Details of Horwitz values.
\\n\\n
IntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\\n\\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\\n\\nLaunching 2021
\\n\\nArtificial Intelligence, ISSN 2633-1403
\\n\\nVeterinary Medicine and Science, ISSN 2632-0517
\\n\\nBiochemistry, ISSN 2632-0983
\\n\\nBiomedical Engineering, ISSN 2631-5343
\\n\\nInfectious Diseases, ISSN 2631-6188
\\n\\nPhysiology (Coming Soon)
\\n\\nDentistry (Coming Soon)
\\n\\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\\n\\nNote: Edited in October 2021
\\n"}]',published:!0,mainMedia:{caption:"",originalUrl:"/media/original/132"}},components:[{type:"htmlEditorComponent",content:'With the desire to make book publishing more relevant for the digital age and offer innovative Open Access publishing options, we are thrilled to announce the launch of our new publishing format: IntechOpen Book Series.
\n\nDesigned to cover fast-moving research fields in rapidly expanding areas, our Book Series feature a Topic structure allowing us to present the most relevant sub-disciplines. Book Series are headed by Series Editors, and a team of Topic Editors supported by international Editorial Board members. Topics are always open for submissions, with an Annual Volume published each calendar year.
\n\nAfter a robust peer-review process, accepted works are published quickly, thanks to Online First, ensuring research is made available to the scientific community without delay.
\n\nOur innovative Book Series format brings you:
\n\nIntechOpen Book Series will also publish a program of research-driven Thematic Edited Volumes that focus on specific areas and allow for a more in-depth overview of a particular subject.
\n\nIntechOpen Book Series will be launching regularly to offer our authors and editors exciting opportunities to publish their research Open Access. We will begin by relaunching some of our existing Book Series in this innovative book format, and will expand in 2022 into rapidly growing research fields that are driving and advancing society.
\n\nLaunching 2021
\n\nArtificial Intelligence, ISSN 2633-1403
\n\nVeterinary Medicine and Science, ISSN 2632-0517
\n\nBiochemistry, ISSN 2632-0983
\n\nBiomedical Engineering, ISSN 2631-5343
\n\nInfectious Diseases, ISSN 2631-6188
\n\nPhysiology (Coming Soon)
\n\nDentistry (Coming Soon)
\n\nWe invite you to explore our IntechOpen Book Series, find the right publishing program for you and reach your desired audience in record time.
\n\nNote: Edited in October 2021
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More focus is placed on relieving the symptoms instead of curing the disease. Mostly, patients are turned into lifetime medication-dependent individuals. New medicines are needed to overcome the side effects, complications, resistance, and intolerance caused by pharmacological and interventional therapies. In hopes of drug-free and painless alternative treatments with fewer complications, there has been a trend to revisit traditional methods that have been dismissed by modern medicine. Traditional medicine has to be reevaluated with modern scientific methods to complement and integrate with evidence-based modern medicine.",isbn:"978-1-78985-377-3",printIsbn:"978-1-78984-183-1",pdfIsbn:"978-1-78985-378-0",doi:"10.5772/intechopen.78452",price:119,priceEur:129,priceUsd:155,slug:"traditional-and-complementary-medicine",numberOfPages:110,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"60eadb1783d9bba245687adf284d4871",bookSignature:"Cengiz Mordeniz",publishedDate:"December 11th 2019",coverURL:"https://cdn.intechopen.com/books/images_new/8323.jpg",numberOfDownloads:8141,numberOfWosCitations:17,numberOfCrossrefCitations:29,numberOfCrossrefCitationsByBook:0,numberOfDimensionsCitations:42,numberOfDimensionsCitationsByBook:1,hasAltmetrics:1,numberOfTotalCitations:88,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"June 5th 2018",dateEndSecondStepPublish:"October 8th 2018",dateEndThirdStepPublish:"December 7th 2018",dateEndFourthStepPublish:"February 25th 2019",dateEndFifthStepPublish:"April 26th 2019",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"214664",title:"Associate Prof.",name:"Cengiz",middleName:null,surname:"Mordeniz",slug:"cengiz-mordeniz",fullName:"Cengiz Mordeniz",profilePictureURL:"https://mts.intechopen.com/storage/users/214664/images/system/214664.jpeg",biography:"Cengiz Mordeniz is an associate professor at the Department of Anesthesiology and Intensive Care and Pain Medicine at Namık Kemal University, Turkey. He is the founder of the Traditional and Complementary Medical Center at The University Hospital where he also works. He obtained specialization in Anesthesiology and Intensive Care at Istanbul University and a master’s degree in Forensic Medicine and Clinical Deontology at Acibadem University, Turkey. He pursued research and clinical practice at Rigs Hospitalet, Denmark; Heidelberg and Giessen Universities, Germany; and Plovdiv University, Bulgaria. He was trained at Moscow Quantum Medicine Academy, Russia, and School of Advanced International Studies on Applied Theoretical and Non-Linear Methodologies of Physics, Italy. He completed the Clinical Research Program at Harvard University. He is a member of HeartMath Institute, USA.",institutionString:"Namık Kemal University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Namık Kemal University",institutionURL:null,country:{name:"Turkey"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"199",title:"TCM and Alternative Medicine",slug:"tcm-and-alternative-medicine"}],chapters:[{id:"67066",title:"Introductory Chapter: Traditional and Complementary Medicine",doi:"10.5772/intechopen.86373",slug:"introductory-chapter-traditional-and-complementary-medicine",totalDownloads:1230,totalCrossrefCites:8,totalDimensionsCites:11,hasAltmetrics:0,abstract:null,signatures:"Cengiz Mordeniz",downloadPdfUrl:"/chapter/pdf-download/67066",previewPdfUrl:"/chapter/pdf-preview/67066",authors:[{id:"214664",title:"Associate Prof.",name:"Cengiz",surname:"Mordeniz",slug:"cengiz-mordeniz",fullName:"Cengiz Mordeniz"}],corrections:null},{id:"67739",title:"Integration of Traditional and Complementary Medicine into Evidence-Based Clinical Practice",doi:"10.5772/intechopen.87061",slug:"integration-of-traditional-and-complementary-medicine-into-evidence-based-clinical-practice",totalDownloads:1186,totalCrossrefCites:0,totalDimensionsCites:3,hasAltmetrics:1,abstract:"Traditional and complementary medicine regains popularity not only in developing countries but also in developed countries. Modern medicine often fails to cure and just tries to alleviate the symptoms. The patient feels better as long as the effect of the drug continues but his/her symptoms reappear after the elimination of the drug. In this way, instead of healing the patients, we turn them into life-time drug dependent. Traditional and complementary medicine, being turned scientifically into evidence-based medicine, will change the medical philosophy and treatment such as individualized and holistic approach. Complementary interventions are used together with conventional treatments, whereas alternative interventions are used instead of conventional medicine.",signatures:"Cengiz Mordeniz",downloadPdfUrl:"/chapter/pdf-download/67739",previewPdfUrl:"/chapter/pdf-preview/67739",authors:[{id:"214664",title:"Associate Prof.",name:"Cengiz",surname:"Mordeniz",slug:"cengiz-mordeniz",fullName:"Cengiz Mordeniz"}],corrections:null},{id:"65475",title:"African Traditional Medicine: South African Perspective",doi:"10.5772/intechopen.83790",slug:"african-traditional-medicine-south-african-perspective",totalDownloads:3772,totalCrossrefCites:19,totalDimensionsCites:23,hasAltmetrics:1,abstract:"African traditional medicine (ATM) has been used by African populations for the treatment of diseases long before the advent of orthodox medicine and continues to carry a part of the burden of health for the majority of the population. South Africa, as a member state of the World Health Organisation, has been set on the path of institutionalising African traditional medicine. This chapter outlines the processes and progress pertaining to the acceptance and acknowledgement of the role of ATM in health care. It sets out to describe the strides made with regard to the traditional health practitioners’ Act and other laws, research in ATM, education of both health care and traditional health practitioners, including the role of collaboration. An overview of the practice of African traditional medicine is provided.",signatures:"Mmamosheledi E. 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The development of the “Self-Organizing Factors of Biofield” (BioFAO) with complex of seven homeopathic medicines will be presented applied in life sciences. BioFAO corroborates Hering’s Healing Laws and obstacles to healing. Regardless of the point of view, innovations happen in Homeopathy, either in the stricto sensu or in the lato sensu of its classical known terminology. The La Gioconda effect mysteriously maintains Homeopathy for centuries, as well as Mona Lisa’s trajectory of magnetism over people, which made it become the most famous painting of mankind. Quantum theory brings elements that can fundamentally be connected with phenomena applied with living beings already observed.",signatures:"Silvio Leite Monteiro da Silva",downloadPdfUrl:"/chapter/pdf-download/65378",previewPdfUrl:"/chapter/pdf-preview/65378",authors:[{id:"219698",title:"Dr.",name:"Silvio",surname:"Leite Monteiro Da Silva",slug:"silvio-leite-monteiro-da-silva",fullName:"Silvio Leite Monteiro Da Silva"}],corrections:null},{id:"65194",title:"A Review on Natural Antioxidants",doi:"10.5772/intechopen.82636",slug:"a-review-on-natural-antioxidants",totalDownloads:1277,totalCrossrefCites:2,totalDimensionsCites:5,hasAltmetrics:0,abstract:"Free radicals and related species have attracted a great deal of attention in recent years. Oxidative stress has been considered a major contributory factor to the diseases. They are mainly derived from oxygen (reactive oxygen species (ROS)) and nitrogen (reactive nitrogen species (RNS)) and are generated in our body by various endogenous systems and exposure to different physicochemical conditions or pathophysiological states. Free radical damage to protein can result in loss of enzyme activity. There are epidemiological evidences correlating higher intake of components/foods with antioxidant abilities to lower incidence of various human morbidities or mortalities. The sources and origin of antioxidants which include fruits and vegetables, meats, poultry, and fish were treated in this study. The classification and characteristics of antioxidant, its measurements and level in food and free radicals, were also documented. The chemistry of antioxidants which includes chain reactions, molecular structures, food antioxidants and reaction mechanisms, biochemical activity, therapeutic properties, and future choice of antioxidants was reported in this review.",signatures:"Arun Rasheed and Rinshana Fathima Abdul Azeez",downloadPdfUrl:"/chapter/pdf-download/65194",previewPdfUrl:"/chapter/pdf-preview/65194",authors:[{id:"277345",title:"Dr.",name:"Arun",surname:"Rasheed",slug:"arun-rasheed",fullName:"Arun Rasheed"}],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"9050",title:"Hypnotherapy and Hypnosis",subtitle:null,isOpenForSubmission:!1,hash:"f5686a1d5917736fa774b2f46e7da8a5",slug:"hypnotherapy-and-hypnosis",bookSignature:"Cengiz Mordeniz",coverURL:"https://cdn.intechopen.com/books/images_new/9050.jpg",editedByType:"Edited by",editors:[{id:"214664",title:"Associate Prof.",name:"Cengiz",surname:"Mordeniz",slug:"cengiz-mordeniz",fullName:"Cengiz Mordeniz"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8593",title:"Plant Extracts",subtitle:null,isOpenForSubmission:!1,hash:"93ae18175f7b16937a3dfddc10a51572",slug:"plant-extracts",bookSignature:"Aman Dekebo",coverURL:"https://cdn.intechopen.com/books/images_new/8593.jpg",editedByType:"Edited by",editors:[{id:"191684",title:"Dr.",name:"Aman",surname:"Dekebo",slug:"aman-dekebo",fullName:"Aman Dekebo"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. 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Chapters cover topics including rocket engines, electric propulsion, mechanisms of force, and more.",isbn:"978-1-83968-835-5",printIsbn:"978-1-83968-834-8",pdfIsbn:"978-1-83968-836-2",doi:"10.5772/intechopen.87830",price:119,priceEur:129,priceUsd:155,slug:"propulsion-new-perspectives-and-applications",numberOfPages:102,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"042ab0c0a8270b1bacf6a8e385601863",bookSignature:"Kazuo Matsuuchi and Hiroaki Hasegawa",publishedDate:"December 15th 2021",coverURL:"https://cdn.intechopen.com/books/images_new/10007.jpg",keywords:null,numberOfDownloads:1417,numberOfWosCitations:0,numberOfCrossrefCitations:2,numberOfDimensionsCitations:4,numberOfTotalCitations:6,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"September 16th 2020",dateEndSecondStepPublish:"October 14th 2020",dateEndThirdStepPublish:"December 13th 2020",dateEndFourthStepPublish:"March 3rd 2021",dateEndFifthStepPublish:"May 2nd 2021",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 years",secondStepPassed:!0,areRegistrationsClosed:!0,currentStepOfPublishingProcess:5,editedByType:"Edited by",kuFlag:!1,biosketch:"Obtained his Ph.D. in Engineering from Osaka University and most of his career spent at the University of Tsukuba where he finally earned his Professor Emeritus title.",coeditorOneBiosketch:"Prof. Hasegawa worked for the Japan Defense Agency for ten years and obtained his Ph.D. in Engineering from the University of Tsukuba in 1999, his research interests lie in the application of fluid mechanics in the fields of aviation, outer space, medicine, and sports.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"42387",title:"Prof.",name:"Kazuo",middleName:null,surname:"Matsuuchi",slug:"kazuo-matsuuchi",fullName:"Kazuo Matsuuchi",profilePictureURL:"https://mts.intechopen.com/storage/users/42387/images/system/42387.jpg",biography:"Dr. Kazuo Matsuuchi obtained his Ph.D. in Engineering from Osaka University, Japan, in 1976. In 1977, he served as a research assistant at the Institute of Structural Engineering, University of Tsukuba, Japan. He became a full professor at the same university in 1995. In 2012 he earned the title of Professor Emeritus and he is still active at the University of Tsukuba. 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Method validation is a procedure of performing numerous assessments designed to verify that an analytical test system is suitable for its intended reason and is capable of providing beneficial and legitimate analytical data [4, 5, 6, 7, 8]. A validation examine includes testing multiple attributes of a method to determine that it may provide useful and valid facts whilst used robotically [9, 10, 11]. To accurately investigate method parameters, the validation test ought to consist of normal test conditions, which includes product excipients [11, 12, 13, 14]. Therefore, a method validation examine is product-specific.
Selectivity/Specificity
Precision
Accuracy
Linearity
Range
Stability
Limit of Detection (LOD) and Limit of Quantitation (LOQ)
Selectivity of an analytical method is its ability to measure accurately an analyte in the presence of interferences that may be expected to be present in the sample matrix.
Selectivity is checked by examining chromatographic blanks (from a sample that is known to contain no analyte) in the expected time window of the analyte peak. And the raw data for selectivity will be recorded in the raw data in approved formats.
Precision of a method is the degree of agreement among individual test results when the procedure is applied repeatedly to multiple samplings.
Precision is measured by injecting a series of standards or analyzing series of samples from multiple samplings from a homogeneous lot. From the measured standard deviation (SD) and Mean values, precision as relative standard deviation (% rsd) is calculated.
The raw data for precision will be recorded in the approved format and the acceptance criteria for precision will be given in the respective study plan or amendment to the study plan.
Precision can be also calculated by using Horwitz equation:
The acceptable percent of relative standard deviation results for precision may be based on the Horwitz equation, an exponential relationship between the among-laboratory relative standard deviation (RSDR) and Concentration (C): [15]
For estimation of repeatability (RSDr), is modified to:
The Horwitz curve has been empirically derived and has been proven to be more or less independent of analyte, matrix and method of evaluation over the concentration range C = 1 (100%) to C = 10−9 by the evaluation of vast numbers of method precision studies. The modified Horwitz values for repeatability CV given under may be used for guidance. If measured repeatability is outside those values, suggested explanation must be submitted for consideration. The details were presented in Table 1.
Percent of analyte | Proposed acceptable % RSDr (Horwitz value × 0.67) |
---|---|
100.00 | 1.340 |
50.00 | 1.490 |
20.00 | 1.710 |
10.00 | 1.900 |
5.00 | 2.100 |
2.00 | 2.410 |
1.00 | 2.680 |
0.25 | 3.300 |
Details of Horwitz values.
Note: The unmodified Horwitz equation is used as a criterion of acceptability for methods collaboratively tested by CIPAC.
The accuracy of an analytical method is the degree of agreement of test results generated by the method to the true value.
Accuracy is measured by spiking the sample matrix of interest with a known concentration of analyte standard and analyzing the sample using the “method being validated.” The procedure and calculation for Accuracy (as% recovery) will be varied from matrix to matrix and it will be given in respective study plan or amendment to the study plan.
The linearity of an analytical method is its capability to elicit check consequences which might be at once, or with the aid of well described mathematical adjustments, proportional to the concentration of analytes in within a given range.
Linearity is determined by injecting a series of standards of stock solution/diluted stock solution using the solvent/mobile phase, at a minimum of five different concentrations in the range of 50–150% of the expected working range. The linearity graph will be plotted manually/using Microsoft Excel or software of the computer (Concentration vs. Peak Area Response) and which will be attached to respective study files.
The range of an analytical method is the interval between the upper and lower levels that have been demonstrated to be determined with precision, accuracy and linearity using the set method. This range will be the concentration range in which the Linearity test is done.
Many analytes readily decompose prior to chromatography investigations, for example during the preparation of the sample solutions, during extraction, clean-up, phase transfer, and during storage of prepared vials. Under these circumstances, method development should investigate the stability of the analyte. Accuracy test takes care of stability. It is required to mention in the method how long a sample after extraction can be stored before final analysis, based on the duration taken for accuracy test.
The term LOD is defined as the lowest concentration at which the instrument is able to detect but not quantify and the noise to signal ratio for LOD should be 1:3. The term LOQ is defined as the lowest concentration at which the instrument is able to detect and quantify. The noise to signal ratio for LOQ should be 1:10.
Determination of Limit of Detection (LOD) and Limit of Quantitation (LOQ) from Detector Linearity experiments (applicable to only instrument sensitivity).
LOD and LOQ values are calculated manually by taking Noise to signal ratio of a lowest/known concentration of linearity samples and it will be expressed in μg/ml or ppm. To calculate in %, values of LOD and LOQ will be multiplied by 100/lowest or known concentration of test item (mg/L) taken for analysis of that particular a.i. or impurity analysis.
Prepare a series of standard solutions (minimum five concentrations covering working concentrations used for routine analysis) and analyze each solution minimum twice and record the instruments response.
Using the concentrations and corresponding instrument response, LOD and LOQ can be calculated as follows:
Let the linear regression equation be
Where, X and Y are the variables (data of two parameters). Generally, X is called the independent variable and Y, the dependent variable.
Take concentration on X-axis and instrument response on Y-axis.
“a” and “b” are the regression constants. Further, “a” is known as the intercept and “b,” the slope of the line.
Let (X1, Y1), (X2, Y2), (X3, Y3)…(Xn, Yn) be the set of values required to be fit in the linear equation.
a. Method of arriving at “a” and “b”
Tabulate as given below:
X1 Y1
X2 Y2
. .
. .
. .
Xn Yn
____________________________________
____________________________________
ii. Calculate the following parameters:
iii. Calculate the slope “b,” and intercept “a” as given below:
b. Method of calculation r (correlation coefficient)
c. Method of calculation standard deviation for “a” and “b”
The standard deviation of the individual deviations of measured values in Y, above and below the linear line (fitted line) is:
From this, the standard deviation for “a” and “b” are calculated.
Standard deviation
for “a,” represented =
as Sa
Standard deviation.
For “b,” represented =
as Sb
When Sa is obtained for a linear calibration line, then it provides a clear information on the standard deviation of the “Blank” (or Control) response from the instruments.
The LOD and LOQ can be worked out, as given below:
The above calculations can be programmed in a computer but before every use, the computer program must be validated using the example given in section
The above procedure can also be used for obtaining LOD and LOQ of the method from recovery test results by taking fortified concentration on X-axis and obtained concentrations on Y-axis.
In this example, the linear regression equation is employed to find out the extent of linear response of an Detector to a reference analytical standard in the concentration range of about 0.2–3.0 ppm.
Each of these working standards is injected thrice (1 μl per injection), and the peak area counts corresponding to the active ingredient peak are given below.
From the peak areas corresponding to each concentration level, the mean, standard deviation (SD) and coefficient of variation (%CV) are also calculated. The details were presented in Table 2.
Conc. of standard solution (μg/ml) | Peak area | Mean | SD (n − 1) | %CV | ||
---|---|---|---|---|---|---|
1 | 2 | 3 | ||||
0.1956 | 32,827 | 33,299 | 32,731 | 32,952 | 304 | 0.923 |
0.4890 | 87,783 | 88,480 | 87,446 | 87,903 | 527 | 0.600 |
0.9780 | 176,037 | 174,675 | 177,203 | 175,972 | 1265 | 0.719 |
1.467 | 246,212 | 250,786 | 246,849 | 247,949 | 2477 | 0.999 |
1.956 | 319,143 | 319,615 | 315,316 | 318,025 | 2358 | 0.741 |
2.934 | 415,059 | 410,773 | 418,407 | 414,746 | 3827 | 0.923 |
Calculation details of mean, SD, and %CV.
%CV = SD × 100/Mean: The coefficient of variation (CV) shows that the Injection variation is less than 1%.
Let the equation be
Where, Y = Mean peak area counts and X = Concentration of standard solution, μg/ml.
The calculations were presented in Table 3.
Analytical methods for quantitation of major excipients and/or active ingredients, and preservatives in finished goods.
Analytical methods for determination of impurities or degradation compounds in finished goods. These methods include quantitative assays and limit tests, titrimetric and bacterial endotoxin tests.
Analytical methods for determination of performance characteristics, e.g., sterility testing, dissolution and drug release for pharmaceutical products.
Details of required validation parameters of assay presented in Table 4.
Sl. no. | Y | X |
---|---|---|
1. | 32952 | 0.1956 |
2. | 87903 | 0.4890 |
3. | 175972 | 0.9780 |
4. | 247949 | 1.4670 |
5. | 318025 | 1.9560 |
6. | 414746 | 2.9340 |
Calculation details of additional parameters.
Analytical validation data playing a fundamental role in pharmaceutical industry, pesticide industry for releasing the economic batch and long term stability information consequently, the records must be produced to suited regulatory authority requirements.
Adenosine 5′-triphosphate (ATP) is abundantly generated in the cytosol through respiration and glycolysis. Primarily, these are the “energy currency” of the cell as ATP hydrolysis release energy and is essential to maintain the cellular homeostasis and activity [1]. Extracellular activity of ATP was first described by Drury and Szent-Györgyi in 1929 [2]. Later, in 1970s, ATP was shown to be involved in non-adrenergic, non-cholinergic nerve-mediated responses, and further its function as a neurotransmitter was established that led to introduction of the term “purinergic signaling” [3]. Burnstock has described about the purinergic signaling and purinergic systems in very detail, which consists of (a) purine or pyrimidine derivatives that serve as an “extracellular messenger,” (b) “membrane transporter” that are responsible for the extracellular release of these nucleotides or nucleosides, (c) “metabolizing enzymes” present on the cell surface that hydrolyze the ATP to adenosine diphosphate (ADP) then to adenosine monophosphate (AMP) and adenosine and, (d) “purinergic receptors” that sense the extracellular purine or pyrimidine derivatives [3, 4, 5, 6, 7].
In the beginning, purinergic signaling was determined to have a role in neuronal signaling but now, their role in immune responses, inflammation, pain, exocrine and endocrine secretion, platelet aggregation, and endothelial-mediated vasodilatation had been explored and established [3, 4, 6, 8]. Additionally, cross talk of purinergic signaling with other signaling network also associates with the impact on cell proliferation, differentiation, and death that occur during the development and regeneration processes. Under normal condition, purinergic signaling operate in a very well-regulated manner to maintain the physiological function of different organ systems. Dysregulation in any component of the purinergic signaling network depending on the expression or activation of purinergic receptors, ectonucleotidases or release of agonist from damaged cell resulting from stress, inflammation serves as a potent modulator of inflammation and key promoters of host defenses, immune cells activation, pathogen clearance, and tissue repair that contributes to the disease pathogenesis [9]. Thus, their knowledge is of great importance for a full understanding of the pathophysiology of acute and chronic inflammatory diseases and will give an insight on novel therapeutic approaches to overcome inflammation. This chapter describes the component of purinergic system, its cross talk with immune signaling. Major focus of this chapter is to present the dynamics of purinergic signaling under normal physiological condition and its role in modulating the immune and inflammatory response under various diseased conditions like autoimmunity, and microbial infection.
Extracellular ATP (eATP) has been well established as a ligand for autocrine and paracrine signaling that has a pathophysiological role. In addition, to eATP other nucleotides and nucleosides such as the adenosine, adenosine monophosphate (AMP), adenosine diphosphate (ADP), uridine diphosphate (UDP), uridine triphosphate (UTP), and nicotinamide adenine dinucleotide (NAD+) also serve as a potent purinergic signaling modulator. The release of nucleotides into the extracellular space occurs via regulated and unregulated mechanisms. Regulated mode of release of nucleotide is mediated through classical exocytosis [10] or conductive ATP release through ATP-permeable channels [11]. Currently, five groups of ATP-release channels are known such as: connexin hemichannels, Pannexin (PANX), calcium homeostasis modulator 1 (CALHM1), volume-regulated anion channels (VRACs), and maxi-anion channels (MACs) [12].
The ATP release by exocytosis is an active release mechanism that involves vesicular nucleotide transporter (VNUT). It is responsible for the accumulation and exocytosis of ATP from exocytotic vesicles that occurs in a proton-dependent electrochemical gradient manner generated by a vacuolar-ATPase (v-ATPase). Further, intracellular Ca+2 level and soluble N-ethylmaleimide-sensitive factor attachment protein receptor (SNARE) drives the fusion of the exocytotic vesicles with the plasma membrane ultimately resulting in the release of nucleotides into the extracellular space [13, 14]. Hemichannels are the ATP permeable channels that support the release of ATP under specific pathological condition. Primarily, these channels contribute to various cellular and physiological functions by forming gap junctions or hemichannels, to allow intercellular communication. They are categorized into two based on their functions, [1] connexins that has both gap junction and form hemichannel function whereas [2] PANX only form hemichannel [15]. These channels are in closed state under normal condition to avoid the loss of vital ionic, energetic, and metabolic gradients. However, chemical and biochemical stimuli resulting from pathological conditions trigger their opening and lead to release of ATP. Till date, 21 isoforms of connexins are reported in human of which connexin-43, -37, -26, and -36 have been shown to support ATP release [16]. Connexin-43 is widely expressed and very well studied. It is activated by increase in the intracellular Ca+2 concentration, plasma membrane depolarization, reactive oxygen species (ROS) or nitric oxide (NO) [17, 18]. The PANX (PANX) family is comprised of three members, PANX-1, -2, and -3 of which PANX-1 and -3 are widely expressed in different tissues, while PANX-2 is exclusively found in the brain [19]. In resting state, PANX channels are closed, mainly due to the blockage of the pore by C-terminal tail from the intracellular side [18]. However, in response to apoptosis or pyroptosis, C-terminal tail gets cleaved by caspase-3, -7, or -11 leading to opening of PANX-1 and allows nucleotides to cross the plasma membrane [20, 21]. Additionally, other stimuli such as intracellular calcium increase, redox potential changes, mechanical stress, and activation of the P2X7R can trigger PANX-1 channel opening [22].
Another mechanism involves the disruption of the cell membrane by apoptosis, necrosis, pyroptosis, or netosis, which leads to the unregulated leakage of ATP as well as other large cytosolic molecules including enzymes [11, 23, 24].
The life span of eATP is controlled by purinergic ectoenzymes that coordinate a sequential two-step process of hydrolyzing ATP into AMP and then into the potent anti-inflammatory adenosine. This make ectonucleotidases enzymes a crucial component of the purinergic system, which balance the level of eATP as well as other nucleotide derivatives UTP, NAD+, and their metabolites, thereby controlling the activation of purinergic receptors and biochemical composition of the inflammatory microenvironment. These enzymes are classified into four major families: (a)
Briefly, CD39 has an anti-inflammatory property that controls the extracellular level of ATP by converting it into adenosine in conjunction with CD73. CD39 and CD73 exhibit an immunosuppressive activity as shown by its expression on Tregs cells [29, 30, 31]; CD8 T cells [32] and B cells [33] and inhibits the pathogenic T cells. Breakdown of eATP by CD39 prevents the activation of P2X7R and attenuates the secretion of IL-1β and IL-18 [34]. The expression pattern of CD38 varies during the differentiation and maturation of B and T cells [35, 36]. The enzymatic activity of CD38 generates cADPR/ADPR and triggers Ca+2 release from intracellular stores and Ca+2 influx from the extracellular space that have role in transmigration and chemotaxis of neutrophils, monocytes and DCs, and cytokine release [37]. Elevated level of cADPR/ADPR and intracellular Ca+2 regulates cellular chemotaxis [38], phagocytosis [39], and antigen presentation [40] in a CD38 dependent manner. Thus, dysregulation of CD38 has been implicated in several inflammatory pathologies such as autoimmunity and cancer [37, 41]. It is important to note that cADPR is generated by hydrolysis of NAD+, disruption in the metabolism of NAD+ has been associated with multiple pathological conditions [42]. Different types of NPPs have been implicated in a various of pathologic conditions such as tumor invasion and metastasis, inflammation, and angiogenesis (NPP2), tissue calcification and bone development (NPP1), and hemostasis and platelet aggregation (NPP4) [43]. However, NPP2 (ATX) is widely studied, ATX-LPA signaling axis induces inflammatory mediators such as IL-8, IL-6, TNF-α, and growth factors such as the vascular endothelial growth factor (VEGF) and the granulocyte colony-stimulating factor (G-CSF) thereby augmenting the cytokine production and lymphocyte infiltration that ultimately aggravates the inflammation in conditions such as asthma, pulmonary fibrosis, and rheumatoid arthritis [44, 45].
Purinergic receptors are divided into two subtypes based on their binding tendency to different purine derivatives—P1 receptor (P1R) has affinity to bind adenosine only, whereas P2 can bind ATP, ADP, UDP-glucose, UDP and UTP [46]. Adenosine receptors (AR) belong to rhodopsin-like family of G protein receptors and consist of four subtypes such as A1, A2A, A2B, and A3. Adenosine generated by the hydrolysis of extracellular ATP, ADP, or AMP are either metabolized by adenosine deaminase (ADA) or shuttled back to the cells via two types of transporters, the equilibrate nucleoside transporters (ENTs) and the concentrative nucleoside transporters (CNTs) to stimulate various intracellular pathways like AMP-activated protein kinase, adenosine kinase and S-adenosyl homocysteine hydrolase [47]. Although it may depend on the concentration of adenosine and the given P1 receptor subtype engaged, but adenosine primarily, have anti-inflammatory and immune suppressive functions. The immunosuppressant activity of adenosine relies on the inhibition of virtually all immune cell populations such as T and B lymphocytes, NK cells, DCs, granulocytes, monocytes, and macrophages.
P2 receptors further categorized into two families based on molecular structure and second messenger systems, namely P2X ionotropic ligand-gated ion channel receptors that only binds to ATP and P2Y metabotropic G protein-coupled receptors (GPCR) can bind to ADP, UDP- glucose, UDP, and UTP [46]. The family of P2X receptors comprises seven members (P2X1–7), which perform tissue-specific functions by forming homo- or hetero-trimeric complexes. At least three P2X subunits assemble to form hetero- (e.g., P2X2/3 and P2X1/5) or homo-trimeric (P2X7) channels. This kind of assembly confers to P2X receptors a large repertoire of physiological functions in different tissues. Among P2XRs, the P2X7R has a special place in inflammation since its stimulation promotes NLRP3 inflammasome assembly and the associated IL-1β secretion. There are eight subtypes of P2Y receptors, which is further characterized into two subfamilies P2Y1 and P2Y12 based on their coupling to Gq and Gi, respectively. P2Y1 subfamily includes P2Y1, P2Y2, P2Y4, P2Y6, and P2Y11 receptors. The second subfamily is P2Y12, which contains P2Y12, P2Y13, and P2Y14 receptors. Each P2Y receptors has different affinity towards different nucleotides and has a tissue-specific function. For instance, P2YR11 has affinity for ATP; P2YR1, P2YR12, and P2YR13 for ADP; P2YR2 and P2YR4 for UTP; P2YR6 for UDP; and P2YR14 for UDP-glucose and UDP-galactose [5].
The purinoceptors are expressed on almost all kinds of peripheral tissues and are involved in short-term as well as long-term regulation of variety of functions, ranging from neuromuscular and synaptic transmission to secretion in gut, kidney, liver, and reproductive systems. Their contribution in immune signaling is enormous, as these receptors are expressed on almost all types of immune cells. The purine nucleotides orchestrate the onset, magnitude duration, and resolution of the inflammatory response through the activation of purinergic receptors, which is also governed by the activity of ectonucleotidases (Figures 1 and 2). Any alterations in the purinergic machinery could contribute to the pathophysiological processes underlying the onset and development of immunological diseases, neurodegeneration, cancer, diabetes, and hypertension [7, 46, 48].
Cartoon depicting the components of purinergic system and their functions. Mechanism of nucleotide release from the intact cells via exocytosis or transport channels as well as leakage of ATP from apoptotic and netosis (bottom of the image). The nucleotide triggers the activation of immune cells via specific purinergic receptor (top of the image). Activation of purinergic receptors ATP or their hydrolyzed metabolites ADP/AMP and adenosine by ectonucleotidases (middle of the image).
Pictorial representation of cross talk of purinergic and immune signaling during normal physiological condition and inflammatory condition.
Beyond the physical and chemical barrier of skin and mucous lining, our body is guarded from the pathogens as well as self-attacking/cancerous cells by two different kinds of immune responses that acts in a coordinated manner. This includes (a) innate immune response comprising myeloid lineage derived cells (monocytes, macrophages, neutrophils, and DCs) and NK cells derived from lymphoid progenitors, and (b) adaptive immune response consists of B and T cells. Innate immune response provides the first line of defense against pathogens. It is an antigen-independent defense mechanism that is elicited when immune cells encounter pathogens. This response has no memory and remains similar during the lifetime. On the other hand, adaptive immune response is an antigen dependent, antigen specific, and has the tendency to form memory cells to elicit rapid response based on the previous encounter with the similar kind of antigen or pathogenic exposure. Innate and adaptive immune responses are not mutually exclusive defense mechanisms. They work in a very organized fashion and complement the functions, as activation of T cells requires antigen presentation by professional antigen presenting cells (dendritic cells, B-cells, or macrophages), together with the major histocompatibility complex (MHC) type I or II [49]. Defects in any of the component increases the vulnerability towards infection and disease.
ATP and adenosine are the key modulators of the immune response, ATP being an immunostimulant, whereas adenosine has an immunosuppressive effect thus balance between the two is crucial for the proper functioning of immune system. Extracellular signals by ATP and adenosine are detected and transduced by P2 and P1 receptors (Figure 2), respectively which is present on all kinds of immune cells, thus purinergic signaling affects all aspects of immunity and inflammation [50], which is described in detail in further section.
Macrophages are the subset of myeloid cells that have immune surveillance function and sense even a minute changes in the tissue microenvironment. They express a variety of pattern recognition receptors (PRRs) that are present either on the surface, cytosol or in the endosome such as toll like receptors (TLRs), NOD like receptor (NLRs), retinoic acid inducible gene I like receptors (RLR), transmembrane C-type lectin receptors, and absent in melanoma (AIM)2-like receptors (ALRs) that recognize either pathogen associated or damage associated molecular patterns (PAMP and DAMP, respectively). These cells are highly plastic that could undergo profound metabolic modifications after sensing the pathogens or damage signal via PRRs to elicit the immune response. In addition, macrophages are endowed with purinergic P1, P2X, and P2Y receptors that also respond to damage associated molecules, extracellular nucleotides, and their derivatives, and undergo reprogramming from pro-inflammatory profile M1-like phenotype to an anti-inflammatory M2-like phenotype. As indicated by Elliott et al., that monocytes or macrophages sense extracellular nucleotide as a danger signal for “find me” or “eat me” to engulf and phagocytose the dying cells [24]. These cells not only sense the distant signal but also amplify the signaling for chemotaxis by releasing ATP by “autocrine purinergic loop” via P2Y2 and A3 receptors [51, 52]. Macrophages control their activation state in an autoregulatory mechanism by inducing the production of ATP and extracellular degradation to adenosine. Deficiency of CD39 promotes a sustained inflammatory activation state and inhibits the switch to an immunosuppressive phenotype [53]. Presence of extracellular adenosine stimuli in macrophages drives the polarization towards M2 phenotype with diminished expression of inflammatory genes TNF-α and IL-6 and increased expression of anti-inflammatory cytokines such as IL-10 and VEGF via A2A and A2B receptors [54]. Furthermore, macrophages exhibit a unique repertoire of P2X receptors such as expression of P2X1, P2X4, as well as P2X7 [55]. Among P2Y receptors, P2Y1 and P2Y4 receptors play minor roles, whereas the functions of P2Y2, P2Y6, P2Y11, P2Y12, P2Y13, and P2Y14 are more established in the macrophage biology as described elsewhere [56]. A recent study demonstrated that bone marrow derived macrophages display unique expression pattern of purinergic receptors that correlates with a M1or M2 inflammatory phenotype. M1 phenotype exhibit a unique and more pronounced P2X7 negative macrophage population, which associates with decreased inflammasome formation. P1 receptors A2A and A2B are upregulated in M1 and M2. P2Y1 and P2Y6 exclusively upregulated in M2, whereas P2Y13 and P2Y14 are overexpressed in M1 [57]. This unique feature demonstrates capability of purinergic receptors on macrophages to adapt to pro- and anti-inflammatory macrophage differentiation with functional consequences to nucleotide stimulation.
DCs are professional antigen-presenting cells (APCs), which has a crucial role in initiating and regulating the adaptive immune response by directing the activation and differentiation of naive T cells. Immature DCs (iDCs) sense the danger signals in the similar fashion as monocytes and macrophages do, however upon exposure, DCs lose their phagocytotic capacity, migrate to secondary lymphoid organs and transition to a mature DC (mDC) by acquiring MHC and costimulatory molecules, such as CD54, CD80, CD83, and CD86. Migration of DCs to the inflamed tissue is mediated by A1 and A3 ARs [58]. Adenosine upregulates the expression of co-stimulatory molecules on mDCs [59]. Both, A2A and A2B ARs suppress maturation of DCs as well as their capacity to initiate Th1 response, however, it increases pro-angiogenic VEGF, IL-10 and cytokines that contribute to Th17 cell polarization [59, 60]. Adenosine also mediates the attraction of DC and Treg cells, which is crucial for the immunosuppressive activity of Treg cells [61]. Similarly, ATP also acts as a chemoattractant for iDCs, and enhance the migration by autocrine signaling loop mechanism via P2X7. This signaling is further amplified by the release of ATP by PANX-1 channels [62]. Furthermore, eATP had been shown to activate P2X7R to promote the maturation of dendritic cells via NF-κB (p65) pathway [63]. On the other hand, P2Y6 has inhibitory role in the maturation and activation of DCs via NF-κB by inhibiting the production of IL-12 and IL-23 and the polarization of Th1 and Th17. Loss of P2Y6 enhances the DC mediates differentiation of Th1 and Th17 subsets [64]. The ATP-P2X7 signaling axis of DCs also promotes interleukin (IL)-1β and IL-18 secretion by activating NLRP3 inflammasome and induces Th2/Th17 differentiation [65]. P2X4 acts in conjunction with P2X7 to regulate IL-1β production by DCs [66]. As described previously, the balance of proinflammatory-ATP and anti-inflammatory adenosine is regulated by CD39 and CD73 present on the immune cells. In context of DCs, their expression fine tunes the DCs function either as tolerance (higher expression) or as immunity (lower expression) ensues [67, 68].
Neutrophils belongs to the granulocyte family, which has a major role during the early stages of the inflammatory response. They are the first cell to arrive at the inflammation site, which employ an extracellular ATP-dependent mechanism to generate a chemotactic gradient and orientate its migration. Remarkably, the purinergic system regulates many effector functions of neutrophils such as phagocytosis, oxidative burst, degranulation, and neutrophil extracellular traps (NETs) formation via Netosis [69, 70]. Apoptotic neutrophils release ATP to stimulate mononuclear phagocytic cell influx and promote engulfment and clearance functions. Nucleotides released as a result of the apoptosis and netosis serve as danger or find me signal to initiate immune cell chemotaxis via P2Y2 receptor towards inflamed tissue and fine-tuned control local inflammation and promote phagocytosis and clearance [24, 71]. Similar to other phagocytic cells such as monocytic and dendritic cells, neutrophils in the immune microenvironment also release ATP via PANX-1 to induce chemotaxis by autocrine stimulation of P2Y2 [51, 52, 62, 72]. On the other hand, P1 receptor, A2A (activated by adenosine) blocks the chemoattractant signaling, whereas alternative binding of adenosine to A3 receptors, stimulate immune migration. Thus, P2Y2 and A3 receptors are responsible for the amplification of the chemotaxis signal via feedback loop mechanism [52]. P2Y2 receptors play crucial role in neutrophil activation by regulating the release of IL-8, a major chemokine for neutrophils chemotaxis [73]. IL-8 secretion is in turn controlled by CD39 [74]. Thus, the local microenvironment composed by ATP and the consequent degradation to adenosine by CD39 and CD73 ectoenzymes influence reprogramming of the innate immune cells and their response towards pathogens and other diseased condition.
NK cells are considered as a component of innate immune system due to the lack antigen-specific cell surface receptors but morphologically they resemble lymphocytes as they originate from the common lymphoid progenitor cell in the bone marrow. NK cells exert sophisticated biological functions that attribute to both innate and adaptive immunity, thus the functional boundary between these two arms of the immune response is obscure [75]. These cells express a repertoire of activating (NKG2 C-H) and inhibitory receptors (NKG2 A and B) through which it interacts with pathogens by recognizing MHC-I molecule [76]. Activation of the NK cell leads to cytolytic killing of infected cells. Adenosine receptors A1, A3 and A2A, A2B have an antagonistic effect in controlling the intracellular cAMP levels. A1, A3 inhibits the adenylyl cyclase and decreases the intracellular cAMP level, which has a stimulatory effect on NK cell and promote the cytotoxic activity whereas, A2A and A2B has the immunosuppressive effects on NK cells [76, 77]. NAD+ and ADP-ribose inhibited human NK proliferation [78]. Nucleotide triphosphates (ATP, GTP) have high potency in inhibiting NK cell-mediated cytotoxicity, this tendency however decreases with reduced negative charge due to less phosphate group [(ADP, GDP) > (AMP, GMP)]. Ectonucleotidases do not have any significant role in modulating the cytolytic effect of NK cells by extracellular ATP/ADP/AMP [79]. NK cells express lower level of CD73 even with IL-15 and IL-12 priming [74]. Decreased expression of P2Y6 promotes the development of the NK precursor cells into immature NK and mature NK cells suggesting P2Y6 as a negative regulator of NK cell maturation and function [80]. Among other extracellular purine derivatives, NKT cells display higher sensitivity to NAD+ and induce cell death via P2X7 pathway [81, 82]. Furthermore, another phenotypically heterogeneous NKT cells subset includes invariant natural killer T (iNKT), which are CD4 and CD8 negative but express NK cell marker and produce IL-4 and IFNγ. iNKT recognizes lipid antigens combined with CD1d on the surface [83]. Activation of iNKTs
Activation of T cell immune response is the key in adaptive immune system functions, which elicits both cellular and humoral immunity. Naïve T cells are activated by APCs, but they require two subsequent signals, first one is the binding of TCR to peptide–MHC complex and the second one is the co-stimulatory interaction at the interface between APCs and T cells via B7/CD28, LFA-1/ICAM-1 and ICAM2, and CD2/LFA-3 ligand and receptor complex [87]. Di Virgilio et al. was the first to show T cell responsiveness to extracellular ATP (eATP), back to 1989 [88]. Once T cells are activated, they release ATP via PANX-1 channels, resulting in the activation of P2X1, P2X4, and P2X7 receptors that promotes downstream signal transduction pathways leading to IL-2 expression and T cell proliferation via Ca+2 influx [89]. P2X7 receptor stands out among P2X family members as the most important regulator of T cell function [90]. The released ATP stimulates purinergic receptors that also contributes to the amplification of co-stimulatory TCR/CD28 signal at the immune synapse by autocrine stimulation of P2X7 [91] and P2Y1 receptors [92]. In addition, the T cell activation via P2X7R inhibits the immunosuppressive Tregs cells [93]. P2X7R is also crucial for the activation of CD8 T cells, and its expression increases as they differentiate to TCM (central memory) and TRM (tissue-resident memory) suggesting its key role in generating long-lived memory CD8 T cells [94]. However, another study demonstrated that eATP treatment can trigger cell death in the naive CD8 (CD44loCD45RBhi) subset, but it is unable to induce these cellular activities in the effector/memory CD8 (CD44hiCD45RBhi) subset. Even though both subsets express similarly low levels of P2X7R, but they demonstrate different sensitivity to ATP depending on the stage of differentiation instead of P2X7R expression levels [95]. Importantly, expression of CD39 and CD73, the ecto-5′-nucleotidase that degrades extracellular AMP into adenosine, by other immune and tissue-resident cells can dramatically condition the outcome of T cell responses [96]. On the other hand, A2A receptor signal inhibits Th1 cell generation and IFN-γ production, triggering the induction of FoxP3 + Treg cell subset and the production of TGF-β. ATP catabolism and generation of retaliatory metabolite adenosine is a typical suppression mechanism of regulatory cells involving Treg, type-1 regulatory (Tr1) T cells, and myeloid-derived suppressor cells (MDSCs) [97]. These regulatory cells express CD39 and CD73 to abrogate ATP-related effects and enable the inhibitory properties. P2X7R can imprint distinct outcomes to the T cell depending on the metabolic fitness and/or developmental stage via autocrine signaling or microenvironment’s clues. The peculiarity of P2X7R function as cationic channel and cytolytic pore could be responsible for some apparently contradictory findings on P2X7R dependent responses in particular T cell subsets in different experimental settings [94, 95, 96].
Another important arm of adaptive immune response is the humoral immunity, which is mediated by B cells. These cells are also necessary for the development of T-cell immunity because they serve as an APC, providing costimulatory signals and producing cytokines necessary for effector functions of T cells. B cells exhibit expression of the membrane B cell receptor (BCR), which can recognize antigens in their native forms, thus B cells do not need antigen presentation for activation. Antigen recognition, together with signals from activated Th2 cells, induces B cells to proliferate and generate effector plasma cells and memory B cells. B cells expresses ectonucleotidases—CD39 and CD73, P1 receptors—A1, A2A, and A3, and P2 receptors—P2X1, P2X2, P2X4, and P2X7 [33, 98, 99]. The function and activity of B cells are largely governed by the concentration of adenosine and ATP in the microenvironment. Adenosine imposes suppressive effect on B cells, whereas increased ATP release and production are associated with activated B cells thereby exerting pro-inflammatory effect on the target tissue and IgM release [100].
A healthy individual has a practically insignificant amount ATP in the extracellular microenvironment (at the nanomolar range), whereas, they have significantly higher concentration of ATP in the intracellular environment (reaching several millimolar), as ATPs are the powerhouse of the cell. Inflammatory stress due to the increased production of proinflammatory mediators associates with release of ATP and other nucleotides into the extracellular space (Figure 1). These extracellular nucleotides trigger a stimulation of purinergic receptors, which is a normal physiological phenomenon and beneficial for preventing tissue damage ensuring host survival, it may also be detrimental for clearance of pathogens or dying cells. However, failure in the fine tuning of the immune response alters inflammatory and regulatory microenvironments, leading to unbalanced stimulation and culminates a hyperinflammatory condition generating numerous pathologies such as autoimmunity, chronic infectious diseases, and cancer (Figure 2).
Autoimmune diseases are characterized by diverse clinical manifestations including dysregulated innate and adaptive immune signaling, chronic inflammation, autoreactive immune cells, generation of autoantibodies to self-nuclear and cytoplasmic component. Based on the target organ and tissues, they are represented as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), multiple sclerosis (MS), Sjogren’s syndrome (SS), systemic sclerosis (SSc), etc. As described previously that some of the purinergic receptors are coupled with inflammasome assembly, pro-inflammatory cascades, secretion of IL-1β, IL-18, and T and B cell activation, and maturation, all these events play a pivotal role in autoimmunity [105].
SLE is an inflammatory autoimmune disease that affects many organs, including the skin, joints, the central nervous system, and the kidneys. A frequent and serious manifestation of SLE includes glomerulonephritis (GN), a condition that can cause proteinuria and progresses to kidney failure. These diverse clinical features include hematological and serological abnormalities, such as decreased levels of complement and increased levels of autoantibodies [106, 107]. SLE has multiple etiology like genetic, environmental, and hormonal factor but involvement of dysfunctional innate and the adaptive system is prominent [108]. Purinergic signaling is another key pathway that connects with the inflammatory signaling cascade and contributes to the immunopathogenesis of SLE.
Till date, more than 180 autoantibodies have been documented in SLE patients [107]. Source of the diverse pool of autoantigens are apoptosis [109], netosis [110], and pyroptosis [111]. Simultaneously, SLE patient also exhibit impairment of phagocytotic clearance and NET degradation [112, 113], which together represent a mechanism that trigger to breakdown of the self-tolerance against autoantigens and leading to initiation of SLE. Defects in the purinergic signaling and its role in SLE pathogenesis and disease severity had been described at several instances. Therefore, P2X7R activation by ATP or by extracellular complexes, such as NETs, might have a dual pathogenetic role in promoting inflammation in lupus: on one hand, it directly triggers inflammation by stimulating the NLRP3 inflammasome, and on the other it has an indirect pro-inflammatory effect by inducing pyroptotic cell death [114]. Presence of the NETs in the microenvironment induce NLRP3 inflammasome, in macrophages and results in the amplification of inflammation by releasing of IL-1β and IL-18, which is mediated via P2X7R [115]. Induction of inflammasome and IL-1β and IL-18 release have been shown to contribute to the cardiovascular, skin, and nephritis manifestations [116, 117, 118]. Evidence suggests the higher P2X7R in renal tissue of lupus nephritis patients [119]. In that context, a study demonstrated substantial up-regulation of P2X7R, NLRP3, and ASC, in the kidneys of MLR/lpr mice compared to control mice and inhibition of P2X7R ameliorates the disease phenotype mainly diminished both the severity of nephritis and levels of circulating anti-dsDNA antibodies [120, 121]. The presence of single nuclear polymorphism (SNP) 489C>T in P2X7 receptor had been associated with increased inflammasome activation in SLE patients and shows involvement in pericarditis [122, 123]. Th1, Th17, and Regulatory T (Treg) cells in SLE patients display higher expression of P2X7 receptor, which correlates with active SLE disease and increased levels of IFN-
Furthermore, P2X7R has an important function of restricting the expansion of T follicular helper (Tfh) cells by pyroptosis and controls the development of pathogenic ICOS+ IFN-γ–secreting cells and in turn prevents the overproduction of autoantibodies and activation of T cells that ultimately controls the production of autoantibodies conditions [126]. SLE patients exhibit deletion of P2X7R genes that have deleterious effect of autoantibody generation [126]. Another study had reported that deletion of P2X7R could amplify the defect in peripheral T cell homeostasis due to the FAS mutation and thus contribute to the autoimmune pathology [127]. In similar way, another purinergic receptor P2Y8R restricts the proliferation of self-tolerant B cells. Distinct variant of P2Y8R had been shown to be downregulated in SLE patients and these are associated with the loss of function, which leads to increased expansion of self-reactive B cells, resulting in the increased autoantibody production. P2Y8R correlated with lupus nephritis and increased age-associated B cells and plasma cells indicating a role of P2Y8R in immunological tolerance and lupus pathogenesis [128].
The role of CD39 in the maintenance of immune tolerance is associated with its capacity of degrading ATP and consequently inhibiting the production of IL-17, which stimulates B cells to produce autoantibodies. Ectonucleotide provides protection in by converting eATP to adenosine. Deletion of ectonucleotides mainly, CD39 and CD73 lead to higher levels of anti-RNP antibodies in response to pristane, with CD73 deletion in particular promoting expansion of splenic B cell and T cell populations that likely contribute to autoantibody production [129]. B cells show the highest CD73 surface expression among human circulating immune cells. In SLE patients, the activity of CD73 and CD38 was found to be selectively silenced in B cells. Since CD73 is the bottleneck of extracellular nucleotide degradation to anti-inflammatory adenosine, this pathway is likely to be a crucial step in the pathophysiology of SLE involving B cell immune cell interactions [130].
RA is a chronic inflammatory disease of joints characterized by damage of bone and cartilage, which leads to joint destruction and disability. Primarily, it is driven by proliferation of synovial fibroblasts, inflammatory response of innate and adaptive immune response, differentiation of macrophage into osteoclasts, and impaired differentiation of mesenchymal stem cells into osteoblasts. The incidence is about 5 per 1000 people and can lead to severe joint damage and disability [131]. Studies have shown a critical role for P2 receptors in osteoblastogenesis and mineralization, synoviocytes proliferation, inflammation of immune cells, and differentiation of macrophages into osteoclasts [132]. Specifically, P2X7, P2Y14, P2Y12, P2Y6, P2Y1, P2Y2, and P2X4 receptors are involved in modulating bone and joint biology [133]. Pain is the major symptom of RA, which associates with the involvement of P2X4R had been reported in chronic arthritis [134]. Knockout of this gene in mice model alleviates the pain [135]. P2X4R control the production of Th17 cells, as shown by the inhibition of P2X4 receptor which reduced the production of IL-17 but not of IFN-γ by effector/memory CD4+ T cells isolated from patients with rheumatoid arthritis [136]. Inhibition of P2X4R associated with the attenuation of synovial inflammation and joint destruction as well as decreased the levels of serum IL-1β, TNF-α, IL-6, and IL-17 via NLRP1 [137]. Similar to SLE, SNP in P2X7 is associated with increased inflammatory response and susceptibility to RA [123, 125]. P2X7 receptor-mediates the release of cathepsins from macrophages is a cytokine-independent mechanism potentially involved in joint diseases and is important for osteoclastogenesis [138]. It also regulates the differentiation of Th17 cells and type II collagen-induced arthritis in mice [139]. P2Y receptor also contribute to the development of RA such as P2Y11 receptor induce inflammation in primary fibroblast-like synoviocytes [140], P2Y12 and P2Y14 receptors induce bone lysis by activating osteoclasts [141, 142, 143]. RA patients demonstrate differential expression of adenosine receptors on synovium with preferential expression of A3 and its variant. However, in a separate RA cohort treated with methotrexate shows overexpression A2A and A2B indicating the anti-inflammatory property via these adenosine receptors [144]. Under hypoxia condition, bone resorption is increased in RA patients via A2B receptors. Inhibition of A2B receptors potentially prevent the hypoxia-mediated pathological osteolysis in RA [145].
The expression of CD39 in Tregs is limited by single nucleotide polymorphisms (SNP). It has been shown that AA genotype of the rs10748643 SNP, a low-expressing CD39 variant, is involved in the regulation of the immune system in autoimmunity [146]. A reduced response to methotrexate (MTX) in patients with rheumatoid arthritis was also shown to be related to an SNP that decreases the frequencies of CD39-expressing Tregs, the rs7071836 SNP [147]. Lower expression of CD73 in lymphocytes at the sites of inflammation has been associated with disease severity in juvenile idiopathic arthritis [148].
Multiple sclerosis (MS) is a chronic inflammatory demyelinating disease of the central nervous system, characterized by the presence of focal lesions in white and gray matter, which is associated with pathological and progression neurological dysfunction. Presence of peripheral immune cells infiltration is a main diagnostic hallmark of the disease. Purinergic receptors control immune cell function as well as neuronal and oligodendroglia survival, and the activation of astrocytes and microglia, the endogenous brain immune cells. Genetic variation in P2X4 and P2X7 receptors show susceptibility to MS. Functionally, the variants impair the expression of P2X7 on the surface resulting in the inhibition of ATP-induced pore function and phagocytic activity [149]. Cortical microglia from MS patient exhibit loss of P2Y12 receptor, which associates with the pro-inflammatory and neuronal damaging profile in MS [150]. On the other hand, P2Y12 is the markers of platelet and megakaryocyte activation. Its increased expression in MS patients associates with cardiovascular disease [151]. A study in mice model show that the loss of P2Y6 develop more severe experimental autoimmune encephalomyelitis compared with wild-type mice as it has pivotal role in DCs regulation [64]. Lymphocytes from MS patients also exhibit upregulation of A2A receptor, which modulates the release of proinflammatory cytokine TNF-α, IFN-γ, IL-6, IL-1β, IL-17 via NF-κB. A2A receptor upregulation was observed in lymphocytes from MS patients in comparison with healthy subjects. The stimulation of these receptors mediated a significant inhibition of TNF-α, IFN-γ, IL-6, IL-1β, IL-17, and cell proliferation as well as very late antigen (VLA)-4 expression and NF-κB activation [152].
CD39 expressing Treg cells controls the neuroinflammation in MS by suppressing the pathogenic Th17 cells and IL-17 production [31]. Its activity and the frequency were elevated in relapsing MS patients [153]. Furthermore, a study on animal model demonstrated that overexpression of CD39 on reactive microglia/macrophages that associates with either pro-inflammatory (M1-subtype) or neuroprotective (M2-subtype) at different stages of the disease. At the peak of EAE, CD39 immunoreactivity showed much higher co-occurrence with Arg1 immunoreactivity in microglia and macrophages, compared to iNOS, implying its stronger association with M2-like reactive phenotype [154]. Thus, modulation of purinergic signaling using an agonist or antagonist provides a new avenue for treatment of disease [155, 156].
Infectious diseases are caused by the invasion of pathogenic microorganisms. After infection, host immune system elicits the anti-microbial immune response and at the same time microorganisms develop strategies to evade host defense mechanism. This involves generation of a variety of inflammatory and suppressive responses along with regulatory feedback systems to eliminate the pathogens but also to restore the homeostatic condition following infection or injury [157]. The purinergic system has the dual function of regulating the immune response and triggering effector antimicrobial response against bacterial and viral infections. During the infections, the ATP release initiates a cascade that activates purinergic receptors. This receptor activation enhances the secretion of pro-inflammatory cytokines and performs the chemotaxis of macrophages and neutrophils, generating an association between the immune and the purinergic systems. Immunomodulation by purinergic signaling has been widely discussed elsewhere [26, 158]. Some instances of involvement of purinergic signaling in bacterial infection include, reduced CD73 expression was associated with macrophage phagocytosis and an efficient clearance of
Immunomodulation of purinergic signaling had been implicated in wide variety of viral infections such as human immunodeficiency virus (HIV)-1, hepatitis virus, dengue virus, and SARS-CoV2 [166, 167, 168, 169]. HIV-1 primarily infects CD4 T cells, but also affects myeloid dendritic cells and monocyte, macrophages populations that express CD4 receptor. Infected patients exhibit decreased CD4 T cell counts and a reversed CD4/CD8 T cells ratio. Adenosine has an immunosuppressive effect, patients with HIV infection show upregulated CD39 on Treg cells which is inversely related with the CD4 T cell count [167, 170]. In contrast to CD39, CD73 expression was diminished on CD4 T cells, which represent a phenotypically and functionally different subpopulation of CD73+ CD4 T cells. This T cell subsets are preferentially reduced in HIV patients, which suggests the effect of an adenosine diminished microenvironment that cannot prevent persistent immune activation. CD73+ CD4+ T cell counts were inversely associated with T cell activation, as well as plasma C reactive protein levels [171]. Besides, CD73 is involved in the expansion of HIV-specific CD8 T cells, whereas CD73 expression is higher in memory CD8+ T cell subset. The frequency of CD73+ CD8+ T cells is inversely associated with cell activation and plasma viral load [172]. PANX-1 hemichannel opening, activation of P2Y2R, P2X1R are involved in the mediating the effective viral entry and replication in CD4 or target cells [173, 174, 175]. Blocking the P2X1 and P2X7 receptors inhibits the viral entry and fusion [176]. Similarly, the P2X1R, P2X4R and P2X7R expression increased in during hepatitis C virus infection and Dengue virus infection [168, 177]. Blocking P2X receptor with antagonist improves the anti-viral response and T cell function [168, 178].
Given the pathophysiological role of purinergic signaling in highly prevalent viral infections has developed a potential interest in investigating the effects of purinergic system in severe acute respiratory syndrome coronavirus 2 virus (SARS-CoV-2). SARS-CoV-2 infection had impacted more than millions of people worldwide since its emergence in December 2019, in Wuhan, China. The clinical manifestations of SARS-CoV-2 include pneumonia, acute respiratory distress syndrome (ARDS), and hyperinflammation. SARS-CoV-2 primarily invade the alveolar epithelia of respiratory tract and lungs where they replicate, triggers the activation of the immune system resulting in the release of cytokines as a defense mechanism, but the response become exaggerated and prompt the so-called “cytokine storm.” This is a state of hyperinflammatory response, which develops acute respiratory syndrome (SARS). This is characterized by fever, cough, and difficulty breathing, which can progress to pneumonia, failure of different organs, and death. Patients with SARS-CoV-2 infection exhibit increased purinergic signaling, which has been suggested to have a role in hyperinflammatory state [179]. The mechanisms have been described in very detail in review articles [169, 180]. The increased inflammations resulting from activated purinergic signaling in SARS-Cov-2 infections are also associated with different pathological conditions such as neuropathy [181], thrombopathy [182, 183]. As observed in other viral infections patients with SARS-CoV-2 shows reduced expression of CD73 on circulating CD8, NK, and NKT cells. However, cells lacking CD73 exhibit increased cytotoxic effector capacity compared to their counterpart CD73+ [184]. P2X7R-NLRP3 signaling axis are the key driver of inflammation in SARS-CoV-2 [185]. Therefore, P2X7R could serve as a potential therapeutic target to control the inflammation [186]. The readily available and affordable P2X7R antagonist lidocaine can abrogate hyperinflammation and restore the normal immune function [169]. Understanding this biology is very crucial as anti-inflammatory drugs are not effective and sometimes accompanied by serious adverse effects.
This chapter has highlighted the importance of purinergic signaling in modulating the immune system in various therapeutic areas. Purinergic system is capable of fine tuning the levels of nucleotides and their derivative in the extracellular space thereby controlling the chemotaxis, proliferation, differentiation of various immune cell presents locally or far from the infectious site. Dysregulation of purinergic signaling because of genetic factor or escape mechanism employed by the microbes or regulatory cell leads to overt inflammation that contributes to the disease. Special attention has been paid to the mechanisms through which alterations in the various compartments of the purinergic system could contribute to the patho-pathophysiology of autoimmune disease and microbial infection. This chapter could help in gaining insight on the possibility of counteracting such dysfunctions by means of pharmacological interventions on purinergic molecular targets.
IntechOpen - where academia and industry create content with global impact
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\n\nSara Uhac, COO
\n\nSara Uhac was appointed Managing Director of IntechOpen at the beginning of 2014. She directs and controls the company’s operations. Sara joined IntechOpen in 2010 as Head of Journal Publishing, a new strategically underdeveloped department at that time. After obtaining a Master's degree in Media Management, she completed her Ph.D. at the University of Lugano, Switzerland. She holds a BA in Financial Market Management from the Bocconi University in Milan, Italy, where she started her career in the American publishing house Condé Nast and further collaborated with the UK-based publishing company Time Out. Sara was awarded a professional degree in Publishing from Yale University (2012). She is a member of the professional branch association of "Publishers, Designers and Graphic Artists" at the Croatian Chamber of Commerce.
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\n\nDr Alex Lazinica
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This chapter provides a brief history of VR and AR in medicine, as well as the principles and standards of their function. Finally, the studies that show the effect of the implementation of these methods in different fields of medical training are summarized and presented.",book:{id:"6211",slug:"medical-and-surgical-education-past-present-and-future",title:"Medical and Surgical Education",fullTitle:"Medical and Surgical Education - Past, Present and Future"},signatures:"Panteleimon Pantelidis, Angeliki Chorti, Ioanna Papagiouvanni,\nGeorgios Paparoidamis, Christos Drosos, Thrasyvoulos\nPanagiotakopoulos, Georgios Lales and Michail Sideris",authors:[{id:"211650",title:"M.D.",name:"Panteleimon",middleName:null,surname:"Pantelidis",slug:"panteleimon-pantelidis",fullName:"Panteleimon Pantelidis"},{id:"211654",title:"Ms.",name:"Angeliki",middleName:null,surname:"Chorti",slug:"angeliki-chorti",fullName:"Angeliki Chorti"},{id:"220557",title:"Ms.",name:"Ioanna",middleName:null,surname:"Papagiouvanni",slug:"ioanna-papagiouvanni",fullName:"Ioanna Papagiouvanni"},{id:"220558",title:"Mr.",name:"Georgios",middleName:null,surname:"Paparoidamis",slug:"georgios-paparoidamis",fullName:"Georgios Paparoidamis"},{id:"220559",title:"Mr.",name:"Georgios",middleName:null,surname:"Lales",slug:"georgios-lales",fullName:"Georgios Lales"},{id:"220560",title:"Mr.",name:"Thrasyvoulos",middleName:null,surname:"Panagiotakopoulos",slug:"thrasyvoulos-panagiotakopoulos",fullName:"Thrasyvoulos Panagiotakopoulos"},{id:"220561",title:"Mr.",name:"Christos",middleName:null,surname:"Drosos",slug:"christos-drosos",fullName:"Christos Drosos"},{id:"220562",title:"Dr.",name:"Michail",middleName:null,surname:"Sideris",slug:"michail-sideris",fullName:"Michail Sideris"}]},{id:"50915",doi:"10.5772/63266",title:"Doped Bioactive Glass Materials in Bone Regeneration",slug:"doped-bioactive-glass-materials-in-bone-regeneration",totalDownloads:3499,totalCrossrefCites:13,totalDimensionsCites:34,abstract:"In the arena of orthopaedic surgery, autograft is considered to be the gold standard for correction of fracture repair or other bone pathologies. But, it has some limitations such as donor site morbidity and shortage of supply, which evolved the use of allograft that also has some disadvantages such as immunogenic response to the host, low osteogenicity as well as possibilities of disease transmission. Despite the benefits of autografts and allografts, the limitations of each have necessitated the pursuit of alternatives biomaterials that has the ability to initiate osteogenesis, and the graft should closely mimic the natural bone along with regeneration of fibroblasts. A variety of artificial materials such as demineralised bone matrix, coralline hydroxyapatite and calcium phosphate-based ceramics such as hydroxyapatite (HA), β-tricalcium phosphate (β-TCP) and bioactive glass have been used over the decades to fill bone defects almost without associated soft tissue development. Most of them were having only the properties of osteointegration and osteoconduction. Only bioactive glass possesses osteogenic property that stimulates proliferation and differentiation of osteoprogenitor cells and in some cases influencing the fibroblastic properties. But, this material has also some disadvantages such as short-term and low mechanical strength along with decreased fracture resistance; but, this was further minimised by ion doping that positively enhanced new bone formation. There are many metal ions such as magnesium (Mg), strontium (Sr), manganese (Mn), iron (Fe), zinc (Zn), silver (Ag) and some rare earths that have been doped successfully into bioactive glass to enhance their mechanical and biological properties. In some of the cases, mesoporous bioactive glass materials with or without such doping have also been employed (with homogeneous distribution of pores in the size ranging between 2 and 50 nm). These biomaterials can be served as scaffold for bone regeneration with adequate mechanical properties to restore bone defects and facilitate healing process by regeneration of soft tissues as well. This chapter encompasses the use of bioactive glass in bulk and mesoporous form with doped therapeutic ions, their role in bone tissue regeneration, use as delivery of growth factors as well as coating material for orthopaedic implants.",book:{id:"5164",slug:"advanced-techniques-in-bone-regeneration",title:"Advanced Techniques in Bone Regeneration",fullTitle:"Advanced Techniques in Bone Regeneration"},signatures:"Samit Kumar Nandi, Arnab Mahato, Biswanath Kundu and Prasenjit\nMukherjee",authors:[{id:"60514",title:"Dr.",name:"Samit",middleName:null,surname:"Nandi",slug:"samit-nandi",fullName:"Samit Nandi"}]},{id:"37120",doi:"10.5772/29607",title:"Trigeminocardiac Reflex in Neurosurgery - Current Knowledge and Prospects",slug:"the-trigeminocardiac-reflex-in-neurosurgery-current-knowledge-and-prospects",totalDownloads:3434,totalCrossrefCites:10,totalDimensionsCites:27,abstract:null,book:{id:"749",slug:"explicative-cases-of-controversial-issues-in-neurosurgery",title:"Explicative Cases of Controversial Issues in Neurosurgery",fullTitle:"Explicative Cases of Controversial Issues in Neurosurgery"},signatures:"Amr Abdulazim, Martin N. Stienen, Pooyan Sadr-Eshkevari, Nora Prochnow, Nora Sandu, Benham Bohluli and Bernhard Schaller",authors:[{id:"78171",title:"Prof.",name:"Bernhard",middleName:null,surname:"Schaller",slug:"bernhard-schaller",fullName:"Bernhard Schaller"},{id:"78525",title:"Mr.",name:"Amr",middleName:null,surname:"Abdulazim",slug:"amr-abdulazim",fullName:"Amr Abdulazim"},{id:"78530",title:"Dr",name:"Pooyan",middleName:null,surname:"Sadr-Eshkevari",slug:"pooyan-sadr-eshkevari",fullName:"Pooyan Sadr-Eshkevari"},{id:"126039",title:"Dr.",name:"Martin",middleName:"Nikolaus",surname:"Stienen",slug:"martin-stienen",fullName:"Martin Stienen"},{id:"126040",title:"Dr.",name:"Nora",middleName:null,surname:"Prochnow",slug:"nora-prochnow",fullName:"Nora Prochnow"},{id:"126041",title:"Dr.",name:"Benham",middleName:null,surname:"Bohluli",slug:"benham-bohluli",fullName:"Benham Bohluli"}]},{id:"26863",doi:"10.5772/26362",title:"The Bearing Surfaces in Total Hip Arthroplasty – Options, Material Characteristics and Selection",slug:"the-bearing-surfaces-in-total-hip-arthroplasty-options-material-characteristics-and-selection",totalDownloads:9526,totalCrossrefCites:10,totalDimensionsCites:21,abstract:null,book:{id:"938",slug:"recent-advances-in-arthroplasty",title:"Recent Advances in Arthroplasty",fullTitle:"Recent Advances in Arthroplasty"},signatures:"Hamid Reza Seyyed Hosseinzadeh, Alireza Eajazi and Ali Sina Shahi",authors:[{id:"66361",title:"Dr.",name:"Alireza",middleName:null,surname:"Eajazi",slug:"alireza-eajazi",fullName:"Alireza Eajazi"},{id:"74857",title:"Dr.",name:"Hamid Reza",middleName:null,surname:"Seyyed Hosseinzadeh",slug:"hamid-reza-seyyed-hosseinzadeh",fullName:"Hamid Reza Seyyed Hosseinzadeh"},{id:"173207",title:"Dr.",name:"Alisina",middleName:null,surname:"Shahi",slug:"alisina-shahi",fullName:"Alisina Shahi"}]}],mostDownloadedChaptersLast30Days:[{id:"65467",title:"Anesthesia Management for Large-Volume Liposuction",slug:"anesthesia-management-for-large-volume-liposuction",totalDownloads:6203,totalCrossrefCites:1,totalDimensionsCites:2,abstract:"The apparent easiness with which liposuction is performed favors that patients, young surgeons, and anesthesiologists without experience in this field ignore the many events that occur during this procedure. Liposuction is a procedure to improve the body contour and not a surgery to reduce weight, although recently people who have failed in their plans to lose weight look at liposuction as a means to contour their body figure. Tumescent liposuction of large volumes requires a meticulous selection of each patient; their preoperative evaluation and perioperative management are essential to obtain the expected results. The various techniques of general anesthesia are the most recommended and should be monitored in the usual way, as well as monitoring the total doses of infiltrated local anesthetics to avoid systemic toxicity. The management of intravenous fluids is controversial, but the current trend is the restricted use of hydrosaline solutions. The most feared complications are deep vein thrombosis, pulmonary thromboembolism, fat embolism, lung edema, hypothermia, infections and even death. The adherence to the management guidelines and prophylaxis of venous thrombosis/thromboembolism is mandatory.",book:{id:"6221",slug:"anesthesia-topics-for-plastic-and-reconstructive-surgery",title:"Anesthesia Topics for Plastic and Reconstructive Surgery",fullTitle:"Anesthesia Topics for Plastic and Reconstructive Surgery"},signatures:"Sergio Granados-Tinajero, Carlos Buenrostro-Vásquez, Cecilia\nCárdenas-Maytorena and Marcela Contreras-López",authors:[{id:"273532",title:"Dr.",name:"Sergio Octavio",middleName:null,surname:"Granados Tinajero",slug:"sergio-octavio-granados-tinajero",fullName:"Sergio Octavio Granados Tinajero"}]},{id:"42855",title:"Critical Care Issues After Major Hepatic Surgery",slug:"critical-care-issues-after-major-hepatic-surgery",totalDownloads:8935,totalCrossrefCites:2,totalDimensionsCites:2,abstract:null,book:{id:"3164",slug:"hepatic-surgery",title:"Hepatic Surgery",fullTitle:"Hepatic Surgery"},signatures:"Ashok Thorat and Wei-Chen Lee",authors:[{id:"52360",title:"Prof.",name:"Wei-Chen",middleName:null,surname:"Lee",slug:"wei-chen-lee",fullName:"Wei-Chen Lee"},{id:"157213",title:"Dr.",name:"Ashok",middleName:null,surname:"Thorat",slug:"ashok-thorat",fullName:"Ashok Thorat"}]},{id:"72175",title:"Fontan Operation: A Comprehensive Review",slug:"fontan-operation-a-comprehensive-review",totalDownloads:1299,totalCrossrefCites:3,totalDimensionsCites:2,abstract:"Since the first description of the Fontan operation in the early 1970s, a number of modifications have been introduced and currently staged, total cavopulmonary connection with fenestration has become the most commonly used multistage surgery in diverting the vena caval blood flow into the lungs. The existing ventricle, whether it is left or right, is utilized to supply systemic circuit. During Stage I, palliative surgery is performed, usually at presentation in the neonatal period/early infancy, on the basis of pathophysiology of the cardiac defect. During Stage II, a bidirectional Glenn procedure is undertaken in which the superior vena caval flow is diverted into the lungs at an approximate age of 6 months. During Stage IIIA, the blood flow from the inferior vena cava (IVC) is rerouted into the pulmonary arteries, typically by an extra-cardiac conduit along with a fenestration, generally around 2 years of age. During Stage IIIB, the fenestration is closed by transcatheter methodology 6–12 months after Stage IIIA. The evolution of Fontan concepts, the indications for Fontan surgery, and the results of old and current types of Fontan operation form the focus of this review.",book:{id:"9585",slug:"advances-in-complex-valvular-disease",title:"Advances in Complex Valvular Disease",fullTitle:"Advances in Complex Valvular Disease"},signatures:"P. Syamasundar Rao",authors:[{id:"68531",title:"Dr.",name:"P. Syamasundar",middleName:null,surname:"Rao",slug:"p.-syamasundar-rao",fullName:"P. Syamasundar Rao"}]},{id:"45712",title:"Serdev Sutures® in Middle Face",slug:"serdev-sutures-in-middle-face",totalDownloads:4952,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"2989",slug:"miniinvasive-face-and-body-lifts-closed-suture-lifts-or-barbed-thread-lifts",title:"Miniinvasive Face and Body Lifts",fullTitle:"Miniinvasive Face and Body Lifts - Closed Suture Lifts or Barbed Thread Lifts"},signatures:"Nikolay Serdev",authors:[{id:"32585",title:"Dr.",name:"Nikolay",middleName:null,surname:"Serdev",slug:"nikolay-serdev",fullName:"Nikolay Serdev"}]},{id:"55812",title:"Postural Restoration: A Tri-Planar Asymmetrical Framework for Understanding, Assessing, and Treating Scoliosis and Other Spinal Dysfunctions",slug:"postural-restoration-a-tri-planar-asymmetrical-framework-for-understanding-assessing-and-treating-sc",totalDownloads:7701,totalCrossrefCites:0,totalDimensionsCites:1,abstract:"Current medical practice does not recognize the influence of innate, physiological, human asymmetry on scoliosis and other postural disorders. Interventions meant to correct these conditions are commonly based on symmetrical models of appearance and do not take into account asymmetric organ weight distribution, asymmetries of respiratory mechanics, and dominant movement patterns that are reinforced in daily functional activities. A model of innate, human asymmetry derived from the theoretical framework of the Postural Restoration Institute® (PRI) explicitly describes the physiological, biomechanical, and respiratory components of human asymmetry. This model is important because it gives an accurate baseline for understanding predisposing factors for the development of postural disorders, which, without intervention, will likely progress to structural dysfunction. Clinical tests to evaluate tri-planar musculoskeletal relationships and function, developed by PRI, are based on this asymmetric model. These tests are valuable for assessing patient’s status in the context of human asymmetry and in guiding appropriate exercise prescription and progression. Balancing musculoskeletal asymmetry is the aim of PRI treatment. Restoration of relative balance decreases pain, restores improved alignment, and strengthens appropriate muscle function. It can also halt the progression of dysfunction and improve respiration, quality of life, and appearance. PRI’s extensive body of targeted exercise progressions are highly effective due to their basis in the tri-planar asymmetric human model.",book:{id:"5816",slug:"innovations-in-spinal-deformities-and-postural-disorders",title:"Innovations in Spinal Deformities and Postural Disorders",fullTitle:"Innovations in Spinal Deformities and Postural Disorders"},signatures:"Susan Henning, Lisa C. Mangino and Jean Massé",authors:[{id:"204825",title:"Dr.",name:"Susan",middleName:null,surname:"Henning",slug:"susan-henning",fullName:"Susan Henning"},{id:"206242",title:"Dr.",name:"Lisa C",middleName:null,surname:"Mangino",slug:"lisa-c-mangino",fullName:"Lisa C Mangino"},{id:"206245",title:"Dr.",name:"Jean",middleName:null,surname:"Massé",slug:"jean-masse",fullName:"Jean Massé"}]}],onlineFirstChaptersFilter:{topicId:"202",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"82020",title:"Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Novel Technique and Technology with Case Series",slug:"minimally-invasive-transforaminal-lumbar-interbody-fusion-a-novel-technique-and-technology-with-case",totalDownloads:6,totalDimensionsCites:0,doi:"10.5772/intechopen.105187",abstract:"Minimally invasive spine surgery (MIS) transforaminal lumbar interbody fusion (MI-TLIF) has been utilized to treat a variety of spinal disorders. Like other minimally invasive spine surgery techniques and technology, the MI-TLIF approach has the potential to limit the morbidity associated with larger exposures required for open surgery. The MI-TLIF approach has a number of advantages over many other minimally invasive spine surgery approaches including direct decompression of neural elements, collection of morselized autograph from the surgical site to achieve high fusion rates, restoration of spinal canal diameter, foraminal diameter, disk height, and reduction of spondylolisthesis. In this chapter, we discuss a novel technique for performing MI-TLIF developed by the senior author who is a leading minimally invasive spine surgeon. The technique and technology illustrated in this chapter were developed out of a recognition of a need to reduce the learning curve for performing MI-TLIF, as well as need for a cost-effective method that provides a high fusion rate, excellent clinical outcomes, and low complication rate. The indications, surgical planning, postoperative care, complications, and patient outcomes in a large series will be reviewed using this novel MI-TLIF technique.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Mick Perez-Cruet, Ramiro Pérez de la Torre and Siddharth Ramanathan"},{id:"78335",title:"Safety and Efficiency of Cervical Disc Arthroplasty in Ambulatory Surgery Centers",slug:"safety-and-efficiency-of-cervical-disc-arthroplasty-in-ambulatory-surgery-centers",totalDownloads:5,totalDimensionsCites:0,doi:"10.5772/intechopen.99589",abstract:"Introduction Anterior cervical surgeries have been safely performed in ambulatory surgery centers since 1995 with the first cases being one level anterior cervical discectomies without fusion, then in 1996, one level anterior cervical discectomies with fusion (ACDF). When it is was certain that outpatient fusion was safe, the number of ACDF levels slowly and methodically were increased to the now standard outpatient maximum of four level ACDF. During this evolution, with the introduction of arthroplasty surgery, one level arthroplasties were considered appropriate for outpatient surgery and now two-level outpatient cervical arthroplasties are routine and some three level arthroplasties have been performed with no additional morbidity compared to one level procedures. The author first reported a series of 27 patients in 2010 who underwent cervical disc replacement at an ASC. (Wohns, R. Safety and cost-effectiveness of outpatient cervical disc arthroplasty. Surg. Neurol. Int. 1, 77, 2010). The average operative time was 40 minutes and the patients were observed over a period of three hours prior to discharge. None of the patients had major complications and there were no reports of worsening or persistent pain. The results of a Delphi study in 2018 compared the safety and efficiency of one-level and two-level arthroplasty procedures performed in an ASC and in a hospital setting. (Gornet et al. Safety and Efficiency of Cervical Disc Arthroplasty in Ambulatory Surgery Centers vs Hospital Settings. Int’l J of Spine Surgery. Vol. 12, No.5, 2018, pp. 557-564). The study analyzed outcomes of 145 ASC patients, 348 hospital outpatients and 65 hospital inpatients and the conclusion was that both one and two-level arthroplasties may be performed safely in an ASC. Surgeries in ASCs are of shorter duration and performed with less blood loss without increased AEs. At the present time, there does not appear to be any contra-indication to performing the vast majority of cervical arthroplasties in an ambulatory surgery center (ASC). Furthermore, the cost of an outpatient arthroplasty is commonly 30% to 50% of the cost of hospital-based procedures.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Richard N.W. Wohns"},{id:"82255",title:"Minimally Invasive Laminectomy for Lumbar Stenosis with Case Series of Patients with Multi-level (3 or More Levels) Stenosis",slug:"minimally-invasive-laminectomy-for-lumbar-stenosis-with-case-series-of-patients-with-multi-level-3-o",totalDownloads:28,totalDimensionsCites:0,doi:"10.5772/intechopen.105186",abstract:"Lumbar stenosis is the most common pathology seen and treated by spine surgeons. It is often seen in the elderly population who frequently have multiple medical co-morbidities. Traditional approaches remove the spinous process and detach paraspinous muscles to achieve adequate canal decompression. This approach can damage the posterior tension band leading to permanent muscle damage, scar tissue formation, iatrogenic flatback syndrome, and increase risk of adjacent segment disease requiring reoperation. Performing lumbar laminectomy in a cost-effective manner is critical in effectively treating patients with lumbar stenosis. This chapter reviews a minimally invasive muscle-sparing approach to treating lumbar stenosis. The technique is performed through a tubular retractor. Direct decompression of the spinal stenosis is achieved while preserving the paraspinous muscle attachments and spinous process. This technique has multiple advantages and can potentially reduce load stress on adjacent levels and subsequent adjacent level pathology leading to further surgical intervention. In addition, the procedure shows how facet fusion is performed using the patient’s own locally harvested drilled morselized autograph to achieve bilateral facet fusion. By fusing the facets, we have shown that restenosis at the operative level is less likely to occur. This chapter will review a case series of multilevel lumbar stenosis including clinical outcomes.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Mick Perez-Cruet, Ramiro Pérez de la Torre and Siddharth Ramanathan"},{id:"80705",title:"Cervical Arthroplasty",slug:"cervical-arthroplasty",totalDownloads:37,totalDimensionsCites:0,doi:"10.5772/intechopen.102964",abstract:"Technological advances have allowed spine surgery to follow the trend toward minimally invasive surgery in general. Specifically, we have seen a corresponding rise in the popularity of cervical arthroplasty. For the treatment of cervical disc disease, arthroplasty is a less invasive option than the gold standard of cervical discectomy and arthrodesis, which by nature is more disruptive to surrounding tissues. Arthroplasty preserves the facets, maintains motion, and reduces the rate of adjacent segment breakdown. These factors counteract the negative impacts of fusion while maintaining the benefits. Arthroplasty implants themselves have become more streamlined to implant as well with less native bone destruction, and biomechanics more compatible with the native disc. While initial implants were ball and socket devices with complex fixation and plane-specific movements, later devices incorporated such motions as translation and compression. Viscoelastic components and materials more closely resembling native tissues afford a more biocompatible implant profile. Until cell-based therapies can successfully reproduce native tissue, we will rely on artificial components that closely resemble and assimilate them.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Jason M. Highsmith"},{id:"80605",title:"Minimally Invasive Treatment of Spinal Metastasis",slug:"minimally-invasive-treatment-of-spinal-metastasis",totalDownloads:42,totalDimensionsCites:0,doi:"10.5772/intechopen.102485",abstract:"Advancements in the treatment of systemic cancer have improved life expectancy in cancer patients and consequently the incidence of spinal metastasis. Traditionally, open spinal approaches combined with cEBRT (conventional external beam radiation therapy) allowed for local tumor control as well as stabilization and decompression of the spine and neural elements, but these larger operations can be fraught with one complications and delayed healing as well as additional morbidity. Recently, minimally invasive spine techniques are becoming increasingly popular in the treatment of spinal metastasis for many reasons, including smaller incisions with less perioperative complications and potential for expedited time to radiation therapy. These techniques include kyphoplasty with radiofrequency ablation, percutaneous stabilization, laminectomy, and epidural tumor resection through tubular retractors, as well as minimally invasive corpectomy. These techniques combined with highly conformal stereotactic radiosurgery have led to the advent of separation surgery, which allows for decompression of neural elements while creating space between neural elements and the tumor so adequate radiation may be delivered, improving local tumor control. The versatility of these minimally invasive techniques has significantly improved the modern management of metastatic disease of the spine by protecting and restoring the patient’s quality of life while allowing them to quickly resume radiation and systemic treatment.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Eric R. Mong and Daniel K. Fahim"},{id:"76620",title:"Minimally Invasive Lateral Approach for Anterior Spinal Cord Decompression in Thoracic Myelopathy",slug:"minimally-invasive-lateral-approach-for-anterior-spinal-cord-decompression-in-thoracic-myelopathy",totalDownloads:146,totalDimensionsCites:0,doi:"10.5772/intechopen.97669",abstract:"Myelopathy can result from a thoracic disc herniation (TDH) compressing the anterior spinal cord. Disc calcification and difficulty in accessing the anterior spinal cord pose an operative challenge. A mini-open lateral approach to directly decompress the anterior spinal cord can be performed with or without concomitant interbody fusion depending on pre-existing or iatrogenic spinal instability. Experience using stand-alone expandable spacers to achieve interbody fusion in this setting is limited. Technical advantages, risks and limitations of this technique are discussed. We conducted a retrospective chart review of all patients with thoracic and upper lumbar myelopathy treated with a lateral mini-open lateral approach. Review of the literature identified 6 other case series using similar lateral minimally invasive approaches to treat thoracic or upper lumbar disc herniation showing efficient and safe thoracic disc decompression procedure for myelopathy. This technique can be combined with interbody arthrodesis when instability is suspected.",book:{id:"10634",title:"Minimally Invasive Spine Surgery - Advances and Innovations",coverURL:"https://cdn.intechopen.com/books/images_new/10634.jpg"},signatures:"Edna E. Gouveia, Mansour Mathkour, Erin McCormack, Jonathan Riffle, Olawale A. Sulaiman and Daniel J. Denis"}],onlineFirstChaptersTotal:12},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:330,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:9,numberOfPublishedChapters:139,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:122,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:112,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:21,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. 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