IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\\n\\n
By listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
All three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\\n\\n
"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
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"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
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In conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\\n\\n
“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\\n\\n
We invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\\n\\n
Feel free to share this news on social media and help us mark this memorable moment!
After years of being acknowledged as the world's leading publisher of Open Access books, today, we are proud to announce we’ve successfully launched a portfolio of Open Science journals covering rapidly expanding areas of interdisciplinary research.
\n\n\n\n
IntechOpen was founded by scientists, for scientists, in order to make book publishing accessible around the globe. Over the last two decades, this has driven Open Access (OA) book publishing whilst levelling the playing field for global academics. Through our innovative publishing model and the support of the research community, we have now published over 5,700 Open Access books and are visited online by over three million academics every month. These researchers are increasingly working in broad technology-based subjects, driving multidisciplinary academic endeavours into human health, environment, and technology.
\n\n
By listening to our community, and in order to serve these rapidly growing areas which lie at the core of IntechOpen's expertise, we are launching a portfolio of Open Science journals:
All three journals will publish under an Open Access model and embrace Open Science policies to help support the changing needs of academics in these fast-moving research areas. There will be direct links to preprint servers and data repositories, allowing full reproducibility and rapid dissemination of published papers to help accelerate the pace of research. Each journal has renowned Editors in Chief who will work alongside a global Editorial Board, delivering robust single-blind peer review. Supported by our internal editorial teams, this will ensure our authors will receive a quick, user-friendly, and personalised publishing experience.
\n\n
"By launching our journals portfolio we are introducing new, dedicated homes for interdisciplinary technology-focused researchers to publish their work, whilst embracing Open Science and creating a unique global home for academics to disseminate their work. We are taking a leap toward Open Science continuing and expanding our fundamental commitment to openly sharing scientific research across the world, making it available for the benefit of all." Dr. Sara Uhac, IntechOpen CEO
\n\n
"Our aim is to promote and create better science for a better world by increasing access to information and the latest scientific developments to all scientists, innovators, entrepreneurs and students and give them the opportunity to learn, observe and contribute to knowledge creation. Open Science promotes a swifter path from research to innovation to produce new products and services." Alex Lazinica, IntechOpen founder
\n\n
In conclusion, Natalia Reinic Babic, Head of Journal Publishing and Open Science at IntechOpen adds:
\n\n
“On behalf of the journal team I’d like to thank all our Editors in Chief, Editorial Boards, internal supporting teams, and our scientific community for their continuous support in making this portfolio a reality - we couldn’t have done it without you! With your support in place, we are confident these journals will become as impactful and successful as our book publishing program and bring us closer to a more open (science) future.”
\n\n
We invite you to visit the journals homepage and learn more about the journal’s Editorial Boards, scope and vision as all three journals are now open for submissions.
\n\n
Feel free to share this news on social media and help us mark this memorable moment!
\n\n
\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{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"}]},book:{item:{type:"book",id:"9040",leadTitle:null,fullTitle:"Pedagogy in Basic and Higher Education - Current Developments and Challenges",title:"Pedagogy in Basic and Higher Education",subtitle:"Current Developments and Challenges",reviewType:"peer-reviewed",abstract:"This book takes a holistic approach to pedagogy and argues that the purpose of education is to educate the student's whole personality including cognitive, social, and moral domains. The four sections and twelve chapters address the current pedagogical challenges in basic and higher education in international contexts. The authors describe the principles and practices through which meaningful education is promoted and enhanced in a variety of ways. The challenges educators face in their profession as well as ways to overcome them are elaborated on both theoretically and empirically. The book allows both researchers, teachers, and educational policy makers to reflect on current developments, challenges, and areas of development in educational institutions when aiming to support student growth and learning.",isbn:"978-1-83880-268-4",printIsbn:"978-1-83880-267-7",pdfIsbn:"978-1-83880-120-5",doi:"10.5772/intechopen.83007",price:119,priceEur:129,priceUsd:155,slug:"pedagogy-in-basic-and-higher-education-current-developments-and-challenges",numberOfPages:234,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"3ef45143bf2a8d798f0e423e098afe6c",bookSignature:"Kirsi Tirri and Auli Toom",publishedDate:"February 19th 2020",coverURL:"https://cdn.intechopen.com/books/images_new/9040.jpg",numberOfDownloads:10869,numberOfWosCitations:9,numberOfCrossrefCitations:19,numberOfCrossrefCitationsByBook:1,numberOfDimensionsCitations:27,numberOfDimensionsCitationsByBook:2,hasAltmetrics:1,numberOfTotalCitations:55,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 8th 2019",dateEndSecondStepPublish:"September 2nd 2019",dateEndThirdStepPublish:"November 1st 2019",dateEndFourthStepPublish:"January 20th 2020",dateEndFifthStepPublish:"March 20th 2020",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"234399",title:"Prof.",name:"Kirsi",middleName:null,surname:"Tirri",slug:"kirsi-tirri",fullName:"Kirsi Tirri",profilePictureURL:"https://mts.intechopen.com/storage/users/234399/images/system/234399.jpeg",biography:"Dr. Kirsi Tirri is a Professor of Education and Research Director at the Helsinki Collegium for Advanced Studies and Department of Education at the University of Helsinki, Finland. She is also a visiting Professor at St. John’s University, New York, USA and University of Tallinn in Estonia. She has published widely in international educational journals and books on teacher education, moral education and talent development. She also serves on the Editorial Boards of 13 educational journals. You can read more of her work at: http://www.helsinki.fi/~ktirri",institutionString:"University of Helsinki",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"4",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"University of Helsinki",institutionURL:null,country:{name:"Finland"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"298433",title:"Dr.",name:"Auli",middleName:null,surname:"Toom",slug:"auli-toom",fullName:"Auli Toom",profilePictureURL:"https://mts.intechopen.com/storage/users/298433/images/system/298433.jpeg",biography:"Dr Auli Toom is a Professor of Higher Education and the Director\nof the Centre for University Teaching and Learning at University\nof Helsinki, Finland. She is a Visiting Professor at the University\nof Tartu, Estonia. Professor Toom is also the director of the doctoral program PsyCo (Psychology, Learning and Communication). Professor Toom is the President of the Finnish Educational\nResearch Association (FERA). Her research interests include\nteacher knowing, competence, expertise, and agency among students and teachers. She investigates these factors in basic education, teacher education, and higher\neducation contexts. She leads several research projects on higher education and\nteacher education. You can read about her work at https://researchportal.helsinki.fi/\nen/persons/auli-toom",institutionString:"University of Helsinki",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Helsinki",institutionURL:null,country:{name:"Finland"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1316",title:"Higher Education",slug:"higher-education"}],chapters:[{id:"70433",title:"The Moral Role of Pedagogy as the Science and Art of Teaching",doi:"10.5772/intechopen.90502",slug:"the-moral-role-of-pedagogy-as-the-science-and-art-of-teaching",totalDownloads:1140,totalCrossrefCites:6,totalDimensionsCites:6,hasAltmetrics:0,abstract:"The purpose of this chapter is to present the key concepts and actors in pedagogy and didactics in the context of institutional teaching. We present a holistic approach to education and view human beings as lifelong learners who need to be educated comprehensively to actualize their full potential. In this chapter we discuss how pedagogy, the science and art of teaching, can promote the educational goals identified in the curriculum. In this chapter we adhere to the Didaktik curriculum tradition in which values and morals are emphasized in guiding the teaching-studying-learning process. This means that pedagogy is moral in nature, and the teacher’s main task is to reflect the values underlying her teaching and the purposes she wants to advance in her teaching. We also discuss the current pedagogical challenges in both basic and higher education in educating students for the twenty-first century.",signatures:"Kirsi Tirri and Auli Toom",downloadPdfUrl:"/chapter/pdf-download/70433",previewPdfUrl:"/chapter/pdf-preview/70433",authors:[{id:"234399",title:"Prof.",name:"Kirsi",surname:"Tirri",slug:"kirsi-tirri",fullName:"Kirsi Tirri"},{id:"298433",title:"Dr.",name:"Auli",surname:"Toom",slug:"auli-toom",fullName:"Auli Toom"}],corrections:null},{id:"67600",title:"Values as the Pedagogy: Countering Instrumentalism",doi:"10.5772/intechopen.86823",slug:"values-as-the-pedagogy-countering-instrumentalism",totalDownloads:920,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"The chapter sets out to identify ways in which the dominant pedagogy in the west has been shaped and influenced by instrumentalist imperatives emanating from the high age of logical positivism. It will furthermore expose the harm that has been done to education as a result, limitations on learning that are most apparent with the insights of updated sciences. The chapter will propose a values approach to pedagogy as a way of countering the narrow bounds of instrumentalism with an approach that possesses greater potential to address the whole person and the full range of human development measures, including personal, social, emotional, moral, spiritual and academic learning. The chapter will utilize international research that supports the beneficial claims of values pedagogy, with special reference to data from the Australian Values Education Program.",signatures:"Terence Lovat",downloadPdfUrl:"/chapter/pdf-download/67600",previewPdfUrl:"/chapter/pdf-preview/67600",authors:[null],corrections:null},{id:"67633",title:"A Philosophical Outlook on Africa’s Higher Education in the Twenty-First Century: Challenges and Prospects",doi:"10.5772/intechopen.86885",slug:"a-philosophical-outlook-on-africa-s-higher-education-in-the-twenty-first-century-challenges-and-pros",totalDownloads:833,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Higher education is perceived as key to the comprehensive development of Africa. In line with this perception, various governments have initiated several policies and models in an attempt to build quality higher education for developing Africa’s human capital to positively respond to the global challenges of the twenty-first century. Despite these efforts, an observable gap still exists between higher education and socioeconomic development of Africa. This gap raises the question of how the quality of higher education in Africa could be improved to make the needed contribution to the comprehensive development of Africa. This chapter casts a philosophical outlook on higher education in Africa and doubts its relevance in Africa. The chapter reveals that commercialization of teaching and learning, scarcity of qualified faculty, inadequate resources for research, and ineffective governance of higher education institutions hinder African higher education from playing its role as a development agent. The chapter further claims that research collaborations across disciplines in higher education institutions, improvement in irregular/nontraditional modes of teaching and learning, utilization of student-based learning models, and restructuring the governance of higher institutions will help the African society reimagine the significance of these institutions to the socioeconomic developmental goals of the African society.",signatures:"Dei Daniel, Osei-Bonsu Robert and Amponsah Samuel",downloadPdfUrl:"/chapter/pdf-download/67633",previewPdfUrl:"/chapter/pdf-preview/67633",authors:[null],corrections:null},{id:"69604",title:"Approach to Pedagogy and Scenarios Poor People Face in the Pursuit of Basic and Higher Education",doi:"10.5772/intechopen.88521",slug:"approach-to-pedagogy-and-scenarios-poor-people-face-in-the-pursuit-of-basic-and-higher-education",totalDownloads:495,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"This chapter addresses some key issues related to pedagogical approaches and scenarios marginalised groups face in the pursuit of basic and higher education in African countries. Based on a case study carried out in Tanzania and South Africa, this chapter explores debates within the theory and practice of education and teaching environment, and elaborates what the notion pedagogy encompasses in the act of teaching and learning, inequality systems linked to opportunities offered by the new Information Technology, lack of quality teachers and infrastructure all focused to poor people entering the labour market. This chapter considers how pedagogical challenges can be diminished and overcome the growing knowledge and skills shortages. Finally, it offers recommendations towards turning both pedagogy and pedagogical challenges into a success story focused on investing in human capital for the poor in Africa.",signatures:"Charles Enock Mulimba Ruyembe",downloadPdfUrl:"/chapter/pdf-download/69604",previewPdfUrl:"/chapter/pdf-preview/69604",authors:[null],corrections:null},{id:"70195",title:"Using the Research Tutorial as a Training Strategy for Tutor Professional Development in an Undergraduate Course",doi:"10.5772/intechopen.90150",slug:"using-the-research-tutorial-as-a-training-strategy-for-tutor-professional-development-in-an-undergra",totalDownloads:667,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"This chapter is part of a larger research project that seeks to investigate sustainable ways of improving group-based tutoring in higher education courses. A growing body of research into teaching and learning in higher education acknowledges that higher education institutions are regarded as bastions of active teaching and learning that encourage students’ deep learning and critical engagement. However, existing research also suggests that there is a lack of active participation by students during learning activities in tutorials; one of the reasons is the poor quality of the interactions between tutors and students during tutorials. Postgraduate students, who make up the majority of tutors, receive little formal training and lack sophisticated instructional skills on how to facilitate tutorials. By using an example, this chapter argues for the use of a research tutorial as a training strategy for tutor professional development (TPD) in an undergraduate Quantitative Literacy (QL) intervention course. The research methodology employed in this study is the lesson study. A research tutorial is a tutorial designed by both tutors and researchers that is used for TPD purposes. Suggestions for future research include focussing on how tutors notice, and attend to, the students’ productive struggles during an undergraduate QL tutorial.",signatures:"Duncan Mhakure",downloadPdfUrl:"/chapter/pdf-download/70195",previewPdfUrl:"/chapter/pdf-preview/70195",authors:[null],corrections:null},{id:"69290",title:"The Power of Appearance: Students’ Impression Management within Class",doi:"10.5772/intechopen.88850",slug:"the-power-of-appearance-students-impression-management-within-class",totalDownloads:827,totalCrossrefCites:1,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Although educational research acknowledges that social perception processes are relevant for understanding but also evaluating situations, the topic of impression management (IM) has achieved only little attention so far. Individuals have discussed rather as passively exposed to the mechanism of social interaction and perception processes. This contribution changes perspectives and addresses the question of conscious impression management within classes. The chapter asks whether students use self-presentation tactics in order to deliberately navigate the impression their teachers should have of them. By means of an empirical study, country- and gender-specific differences with regard to impression management were found. Likewise, students with a high educational aspiration and good school grades scored higher or at least differently on impression management than students with a low educational aspiration level and low school grades. And students with a high educational aspiration but low grades try to overcome this discrepancy by means of personally adapting to the teachers’ expectations. Even though the influence mechanism of impression management on school success cannot conclusively be answered, this paper opens new perspectives on the scientific discourse of social inequality as well as teaching quality and discusses implications for teacher education.",signatures:"Sarah Forster-Heinzer, Arvid Nagel and Horst Biedermann",downloadPdfUrl:"/chapter/pdf-download/69290",previewPdfUrl:"/chapter/pdf-preview/69290",authors:[null],corrections:null},{id:"70718",title:"Students’ Productive Struggles in Mathematics Learning",doi:"10.5772/intechopen.90802",slug:"students-productive-struggles-in-mathematics-learning",totalDownloads:912,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:1,abstract:"Using a predetermined framework on students’ productive struggles, the purpose of this study is to explore high school students’ productive struggles during the simplification of rational algebraic expressions in a high school mathematics classroom. This study is foregrounded in the anthropological theory of the didactic, and its central notion of a “praxeology” – a praxeology refers to the study of human action, based on the notion that humans engage in purposeful behavior of which the simplification of rational algebraic expressions is an example. The research methodology comprised a lesson study involving a sample of 28 students, and the productive struggle framework was used for data analysis. Findings show that the productive struggle framework is a useful tool that can be used to analyze students’ thinking processes during the simplification of rational algebraic expressions. Further research is required on the roles that noticing and questioning can play for mathematics teachers to respond to and effectively support the students’ struggles during teaching and learning.",signatures:"Anthony Sayster and Duncan Mhakure",downloadPdfUrl:"/chapter/pdf-download/70718",previewPdfUrl:"/chapter/pdf-preview/70718",authors:[null],corrections:null},{id:"69330",title:"Perception of Student-Teachers Regarding Self-Regulated Learning",doi:"10.5772/intechopen.88728",slug:"perception-of-student-teachers-regarding-self-regulated-learning",totalDownloads:765,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"In this chapter of the book we have described and analyzed what student-teachers understand by self-regulated learning, what they do when applying the different phases of this process and what are the difficulties, they have to regulate their learning. Student-teachers participating in the study are pre-service teachers who are trained to work in the school system as secondary school teachers. The sample consisted of 60 student-teachers from a university in southern Chile. The main findings show that students relate the concept of self-regulated learning mainly with the general organization prior to the study and with the regulation of their emotions. Regarding the process of self-regulated learning, it is suggested that the planning and execution phase are incipient because there is: (i) lack of strategic planning in the planning phase, (ii) lack of motivational self-control processes, which influences the lack of regulation as: disorganization and uncontrolled emotions, (iii) absence of self-records that allow them to compare and monitor the execution of the study. Additionally, it is proposed conceptual model includes components that represent: (i) the understanding of the concept of self-regulation of learning, (ii) development of the process of self-regulation of learning, (iii) lack of regulation and (iv) external agent’s antiregulation of learning.",signatures:"Carolina Zambrano-Matamala, Darío Rojas-Diaz, Pedro Salcedo-Lagos, Felipe Albarran-Torres and Alejandro Diaz-Mujica",downloadPdfUrl:"/chapter/pdf-download/69330",previewPdfUrl:"/chapter/pdf-preview/69330",authors:[null],corrections:null},{id:"68565",title:"Teaching, Reflecting and Learning: Exploring Teacher Education Study Abroad Programs as Transformational Learning Opportunities",doi:"10.5772/intechopen.88578",slug:"teaching-reflecting-and-learning-exploring-teacher-education-study-abroad-programs-as-transformation",totalDownloads:809,totalCrossrefCites:2,totalDimensionsCites:2,hasAltmetrics:0,abstract:"An essential goal of teacher education is to reveal cultural blindness, bias that may be hidden from preservice teachers’ awareness. This may include unintentional biases, misunderstandings, and stereotypes, which can affect what happens in the classroom. Transformational learning through cultural immersion experiences can reveal what is hidden, allowing students to critically reflect and revise assumptions and perspectives leading to cultural competence and culturally relevant pedagogy. Teacher education study abroad experiences can transform preservice teachers’ ethnocentric worldviews and lead them to adopt more culturally competent mindsets. Reflection is key to participants understanding the impacts from a study abroad experience, and several years may pass before participants realize how much impact their experiences abroad had upon them. We used case study methodology to examine the meanings four teachers make of the long-term effect of a study abroad experience on their cultural awareness and pedagogical decisions. This use of retrospective methods may help to understand that the impacts of teacher education study abroad are difficult to articulate and assess directly after the program, and thus encourage program designers and researchers to provide participants opportunities to venture out of their cultural comfort zones and reflect upon their experiences a year or more after the study abroad program.",signatures:"Allison Freed, Aerin Benavides and Lacey Huffling",downloadPdfUrl:"/chapter/pdf-download/68565",previewPdfUrl:"/chapter/pdf-preview/68565",authors:[null],corrections:null},{id:"68730",title:"Categorization of Educational Technologies as Related to Pedagogical Practices",doi:"10.5772/intechopen.88629",slug:"categorization-of-educational-technologies-as-related-to-pedagogical-practices",totalDownloads:1086,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:1,abstract:"Educational technologies are not homogeneous. This chapter proposes a framework to categorize various technologies in the K-12 educational setting into groups of operational technologies and pedagogical technologies by whether they directly participate in the process of teaching and learning. Furthermore, pedagogical technologies are split into tool-based and program-based technologies based on whether they are teacher-driven tools or algorithm-driven learning programs. Efficient adoption of tool-based technologies requires a redefinition of learning goals to embrace student-centered education. Program-based technologies need more research to be fully understood and improved, and current ones are under-researched and fail to engage and motivate students to learn.",signatures:"Perry P. Gao, Arvid Nagel and Horst Biedermann",downloadPdfUrl:"/chapter/pdf-download/68730",previewPdfUrl:"/chapter/pdf-preview/68730",authors:[null],corrections:null},{id:"69424",title:"School-University Partnership for Evidence-Driven School Improvement in Estonia",doi:"10.5772/intechopen.89513",slug:"school-university-partnership-for-evidence-driven-school-improvement-in-estonia",totalDownloads:987,totalCrossrefCites:2,totalDimensionsCites:2,hasAltmetrics:0,abstract:"It has been acknowledged that evidence-driven practices may lead schools to improved instructional practices, student learning, or organizational improvement; still the evidence is underused by the teachers or school leaders. This study focuses on analyzing how to strengthen the evidence-driven school improvement in school-university partnership programs. Five schools learnt over a period of one school year in collaboration with the university coaches how to collect evidence in classroom and organizational level for improvement process. The results of our study illustrate profiles of the schools based on the usage of data-informed evidence, research-based evidence, or both to make decisions in the instructional and organizational level. Enablers and barriers of data use from the perspective of organizational, user, and data characteristics to implement evidence-driven practices are discussed.",signatures:"Kätlin Vanari, Kairit Tammets and Eve Eisenschmidt",downloadPdfUrl:"/chapter/pdf-download/69424",previewPdfUrl:"/chapter/pdf-preview/69424",authors:[null],corrections:null},{id:"69651",title:"Parental Engagement in Children’s Learning: A Holistic Approach to Teacher-Parents’ Partnerships",doi:"10.5772/intechopen.89841",slug:"parental-engagement-in-children-s-learning-a-holistic-approach-to-teacher-parents-partnerships",totalDownloads:1431,totalCrossrefCites:6,totalDimensionsCites:9,hasAltmetrics:0,abstract:"This study presents the standpoint of parental engagement, conceptualized by Janet Goodall and collaborators, as a framework that is coherent to the principles of the holistic approach of pedagogy to teacher-parents’ partnerships. We bring forward the evolution of the concept of parental engagement and its main standpoints, in relation to more traditional theories on parental involvement. We also discuss previous findings about teachers’ and parents’ roles in education and teacher-parents’ partnerships, as well as how do changes in educational paradigms challenge home-school collaboration. Finally, the article highlights the need to implement research-based parental engagement practices in educational systems around the world.",signatures:"Cristiana Levinthal de Oliveira Lima and Elina Kuusisto",downloadPdfUrl:"/chapter/pdf-download/69651",previewPdfUrl:"/chapter/pdf-preview/69651",authors:[null],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"1990",title:"International Perspectives of Distance Learning in Higher Education",subtitle:null,isOpenForSubmission:!1,hash:"e9f445b89a42e6221004f529ac247127",slug:"international-perspectives-of-distance-learning-in-higher-education",bookSignature:"Joi L. Moore and Angela D. Benson",coverURL:"https://cdn.intechopen.com/books/images_new/1990.jpg",editedByType:"Edited by",editors:[{id:"102403",title:"Dr.",name:"Joi L.",surname:"Moore",slug:"joi-l.-moore",fullName:"Joi L. 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\r\n\tNowadays, the Internet of things (IoT) is a relatively new research field, so several developments and research works focused on this matter can be found in the literature and the market.
\r\n
\r\n\t \r\n\tHowever, now that this technology has advanced enough, it is important to focus our attention on the use that is being made of it to expand its field of application and improve the current systems.
\r\n
\r\n\t \r\n\tTo achieve this goal, this book aims to collect a series of multidisciplinary works and studies about security in IoT systems, reliability mechanism for data transmission, the correct use of the information provided by those systems, and the inference about the data obtained. Moreover classical IoT systems with new approaches will be included.
\r\n
\r\n\t \r\n\tThe main goal of this book is to give a new vision inside IoT systems by combining them with other new technologies, and without losing sight of the new advances and applications around these systems.
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1. Introduction
Dysphagia is a widely prevalent phenomenon that brings the risk of other conditions like malnutrition, pneumonia, and even the necessity for non-oral feeding solutions [1, 2, 3]. It always leads to reduced quality of life, and can even be fatal [4].
1.1 Few real solutions
The ways that patients with dysphagia are cared for fall into two broad categories, of which the first is by far the most common. Patients are often provided with compensatory care, [5, 6] which allows them to live with the disabilities that dysphagia brings. These therapies may include modified often puréed solid foods that are easier to swallow, and thickened drinks that can be swallowed more safely with less risk of aspiration. Instruction on posture, eating habits, oral hygiene and more, are also common.
The second category of care is rehabilitation treatment [7, 8, 9, 10, 11] to address the causes of the dysphagia. In general they focus on increasing muscle strength in the affected organs.
1.2 A new, innovative solution
This chapter introduces a simple neuromuscular treatment using an oral therapy - IQoro (Figure 1) - that can usually be self-administered by the patient. The treatment has clinical evidence and scientific proof of striking success in treating people of all ages with all forms of dysphagia: oral-, pharyngeal- and esophageal [12, 13, 14]. When used with stroke survivors, the research shows equally good outcomes regardless of whether treatment started immediately, or long after the onset of stroke [10]. In scientific studies, the observed improved outcomes were still present at long-term follow-ups performed up to 18 months after the end of treatment [11, 12, 15, 16, 17].
Figure 1.
The IQoro neuromuscular training device.
2. Two innovative clinicians
2.1 Mary’s journey
Associate professor Mary Hägg started her professional life as a hospital dentist where she became fascinated with the swallowing problems that some of her patients presented with. In Sweden, the remit of the dentist is wider than in some other countries and can encompass more orofacial issues than just teeth and gums. The more she worked with patients with swallowing difficulties some after stroke the more fascinated she became. She worked with exercises to strengthen the delinquent muscles and became more and more renowned for her focus on dysphagia.
In 1990, Mary founded a specialist multi-disciplinary unit within the ENT department of a Swedish teaching hospital and has managed it since its inception. The purpose of this speech and the swallowing unit is to encourage and ensure cooperation across a range of clinical specialties to deliver improved patient outcomes.
In 1997 she was awarded a stipend to visit and study the subject more deeply with Dr. Castillo Morales, Cordoba, Argentina, and in 2001 with Professor Bronwyn Jones, Dept. of Radiology, The Johns Hopkins Hospital, medical center in Baltimore, Maryland, USA.
As she treated more and more patients that were referred to her, she came to two conclusions: firstly, those swallowing difficulties manifest themselves as a muscular deficiency, but usually have a neurological dysfunction at the root; and secondly, that there were few effective treatment options. In many cases, patients received only compensatory care which allowed them to function with their disability, but with no active plan to address the underlying problem.
To address the first issue Mary decided that she must study to be a doctor in order to understand the neurology that lies behind dysphagia. It is clear that the day before a patient has a stroke that his or her swallowing can be fine and that it is the neurological event that causes the immediate onset of dysphagia. Mary’s Ph.D. thesis “Sensory-motor brain plasticity in stroke patients with dysphagia. A methodological study on investigation and treatment” 2007, used massage to restore muscular strength by stimulating brain activity. Mary invented and had manufactured a validated scientific instrument to measure the strength of certain components in the swallowing chain by measuring resistance in the pharyngeal sling or buccinator mechanism [18, 19]. She also developed and validated orofacial motor test methodologies [20].
The second problem, the lack of suitable treatments [21, 22] that could be easily and widely used even by the patients themselves was a harder task. Her journey took her through working with all types of dysphagia in people from premature babies through children, adults, and to end-of-life. The journey resulted in her inventing, developing, and patenting the revolutionary IQoro device that is now, July 2021, used by over 50,000 people in many countries.
2.2 Natalie’s vision
Decades later Natalie Morris came across the IQoro device, and it set her wondering if it would help her patients too. Natalie is a Speech and Language Therapist working in the UK and is the founder and CEO of The Feeding Trust a not-for-profit multi-disciplinary feeding clinic in the Midlands. During her 20-year career as an SLT, Natalie has become specialist in the assessment and treatment of communication and swallowing difficulties in children and young people (CYP) with neuro-developmental disabilities and acquired brain injuries. She is the founder of Integrated Therapy Solutions Ltd. where she and her team help CYP with swallowing difficulties.
She looked at the scientific evidence supporting IQoro and was disappointed to find that there was none that was directly relevant to one of her main patient groups: CYP clients with Cerebral Palsy (CP). This was significant because NICE guidelines for the management of saliva control in CP [23] offer few options:
Assess contributory factors before starting drug therapy
Medication
Botulinum toxin injections
Surgery
In other words, the only treatment options after considering compensatory strategies such as positioning, are drug therapy or surgery. But the Cochrane review of interventions for drooling in children with CP according to Walshe M, Smith M, Pennington L 2012 [24] concludes: “There is no clear consensus on which interventions are safe and effective in managing drooling in children with CP.” Her own clinical observations and experiences over the years have been that difficulties with saliva control are a persistent problem with no real effective treatment.
Natalie reasoned that if IQoro could help patients with neurological problems such as after a stroke, then it might help her patients with CP too. And if there was no evidence to prove that it worked, then she would have to investigate it herself.
This chapter will show the success of these two clinicians’ work.
3. The physiology of the swallow
This is a brief description of the four different physiological phases of the swallowing process, the following section will look at the neurology of the swallow in detail [5, 25].
During a day, a normal person swallows approximately 600 times: 350 of these are during the day, 200 when eating or drinking, and 50 times when asleep. We use our voluntary muscles to transfer food to our mouths and chew it, after this our reflexive systems take over to complete the swallow unconsciously. When we swallow whilst asleep it is, of course, an entirely reflexive process.
3.1 The phases of the swallow
3.1.1 Pre-oral phase
Simply described, the swallowing process starts when we transfer food from the plate to the mouth (Figure 2). This phase is negatively affected when postural control or arm and hand motility are reduced, possibly after stroke [17].
Figure 2.
The four phases of the swallowing process.
Figure 3.
Functional and dysfunctional swallow.
3.1.2 Oral phase
The oral phase (Figure 2) starts when we close our lips, chew, reduce the food to manageable pieces and mix it with saliva. As the food is formed into a bolus the tongue’s backward and upwards movements propel it towards the pharynx, at the same time the floor of the mouth rises. And then immediately before the swallowing reflex is triggered we press our lips together creating a low pressure in the mouth. This activity normally takes up to 10 seconds [5]. The decrease in pressure in the mouth eases the transport of the food mixture from the mouth to the pharynx.
The phases employ a mixture of voluntary and involuntary commands.
3.1.3 Pharyngeal phase
Once the bolus has passed the anterior palatal arch towards the pharynx, the swallow reflex takes over. This is controlled by the brain stem no longer consciously controlled as the pre-oral and oral phases were. The interplay between the voluntary and involuntary processes is described in the following section on the neurology of the swallow.
A normal swallow requires a balance between the infrahyoid and suprahyoid muscles to stimulate the swallowing reflex [20, 26].
In a later section “The neurology of the swallow” we will see that these muscles are triggered by the following nerves - Infrahyoidal muscles: CN XII hypoglossus.
– Suprahyoidal muscles: CN VII facialis, CN V trigeminus, CN XII hypoglossus.
Middle illustration: A Functional swallow is prepared when the hyoid bone is pulled backward and upwards (red arrow) by the styloid muscles (CN VII) and the posterior part of the digastric muscles (CN VII), at the same moment as the tongue base retracts.
The swallow reflex is then triggered when the hyoid bone is pulled forwards and upwards (blue arrow) by the digastricus anterior abdomen (CN V), m. mylohyoideus (CN V), and m. geniohyoideus (CN XII). At the same moment, a breathing suspension is caused as the epiglottis closes the laryngeal air pathway, and tongue forward movement is initiated. The chewing muscles are active throughout the swallow.
Left illustration: A dysfunctional swallow. If the chewing muscles are weak, the patient cannot lift his lower jaw and close his lips fully, which hinders swallowing. At the same time, the lower muscle groups of the tongue pull the hyoid bone downwards, which further degrades swallowing ability. The same thing happens when grinding the teeth.
Right illustration: A dysfunctional swallow. When the head falls backward, because of impaired head control, the mouth opens spontaneously and the equilibrium of the hyoid bone is completely upset, resulting in swallowing difficulties.
The pharyngeal phase (Figures 2–4) is a critical part of the swallow controlled purely reflexively and takes between 0.5 and 1 second. It requires a precise interplay between breathing and swallowing functions [5, 13]. When the bolus is to be swallowed, the tongue moves it back towards the anterior palatal arch and the smooth palate which seals against the nasal passages. The larynx raises reflexively, and the tongue starts its forward movement.
Figure 4.
The pharyngeal phase - a critical phase requiring coordination of swallowing and breathing.
The first of four security levels to prevent aspiration of food or drink is now activated. The constrictor muscles: Constrictor pharyngeus superior, Constrictor pharyngeus middle, Constrictor pharyngeus inferior contract [27]. The last of these is also known as the UES [28]. The second level is achieved when the epiglottis closes over the trachea or air pathway. The third and fourth levels are executed as first the false vocal cords close, and then the true vocal cords themselves.
There is perhaps more crossover in dysfunction in the different phases than is often thought. Misdiagnosis is a risk when healthcare professionals concentrate too much on their own specialities without considering a more holistic approach.
For example:
Mis-directed swallowing, post-nasal drip, aspiration, hoarse or gurgly voice, persistent non-productive cough, something stuck in the throat, and blockage are all symptoms often thought of as being caused by a brain injury. Causes of such brain damage can be a stroke, trauma, progressive neurological diseases, or other. In fact, all the symptoms described could equally well be caused by a Hiatal hernia [14].
Patients exhibiting voice changes are often referred in firsthand to a speech and language therapist. If the SLT is not aware that the cause of the problem may be dysfunction in the esophageal phase - like a Hiatal hernia - then optimal outcomes may not be achieved. This problem is aggravated by the fact that SLTs in some countries are not routinely concerned with esophageal dysfunction.
Patients with symptoms of Hiatal hernia are often referred to a medical consultant to rule out the possibility of stroke. When this has been done, then the finger may be pointed at a brain tumor, ALS, or some other neurological condition. Examination for these conditions is both alarming for the patient whilst waiting for examination and results, and expensive. Around 20% of the world’s population suffers from a reflux-based condition, and it is thus logical in many cases to start treating for a Hiatal hernia as soon as stroke has been ruled out.
3.1.4 Esophageal phase
The esophageal phase (Figure 2) concerns the movement of food and drink from the esophagus down to the stomach. The esophagus’ longitudinal musculature is activated, forming a stiff pipe and allowing the entrance to the Upper Esophageal Sphincter (UES) to relax and open to allow the passage of the bolus into the esophagus. At the same time, the Lower Esophageal Sphincter (LES) opens to allow the entrance of the bolus to the stomach [5, 29]. This phase takes around 7 seconds to complete.
As well as the outer longitudinal layer of muscles, the esophagus also has an inner layer of circular muscles. To transport the food down to the stomach, these circular muscles produce coordinated peristaltic wave motions - this explains why we can swallow even if we were hanging upside down.
4. The neurology of the swallow
4.1 The phases of the swallow
The four phases of the swallowing process described above involve 148 muscles and six cranial nerves. Of course, the muscular activities described are not separate from the nerve and brain activity that control them, the entire neurophysiology [25] of the swallowing process must work correctly. Understanding how is fundamental to appreciating how a dysfunctional swallow can be treated.
Figure 5 illustrates four important areas of the brain [25].
Brain stem: It controls non-voluntary “unconscious” automatic functions such as breathing, blood pressure, heart rhythm, the reflex swallowing phases; and also functions as a communication node between the cerebrum, the cerebellum, the spinal cord, and the peripheral nervous system.
Cortex: It controls our voluntary “conscious” most advanced functions such as language, thinking, fine-motor skills, and the voluntary swallowing phases.
Cerebellum: It co-ordinates our movements, our balance, and our ability to act in response to our immediate surroundings.
Corpus callosum: It connects the two brain hemispheres’ cortex areas with each other. It consists of some 200 to 800 million nerves that coordinate the activities of the brain’s two hemispheres.
Figure 5.
The brain.
4.2 Brain functions in swallowing
The sensory nerves report perceptions of pressure, texture, taste, and temperature, and these are transmitted by these afferent nerves to the brain. The primary source of these stimuli is from the nerves in the lips and then, in turn, the tongue, soft palate, and pharynx (Figure 6) [5, 29]. The (CN V) Trigeminus is the thickest and fastest of the efferent nerves, and thus the signals from the lips are the first to reach the brain stem. It is therefore a mistake to concentrate on therapies for the tongue, soft palate, and pharynx that omit the importance of the lips.
Figure 6.
The cranial nerves and reflex points of the oral cavity.
The five cranial motor nerves that are important for swallowing are CN V Trigeminus, CN VII Facialis, CN IX Glossopharyngeus, CN X, Vagus, and CN XII Hypoglossus. The first four are both sensory (afferent), and motor (efferent) nerve pathways; which send information both to and from the brain - the sensory-motoric reflex arc.
In the brain stem (Figure 7) we find the Nucleus Tractus Solitarius (NTS): the afferent nucleus. The NTS is the core that gathers all incoming sensory signals via the afferent nerve pathways as described (Figure 7). The NTS then transmits the signals onwards either to the brain’s cortex or directly to the network-like system in the brainstem called the Formatio Reticularis (FR). These efferent motor signals are transmitted to the musculature of the face, mouth, esophagus, diaphragm, down to the stomach, the intestines, and the rectum. The process by which the incoming sensory signals trigger afferent commands is known as the sensory-motoric reflex arc (Figure 7) [5, 25, 26, 29].
Figure 7.
The sensory-motor reflex arc (level 1).
The three swallowing centers’ interactions - from the brain stem to muscles.
In the FR, the afferent signals from the NTS and the cortex (Figure 7) are first interpreted and then passed through various distribution nodes to the efferent nuclei: the Nucleus Ambiguus (NA), and the Nucleus Dorsalis Nervi Vagi (NDNV).
The NA (Figure 7) sends impulses to the skeletally striated musculature in the oral and pharyngeal regions; and the NDNV (Figure 7) to the smooth musculature of the esophagus and beyond. How these function during swallowing we will explain in more detail below.
In the FR there are three distribution nodes (swallowing centers) that are key to the swallowing process; as well as a number of other centers that control breathing, speech, chewing, coughing, vomiting, evacuation of the bowels and bladder, and those muscles that control the body’s posture (Figure 8). [5, 25, 26, 29].
Figure 8.
The Formatio Reticularis (FR) is the control centre for a variety of vital functions.
The Formatio Reticularis is the control centre for several vital functions including breathing, speech, chewing, coughing, vomiting, evacuation of the bowels and bladder, and those muscles that control the body’s posture.
The incoming information is routed by the Nucleus Tractus Solitarius (NTS) in two pathways: some directly to the first of the three swallowing centers in the brain stem, whilst the remainder of the information continues upwards to the cortex to be processed before being also directed to the first swallowing center (Figure 7).
4.3 The swallowing centers
4.3.1 First swallowing center
If the combination of information received by the first swallowing center (Figure 9) from the NTS and from the cortex is interpreted as that something is to be swallowed, this instruction is sent to the second swallowing center.
Figure 9.
The sensory-motoric reflex arc (level 1–3).
4.3.2 Second swallowing center
The second swallowing center (Figure 9) transmits signals to the muscles via the motor nerves – the downward-transmitting efferent nerve pathways. Here, there is a pre-programmed “swallow / don’t swallow” stereotypical muscle response.
If the food is to be swallowed, a command is sent to the NA, which in its turn sends the instruction via the efferent nerve pathways to the striated musculature in the oral and pharyngeal regions of the swallowing chain. Concurrently, impulses are also sent to the third swallowing center.
4.3.3 Third swallowing center
The third swallowing center (Figure 9) transmits information to the NDNV - an efferent nucleus and then onwards to the esophagus’ smooth musculature to complete the swallowing action and to transport the bolus downwards to the stomach.
The three swallowing centers’ interactions from the 2nd center to the striated muscles, and the 3rd center to the smooth muscles is illustrated here.
The 3rd swallowing center transmits information to the Nucleus Dorsalis Nervi Vagi (NDNV), and then onwards to the smooth muscles including those in the esophagus (Figures 9 and 10).
Figure 10.
Three types of motor neurons.
4.4 The motor neurons
The motor signals are transmitted via efferent nerves that can be thought of as cables containing various fibers and motor neurons to the muscles and glands. There are three different kinds of motor neurons that are important in the swallowing process (Figure 10) [5, 25, 29].
The General Somatic Efferent (GSE) motor neurons are present in the CN Hypoglossus (XII) and CN Oculomotorius (III) which transmit signals onwards to the tongue’s and the inner eyes’ voluntary skeletal striated musculature.
The Special Visceral Efferent (SVE) motor neurons act through the CN Trigeminus (V), CN Facialis (VII), CN Glossopharyngeus (IX), CN Vagus (X) and CN Accessorius (XI) which transmit signals to the voluntary musculature in the mouth, chewing muscles, facial musculature, pharynx, larynx, esophagus, and diaphragm.
The General Visceral Efferent (GVE) motor neurons act via CN Facialis (VII) and CN Glossopharyngeus (IX) which transmit signals to the glands, blood vessels, and smooth muscles in the pharynx, stomach, and rectum.
The sum of all the above signals executes pre-programmed cooperation between the 148 muscles that are involved in the transport of each food bite from the mouth down to the stomach.
The efferent nerves send signals via the three different motor neuron fiber types to the muscles and glands.
4.5 Understanding the three neurological phases
4.5.1 Oral phase
As we have said earlier, the oral phase is consciously controlled (voluntary) and is managed by the brain’s cortex region [5, 25]. But when the bolus has passed the anterior palatal arch towards the pharynx, the swallow reflex takes over and this is controlled by the brain stem – no longer consciously or voluntarily controlled.
4.5.2 Pharyngeal phase
The tongue’s movement backward and upwards transports the food towards the pharynx. When the bolus reaches the anterior palatal arch and the smooth palate, the reflexive phase of the swallow starts [5, 6] causing the larynx to rise, As the tongue begins its return movement forward, the epiglottis seals the airway and the food passes into the pharynx. The pharyngeal phase takes between 0.5 and 1 second.
In this phase, the coordination between breathing and swallowing is crucial to avoid food ‘going down the wrong way’ [5, 25, 30, 31]. Breathing and swallowing are guided by different centers in the brain stem, however, all the muscles that are active in these two functions are controlled from the same concentrated grouping of specialized nerves nucleus in the brain stem. This allows the swallowing center to take control of breathing during a crucial phase in the act of swallowing. When the 1st and 2nd Swallowing Centers signal that swallowing is underway, the body breathes in. During the subsequent exhalation, the food portion is driven to the back of the tongue and the exhalation stops as the bolus crosses the airway. Breathing ceases for 2 seconds about twice as long as it takes for the bolus to pass the pharynx then breathing is resumed with a continued exhalation.
4.5.3 Esophageal phase
The esophagus’ longitudinal musculature forms a stiff pipe, the UES relaxes and opens to allow the passage of the bolus into the esophagus. The sphincter to the stomach – LES - opens to enable the entrance of the food.
The muscle function and the downwards transport of the bolus are controlled by the Vagus CN X and a branch of the Glossopharyngeal CN IX. Together these nerve pathways build a local network in the esophagus’ Plexus Pharyngeus [25].
Both types of muscle: voluntary skeletal striated muscles and involuntary smooth muscles are present in the esophagus. The voluntary musculature is the same type as we have, for example, in our arms and legs: so-called skeletal striated muscles which are attached to the skeleton or tissue, and that are voluntarily controlled. The smooth musculature cannot be controlled voluntarily but is instead controlled by the autonomic nervous system: functioning unconsciously and involuntarily. These muscles are stimulated via the GVE motor neurons (Figure 10) in the brain stem which sends signals to the involuntary musculature.
The esophagus’ upper third consists of skeletal striated muscles, the middle third is a mixture of skeletal striated muscles and smooth musculature, and the bottom third is solely smooth muscle.
5. Dysphagia and reflux diseases are related
5.1 What are reflux-based diseases?
This chapter has so far focussed mostly on the swallowing process of conveying food and drink to the stomach successfully, Hiatus hernia has been mentioned only in passing. Here we explain more about this condition. IQoro treats all dysfunctions in the process of swallowing food and drinks safely and successfully, and in retaining it in the stomach without reflux [14, 32]. A distinction between these two areas although often regarded as separate from a healthcare perspective is artificial. The same neuro-physiological processes are common to both dysfunctional swallowing and reflux.
5.1.1 Prevalence and symptoms
Reflux-based diseases are thought to affect around 20% of the world’s population [33, 34]. Reflux is a condition in which stomach acids sometimes bubble up from the stomach, through the esophagus, and into the throat, larynx, and pharynx. The effect of these acids is to cause the symptoms of [35]:
Heartburn
Burning sensation in the chest
Acidic reflux
Swallowing difficulties
Feeling of a lump in the throat
Feeling of a blockage in the chest when eating
Chest pains
Pain under the breastbone (sternum)
Stomach pains before eating
Stomach pains after eating
Reduced appetite
Early “Full up’\' feeling
Feeling sick
Constipated, gassy
Vomiting
Persistent dry or phlegmy cough
Food or drink ‘goes down the wrong way’
Hoarseness
Breathing difficulties
It should be noted that if some of the above symptoms are chronic, and especially if they do not respond to medication, they could be caused by cancer or other diseases [36], and this should be considered before diagnosing reflux as the sole cause.
Refluxing stomach acids is the underlying cause of several conditions: LPR, GERD (or GORD), Silent Reflux, IED, Dyspepsia, etc. These conditions are sometimes known by their full names: Laryngopharyngeal Reflux, Gastroesophageal Reflux Disease, and Intermittent Esophageal Dysphagia. These various conditions exhibit some or all of the symptoms listed above, they vary slightly but are all caused by the corrosive effect of the refluxed stomach acids.
5.1.2 Cause of reflux
These symptoms occur when stomach acids reflux into the esophagus. The normal position of the stomach and the LES - the valve at the mouth of the stomach - is below the diaphragm. The esophagus passes through the diaphragm muscle through an aperture called the hiatus canal. In functional anatomy the muscle grips tightly around the esophagus and holds the stomach down in its correct position. The LES behaves like a trapdoor in this position, swinging downwards to let food and drink into the stomach before closing again. The LES cannot open upwards to allow reflux. An exception to this is if we need to belch or vomit; then the LES intrudes through the diaphragm slightly into the chest cavity and can flap open upwards and allow stomach gases, liquids or solids to reflux.
A Hiatal hernia is a weakening in the muscle that grips around the esophagus where it passes through the diaphragm. When this occurs the mouth of the stomach and the LES can intrude in an unwanted and uncontrolled fashion and allow reflux to occur.
5.1.3 Existing treatments for reflux-based diseases
The treatment options for reflux-based diseases fall into two broad camps: reducing the symptoms, or addressing the underlying cause.
In the former category, symptom reduction can be achieved by lifestyle changes or medication. Changing poor living, smoking, drinking, eating and diet habits can improve the impact of reflux, but lifestyle changes have an inconclusive effect [37].
Many Over the Counter (OTC) medications have a base pH and address the problem of reflux by reducing the acidity of the stomach acids which are being refluxed. Although the unpleasant sensations of reflux are reduced, the harmful effects on the vulnerable esophagus and other organs continue. Long-term use of OTC medication is generally regarded to be free from harmful side effects.
Prescribed PPI medications act by inhibiting the amount and strength of the acids produced in the stomach. PPI medications have significant known side effects and hence long-term PPI usage is generally discouraged and several countries insist that clinicians perform a medication review before renewing PPI prescriptions. At least once per year is recommended in the UK [38]. PPI medication is usually not expensive in itself, but the costs of repeat Healthcare Professional (HCP) interventions build to a considerable amount when prescribed for rest-of-life.
PPI drugs belong to one of the safest medication groups, but some research suggests a list of unwanted side effects [39, 40] include increased risk of cardiovascular disease, osteoporosis, dementia, male infertility, diabetes, and increased vulnerability to severe covid19 infection.
In addition, harmful bacteria in the stomach like Helicobacter pylori (HP) that would not survive in normal circumstances, can thrive in the weakened acids after PPI treatment. These germs can enter the body and live in the digestive tract. After many years, they can cause sores, called ulcers, in the lining of the stomach or the upper part of the small intestine. For some people, an infection can lead to stomach cancer.
In the case of all medications, there is no expectation that the underlying cause of the reflux – the weakened diaphragm musculature [34, 41]– will be addressed, merely the severity of the reflux symptoms.
The muscular deficiency at the root of the problem can sometimes be remedied by a surgical operation [42] that re-wraps muscles in the hiatal canal around the esophagus, or a similar procedure. Clearly, addressing the underlying cause is preferable in many ways to long-term medication and IQoro, as presented here, offers a simple non-invasive alternative to a surgical operation.
5.1.4 Existing treatments for dysphagia
As discussed, patients with a dysfunctional swallow sometimes after stroke are often treated with compensatory treatments [5, 6]. These care pathways allow patients to live within the limitations of their conditions. Direct and successful treatment of the dysfunctional swallowing chain is to be preferred and is presented in this chapter.
5.1.5 Treating the muscles
If the cause of both dysphagia and reflux is known to be neuromuscular, why are the most common treatments medication or surgical intervention? It is easy to grasp the idea that rebuilding muscle strength will improve swallowing, and allow the muscles in the Hiatal canal to regain their ability to grip around the esophagus.
If a patient presented with an arm that had atrophied because it had been in a plaster cast for some weeks, we might expect a rehab program based on weights and exercises. However, the atrophied-arm parallel has an important disconnect. As we have explained earlier, there are key differences between the arm muscles and many of the muscles that are needed to ensure an effective swallow and to prevent LES intrusion through the diaphragm allowing reflux. The arm is made up of skeletally striated muscles that can be commanded by the individual to flex, and can therefore be consciously exercised; whereas most of the muscles in the swallowing chain cannot, they are controlled and commanded through other nerve types and command systems. The paradox then is how to exercise muscles that cannot be commanded to flex.
6. IQoro
6.1 What is IQoro?
IQoro (Figure 1) is a simple hand-held plastic device that is inserted pre-dentally (inside the lips and in front of the teeth) by a patient and pulled forward against lip pressure to exercise the swallow. At the time of writing, July 2021, it has been used by more than 50,000 individuals and is used by healthcare professionals to treat patients in hospitals and other settings across several countries. It is a CE-marked Class 1 Medical device, internationally patented and costing around USD 150.
6.2 How to train
The patient inserts the device pre-dentally and seals the lips against the handle, then pulls forward firmly displacing the lips forward slightly. This position is held for 10 seconds, followed by a short pause to relax, and then the action is repeated twice more. This 30-second training session should be carried out three times per day, preferably before mealtimes (Figures 11–13).
Figure 11.
(a, b): IQoro training action. (a) the IQoro is inserted pre-dentally, behind closed lips. (b) the patient presses his lips firmly together whilst pulling straight forward strongly for 5–10 seconds, and does this 3 times with 3 seconds rest between each pull. These sessions are performed three times per day, preferably before mealtimes. Video 1.
Figure 12.
Video 1. [43].
Figure 13.
Neurological and physiological considerations in muscle stimulation when eating or during neuromuscular training with IQoro.
Where a patient initially lacks lip strength or has diminished hand or arm function – perhaps after stroke - an assistant can help with this procedure. The vast majority of IQoro users self-treat without assistance.
6.3 How it works
IQoro causes all the muscles in the swallowing chain to be flexed and thus retrained and strengthened.
Training with IQoro triggers the sensory-motor reflex arc.
The muscles in the chain from the lips through to the upper third of the esophagus are mostly skeletally striated and are voluntarily activated [5, 29] when eating normally. Smooth musculature is present in the lower part of the esophagus, and down through the hiatus canal, LES, stomach, intestines, and rectum, and these muscles can only be activated by signals from the autonomic system [5, 29]. It is thus the case that striated musculature is activated by voluntary neurological and physiological commands, but the smooth muscle can only be activated and exercised via commands from the autonomic system.
Studies show that rehabilitation of the smooth musculature traditionally takes longer [14, 32, 44] and requires ongoing maintenance training after treatment.
When you close your lips tightly against the handle and pull the device forward, a low pressure is created in the mouth, making the tongue retract and seal against the anterior palatal arch and the soft palate. The effect of this is to strongly stimulate the sensory nerves in the oral cavity which send afferent signals to the brainstem as described in the neurology section above. Here they provoke a so-called sensory-motor reflex arc which causes intense efferent motor signals to exercise the muscles in the swallowing chain. In this way, IQoro training reaches and strengthens even the smooth musculature that cannot be voluntarily commanded by the patient.
Training with IQoro activates all the muscles in the swallowing chain, including the outer longitudinal muscles that run along the sides of the esophagus and fasten under the diaphragm. As they are activated by IQoro training they exercise the muscles at the site of the rupture, strengthening the weakened muscles back into a functional condition.
In other words, the training action and regime used to treat dysphagia [10] are equally appropriate for Hiatal hernia and reflux-based conditions [14, 32, 44].
7. Evidence of IQoro’s efficacy
This section presents the scientific support for the efficacy of IQoro in treating the two closely related conditions of dysphagia and reflux-based diseases caused by a hiatal hernia. For reasons of space and readability, most studies have been reduced to short summaries of their purpose and conclusions and a link to the full article. Exceptions to this are 8.1.4 and 8.1.5 which are presented in more detail, having not been published in a scientific journal previously.
7.1 Dysphagia
7.1.1 Dysphagia studies
The evidence behind the efficacy of IQoro as a treatment for dysphagia includes more than a dozen peer-reviewed and internationally published scientific research papers.
7.1.1.1 Study: Effects on facial dysfunction and swallowing capacity of intraoral stimulation early and late after stroke
Study type
Peer-reviewed, prospective, cohort pre and post-study designed according to Good Clinical Practice (GCP) [15].
This study showed that IQoro is effective in improving swallowing ability, facial activity in all four facial quadrants in patients, and pharyngeal sling force after stroke, irrespective of time from stroke debut to start of treatment. Improvements were still present at late follow-up (>1 year after the end of treatment).
The 31 patients were grouped according to having had a stroke with recent onset, or a long time before. By implication, the similarly successful results in the two groups rule out spontaneous recovery as a likely cause of the improvements seen.
Conclusion
IQoro is effective in improving swallowing ability, facial activity in all four facial quadrants, and pharyngeal sling force after stroke, irrespective of time from stroke debut to start of treatment.
7.1.1.2 Study: Effect of IQoro training on impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke
Study type
Peer-reviewed, prospective, cohort pre and post-study [17].
The study used IQoro as a treatment for 12 weeks in a patient group that had pathological levels for both Impaired Postural Control (IPC) and Oropharyngeal Motor Dysfunction (OPMD).
The 26 adults recruited to the study were divided between those with recent stroke, and those who had stroke onset a long time before. Results were equally positive in both groups showing the efficacy of IQoro in immediate intervention or in chronic sufferers. Once again, the similar results in the two groups rule out spontaneous recovery as a likely cause of the improvements seen.
At end of training significant improvement (p < 0.001) in tongue and velum function, velopharyngeal closure, and swallowing ability were recorded in the late intervention group. Almost all other outcome improvements in this group showed a (p < 0.01) statistical significance, as did all measures in the early intervention group.
Improvements were maintained at late follow-up (median 59 weeks after the end of training).
Two patients showed no improvement in either IPC or OPMD, all others regained normal abilities in both functions. Five patients presented with Percutaneous Endoscopic Gastrostomy (PEG) feeds at recruitment; all five PEGs were removed by/at end-of-training and all recovered the ability to eat and drink unmodified foods and liquids.
Conclusion
IQoro successfully treats impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke.
PEGs can be removed after several years of use, after 3 months’ IQoro treatment.
Velum function is significantly improved by IQoro training.
Improvements made are still present at long-term follow-up.
The similarity of results in the two intervention groups further supports the contention that improvement is not due to spontaneous remission.
The effectiveness of IQoro treatment is not affected by the time from stroke to the start of treatment, nor the age or gender of the patient.
The positive effect on muscle groups not directly accessed by IQoro neuromuscular training supports the contention that the improvements are triggered by neurological rehabilitation.
7.1.1.3 Study: Effects of oral neuromuscular training on swallowing dysfunction among older people in intermediate care: A cluster randomized, controlled trial
Study type
Peer-reviewed, prospective, cohort pre and post-study, Randomized Controlled Trial (RCT) [12].
385 elderly participants in intermediate care units were screened, and 116 with impaired swallowing were randomly assigned to IQoro neuromuscular training or usual care. Standard IQoro training was employed: 3 x 10 seconds, three times per day for 5 weeks and patients, were measured at three-time points: before training, at end of training, and at late follow up (6 months post-treatment).
At end of treatment, the geometric mean of the swallowing rate in the intervention group had significantly improved 60% more than that of controls (p = 0.007).
Signs of aspiration were significantly reduced in the intervention group compared with controls (p = 0.01).
At 6 months post-treatment, the swallowing rate of the intervention group remained significantly better (p = 0.031).
No significant between-group differences were found for swallowing-related quality of life.
Conclusion
Treatment ended at discharge from the residential facility in order that a long-term follow-up could determine that the improvements seen at end-of-treatment were sustained. Oral neuromuscular training is a new promising swallowing rehabilitation method for older people in intermediate care. Better clinical results would likely have been achieved if IQoro treatment had continued for longer than 5 weeks.
7.1.1.4 Study: Measuring the effectiveness of IQoro® treatment of saliva control dysfunction in children and young people with cerebral palsy using practice-based evidence outcome measures
This study is that performed by Natalie Morris and her team and referred to at the beginning of this chapter.
Saliva control difficulties.
Difficulty in controlling saliva is a common problem for people with Cerebral Palsy (CP). Drooling is not normally a result of overproduction but inefficient control of salivary secretions due to:
Inadequate lip closure / habitual open mouth posture
Reduced or impaired sensory feedback
Atypical muscle tone
Underlying swallowing difficulties
Dental problems
Side effects from other medications
Impaired postural control
Existing and recommended treatments
Natalie’s own clinical observations and experiences of working with children and young people (CYP) with CP were that difficulty with saliva control is a persistent problem with no real effective treatment. The Cochrane review of interventions for drooling in children with cerebral palsy concludes, “There is no clear consensus on which interventions are safe and effective in managing drooling in children with CP. There is insufficient evidence to inform clinical practice on interventions for drooling in children with CP” [24].
The UK’s National Institute for Health and Care Excellence (NICE) guidance [23] on the assessment and management of CP in under 25 s recommends clinicians assess factors that may affect drooling in children and young people with cerebral palsy, these include:
Compensatory strategies and management of contributory factors such as positioning - Multi-Disciplinary Teams (MDT) working with Occupational Therapists (OT) and Physiotherapists to promote head control.
Increasing awareness of saliva - behavioral approaches to prompt children to swallow more often and wipe their faces. However, many people with CP have reduced sensory feedback and are often unaware that their chin is wet. Furthermore, the physical action of wiping their own chin can be difficult.
Oral-motor therapy - aims to target musculature that can be voluntarily trained to improve muscle strength, tonicity, and coordination. However, from a neurological point of view, it is important to consider that although some of our swallows are initiated during the conscious process of eating, drinking, and specific exercises, the majority are reflexive: swallowing away our saliva without conscious involvement. The autonomic nervous system is responsible for the overall control of salivation: these nerves are not under conscious control.
Improving oral health - reducing reflux and maintaining good oral hygiene will reduce the bacterial load of saliva and reduce the risk of infection.
Eliminating mouthing behaviors - some tools that are provided to improve oral skills e.g., chewy tubes for jaw stability, can precipitate difficulties with saliva control if used incorrectly and not as part of a structured program.
Most CYP with CP is given some form of medication to help with saliva control.
NICE produced guidelines in 2017 [23] on the treatment of drooling in children with CP.
The most common medications prescribed are:
Oral Glycopyrronium Bromide
NICE concludes there is moderate evidence for the effectiveness of this treatment and no evidence for the long-term safety. Side effects include dry mouth, vomiting, constipation, and thickening of secretions, which may increase the risk of respiratory infection and pneumonia. Many children are kept on this medication for years, at great cost to the NHS (NICE gives an average of GBP 320 per bottle, around GBP 430 for 28 days’ treatment, approx. GBP 5160 per year).
Hyocine patches + Trihexyphenidyl Hydrochloride
Although commonly prescribed, at the time of publication (January 2017), neither medication had a UK marketing authorization for use in CYP under 18 for treatment of hypersalivation.
Finally, if other treatment methods have been investigated, Botulinum Toxin injections into the salivary glands or surgery to remove the glands may be considered. Although these would obviously be highly aversive experiences and considered only as a last resort.
IQoro as a possible treatment
In 2018, Natalie attended the Association of Speech and Language Therapists in Independent Practice (ASLTIP) conference in London and came across IQoro neuromuscular training device that exercises and strengthens the muscles needed for feeding and swallowing by activating the nervous system to and from the brain. The manufacturers suggest that while traditional oral-motor therapy can target.
The musculature that can be voluntarily trained to improve muscle strength, tonicity, and coordination, it does not target the two-thirds of the swallowing process that is controlled by the autonomic nervous system. IQoro claimed to trigger the sensory-motoric reflex arc which enables messages to be sent to musculature beyond the reach of voluntary control. The sensory-motoric reflex arc [5, 25], (Figure 14) effectively has a “leveraging” effect on direct muscular training and can improve the entire swallowing process.
Figure 14.
The sensory-motoric reflex arc.
IQoro could point to an impressive amount of research that had been conducted on adults with acquired swallowing difficulties, but no evidence to support its use with children. The question that interested Natalie was: “Does IQoro improve saliva control in CYP with CP?” Over a 20-week period, she collected ground-breaking practice-based evidence to answer this question.
Study method and design
The programme used a case series design: 10 participants aged between 6 and 22 years old all had a primary diagnosis of CP. A single case study design was applied to each individual and in addition to individual outcomes, inferences were drawn from the collective data.
Several measures were taken to establish baselines, and these were compared to the measurements taken after the treatment phase.
She and her team used a mixed-method strategy, producing quantitative data regarding oral motor and swallowing ability as well as collecting qualitative data about how the patients/carers / MDT members perceived the value of the tool.
Data collection & interventions
Natalie chose to use a Goal Attainment Scaling in Rehabilitation (GAS) method; GAS statistically scores the extent to which each patient’s individual goals are achieved in the course of intervention. There is substantial literature that demonstrates its usefulness, both as part of the communication and decision-making process and as a person-centered outcome measure for rehabilitation [45]. Original: [46].
Baseline assessments were taken of swallowing ability, oral motor function, and speech.
Rating scales were used that allowed for skill breakdown and functional description of each area.
The baseline assessment scores were used to set for intervention.
An individual program for using the IQoro was designed for each patient and then carried out 3 x per day (by parents/carers) for 20 weeks.
Results
The composite GAS is transformed into a standardized measure with a mean of 50. If goals are set in an unbiased fashion, one would expect a normal distribution of scores, and the GAS thus performs at the interval level. If goals have been fully achieved, we would expect to see a score of 50 (Table 1).
GAS Score
Swallowing
Oral Motor
Speech
Baseline
35.1
34.5
32.2
Range
34.9–35.8
31.3–36.3
26.5–35.2
Achieved
53.7
48.1
32.2
Range
44.3–60.3
45.8–51.6
26.5–35.2
Change
18.8
13.6
0
Range
8.5–25.3
10.6–20.3
0
Table 1.
Results showing GAS scores pre and post-treatment.
Results indicated that IQoro does improve saliva control in children with CP, with improvements also demonstrated with oral motor skills. Using the measures of articulation, there was no change to speech. However, changes to voice were observed in the qualitative analysis (Table 2).
Table 2.
Improved outcomes in swallowing and oral motor skills, but not speech.
Discussion, quantitative and qualitative analysis
In this study, it has been possible to demonstrate an improvement with saliva control resulting from treatment using IQoro. On average, ratings reduced from 4 (“unable to control”, saliva loss 75–100% of the time) to 2 (“moderate difficulty”, saliva loss 25–50% of the time). However, at least half of the participants improved further to a score of 1 (“mild difficulty”, saliva loss 10–25% of the time).
Qualitative data reported (but not measured) saw improvements with: teeth brushing; nasal breathing; breath control for speech; reduction in chest infections; sensory feedback (perception of saliva on chin) and tongue retraction. Positive feedback has been received from schools (less damage from saliva to IT equipment and worksheets) and physio colleagues (able to work in supine for longer periods due to an increase in swallowing of secretions).
Future plans include creating an assessment protocol and running a training program. Further research is indicated to see if this would be a cost-effective treatment that could be made available on the NHS.
Conclusion
It has been the case that there is a severe lack of options in treating children and young people with Cerebral Palsy with dysfunction that leads to drooling. Existing medication and surgical intervention alternatives are often ineffective, invasive, and even not strictly approved for patients in these age groups. Many medication alternatives are expensive when compared with IQoro treatment.
IQoro has been proved to be a suitable treatment for the group studied, including those at the higher end of the scale of motoric and other difficulties. In the case of some of the latter, two assistants were required to perform the training.
Swallowing and oral motor competence improved significantly to a level around the 50-point target of the GAS goals, although the measured speech ability did not. Other functions and abilities important in daily life also improved as reported above.
Much-improved drooling and saliva control had great influence in improving the patients’ quality of life, not least where it allowed the use of laptops, books, and other educational material in schools.
7.1.1.5 Study: IQoro dysphagia therapy in an NHS setting: A service evaluation
A service evaluation was carried out in southern England in 2020 resulting in the following abstract.
Background
This evaluation explored the introduction of IQoro into a National Health Service (NHS) setting.
Method
Patients with chronic dysphagia were recruited from acute and community settings and completed a 12-week program using IQoro. Clinical and well-being measures were taken pre and post-training. Feedback was gained from the Speech and Language Therapists delivering this program.
Results
25 patients were recruited into the evaluation, 21 completed the program. There were significant improvements in self-reported quality of life scores, including the overall scores and burden of dysphagia and mental health subscales. There was a significant improvement in functional measures of dysphagia, including the consistencies of food and drink that patients could safely manage. There was also a significant improvement in the facial movement and symmetry of the lower half of the face. Feedback from SLTs indicated that IQoro improved the range of therapy options available and many planned to use it again. Qualitative feedback suggested that the use of IQoro may change SLTs clinical thinking, including in relation to intervention or compensation for dysphagia.
Conclusion
IQoro can be successfully introduced into an NHS team and can be effective in supporting patients with chronic dysphagia. However, factors such as the ability to follow patients across different settings and the individual risk of further decline need to be considered.
7.1.1.6 Customer survey
In an email survey in June 2021 of all IQoro users that had purchased within the previous 1–15 months, users were canvassed on the effectiveness of IQoro treatment for dysphagia. Totally 4440 responses were received, 983 were specifically treating symptoms associated with dysphagia after stroke. Patients had trained for 1 month or more (Table 3).
Symptom free
Big improvement
Small improvement
No improvement yet
Difficulty in swallowing liquids safely
11%
42%
33%
14%
100%
Difficulty in swallowing solid foods
7%
35%
38%
21%
100%
Drooling
9%
24%
44%
23%
100%
Facial or speech weakness
4%
28%
47%
21%
100%
Table 3.
Improved outcomes in swallowing and facial abilities.
Conclusion
This survey of a large population of people using IQoro to treat various types of dysphagia and facial weakness is that their outcome experience is positive. This survey differs from the studies quoted elsewhere in this chapter in that the results shown are not at end-of-training in all cases. Many had not trained long enough at the time of the survey to experience the full effect in symptom reductions: some having only trained for as little as 1 month. Nevertheless, 79% - 86% reported symptom improvements since starting training.
7.1.1.7 Medtech Innovation Briefings
The UK’s National Institution for Health and Care Excellence (NICE)), was commissioned by the UK government and advises and supports National Health Service and social care commissioners and have made a review of IQoro and its claims and effectiveness. They have issued a Medtech Innovation Briefing [47] that recognized “IQoro is an innovative treatment, with no similar technologies currently recommended, and that the intended place in therapy would be in addition to standard speech and language therapy in people with stroke-related dysphagia”.
7.1.2 Hiatus hernia and reflux-based conditions
Reflux occurs when the neck of the stomach and the Lower Esophageal Sphincter (LES) intrude through the diaphragm into the chest cavity. In this position, the LES can open upwards and allow stomach contents to reflux, in its correct position it can only allow one-way traffic downwards. This intrusion or hernia is made possible when the musculature of the diaphragm around the hiatal canal is weakened (Figure 15).
Figure 15.
(A) Sliding hiatal hernia. The upper part of the stomach and the LES has slid up through the hiatal canal. This allows gastroesophageal reflux and also causes difficulties with opening the PES at the top of the esophagus. (B) Normal anatomy. The neck of the stomach is correctly held below the diaphragm promoting normal LES function and preventing reflux.
IQoro is an effective treatment for reflux-based diseases and their various symptoms: heartburn, pain behind the sternum, persistent unproductive cough, blockage in the throat, and more. Training with IQoro provokes stimuli from the brainstem to flex and strengthen all the muscles in the swallowing chain including those allowing a Hiatal hernia.
The evidence behind the efficacy of IQoro as a treatment for Hiatus hernia includes the following three peer-reviewed and internationally published scientific research papers which are briefly summarized here.
7.1.2.1 Study: Esophageal dysphagia and reflux symptoms before and after oral IQoro training
Study type
Peerreviewed, Prpospective, cohort pre and post-study [14].
43 patients who had esophageal dysphagia for a median of 3 years (range: 1–15 years) were recruited to this study. All displayed the symptoms of a Hiatal hernia, but only 21 had had their condition confirmed by examination. All had been prescribed Proton Pump Inhibitor (PPI) medication for more than 1 year without any effect, all medication ceased at the start of IQoro treatment.
Outcome measurements
A validated test battery was employed at baseline and at end of training including questionnaires and tests for all patients. In addition to these measures 12 patients with confirmed hiatal hernia were measured using High Resolution Manometry (HRM) [48] to measure pressure at resting and during IQoro traction.
Results
No statistical difference (p = NS) between symptoms or outcomes between those with or without confirmed Hiatal hernia diagnosis – both before and after treatment.
Esophageal dysphagia was present in all 43 patients at start of treatment, and 98% of patients showed improvement after IQoro neuromuscular training (p < 0.001).
Reflux symptoms were reported before training in 86% of the patients, 100% of these showed improvement at end of training, (p < 0.001) and 58% were entirely symptom free. All patients ceased PPI medication at recruitment to the study.
VAS scores were classified as pathologic in all 43 patients, and 100% showed improvement after IQoro neuromuscular training (p < 0.001).
Pharyngeal sling force and velum closure test values were both significantly higher (p < 0.001) after IQoro neuromuscular training.
Those tested with HRM showed the following results:
During IQoro traction there was an increase in mean pressure in the diaphragmatic hiatus region and in the Upper Esophageal Sphincter (UES) (Table 4).
Items Pressures in mmHg
UES n = 12
Hiatus n = 12
Normal pressure
>30
10–35
Resting pressure
68 (40–110)
0 (0–0)
During IQoro traction
95 (80–130)
65 (20–100)
Table 4.
High-resolution manometry (HRM) results in UES and hiatus both at rest and during IQoro traction.
Data are mean (range) mmHg.
Conclusion
IQoro neuromuscular training can relieve/improve esophageal dysphagia and reflux symptoms in adults, likely due to improved hiatal competence. The similarity of the results in the two groups suggests that many people suffer from Hiatus hernia despite this not having been confirmed by diagnosis.
7.1.2.2 Study: Effect of IQoro training in hiatal hernia patients with misdirected swallowing and esophageal retention symptoms
Study type
Peer-reviewed, prospective, cohort pre and post-study [17].
The study investigated whether 28 patients with hiatal hernia and misdirected swallowing and esophageal retention symptoms could be successfully treated with a 6-month regime of standard IQoro training: 30 seconds three times per day. Patients had had their condition for median of 4 years (range 1–28).
Results
Reflux symptoms were reported before training in all patients,
100% of these showed improvement (p < 0.001) at end of the training, and 61% were entirely symptom-free despite ceasing PPI medication at the start of training.
All hiatal hernia patients were improved after training with IQoro and showed significant improvements (p < 0.001) in
misdirected swallowing,
cough,
hoarseness,
esophageal retention,
globus sensation,
scores for VAS, pharyngeal sling force, VCT, and TWST.
Traction during the training action with IQoro resulted in a 65 mmHg increase in the mean pressure of the diaphragmatic hiatus as measured by high-resolution manometry (Table 4).
Conclusion
IQoro training significantly improves all the symptoms of hiatus hernia, likely through improved hiatal competence.
7.1.2.3 Study: Oral neuromuscular training relieves hernia-related dysphagia and GERD symptoms as effectively in obese as in non-obese patients
Study type
Peer reviewed, prospective, clinical study, cohort pre and post-study [32].
It has been thought that treatment of Hiatus hernia in overweight patients can be unproductive and that weight loss should be a prior step to interventions.
In this study 86 adult patients with verified hiatal hernias and long-standing Intermittent Esophageal Disease (IED) and other Gastro-Esophageal Reflux Disease (GERD) symptoms were grouped according to their Body Mass Index (BMI), before entry into the study (Table 5): Group A: normal weight, Group B: moderately obese, Group C: severely obese.
Items
Group A; n = 37
Group B; n = 28
Group C; n = 21
Median age
69 yrs. (20–85)
57 yrs. (22–85)
62 yrs. (44–87)
Gender
19 women, 18 men
16 women, 12 men
11 women, 10 men
GERD symptom duration
5 yrs. (1–75)
6 yrs. (1–15)
3 yrs. (1–29)
BMI before/after IQNT
23 (17–24) /23 (20–25)
28 (26–29) / 27 (24–29)
33 (30–37) / 31 (27–38)
Table 5.
Analysis of subjects by BMI grouping - age, gender, and GERD symptom duration.
Ranges in parentheses. BMI and GERD: median values; IQNT: Neuromuscular training with an oral IQoro.
Results
At entry into the study there were no significant differences between the three BMI groups in baseline testing for swallowing ability, or for IED and GERD symptom severity, except that:
Heartburn and cough were significantly more common in Groups B (moderately obese) and C (severely obese).
Misdirected swallowing was significantly more common in Group C.
After IQoro neuromuscular training, the following was observed in all three BMI groups:
All IED and GERD symptom scores were significantly improved or reduced (p < 0.001).
Median BMI was not significantly changed.
Self-assessed GERD symptom improvement showed no significant difference across the groups, except for heartburn, cough, and misdirected swallowing which were significantly (p < 0.01) more reduced in obese patients than in normal bodyweight patients.
The swallowing tests showed significant improvement (p < 0.001) in median values, with no significant difference between the BMI groups except for:
Timed Water Swallow Test (TWST) values, which were significantly (p < 0.01) more improved in Group C (severely obese) than in Group A (normal weight).
pharyngeal sling force, which was significantly (p < 0.05) more improved in Group B (moderately obese) than in Group A.
Conclusion
IQoro neuromuscular training (IQNT), a non-surgical treatment for IED and other GERD symptoms in hiatal hernia patients, is equally successful in treating moderately or severely obese patients as in treating sufferers of normal weight. Obesity in itself does not, therefore, seem to be a handicap in treating IED and other GERD symptoms by IQNT.
7.1.2.4 Customer survey
In an email survey in June 2021 of all IQoro users that had purchased within the previous 15 months, users were canvassed on the effectiveness of IQoro treatment for dysphagia. Totally 4440 responses were received of which 3436 were specifically treating classic reflux symptoms caused by Hiatus hernia, the rest of the responses were from people treating symptoms associated with dysphagia after stroke or snoring and sleep apnoea. Patients had trained for 1 month or more.
76%–84% of respondents reported symptom improvement, it can be assumed that some of those not yet reporting improvements had only trained for a short while (Table 6).
Symptom free
Big improvement
Small improvement
No improvement yet
Reflux / acid reflux
6%
40%
37%
17%
100%
Heartburn
9%
42%
34%
15%
100%
A sensation of something stuck in your throat
12%
38%
34%
17%
100%
Excessive or thick phlegm
4%
30%
42%
24%
100%
Dry, persistent cough
8%
34%
36%
22%
100%
Gassy, burping often
4%
35%
39%
22%
100%
Pain in your chest or esophagus
11%
39%
33%
17%
100%
Food that you have swallowed comes up again
15%
38%
31%
16%
100%
Hoarseness
8%
29%
39%
24%
100%
Table 6.
Improved outcomes in hiatal hernia related symptoms.
Conclusion
A large population, 3436 people, using IQoro to treat reflux symptoms showed positive outcome experiences. This survey differs from the studies quoted elsewhere in this chapter in that the results shown are not at end-of-training in all cases. Many had not trained long enough at the time of the survey to experience the full effect in symptom reductions: some having only trained for as little as 1 month. Nevertheless, 76% - 85% reported symptom improvements since starting training.
7.1.3 NICE Medtech innovation briefing
In March 2019 the UK’s National Institute for Health and Care Excellence (NICE) developed a Medtech Innovation Briefing (MIB) [49] regarding the use of IQoro to treat Hiatus hernia, it points out the innovative nature of the device and its potential to save the NHS money.
“The NICE MIB highlights the innovative nature of IQoro as being its uniqueness in treating Hiatus Hernia through an exercise regime with an oral device. It also highlights that the resource impact of using IQoro could be to reduce costs for the NHS in the long term, one of the main points of our analysis of possible cost savings in this briefing is the device’s potential to be resource releasing when compared to long term PPI maintenance.”
8. Conclusions
All versions of dysphagia have an unsatisfactory range of treatment options. Swallowing difficulties, reflux, and other manifestations are often met with compensatory strategies instead of the treatment of the underlying causes. IQoro is simple, inexpensive, non-invasive, and takes just 90 seconds per day.
IQoro is proven both in clinical practice and in research studies to be highly effective in treating the underlying causes of the conditions and symptoms described in this book. The evidence base for its efficacy is strong.
This innovative device and treatment are shown to be effective in treating all types of dysphagia in the pre-oral, oral, pharyngeal, and esophageal phases. Similarly, Hiatus hernia and its resulting reflux symptoms can be addressed successfully. In all of these conditions, it is shown that time from onset of the condition stroke or Hiatus hernia for example, to the time when IQoro treatment starts, does not affect the positive outcome results of the treatment. The stroke studies show that improvements achieved at end-of-treatment persist at long-term follow-up. Several studies and evaluations show that patients with PEG feeding tubes have had them removed after IQoro therapy.
All healthcare professionals working with dysphagia and its related conditions should want to know more about IQoro and how it improves patient outcomes and gives clinicians an important and powerful new treatment option.
Acknowledgments
The authors would like to thank Terry Morris (no relation to the author) for his assistance in authoring this chapter, for creating the summary of abstracts from which several of the above studies are copied, and for performing the data analysis on the customer survey referred to above.
The authors would also like to thank Gill Hardy, Speech and Language Therapist, Clinical Lead Neurology, and her colleagues at the Royal Devon and Exeter NHS Foundation Trust and also Roseanne Exell and Hayley McBain at the South West Academic Health Science Network for their kind permission to reproduce the abstract of their service evaluation shown above.
Some studies reproduced above were supported by grants from The Centre for Research & Development, Uppsala University/County Council of Gävleborg, Gävle, Sweden, and The Council for Regional Research in Uppsala and Örebro region, Sweden.
Conflict of interest
IQoro is patented in Sweden - SE 1350314-9, 2014 July 14 - and widely internationally. It is CE-marked as a Class 1 Medical Device for therapeutic use by the manufacturer MYoroface AB. Mary Hägg is the inventor.
The authors, Mary Hägg and Natalie Morris declare that they have no conflict of interest.
Notes/thanks/other declarations
All studies were performed according to the Helsinki Declaration. Informed written and verbal consent was obtained from all the participants in the studies. All images are kindly provided by MYoroface AB.
\n',keywords:"oropharyngeal dysphagia, esophageal dysphagia, reflux, hiatal hernia, neuromuscular training, cerebral palsy, service evaluation in NHS, NICE briefing",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/79510.pdf",chapterXML:"https://mts.intechopen.com/source/xml/79510.xml",downloadPdfUrl:"/chapter/pdf-download/79510",previewPdfUrl:"/chapter/pdf-preview/79510",totalDownloads:134,totalViews:0,totalCrossrefCites:0,dateSubmitted:"August 24th 2021",dateReviewed:"October 8th 2021",datePrePublished:"November 30th 2021",datePublished:"July 20th 2022",dateFinished:"November 30th 2021",readingETA:"0",abstract:"There is a clear need for new advances in treating dysphagia; healthcare professionals currently have a restricted range of options to treat swallowing problems and related conditions. Usual treatments for dysphagia are based on compensatory measures which allow patients to live within the limitations of their condition. These measures do not address the underlying cause of dysphagia: neurological and physiological dysfunction. A senior speech and language therapist working with young people with Cerebral Palsy bemoans the fact that official care pathway guidelines list only medication and surgical intervention as alternatives to treat drooling. Neither of which, she contends, is effective or desirable. Esophageal dysphagia causes reflux-based diseases, which are also poorly served by current treatment alternatives and are currently managed by medication, or remedied by surgical intervention. Medication reduces the symptoms of reflux but does nothing to address the underlying pathophysiology, muscular dysfunction, at the root of the problem. That now changes with IQoro: a simple, innovative treatment that is available to patients and healthcare professionals to address all of the above conditions. The chapter explains the physiological and neurological process of the functional swallow in detail, with illustrations and explanations. The efficacy of IQoro treatment is proven with evidence from internationally published scientific studies, case studies, an NHS service evaluation, and NICE briefings.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/79510",risUrl:"/chapter/ris/79510",signatures:"Mary Hägg and Natalie R. Morris",book:{id:"11044",type:"book",title:"Dysphagia",subtitle:"New Advances",fullTitle:"Dysphagia - New Advances",slug:"dysphagia-new-advances",publishedDate:"July 20th 2022",bookSignature:"Monjur Ahmed",coverURL:"https://cdn.intechopen.com/books/images_new/11044.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-78985-410-7",printIsbn:"978-1-78985-409-1",pdfIsbn:"978-1-83962-510-7",isAvailableForWebshopOrdering:!0,editors:[{id:"206355",title:"Associate Prof.",name:"Monjur",middleName:null,surname:"Ahmed",slug:"monjur-ahmed",fullName:"Monjur Ahmed"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"429433",title:"Dr.",name:"Mary",middleName:null,surname:"Hägg",fullName:"Mary Hägg",slug:"mary-hagg",email:"mary@myoroface.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"429603",title:"MSc.",name:"Natalie R.",middleName:null,surname:"Morris",fullName:"Natalie R. Morris",slug:"natalie-r.-morris",email:"natalie@integratedtherapysolutions.co.uk",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_1_2",title:"1.1 Few real solutions",level:"2"},{id:"sec_2_2",title:"1.2 A new, innovative solution",level:"2"},{id:"sec_4",title:"2. Two innovative clinicians",level:"1"},{id:"sec_4_2",title:"2.1 Mary’s journey",level:"2"},{id:"sec_5_2",title:"2.2 Natalie’s vision",level:"2"},{id:"sec_7",title:"3. The physiology of the swallow",level:"1"},{id:"sec_7_2",title:"3.1 The phases of the swallow",level:"2"},{id:"sec_7_3",title:"3.1.1 Pre-oral phase",level:"3"},{id:"sec_8_3",title:"3.1.2 Oral phase",level:"3"},{id:"sec_9_3",title:"3.1.3 Pharyngeal phase",level:"3"},{id:"sec_10_3",title:"3.1.4 Esophageal phase",level:"3"},{id:"sec_13",title:"4. The neurology of the swallow",level:"1"},{id:"sec_13_2",title:"4.1 The phases of the swallow",level:"2"},{id:"sec_14_2",title:"4.2 Brain functions in swallowing",level:"2"},{id:"sec_15_2",title:"4.3 The swallowing centers",level:"2"},{id:"sec_15_3",title:"4.3.1 First swallowing center",level:"3"},{id:"sec_16_3",title:"4.3.2 Second swallowing center",level:"3"},{id:"sec_17_3",title:"4.3.3 Third swallowing center",level:"3"},{id:"sec_19_2",title:"4.4 The motor neurons",level:"2"},{id:"sec_20_2",title:"4.5 Understanding the three neurological phases",level:"2"},{id:"sec_20_3",title:"4.5.1 Oral phase",level:"3"},{id:"sec_21_3",title:"4.5.2 Pharyngeal phase",level:"3"},{id:"sec_22_3",title:"4.5.3 Esophageal phase",level:"3"},{id:"sec_25",title:"5. Dysphagia and reflux diseases are related",level:"1"},{id:"sec_25_2",title:"5.1 What are reflux-based diseases?",level:"2"},{id:"sec_25_3",title:"5.1.1 Prevalence and symptoms",level:"3"},{id:"sec_26_3",title:"5.1.2 Cause of reflux",level:"3"},{id:"sec_27_3",title:"5.1.3 Existing treatments for reflux-based diseases",level:"3"},{id:"sec_28_3",title:"5.1.4 Existing treatments for dysphagia",level:"3"},{id:"sec_29_3",title:"5.1.5 Treating the muscles",level:"3"},{id:"sec_32",title:"6. IQoro",level:"1"},{id:"sec_32_2",title:"6.1 What is IQoro?",level:"2"},{id:"sec_33_2",title:"6.2 How to train",level:"2"},{id:"sec_34_2",title:"6.3 How it works",level:"2"},{id:"sec_36",title:"7. Evidence of IQoro’s efficacy",level:"1"},{id:"sec_36_2",title:"7.1 Dysphagia",level:"2"},{id:"sec_36_3",title:"Table 1.",level:"3"},{id:"sec_36_4",title:"7.1.1.1 Study: Effects on facial dysfunction and swallowing capacity of intraoral stimulation early and late after stroke",level:"4"},{id:"sec_37_4",title:"7.1.1.2 Study: Effect of IQoro training on impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke",level:"4"},{id:"sec_38_4",title:"7.1.1.3 Study: Effects of oral neuromuscular training on swallowing dysfunction among older people in intermediate care: A cluster randomized, controlled trial",level:"4"},{id:"sec_39_4",title:"Table 1.",level:"4"},{id:"sec_40_4",title:"7.1.1.5 Study: IQoro dysphagia therapy in an NHS setting: A service evaluation",level:"4"},{id:"sec_41_4",title:"Table 3.",level:"4"},{id:"sec_42_4",title:"7.1.1.7 Medtech Innovation Briefings",level:"4"},{id:"sec_44_3",title:"Table 4.",level:"3"},{id:"sec_44_4",title:"Table 4.",level:"4"},{id:"sec_45_4",title:"7.1.2.2 Study: Effect of IQoro training in hiatal hernia patients with misdirected swallowing and esophageal retention symptoms",level:"4"},{id:"sec_46_4",title:"Table 5.",level:"4"},{id:"sec_47_4",title:"Table 6.",level:"4"},{id:"sec_49_3",title:"7.1.3 NICE Medtech innovation briefing",level:"3"},{id:"sec_52",title:"8. Conclusions",level:"1"},{id:"sec_53",title:"Acknowledgments",level:"1"},{id:"sec_56",title:"Conflict of interest",level:"1"},{id:"sec_53",title:"Notes/thanks/other declarations",level:"1"}],chapterReferences:[{id:"B1",body:'Serra-Prat M, Palomera M, Gomez C, Sar-Shalom D, Saiz A, Montoya JG, et al. Oropharyngeal dysphagia as a risk factor for malnutrition and lower respiratory tract infection in independently living older persons: A population-based prospective study. Age and Ageing. 2012;41(3):376-381'},{id:"B2",body:'Martino R, Foley N, Bhogal S, Diamant N, Speechley M, Teasell R. Dysphagia after stroke: Incidence, diagnosis, and pulmonary complications. Stroke. 2005;36(12):2756-2763'},{id:"B3",body:'Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P. Social and psychological burden of dysphagia: Its impact on diagnosis and treatment. Dysphagia. 2002;17(2):139-146'},{id:"B4",body:'Neyens J, Halfens R, Spreeuwenberg M, Meijers J, Luiking Y, Verlaan G, et al. Malnutrition is associated with an increased risk of falls and impaired activity in elderly patients in Dutch residential long-term care (LTC): A cross-sectional study. Archives of Gerontology and Geriatrics. 2013;56(1):265-269'},{id:"B5",body:'Logemann JA. Evaluation and Treatment of Swallowing Disorders. 2nd ed. Austin, Tex: PRO-ED; 1998'},{id:"B6",body:'Ekberg O, Hamdy S, Woisard V, Wuttge-Hannig A, Ortega P. Social and psychological burden of dysphagia: Its impact on diagnosis and treatment. Dysphagia. 2002;17:139-146. DOI: 10.1007/s00455-001-0113-5'},{id:"B7",body:'Shaker R, Easterling C, Kern M, et al. Rehabilitation of swallowing by exercise in tube-fed patients with pharyngeal dysphagia secondary to abnormal UES opening. Gastroenterology. 2002;122:1314-1321. DOI: 10.1053/gast.2002.32999'},{id:"B8",body:'Huckabee ML, Cannito MP. Outcomes of swallowing rehabilitation in chronic brainstem dysphagia: A retrospective evaluation. 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Effect of IQoro® training on impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke. Acta Oto-Laryngologica. 2016;136(7):742-748. DOI: 10.3109/00016489.2016.1145797'},{id:"B18",body:'Hägg M, Olgarsson M, Anniko M. Reliable lip force measurement in healthy controls and in patients with stroke. A methodological study. Dysphagia. 2008;2:291-296'},{id:"B19",body:'Perkins RE, Blanton PL, Biggs N. Electromyographic analysis of the “buccinator mechanism” in human beings. Journal of Dental Research. 1977;56:783-794'},{id:"B20",body:'Hägg M, Larsson B. Effects of motor and sensory stimulation in stroke patients with long-lasting dysphagia. Dysphagia. 2004;19:219-230'},{id:"B21",body:'Ney DM, Weiss JM, Kind AJH, Robbins J. Senescent Swallowing: Impact, Strategies, and Interventions. Nutrition in Clinical Practice. 2009;24(3):395-413'},{id:"B22",body:'Carnaby G, Hankey GJ, Pizzi J. Behavioural intervention for dysphagia in acute stroke: a randomised controlled trial. Lancet Neurology. 2006 Jan;5(1):31-37'},{id:"B23",body:'Severe sialorrhoea (drooling) in children and young people with chronic neurological disorders: Oral glycopyrronium bromide https://www.nice.org.uk/advice/es5/chapter/Introduction-and-current-guidance.x'},{id:"B24",body:'Walshe M, Smith M, Pennington L. Interventions for drooling in children with cerebral palsy. Cochrane Database of Systematic Reviews. 2012;11:CD008624. DOI: 10.1002/14651858.CD008624.pub3'},{id:"B25",body:'Ertekin C, Aydogdu I. Neurophysiology of swallowing. Clinical Neurophysiology. 2003;114:2226-2244'},{id:"B26",body:'Castillo Morales RC, Brondo JJ, Haberstock B. Die orofaziale Regulationstherapie. 1st ed. München: Richard Pflaum Verlag GmbH & Co.; 1991. pp. 21-188'},{id:"B27",body:'Ekberg O, Nylander G. Pharyngeal constrictor paresis in patients with dysphagia: A cineradiographic study. 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GERD for the nongastroenterologist: Successful evaluation, management, and lifestyle-based symptom control. Annals of the New York Academy of Sciences. Dec 2020;1482(1):106-112. DOI: 10.1111/nyas.14496'},{id:"B38",body:'National Institute for Health and Care Excellence. Gastro-Oesophageal Reflux Disease and Dyspepsia in Adults: Investigation and Management. (September 2014) (CG184). Available at: www.nice.org.uk/guidance/cg184/resources/gastrooesophageal-reflux-disease-and-dyspepsia-inadults-investigation-and-management-35109812699845'},{id:"B39",body:'Bjornsson E, Abrahamsson H, Simren M, et al. Discontinuation of proton pump inhibitors in patients on long-term therapy: A double-blind, placebo-controlled trial. Alimentary Pharmacology & Therapeutics. 2006;24(6):945-954'},{id:"B40",body:'Chubineh S, Birk J. Proton pump inhibitors: The good, the bad, and the unwanted. Southern Medical Journal. 2012;105(11):613-618. DOI: 10.1097/SMJ.0b013e31826efbea'},{id:"B41",body:'Johansson KE, Ask P, Boeryd B, Fransson SG, Tibbling L. Oesophagitis, signs of reflux, and gastric acid secretion in patients with symptoms of gastrooesophageal reflux disease. Scandinavian Journal of Gastroenterology. 1986;21:837-847 [PMID: 3775250]'},{id:"B42",body:'Mayo D, Darbyshire A, Mercer S, et al. Technique and outcome of day case laparoscopic hiatus hernia surgery for small and large hernias: A five-year retrospective reflux as a risk factor for esophageal adenocarcinoma. The New England Journal of Medicine. 1999;340(11):825-831. Review from a high-volume UK centre. Ann R Coll Surg Engl. 2020 Oct;102(8):611–615. DOI: 10.1308/rcsann.2020.0151. Epub 2020 Jul 31'},{id:"B43",body:'Video 1_IQoro_This is how you exercise_A short version'},{id:"B44",body:'Hägg M, Tibbling L, Franzén T. Effect of IQoro® training in hiatal hernia patients with misdirected swallowing and esophageal retention symptoms. 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Available from: https://www.nice.org.uk/advice/mib176'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Mary Hägg",address:"mary@myoroface.com",affiliation:'
Assoc. Prof., DDS. Speech and Swallowing Centre, Department of Otorhinolaryngology, Hudiksvall Hospital, Sweden
Centre for Research and Development, Uppsala University/Region, Sweden
'},{corresp:null,contributorFullName:"Natalie R. Morris",address:null,affiliation:'
Reg. Mem. RCSLT, HCPC
The Feeding Trust, Birmingham, UK. (Founder and CEO)
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\n\n
\n\t
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If you are associated with any of the institutions in our list below, you can apply to receive OA publication funds by following the instructions provided in the links. Please consult the Open Access policies or grant Terms and Conditions of any institution with which you are linked to explore ways to cover your publication costs (also accessible by clicking on the link in their title).
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Polymorphism at the DNA level includes a wide range of variations from single base pair change, many base pairs, and repeated sequences. Genomic variability can be present in many forms, including single nucleotide polymorphisms (SNPs), variable number of tandem repeats (VNTRs, e.g., mini- and microsatellites), transposable elements (e.g., Alu repeats), structural alterations, and copy number variations. Different forms of DNA polymorphisms can be tracked using a variety of techniques; some of these techniques include restriction fragment length polymorphisms (RFLPs) with Southern blots, polymerase chain reactions (PCRs), hybridization techniques using DNA microarray chips, and genome sequencing. During the last years, the recent advance of molecular technologies revealed new discoveries of DNA polymorphisms. DNA polymorphisms are endless, and more discoveries continue at a rapid rate. Mapping the human genome requires a set of genetic markers. DNA polymorphism serves as a genetic marker for its own location in the chromosome; thus, they are convenient for analysis and are often used as in molecular genetic studies.",book:{id:"6719",slug:"genetic-diversity-and-disease-susceptibility",title:"Genetic Diversity and Disease Susceptibility",fullTitle:"Genetic Diversity and Disease Susceptibility"},signatures:"Salwa Teama",authors:[{id:"249329",title:"Dr.",name:"Salwa",middleName:null,surname:"Teama",slug:"salwa-teama",fullName:"Salwa Teama"}]},{id:"58467",title:"Generation of Antibody Diversity",slug:"generation-of-antibody-diversity",totalDownloads:3217,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Because of the huge diversity, the immunoglobulin repertoire cannot be encoded by static genes, which would explode the genomic capacity comprising about 20,000–25,000 human genes. The immunoglobulin repertoire is provided by the process of somatic germ line recombination, which is the only controlled alteration of the genomic DNA after meiosis. It takes place in mammalian B lymphocyte (B cells) precursors in the bone marrow. The genome germ line sequence of undeveloped B cells is organized in gene segments and compromise V (variable), D (diversity), and J (joining) gene segments constituting the variable domain of the heavy chain and only V and J genes for building up the variable domain of the light chain. The rearrangement of the variable region follows a strict order. The following processes that participate in the generation of antibody diversity were summarized—allelic, combinational, and junctional diversity, pairing of IgH and IgL, and receptor editing—which all together produce the primary antigen repertoire (pre-antigen stimulation). When a B cell encounters a foreign antigen, affinity maturation and class switch are induced. Thereby the antibody repertoire increases. The resulting secondary immunoglobulin repertoire reveals in humans at least 1011 specificities for different antigens.",book:{id:"5784",slug:"antibody-engineering",title:"Antibody Engineering",fullTitle:"Antibody Engineering"},signatures:"Oliver Backhaus",authors:[{id:"177685",title:"M.Sc.",name:"Oliver",middleName:null,surname:"Backhaus",slug:"oliver-backhaus",fullName:"Oliver Backhaus"}]},{id:"61204",title:"Polymorphisms",slug:"polymorphisms",totalDownloads:2089,totalCrossrefCites:3,totalDimensionsCites:11,abstract:"Polymorphism or variation in DNA sequence can affect individual phenotypes such as color of skin or eyes, susceptible to diseases, and respond to drug, vaccine, chemical, and pathogen. It occurs more often than mutations (frequency ≥ 1%). The common polymorphism is single nucleotide polymorphism (SNP) which is a single base change in a DNA sequence that occurs most commonly in the human genome. SNPs have been used as molecular markers in a wide range of studies. Genome-wide association studies (GWAS) searches for SNPs that occur more frequently in person with a particular disease than in person without the disease and pinpoint genes or regions that may contribute to a risk of disease. This topic describes about polymorphisms, SNPs, GWAS, linkage disequilibrium (LD), minor allele frequency, haplotype, method for SNP genotyping, and application of SNPs and genome-wide association study in human diseases and drug development.",book:{id:"6719",slug:"genetic-diversity-and-disease-susceptibility",title:"Genetic Diversity and Disease Susceptibility",fullTitle:"Genetic Diversity and Disease Susceptibility"},signatures:"Wasana Sukhumsirichart",authors:[{id:"238537",title:"Associate Prof.",name:"Wasana",middleName:null,surname:"Sukhumsirichart",slug:"wasana-sukhumsirichart",fullName:"Wasana Sukhumsirichart"}]},{id:"21711",title:"Screening of Bacterial Recombinants: Strategies and Preventing False Positives",slug:"screening-of-bacterial-recombinants-strategies-and-preventing-false-positives",totalDownloads:28539,totalCrossrefCites:1,totalDimensionsCites:5,abstract:null,book:{id:"375",slug:"molecular-cloning-selected-applications-in-medicine-and-biology",title:"Molecular Cloning",fullTitle:"Molecular Cloning - Selected Applications in Medicine and Biology"},signatures:"Sriram Padmanabhan, Sampali Banerjee and Naganath Mandi",authors:[{id:"46458",title:"Dr.",name:"Sriram",middleName:null,surname:"Padmanabhan",slug:"sriram-padmanabhan",fullName:"Sriram Padmanabhan"},{id:"136523",title:"Prof.",name:"Sampali",middleName:null,surname:"Banerjee",slug:"sampali-banerjee",fullName:"Sampali Banerjee"},{id:"136524",title:"Prof.",name:"Naganath",middleName:null,surname:"Mandi",slug:"naganath-mandi",fullName:"Naganath Mandi"}]},{id:"49200",title:"Human Embryology",slug:"human-embryology",totalDownloads:3618,totalCrossrefCites:5,totalDimensionsCites:7,abstract:"The study of human embryology has a very long history. Modern embryology owes its initial development to the key embryo collections that began in the 19th century. The first large collection was that of Carnegie, and this was followed later by the major 7 collections. The second role of the Carnegie collection was for researchers to establish a defined set of Carnegie stages based on embryo morphological features. Today, embryos are imaged three-dimensionally (3D) by a range of imaging modalities including, magnetic resonance microscopy (MRM), episcopic fluorescence image capture (EFIC), phase-contrast X-ray computed tomography (pCT), and optical projection tomography (OPT). Historically, embryo serial images were reconstructed using wax-plate and model techniques. The above new 3D imaging techniques now allow 3D computer reconstructions, analysis, and even 3D printing. This chapter will describe how the classical embryology collections and techniques have developed into today’s imaging and analysis techniques, giving new insights to human embryonic development.",book:{id:"4588",slug:"new-discoveries-in-embryology",title:"New Discoveries in Embryology",fullTitle:"New Discoveries in Embryology"},signatures:"Shigehito Yamada, Mark Hill and Tetsuya Takakuwa",authors:[{id:"49486",title:"Prof.",name:"Shigehito",middleName:null,surname:"Yamada",slug:"shigehito-yamada",fullName:"Shigehito Yamada"},{id:"90205",title:"Prof.",name:"Tetsuya",middleName:null,surname:"Takakuwa",slug:"tetsuya-takakuwa",fullName:"Tetsuya Takakuwa"},{id:"175453",title:"Dr.",name:"Mark",middleName:null,surname:"Hill",slug:"mark-hill",fullName:"Mark Hill"}]}],onlineFirstChaptersFilter:{topicId:"54",limit:6,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:330,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:9,numberOfPublishedChapters:140,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:123,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:112,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:22,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:11,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"11",title:"Biochemistry",doi:"10.5772/intechopen.72877",issn:"2632-0983",scope:"Biochemistry, the study of chemical transformations occurring within living organisms, impacts all areas of life sciences, from molecular crystallography and genetics to ecology, medicine, and population biology. Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. This Biochemistry Series will address the current research on biomolecules and the emerging trends with great promise.",coverUrl:"https://cdn.intechopen.com/series/covers/11.jpg",latestPublicationDate:"August 2nd, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:33,editor:{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",slug:"miroslav-blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"14",title:"Cell and Molecular Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",isOpenForSubmission:!0,editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",slug:"rosa-maria-martinez-espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",biography:"Dr. Rosa María Martínez-Espinosa has been a Spanish Full Professor since 2020 (Biochemistry and Molecular Biology) and is currently Vice-President of International Relations and Cooperation development and leader of the research group 'Applied Biochemistry” (University of Alicante, Spain). Other positions she has held at the university include Vice-Dean of Master Programs, Vice-Dean of the Degree in Biology and Vice-Dean for Mobility and Enterprise and Engagement at the Faculty of Science (University of Alicante). She received her Bachelor in Biology in 1998 (University of Alicante) and her PhD in 2003 (Biochemistry, University of Alicante). She undertook post-doctoral research at the University of East Anglia (Norwich, U.K. 2004-2005; 2007-2008).\nHer multidisciplinary research focuses on investigating archaea and their potential applications in biotechnology. She has an H-index of 21. She has authored one patent and has published more than 70 indexed papers and around 60 book chapters.\nShe has contributed to more than 150 national and international meetings during the last 15 years. Her research interests include archaea metabolism, enzymes purification and characterization, gene regulation, carotenoids and bioplastics production, antioxidant\ncompounds, waste water treatments, and brines bioremediation.\nRosa María’s other roles include editorial board member for several journals related\nto biochemistry, reviewer for more than 60 journals (biochemistry, molecular biology, biotechnology, chemistry and microbiology) and president of several organizing committees in international meetings related to the N-cycle or respiratory processes.",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"15",title:"Chemical Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",isOpenForSubmission:!0,editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",slug:"sukru-beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",biography:"Dr. Şükrü Beydemir obtained a BSc in Chemistry in 1995 from Yüzüncü Yıl University, MSc in Biochemistry in 1998, and PhD in Biochemistry in 2002 from Atatürk University, Turkey. He performed post-doctoral studies at Max-Planck Institute, Germany, and University of Florence, Italy in addition to making several scientific visits abroad. He currently works as a Full Professor of Biochemistry in the Faculty of Pharmacy, Anadolu University, Turkey. Dr. Beydemir has published over a hundred scientific papers spanning protein biochemistry, enzymology and medicinal chemistry, reviews, book chapters and presented several conferences to scientists worldwide. He has received numerous publication awards from various international scientific councils. He serves in the Editorial Board of several international journals. Dr. Beydemir is also Rector of Bilecik Şeyh Edebali University, Turkey.",institutionString:null,institution:{name:"Anadolu University",institutionURL:null,country:{name:"Turkey"}}},editorTwo:{id:"13652",title:"Prof.",name:"Deniz",middleName:null,surname:"Ekinci",slug:"deniz-ekinci",fullName:"Deniz Ekinci",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLT1QAO/Profile_Picture_1634557223079",biography:"Dr. Deniz Ekinci obtained a BSc in Chemistry in 2004, MSc in Biochemistry in 2006, and PhD in Biochemistry in 2009 from Atatürk University, Turkey. He studied at Stetson University, USA, in 2007-2008 and at the Max Planck Institute of Molecular Cell Biology and Genetics, Germany, in 2009-2010. Dr. Ekinci currently works as a Full Professor of Biochemistry in the Faculty of Agriculture and is the Head of the Enzyme and Microbial Biotechnology Division, Ondokuz Mayıs University, Turkey. He is a member of the Turkish Biochemical Society, American Chemical Society, and German Genetics society. Dr. Ekinci published around ninety scientific papers, reviews and book chapters, and presented several conferences to scientists. He has received numerous publication awards from several scientific councils. Dr. Ekinci serves as the Editor in Chief of four international books and is involved in the Editorial Board of several international journals.",institutionString:null,institution:{name:"Ondokuz Mayıs University",institutionURL:null,country:{name:"Turkey"}}},editorThree:null},{id:"17",title:"Metabolism",coverUrl:"https://cdn.intechopen.com/series_topics/covers/17.jpg",isOpenForSubmission:!0,editor:{id:"138626",title:"Dr.",name:"Yannis",middleName:null,surname:"Karamanos",slug:"yannis-karamanos",fullName:"Yannis Karamanos",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002g6Jv2QAE/Profile_Picture_1629356660984",biography:"Yannis Karamanos, born in Greece in 1953, completed his pre-graduate studies at the Université Pierre et Marie Curie, Paris, then his Masters and Doctoral degree at the Université de Lille (1983). He was associate professor at the University of Limoges (1987) before becoming full professor of biochemistry at the Université d’Artois (1996). He worked on the structure-function relationships of glycoconjugates and his main project was the investigations on the biological roles of the de-N-glycosylation enzymes (Endo-N-acetyl-β-D-glucosaminidase and peptide-N4-(N-acetyl-β-glucosaminyl) asparagine amidase). From 2002 he contributes to the understanding of the Blood-brain barrier functioning using proteomics approaches. He has published more than 70 papers. His teaching areas are energy metabolism and regulation, integration and organ specialization and metabolic adaptation.",institutionString:null,institution:{name:"Artois University",institutionURL:null,country:{name:"France"}}},editorTwo:null,editorThree:null},{id:"18",title:"Proteomics",coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",isOpenForSubmission:!0,editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",slug:"paolo-iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",biography:"Paolo Iadarola graduated with a degree in Chemistry from the University of Pavia (Italy) in July 1972. He then worked as an Assistant Professor at the Faculty of Science of the same University until 1984. In 1985, Prof. Iadarola became Associate Professor at the Department of Biology and Biotechnologies of the University of Pavia and retired in October 2017. Since then, he has been working as an Adjunct Professor in the same Department at the University of Pavia. His research activity during the first years was primarily focused on the purification and structural characterization of enzymes from animal and plant sources. During this period, Prof. Iadarola familiarized himself with the conventional techniques used in column chromatography, spectrophotometry, manual Edman degradation, and electrophoresis). Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. More recently, Prof. Iadarola was involved in developing techniques such as two-dimensional electrophoresis coupled to liquid chromatography/mass spectrometry (2DE-LC/MS) for the proteomic analysis of biological fluids aimed at the identification of potential biomarkers of different lung diseases. He is the author of about 150 publications (According to Scopus: H-Index: 23; Total citations: 1568- According to WOS: H-Index: 20; Total Citations: 1296) of peer-reviewed international journals. He is a Consultant Reviewer for several journals, including the Journal of Chromatography A, Journal of Chromatography B, Plos ONE, Proteomes, International Journal of Molecular Science, Biotech, Electrophoresis, and others. He is also Associate Editor of Biotech.",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorTwo:{id:"201414",title:"Dr.",name:"Simona",middleName:null,surname:"Viglio",slug:"simona-viglio",fullName:"Simona Viglio",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKDHQA4/Profile_Picture_1630402531487",biography:"Simona Viglio is an Associate Professor of Biochemistry at the Department of Molecular Medicine at the University of Pavia. She has been working since 1995 on the determination of proteolytic enzymes involved in the degradation process of connective tissue matrix and on the identification of biological markers of lung diseases. She gained considerable experience in developing and validating new methodologies whose applications allowed her to determine both the amount of biomarkers (Desmosine and Isodesmosine) in the urine of patients affected by COPD, and the activity of proteolytic enzymes (HNE, Cathepsin G, Pseudomonas aeruginosa elastase) in the sputa of these patients. Simona Viglio was also involved in research dealing with the supplementation of amino acids in patients with brain injury and chronic heart failure. She is presently engaged in the development of 2-DE and LC-MS techniques for the study of proteomics in biological fluids. The aim of this research is the identification of potential biomarkers of lung diseases. She is an author of about 90 publications (According to Scopus: H-Index: 23; According to WOS: H-Index: 20) on peer-reviewed journals, a member of the “Società Italiana di Biochimica e Biologia Molecolare,“ and a Consultant Reviewer for International Journal of Molecular Science, Journal of Chromatography A, COPD, Plos ONE and Nutritional Neuroscience.",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorThree:null}]},overviewPageOFChapters:{paginationCount:42,paginationItems:[{id:"82914",title:"Glance on the Critical Role of IL-23 Receptor Gene Variations in Inflammation-Induced Carcinogenesis",doi:"10.5772/intechopen.105049",signatures:"Mohammed El-Gedamy",slug:"glance-on-the-critical-role-of-il-23-receptor-gene-variations-in-inflammation-induced-carcinogenesis",totalDownloads:11,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Chemokines Updates",coverURL:"https://cdn.intechopen.com/books/images_new/11672.jpg",subseries:{id:"18",title:"Proteomics"}}},{id:"82875",title:"Lipidomics as a Tool in the Diagnosis and Clinical Therapy",doi:"10.5772/intechopen.105857",signatures:"María Elizbeth Alvarez Sánchez, Erick Nolasco Ontiveros, Rodrigo Arreola, Adriana Montserrat Espinosa González, Ana María García Bores, Roberto Eduardo López Urrutia, Ignacio Peñalosa Castro, María del Socorro Sánchez Correa and Edgar Antonio Estrella Parra",slug:"lipidomics-as-a-tool-in-the-diagnosis-and-clinical-therapy",totalDownloads:7,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Fatty Acids - Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/11669.jpg",subseries:{id:"17",title:"Metabolism"}}},{id:"82440",title:"Lipid Metabolism and Associated Molecular Signaling Events in Autoimmune Disease",doi:"10.5772/intechopen.105746",signatures:"Mohan Vanditha, Sonu Das and Mathew John",slug:"lipid-metabolism-and-associated-molecular-signaling-events-in-autoimmune-disease",totalDownloads:17,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Fatty Acids - Recent Advances",coverURL:"https://cdn.intechopen.com/books/images_new/11669.jpg",subseries:{id:"17",title:"Metabolism"}}},{id:"82483",title:"Oxidative Stress in Cardiovascular Diseases",doi:"10.5772/intechopen.105891",signatures:"Laura Mourino-Alvarez, Tamara Sastre-Oliva, Nerea Corbacho-Alonso and Maria G. Barderas",slug:"oxidative-stress-in-cardiovascular-diseases",totalDownloads:10,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Importance of Oxidative Stress and Antioxidant System in Health and Disease",coverURL:"https://cdn.intechopen.com/books/images_new/11671.jpg",subseries:{id:"15",title:"Chemical Biology"}}}]},overviewPagePublishedBooks:{paginationCount:33,paginationItems:[{type:"book",id:"7006",title:"Biochemistry and Health Benefits of Fatty Acids",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7006.jpg",slug:"biochemistry-and-health-benefits-of-fatty-acids",publishedDate:"December 19th 2018",editedByType:"Edited by",bookSignature:"Viduranga Waisundara",hash:"c93a00abd68b5eba67e5e719f67fd20b",volumeInSeries:1,fullTitle:"Biochemistry and Health Benefits of Fatty Acids",editors:[{id:"194281",title:"Dr.",name:"Viduranga Y.",middleName:null,surname:"Waisundara",slug:"viduranga-y.-waisundara",fullName:"Viduranga Y. Waisundara",profilePictureURL:"https://mts.intechopen.com/storage/users/194281/images/system/194281.jpg",biography:"Dr. Viduranga Waisundara obtained her Ph.D. in Food Science\nand Technology from the Department of Chemistry, National\nUniversity of Singapore, in 2010. She was a lecturer at Temasek Polytechnic, Singapore from July 2009 to March 2013.\nShe relocated to her motherland of Sri Lanka and spearheaded the Functional Food Product Development Project at the\nNational Institute of Fundamental Studies from April 2013 to\nOctober 2016. She was a senior lecturer on a temporary basis at the Department of\nFood Technology, Faculty of Technology, Rajarata University of Sri Lanka. She is\ncurrently Deputy Principal of the Australian College of Business and Technology –\nKandy Campus, Sri Lanka. She is also the Global Harmonization Initiative (GHI)",institutionString:"Australian College of Business & Technology",institution:{name:"Kobe College",institutionURL:null,country:{name:"Japan"}}}]},{type:"book",id:"6820",title:"Keratin",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/6820.jpg",slug:"keratin",publishedDate:"December 19th 2018",editedByType:"Edited by",bookSignature:"Miroslav Blumenberg",hash:"6def75cd4b6b5324a02b6dc0359896d0",volumeInSeries:2,fullTitle:"Keratin",editors:[{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",slug:"miroslav-blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}}]},{type:"book",id:"7978",title:"Vitamin A",subtitle:null,coverURL:"https://cdn.intechopen.com/books/images_new/7978.jpg",slug:"vitamin-a",publishedDate:"May 15th 2019",editedByType:"Edited by",bookSignature:"Leila Queiroz Zepka, Veridiana Vera de Rosso and Eduardo Jacob-Lopes",hash:"dad04a658ab9e3d851d23705980a688b",volumeInSeries:3,fullTitle:"Vitamin A",editors:[{id:"261969",title:"Dr.",name:"Leila",middleName:null,surname:"Queiroz Zepka",slug:"leila-queiroz-zepka",fullName:"Leila Queiroz Zepka",profilePictureURL:"https://mts.intechopen.com/storage/users/261969/images/system/261969.png",biography:"Prof. Dr. Leila Queiroz Zepka is currently an associate professor in the Department of Food Technology and Science, Federal University of Santa Maria, Brazil. She has more than fifteen years of teaching and research experience. She has published more than 550 scientific publications/communications, including 15 books, 50 book chapters, 100 original research papers, 380 research communications in national and international conferences, and 12 patents. She is a member of the editorial board of five journals and acts as a reviewer for several national and international journals. 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He received his post-doctoral training in oncology and cancer proteomics for two years at the Cancer Research Institute of Human Medical University in China. In 2001, he went to the University of Tennessee Health Science Center (UTHSC) in USA, where he was a post-doctoral researcher and focused on mass spectrometry and cancer proteomics. Then, he was appointed as an Assistant Professor of Neurology, UTHSC in 2005. He moved to the Cleveland Clinic in USA as a Project Scientist/Staff in 2006 where he focused on the studies of eye disease proteomics and biomarkers. He returned to UTHSC as an Assistant Professor of Neurology in the end of 2007, engaging in proteomics and biomarker studies of lung diseases and brain tumors, and initiating the studies of predictive, preventive, and personalized medicine (PPPM) in cancer. In 2010, he was promoted to Associate Professor of Neurology, UTHSC. Currently, he is a Professor at Xiangya Hospital of Central South University in China, Fellow of Royal Society of Medicine (FRSM), the European EPMA National Representative in China, Regular Member of American Association for the Advancement of Science (AAAS), European Cooperation of Science and Technology (e-COST) grant evaluator, Associate Editors of BMC Genomics, BMC Medical Genomics, EPMA Journal, and Frontiers in Endocrinology, Executive Editor-in-Chief of Med One. He has\npublished 116 peer-reviewed research articles, 16 book chapters, 2 books, and 2 US patents. His current main research interest focuses on the studies of cancer proteomics and biomarkers, and the use of modern omics techniques and systems biology for PPPM in cancer, and on the development and use of 2DE-LC/MS for the large-scale study of human proteoforms.",institutionString:null,institution:{name:"Xiangya Hospital Central South University",country:{name:"China"}}},{id:"40482",title:null,name:"Rizwan",middleName:null,surname:"Ahmad",slug:"rizwan-ahmad",fullName:"Rizwan Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/40482/images/system/40482.jpeg",biography:"Dr. Rizwan Ahmad is a University Professor and Coordinator, Quality and Development, College of Medicine, Imam Abdulrahman bin Faisal University, Saudi Arabia. Previously, he was Associate Professor of Human Function, Oman Medical College, Oman, and SBS University, Dehradun. Dr. Ahmad completed his education at Aligarh Muslim University, Aligarh. He has published several articles in peer-reviewed journals, chapters, and edited books. His area of specialization is free radical biochemistry and autoimmune diseases.",institutionString:"Imam Abdulrahman Bin Faisal University",institution:{name:"Imam Abdulrahman Bin Faisal University",country:{name:"Saudi Arabia"}}},{id:"41865",title:"Prof.",name:"Farid A.",middleName:null,surname:"Badria",slug:"farid-a.-badria",fullName:"Farid A. Badria",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41865/images/system/41865.jpg",biography:"Farid A. Badria, Ph.D., is the recipient of several awards, including The World Academy of Sciences (TWAS) Prize for Public Understanding of Science; the World Intellectual Property Organization (WIPO) Gold Medal for best invention; Outstanding Arab Scholar, Kuwait; and the Khwarizmi International Award, Iran. He has 250 publications, 12 books, 20 patents, and several marketed pharmaceutical products to his credit. He continues to lead research projects on developing new therapies for liver, skin disorders, and cancer. Dr. Badria was listed among the world’s top 2% of scientists in medicinal and biomolecular chemistry in 2019 and 2020. He is a member of the Arab Development Fund, Kuwait; International Cell Research Organization–United Nations Educational, Scientific and Cultural Organization (ICRO–UNESCO), Chile; and UNESCO Biotechnology France",institutionString:"Mansoura University",institution:{name:"Mansoura University",country:{name:"Egypt"}}},{id:"329385",title:"Dr.",name:"Rajesh K.",middleName:"Kumar",surname:"Singh",slug:"rajesh-k.-singh",fullName:"Rajesh K. Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329385/images/system/329385.png",biography:"Dr. Singh received a BPharm (2003) and MPharm (2005) from Panjab University, Chandigarh, India, and a Ph.D. (2013) from Punjab Technical University (PTU), Jalandhar, India. He has more than sixteen years of teaching experience and has supervised numerous postgraduate and Ph.D. students. He has to his credit more than seventy papers in SCI- and SCOPUS-indexed journals, fifty-five conference proceedings, four books, six Best Paper Awards, and five projects from different government agencies. He is currently an editorial board member of eight international journals and a reviewer for more than fifty scientific journals. He received Top Reviewer and Excellent Peer Reviewer Awards from Publons in 2016 and 2017, respectively. He is also on the panel of The International Reviewer for reviewing research proposals for grants from the Royal Society. He also serves as a Publons Academy mentor and Bentham brand ambassador.",institutionString:"Punjab Technical University",institution:{name:"Punjab Technical University",country:{name:"India"}}},{id:"142388",title:"Dr.",name:"Thiago",middleName:"Gomes",surname:"Gomes Heck",slug:"thiago-gomes-heck",fullName:"Thiago Gomes Heck",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/142388/images/7259_n.jpg",biography:null,institutionString:null,institution:{name:"Universidade Regional do Noroeste do Estado do Rio Grande do Sul",country:{name:"Brazil"}}},{id:"336273",title:"Assistant Prof.",name:"Janja",middleName:null,surname:"Zupan",slug:"janja-zupan",fullName:"Janja Zupan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/336273/images/14853_n.jpeg",biography:"Janja Zupan graduated in 2005 at the Department of Clinical Biochemistry (superviser prof. dr. Janja Marc) in the field of genetics of osteoporosis. Since November 2009 she is working as a Teaching Assistant at the Faculty of Pharmacy, Department of Clinical Biochemistry. In 2011 she completed part of her research and PhD work at Institute of Genetics and Molecular Medicine, University of Edinburgh. She finished her PhD entitled The influence of the proinflammatory cytokines on the RANK/RANKL/OPG in bone tissue of osteoporotic and osteoarthritic patients in 2012. From 2014-2016 she worked at the Institute of Biomedical Sciences, University of Aberdeen as a postdoctoral research fellow on UK Arthritis research project where she gained knowledge in mesenchymal stem cells and regenerative medicine. She returned back to University of Ljubljana, Faculty of Pharmacy in 2016. She is currently leading project entitled Mesenchymal stem cells-the keepers of tissue endogenous regenerative capacity facing up to aging of the musculoskeletal system funded by Slovenian Research Agency.",institutionString:null,institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"357453",title:"Dr.",name:"Radheshyam",middleName:null,surname:"Maurya",slug:"radheshyam-maurya",fullName:"Radheshyam Maurya",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/357453/images/16535_n.jpg",biography:null,institutionString:null,institution:{name:"University of Hyderabad",country:{name:"India"}}},{id:"418340",title:"Dr.",name:"Jyotirmoi",middleName:null,surname:"Aich",slug:"jyotirmoi-aich",fullName:"Jyotirmoi Aich",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038Ugi5QAC/Profile_Picture_2022-04-15T07:48:28.png",biography:"Biotechnologist with 15 years of research including 6 years of teaching experience. Demonstrated record of scientific achievements through consistent publication record (H index = 13, with 874 citations) in high impact journals such as Nature Communications, Oncotarget, Annals of Oncology, PNAS, and AJRCCM, etc. Strong research professional with a post-doctorate from ACTREC where I gained experimental oncology experience in clinical settings and a doctorate from IGIB where I gained expertise in asthma pathophysiology. A well-trained biotechnologist with diverse experience on the bench across different research themes ranging from asthma to cancer and other infectious diseases. An individual with a strong commitment and innovative mindset. Have the ability to work on diverse projects such as regenerative and molecular medicine with an overall mindset of improving healthcare.",institutionString:"DY Patil Deemed to Be University",institution:null},{id:"349288",title:"Prof.",name:"Soumya",middleName:null,surname:"Basu",slug:"soumya-basu",fullName:"Soumya Basu",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035QxIDQA0/Profile_Picture_2022-04-15T07:47:01.jpg",biography:"Soumya Basu, Ph.D., is currently working as an Associate Professor at Dr. D. Y. Patil Biotechnology and Bioinformatics Institute, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India. With 16+ years of trans-disciplinary research experience in Drug Design, development, and pre-clinical validation; 20+ research article publications in journals of repute, 9+ years of teaching experience, trained with cross-disciplinary education, Dr. Basu is a life-long learner and always thrives for new challenges.\r\nHer research area is the design and synthesis of small molecule partial agonists of PPAR-γ in lung cancer. She is also using artificial intelligence and deep learning methods to understand the exosomal miRNA’s role in cancer metastasis. Dr. Basu is the recipient of many awards including the Early Career Research Award from the Department of Science and Technology, Govt. of India. She is a reviewer of many journals like Molecular Biology Reports, Frontiers in Oncology, RSC Advances, PLOS ONE, Journal of Biomolecular Structure & Dynamics, Journal of Molecular Graphics and Modelling, etc. She has edited and authored/co-authored 21 journal papers, 3 book chapters, and 15 abstracts. She is a Board of Studies member at her university. She is a life member of 'The Cytometry Society”-in India and 'All India Cell Biology Society”- in India.",institutionString:"Dr. D.Y. Patil Vidyapeeth, Pune",institution:{name:"Dr. D.Y. Patil Vidyapeeth, Pune",country:{name:"India"}}},{id:"354817",title:"Dr.",name:"Anubhab",middleName:null,surname:"Mukherjee",slug:"anubhab-mukherjee",fullName:"Anubhab Mukherjee",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y0000365PbRQAU/ProfilePicture%202022-04-15%2005%3A11%3A18.480",biography:"A former member of Laboratory of Nanomedicine, Brigham and Women’s Hospital, Harvard University, Boston, USA, Dr. Anubhab Mukherjee is an ardent votary of science who strives to make an impact in the lives of those afflicted with cancer and other chronic/acute ailments. He completed his Ph.D. from CSIR-Indian Institute of Chemical Technology, Hyderabad, India, having been skilled with RNAi, liposomal drug delivery, preclinical cell and animal studies. He pursued post-doctoral research at College of Pharmacy, Health Science Center, Texas A & M University and was involved in another postdoctoral research at Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Santa Monica, California. In 2015, he worked in Harvard-MIT Health Sciences & Technology as a visiting scientist. He has substantial experience in nanotechnology-based formulation development and successfully served various Indian organizations to develop pharmaceuticals and nutraceutical products. He is an inventor in many US patents and an author in many peer-reviewed articles, book chapters and books published in various media of international repute. Dr. Mukherjee is currently serving as Principal Scientist, R&D at Esperer Onco Nutrition (EON) Pvt. Ltd. and heads the Hyderabad R&D center of the organization.",institutionString:"Esperer Onco Nutrition Pvt Ltd.",institution:null},{id:"319365",title:"Assistant Prof.",name:"Manash K.",middleName:null,surname:"Paul",slug:"manash-k.-paul",fullName:"Manash K. Paul",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/319365/images/system/319365.png",biography:"Manash K. Paul is a Principal Investigator and Scientist at the University of California Los Angeles. He has contributed significantly to the fields of stem cell biology, regenerative medicine, and lung cancer. His research focuses on various signaling processes involved in maintaining stem cell homeostasis during the injury-repair process, deciphering lung stem cell niche, pulmonary disease modeling, immuno-oncology, and drug discovery. He is currently investigating the role of extracellular vesicles in premalignant lung cell migration and detecting the metastatic phenotype of lung cancer via machine-learning-based analyses of exosomal signatures. Dr. Paul has published in more than fifty peer-reviewed international journals and is highly cited. He is the recipient of many awards, including the UCLA Vice Chancellor’s award, a senior member of the Institute of Electrical and Electronics Engineers (IEEE), and an editorial board member for several international journals.",institutionString:"University of California Los Angeles",institution:{name:"University of California Los Angeles",country:{name:"United States of America"}}},{id:"311457",title:"Dr.",name:"Júlia",middleName:null,surname:"Scherer Santos",slug:"julia-scherer-santos",fullName:"Júlia Scherer Santos",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311457/images/system/311457.jpg",biography:"Dr. Júlia Scherer Santos works in the areas of cosmetology, nanotechnology, pharmaceutical technology, beauty, and aesthetics. Dr. Santos also has experience as a professor of graduate courses. Graduated in Pharmacy, specialization in Cosmetology and Cosmeceuticals applied to aesthetics, specialization in Aesthetic and Cosmetic Health, and a doctorate in Pharmaceutical Nanotechnology. Teaching experience in Pharmacy and Aesthetics and Cosmetics courses. She works mainly on the following subjects: nanotechnology, cosmetology, pharmaceutical technology, aesthetics.",institutionString:"Universidade Federal de Juiz de Fora",institution:{name:"Universidade Federal de Juiz de Fora",country:{name:"Brazil"}}},{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",slug:"abdulsamed-kukurt",fullName:"Abdulsamed Kükürt",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/219081/images/system/219081.png",biography:"Dr. Kükürt graduated from Uludağ University in Turkey. He started his academic career as a Research Assistant in the Department of Biochemistry at Kafkas University. In 2019, he completed his Ph.D. program in the Department of Biochemistry at the Institute of Health Sciences. He is currently working at the Department of Biochemistry, Kafkas University. He has 27 published research articles in academic journals, 11 book chapters, and 37 papers. He took part in 10 academic projects. He served as a reviewer for many articles. He still serves as a member of the review board in many academic journals. He is currently working on the protective activity of phenolic compounds in disorders associated with oxidative stress and inflammation.",institutionString:null,institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"178366",title:"Dr.",name:"Volkan",middleName:null,surname:"Gelen",slug:"volkan-gelen",fullName:"Volkan Gelen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178366/images/system/178366.jpg",biography:"Volkan Gelen is a Physiology specialist who received his veterinary degree from Kafkas University in 2011. Between 2011-2015, he worked as an assistant at Atatürk University, Faculty of Veterinary Medicine, Department of Physiology. In 2016, he joined Kafkas University, Faculty of Veterinary Medicine, Department of Physiology as an assistant professor. Dr. Gelen has been engaged in various academic activities at Kafkas University since 2016. There he completed 5 projects and has 3 ongoing projects. He has 60 articles published in scientific journals and 20 poster presentations in scientific congresses. His research interests include physiology, endocrine system, cancer, diabetes, cardiovascular system diseases, and isolated organ bath system studies.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"418963",title:"Dr.",name:"Augustine Ododo",middleName:"Augustine",surname:"Osagie",slug:"augustine-ododo-osagie",fullName:"Augustine Ododo Osagie",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/418963/images/16900_n.jpg",biography:"Born into the family of Osagie, a prince of the Benin Kingdom. I am currently an academic in the Department of Medical Biochemistry, University of Benin. Part of the duties are to teach undergraduate students and conduct academic research.",institutionString:null,institution:{name:"University of Benin",country:{name:"Nigeria"}}},{id:"192992",title:"Prof.",name:"Shagufta",middleName:null,surname:"Perveen",slug:"shagufta-perveen",fullName:"Shagufta Perveen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192992/images/system/192992.png",biography:"Prof. Shagufta Perveen is a Distinguish Professor in the Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia. Dr. Perveen has acted as the principal investigator of major research projects funded by the research unit of King Saud University. She has more than ninety original research papers in peer-reviewed journals of international repute to her credit. She is a fellow member of the Royal Society of Chemistry UK and the American Chemical Society of the United States.",institutionString:"King Saud University",institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"49848",title:"Dr.",name:"Wen-Long",middleName:null,surname:"Hu",slug:"wen-long-hu",fullName:"Wen-Long Hu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49848/images/system/49848.jpg",biography:"Wen-Long Hu is Chief of the Division of Acupuncture, Department of Chinese Medicine at Kaohsiung Chang Gung Memorial Hospital, as well as an adjunct associate professor at Fooyin University and Kaohsiung Medical University. Wen-Long is President of Taiwan Traditional Chinese Medicine Medical Association. He has 28 years of experience in clinical practice in laser acupuncture therapy and 34 years in acupuncture. He is an invited speaker for lectures and workshops in laser acupuncture at many symposiums held by medical associations. He owns the patent for herbal preparation and producing, and for the supercritical fluid-treated needle. Dr. Hu has published three books, 12 book chapters, and more than 30 papers in reputed journals, besides serving as an editorial board member of repute.",institutionString:"Kaohsiung Chang Gung Memorial Hospital",institution:{name:"Kaohsiung Chang Gung Memorial Hospital",country:{name:"Taiwan"}}},{id:"298472",title:"Prof.",name:"Andrey V.",middleName:null,surname:"Grechko",slug:"andrey-v.-grechko",fullName:"Andrey V. Grechko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/298472/images/system/298472.png",biography:"Andrey Vyacheslavovich Grechko, Ph.D., Professor, is a Corresponding Member of the Russian Academy of Sciences. He graduated from the Semashko Moscow Medical Institute (Semashko National Research Institute of Public Health) with a degree in Medicine (1998), the Clinical Department of Dermatovenerology (2000), and received a second higher education in Psychology (2009). Professor A.V. Grechko held the position of Сhief Physician of the Central Clinical Hospital in Moscow. He worked as a professor at the faculty and was engaged in scientific research at the Medical University. Starting in 2013, he has been the initiator of the creation of the Federal Scientific and Clinical Center for Intensive Care and Rehabilitology, Moscow, Russian Federation, where he also serves as Director since 2015. He has many years of experience in research and teaching in various fields of medicine, is an author/co-author of more than 200 scientific publications, 13 patents, 15 medical books/chapters, including Chapter in Book «Metabolomics», IntechOpen, 2020 «Metabolomic Discovery of Microbiota Dysfunction as the Cause of Pathology».",institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"199461",title:"Prof.",name:"Natalia V.",middleName:null,surname:"Beloborodova",slug:"natalia-v.-beloborodova",fullName:"Natalia V. Beloborodova",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/199461/images/system/199461.jpg",biography:'Natalia Vladimirovna Beloborodova was educated at the Pirogov Russian National Research Medical University, with a degree in pediatrics in 1980, a Ph.D. in 1987, and a specialization in Clinical Microbiology from First Moscow State Medical University in 2004. She has been a Professor since 1996. Currently, she is the Head of the Laboratory of Metabolism, a division of the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation. N.V. Beloborodova has many years of clinical experience in the field of intensive care and surgery. She studies infectious complications and sepsis. She initiated a series of interdisciplinary clinical and experimental studies based on the concept of integrating human metabolism and its microbiota. Her scientific achievements are widely known: she is the recipient of the Marie E. Coates Award \\"Best lecturer-scientist\\" Gustafsson Fund, Karolinska Institutes, Stockholm, Sweden, and the International Sepsis Forum Award, Pasteur Institute, Paris, France (2014), etc. Professor N.V. Beloborodova wrote 210 papers, five books, 10 chapters and has edited four books.',institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"354260",title:"Ph.D.",name:"Tércio Elyan",middleName:"Azevedo",surname:"Azevedo Martins",slug:"tercio-elyan-azevedo-martins",fullName:"Tércio Elyan Azevedo Martins",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/354260/images/16241_n.jpg",biography:"Graduated in Pharmacy from the Federal University of Ceará with the modality in Industrial Pharmacy, Specialist in Production and Control of Medicines from the University of São Paulo (USP), Master in Pharmaceuticals and Medicines from the University of São Paulo (USP) and Doctor of Science in the program of Pharmaceuticals and Medicines by the University of São Paulo. Professor at Universidade Paulista (UNIP) in the areas of chemistry, cosmetology and trichology. Assistant Coordinator of the Higher Course in Aesthetic and Cosmetic Technology at Universidade Paulista Campus Chácara Santo Antônio. Experience in the Pharmacy area, with emphasis on Pharmacotechnics, Pharmaceutical Technology, Research and Development of Cosmetics, acting mainly on topics such as cosmetology, antioxidant activity, aesthetics, photoprotection, cyclodextrin and thermal analysis.",institutionString:null,institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"334285",title:"Ph.D. Student",name:"Sameer",middleName:"Kumar",surname:"Jagirdar",slug:"sameer-jagirdar",fullName:"Sameer Jagirdar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334285/images/14691_n.jpg",biography:"I\\'m a graduate student at the center for biosystems science and engineering at the Indian Institute of Science, Bangalore, India. I am interested in studying host-pathogen interactions at the biomaterial interface.",institutionString:null,institution:{name:"Indian Institute of Science Bangalore",country:{name:"India"}}},{id:"329248",title:"Dr.",name:"Md. Faheem",middleName:null,surname:"Haider",slug:"md.-faheem-haider",fullName:"Md. Faheem Haider",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329248/images/system/329248.jpg",biography:"Dr. Md. Faheem Haider completed his BPharm in 2012 at Integral University, Lucknow, India. In 2014, he completed his MPharm with specialization in Pharmaceutics at Babasaheb Bhimrao Ambedkar University, Lucknow, India. He received his Ph.D. degree from Jamia Hamdard University, New Delhi, India, in 2018. He was selected for the GPAT six times and his best All India Rank was 34. Currently, he is an assistant professor at Integral University. Previously he was an assistant professor at IIMT University, Meerut, India. He has experience teaching DPharm, Pharm.D, BPharm, and MPharm students. He has more than five publications in reputed journals to his credit. Dr. Faheem’s research area is the development and characterization of nanoformulation for the delivery of drugs to various organs.",institutionString:"Integral University",institution:{name:"Integral University",country:{name:"India"}}},{id:"329795",title:"Dr.",name:"Mohd Aftab",middleName:"Aftab",surname:"Siddiqui",slug:"mohd-aftab-siddiqui",fullName:"Mohd Aftab Siddiqui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329795/images/system/329795.png",biography:"Dr. Mohd Aftab Siddiqui is an assistant professor in the Faculty of Pharmacy, Integral University, Lucknow, India, where he obtained a Ph.D. in Pharmacology in 2020. He also obtained a BPharm and MPharm from the same university in 2013 and 2015, respectively. His area of research is the pharmacological screening of herbal drugs/natural products in liver cancer and cardiac diseases. He is a member of many professional bodies and has guided many MPharm and PharmD research projects. Dr. Siddiqui has many national and international publications and one German patent to his credit.",institutionString:"Integral University",institution:null}]}},subseries:{item:{id:"10",type:"subseries",title:"Animal Physiology",keywords:"Physiology, Comparative, Evolution, Biomolecules, Organ, Homeostasis, Anatomy, Pathology, Medical, Cell Division, Cell Signaling, Cell Growth, Cell Metabolism, Endocrine, Neuroscience, Cardiovascular, Development, Aging, Development",scope:"Physiology, the scientific study of functions and mechanisms of living systems, is an essential area of research in its own right, but also in relation to medicine and health sciences. The scope of this topic will range from molecular, biochemical, cellular, and physiological processes in all animal species. Work pertaining to the whole organism, organ systems, individual organs and tissues, cells, and biomolecules will be included. Medical, animal, cell, and comparative physiology and allied fields such as anatomy, histology, and pathology with physiology links will be covered in this topic. Physiology research may be linked to development, aging, environment, regular and pathological processes, adaptation and evolution, exercise, or several other factors affecting, or involved with, animal physiology.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/10.jpg",hasOnlineFirst:!1,hasPublishedBooks:!1,annualVolume:11406,editor:{id:"202192",title:"Dr.",name:"Catrin",middleName:null,surname:"Rutland",slug:"catrin-rutland",fullName:"Catrin Rutland",profilePictureURL:"https://mts.intechopen.com/storage/users/202192/images/system/202192.png",biography:"Catrin Rutland is an Associate Professor of Anatomy and Developmental Genetics at the University of Nottingham, UK. She obtained a BSc from the University of Derby, England, a master’s degree from Technische Universität München, Germany, and a Ph.D. from the University of Nottingham. She undertook a post-doctoral research fellowship in the School of Medicine before accepting tenure in Veterinary Medicine and Science. Dr. Rutland also obtained an MMedSci (Medical Education) and a Postgraduate Certificate in Higher Education (PGCHE). She is the author of more than sixty peer-reviewed journal articles, twelve books/book chapters, and more than 100 research abstracts in cardiovascular biology and oncology. She is a board member of the European Association of Veterinary Anatomists, Fellow of the Anatomical Society, and Senior Fellow of the Higher Education Academy. Dr. Rutland has also written popular science books for the public. https://orcid.org/0000-0002-2009-4898. www.nottingham.ac.uk/vet/people/catrin.rutland",institutionString:null,institution:{name:"University of Nottingham",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null,series:{id:"10",title:"Physiology",doi:"10.5772/intechopen.72796",issn:"2631-8261"},editorialBoard:[{id:"306970",title:"Mr.",name:"Amin",middleName:null,surname:"Tamadon",slug:"amin-tamadon",fullName:"Amin Tamadon",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002oHR5wQAG/Profile_Picture_1623910304139",institutionString:null,institution:{name:"Bushehr University of Medical Sciences",institutionURL:null,country:{name:"Iran"}}},{id:"251314",title:"Dr.",name:"Juan Carlos",middleName:null,surname:"Gardón Poggi",slug:"juan-carlos-gardon-poggi",fullName:"Juan Carlos Gardón 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