\r\n\tThe following book will aim to explain clearly the main principles of mammography - advantages, disadvantages, benefits, and risks. Also, it has to offer detailed information about the screening, the early mammographic findings in breast cancer and the normal imaging anatomy of the breast and the process of aging. A significant part of the book will be dedicated to successful differentiation between benign and malignant breast calcifications. Another important task is to focus attention to the potential for radiation-induced breast cancer and to the screening of people with a family history of malignant breast tumors. Тhere will be included also practical advice and mammographic guidelines useful in daily medical practice.
",isbn:null,printIsbn:"979-953-307-X-X",pdfIsbn:null,doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"782ad34f33b5e2f22c6c995661223487",bookSignature:"Associate Prof. Lachezar Manchev",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/9130.jpg",keywords:"Mammography, Screening, Malignant Breast Tumors, Benign Brest Tumors, Microcalcifications, Profilaxis, Breast Variations, Normal Breast Parenchyma, Calcifications, Radiation-induced Breast Cancer, Ionizing Radiation, Risk Factors",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 7th 2019",dateEndSecondStepPublish:"September 11th 2019",dateEndThirdStepPublish:"November 10th 2019",dateEndFourthStepPublish:"January 29th 2020",dateEndFifthStepPublish:"March 29th 2020",remainingDaysToSecondStep:"a year",secondStepPassed:!0,currentStepOfPublishingProcess:5,editedByType:null,kuFlag:!1,biosketch:null,coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"252432",title:"Associate Prof.",name:"Lachezar",middleName:null,surname:"Manchev",slug:"lachezar-manchev",fullName:"Lachezar Manchev",profilePictureURL:"https://mts.intechopen.com/storage/users/252432/images/system/252432.jpeg",biography:"Associate Professor Lachezar Ivanov Manchev (MD, PhD) graduated in medicine from the Medical Faculty, Trakia University, Stara Zagora in 2010. Since 2010, he has worked as a radiologist in the Department of Diagnostic Imaging at the University Hospital, Stara Zagora. Between 2013 and 2018, he was assistant professor in the Department of Radiology in the Medical Faculty, Trakia Universtity, Stara Zagora. Since 2018, he has been an associate professor in Radiology at the same university. In his practice, he presents lectures and tutorials in Bulgarian to medical, nursing, midwifery and rehabilitation students, in subject areas including X-ray, CT, MRI, angiography, mammography, ultrasound and DSG. Dr Manchev also delivers lectures and tutorials in English to medical students from the United Kingdom and the Republic of Ireland. Since 2016, he works as a part-time lecturer for the Faculty of Public Health and Health Care, University Professor Doctor Asen Zlatarov, Burgas, Bulgaria.",institutionString:"Trakia University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Trakia University",institutionURL:null,country:{name:"Bulgaria"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"177730",firstName:"Edi",lastName:"Lipovic",middleName:null,title:"Mr.",imageUrl:"https://mts.intechopen.com/storage/users/177730/images/4741_n.jpg",email:"edi@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"878",title:"Phytochemicals",subtitle:"A Global Perspective of Their Role in Nutrition and Health",isOpenForSubmission:!1,hash:"ec77671f63975ef2d16192897deb6835",slug:"phytochemicals-a-global-perspective-of-their-role-in-nutrition-and-health",bookSignature:"Venketeshwer Rao",coverURL:"https://cdn.intechopen.com/books/images_new/878.jpg",editedByType:"Edited by",editors:[{id:"82663",title:"Dr.",name:"Venketeshwer",surname:"Rao",slug:"venketeshwer-rao",fullName:"Venketeshwer Rao"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"61616",title:"Synopsis of Mangle Species in Mexico",doi:"10.5772/intechopen.76975",slug:"synopsis-of-mangle-species-in-mexico",body:'\nRegarding mangroves, taxonomic uncertainties persist despite the fact that there are currently many works that refer to these tree and shrub species; this is due to the fact that the characteristics that separate mangrove species are diffuse as they belong to different families, some of them more related to terrestrial environments. In addition, identifications in herbaria are erroneous even by specialists. As a consequence of these situations, the systematic and taxonomic knowledge of the mangroves is recent, despite the fact that their study goes back 300 years [47]. It is important to have a synopsis that outlines the main characteristics that distinguish mangrove species, in this chapter, referring to those found on the coasts of Mexico.
\nThe material examined consisted of printed books and information obtained on the Internet concerning the species Rhizophora mangle L., Avicennia germinans (L.) L., Laguncularia racemosa (L.) C.F. Gaertn., Conocarpus erectus L., Rhizophora harrisonii Leechm., and Avicennia bicolor Standl.
\nThe mangroves present in Mexico comprise three families, four genera, and six species. They are distributed in the 17 coastal states of the country, the largest amount of species in the state of Chiapas. In 16 states of the country there are four species (R. mangle, A. germinans, L. racemosa, and C. erectus); in Chiapas, in addition to the previous ones, R. harrisonii and A. bicolor are presented.
\nThe family Rhizophoraceae comprises one genus, Rhizophora, and two species, R. mangle and R. harrisonii; the family Acanthaceae is represented by one genus, Avicennia, and two species A. germinans and A. bicolor; and the family Combretaceae has two genera, Laguncularia, with the species L. racemosa and the genus Conocarpus, with the species C. erectus.
\nValid name
\nAvicennia bicolor Standl. Journal of the Washington Academy of Sciences 13 (15): 354. 1923. (J. Wash. Acad. Sci.) By Paul Carpenter Standley [51].
\nSynonym
\nTomlinson [46] considered Avicennia tonduzii as a synonym for this species. A. tonduzii was described by Mondelke in 1938 in Phytology 1: 273–4. Tomlinson [47], states that A. tonduzii appears to be only a variant of A. bicolor, distinguishing itself by its narrow leaves and the particular shape of its panicles with pairs of individual flowers separated therefrom.
\nTaxonomy
\nAffinities
\nSuprageneric
\nKingdom Plantae
\nSubkingdom Tracheobionta
\nSuperdivision Spermatophyta
\nDivision Magnoliophyta
\nClass Magnoliopsida
\nSubclass Asteridae
\nOrder Lamiales
\nFamily Acanthaceae (Verbenaceae; Avicenniaceae)
\nSubfamily Avicennioideae
\nGeneric
\nAvicennia L. (1753) is currently derived from the Acanthaceae family, as per recent phylogenetic studies [5, 36, 45]. Although, it has been placed in the families Verbenaceae or Avicenniaceae in some classifications [33]. The genus can be treated as the subfamily Avicenniaceae [21].
\nThe genus Avicennia was named in honor of the famous doctor and scientist, Abu-Ali al-Husayn ibn-Sina, known as Avicenna (980–1073 BC) [37].
\nSpecifics
\nIt is a bicolor species—bi meaning two. The corolla of the flower is white and may have a yellow hue at its base so that its flower is considered bicolor [46].
\nType specimens
\nFor Avicennia bicolor Standl. A, holotype has been reported in
Type-protologue: distribution
\nPanama: Province of Coclé: collected in mangroves in Aguadulce, December 5, 1911 [51].
\nDiagnosis
\nIt is a small tree with an irregular crown. Its bark is whitish or light gray-brown (in contrast to the dark grayish coffee of Avicennia germinans). The leaves are elliptical, with a bright beam and totally without hairs, characteristic with which it can be differentiated from A. germinans, since this one has crystals in the beam and the back. The underside is somewhat hairy and is usually covered by salt crystals. The inflorescence is a terminal or axillary panicle of white, hairless flowers. The fruit is a rounded and a smooth capsule. It has vertical, spongy roots that project over the mud, absorb the air, and ventilate the support root system [4].
\nCommon and vernacular names
\nPalo de sal [46]
\nOther common names in Mexico: Mangle negro [34].
\nCommon names in other countries: Curumo blanco—Honduras; Madresal—El Salvador; mangle gateador—Panama; mangle salado—Panama; and Palo de sal (Guanacaste-Costa Rica) [4, 26].
\nDistribution
\nMoldenke [40], Tovilla-Hernández et al. [48], and, later, Nettel et al. [41] report that the geographical distribution of Avicennia bicolor Standl., at its northernmost end, is in Tonalá, Chiapas, in Mexico (9° 51 ‘N 84° 41’ W). Recent studies by the Southern Border College of Tapachula Unit have located a mature A. bicolor forest between the municipal boundaries of Tonalá and Pijijiapan, Chiapas, in addition to finding new distribution sites for Rhizophora harrisonii Leechm.(Tovilla, 2012 com. in [44]).
\nFlowers and propagules of Avicennia bicolor. Cistian Tovilla Hernández. Diplomado Internacional en ecología, manejo, restauración y legislación en sistemas de manglares (2017). ECOSUR.
Valid name
\nAvicennia germinans (L.) L. Linnaeus, Carl Von. Published in: Species Plantarum, ed. 3, 2: 891. 1764. Sp. Pl (ed.3) [52].
\nBasionym
\nBontia germinans was published in Systema Naturae, Editio Decima 2: 1122. 1759. Syst. Nat. (Ed.10). 19 Synonym; 1 HomonymAvicennia germinans (L.) Stearn; 6 Ifraspecific categories (form and variety) [52].
\nTaxonomy
\nAffinities
\nSuprageneric
\nKingdom Plantae
\nSubkingdom Tracheobionta
\nSuperdivision Spermatophyta
\nDivision Magnoliophyta
\nClass Magnoliopsida
\nSubclass Asteridae
\nOrder Lamiales
\nFamily Acanthaceae (Verbenaceae; Avicenniaceae)
\nSubfamily Avicennioideae
\nGeneric
\nAvicennia L. (1753) is derived from the Acanthaceae family, as per recent phylogenetic studies [5, 36, 45], although it has been placed in the families Verbenaceae or Avicenniaceae in some classifications [33]. The genus can be treated as subfamily Avicennioideae [21].
\nThe genus Avicennia was named in the honor of the famous doctor and scientist, Abu-Ali al-Husayn ibn-Sina, known as Avicenna (980–1073 BC) [37].
\nSpecifics
\nGerminans is a Latin word meaning “sprouting” in reference to its particular form of reproduction; this is due to the early germination of the seed within the fruit [4].
\nType specimens
\nFor Avicennia germinans (L.) L., a lectotype, related to its basionym Bontia germinans, has been reported in the Atlas of Florida Plants and Tropicos ® as follows: JAMAICA: Without data, Browne s.n. (lectotype: LINN 813.2). Lectotypified by Stearn, Kew Bull. 1958: 34, 1958 [64] and LT: Browne s.n.; Jamaica (LINN-813.2) LT designated by Stearn, Kew Bull. 13: 35 (1958) [53].
\nType-protologue: distribution
\nJamaica: No data, Browne s.n. (lectotype: LINN 813.2). Lectured by Stearn, Kew Bull. 1958: 34, 1958 [64].
\nDiagnosis
\nIt is a tree or shrub that reaches a size of 3–10 m in height [6]. Leaves excrete salt through specialized glands and can be covered by salt, thus contributing to salty leaf litter [35]. Panicle inflorescence in the form of spikes or panicles composed, 9 cm long and 2–5 cm wide. Fruit ovate-oblique, apiculate, 1.5–2 cm long and 1–1.5 cm wide, is sparsely sericeous [6].
\nIt grows on sandy, muddy, or argillaceous soils. It is found in heavily oxidized clays or in soils with high concentrations of pyrite [3]. The species is sensitive to frost but is considered to be the most tolerant mangle species to low temperatures [11].
\nCommon and vernacular names
\nMangle negro, Mangle prieto [12].
\nOther common names in Mexico: mangle blanco—Veracruz, Oaxaca, Tabasco, Yucatan; mangle negro, madre de sal—Acapetagua, Chis; Mangle prieto—Yucatán; Puyeque—Sinaloa [14]. Maya: tab che ‘, taab che’ tat xiül [12].
\nBlack mangrove (Belize); Culumate (Costa Rica); Curumo negro (Honduras); istatén (Costa Rica and El Salvador); mangle negro (El Salvador, Guatemala, Nicaragua, and Panama); Mangle prieto, Mangle salado (Panama); Mangle salsa (Costa Rica); Palo de sal (Costa Rica, Nicaragua) [4]; mangle iguanero (Colombia and Ecuador); mangle rosado (Venezuela) [8].
\nDistribution
\nIt is found on both coastlines of the country, from the state of Tamaulipas to the Yucatan Peninsula in the Gulf of Mexico and the Caribbean Sea and from the states of Baja California and Sonora to Chiapas in the coast of the Pacific Ocean [42].
\nFlowers and propagules of Avicennia germinans. Agustín de Jesús Basáñez Muñoz (2006). Universidad Veracruzana.
Valid name
\nConocarpus erectus L. Linnaeus, Carl Von. Published in: Species Plantarum 1: 176. 1753. (1 May 1753) (Sp. Pl.) As erecta [54].
\nBasionym
\nThe species Conocarpus erectus L. has as basionym Terminalia erecta (L.) Baill *, which means that this species was initially described by Linnaeus in the genus Conocarpus and later reported by Baillon in the genus Terminalia. 10 Synonyms; 8 Ifraspecific name (form and variety) [54].
\nTaxonomy
\nAffinities
\nSuprageneric
\nKingdom Plantae
\nSubkingdom Tracheobionta
\nSuperdivision Spermatophyta
\nDivision Magnoliophyta
\nClass Magnoliopsida
\nSubclass Rosidae
\nOrder Myrtales
\nFamily Combretaceae
\nGeneric
\nThe genus Conocarpus L. comes from the Greek word “konos”, cone and “carpos” fruit because the fruits resemble a conical shape [31].
\nSpecifics
\nerectus.- masculine erectus, feminine erecta, neuter erectum; means erect, right; by the erect habit of the plant [63].
\nType specimens
\nFor Conocarpus erectus L., the Atlas of Florida Plants and Tropicos ® have reported as follows: JAMAICA: Without data (lectotype: Sloane, Voy Jamaica t 161 (2) 1703.). Lectotipified by Wijnands, Bot. Commelins 66, 1983 [64] and LT: Sloane, Voy. Jamaica t. 161, f. 2 (1725); LT designated by Wijnands, Bot. Commelins 66 (1983); TOP: Sloane Herb., 5: fol. 63 TT designated by C.E. Jarvis [54].
\nType protologue: distribution
\nJamaica: No data (lectotype: Sloane, Voy Jamaica, 161 (2) 1703.). Lectotipified by Wijnands, Bot. Commelins 66, 1983 [64].
\nDiagnosis
\nConocarpus erectus L.: differs from mangroves in their reproductive strategy; it is reproduced through seeds [30].
\nIt has an erect trunk or several trunks but may assume a prostrate body; the crust is gray or brown, wrinkled, fibrous, and moderately thin; the inner crust is dark cream color. The leaves are alternate, simple, and oblong, 2–7 cm in length (rarely 10 cm long) and 1–3 cm in width, with a decrease in the tip; they are dark green and bright in the bundle and pale in tone and with fine silky hairs on the underside. The inflorescences are terminal or axillary panicles, of small flowers of greenish-white color grouped in spheroidal heads of 3–5 mm in diameter. Fruits, 4-mm winged nuts, are added in globose brown heads, 1–1.3 cm in diameter. Conocarpus erectus L. is intolerant to shade [28].
\nCommon and vernacular names
\nMangle botoncillo [15].
\nOther common names in Mexico: mangle negro, mangle prieto—Veracruz, Tabasco, Campeche, Oaxaca, Guerrero; mangle botoncillo—Yucatan and Veracruz [42]. Maaya: k’an che ‘[27].
\nBotoncillo (El Salvador, Honduras, Nicaragua); buttonwood (Belize); mangle boton (Costa Rica, Panama); mangle botoncillo (Guatemala); mangle gris (Honduras); mangle negro (Costa Rica); palo boton (Honduras) [4]. Mangle zaragoza (Costa Rica, Panama) [29].
\nDistribution
\nIt is found on both coastlines of the country, from the state of Tamaulipas to the Yucatan Peninsula in the Gulf of Mexico and the Caribbean Sea and from the states of Baja California and Sonora to Chiapas in the Pacific Ocean [42].
\nFlowers and fruits of Conocarpus erectus. Agustín de Jesús Basáñez Muñoz (2006). Universidad Veracruzana.
Valid name
\nLaguncularia racemosa (L.) C.F. Gaertn. Gaertner, Carl (Karl) Friedrich Von. Published in: Supplementum Carpologiae 209. 1807. (Suppl Carp) [55].
\nBasionym
\nThe basionym of this species is Conocarpus racemosus L. *, initially described in the genus Conocarpus by Linnaeus and translated by C.F. Gaertner in 1807 to the genus Laguncularia. The first publication of the species Conocarpus racemosus was in Systema Naturae, Editio Decima 2: 930. 1759. Syst. Nat. (Ed.10). 5 Synonym; 2 Ifraspecific categories (form and variety) [55].
\nTaxonomy
\nAffinities
\nSuprageneric
\nKingdom Plantae
\nSubkingdom Tracheobionta
\nSuperdivision Spermatophyta
\nDivision Magnoliophyta
\nClass Magnoliopsida
\nSubclass Rosidae
\nOrder Myrtales
\nFamily Combretaceae
\nGeneric
\nLaguncularia Gaertn (1807) is a monotypic genus (a single species) from tropical America and Africa [22].
\nIts name (Laguncularia) comes from the Latin term “laguncula,” diminutive of “lagena,” which means bottle; because the limbus of the chalice, when closing, constitutes the shape of the fruit (propagule), it is shaped like a small bottle [31] (and Personal Commentary, 2018).
\nSpecifics
\nracemosa comes from the Latin racemosa, which means cluster, which alludes to the type of inflorescence that the plant presents (cluster type) [39].
\nType specimens
\nThe Atlas of Florida Plants and Tropicos ® [2] report a lectotype for Laguncularia racemosa (L.) C.F. Gaertn. rather related to his basionym Conocarpus racemosus: Without data (lectotype: LINN 237.2). Lectotypified by Bornstein, in R. A. Howard, Fl. Antill., Dicot. 2: 459, 1989 [64] and LT: Anon.; (LINN-237.2) LT designated by Bornstein, Fl. Lesser Antilles 5: 459 (1989) [56].
\nType protologue: distribution
\nJamaica: Without data (lectotype: Sloane, Voy, Jamaica, 161 (2), 1703). Lectotypified by Wijnands, Bot. Commelins 66, 1983 [64].
\nDiagnosis
\nThis species presents as shrubs or trees, which reach a size of up to 10 m high, frequently with pneumatophores. Its trunk is straight with ascending branches, rounded, and a dense cup. The leaves of the white mangrove are opposite, elliptical, and rounded at both the base and the apex; they measure from 4–10 cm in length and from 2–4 cm in width; the top of the leaf (beam) is bright dark green and the bottom (underside) is yellowish green. The flowers appear in axillary and terminal panicles, are fragrant, and measure 1.5 mm in diameter [4].
\nIts silky and fleshy fruits have a flattened bottle shape, measure between 1 and 2.5 cm in length, and have several longitudinal grooves. They contain a seed; the seed often begins to germinate inside the fruit when it is still attached to the tree [42].
\nCommon and vernacular names
\nMangle blanco [16].
\nOther common names in Mexico: Mangle blanco—Tamaulipas, Oaxaca; mangle bobo—Yucatán; Mangle chino—Sinaloa [14] Sak-okom (Mayan language)—Yucatan; tzakol-kon—Yucatan Peninsula (Martínez, 1979 in [14]).
\nPatabán (Cuba); White mangrove (United States); Cincahuite, Palo de Sal (Costa Rica); akira (Suriname); jeli de mangle (Peru). [16].
\nDistribution
\nIt is found on both coastlines of the country, from the state of Tamaulipas to the Yucatan Peninsula in the Gulf of Mexico and the Caribbean Sea and from the states of Baja California and Sonora to Chiapas in the Pacific Ocean [42].
\nFlowers and propagules of Laguncularia racemosa. Agustín de Jesús Basáñez Muñoz (2006). Universidad Veracruzana.
Valid name
\nRhizophora harrisonii Leechm: Bulletin of Miscellaneous Information Kew 1918 (1): 8, f. A. 1918. (Bull Misc.Kew Inform) [57].
\nSynonym
\nRhizophora brevistyla Salvoza [57].
\nTaxonomy
\nAffinities
\nSuprageneric
\nKingdom Plantae
\nSubkingdom Tracheobionta
\nSuperdivision Spermatophyta
\nDivision Magnoliophyta
\nClass Magnoliopsida
\nSubclass Rosidae
\nOrder Malpighiales
\nFamily Rhizophoraceae
\nGeneric
\nRhizophora: The word “rhiza” (root) and “phoros” (bearer or bearer) means in Greek “bearing the roots” and refers to its aerial (willow) roots’ characteristics of the genus [25].
\nSpecific
\nHarrisonii: In the honor of Professor J.B. Harrison, C.M.G., M.A. Director of Science and Agriculture in British (English) Guiana [32].
\nAn important aspect to emphasize is the use of taxonomic status:
\nRhizophora x harrisonii was proposed by Tomlinson in 1986 [18] in his book “The Botany of Mangroves.” The author mentions that “in relation to Rhizophora x harrisonii, there is circumstantial evidence that the species is a hybrid between Rhizophora mangle and Rhizophora racemosa.”
\nIn this regard, a study of hybridization and introgression between the species of the genus Rhizophora of the New World (R. mangle, R. racemosa and R. harrisonii) carried out by Cerón et al. [10], concludes that “our data support an ancient and persistent hybridization of the Rhizophora genus and propose a complete review of the group’s systematic relationships based on finer morphological, ecological and genetic analyzes.” “However, we found no genetic evidence that R. harrisonii is a hybrid species”. Rather, R. harrisonii appears to represent a morphotype produced by a process of hybridization and backcrossing between R. mangle and R. racemosa [10].
\nType specimens
\nRhizophora harrisonii Leechm. has a lectotype as follows: LT: Leechman s.n.; Guyana (K) LT designated by Barrie, Fl. Mesoamer. 4 (1): ined. [57].
\nType-protologue: distribution
\nGuyana: British Guiana: Two-mile stretch of coast, in the vicinity of Georgetown [57].
\nDiagnosis
\nRhizophora harrisonii Leechm. are trees up to 25 m with leaves from 9–13 cm in length and from 3–8 cm in width, elliptic, acute apex, and the petiole measures are from 1–3 cm. It presents dichotomically branched inflorescences of 5–6 times or the first tricotómica branch; the branches are thin, laxas, and arranged in acute angles. The flower buds are 3–9 mm, ellipsoid, and the apex is slightly attenuated; sepals are of 8–10 mm compared to their petals of 5–6 mm; they are deciduous, abaxially glabrous, villous margins; they present 8 stamens of 4.5–5 mm and sessile and are apiculated. The fruit is 28–33 mm long with its hypocotyl from 11–40 cm, straight or curved [58].
\nCommon and vernacular names
\nMangle caballero, Mangle zapatero [7].
\nCommon name in other countries: Mangle rojo—Venezuela [20].
\nDistribution
\nRico-Gray [43] said that Rhizophora harrisonii Leechm. “is a new record for the coasts of Mexico”, reporting to the species for the State of Chiapas. Recent studies by the South Border College of Tapachula Unit have located a mature forest of Avicennia bicolor between the municipal boundaries of Tonalá and Pijijiapan, Chiapas, in addition to finding new distribution sites for Rhizophora harrisonii (Tovilla, 2012 com. [44]).
\nFlowers and propagules of Rhizophora harrisonii. Cistian Tovilla Hernández. Diplomado Internacional en ecología, manejo, restauración y legislación en sistemas de manglares (2017). ECOSUR.
Valid name
\nRhizophora mangle L. Linnaeus, Carl Von. Species Plantarum 1: 443. 1753. (1 May 1753) (Sp. Pl.) [59].
\nSynonym
\nRhizophora americana Nutt.
\nRhizophora mangle var. samoensis Hochr.
\nRhizophora samoensis (Hochr.) Salvoza.
\nName accepted
\nNasir and Ali in 1972 [38], consider Rhizophora mucronata Lam. as an accepted name (it is the name which can be used to refer to species (or subspecies, varieties, or forms) of Rhizophora mangle L. 2 Ifraspecific categories (variety).
\nTaxonomy
\nAffinities
\nSuprageneric
\nKingdom Plantae
\nSubKingdom Tracheobionta
\nSuperdivision Spermatophyta
\nDivision Magnoliophyta
\nClass Magnoliopsida
\nSubclass Rosidae
\nOrder Malpihiales
\nFamily Rhizophoraceae
\nGeneric
\nRhizophora: The word “rhiza” (root) and “phoros” (bearer or bearer) means in Greek “bearing the roots” and refers to its aerial (willow) roots characteristics of the genus [25].
\nSpecific
\nMangle: The word mangle is derived from Guarani and means “twisted tree” [1].
\nType specimens
\nThe
Type protologue: distribution
\nJamaica (F; EET: DUKE, MICH) ET designated by Barrie, Fl. Mesoamer. 4 (1): ined. [59].
\nDiagnosis
\nThe trees of Rhizophora mangle are from 4 to 10 m in height, their shape is like a tree or and evergreen shrub. The leaves are simple, opposite, petiolate, with rounded leaf, and they are elliptic to oblong; these are agglomerated at the tips of the branches, their color is dark green in the bundle, and yellowish on the underside. The flowers are small, 2.5 cm in diameter with four speared sepals, thick and leathery. The flower has four yellowish white petals. It has two to four flowers per stem or peduncle. The fruits are presented in the form of a brown, coriaceous, hard, piriform, farinous berry. A seed is developed, rarely two, per fruit [62].
\nCommon and vernacular names
\nCommon names in Mexico: Candelón—Veracruz, Colima, Sinaloa; Mangle; Mangle colorado; Mangle dulce—Baja California, Oaxaca; Mangle rojo; Mangle tinto—Veracruz [17, 62]. Maya: Tabché, Tapché, Xtabché [17, 62].
\nMangle colorado, mangle (Honduras); mangle rojo (Costa Rica); mangle salado (Panama); Candelin, Mangle dulce (Mexico); mangle caballero, mangle gateador (Colombia); Mangle verdadero, mangle zapatero (Ecuador); purgua (Venezuela); apareiba, mangle zapateiro, mangle vermelho (Brazil); mang wouj (Haiti) [8].
\nDistribution
\nIt is found on both coastlines of the country, from the state of Tamaulipas to the Yucatan Peninsula in the Gulf of Mexico and the Caribbean Sea and from the states of Baja California and Sonora to Chiapas in the Pacific Ocean [42].
\nFlowers and propagules of Rhizophora mangle. Agustín de Jesús Basáñez Muñoz (2006). Universidad Veracruzana.
Mexico is among the five countries in the world with the largest extension of mangroves distributed; by 2015, 7,75,555 ha of mangroves have been registered in both coasts of the country covering at least 60% of the coastline [61].
\nIn 2005, the National Commission for the Knowledge and Use of Biodiversity (CONABIO) initiated the bases for what is now called the Mangrove Monitoring System of Mexico. The aim of the SMMM is to generate information about changes in the mangrove ecosystem through the evaluation of its spatial distribution and condition over time. From this information, we also look for the identification of existing, latent threats and trends of changes (loss, deterioration, or recovery), in such a way as to support their conservation, understanding, and management. Based on the information generated, the threats and trends of change that through analysis have been incorporated into the conservation of this ecosystem have been identified. The results show a strong occurrence of both natural processes and human activities, which influence the loss of coverage or disturbance of the mangrove. Of these, those of anthropic origin stand out for their importance. In this category, two classes are presented: the agricultural-livestock and a pattern of occupation of land use derived from development. The first one is related to primary economic activities, that is to say agriculture (both irrigation and seasonal), livestock, and forestry. The second class encompasses land uses, such as rural areas, urban areas, industrial zones, aquaculture farms, ports, tourist infrastructure, and so on [61].
\nThe tendency of loss of coverage occurred mainly in the period from 1970 to 2005 (up to 27,557 ha), there being a drastic change from 2005 to 2015, with the last period reported from 2010 to 2015 with a loss of 1090 ha but a profit of 1296 ha. Within the categories identified by the SMMM as threats in the loss of mangrove are the areas under construction, aquaculture farms and artificial ponds, hydraulic infrastructure (canals or dams), industrial zones (oil wells, salt pans, thermoelectric plants, complexes), and communication routes [61].
\nIn Mexico, 6 of the world’s 70 mangrove species (8.5%) have been reported [50] and contribute 5.4% of the total mangrove area, after Indonesia with 22.6%, Australia with 7.1%, and Brazil with 7% [60].
\nIts biological importance lies in being places of rest and nesting of birds (Egretta caerulea, E. rufescens, E. tricolor, Ardea herodias, Aramides cajaneus, Sula leucogaster, Phalacrocorax auritus, Fregata magnificens, Ajaia ajaja, among others). They represent an important habitat for species with some risk category (NOM-059-SEMARNAT-2010) such as Mexican Tamandua mexicana, Buteogallus anthracinus, Rostrhamus sociabilis, Mycteria americana, Vireo pallens, Megascops cooperi, Crocodylus acutus, C. moreletii, Ctenosaura pectinata, C quinquecarinata, C. similis, C. acanthura, C. hemilopha, and Iguana iguana [50].
\nThe biological and ecological importance of mangroves has led CONABIO to establish 81 priority sites, determined by specialists in the subject; of these 29 are located on the Pacific coast, 27 in the Gulf of Mexico, and 25 in the Yucatan Peninsula. Each of these sites of interest has a characterization sheet with information on site location, physical characteristics, socioeconomic, uses, importance, impacts, and threats and transformation processes [13].
\nThey are used in firewood and coal; poles for fences, piles, railway sleepers, piers, boats, telegraph poles, and electricity; and furniture, cabinets, door frames, musical instruments, handles for tools, and agricultural implements. Newborn seedlings are edible if cooked but raw seeds are poisonous. The bark contains tannin and is used to tan skins. The infusion of its cooking is drunk as a remedy for diarrhea, intestinal irritation and colic, washing or bathing to heal wounds and hemorrhoids, or in bleeding gums rinses. The flowers are rich in honey and in nectar. The honey obtained is white, clear, and of excellent quality [4].
\nIn Mexico, the mangrove is considered a commonly used asset, although the General Law of National Assets prevents a private or public entity from making use of them; it will require the processing of a concession or assignment, which will never generate real rights, exclusively and without prejudice to third parties; it will only generate the right to use or exploit the assets with the limits set forth by the laws and concession. Revocation of a concession may exist, for example, if fixed constructions are made that damage the present ecosystems. From this regulation, in 1996, the General Law of Ecological Equilibrium and Environmental Protection (LGEEPA) determines, in its Article 28, that the environmental impact assessment procedure should start if works or activities that can be carried out are carried out. A delay can cause ecological imbalances in coastal ecosystems, coastal wetlands, mangroves, lagoons, rivers, lakes, and estuaries connected to the sea. In 2000, the General Wildlife Law was enacted, which excludes timber resources from sustainable use and species whose livelihood is water, if they are considered as species or populations at risk. To consider those species that were considered at risk, in 2001, Official Mexican Standard NOM-059-ECOL-2001 was published, listing the species referred to in the General Wildlife Law. In this Official Mexican Standard the four mangrove species with a national presence (Rhizophora mangle, Avicennia germinans, Laguncularia racemosa, and Conocarpus erectus) are integrated with the status of special protection. In the reform of the Official Mexican Standard (NOM-059-SEMARNAT-2010 [24]) mangrove species are considered as threatned.
\nParallel to these instruments of environmental policy, since 2000, work began on an Official Mexican Standard (NOM) that established the specifications for the preservation, conservation, sustainable use, and restoration of coastal wetlands in mangrove areas; in 2003, when it is published, the NOM refers to a series of provisions that are mandatory for those responsible for carrying out works or activities that are intended to be located in coastal wetlands or whose characteristics may negatively influence them. At the same time, with the enactment of the General Law of Sustainable Forestry Development in 2003, legal uncertainty was created in the protection of mangroves when considering, in Article 28 of its regulation (published in 2005), that the areas with mangrove vegetation are areas of conservation and restricted use.
\nTo give greater legal certainty to the protection of mangroves, in 2007, a reform to the General Wildlife Law was published, Article 60 TER, which specifies that any activity that affects the integrity of the species and its productivity is prohibited, as well as the hydrological flow and environmental services provided by the mangroves [9, 49]. Actions in favor of mangroves in the face of climate change are considered in the General Law on Climate Change published in 2012, which in its Article 26 mentions as the fundamental principle of the Law the conservation of ecosystems and their biodiversity, giving priority to wetlands, mangroves, reefs, dunes, coastal zones, and lagoons, that provide environmental services, fundamental to reduce vulnerability.
\nTo support the protection of mangroves, the government of Mexico, through NOM-022-SEMARNAT-2003 [23], empowers the Federal Environmental Protection Agency (PROFEPA) to monitor the provisions stipulated. PROFEPA has established a policy of inspection and surveillance for the conservation of mangroves in which non-compliance with the provisions of prevention, conservation, sustainable use, and restoration is considered an environmental crime. In turn, the Secretariat of the Navy (SEMAR) through its institutional program for protection, conservation, restoration, and reforestation of the mangrove collaborates in the protection and conservation of the mangrove in places that are outside of some kind of special protection (e.g., that are not within protected natural areas) to diminish their deterioration.
\nIn Mexico there are no regulations for the species Avicennia bicolor Standl and Rhizophora harrisonii Leechm. The International Union for the Conservation of Nature (IUCN) has them in the category of vulnerable species, given that there are only reports of few individuals (without specifying how many) present of these species within the mangrove (dominated by the other species of mangrove), without forming extensive pure masses.
\nThe current situation of the mangroves of Mexico is presented in a favorable context due to the fifth place that occupies worldwide by surface covered in mangrove, the existence of six species whit the representativeness of four of them in the 17 coastal states and they covered 60% of the coastal surface. Although there are threats that can cause loss of mangrove areas, 9.4% in 45 years (70–2015) due mainly to the lack of urban, industrial, and tourist development planning, as well as the advancement of the agricultural frontier and the activities related to aquaculture, there is legislation and regulations for its long-term protection. The protection strategies hitherto employed have yielded good results, although there is still a need for more constant vigilance and not only through programmed operations. In relation to their conservation, the decrees of Natural Protected Areas and Ramsar Sites have under their protection more than 50% of the mangroves of the country; the actions aimed to generate greater decrees of mangrove zones are continued. The support to the rehabilitation and restoration of the mangroves has become a national strategy of government agencies that are related to these communities, including the Secretary of Environment and Natural Resources (SEMARNAT), the National Commission of Natural Protected Areas (CONANP), the National Forestry Commission (CONAFOR), the National Commission for the Knowledge and Use of Biodiversity (CONABIO), as well as decentralized public agencies such as Petroleos Mexicanos (PEMEX) and the Federal Electricity Commission (CFE).
\nThe conservation of mangroves not only ensures the perpetuity of mangrove species but also the species that inhabit or rest in these environments—both at the level of those that are under some risk status and at the level of those that maintain the fishing production of the coastal zones.
\nThe documented material consisted of printed books [9] and information obtained on the Internet concerning the species Rhizophora mangle L., Avicennia germinans (L.) L., Laguncularia racemosa (L.) C.F. Gaertn., Conocarpus erectus L., Rhizophora harrisonii Leechm., and Avicennia bicolor Standl. It was observed that the information obtained through written means is more truthful and reliable than the information obtained via the Internet. The information obtained from the Internet is more practical and easy to find, but when reviewing and analyzing this information we can see a repetition of pages, with the same information but with different authorship for different species of mangroves and in most cases the author of the informative text does not appear (reason why it was discarded).
\nIt should be noted that the most reliable and quoted information was found on websites of other countries, mainly the United States and Australia. In addition, translations from English, French, and Portuguese into Spanish had to be done. On other occasions the original documents of the description of the species had to be reviewed, such as R. harrisonii and A. bicolor, using the search engine Biodiversity Heritage Library (
With the proposed synopsis, we have a broad overview of the systematic and taxonomic information of mangrove species in Mexico, which is not easily found in a single compendium, so that their contribution is of special interest to students of the upper levels, as well as the people who are interested in the topic of mangroves. A thorough investigation was undertaken on the meaning of their scientific names, an exercise that is not very common in the disclosure of species fills that gap of information. The topics of its importance, uses, and protection were approached with the most recent knowledge available, complemented by the authors’ opinions. In relation to the importance of the mangroves, the species that are found listed in irrigation in the NOM-059-SEMARNAT-2010 [24] and that inhabit the mangroves stand out. The uses of mangrove species have not yet been addressed by citizen participation research in which use values are discussed; only references are made in relation to surveys among the inhabitants, and there is a lack of information. Legislation that protects mangroves is effective in the written word, but greater vigilance is needed in their compliance; their conservation strategies are carried out through decrees of Natural Protected Areas and Ramsar Sites but there are still strategic mangrove sites that they must be incorporated. The support granted to the rehabilitation and restoration of the mangroves is used by the inhabitants who adjoin these communities; the non-governmental organizations and the researchers of universities and institutes are to work in favor of this precious resource.
\nPsoriasis is an inflammatory chronic skin disease, affecting over 100 million individuals worldwide [1, 2]. The development of this autoimmune disease depends on a complex interplay of genetic and environmental factors. In the immunological mediated process involved, the epidermal keratinocytes and mononuclear leukocytes lead to the formation of the psoriatic lesion [3, 4]. The peripheral HTA axis of the skin modulates inflammatory mediators in response to stress and stress-related hormones that influence the disease development and the response to treatment. Besides stress, other endogenous factors with impact upon psoriasis are allergies and hormones [5, 6, 7]. Sex hormones and prolactin seem to have a major role in psoriasis pathogenicity, while glucocorticoids, epinephrine, thyroid hormones and insulin may influence psoriasis clinical manifestations [7]. Psoriasis has a multisystemic involvement and it is associated with several comorbid conditions: cardiovascular disease (hypertension, prothrombotic state, and atherogenic dyslipidemia), metabolic syndrome (in which the main pathogenic factor is obesity with risk of developing insulin-resistance), nonalcoholic fatty liver disease and diabetes mellitus [5].
This chapter focuses on the clinical approaches to psoriasis patients that are reliable in practice. Besides describing the current status of psoriasis diagnosis, the chapter focuses on psoriasis comorbidities. The chapter also provides an objective assessment of the main investigation tools: detailed medical history collection (including prior exposure to treatment and evaluation of comedication), the physical examination with a complete check for malignancies before and during psoriasis treatment (including lymphoma and skin cancer, evidence of active and chronic infection: Tuberculosis or Crohn’s disease), the dermatologic assessment with the completion of the objective scales (PASI/BSA/PGA; arthritis scales, completion of DLQI and checking for depression or anxiety signs. The major part of the chapter is devoted to the European Guidelines for special populations of psoriasis patients, that encourage the dermatologist to check for hypersensitivity, metabolic, gastro-intestinal and renal disorders, hepatitis or other hepatological dysfunctions, HIV, neurological and psychiatric diseases, to check also for the need of vaccines and contraception (must be pursued 20 weeks after discontinuation of biological therapy) and to pay attention to females with wish for pregnancy in the near future (pregnancy, breast-feeding, fertility).
We discuss three different categories of evaluation options: pre-treatment, during-treatment and post-treatment. The chapter presents the recommended laboratory investigations in pretreatment and when indicated by medical history or physical examination findings (usually every 2–5 months): blood count (Hb, Htc, leucocytes, platelets, differential blood count), CRP, liver enzymes (ALT, AST, AP, γGT), serum creatinine/eGFR, urine status (including urine pregnancy test in females), as for hepatitis B, C and HIV testing, they are optional only in some cases. Further specific testing may be required according to clinical signs, risk, and exposure.
The chapter also presents the great physical, emotional and social burden generated by psoriasis, (leading to an impaired quality of life that is often similar to that of patients who have heart failure and cancer), suggesting the need of psychological evaluation and support. In this context, we underline the necessity of a complete screening by using precise evaluation tools for the assessment of psoriasis patients.
The medical history section or case history of a patient starts by noting the patients’ gender and age. Psoriasis is considered equally prevalent in both sexes, even if some studies indicated that the disease is more common in men [5]. Psoriasis can occur at any age, but the average age of onset for psoriasis is 33 years and the two peaks of the disease onset are between 16 and 22 years of age and 57–60, respectively [6, 8]. It is important to determine the date/age of onset in order to classify psoriasis according to the date of onset into type I (onset before or at the age of 40, positive family history and frequent association with Human Leukocyte Antigen Cw6, noted HLACw6) or type II (onset after the age of 40, negative family history and normal frequency of the Cw6 allele [9]. Positive family history for psoriasis patients is common in 30% up to 90% of cases, as genetic factors have an important role in the disease susceptibility and expression [10, 11, 12]. Literature findings present a threefold increased risk of developing psoriasis in monozygotic twins compared to fraternal twins [13]. Race of the patient is also important, as psoriasis is more common in Caucasians (3.6%), followed by African Americans (1.9%) and Hispanics (1.6%) [3, 4].
One of the most important things in collecting the information consists of listening to the patient carefully. The dermatologist must identify if other dermatological, autoimmune, endocrinologic diseases, chronic illnesses or psychiatric disorders are present in the past medical history of the patient, and if positive, they should be properly investigated and treated. It is necessary to determine if associated factorsare present, such as: smoking, alcohol intake, metabolic syndrome, lymphoma, depression, melanoma, cardiovascular disease, respiratory disease, diabetes, kidney disease or arthritis. It has been reported that there is an association between smoking and the development of psoriasis (also smoking increases the disease severity), as smoking leads to oxidative stress, which may stimulate chronic inflammation. Some literature data confirm that excessive alcohol intake may be a risk factor for psoriasis development [2].
One should document illnesses prior to the onset of psoriasis or other possible trigger factors in the previous months, such as stress, injury of skin, certain medication, infections which may determine psoriasis onset (streptococcus infection associated with guttate psoriasis onset) or flare-ups (earache, bronchitis, tonsillitis, respiratory infection) and allergies (with low scientific proof) [14]. The patient can usually tell if the onset of psoriasis was correlated to other medical issue or personal event. A study revealed that a recent life crisis was the trigger for plaque psoriasis in more than 45% of the cases, as stress represents the catalyst for the onset and later, the exacerbation of psoriasis [15, 16, 17]. The medication used by the patient should also be taken into consideration, as Lithium, Antimalarial, Inderal, Quinidine, Indometacin may induce psoriasis onset. Co-medication (with CYP3A4 enzyme inducers, warfarin, AINS, etc.) must be assess in order to prevent drug–drug interactions or drug-triggered psoriasis. In most of the cases, the psoriatic lesions are induced by trauma (scratches, insect bites, vaccinations and sunburns) and appear 7 to 14 days after injury, aspect called the Koebner sign or the isomorphic response. Psoriasis lesions can appear at all sites of the skin injury and the lifetime prevalence of the phenomenon ranges between 25 and 75% [18].
Physiological changes, such as childbirth, should be considered, too as psoriasis lesions slowly improve during pregnancy in 60% of the female patients, and if so, the same experience will be found across the next pregnancies. In some cases the stress attributed to childbirth will lead to the development of psoriasis. Postpartum, females will usually face a significant disease flare. More than 50% of the patients have genital involvement, raising discomfort in the delivery and postpartum period. During pregnancy and for breastfeeding patients, the treatment options are unfortunately limited [19]. Other physiological changes such as menopause may affect psoriasis evolution, since dropping estrogen levels lead to psoriasis flares [7]. Some dermatologists consider that hormone replacement therapy during menopause with contraceptives does not affect psoriasis symptoms, therefore they do not recommend it [7].
The dermatologist should also focus on the chronology of the symptoms and complaints, which may include: worsening of a long-term erythematous scaly area, sudden onset of many small areas of scaly redness, pain (long-term rash with recent presentation of joint pain or joint pain with stiffness, pain, throbbing, swelling, tenderness, but without any visible skin findings), pruritus, sometimes fever, a viral infections, dystrophic nails, ocular findings such as redness and tearing due to conjunctivitis or blepharitis [20].
It is also important to assess how much does each of the above bother the patient [6]. The psychological impact of this skin disorder is severe in more than 62% of the patients with psoriasis, especially for those with disfiguring symptoms (scaling, redness etc.) on readily visible portions of the body [21, 22]. Patients with a longer disease history, particularly with the onset during childhood and adolescence, seem to be affected to a higher degree [14].
Next, the dermatologist must find out what type of treatment (topical, systemic therapy and new oral treatment, phototherapy, biological through injection or perfusion, complementary or alternative treatments, etc.) the patients have used until now and with what outcome from their personal point of view. Finding out what type of treatment the patient would prefer, in order to achieve a good patient compliance and disease management with the reduction of symptoms is important, too [23].
The patient will be questioned about the rate of the disease progression and if it has any season pattern. Fewer symptoms and flares have been reported during summer and more during winter times. Psoriasis is an incurable, but treatable chronic condition, and symptoms may vary in severity and occur in cycles: active disease, flare-up, improvement or remission [24]. Patients should be asked if they can avoid some of the triggers, in order to reduce flare frequency and extend remission periods, which are common in almost half of the psoriasis population. Psoriasis is an unpredictable disease and spontaneous remission (without treatment) has been observed in some individuals [25].
Psoriasis lesions consist of red, inflamed patches of skin with erythematous macules, that progress into maculopapules and well-demarcated, noncoherent, raised plaques with white micaceous scale, overlying a glossy homogeneous erythema [1, 2, 3, 4, 5]. The dry flakes of skin scales result from the excessively rapid proliferation of skin cells triggered by inflammatory responses, the rapid overproduction leading to the buildup of skin cells.
Lesions may vary in size (from pinpoint papules to large plaques) and in distribution, but are usually found symmetrical on the scalp, postauricular skin, elbows, back, gluteal cleft, and knees. Clinical findings are variable among patients and can change quickly within the same patient [18]. Even after plaques have cleared, permanent dyschromia may be present. Literature reports state that the most common symptoms of psoriasis include: scaling of the skin in non-scalp areas (92% of cases), itching (72%), erythema (69%), fatigue (27%), swelling (23%), burning and bleeding (20% of the individuals) [26]. Another study found rash (74% of cases), skin pain and scaling of scalp areas (62%), flare-ups (49%), joint pain of swollen, stiff joints (42%), skin cracking (39%), dry skin that may bleed or ooze (34%), physical discomfort (32%) and nail modifications (thick, ridged nails in 22% of patients) [27].
The diagnosis of psoriasis is clinical. Pinpoint bleeding caused by removing the scale is called the Auspitz sign and represents the dilated capillaries below the epidermis and thinned suprapapillary plate. A hypopigmented ring on the periphery of an individual plaque, called Woronoff ring, may occur after treatment with UV radiation or topical steroids and is associated with lesional clearing and good prognosis [18].
Besides examining the patient’s skin and scalp for psoriasis lesions, the dermatologist should also check the nails, oral mucosa and tongue for specific signs of psoriasis.
Findings on physical examination depend on the type of psoriasis present: Plaque Psoriasis, Pustular Psoriasis, Erythrodermic Psoriasis, Guttate psoriasis, Inverse Psoriasis or others including Scalp psoriasis and Nail psoriasis. The area of the skin involvement varies with the form of psoriasis. Psoriasis has a common etiology underlying diffuse erythroderma, or exfoliative dermatitis.
Classic plaque psoriasis also called chronic stationary psoriasis or psoriasis vulgaris is the most common type of psoriasis, affecting 58–97% of patients [28, 29]. It is characterized by inflammatory red, sharply demarcated, raised, dry, differently sized erythematous plaques covered by thick silver or white scale and variable shape or diameter with a predilection for scalp and retroauricular regions, extensor surfaces (especially elbows and knees), trunk and lumbosacral area.
Pustular psoriasis presents as clearly defined, raised, small, coalescing pustules, filled with non-infectious pus, appearing generalized (diffusely over the body as a single episode, called von Zumbusch variant, accompanied by fever and intense ill feeling) or localized to the distal extremities (palms, fingertips, nails and soles of feet, called Acrodermatitis continua of Hallopeau). Pustular psoriasis affects between 1 and 12% of cases, and patients may cycle through erythema, pustules, then scaling [29, 30].
Erythrodermic psoriasis typically occurs in 0.4–7% of cases, in people with unstable plaque psoriasis and presents as a deep red rash all over the body, with burned look skin and shedding of skin in sheets, instead of small scales with severe pain and itching. It may be accompanied by fluctuating body temperature (fever, chills, hypothermia), dehydration secondary to the large body surface area involvement, fluid retention with ankle swelling. It represents a potentially life-threatening situation, as the patient may experience cardiac instability and hypotension due to massive vascular shunting in the skin, and may pneumonia [29, 30].
Guttate psoriasis is characterized by small red 1–10 mm in diameter drops-like papules and plaques, predominately on the trunk, arms and legs. It classically appears suddenly in 0.6–20% of patients in childhood or adolescence, approximately 2–3 weeks after a streptococcal infection of the upper respiratory tract or other infection [29, 31].
Inverse or intertriginous psoriasis affects 12–26% of patients and it is characterized by smooth, flat, deep-red or white, inflamed lesions wet patches or plaques without scaling, due to the moist nature of the areas affected: flexural skin folds, axillae, antecubital fossae, inframammary creases, umbilicus, groins and genital area, gluteal cleft, popliteal fossae or body folds [30, 32].
Scalp psoriasis affects approximately 50% of patients and is characterized by erythematous raised plaques with silvery white scales on the scalp. Severe forms may induce sever dandruff and itching, even hair loss [33].
Nail psoriasis occurs in 4–69% of psoriasis patients and may cause pits on the nails and oil spots (specific findings, caused by exocytosis of leukocytes beneath the nail plate), also generating a thickened and yellowish nail, that can be confused with nail fungus [34]. Onycholysis can occur due to the parakeratosis of the distal nail bed, and one or more nails can associate with severe nail destruction or loss, restricting manual dexterity [5]. Psoriatic nails develop onychomycosis or bacterial infections in 4–30% of the cases, because of the nail separation and subungual debris [31, 35]. Patients with nail psoriasis have significantly higher psoriasis severity scores, days unfit to work and lower quality of life (QoL) compared to those without nail involvement [36].
Oral psoriasis may present with whitish lesions on the oral mucosa, changing daily in severity and can trigger different symptoms (oral pain, burning or change in taste perception) that resemble other conditions affecting the mouth and lips, such as stomatitis, oral thrush, or chronic eczema. It may also present as severe cheilosis with extension onto the surrounding skin, crossing the vermillion border. Psoriasis patients may be prone to develop the geographic tongue (unpainful red areas of varying size surrounded by a white border, appearing on the top and sides of the tongue), considered to be an oral form of psoriasis [37].
Most cases of psoriasis are diagnosed clinically, but some pustular forms are difficult to recognize. Punch biopsy of the skin may act as a confirmatory workup procedure for atypical cases and exclude other conditions in cases of diagnostic uncertainty: atopic dermatitis (eczema), tinea corporis (ringworm), pityriasis rosea or rubra pilaris, seborrheic dermatitis, etc. Biopsy of acral skin may be less useful for the clinician as chronic eczematous dermatitis may be psoriasiform, while psoriasis of the palms and soles may show spongiosis more often associated with eczema [38].
After local disinfection with alcohol, iodine or similar solution, the local anesthesia is usually performed with 1% lidocaine with epinephrine. After a wait time of 10 minutes (for maximum vasoconstriction), the punch tool (a 4 or 6 mm-punch biopsy for vertical sectioning) is placed on top of the skin. The pressure is applied until the sampling goes down to subcutis, then with the help of a needle tip, the excised skin is removed. The skin defect can be closed with classic stitches (removed in 10–14 days) or dissolving stitches (dissolving in 6–8 weeks), still in most of the cases the wound is left open.
Another method that can be used is the shave biopsy. A thin sliver of skin is shaved off using a very sharp blade, causing some bleeding. The dermatologist will apply pressure to the area, apply a dressing and sometimes a topical medicine [39].
Biopsy of the skin lesion may reveal basal cell hyperplasia, proliferation of subepidermal vasculature, absence of normal cell maturation and keratinization, neutrophils aggregation in the epidermis.
The following histologic dermal findings are present:
signs of inflammation throughout the dermis
marked hypervascularity and enlarged dermal papillae
an activated CD3+ lymphocytic infiltrate around blood vessels
neutrophils aggregation in the dermis that extends up into the epidermis
The histologic epidermal findings include the following:
Mitotic activity of basal keratinocytes is increased almost 50-fold, with keratinocytes migrating from the basal to the cornified layers in only 3–5 days rather than the normal 28–30 days. Stratum corneum contains flattened nuclei (parakeratosis).
Abnormal keratinocyte differentiation throughout the psoriatic plaques is manifested by the loss of the granular layer.
The epidermis becomes thickened or acanthotic and the rete ridges are increased in size. The epidermis can be variably spongiotic.
Two findings are pathognomonic for psoriasis and can be found in active plaque psoriasis, also in the pustular form:
Besides skin, nails and mucosa assessment in psoriasis patients, an eye and joints checkup should also be performed. Screening is needed for the most common psoriasis comorbidities: cardiovascular disease (hypertension, prothrombotic state, atherogenic dyslipidemia), metabolic syndrome (central obesity, atherogenic dyslipidemia, systemic arterial hypertension, insulin resistance), type 2 diabetes mellitus, nonalcoholic fatty liver disease. Long-term monitoring is indicated and it is specific for the type of psoriasis treatment applied: screening for cancers (skin cancers after phototherapy and lymphomas after systemic treatment with immune-suppressing medications), screening for active and chronic infections (Tuberculosis or Crohn’s disease after biologic treatment), screening for liver disease (in systemic treated patients with methotrexate), and kidney disease etc.
Ocular findings are common in 10% of patients, and the skin is usually affected first and afterwards the lid, conjunctiva and cornea. Blepharitis is the most common ocular finding in psoriasis patients, followed by dry eyes with lower incidence. Blepharitis is diagnosed by clinical examination, slit-lamp examination or swabbing the skin for bacterial and fungic testing.
Psoriasis may determine madarosis, cicatricial ectropion and trichiasis, even loss of the lid tissue, chronic nonspecific conjunctivitis (pink eye) and conjunctival hyperemia, and corneal dryness with a frequent punctate keratitis (inflammation of the cornea) and corneal melt [42, 43].
Acute anterior uveitis is usually associated with psoriatic arthritis and tends to be bilateral, prolonged, and more severe than nonpsoriatic cases. Diagnostic of acute anterior uveitis is challenging and it is performed based on clinical aspect, examination with slit-lamp (white blood cells accumulate in the fluid filled space in the front of the eye, in the anterior chamber) and basic workup for syphilis and sarcoidosis testing, for HLA-B27, tuberculosis or viral etiology screening (herpes simplex, herpes zoster, cytomegalovirus) [44].
Psoriatic arthritis affects approximately 10–30% of psoriasis patients and is characterized by stiffness, pain, throbbing, swelling, tenderness of the joints and progressive joint damage. Peripheral arthritis, spondylitis, enthesitis (inflammation of the sites where tendons insert into the bone), arthritis in the fingers and dactylitis (profuse swelling of the fingers or toes) are the most common manifestations.
The large joints are occasionally affected, but the distal joints, such as the fingers, toes, wrists, knees, and ankles are most often involved. In more than 20% of the cases, arthritis symptoms occur before the psoriasis ones [2].
Psoriasis severity and certain locations (the scalp and intergluteal and/or perianal region) have been associated with the development of psoriatic arthritis (PsA) [45]. Also, a retrospective study from 2014 on more than 4000 patient’s reports that nail involvement in psoriasis was a significant predictor of the patient also having psoriatic arthritis [46]. Earlier age of onset of psoriasis had a positive correlation with the development of PsA, suggesting that the disease duration and inflammatory burden over time have an important part [47]. Arthritic changes cannot be reversed and may be may be mutilating and debilitating, suggesting the need of early treatment initiation. Patients who suffer also of osteoarthritis or rheumatoid arthritis of the finger joints have a higher risk to develop arthritis mutilans, in which bones are resorbed, leading to a collapse of the soft tissue (telescopic fingers of the hands).
Radiographs of affected joints can facilitate the diagnosis of psoriatic arthritis. Bone scans usually identify early joint involvement. Arthritis patients must be periodically screened with review of systems and physical examination and imaging tests.
The differentiation of psoriatic arthritis from rheumatoid arthritis and gout can be facilitated by the absence of the typical laboratory findings of those conditions and the radiographic aspect of the affected joints. Overlap with other arthritic syndromes is also possible.
The risk of cancer in patients with psoriasis remains a cause of special concern. The risk of carcinogenesis can occur due to the chronic inflammatory nature of psoriasis, the type of treatment applied (past immunosuppressive therapies such as MTX and cyclosporine immune-suppressive, PUVA or phototherapy), the increased prevalence of comorbid and other risk factors for cancer (smoking and obesity) [48, 49].
Cutaneous malignancies (melanoma and non-melanoma skin-cancer) seem to be directly related to phototherapy performed by the psoriasis patients. A significantly increased risk for SCC and BCC was detected in psoriasis patients treated with higher doses of PUVA compared to lower doses [52]. Scientists suggested that this malignancy risk can be decreased by using sunscreen or trying to stay out of the sun, and cease smoking, a risk factor for both psoriasis patients and skin cancer. Malignancy records for psoriasis patients also mention the development of leukemia, prostate, pancreatic, breast and colon cancer.
Latest data suggests patients with more severe psoriasis have an increased risk of cancer-related mortality, this association being the strongest for lymphoproliferative malignancies and cutaneous malignancies [50, 51]. The increased risk is likely linked to male gender, advancing age or COPD in patients with psoriasis arthritis [53].
Even though long-term control trials and observational studies are still needed, the addition of malignancy as a potential adverse event has been added in the medication packaging of biological therapies [48, 54]. Specific medications have raised concern in concurrent use, being suspected to increase the risk of malignancy: the addition of a biologic agent to potent immunosuppressive treatments, also the use of AZA, 6-MP, cyclosporine, or cyclophosphamide with TNF blockers [48]. According to published guidelines, a history of lymphoma, represents an absolute contraindication to TNF-antagonist therapy, while biologic therapy is contraindicated in patients with an active or recent (within 5 years) history of malignancy, with the exception of treated nonmelanoma skin cancers.
For cutaneous malignancy detection, skin self-examination would be the first step, followed by complete skin examination performed by the dermatologist, with the use of dermoscopy and histopathological results confirmation after excision of the lesion.
For both Hodgkin and non-Hodgkin types of lymphoma, a specific screening test is not available and for a definitive diagnosis a biopsy is required. For leukemia, no screening test is available, but the condition may be detected through a Chest X-ray or CAT scan (showing swollen lymph nodes or signs of infection), Spinal tap (presence of leukemia cells in the cerebrospinal fluid), Bone marrow aspiration and biopsy from the hip bone (the existence of leukemia cells in the bone marrow).
The lung cancer screening is recommended to be performed each year by Low-dose helical or spiral computed tomography (CT) scan. to people aged 55 to 80 who have smoked for 30 pack years or more or who have quit within the past 15 years. People who routinely used tobacco products and/or drink alcohol should receive general health screening examination at least once a year for the detection of head and neck cancer.
Breast cancer screening should start with the patient’s self-examination, followed by clinical breast examination and mammography over the age of 45 years old, and in some cases magnetic resonance imaging is used.
Screening and diagnostic of prostate cancer is recommended over the age of 50 years old and it is performed by digital rectal examination and prostate-specific antigen test.
According to the latest recommendations, for patients over the age of 50 years old, colorectal cancer screening primary tests should be used (guaiac-based fecal occult blood test or fecal immunochemical test every year), followed by flexible sigmoidoscopy every 5 years or colonoscopy every 10 years [54].
Mild to serious secondary infections can occur directly related to the immune-suppressing medication during psoriasis treatment.
People with HIV seem to be more likely to develop psoriasis. Clinical observation suggests that HIV-1 infection can trigger new-onset psoriasis or exacerbate existing psoriasis. As HIV-1 infection progresses and CD4+ T cell counts decrease, psoriasis can worsen. According to the Centers for Disease Control and Prevention HIV screening should be performed at least once by patients over 13 years old and pregnant women and more often for people with risk factors such as: having unprotected sex with positive or unknown HIV status subjects or multiple partners, injecting drugs and sharing needles, syringes, etc. There are three testing methods for HIV: antibody tests (detect HIV infection from blood or saliva about 3 to 12 weeks from the time of infection), combination tests (antibody/antigen tests detect HIV infection from blood about 2 to 6 weeks from the time of infection) and the very expensive nucleic acid tests (NATs) (detect HIV infection from blood sample about 7 to 28 days from the time of infection). The combination of two methods is highly accurate and recommended for all patients.: if antibodies are detected by initial ELISA method testing, the second test will be performed using the Western blot procedure [55].
Literature data indicate that immunosuppressive and immunomodulatory therapies for psoriasis and psoriatic arthritis are risk factors for allowing latent TB to transform into active TB in some patients. The consensus statement from 2008 of the National Psoriasis Foundation recommended all patients to be screened for latent TB infection prior to initiating any immunologic therapy with systemic and biologic agents, also recommended that delaying immunologic therapy should be performed until latent TB infection prophylaxis is completed [56].
Dermatologists should also screen psoriasis patients for hepatitis B virus (HBV) using triple serology testing: hepatitis B surface antigen, hepatitis B surface antibody, and hepatitis B core antibody, before beginning treatment with tumor necrosis factor (TNF) inhibitors or biologics (including ustekinumab and secukinumab), according to the latest recommendations.
If the patient is at risk for reactivation of HBV, liver function tests, hepatitis B surface antibody, hepatitis B core e antigen, and HBV DNA should also be tested. Routine follow-up with testing for reactivation should continue for at least 6 months after the TNF inhibitor is discontinued. In case of patients suffering of chronic HBV for whom biologics are considered, etanercept is recommended as first-line therapy [56].
As far as the systemic treated patients with methotrexate are concerned, the screening should be made in order to evaluate the liver injury. Besides the liver function tests, the liver biopsy was performed, but it was associated with significant morbidity and mortality. A recent Australasian position statement recommends transient elastography (which measures the speed of shear waves used to estimate hepatic tissue stiffness) for monitoring methotrexate therapy, repeated every 3 years if kPa < 7.5 and yearly if kPa > 7.5 [57].
The association of psoriasis with kidney disease in recent studies expands the list of bodily systems that psoriasis is affecting beyond the skin. The kidney seems to be both a target of classic cardiovascular risk factors and susceptible to the toxic effects of psoriasis traditional drugs. Medication such as cyclosporine and methotrexate may have contributed somewhat to the increased frequency observed [58].
Moderate to severe psoriasis, affecting over 20% of patients worldwide has been linked to a higher risk of kidney disease. The analysis performed on 143,883 psoriasis medical records in the United Kingdom concluded that severe psoriasis subjects were twice as likely to acquire chronic kidney disease compared to those with mild psoriasis or no psoriasis at all. Latest reports show that psoriatic arthritis is an independent predictor of renal damage in patients with psoriasis [59].
Several studies demonstrated a greater incidence of proteinuria and elevated creatinine in patients suffering from psoriasis [60]. Patients with psoriasis and/or psoriatic arthritis, particularly when they are candidates for systemic therapy, should be screened for an underlying renal damage by laboratory tests including glomerular filtration rate and a simple urine test to screen for albuminuria (albumin/creatinine ratio).
Gastrointestinal disease screening is indicated in patients with decreased growth rate, unexplained weight loss, or symptoms of inflammatory bowel disease. Celiac disease, sclerosis and the inflammatory bowel disease (Crohn’s disease) are autoimmune disorders, which may be present in psoriasis patients.
In Celiac disease, an autoimmune gluten-induced bowel disease, the small intestine is affected, leading to gastrointestinal manifestations (diarrhea and steatorrhea, weight loss) and malabsorption-related problems (folic acid, calcium, vitamin D and selenium malabsorption, cooper and zinc deficiencies, iron deficiency or megaloblastic anemia) [61]. Celiac patients have an increased risk of developing adenocarcinoma and lymphoma of the small bowel. Screening for Celiac disease is performed with anti-transglutaminase and anti-endomysial antibodies, both having high sensitivity to diagnose patients with classic symptoms and complete villous atrophy and also 50% of the patients with minor mucosal lesions with normal villi. Professional guidelines recommend that a positive blood test must be followed by endoscopy/gastroscopy and biopsy. Checking total serum IgA level is also indicated and if negative, anti-DGP antibodies (antibodies against deamidated gliadin peptides) should be determined [62].
Crohn’s disease, a type of inflammatory bowel disease (IBD), may affect any part of the gastrointestinal tract and presents gastrointestinal, systemic and extraintestinal manifestation. The diagnosis of Crohn’s disease can sometimes be challenging and may take several years. A colonoscopy with a biopsy is the recommended test for diagnosis and it is approximately 70% effective in diagnosing the disease [63]. It allows direct visualization of the colon and the terminal ileum, identifying the pattern of disease involvement and presentation: stricturing, penetrating or inflammatory type. Modern investigation options of the small-bowel disease are the computed tomographic enteroclysis (hybrid technique that combines the methods of fluoroscopic intubation-infusion small bowel examinations with that of abdominal CT) and the capsule endoscopy, with a specific role in the investigation of Crohn disease. Blood determinations for anemia or infections are recommended, as well as a total blood count, erythrocytes sedimentation rates, body mineral levels and protein levels determination. Stool samples are checked for occult blood loss or infectious microbes. Expert guidelines do not currently recommend antibody or genetic testing for Crohn’s disease, but the Saccharomyces cerevisiae antibodies (ASCA) and antineutrophil cytoplasmic antibodies(ANCA) are used to identify inflammatory diseases of the intestine and to differentiate Crohn’s disease from ulcerative colitis [64].
Folate or acid folic deficiency represents the deficiency of B9 vitamin, vital for proper nerve function and preventing birth defects, also normalizing the high levels of homocysteine, which can increase the risk of heart disease. Folate deficiency is common in subjects with celiac disease or Crohn’s disease. Patients with severe psoriasis seem to have a higher risk of developing folate deficiency [65]. The mechanism is believed to be an impaired absorption of folate and an excess loss of folate in the skin scales of patients suffering from psoriasis and mycosis fungoides [66]. In the screening of acid folic deficiency, ruling out cobalamin deficiency (vitamin B12) is important, as both cause megaloblastic anemia and neurologic manifestations, the serum folate level cannot be used alone to establish the diagnosis of folate deficiency. Additional follow-up tests include serum homocysteine (which is elevated in vitamin B-12 and folate deficiency) and serum methylmalonic acid (which is elevated in vitamin B-12 deficiency only). A recent study pointed out that 75% of the psoriasis patients treated with methotrexate in UK receives folic acid supplementation. Literature confirms a reduction in the adverse effects of MTX, but it questions if this may impact efficacy [67].
Patients with psoriasis have a higher risk of developing Parkinson’s disease probably due to the detrimental effect of chronic inflammation on the neuronal tissue [68]. Risk factors for this association from FDA reports would be: male gender, age over 60 years old, previous Azilect treatment and presence of high blood pressure. Latest findings suggest that an immune response to alpha-synuclein proteins (which accumulate inside the brain of Parkinson’s disease patients) play a role in the disease, suggesting an autoimmune etiology. Diagnosis of Parkinson disease is challenging because of the highly variable clinical aspect and lack of reliable objective test. Still it is the updated diagnostic criteria that must guide the clinician [69].
Polycystic ovary syndrome (PCOS) in female psoriasis patients has a remarkably higher prevalence than in age- and BMI-matched control women. Women who present both PCOS and psoriasis are more likely to have insulin-resistance, hyperinsulinemia, reduced HDL cholesterol levels and a more severe degree of skin disease, compared to patients who suffer only of psoriasis. Similar to psoriasis, the components of metabolic syndrome seem to be closely related to PCOS as well. The ovulatory phenotype of the disease seems to be associated with milder psoriasis forms, while the phenotypes with oligoamenorrhea with higher severity scores of disease [70].
For PCOS screening and diagnosis two of the following criteria are sufficient: oligo- or anovulation, biochemical or clinical hyperandrogenism, and polycystic ovaries on ultrasound examination [71].
Genetic susceptibility, inflammatory pathways and common environmental factors (tobacco smoking, alcohol consumption, psychological stress and low physical activity) are responsible for the development of psoriasis and metabolic comorbidities. These disorders share similar pathophysiological phenomena: chronic inflammation with high production of pro-inflammatory cytokines (especially TNF-alpha, IFN-gamma, IL-1, IL-2, IL-6, IL-8 and IL-17) that induces angiogenesis, adipogenesis, oxidative stress, insulin signaling, lipid metabolism and immune cell traffic [72, 73]. Metabolic aspects of chronic inflammation Th-1/Th-17 in psoriasis would have a role of predisposition and reciprocal aggravation on other conditions, such as obesity, diabetes and atherosclerosis [74].
Literature data prove in large observational studies the association of psoriasis to increased prevalence of metabolic syndrome, as well as its individual components: central obesity, atherogenic dyslipidemia, hypertension and insulin resistance [75, 76]. Severe psoriasis cases present higher chances for the development of metabolic syndrome, compared to mild forms of the disease [77].
Obesity or weight gain has been shown to be an independent risk factor for psoriasis. As obesity is also associated with reduced efficacy of psoriasis treatment, weight loss intervention programs should be included in psoriasis management.
Latest review on the topic emphasize the critical need for providers to screen psoriasis patients for cardio metabolic diseases, using the criteria abdominal circumference (>102 cm in males, >88 in females) plus two of the following: low HDL-cholesterol (<40 mg/dL men, <50 mg/dL in women), hypertriglyceridemia (≥150 mg/dL), high blood pressure (≥130/85 mmHg) or high fasting glucose (≥110 mg/dL). The guidelines recommend annual measuring of waist circumference, quarterly determination of fasting lipids and glucose, monthly measurement of weight, body mass index and blood pressure. Screening is useful in patients with risk factors: female gender, advancing age, illiteracy, unemployment, positive family history, obesity and a sedentary lifestyle [78].
It is believed that fat cells in psoriasis patients secrete cytokines that raise insulin resistance in the liver and muscle, which initiates the destruction of the insulin-producing beta cells in the pancreas [79].
Several observational studies have investigated the association between diabetes mellitus type 2 and psoriasis or psoriatic arthritis(PsA). The highest risk for diabetes mellitus type 2 was detected for patients suffering from PsA Literature data indicated a dose effect in the risk of suffering from type 2 diabetes mellitus, as patients having severe psoriasis had higher risk [80].
Screening of patients for diabetes mellitus type 2 is recommended annually in.
patients over 45 years or in patients younger than 45 years with major risk factors (positive family history, overweight, high blood pressure, etc.), and every 3 years for obese patients regardless of risk factors. Guidelines recommend a diagnostic of diabetes mellitus to be established with: single random plasma glucose level ≥ 200 mg/dL plus typical symptoms of hyperglycemia, while determinations should be repeated on the next day for the following situations: a fasting plasma glucose level ≥ 126 mg/dL; an A1C level of 6.5% or greater; a random plasma glucose level ≥ 200 mg/dL; a 75-g 2-hour oral glucose tolerance test with a plasma glucose level ≥ 200 mg/dL [81].
Psoriasis seems to be associated with cardiovascular and metabolic comorbidities, particularly in young patients and patients with more severe forms of the disease. Psoriasis patients have a twice as high risk to develop a cardiovascular disease, maybe due to the increased burden of subclinical atherosclerosis and vascular inflammation [76]. Psoriasis seems to be associated with atrial fibrillation and stroke, which may be aggravated in young patients. Studies noted significantly higher levels of serum lipids, including triglycerides and total cholesterol in psoriasis patients compared to healthy controls [82].
For screening of cardiovascular diseases (coronary artery disease being the most common heart disease) the completion of the Framingham 10 Year Risk of General Cardiovascular Disease Score and the dosing of the following parameters are necessary: LDL cholesterol and HDL cholesterol (every 4–6 years for normal risk patients), blood glucose level (start annual screening at 45 years old if normal weight or at 40 years old if obese) and amount of high-sensitivity C-reactive protein (used for those with intermediate risk, up to 20%, of having a heart attack within the next 10 years), blood pressure level determination (every 2 years if values are under 120/80 mmHg). Additional testing is required in the presence of risk factors (increased cholesterol, increased high blood pressure, diabetes, obesity, cigarette smoking, family history of premature disease in a first-degree relative) and it includes: electrocardiography (ECG), exercise cardiac stress test, echocardiography, coronary CR angiography, etc.
Observational studies suggest that patients with psoriasis are up to threefold.
more likely to have fatty liver disease over controls. An explanation could be the fact that proinflammatory adipokines or skin-derived cytokines may lead to insulin resistance and hepatic lipid accumulation [83].
Patients with nonalcoholic fatty liver disease and psoriasis have more severe skin disease and are at higher risk of severe liver fibrosis than patients without psoriasis.
The risk was significantly correlated with obesity, insulin resistance, and metabolic syndrome and psoriatic arthritis [84].
As nonalcoholic fatty liver disease causes no symptoms in most cases, it is frequently diagnosed without this certain purpose. Liver screening includes liver enzyme and liver function tests, tests for chronic viral hepatitis (hepatitis A, hepatitis C and others), plain ultrasound showing steatosis. A liver biopsy is necessary in order to distinguishing NASH from other forms of liver disease. Non-invasive diagnostic tests are available: FibroTest for estimating liver fibrosis and SteatoTest for estimating steatosis [85].
It is well known that the nervous system, the endocrine system and the skin have the same embryological origin, from the ectoderm [86]. Also, the function and the normal development of the skin are influenced by hormones, among them sex hormones, thyroid hormones or stress hormones [87]. Literature data present different endocrine conditions in association with psoriasis onset or exacerbation. Thus, a complete assessment of psoriatic patients should be performed, in order to identify concomitant disorders that can sustain or trigger psoriasis.
The involvement of sex hormones in psoriasis was taken into consideration due to the fact that the incidence of this chronic disease is higher in time periods characterized by hormonal imbalance, such as puberty, postpartum or menopause [88, 89, 90].
Thus, a significant correlation was found by Murase et al. between estradiol and psoriasis body surface area (BSA), with the improvement of the disease during pregnancy [7]. Also, a cohort study, published in 2016, suggested a possible association between hormonal imbalance, induced by irregular menstrual cycles or surgical menopause, and psoriasis risk in women [91].
Testing the level of estradiol in male patients with psoriasis, Cemil et al. found an inverse correlation between the severity of the disease, evaluated by PASI score, and the level of hormones [92].
This pituitary hormone involved in reproduction and lactation exerts immunomodulatory effects also, being considered a member of type I cytokine family [93]. Several observations that sustain the role of PRL in psoriasis pathogenesis are linked, first, with the exacerbation of the disease due to prolactinoma development, secondly, with lesions remission in the context of bromcriptine administration, a dopaminergic inhibitor of PRL secretion [87].
The level of PRL in psoriasis patients was assessed in different studies and compared with controls. The correlation with PASI score was also evaluated, but the results were contradictory, as it is shown in the first meta-analysis regarding this topic. However, the conclusions of this recent study sustain the significantly increased level of PRL in psoriasis patients compared to controls and the positive association with PASI [94].
The involvement of thyroid hormones in skin homeostasis is suggested by the variety of modifications associated with thyroid disorders, whether hyperthyroidism or hypothyroidism. Moreover, literature data confirm the presence of thyroid hormones receptors in the skin and the stimulatory effect upon epidermal growth factor, with the consequent keratinocytes hyperproliferation [95].
Thus, in several studies, an evaluation of thyroid function was performed in patients with psoriatic disease. Among these studies some case reports suggest the benefits of antithyroid drugs (e.g. propylthiouracil) in psoriasis evolution, or resolution of the disease after thyroidectomy [87].
Recent data presented a higher incidence of new cases of thyroid disorders (small thyroid, positive antithyroidperoxidase antibody-AbTPO, hypothyroidism) in patients with psoriatic arthritis, particularly in women, compared to control group. The females at risk are those with a level of thyroid-stimulating hormone (TSH) at the superior limit of the normal range, positive AbTPO or a small volume of thyroid gland [96]. The association between autoimmune thyroid disease and the prevalence of psoriatic disease was also suggested as a conclusion in a meta-analysis from 2017, due to Th1 immune predominance and high circulating levels of CXCL10 [97].
Stress is one of the major factors that may trigger/exacerbate psoriasis lesions. The mechanisms include the activation of hypothalamic–pituitary–adrenocortical (HPA) axis and the sympathoadrenomodulatory system (SAM), with the consequent release of proinflammatory cytokines. Cortisol is an indicator of HPA activity. In patients with psoriasis the cortisol response to stress is lower than in controls [87]. Also, they present increased levels of epinephrine and adrenocorticotropic hormone, which seem to be involved in maintaining and exacerbation of psoriasis lesions [98]. Moreover, the cutaneous glucosteroidogenesis is also defective in patients with psoriasis, which favors the specific clinical aspect of the lesions [99].
For psoriasis severity assessment, more than 40 different tools have been used. Commonly used measures by the dermatologist include: the Psoriasis Area and Severity Index (PASI), body surface area (BSA), the Physician Global Assessment (IGA) or the simplified Lattice-System Physician’s Global Assessment (LS-PGA) and The Nail Psoriasis Severity Index (NAPSI) [100]. The patients can also assess the disease, using the Self-Administered PASI (SAPASI). Unfortunately, none of the currently published severity scores for psoriasis meets all the criteria required for an ideal score, and for a reliable assessment of psoriasis severity several independent evaluations are performed simultaneously [101].
Mild psoriasis is considered if it covers less than 3% of the body, moderate form, if 3–10% of the body has psoriasis lesions, and severe if psoriasis lesions are present on more than 10% of the body. Disease severity cohorts were categorized based on PASI severity scores as follows: mild disease with PASI up to 5, moderate form with PASI score from 5 to 12, severe form between 12 and 20 PASI score, very severe over 20.
PASI represents the most widely used tool for the measurement of the physical extent and severity of the disease (higher PASI scores indicate more severe psoriasis).PASI calculation consists of two major steps: calculating the BSA covered with lesions and the assessment of the lesions severity. The affected area and lesion characteristics generate a score from 0 to 72.
The amount of disease (BSA covered with lesions) is estimated by determining what percentage of the skin on a person’s body is affected, with the size of the palm of the hand equal to about 1 percent of the skin. The body of the patient is divided into four sections, each scored by itself: head (H) -representing 10% of the skin surface, arms (A) (20%), trunk (T) (30%), legs (L) (40%). For each section, a grade from 0 to 6 is attributed for the percent of skin involved: 0—0% involvement, 2—less than 10%, 3—between 10 and 29% of involved area, 4—between 30 and 49%, 5—between 50 and 69%, 6—between 70 and 89%, 7—between 90 and 100%.
Within each area, the lesions severity is estimated by: erythema (redness), induration (thickness), desquamation (scaling), the severity of each parameter are noted on a scale from 0 (none) to 4 (maximum). The sum of all three severity parameters is then calculated for each section of skin, multiplied by the area score for that area, then multiplied by the weight of respective section (0.1 for head, 0.2 for arms, 0.3 for body and 0.4 for legs) [101, 102].
PASI scores are used at baseline for entering a trial, and at follow-ups, to assess treatment efficacy and outcomes, usually expressed as a percentage response rate; for example, PASI 50, PASI 75, PASI 90, PASI 100. The PASI assessments were found to be non-reproducible and it was noticed that the physician’s estimations of the psoriatic lesion area tended to be overestimated.
The modified PASI which involves the computerized measurement of the area on the digital photograph is called Computer aided psoriasis continuous area and severity scores (cPcASI) and was successfully used in several clinical trials [103].
Physician Global Assessment (PGA) is also called Investigator Global Assessment (IGA) and represents a 5 or 6-point ordinal rating scale, ranging from clear to severe psoriasis.
Score 0 means Cleared psoriasis, with no plaque elevation, erythema or scaling, but hyperpigmentation may be present. Score 1 means Minimal psoriasis, with minimal plaque elevation (=0.25 mm), faint erythema, minimal scaling with occasional fine scale over <5% of lesion. Score 2 means Mild psoriasis with mild plaque elevation (−0.5 mm), light red coloration, fine scales predominates. Score 3 means Moderate psoriasis with moderate plaque elevation (=0.75 mm), moderate red coloration, coarse scale predominates. Score 4 means Marked psoriasis, with moderate plaque elevation (=1 mm), bright red coloration, thick, nontenacious scales predominates. Score 5 means Severe psoriasis, with severe plaque elevation (>1.25 mm), dusky to deep red coloration, very thick and tenacious scale predominates [101, 102].
Nail Psoriasis Severity Index (NAPSI) represents a numeric, reproducible and objective tool used to evaluate the severity of nail bed psoriasis and nail matrix psoriasis by area of involvement in the nail unit., which is divided into quadrants by imaginary longitudinal and horizontal lines. The Nail plate is assessed for nail matrix psoriasis by the presence of: nail pitting, leukonychia, red spots in the lunula, and crumbling in each quadrant of the nail. The nail bed psoriasis is assessed by the presence of: onycholysis, oil drop (salmon patch) dyschromia, splinter hemorrhages, and nail bed hyperkeratosis in each quadrant of the nail. Score 0 means the findings are not present, Score 1 means they are present in one quadrant of the nail, Score 2 if present in two quadrants of a nail, 3 if present in three quadrants of a nail, and 4 if present in four quadrants of a nail. Each nail has a matrix score (0–4) and a nail bed score (0–4), and the total nail score is the sum of those two individual scores (0–8). The sum of the total score of all involved fingernails is the total NAPSI score of the psoriasis patient [104].
Accurate and reliable methods are needed to measure disease activity, progression, and change with therapy in psoriatic arthritis (PsA). Some evaluation tools have been developed specifically for PsA, while others were borrowed and adapted from the fields of rheumatoid arthritis, ankylosing spondylitis, and psoriasis. Key domains of interest for psoriasis arthritis assessment are joints, skin, enthesitis, dactylitis, spine, joint damage evaluated from the radiological, quality of life and functioning point of view. In 2007, the GRAPPA-OMERACT achieved consensus on 6 core domains that should be assessed in trials on subjects with PsA (peripheral joint activity, skin activity, pain, patient global assessment (PGA), physical function, and health-related quality of life) and other important but non mandatory domains (spinal disease, dactylitis, enthesitis, fatigue, nail disease, radiography, physician global assessment, and acute-phase reactants). Most of the clinical trials have used: the ACR scoring system, VAS scores of patient pain, patient global, physician global, the Health Assessment Questionnaire (HAQ), and acute phase reactant, C-reactive protein (CRP) or erythrocyte sedimentation rate (ESR) [104, 105].
A PsA specific response index was developed and then improved and renamed as PsA specific response criteria PsARC. Two of the following were needed to achieve response in a psoriatic arthritis patient: a joint count and no worsening of any measure (tender or swollen joint count improvement of at least 30%, patient global improvement by one point on a five point Likert scale, or physician global improvement on the same scale).
Unlike the ACR criteria (only measuring change in disease activity), the DAS evaluation was useful in determining the current amount of disease activity. as well as the change of disease activity with therapy in RA. The original DAS used the Ritchie Articular Index (RAI), swollen joint count (SJC), ESR, and general health status (GH) (VAS) [106, 107].
Latest literature data report that psoriatic patients have a higher incidence of depression, anxiety, low self-esteem and social withdraw or isolation. Depression affects a high percentage of psoriasis patients and leads to chronic fatigue, loss of interest in life and everyday activities, appetite changes, sleep disturbances and negative coping mechanisms (use of alcohol and/or drugs, self-harm or other high-risk behavior). Psoriasis patients may also face feelings of guilt, shame, embarrassment or helplessness and stress (which can trigger flares of psoriasis). Sexual dysfunction may occur due to self-consciousness or painful lesions, which can also interface with activities of daily living, including dressing, bathing and sleeping. Psoriasis determines a negative impact on the patient’s family functioning, including financial hardship and degeneration of patient–family relationships. It may also generate decreased vocational opportunities due to discrimination or perceived restrictions on career choices, which can lead to employment and economic difficulties. According to a national survey performed in USA on patients with severe forms of psoriasis: 20% said that their psoriasis contributed towards the loss of a job or resignation; 25% believed that their psoriasis has caused an intimate relationship to end; 43% said psoriasis had prevented them from making new friends; 83% expressed dissatisfaction with their current treatment [108].
Even if the dermatological condition can improve under treatment, the emotional problems may persist or aggravate in some patients. Suicidal ideation, occurred in up to 10% of psoriasis patients. A significant number of psoriasis patients reported a negative mental and physical impact that is similar to cancer, hypertension, heart disease, depression and diabetes.
The negative impact of psoriasis can be measured by using the following instruments: Dermatological Quality of Life Index (DQLI), Psoriasis Disability Index (PDI), The Family Psoriasis Index (PFI-14) questionnaire, the Health-Related Quality of Life (HRQoL) or SkinDex 29 or 17 [108].
Laboratory studies and findings for psoriasis patients may include the following:
test for rheumatoid factor (RF) (usually negative result), erythrocyte sedimentation rate (usually normal, except in pustular and erythrodermic psoriasis), uric acid level (may be elevated especially in pustular psoriasis, causing confusion with gout in psoriatic arthritis). If fluid is collected from the pustules, the results will indicate a sterile fluid with neutrophil infiltrate. Fungal studies can be performed, especially important in cases of hand and foot psoriasis that seem to be worsening with the use of topical steroids.
If starting systemic therapies such as immunological inhibitors, consider obtaining baseline laboratory studies in pretreatment and when indicated by medical history or physical examination findings (usually every 2–5 months): blood count (Hb, Htc, leucocytes, platelets, differential blood count), CRP, liver enzymes (ALT, AST, AP, γGT), serum creatinine/eGFR, urine status (including urine pregnancy test in females), as for hepatitis B, C, tuberculosis and HIV testing, they are optional only in some cases. Further specific testing may be required according to clinical signs, risk, and exposure.
There are three different algorithms regarding the evaluation of psoriasis patients related to treatment: pre-treatment, during-treatment and post-treatment.
Pre-treatment evaluation indications include: medical history (also checking for comedication) and physical examination with the objective assessment of the disease with specific scales (PASI/PGA, DLQI, etc.), performing laboratory controls (pregnancy test included), checking for skin cancer, evidence of active and chronic infection (exclusion of tuberculosis), checking for hypersensitivity, metabolic, gastrointestinal and renal disorders, underweight or depression, check for contraception and breastfeeding, need of vaccines.
During treatment evaluation indications include: medical history and physical examination (focusing on malignancies, infections, contraception, depression, anxiety) including the objective assessment of the disease with specific scales (PASI/PGA, DLQI, etc.), performing laboratory controls only when indicated on medical history or physical examination (tuberculosis testing included).
Post-treatment evaluation indications: discussing contraception (which can be pursued at least 20 weeks after discontinuation of biological treatment), continuing follow-up focusing on malignancies, infections, etc.
As a conclusion, care for psoriasis patients require more than the management of the skin lesions and of the joint involvement. The complexity of the disease requires a holistic approach of the patient, performed with utmost attention. Screening at regular intervals for associated diseases and prevention of comedication interactions, as well as recognition and avoidance of trigger factors, are essential. Psychosocial interventions, such as patient education and psychological treatment, may be needed in psoriasis management.
Ove Odredbe i uvjeti ističu pravila i regulacije u svezi korištenja IntechOpenove stranice www.intechopen.com i svih poddomena u vlasništvu IntechOpena, tvrtke sa sjedištem u 5 Princes Gate Court, London, SW7 2QJ, Ujedinjeno Kraljevstvo.
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\\n\\nSljedeća terminologija odnosi se na Odredbe i uvjete, te na sve naše ugovore:
\\n\\nKlijent, stranka, vi, vaš odnosi se na vas, osobu koja pristupa ovoj stranici i prihvaća IntechOpenove Odredbe i uvjete;
\\n\\nKompanija, tvrtka, mi, naše odnosi se na tvrtku IntechOpen;
\\n\\nStranke, strane odnosi se na klijenta i na nas, ili samo na klijenta ili nas.
\\n\\nSve odredbe koje se odnose na ponudu, prihvat ili razmatranje plaćanja, a za koja mi pružamo asistenciju klijentu, bilo na ugovoreni ili fiksni način, a s ciljem da se ostvare potrebe i želje klijenta u svezi s našim uslugama, su podložne zakonskim odredbama Ujedinjenog Kraljevstva.
\\n\\nOsim ako nije suprotno navedeno, IntechOpen i/ili svi davatelji licence vlasnici su intelektualnog vlasništva nad svim materijalima na www.intechopen.com. Sva prava intelektualnog vlasništva su pridržana. Stranice sa www.intechopen.com možete gledati, preuzimati, dijeliti, dijeliti poveznice i printati za osobnu uporabu, a temeljem pravila sadržanih u ovim Odredbama i uvjetima.
\\n\\nMi koristimo kolačiće. Korištenjem IntechOpenove stranice slažete se s korištenjem kolačića u skladu s IntechOpenovom Politikom privatnosti. Većina modernih, interaktivnih stranica koristi kolačiće kako bi omogućila ponovno pronalaženje korisničkih detalja kod svakog posjeta. Na našoj stranici kolačići se uglavnom koriste kako bi omogućili funkcionalnost i olakšali posjetiteljima korištenje stranice.
\\n\\nIntechOpen ili njegovi suradnici niti u jednom slučaju neće biti odgovorni za štete (štete uključuju gubitak podataka ili profita, druge poslovne prekide, te sve ostale štete) koje nastanu zbog korištenja materijala na IntechOpenovoj stranici ili nemogućnosti da se iste koriste, čak i ako je IntechOpen ili njegov predstavnik o takvoj šteti obaviješten pismenim ili usmenim putem. Neke jurisdikcije ne dozvoljavaju ograničenja garancija ili ograničenja obveza za posljedične ili slučajne štete pa se u tom slučaju ova ograničenja možda ne odnose na vas.
\\n\\nMaterijali koji se pojavljuju na IntechOpenovoj stranici mogu sadržavati manje greške, tipfelere ili fotografske greške. IntechOpen može napraviti promjene na bilo kojem materijalu koji se nalazi na stranici u bilo koje vrijeme.
\\n\\nIntechOpen nije formalno povezan niti s jednom vanjskom stranicom čije poveznice vode na www.intechopen.com, osim ako to nije izravno navedeno. Iz tog razloga IntechOpen nije odgovoran za sadržaj koji se pojavljuje na takvim stranicama. Poveznica na IntechOpenovu stranicu ne implicira povezanost sa IntechOpenom. Korištenje takvih poveznica isključiva je odgovornost korisnika.
\\n\\nZadržavamo pravo vlasništva nad cjelokupnom stranicom www.intechopen.com i nad svim materijalom na toj stranici. Koristeći se našim uslugama, slažete se da maknete sve poveznice na našu stranicu odmah nakon što to od vas zatražimo. Također, zadržavamo pravo da ove Odredbe i uvjete, i politiku o poveznicama izmjenimo u bilo koje vrijeme. Koristeći se poveznicama na naše stranice slažete se s ovim Odredbama i uvjetima.
\\n\\nAko smatrate da je bilo koja poveznica na našoj stranici sumnjiva iz bilo kojeg razloga, molimo vas da nas kontaktirate. U tom slučaju razmotrit ćemo micanje poveznice s naše stranice, iako nismo obvezni to napraviti.
\\n\\nBez prethodne privole i izričite pisane dozvole, ne možete stvarati okvire oko naših stranica ili koristiti druge tehnike koje na bilo koji način mogu promijeniti prezentaciju ili izgled naše stranice.
\\n\\nIntechOpen može ove Odredbe izmijeniti u bilo koje vrijeme i bez prethodne obavijesti. Koristeći ovu stranicu vi se slažete s trenutnim Odredbama i uvjetima koje su na snazi.
\\n\\nOve Odredbe i uvjeti su sastavljeni u skladu s odredbama prava Ujedinjenog Kraljevstva, a za sve sporove nadležan je sud u Londonu, Ujedinjeno Kraljevstvo.
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\n\nSljedeća terminologija odnosi se na Odredbe i uvjete, te na sve naše ugovore:
\n\nKlijent, stranka, vi, vaš odnosi se na vas, osobu koja pristupa ovoj stranici i prihvaća IntechOpenove Odredbe i uvjete;
\n\nKompanija, tvrtka, mi, naše odnosi se na tvrtku IntechOpen;
\n\nStranke, strane odnosi se na klijenta i na nas, ili samo na klijenta ili nas.
\n\nSve odredbe koje se odnose na ponudu, prihvat ili razmatranje plaćanja, a za koja mi pružamo asistenciju klijentu, bilo na ugovoreni ili fiksni način, a s ciljem da se ostvare potrebe i želje klijenta u svezi s našim uslugama, su podložne zakonskim odredbama Ujedinjenog Kraljevstva.
\n\nOsim ako nije suprotno navedeno, IntechOpen i/ili svi davatelji licence vlasnici su intelektualnog vlasništva nad svim materijalima na www.intechopen.com. Sva prava intelektualnog vlasništva su pridržana. Stranice sa www.intechopen.com možete gledati, preuzimati, dijeliti, dijeliti poveznice i printati za osobnu uporabu, a temeljem pravila sadržanih u ovim Odredbama i uvjetima.
\n\nMi koristimo kolačiće. Korištenjem IntechOpenove stranice slažete se s korištenjem kolačića u skladu s IntechOpenovom Politikom privatnosti. Većina modernih, interaktivnih stranica koristi kolačiće kako bi omogućila ponovno pronalaženje korisničkih detalja kod svakog posjeta. Na našoj stranici kolačići se uglavnom koriste kako bi omogućili funkcionalnost i olakšali posjetiteljima korištenje stranice.
\n\nIntechOpen ili njegovi suradnici niti u jednom slučaju neće biti odgovorni za štete (štete uključuju gubitak podataka ili profita, druge poslovne prekide, te sve ostale štete) koje nastanu zbog korištenja materijala na IntechOpenovoj stranici ili nemogućnosti da se iste koriste, čak i ako je IntechOpen ili njegov predstavnik o takvoj šteti obaviješten pismenim ili usmenim putem. Neke jurisdikcije ne dozvoljavaju ograničenja garancija ili ograničenja obveza za posljedične ili slučajne štete pa se u tom slučaju ova ograničenja možda ne odnose na vas.
\n\nMaterijali koji se pojavljuju na IntechOpenovoj stranici mogu sadržavati manje greške, tipfelere ili fotografske greške. IntechOpen može napraviti promjene na bilo kojem materijalu koji se nalazi na stranici u bilo koje vrijeme.
\n\nIntechOpen nije formalno povezan niti s jednom vanjskom stranicom čije poveznice vode na www.intechopen.com, osim ako to nije izravno navedeno. Iz tog razloga IntechOpen nije odgovoran za sadržaj koji se pojavljuje na takvim stranicama. Poveznica na IntechOpenovu stranicu ne implicira povezanost sa IntechOpenom. Korištenje takvih poveznica isključiva je odgovornost korisnika.
\n\nZadržavamo pravo vlasništva nad cjelokupnom stranicom www.intechopen.com i nad svim materijalom na toj stranici. Koristeći se našim uslugama, slažete se da maknete sve poveznice na našu stranicu odmah nakon što to od vas zatražimo. Također, zadržavamo pravo da ove Odredbe i uvjete, i politiku o poveznicama izmjenimo u bilo koje vrijeme. Koristeći se poveznicama na naše stranice slažete se s ovim Odredbama i uvjetima.
\n\nAko smatrate da je bilo koja poveznica na našoj stranici sumnjiva iz bilo kojeg razloga, molimo vas da nas kontaktirate. U tom slučaju razmotrit ćemo micanje poveznice s naše stranice, iako nismo obvezni to napraviti.
\n\nBez prethodne privole i izričite pisane dozvole, ne možete stvarati okvire oko naših stranica ili koristiti druge tehnike koje na bilo koji način mogu promijeniti prezentaciju ili izgled naše stranice.
\n\nIntechOpen može ove Odredbe izmijeniti u bilo koje vrijeme i bez prethodne obavijesti. Koristeći ovu stranicu vi se slažete s trenutnim Odredbama i uvjetima koje su na snazi.
\n\nOve Odredbe i uvjeti su sastavljeni u skladu s odredbama prava Ujedinjenog Kraljevstva, a za sve sporove nadležan je sud u Londonu, Ujedinjeno Kraljevstvo.
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I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. 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I received a B.Eng. degree in Computer Engineering with First Class Honors in 2008 from Prince of Songkla University, Songkhla, Thailand, where I received a Ph.D. degree in Electrical Engineering. My research interests are primarily in the area of biomedical signal processing and classification notably EMG (electromyography signal), EOG (electrooculography signal), and EEG (electroencephalography signal), image analysis notably breast cancer analysis and optical coherence tomography, and rehabilitation engineering. I became a student member of IEEE in 2008. During October 2011-March 2012, I had worked at School of Computer Science and Electronic Engineering, University of Essex, Colchester, Essex, United Kingdom. In addition, during a B.Eng. 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I am a Reviewer for several refereed journals and international conferences, such as IEEE Transactions on Biomedical Engineering, IEEE Transactions on Industrial Electronics, Optic Letters, Measurement Science Review, and also a member of the International Advisory Committee for 2012 IEEE Business Engineering and Industrial Applications and 2012 IEEE Symposium on Business, Engineering and Industrial Applications.",institutionString:null,institution:{name:"Joseph Fourier University",country:{name:"France"}}},{id:"55578",title:"Dr.",name:"Antonio",middleName:null,surname:"Jurado-Navas",slug:"antonio-jurado-navas",fullName:"Antonio Jurado-Navas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/55578/images/4574_n.png",biography:"Antonio Jurado-Navas received the M.S. degree (2002) and the Ph.D. degree (2009) in Telecommunication Engineering, both from the University of Málaga (Spain). He first worked as a consultant at Vodafone-Spain. 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