Results showing GAS scores pre and post-treatment.
\r\n\tThis book chapter’s main theme will be focused on transmission dynamics, pathogenesis, mechanisms of host interaction and response, epigenetics and markers, molecular diagnosis, RNA interacting proteins, RNA binding proteins, advanced development of tools for diagnosis, possible development of concepts for vaccines and anti drugs for RNA viruses, immunological mechanisms, treatment, prevention and control.
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Plasmonics is the emerging research field, indicating the ability of materials to control light at nanoscale range to examine them for various properties and functions. The plasmonic materials exploit the surface plasmon resonance effects to achieve astonishing optical properties that originate with light-matter interaction and leads to remarkable results. Surface plasmon can confine electromagnetic fields at very small scales whereas various structures can be employed to control surface plasmons. Previously, Ag, Au, and Al metals were used as plasmonic materials but they did not perform well because of radiative losses, high amount of energy dissipation, and their poor tuneability. To overcome these problems for efficient plasmonic applications, a class of two-dimensional (2D) materials is proposed which presents a significant light-matter interaction phenomenon resulting in efficient quantum confinement effects. A variety of materials including semiconductors, conductive oxides, and dielectric materials have been investigated as plasmonic materials owing to their extra-ordinary plasmonic properties. Considering the advanced properties along with bandgap manipulation and electron transfer, 2D materials got higher attention for plasmonic applications [1, 2].
Graphene was the first 2D material investigated with zero bandgap having exceptional conductivity because of its high electron mobility. Considering graphene’s achievements and enormous applications at the laboratory and industry level, researchers have started investigating further 2D materials to explore their potential for plasmonic applications. Currently, almost 150 members of the 2D materials family are serving in elementary and advanced technologies such as light-emitting diodes (LEDs), Field-effect transistors (FETs), environmental applications, sensing applications, and physical catalysis [3, 4, 5]. Some important under discussion members of 2D materials, analogous to graphene are; hexagonal boron nitride (hBN), black phosphorene, metal oxides, metal carbides and nitrides (MXenes), metal halides, pnictogens, and non-metals which are being considered as potential plasmonic materials [6, 7, 8]. This 2D materials family exhibits a broad electronic and plasmonic characteristic spectrum covering a wide range of properties such as; high surface area, surface state nature, minimum dangling bonds, spin-orbit coupling, and quantum spin Hall effects [9, 10].
On the other hand, stacking of different 2D materials is also the emerging part of the material industry which yields novel heterostructure materials capable of introducing some building blocks in a materials family with enhanced physical and chemical properties. The novel 2D materials such as metal carbides and nitrides, metal oxides and graphene-based materials have mixed properties and can be further tuned by adjusting bandgap that would result in increased light-harvesting efficiency which is the basis to achieve desired optical, electronic, and optoelectronic properties, making them promising materials for plasmonic applications [11, 12]. In addition, the plasmonic efficiency of 2D materials can also be enhanced by injecting plasmonic hot electrons to alter carrier intensity in 2D materials for higher photocatalysis output [13]. The recent extension of plasmonic materials from traditional metals to semiconductors to semi-metal graphene are identified as an ideal materials for surface plasmon resonance in plasmonic structures and their subsequent applications needed to be addressed accordingly. Moreover, the coupling effects between excitons and plasmons for 2D materials are the growing research interests that profound further studies for light-matter interactions to discover novel materials for innovative device applications.
The radiation-matter interaction is more prominent in 2D materials because of their thin sheet structures and significant quantum confinement effects that lead to enhanced electronic and optical properties. Owing to their advanced nature, 2D materials are advantageously evaluated for plasmonic characteristics, and multiple studies have been conducted for hBN to investigate plasmon molecular vibration coupling, plasmon substrate phonon coupling, and graphene plasmon-phonon polaritons coupling [14, 15, 16]. The 2D graphene structure exhibits exciting results due to its single-atom thickness and their environmental sensitivity. Other than environmental sensitivity, graphene plasmons can also be tuned with external magnetic and electric fields [17]. The effectiveness of graphene-based plasmonics can be determined by charge carrier density, and heavily doped graphene exhibits high efficiency which is required for plasmonic applications [18]. As a result, graphene is an excellent plasmonic material, and combining graphene with other 2D materials is favorable to obtain optimum efficiency [19].
Hexagonal Boron Nitride (hBN) is one of the most intriguing findings in 2D materials for plasmonics, having the unique ability to be fabricated within the host material, and can be used as a promising substrate for graphene-based plasmonic applications because of its graphene-matched crystal structure [18, 20]. The hBN-graphene mixture is helpful to enhance grapheme-plasmon lifetime when compared with other 2D materials and can maintain its bandgap even in varied thicknesses depicting a wide range of plasmonic properties including electro-optic and quantum-optics [21, 22]. Moreover, the point defects in hBN at room temperature demonstrate single-photon emission properties that can be used to integrate plasmonic nanostructures. Despite its wide bandgap, hBN offers high quantum efficiency, optical nonlinearity, and novel plasmonic properties to make it the best choice as 2D plasmonic material [23]. Its structure is shown in Figure 1 [24].
Schematics of hBN structure [
The MXenes are a new class of 2D materials that contain carbides and nitrides, and they are the biggest family currently available, as seen in Figure 2 [25]. This family of materials is substantially more stable than graphene with high metallic conductivity, folding and molding properties, and good electromagnetic properties, possessing the unique property of being combined with other materials to tune their properties for desired applications. They can be employed in a variety of applications including energy storage devices, photonic-plasmonic structures as well as photocatalytic devices [26], and because of their metallic character along with high conductive nature, they may be used as plasmonic materials equivalent to graphene.
MXene sheets with multiple layers where larger spheres represent transient metal, while smaller spheres are C, N, or CN [
Researchers anticipated the group VA elements such as nitrogen, arsenic, antimony as well as bismuth as single-layer 2D structures with the introduction of 2D materials synthesis, and these elements are referred to as pnictogens and are shown in Figure 3 [27]. These materials feature a honeycomb, washboard, and square-octagon structure, and they offer outstanding electrical, optical, electro-optical, and plasmonic properties having strong spin-orbit coupling, a narrow bandgap, and band inversion properties, making them ideal for plasmonic device applications [27].
Pnictogens and their schematic 2D structures [
Photonics deals with the light-matter interaction which usually results in the formation of a single electron–hole pair by interacting light photons with free charge carriers in a metal, whereas in plasmonics, there is a large number of charge Carriers present that leads to collective oscillations which is the fundamental problem in plasmonics because all charge carriers are not part of the solid and can be influenced by structural defects as well as other materials defects such as dislocations. As a result, multi-scale modeling at various structural complexity levels is required for theoretical exploration of these complex models and plasmonic excitations in bulk materials and localized plasmons in metallic structures. To analyze this complicated issue, several theoretical and numerical models have been presented, although only a few of them are described here.
The Drude-Lorentz model which gives a theoretical insight into a material and can be employed in plasmonic applications is an intuitive way to study the underlying dielectric characteristics of solids [28, 29]. The Drude-Lorentz model, also known as the oscillator model, entails representing an electron as a driven damped harmonic oscillator in which the electron is connected to the nucleus by a hypothetical spring with an oscillating electric field acting as a driving force. It also describes the behavior of electrons in terms of their electro-optical characteristics when light interacts with them [30]. The Drude-Lorentz model’s predictions are completely supported by the classical oscillator model as well as quantum mechanical features like electronic dipole moments of materials. To justify the microscopic qualities exhibited by classical and quantum techniques using this model, it is necessary to understand the Ehrenfest theorem which shows that quantum mechanical predicted values fundamentally follow classical mechanical conditions [31]. The Kohn-Sham approach is praised for its ease of use in relating a many-body system to a non-interacting system and thereby solving it using Kohn-Sham density functional theory [32]. Figure 4 illustrates such a model [32].
Kohn-sham mapping of the interacting and non-interacting systems [
With the developments in computing, new algorithms are being devised to accomplish difficult jobs rapidly and accurately. Different approaches and models for electrical and photonic systems are being explored to accurately anticipate their characteristics, which were previously explored using differential equations. This section discusses the frequency domain approach and the time domain method to have a better knowledge of computational model advancements [33].
The decomposition of periodic systems into harmonic time-dependent eigenmodes is a basic approach for understanding the optoelectronic and plasmonic characteristics of materials. The frequency-domain approach is a subset of these decompositions that enlarges electromagnetic fields into Fourier eigenmodes which may be used to comprehend optical material properties in the absence of nonlinear effects [34]. This approach is usually started from fundamental photonic systems with translational symmetry which produces electromagnetic states and photonic band structures using Maxwell equations and wave Equations [35]. Although the frequency-domain technique is effective for defining material characteristics, but it is an expensive method that restricts its application in numerical models and as a result, the finite-difference time-domain method was presented as an alternative. The time-domain technique is a grid-based method that is linked to several other finite methods. This approach models electromagnetic wave propagation in dielectric media without needing derivation methods, making it easier to be utilized in complicated geometrical simulations, such as non-linear systems, which were previously difficult to manage using the frequency-domain method. Furthermore, in this approach, Maxwell equations are discretized by differences arising from spatial and time derivatives, and the obtained results are solved in a leapfrog fashion on a staggered grid which is a good method being utilized in fluid dynamics [36]. Using the Phyton modules, these simulations can also be used to determine the plasmonic characteristics of materials [37].
The plasmonic material’s behavior can be determined by studying the frequency-dependent dielectric factor linked with the excited state of the material. It is essential to analyze both the ground and excited states of material while calculating optical transitions based on material states. For the analysis of material characteristics based on these facts,
Band structure of graphene and hBN computed within DFT (PBE) [
The material characteristics such as its dimension, morphology, physical as well as chemical properties, orientation, and crystallinity mainly depend on the material’s electronic properties which are impacted by the synthesis technique and experimental conditions. Mechanical exfoliation techniques have been tried in the past, but they have failed due to insufficient van-der-wall forces between 2D material layers, which limit uniformity and quality control, as well as their inability to scale-up [42]. Physical and chemical synthesis methods with controlled structural fabrication can be used with the top-down approach having the disadvantage of poor product yield and sheet restacking, limiting its application, and the bottom-up approach yielding promising results by assembling materials in a substrate using vapor deposition techniques such as physical vapor deposition (PVD), chemical vapor deposition (CVD), and atomic layer deposition. These are the most often utilized promising ways for fabricating 2D materials with customized thickness, dimensional control, high conductivity, and flexibility for electron transport; all of which are highly sought quantities for plasmonic applications [43].
CVD allows for the controlled synthesis of large areas of 2D materials with the added benefit of step-by-step film synthesis on various substrates and adjustable growth parameters to get the desired output. Metal–organic chemical vapor deposition (MOCVD) is a modified version of CVD that is used to synthesize high-quality, large-area 2D materials for a variety of applications [44]. New research shows that a metal gas-phase precursor might be employed for regulated and uniform thickness instead of a powder precursor, which results in inhomogeneous nucleation and hence uncontrolled synthesis. Furthermore, temperature and pressure have an important impact on deposition uniformity, for example, high temperature and moderate pressure would result in excellent precursor coverage with regulated dimensions while excessively high temperatures might have negative consequences [45]. A comparison of various synthesis techniques is shown in Figure 6 [46].
Comparison of various 2D materials synthesis techniques [
Many techniques are available for producing uniform 2D materials and heterostructures with atomic layer deposition (ALD) being a refinement of the vapor-based deposition method in which the self-limiting reaction of the precursor is an essential aspect of ALD and the fact that a self-saturating surface monolayer is created after each precursor exposure distinguishes it from other deposition processes. In addition, ALD allows for the creation of 2D materials with fewer flaws and the synthesis of 2D material heterostructures with a small atom size thickness [47]. As a result of the advancements, ALD has opened up new means of synthesis with decreased interfacial impurities and large area deposition conformity with improved structural properties [48].
Apart from vapor-based synthesis approaches, liquid-phase exfoliation is another good way to get 2D materials in which the surface oxide of liquid metals produces unexpected results from a combination of physical and chemical features of liquid alloys [49]. While interacting with their ambient conditions, liquid metals with electron-rich metallic cores form a natural 2D film; the self-limiting surface oxide film with a thickness of a few atoms [50]. These liquid ingredients serve as host materials for the production of high-quality, one-kind films for innovative applications. The origin to define its development characteristics is the host materials fluidity, chemical composition, and thermodynamic properties that are the building block for examining the resultant 2D materials [51].
Graphene, graphene oxides (GO), MXenes, pnictogens, and hBN are just a few of the commonly utilized plasmonic materials described in this section.
Graphene is proving itself a revolutionary material for a wide range of applications since 2004 because of its electronic behavior which is responsible for exceptional features including, high mobility charge carriers, optical transmission, and tunable carrier densities [52, 53, 54, 55, 56, 57, 58, 59, 60]. The ability of graphene’s structure to strongly confine excited surface plasmons in comparison to other materials as well as its ability to tune surface plasmons by manipulating charge densities is remarkable for prospective applications primarily in optoelectronics and plasmonics [61]. Experimental studies [62] show that graphene surface plasmons may be coupled with electrons and photons, allowing them to be used in more promising applications. This graphene coupling is in the form of quasi-particles that hold an intense interest in optoelectronics and condensed matter physics [63]. Surface plasmons in graphene offer a variety of significant advantages over other plasmonic materials, including high confinement, high tuneability, reduced frequency loss, improved electron relaxation time, and high many-body interactions. Figure 7 shows the structure and band description of graphene [64].
(a) Graphene lattice structure, (b) BZ of graphene, (c) lattice electronic dispersion, (d) graphene electronic structure Bloch band description, (e) Low EBS approximation [
Graphene oxide (GO) is an amorphous insulator with carbon network bases on the hexagonal rings with both sp2 and sp3 hybridization as well as hydroxyl and epoxide groups on sheet sides and carboxyl and carbonyl groups on sheet edges. This kind of morphological structure is responsible for its wide range of technological applications mainly in nano-electronics, nano-photonics, and nano-composites. Because of the oxygen functionalities present, GO has a significant benefit when mixed with other polymeric or ceramic materials, resulting in improved electrical and mechanical properties [65]. The GO is in high demand in both industry and academics because of its zero-bandgap feature and excellent flexibility with superior thermal and electrical conductivity. In addition, one of GO’s unique properties is the coexistence of its size, shape, and hybridization domains via a reduction mechanism that may eventually control the bandgap and convert GO to a semi-metal form. The main distinction between GO and reduced graphene oxide (r-GO) is that GO has oxygen-containing functional groups, whereas reduced graphene oxide does not [66]. Owing to heterogeneous electrical structure, GO is fluorescent throughout a wide wavelength range, while reduced GO allows quick response in GO-based electronics [67]. The GO is a promising choice for novel photonic materials, solar cells, optical devices, and a range of other applications due to its unique features. Figure 8 depicts the difference between GO and r-GO [66].
Schematic flow from graphene-to-graphene oxide (GO) and reduced graphene oxide (r-GO) [
The hBN is a traditional 2D heterostructure material that was previously used as a substrate for thin-layered materials but now has the potential to be employed as an active plasmonic material. It is an excellent encapsulant for graphene because it protects it from the environment and increases its electrical mobility, extending the life of surface plasmon polaritons in plasmonic applications [18, 68]. It has a crystal nature and polar bonding, allowing it to perform a wide range of optical, electrical, optoelectronic, and quantum optic functions for device applications. Also, it has a wide bandgap, high internal quantum efficiency, and significant optical nonlinearities that depend on material thickness and is specified by the rotation angle between heterostructure material layers [23, 69]. Its structure and band properties are displayed in Figure 9 [70].
hBN and its band structure properties [
MXenes are new types of 2D plasmonic materials made up of nitrides and carbides that were discovered in 2011. They are more stable than graphene, can be readily shaped and folded, have superior electromagnetic properties, and can be coupled with other materials to exhibit a wide range of applications in energy storage, supercapacitors, photonics, and plasmonics. The properties of MXenes can be determined by exploring surface termination, composition, doping, or mixing with other materials, resulting in adjustable conductivity that can change the material’s properties as a metal or semiconductor [71]. The relative dielectric permittivity of MXenes for plasmonic applications can be studied by inter- and intra-band transitions that define optical parameters such as, absorption coefficient, refractive index, transmittance, and reflectance, and are linked to the material’s electrical conductivity, which has already been demonstrated computationally and experimentally to find a place in electronic and optoelectronic applications [72, 73].
Pnictogens are monolayer stable structures found from elements of group VA (nitrogen, arsenic, antimony, and bismuth) after the discovery of black phosphorene. These materials are named as nitrogen in hexagonal buckled structure, arsenic in hexagonal buckled as well as symmetric washboard structure, antimony, and bismuth in either hexagonal buckled or asymmetric washboard structure, but later on, these elements occurred to have other exotic structures [74]. The pnictogens stability can be depicted using molecular dynamic simulations performed at high temperatures and materials phonon frequencies [75]. Pnictogens, as contrasted with group IV elements, are significantly more stable semiconductor materials with an appropriate bandgap for numerous device applications. Also, in contrast to black phosphorus (BP), they are thermodynamically stable monolayer structures with rhombohedral structural characteristics and interlayer covalent connections which decrease as anisotropy decreases and metallic character increases from arsenic to antimony to bismuth [76]. The 2D monolayer structures of pnictogens exhibit strong directionality in various physical properties that can be implied on plane lateral heterostructures to produce parallel strips of 2D pnictogens with advanced technological applications while the same effect can be observed by a monoatomic chain of group VA elements attached to their monolayers. Figure 10 represents structures as well as binding energies of pnictogens [77].
(a) Honeycomb structures, (b) average binding energies of 2D pnictogens [
Metal oxides show strong metallic behavior owing to stable charge carrier concentration when doped with various significant dopants such as aliovalent, oxygen vacancies, or interstitial dopants that result in localized surface plasmon resonance and by carefully choosing the host material as well as doped material, these surface plasmonic resonances can be tuned in the range of near- and mid-infrared (IR) region spectrum. The optical modeling of metal oxides illustrates the importance of defects and their impact on charge carrier mobility and the electronic structure of the material which reveals the choice of dopant as an important factor for metal oxides as plasmonic materials. Metal oxides are different from ordinary metals in the sense that they may change their localized surface plasmon resonance by changing their elemental composition, regardless of material size or shape, and these plasmon resonances can also be adjusted by altering external stimuli, resulting in the unique features of plasmonic materials as a result of crystal and morphological configurations that are useful for a variety of device applications [78].
The 2D materials can generally be categorized on the basis of electrical and optoelectronic properties in device applications such as flash memories, sensors, tunnel junctions, photodetectors, photonic crystals, optical metamaterials, nanophotonics, and quantum optics. The 2D graphene-based photonic and optoelectronic devices dragged much attention because of their versatile applications in broad fields such as sensing, communication, and imaging technologies [79]. In terms of density of state and band structure, graphene has an adjustable light absorption spectrum and carrier density which may be used in waveguide-integrated graphene photonic devices and molecular sensor detection. Graphene with optical adjustments has also been used for light modulation and detection, and its derivatives are proving to be a feasible alternative for a variety of applications. The GO can be utilized in the manufacture of electrical devices such as FETs and GFETs, LEDs, and solar cells, while r-GO dispersed in solvents may be utilized to replace FTO and ITO electrodes in transparent electrode manufacture; moreover, their large surface area and conductivity allow them to function as energy storage devices for longer periods with a greater capacity [80]. Recent investigations have shown that near-field IR optical microscopy and IR microscopy of graphene are responsible for surface plasmon modeling in plasmonic applications [81]. An overview of 2D plasmonic materials-based devices is shown in Figure 11 [82].
2D plasmonic material-based devices for optoelectronic applications [
The hBN has exciting technological applications including, photonics, and its nanostructures feature weak polaritons that interact poorly with light and might be utilized to control the optical angular momentum of hyperbolic phonon polaritons, implying maximum optical density of state and/or improving molecular IR vibrational absorption through surface enhancement [83]. Hybridization of hBN phonon-polariton with graphene surface plasmon-polaritons resulted in the active tuning of the polaritons which is a potential characteristic for chip-based nano-photonics [84], photonic devices, modulators, and hyper-lensing [85]. The hBN defects that reduce phonon lifespan have uses in single-photon emitters (SPEs), which have certain appealing properties such as high quantum efficiency, optical stability, linear polarization, and high brightness. In addition, owing to its high efficiency and extended life in device applications, hBN has been utilized to replace AlGaN in deep-UV applications. Another method for incorporation of hBN is to link emission with plasmonic resonator-based structures in which localized surface plasmons cause broad field confinements throughout a wide range of emission, resulting in substantial Purcell amplification for dipole emission coupled to these resonators. When compared to uncoupled devices, the hBN quantum emitter coupling with plasmonic arrays has previously been demonstrated, with studies revealing PL enhancement and lifespan reduction with a quantum efficiency of around 40% and enhanced saturation count rates [86].
MXenes plasmonics is a relatively new field with a wide range of possible applications, including surface-enhanced Raman spectroscopy, conductive substrates, and plasmonic sensing [72]. Nonlinear optical applications based on the nonlinear absorption process by plasmonic illumination near plasma frequency have been suggested for MXenes, and these nonlinear applications include ultrafast lasers, optical switching, and optical rectification devices like optical diodes. At near-infrared frequencies, arrays of two-dimensional titanium carbide (Ti3C2Tx) MXene nanodisks exhibit strongly localized surface plasmon resonances, which have been exploited to produce broadband plasmonic metamaterial absorber [87]. MXenes are also used as super-absorbers in broadband plasmonic metamaterials, and these super-absorbers may be used for photodetection and energy harvesting. Figure 12 shows an MXenes super-absorber [88] with configurable nano-aperture width for broadband applications.
MXene broadband super-absorber [
Pnictogens with a 2D structure are in great demand for high-performance device applications, since they have a midrange tunable bandgap and unparalleled mobility, allowing them to be employed in FETs for more efficient response than other materials. Because 2D materials lack a suitable bandgap, photodetectors are a major challenge, but pnictogens direct and tunable bandgap has solved this problem acting as a bridge between narrow and wider bandgap materials, attracting a lot of interest in photodetectors with improved photo-responsivity for telecommunication applications. The BP has an intriguing direct bandgap from visible to IR, making it a potential material for optoelectronic applications [89], while ultra-thin BP FETs have been described as effective NO2 gas sensors with remarkable stability of pnictogens-based FETs during sensing [90, 91]. The 2D metals and metal oxide semiconductors, whether conducting or insulating, are useful for thin-film transistors and numerous device applications, where they can be employed in any component such as the source, drain, gate, electrodes, or gate dielectrics. Metal oxides are also useful in p-n junction device fabrications for diode rectifiers, solar cells, and organic photovoltaic applications, where they operate as a charge extracting interfacial layer to improve power conversion efficiency.
Plasmonics has advanced to the forefront of science due to technical advances in the experimental and computational fields as well as contributions to scientific applications. These contributions also confront some challenges that must be addressed in the future for effective plasmonic applications. To begin with, plasmonic nanostructures of controlled size and features cannot simply embed in their surroundings because they change the dielectric function of the surrounding medium, affecting plasmonic switching and hence plasmonic applications. Another problem is optical pumping, which has the potential to deliver ultrafast plasmonic switching but has the drawbacks of destructive heat accumulation and high-power consumption. A major shortcoming of plasmonic materials is that self-tuned plasmonic structures lack effective plasmon coupling control abilities. Also, it is difficult to fabricate colloidal metal nano-crystals in controlled symmetry for plasmonic device applications on a large scale, even though lithography techniques performed well but had some drawbacks such as high cost, long-time consumption, and difficulty with damped plasmonic properties on a large scale [92].
Plasmonics must control light at the nanoscale with minimal losses, and to do so, light localization must be pushed to new heights without jeopardizing its propagation nature. Similarly, advances in topological plasmons must be incorporated in nanophotonic circuits by maintaining plasmon propagation stability and improving manufacturing techniques. For the experimental process to be effective, theoretical models must be improved to acquire the nonlinear and nonlocal physics of plasmonic devices. In short, both light and matter quantization are required to make a fine path toward a better understanding of light-matter interactions for advanced large-scale applications. The numerical approaches outlined are strong tools in terms of computing but they have conceptual limitations and their validity range becomes inefficient when a heterogeneous system is studied. To tackle plasmonic multi-scale challenges, the validity of numerical models must be improved by combining them with other numerical tools which is not well understood at this time and requires future considerations.
We have briefly addressed 2D plasmonic materials and their active properties in this chapter that are responsible for their wide range of applications in the electrical, photonic, and optoelectronic fields such as, FETs and GFETs, LEDs, and solar cells, modulators, hyper lensing, metamaterial absorbers, super-absorbers as well as nonlinear applications including ultrafast lasers, optical switching, and optical rectification devices like optical diodes. The synthesis techniques employed for 2D plasmonic materials have also been reviewed, with pulsed laser deposition (PLD) and CVD being the most extensively used and promising approaches for more controlled and conformational film growth. Also, these techniques have the advantage to provide desirable results by tuning their functional parameters such as temperature, pressure, substrate angles, and deposition time. Computational models have to be examined to carry out a successful experiment, and there is a need to update simulation approaches to address problems in achieving desired plasmonic device features. Finally, we have outlined new prospective applications of 2D plasmonic materials and their significance in the industry as well as the drawbacks of materials that prohibit them from performing properly while providing the possible directions for future research.
There are no conflicts of interest to declare.
US spelling with serial comma.
Dysphagia is a widely prevalent phenomenon that brings the risk of other conditions like malnutrition, pneumonia, and even the necessity for non-oral feeding solutions [1, 2, 3]. It always leads to reduced quality of life, and can even be fatal [4].
The ways that patients with dysphagia are cared for fall into two broad categories, of which the first is by far the most common. Patients are often provided with compensatory care, [5, 6] which allows them to live with the disabilities that dysphagia brings. These therapies may include modified often puréed solid foods that are easier to swallow, and thickened drinks that can be swallowed more safely with less risk of aspiration. Instruction on posture, eating habits, oral hygiene and more, are also common.
The second category of care is rehabilitation treatment [7, 8, 9, 10, 11] to address the causes of the dysphagia. In general they focus on increasing muscle strength in the affected organs.
This chapter introduces a simple neuromuscular treatment using an oral therapy - IQoro (Figure 1) - that can usually be self-administered by the patient. The treatment has clinical evidence and scientific proof of striking success in treating people of all ages with all forms of dysphagia: oral-, pharyngeal- and esophageal [12, 13, 14]. When used with stroke survivors, the research shows equally good outcomes regardless of whether treatment started immediately, or long after the onset of stroke [10]. In scientific studies, the observed improved outcomes were still present at long-term follow-ups performed up to 18 months after the end of treatment [11, 12, 15, 16, 17].
The IQoro neuromuscular training device.
Associate professor Mary Hägg started her professional life as a hospital dentist where she became fascinated with the swallowing problems that some of her patients presented with. In Sweden, the remit of the dentist is wider than in some other countries and can encompass more orofacial issues than just teeth and gums. The more she worked with patients with swallowing difficulties some after stroke the more fascinated she became. She worked with exercises to strengthen the delinquent muscles and became more and more renowned for her focus on dysphagia.
In 1990, Mary founded a specialist multi-disciplinary unit within the ENT department of a Swedish teaching hospital and has managed it since its inception. The purpose of this speech and the swallowing unit is to encourage and ensure cooperation across a range of clinical specialties to deliver improved patient outcomes.
In 1997 she was awarded a stipend to visit and study the subject more deeply with Dr. Castillo Morales, Cordoba, Argentina, and in 2001 with Professor Bronwyn Jones, Dept. of Radiology, The Johns Hopkins Hospital, medical center in Baltimore, Maryland, USA.
As she treated more and more patients that were referred to her, she came to two conclusions: firstly, those swallowing difficulties manifest themselves as a muscular deficiency, but usually have a neurological dysfunction at the root; and secondly, that there were few effective treatment options. In many cases, patients received only compensatory care which allowed them to function with their disability, but with no active plan to address the underlying problem.
To address the first issue Mary decided that she must study to be a doctor in order to understand the neurology that lies behind dysphagia. It is clear that the day before a patient has a stroke that his or her swallowing can be fine and that it is the neurological event that causes the immediate onset of dysphagia. Mary’s Ph.D. thesis “Sensory-motor brain plasticity in stroke patients with dysphagia. A methodological study on investigation and treatment” 2007, used massage to restore muscular strength by stimulating brain activity. Mary invented and had manufactured a validated scientific instrument to measure the strength of certain components in the swallowing chain by measuring resistance in the pharyngeal sling or buccinator mechanism [18, 19]. She also developed and validated orofacial motor test methodologies [20].
The second problem, the lack of suitable treatments [21, 22] that could be easily and widely used even by the patients themselves was a harder task. Her journey took her through working with all types of dysphagia in people from premature babies through children, adults, and to end-of-life. The journey resulted in her inventing, developing, and patenting the revolutionary IQoro device that is now, July 2021, used by over 50,000 people in many countries.
Decades later Natalie Morris came across the IQoro device, and it set her wondering if it would help her patients too. Natalie is a Speech and Language Therapist working in the UK and is the founder and CEO of The Feeding Trust a not-for-profit multi-disciplinary feeding clinic in the Midlands. During her 20-year career as an SLT, Natalie has become specialist in the assessment and treatment of communication and swallowing difficulties in children and young people (CYP) with neuro-developmental disabilities and acquired brain injuries. She is the founder of Integrated Therapy Solutions Ltd. where she and her team help CYP with swallowing difficulties.
She looked at the scientific evidence supporting IQoro and was disappointed to find that there was none that was directly relevant to one of her main patient groups: CYP clients with Cerebral Palsy (CP). This was significant because NICE guidelines for the management of saliva control in CP [23] offer few options:
Assess contributory factors before starting drug therapy
Medication
Botulinum toxin injections
Surgery
In other words, the only treatment options after considering compensatory strategies such as positioning, are drug therapy or surgery. But the Cochrane review of interventions for drooling in children with CP according to Walshe M, Smith M, Pennington L 2012 [24] concludes: “
Natalie reasoned that if IQoro could help patients with neurological problems such as after a stroke, then it might help her patients with CP too. And if there was no evidence to prove that it worked, then she would have to investigate it herself.
This chapter will show the success of these two clinicians’ work.
This is a brief description of the four different physiological phases of the swallowing process, the following section will look at the neurology of the swallow in detail [5, 25].
During a day, a normal person swallows approximately 600 times: 350 of these are during the day, 200 when eating or drinking, and 50 times when asleep. We use our voluntary muscles to transfer food to our mouths and chew it, after this our reflexive systems take over to complete the swallow unconsciously. When we swallow whilst asleep it is, of course, an entirely reflexive process.
Simply described, the swallowing process starts when we transfer food from the plate to the mouth. (Figure 2). This phase is negatively affected when postural control or arm and hand motility are reduced, possibly after stroke [17].
The four phases of the swallowing process.
Functional and dysfunctional swallow.
The oral phase (Figure 2) starts when we close our lips, chew, reduce the food to manageable pieces and mix it with saliva. As the food is formed into a bolus the tongue’s backward and upwards movements propel it towards the pharynx, at the same time the floor of the mouth rises. And then immediately before the swallowing reflex is triggered we press our lips together creating a low pressure in the mouth. This activity normally takes up to 10 seconds [5]. The decrease in pressure in the mouth eases the transport of the food mixture from the mouth to the pharynx.
The phases employ a mixture of voluntary and involuntary commands.
Once the bolus has passed the anterior palatal arch towards the pharynx, the swallow reflex takes over. This is controlled by the brain stem no longer consciously controlled as the pre-oral and oral phases were. The interplay between the voluntary and involuntary processes is described in the following section on the neurology of the swallow.
A normal swallow requires a balance between the infrahyoid and suprahyoid muscles to stimulate the swallowing reflex [20, 26].
In a later section “The neurology of the swallow” we will see that these muscles are triggered by the following nerves - Infrahyoidal muscles: CN XII hypoglossus.
– Suprahyoidal muscles: CN VII facialis, CN V trigeminus, CN XII hypoglossus.
The swallow reflex is then triggered when the hyoid bone is pulled forwards and upwards (blue arrow) by the digastricus anterior abdomen (CN V), m. mylohyoideus (CN V), and m. geniohyoideus (CN XII). At the same moment, a breathing suspension is caused as the epiglottis closes the laryngeal air pathway, and tongue forward movement is initiated. The chewing muscles are active throughout the swallow.
The pharyngeal phase (Figures 2–4) is a critical part of the swallow controlled purely reflexively and takes between 0.5 and 1 second. It requires a precise interplay between breathing and swallowing functions [5, 13]. When the bolus is to be swallowed, the tongue moves it back towards the anterior palatal arch and the smooth palate which seals against the nasal passages. The larynx raises reflexively, and the tongue starts its forward movement.
The pharyngeal phase - a critical phase requiring coordination of swallowing and breathing.
The first of four security levels to prevent aspiration of food or drink is now activated. The constrictor muscles:
There is perhaps more crossover in dysfunction in the different phases than is often thought. Misdiagnosis is a risk when healthcare professionals concentrate too much on their own specialities without considering a more holistic approach.
For example:
Mis-directed swallowing, post-nasal drip, aspiration, hoarse or gurgly voice, persistent non-productive cough, something stuck in the throat, and blockage are all symptoms often thought of as being caused by a brain injury. Causes of such brain damage can be a stroke, trauma, progressive neurological diseases, or other. In fact, all the symptoms described could equally well be caused by a Hiatal hernia [14].
Patients exhibiting voice changes are often referred in firsthand to a speech and language therapist. If the SLT is not aware that the cause of the problem may be dysfunction in the esophageal phase - like a Hiatal hernia - then optimal outcomes may not be achieved. This problem is aggravated by the fact that SLTs in some countries are not routinely concerned with esophageal dysfunction.
Patients with symptoms of Hiatal hernia are often referred to a medical consultant to rule out the possibility of stroke. When this has been done, then the finger may be pointed at a brain tumor, ALS, or some other neurological condition. Examination for these conditions is both alarming for the patient whilst waiting for examination and results, and expensive. Around 20% of the world’s population suffers from a reflux-based condition, and it is thus logical in many cases to start treating for a Hiatal hernia as soon as stroke has been ruled out.
The esophageal phase (Figure 2) concerns the movement of food and drink from the esophagus down to the stomach. The esophagus’ longitudinal musculature is activated, forming a stiff pipe and allowing the entrance to the Upper Esophageal Sphincter (UES) to relax and open to allow the passage of the bolus into the esophagus. At the same time, the Lower Esophageal Sphincter (LES) opens to allow the entrance of the bolus to the stomach. [5, 29] This phase takes around 7 seconds to complete.
As well as the outer longitudinal layer of muscles, the esophagus also has an inner layer of circular muscles. To transport the food down to the stomach, these circular muscles produce coordinated peristaltic wave motions - this explains why we can swallow even if we were hanging upside down.
The four phases of the swallowing process described above involve 148 muscles and six cranial nerves. Of course, the muscular activities described are not separate from the nerve and brain activity that control them, the entire neurophysiology [25] of the swallowing process must work correctly. Understanding how is fundamental to appreciating how a dysfunctional swallow can be treated.
Figure 5 illustrates four important areas of the brain [25].
Brain stem: It controls non-voluntary “unconscious” automatic functions such as breathing, blood pressure, heart rhythm, the reflex swallowing phases; and also functions as a communication node between the cerebrum, the cerebellum, the spinal cord, and the peripheral nervous system.
Cortex: It controls our voluntary “conscious” most advanced functions such as language, thinking, fine-motor skills, and the voluntary swallowing phases.
Cerebellum: It co-ordinates our movements, our balance, and our ability to act in response to our immediate surroundings.
Corpus callosum: It connects the two brain hemispheres’ cortex areas with each other. It consists of some 200 to 800 million nerves that coordinate the activities of the brain’s two hemispheres.
The brain.
The sensory nerves report perceptions of pressure, texture, taste, and temperature, and these are transmitted by these afferent nerves to the brain. The primary source of these stimuli is from the nerves in the lips and then, in turn, the tongue, soft palate, and pharynx (Figure 6
The cranial nerves and reflex points of the oral cavity.
The five cranial motor nerves that are important for swallowing are CN V Trigeminus, CN VII Facialis, CN IX Glossopharyngeus, CN X, Vagus, and CN XII Hypoglossus. The first four are both sensory (afferent), and motor (efferent) nerve pathways; which send information both to and from the brain - the sensory-motoric reflex arc.
In the brain stem (Figure 7) we find the Nucleus Tractus Solitarius (NTS): the afferent nucleus. The NTS is the core that gathers all incoming sensory signals via the afferent nerve pathways as described (Figure 7). The NTS then transmits the signals onwards either to the brain’s cortex or directly to the network-like system in the brainstem called the Formatio Reticularis (FR). These efferent motor signals are transmitted to the musculature of the face, mouth, esophagus, diaphragm, down to the stomach, the intestines, and the rectum. The process by which the incoming sensory signals trigger afferent commands is known as the sensory-motoric reflex arc (Figure 7) [5, 25, 26, 29].
The sensory-motor reflex arc (level 1).
The three swallowing centers’ interactions - from the brain stem to muscles.
In the FR, the afferent signals from the NTS and the cortex (Figure 7) are first interpreted and then passed through various distribution nodes to the efferent nuclei: the Nucleus Ambiguus (NA), and the Nucleus Dorsalis Nervi Vagi (NDNV).
The NA (Figure 7) sends impulses to the skeletally striated musculature in the oral and pharyngeal regions; and the NDNV (Figure 7) to the smooth musculature of the esophagus and beyond. How these function during swallowing we will explain in more detail below.
In the FR there are three distribution nodes (swallowing centers) that are key to the swallowing process; as well as a number of other centers that control breathing, speech, chewing, coughing, vomiting, evacuation of the bowels and bladder, and those muscles that control the body’s posture (Figure 8). [5, 25, 26, 29].
The Formatio Reticularis (FR) is the control centre for a variety of vital functions.
The Formatio Reticularis is the control centre for several vital functions including breathing, speech, chewing, coughing, vomiting, evacuation of the bowels and bladder, and those muscles that control the body’s posture.
The incoming information is routed by the Nucleus Tractus Solitarius (NTS) in two pathways: some directly to the first of the three swallowing centers in the brain stem, whilst the remainder of the information continues upwards to the cortex to be processed before being also directed to the first swallowing center (Figure 7).
If the combination of information received by the first swallowing center (Figure 9) from the NTS and from the cortex is interpreted as that something is to be swallowed, this instruction is sent to the second swallowing center.
The sensory-motoric reflex arc (level 1–3).
The second swallowing center (Figure 9) transmits signals to the muscles via the motor nerves – the downward-transmitting efferent nerve pathways. Here, there is a pre-programmed “swallow / don’t swallow” stereotypical muscle response.
If the food is to be swallowed, a command is sent to the NA, which in its turn sends the instruction via the efferent nerve pathways to the striated musculature in the oral and pharyngeal regions of the swallowing chain. Concurrently, impulses are also sent to the third swallowing center.
The third swallowing center (Figure 9) transmits information to the NDNV - an efferent nucleus and then onwards to the esophagus’ smooth musculature to complete the swallowing action and to transport the bolus downwards to the stomach.
The three swallowing centers´ interactions from the 2nd center to the striated muscles, and the 3rd center to the smooth muscles is illustrated here.
The 3rd swallowing center transmits information to the Nucleus Dorsalis Nervi Vagi (NDNV), and then onwards to the smooth muscles including those in the esophagus (Figures 9 and 10).
Three types of motor neurons.
The motor signals are transmitted via efferent nerves that can be thought of as cables containing various fibers and motor neurons to the muscles and glands. There are three different kinds of motor neurons that are important in the swallowing process (Figure 10) [5, 25, 29].
The General Somatic Efferent (GSE) motor neurons are present in the CN Hypoglossus (XII) and CN Oculomotorius (III) which transmit signals onwards to the tongue’s and the inner eyes’ voluntary skeletal striated musculature.
The Special Visceral Efferent (SVE) motor neurons act through the CN Trigeminus (V), CN Facialis (VII), CN Glossopharyngeus (IX), CN Vagus (X) and CN Accessorius (XI) which transmit signals to the voluntary musculature in the mouth, chewing muscles, facial musculature, pharynx, larynx, esophagus, and diaphragm.
The General Visceral Efferent (GVE) motor neurons act via CN Facialis (VII) and CN Glossopharyngeus (IX) which transmit signals to the glands, blood vessels, and smooth muscles in the pharynx, stomach, and rectum.
The sum of all the above signals executes pre-programmed cooperation between the 148 muscles that are involved in the transport of each food bite from the mouth down to the stomach.
The efferent nerves send signals via the three different motor neuron fiber types to the muscles and glands.
As we have said earlier, the oral phase is consciously controlled (voluntary) and is managed by the brain’s cortex region [5, 25]. But when the bolus has passed the anterior palatal arch towards the pharynx, the swallow reflex takes over and this is controlled by the brain stem – no longer consciously or voluntarily controlled.
The tongue’s movement backward and upwards transports the food towards the pharynx. When the bolus reaches the anterior palatal arch and the smooth palate, the reflexive phase of the swallow starts [5, 6] causing the larynx to rise, As the tongue begins its return movement forward, the epiglottis seals the airway and the food passes into the pharynx. The pharyngeal phase takes between 0.5 and 1 second.
In this phase, the coordination between breathing and swallowing is crucial to avoid food ‘going down the wrong way’ [5, 25, 30, 31]. Breathing and swallowing are guided by different centers in the brain stem, however, all the muscles that are active in these two functions are controlled from the same concentrated grouping of specialized nerves nucleus in the brain stem. This allows the swallowing center to take control of breathing during a crucial phase in the act of swallowing. When the 1st and 2nd Swallowing Centers signal that swallowing is underway, the body breathes in. During the subsequent exhalation, the food portion is driven to the back of the tongue and the exhalation stops as the bolus crosses the airway. Breathing ceases for 2 seconds about twice as long as it takes for the bolus to pass the pharynx then breathing is resumed with a continued exhalation.
The esophagus’ longitudinal musculature forms a stiff pipe, the UES relaxes and opens to allow the passage of the bolus into the esophagus. The sphincter to the stomach – LES - opens to enable the entrance of the food.
The muscle function and the downwards transport of the bolus are controlled by the Vagus CN X and a branch of the Glossopharyngeal CN IX. Together these nerve pathways build a local network in the esophagus’
Both types of muscle: voluntary skeletal striated muscles and involuntary smooth muscles are present in the esophagus. The voluntary musculature is the same type as we have, for example, in our arms and legs: so-called skeletal striated muscles which are attached to the skeleton or tissue, and that are voluntarily controlled. The smooth musculature cannot be controlled voluntarily but is instead controlled by the autonomic nervous system: functioning unconsciously and involuntarily. These muscles are stimulated via the GVE motor neurons (Figure 10) in the brain stem which sends signals to the involuntary musculature.
The esophagus’ upper third consists of skeletal striated muscles, the middle third is a mixture of skeletal striated muscles and smooth musculature, and the bottom third is solely smooth muscle.
This chapter has so far focussed mostly on the swallowing process of conveying food and drink to the stomach successfully, Hiatus hernia has been mentioned only in passing. Here we explain more about this condition. IQoro treats all dysfunctions in the process of swallowing food and drinks safely and successfully, and in retaining it in the stomach without reflux [14, 32]. A distinction between these two areas although often regarded as separate from a healthcare perspective is artificial. The same neuro-physiological processes are common to both dysfunctional swallowing and reflux.
Reflux-based diseases are thought to affect around 20% of the world’s population [33, 34]. Reflux is a condition in which stomach acids sometimes bubble up from the stomach, through the esophagus, and into the throat, larynx, and pharynx. The effect of these acids is to cause the symptoms of [35]:
Heartburn
Burning sensation in the chest
Acidic reflux
Swallowing difficulties
Feeling of a lump in the throat
Feeling of a blockage in the chest when eating
Chest pains
Pain under the breastbone (sternum)
Stomach pains before eating
Stomach pains after eating
Reduced appetite
Early “Full up’\' feeling
Feeling sick
Constipated, gassy
Vomiting
Persistent dry or phlegmy cough
Food or drink ‘goes down the wrong way’
Hoarseness
Breathing difficulties
It should be noted that if some of the above symptoms are chronic, and especially if they do not respond to medication, they could be caused by cancer or other diseases [36], and this should be considered before diagnosing reflux as the sole cause.
Refluxing stomach acids is the underlying cause of several conditions: LPR, GERD (or GORD), Silent Reflux, IED, Dyspepsia, etc. These conditions are sometimes known by their full names: Laryngopharyngeal Reflux, Gastroesophageal Reflux Disease, and Intermittent Esophageal Dysphagia. These various conditions exhibit some or all of the symptoms listed above, they vary slightly but are all caused by the corrosive effect of the refluxed stomach acids.
These symptoms occur when stomach acids reflux into the esophagus. The normal position of the stomach and the LES - the valve at the mouth of the stomach - is below the diaphragm. The esophagus passes through the diaphragm muscle through an aperture called the hiatus canal. In functional anatomy the muscle grips tightly around the esophagus and holds the stomach down in its correct position. The LES behaves like a trapdoor in this position, swinging downwards to let food and drink into the stomach before closing again. The LES cannot open upwards to allow reflux. An exception to this is if we need to belch or vomit; then the LES intrudes through the diaphragm slightly into the chest cavity and can flap open upwards and allow stomach gases, liquids or solids to reflux.
A Hiatal hernia is a weakening in the muscle that grips around the esophagus where it passes through the diaphragm. When this occurs the mouth of the stomach and the LES can intrude in an unwanted and uncontrolled fashion and allow reflux to occur.
The treatment options for reflux-based diseases fall into two broad camps: reducing the symptoms, or addressing the underlying cause.
In the former category, symptom reduction can be achieved by lifestyle changes or medication. Changing poor living, smoking, drinking, eating and diet habits can improve the impact of reflux, but lifestyle changes have an inconclusive effect [37].
Many Over the Counter (OTC) medications have a base pH and address the problem of reflux by reducing the acidity of the stomach acids which are being refluxed. Although the unpleasant sensations of reflux are reduced, the harmful effects on the vulnerable esophagus and other organs continue. Long-term use of OTC medication is generally regarded to be free from harmful side effects.
Prescribed PPI medications act by inhibiting the amount and strength of the acids produced in the stomach. PPI medications have significant known side effects and hence long-term PPI usage is generally discouraged and several countries insist that clinicians perform a medication review before renewing PPI prescriptions. At least once per year is recommended in the UK [38]. PPI medication is usually not expensive in itself, but the costs of repeat Healthcare Professional (HCP) interventions build to a considerable amount when prescribed for rest-of-life.
PPI drugs belong to one of the safest medication groups, but some research suggests a list of unwanted side effects [39, 40] include increased risk of cardiovascular disease, osteoporosis, dementia, male infertility, diabetes, and increased vulnerability to severe covid19 infection.
In addition, harmful bacteria in the stomach like Helicobacter pylori (HP) that would not survive in normal circumstances, can thrive in the weakened acids after PPI treatment. These germs can enter the body and live in the digestive tract. After many years, they can cause sores, called ulcers, in the lining of the stomach or the upper part of the small intestine. For some people, an infection can lead to stomach cancer.
In the case of all medications, there is no expectation that the underlying cause of the reflux – the weakened diaphragm musculature [34, 41]– will be addressed, merely the severity of the reflux symptoms.
The muscular deficiency at the root of the problem can sometimes be remedied by a surgical operation [42] that re-wraps muscles in the hiatal canal around the esophagus, or a similar procedure. Clearly, addressing the underlying cause is preferable in many ways to long-term medication and IQoro, as presented here, offers a simple non-invasive alternative to a surgical operation.
As discussed, patients with a dysfunctional swallow sometimes after stroke are often treated with compensatory treatments [5, 6]. These care pathways allow patients to live within the limitations of their conditions. Direct and successful treatment of the dysfunctional swallowing chain is to be preferred and is presented in this chapter.
If the cause of both dysphagia and reflux is known to be neuromuscular, why are the most common treatments medication or surgical intervention? It is easy to grasp the idea that rebuilding muscle strength will improve swallowing, and allow the muscles in the Hiatal canal to regain their ability to grip around the esophagus.
If a patient presented with an arm that had atrophied because it had been in a plaster cast for some weeks, we might expect a rehab program based on weights and exercises. However, the atrophied-arm parallel has an important disconnect. As we have explained earlier, there are key differences between the arm muscles and many of the muscles that are needed to ensure an effective swallow and to prevent LES intrusion through the diaphragm allowing reflux. The arm is made up of skeletally striated muscles that can be commanded by the individual to flex, and can therefore be consciously exercised; whereas most of the muscles in the swallowing chain cannot, they are controlled and commanded through other nerve types and command systems. The paradox then is how to exercise muscles that cannot be commanded to flex.
IQoro (Figure 1) is a simple hand-held plastic device that is inserted pre-dentally (inside the lips and in front of the teeth) by a patient and pulled forward against lip pressure to exercise the swallow. At the time of writing, July 2021, it has been used by more than 50,000 individuals and is used by healthcare professionals to treat patients in hospitals and other settings across several countries. It is a CE-marked Class 1 Medical device, internationally patented and costing around USD 150.
The patient inserts the device pre-dentally and seals the lips against the handle, then pulls forward firmly displacing the lips forward slightly. This position is held for 10 seconds, followed by a short pause to relax, and then the action is repeated twice more. This 30-second training session should be carried out three times per day, preferably before mealtimes (Figures 11–13).
(a, b): IQoro training action. (a) the IQoro is inserted pre-dentally, behind closed lips. (b) the patient presses his lips firmly together whilst pulling straight forward strongly for 5–10 seconds, and does this 3 times with 3 seconds rest between each pull. These sessions are performed three times per day, preferably before mealtimes.
Video 1. [
Neurological and physiological considerations in muscle stimulation when eating or during neuromuscular training with IQoro.
Where a patient initially lacks lip strength or has diminished hand or arm function – perhaps after stroke - an assistant can help with this procedure. The vast majority of IQoro users self-treat without assistance.
IQoro causes all the muscles in the swallowing chain to be flexed and thus retrained and strengthened.
Training with IQoro triggers the sensory-motor reflex arc.
The muscles in the chain from the lips through to the upper third of the esophagus are mostly skeletally striated and are voluntarily activated [5, 29] when eating normally. Smooth musculature is present in the lower part of the esophagus, and down through the hiatus canal, LES, stomach, intestines, and rectum, and these muscles can only be activated by signals from the autonomic system [5, 29]. It is thus the case that striated musculature is activated by voluntary neurological and physiological commands, but the smooth muscle can only be activated and exercised via commands from the autonomic system.
Studies show that rehabilitation of the smooth musculature traditionally takes longer [14, 32, 44] and requires ongoing maintenance training after treatment.
When you close your lips tightly against the handle and pull the device forward, a low pressure is created in the mouth, making the tongue retract and seal against the anterior palatal arch and the soft palate. The effect of this is to strongly stimulate the sensory nerves in the oral cavity which send afferent signals to the brainstem as described in the neurology section above. Here they provoke a so-called sensory-motor reflex arc which causes intense efferent motor signals to exercise the muscles in the swallowing chain. In this way, IQoro training reaches and strengthens even the smooth musculature that cannot be voluntarily commanded by the patient.
Training with IQoro activates all the muscles in the swallowing chain, including the outer longitudinal muscles that run along the sides of the esophagus and fasten under the diaphragm. As they are activated by IQoro training they exercise the muscles at the site of the rupture, strengthening the weakened muscles back into a functional condition.
In other words, the training action and regime used to treat dysphagia [10] are equally appropriate for Hiatal hernia and reflux-based conditions [14, 32, 44].
This section presents the scientific support for the efficacy of IQoro in treating the two closely related conditions of dysphagia and reflux-based diseases caused by a hiatal hernia. For reasons of space and readability, most studies have been reduced to short summaries of their purpose and conclusions and a link to the full article. Exceptions to this are 8.1.4 and 8.1.5 which are presented in more detail, having not been published in a scientific journal previously.
The evidence behind the efficacy of IQoro as a treatment for dysphagia includes more than a dozen peer-reviewed and internationally published scientific research papers.
Peer-reviewed, prospective, cohort pre and post-study designed according to Good Clinical Practice (GCP) [15].
This study showed that IQoro is effective in improving swallowing ability, facial activity in all four facial quadrants in patients, and pharyngeal sling force after stroke, irrespective of time from stroke debut to start of treatment. Improvements were still present at late follow-up (>1 year after the end of treatment).
The 31 patients were grouped according to having had a stroke with recent onset, or a long time before. By implication, the similarly successful results in the two groups rule out spontaneous recovery as a likely cause of the improvements seen.
IQoro is effective in improving swallowing ability, facial activity in all four facial quadrants, and pharyngeal sling force after stroke, irrespective of time from stroke debut to start of treatment.
Peer-reviewed, prospective, cohort pre and post-study [17].
The study used IQoro as a treatment for 12 weeks in a patient group that had pathological levels for both Impaired Postural Control (IPC) and Oropharyngeal Motor Dysfunction (OPMD).
The 26 adults recruited to the study were divided between those with recent stroke, and those who had stroke onset a long time before. Results were equally positive in both groups showing the efficacy of IQoro in immediate intervention or in chronic sufferers. Once again, the similar results in the two groups rule out spontaneous recovery as a likely cause of the improvements seen.
At end of training significant improvement (p < 0.001) in tongue and velum function, velopharyngeal closure, and swallowing ability were recorded in the late intervention group. Almost all other outcome improvements in this group showed a (p < 0.01) statistical significance, as did all measures in the early intervention group.
Improvements were maintained at late follow-up (median 59 weeks after the end of training).
Two patients showed no improvement in either IPC or OPMD, all others regained normal abilities in both functions. Five patients presented with Percutaneous Endoscopic Gastrostomy (PEG) feeds at recruitment; all five PEGs were removed by/at end-of-training and all recovered the ability to eat and drink unmodified foods and liquids.
IQoro successfully treats impaired postural control and oropharyngeal motor function in patients with dysphagia after stroke.
PEGs can be removed after several years of use, after 3 months’ IQoro treatment.
Velum function is significantly improved by IQoro training.
Improvements made are still present at long-term follow-up.
The similarity of results in the two intervention groups further supports the contention that improvement is not due to spontaneous remission.
The effectiveness of IQoro treatment is not affected by the time from stroke to the start of treatment, nor the age or gender of the patient.
The positive effect on muscle groups not directly accessed by IQoro neuromuscular training supports the contention that the improvements are triggered by neurological rehabilitation.
Peer-reviewed, prospective, cohort pre and post-study, Randomized Controlled Trial (RCT) [12].
385 elderly participants in intermediate care units were screened, and 116 with impaired swallowing were randomly assigned to IQoro neuromuscular training or usual care. Standard IQoro training was employed: 3 x 10 seconds, three times per day for 5 weeks and patients, were measured at three-time points: before training, at end of training, and at late follow up (6 months post-treatment).
At end of treatment, the geometric mean of the swallowing rate in the intervention group had significantly improved 60% more than that of controls (
Signs of aspiration were significantly reduced in the intervention group compared with controls (
At 6 months post-treatment, the swallowing rate of the intervention group remained significantly better (
No significant between-group differences were found for swallowing-related quality of life.
Treatment ended at discharge from the residential facility in order that a long-term follow-up could determine that the improvements seen at end-of-treatment were sustained. Oral neuromuscular training is a new promising swallowing rehabilitation method for older people in intermediate care. Better clinical results would likely have been achieved if IQoro treatment had continued for longer than 5 weeks.
This study is that performed by Natalie Morris and her team and referred to at the beginning of this chapter.
Difficulty in controlling saliva is a common problem for people with Cerebral Palsy (CP). Drooling is not normally a result of overproduction but inefficient control of salivary secretions due to:
Inadequate lip closure / habitual open mouth posture
Reduced or impaired sensory feedback
Atypical muscle tone
Underlying swallowing difficulties
Dental problems
Side effects from other medications
Impaired postural control
Natalie’s own clinical observations and experiences of working with children and young people (CYP) with CP were that difficulty with saliva control is a persistent problem with no real effective treatment. The Cochrane review of interventions for drooling in children with cerebral palsy concludes, “
The UK’s National Institute for Health and Care Excellence (NICE) guidance [23] on the assessment and management of CP in under 25 s recommends clinicians assess factors that may affect drooling in children and young people with cerebral palsy, these include:
Compensatory strategies and management of contributory factors such as positioning - Multi-Disciplinary Teams (MDT) working with Occupational Therapists (OT) and Physiotherapists to promote head control.
Increasing awareness of saliva - behavioral approaches to prompt children to swallow more often and wipe their faces. However, many people with CP have reduced sensory feedback and are often unaware that their chin is wet. Furthermore, the physical action of wiping their own chin can be difficult.
Oral-motor therapy - aims to target musculature that can be voluntarily trained to improve muscle strength, tonicity, and coordination. However, from a neurological point of view, it is important to consider that although some of our swallows are initiated during the conscious process of eating, drinking, and specific exercises, the majority are reflexive: swallowing away our saliva without conscious involvement. The autonomic nervous system is responsible for the overall control of salivation: these nerves are not under conscious control.
Improving oral health - reducing reflux and maintaining good oral hygiene will reduce the bacterial load of saliva and reduce the risk of infection.
Eliminating mouthing behaviors - some tools that are provided to improve oral skills e.g., chewy tubes for jaw stability, can precipitate difficulties with saliva control if used incorrectly and not as part of a structured program.
Most CYP with CP is given some form of medication to help with saliva control.
NICE produced guidelines in 2017 [23] on the treatment of drooling in children with CP.
The most common medications prescribed are:
Oral Glycopyrronium Bromide
NICE concludes there is moderate evidence for the effectiveness of this treatment and no evidence for the long-term safety. Side effects include dry mouth, vomiting, constipation, and thickening of secretions, which may increase the risk of respiratory infection and pneumonia. Many children are kept on this medication for years, at great cost to the NHS (NICE gives an average of GBP 320 per bottle, around GBP 430 for 28 days’ treatment, approx. GBP 5160 per year).
Hyocine patches + Trihexyphenidyl Hydrochloride
Although commonly prescribed, at the time of publication (January 2017), neither medication had a UK marketing authorization for use in CYP under 18 for treatment of hypersalivation.
Finally, if other treatment methods have been investigated, Botulinum Toxin injections into the salivary glands or surgery to remove the glands may be considered. Although these would obviously be highly aversive experiences and considered only as a last resort.
In 2018, Natalie attended the Association of Speech and Language Therapists in Independent Practice (ASLTIP) conference in London and came across IQoro neuromuscular training device that exercises and strengthens the muscles needed for feeding and swallowing by activating the nervous system to and from the brain. The manufacturers suggest that while traditional oral-motor therapy can target.
The musculature that can be voluntarily trained to improve muscle strength, tonicity, and coordination, it does not target the two-thirds of the swallowing process that is controlled by the autonomic nervous system. IQoro claimed to trigger the sensory-motoric reflex arc which enables messages to be sent to musculature beyond the reach of voluntary control. The sensory-motoric reflex arc [5, 25], (Figure 14) effectively has a “leveraging” effect on direct muscular training and can improve the entire swallowing process.
The sensory-motoric reflex arc.
IQoro could point to an impressive amount of research that had been conducted on adults with acquired swallowing difficulties, but no evidence to support its use with children. The question that interested Natalie was: “
The programme used a case series design: 10 participants aged between 6 and 22 years old all had a primary diagnosis of CP. A single case study design was applied to each individual and in addition to individual outcomes, inferences were drawn from the collective data.
Several measures were taken to establish baselines, and these were compared to the measurements taken after the treatment phase.
She and her team used a mixed-method strategy, producing quantitative data regarding oral motor and swallowing ability as well as collecting qualitative data about how the patients/carers / MDT members perceived the value of the tool.
Natalie chose to use a Goal Attainment Scaling in Rehabilitation (GAS) method; GAS statistically scores the extent to which each patient’s individual goals are achieved in the course of intervention. There is substantial literature that demonstrates its usefulness, both as part of the communication and decision-making process and as a person-centered outcome measure for rehabilitation [45]. Original: [46].
Baseline assessments were taken of swallowing ability, oral motor function, and speech.
Rating scales were used that allowed for skill breakdown and functional description of each area.
The baseline assessment scores were used to set for intervention.
An individual program for using the IQoro was designed for each patient and then carried out 3 x per day (by parents/carers) for 20 weeks.
The composite GAS is transformed into a standardized measure with a mean of 50. If goals are set in an unbiased fashion, one would expect a normal distribution of scores, and the GAS thus performs at the interval level. If goals have been fully achieved, we would expect to see a score of 50 (Table 1).
GAS Score | Swallowing | Oral Motor | Speech |
---|---|---|---|
Baseline | 35.1 | 34.5 | 32.2 |
Range | 34.9–35.8 | 31.3–36.3 | 26.5–35.2 |
Achieved | 53.7 | 48.1 | 32.2 |
Range | 44.3–60.3 | 45.8–51.6 | 26.5–35.2 |
Change | 18.8 | 13.6 | 0 |
Range | 8.5–25.3 | 10.6–20.3 | 0 |
Results showing GAS scores pre and post-treatment.
Results indicated that IQoro does improve saliva control in children with CP, with improvements also demonstrated with oral motor skills. Using the measures of articulation, there was no change to speech. However, changes to voice were observed in the qualitative analysis (Table 2).
Improved outcomes in swallowing and oral motor skills, but not speech.
In this study, it has been possible to demonstrate an improvement with saliva control resulting from treatment using IQoro. On average, ratings reduced from 4 (“unable to control”, saliva loss 75–100% of the time) to 2 (“moderate difficulty”, saliva loss 25–50% of the time). However, at least half of the participants improved further to a score of 1 (“mild difficulty”, saliva loss 10–25% of the time).
Qualitative data reported (but not measured) saw improvements with: teeth brushing; nasal breathing; breath control for speech; reduction in chest infections; sensory feedback (perception of saliva on chin) and tongue retraction. Positive feedback has been received from schools (less damage from saliva to IT equipment and worksheets) and physio colleagues (able to work in supine for longer periods due to an increase in swallowing of secretions).
Future plans include creating an assessment protocol and running a training program. Further research is indicated to see if this would be a cost-effective treatment that could be made available on the NHS.
It has been the case that there is a severe lack of options in treating children and young people with Cerebral Palsy with dysfunction that leads to drooling. Existing medication and surgical intervention alternatives are often ineffective, invasive, and even not strictly approved for patients in these age groups. Many medication alternatives are expensive when compared with IQoro treatment.
IQoro has been proved to be a suitable treatment for the group studied, including those at the higher end of the scale of motoric and other difficulties. In the case of some of the latter, two assistants were required to perform the training.
Swallowing and oral motor competence improved significantly to a level around the 50-point target of the GAS goals, although the measured speech ability did not. Other functions and abilities important in daily life also improved as reported above.
Much-improved drooling and saliva control had great influence in improving the patients’ quality of life, not least where it allowed the use of laptops, books, and other educational material in schools.
Roseanne, Exell 1; Hayley McBain 2; Sam Turvey 2; Gill Hardy 1
Royal Devon and Exeter NHS Foundation Trust
South West Academic Health Science Network
A service evaluation was carried out in southern England in 2020 resulting in the following abstract.
This evaluation explored the introduction of IQoro into a National Health Service (NHS) setting.
Patients with chronic dysphagia were recruited from acute and community settings and completed a 12-week program using IQoro. Clinical and well-being measures were taken pre and post-training. Feedback was gained from the Speech and Language Therapists delivering this program.
25 patients were recruited into the evaluation, 21 completed the program. There were significant improvements in self-reported quality of life scores, including the overall scores and burden of dysphagia and mental health subscales. There was a significant improvement in functional measures of dysphagia, including the consistencies of food and drink that patients could safely manage. There was also a significant improvement in the facial movement and symmetry of the lower half of the face. Feedback from SLTs indicated that IQoro improved the range of therapy options available and many planned to use it again. Qualitative feedback suggested that the use of IQoro may change SLTs clinical thinking, including in relation to intervention or compensation for dysphagia.
IQoro can be successfully introduced into an NHS team and can be effective in supporting patients with chronic dysphagia. However, factors such as the ability to follow patients across different settings and the individual risk of further decline need to be considered.
In an email survey in June 2021 of all IQoro users that had purchased within the previous 1–15 months, users were canvassed on the effectiveness of IQoro treatment for dysphagia. Totally 4440 responses were received, 983 were specifically treating symptoms associated with dysphagia after stroke. Patients had trained for 1 month or more (Table 3).
Symptom free | Big improvement | Small improvement | No improvement yet | ||
---|---|---|---|---|---|
Difficulty in swallowing liquids safely | 11% | 42% | 33% | 14% | 100% |
Difficulty in swallowing solid foods | 7% | 35% | 38% | 21% | 100% |
Drooling | 9% | 24% | 44% | 23% | 100% |
Facial or speech weakness | 4% | 28% | 47% | 21% | 100% |
Improved outcomes in swallowing and facial abilities.
This survey of a large population of people using IQoro to treat various types of dysphagia and facial weakness is that their outcome experience is positive. This survey differs from the studies quoted elsewhere in this chapter in that the results shown are not at end-of-training in all cases. Many had not trained long enough at the time of the survey to experience the full effect in symptom reductions: some having only trained for as little as 1 month. Nevertheless, 79% - 86% reported symptom improvements since starting training.
The UK’s National Institution for Health and Care Excellence (NICE)), was commissioned by the UK government and advises and supports National Health Service and social care commissioners and have made a review of IQoro and its claims and effectiveness. They have issued a Medtech Innovation Briefing [47] that recognized “
Reflux occurs when the neck of the stomach and the Lower Esophageal Sphincter (LES) intrude through the diaphragm into the chest cavity. In this position, the LES can open upwards and allow stomach contents to reflux, in its correct position it can only allow one-way traffic downwards. This intrusion or hernia is made possible when the musculature of the diaphragm around the hiatal canal is weakened (Figure 15).
(A) Sliding hiatal hernia. The upper part of the stomach and the LES has slid up through the hiatal canal. This allows gastroesophageal reflux and also causes difficulties with opening the PES at the top of the esophagus. (B) Normal anatomy. The neck of the stomach is correctly held below the diaphragm promoting normal LES function and preventing reflux.
IQoro is an effective treatment for reflux-based diseases and their various symptoms: heartburn, pain behind the sternum, persistent unproductive cough, blockage in the throat, and more. Training with IQoro provokes stimuli from the brainstem to flex and strengthen all the muscles in the swallowing chain including those allowing a Hiatal hernia.
The evidence behind the efficacy of IQoro as a treatment for Hiatus hernia includes the following three peer-reviewed and internationally published scientific research papers which are briefly summarized here.
Peerreviewed, Prpospective, cohort pre and post-study [14].
43 patients who had esophageal dysphagia for a median of 3 years (range: 1–15 years) were recruited to this study. All displayed the symptoms of a Hiatal hernia, but only 21 had had their condition confirmed by examination. All had been prescribed Proton Pump Inhibitor (PPI) medication for more than 1 year without any effect, all medication ceased at the start of IQoro treatment.
A validated test battery was employed at baseline and at end of training including questionnaires and tests for all patients. In addition to these measures 12 patients with confirmed hiatal hernia were measured using High Resolution Manometry (HRM) [48] to measure pressure at resting and during IQoro traction.
No statistical difference (p = NS) between symptoms or outcomes between those with or without confirmed Hiatal hernia diagnosis – both before and after treatment.
Esophageal dysphagia was present in all 43 patients at start of treatment, and 98% of patients showed improvement after IQoro neuromuscular training (p < 0.001).
Reflux symptoms were reported before training in 86% of the patients, 100% of these showed improvement at end of training, (p < 0.001) and 58% were entirely symptom free. All patients ceased PPI medication at recruitment to the study.
VAS scores were classified as pathologic in all 43 patients, and 100% showed improvement after IQoro neuromuscular training (p < 0.001).
Pharyngeal sling force and velum closure test values were both significantly higher (p < 0.001) after IQoro neuromuscular training.
Those tested with HRM showed the following results:
During IQoro traction there was an increase in mean pressure in the diaphragmatic hiatus region and in the Upper Esophageal Sphincter (UES) (Table 4).
Items Pressures in mmHg | UES | Hiatus |
---|---|---|
Normal pressure | >30 | 10–35 |
Resting pressure | 68 (40–110) | 0 (0–0) |
During IQoro traction | 95 (80–130) | 65 (20–100) |
High-resolution manometry (HRM) results in UES and hiatus both at rest and during IQoro traction.
Data are mean (range) mmHg.
IQoro neuromuscular training can relieve/improve esophageal dysphagia and reflux symptoms in adults, likely due to improved hiatal competence. The similarity of the results in the two groups suggests that many people suffer from Hiatus hernia despite this not having been confirmed by diagnosis.
Peer-reviewed, prospective, cohort pre and post-study [17].
The study investigated whether 28 patients with hiatal hernia and misdirected swallowing and esophageal retention symptoms could be successfully treated with a 6-month regime of standard IQoro training: 30 seconds three times per day. Patients had had their condition for median of 4 years (range 1–28).
Reflux symptoms were reported before training in all patients,
100% of these showed improvement (p < 0.001) at end of the training, and 61% were entirely symptom-free despite ceasing PPI medication at the start of training.
All hiatal hernia patients were improved after training with IQoro and showed significant improvements (p < 0.001) in
misdirected swallowing,
cough,
hoarseness,
esophageal retention,
globus sensation,
scores for VAS, pharyngeal sling force, VCT, and TWST.
Traction during the training action with IQoro resulted in a 65 mmHg increase in the mean pressure of the diaphragmatic hiatus as measured by high-resolution manometry (Table 4).
IQoro training significantly improves all the symptoms of hiatus hernia, likely through improved hiatal competence.
Peer reviewed, prospective, clinical study, cohort pre and post-study [32].
It has been thought that treatment of Hiatus hernia in overweight patients can be unproductive and that weight loss should be a prior step to interventions.
In this study 86 adult patients with verified hiatal hernias and long-standing Intermittent Esophageal Disease (IED) and other Gastro-Esophageal Reflux Disease (GERD) symptoms were grouped according to their Body Mass Index (BMI), before entry into the study (Table 5): Group A: normal weight, Group B: moderately obese, Group C: severely obese.
Items | Group A; | Group B; | Group C; |
---|---|---|---|
Median age | 69 yrs. (20–85) | 57 yrs. (22–85) | 62 yrs. (44–87) |
Gender | 19 women, 18 men | 16 women, 12 men | 11 women, 10 men |
5 yrs. (1–75) | 6 yrs. (1–15) | 3 yrs. (1–29) | |
BMI before/after IQNT | 23 (17–24) /23 (20–25) | 28 (26–29) / 27 (24–29) | 33 (30–37) / 31 (27–38) |
Analysis of subjects by BMI grouping - age, gender, and GERD symptom duration.
Ranges in parentheses. BMI and GERD: median values; IQNT: Neuromuscular training with an oral IQoro.
At entry into the study there were no significant differences between the three BMI groups in baseline testing for swallowing ability, or for IED and GERD symptom severity, except that:
Heartburn and cough were significantly more common in Groups B (moderately obese) and C (severely obese).
Misdirected swallowing was significantly more common in Group C.
After IQoro neuromuscular training, the following was observed in all three BMI groups:
All IED and GERD symptom scores were significantly improved or reduced (p < 0.001).
Median BMI was not significantly changed.
Self-assessed GERD symptom improvement showed no significant difference across the groups, except for heartburn, cough, and misdirected swallowing which were significantly (p < 0.01) more reduced in obese patients than in normal bodyweight patients.
The swallowing tests showed significant improvement (p < 0.001) in median values, with no significant difference between the BMI groups except for:
Timed Water Swallow Test (TWST) values, which were significantly (p < 0.01) more improved in Group C (severely obese) than in Group A (normal weight).
pharyngeal sling force, which was significantly (p < 0.05) more improved in Group B (moderately obese) than in Group A.
IQoro neuromuscular training (IQNT), a non-surgical treatment for IED and other GERD symptoms in hiatal hernia patients, is equally successful in treating moderately or severely obese patients as in treating sufferers of normal weight. Obesity in itself does not, therefore, seem to be a handicap in treating IED and other GERD symptoms by IQNT.
In an email survey in June 2021 of all IQoro users that had purchased within the previous 15 months, users were canvassed on the effectiveness of IQoro treatment for dysphagia. Totally 4440 responses were received of which 3436 were specifically treating classic reflux symptoms caused by Hiatus hernia, the rest of the responses were from people treating symptoms associated with dysphagia after stroke or snoring and sleep apnoea. Patients had trained for 1 month or more.
76%–84% of respondents reported symptom improvement, it can be assumed that some of those not yet reporting improvements had only trained for a short while (Table 6).
Symptom free | Big improvement | Small improvement | No improvement yet | ||
---|---|---|---|---|---|
Reflux / acid reflux | 6% | 40% | 37% | 17% | 100% |
Heartburn | 9% | 42% | 34% | 15% | 100% |
A sensation of something stuck in your throat | 12% | 38% | 34% | 17% | 100% |
Excessive or thick phlegm | 4% | 30% | 42% | 24% | 100% |
Dry, persistent cough | 8% | 34% | 36% | 22% | 100% |
Gassy, burping often | 4% | 35% | 39% | 22% | 100% |
Pain in your chest or esophagus | 11% | 39% | 33% | 17% | 100% |
Food that you have swallowed comes up again | 15% | 38% | 31% | 16% | 100% |
Hoarseness | 8% | 29% | 39% | 24% | 100% |
Improved outcomes in hiatal hernia related symptoms.
A large population, 3436 people, using IQoro to treat reflux symptoms showed positive outcome experiences. This survey differs from the studies quoted elsewhere in this chapter in that the results shown are not at end-of-training in all cases. Many had not trained long enough at the time of the survey to experience the full effect in symptom reductions: some having only trained for as little as 1 month. Nevertheless, 76% - 85% reported symptom improvements since starting training.
In March 2019 the UK’s National Institute for Health and Care Excellence (NICE) developed a Medtech Innovation Briefing (MIB) [49] regarding the use of IQoro to treat Hiatus hernia, it points out the innovative nature of the device and its potential to save the NHS money.
All versions of dysphagia have an unsatisfactory range of treatment options. Swallowing difficulties, reflux, and other manifestations are often met with compensatory strategies instead of the treatment of the underlying causes. IQoro is simple, inexpensive, non-invasive, and takes just 90 seconds per day.
IQoro is proven both in clinical practice and in research studies to be highly effective in treating the underlying causes of the conditions and symptoms described in this book. The evidence base for its efficacy is strong.
This innovative device and treatment are shown to be effective in treating all types of dysphagia in the pre-oral, oral, pharyngeal, and esophageal phases. Similarly, Hiatus hernia and its resulting reflux symptoms can be addressed successfully. In all of these conditions, it is shown that time from onset of the condition stroke or Hiatus hernia for example, to the time when IQoro treatment starts, does not affect the positive outcome results of the treatment. The stroke studies show that improvements achieved at end-of-treatment persist at long-term follow-up. Several studies and evaluations show that patients with PEG feeding tubes have had them removed after IQoro therapy.
All healthcare professionals working with dysphagia and its related conditions should want to know more about IQoro and how it improves patient outcomes and gives clinicians an important and powerful new treatment option.
The authors would like to thank Terry Morris (no relation to the author) for his assistance in authoring this chapter, for creating the summary of abstracts from which several of the above studies are copied, and for performing the data analysis on the customer survey referred to above.
The authors would also like to thank Gill Hardy, Speech and Language Therapist, Clinical Lead Neurology, and her colleagues at the Royal Devon and Exeter NHS Foundation Trust and also Roseanne Exell and Hayley McBain at the South West Academic Health Science Network for their kind permission to reproduce the abstract of their service evaluation shown above.
Some studies reproduced above were supported by grants from The Centre for Research & Development, Uppsala University/County Council of Gävleborg, Gävle, Sweden, and The Council for Regional Research in Uppsala and Örebro region, Sweden.
IQoro is patented in Sweden - SE 1350314-9, 2014 July 14 - and widely internationally. It is CE-marked as a Class 1 Medical Device for therapeutic use by the manufacturer MYoroface AB. Mary Hägg is the inventor.
The authors, Mary Hägg and Natalie Morris declare that they have no conflict of interest.
All studies were performed according to the Helsinki Declaration. Informed written and verbal consent was obtained from all the participants in the studies. All images are kindly provided by MYoroface AB.
"Open access contributes to scientific excellence and integrity. It opens up research results to wider analysis. It allows research results to be reused for new discoveries. And it enables the multi-disciplinary research that is needed to solve global 21st century problems. Open access connects science with society. It allows the public to engage with research. To go behind the headlines. And look at the scientific evidence. And it enables policy makers to draw on innovative solutions to societal challenges".
\n\nCarlos Moedas, the European Commissioner for Research Science and Innovation at the STM Annual Frankfurt Conference, October 2016.
",metaTitle:"About Open Access",metaDescription:"Open access contributes to scientific excellence and integrity. It opens up research results to wider analysis. It allows research results to be reused for new discoveries. And it enables the multi-disciplinary research that is needed to solve global 21st century problems. Open access connects science with society. It allows the public to engage with research. To go behind the headlines. And look at the scientific evidence. And it enables policy makers to draw on innovative solutions to societal challenges.\n\nCarlos Moedas, the European Commissioner for Research Science and Innovation at the STM Annual Frankfurt Conference, October 2016.",metaKeywords:null,canonicalURL:"about-open-access",contentRaw:'[{"type":"htmlEditorComponent","content":"The Open Access publishing movement started in the early 2000s when academic leaders from around the world participated in the formation of the Budapest Initiative. They developed recommendations for an Open Access publishing process, “which has worked for the past decade to provide the public with unrestricted, free access to scholarly research—much of which is publicly funded. Making the research publicly available to everyone—free of charge and without most copyright and licensing restrictions—will accelerate scientific research efforts and allow authors to reach a larger number of readers” (reference: http://www.budapestopenaccessinitiative.org)
\\n\\nIntechOpen’s co-founders, both scientists themselves, created the company while undertaking research in robotics at Vienna University. Their goal was to spread research freely “for scientists, by scientists’ to the rest of the world via the Open Access publishing model. The company soon became a signatory of the Budapest Initiative, which currently has more than 1000 supporting organizations worldwide, ranging from universities to funders.
\\n\\nAt IntechOpen today, we are still as committed to working with organizations and people who care about scientific discovery, to putting the academic needs of the scientific community first, and to providing an Open Access environment where scientists can maximize their contribution to scientific advancement. By opening up access to the world’s scientific research articles and book chapters, we aim to facilitate greater opportunity for collaboration, scientific discovery and progress. We subscribe wholeheartedly to the Open Access definition:
\\n\\n“By “open access” to [peer-reviewed research literature], we mean its free availability on the public internet, permitting any users to read, download, copy, distribute, print, search, or link to the full texts of these articles, crawl them for indexing, pass them as data to software, or use them for any other lawful purpose, without financial, legal, or technical barriers other than those inseparable from gaining access to the internet itself. The only constraint on reproduction and distribution, and the only role for copyright in this domain, should be to give authors control over the integrity of their work and the right to be properly acknowledged and cited” (reference: http://www.budapestopenaccessinitiative.org)
\\n\\nOAI-PMH
\\n\\nAs a firm believer in the wider dissemination of knowledge, IntechOpen supports the Open Access Initiative Protocol for Metadata Harvesting (OAI-PMH Version 2.0). Read more
\\n\\nLicense
\\n\\nBook chapters published in edited volumes are distributed under the Creative Commons Attribution 3.0 Unported License (CC BY 3.0). IntechOpen upholds a very flexible Copyright Policy. There is no copyright transfer to the publisher and Authors retain exclusive copyright to their work. All Monographs/Compacts are distributed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0). Read more
\\n\\nPeer Review Policies
\\n\\nAll scientific works are Peer Reviewed prior to publishing. Read more
\\n\\nOA Publishing Fees
\\n\\nThe Open Access publishing model employed by IntechOpen eliminates subscription charges and pay-per-view fees, enabling readers to access research at no cost. In order to sustain operations and keep our publications freely accessible we levy an Open Access Publishing Fee for manuscripts, which helps us cover the costs of editorial work and the production of books. Read more
\\n\\nDigital Archiving Policy
\\n\\nIntechOpen is committed to ensuring the long-term preservation and the availability of all scholarly research we publish. We employ a variety of means to enable us to deliver on our commitments to the scientific community. Apart from preservation by the Croatian National Library (for publications prior to April 18, 2018) and the British Library (for publications after April 18, 2018), our entire catalogue is preserved in the CLOCKSS archive.
\\n\\nOpen Science is transparent and accessible knowledge that is shared and developed through collaborative networks.
\\n\\nOpen Science is about increased rigour, accountability, and reproducibility for research. It is based on the principles of inclusion, fairness, equity, and sharing, and ultimately seeks to change the way research is done, who is involved and how it is valued. It aims to make research more open to participation, review/refutation, improvement and (re)use for the world to benefit.
\\n\\nOpen Science refers to doing traditional science with more transparency involved at various stages, for example by openly sharing code and data. It implies a growing set of practices - within different disciplines - aiming at:
\\n\\nWe aim at improving the quality and availability of scholarly communication by promoting and practicing:
\\n\\n\\n"}]'},components:[{type:"htmlEditorComponent",content:'
The Open Access publishing movement started in the early 2000s when academic leaders from around the world participated in the formation of the Budapest Initiative. They developed recommendations for an Open Access publishing process, “which has worked for the past decade to provide the public with unrestricted, free access to scholarly research—much of which is publicly funded. Making the research publicly available to everyone—free of charge and without most copyright and licensing restrictions—will accelerate scientific research efforts and allow authors to reach a larger number of readers” (reference: http://www.budapestopenaccessinitiative.org)
\n\nIntechOpen’s co-founders, both scientists themselves, created the company while undertaking research in robotics at Vienna University. Their goal was to spread research freely “for scientists, by scientists’ to the rest of the world via the Open Access publishing model. The company soon became a signatory of the Budapest Initiative, which currently has more than 1000 supporting organizations worldwide, ranging from universities to funders.
\n\nAt IntechOpen today, we are still as committed to working with organizations and people who care about scientific discovery, to putting the academic needs of the scientific community first, and to providing an Open Access environment where scientists can maximize their contribution to scientific advancement. By opening up access to the world’s scientific research articles and book chapters, we aim to facilitate greater opportunity for collaboration, scientific discovery and progress. We subscribe wholeheartedly to the Open Access definition:
\n\n“By “open access” to [peer-reviewed research literature], we mean its free availability on the public internet, permitting any users to read, download, copy, distribute, print, search, or link to the full texts of these articles, crawl them for indexing, pass them as data to software, or use them for any other lawful purpose, without financial, legal, or technical barriers other than those inseparable from gaining access to the internet itself. The only constraint on reproduction and distribution, and the only role for copyright in this domain, should be to give authors control over the integrity of their work and the right to be properly acknowledged and cited” (reference: http://www.budapestopenaccessinitiative.org)
\n\nOAI-PMH
\n\nAs a firm believer in the wider dissemination of knowledge, IntechOpen supports the Open Access Initiative Protocol for Metadata Harvesting (OAI-PMH Version 2.0). Read more
\n\nLicense
\n\nBook chapters published in edited volumes are distributed under the Creative Commons Attribution 3.0 Unported License (CC BY 3.0). IntechOpen upholds a very flexible Copyright Policy. There is no copyright transfer to the publisher and Authors retain exclusive copyright to their work. All Monographs/Compacts are distributed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0). Read more
\n\nPeer Review Policies
\n\nAll scientific works are Peer Reviewed prior to publishing. Read more
\n\nOA Publishing Fees
\n\nThe Open Access publishing model employed by IntechOpen eliminates subscription charges and pay-per-view fees, enabling readers to access research at no cost. In order to sustain operations and keep our publications freely accessible we levy an Open Access Publishing Fee for manuscripts, which helps us cover the costs of editorial work and the production of books. Read more
\n\nDigital Archiving Policy
\n\nIntechOpen is committed to ensuring the long-term preservation and the availability of all scholarly research we publish. We employ a variety of means to enable us to deliver on our commitments to the scientific community. Apart from preservation by the Croatian National Library (for publications prior to April 18, 2018) and the British Library (for publications after April 18, 2018), our entire catalogue is preserved in the CLOCKSS archive.
\n\nOpen Science is transparent and accessible knowledge that is shared and developed through collaborative networks.
\n\nOpen Science is about increased rigour, accountability, and reproducibility for research. It is based on the principles of inclusion, fairness, equity, and sharing, and ultimately seeks to change the way research is done, who is involved and how it is valued. It aims to make research more open to participation, review/refutation, improvement and (re)use for the world to benefit.
\n\nOpen Science refers to doing traditional science with more transparency involved at various stages, for example by openly sharing code and data. It implies a growing set of practices - within different disciplines - aiming at:
\n\nWe aim at improving the quality and availability of scholarly communication by promoting and practicing:
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His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. 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On the other hand, the accumulation of huge amounts of food wastes every year has led to environmental degradation and especially to significant loss of valuable material that could otherwise be exploited as new health-promoting ingredients, fuels and a great variety of additives. In this respect, the biggest challenge of the current scientific world is to convert the underutilised by-products generated by the food and beverage industries into more profitable and marketable added value products which would also contribute significantly to meet the nowadays society needs. This chapter gives an overview regarding the possibility of exploiting the brewing industry wastes as sources of bioactive compounds in order to produce functional ingredients and products with added value.",book:{id:"5967",slug:"brewing-technology",title:"Brewing Technology",fullTitle:"Brewing Technology"},signatures:"Anca Corina Fărcaş, Sonia Ancuța Socaci, Elena Mudura, Francisc\nVasile Dulf, Dan C. 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Initially, the differences between Saccharomyces cerevisiae and Saccharomyces pastorianus in the production of “ale” and “lager” beers are analyzed. Then, the relationships between beer nutrients and yeast growth are discussed, with special emphasis on the production of the flavor compounds. The impact of the wort composition on flocculation is also discussed. Furthermore, conventional approaches to starter yeast selection and the development of genetically modified microorganisms are analyzed. Recent discoveries relating to the use of S. cerevisiae strains isolated from different food matrices (i.e., bread and wine) and the potential for the use of non-Saccharomyces starter strains in beer production are discussed. A detailed review of the selection of starter strains for the production of specialty beers then follows, such as for gluten-free beers and biologically aged beers. Yeast recovery from top-cropping and bottom-cropping systems and the methodologies and issues in yeast propagation in the laboratory and brewery (i.e., re-pitching) are also analyzed. Finally, the available commercial preparations of starter yeast and the methods to evaluate yeast viability prior to inoculation of the must are analyzed.",book:{id:"5967",slug:"brewing-technology",title:"Brewing Technology",fullTitle:"Brewing Technology"},signatures:"Marilena Budroni, Giacomo Zara, Maurizio Ciani and Francesca\nComitini",authors:[{id:"201812",title:"Prof.",name:"Marilena",middleName:null,surname:"Budroni",slug:"marilena-budroni",fullName:"Marilena Budroni"},{id:"202915",title:"Dr.",name:"Giacomo",middleName:null,surname:"Zara",slug:"giacomo-zara",fullName:"Giacomo Zara"},{id:"206674",title:"Prof.",name:"Maurizio",middleName:null,surname:"Ciani",slug:"maurizio-ciani",fullName:"Maurizio Ciani"},{id:"206675",title:"Prof.",name:"Francesca",middleName:null,surname:"Comitini",slug:"francesca-comitini",fullName:"Francesca Comitini"}]},{id:"55333",doi:"10.5772/intechopen.68822",title:"Electronic Noses Applications in Beer Technology",slug:"electronic-noses-applications-in-beer-technology",totalDownloads:2250,totalCrossrefCites:6,totalDimensionsCites:14,abstract:"This chapter describes and explains in detail the electronic noses (e-noses) as devices composed of an array of sensors that measure chemical volatile compounds and apply classification or regression algorithms. Then, it reviews the most significant applications of such devices in beer technology, with examples about defect detection, hop classification, or beer classification, among others. After the review, the chapter illustrates two applications from the authors, one about beer classification and another about beer defect detection. Finally, after a comparison with other analytical techniques, the chapter ends with a summary, conclusions, and the compelling future of the e-noses applied to beer technology.",book:{id:"5967",slug:"brewing-technology",title:"Brewing Technology",fullTitle:"Brewing Technology"},signatures:"José Pedro Santos, Jesús Lozano and Manuel Aleixandre",authors:[{id:"202750",title:"Dr.",name:"José Pedro",middleName:null,surname:"Santos",slug:"jose-pedro-santos",fullName:"José Pedro Santos"},{id:"202993",title:"Dr.",name:"Jesús",middleName:null,surname:"Lozano",slug:"jesus-lozano",fullName:"Jesús Lozano"},{id:"202994",title:"Dr.",name:"Manuel",middleName:null,surname:"Aleixandre",slug:"manuel-aleixandre",fullName:"Manuel Aleixandre"}]},{id:"55582",doi:"10.5772/intechopen.68793",title:"Use of Non-Saccharomyces Yeasts in Bottle Fermentation of Aged Beers",slug:"use-of-non-saccharomyces-yeasts-in-bottle-fermentation-of-aged-beers",totalDownloads:2370,totalCrossrefCites:8,totalDimensionsCites:14,abstract:"Bottle fermented and brewed beers are reaching more recognition in present days due to their high sensory complexity. These beers normally are produced by an initial tank fermentation to metabolize the sugars obtaining the typical alcoholic degree, and later the foam and CO2 pressure is produced by subsequent bottle fermentation. The sensory profile is improved by the formation of some fermentative volatiles, but also by the ageing on lees, because beers are brewed during several months with the yeast cells that performed the fermentation. The use of non-Saccharomyces yeast is a trending topic in many fermentative food industries (wines, beer, bread, etc.). They open new possibilities to modulate flavor and other sensory properties during fermentation and biological ageing. This chapter review the effect of some non-Saccharomyces yeasts such as Schizosaccharomyces pombe, Torulaspora delbrueckii, Lachancea thermotolerans, Saccharomycodes ludwigii, and Brettanomyces bruxellensis in the bottle fermentation and brewing of beers analyzing their metabolic specificities and sensory contribution on beer taste.",book:{id:"5967",slug:"brewing-technology",title:"Brewing Technology",fullTitle:"Brewing Technology"},signatures:"María Jesús Callejo, Carmen González and Antonio Morata",authors:[{id:"180952",title:"Prof.",name:"Antonio",middleName:null,surname:"Morata",slug:"antonio-morata",fullName:"Antonio Morata"},{id:"201383",title:"Prof.",name:"María Jesús",middleName:null,surname:"Callejo",slug:"maria-jesus-callejo",fullName:"María Jesús Callejo"},{id:"201384",title:"Prof.",name:"Carmen",middleName:null,surname:"González",slug:"carmen-gonzalez",fullName:"Carmen González"}]},{id:"54903",doi:"10.5772/intechopen.68359",title:"Barley (Hordeum vulgare L.) 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We aimed to discuss some important and/or recent studies and improvements about barley for understanding the factors responsible for converting barley plants into the superior cereals, which occurred through gene transfers, gene editing and molecular breeding, which is important and could help us enhance the current pool of cultivated barley species to provide enough material for the future.",book:{id:"5967",slug:"brewing-technology",title:"Brewing Technology",fullTitle:"Brewing Technology"},signatures:"Nermin Gozukirmizi and Elif Karlik",authors:[{id:"185345",title:"Dr.",name:"Nermin",middleName:null,surname:"Gozukirmizi",slug:"nermin-gozukirmizi",fullName:"Nermin Gozukirmizi"},{id:"201910",title:"MSc.",name:"Elif",middleName:null,surname:"Karlik",slug:"elif-karlik",fullName:"Elif Karlik"}]}],mostDownloadedChaptersLast30Days:[{id:"55333",title:"Electronic Noses Applications in Beer Technology",slug:"electronic-noses-applications-in-beer-technology",totalDownloads:2250,totalCrossrefCites:6,totalDimensionsCites:14,abstract:"This chapter describes and explains in detail the electronic noses (e-noses) as devices composed of an array of sensors that measure chemical volatile compounds and apply classification or regression algorithms. Then, it reviews the most significant applications of such devices in beer technology, with examples about defect detection, hop classification, or beer classification, among others. After the review, the chapter illustrates two applications from the authors, one about beer classification and another about beer defect detection. 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As a determinant factor for flavor, taste, and color of alcoholic beverages, Nuruk is an indispensable ingredient for brewing alcoholic beverages in Korea. Nuruk shows significant variation in the shape, and in the brewing and fermentation methods, which are dependent on the unique climate in each area. Therefore, it is worthy to note that the characteristics of Korean traditional Nuruk are based on its diversity. Thus, this chapter is aimed to scientifically identify the characteristics of traditional Nuruk on brewing technology. In this chapter, the concept of Nuruk will be discussed in terms of its history, production, microorganism diversity, and enzymatic function.",book:{id:"5967",slug:"brewing-technology",title:"Brewing Technology",fullTitle:"Brewing Technology"},signatures:"Jang-Eun Lee and Jae-Ho Kim",authors:[{id:"201205",title:"Dr.",name:"Jang Eun",middleName:null,surname:"Lee",slug:"jang-eun-lee",fullName:"Jang Eun Lee"},{id:"204620",title:"Dr.",name:"Jae-Ho",middleName:null,surname:"Kim",slug:"jae-ho-kim",fullName:"Jae-Ho Kim"}]},{id:"55278",title:"Saccharomyces and Non-Saccharomyces Starter Yeasts",slug:"saccharomyces-and-non-saccharomyces-starter-yeasts",totalDownloads:2342,totalCrossrefCites:9,totalDimensionsCites:17,abstract:"This chapter describes the importance of yeast in beer fermentation. Initially, the differences between Saccharomyces cerevisiae and Saccharomyces pastorianus in the production of “ale” and “lager” beers are analyzed. Then, the relationships between beer nutrients and yeast growth are discussed, with special emphasis on the production of the flavor compounds. The impact of the wort composition on flocculation is also discussed. Furthermore, conventional approaches to starter yeast selection and the development of genetically modified microorganisms are analyzed. Recent discoveries relating to the use of S. cerevisiae strains isolated from different food matrices (i.e., bread and wine) and the potential for the use of non-Saccharomyces starter strains in beer production are discussed. A detailed review of the selection of starter strains for the production of specialty beers then follows, such as for gluten-free beers and biologically aged beers. Yeast recovery from top-cropping and bottom-cropping systems and the methodologies and issues in yeast propagation in the laboratory and brewery (i.e., re-pitching) are also analyzed. 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On the other hand, the accumulation of huge amounts of food wastes every year has led to environmental degradation and especially to significant loss of valuable material that could otherwise be exploited as new health-promoting ingredients, fuels and a great variety of additives. In this respect, the biggest challenge of the current scientific world is to convert the underutilised by-products generated by the food and beverage industries into more profitable and marketable added value products which would also contribute significantly to meet the nowadays society needs. This chapter gives an overview regarding the possibility of exploiting the brewing industry wastes as sources of bioactive compounds in order to produce functional ingredients and products with added value.",book:{id:"5967",slug:"brewing-technology",title:"Brewing Technology",fullTitle:"Brewing Technology"},signatures:"Anca Corina Fărcaş, Sonia Ancuța Socaci, Elena Mudura, Francisc\nVasile Dulf, Dan C. 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He has both an MS and Ph.D. in Biomedical Engineering. He was previously a research scientist at the University of California Los Angeles (UCLA) and visiting professor and researcher at the University of North Dakota. He is currently working in artificial intelligence and its applications in medical signal processing. In addition, he is using digital signal processing in medical imaging and speech processing. Dr. Asadpour has developed brain-computer interfacing algorithms and has published books, book chapters, and several journal and conference papers in this field and other areas of intelligent signal processing. He has also designed medical devices, including a laser Doppler monitoring system.",institutionString:"Kaiser Permanente Southern California",institution:null},{id:"169608",title:"Prof.",name:"Marian",middleName:null,surname:"Găiceanu",slug:"marian-gaiceanu",fullName:"Marian Găiceanu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/169608/images/system/169608.png",biography:"Prof. Dr. Marian Gaiceanu graduated from the Naval and Electrical Engineering Faculty, Dunarea de Jos University of Galati, Romania, in 1997. He received a Ph.D. (Magna Cum Laude) in Electrical Engineering in 2002. Since 2017, Dr. Gaiceanu has been a Ph.D. supervisor for students in Electrical Engineering. He has been employed at Dunarea de Jos University of Galati since 1996, where he is currently a professor. Dr. Gaiceanu is a member of the National Council for Attesting Titles, Diplomas and Certificates, an expert of the Executive Agency for Higher Education, Research Funding, and a member of the Senate of the Dunarea de Jos University of Galati. He has been the head of the Integrated Energy Conversion Systems and Advanced Control of Complex Processes Research Center, Romania, since 2016. He has conducted several projects in power converter systems for electrical drives, power quality, PEM and SOFC fuel cell power converters for utilities, electric vehicles, and marine applications with the Department of Regulation and Control, SIEI S.pA. (2002–2004) and the Polytechnic University of Turin, Italy (2002–2004, 2006–2007). He is a member of the Institute of Electrical and Electronics Engineers (IEEE) and cofounder-member of the IEEE Power Electronics Romanian Chapter. He is a guest editor at Energies and an academic book editor for IntechOpen. He is also a member of the editorial boards of the Journal of Electrical Engineering, Electronics, Control and Computer Science and Sustainability. Dr. Gaiceanu has been General Chairman of the IEEE International Symposium on Electrical and Electronics Engineering in the last six editions.",institutionString:'"Dunarea de Jos" University of Galati',institution:{name:'"Dunarea de Jos" University of Galati',country:{name:"Romania"}}},{id:"4519",title:"Prof.",name:"Jaydip",middleName:null,surname:"Sen",slug:"jaydip-sen",fullName:"Jaydip Sen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/4519/images/system/4519.jpeg",biography:"Jaydip Sen is associated with Praxis Business School, Kolkata, India, as a professor in the Department of Data Science. His research areas include security and privacy issues in computing and communication, intrusion detection systems, machine learning, deep learning, and artificial intelligence in the financial domain. He has more than 200 publications in reputed international journals, refereed conference proceedings, and 20 book chapters in books published by internationally renowned publishing houses, such as Springer, CRC press, IGI Global, etc. Currently, he is serving on the editorial board of the prestigious journal Frontiers in Communications and Networks and in the technical program committees of a number of high-ranked international conferences organized by the IEEE, USA, and the ACM, USA. He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:null},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). He leads the working group of experts representing Brazil in the Global Partnership on Artificial Intelligence (GPAI), on the theme \"AI and the Pandemic Response\".",institutionString:"Manufacturing and Technology Integrated Campus – SENAI CIMATEC",institution:null},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:"Polytechnic University of Timişoara",institution:{name:"Polytechnic University of Timişoara",country:{name:"Romania"}}},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:null},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. 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