Summary of contemporary randomized trials on LD‐EBRT of painful heel spurs: tested schedules, results, and conclusions.
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\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:"10167",leadTitle:null,fullTitle:"Forest Biomass - From Trees to Energy",title:"Forest Biomass",subtitle:"From Trees to Energy",reviewType:"peer-reviewed",abstract:"Forests are responsible for the largest net biomass carbon production. They store the most standing biomass and carbon and thus they are an important source of bioenergy. Their importance is linked to their relative abundance and uniformity worldwide and the neutrality of CO2 emissions from biomass conversion to energy. Yet, the use of biomass for energy presents risks related to forest system sustainability and demands for new environmentally sustainable strategies for its use. This book provides a comprehensive overview of the current state of the art in a multitude of subjects related to forest bioenergy, ranging from trees, forest stand management, and biomass assessment to waste management, conversion technologies, and routes and energy applications.",isbn:"978-1-83962-971-6",printIsbn:"978-1-83962-970-9",pdfIsbn:"978-1-83962-972-3",doi:"10.5772/intechopen.90324",price:119,priceEur:129,priceUsd:155,slug:"forest-biomass-from-trees-to-energy",numberOfPages:190,isOpenForSubmission:!1,isInWos:1,isInBkci:!1,hash:"44e2683e29770ccb1462894a48e2afb5",bookSignature:"Ana Cristina Gonçalves, Adélia Sousa and Isabel Malico",publishedDate:"February 10th 2021",coverURL:"https://cdn.intechopen.com/books/images_new/10167.jpg",numberOfDownloads:3231,numberOfWosCitations:3,numberOfCrossrefCitations:5,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:9,numberOfDimensionsCitationsByBook:1,hasAltmetrics:1,numberOfTotalCitations:17,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 30th 2019",dateEndSecondStepPublish:"January 31st 2020",dateEndThirdStepPublish:"May 1st 2020",dateEndFourthStepPublish:"July 2nd 2020",dateEndFifthStepPublish:"June 7th 2020",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!0,featuredMarkup:null,editors:[{id:"194484",title:"Prof.",name:"Ana Cristina",middleName:null,surname:"Gonçalves",slug:"ana-cristina-goncalves",fullName:"Ana Cristina Gonçalves",profilePictureURL:"https://mts.intechopen.com/storage/users/194484/images/system/194484.jpg",biography:"Ana Cristina Gonçalves is an Assistant Professor with Habilitation in the Department of Rural Engineering, University of Évora, Portugal, and a researcher at the Mediterranean Institute for Agriculture, Environment and Development (MED). She holds a Ph.D. in Forestry. Dr. Gonçalves has authored more than 100 publications and participated in 20 research projects. Her research is focused on silviculture and modelling in pure, mixed, and even-aged and uneven-aged stands, and forest management and planning integrated into a GIS environment.",institutionString:"University of Évora",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"10",totalChapterViews:"0",totalEditedBooks:"3",institution:{name:"University of Évora",institutionURL:null,country:{name:"Portugal"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"187880",title:"Prof.",name:"Adélia",middleName:null,surname:"Sousa",slug:"adelia-sousa",fullName:"Adélia Sousa",profilePictureURL:"https://mts.intechopen.com/storage/users/187880/images/system/187880.jpg",biography:"Adélia Sousa is an assistant professor in the Rural Department, University of Évora, Portugal, and a researcher at the Institute for Mediterranean Agrarian Sciences (ICAAM). She holds a Ph.D. in Rural Engineering from the University of Évora and has authored more than fifty publications. She has worked on around twenty-five national and international research projects in both the academic and private sectors. Her research focuses on the application of remote sensing and GIS techniques to monitoring and management of natural resources, especially in the forest and agriculture.",institutionString:"University of Évora",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"6",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Évora",institutionURL:null,country:{name:"Portugal"}}},coeditorTwo:{id:"252288",title:"Prof.",name:"Isabel",middleName:null,surname:"Malico",slug:"isabel-malico",fullName:"Isabel Malico",profilePictureURL:"https://mts.intechopen.com/storage/users/252288/images/system/252288.jpg",biography:"Isabel Malico is an assistant professor in the Physics Department, University of Évora, Portugal, and a researcher at the Associated Laboratory for Energy, Transport and Aeronautics (LAETA). She holds a Ph.D. in Mechanical Engineering from the University of Lisbon and has authored more than 100 publications. She has worked on around twenty research projects in both the academic and private sectors. Her research focuses on computational fluid mechanics, energy systems, and bioenergy.",institutionString:"University of Évora",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Évora",institutionURL:null,country:{name:"Portugal"}}},coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"885",title:"Bioenergy",slug:"sustainable-energy-bioenergy"}],chapters:[{id:"73136",title:"Energy Production from Forest Biomass: An Overview",doi:"10.5772/intechopen.93361",slug:"energy-production-from-forest-biomass-an-overview",totalDownloads:472,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"As long as care is taken regarding stand and forest sustainability, forest biomass is an interesting alternative to fossil fuels because of its historical use as an energy source, its relative abundance and availability worldwide, and the fact that it is carbon-neutral. This study encompasses the revision of the state of the sources of forest biomass for energy and their estimation, the impacts on forests of biomass removal, the current demand and use of forest biomass for energy, and the most used energy conversion technologies. Forests can provide large amounts of biomass that can be used for energy. However, as the resources are limited, the increasing demand for biomass brings about management challenges. Stand structure is determinant for the amount of residues produced. Biomass can be estimated with high accuracy using both forest inventory and remote sensing. Yet, remote sensing enables biomass estimation and monitoring in shorter time periods. Different bioenergy uses and conversion technologies are characterized by different efficiencies, which should be a factor to consider in the choice of the best suited technology. Carefully analyzing the different options in terms of available conversion technologies, end-uses, costs, environmental benefits, and alternative energy vectors is of utmost importance.",signatures:"Ana Cristina Gonçalves, Isabel Malico and Adélia M.O. Sousa",downloadPdfUrl:"/chapter/pdf-download/73136",previewPdfUrl:"/chapter/pdf-preview/73136",authors:[{id:"194484",title:"Prof.",name:"Ana Cristina",surname:"Gonçalves",slug:"ana-cristina-goncalves",fullName:"Ana Cristina Gonçalves"},{id:"187880",title:"Prof.",name:"Adélia",surname:"Sousa",slug:"adelia-sousa",fullName:"Adélia Sousa"},{id:"252288",title:"Prof.",name:"Isabel",surname:"Malico",slug:"isabel-malico",fullName:"Isabel Malico"}],corrections:null},{id:"73010",title:"The Potential of Sentinel-2 Satellite Images for Land-Cover/Land-Use and Forest Biomass Estimation: A Review",doi:"10.5772/intechopen.93363",slug:"the-potential-of-sentinel-2-satellite-images-for-land-cover-land-use-and-forest-biomass-estimation-a",totalDownloads:662,totalCrossrefCites:2,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Mapping land-cover/land-use (LCLU) and estimating forest biomass using satellite images is a challenge given the diversity of sensors available and the heterogeneity of forests. Copernicus program served by the Sentinel satellites family and the Google Earth Engine (GEE) platform, both with free and open services accessible to its users, present a good approach for mapping vegetation and estimate forest biomass on a global, regional, or local scale, periodically and in a repeated way. The Sentinel-2 (S2) systematically acquires optical imagery and provides global monitoring data with high spatial resolution (10–60 m) images. Given the novelty of information on the use of S2 data, this chapter presents a review on LCLU maps and forest above-ground biomass (AGB) estimates, in addition to exploring the efficiency of using the GEE platform. The Sentinel data have great potential for studies on LCLU classification and forest biomass estimates. The GEE platform is a promising tool for executing complex workflows of satellite data processing.",signatures:"Crismeire Isbaex and Ana Margarida Coelho",downloadPdfUrl:"/chapter/pdf-download/73010",previewPdfUrl:"/chapter/pdf-preview/73010",authors:[{id:"316211",title:"Dr.",name:"Crismeire",surname:"Isbaex",slug:"crismeire-isbaex",fullName:"Crismeire Isbaex"},{id:"320789",title:"Mrs.",name:"Ana Margarida",surname:"Coelho",slug:"ana-margarida-coelho",fullName:"Ana Margarida Coelho"}],corrections:null},{id:"73176",title:"Biomass Estimation Using Satellite-Based Data",doi:"10.5772/intechopen.93603",slug:"biomass-estimation-using-satellite-based-data",totalDownloads:472,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"Comprehensive measurements of global forest aboveground biomass (AGB) are crucial information to promote the sustainable management of forests to mitigate climate change and preserve the multiple ecosystem services provided by forests. Optical and radar sensors are available at different spatial, spectral, and temporal scales. The integration of multi-sources sensor data with field measurements, using appropriated algorithms to identify the relationship between remote sensing predictors and reference measurements, is important to improve forest AGB estimation. This chapter aims to present different types of predicted variables derived from multi-sources sensors, such as original spectral bands, transformed images, vegetation indices, textural features, and different regression algorithms used (parametric and non-parametric) that contribute to a more robust, practical, and cost-effective approach for forest AGB estimation at different levels.",signatures:"Patrícia Lourenço",downloadPdfUrl:"/chapter/pdf-download/73176",previewPdfUrl:"/chapter/pdf-preview/73176",authors:[{id:"315868",title:"Dr.",name:"Patricia",surname:"Lourenco",slug:"patricia-lourenco",fullName:"Patricia Lourenco"}],corrections:null},{id:"72821",title:"Management of Maritime Pine: Energetic Potential with Alternative Silvicultural Guidelines",doi:"10.5772/intechopen.93222",slug:"management-of-maritime-pine-energetic-potential-with-alternative-silvicultural-guidelines",totalDownloads:280,totalCrossrefCites:0,totalDimensionsCites:2,hasAltmetrics:0,abstract:"The interest in the use of energy of the forests has been increasing in recent decades. Biomass has the potential to provide a cost-effective and sustainable supply of renewable energy. Moreover, it could be valuable for reducing the severity of forest fires and create employment in extremely needy regions. This chapter brings to discuss the effect of forest management on the potential of energy provided by the woodlands. The authors selected as a case study the management of maritime pine (Pinus pinaster Ait.), an important softwood species in the southwest of Europe and, in particular, in Portugal where it represents around 22% of the forest area. A summary of traditional and new silvicultural guidelines for the species, used or proposed to be followed at the national level, is presented. The study follows with the evaluation of stand yield and the potential of energy associated with four alternative silvicultural guidelines. Two scenarios follow traditional standards (an initial density of 1100–1200 trees/ha), while the other two consider managing a high density stand (an initial density of 40,000 trees/ha). Simulations were performed with the ModisPinaster model. The results show that the new designs provide a considerable yield in terms of biomass and energy.",signatures:"Teresa Fonseca and José Lousada",downloadPdfUrl:"/chapter/pdf-download/72821",previewPdfUrl:"/chapter/pdf-preview/72821",authors:[{id:"79412",title:"Dr.",name:"Teresa",surname:"Fidalgo Fonseca",slug:"teresa-fidalgo-fonseca",fullName:"Teresa Fidalgo Fonseca"},{id:"316782",title:"Dr.",name:"José",surname:"Lousada",slug:"jose-lousada",fullName:"José Lousada"}],corrections:null},{id:"74636",title:"Evergreen Oak Biomass Residues for Firewood",doi:"10.5772/intechopen.95417",slug:"evergreen-oak-biomass-residues-for-firewood",totalDownloads:275,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"This chapter presents the assessment of the availability for residential heating of residual biomass from cork and holm oaks in a 12,188 ha agroforest area in Portugal. First, the above-ground biomass of evergreen oaks using very high spatial resolution satellite images was determined, followed by the definition of different scenarios for residues removal from the stands. The useful energy potential of the firewood that can be collected from the study area under the various silviculture scenarios was determined considering different energy conversion technologies: open fireplaces (still popular in Portugal) and more efficient closed burning appliances. Additionally, emissions of airborne pollutants from combusting all the available residual biomass in the study area were determined. Depending on the percentage of residues collected when the trees are pruned and on the conversion technologies used, the energy potential of evergreen oak firewood ranged from 5.0 × 106 MJ year−1 to 7.5 × 107 MJ year−1. Heavier pruning combined with the use of open fireplaces generates less useful heat and much higher emissions of pollutants per unit useful energy produced than lighter pruning combined with a more efficient technology. This case study illustrates the need to promote the transition from inefficient to more efficient and cleaner technologies.",signatures:"Isabel Malico, Ana Cristina Gonçalves and Adélia M.O. Sousa",downloadPdfUrl:"/chapter/pdf-download/74636",previewPdfUrl:"/chapter/pdf-preview/74636",authors:[{id:"194484",title:"Prof.",name:"Ana Cristina",surname:"Gonçalves",slug:"ana-cristina-goncalves",fullName:"Ana Cristina Gonçalves"},{id:"187880",title:"Prof.",name:"Adélia",surname:"Sousa",slug:"adelia-sousa",fullName:"Adélia Sousa"},{id:"252288",title:"Prof.",name:"Isabel",surname:"Malico",slug:"isabel-malico",fullName:"Isabel Malico"}],corrections:null},{id:"72657",title:"Koroch (Pongamia pinnata): A Promising Unexploited Resources for the Tropics and Subtropics",doi:"10.5772/intechopen.93075",slug:"koroch-em-pongamia-pinnata-em-a-promising-unexploited-resources-for-the-tropics-and-subtropics",totalDownloads:297,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"The demand of petroleum fuel is increasing day by day. To meet up the energy demand, people of developing countries like Bangladesh basically used energy from indigenous sources, which are reducing quickly. Hence, it should be emphasized to explore unconventional fuel to overwhelm the crisis of petroleum fuels. Koroch (Pongamia pinnata L. Pierre) is a quick-growing leguminous tree that has the ability to grow on marginal land. Higher oil yield as well as physicochemical properties increases the suitability of using Pongamia as a promising substitute for supplying feedstock of biofuel production. Besides biofuel production, P. pinnata has multipurpose uses as traditional medicine to animal feed, bio-pesticides, and bio-fertilizers. A better understanding and knowledge on the ecological distribution, botanical characteristics, physiology, and mode of reproduction along with physicochemical properties, and biosynthesis of oil is essential for sustainable production of biofuel from P. pinnata. In this chapter, we discuss overall biological and physicochemical properties as well as cultivation and propagation methods that provide a fundamentals for exploiting and improving of P. pinnata as a promising renewable source of biofuel feedstock.",signatures:"Abul Kalam Mohammad Aminul Islam, Swapan Chakrabarty, Zahira Yaakob, Mohammad Ahiduzzaman and Abul Kalam Mohammad Mominul Islam",downloadPdfUrl:"/chapter/pdf-download/72657",previewPdfUrl:"/chapter/pdf-preview/72657",authors:[{id:"77958",title:"Prof.",name:"Zahira",surname:"Yaakob",slug:"zahira-yaakob",fullName:"Zahira Yaakob"},{id:"234696",title:"Prof.",name:"A. K. M. Mominul",surname:"Islam",slug:"a.-k.-m.-mominul-islam",fullName:"A. K. M. Mominul Islam"},{id:"320606",title:"Prof.",name:"A. K. M. Aminul",surname:"Islam",slug:"a.-k.-m.-aminul-islam",fullName:"A. K. M. Aminul Islam"},{id:"320653",title:"Mr.",name:"Swapan",surname:"Chakrabarty",slug:"swapan-chakrabarty",fullName:"Swapan Chakrabarty"},{id:"320704",title:"Dr.",name:"M.",surname:"Ahiduzzaman",slug:"m.-ahiduzzaman",fullName:"M. Ahiduzzaman"}],corrections:null},{id:"72739",title:"Case Study: Pathways from Forest to Energy in a Circular Economy at Lafões",doi:"10.5772/intechopen.93070",slug:"case-study-pathways-from-forest-to-energy-in-a-circular-economy-at-laf-es",totalDownloads:270,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The present case study deals with new pathways in demand for forest residues disposal in the Lafões region (Portugal), since this biomass is presently regarded as a residue and eliminated through open air burning. Different biomass-to-energy conversion systems have a high sustainability value and, thus, the energy potential of the biomass supplied by the forest of Lafões was assessed, using GIS-based methods and assumptions from the literature. The Lafões region produces large amounts of chicken manure from which energy can be recovered through anaerobic digestion. The energy potential held by the effluent of the several classes of the poultry industry of Lafões was assessed, using IPCC 2006 guidelines to estimate their biomass and methane production potential. Furthermore, integrated solutions were pursued. The present challenge is to explore complementarities between effluents for anaerobic digestion to achieve improved energy and waste management system performances. The complementarity between the residues from maritime pine forest management and from broiler production was assessed through bench-scale anaerobic co-digestion assays, leading to increased methane production when compared to those achieved with single substrate anaerobic digestion. This result highlights the interest of further research concerning complementarities between other effluents in the Lafões region.",signatures:"Ana d’Espiney, Isabel Paula Marques and Helena Maria Pinheiro",downloadPdfUrl:"/chapter/pdf-download/72739",previewPdfUrl:"/chapter/pdf-preview/72739",authors:[{id:"316041",title:"Ph.D.",name:"Isabel",surname:"Marques",slug:"isabel-marques",fullName:"Isabel Marques"},{id:"320949",title:"Prof.",name:"Helena",surname:"Pinheiro",slug:"helena-pinheiro",fullName:"Helena Pinheiro"},{id:"346460",title:"Dr.",name:"Ana",surname:"d’Espiney",slug:"ana-d'espiney",fullName:"Ana d’Espiney"}],corrections:null},{id:"72247",title:"Methodology for the Evaluation of the Electrical Energy Potential of Residual Biomass from the Wood Industry: A Case Study in Brazil",doi:"10.5772/intechopen.92642",slug:"methodology-for-the-evaluation-of-the-electrical-energy-potential-of-residual-biomass-from-the-wood-",totalDownloads:214,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"This chapter presents in a consolidated manner the step-by-step methodology to estimate the electrical energy potential of industrial wood residues considering the dependency of the efficiency of the power plants with their size. A function of the overall efficiency with power was obtained from a best curve fit of real data both taken from the literature and from Brazilian biomass-fired power plants. The methodology was applied to the determination of the electrical energy potential of wood industry residues in the State of Pará (data collected in 2004). Two cases were analyzed: one where a constant electrical efficiency of 25% was considered (independently of the amount of residues generated) and another where the proposed function of efficiency with power was used. Results show that in the State of Pará, the existent 675 sawmills generated 2.95 × 106 t in dry basis. When the dependency of efficiency with plant size is not considered, the electrical energy potential and average installed power (3140.4 GWh and 2 MWe) are overestimated in comparison to the herein proposed methodology (1868.8 GWh and 1 MWe). The present methodology, considering the efficiency as a function of the power, results in an average efficiency of 12.3% (lower than 25%).",signatures:"Augusto César de Mendonça Brasil",downloadPdfUrl:"/chapter/pdf-download/72247",previewPdfUrl:"/chapter/pdf-preview/72247",authors:[{id:"317937",title:"Dr.",name:"Augusto César de Mendonça",surname:"Brasil",slug:"augusto-cesar-de-mendonca-brasil",fullName:"Augusto César de Mendonça Brasil"}],corrections:null},{id:"73099",title:"Opportunities of Circular Economy in a Complex System of Woody Biomass and Municipal Sewage Plants",doi:"10.5772/intechopen.93474",slug:"opportunities-of-circular-economy-in-a-complex-system-of-woody-biomass-and-municipal-sewage-plants",totalDownloads:289,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"In this chapter, we present the opportunities and general importance of woody biomass production (forests and short-rotation coppices) and waste management in a common system. Wastewater and different forms of sewage sludge, as energy- and nutrient-rich materials, can contribute to reaching resource efficiency, savings in energy, and reduction of CO2 emissions. Within certain limits, these woody plantations are suitable options for the environmentally sound disposal of wastewater and/or sewage sludge; in addition, they can facilitate the realization of full or partial energy self-sufficiency of the wastewater plant through bioenergy production. Focusing on circular economy, we introduce the aspects of the treatment process and the sizing issues regarding the municipal wastewater treatment and the woody biomass in a complex system. Based on a specific case study, approximately 826 ha of short-rotation coppices (with a 2-year rotation) are required for the disposal of sewage sludge generated by a 250,000 population equivalent wastewater treatment plant. If we look at the self-sufficiency of its energy output, 120–150 ha of short-rotation coppices may be adequate. This complex system can replace the emissions of around 5650 t of CO2 through electricity generation alone and another 1490 t of CO2 by utilizing the waste heat.",signatures:"Attila Bai and Zoltán Gabnai",downloadPdfUrl:"/chapter/pdf-download/73099",previewPdfUrl:"/chapter/pdf-preview/73099",authors:[{id:"271760",title:"Prof.",name:"Attila",surname:"Bai",slug:"attila-bai",fullName:"Attila Bai"},{id:"271761",title:"Dr.",name:"Zoltán",surname:"Gabnai",slug:"zoltan-gabnai",fullName:"Zoltán Gabnai"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"6894",title:"Conifers",subtitle:null,isOpenForSubmission:!1,hash:"08346de6b4e92146db7819ccbefd4130",slug:"conifers",bookSignature:"Ana Cristina Gonçalves",coverURL:"https://cdn.intechopen.com/books/images_new/6894.jpg",editedByType:"Edited by",editors:[{id:"194484",title:"Prof.",name:"Ana 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Applications",subtitle:null,reviewType:"peer-reviewed",abstract:"\r\n\tDue to the growth of the find, new engineering materials that can replace the already traditional, research, and applications on adhesives are increasing in academic and industrial areas. Adhesive bonding is a recent technology that in many applications, can replace the techniques already known in engineering, such as rivets, bolts, welds, etc. The adhesives have the advantage of being lightweight. The use of adhesives in engineering is already present in several areas, for example, aeronautics, nautical, renewable energy, mechanics, etc.
\r\n\tAs the subject of adhesives is in constant development, this book's purpose is to get together information about adhesives science and technology, recent advances, and applications that use adhesive technology. Also, to make these contents available to engineering students, engineers, researchers, and the people interested in this topic. The book is expected to present works that aim to contribute to the development of new technologies and the use of non-traditional materials in engineering.
In recent years, there has been a great deal of attention toward the field of free radical chemistry. Our body generates free radicals of reactive oxygen species or reactive nitrogen species by various endogenous systems, exposure to different physiochemical conditions. To balance the free radicals and antioxidants is necessary for proper physiological function. If we can regulate free radicals to reduce the potential reactive oxygen species over tension on body’s ability, it will not cause oxidative stress damage. Free radicals thus do not adversely alter lipids, proteins, DNA and trigger many diseases. As a result application of an external source of antioxidants likes oral hydrogen water can assist in coping this oxidative stress.
\nThis metabolism phenomenon also occurs in many other animals or even insects that are less evolved. In 1946, the fruit flies were successfully carried out by National Aeronautics and Space Administration (NASA) for the biological experiments in space. About 75% of the genetic code of fruit flies has similarities to all human pathogenic genes. Insect life is much shorter than human. Drosophila flies also has found free radicals in their cells. The scientists take Drosophila to study aging effects much efficiently due to shortening the time in experiments. It is an important reason why studying
According to past research reports, fasting or severely hungry animals will rapidly accumulate a large number of free radicals in cells because of lack of well physiological functions. Excessive free radicals, however, can damage the cell’s genetic material and cell membranes, eventually killing the fruit fly. And the flies of the mutant species are more likely to accumulate free radicals in vivo because the chromosome of the Drosophila cell, an enzyme gene that removes peroxidase free radicals by hydrazine, is removed so that the number of free radicals is out of control. Although the fruit fly of this mutant species can still develop to adults, its lifespan is shorter than that of wild fruit flies. I used this kind of fruit fly to do experiments because they have accumulated many free radicals in the body, and alkaline hydrogen water (negatively charged) can neutralize positively charged free radicals, so feeding hydrogen-water on the mutant flies are more evident than wild species. In the course of the experiment, I found that the mutant flies fasting (stop feeding water), causing the flies to die. It proved that the fruit fly did have poor anti oxidative stress, so I did not fast-feed the fruit flies in advance during the experiment. Only for the wild flies, fasting beforehand.
\nIn the study, the experimental result shows that the mutant fruit flies of
The untreated tap water is almost neutral at about pH 7.0 with a positive oxidative potential of +150 mV. The tap water after filtered and electrolysis treated, the cathode hydrogen dissolving water belongs to be alkaline at a pH over 8.0 with a relatively high negative reductive potential of −150 to −300 mV. Recently, a lot of literatures [1, 2, 3] found that drinking hydrogen water increases the activity of a critical detoxifying enzyme of superoxide dismutase in the body. It protects against free radicals toxic damage on protein, enzyme, DNA, lipid, and membrane in cells (see Figure 1). Since the alkaline hydrogen water molecules with an extra amount of free electrons, which can neutralize the highly reactive free radicals before free radicals take away free electrons from intracellular molecules.
\nFree radicals toxic damage on protein, enzyme, DNA, lipid, and membrane.
Water, which constitutes over 70% of the body, is involved in virtually every function of life. It forms the bodily fluids, such as blood, lymph, cerebrospinal fluid, saliva, and digestive fluids to regulate the metabolism of joint lubrication, detoxification, and maintaining the blood pressure. While the water molecules around the cell membranes, they show a long-range ordering feature and like an epitaxial liquid crystal with distinct properties from the bulk state [1]. Shirahata et al. [2] showed that drinking hydrogen water increases the activity of a critical detoxifying enzyme, superoxide dismutase (SOD), which exists in humans, animals, plants, and micro-organisms, as an essential antioxidant to protect cell under oxidative stress damage in vitro. Superoxide is one of the primary reactive oxygen species in the cell. So SODs serves a key antioxidant role. This antioxidant function exerted by molecular hydrogen has been proved [3]. In the rat model, drinking hydrogen water showed signs in the decrease of the peroxided lipid level in their urine. When comparing to tap water to hydrogen-water, the rat drinks hydrogen-water can extended to live 20–50% longer [4]. Finally, we studied the survival rate of drinking hydrogen-water on Drosophila flies after fasting, which related to the regulatory function of oxidative stress attacked by free radicals in cells.
\nDrosophila lacking SOD1 has a dramatically shortened lifespan, whereas fly lacking SOD2 will die before birth. Lacking SOD3 does not show any visible defects and exhibit an average lifespan, though more sensitive to hyper oxidative injury.
Female (left) and male (right) of
The wild-type and mutant-type flies obtained from the
For the control group, every two tubes are wild and mutant species of fruit flies feed with pure water of pH 7. One is female fly, and another is male fly. For the treatment group, every four tubes are wild and mutant species with the female and the male ones fed with alkaline hydrogen water of pH 8.5 and 9.5, respectively. Generally, regardless of whether it is a wild fruit fly or a mutant fruit fly, in the fasting state, feeding of hydrogen water has a significant increase in the survival rate (see Figures 3, 4, 5, 6).
\nSurvival percent in % of female-mutant fruit flies vs. day after fasting. Note: pH 7: pure water; pH 8.5: weak-alkaline-H2-water.
Survival percent in % of male-mutant fruit flies vs. day after fasting. Note: pH 7: pure water; pH 8.5: weak-alkaline-H2-water.
Survival percent in % of female-wild flies vs. day after fasting. Note: pH 7: pure water; pH 8.5: weak-alkaline-H2-water; pH 9.5: medium-alkaline-H2-water.
Survival percent in % of male-wild flies vs. day after fasting. Note: pH 7: pure water; pH 8.5: weak-alkaline-H2-water; pH 9.5: medium-alkaline-H2-water.
If we compare with the results of the mutant and wild species, the mutant fruit fly of males to feed weak alkaline hydrogen water of pH 8.5 is the most significant change in survival among them (see Figure 3 vs. Figure 5; Figure 4 vs. Figure 6). In the case of feeding mutant flies with pure water of pH 7, for example, when fasting for more than 4 days, half number of deaths occur. If weak alkaline hydrogen water of pH 8.5 fed, it will delay to more than 9 days to happen it (see Figure 3). That is about a twice of increase in the lifespan. Therefore, a weak alkaline hydrogen water of pH 8.5 seems to have a positive effect on the survival rate of flies in the state of starvation.
\nPast research results have shown that the average lifespan of females is longer than that of males. Our experimental results showed that the effect in response to the feeding of hydrogen water, the male-fly was significantly more than the female-fly for all the wild and mutant species. While the case of feeding wild flies with pure water, for example, fasting for more than four to 6 days, to dead a half (see Figures 5 and 6). If hydrogen water supplied, fasting time of female fly and male fly extended for more than 7 days. However, hydrogen water seems to have a less help on the survival rate of wild female flies in the state of starvation (see Figure 5). This result implies that hydrogen water appears to be of much more help to individuals with weaker constitutions than to individuals who have stronger ones.
\nTested for the relationship between the alkaline pH (pH 8.5 and 9.5) and the survival response. Our previous results have shown that drinking hydrogen water seems to be helpful for the survival rate of Drosophila in the case of starvation. Therefore, it is worthwhile to analyze hydrogen water in alkalinity further the impact on the survival rate of Drosophila. When the pH of the hydrogen water increased from 8.5 to 9.5, after fasting time more than 4 days the significant increase in the survival rate of the male fly observed in Figure 6. However, for the female fly, the result is not the same. Interestingly, although the wild species of female fruit fly, hydrogen water increased from pH 8.5 to 9.5, the survival response was slightly decreased. That is to say, further addition in alkalinity, however, has the opposite effect on the female flies, and the survival rate does not rise any longer.
\nIn the past, many works of literature have reported that human aging may be related to the function of free radicals to destroy cells. However, why do free radicals come? For example, the role of cells depends on the oxidation and decomposes the nutrients in the body. It is like gasoline, which burns oxygen to release heat energy and promote steam. However, in the process of redox, cells produce a byproduct, oxygen free radicals. The oxygen molecule (O2) itself has 16 electrons, but it loses one electron in the process of the redox reaction, and the oxygen that becomes a single electron becomes very unstable, and it will destroy the function of the cell and even cause disease. Interestingly, if the neutral water is decomposed using a water electrolysis generator, the water molecules will change to negatively charged alkaline hydrogen water. If the electrolytic liquids are separated, acidic water will act like oxygen free radicals to destroy the cells. However, hydrogen water is the opposite, with an extra free electron, which can combine with free radicals to neutralize the ability to equilibrate free radicals before free radicals take away an electron from intracellular molecules. Therefore, hydrogen water may have anti-oxidant function and protect cells from free radical damage.
\nThis experiment supports that drink hydrogen water may help the fasting fly survival rate. When oxygen free radicals in the intestine are out of balance, hydrogen water may neutralize free radicals and reduce damage to cells. Drosophila has an innate immune system similar to humans, and the structure and physiology of the fruit fly’s gastro-intestine, cardiac, and neurological diseases resemble that of humans. Even if the genes and mechanisms that they are involved whether conserved or not, the biological process in a similar genes species often provides a valuable framework to study anti-oxidative stress effect and allow development of potential clinical applications.
\nWhen Drosophila intestinal oxygen free radicals increase due to fasting, the increased reactive oxygen species in the intestine pass through nitric oxide, erythrocytes, and another non-nitric oxide signal to activate transcription of NF-κB protein in the fat of Drosophila. The factor, Drosophila liver, promptly initiated in the response of cells to many stimuli, including oxidative stress, cytokines, free radicals, ultraviolet radiation, and immune response of the antibacterial peptide, causing a systemic immune response in the Drosophila. The biological model of Drosophila used to simulate that the immune response of human organs is closely related to intestinal health [7].
\nHowever, this does not mean that drinking hydrogen water is beneficial to all healthy individual because, in the body, some enzymes that regulate free radicals, which can balance the problems caused by the accumulation of free radicals. Therefore, drinking a significant amount of hydrogen water in a healthy state may be interference to the body’s natural regulation mechanism. In other words, as healthy people do not need and should not take medicine, only those who are sick need to follow the doctor’s instructions. All in all, the function of hydrogen water on the human body needs further experiments to be further studied. This experiment can only support the flies in the extreme unfavorable environmental pressure; feeding hydrogen water may increase its survival rate.
\nAbout 7% of the population >65 years suffer from a painful heel, even though younger people are often affected, too [1]. The most common cause of this symptom is the so‐called “plantar fasciitis” [2]. This term is widely used, although “plantar fasciopathy” or “plantar fasciosis” would be a better description to point out the degenerative nature of the disease. However, as more than 1100 citations in Pubmed quote “plantar fasciitis” (in comparison with only 50), we will use the traditional term in the following.
Plantar fasciitis has been associated with obesity, with acute or chronic work overload, or with work on hard surfaces [2, 3]. It seems that physiological degeneration of the fascia at the calcaneal insertion exacerbates due to repetitive microtraumas caused by vertical compression [4]. This causes inflammatory tissue reactions. As a result, the fascia is thickened with an associated fluid collection to 4.0 mm and more in ultrasonography [5]. Furthermore, this inflammation may trigger bone formation, the so‐called “plantar heel spur.” This process has been studied intensively by Kumai and Benjamin [6]. They proposed three stages of spur growth: “(a) an initial formation of cartilage cell clusters and fissures at the plantar fascia enthesis; (b) thickening of the subchondral bone plate at the enthesis as small spurs form; and (c) development of vertically oriented trabeculae buttressing the proximal end of larger spurs” [6]. The first description of this spur formation and correlation with the clinical symptoms was carried out by Plettner in 1900 [7]. However, not every heel spur is associated with heel pain, as these spurs are found in 11–16% of the normal asymptomatic population [4]. On the other hand, some patients with painful plantar fasciitis do not have a radiographic confirmation of a spur formation.
A similar mechanism (although caused by longitudinal traction and not by vertical compression) of bone formation has been described at the insertion of the Achilles tendon [8].
According to the American clinical practice guidelines from 2010, diagnosis is established by the typical anamnesis and the characteristic localizations of tenderness. Still, weight‐bearing radiographs are also recommended [9].
Single doses of external beam radiotherapy (EBRT) in the range of 0.3–1 Gy are called “low dose EBRT” (LD‐EBRT). These single fractions are applied two or three times a week until a total dose of about 3–6 Gy is reached. Such radiotherapeutic concepts are used for diverse nonmalignant conditions, e.g., osteoarthrosis, tendinopathy, epicondylitis, or bursitis. A comprehensive review of the historical developments in LD‐EBRT for benign diseases is given by Trott [10].
In contrast, EBRT in oncology is characterized by much higher single and total doses. “Normofractionation” describes single doses of 1.8–2 Gy, applied about five times a week. To treat breast cancer, the total doses of about 62 Gy are necessary, in prostate cancer even more than 72 Gy. From a radiobiological point of view, these high cumulative doses are used to induce DNA double strand breaks. Due to errors in a repair mechanism (nonhomologous end joining), dicentric chromosomes can occur. These can result in unfinished mitoses, the so‐called “mitotic catastrophe,” the main mechanism to reduce clonogenic survival in tumor cells [11]. High doses of EBRT induce local inflammation and tissue reactions.
The much lower doses of LD‐EBRT act via different mechanisms. In the last two decades, several anti‐inflammatory effects have been discovered, contrary to the effects of the above‐mentioned high EBRT doses.
Furthermore, doses between 0.1 and 0.5 Gy reduced the adhesion of PBMC significantly to endothelial cells (ECs)
A third mechanism was the suppression of nitric oxide (NO) production in activated macrophages by LD‐EBRT between 0.3 and 1.25 Gy [18]. As the expression of inducible nitric oxide synthases (iNOS) proteins was not altered, the LD‐EBRT seemed to act at the translational or posttranslational level. Furthermore, a dose of 0.5 Gy significantly reduced oxidative burst and superoxide production of stimulated macrophages [19]. A diminished release of reactive oxygen species (ROS) can also contribute to the anti‐inflammatory effects of LD‐EBRT.
Taken together, all of these pathways and mechanisms showed a similar dose dependence with a maximum effect between 0.3 and 0.7 Gy regarding a discontinuous dose‐effect relation [20].
There are several
Since 1937 [21] for decades, large retrospective studies on the efficacy of LD‐EBRT in calcaneodynia have been published (overview in 22). In 1970, one negative randomized trial was reported and heavily criticized but had not been repeated [23]. Starting in the 1980s, patients were systematically clinically examined and interrogated in a structured manner to try to control for diverse risk factors and to compare the efficacy of different fractionation schemes and total doses [24].
It took until the past decade to perform and report prospectively randomized trials to proof the efficacy of LD‐EBRT and to identify the optimal dose fractionation schedule. In the following, we report the design and the results of these trials. Table 1 gives a short overview of the studied dose concepts and the results. Due to methodological reasons, we will describe the studies not following their publications dates, but according to a systematic order.
Since the publication of the first randomized trial on LD-EBRT in 1970, the efficacy of LD‐EBRT was questioned [23]. Goldie et al. randomized 399 patients, however, only nine patients suffered from calcaneodynia. This is why these results cannot be extrapolated to LD‐EBRT of a painful heel spur. Furthermore, endpoints were not clearly defined, and therapy was started in an acute stage of the disease [25].
The landmark study to prove the efficacy of LD‐EBRT was performed by the German cooperative group on the radiotherapy for benign diseases (GCGBD) under the responsibility of Niewald et al. [26]. A very low dose EBRT (6 × 0.1 Gy applied twice a week up to a total dose of 0.6 Gy) was randomized to a standard dose LD‐EBRT (6 × 1 Gy twice a week up to a total dose of 6 Gy). In the case of an unfavorable response after 3 months, the patient was offered a second treatment series (“reirradiation”) applying a standard dose. The dosage of the experimental arm was chosen to examine if very low doses are effective at all. Second, it acted as a placebo irradiation, as a sham irradiation was regarded unethical. LD‐EBRT was applied using a linear accelerator (4‐ to 6‐MV photons) using lateral parallel opposing fields.
Inclusion criteria were tenderness of the calcaneus with a limitation of the painless walking distance and duration of the symptoms for more than 6 months. Furthermore, a radiological proof of a heel spur was required, and the patients had to be least 40 years of age. Patients with previous traumata to the foot, rheumatic or vascular diseases, lymphatic edema, pregnancy, or breastfeeding were excluded. Concomitant therapy with oral analgesics was not limited. However, local injections with steroids during the study period were not permitted.
Initially, 200 patients were planned [27] to detect a difference of 10% in the quality of life (QOL) sum score (SF‐12) [28] and calcaneodynia sum score (CS) [29] (Table 2) with a power of 80% and an error probability of 5%. Furthermore, the visual analogue scale (VAS) to evaluate pain intensity was used. However, after randomization of 66 patients and interim analysis of 62 patients (4 had to be excluded due to a withdrawal of informed consent or violation of the inclusion criteria), the differences in efficacy between the two treatment arms were so pronounced, that the trial was closed early.
Author | Year | N | Standard arm | Experimental arm | Results | Conclusions |
---|---|---|---|---|---|---|
2012 | 66 | 6 × 1 Gy twice a week | 6 × 0.1 Gy | 3 months: VAS/CS/SF12 sig. better with standard | 1. Dose‐response relationship | |
1 year: less second treatment series with standard | 2. Proof of therapeutic effect of LD‐EBRT | |||||
2007 | 130 | 6 × 1 Gy twice a week | 6 × 0.5 Gy | 6 months: CS no sig. differences | 6 × 0.5 Gy as standard fractionation | |
2014 | 457 | 6 × 1 Gy twice a week | 6 × 0.5 Gy | 6 weeks, 2.5 years: VAS/CS no sig. differences | 6 × 0.5 Gy as standard confirmed | |
2015 | 127 | 6 × 1 Gy twice a week | 12 × 0.5 Gy thrice a week | 3 months: VAS/CS/SF12 no sig. differences | Efficacy not increased with 12 × 0.5 Gy standard still 6 × 0.5 Gy |
Summary of contemporary randomized trials on LD‐EBRT of painful heel spurs: tested schedules, results, and conclusions.
Criteria | Extent of symptoms/alteration | Points |
---|---|---|
S = Pain at | 6 / 4 / 2 / 0 | |
(total: 30%) | N = Pain during D = Pain during R = Pain at I = Pain at none = 6 ; slight = 4 ; moderate = 2 ; severe = 0 points ⇨ | 6 / 4 / 2 / 0 6 / 4 / 2 / 0 6 / 4 / 2 / 0 6 / 4 / 2 / 0 |
per single criterion | ||
(total: 15%) | None Orthopedic shoe, insoles, heel cushion One cane or crutch Two canes or crutches ⇨ | 15 10 5 0 |
(total: 20%) | No limitation, maximum professional strain possible Slight limitation, normal professional work possible Moderate limitation, reduced professional activity Severe limitation, daily professional work impossible ⇨ | 20 10 5 0 |
(total: 15%) | No limitation of daily and leisure activities and sports Slightly limitation/reduced leisure activities and sports Moderate limitation/no leisure activities and sports Complete limitation of any daily and leisure activities ⇨ | 15 10 5 0 |
(total: 20%) | No limp, normal walking is possible without a limitation Slightly altered, limp after walking Moderately altered, limp after walking Severely altered, normal walking is impossible ⇨ | 20 10 5 0 |
The mean age of patients was 54 years in the standard dose group and 58 years in the 6 × 0.1 Gy group. Sixty‐one patients had a plantar, one patient a dorsal heel spur. In mean, patients in the standard dose group suffered for 15.3 months before the start of LD‐EBRT, in the 6 × 0.1 Gy group for 18.8 months. Twenty‐one patients had symptoms on both sides. In 28 patients the pain irradiated into the calf, only in 18 patients it was localized to the sole of the foot. Two patients had received surgery for LD‐EBRT.
Three months after therapy VAS values, CS‐ and QOL‐scores were significantly better after the standard dose in comparison with the very low dose treatment arm. The higher pain relief resulted in a better QOL. Twelve months after therapy about 64% of the patients after 6 × 0.1 Gy had to receive a second treatment series due to insufficient treatment results, in comparison with only 17% of the patients in the standard dose treatment group. As the second series was applied with a standard dose (6 × 1 Gy), patients in the 6 × 0.1 Gy group who were reirradiated showed equally favorable results compared with those in the standard‐dose group who did not receive a second course [26]. This is why the second treatment series in this clinical setting acted as a “salvage therapy.” Another interesting finding was that patients with a good response already at 3 months remained stable or even improved at 12 months. Furthermore, this underlines the long‐lasting efficacy of LD‐EBRT.
Acute side effects or long‐term toxicity did not occur.
In conclusion, this randomized trial established a dose‐response‐relationship of the analgesic effect of LD‐EBRT, thus providing a clinical and methodological proof of the efficacy of 6 × 1 Gy LD‐EBRT on the clinical course of painful heel spurs. The early termination of the study was justified due the interim analysis showing significant differences in the clinical outcome between both treatment arms. Still, the trial was not blinded, so both the patients and the staff were aware of the received dose. With modern linear accelerators, a complete blinding of the staff is nearly impossible. The only option would be a shame irradiation with closed collimator jaws, reducing the dose to the unavoidable “leakage” radiation. A much easier and straight forward way was used in the above‐mentioned study by application of a minimal physical dose with 0.1 Gy. Another critical point might be that only half of the patients were examined 12 months after therapy (
Another potential confounder not only in this study but also in all other published prospective and retrospective case series might be that a lot of the patients had received diverse and other conservative therapies before being referred to LD‐EBRT. An interaction between one of these other treatments and LD‐EBRT cannot be ruled out due to methodological reasons. This reflects clinical reality. Still, an interaction between one of these therapies and LD‐EBRT is rather unlikely and counter‐intuitive, as patients were referred to LD‐EBRT after the clinical failure of all the other conservative treatments.
Two randomized studies investigated the efficacy of 0.5 Gy single dose in comparison to 1 Gy.
The first trial was conducted by Heyd et al. [30]. They randomized 130 patients between 6 × 0.5 Gy twice weekly (low dose) and 6 × 1 Gy (standard dose). A linear accelerator was used, applying a single field technique.
Inclusion criteria were clinical signs of a painful heel spur, radiological evidence of spur formation, patient age ≥30 years and a relapse after previous conservative treatments, in patients >45 years LD‐EBRT could be used as the primary treatment. Endpoints of the study were changes in the “original” calcaneodynia score [31], that was documented before LD‐EBRT, at the end of the course, and 6 weeks and 6 months afterward.
One hundred and thirty patients were randomized. Mean age was 58.4 years. A 102 patients suffered from a plantar, one patient from a dorsal, and 27 patients from combined spurs. In mean, patients had been suffering from symptoms for 9.8 months. The symptoms had been present in 58 patients for less than 6 months, in 72 patients for a longer time. In 7 heels LD‐EBRT was the first therapeutic approach.
At the end of LD‐EBRT, 66% in the low dose group vs. 59% in the standard dose experienced an improvement in symptoms, 6 weeks later 80 vs. 85%. At this time point, 1.5% in each group reported an increase in symptoms, 19 vs. 14% no change. No statistically significant differences were noted. In case of insufficient treatment results patients were offered a second EBRT series. Thus 26 vs. 37% were treated a second time. Six weeks after that, 71 vs. 79% of these patients reported a further improvement. Six months after LD‐EBRT 88% of the patients in both groups had an amelioration of their symptoms, the remaining patients reported no change. During the EBRT series a slight increase in pain was reported by 26 vs. 29% of the patients. No other acute or late toxicity occurred.
In conclusion, 6 × 0.5 Gy twice weekly was as effective as 6 × 1 Gy.
These results were confirmed by a second randomized trial [32, 33]. Ott et al. randomized 457 patients between 6 × 0.5 Gy (low dose) and 6 × 1 Gy (standard dose). In contrast to the above‐cited “Heyd‐study” [30] an X‐ray unit (orthovoltage) and not linear accelerators was used. Patients received a single field (6 × 8 cm on the plantar calcaneus) with 150 kV, 15 mA, 1 mm Cu‐filter, with source‐to‐skin distance (SSD) of 40 cm. Six weeks after the LD‐EBRT a second series was offered to patients with an insufficient response. The endpoint was pain reduction. CS score and VAS values were measured before and at the end of LD‐EBRT (early response), 6 weeks (delayed), and 2.5 years (long‐term) afterward.
With a median follow‐up of 32 months the mean VAS values before treatment, for early, delayed, and long‐term response for the 0.5 and 1.0 Gy groups were 65.5 ± 22.1 and 64.0 ± 20.5 (
Taken together, the above‐mentioned studies proofed an equivalent clinical efficacy of 6 × 0.5 Gy in comparison to 6 × 1 Gy, thus defining a new clinical treatment standard with six times 0.5 Gy twice weekly as the minimum effective dose.
Before proofing 0.5 Gy as the new standard single dose, another randomized study tried to increase efficacy in reaching the “old” cumulative dose of 6 Gy with a single dose of 0.5 Gy. Niewald et al. randomized between 6 × 1 Gy twice a week (old “standard dose”) and 12 × 0.5 Gy three times a week (“experimental dose”) [25]. The aim was not just to get comparable results, but to further improve the analgesic effects. Linear accelerators (6 MV photons) applying a lateral opposing field technique were used.
Inclusion and exclusion criteria were quite similar to the ones used in the landmark study [26]: Clinical evidence of a painful heel spur, and duration of the symptoms for more than 6 months; radiological proof of a spur formation; age at least 40 years; Karnofsky‐Index at least 70%. Patients with previous radiotherapy or previous trauma to the foot, rheumatic or vascular diseases, lymphatic edema, pregnancy, breastfeeding, or severe psychiatric disorders were excluded. Concomitant therapy with analgesics was allowed. However, patients receiving surgery or shock wave therapy after randomization were excluded.
Endpoints were the SF‐12 sum score, the CS sum score (Table 2), and VAS. Follow‐up was scheduled every 6 weeks for 1 year.
Two‐hundred and forty patients were calculated to detect a difference of 15% in the VAS and CS score, with a power of 80%, and an error probability of 5%. After randomization of 127 patients and an interim analysis of 107 patients, the study was closed early, as the intended increase in analgesic efficacy by the experimental treatment was very unlikely to be achieved.
The mean age of the patients in the standard group was 56.1 Gy in comparison with 58.1 Gy in the experimental group. The mean duration of symptoms before initiation of LD‐EBRT was 17 vs. 16 months. In 98% of the standard group and 93% of the experimental group a plantar spur was treated, in 2 and 7% a combined (plantar and dorsal) spur.
Results after 3 months have been issued so far [25], longer follow‐up has yet to be published. After 3 months, there were no significant differences neither in the VAS (standard 42.3 vs. experimental 44.4) nor the CS sum score (28 vs. 28.4) nor in the QOL (SF‐12) scores. Although longer follow‐up has to be awaited, a further increase in the analgesic effect by applying 12 × 0.5 Gy three times a week is unlikely. This is why this fractionation schedule is currently not recommended, as it does not follow the “as low as reasonable achievable” principle of radiation protection.
Further reduced single doses in LD‐EBRT (with the exception of 0.1 Gy [26]) have never been tested in a prospectively randomized clinical trial. In radiotherapy of degenerative joint disorders, single doses of about 0.3–0.4 Gy were established by von Pannewitz in the late 1920s and published in 1933 and 1970 [34, 35]. However, two studies on calcaneodynia have raised serious concerns on single doses as low as 0.3 Gy.
Seegenschmiedt et al. analyzed treatment efficacy in 141 patients (170 irradiated heels), who were treated from 1984–1994 with X‐ray units (250 kV/200 kV, 20 mA, 40 cm SSD), applying a single field of 6 × 8 cm [24]. Seventy‐two heels received 12 Gy with 6 × 1 Gy (three times a week) –6 weeks break – 6 × 1 Gy (group A), 50 heels were treated with 10 × 0.3 Gy every day (group B1), and 38 heels 10 × 0.5 Gy every day (group B2). The endpoint was the value of a semiquantitative pain score 3 months and in mean 4 years after LD‐EBRT.
The median age of patients was 55 years in group A and 59 years in group B1/B2. The mean duration of symptoms before LD‐EBRT was 8 months, in one‐third, the symptoms persisted for more than 6 months.
Complete pain remission was achieved in 68–71% of the patients without significant differences between the treatment groups. However, there were differences in the clinical course of patients with partial remission of the symptoms: The best results in these patients were achieved during longer follow‐up in group B1 (10 × 0.5 Gy), followed by group A (6 × 1–6 × 1 Gy), followed by group B2 (10 × 0.3 Gy). The latter group showed a significantly worse amelioration of symptoms than the other groups.
A reduced efficacy was also reported in another retrospective case series, comprising 673 heels treated with a single dose of 0.3 Gy three times weekly up to 1.5 Gy (X‐ray) [36]. In case of insufficient treatment results the patients were offered a second course. After the first treatment, only 13% reported CR, nearly all patients had undergone a second LD‐EBRT.
Taken together, to the best of our current knowledge a single dose of 0.5 Gy is standard of care and should only be modified in controlled clinical trials.
In Table 3 selected contemporary randomized trials and patient series are shown broken down into several factors that might be correlated with treatment efficacy. For a better overview, we did not differentiate between univariate and multivariate analyses. We did not try to collect all ever published data.
Duration of symptoms before start of LD‐EBRT has been shown to be correlated with treatment efficacy in numerous studies.
Muecke et al. analyzed in a retrospective multicenter study 502 patients [22]. Duration of symptoms ≤6 months was associated with 76% treatment success vs. 44% after a history >6 months. Also Seegenschmiedt et al. found in their large collectives a correlation between the duration of heel pain and treatment outcome [24]. A significant influence of duration of symptoms before LD‐EBRT was also reported in 73 heels by Schneider et al. [37]. With a history of 3–6 months, the VAS value was reduced by 85%, 28 months after LD‐EBRT in comparison with a reduction of 58% with a history > 6 months. Similar results were obtained by Hermann et al. in 285 heels comparing <12 month history of pain vs. >12 months [38].
In contrary, another study could not confirm these results [30].
To the best of our knowledge, in no study, an influence of gender on treatment outcome has been confirmed [22, 24, 30, 38, 39]. In contrast to radiotherapy for oncological indications with high doses, efficacy and tolerability of LD‐EBRT seems to be the same concerning gender.
Several studies described a correlation between older age and better treatment results, at least 6 weeks after LD‐EBRT [37]. Age somewhat over 50 years seems to be important: >50 years [40], > 53 [38], or > 58 [22]. For a possible explanation see Section 2.3.7.
However, other studies found no influence of this patient characteristic on treatment outcome [24, 30, 39].
A very precise registration of changes in pain intensity (VAS) was done by Schneider at al. [37]. Sixty‐two patients (73 treated heels) were prospectively scored every week during LD‐EBRT, at the end of therapy, 6 weeks, 28 months, and 40 months later. Additionally, subjective mechanical heel stress during LD‐EBRT was estimated. A linear accelerator (10 MV) was used, applying one single field with a size of 12 × 17 cm. Patients were treated twice a week to a total dose of 5 Gy, with increasing single fraction doses (0.25 – 0.25 – 0.5 – 1 – 1 – 1 – 1 Gy). Mean patient age was 54 years, and all had a radiologically proven plantar spurn, mean symptom duration before LD‐EBRT was 6.5 months. Nearly all patients had received other conservative therapies before LD‐EBRT with insufficient results.
Interestingly, VAS scores decreased continuously during LD‐EBRT: before treatment the mean value was 6.3 ± 1.5, after the first week of LD‐EBRT 6.2 ± 1.8, after the second week 5.5 ± 2 (
In standard schedules with fixed single doses a slight increase in pain during the treatment series was reported by 26% (during 6 × 0.5 Gy) vs. 29% (6 × 1 Gy) of the patients [30]. Unfortunately, a possible correlation of this phenomenon with definite treatment results was not investigated.
Without further quantification, another study (6 × 1 vs. 6 × 0.1 Gy) stated, that this initial increase in symptoms “had no influence on the final pain relief 3 and 12 months after treatment” [26]. Older studies postulated a temporary reduction of the pH value in the irradiated tissues at the beginning of the treatment series, without consequences for the long‐term efficacy of LD‐EBRT [41].
This is contrasted by observations of LD‐EBRT in peritendinitis humeroscapularis [42]. In 73 patients (86 shoulders) initial increase of pain during the treatment course was significantly associated with a good response.
Muecke et al. analyzed in a retrospective multicenter study the influence of different treatment techniques in 502 patients [22]. Treatment failure was defined as pain persistence after LD‐EBRT and recurrence of pain during follow‐up. Treatment with MV (6–10 MV) was a significant prognostic factor for pain relief in multivariate analysis, as MV was associated with an eight‐year event‐free probability of 68 vs. 61% after X‐ray beams (175 kV). There are two possible explanations for this finding: besides the possibility of a random result, the authors postulate a more homogenous dose distribution with MV treatment in comparison with KV [22].
Schneider et al. reported an efficacy of just one‐third after a second LD‐EBRT course (so‐called “re‐irradiation”) in comparison with the effects of the first course [37]. Out of 73 heels treated with 5 Gy LD‐EBRT 18 heels received reirradiation due to insufficient treatment response. However, pain reduction measured by means of changes in VAS shortly after the second course and during long‐term follow‐up was significantly diminished in comparison with the efficacy of the first course (about 30% reduction in pain at the last evaluation vs. 86%).
Similar results were obtained in the large retrospective series (502 patients) by Muecke et al. [22]. Treatment failure was significantly associated with the number of treatment series: eight‐year event‐free probability was about 70% after the first course in comparison with just about 30% after reirradiation.
A systematic study on the efficacy of a reirradiation has been published by Hautmann et al. [43]. Eighty‐three patients (101 heels) with insufficient response to the first course or recurrent pain afterward due to plantar fasciitis (83 heels), or achillodynia (28 heels) received a second LD‐EBRT course in median 10 weeks (range 4 weeks to 63 months) after the first LD‐EBRT. About 75% of the patients were treated with 6 × 1 Gy, the others 6 × 0.5 Gy. The pain was assessed using the numeric rating scale (NRS) before and at the end of LD‐EBRT, 6, and 12 weeks, and 6, 12, and 24 months thereafter.
Before reirradiation NRS values were 6 (interquartile range 5–8), at the end of LD‐EBRT 5 (2–6), 6 weeks later 2 (1–4), at 12 weeks 1 (0–3), at 6 months 0 (0–2), at 12 and 24 months 0 (0–1). Interestingly, not only the patients with recurrent pain after the first course but also patients with insufficient responses to the first course experienced a profound and long‐lasting amelioration of their symptoms after the second course.
This is why a second treatment course should be recommended in case of insufficient efficacy of the first course.
A significant correlation between avoidance of heel stress during LD‐EBRT and efficacy of LD‐EBRT 6 weeks after therapy was reported by Schneider et al. in 73 heels [37]. With a Pearson\'s correlation coefficient of -0.467 (
An intuitive explanation is given by the authors [37]: As patient age was associated with positive treatment results, too, they proposed that older patients are often retired, thus being able to take more care of their heels.
Interestingly, all randomized trials required the radiological proof of a heel spur before including patients into the studies. Furthermore, most of the prospective and retrospective series warranted such an objective sign. However, as a substantial part of the patients suffers from plantar heel pain without having developed a heel spur, LD‐EBRT should be effective in these patients, too.
Hermann et al. analyzed treatment efficacy in 250 patients (285 heels), who received LD‐EBRT predominantly with 6 × 1 Gy [38]. In this series, 33% of the treated heels were without radiological evidence of a spur. In 185 patients a spur was confirmed with a mean length of 6.5 mm (range 0.6–25 mm). Patients without evidence of a plantar heel spur had a significantly higher chance of CR after LD‐EBRT (43 vs. 35%). Furthermore, the length of the spurs correlated directly with treatment outcome. Spurs >6.5 mm had just a 30% chance of experiencing CR in comparison with shorter ones. No statistical differences were found between treatment results of heels without spurs and those with spurs ≤6.5 mm.
Miszczyk et al. reported on 327 patients (623 LD‐EBRT series) mostly treated with X‐ray (180 kV, usually 1mm Cu filters) with single doses of 1.5 Gy (range 1–3 Gy) up to a total dose between 9 and 12 Gy (range 1–45 Gy) [39]. Mean spur size was 9 mm (range 1–30 mm). With a mean follow‐up of 74 months, no correlation between spur size and duration of pain relief was found. Analysis concerning spur length and treatment outcome in itself were unfortunately not reported.
Multivariate logistic regression enables the identification of factors independently predicting treatment outcome. By combining these factors, models can be calculated, that predict treatment outcome with a high probability. An example from the study of Hermann et al. is given in Table 4: in 285 heels treated with 6 × 1 Gy/6 × 0.5 Gy the influences of the patient characteristics age, spur length, and duration of symptoms before LD-EBRT alone and in combination were calculated [38]. The best results were obtained for patients > 53 years, spur length <6 mm, and a duration of symptoms <12 months with a probability for CR of 55% (CI 36–73%) and PR of 38% (CI 22–58%). Without these characteristics, the chance for CR was just 18% (CI 9–33%), for PR 31% (17–48%).
Study (citation) | [30] | [26] | [24] | [37] | [39] | [22] | [38] | [40] | [83] |
---|---|---|---|---|---|---|---|---|---|
Rand | Rand | Prospect | Prospect | Retrospect | Retrospect | Retrospect | Retrospect | Retrospect | |
130 | 66 | 170 | 73 | 623 | 502 | 285 | 161 | 7947 | |
MV | MV | KV | MV | KV | MV, KV | MV | KV | MV, KV | |
calcaneus | calcaneus | calcaneus | entire dorsal and middle foot | insertion of plantar fascia | calcaneus | calcaneus vs. insertion of calcaneus | calcaneus | entire dorsal foot vs. calcaneus vs. insertion of plantar fascia | |
6 × 1 vs. 6 × 0.5 Gy | 6 × 1 Gy vs. 6 × 0.1 Gy | 12, 3, 5 Gy | 5 Gy (increasing single dose) | 1.5 (1–3) up to 9–12 Gy (1–45) | 5–10 × 0.5–1 Gy | 6 × 1 Gy6 × 0.5 Gy | 6 × 1 Gy | 0.3–1.5 Gy; 2–3x weekly 2.5–18.76 Gy | |
History of symptoms | 0 | n.i. | + | + | 0 | + | + | + | + |
Gender | 0 | n.i. | 0 | n.i. | 0 | 0 | 0 | n.i. | n.i. |
Patient\'s age | 0 | n.i. | 0 | + | 0 | + | + | + | n.i. |
Initial worsening of pain during LD‐EBRT | n.i. | n.i. | n.i. | n.i. | n.i. | n.i. | n.i. | n.i. | n.i. |
MV vs. KV | n.i. | n.i. | n.i. | n.i. | n.i. | + | n.i. | n.i. | 0 |
Number of therapy series | n.i. | n.i. | n.i. | + | n.i. | + | n.i. | n.i. | + |
Heel stress during LD‐EBRT | n.i. | 0 | n.i. | + | n.i. | n.i. | n.i. | n.i. | n.i. |
Factors associated with treatment efficacy in contemporary studies.
Patient\'s age >53 | No spur or spur ≤6.5 mm | Duration of symptoms <12 months | Probability of | ||
---|---|---|---|---|---|
No change | Partial remission | Complete remission | |||
1 | 1 | 1 | 0.07 (0.03–0.14) | 0.38 (0.22–0.58) | 0.55 (0.36–0.73) |
1 | 1 | 0 | 0.13 (0.07–0.28) | 0.37 (0.21–0.57) | 0.50 (0.30–0.70) |
1 | 0 | 1 | 0.15 (0.06–0.24) | 0.53 (0.33–0.72) | 0.32 (0.17–0.53) |
1 | 0 | 0 | 0.25 (0.13–0.45) | 0.48 (0.27–0.69) | 0.27 (0.13–0.48) |
0 | 1 | 1 | 0.17 (0.10–0.31) | 0.33 (0.19–0.50) | 0.50 (0.33–0.66) |
0 | 1 | 0 | 0.34 (0.20–0.53) | 0.40 (0.24–0.59) | 0.26 (0.13–0.45) |
0 | 0 | 1 | 0.30 (0.20–0.46) | 0.29 (0.18–0.43) | 0.41 (0.27–0.56) |
0 | 0 | 0 | 0.51 (0.35–0.69) | 0.31 (0.17–0.48) | 0.18 (0.09–0.33) |
Probabilities (95%‐CI) for NC, PR and CR calculated by polytomous logistic regression in dependence of the risk factors age, spur length, and duration of symptoms before LD‐EBRT according to Hermann et al. in a collective of 285 heels treated with 6 × 1/6 × 0.5 Gy (taken from [38]).
In modern radiotherapeutic departments, X‐ray sources are less and less available. This is why nowadays most patients are treated with linear accelerators, which were initially developed for the treatment of oncological diseases. However, these machines can be used in the treatment of benign diseases without any modifications or problems. Due to the high efforts in physical, technical, and organizational quality assurances for the operation of an accelerator or an X-ray source, the concentration on accelerators and their use for all indications is recommended.
For irradiation of the heel, the patient has to be placed on the treatment couch with the feet toward the gantry of the accelerator (so‐called “feet first”). Two different patient positions are widely used. He can be placed in supine position, with the irradiated leg is stretched out, while the other leg is angled. Another option is to place the patient in a lateral decubitus position on the side of the involved heel. Again, the symptomatic leg is stretched, while the contralateral leg is bent, with a cushion placed beneath the knee. Using X‐rays, the ipsilateral knee is bent by 90% and the foot is positioned on the treatment table. One anterior‐posterior (AP) beam is usually applied in this technique.
For the treatment itself, there are also two different options. Irradiation may be given as a single stationary field (SSD 100cm by convention). Alternatively, parallel opposing fields from 0° and 180° gantry position (in decubitus position) or lateral opposing fields (90° and 270° in supine position) are also applicable but take a little bit longer in daily clinical practice. The hypothetical advantage of using two opposing fields is a uniform dose distribution in the entire beam path in the calcaneus (Figure 1). However, there has never been a clinical proof, whether this theoretical assumption translates into any clinical advantage for the patient. When applying opposing fields, the dose is specified according to the ICRU 50 report, normally in the center of the calcaneus.
Dose distribution of two different treatment techniques generated in a treatment planning system (XIO®). In A and B just one single 6 MV photon field (8 × 8 cm) is applied, while C and D shows the dose distribution with two opposing fields from 0 and 180°. In the upper row, the so‐called “beams eye views” are given, while in the lower row the respective dose distributions on an axial CT scan directly at the calcaneal insertion are shown. Note the more uniform dose distribution with opposing fields. The 95% isodose is given as a green line (2.85 Gy). This dose encompasses larger parts of the calcaneal bone in D (opposing fields) than in B (single field). More information is given in Section 2.4.
A third option is the so‐called “plantar field” with the patient lying in prone position. A single field is positioned directly over the plantar insertion/calcaneus, potentially with rotations of the patient table and the gantry to compensate for inclinations of the patients surface in the irradiated field. However, this technique is regarded problematic when using linear accelerators due to the dose build‐up effect in the critical tissue depth. This problem is illustrated in Figure 2: photons with 6 MV reach just the half of the prescribed dose at the skin level, 100% is reached at 1.5 cm tissue depth. This would result in an insufficient dose in the critical structures (plantar fascia and heel spur). To overcome this problem, a silicone flap of about 1 cm diameter must be positioned on the skin before radiation.
Depth curves of different megavoltage energies. Blue 6 MV photons, red 15 MV photons. At the surface of the body/skin (depth 0 mm), only half (or even less with 15 MV) of the prescribed dose is applied. By physical interactions between photons and the tissue/water, there is a steep increase in dose. A 100% is reached at 1.5 cm depth with 6 MV and at about 3 cm depth with 15 MV. KV‐radiation reaches the maximum dose directly under the surface/skin (not shown). More information is given in Section 2.4.
Patients are often sent to the radiotherapist after a long unsuccessful history of diverse conservative treatments. The reason for this is a widespread fear among general practitioners that LD‐EBRT might be associated with severe side effects and risks. These fears are not substantiated, as reactions of the nerves or vessels require much higher doses than used for LD‐EBRT. For example, a dose of 45 Gy in normofractionated oncological therapy is considered to be safe for the spinal cord and therefore daily clinical practice [44]. Peripheral nerves are even more radioresistant. Acute or chronic side‐effects have never been reported in all contemporary studies on LD‐EBRT.
Acute side effects are negligible, as very low doses of ionizing radiation (in comparison with oncological treatments) are applied to a distal extremity. The total dose of LD‐EBRT with 3 or 6 Gy is far too low to cause any acute or late reactions on the skin overlaying the calcaneus. During normofractionated EBRT (single doses of 1.8–2 Gy, treatment on 5 days a week) erythema and mild edema develop at about 30 Gy [45]. Hyperpigmentation occurs at about 45 Gy, moist epitheliolyses at about 50 Gy. A 50–60 Gy might cause telangiectasias years after the therapy. This is why there is no report on acute treatment side effects in LD‐EBRT until now to the best of our knowledge.
About one‐third of the patients might experience a slight increase in pain during LD‐EBRT. In the randomized trial by Heydt et al. this phenomenon was seen in 26% (during 6 × 0.5 Gy) vs. 29% (6 × 1 Gy) [30]. It does not seem to be correlated with treatment outcome; further detailed information is given in Section 2.3.4.
The dose scattered to the male gonads is somewhat higher than to the ovaries. Jansen et al. calculated for 6 × 0.5 Gy about 1.5 mSv received by the testes and 0.75 mSv to the ovaries [46]. Comparable results have repeatedly been measured in the past [47, 48].
Taken together, the dose received by the gonads is insignificant. As the distal extremity is irradiated, scattered dose to the gonads is comparable to normal diagnostic radiological imaging [49]. The hereditary effects of these doses are very small and very likely negligible [46].
Although spermatogonial cells are very radiosensitive, a single dose of at least 100 mSv is needed to induce a temporary failure of spermatogenesis [50]. A single dose of 1000 mSv (equivalent to 1 Gy photon irradiation) results in an azoospermia for 9–18 months [51]. Interestingly, fractionated doses harm these cells even more. A temporary oligospermia is reported after receiving several fractions up to a cumulative dose of 160 mSv [52]. An azoospermia lasting for 14–22 months has been reported for fractionated doses of 620–860 mSv [53]. The actually during LD‐EBRT received testicular dose is about 100 times smaller than the lowest dose causing temporary changes in testicular tissues.
The dose to the testicles can be further reduced by utilizing a special testicular shielding. However, clinically meaningful dose reductions have been only measured in MV treatment of subdiaphragmatic/pelvine lymphatic regions or tumors [54, 55].
The mean lethal dose for human oocytes has been estimated at 2 Gy (2000 mSv) [56]. Permanent ovarian failure after radiotherapy is age dependent: in perimenopausal women, a dose of 6 Gy is sufficient [57], while in younger women up to 20 Gy are tolerated. The dose scattered to the ovaries during LD‐EBRT for calcaneodynia cannot cause such sequelae (0.75 mSv).
Naturally, pregnancy has to be excluded in all premenopausal women before beginning with LD‐EBRT, to avoid any risk to the fetus.
So far, no studies with long‐term observation periods have been published, describing a case of malignancy induced by LD‐EBRT for calcaneodynia. However, induction of malignancies is a stochastic effect of ionizing radiation. This means that there is no threshold dose—in contrast for example to the above‐mentioned reactions of the skin. A photon can accidentally trigger a mutation, which in turn leads to tumor formation many years later. The higher the radiation dose, the higher the probability of such an event occurring.
The best available data on tumor induction of full dose EBRT in oncology has been collected in patients treated with breast cancer. Almost 11,000 patients have been followed for over 20 years. The risk of a radiation‐induced tumor was approx. 1% per decade after radiotherapy [58].
To estimate the risk associated with much lower doses of LD‐EBRT, mathematical models on the basis of epidemiological long‐term observations of atomic bomb victims have been developed by the ICRP [59].
Jansen et al. applied the ICRP model on LD‐EBRT of a painful heel spur [46]. Assumed was a single field entering at the foot sole with a size of 8 × 10 cm, 200 kV photons, SSD 40 cm. For an LD‐EBRT series with 6 × 1 Gy the average attributable lifetime risk for induction of a fatal tumor was calculated to be about 0.5 in a thousand patients. An important risk factor for radiogenic‐induced cancer is the patient\'s age by the time the radiation exposure occurs. The risk is already reduced in the 3rd decade of the patient\'s life, it starts to decrease steadily from the age of 40 [60]. Applying these calculations, the estimated lifetime risk per one thousand patients for a fatal tumor accounts for the age of 25 0.6 (male)/0.8 (female), for the age of 50 0.2/0.3, for the age of 75 0.07/0.1 [46].
However, it must be critically noted that this mathematical model was developed for radiation protection and relates to the exposure of complete organ systems with approx. 1 Gy. Therefore, other groups argue that a significantly lower risk of radiogenic cancer induction— approx. ten times less—should be adopted [49, 61]. Furthermore, taken the new standard scheme with 6 × 0.5 Gy into account, these risks are additionally halved.
This risk (max. 1/1000, very likely much lower) must be seen in relation to the tumor risk of the not additionally radiotherapeutical‐treated population. In 2008, the lifetime risk of a man in Germany to suffer from cancer was 50.7% (25.9% to die from malignancy), in women 42.8% and 20.2% respectively [62].
By limiting the application of LD‐EBRT treatment to patients > 30 years of age, an exposure of the juvenile “relatively higher risk” patient population is avoided.
Traditionally target volume definition has been quite large. Field sizes of 12 × 17cm were treated, including the entire dorsal and middle foot, and not just the calcaneus [37, 82] (Figure 3A).
Field definitions in LD‐EBRT of a painful plantar heel spur/fasciitis. (A) traditional field definition including the entire dorsal and middle foot. (B) In randomized trials and large prospective series commonly used field definition encompassing the entire calcaneus, including insertion of the plantar fascia and the Achilles tendon. (C) Proposed small field definition for localized painful plantar fasciitis/plantar spur, encompassing only the painful area with 2 cm margins extending into the neighboring areas (calcaneus, fascia, fat pad).
In the recent randomized trials and prospective observational studies target volume definition was more restricted and confined to the calcaneus (Figure 3B). “The target volume consisted of the calcaneus and the region of the plantar aponeurosis” [26]. “The ventral margin is corresponding to the ventral surface of the calcaneus, the plantar and dorsal margins are surrounding the soft‐tissue border, and the cranial margin is below the ankle” [30]. “Target volume is the calcaneus, normally with a field size of 6 cm × 8 cm” [32]. “The calcaneus and the plantar aponeurosis were included in the target volume” [25].
In a German national survey 2001 on LD‐EBRT of painful heel spurs the target volume definition “large” (dorsal and middle foot) vs. “small” (entire calcaneus) was not correlated with treatment outcome [83]. Consequently, very large field definitions should be regarded as obsolete.
However, as the pathophysiological cause of calcaneodynia is thought to be a localized inflammatory process (see Section 1), it is questionable, whether the entire calcaneus has to be irradiated (as long as there are not a plantar as well as a painful dorsal spurs). There are some clinical data that support a further restriction of target volume definition.
Field sizes have been given in the study by Miszczyk et al. on 327 patients treated with X‐ray beams [39]. Target volume was “… the insertion of the plantar fascia with a calcaneal spur and a reasonable margin. The field size varied from 27 to 150 cm2 (mean 47 cm2).” However, although not explicitly stated, no correlation was found between field size and duration of pain relief after LD‐EBRT. Treatment efficacy in itself was apparently not investigated.
In the above‐mentioned series of 285 heels Hermann et al. analyzed treatment efficacy in dependence of field sizes, too [38]. The mean field size was 74 cm2. No correlation between field size (smaller vs. larger than 74 cm2) with treatment efficacy was found. Further analyses of small fields (< 6 × 6 cm), medium‐sized fields (36–64 cm2) and larger fields revealed no significant differences.
This is why it seems to suffice to encompass the painful region with 2 cm margins extending into the neighboring areas (calcaneus, fascia, fat pad; Figure 3C). However, this recommendation is deducted from pathophysiological considerations and the above‐mentioned case series. A randomized trial is necessary to proof clinical equivalence of a field definition “entire calcaneus” (Figure 3B) vs. “insertion of the plantar fascia” (Figure 3C).
The optimal fractionation schedule has not been elucidated yet. All randomized trial used twice weekly treatments. Only one experimental arm was scheduled three times a week [25]. In a National Survey in Germany with 146 answering institutions, about 45% applied two fractions and 37.5% three fractions weekly [83].
Interestingly, in the landmark study by von Pannewitz a fractionation schedule of only once per week was established [34]. Until now, there is no proof of a higher efficacy applying LD‐EBRT twice or three times per week.
In radiotherapy of another benign disease (endocrine orbitopathy) a 1 Gy per week over 20 weeks schedule was more effective than the standard schedules (10 × 2 Gy or 10 × 1 Gy every working day) [84]. Although other immunological mechanisms cause endocrine orbitopathy in comparison with plantar fasciitis, there is sufficient clinical evidence to test in a randomized trial different fractionation schedules (twice a week vs. once a week, possibly thrice a week).
Other therapies than LD‐EBRT have been applied in painful heel spur. In the following, just a rough overview can be given.
Different kinds of insoles and foot orthoses have been developed. The goal was to reduce plantar contact pressure and to distribute the pressure uniformly over the whole rearfoot [63]. Magnetic insoles do not seem to provide additional benefit [64]. As a short‐term treatment, low‐Dye taping techniques are often used. However, in a randomized trial only a modest improvement in ‘first‐step’ pain was seen in comparison with sham‐intervention [65].
Manual stretching is often recommended. A systematic review of six studies found only statistically significant differences in comparison with the control in one study combining calf muscle and plantar fascia stretches [66].
Several trials have investigated acupuncture. A systematic review from 2010 showed (limited) evidence for the effectiveness [67]. A randomized trial published in 2014 recruited 84 patients [68]. The authors concluded, that “dry needling provided statistically significant reductions in plantar heel pain, but the magnitude of this effect should be considered against the frequency of minor transitory adverse events.”
Ultrasound therapy has led to questionable results [69], but a randomized trial on cryo‐ultrasound with about 100 patients published in 2014 showed good effectiveness [70].
Low‐level laser light (635 nm), given twice a week for a total of six applications, reduced in a randomized trial VAS scores significantly after 8 weeks in comparison with placebo [71]. However, the study comprised of just 69 patients; other similar studies have not been reported so far.
Extracorporeal shock waves are widely applied. Three metaanalyses comprising at least five randomized trials found significant short‐term pain relief and improved functional outcomes for this therapeutic option [72–74]. Another study compared the analgesic efficacy of ultrasound and shock wave therapy in 47 patients [75]. The results suggested that the shock wave therapy had greater analgesic efficacy.
Another basic approach is the oral administration of nonsteroidal anti‐inflammatory drugs (NSAID) to achieve a symptomatic relief. Injections into the painful area are also recommended. A recent review summarized ten randomized trials on corticosteroid injections into the plantar fascia [76]. A significant effect of the steroids on the pain has been shown. However, it was usually short‐term, lasting 4–12 weeks in duration. No advantage of ultrasound‐guided injection techniques in comparison with palpation guidance was found, and no superiority of one type of corticosteroid over another was seen. A longer lasting pain relief has been suggested by a small randomized trial of botulinum toxin injections [77]. Another option is the injection of autologous platelet‐rich plasma. A recent review identified three randomized trials, all showing promising results [78]. However, a very small trial challenged this method of plasma preparation, as the same clinical effectivity was observed after the injection of whole blood [79].
Different surgical approaches have been developed. Releases of the plantar fascia are done, in some studies combined with a spur resection [80]. Due to a probably faster recovery after surgery with comparable functional results endoscopic procedures are recommended nowadays [81]. Surgery is usually indicated after failure of conservative therapies as the ultimate “salvage‐therapy.”
There is only a limited amount of studies randomizing patients between LD‐EBRT and the above‐mentioned alternative therapies.
Canyilmaz et al. randomized 123 patients between LD‐EBRT (6 × 1 Gy, three times a week) and 1 ml injection of 40 mg methylprednisolone and 0.5 ml 60 mg 1% lidocaine under the guidance of palpation [85]. After 3 and 6 months, VAS values and CS‐scores were compared between both groups. After 3 months, the results in the radiotherapy arm were significantly superior compared with those after injections.
To corroborate these findings, similar studies should be conducted. Furthermore, more studies randomizing LD‐EBRT against other therapies (e.g. extracorporeal shock waves) are needed. A minimum size of 50 patients per treatment arm should be assured to gain more statistically relevant results. Recruiting patients without prior excessive other therapies for these studies would be optimal.
The goal must be an evidence‐based algorithm defining the therapeutic sequence of the different conservative treatment modalities for plantar fasciitis.
LD‐EBRT for painful plantar fasciitis/heel spur is an effective and safe treatment option for patients over 30 years of age and after exclusion of pregnancy. A fractionation of 6 × 0.5 Gy twice weekly up to a total dose of 3 Gy is currently recommended. In the case of an insufficient response a second course can be offered to the patient.
Randomized trials on target volume definition and further optimization of LD‐EBRT fractionation are currently in the process of planning. Further trials to compare the different conservative therapies for plantar fasciitis with each other are necessary to allow the development of an evidence‐based treatment algorithm.
This chapter is dedicated to Professor Gisela Hermann‐Brennecke on the occasion of her 70th birthday.
AP | anterior‐posterior |
CI | confidence interval |
CR | complete remission |
CS | Calcaneodynia score |
Cu | chemical element symbol for copper |
EC | endothelial cells |
GCG‐BD | German Cooperative Group on Radiotherapy for Benign Diseases |
Gy | Gray |
ICRP | International Commission on Radiological Protection |
IL | interleukin |
iNOS | inducible nitric oxide synthases |
KV | kilovoltage |
LD‐EBRT | low dose external beam radiotherapy |
mA | milliampere |
mRNA | messenger ribonuclein acid |
mSv | milliSievert |
MV | megavoltage |
NC | no change |
NF‐κB | nuclear factor kappa B |
NO | nitric oxide |
NSAID | non‐steroidal anti‐inflammatory drug |
PBMC | peripheral blood mononuclear cells |
PR | partial remission |
QOL | quality of life |
ROS | reactive oxygen species |
SSD | skin‐to‐source distance |
TGF‐β1 | transforming growth factor β1 |
VAS | visual analogue scale |
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All published Book Chapters are licensed under a Creative Commons Attribution 3.0 Unported License. Monographs are licensed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) license granted to all others. Our Copyright Policy aims to guarantee that original material is published while at the same time giving significant freedom to our Authors. IntechOpen upholds a flexible Copyright Policy meaning that there is no copyright transfer to the publisher and Authors hold exclusive copyright to their work.
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Among these heavy metals, a few have direct or indirect impact on the human body. Some of these heavy metals such as copper, cobalt, iron, nickel, magnesium, molybdenum, chromium, selenium, manganese and zinc have functional roles which are essential for various diverse physiological and biochemical activities in the body. However, some of these heavy metals in high doses can be harmful to the body while others such as cadmium, mercury, lead, chromium, silver, and arsenic in minute quantities have delirious effects in the body causing acute and chronic toxicities in humans. The focus of this chapter is to describe the various mechanism of intoxication of some selected heavy metals in humans along with their health effects. Therefore it aims to highlight on biochemical mechanisms of heavy metal intoxication which involves binding to proteins and enzymes, altering their activity and causing damage. More so, the mechanism by which heavy metals cause neurotoxicity, generate free radical which promotes oxidative stress damaging lipids, proteins and DNA molecules and how these free radicals propagate carcinogenesis are discussed. Alongside these mechanisms, the noxious health effects of these heavy metals are discussed.",book:{id:"7111",slug:"poisoning-in-the-modern-world-new-tricks-for-an-old-dog-",title:"Poisoning in the Modern World",fullTitle:"Poisoning in the Modern World - New Tricks for an Old Dog?"},signatures:"Godwill Azeh Engwa, Paschaline Udoka Ferdinand, Friday Nweke Nwalo and Marian N. 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The traditional healer provides health care services based on culture, religious background, knowledge, attitudes, and beliefs that are prevalent in his community. Illness is regarded as having both natural and supernatural causes and thus must be treated by both physical and spiritual means, using divination, incantations, animal sacrifice, exorcism, and herbs. Herbal medicine is the cornerstone of traditional medicine but may include minerals and animal parts. The adjustment is ok, but may be replaced with –‘ Herbal medicine was once termed primitive by western medicine but through scientific investigations there is a better understanding of its therapeutic activities such that many pharmaceuticals have been modeled on phytochemicals derived from it. Major obstacles to the use of African medicinal plants are their poor quality control and safety. Traditional medical practices are still shrouded with much secrecy, with few reports or documentations of adverse reactions. 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The main global health organizations have incorporated patient safety in their review of work practices. The data provided by the medical laboratories have a direct impact on patient safety and a fault in any of processes such as strategic, operational and support, could affect it. To provide appreciate and reliable data to the physicians, it is important to emphasize the need to design risk management plan in the laboratory. Failure Mode and Effect Analysis (FMEA) is an efficient technique for error detection and reduction. Technical Committee of the International Organization for Standardization (ISO) licensed a technical specification for medical laboratories suggesting FMEA as a method for prospective risk analysis of high-risk processes. FMEA model helps to identify quality failures, their effects and risks with their reduction/elimination, which depends on severity, probability and detection. Applying FMEA in clinical approaches can lead to a significant reduction of the risk priority number (RPN).",book:{id:"9808",slug:"contemporary-topics-in-patient-safety-volume-1",title:"Contemporary Topics in Patient Safety",fullTitle:"Contemporary Topics in Patient Safety - Volume 1"},signatures:"Hoda Sabati, Amin Mohsenzadeh and Nooshin Khelghati",authors:[{id:"340486",title:"M.Sc.",name:"Hoda",middleName:null,surname:"Sabati",slug:"hoda-sabati",fullName:"Hoda Sabati"},{id:"348872",title:"M.Sc.",name:"Amin",middleName:null,surname:"Mohsenzadeh",slug:"amin-mohsenzadeh",fullName:"Amin Mohsenzadeh"},{id:"348874",title:"MSc.",name:"Nooshin",middleName:null,surname:"Khelghati",slug:"nooshin-khelghati",fullName:"Nooshin Khelghati"}]},{id:"64762",title:"Mechanism and Health Effects of Heavy Metal Toxicity in Humans",slug:"mechanism-and-health-effects-of-heavy-metal-toxicity-in-humans",totalDownloads:10088,totalCrossrefCites:90,totalDimensionsCites:209,abstract:"Several heavy metals are found naturally in the earth crust and are exploited for various industrial and economic purposes. Among these heavy metals, a few have direct or indirect impact on the human body. Some of these heavy metals such as copper, cobalt, iron, nickel, magnesium, molybdenum, chromium, selenium, manganese and zinc have functional roles which are essential for various diverse physiological and biochemical activities in the body. However, some of these heavy metals in high doses can be harmful to the body while others such as cadmium, mercury, lead, chromium, silver, and arsenic in minute quantities have delirious effects in the body causing acute and chronic toxicities in humans. The focus of this chapter is to describe the various mechanism of intoxication of some selected heavy metals in humans along with their health effects. Therefore it aims to highlight on biochemical mechanisms of heavy metal intoxication which involves binding to proteins and enzymes, altering their activity and causing damage. 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Liposuction is a procedure to improve the body contour and not a surgery to reduce weight, although recently people who have failed in their plans to lose weight look at liposuction as a means to contour their body figure. Tumescent liposuction of large volumes requires a meticulous selection of each patient; their preoperative evaluation and perioperative management are essential to obtain the expected results. The various techniques of general anesthesia are the most recommended and should be monitored in the usual way, as well as monitoring the total doses of infiltrated local anesthetics to avoid systemic toxicity. The management of intravenous fluids is controversial, but the current trend is the restricted use of hydrosaline solutions. The most feared complications are deep vein thrombosis, pulmonary thromboembolism, fat embolism, lung edema, hypothermia, infections and even death. The adherence to the management guidelines and prophylaxis of venous thrombosis/thromboembolism is mandatory.",book:{id:"6221",slug:"anesthesia-topics-for-plastic-and-reconstructive-surgery",title:"Anesthesia Topics for Plastic and Reconstructive Surgery",fullTitle:"Anesthesia Topics for Plastic and Reconstructive Surgery"},signatures:"Sergio Granados-Tinajero, Carlos Buenrostro-Vásquez, Cecilia\nCárdenas-Maytorena and Marcela Contreras-López",authors:[{id:"273532",title:"Dr.",name:"Sergio Octavio",middleName:null,surname:"Granados Tinajero",slug:"sergio-octavio-granados-tinajero",fullName:"Sergio Octavio Granados Tinajero"}]},{id:"30178",title:"Chest Mobilization Techniques for Improving Ventilation and Gas Exchange in Chronic Lung Disease",slug:"chest-mobilization-techniques-for-improving-ventilation-and-gas-exchange-in-chronic-lung-disease",totalDownloads:30993,totalCrossrefCites:0,totalDimensionsCites:5,abstract:null,book:{id:"648",slug:"chronic-obstructive-pulmonary-disease-current-concepts-and-practice",title:"Chronic Obstructive Pulmonary Disease",fullTitle:"Chronic Obstructive Pulmonary Disease - Current Concepts and Practice"},signatures:"Donrawee Leelarungrayub",authors:[{id:"73709",title:"Associate Prof.",name:"Jirakrit",middleName:null,surname:"Leelarungrayub",slug:"jirakrit-leelarungrayub",fullName:"Jirakrit Leelarungrayub"}]}],onlineFirstChaptersFilter:{topicId:"3",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81721",title:"Atrial Fibrillation and Stroke",slug:"atrial-fibrillation-and-stroke",totalDownloads:0,totalDimensionsCites:null,doi:"10.5772/intechopen.104619",abstract:"Atrial fibrillation (AF) represents a major cause of morbidity and mortality in adults, especially for its strong association with thromboembolism and stroke. In this chapter, we aim to provide an overview on this cardiac arrhythmia, addressing several important questions. Particularly, we faced the possible mechanisms leading to an increased risk of embolism in AF, emphasizing how Virchow’s triad for thrombogenesis is unable to fully explain this risk. Disentangling the risk of stroke caused by AF and by other associated vascular conditions is extremely challenging, and risk stratification of patients with AF into those at high and low risk of thromboembolism has become a crucial determinant of optimal antithrombotic prophylaxis. Moreover, we discuss the typical clinical and radiological characteristics of cardioembolic strokes, addressing acute, time-dependent reperfusional therapies in case of ischemic stroke. The role of anticoagulation in AF is also fully analyzed; the benefit of oral anticoagulation generally outweighs the risk of bleeding in AF patients, and a variety of scoring systems have been developed to improve clinical decision-making when initiating anticoagulation. With their predictable pharmacokinetic profiles, wide therapeutic windows, fewer drug–drug and drug-food interactions, and the non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) have changed the landscape of thromboprophylaxis for AF patients, offering the opportunity to use effective anticoagulants without the need for intensive therapeutic drug monitoring.",book:{id:"10782",title:"Cerebrovascular Diseases - Elucidating Key Principles",coverURL:"https://cdn.intechopen.com/books/images_new/10782.jpg"},signatures:"Francesca Spagnolo, Vincenza Pinto and Augusto Maria Rini"},{id:"80743",title:"Air Quality and Health in West Africa",slug:"air-quality-and-health-in-west-africa",totalDownloads:0,totalDimensionsCites:null,doi:"10.5772/intechopen.102706",abstract:"One of the most important elements for survival is air. Its significance cannot be overstated, necessitating proactive measures and regulations to ensure clean air in our atmosphere. Africa is one of the continents with the worst air quality. According to NASA modelling research, air pollution causes approximately 780,000 premature deaths per year in Africa. Experiments were carried out by the European-African consortium DACCIWA to investigate the causes and effects of air pollution by looking at the entire chain of natural and human-made emissions, from formation to dispersion to repercussions. The findings suggest that air pollution has already reached a dangerous threshold for human health in most West African countries. The aim of this chapter is to highlight and increase awareness about the severe risk that air pollution poses to the health of inhabitants of West African countries.",book:{id:"11231",title:"Air Quality and Health",coverURL:"https://cdn.intechopen.com/books/images_new/11231.jpg"},signatures:"Odubanjo D. Adedolapo"},{id:"81915",title:"Paracetamol-Induced Hepatotoxicity",slug:"paracetamol-induced-hepatotoxicity",totalDownloads:0,totalDimensionsCites:0,doi:"10.5772/intechopen.104729",abstract:"Drug-induced hepatotoxicity is common in clinical settings, one of the commonly used drugs leading to liver injury is paracetamol. It is a commonly used analgesic and antipyretic drug. The toxicity of paracetamol has been described in accidental, iatrogenic, and intentional ingestion; also, the extent of liver injury varies from person to person depending on host factors, nutritional status, age, etc. The toxicity of paracetamol is not usually recognized by clinicians as initially, the symptoms are subtle. There is a specific antidote available for paracetamol-induced liver injury to prevent acute liver failure; however, it needs to be given time for proper action, therefore a strong clinical suspicion is to be taken when there is no proper history of ingestion.",book:{id:"11265",title:"Hepatotoxicity",coverURL:"https://cdn.intechopen.com/books/images_new/11265.jpg"},signatures:"Nida Mirza"},{id:"80928",title:"Trauma Resuscitation, Mass Casualty Incident Management and COVID 19: Experience from a South African Trauma Unit",slug:"trauma-resuscitation-mass-casualty-incident-management-and-covid-19-experience-from-a-south-african-",totalDownloads:1,totalDimensionsCites:0,doi:"10.5772/intechopen.103971",abstract:"The COVID 19 pandemic has spanned 2 years and is still ongoing with many questions arising. We attempt to answer some pertinent questions with literature as well as anecdotal evidence from our facility. To describe any changes to the resuscitation of trauma patients during the COVID 19 pandemic if any. During the COVID 19 pandemic, Johannesburg a city in the Gauteng Province of South Africa experienced civil unrest and a fire at one of its trauma units, this resulted in a mass casualty incident (MCI) at the only functional trauma unit in the public sector. Results of this observational study will be elucidated. Focus is placed on PPE protocols, trauma resuscitations, MCI management, triage principles and the changing surgeon’s role within the pandemic.",book:{id:"11297",title:"ICU Management and Protocols",coverURL:"https://cdn.intechopen.com/books/images_new/11297.jpg"},signatures:"Naadiyah Laher"},{id:"81912",title:"Renal Replacement Therapies in the Intensive Care Unit",slug:"renal-replacement-therapies-in-the-intensive-care-unit",totalDownloads:1,totalDimensionsCites:0,doi:"10.5772/intechopen.105033",abstract:"Renal replacement therapies (RRT) are commonly used in critically ill patients to achieve solute clearance, maintain acid-base status, and remove fluid excess. The last two decades have seen the emergence of large randomized control trials bringing new evidence regarding how RRT should now be managed in the ICU. RRT is considered a vital supportive care and needs to be adequately prescribed and delivered. This chapter first summarizes the basic principles and characteristics of the three major RTT modalities: intermittent hemodialysis (IHD), prolonged intermittent RRT (PIRRT), and continuous RRT (CRRT). Then, the large body of literature regarding indications for initiation (early vs late), choice of modality (intermittent vs continuous and diffusion vs convection), dosing (intensive vs less-intensive), and anticoagulation alternatives is reviewed to guide clinical decision-making. Recent evidence in the optimal timing of discontinuing RRT is reported. Finally, troubleshooting scenarios frequently seen in clinics and requiring an adapted RRT prescription are also discussed.",book:{id:"11297",title:"ICU Management and Protocols",coverURL:"https://cdn.intechopen.com/books/images_new/11297.jpg"},signatures:"Dominic Godbout, Philippe Lachance and Jean-Maxime Côté"},{id:"81919",title:"A Role for Cardiac Glycosides in GBM Therapy",slug:"a-role-for-cardiac-glycosides-in-gbm-therapy",totalDownloads:1,totalDimensionsCites:0,doi:"10.5772/intechopen.105022",abstract:"There is a pressing need for new effective therapeutic strategies to treat glioblastoma (GBM). Cardiac glycoside compounds consisting of both cardenolides and bufadienolides have been shown to possess potent activity against GBM cell lines and in vivo GBM tumors. In addition, recent research has shown that certain cardiac glycoside compounds contribute to an additive and even synergistic manner with the standard of care GBM treatments such as radiotherapy and chemotherapy. Finally, the finding that cardiac glycosides may offer a unique role in the control of GBM stem cells offers hope for better therapeutic outcomes in treating this deadly form of brain cancer.",book:{id:"11597",title:"Glioblastoma - Current Evidences",coverURL:"https://cdn.intechopen.com/books/images_new/11597.jpg"},signatures:"Yuchen Du, Xiao-Nan Li, Peiying Yang and Robert A. 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