Potential mechanisms of hypertension related cerebral dysfunction.
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More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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This book covers many of these aspects and presents a core thesis that government is a fundamental instrument of the social welfare of communities. It provides the reader with a comprehensive overview of new era states, and answers the question, does the new era require new government policies? Over five chapters, authors from a variety of disciplines and methodological approaches cover topics such as welfare states and social policies, borrowing in the context of public debt theory, and new budgetary approaches. 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The stabilization programs proposed by the IMF led to government guarantee of private sector external debts in the developing countries and led to a rapid increase in the public debt stock.",signatures:"Sibel Aybarç",downloadPdfUrl:"/chapter/pdf-download/65684",previewPdfUrl:"/chapter/pdf-preview/65684",authors:[{id:"286689",title:"Dr.",name:"Sibel",surname:"Aybarç",slug:"sibel-aybarc",fullName:"Sibel Aybarç"}],corrections:null},{id:"64648",title:"New Approaches in Public Budgeting",doi:"10.5772/intechopen.82371",slug:"new-approaches-in-public-budgeting",totalDownloads:1534,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"This study intends to evaluate the contributions of new budgetary approaches classified as (i) environment-friendly budgetary approach, (ii) citizen-centred budgetary approach, (iii) citizen’s budget approach, (iv) participatory budget approach and (v) gender-responsive budgeting approach, to contemporary budgetary system implementations. 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This chapter gives an account of one of the perspectives framed in the Latin American critical theory around the processes of research: decolonial perspective. This theory, emerged at the end of the last century, has been generating more and more theoretical-methodological, ethical-political, and epistemological inputs, which have allowed to address reality in a social-historical framework from the Global South. The concepts of Global North and the Global South refer, more than to territorial delimitations around the northern hemisphere and the southern hemisphere of the globe, to epistemic demarcations in the production of knowledge of societies that have been colonizing or colonized and the power that this provides in the apprehension of knowledge and deconstruction of reality particularized and mediated by it. This epistemic break enhances the recognition of reality from a perspective that deconstructs the coloniality/modernity of the Global North, which has been internalized as absolute truth.
\nThe logic of the exposition goes to the presentation of decoloniality as a theoretical-methodological approach to carry out the analysis of discourses and, substantially, to analyze them reflexively from a perspective that breaks the instituted and normative of the heterogeneity of the “should be.” In this way, this decolonial turn is presented in his short history, to later reflect on the power that it has in the analysis of discourses.
\nIn the mid-90s of the last century, various Latin American authors of social and human sciences began to meet in university spaces, such as Enrique Dussel, Aníbal Quijano, Walter Mignolo, Ramón Grosfoguel, Nelson Maldonado, and several others. These spaces would come to be the so-called Modernity/Coloniality Group. This generated the power of a collective feed through the analysis of reality from the particularities of a Global South colonized on the plane of being and thinking by a Global North in constant expansion.
\nFor the presentation of this shallow development, the publication of Castro-Gómez and Grosfoguel [1] is taken as the main source.
\nIn 1996, the Peruvian sociologist, Aníbal Quijano, worked at the State University of New York (SUNY), in Binghamton, with Immanuel Wallerstein, who at the time was the director of the Ferdinand Braudel Center in Paris. Both authors were recognized in the international sphere since the 70s for their productions around the Theory of Dependence and System-World Analysis. By this time, Quijano participated in the seminars organized by the “Coloniality Working Group”, directed by Kelvin Santiago, in which the Puerto Rican Grosfoguel also participated. Afro-Caribbean thinker Sylvia Wynters was also a part of that group, well-known in the United States for her work on colonial heritages.
\nIn 1998, Edgardo Lander, a sociologist based in Venezuela, organized an event in Caracas, where Mignolo, Escobar, Quijano, Dussel, and Coronil were invited. From that event came one of the most important books produced by the group: “The coloniality of knowledge: Eurocentrism and social sciences”, published in Buenos Aires in 2000. Also in that year, Grosfoguel and Quijano organized in Binghamton the international congress “Transmodernity, historical capitalism, and coloniality: a post-disciplinary dialogue”, where Quijano, Wallerstein, and the Argentinians philosopher Enrique Dussel and semiologist Walter Mignolo participated. It was at this congress that Dussel, Quijano, and Mignolo met for the first time to discuss their approach to colonial legacies in Latin America, in dialog with Wallerstein\'s world-system analysis. Dussel was known in Latin America for being one of the founders of the Philosophy of Liberation in the 70s, while Mignolo was beginning to be recognized in the growing circle of postcolonial studies as a result of his book “The Darker Side of the Renaissance.”
\nIn 1999, the Binghamton group organized the event “History Sites of Colonial Disciplinary Practices: The Nation-State, the Bourgeois Family and the Enterprise”, where the dialog with the postcolonial theories of Asia, Africa, and Latin America was opened. In this event, Vandana Swami, Chandra Mohanty, Zine Magubane, Sylvia Winters, Walter Mignolo, Anibal Quijano, and the Venezuelan anthropologist Fernando Coronil participated. On the other hand, Oscar Guardiola and Santiago Castro-Gómez organized, with the support of the Pontificia Universidad Javeriana, the International Symposium “The restructuring of the social sciences in the Andean countries.” Argentinean semiologist, Zulma Palermo, and German Romanist, Freya Schiwy, also joined. This event served as a catalyst for everything that had been happening in the other nodes of the network. From this activity, an academic cooperation agreement was signed between the Javeriana University of Bogotá, the Duke University, the University of North Carolina, and the Andean Simón Bolívar University of Quito to organize activities and publications on the subject of the geopolitics of knowledge and coloniality of power. From these spaces arise two books that will be the first publications of the group: “Think (in) the interstices, Theory and practice of postcolonial criticism” (1999) and “The restructuring of social sciences in Latin America” (2000).
\nFor the beginning of the present millennium, the confluence of the System-World Analysis and the Latin American Theories on Coloniality were directed toward the production of knowledge of a new way of being and thinking. In the year 2000, Grosfoguel organized in Boston the conference corresponding to the 24th edition of the PEWS “Political Economy of the World-System,” inviting the Colombian philosophers Santiago Castro-Gómez and Oscar Guardiola Rivera, of the Thinking Institute of the Javeriana University. At that time, a new node of the network in Colombia was also being formed, based on the activity generated by Santiago Castro-Gómez at the Institute of Social and Cultural Studies Pensar.
\nIn 2001, a first group meeting was organized, where the progress made from the different spaces that were working on the theme was discussed. The event meeting was organized by Walter Mignolo at Duke University under the name “Knowledge and the Known”, which was also joined by the Bolivian cultural theorist Javier Sanjinés and the American linguist Catherine Walsh, professor at the Andean University Simón Bolívar.
\nIn 2002, the second meeting of this group was held in Quito, by Catherine Walsh. Here, a dialog was established with indigenous and Afro-American intellectuals from Ecuador. This meeting produced the book “Indisciplinary Social Sciences. Geopolitics of knowledge and coloniality of power,” edited by Catherine Walsh, Freya Schiwy, and Santiago Castro-Gómez.
\nIn 2003, the third meeting of the group was held at the University of California (Berkeley), this time organized by Grosfoguel and Saldívar. In that moment, the Puerto Rican philosopher Nelson Maldonado-Torres joined the group. The result of this meeting was the book “Unsettling Postcoloniality: Coloniality, Transmodernity and Border Thinking,” published in 2007.
\nIn 2004, the fourth meeting of the group “Modernity/Coloniality” was organized by Grosfoquel, Maldonado-Torres, and Saldívar in the University of California. The main topic was the decolonization of the American empire in the twenty-first century. In this instance, the group begins a dialog with the Afro-Caribbean philosopher, Lewis Gordon, (president of the Caribbean Philosophy Association) and the Portuguese sociologist, Boaventura de Sousa Santos [6], one of the most important organizers and theoreticians of the World Social Forum. The book “Latins in the World System: Decolonization Struggles in the 21st Century US Empire” (published in 2005), and the volume edited by Ramón Grosfoguel in an academic journal directed by Immanuel Wallerstein, entitled “From Postcolonial Studies to Decolonial Studies”. In the same year, a few months later, the fifth meeting of the group was held by Escobar and Mignolo under the name “Critical theory and decoloniality.” The publication “Globalization and Decolonial Thinking” arises.
\nIn 2005, the sixth meeting of the group was held in Berkeley, called “Mapping the Decolonial Turn”, by Maldonado-Torres, and coordinated together with Grosfoguel and Saldívar. It counted with the participation of members of the Caribbean Philosophical Association and a group of Latin American, African-American, and Chicano intellectuals.
\nIn 2006, the seventh meeting was held in Quito, organized by Catherine Walsh.
\nIn the following decade, the Modernity/Coloniality Group continued to produce knowledge about the epistemic turn of the Global South, generating the most diverse accessions and critical reproductions of this analytical-reflective proposal of social reality.
\nThis new matrix of analysis distanced itself from postcolonial studies of the time, which had emerged from French poststructuralism instead of
In contrast, the called “decolonial turn” proposed since the beginning
In this sense, Mignolo ([1]) suggests that conceptualizing coloniality as constitutive of modernity implies positioning itself from a decolonial perspective. Modernity, in its phenomenal2 discursive anchoring of the rhetoric of salvation and progress, does not offer greater margins of objectification before the ideological components that make it up, nor concretions in an asphyxiating global capitalism for most of the people. The various forms that today are added to the expression of the “social question”3 are hardly understood within the framework of coloniality
As stated by Maldonado [2], the decolonial attitude provides the basis for what he calls decolonial reason. These (attitude and reason) are substantial in this “decolonial turn.”
\nIt is considered that recognizing the social framework in which the people (singular and collective subjects) unfold in a universality that accounts for a historical-social totality enables one to think about their particular and singular realities beyond the phenomenal. Further, Quijano (In [1]) raises its decolonial court also through its distance from the Hegelian totality; personally, it is understood that the analysis that this author makes at this specific point may have other reflective edges. A social-historical totality is thus proposed in the dialectic of the universal-particular-singular for the understanding of the singular and collective reality of people within the framework of specific and generic territorial contexts mediated by ideological logics that transcend their daily lives. Hence, the objectification process that is achieved through research is key to the materialization of what the knowledge apprehended generates for this analysis of reality.
\nThis decolonial perspective gives power to the social and human sciences of today, since it allows thinking and producing knowledge about the long-term processes that cross-section people in the disputes over the
Taking the theoretical-methodological, ethical-political, and epistemological foundations of decoloniality, it is presented below what the analysis of discourses from decoloniality would be, in the overcoming of master-slave relations in a historical-social framework that contains both (who investigates as who is the subject of the investigation).
\nThe awakening of the Global South before the internalized ideologies of the Global North was a fundamental point to generate new ways of understanding reality, and to investigate and intervene in it. These forms of apprehension of reality are far from the concretions of capitalism in the daily people and communities lives.
\nHow to investigate from a decolonial perspective when what is demanded in the academy is clearly the opposite? How to overcome colonial logics that generate gaps between “us” and “others” so that it is possible to objectify oneself in the historical-social totality? It is believed that the social and human sciences of today are conditioned by a context of exercise and power logic of big capital (colonial/modern), and it should not throw away the objectification that is achieved from the delimitation of the research object from theoretical-methodological, ethical-political, and epistemological frameworks “others.” That exercise is learned, strengthened, and expanded (or constrained) from the “think” spaces of the academy.
\nResearch from a decolonial perspective enables to generate knowledge and provides tools to achieve real processes of objectification in the subject-subject relationship. This is considered substantial since the colonial forms of power in modernity have been in charge of
Based on what has been raised about decoloniality, the relationship between the researcher and who is the subject of the research changes epistemic and methodological substance, giving rise to the potential to generate analytical tools that account for this substance. In this context, the analysis of the discourses comes to contain a strong implication in the reflection on what was said and not said, how it was said and the sensations and perceptions that mediate the people, who are raising their experiences, their pains, their joys, their expectations, etc. In this way, the breakthroughs that this decolonial perspective generates in the analysis of discourses for the social and human sciences are presented:
Relationships comprised in decolonial power logics (based on subject-subject relations and joint processes of objectification) that overcome the colonial (diverse and metamorphosed reproductions of inequalities).
Recognition of a historical-social totality as a field of research, where the overcoming of the logic of modernity/coloniality anticipates the knowledge.
Ethical exercise in research processes that generate knowledge from both: the subjects who investigate and the subjects of research.
To know part of a societal framework that contains and expands singular and collective pains of hegemonic logics of big capital, which violent symbolically and/or literally, and that only in the encounter in and with the others there is the power for change it.
These aspects generate the possibility of intersubjective relationship between the researcher and who is the subject of the research, analyzing the discourses not only from the spoken word, but incorporating sensations, perceptions, emotions, etc. framed in a social-historical context. Recognizing parts of a network that produces and reproduces the logic of modernity allows us to analyze these discourses by grounding the belief of an absolute truth (aletheia), and relocating them in collective historical processes of social pains generated by the imposed coloniality.
\nIn this sense, it is imperative to distance oneself from the internalized colonialities imposed by a “unique” scientific knowledge from the Global North for the analysis of a dissimilar societal framework such as that of the societies of decoloniality. As Zimmermann says, with this decolonial turn, they are enabled and share
In this framework, the language becomes a core substance in this analytical logic, since it enables to reconstruct the social and cultural reality of the subjects through the meaning given in the interaction generated by one and another subject of the enunciation:
From decoloniality, language is substantial in the framework of the social historical totality that accounts for its materialization, as well as grammatical reflection, which
Likewise, the concretion of the language displayed in the speeches is expressed through writing, which also contains ideological components that cross it out, since
In this way, both the subject who investigates and the subject of the investigation pass through the encounter of the discursive in an imprint that must be located in the social historical totality, on the one hand, and in the singularized concretions that give substance to reality. The way in which this is expressed in the writing is preoccupied with ideological components that the researcher must retrace to avoid falling into false ethnocentrisms typical of colonial modernity. Through the analysis and exposure of economies “others,” subjects “others,” ideologies “others,” a process of discourse analysis is formed from the decoloniality of power and knowledge, with a view to meeting both the subject (singular or collective) as with the object in the process of delimitation.
\nIn synthesis, the proposed decolonial turn as a theoretical-methodological and epistemological frame of reference for the analysis of discourses leads to “other” encounters between subjects that, on the one hand, on the plane of being reproduce in everyday life ways of being, being, feel and think proper to decoloniality, and, on the other hand, on the plane of thinking, enables the epistemic break with the colonialities imposed ideologically, culturally, and symbolically. From the decoloniality of discourses, in the comprehension of their boundless heterogeneity, analytic-reflexive detours are generated, where language is a substantial point as a construction of reality.
\nDue to this decolonial turn could be interiorized to the analysis of discourses; in this part of the chapter, some examples will be presented.
\nIn spaces of intersubjective communication exchange between the subject that investigates and the subject of the research, sensations and perceptions are enunciated and interpreted by each one. For example, when a space for interviews with people in a situation of disability is generated for the understanding of the reality that this population lives in Uruguay, the researcher must understand the social historical totality of these subjects, who materialize in expressions, gestures, looks, silences, etc. Who investigates from a decolonial perspective, is a constitutive part of the interview as a network shared with the subject of the investigation, where the knowledge of both sides is as valid as it is substantial for the subsequent discursive analysis. In this process, the naturalized hierarchies of knowledge and the asymmetry and inequality relations are overcome. The reality that is presented through the language that is handled is understood. The analysis becomes here in “other” ways, without truths as generic absolutes posited by coloniality.
\nIn colonial modernity, the symbolic status of the researcher is produced and reproduced by the socially shared representations that place him as subject of knowledge. The domain of the latter on the subject of the research (in the present example, people with disabilities) is naturalized by the internalized ideological components of this colonial modernity. Thus, inequalities and asymmetries are the externalization of hierarchies imposed by the coloniality of knowledge that, in its processuality, also results in the coloniality of being. From this perspective, everything that happens in the instances of joint discourses are materialized and later analyzed from a pattern of domination. In the words of Pereira Lázaro:
When located from this perspective, where modernity is part of a civilizatory project, the subject who investigates is positioned as a subject of domination, generating
Restrepo and Rojas [5] argue that to overcome this colonial difference of being and knowledge is necessary to make a decolonial inflection, which
As stated in the previous point, Mignolo [6] proposes the decoloniality of being and knowledge, overcoming the traditional conception of the coloniality of power. This allows us to understand and interpret the forms of domination imposed by the colonial power in the epistemic frameworks that produce, naturalize, and legitimize knowledge anchored in the distinction of the we-others that make any attempt at dialog and discourse analysis impossible without colonial premonitions and interpretations. Language enters into this discursive logic materializing the coloniality. The decolonial perspective in the analysis of discourses demystifies this created alterity and proposes the recognition and power found in cultural, ethnic, identity, age, disability, etc. distinctions for the delimitation of the research object that overcomes the “scientific objectivity” typical of the Global North.
\nThe rhetoric becomes very important to complete the discourse analysis scheme, where the coloniality of being and of knowledge cross the language materialized in the dialogues that are generated in the framework of the interviews. The “art of good saying”, as rhetoric is defined in the Dictionary of the Royal Spanish Academy, preconfigure valuations of “good” and “bad” sayings, depending on the subject of the enunciation. In this way, in the example of people in a situation of disability, who are interviewed by the subject who investigates, they are relegated to a “bad saying” of their feelings, emotions, perceptions, and approaches regarding what disability policies would be in Uruguay. This “bad saying” will be corrected, reformulated, and metamorphosed by the subject that investigates from the colonial perspective to a “good to say”. Thus, the rhetoric is imbued with pre-notional charges that distinguish between the plane of being and thinking of one and another subject.
\nThe ideological components for these impositions have been (and are) centered on the Eurocentric idea of modernity of a Global North (civilized) superior to the Global South (barbarian), which unfolds in these binary logics in the various societal and intersubjective frameworks when they find subjects understood as diverse. These “others” will be both the subjects of the Global South in relation to the Global North, the subjects of the investigation in relation to the subject who investigates, the subjects who learn in relation to the subject who teaches, and so on. These “others,” as proposed by Dussel ([7], p. 50), receive the
If this rhetoric is posed from the decolonial perspective, the logic of coloniality is revealed in its political fabric of modernity, globalization, and capitalism:
The analysis of discourses from decolonial perspective invites to unlearn the internalized, imposed, assumed, and externalized of coloniality, in order to reconstitute being in an emancipatory process. These standardized and modern institutes, just as they were created and scattered by the imperialist logic of the colonizers, are now being deconstructed by the colonized. Just as colonial logics have been imposed, there is no reason for their overcoming, which generates ways of thinking and being emancipated from decolonized subjects.
\nThe ideological imperative of knowledge of the Global North has been imposed on the knowledge of the Global South from a unidirectionality that has truncated ways of being, living, and thinking proper to the peoples who have been colonized. The knowledge generated by this unidirectional way turns with the decolonial perspective, giving its power and recognition.
\nThe Latin American social and human sciences converge in a constant reproduction of power relations, where on the one hand, it is exercised, and at the same time, on the other hand, it is experienced in the coloniality of power. Realizing these contradictions would be a first step to delineate a path with as few paradoxes as possible. In this context, discourse analysis is essential to produce knowledge that is not only demarcated by the researcher but also by who is the subject of the research. This means a substantial turn of the screw toward what Mignolo referred to as
After the discovery of America, the creation and consolidation of a modern Europe with hegemonic ways of being and thinking in the understanding of the demarcation of “some” civilized and “other” barbarians to colonize were materialized. Thus arises the conviction from this Global North that everything that is “outside” of its territoriality and episteme is noncivilized, nonpolitical, and therefore, nonhuman. In this framework, these “barbarians” are required to think of themselves as responsible for their own misfortunes, and forced to reproduce the logic of modernity in favor of their dignity. According to Dussel [7], an
Transposing this to the analysis of discourses, in the relation subject that investigates—subject of the investigation, the process to be realized must be a double movement in the decoloniality of the being and of the knowledge. In this way,
In turn, this naturalization and discursive legitimation that adorns modern knowledge, generates a concrete link between knowledge and power that, according to Coronil [10], is characterized by the following components:
The discourse analysis from decolonial perspective invites the real encounter between the subject that investigates and the subject of the investigation, in a transfer that surpasses the predicted logics and sinks its roots in the decoloniality of being and thinking. The relations of asymmetry characterized by the Global North, where colonizers and colonized are located as civilized and barbarian, respectively, find other correlates mediated by the fundamental knowledge of both parties for the process of research.
\nIt is considered that decolonial perspective provides a theoretical-methodological frame of reference to transcend imposed by a “must be” hegemonic own the Global North. The power that the social and human sciences have in the analysis of a convoluted and chaotic reality is the engine that nourishes the collections of knowledge and objective social research. That is the decoloniality of power and knowledge that invades the being for the deployment of the encounter with “the others” in relations of expansion of the
Systemic hypertension is one of the most common and devastating disorders affecting the human race. It is a major cause of premature death worldwide and is the risk factor with greatest impact on the global burden of disease. It is the leading modifiable risk factor for cardiovascular disease and all-cause mortality [1, 2].
Worldwide, an estimated 1.38 billion individuals (31.1% of the adult population) have hypertension, defined as systolic blood pressure (BP) ≥ 140 mm Hg and/or diastolic BP ≥ 90 mm Hg, and/or current use of antihypertensive medication. The age-standardized prevalence of hypertension is marginally higher in men (31.9%) than in women (30.1%) and is lower in high-income countries (HICs), as compared to low and middle-income countries (LMICs) (28.5% vs. 31.5%) [3]. According to global estimates in 2010, only 45.6% of individuals with hypertension were aware of the disease, only 36.9% were receiving treatment and only 13.8% had achieved adequate BP control (defined as systolic BP < 140 mm Hg and diastolic BP < 90 mm Hg). Also, the proportion of hypertension awareness and treatment was nearly twice and the proportion of hypertension control was four times in HICs as compared to LMICs. In the last 2 decades, HICs have shown substantial increases in the proportions of hypertension awareness, treatment and control. However, during the same period, awareness and treatment have increased only modestly in LMICs and the proportion of hypertensive patients having adequately controlled BP has decreased slightly [3].
The global prevalence of hypertension is increasing steadily as a result of aging of the population and increase in lifestyle risk factors like unhealthy diets (high sodium, low potassium intake, high intake of saturated and trans-fats and low intake of fruits and vegetables), physical inactivity, increased consumption of alcohol and tobacco, and being overweight or obese. However, the changes in the prevalence of hypertension have not been uniform worldwide. In the last two decades, a modest decline has been noted in hypertension prevalence in HICs, whereas LMICs have experienced significant increases. These trends can impose a greater burden of hypertension and related cardiovascular disorders on the fragile health-care systems of LMICs, many of which are also facing a substantial burden of infectious diseases [4].
Hypertension is often called a “silent killer”, as most hypertensives are unaware of the problem due to lack of warning symptoms or signs. Hypertension can cause sub-clinical target organ damage for years, before any symptoms or signs develop. It is the leading modifiable risk factor implicated in the causation of coronary heart disease (CHD), cerebrovascular disease, renal dysfunction, peripheral arterial disease (PAD), heart failure and atrial fibrillation. The brain is a major target for hypertension related end-organ damage and hypertension is a prominent risk factor for two major categories of brain diseases: stroke and dementia. In the following sections, we discuss the role of hypertension in causation of these diseases, along with prevention and treatment strategies.
Human brain, in general, is highly vulnerable to the harmful effects of elevated BP and it represents the classic target organ of hypertension-induced damage. Arterial hypertension, besides being responsible for its well-known effect in causing clinical stroke, is also associated with the development of asymptomatic, subclinical brain damage, such as cerebral small vessel disease with resultant cognitive impairment, memory loss and dementia. Also, sudden and marked elevations of blood pressure can lead to the development of hypertensive encephalopathy, characterized by severe headache, seizures and other neurological symptoms like cerebral edema.
Globally, stroke ranks second among the causes of mortality and third among the causes of disability. In recent decades a trend towards reduction in the incidence, prevalence and mortality of stroke has been noted, but the overall disease burden continues to rise in terms of total number of patients affected [5].
Stroke is usually categorized into ischemic and hemorrhagic forms. Ischemic stroke has further subtypes including large vessel occlusive disease, lacunar infarctions due to small vessel disease, cerebral embolism including cardioembolic stroke, non-atherogenic stroke and cryptogenic stroke. Various subtypes of hemorrhagic stroke include intra-parenchymal hemorrhage, subarachnoid hemorrhage and intraventricular hemorrhage.
Hypertension is the most prevalent risk factor for stroke and has been reported in nearly two-thirds of stroke patients [6]. In LMICs, the reported prevalence of risk factors among patients with stroke is lower, however the in-hospital mortality rates have been higher, probably related to delays in presentation, differences in healthcare system responses and acute management of stroke [7].
There is robust evidence from observational and interventional studies, implicating hypertension as a strong risk factor for all types of strokes. The Framingham heart study in 1970 showed a significant association between the risk of stroke and blood pressure ≥ 160/95 mm Hg at all ages and in both sexes [8]. Persons with a normal BP (<120/80 mm Hg) had been reported approximately half the lifetime risk of stroke compared to those with high BP (≥140/90 mm Hg) [9].
Large epidemiological studies have consistently shown the relationship between the level of BP and risk of stroke to be consistent, continuous, and independent of other risk factors. Older epidemiological studies gave more importance to the diastolic BP as a determinant of stroke risk, and consistently showed a higher risk of stroke with increasing levels of diastolic BP [10, 11]. MacMahon et al., in their meta-analysis of nine observational studies conducted between 1958 and 1990, showed that as the level of BP decreased so did the risk of stroke. A decrease in diastolic BP of 5, 7.5, and 10 mm Hg was associated with a lowering of stroke risk by 34, 46, and 56%, respectively [11]. Similarly, The Eastern Stroke and Coronary Heart Disease Collaborative Research project, showed that for every 5 mm Hg fall in the diastolic BP resulted in nearly 50% reduction in the risk of ischemic (odds ratio (OR) 0.61; 95% confidence interval 0.57–0.66) and hemorrhagic stroke (odds ratio 0.54, 95% confidence interval 0.50–0.58) [12]. Systolic BP attracted greater attention in 1990s after the results from many epidemiological studies suggested that it could have more robust association with stroke as compared to diastolic BP. Systolic BP also showed a stronger correlation with 12 year stroke mortality than the diastolic BP in Framingham heart study [13]. Similarly, the prospective population-based Copenhagen city heart study demonstrated systolic BP to be a better predictor of stroke than the diastolic BP [14]. The Asia Pacific Cohort Studies Collaboration (APCSC), an extension of the Eastern Stroke and Coronary Heart Disease Collaborative project, which analyzed 37 cohort studies of 425,325 patients in the Asia Pacific region, demonstrated a continuous, log-linear association between systolic BP and risk of stroke down to the levels of 115 mm Hg of systolic BP. In the age groups of <60, 60–69, and >70 years, a 10 mm Hg lower systolic BP was associated with 54%, 36% and 25% lower risk of stroke respectively [15]. In a meta-analysis of 61 prospective studies by the Prospective Study Collaboration (PSC), it was demonstrated that there was more than a twofold decrease in stroke mortality with each 20 mm Hg of decrease in systolic BP for patients aged 40–69 years; and throughout middle and old age, usual BP is directly and strongly related to vascular (and overall) mortality, without any evidence of a threshold down to at least 115 mm Hg of systolic BP and 75 mm Hg of diastolic BP [16].
Age is an important cofactor in the relationship between hypertension and stroke. The direct relation between elevated BP and stroke risk is weaker in older aged populations than in middle-aged individuals. The APCSC observed a lower percentage reduction in stroke risk with similar reduction in systolic BP with increasing age [15]. A similar trend was observed in the PSC study [16]. Although there is a less robust association between hypertension and stroke risk in older populations, lowering BP in this population is still beneficial owing to the higher incidence of stroke and higher morbidity/mortality rates in this population [17].
Racial and ethnic disparities in the relationship between elevated BP and stroke have been reported from several observational studies from the United States. The Baltimore-Washington Cooperative Young Stroke Study, demonstrated a positive relationship between hypertension and the risk of ischemic stroke in whites and blacks for both sexes. In this study, age-adjusted odds ratios and 95% confidence interval for ischemic stroke with a history of hypertension in white males, white females, black males, and black females were 1.6 (0.7–3.2), 2.5 (1.1–5.9), 3.8 (1.8–7.9), and 4.2 (2.4–7.5), respectively [18]. Similarly, the Northern Manhattan Stroke Study showed higher odds ratios for hypertension and ischemic stroke in blacks as compared to whites and hispanics (OR 2.0 vs. 1.8, 1.2 respectively) [19]. A similar increase in systolic BP is associated with a nearly three times higher risk of stroke risk in blacks as compared to whites [20].
Although arterial hypertension is a major risk factor for both stroke and myocardial infarction, stroke is much more closely related to elevated levels of BP per se. It has been suggested that a sustained reduction in systolic blood pressure of 10 mm Hg would reduce stroke risk by 56%, but reduce the risk of myocardial infarction by only 37% [11]. This difference is largely attributed to the possibility that elevated levels of blood pressure are directly responsible for strokes occurring due to small vessel disease, but is only indirectly related to the development of atherosclerotic changes. Atherosclerosis in the arterial tree is usually focal and is usually seen at the branching points of the arteries or where arteries take a bend. It is likely that the effects of hypertension on atherosclerosis are not per se due to pressure energy, but are more likely related to the transmission of kinetic energy to the arterial wall at sites of flow disturbance, thus leading to the formation of atherosclerotic plaques at the areas of low shear stress [21].
Strokes due to small vessel disease, in contrast, are directly caused by elevated blood pressure. For this reason, these tend to occur in a particular distribution at the base of the brain, where short, straight arteries with limited branches result in direct transmission of high blood pressure directly from the large arteries to the smaller resistance vessels, with resultant damage to the walls of the arterioles. This results in the pathological changes of hyaline degeneration and fibrinoid necrosis, with consequent lacunar infarctions where the arterioles occlude and hypertensive intracerebral hemorrhages where they rupture. These pathophysiological changes account for the fact that true lacunar infarctions and intracerebral hemorrhages are particularly distributed in the areas of basal ganglia, internal capsule, thalamus, cerebellum, and brainstem [22].
Hypertension can indirectly contribute to the development of stroke as it is an important etiological factor for atrial fibrillation and for acute myocardial infarction and left ventricular clot formation; with attendant risk of cardioembolic stroke.
There are many theories related to the pathophysiological mechanisms of hypertension related brain dysfunction. Central to these theories are the mechanisms related to impaired cerebrovascular auto-regulation in hypertension and the chronic maladaptive changes in the structure of the cerebral vasculature in hypertensive patients.
Cerebrovascular autoregulation is the process by which cerebral vasculature regulates intracranial blood flow, so that a steady perfusion is maintained to meet the metabolic needs of the brain tissue across a range of systemic blood pressures. This control is achieved by the ability of the cerebral arterioles to compensate for a decrease in cerebral perfusion pressure by vasodilatation, and also, to protect the brain against increased perfusion pressure by vasoconstriction, thus keeping the cerebral blood flow constant. This complex process is regulated by interplay between sympathetic nervous system, brain carbon dioxide and other metabolites, and neurovascular coupling. In normotensive individuals, this response occurs over a range of approximately 60–160 mm Hg systolic BP; but, in patients with hypertension, this range may be shifted to higher pressures [23, 24]. This upward shift in the limits of pressure autoregulation, make hypertensive patients especially susceptible to episodes of hypotension, which plays a role in the development of white matter changes. Also, elderly hypertensive patients often have impaired cerebrovascular autoregulation which contributes to the development of stroke, cognitive dysfunction and vascular dementia. Impaired autoregulation increases the transmission of elevated pressures to cerebral capillaries resulting in increased permeability of blood brain barrier (BBB), parenchymal edema, inflammation neuronal degeneration that is commonly seen in patients with vascular cognitive dysfunction [25]. Chronic hypertension has been reported to promote arteriolar and capillary rarefaction, especially in the deep hemispherical white matter and basal ganglia [26]. This is associated with infiltration of perivascular macrophages, endothelial dysfunction, increased oxidative stress, and impaired functional hyperemia [27]. These changes promote the development of lacunar infarcts, white matter hyper-intensities, microinfarcts, and microbleeds [28].
Chronic elevation of intraluminal pressure stimulates the growth of smooth muscle cells and increases media thickness in resistance arteries, resulting in hypertrophic remodeling, thus causing an elevated vascular resistance. There may also be eutrophic remodeling, characterized by inward remodeling with rearrangement of the vessel wall components that leads to a reduction in lumen diameter and elevated vascular resistance. Hypertension may also result in narrowing of the intermediate and small vessels due to lipo-hyalinosis and micro-atherosclerosis. Also, chronically elevated BP promotes hyaline degeneration, fibrinoid degeneration and formation of microaneurysms in small vessels of the cerebral vasculature. These small vessel alterations predispose these patients to the development of ischemic and hemorrhagic complications [29].
Hypertension promotes atherosclerosis in large extracranial and intracranial arteries, which predispose to the development of atherothrombotic infarctions. The most frequent sites of atherosclerosis are common carotid artery bifurcation, origin and intra-cavernous part of internal carotid artery, first segment of middle cerebral artery, origin and distal part of vertebral artery, and middle portion of basilar artery [29]. These atherosclerotic plaques are usually progressive and lead to ischemic strokes by thrombotic occlusion of the narrowed lumen or, more often, by their acute rupture, which causes atheroembolism resulting in occlusion of distal intracranial vessels [29]. Major mechanisms of hypertension related cerebral dysfunction are summarized in Table 1.
Impairment of cerebral autoregulation |
Increased permeability of blood brain barrier |
Endothelial dysfunction, oxidative stress, impaired functional hyperemia |
Small vessel changes: remodeling, increased vascular resistance, lipo-hyalinosis, micro-atherosclerosis, micro aneurysms, lacunar infarcts |
Large vessel changes: atherosclerosis with atherothrombotic, atheroembolic infarctions |
Potential mechanisms of hypertension related cerebral dysfunction.
The relation between BP and stroke risk is direct, strong, linear, and etiologically predictive. Thus, within the usual BP ranges, including non-hypertensive ones, the higher levels of BP are associated with increased risk of stroke [16]. Non-hypertensive individuals with slight elevations of BP (prehypertension, defined as systolic BP of 120–139 mm Hg and/or diastolic BP of 80–89 mm Hg) derive benefit from lifestyle changes with or without pharmacological therapies. A meta-analysis with 70,664 prehypertensive individuals from 16 trials demonstrated a robust 22% reduction in the stroke risk in individuals randomized to pharmacological therapy arm as compared to the placebo arm. In hypertensive patients, lifestyle approaches combined with adequate BP treatment and control produced a 35–40% decrease in the stroke risk [30, 31].
Practical strategies for hypertension management for primary stroke prevention, on the basis of recommendations made by the American Heart Association (AHA)/American Stroke Association (ASA) [32, 33], and European Society of Cardiology (ESC)/European Society of Hypertension (ESH) [34] include:
Regular screening for hypertension and management of raised BP using lifestyle modifications and pharmacological therapies are recommended.
According to European guidelines the target BP in those with hypertension should be <140/90 mm Hg, whereas, the recent American guidelines recommend a BP goal to lower levels of <130/80 mm Hg, even in very elderly.
Successful attainment of BP goal is emphasized over the administration of a particular anti-hypertensive agent.
Individualized BP treatment is recommended, based on particular patient characteristics and tolerance to medications.
Self-monitoring of BP is recommended to help in adequate BP control.
Management of elevated BP in acute ischemic stroke (AIS) has been a matter of considerable debate. AIS is usually associated with islands of infarcted tissue with surrounding areas of potentially salvageable tissue, referred to as ischemic penumbra. Moreover, the infarcted tissue is characterized by loss of autoregulation with increased vessel permeability [35]. Hence an over aggressive approach of lowering BP can result in extension of infarction and worsening of neurological dysfunction. On the other hand, if the elevated BP is not lowered sufficiently, there is risk of excessive cerebral edema and hemorrhagic transformation of the infarcted tissue. Furthermore, as the cerebrovascular auto regulatory response is set at a higher level in chronic hypertensive patients, these individuals are at risk of impaired cerebral perfusion if BP is lowered very aggressively.
Practical strategies for management of hypertension in AIS, based on recommendations of AHA/ASA [36], and European stroke organization (ESO) [37] include:
In patients with AIS who are not eligible for systemic thrombolysis or mechanical thrombectomy and who have a BP > 220/120 mm Hg, guarded BP reduction (<15% systolic BP reduction over 24 h) is reasonable and is likely to be safe. No recommendations are made regarding the use of a specific anti-hypertensive agent to achieve this goal.
In hospitalized patients with AIS and blood pressure < 220/110 mm Hg not treated with intravenous thrombolysis or mechanical thrombectomy, there is suggestion against the routine use of blood pressure lowering agents at least in first 24 h following symptom onset, unless this is necessary for specific comorbid conditions like acute aortic dissection, acute myocardial infarction, pulmonary edema, hypertensive encephalopathy and acute renal failure.
In patients with AIS undergoing treatment with intravenous thrombolysis (with or without mechanical thrombectomy) it is suggested that BP is maintained below 185/110 mm Hg before bolus and below 180/105 mm Hg after bolus, and for 24 h after alteplase infusion.
In patients with AIS undergoing treatment with intravenous thrombolysis (with or without mechanical thrombectomy), there is suggestion against lowering systolic blood pressure to a target of 130–140 mm Hg compared to <180 mm Hg during the first 72 h following of symptom onset.
Initiating or continuing anti-hypertensive agents during hospitalization for AIS, if BP > 140/90 mm Hg: BP lowering is generally safe in AIS if patient is medically and neurologically stable, and there are no contraindications for BP lowering. The time window for administration of such therapies is usually 2–3 days after the symptom onset.
Drug options to treat hypertension in patients with AIS who are planned for emergency reperfusion therapy are shown in Table 2.
Labetalol: 10–20 mg intra-venous over 1–2 min, may be repeated once; or |
Nicardipine: 5 mg/h intra-venous, dose may be up-titrated by 2.5 mg/h in every 5–15 min to a maximum of 15 mg/h; when desired BP levels is obtained, adjust the dose to maintain proper BP levels; or |
Clevidipine: 1–2 mg/h intra-venous, up-titrate by doubling the dose in every 2–5 min until desired BP level is obtained; maximum dose 21 mg/h |
Other agents like enalaprilat, hydralazine may also be useful |
If BP is not controlled or diastolic BP > 140 mm Hg, consider intravenous nitroprusside (may increase intracranial pressure). |
Observational studies have suggested that BP is often markedly elevated in the acute phase of hemorrhagic stroke, significantly higher than that seen after AIS [38]. High levels of BP in acute hemorrhagic stroke are often associated with hematoma expansion and poor clinical outcomes [39]. Simultaneously, there have been suggestions that high BP may be necessary to maintain adequate cerebral perfusion after intracranial hemorrhage, and that aggressively lowering it may be deleterious. These concerns are however, opposed by the evidence suggesting that adequate cerebral perfusion is maintained after acute BP reduction in patients with hemorrhagic stroke [40, 41]. However, results of the two largest randomized clinical trials (INTERACT2, ATACH-2) of intensive BP lowering early after intracranial hemorrhage have renewed this uncertainty [42, 43]. Meta-analyses of these trials and many other smaller studies have shown that early intensive BP reduction after hemorrhagic stroke is safe, but without mortality benefit or significant functional improvement [44, 45, 46, 47]. In contrast, a recent meta-analysis of the two largest trials demonstrated a direct linear relation between the level of systolic BP achieved during the first 24 h of hemorrhagic stroke and the functional status. The improvements in the functional status were noted for systolic BP levels of as low as 120–130 mm Hg [48]. These studies however excluded patients with severe, large hematomas and hence caution is warranted in too aggressive lowering of BP in such patients as it might predispose to harmful consequences [49].
Practical strategies for BP control in patients with acute hemorrhagic stroke based on recent AHA/ASA [50], and ESO [37] guidelines include:
If initial systolic BP is >220 mm Hg, it is reasonable to administer continuous intravenous BP lowering therapy to achieve an initial reduction of about 15%. Choice of drugs is similar to that used in AIS (Table 2).
In patients with initial systolic BP of 150–220 mm Hg, American guidelines suggest a target goal of 140–150 mm Hg of systolic BP [50], however, the recent ESO guidelines [37] recommend even more aggressive lowering of systolic BP to less than 140 mm Hg (but to keep it above 110 mm Hg) to reduce hepatoma expansion.
Control of blood pressure variability may be helpful in improving the outcomes [51].
After hemorrhagic stroke, the optimal timing for initiation of antihypertensive therapies for secondary stroke prevention has not been well established. It may be reasonable to start such treatment when the patient is medically and neurologically stable. The target BP goal for secondary stroke prevention is <130/80 mm Hg [50].
About a quarter of strokes are recurrent, the annual risk of recurrence is nearly 4% and the mortality rate after a recurrent stroke is 41% [33, 34]. A large proportion of strokes can be prevented by adequate BP control, regular physical activity, healthy dietary habits and cessation of smoking. In fact, the INTERSTROKE study demonstrated that these 5 factors—hypertension, imbalanced diet, lack of adequate physical activity, abdominal obesity and smoking—were responsible for 82% and 90% of the population attributable risk (PAR) for ischemic and hemorrhagic stroke respectively [6]. Also, the Global Burden of Disease Study suggested that nearly 90% of the global stroke burden was attributable to the modifiable risk factors [52]. A modeling study has shown that targeting multiple modifiable risk factors of stroke has additive benefits in secondary prevention of stroke. According to this study, aspirin, anti-hypertensive therapies and statins, along with dietary modification and adequate exercise, can lead to an 80% cumulative risk reduction in the incidence of recurrent vascular events [53].
Practical strategies for BP control for secondary recent AHA/ASA guidelines [54] include:
In hypertensive patients who suffer a stroke or transient ischemic attack (TIA), an office BP goal of <130/80 mm Hg is recommended for most patients to reduce the risk of recurrent stroke and vascular events.
In individuals with no history of hypertension who experience a stroke or TIA and have an average office BP of ≥130/80 mm Hg, antihypertensive drug treatment can be beneficial to decrease the risk of recurrent stroke, intracranial hemorrhage, and other vascular events.
A thiazide diuretic, angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) may be useful, however, other classes of BP lowering therapy can be used to achieve the target BP goals (e.g., calcium channel blocker, newer generation beta blocker).
Individualized drug treatments that take into account patient comorbidities, pharmacological class of the drug, and patient preferences are recommended to maximize the drug efficacy.
Dementia is characterized by a progressive and often irreversible decline of cognitive function which is most commonly seen in older adults. It is one of the most common neurological diseases, nearly affecting 30–40 million people worldwide. The number of people with dementia is estimated to triple by 2050, largely driven by the aging of the population, demographic shifts, and lack of disease-modifying therapies [55]. Alzheimer disease (AD) and cerebrovascular diseases are the major causes of cognitive dysfunction, accounting for nearly 80% of the cases and often have a mixture of both the pathologies [55]. Although the majority of dementias including AD are primarily considered as neuro-degenerative diseases of unknown cause, recent studies have shown that cerebrovascular disease and microscopic vascular lesions are often found in patients affected by these conditions [56].
The term vascular cognitive impairment (VCI) refers to the entire spectrum of cognitive abnormalities caused by vascular etiologies, whereas the term vascular dementia is used for cases with more profound vascular cognitive deficits which negatively affect the daily functioning of an individual [57].
Among the various vascular risk factors, systemic hypertension is a major factor contributing to cognitive impairment [57]. It has been been associated with decreased abstract reasoning, reduced mental processing speed, and, less commonly, memory deficits [58]. Although dementia due to AD and vascular dementia have classically been considered as separate entities, recent evidence indicates that the two conditions are frequently coexistent [59, 60]. In nearly 40–50% of cases with a clinical diagnosis of AD, the pathological hallmarks of AD (amyloid plaques and the neurofibrillary tangles), are associated with micro-cerebrovascular and macro-cerebrovascular lesions [61]. Moreover, ischemic lesions markedly elevate the effect of AD pathology on cognitive function [62, 63]. Also, traditional cardiovascular risk factors have been suggested to have a role in the development of AD [64], and some estimates suggest that risk factor modification, especially the treatment of hypertension, could decrease the incidence of clinically diagnosed AD by up-to 30% [65].
Hypertension-related cognitive dysfunction occurs as a result of complex interplay between functional alterations and structural changes seen in the brain parenchyma and the cerebral vasculature, many of which have been discussed previously in Section 2.1.2. Briefly, these changes include increased cerebrovascular resistance, reduced vasomotor reactivity, decreased cerebral blood flow, vascular remodeling, lacunar infarcts, white matter lesions, micro bleeds, enlarged perivascular spaces and cerebral atrophy [66]. These overlapping pathophysiological changes might account for the correlation between hypertension and stroke or vascular dementia. This relation may also hold true for other forms of dementia; like, for example the link between chronic hypertension and the AD has been documented, as hypertension is often associated with formation of neurofibrillary tangles and senile plaques, the presence of which was seen in brains of hypertensive patients even in the absence of clinical features of dementia [67].
Hypertension is a major modifiable risk factor for cognitive dysfunction, VCI and AD. Robust clinical evidence has demonstrated that antihypertensive therapies, besides preventing major cerebrovascular events [57], also reduce the incidence and/or delay the progression of cognitive dysfunction [68, 69]. The Syst-Eur randomized clinical trial showed that, on treating 1000 hypertensive individuals with anti-hypertension therapies for 5 years, 19 cases of dementia could be prevented [70]. Similarly, the PROGRESS trial observed that therapy with a perindopril (a long-acting ACE inhibitor), and indapamide (a thiazide-like diuretic), was associated with reduced risks of cognitive dysfunction and dementia on a mean follow-up of 3.9 years [71]. Also, various clinical and experimental studies have suggested that antihypertensive drugs, including ACE inhibitors, angiotensin receptor blockers (ARBs) and diuretics, might cause an improvement in the biomarkers of AD, and decrease the incidence of AD and/or delay its progression [72].
Interestingly, antihypertensive drug therapies might have class specific effects on cognitive function. Both ACE inhibitors and calcium channel blockers have been reported to delay the development of cognitive dysfunction [72]. However, results from the Canadian Study of Health and Aging suggested that hypertensive individuals aged ≥65 years who received treatment with calcium channel blockers had a more marked cognitive decline than those receiving other antihypertensive drugs at follow-up of 5 years [73]. These findings lend support to the hypothesis that the systemic and local renin-angiotensin systems may respond differently to different antihypertensive drugs [74]. Furthermore, calcium channel blockers may potentially cause an impairment of myogenic autoregulatory protective responses in the cerebral vasculature. Taking these factors into account, it might be suggested that ACE inhibitors and ARBs might be preferable to calcium channel antagonists for dementia prevention in hypertensive patients [75].
The subject of optimum BP targets for the prevention of dementia has generated considerable debate and controversy. In the SPRINT MIND trial, it was seen that in ambulatory hypertensive individuals, a more intensive BP control strategy (target systolic BP of <120 mm Hg as compared to a target of <140 mm Hg) was not associated with any significant cognitive benefits [76]. An important point to be considered here is that due to the adaptive rightward shift of the cerebrovascular autoregulatory curve in hypertension, too aggressive lowering of BP may result in cerebral hypoperfusion and consequential negative impact on the brain. These U-shaped associations between BP and cognitive function in the elderly individuals have been reported in many studies [77, 78]. These findings stress the importance of individualized blood pressure management strategies for prevention of cognitive dysfunction.
Hypertension is also a major contributor to the risk of stroke, which nearly doubles the risk of developing dementia. It is estimated that about one-third cases of dementia can be prevented by preventing the development of stroke [79]. Clinical studies have shown that prevention of stroke by using anticoagulation in atrial fibrillation and BP-lowering therapies in hypertensive patients can significantly decrease the risk of dementia [80]. Based on these results, the World Stroke Organization came out with a manifesto stressing the need for a joint strategy for prevention of stroke and dementia [79].
Hypertension is a major global public health problem and is the major cause of premature death worldwide. Human brain is highly vulnerable to the deleterious effects of elevated blood pressures. Hypertension related cerebrovascular diseases include stroke, cognitive dysfunction and dementia. Elevated blood pressure levels are strongly, directly and linearly related to the incidence and prevalence of these diseases. Adequate management of hypertension can go a long way in mitigating the global burden of these cerebrovascular diseases.
Elevated systemic blood pressures are associated with increased risk of cerebrovascular diseases including stroke and dementia. Good blood pressure control, which can be achieved easily in majority of the patients, is necessary for prevention of these cerebrovascular diseases.
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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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\n\n\n\nAll chapters will be published via IntechOpen's 'Online First' service meaning chapters will be published individually, immediately after review and before the entire book is ready for publication, allowing content to be shared, searched and cited straightaway, thereby generating early stage interest and momentum for your research
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\n\nChapters will remain listed as Online First until the final versions of the books are published online. Following publication of the full monograph, Chapters will be redirected from the Online First version and will be available only through the final link of the official published page.
\n\nYou are invited to download, use, reproduce, make derivative works of, display, distribute and cite the Online First works. You can find "How to Cite and Reference" by following the link at the end of each online book chapter. Please be aware that it is possible that further editing and changes might be made before the final release of the book.
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Almost all the parts of this plant, that are, fruit, leaves, flower bud, trunk, and pseudo-stem, can be utilized. This chapter deals with the fiber extracted from the pseudo-stem of the banana plant. It discusses the production of banana pseudo-stem fiber, which includes plantation and harvesting; extraction of banana pseudo-stem fiber; retting; and degumming of the fiber. It also deals with the characteristics of the banana pseudo-stem fiber, such as morphological, physical and mechanical, durability, degradability, thermal, chemical, and antibacterial properties. Several potential applications of this fiber are also mentioned, such as the use of this fiber to fabricate rope, place mats, paper cardboard, string thread, tea bags, high-quality textile materials, absorbent, polymer/fiber composites, etc.",book:{id:"7544",slug:"banana-nutrition-function-and-processing-kinetics",title:"Banana Nutrition",fullTitle:"Banana Nutrition - Function and Processing Kinetics"},signatures:"Asmanto Subagyo and Achmad Chafidz",authors:[{id:"257742",title:"M.Sc.",name:"Achmad",middleName:null,surname:"Chafidz",slug:"achmad-chafidz",fullName:"Achmad Chafidz"},{id:"268400",title:"Mr.",name:"Asmanto",middleName:null,surname:"Subagyo",slug:"asmanto-subagyo",fullName:"Asmanto Subagyo"}]},{id:"69568",title:"Water Quality Parameters",slug:"water-quality-parameters",totalDownloads:10165,totalCrossrefCites:14,totalDimensionsCites:36,abstract:"Since the industrial revolution in the late eighteenth century, the world has discovered new sources of pollution nearly every day. So, air and water can potentially become polluted everywhere. Little is known about changes in pollution rates. The increase in water-related diseases provides a real assessment of the degree of pollution in the environment. This chapter summarizes water quality parameters from an ecological perspective not only for humans but also for other living things. According to its quality, water can be classified into four types. Those four water quality types are discussed through an extensive review of their important common attributes including physical, chemical, and biological parameters. These water quality parameters are reviewed in terms of definition, sources, impacts, effects, and measuring methods.",book:{id:"7718",slug:"water-quality-science-assessments-and-policy",title:"Water Quality",fullTitle:"Water Quality - Science, Assessments and Policy"},signatures:"Nayla Hassan Omer",authors:null},{id:"40180",title:"Plant Tissue Culture: Current Status and Opportunities",slug:"plant-tissue-culture-current-status-and-opportunities",totalDownloads:66561,totalCrossrefCites:45,totalDimensionsCites:96,abstract:null,book:{id:"3568",slug:"recent-advances-in-plant-in-vitro-culture",title:"Recent Advances in Plant in vitro Culture",fullTitle:"Recent Advances in Plant in vitro Culture"},signatures:"Altaf Hussain, Iqbal Ahmed Qarshi, Hummera Nazir and Ikram Ullah",authors:[{id:"147617",title:"Dr.",name:"Altaf",middleName:null,surname:"Hussain",slug:"altaf-hussain",fullName:"Altaf Hussain"}]},{id:"66996",title:"Ethiopian Common Medicinal Plants: Their Parts and Uses in Traditional Medicine - Ecology and Quality Control",slug:"ethiopian-common-medicinal-plants-their-parts-and-uses-in-traditional-medicine-ecology-and-quality-c",totalDownloads:4172,totalCrossrefCites:6,totalDimensionsCites:11,abstract:"The main purpose of this review is to document medicinal plants used for traditional treatments with their parts, use, ecology, and quality control. Accordingly, 80 medicinal plant species were reviewed; leaves and roots are the main parts of the plants used for preparation of traditional medicines. The local practitioners provided various traditional medications to their patients’ diseases such as stomachaches, asthma, dysentery, malaria, evil eyes, cancer, skin diseases, and headaches. The uses of medicinal plants for human and animal treatments are practiced from time immemorial. Stream/riverbanks, cultivated lands, disturbed sites, bushlands, forested areas and their margins, woodlands, grasslands, and home gardens are major habitats of medicinal plants. Generally, medicinal plants used for traditional medicine play a significant role in the healthcare of the majority of the people in Ethiopia. The major threats to medicinal plants are habitat destruction, urbanization, agricultural expansion, investment, road construction, and deforestation. Because of these, medicinal plants are being declined and lost with their habitats. Community- and research-based conservation mechanisms could be an appropriate approach for mitigating the problems pertinent to the loss of medicinal plants and their habitats and for documenting medicinal plants. Chromatography; electrophoretic, macroscopic, and microscopic techniques; and pharmaceutical practice are mainly used for quality control of herbal medicines.",book:{id:"8502",slug:"plant-science-structure-anatomy-and-physiology-in-plants-cultured-in-vivo-and-in-vitro",title:"Plant Science",fullTitle:"Plant Science - Structure, Anatomy and Physiology in Plants Cultured in Vivo and in Vitro"},signatures:"Admasu Moges and Yohannes Moges",authors:[{id:"249746",title:"Ph.D.",name:"Admasu",middleName:null,surname:"Moges",slug:"admasu-moges",fullName:"Admasu Moges"},{id:"297761",title:"MSc.",name:"Yohannes",middleName:null,surname:"Moges",slug:"yohannes-moges",fullName:"Yohannes Moges"}]},{id:"29764",title:"Underlying Causes of Paresthesia",slug:"underlying-causes-of-paresthesia",totalDownloads:193348,totalCrossrefCites:3,totalDimensionsCites:7,abstract:null,book:{id:"1069",slug:"paresthesia",title:"Paresthesia",fullTitle:"Paresthesia"},signatures:"Mahdi Sharif-Alhoseini, Vafa Rahimi-Movaghar and Alexander R. Vaccaro",authors:[{id:"91165",title:"Prof.",name:"Vafa",middleName:null,surname:"Rahimi-Movaghar",slug:"vafa-rahimi-movaghar",fullName:"Vafa Rahimi-Movaghar"}]}],onlineFirstChaptersFilter:{topicId:"2",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"83012",title:"Cotton Based Cellulose Nanocomposites: Synthesis and Application",slug:"cotton-based-cellulose-nanocomposites-synthesis-and-application",totalDownloads:0,totalDimensionsCites:0,doi:"10.5772/intechopen.106473",abstract:"Nanocellulose is a renewable natural biomaterial which has risen to prominence due to its biodegradability and physiochemical properties making it a promising candidate to replace non-biodegradable synthetic fibers. Due to its profound qualities, nanocellulose extracted from cotton fibers have tremendous application potential and have been intensively studied particularly in the generation of nanofillers and as reinforcement components in polymer matrixes. Deposition of inorganic nanoparticles on cotton fabric result in antimicrobial textiles with multifunctional use particularly in manufacture of PPE and as filtration devices against environmental pollutants and pathogens. This chapter compiles three main sections. The first section gives an overview of the extent of work done in the creation and application potential of cotton-based nanocomposites. The second section describes the in situ and ex situ methods of nanoparticle deposition and self assembly on cotton fabrics to generate multifunctional cotton-based nanocomposites with antimicrobial potential while the final section describes the incorporation of cotton nanofibers in polymer matrices, their reinforcing properties, as well as surface modification to assist their incorporation. Finally in the conclusion, a summary of the up-to-date challenges and progresses is presented postulating the undiscovered arenas and future undertakings of this venture.",book:{id:"11362",title:"Cotton",coverURL:"https://cdn.intechopen.com/books/images_new/11362.jpg"},signatures:"Patricia Jayshree Samuel Jacob"},{id:"82465",title:"Agroforestry: An Approach for Sustainability and Climate Mitigation",slug:"agroforestry-an-approach-for-sustainability-and-climate-mitigation",totalDownloads:0,totalDimensionsCites:0,doi:"10.5772/intechopen.105406",abstract:"Agroforestry Systems (AFS), or the association of trees with crops (or animals), is a strategy for land management and use that allows production within the sustainable development: (a) environmentally (production environmentally harmonic); (b) technically (integrating existing resources on the farm); (c) economically (increase in production), and (d) socially (equality of duties and opportunities, quality of life of the family group). As an intentional integration of trees or shrubs with crop and animal production, this practice makes environmental, economic, and social benefits to farmers. Given that there is a set of definitions, rather than a single definition of Agroforestry (AF) and AFS, it is justified to explore the historical evolution and the minimum coincidences of criteria to define them and apply them in the recovery of degraded areas. Knowing how to classify AFS allows us to indicate which type or group of AFS is suitable for a particular area with its characteristics. The greatest benefit that AFS can bring to degraded or sloping areas lies in their ability to combine soil conservation with productive functions. In other words, AF is arborizing agriculture and animal production to obtain more benefits including climate change adaptation and mitigation by ecosystem services.",book:{id:"11663",title:"Vegetation Dynamics, Changing Ecosystems and Human Responsibility",coverURL:"https://cdn.intechopen.com/books/images_new/11663.jpg"},signatures:"Ricardo O. Russo"},{id:"82972",title:"Actinomycosis: Diagnosis, Clinical Features and Treatment",slug:"actinomycosis-diagnosis-clinical-features-and-treatment",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.104698",abstract:"Actinomycosis is a filamentous bacterium that forms part of the normal human flora of the gastrointestinal, oropharynx and female genitalia. This indolent infection is characterized by abscess formation, widespread granulomatous disease, fibrosis, cavitary lung lesions and mass-like consolidations, simulating an active malignancy or systemic inflammatory diseases. It is subacute, chronic and variable presentation may delay diagnosis due to its capability to simulate other conditions. An accurate diagnostic timeline is relevant. Early diagnosis of pulmonary actinomycosis decreases the risk of indolent complications. Proper treatment reduces the need for invasive surgical methods. Actinomycosis can virtually involve any organ system, the infection spread without respecting anatomical variables as metastatic disease does, making malignancy an important part of the differential diagnosis. As it is normal gastrointestinal florae, it is difficult to cultivate, and share similar morphology to other organisms such as Nocardia and fungus. It is often difficult to be identified as the culprit of disease. Its true imitator capability makes this infectious agent a remarkable organism within the spectra of localized and disseminated disease. In this chapter, we will discuss different peculiarities of actinomycosis as an infectious agent, most common presentation in different organ systems, and challenging scenarios.",book:{id:"10893",title:"Actinobacteria",coverURL:"https://cdn.intechopen.com/books/images_new/10893.jpg"},signatures:"Onix J. Cantres-Fonseca, Vanessa Vando-Rivera, Vanessa Fonseca-Ferrer, Christian Castillo Latorre and Francisco J. Del Olmo-Arroyo"},{id:"82476",title:"Joint Action of Herbicides on Weeds and Their Risk Assessment on Earthworm (Eisenia fetida L.)",slug:"joint-action-of-herbicides-on-weeds-and-their-risk-assessment-on-earthworm-eisenia-fetida-l",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.105462",abstract:"Frequent and intensive use of similar modes of action herbicides increases selection pressure resulting in nature adapt and a number of herbicide-resistant weeds. The most effective methods to prevent and delay herbicide-resistant weeds are herbicide tank mixture and adjuvant mixed herbicides. This chapter intends to explain the advantages of herbicide tank mixture and adjuvant mixed herbicides. In addition, the models of estimated herbicide mixture interaction response have been explained. Although herbicide mixtures have benefits, they may present risks leading to soil pollution and affecting soil fauna such as earthworms. Therefore, we discussed the negative effect of mixture herbicides on Eisenia fetida. On the other hand, various models to calculate mixture herbicide toxicity on earthworms will be present in this chapter.",book:{id:"11610",title:"New Insights in Herbicide Science",coverURL:"https://cdn.intechopen.com/books/images_new/11610.jpg"},signatures:"Mohammad Taghi Alebrahim, Elham Samadi Kalkhoran and Te-Ming Paul Tseng"},{id:"82953",title:"Early Visual Areas are Activated during Object Recognition in Emerging Images",slug:"early-visual-areas-are-activated-during-object-recognition-in-emerging-images",totalDownloads:1,totalDimensionsCites:0,doi:"10.5772/intechopen.105756",abstract:"Human observers can reliably segment visual input and recognise objects. However, the underlying processes happen so quickly that they normally cannot be captured with fMRI. We used Emerging Images (EI), which contains a hidden object and extends the process of recognition, to investigate the involvement of early visual areas (V1, V2 and V3) and lateral occipital complex (LOC) in object recognition. The early visual areas were located with a retinotopy scan and the LOC with a localiser. The participants (N=8) then viewed an EI, followed by the hidden object’s silhouette (disambiguation), and then, the EI was repeated. BOLD responses before and after disambiguation were compared. The retinotopy parameters were used to back-project the BOLD response onto the visual field, creating spatially detailed maps of the activity change. V1 and V2 (but not V3) showed stronger response after disambiguation, while there was no difference in the LOC. The back-projections revealed no distinct pattern or changes in activity on object location, indicating that the activity in V1 and V2 is not specific for voxels corresponding to the object location. 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The applications of this research cover many related fields, such as biotechnology and medicine, where, for example, Bioinformatics contributes to faster drug design, DNA analysis in forensics, and DNA sequence analysis in the field of personalized medicine. Personalized medicine is a type of medical care in which treatment is customized individually for each patient. Personalized medicine enables more effective therapy, reduces the costs of therapy and clinical trials, and also minimizes the risk of side effects. Nevertheless, advances in personalized medicine would not have been possible without bioinformatics, which can analyze the human genome and other vast amounts of biomedical data, especially in genetics. The rapid growth of information technology enabled the development of new tools to decode human genomes, large-scale studies of genetic variations and medical informatics. 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Main aspects of the topic are: Applying bioinformatics in drug discovery and development; Bioinformatics in clinical diagnostics (genetic variants that act as markers for a condition or a disease); Blockchain and Artificial Intelligence/Machine Learning in personalized medicine; Customize disease-prevention strategies in personalized medicine; Big data analysis in personalized medicine; Translating stratification algorithms into clinical practice of personalized medicine.",annualVolume:11403,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"5886",title:"Dr.",name:"Alexandros",middleName:"T.",surname:"Tzallas",fullName:"Alexandros Tzallas",profilePictureURL:"https://mts.intechopen.com/storage/users/5886/images/system/5886.png",institutionString:"University of Ioannina, Greece & Imperial College London",institution:{name:"University of Ioannina",institutionURL:null,country:{name:"Greece"}}},{id:"257388",title:"Distinguished Prof.",name:"Lulu",middleName:null,surname:"Wang",fullName:"Lulu Wang",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRX6kQAG/Profile_Picture_1630329584194",institutionString:"Shenzhen Technology University",institution:{name:"Shenzhen Technology University",institutionURL:null,country:{name:"China"}}},{id:"225387",title:"Prof.",name:"Reda R.",middleName:"R.",surname:"Gharieb",fullName:"Reda R. Gharieb",profilePictureURL:"https://mts.intechopen.com/storage/users/225387/images/system/225387.jpg",institutionString:"Assiut University",institution:{name:"Assiut University",institutionURL:null,country:{name:"Egypt"}}}]},{id:"8",title:"Bioinspired Technology and Biomechanics",keywords:"Bioinspired Systems, Biomechanics, Assistive Technology, Rehabilitation",scope:'Bioinspired technologies take advantage of understanding the actual biological system to provide solutions to problems in several areas. Recently, bioinspired systems have been successfully employing biomechanics to develop and improve assistive technology and rehabilitation devices. The research topic "Bioinspired Technology and Biomechanics" welcomes studies reporting recent advances in bioinspired technologies that contribute to individuals\' health, inclusion, and rehabilitation. Possible contributions can address (but are not limited to) the following research topics: Bioinspired design and control of exoskeletons, orthoses, and prostheses; Experimental evaluation of the effect of assistive devices (e.g., influence on gait, balance, and neuromuscular system); Bioinspired technologies for rehabilitation, including clinical studies reporting evaluations; Application of neuromuscular and biomechanical models to the development of bioinspired technology.',annualVolume:11404,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"49517",title:"Prof.",name:"Hitoshi",middleName:null,surname:"Tsunashima",fullName:"Hitoshi Tsunashima",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTP4QAO/Profile_Picture_1625819726528",institutionString:null,institution:{name:"Nihon University",institutionURL:null,country:{name:"Japan"}}},{id:"425354",title:"Dr.",name:"Marcus",middleName:"Fraga",surname:"Vieira",fullName:"Marcus Vieira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003BJSgIQAX/Profile_Picture_1627904687309",institutionString:null,institution:{name:"Universidade Federal de Goiás",institutionURL:null,country:{name:"Brazil"}}},{id:"196746",title:"Dr.",name:"Ramana",middleName:null,surname:"Vinjamuri",fullName:"Ramana Vinjamuri",profilePictureURL:"https://mts.intechopen.com/storage/users/196746/images/system/196746.jpeg",institutionString:"University of Maryland, Baltimore County",institution:{name:"University of Maryland, Baltimore County",institutionURL:null,country:{name:"United States of America"}}}]},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering",scope:"The Biotechnology - Biosensors, Biomaterials and Tissue Engineering topic within the Biomedical Engineering Series aims to rapidly publish contributions on all aspects of biotechnology, biosensors, biomaterial and tissue engineering. We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics can include but are not limited to: Biotechnology such as biotechnological products and process engineering; Biotechnologically relevant enzymes and proteins; Bioenergy and biofuels; Applied genetics and molecular biotechnology; Genomics, transcriptomics, proteomics; Applied microbial and cell physiology; Environmental biotechnology; Methods and protocols. Moreover, topics in biosensor technology, like sensors that incorporate enzymes, antibodies, nucleic acids, whole cells, tissues and organelles, and other biological or biologically inspired components will be considered, and topics exploring transducers, including those based on electrochemical and optical piezoelectric, thermal, magnetic, and micromechanical elements. Chapters exploring biomaterial approaches such as polymer synthesis and characterization, drug and gene vector design, biocompatibility, immunology and toxicology, and self-assembly at the nanoscale, are welcome. Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",annualVolume:11405,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"35539",title:"Dr.",name:"Cecilia",middleName:null,surname:"Cristea",fullName:"Cecilia Cristea",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYQ65QAG/Profile_Picture_1621007741527",institutionString:null,institution:{name:"Iuliu Hațieganu University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"40735",title:"Dr.",name:"Gil",middleName:"Alberto Batista",surname:"Gonçalves",fullName:"Gil Gonçalves",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYRLGQA4/Profile_Picture_1628492612759",institutionString:null,institution:{name:"University of Aveiro",institutionURL:null,country:{name:"Portugal"}}},{id:"211725",title:"Associate Prof.",name:"Johann F.",middleName:null,surname:"Osma",fullName:"Johann F. 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