\r\n\tAccording to the protection and control strategies in recent years; Although WHO has reduced the rates somewhat with the application of mass medication in children in places where the prevalence of roundworm is over 20%, to control morbidity and eliminate STN as a public health problem, the mathematical applications have been to apply the treatments to adults as well.
\r\n
\r\n\tIn this book, roundworms transmitted through soil or arthropods; Developments in epidemiology, life cycles, pathophysiology, clinical diagnosis, management, and public health control in the world will be reviewed with the contribution of studies on this subject from past to present. In addition, this book aims to highlight the connection between helminths and autoimmune and allergic diseases: the determination, treatment, and control strategies.
",isbn:"978-1-80356-714-3",printIsbn:"978-1-80356-713-6",pdfIsbn:"978-1-80356-715-0",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"5edc96349630be8bb4e67170be677d8c",bookSignature:"Dr. Nihal Dogan",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11801.jpg",keywords:"Ascaris, Trichuris, Hookworms, Strongyloides, Wuchereria, Brugia, Onchocerca, Trichinella, Larval Infection, Visceral Larva Migrans, Cutaneous Larva Migrans, Ocular",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"March 23rd 2022",dateEndSecondStepPublish:"May 27th 2022",dateEndThirdStepPublish:"July 26th 2022",dateEndFourthStepPublish:"October 14th 2022",dateEndFifthStepPublish:"December 13th 2022",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"A leading academic in parasitology at the Department of Microbiology at the Faculty of Medicine of Eskişehir Osmangazi University, expertise in hydatid cysts, toxoplasma, leishmania, parasitic diseases transmitted by water and intestinal parasites. She wrote numerous book chapters on infectious diseases, clinical parasitology, clinical microbiology, and medical microbiology laboratory applications and manuals.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"169552",title:"Dr.",name:"Nihal",middleName:null,surname:"Dogan",slug:"nihal-dogan",fullName:"Nihal Dogan",profilePictureURL:"https://mts.intechopen.com/storage/users/169552/images/system/169552.png",biography:"Prof. Dr Nihal Doğan is the leading academic in the Field of Parasitology at the Department of Microbiology at the Faculty of Medicine of Eskişehir Osmangazi University since 1993. She was granted a professorship in 2008 and has expertise in parasitology and epidemiology of parasitic diseases. She took part as an executive academic on 6 projects hydatid cysts, toxoplasma, leishmania, parasitic diseases transmitted by water and intestinal parasites. Her research is published in more than 40 national and international journals and she took part as a keynote speaker and as abstract and poster presenter in more than international and national congresses and conferences. She wrote numerous book chapters on infectious diseases, clinical parasitology, clinical microbiology and medical microbiology laboratory applications and manuals. \nShe concluded her Master and PhD Thesis at Eskişehir Anadolu University and Eskişehir Osmangazi University Medical Faculty and focused on the field of diagnosis and seroepidemiology of Toxoplasmosis. She visited the University of Virginia Department of Parasitology as a visiting researcher in 2003 for 3 months and worked on the diagnosis of Entamoeba histolytica and Universidad De Chile Faculty of Medicine as an observer researcher in 2016 for 1 month and worked on Trypanosomes.\nHer research interests include medical ethics, seroepidemiological survey; intestinal, blood, tissue and ocular parasites, vector-borne diseases, zoonotic parasites.",institutionString:"Eskisehir Osmangazi University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"13",title:"Immunology and Microbiology",slug:"immunology-and-microbiology"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"466998",firstName:"Dragan",lastName:"Miljak",middleName:"Anton",title:"Mr.",imageUrl:"https://mts.intechopen.com/storage/users/466998/images/21564_n.jpg",email:"dragan@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. 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1. History
A practising anaesthesiologist will understand the fear exhibited by patients receiving anaesthesia, but fortunately, death from anaesthesia has reduced dramatically with the emergence of modern anaesthesia practice [1]. The development of anaesthesia drugs and monitoring and the evolving anaesthesia training have increased anaesthesia safety, especially for patients who are free of comorbidities. This reduction of mortality was first published by the Institute of Medicine (IOM) in the report To Err Is Human: they mentioned that death from anaesthesia has decreased from 2 deaths per 10,000 anaesthetics administered in the 1980s to about 1 death per 200,000 to 300,000 anaesthetics administered at the beginning of the twenty-first century [2, 3, 4].
Whenever anaesthesia-related death is considered, the American Society of Anesthesiologists Physical Status classification (ASA PS) is mentioned. It is the most commonly used tool by practising anaesthesiologist in the preoperative assessment of patients. This extensive use is owed to its simplicity and seniority. The American Society of Anesthesiologists (ASA) introduced the ASA PS back in 1941 [5]. During that period, the common practice was to classify patients according to their operative risk, but the vision of the ASA committee has helped them to appreciate the complexity of the situation; they admitted that estimating postoperative mortality using preoperative data is a statistically challenging situation, so they have changed the notion of operative risk into physical status. The purpose of that classification was to create a common platform for doctors to guide the patient classification for further future statistical analysis. There were four classes (Table 1), and if there was an emergency surgery, then the class will be five for a patient who was classified as 1–2 and six for a patient who was classified as 3–4. Surgery was considered an emergency whenever the surgeon said so [5]. Clinical scenarios were assigned to each class for easy use. They further added an alphabetic scaling, ranging from A to D according to the objective evidence of cardiovascular decompensation, with A being no evidence and D being severely decompensated (Table 2).
Class
Definition
Examples
I
No organic pathology or patient in whom the pathological process is localised and does not cause any systemic disturbance or abnormality
Fractures without: shock, blood loss, emboli or systemic signs of injury Congenital deformities without systemic disturbance Localised infection without fever Osseous deformities Uncomplicated hernias Any type of operation may fall in this class since only the patient’s physical condition is considered
II
A moderate but definite systemic disturbance caused either by the condition that is to be treated by surgical intervention or by other existing pathological processes
Mild diabetes Function capacity I or IIa Psychotic patients unable to care for themselves Mild acidosis Moderate anaemia Septic or acute pharyngitis Acute sinusitis Superficial infection that causes a systemic reaction. Non-toxic thyroid adenoma with all but partial respiratory obstruction Mild thyrotoxicosis
III
Severe systemic disturbance from any cause or causes. It is not possible to state an absolute measure of severity, as this is a matter of clinical judgement
Complicated or severe diabetes Functional capacity IIb Combination of heart and lung diseases that severely impair function Complete intestinal obstruction with serious physiological disturbance Pulmonary tuberculosis causing tachycardia or dyspnoea Prolonged illness with weakness of all or several systems
IV
Extreme systemic disorders which have already become an imminent threat to life regardless of treatment. Due to their duration or nature, there has already been damage to the organism that is irreversible. This class is intended to include only patients who are in extremely poor physical state
Functional capacity III – (cardiac decompensation) Severe trauma with irreparable damage Complete intestinal obstruction in a previously debilitated patient Cardiovascular disease with marked renal impairment Anaesthesia to arrest marked blood loss from secondary haemorrhage in a patient in poor condition
V
Emergencies that would be otherwise graded as Class 1 or 2
VI
Emergencies that would otherwise be graded as Class 3–4
No objective evidence of cardiovascular disease. No symptoms and no limitation in ordinary physical activity
B
Objective evidence of minimal cardiovascular disease. Mild symptoms and slight limitation during ordinary activity. Comfortable at rest
C
Objective evidence of moderately severe cardiovascular disease. Marked limitation in activity due to symptoms, even during less-than-ordinary activity. Comfortable only at rest
D
Objective evidence of severe cardiovascular disease. Severe limitations. Experiences symptoms even while at rest
Table 2.
Additional clinical classification based on cardiovascular state [5].
After 20 years, some authors removed the clinical scenarios, added a fifth class, and added the letter E to indicate emergencies (Figure 1). This change was a result of a large study that was aiming to assess the postoperative motility using preoperative physical status [6].
Figure 1.
The latest update on ASA [8].
Retrospectives trials to validate ASA scale have then become numerous added to the many prospective trials, and they gave birth to ASA pooled mortality [7]. In 1980 another revision (Table 3) was carried out, which resulted in the addition of a new class that considers braindead patients [8].
Physiological variables
Operative variables
Chest Hx
Type of surgery
Age
Severity
Cardiovascular Hx
Number of procedures
ECG
Blood loss
BP
Malignancy
HR
GCS
WBC
Hb
Urea
Na+
K+
Table 3.
POSSUM variables.
Although ASA PS is widely used, it appears that no much effort or attention was paid by the researcher to improve this tool until recently when some models considered ASA physical status as a part of their risk assessment system.
2. Risk assessment systems
2.1 The surgical risk scale
The Surgical Risk Scale is a simple tool that was created by the combination of ASA scale and the British United Provident Association (BUPA) along with the Confidential Enquiry into Perioperative Death (NCEPOD). It was tested in a prospective study; they used logistic regression analysis and created a scale ranging from 3 to 14, which is simple and accurate [9].
2.2 The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)
The ACS main idea behind this study was to compare particular risk assessment scores to a universal tool. They provided surgeons with an online application that considers ASA scale. The study results showed that ACS NSQIP variables are significant in ASA scale validation [10].
2.3 The surgical outcome risk tool (SORT)
This risk assessment tool was developed and validated in 2014 in the UK. ASA PS was added along with other six variables: the urgency of surgery, high-risk surgery, severity, age, and the presence of cancer obtained from NCEPOD data analysis [11].
2.4 The National Emergency Laparotomy Audit (NELA) score
As the name implies, it’s an audit for more than 50,000 cases. All patients were above 18 years. It was only used to assess mortality inpatient undergoing laparotomy for small bowel obstruction. ASA scale was studied for its association with the patient outcome.
3. Validity
Something is valid when it can fulfil the objective against which it’s being tested, and its reliability depends on consistency. Every reliable tool is valid, but not every valid tool is reliable.
In terms of assessing mortality, the ASA scale is not valid by itself, but this is not a discovery; this was first mentioned in the same original paper by ASA committee itself [12]. Assessing the patient physical status is surely what ASA scale is best used for, but here comes the issue of how reliable it is.
Subjectivity in patient assessment is the source of the variability in the scale use.
Many studies have been investigating ASA scale reliability. They either assessed the consistency of the classification of many patients by a specific number of doctors to evaluate the factors associated with inconsistency if found or evaluated the classification of particular cases among doctors. Effective studies to assess the statistical validity of the scale started to appear 20 years after the original scale was described [6]. Studies to determine the reliability of the scale by assessing its consistency only begun in the late 1970s [13]. In 1978 a questionnaire was developed and was emailed to more than 200 anaesthesiologists to test how consistent is ASA scale in the classification of 10 imaginary clinical scenarios (Figure 2). They reported a consistency rate of 5.9, which was affected by whether the anaesthesiologist was doing a private or academic work and with no effect of the region of practice [13]. Age, history of ischemic heart disease, abnormal BMI, and low haemoglobin level appeared to be where conflicts arise. Many years after a study found that there is no significant correlation between expertise in anaesthesia and scale reliability [14]. A more recent study confirmed that result and showed the absence of a relationship between the scale reliability and the age, level of training, or how expert the anaesthesiologist is [15].
Figure 2.
Example of a clinical scenario used for the validation [13].
The association between the accuracy of scale and whether the user is an anaesthesiologist or not appeared to be significant [16]. Some recent studies claimed that the removal of clinical scenarios affected the scale reliability; they consider it to be a self-correcting tool that empowers the system [17, 12].
4. Alternatives
Stop your flow of thoughts for a moment. Now think of this question, what is the main aim of medical care? Many doctors will say that it depends on the specialty. That is partially correct because there is a common place where all doctors meet along the road of patient care, which is to alleviate the patient suffering. So we are not fighting death, and we want to make sure that the patient is not going to die from a preventable cause and is not going to suffer from a bad quality of life. Reducing avoidable mortality along with the people who desire to know their chances of being alive after undergoing surgery has motivated doctors from specialties that are concerned with the preoperative assessment of patients to develop many tools and scales to assess the expected patient mortality.
For us to talk about the possible alternative scores for ASA physical status scale, we need to point out for what reason the scale was created and what variables were included. ASA introduced the classification system back in 1941 to facilitate the statistical calculation of operative patient risk rather than indicating it. They classified the patients according to their physical status to create a common background for patients sorting by surgeons and anaesthesiologists and then assess the association between different classes and patient outcome. The ASA classification itself does not consider many other important factors that may affect the patient outcome (severity of the surgery, the experience of the surgeon, the quality of the hospitals, etc.) [5]. So in terms of patient sorting function, ASA classification is standing on the top if not alone with only a mild problem of subjectivity. But in mortality assessment, it can only be a part of bigger scales, as the pooled mortality for ASA grades obtained using clinical audits was found to be increased with many other factors like intraoperative blood loss, duration of the operation, and in-hospital mortality [7].
There are many scores to predict patient mortality after surgery or in specific conditions. In this chapter, we will only review nonselective scores that predict mortality in surgical patients.
4.1 ASA pooled mortality
After the ASA was being revised into five classes in 1961 [18], many retrospective studies have shown a link between ASA classes and perioperative mortality rate [19, 20, 21, 22]. The first prospective study to determine the correlation between ASA classification, perioperative risks, and postoperative outcome with a large number of patients was in 1996. They assigned patients with all types of surgery, and they have taken into account the type of surgery, patient lab results, perioperative risk variables, time of the operation, and the type of anaesthesia. They used univariate analysis and logistic regression analysis to estimate the mortality rate (Figure 3) for each ASA class [7].
Figure 3.
ASA pooled mortality.
4.2 Physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM)
This is a risk assessment tool that uses both physiological and operative factors into account (Table 3). A prospective study of 10,000 surgical interventions except for paediatric surgery and day-case surgery, applying logistic regression analysis, showed that the POSSUM equation overestimates mortality [23]. A further modification of POSSUM, which was named P-POSSUM, was found to be more accurate in mortality prediction [23].
4.3 Preoperative score to predict postoperative mortality (POSPOM)
A very large cohort study for 1 year was conducted in France. Seventeen variables were used to estimate the mortality risk for 2,717,902 patients. The risk tool was validated by using the logistic model.
4.4 Frailty scores
Assessing frailty in the elderly has become an evolving practice of the twenty-first century. Validated frailty criteria (weakness, fatigue, decreased physical activity, and walking speed), also known as frailty phenotype, were the result of a cohort study that used the cardiovascular health study database. Two cohorts were randomised in 1989, and they were followed for 4 to 7 years [24]. Another model that exists in the literature is the frailty index, which is the impact of frailty detected during geriatric assessment [25]. Notice that each criterion has its particular measurement consideration, and it is not discussed as it is beyond the scope of this chapter. Many studies have used these criteria to assess postoperative mortality in different pathologies [26, 27, 28].
5. Comparison of systems
Many studies have explored the issue of which the scale is superior to others, but we have to keep in mind that many variables will be adjusted to make the comparison possible, and this is mainly because of the broad variability between these scores and the different objectives and settings at which each score was introduced.
To understand this in a better way, we must understand the meaning of risk in anaesthesia. Risk indicates the negative impact of a process which may be started in the past, may be happening now, or is probably going to occur in the future. Human survival nature is evident in the efforts that we put on trying to reduce all the risks.
For every patient undergoing surgery, four broad risk categories can be faced:
Hospital hazard.
Risk of anaesthesia.
Surgery.
Patient factors.
The ASA PS focuses only on patient status and the risk of anaesthesia; POSPOM, POSSUM, and P-POSSUM have an additional focus on surgical risk. But every score assesses the same variable differently because this is affected by the use of the tool in practice; as ASA is the standard practice for years, then it will have the upper arm in assessing patient factors. None of them considered hospital hazard. The ASA itself varies on its validity between its different versions. The original ASA used to have clinical scenarios that approximate the subjective variations between doctors, which were removed from the updated versions. The authors of the study that introduced and validated POSPOM in 2016 claimed that ASA PS is a deficient tool for assessing mortality risk because it does not take risks apart from patient factors and anaesthesia risk into account [29]. Many retrospective and prospective studies have studied ASA PS correlation with mortality after considering all the other elements, and many other trails have tackled the issue off subjectivity and figured to solve it with a robust statistical methodology many years before 2016 [7, 30].
This risk assessment issue can be solved with a meeting that involves public health, anaesthesia, surgery, and medical statistic expertise to create an assessment tool that considers all these risks and to be statistically applicable and clinically standardised to avoid subjectivity.
\n',keywords:"American, society, anaesthesiologists, physical, status, classification",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/70432.pdf",chapterXML:"https://mts.intechopen.com/source/xml/70432.xml",downloadPdfUrl:"/chapter/pdf-download/70432",previewPdfUrl:"/chapter/pdf-preview/70432",totalDownloads:789,totalViews:0,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:1,introChapter:null,impactScore:0,impactScorePercentile:34,impactScoreQuartile:2,hasAltmetrics:1,dateSubmitted:"April 8th 2019",dateReviewed:"September 13th 2019",datePrePublished:"December 12th 2019",datePublished:"October 7th 2020",dateFinished:"December 12th 2019",readingETA:"0",abstract:"The American Society of Anesthesiologists Physical Status (ASA PS) classification has long been used as a ranking system that quantifies patient health before anaesthesia and surgery. When initially developed, the ASA PS intended application was purely statistical. However, nowadays it is commonly used by surgical specialties to determine a patient’s likelihood of developing postoperative complications, despite studies reporting scoring method subjectivity and inconsistencies among anaesthesiologists in assigning these scores. Over the years, the ASA PS classifications have undergone many changes and modifications to address its limitations. There are a few points to be discussed if all shortcomings are to be treated and interobserver variability is to be limited.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/70432",risUrl:"/chapter/ris/70432",book:{id:"7936",slug:"surgical-recovery"},signatures:"Sohel M.G. Ahmed, Malek Ahmad Alali, Kathy Lynn Gaviola Atuel and Mogahed Ismail Hassan Hussein",authors:[{id:"205787",title:"Dr.",name:"Sohel Mohamed Gamal",middleName:null,surname:"Ahmed",fullName:"Sohel Mohamed Gamal Ahmed",slug:"sohel-mohamed-gamal-ahmed",email:"sohelm@yahoo.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Hamad Medical Corporation",institutionURL:null,country:{name:"Qatar"}}},{id:"310363",title:"Dr.",name:"Malek Ahmad",middleName:null,surname:"Alali",fullName:"Malek Ahmad Alali",slug:"malek-ahmad-alali",email:"drmalek91@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Hamad Medical Corporation",institutionURL:null,country:{name:"Qatar"}}},{id:"310364",title:"Dr.",name:"Kathy Lynn Gaviola",middleName:null,surname:"Atuel",fullName:"Kathy Lynn Gaviola Atuel",slug:"kathy-lynn-gaviola-atuel",email:"kathylynn_md@yahoo.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Hamad Medical Corporation",institutionURL:null,country:{name:"Qatar"}}},{id:"310365",title:"Dr.",name:"Mogahed Ismail Hassan",middleName:null,surname:"Hussein",fullName:"Mogahed Ismail Hassan Hussein",slug:"mogahed-ismail-hassan-hussein",email:"Mihhm@hotmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"University of Gezira",institutionURL:null,country:{name:"Sudan"}}}],sections:[{id:"sec_1",title:"1. History",level:"1"},{id:"sec_2",title:"2. Risk assessment systems",level:"1"},{id:"sec_2_2",title:"2.1 The surgical risk scale",level:"2"},{id:"sec_3_2",title:"2.2 The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP)",level:"2"},{id:"sec_4_2",title:"2.3 The surgical outcome risk tool (SORT)",level:"2"},{id:"sec_5_2",title:"2.4 The National Emergency Laparotomy Audit (NELA) score",level:"2"},{id:"sec_7",title:"3. Validity",level:"1"},{id:"sec_8",title:"4. Alternatives",level:"1"},{id:"sec_8_2",title:"4.1 ASA pooled mortality",level:"2"},{id:"sec_9_2",title:"4.2 Physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM)",level:"2"},{id:"sec_10_2",title:"4.3 Preoperative score to predict postoperative mortality (POSPOM)",level:"2"},{id:"sec_11_2",title:"4.4 Frailty scores",level:"2"},{id:"sec_13",title:"5. Comparison of systems",level:"1"}],chapterReferences:[{id:"B1",body:'Cooper JB, Gaba D. No myth: Anesthesia is a model for addressing patient safety. Anesthesiology. 2002;97(6):1335-1337'},{id:"B2",body:'Cranshaw J, Gupta KJ, Cook TM. Litigation related to drug errors in anaesthesia: An analysis of claims against the NHS in England 1995–2007. Anaesthesia. 2009;64(12):1317-1323'},{id:"B3",body:'Lagasse RS. Anesthesia safety: Model or myth? Anesthesiology. 2002;97(6):1609-1617'},{id:"B4",body:'To Err Is Human, Washington. D.C.: National Academies Press; 2000'},{id:"B5",body:'Uwe K. Grading patients for surgical procedures. Anesthesiology. 1941;31(4):305-309'},{id:"B6",body:'Dripps RD, Lamont A, Eckenhoff JE. The role of anesthesia in surgical mortality. JAMA. 1961;178(3):261'},{id:"B7",body:'Wolters U, Wolf T, Stützer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcome. British Journal of Anaesthesia. 1996;77(2):217-222'},{id:"B8",body:'Fitz-Henry J. The ASA classification and peri-operative risk. Annals of the Royal College of Surgeons of England. 2011;93(3):185-187'},{id:"B9",body:'Sutton R, Bann S, Brooks M, Sarin S. The surgical risk scale as an improved tool for risk-adjusted analysis in comparative surgical audit. The British Journal of Surgery. 2002;89(6):763-768'},{id:"B10",body:'Bilimoria KY et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: A decision aid and informed consent tool for patients and surgeons. Journal of the American College of Surgeons. 2013;217(5):833-842.e3'},{id:"B11",body:'Protopapa KL, Simpson JC, Smith NCE, Moonesinghe SR. Development and validation of the surgical outcome risk tool (SORT). The British Journal of Surgery. Dec. 2014;101(13):1774-1783'},{id:"B12",body:'Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status—Historical perspectives and modern developments. Anaesthesia. 2019;74(3):373-379'},{id:"B13",body:'Owens WD, Felts JA, Spitznagel EL. ASA physical status classifications. Anesthesiology. 1978;49(4):239-243'},{id:"B14",body:'Haynes SR, Lawler PGP. An assessment of the consistency of ASA physical status classification allocation. Anaesthesia. 1995;50(3):195-199'},{id:"B15",body:'Riley RH, Holman CDJ, Fletcher DR. Inter-rater reliability of the ASA physical status classification in a sample of anaesthetists in Western Australia. Anaesthesia and Intensive Care. 2014;42(5):614-618'},{id:"B16",body:'Curatolo C, Goldberg A, Maerz D, Lin HM, Shah H, Trinh M. ASA physical status assignment by non-anesthesia providers: Do surgeons consistently downgrade the ASA score preoperatively? Journal of Clinical Anesthesia. 2017;38:123-128'},{id:"B17",body:'Hurwitz EE et al. Adding examples to the ASA-physical status classification improves correct assignment to patients. Anesthesiology. Apr. 2017;126(4):614-622'},{id:"B18",body:'Dripps. New classification of physical status. Anesthesiology. 1961;24:111'},{id:"B19",body:'Farrow SC, Fowkes FGR, Lunn JN, Robertson IB, Samuel P. Epidemiology in anesthesia II: Factors affecting mortality in hospitals. British Journal of Anaesthesia. 1982;54(8):811-817'},{id:"B20",body:'Pedersen T et al. Risk factors, complications and outcome in anaesthesia. A pilot study. European Journal of Anaesthesiology. May 1986;3(3):225-239'},{id:"B21",body:'Marx GF, Mateo CV, Orkin LR. Computer analysis of postanesthetic deaths. Anesthesiology. Jul. 1973;39(1):54-58'},{id:"B22",body:'Vacanti CJ, VanHouten RJ, Hill RC. A statistical analysis of the relationship of physical status to postoperative mortality in 68,388 cases. Anesthesia & Analgesia. 1970;49(4):564-566'},{id:"B23",body:'Peacock O et al. Thirty-day mortality in patients undergoing laparotomy for small bowel obstruction. The British Journal of Surgery. Jul. 2018;105(8):1006-1013'},{id:"B24",body:'Fried LP et al. Frailty in older adults: Evidence for a phenotype. The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences. Mar. 2001;56(3):M146-M156'},{id:"B25",body:'Chen X, Mao G, Leng SX. Frailty syndrome: An overview. Clinical Interventions in Aging. 2014;9:433-441'},{id:"B26",body:'McGuckin DG, Mufti S, Turner DJ, Bond C, Moonesinghe SR. The association of peri-operative scores, including frailty, with outcomes after unscheduled surgery. Anaesthesia. 2018;73(7):819-824'},{id:"B27",body:'Makary MA et al. Frailty as a predictor of surgical outcomes in older patients. Journal of the American College of Surgeons. 2010;210(6):901-908'},{id:"B28",body:'Kim S et al. Multidimensional frailty score for the prediction of postoperative mortality risk. JAMA Surgery. 2014;149(7):633'},{id:"B29",body:'Le Manach Y et al. Preoperative score to predict postoperative mortality (POSPOM). Anesthesiology. 2016;124(3):570-579'},{id:"B30",body:'Davenport DL, Bowe EA, Henderson WG, Khuri SF, Mentzer RM. National Surgical Quality Improvement Program (NSQIP) risk factors can be used to validate American Society of Anesthesiologists Physical Status Classification (ASA PS) levels. Annals of Surgery. 2006;243(5):636-644'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Sohel M.G. Ahmed",address:"sohelm@yahoo.com",affiliation:'
Department of Anaesthesia and Perioperative Medicine, Hamad Medical Corporation, Qatar
'},{corresp:null,contributorFullName:"Malek Ahmad Alali",address:null,affiliation:'
Department of Anaesthesia and Perioperative Medicine, Hamad Medical Corporation, Qatar
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1. Introduction
Air, water and soil which are the essential elements of life are contaminated rapidly due to increasing population, urbanization, mining activities and industrialization [1]. Heavy metals toxicity is causing problem to humans, animals, aquatic animals, plants and even microbes too.
Various methods are introduced to remove the heavy metal pollution like chemical techniques such as chemical precipitation, oxidation or reduction method, electrochemical treatment. Physical techniques such as ion exchange, evaporation, filtration, membrane technology, reverse osmosis. Biological techniques like microorganisms such as bacteria, fungi, algae, cynobacteria, lichens, etc.
Heavy metals damage cell membranes, alter functioning of enzymes, inhibit protein synthesis, denature protein and damage the structure of DNA. Toxicity is mainly created by the dislocation of essential metals from their real binding sites or ligand interactions [2]. Bioremediation is cost-effective, safe and eco-friendly; can be virtually restored a result to the heavy metal pollution issue as it is natural process. Biological methods are best to control short term or long term environmental pollution. Various heavy metals are accumulated with the help of bacteria, fungi, cyanobacteria, lichens, etc. and helps in bioremediation and used as bio-indicators. They are not harmful human heath as well as ecosystem. Such organisms are used for indication and controlling heavy metal pollution. Mostly genes encoded by heavy metal resistant bacteria are located on plasmids. Biosorption is environmentally safe and low cost methodology of removing metals from the ecosystem. Various analysis were observed throughout previous 5 decades provided quantity of data regarding differing kinds of biosorbents and their mechanism of absorption of heavy metal. Additional research is to explore new biosorbents from surroundings [3].
Since last few years, various physical and chemical methods are used to remove heavy metals but it is expensive, needs laboratory and inefficient. According to various studies bioremediation and biosorption techniques are much more beneficial, cheap, non-toxic, natural process.
Minimum inhibitory concentration (MIC) is the lowest concentration at which the isolate or antimicrobial agent is completely suppressed is recorded. Microorganisms correspond to heavy metals using various defense systems, such as exclusion, compartmentalization [4], complex formation and synthesis of binding proteins, such as metallothioneins [5].
Bioremediation strategies have been proposed as an attractive alternative owing to their low cost and high efficiency [6].
Different methods are used to study characterization of heavy metals on microbes by 16S RNA sequence, biodegradability test, siderophore assay, biochemical test, morphological test, antibiotic resistance, nucleotide sequencing, etc. Microbial pigmentation and enzymatic activities like catalase, gelatin hydrolysis, oxidase, nitrate reductase, were characteristics selected to examine their outcomes.
Bioremediation is of two types: in-situ bioremediation and ex-situ bioremediation. In-situ bioremediation process is mainly used due to its ability in decreasing disturbance of ecosystem at the heavy metal polluted sites whereas ex-situ bioremediation, it takes place inside bioreactors, bio-piles and land farming. In-situ bioremediation is much more efficient and eco-friendly (Figure 1).
Figure 1.
Bioremediation (enzyme-catalyzed destruction) of contaminants. The use of power ultrasound in biofuel production, bioremediation and other applications [7].
Metal microbe interactions developed by microbial cells are bio-transformation, bio-leaching, bio-degradation, bio-mineralization, bio-adsorption and bio-accumulation in bioremediation method.
Biofilm used as efficient bioremediation tool and stabilization too. Even at harmful conditions, they show high resistance towards heavy metals. With the help of genetic engineering one can insert desired characters like ability to resist heavy metals, tolerate metal stress, etc. For example: engineered Chlamydomonas reinhardtii shows increased resistance to cadmium toxicity. Corynebacterium glutamicum was genetically modified using ars (operon) to accumulate arsenic polluted sites. Biofilm combines or work with biosorbent or any exopolymeric substance which consist of surfactants or emulsifier properties. The study was conducted on Rhodotorula mucilaginosa shows efficiency in heavy metal removal and develops 91.7–95.4% biofilm cells. Biosurfactants studied were surfactin, rhamnolipid and sophorolipid for removal of several heavy metals.
The aim of the review is to study the source of the heavy metals on earth, consequences of the heavy metals on plants as well as on animals, various isolated microbial strains from bacteria, fungi and algae tolerance towards heavy metals and to study mechanism adapted by strain to accumulate heavy metals.
Future approaches in bioremediation are genetic modification of microbes or genetic engineered microbes, genetic technologies and forms specificity using biofilm by optimization process and immobilization process can be attained, biofilm mediated remediation, formation of microbial fuel cell (MFC), use of nano-particles with algae and bacteria, gene transfer within biofilm, transgenic cynobacteria, modify gene or enzyme in microbes. In Rhizo-remediation technique, rhizosphere bacteria and mycorrhizae combine for uptake.
2. Source of the heavy metals
High amount of heavy metals in the soil, water and air arise from various sources, which consist of natural sources include natural emission, atmospheric decomposition, sea salt spray, forest fires, rock weathering, biogenic means and wind borne soil particles and artificial sources such as mining activities, agricultural waste, domestic effluents, smelters, sewage sludge irrigation, improper stacking of the industrial solid waste, the excess utilization of pesticides, insecticides and fertilizers, etc. [8, 9].
2.1 Lead in environment
Lead (Pb) is unnecessary metal on the crust. It is a important contaminant that is present in the soil, water and air as a dangerous waste. It is extremely injurious to the human, animals, plants and even microbes too. The crucial sources of lead metal are children toys, drinking water, dust, petroleum, electronic industries, water pipes, battery, pottery, paint, stained glass, cosmetics and biocide preparation [10, 11].
2.2 Arsenic in environment
Arsenic (As) is non-essential metal. Arsenic is also present in pyrotechnics, in bronzing and hardening other metals. Arsenic is originated from the weathering of rocks and mineral, volcanic eruptions, fossil fuels, agricultural products, preservatives, medicinal products and industrial activities. Herbicides, pesticides, insecticides, fungicides and fertilizers also contribute to arsenic contamination and extremely deadly and carcinogenic [12] (Figure 2).
Figure 2.
Heavy metal sources in the environment [13].
2.3 Mercury in environment
Natural activities like volcanoes and forest fire release mercury in environment. The burning of coal, oil, wood and mining of gold releases mercury in the environment. It affects immune system as well as nervous system. Methyl-mercury damages the developing embryos too [14, 15].
2.4 Chromium in environment
Chromium is released to environment by combustion processes and from metal industries and chemical manufacturing industries as waste. Chromium 4 is most dangerous form and may lead health issues like allergy, nose irritations, skin rashes, liver damage, kidney damage and even death [16, 17].
2.5 Cadmium in environment
Cadmium is also a non-essential member and highly dangerous to mankind. Cadmium is used in semiconductors, nickel-cadmium batteries, electroplating, municipal wastes such as plastics, PVC manufacturing, alloys, overuse of fertilizers rich in phosphate and control rod for nuclear reactors. Soils and water pollution by cadmium produced by the mining sites and smelting industries, sewage sludge application and burning of fossil fuels like coal, petroleum, etc. Chronic exposure of cadmium in human has many harmful effects such as high blood pressure and destroys to different organs such as lung, liver kidney and testes in males [18, 19].
2.6 Copper in environment
Copper a transition metal and also an essential element for living organisms including humans and other animals at low concentrations. Copper is released in ecosystem through decaying of vegetation, forest fire, sea-sprays, wind-blown dust. Copper is utilized as the alloy in the manufacture of wire, pipe, and various metal products. Copper are majorly used in agriculture to treat plant diseases, like mildew, or for water treatment and as preservatives, leather and fabrics. Intake of excessive amount of copper, it can cause nausea, vomiting, stomach cramps, diarrhea and can destroy liver and kidney and even lead to death [20, 21].
2.7 Zinc in environment
Zinc (Zn) is also a transition metal and zinc is utilized in galvanizing and alloying and also in the manufacture of electric goods, dying, insecticides, pesticides and cosmetics. Mining activities, smelting of metals and production of steel and other waste can release zinc into the environment. It may cause health issues in living organisms such as dehydration, nausea, electrolyte imbalance, vomiting, abdominal pain, dizziness, acute renal failure, muscular incardination and damage of hepatic parenchyma [22].
2.8 Manganese in environment
Manganese is released from sewage sludge, combustion of fossil fuels, mining processes, etc. it can cause toxicity in plants and causes swelling of cell walls, brown spots on leaves, etc. [23].
2.9 Iron in environment
The major sources of iron are metal refining, sewage, dust from iron mining, iron and steel industry. Iron sulphate is utilized in fertilizer and herbicide [24].
2.10 Other heavy metals in environment
Thallium is present in insecticides, metal alloys and fire cracker. Phosphorus is found in insecticides such as organophosphate for example: malathion [25].
The environmental factors plays very crucial role in biosorption of heavy metals and these factors are pH, temperature, biomass concentration, metal ion concentration. Algae, fungi and bacteria acts as biosorbents and helps in mechanism of biosorption [26].
3. Adverse effects of heavy metals
Heavy metal pollution is causing severe health effects in human body as well as animals and plants too. Heavy metals are also effected the growth of microbes which are used in treatment or accumulation of heavy metals by damaging their DNA. Heavy metals can cause skin allergies, cancer, effect major organs like kidney, liver, brain, lung, etc., and enter in blood stream and even death too in animals and humans. Retarded growth and development, bad shoot induction and root formation, less nutrient and mineral content and can even cause death in plants [27].
3.1 Adverse affects of heavy metals on humans
Heavy metals like lead, chromium, nickel, mercury, cadmium, arsenic, etc. may destroy and alter functioning of various prime organs such as the liver, lungs, kidney, brain, heart and even blood also. Heavy metal infectivity may be either quick (within few hours/days) or long term (within months). Prolonged exposure of few toxic heavy metals at even less concentration can cause cancer or even death too. Heavy metals may cause various severe health risk and diseases [28].
Heavy metals can affect human body by lead is carring to liver and kidney by red blood cells. Cadmium binds to blood cells, liver and kidney tissues. Arsenic is accumulated in blood, kidney, heart, muscle, lung liver and also in nails, hair, etc.
The effect of toxicity depends on the exposure route and chemical nature of particular heavy metal like lipid solubility, volatility, etc.
Some heavy metals like arsenic, lead, mercury, nickel, cadmium, etc. have carcinogenic effect. Some heavy metals like lead, manganese, etc. may induce neurotoxicity [29].
Heavy metals function as a pseudo element of the body while they can interrupt with metabolic processes. Few metals, like aluminum may be separated through excretory activities, and few metals get absorbed in the body and even in food chain, showing long term exposure. Heavy metal toxicity depends upon the absorbed amount, the path of exposure and time of exposure. This may lead to several health risks and can also result in huge loss due to oxidative stress induced by free radical formation [30].
Arsenic is most harmful heavy metal which is highly toxic and carcinogenic. It mainly affects endocrine system, lungs, kidney, pulmonary, nervous system and skin. It causes skin cancer, respiratory cancer, perforation of nasal septum, dermatomes, etc. ingestion in gastrointestinal tract results in vomiting, disturbance in circulation, damage nervous system and led to death. Other consequences are high blood pressure, heart attacks, decrease in production of blood cells, enlargement of liver, change in skin color, loss of sensation in limbs. Exposure of arsenic through air can cause lung cancer and bladder cancer [31].
Cadmium is another dangerous heavy metal and it targets renal region, bones, testes, cardiovascular, skeletal system and pulmonary organ. It causes proteinuria, glucosuria, osteomalacia, emphysemia, aminoaciduria, etc. It may damage kidney and lung [19].
Chromium damages the organ such as lungs, kidney, pancreas, testes, liver, pulmonary region of body. It causes problems like ulcer, perforation of nasal septum, respiratory track cancer [17].
Lead is also very toxic even in less amount and targets multiple organs such as spleen, bones, the nervous system, hemotopoietic system, cardiovascular, gastrointestinal, renal region and reproduction system too. It causes issues like anemia, central nervous system disorders, peripheral neuropathy, encephalopathy [32].
Manganese is required in small concentration in body but in excessive damages nervous system and led to central and peripheral neuropathies and brain damage [23].
Nickel damages pulmonary system and skin too. It results high chances of lung cancer, nose cancer, larynx cancer and prostate cancer and skin allergy or skin rashes. It also shows symptom like sickness, dizziness, birth defects, asthma, chronic bronchitis, lung embolism, heart disorders [19].
Zinc may cause nausea, vomiting, illness, anemia, stomach cramps, damage to nervous system and skin irritation. It causes skin allergy, dermatitis, brain disorder. Increased amount of zinc effects pancreas, disturbs the metabolism of protein and amino acids in body and arteriosclerosis too [33].
Cobalt can cause vomiting, nausea, loss of appetite and may affect on lungs causing asthma, pneumonia and wheezing when exposed with cobalt metal and may develop various allergies or skin rashes. Mainly it is dangerous for heart muscle and causes heart muscle disease known as cardiomyopathy and shows rapid increase in count of red blood cells after long time exposure [34].
Copper damages liver, brain, cornea, lungs, immune system including blood cells. It causes gastrointestinal symptoms such as vomiting, nausea, abdominal pain and even lead to liver and kidney damage, genetic disorders, reproductive or developmental effects, delayed growth, prolonged bone formation and less body weights [35].
Tin effect both nervous system and pulmonary system. Exposure may lead to skin and eye irritation or respiratory tract problems. It causes pneumoconiosis, central nervous system disorders, visual defects, changes in EEG too [36]. Phosphorus symptom caused by exposure of phosphorus on human health includes sweating, headache, vomiting, abdominal cramps, weakness, ptosis, miosis, and severe issues are sensorimotor, polyneuropathy, atrophy and even led to respiratory paralysis [37].
The consequences of thallium exposure include blood vomiting, nausea, abdomen pain, eye disorder, mental retardation, hair loss and severe issues are cardiac failure, brain disorder and even coma too [25].
Mercury attacks the nervous system and renal region and may cause proteinuria. Inhalation of mercury may cause headache, memory loss, insomnia, tremors, neuromuscular and thyroid damage. It damages the chromosome structure and DNA. Effects on reproductive system by low sperm count, birth defects and even miscarriages too. During pregnancy, it may pass through placental barrier to embryo or baby for exposure [38].
The major organs targeted by these heavy metal mercury and lead causes neurotoxicity (brain), arsenic lead to hepatotoxicity (liver), cadmium causes nephrotoxicity (kidney)/pulmonotoxicity (lungs) and zinc mainly induce hematoxicity (blood).
The heavy metals interrupt in metabolic processes in two ways [39]:
They are absorbed and thereby disturb role in major organs and glands such as the heart, liver, brain, kidneys, bone, etc.
They displace the important nutritional minerals from their real place hindering their biological function. Consumption of foods, beverages, skin exposure, and the inhaled air are ways through which these contaminants can be present in body. It is unfeasible to reside in heavy metal free surrounding.
Various heavy metals produce ROS and damages DNA of the cell and disrupt reproduction cycle. Arsenic damages kidney and liver and may cause abdominal cramping, etc.
3.2 Adverse effects of heavy metals on marine animals
Heavy metals present in water by industrial effluent or agricultural waste like fertilizers, pesticides, etc. and deposited in water bodies and settle down and can present on surface with help of aquatic plants and aquatic macrophytes. Heavy metals stimulate the production of reactive oxygen species (ROS) that can damage aquatic organisms.
Several heavy metals accumulate in various major organs of the fish causing mortality. Firstly it affects the circulatory system by entering in blood and alters the components of blood. It makes the fish anemic and weak.
Huge amount of heavy metal shows inhibitory effects on the growth and development of aquatic organisms like fishes, phytoplankton and zooplankton. Heavy metals may cause disruption in respiration, damage respiratory track which leads to suffocation, reduces the sperm count, egg production and short life span. Heavy metals can disturb oxygen level, reduction of developmental growth or give rise to developmental anomalies, byssus formation and reproduction too. In juvenile phase shows high mortality and in adults decreased breeding ability. Heavy metal shows changes in structure and organs and may exhibit functional changes and transform metabolic pathways. Results of a research [40] showed that ten different fish species had the highest concentration of heavy metals is in liver and kidney.
The fishes like Labeo rohita and aquatic organism are eaten by humans as rich protein sources and heavy metal pollution may cause health risk in humans too through aquatic species. Cadmium can be bioaccumulated in mussels, oysters, shrimps, lobsters and fishes too.
Mercury in fish muscles occur as Methyl mercury which is formed in aquatic sediments. Movement of heavy metals in fish takes place through the blood where the ions are generally attached to proteins. There are five potential routes for the contaminants to enter an aquatic organism. The pathways are through the food, non-food particles, gills, the skin and oral consumption of water. Once the contaminants are accumulated, they are carried by the blood to the liver for modification and storage. If contaminants are altered by the liver, they can be stored or excreted in the bile produced in liver or reversed back into the blood stream for elimination by the gills or kidneys or stored in fat which is a hepatic tissue.
3.3 Adverse affects of heavy metals on plants
Plants require various heavy metals for their growth and excessive amount of heavy metals can damage cell structure, inhibition of major enzymes, inhibit the photosynthesis process and growth of plants, altered water balance, nutrient assimilation and can even cause plant death [41].
Heavy metal give rise to chlorosis, slow and poor plant growth, yield depression and even less nutrient absorption, disorders in plant metabolic processes and decreased potential to fixate molecular nitrogen in legumes of plants.
Seed germination was gradually retarded in the presence of large amount of lead. It can be due to long term incubation of the seeds and have resulted to compensate the toxic outcomes of lead by various mechanisms such as leaching, chelation, metal binding or absorption by microorganisms [42].
Replacing of major essential nutrients at cation exchange sites reveals indirect toxic effects on plant development. Enzyme metabolism is extremely crucial for growth and development of plants and heavy metals effect enzymes to inhibit many other major metabolisms in plants.
Heavy metals may lead to loss of fertility of soil by reduction in decomposition of organic matter by depletion of various microbes present inside the soil [43].
Copper is required as micronutrients in plants and helps in synthesis of ATP and assimilation of carbon dioxide. Excessive copper may exhibit oxidative stress and decreases growth of root.
Zinc required as micronutrient for synthesis of chlorophyll in plants. It retards growth of plants and nutrient level. It causes manganese and copper deficiency in shoot region.
Cadmium results in inhibition of growth and development, browning of roots tips and even death too.
Mercury can effects whole food chain and induces ROS and oxidative stress too. It causes depletion of germination in seeds, height of plant reduced flowering and fruit production, retarded growth and development.
Chromium induces the oxidative stress and degrades photosynthesis pigments in plants [30].
Lead degrades the development of roots and arsenic effects yield of crop and chlorosis, plant height and decreases ability of seed for germination [44].
Nickel is important and considered as macronutrient in plants but present in excessive amount can inhibit root growth, short shoot yield, etc. [45].
Enzymes and co-enzymes both are made up various elements such as cobalt. High concentration of cobalt may cause depletion in nutrients like proteins, amino acids, carbohydrates, etc. Also exhibit retarded plant growth and development.
Photosynthesis is prime phenomena in plants and it requires iron element. The excessive concentration of iron can inhibit photosynthesis itself [24].
Plants experience oxidative stress upon exposure to heavy metals that leads to cellular damage and disrupt of cellular ionic homeostasis. To decrease the detrimental outcomes of heavy metal exposure and their absorption, plants have participated in detoxification processes highly based on chelation and sub-cellular compartmentalization. A primary class of heavy metal chelator known in plants is phytochelatins (PCs), are produced by non-translation from reduced glutathione (GSH) in a transpeptidation reaction catalyzed by the enzyme phytochelatin synthase (PCS) [39].
The various biosorption techniques adopted by the plants such as phytoextraction, phytoextraction, rhizofiltration, phytovolatilisation and many others.
4. Bioremediation of heavy metals by microbial strains
Various microbial strains can accumulate the toxicity of heavy metals from bacteria, fungi, algae and helps in bioremediation and biosorption [46]. Bacterial strains show five different mechanisms in resistance to heavy metals. These mechanisms are by inhibiting the entrance of metals into the cell. The cell wall, membrane and capsule prohibit entry of metal ions inside the cellular body. Carbonyl group in polysaccharides of bacterial capsule accumulates the ions of heavy metals. Ions of metal like zinc, lead, and copper resulted resistance by Pseudomonas aeruginous biofilm [47].
In bacteria, active transport illustrate largest group of heavy metal resistance. Active transport remove metal ions from cell membrane and it can be placed on either on plasmid or on chromosomes [48, 49].
In intracellular sequestration, combination of metal ions to form large ion is done by several compounds inside cytoplasm of cell. Example; P. putida shows potential of intracellular sequestration of metal ions such as zinc, candium and copper [50].
In extracellular sequestration, metal ions are collected by periplasm or outer membrane of cells as insoluble compounds [51].
Condensation of metal ions was done by the bacterial strains. Strains decreasing chromate, vanadate and moyhybadate were observed from surroundings. Metal ions were utilized as electron donors for generating energy by bacterial isolates. Example: S. aureus strain for resistance of arsenic (As5+/As3+) [52], Klebsiella pneumonia for resistance of mercury (Hg2+/Hg) [53].
4.1 Tolerance against heavy metals in bacteria
There are various processes of heavy metal resistance like extracellular barrier, extracellular sequestration, and active transport of metal ions (efflux), intracellular sequestration, and reduction of metal ions by microbial cells.
B. subtilis revealed the excessive potential to remove the amount of the cadmium.
Bacteria resistant to mercury are Alcaligenes faecalis, Bacillus pumilus, Pseudomonas aeruginosa, and Brevibacterium iodinium for the eradication of cadmium and lead metals.
59 isolated actinobacteria have shown resistance to the five heavy metals. Using molecular identification 16S rRNA, 27 strains were found to classified in the Streptomyces and Amycolatopsis genera [54].
Three strains were identified up to genus level based on their morphological, cultural, physiological and biochemical characteristics as Gemella sp., Micrococcus sp. and Hafnia sp. Among these three isolates, Gemella sp. and Micrococcus sp. exhibited the resistance towards lead, chromium and cadmium metals whereas Hafnia sp. exhibited reactivity to cadmium (Cd). All strains revealed dissimilar MICs against the heavy metals at different concentrations using Atomic Absorption Spectrophotometer [55].
Bacterial cell wall experiencing the metal ion is the primary constituent of biosorption. The metal ions get connected to the various functional groups such as (amine, carboxyl, hydroxyl, phosphate, sulfate, amines) exist on the cell wall of the microbe. The metal uptake mechanism involves binding of metal ions to reactive groups lies on cell wall followed by internalization of metal ions inside cell protoplast. Some metal in more amount are accumulated by Gram positive strains due to presence of glycoproteins in their cell wall. Fewer metal absorption by Gram negative strains is reported due to phospholipids and LPS in their cell wall.
4.1.1 Arsenic resistant bacteria
Gram positive and gram negative bacterial strains have been investigated in the absorption of heavy metals.
Arsenic resistant bacteria species are Enterobacter sp. and Klebsiella pneumoniae based on phylogenetic analysis of 16S rDNA sequence [56].
The Enterobacter sp. (MNZ1), K. pneumoniae 1 (MNZ4) and Klebsiella pneumonia 2 (MNZ6) species shows resistance towards arsenic and survive in the presence of high level of arsenic [57].
10 isolates of rhizobacteria out of which some were Gram-positive bacteria Arthrobacter globiformis, Bacillus megaterium, Bacillus cereus, B. pumilus, and Staphylococcus lentus), and few were Gram-negative bacteria (Enterobacter asburiae and Rhizobium radiobacter). R. radiobacter exhibited the highest MIC of greater than 1500 ppm of the arsenic metal [58].
Aeromonas, Exiguobacterium, Acinetobacter, Bacillus and Pseudomonas are isolates of bacteria that can tolerate high levels of arsenic species [59].
Acidithiobacillus, Deinococcus, Bacillus, Desulfitobacterium and Pseudomonas show resistance against arsenic [60] (Table 1).
Cadmium resistant bacterium, Salmonella enterica 43C is isolated from industrial effluent was characterized on the basis of biochemical and 16S rRNA ribotyping [62].
The efflux processes involves cadA and cadB gene method, and encodes several efflux pump proteins and various functional groups like amine, carboxyl, phosphate and hydroxyl ease cadmium binding sites to bacterial surface such as chemisorption. The membrane impermeablility is regulated by enzymes used in detoxifying the cadmium metal [63]. Various processes on the basis of morphological, biochemical characteristics, 16S rDNA gene sequencing and phylogeny analysis exhibited that the strain RZCd1 was recognized as Pseudomonas sp. M3. In log phase, industrial strains revealed more than 70% of the cadmium accumulation [57] (Table 2).
Removal of heavy metal by cadmium resistant bacteria.
4.1.3 Mercury resistant bacteria
With the help of 16S rRNA gene sequence, Vibrio fluvialis CASKS5 strain was recognized. The mercury-absorption ability of V. fluvialis was examined at several amount of concentration and exhibit large MIC (Minimum Inhibitory Concentration) but low antibiotic resistance [68].
Staphylococcus, Bacillus, Pseudomonas, Citrobacteria, Klebsiella, and Rhodococcus are several species mainly used in bioremediation of mercury [69].
Highly mercury resistant bacteria strains were Brevundimonas sp. HgP1 and Brevundimonas sp. HgP2 with 16S rDNA from a gold mine situated in village Pongkor, West Java with high MIC of 575 ppm. The aim was to examine the effect of mercury on bacterial development and morphological changes of bacterial population. The development was observed by measuring optical density at 600 n [70].
Mercury-resistance in the bacteria isolates were classified into the various genera such as Pseudomonas, Enterobacteriaceae, Proteus, Xanthomonas, Alteromona, and Aeromonas [71].
Attachment to the cell membrane, influx and efflux adsorption, detoxification of toxic metals to less harmful form, the use of metallothionein protein were several processes for heavy metal resistance. Removal of the any ion can be decreased by efflux, an active extrution of the heavy-metal ion [72] (Table 3).
Lead accumulation processes operated by the lead resistant bacteria isolates includes efflux mechanism, extracellular sequestration, biosorption, precipitation, alteration in cell morphology, enhanced siderophore production and intracellular lead bioaccumulation [73].
Four distinct bacteria were isolated with high levels of resistance to lead, each exhibited resistance to 2 mM lead on the minimal medium. Two were identified as Gram-positive genus Corynebacterium and two were the Gram-negative genus Pseudomonas. Three strains transferred no observable plasmid, indicating that the metal resistance is encoded by chromosomal [74] (Table 4).
Lead-resistant bacteria play an important role in the development of lead-exposed plants. The endophyte Bacillus sp. MN3-4 increases Pb(II) absorption in Alnusfirma, and Pseudomonas fluorescens G10 and Mycobacterium sp. G16 enhances plant development and growth and decreased Pb toxicity in Brassica napus [75].
4.1.5 Nickel resistant bacteria
The nickel-resistant bacteria were identified as Shigella, Enterococci and Enterobacter, but they were anaerobic, they only grew in the human samples from obese people and they tolerated a maximum concentration of 1 mM nickel [76].
Few strains Cupriavidus sp. ATHA3, Klebsiellaoxytoca ATHA6 and Methylobacterium sp. ATHA7 and their recognization was concluded on the basis of morphological, biochemical characteristics and 16SrDNA gene sequencing [77] (Table 5).
AIcaligenes eutrophus H16 and N9A strains and derivatives of strain CH34 lacking one or another of its natural metal resistance plasmid were used as recipients. Both of the plasmid, pTOM8 and pTOM9 of strain 31A conveyed resistance features which were expressed except A. eutrophus H16 [79].
Nickel resistance isolates from bacteria isolated from New caledonia by DNA-DNA hybridization. The biotinylated probes of DNA were obtained from Alcaligeneseutrophus CH34, Alcaligenes xylosoxidans 31A, Alcaligenes denitrificans 4a-2, and Klebsiella oxytoca CCUG 15788. 9 probes were crossed with endonuclease-cleaved plasmid and all DNA samples from 56 nickel-resistant determinants. Few Caledonian isolates were recognized as Acinetobacter, Pseudomonas mendocina, Comamonas, Hafniaalvei, Burkholderia, Arthrobacter aurescens, and Arthrobacter ramosusisolates [80].
4.1.6 Copper resistant bacteria
Copper-resistant bacteria have been isolated from the different sources, but copper-resistant Escherichia coli strains were isolated from agricultural sewage and phytopathogenic Pseudomonas and Xanthomonas strains.
The copA gene was noticed in the copper resistant strains Sphingomonas, Stenotrophomonas and Arthrobacter isolated from the contaminated soil from agricultural fields [81] (Table 6).
Bacterial strains showed high level of removal of heavy metals, determinants like YJ3 and YJ7 maybe resistance to Cu and isolates like SWJ11, MT16, GZC24 and YAH27 may be resistance to heavy metals such as Cu, Pb, Cd, Ni and Zn. It has been observed that plant growth-promoting bacteria can enhance the development and heavy metal uptake of plants [83, 84].
Numerous bacterial species show resistance to heavy metal such as thallium, tungsten, uranium, plutonium, have been observed from sediment and water sample. Pseudomonas aeruginosa strains results in accumulation and resistance to these heavy metals. Plutonium is harmful for soil microorganism even at very low concentration and stops the growth of bacteria fungi present in soil and affects soil respiration [85].
4.2 Tolerance against heavy metals in fungi
Fungi are ubiquitous in nature and found in water and soil. Recent strains isolated from contaminated sites have shown exceptional potential to tolerate heavy metals [86].
Fungi show potential as biocatalysts to accumulate heavy metals and convert them into very less toxic metals. Fungi mostly use chelation method to upgrade the tolerance to harmful heavy metals.
Recent studies have concluded many fungal strains like Rhizopus stolonifer in tolerance to lead, cadmium, copper and zinc. Pleurotus ostreatus in strain is used in nickel resistance. Aspergillus niger lead to the removal of lead, zinc, iron by bioleaching process and Aspergillus niger lead to removal of Zinc, nickel, lead, cadmium, manganese by immobilized cells [87].
Fungus as biosorbents used in removal of heavy metal ions. Bioleaching involves use of heterotrophic fungi and their metabolic products for accumulation of heavy metals from solid waste. Bioleaching is alternative method to traditional methods and fungal strains such as Aspergillus and Penicillin are used. Micro colonial fungi (MCF) can be used as a aspect of future research in bioremediation field.
Fungi show two mechanisms for heavy metal tolerance:
Extracellular sequestration.
Intracellular sequestration.
Extracellular mechanism inhibits metal ions to entrance and intracellular mechanism decrease metal ions inside the cytosol. In extracellular system, fungal cells excrete the organic compound that does not belong to cell wall compounds to chelate metal ions.
In intercellular system, metal transport proteins show resistant by ejection of metal ions from inside the cytosol [88].
Fungi strains to tolerate heavy metals are Aspergillus foetidus and Penicillin simplicissimum.
4.2.1 Cadmium resistant fungi
Aspergillus versicolor, Aspergillus fumigatus, Microsporum species, Cladosporium species, Paecilomyces species, Terichoderma were investigated by results of Fazli et al. [89]. Biological mechanism of fungal isolate directly relies on resistance against cadmium metal. Paecilomyces species could accumulate 400 mg/L concentration of cadmium which is the highest MIC standard observed yet. Highly versatile fungus to cadmium stress was Aspergillus versicolor and most sensitive fungus species for inhibition of mycelia growth are Microsporum species and Cladosporium species. Unique and advance technologies in bio treatment of heavy metals are metal uptake technique natively, utilizing combination of isolates and cell structures manipulation by autoclaving [90] (Table 7).
Metal concentration of cadmium used in studying metal resistance in fungi.
4.2.2 Lead resistant fungi
Penicillin oxalicumis species acts as a biosorbent and removes lead from aqueous solution. The isolates reveals uptake ability and tolerance to lead are Aspergillus fumigatus, Penicllum simplicissimum etc. Fungus biomass which is physically and chemically retreated again was a technique applied for biosorption of lead metal [94] (Table 8).
Metal concentration of Lead used in studying metal resistance in fungi.
4.2.3 Mercury resistant fungi
Aspergillus niger and Aspergillus flavus used in bioremediation process in mercury contaminated soil. Both belongs to phylum Ascomycota and are soil fungi [95].
Fungal sensitivity against heavy metals alters the origination of fungal spores. Sporulation is a natural response created by fungi as metal avoidance strategy in heavy metal contaminated sites.
Formation of Metallothionein polypeptides reduce cytotoxicity and metabolize heavy metals in fungi.
Metal concentration of mercury used in metal resistance in fungi.
4.2.4 Nickel resistant fungi
Various fungi species such as Aspergillus niger, Aspergillus giganteus, Penicillin vermiculatum, Gliocladium species, Beauvaria species, Trichodermaviride and Rhizopusstolonifera induces shows sporulation due to increase in concentration of nickel in contaminated sites. Environmental factors like pH temperature organic matter and metal ions impacts toxicity of nickel. Alteration of magnesium transport minimizes nickel. Generation of chelating compounds like glutathione deactivates toxicity of nickel [97] (Table 10).
Bioaccumulation and biovolatilization through arsenic resistant species like Penicillin sp., Aspergillus sp., Neosartorya sp., Gliocladiumreseum and the yeast Candida humicola in removal of arsenic have been studied [98, 99, 100, 101].
Microbes involved in biochemical mechanisms to exploit arsenic oxy-anions either as an electron acceptor (arsenate) for anaerobic respiration or as an electron donor (arsenite) to support chemoautotrophic fixation of carbon dioxide into cell carbon [102].
Two arsenic resistant fungi are Fimetariella rabenhortii and Hormonema viticola were isolated from contaminated soil. In fungi, Evaluation of plant growth promoting factors. Arsenic shows resistance by mediation of phosphate solubilization. F. rabenhortii and H. viticola had capacity to produce indole acetic acid and siderophores [103].
acrA biosensor strain is first fungal biosensor for arsenic detection. Using fungi as whole cell biosensors have various advantages [104].
A non-pathogenic strain Aspergillus niger is broadly used in Industrial applications. Presence of lead and zinc does not affect the fungal spore growth (Table 11).
Iron is essential in low concentration but very harmful in high amount of concentration. The fungal strains useful in iron resistance are Aspergillus niger and Aspergillus foetidus and some Penicillium species too. Fungal strains have good ability for bio leaching process by interfering functional groups of enzymes [105] (Table 12).
Cobalt metal is found in state of cobaltite, linnaeite, smaltite, etc. Some fungal strains help in accumulation of cobalt are Aspergillus niger, Aspergillus foetidus and Penicillium spp. The factors that improve the removal of cobalt were fungal biomass, incubation time, pH, temperature, concentration of metal ions [106] (Table 13).
Metal detoxification or chelation is one more strategy defense for heavy metal resistance. Algae secrete chelating molecules in response to metal ions that successively bind to them resulting in the sequestration of complexed metals in cellular organelles. Most of the algae strains are rumored to accumulate elevated metal ion concentration in cellular organelles. Additionally, the appliance of this metal resistance in biogenesis of metal nano-particles and metal compound nano-particles has been investigated by [107].
Algae are aquatic plants which absence of true roots and stems. Even when less nutrition is provided still they can grow in large biomass. Large size, high sorption ability and no production of harmful components are responsible for good biosorbent material. Features required for binding algae surface to heavy metal ions are algae species, ionic charge of metal and chemical composition of metal ion solution. Amine, carboxyl, sulfate, phosphate, sulfhydryl, hydroxyl, imidazole groups are metal ion binding sites on algal surfaces [108].
Algae show various mechanism such as formation of proteins which binds with metals, changes in structure of cell membrane, complexation or elimination of ions. Heavy metals can be eliminated for contaminated sites by either living cells or dead cells by usage of inactive biomass. Mechanism of absorption of living cells is very much complex than intracellular uptake [109].
Two processes in algal biosorption are involved. 1. Ion exchange method where ions present on algal membrane Ca, Mg, K, Na. They are displaced by metal ions. 2. Complexation between metal ions and functional groups. The metal removal process of algae is similar to bacteria by bonding of metal ions with the membrane [110].
Cladophora species are best bio indicator and scenedesmus species results in stress tolerance and accumulation of heavy metal like copper and chromium. In brown algae, cell wall contains fucoidin and olginic acid which helps in accumulation of heavy metals too [111].
Three fresh water microalgal determinants Phormidium ambiguum (Cyanobacterium), Pseudochlorococcum typicum and Scenedesmus quadricauda var. quadrispina (Chlorophyta) were tried for resistance and absorption of mercury (Hg2+), lead (Pb2+) and cadmium (Cd2+) in aqueous solution. Transmission electron microscopy (TEM) was examined to contemplate the connection between heavy metal ions and P. typicum cells. At ultrastructural level, electron thick layers were recognized on the algal cell membranes when exposed to Cd, Hg and Pb [110] (Table 14).
Heavy metal shows biosorption potential in algal species.
Bifurcaria bifurcate, oocystis, Pithophora spp., Sargassum sp., Sagassumtenerrimum, Fucusvesiculosus (brown algae), Ascophyllumnodosumare resistant to cadmium. Pithophora spp., Sargassum sp., Spirogyra sp., are resistant to chromium. Calotropisprocera, Pithophora spp., Fucusvesiculosus are species resistant to lead. Cladophorafascicularis, Spirogyra hyaline, Sargassum sp. are resistant to mercury metal and Sargassum sp., Fucusvesiculosus, Ascophyllumnodosum are resistant to nickel [121].
Red algae Porphyra leucostica was used to treatment heavy metal accumulation in wastewater and contaminated water sites by Ye et al. [122]. It was reported that this species are so efficient biosorbent.
Microalgae are also capable in utilizing the removal of heavy metals for water contaminated sites. Microalgae are unicellular organisms and also known as phytoplankton which are visible under microscope only and found in both fresh and marine water. Microalgae show positive responses in the resistance towards the heavy metals and convey better chances of bioremediation. Microalgae are also used as a bio-indicator to check or identify the effects of contaminants on ecosystem. Microalgae exhibit biosorption methods to accumulate heavy metals by showing extracellular mechanism and intracellular mechanism to deal with high toxic concentration. Microalgae mostly used to treat wastewater as it releases oxygen as a byproduct during process [123].
Bioremediation by Cynobacteria (Blue Green algae):
Cynobacteria is efficient tool for enhancing the productivity of crop, and plants, formation of bio fuel, rise in fertility of soil and bioremediation also. To explore multiple functional bioagents, genetically engineered cynobacteria should be introduced heavy metals like cadmium, lead, copper, cobalt, manganese were treated with different cynobacterial species such as N. muscorum, A. subcylindrica, Nostoc, linckia, N. rivularis, etc present in sewage and industrial waste water [124, 125].
Heavy metals develop oxidative stress by generation of reactive oxygen species (ROS) which is extremely toxic and damages the nucleic acid-DNA and RNA, protein and lipids also.
Cynobacteria acts as bioremediator because of their photoautotrophic nature and capability in nitrogen fixation. It is able to tertiary level of agro industrial effluents like oil refineries, paper and pharmaceutical industry. Nostoc species and Microcystis species accumulate wide range of organophosphate insecticides. As it is found in contaminated water sites and helps in high yield of plants and utilized for bioaccumulation. It can help to enhance the fertility of soil and useful as bio-fuels. It can be used as a good biofertilizers. Mechanism adopted by cynobacteria response to salanity result in bio-polymer production.
Cynobacteria develop bio-flocculants that shield there body mechanism from toxicity of heavy metas. Bio-flocculants are outlined by the presence of various negatively charged binding sides that permit cynobacteria in resistance of heavy metal from contaminated sites [126]. Cynobacteria have flourished numerous mechanisms for reducing the metal stress by intracellular metal sequestration, extracellular mechanism or binding of metals ions.
Metalithionein are metal binding proteins released by cynobacteria that support organism in metal sequestration of dangerous heavy metal ions.
Use of cynobacteria is much better than other microbes like bacteria fungi because of various other benefits like growth promoters, bio stabilizer, bio energy resource (bio-diesel), bio fertilizer, wasteland reclamation, carbon dioxide sequestration, methane oxidation.
Cynobacteria are very much efficient because of short generation time and helps in atmospheric nitrogen fixation.
Lichens in bioremediation:
Lichens are made by symbiotic association of fungi and algae in which both benefit each other. In wastewater remediation, lichens used as a biosorbents.
In heavy metal contamination, lichens can be used as bio-monitors too and the capability to accumulate heavy metal allows the monitoring ability. Lichen Permelia perlata shows the potential in biodegradation in contaminated sites.
Lichens adopt numerous processes for metal uptake such as extracellular uptake by ion exchange method intracellular removal and capturing of metal particles. The studies done by UK researchers on lichen results that lichen reproduces on land contaminated with uranium particles from mining activities and lichen converts uranium into dark particles. Endolithic lichen can be studied as a future approach in field of bioremediation [127].
5. Conclusion
Heavy metal pollution are very harmful for humans, animals, aquatic species and plants too and they were accumulated on earth crust by natural process as well as human activities such as industrialization, urbanization, mining and extraction, agricultural practices, etc. Bioremediation is the process which use either naturally occurring or deliberately introduced microorganisms to consume and break down environmental pollutants, in order to clean a polluted site. Various studies had been done and various strains were investigated are above mentioned. Bacteria, Fungi, Algae all are helpful in maintaining tolerance against heavy metals in different contaminated sites. There are several microbes present that provide heavy metal resistance through develop different method of resistance against different heavy metal. It can reduce heavy metals from environment to some extent. Further research area needs to be extended on the focus of gene transfer within bio-films for Bioremediation and use of genetic modified organisms. These strategies would facilitate the development of improved techniques for the bioremediation of heavy metals in the environment.
Acknowledgments
I would like to thank Lovely Professional University providing me the opportunity. I thank the anonymous referees for their useful suggestions.
Conflict of interest
The authors declare that they have no conflict of interest in the publication.
Author contribution
This study was conducted in collaboration between all the authors. All authors read and approved the final manuscript.
\n',keywords:"heavy metal resistance, bioremediation, biosorption, bioleaching, plasmid",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/79944.pdf",chapterXML:"https://mts.intechopen.com/source/xml/79944.xml",downloadPdfUrl:"/chapter/pdf-download/79944",previewPdfUrl:"/chapter/pdf-preview/79944",totalDownloads:220,totalViews:0,totalCrossrefCites:0,dateSubmitted:"September 27th 2021",dateReviewed:"November 13th 2021",datePrePublished:"January 7th 2022",datePublished:"April 20th 2022",dateFinished:"January 7th 2022",readingETA:"0",abstract:"Heavy metals accumulated the earth crust and causes extreme pollution. Accumulation of rich concentrations of heavy metals in environments can cause various human diseases which risks health and high ecological issues. Mercury, arsenic, lead, silver, cadmium, chromium, etc. are some heavy metals harmful to organisms at even very low concentration. Heavy metal pollution is increasing day by day due to industrialization, urbanization, mining, volcanic eruptions, weathering of rocks, etc. Different microbial strains have developed very efficient and unique mechanisms for tolerating heavy metals in polluted sites with eco-friendly techniques. Heavy metals are group of metals with density more than 5 g/cm3. Microorganisms are generally present in contaminated sites of heavy metals and they develop new strategies which are metabolism dependent or independent to tackle with the adverse effects of heavy metals. Bacteria, Algae, Fungi, Cyanobacteria uses in bioremediation technique and acts a biosorbent. Removal of heavy metal from contaminated sites using microbial strains is cheaper alternative. Mostly species involved in bioremediation include Enterobacter and Pseudomonas species and some of bacillus species too in bacteria. Aspergillus and Penicillin species used in heavy metal resistance in fungi. Various species of the brown algae and Cyanobacteria shows resistance in algae.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/79944",risUrl:"/chapter/ris/79944",signatures:"Madhuri Girdhar, Zeba Tabassum, Kopal Singh and Anand Mohan",book:{id:"10681",type:"book",title:"Biodegradation Technology of Organic and Inorganic Pollutants",subtitle:null,fullTitle:"Biodegradation Technology of Organic and Inorganic Pollutants",slug:"biodegradation-technology-of-organic-and-inorganic-pollutants",publishedDate:"April 20th 2022",bookSignature:"Kassio Ferreira Mendes, Rodrigo Nogueira de Sousa and Kamila Cabral Mielke",coverURL:"https://cdn.intechopen.com/books/images_new/10681.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83968-896-6",printIsbn:"978-1-83968-895-9",pdfIsbn:"978-1-83968-897-3",isAvailableForWebshopOrdering:!0,editors:[{id:"197720",title:"Ph.D.",name:"Kassio",middleName:null,surname:"Ferreira Mendes",slug:"kassio-ferreira-mendes",fullName:"Kassio Ferreira Mendes"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"119021",title:"Dr.",name:"Anand",middleName:null,surname:"Mohan",fullName:"Anand Mohan",slug:"anand-mohan",email:"anandmohan77@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Lovely Professional University",institutionURL:null,country:{name:"India"}}},{id:"350374",title:"Assistant Prof.",name:"Madhuri",middleName:null,surname:"Girdhar",fullName:"Madhuri Girdhar",slug:"madhuri-girdhar",email:"madhurigirdhar007@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"350380",title:"Ms.",name:"Kopal",middleName:null,surname:"Singh",fullName:"Kopal Singh",slug:"kopal-singh",email:"srishtisingh162@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Lovely Professional University",institutionURL:null,country:{name:"India"}}},{id:"438770",title:"MSc.",name:"Zeba",middleName:null,surname:"Tabassum",fullName:"Zeba Tabassum",slug:"zeba-tabassum",email:"saloniarora238@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Lovely Professional University",institutionURL:null,country:{name:"India"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Source of the heavy metals",level:"1"},{id:"sec_2_2",title:"2.1 Lead in environment",level:"2"},{id:"sec_3_2",title:"2.2 Arsenic in environment",level:"2"},{id:"sec_4_2",title:"2.3 Mercury in environment",level:"2"},{id:"sec_5_2",title:"2.4 Chromium in environment",level:"2"},{id:"sec_6_2",title:"2.5 Cadmium in environment",level:"2"},{id:"sec_7_2",title:"2.6 Copper in environment",level:"2"},{id:"sec_8_2",title:"2.7 Zinc in environment",level:"2"},{id:"sec_9_2",title:"2.8 Manganese in environment",level:"2"},{id:"sec_10_2",title:"2.9 Iron in environment",level:"2"},{id:"sec_11_2",title:"2.10 Other heavy metals in environment",level:"2"},{id:"sec_13",title:"3. Adverse effects of heavy metals",level:"1"},{id:"sec_13_2",title:"3.1 Adverse affects of heavy metals on humans",level:"2"},{id:"sec_14_2",title:"3.2 Adverse effects of heavy metals on marine animals",level:"2"},{id:"sec_15_2",title:"3.3 Adverse affects of heavy metals on plants",level:"2"},{id:"sec_17",title:"4. Bioremediation of heavy metals by microbial strains",level:"1"},{id:"sec_17_2",title:"4.1 Tolerance against heavy metals in bacteria",level:"2"},{id:"sec_17_3",title:"Table 1.",level:"3"},{id:"sec_18_3",title:"Table 2.",level:"3"},{id:"sec_19_3",title:"Table 3.",level:"3"},{id:"sec_20_3",title:"Table 4.",level:"3"},{id:"sec_21_3",title:"Table 5.",level:"3"},{id:"sec_22_3",title:"Table 6.",level:"3"},{id:"sec_24_2",title:"4.2 Tolerance against heavy metals in fungi",level:"2"},{id:"sec_24_3",title:"Table 7.",level:"3"},{id:"sec_25_3",title:"Table 8.",level:"3"},{id:"sec_26_3",title:"Table 9.",level:"3"},{id:"sec_27_3",title:"Table 10.",level:"3"},{id:"sec_28_3",title:"Table 11.",level:"3"},{id:"sec_29_3",title:"Table 12.",level:"3"},{id:"sec_30_3",title:"Table 13.",level:"3"},{id:"sec_32_2",title:"4.3 Tolerance against heavy metals in algae",level:"2"},{id:"sec_34",title:"5. 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Biological removal of arsenic pollution by soil fungi. Science of the Total Environment. 2011;409(12):2430-2442. DOI: 10.1016/j.scitotenv.2011.03.002'},{id:"B102",body:'Wang S, Zhao X. On the potential of biological treatment for arsenic contaminated soils and groundwater. Journal of Environmental Management. 2009;90(8):2367-2376. DOI: 10.1016/j.jenvman.2009.02.001'},{id:"B103",body:'Soto J, Ortiz J, Herrera H, Fuentes A, Almonacid L, Charles TC, et al. Enhanced arsenic tolerance in Triticum aestivum inoculated with arsenic-resistant and plant growth promoter microorganisms from a heavy metal-polluted soil. Microorganisms. 2019;7(9):348. Available from: https://pubmed.ncbi.nlm.nih.gov/31547348/'},{id:"B104",body:'Choe SI, Gravelat FN, Al Abdallah Q, Lee MJ, Gibbs BF, Sheppard DC. Role of Aspergillus niger acrA in arsenic resistance and its use as the basis for an arsenic biosensor. Applied and Environmental Microbiology. 2012;78(11):3855-3863. 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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419588",title:"Ph.D.",name:"Sergio",middleName:"Alexandre",surname:"Gehrke",slug:"sergio-gehrke",fullName:"Sergio Gehrke",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038WgMKQA0/Profile_Picture_2022-06-02T11:44:20.jpg",biography:"Dr. Sergio Alexandre Gehrke is a doctorate holder in two fields. The first is a Ph.D. in Cellular and Molecular Biology from the Pontificia Catholic University, Porto Alegre, Brazil, in 2010 and the other is an International Ph.D. in Bioengineering from the Universidad Miguel Hernandez, Elche/Alicante, Spain, obtained in 2020. In 2018, he completed a postdoctoral fellowship in Materials Engineering in the NUCLEMAT of the Pontificia Catholic University, Porto Alegre, Brazil. He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\r\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\r\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Orthodontist, Assoc Prof in the Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. Her knowledge of English is at an advanced level.",institutionString:null,institution:null},{id:"332914",title:"Dr.",name:"Muhammad Saad",middleName:null,surname:"Shaikh",slug:"muhammad-saad-shaikh",fullName:"Muhammad Saad Shaikh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jinnah Sindh Medical University",country:{name:"Pakistan"}}},{id:"315775",title:"Dr.",name:"Feng",middleName:null,surname:"Luo",slug:"feng-luo",fullName:"Feng Luo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sichuan University",country:{name:"China"}}},{id:"344229",title:"Dr.",name:"Sankeshan",middleName:null,surname:"Padayachee",slug:"sankeshan-padayachee",fullName:"Sankeshan Padayachee",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"315727",title:"Ms.",name:"Kelebogile A.",middleName:null,surname:"Mothupi",slug:"kelebogile-a.-mothupi",fullName:"Kelebogile A. 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The endocrine and nervous systems play important roles in maintaining homeostasis in the human body. Integration, which is the biological basis of physiology, is achieved through communication between the many overlapping functions of the human body's systems, which takes place through electrical and chemical means. Much of the basis of our knowledge of human physiology has been provided by animal experiments. Because of the close relationship between structure and function, studies in human physiology and anatomy seek to understand the mechanisms that help the human body function. 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