflatoxins contamination in peanuts and peanut products (especially in ground peanuts) has an adverse effect on the health of the Thai population [14].
In order to eliminate aflatoxins from contaminated peanut materials, numerous physical, chemical and biological methods have been developed. In addition, there are some genetic studies for developing peanut cultivars resistant to a broad spectrum of pathogens that pose a recurring threat to peanut health as well [15]. The work to be done in this context should be considered to have a minimum effect on the nutritional value and chemical composition of the nuts. It is known that peanut contents are very valuable and include 7% water, 25.8 g protein, 16.1 g carbs, 4.7 g sugar, 8.5 g fibre and 49.2 g fat (saturate: 6.28 g; monosaturated: 24.43 g; polysaturated:15.56 g, Omega‐3:0 g; Omega 6:15.56 g; trans fat) [16].
An expanding amount of logical research has been given to adapt more about aflatoxin development issues and conceivable arrangements, including utilising hereditarily changed or hybridised seeds detailed for mold resistance or through utilisation of items, for example, AflaSafe, now utilised in Africa. AflaSafe’s “biological approach” utilises a firmly related, non‐aflatoxin‐delivering mold to out‐compete the aflatoxin‐creating molds. In mild atmospheres, aflatoxin issues have been controlled largely with ventilation amid cooler evenings and through lower winter temperatures [17].
During the past decade, there has been increasing interest in the hypothesis that, the absorption of aflatoxin in consumed food is may be inhibited in the gastrointestinal tract. In recent years, some biological control strategies have been used to reduce aflatoxin contamination in various food materials. Aflatoxins contamination may occur in the field before harvest, during harvesting or during storage and processing; thus, methods for the prevention of aflatoxin contamination can conveniently be divided into pre‐harvest, harvest and drying of unshelled peanuts, shelling post‐harvest storage strategies. In addition, because of the high occurrence of aflatoxins in crops worldwide, fast and cost‐effective analytical methods are required for the identification of contaminated agricultural commodities before they are processed into final products. In addition, there have been several reports on AFB1 outbreaks, especially in many undeveloped countries. Therefore due to its potential threat in every step of the food production, analytical methods have been developed for the determination of AFB1 in various matrices including liquid chromatography (LC), thin‐layer chromatography, TLC), high‐performance liquid chromatography (HPLC) immunoaffinity chromatography (IAC), enzyme‐linked immunosorbent assay (ELISA), electrochemical immunosensor, etc. [18].
The risk of such contamination can be greatly increased because of the poor traditional practices. However, certain treatments have been found to reduce aflatoxin formation in peanuts, and the complete elimination of aflatoxin is not realistically achievable [19].
In the 1980s, numerous scientists had endeavoured to discover peanut cultivars resistant to
It is outstanding that peanuts can develop in various soil sorts such as light sandy soil and heavier soils. Light sandy soil benefits for the quick multiplication of
Soil preparation is necessary for planting peanut in order to reduce the incidence of aflatoxin contamination. Several chemical control agents have been reported to inhibit aflatoxigenic mold growth and subsequent aflatoxin biosynthesis. Although some studies suggested that pesticides and fungicides might be useful in controlling mycotoxin production under field conditions, other results have found that pesticides were ineffective in controlling mycotoxin production by
Soil is a repository of fluctuated microorganisms including organisms, and peanuts are in direct contact with soil populaces of aflatoxigenic growths [34]. Regular fungal contaminants of peanuts involve
Taylor et al. [40] detailed that aflatoxin defilement occurred in most developing zones; however, the most incidence of aflatoxin was in the hotter, more humid developing locales and took after the same geological example.
Sanders et al. [45] documented that aflatoxin contamination is not generally straightforwardly associated with the rate of attack by
Inappropriate agricultural pursuits, such as crop revolution, culturing, planting date, fertilisation and irrigation, can likewise expand the occurrence of
In non‐inoculated, non‐insecticide‐sprayed territories, thick populace of plants or condensed fertilisation seem to affect the frequency of contamination by aflatoxin [53]. Insects may assume a vital part in the aflatoxin contamination of yields since almost all aflatoxins were found in regions harmed by insects. The insect harms peanut tissue, in this manner making section entrances for the fungus, and after that prompts to the high aflatoxin formation in peanuts [28, 53]. The research of Var and Uçkun [54] showed that the peanuts in the healthy shell have been preserved very well [54]. Numerous authors reported that a few insecticides and fungicides can repress aflatoxigenic fungi development and consequent aflatoxin biosynthesis in field [55, 56]. Bowen and Mack [57] utilised the insecticide to treat peanuts during development and decreased the levels of
Phytoalexins are described as antimicrobial substances combined by plants that collect quickly at territories of pathogen infection. In spite of the fact that the substance nature of the phytoalexins was not determined, it was demonstrated that peanuts created phytoalexins when tested by a few types of fungi, including
Generally, kernel moisture contents of 10% or higher post‐harvest peanuts are prone to generate aflatoxins. Timely drying and keeping at safe moisture level can effectively control aflatoxin contamination of peanuts after harvest [26]. Diener and Davis [61] found that aflatoxin generation can be blocked by quickly drying to or beneath an aw of 0.83 for post‐harvest peanuts. Before‐storage separating to remove contaminated peanuts is the best approach to decrease aflatoxin generation [62, 63]. To keep an expansion in aflatoxin occurring during capacity and transportation, it is essential to control the dampness content, the temperature in the environment and the hygienic conditions [64]. Unsuitable kernel dampness during storage can continue from leaky roofs, reduction because of inappropriate ventilation in the warehouse, high‐dampness outside material related with put away peanuts and high‐dampness peanuts at first going into storage [65]. Thus, the storage and transportation conditions are the most vital reasons controlling aflatoxin defilement of peanuts.
During harvesting, mechanical damage to peanuts must be avoided because it enhances susceptibility to contamination. Moreover, only mature peanuts should be harvested since fungal infection is more likely to occur in shrivelled and cracked kernels [66].
Recently, biosensors based on the use of monoclonal or polyclonal antibodies have seen great development in the field of small molecules analytical determination and specifically in the mycotoxins analyses [67]. Early and reliable precise methods protect health and life by preventing the entry of toxins into food chain. For this reason, it is necessary to transport these fast technologies to commercial products from the research stage using appropriate subsidies [68]. On the other hand, new unthermal preservation methods (Ozone, UV‐C, ultrasound and manosound) are used for reducing aflatoxin content on some food and commodities. In addition, some studies try to show that these unthermal preservation methods could be used with hyperspectral imaging methods. Hyperspectral imaging methods could show us about the product or crop composition and distribution of food components [69]. In their research, Kandpal et al. [70] used hyperspectral imaging method for the detection of aflatoxin contamination on corn kernels. They have been reported that corn specimens were inoculated with four different concentrations (10, 100, 500 and 1000 mg/kg) with aflatoxin B1 (AFB1), and control specimens surface was sterilised with a PBs. Both contaminated and control specimens were scanned with an SWIR hyperspectral for the spectral range from 1100 to 1700 nm. The PLS‐DA model has been created to arrange control and contaminated kernels and was discovered that most elevated general arrangement exactness yielded of the created model was 96.9% [70]. In their study, Jiang et al. [71] focused to identify the moldy peanuts using near‐infrared (NIR) hyperspectral images, and NIR hyperspectral images were obtained at the wavelength ranging from 970 to 2570 nm. In order to select sensitive bands, principle component analysis (PCA) in the spectral dimension was used as well as the spectral vector was employed to identify the moldy information [71]. In another work, utilising a FRET‐based method, Sabet et al. [72] have developed a nanobiosensor for detection of AFB1 in agricultural foods. Aptamer‐conjugated quantum dots (QDs) are adsorbed to Au nanoparticles (AuNPs) due to interaction of aptamers with AuNPs leading to quenching effect on QDs fluorescence. Upon the addition of AFB1, the specific aptamers are attracted to AFB1, getting distance from AuNPs which result in fluorescence recovery. Under optimised conditions, the detection limit of proposed nanobiosensor was 3.4 nM with linear range of 10–400 nM. Selectivity test demonstrates that the nanobiosensor could be a promising tool for specific evaluation of food stuff. This method was successfully applied for the analysis of AFB1 in rice and peanut samples [72].
Traditional methods that require intense labour force are currently being used to separate aflatoxinous products. Workers are trying to determine whether there are aflatoxins in the products that pass through the tapes by standing on the UV lamp stands set up in a dark room for 8–12 h a day. Güzel et al. [73] stated that this manual separation technique reduces working efficiency and negatively affects the health of workers exposed to long periods of light. In addition, due to the distraction created by fatigue, the diseased products that need to be separated can escape attention. Therefore, the researchers had developed a UV light‐based separator that does not escape toxic products, more rapid sorting and less use of human power. Güzel et al. [73] have believed that many negative conditions will come to an end with their machine.
The drying stage is all important to reduce attack and damage fungi. Lavkor and Bicici [74] reported that peanut kernels aflatoxin analysis was performed at four distinct periods: harvest, post‐harvest, drying and pre‐storage, and analysis results showed that aflatoxin contamination was not found on 96 samples sundried on drying sheet at experimental area in 2010 and 2011. According to Cole et al., it seems that post‐harvest screening is a chance to decrease or eliminate aflatoxin at defiled seed. Probably, there are generally few, but highly contaminated seeds dispersed in the peanut lots when aflatoxin contamination occurred [65]. Practical methods include manual sorting, seed size and density separation, or electronic colour sorting. Electronic colour sorting has proven to be the most effective aflatoxin management strategy available in the processing phase [75]. Guchi [75] reported that electronic colour sorting is another means that can be used. For example, peanut that has been colonised by aflatoxin‐producing fungi is often discoloured. Microwave heating shows great potential for the destruction of aflatoxin in contaminated peanut. Aflatoxin B1 is sensitive to UV radiation and absorbs UV light at 222, 265 and 362 nm with the maximum absorption occurring at 362 nm. One strategy to reduce the entry of aflatoxin into the peanut chain is the use of chemical treatments such as acetosyringone, syringaldehyde and sinapinic acid and ammonia applications during post‐harvest to reduce both fungal growth and toxin production [76]. Ozone due to its safety, environment‐friendly, low cost and high efficiency in decomposing aflatoxin B1 has been widely studied and used in the food industry [1]. Proctor et al. [77] achieved the highest level of degradation for aflatoxin B1 (77±2%) after ozonation of peanut kernels for 10 min at 75°C [77]. In their study, Chen et al. [78] focused on the optimization of aflatoxin reduction by ozone during air drying of peanuts. They have observed that 5% moisture in peanut provided sensitivity of aflatoxins to ozone and reacted with 6.0 mg/l of ozone at the room temperature for 30 min simply degraded. They also found that the diminution of the total aflatoxins and aflatoxin B1 (AFB1) was 65.8% and 65.9%, respectively. In this research, they also examined the quality of peanut samples, and it has been observed that no significant differences (
In another study, Luo et al. [79] examined the ozone treatment effect in reducing aflatoxin B1 in corn with different moisture content. In this study, the toxicity of the degradation products (DPs) of the ozone‐treated aflatoxin B1 contaminated corn was also evaluated using the human hepatocellular carcinoma cell line (HepG2) as model cells. It was observed that the degradation rate of aflatoxin B1 in corn increases with ozone concentration and treatment time. It was also observed that aflatoxin B1 contaminated corn with 13.47% moisture content was easier to be degraded by ozone than with 20.37% moisture content. In this study, when the safety of ozone used on aflatoxin B1 contaminated corn was evaluated, the results showed that aflatoxin B1 contaminated corn had high cell toxicity while the toxicity of ozone‐treated aflatoxin B1 contaminated corn had no significant difference with that of the aflatoxin B1 free culture solution. The researchers suggested that ozonation can quickly and effectively degrade aflatoxin B1 in corn and diminish aflatoxin B1 contaminated corn’s toxicity, and therefore, ozonation is expected to be an effective, fast and safe method for aflatoxin B1 degradation in aflatoxin B1 contaminated corn [79].
Diao et al.’s [1] study aimed to verify the ozonolysis efficiency of AFB1 and to evaluate the oral safety of ACPs treated by ozone through a short‐term subchronic toxicity study with Wistar rats. As a result of the study, they found that 89.40% of aflatoxin B1 (AFB1) in peanuts was decomposed by ozone with a concentration of 50 mg/L and flow rate of 5 L/min for 60 h. In their subchronic toxicity experiment, they declined that all rats did not have unusual changes in behaviour, and no signs of intoxication were observed except for several dead rats due to inappropriate gavage or anaesthesia. The researchers suggested that the deleterious effects of AFB1 could be highly reduced by ozone, and ozone itself did not show any toxic effects on animals in this processing [1].
Mechanical harm to food stuff during shell extraction makes them much more susceptible to attack by moulds such as
As evidenced by the storage structures, traditional crop storage is not yet improved. The storage conditions should be cool and dry, should be defended from insects, rodents and birds; should be easy to clean and should be waterproof and protected from flooding. These conditions are indispensable for modern or traditional storage. These suggestions are so important to prevent
Globally, there have been increasing incidences relating to foodborne diseases including aflatoxins in both developed and developing countries. Because of the lack of proper hygiene practices and personal sanitation are not applied for food products, significant public health crisis can result from aflatoxins contamination. Studies conducted in these areas indicate that due to the low consciousness and knowledge of food handlers and workers in these subjects, aflatoxin contamination is seen in food and especially in groundnut products. According to some researchers, raising the level of public knowledge by arranging awareness campaigns can diminish the risk of aflatoxin contamination. The important factors to ensure that food handlers are proficient and knowledgeable on the principles of food safety and personal sanitation are advised trainings, food safety education and the developments of food safety certifications [85]. Therefore, Azaman et al. [85] planned a study that was to identify the differences in terms of knowledge, attitude and practices (KAP) of aflatoxins contamination among stakeholders of peanut‐based products and to determine factors that mostly influence stakeholders’ hygienic practices in peanut‐based products. As a result of the study, they strongly emphasised the need for continuous hygiene improvement and training programmes by the stakeholders of peanut‐based products. In addition, they stated that relevant strategies such as promotion and motivational models on health education and food safety campaigns would increase awareness and knowledge on food contaminants [85].
It is known that despite all these there remains aflatoxin contamination in the products. Therefore, in order to minimise aflatoxin exposure among consumers, it is essential to prevent highly contaminated kernels from re‐entering food chains, and decontamination of such kernels should complement some sorting practices. Schwartzbord and Brown [86], in their study, focussed on to explore a process to transform oil from contaminated peanuts into a safe edible product. Schwartzbord and Brown [86], in their study, focussed on to explore a process to transform oil from contaminated peanuts into a safe edible product. As a result of the study, the researchers found that in extracted oil included aflatoxin concentration was approximately 10% of that of unextracted oil, which means it had a concentration that was only 5% of the original contaminated peanuts.
Therefore, they displayed that without pre‐filtration aflatoxin concentration in the final product was 99.5% less than that found in the original peanuts [86].
Extrusion cooking is an important process widely applied in the food industry. The extrusion of AFT in cereals had been studied by different research groups. In one research, ıt was investigated the extrusion of AFT contaminated corn grits at 105°C and found that the levels of AFT were reduced by 50%–80% after processing in the extruded corn grits [87]. In their study, Azaman et al. [85] explored the feasibility of degrading aflatoxin B1 (AFB1) in contaminated peanut meal by extrusion cooking. In this study, the effects of barrel temperature, material moisture content, feed rate, and screw speed as well as their interactions on the reduction rate of AFB1 in peanuts meal were evaluated by response surface methodology (RSM) to optimise the extrusion conditions [85]. Zheng et al. [87] emphasised that the study indicated that extrusion cooking was an effective way to remove total AFB1 from contaminated peanut meal. Moreover, the researchers stated that extrusion cooking can be used to treat other cereals. Although extrusion cooking has wide application prospects in food processing industry, but the researchers advised that it is required to perform further research to determine whether certain toxic products are generated during the decomposition of AFB1 [87].
Because of the high occurrence of aflatoxins in crops worldwide, fast and cost‐effective analytical methods are required for the identification of contaminated agricultural commodities before they are processed into final products. So far, many aflatoxin detection technologies have been developed for the determination of AFB1 in various matrices including liquid chromatography (LC), thin‐layer chromatography (TLC), high‐performance liquid chromatography (HPLC) immunoaffinity chromatography (IAC), enzyme‐linked immunosorbent assay (ELISA) and electrochemical immunosensor, LC‐MS/MS, Fluorescence polarisation immunoassay, capillary electrophoresis, near infrared spectroscopy, hyperspectral imaging electronic nose [88]. Actually, there are some advantages and disadvantages of these aflatoxin detection technologies, and these are still discussed.
Thiel et al. [89], in their study, had described the application of a technique for the determination of aflatoxins by reverse phase HPLC and fluorescence detection incorporating post‐column derivatisation with iodine. They stated that the procedure proved to be extremely sensitive and reproducible [89]. Researchers suggested new tools for screening aflatoxins in food. For this purpose, one is for aflatoxin B1 and the other for total aflatoxin, they developed two prototypes to be used in the ELISA method. For this reason, they highlighted that seven monoclonal antibodies were produced that were with matchless high sensitivity and at the same time good cross‐reactivity properties [90]. However due to limitations associated with these methods, including extensive sample preparation, expensive procedure and unavailability for onsite screening, increasing demand has been emerged especially in developing countries for more simple and cost‐effective methods [72]. Utilising a FRET‐based method, it has developed a nanobiosensor for detection of AFB1 in agricultural foods. According to Sabet et al. [72] Aptamer‐conjugated Quantum dots (QDs) are adsorbed to Au nanoparticles (AuNPs) due to the interaction of aptamers with AuNPs leading to quenching effect on QDs fluorescence. Upon the addition of AFB1, the specific aptamers are attracted to AFB1, obtaining distance from AuNPs, which result in fluorescence recovery [72]. Semiconductor quantum dots (QDs), as a new type of fluorescent probes, have unique optical characteristics such as photostability and high quantum yield originated from “quantum size” effect and have been proven to be of many uses in biosensing application. In their research, Sabet et al. found that selectivity test demonstrates that the nanobiosensor could be a promising tool for specific evaluation of food stuff. Moreover, they stated that this method was successfully applied for the analysis of AFB1 in rice and peanut samples. In recent years, with the rapid development of nanostructured materials and nanotechnology in the fields of biotechnology and contaminant detection, magnetic nanoparticles (MNPs) have been receiving considerable attention. In their research, Sun et al. [91] used artificial antigen‐modified MNPs employed as immune sensing probes, and antibody functionalised UCNPs were used as signal probes. Besides in this study, the antibodies‐functionalised UCNPs were linked to the surface of the MNPs by antibody‐antigen affinity [91]. According to Sun and co‐workers, rare earth‐doped upconversion nanoparticles were used successfully to assemble for sensing Aflatoxins B1 in actual food samples (peanut oil) [91]. Ezekiel et al. [92] described a reliable and simple analytical method for the determination of aflatoxins (AFB1, AFB2, AFG1 and AFG2) in cereals, peanuts, vegetable oils and fermented foods such as beer, soybean sauce and soybean paste based on immunoaffinity column (IAC) cleanup coupled with direct competitive enzymelinked immunosorbent assay (dcELISA) detection and confirmed by ultra‐high performance liquid chromatography tandem mass spectrometry (UHPLC‐MS/MS) in their research. As a conclusion, they suggested this assay could be used as an effective analytical method for the determination of aflatoxins in complex grain foods [92].
As we can see above, there are various methods aimed at minimising the aflatoxins in foods, but there still exists Aflatoxin problem in food. Since it is difficult to achieve zero tolerance with AF contamination in commodities, AFs should be minimised in foods as much as possible to prevent the risk of cancer and the other health problems. Thus, legal tolerance limits based on scientific evidence obtained from risk assessment in different countries have been set for AFB1 and total aflatoxin (AF) in foods and feeds. The limits vary between 4 and 20 parts per billion (ppb) through different countries [93]. The Codex Alimentarius Commission (CAC) has adopted the maximum permissible limits for AFs in unprocessed peanuts and tree nuts, which is 15 ppb as well as10 ppb in ready‐to‐eat tree nuts. However, European Union (EU) has adopted the level of 4ppb, which is the strictest limit in the world for AFs [93].
In a study, 60 peanut samples were analysed for aflatoxin B1 using thin layer chromatography. The Democratic Republic of Congo is among African countries listed with high prevalence of liver cancer. As a result, Kamika and Takoy showed that aflatoxin B1 levels increased from the dry season to the rainy season with values ranging from 1.5 to 390 and 12 to 937, respectively. They reported that 70% of the peanut samples from both seasons exceeded the maximum limit of 5 mg/kg prescribed by the World Health Organization (WHO). Therefore, they emphasised continuous research on aflatoxin B1 should be sought after [94]. In a study in Zambia, another African country, it showed that the high level of AFs in raw peanuts from both open markets and supermarkets samples are a health hazard for the population of the Lusaka region in Zambia. Therefore, the researchers stated that intervention tactics is urgently required to decrease the levels of AF contamination in peanuts [93].
In another Asian country, in Punjab major city of Pakistan, the focused on the assessment of the frequency of aflatoxin contamination in peanut and peanut products (peanut butter, roasted peanut, peanut bran and groundnut nimko) on the market. The researchers reported that the survey is of high importance to create the awareness among consumers, policy makers and law enforcement agencies to establish permissible limits for these toxins. As a result of their study, they told that the level of Aflatoxins in peanut and peanut products is high and poses a significant threat for the health of people [95].
One of the studies about aflatoxins in peanuts comes from Nigeria, which was planned to show the presence of aflatoxigenic
As seen before, most studies have showed us that aflatoxin contamination of peanuts can occur in the field (pre‐harvest) when severe late‐season drought stress occurs and poor agricultural practice and during storage (post‐harvest) when improper conditions of moisture and temperature exist. Moreover, several techniques for aflatoxin controls have been proposed in the scientific literature, but just some are currently used by the peanut producers. So, aflatoxin control strategies are necessary to prevent health risks and economic losses for result from aflatoxin contamination. Besides, the studies and regulations related to Aflatoxins especially in peanuts and the other foods should be improved and carry on.
Hepatic encephalopathy (HE) is a serious clinical problem of portal hypertension and cirrhosis that is characterized by neurologic and neuropsychiatric abnormalities. It is manifested by personality changes, cognitive dysfunction, and altered level of consciousness [1, 2]. Based on the severity, HE is classified into two groups: overt HE (OHE) presents episodically or continuously with obvious and clinically detectable symptoms; in contrast, covert HE (CHE) combines the two lowest grades of HE (minimal HE (MHE) and HE grade 1) [3]. Therefore, under the new classification (Table 1), OHE starts with grade 2 or with evidence of asterixis and disorientation. MHE is characterized by subtle cognitive and psychomotor deficits in the absence of recognizable clinical symptoms and signs of HE and is documented by neuropsychometric (NP) tests and neurophysiological tests, but HE grade 1 is defined by the presence of mild clinical alterations like euphoria, anxiety, or a shortened attention span. Although the consequences are serious, mostly CHE is often unnoticed or even neglected in routine clinical practice due to only very mild symptoms associated with grade 1, or no diagnostics in case of MHE [4, 5].
\nClassification | \nCovert HE | \nOvert HE | \n|||
---|---|---|---|---|---|
MHE | \nGrade I | \nGrade II | \nGrade III | \nGrade IV | \n|
Description | \n* Absence of recognizable clinical symptoms and signs * Impairments only measurable with psychometric tests (psychomotor speed/executive functions or neurophysiological alterations) | \n* Minor lack of awareness * Euphoria or anxiety * Shortened attention span * Altered sleep rhythm | \n* Fatigue, apathy, or lethargy * Slight disorientation for time and place * Obvious personality change * Inappropriate behavior * Asterixis | \n* Somnolence to semi-stupor * Confused * Marked disorientation to time and place *Aggression | \n* Coma * Signs of increased intracranial pressure | \n
New classification combining covert and overt HE.
Minimal hepatic encephalopathy may have a bad impact on quality of life, risk of road traffic accidents, and can progress to overt HE [6, 7]. Still, there are no current guidelines for the ascertained diagnosis of MHE. The Working Group on HE endorsed that, at least two of the following neuropsychologic tests should be used for diagnosing MHE: number connection test-A (NCT-A), NCT-B, block-design test (BDT), and the digit-symbol test (DST) [4]. The existing definition of MHE is built on psychometric test results that are two SDs more than normal on at least two psychometric tests [8]. Therapy for MHE is targeted toward the gut, due to the ammoniagenic role of the gut contents, which have been hypothesized to play a part in MHE pathogenesis. Guidelines for HE in chronic liver disease do not recommend routine treatment of MHE. However, they state that when a patient has clear cognitive impairment, or deterioration of quality of life (QoL), skills for driving, or ability to perform jobs that require manual labor or have high public risk, the patient should be treated [3, 9].
\nMHE is considered as a part of wide spectrum of typical neurocognitive alterations in liver cirrhosis, mostly involving the areas of attention, alertness, response inhibition, and executive functions [10, 11]. Depending on the population studied, patient level of education, age of the patients, and the diagnostic tool used, MHE incidence varies from 20 to 80% of cirrhotic patients [12, 13, 14, 15].
\nThe pathogenesis of MHE is nearly similar to that of OHE [16]. The ammonia toxicity remains the key factor, but recently there is increased evidence that, hyperammonemia acts synergistically with systemic inflammation, oxidative stress, and gut microbiota [17, 18]. Numerous investigators suggested that, hepatic encephalopathy is a disorder of astrocyte function that plays a role in the detoxification of ammonia [19].
\nAmmonia is a key intermediate product in the metabolism of proteins. It is manufactured by the bacterial metabolism of amino acids and purines that are consumed in the human diet [20]. Under physiological environment, about 90% of the ammonium is primarily cleared by the synthesis of urea in the liver (by the Krebs cycle) and subsequently cleared by the kidneys and to a lesser extent by the muscles (Figure 1). Ammonia is also consumed in the conversion of glutamate to glutamine, a reaction that depends upon the activity of glutamine synthetase [21]. In liver cirrhosis, there are two factors that contribute to hyperammonemia: the first is a decrease in the healthy hepatocytes, resulting in deficiency of NH3 detoxification; the second is the existence of porto-systemic shunting that results in shifting of NH3-rich portal blood to the systemic circulation without hepatic detoxification—subsequently, the extrahepatic metabolization of ammonia by the brain and skeletal muscle cells becomes more important [17, 22, 23]. The skeletal muscle plays a significant role in ammonia metabolism as it contains glutamine synthetase. However, the muscle wasting that is clear in advanced cirrhosis may increase hyperammonemia. The kidneys express glutaminase and, somewhat, play a role in ammonia production. Similarly, the kidneys express glutamine synthetase and play a key role in ammonia metabolism and excretion [20]. Ammonia crosses the blood-brain barrier and is metabolized in the astrocytes by glutamine synthetase, which converts NH3 and glutamate to glutamine [17]. Increasing glutamine in astrocytes produces an osmotic gradient (Figure 2), promotes water shift into astrocyte producing edema [23], and generation of reactive oxygen species, thereby contributing to the cerebral dysfunction seen in HE [17]. The high-energy consumption by this process leads to oxidative stress which is accompanied by cellular dysfunction and disruption of neurotransmission predominantly of glutamate and γ-aminobutyric acid [24]. In the brain, NH3 produces inactivation of neuronal chloride extrusion pumps; these processes result in inhibition of both axonal conduction and excitatory postsynaptic potentials, subsequently suppressing inhibitory postsynaptic potential formation and depolarizing neurons [25, 26].
\nAmmonia is produced primarily in colon from breakdown of amino acids and urea by bacteria. The ammonia is taken up by hepatocytes and converted, in the urea cycle, to urea, which is passed into blood. Urea is primarily excreted in the kidneys (75%) and the intestine (around 25%).
Pathogenesis of hepatic encephalopathy. In normal conditions, gut release of ammonia results in high portal vein ammonia levels. Microbiota is also responsible for the formation of ammonia, endotoxins. In liver cirrhosis, the liver extracts portal venous ammonia poorly. The subsequent increase of arterial ammonia levels leads to increased disposition of ammonia in other tissues. Both the brain and muscle lack a complete urea cycle and rely on the formation of glutamine. Thus, the brain and muscle become ammonia-uptake and glutamine-releasing organs. In the brain, astrocytes metabolize ammonia through glutamine synthetase, converting glutamate and ammonia to glutamine which is osmotically active and promotes water shift into the astrocyte, thus producing intracellular swelling and edema.
Studies demonstrated that, severity of MHE might not correlate with severity of liver disease or the level of ammonia, proposing the existence of other pathogenic stimuli. Inflammation is one such stimulus that may add to the advancement of MHE and its progression to overt HE [27]. The studies suggested that, inflammation plays a synergistic role with ammonia in producing and modulating MHE [27, 28, 29]. Studies in patients with cirrhosis have documented higher levels of proinflammatory cytokines like tumor necrosis factor (TNF)-α, interleukin (IL)-1β and IL-6. This reflects the possibility of developing a systemic inflammatory response that alters the blood-brain barrier (BBB) permeability and allows diffusion of ammonia moreover [30, 31].
\nStudies suggested that, many interactions with gut microbiota can play an active role in MHE (Figure 2). Microbiota changes have been linked with impaired cognition, endotoxemia, and inflammation. With the progression of cirrhosis, there is dysbiosis (unfavorable change in the composition of the microbiome) with decreased levels of autochthonous taxa (native Firmicutes) bacteria and increased levels of other taxa (Bacteroidetes, Actinobacteria). The native bacteria are important for the harmony of the gastrointestinal flora and for the well-being of the entire body. The autochthonous bacteria produce short-chain fatty acids that feed the colonic mucosal cells and reduce local colonic inflammation, and produce anti-bacterial peptides [32]. In patients with minimal HE, stool microbiota studies demonstrated an increase in
The incidence of MHE increases with progression of liver disease. With time, MHE may improve or progress to OHE [36, 37]. The rate of progression to overt HE was much higher in patients with MHE and Child-Pugh score > 6 than in those with MHE and Child-Pugh score ≤ 6 [38]. Moreover, MHE in patients with large portal-systemic shunts had a better outcome due to preserved hepatocytes [39]. Real probability of OHE at 3 years was 56% in patients of liver cirrhosis in the presence of MHE and 8% for those without MHE [37]. In addition, existence of MHE in cirrhosis associated with shorter survival time and increased mortality rate compared to those without MHE [40, 41, 42, 43].
\nMHE has a significant impact on daily activities. It decreases patients’ quality of life (QoL) [43, 44] and driving impairment due to the attention and visuomotor coordination deficits [45, 46, 47]. The Sickness Impact Profile was studied in a group of patients with cirrhosis to evaluate QoL indicators such as sleep, rest, eating, work, home management, recreation, ambulation, daily care, movement, and emotional behavior. All scales were significantly decreased in patients with MHE compared with individuals without MHE [48]. Moreover, those patients suffer from falls [49] and have a high risk of development of episodic HE [2].
\nQuality of life is a multidimensional index that reports all aspects of human well-being, including physical and cognitive capabilities, functional behavior, emotional status, and psychosocial adjustment [50]. The American Association for the Study of Liver Diseases survey conducted in 2007 demonstrated that, most clinicians believe MHE to be a significant problem. However, only 50% of clinicians had examined whether their patients might have MHE, and 38% had never studied their patients with liver cirrhosis [51]. Several evidences show that, HRQoL may seem to be influenced by the coexistence of MHE [48, 52, 53, 54, 55, 56]. MHE increases the incidence of disability, and has a negative effect on daily activities. The impact of the perception of the disease, in the form of a “Sickness Impact Profile,” has been studied in cirrhotic patients to assess the indicators of QoL. Each profile was significantly reduced in patients with MHE compared to individuals without MHE [48]. In addition, in the presence of MHE, QoL indicators, such as the capacity to drive a car, and the incidence of sleep disorders were also negatively affected [57, 58].
\nMinimal hepatic encephalopathy is significantly associated with high risk of falls explaining the increased healthcare and hospitalization rate in patients with MHE compared to cirrhotic patients without MHE [49, 59, 60]. The presence of cognitive impairment was the only independent factor predictive of a fall. The chance of a fall in 1 year was found to be significantly higher in patients with MHE compared to those without MHE. Urios et al. demonstrated that, MHE patients show impaired balance, mainly on an unstable surface with eyes open, with longer reaction and confinement times and lower success in stability test limits compared to patients without MHE [61].
\nTraffic accidents are more common in patients with MHE compared to normal individuals, as the driving process in patients with MHE is affected by defects in many factors such as, defects in attention and information processing, slow reactions, improper estimation of traffic conditions, and lack of coordination [48, 62]. As many as 33% of MHE patients reported a traffic accident or violation within the past year [63]. Interestingly, treatment with lactulose could substantially reduce societal costs by preventing motor vehicle accidents [64].
\nMHE has been found to predict the development of overt HE in cirrhotic patients [2]. A recent study demonstrated that, CHE and elevated blood NH3 levels contributed to OHE development in cirrhotic patients [65]. The results of Wang et al. showed that, solely serum albumin level < 30 g/L is the predictor for developing OHE in CHE patients [66]. In a study of Thomsen et al., that enrolled 106 clinically stable cirrhotic patients with no previous history of OHE and followed them for 230 ± 95 d, it was found that, 13.3% of CHE patients developed OHE [67]. In a multicenter study by Patidar et al., a total of 170 cirrhotic patients were followed for a mean of 13 months. They found that 30% of cirrhotic patients developed at least one OHE episode, and that CHE increased their risk of developing OHE, hospitalization, and death/transplant [36].
\nThere is no single optimal measure for diagnosis of MHE because none of the diagnostic strategies covers all aspects of deficits that are present in MHE [68, 69]. Testing approaches can be divided into two major types: psychometric and neurophysiological [70, 71]. As MHE affects many elements of cognitive functioning, which may not be impaired to identical degrees, the International Society for Hepatic Encephalopathy and Nitrogen Metabolism (ISHEN) recommends the use of at least two tests, based on the local population norms and availability, and if possible, with one of the tests being more widely accepted to serve as a comparator [72].
\nThe diagnosis requires the indication of tests in subjects who appear normal, but may suffer from cirrhosis, as the physician usually does not observe MHE [73]. Further group of patients who are not cirrhotic and may develop MHE are those with porto-systemic shunts of inborn origin or secondary to portal thrombosis. The available data of the neuropsychological characteristics of these patients indicate that cognitive abnormalities are indistinguishable from MHE [74].
\nThere is no consensus on patients to test for MHE. Some physicians recommend screening of all cirrhotic patients. However, testing should be completed in patients at risk (Table 2) for MHE such as, cirrhosis or porto-systemic shunts [5]. Special attention should be given to active drivers, patients handling heavy machines or reporting decline in work performance [75, 76].
\nPatients at risk of accidents \n
| \n
Patients who complain of cognitive symptoms \n
| \n
Patients with decline in work performance observed by relatives or colleagues | \n
Patients with previous history of episodic HE | \n
Patients with cirrhosis, portal vein thrombosis, or porto-systemic shunts who should undergo tests for MHE.
The American Association for the Study of Liver Diseases (AASLD) and the European Association for the Study of the Liver recommended neurophysiological and psychometric tests to diagnose MHE [3, 51]. Many tests are used for diagnosis of MHE (Table 3); however, the gold standard and the most frequently used psychometric test for MHE diagnosis is psychometric hepatic encephalopathy score (PHES) [3, 4, 42].
\nTest | \nTested domain | \nTime required (minuets) | \nAdvantages | \nDisadvantages | \nImpact factor | \n
---|---|---|---|---|---|
NCT-A | \nPsychomotor speed | \n1–2 | \nGold standard for MHE diagnosis validated internationally | \nLearning effects | \nAge and culture | \n
NCT-B | \nPsychomotor speed, set shifting, divided attention | \n1–3 | \nValidated internationally | \nLearning effects | \nAge and culture | \n
DST | \nPsychomotor speed, attention | \n4 | \nVery sensitive and is an early indicator | \nLearning effects | \nAge and culture | \n
BDT | \nVisuospatial reasoning, praxis, psychomotor speed | \n10–20 | \nIt can be used for dementia testing as well | \nLearning effects | \nAge and culture | \n
SDT | \nPsychomotor speed | \n1–2 | \nOnly tests psychomotor speed, a higher sensitivity | \nLearning effects; only tests psychomotor speed | \nAge and culture | \n
LTT | \nPsychomotor speed, visuomotor ability | \n2–4 | \nTests a balance between speed and accuracy | \nLearning effects, outcomes are errors and time | \nAge and culture | \n
Animal-naming test | \nSemantic fluency test, verbal retrieval and recall | \n1 | \nEasy test that has the required characteristics of simplicity, speed, for illiterate patients | \nLess validated test | \n\n |
CFF | \nVisual discrimination and general arousal | \n10 | \nEasy administration, application by a non-specialist, and results are independent of literacy and age, test can be administered at bedside | \nNot suitable for red-green blindness and visual impairment | \nAge | \n
ICT | \nResponse inhibition, working memory, vigilance, attention | \n15–20 | \nSimple administration, higher sensitivity/specificity | \nNeed highly functional patients, not suitable for non-English-speaking patients | \nAge and education | \n
Stroop test | \nPsychomotor speed and cognitive alertness | \n10 | \nQuick to explain to patients, and simple to score and evaluate | \nShould be familiar with iPhone/iPad | \nAge and education | \n
The SCAN Test | \nWorking memory, vigilance, attention | \n15–20 | \nSimple administration | \nLearning effects | \nAge and education | \n
CDR assessment battery | \nReaction time, memory, and recognition | \n15 | \nAppreciable test-retest reliability | \nLearning effects | \nAge, education, and culture | \n
EEG | \nGeneralized brain activity | \n10–15 | \nCan be done in comatose patients, no need of patient cooperation or risk of a learning effect | \nNonspecific and may be influenced by accompanying metabolic disturbances | \nRequires neurological expertise in evaluation | \n
Psychometric tests recommended for diagnosing minimal hepatic encephalopathy.
Neuropsychological testing is a useful methodology for quantifying cognitive impairment. These tests directly measure cognitive functions that are directly related to activities of daily living. These include the number connection test A (NCT-A), number connection test B (NCT-B), figure connection test (FCT A), figure connection test B (FCT B), digit symbol test (DST), and serial-dotting test (SDOT) [77].
\nThe NCT-A accesses the visual-spatial orientation and psychomotor speed. Twenty-five circles numbered from 1 to 25 are scattered randomly on a sheet of paper. The patients must connect the numbers in order in the shortest time possible without mistakes. If a mistake is made, the subject must stop, correct the error, and then continue without stopping the clock. The test score is the time needed to perform the test, including the time needed to correct all errors. Poorer performance is shown by a longer time for completion (Figure 3). In the NCT-B
Number connection tests-A.
Number connection tests-B.
According to the guidelines of the International Society for Hepatic Encephalopathy and Nitrogen Metabolism [79], the results of NCT-A will be considered abnormal when the test scores are more than the mean + 2 standard deviations (SDs) from the age-matched normal values. A newly developed electronic number connection test (eNCT) was developed. This test flashes the numbers 1–25 on a screen and needs the participant to click them in order while being timed [80]. These tests are time-consuming, and their results are influenced by age and educational status. However, these tests are recommended for diagnosis of MHE [42, 81].
\nNine fixed pairs of numbers and symbols are present at the top of the test sheet. The patient is given a series of double boxes with a number given in the upper part. The target is to draw a symbol related to this number into the lower part of the boxes. The test result is the number of boxes correctly filled in 90 s (Figure 5). Pathological test results indicate a deficit in visuoconstructive abilities. [82]. DST will be considered abnormal when the test scores are less than the mean − 2 SDs from the age-matched normal values [79].
\nDigit symbol test.
This test recorded speed and accuracy. The task is to take 6–9 blocks that have all white sides, all red sides, and red-and-white sides followed by arranging them according to a pattern formed by examiner or shown on a card [83].
\nIt consists of five paper-pencil tests: NCT-A/B, line tracing time (LTT), digit symbol test, and serial-dotting test (SDOT). This battery measures psychomotor speed and precision, visual perception, visuospatial orientation, visual construction, concentration, attention, and memory and can be completed in less than 20 minutes [68]. The results of PHES can be affected by age and education status of patients. A score is defined as the number of standard deviations of the difference between the two values for each test. MHE was diagnosed with the sum of all scores less than or equal to −4 points. Score < −4 suggests the presence of MHE [1, 84]. A simplified form of PHES, developed using only three of the original five tests, can be as good as the PHES in diagnosing [84]. For illiterate patients, the figure connection test has been used as a subtest instead of the number connection test [1]. PHES has a prognostic value for the occurrence of attacks of overt HE and mortality in cirrhotic patients [42, 43].
\nThe ANT (maximum number of animals listed in 1 minute) has recently been developed to predict OHE. ANT is an easy test that has all the required characteristics of simplicity, speed, no cost, and relationship with clinical events to be used routinely for rapid investigation of HE in patients with cirrhosis at the office and at the bedside [85].
\nNumerous current studies have showed that, computerization of psychometric tests could lead to simplification and easy administration in the clinic within a few minutes [10, 86, 87].
\nCFF test is a psychophysiological tool that studies the frequency at which a fused light (presented from 60 Hz downward) appears to be flickering to the observer. Similarly, the general arousal of the patient is measured. Earlier studies have shown a reduction in its performance with worsening cognition and improvement after therapy. The CFF test needs numerous trials, intact binocular vision, absence of red-green blindness, and specialized equipment [15]. CFF predicts the first episode of OHE in cirrhotic patients who had never experienced OHE, and predicts mortality risk [88]. CFF test has many advantages, for example, easy administration, application by a non-specialist personal, and results that are independent of numeracy, literacy, and age [89].
\nThis test assesses the motor reaction time by having the patient press a button in response to auditory stimuli (through headphones). The most important test result is the CRT index, which measures the stability of the reaction times. The test result can differentiate between organic and metabolic brain impairment. The test is not affected by the patient’s age, gender with no learning or tiring impact [90, 91].
\nIt is a computerized test of response inhibition and working. The ICT requires highly functional patients (Figure 6). The ICT can be done using a laptop and is analyzed using an automatic computerized system that significantly improves the convenience and flexibility of using this test in the clinical situation [92]. It has been validated for the diagnosis and follow-up of MHE in the USA. It was found that the ICT is simple to administer and has higher sensitivity/specificity for screening MHE than the standard psychometric test (SPT). On the other side, Taneja et al. found that the ICT is not as useful as the PHES in diagnosing MHE in patients with cirrhosis [93].
\nInhibitory control test. A continuous sequence of letters is displayed on the computer screen every 500 ms. The patient is educated to respond only if an X is preceded by a Y, or a Y is preceded by an X, but responses must be inhibited if an X is followed by an X, or a Y is followed by a Y.
In 2013, Bajaj et al. developed an application, the EncephalApp-Stroop App, for screening MHE that is operated by the iOS system on the iPhone and iPad. The core of this innovative application is the Stroop test, which assesses psychomotor speed and cognitive alertness by measuring the time required to correctly identify a series of symbols and printed words with different colors [86]. The Stroop test evaluates psychomotor speed and cognitive flexibility by the interference between recognition reaction time to a colored field and a written color name. [86]. In a multicenter study that compared the EncephalApp-Stroop App to the PHES and ICT, the EncephalApp-Stroop App had good sensitivity (70–80%) for MHE screening and was predictive of the progression to OHE [94].
\nIt is a computerized test that measures the patient’s speed and accuracy to perform a digit recognition memory task of increasing complexity [40, 95]. It is done by randomly displaying a series of 72 sorted pairs of numbers for 3 s on a computer screen. Patients are instructed to press the appropriate number on a keyboard if they identify a common digit in the sequence of numbers presented. The mean reaction times and the percentage of errors are recorded, and the results are evaluated using the reaction times weighted by the number of errors [96].
\nIt is a computerized battery of cognitive tests designed by the Cognitive Drug Research Ltd. (Goring-on-Thames, UK). The test contains five psychometric subsets that test attention power, attention continuity, speed of memory, and quality of episodic and working memory. It measures reaction time, memory, and recognition. The task stimuli are existing on a laptop, and patients provide the correct response using the “YES” and “NO” buttons on a two-button response box, which records both accuracy and reaction time. The sensitivity and specificity of the CDR assessment battery for screening MHE are 86.4 and 81%, respectively [10].
\nEEG can discover changes in cortical cerebral activity across the spectrum of HE without patient cooperation or risk of a learning effect [97]. Newly, an-economy friendly device has been found to produce similar results compared with a standard EEG machine across the HE spectrum [97].
\nTreatment of minimal hepatic encephalopathy with lactulose, probiotics, or l-ornithine-l-aspartate was seen to be effective in reducing abnormal tests and delay or eradicating risky motor car accident [47, 98, 99, 100, 101, 102, 103]. It is therefore rational, especially if the patients or their family/caregivers report symptoms/signs compatible with MHE, to introduce treatment specially in patients who are at particular risk of the consequences of MHE, such as falls, impaired, and driving ability.
\nRifaximin is an orally administered, non-absorbable, semi-synthetic antibiotic with a broad spectrum of effect on both Gram-positive and Gram-negative bacteria [11,, 104]. It was found that patients with MHE treated with rifaximin for an 8-week period showed significantly greater improvements in driving and cognitive performance and in the psychosocial dimension of the Sickness Impact Profile than those given a placebo [67]. Recently, a randomized controlled trial compared the efficacy of rifaximin with lactulose in reversal of MHE and improvement in HRQoL in cirrhotic patients with MHE. The study concluded that both drugs improve HRQoL equally well, in cirrhotic patients with MHE [105].
\nThe recommended standard of care for people with hepatic encephalopathy includes use of the non-absorbable disaccharides (lactulose and lactitol) [106, 107]. It was found that cirrhotic patients with MHE had improvement in health-related quality of life and psychometric performance after lactulose therapy [108]. Lactulose and lactitol, both, have effects on gut flora and are regarded as intestinal prebiotics. Adding lactulose to food can produce a bifidogenic effect connected to a favorable effect on colonic ammonia metabolism [109]. However, a recent meta-analysis evaluating the role of non-absorbable disaccharides in patients with MHE failed to show clear evidence in improving cognitive function and HRQoL [110].
\nAmmonia scavengers, including l-ornithine-l-aspartate, are agents that reduce blood ammonia concentration by enhancing the metabolism of ammonia to glutamine [111, 112, 113]. Bai et al. assessed eight RCTs (646 total patients, 46% diagnosed with MHE), evaluating the efficacy of LOLA compared to placebo in patients with cirrhosis. He found that treatment with LOLA diminished serum ammonia levels [114]. Evidence of important benefit of LOLA was also described in RCTs of patients with MHE assessed by psychometric testing or critical flicker frequency analysis. The oral formulation of LOLA was determined to be particularly effective for the treatment of OHE or MHE [115].
\nPrebiotics are non-digestible food ingredients that selectively stimulate the growth and/or activity of the bacteria in the colon. Probiotics are live microbes that alter the intestinal balance of the microflora. The combination of prebiotics and probiotics is named synbiotics. The meta-analysis of nine studies showed substantial evidence for the efficacy of prebiotics, probiotics, and synbiotics in the treatment of MHE [116]. A Cochrane Review examining the use of probiotics in the treatment of HE included seven trials and presented an advantage of probiotics to no treatment in all-cause mortality, number of adverse events, and QoL. Findings included reduced plasma concentrations of ammonia [117].
\nZinc, considered as a cofactor of urea cycle enzymes, is deficient in patients with cirrhosis, especially with malnutrition or encephalopathy [118]. Zinc is essential for the synthesis of coenzymes that mediate biogenic amine synthesis and metabolism [14]. Zinc deficiency also leads to change of neurotransmitters like γ aminobutyric acid and norepinephrine [119]. A recent RCT revealed that zinc supplementation can improve MHE in patients with liver cirrhosis associated with significant improvement in neuropsychometric tests and significantly decreased arterial ammonia level [76].
\nThe prevalence of MHE is high in liver cirrhosis. MHE is characterized by subtle motor and cognitive deficits, and impairs health-related quality of life. Detection of MHE and subsequent treatment could substantially reduce societal costs by preventing motor vehicle accident.
\nThe authors declare that there is no conflict of interest.
This research received no specific grant from any funding agency in the public, commercial, or not for-profit sectors.
\n"Open access contributes to scientific excellence and integrity. It opens up research results to wider analysis. It allows research results to be reused for new discoveries. And it enables the multi-disciplinary research that is needed to solve global 21st century problems. Open access connects science with society. It allows the public to engage with research. To go behind the headlines. And look at the scientific evidence. And it enables policy makers to draw on innovative solutions to societal challenges".
\n\nCarlos Moedas, the European Commissioner for Research Science and Innovation at the STM Annual Frankfurt Conference, October 2016.
",metaTitle:"About Open Access",metaDescription:"Open access contributes to scientific excellence and integrity. It opens up research results to wider analysis. It allows research results to be reused for new discoveries. And it enables the multi-disciplinary research that is needed to solve global 21st century problems. Open access connects science with society. It allows the public to engage with research. To go behind the headlines. And look at the scientific evidence. And it enables policy makers to draw on innovative solutions to societal challenges.\n\nCarlos Moedas, the European Commissioner for Research Science and Innovation at the STM Annual Frankfurt Conference, October 2016.",metaKeywords:null,canonicalURL:"about-open-access",contentRaw:'[{"type":"htmlEditorComponent","content":"The Open Access publishing movement started in the early 2000s when academic leaders from around the world participated in the formation of the Budapest Initiative. They developed recommendations for an Open Access publishing process, “which has worked for the past decade to provide the public with unrestricted, free access to scholarly research—much of which is publicly funded. Making the research publicly available to everyone—free of charge and without most copyright and licensing restrictions—will accelerate scientific research efforts and allow authors to reach a larger number of readers” (reference: http://www.budapestopenaccessinitiative.org)
\\n\\nIntechOpen’s co-founders, both scientists themselves, created the company while undertaking research in robotics at Vienna University. Their goal was to spread research freely “for scientists, by scientists’ to the rest of the world via the Open Access publishing model. The company soon became a signatory of the Budapest Initiative, which currently has more than 1000 supporting organizations worldwide, ranging from universities to funders.
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\\n\\nOA Publishing Fees
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\\n\\nOpen Science is transparent and accessible knowledge that is shared and developed through collaborative networks.
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The Open Access publishing movement started in the early 2000s when academic leaders from around the world participated in the formation of the Budapest Initiative. They developed recommendations for an Open Access publishing process, “which has worked for the past decade to provide the public with unrestricted, free access to scholarly research—much of which is publicly funded. Making the research publicly available to everyone—free of charge and without most copyright and licensing restrictions—will accelerate scientific research efforts and allow authors to reach a larger number of readers” (reference: http://www.budapestopenaccessinitiative.org)
\n\nIntechOpen’s co-founders, both scientists themselves, created the company while undertaking research in robotics at Vienna University. Their goal was to spread research freely “for scientists, by scientists’ to the rest of the world via the Open Access publishing model. The company soon became a signatory of the Budapest Initiative, which currently has more than 1000 supporting organizations worldwide, ranging from universities to funders.
\n\nAt IntechOpen today, we are still as committed to working with organizations and people who care about scientific discovery, to putting the academic needs of the scientific community first, and to providing an Open Access environment where scientists can maximize their contribution to scientific advancement. By opening up access to the world’s scientific research articles and book chapters, we aim to facilitate greater opportunity for collaboration, scientific discovery and progress. We subscribe wholeheartedly to the Open Access definition:
\n\n“By “open access” to [peer-reviewed research literature], we mean its free availability on the public internet, permitting any users to read, download, copy, distribute, print, search, or link to the full texts of these articles, crawl them for indexing, pass them as data to software, or use them for any other lawful purpose, without financial, legal, or technical barriers other than those inseparable from gaining access to the internet itself. The only constraint on reproduction and distribution, and the only role for copyright in this domain, should be to give authors control over the integrity of their work and the right to be properly acknowledged and cited” (reference: http://www.budapestopenaccessinitiative.org)
\n\nOAI-PMH
\n\nAs a firm believer in the wider dissemination of knowledge, IntechOpen supports the Open Access Initiative Protocol for Metadata Harvesting (OAI-PMH Version 2.0). Read more
\n\nLicense
\n\nBook chapters published in edited volumes are distributed under the Creative Commons Attribution 3.0 Unported License (CC BY 3.0). IntechOpen upholds a very flexible Copyright Policy. There is no copyright transfer to the publisher and Authors retain exclusive copyright to their work. All Monographs/Compacts are distributed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0). Read more
\n\nPeer Review Policies
\n\nAll scientific works are Peer Reviewed prior to publishing. Read more
\n\nOA Publishing Fees
\n\nThe Open Access publishing model employed by IntechOpen eliminates subscription charges and pay-per-view fees, enabling readers to access research at no cost. In order to sustain operations and keep our publications freely accessible we levy an Open Access Publishing Fee for manuscripts, which helps us cover the costs of editorial work and the production of books. Read more
\n\nDigital Archiving Policy
\n\nIntechOpen is committed to ensuring the long-term preservation and the availability of all scholarly research we publish. We employ a variety of means to enable us to deliver on our commitments to the scientific community. Apart from preservation by the Croatian National Library (for publications prior to April 18, 2018) and the British Library (for publications after April 18, 2018), our entire catalogue is preserved in the CLOCKSS archive.
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Her research interests include archaea metabolism, enzymes purification and characterization, gene regulation, carotenoids and bioplastics production, antioxidant\ncompounds, waste water treatments, and brines bioremediation.\nRosa María’s other roles include editorial board member for several journals related\nto biochemistry, reviewer for more than 60 journals (biochemistry, molecular biology, biotechnology, chemistry and microbiology) and president of several organizing committees in international meetings related to the N-cycle or respiratory processes.",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"15",title:"Chemical Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",isOpenForSubmission:!0,editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",slug:"sukru-beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",biography:"Dr. Şükrü Beydemir obtained a BSc in Chemistry in 1995 from Yüzüncü Yıl University, MSc in Biochemistry in 1998, and PhD in Biochemistry in 2002 from Atatürk University, Turkey. 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Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}}]},{type:"book",id:"7978",title:"Vitamin A",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7978.jpg",slug:"vitamin-a",publishedDate:"May 15th 2019",editedByType:"Edited by",bookSignature:"Leila Queiroz Zepka, Veridiana Vera de Rosso and Eduardo Jacob-Lopes",hash:"dad04a658ab9e3d851d23705980a688b",volumeInSeries:3,fullTitle:"Vitamin A",editors:[{id:"261969",title:"Dr.",name:"Leila",middleName:null,surname:"Queiroz Zepka",slug:"leila-queiroz-zepka",fullName:"Leila Queiroz Zepka",profilePictureURL:"https://mts.intechopen.com/storage/users/261969/images/system/261969.png",biography:"Prof. Dr. Leila Queiroz Zepka is currently an associate professor in the Department of Food Technology and Science, Federal University of Santa Maria, Brazil. She has more than fifteen years of teaching and research experience. She has published more than 550 scientific publications/communications, including 15 books, 50 book chapters, 100 original research papers, 380 research communications in national and international conferences, and 12 patents. She is a member of the editorial board of five journals and acts as a reviewer for several national and international journals. 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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. Her main research interest is sarcopenia in older adults, especially its association with nutritional status. Additionally, to understand how to maintain and improve physical function in older adults, to conduct studies about the mechanism of sarcopenia and determine when possible interventions are needed.",institutionString:null,institution:{name:"Ritsumeikan University",institutionURL:null,country:{name:"Japan"}}},editorThree:null,series:{id:"10",title:"Physiology",doi:"10.5772/intechopen.72796",issn:"2631-8261"},editorialBoard:[{id:"213786",title:"Dr.",name:"Henrique P.",middleName:null,surname:"Neiva",slug:"henrique-p.-neiva",fullName:"Henrique P. 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