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Although invasive procedures such as facelifts can achieve skin tightening quickly, they do not rejuvenate the skin and subcutaneous tissues and are accompanied with prolonged downtime and potential adverse effects. Ablative procedures such as traditional skin resurfacing with CO2 laser devices are also effective for skin tightening, however they are associated with extended recovery time, bleeding, oozing, and risk of post-treatment hyper- or hypopigmentation [1, 2]. In addition, laser treatments can be very problematic for treating darker skin types or sensitive Asian skin.
A major cause of wrinkles and laxity is the reduction in the quantity and quality of collagen fibers in the dermis and hypodermis [3]. Therefore, various devices have been introduced to stimulate collagen production. I previously reported that near-infrared can penetrate deep into human tissue, achieve skin tightening and muscle thinning, and nonthermally induce various responses in the skin and subcutaneous tissues [4, 5, 6, 7, 8, 9, 10, 11]. In addition, I previously reported that near-infrared or radiofrequency (RF) treatments stimulate collagen and elastin production while safely and effectively promoting long-lasting skin tightening results that decrease wrinkles and laxity [12, 13].
RF treatments for skin tightening are common, as they heat the dermis and subcutaneous tissues, thereby stimulating dermal collagen remodeling. It is well documented that dermal heating induces an immediate change in collagen structure followed by a long-term stimulation of neocollagenesis [14]. These thermal effects can improve wrinkle appearance, skin laxity and contour of both face and body.
RF has been shown to overcome several disadvantages inherited in optical light-based treatments by offering enhanced tissue penetration that is independent of skin color, and beneficial skin tightening effects. The working principle of RF devices is to heat the dermis and subcutaneous tissues [15], and to induce both collagen remodeling and skin tightening. RF techniques have been proven to be safe and effective for both nonablative skin tightening and fractional RF skin resurfacing [16, 17, 18].
The thermal effects of different RF technologies such as monopolar and bipolar RF have been proven to be beneficial in skin tightening. Nevertheless, these effects were frequently partial or unpredictable because of the uncontrolled nature of monopolar or unipolar RF and the superficial nature of energy flow for bipolar, tripolar or multipolar configurations. These first-generation RF systems lack adaptation of delivered power to address the differences in individual skin impedances. Therefore, I have been using a multisource phase–controlled system, which allows continuous real-time measurement of skin impedance and delivers constant adjusted energy to the patient skin, independent of changes in its impedance.
In fractional laser or skin resurfacing treatments, thermally ablated or coagulated microscopic zones from the epidermis to the dermis are spaced in a grid over the skin surface with the nonablated zones in the undamaged surrounding tissue serving as a reservoir of cells that accelerate and promote rapid healing [19]. Same principle is implemented with microneedling, as a healthy tissue reservoir assists to reduce downtime.
The first generation of microneedle RF delivery technology used insulated needles to provide skin rejuvenation and treat acne scars. With insulated RF microneedles, the energy flows only through the tip of the needle, resulting in a small, coagulated sphere-like shape in the dermis. However, insulated RF microneedles can have several disadvantages, including: (i) micro-bleeding during treatment; (ii) the need for several passes at different lengths to affect the entire depth of the dermis [15, 18, 20]; (iii) ineffective for skin laxity.
Therefore, in my studies I have been using a tapered, noninsulated microneedle radiofrequency (NIMNRF) applicator with novel fractionated pulse mode. This device achieves cylindrical micro zones of coagulation in the papillary and reticular dermis with minimal damage to the epidermis. The needles are inserted into the skin by a specially designed smooth motion motor that is electronically controlled to minimize patient discomfort. Furthermore, RF emission delivered throughout the whole dermal portion of the needle allows for effective coagulation, resulting in minimal or no bleeding, together with bulk volumetric heating.
RF technology is now considered to be one of the standard options for esthetic treatments, and as such I would like to provide clinical evidence of skin tightening using multisource phase-controlled RF treatment in this chapter. Many previous studies have reported the efficacy of various types of esthetic devices, but these studies have not included sufficient objective evaluations. Conventional evaluations using before and after treatment photographs have been widely used, but they do not provide accurate objective assessment [12, 13, 21]. For quantitative volume measurements, I have used a 3-dimensional photographic system to objectively evaluate the amount of post-treatment volume change in my clinical research.
RF is a part of the electromagnetic spectrum. RF can induce thermal effects in the deep tissue, whereas nonablative intense pulse light only reaches the superficial dermis, which is not clinically sufficient to treat laxity (Figure 1).
The electromagnetic spectrum covers a wide range of energy radiation types.
RF has been traditionally used for tissue heating in the field of surgery, especially as a method of coagulation for hemostasis. Tissue heating for skin tightening is achieved through tissue resistance to RF conductivity current (Joule’s law). A major cause of wrinkles, laxity and cellulite is the reduction in the quantity and quality of collagen in the dermis and hypodermis. A loss of normal elastic fiber function is a common age-associated feature of both photoaging and intrinsic aging processes. The accelerated aging and sagging of the skin seen in several hereditary disorders involves collagen or elastin deficiency. RF is considered to be safe and very effective procedure to stimulate production of water-binding proteins, such as collagen and elastin. The effects induced by RF treatment are independent of skin color.
Monopolar RF was the first nonablative RF technology shown to be effective for skin tightening. Although deep penetration could be more effective, the treatment by use of monopolar RF is painful. Due to the uncontrolled RF flow, the treatment is less safe and requires high energy of RF and intense cooling to protect the epidermis (Figure 2). Finally, because the device has a disposable tip, cost effectiveness is another important concern.
Monopolar RF technologies. One RF generator controls one electrode. Penetration is deeper than bipolar, since there is a flow of energy through the body to the grounding pad. Monopolar RF energy delivery results in high temperature near the electrode, requiring intense epidermal cooling, and uncontrolled energy spreading toward the grounding pad. Monopolar RF may be painful since higher power is required to “push” the RF from the single electrode into the skin.
Bipolar and multipolar devices have one RF generator, which connects to two or more electrodes. Because the RF energy delivery is superficial, following the shortest path between the electrodes, the treatment is relatively safe. However, with these devices, RF energy does not penetrate to the required depth and therefore is less efficient for skin tightening (Figure 3). Bipolar RF devices require active cooling of electrodes to prevent epidermal burns, whereas multipolar RF devices does not need cooling because the energy is split between two or more receiving electrodes. Moreover, at any given moment during treatment only a single path is made between two electrodes.
Bipolar RF technologies (left). One RF generator controls two electrodes. There is only superficial penetration since the energy flows along the shortest path, between the two electrodes. It requires active cooling of electrodes to prevent epidermal burns. “Multi-polar” RF Technologies (right). One RF generator controls 3–5 electrodes. There is only superficial penetration since the energy flows along the shortest path, between the 3–5 electrodes (similar to bipolar RF). No cooling is needed because the energy is split between two or more receiving electrodes.
The effects induced by monopolar, bipolar, and multipolar RF devices have been frequently partial or unpredictable because of the uncontrolled nature of monopolar or unipolar RF and the superficial nature of energy flow for bipolar, tripolar or multipolar configurations. These first-generation RF systems lack adaptation of delivered power to differences in individual skin impedance.
Due to this lack of efficacy in these traditional RF technologies, I have been using a multisource phase–controlled RF system, which allows continuous real-time measurement of skin impedance and delivers constant energy to the patient skin independent of changes in its impedance. The RF device I have been using is an EndyMed PRO™ 3DEEP treatment platform (EndyMed Medical, Caesarea, Israel), a phase-controlled, multisource RF system that emits at 1 MHz at 1–65 W. This RF device has a unique way to deliver energy to the deep dermis and hypodermis while minimizing epidermal heating. It has six phase-controlled RF generators, allowing a complex 3D interaction between the electromagnetic fields produced in the tissue. The inner electrodes current acts as a potential barrier, which forces the next set of electrode current to penetrate deep below, and so on, creating a 3DEEP energy complex. In addition, due to the repulsion of electrical fields with the same polarity, no current is created between these electrodes on the skin surface, allowing minimal epidermal flow (Figures 4 and 5).
Multisource phase-controlled, RF system. This system can deliver RF energy to deep layers of the skin. Focused & contained deep energy flow. Minimal surface energy flow eliminates the need for intense cooling. Totally safe & painless. Personalized parameters based on multiple unique automatic skin sensing feedback mechanisms.
Comparison of bipolar vs. multisource phase-controlled RF system. With bipolar device (300 W, 1 s), superficial flow of energy, penetrates only to 1.5 mm depth. Multisource phase-controlled RF system (4 electrode, 2 × 150 W, 1 s) shows vertical flow of energy, penetrates to 6 mm depth. Absolutely no surface heat between the external electrodes. The surface flow is only between the two middle electrodes.
I typically perform treatments using approximately 33 W output, which is low enough that the sensation of excessive heat would not be felt. If the patient reports a strong sensation of heat, treatment movement can be performed slightly faster and/or the handpiece head can be moved slightly away from the point of heat sensation. No topical anesthetics or oral analgesics are needed before, during, or after the treatment, and skin cooling is not required.
I have been using the tapered noninsulated microneedle radiofrequency (NIMNRF) applicator operating with a novel fractionated pulse mode (Intensif Handpiece, EndyMed Medical, Caesarea, Israel) for tightening and acne scar treatments (Figures 6 and 7) [22, 23, 24, 25]. The system platform (1MHZ) incorporates six independent phase controlled RF generators that allow the RF microneedles to induce skin remodeling through controlled dermal coagulation. The needle penetration depth is up to 3.5 mm in digitally controlled increments of 0.1 mm. The power is adjustable from 0 to 25 W with increments of 1 W. The pulse duration can be changed in 30 ms increments (maximal pulse duration is 200 ms) [15].
FDA-cleared, very sharply tapered noninsulated gold plated microneedle RF applicator operating with a novel fractionated pulse mode (above). Sterilized treatment tip with 25 microneedles (300 micron diameter at the base that gradually tapers to an especially sharp edge. Microneedles are inserted into the skin by a specially designed smooth motion motor that is electronically controlled to minimize patient discomfort (below).
A heat schematic of fractional lasers and microneedles. Images from left to right show fractional lasers, insulated needles, noninsulated needles, and very sharply tapered noninsulated gold plated microneedles. (left). RF emission delivered over the whole dermal portion of the needle allows effective coagulation resulting in minimal or no bleeding, together with bulk volumetric heating. Histology of in vivo pig skin (right). This biopsy was taken immediately after treatment. The protocol was approved by the institutional ethics committee. H & E staining show dermal coagulation that matches the needle penetration depth. The parameters are 15 W, 140 ms, 2.5 mm. Scale bar = 500 μm. Cited from
Thermography during a laboratory model simulation taken by a thermal camera (FLIR SC640, FLIR, Boston, MA, USA) using a laboratory skin model with an impedance that is similar to that of the human dermis. The penetration depth is 2.5 mm. The temperatures shown in this figure are relatively low because this is a laboratory model simulation wherein low power RF was used to obtain qualitative imaging. In vivo temperatures would be higher than those of a laboratory model simulation, as demonstrated by histology and coagulative effects on capillaries. Patients undergoing Intensif treatment received from 500 to 1000 pulses with the following parameters: pulse duration 80–110 ms, power 10–14 W and 1.5–2.5 mm penetration depth.
Twenty Japanese patients (18 females and 2 males) aged 26–69 years (mean age, 42.4 ± 9.92 years) with Fitzpatrick skin type III to V were enrolled.
None of the subjects had a history of any type of skin disease or any cosmetic procedures affecting the treatment areas within the last 3 years. No topical pretreatment was used, and the post-treatment skin care regimen consisted of a gentle cleanser and sunblock. All patients gave written informed consent for participation in the study after reading the experimental protocol and being advised about the risks of treatments.
Objective assessments, evaluated by gray scale images and 3-dimensional color schematic representation with quantitative volume measurements, showed significant improvement after the multisource phase-controlled RF treatment (Figures 8–10).
Representative photographs of tightening effects treated with multisource phase-controlled RF treatments. Pretreatment (above, left), a 44-year-old Japanese woman exhibited skin laxity in cheek, mental portion, and neck, and wrinkles such as nasolabial fold. Cheek and neck were treated. Three treatments at 33 W. Three months post-treatment (above, right), significant improvements were noted in both skin laxity and wrinkles. Three-dimensional color schematic representation shows the varying degrees of tightening achieved in colors yellow to red (below). Green areas remain unchanged. These images indicate significant improvement of appearance, skin laxity, and wrinkles after multisource phase-controlled RF treatments.
Representative photographs of tightening effects treated with multisource phase-controlled RF treatment. Pretreatment (above, left), a 50-year-old Japanese woman exhibited skin laxity in cheek, mental portion, and neck, and wrinkles such as nasolabial fold. Cheek and neck were treated. Three treatments at 33 W. Three months post-treatment (above, right), significant improvements were noted in both skin laxity and wrinkles. Three-dimensional color schematic representation shows the varying degrees of tightening achieved in colors yellow to red (below). Green areas remain unchanged. These images indicate significant improvement of appearance, skin laxity, and wrinkles after multisource phase-controlled RF treatments.
Representative photographs of tightening effects treated with multisource phase-controlled RF treatment. Pretreatment (left), a 43-year-old Japanese woman exhibited skin laxity in cheek, mental portion, and neck, and wrinkles such as nasolabial fold. Cheek and neck were treated. Three treatments at 33 W only to patient’s left cheek. Three months post-treatment (right), significant improvements were noted in both skin laxity and wrinkles. Three-dimensional color schematic representation shows the varying degrees of tightening achieved in colors yellow to red (below). These images indicate significant improvement of appearance, skin laxity, and wrinkles after multisource phase-controlled RF treatments.
Human skin specimens from the face (3–5 from each patient) were obtained for microscopic investigation. Biopsies were taken pretreatment as a control and at 2 month after the final treatment. The specimens were fixed in 20% neutral buffered formalin, processed for paraffin embedding and serially sectioned along the sagittal plane (3–4 μm thickness). Tissue sections were stained by Victoria Blue staining (Figure 11). Elastin densities stained by Victoria Blue staining in the dermis were calculated after an optimized color threshold was applied to each image to distinguish between the stained areas and background. Images were scanned and quantified in five representative fields per section, and subsequently averaged to obtain a final score (Figure 12). The sections were photographed under an Olympus BX50 microscope (Olympus, Tokyo, Japan). The digital photographs were processed using Adobe Photoshop (Adobe, San Jose, CA, USA).
A representative histology of Japanese patients’ cheek skin evaluated by Victoria blue staining. The amount of elastin stained in blue significantly increased post-treatment compared with control. Scale bars = 100
Mean densities of elastin in the dermis. Skin biopsies were taken from five Japanese female patients who had visited the Clinica Tanaka Anti-Aging Center to remove some pigmented nevi (more than one pigmented nevus on both control and treated side of the cheek) and achieve skin rejuvenation on their faces. The densities of elastin were significantly increased compared with controls (
Fifteen Asian patients (14 females and 1 male) aged 31–66 years (mean age, 43.4 ± 9.0 years) with Fitzpatrick skin type III-V were enrolled. All of the patients had visited the Clinica Tanaka Anti-Aging Center to achieve full facial skin tightening. None of the patients had a history of any type of skin disease or cosmetic procedure that affected the treatment areas. Topical anesthetic cream was applied to the patient’s skin for 60 min before the treatment. The post-treatment skin care regimen consisted of a gentle cleanser and sunblock. Patients did not use any specific skin care products and had no specific diet. Patients who exhibited weight loss during the study period were excluded from volumetric measurement analyses because changes in diet and/or exercise may affect volumetric changes. After reading the experimental protocol and being advised of the treatment risks, all patients gave written informed consent for participation.
Objective assessments evaluated with a superimposed 3-D color schematic representation showed long-lasting and significant volumetric reduction after the treatment. Representative 2-D color, and superimposed 3-D color images and volumetric reductions are shown in Figures 13–16.
A 31-year-old female. Cheek mode: Pulse width; 110 ms, 14 W, 2.5 mm, 200 shots + Periorbital mode: 80 m, 10 W, 1.5 mm, 100 shots. Images from left to right show the appearance pretreatment to 12 months after the treatment. Improvement of skin texture and dilated skin pores was observed after treatment with time (above). Volumetric reduction (ml) at 6 and 12 months follow up point relative to the pretreatment volume (below, left). Superimposed 3-D color images that show the volumetric change distribution 6 and 12 months after the treatment compared to pretreatment (below, right). The varying degrees of tightening are artificially colored and range from yellow to red (red, −5 mm change). Green areas indicated no changes to the face, and gray areas indicate changes over −5 mm. Significant volumetric reduction in the nasal and perioral areas was observed. Cited from
A 40-year-old male. Cheek mode: Pulse width; 110 ms, 14 W, 2.5 mm, 300 shots + Periorbital mode: 80 ms, 10 W, 1.5 mm, 200 shots. Images from left to right show the appearance pretreatment to 12 months after the treatment. Improvement of skin texture and dilated skin pores was observed after treatment with time (above). Volumetric reduction (ml) at 6 and 12 months follow up point relative to the pretreatment volume (below, left). Superimposed 3-D color images that show the volumetric change distribution 6 and 12 months after the treatment compared to pretreatment (below, right). The varying degrees of tightening are artificially colored and range from yellow to red (red, −5 mm change). Green areas indicated no changes to the face, and gray areas indicate changes over −5 mm. Significant volumetric reduction in the nasal and perioral areas was observed. Cited from
A 47-year-old male. Cheek mode: Pulse width; 110 ms, 14 W, 2.5 mm, 300 shots + Periorbital mode: 80 ms, 10 W, 1.5 mm, 200 shots. Images from left to right show the appearance pretreatment to 12 months after the treatment. Improvement of skin texture and dilated skin pores was observed after treatment with time (above). Volumetric reduction (ml) at 6 and 12 months follow up point relative to the pretreatment volume (below, left). Superimposed 3-D color images that show the volumetric change distribution 6 and 12 months after the treatment compared to pretreatment (below, right). The varying degrees of tightening are artificially colored and range from yellow to red (red, −5 mm change). Green areas indicated no changes to the face, and gray areas indicate changes over −5 mm. Significant volumetric reduction in the nasal and perioral areas was observed. Cited from
Median volumetric reductions at 6 and 12 months post-treatment were 14.1 and 13.8 ml, respectively. Significant volumetric reductions were observed at 6 and 12 months post-treatment compared with pretreatment (
Objective assessments of skin laxity showed significant improvements, and most patients were satisfied with the results after multisource phase-controlled radiofrequency RF treatments. The advantages of the multisource RF treatments are the reduction in discomfort and side effects. The results indicate that multisource phase-controlled radiofrequency RF treatments provide safe and effective long-term stimulation of elastin, which is beneficial for skin rejuvenation by improving skin laxity and wrinkles.
A multisource phase-controlled radiofrequency RF treatments system was used in this study, which allows continuous real-time measurement of skin impedance and the delivery of constant energy to the patient skin, independent of changes in its impedance. By using this multisource phase-controlled radiofrequency RF system, less thermal damage of the dermis and subcutaneous tissues occurred compared to monopolar or unipolar RF treatments. Multisource phase-controlled radiofrequency RF technology is based on the fact that due to the use of six RF generators, the energy flow on the skin surface is minimal, since all the energy is directed to the depth of the tissue. This is achieved by repulsion between electrical field of the same polarity on each side of the handpiece electrodes [14]. Since multisource phase-controlled radiofrequency RF handpiece delivers energy in constant circulatory motion, the effect will be an average lower temperature on the epidermis (<42°C) and higher temperature in the lower skin layers, without the need for cooling. This technology allows the system to keep epidermal temperature bellow 42°C while reaching up to 57°C in the depth of the tissue 14.
Furthermore, most of the patients did not report feeling pain during the treatment, even though it was performed without anesthesia and contact cooling. A 33 W output was used, which was low enough so that the sensation of heat was not felt. According to peer-reviewed papers, even higher energies used with EndyMed systems were well tolerated by patients without any adverse events.
Side effects, such as epidermal burns, adipose tissue atrophy, and contraction, were not observed, and the patients felt comfortable during multisource phase-controlled radiofrequency RF treatment.
The results obtained by RF microneedle treatments appear to be significant even though patients were only treated once. This significant efficacy can be explained by three specific features of the tested RF microneedle device. First, this procedure produced deeper skin penetration of the microneedles (up to 3.5 mm) relative to fractional lasers that usually have a penetration of no more than 1.6 mm. Electronically controlled penetration allows exact monitoring of the penetration depth, which can be customized for different treatment areas. Second, the gold plated noninsulated needles have a smooth insertion that provides a significant advantage over first generation insulated and stainless steel needles. The clinical efficacy of insulated needles is limited due to the small volume of heat produced by RF emission only at the noninsulated area near the tip and significant micro-bleeding induced by the treatment. In contrast, the noninsulated gold plated needles used here emit RF throughout the whole length, thus allowing heating of three times the volume [26]. After the needle is inserted to its maximal depth, due to the lower impedance in the dermis relative to the epidermis, the RF will flow through the dermis with no epidermal coagulation and thus there is no need for needle insulation.
Third, smooth insertion of the needle by an electronically controlled motor that was used in the system tested here resulted in minimal patient pain and downtime while also minimizing trauma to the epidermis and bleeding. Other technologies that use fixed needles, which are inserted by hand or by a spring mechanism, are frequently more damaging to the epidermis and may increase the incidence of post-treatment hyperpigmentation [26].
Most of the patients in this study reported no severe pain during the treatment, even though it was performed without oral or intravenous anesthesia and contact cooling. This reduction in reported pain seen for the fractional RF microneedle treatment may be related to the sharpness of the needles and the unique motorized needle insertion.
Post-treatment complications include burning sensation and mild erythema, but these were minor and lasted less than 5 hours. Furthermore, PIH, epidermal burns and scar formation were not observed.
Nonthermal epidermis penetration performed with a tapered microneedle inserted by smooth motion is less traumatic to the epidermis and epidermal-dermal junction, and in turn decreases the likelihood of extended post-treatment erythema and PIH as compared to ablative and nonablative lasers or other manual or fixed microneedle RF systems. In addition, RF emission through the length of the needle provides for shorter treatment times and a coagulation effect that eliminate micro-bleeding and improve the patient experience [22, 23, 24, 25, 26]. Digital control of the needle penetration depth with automatic motorized insertion improves the patient experience by reducing discomfort and side effects [22, 23, 24, 25, 26].
Significant improvements in skin laxity were observed through objective and histological assessments after receiving EndyMed 3DEEP RF treatments. The results indicate that these RF treatments provide safe and effective stimulation of elastin, which is beneficial for skin rejuvenation by improving skin laxity and rhytids. The advantages of EndyMed RF treatments are long-lasting high efficacy with minimal downtime or side effects. Furthermore, EndyMed RF treatments are convenient for patients and require almost no downtime. Because of these advantages, it will be easily accepted by even socially active individuals regardless of age or sex.
Pulmonary tuberculosis (TB), a severe respiratory infection whose causative agent is
Pulmonary tuberculosis is divided into asymptomatic infection and active TB disease (ATB) [4]. Asymptomatic (latent) TB (LTB) is a clinically dormant form of infection whose mechanisms of activation and physiological maintenance with respect to host-pathogen dynamics are not fully characterized and although advances in imaging and high-throughput approaches have allowed for findings of tremendously higher resolution, details of the intricate dance between Mtb and the host remain moot [5]. Active tuberculosis is characterized with a wide spectrum of clinical manifestations, hallmarked by a purulent, bloody cough that aerosolizes into infectious droplet nuclei containing the pathogen [6, 7]. Although progress has been made in studying the immunogenetics and antimycobacterial mechanisms of the host, developing a broader comprehension of the matter has stagnated due to the underlying complexity of the relationship between the host and Mtb. Regardless, the innate immune response to inhalation of viable Mtb cells has been well studied and characterized with modest comprehensiveness, with a rigorously preserved hypothesis ascribing the most pathological importance to the TB granuloma [8, 9, 10, 11]. Whether inhalation of infectious droplet nuclei will result in active TB disease or LTB, depends on a plethora of genetic and external factors, some of which are better understood than others, and research is currently being directed at understanding these issues [12]. One such factor is the natural degree of resistance humans possess to the development of active TB disease upon being infected [8, 9, 13, 14]. Resistance to TB disease, however, is evidently influenced by numerous factors originating from the host, the pathogen and the environment. Innate resistance to the Mtb, however, is not fully understood from the aspect of human immunogenetics, although significant progress has been made in this field [15]. Furthermore, primary and post-primary tuberculosis—two entities of infection with distinct immunopathologic continua—seem to be studied in a disproportionate manner; primary TB is at the forefront of research, whilst the relevance of secondary TB is substantially overlooked [15]. Available evidence, however, suggests that the subsequent initiation of secondary TB is essential for Mtb survival in the host, which may elicit a need for a broadening of research focus within the domain of TB prophylaxis [2, 16, 17]. Regardless, the innate response to Mtb inhalation has been a topic of intense study in the field of immunology. These molecularly-oriented studies have synthesized a rather large number of vaccine candidates, many of which are currently undergoing clinical trials [17, 18]. In fact, nearly each novel human vaccine candidate primarily functions by amplifying the TH1 innate immune response; an approach owed to the general understanding that an insufficient magnitude of TH1 immunity leads to poor control and subsequent proliferation of Mtb; something based in a rather large body of literature [17, 19, 20, 21].
Immunization strategies for tuberculosis currently undergoing clinical trials include killed, whole cell mycobacteria (DAR-901,
This chapter comes at a crucial and exciting epoch in the domain of tuberculosis research, primarily facilitated by the rise of extensively-drug-resistant tuberculosis (XDR TB), multiple-drug-resistant tuberculosis (MDR TB) and totally-drug-resistant TB (TDR TB) across the world, and the diminishment of sensical and safe treatment options for all forms of TB [2, 23]. An imperative to expedite current research efforts directed towards development and discovery of more efficient treatment and diagnostic methods, has even been a topic of discussion by the United Nations, although this did not prove to be as fruitful as initially [2, 24]. Recent studies have incorporated other therapeutics into this treatment protocol, however the results on their efficacy appear to be population and circumstance-specific [23, 25, 26, 27]. Thus, tuberculosis is currently categorized as a global health ‘emergency’ by the WHO. It seems a rather sensical approach to focus research and provide comprehensive reviews on the immunopathologic course of TB and the relevant underlying genetic background that influences the outcome of TB infection.
The scope of this chapter includes the variability of the immune response to Mtb infection, concordant to differences in the immunogenetic profiles of the infected hosts across different populations in the context of immunoreceptors expressed on macrophage surfaces. We aim to present the most relevant findings in TB-related immunopathology and the corresponding implications in treatment and patient outcome in the context of macrophage involvement.
Five stages of pulmonary tuberculosis (Figure 1) have been distinguished by Lurie’s 1964 study on rabbits [5, 12, 18, 28, 29]. The importance of this study is seen in its high degree of fidelity with respect to the natural mode of contagion, which cannot be replicated by in vitro conditions [30]. Upon inhalation of even as few as 10 Mtb cells, the first stage is characterized by the rapid action taken by the innate immune defenses; phagocytosis of Mtb cells by resident macrophages (Mɸs) and other antigen-presenting cells (APCs) such as pulmonary dendritic cells (DCs) [31]. Varying immunopathologic continua may be observed for different phagocytic cells lines that phagocytize Mtb once it reaches the lung tissue upon inhalation, as the pathogen is able to employ different tactics to evade the host’s immune defenses and interfere with every involved component of the immune system [7, 13, 32]. The evolutionary battle between the human host and Mtb prompted the pathogen to enhance its entry tactics into phagocytes by engaging a specific set of phagocytic receptors and efficiently modulating and interfering with every immunobiological process that plays a role in TB infection, often with staggering success [7]. Ergo, the ability of Mtb to create a survivability niche within the bactericidal environment of phagocytes is considered essential for bacterial survival and intracellular persistence.
The immune response to inhalation of
Pattern recognition receptors (PRRs) located on the surface of APCs and respiratory epithelial cells that are engaged by Mtb include complement receptors (CRs), immunoglobulin fragment carrying the constant region of the heavy chain (Fc), C-type lectins (CTLs), toll like receptors (TLRs) and the scavenger receptors (SRs) (Image 1) [29]. Despite several receptors displaying partial redundancy in knockout murine models, engagement of each receptor has pathologically relevant implications in TB pathogenesis. For instance, studies on murine models revealed significant reduction in the number of opsonized mycobacteria actively internalized by Mɸs and other phagocytes in the absence of CR3s [28, 33]. C-type lectins located on Mɸs and DCs are likely favored by Mtb since their engagement opens an opportunity for the pathogen to modulate the intensity of the associated inflammatory responses [34]. Specifically, Mtb has the ability to suppress the MR-TLR2-associated pro-inflammatory response by secreting the early secreted antigenic target protein 6 (ESAT-6), which inhibits the activity of NF-kappa (NF-κB) by downregulating reactive oxygen species (ROS) production [26, 35, 36]. Relevant to this discussion is that ESAT-6 is used in the IGRA due to its potency as a T cell antigen; thus, this secretory mycobacterial protein is an important hallmark of TB infection [37]. Fcγ receptors (FcγR) play a role in regulating the intensity of the host immune response and are concordantly divided into activating and inhibiting types. Toll-like receptors (TLRs) play a cardinal role in priming both pro-inflammatory and anti-inflammatory responses [38]. The cytoplasmic domain of these phylogenetically conserved transmembrane proteins is homologous to the interleukin-1 receptor (IL-1R) signaling domain, which links to IL-1R-associated kinase (IRAK) in order to activate transcription factors that will promote cytokine production. Furthermore, phagocytosis of Mtb does not lead to a pro-inflammatory immune response in the absence of TLRs; particularly relevant is the TLR2, although other TLRs have demonstrated notable roles in immunopathology [7, 32]. With regards to an efficient immune response, TLR recognition of Mtb cell wall lipoproteins will induce the secretion of IL-12—a proinflammatory cytokine that promotes maturation of naïve T cells into Th1 cells—by infected phagocytes [7, 13]. Mutations or genetic polymorphisms will likely, therefore, compromise the ability of the human host to mount an appropriately controlled inflammatory response to TB [39, 40, 41, 42, 43, 44, 45, 46]. Aforementioned avenues for phagocytic receptor engagement make it all the more sensical that Mtb favors entry routes that seldom elicit a pro-inflammatory response, at least in early stages of infection. Pathways activated through the engagement of these receptors allow for immunobiological modulations that comprise the mycobacterial intracellular and intragranular persistence mechanism [37]. Although the intrinsic potency of Mɸs to kill internalized mycobacteria is evidently high through utilization of a barrage of bactericidal tactics, sufficiently virulent Mtb cells manage to evade or block these mechanisms [4, 47]. Thus, the intrinsic Mɸ competence and mycobacterial virulence significantly influence the course of the infection upon phagocytosis. Mycobacterial cells that evade the intrinsic killing mechanisms of phagocytes trigger an immunopathologic continua designated as the second stage, in which logarithmically multiplying Mtb cells inhibit the process of phagosome maturation and disrupt other incoming immune cells [18, 28, 48, 49, 50, 51, 52, 53, 54, 55]. Immature phagocytes infected with multiplying mycobacteria attract monocytes and other inflammatory-oriented immune cells in an attempt to swiftly contain the bacilli [56, 57, 58]. Studies conducted on murine models and human monocytic cell lines have somewhat elucidated the process by which Mtb blocks the phagosome maturation process, and are further discussed in the following sections.
Approximately 2–3 weeks after engulfing Mtb, infected phagocytes release cytokines in order to recruit antigen-specific T cells (CD4+) to primary tubercle lesions in order to form adaptive immunity [32, 49, 56]. Activated T cells undergo clonal expansion and initiate the killing mechanisms of Mɸs infected with mycobacteria. Within the Mɸ environment, the third stage commences, whereupon logarithmic Mtb growth is halted through various bacteriostatic mechanisms [26, 37]. Infected Mɸs generally go through apoptosis, a consequence of recruiting the tumor necrosis factor alpha (TNF-α), whose inhibition significantly improves Mɸ survivability in the host lungs [37]. Progressive intragranular apoptosis leads to central solid necrosis, which may be followed by liquification of the caseous foci [26]. Survivability of Mtb in dead phagosomes, however, has been continuously reported throughout the years, as necrosis is an outcome favorable for pathogen dissemination and immune evasion [58, 59, 60]. Progression of the solid necrotized lesions containing metabolically dormant bacilli into liquified caseous lesions forms ideal conditions for bacterial re-activation and rapid multiplication [5, 7, 13, 14, 15, 61, 62, 63, 64, 65]. Although immunocompetent patients are evidently able to suppress the development of TB disease, host genetics and pathogen virulence determine whether dormant Mtb bacilli remain contained in the granuloma, or cause the formation of liquified caseous foci [8, 9, 59]. These foci progress to form cavities in which Mtb extracellularly multiplies, causing subsequent bronchial rupture and migration of the bacilli outside of their containment [10].
Perhaps the most direct evidence of constitutional human resistance to TB infection and disease may be extrapolated from the 1926 Lübeck disaster, in which 251 neonates were orally administered a large dose of live, virulent
Innate immunity is critical for early anti-mycobacterial responses, it is also important for the progression of infection and long-term control of Mtb by continually priming and educating adaptive immune responses and by regulating inflammation [28]. The system comprises two components, cellular and humoral, the latter including circulating complement proteins, defensins, cytokines and chemokines secreted by innate immune cells [72]. The cellular component which requires our attention comprises of innate immune cells which consist of epithelial cells, endothelial cells (ECs), granulocytes (neutrophils, basophils, eosinophils, mast cells (MCs)), monocytes, macrophages, natural killer (NK) cells, dendritic cells (DCs), invariant NKT cells (iNKT cells), γδT cells, innate immune T cells called mucosal invariant T cells (MAIT) cells and innate lymphoid cells (ILCs). These cells are crucial for the maintenance of the immune homeostasis and regulation of the adaptive immune system; they act as antigen presenting cells (APCs) as well as provide other signaling molecules/factors required in the effective adaptive immune response in response to infection or chronic inflammatory diseases [72].
In the case of TB, the earliest encounter between the host’s immune system and Mtb occurs at the interface between resident lung (alveolar) macrophages and the virulent bacterial cells. These cells are often niches for bacterial replication and Mtb utilizes a myriad of strategies that subvert innate immune responses to establish a chronic infection [4]. During the past several decades, much has been uncovered and mechanisms through which the immune system responds to Mtb are in many ways illuminated, even though much still lingers in the shadows, which will hopefully be cast away over time. The first step is the recognition of mycobacteria as invading pathogens, followed by activation of innate host defense responses, and the subsequent initiation of adaptive immune responses [4]. Knowledge about these processes is crucial for understanding the pathophysiology of tuberculosis and for the development of novel strategies for vaccination and treatment such as immunotherapy.
The initiation process of the innate immune response starts with pattern recognition of microbial structures called pathogen-associated molecular patterns (PAMPs). Recognition of PAMPs is performed by germline-encoded receptors expressed mainly on immune cells termed pattern recognition receptors; in this case, being alveolar macrophages [26].
Recruitment of innate immune cells in the early stages of infection is the result of secretion of cytokines and chemokines either by infected phagocytic cells or respiratory lung epithelial cells [56]. Studies have shown that primary lung epithelial cells possess the ability to cross-talk with infected macrophages, which benefits the process of monocyte recruitment. Infected phagocytic cells, inside of which the first stage of Mtb infection commences, may either migrate to the mediastinal lymph nodes in order to prime a T cell response via antigen presentation, or directly prime naïve T cells [73]. In the context of innate immunity, recruitment of polymorphonuclear leukocytes (PMNLs) to the sight of infection seems to be a ‘double-edged’ sword that either leads to effective control of infection, or damaging inflammation [73]. A mouse study on the recruitment of PMNs by alveolar epithelial cells during early stages of infection, concluded that severely damaging inflammation can occur as a consequence of this process [73]. It was discovered that CXCR2 and CXCL5 significantly contribute to a high influx of PMNLs, which is the mechanism behind the destructive inflammatory response during the initial stages of infection in mice and non-human primates (NHP) [73, 74]. Numerous CXCR2 ligands seem to positively regulate PMNL recruitment in murine models.
With regards to TB in vivo infection, TLR2 recognition of Mtb molecular patterns induces expression of CXCL5 by alveolar epithelial cells, which subsequently recruits PMNLs via CXCR2. Tlr2−/− mutants demonstrated significantly diminished, although not abolished, secretion of CXCL5 in vivo [73, 75]. Considering that alveolar epithelial cells are not the only cells present in the bronchoalveolar space during Mtb infection, and that those cells secrete inflammatory mediators that promote secretion of CXCL5, this finding is not at all surprising. There is an absolute dependency on CXCR5 for recruitment of PMNLs into the bronchoalveolar space during Mtb infection [73]. In contrast, PMNL recruitment induced by CXCL5 was found to account for roughly 60% of PMNLs recruited to the airspaces in vivo [73]. Exacerbated inflammation occurs with an incredibly high degree of dependence to CXCL5 secretion and the dose of Mtb that has infected the host [56, 73]. CXCL5 is not only expressed by alveolar epithelial cells, but rather a variety of other tissue-resident cells, making its role in tissue inflammatory responses well emphasized [76]. Although much work lies ahead in understanding the implications of CXCL5 and CXCR2 in TB immunopathology in the context of innate and acquired immunity, having a better understanding of these pathways could aid in devising treatment approaches that would allow for avoidance of the devastating inflammatory damage seen in certain subpopulations of TB patients. As for these findings corresponding to human immunopathology in TB, the ENA-78 neutrophil attractant secreted by human pulmonary epithelial cells is very similar to murine CXCL5 [77]. Of course, further studies should be conducted in order to comprehensively understand whether the studies on CXCL5 could be translated to human TB. Unfortunately, this particular aspect of Mtb infection in humans has thus far received modest attention, however current research is indicative of this likely being the case.
The continuous development in the field of immunology has established their role in various immunological and non-immunological processes including embryonic development. Along with acting as phagocytic cells involved in the phagocytosis of pathogens, xenobiotics, these cells also secrete various cytokines, chemokines, and growth factors including TNF-α, TGF-β, platelet-derived growth factor (PDGF), endothelial growth factor (EGF), and vascular endothelial growth factor (VEGF) [72].
Alveolar macrophages encounter Mtb within the first 48 hours of infection, thereby representing the primary replicative niche for the bacillus [77]. Once Mtb is recognized by alveolar macrophages, it is engulfed through surface receptors, which leads to phagocytosis of the bacterium into phagosomes, which typically fuses with lysosomes for pathogen eradication and further consequent acidification of the pathogen-containing phagolysosome. Until recently the mechanism behind the establishment of a chronic infection in mammalian primates remained rather obscure; the lung interstitium, however, was definitely known to be the focal point of the infection based on previous studies [77]. In a 2018 study, performed by Cohen et al., discovered that alveolar macrophages transport Mtb from the alveoli to the interstitial tissue, under the influence of interleukin-1 signaling and the Mtb ESX1 secretion system [77]. Furthermore, localization of infected alveolar macrophages to the lung interstitial tissue leads to virulent Mtb cells being introduced to replication-permissive monocytes [13, 78]. Involvement of IL-1 in this process is not surprising considering that Mtb is a potent stimulator of the inflammasome, which regulates IL-1 production [79]. Contextually to recognition of mycobacterial antigens, one of the most important receptors for mycobacteria is the complement receptor 3, while other receptors such as CR1 and CR4, mannose receptor, surfactant protein A receptor, CD14, Fcγ receptor, scavenger receptors, have also been implicated in phagocytosis and internalization of mycobacteria inside the Mɸs [57].
The mycobacterial surface glycoprotein, mannose-capped lipoarabinomannan (Man-LAM) is recognized by the C-type lectins and the macrophage mannose receptor (MMR). An important role of toll-receptors, mainly the TLR2, has been demonstrated for the attachment of mycobacteria to macrophages [57]. Mtb is capable of inhibiting that process of phagosome maturation, as a result of which acidification of the phagosome is compromised, thus avoiding degradation and antigen processing [57]. Mtb is equipped with a variety of mechanisms that enable such form of survival, the key ones of which are stress-adaptive genes that are expressed in Mtb in order to counter the nitrosative, oxidative, hypoxic, and nutrient-diminished phagosome environment [80]. From an evolutionary point of view, it is clear that Mtb has developed alongside humans and thus adapted for a lifestyle inside the Mɸ, employing many strategies to survive within these cells.
Mtb entry intro Mɸs through different receptors can induce the activation of different pathways that can either inhibit or promote bacterial replication. Mɸ defenses include antimicrobial peptides (AMPs), nitrosative stresses, phagolysosome fusion and autophagy and may operate independently of or subsequent to IFN-γ signaling [7]. The overall interaction of multiple receptors and their engagement with Mtb ligands is a complex and dynamic issue. For instance, TLR-2 recognition of mycobacterial ManLAM activates NF-κB and NOS2 gene transcription that leads to antimycobacterial nitric oxide (NO) production, which is strongly associated with resistance to Mtb, even though evidence for that is stronger in mouse models [72, 81]. It has been shown that the reactive nitrogen intermediates (RNI) in mice are toxic to mycobacteria in vitro and by inhibition of NOs in vitro or in vivo infection can be exacerbated [44]. In relation, mice with disrupted NOS2 alleles display exacerbated disease following Mtb infection [44]. As for humans, in vitro studies using human alveolar macrophages and primary monocytes showed no anti-mycobacterial properties for NO, but specific staining for NOS2 in the bronchoalveolar lavage (BAL) of TB patients revealed upregulation in infected individuals compared to healthy controls. Another interesting fact is that mutations in Gp91phox, encoded by CYBB, a subunit of phagocyte oxidase enzyme complex (NADPH), pivotal for ROS (reactive oxygen species) are significantly correlated with reduced risk of TB [44].
In human macrophages, TLR-mediated recognition of Mtb is reported to synergize with the vitamin D pathway to induce the antimicrobial peptide (AMP), cathelicidin [77]. That process happens through calcitriol, a biologically active vitamin D metabolite, which induces the hCAP-18 gene encoding the pro-form of cathelicidin, following TLR ligation of macrophages. Studies have shown that cathelicidin exerts antimicrobial functions by activating transcription of host autophagy genes Beclin-1 and Atg5 [4]. Besides that, the vitamin D pathway also synergizes with IFN-γ secreted by T-cells to induce IL-15 autocrine signaling to promote autophagy and phagosome maturation in Mtb-infected human macrophages [4, 79].
Autophagy also plays a role in promoting phagosome maturation to enhance bacterial killing and it is integrated into the host response to Mtb infection by synergizing with pathogen sensing, phagosome maturation, and IFN-γ inducible pathways to mediate anti-mycobacterial immunity [4]. Autophagy-related proteins are likely to perform multiple functions and care must be taken when interpreting specific knockouts or knockdowns of individual genes. For instance, myeloid cell-specific ablation of Atg5 compromised control of Mtb in mouse studies. Deletion of autophagy-related genes Ulk1, Ulk2, Atg4B, or p62 compromised the ability to induce autophagy, but were dispensable for control of
The factor responsible for macrophage activation is IFN-γ produced by CD8+ cytotoxic T (Tc1) cells, CD4+ T helper 1 (Th1) T cells, and natural killer (NK) cells. IFN-γ activation leads to conversion of macrophages to potent phagocytotic cells with increased production of reactive oxygen intermediates and reactive nitrogen intermediates, superoxides and proinflammatory cytokines helping the cells to efficiently kill the intracellular pathogens. This type of IFN-γ-mediated activation induces M1 macrophages [57].
On the other hand, T helper 2 (Th2) type of cytokines, IL-4 and IL-13, induce a response different from the one induced by IFN-γ with distinct set of genes being expressed to form what is known as the alternative activation pathway of macrophages, and the cells are named as alternative activated type 2 or M2 macrophages [13, 72]. Various immune complexes, IL-10, vitamin D3 can also contribute to the activation of M2 macrophages [57]. M2 macrophages generally exhibit a higher phagocytic activity, mannose and galactose receptors, produce higher concentration of ornithine and polyamines due to high arginase pathway, secrete high amount of IL-10 and express higher levels of the IL-1 decoy receptor and IL-1RA. Having all these characteristics, M2 macrophages play a crucial role in anti-parasitic immune response [72].
Mannose receptors (CD206) play an important role in TB innate immunity due to their efficacy and specificity as endocytic receptor through engagement of virulence-associated mycobacterial cell wall components that contain mannose, particularly glycoproteins and sulphated and non-sulphated polysaccharides [82]. MR-positive immune cells are able to deliver various antigens to sites where humoral and cellular responses occur, therefore playing a role in bridging innate and acquired immunity [83, 84, 85, 86]. This CTL is a Ca2+-dependent type I transmembrane glycoprotein contains an extracellular N terminal, cysteine-rich (CR) domain, a fibronectin II (FNII) domain, eight carbohydrate recognition domains, a cytoplasmic tail and a transmembrane domain. The cytoplasmic tail contains 49 amino acids and there is a tyrosine residue on the 18th position that has been heavily implicated in endocytosis [51]. Much has been uncovered about the signaling pathways of CD206 in recent years, implicating this receptor in functions such as M2 macrophage polarization, antigen presentation, entry trafficking, macrophage-associated tumor biology and receptor targeting for therapeutic purposes [71, 79, 87]. CTL signaling is achieved through various adaptor proteins, of which the FcRγ chain is the most common [51]. Although the implications of this remain in question, heat shock proteins (HSP) in unstimulated cells interact with CD206 [88, 89]. Furthermore, it is not fully understood how this alters the structural configuration of MR upon their activation in vivo, although strides have been made in uncovering the significance of actin remodeling in this process, and its implication in phagolysosome maturation [51]. Phagocytosis is an actin-dependent process, therefore MR-mediated phagocytosis requires receptor clustering, recruitment and engagement of various adaptor proteins and activation of the Rho family of small GTPases in order to facilitate cytoskeletal remodeling [51]. Surface localization of CD206 depends on its ability to interact with FcRγ, which likely occurs at the interface of the positively-charged transmembrane region of the receptor [51]. This is where the value of murine models in understanding receptor-related aspects of TB immunopathology in humans sees its shortcomings: the cytoplasmic tail and TM region of the murine MR is neutrally charged, likely leading to reduced FcRγ tail binding and diminished surface MR exposure [51]. In the contest of human macrophages, recruitment and activation of the Src homology region 2 domain-containing phosphatase 1 (SHP-1) is an MR-dependent event that occurs during Mtb infection; SHP-1 phosphorylates and co-localizes with phagosomes containing Mtb [51]. As a consequence of this, SHP-1 reduces the activity of class III PI3P by interfering with the serine/threonine-protein kinase Vps15 and the phosphatidylinositol 3-kinase (PI3) hVPS34 [29, 87, 90]. Inhibition of SHP-1 has been found to lead to enhanced phagolysosome fusion [34].
Once Mtb is phagocytosed through CD206 engagement, subsequent immunomodulation facilitated by mycobacterial cell wall components may lead to the development of active disease. Mycobacterial ManLAM heavily influences several immunobiological processes throughout the continua of the immune response (Figure 2) [91]. ManLAM inhibits the process of phagolysosome fusion, which is considered a key aspect of TB infection with regards to mycobacterial intracellular persistence. It does so by blocking a crucial phosphatidylinositol 3-phosphate (PI3P)-regulated pathway involved in transportation of lysosomal and other crucial components from the trans-Golgi network to immature phagosomes; a process required for phagosome maturation [29, 87, 92, 93]. Two rab5 effector hVPS34 and the early endosomal antigen 1 (EEA1) are components crucial for phagosome maturation [32]. EEA1 binds to the membrane-associated PI3P via its FYVE and PX domains, to which ManLAM may competitively bind and thus preclude phagolysosome fusion. It was discovered that Mtb ManLAM interferes with a pathway involving Ca2+, calmodulin and the Ca2+/calmodulin-dependent protein kinase II (CaMKII) [29, 32, 87, 91, 92, 94]. EEA1 and Syntaxin 6 deliver various lysosomal components from the trans-Golgi network to immature phagosomes, making them crucial for phagosome maturation. However, Mtb uses ManLAM to disrupt recruitment of EEA1 to phagosome membranes by inhibiting the rise in cytosolic Ca2+, thus rendering the Ca2+/Calmodulin pathway, impotent [7]. Considering that hVPS34 interacts with calmodulin in order to generate PI3P, physiological maintenance of PI3P on phagosomes and other intracellular membranes requires calmodulin [91]. In summary, Mtb-associated ManLAM provides a survivability niche within macrophages by blocking the increase in Ca2+ transients, therefore effectively disrupting a Ca2+/Calmodulin associated pathway required for phagosome maturation. Physiological increase in cytosolic Ca2+ is heavily influenced by sphingosine kinase (SK), whose signaling pathways is triggered by FcR clustering. Studies suggest that the mechanism by which ManLAM disrupts the increase in cytosolic Ca2+ is likely through interference with SK signaling pathways [30].
The process of successful and unsuccessful phagosome-lysosome fusion during pulmonary tuberculosis. Abbreviations: Golgi—Golgi apparatus, ER—endoplasmic reticulum, PRRs—pattern recognition receptors, Mtb—
Cytotoxicity of ManLAM, however, is diminished when dissociated from mycobacterial cells via the activity of the respiratory mucosa [92]. ManLAM debris are incapable of inhibiting the process of phagolysosome fusion, allowing for the attractive assumption that the human respiratory tract evolved in such a way to amplify the immune response to Mtb by creating these highly immunostimulatory debris in the early stages of infection [92]. Despite the evident potency and relevance of this Mtb-associated mechanism, ManLAM-mediated prevention of phagolysosome fusion is but one of the several mechanisms in the arsenal of Mtb, some of which have only been recently discovered [92].
Preferred engagement of the CR and MR-dependent phagocytic pathways was a sensical evolutionary approach by Mtb, since engulfment of microbes via CRs and MRs do not necessarily incite an inflammatory response by the host, and MR-abundant alveolar macrophages act as chaperones that deliver Mtb to replication-permissive cells [26, 30]. The mechanism by which CTLs elicit an anti-inflammatory response is found in the ManLAM-mediated stimulation of a nuclear receptor peroxisome proliferator-activated receptor gamma (PPAR-γ), which in turn triggers such a response. Limited phagosome-lysosome fusion is specific only for monocytes expressing MR, whereupon absence of this receptor on Mɸs and DCs does not lead to the inhibition of phagosome maturation. LAM may be exported from the infected Mɸs and presented to T-cells via the MHC I CD1 molecules [21, 95]. Previous research suggests that Mtb uses LAM to recruit host immune cells whose function it will subsequently modulate in order to facilitate survival.
Toll-like receptors are type 1 transmembrane pattern recognition receptors instrumental to animal immunity [96]. They contain an extracellular leucine-rich repeat (LRR) domain—involved in signal transduction and molecular recognition—and intracellular toll/interleukin-1 receptor (TIR) domain, which represents a highly conserved protein-protein module. These receptors are expressed in a wide range of cells, with the most relevant for this discussion being Mɸs. Thus far 10 TLRs have been nominated in humans, with each of them playing cardinal roles in both innate and acquired immunity to Mtb infection. Upon recognition of Mtb molecular patterns via the receptor LRR domain, the Myeloid Differentiation Primary Response 88 (MyD88) is activated, which is utilized by all TLRs lest except for TLR3 (Figure 3). A wide spectrum of anti-mycobacterial actions taken by the immune system involve the synergic activity of TLRs and MyD88, leading to the subsequent involvement of IRAK, TNF receptor associated factor 6 (TRAF6), transforming growth factor beta-activated kinase 1 (TAK1) and mitogen-activated protein kinases (MAPK); it should be noted, however, that each TLR alone is capable of initiation a separate immunopathologic continua as means of amplifying the anti-Mtb immune response. Each TLR can bind a specific subset of pathogen-associated molecular patterns (PAMPs), they activate the innate immune system and help with the host protection. TLR2, TLR4, and TLR9 are the most common TLRs that detect Mtb, with TLR2 playing the most important role 5. TLRs recognize Mtb PAMPs, which triggers an intracellular signaling cascade that binds the myeloid differentiation primary response protein 88 (MyD88) to TLRs intracellular domains6. MTB is an acid-fast bacterium because its cell wall is mostly made up of hydrophobic mycolic acids. This is a component of the mycobacterial cell wall that accounts for half of its dry weight. The admission of nutrients is slowed by this thick layer of mycolic acids, causing mycobacteria to proliferate slowly, but it also boosts cellular resistance to lysosomal enzyme destruction. The mycolic acids are typically found in a thick layer on the cell wall’s exterior surfaces7. Lipids and polysaccharides make up the mycobacterial wall, which also contains a lot of mycolic acid.
Schematic representation of toll like (TLR) signaling. NF-κB gets translocated into the nucleus to initiate the transcription of inflammatory cytokine genes. Abbreviations: MyD88—Myeloid differentiation primary response, TRIF—TIR-domain-containing adapter-inducing interferon-β, NF-κB—NF-kappa B.
TLR2 and TLR4 are activated by purified cell wall components of mycobacteria [81]. Lipomannan and lipoarabinomannan are two lipoglycans with substantial immunomodulatory properties [30, 38]. TLR2, in conjunction with TLR1, can identify Mtb cell wall lipoprotein antigens, which cause macrophages to produce cytokines. TLR9 is triggered by mycobacterial DNA. The engagement of IL-1 receptor-associated kinases, TNF receptor-associated factor 6, TGF-activated protein kinase 1 and mitogen-activated protein kinase is then enhanced by MyD88 [97]. The transcription factor NF-κB is activated and translocated to the nucleus as a result of this signaling cascade. Multiple pro-inflammatory cytokines, including tumor necrosis factor, interleukin-1 and interleukin-12, are produced as a result [98]. Tumor necrosis factor and interleukin-12 are then secreted, causing nearby natural killer and T cells to produce IFN-y. IFN-y is a key macrophage stimulator and activator of major histocompatibility complex class II molecule production. IFN’s importance in the immune system arises from its capacity to directly suppress virus replication, as well as its immunomodulatory properties. IFN-y stimulates macrophages, enhancing antigen presentation and promoting anti-mycobacterial effector mechanisms such as reactive oxygen and nitrogen intermediates, autophagy, phagolysosome fusion and acidification autophagy [99, 100].
For instance, TLR2 has been implicated in regulating T cell trafficking by inducing the production of CCL8, a CD4+ chemokine, and in recruiting regulatory T cells (Treg) to infection foci in order to regulate inflammation. Tampering with the inflammatory response in the context of TLR2 is at least in part owed to the TLR2-induced secretion of CXCL5, considering that PMNL recruitment by this chemokine has the potency to drive destructive inflammation during early stages of infection [81]. Mycobacterial ESAT-6 readily promotes macrophage apoptosis by activating the TLR2/NF-κB [101]. One of the ways that Mtb causes a delay in priming the adaptive immune response is through the activities of mycolic acid and various mycobacterial lipoproteins, which have potency to downregulate MHC II expression and pro-inflammatory responses. Furthermore, TLR2 enhances the expression of vitamin D receptor genes [81, 102, 103, 104]. It should be noted that induction of ROS can be achieved through TLR2/dectin-1 cooperation [105]. Induction of a rather wide range of anti-mycobacterial mechanisms is also partly owed to TLR2 [63, 64, 65, 106, 107]. TLR2−/− mice have also exhibited increased inflammation, pneumonitis of the interstitial lung tissue and abnormal granuloma morphology, with a very modest increase in bacterial burden [108]. Concordantly to these findings, concluding that TLR2 plays both beneficial and detrimental roles in Mtb infection seems to be rather prudent, as TLR2 signaling is influenced by numerous components of both the immune system and mycobacterial virulence, with notable implications in innate immunity and priming of adaptive immunity.
Functions of TLR4 have been reported to include promotion of CD4 and CD8 T cell recruitment, polarization of T effector cells towards a Th1 cell phenotype and numerous other activities that may be construed as both beneficial and detrimental [81]. Mycobacterial phosphatidyl inositol mannosides can inhibit the production of proinflammatory cytokines and NO by interfering the synergic activity of TLR4 and MyD88. Repressing the host’s ability to produce NO is a sensical approach, as low levels of NO have been associated with the activation of dormancy-related genetic programs such as the DosRST regulon [106]. With the recently uncovered detrimental role of alveolar macrophages during early stages of infection, this could be a mechanism used by Mtb to ensure survivability of infected phagocytes in order to be transported to the lung interstitial tissue abundant in replication-permissive monocytes. The Mtb-associated resuscitation-promoting factor B (RpfB) interacts with TLR4 on DCs, activating the synergic signaling of MyD88 and toll/IL-1R homology domain-containing adapter-inducing IFN-β (TRIF), in order to ensure downstream signaling to MAPK and NF-κB [108]. This signaling pathway promotes education of naïve T cells and their subsequent polarization to CD4+ and CD8+, which will secrete IFN-γ and IL-2 [105]. Furthermore, this pathway induces T cell proliferation and polarization in the context of Th1 immunity, further emphasizing the importance of TLR2 signaling in TB immunopathology [105].
Plasmacytoid DCs (pDC), a special subset of DCs, function in close cooperation with TLR9 in such a way as to allow these immune cells to conduct their immune functions, including initiation of the immune response and control of inflammation through the induction of chemokines (Figure 4). pDCs are known to play an important role in recruiting NK cells; pDC−/− mice show a drastic reduction in NK cell recruitment upon intraperitoneal injection. Considering that pDCs express the CCR5, CCR2 and the CXCR3 ligand receptors on their surface, this likely translates to diminished binding of chemokines CCL2, CCL3, CCL4, CXCL10 and CXCL9 [109]. Mycobacterial DNA, the unmethylated CpG oligodeoxynucleotide motif in particular, acts as a TLR9 ligand and initiates the signaling pathway that promotes such pDC activity in Mtb infection [105]. Abrogation of TLR9 in mutant mice leads to higher susceptibility to TB diseases, in contrast to wild-type mice. Interestingly, previous studies on the synergic activity of TLR9 and TLR2 found that TLR9−/− mice demonstrated only mild differences in overall lung histopathology and granuloma formation [105]. However, focal necrosis was seen in TLR9/2−/− mice, a pathological outcome that also occurs for MyD88−/− mice, albeit the lung pathology in MyD88−/− mice is evidently more severe, further emphasizing the importance of MyD88 in TB immunopathology [109]. It should be noted, however, that no relevant difference in susceptibility was discovered in either TLR9−/− or TLR2−/− mice; alterations in granulomatous pathology and TNF-α secretion occur only for high-dose inoculums of Mtb as a consequence of TLR9 deficiency [105]. Considering that pDCs secrete IL-12—a cytokine that induces and controls the production of IFN-γ by CD4+ T cells—the relevance of TLR9-mediated signaling is evidently pivotal in both innate and acquired immunity [110, 111]. It would appear that synergic activity of a minimum of two TLRs is important in the signaling pathways that initiate competent immune responses to TB, although each receptor alone has proven to be relevant in vivo in gene knockout studies conducted on mice. Interestingly, a recent mouse study has concluded that TLR2 and TLR9 signaling is not necessary for vaccine-induced immunity [24, 112]. It should be noted, however, that an immunization strategy based on the combination of enhancement of TLR4, TLR3 and TLR9 signaling and the Mtb antigen Rv2034—a powerful CD4+ cell stimulant—has been successfully explored in mice and guinea pigs [113].
Plasmacytoid cells in tuberculosis immunopathology. Abbreviations: IFNα/γ—interferon α/γ; IL-2/6/10/12—Interleukin-2/6/10/12, Ab—antibodies, NK cells—natural killer cells.
Although certain TLRs are part of signaling pathways relevant to TB immunopathology, they alone are only but a cog in a very complex machinery that comprises the TLR-mediated immune response to Mtb infection. It is attractive to speculate that devising immunotherapies guided towards enhancing TLR signaling due to their pivotal role in priming Th1 immunity through cytokine secretion, could be a fruitful avenue to pursue. Rampant inflammation at the level of innate immunity, influenced by TLR signaling, may also be a target of novel immunotherapies directed at diminishing the violent effects that excess PMNL recruitment has on the lung tissue [33, 105, 108]. However, to infer that enhanced TLR signaling alone would be sufficient in combating tuberculosis, would be rather misinformed. Namely, it was discovered that, in murine models, XDR TB reduces the expression of TLR2 and TLR4 and consequently the production of cytokines that were otherwise abundantly present in mice infected with DS Mtb [114]. The inhibitory effects of XDR strains reduced the overall lung pathology in such a way that alveolar damage was reduced and granulomatous formations were smaller in size, in contrast with the detrimental immunopathologic events that were caused by DS TB. In light of this particular finding, one may infer that XDR TB was less virulent due to its down regulating effects on TLRs than DS strains, although much work is needed to further understand the implications of these results.
Many have questioned the purpose of the granuloma (Figure 5) within the body, but some would argue that the formation of the granuloma by the various white blood cells and macrophages in the body is an attempt by the adaptive immune system to contain the cells already infiltrated by Mtb cells [58]. It is begun as an innate immune system response but evolves in complexity as the adaptive immune system takes over [122]. The granuloma will begin forming as a group of macrophages who have been infiltrated and infected by Mtb, which are then surrounded by other macrophages and white blood cells in order to isolate these infected macrophages with their surrounding environment [123]. The granuloma will then be enclosed by a fibrous cuff and the surrounding area will undergo significant angiogenesis, similar to what occurs when a cancerous tumor forms [124]. The macrophages and white blood cells within the granuloma will trigger conditions of hypoxia and lower nutrient availability [122]. Within the granuloma, it is believed that the bacteria do not continue replicating but instead focus their resources on gluconeogenesis to ensure their survival [58].
Graphic illustration of the tuberculosis granuloma.
Of course, this also has a negative effect on the human body’s own cells, and can eventually result in a necrotic or caseating granuloma [125]. This is partly due to “foamy” or lipid droplet-containing macrophages, which are formed by increased diffusion of LDL vesicles in the macrophage cells, and whatever is not exported by ATP active transport methods is esterified to convert it into lipid bodies, which give the cell its foamy appearance [123]. These cells are proinflammatory, and the increased presence of them promotes Mtb within the granuloma, enhancing the deteriorating conditions around and inside it and leading to eventual necrosis [55]. Lipid droplets released from the cell in the form of triglycerides can be absorbed by Mtb-infected macrophages, where they are then used by the Mtb bacteria for lipid metabolism [123]. Additionally, superoxide and NO production from the macrophages is severely limited due to the hypoxic conditions, so many times in the case of a granuloma, the best that can be hoped for is an isolated environment containing the bacteria, as bactericidal action by the macrophages becomes more difficult [123]. The most devastating problem presented by the granuloma is Mtb’s ability to hijack the process for its own survival. Mtb bacteria have adapted to the formation of the granuloma, and mycobacterial recruitment proteins like ESX-1 release compounds to recruit macrophages to form the granuloma [4]. The reason for this is to provide the bacteria a fresh supply of macrophages for them to infect while simultaneously cutting themselves off from lymphocytes, who have a more pronounced bactericidal action against them [123]. The structure of the granuloma also creates difficulty for penetration by drugs and other therapies, and some have even considered treating the granuloma using similar methods to cancerous tumor treatment [126]. There are various types and stages of the granuloma ranging from primary granulomas to acute caseating granulomas. Caseating granulomas will begin descending into necrosis, releasing the Mtb into the surrounding lung tissue, which can then further infect others by being released in aerosolized droplets [18, 127].
The bacillus once engulfed by the alveolar macrophage (AM) into the phagolysosome sabotages the lysosomal pathways. By incorporating proton pumps into the phagolysosome membrane, fusion to lysosomes is blocked, as they accommodate the environment suitable for replication and hence polarize into the M2 macrophage phenotype [128, 129]. In later stages, the bacillus may subvert the functional role of lysosome pathways by inducing cell necrosis as a means of dissemination, creating granulomas in the lung interstitium [130, 131]. Granulomas exist in several types wherein diverse macrophages are primary residents, leading to a range of unique microenvironments that are statistically independent of each other in a host body [132]. The outcome of the infection will depend on the phenotype of macrophages present (M1/M2 polarization) altered by the bacillus within the granulomas. The precedent to granuloma establishment—the translocation of the AM from the alveolus to the lung interstitium—depends on several signaling pathways. ESX-1 secretion system is necessary for the bacillus’ escape from the AM phagolysosome by potentiating inflammasome (comprised of NLRP3, ASC and caspase-1) activation within the AM and hence interleukin-1β (IL-1β) release, which increases alveolar permeability once bound to IL-1R on the epithelial barrier [133]. The RD1-dependent inflammasome signaling pathway transfers the living Mtb-infected AM whereas the STING pathway facilitates movement across the epithelial barrier by transferring the bacillus from the AM to a
Human tuberculosis is a tremendously complex infection, leaving no compartment of the immune system spared. Thus, conclusive studies on this disease from an immunological standpoint are difficult to conduct, due to the heterogenicity present within different populations in the context of host immunogenetics and potential previous exposure to pathogenic and non-pathogenic mycobacteria. Though other innate immune cells eventually come into play, macrophages play a pivotal role in the immune response to infections with
The authors would like to thank Dado Latinović from the International Burch University for designing and generating all of the scientific illustrations provided within this work.
None to declare.
We sincerely hope that, with the rapid expansion and improvement of scientific methods, we will eventually understand
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He performed post-doctoral studies at Max-Planck Institute, Germany, and University of Florence, Italy in addition to making several scientific visits abroad. He currently works as a Full Professor of Biochemistry in the Faculty of Pharmacy, Anadolu University, Turkey. Dr. Beydemir has published over a hundred scientific papers spanning protein biochemistry, enzymology and medicinal chemistry, reviews, book chapters and presented several conferences to scientists worldwide. He has received numerous publication awards from various international scientific councils. He serves in the Editorial Board of several international journals. Dr. Beydemir is also Rector of Bilecik Şeyh Edebali University, Turkey.",institutionString:null,institution:{name:"Anadolu University",institutionURL:null,country:{name:"Turkey"}}},editorTwo:{id:"13652",title:"Prof.",name:"Deniz",middleName:null,surname:"Ekinci",slug:"deniz-ekinci",fullName:"Deniz Ekinci",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYLT1QAO/Profile_Picture_1634557223079",biography:"Dr. Deniz Ekinci obtained a BSc in Chemistry in 2004, MSc in Biochemistry in 2006, and PhD in Biochemistry in 2009 from Atatürk University, Turkey. He studied at Stetson University, USA, in 2007-2008 and at the Max Planck Institute of Molecular Cell Biology and Genetics, Germany, in 2009-2010. Dr. Ekinci currently works as a Full Professor of Biochemistry in the Faculty of Agriculture and is the Head of the Enzyme and Microbial Biotechnology Division, Ondokuz Mayıs University, Turkey. He is a member of the Turkish Biochemical Society, American Chemical Society, and German Genetics society. Dr. Ekinci published around ninety scientific papers, reviews and book chapters, and presented several conferences to scientists. He has received numerous publication awards from several scientific councils. 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He worked on the structure-function relationships of glycoconjugates and his main project was the investigations on the biological roles of the de-N-glycosylation enzymes (Endo-N-acetyl-β-D-glucosaminidase and peptide-N4-(N-acetyl-β-glucosaminyl) asparagine amidase). From 2002 he contributes to the understanding of the Blood-brain barrier functioning using proteomics approaches. He has published more than 70 papers. 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Since then, he has been working as an Adjunct Professor in the same Department at the University of Pavia. His research activity during the first years was primarily focused on the purification and structural characterization of enzymes from animal and plant sources. During this period, Prof. Iadarola familiarized himself with the conventional techniques used in column chromatography, spectrophotometry, manual Edman degradation, and electrophoresis). Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. More recently, Prof. Iadarola was involved in developing techniques such as two-dimensional electrophoresis coupled to liquid chromatography/mass spectrometry (2DE-LC/MS) for the proteomic analysis of biological fluids aimed at the identification of potential biomarkers of different lung diseases. He is the author of about 150 publications (According to Scopus: H-Index: 23; Total citations: 1568- According to WOS: H-Index: 20; Total Citations: 1296) of peer-reviewed international journals. 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She gained considerable experience in developing and validating new methodologies whose applications allowed her to determine both the amount of biomarkers (Desmosine and Isodesmosine) in the urine of patients affected by COPD, and the activity of proteolytic enzymes (HNE, Cathepsin G, Pseudomonas aeruginosa elastase) in the sputa of these patients. Simona Viglio was also involved in research dealing with the supplementation of amino acids in patients with brain injury and chronic heart failure. She is presently engaged in the development of 2-DE and LC-MS techniques for the study of proteomics in biological fluids. The aim of this research is the identification of potential biomarkers of lung diseases. 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He was elected a Yangtze River Scholars Distinguished Professor in 2013, a member of the International Statistical Institute (ISI) in 2016, a member of the board of the International Chinese Statistical Association (ICSA) in 2018, and a fellow of the Institute of Mathematical Statistics (IMS) in 2021. He received the ICSA Outstanding Service Award in 2018 and the National Science Foundation for Distinguished Young Scholars of China in 2012. He serves as a member of the editorial board of Statistics and Its Interface and Journal of Systems Science and Complexity. He is also a field editor for Communications in Mathematics and Statistics. His research interests include biostatistics, empirical likelihood, missing data analysis, variable selection, high-dimensional data analysis, Bayesian statistics, and data science. He has published more than 190 research papers and authored five books.",institutionString:"Yunnan University",institution:{name:"Yunnan University",country:{name:"China"}}},{id:"1177",title:"Prof.",name:"António",middleName:"J. R.",surname:"José Ribeiro Neves",slug:"antonio-jose-ribeiro-neves",fullName:"António José Ribeiro Neves",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1177/images/system/1177.jpg",biography:"Prof. António J. R. Neves received a Ph.D. in Electrical Engineering from the University of Aveiro, Portugal, in 2007. Since 2002, he has been a researcher at the Institute of Electronics and Informatics Engineering of Aveiro. Since 2007, he has been an assistant professor in the Department of Electronics, Telecommunications, and Informatics, University of Aveiro. He is the director of the undergraduate course on Electrical and Computers Engineering and the vice-director of the master’s degree in Electronics and Telecommunications Engineering. He is an IEEE Senior Member and a member of several other research organizations worldwide. His main research interests are computer vision, intelligent systems, robotics, and image and video processing. He has participated in or coordinated several research projects and received more than thirty-five awards. He has 161 publications to his credit, including books, book chapters, journal articles, and conference papers. He has vast experience as a reviewer of several journals and conferences. As a professor, Dr. Neves has supervised several Ph.D. and master’s students and was involved in more than twenty-five different courses.",institutionString:null,institution:{name:"University of Aveiro",country:{name:"Portugal"}}},{id:"11317",title:"Dr.",name:"Francisco",middleName:null,surname:"Javier Gallegos-Funes",slug:"francisco-javier-gallegos-funes",fullName:"Francisco Javier Gallegos-Funes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/11317/images/system/11317.png",biography:"Francisco J. Gallegos-Funes received his Ph.D. in Communications and Electronics from the Instituto Politécnico Nacional de México (National Polytechnic Institute of Mexico) in 2003. He is currently an associate professor in the Escuela Superior de Ingeniería Mecánica y Eléctrica (Mechanical and Electrical Engineering Higher School) at the same institute. His areas of scientific interest are signal and image processing, filtering, steganography, segmentation, pattern recognition, biomedical signal processing, sensors, and real-time applications.",institutionString:"Instituto Politécnico Nacional",institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"428449",title:"Dr.",name:"Ronaldo",middleName:null,surname:"Ferreira",slug:"ronaldo-ferreira",fullName:"Ronaldo Ferreira",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/428449/images/21449_n.png",biography:null,institutionString:null,institution:{name:"University of Aveiro",country:{name:"Portugal"}}},{id:"165328",title:"Dr.",name:"Vahid",middleName:null,surname:"Asadpour",slug:"vahid-asadpour",fullName:"Vahid Asadpour",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/165328/images/system/165328.jpg",biography:"Vahid Asadpour, MS, Ph.D., is currently with the Department of Research and Evaluation, Kaiser Permanente Southern California. He has both an MS and Ph.D. in Biomedical Engineering. He was previously a research scientist at the University of California Los Angeles (UCLA) and visiting professor and researcher at the University of North Dakota. He is currently working in artificial intelligence and its applications in medical signal processing. In addition, he is using digital signal processing in medical imaging and speech processing. Dr. Asadpour has developed brain-computer interfacing algorithms and has published books, book chapters, and several journal and conference papers in this field and other areas of intelligent signal processing. He has also designed medical devices, including a laser Doppler monitoring system.",institutionString:"Kaiser Permanente Southern California",institution:null},{id:"169608",title:"Prof.",name:"Marian",middleName:null,surname:"Găiceanu",slug:"marian-gaiceanu",fullName:"Marian Găiceanu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/169608/images/system/169608.png",biography:"Prof. Dr. Marian Gaiceanu graduated from the Naval and Electrical Engineering Faculty, Dunarea de Jos University of Galati, Romania, in 1997. He received a Ph.D. (Magna Cum Laude) in Electrical Engineering in 2002. Since 2017, Dr. Gaiceanu has been a Ph.D. supervisor for students in Electrical Engineering. He has been employed at Dunarea de Jos University of Galati since 1996, where he is currently a professor. Dr. Gaiceanu is a member of the National Council for Attesting Titles, Diplomas and Certificates, an expert of the Executive Agency for Higher Education, Research Funding, and a member of the Senate of the Dunarea de Jos University of Galati. He has been the head of the Integrated Energy Conversion Systems and Advanced Control of Complex Processes Research Center, Romania, since 2016. He has conducted several projects in power converter systems for electrical drives, power quality, PEM and SOFC fuel cell power converters for utilities, electric vehicles, and marine applications with the Department of Regulation and Control, SIEI S.pA. (2002–2004) and the Polytechnic University of Turin, Italy (2002–2004, 2006–2007). He is a member of the Institute of Electrical and Electronics Engineers (IEEE) and cofounder-member of the IEEE Power Electronics Romanian Chapter. He is a guest editor at Energies and an academic book editor for IntechOpen. He is also a member of the editorial boards of the Journal of Electrical Engineering, Electronics, Control and Computer Science and Sustainability. Dr. Gaiceanu has been General Chairman of the IEEE International Symposium on Electrical and Electronics Engineering in the last six editions.",institutionString:'"Dunarea de Jos" University of Galati',institution:{name:'"Dunarea de Jos" University of Galati',country:{name:"Romania"}}},{id:"4519",title:"Prof.",name:"Jaydip",middleName:null,surname:"Sen",slug:"jaydip-sen",fullName:"Jaydip Sen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/4519/images/system/4519.jpeg",biography:"Jaydip Sen is associated with Praxis Business School, Kolkata, India, as a professor in the Department of Data Science. His research areas include security and privacy issues in computing and communication, intrusion detection systems, machine learning, deep learning, and artificial intelligence in the financial domain. He has more than 200 publications in reputed international journals, refereed conference proceedings, and 20 book chapters in books published by internationally renowned publishing houses, such as Springer, CRC press, IGI Global, etc. Currently, he is serving on the editorial board of the prestigious journal Frontiers in Communications and Networks and in the technical program committees of a number of high-ranked international conferences organized by the IEEE, USA, and the ACM, USA. He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:{name:"Association for Computing Machinery",country:{name:"United States of America"}}},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:'"Politechnica" University Timişoara',institution:null},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. He is a Senior Member of the IEEE, and a recipient of the Biscay Talent prize for his academic career.",institutionString:"Tecnalia Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"278948",title:"Dr.",name:"Carlos Pedro",middleName:null,surname:"Gonçalves",slug:"carlos-pedro-goncalves",fullName:"Carlos Pedro Gonçalves",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRcmyQAC/Profile_Picture_1564224512145",biography:'Carlos Pedro Gonçalves (PhD) is an Associate Professor at Lusophone University of Humanities and Technologies and a researcher on Complexity Sciences, Quantum Technologies, Artificial Intelligence, Strategic Studies, Studies in Intelligence and Security, FinTech and Financial Risk Modeling. He is also a progammer with programming experience in:\n\nA) Quantum Computing using Qiskit Python module and IBM Quantum Experience Platform, with software developed on the simulation of Quantum Artificial Neural Networks and Quantum Cybersecurity;\n\nB) Artificial Intelligence and Machine learning programming in Python;\n\nC) Artificial Intelligence, Multiagent Systems Modeling and System Dynamics Modeling in Netlogo, with models developed in the areas of Chaos Theory, Econophysics, Artificial Intelligence, Classical and Quantum Complex Systems Science, with the Econophysics models having been cited worldwide and incorporated in PhD programs by different Universities.\n\nReceived an Arctic Code Vault Contributor status by GitHub, due to having developed open source software preserved in the \\"Arctic Code Vault\\" for future generations (https://archiveprogram.github.com/arctic-vault/), with the Strategy Analyzer A.I. module for decision making support (based on his PhD thesis, used in his Classes on Decision Making and in Strategic Intelligence Consulting Activities) and QNeural Python Quantum Neural Network simulator also preserved in the \\"Arctic Code Vault\\", for access to these software modules see: https://github.com/cpgoncalves. He is also a peer reviewer with outsanding review status from Elsevier journals, including Physica A, Neurocomputing and Engineering Applications of Artificial Intelligence. Science CV available at: https://www.cienciavitae.pt//pt/8E1C-A8B3-78C5 and ORCID: https://orcid.org/0000-0002-0298-3974',institutionString:"University of Lisbon",institution:{name:"Universidade Lusófona",country:{name:"Portugal"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). He leads the working group of experts representing Brazil in the Global Partnership on Artificial Intelligence (GPAI), on the theme \"AI and the Pandemic Response\".",institutionString:null,institution:null},{id:"241400",title:"Prof.",name:"Mohammed",middleName:null,surname:"Bsiss",slug:"mohammed-bsiss",fullName:"Mohammed Bsiss",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241400/images/8062_n.jpg",biography:null,institutionString:null,institution:null},{id:"276128",title:"Dr.",name:"Hira",middleName:null,surname:"Fatima",slug:"hira-fatima",fullName:"Hira Fatima",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/276128/images/14420_n.jpg",biography:"Dr. Hira Fatima\nAssistant Professor\nDepartment of Mathematics\nInstitute of Applied Science\nMangalayatan University, Aligarh\nMobile: no : 8532041179\nhirafatima2014@gmal.com\n\nDr. Hira Fatima has received his Ph.D. degree in pure Mathematics from Aligarh Muslim University, Aligarh India. Currently working as an Assistant Professor in the Department of Mathematics, Institute of Applied Science, Mangalayatan University, Aligarh. She taught so many courses of Mathematics of UG and PG level. Her research Area of Expertise is Functional Analysis & Sequence Spaces. She has been working on Ideal Convergence of double sequence. She has published 17 research papers in National and International Journals including Cogent Mathematics, Filomat, Journal of Intelligent and Fuzzy Systems, Advances in Difference Equations, Journal of Mathematical Analysis, Journal of Mathematical & Computer Science etc. She has also reviewed few research papers for the and international journals. She is a member of Indian Mathematical Society.",institutionString:null,institution:null},{id:"417317",title:"Mrs.",name:"Chiedza",middleName:null,surname:"Elvina Mashiri",slug:"chiedza-elvina-mashiri",fullName:"Chiedza Elvina Mashiri",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"352140",title:"Dr.",name:"Edina",middleName:null,surname:"Chandiwana",slug:"edina-chandiwana",fullName:"Edina Chandiwana",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"342259",title:"B.Sc.",name:"Leonard",middleName:null,surname:"Mushunje",slug:"leonard-mushunje",fullName:"Leonard Mushunje",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"347042",title:"Mr.",name:"Maxwell",middleName:null,surname:"Mashasha",slug:"maxwell-mashasha",fullName:"Maxwell Mashasha",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Midlands State University",country:{name:"Zimbabwe"}}},{id:"2941",title:"Dr.",name:"Alberto J.",middleName:"Jorge",surname:"Rosales-Silva",slug:"alberto-j.-rosales-silva",fullName:"Alberto J. Rosales-Silva",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"437913",title:"Dr.",name:"Guillermo",middleName:null,surname:"Urriolagoitia-Sosa",slug:"guillermo-urriolagoitia-sosa",fullName:"Guillermo Urriolagoitia-Sosa",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"435126",title:"Prof.",name:"Joaquim",middleName:null,surname:"José de Castro Ferreira",slug:"joaquim-jose-de-castro-ferreira",fullName:"Joaquim José de Castro Ferreira",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Aveiro",country:{name:"Portugal"}}},{id:"437899",title:"MSc.",name:"Miguel Angel",middleName:null,surname:"Ángel Castillo-Martínez",slug:"miguel-angel-angel-castillo-martinez",fullName:"Miguel Angel Ángel Castillo-Martínez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"289955",title:"Dr.",name:"Raja",middleName:null,surname:"Kishor Duggirala",slug:"raja-kishor-duggirala",fullName:"Raja Kishor Duggirala",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jawaharlal Nehru Technological University, Hyderabad",country:{name:"India"}}}]}},subseries:{item:{id:"27",type:"subseries",title:"Multi-Agent Systems",keywords:"Collaborative Intelligence, Learning, Distributed Control System, Swarm Robotics, Decision Science, Software Engineering",scope:"Multi-agent systems are recognised as a state of the art field in Artificial Intelligence studies, which is popular due to the usefulness in facilitation capabilities to handle real-world problem-solving in a distributed fashion. The area covers many techniques that offer solutions to emerging problems in robotics and enterprise-level software systems. Collaborative intelligence is highly and effectively achieved with multi-agent systems. Areas of application include swarms of robots, flocks of UAVs, collaborative software management. Given the level of technological enhancements, the popularity of machine learning in use has opened a new chapter in multi-agent studies alongside the practical challenges and long-lasting collaboration issues in the field. It has increased the urgency and the need for further studies in this field. We welcome chapters presenting research on the many applications of multi-agent studies including, but not limited to, the following key areas: machine learning for multi-agent systems; modeling swarms robots and flocks of UAVs with multi-agent systems; decision science and multi-agent systems; software engineering for and with multi-agent systems; tools and technologies of multi-agent systems.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/27.jpg",hasOnlineFirst:!0,hasPublishedBooks:!1,annualVolume:11423,editor:{id:"148497",title:"Dr.",name:"Mehmet",middleName:"Emin",surname:"Aydin",slug:"mehmet-aydin",fullName:"Mehmet Aydin",profilePictureURL:"https://mts.intechopen.com/storage/users/148497/images/system/148497.jpg",biography:"Dr. Mehmet Emin Aydin is a Senior Lecturer with the Department of Computer Science and Creative Technology, the University of the West of England, Bristol, UK. His research interests include swarm intelligence, parallel and distributed metaheuristics, machine learning, intelligent agents and multi-agent systems, resource planning, scheduling and optimization, combinatorial optimization. Dr. Aydin is currently a Fellow of Higher Education Academy, UK, a member of EPSRC College, a senior member of IEEE and a senior member of ACM. In addition to being a member of advisory committees of many international conferences, he is an Editorial Board Member of various peer-reviewed international journals. He has served as guest editor for a number of special issues of peer-reviewed international journals.",institutionString:null,institution:{name:"University of the West of England",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null,series:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403"},editorialBoard:[{id:"275140",title:"Dr.",name:"Dinh Hoa",middleName:null,surname:"Nguyen",slug:"dinh-hoa-nguyen",fullName:"Dinh Hoa Nguyen",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRbnKQAS/Profile_Picture_1622204093453",institutionString:null,institution:{name:"Kyushu University",institutionURL:null,country:{name:"Japan"}}},{id:"20259",title:"Dr.",name:"Hongbin",middleName:null,surname:"Ma",slug:"hongbin-ma",fullName:"Hongbin Ma",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRhDJQA0/Profile_Picture_2022-05-02T08:25:21.jpg",institutionString:null,institution:{name:"Beijing Institute of Technology",institutionURL:null,country:{name:"China"}}},{id:"28640",title:"Prof.",name:"Yasushi",middleName:null,surname:"Kambayashi",slug:"yasushi-kambayashi",fullName:"Yasushi Kambayashi",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYOQxQAO/Profile_Picture_1625660525470",institutionString:null,institution:{name:"Nippon Institute of Technology",institutionURL:null,country:{name:"Japan"}}}]},onlineFirstChapters:{paginationCount:8,paginationItems:[{id:"83117",title:"Endothelial Secretome",doi:"10.5772/intechopen.106550",signatures:"Luiza Rusu",slug:"endothelial-secretome",totalDownloads:0,totalCrossrefCites:0,totalDimensionsCites:0,authors:[{name:"Luiza",surname:"Rusu"}],book:{title:"Periodontology - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11566.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"83087",title:"Role of Cellular Responses in Periodontal Tissue Destruction",doi:"10.5772/intechopen.106645",signatures:"Nam Cong-Nhat Huynh",slug:"role-of-cellular-responses-in-periodontal-tissue-destruction",totalDownloads:8,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Periodontology - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11566.jpg",subseries:{id:"1",title:"Oral Health"}}},{id:"82654",title:"Atraumatic Restorative Treatment: More than a Minimally Invasive Approach?",doi:"10.5772/intechopen.105623",signatures:"Manal A. 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