\r\n\tThe major pathogenetic mechanisms resulting from RAAS overactivity include activation of the sympathetic nervous system, endothelial dysfunction, proinflammatory, and procoagulant states. \r\n\tEmerging from basic science evidence, major clinical trials established the beneficial effects of inhibitors of the different components of RAAS such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), aldosterone antagonists. These effects range from treatment of hypertension, diabetic nephropathy, CHF, as well as improvement of outcomes after myocardial infarction and improvement in glucose homeostasis and prevention of type 2 diabetes with some agents.
\r\n
\r\n\tIn this book, written by a world-renowned scholar, we will address the major concepts and topics related to RAAS activation including the pathogenetic mechanisms underlying the deleterious effects of activated RAAS and the role of local tissue RAAS in various organ systems such as the heart and vasculature, the skeletal muscle, adipose tissues, pancreas and the angiotensinergic pathways in the brain. Cutting-edge information is provided that will address the need for a wide range of readers including a medical student, clinical practitioner, and basic science investigators alike. This book will be bridging the gap between basic science and clinical practice regarding the RAAS system, which is imminently critical and highly relevant to the practice of medicine.
\r\n
\r\n\tFinally, with data emerging from the COVID-19 pandemic indicating overrepresentation of people with diseases associated with RAAS activation such as hypertension, chronic kidney disease, and diabetes, the role of RAAS activation and RAAS inhibition in the pathogenesis and clinical outcomes in COVID-19 has garnered a great deal of interest. In this book, we will dedicate a chapter addressing this topical and highly critical subject. \r\n\t
",isbn:"978-1-83968-287-2",printIsbn:"978-1-83968-286-5",pdfIsbn:"978-1-83968-458-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,hash:"5815b21958b2b2d5b653771c3f0cc35c",bookSignature:"Prof. Samy I. McFarlane",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10488.jpg",keywords:"Renin-Angiotensin-Aldosterone System, Pathogenesis, Angiotensin-Converting Enzyme Inhibitors, Angiotensin Receptor Blockers, Aldosterone, Congestive Heart Failure, Type 2 Diabetes, Clinical Trials, Local Tissue RAAS, Angiotensinergic Pathways, SARS-CoV-2 Spike Protein, Population Studies",numberOfDownloads:14,numberOfWosCitations:0,numberOfCrossrefCitations:0,numberOfDimensionsCitations:0,numberOfTotalCitations:0,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"October 29th 2020",dateEndSecondStepPublish:"November 26th 2020",dateEndThirdStepPublish:"January 25th 2021",dateEndFourthStepPublish:"April 15th 2021",dateEndFifthStepPublish:"June 14th 2021",remainingDaysToSecondStep:"5 months",secondStepPassed:!0,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"A leading physician-scientist and renowned author and mentor. He has edited several books and authored over 300 publications on diabetes, hypertension, dyslipidemia, cardiovascular disease, and related areas. His work has been among the most read articles with over 10,000 citations in major medical journals.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"53477",title:"Prof.",name:"Samy I.",middleName:null,surname:"McFarlane",slug:"samy-i.-mcfarlane",fullName:"Samy I. McFarlane",profilePictureURL:"https://mts.intechopen.com/storage/users/53477/images/system/53477.jpg",biography:"Dr. Samy I. McFarlane, MD, MPH, MBA, FACP is a distinguished\nteaching professor of Medicine and Endocrinology and an Associate Dean at the College of Medicine, State University of New York, Downstate Health Science University, USA.\nHe has extensive experience in clinical and translational research\nand has led the largest center in North America in the landmark\ndiabetes prevention trial, the DREAM trial using the commonly prescribed ACE-inhibitor ramipril. He has edited several\nbooks and authored over 300 publications on diabetes, hypertension, dyslipidemia,\ncardiovascular disease, and related areas. His work has been among the most read\narticles with over 10,000 citations in major medical journals. He is the Founding\nEditor-In-Chief for the International Journal of Clinical Research and Trials and has\nserved as the Editor-In-Chief for several other journals. He is a nationally and internationally recognized scholar who served as a member at the National Institute of\nHealth-NIDDK committee (3x 4- year terms) and as a chair of the NIH-NIDDK U01 review\ncommittee (thrice). He has received multiple recognitions including Certificate of\nSpecial Congressional Recognition and he also served as District President for the\nAmerican College of Physicians. He is also a well-recognized mentor with some of his\ntrainees serving in leadership positions at the NIH and other major institutions.",institutionString:"SUNY-Downstate Health Science University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"1",institution:null}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"16",title:"Medicine",slug:"medicine"}],chapters:[{id:"75639",title:"The Role of the Renin-Angiotensin-Aldosterone System in Cardiovascular Disease: Pathogenetic Insights and Clinical Implications",slug:"the-role-of-the-renin-angiotensin-aldosterone-system-in-cardiovascular-disease-pathogenetic-insights",totalDownloads:15,totalCrossrefCites:0,authors:[null]}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"205697",firstName:"Kristina",lastName:"Kardum Cvitan",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/205697/images/5186_n.jpg",email:"kristina.k@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"7556",title:"Dyslipidemia",subtitle:null,isOpenForSubmission:!1,hash:"dfd1faefe925f0f8335c42cdb36256c1",slug:"dyslipidemia",bookSignature:"Samy I. McFarlane",coverURL:"https://cdn.intechopen.com/books/images_new/7556.jpg",editedByType:"Edited by",editors:[{id:"53477",title:"Prof.",name:"Samy I.",surname:"McFarlane",slug:"samy-i.-mcfarlane",fullName:"Samy I. McFarlane"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6550",title:"Cohort Studies in Health Sciences",subtitle:null,isOpenForSubmission:!1,hash:"01df5aba4fff1a84b37a2fdafa809660",slug:"cohort-studies-in-health-sciences",bookSignature:"R. Mauricio Barría",coverURL:"https://cdn.intechopen.com/books/images_new/6550.jpg",editedByType:"Edited by",editors:[{id:"88861",title:"Dr.",name:"R. Mauricio",surname:"Barría",slug:"r.-mauricio-barria",fullName:"R. Mauricio Barría"}],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:"Theophanides",surname:"Theophile",slug:"theophanides-theophile",fullName:"Theophanides Theophile"}],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"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3092",title:"Anopheles mosquitoes",subtitle:"New insights into malaria vectors",isOpenForSubmission:!1,hash:"c9e622485316d5e296288bf24d2b0d64",slug:"anopheles-mosquitoes-new-insights-into-malaria-vectors",bookSignature:"Sylvie Manguin",coverURL:"https://cdn.intechopen.com/books/images_new/3092.jpg",editedByType:"Edited by",editors:[{id:"50017",title:"Prof.",name:"Sylvie",surname:"Manguin",slug:"sylvie-manguin",fullName:"Sylvie Manguin"}],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. Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"72",title:"Ionic Liquids",subtitle:"Theory, Properties, New Approaches",isOpenForSubmission:!1,hash:"d94ffa3cfa10505e3b1d676d46fcd3f5",slug:"ionic-liquids-theory-properties-new-approaches",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/72.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"314",title:"Regenerative Medicine and Tissue Engineering",subtitle:"Cells and Biomaterials",isOpenForSubmission:!1,hash:"bb67e80e480c86bb8315458012d65686",slug:"regenerative-medicine-and-tissue-engineering-cells-and-biomaterials",bookSignature:"Daniel Eberli",coverURL:"https://cdn.intechopen.com/books/images_new/314.jpg",editedByType:"Edited by",editors:[{id:"6495",title:"Dr.",name:"Daniel",surname:"Eberli",slug:"daniel-eberli",fullName:"Daniel Eberli"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"57",title:"Physics and Applications of Graphene",subtitle:"Experiments",isOpenForSubmission:!1,hash:"0e6622a71cf4f02f45bfdd5691e1189a",slug:"physics-and-applications-of-graphene-experiments",bookSignature:"Sergey Mikhailov",coverURL:"https://cdn.intechopen.com/books/images_new/57.jpg",editedByType:"Edited by",editors:[{id:"16042",title:"Dr.",name:"Sergey",surname:"Mikhailov",slug:"sergey-mikhailov",fullName:"Sergey Mikhailov"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1373",title:"Ionic Liquids",subtitle:"Applications and Perspectives",isOpenForSubmission:!1,hash:"5e9ae5ae9167cde4b344e499a792c41c",slug:"ionic-liquids-applications-and-perspectives",bookSignature:"Alexander Kokorin",coverURL:"https://cdn.intechopen.com/books/images_new/1373.jpg",editedByType:"Edited by",editors:[{id:"19816",title:"Prof.",name:"Alexander",surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"64013",title:"Interactions of Candida albicans Cells with Aerobic and Anaerobic Bacteria during Formation of Mixed Biofilms in the Oral Cavity",doi:"10.5772/intechopen.81537",slug:"interactions-of-candida-albicans-cells-with-aerobic-and-anaerobic-bacteria-during-formation-of-mixed",body:'\n
\n
1. The oral cavity: a common place for polymicrobial biofilm formation
\n
The oral cavity comprises the most complex niches of the human body colonized by a wide variety of bacteria and fungi species. These commensal or often opportunistic and pathogenic colonizers tend to form biofilms—structured microbial communities, attached to natural or artificial surfaces, which are directly attributable to the virulence of these microorganisms and their ability to cause infections [1].
\n
The variety of microbial species inhabiting the oral cavity results from the presence of two different functional surfaces, the mucosal surface and the teeth, representing various conditions in terms of nutrient and oxygen availability [2]. The microorganisms that early colonize the salivary pellicle on the tooth surface are streptococci such as the oral commensal—Streptococcus gordonii. Further biofilm formation involves some bridging microorganisms such as Fusobacterium nucleatum [3]. As the biofilm extends below the gum line and becomes subgingival plaque, more pathogenic, Gram-negative anaerobes such as Porphyromonas gingivalis or Tannerella forsythia are embedded [4].
\n
For polymicrobial growth and survival in the human oral cavity, establishing a well-functioning community, i.e., biofilm, is essential. The formation of biofilm increases a resistance to antimicrobial agents and nutritional changes. However, the transition from planktonic type of growth to biofilm community requires many transcriptional and proteomic changes. Most of them concern co-aggregation/-adhesion processes, sensing diffusible signals, and metabolic interactions. Such a developed biofilm is still exposed to changes of nutrition and oxygen availability, pH fluctuation, antimicrobial properties of saliva, and is also modified by the contact with host tissues [5].
\n
The latest studies of oral microbiome pointed at an opportunistic inhabitant of oral mucosa—the Candida albicans yeast-like fungus—as an important biofilm player among microbiota that contacts with mucosal tissues of the host. Under colonization or infection conditions, C. albicans adheres to tissues, interacting with a variety of host extracellular matrix molecules that promote adhesion to the host surfaces [6]. The adherence is strictly dependent on C. albicans ability to switch morphology between yeast and hyphal forms [7, 8].
\n
Numerous observations supported a hypothesis that fungi have a beneficial or favorable role in maintaining the healthy balance between microbes and the host. On the other hand, C. albicans well adapted to constantly changing demands in the human host environment [9] seems to be able to use the different colonizing strategy under situations that emerge in the pathological disparities.
\n
Tracking the yeast oral infections showed that the same initiating and bridging microorganisms composing biofilms were involved in the interaction with hyphal filaments of C. albicans, promoting co-colonization of these surfaces by yeast [10]. Moreover, the interactions between yeast and streptococci appear to be synergistic. In addition to providing adhesion sites, streptococci excrete lactate that can act as a carbon source for yeast growth [11]. On the other hand, C. albicans may provide bacteria with growth stimulatory factors, resulting from the nutrition metabolism [12] and can reduce the oxygen pressure to the level, preferred by streptococci.
\n
C. albicans also co-aggregates with an obligatory anaerobe, F. nucleatum [13], or a facultative anaerobe—Actinomyces oris [14].
\n
Current studies [15, 16, 17] report that C. albicans biofilms protect the obligatory anaerobes, like P. gingivalis and T. forsythia, under aerobic culture conditions. It is possible because oxygen depletion within the structured fungal biofilm or its fast consumption by fungal cells results in creation of anaerobic micro-niches that help strict anaerobic bacteria to survive and proliferate. The observed depletion of oxygen could depend on the number of C. albicans cells or their respiratory rate.
\n
\n
\n
2. Mechanisms and structures involved in formation of Candida albicans biofilms
\n
The ability of C. albicans to form a biofilm is closely related to the virulence potential of pathogenic form of C. albicans and is characterized by a high heterogeneity among different clinical isolates [18, 19]. This form of fungal community depends on the cell surrounding and proceeds via sequential steps. The process starts with the initial adhesion of single yeast-like cells to the artificial or mucosal surface (Figure 1) and formation of a basal yeast cells layer [20, 21, 22]. During this phase both the surface properties on which microorganism form aggregate, its structure, charge, hydrophobicity, or roughness, as well as the structure of molecules present at the surface of pathogen cells play important roles [23]. In the further cell proliferation step, the fungi develop the filamentous hyphal form of the cells accompanied by production of an extracellular polysaccharide matrix in mature biofilm, which protects them, and strengthens the biofilm structure [24]. These processes lead to a significant increase in the thickness of the biofilm, and its maturation is controlled by at least nine master transcription regulators (Ndt80, Bcr1, Efg1, Rfx2, Flo8, Rob1, Brg1, Gal4, and Tec1) that supervise the network of about 1000 of targeted genes involved in biofilm formation [21, 25]. Then, the dispersion of biofilm-associated yeast-like cells can occur with further fungal cell dissemination, often associated with invasive diseases [24, 26].
\n
Figure 1.
Polymicrobial biofilm: stages of development and host responses.
\n
Numerous different mechanisms and molecules are involved in the overall complex process of C. albicans biofilm formation [27]. Initially, the general physicochemical properties of C. albicans cell surface and subsequent activity of cell wall adhesive proteins play extremely important roles, allowing the cells to adhere to the targeted substrates or materials [28]. This essential group of molecules responsible for in vitro and in vivo biofilm development includes several proteins covalently bound to the fungal cell wall and equipped with a signal peptide for classical secretion and glycosylphosphatidylinositol (GPI)-anchor site, i.e., hyphal cell wall protein Hwp1 [29], proteins from agglutinin-like sequence (Als) protein family, such as Als1 and Als3 [28], and hyphally regulated cell wall protein Hyr1 [28]. Their transcription is regulated by the transcription factor Bcr1 [30] and is primarily associated with the morphological transition from yeast cells to filamentous forms, thus implicating their association mainly with the cell wall of hyphae [31, 32, 33]. Additionally, other adhesins are required for C. albicans adhesion and proper biofilm formation, including Eap1 (enhanced adhesion to polystyrene 1) protein present at the cell surface of both yeast cells and hyphal forms [34, 35]. Adhesion-related proteins are important not only for the binding of fungal cells to the receptors on host tissues or to the artificial surfaces, but also for maintaining the cell-cell interactions within the biofilm that allow further stabilization of the structure and avoiding the removal of fungal cells by the action of host defense mechanisms such as the salivary flow. In the process of aggregation and intracellular interactions between fungal cells, fragments of adhesins that consist of amino acid sequences predicted to form amyloid-like β-aggregates and mediating amyloid formation may participate, as described for the protein Rbt1 (repressed by TUP1), a GPI-anchored cell wall protein with a similarity to Hwp1 [36, 37].
\n
After the adhesion step, further proliferation of cells and production of filamentous forms lead to the enhanced development of biofilm [38], processes related not only to the change in the surface properties of fungal cells and the increase of their adhesiveness, but also to the production of further virulence factors and biofilm matrix components [24]. Among the large repertoire of extracellular hydrolytic enzymes produced by C. albicans that play a pivotal role during the invasion on host tissues during the infection and are involved in biofilm-related pathogenesis, representatives of families of lipases, phospholipases, and secreted aspartyl proteinases (Saps) can be included [39]. The major biofilm-associated Saps are hypha-specific Sap5 and Sap6, responsible for the acquisition of nutrients, aggregation of fungal cells, intracellular communication, and production of extracellular matrix during biofilm development [40, 41, 42].
\n
The highly complicated and heterogeneous extracellular biofilm matrix (ECM) is composed of numerous proteins (55%), carbohydrates (25%), mainly branched α-1,6-mannans, unbranched β-1,6-glucans, and β-1,3-glucans, as well as lipids (15%), including neutral glycerolipids, polar glycerolipids and sphingolipids, and nucleic acids (5%) [43]. The matrix that strengthens the biofilm significantly contributes to the development of biofilm resistance to adverse environmental conditions and penetration of antifungal drugs [43, 44, 45]. Several matrix-associated proteins have been identified, both involved in the basic cellular metabolism, as well as the proteins responsible for the rearrangement of the matrix structure and maintenance of its functionality (glucan-modifying enzymes and protein mannosyltransferases, i.e., Xog1, Exg1, Bgl2, Pmt1, Pmt2, Pmt4, Pmt6) [46, 47]. Extracellular DNA (eDNA) detected in C. albicans biofilm matrix is probably mainly responsible for the structural integrity [48].
\n
In the process of biofilm dispersion, the molecular chaperone, heat shock protein 90 (Hsp90) is strongly involved [49], affecting the morphogenetic transition from yeast cells to hyphal forms and repressing Ras1/PKA (cAMP-dependent protein kinase) signaling cascade [50]. Furthermore, the conserved histone deacetylase complex, including Set3, Hos2, Snt1, and Sif2 proteins also participates in the dispersal of biofilm, modulating the transcription kinetics of the genes that regulate biofilm maturation [51].
\n
\n
\n
3. C. albicans interactions with bacteria during mutual biofilm formation
\n
C. albicans colonizes the oral cavity, presenting the commensal or pathogenic properties that can be modified by direct or indirect interactions with different types of bacteria, depending on the localization of the microbial communities, such as the supragingival plaque, subgingival plaque, and tongue coating. The metabolic activity of microorganisms that colonize the supragingival sites, i.e., nonmutans streptococci and Actinomyces enriches the environment in lactic acid, creating a temporarily acidic environment that favors the entrance of the more cariogenic microorganisms, mutans streptococci into the ecosystem. Conversely, at subgingival sites, colonized by Fusobacteria and Prevotella, a neutral pH and anaerobic environment dominate and facilitate the establishment of a less acid-tolerant but periodontopathogenic bacterium, P. gingivalis [52].
\n
The mitis group of streptococci (MGS), including Streptococcus mitis, Streptococcus oralis, Streptococcus gordonii, and Streptococcus sangunis [53, 54] belongs to the early colonizers of oral cavity and appears to interact synergistically with C. albicans hyphal filaments providing the physical and metabolic interactions by the exposition of specific adhesion sites and excreting lactate that serves as a carbon source for yeast growth [55]. On the other hand, C. albicans can provide bacteria with growth stimulatory factors, resulting from the fungal nutrition metabolism [12] and reduces the oxygen pressure to the level, preferred by streptococci. Moreover, a mutual collaboration of C. albicans and S. oralis increases the inflammatory host responses compared to monospecies infections [56, 57]. The consequence for the host is provided by the precise interactions between the cell surface proteins of S. oralis, S. mitis and S. gordonii, especially SspA and SspB [58, 59] and the candidal cell wall adhesins of agglutinin-like family, mainly Als3, presented on the surface of fungal hyphae [60]. Some parts of these proteins seem to be particularly important for the interactions but a precise mechanism of the interaction requires further research, especially to clarify a significance of cell wall mannosylation [57, 61] in this process.
\n
Moreover, the polysaccharides of both types of interacting microorganisms that compose ECM not only protect the cells, but also create a new platform for mutual interactions between fungal glucans and mannans and bacterial glucosyltransferases within the ECM matrix structure [46, 62, 63].
\n
The best example of microbial cooperation for increased pathogenic properties of mixed biofilm is represented by the interactions of C. albicans with S. aureus, identified in oral cavity and being a source of systemic infection [64, 65, 66, 67]. The bacteria prefer hyphal filaments of C. albicans [68, 69] for adhesion, but its localization within the biofilm seems to depend on the surface colonization sequence. When bacteria are the first colonizer, the development of fungal biofilm is slower and bacteria cells are spread in whole three-dimensional biofilm structure [68]. On the other hand, a simultaneous contact of microorganisms with the surface favors the rapid formation of the mixed biofilm with S. aureus localization within upper layers of fungal biofilm and with involvement of multiple microbial proteins. However, the role of fungal adhesins from Als family in these interactions has been questioned [70]. The formed biofilm and its ECM with extracellular fungal DNA protect the bacteria against the antibiotic treatment [71, 72, 73].
\n
C. albicans co-aggregates with an obligatory anaerobe F. nucleatum [13], with engagement of a mannan receptor on the C. albicans surface [74]. A facultative anaerobe—A. oris—makes its own carbohydrate-containing surface molecules available to the interaction with C. albicans [14]. Last studies have also shown that C. albicans is able to interact with keystone pathogen of subgingival plaque—P. gingivalis—the obligatory anaerobe. However, it is difficult to judge whether the pathogens apply a synergistic or concurrence style of interactions. It was demonstrated that P. gingivalis suppressed Candida biofilm formation by a reduction of fungal cell viability [75]. Recently, the gingipain activity has been suggested to be the main destructive force influencing fungal cells wall within the mixed bacterial-fungal biofilm (unpublished data). On the other hand, P. gingivalis was also shown to induce germ-tube formation by C. albicans cells, generating a more invasive phenotype of fungal cells [76]. But such an effect could also result from fungal protection toward contacting bacteria and their virulence potential (unpublished data). The mutual interactions are supported by the involvement of adhesins, especially fungal Als3, Mp65 and surface-located enolase, aand a bacterial internalin, InlJ or gingipains ([77], unpublished data). The important role in the interaction between C. albicans and P. gingivalis has been also assigned to peptydylarginine transferase of P. gingivalis (PPAD), the enzyme capable of modifying Arg residues to citrullines. Its action can directly contribute to the change in the spatial structure of the molecule [78]. A bacterial mutant deprived of PPAD forms a reduced mixed biofilm compared to the wild-type strain. Potential molecules whose citrullination may affect the effectiveness of biofilm formation include arginine-specific cysteine proteinase (RgpA) and adhesive Mfa1 fimbrilin [17, 79].
\n
The interaction of both microbes seems to exert marked consequences to the host. However, it was presented that both microbes appear to have antagonistic effects on one another, as P. gingivalis inhibited the adhesion of C. albicans to buccal epithelial cells [80]. But the presence of C. albicans did not enhance adhesion of P. gingivalis to gingival epithelial cells or gingival fibroblasts. On the other hand, a pre-exposure of gingival epithelial cells and fibroblasts to C. albicans enhanced the cell invasion by P. gingivalis [81].
\n
\n
\n
4. Host responses to the candidal biofilms
\n
Clinical candidal oral biofilm inhabiting mucosal surfaces or artificial devices may trigger more or less similar host responses (Figure 1). Regardless of the biofilm origin, it remains under the influence of immune factors produced by contacting epithelial cells [82].
\n
Dongari-Bagtzoglou et al. [83] analyzed the candidal biofilm in a murine model and found that this fungal cell community induced a hyperkeratotic response and epithelial cell desquamation. Moreover, the matrix that surrounded the fungal biofilm was enriched in keratin and desquamated cells.
\n
Also, in a rat model of chronic denture gingival dermatitis, the host proteins were prominent in the extracellular matrix, including amylase, hemoglobin, and antimicrobial peptides [84, 85].
\n
The oral biofilm elicits responses of human immune cells (Figure 1). The neutrophil migration and their deeper localization within the biofilm were identified, but these defense cells were not effective in clearing these infections [82]. An analysis of neutrophil responses in the ex vivo models of their contact with C. albicans biofilm also showed a diminished activity of neutrophils against this structured fungal community, compared to the responses against the planktonic form of fungal cells [86].
\n
Upon a contact with pathogens, neutrophils can activate many mechanisms of response to suppress the infection. These include degranulation, phagocytosis, and neutrophil extracellular traps (NETs) formation [87]. The latter process aims at entrapment of large objects such as fungal hyphae [88]. Nevertheless, a group of Johnson showed that neutrophils failed to release NETs in contact with fungal biofilm [89]. These results were described as an immunological silence, where host immune system ignored contacting biofilm because of its shielding by the matrix components [90]. The biofilm matrix prevents the exposition of so called pathogen-associated molecular patterns (PAMPs) that can be recognized by highly specialized pattern recognition receptors (PRRs) of human immune cells [91, 92].
\n
Another explanation proposed to interpret the evasion of host response by the biofilm was an immune deviation that could result from action of yet unidentified fungal compounds. They could act directly or indirectly by triggering host immunomodulatory factors that transform the immune response into ineffective form [93]. Such hypothesis was supported by the observation that C. albicans cell wall components were able to induce the expression of Il-10 influencing Th2 response [94].
\n
A further explanation of biofilm survival was represented by a model of immune resistance proposed in [95], where GPI-anchored cell wall protein Hyr1 could play an important role [96]. Moreover, all of proposed mechanisms or their combinations could be involved in local paucity of PMN responses. Katragkou et al. [86, 97] and Xie et al. [98] documented that developed biofilm covered by ECM exposed fungal β-glucans that were involved in hindered neutrophil responses to cytokine priming of PMNs or fungal cell opsonization. Such an argument was also strengthened by the observation that pre-treatment of PMNs with interferon-γ or granulocyte colony-stimulating factor (G-CSF) did not significantly enhance their activity against opsonized or nonopsonized C. albicans biofilms. Moreover, neutrophils contacting the mature biofilm did not produce reactive oxygen species, necessary for triggering of phagocytosis, or one of the pathways of NET production [99]. Nevertheless, the precise mechanism of this phenomenon remained to be clarified.
\n
Similar, diminished responses were also observed for a contact of fungal biofilm with mononuclear cells, compared to their co-culture with fungal planktonic form [100]. Although the migration of the mononuclear cells through biofilm was detected with their main compaction in the basal part of biofilm, their phagocytosis properties were suppressed, and the production of pro-inflammatory cytokines in response to biofilm decreased. Surprisingly, the mononuclear cells augmented biofilm proliferation, increasing the biofilm thickness over two-fold [97, 101].
\n
Most of the presented observations were made concerning host response to contact with fungal biofilm, but the host immune system usually has to face an ongoing polymicrobial infection [102] about which the information are rather scarce [103]. An example of the cross-kingdom infection of the human host was represented by C. albicans biofilm contacting gingival anaerobic bacteria, P. gingivalis. In this case, an attenuation of the human macrophage responses was observed [17]. Moreover, some studies presented that the host responses can vary depending on the pathogen that contacts the fungal biofilm [104]. The pathogen interactions can be synergistic as well as antagonistic. For example, in a rat model, the colonization of the airway by C. albicans impaired functions of alveolar macrophages and, in consequence, led to the reduced clearance of Pseudomonas aeruginosa [105]. On the other hand, Lopez-Medina et al. [106] showed in a mouse gut model that the co-infection of P. aeruginosa with Candida cells suppressed the expression of bacterial genes responsible for iron acquisition, and thus suppressed the infection. Nevertheless, our understanding of host responses to mixed biofilm formed between different type of pathogens remains still at its infancy and needs many further studies.
\n
\n
\n
5. Quorum sensing within the mixed biofilm and its significance for the host
\n
An important phenomenon occurring in the process of biofilm formation is also the transmission of signals between microbial cells located within the biofilm, thus stimulating them to further growth and dispersion of the cells or, in contrary, suppressing them. In addition, signaling molecules can also affect microbial cells of other species that inhabit the same niche in the host organism, and thus promote synergistic or antagonistic interactions between different pathogens which can result in clinical outcomes. This phenomenon of the communication between microorganisms through the secretion of low molecular weight compounds, referred to as the quorum sensing (QS) [107], involves specific chemical compounds whose increasing concentration is a signal to change the expression of selected genes in the cells of the entire biofilm population [108].
\n
C. albicans produces autoregulatory substances involved in quorum sensing (quorum-sensing molecules, QSMs) that affect important virulence traits, such as transformation of the morphological forms [109]. One of them is farnesol—an alcohol from the terpene group, secreted by C. albicans in the later stages of biofilm formation, with a function of blocking the formation of filamentous forms of this yeast [110]. A function opposite to farnesol has a second fungal QS compound, tyrosol, which stimulates the phase of active growth of the C. albicans cell population and the formation of hyphae in the initial phases of biofilm formation, thus increasing the thickness of the biofilm [111, 112, 113].
\n
When the concentration of farnesol is higher than that of tyrosol, the conversion of yeast form to hyphae is inhibited and a release of individual cells from the biofilm is stimulated. Such effect indicates possible interactions between these two QS systems in the process of biofilm building [112]. Additionally, C. albicans secretes two aromatic alcohols, phenylethyl alcohol and tryptophol, also identified as QSM [113].
\n
The role of QSM seems to be particularly important in mixed biofilms, in which the coexistence of fungi and bacteria is associated with their mutual communications. QSM secreted by the bacteria can exert both stimulatory and inhibitory effects on the cell morphology and biofilm formation by C. albicans cells. It is likely that a combination of these contradictory signals orchestrates the balance between the cellular and filamentous form in biofilms, preventing the excessive growth of C. albicans within these communities [114].
\n
One example of cross-species communication using QS signals are biofilms formed between C. albicans and Gram-negative bacteria P. aeruginosa. It has been shown that the presence of farnesol produced by C. albicans inhibits functioning of bacteria, and suppresses the production of a bacterial quinolone signaling molecule—PQS, and the piocyjanin—an important bacterial virulence factor [115]. On the other hand, under formation of mixed biofilms, P. aeruginosa produces homoserine lactone that may fulfill a role similar to farnesol, reducing the production of fungal hyphae in vitro [116].
\n
Another example is the biofilm with participation of S. mutans, in which the inhibition of biofilm formation was observed in response to a high concentration of farnesol (>100 μM), while a low level of farnesol (~25 μM) promoted bacterial growth [117, 118, 119].
\n
In other studies, S. mutans could both, reduce the farnesol production by C. albicans [119] and inhibit the formation of filamentous form of C. albicans by the competence-peptide CSP, produced on the early stages of biofilm development [120, 121].
\n
The same peptide produced by S. gordonii inhibited the formation of C. albicans biofilm, but not the hyphal growth [122]. In contrast, other bacterial QSM—the autoinducer-2 (AI-2), as well as H2O2 secreted by S. gordonii affected the morphogenesis and production of farnesol. The strains with the deletion of the LuxS quorum-sensing system responsible for AI-2 production in S. gordonii presented a reduced ability to stimulate the growth of C. albicans hyphae and thereby a general reduction of biofilm biomass. The identified responses correlated with an invasion into the host epithelial cells [10, 27].
\n
An interesting interspecies communication is presented by the Gram-negative Aggregatibacter actinomycetemcomitans, acting in periodontal disease, which can inhibit the formation of C. albicans biofilm by producing AI-2. Although AI-2 has been described as QSM of different bacteria, other species give off other AI derivatives, so that the results obtained for different species do not have to be identical to one another. Interestingly, A. actinomycetemcomitans is one of the bacterium having a dual inhibitory system acting toward C. albicans biofilm. In addition to QSM, it also includes cytolethal distending toxin (CDT). One of the emerging hypotheses suggests that secreted QSM is a warning signal for C. albicans against a competitor that secretes the toxins [120, 123].
\n
QSM also plays an important role in a communication between C. albicans and the Gram-positive bacterium—S. aureus. Farnesol, secreted by C. albicans inhibits the formation of S. aureus biofilm and increases its susceptibility to antibiotics [124, 125]. There were also studies, indicating that S. aureus stimulated the growth of C. albicans biofilm possibly by QSM [69]. It was also proposed that in the presence of farnesol, S. aureus acquires a resistant phenotype that induces oxidative stress, resulting in the upregulation of bacterial drug efflux pumps [126].
\n
QS production within the biofilm has also an impact on the efficiency and the functioning of host defense systems. The gingival epithelial cells presented an upregulation of the toll-like receptor TLR2, and a decrease of the expression of TLR4 and TLR6 upon treatment with farnesol, suggesting the resulting activation of antifungal defense. Considering the role of epithelial cells in the secretion of pro-inflammatory cytokines, it was also shown that farnesol increased the secretion of IL-6 and IL-8. Moreover, farnesol modulated the secretion of antimicrobial peptides by epithelial cells, including hBD1 and hBD2. C. albicans cells, via production of farnesol, suppressed the epithelial secretion of hBD1, with a simultaneous increase in hBD2 secretion. Since both peptides have a high efficacy in C. albicans killing, the results suggest that farnesol may be a key factor in promoting host defense [127]. An additional function performed by farnesol includes its ability to activate neutrophils and monocytes and to reduce the phagocytic activity of mouse macrophages. Farnesol also impairs the differentiation of monocytes into dendritic cells and decreases their ability to activate and expand T cells, which consequently reduce the induction of IL-12 [128].
\n
In summary, mutual QS interactions between fungi and bacteria may play an important role as a virulence mechanism that mediates the communication between the host and the formed biofilm, and could inspire future applications in diagnostics and biofilm treatment.
\n
\n
\n
6. Resistance of oral biofilm
\n
The biofilm formed on mucosal or artificial surfaces in oral cavity is difficult to eliminate since the biofilm structure protects the pathogenic cells against antimicrobial drugs, especially against antifungal agents, and suppresses immune responses [129]. Moreover, cooperating invaders often present increasing virulence resulting from synergistic and complex interactions between microorganisms [130]. It has been demonstrated that Staphylococcus adheres to yeast and hyphal forms, and this interaction benefits the growth and antibiotic resistance of S. epidermidis. In addition, the components of the biofilm extracellular matrix produced by the wild-type of S. epidermidis prevent the effective penetration of antimycotic molecules such as fluconazole into the biofilm and promote the spread of yeast infection [131].
\n
The low susceptibility of biofilms to medical treatment is attributed to multifactorial events, represented by upregulation of efflux pumps, the presence of extracellular matrix and appearance of recalcitrant persister cells [132].
\n
The two classes of fungal efflux pumps (FEP: Cdr1, Cdr2, and Mdr1) are activated in planktonic cells in contact with antifungal drugs but in biofilms FEP are upregulated probably in response to contact with other partners that compose the biofilm. Such an explanation was supported by an observation that FEP efficient function appeared shortly after the cell surface adhesion and remains upregulated during whole process of mixed biofilm formation [21].
\n
Another contributor to mixed biofilm resistance is the extracellular matrix and its components. This three-dimensional complex structure effectively inhibits antibiotic and antimycotic diffusion [133]. Moreover, the biofilm-composing polysaccharides not only mask the biofilm against its recognition by the host receptors, but also can directly bind and inactivate the drugs, as it was presented in a case of antifungal-acting amphotericin B, sequestered by β-1,3-glucan, composing ECM [134].
\n
Also, eDNA is an especially important biofilm component, whose viscosity and negative electric charge influences the structural integrity and stability of biofilms but also contributes to drug resistance via acting as drug chelator. eDNA also binds magnesium ions, whose decreased level serves as a signal, inducing PhoPQ and PmrAB systems, responsible for P. aeruginosa resistance to antimicrobial peptides and to aminoglycosides [135].
\n
An important phenomenon that plays a key role in the development of drug resistance by oral microbiome is the horizontal gen transfer (HGT) [131]. The biofilm structure provides a suitable environment for gene exchange, because the microbial cells are in close proximity and the virulence genes are dynamically spread between different species of bacteria composing biofilm. The most popular mobile genetic element in oral microflora is the conjugative transposon Tn916, which contains genes encoding ribosomal protection proteins [131]. These proteins inhibit the action of tetracycline, the most popular antibiotic used in periodontal disease treatment, by preventing the binding of this antibiotic to the bacterial ribosome [136]. Another biofilm protective function is carried out by membrane vesicles (MVs), present in ECM [137], which protect bacteria against some antibiotics by the degradative properties of MV enzymes, such as β-lactamase [138].
\n
The important factors that contribute to the biofilm resistance are the persister cells detected in bacterial and fungal biofilm [20, 139]. The persister cells are a minor subset of metabolically dormant cells presented within biofilms that possess extreme resistance to antimicrobial agents and are responsible for the severe chronic infectious disease. However, the mechanism of this resistance of persister cells remains to be discover; they could possibly be a good target for further antimicrobial therapies.
\n
\n
\n
7. The challenges for medical treatment of mixed oral biofilm
\n
As no biofilm-specific drugs exist today, the treatment of infections caused by mixed species community remains a major challenge for contemporary medical biotechnology and the developing of new effective strategies for biofilm eradication becomes critical.
\n
One of the strategies for combating biofilms formed by bacteria and yeasts can be a degradation of ECM. It has been demonstrated that enzymatic degradation of some biofilm-forming components facilitates the penetration of antibiotic and antimycotic molecules and affects the biofilm structural integrity [140, 141]. For example, a study demonstrated that a combined use of deoxyribonuclease and amphotericin B reduced the survival of C. albicans cells.
\n
An effective alternative to antibiotic therapy may be a treatment with anti-biofilm peptides. These compounds easily penetrate the structure of multispecies biofilm and inhibit the growth of Gram-positive and Gram-negative bacteria. An example of such an anti-biofilm compound is a short synthetic peptide 1018 (amino acid sequence: VRLIVAVRIWRR), which blocks a stress response through an activation of the stress-signaling nucleotide degradation [142]. Another example of an anti-biofilm compound is D-enantiomeric peptide DJK-5 that has a similar mechanism of action to peptide 1018 [143]. The main advantage of the DJK-5 is its resistance to proteases produced by the host and bacteria. Moreover, DJK-5 possesses a higher biological activity than peptide 1018 and kills most of the oral biofilm-forming bacteria in a few minutes. It has been demonstrated that the use of anti-biofilm peptides in combination with conventional antibiotics both increases the effectiveness of treatment and reduces the required concentration of antibiotics [144].
\n
Several natural products have been also proposed for fungal biofilm treatment. An example of plant metabolites with antifungal activity are terpenoids, such as xanthorrhizol extracted from Curcuma xanthorrhiza [145]. It has been demonstrated that this compound effectively inhibits the development of mature biofilms formed by various Candida species. Moreover, in contrast to commonly used antifungal drugs, xanthorrhizol is nontoxic to human cells even at very high concentrations.
\n
Also, chemical signal molecules involved in quorum sensing possess a potential for the therapy of oral infections disease. There are two main mechanisms of action of the known QS inhibitors [146]. Some of these cause an enzymatic degradation of signaling molecules. The enzymes—AHL-lactonases and AHL-acylase can be classified to this group. Other inhibitors such as furanones that are produced by red marine algae are structural analogs that prevent bacterial biofilm development via binding to LuxR [147]. In the case of oral C. albicans infections, the use of farnesol has been proposed [148]. In vivo studies have shown that the addition of farnesol suppresses the hyphal growth on the mouse tongue at the first step of biofilm formation, and as a result prevents the invasion of mucosal membrane by the yeast and bacteria.
\n
An interesting proposal for the treatment of mixed biofilm can be the photodynamic antimicrobial chemotherapy (PACT) that applies the nontoxic dye (photosensitizer) activated by visible light [149]. Singlet oxygen, which is effectively produced during this process, effectively kills pathogen cells. This novel method has been successfully used against C. albicans biofilm and can be a promising antimicrobial therapy that has many advantages such as the high target specificity. What is more, the development of resistance to PACT is unlikely because microorganisms have no resistance mechanism against singlet oxygen [150].
\n
A better understanding of the molecular mechanisms underlying the formation and maintenance of the mixed species biofilm is crucial for the development of their effective treatments in the future.
\n
\n
Acknowledgments
\n
This work was supported in part by the National Science Center of Poland (grant UMO-2015/17/B/NZ6/02078 awarded to M.R.-K).
\n
\n',keywords:"Candida albicans, biofilm, aerobic and anaerobic bacteria, quorum-sensing, host responses, anti-biofilm therapies",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/64013.pdf",chapterXML:"https://mts.intechopen.com/source/xml/64013.xml",downloadPdfUrl:"/chapter/pdf-download/64013",previewPdfUrl:"/chapter/pdf-preview/64013",totalDownloads:612,totalViews:223,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,dateSubmitted:"April 19th 2018",dateReviewed:"September 15th 2018",datePrePublished:"November 5th 2018",datePublished:"April 24th 2019",dateFinished:"October 11th 2018",readingETA:"0",abstract:"Biofilm is a compact coating formed on various artificial and physiologic surfaces by a population of microorganisms which in this habitat establish a close cooperation, exploiting both the physical interactions that stabilize the community and chemical cooperation, engaging numerous agents to modify the environment, i.e., to influence the acidity, nutrient acquisition, or oxygen availability. Microorganisms can also communicate using quorum-sensing molecules carrying specific messages. Some microbes temporarily dominate, while others are constantly replaced by different community members. But these co-operations or competitions have a deep sense—they serve to protect the whole community against the defense system of the host to assure survival. The oral cavity is inhabited by diverse microorganisms, including bacteria, but also yeast-like fungi from the genus Candida that stay under a tight control of the host as long as its immune system is not weakened; then these relatively mild commensals convert to dangerous pathogens that start the invasion often in collaboration with other microbes. Elongated hyphal forms of fungal cells favor the biofilm type of growth and communication with other microbes supporting immune resistance of the biofilm. In this chapter, we discuss the mechanisms of interactions between bacteria and C. albicans in the oral cavity, their communication, host responses, and possible strategies of anti-biofilm treatment.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/64013",risUrl:"/chapter/ris/64013",book:{slug:"candida-albicans"},signatures:"Maria Rapala-Kozik, Marcin Zawrotniak, Mariusz Gogol, Dominika\nBartnicka, Dorota Satala, Magdalena Smolarz, Justyna Karkowska-\nKuleta and Andrzej Kozik",authors:[{id:"198701",title:"Associate Prof.",name:"Maria",middleName:null,surname:"Rapala-Kozik",fullName:"Maria Rapala-Kozik",slug:"maria-rapala-kozik",email:"maria.rapala-kozik@uj.edu.pl",position:null,institution:{name:"Jagiellonian University",institutionURL:null,country:{name:"Poland"}}},{id:"200045",title:"Prof.",name:"Andrzej",middleName:null,surname:"Kozik",fullName:"Andrzej Kozik",slug:"andrzej-kozik",email:"andrzej.kozik@uj.edu.pl",position:null,institution:null},{id:"274639",title:"Dr.",name:"Marcin",middleName:null,surname:"Zawrotniak",fullName:"Marcin Zawrotniak",slug:"marcin-zawrotniak",email:"marcin.zawrotniak@uj.edu.pl",position:null,institution:null},{id:"274640",title:"MSc.",name:"Dominika",middleName:null,surname:"Bartnicka",fullName:"Dominika Bartnicka",slug:"dominika-bartnicka",email:"dominika.bartnicka@uj.edu.pl",position:null,institution:null},{id:"274641",title:"Dr.",name:"Mariusz",middleName:null,surname:"Gogol",fullName:"Mariusz Gogol",slug:"mariusz-gogol",email:"mariusz.gogol@uj.edu.pl",position:null,institution:null},{id:"274642",title:"MSc.",name:"Dorota",middleName:null,surname:"Satala",fullName:"Dorota Satala",slug:"dorota-satala",email:"dorota.satala@uj.edu.pl",position:null,institution:null},{id:"274643",title:"MSc.",name:"Magdalena",middleName:null,surname:"Smolarz",fullName:"Magdalena Smolarz",slug:"magdalena-smolarz",email:"magdalena.smolarz@uj.edu.pl",position:null,institution:null},{id:"274644",title:"Dr.",name:"Justyna",middleName:null,surname:"Karkowska-Kuleta",fullName:"Justyna Karkowska-Kuleta",slug:"justyna-karkowska-kuleta",email:"justyna.karkowska-kuleta@uj.edu.pl",position:null,institution:null}],sections:[{id:"sec_1",title:"1. The oral cavity: a common place for polymicrobial biofilm formation",level:"1"},{id:"sec_2",title:"2. Mechanisms and structures involved in formation of Candida albicans biofilms",level:"1"},{id:"sec_3",title:"3. C. albicans interactions with bacteria during mutual biofilm formation",level:"1"},{id:"sec_4",title:"4. Host responses to the candidal biofilms",level:"1"},{id:"sec_5",title:"5. Quorum sensing within the mixed biofilm and its significance for the host",level:"1"},{id:"sec_6",title:"6. Resistance of oral biofilm",level:"1"},{id:"sec_7",title:"7. The challenges for medical treatment of mixed oral biofilm",level:"1"},{id:"sec_8",title:"Acknowledgments",level:"1"}],chapterReferences:[{id:"B1",body:'Huse SM, Ye Y, Zhou Y, Fodor AA. A core human microbiome as viewed through 16S rRNA sequence clusters. PLoS One. 2012;7(6):e34242\n'},{id:"B2",body:'Simón-Soro A, Belda-Ferre P, Cabrera-Rubio R, Alcaraz LD, Mira A. A tissue-dependent hypothesis of dental caries. Caries Research. 2013;47(6):591-600\n'},{id:"B3",body:'He X, Hu W, Kaplan CW, Guo L, Shi W, Lux R. Adherence to Streptococci facilitates Fusobacterium nucleatum integration into an oral microbial community. Microbial Ecology. 2012;63(3):532-542\n'},{id:"B4",body:'Kuboniwa M, Lamont RJ. Subgingival biofilm formation. Periodontology 2000. 2010;52(1):38-52\n'},{id:"B5",body:'Jakubovics NS, Kolenbrander PE. The road to ruin: The formation of disease-associated oral biofilms. Oral Diseases. 2010;16(8):729-739\n'},{id:"B6",body:'Cannon RD, Chaffin WL. Colonization is a crucial factor in oral candidiasis. Journal of Dental Education. 2001;65(8):785-787\n'},{id:"B7",body:'Mayer FL, Wilson D, Hube B. Candida albicans pathogenicity mechanisms. Virulence. 2013;4(2):119-128\n'},{id:"B8",body:'Polke M, Hube B, Jacobsen ID. Candida survival strategies. Advances in Applied Microbiology. 2015;91:139-235\n'},{id:"B9",body:'Li D, Bernhardt J, Calderone R. Temporal expression of the Candida albicans genes CHK1 and CSSK1, adherence, and morphogenesis in a model of reconstituted human esophageal epithelial candidiasis. Infection and Immunity. 2002;70(3):1558-1565\n'},{id:"B10",body:'Bamford CV, D’Mello A, Nobbs AH, Dutton LC, Vickerman MM, Jenkinson HF. Streptococcus gordonii modulates Candida albicans biofilm formation through intergeneric communication. Infection and Immunity. 2009;77(9):3696-3704\n'},{id:"B11",body:'Holmes AR, Gopal PK, Jenkinson HF. Adherence of Candida albicans to a cell surface polysaccharide receptor on Streptococcus gordonii. Infection and Immunity. 1995;63(5):1827-1834\n'},{id:"B12",body:'Jenkinson HFDL. Candida interactions with bacterial biofilms. In: Brogden KAGJ, editor. Polymicrobial Infections and Disease. Washington, DC: ASM Press; 2002. pp. 357-373\n'},{id:"B13",body:'Grimaudo NJ, Nesbitt WE. Coaggregation of Candida albicans with oral Fusobacterium species. Oral Microbiology and Immunology. 1997;12(3):168-173\n'},{id:"B14",body:'Grimaudo NJ, Nesbitt WE, Clark WB. Coaggregation of Candida albicans with oral Actinomyces species. Oral Microbiology and Immunology. 1996;11(1):59-61\n'},{id:"B15",body:'Fox EP, Cowley ES, Nobile CJ, Hartooni N, Newman DK, Johnson AD. Anaerobic bacteria grow within Candida albicans biofilms and induce biofilm formation in suspension cultures. Current Biology. 2014;24(20, 20):2411-2416\n'},{id:"B16",body:'Janus MM, Crielaard W, Volgenant CMC, der Veen MH, Brandt BW, Krom BP. Candida albicans alters the bacterial microbiome of early in vitro oral biofilms. Journal of Oral Microbiology. 2017;9(1):1-10\n'},{id:"B17",body:'Karkowska-Kuleta J, Bartnicka D, Zawrotniak M, Zielinska G, Kieronska A, Bochenska O, et al. The activity of bacterial peptidylarginine deiminase is important during formation of dual-species biofilm by periodontal pathogen Porphyromonas gingivalis and opportunistic fungus Candida albicans. Pathogens and Disease. 2018;76(4)\n'},{id:"B18",body:'Sherry L, Rajendran R, Lappin DF, Borghi E, Perdoni F, Falleni M, et al. Biofilms formed by Candida albicans bloodstream isolates display phenotypic and transcriptional heterogeneity that are associated with resistance and pathogenicity. BMC Microbiology. 2014;14(1):182\n'},{id:"B19",body:'Rajendran R, Sherry L, Nile CJ, Sherriff A, Johnson EM, Hanson MF, et al. Biofilm formation is a risk factor for mortality in patients with Candida albicans bloodstream infection—Scotland, 2012-2013. Clinical Microbiology and Infection. 2016;22(1):87-93\n'},{id:"B20",body:'Mathé L, Van Dijck P. Recent insights into Candida albicans biofilm resistance mechanisms. Current Genetics. 2013;59(4):251-264\n'},{id:"B21",body:'Nobile CJ, Fox EP, Nett JE, Sorrells TR, Mitrovich QM, Hernday AD, et al. A recently evolved transcriptional network controls biofilm development in Candida albicans. Cell. 2012;148(12):126-138\n'},{id:"B22",body:'Tournu H, Van Dijck P. Candida biofilms and the host: models and new concepts for eradication. International Journal of Microbiology. 2012;2012:845352\n'},{id:"B23",body:'Fox EP, Nobile CJ. A sticky situation. Transcription. 2012;3(6):315-322\n'},{id:"B24",body:'Tsui C, Kong EF, Jabra-Rizk MA. Pathogenesis of Candida albicans biofilm. Mobley H, editor. Pathogens and Disease. 2016;74(4):ftw018\n'},{id:"B25",body:'Fox EP, Bui CK, Nett JE, Hartooni N, Mui MC, Andes DR, et al. An expanded regulatory network temporally controls Candida albicans biofilm formation. Molecular Microbiology. 2015;96(6):1226-1239\n'},{id:"B26",body:'Uppuluri P, Chaturvedi AK, Srinivasan A, Banerjee M, Ramasubramaniam AK, Köhler JR, et al. Dispersion as an important step in the Candida albicans biofilm developmental cycle. Doering TL, editor. PLoS Pathogens. 2010;6(3):e1000828\n'},{id:"B27",body:'Lohse MB, Gulati M, Johnson AD, Nobile CJ. Development and regulation of single- and multi-species Candida albicans biofilms. Nature Reviews. Microbiology. 2018;16(1):19-31\n'},{id:"B28",body:'Kriznik A, Bouillot M, Coulon J, Gaboriaud F. Morphological specificity of yeast and filamentous Candida albicans forms on surface properties. Comptes Rendus Biologies. 2005;328(10-11):928-935\n'},{id:"B29",body:'Nobile CJ, Nett JE, Andes DR, Mitchell AP. Function of Candida albicans adhesin Hwp1 in biofilm formation. Eukaryotic Cell. 2006;5(10):1604-1610\n'},{id:"B30",body:'Nobile CJ, Schneider HA, Nett JE, Sheppard DC, Filler SG, Andes DR, et al. Complementary adhesin function in C. albicans biofilm formation. Current Biology. 2008;18(14):1017-1024\n'},{id:"B31",body:'Bailey DA, Feldmann PJ, Bovey M, Gow NA, Brown AJ. The Candida albicans HYR1 gene, which is activated in response to hyphal development, belongs to a gene family encoding yeast cell wall proteins. Journal of Bacteriology. 1996;178(18):5353-5360\n'},{id:"B32",body:'Ohkuni K, Hayashi M, Yamashita I. Bicarbonate-mediated social communication stimulates meiosis and sporulation of Saccharomyces cerevisiae. Yeast. 1998;14(7):623-631\n'},{id:"B33",body:'Argimón S, Wishart JA, Leng R, Macaskill S, Mavor A, Alexandris T, et al. Developmental regulation of an adhesin gene during cellular morphogenesis in the fungal pathogen Candida albicans. Eukaryotic Cell. 2007;6(4):682-692\n'},{id:"B34",body:'Li F, Palecek SP. EAP1, a Candida albicans gene involved in binding human epithelial cells. Eukaryotic Cell. 2003;2(6):1266-1273\n'},{id:"B35",body:'Li F, Svarovsky MJ, Karlsson AJ, Wagner JP, Marchillo K, Oshel P, et al. Eap1p, an adhesin that mediates Candida albicans biofilm formation in vitro and in vivo. Eukaryotic Cell. 2007;6(6):931-939\n'},{id:"B36",body:'Monniot C, Boisramé A, Da Costa G, Chauvel M, Sautour M, Bougnoux M-E, et al. Rbt1 Protein domains analysis in Candida albicans brings insights into hyphal surface modifications and Rbt1 potential role during adhesion and biofilm Formation. Arkowitz RA, editor. PLoS One. 2013;8(12):e82395\n'},{id:"B37",body:'Lipke PN, Klotz SA, Dufrene YF, Jackson DN, Garcia-Sherman MC. Amyloid-like β-aggregates as force-sensitive switches in fungal biofilms and infections. Microbiology and Molecular Biology Reviews. 2018;82(1):e00035-17\n'},{id:"B38",body:'Baillie GS, Douglas LJ. Role of dimorphism in the development of Candida albicans biofilms. Journal of Medical Microbiology. 1999;48(7):671-679\n'},{id:"B39",body:'Nailis H, Kucharíková S, Ricicová M, Van Dijck P, Deforce D, Nelis H, et al. Real-time PCR expression profiling of genes encoding potential virulence factors in Candida albicans biofilms: identification of model-dependent and -independent gene expression. BMC Microbiology. 2010;10:114\n'},{id:"B40",body:'Joo MY, Shin JH, Jang H-C, Song ES, Kee SJ, Shin MG, et al. Expression of SAP5 and SAP9 in Candida albicans biofilms: comparison of bloodstream isolates with isolates from other sources. Medical Mycology. 2013;51(8):892-896\n'},{id:"B41",body:'Kumar R, Saraswat D, Tati S, Edgerton M. Novel aggregation properties of Candida albicans secreted aspartyl proteinase sap6 mediate virulence in oral Candidiasis. Infection and Immunity. 2015;83(7):2614-2626\n'},{id:"B42",body:'Winter MB, Salcedo EC, Lohse MB, Hartooni N, Gulati M, Sanchez H, et al. Global Identification of biofilm-specific proteolysis in Candida albicans. MBio. 2016;7(5):e01514-16\n'},{id:"B43",body:'Zarnowski R, Westler WM, Lacmbouh GA, Marita JM, Bothe JR, Bernhardt J, et al. Novel entries in a fungal biofilm matrix encyclopedia. MBio. 2014;5(4):5\n'},{id:"B44",body:'Dominguez E, Zarnowski R, Sanchez H, Covelli AS, Westler WM, Azadi P, et al. Conservation and divergence in the Candida species biofilm matrix mannan-glucan complex structure, function, and genetic control. MBio. 2018;9(2):e00451-18\n'},{id:"B45",body:'Al-Fattani MA. Biofilm matrix of Candida albicans and Candida tropicalis: Chemical composition and role in drug resistance. Journal of Medical Microbiology. 2006;55(8):999-1008\n'},{id:"B46",body:'Taff HT, Nett JE, Zarnowski R, Ross KM, Sanchez H, Cain MT, et al. A Candida biofilm-induced pathway for matrix glucan delivery: Implications for drug resistance. Doering TL, editor. PLoS Pathogens. 2012;8(8):e1002848\n'},{id:"B47",body:'Peltroche-Llacsahuanga H, Goyard S, D’Enfert C, Prill SK-H, Ernst JF. Protein o-mannosyltransferase isoforms regulate biofilm formation in Candida albicans. Antimicrobial Agents and Chemotherapy. 2006;50(10):3488-3491\n'},{id:"B48",body:'Martins M, Uppuluri P, Thomas DP, Cleary IA, Henriques M, Lopez-Ribot JL, et al. Presence of extracellular DNA in the Candida albicans biofilm matrix and its contribution to biofilms. Mycopathologia. 2010;169(5):323-331\n'},{id:"B49",body:'Robbins N, Uppuluri P, Nett J, Rajendran R, Ramage G, Lopez-Ribot JL, et al. Hsp90 governs dispersion and drug resistance of fungal biofilms. May RC, editor. PLoS Pathogens. 2011;7(9):e1002257\n'},{id:"B50",body:'Shapiro RS, Uppuluri P, Zaas AK, Collins C, Senn H, Perfect JR, et al. Hsp90 orchestrates temperature-dependent Candida albicans morphogenesis via Ras1-PKA signaling. Current Biology. 2009;19(8):621-629\n'},{id:"B51",body:'Nobile CJ, Fox EP, Hartooni N, Mitchell KF, Hnisz D, Andes DR, et al. A histone deacetylase complex mediates biofilm dispersal and drug resistance in Candida albicans. MBio. 2014;5(3):e01201-14\n'},{id:"B52",body:'Takahashi N. Microbial ecosystem in the oral cavity: Metabolic diversity in an ecological niche and its relationship with oral diseases. International Congress Series. 2005;1284:103-112\n'},{id:"B53",body:'Kawamura Y, Hou XG, Sultana F, Miura H, Ezaki T. Determination of 16S rRNA sequences of Streptococcus mitis and Streptococcus gordonii and phylogenetic relationships among members of the genus Streptococcus. International Journal of Systematic Bacteriology. 1995;45(2):406-408\n'},{id:"B54",body:'Diaz PI, Dupuy AK, Abusleme L, Reese B, Obergfell C, Choquette L, et al. Using high throughput sequencing to explore the biodiversity in oral bacterial communities. Molecular Oral Microbiology. 2012;27(3):182-201\n'},{id:"B55",body:'Holmes AR, van der Wielen P, Cannon RD, Ruske D, Dawes P. Candida albicans binds to saliva proteins selectively adsorbed to silicone. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics. 2006;102(4):488-494\n'},{id:"B56",body:'Xu H, Sobue T, Thompson A, Xie Z, Poon K, Ricker A, et al. Streptococcal co-infection augments Candida pathogenicity by amplifying the mucosal inflammatory response. Cellular Microbiology. 2014;16(2):214-231\n'},{id:"B57",body:'Dutton LC, Nobbs AH, Jepson K, Jepson MA, Vickerman MM, Aqeel Alawfi S, et al. O-mannosylation in Candida albicans enables development of interkingdom biofilm communities. MBio. 2014;5(2):e00911\n'},{id:"B58",body:'Jenkinson HF, Lala HC, Shepherd MG. Coaggregation of Streptococcus sanguis and other streptococci with Candida albicans. Infection and Immunity. 1990;58(5):1429-1436\n'},{id:"B59",body:'Holmes ARR, McNab R, Jenkinson HFF. Candida albicans binding to the oral bacterium Streptococcus gordonii involves multiple adhesin-receptor interactions. Infection and Immunity. 1996;64(11):4680-4685\n'},{id:"B60",body:'Bamford CV, Nobbs AH, Barbour ME, Lamont RJ, Jenkinson HF. Functional regions of Candida albicans hyphal cell wall protein Als3 that determine interaction with the oral bacterium Streptococcus gordonii. Microbiology. 2015;161(Pt 1):18-29\n'},{id:"B61",body:'Hoyer LL, Oh S-H, Jones R, Cota E. A proposed mechanism for the interaction between the Candida albicans Als3 adhesin and streptococcal cell wall proteins. Frontiers in Microbiology. 2014;5:564\n'},{id:"B62",body:'Gregoire S, Xiao J, Silva BB, Gonzalez I, Agidi PS, Klein MI, et al. Role of glucosyltransferase B in interactions of Candida albicans with Streptococcus mutans and with an experimental pellicle on hydroxyapatite surfaces. Applied and Environmental Microbiology. 2011;77(18):6357-6367\n'},{id:"B63",body:'Falsetta ML, Klein MI, Colonne PM, Scott-Anne K, Gregoire S, Pai C-H, et al. Symbiotic relationship between Streptococcus mutans and Candida albicans synergizes virulence of plaque biofilms in vivo. Infection and Immunity. 2014;82(5):1968-1981\n'},{id:"B64",body:'Merghni A, Ben Nejma M, Hentati H, Mahjoub A, Mastouri M. Adhesive properties and extracellular enzymatic activity of Staphylococcus aureus strains isolated from oral cavity. Microbial Pathogenesis. 2014;73:7-12\n'},{id:"B65",body:'Koukos G, Sakellari D, Arsenakis M, Tsalikis L, Slini T, Konstantinidis A. Prevalence of Staphylococcus aureus and methicillin resistant Staphylococcus aureus (MRSA) in the oral cavity. Archives of Oral Biology. 2015;60(9):1410-1415\n'},{id:"B66",body:'Schlecht LM, Peters BM, Krom BP, Freiberg JA, Hänsch GM, Filler SG, et al. Systemic Staphylococcus aureus infection mediated by Candida albicans hyphal invasion of mucosal tissue. Microbiology. 2015;161(Pt 1):168-181\n'},{id:"B67",body:'Mathews J, Patel M. Bacterial endotoxins and microorganisms in the oral cavities of patients on cancer therapy. Microbial Pathogenesis. 2018;123(July):190-195\n'},{id:"B68",body:'Peters BM, Jabra-Rizk MA, Scheper MA, Leid JG, Costerton JW, Shirtliff ME. Microbial interactions and differential protein expression in Staphylococcus aureus-Candida albicans dual-species biofilms. FEMS Immunology and Medical Microbiology. 2010;59(3):493-503\n'},{id:"B69",body:'Lin YJ, Alsad L, Vogel F, Koppar S, Nevarez L, Auguste F, et al. Interactions between Candida albicans and Staphylococcus aureus within mixed species biofilms. Bios. 2013;84(1):30-39\n'},{id:"B70",body:'Harriott MM, Noverr MC. Ability of Candida albicans mutants to induce Staphylococcus aureus vancomycin resistance during polymicrobial biofilm formation. Antimicrobial Agents and Chemotherapy. 2010;54(9):3746-3755\n'},{id:"B71",body:'Pammi M, Liang R, Hicks JM, Barrish J, Versalovic J. Farnesol decreases biofilms of staphylococcus epidermidis and exhibits synergy with nafcillin and vancomycin. Pediatric Research. 2011;70(6):578-583\n'},{id:"B72",body:'Rajendran R, Sherry L, Lappin DF, Nile CJ, Smith K, Williams C, et al. Extracellular DNA release confers heterogeneity in Candida albicans biofilm formation. BMC Microbiology. 2014;14:303\n'},{id:"B73",body:'Sapaar B, Nur A, Hirota K, Yumoto H, Murakami K, Amoh T, et al. Effects of extracellular DNA from Candida albicans and pneumonia-related pathogens on Candida biofilm formation and hyphal transformation. Journal of Applied Microbiology. 2014;116(6):1531-1542\n'},{id:"B74",body:'Jabra-Rizk MA, Falkler WA, Merz WG, Kelley JI, Baqui AAMA, Meiller TF. Coaggregation of Candida dubliniensis with Fusobacterium nucleatum. Journal of Clinical Microbiology. 1999;37(5):1464-1468\n'},{id:"B75",body:'Thein ZM, Samaranayake YH, Samaranayake LP. Effect of oral bacteria on growth and survival of Candida albicans biofilms. Archives of Oral Biology. 2006;51(8):672-680\n'},{id:"B76",body:'Nair RG, Anil S, Samaranayake LP. The effect of oral bacteria on Candida albicans germ-tube formation. APMIS. 2001;109(2):147-154\n'},{id:"B77",body:'Sztukowska MN, Dutton LC, Delaney C, Ramsdale M, Ramage G, Jenkinson HF, et al. Community development between Porphyromonas gingivalis and Candida albicans mediated by InlJ and Als3. MBio. 2018;9(2):e00202-18\n'},{id:"B78",body:'Goulas T, Mizgalska D, Garcia-Ferrer I, Kantyka T, Guevara T, Szmigielski B, et al. Structure and mechanism of a bacterial host-protein citrullinating virulence factor, Porphyromonas gingivalis peptidylarginine deiminase. Scientific Reports. 2015;5(1):11969\n'},{id:"B79",body:'Stobernack T, Glasner C, Junker S, Gabarrini G, De Smit M, De Jong A, et al. Extracellular proteome and citrullinome of the oral pathogen Porphyromonas gingivalis. Journal of Proteome Research. 2016;15(12):4532-4543\n'},{id:"B80",body:'Nair RG, Samaranayake LP. The effect of oral commensal bacteria on candidal adhesion to human buccal epithelial cells in vitro. Journal of Medical Microbiology. 1996;45(3):179-185\n'},{id:"B81",body:'Tamai R, Sugamata M, Kiyoura Y. Candida albicans enhances invasion of human gingival epithelial cells and gingival fibroblasts by Porphyromonas gingivalis. Microbial Pathogenesis. 2011;51(4):250-254\n'},{id:"B82",body:'Nett JE. The host’s reply to Candida biofilm. Pathogens. 2016;5(1):33\n'},{id:"B83",body:'Dongari-Bagtzoglou A, Kashleva H, Dwivedi P, Diaz P, Vasilakos J. Characterization of mucosal Candida albicans biofilms. PLoS One. 2009;4(11):e7967\n'},{id:"B84",body:'Nett JE, Zarnowski R, Cabezas-Olcoz J, Brooks EG, Bernhardt J, Marchillo K, et al. Host contributions to construction of three device-associated Candida albicans biofilms. Infection and Immunity. 2015;83(12):4630-4638\n'},{id:"B85",body:'Nett JE, Marchillo K, Spiegel CA, Andes DR. Development and validation of an in vivo Candida albicans biofilm denture model. Infection and Immunity. 2010;78(9):3650-3659\n'},{id:"B86",body:'Katragkou A, Kruhlak MJ, Simitsopoulou M, Chatzimoschou A, Taparkou A, Cotten CJ, et al. Interactions between human phagocytes and Candida albicans biofilms alone and in combination with antifungal agents. The Journal of Infectious Diseases. 2010;201(12):1941-1949\n'},{id:"B87",body:'Urban CF, Ermert D, Schmid M, Abu-Abed U, Goosmann C, Nacken W, et al. Neutrophil extracellular traps contain calprotectin, a cytosolic protein complex involved in host defense against Candida albicans. PLoS Pathogens. 2009;5(10):e1000639\n'},{id:"B88",body:'Kernien JF, Snarr BD, Sheppard DC, Nett JE. The interface between fungal biofilms and innate immunity. Frontiers in Immunology. 2017;8:1968\n'},{id:"B89",body:'Johnson CJ, Cabezas-Olcoz J, Kernien JF, Wang SX, Beebe DJ, Huttenlocher A, et al. The extracellular matrix of Candida albicans biofilms impairs formation of neutrophil extracellular traps. PLoS Pathogens. 2016;12(9):e1005884\n'},{id:"B90",body:'Garcia-Perez JE, Mathé L, Humblet-Baron S, Braem A, Lagrou K, Van Dijck P, et al. A framework for understanding the evasion of host immunity by Candida biofilms. Frontiers in Immunology. 2018;9:538\n'},{id:"B91",body:'Williams DW, Jordan RPC, Wei X-Q, Alves CT, Wise MP, Wilson MJ, et al. Interactions of Candida albicans with host epithelial surfaces. Journal of Oral Microbiology. 2013;5\n'},{id:"B92",body:'Höfs S, Mogavero S, Hube B. Interaction of Candida albicans with host cells: Virulence factors, host defense, escape strategies, and the microbiota. Journal of Microbiology. 2016;54(3):149-169\n'},{id:"B93",body:'Netea MG, Joosten LA, van der Meer JW, Kullberg BJ, van de Veerdonk FL. Immune defence against Candida fungal infections. Nature Reviews. Immunology. 2015;15(10):630-642\n'},{id:"B94",body:'Chaudhry A, Samstein RM, Treuting P, Liang Y, Pils MC, Heinrich J-M, et al. Interleukin-10 signaling in regulatory T cells is required for suppression of Th17 cell-mediated inflammation. Immunity. 2011;34(4):566-578\n'},{id:"B95",body:'Mitchell KF, Zarnowski R, Sanchez H, Edward JA, Reinicke EL, Nett JE, et al. Community participation in biofilm matrix assembly and function. Proceedings of the National Academy of Sciences of the United States of America. 2015;112(13):4092-4097\n'},{id:"B96",body:'Mathews J, Patel M. Bacterial endotoxins and microorganisms in the oral cavities of patients on cancer therapy. Davis D, editor. Microbial Pathogenesis. 2018;123(1):190-195\n'},{id:"B97",body:'Katragkou A, Simitsopoulou M, Chatzimoschou A, Georgiadou E, Walsh TJ, Roilides E. Effects of interferon-γ and granulocyte colony-stimulating factor on antifungal activity of human polymorphonuclear neutrophils against Candida albicans grown as biofilms or planktonic cells. Cytokine. 2011;55(3):330-334\n'},{id:"B98",body:'Xie Z, Thompson A, Sobue T, Kashleva H, Xu H, Vasilakos J, et al. Candida albicans biofilms do not trigger reactive oxygen species and evade neutrophil killing. The Journal of Infectious Diseases. 2012;206(12):1936-1945\n'},{id:"B99",body:'Zawrotniak M, Bochenska O, Karkowska-Kuleta J, Seweryn-Ozog K, Aoki W, Ueda M, et al. Aspartic proteases and major cell wall components in Candida albicans trigger the release of neutrophil extracellular traps. Frontiers in Cellular and Infection Microbiology. 2017;7(September):1-21\n'},{id:"B100",body:'Chandra J, McCormick TS, Imamura Y, Mukherjee PK, Ghannoum MA. Interaction of Candida albicans with adherent human peripheral blood mononuclear cells increases C. albicans biofilm formation and results in differential expression of pro- and anti-inflammatory cytokines. Infection and Immunity. 2007;75(5):2612-2620\n'},{id:"B101",body:'Wheeler RT, Fink GR. A drug-sensitive genetic network masks fungi from the immune system. PLoS Pathogens. 2006;2(4):e35\n'},{id:"B102",body:'Kean R, McKloud E, Townsend EM, Sherry L, Delaney C, Jones BL, et al. The comparative efficacy of antiseptics against Candida auris biofilms. International Journal of Antimicrobial Agents. 2018;S0924-8579(18):30138-9. In Press\n'},{id:"B103",body:'Nobile CJ, Johnson AD. Candida albicans biofilms and human disease. Annual Review of Microbiology. 2015;69:71-92\n'},{id:"B104",body:'Peleg AY, Hogan DA, Mylonakis E. Medically important bacterial–fungal interactions. Nature Reviews. Microbiology. 2010;8(5):340-349\n'},{id:"B105",body:'Roux D, Gaudry S, Dreyfuss D, El-Benna J, de Prost N, Denamur E, et al. Candida albicans impairs macrophage function and facilitates Pseudomonas aeruginosa pneumonia in rat. Critical Care Medicine. 2009;37(3):1062-1067\n'},{id:"B106",body:'Lopez-Medina E, Fan D, Coughlin LA, Ho EX, Lamont IL, Reimmann C, et al. Candida albicans inhibits Pseudomonas aeruginosa virulence through suppression of pyochelin and pyoverdine Biosynthesis. Hogan DA, editor. PLoS Pathogens. 2015;11(8):e1005129\n'},{id:"B107",body:'Wongsuk T, Pumeesat P, Luplertlop N. Fungal quorum sensing molecules: Role in fungal morphogenesis and pathogenicity. Journal of Basic Microbiology. 2016;56(5):440-447\n'},{id:"B108",body:'Williams P. Quorum sensing, communication and cross-kingdom signalling in the bacterial world. Microbiology. 2007;153(12):3923-3938\n'},{id:"B109",body:'Hazen KC, Cutler JE. Autoregulation of germ tube formation by Candida albicans. Infection and Immunity. 1979;24(3):661-666\n'},{id:"B110",body:'Hornby JM, Jensen EC, Lisec AD, Tasto JJ, Jahnke B, Shoemaker R, et al. Quorum sensing in the dimorphic fungus Candida albicans is mediated by farnesol. Applied and Environmental Microbiology. 2001;67(7):2982-2992\n'},{id:"B111",body:'Ramage G, Saville SP, Wickes BL, López-Ribot JL. Inhibition of Candida albicans biofilm formation by farnesol, a quorum-sensing molecule. Applied and Environmental Microbiology. 2002;68(11):5459-5463\n'},{id:"B112",body:'Alem MAS, Oteef MDY, Flowers TH, Douglas LJ. Production of tyrosol by Candida albicans biofilms and its role in quorum sensing and biofilm development. Eukaryotic Cell. 2006;5(10):1770-1779\n'},{id:"B113",body:'Chen H, Fujita M, Feng Q, Clardy J, Fink GR. Tyrosol is a quorum-sensing molecule in Candida albicans. Proceedings of the National Academy of Sciences. 2004;101(14):5048-5052\n'},{id:"B114",body:'Förster TM, Mogavero S, Dräger A, Graf K, Polke M, Jacobsen ID, et al. Enemies and brothers in arms: Candida albicans and gram-positive bacteria. Cellular Microbiology. 2016;18(12):1709-1715\n'},{id:"B115",body:'Cugini C, Calfee MW, Farrow JM, Morales DK, Pesci EC, Hogan DA. Farnesol, a common sesquiterpene, inhibits PQS production in Pseudomonas aeruginosa. Molecular Microbiology. 2007;65(4):896-906\n'},{id:"B116",body:'Hogan DA, Vik A, Kolter R. A Pseudomonas aeruginosa quorum-sensing molecule influences Candida albicans morphology. Molecular Microbiology. 2004;54(5):1212-1223\n'},{id:"B117",body:'Fernandes RA, Monteiro DR, Arias LS, Fernandes GL, Delbem ACB, Barbosa DB. Biofilm formation by Candida albicans and Streptococcus mutans in the presence of farnesol: A quantitative evaluation. Biofouling. 2016;32(3):329-338\n'},{id:"B118",body:'Koo H. Inhibition of Streptococcus mutans biofilm accumulation and polysaccharide production by apigenin and tt-farnesol. The Journal of Antimicrobial Chemotherapy. 2003;52(5):782-789\n'},{id:"B119",body:'Kim D, Sengupta A, Niepa THR, Lee B-H, Weljie A, Freitas-Blanco VS, et al. Candida albicans stimulates Streptococcus mutans microcolony development via cross-kingdom biofilm-derived metabolites. Scientific Reports. 2017;7(1):41332\n'},{id:"B120",body:'Jarosz LM, Deng DM, van der Mei HC, Crielaard W, Krom BP. Streptococcus mutans competence-stimulating peptide inhibits Candida albicans hypha formation. Eukaryotic Cell. 2009;8(11):1658-1664\n'},{id:"B121",body:'Sztajer H, Szafranski SP, Tomasch J, Reck M, Nimtz M, Rohde M, et al. Cross-feeding and interkingdom communication in dual-species biofilms of Streptococcus mutans and Candida albicans. The ISME Journal. 2014;8(11):2256-2271\n'},{id:"B122",body:'Jack AA, Daniels DE, Jepson MA, Vickerman MM, Lamont RJ, Jenkinson HF, et al. Streptococcus gordonii comCDE (competence) operon modulates biofilm formation with Candida albicans. Microbiology. 2015;161(Pt 2):411-421\n'},{id:"B123",body:'Bachtiar EW, Bachtiar BM, Jarosz LM, Amir LR, Sunarto H, Ganin H, et al. AI-2 of Aggregatibacter actinomycetemcomitans inhibits Candida albicans biofilm formation. Frontiers in Cellular and Infection Microbiology. 2014;4:94\n'},{id:"B124",body:'Akiyama H, Oono T, Huh W-K, Yamasaki O, Ogawa S, Katsuyama M, et al. Actions of farnesol and xylitol against Staphylococcus aureus. Chemotherapy. 2002;48(3):122-128\n'},{id:"B125",body:'Unnanuntana A, Bonsignore L, Shirtliff ME, Greenfield EM. The effects of farnesol on Staphylococcus aureus biofilms and osteoblasts. An in vitro study. The Journal of Bone and Joint Surgery. American Volume. 2009;91(11):2683-2692\n'},{id:"B126",body:'Kong EF, Tsui C, Kucharíková S, Van Dijck P, Jabra-Rizk MA. Modulation of Staphylococcus aureus response to antimicrobials by the Candida albicans quorum sensing molecule farnesol. Antimicrobial Agents and Chemotherapy. 2017;61(12):e01573-17\n'},{id:"B127",body:'Décanis N, Savignac K, Rouabhia M. Farnesol promotes epithelial cell defense against Candida albicans through Toll-like receptor 2 expression, interleukin-6 and human β-defensin 2 production. Cytokine. 2009;45(2):132-140\n'},{id:"B128",body:'Leonhardt I, Spielberg S, Weber M, Albrecht-Eckardt D, Bläss M, Claus R, et al. The fungal quorum-sensing molecule farnesol activates innate immune cells but suppresses cellular adaptive immunity. MBio. 2015;6(2):e00143-15\n'},{id:"B129",body:'Gilbert P, Das J, Foley I. Biofilm susceptibility to antimicrobials. Advances in Dental Research. 1997;11(1):160-167\n'},{id:"B130",body:'Burmølle M, Webb JS, Rao D, Hansen LH, Sørensen SJ, Kjelleberg S. Enhanced biofilm formation and increased resistance to antimicrobial agents and bacterial invasion are caused by synergistic interactions in multispecies biofilms. Applied and Environmental Microbiology. 2006;72(6):3916-3923\n'},{id:"B131",body:'Roberts AP, Kreth J. The impact of horizontal gene transfer on the adaptive ability of the human oral microbiome. Frontiers in Cellular and Infection Microbiology. 2014;4(September):1-9\n'},{id:"B132",body:'Gulati M, Nobile CJ. Candida albicans biofilms: development, regulation, and molecular mechanisms. Microbes and Infection. 2016;18(5):310-321\n'},{id:"B133",body:'Stewart PS. Mechanisms of antibiotic resistance in bacterial biofilms. International Journal of Medical Microbiology. 2002;292(2):107-113\n'},{id:"B134",body:'Vediyappan G, Rossignol T, D’Enfert C. Interaction of Candida albicans biofilms with antifungals: Transcriptional response and binding of antifungals to beta-glucans. Antimicrobial Agents and Chemotherapy. 2010;54(5):2096-2111\n'},{id:"B135",body:'Mulcahy H, Charron-Mazenod L, Lewenza S. Extracellular DNA chelates cations and induces antibiotic resistance in Pseudomonas aeruginosa biofilms. PLoS Pathogens. 2008;4(11):e1000213\n'},{id:"B136",body:'Connell SR, Tracz DM, Nierhaus KH, Taylor DE. Ribosomal protection proteins and their mechanism of tetracycline resistance. Antimicrobial Agents and Chemotherapy. 2003;47(12):3675-3681\n'},{id:"B137",body:'Domingues S, Nielsen KM. Membrane vesicles and horizontal gene transfer in prokaryotes. Current Opinion in Microbiology. 2017;38:16-21\n'},{id:"B138",body:'Ciofu O, Beveridge TJ, Kadurugamuwa J, Walther-Rasmussen J, Høiby N. Chromosomal beta-lactamase is packaged into membrane vesicles and secreted from Pseudomonas aeruginosa. The Journal of Antimicrobial Chemotherapy. 2000;45(1):9-13\n'},{id:"B139",body:'Singh S, Singh SK, Chowdhury I, Singh R. Understanding the mechanism of bacterial biofilms resistance to antimicrobial agents. The Open Microbiology Journal. 2017;11(1):53-62\n'},{id:"B140",body:'Martins M, Henriques M, Lopez-Ribot JL, Oliveira R. Addition of DNase improves the in vitro activity of antifungal drugs against Candida albicans biofilms. Mycoses. 2012;55(1):80-85\n'},{id:"B141",body:'Høiby N, Bjarnsholt T, Givskov M, Molin S, Ciofu O. Antibiotic resistance of bacterial biofilms. International Journal of Antimicrobial Agents. 2010;35(4):322-332\n'},{id:"B142",body:'Wang Z, De La Fuente-Núñez C, Shen Y, Haapasalo M, Hancock REW. Treatment of oral multispecies biofilms by an anti-biofilm peptide. PLoS One. 2015;10(7):1-16\n'},{id:"B143",body:'Zhang T, Wang Z, Hancock REW, De La Fuente-Núñez C, Haapasalo M. Treatment of oral biofilms by a D-enantiomeric peptide. PLoS One. 2016;11(11):1-16\n'},{id:"B144",body:'De La Fuente-Núñez C, Reffuveille F, Mansour SC, Reckseidler-Zenteno SL, Hernández D, Brackman G, et al. D-Enantiomeric Peptides that eradicate wild-type and multidrug-resistant biofilms and protect against lethal Pseudomonas aeruginosa infections. Chemistry & Biology. 2015;22(2):196-205\n'},{id:"B145",body:'Shankar Raut J, Mohan Karuppayil S. Phytochemicals as inhibitors of Candida biofilm. Current Pharmaceutical Design. 2016;22(27):4111-4134\n'},{id:"B146",body:'Basavaraju M, Sisnity VS, Palaparthy R, Addanki PK. Quorum quenching: Signal jamming in dental plaque biofilms. Journal of Dental Sciences. 2016;11(4):349-352\n'},{id:"B147",body:'Lazar V. Quorum sensing in biofilms—How to destroy the bacterial citadels or their cohesion/power? Anaerobe. 2011;17(6):280-285\n'},{id:"B148",body:'Hisajima T, Maruyama N, Tanabe Y, Ishibashi H, Yamada T, Makimura K, et al. Protective effects of farnesol against oral candidiasis in mice. Microbiology and Immunology. 2008;52(7):237-333\n'},{id:"B149",body:'Rosseti IB, Chagas LR, Costa MS. Photodynamic antimicrobial chemotherapy (PACT) inhibits biofilm formation by Candida albicans, increasing both ROS production and membrane permeability. Lasers in Medical Science. 2014;29(3):1059-1064\n'},{id:"B150",body:'Costa ACBP, Campos Rasteiro VM, Da Silva Hashimoto ESH, Araújo CF, Pereira CA, Junqueira JC, et al. Effect of erythrosine- and LED-mediated photodynamic therapy on buccal candidiasis infection of immunosuppressed mice and Candida albicans adherence to buccal epithelial cells. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology. 2012;114(1):67-74\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Maria Rapala-Kozik",address:"maria.rapala-kozik@uj.edu.pl",affiliation:'
Department of Comparative Biochemistry and Bioanalytics, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Poland
Department of Analytical Biochemistry, Faculty of Biochemistry, Biophysics and Biotechnology, Jagiellonian University, Poland
'}],corrections:null},book:{id:"6923",title:"Candida Albicans",subtitle:null,fullTitle:"Candida Albicans",slug:"candida-albicans",publishedDate:"April 24th 2019",bookSignature:"Doblin Sandai",coverURL:"https://cdn.intechopen.com/books/images_new/6923.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"179627",title:"Dr.",name:"Doblin",middleName:null,surname:"Sandai",slug:"doblin-sandai",fullName:"Doblin Sandai"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},chapters:[{id:"63094",title:"Emerging Pathogens of the Candida Species",slug:"emerging-pathogens-of-the-candida-species",totalDownloads:1109,totalCrossrefCites:2,signatures:"Bo Yang and Reeta Rao",authors:[{id:"261208",title:"Associate Prof.",name:"Reeta",middleName:null,surname:"Rao",fullName:"Reeta Rao",slug:"reeta-rao"},{id:"268249",title:"Ms.",name:"Bo",middleName:null,surname:"Yang",fullName:"Bo Yang",slug:"bo-yang"}]},{id:"63650",title:"Antifungal Activity of Brazilian Medicinal Plants against Candida Species",slug:"antifungal-activity-of-brazilian-medicinal-plants-against-candida-species",totalDownloads:934,totalCrossrefCites:1,signatures:"Vagner Rodrigues Santos and Elizete Maria Rita Pereira",authors:[{id:"79610",title:"Dr.",name:"Vagner Rodrigues",middleName:"Rodrigues",surname:"Santos",fullName:"Vagner Rodrigues Santos",slug:"vagner-rodrigues-santos"},{id:"265619",title:"Dr.",name:"Elizete Maria Rita",middleName:null,surname:"Pereira",fullName:"Elizete Maria Rita Pereira",slug:"elizete-maria-rita-pereira"}]},{id:"63088",title:"Carbon Sources Attribute to Pathogenicity in Candida albicans",slug:"carbon-sources-attribute-to-pathogenicity-in-candida-albicans",totalDownloads:487,totalCrossrefCites:0,signatures:"Doblin Sandai, Yasser Tabana and Rosline Sandai",authors:[{id:"179627",title:"Dr.",name:"Doblin",middleName:null,surname:"Sandai",fullName:"Doblin Sandai",slug:"doblin-sandai"},{id:"256555",title:"Mr.",name:"Yasser",middleName:null,surname:"Tabana",fullName:"Yasser Tabana",slug:"yasser-tabana"},{id:"256559",title:"Dr.",name:"Rosline",middleName:null,surname:"Sandai",fullName:"Rosline Sandai",slug:"rosline-sandai"}]},{id:"66105",title:"The Cell Wall of Candida albicans: A Proteomics View",slug:"the-cell-wall-of-candida-albicans-a-proteomics-view",totalDownloads:768,totalCrossrefCites:3,signatures:"Elizabeth Reyna-Beltrán, César Isaac Bazán Méndez, María Iranzo,\nSalvador Mormeneo and Juan Pedro Luna-Arias",authors:[{id:"259166",title:"Ph.D.",name:"Juan Pedro",middleName:null,surname:"Luna-Arias",fullName:"Juan Pedro Luna-Arias",slug:"juan-pedro-luna-arias"},{id:"259168",title:"Dr.",name:"Elizabeth",middleName:null,surname:"Reyna-Beltrán",fullName:"Elizabeth Reyna-Beltrán",slug:"elizabeth-reyna-beltran"},{id:"259169",title:"MSc.",name:"Cesar Isaac",middleName:null,surname:"Bazán-Méndez",fullName:"Cesar Isaac Bazán-Méndez",slug:"cesar-isaac-bazan-mendez"},{id:"259170",title:"Prof.",name:"Salvador",middleName:null,surname:"Mormeneo",fullName:"Salvador Mormeneo",slug:"salvador-mormeneo"},{id:"259172",title:"Dr.",name:"María",middleName:null,surname:"Iranzo",fullName:"María Iranzo",slug:"maria-iranzo"}]},{id:"63492",title:"The Role of Phagocytes in Immunity to Candida albicans",slug:"the-role-of-phagocytes-in-immunity-to-candida-albicans",totalDownloads:737,totalCrossrefCites:0,signatures:"Annabelle G. Small, Jovanka R. King, Deborah A. Rathjen and\nAntonio Ferrante",authors:[{id:"65156",title:"Prof.",name:"Antonio",middleName:null,surname:"Ferrante",fullName:"Antonio Ferrante",slug:"antonio-ferrante"},{id:"270166",title:"Ms.",name:"Annabelle",middleName:null,surname:"Small",fullName:"Annabelle Small",slug:"annabelle-small"},{id:"270167",title:"Dr.",name:"Jovanka",middleName:null,surname:"King",fullName:"Jovanka King",slug:"jovanka-king"},{id:"270168",title:"Dr.",name:"Deborah",middleName:null,surname:"Rathjen",fullName:"Deborah Rathjen",slug:"deborah-rathjen"}]},{id:"64013",title:"Interactions of Candida albicans Cells with Aerobic and Anaerobic Bacteria during Formation of Mixed Biofilms in the Oral Cavity",slug:"interactions-of-candida-albicans-cells-with-aerobic-and-anaerobic-bacteria-during-formation-of-mixed",totalDownloads:612,totalCrossrefCites:0,signatures:"Maria Rapala-Kozik, Marcin Zawrotniak, Mariusz Gogol, Dominika\nBartnicka, Dorota Satala, Magdalena Smolarz, Justyna Karkowska-\nKuleta and Andrzej Kozik",authors:[{id:"198701",title:"Associate Prof.",name:"Maria",middleName:null,surname:"Rapala-Kozik",fullName:"Maria Rapala-Kozik",slug:"maria-rapala-kozik"},{id:"200045",title:"Prof.",name:"Andrzej",middleName:null,surname:"Kozik",fullName:"Andrzej Kozik",slug:"andrzej-kozik"},{id:"274639",title:"Dr.",name:"Marcin",middleName:null,surname:"Zawrotniak",fullName:"Marcin Zawrotniak",slug:"marcin-zawrotniak"},{id:"274640",title:"MSc.",name:"Dominika",middleName:null,surname:"Bartnicka",fullName:"Dominika Bartnicka",slug:"dominika-bartnicka"},{id:"274641",title:"Dr.",name:"Mariusz",middleName:null,surname:"Gogol",fullName:"Mariusz Gogol",slug:"mariusz-gogol"},{id:"274642",title:"MSc.",name:"Dorota",middleName:null,surname:"Satala",fullName:"Dorota Satala",slug:"dorota-satala"},{id:"274643",title:"MSc.",name:"Magdalena",middleName:null,surname:"Smolarz",fullName:"Magdalena Smolarz",slug:"magdalena-smolarz"},{id:"274644",title:"Dr.",name:"Justyna",middleName:null,surname:"Karkowska-Kuleta",fullName:"Justyna Karkowska-Kuleta",slug:"justyna-karkowska-kuleta"}]},{id:"63926",title:"Nanoparticles as New Therapeutic Agents against Candida albicans",slug:"nanoparticles-as-new-therapeutic-agents-against-candida-albicans",totalDownloads:1047,totalCrossrefCites:3,signatures:"Hilda Amelia Piñón Castillo, Laila Nayzzel Muñoz Castellanos,\nRigoberto Martínez Chamorro, Reyna Reyes Martínez and Erasmo\nOrrantia Borunda",authors:[{id:"34191",title:"Prof.",name:"Erasmo",middleName:null,surname:"Orrantia-Borunda",fullName:"Erasmo Orrantia-Borunda",slug:"erasmo-orrantia-borunda"},{id:"207108",title:"Dr.",name:"Hilda Amelia",middleName:null,surname:"Piñon-Castillo",fullName:"Hilda Amelia Piñon-Castillo",slug:"hilda-amelia-pinon-castillo"},{id:"257111",title:"Dr.",name:"Laila Nayzzel",middleName:null,surname:"Muñoz Castellanos",fullName:"Laila Nayzzel Muñoz Castellanos",slug:"laila-nayzzel-munoz-castellanos"},{id:"266658",title:"BSc.",name:"Rigoberto",middleName:null,surname:"Martínez Chamorro",fullName:"Rigoberto Martínez Chamorro",slug:"rigoberto-martinez-chamorro"},{id:"266659",title:"Dr.",name:"Reyna",middleName:null,surname:"Reyes Martínez",fullName:"Reyna Reyes Martínez",slug:"reyna-reyes-martinez"}]}]},relatedBooks:[{type:"book",id:"22",title:"Fungicides",subtitle:null,isOpenForSubmission:!1,hash:null,slug:"fungicides",bookSignature:"Odile Carisse",coverURL:"https://cdn.intechopen.com/books/images_new/22.jpg",editedByType:"Edited by",editors:[{id:"14447",title:"Dr.",name:"Odile",surname:"Carisse",slug:"odile-carisse",fullName:"Odile Carisse"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"},chapters:[{id:"12379",title:"Curative and Eradicative Effects of Fungicides",slug:"curative-and-eradicative-effects-of-fungicides",signatures:"Dario Ivic",authors:[{id:"15835",title:"Dr.",name:"Dario",middleName:null,surname:"Ivic",fullName:"Dario Ivic",slug:"dario-ivic"}]},{id:"12380",title:"Factors Affecting Fungicide Efficacy in the Tropics",slug:"factors-affecting-fungicide-efficacy-in-the-tropics",signatures:"Ricardo Balardin",authors:[{id:"15252",title:"Dr.",name:"Ricardo",middleName:null,surname:"Balardin",fullName:"Ricardo Balardin",slug:"ricardo-balardin"}]},{id:"12381",title:"Fungicides and Biological Products Activities towards Fungi Causing Diseases on Banana and Vegetable in Cote d'Ivoire",slug:"activity-of-fungicides-and-biological-products-on-fungi-causing-diseases-on-banana-and-vegetable-in-",signatures:"Daouda Koné, Camara Brahima, Badou Jean Odjochounou, Doumbouya Mohamed, Soro Sibirina, Carine Aya N'Guessan and Bomisso Edson Lezin",authors:[{id:"13545",title:"Dr.",name:"Daouda",middleName:null,surname:"Koné",fullName:"Daouda Koné",slug:"daouda-kone"},{id:"16414",title:"Prof.",name:"Doumbouya",middleName:null,surname:"Mohamed",fullName:"Doumbouya Mohamed",slug:"doumbouya-mohamed"},{id:"23885",title:"Mrs",name:"Carine Aya",middleName:null,surname:"N'Guessan",fullName:"Carine Aya N'Guessan",slug:"carine-aya-n'guessan"},{id:"23909",title:"Prof.",name:"Badou Jean",middleName:null,surname:"Odjochounou",fullName:"Badou Jean Odjochounou",slug:"badou-jean-odjochounou"}]},{id:"12382",title:"A Multi-Aspect Comparative Investigation on the Use of Strobilurin and Triazole-based Fungicides for Winter Wheat Disease Control",slug:"a-multi-aspect-comparative-investigation-on-the-use-of-strobilurin-and-triazole-based-fungicides-for",signatures:"Irena Gaurilčikienė, Bronislava Butkutė, Audronė Mankevičienė and Vanda Paplauskienė",authors:[{id:"14064",title:"Dr.",name:"Irena",middleName:null,surname:"Gaurilčikienė",fullName:"Irena Gaurilčikienė",slug:"irena-gaurilcikiene"},{id:"15846",title:"Dr.",name:"Bronislava",middleName:null,surname:"Butkutė",fullName:"Bronislava Butkutė",slug:"bronislava-butkute"},{id:"15847",title:"Dr.",name:"Audronė",middleName:null,surname:"Mankevičienė",fullName:"Audronė Mankevičienė",slug:"audrone-mankeviciene"},{id:"15848",title:"Dr.",name:"Vanda",middleName:null,surname:"Paplauskienė",fullName:"Vanda Paplauskienė",slug:"vanda-paplauskiene"}]},{id:"12383",title:"Fungicides for Wood Protection - World Viewpoint and Evaluation/Testing in Slovakia",slug:"fungicides-for-wood-protection-world-viewpoint-and-evaluation-testing-in-slovakia",signatures:"Ladislav Reinprecht",authors:[{id:"14159",title:"Dr.",name:"Ladislav",middleName:null,surname:"Reinprecht",fullName:"Ladislav Reinprecht",slug:"ladislav-reinprecht"}]},{id:"12384",title:"Challenges of Fungicide Control on Wheat Rusts in Kenya",slug:"challenges-of-fungicide-control-on-wheat-rusts-in-kenya",signatures:"Ruth Wanyera, Joseph Kinyoro Macharia and Samuel Kilonzo",authors:[{id:"15636",title:"Ms.",name:"Ruth",middleName:"Otinga",surname:"Wanyera",fullName:"Ruth Wanyera",slug:"ruth-wanyera"},{id:"16421",title:"Prof.",name:"Joseph",middleName:null,surname:"Kinyoro Macharia",fullName:"Joseph Kinyoro Macharia",slug:"joseph-kinyoro-macharia"},{id:"16497",title:"Prof.",name:"Samuel",middleName:null,surname:"Kilonzo",fullName:"Samuel Kilonzo",slug:"samuel-kilonzo"}]},{id:"12385",title:"Fungicides Application against Fusarium Head Blight in Wheat and Barley for Ensuring Food Safety",slug:"fungicides-application-against-fusarium-head-blight-in-wheat-and-barley-for-ensuring-food-safety",signatures:"Takashi Nakajima",authors:[{id:"15574",title:"Dr.",name:"Takashi",middleName:null,surname:"Nakajima",fullName:"Takashi Nakajima",slug:"takashi-nakajima"}]},{id:"12386",title:"Advances of Fungicide Application for Winter Oilseed Rape",slug:"advances-of-fungicide-application-for-winter-oilseed-rape-",signatures:"Zinta Gaile, Oskars Balodis and Biruta Bankina",authors:[{id:"14288",title:"Dr.",name:"Biruta",middleName:null,surname:"Bankina",fullName:"Biruta Bankina",slug:"biruta-bankina"},{id:"14289",title:"Prof.",name:"Zinta",middleName:null,surname:"Gaile",fullName:"Zinta Gaile",slug:"zinta-gaile"},{id:"14290",title:"Msc.",name:"Oskars",middleName:null,surname:"Balodis",fullName:"Oskars Balodis",slug:"oskars-balodis"}]},{id:"12387",title:"Disease Decision Support Systems: Their Impact on Disease Management and Durability of Fungicide Effectiveness",slug:"disease-decision-support-systems-their-impact-on-disease-management-and-durability-of-fungicide-effe",signatures:"Odile, Carisse, David-Mathieu, Tremblay, Tristan, Jobin, and Anne Sophie, Walker",authors:[{id:"14447",title:"Dr.",name:"Odile",middleName:null,surname:"Carisse",fullName:"Odile Carisse",slug:"odile-carisse"}]},{id:"12388",title:"The QoI Fungicides, the Rise and Fall of a Successful Class of Agricultural Fungicides",slug:"the-qoi-fungicides-the-rise-and-fall-of-a-successful-class-of-agricultural-fungicides",signatures:"Dolores Fernández-ortuño, Juan A. Torés, Antonio De Vicente and Alejandro Pérez-garcía",authors:[{id:"14104",title:"Dr.",name:"Alejandro",middleName:null,surname:"Pérez-García",fullName:"Alejandro Pérez-García",slug:"alejandro-perez-garcia"},{id:"15417",title:"Prof.",name:"Antonio",middleName:null,surname:"de Vicente",fullName:"Antonio de Vicente",slug:"antonio-de-vicente"},{id:"15419",title:"Dr.",name:"Juan A.",middleName:null,surname:"Torés",fullName:"Juan A. Torés",slug:"juan-a.-tores"},{id:"15420",title:"Dr.",name:"Dolores",middleName:null,surname:"Fernández-Ortuño",fullName:"Dolores Fernández-Ortuño",slug:"dolores-fernandez-ortuno"}]},{id:"12389",title:"Fungicide Resistance in Cucurbit Powdery Mildew Fungi",slug:"fungicide-resistance-in-cucurbit-powdery-mildew-fungi",signatures:"Ales Lebeda, Margaret T. MgGrath and Bozena Sedlakova",authors:[{id:"16730",title:"Dr.",name:"Ales",middleName:null,surname:"Lebeda",fullName:"Ales Lebeda",slug:"ales-lebeda"},{id:"16731",title:"Dr.",name:"Margaret T.",middleName:null,surname:"McGrath",fullName:"Margaret T. McGrath",slug:"margaret-t.-mcgrath"},{id:"16732",title:"Dr.",name:"Bozena",middleName:null,surname:"Sedlakova",fullName:"Bozena Sedlakova",slug:"bozena-sedlakova"}]},{id:"12390",title:"Phenotypic Analyses of Fenhexamid Resistant Botrytis cinerea Mutants",slug:"phenotypic-analyses-of-fenhexamid-resistant-botrytis-cinerea-mutants",signatures:"Seiya Saito, Seiichi Furuya, Tsutomu Takayanagi and Shunji Suzuki",authors:[{id:"13729",title:"Dr.",name:"Shunji",middleName:null,surname:"Suzuki",fullName:"Shunji Suzuki",slug:"shunji-suzuki"},{id:"15367",title:"Dr.",name:"Seiya",middleName:null,surname:"Saito",fullName:"Seiya Saito",slug:"seiya-saito"},{id:"15368",title:"Prof.",name:"Seiichi",middleName:null,surname:"Furuya",fullName:"Seiichi Furuya",slug:"seiichi-furuya"},{id:"23635",title:"Prof.",name:"Tsutomu",middleName:null,surname:"Takayanagi",fullName:"Tsutomu Takayanagi",slug:"tsutomu-takayanagi"}]},{id:"12391",title:"Utilization of Sweat Potato Starch Wastewater and Monosodium Glutamate Wastewater for Cultivation of an Anti-Fungal Biocontrol Agent Paenibacillus Polymyxa",slug:"utilization-of-sweat-potato-starch-wastewater-and-monosodium-glutamate-wastewater-for-cultivation-of",signatures:"Zhihui Bai, Likun Gu, Yanming Su, Bo Jin and Guoqiang Zhuang",authors:[{id:"15766",title:"Dr.",name:"Zhihui",middleName:null,surname:"Bai",fullName:"Zhihui Bai",slug:"zhihui-bai"}]},{id:"12733",title:"Environmental Risks of Fungicides Used in Horticultural Production Systems",slug:"environmental-risks-of-fungicides-used-in-horticultural-production-systems",signatures:"Adam Wightwick, Robert Walters, Graeme Allinson, Suzanne Reichman and Neal Menzies",authors:[{id:"13708",title:"BSc.",name:"Adam",middleName:"Mark",surname:"Wightwick",fullName:"Adam Wightwick",slug:"adam-wightwick"},{id:"14050",title:"Dr.",name:"Suzanne",middleName:null,surname:"Reichman",fullName:"Suzanne Reichman",slug:"suzanne-reichman"},{id:"14051",title:"Dr.",name:"Graeme",middleName:null,surname:"Allinson",fullName:"Graeme Allinson",slug:"graeme-allinson"},{id:"14052",title:"Prof.",name:"Neal",middleName:null,surname:"Menzies",fullName:"Neal Menzies",slug:"neal-menzies"},{id:"23793",title:"Mr.",name:"Robert",middleName:null,surname:"Walters",fullName:"Robert Walters",slug:"robert-walters"}]},{id:"12392",title:"Benzimidazole Fungicides in Environmental Samples: Extraction and Determination Procedures",slug:"benzimidazole-fungicides-in-environmental-samples-extraction-and-determination-procedures-",signatures:"José Juan Santana Rodríguez, Mª Esther Torres Padrón, Jana Aufartová and Zoraida Sosa Ferrera",authors:[null]},{id:"12393",title:"Propiconazole Toxicity on the Non-Target Organism, the Arbuscular Mycorrhizal Fungus, Glomus irregulare",slug:"propiconazole-toxicity-on-the-non-target-organism-the-arbuscular-mycorrhizal-fungus-glomus-sp-",signatures:"Maryline Calonne, Joël Fontaine, Djouher Debiane, Frédéric Laruelle, Anne Grandmougin-Ferjani and Anissa Lounès-Hadj Sahraoui",authors:[null]},{id:"12394",title:"Fungicides and Their Effects on Animals",slug:"fungicides-and-their-effects-on-animals",signatures:"Hasan H. Oruc",authors:[{id:"13562",title:"Dr.",name:"Hasan H.",middleName:null,surname:"Oruc",fullName:"Hasan H. Oruc",slug:"hasan-h.-oruc"}]},{id:"12734",title:"Introduction and Toxicology of Fungicides",slug:"introduction-and-toxicology-of-fungicides",signatures:"Rachid Rouabhi",authors:[{id:"13583",title:"Dr.",name:"Rachid",middleName:null,surname:"Rouabhi",fullName:"Rachid Rouabhi",slug:"rachid-rouabhi"}]},{id:"12735",title:"Interactions of Fungicides and Pesticides with Specific Enzymes",slug:"interactions-of-fungicides-and-pesticides-with-specific-enzymes",signatures:"Deniz Ekinci and Murat Şentürk",authors:[{id:"13652",title:"Associate Prof.",name:"Deniz",middleName:null,surname:"Ekinci",fullName:"Deniz Ekinci",slug:"deniz-ekinci"},{id:"14794",title:"Dr.",name:"Murat",middleName:null,surname:"Şentürk",fullName:"Murat Şentürk",slug:"murat-senturk"}]},{id:"12395",title:"Neurotoxic Effects of Triazole Fungicides on Nigrostriatal Dopaminergic Neurotransmission",slug:"neurotoxic-efects-of-triazole-fungicides-on-nigrostriatal-dopaminergic-neurotransmission",signatures:"Lilian Rosana Faro",authors:[{id:"13834",title:"Dr.",name:"Lilian Rosana",middleName:null,surname:"Faro",fullName:"Lilian Rosana Faro",slug:"lilian-rosana-faro"}]},{id:"12396",title:"Influence of Fungicide Residues in Wine Quality",slug:"influence-of-fungicide-residues-in-wine-quality",signatures:"Alberto Barba, José Oliva and Paula Payá",authors:[{id:"14020",title:"Dr.",name:"Alberto",middleName:null,surname:"Barba-Navarro",fullName:"Alberto Barba-Navarro",slug:"alberto-barba-navarro"},{id:"15891",title:"Dr.",name:"José",middleName:null,surname:"Oliva Ortiz",fullName:"José Oliva Ortiz",slug:"jose-oliva-ortiz"},{id:"23736",title:"Dr.",name:"Paula",middleName:null,surname:"Payá Peñalver",fullName:"Paula Payá Peñalver",slug:"paula-paya-penalver"}]},{id:"12397",title:"Do Cytochrome P450 Enzymes Contribute to the Metabolism of Xenobiotics in Human?",slug:"do-cytochrome-p450-enzymes-contribute-to-the-metabolism-of-xenobiotics-in-human-",signatures:"Khaled Abass, Petri Reponen, Miia Turpeinen, Sampo Mattila and Olavi Pelkonen",authors:[{id:"13581",title:"Dr.",name:"Khaled",middleName:"M.",surname:"Abass",fullName:"Khaled Abass",slug:"khaled-abass"},{id:"23800",title:"Prof.",name:"Petri",middleName:null,surname:"Reponen",fullName:"Petri Reponen",slug:"petri-reponen"},{id:"23801",title:"Dr.",name:"Miia",middleName:null,surname:"Turpeinen",fullName:"Miia Turpeinen",slug:"miia-turpeinen"},{id:"23802",title:"Dr.",name:"Sampo",middleName:null,surname:"Mattila",fullName:"Sampo Mattila",slug:"sampo-mattila"},{id:"23803",title:"Prof.",name:"Olavi",middleName:null,surname:"Pelkonen",fullName:"Olavi Pelkonen",slug:"olavi-pelkonen"}]},{id:"12398",title:"Neural Computation Methods in the Determination of Fungicides",slug:"neural-computation-methods-in-the-determination-of-fungicides",signatures:"Carmen Paz Suarez Araujo, Patricio García Báez and Yaride Hernández Trujillo",authors:[{id:"14150",title:"Prof.",name:"Carmen Paz",middleName:null,surname:"Suarez Araujo",fullName:"Carmen Paz Suarez Araujo",slug:"carmen-paz-suarez-araujo"},{id:"15989",title:"Prof.",name:"Patricio",middleName:null,surname:"García Báez",fullName:"Patricio García Báez",slug:"patricio-garcia-baez"},{id:"33368",title:"Dr.",name:"Yaride",middleName:null,surname:"Hernández-Trujillo",fullName:"Yaride Hernández-Trujillo",slug:"yaride-hernandez-trujillo"}]},{id:"12399",title:"Research and Development of Macrocyclic Compounds as Fungicides",slug:"research-and-development-of-macrocyclic-compounds-as-fungicides",signatures:"Dao-Quan Wang",authors:[{id:"14226",title:"Prof.",name:"Daoquan",middleName:null,surname:"Wang",fullName:"Daoquan Wang",slug:"daoquan-wang"}]},{id:"12400",title:"Two-Component Signaling System in Filamentous Fungi and the Mode of Action of Dicarboximide and Phenylpyrrole Fungicides",slug:"two-component-signaling-system-in-filamentous-fungi-and-the-mode-of-action-of-dicarboximide-and-phen",signatures:"Chihiro Tanaka and Kosuke Izumitsu",authors:[{id:"15717",title:"Dr.",name:"Chihiro",middleName:null,surname:"Tanaka",fullName:"Chihiro Tanaka",slug:"chihiro-tanaka"},{id:"15887",title:"Dr.",name:"Kosuke",middleName:null,surname:"Izumitsu",fullName:"Kosuke Izumitsu",slug:"kosuke-izumitsu"}]}]}]},onlineFirst:{chapter:{type:"chapter",id:"70802",title:"Sickle Cell Anemia, Representations and Care: Experience of a Brother of a Sick Child in Cameroon",doi:"10.5772/intechopen.90995",slug:"sickle-cell-anemia-representations-and-care-experience-of-a-brother-of-a-sick-child-in-cameroon",body:'\n
\n
1. Introduction
\n
Sickle cell anemia is a genetic disease that confronts families with iterative, intense and unpredictable crises associated with the physical manifestation on the sick child [1] to his death thought to be imminent and inevitable. It is a taboo in most sub-Saharan African families [2] where it is difficult to meet unique children. Few psychological studies have focused on what happens to children who grow up with a sibling with sickle cell disease which is characterized by severe pain, frequent hospitalization and early death not to mention the high cost of treatment (traditional and medical) for families. However, it is unclear how families live the traditional and medical care of the disease.
\n
This article includes an interview and drawing analysis done with a brother of a sick child in the context of research whose framework and method will be briefly presented. It highlights the way in which a child perceives the healthcare of his sister, both by Western medicine professionals and traditional healers—two types of care specialists with virtually different processes and goals. It is therefore a question of understanding the psychological impact of the concurrent consultation of medical and traditional care of a sick child on his brother. The article illuminates and questions the simultaneous existence of two sickle cell care systems within a Cameroonian family and tries to understand its effects on a brother of a sick child. It shows the complexity of the experiences of children growing up with a sick sibling and its close interweaving with the family experiences as they care for the child. The objective is to build on this knowledge to open up the design of care devices that better take into account the specificity of the experiences of siblings of children with sickle cell anemia.
\n
\n
\n
2. Theoretical consideration
\n
\n
2.1 The sickle cell anemia, a serious and deadly genetic disease
\n
Sickle cell anemia is the most prevalent genetic disease in the world, with approximately 500 million individuals with sickle cell traits and 50 million individuals with the disorder itself worldwide [3]. Originally spread across malaria-endemic areas such as sub-Saharan African countries, historical migrations linked to the slave trade and the recent acceleration of migration flows have gradually changed its distribution worldwide [4]. It is found in almost all countries with large populations from Africa and regions around the Mediterranean. In France, for example, it is a rare disease, but nonetheless the most common genetic disease with a prevalence of one child per 1900 births [5].
\n
With a prevalence rate of at least 2% in the general population and an estimated mortality rate of more than 70% among children under the age of 5 [6], the African continent is most affected by sickle cell anemia. Cameroon is one of the most affected countries, with a prevalence of 8.34% in the general population [7]. In sub-Saharan Africa, the unavailability of bone marrow transplantation—the only effective treatment for seizures—increases the risk of death in children under 5 years old [8].
\n
The disease is an autosomal recessive pathology transmitted to the child by both parents. The presence of abnormal hemoglobin in the blood causes a deficiency in the supply of oxygen to various organs in the body by the red blood cells that have reduced life cycles. This leads to anemia and chronic, unpredictable pain [4, 9] that the patient identifies [1], resulting in multiple expensive hospitalizations and care organized by their parents [10] both in the hospital and among traditional healers.
\n
\n
\n
2.2 The sickle cell anemia, a persecution figure of the family group
\n
In the sub-Saharan African cultural context, sickle cell anemia is thought of as an “evil” that can attack any member of the family, even after the death of the patient [11]. The sick child is immersed in a society structured by traditional taboos, rituals and attitudes of which women are custodians [12]. The illness or handicap of the child is inscribed in this cultural structure, which gives it meaning and produces effects.
\n
Sickle cell anemia is thought to be a manifestation of the possession of the sick child and his family by an evil spirit or bewitchment by a wizard [13]. It can also be perceived as a request of the ancestors to repair a transgression of an ancestral norm, addressed to the patient’s family [14]. Generally, the mother is designated as responsible for this transgression and the overprotection of the sick child, by her and by the family members, constitutes a defense allowing them to feel guilt-free and to put the child in the family’s history [14] alongside his brothers and sisters.
\n
\n
\n
2.3 The specificities of the medical care of sickle cell anemia in Cameroon
\n
The hospital is a place regularly frequented by sick children and their families. Described as the disease of hospitals in several African countries [15], sickle cell anemia makes hospital services a second home for the patient and their families around them. The frequency of hospitalizations in Cameroon is estimated to be between three and four hospitalizations per month in children under five, between five and seven hospitalizations per month in adolescents and two hospitalizations per month in adults [16]. The reasons for these hospitalizations are sometimes varied in one subject and identical in others. In general, sick children are regularly hospitalized for pain attacks, severe anemia and/or chronic complications (stroke and heart attacks). Stroke is also a cause of hospitalization for sickle cell patients. For the latter, the probabilities of having a stroke before the ages of 20, 30 and 45 are, respectively, 11, 15 and 24% [17]. In Cameroon, the prevalence of stroke is 6–7% in patients aged 7 months–35 years [18].
\n
The medical management of patients has undergone an important evolution within the past 20 years due to the intensification of available treatments for children at risk of severe complications [19]. These treatments consist mainly of yoglycurea, transfusion programs and family transplants. Indeed, yoglycan significantly reduces the frequency of onset of occlusive seizures, acute thoracic syndrome and the degree of hemolysis. The establishment of transfusion programs for children detected as at risk of stroke by transcranial Doppler has significantly reduced this risk from 11 to 2% [19].
\n
Allogeneic transplantation is currently the only treatment that can cure approximately 95% of children with sickle cell anemia [8, 20]. This treatment involves grafting from a brother or sister of the patient, based on their genetic compatibility with hematopoietic stem cells located in the bone marrow of the patient.
\n
Sickle cell anemia is essentially a disease of the south whose treatment is in the north. This caricature seems more appropriate to address the lethal nature of this pathology in sub-Saharan African countries, including Cameroon, where it remains a chronic and orphan disease [21] because of the absence of hematopoietic stem cell allograft and the gene editing systems, the only treatments available against this disease [8, 9, 22]. Therefore, the therapeutic approach of the disease remains curative and focuses on the nature of the crises. The patient is supported in relation to the type of crisis he manifests. The primary purpose of medicine, in this case, is to alleviate the suffering of the patient by managing the symptoms. Crisis treatment incorporates several therapeutic products and postures. Severe attacks (mild pain, modeled fever) are often treated at home in collaboration with a doctor or by self-medication. The patient is advised to rest, drink abundantly and is given an analgesic treatment including acetylsalicylic acid, paracetamol or Di-Antalvic. In case of severe attacks involving localized or generalized pain, rest and rehydration are recommended. If these measures do not calm the crisis, a transfusion is performed.
\n
The management of anemia, meanwhile, requires a transfusion of phenotyped erythrocyte concentrates, leukocyte depleted and filtered. The intervention in cases of severe pain attacks is based on the transfusion and/or hydroxyurea of the patient. Hydroxycarbamide is the only current attenuator therapy used in the management of vaso-occlusive seizures and severe anemias. The price of these products, combined with that of many hospitalizations, is relatively high for most Cameroonian families who generally do not have social security [16].
\n
\n
\n
2.4 Balancing between traditional care and medical care
\n
Parents of sick children, supported by the members of their extended families, are frequently searching for ways to relieve their suffering. With the advent of globalization, they resort to several therapies. The therapeutic route is, in this sense, a sort of mosaic between traditional therapies and imported Western and messianic therapies. In this way, the traditional therapist, the doctor and the Imam, pastor or priest are consulted at the same time. This system of “round care” [23] is one that perfectly summarizes the therapeutic path of most African families in sub-Saharan Africa. At each source, they seek the healing of a specific aspect of the child’s suffering. The quests for meaning of the child’s illness, ancestral protection and reconciliation with the ancestors lead parents to traditional healers. With the priest, the pastor or the Imam, families seek the divine therapy to ensure protection from God. They usually do this because they yearn for the healing of the child under the mercy of God. With the medical doctor, they seek the somatic healing of the child. These families are part of a permanent search for identity reconstruction [24, 25]. The identities of Africans remain very complex as they continually attempt to find their identities, following the effects of globalization [14, 26].
\n
The traditional treatment of sickle cell anemia is based on cultural representations of this disease that people have. It does not aim to repair physiological disorders. It focuses on restoring social order by reconciling the patient and their groups with their social and supernatural environments [14]. This therapy considers the sick child as a messenger, a person who talks about the transgressions of ancestral norms by a member of his family or the persecution of his family by a wizard. This is the reason why parents, uncles, aunts, brothers, sisters and cousins of the patient are all also patients of the traditional therapists.
\n
\n
\n
2.5 Cameroonian families oscillating between modernity and tradition
\n
African families have retained certain intrinsic cultural values such as polygamy and the maintenance of family life through the births of several children. They have also opened up to modernity by gradually applying family planning practices.
\n
In Cameroonian families, the cultural tradition is neither past nor “outdated” [14]. The behaviors of the subjects are always marked by identifiable traditional elements. These families have neither resisted nor surrendered to modernity. These are simultaneously modern and traditional families, not necessarily modern or traditional. In Cameroon, there are several types of families; nuclear families, extended families, polygamous families, monogamous families, etc. [27]. These categories reflect the diversity and complexity of family dynamics in Cameroon, and potentially the lives of children confronted by a sick sibling.
\n
\n
\n
2.6 The experiences of the brothers and sisters of sick children
\n
A child’s illness has repercussions on their siblings who experience ambivalent feelings towards them. These relate specifically to shame, guilt, love, hatred, complicity, rivalry, anguish and the desire for the death of the sick child [28]. In order not to aggravate the suffering of their parents and that of the patient, brothers and sisters often attempt to prevent them from suffering [29].
\n
Studies on sickle cell anemia patients indicate the psychological suffering of sick children and their parents [9, 14, 30]. The experiences of their siblings are often studied from the parents’ stories. Overprotection of the child causes parents to progressively neglect caring for their other children [31]. The latter experience emotional breakdowns resulting in feelings of rejection, marginalization and exclusion on the part of parents and the extended family [32, 33]. They express jealousy towards the patient that they designate as the main person responsible for crises that destabilize the family financially and emotionally [34]. They feel guilty for having negative thoughts such as jealousy towards the patient; they consider themselves “bad siblings” [35]. They experience, at the same time, the desire for the death of the patient and the fear of this death [36]. Their experiences are usually influenced by parental intrusions in their relationships with the sick child because they are often parented by parents [36]. In the absence of the parents, they are the ones who supervise the sick child. Supervision ranges from daily monitoring of treatment and observation of medical instructions by the patient [2] to the bodily care of the patient and their assistance during hospitalization [37]. This has great implications on the sisters of sick children, particularly on girls’ education. In many sub-Saharan African societies, the main objective is to bring up girls to be good mothers, thus making them the person most likely to take care of children [21].
\n
\n
\n
\n
3. Material and method
\n
\n
3.1 Specificities of the method
\n
The methodology of this research is similar to that presented in a previous research [36]. In sub-Saharan African cultures, children who talk to professionals about themselves or anything else are supposed to have been given permission by their families to do so [38]. It is usually parents who talk to professionals about their children, who on their part are obliged to listen and to talk only when adults allow it [39]. Talking with children about sickle cell anemia is not easy and it requires the researcher to make an alliance with the family. This research, which took place in Cameroon worked to get parents to allow their children to talk with the researcher about the way they experience the care of their sick brother or sister. In fact, many children are not allowed to speak to strangers and to speak only to adults who are intimate with the family [40].
\n
The parents signed consent forms concerning the participation of the family and children in the research and designated which of their children would participate. These children were allowed by their parents to speak with the researcher about their family, their sick brother or sister and his/her illness. Indeed they had a mission to talk to the researcher who informed them about their freedom to participate in this research. The method includes an individual interview with each child and a drawing, preceded and followed by a group time. Before the interview, the mother, in front of the whole family, talks about the relations between her sick child and his siblings; the children listen and keep quiet. After the interview and the drawing, the adults question the researcher and the participating child about the content of their meeting. It is therefore an individual meeting, but it takes place in a group setting allowing children to speak as freely as possible.
\n
We report in this article the case of Jules. With Jules, we talked about the illness, his relationship with the sick child and the family. In Jules’ interview, there is an important place for treatment and its effects on the sick child, on his siblings, on his mother and father and on extended family members. This interview was done in the absence of the other members of the family whom we asked to leave the family room to allow for confidentiality. The interview was followed by the drawing session after which the analysis of the drawing was done. The family drawing test followed the approach of [41], taking into account the cultural referent as advocated by [42]. We asked Jules to draw his family on a sheet. The drawing, complementary to the interview allows the child to project on the sheet what he thinks and experiences about his family, his sick brother and his place in the family.
\n
\n
\n
3.2 Jules and his family
\n
In accordance with the ethical requirements, we gave fictitious first names to the persons to guarantee the anonymity and the confidentiality of the meeting.
\n
Aged eleven and a student in fifth grade, Jules is the third child out of five siblings and the older brother of Paulette, his sister with sickle cell anemia. After the death of his father, a nurse who had previously worked in his home village, Jules, accompanied by his sick sister and his mother emigrated from the village to settle in Yaoundé at his elder sister’s home. This sister was a public school teacher. One of the reasons for this rural exordium is the medical follow-up of Paulette, eight, with sickle cell anemia. She is the second-to-last of the five siblings, three boys and two girls. The youngest of two siblings and three boys would probably have died, according to Jules’s older sister, following sickle cell anemia crises. In Cameroon, sickle cell anemia is not well enough known by all public health professionals and some people still do not recognize nor know its symptoms.
\n
Paulette’s illness was diagnosed at the age of seven, when she was first hospitalized following an anemic crisis in a hospital in Yaoundé. The unavailability of prenatal diagnosis and the non-systematization of neonatal diagnosis of sickle cell anemia in Cameroon leads to children being diagnosed relatively late during one of their hospitalizations.
\n
Paulette is usually hospitalized between one and two times a month following anemia attacks, the main symptom of her illness. Her mother, estimates the average duration of each of her hospitalizations to be between 2 and 3 days. During these hospitalizations, her older sister and her mother often assist her.
\n
Jules lives with the eldest daughter in the family, his mother, his sick sister and his one-year-old niece. The eldest daughter of the siblings is separated from the father of her daughter and she is the only child who is a parent herself. Paulette is the only sick child and the mother of the family is unemployed. The eldest daughter and the second child of the siblings contribute to the financing of Paulette’s care. Siblings are therefore a family resource in the financing of care. These first two siblings are employed and the last two are students.
\n
\n
\n
\n
4. Results
\n
Paulette’s fits give rise to many hospitalizations.
\n
\n
4.1 The financing of medical care
\n
Jules does not know the cost of Paulette’s medical care. He knows, however, that it is his older sister and his paternal uncle who finance this care. He exclaims “Ah! I do not know the price. Mom and my older sister do not tell me the price. My older sister pays the hospital. There is also my uncle and my brother who also gives the money for the hospital.”
\n
He behaves as though he was forbidden and/or forbade himself from knowing or asking adults questions about the cost of his sister’s medical care. However, he is grateful for the uncle’s financial support to his mother and older sister. He does not mention the involvement of his brother who is a taxi driver in financing the care.
\n
Her older sister and mother usually accompany Paulette to the hospital. This elder sister plays both the role of father and sister to Jules and Paulette. She finances the care and assists her mother at Paulette’s bedside during hospitalizations. In the end, she plays the role of substitute for the deceased father and the mother for the sick sister. Her status as the eldest daughter of her siblings demands that she cares for her younger siblings, in keeping with the cultural norm that [40] makes the eldest son especially, and the eldest sister also, a parental figure for her brothers and sisters in African families. Jules specifies, “My sister brings Paulette to the doctors of the foundation when the blood reduces.” Therefore, he refers to this sister as a mother for both Paulette and himself.
\n
Jules refers to the fact that the medical professionals at the hospital do not care about his family and his siblings. Their interest is in Paulette and the relief of her crises. Medical treatment is only given to the patient. Jules feels abandoned, forgotten and neglected by these professionals. He says, “they do the remedies only to Paulette” which signifies the sentiment of disregard of his own suffering at the hands of the professionals in the hospital.
\n
\n
\n
4.2 The attendance at the hospital during crises
\n
Jules refers to the fact that Paulette is usually brought to the hospital during her seizures. “When her hands turn white or the eyes start to turn red, it’s because the blood is already reducing. When the blood reduces, she becomes very tired and heats a lot. We bring her to the hospital.”
\n
The hospital is invested as having a curative function, given in urgency. All of this suggests that the family seeks hospital care only after failures of self-medication and preventive measures that it would have implemented to avoid or to relieve the crises. Obviously, this behavior of the family is an adaptation to the expensive nature of healthcare in a context where it is not reimbursed and where health insurance is non-existent [16]. This poses the problem of crisis prevention via the check-up of children with sickle cell anemia in sub-Saharan Africa, in general, and in Cameroon, in particular.
\n
\n
\n
4.3 Recognition of non-effectiveness of crisis treatment in hospitals
\n
Paulette’s seizures are treated in the hospital via transfusions, which relieves seizures for a time without eliminating them. Jules evokes the infernal cycle of crises, hospitalizations and returns home. He says, “in the hospital, she is given a lot of blood. When she takes the blood from the hospital, she comes home. It’s always like that for Paulette.” He recognizes the effectiveness of transfusion in relieving crises, but temporarily. What arouses him is an anguish of death concerning his sick sister “When I see it like that, my body trembles.”
\n
Paulette’s illness is thought of as “a disease of the blood.” Jules knows, therefore, that the “affected” blood must be removed from Paulette’s body. “In order for it to end, you have to empty all the blood from your body. Like that it will come out with the disease.” In his view, this is not what hospital care professionals do because they put new blood in the sick child’s body and do nothing about the “bad” blood.
\n
Hospital care professionals are referred to as “responsible” for the chronicity of crises. Jules disqualifies them and thinks that they cannot permanently relieve these crises. “The people in the hospital just put the blood into the bad blood. That is why the disease always comes back. When they put the good blood in their body, the bad blood eats up all the good blood, and the disease begins again.” This recognition of the inefficiency of hospital care arouses his anger against these professionals whom he designates as ineffective against the worsening of his sister’s state of health. It is possible that Jules, by this anger, projects on these professionals, his feeling of helplessness concerning the crises his sister goes through and the feeling of concomitant guilt. Medical professionals can also understand it as a cry for recognition and take into account his experience.
\n
The hospital is designated as responsible for the death of the last daughter of the mother, who died from a sickle cell anemia crisis during her hospitalization. “They put false blood in her body and she died. It was not necessary to put this blood in her body. When they put that blood, she died two days later. We were only called to be told that the child is dead, that we should take her body to the morgue.” As a result, Jules shows distrust of the hospital, hospital professionals and the handling of crises by these professionals whom he designates as responsible for the death of his sister.
\n
\n
\n
4.4 The traditional healer treats the patient and his family
\n
The traditional healer cares for the sick child, her siblings, her parents and her extended family because the illness is considered an ailment of the patient and his family.
\n
\n
4.4.1 The care of the sick child
\n
The traditional healer cares for the sick child’s body. The body is thought to be possessed by an “evil spirit,” an illness that manifests itself in the patient by chronic anemia and the seizures of pains in the back and feet. These symptoms inform the traditional healer about the extent of possession and persecution of the sick child’s body by wizards. In response to this possession/persecution, the traditional healer provides bodily care to the patient.
\n
Jules says that he was wounded on the body. The painful parts of the sick child’s body are scarified to allow the therapist to act directly on the evil and to limit the destruction of the body by the wizards. He does this by administering a powder with magical powers, effective against sorcerers. Therefore, the care of the patient has a curative aim of “freeing” the patient from this possession and persecution by wizards. Thus, not only is the blood treated here, but also the body too.
\n
\n
\n
4.4.2 Care of the brothers, sisters and the mother
\n
Jules’ mother and his paternal uncle accompanied Paulette to the traditional healer. The brothers and sisters, who were absent from the consultation, received through the uncle the treatment given by the traditional therapist. Jules refers to the fact that his paternal uncle administered on him and his other siblings scarifications and he applied the powder from the traditional healer. Because the father is deceased, the paternal uncle went accompanied his mother and the sick sister to the traditional practitioner. This shows the involvement of the extended family in traditional care and support for the mother in this process apart from acting as an intermediary between the traditional healer and the family. He is also responsible for monitoring the application of the traditional medication.
\n
At the requestion of the traditional healer, his paternal uncle scarified Jules just as he did to his sister. The treatment was administered orally and via scarification of the back. “Even my mother and my older sister ate the same medicine. After eating it, the remaining was put in the blood.” Thus, Paulette’s siblings and her mother who were considered at risk of becoming, and of being persecuted by witches were also subjected to the traditional treatment against sickle cell anemia. The goal of this treatment is to protect them against the ailment.
\n
The traditional practitioner, through these treatments, sought to domesticate the harm represented by the disease. He did not seek to exclude this evil from the family, but to transform it into an entity likely to cohabit in harmony with family members. The “bad” blood of the sick child is thus transformed into “good” blood, into a blood that is no longer a threat to him or to the family members. This therapy does not aim at excluding the “evil” from the family, but to make the ailment an entity of the family and to bring the family members to accept it as such [43].
\n
\n
\n
\n
4.5 The experience of traditional treatment
\n
With Jules, there is a before and an after of traditional treatment. An “unsecured” pre-treatment period where the threat of contamination by the disease looms, and a more “secure” post-treatment period when the threat is contained by receiving traditional treatment.
\n
\n
4.5.1 Treatment reduces feelings of insecurity
\n
Jules thinks of the traditional treatment as a protection against its contamination by the disease. Taking this treatment is associated with a reduction of fear regarding the disease and possible contamination. He says, “I’m not too scared. Before I was very scared. Now, with the remedy in my body, I’m not as afraid as I was before.” It is interesting to note that although the fear of his sister’s death has diminished, it still lingers in his mind. He experiences his body as less vulnerable and more protected against the disease. This indicates that at this point, Jules feels safer with the disease and with the wizards.
\n
The receiving of traditional treatment against sickle cell anemia thus helps Jules contain the fear and anguish that arises in him because of his sister’s illness. It helps him to contain his feelings of persecution by the wizards and the fear of infection with the disease even if it does not totally eliminate this fear.
\n
\n
\n
4.5.2 Treatment makes blood bad for wizards
\n
For Jules, the blood of the patient is a dead blood, a blood possessed by the wizards. In this sense, “a bad blood” attacks the “good blood” transfused into the patient during hospitalizations. According to him, this gives meaning to the chronic anemia and the iterative crises of pain that his sick sister experiences.
\n
The traditional treatment is thought by Jules to be effective against wizards. It makes the blood of the sick and the non-sick unassailable by wizards. His treatment reduces the feeling of persecution by wizards, even in the event that his sister dies. “They will not look for me anymore,” he says. The traditional treatment is thus invested as a protection against the attacks of wizards, against the disease and, of course, against Paulette’s and his own death.
\n
Jules does not associate the death of a patient with the end of the disease as in the case of his mother’s youngest daughter, which preceded that of their father. According to him, the disease survives and invests another child or family member. This leads Jules to think of himself as the next potential victim of the disease in the event of Paulette’s death. “If Paulette dies after her little sister, that means we’re going to get another person to kill. If she dies, another person will die. That’s what scares me.” Jules has a fear of death concerning his sister. He suffers more from this fear of death that he feels threatened by the disease, this “death”. He thinks of his sister’s imminent death and, therefore, his infection with the disease and his own death.
\n
The administration of the traditional treatment leads Jules to say this about the wizards, “it’s over for them, everyone ate the cure, everyone is armored,” and specifically, “when wizards enter the family they do not leave.” In connection with receiving traditional treatment, he says one thing and then contradicts it. He expresses ambivalent feelings of protection against and vulnerability to wizards. This suggests that the sense of security against witchcraft remains feeble, as the feelings of insecurity were never really eliminated.
\n
\n
\n
\n
4.6 The contribution of the drawing
\n
The drawing was made, after the interview, on the dining table in the living room, lit by sunlight.
\n
\n
4.6.1 The complexity of the instructions
\n
Following the instruction “I would like you to draw your family” Jules says he does not know how to draw human beings. Regarding his family, he thinks he is too tall to be represented on a sheet of paper and he asked for a second drawing sheet. He was told that for this drawing, it is recommended that he use a single sheet.
\n
Jules persisted in his request by asking whether he could draw the other people on the back of the paper. To this question, the answer was negative. Following these requests for clarification of the instructions, he resigned himself to drawing according to the rules. This behavior is informative about the limits of family design in this context where the family is not limited to the father, the mother and the children. It is an extended family leading to the need to (re)think the handover, analysis and interpretation of this drawing in a sub-Saharan African context following [42].
\n
\n
\n
4.6.2 The drawing of the extended family
\n
The eldest daughter in the family (“grande soeur,” on the drawing) is the first character drawn by Jules, followed by his father (“papa” on the drawing) the second character. This can signify in Jules that this sister is the most important person in the family because she provides a home near the hospital and money for medical bills. She took the role of the father. That can be why the father is then drawn second. Mother (“maman” on drawing), older brother (“grand frère Willie” on drawing), cousin (“grand frère Hugo” on drawing), maternal uncle and aunt, mother’s aunt, paternal aunt, other maternal uncle, cousin mother (“grande soeur Manuella” on drawing), her maternal cousin (“petit frère” on the drawing) and her maternal grandmother were, respectively, drawn by Jules. All the characters in the drawing are real. There are no fictional characters. The drawing is invested as a projective support on which Jules illustrates what he lives and thinks about his family in connection with the illness of his sister.
\n
That Jules’s drawing includes his extended family reflects his sense of belonging to it and the support it brings to his immediate family in the face of his sister’s illness and the successive deaths of his father and youngest sister. It is thus a drawing on which is projected the family solidarity surrounding his sister’s illness (Figure 1).
\n
Figure 1.
Jules Family drawing.
\n
The characters are not very invested by Jules, who drew them in a very minimalist way. It is possible that he wanted to draw all the members of the extended family, which would have led him to drawing his characters in a minimalist way on the sheet. It may also reflect an inhibition of affects in Jules concerning his family ties. Moreover, this is the first time that he drew human characters without drawing on a predefined model as he often does at school. However, a large part of the sheet is empty. The drawing is in the “upper central part” high center of the sheet, in a portrait orientation. The drawing location in the upper part of the document can signify the escape of the present, the escape towards the unreal and the distance from oneself according to [41]. It is therefore possible that this drawing signifies Jules’ avoidance concerning his family, which is “inhabited” by death and disease. This may justify his lack of drawing.
\n
No character is in contact with others as they do not touch each other. This can be interpreted as lack of family support and the isolation of family members according to [41]. This interpretation is questionable, however, in a cultural context where affection and support do not necessarily manifest themselves through physical contact [26] through touch, caress or hug, for example, thus reflecting the complexity of this child’s life.
\n
\n
\n
4.6.3 The elder sister, a father figure
\n
Jules says he drew “these people” in his father’s house, at his father’s funeral in his village. Of all these characters, the elder sister (“la grande soeur” on the drawing) is designated as the happiest person. This is because, according to Jules, she bought the coffin for the burial of his father. The mother is referred to as the least happy person in the drawing because “she was crying because she had lost her husband.” The elder sister is invested psychologically and symbolically as the father of the family. She is the one who provided financial support for the funeral. She is designated as the nicest person in the drawing because she looks after her siblings. The fact that Jules first drew his older sister might reflect her emotional over-investment. She is invested as a mother emotionally and symbolically. The least kind person is the paternal aunt (paternal aunt, on the drawing). Jules justifies himself by declaring, “It is they who caused the village to be fired. They are mean. They said that mom killed her husband.”
\n
When asked what role he would like to take within the family dynamic in the drawing, if he had the opportunity, Jules points to his mother saying, “She is kind. As I go to school, she always buys me lunch.” This reveals the mother’s nurturing role in the family and invests her as an identification figure.
\n
\n
\n
4.6.4 The absence of Jules on the drawing of a mourning scene
\n
Jules said he had drawn his family members in his father’s house during his father’s funeral in his village. This tells us that he is still suffering grieving the death of his father. It is possible that Jules represents himself and associates his family with death, due to the past deaths of his father and his youngest sister, along with the imminent and distressing risk of the death of his sick sister. The family is therefore thought to be inhabited by death.
\n
Jules’s absence from the drawing may reflect his avoidance of the family, which he associates with disease and death. With this, he avoids living psychologically in this family dynamic, where he feels insecure about the circumstances. The sick child is also absent from the drawing. This can translate, for Jules, the anguish regarding the potential death of his sister. The sick sister is thus excluded from the family dynamic, thought of as not making/leaving her because of an illness that makes her a “dead” person. It could also be a way of distancing himself from this sister who reminds him of the suffering of the family. This absence contrasts with the presence of his later father.
\n
The presence of the father in the drawing can explain in Jules the incomplete mourning process of this father who is still invested as alive. He remains present beyond his death; unlike the other daughter who died before him. While the dead father remains present (illustrated on the drawing), the sick sister’ s absence from the drawing may signify Jules’ avoidance of this sister and therefore, avoidance of the threat of death that accompanies her illness. On a psychological level, Jule’s drawing may signify that, the living sister is dead, while the dead father remains alive. This complexity of Jules’s experiences is illustrated within his drawing.
\n
\n
\n
4.6.5 Friends and other supporters of Jules
\n
Jules perceives the children in the neighborhood as helpers and supporters concerning his sister’s illness. They are friends who support him by protecting his sister during games and other interactions with her. “The children do not bother Paulette. They go to school and come back together. They do not cause any problems. Even when we play together, there are no provocations.” Of course, these friends know that Jules is protective of his sick sister. They support him in this way by also protecting her and he is grateful for this.
\n
Jules’ friends are curiously absent from the drawing. He differentiates them from the members of the family. He does not make them part of his family; and hence their absence. In a cultural context where people with whom the subject has special relationships are considered to be members of their family [14], the absence of friends of the drawing is significant. This can tell you that Jules differentiates his friends from family members. Therefore, the support provided by the friends does not compensate for his feeling of abandonment by family members. They are considered outsiders and they may have no obligation over his situation. It could also exhibit his need for more support from within as the outside support could be a privilege.
\n
\n
\n
4.6.6 The absence of care professionals
\n
Healthcare professionals (hospital and traditional healers) are completely absent from the drawing. This absence can translate into their investment by Jules as outsiders to the family.
\n
It is also possible that Jules did not draw them because their presence acts as that of the disease and, obviously, the risk of contamination and death. This absence can indicate a psychological effort to avoid anything that reminds him of the disease. In Jules, this absence can refer to the feeling that the traditional therapist does not protect him against the idea of possible contamination by the disease. It is possible that he did not draw the hospital professionals in order to protect himself against the feeling of abandonment by them.
\n
\n
\n
4.6.7 The request for recognition of his experience
\n
At the end of the drawing, Jules handed his drawing to me while smiling and he asked me to protect it well because it is very fragile. By a projection mechanism, he could be asking me to pay attention to his psychological suffering.
\n
At the end of the meeting, with the agreement of Jules and following the requests of his elder sister, we presented the drawing to her and the mother. It is possible that Jules found by this means a way to make them understand his experience with Paulette’s disease in a family context where talking about the disease remains taboo. Particularly moved by finding themselves in the drawing, the elder sister and the mother criticized the “non-human” nature of the characters he drew and the absence of the use of many colors on the drawing. The elder sister put this in relation to the pedagogical approaches used at school, which do not enable children to draw freely.
\n
\n
\n
\n
\n
5. Discussion
\n
With the exception of the sick child who is named by Jules during the interview, parents and siblings are referred to as parents or siblings. The eldest daughter is referred to as “my big sister,” the brother who is a taxi driver as “my older brother,” the sick sister as “the last daughter of mother,” this is very important as she also died of sickle cell anemia. He does not refer to her as ‘sister’ maybe because he wants to distance himself from the condition which eventually led to her death, the things he fears most, and that have become a part of his family. This shows the specificity of his links to his sick sister. Jules refers to her niece as “the daughter of my older sister,” thereby differentiating his brothers and sisters from his niece. He referred the father and mother as “father” and “mother.”
\n
Four people appear in Jules’s drawing. Referred to in the interview as “my older sister,” the eldest daughter is designated on the drawing as “the big sister.” The brother who is a taxi driver is, however, named “big brother Willie” on the drawing while he is referred to as “my big brother” in the interview. The father and the mother are designated in the drawing by “daddy” and “mother.” However, the father is absent from the interview. The absence of the father within Jules’ speech is not synonymous with his absence in the psychological universe of the interviewee, as he is present on the drawing. This makes the drawing a mediator to speech and a complementary tool in the interview.
\n
Not all the people mentioned in the interviews appear in the drawing, and those in the interviews are named differently in the interviews. This account for Jules’ psychological dynamics concerning his links to family members and the complexity of these links.
\n
The valorization of the traditional treatment (as financially expensive for the families as the medical treatment) contrasts with Jules persistence of the feeling of insecurity regarding wizards. It suggests that the treatment is not necessarily valued for its therapeutic efficacy. In a context where the traditional practitioner is considered as the intermediary between the ancestors and the living [44], it is forbidden to devalue their treatment. To do so would amount to devaluing the ancestors and running the risk of punishment, which could lead to death. The ancestor is incomparable [45] and therefore not criticizable. It can be dangerous to criticize the traditional treatment, as Jules emphasizes that it “alleviates” the fear and concerns the whole family.
\n
Jules did not mention any consultation with a pastor, a priest or an imam. This is a problem in a context where families normally invest religious institutions (churches and mosques) to express their suffering and overwhelming misfortune [46]. It is possible that Jules, whose family is Christian, avoided talking about the care of his sister by the priest or by the pastor to a researcher whose family is of Muslim descent. He would have considered it disrespectful to talk about his religion to a researcher belonging to another religious denomination. It is also possible that, in not telling the researcher about his sister’s consultation with priests or pastors, this young boy avoided hitting the researcher’s religious sensitivity. He may not have talked to the researcher about this so as not to make him feel uncomfortable during the meeting.
\n
In addition, this study showed that the traditional healer assigns, the uncle rather than the mother in the administration and follow-up of the care of the children and the family. This can be understood by the fact that the woman is often considered by traditional healers, as a being who can reduce the effectiveness of the treatment if she were to touch the patient [47]. Consequently, men are more often empowered to monitor and to enforce the prescriptions of traditional healers. It is also possible that the exclusion of women in this follow-up is motivated by the fact that they are considered to be responsible for the transmission of the disease to the child [14] and hence as a “stain” in family [4] and a hindrance to traditional treatment. In this case, it would be interesting to understand how mothers and fathers experience the care of their children with sickle cell anemia by hospital and traditional healers.
\n
Jules’s family agreed to participate in the research despite the fact that sickle cell anemia remains a taboo subject in African families [2]. It is possible that this family invested the research as a means of understanding the experience of the brothers and sisters of the sick child. The researcher can be considered a mediator who allows the family to talk indirectly about sickle cell anemia with the sick child and his siblings. The parents do not themselves talk with the children about this disease, but they prefer that someone else did it. Although this can be a coping mechanism due to the guilt they experience regarding the situation, they consider themselves as parents who have transgressed a cultural norm whose consequence is the child’s illness. This behavior of the parents remains complex. Anyway, the participation of the family in this research shows the interest they had in understanding the experience of all the children in relation to the disease.
\n
This research also allowed Jules to tell the researcher, his family and care professionals his experience with his sister’s illness despite it being a taboo subject. It has therefore d upset the norm or violated the family taboo on sickle cell anemia. It would be interesting to understand the impact of Jules and his family’s participation in this research on the mother, the sick child and Jules himself.
\n
\n
\n
6. Conclusion
\n
This article presents results similar to those of other works concerning the co-existence of traditional and modern representations of sickle cell anemia among sub-Saharan African families [9, 36] and their involvement in traditional and modern care systems [46]. Finally, Jules knows that in the event of seizures, only the hospital (where she is taken only for emergencies) can mitigate them and that there is a possibility that the treatment can fail and lead to her death, the brothers and sisters are then absent from this care. The traditional healers, meanwhile, intervene before crises in order to prevent them before they occur. This intervention protects the sick child and their family against the wizards, who are designated as responsible for the attacks and thereby the danger of a possible transmission of the disease to the patient’s brothers and sisters.
\n
This research indicates the need for spaces of speech within healthcare institutions that can enable families, parents and children to express their experiences with illness and care. It also indicates the need for professionals to take these experiences into account. It would therefore be interesting to question the experience of the sick child with the side by side existence of two care systems within the family.
\n
\n
Acknowledgments
\n
Our heartfelt gratitude and thanks to Joy Gursky and Josephine Atieno for proofreading this work.
\n
Conflict of interest
None.
\n',keywords:"sickle cell anemia, care, tradition, modernity, siblings, Cameroon",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/70802.pdf",chapterXML:"https://mts.intechopen.com/source/xml/70802.xml",downloadPdfUrl:"/chapter/pdf-download/70802",previewPdfUrl:"/chapter/pdf-preview/70802",totalDownloads:152,totalViews:0,totalCrossrefCites:0,dateSubmitted:"September 30th 2019",dateReviewed:"December 24th 2019",datePrePublished:"January 16th 2020",datePublished:"February 17th 2021",dateFinished:"January 12th 2020",readingETA:"0",abstract:"In Africa, families often with more than one child consult with both modern and traditional African medicine to treat their child with sickle cell anemia. This research aimed to understand how a child experiences both the medical and traditional care of his sister. We collected data from an interview and family drawing of a young boy growing up with an affected sister in Cameroon. Results showed this child persisted to feel as though his sister had fallen victim to a sorcerer and that he was at risk of the same fate even after the two of them received traditional treatment. He also felt neglected about his suffering because of his sister’s disease by hospital professionals that were caring for her. It is therefore necessary to establish a support system for affected children and their family by providing a safe space in hospitals where they can express and contain their experiences with the disease.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/70802",risUrl:"/chapter/ris/70802",signatures:"Hassan Njifon Nsangou and Régine Scelles",book:{id:"9027",title:"Human Blood Group Systems and Haemoglobinopathies",subtitle:null,fullTitle:"Human Blood Group Systems and Haemoglobinopathies",slug:"human-blood-group-systems-and-haemoglobinopathies",publishedDate:"February 17th 2021",bookSignature:"Osaro Erhabor and Anjana Munshi",coverURL:"https://cdn.intechopen.com/books/images_new/9027.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"35140",title:null,name:"Osaro",middleName:null,surname:"Erhabor",slug:"osaro-erhabor",fullName:"Osaro Erhabor"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"312724",title:"Ph.D.",name:"Hassan",middleName:null,surname:"Njifon Nsangou",fullName:"Hassan Njifon Nsangou",slug:"hassan-njifon-nsangou",email:"hassannji75@yahoo.fr",position:null,institution:null},{id:"312830",title:"Prof.",name:"Régine",middleName:null,surname:"Scelles",fullName:"Régine Scelles",slug:"regine-scelles",email:"scelles@free.fr",position:null,institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Theoretical consideration",level:"1"},{id:"sec_2_2",title:"2.1 The sickle cell anemia, a serious and deadly genetic disease",level:"2"},{id:"sec_3_2",title:"2.2 The sickle cell anemia, a persecution figure of the family group",level:"2"},{id:"sec_4_2",title:"2.3 The specificities of the medical care of sickle cell anemia in Cameroon",level:"2"},{id:"sec_5_2",title:"2.4 Balancing between traditional care and medical care",level:"2"},{id:"sec_6_2",title:"2.5 Cameroonian families oscillating between modernity and tradition",level:"2"},{id:"sec_7_2",title:"2.6 The experiences of the brothers and sisters of sick children",level:"2"},{id:"sec_9",title:"3. Material and method",level:"1"},{id:"sec_9_2",title:"3.1 Specificities of the method",level:"2"},{id:"sec_10_2",title:"3.2 Jules and his family",level:"2"},{id:"sec_12",title:"4. Results",level:"1"},{id:"sec_12_2",title:"4.1 The financing of medical care",level:"2"},{id:"sec_13_2",title:"4.2 The attendance at the hospital during crises",level:"2"},{id:"sec_14_2",title:"4.3 Recognition of non-effectiveness of crisis treatment in hospitals",level:"2"},{id:"sec_15_2",title:"4.4 The traditional healer treats the patient and his family",level:"2"},{id:"sec_15_3",title:"4.4.1 The care of the sick child",level:"3"},{id:"sec_16_3",title:"4.4.2 Care of the brothers, sisters and the mother",level:"3"},{id:"sec_18_2",title:"4.5 The experience of traditional treatment",level:"2"},{id:"sec_18_3",title:"4.5.1 Treatment reduces feelings of insecurity",level:"3"},{id:"sec_19_3",title:"4.5.2 Treatment makes blood bad for wizards",level:"3"},{id:"sec_21_2",title:"4.6 The contribution of the drawing",level:"2"},{id:"sec_21_3",title:"4.6.1 The complexity of the instructions",level:"3"},{id:"sec_22_3",title:"4.6.2 The drawing of the extended family",level:"3"},{id:"sec_23_3",title:"4.6.3 The elder sister, a father figure",level:"3"},{id:"sec_24_3",title:"4.6.4 The absence of Jules on the drawing of a mourning scene",level:"3"},{id:"sec_25_3",title:"4.6.5 Friends and other supporters of Jules",level:"3"},{id:"sec_26_3",title:"4.6.6 The absence of care professionals",level:"3"},{id:"sec_27_3",title:"4.6.7 The request for recognition of his experience",level:"3"},{id:"sec_30",title:"5. Discussion",level:"1"},{id:"sec_31",title:"6. Conclusion",level:"1"},{id:"sec_32",title:"Acknowledgments",level:"1"},{id:"sec_35",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'\nJosset-Raffet E, Yi MK, Benkerrou M. La trajectoire corporelle et psychique de la douleur chez l’enfant atteint de drépanocytose. Neuropsychiatrie de l’Enfance et de l\'Adolescence. 2016;64(2):131-138. Disponible sur: http://www.sciencedirect.com/science/article/pii/S0222961716000040 [cité 8 sept 2017]\n'},{id:"B2",body:'\nBonnet D. Rupture d’alliance contre rupture de filiation: Le cas de la drépanocytose. In: Dozon J-P, Fassin D, éditeurs. Critique de la santé publique: Une approche anthropologique. Paris: Balland; 2001. pp. 257-280. (Voix et Regards)\n'},{id:"B3",body:'\nWorld Health Organization. Sickle cell anaemia. Agenda item 11.4. 59th World Health Assembly [Internet]. 2006. Disponible sur: http://www.who.int/gb/ebwha/pdf_files/WHA59-REC1/e/WHA59_2006_REC1 [cité 12 juin 2012]\n'},{id:"B4",body:'\nGernet S, Mestre C, Runel-Belliard C. Du pays d’origine au pays «d’accueil»: Perception de la maladie chez 26 familles drépanocytaires suivies au CHU de Bordeaux. Journal de pédiatrie et de puériculture. 2012;25(6):309-315. Disponible sur: http://www.em-consulte.com/en/article/771297 [cité 14 juill 2017]\n'},{id:"B5",body:'\nNjifon Nsangou H, Falck J, Scelles R. Culture familiale de la drépanocytose et image du corps chez les enfants atteints. Annales Médico-psychologiques, revue psychiatrique. 2019. Disponible sur: http://www.sciencedirect.com/science/article/pii/S0003448719302999 [cité 3 déc 2019]\n'},{id:"B6",body:'\nOrganisation Mondiale de la Santé. Drépanocytose: Une stratégie pour la Région africaine de l’OMS: Rapport du Directeur régional. OMS. Bureau régional de l’Afrique 2011. Disponible sur: http://www.who.int/iris/handle/10665/1727 [cité 7 juill 2017]\n'},{id:"B7",body:'\nWeatherall DJ, Clegg JB. Inherited haemoglobin disorders: An increasing global health problem. Bulletin of the World Health Organization. 2001;79(8):704-712. Disponible sur: http://www.scielosp.org/scielo.php?script=sci_abstract&pid=S0042-96862001000800005&lng=en&nrm=iso&tlng=en [cité 9 juill 2017]\n'},{id:"B8",body:'\nPradère J, Drain É, Taïeb O, Dutray B, Abbal T, Champion M, et al. Le travail de guérison d’une maladie chronique de l’enfant: Enjeux, processus et vulnérabilités. La Psychiatrie de l’Enfant. 2008;51(1):73-124. Disponible sur: http://www.cairn.info/revue-la-psychiatrie-de-l-enfant-2008-1-p-73.htm [cité 7 juill 2017]\n'},{id:"B9",body:'\nd’Autume C, Cavadini R, Giannica D, Drain É, Giraud F, Moro MR, et al. «Le sang de mon frère». Expérience de la greffe intrafamiliale à travers dessins et discours d’enfants drépanocytaires, « My brother’s blood ». The experience of an intrafamilial transplant through drawings and the words of drepanocytic children. La Psychiatrie de l’Enfant. 2015;57(2):355-408. Disponible sur: http://www.cairn.info/revue-la-psychiatrie-de-l-enfant-2014-2-p-355.htm [cité 12 juill 2017]\n'},{id:"B10",body:'\nMbassa Menick D, Ngoh F. Maltraitance psychologique d’enfants drépanocytaires au Cameroun: Description et analyse de cas. Médecine Tropicale. 2001;61:163-168\n'},{id:"B11",body:'\nFotso-Djemo J-B. Le regard de l’autre: Médecine traditionnelle africaine. Paris: Agence de Coopération Culturelle et Technique EdSilex; 1982. 447 p\n'},{id:"B12",body:'\nKeita T. Phénoménologie traditionnelle de l’enfance en Afrique. In: Itoua F, Tettekpoe DA, Traoré A, Keita T, M’Baye M, Kotto E, et al., éditeurs. Famille, enfant et développement en Afrique. Paris: Uneso; 1988. pp. 99-139\n'},{id:"B13",body:'\nBonnet D. Au-delà du gène et de la culture. Hommes et Migrations. 2000;1225(1):23-38. Disponible sur: http://www.persee.fr/doc/homig_1142-852x_2000_num_1225_1_3508 [cité 3 juill 2017]\n'},{id:"B14",body:'\nTsala Tsala J-P. Familles africaines en thérapie : Clinique de la famille camerounaise. Paris: Editions L’Harmattan; 2009. 268 p\n'},{id:"B15",body:'\nBouchaud O. Intégrer les représentations culturelles dans la prise en charge des migrants. La Santé de l’Homme. 2007;392:25-27. Disponible sur: http://inpes.santepubliquefrance.fr/SLH/articles/392/03.htm [cité 7 mars 2017]\n'},{id:"B16",body:'\nNdjiengwe F. Du stigmate physique au marquage symbolique: Évolution de la construction identitaire dans la drépanocytose. In: Lainé A, Bonnet D, Keclard L, Romana M, éditeurs. La drépanocytose Regards croisés sur une maladie orpheline. Paris: KARTHALA Editions; 2004. pp. 221-228\n'},{id:"B17",body:'\nOhene-Frempong K, Weiner SJ, Sleeper LA, Miller ST, Embury S, Moohr JW, et al. Cerebrovascular accidents in sickle cell disease: Rates and risk factors. Blood. 1998;91(1):288-294. Disponible sur: http://www.bloodjournal.org/content/91/1/288 [cité 7 juill 2017]\n'},{id:"B18",body:'\nNjamnshi AK, Mbong EN, Wonkam A, Ongolo-Zogo P, Djientcheu VD, Sunjoh FL, et al. The epidemiology of stroke in sickle cell patients in Yaounde, Cameroon. Journal of the Neurological Sciences. 2006;250(1):79-84. Disponible sur: http://www.sciencedirect.com/science/article/pii/S0022510X06003327 [cité 7 juill 2017]\n'},{id:"B19",body:'\nKamdem A. L’évolution des pratiques dans la prise en charge de la drépanocytose chez l’enfant. In: 4ème symposium international du Réseau d’Etude de la Drépanocytose en Afrique Centrale (REDAC). Yaoundé; 2013. pp. 12-14\n'},{id:"B20",body:'\nBenkerrou M. Place de la greffe de cellules souches hématopoïétiques dans la drépanocytose. In: 4ème symposium international du Réseau d’Etude de la Drépanocytose en Afrique Centrale (REDAC). Yaoundé; 2013. pp. 30-33\n'},{id:"B21",body:'\nLainé A. Parents d’enfants drépanocytaires face à la maladie et au système de soin. [Internet]. Paris; 2007. Disponible sur: https://hal.archives-ouvertes.fr/hal-00326056 [cité 13 juill 2017]\n'},{id:"B22",body:'\nDrain E, Pradère J, Taieb O, Dutray B, Champion M, Bonnet D, et al. Processus de guérison d’une maladie chronique: La drépanocytose traitée par allogreffe de cellules souches hématopoïétiques: Principaux résultats chez les adolescents. Neuropsychiatrie de l’Enfance et de l’Adolescence. 2008;56(4-5):305-310. Disponible sur: http://www.documentation.ird.fr/hor/fdi:010047377 [cité 4 juill 2017]\n'},{id:"B23",body:'\nMboussou M. Soigner en rond : Sur le front du Partage de l’espace thérapeutique en Afrique noire. Nervure. 2002;1(15):22-25\n'},{id:"B24",body:'\nMbassa Menick D. Les représentations sociales et culturelles du handicap de l’enfant en Afrique noire, Social and cultural perceptions of child disability in Subsaharian Africa. Perspectives Psy. 2015;54(1):30-43. Disponible sur: http://www.cairn.info/revue-perspectives-psy-2015-1-p-30.htm [cité 7 juill 2017]\n'},{id:"B25",body:'\nMenick DM, Simliwa DK. Nouvelles religiosités en Afrique: Des croyants à l’épreuve de la folie. Perspectives Psy. 2007;46(4):387-404. Disponible sur: http://www.cairn.info/revue-perspectives-psy-2007-4-p-387.htm [cité 7 juill 2017]\n'},{id:"B26",body:'\nTsala Tsala J-P. Secret de famille et clinique de la famille africaine. Le Divan familial. 2010;19:31-46. Disponible sur: http://www.cairn.info/revue-le-divan-familial-2007-2-p-31.htm [cité 9 juill 2017]\n'},{id:"B27",body:'\nEkomo Engolo C. Mutations socio-économiques et conditions de vie des ménages ruraux au Cameroun. Revue Française de Sociologie. 2001;42(2):281-294. Disponible sur: https://www.persee.fr/doc/rfsoc_0035-2969_2001_num_42_2_5355 [cité 21 mai 2018]\n'},{id:"B28",body:'\nScelles R. Liens fraternels et handicap: De l’enfance à l’âge adulte, souffrances et ressources. Toulouse: Érès; 2010\n'},{id:"B29",body:'\nScelles R. Frères et soeurs, complices et rivaux. Paris: Fleurus; 2003. 150 p (Le métier de parents)\n'},{id:"B30",body:'\nEvans RC, Burlew AK, Oler CH. Children with sickle-cell anemia: Parental relations, parent-child relations, and child behavior. Social Work. 1988;33(2):127-130. Disponible sur: https://academic.oup.com/sw/article/33/2/127/1897973/Children-with-Sickle-Cell-Anemia-Parental [cité 14 juill 2017]\n'},{id:"B31",body:'\nAdegoke SA, Kuteyi EA. Psychosocial burden of sickle cell disease on the family, Nigeria: Original research. African Journal of Primary Health Care and Family Medicine. 2012;4(1):1-6. Disponible sur: https://journals.co.za/content/phcfm/4/1/EJC133881 [cité 14 juill 2017]\n'},{id:"B32",body:'\nAssimadi JK, Gbadoé AD, Nyadanu M. L’impact familial de la drépanocytose au Togo. Archives de Pédiatrie. 2000;7(6):615-620. Disponible sur: http://www.sciencedirect.com/science/article/pii/S0929693X00801281 [cité 14 juill 2017]\n'},{id:"B33",body:'\nBurlew AK, Evans R, Oler C. The impact of a child with sickle cell disease on family dynamics. Annals of the New York Academy of Sciences. 1989;565:161-171\n'},{id:"B34",body:'\nLuboya E, Tshilonda J-CB, Ekila MB, Aloni MN. Répercussions psychosociales de la drépanocytose sur les parents d’enfants vivant à Kinshasa, République Démocratique du Congo: Une étude qualitative. The Pan African Medical Journal. 2014;19. Disponible sur: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4282867/ [cité 14 juill 2017]\n'},{id:"B35",body:'\nGesteira ECR, Bousso RS, Misko MD, Ichikawa CRF, Oliveira PP. Families of children with sickle cell disease: An integrative review. Online Brazilian Journal of Nursing. 2016;15(2):276-290. Disponible sur: http://www.objnursing.uff.br/index.php/nursing/article/view/5289 [cité 14 juill 2017]\n'},{id:"B36",body:'\nNjifon Nsangou H, Scelles R. Drépanocytose et fratrie: Regard croisé du vécu d’une sœur et d’un frère d’un enfant malade. Journal de Pédiatrie et de Puériculture. 2019;32(2):75-84. Disponible sur: http://www.sciencedirect.com/science/article/pii/S0987798319300295 [cité 29 mars 2019]\n'},{id:"B37",body:'\nSouley A. «Emassi»: Discours autour de la drépanocytose en milieu Haoussa au Niger. In: Lainé A, Bonnet D, Keclard L, Romana M, éditeurs. La Drépanocytose: Regards croisés sur une maladie orpheline. Paris: Karthala; 2004. pp. 141-169\n'},{id:"B38",body:'\nAnate K. L’imaginaire de la communication à travers le concept de parole en Afrique et en Occident. Communication et organisation. 2002;22:12-21. Disponible sur: http://journals.openedition.org/communicationorganisation/2773 [cité 23 août 2018]\n'},{id:"B39",body:'\nMappa S. Pouvoirs traditionnels et pouvoir d’Etat en Afrique: L’illusion universaliste. Paris: Karthala Editions; 1998. 210 p\n'},{id:"B40",body:'\nOrtigue MC, Ortigue E. Oedipe africain. Plon; 1973\n'},{id:"B41",body:'\nJourdan C, Lachance J. Le dessin de famille: Présentation, grille de cotation, éléments d’interprétation. Paris: EAP Editions et Applications Psychologiques; 2000\n'},{id:"B42",body:'\nTsala Tsala J-P. Test du dessin de famille et familles africaines. Le cas du Cameroun. Problèmes et méthodologie de la recherche. Annales de la Faculté des Arts. Lettres et Sciences Humaines. 1990;VI(1 et 2):201-216\n'},{id:"B43",body:'\nBello MM, Giannotti A. Renaître en pays dendi. Couvade et possession au nord Benin. Paris: Le Grand Jardin; 2017. 164 p\n'},{id:"B44",body:'\nBurguet D. Au fil du récit d’un devin-guérisseur. Alliances avec les esprits ancestraux et de la nature (Vonizongo, Imerina). Études océan Indien. 2014;51-52. Disponible sur: http://journals.openedition.org/oceanindien/1560 [cité 13 oct 2018]\n'},{id:"B45",body:'\nSow I. Les structures anthropologiques de la folie en Afrique Noire. Paris: Payot; 1978\n'},{id:"B46",body:'\nMbassa Menick D. Famille, Foi, Folie et Soins en Afrique. Une pluralité des recours thérapeutiques complémentaires. Paris: Paari; 2018\n'},{id:"B47",body:'\nFaye SL. Quand les tradithérapeutes ouest-africains soignent l’infertilité conjugale à Dakar (Sénégal): Recompositions et dynamiques entrepreneuriales. Anthropologie & Santé Revue internationale francophone d’anthropologie de la santé. 2011;3. Disponible sur: http://journals.openedition.org/anthropologiesante/755 [cité 27 août 2018]\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Hassan Njifon Nsangou",address:"hassannji75@yahoo.fr",affiliation:'
Département de Philosophie-Psychologie-Sociologie, Université de Dschang, Cameroon
Laboratoire Clipsyd, Université Paris Nanterre, France
Laboratoire Clipsyd, Université Paris Nanterre, France
'}],corrections:null},book:{id:"9027",title:"Human Blood Group Systems and Haemoglobinopathies",subtitle:null,fullTitle:"Human Blood Group Systems and Haemoglobinopathies",slug:"human-blood-group-systems-and-haemoglobinopathies",publishedDate:"February 17th 2021",bookSignature:"Osaro Erhabor and Anjana Munshi",coverURL:"https://cdn.intechopen.com/books/images_new/9027.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",editors:[{id:"35140",title:null,name:"Osaro",middleName:null,surname:"Erhabor",slug:"osaro-erhabor",fullName:"Osaro Erhabor"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}}},profile:{item:{id:"309845",title:"Dr.",name:"Parwsha",middleName:null,surname:"Zaib",email:"parwshazaib@yahoo.com",fullName:"Parwsha Zaib",slug:"parwsha-zaib",position:null,biography:null,institutionString:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",totalCites:0,totalChapterViews:"0",outsideEditionCount:0,totalAuthoredChapters:"1",totalEditedBooks:"0",personalWebsiteURL:null,twitterURL:null,linkedinURL:null,institution:null},booksEdited:[],chaptersAuthored:[{title:"Introductory Chapter: Recent Trends in “Cotton Research”",slug:"introductory-chapter-recent-trends-in-cotton-research-",abstract:null,signatures:"Parwasha Zaib, Muhammad Iqbal, Roshina Shahzadi, Hafiz Muhammad Ahmad, Bilal Rasool, Shahbaz Ali Khan and Mahmood-ur-Rahman Ansari",authors:[{id:"185476",title:"Dr.",name:"Mahmood-Ur-",surname:"Rahman Ansari",fullName:"Mahmood-Ur- Rahman Ansari",slug:"mahmood-ur-rahman-ansari",email:"mahmood1233@yahoo.com"},{id:"252872",title:"Dr.",name:"Muhammad",surname:"Iqbal",fullName:"Muhammad Iqbal",slug:"muhammad-iqbal",email:"iqbal.farhad@gmx.at"},{id:"291187",title:"Ph.D. Student",name:"Hafiz",surname:"Muhammad Ahmad",fullName:"Hafiz Muhammad Ahmad",slug:"hafiz-muhammad-ahmad",email:"hafizahmad90@yahoo.com"},{id:"306496",title:"Dr.",name:"Bilal",surname:"Rasool",fullName:"Bilal Rasool",slug:"bilal-rasool",email:"bilalisb2001@yahoo.com"},{id:"309845",title:"Dr.",name:"Parwsha",surname:"Zaib",fullName:"Parwsha Zaib",slug:"parwsha-zaib",email:"parwshazaib@yahoo.com"},{id:"309846",title:"Dr.",name:"Roshina",surname:"Shahzadi",fullName:"Roshina Shahzadi",slug:"roshina-shahzadi",email:"roshina_shahzadi32@yahoo.com"},{id:"309847",title:"Dr.",name:"Bilal",surname:"Rasool",fullName:"Bilal Rasool",slug:"bilal-rasool",email:"shahbaz_2010@live.com"}],book:{title:"Advances in Cotton Research",slug:"advances-in-cotton-research",productType:{id:"1",title:"Edited Volume"}}}],collaborators:[{id:"185476",title:"Dr.",name:"Mahmood-Ur-",surname:"Rahman Ansari",slug:"mahmood-ur-rahman-ansari",fullName:"Mahmood-Ur- Rahman Ansari",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/185476/images/system/185476.jpg",biography:"Dr. Mahmood-ur-Rahman Ansari is an Associate Professor of Molecular Biology at the Department of Bioinformatics and Biotechnology, GC University – Faisalabad, Pakistan. He received his BSc (Hons) in Plant Breeding and Genetics from the University of Agriculture, Faisalabad, Pakistan in 2003. He received his MPhil and Ph.D. in Molecular Biology from the National Centre of Excellence in Molecular Biology, Lahore, Pakistan in 2006 and 2011 respectively. He has published over 60 papers in international peer-reviewed journals in the field of Molecular Biology, Biotechnology, and Bioinformatics. He has also published over 10 book chapters and edited 3 books. He is involved in research projects to understand the molecular mechanisms of stress tolerance in plants. He has been involved in genetic modification of rice and cotton, their greenhouse and field testing as well as biosafety studies. He is a member of various national and international professional societies.",institutionString:"GC University",institution:null},{id:"250521",title:"Mr.",name:"Muhammad",surname:"Farooq",slug:"muhammad-farooq",fullName:"Muhammad Farooq",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"252872",title:"Dr.",name:"Muhammad",surname:"Iqbal",slug:"muhammad-iqbal",fullName:"Muhammad Iqbal",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"281663",title:"Dr.",name:"Muhammad Rafiq",surname:"Shahid",slug:"muhammad-rafiq-shahid",fullName:"Muhammad Rafiq Shahid",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/281663/images/system/281663.jpg",biography:"Dr. Muhammad Rafiq Shahid has a 12 year research experience in cotton pest management. He currently works at Cotton Research Institute Multan, Pakistan. He is the project manager / team leader of 2 different projects and author of 30 research publications.",institutionString:"Central Cotton Research Institute Multan",institution:null},{id:"281741",title:"Dr.",name:"Muhammad",surname:"Shakeel",slug:"muhammad-shakeel",fullName:"Muhammad Shakeel",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"281743",title:"Dr.",name:"Saghir",surname:"Ahmad",slug:"saghir-ahmad",fullName:"Saghir Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/281743/images/system/281743.jpg",biography:"Dr. Saghir Ahmad has a research experience of 30 years in cotton breeding, during which he bred 6 prominent cotton cultivars. He currently works at Cotton Research Institute Multan, Multan and Ayub Agricultural Research Institute, Faisalabad (Pakistan). He successfully worked as project manager and team leader of 4 different projects. He authored 60 research publications, and traveled and attended conferences in different countries, including USA, Australia, and China.",institutionString:"Central Cotton Research Institute Multan",institution:null},{id:"281744",title:"Dr.",name:"Abid",surname:"Mahmood",slug:"abid-mahmood",fullName:"Abid Mahmood",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"291898",title:"Associate Prof.",name:"Rafat",surname:"Al Afif",slug:"rafat-al-afif",fullName:"Rafat Al Afif",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"291903",title:"Prof.",name:"Christoph",surname:"Pfeifer",slug:"christoph-pfeifer",fullName:"Christoph Pfeifer",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"291904",title:"Prof.",name:"Tobias",surname:"Pröll",slug:"tobias-proll",fullName:"Tobias Pröll",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null}]},generic:{page:{slug:"horizon-2020-compliance",title:"Horizon 2020 Compliance",intro:'
General requirements for Open Access to Horizon 2020 research project outputs are found within Guidelines on Open Access to Scientific Publication and Research Data in Horizon 2020. The guidelines, in their simplest form, state that if you are a Horizon 2020 recipient, you must ensure open access to your scientific publications by enabling them to be downloaded, printed and read online. Additionally, said publications must be peer reviewed.
',metaTitle:"Horizon 2020 Compliance",metaDescription:"General requirements for Open Access to Horizon 2020 research project outputs are found within Guidelines on Open Access to Scientific Publication and Research Data in Horizon 2020. The guidelines, in their simplest form, state that if you are a Horizon 2020 recipient, you must ensure open access to your scientific publications by enabling them to be downloaded, printed and read online. Additionally, said publications must be peer reviewed. ",metaKeywords:null,canonicalURL:null,contentRaw:'[{"type":"htmlEditorComponent","content":"
Publishing with IntechOpen means that your scientific publications already meet these basic requirements. It also means that through our utilization of open licensing, our publications are also able to be copied, shared, searched, linked, crawled, and mined for text and data, optimizing our authors' compliance as suggested by the European Commission.
\\n\\n
Metadata for all publications is also automatically deposited in IntechOpen's OAI repository, making them available through the Open Access Infrastructure for Research in Europe's (OpenAIRE) search interface further establishing our compliance.
\\n\\n
In other words, publishing with IntechOpen guarantees compliance.
When choosing a publication, Horizon 2020 grant recipients are encouraged to provide open access to various types of scientific publications including monographs, edited books and conference proceedings.
\\n\\n
IntechOpen publishes all of the aforementioned formats in compliance with the requirements and criteria established by the European Commission for the Horizon 2020 Program.
\\n\\n
Authors requiring additional information are welcome to send their inquiries to funders@intechopen.com
Publishing with IntechOpen means that your scientific publications already meet these basic requirements. It also means that through our utilization of open licensing, our publications are also able to be copied, shared, searched, linked, crawled, and mined for text and data, optimizing our authors' compliance as suggested by the European Commission.
\n\n
Metadata for all publications is also automatically deposited in IntechOpen's OAI repository, making them available through the Open Access Infrastructure for Research in Europe's (OpenAIRE) search interface further establishing our compliance.
\n\n
In other words, publishing with IntechOpen guarantees compliance.
When choosing a publication, Horizon 2020 grant recipients are encouraged to provide open access to various types of scientific publications including monographs, edited books and conference proceedings.
\n\n
IntechOpen publishes all of the aforementioned formats in compliance with the requirements and criteria established by the European Commission for the Horizon 2020 Program.
\n\n
Authors requiring additional information are welcome to send their inquiries to funders@intechopen.com
\n'}]},successStories:{items:[]},authorsAndEditors:{filterParams:{sort:"featured,name"},profiles:[{id:"6700",title:"Dr.",name:"Abbass A.",middleName:null,surname:"Hashim",slug:"abbass-a.-hashim",fullName:"Abbass A. Hashim",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/6700/images/1864_n.jpg",biography:"Currently I am carrying out research in several areas of interest, mainly covering work on chemical and bio-sensors, semiconductor thin film device fabrication and characterisation.\nAt the moment I have very strong interest in radiation environmental pollution and bacteriology treatment. The teams of researchers are working very hard to bring novel results in this field. I am also a member of the team in charge for the supervision of Ph.D. students in the fields of development of silicon based planar waveguide sensor devices, study of inelastic electron tunnelling in planar tunnelling nanostructures for sensing applications and development of organotellurium(IV) compounds for semiconductor applications. I am a specialist in data analysis techniques and nanosurface structure. I have served as the editor for many books, been a member of the editorial board in science journals, have published many papers and hold many patents.",institutionString:null,institution:{name:"Sheffield Hallam University",country:{name:"United Kingdom"}}},{id:"54525",title:"Prof.",name:"Abdul Latif",middleName:null,surname:"Ahmad",slug:"abdul-latif-ahmad",fullName:"Abdul Latif Ahmad",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"20567",title:"Prof.",name:"Ado",middleName:null,surname:"Jorio",slug:"ado-jorio",fullName:"Ado Jorio",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidade Federal de Minas Gerais",country:{name:"Brazil"}}},{id:"47940",title:"Dr.",name:"Alberto",middleName:null,surname:"Mantovani",slug:"alberto-mantovani",fullName:"Alberto Mantovani",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"12392",title:"Mr.",name:"Alex",middleName:null,surname:"Lazinica",slug:"alex-lazinica",fullName:"Alex Lazinica",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/12392/images/7282_n.png",biography:"Alex Lazinica is the founder and CEO of IntechOpen. After obtaining a Master's degree in Mechanical Engineering, he continued his PhD studies in Robotics at the Vienna University of Technology. Here he worked as a robotic researcher with the university's Intelligent Manufacturing Systems Group as well as a guest researcher at various European universities, including the Swiss Federal Institute of Technology Lausanne (EPFL). During this time he published more than 20 scientific papers, gave presentations, served as a reviewer for major robotic journals and conferences and most importantly he co-founded and built the International Journal of Advanced Robotic Systems- world's first Open Access journal in the field of robotics. Starting this journal was a pivotal point in his career, since it was a pathway to founding IntechOpen - Open Access publisher focused on addressing academic researchers needs. Alex is a personification of IntechOpen key values being trusted, open and entrepreneurial. Today his focus is on defining the growth and development strategy for the company.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"19816",title:"Prof.",name:"Alexander",middleName:null,surname:"Kokorin",slug:"alexander-kokorin",fullName:"Alexander Kokorin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/19816/images/1607_n.jpg",biography:"Alexander I. Kokorin: born: 1947, Moscow; DSc., PhD; Principal Research Fellow (Research Professor) of Department of Kinetics and Catalysis, N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow.\r\nArea of research interests: physical chemistry of complex-organized molecular and nanosized systems, including polymer-metal complexes; the surface of doped oxide semiconductors. He is an expert in structural, absorptive, catalytic and photocatalytic properties, in structural organization and dynamic features of ionic liquids, in magnetic interactions between paramagnetic centers. The author or co-author of 3 books, over 200 articles and reviews in scientific journals and books. He is an actual member of the International EPR/ESR Society, European Society on Quantum Solar Energy Conversion, Moscow House of Scientists, of the Board of Moscow Physical Society.",institutionString:null,institution:{name:"Semenov Institute of Chemical Physics",country:{name:"Russia"}}},{id:"62389",title:"PhD.",name:"Ali Demir",middleName:null,surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62389/images/3413_n.jpg",biography:"Dr. Ali Demir Sezer has a Ph.D. from Pharmaceutical Biotechnology at the Faculty of Pharmacy, University of Marmara (Turkey). He is the member of many Pharmaceutical Associations and acts as a reviewer of scientific journals and European projects under different research areas such as: drug delivery systems, nanotechnology and pharmaceutical biotechnology. Dr. Sezer is the author of many scientific publications in peer-reviewed journals and poster communications. Focus of his research activity is drug delivery, physico-chemical characterization and biological evaluation of biopolymers micro and nanoparticles as modified drug delivery system, and colloidal drug carriers (liposomes, nanoparticles etc.).",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"61051",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"100762",title:"Prof.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"St David's Medical Center",country:{name:"United States of America"}}},{id:"107416",title:"Dr.",name:"Andrea",middleName:null,surname:"Natale",slug:"andrea-natale",fullName:"Andrea Natale",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Texas Cardiac Arrhythmia",country:{name:"United States of America"}}},{id:"64434",title:"Dr.",name:"Angkoon",middleName:null,surname:"Phinyomark",slug:"angkoon-phinyomark",fullName:"Angkoon Phinyomark",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/64434/images/2619_n.jpg",biography:"My name is Angkoon Phinyomark. I received a B.Eng. degree in Computer Engineering with First Class Honors in 2008 from Prince of Songkla University, Songkhla, Thailand, where I received a Ph.D. degree in Electrical Engineering. My research interests are primarily in the area of biomedical signal processing and classification notably EMG (electromyography signal), EOG (electrooculography signal), and EEG (electroencephalography signal), image analysis notably breast cancer analysis and optical coherence tomography, and rehabilitation engineering. I became a student member of IEEE in 2008. During October 2011-March 2012, I had worked at School of Computer Science and Electronic Engineering, University of Essex, Colchester, Essex, United Kingdom. In addition, during a B.Eng. I had been a visiting research student at Faculty of Computer Science, University of Murcia, Murcia, Spain for three months.\n\nI have published over 40 papers during 5 years in refereed journals, books, and conference proceedings in the areas of electro-physiological signals processing and classification, notably EMG and EOG signals, fractal analysis, wavelet analysis, texture analysis, feature extraction and machine learning algorithms, and assistive and rehabilitative devices. I have several computer programming language certificates, i.e. Sun Certified Programmer for the Java 2 Platform 1.4 (SCJP), Microsoft Certified Professional Developer, Web Developer (MCPD), Microsoft Certified Technology Specialist, .NET Framework 2.0 Web (MCTS). I am a Reviewer for several refereed journals and international conferences, such as IEEE Transactions on Biomedical Engineering, IEEE Transactions on Industrial Electronics, Optic Letters, Measurement Science Review, and also a member of the International Advisory Committee for 2012 IEEE Business Engineering and Industrial Applications and 2012 IEEE Symposium on Business, Engineering and Industrial Applications.",institutionString:null,institution:{name:"Joseph Fourier University",country:{name:"France"}}},{id:"55578",title:"Dr.",name:"Antonio",middleName:null,surname:"Jurado-Navas",slug:"antonio-jurado-navas",fullName:"Antonio Jurado-Navas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/55578/images/4574_n.png",biography:"Antonio Jurado-Navas received the M.S. degree (2002) and the Ph.D. degree (2009) in Telecommunication Engineering, both from the University of Málaga (Spain). He first worked as a consultant at Vodafone-Spain. From 2004 to 2011, he was a Research Assistant with the Communications Engineering Department at the University of Málaga. In 2011, he became an Assistant Professor in the same department. From 2012 to 2015, he was with Ericsson Spain, where he was working on geo-location\ntools for third generation mobile networks. Since 2015, he is a Marie-Curie fellow at the Denmark Technical University. His current research interests include the areas of mobile communication systems and channel modeling in addition to atmospheric optical communications, adaptive optics and statistics",institutionString:null,institution:{name:"University of Malaga",country:{name:"Spain"}}}],filtersByRegion:[{group:"region",caption:"North America",value:1,count:5816},{group:"region",caption:"Middle and South America",value:2,count:5281},{group:"region",caption:"Africa",value:3,count:1754},{group:"region",caption:"Asia",value:4,count:10511},{group:"region",caption:"Australia and Oceania",value:5,count:906},{group:"region",caption:"Europe",value:6,count:15913}],offset:12,limit:12,total:119061},chapterEmbeded:{data:{}},editorApplication:{success:null,errors:{}},ofsBooks:{filterParams:{topicId:"1175"},books:[],filtersByTopic:[{group:"topic",caption:"Agricultural and Biological Sciences",value:5,count:26},{group:"topic",caption:"Biochemistry, Genetics and Molecular Biology",value:6,count:8},{group:"topic",caption:"Business, Management and Economics",value:7,count:3},{group:"topic",caption:"Chemistry",value:8,count:11},{group:"topic",caption:"Computer and Information Science",value:9,count:9},{group:"topic",caption:"Earth and Planetary Sciences",value:10,count:9},{group:"topic",caption:"Engineering",value:11,count:25},{group:"topic",caption:"Environmental Sciences",value:12,count:2},{group:"topic",caption:"Immunology and Microbiology",value:13,count:4},{group:"topic",caption:"Materials Science",value:14,count:7},{group:"topic",caption:"Mathematics",value:15,count:2},{group:"topic",caption:"Medicine",value:16,count:45},{group:"topic",caption:"Neuroscience",value:18,count:3},{group:"topic",caption:"Pharmacology, Toxicology and Pharmaceutical Science",value:19,count:3},{group:"topic",caption:"Physics",value:20,count:4},{group:"topic",caption:"Psychology",value:21,count:4},{group:"topic",caption:"Robotics",value:22,count:1},{group:"topic",caption:"Social Sciences",value:23,count:3},{group:"topic",caption:"Technology",value:24,count:1},{group:"topic",caption:"Veterinary Medicine and Science",value:25,count:2}],offset:12,limit:12,total:0},popularBooks:{featuredBooks:[{type:"book",id:"8472",title:"Bioactive Compounds in Nutraceutical and Functional Food for Good Human Health",subtitle:null,isOpenForSubmission:!1,hash:"8855452919b8495810ef8e88641feb20",slug:"bioactive-compounds-in-nutraceutical-and-functional-food-for-good-human-health",bookSignature:"Kavita Sharma, Kanchan Mishra, Kula Kamal Senapati and Corina Danciu",coverURL:"https://cdn.intechopen.com/books/images_new/8472.jpg",editors:[{id:"197731",title:"Dr.",name:"Kavita",middleName:null,surname:"Sharma",slug:"kavita-sharma",fullName:"Kavita Sharma"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9685",title:"Agroecosystems",subtitle:"Very Complex Environmental Systems",isOpenForSubmission:!1,hash:"c44f7b43a9f9610c243dc32300d37df6",slug:"agroecosystems-very-complex-environmental-systems",bookSignature:"Marcelo L. Larramendy and Sonia Soloneski",coverURL:"https://cdn.intechopen.com/books/images_new/9685.jpg",editors:[{id:"14764",title:"Dr.",name:"Marcelo L.",middleName:null,surname:"Larramendy",slug:"marcelo-l.-larramendy",fullName:"Marcelo L. Larramendy"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8564",title:"Cell Interaction",subtitle:"Molecular and Immunological Basis for Disease Management",isOpenForSubmission:!1,hash:"98d7f080d80524285f091e72a8e92a6d",slug:"cell-interaction-molecular-and-immunological-basis-for-disease-management",bookSignature:"Bhawana Singh",coverURL:"https://cdn.intechopen.com/books/images_new/8564.jpg",editors:[{id:"315192",title:"Dr.",name:"Bhawana",middleName:null,surname:"Singh",slug:"bhawana-singh",fullName:"Bhawana Singh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9629",title:"Electroencephalography",subtitle:"From Basic Research to Clinical Applications",isOpenForSubmission:!1,hash:"8147834b6c6deeeec40f407c71ad60b4",slug:"electroencephalography-from-basic-research-to-clinical-applications",bookSignature:"Hideki Nakano",coverURL:"https://cdn.intechopen.com/books/images_new/9629.jpg",editors:[{id:"196461",title:"Prof.",name:"Hideki",middleName:null,surname:"Nakano",slug:"hideki-nakano",fullName:"Hideki Nakano"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8760",title:"Structure Topology and Symplectic Geometry",subtitle:null,isOpenForSubmission:!1,hash:"8974840985ec3652492c83e20233bf02",slug:"structure-topology-and-symplectic-geometry",bookSignature:"Kamal Shah and Min Lei",coverURL:"https://cdn.intechopen.com/books/images_new/8760.jpg",editors:[{id:"231748",title:"Dr.",name:"Kamal",middleName:null,surname:"Shah",slug:"kamal-shah",fullName:"Kamal Shah"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9161",title:"Frailty in the Elderly",subtitle:"Understanding and Managing Complexity",isOpenForSubmission:!1,hash:"a4f0f2fade8fb8ba35c405f5ad31a823",slug:"frailty-in-the-elderly-understanding-and-managing-complexity",bookSignature:"Sara Palermo",coverURL:"https://cdn.intechopen.com/books/images_new/9161.jpg",editors:[{id:"233998",title:"Ph.D.",name:"Sara",middleName:null,surname:"Palermo",slug:"sara-palermo",fullName:"Sara Palermo"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8445",title:"Dam Engineering",subtitle:"Recent Advances in Design and Analysis",isOpenForSubmission:!1,hash:"a7e4d2ecbc65d78fa7582e0d2e143906",slug:"dam-engineering-recent-advances-in-design-and-analysis",bookSignature:"Zhongzhi Fu and Erich Bauer",coverURL:"https://cdn.intechopen.com/books/images_new/8445.jpg",editors:[{id:"249577",title:"Dr.",name:"Zhongzhi",middleName:null,surname:"Fu",slug:"zhongzhi-fu",fullName:"Zhongzhi Fu"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9385",title:"Renewable Energy",subtitle:"Technologies and Applications",isOpenForSubmission:!1,hash:"a6b446d19166f17f313008e6c056f3d8",slug:"renewable-energy-technologies-and-applications",bookSignature:"Tolga Taner, Archana Tiwari and Taha Selim Ustun",coverURL:"https://cdn.intechopen.com/books/images_new/9385.jpg",editors:[{id:"197240",title:"Associate Prof.",name:"Tolga",middleName:null,surname:"Taner",slug:"tolga-taner",fullName:"Tolga Taner"}],equalEditorOne:{id:"186791",title:"Dr.",name:"Archana",middleName:null,surname:"Tiwari",slug:"archana-tiwari",fullName:"Archana Tiwari",profilePictureURL:"https://mts.intechopen.com/storage/users/186791/images/system/186791.jpg",biography:"Dr. Archana Tiwari is Associate Professor at Amity University, India. Her research interests include renewable sources of energy from microalgae and further utilizing the residual biomass for the generation of value-added products, bioremediation through microalgae and microbial consortium, antioxidative enzymes and stress, and nutraceuticals from microalgae. She has been working on algal biotechnology for the last two decades. She has published her research in many international journals and has authored many books and chapters with renowned publishing houses. She has also delivered talks as an invited speaker at many national and international conferences. Dr. Tiwari is the recipient of several awards including Researcher of the Year and Distinguished Scientist.",institutionString:"Amity University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Amity University",institutionURL:null,country:{name:"India"}}},equalEditorTwo:{id:"197609",title:"Prof.",name:"Taha Selim",middleName:null,surname:"Ustun",slug:"taha-selim-ustun",fullName:"Taha Selim Ustun",profilePictureURL:"https://mts.intechopen.com/storage/users/197609/images/system/197609.jpeg",biography:"Dr. Taha Selim Ustun received a Ph.D. in Electrical Engineering from Victoria University, Melbourne, Australia. He is a researcher with the Fukushima Renewable Energy Institute, AIST (FREA), where he leads the Smart Grid Cybersecurity Laboratory. Prior to that, he was a faculty member with the School of Electrical and Computer Engineering, Carnegie Mellon University, Pittsburgh, PA, USA. His current research interests include power systems protection, communication in power networks, distributed generation, microgrids, electric vehicle integration, and cybersecurity in smart grids. He serves on the editorial boards of IEEE Access, IEEE Transactions on Industrial Informatics, Energies, Electronics, Electricity, World Electric Vehicle and Information journals. Dr. Ustun is a member of the IEEE 2004 and 2800, IEC Renewable Energy Management WG 8, and IEC TC 57 WG17. He has been invited to run specialist courses in Africa, India, and China. He has delivered talks for the Qatar Foundation, the World Energy Council, the Waterloo Global Science Initiative, and the European Union Energy Initiative (EUEI). His research has attracted funding from prestigious programs in Japan, Australia, the European Union, and North America.",institutionString:"Fukushima Renewable Energy Institute, AIST (FREA)",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"National Institute of Advanced Industrial Science and Technology",institutionURL:null,country:{name:"Japan"}}},equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8937",title:"Soil Moisture Importance",subtitle:null,isOpenForSubmission:!1,hash:"3951728ace7f135451d66b72e9908b47",slug:"soil-moisture-importance",bookSignature:"Ram Swaroop Meena and Rahul Datta",coverURL:"https://cdn.intechopen.com/books/images_new/8937.jpg",editors:[{id:"313528",title:"Associate Prof.",name:"Ram Swaroop",middleName:null,surname:"Meena",slug:"ram-swaroop-meena",fullName:"Ram Swaroop Meena"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7031",title:"Liver Pathology",subtitle:null,isOpenForSubmission:!1,hash:"631321b0565459ed0175917f1c8c727f",slug:"liver-pathology",bookSignature:"Vijay Gayam and Omer Engin",coverURL:"https://cdn.intechopen.com/books/images_new/7031.jpg",editors:[{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8158",title:"Veganism",subtitle:"a Fashion Trend or Food as a Medicine",isOpenForSubmission:!1,hash:"d8e51fc25a379e5b92a270addbb4351d",slug:"veganism-a-fashion-trend-or-food-as-a-medicine",bookSignature:"Miljana Z. Jovandaric",coverURL:"https://cdn.intechopen.com/books/images_new/8158.jpg",editors:[{id:"268043",title:"Dr.",name:"Miljana Z.",middleName:"Z",surname:"Jovandaric",slug:"miljana-z.-jovandaric",fullName:"Miljana Z. Jovandaric"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"2160",title:"MATLAB",subtitle:"A Fundamental Tool for Scientific Computing and Engineering Applications - Volume 1",isOpenForSubmission:!1,hash:"dd9c658341fbd264ed4f8d9e6aa8ca29",slug:"matlab-a-fundamental-tool-for-scientific-computing-and-engineering-applications-volume-1",bookSignature:"Vasilios N. Katsikis",coverURL:"https://cdn.intechopen.com/books/images_new/2160.jpg",editors:[{id:"12289",title:"Prof.",name:"Vasilios",middleName:"N.",surname:"Katsikis",slug:"vasilios-katsikis",fullName:"Vasilios Katsikis"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],offset:12,limit:12,total:5315},hotBookTopics:{hotBooks:[],offset:0,limit:12,total:null},publish:{},publishingProposal:{success:null,errors:{}},books:{featuredBooks:[{type:"book",id:"8472",title:"Bioactive Compounds in Nutraceutical and Functional Food for Good Human Health",subtitle:null,isOpenForSubmission:!1,hash:"8855452919b8495810ef8e88641feb20",slug:"bioactive-compounds-in-nutraceutical-and-functional-food-for-good-human-health",bookSignature:"Kavita Sharma, Kanchan Mishra, Kula Kamal Senapati and Corina Danciu",coverURL:"https://cdn.intechopen.com/books/images_new/8472.jpg",editors:[{id:"197731",title:"Dr.",name:"Kavita",middleName:null,surname:"Sharma",slug:"kavita-sharma",fullName:"Kavita Sharma"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9685",title:"Agroecosystems",subtitle:"Very Complex Environmental Systems",isOpenForSubmission:!1,hash:"c44f7b43a9f9610c243dc32300d37df6",slug:"agroecosystems-very-complex-environmental-systems",bookSignature:"Marcelo L. Larramendy and Sonia Soloneski",coverURL:"https://cdn.intechopen.com/books/images_new/9685.jpg",editors:[{id:"14764",title:"Dr.",name:"Marcelo L.",middleName:null,surname:"Larramendy",slug:"marcelo-l.-larramendy",fullName:"Marcelo L. Larramendy"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8564",title:"Cell Interaction",subtitle:"Molecular and Immunological Basis for Disease Management",isOpenForSubmission:!1,hash:"98d7f080d80524285f091e72a8e92a6d",slug:"cell-interaction-molecular-and-immunological-basis-for-disease-management",bookSignature:"Bhawana Singh",coverURL:"https://cdn.intechopen.com/books/images_new/8564.jpg",editors:[{id:"315192",title:"Dr.",name:"Bhawana",middleName:null,surname:"Singh",slug:"bhawana-singh",fullName:"Bhawana Singh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9629",title:"Electroencephalography",subtitle:"From Basic Research to Clinical Applications",isOpenForSubmission:!1,hash:"8147834b6c6deeeec40f407c71ad60b4",slug:"electroencephalography-from-basic-research-to-clinical-applications",bookSignature:"Hideki Nakano",coverURL:"https://cdn.intechopen.com/books/images_new/9629.jpg",editors:[{id:"196461",title:"Prof.",name:"Hideki",middleName:null,surname:"Nakano",slug:"hideki-nakano",fullName:"Hideki Nakano"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8760",title:"Structure Topology and Symplectic Geometry",subtitle:null,isOpenForSubmission:!1,hash:"8974840985ec3652492c83e20233bf02",slug:"structure-topology-and-symplectic-geometry",bookSignature:"Kamal Shah and Min Lei",coverURL:"https://cdn.intechopen.com/books/images_new/8760.jpg",editors:[{id:"231748",title:"Dr.",name:"Kamal",middleName:null,surname:"Shah",slug:"kamal-shah",fullName:"Kamal Shah"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9161",title:"Frailty in the Elderly",subtitle:"Understanding and Managing Complexity",isOpenForSubmission:!1,hash:"a4f0f2fade8fb8ba35c405f5ad31a823",slug:"frailty-in-the-elderly-understanding-and-managing-complexity",bookSignature:"Sara Palermo",coverURL:"https://cdn.intechopen.com/books/images_new/9161.jpg",editors:[{id:"233998",title:"Ph.D.",name:"Sara",middleName:null,surname:"Palermo",slug:"sara-palermo",fullName:"Sara Palermo"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8445",title:"Dam Engineering",subtitle:"Recent Advances in Design and Analysis",isOpenForSubmission:!1,hash:"a7e4d2ecbc65d78fa7582e0d2e143906",slug:"dam-engineering-recent-advances-in-design-and-analysis",bookSignature:"Zhongzhi Fu and Erich Bauer",coverURL:"https://cdn.intechopen.com/books/images_new/8445.jpg",editors:[{id:"249577",title:"Dr.",name:"Zhongzhi",middleName:null,surname:"Fu",slug:"zhongzhi-fu",fullName:"Zhongzhi Fu"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"9385",title:"Renewable Energy",subtitle:"Technologies and Applications",isOpenForSubmission:!1,hash:"a6b446d19166f17f313008e6c056f3d8",slug:"renewable-energy-technologies-and-applications",bookSignature:"Tolga Taner, Archana Tiwari and Taha Selim Ustun",coverURL:"https://cdn.intechopen.com/books/images_new/9385.jpg",editors:[{id:"197240",title:"Associate Prof.",name:"Tolga",middleName:null,surname:"Taner",slug:"tolga-taner",fullName:"Tolga Taner"}],equalEditorOne:{id:"186791",title:"Dr.",name:"Archana",middleName:null,surname:"Tiwari",slug:"archana-tiwari",fullName:"Archana Tiwari",profilePictureURL:"https://mts.intechopen.com/storage/users/186791/images/system/186791.jpg",biography:"Dr. Archana Tiwari is Associate Professor at Amity University, India. Her research interests include renewable sources of energy from microalgae and further utilizing the residual biomass for the generation of value-added products, bioremediation through microalgae and microbial consortium, antioxidative enzymes and stress, and nutraceuticals from microalgae. She has been working on algal biotechnology for the last two decades. She has published her research in many international journals and has authored many books and chapters with renowned publishing houses. She has also delivered talks as an invited speaker at many national and international conferences. Dr. Tiwari is the recipient of several awards including Researcher of the Year and Distinguished Scientist.",institutionString:"Amity University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"3",totalChapterViews:"0",totalEditedBooks:"1",institution:{name:"Amity University",institutionURL:null,country:{name:"India"}}},equalEditorTwo:{id:"197609",title:"Prof.",name:"Taha Selim",middleName:null,surname:"Ustun",slug:"taha-selim-ustun",fullName:"Taha Selim Ustun",profilePictureURL:"https://mts.intechopen.com/storage/users/197609/images/system/197609.jpeg",biography:"Dr. Taha Selim Ustun received a Ph.D. in Electrical Engineering from Victoria University, Melbourne, Australia. He is a researcher with the Fukushima Renewable Energy Institute, AIST (FREA), where he leads the Smart Grid Cybersecurity Laboratory. Prior to that, he was a faculty member with the School of Electrical and Computer Engineering, Carnegie Mellon University, Pittsburgh, PA, USA. His current research interests include power systems protection, communication in power networks, distributed generation, microgrids, electric vehicle integration, and cybersecurity in smart grids. He serves on the editorial boards of IEEE Access, IEEE Transactions on Industrial Informatics, Energies, Electronics, Electricity, World Electric Vehicle and Information journals. Dr. Ustun is a member of the IEEE 2004 and 2800, IEC Renewable Energy Management WG 8, and IEC TC 57 WG17. He has been invited to run specialist courses in Africa, India, and China. He has delivered talks for the Qatar Foundation, the World Energy Council, the Waterloo Global Science Initiative, and the European Union Energy Initiative (EUEI). His research has attracted funding from prestigious programs in Japan, Australia, the European Union, and North America.",institutionString:"Fukushima Renewable Energy Institute, AIST (FREA)",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"National Institute of Advanced Industrial Science and Technology",institutionURL:null,country:{name:"Japan"}}},equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"8937",title:"Soil Moisture Importance",subtitle:null,isOpenForSubmission:!1,hash:"3951728ace7f135451d66b72e9908b47",slug:"soil-moisture-importance",bookSignature:"Ram Swaroop Meena and Rahul Datta",coverURL:"https://cdn.intechopen.com/books/images_new/8937.jpg",editors:[{id:"313528",title:"Associate Prof.",name:"Ram Swaroop",middleName:null,surname:"Meena",slug:"ram-swaroop-meena",fullName:"Ram Swaroop Meena"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}},{type:"book",id:"7031",title:"Liver Pathology",subtitle:null,isOpenForSubmission:!1,hash:"631321b0565459ed0175917f1c8c727f",slug:"liver-pathology",bookSignature:"Vijay Gayam and Omer Engin",coverURL:"https://cdn.intechopen.com/books/images_new/7031.jpg",editors:[{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],latestBooks:[{type:"book",id:"8472",title:"Bioactive Compounds in Nutraceutical and Functional Food for Good Human Health",subtitle:null,isOpenForSubmission:!1,hash:"8855452919b8495810ef8e88641feb20",slug:"bioactive-compounds-in-nutraceutical-and-functional-food-for-good-human-health",bookSignature:"Kavita Sharma, Kanchan Mishra, Kula Kamal Senapati and Corina Danciu",coverURL:"https://cdn.intechopen.com/books/images_new/8472.jpg",editedByType:"Edited by",editors:[{id:"197731",title:"Dr.",name:"Kavita",middleName:null,surname:"Sharma",slug:"kavita-sharma",fullName:"Kavita Sharma"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8760",title:"Structure Topology and Symplectic Geometry",subtitle:null,isOpenForSubmission:!1,hash:"8974840985ec3652492c83e20233bf02",slug:"structure-topology-and-symplectic-geometry",bookSignature:"Kamal Shah and Min Lei",coverURL:"https://cdn.intechopen.com/books/images_new/8760.jpg",editedByType:"Edited by",editors:[{id:"231748",title:"Dr.",name:"Kamal",middleName:null,surname:"Shah",slug:"kamal-shah",fullName:"Kamal Shah"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9536",title:"Education at the Intersection of Globalization and Technology",subtitle:null,isOpenForSubmission:!1,hash:"0cf6891060eb438d975d250e8b127ed6",slug:"education-at-the-intersection-of-globalization-and-technology",bookSignature:"Sharon Waller, Lee Waller, Vongai Mpofu and Mercy Kurebwa",coverURL:"https://cdn.intechopen.com/books/images_new/9536.jpg",editedByType:"Edited by",editors:[{id:"263302",title:"Dr.",name:"Sharon",middleName:null,surname:"Waller",slug:"sharon-waller",fullName:"Sharon Waller"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8564",title:"Cell Interaction",subtitle:"Molecular and Immunological Basis for Disease Management",isOpenForSubmission:!1,hash:"98d7f080d80524285f091e72a8e92a6d",slug:"cell-interaction-molecular-and-immunological-basis-for-disease-management",bookSignature:"Bhawana Singh",coverURL:"https://cdn.intechopen.com/books/images_new/8564.jpg",editedByType:"Edited by",editors:[{id:"315192",title:"Dr.",name:"Bhawana",middleName:null,surname:"Singh",slug:"bhawana-singh",fullName:"Bhawana Singh"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9629",title:"Electroencephalography",subtitle:"From Basic Research to Clinical Applications",isOpenForSubmission:!1,hash:"8147834b6c6deeeec40f407c71ad60b4",slug:"electroencephalography-from-basic-research-to-clinical-applications",bookSignature:"Hideki Nakano",coverURL:"https://cdn.intechopen.com/books/images_new/9629.jpg",editedByType:"Edited by",editors:[{id:"196461",title:"Prof.",name:"Hideki",middleName:null,surname:"Nakano",slug:"hideki-nakano",fullName:"Hideki Nakano"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9685",title:"Agroecosystems",subtitle:"Very Complex Environmental Systems",isOpenForSubmission:!1,hash:"c44f7b43a9f9610c243dc32300d37df6",slug:"agroecosystems-very-complex-environmental-systems",bookSignature:"Marcelo L. Larramendy and Sonia Soloneski",coverURL:"https://cdn.intechopen.com/books/images_new/9685.jpg",editedByType:"Edited by",editors:[{id:"14764",title:"Dr.",name:"Marcelo L.",middleName:null,surname:"Larramendy",slug:"marcelo-l.-larramendy",fullName:"Marcelo L. Larramendy"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9524",title:"Organ Donation and Transplantation",subtitle:null,isOpenForSubmission:!1,hash:"6ef47e03cd4e6476946fc28ca51de825",slug:"organ-donation-and-transplantation",bookSignature:"Vassil Mihaylov",coverURL:"https://cdn.intechopen.com/books/images_new/9524.jpg",editedByType:"Edited by",editors:[{id:"313113",title:"Associate Prof.",name:"Vassil",middleName:null,surname:"Mihaylov",slug:"vassil-mihaylov",fullName:"Vassil Mihaylov"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9280",title:"Underwater Work",subtitle:null,isOpenForSubmission:!1,hash:"647b4270d937deae4a82f5702d1959ec",slug:"underwater-work",bookSignature:"Sérgio António Neves Lousada",coverURL:"https://cdn.intechopen.com/books/images_new/9280.jpg",editedByType:"Edited by",editors:[{id:"248645",title:"Dr.",name:"Sérgio António",middleName:null,surname:"Neves Lousada",slug:"sergio-antonio-neves-lousada",fullName:"Sérgio António Neves Lousada"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9161",title:"Frailty in the Elderly",subtitle:"Understanding and Managing Complexity",isOpenForSubmission:!1,hash:"a4f0f2fade8fb8ba35c405f5ad31a823",slug:"frailty-in-the-elderly-understanding-and-managing-complexity",bookSignature:"Sara Palermo",coverURL:"https://cdn.intechopen.com/books/images_new/9161.jpg",editedByType:"Edited by",editors:[{id:"233998",title:"Ph.D.",name:"Sara",middleName:null,surname:"Palermo",slug:"sara-palermo",fullName:"Sara Palermo"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8158",title:"Veganism",subtitle:"a Fashion Trend or Food as a Medicine",isOpenForSubmission:!1,hash:"d8e51fc25a379e5b92a270addbb4351d",slug:"veganism-a-fashion-trend-or-food-as-a-medicine",bookSignature:"Miljana Z. Jovandaric",coverURL:"https://cdn.intechopen.com/books/images_new/8158.jpg",editedByType:"Edited by",editors:[{id:"268043",title:"Dr.",name:"Miljana Z.",middleName:"Z",surname:"Jovandaric",slug:"miljana-z.-jovandaric",fullName:"Miljana Z. Jovandaric"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},subject:{topic:{id:"1021",title:"Hepatology",slug:"gastroenterology-hepatology",parent:{title:"Gastroenterology",slug:"gastroenterology"},numberOfBooks:56,numberOfAuthorsAndEditors:1687,numberOfWosCitations:492,numberOfCrossrefCitations:385,numberOfDimensionsCitations:921,videoUrl:null,fallbackUrl:null,description:null},booksByTopicFilter:{topicSlug:"gastroenterology-hepatology",sort:"-publishedDate",limit:12,offset:0},booksByTopicCollection:[{type:"book",id:"7888",title:"Hepatitis A and Other Associated Hepatobiliary Diseases",subtitle:null,isOpenForSubmission:!1,hash:"e027bb08025546d9beb242d55e87c84c",slug:"hepatitis-a-and-other-associated-hepatobiliary-diseases",bookSignature:"Costin Teodor Streba, Cristin Constantin Vere, Ion Rogoveanu, Valeria Tripodi and Silvia Lucangioli",coverURL:"https://cdn.intechopen.com/books/images_new/7888.jpg",editedByType:"Edited by",editors:[{id:"55546",title:"Dr.",name:"Costin Teodor",middleName:"Teodor",surname:"Streba",slug:"costin-teodor-streba",fullName:"Costin Teodor Streba"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"7887",title:"Hepatitis B and C",subtitle:null,isOpenForSubmission:!1,hash:"8dd6dab483cf505d83caddaeaf497f2c",slug:"hepatitis-b-and-c",bookSignature:"Luis Rodrigo",coverURL:"https://cdn.intechopen.com/books/images_new/7887.jpg",editedByType:"Edited by",editors:[{id:"73208",title:"Prof.",name:"Luis",middleName:null,surname:"Rodrigo",slug:"luis-rodrigo",fullName:"Luis Rodrigo"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8330",title:"Nonalcoholic Fatty Liver Disease",subtitle:"An Update",isOpenForSubmission:!1,hash:"d0f8ff2a0673b7be22f7e7c531a2e410",slug:"nonalcoholic-fatty-liver-disease-an-update",bookSignature:"Emad Hamdy Gad",coverURL:"https://cdn.intechopen.com/books/images_new/8330.jpg",editedByType:"Edited by",editors:[{id:"222727",title:"Associate Prof.",name:"Emad Hamdy",middleName:null,surname:"Gad",slug:"emad-hamdy-gad",fullName:"Emad Hamdy Gad"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"8838",title:"Liver Cirrhosis",subtitle:"Debates and Current Challenges",isOpenForSubmission:!1,hash:"17163eb18a082da0fe70ccc20b7fe69a",slug:"liver-cirrhosis-debates-and-current-challenges",bookSignature:"Georgios Tsoulfas",coverURL:"https://cdn.intechopen.com/books/images_new/8838.jpg",editedByType:"Edited by",editors:[{id:"57412",title:"Prof.",name:"Georgios",middleName:null,surname:"Tsoulfas",slug:"georgios-tsoulfas",fullName:"Georgios Tsoulfas"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6718",title:"Hepatitis C",subtitle:"From Infection to Cure",isOpenForSubmission:!1,hash:"7448805e61bfa52ce552c427ad6f16fc",slug:"hepatitis-c-from-infection-to-cure",bookSignature:"Imran Shahid",coverURL:"https://cdn.intechopen.com/books/images_new/6718.jpg",editedByType:"Edited by",editors:[{id:"188219",title:"Prof.",name:"Imran",middleName:null,surname:"Shahid",slug:"imran-shahid",fullName:"Imran Shahid"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6663",title:"Management of Chronic Liver Diseases",subtitle:"Recent Advances",isOpenForSubmission:!1,hash:"833ebcb9a2596f81deff0246ed7c9642",slug:"management-of-chronic-liver-diseases-recent-advances",bookSignature:"Xingshun Qi",coverURL:"https://cdn.intechopen.com/books/images_new/6663.jpg",editedByType:"Edited by",editors:[{id:"197501",title:"Dr.",name:"Xingshun",middleName:null,surname:"Qi",slug:"xingshun-qi",fullName:"Xingshun Qi"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6440",title:"Liver Research and Clinical Management",subtitle:null,isOpenForSubmission:!1,hash:"e4bbd66ccead286ab737f23feb053cf8",slug:"liver-research-and-clinical-management",bookSignature:"Luis Rodrigo",coverURL:"https://cdn.intechopen.com/books/images_new/6440.jpg",editedByType:"Edited by",editors:[{id:"73208",title:"Prof.",name:"Luis",middleName:null,surname:"Rodrigo",slug:"luis-rodrigo",fullName:"Luis Rodrigo"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6073",title:"Non-Alcoholic Fatty Liver Disease",subtitle:"Molecular Bases, Prevention and Treatment",isOpenForSubmission:!1,hash:"6141320881651ddc40a3f35893c209e7",slug:"non-alcoholic-fatty-liver-disease-molecular-bases-prevention-and-treatment",bookSignature:"Rodrigo Valenzuela",coverURL:"https://cdn.intechopen.com/books/images_new/6073.jpg",editedByType:"Edited by",editors:[{id:"72355",title:"Prof.",name:"Rodrigo",middleName:null,surname:"Valenzuela Baez",slug:"rodrigo-valenzuela-baez",fullName:"Rodrigo Valenzuela Baez"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5931",title:"Stomach Disorders",subtitle:null,isOpenForSubmission:!1,hash:"489f823dd49e3fa397e477a8101ca4ff",slug:"stomach-disorders",bookSignature:"Jianyuan Chai",coverURL:"https://cdn.intechopen.com/books/images_new/5931.jpg",editedByType:"Edited by",editors:[{id:"28281",title:"Dr.",name:"Jianyuan",middleName:null,surname:"Chai",slug:"jianyuan-chai",fullName:"Jianyuan Chai"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5714",title:"Esophageal Abnormalities",subtitle:null,isOpenForSubmission:!1,hash:"132a5e5097b78a76535fde4196596ac9",slug:"esophageal-abnormalities",bookSignature:"Jianyuan Chai",coverURL:"https://cdn.intechopen.com/books/images_new/5714.jpg",editedByType:"Edited by",editors:[{id:"28281",title:"Dr.",name:"Jianyuan",middleName:null,surname:"Chai",slug:"jianyuan-chai",fullName:"Jianyuan Chai"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6061",title:"Ascites",subtitle:"Physiopathology, Treatment, Complications and Prognosis",isOpenForSubmission:!1,hash:"ead9b3e5c36413f9ff2c3129fbc57574",slug:"ascites-physiopathology-treatment-complications-and-prognosis",bookSignature:"Luis Rodrigo",coverURL:"https://cdn.intechopen.com/books/images_new/6061.jpg",editedByType:"Edited by",editors:[{id:"73208",title:"Prof.",name:"Luis",middleName:null,surname:"Rodrigo",slug:"luis-rodrigo",fullName:"Luis Rodrigo"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"6014",title:"Update on Hepatitis C",subtitle:null,isOpenForSubmission:!1,hash:"b812442f63938a061f1c84b2338bb187",slug:"update-on-hepatitis-c",bookSignature:"Martina Smolic, Aleksandar Vcev and George Y. Wu",coverURL:"https://cdn.intechopen.com/books/images_new/6014.jpg",editedByType:"Edited by",editors:[{id:"172734",title:"Dr.",name:"Martina",middleName:null,surname:"Smolic",slug:"martina-smolic",fullName:"Martina Smolic"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"3",chapterContentType:"chapter",authoredCaption:"Authored by"}}],booksByTopicTotal:56,mostCitedChapters:[{id:"46479",doi:"10.5772/57353",title:"Floating Drug Delivery Systems for Eradication of Helicobacter pylori in Treatment of Peptic Ulcer Disease",slug:"floating-drug-delivery-systems-for-eradication-of-helicobacter-pylori-in-treatment-of-peptic-ulcer-d",totalDownloads:2046,totalCrossrefCites:85,totalDimensionsCites:196,book:{slug:"trends-in-helicobacter-pylori-infection",title:"Trends in Helicobacter pylori Infection",fullTitle:"Trends in Helicobacter pylori Infection"},signatures:"Yousef Javadzadeh and Sanaz Hamedeyazdan",authors:[{id:"94276",title:"Prof.",name:"Yousef",middleName:null,surname:"Javadzadeh",slug:"yousef-javadzadeh",fullName:"Yousef Javadzadeh"},{id:"98229",title:"Dr.",name:"Sanaz",middleName:null,surname:"Hamedeyazdan",slug:"sanaz-hamedeyazdan",fullName:"Sanaz Hamedeyazdan"}]},{id:"22945",doi:"10.5772/17640",title:"Pathophysiology of Gastric Ulcer Development and Healing: Molecular Mechanisms and Novel Therapeutic Options",slug:"pathophysiology-of-gastric-ulcer-development-and-healing-molecular-mechanisms-and-novel-therapeutic-",totalDownloads:11792,totalCrossrefCites:8,totalDimensionsCites:21,book:{slug:"peptic-ulcer-disease",title:"Peptic Ulcer Disease",fullTitle:"Peptic Ulcer Disease"},signatures:"Matteo Fornai, Luca Antonioli, Rocchina Colucci, Marco Tuccori and Corrado Blandizzi",authors:[{id:"28973",title:"Prof.",name:"Corrado",middleName:null,surname:"Blandizzi",slug:"corrado-blandizzi",fullName:"Corrado Blandizzi"},{id:"44227",title:"Dr.",name:"Matteo",middleName:null,surname:"Fornai",slug:"matteo-fornai",fullName:"Matteo Fornai"},{id:"44229",title:"Dr.",name:"Luca",middleName:null,surname:"Antonioli",slug:"luca-antonioli",fullName:"Luca Antonioli"},{id:"44230",title:"Dr.",name:"Rocchina",middleName:null,surname:"Colucci",slug:"rocchina-colucci",fullName:"Rocchina Colucci"},{id:"44231",title:"Dr.",name:"Marco",middleName:null,surname:"Tuccori",slug:"marco-tuccori",fullName:"Marco Tuccori"}]},{id:"35446",doi:"10.5772/47946",title:"Delivery of Probiotic Microorganisms into Gastrointestinal Tract by Food Products",slug:"delivery-of-probiotic-microorganisms-into-gastrointestinal-tract-by-food-products",totalDownloads:5861,totalCrossrefCites:0,totalDimensionsCites:19,book:{slug:"new-advances-in-the-basic-and-clinical-gastroenterology",title:"New Advances in the Basic and Clinical Gastroenterology",fullTitle:"New Advances in the Basic and Clinical Gastroenterology"},signatures:"Amir Mohammad Mortazavian, Reza Mohammadi and Sara Sohrabvandi",authors:[{id:"97458",title:"Dr.",name:"Amir M.",middleName:null,surname:"Mortazavian",slug:"amir-m.-mortazavian",fullName:"Amir M. Mortazavian"},{id:"99974",title:"Dr.",name:"Sarah",middleName:null,surname:"Sohrabvandi",slug:"sarah-sohrabvandi",fullName:"Sarah Sohrabvandi"}]}],mostDownloadedChaptersLast30Days:[{id:"45493",title:"Biliary Dyspepsia: Functional Gallbladder and Sphincter of Oddi Disorders",slug:"biliary-dyspepsia-functional-gallbladder-and-sphincter-of-oddi-disorders",totalDownloads:5553,totalCrossrefCites:3,totalDimensionsCites:4,book:{slug:"dyspepsia-advances-in-understanding-and-management",title:"Dyspepsia",fullTitle:"Dyspepsia - Advances in Understanding and Management"},signatures:"Meena Mathivanan, Liisa Meddings and Eldon A. Shaffer",authors:[{id:"165693",title:"Dr.",name:"Eldon",middleName:null,surname:"Shaffer",slug:"eldon-shaffer",fullName:"Eldon Shaffer"}]},{id:"56262",title:"Anatomy of Esophagus",slug:"anatomy-of-esophagus",totalDownloads:2872,totalCrossrefCites:1,totalDimensionsCites:2,book:{slug:"esophageal-abnormalities",title:"Esophageal Abnormalities",fullTitle:"Esophageal Abnormalities"},signatures:"Murat Ferhat Ferhatoglu and Taner Kıvılcım",authors:[{id:"200126",title:"M.D.",name:"Murat Ferhat",middleName:null,surname:"Ferhatoglu",slug:"murat-ferhat-ferhatoglu",fullName:"Murat Ferhat Ferhatoglu"},{id:"206240",title:"Dr.",name:"Taner",middleName:null,surname:"Kivilcim",slug:"taner-kivilcim",fullName:"Taner Kivilcim"}]},{id:"56068",title:"Minimally Invasive Esophagectomy",slug:"minimally-invasive-esophagectomy",totalDownloads:924,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"esophageal-abnormalities",title:"Esophageal Abnormalities",fullTitle:"Esophageal Abnormalities"},signatures:"Rafael Cholvi Calduch, Isabel Mora Oliver, Fernando Lopez Mozos\nand Roberto Martí Obiol",authors:[{id:"203292",title:"Ph.D.",name:"Fernando",middleName:null,surname:"Lopez",slug:"fernando-lopez",fullName:"Fernando Lopez"},{id:"203687",title:"Dr.",name:"Roberto",middleName:null,surname:"Martí",slug:"roberto-marti",fullName:"Roberto Martí"},{id:"204943",title:"Dr.",name:"Rafael",middleName:null,surname:"Cholvi",slug:"rafael-cholvi",fullName:"Rafael Cholvi"},{id:"204944",title:"Dr.",name:"Isabel",middleName:null,surname:"Mora",slug:"isabel-mora",fullName:"Isabel Mora"}]},{id:"21425",title:"Histopathological Diagnosis of Non-Alcoholic and Alcoholic Fatty Liver Disease",slug:"histopathological-diagnosis-of-non-alcoholic-and-alcoholic-fatty-liver-disease",totalDownloads:2948,totalCrossrefCites:2,totalDimensionsCites:2,book:{slug:"liver-biopsy-in-modern-medicine",title:"Liver Biopsy in Modern Medicine",fullTitle:"Liver Biopsy in Modern Medicine"},signatures:"Andrea Tannapfel and Berenike Flott-Rahmel",authors:[{id:"34863",title:"Dr.",name:"Andrea",middleName:null,surname:"Tannapfel",slug:"andrea-tannapfel",fullName:"Andrea Tannapfel"},{id:"53108",title:"Prof.",name:"Berenike",middleName:null,surname:"Flott-Rahmel",slug:"berenike-flott-rahmel",fullName:"Berenike Flott-Rahmel"}]},{id:"55879",title:"Portal Hypertensive Gastropathy (PHG)",slug:"portal-hypertensive-gastropathy-phg-",totalDownloads:1115,totalCrossrefCites:1,totalDimensionsCites:1,book:{slug:"stomach-disorders",title:"Stomach Disorders",fullTitle:"Stomach Disorders"},signatures:"Samia Ali Gamie",authors:[{id:"204157",title:"Prof.",name:"Samia",middleName:null,surname:"Ali Abdo Gamie",slug:"samia-ali-abdo-gamie",fullName:"Samia Ali Abdo Gamie"}]},{id:"57005",title:"Health-Related Quality of Life in Antiviral-Treated Chronic Hepatitis C Patients",slug:"health-related-quality-of-life-in-antiviral-treated-chronic-hepatitis-c-patients",totalDownloads:988,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"update-on-hepatitis-c",title:"Update on Hepatitis C",fullTitle:"Update on Hepatitis C"},signatures:"Aleksandar Včev, Jelena Jakab, Lucija Kuna and Martina Smolić",authors:[{id:"154595",title:"Prof.",name:"Aleksandar",middleName:null,surname:"Vcev",slug:"aleksandar-vcev",fullName:"Aleksandar Vcev"},{id:"172734",title:"Dr.",name:"Martina",middleName:null,surname:"Smolic",slug:"martina-smolic",fullName:"Martina Smolic"},{id:"204953",title:"Ms.",name:"Lucija",middleName:null,surname:"Kuna",slug:"lucija-kuna",fullName:"Lucija Kuna"},{id:"205159",title:"Dr.",name:"Jelena",middleName:null,surname:"Jakab",slug:"jelena-jakab",fullName:"Jelena Jakab"}]},{id:"55818",title:"Tissue Engineering of Esophagus",slug:"tissue-engineering-of-esophagus",totalDownloads:998,totalCrossrefCites:0,totalDimensionsCites:0,book:{slug:"esophageal-abnormalities",title:"Esophageal Abnormalities",fullTitle:"Esophageal Abnormalities"},signatures:"Yabin Zhu, Mi Zhou and Ruixia Hou",authors:[{id:"40618",title:"Prof.",name:"Yabin",middleName:null,surname:"Zhu",slug:"yabin-zhu",fullName:"Yabin Zhu"}]},{id:"55045",title:"Hemodynamic Optimization Strategies in Anesthesia Care for Liver Transplantation",slug:"hemodynamic-optimization-strategies-in-anesthesia-care-for-liver-transplantation",totalDownloads:1298,totalCrossrefCites:0,totalDimensionsCites:1,book:{slug:"liver-cirrhosis-update-and-current-challenges",title:"Liver Cirrhosis",fullTitle:"Liver Cirrhosis - Update and Current Challenges"},signatures:"Alexander A. Vitin, Dana Tomescu and Leonard Azamfirei",authors:[{id:"201176",title:"Associate Prof.",name:"Alexander",middleName:null,surname:"Vitin",slug:"alexander-vitin",fullName:"Alexander Vitin"},{id:"202442",title:"Dr.",name:"Dana",middleName:null,surname:"Tomescu",slug:"dana-tomescu",fullName:"Dana Tomescu"},{id:"202600",title:"Prof.",name:"Leonard",middleName:null,surname:"Azamfirei",slug:"leonard-azamfirei",fullName:"Leonard Azamfirei"}]},{id:"56177",title:"Nutritional Management of Esophageal Cancer Patients",slug:"nutritional-management-of-esophageal-cancer-patients",totalDownloads:1240,totalCrossrefCites:1,totalDimensionsCites:1,book:{slug:"esophageal-abnormalities",title:"Esophageal Abnormalities",fullTitle:"Esophageal Abnormalities"},signatures:"Dimitrios Schizas, Irene Lidoriki, Demetrios Moris and Theodore\nLiakakos",authors:[{id:"203349",title:"Dr.",name:"Dimitrios",middleName:null,surname:"Schizas",slug:"dimitrios-schizas",fullName:"Dimitrios Schizas"},{id:"204000",title:"MSc.",name:"Irene",middleName:null,surname:"Lidoriki",slug:"irene-lidoriki",fullName:"Irene Lidoriki"},{id:"204001",title:"Dr.",name:"Demetrios",middleName:null,surname:"Moris",slug:"demetrios-moris",fullName:"Demetrios Moris"},{id:"204002",title:"Prof.",name:"Theodore",middleName:null,surname:"Liakakos",slug:"theodore-liakakos",fullName:"Theodore Liakakos"}]},{id:"46479",title:"Floating Drug Delivery Systems for Eradication of Helicobacter pylori in Treatment of Peptic Ulcer Disease",slug:"floating-drug-delivery-systems-for-eradication-of-helicobacter-pylori-in-treatment-of-peptic-ulcer-d",totalDownloads:2046,totalCrossrefCites:86,totalDimensionsCites:196,book:{slug:"trends-in-helicobacter-pylori-infection",title:"Trends in Helicobacter pylori Infection",fullTitle:"Trends in Helicobacter pylori Infection"},signatures:"Yousef Javadzadeh and Sanaz Hamedeyazdan",authors:[{id:"94276",title:"Prof.",name:"Yousef",middleName:null,surname:"Javadzadeh",slug:"yousef-javadzadeh",fullName:"Yousef Javadzadeh"},{id:"98229",title:"Dr.",name:"Sanaz",middleName:null,surname:"Hamedeyazdan",slug:"sanaz-hamedeyazdan",fullName:"Sanaz Hamedeyazdan"}]}],onlineFirstChaptersFilter:{topicSlug:"gastroenterology-hepatology",limit:3,offset:0},onlineFirstChaptersCollection:[],onlineFirstChaptersTotal:0},preDownload:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[{type:"book",id:"10176",title:"Microgrids and Local Energy Systems",subtitle:null,isOpenForSubmission:!0,hash:"c32b4a5351a88f263074b0d0ca813a9c",slug:null,bookSignature:"Prof. Nick Jenkins",coverURL:"https://cdn.intechopen.com/books/images_new/10176.jpg",editedByType:null,editors:[{id:"55219",title:"Prof.",name:"Nick",middleName:null,surname:"Jenkins",slug:"nick-jenkins",fullName:"Nick Jenkins"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter"}}],offset:8,limit:8,total:1},route:{name:"profile.detail",path:"/profiles/309845/parwsha-zaib",hash:"",query:{},params:{id:"309845",slug:"parwsha-zaib"},fullPath:"/profiles/309845/parwsha-zaib",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()