Atherosclerosis-related cardiovascular or cerebrovascular diseases
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Barely three months into the new year and we are happy to announce a monumental milestone reached - 150 million downloads.
\n\nThis achievement solidifies IntechOpen’s place as a pioneer in Open Access publishing and the home to some of the most relevant scientific research available through Open Access.
\n\nWe are so proud to have worked with so many bright minds throughout the years who have helped us spread knowledge through the power of Open Access and we look forward to continuing to support some of the greatest thinkers of our day.
\n\nThank you for making IntechOpen your place of learning, sharing, and discovery, and here’s to 150 million more!
\n\n\n\n\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"7126",leadTitle:null,fullTitle:"Prostatectomy",title:"Prostatectomy",subtitle:null,reviewType:"peer-reviewed",abstract:"The prostate gland is one of the male organs that have changed over the years. Those changes lead to a disruption of the quality of life and risk of prostate cancer in men over 50 years of age. In the era of prostate-specific antigen it is possible to overcome prostate cancer through early diagnosis. This made it possible to treat the diagnosis of prostate cancer and prevent the development of prostate cancer disease in the patient. In addition, early diagnosis has led to advances in the technological development of the basic surgical technique - prostatectomy. This book contains the efforts of a number of doctors and scientists interested in the prostate gland from different countries around the world. Some of these studies are likely to pose new challenges and trends in the diagnosis of the prostate gland and basic surgical technique.",isbn:"978-1-83880-685-9",printIsbn:"978-1-83880-684-2",pdfIsbn:"978-1-83880-686-6",doi:"10.5772/intechopen.73923",price:119,priceEur:129,priceUsd:155,slug:"prostatectomy",numberOfPages:184,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"ffd82b0f0d267e6d98b8c68afebbd7b2",bookSignature:"Tsvetin Genadiev",publishedDate:"May 29th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/7126.jpg",numberOfDownloads:9810,numberOfWosCitations:3,numberOfCrossrefCitations:6,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:12,numberOfDimensionsCitationsByBook:0,hasAltmetrics:0,numberOfTotalCitations:21,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 14th 2018",dateEndSecondStepPublish:"March 7th 2018",dateEndThirdStepPublish:"May 6th 2018",dateEndFourthStepPublish:"July 25th 2018",dateEndFifthStepPublish:"September 23rd 2018",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"29780",title:"Associate Prof.",name:"Tsvetin",middleName:"Trifonov",surname:"Genadiev",slug:"tsvetin-genadiev",fullName:"Tsvetin Genadiev",profilePictureURL:"https://mts.intechopen.com/storage/users/29780/images/6739_n.jpg",biography:"Dr. Tsvetin Genadiev attended the High Medical Education at High Medical University, Faculty of Medicine, Sofia, Bulgaria from 1987 till 1994. From 1994 till 1998 he had a Residency training in Urology at High Military Medical Academy, Sofia, Bulgaria.\nHis interests are Prostate, Prostate Cancer and BPH, Diagnosis, Laparoscopic Urology, Radical prostatectomy, HDR Brachytherapy in prostate cancer and Thulium Laser prostate surgery.\nIn 2007 he obtained a PhD Degree in Laparoscopic Lymph Node Dissection in Prostate Cancer and in 2010 he became Associate Professor of Urology at University of Sofia, Bulgaria.\nHe has published many papers on Laparoscopy, Laparoscopic Extraperitoneal Approach for Urinary Bladder, and Stones Removal. He has also published a monograph on Laparoscopic Urology and is Editorial boards member of few Medical Journals. Dr. Genadiev is currently consultant urologist in Vita Hospital, Sofia, Bulgaria.",institutionString:null,position:"Consultant urologist",outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"1",institution:null}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1079",title:"Genitourinary Oncology",slug:"genitourinary-oncology"}],chapters:[{id:"64354",title:"Introductory Chapter: Prostatectomy - Challenge in the Past and Today",doi:"10.5772/intechopen.81804",slug:"introductory-chapter-prostatectomy-challenge-in-the-past-and-today",totalDownloads:810,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:null,signatures:"Tsvetin Trifonov Genadiev",downloadPdfUrl:"/chapter/pdf-download/64354",previewPdfUrl:"/chapter/pdf-preview/64354",authors:[{id:"29780",title:"Associate Prof.",name:"Tsvetin",surname:"Genadiev",slug:"tsvetin-genadiev",fullName:"Tsvetin Genadiev"}],corrections:null},{id:"62783",title:"Biomarkers for Diagnosis and Prognosis of Prostate Cancer",doi:"10.5772/intechopen.79726",slug:"biomarkers-for-diagnosis-and-prognosis-of-prostate-cancer",totalDownloads:2145,totalCrossrefCites:4,totalDimensionsCites:8,hasAltmetrics:1,abstract:"Since its discovery, elevated prostate-specific antigen (PSA) has been the measurement to indicate possibility of prostate cancer, as well as biochemical recurrence following treatment. Although PSA has led to decrease in prostate cancer–related mortalities, PSA is a nonspecific prostate cancer biomarker reflective of other prostate-related conditions such as benign prostatic hyperplasia (BPH), resulting in a high false-positive rate. This has led to overtreatment of men with clinically insignificant disease. While most prostate cancer patients have slowly progressive disease and should be treated conservatively, roughly 10% of patients will progress to have metastatic disease, of which the majority of prostate cancer deaths can be attributed. Stratifying these patients based on prognosis so that they may benefit from aggressive treatment is critical to their survival. Biomarkers for prostate cancer diagnosis and subsequent prognostic screening have significantly advanced this field. Here, we review some of the current blood, tissue, and urine biomarker tools used to measure an array of molecules including DNA, RNA, protein, or even epigenetic modifications. Utilizing the technologies described here, as well as looking to the future, correct early identification of prostate cancer with powerful prognostic value is much closer than ever before.",signatures:"Meghan A. Rice and Tanya Stoyanova",downloadPdfUrl:"/chapter/pdf-download/62783",previewPdfUrl:"/chapter/pdf-preview/62783",authors:[null],corrections:null},{id:"62261",title:"Pre-Therapeutic Dosimetry Employing Scandium-44 for Radiolabeling PSMA-617",doi:"10.5772/intechopen.79157",slug:"pre-therapeutic-dosimetry-employing-scandium-44-for-radiolabeling-psma-617",totalDownloads:1010,totalCrossrefCites:0,totalDimensionsCites:2,hasAltmetrics:0,abstract:"In recent years, the positron emitter scandium-44 moved into the focus of research providing favorable nuclide properties for an application in nuclear medicine. Radiolabeling of PSMA-617 with scandium-44 as diagnostic match for [177Lu]Lu-PSMA-617 instead of gallium-68 would enable pre-therapeutic dosimetry in clinical setting. Due to the chemical similarities of scandium and lutetium, the in vitro and in vivo characteristics of [177Lu]Lu-PSMA-617 are more similar to [44Sc]Sc-PSMA-617 than to the 68Ga-compounds [68Ga]Ga-PSMA-617 or [68Ga]Ga-PSMA-11. [44Sc]Sc-PSMA-617 showed its potential in a clinical setting as a PET imaging agent of prostate cancer providing several advantages over gallium-68 labeled tracers. The longer half-life of the nuclide would allow, for example, an optimized patient management and treatment, long-term or late time point imaging as well as transportation to more distant PET centers. However, especially clinical applications like individual dosimetry or intraoperative applications are still under investigation.",signatures:"Elisabeth Eppard",downloadPdfUrl:"/chapter/pdf-download/62261",previewPdfUrl:"/chapter/pdf-preview/62261",authors:[{id:"245845",title:"Dr.",name:"Elisabeth",surname:"Eppard",slug:"elisabeth-eppard",fullName:"Elisabeth Eppard"}],corrections:null},{id:"62775",title:"Bipolar Endoscopic Enucleation of Big Benign Prostate Enlargement",doi:"10.5772/intechopen.79125",slug:"bipolar-endoscopic-enucleation-of-big-benign-prostate-enlargement",totalDownloads:918,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Large benign prostatic enlargement (BPE) has been a major health problem and the surgical management could be technically challenging to urologists due to the limitation of conventional monopolar transurethral resection of prostate. Bipolar endoscopic enucleation of prostate aimed to remove the adenoma of BPE by stepwise adenoma devascularization and maximal adenoma removal through minimally invasive surgery. In this chapter we described the general principle, the surgical techniques of bipolar endoscopic enucleation and the related modifications of the technique in the recent years. As compared with open prostatectomy, bipolar endoscopic enucleation avoided the wound complications but achieved similar functional outcome. Bipolar endoscopic enucleation also allowed much more adenoma removal comparing with transurethral resection of the prostate. Unlike Holmium laser or thulium laser enucleation of the prostate, the required instruments for bipolar endoscopic enucleation of the prostate were familiar and more readily available to most urologists.",signatures:"Wai Hee Steve Chan, Chi Fai Kan and Churk Fai Trevor Li",downloadPdfUrl:"/chapter/pdf-download/62775",previewPdfUrl:"/chapter/pdf-preview/62775",authors:[null],corrections:null},{id:"62468",title:"Laparoscopic Simple Prostatectomy",doi:"10.5772/intechopen.79549",slug:"laparoscopic-simple-prostatectomy",totalDownloads:992,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Benign prostatic hyperplasia (BPH) is the most common benign tumor and cause of urinary retention in middle-aged male patients. Transurethral resection of the prostate (TURP) is the gold standard surgical treatment for benign prostatic obstruction. Although widely performed, TURP is associated with significant morbidity. Open prostatectomy is performed in larger glands, which are more than 80 grams, with higher morbidity. Advances in technology, such as holmium laser enucleation of the prostate (HoLEP) and KTP laser vaporization, are other options that are widely used despite their limitations. Laparoscopic simple prostatectomy (LSP) is a minimally invasive treatment option with equivalent functional outcomes and is useful in larger prostatic adenomas, with low morbidity in experienced hands.",signatures:"Yusuf Ilker Comez",downloadPdfUrl:"/chapter/pdf-download/62468",previewPdfUrl:"/chapter/pdf-preview/62468",authors:[null],corrections:null},{id:"64606",title:"Endoscopic Extraperitoneal Transvesicocapsular Adenomectomy of Prostate (EETAP): A New Operative Method with an Innovative Learning Protocol for Its Performance",doi:"10.5772/intechopen.82225",slug:"endoscopic-extraperitoneal-transvesicocapsular-adenomectomy-of-prostate-eetap-a-new-operative-method",totalDownloads:970,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The standard surgical treatment of obstructive symptoms of the lower urinary tract by benign prostatic hyperplasia is transurethral resection or classical simple prostatectomy. Inspired by our experience with laparoscopic radical prostatectomy and for the protection of urethra from stricture during prolonged transurethral resection, we studied the literature and started a prospective study for performing a laparoscopic simple prostatectomy. Following informed patient consent, we performed laparoscopic extraperitoneal simple prostatectomy in 17 patients with moderate to severe obstructive symptoms of benign prostatic hyperplasia with a prostate volume of over 80 ml. We did not find a laparoscopic technique for a simple prostatectomy which is the same as our method that we describe and publish. We called our method endoscopic extraperitoneal transvesicocapsular adenomectomy of prostate. We identified an abbreviation for the method of its popularization and systematic presentation, EETAP. In this chapter, we publish for the first time in the literature a minimally invasive surgical method for endoscopic extraperitoneal transvesicocapsular prostate adenоmectomy. We describe and publish the details of the method, the abbreviation of the method, an innovative learning protocol for its performance, as well as hypotheses for preoperative and intraoperative differential diagnosis. In our opinion, a multicenter study of this method could lead to its standardization in the broad urological practice.",signatures:"Genadiev Tsvetin Trifonov",downloadPdfUrl:"/chapter/pdf-download/64606",previewPdfUrl:"/chapter/pdf-preview/64606",authors:[{id:"29780",title:"Associate Prof.",name:"Tsvetin",surname:"Genadiev",slug:"tsvetin-genadiev",fullName:"Tsvetin Genadiev"}],corrections:null},{id:"62329",title:"Reduced Port Extraperitoneal Laparoscopic Radical Prostatectomy",doi:"10.5772/intechopen.79364",slug:"reduced-port-extraperitoneal-laparoscopic-radical-prostatectomy",totalDownloads:939,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Robot-assisted laparoscopic prostatectomy (RALP) is more popular than laparoscopic radical prostatectomy (LRP) in twenty-first century. However, RALP is still an expensive surgery. Open radical prostatectomy (ORP) was a gold standard and not an expensive surgery. However, ORP is not minimum invasive. LRP is relative expensive and minimum invasive. The problem of RALP or LRP is necessary to spread the wound for removing prostate and the pain of wound is often a problem. Using U-shaped incision at umbilicus, spreading the wound is not necessary to remove prostate. Single-port surgery is a challenging procedure for surgeons in spite of faster recovery and higher patient satisfaction than conventional laparoscopy. Adding one or two port, reduced port surgery is easier than single-port surgery. Reduced port LRP is an extension of conventional LRP. The procedure is as same as conventional LRP. Curved or flexible instruments are not always necessary in the reduced port LRP. Reduced port LRP has less pain and better cosmetics than conventional LRP because the prostate is removed from the umbilicus. It is not necessary to spread the wound for removing prostate.",signatures:"Kazuhiro Araki and Yukio Naya",downloadPdfUrl:"/chapter/pdf-download/62329",previewPdfUrl:"/chapter/pdf-preview/62329",authors:[null],corrections:null},{id:"62729",title:"Preventing Erectile Dysfunction after Radical Prostatectomy: Nerve-Sparing Techniques, Penile Rehabilitation, and Novel Regenerative Therapies",doi:"10.5772/intechopen.79398",slug:"preventing-erectile-dysfunction-after-radical-prostatectomy-nerve-sparing-techniques-penile-rehabili",totalDownloads:2027,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Erectile dysfunction is a known and much-dreaded functional consequence of radical prostatectomy. Dr. Patrick Walsh pioneered the nerve-sparing radical retropubic prostatectomy in the early 1980s, which has mitigated the morbidity of this surgery. Post-operative potency rates range widely from 20 to 80%, however, and depend on myriad factors including age, preoperative potency, and degree of nerve-sparing during surgery. Over the past four decades several developments have continued to offer hope to patients and clinicians alike, including refined understanding of cavernosal nerve neuroanatomy, beneficial modifications in surgical technique, as well as the advent of robotic surgery. Furthermore, multiple pre- and post-operative penile rehabilitation techniques using mechanotherapy and pharmaceuticals have also improved functional recovery. This paper examines erectile dysfunction as a consequence of radical prostatectomy, including the physiology of erections, the pathophysiology of post-operative erectile dysfunction, novel surgical techniques to enhance neurovascular bundle preservation, and penile rehabilitation strategies involving hyperbaric oxygen, neuroprotective pharmaceuticals, dehydrated human amnion-chorion membrane allografts, and mesenchymal stem cell therapy.",signatures:"Michael Whalen",downloadPdfUrl:"/chapter/pdf-download/62729",previewPdfUrl:"/chapter/pdf-preview/62729",authors:[null],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"3274",title:"Advances in Prostate Cancer",subtitle:null,isOpenForSubmission:!1,hash:"fb7257d982e3228ceb9320f595ae1c58",slug:"advances-in-prostate-cancer",bookSignature:"Gerhard Hamilton",coverURL:"https://cdn.intechopen.com/books/images_new/3274.jpg",editedByType:"Edited by",editors:[{id:"67794",title:"Prof.",name:"Gerhard",surname:"Hamilton",slug:"gerhard-hamilton",fullName:"Gerhard Hamilton"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1312",title:"Advances in Cancer Management",subtitle:null,isOpenForSubmission:!1,hash:"dc1cad15f23e313cd067e7e7b4511005",slug:"advances-in-cancer-management",bookSignature:"Ravinder Mohan",coverURL:"https://cdn.intechopen.com/books/images_new/1312.jpg",editedByType:"Edited by",editors:[{id:"58197",title:"Prof.",name:"Ravinder",surname:"Mohan",slug:"ravinder-mohan",fullName:"Ravinder Mohan"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"559",title:"Bladder Cancer",subtitle:"From Basic Science to Robotic Surgery",isOpenForSubmission:!1,hash:"117cbfaa858282ed2cdb9a81ce411def",slug:"bladder-cancer-from-basic-science-to-robotic-surgery",bookSignature:"Abdullah Erdem Canda",coverURL:"https://cdn.intechopen.com/books/images_new/559.jpg",editedByType:"Edited by",editors:[{id:"69657",title:"Prof.",name:"Abdullah Erdem",surname:"Canda",slug:"abdullah-erdem-canda",fullName:"Abdullah Erdem Canda"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"789",title:"Emerging Research and Treatments in Renal Cell Carcinoma",subtitle:null,isOpenForSubmission:!1,hash:"616688465519d2b5bcb1d867a3806714",slug:"emerging-research-and-treatments-in-renal-cell-carcinoma",bookSignature:"Robert J. Amato",coverURL:"https://cdn.intechopen.com/books/images_new/789.jpg",editedByType:"Edited by",editors:[{id:"73752",title:"Dr.",name:"Robert",surname:"Amato",slug:"robert-amato",fullName:"Robert Amato"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1845",title:"Prostate Cancer",subtitle:"Diagnostic and Therapeutic Advances",isOpenForSubmission:!1,hash:"3be3f6b756cec080cfcacd2251b62a5c",slug:"prostate-cancer-diagnostic-and-therapeutic-advances",bookSignature:"Philippe E. Spiess",coverURL:"https://cdn.intechopen.com/books/images_new/1845.jpg",editedByType:"Edited by",editors:[{id:"64476",title:"Dr.",name:"Philippe E.",surname:"Spiess",slug:"philippe-e.-spiess",fullName:"Philippe E. Spiess"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5256",title:"Human Papillomavirus",subtitle:"Research in a Global Perspective",isOpenForSubmission:!1,hash:"8d66d3c0bc41a12be8217ca0cee52b60",slug:"human-papillomavirus-research-in-a-global-perspective",bookSignature:"Rajamanickam Rajkumar",coverURL:"https://cdn.intechopen.com/books/images_new/5256.jpg",editedByType:"Edited by",editors:[{id:"120109",title:"Dr.",name:"Rajamanickam",surname:"Rajkumar",slug:"rajamanickam-rajkumar",fullName:"Rajamanickam Rajkumar"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"960",title:"Cancer of the Uterine Endometrium",subtitle:"Advances and Controversies",isOpenForSubmission:!1,hash:"e31a8846983568317bbe451b6e32b4c6",slug:"cancer-of-the-uterine-endometrium-advances-and-controversies",bookSignature:"J. Salvador Saldivar",coverURL:"https://cdn.intechopen.com/books/images_new/960.jpg",editedByType:"Edited by",editors:[{id:"71352",title:"Dr.",name:"J.S.",surname:"Saldivar",slug:"j.s.-saldivar",fullName:"J.S. 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It is a disease of the arteries characterized by the deposition of fatty plaques on their inner walls, which hardens or narrows medium to large blood vessels, especially the aorta, coronary arteries, and cerebral arteries [1]. Atherosclerosis-related diseases often lead to serious outcomes such as sudden cardiac death, unstable angina pectoris, acute myocardial infarction, stroke, and intermittent claudication due to vessel obliteration or plaque rupture with subsequent thrombosis [1,2]. Epidemiological studies indicate that, because of the adoption of Western lifestyle, the prevalence of atherosclerosis is increasing all over the world and will likely reach epidemic proportions in the coming decades [2]. The earliest visible lesion in the development of atherosclerosis is the fatty streak. It consists of aggregates of foam cells (i.e., lipoprotein-loaded macrophages) in the subendothelial space. Fatty streaks may also include T cells, aggregated platelets, and smooth muscle cells. A fatty streak is the precursor lesion of an atheroma that may become an atheromatous plaque [2]. In response to plaque growth, the arterial wall can remodel itself by increasing its external diameter to accommodate the plaque without narrowing the lumen. Thrombosis is the last stage in the disease process that is responsible for clinically observable adverse events mentioned previously.
Traditional Chinese medicine (TCM), especially herbal medicine, has been used for the treatment of cardiovascular diseases for hundreds of years, as documented in the
The pathology of atherosclerosis is a progressive process with increasing age that is related to some risk factors such as hypertension, hyperlipidemia, diabetes mellitus, obesity, and cigarette smoking [1]. Atherosclerosis begins with damage to the endothelium, which results in endothelial vasodilator dysfunction. The endothelium subsequently cannot modulate tone, growth, hemostasis, and inflammation throughout the circulatory system. Injured endothelial cells (EC) produce cell surface adhesion molecules such as vascular cell adhesion molecule-1 (VCAM-1), and thereby cause monocytes and T-lymphocytes to adhere to the endothelium and migrate beneath it [1,2]. Circulating monocytes and T-lymphocytes provoke an inflammatory response. The tight junctions between EC loosen and increase the permeability to lipids, especially low-density lipoprotein (LDL). Once the oxidation of LDL has crossed the damaged endothelium into the intima, monocytes differentiate into macrophages and begin to take up oxidized LDL [1]. Macrophages bite and retain the lipid, and then become foam cells. The fatty streak consisting of lipid-containing foam cells in the arterial wall can evolve into atherosclerotic plaques or atheromas [1]. In addition, T-lymphocytes secrete cytokines that induce vascular smooth muscle cells to migrate from the media to the intima and proliferate shortly thereafter [1]. Over time, a growing lesion consisting of lipid and smooth muscle cells invade and narrow the lumen of the artery. Other extracellular matrix (ECM) components such as collagen, elastin, glycoprotein, and proteoglycans give tensile strength and viscoelasticity to the arterial wall. Increasing the synthesis of ECM components such as matrix metalloproteinases (MMPs) contributes significantly to ECM destruction, which renders the plaque more prone to rupture [1]. Once a plaque ruptures, it can trigger an acute thrombosis or embolism by activating platelets. It may finally lead to myocardial infarction, stroke, and even death.
Atherosclerosis treatment usually begins with lifestyle changes such as a low cholesterol diet, regular exercise, and quitting smoking. Depending on the severity of the disease, a person may be prescribed oral medication such as antiplatelets, angiotensin-converting enzyme (ACE) inhibitors, or beta-blockers. In patients with advanced disease, certain medical procedures such as percutaneous transluminal coronary angioplasty or coronary artery bypass surgery may be necessary.
Conventional medical costs paid by patients or by the Bureau of National Health Insurance (Taipei, Taiwan) are expensive. The caregiver burden on the patients’ families and government has increased yearly. In addition, conventional therapies for atherosclerosis-related diseases have some limitations such as statin-induced rhabdomyolysis or hepatitis, and antiplatelet agent-related gastrointestinal bleeding or peptic ulcer. Complementary and alternative therapy is another option for atherosclerosis medication. Traditional Chinese medicine is the primary complementary therapy used in the Chinese community. The aim of this paper is to explore complementary therapy with traditional Chinese medication for treating atherosclerosis-related diseases.
According to TCM theory, obstructed circulation of blood results in blood stasis syndrome (Xue Yu), which is an important pattern of slowing or retardation of the blood circulation. The main symptoms may include stabbing pain with a fixed position, tenderness, local purpura, lumps, dark-purple lips and finger nails, a blue-purple tongue, and a thready or hesitant pulse. Blood stasis syndrome in TCM corresponds to atherosclerosis in modern Western medicine. Both blood stasis syndrome and atherosclerosis are the predevelopment or initial stage of ischemic heart disease, myocardial infarction, or stroke (Figure 1). With early treatment by medication, the progression of cardiovascular or cerebral vascular disease will not worsen.
Progression from health to cardiovascular or cerebrovascular disease. EKG, electrocardiogram.
Table 1 shows atherosclerosis-related cardiovascular or cerebrovascular diseases. Atherosclerosis can cause embolism, thrombosis, ischemia, infarction, stenosis, or occlusion of the arteries. Some Chinese herbs can promote blood circulation or remove blood stasis and may be useful for treating atherosclerosis-related diseases.
\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
4140 | \n\t\t\tCoronary atherosclerosis | \n\t\t
4400 | \n\t\t\tAtherosclerosis of the aorta | \n\t\t
4149 | \n\t\t\tChronic ischemic heart disease, unspecified | \n\t\t
4148 | \n\t\t\tOther specified forms of chronic ischemic heart disease | \n\t\t
4118 | \n\t\t\tOther acute and subacute forms of ischemic heart disease | \n\t\t
410 | \n\t\t\tAcute myocardial infarction | \n\t\t
4110 | \n\t\t\tPostmyocardial infarction syndrome | \n\t\t
412 | \n\t\t\tOld myocardial infarction | \n\t\t
4297 | \n\t\t\tOther certain sequelae of myocardial infarction, not elsewhere classified | \n\t\t
444 | \n\t\t\tArterial embolism and thrombosis | \n\t\t
4292 | \n\t\t\tCardiovascular disease, unspecified | \n\t\t
433 | \n\t\t\tOcclusion and stenosis of precerebral arteries | \n\t\t
434 | \n\t\t\tOcclusion of cerebral arteries | \n\t\t
Atherosclerosis-related cardiovascular or cerebrovascular diseases
ICD-9-CM,
Several strategies exist for the treatment of atherosclerosis and associated diseases such as risk factor modification, antioxidation, anti-inflammation, and antiplatelet accumulation. Hypercholesterolemia, a primary risk factor that leads to atherosclerosis, is associated with the development and progression of atherosclerosis. Hypercholesterolemia and endothelial injury lead to the infiltration of LDL particles into the subendothelial space. Lowering cholesterol can provide the initial blockade [2].
The 10 traditional Chinese herbs commonly used in clinical practice that reportedly reduce the production of LDL and/or oxidative LDL are
As Table 2 shows, single compounds and/or herbal extracts from these 10 TCM herbs inhibit the expression of adhesion molecules (i.e., VCAM-1 and ICAM-1). Among them,
\n\t\t\t\t \n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t\t\n\t\t\t\t | \n\t\t
\n\t\t\t\t | \n\t\t\t | \n\t | \n | \n | \n | \n | \n | \n | \n | \n
\n\t\t | \n\t\n\t | | \n | \n | \n | \n | \n | \n | \n\n |
\n\t\t | \n\t | \n | \n | \n | \n | \n\n | \n | | \n\n |
\n\t\t | \n\t\n\t | | \n | \n | \n | \n\n | \n | | \n | \n
\n\t\t | \n\t\n\t | | \n | \n | \n | \n\n | \n | \n | \n |
\n\t\t | \n\t\n\t | | \n | \n | \n\n | \n | \n | | \n | \n
\n\t\t | \n\t | \n | \n | \n | \n\n | \n | \n | | \n\n |
\n\t\t | \n\t\n | \n | \n | \n | \n | ||||
\n\t\t | \n\t\n\t | | \n | \n | \n | \n\n | | \n | \n | \n
Red yeast rice | \n\t | \n | \n | \n | \n | \n\n | \n | | \n\n |
Acupuncture | \n\t | \n | \n\n | | \n | \n\n | | \n\n | | \n
\n\t\t | \n\t\n\t | | \n\n | \n | \n | \n | \n | \n | \n |
Multiple signaling molecules involved in atherosclerosis and regulated by Chinese herbs
The up arrow (
eNOS, endothelial nitric oxide synthase; ICAM-1, intercellular adhesion molecule; LDL, low-density lipoprotein; MCP-1, macrophage chemoattractant protein; MMP-9, matrix metalloproteinase-9; NF-κB, nuclear factor-kappaB; NO, nitric oxide; ox-LDL, oxidized low-density lipoprotein; TNF-α, tumor necrosis factor alpha; VCAM-1, vascular cell adhesion molecule-1.
Stimulated by inflammatory cytokines such as interleukin-1α (IL-1α) and TNF-α, VSMCs propagate and migrate from the media to the intima and produce collagen, which forms the substance of the fibrous cap of the mature lesion [1,20]. Signaling interactions between CD40- and CD40L-expressing cells result in the formation of matrix metalloproteinases (MMPs), which degrade collagens and the thin fibrous cap and lead to the formation of vulnerable plaques and rupture [20]. Among the 10 TCM herbs,
\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t\t\n\t\t\t | \n\t
\n\t\t\t | \n\t\tProtocatechuic Aldehyde | \n\t\tReduce caspase-3, and VSMC migration and proliferation | \n\t\t[28,29] | \n\t
\n\t\t | Cryptotanshinone | \n\t\tIncrease NO; reduce ox-LDL, ICAM-1, VCAM-1, and monocyte adhesion | \n\t\t[30] | \n\t
\n\t\t | Tanshinone IIA | \n\t\tReduce ROS, Bax/Bcl-2, caspase-3, LOX-1, NF-κB, ox-LDL, monocyte adhesion, VSMC migration and proliferation, macrophage, cholesterol accumulation, CD 40, TNF-α MMP-2, MMP-9, and platelet aggregation | \n\t\t[34,35,36,43,49] | \n\t
\n\t\t | \n\t\t\t | \n\t\tReduce ICAM-1, E-selectin, NF-κB, ox-LDL, MMP-2, and MMP-9 | \n\t\t[31-33] | \n\t
\n\t\t\t | \n\t\t\n\t\t\t \n\t\t\t | \n\t\tReduce ICAM-1, VCAM-1, ox-LDL, IL-1β, MMP-9, MMP-2, NF-κB, CD40, and MCP-1 | \n\t\t[4,21,38] | \n\t
\n\t\t\t | \n\t\t\n\t\t\t Extract | \n\t\tIncrease eNOS/NO; Reduce LDL, VCAM-1, ICAM-1, E-selectin, MMP-2, and NF-κB | \n\t\t[5,14,22,39,40] | \n\t
\n\t\t\t | \n\t\tCurcumin | \n\t\tReduce LDL, VCAM-1, ICAM-1, MMP-2, MMP-9, TNF-α, and NF-κB | \n\t\t[6,19,23,41] | \n\t
\n\t\t\t | \n\t\t\n\t\t\t | \n\t\tReduce LDL, VCAM-1, ICAM-1, and MMP-9 | \n\t\t[7,24] | \n\t
\n\t\t\t | \n\t\tPaeonol | \n\t\tReduce VCAM-1, ICAM-1, and TNF-α | \n\t\t[42,43] | \n\t
\n\t\t | Total glucosides of peony | \n\t\tReduce LDL and TNF-α | \n\t\t[8] | \n\t
\n\t\t\t | \n\t\t\n\t\t\t | \n\t\tIncrease eNOS/NO; reduce LDL, VCAM-1, ICAM-1, and NF-κB | \n\t\t[9,38,44] | \n\t
\n\t\t\t | \n\t\t2,3,5,4\'-tetrahydroxystilbene-2-O-beta-D-glucoside (TSG) | \n\t\tIncrease eNOS/NO; reduce LDL, VCAM-1, and ICAM-1 | \n\t\t[10,15,39,45] | \n\t
\n\t\t\t | \n\t\tBerberine | \n\t\tReduce LDL, ox-LDL, VCAM-1, ICAM-1, MMP-9, MCP-1, NF-κB, and TNF-α | \n\t\t[11,12,18,25,40,46] | \n\t
Red yeast rice | \n\t\t\n\t\t\t | \n\t\tIncrease eNOS/NO; reduce LDL, VCAM-1, ICAM-1, MMP-9, MMP-2, and NF-κB | \n\t\t[13,16,26,41,42,47,48] | \n\t
The target activity of herbal extracts or compounds in atherosclerosis
eNOS, endothelial nitric oxide synthase; ICAM-1, intercellular adhesion molecule; IL-1β, interleukin 1β; LDL, low-density lipoprotein; LOX1, lectin-like oxidized low-density lipoprotein receptor-1; MCP-1, macrophage chemoattractant protein; MMP, matrix metalloproteinase; NF-κB, nuclear factor-kappaB; NO, nitric oxide; ox-LDL, oxidized low-density lipoprotein; ROS, reactive oxygen species; TNF-α, tumor necrosis factor alpha; VCAM-1, vascular cell adhesion molecule-1; VSMC, vascular smooth muscle cells.
Tanshinone IIA, another compound derived from
Hung et al. [37] report that a low dose (0.015 mg/mL) of
In addition to herbal medicine, acupuncture has been used for a long time in the treatment of cardiovascular disease in Asia. Acupuncture is applied in the treatment of hypertension and hyperlipidemia, which are risk factors leading to atherosclerosis. Kim et al. [50] demonstrated that electroacupuncture on the
The World Health Organization (WHO) standard acupuncture point locations of ST36, ST40, PC6, and BL15 [
Certain mental disorders and stress are conducive to atherosclerosis. Kroenke et al. [57] revealed that a negative mood is predictive of a greater progression of calcified atherosclerosis, compared to a positive mood. Everson-Rose et al. [58] found that high levels of stress, hostility, and depressive symptoms are associated with a significantly increased risk of incident stroke or transient ischemic attacks in middle-aged and older adults. Stillman et al. [59] and Wang et al. [60] also noted that anxiety can potentially predict a worse outcome through worsening of vascular function in patients with coronary atherosclerotic disease.
Meditation is an alternative medicine practice for mental and physical health. It has salutary effects on patients with anxiety [61, 62], depression [61, 63], and stress [64, 65]. Some articles report that meditation can calm the emotions and produce beneficial effects on the cardiovascular system, particularly with regard to vascular aspects [66-68]. Walton et al. [68] advocate meditation to reduce traditional and novel risk factors for cardiovascular diseases; for example, meditation (1) decreases blood pressure; (2) reduces the use of tobacco and alcohol; (3) lowers the cholesterol level and lipid oxidation; and (4) decreases psychosocial stress.
The mechanism and neurobiological effects of mindfulness meditation involve (1) deactivation of the default mode network, which generates spontaneous thoughts, contributes to the maintenance of the autobiographical self, and is associated with anxiety and depression; (2) the anterior cingulate cortex, which underpins attention functions; (3) the anterior insula, which is associated with the perception of visceral sensation, the detection of the heartbeat and respiratory rate, and the affective response to pain; (4) the posterior cingulate cortex, which helps one to understand the context from which a stimulus emerges; (5) the temporoparietal junction, which assumes a central role in empathy and compassion; and (6) the amygdala, which is implicated in fear responses [69].
There are few studies on formulas or single herbal drugs interaction in the treatment of atherosclerosis. In accordance with evidence-based medicine, well-designed and conducted clinical studies such as randomized control clinical trials will be necessary in the future.
Atherosclerosis-related diseases are the primary causes of death. In addition to standard treatment, complementary therapy needs to be face up. Traditional Chinese medicine is a popular complementary and alternative medicine (CAM) in East Asia and throughout the world. There is increasing scientific evidence demonstrating that TCM has potential for treating atherosclerosis and its associated conditions. Acupuncture,
In December 2019 primary cases of COVID-19 were reported in Wuhan (China), which was later declared as a pandemic by WHO in March 2020 [1]. The COVID-19 is caused by the contagious virus SARS-CoV-2 (Severe acute respiratory syndrome coronavirus 2), belonging to the same family as MERS-CoV (Middle East respiratory syndrome coronavirus) and SARS-CoV-1 [2]. Typical symptoms of COVID-19 span a wide range, including fever, dry cough, sore throat and shortness of breath [3]. These symptoms are similar to flu and other respiratory illnesses. In order to provide appropriate care and treatment for COVID-19, it is critical to diagnose SARS-CoV-2 (referred to as CoV-2 hereafter) infections distinctly from other similar diseases. Another complexity to this is that some CoV-2 infected individuals do not exhibit exaggerated symptoms, termed as asymptomatic carriers [4]. It has been shown that the asymptomatic carriers can spread the virus to the same extent as the symptomatic individuals, in the absence of appropriate precautions [4]. Thus, it is imperative to identify all infections efficiently, quarantine and treat appropriately to cease the spread of CoV-2. To achieve this, many diagnostic tests (assays) have been developed and improved by multiple referring (participating) laboratories and CDC (Centers for Disease Control and Prevention). This chapter is focused on simplifying the basic principles of these diagnostic assays. Many scientific review articles which dive deep into the science of CoV-2 diagnostic testing have been published [1, 3, 5, 6, 7]. This chapter, however, aims at explaining the same in non-technical terms, intended for a general audience.
SARS-CoV-2 belongs to the family
Cartoon representing the human SARS-CoV-2 virus structure. (Left) Sphere showing the outside of the virus. (Right) A cross-section of the virus sphere depicting the membrane structural proteins (S, M and E), along with the ss RNA genetic material which is wound around the nucleocapsid (N) proteins.
The genome of CoV-2 was successfully sequenced by January 2020 [13]. The ss RNA is ~30 kb (kilobases) in length [2], encompassing all the information for protein syntheses and assembly of the new virus particles (virions). There is another group of non-structural proteins (NSPs) which are involved in non-structural functions such as genetic material replication or the assembly of virions [2]. There are 16 such NSPs identified in the CoV-2 genome, which include an RNA-dependent RNA polymerase (RdRP), ExoN (exonuclease) and ORF proteins [2]. RdRP synthesizes new viral genetic material, while ExoN is responsible for genome stability and for removing any errors in the newly synthesized genetic RNA sequence. ORF proteins act as accessory proteins [2].
Viruses have been traditionally categorized in a separate class, from the biotic or living organisms. This is due to their inability to replicate in the absence of a host. In general, the virus invades the host cell, releases its genetic material and hijacks the host machinery for synthesizing its own macromolecules (nucleic acid and proteins) [14]. Upon assembly of virions (new viruses), the host cell is lysed (broken open) to release the new infectious particles [14]. The host cells try to combat the invasion by evoking an immune response specific to the virus (adaptive immunity) [15]. This is attempted through the presentation of fragments of the foreign macromolecules on the host cell surface. These non-indigenous particles, called antigens, are sensed by the immune cells which initiate the production of antibodies against them [15]. Thereafter, any particle resembling the antigen is attacked and cleared by the host immune cells. Antibodies are broadly classified into 5 main immunoglobulin (Ig) classes: G, A, M, E and D. They differ in their structures, capacity to recognize the antigen and occurrence in the course of immune response [15]. These antibodies encompass a structural region which is specific to binding the antigen (called the variable region). The immune response and components are much more complicated than this simple excerpt presented here, and the readers are encouraged to refer to other reviews on the immune system [15].
The observation that the virus from asymptomatic carriers is equally infectious as those exhibiting clear symptoms of COVID-19 [4, 16], makes it imperative to identify the asymptomatic individuals in order to take appropriate measures for their seclusion and treatment. This is highly dependent on the reliability and accuracy of the diagnostic tests. Further, these assays also permit the recognition of patients with CoV-2 infections at hospitals where it is crucial for their segregation into the COVID-19 specific wards. This is important to prevent further transmission of the virus to admitted and highly vulnerable patient populations. Reliability of a diagnostic test depends on its specificity and sensitivity. Specificity is the ability of the test to correctly detect the negative samples as negative, thus reducing false-positive results [17]. On the other hand, sensitivity is the ability of the test to correctly identify the positive cases as positive, thereby decreasing false-negative results [17]. It is essential that a test is dependable for both these features. False results, either way, will aid in the spread of the virus, and misdirect contact tracing.
In the face of a pandemic, such as the one we face currently, a diagnostic assay should have:
High sensitivity
High specificity
Easy read-out method
Rapid turn-around-time (TAT, time to get the results)
Low cost
Easy transport and storage
High reproducibility
Present diagnostic assays for CoV-2 have been categorized as shown in Figure 2.
Categorization of available CoV-2 diagnostic tests. The present diagnostic assays for CoV-2 can be segregated into two broad classes- molecular and serological. Molecular tests determine the presence of the virus by detecting its genome. For molecular assays, specimens can be collected from multiple relevant areas, such as the nasal swab, BAL, etc. Serological tests detect either the presence of the antigen (a protein that is only expressed by the virus) or the antibodies (generated by the host’s immune system in response to the infection) in blood samples. While PCR (molecular) and antigen tests detect the presence of the virus at the time of testing, antibody assays mainly determine previous infection. All these tests can identify both, symptomatic and asymptomatic carriers of the virus. The PCR assays include reverse transcription-PCR (RT-PCR), recombinase polymerase amplification (RPA), reverse transcription-loop mediated isothermal amplification (RT-LAMP), and CRISPR-Cas based tests. These PCR assays will be discussed in this chapter.
These diagnostic assays detect the virus through the presence of their genetic material, which is amplified to produce a detectable signal. To fully comprehend the mechanism of these assays, it is essential to first understand the central dogma (Figure 3). The common genetic material is DNA (deoxyribonucleic acid), a comparatively more stable nucleic acid than RNA. Generally, DNA is a double-stranded (ds) molecule composed of plus (+) and minus (−) strands [18]. It is made of deoxyribose sugar molecules as backbone and are attached with bases or nucleotides A (adenine), T (thymine), G (guanine) or C (cytosine) [18]. The complementary nature of the bases, i.e. their ability to pair specifically, provides the ds structure. The same feature allows faithful replication of the DNA and syntheses of RNA, thus enabling truthful relaying of the message. The base pairings are A-T and C-G [18]. The deoxyribose (and ribose) sugars provide a directionality to the nuclei acids with their chemical groups, 5′ end and 3′ end [19]. All DNA strands are synthesized by DNA polymerases in 5′ - > 3′ direction [19]. The two strands, however, run in opposite directions i.e. the 5′ end of plus strand is closest to the 3′ end of minus strand, while the 3′ end of the plus strand is opposite to the 5′ end of the minus end [19]. Based on the ATGC code (sequence) carried by the plus strand, the minus complementary strand is built [19]. For example, 5′-AGGCTC-3′ sequence on the plus strand will be paired with 5′-GAGCCT-3′.
Central dogma. The message in the double stranded DNA is converted to single stranded RNA by transcription, through complementary base pairing. The code in RNA is converted to proteins by a process called translation (three bases constitute a codon, which represents one amino acid). Amino acids are the building blocks of proteins. RNA can be converted back to double stranded DNA (cDNA) through reverse transcription.
The information in the genetic material needs to be converted to proteins, which act at the functional level. In this process, a key intermediate is the RNA. The code in the DNA is first converted to RNA through transcription by RNA polymerases [20]. The complementarity of the bases is used to transfer the information faithfully into RNA. Usually, RNA is a ss molecule, with the same complementary base pairings as the DNA. In RNA, T is replaced by U (uracil) which also pairs with A (A-U) [19]. In some viruses, ds RNA serves as the genetic material. However, the rules of complementation and the ss RNA intermediate for protein synthesis remain the same.
The code carried by RNA is used for the synthesis of proteins, through translation [20]. Proteins are composed of amino acids building blocks. A codon in the RNA, which is composed of three bases in a specific order, codes for a particular amino acid [20]. So, the sequence of the amino acids in the protein are built according to the sequence of the codons in the respective RNA. Proteins are the macromolecules which acts as support structures, catalyze reactions, relay signaling information, and many other functions.
The dependency of protein synthesis on RNA has been ingeniously employed in the current Pfizer and Moderna vaccines [21]. These vaccines carry an mRNA (messenger RNA) which carries the code for an antigenic fragment of the CoV-2 S-protein [21]. The host cells produce the S-protein fragments which elicit an appropriate immune response. This leads to the production of antibodies that can identify the CoV-2 S-protein upon an actual infection.
PCR is the process of photocopying a specific region (target region) of the DNA, achieved through base complementation. This amplification process is used to produce a detectable signal, which can be correlated to the presence and amount of target DNA present in the reaction (Figure 4). In PCR, a specific target region in the DNA sample is demarcated through primers, which are short stretches of DNA ranging from 8–20 nucleotide bases. Short DNA strands are termed as oligonucleotides, where primers are a sub-group which are used in PCR reactions. Primers are complementary to the boundaries of the target region in the DNA sample. In PCR, two primers are required to bind at the 5′ end boundaries, one each for the plus and minus strands. The primers provide a pre-requisite platform for the DNA polymerase to bind and extend the new complementary strands [22], one for each of the two original template strands (Figure 4B).
RT-PCR. (A) Viral ss RNA is converted to ds DNA by the reverse transcriptase enzyme. (B) In PCR, the cDNA acts the template (1). The two strands of the cDNA are separated (denatured) through high heat (2). This allows the annealing of the primers (forward and reverse) and the probe with their complementary regions on the template DNA strands (3). The DNA polymerase extends the primers to synthesize new DNA strands. In this process, the polymerase displaces and separates the fluorescent reporter (F) and the quencher (4). (C) Explanation of the read-out signal generation. At the ground state, the quencher is in close proximity to the reporter, and thus suppresses its emission. Upon cleavage by the polymerase (during extension step), the reporter is released. This relieves its inhibition thereby producing a fluorescent signal. Thus, with an increase in amplification of the template DNA, there is a corresponding increase in the detectable fluorescent signal.
When the starting material for PCR is RNA, as in the case of CoV-2, the RNA template is first reverse transcribed to complementary DNA (cDNA) (Figure 4A). The cDNA then serves as a template for PCR amplification using targeted primers. The conversion of RNA to DNA is achieved through naturally occurring RNA-dependent DNA polymerases, aptly called reverse transcriptase (RT). PCR reactions which depend on the RT enzyme are generally categorized as RT-PCR.
The amplified DNA region was traditionally detected using color or fluorescent agents which bind to ds DNA products [23]. Thus, with an increase in amplification there is an increase in the color/fluorescent signal. PCR read-outs are of two types: quantitative and qualitative. The former, quantitative, yields the amounts of template DNA, either absolute or relative values. On the other hand, qualitative PCR provides information on whether the template DNA is present in a sample. For CoV-2 RNA detection, a simple answer on its presence or absence is essential.
The general types of PCR techniques employed or developed for COVID-19 diagnosis are discussed below.
The first diagnostic kit developed to detect the CoV-2 infection was based on RT-PCR. As described above, the viral genomic RNA in the specimen is reverse transcribed to cDNA, followed by PCR amplification of a target gene using primers (Figure 4). There are two variants of this reaction: 1-step and 2-steps [3]. In 1-step, reverse transcription and PCR are conducted in the same tube, in tandem. This minimizes the chances of contamination by reducing handling. The 2-steps variation separates the RT reaction which provides cDNA in a separate tube for retention. This is useful since it is easier to store and handle DNA than RNA, and the cDNA can be used for further testing of other genes, if needed.
Choosing the target gene and region within that gene (usually PCR is directed at amplifying only a small region within a gene) is important, as it needs to be specific to the virus, excluding any overlap with the host genome or any other parasite/virus. For CoV-2 PCR, regions within the N, E, RdRP, S and ORF1ab genes have been successfully used as targets for RT-PCR [3]. It was recommended to use PCRs directed at amplifying at least two target regions for higher specificity. In addition to the viral genes, the human RNase P gene which is present ubiquitously in all cells is also amplified separately [3]. Detection of RNase P ensures that the PCR reaction did receive the specimen. This is important especially in determining negative results for viral gene targets.
During the PCR, the two strands of DNA template (plus and minus strands) are separated using high temperature to break the complementary pairs (reversible). This step is termed as “denaturation” in PCR, which is required to expose the bases for the primers to bind. This is followed by an “annealing” step which is ambient for primer binding to the complementary regions. Entailing this step is “extension” of the primers by DNA polymerase to synthesize complementary product strands. These three key steps are repeated multiple times in the same order to amplify the signal (referred to as PCR cycles). The newly synthesized DNA fragments can then themselves act as templates in the following PCR cycles, thereby giving an exponential amplification pattern. Thus, even a small amount of starting DNA is sufficient to generate a positive signal. Although, the annealing and extension temperatures can be synchronized through appropriate designing of the primers, denaturation requires a higher temperature. This demands the use of thermocyclers for RT-PCR, which can change temperatures of the reaction cyclically. Further, RT-PCR read-out is generally a fluorescent signal which also requires a specific detection instrument. These limit the use of this assay at point-of-care (POC), i.e. use by medical practitioners for instant results to make informed and immediate decisions.
A variation of this conventional assay, TaqMan PCR, was employed as a primary technique for CoV-2 diagnostics [24]. It involves the addition of another oligonucleotide called the probe. This probe, which is complementary to the plus strand is usually positioned towards the center of the target region i.e. between the two opposing primers. Probe is flanked by a fluorescent reporter molecule at its 5′ end and a quencher molecule at the 3′ end (as explained earlier, all oligonucleotides have a direction imparted by the backbone sugar molecules). The fluorescent reporter signal is suppressed by the quencher due to their close proximity. When the probe binds to the plus strand of the template (after denaturation), the DNA polymerase starts synthesizing the new strand from the 3’end of the forward primer (the quencher molecule in the probe 3′ end will not allow the polymerase to start at the probe). In this process, the polymerase cleaves the probe and releases the fluorescent and quencher molecules separately. Due to this irreversible separation, the signal from the fluorescent reporter is uninhibited and detectable. Thus, the level of signal from the reaction is proportional to the amount of new DNA products. TaqMan PCR retains the need for a thermocycler and a fluorescence reader, but provides more specificity than the traditional technique.
During the early stages of the COVID-19 pandemic, samples from multiple individuals were pooled together to reduce the testing times [25]. Upon detecting a positive result, the samples from that pool were individually tested to identify the infected individual/s.
Advantages:
RT-PCR is a commonly used assay in most laboratories. Hence, it was easily absorbed as a CoV-2 diagnostic test during the start of this pandemic.
It has high specificity, determined by the rigor of the chosen primers/probes.
This assay can be easily modified to adapt the mutations of the virus, as reported for CoV-2 S-protein in UK in December 2020 [26].
This test has the capability to multiplex. It has been recently modified by the CDC to detect the presence of CoV-2, Influenza strains A and B [3].
There is no requirement for a purification step in RT-PCR.
Limitations:
This assay depends on a thermocycler and a fluorescence reader, limiting its use at POC.
The RT and PCR reactions yield a TAT of ~3–24 hours [27], depending on the number of samples and the handling capacity of the testing center.
This assay works on the same principle as the RT-PCR but bypasses the need for temperature variations for DNA amplification. It eliminates the denaturation high temperature step, and then combines the annealing and extension steps to a single temperature [28]. The assays which use a single temperature to complete all the reactions are termed as ‘isothermal’, thus eliminating the need for a thermocycler.
RPA achieves isothermal amplification through the inclusion of a few key components in the reaction mixture (Figure 5). The first is the recombinase enzyme, which is incubated with the primers to form a complex, in the presence of a crowding agent (increases viscosity of the solution). The recombinase-primers complex is then added to the reaction with the cDNA derived from viral RNA. Thus, this assay also depends on RNA isolation and RT reaction. The recombinase allows the invasion of the ds cDNA by the primers to bind to their complementary regions. The ss DNA regions (or loops) that are created due to this invasion are stabilized by the binding of ss DNA-binding proteins (SSBPs). This prevents the re-binding of the original template strands (plus and minus). The recombinase enzyme is then displaced from the DNA by a strand-displacing DNA polymerase. This polymerase opens the template DNA structure as it synthesizes new DNA strands emanating from the primer (i.e. strand-displacing). All these components of RPA aim towards the elimination of the denaturation step in the PCR cycle, thus making it isothermal. This assay holds the capacity to be carried out in solid-phase, i.e. on a dry surface with immobilized components [28]. Although the load-of-detection (LOD) and time are compromised in solid-phase RPA [28], this feature can enable the designing of lyophilized kits with minimal storage and transport requirements.
Recombinase polymerase amplification (RPA). The primers and the recombinase enzyme are allowed to form a complex (1). The recombinase opens up the cDNA template, while the primers bind to their complementary regions (2). The ss DNA regions generated due to the opening of the template structure are stabilized through the binding of the single-strand binding proteins (SSBPs) (3). The DNA polymerase binds to the primers attached to the template DNA, detaching the recombinase (4). The polymerase extends the primers, while opening the ds template on its way. It also moves the SSBPs while synthesizing the new strands (5). New strands are synthesized by the polymerase (6). New ds DNA products which can act as templates for the following amplification cycles (7).
End-point detection of RPA has been vastly calibrated to fit the lateral flow assays (LFA) [28]. This assay yields rapid results in a visual read-out format (Figure 6). To adapt RPA to LFA, three different oligonucleotides (2 primers and 1 probe) and a
Lateral flow assay. (A) The strip consists of the regions depicted in the figure. The sample is loaded onto the sample pad. The sample then moves upwards, towards the absorption pad due to capillary action. Sample comprises of the amplified ds DNA products with tags FAM and biotin at two separate ends. From the sample pad, the sample first moves to the conjugation pad which is pre-loaded with Ab1 (antibodies against FAM). The Ab1 antibodies bind to the FAM-DNA-biotin products. These complexes move upward and are captured at the test line by the immobilized biotin-binding proteins. This produces a visible test line. The unbound free Ab1 antibodies (excess) from the conjugation pad also move upwards. These antibodies, however, move past the test line as they do not possess any biotin for interaction at this line. Upon reaching the control line, these antibodies are captured by Ab2 (antibodies that can bind Ab1). This interaction produces a visible control line. (B) The appearance of the positive, negative and invalid results. Positive result should show two lines, since it ensures the working of all components of the LFA strip. A conclusive negative result will only produce a control line which is generated by the interaction of immobilized Ab2 with free unbound Ab1. All other results are considered invalid.
Advantages:
Solid-phase RPA can yield kits with minimal needs for transport and storage, thereby significantly improving diagnostics at POC. However, more research is required in improving its LOD and TAT.
The LFA compatibility is useful in non-laboratory settings, again increasing its usage at POC.
RPA can be easily modified to accommodate the new mutations in target regions.
Limitations:
At present, RPA kits are sold by one company. This restricts modifications at the user’s end.
Prior to LFA, there is a protein purification step to avoid impaired flow of the sample on the strip. This adds to TAT.
This assay still requires RNA isolation and reverse transcription steps. These add to the detection times.
LAMP is another isothermal amplification technique which produces long, self-complementary looping DNA strands to generate a detectable signal. This technique employs an engineered DNA polymerase
Generally, a set of 4 (or 6) specific primers are used in LAMP assay. These primers cover at least six distinct regions, flanking the entirety of the target region. A glimpse of the assay steps is described in Figure 7. The self-complementary regions of the primers promote the formation of looped DNA products. This allows LAMP to yield concatemers of various lengths, which are long DNA strands with multiple copies of the target region aligned back to each other [29]. Concatemers multiply the read-out signal at a much faster rate than RT-PCR. The mechanism is explained in the Figure 7. A review article by Thompson and Lei [29] is recommended for further reading on this assay. Here, I would like to highlight the modifications made to RT-LAMP to progress COVID-19 diagnostics.
LAMP. Six specific regions (A, B, C, D, E, F) flanking the target DNA are chosen to design the primers (1). The forwards inner primer (FIP) invades the target DNA. This primer encompasses a self-complementary region (C) on its 5′ end (2). The new strand synthesized with FIP is displaced by the forward primer (3). The DNA products synthesized by the forward primer is similar to the original cDNA template (4). Due to the self-complementarity region on the FIP, it folds on itself forming a loop. This strand is invaded by the backward inner primer (BIP) and backward primer (5). The product formed by BIP on the FIP strand leads to two loops at the ends, forming a dumbbell shaped structure (6). These strands can be extended to form concatemeric DNA products (7). Concatemeric products of variable lengths (8).
This detection assay was developed to provide a visible color read-out. A colorimetric detection was incorporated using a simple pH-sensitive dye such as phenol red [29]. The color of this dye is closer to red when the pH is neutral (pH 7.0), and changes towards the yellow spectrum with acidic pH (pH < 7.0). The byproducts of DNA synthesis are acidic, which reduce the pH of the solution. This color change can be easily noted by eye, without any instrument. However, this detection method is limited by the baseline differences in the pH of collected specimens. To circumvent this, fluorescent dyes such as GeneFinder have been employed [29]. This dye produces green color under blue light illuminator to report positive results. Another variation of this assay excluded RNA isolation step to find comparable amplification of the N-protein gene under laboratory conditions [29]. This modification still needs more testing and evaluation with patient samples, prior to field use. After calibration, this assay could significantly reduce the TAT.
Moreover, individual samples can be tagged with specific barcodes in LAMP assay which allow tracing in a pooled sample [29]. A common method of barcoding is the transposase Tn5-adapter system [30]. The original article on this barcoding method is recommended to readers for understanding its mechanism and potential in diagnostics [30]. The barcodes, however, have to be read through NGS (next-generation sequencing), which requires specific lab equipment. This adds time for obtaining the results. It is possible that the bargain between time saved by pooling samples and the time added by NGS could be a deciding factor for the field-use application of this assay.
An important feature of LAMP is its amenability to be paired with other PCR techniques to combine their advantages. So far, the efficacy of LAMP has been tested after merging with RPA, using lab samples [29]. The combined assay is found to have increased sensitivity. RT-LAMP when integrated with CRISPR-Cas12 assay (described below) was shown to reduce detection time considerably [3].
Advantages:
This assay is conducted at a single temperature, and thus without a thermocycler.
The detection rate is much shorter than other mentioned techniques [3].
LAMP offers flexibility to be paired with other assays for improving their detection abilities.
This assay can be adapted to lab instrument-free detection methods.
Specificity of LAMP is higher than RT-PCR [3].
Limitations:
CRISPR (Clustered regularly interspaced short palindromic repeats)-Cas (CRISPR-associated nuclease) technology has been recently tested for its potency in the field of diagnostics. This technique, which was given recognition through the Nobel Prize in Chemistry 2020, is a modified biological process of the bacterial (prokaryotic) adaptive immune system [1]. Here a ss guide RNA (sgRNA or crRNA) leads/guides the CRISPR-Cas complex to the target nucleic acid region [1], owing to its complementarity to this region (Figure 8). Upon binding, Cas nuclease cleaves the template nucleic acid [1], along with non-specific cleavage of nearby ss DNA/RNA. This feature is called “collateral cleavage” activity [1], and has been used in designing read-out methods for diagnostic tests. This assay is equipped with ss DNA or RNA probes with a fluorescent or traceable reporter molecule, which produces a detectable signal only upon cleavage through collateral activity.
CRISPR-Cas cleavage system. Viral RNA is reverse transcribed to ds cDNA, which can be further transcribed to amplified RNA through an
The target for CRISPR-Cas cleavage complex can be modified by changing the crRNA strand sequence, similar to the primers/probes in RT-PCR. Based on the Cas nuclease paired with the crRNA in the assay, the template can vary. For example, Cas13 targets ss RNA, while Cas9 or Cas12 target ds DNA [1]. Thus, in case of CoV-2, the virus ss RNA will need to be reverse transcribed to cDNA which will be either amplified as DNA products or through
A recently invented SHERLOCK (Specific high-sensitivity enzymatic reporter unlocking) technique includes the crRNA-Cas13a complex to target RNA molecules [1]. This technique uses RPA amplification assay and a non-targeting RNA strand tagged with a fluorescent dye [31]. Patchsung
Ding
Advantages:
CRISPR-Cas reactions can be conducted at 37 °C temperature. This is an achievable temperature at POC.
This is an isothermal reaction, and thereby does not depend on a thermocycler.
The basic CRISPR-Cas technology has the flexibility to be paired with other assays to reap advantages from both techniques.
DETECTR assay has a shorter process time as compared to conventional RT-PCR tests [3].
The sensitivity of CRISPR-based assays is higher than the other mentioned tests.
These assays can be adapted to non-instrumental detection methods like LFA or visible color change under blue light [3, 34].
Limitations:
Specificity of CRISPR-based assays is lower than that reported for RT-PCR.
These assays also require RNA extraction which adds to TAT.
Currently, there is no portable CRISPR-based devices which have been developed for CoV-2. Thus, more research in needed in this field.
Calibration of the assays is more complicated than the standard RT-PCR or RPA. Thus, although possible, it will take longer to modify these tests to detect new mutations of the target gene.
The current molecular diagnostic tests provide variable degrees of sensitivity and specificity to the detection of SARS-CoV-2. It is clear that at present there is no single assay which fits all the requirements. However, there are constant research efforts aimed at improving the efficiency and accessibility of these assays to meet the growing demand of this pandemic. The improved assays will increase our ability to combat COVID-19 spread, and enhance our preparedness for any future infectious agents by providing a strong platform for building new diagnostic tests.
All figures have been created with BioRender.com.
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All published Book Chapters are licensed under a Creative Commons Attribution 3.0 Unported License. Monographs are licensed under the Creative Commons Attribution-NonCommercial 4.0 International (CC BY-NC 4.0) license granted to all others. Our Copyright Policy aims to guarantee that original material is published while at the same time giving significant freedom to our Authors. IntechOpen upholds a flexible Copyright Policy meaning that there is no copyright transfer to the publisher and Authors hold exclusive copyright to their work.
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Cárdenas-Aguayo, M. del C. Silva-Lucero, M. Cortes-Ortiz,\nB. Jiménez-Ramos, L. Gómez-Virgilio, G. Ramírez-Rodríguez, E. Vera-\nArroyo, R. Fiorentino-Pérez, U. García, J. Luna-Muñoz and M.A.\nMeraz-Ríos",authors:[{id:"42225",title:"Dr.",name:"Jose",middleName:null,surname:"Luna-Muñoz",slug:"jose-luna-munoz",fullName:"Jose Luna-Muñoz"},{id:"114746",title:"Dr.",name:"Marco",middleName:null,surname:"Meraz-Ríos",slug:"marco-meraz-rios",fullName:"Marco Meraz-Ríos"},{id:"169616",title:"Dr.",name:"Maria del Carmen",middleName:null,surname:"Cardenas-Aguayo",slug:"maria-del-carmen-cardenas-aguayo",fullName:"Maria del Carmen Cardenas-Aguayo"},{id:"169857",title:"Dr.",name:"Maria del Carmen",middleName:null,surname:"Silva-Lucero",slug:"maria-del-carmen-silva-lucero",fullName:"Maria del Carmen Silva-Lucero"},{id:"169858",title:"Dr.",name:"Maribel",middleName:null,surname:"Cortes-Ortiz",slug:"maribel-cortes-ortiz",fullName:"Maribel Cortes-Ortiz"},{id:"169859",title:"Dr.",name:"Berenice",middleName:null,surname:"Jimenez-Ramos",slug:"berenice-jimenez-ramos",fullName:"Berenice Jimenez-Ramos"},{id:"169860",title:"Dr.",name:"Laura",middleName:null,surname:"Gomez-Virgilio",slug:"laura-gomez-virgilio",fullName:"Laura Gomez-Virgilio"},{id:"169861",title:"Dr.",name:"Gerardo",middleName:null,surname:"Ramirez-Rodriguez",slug:"gerardo-ramirez-rodriguez",fullName:"Gerardo Ramirez-Rodriguez"},{id:"169862",title:"Dr.",name:"Eduardo",middleName:null,surname:"Vera-Arroyo",slug:"eduardo-vera-arroyo",fullName:"Eduardo Vera-Arroyo"},{id:"169863",title:"Dr.",name:"Rosana Sofia",middleName:null,surname:"Fiorentino-Perez",slug:"rosana-sofia-fiorentino-perez",fullName:"Rosana Sofia Fiorentino-Perez"},{id:"169864",title:"Dr.",name:"Ubaldo",middleName:null,surname:"Garcia",slug:"ubaldo-garcia",fullName:"Ubaldo Garcia"}]},{id:"58070",doi:"10.5772/intechopen.72427",title:"MRI Medical Image Denoising by Fundamental Filters",slug:"mri-medical-image-denoising-by-fundamental-filters",totalDownloads:2564,totalCrossrefCites:17,totalDimensionsCites:30,abstract:"Nowadays Medical imaging technique Magnetic Resonance Imaging (MRI) plays an important role in medical setting to form high standard images contained in the human brain. MRI is commonly used once treating brain, prostate cancers, ankle and foot. The Magnetic Resonance Imaging (MRI) images are usually liable to suffer from noises such as Gaussian noise, salt and pepper noise and speckle noise. So getting of brain image with accuracy is very extremely task. An accurate brain image is very necessary for further diagnosis process. During this chapter, a median filter algorithm will be modified. Gaussian noise and Salt and pepper noise will be added to MRI image. A proposed Median filter (MF), Adaptive Median filter (AMF) and Adaptive Wiener filter (AWF) will be implemented. The filters will be used to remove the additive noises present in the MRI images. The noise density will be added gradually to MRI image to compare performance of the filters evaluation. The performance of these filters will be compared exploitation the applied mathematics parameter Peak Signal-to-Noise Ratio (PSNR).",book:{id:"6144",slug:"high-resolution-neuroimaging-basic-physical-principles-and-clinical-applications",title:"High-Resolution Neuroimaging",fullTitle:"High-Resolution Neuroimaging - Basic Physical Principles and Clinical Applications"},signatures:"Hanafy M. Ali",authors:[{id:"213318",title:"Dr.",name:"Hanafy",middleName:"M.",surname:"Ali",slug:"hanafy-ali",fullName:"Hanafy Ali"}]},{id:"41589",doi:"10.5772/50323",title:"The Role of the Amygdala in Anxiety Disorders",slug:"the-role-of-the-amygdala-in-anxiety-disorders",totalDownloads:9671,totalCrossrefCites:4,totalDimensionsCites:28,abstract:null,book:{id:"2599",slug:"the-amygdala-a-discrete-multitasking-manager",title:"The Amygdala",fullTitle:"The Amygdala - A Discrete Multitasking Manager"},signatures:"Gina L. Forster, Andrew M. Novick, Jamie L. Scholl and Michael J. Watt",authors:[{id:"145620",title:"Dr.",name:"Gina",middleName:null,surname:"Forster",slug:"gina-forster",fullName:"Gina Forster"},{id:"146553",title:"BSc.",name:"Andrew",middleName:null,surname:"Novick",slug:"andrew-novick",fullName:"Andrew Novick"},{id:"146554",title:"MSc.",name:"Jamie",middleName:null,surname:"Scholl",slug:"jamie-scholl",fullName:"Jamie Scholl"},{id:"146555",title:"Dr.",name:"Michael",middleName:null,surname:"Watt",slug:"michael-watt",fullName:"Michael Watt"}]},{id:"26258",doi:"10.5772/28300",title:"Excitotoxicity and Oxidative Stress in Acute Ischemic Stroke",slug:"excitotoxicity-and-oxidative-stress-in-acute-ischemic-stroke",totalDownloads:7157,totalCrossrefCites:6,totalDimensionsCites:25,abstract:null,book:{id:"931",slug:"acute-ischemic-stroke",title:"Acute Ischemic Stroke",fullTitle:"Acute Ischemic Stroke"},signatures:"Ramón Rama Bretón and Julio César García Rodríguez",authors:[{id:"73430",title:"Prof.",name:"Ramon",middleName:null,surname:"Rama",slug:"ramon-rama",fullName:"Ramon Rama"},{id:"124643",title:"Prof.",name:"Julio Cesar",middleName:null,surname:"García",slug:"julio-cesar-garcia",fullName:"Julio Cesar García"}]},{id:"62072",doi:"10.5772/intechopen.78695",title:"Brain-Computer Interface and Motor Imagery Training: The Role of Visual Feedback and Embodiment",slug:"brain-computer-interface-and-motor-imagery-training-the-role-of-visual-feedback-and-embodiment",totalDownloads:1439,totalCrossrefCites:13,totalDimensionsCites:23,abstract:"Controlling a brain-computer interface (BCI) is a difficult task that requires extensive training. Particularly in the case of motor imagery BCIs, users may need several training sessions before they learn how to generate desired brain activity and reach an acceptable performance. A typical training protocol for such BCIs includes execution of a motor imagery task by the user, followed by presentation of an extending bar or a moving object on a computer screen. In this chapter, we discuss the importance of a visual feedback that resembles human actions, the effect of human factors such as confidence and motivation, and the role of embodiment in the learning process of a motor imagery task. Our results from a series of experiments in which users BCI-operated a humanlike android robot confirm that realistic visual feedback can induce a sense of embodiment, which promotes a significant learning of the motor imagery task in a short amount of time. We review the impact of humanlike visual feedback in optimized modulation of brain activity by the BCI users.",book:{id:"6610",slug:"evolving-bci-therapy-engaging-brain-state-dynamics",title:"Evolving BCI Therapy",fullTitle:"Evolving BCI Therapy - Engaging Brain State Dynamics"},signatures:"Maryam Alimardani, Shuichi Nishio and Hiroshi Ishiguro",authors:[{id:"11981",title:"Prof.",name:"Hiroshi",middleName:null,surname:"Ishiguro",slug:"hiroshi-ishiguro",fullName:"Hiroshi Ishiguro"},{id:"231131",title:"Dr.",name:"Maryam",middleName:null,surname:"Alimardani",slug:"maryam-alimardani",fullName:"Maryam Alimardani"},{id:"231134",title:"Dr.",name:"Shuichi",middleName:null,surname:"Nishio",slug:"shuichi-nishio",fullName:"Shuichi Nishio"}]}],mostDownloadedChaptersLast30Days:[{id:"29764",title:"Underlying Causes of Paresthesia",slug:"underlying-causes-of-paresthesia",totalDownloads:192666,totalCrossrefCites:3,totalDimensionsCites:7,abstract:null,book:{id:"1069",slug:"paresthesia",title:"Paresthesia",fullTitle:"Paresthesia"},signatures:"Mahdi Sharif-Alhoseini, Vafa Rahimi-Movaghar and Alexander R. Vaccaro",authors:[{id:"91165",title:"Prof.",name:"Vafa",middleName:null,surname:"Rahimi-Movaghar",slug:"vafa-rahimi-movaghar",fullName:"Vafa Rahimi-Movaghar"}]},{id:"63258",title:"Anatomy and Function of the Hypothalamus",slug:"anatomy-and-function-of-the-hypothalamus",totalDownloads:4558,totalCrossrefCites:6,totalDimensionsCites:12,abstract:"The hypothalamus is a small but important area of the brain formed by various nucleus and nervous fibers. Through its neuronal connections, it is involved in many complex functions of the organism such as vegetative system control, homeostasis of the organism, thermoregulation, and also in adjusting the emotional behavior. The hypothalamus is involved in different daily activities like eating or drinking, in the control of the body’s temperature and energy maintenance, and in the process of memorizing. It also modulates the endocrine system through its connections with the pituitary gland. Precise anatomical description along with a correct characterization of the component structures is essential for understanding its functions.",book:{id:"6331",slug:"hypothalamus-in-health-and-diseases",title:"Hypothalamus in Health and Diseases",fullTitle:"Hypothalamus in Health and Diseases"},signatures:"Miana Gabriela Pop, Carmen Crivii and Iulian Opincariu",authors:null},{id:"57103",title:"GABA and Glutamate: Their Transmitter Role in the CNS and Pancreatic Islets",slug:"gaba-and-glutamate-their-transmitter-role-in-the-cns-and-pancreatic-islets",totalDownloads:3478,totalCrossrefCites:3,totalDimensionsCites:9,abstract:"Glutamate and gamma-aminobutyric acid (GABA) are the major neurotransmitters in the mammalian brain. Inhibitory GABA and excitatory glutamate work together to control many processes, including the brain’s overall level of excitation. The contributions of GABA and glutamate in extra-neuronal signaling are by far less widely recognized. In this chapter, we first discuss the role of both neurotransmitters during development, emphasizing the importance of the shift from excitatory to inhibitory GABAergic neurotransmission. The second part summarizes the biosynthesis and role of GABA and glutamate in neurotransmission in the mature brain, and major neurological disorders associated with glutamate and GABA receptors and GABA release mechanisms. The final part focuses on extra-neuronal glutamatergic and GABAergic signaling in pancreatic islets of Langerhans, and possible associations with type 1 diabetes mellitus.",book:{id:"6237",slug:"gaba-and-glutamate-new-developments-in-neurotransmission-research",title:"GABA And Glutamate",fullTitle:"GABA And Glutamate - New Developments In Neurotransmission Research"},signatures:"Christiane S. Hampe, Hiroshi Mitoma and Mario Manto",authors:[{id:"210220",title:"Prof.",name:"Christiane",middleName:null,surname:"Hampe",slug:"christiane-hampe",fullName:"Christiane Hampe"},{id:"210485",title:"Prof.",name:"Mario",middleName:null,surname:"Manto",slug:"mario-manto",fullName:"Mario Manto"},{id:"210486",title:"Prof.",name:"Hiroshi",middleName:null,surname:"Mitoma",slug:"hiroshi-mitoma",fullName:"Hiroshi Mitoma"}]},{id:"35802",title:"Cross-Cultural/Linguistic Differences in the Prevalence of Developmental Dyslexia and the Hypothesis of Granularity and Transparency",slug:"cross-cultural-linguistic-differences-in-the-prevalence-of-developmental-dyslexia-and-the-hypothesis",totalDownloads:3601,totalCrossrefCites:2,totalDimensionsCites:7,abstract:null,book:{id:"673",slug:"dyslexia-a-comprehensive-and-international-approach",title:"Dyslexia",fullTitle:"Dyslexia - A Comprehensive and International Approach"},signatures:"Taeko N. Wydell",authors:[{id:"87489",title:"Prof.",name:"Taeko",middleName:"N.",surname:"Wydell",slug:"taeko-wydell",fullName:"Taeko Wydell"}]},{id:"58597",title:"Testosterone and Erectile Function: A Review of Evidence from Basic Research",slug:"testosterone-and-erectile-function-a-review-of-evidence-from-basic-research",totalDownloads:1331,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Androgens are essential for male physical activity and normal erectile function. Hence, age-related testosterone deficiency, known as late-onset hypogonadism (LOH), is considered a risk factor for erectile dysfunction (ED). This chapter summarizes relevant basic research reports examining the effects of testosterone on erectile function. Testosterone affects several organs and is especially active on the erectile tissue. The mechanism of testosterone deficiency effects on erectile function and the results of testosterone replacement therapy (TRT) have been well studied. Testosterone affects nitric oxide (NO) production and phosphodiesterase type 5 (PDE-5) expression in the corpus cavernosum through molecular pathways, preserves smooth muscle contractility by regulating both contraction and relaxation, and maintains the structure of the corpus cavernosum. Interestingly, testosterone deficiency has relationship to neurological diseases, which leads to ED. Testosterone replacement therapy is widely used to treat patients with testosterone deficiency; however, this treatment might also induce some problems. Basic research suggests that PDE-5 inhibitors, L-citrulline, and/or resveratrol therapy might be effective therapeutic options for testosterone deficiency-induced ED. Future research should confirm these findings through more specific experiments using molecular tools and may shed more light on endocrine-related ED and its possible treatments.",book:{id:"5994",slug:"sex-hormones-in-neurodegenerative-processes-and-diseases",title:"Sex Hormones in Neurodegenerative Processes and Diseases",fullTitle:"Sex Hormones in Neurodegenerative Processes and Diseases"},signatures:"Tomoya Kataoka and Kazunori Kimura",authors:[{id:"219042",title:"Ph.D.",name:"Tomoya",middleName:null,surname:"Kataoka",slug:"tomoya-kataoka",fullName:"Tomoya Kataoka"},{id:"229066",title:"Prof.",name:"Kazunori",middleName:null,surname:"Kimura",slug:"kazunori-kimura",fullName:"Kazunori Kimura"}]}],onlineFirstChaptersFilter:{topicId:"18",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81646",title:"Cortical Plasticity under Ketamine: From Synapse to Map",slug:"cortical-plasticity-under-ketamine-from-synapse-to-map",totalDownloads:15,totalDimensionsCites:0,doi:"10.5772/intechopen.104787",abstract:"Sensory systems need to process signals in a highly dynamic way to efficiently respond to variations in the animal’s environment. For instance, several studies showed that the visual system is subject to neuroplasticity since the neurons’ firing changes according to stimulus properties. This dynamic information processing might be supported by a network reorganization. Since antidepressants influence neurotransmission, they can be used to explore synaptic plasticity sustaining cortical map reorganization. To this goal, we investigated in the primary visual cortex (V1 of mouse and cat), the impact of ketamine on neuroplasticity through changes in neuronal orientation selectivity and the functional connectivity between V1 cells, using cross correlation analyses. We found that ketamine affects cortical orientation selectivity and alters the functional connectivity within an assembly. These data clearly highlight the role of the antidepressant drugs in inducing or modeling short-term plasticity in V1 which suggests that cortical processing is optimized and adapted to the properties of the stimulus.",book:{id:"11374",title:"Sensory Nervous System - Computational Neuroimaging Investigations of Topographical Organization in Human Sensory Cortex",coverURL:"https://cdn.intechopen.com/books/images_new/11374.jpg"},signatures:"Ouelhazi Afef, Rudy Lussiez and Molotchnikoff Stephane"},{id:"81582",title:"The Role of Cognitive Reserve in Executive Functioning and Its Relationship to Cognitive Decline and Dementia",slug:"the-role-of-cognitive-reserve-in-executive-functioning-and-its-relationship-to-cognitive-decline-and",totalDownloads:23,totalDimensionsCites:0,doi:"10.5772/intechopen.104646",abstract:"In this chapter, we explore how cognitive reserve is implicated in coping with the negative consequences of brain pathology and age-related cognitive decline. Individual differences in cognitive performance are based on different brain mechanisms (neural reserve and neural compensation), and reflect, among others, the effect of education, occupational attainment, leisure activities, and social involvement. These cognitive reserve proxies have been extensively associated with efficient executive functioning. We discuss and focus particularly on the compensation mechanisms related to the frontal lobe and its protective role, in maintaining cognitive performance in old age or even mitigating the clinical expression of dementia.",book:{id:"11742",title:"Neurophysiology",coverURL:"https://cdn.intechopen.com/books/images_new/11742.jpg"},signatures:"Gabriela Álvares-Pereira, Carolina Maruta and Maria Vânia Silva-Nunes"},{id:"81488",title:"Aggression and Sexual Behavior: Overlapping or Distinct Roles of 5-HT1A and 5-HT1B Receptors",slug:"aggression-and-sexual-behavior-overlapping-or-distinct-roles-of-5-ht1a-and-5-ht1b-receptors",totalDownloads:19,totalDimensionsCites:0,doi:"10.5772/intechopen.104872",abstract:"Distinct brain mechanisms for male aggressive and sexual behavior are present in mammalian species, including man. However, recent evidence suggests a strong connection and even overlap in the central nervous system (CNS) circuitry involved in aggressive and sexual behavior. The serotonergic system in the CNS is strongly involved in male aggressive and sexual behavior. In particular, 5-HT1A and 5-HT1B receptors seem to play a critical role in the modulation of these behaviors. The present chapter focuses on the effects of 5-HT1A- and 5-HT1B-receptor ligands in male rodent aggression and sexual behavior. Results indicate that 5-HT1B-heteroreceptors play a critical role in the modulation of male offensive behavior, although a definite role of 5-HT1A-auto- or heteroreceptors cannot be ruled out. 5-HT1A receptors are clearly involved in male sexual behavior, although it has to be yet unraveled whether 5-HT1A-auto- or heteroreceptors are important. Although several key nodes in the complex circuitry of aggression and sexual behavior are known, in particular in the medial hypothalamus, a clear link or connection to these critical structures and the serotonergic key receptors is yet to be determined. This information is urgently needed to detect and develop new selective anti-aggressive (serenic) and pro-sexual drugs for human applications.",book:{id:"10195",title:"Serotonin and the CNS - New Developments in Pharmacology and Therapeutics",coverURL:"https://cdn.intechopen.com/books/images_new/10195.jpg"},signatures:"Berend Olivier and Jocelien D.A. Olivier"},{id:"81093",title:"Prehospital and Emergency Room Airway Management in Traumatic Brain Injury",slug:"prehospital-and-emergency-room-airway-management-in-traumatic-brain-injury",totalDownloads:49,totalDimensionsCites:0,doi:"10.5772/intechopen.104173",abstract:"Airway management in trauma is critical and may impact patient outcomes. Particularly in traumatic brain injury (TBI), depressed level of consciousness may be associated with compromised protective airway reflexes or apnea, which can increase the risk of aspiration or result in hypoxemia and worsen the secondary brain damage. Therefore, patients with TBI and Glasgow Coma Scale (GCS) ≤ 8 have been traditionally managed by prehospital or emergency room (ER) endotracheal intubation. However, recent evidence challenged this practice and even suggested that routine intubation may be harmful. This chapter will address the indications and optimal method of securing the airway, prehospital and in the ER, in patients with traumatic brain injury.",book:{id:"11367",title:"Traumatic Brain Injury",coverURL:"https://cdn.intechopen.com/books/images_new/11367.jpg"},signatures:"Dominik A. Jakob, Jean-Cyrille Pitteloud and Demetrios Demetriades"},{id:"81011",title:"Amino Acids as Neurotransmitters. The Balance between Excitation and Inhibition as a Background for Future Clinical Applications",slug:"amino-acids-as-neurotransmitters-the-balance-between-excitation-and-inhibition-as-a-background-for-f",totalDownloads:19,totalDimensionsCites:0,doi:"10.5772/intechopen.103760",abstract:"For more than 30 years, amino acids have been well-known (and essential) participants in neurotransmission. They act as both neuromediators and metabolites in nervous tissue. Glycine and glutamic acid (glutamate) are prominent examples. These amino acids are agonists of inhibitory and excitatory membrane receptors, respectively. Moreover, they play essential roles in metabolic pathways and energy transformation in neurons and astrocytes. Despite their obvious effects on the brain, their potential role in therapeutic methods remains uncertain in clinical practice. In the current chapter, a comparison of the crosstalk between these two systems, which are responsible for excitation and inhibition in neurons, is presented. The interactions are discussed at the metabolic, receptor, and transport levels. Reaction-diffusion and a convectional flow into the interstitial fluid create a balanced distribution of glycine and glutamate. Indeed, the neurons’ final physiological state is a result of a balance between the excitatory and inhibitory influences. However, changes to the glycine and/or glutamate pools under pathological conditions can alter the state of nervous tissue. Thus, new therapies for various diseases may be developed on the basis of amino acid medication.",book:{id:"10890",title:"Recent Advances in Neurochemistry",coverURL:"https://cdn.intechopen.com/books/images_new/10890.jpg"},signatures:"Yaroslav R. 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Endotheliitis of CNS vessels can lead to vessel occlusion and stroke. COVID-19 can also result in cerebral hemorrhage and sinus thrombosis possibly related to changes in clotting behavior. Vaccination is most important to prevent COVID-19 in the nervous system. There are symptomatic or/and curative therapeutic approaches to combat COVID-19 related nervous system damage that are partly still under study.",book:{id:"10890",title:"Recent Advances in Neurochemistry",coverURL:"https://cdn.intechopen.com/books/images_new/10890.jpg"},signatures:"Robert Weissert"}],onlineFirstChaptersTotal:17},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:0,limit:8,total:null},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:99,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:27,numberOfPublishedChapters:289,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:9,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:139,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:0,numberOfUpcomingTopics:2,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!1},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:108,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:2,numberOfUpcomingTopics:1,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:0,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!1},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:11,numberOfOpenTopics:4,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. 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Dr. Khalid\\'s research interests include leadership and negotiations, digital transformations, gamification, eLearning, blockchain, Big Data, and management of information technology. Dr. Bilal Khalid also serves as an academic editor at Education Research International and a reviewer for international journals.",institutionString:"KMITL Business School",institution:{name:"King Mongkut's Institute of Technology Ladkrabang",country:{name:"Thailand"}}},{id:"418514",title:"Dr.",name:"Muhammad",middleName:null,surname:"Mohiuddin",slug:"muhammad-mohiuddin",fullName:"Muhammad Mohiuddin",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038UqSfQAK/Profile_Picture_2022-05-13T10:39:03.jpg",biography:"Dr. Muhammad Mohiuddin is an Associate Professor of International Business at Laval University, Canada. He has taught at Thompson Rivers University, Canada; University of Paris-Est, France; Osnabruck University of Applied Science, Germany; and Shanghai Institute of Technology and Tianjin University of Technology, China. He has published research in Research Policy, Applied Economics, Review of Economic Philosophy, Strategic Change, International Journal of Logistics, Sustainability, Journal of Environmental Management, Journal of Global Information Management, Journal of Cleaner Production, M@N@GEMENT, and more. He is a member of CEDIMES Institut (France), Academy of International Business (AIB), Strategic Management Society (SMS), Academy of Management (AOM), Administrative Science Association of Canada (ASAC), and Canadian council of small business and entrepreneurship (CCSBE). He is currently the director of the Research Group on Contemporary Asia (GERAC) at Laval University. He is also co-managing editor of Transnational Corporations Review and a guest editor for Electronic Commerce Research and Journal of Internet Technology.",institutionString:"Université Laval",institution:{name:"Université Laval",country:{name:"Canada"}}},{id:"189147",title:"Dr.",name:"Hailan",middleName:null,surname:"Salamun",slug:"hailan-salamun",fullName:"Hailan Salamun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/189147/images/19274_n.jpeg",biography:"Hailan Salamun, (Dr.) was born in Selangor, Malaysia and graduated from Tunku Ampuan Jamaah Religious High School at Shah Alam. Obtained a degree from the International Islamic University (UIA), Gombak in the field of Islamic Revealed Knowledge and Heritage. Next, I furthered my studies to the professional level to obtain a Diploma in Education at UIA. After serving for several years in school, I furthered my studies to the Master of Dakwah and Leadership at Universiti Kebangsaan Malaysia (UKM), Bangi. I graduated with a Doctor of Philosophy in Principalship Leadership from the University of Malaya (UM) in 2010. I am currently a senior lecturer in the Department of Nationalism and Civilization, Center for Basic and Continuing Education, Universiti Malaysia Terengganu. Prior to that, I had served in several educational institutions such as schools, the Institute of Teacher Education (IPG), and also the University of Malaya. I am also actively involved in paper presentation, writing and publishing. My research interests are focused on leadership, education, society and Islamic civilization. This area of research requires a detailed understanding of Islamic studies and research studies in leadership. 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