Main indications for adult scoliosis bracing with frequency classification.
\r\n\tThere will be a chapter on secondary causes of sexual dysfunction disorders related to diabetes, cardiovascular disease, and obesity. A chapter on remedial measures to enhance sexual activity and maintain human relationships will be discussed. As there is a growing number of cancer survivors a chapter on cancer-related sexual dysfunction will be welcomed for including it.
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The first Lyon brace, which was made of leather and steel, was created by Stagnara 70 years ago. It undergone a first change with the replacement of leather by polymethacrylate. This brace was used in adults in addition to surgery while waiting for the graft fusion, at a time when osteosynthesis did not have the current quality. In 2013, the use of adult ARTbrace in Europlex’O in polyamide and asymmetry allowed to avoid the plaster cast which has always been the characteristic of the Lyon management. The use of polyamide and digital allows treatment of thoracic and double major curves.
Vanderpool et al. [1] shows that the frequency of scoliosis in adults increases steadily with age, from 6% of scoliosis after the patient reaches 40 years until it reaches 10% of the population at age 65. The sex ratio was 2 females to 1 male. It is women who have the most painful instabilities and imbalances. Their bone mass is lower than that of men with a vertebral fracture threshold at age 65. Pregnancy and menopause could be also aggravating factors [2].
Akbarnia et al. [3] described the key features as curve stiffness, degeneration of the discs, osteoporosis, spinal imbalance both coronal and sagittal, rotary subluxation, spinal stenosis, and higher rate of complications (pulmonary, etc.). The esthetic aspect is not negligible, and even surgery performed during adolescence does not solve everything. Edgar and Mehta [4] has shown that self-image representation and social life is different after surgery in adolescence. 82% of adult scoliosis without surgery was married compared to 60% of scoliosis operated in adolescence. O’Brien [5] analyzes the consequences of scoliosis in adulthood. He noted that for adult scoliosis abnormal physical appearance and diminished self-esteem may always be present, but breathing limitations, inability to function, and other quality of life issues generally become the driving forces for clinical examination, diagnosis, and treatment.
The complications were analyzed by many authors. For Baron and Albert [6] the incidence of medical complications ranges between 40 and 86%. Local complications include infection, pseudarthrosis or failure of instrumentation, and neurological and adjacent-level degeneration or instability. Common medical complications include pneumonia, atelectasis, ileus, delirium, and cerebrovascular incidents. Smith et al. [7] studied the incidence of complications according to age. His conclusions were the following: the oldest age group (65–85 years) has nearly four times the number of minor complications and nearly five times the number of major complications when compared with the youngest age group (25–44 years). As invasive surgical therapy needs a perfect understanding of risk/benefit, Ogilvie [8] suggests that the decision to proceed with surgical treatment even if justified in many cases must be based on a thorough understanding of the anticipated benefits from surgical treatment and the risk of serious complications. These potential complications lead to multiple surgeries with results that can be less desirable than the original condition. The results of conservative orthopedic treatment are more difficult to assess. Kluba et al. [9] compares surgical and conservative treatment for degenerative lumbar scoliosis. He finds a significantly higher rate of spinal stenosis and degenerative spondylolisthesis in the group of patients with surgery. However no significant difference was evident between the two groups in terms of lumbar back pain after 4 years, respectively.
Everett and Patel [10] conducted a systematic review of non-operative treatment. There is indeterminate, level III/IV evidence on the effectiveness of any conservative option; level IV evidence on the role of physical therapy, chiropractic care, and bracing; and level III evidence for injections in the conservative treatment of adult deformity. The use of rigid or hard bracing in adult scoliosis is generally not recommended. This is due to the risk of muscle weakening effects from hard bracing and the fact that this could accelerate the degenerative process in some cases. Chuah et al. [11] notes that bracing may sometimes help the symptoms, but it has no effect on curve progression.
Pain is not synonymous with deformity progression. Some stable scoliosis patient report pain, and others evolve without pain. It will be necessary to try to make the difference between the “physical” pain and the “emotional” suffering when the patient does not support his deformation anymore.
Thoracolumbar pain often corresponds to minor joint instability.
The pain of convexity is of muscular origin.
The pain of the concavity is posterior: facet syndrome.
The lumbosacral pain is of ligament origin.
These pains respond perfectly to physiotherapy.
When scoliosis progresses, it is either (1) the evolution in adulthood of an adolescent idiopathic scoliosis, (2) a de novo scoliosis usually of discal origin, or (3) a camptocormia of muscular origin. In all cases, there may be a disc disease with sometimes rotatory dislocation, postural impairment with imbalance, extrapyramidal muscle involvement, and bone involvement (osteoporosis). In these progressive cases of instability, bracing or surgery may be necessary.
From 20 to 30 years old, the main problem is the anatomical pain.
From 30 to 50 years old, the main problem is the discal decompensation.
After 50 years old, there are two main problems: degenerative scoliosis very rigid with arthrosis and camptocormia reducible with paravertebral muscular atrophy.
Early works on scoliosis progression in adulthood were pessimistic [12], but at this time, idiopathic scoliosis, especially rachitic infantile, is mixed with neurological poliomyelitis that no longer exists.
In 2003 Weinstein published the spontaneous evolution of 117 idiopathic scolioses over more than 50 years [13]. Thoracic curves of more than 50 degrees at skeletal maturity progressed with an average of 29.4 degrees. Thoracolumbar curves between 50 and 75 degrees increased with an average of 22.3 degrees. Lumbar curves had the most progression, especially when the L5 vertebra was not well seated and when the apical rotation was greater than 33%. He does not observe a functional respiratory or painful repercussion below 70°. This angulation could be currently the functional surgical Cobb limit. Pregnancy does not change the progression of scoliosis in adulthood, except in cases of twin pregnancy.
In 2007 Marty-Poumarat [14] describes two specific adult scoliosis entities: adolescent scoliosis in adult (ASA) and degenerative de novo scoliosis (DDS).
Group A (ASA) = adult progression of AIS > 40° with first dislocation at 45 years. The progression can be sometimes regular, sometimes chaotic.
Group B (DDS) = de novo scoliosis with low Cobb after 50°, first dislocation at 52 years after menopause. DDS is more progressive than AIS. Because DDS is a result of degenerative disc instability, it is almost always progressive. Lumbar and thoracolumbar are the most progressive degenerative curves. Duval-Beaupere and Dubousset [15] have first described the mechanism of rotatory subluxation. Following their work, many authors have insisted on the importance of the lumbo-pelvic parameters [16, 17, 18].
The radiological risk factors for instability are (1) rotatory dislocation with lateral olisthesis (Figure 1), (2) L3–L4 inclination, (3) hypolordosis, and (4) increased thoracolumbar kyphosis [19, 20].
De novo scoliosis with constitution of a rotatory dislocation in 2 years, then scoliosis worsening by osteoporotic cuneiformization.
The physical activity and fracture rate of adult scoliosis is identical to that of the general population, except for operated patients who have less physical activity [21]. Unlike adolescence, when bracing is systematic when scoliosis progresses, the corrective bracing indication in adults is less related to Cobb angulation but more to the instability which results in pain, abnormal angular evolution, or imbalances (Figure 2).
Clinical imbalances in the frontal and the sagittal planes.
From a database started in 1998, we selected all adult scoliosis in which conservative orthopedic treatment has been proposed to, even if the treatment had not been achieved by the patient. Scoliosis treated during adolescence and monitored in adulthood were excluded [22]. In this case series study, we analyzed 779 patients referred for nonsurgical treatment, and we correlated three parameters: the etiology, age, and Cobb angulation (Table 1).
Indications ARTbrace adult (n = 779) | Rate % | Mean age | Mean angulation |
---|---|---|---|
Rotatory dislocation (n = 361) | 46.5% | 59.73 y ± 13.50 | 39.08° ± 16.56 |
Segmental instability (n = 150) | 19% | 46.03 y ± 15.49 | 25.29° ± 12.29 |
Instability post-surgery (n = 86) | 11% | 53.09 y ± 12.91 | 40.49° ± 15.38 |
Camptocormia (n = 68) | 9% | 69.78 y ± 12.19 | 38.09° ± 14.23 |
Kyphosis (thoracolumbar) (n = 62) | 8% | 60.73 y ± 15.51 | 43.34° ± 21.48 |
Disabling pain (n = 33) | 4% | 48.36 y ± 13.73 | 36.45° ± 21.48 |
Spondylolisthesis and spinal stenosis (n = 19) | 2.5% |
Main indications for adult scoliosis bracing with frequency classification.
The rate of dropout patients not wearing the brace is 17% which is not excessive, especially since the plaster cast at that time was made before the brace discouraged patients.
A tentative classification according to etiology, age, and angulation is proposed (Figure 3).
Indications of nonsurgical treatment by etiology (n = 739).
More than half of the indications concern the rotational dislocation, which is the specific complication of adult scoliosis. The rotary dislocation is visible on the CT scan with subluxation and joint narrowing on the sliding side and widening of the articular space on the opposite side.
One-fourth of the indications concern disc instability, which can be considered as the early stage of rotational dislocation.
The other etiologies are less frequent: lumbar-pelvic-femoral kyphosis, secondary instability under arthrodesis, root pain, and rarely spinal stenosis which requires neurosurgery. Camptocormia is linked to weakness of the deep posterior musculature [23]. The patient increases kyphosis gradually to tighten his weak paravertebral muscles. There is often an extrapyramidal context of Parkinson’s disease [23]. MRI cross sections highlight the fatty degeneration. Some authors have mentioned paravertebral myopathy [24].
According to age, there is no Cobb angle difference between patients aged 39 and 80 years old, even if we notice a slight worsening between patients aged 80 and 90 years old. It can be concluded that after 40 years, for the same angulation, the risk of decompensation does not depend on age [22].
If we examine in more detail the distribution of patients according to Cobb angle, we find that Cobb angle is not a discriminating factor like aging.
One of the bracing eligibility tests especially for camptocormia is self-correction by using the hands on the thighs, even if this self-correction does not last long in time. The second test of reducibility is carried out in supine position. The occipital patient must rely on the plane of the examination table. The placement of the ARTbrace is performed by the patient who stabilizes the brace at the pelvic level then unrolls the spine using the rigidity of the posterior bar and finally blocks the upper part. As for children, the “mayonnaise tube” effect of the two lateral hemi-valves completes the correction in the sagittal plane.
Adult scoliosis bracing is performed only in technically equipped medical clinics. Hospitalization is not essential because the use of the brace must be integrated into the patient’s environment. On the other hand, physiotherapy scoliosis-specific exercises (PSSE) is mandatory.
The brace wearing time protocol is a total time of 24 hours a day during 3 weeks with a plaster cast (or digital cast) to adjust the length of the ligaments with plastic deformation and, then, at least 4 hours per day for a minimum of 6 months, including systematically for 2 hours after the practice of sports activity (Table 2).
Management | Wearing time | Particularity | Follow-up examination |
---|---|---|---|
First 3 weeks | Total time 24/24 | Only 10′ for shower, no work interruption | At the end of total time without X-ray |
First 6 months | 4 hours/24 | Systematically for 2 hours after physical activity | At 6 months with X-ray |
6 m to 2 years | On demand and 2 hours after sport | In case of pain, in prevention before major efforts | At 2 years with X-ray |
After 2 years | No specific indication | Brace is kept for safety | AT 5 years with X-ray, then every 5 years |
Adult bracing management (Lyon ARTbrace).
Wearing the brace for a “total time” allows the patient to relearn all the gestures of daily living in a good posture, for example, the sitting writing posture with feet behind the chair and buttocks in front of the seat. The lower part of the chest touches the anterior edge of the table, and the forearms rest on the desktop.
The digital cast is made in three blocks according to the deviations as in the teenager, but in deep inspiration. In many cases, only a scan in maximum corrective posture perfectly balanced is performed. The corrective posture is derived from Schroth. The sagittal plane and the frontal plane are simultaneously corrected, ensuring the overall balance of the spine. The spine is placed in maximum extension to promote lumbar lordosis and reduce thoracic hyperkyphosis. The convex hand is placed on the vertical support, the concave hand is placed on the head, and the operator supports the patient’s elbow (Figure 4).
Digital cast with simultaneous correction in the frontal and in the sagittal planes.
The thickness of Europlex’O used in adults is 3 mm. The digital cast is made in blocks according to the deviations as in the teenager, but in deep inspiration. The advantages are manifold: (1) The patient can maintain the maximum corrected position for a few seconds while standing; (2) breathing is controlled, and the patient can be asked to perform maximum inspiration; and (3) the accuracy of the eight structure sensors is less than 1 mm. The 3 mm Europlex’O with very high rigidity can be used instead of polyethylene. It is possible to work bare skin, but the thin optical vest in jersey allows the use of landmarks for the superposition of the three blocks. The processing with a specific software allows the creation of a positive which will be milled by a digital milling machine. The CPO has all the tools to rework on the captured shapes. After a period of 3 weeks of “total time,” the brace is worn for a minimum of 4 hours/24 for 6 months, then on demand.
Instability pain management is obtained by:
A skin contact of the brace like a massage.
A discharge of the lumbar discs and vertebral body by the “composite beam effect.” The discharge of 30% is provided by the waist grip in the frontal plane, while the sagittal plane is free to prevent an excessive abdominal pressure.
A rebalancing spine in the frontal and sagittal plane.
A limitation of extreme postures.
The rigid brace is an active brace. The patient spontaneously tends to contract the paravertebral musculature in the sense of self-active axial elongation. Associated physiotherapy is however essential.
The brace can reshape the waist. It can also symmetrize the body for the largest scoliotic curves by the adjunction of a foam cushion in the concavity.
The lock automatically performed by the brace facilitates motion and strengthens the musculature of the lower limbs. There is also a better mobility of shoulder girdle because of the stabilization of shoulder blades in a more physiological position.
The wearing of a rigid brace is obligatorily supplemented by physiotherapy scoliosis-specific exercises. The ideal is to act when the spine begins to disrupt or becomes painful, indicating instability. The therapeutic progression is usual:
Analgesia.
Preventing muscle atrophy lumbo-abdominal strengthening in isometric and improving paravertebral deep muscles (Figure 5).
Promoting more flexible self-active axial elongation (Figure 6).
Correcting 3D spine balance: in the frontal plane, rebalance of the occipital axis; in the sagittal plane, restoration of sagittal lumbar and pelvic curvatures (pelvic anteversion and lumbar lordosis (strengthening of the iliopsoas)); and in the horizontal plane, dissociation of pelvic and shoulder girdles.
Developing compensation at the lower and upper limbs: relaxation under pelvic extension (hamstring stretching) (Figure 7).
Stimulating the mechanisms of postural correction with reharmonization of the paravertebral tensions (muscular chains) (Figure 8).
Isometric strengthening of the deep front line with correction of thoracolumbar kyphosis.
Self-active axial elongation in closed kinetic chain (hands/espalier).
Posture of stretching posterior chains of the lower limbs.
Reharmonization of paravertebral tensions with mirror control.
The main differences between adolescent and adult scoliosis are demonstrated in Table 3.
Physiology and biomechanics | Adolescent | Adult |
---|---|---|
No specific pain in adolescents. Painful instability in adults | No pain relief techniques | Pain relief techniques, massage, and others |
Flat back in the teenager. Loss of lordosis and hyperkyphosis in adults | Restoration of physiological sagittal curves (arms projected forward) | Physiotherapy in lumbar lordosis (hands crossed in the back) |
The brace aims to stiffen the spine (rust the spring). Spine mobilization in adults can lead to curve progression | Spine mobilization during cast and brace in all the amplitudes | No spine mobilization beyond the corrected posture |
Strengthening muscle fibers (adult sarcopenia) | Reinforcement of the reticulospinal system (aerobic) | Reinforcement of voluntary musculature in anaerobic metabolism. |
Translation along the vertical axis | Active axial self-elongation in standing position (grand porter) Open kinetic chain | Active axial self-elongation trunk bent at 90°, hands resting on the espalier. Closed kinetic chain |
Lumbo-pelvic region | Opening the iliolumbar angle | Anterior lumbo-pelvic strengthening (iliopsoas, abdo, quad) |
Lower limbs | No specific stretching. Global training without excessive resistance | Stretching of the posterior chain at the level of the lower limbs |
One-third of the thorax volume develops after the end of the stature growth | Resistance breathing exercises (inflating a balloon) | Breathing exercises in forced expiration |
Main differences between adolescent and adult scoliosis Lyon method physiotherapy.
First week. Physiotherapy is for analgesic purposes and is performed in the supine position by soft traction and a muscular work with irradiation of the short external rotators. Breathing is controlled because of the limitation of the abdominal expansion. The thoracic breathing is facilitated by the mobilization of the intercostal muscles.
Second week. The iliolumbar angle is mobilized to adjust tension at the iliolumbar level. The hump can be modeled with progressive closure of the ratcheting buckle. Physiotherapy is performed in sitting position.
Third week. Physiotherapy is more global, more general, more tonic, and stronger. The lever arm of shoulder and pelvic girdles is used. The sessions are made in standing position.
We first determine the sagittal direction of muscular work, usually lordosis for lumbar and thoracolumbar scoliosis. For each session there is a progression from supine to sitting and standing position.
In case of major disc degeneration, physiotherapy will be conducted in physiological lordosis, rather than in a standing position.
In case of major facet joint degeneration, physiotherapy will be conducted in physiological lordosis in prone position, legs bent or in a sitting position.
In case of leg length discrepancy, the feet imbalances adjustment with a shoe lift of 5 mm if it improves both pelvic and spine alignment.
In the sagittal plane, one can use small high heel stubs from 3 to 5 cm to reduce a lumbar kyphosis.
The food control helps to reduce overweight.
The postural control concerns mainly the workstation.
The regular practice of physical activity outside is essential. It is necessary to insist on the strict brace wearing during 2 hours after the sports activity.
Excessive mobilization of passive structures may lead to a progression of scoliosis, so the hyper flexibility is avoided and a position closest to that of the brace is better.
High thoracic breathing is less efficient than the usual abdominal breathing, and we must insist on improving the vital capacity for thoracic or double major curves. If lumbar scoliosis is treated, the risk of an increase of scoliosis during inspiration is low; however, breathlessness is to be avoided.
As the brace can be asymmetrical in the direction of the rebalancing of the spine, it will, however, always ensure the balance of the shoulder girdle.
When the body is fully developed, we advise high-impact sports such as running and dance, to favor the fixation of the calcium on the bone and the constitution of an important bony mass.
In a specific way when ribs are asymmetric, we recommend avoiding deep and quick inhalation which favors the vertebral rotation and therefore the breathlessness during the practice of sports.
For lumbar curves, we advise, as well, against the quick flexions of the trunk forward or the position extending with an anterior flexion of the trunk.
During the period of maximal tensegrity up to 40 years, all sports can be performed at a high level as long as the spine is straight.
After 40 years, decreased intervertebral disc height and sarcopenia reduce the body’s performance.
After 65 years, osteoarthritis is predominant. Swimming avoids overloading the lower limbs and helps maintain lumbar lordosis (Table 4).
Age (girls) | Physiology | Activity (example) |
---|---|---|
15–21 years | Before complete bone mass | Jogging and running Axial impact and spiral chains |
21–40 years | Before sarcopenia and osteopenia (tensegrity) | Fitness, sports reinforcing spiral chains |
40 to retirement | Before extrapyramidal weakness (postural system) | Nordic walking, cycling |
Retirement | Osteoarthritis, Pisa syndrome | Swimming |
Sports activity according to the age.
Immobilization braces made of polyethylene have been used for more than 50 years in case of mechanical pain. They complement classical physiotherapy by reducing load by 30% at the lumbar spine. We specifically studied the 158 patients with 5-year follow-up from our prospective database [25].
The principle of bracing is completely different from that of adolescent scoliosis. Indeed, we try to:
Decompress the discs with the “sandglass effect” lifting the trunk under the ribs and transferring the load on the pelvis.
Rebalance the spine in both the frontal plane and in the sagittal planes, mostly by recreating lumbar lordosis.
Relieve pain by the analgesic effect of rigid low back brace.
A specific frame is used to stabilize the patient in the most corrective posture in the frontal and the sagittal plane.
For those patients who had a progressive scoliosis, Cobb angle is stabilized or improved by more than 5° in 80% of cases, and only 20% of scoliosis remain candidates for surgery [25].
The frontal and horizontal clinical parameters are improved, but not the sagittal parameters with the forward trunk projection (Figure 9).
Insufficient correction in the sagittal plane.
The sternoclavicular support is poorly tolerated, and due to reduced dexterity in the older person, lateral closure is a handicap for elderly patients, even if adaptations are possible, that is why we currently use the 3 mm Europlex’O.
Instability in adulthood is frequent, and surgery is the most frequently offered solution despite the high rate of complications, as there was no alternative to date for thoracic and thoracolumbar curves. Only overlapped bivalve polyethylene braces were used for lumbar scoliosis with good frontal stabilization but no control in the sagittal plane (Figure 9). The ARTbrace in Europlex’O which allows an average reduction of 70% for the children has been used since 2015 in the adult for all the deviations.
The results of a consecutive series of 62 patients (6.2% of all ARTbrace patients) were treated between 2015 and 2016, as an alternative to surgery.
Nine patients (15%) which constitute the dropout were not seen at 6 months, which is very little considering the general condition and age of patients. The percentage of dropouts is identical to the previous series of lumbar curves treatments. Despite the very high rigidity, Europlex’O which needs a precision of 1 mm is therefore as well tolerated as polyethylene.
In the frontal plane, the average in-brace reduction is 27%, slightly higher for lumbar and thoracolumbar curvatures. The reduction to 2 years without brace is 15%, and especially the symptomatology of instability disappears. It is now possible to stabilize all thoracolumbar, thoracic, and double major scoliosis (Figure 10).
Reduction in the frontal plane after decompensation upon arthrodesis.
In the sagittal plane, the average in-brace reduction is 32% and at 2 years without brace of 25% (Figure 11).
Correction of kyphosis in the sagittal plane.
In the horizontal plane, some characteristic case study with EOS 3D confirms that adult ARTbrace is indeed, as in the child, a detorsion brace. Adult ARTbrace is the only brace to correct kyphosis and thus compensate for the insufficiency of polyethylene whose sternoclavicular support was not tolerated (Figure 12).
EOS 3D confirms thoracolumbar spine detorsion in ARTbrace.
Adult deformity is a major demographic health issue in the geriatric population. Surgeons are often very conservative in the treatment of adult scoliosis because of the complication rates associated with the surgeries and the marginal bone quality endemic to this population. Medical complications are a major concern in adult spinal deformity surgery [26]. The incidence ranges between 40% and 86%, but there is indeterminate level III/IV evidence on the effectiveness of any usual conservative care option. There is currently a lack of consensus on the most efficacious conservative treatments for adult deformity.
Very few results have been published concerning scoliosis adult bracing. Most of them only concern low back pain [27, 28]. Pain is the usual reason of medical consultation. Pain means instability when combined with the following clinical signs:
Frontal and sagittal Imbalance. The lumbar kyphoscoliosis is due to pelvic retroversion. The hips are extended under a retroverted pelvis, femurs were oriented downward and forward, and knees and ankles compensate with flexion deformity. Pelvic retroversion is limited by osteoarthritis of the hip, flexion deformity of the knee is poorly tolerated, and the patient will use a walking stick to walk. The thorax can enter in conflict with the pelvis at the concavity level pushing the viscera down. The patient suffers from breathing difficulty; digestive disorders are common and promote abdominal hypertension and sphincter disorders. The loss of lumbar lordosis has multiple causes: a decrease in the anterior height of the disc, hypertrophy of the facet joints and spinous process increasing the posterior height, and loss of extensors muscle strength [29].
In the horizontal plane, there is a rotation of the shoulder girdle as if the patient looks on the concave side of thoracic scoliosis. The pelvis is drawn by lumbar scoliosis. The convex hemi-pelvis moves back, and the hip is placed in internal rotation, while the concave hemi-pelvis moves forward, and the hip is placed in external rotation.
On each occasion when examining a patient at least every 5 years, verification X-ray is necessary in order to define a progression while being aware that in many cases the progression is chaotic.
The most characteristic sign of decompensating is the disc height loss that can sometimes exceed 10 mm. The disc corruption results in loss of physiological lordosis and ligament instability by hypermobility.
The losses of the gluteal muscles are very distinct when we make the plaster cast. It explains in part the pelvic retroversion; the spine tends to relocate along the line of gravity.
Muscular atrophy is a common criticism for rigid braces. In fact, the conservative orthopedic treatment does not suffer approximation. Its teamwork incorporates a specific physical therapy, the continuation of normal activity, and the practice of regular physical activity. No patient is wearing the brace for pleasure. The risk of overtreatment is zero.
Usually the total time bracing relieves pain, and the partial time bracing extends the improvement obtained. When the patient is not relieved, we can discuss the surgery with better arguments. The nonsurgical treatment treats the cause of lumbar instability mainly by discharging the pressure in the disc and stabilizing the lumbar area in lordosis to restore the tensegrity of the spine.
The esthetic improvement of the rib hump and asymmetrical waist is logical; the orthopedic brace is the best way to remodel a trunk. The cosmetic result continues 5 years after starting the treatment, with improvement of the rib hump measured with the plumb line and the Bunnel angle of trunk rotation (Figure 9).
The nonsurgical treatment can fit into a therapeutic progression. The indications may be progressive: observation, physiotherapy, medicine, conservative orthopedic Treatment, and surgery.
The good surgical indications concern the degenerative scoliosis not relieved by bracing, or relieved by total time, but insufficiently by partial time and especially if there is a spinal stenosis. It can also be used to complete surgery if remaining instability.
The Greek study [30] associating Schroth and Chêneau brace shows that patients have great difficulty to follow the protocol. For the quarter of patients following the protocol, the results are correct on pain and posture, but in 39% of patients, Cobb angle continues to increase.
Josette Bettany [31] confirms that for adult scoliosis, there are only a few studies on the effectiveness of PSSEs and a conclusion cannot yet be drawn. Recently a RCT proves the effectiveness of a motor and cognitive rehabilitation [32].
The motivation of the patient is fundamental. The brace should be designed as a tool to facilitate physiotherapy.
The use of an instantaneous and accurate CAD/CAM is better because the adult patient can only maintain the corrected position for a few seconds.
The scan is made in deep inspiration to not limit the vital capacity.
The management is 4 hours a day including systematically for 2 hours after any physical activity. Physiotherapy is even more important than during adolescence [33].
The frequency of adult scoliosis makes it a public health problem. The new digital technologies have changed the adult scoliosis bracing, and conservative care in general may be a helpful option for adult deformity, but evidence for this decision was lacking. Lyon nonsurgical treatment is effective and offers new perspectives to adult scoliosis bracing. Not only does the brace relieve pain and support the spine, but for the first time, it corrects deviations in the frontal, sagittal, and horizontal planes. Immobilization braces in polyethylene allow a treatment of the cause of pain without side effects. Worn a few hours in the day, they complement physiotherapy. The first results confirm the excellent tolerance of Europlex’O adult ARTbrace with its ease of implementation and corrections unmatched to date in adults. These corrections make it possible to restore stability of the deviations without surgery. Adult scoliosis bracing as an alternative to surgery could be possible. Initially reserved for the most severe cases, this management deserves to be more widely used for adult scoliosis. The increasing number of CPO using the most modern CAD/CAM technologies should facilitate research in the field of very high rigidity.
Thanks to my daughter Agnès Thornton de Mauroy, for proofreading in English.
asymmetrical rigid torsion brace
adolescent scoliosis in adult
computer-aided design/computer-aided manufacturing
certified prosthetist/orthotist
computed tomography scan
degenerative de novo scoliosis
low-dose X-ray imaging
magnetic resonance imaging
physiotherapy scoliosis-specific exercises
randomized controlled trial
There is an urgent need to implement intervention measures and health policies to reduce mortality associated to cardiovascular disease (CVD), which will result in more adequate, healthy, and sustainable development per each country. CVD has caused 6.2 million deaths worldwide in people aged 30–70 years in 2019 [1].
Regarding cardiovascular health, there are certain modifiable risk factors that can be intervened upon to improve health. These factors include: hypertension, elevated fasting plasma glucose, elevated low-density lipoprotein (LDL) or cholesterol, and alterations in renal function. Environmental factors such as air and household pollution, smoking, low physical activity, and overweight and obesity are also included. In addition, in the case of women, the consumption of oral contraceptives and the presence of polycystic ovaries syndrome increase the risk of suffering CVD [2].
There are numerous studies linking diet and health, and this is most evident in the case of cardiovascular risk. Both dietary patterns, such as a diet rich in antioxidants, fiber (from vegetables, whole grains, fruits, nuts, pulses) fish, poor in processed foods (with high content in sugar or animal fats), together with the food intake containing specific bioactive substances or nutrients can modulate the risk factors [3, 4]. Therefore, changes in lifestyle and diet can prevent these diseases [5].
CVD is linked to the development of atherosclerosis and is directly related with an inflammatory response. This response is prompted by bad diet habits, sedentary lifestyle, obesity, and stress [6].
Herbal measurements are used to develop new drugs with higher potency and fewer adverse effects targeting the modulation of biological activities.
Ginger (
The term nutraceutical is used for any food or ingredient with a beneficial effect on health beyond the traditional nutritional effects; further, it has a positive impact on health, physical or cognitive state [8]. Numerous nutraceuticals are used for the prevention of CVDs, including ginger (see Table 1).
Nutraceuticals | Properties |
---|---|
PUFA n-3 (polyunsaturated fatty acid) | Arrhythmias, sudden death, hypertriglyceridemia, antiplatelet agents, anti-inflammatories |
Q10 coenzyme | Antioxidant, antihypertensive |
Vitamin D | Depression, atherosclerosis, valvular calcification |
Resveratrol | Anti-inflammatories, antioxidant |
Red yeast rice | Improves dyslipidemia |
Phytosterols | Lowers cholesterol, LDL-C, antihypertensive |
Flavonoids | Antiplatelet agents, anti-inflammatories antioxidant, antihypertensive |
Dietary fiber | Dyslipidemia, metabolic syndrome decreases total cholesterol, LDL-C, triglycerides, blood glucose, and body weight |
Ginger | Anti-inflammatories, antioxidant antiplatelet agent, antihypertensive |
B complex | Reduces hyperhomocysteinemia |
Nutraceuticals in the prevention of cardiovascular diseases [9].
Apart from its cardioprotective effects, ginger has numerous properties such as antimicrobial, antioxidant, anti-inflammatory, anti-carcinogenic, and neurodegenerative diseases prevention. It prevents chemotherapy-induced emesis, nausea, and respiratory disorders [9, 10].
Ginger’s flavor and aroma come from its volatile oils (∼1–3% of the weight of fresh ginger) and nonvolatile pungent oleoresins. Further, the pharmacological properties are due to its oleoresin’s composition, rich in zingerone (ZGR), gingerols (6/8/10-gingerols), and shogaols (6/8/10-shogaols and 6-hydroshogaol). The spiciness character of dried ginger rhizome comes from the gingerols, especially 6-gingerol. During drying, gingerols transform into ZGR, reducing pungency and providing a spicy-sweet aroma, and shogaols concentration increases [11].
Ginger inhibits lipid peroxidation through its antioxidant effect. 6-Gingerol increases Beclin1 expression to promote autophagy in human endothelial cells and inhibits
Ginger could prevent atherosclerosis, since consumption of a ginger extract has been observed to improve lipoprotein results in hamsters thanks to an increased activity of the liver enzyme CYP7A1 and decreased mRNA levels of intestinal cholesterol absorption proteins such as MTP, ACAT2, and NPC1L1 [13].
6-Gingerol regulates lipogenesis, fatty acid oxidation, mitochondrial dysfunction, and oxidative stress of aging rats. Several authors observed that 8-gingerol due to its antioxidant properties could inhibit melanogenesis in murine melanoma cells. In addition, it increases the activity of the antioxidant enzyme superoxide dismutase (SOD) and decreases the levels of malondialdehyde (MDA), a marker of lipid peroxidation, in a concentration-dependent manner [14, 15].
Inflammation associated with CVD induces an increase in proinflammatory cytokines such as tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β), and interleukin-6 (IL-6). Several authors have observed that ginger significantly reduces TNF-α values, and 6-gingerol reduces the levels of inducible nitric oxide (NO) synthase enzyme and inflammatory factors [16].
Ginger can also be used in moderate obesity, a cardiovascular risk factor. Ginger increases lipolysis and thermogenesis and inhibits lipogenesis; therefore, it could be used to prevent obesity [17].
In summary, ginger consumption in the diet could improve cardiovascular health by lowering blood pressure, improving lipid profile, preventing obesity, improving glycemic control, and vascular health. The benefits of ginger on cardiovascular risk factors are mediated by transcription factors such as adenosine-monophosphate-activated protein kinase, peroxisome proliferator-activated receptors, peroxisome proliferator-activated protein kinase, and nuclear factor kappa B (NF-κB) [8, 18]. Having that in mind, the purpose of the present review chapter is to summarize the effects of bioactive compounds in ginger on CVD.
CVD is a group of disorders of the heart and blood vessels. It includes a large number of pathologies, among which it is worth highlighting: coronary heart disease, cerebrovascular diseases, peripheral arteriopathies, and rheumatic and congenital heart disease, among others. In most of them there is a common pathological process, atherosclerosis [19, 20]. This condition occurs when fat and cholesterol build up on the walls of blood vessels or in the arteries. This accumulation gives rise to atherosclerotic plaques. Over time, plaques can narrow blood vessels and cause problems throughout the body. If an artery becomes blocked, it can lead to a heart attack or stroke [21].
Cardiovascular risk factors are those that are associated with a greater probability of suffering from CVD. It is widely described that the most developed countries’ lifestyles entail an increased risk of suffering from CVD. There are many studies that showed that a significant percentage of CVD and its mortality can be prevented by acting on cardiovascular risk factors [3].
Atherosclerosis is a multifactorial disease, in which several risk factors are involved [22]. The prevalence and potency of these risk factors vary. Cardiovascular risk factors improve CVD by reducing plaque formation.
Two types of risk factors can be differentiated: modifiable and non-modifiable. Pencina et al. established the importance of both and determined that the non-modifiable factors (sex, age, and race) account for between 63 and 80% of the risk factors, while the weight of the modifiable factors is much lower. But, control of modifiable risk factors leads to substantial reductions of cardiovascular events [23, 24].
Non-modifiable risk factors are sex, age, race, and genotype. They are those that are not likely to be modified, therefore nothing can be done about them. It has been proven that cardiovascular risk is higher in men than in women, increases after 35 years, and Hispanics, Latinos, and Southeast Asians have a higher cardiovascular risk [24].
Modifiable risk factors are hypertension, hypertension; obesity and diabetes; dyslipidemias; chronic stress; diet; tobacco; and sedentary lifestyle [25]. They are those that are likely to be modified, where actions can be directed attempting to prevent and/or improve atherosclerosis and therefore CVD.
Hypertension is the most important CVD risk factor. There is a direct relationship between increased blood pressure and the development of CVD. When properly treated, CVD mortality is reduced. Its pathophysiology is very complex and different mechanisms are involved, including the central nervous system, the immune system, and the neurohumoral system [26].
The prevalence of obesity in the world is increasing in a very worrying way across all ages [27]. The relationship between obesity and CVD is clear. It has been shown how it contributes to atherosclerosis through different mechanisms. On the other hand, it must be taken into account that obesity is a risk factor for other comorbidities such as diabetes, sleep apnea, dyslipidemia, hypertension, and even cancer [28, 29].
Since lipids are involved in the formation of atherosclerotic plaque, especially LDL cholesterol and TG, increases of their plasmatic levels entail a risk of atherosclerosis and CVD. This is what happens in dyslipidemias. Reducing them is a fundamental therapeutic strategy to reduce CVD risk [30, 31].
It is one of the most important cardiovascular risk factors. Chronic stress is a situation maintained over time in which the body generates a nonspecific and systemic response as a result of exposure to negative external factors. The relationship between chronic stress and the risk of CVD has been widely demonstrated [32].
It is clear that diet influences the maintenance of good cardiovascular health. And it is an essential tool to control other risk factors such as diabetes, obesity, dyslipidemia, and even hypertension. It has been proven that diets such as the Mediterranean or DASH reduce cardiovascular risk. They are diets that improve markers of inflammation and oxidative stress and also contribute to improving the lipid and glycemic (improvement of insulin sensitivity) profiles, and endothelial function. In addition, they have proven antithrombotic properties. The consumption of fiber, omega-3 acids, vegetables and fruits, and whole grains seems to be decisive in reducing cardiovascular risk [33, 34, 35, 36].
Tobacco continues to be one of the most important cardiovascular risk factors. Since its consumption increases the formation of atherosclerotic plaque, through an enhanced inflammation, endothelial dysfunction, arterial stiffness, and lipid profile [37]. In addition, its consumption increases the heart rate; myocardial contractility; thrombus formation by increased platelet activation and adhesion and procoagulant profile [38].
Regular and moderate physical activity, which modifies muscle tissue and adipose tissue, has been shown to have a positive impact on health. It reduces systemic inflammation and has an antiatherogenic effect. Therefore, lack of physical activity is a cardiovascular risk factor [39].
Ginger, the rhizome of
The main pungent and most abundant compound, 6-gingerol, which is present in fresh ginger, attenuates various chronic disorders. By dehydration and after long storage, this compound is converted into 6-shogaol, which is more stable and has greater pharmacological effects than its precursor 6-gingerol [46, 47]. 6-Shogaol is converted to 6-paradol by bacterial metabolism, and both possess similar anti-inflammatory and antioxidant properties [40, 47]. Antioxidant, antitumoral, antilipidermic, antibacterial, and anti-inflammatory actions are attributed to ZGR, and it is synthesized by reverse aldolization of gingerols when heating fresh ginger [47, 48]. Figure 1 summarizes the metabolization pathways of 6-gingerol as a function of thermal processing.
Properties and metabolism of gingerols.
Zick et al. [49] observed that 6-shogaol and the 6-, 8-, and 10-gingerols have good bioavailability when consumed orally, being detected as sulfate and glucuronide conjugates. However, 6-gingerol has not been detected free in plasma after an oral dose of 2 g, despite it being the major compound in ginger extracts (2–64%) [50]. Pharmacokinetic studies showed that the half-life of the major compounds of ginger and its metabolites is approximately 1–3 hours. Based on bioavailability data, 6-, 8-, and 10-gingerol glucuronides and sulfates along with 6-shogaols could be good markers of ginger intake [50].
As for its therapeutic use, given its various anti-inflammatory, antimicrobial, anticancer, and antioxidant biological activities, ginger appears to be effective in the prevention and treatment of neurodegenerative, cardiovascular, obesity, diabetes mellitus, or respiratory disorders [45].
Oxidative stress is increased under the condition in which there is a decrease in the body’s antioxidant defenses; therefore, there is an imbalance between the production and elimination of reactive oxygen species (ROS). As a consequence of this imbalance, ROS accumulate, generating cellular damage in the different systems of the organism, since they produce lipid peroxidation [51, 52].
Ginger has great antioxidant activity; in fact, many of its therapeutic applications are due to this activity. That ginger has antioxidant activity is a fact that has been shown both in vitro and in vivo. Although studies on the effects to human are not as numerous, it is beginning to be verified that its intake is capable of increasing the concentration of antioxidant enzymes and decreasing oxidative stress markers in cancer patients [53]. Morvaridzadeh et al. carried out a systematic review and meta-analysis where they concluded that there is sufficient evidence to show that ginger intake increases the levels of oxidative stress parameters [54]. There are many bioactive compounds in ginger that exhibit antioxidant activity, such as 6-gingerol, 8-gingerol, 10-gingerol, and 6-shogaol. Of all of them, the one with the highest antioxidant activity in vitro is 6-gingerol, followed by 6-shogaol [55].
The mechanism involved in its antioxidant activity has to do both with preventing the appearance of free radicals [56] and with being able to eliminate them [57]. 6-Gingerol has been shown to be capable of inhibiting xanthine oxidase, an enzyme that catalyzes the oxidation of hypoxanthine to xanthine and of xanthine to uric acid in the last stage of purine metabolic degradation, with the production of reactive oxygen species [58]. In addition, it has been proven that this compound is capable of increasing superoxide dismutase and catalase activity, two antioxidant enzymes [53].
It has been seen how the antioxidant activity depends on the time of harvest of ginger, if it is early, the antioxidant activity is higher, decreasing if the harvest is done later [59].
Another of the great biological activities attributed to ginger is its anti-inflammatory activity. Inflammation is one of the body’s first responses to a risk situation [60]. When that inflammation is maintained over time, is then problematic. Today it is known that there are many diseases in which inflammation plays a determining role, in fact it is being studied how low-grade systemic inflammation is related to the development of different pathologies (autoimmune diseases, metabolic diseases, CVDs, cancer) [61, 62]. In chronic or low-grade inflammation, different proinflammatory factors are released, such as cytokines and prostaglandins [61].
Many researchers have shown that ginger reduces different proinflammatory markers such as: NF-κB, signal transducer activators of transcription (STAT), proteins of the Nod-like receptor family (NLRP), receptors toll-like (TLR), mitogen-activated protein kinase (MAPK), and mTOR (mTOR) pathways, in addition to inhibiting several proinflammatory cytokines [19, 58].
In the systematic review and meta-analysis carried out by Jalali et al, it is shown how ginger is capable of significantly reducing the levels of different proinflammatory parameters such as IL-6, TAC, CRP, TNF-α, MDA, and the serum prostaglandin E2 (PGE2) [63]. Song et al. have examined how ginger extract is capable of reducing proinflammatory markers produced by
The most active compounds from the anti-inflammatory point of view of ginger are 6-shogaol, 6-gingerol, and 6-dehydroshogaol [45, 65, 66]. It has been described how 6-shogaol has an anti-inflammatory effect because it inhibits the production of PGE2 and proinflammatory cytokines (IL-1β and TNF-α) and decreases the expression of cyclooxygenase-2 (COX-2), p38 mitogen-activated protein kinase (MAPK), and nuclear NF-κB [45]. In other studies, 6-shogaol has been shown to inhibit LPS-induced iNOS and COX-2 expression in macrophages [67]. Furthermore, studies showed that 6-shogaol could protect against lipopolysaccharide (LPS)-induced toxicity in murine astrocytes [68].
Worldwide, obesity has become the main pandemic of the twenty-first century [69, 70], as the rates of this pathology have increased considerably during the last decades [71, 72]. According to the World Health Organization (WHO), obesity is characterized by an excessive accumulation of fatty tissue in the body, causing harmful effects on health [73]. Concerning problems associated with obesity are mainly its deleterious effect on other non-detectable diseases: CVDs, hypertension, nonalcoholic fatty liver disease, various types of cancer, and hyperlipidemia [74, 75]. In addition, it should be noted that patients with obesity show worse prognosis against COVID-19 infection and higher mortality rates [76, 77]. Additionally, it induces low-grade inflammation, oxidative stress, and contributes in the etiology of type 2 diabetes mellitus [78]. In recent years, natural compounds have aroused great interest in the prevention/treatment of obesity, and several studies have shown that ginger seems to be effective for this pathology [45].
It seems that gingerenone-A has a more potent inhibitory effect on adipogenesis and lipid accumulation than gingerols and 6-shogaol in 3T3-L1 preadipocyte cells, while it appears to activate the adenine monophosphate (AMP)-activated protein kinase (AMPK) pathway modulating fatty acid metabolism, thus attenuating obesity [79]. For its part, the daily dose of 2 g of ginger powder in obese women resulted in a decrease in body mass index (BMI) [80]. Daily dose of ginger powder also appears to increase fat oxidation in humans [81]. Several studies have shown that ginger can reduce body weight by increasing thermogenesis through catecholamines as well as lipolysis of white adipose tissue [78]. Therefore, it seems evident that both ginger and certain bioactive components are effective against obesity by enhancing lipolysis and inhibiting adipogenesis.
Diabetes is a serious metabolic disorder characterized by an abnormal increase in blood glucose. For this reason, several research studies have considered evaluating the possible effect of ginger and its main bioactive components in the reduction of blood glucose [82].
It has been shown that the administration of 6-gingerol stimulates the activity of glycogen synthase 1 and at the same time favors the translocation of the glucose transporter type 4 (GLUT-4) to the cell membrane, favoring insulin to allow glucose entry in skeletal muscles and subsequent storage as glycogen [83]. Ginger consumption seems to reduce our values of glycosylated hemoglobin (HbA1c), fasting plasma glucose, insulin, total cholesterol, and triglycerides in patients with type 2 diabetes mellitus [84].
The greatest cause of atherosclerosis is characterized by altered blood lipid values and consequently CVD. In addition, the factors previously mentioned, such as overweight/obesity and high blood glucose values, are factors that will have a greater effect on this pathology.
Impaired blood lipid values are the major cause of CVD. In a recent systematic review and meta-analysis of clinical trials in 2018, it was concluded that ginger has a favorable effect in reducing triglycerides and LDL cholesterol, without significant reductions in total cholesterol. However, doses lower than 2 g/day of dairy ginger powder seem to be more effective in lowering both triglycerides and total cholesterol [83]. Since it is a safe and inexpensive supplement, it could be used to improve the lipid profile of subjects and thus prevent CVD.
Clinical studies have been conducted to evaluate the effect of ginger supplementation on the lipid profile of different populations. Doses of up to 1.8 g/day have been shown to significantly reduce triglyceride, total and LDL cholesterol levels compared with placebo in obese patients treated with metformin (Table 2) [85].
Population | Intervention | Outcomes | Ref. |
---|---|---|---|
Obese Egyptian patients with new-onset T2DM ( | 600 mg 3 times/day 8 weeks | ↓ BMI, ↓ TC, ↓ LDL-C, ↓ TG ↑ HDL-C ginger vs. placebo | [86] |
Hyperlipidemic non diabetic patients ( | 3 g/day 45 days | ↓ TC, ↓ TG ginger vs. placebo | [87] |
Obese men ( 18–30 years | 1 g/day 10 weeks with/out resistance training | n.s. TC, TG, LDL-C, HDL-C ginger vs. placebo ↓ TC, ↓ fat mass training groups | [88] |
Obese women with breast cancer ( | 3 g/day, 6 weeks, with/out exercise training | ↓ LDL, ↓ TC, ↓ TG, ↑ HDL ginger + exercise | [89] |
T2DM patients ( 38–65 years | 2 g/day 8 weeks | ↓ LDL, ↓ TG | [90] |
T2DM patients ( 20–60 years | 1.6 g/day 12 weeks | ↓ TC, ↓ TG | [85] |
Obese women ( 18–45 years | 2 g/day 12 weeks vs. placebo | ↓ TG ginger vs. placebo Both groups: ↓ TC, ↓ TG, ↓ LDL/HDL ratio, ↓ TC/HDL ratio, ↑ HDL | [91] |
T2DM ( 20–60 years | 2 g/day 12 weeks | ↓ ApoB, ↓ ApoB/Apo A1 ratio, ↑ Apo A1 | [92] |
T2DM ( | 3 g/day 8 weeks | ↓ TC | [93] |
Hyperlipidemic patients ( | 3 g/day 30 days | ↓ TC | [94] |
T2DM ( | 2 g/day 10 weeks | ↓ LDL/HDL ratio ginger vs. placebo | [83] |
Menopausal women ( | 1 g/day 16 weeks vs. 900 mg/day garlic with/out aerobic exercise | No effects in ginger groups ↓ TC, ↓ LDL with garlic | [95] |
Summary of the effect of ginger supplementation on the lipid profile in different clinical trials and populations.
Significant lowering effect of ginger compared with placebo has also been observed in [86, 87]. However, other studies failed to observe a positive effect, and ginger supplementation exerted no effect on blood lipid profiles and body composition [88] and no significant differences in cholesterol lipoproteins profile between ginger and placebo [89]. In some cases, the results are inconsistent, with significant differences in some markers as LDL/HDL ratio after ginger intake and no changes on mean levels of total cholesterol or triglycerides [90], or reductions in levels of serum triglycerides and LDL with no effects on total cholesterol or high-density lipoprotein (HDL) [91].
Levels of apolipoprotein B and apolipoprotein B/apolipoprotein A-I ratio reduced and apolipoprotein A1 increased after ginger supplementation (2 g/day) for 12 weeks [92]. The overexpression of ApoA1 could explain the increases observed in HDL levels in some trials.
Discrepancies in the results could be due to the different characteristics of the populations studied, stage of the disease, pharmacological treatments, format of ginger administered.
Meta-analysis studies have concluded that ginger significantly increases HDL levels and reduces plasma levels of triglycerides and total cholesterol, with different extent depending on the clinical condition (hyperlipidemia and T2DM) [93, 94]. The analysis conducted by Pourmasoumi et al. [83] revealed a better effect of total cholesterol and triglycerides with doses < 2 g/day and a maximum of 50 days of supplementation.
Among the different mechanisms of action attributed to ginger components is the inhibition of intestinal lipase enzymes, thus avoiding fat hydrolysis and absorption and the increase in plasma levels of triglycerides. In case of cholesterol, its decrease in plasma concentrations has been related to an inhibition in cellular cholesterol synthesis and an increase of hepatic enzyme activity of cholesterol 7 α-hydrozylase CYP7A1a, implicated in the conversion of cholesterol into bile acids for its clearance by fecal excretion [95]. Ginger is implicated in the inhibition of expression of adipogenesis and lipogenesis genes as PPAR γ and carbohydrate-responsive element-binding protein (ChREBP) gene expression in the liver [66]. ChREBP reduced expression further decreases the expression of glucogenic and lipogenic enzymes (as fatty acid synthase, steatoryl-CoA-desaturase-1, acetyl-CoA carboxylase 1, among others [95].
It is well known that healthy diet and lifestyle can control blood pressure and endothelial dysfunction. Inflammation associated with cardiovascular events contributes to hypertension by affecting the renin-angiotensin system [96]. Elevated blood pressure (BP) has also been known to be a strong risk factor cardiovascular [97].
The compounds in ginger responsible for its antihypertensive effect are 6-shogaol and 9-gingerol. These compounds reduce cholesterol and LDL levels, inhibit atheroma plaque formation, and increase vessel elasticity. They also reduce the release of inflammatory mediators responsible for endothelial dysfunction by decreasing intercellular adhesion molecule 1 (ICAM-1) levels [98]. Several authors [99] show the antihypertensive effect of ginger in volunteers with mean ≤ 50 years, with ginger doses ≥ 3 g/day, and during an intervention period ≤ 8 weeks. This effect could be due to its antioxidant activity.
A systematic review with 345 participants from six clinical trials showed that ginger consumption has favorable effects on blood pressure. These authors observed that increasing ginger intake decreased the probability of ischemic heart disease and hypertension [100]. This result coincides with that observed in a clinical trial with 4628 participants in which the efficacy of ginger in coronary heart disease and as an antihypertensive was observed [101].
Platelet aggregation and activation play an important role in developing thrombosis and atherosclerosis. Numerous nutrients and bioactive compounds have a potential role in platelet function and may decrease cardiovascular risk. These include berries, caffeine, chocolate, garlic, ginger, the omega-3 polyunsaturated fatty acids (PUFA), onion, and tomato [102].
ZGR is a compound (phenolic alkanose) found in
Several authors [104] observed that consumption of a 10 g dose of powdered ginger after 4 hours significantly reduced ADP- and adrenaline-induced platelet aggregation. McEwen analyzed the
Ginger has a vascular protective effect mediated by different mechanisms such as reduction of inflammation and oxidative stress, increase of nitric oxide synthesis, which is a potent vasodilator, the promotion of autophagy, and inhibition of vascular smooth muscle cell [105].
Comparing different ginger compounds, several investigators have shown that 6-gingerol and 6-shogaol showed the most potent bioactivity against cholesterol (Chol), arachidonic acid (AA), thrombin, and PAF-induced platelet aggregation [106]. The 6-paradol, 10-dehydrogingerol, 10-gingerol showed the most significant inhibition of AA-induced aggregation [107].
Nurtjahja-Tjendraputra et al. observed that 8-paradol is the most effective anticoagulant, being a COX-1 inhibitor [108].
Thomson et al. fed rats with ginger aqueous extract and observed a decrease in triglyceride, thromboxane-B2 cholesterol and PGE2 levels, and in adenosine deaminase (ADA) activity of plaques, together with an increase in adenosine levels. In this way, it favors vasodilatation, reducing the complications of hypertension and preventing from unnecessary platelet aggregation [108].
Ginger contains diverse bioactive compounds and demonstrates multiple bioactive properties. It is a potent antioxidant, anti-inflammatory, regulator of lipid profile, inhibitor of VSMC proliferation, blocker of voltage-dependent Ca2+ channels, inhibitor of platelet aggregation, regulator of endothelial dysfunction and NO synthesis, enhancer of cholesterol efflux from macrophages, inhibitor of angiogenesis, and promoter of autophagy.
The biological activities, health benefits, and cardioprotective properties of ginger/ginger constituents along with related mechanisms of action gave new insights to show new avenues in the treatment of CVDs.
It is valuable to explore new anti-platelet aggregation drugs based on the skeleton of [ acetyl-CoA acetyltransferase 2 adenosine deaminase adenosine diphosphate adenine monophosphate activated protein kinase body mass index carbohydrate-responsive element-binding protein glucose transporter type 4 cyclooxygenase-1 cyclooxygenase-2 cardiovascular diseases dietary approaches to stop hypertension coagulation factor Xa glycosylated hemoglobin high-density lipoprotein human umbilical endothelial cells intercellular adhesion molecule 1 interleukin inducible NOS low-density lipoprotein lipopolysaccharide mitogen-activated protein kinase messenger ribonucleic acid mammalian target of rapamycin microsomal triglyceride transfer protein factor kappa B nod-like receptor oxide nitric oxide nitric synthase Niemann-Pick disease, type C1, gene-like 1 is a mouse monoclonal antibody prostaglandin E2 polyunsaturated fatty acids reactive oxidative species substrate S-2222 in a non-competitive inhibition model superoxide dismutase signal transducer activators of transcription receptors toll-like tumor necrosis tumoral alpha a stable thromboxane receptor (TP receptor) agonist) vascular smooth muscle cell World Health Organization zingeroneAcronyms and abbreviations
The authors declare no conflict of interest.
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He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. 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\r\n\tThe environment is subject to severe anthropic effects. Among them are those associated with pollution, resource extraction and overexploitation, loss of biodiversity, soil degradation, disorderly land occupation and planning, and many others. These anthropic effects could potentially be caused by any inadequate management of the environment. However, ecosystems have a resilience that makes them react to disturbances which mitigate the negative effects. It is critical to understand how ecosystems, natural and anthropized, including urban environments, respond to actions that have a negative influence and how they are managed. It is also important to establish when the limits marked by the resilience and the breaking point are achieved and when no return is possible. The main focus for the chapters is to cover the subjects such as understanding how the environment resilience works, the mechanisms involved, and how to manage them in order to improve our interactions with the environment and promote the use of adequate management practices such as those outlined in the United Nations’ Sustainable Development Goals.
",coverUrl:"https://cdn.intechopen.com/series_topics/covers/39.jpg",keywords:"Anthropic Effects, Overexploitation, Biodiversity Loss, Degradation, Inadequate Management, SDGs Adequate Practices"},{id:"38",title:"Pollution",scope:"\r\n\tPollution is caused by a wide variety of human activities and occurs in diverse forms, for example biological, chemical, et cetera. In recent years, significant efforts have been made to ensure that the environment is clean, that rigorous rules are implemented, and old laws are updated to reduce the risks towards humans and ecosystems. However, rapid industrialization and the need for more cultivable sources or habitable lands, for an increasing population, as well as fewer alternatives for waste disposal, make the pollution control tasks more challenging. Therefore, this topic will focus on assessing and managing environmental pollution. It will cover various subjects, including risk assessment due to the pollution of ecosystems, transport and fate of pollutants, restoration or remediation of polluted matrices, and efforts towards sustainable solutions to minimize environmental pollution.
",coverUrl:"https://cdn.intechopen.com/series_topics/covers/38.jpg",keywords:"Human Activity, Pollutants, Reduced Risks, Population Growth, Waste Disposal, Remediation, Clean Environment"},{id:"41",title:"Water Science",scope:"