\r\n\tThis book will consist of chapters that are an elegant mix of reviews and current developments on the subject that will be useful both to an expert on the subject as well as a newcomer to this area of research.
",isbn:"978-1-83969-076-1",printIsbn:"978-1-83969-075-4",pdfIsbn:"978-1-83969-092-1",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"8a2fd9bbbbae283bf115881d9d5cc47a",bookSignature:"Dr. Ashim Kumar Dutta",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11857.jpg",keywords:"Frenkel Excitons, Wannier-Mott Excitons, Low Dimensional Solids, Molecular Crystals and Aggregates, Exciton Diffusion and Hopping, Exciton–Exciton Annihilation, Dynamics, Scaling Laws, Photoluminescence, Exciton Lifetime, Energy Harvesting, Semiconductors",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 19th 2022",dateEndSecondStepPublish:"June 23rd 2022",dateEndThirdStepPublish:"August 22nd 2022",dateEndFourthStepPublish:"November 10th 2022",dateEndFifthStepPublish:"January 9th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"9 days",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Ashim Kumar Dutta received his Ph.D. in physical chemistry from the Indian Association for the Cultivation of Science (IACS). He has worked on various international post-doctoral fellowships in Japan, Canada, and USA. Dr. Dutta has worked as head of research and product development in several companies, and presently works as vice-president for India Glycols Limited. He has authored/co-authored 36 articles in international journals and 21 patents.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"277477",title:"Dr.",name:"Ashim",middleName:"Kumar",surname:"Dutta",slug:"ashim-dutta",fullName:"Ashim Dutta",profilePictureURL:"https://mts.intechopen.com/storage/users/277477/images/system/277477.jpg",biography:"Dr. Ashim Kumar Dutta presently works as the vice president (R&D) with India Glycols Limited, one of the largest manufacturers of Green Surfactants in South East Asia. Earlier, he had worked with Unilever as a senior researcher and product development manager in their Home and Personal Care Category, with United Phosphorus Limited and Indofil as their global head for agrochemical formulations. He has authored/co-authored 36 articles in international journals and 19 patents. He received his Ph.D in physical chemistry from Indian Association for the Cultivation of Science (IACS) – a premiere research institute in India in 1993. Dr. Dutta has worked on various international post-doctoral fellowships in Japan, Canada and USA. 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From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. 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Introduction
\n
The aims of regenerative medicine are to renew cells, regenerate fully functional tissues, and organs or structures that are lost or damaged after disease, injury, or aging [1]. In recent years, the mesenchymal stem cells or multipotent mesenchymal stromal cells (MSCs) have attracted much attention due to their potential use in regenerative medicine and tissue engineering as shown by the main applications described in the literature and the noteworthy progress that has been made toward their better understanding and characterization [2]. Those cells display a significant therapeutic plasticity as reflected by their advantageous characteristics: the ability to enhance tissue renovation, the immunomodulatory, and anti-inflammatory effects [3, 4] and the possibility to be used for both autologous and allogeneic therapies [5]. For these reasons, MSC-based cell therapies have been investigated for several years in human medicine and, more recently, the same approach has been considered in veterinary medicine as a novel potential therapy for animal diseases [6–9]. While most studies using animal models and even small clinical trials have utilized fresh MSC cultured on-site, cryopreservation of MSC is essential to the widespread application of MSC-based therapies. Cryopreservation allows for MSC to be prepared by specialized facilities, in large batches under the application of accepted quality control measures to ensure their safety. Currently, much information concerning the effects of cryopreservation on MSCs is difficult to interpret because MSCs are frequently isolated from different tissue sources and stored for variable periods of time. The capability of MSCs to survive to storage, maintain their phenotype, and differentiate along multiple lineage pathways upon thawing is of paramount importance if they are banked for future therapeutic purposes.
\n
\n2. Mesenchymal stem cells
\n
MSCs were first described as a specific cell population by Friedenstein’s research group in the late 1960s [10]. Previously, stem cell populations were supposed to reside solely in adult tissues with a high turnover rate, such as blood, skin, hair, gastrointestinal epithelium, and bone. Indeed, these cells are present in variable amounts in specific stem cell “niches” (organs), in almost all the body tissues and even if the exact locations of these niches are poorly understood, there is growing evidence suggesting a close relationship with pericytes [11]. Generally, these cells remain in a quiescent state until activated by significant events, such as during tissue repair after injury or following transplantation, to regain tissues’ homeostasis [12, 13]. MSCs are undifferentiated, self-renewable, multipotent adult stem cells originated from the mesoderm germ layer during the embryonic development, characterized by the ability to evolve both in vitro and in vivo along multiple lineage pathways [14]. Furthermore, MSCs have shown evidence of plasticity by trans-differentiating into a broad range of cell types of mesodermal origin (osteocytes, chondrocytes, adipocytes, and myocytes) [15, 16], but also deriving from other germ layers including ectodermal neurons [17] endodermal hepatocytes [18], endothelial cells [11], and cardiomyocytes [19].
\n
\n3. Properties of MSCs for cellular therapy
\n
Although MSCs first attracted attention due to their ability to differentiate into various cell types, current data suggest that MSCs, as a result of their peculiar biological features, may not only replace damaged tissues, but may be also capable of secreting several bioactive molecules with paracrine and autocrine properties. Such functional secretions of factors are responsible for trophic [20], antiapoptotic, angiogenic, and antiscar effects [21, 22]. MSCs have a further interesting characteristic, related to the capacity to exert immunoregulatory effects on cells of adaptive and innate immunity, such as T and B lymphocytes, dendritic cells, natural killer cells, and monocytes [23]. These immunomodulatory properties that have been extensively demonstrated by several in vitro and in vivo studies, seem to permit MSC-allogenic transplantation.
\n
\n4. Sources of MSCs
\n
In veterinary medicine, the first source reported to contain MSCs was the bone marrow (BM) that in the past was also the most widely used [15]. Nevertheless, more recent studies have identified MSCs with similar properties in almost all mammalian tissues such as skeletal muscle [24, 25], tendon [26], skin [27, 28], adipose tissue [29], periosteum [30], synovial membrane [31], dental pulp [32], peripheral blood [33], umbilical cord blood [34], amniotic fluids [35], and cornea [36].
\n
\n5. Isolation of MSCs from bone marrow
\n
The postnatal bone marrow (BM) has been the most studied tissue as a source of progenitor cells. It contains at least two cell populations: the hematopoietic stem cells (HSCs), located in proximity to the endosteum, and MSCs that surround the trabeculae and blood vessels [37]. HSCs are capable of regenerating the peripheral blood cell lines and the immune system, and the MSCs [38] are capable of giving rise to tissues of each of the three germ layers. Although MSCs derived from BM are easily separated from the nonadherent hematopoietic fraction of cells by culture and adherence to plastic dishes, BM harvest is an invasive and painful surgical procedure that requires the anesthesia and it could be associated with the risk of complications such as hemorrhage, infection, pneumothorax, or pneumopericardium in horses [39, 40]. Moreover, there is only a very low frequency (0.001–0.01%) of MSCs in bone marrow and these numbers decline with the age of the individual.
\n
\n6. Isolation of MSCs from adipose tissue
\n
The isolation of rat mature adipocytes and adipose tissue progenitor cells was described in literature for the first time by Rodbell [41]. The protocol was based on the fragmentation of adipose tissue into small portions, followed by enzymatic digestion with collagenase type I at 37°C and the subsequent centrifugation to separate the different cell fractions. The obtained supernatant was composed of mature adipocytes and the pellet fraction consisted of the stromal vascular fraction (SVF) components, which comprise a heterogeneous cell population, including circulating blood cells, fibroblasts, pericytes, and endothelial cells, as well as “pre-adipocytes” or adipocyte progenitors. Stem cells and progenitor cells represent about the 3% of all cell populations [42]. Stem cells derived from the adipose tissue (ASCs) represent a purified population of the adherent stem cells present in the adipose tissue, since all other cell types are removed or die with time. Currently, ASC recovery is quick and easy to perform from the subcutaneous adipose tissue, as it could be successfully collected via lipectomy or from the tail base in horses and from the inguinal region [43] or during ovariohisterectomies in dogs and cats. Stem cells derived from the adipose tissue have been increasingly used for cell therapy both in humans and animals [44], either as freshly isolated, SVF cells, or as cultivated ASCs [43]. ASCs proliferate rapidly with a high cellular activity, making them an ideal source to obtain MSCs [45]. The most important advantage of adipose-derived stem cells is their abundance: from 1 g of adipose tissue an average of 0.5–2.0 × 106 SVF cells can be isolated, which gives 1–10% of stem cell yield [46]; in comparison, MSCs constitute only 0.001–0.01% of BM [15]. When autologous ASCs are used, the adipose tissue is collected 2 or 3 weeks before the treatment and the animal receives the cultivated cells, but long-term cultivation of ASCs before therapeutic use is not recommended, since the cells may lose their progenitor characteristics [47]. The use of allogeneic ASCs has been also performed; since these cells have immunoregulatory properties [48], this approach would allow the use of species-specific allogeneic cryopreserved cells, avoiding the need for collection of tissue from the patient [49].
\n
\n7. Cryopreservation
\n
Biopreservation has been characterized by a recent rapid growth since advances in cell therapy, stem-cell research, personalized medicine, cell banking, etc. drive the need for optimized storage protocols. Nevertheless, this field still experiences significant issues with the current techniques including suboptimal survival, loss of poststorage cell function, addition of animal components in storage solutions, and activation of cellular stress pathways which can lead to changes in gene expression and protein denaturation [50]. The clinical application of autologous or allogeneic MSCs requires on demand access to a ready off-the-shelf amount of viable therapeutic doses of MSC and therefore necessitates fast availability to cryopreserved MSC stocks. The aim of cryopreservation is to preserve the therapeutic properties of those cells that maintain unaltered the characteristics of the freshly isolated samples, but the freezing and thawing procedures could determine an alteration of the cellular osmosis which can cause cell injury.
\n
7.1. Freezing
\n
The freezing rate is a fundamental factor for all biological systems in the determination of viability following cryopreserved storage. Several studies have shown that successful cryopreservation of cells in suspension needs sufficiently high cooling rates to reach quickly low temperatures and avoid slow-cooling injury, but low enough cooling rates to decrease the formation of intracellular ice and avoid rapid-cooling injury [51]. The responses to cooling rates are cell-type specific, as distinct cell types have different membrane permeability parameters. The intracellular dynamics during freezing or thawing could be influenced by many factors which influence cell viability after both of these procedures, affecting the therapeutic outcomes. Among these factors, the subtract desegregation stress before cryopreservation of the cells attached to the plastic, the intracellular ice formation during freezing which can compromise the integrity of the cell membranes and, after thawing, the risk of impairing the membrane and altering other cellular functional characteristics can be listed [52]. Currently, there are two procedures to achieve the efficient cryopreservation of MSCs: conventional slow-freezing and vitrification (rapid cooling). Both of these methods may lead to cell damage during loading/unloading of the cryoprotectant agents (CPAs), freezing, and thawing steps. The slow-freezing procedure is the most commonly used cryopreservation technique in clinics and research laboratories today, because it allows the preparation of large amounts of vials at one time. Cryopreservation by vitrification has shown higher cell survival and it has been recognized as a promising strategy for long-term cell banking. Nevertheless, the difficulty to generate a fast enough heating rate to minimize devitrification and recrystallization-induced intracellular ice formation during rewarming is one of the major problems to be overcome. However, the high CPA concentration that is required to achieve vitrification results in osmotic dehydration to cells. For these reasons, new vitrification methods have emerged as alternative techniques, which have shown the ability to significantly reduce cryoinjury. This approach has been improved for the cryopreservation of organized tissues where even extracellular freezing causes several damages. In fact, in a recent study reported by Wang et al. [53], magnetic induction heating of superparamagnetic nanoparticles was successfully applied to enhance rewarming, with promising results of the vitrified human umbilical cord matrix MSC survival.
\n
\n
7.2. Cryoprotectants
\n
In addition to controlling the cooling rates, one of the major challenges to obtain an effective cryopreservation method is the selection of a suitable CPA, which minimizes the damaging effects of freezing. The most commonly employed CPA for cultured mammalian cells is dimethyl sulfoxide (DMSO) solution, because it is cheap and it has a relatively low cell toxicity. DMSO penetrates cell membrane, reduces intracellular ice formation, and prevents cell damage due to dehydration caused by extracellular ice formed during freezing; on the other hand, it can also decrease the survival rate [54, 55] or induce cell differentiation to neuronal-like cells when added to the cell culture medium [56]. The most common cryopreservation medium to store several types of stem cells has become a solution of 10% (v/v) DMSO and up to 90% (v/v) fetal bovine serum (FBS), despite showing disadvantages. To improve this procedure, MSCs have been cryopreserved using both DMSO and FBS free systems, comprising different polymers either alone or in combination with ethylene glycol, 1,2-propylene glycol, trehalose, sucrose, and/or glucose. In contrast to DMSO that penetrates quickly into the cell, the high molecular weight polymers such as polyvinylpyrrolidone, polyethylene glycol, polyethylene oxide, or polyvinyl alcohol are nonpenetrating and seems to act extracellularly (at 10–40% concentrations), with the increasingly high viscosities at low temperature and avoiding that water molecules form ice crystals [52]. In a study reported by Renzi et al. [57], several cryopreservation solutions for MSCs isolated from equine, ovine, rodent bone marrow, and equine adipose tissue were compared: the best results regarding cell viability were obtained using a solution of fetal bovine serum added with 10% of DMSO. Conversely, in a previous study, Ock and Rho [58] reported that the survival and number of colonies formed by porcine MSCs were significantly decreased following short-term storage (less than a month) into liquid nitrogen (−196°C) and the amount of this decrease was inversely proportional to the DMSO concentration. Those data strongly suggest the use of 5% DMSO instead of conventional 10% DMSO for the cryopreservation of porcine MSCs, for minimizing the CPA toxicity on cells. However, slow freezing with reduced concentration of CPAs has gained much interest in order to decrease the effect of the osmotic shock and chemical toxicity. Nevertheless, the commonly used CPAs are highly toxic at 37°C (body temperature) and could not be applied to patients. For this reason, multistep washing is required to completely remove the highly toxic, cell membrane-permeable cryoprotectants from cryopreserved cells for clinical use, though this procedure is often associated with significant loss of precious cells (~10% during each washing step). Therefore, it is important to achieve cell cryopreservation with nontoxic CPAs. Recently, Rao et al. [59] demonstrate that nanoparticle-mediated delivery of trehalose into mammalian cells has great potential for cryopreserving the human primary adipose derived stem cells (hADSCs) and possibly other types of stem cells to facilitate their ready availability for clinical use. In fact, successful results on cryopreservation of hADSCs using only trehalose as cryoprotectant has been achieved with high survival and undamaged function post cryopreservation.
\n
\n
7.3. Thawing and viability assessment
\n
As well as cooling, optimizing the thawing method of frozen MSCs is also important. Furthermore, in clinical transplantation applications the post-thaw viability assessment has shown to be of paramount importance. Several techniques have already been suggested for thawing frozen sample. A procedure of thaw and wash allows to remove DMSO and cell fragments, but may cause cell loss or cellular aggregation during centrifugation. Thaw, dilution, and wash procedure avoids the problem due to the centrifugation, allowing an osmolar equilibration, but the untoward effects of DMSO and cell debris infusion are not prevented. Currently, the standard method for thaw frozen MSCs, either from slow freezing or vitrification, is to warm them rapidly (>100°C/min) in a water bath at 37°C, until all ice crystals disappear. This method generally results in high post-thaw recovery of viable cells without using high-cost equipment, but it is safer to thaw cells using a dry warming procedure, due to the potential microbiological contaminations of the water bath [60]. Literature suggests that rapid thawing rates (>100°C/min) that can prevent damaging ice crystals during recrystallization are optimal choice and generally results in the best post-thaw recovery and viability of cells [61]. High post-thaw viability of MSCs, comparable to those thawed with the standard method, were obtained by Thirumala et al. [62] with a thawing procedure in a controlled-rate freezing/thawing chamber at 10°C/min. For evaluating the cryopreservation outcomes in terms of post-thaw cell quality and quantity, the selection of the correct viability measurement is essential. The most commonly utilized test, owing to its easiness and quickness, is the Trypan blue dye exclusion assay; however, this method has the disadvantage that it generally overestimates the viable population. Several reports suggested that fluorescence dyes are more accurate and reliable indicators of cell viability [63].
\n
\n
\n8. Microbiological controls
\n
Biosafety assessment of cryopreserved MSCs is necessary to ensure the safe use of the cells prior to clinical applications. Specific tests for the detection of bacteria, yeast, fungi, mycoplasmas, and viruses should be used as a part of routine and regular quality control screening procedures. To detect low levels of contamination, samples from the cell cultures and their products may be inoculated in either liquid tryptic soy broth (TSB) for the detection of aerobes, facultative anaerobes, and fungi, fluid thioglycollate medium (FTM) for the detection of aerobic and anaerobic bacteria, or onto solid (trypticase soy agar, blood agar, Sabouraud’s dextrose agar, and malt extract agar) growth media. These inoculated media may be incubated at different temperatures, reflecting conditions for pathogen culture (37°C) and environmental organisms with lower growth temperature optimal (25°C) in microbiological culture incubators, depending on the specific testing standards used. Mycoplasmas competes with the cells for the nutrients in the culture medium, typical signs of contamination consist in a reduction of the rate of cell proliferation, and changes in cellular physiology including gene expression, metabolism, and phenotype. Among the wide variety of techniques that have been developed to detect mycoplasma contamination of cell cultures, Uphoff and Drexler [64] recommended the PCR analysis for the screening, as it considered the most reliable and useful detection method. The presence of viral agents could be evaluated by a panel of tests to detect pathogens and adventitious viruses. Usually, this panel of tests includes: electronic microscopy, reverse transcriptase detection (as a general test for retroviruses), and other tests to find specific agents, depending on the animal species of the sample.
\n
\n9. Storage of MSCs
\n
MSCs should be preserved without direct exposure to liquid nitrogen, to reduce the risk of pathogenic cross-contamination. This issue enforces the stem cells banks to store materials at vapor phase of liquid nitrogen. However, recent evidence suggests that storage in vapor phase above liquid nitrogen still carries the risk of cross-contamination [65]. Potentially, infective agents may also enter storage directly from the facility atmosphere, contaminated surfaces, or leaking samples, and they can be accumulated in viable condition. Stem cell banks should also maintain secure liquid nitrogen storage equipment in cryogenic tanks monitored by a specific control and alarm system (−196°C), in order to avoid catastrophic loss of cryopreserved samples. Furthermore, proper storage requires the use of cryovials and labeling systems that will withstand the intended storage conditions: labels and bar codes or other printing systems are chosen for extended storage periods.
\n
\n10. Future perspectives
\n
MSC-based therapy is a promising treatment in repair and regeneration of injured and pathological tissues. Nowadays, even if this innovative therapy in veterinary medicine is still limited, stem cell technology has attracted attention and is a quickly evolving field, among either competitive horses or companion animals, due to the limitations of pharmacological and other current therapeutic strategies. The clinical application of autologous or allogeneic MSCs requires a ready off-the-shelf amount of viable cells that maintain unaltered the characteristics of the freshly isolated samples. Although the long experience of cells’ processing facilities, consensus is lacking on a universally accepted method for the effective cryopreservation protocol of MSCs and on the maximum time of cryopreserved storage. For these reasons, even if several successful clinical results have been reported by several groups, the methods of stem cells administration need to be improved and the protocols standardized, before a broad spectrum of clinical applications can be successfully achieved. Currently, the Italian Ministry of Health funded a research project to evaluate the safety and efficacy of animal cryopreserved MSCs for allogenic use. These cells are stored and available at the Italian Biobank of Veterinary Resources of IZSLER (http://www.ibvr.org) and the activity is in progress (data not published).
\n
\n\n',keywords:"mesenchymal stromal cells, cryopreservation, cryoprotectant, regenerative medicine",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/52273.pdf",chapterXML:"https://mts.intechopen.com/source/xml/52273.xml",downloadPdfUrl:"/chapter/pdf-download/52273",previewPdfUrl:"/chapter/pdf-preview/52273",totalDownloads:1784,totalViews:228,totalCrossrefCites:1,totalDimensionsCites:1,totalAltmetricsMentions:0,impactScore:0,impactScorePercentile:23,impactScoreQuartile:1,hasAltmetrics:0,dateSubmitted:"March 8th 2016",dateReviewed:"July 19th 2016",datePrePublished:null,datePublished:"November 30th 2016",dateFinished:"September 1st 2016",readingETA:"0",abstract:"Scientific progress in cellular and molecular biotechnology has led to the development of advanced therapies, such as gene therapy, cell therapy, and tissue engineering. The application of stem cells as therapeutic agents has been investigated for several years in human medicine and, more recently, the same approach has been considered in the veterinary field as a novel opportunity for the treatment of animal diseases. Mesenchymal stem cell (MSC)-based therapies seem to contribute to the healing process by several mechanisms due to their peculiar biological features. It has been shown that MSCs could effectively differentiate into the required cell type to replace the damaged tissue. Furthermore, due to their autocrine and paracrine secretory activities, these cells are a powerful source of trophic mediators, growth factors, cytokines, and extracellular matrix components. The clinical application of MSCs needs great amounts of cells designed for in vivo implantation that can be obtained following their in vitro isolation, serial subcultivations, cryopreservation, and thawing. These procedures could determine their feature changes which could interfere with the therapeutic outcome. For these reasons, to preserve MSCs after in vitro manipulation for future applications, standardized quality controls and a reliable long-term cryopreservation method are required.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/52273",risUrl:"/chapter/ris/52273",book:{id:"5367",slug:"cryopreservation-in-eukaryotes"},signatures:"Tina Lombardo, Sabrina Renzi, Silvia Dotti, Stefano Cinotti and\nMaura Ferrari",authors:[{id:"186219",title:"Dr.",name:"Maura",middleName:null,surname:"Ferrari",fullName:"Maura Ferrari",slug:"maura-ferrari",email:"maura.ferrari@izsler.it",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"187114",title:"Dr.",name:"Tina",middleName:null,surname:"Lombardo",fullName:"Tina Lombardo",slug:"tina-lombardo",email:"tina.lombardo@izsler.it",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"187173",title:"Dr.",name:"Sabrina",middleName:null,surname:"Renzi",fullName:"Sabrina Renzi",slug:"sabrina-renzi",email:"sabrina.renzi@izsler.it",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"187174",title:"Dr.",name:"Silvia",middleName:null,surname:"Dotti",fullName:"Silvia Dotti",slug:"silvia-dotti",email:"silvia.dotti@izsler.it",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"194159",title:"Prof.",name:"Stefano",middleName:null,surname:"Cinotti",fullName:"Stefano Cinotti",slug:"stefano-cinotti",email:"stefano.cinotti@izsler.it",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Mesenchymal stem cells",level:"1"},{id:"sec_3",title:"3. Properties of MSCs for cellular therapy",level:"1"},{id:"sec_4",title:"4. Sources of MSCs",level:"1"},{id:"sec_5",title:"5. Isolation of MSCs from bone marrow",level:"1"},{id:"sec_6",title:"6. Isolation of MSCs from adipose tissue",level:"1"},{id:"sec_7",title:"7. Cryopreservation",level:"1"},{id:"sec_7_2",title:"7.1. Freezing",level:"2"},{id:"sec_8_2",title:"7.2. Cryoprotectants",level:"2"},{id:"sec_9_2",title:"7.3. Thawing and viability assessment",level:"2"},{id:"sec_11",title:"8. Microbiological controls",level:"1"},{id:"sec_12",title:"9. Storage of MSCs",level:"1"},{id:"sec_13",title:"10. Future perspectives",level:"1"}],chapterReferences:[{id:"B1",body:'[Brockes JP, Kumar A. Appendage regeneration in adult vertebrates and implications for regenerative medicine. Science. 2005;310(5756):1919–1923. 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'},{corresp:null,contributorFullName:"Sabrina Renzi",address:null,affiliation:'- Cell Culture Centre, Experimental Zooprophylactic Institute of Lombardia and Emilia Romagna (IZSLER), Brescia, Italy
'},{corresp:null,contributorFullName:"Silvia Dotti",address:null,affiliation:'- Cell Culture Centre, Experimental Zooprophylactic Institute of Lombardia and Emilia Romagna (IZSLER), Brescia, Italy
'},{corresp:null,contributorFullName:"Stefano Cinotti",address:null,affiliation:'- Cell Culture Centre, Experimental Zooprophylactic Institute of Lombardia and Emilia Romagna (IZSLER), Brescia, Italy
'},{corresp:null,contributorFullName:"Maura Ferrari",address:null,affiliation:'- Cell Culture Centre, Experimental Zooprophylactic Institute of Lombardia and Emilia Romagna (IZSLER), Brescia, Italy
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Introduction
In pediatric age group the Grave’s-Basedow disease (GD) is by far the most common cause of hyperthyroidism, accounting for greater than 95% of cases. The underlying process is an autoimmune reaction with cell proliferation and excess function (overproduction of thyroid hormone) caused by anti-thyrotropin receptor antibody (TRAb). When using term thyrotoxicosis, it depicts the clinical and biochemical manifestations of excess thyroid hormones. The annual incidence of thyrotoxicosis was less than 1 per 100,000 children <15 years of age in the last century and rised slowly above 1.5 per 100,000 by 2012 with the pubertal dominance up to 80%. In spite of the GD is a rare disorder in children, physicians should consider Graves’ Disease in any child with clinical manifestations of hyperthyroidism, regardless of the age.
All but a few GD children present with some degree of thyroid gland enlargement and most have two or more signs of excessive thyroid activity. The clinical manifestations of hyperthyroidism during fetal life are tachycardia, cardiac arrhythmia, intrauterine growth retardation and may be associated with nonimmune fetal hydrops, craniosynostosis. Features of this condition in the neonate include irritability, tachycardia, hypertension, cardiac failure and arrhythmias, diarrhea, poor weight gain, vomiting, jaundice, hepatosplenomegaly, ophthalmopathy, craniosynostosis and thyroid enlargement. In childhood hyperkinesis, tachycardia, tremor, frequent stools, nervousness are the signs of hyperthyroidism but in young children these are less characteristic, often unrecognized. In school-age hyperthyroidism neuropsychiatric symptoms such as hyperactivity and poor school performance are common features. Adolescents usually present with classic signs including weight loss despite of good appetite, diarrhea, nervousness, and heat intolerance. Fully developed clinical picture is easy to recognize while often the onset is insidious. Thyroid hormones affect many body systems, so signs and symptoms of Graves’ Disease can be wide ranging.
This chapter is aimed to draw attention to less common or less distinctive signs and symptoms which can be in relation to GD at the time of diagnosis. A survey was conducted on PubMed literature to gather all published pediatric Graves-Basedow’s cases with unusual presentation at the time of diagnosis. We found all together 70 publications with relevant information from 1978 to 2020 but mainly adult cases. Half of them (36) were found to meet the criteria we focused on and were included in this paper, though in some situation the unusual findings do not consist part of hyperthyroidism, the rare manifestation is only a coexistence, or the serious disease even precedes the GD. Awareness about the relation of these rare manifestations or disorders to GD is essential to avoid wrong diagnosis, unnecessary investigations, or fatal outcome due to delay of diagnosis.
2. Unusual signs and symptoms
2.1 Dermopathy and acropachy
Thyroid dermopathy (TD), also called pretibial myxedema and thyroid acropachy (TA) together with Graves’ orbitopathy (GO) are extrathyroidal manifestations of GD. Graves’ ophthalmopathy in children not as common as in adults and less severe than in later age. Dermatological symptoms are rare and in general develop sequentially: Dermopathy is usually present if the patient is also affected with GO. The very rare acropachy occurs only in patients who also have dermopathy [1]. Or in other words, acropachy is an indicator of severity of ophthalmopathy and dermopathy. All have an autoimmune origin, the immune reaction is targeted to TSH receptor and, likely, the IGF-I receptor. Typical presentation of dermopathy is nonpitting edema or plaque-like lesions on the pretibial region, while thyroid acropachy presents as digital clubbing, swelling of digits and toes, and periosteal reaction of extremity bones. Awareness about the relation of TA to GD is important as clubbing usually is not a patient complaint and is noted only by clinical observers. Recently Kraus CN and al. reported a case of acropachy in a child as well as reviewed the literature of pediatric thyroid dermopathy [2].
2.2 Cholestasis
Hepatic dysfunction is commonly observed in patients with thyroid disease, it can be categorized mainly into group with either hepatocellular damage (transaminases elevations), or intrahepatic cholestasis (bilirubin elevation). In newborn, the hypothyroidism is the most typical thyroid disorder associated with cholestasis. Jaundice due to intrahepatic cholestasis may be a salient symptom in GD patients, and very occasionally, it is the presenting manifestation of thyrotoxicosis. The mechanism of liver injury in pure hyperthyroid states is not well understood, and no correlation was documented between abnormal liver biochemical tests and thyroid hormone levels. A contributing factor appears to be relative hypoxia in the perivenular regions, due to an increase in hepatic oxygen demand without an appropriate increase in hepatic blood flow [3], the other might be the thyroid hormones themselves with a direct toxic effect on hepatic tissue in hypermetabolic state [4]. If other possible causes of cholestasis are excluded, recovery occurs parallelly with restoration of euthyroidism. In the absence of another evidence of liver disease, and when jaundice is purely due to the hyperthyroidism, thionamide drugs may be used with monitoring of serum bilirubin and liver function tests [5]. Newborns and adolescent patient were reported with jaundice/hyperbilirubinemia as manifestation of GD hyperthyroidism [6, 7, 8].
2.3 Polydipsia, nocturnal enuresis
Disturbance of water homeostasis can lead to polyuria-polydipsia syndrome, which is a diagnostic challenge. Polydipsia is a nonspecific symptom in various diseases, often accompanied by polyuria. Increased thirst and/or nocturnal enuresis can be the main complains, and a careful case history usually reveals the primary reason (disturbed input or output). Polydipsia has been described as a presenting symptom of hyperthyroidism in adults. A few years back a serendipitous identification of GD in identical twin girls with polydipsia was published [9]. Though etiology of nocturnal enuresis is not fully understood, evidence is growing that enuresis may have a central origin: bedwetting children have lower brainstem reflex control (impaired prepulse inhibition) than normal controls [10]. A case of a 9-year-old boy has been reported by the same team who suffered from hyperthyroidism and a new appearance of enuresis. Bedwetting ceased and prepulse inhibition – measured as a parameter of central control – increased during on course of anti-thyroid therapy [11]. In our praxis we experienced two GD cases where nighttime incontinence was the presenting feature of recurrent hyperthyroidism.
3. Rare concomitant disorders
3.1 Thyrotoxic periodic paralysis
Thyrotoxic periodic paralysis (TPP) is a rare disease of the muscles secondary to hyperthyroidism presenting sudden attacks of short-term muscle weakness, stiffness, or paralysis. The underlying mechanism is malfunctions in the ion channels in skeletal muscle cell membranes: An increased influx of potassium into skeletal muscle cells leads to profound hypokalemia and paralysis. Hypokalemia in thyrotoxic hypokalemic periodic paralysis (THPP) results from an intracellular shift of potassium and not total body depletion. The symptoms may be mild or severe, and they may last for minutes or days, involving the whole body or just one or both limbs. The severity of the disease does not correlate with the hormone levels, and muscle paralysis simply resolves by achieving the euthyroid state. TPP most frequently seen in Asian men and also reported in Hispanic adolescent males [12, 13]. Fatal outcome of a 10-years-old girl with delayed diagnosis of hyperthyroidism should draw attention to the awareness about this rare but potentially lethal disorder [14].
3.2 Encephalopathy
Presenting feature of encephalopathy in GD and Hashimoto’s thyroiditis would be similar (seizures, stroke-like episodes, cognitive decline, neuropsychiatric symptoms etc.) but characteristics of thyroid derangement is reversed. Thyroid function is not an issue in Hashimoto’s encephalopathy which is renamed now as ‘steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT)’, while brain dysfunction is associated to hyperthyroid state in GD. Hecht T and coworkers reported on a 7-year-old girl with generalized seizures, somnolence, fever, and respiratory distress. The increase of sinus tachycardia with good hydration, sufficient analgesia, and hyperthermia led to the determination of thyroid hormones, and therefore finally to the diagnosis of a thyrotoxic crisis in Graves’ Disease. Symptoms were disappeared by thyrostatic therapy [15]. They concluded that thyrotoxic crisis should be considered a differential diagnosis in case of resistant unexplained sinus tachycardia, seizures, and encephalopathy.
4. TSHR-blocking autoantibody (TBAb)
In Graves-Basedow’s patients TRAb stimulates thyroid hormone synthesis by activating the TSH receptor (stimulating TRAb /TSAb/, TSHR agonist). TSHR antibodies that lack agonistic activity but are competitive inhibitors of TSH binding can cause hypothyroidism (blocking TRAb/TBAb/, TSHR antagonist). There is a wide variety of TSHR antibody assays employed in the past and nowadays. Depending on the underlying method, two types of assays are important for determination of circulating autoantibodies: Competition for ligand binding or measuring bio-response. A rare history of monozygotic 10-year-old twins was published who presented with hyper- and hypothyroidism, respectively [16]. Both girls had antibodies against thyrotropin receptors as measured by a radioreceptor assay. Analyzing further the sera in a functional bioassay, the TSH receptor antibodies of the hyperthyroid twin displayed stimulatory activity typical of Graves’ Disease, while the antibodies of the hypothyroid twin acted as pure antagonists at the TSH receptor level. This is a proven pediatric case with hypothyroidism due to thyroid (or TSH)-blocking antibodies, where the pathogenesis was similar to GD. In the following 30 years an extensive work of research groups has led to significant improvements that has enabled bioassays to be employed routinely in clinical laboratories: 1, Two human monoclonal antibodies (MAbs) with TSHR agonist activity (M22 and K1-18), one human MAb with TSHR antagonist activity (K1-70) and one human MAb (5C9) with both TSHR antagonist and TSHR inverse agonist activity have been isolated [17]. 2, Currently available highly sensitive and specific assays to measure TRAbs use the human TSHR monoclonal antibody (Mab) M22 instead of the TSH [18]. Based on a research-use only service offered by RSR Limited, an adult case of woman with fluctuating hypo- and hyperthyroidism was published providing proof that a patient can produce a mixture of blocking and stimulating TSHR autoantibodies at the same time [19].
5. Metamorphic thyroid autoimmunity
Here we overview the phenomenon of metamorphic thyroid autoimmunity anticipating, that more investigational studies are needed to reveal the underlying mechanism, and larger epidemiological studies are needed to confirm that this finding is not unusual but is rather under-recognized in pediatric population. The term metamorphic thyroid autoimmunity was introduced by Ludgate M. and Emerson H. commenting cases with a conversion from Hashimoto thyroiditis (HT) to GD or vice versa [20, 21, 22]. A few years later Wasniewska M et al. aimed to ascertain HT in the history of GD children order to assess the relative frequency of this phenomenon [23]. Based on retrospective data of a cohort of 109 GB children and adolescents without coexistent chromosome abnormalities they calculated the frequency between 3 and 4%. Reporting results they confirmed the existence of a possible continuum between HT and GD within the spectrum of autoimmune thyroid diseases. In search of switching process from HT to GB in patient with either Turner syndrome (TS) or Down syndrome (DS) the same team found that antecedents of HT were significantly more common in chromosomopathy group (9/35 = 25.7%) compared to age-matched GD patients (4/109 = 3.7%) [24]. Guessing the clue of this immunological paradigm it should take into high consideration that attribute of HE is a cell-mediated destruction of thyroid tissue with hypo- or euthyroidism while GB is a TRAB-mediated gland activation presented in hyperthyroidism. In general, thyroid autoimmunity involves loss of tolerance to thyroid proteins in genetically susceptible individuals in association with environmental factors, no single mechanism explains the altered immune-reaction. Further immunological and genetic investigations can add explanatory information to this unusual pendulum swinging thyroid autoimmunity.
6. Peculiarities in Down syndrome
6.1 Asymptomatic vs. cumulative presentation
Thyroid derangement is the most frequently encountered endocrinopathy in Down syndrome (DS) affecting almost half of the patients (7 - 66%). Based on this fact the life-long monitoring of the thyroid function is recommended for all DS patients. Thyroid abnormalities encompass mainly any kind of hypothyroidism (congenital, primary, subclinical, or overt hypothyroidism), isolated hyperthyrotropinemia, Hashimoto thyroiditis or very rarely GD. Autoimmune thyroid disease is uncommon in young children with Down’s syndrome but is common after 8 years of age [25]. A Spanish group [26] reported on three DS children with GD: Two of them were asymptomatic for thyroid hyperfunction (a 14-year-old girl and an 8-year-old boy), while the third child (a 12-year-old girl) presented goiter, nervousness, weight loss and tachycardia. In addition to the typical features of hyperthyroidism, the patient showed right-side heart failure and elevated transaminases, which disappeared with antithyroid treatment. Though annual biochemical screening for early detection of thyroid hypofunction is reasonable, regular auxological and clinical assessment in syndromic patients is also important.
6.2 Metamorphic thyroid autoimmunity
HT and GB are two different disease entities in the spectrum of thyroid autoimmunity presenting dominantly with hypothyroidism (HT) or with hyperthyroidism (GB). A metamorphosis of both clinical and biochemical phenotype from HT to GD or vice versa has been discussed for more than 10 years [22] based on sporadic cases. A tapered Italian team conducted several retrospective studies to shed light on this phenomenon in pediatric population. In 2015 they published a research paper reconstructing the conversion process from HT to GD and the subsequent evolution of GD in a series of 12 children (7 girls/5 boys) with DS [27]. All patients fulfilled the criteria for diagnosis of HT and GD taking laboratory measurements and ultrasonography scan. Time interval between HT diagnosis and GB presentation ranged from 0.7 to 6.5 years, and Graves’ Disease showed a milder clinical and biochemical course in this cohort. Summing up they conclude that „1, DS children might be incline to manifest over time a phenotypic metamorphosis from HT to GH and to subsequently fluctuate from hyperthyroidism to hypothyroidism; 2) in DS GD may have a mild biochemical and clinical course” [27].
6.3 Unusual scenario
A DS case with an unusual thyroid constellation were published by Nebesio TD and Eugster EA. „ A 10-year-old girl with Down syndrome was diagnosed with congenital hypothyroidism in the newborn period due to left thyroid hemiagenesis. Unexpectedly, her hypothyroidism resolved at the age of 3 years. After being off thyroid hormone replacement for 7 years and having normal thyroid function, she developed Graves’ Disease with typical signs and symptoms of hyperthyroidism including diarrhea, inattention, and hyperactivity” [28]. This case highlights also the unpredictable course of thyroid disease which may occur in children with Down syndrome.
7. Coincidence in polyendocrinopathy APS3
The autoimmune polyglandular syndromes (APS1-4) encompass a wide clinical spectrum of disease with different (monogenic/complex) genetic etiologies and heterogeneous presentation. APS2 is defined by presence of primary adrenocortical insufficiency with either autoimmune thyroid disease or type 1 diabetes mellitus in the same patient. The clinical diagnosis of APS3 requires the presence of an autoimmune thyroid disease and an additional autoimmune illness other than Addison’s disease; a frequent combination is pernicious anemia, vitiligo, alopecia, myasthenia gravis and Sjögren sy. Thyroid disease purports a variety of thyroid disorders. Hypothyroidism is more common than Graves’ Disease, and GD tends to manifest at a younger age. Recently Klenczar K and coworkers reported on a 11-year-old female patient, who presented coincidence of T1DM with other autoimmune diseases, such as Graves-Basedow’s disease, myasthenia gravis, vitiligo, and IgA deficiency [29]. The clinical picture of this case fulfilled the criteria of autoimmune polyglandular syndrome type 3.
8. Unexpected coexistence
Stickler syndrome is a rare genetically heterogeneous disorder of the connective tissue, caused by abnormal synthesis of type II, XI, or IX collagen. It is characterized by a distinctive facial appearance, eye abnormalities, hearing loss and joint problems. Ocular involvements are early onset cataract, myopia, abnormal vitreous humor, retinal detachment, and most of the patients exhibit short stature. Onesimo R et al. reported on a 5-year-old girl affected by Stickler syndrome who was diagnosed with GD in preclinical state, during health supervision and evaluation by pediatric endocrinologist for short stature [30]. None of her family member suffered from autoimmune thyroid disorder and her medical history was negative for autoimmune disease. Association between Stickler’s syndrome and GD in this case seems to be an incidental coexistence.
9. Reconstitution Graves’ Disease
Reviewing the manuscripts on Graves’ Disease and rare comorbidity, a new issue has been raised. Growing numbers of publication on the association between biological treatment for life-threatening and/or medication-refractory disorders, and the development of autoimmune hyperthyroidism in adults, call the attention to secondary GD [31, 32]. The use of different modality targeting the immune system as a curative therapy (e.g. hematopoietic stem cell transplantation /HSCT/, antithymocite globulin/ATG/, antiretroviral therapy/ART/etc.), has had a profound impact on clinical outcomes. A subset of patients may experience immune restoration disease (IRD)/immune reconstitution inflammatory syndrome (IRIS) affecting the thyroid gland in two form, such as Hashimoto thyroiditis or Graves’ hyperthyroidism. Although both are more common in children because of early thymic damage, it has received little attention in pediatric literature [33]. Sporadic cases were reported on challenging autoimmune processes: Defective T-cell function take place during the pathogenesis both of aplastic anemia (AA) and GD. Antithyroid drugs used for the management of GD may induce AA and GD may occur following treatment of severe aplastic anemia (SAA). The latter occurred in a 11-year-old girl who had been treated with allogenic HSCT at age of 8 years as having severe acquired AA [34]. A case of another child was published earlier with chronic relapsing severe aplastic anemia and GD [35]. Authors supposed a close relation in manifestation of hypertyroidism due to withdrawal of immunosuppressants. In adult patients the secondary GD may exhibit a fluctuating course, with alternating phases of hyper- and hypothyroidism, due to the coexistence of TRAb with stimulating and blocking function [36]. Clinicians need to remain vigilant when initiating immune reconstitution therapy, and a careful management and follow-up for thyroid function after these treatments are essential.
10. Discussion
In this chapter we presented a spectrum of unusual clinical findings, signs of Graves-Basedow’s disease in childhood, but atypical laboratory results. Less common and less distinctive features detailed above are well documented in adults, which suggests that these are neither age-dependent nor characteristic to pediatric GD. Though the mechanism remains uncertain in majority of unusual manifestations, the recovery that occurs parallelly with restoration of euthyroidism, gives the evidence of their relation to GB hyperthyroidism. Metamorphic thyroid autoimmunity, a phenomenon of conversion from Hashimoto thyroiditis to Graves’ Disease is also summarized without guessing the clue of this immunological paradigm. Existence of a continuum between HT and GD within the spectrum of thyroid autoimmunity is confirmed in pediatric population without coexistent chromosome abnormalities, also in children with Turner or Down syndrome. Beside this peculiar event sequence, GD in DS patient can be insidious by presenting delayed clinical symptoms even with multiple organ derangements. In some rare syndromic disorder regular clinical assessment and biochemical screening supports to reveal the occurrence of Graves’ hyperthyroidism. Finally, a very vulnerable population with malignancy, immune deficiency syndromes, hemoglobinopathies and other disorders attract attention with a possible secondary GB following immune reconstitution therapy. Awareness about the relation of these remote findings to GD, or frequent coexistence with GD is important for early diagnosis, and a reasonable suspicion for Graves’ Disease may ultimately help to prevent unnecessary investigations and treatment.
\n',keywords:"hyperthyroidism, thyrotoxicosis, thyroid autoimmunity, antibodies, rare disorder, Hashimoto thyroiditis, Turner syndrome, Down syndrome, reconstitution GD, children",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/76595.pdf",chapterXML:"https://mts.intechopen.com/source/xml/76595.xml",downloadPdfUrl:"/chapter/pdf-download/76595",previewPdfUrl:"/chapter/pdf-preview/76595",totalDownloads:171,totalViews:0,totalCrossrefCites:0,dateSubmitted:"January 8th 2021",dateReviewed:"April 5th 2021",datePrePublished:"May 13th 2021",datePublished:"December 1st 2021",dateFinished:"May 5th 2021",readingETA:"0",abstract:"Graves’-Basedow’s disease (GD) is a well-defined hyperthyroid disorder caused by circulating antibodies that results the overproduction of thyroid hormones. All but a few children present with some degree of thyroid gland enlargement and most have two or more signs of excessive thyroid activity, such as tremor, irritability/nervousness, tachycardia etc. Fully developed clinical picture is easy to recognize while often the onset is insidious. Thyroid hormones affect many body systems, so signs and symptoms of Graves’ disease can be wide ranging. A survey on PubMed literature was conducted to gather all published pediatric Graves-Basedow’s cases with unusual presentation at the time of diagnosis. We found all together 70 manuscripts with relevant information from 1978 to 2020 but mainly adult cases. One third of them were found to meet the criteria we focused on and were included in this paper, though in some situation the unusual findings do not consist part of hyperthyroidism, the rare manifestation is only a coexistence, or the serious disease even precedes the GD. Dermatopathy, hepatic dysfunction, impaired fluid balance, concomitant disorders in thyrotoxicosis, tricky laboratory findings, a phenomenon of metamorphic thyroid autoimmunity, peculiarities of thyroid dysfunction in children with Down syndrome, apparent associations, and reconstitution GD are highlighted in this chapter. Awareness about the relation of these remote findings to GD, or frequent coexistence with GD is important for early diagnosis. Finally, a reasonable suspicion for Graves’ disease may ultimately help to prevent unnecessary investigations and treatment.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/76595",risUrl:"/chapter/ris/76595",signatures:"Agota Muzsnai",book:{id:"10312",type:"book",title:"Graves' Disease",subtitle:null,fullTitle:"Graves' Disease",slug:"graves-disease",publishedDate:"December 1st 2021",bookSignature:"Robert Gensure",coverURL:"https://cdn.intechopen.com/books/images_new/10312.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83968-774-7",printIsbn:"978-1-83968-773-0",pdfIsbn:"978-1-83968-775-4",isAvailableForWebshopOrdering:!0,editors:[{id:"16515",title:"Dr.",name:"Robert",middleName:null,surname:"Gensure",slug:"robert-gensure",fullName:"Robert Gensure"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"161205",title:"Dr.",name:"Ágota",middleName:null,surname:"Muzsnai",fullName:"Ágota Muzsnai",slug:"agota-muzsnai",email:"muzsnaia@freemail.hu",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Unusual signs and symptoms",level:"1"},{id:"sec_2_2",title:"2.1 Dermopathy and acropachy",level:"2"},{id:"sec_3_2",title:"2.2 Cholestasis",level:"2"},{id:"sec_4_2",title:"2.3 Polydipsia, nocturnal enuresis",level:"2"},{id:"sec_6",title:"3. Rare concomitant disorders",level:"1"},{id:"sec_6_2",title:"3.1 Thyrotoxic periodic paralysis",level:"2"},{id:"sec_7_2",title:"3.2 Encephalopathy",level:"2"},{id:"sec_9",title:"4. TSHR-blocking autoantibody (TBAb)",level:"1"},{id:"sec_10",title:"5. Metamorphic thyroid autoimmunity",level:"1"},{id:"sec_11",title:"6. Peculiarities in Down syndrome",level:"1"},{id:"sec_11_2",title:"6.1 Asymptomatic vs. cumulative presentation",level:"2"},{id:"sec_12_2",title:"6.2 Metamorphic thyroid autoimmunity",level:"2"},{id:"sec_13_2",title:"6.3 Unusual scenario",level:"2"},{id:"sec_15",title:"7. Coincidence in polyendocrinopathy APS3",level:"1"},{id:"sec_16",title:"8. Unexpected coexistence",level:"1"},{id:"sec_17",title:"9. Reconstitution Graves’ Disease",level:"1"},{id:"sec_18",title:"10. Discussion",level:"1"}],chapterReferences:[{id:"B1",body:'[Bartalena L, Fatourechi V: Extrathyroidal manifestations of Graves\' disease: a 2014 update. J Endocrinol Invest. 2014 Aug;37(8):691-700. doi: 10.1007/s40618-014-0097-2. Epub 2014 Jun 10]'},{id:"B2",body:'[Kraus CN, Sodha P, Vaidyanathan P, Kirkorian AY: Thyroid dermopathy and acropachy in pediatric patients. Pediatr Dermatol. 2018 Nov;35(6):e371-e374. doi: 10.1111/pde.13670. Epub 2018 Sep 6. PMID: 30187962]'},{id:"B3",body:'[Malik R and Hodgson H: The relationship between the thyroid gland and the liver. QJM, vol. 95, no. 9, pp. 559-569, 2002]'},{id:"B4",body:'[Owen PJ, Baghomian A, Lazarus JH, Godkin AJ: An unusual cause of jaundice. British Medical Journal, vol. 335, no. 7623, pp. 773-774, 2007]'},{id:"B5",body:'[Hegazi MO, Ahmed S: Atypical clinical manifestations of Graves\' disease: An analysis in depth. J Thyroid Res. 2012; 2012: 768019. Published online 2011 Nov 1. doi: 10.1155/2012/768019 PMCID: PMC3206356]'},{id:"B6",body:'[Beroukhim RS, Moon TD, Felner EI: Neonatal thyrotoxicosis and conjugated hyperbilirubinemia. J Matern Fetal Neonatal Med. 2003;13(6):426-428]'},{id:"B7",body:'[Loomba-Albrecht LA, Bremer AA, Wong A, Philippset AF: Neonatal cholestasis due to hyperthyroidism: an unusual case and clinical implications. J Pediatr Gastroenterol Nutr 2012;54:433-434]'},{id:"B8",body:'[Regelmann MO, Miloh T, Arnon R, Morotti R, Kerkar N, Rapaport R: Graves\' disease presenting with severe cholestasis. Thyroid. 2012 Apr;22(4):437-439. doi: 10.1089/thy.2011.0267]'},{id:"B9",body:'[Goldyn AK, Eugster EA, Nebesio TD: Serendipitous identification of Graves\' disease in identical twins with polydipsia. 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After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. 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In-service vehicles equipped with sensors and GPS systems can act as probes to detect and analyse real-time vehicle vibration. Recently, a compact on-board sensing device has been developed. This chapter describes the track condition monitoring system that uses a compact on-board sensing device and diagnosis software. The diagnosis software provides the function of detecting track faults using the root mean square (RMS) of the car-body acceleration. It also allows analysis in the time-frequency domain using wavelet transform. A monitoring experiment in a local railway line showed that the system is effective for practical application.",book:{id:"4789",slug:"railway-research-selected-topics-on-development-safety-and-technology",title:"Railway Research",fullTitle:"Railway Research - Selected Topics on Development, Safety and Technology"},signatures:"Hitoshi Tsunashima, Hirotaka Mori, Masayuki Ogino and Akira\nAsano",authors:[{id:"49517",title:"Prof.",name:"Hitoshi",middleName:null,surname:"Tsunashima",slug:"hitoshi-tsunashima",fullName:"Hitoshi Tsunashima"}]},{id:"59302",doi:"10.5772/intechopen.74277",title:"Model-Based Fault Analysis for Railway Traction Systems",slug:"model-based-fault-analysis-for-railway-traction-systems",totalDownloads:1384,totalCrossrefCites:1,totalDimensionsCites:5,abstract:"Fault analysis in industrial equipment has been usually performed using classical techniques such as failure modes and effects analysis (FMEA) and fault tree analysis (FTA). Model-based fault analysis has been used during the last several years in order to overcome the limitations of classical methods when complex industrial equipment has to be analyzed. In railway and automotive sectors, the development and validation of new products are based on hardware-in-the-loop (HIL) platforms. In this chapter, a methodology to enhance classical FMEAs is presented. Based on HIL simulations, the objective is to improve the results of the fault analysis with quantitative information about the effects of each fault mode. In this way, the impact of the fault analysis in the design of the traction system, the development of new diagnostic functionalities and in the maintenance tasks will increase.",book:{id:"6065",slug:"modern-railway-engineering",title:"Modern Railway Engineering",fullTitle:"Modern Railway Engineering"},signatures:"Jon del Olmo, Fernando Garramiola, Javier Poza and Gaizka\nAlmandoz",authors:[{id:"149511",title:"Dr.",name:"Gaizka",middleName:null,surname:"Almandoz",slug:"gaizka-almandoz",fullName:"Gaizka Almandoz"},{id:"149644",title:"Dr.",name:"Javier",middleName:null,surname:"Poza",slug:"javier-poza",fullName:"Javier Poza"},{id:"235660",title:"Dr.",name:"Jon",middleName:null,surname:"Del Olmo",slug:"jon-del-olmo",fullName:"Jon Del Olmo"},{id:"241062",title:"Mr.",name:"Fernando",middleName:null,surname:"Garramiola",slug:"fernando-garramiola",fullName:"Fernando Garramiola"}]},{id:"49375",doi:"10.5772/61517",title:"Experimental and Simulation Study of the Superstructure and Its Components",slug:"experimental-and-simulation-study-of-the-superstructure-and-its-components",totalDownloads:2553,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"The issues discussed in this chapter are of interest of both the manufacturers and the experts responsible for condition of the track superstructure. In general, stress in steel elements may affect the energy state, phase changes, and corrosion. It may reduce fatigue strength and cause damage and cracks of the rails. It is one of the causes of accelerated development of standard railhead defects. Proper selection of, e.g., bending process parameters provides uniform distribution and acceptable level of residual stresses in the bent components. Residual stresses that develop during manufacturing process in the railway turnout steel components can change their strength properties. The first part of this chapter presents ultrasonic measurement method and computer simulation that allowed to develop a method to diagnose state and distribution of residual stresses in steel components of the railway turnout (wing rails and switch blades) in the production process. The second part of this chapter includes experimental and simulation studies of superstructure in operational conditions. A track substructure with a crashed stone composite is a solution of reinforced standard track substructure. The results are used to draw conclusions concerning further development and possible modifications of a proposed solution. A significant number of simulation calculations also allow to determine the duration of guaranteed functionality of a reinforced track substructure.",book:{id:"4789",slug:"railway-research-selected-topics-on-development-safety-and-technology",title:"Railway Research",fullTitle:"Railway Research - Selected Topics on Development, Safety and Technology"},signatures:"Jacek Kukulski",authors:[{id:"175842",title:"Ph.D.",name:"Jacek",middleName:null,surname:"Kukulski",slug:"jacek-kukulski",fullName:"Jacek Kukulski"}]},{id:"49716",doi:"10.5772/62080",title:"A Systems View of Railway Safety and Security",slug:"a-systems-view-of-railway-safety-and-security",totalDownloads:4110,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"This chapter approaches the concerns over safety and security of modern mainline and light railways from a systems perspective. It addresses the two key concerns from the view point of systemic emergence arising from the interaction between all the principal constituents of the railway system, namely infrastructure, rolling stock, energy and human element comprising workers, passengers and the neighbours of the railways.",book:{id:"4789",slug:"railway-research-selected-topics-on-development-safety-and-technology",title:"Railway Research",fullTitle:"Railway Research - Selected Topics on Development, Safety and Technology"},signatures:"Ali G. Hessami",authors:[{id:"108303",title:"Prof.",name:"Ali G.",middleName:null,surname:"Hessami",slug:"ali-g.-hessami",fullName:"Ali G. Hessami"}]},{id:"57840",doi:"10.5772/intechopen.71768",title:"Advanced Train Positioning/Communication System",slug:"advanced-train-positioning-communication-system",totalDownloads:1660,totalCrossrefCites:3,totalDimensionsCites:3,abstract:"In the past, in order to ensure train positioning as well as ground-to-train information exchange, railways have adopted various technologies. Over time, each new generation of equipment enriched the global information exchange but, as a consequence, necessitated higher data rate transfers. For the positioning functionality, the existing localisation systems are still limited, since most of them require an infrastructure installation with constraints such as laying equipment between the rails or having high database maintenance requirements and computational costs. Moreover, some of them accumulate errors (odometers and inertial sensors) or offer limited coverage in shadowed areas (GNSS, etc.). Currently, in railway applications, a widely used localization system is based on proprioceptive sensors embarked in the train. This on-board system is coupled to the use of balises located at ground between the rails. These balises are kilometre markers. They are used to compensate for the drift of the localization information computed using the proprioceptive sensors alone, when the train moves. The balises provide absolute localization information whenever the train passes over them. They can also provide spot communication during the short period of time when trains are passing over them. In the first part of this chapter, techniques for achieving train positioning and data exchanges between trains and infrastructure are introduced. In the second part, a new balise is proposed. Particular attention is paid to the contribution of this new solution in terms of localization error and communication performances.",book:{id:"6065",slug:"modern-railway-engineering",title:"Modern Railway Engineering",fullTitle:"Modern Railway Engineering"},signatures:"Fouzia Elbahhar and Marc Heddebaut",authors:[{id:"140822",title:"Dr.",name:"Fouzia",middleName:null,surname:"Elbahhar",slug:"fouzia-elbahhar",fullName:"Fouzia Elbahhar"}]}],mostDownloadedChaptersLast30Days:[{id:"57056",title:"Transmission-Based Signaling Systems",slug:"transmission-based-signaling-systems",totalDownloads:3049,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"In this chapter, we describe the principal communication systems applied to the transmission-based signaling (TBS) systems for railways. Typical examples are communication-based train control (CBTC), European Rail Traffic Management System (ERTMS), and distance to go (DTG). Moreover, to properly address some of the challenges that need to face these systems, we will provide a deep insight on propagation issues related to all the environments (urban, suburban, rural, tunnel, etc.). We will highlight all the communication-related issues and the operational as well. Finally, a detailed survey on the directions of research on all these topics is provided, in order to properly cover this interesting subject. In this research, hot topics like virtual coupling are explained as well.",book:{id:"6065",slug:"modern-railway-engineering",title:"Modern Railway Engineering",fullTitle:"Modern Railway Engineering"},signatures:"Cesar Briso-Rodríguez, Juan Moreno García-Loygorri and Lei Zhang",authors:[{id:"171013",title:"Dr.",name:"Cesar",middleName:null,surname:"Briso",slug:"cesar-briso",fullName:"Cesar Briso"},{id:"216915",title:"Dr.",name:"Juan",middleName:null,surname:"Moreno Garcia-Loygorri",slug:"juan-moreno-garcia-loygorri",fullName:"Juan Moreno Garcia-Loygorri"},{id:"216916",title:"Dr.",name:"Lei",middleName:null,surname:"Zhang",slug:"lei-zhang",fullName:"Lei Zhang"}]},{id:"49375",title:"Experimental and Simulation Study of the Superstructure and Its Components",slug:"experimental-and-simulation-study-of-the-superstructure-and-its-components",totalDownloads:2553,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"The issues discussed in this chapter are of interest of both the manufacturers and the experts responsible for condition of the track superstructure. In general, stress in steel elements may affect the energy state, phase changes, and corrosion. It may reduce fatigue strength and cause damage and cracks of the rails. It is one of the causes of accelerated development of standard railhead defects. Proper selection of, e.g., bending process parameters provides uniform distribution and acceptable level of residual stresses in the bent components. Residual stresses that develop during manufacturing process in the railway turnout steel components can change their strength properties. The first part of this chapter presents ultrasonic measurement method and computer simulation that allowed to develop a method to diagnose state and distribution of residual stresses in steel components of the railway turnout (wing rails and switch blades) in the production process. The second part of this chapter includes experimental and simulation studies of superstructure in operational conditions. A track substructure with a crashed stone composite is a solution of reinforced standard track substructure. The results are used to draw conclusions concerning further development and possible modifications of a proposed solution. A significant number of simulation calculations also allow to determine the duration of guaranteed functionality of a reinforced track substructure.",book:{id:"4789",slug:"railway-research-selected-topics-on-development-safety-and-technology",title:"Railway Research",fullTitle:"Railway Research - Selected Topics on Development, Safety and Technology"},signatures:"Jacek Kukulski",authors:[{id:"175842",title:"Ph.D.",name:"Jacek",middleName:null,surname:"Kukulski",slug:"jacek-kukulski",fullName:"Jacek Kukulski"}]},{id:"59304",title:"Improving Feasibility of High-Speed Train Project: Creating Added Value",slug:"improving-feasibility-of-high-speed-train-project-creating-added-value",totalDownloads:1471,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"Infrastructure plays a significant role in increasing economic development by providing access of transportation and improving connectivity. High-speed train (HST), one of mega infrastructure projects, has a positive impact on economic development of a nation. However, the project feasibility requires the maximum value for money and an acceptable risk to attract private investors. This study aims to improve the feasibility of the project by producing a conceptual design of Jakarta-Surabaya high-speed train in Indonesia. Value engineering will be used to evaluate both technical and financial aspects of the project. The methodology uses both qualitative and quantitative approaches through a case study, in-depth interviews, and life-cycle cost analysis. The result shows an optimum route sketching for the project and potential added value to the project. It consists of the solar cell, fiber optic, tourism, and transit-oriented development. The output also generates the division of responsibility between the government and business entity during the project lifecycle regarding the project financing. The institutional scheme will regulate the position and roles for each related stakeholder that was involved in the HST project development.",book:{id:"6065",slug:"modern-railway-engineering",title:"Modern Railway Engineering",fullTitle:"Modern Railway Engineering"},signatures:"Mohammed Ali Berawi",authors:[{id:"207251",title:"Dr.",name:"Mohammed Ali",middleName:null,surname:"Berawi",slug:"mohammed-ali-berawi",fullName:"Mohammed Ali Berawi"}]},{id:"57840",title:"Advanced Train Positioning/Communication System",slug:"advanced-train-positioning-communication-system",totalDownloads:1660,totalCrossrefCites:3,totalDimensionsCites:3,abstract:"In the past, in order to ensure train positioning as well as ground-to-train information exchange, railways have adopted various technologies. Over time, each new generation of equipment enriched the global information exchange but, as a consequence, necessitated higher data rate transfers. For the positioning functionality, the existing localisation systems are still limited, since most of them require an infrastructure installation with constraints such as laying equipment between the rails or having high database maintenance requirements and computational costs. Moreover, some of them accumulate errors (odometers and inertial sensors) or offer limited coverage in shadowed areas (GNSS, etc.). Currently, in railway applications, a widely used localization system is based on proprioceptive sensors embarked in the train. This on-board system is coupled to the use of balises located at ground between the rails. These balises are kilometre markers. They are used to compensate for the drift of the localization information computed using the proprioceptive sensors alone, when the train moves. The balises provide absolute localization information whenever the train passes over them. They can also provide spot communication during the short period of time when trains are passing over them. In the first part of this chapter, techniques for achieving train positioning and data exchanges between trains and infrastructure are introduced. In the second part, a new balise is proposed. Particular attention is paid to the contribution of this new solution in terms of localization error and communication performances.",book:{id:"6065",slug:"modern-railway-engineering",title:"Modern Railway Engineering",fullTitle:"Modern Railway Engineering"},signatures:"Fouzia Elbahhar and Marc Heddebaut",authors:[{id:"140822",title:"Dr.",name:"Fouzia",middleName:null,surname:"Elbahhar",slug:"fouzia-elbahhar",fullName:"Fouzia Elbahhar"}]},{id:"49716",title:"A Systems View of Railway Safety and Security",slug:"a-systems-view-of-railway-safety-and-security",totalDownloads:4110,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"This chapter approaches the concerns over safety and security of modern mainline and light railways from a systems perspective. 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He also obtained an MSc in Molecular and Genetic Medicine, and a Ph.D. in Clinical Immunology and Human Genetics from the University of Sheffield, UK. He also completed a short-term fellowship in Pediatric Clinical Immunology and Bone Marrow Transplantation at Newcastle General Hospital, England. Dr. Rezaei is a Full Professor of Immunology and Vice Dean of International Affairs and Research, at the School of Medicine, Tehran University of Medical Sciences, and the co-founder and head of the Research Center for Immunodeficiencies. He is also the founding president of the Universal Scientific Education and Research Network (USERN). Dr. Rezaei has directed more than 100 research projects and has designed and participated in several international collaborative projects. He is an editor, editorial assistant, or editorial board member of more than forty international journals. He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. 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