Comparison of the reaction rate constants of superoxide anion (O2•‾) with nitric oxide (•NO), superoxide dismutase (SOD) and ascorbic acid (AscH2).
\\n\\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\\n\\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\nThroughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\nReleased this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\nWe wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"2021",leadTitle:null,fullTitle:"Cutting Edge Research in New Technologies",title:"Cutting Edge Research in New Technologies",subtitle:null,reviewType:"peer-reviewed",abstract:'The book "Cutting Edge Research in New Technologies" presents the contributions of some researchers in modern fields of technology, serving as a valuable tool for scientists, researchers, graduate students and professionals. The focus is on several aspects of designing and manufacturing, examining complex technical products and some aspects of the development and use of industrial and service automation. The book covered some topics as it follows: manufacturing, machining, textile industry, CAD/CAM/CAE systems, electronic circuits, control and automation, electric drives, artificial intelligence, fuzzy logic, vision systems, neural networks, intelligent systems, wireless sensor networks, environmental technology, logistic services, transportation, intelligent security, multimedia, modeling, simulation, video techniques, water plant technology, globalization and technology. 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He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"51172",title:"Novel Antioxidant Therapy Against Myocardial Ischemia– Reperfusion Injury During Percutaneous Coronary Angioplasty",doi:"10.5772/63658",slug:"novel-antioxidant-therapy-against-myocardial-ischemia-reperfusion-injury-during-percutaneous-coronar",body:'\nAccording to the World Health Organization, a total of 56 million deaths occurred worldwide during 2012 and 17.5 million (31.25%) were due to cardiovascular diseases, still the principal cause of death by noncommunicable diseases. In addition, deaths due to ischemic heart disease (IHD) in 2012 were estimated as 7.4 million (13.2%), remaining as the leading cause of death over the past decade [1, 2], with a considerable social impact due to mortality, morbidity, loss of quality of life and high economic cost. In IHD, severe and prolonged myocardial ischemic events occur through thrombotic complications from atherosclerotic plaques in pericardial coronary arteries, leading to cardiomyocyte death. The latter becomes more significant when ischemia is caused by complete coronary occlusion, generating an acute myocardial infarction (AMI) where the coronary microcirculation is significantly reduced, affecting most of the left ventricular wall thickness together with structural and functional impairments, scarring and adverse remodeling [3, 4]. The most effective therapeutic intervention for reducing the size of a myocardial infarct and improving the clinical outcome is timely and effective restoring of coronary flow using either thrombolytic therapy or percutaneous coronary angioplasty (PCA), but this process can itself induce further viable cardiomyocyte death and increased infarct size, a phenomenon known as myocardial reperfusion injury (MRI), thus reducing the beneficial effects. The MRI causes four types of cardiac dysfunction, the first two being reversible and the others irreversible: (i) reperfusion-induced arrhythmias; (ii) myocardial stunning; (iii) microvascular obstruction or no-reflow phenomenon; and (iv) lethal myocardial reperfusion injury (LMRI). LMRI is the most important because may account for up to 50% of the myocardial infarct (MI) final size as shown in both experimental ischemia–reperfusion (I/R) models and patients with ST-segment elevation MI applying therapeutic interventions solely at the onset of myocardial reperfusion [5, 6]. In addition, several experimental studies have shown the important role of oxidative stress in MRI and it has been postulated as a therapeutic target for cardioprotection [7–13]. However, the clinical trials have shown mixed results with no clear confirmation of the beneficial effects of exogenous antioxidant therapy at the onset of myocardial revascularization, possibly due to differences in the design and methodology [14]. Next, we describe the pathophysiological mechanisms involved in MRI and the molecular basis for a novel cardioprotective treatment of patients with AMI subjected to PCA, based on a reinforcement of the antioxidant system.
\nOcclusion of a coronary artery decreases blood flow to myocardial tissue causing a state of prolonged ischemia. The lack of oxygen and nutrients triggers a series of abrupt metabolic and biochemical changes within the cardiomyocyte that lead to several mechanisms of cell death, which are enhanced in the reperfusion (Figure 1).
\nDuring acute myocardial ischemia, the absence of oxygen in the mitochondrial electron transport chain (mETC) causes a drop in the production of adenosine triphosphate (ATP), and the glycolytic pathway generates a shift to anaerobic respiration with intracellular accumulation of lactic acid [9, 15]. In addition, the Krebs cycle stops and CO2 cannot be eliminated from the extracellular space due to blood flow arrest. Therefore, a decrease in the intracellular pH (<7.0) occurs, which increases the Na+ influx through the Na+/H+ exchanger, while the ATP depletion stops Na+ efflux through Na+/K+-ATPase. This intracellular Na+ accumulation activates Na+/Ca2+ exchangers in the reverse direction leading to cytosolic Ca2+ overload [16], where the sarcoplasmic reticulum is unable of uptaking Ca2+ from the cytosol because sarco(endo)plasmic reticulum Ca2+-ATPase (SERCA) transporter needs ATP to function [17]. High levels of intracellular Ca2+ induce the conversion, via limited proteolysis and sulfhydryl oxidation, of xanthine dehydrogenase to xanthine oxidase (XO) in endothelial cells mainly, an isoform that produces superoxide anion and hydrogen peroxide (H2O2) from oxygen [18]. The acidic conditions exert a strong inhibitory effect on the mitochondrial permeability transition pore (mPTP) [19], despite the presence of inducing factors opening such as Ca2+ and inorganic phosphate overload, oxidative stress and ADP. The mPTP is an inner mitochondrial membrane protein channel that, when it is open under certain conditions, mediates non-selective permeability to molecules less than 1.5 kDa, collapsing the mitochondrial membrane potential and uncoupling oxidative phosphorylation, leading to ATP depletion, mitochondrial matrix swelling and cell death through apoptosis and necrosis [20]. In addition, acidosis and low levels of ATP reduces the myocardial contractile activity [21].
\nThe coronary revascularization postmyocardial ischemia rapidly increases the level of tissue oxygenation, which triggers a series of mechanisms producing LMRI. The most important mediators of this process are described below.
\nDuring the first minutes of the onset of myocardial reperfusion, a burst of ROS occurs, in accordance with several experiments demonstrating direct measurements of free radicals in isolated hearts and
Schematic representation of the pathophysiological mechanism involved in myocardial damage due to I/R. ATP, adenosine triphosphate; mPTP, mitochondrial permeability transition pore; NOX, NADPH oxidase; NF-κB, nuclear factor kappa B; Nrf2, nuclear factor-erythroid 2-related factor 2; ROS, reactive oxygen species; uncNOS, uncoupled nitric oxide synthase; XO, xanthine oxidase; Ca2+, calcium; DNA, deoxyribonucleic acid.
Exacerbation of oxidative stress during postischemia myocardial reperfusion overwhelms the endogenous antioxidant defenses, causing free radical propagation reactions with direct damage to cellular biomolecules as lipid peroxidation, protein oxidation/nitration and DNA damage [24, 26]. The main effecter of ROS-induced damage is the highly reactive hydroxyl radical generated from Fenton/Haber–Weiss reactions and peroxynitrite (reviewed in Section 3) [24], demonstrating its formation in a postischemia reperfused heart [11]. In addition, ROS can induce activation both of nuclear factor kappa B (NF-κB) and nuclear factor-erythroid 2-related factor 2 (Nrf2)-signaling pathways, although the ROS concentration threshold has not been experimentally determined [27]. NF-κB proteins are a family of transcription factors with a central role in regulating the expression of genes related with inflammation, immune response, cell proliferation and apoptosis [28–30], and different levels of ROS can both activate and inhibit NF-κB-signaling, depending on the context, with a high degree of complexity [31]. On the other hand, Nrf2 is a transcription factor that positively regulates the human antioxidant response element (ARE), leading to the gene expression of endogenous antioxidant defence system. Kelch-like ECH-associated protein 1 (Keap1) is a suppressor protein anchored in the cytoplasm that physically binds Nrf2, but oxidative stress facilitates the complex dissociation and Nrf2 nuclear translocation to ARE-containing promoters [32]. A study demonstrated that Nrf2 is indispensable for the regulation of both constitutive and inducible expression of antioxidants and phase-2 enzymes in mouse primary cardiomyocytes [33]. In clinical trials, the antioxidant therapy at the onset of reperfusion, in patients with AMI subjected to PCA, has mainly considered the use, alone or combined, of ROS scavengers, inhibitors of ROS sources, human recombinant antioxidant enzymes and reduced glutathione donor [14].
\nThe intracellular acidic pH generated in ischemia returns to physiological values during myocardial reperfusion [9]. Bond et al. [34] simulated I/R conditions in cultured neonatal rat cardiac myocytes, demonstrating that when intracellular acidic pH increases to 7.4 hypercontracture and cell death occur. In addition, free Ca2+ increases during simulated ischemia and in simulated reperfusion. Under conditions of ischemia, it was shown in cultured cardiac myocytes and perfused papillary muscles that inhibition of Na+/H+ exchanger delayed the increase of intracellular pH after reperfusion and prevented reperfusion-induced cell killing, but not reduce the increase in intracellular-free Ca2+ [35]. By contrast, reperfusion with inhibition of Na+/Ca2+ exchanger decreases intracellular free Ca2+ but did not reduce cell killing. These results suggest that acidotic pH is generally protective in I/R, and Na+/H+ exchanger contributes to reperfusion washout effect on intracellular acidic pH, leading to a Ca2+-independent lethal reperfusion injury in cardiomyocytes.
\nRecently, it has been proposed that various potential protein components either to form the molecular structure of the mPTP or to regulate its opening [20, 36]. It was shown that the mPTP opening occurs within the first few minutes postischemia myocardial reperfusion [37], with both burst of oxidative stress and intracellular pH normalization (possibly due to the inhibitory effect of acid pH on mPTP is removed) as the main contributing factors [38, 39]. On the other hand, Ca2+ overload seems not to be a causative factor in I/R model. In adult rat myocytes, both cytosolic and mitochondrial Ca2+ increased during ischemia but decreases to basal levels in the first minutes of reperfusion. Ca2+ overload occurred late in both compartments, event that was prevented by mPTP inhibitors. Besides, intramitochondrial Ca2+ chelation did not prevent cell death after reperfusion. Thus, Ca2+ overload appears to be the consequence of bioenergetic failure after mPTP opening [38]. Another study showed that, at the onset of reperfusion, there is a transient increase in cytosolic Ca2+ levels together with a simultaneous transient sarcoplasmic reticulum Ca2+ depletion [40], corroborating the latter. The mPTP is a potential pharmacological target for prevent LMRI, and experimental studies with mPTP inhibitors (such as cyplosporin A), at the onset of myocardial reperfusion, has been reported to reduce MI size by 40–50% [41–44].
\nIschemia is associated with slow infiltration of neutrophils, but recruitment toward the necrotic zone is favored after reperfusion by increased ROS exacerbation that triggers upregulation of adhesion molecules (P-selectin, CD11/CD18, ICAM-1) in cardiomyocytes, with cytokines (TNFα, IL-1, IL-6, IL-8, NAP-1, PAF, MIP-2) and complement, which are released from ischemic-reperfused myocardium. Neutrophils adhesion to coronary vascular endothelium occurs rapidly (within minutes) after onset of reperfusion, with abundant accumulation into the infarct zone during the following 6 hours. Neutrophils release more than 20 different proteolytic enzymes (hydrolases, metalloproteinases, and proteases) and are a major ROS source by generating superoxide anions through NOX, positioning them as important contributors to MRI [45].
\nAfter reviewing the most relevant pathophysiological processes of myocardial ischemia–reperfusion injury, the central role being played by the burst of oxidative stress in the first minutes of revascularization certainly has positioned itself as a pharmacological target of choice. In the following section, we describe the molecular basis of an innovative combined antioxidant therapy, which includes a reinforcement of endogenous antioxidant defences, aimed to prevent or at least ameliorate the MRI in patients with AMI undergoing PCA.
\nVitamin C (ascorbic acid or ascorbate) is a potent water-soluble antioxidant in humans, which cannot be endogenously synthesized [46] and must be incorporated through vegetables and fruits [47]. Vitamin C is an electron donor and is oxidized to dehydroascorbate when acting as a reducing agent, returning to reduced form when is used by the cell [48] (Figure 2). A study in a group of apparently healthy adult nonsmoking population showed an inverse correlation between plasma vitamin C and products of oxidative damage to DNA, proteins and lipids [49]. Another study evaluated oxidant and antioxidant parameters in the blood of the patients with MI before and after thrombolysis and showed that the activity of superoxide dismutase (SOD), an antioxidant enzyme, was significantly reduced, whereas the activity of XO, an oxidant enzyme, together with the levels of malondialdehyde (MDA), a lipid peroxidation biomarker, significantly increased after reperfusion. These parameters improved to normal or near-normal levels when patients were supplemented with oral vitamin C postreperfusion [50], confirming the
Oxidation of ascorbate (AscH‾) to dehydroascorbic acid (Asc) for the loss of two electrons in succession, through the formation of ascorbyl radical intermediate (Asc•‾). Importantly, ascorbate is the ionized form of ascorbic acid (AscH2) at physiological pH (7.4).
Vitamin C has been used in I/R models. Gao et al. [55] demonstrated that in isolated rat hearts subjected to I/R, glutathione monoethyl ester (GSHme), but no ascorbic acid, administered at the onset of reperfusion exerted protective effects against MRI. Furthermore, GSHme coadministered together with ascorbic acid had enhanced protective effects, suggesting a synergistic effect between the two compounds. Another
These results could be explained by the fact that oral administration of vitamin C shows a plasma concentration–time profile, in a dose range of 200–2500 mg/day, producing a steady-state plasma concentration approximately by 80 µmol/l (0.08 mmol/l), due to apparent saturation of tissue uptake and in less degree by function of oral bioavailability and renal excretion [59]. At these physiological concentrations, superoxide anion reacts with NO at a rate 104-fold greater than that at which it reacts with ascorbic acid (Table 1A and C), situation that is favored during the ROS burst in the first minutes of postischemia myocardial reperfusion because superoxide anion levels are exacerbated.
\n\n | Reaction | \nRate constant (M−1 s−1) | \n
---|---|---|
(A) | \n7 × 109 | \n|
(B) | \n2 × 109 | \n|
(C) | \n2.7–3.3 × 105 | \n
Superoxide anion reacts avidly with NO to form peroxynitrite (ONOO−) (Table 1A), an agent very reactive and toxic to biomolecules, with a constant rate higher than that of the reaction between superoxide anion and SOD (Table 1B). Furthermore, peroxynitrite (pKa at 37°C = 6.8) can be protonated in medium with acidotic pH during ischemia, resulting in ONOOH that is inherently unstable. Reperfusion restored the intracellular pH to physiologic levels, favoring decomposition of ONOOH to hydroxyl radical and nitrogen dioxide radical (Figure 3) [24], both responsible for generating oxidative stress and nitrosative stress damage to cardiomyocytes. Thus, peroxynitrite contributes to MRI generating lipid peroxidation and protein nitration in tyrosine residues, affecting the function and structure of the latter; oxidation of thiol groups related to cell antioxidant capacity; rupture of double-stranded DNA; and BH4 NOS cofactor oxidation, which reduces the formation of NO [63].
\nJackson et al. [64] demonstrated
Formation of hydroxyl radical (•OH) and nitrogen dioxide radical (NO2•) from peroxynitrite (ONOO‾) through an intermediary peroxynitrous acid (ONOOH).
When ascorbate is oxidized to dehydroascorbate, it can return to its reduced form through a reduced glutathione (GSH)-dependent recycling mechanism inside the cell, which may be direct [71] or enzyme mediated [72] (Figure 4) and can lead to a dehydroascorbate concentration-dependent decrease in intracellular GSH levels [71, 73, 74]. This process has been described in human erythrocytes [73], bovine aortic endothelial cells [74], among others and fulfills a function of blood antioxidant reserve [75]. Glutathione (γ-glutamyl-cysteinyl-glycine) is an endogenous agent playing a primary role of nonenzymatic antioxidant defence together with participating in metabolic processes and cellular regulation. It has a reduced form (GSH) and an oxidized form (GSSG) which are interconvertible. It is synthesized in all cell types of the organism, being mostly in the cytosol and to a lesser extent in the extracellular plasma [76].
\nReduced glutathione (GSH)-dependent reduction of dehydroascorbic acid (Asc), which may be mediated directly or by enzyme. NADPH, nicotinamide adenine dinucleotide phosphate (reduced form); NADP+, nicotinamide adenine dinucleotide phosphate (oxidized form); GSSG, oxidized glutathione; AscH2, ascorbic acid; RH, unsaturated fatty acid chain; R•, lipid alkyl radical.
If we consider an IV administration of high doses of vitamin C before, during and after PCA in patients with AMI, the burst of ROS will be counteracted by ascorbic acid, which generates large amounts of dehydroascorbic acid. We hypothesized that the latter interact with endogenous GSH and will cause a drop in their levels, limiting the cardioprotective effect. For this reason, we believe essential to reinforcement the endogenous antioxidant defence system with a GSH donor, such as
It has been shown in I/R models of isolated perfused heart that during a period of ischemia the amount of tissue available iron (Fe) increases in a time-dependent manner. Fe is rapidly mobilized through the perfusion fluid leading to very high Fe levels (up to 50-fold compared to pre-ischemic values) in the first small volumes of coronary flow fractions (CFF), returning to baseline over time. In addition, the levels of Fe in the CFFs correlated well with the loss of cardiac function following global ischemia of varying duration [83]. Similarly, the Fe levels increase up to 30-fold in cardiac tissue during ischemia, in a time-dependent manner, due to acidification in ischemia because this effect contributes tremendously to the mobilization of Fe from intracellular ferritin storage. After reperfusion, tissue Fe levels decrease, although it is known that the superoxide anion contributes to the mobilization of Fe from ferritin [84–86]. Langendorff models with myocardial iron overload develop different functional, biochemical and ultrastructural alterations as compared to control groups of myocardial I/R, which are prevented by deferoxamine (DFO), an iron chelator [87], realizing the harmful tissue effect of Fe high levels. The role of Fe in the postischemia MRI has been demonstrated in experimental models by the use of iron chelators at the onset of reperfusion, improving cardiac function relative to control group [88, 89]. Furthermore, a long-term study conducted in randomly selected men aged 42, 48, 54 and 60, who had no symptoms of coronary heart disease at entry, showed that elevated levels of serum ferritin (stored Fe) was a strong risk factor for developing AMI [90].
\nPhysiologically, transition metals, such as iron, are mainly stored or complexed. However, under certain pathological conditions, the nonchelated state iron levels are increased, thus generating oxidative stress. Reduced iron (Fe2+) can react with hydrogen peroxide to generate hydroxyl radical (•OH), a process known as Fenton reaction (Table 2A). At the same time, oxidized iron (Fe3+) can react with superoxide anion to form again Fe2+ and oxygen (Table 2B). The sum of the Fenton reaction and the superoxide-mediated reduction of Fe3+ originates the Haber–Weiss reaction (Table 2C), where hydroxyl radical is generated from superoxide anion and hydrogen peroxide [24]. Thus, during myocardial I/R increase, the Fe2+ availability and ROS levels that favor the formation of highly harmful and reactive hydroxyl radical through these redox reactions, can significantly contribute to MRI. This allows considering the iron overload during I/R as a pharmacological target for cardioprotection.
\n\nIn addition, our interest is focused on the interaction between vitamin C and iron. Ascorbate has pro-oxidant effect because of reduction of Fe3+ to Fe2+ (Table 2D), which is substrate to Fenton reaction leading to ROS production [92]. Under physiological conditions,
\n | Reaction | \nRate constant (M−1 s−1) | \n
---|---|---|
(A) | \n76 | \n|
(B) | \n1.9 × 106 –104 | \n|
(C) | \n<2.3 | \n|
(D) | \n102 | \n
DFO has shown beneficial effects in experimental models of I/R. Isolated, perfused rabbit hearts treated with DFO, during ischemia and reflow, demonstrated improved functional and metabolic recovery of myocardium together a reduction in reperfusion-induced oxygen free-radical generation, compared to control group [96]. In a canine model of I/R, DFO pretreatment before ischemia, but not at the beginning of reperfusion, reduced significantly infarct size and release of GSSG into the coronary sinus during early reflow, compared to control group [97]. Decrease in infarct size by early treatment with DFO was corroborated by another independent study in canine model of I/R [98]. Regarding clinical trials, patients undergoing coronary artery bypass grafting, that received an IV infusion of DFO for 8 hours, prevented the increase in oxidative stress markers and improving ventricular functional parameters after surgery, compared to control group [99]. Other clinical trial in patients with ST-elevation MI subjected to primary percutaneous coronary intervention (PPCI) showed that administration of IV bolus of DFO (500 mg) immediately before surgery, followed by a 12-h infusion (50 mg/kg), significantly reduced in plasma F2-isoprostane levels, with no difference in infarct size, after PPCI compared to placebo group [100].
\nIn this chapter, we have reviewed the molecular processes involved in the pathophysiology of myocardial damage by postischemia reperfusion, emphasizing the central role of oxidative stress as the key mediator of this damage. Accordingly, increased ROS production can give rise to the occurrence of events ranging from inflammation, damage to biomolecules and metabolic cell impairment to even cell death. From this paradigm, a novel antioxidant therapy is proposed as cardioprotective action in patients with AMI subject to PCA. This treatment considers the use of vitamin C (sodium ascorbate) in high doses administered intravenously, combined with NAC and DFO prior to surgery so as to optimize and enhance the beneficial effects and reduce the harmful effects on myocardium occurring in this setting (Figure 5). However, the results from different experimental models are controversial and more studies are still lacking. On this line, it is important to note that MRI is an unsolved problem in the clinical practice. Different strategies to prevent this damage during surgery for revascularization in patients with AMI have been tried without conclusive results, and we expect that our proposal can contribute as an effective, low risk and economic alternative in the near future.
\nDiagram of the proposed combined antioxidant therapy for patients with AMI subject to PCA, which considers the use of: (i) ascorbate (AscH−) in high doses to compete with nitric oxide (•NO) by superoxide anion (O2•‾); (ii) deferoxamine (DFO) to counteract reduced iron (Fe2+) overload and thus prevent the Fenton reaction and interaction with AscH−; (iii)
This study was supported by the Fondo de Fomento al Desarrollo Científico y Tecnológico (FONDEF), grant ID15I10285.
\nEquine recurrent uveitis (ERU) occurs in mules and horses and is a disease that has been known for a long time. From about the beginning of time-counting, ancient writings have described symptoms that are consistent with today’s definition of ERU. Since the end of the nineteenth century and the beginning of the twentieth century, more and more detailed descriptions of this disease have been published [1]. In earlier times, the working power of the horse was quite crucial for the survival of men [2]. Not only during war, but also for the cultivation of the fields, for the transport of people and freight as well as for serving as living motors in preindustrial times, people were dependent on horses and mules.
Without horses, the development of mankind would not have been possible to the extent that has been achieved in the past centuries. All the more the health maintenance of the horses was of paramount importance [3]. The recurrent and painful episodes of uveitis led to reduced performance and not infrequently to blindness and thus often to unserviceability of the affected horses. For this reason, equine recurrent uveitis has preoccupied many generations of owners and veterinarians [3, 4]. There are the most diverse historical treatment approaches and theories about the causes of this disease [3, 5].
Among many causes that had not been confirmed, wet pastures and flooding as well as heritability were discussed [5, 6, 7]. An infectious etiology has been suspected for over 100 years, although
After a link between leptospiral infections and uveitis had been established in human medicine, the Swiss ophthalmologist Gsell and coworkers studied aqueous humor from equine ERU eyes and described for the first time a link between ERU (then called “moon blindness” or “periodic ophthalmia”) and leptospiral infection [11]. Since then, there have been numerous investigations addressing the leptospiral etiology of ERU.
Because antibody detection in intraocular fluids was relatively common [11, 12, 13, 14, 15, 16, 17], but uveitis bouts typically do not become apparent until months or even years after the acute systemic infection [18, 19, 20, 21, 22], it was assumed that the infection was a trigger of ERU, but the bacteria were no longer present when the uveitis attacks started [18, 23]. In addition, a culture of
Different causes of uveitis can occur in horses just like in other species [30, 32, 33]. However, in equine uveitis associated with painful recurrent episodes causing the typical ocular changes, chronic intraocular leptospiral infection has been found to be the cause [34, 35]. Therefore, the term “ERU” will be used hereafter to refer to leptospiral-induced recurrent uveitis.
It was not until the routine use of vitrectomy (irrigation of the vitreous chamber) in horses [36, 37, 38] and the resulting ability to obtain intraocular specimens from eyes affected with ERU [39], that the importance of leptospiral etiology in ERU was confirmed [34, 35, 40, 41, 42, 43, 44].
Only recently it was recognized that recurrent uveitis in horses is a biofilm-mediated disease [45]. The ERU has many aspects that had raised questions and been incomprehensible before the discovery of biofilm formation of pathogenic
Leptospiral-induced uveitis is not only in horses a late consequence of systemic infection [18, 34, 46], but also human leptospiral uveitis often occurs a long time after the acute infection [11, 46, 47, 48, 49, 50, 51]. A causal relationship between uveitis and a previous leptospiral infection is often difficult to recognize when uveitis occurs, because systemic leptospirosis is predominantly inapparent in horses [19, 52] and can also be inapparent in humans [53].
ERU affects quite a lot of horses. In the United States, where there are many leopard coat pattern horses (Appaloosas), it has been reported that up to 25% of horses are affected and lose vision in one or both eyes during the course of the disease [30]. However, in that study, leopard coat pattern uveitis (Section 4.), which accounts for a large proportion of affected horses in the United States, was also classified as ERU. In other studies, the percentage of horses affected with ERU ranges from 7 to 10% [54, 55, 56], with up to one-third of the horses suffering from the disease on both sides [3, 34, 57]. The attacks of uveitis in both eyes often do not start at the same time, but with a time delay of several months up to about 2 years [34].
The first episodes of uveitis are usually noticed in younger horses between 4 and 6 years of age [34]. More rarely, however, horses can still develop ERU up to over 20 years of age. Foals up to 6 months of age typically do not develop ERU. When uveitis occurs in foals younger than 6 months, it is typically septicemia-associated and bilateral, e.g., in the course of rhodococcosis [58, 59, 60, 61].
In ERU, recurrent episodes of uveitis occur in unpredictable intervals and oftentimes not, as the former term “periodic ophthalmia” suggests, periodically. The interval between episodes of uveitis can be less than 2 weeks and up to more than a year. In most cases, ERU episodes are associated with blepharospasm, epiphora, and photophobia, so the owner notices the eye disease and seeks veterinary advice. The severity of uveitis also varies greatly from horse to horse. Sometimes very mild episodes occur, which subside after 1–2 days. Other ERU attacks are so severe that after one or two attacks, the eye may already show significant and irreversible changes and in the worst case may even lose vision. In most horses, the clinically quiescent intervals between episodes of uveitis become shorter over time, and at the same time the uveitis bouts become more severe.
Descriptions of the ophthalmologic findings in ERU have been given repeatedly and in broad agreement [3, 30, 32, 34, 62, 63, 64]. Acute attacks are usually painful or even very painful. Affected horses are depressed, show decreased appetite, can have a moderate rise in body temperature, severe blepharospasm, serous and later sero-mucous lacrimation, and more or less swollen eyelids. These symptoms, although typical, are not pathognomonic and can also occur with other eye lesions.
Ocular examination in horses is the easiest and most informative when a simple handheld (direct) ophthalmoscope with bright light source is used. The handheld ophthalmoscope can be used as a focal light source, magnifying glass, and slit lamp, and is most crucial for examining the posterior segment of the eye (posterior lens surface, vitreous cavity, and fundus). Since serum in horses is yellowish in color, aqueous humor and vitreous humor in acute uveitis (“leakage”) are also jaundiced. Ophthalmic examination typically reveals the following findings during an acute ERU episode:
Reddening of the conjunctiva
Low-grade diffuse corneal haziness
Incipient circular vascularization of the cornea
Jaundiced aqueous humor with positive Tyndall effect, usually also fibrin in the anterior chamber of the eye
Miosis and only delayed and often incompletely medically achievable mydriasis
Diffuse haziness of the vitreous humor
Ocular hypotension (intraocular pressure often <10 mmHg)
In the inflammation-free interval, after mild ERU episodes and meticulous conservative treatment, sometimes no definite changes can be detected in early stages of the disease. However, when multiple ERU attacks have occurred, pathologic changes become increasingly apparent that are also evident during the clinically quiescent phase of the disease:
Gradually increasing atrophy of the globe (if necessary, the inner anterior-posterior diameter can be measured by ultrasound; the difference is definite as from ≥2 mm side-to-side difference)
Delayed pupillary response to light, drug-induced mydriasis also only achievable with delay
In mydriasis, otherwise hidden posterior synechiae or iris residuals may be detected on the anterior lens capsule
Diffuse vitreous opacification may still be recognizable in the inflammation-free interval (in some cases only evident by comparison with the other eye, and if the fundus on the diseased side is less clear compared with the other side)
Vesicular cataract, typically in the periphery of the posterior lens capsule
Dense vitreous deposits, initially visible only in mydriasis and typically located high dorsally close to the ciliary body; in the course of the disease, these deposits become more pronounced and can eventually also be seen in the center of the vitreous cavity, many times in combination with a murky yellowish discoloration of the liquefied vitreous
In more advanced stages of the disease, moderate to severe bulbar atrophy or even phthisis, cataract, lens luxations, and retinal detachment may occur
In 3% of ERU cases, the inflammation occurs primarily in the posterior segment of the eye [65]. Hardly any pain is evident in these horses, and this form of ERU is sometimes detected only as an incidental finding during routine examinations or purchase examinations of horses. Only rarely do very observant owners notice a change in the fundus reflex of the diseased eye and call a veterinarian. In most cases, however, iritis occurs in the course of the disease, which then leads to the typical and easily recognizable pain symptoms. Depending on the changes that have already occurred in the posterior segment of the eye, the prognosis for preservation of vision is often guarded at this point. Sometimes these horses are not presented to the veterinarian until “sudden” blindness due to cataract formation or retinal detachment has occurred.
A significant and strinkly common type of uveitis not caused by leptospires occurs in leopard coat pattern horses [65, 66]. This type of uveitis is strikingly common in leopard coat pattern horses. In contrast to ERU, leopard coat pattern uveitis progresses insidiously and does not present as recurrent painful episodes of uveitis. In the literature, it is therefore often referred to as “insidious uveitis,” but not distinguished from ERU. Other forms of uveitis may be phacogenic, traumatic, tumor-associated, septicemia-associated, or triggered by other infectious causes such as parasites (
History | Typical ophthalmologic findings | Therapy | Prognosis | |
---|---|---|---|---|
ERU | most times recurring episodes of painful uveitis attacks | see Section 3. | acute uveitis: topical atropine and dexamethasone, systemic nonsteroidal anti-inflammatory drugs, see Section 6. quiet interval: see Section 7. and 8. | unfavorable, if exclusively conservative therapy is given, usually increasing cloudiness of the transparent media; good for prevention of recurrences with vitrectomy; good for permanent preservation of vision if vitrectomy is performed before ERU has caused irreversible intraocular damage |
Leopard coat pattern uveitis | no obvious painful uveitis attacks, “suddenly” noticed impaired vision or cloudiness of the eye | lens pathology (initially or very early in the course of the disease), cataract formation, lens (sub-) luxation, sometimes glaucoma, sometimes atrophy of the globe | so far no etiologic therapy possible, only symptomatic treatment (anti-inflammatory, cyclosporine devices, combatting an elevated intraocular pressure) | unfavorable, often enucleation is required; if both eyes are affected, euthanasia may be indicated |
Phacogenic uveitis | often mild uveitis, rarely severe uveitis attacks, sometimes presentation only because of cataract formation | lesions of the lens capsule, sometimes lens fragments in the anterior chamber or in the vitreous chamber, mild or moderate amount of fibrin in the anterior chamber, posterior synechiae (sometimes sealing defects in the anterior lens capsule) | conservative therapy see section 6. phacoemulsification might be considered in selected cases | depending on the degree of leakage of lens proteins and the course of the disease good to unfavorable; phacoemulsification: guarded (risk of retinal detachment) |
Traumatic uveitis | sudden onset of eyelid swelling, no previous uveitis attacks observed; in some cases: observed head and/or globe trauma | sometimes accompanying lesions of the eyelids or the cornea, often sero-hemorrhagic uveitis, sometimes hyphema or even hemophthalmus | if no corneal defects: see section 6., in case of corneal defects: no corticosteroids until the cornea is fluorescein-negative; if the fibrin and especially blood are not decreasing within about 10 days: injection of fibrinolytics (e.g., urokinase) or mechanical removal of the inflammatory products and the blood coagulum (e.g. using a small vitrectomy-cutter) | good if there has been no damage to lens and retina and no severe damage to cornea and sclera |
Chronic iritis, similar to Fuchs’ heterochromic iritis in humans | no painful attacks, most often presented because of corneal cloudiness, rarely because of pigment loss of the iris | often endothelial precipitates and circumscribed depigmentations in the iris, increasing corneal edema, usually slow progression of the disease over years, glaucoma might finally occur | no etiologic, but only symptomatic therapy possible | guarded concerning long-term vision, sometimes enucleation required |
Uveitis caused by severe keratitis or corneal infections (kerato-uveitis) | often very painful, increasing corneal opacification, no satisfying response to treatment | deep corneal ulcer or outlined round dense opacities, sometimes annular opacities (ulcus serpens) | corneal debridement, in case of severe weakening of the cornea and imminent rupture: suturing of a conjunctival flap into the lesion; in case of corneal rupture: corneal transplant | depending on the stage of the disease, the extent of the infection and the pretreatment (topical or systemic nonsteroidal drugs and especially corticosteroids worsen the prognosis) good to unfavorable |
Uveitis accompanying septicemia | uveitis, most often in foals <6 months, rarely adult horses | typical acute uveitis, comparable to an acute ERU-attack, but often both eyes involved, presence of a severe general infection (e.g. rhodococcosis) | treatment of acute uveitis (Section 6.) and treatment of the septicemia | good if septicemia can be treated successfully and if conservative treatment achieves mydriasis; usually no further uveitis attacks occur |
Uveitis caused by intraocular parasitic infections | chronic severe (kerato-) uveitis, not responding to therapy | cloudy cornea, depending on the causative parasite parasites might be visible in the anterior chamber or seen in the ultrasound examination | treatment of acute uveitis (section 6.), but usually uveitis is not responding; if parasites are visible in the anterior chamber: surgical removal may be discussed; enucleation might be indicated | for preserving vision: unfavorable for preserving the globe: guarded to unfavorable |
Uveitis caused by intraocular tumors | presentation because of (mild) uveitis, impaired vision and / or corneal or intraocular opacities | most often iris-melanoma, causing keratitis and sometimes glaucoma, other tumors occur less frequently (e.g. medulloepithelioma or malignant lymphoma); uveitis can be caused mechanically and immunologically | symptomatic treatment as long as possible, if the intraocular tumor causes chronic pain or if the tumor is going to spread enucleation is required | unfavorable for preserving vision and for preserving the globe |
Endophthalmitis | disturbed general condition, fever, severe eyelid swelling | phlegmon of the eyelids, purulent epiphora, circular deep corneal vascularization, severe yellow-green corneal opacity | in case of very early stages: lavage of the vitreous cavity; otherwise enucleation | for vision: unfavorable for preserving the globe: guarded to unfavorable |
Different types of uveitis in horses, symptoms, therapy, and prognosis.
Sometimes recurrent keratitis is misinterpreted as ERU, as some types of keratitis can also cause painful with miosis and responds to the same conservative therapy as ERU. However, in keratitis cases, medical dilation of the miotic pupil results usually more rapidly and completely than in ERU. In recurrent keratitis, however, the changes that almost always are evident in ERU after several episodes of uveitis, even in the inflammation-free interval, are absent.
If an ocular disease is clinically not clearly assignable to an etiology (e.g., “recurrent keratitis” or “uveitis of unknown cause”), it is possible to take aqueous humor during the inflammation-free interval [33]. In horses, approximately 1 ml of aqueous humor can be safely collected and then used for laboratory tests [33, 68, 69, 70]. To investigate for the presence of ERU, testing for both anti-
For the detection of intraocular anti-
Antibody detections are equally reliable in vitreous and aqueous humor samples [70, 76, 77]. Both PCR and leptospiral culture are somewhat more reliable when testing vitreous humor samples compared with testing aqueous humor samples [34, 35, 78]. However, the collection of a vitreous sample is disproportionately risky and should be rejected for a preoperative diagnosis, because the aqueous humor analysis is overall very informative [33]. In rare cases, e.g., no anti-
If time is not an issue, but economic reasons have to be taken into account, a reasonable approach for the examination of aqueous humor samples is to first perform an on-site rapid test for the detection of anti-
In eyes with a history of recurrent inflammations, but without clear evidence of ERU, and thus without aqueous or vitreous humor opacities, protein levels are typically not elevated. If protein levels in intraocular fluids are not elevated, leakage from the blood can be excluded. In these cases, even very low MAT titers are indicative of intraocular antibody production. The authors consider a MAT result of 1:50 as sufficient indication for vitrectomy in these cases. In eyes with obvious aqueous humor and vitreous opacities, however, the diagnosis of ERU is usually unambiguous even without aqueous humor examination. In cases of doubt, the Goldmann-Witmer coefficient can be used to differentiate leakage from intraocular antibody production [79]. It is crucial that not only the intraocular and the serum titer are evaluated, as it often could be read lately [80, 81, 82, 83, 84, 85, 86], but that—as described by Goldmann and Witmer—a reference value is determined both in the aqueous humor and in the serum. Any other antibody titer (e.g., tetanus) can be used as a reference value, provided that antibodies are present in the serum. Alternatively, the total IgG content or, if necessary, even the total protein content can be used as a reference value [33, 34].
Acute ERU is treated in the same way as any other equine uveitis [30, 32, 57, 58]. First of all, it is important to achieve mydriasis to avoid posterior synechiae and resulting cataract formation. Atropine is the drug of choice for this purpose and can be used as of 1–2% eye drops or eye ointment. Since the ophthalmic ointment adheres slightly better and acts more protracted, ointment is preferable, if available.
Atropine should initially be given several times daily or even hourly until the pupil dilates. Thereafter, the intervals can be adjusted to the pupil width and often considerably prolonged. Systemic side effects associated with the topical use of 1–2% atropine in horses do not play a significant role in the authors’ experience and after having treated thousands of horses over a 30-year period. Colic, e.g., due to an impaction or a meteorism, can occur in any hospitalized horse, not just ophthalmic patients. By feeding mash and monitoring the fecal consistency, an impaction can be detected early and countermeasures (e.g., administration of laxatives) can be taken to avoid more serious colic.
Apart from mydriasis, anti-inflammatory treatment is important. Topical application of ophthalmic ointments containing dexamethasone is particularly effective, provided the corneal epithelium is intact. If corneal defects are present, topical corticosteroids must not be given.
In addition, the administration of a nonsteroidal anti-inflammatory drug (NSAID) orally is indicated. Only in exceptional situations and in case of very significant diffuse vitreous opacification, systemic administration of prednisolone (1 mg/kg per os) for several days may be considered additionally. In these particularly severe cases with significant diffuse vitreous opacification, adjunctive therapy with a systemically given antibiotic, e.g., enrofloxacin [87], can also be performed, to eliminate at least part of the intraocular bacteria—even if this does not completely eliminate the infection [88].
Other measures accompanying the therapy are keeping the horse in a dark place and resting in the stall or just light exercise until the acute inflammation has subsided. If it is not possible to keep the horse in the dark, wearing a light absorbing mask can be considered.
Topical atropine has been recognized as an essential therapeutic mydriatic for equine uveitis as early as 1821 and has been considered a standard treatment for ERU in textbooks since 1842 [89]
Topical cocaine has been recommended for the control of pain since the beginning of the last century [90]
Salicylic acid preparations have been included among the treatment options for uveitis since 1922 [91]
Corticosteroids have been used both parenterally [92] and topically [93] to treat uveitis since the middle of the last century
In addition to eye drops and ointments, subconjunctival injections with corticosteroids [94, 95], later also with cocaine and atropine, were suggested to intensify the local effect
Systemic administration of nonsteroidal anti-inflammatory drugs (NASIDs) has also been part of the standard treatment of acute uveitis in horses since their approval for veterinary use in the late 1970s (flunixin meglumine and phenylbutazone) [96, 97]
The most effective treatment for ERU is vitrectomy (removal of diseased vitreous and irrigation of the vitreous cavity). This surgery is performed exclusively in intervals without acute inflammation. Mechanical removal of the vitreous opacities caused by inflammation and accessible vitreous parts very reliably and permanently eliminates the leptospires in the biofilm. Postoperatively, up to 98% of eyes remain free of recurrences when surgery is performed properly [98]. If, exceptionally, further episodes of inflammation occur after surgery, a second vitrectomy can, if necessary, permanently eliminate the infection and prevent further episodes.
Vitrectomy as a vision-preserving procedure is a demanding surgery, having a relatively long learning curve. Prerequisites for successful performing vitrectomies are solid training, availability of for equine ophthalmo-surgery optimized, custom-made instrumentation and equipment as well as careful and intensive perioperative examination and conservative treatment. Any complication may have devastating consequences and can lead to blindness or even enucleation. Only rarely eyes that are already blind undergo surgery in order to prevent both future painful uveitis attacks and removal of the globe, which is cosmetically unsightly.
In order to perform vitrectomy with minimal complications, an experienced team (surgeon, sterile and nonsterile assistant, skilled anesthesiologist) is required, as well as expensive equipment and instruments specially adapted to the dimensions of the horse’s eye. For this reason, only a few specialized equine clinics perform vitrectomies to date. In clinics in which vitrectomy is performed as a routine procedure, it is a quick (total anesthesia time is about 40 minutes, the surgical instrument is in the eye <10 minutes) and relatively safe procedure with a very good prognosis [38, 39, 89, 99].
Apart from vitrectomy, other treatment options have been described, of which two in particular are favored in recent publications. One consists of an intravitreal gentamicin injection. However, the recommended dosage for this purpose (4–6 mg) [80, 100, 101] is 3–4 times the drug concentration that was found to be “safe” with regard to retinal toxicity in experimental studies [102]. So far, there are no long-term results after these injections and the number of horses treated in this way is still limited. Surprisingly, gentamicin injection is not recommended exclusively for equine eyes with intraocular leptospiral infection; other forms of uveitis are also treated with this injection. Improvement after the intravitreal injection is also thought to result from the antibiotic gentamicin having immunomodulatory effects [103].
The second therapeutic option described since the turn of the millennium is the deep intra- or subscleral implantation of a cyclosporine device [104, 105, 106, 107]. These implants lead to less frequent and milder episodes of uveitis over a period of up to about 2 years. However, the uveitis does not stop completely, and if the effect wears off, a new implant may have to be inserted. Like gentamicin injection, implantation of cyclosporine devices is performed independently of leptospiral infection in the vitreous cavity. Only individual authors differentiate and use the implants exclusively when no leptospiral infection is detectable [86]. Attention should also be paid to the drug law in its current version, which currently prohibits the import of cyclosporine devices, at least in the EU [108].
However, neither gentamicin injection nor implantation of cyclosporine devices can remove the dense vitreous floaters that often lead to impaired vision. Over time, these deposits also often adhere to the posterior capsule of the lens and, just like extensive posterior synechiae, can lead to a cataract formation.
In the literature, before the introduction of vitrectomy to the therapeutic measures against ERU, there were only very sporadic reports of cultural detection of leptospires in intraocular specimens from eyes affected with ERU [109, 110]. Numerous investigators failed to obtain cultural evidence of leptospires, casting doubt on chronic intraocular leptospiral infection. It was rather assumed that although leptospires somehow trigger ERU, the inflammations are not subsequently maintained by the presence of the pathogen [22, 24, 63, 68, 111, 112].
Vitrectomy was initially performed to remove vitreous opacities. The aim was to improve vision in the eyes affected by ERU [36, 37]. However, it soon became apparent that vitrectomy was surprisingly effective in preventing further episodes of uveitis. Therefore, more and more horses were sent to the clinic for vitrectomy.
It was only with the routine performance of vitrectomy that it had become possible to examine numerous vitreous samples from horses suffering from ERU. The peculiarity was that the samples were predominantly from eyes still able to see at an early stage of the disease. By collecting the first milliliters aspirated from the vitreous cavity before opening the intraocular infusion line, it was possible to use undiluted vitreous material for investigations. The results of these examinations, in turn, provided insights into which ocular findings were associated with leptospiral infection and which were not. It was also shown that the prognosis in terms of postoperative absence of recurrences was best when eyes with an intraocular leptospiral infection were treated by vitrectomy [98]. In this way, on the other hand, the indication for vitrectomy was optimized.
With careful assessment of the indication for vitrectomy and examination of undiluted vitreous specimens, MAT titers of 1:100 or higher were detected in 382 of 426 vitreous samples (90%) examined [34, 35]. In some MAT-negative specimens, specific anti-
In Germany and neighboring countries, infections with leptospires of the serogroup Grippotyphosa are dominating, accounting for about 80% of intraocular infections in horses suffering from ERU. Infections with leptospires of the Australis serogroup account for about 13–14% of intraocular infections. Less frequently, leptospires of the serogroups Pomona, Sejroe, and Javanica were also detected in the vitreous samples from ERU eyes [34, 35, 114].
Vitreous samples obtained during vitrectomies from eyes affected by ERU were also used for histological and ultrastructural studies. It has been shown that the leptospires in the vitreous of eyes affected with ERU are surrounded by a homogeneous layer, which is lacking the leptospires from culture [115]. This homogeneous layer surrounding the leptospires could be extracellular matrix. In another study, in addition to phagocytosed leptospires, dense roundish structures were detected in vitreous material from eyes affected with ERU [116]. Some of these roundish structures had been phagocytosed, but others of these structures were so large that phagocytosis was impossible. These dense round structures could represent mature leptospiral biofilm constructs.
In 1971, Williams reported on immunologically mediated tissue damage in cases of equine uveitis [22]. However, autoimmune reactions that can be detected at the same time as the leptospiral infection [117, 118, 119, 120, 121] must be autoimmune phenomena accompanying the infection, since they cease as soon as the infection has been eliminated [33, 35]. Thus, there is no evidence of autoimmune disease following ERU.
Since many chronic infections are associated with biofilm formation, it has long been suspected that leptospires also form biofilm in vivo. In in vitro studies, biofilm formation of pathogenic
Recurrent episodes of uveitis and the concomitant intraocular persistence of leptospiral infection over a long period of time meet the criteria of a biofilm infection [127, 128] very well [129].
The infection primarily affects the vitreous cavity. Possibly following the vitreous clearance, leptospires (more rarely) can also enter the anterior chamber of the eye and be detected there [33, 34, 35, 130, 131]. However, the infection obviously remains limited to the eye, there is no evidence of further spreading. As with other local biofilm infections, IgA antibodies are of particular importance in diagnostics [72, 132, 133, 134, 135].
One criterion of biofilm infections is the difficult cultural detection of the causative pathogen and ERU meets this criterion. Despite urgent suspicion of leptospiral infection in ERU (high intraocular antibody titers, intraocular antibody production), however, cultural detection of leptospires is demanding and often failed [24, 25, 26, 136].
In the vitreous of horses suffering from ERU, there are not only high antibody titers, but also immunocompetent cells (besides lymphocytes, especially plasma cells, macrophages, and granulocytes) [116, 137, 138]. The epithelium of the ciliary body shows many plasma cells in eyes affected by ERU [139]. In the area of the ciliary body and the iris root, even lymph follicles develop during the course of ERU, which contain B lymphocytes in the center [30, 140, 141]. Nevertheless, the immune system fails to eliminate the infection from the large vitreous chamber of the horse.
Leptospires localized in the vitreous chamber show high tolerance to antibiotics. The first cultures were performed with samples from the entire lavage fluid collected during vitrectomy [41, 42, 44]. In the lavage fluid, the vitreous material was diluted about 10-fold and the lavage fluid contained 0.08 mg gentamicin/ml. This concentration had been shown to be 100 times the minimum inhibitory concentration (MIC) for WHO strains of pathogenic leptospires in vitro [143]. Cultures with these vitreous samples were less frequently positive than in later studies performed with undiluted vitreous samples [34, 35, 88], but nevertheless several culture sets eventually became positive after further inoculations and thus dilution of the antibiotic concentration [41, 42, 44].
Similar results were found in a study in which horses had been treated preoperatively intravenously with enrofloxacin. In the undiluted vitreous samples obtained at vitrectomy, the enrofloxacin content was above the MIC. Compared with the control group, in which more than 50% of the cultures were positive for pathogenic
ERU with persistent intraocular leptospiral infection over a long period of time meets all criteria of an infection associated with biofilm formation. The most likely route by which leptospires enter the vitreous cavity during acute systemic infection is by the fenestrated capillaries in the Pars plicata region of the ciliary body [30, 33]. In the healthy vitreous with its collagen fibers and viscosity, there are ideal conditions for the formation of leptospiral biofilm (Figure 1) [129].
Schematic illustration of the discussed pathogenesis of equine recurrent uveitis (ERU) caused by a leptospiral biofilm infection in the vitreous chamber. Each uveitis bout leads to increasing damage to the intraocular structures. 1. Infection of horses with
The vitreous body is 98% water and contains a collagen fiber scaffold. It has been shown that plant fibers in rice fields are important sites for biofilms [144]. The vitreous fibers [138] might also serve as “surfaces” to which
Another factor to consider is that the vitreous cavity of the horse has a volume of approximately 28 ml, making it a large immunologic niche [34]. In addition, there is the immune privilege of the eye [146, 147], which effectively suppresses the immune defense. In this way, pathogenic
Only after months or years, when a threshold is exceeded due to gradual multiplication of the leptospires and increase of immune reactions despite the ocular immune privilege, a uveitis attack with disturbance of the blood-aqueous barrier or blood-ocular barrier becomes apparent [33, 34]. The immune response that occurs in conjunction with the inflammation likely results in the elimination of some planktonic bacteria. Other bacteria in the biofilm outlast the inflammatory bout. After the inflammation subsides under antiphlogistic treatment and with the help of intraocular immunosuppressive mechanisms, a clinically apparently inflammation-free interval occurs, which, however, does not represent a totally quiescent phase immunologically [137].
There are reports, and some own experiences seem to support this, that episodes of uveitis can be triggered by exposure to stressful situations (e.g., competitions, long-distance transport, change of stables, general anesthesia and major surgery). It is conceivable that endogenous cortisol release in stressful situations further reduces the immune defense in the eye (in addition to the ocular immune privilege). This in turn might increase the number of planktonic
A gradual spread of biofilm structures in the vitreous cavity could explain that ERU episodes occur at shorter intervals and become more severe over time. In addition, there are immune reactions that fail to eliminate the leptospires but may result in damage to the ocular structures adjacent to the vitreous chamber. One example is neutrophil extracellular traps (NETs), which have been detected in vitreous samples from eyes affected by ERU [148]. These NETs are formed by granulocytes to remove pathogens too large for phagocytosis [149]. A disadvantage of the formation of NETs is that tissue-damaging substances are also secreted, which in turn promote an inflammatory reaction of the surrounding tissue [150, 151], which in ERU cases is the uvea.
The high MAT titers in eyes affected by ERU certainly also play a crucial role in the course of the disease, as they promote agglutination of planktonic leptospires. However, since complete elimination of the bacteria is usually not possible, this agglutination can also be the starting point for new biofilm formation. During agglutination, leptospiral aggregates are formed, extracellular matrix is produced after surface contact of bacteria with each other, and thus new biofilm structures can be built. In this way, the agglutinating antibodies could accelerate the biofilm formation of pathogenic
High levels of serum amyloid A (SAA) [152] and the formation of AA amyloid [153, 154] were detected in intraocular samples from eyes affected with ERU. The formation of amyloid is a good explanation for the fact that the dense vitreous floaters in ERU fail to resolve, but instead increase as the disease progresses. Besides the collagen fibers of the vitreous scaffold, the NETs and the amyloid fibers provide additional fiber structures that could be used for biofilm formation. The formation of NETs and biofilm promote each other [155, 156]. Similar to what has been described for otitis media [157], these numerous fibers could be incorporated into the biofilm and help to reinforce the biofilm scaffold, so that therapeutically only mechanical removal is promising.
With knowledge of the successful cultivation of leptospires from vitreous specimens that contained an active level of gentamicin or enrofloxacin above the MIC, it is questionable whether intraocular gentamicin injections, which are performed therapeutically by some veterinarians, provide lasting success. Biofilms can increase tolerance to antibiotics up to 1000-fold compared with planktonic bacteria [158, 159]. The described improvement of eyes suffering from ERU after gentamicin injection could be due to the fact that planktonic bacteria are eliminated. However, it is questionable whether the bacteria in the biofilm can really be eliminated by the injection. It could also be that the structure and composition of the biofilm change accordingly, so that the bacteria survive protected in the biofilm and then lead to ERU relapses again after some time. With the therapeutically used cyclosporin-devices, spread of the leptospiral biofilm in the vitreous cavity could even be favored, since immune reactions of the host, including those directed against the bacterial pathogen, are suppressed.
In vivo biofilm formation has also been described for other spirochetes. In human medicine, for example, chronic Lyme disease with its various organ manifestations plays an important role [160, 161]. In patients with Lyme disease, in vivo biofilm formation was shown to be associated with the long-term persistence of
The composition of leptospiral biofilms in the vitreous cavity in ERU is still largely unknown. Neither alginates nor curli fibers (bacterial amyloid) could be detected in the in vitro
ERU is a spontaneously occurring intraocular leptospiral biofilm infection. For centuries, only symptomatic conservative treatment was possible, which has become increasingly effective with the availability of modern anti-inflammatory drugs. However, even the most potent anti-inflammatory treatment could not prevent recurrences of uveitis, which led to gradual damage and even destruction of the affected globe. It was not until the introduction of vitrectomy in equine ophthalmology that causative therapy had become possible. Samples containing leptospiral biofilm can easily be collected in the course of therapeutic vitrectomy. Not only can these samples be used for laboratory diagnostics regarding intraocular leptospiral infection, but further studies can be performed on the composition of the biofilm. There could be significant differences between the composition of the biofilm formed in vitro and that formed in vivo, as host tissues (here: vitreous material and collagen fibrils) and interactions with the host immune system (e.g., agglutinating antibodies, macrophages, granulocytes, NETs, fibrin, and amyloid) influence the composition of the biofilm. ERU provides possibilities for investigation of an in vivo biofilm infection without the need for animal experiments and, thus, could serve as a naturally occurring entity for further research.
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Radiotherapy and Nuclear Medicine Technology has always been my aspiration and my life. As years passed I accumulated a tremendous amount of skills and knowledge in Radiotherapy and Nuclear Medicine, Conventional Radiology, Radiation Protection, Bioinformatics Technology, PACS, Image processing, clinically and lecturing that will enable me to provide a valuable service to the community as a Researcher and Consultant in this field. My method of translating this into day to day in clinical practice is non-exhaustible and my habit of exchanging knowledge and expertise with others in those fields is the code and secret of success.",institutionString:null,institution:{name:"Majmaah University",country:{name:"Saudi Arabia"}}},{id:"313277",title:"Dr.",name:"Bartłomiej",middleName:null,surname:"Płaczek",slug:"bartlomiej-placzek",fullName:"Bartłomiej Płaczek",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/313277/images/system/313277.jpg",biography:"Bartłomiej Płaczek, MSc (2002), Ph.D. (2005), Habilitation (2016), is a professor at the University of Silesia, Institute of Computer Science, Poland, and an expert from the National Centre for Research and Development. His research interests include sensor networks, smart sensors, intelligent systems, and image processing with applications in healthcare and medicine. He is the author or co-author of more than seventy papers in peer-reviewed journals and conferences as well as the co-author of several books. He serves as a reviewer for many scientific journals, international conferences, and research foundations. Since 2010, Dr. Placzek has been a reviewer of grants and projects (including EU projects) in the field of information technologies.",institutionString:"University of Silesia",institution:{name:"University of Silesia",country:{name:"Poland"}}},{id:"35000",title:"Prof.",name:"Ulrich H.P",middleName:"H.P.",surname:"Fischer",slug:"ulrich-h.p-fischer",fullName:"Ulrich H.P Fischer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/35000/images/3052_n.jpg",biography:"Academic and Professional Background\nUlrich H. P. has Diploma and PhD degrees in Physics from the Free University Berlin, Germany. He has been working on research positions in the Heinrich-Hertz-Institute in Germany. Several international research projects has been performed with European partners from France, Netherlands, Norway and the UK. He is currently Professor of Communications Systems at the Harz University of Applied Sciences, Germany.\n\nPublications and Publishing\nHe has edited one book, a special interest book about ‘Optoelectronic Packaging’ (VDE, Berlin, Germany), and has published over 100 papers and is owner of several international patents for WDM over POF key elements.\n\nKey Research and Consulting Interests\nUlrich’s research activity has always been related to Spectroscopy and Optical Communications Technology. Specific current interests include the validation of complex instruments, and the application of VR technology to the development and testing of measurement systems. He has been reviewer for several publications of the Optical Society of America\\'s including Photonics Technology Letters and Applied Optics.\n\nPersonal Interests\nThese include motor cycling in a very relaxed manner and performing martial arts.",institutionString:null,institution:{name:"Charité",country:{name:"Germany"}}},{id:"341622",title:"Ph.D.",name:"Eduardo",middleName:null,surname:"Rojas Alvarez",slug:"eduardo-rojas-alvarez",fullName:"Eduardo Rojas Alvarez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/341622/images/15892_n.jpg",biography:null,institutionString:null,institution:{name:"University of Cuenca",country:{name:"Ecuador"}}},{id:"215610",title:"Prof.",name:"Muhammad",middleName:null,surname:"Sarfraz",slug:"muhammad-sarfraz",fullName:"Muhammad Sarfraz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/215610/images/system/215610.jpeg",biography:"Muhammad Sarfraz is a professor in the Department of Information Science, Kuwait University, Kuwait. His research interests include optimization, computer graphics, computer vision, image processing, machine learning, pattern recognition, soft computing, data science, and intelligent systems. Prof. Sarfraz has been a keynote/invited speaker at various platforms around the globe. He has advised/supervised more than 110 students for their MSc and Ph.D. theses. He has published more than 400 publications as books, journal articles, and conference papers. He has authored and/or edited around seventy books. Prof. Sarfraz is a member of various professional societies. He is a chair and member of international advisory committees and organizing committees of numerous international conferences. He is also an editor and editor in chief for various international journals.",institutionString:"Kuwait University",institution:{name:"Kuwait University",country:{name:"Kuwait"}}},{id:"32650",title:"Prof.",name:"Lukas",middleName:"Willem",surname:"Snyman",slug:"lukas-snyman",fullName:"Lukas Snyman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/32650/images/4136_n.jpg",biography:"Lukas Willem Snyman received his basic education at primary and high schools in South Africa, Eastern Cape. He enrolled at today's Nelson Metropolitan University and graduated from this university with a BSc in Physics and Mathematics, B.Sc Honors in Physics, MSc in Semiconductor Physics, and a Ph.D. in Semiconductor Physics in 1987. After his studies, he chose an academic career and devoted his energy to the teaching of physics to first, second, and third-year students. After positions as a lecturer at the University of Port Elizabeth, he accepted a position as Associate Professor at the University of Pretoria, South Africa.\r\n\r\nIn 1992, he motivates the concept of 'television and computer-based education” as means to reach large student numbers with only the best of teaching expertise and publishes an article on the concept in the SA Journal of Higher Education of 1993 (and later in 2003). The University of Pretoria subsequently approved a series of test projects on the concept with outreach to Mamelodi and Eerste Rust in 1993. In 1994, the University established a 'Unit for Telematic Education ' as a support section for multiple faculties at the University of Pretoria. In subsequent years, the concept of 'telematic education” subsequently becomes well established in academic circles in South Africa, grew in popularity, and is adopted by many universities and colleges throughout South Africa as a medium of enhancing education and training, as a method to reaching out to far out communities, and as a means to enhance study from the home environment.\r\n\r\nProfessor Snyman in subsequent years pursued research in semiconductor physics, semiconductor devices, microelectronics, and optoelectronics.\r\n\r\nIn 2000 he joined the TUT as a full professor. Here served for a period as head of the Department of Electronic Engineering. Here he makes contributions to solar energy development, microwave and optoelectronic device development, silicon photonics, as well as contributions to new mobile telecommunication systems and network planning in SA.\r\n\r\nCurrently, he teaches electronics and telecommunications at the TUT to audiences ranging from first-year students to Ph.D. level.\r\n\r\nFor his research in the field of 'Silicon Photonics” since 1990, he has published (as author and co-author) about thirty internationally reviewed articles in scientific journals, contributed to more than forty international conferences, about 25 South African provisional patents (as inventor and co-inventor), 8 PCT international patent applications until now. Of these, two USA patents applications, two European Patents, two Korean patents, and ten SA patents have been granted. A further 4 USA patents, 5 European patents, 3 Korean patents, 3 Chinese patents, and 3 Japanese patents are currently under consideration.\r\n\r\nRecently he has also published an extensive scholarly chapter in an internet open access book on 'Integrating Microphotonic Systems and MOEMS into standard Silicon CMOS Integrated circuitry”.\r\n\r\nFurthermore, Professor Snyman recently steered a new initiative at the TUT by introducing a 'Laboratory for Innovative Electronic Systems ' at the Department of Electrical Engineering. The model of this laboratory or center is to primarily combine outputs as achieved by high-level research with lower-level system development and entrepreneurship in a technical university environment. Students are allocated to projects at different levels with PhDs and Master students allocated to the generation of new knowledge and new technologies, while students at the diploma and Baccalaureus level are allocated to electronic systems development with a direct and a near application for application in industry or the commercial and public sectors in South Africa.\r\n\r\nProfessor Snyman received the WIRSAM Award of 1983 and the WIRSAM Award in 1985 in South Africa for best research papers by a young scientist at two international conferences on electron microscopy in South Africa. He subsequently received the SA Microelectronics Award for the best dissertation emanating from studies executed at a South African university in the field of Physics and Microelectronics in South Africa in 1987. In October of 2011, Professor Snyman received the prestigious Institutional Award for 'Innovator of the Year” for 2010 at the Tshwane University of Technology, South Africa. This award was based on the number of patents recognized and granted by local and international institutions as well as for his contributions concerning innovation at the TUT.",institutionString:null,institution:{name:"University of South Africa",country:{name:"South Africa"}}},{id:"317279",title:"Mr.",name:"Ali",middleName:"Usama",surname:"Syed",slug:"ali-syed",fullName:"Ali Syed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/317279/images/16024_n.png",biography:"A creative, talented, and innovative young professional who is dedicated, well organized, and capable research fellow with two years of experience in graduate-level research, published in engineering journals and book, with related expertise in Bio-robotics, equally passionate about the aesthetics of the mechanical and electronic system, obtained expertise in the use of MS Office, MATLAB, SolidWorks, LabVIEW, Proteus, Fusion 360, having a grasp on python, C++ and assembly language, possess proven ability in acquiring research grants, previous appointments with social and educational societies with experience in administration, current affiliations with IEEE and Web of Science, a confident presenter at conferences and teacher in classrooms, able to explain complex information to audiences of all levels.",institutionString:null,institution:{name:"Air University",country:{name:"Pakistan"}}},{id:"75526",title:"Ph.D.",name:"Zihni Onur",middleName:null,surname:"Uygun",slug:"zihni-onur-uygun",fullName:"Zihni Onur Uygun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/75526/images/12_n.jpg",biography:"My undergraduate education and my Master of Science educations at Ege University and at Çanakkale Onsekiz Mart University have given me a firm foundation in Biochemistry, Analytical Chemistry, Biosensors, Bioelectronics, Physical Chemistry and Medicine. After obtaining my degree as a MSc in analytical chemistry, I started working as a research assistant in Ege University Medical Faculty in 2014. In parallel, I enrolled to the MSc program at the Department of Medical Biochemistry at Ege University to gain deeper knowledge on medical and biochemical sciences as well as clinical chemistry in 2014. In my PhD I deeply researched on biosensors and bioelectronics and finished in 2020. Now I have eleven SCI-Expanded Index published papers, 6 international book chapters, referee assignments for different SCIE journals, one international patent pending, several international awards, projects and bursaries. In parallel to my research assistant position at Ege University Medical Faculty, Department of Medical Biochemistry, in April 2016, I also founded a Start-Up Company (Denosens Biotechnology LTD) by the support of The Scientific and Technological Research Council of Turkey. Currently, I am also working as a CEO in Denosens Biotechnology. The main purposes of the company, which carries out R&D as a research center, are to develop new generation biosensors and sensors for both point-of-care diagnostics; such as glucose, lactate, cholesterol and cancer biomarker detections. My specific experimental and instrumental skills are Biochemistry, Biosensor, Analytical Chemistry, Electrochemistry, Mobile phone based point-of-care diagnostic device, POCTs and Patient interface designs, HPLC, Tandem Mass Spectrometry, Spectrophotometry, ELISA.",institutionString:null,institution:{name:"Ege University",country:{name:"Turkey"}}},{id:"246502",title:"Dr.",name:"Jaya T.",middleName:"T",surname:"Varkey",slug:"jaya-t.-varkey",fullName:"Jaya T. Varkey",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/246502/images/11160_n.jpg",biography:"Jaya T. Varkey, PhD, graduated with a degree in Chemistry from Cochin University of Science and Technology, Kerala, India. She obtained a PhD in Chemistry from the School of Chemical Sciences, Mahatma Gandhi University, Kerala, India, and completed a post-doctoral fellowship at the University of Minnesota, USA. She is a research guide at Mahatma Gandhi University and Associate Professor in Chemistry, St. Teresa’s College, Kochi, Kerala, India.\nDr. Varkey received a National Young Scientist award from the Indian Science Congress (1995), a UGC Research award (2016–2018), an Indian National Science Academy (INSA) Visiting Scientist award (2018–2019), and a Best Innovative Faculty award from the All India Association for Christian Higher Education (AIACHE) (2019). She Hashas received the Sr. Mary Cecil prize for best research paper three times. She was also awarded a start-up to develop a tea bag water filter. \nDr. Varkey has published two international books and twenty-seven international journal publications. She is an editorial board member for five international journals.",institutionString:"St. Teresa’s College",institution:null},{id:"250668",title:"Dr.",name:"Ali",middleName:null,surname:"Nabipour Chakoli",slug:"ali-nabipour-chakoli",fullName:"Ali Nabipour Chakoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/250668/images/system/250668.jpg",biography:"Academic Qualification:\r\n•\tPhD in Materials Physics and Chemistry, From: Sep. 2006, to: Sep. 2010, School of Materials Science and Engineering, Harbin Institute of Technology, Thesis: Structure and Shape Memory Effect of Functionalized MWCNTs/poly (L-lactide-co-ε-caprolactone) Nanocomposites. Supervisor: Prof. Wei Cai,\r\n•\tM.Sc in Applied Physics, From: 1996, to: 1998, Faculty of Physics & Nuclear Science, Amirkabir Uni. of Technology, Tehran, Iran, Thesis: Determination of Boron in Micro alloy Steels with solid state nuclear track detectors by neutron induced auto radiography, Supervisors: Dr. M. Hosseini Ashrafi and Dr. A. Hosseini.\r\n•\tB.Sc. in Applied Physics, From: 1991, to: 1996, Faculty of Physics & Nuclear Science, Amirkabir Uni. of Technology, Tehran, Iran, Thesis: Design of shielding for Am-Be neutron sources for In Vivo neutron activation analysis, Supervisor: Dr. M. Hosseini Ashrafi.\r\n\r\nResearch Experiences:\r\n1.\tNanomaterials, Carbon Nanotubes, Graphene: Synthesis, Functionalization and Characterization,\r\n2.\tMWCNTs/Polymer Composites: Fabrication and Characterization, \r\n3.\tShape Memory Polymers, Biodegradable Polymers, ORC, Collagen,\r\n4.\tMaterials Analysis and Characterizations: TEM, SEM, XPS, FT-IR, Raman, DSC, DMA, TGA, XRD, GPC, Fluoroscopy, \r\n5.\tInteraction of Radiation with Mater, Nuclear Safety and Security, NDT(RT),\r\n6.\tRadiation Detectors, Calibration (SSDL),\r\n7.\tCompleted IAEA e-learning Courses:\r\nNuclear Security (15 Modules),\r\nNuclear Safety:\r\nTSA 2: Regulatory Protection in Occupational Exposure,\r\nTips & Tricks: Radiation Protection in Radiography,\r\nSafety and Quality in Radiotherapy,\r\nCourse on Sealed Radioactive Sources,\r\nCourse on Fundamentals of Environmental Remediation,\r\nCourse on Planning for Environmental Remediation,\r\nKnowledge Management Orientation Course,\r\nFood Irradiation - Technology, Applications and Good Practices,\r\nEmployment:\r\nFrom 2010 to now: Academic staff, Nuclear Science and Technology Research Institute, Kargar Shomali, Tehran, Iran, P.O. Box: 14395-836.\r\nFrom 1997 to 2006: Expert of Materials Analysis and Characterization. Research Center of Agriculture and Medicine. Rajaeeshahr, Karaj, Iran, P. O. Box: 31585-498.",institutionString:"Atomic Energy Organization of Iran",institution:{name:"Atomic Energy Organization of Iran",country:{name:"Iran"}}},{id:"248279",title:"Dr.",name:"Monika",middleName:"Elzbieta",surname:"Machoy",slug:"monika-machoy",fullName:"Monika Machoy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/248279/images/system/248279.jpeg",biography:"Monika Elżbieta Machoy, MD, graduated with distinction from the Faculty of Medicine and Dentistry at the Pomeranian Medical University in 2009, defended her PhD thesis with summa cum laude in 2016 and is currently employed as a researcher at the Department of Orthodontics of the Pomeranian Medical University. She expanded her professional knowledge during a one-year scholarship program at the Ernst Moritz Arndt University in Greifswald, Germany and during a three-year internship at the Technical University in Dresden, Germany. She has been a speaker at numerous orthodontic conferences, among others, American Association of Orthodontics, European Orthodontic Symposium and numerous conferences of the Polish Orthodontic Society. She conducts research focusing on the effect of orthodontic treatment on dental and periodontal tissues and the causes of pain in orthodontic patients.",institutionString:"Pomeranian Medical University",institution:{name:"Pomeranian Medical University",country:{name:"Poland"}}},{id:"252743",title:"Prof.",name:"Aswini",middleName:"Kumar",surname:"Kar",slug:"aswini-kar",fullName:"Aswini Kar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252743/images/10381_n.jpg",biography:"uploaded in cv",institutionString:null,institution:{name:"KIIT University",country:{name:"India"}}},{id:"204256",title:"Dr.",name:"Anil",middleName:"Kumar",surname:"Kumar Sahu",slug:"anil-kumar-sahu",fullName:"Anil Kumar Sahu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204256/images/14201_n.jpg",biography:"I have nearly 11 years of research and teaching experience. I have done my master degree from University Institute of Pharmacy, Pt. Ravi Shankar Shukla University, Raipur, Chhattisgarh India. I have published 16 review and research articles in international and national journals and published 4 chapters in IntechOpen, the world’s leading publisher of Open access books. I have presented many papers at national and international conferences. I have received research award from Indian Drug Manufacturers Association in year 2015. My research interest extends from novel lymphatic drug delivery systems, oral delivery system for herbal bioactive to formulation optimization.",institutionString:null,institution:{name:"Chhattisgarh Swami Vivekanand Technical University",country:{name:"India"}}},{id:"253468",title:"Dr.",name:"Mariusz",middleName:null,surname:"Marzec",slug:"mariusz-marzec",fullName:"Mariusz Marzec",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/253468/images/system/253468.png",biography:"An assistant professor at Department of Biomedical Computer Systems, at Institute of Computer Science, Silesian University in Katowice. Scientific interests: computer analysis and processing of images, biomedical images, databases and programming languages. He is an author and co-author of scientific publications covering analysis and processing of biomedical images and development of database systems.",institutionString:"University of Silesia",institution:null},{id:"212432",title:"Prof.",name:"Hadi",middleName:null,surname:"Mohammadi",slug:"hadi-mohammadi",fullName:"Hadi Mohammadi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/212432/images/system/212432.jpeg",biography:"Dr. Hadi Mohammadi is a biomedical engineer with hands-on experience in the design and development of many engineering structures and medical devices through various projects that he has been involved in over the past twenty years. Dr. Mohammadi received his BSc. and MSc. degrees in Mechanical Engineering from Sharif University of Technology, Tehran, Iran, and his PhD. degree in Biomedical Engineering (biomaterials) from the University of Western Ontario. He was a postdoctoral trainee for almost four years at University of Calgary and Harvard Medical School. He is an industry innovator having created the technology to produce lifelike synthetic platforms that can be used for the simulation of almost all cardiovascular reconstructive surgeries. He’s been heavily involved in the design and development of cardiovascular devices and technology for the past 10 years. He is currently an Assistant Professor with the University of British Colombia, Canada.",institutionString:"University of British Columbia",institution:{name:"University of British Columbia",country:{name:"Canada"}}},{id:"254463",title:"Prof.",name:"Haisheng",middleName:null,surname:"Yang",slug:"haisheng-yang",fullName:"Haisheng Yang",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/254463/images/system/254463.jpeg",biography:"Haisheng Yang, Ph.D., Professor and Director of the Department of Biomedical Engineering, College of Life Science and Bioengineering, Beijing University of Technology. He received his Ph.D. degree in Mechanics/Biomechanics from Harbin Institute of Technology (jointly with University of California, Berkeley). Afterwards, he worked as a Postdoctoral Research Associate in the Purdue Musculoskeletal Biology and Mechanics Lab at the Department of Basic Medical Sciences, Purdue University, USA. He also conducted research in the Research Centre of Shriners Hospitals for Children-Canada at McGill University, Canada. Dr. Yang has over 10 years research experience in orthopaedic biomechanics and mechanobiology of bone adaptation and regeneration. He earned an award from Beijing Overseas Talents Aggregation program in 2017 and serves as Beijing Distinguished Professor.",institutionString:"Beijing University of Technology",institution:null},{id:"255757",title:"Dr.",name:"Igor",middleName:"Victorovich",surname:"Lakhno",slug:"igor-lakhno",fullName:"Igor Lakhno",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255757/images/system/255757.jpg",biography:"Lakhno Igor Victorovich was born in 1971 in Kharkiv (Ukraine). \nMD – 1994, Kharkiv National Medical Univesity.\nOb&Gyn; – 1997, master courses in Kharkiv Medical Academy of Postgraduate Education.\nPhD – 1999, Kharkiv National Medical Univesity.\nDSc – 2019, PL Shupik National Academy of Postgraduate Education \nLakhno Igor has been graduated from an international training courses on reproductive medicine and family planning held in Debrecen University (Hungary) in 1997. Since 1998 Lakhno Igor has worked as an associate professor of the department of obstetrics and gynecology of VN Karazin National University and an associate professor of the perinatology, obstetrics and gynecology department of Kharkiv Medical Academy of Postgraduate Education. Since June 2019 he’s a professor of the department of obstetrics and gynecology of VN Karazin National University and a professor of the perinatology, obstetrics and gynecology department of Kharkiv Medical Academy of Postgraduate Education . He’s an author of about 200 printed works and there are 17 of them in Scopus or Web of Science databases. Lakhno Igor is a rewiever of Journal of Obstetrics and Gynaecology (Taylor and Francis), Informatics in Medicine Unlocked (Elsevier), The Journal of Obstetrics and Gynecology Research (Wiley), Endocrine, Metabolic & Immune Disorders-Drug Targets (Bentham Open), The Open Biomedical Engineering Journal (Bentham Open), etc. He’s defended a dissertation for DSc degree \\'Pre-eclampsia: prediction, prevention and treatment”. Lakhno Igor has participated as a speaker in several international conferences and congresses (International Conference on Biological Oscillations April 10th-14th 2016, Lancaster, UK, The 9th conference of the European Study Group on Cardiovascular Oscillations). His main scientific interests: obstetrics, women’s health, fetal medicine, cardiovascular medicine.",institutionString:"V.N. Karazin Kharkiv National University",institution:{name:"Kharkiv Medical Academy of Postgraduate Education",country:{name:"Ukraine"}}},{id:"89721",title:"Dr.",name:"Mehmet",middleName:"Cuneyt",surname:"Ozmen",slug:"mehmet-ozmen",fullName:"Mehmet Ozmen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/89721/images/7289_n.jpg",biography:null,institutionString:null,institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"243698",title:"M.D.",name:"Xiaogang",middleName:null,surname:"Wang",slug:"xiaogang-wang",fullName:"Xiaogang Wang",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/243698/images/system/243698.png",biography:"Dr. Xiaogang Wang, a faculty member of Shanxi Eye Hospital specializing in the treatment of cataract and retinal disease and a tutor for postgraduate students of Shanxi Medical University, worked in the COOL Lab as an international visiting scholar under the supervision of Dr. David Huang and Yali Jia from October 2012 through November 2013. Dr. Wang earned an MD from Shanxi Medical University and a Ph.D. from Shanghai Jiao Tong University. Dr. Wang was awarded two research project grants focused on multimodal optical coherence tomography imaging and deep learning in cataract and retinal disease, from the National Natural Science Foundation of China. He has published around 30 peer-reviewed journal papers and four book chapters and co-edited one book.",institutionString:"Shanxi Eye Hospital",institution:{name:"Shanxi Eye Hospital",country:{name:"China"}}},{id:"242893",title:"Ph.D. Student",name:"Joaquim",middleName:null,surname:"De Moura",slug:"joaquim-de-moura",fullName:"Joaquim De Moura",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/242893/images/7133_n.jpg",biography:"Joaquim de Moura received his degree in Computer Engineering in 2014 from the University of A Coruña (Spain). In 2016, he received his M.Sc degree in Computer Engineering from the same university. He is currently pursuing his Ph.D degree in Computer Science in a collaborative project between ophthalmology centers in Galicia and the University of A Coruña. His research interests include computer vision, machine learning algorithms and analysis and medical imaging processing of various kinds.",institutionString:null,institution:{name:"University of A Coruña",country:{name:"Spain"}}},{id:"267434",title:"Dr.",name:"Rohit",middleName:null,surname:"Raja",slug:"rohit-raja",fullName:"Rohit Raja",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRZkkQAG/Profile_Picture_2022-05-09T12:55:18.jpg",biography:null,institutionString:null,institution:null},{id:"294334",title:"B.Sc.",name:"Marc",middleName:null,surname:"Bruggeman",slug:"marc-bruggeman",fullName:"Marc Bruggeman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/294334/images/8242_n.jpg",biography:"Chemical engineer graduate, with a passion for material science and specific interest in polymers - their near infinite applications intrigue me. \n\nI plan to continue my scientific career in the field of polymeric biomaterials as I am fascinated by intelligent, bioactive and biomimetic materials for use in both consumer and medical applications.",institutionString:null,institution:null},{id:"244950",title:"Dr.",name:"Salvatore",middleName:null,surname:"Di Lauro",slug:"salvatore-di-lauro",fullName:"Salvatore Di Lauro",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0030O00002bSF1HQAW/ProfilePicture%202021-12-20%2014%3A54%3A14.482",biography:"Name:\n\tSALVATORE DI LAURO\nAddress:\n\tHospital Clínico Universitario Valladolid\nAvda Ramón y Cajal 3\n47005, Valladolid\nSpain\nPhone number: \nFax\nE-mail:\n\t+34 983420000 ext 292\n+34 983420084\nsadilauro@live.it\nDate and place of Birth:\nID Number\nMedical Licence \nLanguages\t09-05-1985. Villaricca (Italy)\n\nY1281863H\n474707061\nItalian (native language)\nSpanish (read, written, spoken)\nEnglish (read, written, spoken)\nPortuguese (read, spoken)\nFrench (read)\n\t\t\nCurrent position (title and company)\tDate (Year)\nVitreo-Retinal consultant in ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl. National Health System.\nVitreo-Retinal consultant in ophthalmology. Instituto Oftalmologico Recoletas. Red Hospitalaria Recoletas. Private practise.\t2017-today\n\n2019-today\n\t\n\t\nEducation (High school, university and postgraduate training > 3 months)\tDate (Year)\nDegree in Medicine and Surgery. University of Neaples 'Federico II”\nResident in Opthalmology. Hospital Clinico Universitario Valladolid\nMaster in Vitreo-Retina. IOBA. University of Valladolid\nFellow of the European Board of Ophthalmology. Paris\nMaster in Research in Ophthalmology. University of Valladolid\t2003-2009\n2012-2016\n2016-2017\n2016\n2012-2013\n\t\nEmployments (company and positions)\tDate (Year)\nResident in Ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl.\nFellow in Vitreo-Retina. IOBA. University of Valladolid\nVitreo-Retinal consultant in ophthalmology. Hospital Clinico Universitario Valladolid. Sacyl. National Health System.\nVitreo-Retinal consultant in ophthalmology. Instituto Oftalmologico Recoletas. Red Hospitalaria Recoletas. \n\t2012-2016\n2016-2017\n2017-today\n\n2019-Today\n\n\n\t\nClinical Research Experience (tasks and role)\tDate (Year)\nAssociated investigator\n\n' FIS PI20/00740: DESARROLLO DE UNA CALCULADORA DE RIESGO DE\nAPARICION DE RETINOPATIA DIABETICA BASADA EN TECNICAS DE IMAGEN MULTIMODAL EN PACIENTES DIABETICOS TIPO 1. Grant by: Ministerio de Ciencia e Innovacion \n\n' (BIO/VA23/14) Estudio clínico multicéntrico y prospectivo para validar dos\nbiomarcadores ubicados en los genes p53 y MDM2 en la predicción de los resultados funcionales de la cirugía del desprendimiento de retina regmatógeno. Grant by: Gerencia Regional de Salud de la Junta de Castilla y León.\n' Estudio multicéntrico, aleatorizado, con enmascaramiento doble, en 2 grupos\nparalelos y de 52 semanas de duración para comparar la eficacia, seguridad e inmunogenicidad de SOK583A1 respecto a Eylea® en pacientes con degeneración macular neovascular asociada a la edad' (CSOK583A12301; N.EUDRA: 2019-004838-41; FASE III). Grant by Hexal AG\n\n' Estudio de fase III, aleatorizado, doble ciego, con grupos paralelos, multicéntrico para comparar la eficacia y la seguridad de QL1205 frente a Lucentis® en pacientes con degeneración macular neovascular asociada a la edad. (EUDRACT: 2018-004486-13). Grant by Qilu Pharmaceutical Co\n\n' Estudio NEUTON: Ensayo clinico en fase IV para evaluar la eficacia de aflibercept en pacientes Naive con Edema MacUlar secundario a Oclusion de Vena CenTral de la Retina (OVCR) en regimen de tratamientO iNdividualizado Treat and Extend (TAE)”, (2014-000975-21). Grant by Fundacion Retinaplus\n\n' Evaluación de la seguridad y bioactividad de anillos de tensión capsular en conejo. Proyecto Procusens. Grant by AJL, S.A.\n\n'Estudio epidemiológico, prospectivo, multicéntrico y abierto\\npara valorar la frecuencia de la conjuntivitis adenovírica diagnosticada mediante el test AdenoPlus®\\nTest en pacientes enfermos de conjuntivitis aguda”\\n. National, multicenter study. Grant by: NICOX.\n\nEuropean multicentric trial: 'Evaluation of clinical outcomes following the use of Systane Hydration in patients with dry eye”. Study Phase 4. Grant by: Alcon Labs'\n\nVLPs Injection and Activation in a Rabbit Model of Uveal Melanoma. Grant by Aura Bioscience\n\nUpdating and characterization of a rabbit model of uveal melanoma. Grant by Aura Bioscience\n\nEnsayo clínico en fase IV para evaluar las variantes genéticas de la vía del VEGF como biomarcadores de eficacia del tratamiento con aflibercept en pacientes con degeneración macular asociada a la edad (DMAE) neovascular. Estudio BIOIMAGE. IMO-AFLI-2013-01\n\nEstudio In-Eye:Ensayo clínico en fase IV, abierto, aleatorizado, de 2 brazos,\nmulticçentrico y de 12 meses de duración, para evaluar la eficacia y seguridad de un régimen de PRN flexible individualizado de 'esperar y extender' versus un régimen PRN según criterios de estabilización mediante evaluaciones mensuales de inyecciones intravítreas de ranibizumab 0,5 mg en pacientes naive con neovascularización coriodea secunaria a la degeneración macular relacionada con la edad. CP: CRFB002AES03T\n\nTREND: Estudio Fase IIIb multicéntrico, randomizado, de 12 meses de\nseguimiento con evaluador de la agudeza visual enmascarado, para evaluar la eficacia y la seguridad de ranibizumab 0.5mg en un régimen de tratar y extender comparado con un régimen mensual, en pacientes con degeneración macular neovascular asociada a la edad. CP: CRFB002A2411 Código Eudra CT:\n2013-002626-23\n\n\n\nPublications\t\n\n2021\n\n\n\n\n2015\n\n\n\n\n2021\n\n\n\n\n\n2021\n\n\n\n\n2015\n\n\n\n\n2015\n\n\n2014\n\n\n\n\n2015-16\n\n\n\n2015\n\n\n2014\n\n\n2014\n\n\n\n\n2014\n\n\n\n\n\n\n\n2014\n\nJose Carlos Pastor; Jimena Rojas; Salvador Pastor-Idoate; Salvatore Di Lauro; Lucia Gonzalez-Buendia; Santiago Delgado-Tirado. Proliferative vitreoretinopathy: A new concept of disease pathogenesis and practical\nconsequences. Progress in Retinal and Eye Research. 51, pp. 125 - 155. 03/2016. DOI: 10.1016/j.preteyeres.2015.07.005\n\n\nLabrador-Velandia S; Alonso-Alonso ML; Di Lauro S; García-Gutierrez MT; Srivastava GK; Pastor JC; Fernandez-Bueno I. Mesenchymal stem cells provide paracrine neuroprotective resources that delay degeneration of co-cultured organotypic neuroretinal cultures.Experimental Eye Research. 185, 17/05/2019. DOI: 10.1016/j.exer.2019.05.011\n\nSalvatore Di Lauro; Maria Teresa Garcia Gutierrez; Ivan Fernandez Bueno. Quantification of pigment epithelium-derived factor (PEDF) in an ex vivo coculture of retinal pigment epithelium cells and neuroretina.\nJournal of Allbiosolution. 2019. ISSN 2605-3535\n\nSonia Labrador Velandia; Salvatore Di Lauro; Alonso-Alonso ML; Tabera Bartolomé S; Srivastava GK; Pastor JC; Fernandez-Bueno I. Biocompatibility of intravitreal injection of human mesenchymal stem cells in immunocompetent rabbits. Graefe's archive for clinical and experimental ophthalmology. 256 - 1, pp. 125 - 134. 01/2018. DOI: 10.1007/s00417-017-3842-3\n\n\nSalvatore Di Lauro, David Rodriguez-Crespo, Manuel J Gayoso, Maria T Garcia-Gutierrez, J Carlos Pastor, Girish K Srivastava, Ivan Fernandez-Bueno. A novel coculture model of porcine central neuroretina explants and retinal pigment epithelium cells. Molecular Vision. 2016 - 22, pp. 243 - 253. 01/2016.\n\nSalvatore Di Lauro. Classifications for Proliferative Vitreoretinopathy ({PVR}): An Analysis of Their Use in Publications over the Last 15 Years. Journal of Ophthalmology. 2016, pp. 1 - 6. 01/2016. DOI: 10.1155/2016/7807596\n\nSalvatore Di Lauro; Rosa Maria Coco; Rosa Maria Sanabria; Enrique Rodriguez de la Rua; Jose Carlos Pastor. Loss of Visual Acuity after Successful Surgery for Macula-On Rhegmatogenous Retinal Detachment in a Prospective Multicentre Study. Journal of Ophthalmology. 2015:821864, 2015. DOI: 10.1155/2015/821864\n\nIvan Fernandez-Bueno; Salvatore Di Lauro; Ivan Alvarez; Jose Carlos Lopez; Maria Teresa Garcia-Gutierrez; Itziar Fernandez; Eva Larra; Jose Carlos Pastor. Safety and Biocompatibility of a New High-Density Polyethylene-Based\nSpherical Integrated Porous Orbital Implant: An Experimental Study in Rabbits. Journal of Ophthalmology. 2015:904096, 2015. DOI: 10.1155/2015/904096\n\nPastor JC; Pastor-Idoate S; Rodríguez-Hernandez I; Rojas J; Fernandez I; Gonzalez-Buendia L; Di Lauro S; Gonzalez-Sarmiento R. Genetics of PVR and RD. Ophthalmologica. 232 - Suppl 1, pp. 28 - 29. 2014\n\nRodriguez-Crespo D; Di Lauro S; Singh AK; Garcia-Gutierrez MT; Garrosa M; Pastor JC; Fernandez-Bueno I; Srivastava GK. Triple-layered mixed co-culture model of RPE cells with neuroretina for evaluating the neuroprotective effects of adipose-MSCs. Cell Tissue Res. 358 - 3, pp. 705 - 716. 2014.\nDOI: 10.1007/s00441-014-1987-5\n\nCarlo De Werra; Salvatore Condurro; Salvatore Tramontano; Mario Perone; Ivana Donzelli; Salvatore Di Lauro; Massimo Di Giuseppe; Rosa Di Micco; Annalisa Pascariello; Antonio Pastore; Giorgio Diamantis; Giuseppe Galloro. Hydatid disease of the liver: thirty years of surgical experience.Chirurgia italiana. 59 - 5, pp. 611 - 636.\n(Italia): 2007. ISSN 0009-4773\n\nChapters in books\n\t\n' Salvador Pastor Idoate; Salvatore Di Lauro; Jose Carlos Pastor Jimeno. PVR: Pathogenesis, Histopathology and Classification. Proliferative Vitreoretinopathy with Small Gauge Vitrectomy. Springer, 2018. ISBN 978-3-319-78445-8\nDOI: 10.1007/978-3-319-78446-5_2. \n\n' Salvatore Di Lauro; Maria Isabel Lopez Galvez. Quistes vítreos en una mujer joven. Problemas diagnósticos en patología retinocoroidea. Sociedad Española de Retina-Vitreo. 2018.\n\n' Salvatore Di Lauro; Salvador Pastor Idoate; Jose Carlos Pastor Jimeno. iOCT in PVR management. OCT Applications in Opthalmology. pp. 1 - 8. INTECH, 2018. DOI: 10.5772/intechopen.78774.\n\n' Rosa Coco Martin; Salvatore Di Lauro; Salvador Pastor Idoate; Jose Carlos Pastor. amponadores, manipuladores y tinciones en la cirugía del traumatismo ocular.Trauma Ocular. Ponencia de la SEO 2018..\n\n' LOPEZ GALVEZ; DI LAURO; CRESPO. OCT angiografia y complicaciones retinianas de la diabetes. PONENCIA SEO 2021, CAPITULO 20. (España): 2021.\n\n' Múltiples desprendimientos neurosensoriales bilaterales en paciente joven. Enfermedades Degenerativas De Retina Y Coroides. SERV 04/2016. \n' González-Buendía L; Di Lauro S; Pastor-Idoate S; Pastor Jimeno JC. Vitreorretinopatía proliferante (VRP) e inflamación: LA INFLAMACIÓN in «INMUNOMODULADORES Y ANTIINFLAMATORIOS: MÁS ALLÁ DE LOS CORTICOIDES. 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