Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
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We wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
IntechOpen is proud to announce that 191 of our authors have made the Clarivate™ Highly Cited Researchers List for 2020, ranking them among the top 1% most-cited.
\n\n
Throughout the years, the list has named a total of 261 IntechOpen authors as Highly Cited. Of those researchers, 69 have been featured on the list multiple times.
\n\n\n\n
Released this past November, the list is based on data collected from the Web of Science and highlights some of the world’s most influential scientific minds by naming the researchers whose publications over the previous decade have included a high number of Highly Cited Papers placing them among the top 1% most-cited.
\n\n
We wish to congratulate all of the researchers named and especially our authors on this amazing accomplishment! We are happy and proud to share in their success!
Note: Edited in March 2021
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1. Introduction
\n
The prevalence of subepithelial lesions (SELs) detected on routine endoscopy is unknown; however, these are frequently encountered with 0.36% of EGD procedures. During the last 10 years, the detection rate has increased, with advances in endoscopic technology with the more widespread use of EUS and close attention paid during routine endoscopy exams and reported with 1%, with an incidence of 1 in 300 patients [1]. The malignant lesions are reported with 13% accuracy [2]. Men and women are equally affected. Most of the patients are more than 50-year old. Usually US, CT and MRI are not sensitive enough to detect and characterize the majority of SELs since they can be smaller than 1 cm in size. SELs have a wide and diverse spectrum of etiologies (normal structures; benign lesions and malignant tumor), clinical course, radiological, and understanding the endoscopic, EUS and underlying pathologic features of SELs is essential for their detection, differential diagnosis, staging and management. They are most commonly found in the stomach, esophagus and duodenum. The lower GI, rectum, and cecum are the commonest sites. Lipomas can be seen any part of the colon. They mostly occur in the rectum and cecum, but familiar lesions such as lipomas may be seen in any part of the colon. In SELs, the order was as follows: Gastrointestinal stromal tumor (GIST), leiomyoma, hemangioma, external compression, pancreatic rest and granular cell tumor (Table 1). Most benign SELs can be diagnosed according to their endoscopic appearance, but findings on routine biopsy are not usually that helpful. Benign SELs tumors have a lower detection rate due to the fact that they are often small and most patients are asymptomatic. A minority of cases present with abdominal pain, vomiting, anemia, dysphagia, or gastrointestinal (GI) bleeding and obstruction, most of which are likely to result from complications and depending on the site and size of the lesion. [3] Among SETs, the malignant potential of GISTs is related to size; however, malignancy can be detected in smaller lesions [4]. However, SETs can have malignant potential, and it is therefore critical to be able to exclude malignant or premalignant lesions [5], the prognoses varying from benign to very aggressive with malignant potential. Therefore, proper diagnostic and therapeutic plans are needed for GI SETs. For this purpose, endoscopic ultrasonography (EUS) is the most accurate diagnostic method [6]. The lesion can be evaluated based on its size, layer of origin and echotexture, echogenic homogeneity, and the presence of echogenic and anechoic foci. Border, extension to adjacent layers, irregular margins and invasion into adjacent organs or structures can all be used to help identify intramural lesions or direct further management (surgical resection, endoscopic submucosal resection/dissection) or studies (special stains and immunohistochemical evaluation of tissue samples) [7, 8]. There are some typical findings for some GI SETs such as lipoma, duplication cysts, and ectopic pancreas [7, 9]. However, most hypoechoic SELs make it difficult to come to a final diagnosis using EUS images alone. Biopsy is necessary for the definite diagnosis of GI SETs. Despite obtaining appropriate biopsy specimens, using an endoscopic biopsy procedure is often difficult and inconclusive [10]. To overcome the limitations of conventional endoscopic biopsy methods, using the bite-on-bite biopsy technique [11], EUS-guided cytology or biopsy methods, such as EUS-guided fine-needle aspiration (EUS-FNA), EUS-guided fine-needle biopsy (EUS-FNB) technique, have now been introduced to obtain sufficient tissue. EUS-tissue sampling is a safe procedure for the diagnosis of GI SETs and is used for cytological studies. Immunohistochemical staining (IHS) methods are used, resulting in good diagnostic yields. Recently, EUS-FNB has been introduced and reportedly provides good results for the diagnosis of GI SETs [8]. Although biopsy, including FNA and FNB or excision, is required for a definitive diagnosis. Management is generally based upon the confidence of diagnosis and whether the lesion causes symptoms. With advanced endoscopy technology and the more common use of EUS, the diagnosis and management of SETs has been changed.
Common benign lesions
1
Lipomas
2
Ectopic pancreas
3
Schwannomas
4
Duplication cysts
Common malignant lesions
1
GIST
2
Lymphoma
3
Metastasis
Table 1.
Differential diagnosis of SELs.
\n
2. Endoscopic ultrasound
\n
Radial EUS and mini-probe EUS can reveal the precise nature and provide accurate diagnosis of GI SETs. SETs such as lipoma, duplication cysts, and ectopic pancreas exhibit some typical findings. Forward-viewing linear EUS has been introduced and has been shown to provide good image quality and shorter observation times in SETs than oblique-viewing linear EUS [12, 42]. EUS is the gold standard for evaluation of SELs with high precision. EUS is able to differentiate external compression from intramural lesion and to determine the layer of origin [13, 14]. The echogenicity of lesions is different. We can thus differentiate GISTs, leiomyomas, and schwannomas. The echogenicity of a leiomyoma is equal to the echogenicity of proper muscle, while a GIST shows slightly higher echogenicity than that of the proper muscle, and a schwannoma shows extremely low echogenicity [2]. In addition, EUS is better at providing a more accurate indication of the size of lesion than other modalities. EUS can evaluate for regional lymphadenopathy. Tissue biopsy can be obtained. Finally, EUS helps to determine appropriate management of the case. Some noninvasive imaging methods, such as transabdominal ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI), have been used, but they are often insufficient. With these methods, the transition zone (the area where the tumor arises from normal gut wall layers) needs to be examined carefully to determine the layer of origin. The reported accuracy of EUS in predicting the pathologic diagnosis of subepithelial lesions showed a wide range, from 45.5 to 82.9% [14–19]. The sensitivity and specificity of EUS malignant finding is 64 and 80%, respectively [6]. However, EUS findings are not sufficient to accurately predict malignancy [10]. If tissue was obtained from EUS-guided fine-needle aspiration (EUS-FNA), the diagnostic accuracy increased markedly, ranging from 63 to 98% [1, 26–28]. EUS-FNA for SETs using a forward-viewing linear EUS has provided good results: full histologic assessment rate of 93.4%, sensitivity of 92.8%, specificity of 100% [20, 42]. Tumor size and location are important factors for good sampling in EUS-FNA for GI SETs. The diagnostic rate for tumors ≥4 cm was 100%, but for tumors of 2–4 and <2 cm, the diagnostic rates were only 86% and 71%, respectively [21, 22]. Using cytology alone, differentially diagnosing GISTs from other mesenchymal tumors is not easy. Findings of mitosis in EUS-FNA specimens are known to be associated with malignant GISTs [29, 30], Ki-67 staining is helpful in evaluating the aggressiveness of GISTs [7, 23, 24]. Many studies have reported the use of various EUS-FNA needles to improve diagnostic accuracy. Tissue sampling and diagnostic rates for SETs were similar when comparing the use of 22 and 25 G EUS-FNA needles (sampling rate, sensitivity, positive predictive value, negative predictive value: 100, 55, 100, and 0% for 22 G needles; 100, 64, 100, and 0% for 25 G needles) [25]. Furthermore, 25 G needles were superior to 22 G needles for diagnosing mobile small lesions. A histologic yield of 95% using this needle was similar to the 90% achieved in EUS-FNB using 19 G Pro-Core (Cook Endoscopy, Wilson-Salem, NC, USA) needles [26]. EUS-FNA with an on-site cytopathologist (rapid on-site cytopathological examination) resulted in a 10–29% increase in the adequacy rates of EUS-FNA specimens and a 10–15% increase in the diagnostic rate [27, 28]. Recently, EUS-FNB using reverse bevel cheese slicer technology has been introduced [29]. A study compared 22 G EUS-FNA and 22 G EUS-FNB in EUS-guided GI SET sampling. The EUS-FNB group required a significantly lower number of needle passes than the EUS-FNA group. The EUS-FNB group had higher yields of optimal macroscopic (30% vs. 92%,) and histological (20% vs. 75%,) core samples with three needle passes, which resulted in a high diagnostic rate (20% vs. 75%) [8]. The EUS helps in deciding whether a lesion should be removed or followed in situ [30]. Lesions confined to the mucosal or submucosal layers can be safely removed endoscopically. Surgical resection, if needed, is generally recommended for lesions located in muscularis propria, although these lesions need to be removed by experienced clinicians. There is minimal risk when using advances in endoscopic techniques such as endoscopic submucosal dissection (ESD) [5, 31, 32]. Follow-up EUS is often used in SETs smaller than 2 cm. For small GI SETs, follow-up after a 1-year interval is recommended. If the size of the mass is unchanged during two serial EUS follow-ups, extended follow-up is suggested [33]. The American Gastroenterological Association Institute Technical Review recommended follow-up by EUS or endoscopy at regular intervals for gastric SETs smaller than 3 cm [34]. However, in 2010, the National Comprehensive Cancer Network has recommended surgical resection of GISTs larger than 2 cm because of their malignant potential [35]. Lesions involving the muscularis propria are usually removed surgically because the complete endoscopic resection of these lesions is associated with the risk of perforation [36]. Endoscopic resection of gastric SETs from the muscularis propria (well-margined, endoluminal growth, 2–5 cm in size), results in complete endoscopic resection in 64% of cases [37].
\n
3. EUS compared to other imaging modalities
\n
Usually US, CT, and MRI are not sensitive enough to detect and characterize smaller SELs. Often it is impossible to differentiate them by endoscopy alone. EUS provides diagnostic information only for very large SELs. Like CT and MRI, it can also provide useful information on perigastric structures and when malignancy and metastasis is suspected. The diagnostic accuracy of MDCT is expected to be improved to even higher levels. Overall accuracy of MDCT in detection of SELs from a recent study was 78.8–85.3% [38], EUS has a history of higher accuracy in detecting and assessing the size and location of SELs comparison to other radiological imaging modalities. The narrow differential diagnosis of SELs afforded by the use of EUS is more effective than when the decision between observations with surveillance in patients with suspected benign lesions or resection when the lesion is likely to be malignant is taken (Table 2). In the differentiation between SELs and extraluminal compression, EUS also demonstrates a higher accuracy than endoscopy, ultrasonography, and CT. It has been reported that US and CT established the diagnosis in only 16% of cases, compared with 100% for EUS. In another comparison study of US, CT and EUS reported an accuracy of 22, 28, and 100%, respectively, in differentiating subepithelial tumors from extraluminal compression [39].
1
Endoscopy
2
Imaging (US, CT, MRI)
3
EUS with or without tissue acquisition
4
Further observation and surveillance for benign lesions
5
Endoscopic vs. surgical resection for premalignant and malignant lesions
Table 2.
The practical approach.
\n
4. Extramural lesions
\n
When EUS demonstrates the integrity of all gut wall layers between the gut lumen and the lesion, it is safe to say that the lesion is an impression caused by an extramural structure. A normal spleen or splenic hilum is the most common etiology for SELs found to be of extramural origin [40]. Other normal anatomic variants such as the left lobe of the liver, the gallbladder, the pancreas tail, and enlarged lymph nodes can also sometimes be interpreted as SELs [41]. Adjacent structures, such as the aortic arch and vertebrae and enlarged lymph nodes can also press on the esophagus. Abnormal structures such as pancreatic pseudocysts, splenic artery aneurysm, aortic aneurysm, cystic tumor of the pancreas or liver, colonic tumors, and lymphoma [42] may also be interpreted as SELs. When using EUS, at a low frequency of 7.5 MHz, the examiner should survey the gross relationship between the extramural structure and the gut wall. Then, at a higher frequency of 12 MHz, the outer hyper-echoic serosal layer should be observed carefully to determine whether it is intact or disrupted. EUS is very sensitive to the identification of these extramural lesions. It has been reported that 11% of these were due to pathologic lesions, while others were related to adjacent normal organs or vessels [43].
\n
5. Intramural lesions
\n
5.1. Gastrointestinal stromal tumors (GIST)
\n
GIST lesions originate from the muscular propria, which is the fourth layer, and specifically from the interstitial cell of Cajal. The pathophysiology of GIST as result of mutation in the KIT gene which codes for the c-Kit protein, a tyrosine kinase receptor and in nearly immunohistochemical 95% positive of CD117 (corresponds to c-kit activation, epitope of kit protein), and, sometimes, CD34 but negative for desmin. Leiomyomas express smooth muscle actin and desmin, and schwannomas produce S-100 protein [42, 44]. Approximately 80% of GI mesenchymal tumors are GISTs, and approximately 10–30% of GISTs are malignant. GIST lesions have the potential for malignant transformation and distant metastases. GIST appeared on endoscopy as submucosal lesions (Figure 1A, B, E). On EUS (Figure 1C, D), a GIST is typically a well-circumscribed, hypoechoic, relatively homogeneous mass that can arise from either the second hypoechoic layer (muscularis mucosa) or more frequently the fourth hypoechoic layer (muscularis propria). In addition to size and mucosal ulcer, other EUS characteristics have been considered as possible predictive factors, but size is the only consistently definitive predictive factor [45–48]. One study suggested that GISTs have a marginal hypoechoic halo and relatively higher echogenicity compared with the adjacent muscular layer [49]. Another study reported that the internal hypoechoic feature could be suggested as a predictive marker of tumor progression [47]. The presence of two of these three features had a positive predictive value of 100% for malignant or borderline-malignant tumors [50]. A multicenter study reported that malignancy or indeterminate GIST status correlated with the presence of ulceration, tumor size larger than 3 cm, irregular margins, and gastric location, but not with hyperechoic or hypoechoic internal foci [51]. With hyperenhanced GIST after infusion of ultrasound contrast, in consequence, the contrast-enhanced harmonic EUS (CEH-EUS) signal intensity of GIST is higher than other benign lesions [52]. In addition, another study reported that prediction of malignant GIST was possible with CEH-EUS by identifying intratumoral irregular vessels with 83% accuracy [63]. EUS-guided fine-needle aspiration (EUS-FNA) and EUS-guided biopsy (EUS) can be performed for immunohistochemical examination to achieve better diagnostic accuracy of GIST [53–62]. Risk of malignancy depends on the size, the number of cells at pathological evaluation and location (Table 3) If the lesion <2 cm and the mitotic count less than 5/50 HPF, the risk of malignancy is very low. A GIST larger 5 cm, 10/50 HPF and small bowel have a much higher risk [3, 40, 72, 73]. Pathologists classify GISTs as “very low risk,” “low risk,” “intermediate risk,” and “high risk” according to the size of the mass and the mitotic count of the resected specimen [50, 63, 64]. Management of the case depends on the size and present symptoms. A lesion of more than 1 cm needs more evaluation, EUS, FNA, and FNB or additional surgical specimens. Because small (<1 cm), asymptomatic mesenchymal tumors are rarely malignant, a close follow-up with EUS may be justified. Referral to a medical oncologist is preferable before surgical resection to consider adjuvant therapy with Imatinib (Gleevec) for high risk lesions.
History of iron–deficiency anemia
Ulcerated GIST
Stigmata of recent bleeding
Small bowel (jejunum or ileum)
Lesion larger than 2 cm
If the lesion is noted to be growing during the surveillance period
Table 3.
GIST, indication of surgery.
Figure 1.
GIST: (A, B) Endoscopy shows an ulcerated submucosal lesion in the stomach. (C) EUS image showing homogeneous hypoechoic lesion. The lesion is located with the fourth layer, corresponding to the muscularis propria. (D) Malignant gastrointestinal stromal tumor (GIST) of the stomach. (E) Endoscopy view of small smooth submucosal mass noted in the rectum.
\n
Excision is advised when growth of the lesion, a change in the echo pattern, or necrosis is noted during yearly follow-up with EUS. Surgical treatment is indicated for lesions >3 cm in diameter, with features suggestive of malignancy (Table 4). For lesions between 1 and 3 cm, EUS-FNA can be recommended, or ESD can be chosen as a definite diagnostic and therapeutic tool with some risk of bleeding and perforation (2 to 3% in specialized centers). When the lesion is confirmed to be a GIST, the risk of malignant transformation needs to be discussed with the patient; more careful follow-up or early resection should then be considered.
Pathology
Muscularis mucosa
Submucosa
Muscularis propria
Serosa
GIST
X
XXX
Leiomyoma
X
XX
Pancreatic rest
XXX
Carcinoid tumor
X
XXX
Duplication cyst
XXX
X
Granular cell tumor
XX
Varices
XXX
Table 4.
Lists of the most common types of subepithelial lesions.
\n
5.2. Leiomyoma
\n
A leiomyoma is a benign tumor originating from the muscular layers (muscularis propria and muscularis mucosa) composed of well-differentiated smooth muscle cells with positive immunihistochemical findings for desmin and a smooth muscle action protein and negative CD117, CD34, and s100. Leiomyomas arise from muscularis mucosa more frequently than do GISTs. True leiomyomas are more commonly found in the esophagus and the small intestine but have been found throughout the GI tract. They rarely occur in the stomach or small bowel. In contrast, GISTs are rare in the esophagus and are more common in the stomach [65]. The risk of malignant transformation is very rare [3]. They appear by EUS as hypoechoic well-circumscribed masses in the muscularis propria or the muscularis mucosae (the fourth and second EUS layers, respectively). The approach and management of these depends on the size of the lesion. A lesion more than 1 cm in size should be referred to EUS for further evaluation. With a lesion <1 cm, annual surveillance with EGD or EUS every 1–2 years should take place if the patient is asymptomatic [66]. Leiomyomas appearing similar to GIST on EUS require tissue sampling with both histologic and immunohistochemical analysis for better diagnosis. The indication of surgical resection symptomatic (bleeding) and if the lesion is noted to be growing and enlarged with structural changes during the surveillance period (Table 5).
Risk of malignancy
Size
Mitotic count
Very low
<2 cm
<5/50 HPF
Low
2–5 cm
<5/50 HPF
Moderate
<5 cm
6–10/50 HPF
>5 cm
<5/50 HPF
High
>5 cm
6-–10/50 HPF
Any size
>10/50 HPF
Table 5.
Association between risk of malignancy and size and mitotic count.
\n
5.3. Lipoma
\n
Lipomas are common benign tumors composed of mature lipocytes, slow growing fatty tumors SELs that originate from the submucosal layer (third layer). They are found incidentally in any part of the GI tract, but more often in the gastric antrum than in the small bowel and can be seen more frequently in the lower tract [67, 68]. Endoscopically, most lipomas are soft solitary, with a smooth bulge and a yellow hue appearance (Figure 2A, B). They are indented when pressed with closed biopsy forceps (pillow or cushion sign) an indication highly specific for lipoma with specificity of 98% and low sensitivity of 40% were reported. On EUS (Figure 2C, D, E), lipomas characteristically appear as intensely hyperechoic, well circumscribed homogeneous lesions with clean regular margins arising from the third layer of the GI tract, which corresponds to the submucosa. The characteristic appearance on EUS is diagnostic and no further evaluation, including biopsy, is indicated [69, 70]. The endoscopic and EUS characteristics make it possible to diagnose lipoma in most cases.
Figure 2.
Lipoma. (A) Endoscopic view of a small elevated lesion covered with normal mucosa in the stomach. (B) Endoscopic view of a large elevated lesion covered with normal mucosa in the duodenum. (C) EUS reveals a homogeneous, hyperechoic lesion with smooth borders within the third gastric wall layer. (D) EUS image showed a heterogeneous, hyperchoic lesion within the third layer of the duodenal wall layer. (E) EUS reveals a large hyperechoic raised from the third colonic wall layer.
\n
Since there is no malignant potential, those lesions, they do not require biopsy or surgical resection or even regular endoscopic surveillance. Jumbo biopsy when performed often reveals nothing more than yellowish adipose tissue [71]. Once a lipoma has been confirmed, follow-up EUS is not recommended. Extremely rare lipomas can become ulcerated [40, 72]. Local excision is then advised for these symptomatic lipomas when associated with bleeding or obstruction. Resection is also recommended when it is impossible to distinguish between a lipoma and a malignant neoplasm, such as a liposarcoma, even though this lesion is rare in the GI tract [73].
\n
5.4. Granular cell tumor
\n
Granular cell tumors (GCT) are rare benign lesions of neural derivation thought to arise from Schwann cells as supported by immunophenotypic and ultrastructural evidence. Granular cell tumors are SELs usually originated from submucosal layer of GI tract and arise from Schwann cell. There are reports of malignant transformation in 2–3% of cases. De Ceglie et al. [74] the tumor grows towards the mucosal layer. Approximately 2.7–8.1% of GCTs involve the digestive tract, and these tumors are multiple in 5–12% of patients, they are usually found incidentally during endoscopy or colonoscopy and are located mostly in the esophagus; other locations include the stomach (10%) and rarely the colon or rectum. Endoscopically, they appear as small firm, isolated nodules or polyps resembling molar teeth, with normal overlying mucosa having a yellow hue (Figure 3A). On EUS (Figure 3B), GCTs appear as hypoechoic, homogeneous lesions with smooth margins originating from the second or third layer of the GI tract, which corresponds to deep mucosa or submucosa. Mucosal biopsy using a regular forceps is usually helpful. The risk of malignancy is low, but the size of the tumor is an important factor. Lesions >4 cm increase the risk to around 2–4% [2]. Cytologic or histopathologic evaluation staining for S-100 can be helpful in differentiating this tumor [75]. For asymptomatic GCTs that are not excised, surveillance with EUS every 1–2 years is recommended to monitor changes in size. Local endoscopic snare excision can be performed for small tumors limited to the mucosa (Figure 3C).
Figure 3.
Granular cell tumor (GCT) of the esophagus. (A) Small, round, molar tooth-like, polypoid lesion in the esophagus. (B) Endosonographic image revealed a homogeneous, hypoechoic lesion with smooth margins is noted within the fourth layer. (C) Endoscopic image showed a EMR defect of GCT.
\n
5.5. Ectopic pancreas
\n
Heterotopic pancreas tissue (aberrant pancreas or ectopic pancreatic tissue)—these terms are used to describe ectopic pancreatic tissue lying outside its normal location with no anatomic or vascular connection to the pancreas proper. They are typically discovered incidentally during endoscopy, surgery, or autopsy, in approximately 1 of every 500 operations performed in the upper abdomen. The incidence in autopsy series has been estimated to be between 1 and 2% and in some reported autopsy series up to 13.7%. About 90% of the lesions are located within the stomach, and mainly in the gastric antrum, the duodenum, the small intestine, or anywhere in the GI tract. Most often asymptomatic incidental findings on endoscopy, they have been reported to present with nausea, epigastric pain, weight loss, hematemesis, ulceration, bleeding, acute pancreatitis and, rarely, gastric cyst formation, outlet obstruction, obstructive jaundice, dysphagia, and malignancy [76, 77]. These lesions have essentially no malignant potential, but there are rare case reports of adenocarcinoma arising from ectopic tissue [78].
\n
Endoscopically (Figure 4A, B), this will typically be a small nodule with a central area of umbilication at the center of the lesion that corresponds to a draining duct. On deep biopsy sampling histologically, the presence of pancreatic acinar tissue will confirm the diagnosis. On EUS (Figure 4C, D) evaluation, it will have a heterogeneous hypoechoic. EUS features are heterogeneous lesions, mainly hypoechoic or intermediate echogenic lesions located within the submucosal layer (the third EUS layer) accompanied by scattered small hyperechoic areas. Generally, an anechoic area and fourth layer thickening will accompany the lesions. Anechoic cystic or tubular structures within the lesion correlate with ductal structures. However, these lesions may develop in any location from the deep mucosal to the serosal layer. The management of aberrant pancreas tissue remains controversial. It should be guided by the symptoms and the possibility of malignancy. Asymptomatic lesions do not necessarily require resection and can simply be followed up. If there are severe symptoms removal is advised. Endoscopic removal is useful both for accurate diagnosis and treatment, although surgical resection is preferred to endoscopic resection when the muscularis propria is involved [79]. Cap-assisted endoscopic mucosal resection is an effective manner of obtaining adequate tissue for histologic diagnosis and management [80].
Figure 4.
Pancreatic rest: (A and B) Endoscopic image of atypical raised submucosal lesion in the gastric antrum. A large umblicated lesion, resembling diffused mucosal lesion (C and D), EUS image (different patient) showing a well defined, hypoechoic lesion involving the third gastric layers.
\n
5.6. Carcinoid tumor
\n
Carcinoid tumors are slow-growing neuroendocrine tumors arising from entero-chromaffin-like (ECL) cells with malignant potential. They may arise at various sites anywhere in the GI tract, most commonly the GI tract and lung. GI carcinoid tumors are generally discovered incidentally during endoscopy, surgery, or autopsy from the appendix, rectum, stomach, and small intestine, and at least 25% of all carcinoid tumors occur within the small bowel (ileum, followed by the jejunum, and then the duodenum). The gastric carcinoid tumors account for 9% of all carcinoid tumors [81, 82]. Rectal carcinoids are common and represent approximately 20% of all GI carcinoid lesions. Female patients predominate. Carcinoid tumors from different areas of the GI tract will have potentially varying presentation and symptoms. Carcinoid tumors are usually asymptomatic, but rare complications include hemorrhage, abdominal pain, intestinal obstruction, and the endocrine carcinoid syndrome that results from the secretion of functionally active substances. Endoscopically (Figure 5A, B), carcinoid tumors appear as small, round, sessile, or polypoid lesions with a smooth surface and a yellow hue. They usually have normal overlying mucosa and seldom ulcerate. Gastric and ileal carcinoids are commonly multiple, whereas those arising elsewhere are typically solitary. Deep mucosal biopsy is normally diagnostic. EUS (Figure 5C, D, E) appearance of carcinoids is usually that of a homogeneous, well demarcated, and mildly hypoechoic or isoechoic mass. These lesions arise from the second layer of the GI tract and may invade beyond the third submucosal layer. Usually originating from the deep mucosal layer and penetrating into the submucosal layer, they may have the classic “salt and pepper” pattern. EUS accurately defines the size and extent of these masses and can guide management. When the lesion is smaller than 2 cm, does not invade further than the third layer, and no adenopathy is noted, endoscopic resection is possible [83, 84] (Figure 5F, Table 6).
Symptomatic (bleeding)
If the lesion is noted to be growing and enlarged with structural changes during the surveillance period
Table 6.
Indication of surgical resection.
Figure 5.
Carcinoid tumor. (A and B) Endoscopic images of a round submucosal lesion in the stomach and duodenal, respectively. (C -E) Endosonographic views of a homogeneous, hypoechoic lesions were located in the gastric and duodenum within the third layer, corresponding to the submucoal layer. (F) Endoscopy image of post-EMR of duodenal carcinoid.
\n
5.7. Rectal carcinoid tumors
\n
Rectal carcinoid tumors are frequently discovered during routine screening by colonoscopy. The size of the lesion is a key factor in risk for metastasis. Lesions <1 cm have rarely metastasized, and endoscopic resection is potentially curative [85, 86]. Small lesions of <1 cm in size that are confined to the submucosa should be removed endoscopically. Larger lesions (>2 cm), or lesions with penetration into the muscularis propria layer on EUS, or lesions with enlarged regional lymphadenopathy should be referred for surgical resection [87, 88].
\n
5.8. Varices
\n
Here, we are talking mainly about gastric varices or those in other areas of the small bowel requiring EUS evaluation (Figure 6A, B), compared to esophageal varices, which are obvious by routine endoscopy [89]. Patient history and portal hypertensive gastropathy will usually support diagnoses of varices versus other etiologies of SELs. Gastric varices can be misdiagnosed endoscopically as submucosal tumors or thickened gastric folds. EUS (Figure 6C) will reveal varices as small, round to oval, and anechoic structures or tubular hypoechoic or anechoic structure within the submucosa (the third EUS layer) that demonstrates venous flow when evaluated with Doppler. When gastric varices grow larger, they appear as anechoic, serpentine, tubular structures with smooth margins, accompanied by perigastric collateral vessels. In comparative studies, EUS was shown to be inferior to endoscopy for detecting and grading esophageal varices, but it permitted detection of fundic varices earlier and more often than endoscopy in patients with portal hypertension. EUS can be one of the interventional modalities of bleeding varices. EUS was used in the treatment of varices by making it possible to inject a sclerosing agent into perforating veins. EUS is used to guide cyanoacrylate injection and case reports of EUS-guided coiling of refractory bleeding varices. [90] Also, there is a report about transesophageal EUS-guided treatment of gastric fundic varices. This procedure was shown to be safe and successful in 96% of cases [91].
Figure 6.
Ectopic duodenal varices. (A and B) Endoscopic views of a large bulging mass lesion at the duodenum. (C) EUS confirmed large, anechoic, tubular, submucosal vessels with multiple extramural collateral vascular structures.
\n
5.9. Cyst and duplication cysts
\n
Gastrointestinal duplication cysts are also identified throughout adulthood [92]. The cysts are benign lesions resulting from an error in the embryonic development of the foregut and can be found either within or adjacent to the wall of the gastrointestinal tract. The cysts can enlarge with secretions resulting in mass effect, infection, rupture, or bleeding [92]. The stomach is the least common site for GI duplication cysts but they can be anywhere in GI tract. On endoscopy appeared as small and smooth subepithelial lesion (Figure 7A) and EUS (Figure 7B–D), cysts in the GI tract appear as anechoic sharply demarcated structures, ounded, or ovoid structures with dorsal acoustic accentuation originating from the second and third layers. However, some may be seen as hypoechoic lesions containing echogenic foci. Cystic submucosal tumors can be classified into three EUS types (simple cystic, multicystic, and solid cystic tumors). Duplication cysts on EUS appear as anechoic, homogeneous lesions with regular margins arising from the third layer or extrinsic to the GI wall. The walls of duplication cysts may be seen as three or five layer structures because of the presence of the submucosa and the muscle layer [93]. Duplication cysts are believed to have a low malignant potential, but some case reports have described malignant transformation. Complications are rare and may include dysphagia, abdominal pain, bleeding, and pancreatitis when the cyst is located near the ampulla of Vater. Bronchogenic cysts represent 50–60% of all mediastinal cysts, and they can be diagnosed easily with EUS as anechoic mass without wall layers. EUS-FNA would cause serious complications, including cyst infection and mediastinitis. Antibiotic prophylaxis is therefore needed and close attention should be paid to avoid accidental instrumentation (Tables 7–9).
Lesion <1 cm
Annual EGD surveillance
Lesion 1–2 cm
Annual EGD surveillance vs. endoscopic resection if there is no deeper penetration to submucosal layer
Type I gastric carcinoid tumors are associated with atrophic gastritis, pernicious anemia and hypergastrinemia
Low malignant potential
Type II gastric carcinoid tumors are also associated with hypergastrinemia, but the high gastrin levels are due to Zollinger-Ellison syndrome or MEN-1 (multiple endocrine neoplasia syndrome, type 1)
Intermediate malignant potential
Type III gastric carcinoid tumors (normal gastrin levels) are the sporadic form
Surgical resection for large lesions >2 cm or Multiple lesions (>5) Antrectomy or fundectomy (removal of G-cell or ECL Surveillance every 6–12 months
Type III lesion (normal gastrin level)
Surgical resection with lymph node dissection
Table 9.
Management of gastric carcinoid tumors.
Figure 7.
Esophageal and gastric cysts: (A) Endoscopic view of a small bulge at the mid-esophagus. (B) EUS revealed a well-demarcated, round, anechoic, within the third layer of esophageal wall. (C and D) EUS images revealed a sharply demarcated, anechoic, ovoid structure within the third gastric wall layer.
\n
5.10. Glomus tumors
\n
A glomus tumor originates from smooth muscle cells of the glomus body and originates from modified vascular smooth muscle cells, and peripheral soft tissue, [94]. A glomus tumor of the gastrointestinal tract is a rare disease, and most of them are found in the stomach. The majority of gastric glomus tumors are benign and found incidentally as a SEL during routine endoscopy. However, some malignant gastric glomus tumors and cases of ulcerative bleeding have been reported. Contrast-enhanced CT reveals a homogeneous hyperdense enhancement on early and delayed phase. On evaluation by EUS, glomus tumors are shown as a circumscribed and hypoechoic mass internal heterogeneous echo mixed with hyperechogenic in the third or fourth layer [95]. Doppler signals suggest the hypervascularity of these lesions located in the submucosa and muscularis propria—also rarely in the serosa (third, fourth, and fifth EUS layers, respectively). Fine-needle aspiration with cytologic and immunohistochemical staining positive for smooth muscle actin and vimentin and negative for CD117 help to differentiate this lesion [96].
\n
5.11. Inflammatory fibroid polyps
\n
Inflammatory fibroid polyp is a rare benign polypoid lesion that is usually found in the stomach, occasionally in the small bowel, and rarely in the esophagus or large bowel [97]. The lesion is located in the second or third layer of the gastric wall, with an intact fourth layer. Sometimes the internal echo pattern is heterogeneous or hyperechoic [98].
\n
5.12. Lymphoma
\n
Primary lymphomas of the GI tract are usually B-cell type lymphomas, including diffuse large B-cell, mantle cell, Burkitt’s, and mucosa associated lymphoid tissue (MALT) [99]. Endoscopy with standard biopsies is often not enough for accurate diagnosis. On EUS, a gastrointestinal lymphoma usually appears as a hypoechoic lesion in the deep mucosa or submucosa (second or third EUS layer). EUS is of key importance for diagnosis with FNA cab being used for flow cytometry [100].
\n
6. Histologic assessment of subepithelial lesions
\n
When the SEL is ulcerated, careful biopsy provides an accurate diagnosis. However, for most SELs, the results of endoscopic biopsy are inconclusive [101]. Trials with a bite-on-bite technique have been undertaken [102, 103]. However, the sensitivity, specificity, and accuracy of cytological evaluations of intramural lesions are all lower than those for SELs in lymph nodes or organs adjacent to the GI tract. It has been reported that the sensitivity of EUS-FNA for mediastinal masses, mediastinal lymph nodes, celiac lymph nodes, pancreatic tumors, and submucosal tumors was 88, 81, 80, 75, and 60%, respectively [104–107]. Subsequent endoscopic resection procedures for these lesions will be difficult. EUS-guided tissue diagnosis is useful for patients with GIST who have metastasis (Figure 8A, B). In these studies, no significant difference in diagnostic accuracy was noted according to the size of the FNA needle, but the 25-G needle easily punctured small mobile SELs and the 19-G needle showed excellent differentiation between GIST and leiomyoma by enabling tissue procurement for immunohistochemical studies (Figure 8C, D). The average reported accuracy of EUS-FNA in the diagnosis of SELs lesions is approximately 80% [108–110]. The development of new EUS-FNB needles promises better GI SET diagnosis rates [111]. In some later prospective studies, however, the diagnostic yield of EUS-TCB in patients with gastric SELs was not better than that of EUS-FNA, and the tissue core obtained with EUS-TCB was not sufficient to examine for mitotic index in GIST. It is clear though that EUS-TCB can be complementary to EUS-FNA [112]. Complications of EUS-FNA and EUS-TCB are very rare, but can include infection, bleeding and perforation. The newly developed ProCore needle (Cook Endoscopy, Winston-Salem, NC, USA) or Side-Port needle (Olympus, Tokyo, Japan) both appear promising. Core biopsy along with aspiration material is made possible with these types of FNA needles [113]. It is important to note that any form of needle biopsy carries the possibility of sampling error, and a negative finding does not exclude malignancy in GISTs. This diagnostic method should be considered for SETs before determining whether tumors should undergo long-term monitoring or surgical resection.
Figure 8.
EUS-FNA of a gastric and rectal GIST. (A and B) FNA needle was inserted into the mass and the stylet was removed as the needle was moved back and forth within the lesion. (C) Slide reveled H&E 20× Spindle Cell Neoplasm. (D) Immunohistochemical stains show a positive reaction of the tumor cells for smooth muscle actin and positive of C-KIT.
\n
7. Management of subepithelial lesions
\n
Management of SELs can be guided by EUS findings. Extraluminal compression by adjacent organs and benign submucosal lesions such as lipomas or simple cysts do not need further treatment or follow-up. Pancreatic rest and inflammatory fibroid polyps can be followed in situ. Suspicious lesions, such as carcinoid tumors, can be diagnosed with endoscopic biopsy. Biopsy should be avoided in lesions that are suspected varices. For deeply located hypoechoic lesions, EUS-FNA, or EUS-TCB can be performed for tissue diagnosis. If resection is planned, ESD can be used as a therapeutic tool for small mass lesions arising from the submucosal or inner circular muscularis propria layer, instead of surgical resection. Surveillance may be appropriate for SELs without definite tissue diagnosis in patients who are at high operative risk. If the lesion is a suspected GIST, changes in size and echogenicity should be monitored. If the size increases or malignant features (echogenic foci, heterogeneity, internal cystic space, irregularity of extraluminal margins, and adjacent lymphadenopathy) develop, resection should be recommended. The follow-up interval depends on the index of suspicion of the examiner and is usually 1 year. When the characteristics of the lesion do not change on two consecutive follow-up examinations with EUS, a longer follow-up interval may be justified [40, 114, 115].
\n
8. Summary
\n
The most common SELs have all been discussed in this chapter. Their characteristics have been summarized and the appropriate diagnostic techniques, therapeutic modalities and immunohistochemical markers used to help in their identification have been reviewed. Most SELs should be referred for EUS evaluation especially if the SEL is more than 1 cm in size. Based on the specific EUS outcomes, majority of the cases a presumptive diagnosis can be made. It is the best test to help and plays an important role in directing further diagnosis and management. EUS-FNA is a good method for tissue diagnosis when a GI SET is suspected. Cytological examination with IHS is essential for the best diagnostic performance in GI SETs. EUS-TCB is good for tissue acquisition, but is associated with some technical challenges. EUS is also plays a major role in endoscopic resection because it can enable the examiner to determine the depth and originating wall layer of the lesion. EUS can also be used in the follow-up lesion if it is not resected.
\n',keywords:"endoscopy, endoscopic ultrasound (EUS), subepithelial lesion (SET), fine-needle aspiration (FNA), fine-needle biopsy (FNB), multidetector computed tomography (MDCT)",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/54024.pdf",chapterXML:"https://mts.intechopen.com/source/xml/54024.xml",downloadPdfUrl:"/chapter/pdf-download/54024",previewPdfUrl:"/chapter/pdf-preview/54024",totalDownloads:2278,totalViews:642,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:0,impactScore:0,impactScorePercentile:12,impactScoreQuartile:1,hasAltmetrics:0,dateSubmitted:"April 15th 2016",dateReviewed:"November 29th 2016",datePrePublished:null,datePublished:"February 8th 2017",dateFinished:"February 2nd 2017",readingETA:"0",abstract:"A subepithelial lesion (SET) is defined as a lesion, bulge or impression visible within the lumen of the gastrointestinal tract that is covered by normally appearing mucosa and usually found incidentally during routine endoscopy. Such a lesion could be either an intramural mass or an impression caused by extramural structures. The old terminology has recently been replaced by the term “subepithelial lesion” because intramural lesions may arise and can be located in any layer of the GI wall underneath the epithelium. The most common SELs are gastrointestinal stromal tumors (GISTs), leiomyomas, lipomas, granular cell tumors (GCTs), pancreatic rests and carcinoid tumors. The prognosis varies from benign to potentially malignant. While the majority of the lesions are considered benign, some tumors such as GISTs and carcinoids have a strong propensity for malignant transformation. Endoscopic ultrasonography (EUS) is the most accurate diagnostic method for distinguishing between extraluminal compressions and intramural lesions and plays a critical role in the detection and management of SELs. This is because EUS can reveal the precise sonographic nature of the lesion even though sometimes there are complex cases, which are difficult to diagnose by EUS alone. Performing routine biopsies and obtaining tissue samples for diagnosis can be difficult because SELs are located beneath the normal epithelial layer. Mostly, EUS allows the practitioner to extract an optimal tissue sample since it allows fine-needle aspiration (FNA) and fine-needle biopsy (FNB) both of which provide good results. With immunocytochemical staining, all these techniques increase the accuracy of the diagnosis. Evaluation of subepithelial lesions by means of EUS imaging will provide further characterization of the lesion to help guide us in appropriate differential diagnosis and further management. In this chapter, we provide a systematic EUS-guided approach to the diagnosis, management and later surveillance for SELs, as well as presenting updated diagnostic techniques that may help physicians to appropriately manage these subepithelial lesions.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/54024",risUrl:"/chapter/ris/54024",book:{id:"5432",slug:"endoscopic-ultrasound-from-usual-to-special"},signatures:"Abed Al-Lehibi and Khaled Bamakhrama",authors:[{id:"189150",title:"Dr.",name:"Khaled",middleName:null,surname:"Bamakhrama",fullName:"Khaled Bamakhrama",slug:"khaled-bamakhrama",email:"khalidgit@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Rashid Hospital",institutionURL:null,country:{name:"United Arab Emirates"}}},{id:"189294",title:"Dr.",name:"Abed",middleName:null,surname:"Al-Lehibi",fullName:"Abed Al-Lehibi",slug:"abed-al-lehibi",email:"aha0021@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Endoscopic ultrasound",level:"1"},{id:"sec_3",title:"3. EUS compared to other imaging modalities",level:"1"},{id:"sec_4",title:"4. Extramural lesions",level:"1"},{id:"sec_5",title:"5. Intramural lesions",level:"1"},{id:"sec_5_2",title:"5.1. Gastrointestinal stromal tumors (GIST)",level:"2"},{id:"sec_6_2",title:"5.2. Leiomyoma",level:"2"},{id:"sec_7_2",title:"5.3. Lipoma",level:"2"},{id:"sec_8_2",title:"5.4. Granular cell tumor",level:"2"},{id:"sec_9_2",title:"5.5. Ectopic pancreas",level:"2"},{id:"sec_10_2",title:"5.6. Carcinoid tumor",level:"2"},{id:"sec_11_2",title:"5.7. Rectal carcinoid tumors",level:"2"},{id:"sec_12_2",title:"5.8. Varices",level:"2"},{id:"sec_13_2",title:"5.9. Cyst and duplication cysts",level:"2"},{id:"sec_14_2",title:"5.10. Glomus tumors",level:"2"},{id:"sec_15_2",title:"5.11. Inflammatory fibroid polyps",level:"2"},{id:"sec_16_2",title:"5.12. Lymphoma",level:"2"},{id:"sec_18",title:"6. 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Endoscopic partial resection with the unroofing technique for reliable tissue diagnosis of upper GI subepithelial tumors originating from the muscularis propria on EUS (with video). Gastrointest Endosc. 2010;71(1):188–94.'},{id:"B103",body:'Pellisé Urquiza M, Fernández-Esparrach G, Solé M, Colomo L, Castells A, Llach J, Mata A, Bordas JM, Piqué JM, Ginès A. Endoscopic ultrasound-guided fine needle aspiration: predictive factors of accurate diagnosis and cost-minimization analysis of on-site pathologist. Gastroenterol Hepatol. 2007;30(6):319–24.'},{id:"B104",body:'Eckardt AJ, Adler A, Gomes EM, Jenssen C, Siebert C, Gottschalk U, Koch M, Röcken C, Rösch T. Endosonographic large-bore biopsy of gastric subepithelial tumors: a prospective multicenter study. Eur J Gastroenterol Hepatol. 2012;24(10):1135–44.'},{id:"B105",body:'Cağlar E, Hatemi I, Atasoy D, Sişman G, Sentürk H. Concordance of endoscopic ultrasonography-guided fine needle aspiration diagnosis with the final diagnosis in subepithelial lesions. Clin Endosc. 2013;46(4):379–83.'},{id:"B106",body:'Rong L, Kida M, Yamauchi H, Okuwaki K, Miyazawa S, Iwai T, Kikuchi H, Watanabe M, Imaizumi H, Koizumi W. Factors affecting the diagnostic accuracy of endoscopic ultrasonography-guided fine-needle aspiration (EUS-FNA) for upper gastrointestinal submucosal or extraluminal solid mass lesions. Dig Endosc. 2012;24(5):358–63.'},{id:"B107",body:'Suzuki T, Arai M, Matsumura T, Arai E, Hata S, Maruoka D, Tanaka T, Nakamoto S, Imazeki F, Yokosuka O. Factors associated with inadequate tissue yield in EUS-FNA for gastric SMT. ISRN Gastroenterol. 2011;2011:619128.'},{id:"B108",body:'Mekky MA, Yamao K, Sawaki A, Mizuno N, Hara K, Nafeh MA, Osman AM, Koshikawa T, Yatabe Y, Bhatia V. Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors. Gastrointest Endosc. 2010;71(6):913–9.'},{id:"B109",body:'Hoda KM, Rodriguez SA, Faigel DO. EUS-guided sampling of suspected GI stromal tumors. Gastrointest Endosc. 2009;69(7):1218–23.'},{id:"B110",body:'Savides TJ, Donohue M, Hunt G, Al-Haddad M, Aslanian H, Ben-Menachem T, Chen VK, Coyle W, Deutsch J, DeWitt J, Dhawan M, Eckardt A, Eloubeidi M, Esker A, Gordon SR, Gress F, Ikenberry S, Joyce AM, Klapman J, Lo S, Maluf-Filho F, Nickl N, Singh V, Wills J, Behling C. EUS-guided FNA diagnostic yield of malignancy in solid pancreatic masses: a benchmark for quality performance measurement. Gastrointest Endosc. 2007;66(2):277–82.'},{id:"B111",body:'Moon JS. Role of endoscopic ultrasonography in guiding treatment plans for upper gastrointestinal subepithelial tumors. Clin Endosc. 2016;49(3):220–5.'},{id:"B112",body:'Săftoiu A, Vilmann P, Guldhammer Skov B, Georgescu CV. Endoscopic ultrasound (EUS)-guided Trucut biopsy adds significant information to EUS-guided fine-needle aspiration in selected patients: a prospective study. Scand J Gastroenterol. 2007;42(1):117–25.'},{id:"B113",body:'Kaffes AJ, Chen RY, Tam W, Norton I, Cho S, Devereaux B, Vaughan R. A prospective multicenter evaluation of a new side-port endoscopic ultrasound-fine-needle aspiration in solid upper gastrointestinal lesions. Dig Endosc. 2012;24(6):448–51.'},{id:"B114",body:'Lee HL. Advances in the management of upper gastrointestinal subepithelial tumor: pathologic diagnosis using endoscopy without endoscopic ultrasound-guided biopsy. Clin Endosc. 2016;49(3):216–9.'},{id:"B115",body:'Jeong ID, Jung SW, Bang SJ, Shin JW, Park NH, Kim DH. Endoscopic enucleation for gastric subepithelial tumors originating in the muscularis propria layer. Surg Endosc. 2011;25(2):468–74.'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Abed Al-Lehibi",address:"aha0021@gmail.com",affiliation:'
Gastroenterology and Hepatology Division, King Saud Bin Abdulaziz University-Health Science, Saudi Arabia
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1. Introduction
Following a meal, pancreatic β-cells produce insulin in response to increasing blood glucose and other metabolite levels for regulating systemic glucose homeostasis. Tissue insulin sensitivity, which characterizes the ability of a given concentration of insulin to correct blood glucose levels, is the driving force behind this homeostasis. Multiple processes in several organs are involved in this typically well-regulated homeostatic mechanism, including decreased glucose output from the liver (hepatic glucose output), increased glucose uptake into skeletal muscle and adipose tissue (where glucose is stored as glycogen), suppression of free fatty acid (FFA) release from adipocytes (suppression of lipolysis), and increased lipid accumulation in the liver and adipocytes. A sophisticated insulin-dependent signal transduction cascade controls these metabolic processes. Insulin resistance (IR) is defined as decreased insulin-stimulated glucose uptake into muscle and adipocytes and faulty insulin regulation of hepatic glucose production in patients with type 2 diabetes (T2D) and in many subjects affected by other conditions characterized by insulin resistance, such as obesity and polycystic ovary syndrome. The term insulin resistance was first coined to explain the considerable variability in the insulin dose necessary to lower high glucose levels in people with T2D, and then to characterize the magnitude of change in blood glucose level when a given amount of insulin and glucose was administered. The “defined quantity of insulin” is crucial because people with insulin resistance often have hyperinsulinemia, a condition in which insulin levels in the blood are higher than normal relative to the amount of blood glucose concentration under both fasting and fed conditions; this hyperinsulinemia compensates for IR in peripheral tissues to bring blood glucose levels back to normal [1].
When pancreas fails to supply excess insulin in humans with insulin resistance, a major defect in whole-body glucose homeostasis occurs, resulting in hyperglycemia and glucose intolerance (the latter including impaired fasting glucose and impaired glucose tolerance), which are the defining features of T2D. It is worth noting that, somewhat counterintuitively, patients with T2D frequently maintain “relative hyperinsulinemia” until the condition is at an advanced stage. IR is defined by insulin’s inability to induce glucose uptake into muscle and adipose cells due to a failure of the glucose transport mechanism mediated, at the molecular level, by glucose transporter type 4 (GLUT4) in those tissues. Furthermore, one of the hallmarks of IR is the inability to decrease hepatic glucose production, which is mostly due to a persistent increase in hepatic gluconeogenesis. IR has been linked to a variety of diseases. Indeed, IR represents a risk factor for various conditions, such as metabolic disorders (including T2D and obesity), heart disease, liver diseases (e.g., non-alcoholic fatty liver disease and non-alcoholic steatohepatitis), cancer, neurodegenerative diseases and frailty [2, 3, 4]. Despite the fact that IR is inextricably linked to T2D, an important factor involved in T2D pathophysiology is represented by the pancreas’ incapacity to function properly to compensate for the significant rise in blood glucose levels by secreting enough insulin to meet the increasing demand and help get blood glucose levels back to normal. IR is a key risk factor for T2D, yet it is not commonly recognized or treated in people without diabetes. The main reason for this phenomenon is that many people with insulin resistance do not have abnormal blood glucose levels. Therefore, diagnosis of IR is based on measuring insulin levels, which is not commonly done in clinical practice. Furthermore, only a small fraction of subjects with IR develop T2D, which is likely due to a propensity to β-cell failure in these subjects. There are no procedures to identify this susceptible subpopulation at this time. Individuals with IR are predisposed to significant disorders linked to T2D, including retinopathy, neuropathy and kidney disease, even if they do not have T2D [5]. In this chapter, the association between the early possible causes of IR is first discussed. Obesity is common in people with IR, but it is unclear whether concomitant hyperinsulinemia contributes to obesity development or whether it is a consequence of obesity-associated IR. We then look at how different metabolic tissues, such as muscle, adipose tissue, and the liver, communicate with one another. The mechanisms of impaired insulin signaling and the role of abnormal GLUT4 trafficking in the development of IR are also discussed. Extracellular factors that may contribute to IR are postulated. This discussion is then followed by a discussion of various intracellular molecular factors that contribute to IR. These factors have been considered as involved in processes that lead to IR. There are several ways for determining insulin action. Many laboratories have lately resorted to employing surrogate markers of insulin sensitivity and IR [6]. The “traditional” definition of IR is a condition in which blood glucose levels are abnormally high and insulin concentration needed to maintain glucose homeostasis is greater than predicted [7, 8].
2. Pathway to insulin resistance
Despite years of research, there is still a lot of uncertainty about the causative and temporal link between obesity, hyperinsulinemia, and IR. The proximal and distal parts of the insulin signaling system, which governs metabolism, can be arbitrarily partitioned. The classical components—which comprise the insulin receptor, insulin receptor substrate (IRS) proteins, phosphoinositide 3-kinase (PI3K) and AKT-constitute the proximal segment of the insulin signaling system. A common trait of the proximal components is their sparseness, which means that just a little part of each element is necessary to elicit a physiological signal. This guarantees signal amplification across the network. The proximal portion is also susceptible to very complex feedforward and feedback control, and is incorporated into a broader network that is dynamically regulated by combinatorial signaling inputs. The AKT substrates that are intimately related to the many physiological activities of insulin and are typically specialized to a particular cell type are referred to as the “distal segment” of the insulin signaling pathway. The distal elements are generally phosphorylated, which is a common trait. Insulin signaling begins with the hormone binding to its surface receptor, followed by activation of the receptor tyrosine kinase and tyrosine phosphorylation. IRS proteins are phosphorylated, causing them to create a signaling complex, which contains proteins with Src homology domains such as PI3K. As a result, phosphatidylinositol (3,4,5)-trisphosphate [PtdIns(3,4,5)P3 or PIP3] is produced. Serine/threonine (Ser/Thr) protein kinases like PDK1 and AKT, for example, are recruited to the inner leaflet of the plasma membrane. AKT is phosphorylated by PDK1 at one of its phosphorylation sites. Partially phosphorylated AKT activates mTORC2, while phosphorylation of AKT specifically at Ser473 results in complete AKT activation. Thus, AKT is a critical node in the insulin signaling pathway. AKT performs a variety of biological roles and is involved in the majority, if not all, of physiological metabolic processes. The Rab GTPase-Activating Protein (GAP) is an AKT substrate, which activates TBC1D4 (TBC1 Domain Family Member 4), a protein that regulates GLUT4 trafficking within the plasma membrane. The activation of glucose transport by insulin is the key mechanism that is disrupted in insulin-resistant muscle and fat cells. The GLUT4 is a facilitative glucose transporter, which is found in skeletal muscle, heart, adipocytes, and insulin-responsive neurons; it regulates muscle/fat glucose transfer. Unlike other transporters (like GLUT1), GLUT4 has a set of specific trafficking cues that let it migrate from endosomes and the trans-Golgi network (TGN) to a special intracellular population of vesicles known as “GLUT4 storage vesicles” (GSVs) [9, 10, 11]. GSVs act as a distinct controlled exocytic compartment that distributes GLUT4 to the cell surface in response to insulin and serves as a storage depot assuring low rates of glucose absorption in the fasting state. Although exercise increases GLUT4 translocation in muscle cells, it does so through a different mechanism than that regulated by insulin. AKT plays a critical role in the insulin-regulated GLUT4 translocation [12, 13]. These characteristics typically coexist, and there is strong evidence that each can cause the other two branches of the triad to emerge: obesity, hyperinsulinemia, and IR are caused by overnutrition in humans and animals; in humans, IR and obesity may also be caused by continuous insulin administration or by genetic factors; in addition, IR in humans may be caused by pharmacological interventions resulting in hyperinsulinemia [14, 15].
3. The trio-axis of obesity-hyperinsulinemia-insulin resistance
Obesity and IR are two topics that come up frequently. The long period during which obesity, IR and hyperinsulinemia develop, makes the determination of causative links between these conditions (which usually coexist in most persons with T2D at the time of diagnosis) particularly difficult. Obesity is common in people with IR, although it is unclear whether simultaneous hyperinsulinemia plays a role in obesity development or it is predominantly a result of obesity-dependent IR [16]. The study of first-degree relatives of people with T2D who only show some of these traits has shown to be one of the most effective strategies for addressing some unanswered questions in humans. As a result, a trait seen in relatives is more likely to appear early in the course of the disease. It has been found that these subjects can have considerable IR in skeletal muscle and liver (and possibly fat), along with modest hyperinsulinemia, even if they are not obese or glucose-intolerant [15, 17, 18]. Individuals who are lean and glucose-tolerant but exhibit IR have been identified in larger cross-sectional studies [19]. In these instances, obesity is unlikely to be the primary cause of tissue IR. However, the term “obesity” is defined differently depending on race and genetic background, and it should therefore used with caution. Body mass index may be more important in determining the risk of IR. Body weight, in general, and visceral fat (but not subcutaneous fat), in particular, should be considered for evaluation [20].
First-degree relatives of people with T2D had greater levels of circulating FFAs and intramuscular lipids than healthy control subjects [21], suggesting that intramyocellular lipid content represents an early abnormality in the pathogenesis of insulin resistance and that it may contribute to the impaired glucose uptake in skeletal muscle of insulin-resistant subjects to a greater extent than overall adiposity. This is in line with severe IR observed in patients with lipodystrophy syndromes, which are a heterogeneous group of diseases characterized by selective absence of adipose tissue, loss of functional adipocytes, ectopic steatosis, and severe dyslipidemia and IR [22, 23]. On the other hand, individuals with moderate or severe obesity can be “metabolically healthy” [24]. While it appears acceptable, based on this research, to conclude that obesity is not a risk factor essential for the development of IR, it is vital to highlight that the majority of subjects with IR are obese. As we will discuss later in the text, the amount and location of adiposity required to create IR varies greatly between subjects.
4. Insulin resistance and hyperinsulinemia
Defining the temporal link between hyperinsulinemia and IR is difficult since, as far as we know, IR does not exist in the absence of hyperinsulinemia in humans, and vice versa. Hyperinsulinemia can produce obesity and IR in humans, as evidenced by trials in which insulin is administered to induce hyperinsulinemia in otherwise healthy individuals or as it occurs naturally in people with insulinomas [25, 26]. Transgenic expression of multiple copies of the normal insulin gene causes hyperinsulinemia in mice, resulting in IR and glucose intolerance [27]. Inhibition of insulin secretion has also been shown to improve insulin sensitivity and to decrease body weight in rodents [28, 29, 30]. In mice, deletion of one copy of the insulin gene resulted in a reduction of the Western diet-induced hyperinsulinemia and in an improvement of insulin sensitivity [31]. Overall, the hypotheses that hyperinsulinemia causes IR and promotes obesity, or that IR associated with obesity causes hyperinsulinemia, both remain acceptable for the initial events involved in T2D pathophysiology. In actuality, IR and hyperinsulinemia coexist and lead to T2D in almost all cases [32]. Several data suggest a concept in which hyperinsulinemia is responsible for, or at least partly contributes to, many of the negative effects of IR; this implies that IR is a state in which many of the insulin actions are preserved, a condition known as “selective IR” [33, 34, 35]. This was first observed in the liver, where increased insulin levels are unable to decrease hepatic glucose output in people with T2D, although lipogenesis (a canonical insulin action in the liver) remains elevated [36, 37]. One explanation for this selectivity is that insulin signaling pathway in the liver splits into two arms, with IR affecting only the arm regulating hepatic gluconeogenesis but not the arm regulating lipid metabolism. Hepatic de novo lipogenesis is essentially a cell-autonomous phenomenon, whereas cell-nonautonomous suppression of hepatic glucose production by insulin depends upon the insulin-mediated decrease of adipocyte lipolysis and circulating FFAs [38]. There has also been evidence of selective IR in muscle and adipose tissue. Those insulin-regulated activities which are not affected by IR—such as lipogenesis, protein synthesis, or transcriptional control mediated by FOXO proteins—are hyperactivated in the context of hyperinsulinemia and are likely to worsen IR or its consequences [33, 34, 39, 40].
5. Heterogeneity in the development of insulin resistance and progression of metabolic disease and T2D
T2D patients are divided into different phenotypic clusters based on their symptoms and clinical features. Individuals in one of these groups share phenotypic traits. As a result, performing a comprehensive analysis of these groups will be of great importance in clinical settings. Phenotype data analysis and combination of phenotype data with genetic data are essential to gain a better understanding of the variability in the development and presentation of IR in humans [10, 11, 41].
6. Tissue-specific progression to insulin resistance
The appearance of IR occurs in various tissues in a specific order. The development of IR in several tissues—including skeletal muscle, liver, and adipose tissue—is a hallmark of fully developed T2D in humans [18, 19, 39, 40, 42]. Evidence shows a hierarchical progression of IR in skeletal muscle, liver and adipose tissue, whereby IR develops in one tissue and then spreads to other tissues via systemic circulating components. For example, IR in the liver and adipose tissue appears to occur prior to IR in muscle in C57Bl/6 mice fed a high-fat diet [43, 44, 45, 46]. An equivalent pattern in humans is unlikely, since first-degree relatives of persons with T2D who are in the early stages of the disease already have IR in both muscle and liver (and possibly fat) [47]. Since insulin sensitivity in humans is often measured as whole-body glucose consumption (to which adipose tissue contributes only to a small extent), the temporal development of IR in adipose tissue in humans is less obvious. Interestingly, multiple investigations show that insulin modulates hepatic glucose production via reducing adipocyte lipolysis in a non-cell-autonomous manner [45]. Given these findings, it is reasonable to believe that adipose tissue IR is a precursor to metabolic disease and T2D. However, there is a clear distinction between insulin action on the liver and insulin action on muscle: even in people with T2D, the defect in insulin sensitivity in the liver can be almost completely overcome by sufficiently high levels of insulin, whereas muscle (and fat) insulin sensitivity defects persist at higher insulin concentrations [40, 48, 49]. This indicates that the processes that cause IR in muscle and liver are distinct.
Tissue-specific insulin receptor gene knockouts in mice have provided persuasive evidence that IR in a particular tissue can at least spread to other organs. Experimenting with a specific deficiency in insulin action in muscle, fat, or liver has resulted in the spread of IR to other tissues in a number of cases [50]. However, depending on the tissue that is first targeted and/or in which a specific gene deletion occurs, the mechanism of inter-tissue communication varies. The deletion of GLUT4, which is essential for glucose uptake in adipose tissue and skeletal muscle, is one of the best examples of this inter-tissue communication. In mice, deletion of GLUT4 resulted in IR not only in the tissue from which the transporter was removed, but also in all metabolic tissues, including the liver. Surprisingly, normalization of blood glucose levels reverses IR in the liver and adipose tissue in muscle-specific Glut4 gene-knockout mice. This shows that glucotoxicity generated IR in this animal model, which is not the case in many other IR models, including the Western diet-fed C57BL/6J mice, which do not show considerable hyperglycemia [48, 49, 50, 51]. As a result, while these animal studies have been useful in uncovering mechanisms of IR in specific tissues, their clinical applicability is less evident because complete deletion of a gene preferentially in one tissue does not occur in humans. Nonetheless, these experiments have provided persuasive evidence that metabolic or signaling changes in one tissue can have systemic effects by influencing insulin activity in other organs, a phenomenon that has been well-validated by clinical findings [50, 51].
7. Impaired insulin signaling in insulin resistance
Over the past 40 years, much research has resulted in a precise understanding of the insulin signaling system, which mediates the insulin’s physiological activities. One popular theory is that IR is caused by a defect in one or more of these signaling components. Another viewpoint is that IR is only caused by a shift in metabolic flux. For example, since the 1960s fatty acids have been proven to impede cells’ ability to utilize carbohydrate by allosterically modifying crucial rate-limiting steps in carbohydrate metabolic pathways. Several pieces of evidence, however, refute this claim. IR can be seen in cells or tissues long after the animal tissues have been removed, implying that changes that contribute to IR are long-lasting and cannot be explained by the acute action of a systemic factor. Fatty acids decrease the insulin-dependent translocation of GLUT4 to the plasma membrane and limit glucose uptake, there is no indication that this inhibition is caused by an allosteric change of GLUT4. Finally, IR can persist even after significant changes in dietary intake and after changes in metabolic state induced by pharmacological interventions. Thus, based on this information, it is reasonable to believe that IR is caused by an alteration in insulin signaling, although the exact location of the defect in the insulin signaling pathway remains unknown. Many essential components of the insulin signaling system have been identified. These components are divided into two parts: (i) the proximal part, which represents the core canonical signaling pathway, which includes the insulin receptor, IRS, PI3K and AKT; and (ii) the distal part, which includes TBC1D4, GSK3 (glycogen synthase kinase-3) and PDE3B (phosphodiesterase 3B). IR has been linked to defects in proximal insulin signaling system, that are associated with cellular stress. Many of the intracellular stressors discussed in the next sections activate a variety of intracellular Ser/Thr kinases, including novel PKCs (protein kinase C), JNK (c-Jun amino-terminal kinase), mTOR (mammalian target of rapamycin)and S6 kinase, which phosphorylate either the insulin receptor or the insulin receptor-related protein (INSRR). This could be a negative-feedback route that inhibits insulin signaling, according to the theory. However, as it will be discussed later, mounting evidence suggests that proximal insulin signaling system is unaffected in IR, implying that IR is caused by abnormalities in distal components of the insulin signaling network [52, 53, 54].
8. Insulin resistance and insulin signaling at the proximal level
The current focus on proximal insulin signaling abnormalities as a cause of IR stems from research into rare, monogenic severe types of IR that were discovered to be caused by mutations in the insulin receptor gene or by the development of insulin receptor blocking antibodies. Because of the superficial parallels between these rare conditions and T2D, it is reasonable to conclude that both diseases are caused by abnormalities in insulin receptor function, with the degree of receptor failure varying only slightly. Despite early enthusiasm for this theory, subsequent research found that IR in most forms of T2D was caused by neither impaired insulin receptor activity nor changes in the expression or quantity of insulin receptors. Insulin-binding experiments in rat adipocytes found that only 2.4% of total insulin receptors are required for a full biological response, implying that metabolic cells like muscle, fat and liver cells have an abundance of insulin receptors; this finding became known as the “spare insulin receptor” hypothesis. Insulin-mediated glucose uptake is reduced in insulin-resistant skeletal muscle cells and adipocytes. Since a slight decrease in the number of insulin receptors could only diminish insulin sensitivity and not the maximal insulin response [54, 55, 56, 57, 58]. While some studies contradict the “spare insulin receptor” hypothesis, recent genetic studies in mice support the idea that insulin signaling is preserved when the number of insulin receptors is reduced: mice with heterozygous loss of the insulin receptor had normal glucose and insulin tolerance and no impairment in AKT signaling in muscle or adipose tissue [59, 60, 61, 62].
The concept of spare insulin receptors shifted focus to a “postreceptor defect”, which is represented by defects in signaling downstream intermediates of the insulin receptor as the cause of IR [57, 58, 63]. Loss-of-function mutations in a number of signaling genes—including TBC1D4, AKT2, and IRS1 in humans—have been linked to severe forms of IR and T2D; moreover, cancer treatments that block PI3K or AKT have been linked to IR and T2D in humans. IR is caused in mice by targeted deletion of these genes. In addition, IR results in reduction of skeletal muscle AKT phosphorylation in response to insulin stimulation [34, 64, 65].
Given evidence of “spareness” for IRS, PI3K and AKT, the possibility that abnormalities in proximal insulin signaling might be responsible for IR has to be questioned, in the same way that the “spare receptor” theory has to be questioned. Homozygous deletion of AKT2, the most prevalent AKT gene isoform, resulted in a 90% reduction in insulin-stimulated AKT phosphorylation, but with no discernible defect in phosphorylation of the AKT substrate, or protein synthesis in response to insulin. In this situation, there was a tiny quantity of AKT1 expression that was not influenced by the gene deletion and was enough to deliver a completely functional message as response to insulin [66, 67]. Similarly, whereas AKT2 accounts for 85% of total AKT in the liver, its ablation does not result in significant glucose intolerance because the remaining AKT1 compensates for this defect [68]. The insulin dose-response curve in adipocytes, where the curve for AKT phosphorylation is “shifted to the right” compared to that for AKT substrate phosphorylation or insulin action, indicates that partial phosphorylation of AKT is sufficient for maximal biological responses, providing additional evidence for “spareness” in proximal insulin signaling network. At “normal” insulin concentrations, phosphorylation of AKT substrates requires only 1% of the entire AKT pool to be activated [69, 70, 71]. Furthermore, AKT phosphorylation is reduced in muscle from T2D patients, while downstream substrate phosphorylation is unaffected. Importantly, studies in animals fed a Western diet have indicated that IR begins before any detectable insulin signaling defect. Only 42 days of Western diet feeding resulted in reduced insulin-stimulated AKT phosphorylation, but TBC1D4 phosphorylation remained normal. As a result, minor changes in phosphorylation of proximal insulin signaling components may result in insulin sensitivity, but they are unlikely to result in a reduction in the maximal physiologic response [53].
Thus, how can the predominance of abnormalities in proximal insulin signaling components observed in diverse IR models, such as lower AKT phosphorylation, be reconciled? It is possible that these defects are a result of defective glucose metabolism rather than the cause. This could be a direct effect secondary to compensatory hyperinsulinemia, a typical hallmark of IR (since persistent hyperinsulinemia can lead to degradation of proximal insulin signaling components); alternatively, it may be a cell-autonomous effect due to a reduction in AKT phosphorylation as a result of defective glycolysis. Many studies used insulin-stimulated AKT phosphorylation in mice (sometimes in response to a maximal, pharmacological dosage of insulin) as an indicator of insulin sensitivity [72, 73, 74, 75].
However, under physiological settings such as the response to a meal (with minimal insulin release), AKT phosphorylation is barely detectable, due to the non-linearity between AKT phosphorylation and phosphorylation of its substrates. As a result, when evaluating the physiological importance of insulin signaling, it is critical to look at the phosphorylation of a variety of AKT substrates to determine if there is a major deficiency in “AKT activity” in vivo. These findings suggest that a minor impairment in proximal insulin signaling network is unlikely to account for the significant reduction in insulin-stimulated glucose uptake observed in patients with T2D. Furthermore, these findings underline that lower AKT2 phosphorylation should not be used as a direct marker or even as a proxy measure of IR [71].
Negative feedback loops originating from Ser/Thr kinases that phosphorylate and limit the action of IRS proteins have also been proposed as a cause of IR. This theory is refuted by a number of studies. Since Platelet-derived growth factor (PDGF) by-passes these proteins to activate glucose uptake, mice bred to overexpress PDGF receptor (PDGFR) in muscle presented an ideal model to explore whether deficiencies in insulin receptor or IRS were implicated in experimental IR. In these mice, PDGF treatment resulted in increased glucose uptake in muscle [76]. Notably, when PDGFR transgenic rats were fed a Western diet, muscle glucose uptake in response to PDGF was decreased to the same degree as insulin-mediated uptake. This refutes a role for inhibitory Ser/Thr phosphorylation of the insulin receptor or IRS as a cause of IR, indicating that the deficiency in glucose uptake or IR does not involve the insulin receptor or IRS [8, 53, 54, 77, 78].
Furthermore, in mice, targeted mutation of one of the major putative inhibitory sites in IRS1 (Ser307), deletion of potential mediators of IR, such as PKC (which is reported to phosphorylate insulin receptor), and pharmacological blockade of key negative feedback pathways, such as mTOR (which is activated by insulin signaling and inhibits signaling by phosphorylating IRS through a negative feedback mechanism) [78, 79, 80, 81].
Finally, investigations in humans with IR or T2D revealed that insulin-stimulated muscle glucose uptake is reduced by 50–100% even at maximum insulin dosages [82, 83, 84, 85], with no change or reduction in AKT phosphorylation [86, 87, 88]. Only a few of these studies addressed the mechanism of AKT substrate phosphorylation in depth, and those that did found no deficiency or poorly linked with IR. These findings support the theory that the proximal insulin signaling network in human tissues has enough “spareness” to overcome even a moderate deficiency in AKT phosphorylation [87, 88, 89], and that lowered AKT phosphorylation is adequate to ensure a normal signal transduction. As previously stated, faulty proximal insulin signaling is most likely a result of IR rather than a cause of IR [90].
9. GLUT4 and insulin resistance
Insulin stimulates the transfer of intracellular GLUT4 storage vesicles to the cell surface, resulting in glucose uptake in skeletal muscle cells and adipocytes (Figure 1) [91, 92, 93, 94]. Insulin-dependent GLUT4 translocation has been linked to IR in both skeletal muscle and adipose tissue. This decrease in GLUT4 availability at the plasma membrane causes a reduced glucose uptake, which can lead to other IR-related consequences like reduced AKT phosphorylation, protein synthesis defects, and increased lipolysis [72, 95, 96]. GLUT4 does not show spareness, unlike proximal insulin signaling components such as IRS1 and AKT. The fact that heterozygous GLUT4 gene-knockout mice acquire metabolic disease exemplifies this concept [97].
Figure 1.
Translocation of glucose transporter type 4 (GLUT4) from GLUT4 storage vesicles (GSVs) to the plasma membrane of normal adipocytes and skeletal muscle cells (a). This process is altered in conditions characterized by insulin resistance (b).
However, while GLUT4 levels are lowered by 50% in human adipose tissue from patients with T2D, such levels remain unaltered in skeletal muscle, implying that GLUT4 levels cannot explain IR development in skeletal muscle [98]. Despite normal GLUT4 levels, insulin-stimulated GLUT4 translocation to the cell surface in skeletal muscle is faulty in both individuals with T2D [92] and in several rodent models of IR [99, 100]. Importantly, while exercise-modulated GLUT4 translocation to the cell surface is unaffected [101], the impairment in muscle GLUT4 trafficking in T2D is insulin signaling-specific. Insulin and exercise both cause GLUT4 translocation to the cell surface from discrete intracellular compartments [102].
The ultimate defect that defines IR is the impaired GLUT4 translocation to the plasma membrane. However, it is unknown how the numerous potential intracellular IR mediators mentioned later affect GLUT4 trafficking. Three options are discussed here. First, GLUT4 translocation requires that GLUT4 is localized in the appropriate intracellular compartment, the so-called GLUT4 storage vesicles (GSVs); GLUT4 targeting to GLUT4 GSVs has been hypothesized to be altered in IR [91, 100]. However, whereas this would likely result in GLUT4 degradation, GLUT4 levels in skeletal muscle from patients with IR remain unaffected. Second, given the importance of protein phosphorylation in insulin action [101, 102, 103, 104], it is possible that the defect is caused by a distal component of the insulin-regulated phosphorylation network such as TBC1D4, which regulates GLUT4 trafficking, although there is no convincing evidence for defective TBC1D4 phosphorylation in IR [105]. TBC1D4 is unlikely to be the only AKT target causing GLUT4 translocation, as cells lacking TBC1D4 still have some insulin-sensitive glucose transport [106]. Recent phosphoproteomics studies have revealed the existence of a wide range of insulin-responsive phosphoproteins in metabolic cells, allowing for the identification of insulin signaling targets in the distal part of the insulin signaling pathway that may be involved in the development of IR [104]. Indeed, IR is associated with massive alterations in the architecture of the entire insulin signaling pathway, according to examination of muscle cells from T2D patients [107]. Finally, a direct alteration of GLUT4 or a defect in a yet undiscovered protein that interacts with GLUT4 could cause the abnormalities in GLUT4 trafficking. This could include carbonylation and oxidation-induced inactivation of GLUT4, which have been observed in humans as a response to short-term overnutrition [108]. Protein carbonylation is linked to H2O2 production, lipid peroxidation and IR, suggesting a link between such molecular processes and the development of IR [109].
10. Adipose tissue and insulin resistance
While IR is regularly seen in lean first-degree relatives of patients with T2D, it is also found in many lean “healthy” individuals, suggesting that IR is more common than previously thought. In this regard, dietary habits, physical activity level and genetics are important factors that can significantly contribute to IR. Adipose tissue makes a significant contribution to the development of IR. Limitations in peripheral adipose tissue storage capacity and expansion in response to over nutrition (as it occurs in overweight and obesity) lead to increased circulating lipids, subsequent lipid accumulation in non-adipose tissues (ectopic lipid in liver, skeletal muscle, heart, and pancreas) and development of lipid-induced IR and metabolic derangements [110, 111]. Because of this, and since there is a clear link between IR and increased adipose tissue mass, we will discuss the role of adipose tissue mass and lipotoxicity as significant drivers of IR, as well as the emerging mechanisms by which adipocytes contribute to systemic IR.
10.1 Adipose tissue dysfunction
IR in adipocytes could be the first step in the progression of adipose tissue dysfunction, similar to IR in muscle and liver. In adipocytes from first-degree relatives of patients with T2D, there is a low expression of markers of insulin sensitivity such as GLUT4 and adiponectin (a crucial systemic insulin-sensitizing adipokine produced by adipose tissue), supporting this theory [112]. Furthermore, adipocyte hypertrophy (increase in adipocyte size) appears to precede T2D onset in Pima Indians, a group of Native Americans with a high incidence of IR and T2D [113]. Additionally, mouse models with adipose-specific IR also have IR in their muscle and liver. Notably, IR in the muscle of adipose-specific Glut4 gene-knockout mice was only present in vivo but not when muscles were isolated and assessed in vitro, implying a role for systemic factors (which did not include circulating FFAs or inflammatory cytokines) in the progression of IR from adipose tissue-specific pathology [114, 115].
Human genetic research has also suggested that adipose tissue plays a significant role in IR. Studies in identical twins or first-degree relatives of T2D patients have shown that inheritance has a substantial influence in IR and T2D [116]. More than 250 genetic loci have been linked to T2D so far, however they only account for 25% of T2D heritability [117]. While these investigations have generally discovered genes linked to beta-cell function and insulin secretion, deeper analysis of phenotypes more closely aligned with IR have begun to uncover genetic drivers of IR in other organs. Surprisingly, several of these drivers are involved in the function of adipose tissue [118]. Although subclinical lipodystrophy is a rare cause of severe IR, it has been suggested that milder forms of lipodystrophy are responsible for IR in general, supporting a model in which excessive lipid spillover into circulation is a proximal, mechanistic cause of altered insulin action. Specifically, when the individual’s capacity to store lipids in adipose tissue has been exceeded, lipid spillover into circulation leads to elevated plasma FFAs and triglyceride levels, which result in increased ectopic storage of these molecules in non-adipose tissues—such as liver and skeletal muscle—and subsequent metabolic derangements via lipotoxicity (lipid-induced toxicity). Surprisingly, genes in the insulin signaling system linked to IR (IRS1 and GRB14) are also linked to familial partial lipodystrophy [119].
PPARG (Peroxisome Proliferator-Activated Receptor Gamma, a master positive regulator of adipogenesis) and CCDC92, DNAH10, and L3MBTL3 (regulators of adipocyte differentiation) were among the 53 loci discovered in a study employing an integrated genomic approach to find genes related to IR. Thiazolidinediones are insulin-sensitizing peroxisome proliferator-activated receptor gamma agonists that are used in the treatment of T2D and act by promoting adipogenesis and adipose tissue growth (through cell size and cell number increase or adipocyte hypertrophy and hyperplasia) [119]. The availability of additional lipid storage induced by thiazolidinediones may therefore promote insulin sensitivity by alleviating lipotoxicity [120]. These drugs also improve insulin sensitivity in first-degree relatives of T2D patients, implying that adipose tissue hypertrophy and “unhealthy” lipid storage are critical regulators of insulin action and contributors to IR [121].
Adipose tissue’s primary function is to store fat and release it into circulation when needed, and it has the unique capacity to expand in response to nutrient overload. Lipids can be released into the bloodstream when the adipocyte capacity to store lipids has been exceeded [39]. There is compelling evidence that the accumulation of excess lipids in non-adipose tissues (e.g., skeletal muscle and liver), known as lipotoxicity (a.k.a. lipid-induced toxicity), plays a role in the development of muscle and liver IR [122]. As a result, studies aimed at understanding the cause and magnitude of increased circulating lipid levels in IR are now being pursued. Furthermore, intracellular lipid accumulation in cells and tissues—including pancreatic beta cells and liver—has been linked to the onset of cellular dysfunctions, such as secretory abnormalities and inflammation (Figure 2). Elevated circulating FFA levels have been linked to IR, and this has been proposed as a possible cause of lipotoxicity [123].
Figure 2.
Excessive adipocyte lipid storage in response to overnutrition, resulting in adipocyte hypertrophy, inflammation and increased release of free fatty acids (FFAs) into circulation, leading to ectopic fat accumulation, lipotoxicity and development of insulin resistance in non-adipose tissues, such as liver and skeletal muscle.
In humans and animals, lipid infusion causes muscle IR and enhanced hepatic gluconeogenesis, the latter attributable to changes in metabolic fluxes rather than to fat accumulation [123, 124, 125]. Furthermore, animals with increased circulating FFA levels due to increased lipolysis develop muscle and hepatic IR, whereas obese mice with reduced fat cell lipolysis are protected from glucose intolerance [126]. It is worth noting that, as discussed elsewhere [127], circulating FFA levels in patients with IR or T2D usually are not elevated. However, there are several confounders in this measurement, including the wide range of FFA levels in healthy adults and the fact that fasting FFAs are typically assessed rather than the more relevant postprandial FFAs. Nonetheless, there is strong evidence that serum FFA levels are elevated in first-degree relatives of patients with T2D [127, 128], implying that this elevation represents an early stage of the disease. It is unclear if the rise in circulating FFA levels is related to defects in insulin-mediated regulation of lipolysis, to alterations in fat storage capacity, or to an increase in adipose tissue mass without defects in lipolysis. Lipolysis per gram of adipose tissue mass is considerably lower in obese subjects, suggesting that enlargement of adipose tissue mass is the principal driver of abnormal FFA homeostasis [129].
Adipose tissue can grow in size by either hypertrophy, which involves the enlargement of existing adipocytes, or hyperplasia, which involves the generation of new fat cells from preadipocytes via adipogenesis, resulting in an increase in the number of tiny adipocytes [130]. Subcutaneous adipose tissue is more expandable than visceral adipose tissue in humans, whereas the opposite is true in C57BL/6J male mice [131]. Female mice, interestingly, show expandability of both adipose tissue depots in response to Western diet feeding, suggesting that sex hormones and other sex-dependent elements play a role in this process [131, 132]. Pathological adipose tissue expandability under situations of overnutrition, particularly adipose tissue hypertrophy, has got a lot of attention as a likely cause of IR. Indeed, first-degree relatives of patients with T2D have greater amounts of hypertrophic adipose tissue, implying that changes in cell size—presumably due to defective adipogenesis—represent an early event in the pathophysiology of T2D. Hypertrophic large adipocytes are linked to poor metabolic outcomes when compared to hyperplastic adipocytes [39, 133], which have been shown to confer metabolic health in obesity [134, 135, 136]. More importantly, hypertrophic adipocytes may contribute to an increase in circulating FFA levels due to their reduced FFA storage capacity. Reduced preadipocyte differentiation, diminished de novo lipogenesis or FFA uptake in hypertrophic adipocytes, and/or reduced adipose tissue expandability due to physical limits on expanding cell size may all contribute to decreased lipid storage capacity by the hypertrophic adipose tissue. Furthermore, adipogenesis abnormalities may result in decreased generation of beige adipocytes, thereby contributing to higher circulating FFA levels; indeed, beige adipocytes differentiate from a subpopulation of progenitors resident in white adipose tissue and have the ability to promote FFA oxidation through thermogenesis [137, 138].
10.2 Circulatory factors released from adipocytes
Adipose tissue secretes a number of factors (termed “adipokines”) into the bloodstream that regulate energy metabolism. These factors include cytokines, hormones, extracellular matrix proteins, as well as growth and vasoactive factors. The type of adipose tissue expansion has been demonstrated to impact the secretion of certain of these factors under IR conditions. Since the discovery of leptin as the first adipokine [139], a growing list of adipose tissue-secreted factors implicated in IR has been discovered, with roles in IR that are either protective or causative [20, 140].
Leptin, for example, regulates whole-body energy metabolism by acting on feeding centers in the brain to suppress food intake and increase energy expenditure; leptin deficiency causes obesity, hyperinsulinemia, IR and impaired glucose homeostasis [141]. Adiponectin, another well-known adipokine secreted from adipocytes, has been linked to regulation of cell insulin sensitivity. In humans, circulating adiponectin levels are favorably linked with whole-body insulin sensitivity; additionally, physical training increases circulating adiponectin levels and the expression of its receptors in muscle, which may mediate the improvement of IR in response to exercise [142]. Surprisingly, small and subcutaneous adipocytes release more adiponectin than visceral or large adipocytes [143]. Anti-atherogenic, anti-inflammatory, and insulin-sensitizing effects of adiponectin have also been discovered [144]. It is worth mentioning, however, that while adiponectin’s positive benefits in rats are outstanding, the role of this adipokine in humans is less obvious, and Mendelian randomization studies on adiponectin’s relationship with metabolic disease in humans have generated inconsistent results [145, 146].
Adipocytes release a variety of substances, including metabolites like lipids and extracellular vesicles that contain proteins and microRNAs. Branched fatty acid esters of hydroxy fatty acids (FAHFAs) are a unique class of lipids synthesized in adipocytes that have been shown to increase insulin sensitivity and reduce inflammation; accordingly, individuals with IR have lower circulating FAHFA levels [147]. As a result, further research into this metabolite class is necessary. Adipocytes, for example, release tiny lipid-encapsulated extracellular vesicles into the bloodstream. These vesicles may alter metabolic processes in other target tissues, such as the liver, according to increasing evidence based on mouse studies. MicroRNAs represent one of the components found in extracellular vesicles that have been linked to this mechanism. While investigations on microRNAs are intriguing, many fundamental aspects about the mechanism of their controlled secretion and their tissue targeting and entry into target cells remain unknown [148, 149].
Many circulating factors are also produced by other adipose tissue-resident cells, such as immune or vascular cells, rather than by adipocytes themselves (the so-called “stromal vascular fraction” of adipose tissue). Some of these adipokines, such as tumor necrosis factor (TNF), resistin or vascular endothelial growth factor (VEGF), are important regulators of tissue homeostasis and may be secreted as a result of adipose tissue enlargement during the development of obesity [150]. Nonetheless, inflammatory cytokines have been widely suggested as possible IR-inducing adipokines, and several of these factors have significant proinflammatory activities [151, 152, 153].
11. Inflammation and insulin resistance
It is now well recognized that cells of both innate and adaptive immunity, notably macrophages, infiltrate hypertrophic adipose tissue in most obesity models, and that this is accompanied by a loss of immunosuppressive regulatory T cells in visceral fat depots [154]. When macrophages in adipose tissue are activated in response to overnutrition, they polarize towards a proinflammatory phenotype and release cytokines that may trigger IR in all metabolic tissues [155]. Diet-induced obesity in mice and humans is unmistakably linked to elevated levels of systemic inflammatory markers, including C-reactive protein (CRP) and enhanced immune cell infiltration of adipose tissue and other organs [156]. In addition, inflammatory cytokines, such as TNF, can elicit IR in metabolic tissues when infused in humans [157]. Although macrophage infiltration into hypertrophic adipose tissue is well documented, the role of inflammation in IR is convoluted and controversial; for example, inflammatory markers are not elevated in first-degree relatives of T2D patients [158]. Furthermore, in Western diet-fed mice, tissue IR occurs before the adipose tissue infiltration by a considerable number of immune cells, and genetic or pharmacological anti-inflammatory methods do not prevent the development of Western diet-induced IR [159, 160]. The administration of a neutralizing antibody against interleukin-1 (IL-1), a proinflammatory cytokine implicated in IR, to approximately 4000 patients with T2D and almost 5000 subjects with prediabetes resulted in a significant decrease in CRP levels, as well as in a modest positive effect on cardiovascular outcomes, but without reducing the frequency of new-onset T2D or increasing fasting glucose levels [161, 162, 163].
Overall, evidence suggests that adipose tissue infiltration by macrophages is unlikely to be the major cause of IR. Macrophage infiltration into the growing adipose tissue may affect its function in addition to systemic inflammation, but the exact impact of this infiltration is unknown [164]. Anti-inflammatory macrophages (M2), on the other hand, have been shown to promote angiogenesis and preadipocyte differentiation, which aids adipose tissue expansion [165, 166]. The diversity of cytokines, their concentrations, and the timing of their release into the tissue are likely to have a considerable impact on the final biological response, contributing to the observed inconsistent results. The ability of genetically induced adipocyte IR to elicit adipose tissue inflammation adds to the growing body of evidence that inflammation may be a consequence rather than a cause of IR. Hyperinsulinemia has been shown to induce adipose tissue inflammation, implying that the latter is a late event in the IR pathophysiology [30].
12. Intracellular mediators and insulin resistance
Many extrinsic stimuli and genetic alterations can antagonize insulin action in vitro and in vivo, and their investigation has led to the identification of a series of molecules as putative intracellular mediators of IR. In the sections that follow, we will look at the role of a few intracellular components that have got a lot of attention as drivers of IR. It is worth noting that mechanisms of action of these components are not well-established yet, and further research is needed to better understand their role in IR development.
12.1 Accumulation of ceramides
Ceramides have been implicated as IR mediators by a large body of research. Ceramides are essential precursors of most of the complex sphingolipids localized in lipid bilayers, including sphingosine, sphingomyelins, and glucosylceramides. Ceramides accumulate in muscle, liver and adipose tissue of subjects with IR, according to human and animal studies [167, 168, 169, 170]. In insulin-resistant tissues, the levels of 16- or 18-carbon chain-length ceramides are raised, whereas the levels of other chain-length ceramides are not consistently changed [171, 172]. Indeed, in adipose tissue from obese subjects, the level of ceramide synthase isoform 6 (CERS6), which synthesizes C16 ceramide, is raised [171]. Surprisingly, the presence of a double bond in the ceramide backbone promotes IR, as ablation of the enzyme responsible for its formation (dihydroceramide desaturase 1) abrogates IR [173]. While it is unclear how specific extrinsic mediators of IR cause increased intracellular ceramide levels, it is possible that excess FFAs serve as a crucial substrates for ceramide biosynthesis [174, 175, 176].
Another theory connects intracellular ceramide to levels of circulating adiponectin. Ceramidase activity is found on adiponectin receptors, and lower adiponectin levels in IR may lead to decreased ceramidase activity and, consequently, to higher ceramide levels [177, 178]. AMP-activated protein kinase (AMPK), a major metabolic sensor that regulates mitochondrial biogenesis and metabolism, is activated by adiponectin, potentially regulating ceramide via increased mitochondrial lipid oxidation [179]. By using small-molecule inhibitors or genetic deletion of ceramide-producing enzymes to neutralize ceramide accumulation in metabolic organs, researchers were able to reverse or prevent IR induced by the Western diet in C57BL/6 mice with diet-induced obesity [122]. The relationship between ceramide and decreased insulin action is not univocal, as it is for many possible intracellular mediators of IR. In fact, ceramide suppresses AKT activity, although IR is unlikely to be caused by defects in AKT, which is a proximal arm of insulin signaling (as it has previously been mentioned). Ceramide could be part of a wider, IR-related stress mechanism that leads to mitochondrial dysfunction and to the production of reactive oxygen species (ROS). Ceramide has also been connected to the release of pro-inflammatory cytokines, which have been involved in IR, as it has previously been described [180, 181].
12.2 Accumulation of diacylglycerol (DAG)
Another popular theory for the cause of IR is the accumulation of diacylglycerols (DAGs) in muscle, adipocytes and liver, as a result of elevated serum FFA levels [182, 183]. Protein kinase C (PKC) is recruited to the plasma membrane by DAGs, where it phosphorylates and inhibits insulin receptor kinase activity. While it is quite plausible that DAG levels are elevated in insulin-resistant tissues, a scenario in which DAG-dependent phosphorylation of the insulin receptor is the major cause of IR raises a number of questions. Given the “spareness” of the insulin receptor and proximal signaling intermediates, it is doubtful that IR is caused solely by abnormalities in these components, at least in muscle. In contrast to other insulin-responsive proteins, the stoichiometry of insulin receptor phosphorylation at the region implicated in DAG-mediated IR is low and not detectable by conventional phosphopeptide analysis [79, 104, 184]. PKC deletion in the liver had little effect on whole-body insulin sensitivity in mice, indicating against PKC being a key target of DAG-induced IR in that tissue [79, 104], although this has since been challenged by studies in rats showing that acute knockdown of PKC in the liver protected animals from IR. However, antisense oligonucleotides were delivered systemically, which could target PKC expression in other organs. While technical differences between these studies and others have been suggested as a reason for the discrepancies observed [183], there appears to be enough disagreement about the role of the DAG-PKC-insulin receptor pathway in IR to warrant further investigation and, in particular, validation by multiple independent laboratories [185].
12.3 Mitochondrial dysfunction and reactive oxygen species (ROS)
IR has been linked to a decrease in mitochondrial function. Mitochondrial dysfunction is a term that has been used to describe a variety of mitochondrial phenotypes, including decreased respiratory capacity and ATP production, decreased number of mitochondria, accumulated mitochondrial damage due to defects in mitophagy, and altered mitochondrial morphology caused by changes in mitochondrial fission-fusion dynamics. Many of these alterations are also linked to an increase in mitochondrial ROS generation, which has long been linked to IR [186, 187, 188].
It is not unexpected that IR is linked to higher levels of reactive oxygen species (ROS). This is due to the fact that IR is frequently accompanied by a positive energy balance, which leads to an excess of reducing equivalents (NADH and FADH2). This determines a reductive stress on the mitochondrial respiratory electron transport chain, which invariably results in the formation of free electrons and, as a result, in an increased production of various forms of ROS [189]. Furthermore, enhanced ROS production has been found in response to a variety of extracellular stressors linked to IR, including inflammation [190]. Superoxide, H2O2, reactive nitrogen andoxidized lipids accumulate in insulin-resistant cells or tissues, and a mitochondria-targeted small molecule transiently produced mitochondrial ROS in muscle and adipocytes, causing IR. As a result, attempts to reduce ROS levels have been proven to reverse or prevent IR in mice [191, 192, 193, 194].
Reduced levels of coenzyme Q (CoQ) have recently been linked to IR in humans [44]. In mitochondria, CoQ is a key component of the electron transport chain, transferring electrons from complex I or II to complex III. Furthermore, unlike complex I, CoQ receives electrons directly from the electron-transferring flavoprotein, and this is unrelated to proton pumping or mitochondrial membrane potential, relying only on the availability of oxidized CoQ. Reduced CoQ accumulates, causing reductive stress in complex I, complex II and other dehydrogenases that feed electrons into the CoQ pool, resulting in increased ROS production [195]. As a result, lowering the total CoQ pool [44] will most likely lower the ROS production threshold at a given energy demand-supply ratio. It is also worth noting that FFA oxidation produces far more ROS than carbohydrate oxidation [195]. This is because the electron-transferring flavoprotein feeds a higher proportion of reducing equivalents straight into the CoQ pool during FFA oxidation. Therefore, as lipid metabolism increases, the supply of reducing equivalents outnumbers the demand, lowering the ratio of oxidized to reduced CoQ. This is likely worsened when total CoQ levels are low, as seen in IR [44], resulting in reductive stress and increased ROS production. The mechanism that regulates CoQ levels in IR is unknown. Intriguingly, statins, which are commonly used as cholesterol-lowering drugs, have been linked to IR in humans [196], with the possibility that this relationship is related to the statin-induced reductions in CoQ biosynthesis [44]. Unfortunately, given the low bioavailability of CoQ , oral supplements, which are frequently recommended as an antioxidant strategy, are unlikely to be successful in replenishing the mitochondrial CoQ pool in patients with IR or even in individuals who take statins. Other hazardous intermediates can be generated, in addition to ROS, as a result of mitochondrial respiration abnormalities. Acylcarnitine is an example of incompletely oxidized lipids produced by lipid overload. Acylcarnitine has been reported to accumulate in IR, indicating a deficiency in or an overabundance of the mitochondrial oxidative ability. In this regard, it has been postulated that lipid-induced mitochondrial stress mediates IR, although the exact mechanisms remain elusive [197].
12.4 Insulin resistance associated with stress pathway
Many of the pathways involved in IR pathophysiology, such as those involving ceramides, DAGs or ROS, are now being linked as part of what we call an “intracellular IR stress pathway”, according to new evidence. Ceramide, for example, promotes mitochondrial fission and ROS production [198, 199]. In subjects with IR, the quantity of mitochondrial ceramide is higher, and enzymes involved in ceramide biosynthesis have been found in mitochondria [185, 200, 201, 202, 203]. Ceramide is involved in apoptosis triggered by mitochondria in some cells, including insulin-producing pancreatic beta cells, but not in other metabolic tissues [204, 205, 206]. Ceramide also contributes to endoplasmic reticulum stress, which frequently co-occurs with mitochondrial stress and has been proposed as a driver of IR, where endoplasmic reticulum stress causes JNK activation, which, as previously described, affects the insulin signaling pathway via inhibitory IRS1 Ser/Thr phosphorylation [204, 205, 206]. Ceramide also induces PKC, a DAG-regulated kinase, to translocate to mitochondria, activating it and causing mitochondrial damage through an unknown mechanism [207]. Ceramides and DAGs are also biochemically connected; sphingomyelin synthase, for example, converts ceramide to DAG. Finally, in rats, reducing mitochondrial ROS levels with mitochondria-targeted catalase improved insulin sensitivity while lowering muscle DAG levels [208]. The potential connection of many of these suspected IR-causing elements into a dynamic network should help to resolve some of the current debates on this topic.
12.5 Signals from the mitochondria
Despite the interest in mitochondrial dysfunction in IR, it is unclear how intramitochondrial signals, like ceramide or ROS, may cause changes in insulin action, such as impaired GLUT4 translocation, which occurs mostly in the cytosol. The mitochondrial permeability transition pore (mPTP), a multiprotein complex located in the inner mitochondrial membrane, is a promising candidate for “inside-out” mitochondrial signaling because it opens under conditions of mitochondrial stress—most notably involving mitochondrial ROS—to allow molecules to be transported from mitochondria to the cytoplasm [209]. In L6 myotubes, inhibiting mPTP prevented ceramide- or palmitate-induced IR, and mice with defective mPTP opening were protected from diet-induced IR in skeletal muscle [210]. Although at least a part of the impact is attributable to its anti-obesogenic effect, deletion of mPTP in the liver has been shown to protect mice from liver steatosis and IR [211].
13. Conclusions and perspectives
The rising frequency of IR, as well as its crucial involvement in a variety of diseases, demands a greater understanding of the processes behind IR pathogenesis and how they interact with genetics and various surroundings, notably dietary factors. We have attempted to offer an overview of the main mechanisms hypothesized to contribute to IR in this chapter, highlighting both supportive and non-confirmatory evidence when appropriate. Many of the molecules and processes studied as causative in IR, in our opinion, function in series as a connected pathway or a loop rather than acting independently. Unfortunately, there has been a recent trend to describe IR as a dysfunction of insulin signaling, regardless of whether a simultaneous examination of insulin action on glucose metabolism has identified a defect in the latter process. We feel that this method has produced significant problems in the field, and we wish to send a message that simple, unitary errors in proximal insulin signaling are unlikely to be a major cause of IR. Rather, IR develops as a result of a variety of challenges that disrupt cellular homeostasis, resulting in cellular stress that can have a variety of deleterious consequences on insulin signal sensing and transmission.
The difficulty in translating findings from model organisms to humans, particularly in terms of differentiating IR causation from the multiplicity of effects, is a key roadblock in investigating the underpinnings of IR. By discovering causal genetic variants, human genetics holds a lot of promise for tackling this problem. However, genetics can only explain a portion of the pathophysiology of IR. Environmental variables play a crucial role in determining susceptibility to IR development and interact with genetics. Furthermore, the heterogeneity of metabolic diseases like T2D demands detailed phenotyping. Focusing on phenotypes that has better track with IR has proven difficult to achieve in the large cohorts. It is required to identify genetic polymorphisms that only explain a small proportion of disease in the human population. Despite these limitations, a number of genetic loci linked to human IR have been discovered, leading to a renewed focus on adipose tissue enlargement as a critical aspect of IR. However, since IR is a systemic condition, we expect future investigations to discover variations in genes governing multiple cellular processes throughout organs as linked to IR pathophysiology.
A more systematic approach involving large-scale omics to analyze the molecular landscape rather than relying on individual components as causal would be required to gain a better understanding of IR. Moreover, while knockout mice have been critical in characterizing the biochemistry of insulin action, they have also sparked numerous debates. One reason for this is that gene deletions typically result in adaptive processes that are difficult to define and may have limited physiological value, as indicated in a recent study with muscle-specific Akt gene-knockout mice [58]. In animals with both insulin and insulin-like growth factor 1 (IGF-1) receptors removed in muscle, similar adaptation mechanisms have been reported [212].
The ultimate goal of understanding mechanisms behind IR is to develop new, effective anti-IR therapeutic strategies. One key point to consider in this endeavor is whether such therapies would be beneficial if the initial insult—nutritional overload—persists. While IR is typically considered abnormal, as it is linked to a variety of disease outcomes, it is also a prevalent component of many normal physiological states, such as starvation, pregnancy, and hibernation. IR is believed to play a protective or adaptive role in such conditions, supporting survival by saving glucose for the brain and other vital tissues and organs or for the fetus during pregnancy. It is possible that IR has a similar function in metabolic disease. Since the primary metabolic tissues are frequently exposed to potentially harmful quantities of nutrients, IR could be a protective mechanism that helps to prevent tissue nutrition overload [190]. However, this comes at a price, namely concomitant hyperinsulinemia, which is the most serious pathophysiological consequence of IR. Insulin-sensitizing drugs may thus act as a “circuit breaker”, reducing hunger, inflammation and IR by suppressing hyperinsulinemia. As a result, we believe there is still a strong need to describe the molecular characteristics that drive IR in order to identify appropriate targets that can break the IR vicious cycle.
Acknowledgments
The authors are also thankful to Guru Nanak Dev University (Amritsar, Punjab, India) for providing various facilities to carry out the present work.
Conflict of interest
The authors declare no conflict of interest.
\n',keywords:"insulin, insulin receptor, insulin resistance, glucose uptake, glucose metabolism",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/82197.pdf",chapterXML:"https://mts.intechopen.com/source/xml/82197.xml",downloadPdfUrl:"/chapter/pdf-download/82197",previewPdfUrl:"/chapter/pdf-preview/82197",totalDownloads:7,totalViews:0,totalCrossrefCites:0,dateSubmitted:"December 13th 2021",dateReviewed:"April 4th 2022",datePrePublished:"June 11th 2022",datePublished:null,dateFinished:"June 11th 2022",readingETA:"0",abstract:"Insulin resistance (IR) is a condition in which insulin-mediated regulation of glucose metabolism in body tissues (primarily liver, adipose tissue and skeletal muscle) becomes disrupted. IR is a characteristic marker of type 2 diabetes and cardiovascular diseases. IR is generally associated with metabolic abnormalities, including hyperinsulinemia, impaired glucose homeostasis, hyperlipidemia and obesity. IR can arise from pathological, genetic and environmental factors or from a combination of these factors. Studies conducted in recent decades showcase the important role of adipose tissue in the development of IR via release of lipids and different circulating factors. These extracellular factors influence the intracellular levels of intermediates including ceramide and various lipids that influence the cell responsiveness to insulin. These intermediates are suggested to promote IR via inhibition of one or more components of insulin signaling pathway (e.g., insulin receptor, insulin receptor substrate proteins). This chapter will shed light on various molecular mechanisms and factors contributing to IR, which will help the researchers to design potential therapeutic strategies and interventions for efficiently managing IR and its related disorders.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/82197",risUrl:"/chapter/ris/82197",signatures:"Atamjit Singh, Nikhita Ghai and PreetMohinder Singh Bedi",book:{id:"11261",type:"book",title:"Insulin Resistance - Evolving Concepts and Treatment Strategies",subtitle:null,fullTitle:"Insulin Resistance - Evolving Concepts and Treatment Strategies",slug:null,publishedDate:null,bookSignature:"Dr. Marco Infante",coverURL:"https://cdn.intechopen.com/books/images_new/11261.jpg",licenceType:"CC BY 3.0",editedByType:null,isbn:"978-1-80355-502-7",printIsbn:"978-1-80355-501-0",pdfIsbn:"978-1-80355-503-4",isAvailableForWebshopOrdering:!0,editors:[{id:"409412",title:"Dr.",name:"Marco",middleName:null,surname:"Infante",slug:"marco-infante",fullName:"Marco Infante"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:null,sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Pathway to insulin resistance",level:"1"},{id:"sec_3",title:"3. The trio-axis of obesity-hyperinsulinemia-insulin resistance",level:"1"},{id:"sec_4",title:"4. Insulin resistance and hyperinsulinemia",level:"1"},{id:"sec_5",title:"5. Heterogeneity in the development of insulin resistance and progression of metabolic disease and T2D",level:"1"},{id:"sec_6",title:"6. Tissue-specific progression to insulin resistance",level:"1"},{id:"sec_7",title:"7. Impaired insulin signaling in insulin resistance",level:"1"},{id:"sec_8",title:"8. Insulin resistance and insulin signaling at the proximal level",level:"1"},{id:"sec_9",title:"9. GLUT4 and insulin resistance",level:"1"},{id:"sec_10",title:"10. Adipose tissue and insulin resistance",level:"1"},{id:"sec_10_2",title:"10.1 Adipose tissue dysfunction",level:"2"},{id:"sec_11_2",title:"10.2 Circulatory factors released from adipocytes",level:"2"},{id:"sec_13",title:"11. Inflammation and insulin resistance",level:"1"},{id:"sec_14",title:"12. Intracellular mediators and insulin resistance",level:"1"},{id:"sec_14_2",title:"12.1 Accumulation of ceramides",level:"2"},{id:"sec_15_2",title:"12.2 Accumulation of diacylglycerol (DAG)",level:"2"},{id:"sec_16_2",title:"12.3 Mitochondrial dysfunction and reactive oxygen species (ROS)",level:"2"},{id:"sec_17_2",title:"12.4 Insulin resistance associated with stress pathway",level:"2"},{id:"sec_18_2",title:"12.5 Signals from the mitochondria",level:"2"},{id:"sec_20",title:"13. Conclusions and perspectives",level:"1"},{id:"sec_21",title:"Acknowledgments",level:"1"},{id:"sec_24",title:"Conflict of interest",level:"1"}],chapterReferences:[{id:"B1",body:'Himsworth HP. Diabetes mellitus: Its differentiation into insulin-sensitive and insulin-insensitive types. 1936. International Journal of Epidemiology. 2013;42:1594-1598'},{id:"B2",body:'Jee SH, Kim HJ, Lee J. Obesity, insulin resistance and cancer risk. 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Adipose tissue inflammation and increased ceramide content characterize subjects with high liver fat content independent of obesity. Diabetes. 2007;56:1960-1968'},{id:"B170",body:'Coen PM et al. Reduced skeletal muscle oxidative capacity and elevated ceramide but not diacylglycerol content in severe obesity. Obesity. 2013;21:2362-2371'},{id:"B171",body:'Turpin SM et al. Obesity-induced CerS6-dependent C16:0 ceramide production promotes weight gain and glucose intolerance. Cell Metabolism. 2014;20:678-686'},{id:"B172",body:'Stöckli J et al. Metabolomic analysis of insulin resistance across different mouse strains and diets. The Journal of Biological Chemistry. 2017;292:19135-19145'},{id:"B173",body:'Siddique MM et al. Ablation of dihydroceramide desaturase 1, a therapeutic target for the treatment of metabolic diseases, simultaneously stimulates anabolic and catabolic signaling. Molecular and Cellular Biology. 2013;33(11):2353-2369'},{id:"B174",body:'Raichur S et al. CerS2 haploinsufficiency inhibits β-oxidation and confers susceptibility to diet-induced steatohepatitis and insulin resistance. Cell Metabolism. 2014;20:687-695'},{id:"B175",body:'Chaurasia B et al. Targeting a ceramide double bond improves insulin resistance and hepatic steatosis. Science. 2019;365:386-392'},{id:"B176",body:'Chavez JA et al. A role for ceramide, but not diacylglycerol, in the antagonism of insulin signal transduction by saturated fatty acids. The Journal of Biological Chemistry. 2003;278:10297-10303'},{id:"B177",body:'Villa NY et al. Sphingolipids function as downstream effectors of a fungal PAQR. Molecular Pharmacology. 2009;75:866-875'},{id:"B178",body:'Mente A et al. Causal relationship between adiponectin and metabolic traits: A Mendelian randomization study in a multiethnic population. PLoS One. 2013;8:e66808'},{id:"B179",body:'Nawrocki AR et al. Mice lacking adiponectin show decreased hepatic insulin sensitivity and reduced responsiveness to peroxisome proliferator-activated receptor gamma agonists. The Journal of Biological Chemistry. 2006;281:2654-2660'},{id:"B180",body:'Cazzolli R, Carpenter L, Biden TJ, Schmitz-Peiffer C. A role for protein phosphatase 2A-like activity, but not atypical protein kinase Czeta, in the inhibition of protein kinase B/Akt and glycogen synthesis by palmitate. Diabetes. 2001;50:2210-2218'},{id:"B181",body:'Fox TE et al. Ceramide recruits and activates protein kinase C zeta (PKC zeta) within structured membrane microdomains. The Journal of Biological Chemistry. 2007;282:12450-12457'},{id:"B182",body:'Lyu K et al. A membrane-bound diacylglycerol species induces PKCε-mediated hepatic insulin resistance. Cell Metabolism. 2020;32:654-664.e5'},{id:"B183",body:'Lyu K et al. Short-term overnutrition induces white adipose tissue insulin resistance through sn-1,2- diacylglycerol/PKCε/insulin receptor Thr1160 phosphorylation. JCI Insight. 2021;6:e139946'},{id:"B184",body:'Gassaway BM et al. PKCε contributes to lipid-induced insulin resistance through cross talk with p70S6K and through previously unknown regulators of insulin signaling. Proceedings of the National Academy of Sciences of the United States of America. 2018;115:E8996-E9005'},{id:"B185",body:'Perreault L et al. Intracellular localization of diacylglycerols and sphingolipids influences insulin sensitivity and mitochondrial function in human skeletal muscle. JCI Insight. 2018;3:e96805'},{id:"B186",body:'Gonzalez-Franquesa A, Patti M-E. Insulin resistance and mitochondrial dysfunction. Advances in Experimental Medicine and Biology. 2017;982:465-520'},{id:"B187",body:'Sangwung P, Petersen KF, Shulman GI, Knowles JW. Mitochondrial dysfunction, insulin resistance, and potential genetic implications. Endocrinology. 2020;161:bqaa017'},{id:"B188",body:'Houstis N, Rosen ED, Lander ES. Reactive oxygen species have a causal role in multiple forms of insulin resistance. Nature. 2006;440:944-948'},{id:"B189",body:'Fisher-Wellman KH, Neufer PD. Linking mitochondrial bioenergetics to insulin resistance via redox biology. Trends in Endocrinology and Metabolism. 2012;23:142-153'},{id:"B190",body:'Hoehn KL et al. Insulin resistance is a cellular antioxidant defense mechanism. Proceedings of the National Academy of Sciences of the United States of America. 2009;106:17787-17792'},{id:"B191",body:'Anderson EJ et al. Mitochondrial H2O2 emission and cellular redox state link excess fat intake to insulin resistance in both rodents and humans. The Journal of Clinical Investigation. 2009;119:573-581'},{id:"B192",body:'Ingram KH et al. Skeletal muscle lipid peroxidation and insulin resistance in humans. Journal of Clinical Endocrinology and Metabolism. 2012;97:E1182-E1186'},{id:"B193",body:'Duplain H et al. Stimulation of peroxynitrite catalysis improves insulin sensitivity in high fat diet-fed mice. The Journal of Physiology. 2008;586:4011-4016'},{id:"B194",body:'Fazakerley DJ et al. Mitochondrial oxidative stress causes insulin resistance without disrupting oxidative phosphorylation. The Journal of Biological Chemistry. 2018;293:7315-7328'},{id:"B195",body:'Boveris A, Oshino N, Chance B. The cellular production of hydrogen peroxide. The Biochemical Journal. 1972;128:617-630'},{id:"B196",body:'Rees-Milton KJ et al. Statin use is associated with insulin resistance in participants of the Canadian multicentre osteoporosis study. Journal of the Endocrine Society. 2020;4:bvaa057'},{id:"B197",body:'Koves TR et al. Mitochondrial overload and incomplete fatty acid oxidation contribute to skeletal muscle insulin resistance. Cell Metabolism. 2008;7:45-56'},{id:"B198",body:'Di Paola M, Cocco T, Lorusso M. Ceramide interaction with the respiratory chain of heart mitochondria. Biochemistry. 2000;39:6660-6668'},{id:"B199",body:'Smith ME et al. Mitochondrial fission mediates ceramide-induced metabolic disruption in skeletal muscle. The Biochemical Journal. 2013;456:427-439'},{id:"B200",body:'Novgorodov SA et al. Novel pathway of ceramide production in mitochondria: Thioesterase and neutral ceramidase produce ceramide from sphingosine and acyl-CoA. The Journal of Biological Chemistry. 2011;286:25352-25362'},{id:"B201",body:'vonHaefen C et al. Ceramide induces mitochondrial activation and apoptosis via a Bax-dependent pathway in human carcinoma cells. Oncogene. 2002;21:4009-4019'},{id:"B202",body:'Ye R, Onodera T, Scherer PE. Lipotoxicity and cell maintenance in obesity and type 2 diabetes. Journal of the Endocrine Society. 2019;3:617-631'},{id:"B203",body:'Turpin SM et al. Examination of ‘lipotoxicity’ in skeletal muscle of high-fat fed 0. The Journal of Physiology. 2009;587:1593-1605'},{id:"B204",body:'Kim Y-R et al. Hepatic triglyceride accumulation via endoplasmic reticulum stress-induced SREBP-1 activation is regulated by ceramide synthases. Experimental & Molecular Medicine. 2019;51:1-16'},{id:"B205",body:'Boslem E et al. A lipidomic screen of palmitate-treated MIN6 β-cells links sphingolipid metabolites with endoplasmic reticulum (ER) stress and impaired protein trafficking. The Biochemical Journal. 2011;435:267-276'},{id:"B206",body:'Flamment M, Hajduch E, Ferré P, Foufelle F. New insights into ER stress-induced insulin resistance. Trends in Endocrinology and Metabolism. 2012;23:381-390'},{id:"B207",body:'Sumitomo M et al. Protein kinase Cdelta amplifies ceramide formation via mitochondrial signaling in prostate cancer cells. The Journal of Clinical Investigation. 2002;109:827-836'},{id:"B208",body:'Lee H-Y et al. Mitochondrial-targeted catalase protects against high-fat diet-induced muscle insulin resistance by decreasing intramuscular lipid accumulation. Diabetes. 2017;66:2072-2081'},{id:"B209",body:'Riojas-Hernández A et al. Enhanced oxidative stress sensitizes the mitochondrial permeability transition pore to opening in heart from Zucker fa/fa rats with type 2 diabetes. Life Sciences. 2015;141:32-43'},{id:"B210",body:'Taddeo EP et al. Opening of the mitochondrial permeability transition pore links mitochondrial dysfunction to insulin resistance in skeletal muscle. Molecular Metabolism. 2014;3:124-134'},{id:"B211",body:'Cho J et al. Mitochondrial ATP transporter depletion protects mice against liver steatosis and insulin resistance. Nature Communications. 2017;8:14477'},{id:"B212",body:'O’Neill BT et al. Differential role of insulin/IGF-1 receptor signaling in muscle growth and glucose homeostasis. Cell Reports. 2015;11:1220-1235'}],footnotes:[],contributors:[{corresp:null,contributorFullName:"Atamjit Singh",address:null,affiliation:'
Department of Pharmaceutical Sciences, Guru Nanak Dev University, India
Department of Pharmaceutical Sciences, Guru Nanak Dev University, India
Drug and Pollution Testing Lab, Guru Nanak Dev University, India
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If your research is financed through any of the below-mentioned funders, please consult their Open Access policies or grant ‘terms and conditions’ to explore ways to cover your publication costs (also accessible by clicking on the link in their title).
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IMPORTANT: You must be a member or grantee of the listed funders in order to apply for their Open Access publication funds. Do not attempt to contact the funders if this is not the case.
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UK Research and Innovation (former Research Councils UK (RCUK) - including AHRC, BBSRC, ESRC, EPSRC, MRC, NERC, STFC.) Processing charges for books/book chapters can be covered through RCUK block grants which are allocated to most universities in the UK, which then handle the OA publication funding requests. It is at the discretion of the university whether it will approve the request.)
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Wellcome Trust (Funding available only to Wellcome-funded researchers/grantees)
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On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. 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Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. His current research interests are in the fields of intelligent control and robotics.",institutionString:null,institution:{name:"Technical University of Sofia",country:{name:"Bulgaria"}}},{id:"585",title:"Prof.",name:"Munir",middleName:null,surname:"Merdan",slug:"munir-merdan",fullName:"Munir Merdan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/585/images/system/585.jpg",biography:"Munir Merdan received the M.Sc. degree in mechanical engineering from the Technical University of Sarajevo, Bosnia and Herzegovina, in 2001, and the Ph.D. degree in electrical engineering from the Vienna University of Technology, Vienna, Austria, in 2009.Since 2005, he has been at the Automation and Control Institute, Vienna University of Technology, where he is currently a Senior Researcher. His research interests include the application of agent technology for achieving agile control in the manufacturing environment.",institutionString:null,institution:null},{id:"605",title:"Prof",name:"Dil",middleName:null,surname:"Hussain",slug:"dil-hussain",fullName:"Dil Hussain",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/605/images/system/605.jpg",biography:"Dr. Dil Muhammad Akbar Hussain is a professor of Electronics Engineering & Computer Science at the Department of Energy Technology, Aalborg University Denmark. Professor Akbar has a Master degree in Digital Electronics from Govt. College University, Lahore Pakistan and a P-hD degree in Control Engineering from the School of Engineering and Applied Sciences, University of Sussex United Kingdom. Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. 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The model parameters deciphered here are the amplitude coefficient (k), horizontal location (x0), depth of the body (z), and shape (q). Inversion of the model parameter suggests that constraining the horizontal location and the shape factor offers the most reliable results. Investigation of convergence rate, histogram, and cross-plot examination suggest that the interpretation method developed for the self-potential anomalies is stable and the model parameters are within the estimated ambiguity. Inversion of synthetic noise-free and noise-corrupted data for single structures and multiple structures in addition to real field information exhibits the viability of the method. The model parameters estimated by the present technique were in good agreement with the real parameters. The method has been used to invert two field examples (Sulleymonkoy anomaly, Ergani, Turkey, Senneterre area of Quebec, Canada) with application of subsurface mineralized bodies. 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In fact, under some specific conditions the NCMs could be used either as effective adsorbent material or alternative source of minerals. This chapter presents an outline of a general review of factors that affect the application ability of NCMs and a descriptive analysis of NH4+ and REE adsorption behavior and extraction of rare earth elements (REE) by an ion-exchange with NH4+ ions onto NCMs. Clays and NCMs both effectively remove various contaminants from aqueous solution and serve as alternative sources of minerals, as extensively discussed in this chapter. This review compiles thorough literature of current research and highlights the key findings of adsorption (NH4+ and REE) that use different NCMs as adsorbents or alternative sources of minerals (i.e., REE). The review confirmed that NCMs excellently remove different cations pollutants and have significant potential as alternative source of REE. However, modification and further development of NCMs applications for getting the best adsorption and the best extraction of REE onto NCMs, which would enhance pollution control and leaching system is still needed.",book:{id:"7315",slug:"minerals",title:"Minerals",fullTitle:"Minerals"},signatures:"Aref Alshameri, Xinghu Wei, Hailong Wang, Yang Fuguo, Xin Chen, Hongping He, Chunjie Yan and Feng Xu",authors:[{id:"172947",title:"Prof.",name:"Xin",middleName:null,surname:"Chen",slug:"xin-chen",fullName:"Xin Chen"},{id:"250327",title:"Dr.",name:"Aref",middleName:null,surname:"Alshameri",slug:"aref-alshameri",fullName:"Aref Alshameri"},{id:"306625",title:"Dr.",name:"Aref",middleName:null,surname:"Alshameri",slug:"aref-alshameri",fullName:"Aref Alshameri"},{id:"306656",title:"Prof.",name:"Fuguo",middleName:null,surname:"Yang",slug:"fuguo-yang",fullName:"Fuguo Yang"},{id:"306658",title:"Dr.",name:"Wei",middleName:null,surname:"Xinghu",slug:"wei-xinghu",fullName:"Wei Xinghu"},{id:"306660",title:"Prof.",name:"Wang",middleName:null,surname:"Hailong",slug:"wang-hailong",fullName:"Wang Hailong"},{id:"306664",title:"Prof.",name:"Yan",middleName:null,surname:"Chunjie",slug:"yan-chunjie",fullName:"Yan Chunjie"},{id:"306665",title:"Dr.",name:"Xu",middleName:null,surname:"Feng",slug:"xu-feng",fullName:"Xu Feng"},{id:"306671",title:"Prof.",name:"He",middleName:null,surname:"Hongping",slug:"he-hongping",fullName:"He Hongping"}]}],mostDownloadedChaptersLast30Days:[{id:"71052",title:"Enhanced Humidity Sensing Response in Eu3+-Doped Iron-Rich CuFe2O4: A Detailed Study of Structural, Microstructural, Sensing, and Dielectric Properties",slug:"enhanced-humidity-sensing-response-in-eu-sup-3-sup-doped-iron-rich-cufe-sub-2-sub-o-sub-4-sub-a-deta",totalDownloads:596,totalCrossrefCites:7,totalDimensionsCites:7,abstract:"The CuFe(2−x)EuxO4 (where x = 0.00, 0.01, 0.02, 0.03) nanoparticles are synthesized by solution combustion method. The influence of Eu3+ on the structural, morphological, dielectrical, and humidity sensing study is recorded. The XRD pattern peaks of the as-prepared CuFe(2−x)EuxO4 (where x = 0.00, 0.01, 0.02, 0.03) nanoparticle confirm the polycrystalline spinel cubic structure with a small amount of CuO impurity phase at 38.87° and 48.96°. Surface morphology of the samples was studied by scanning electron microscope (SEM) images of the nanoparticles, and their respective average grain size was estimated using Image software. Chemical composition of all prepared samples was analyzed by EDS spectra. The dielectric parameters of AC conductivity, electric modulus, and impedance of the samples were measured over a range of frequencies from 0.1 KHz to 1 MHz at room temperature. Europium-doped copper ferrite samples showed good humidity sensing response, response and recover times, and stability over a %RH range of 11–91%. These types of samples are very useful for sensor application, battery applications, electronic applications, and automotive applications.",book:{id:"9247",slug:"mineralogy-significance-and-applications",title:"Mineralogy",fullTitle:"Mineralogy - Significance and Applications"},signatures:"I.C. Sathisha, K. Manjunatha, V. Jagadeesha Angadi, B. Chethan, Y.T. Ravikiran, Vinayaka K. Pattar, S.O. Manjunatha and Shidaling Matteppanavar",authors:[{id:"266255",title:"Dr.",name:"Veerabhadrappa",middleName:null,surname:"Jagadeesha Angadi",slug:"veerabhadrappa-jagadeesha-angadi",fullName:"Veerabhadrappa Jagadeesha Angadi"},{id:"321561",title:"Dr.",name:"I.C.",middleName:null,surname:"Sathisha",slug:"i.c.-sathisha",fullName:"I.C. Sathisha"},{id:"321562",title:"Dr.",name:"K.",middleName:null,surname:"Manjunatha",slug:"k.-manjunatha",fullName:"K. Manjunatha"},{id:"321564",title:"Dr.",name:"B.",middleName:null,surname:"Chethan",slug:"b.-chethan",fullName:"B. Chethan"},{id:"321565",title:"Dr.",name:"Y.T.",middleName:null,surname:"Ravikiran",slug:"y.t.-ravikiran",fullName:"Y.T. Ravikiran"},{id:"321566",title:"Dr.",name:"Vinayaka K.",middleName:null,surname:"Pattar",slug:"vinayaka-k.-pattar",fullName:"Vinayaka K. Pattar"},{id:"321567",title:"Dr.",name:"S.O.",middleName:null,surname:"Manjunatha",slug:"s.o.-manjunatha",fullName:"S.O. Manjunatha"},{id:"321568",title:"Dr.",name:"Shidaling",middleName:null,surname:"Matteppanavar",slug:"shidaling-matteppanavar",fullName:"Shidaling Matteppanavar"}]},{id:"65826",title:"Introductory Chapter: Mineral Exploration from the Point of View of Geophysicists",slug:"introductory-chapter-mineral-exploration-from-the-point-of-view-of-geophysicists",totalDownloads:1635,totalCrossrefCites:3,totalDimensionsCites:3,abstract:null,book:{id:"7315",slug:"minerals",title:"Minerals",fullTitle:"Minerals"},signatures:"Khalid S. Essa and Marc Munschy",authors:[{id:"102766",title:"Prof.",name:"Khalid S.",middleName:null,surname:"Essa",slug:"khalid-s.-essa",fullName:"Khalid S. Essa"},{id:"292929",title:"Prof.",name:"Marc",middleName:null,surname:"Munschy",slug:"marc-munschy",fullName:"Marc Munschy"}]},{id:"69811",title:"Chemical Synthesis and Characterization of Luminescent Iron Oxide Nanoparticles and Their Biomedical Applications",slug:"chemical-synthesis-and-characterization-of-luminescent-iron-oxide-nanoparticles-and-their-biomedical",totalDownloads:564,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The syntheses and characterizations of biocompatible luminescent magnetic iron oxide nanoparticles has drawn particular attention as diagnostic and drug delivery tools for treatment of cancer and many other diseases. This chapter focuses on the chemical synthetic methods, magnetic and luminescent properties, including the biomedical applications of iron oxide nanomaterials and luminescent magnetic iron oxide-based nanocomposite materials. The influences of functionalizing with short ligands such as dopamine and L-cysteine on the magnetic properties of synthesized nanoparticles are described. The chapter contains some data on necessary reagents and protocols for bioconjugation aimed at cell culture and step by step the MTT assays used to evaluate cytotoxicity are also presented. In the final section of the chapter, we focus on the biomedical applications specifically for diagnosis and treatment of breast cancer treatment. This chapter also investigates the application of various characterization techniques for analysis of the structural, optical and magnetic properties of the iron oxide nanoparticles and as their nanocomposites.",book:{id:"9247",slug:"mineralogy-significance-and-applications",title:"Mineralogy",fullTitle:"Mineralogy - Significance and Applications"},signatures:"Martin Onani, Leandre Brandt and Zuraan Paulsen",authors:[{id:"258023",title:"Dr.",name:"Martin",middleName:null,surname:"Onani",slug:"martin-onani",fullName:"Martin Onani"},{id:"302723",title:"Dr.",name:"Leandré Bianca",middleName:null,surname:"Brandt",slug:"leandre-bianca-brandt",fullName:"Leandré Bianca Brandt"},{id:"302725",title:"MSc.",name:"Zuraan",middleName:null,surname:"Paulsen",slug:"zuraan-paulsen",fullName:"Zuraan Paulsen"}]},{id:"27429",title:"An Introduction to Mineralogy",slug:"an-introduction-to-mineralogy",totalDownloads:6621,totalCrossrefCites:0,totalDimensionsCites:0,abstract:null,book:{id:"1600",slug:"an-introduction-to-the-study-of-mineralogy",title:"An Introduction to the Study of Mineralogy",fullTitle:"An Introduction to the Study of Mineralogy"},signatures:"Cumhur Aydinalp",authors:[{id:"98959",title:"Prof.",name:"Cumhur",middleName:"---",surname:"Aydinalp",slug:"cumhur-aydinalp",fullName:"Cumhur Aydinalp"}]},{id:"27435",title:"A Review of Pathological Biomineral Analysis Techniques and Classification Schemes",slug:"a-review-of-pathological-biomineral-analysis-techniques-and-classification-schemes",totalDownloads:4303,totalCrossrefCites:1,totalDimensionsCites:6,abstract:null,book:{id:"1600",slug:"an-introduction-to-the-study-of-mineralogy",title:"An Introduction to the Study of Mineralogy",fullTitle:"An Introduction to the Study of Mineralogy"},signatures:"Maria Luigia Giannossi and Vito Summa",authors:[{id:"101919",title:"PhD.",name:"Maria Luigia",middleName:null,surname:"Giannossi",slug:"maria-luigia-giannossi",fullName:"Maria Luigia Giannossi"},{id:"108348",title:"Dr.",name:"Vito",middleName:null,surname:"Summa",slug:"vito-summa",fullName:"Vito Summa"}]}],onlineFirstChaptersFilter:{topicId:"651",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"81626",title:"Use of Natural Safiot Clay for the Removal of Chemical Substances from Aqueous Solutions by Adsorption: A Combined Experimental and Theoretical Study",slug:"use-of-natural-safiot-clay-for-the-removal-of-chemical-substances-from-aqueous-solutions-by-adsorpti",totalDownloads:24,totalDimensionsCites:0,doi:"10.5772/intechopen.101605",abstract:"The main objective of this work was to investigate the potential of Natural Safiot Clay (NSC), as an adsorbent for the removal of two cationic dyes such as Basic Blue 9 (BB9) and Basic Yellow 28 (BY28) from single and binary systems in aqueous solutions. For this, the effects of three factors controlling the adsorption process, such as initial dye concentration, adsorbent dose, and initial pH on the adsorption extent, were investigated and examined. The natural safiot clay was characterized using the following technique: energy-dispersive X-ray spectroscopy (EDX), scanning electron microscopy (SEM), DRX, and Fourier transform infrared (FT-IR) and pH of the point of zero charge (pHZPC). Energy-dispersive X-ray spectroscopy results indicate high percentages of Silica and Alumina. FT-IR spectrum identified kaolinite as the major mineral phase in the presence of quartz, calcite, and dolomite. The quantum theoretical study confirms the experimental results, through the study of the global and local reactivity and the electrophilicity power of the dyes. The electrophilicity power of dyes affects the removal efficiency. The theoretical study proves that BB9 (ω = 6.178) is more electrophilic than BY28 (ω = 2.480) and more interactions with surface sites. The results of the molecular dynamics simulation indicate that the dyes are adsorbed parallel to the surface of natural Safi clay (kaolinite), implying the strong interaction with the kaolinite atoms. All the results of quantum chemistry calculations and simulations of molecular dynamics are in perfect agreement with the results of the experimental study.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Aziz El Kassimi, Mohammadine El Haddad, Rachid Laamari, Mamoune El Himri, Youness Achour and Hicham Yazid"},{id:"80866",title:"Normative Mineralogy Especially for Shales, Slates, and Phyllites",slug:"normative-mineralogy-especially-for-shales-slates-and-phyllites",totalDownloads:44,totalDimensionsCites:0,doi:"10.5772/intechopen.102346",abstract:"First, an insight into normative mineralogy and the most important methods for calculating the standard or norm minerals, such as the CIPW norm, is given. This is followed by a more detailed explanation of “slatenorm” and “slatecalculation” for low and very low metamorphic rocks, such as phyllites, slates, and shales. They are particularly suitable for fine-grained rocks where the mineral content is difficult to determine. They enable the determination of a virtual mineral inventory from full chemical analysis, including the values of carbon dioxide (CO2), carbon (C), and sulfur (S). The determined norm or standard minerals include the minerals—feldspars, carbonates, micas, hydro-micas, chlorites, ore minerals, and quartz. The advantages of slatenorm and slatecalculation compared to other methods for calculating normal minerals of sedimentary rocks are discussed.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Hans Wolfgang Wagner"},{id:"80770",title:"Mg-Ilmenite from Kimberlites, Its Origin",slug:"mg-ilmenite-from-kimberlites-its-origin",totalDownloads:57,totalDimensionsCites:0,doi:"10.5772/intechopen.102676",abstract:"The main regularities of the saturation of kimberlite rocks with the accessory mineral Mg-ilmenite (Ilm), the peculiarities of the distribution of Ilm compositions in individual pipes, in different clusters of pipes, in diamondiferous kimberlite fields, are considered as the example of studies carried out within the Yakutian kimberlite province (Siberian Craton). Interpretation of different crystallization trends in MgO-Cr2O3 coordinates (conventionally named “Haggerty’s parabola”, “Steplike”, “Hockey stick”, as well as the peculiarities of heterogeneity of individual zonal and polygranular Ilm macrocrysts made it possible to propose a three-stage model of crystallization Ilm: (1) Mg-Cr poor ilmenite crystallizing from a primitive asthenospheric melt; (2) Continuing crystallization in the lithospheric contaminated melt by MgO and Cr2O3; (3) Ilmenite subsequently underwent sub-solidus recrystallization in the presence of an evolved kimberlite melt under increasing oxygen fugacity (ƒO2) conditions.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Sergey I. Kostrovitsky"},{id:"80553",title:"Investigation of Accessory Minerals from the Blatná Granodiorite Suite, Bohemian Massif, Czech Republic",slug:"investigation-of-accessory-minerals-from-the-blatn-granodiorite-suite-bohemian-massif-czech-republic",totalDownloads:48,totalDimensionsCites:0,doi:"10.5772/intechopen.102628",abstract:"The Central Bohemian magmatic complex belongs to the Central European Variscan belt. The granitic rocks of this plutonic complex are formed by several suites of granites, granodiorites, and tonalites, together with small bodies of gabbros, gabbro diorites, and diorites. The granodiorites of the Blatná suite are high-K, calc-alkaline to shoshonitic, and metaluminous to slightly peraluminous granitic rocks. Compared to the common I-type granites, granodiorites of the Blatná suite are enriched in Mg (1.0–3.4 wt.% MgO), Ba (838–2560 ppm), Sr. (257–506 ppm), and Zr (81–236 ppm). For granodiorites of the Blatná suite is assemblage of apatite, zircon, titanite, and allanite significant. Zircon contains low Hf concentrations (1.1–1.7 wt.% HfO2). The composition of titanite ranges from 83 to 92 mol.% titanite end-member. Allanite is relatively Al-poor and displays Feox. ratio 0.2–0.5.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Miloš René"},{id:"80423",title:"Minerals as Prebiotic Catalysts for Chemical Evolution towards the Origin of Life",slug:"minerals-as-prebiotic-catalysts-for-chemical-evolution-towards-the-origin-of-life",totalDownloads:106,totalDimensionsCites:0,doi:"10.5772/intechopen.102389",abstract:"A transition from geochemistry to biochemistry has been considered as a necessary step towards the emergence of primordial life. Nevertheless, how did this transition occur is still elusive. The chemistry underlying this transition is likely not a single event, but involves many levels of creation and reconstruction, finally reaching the molecular, structural, and functional buildup of complexity. Among them, one apparent question is: how the biochemical catalytic system emerged from the mineral-based geochemical system? Inspired by the metal–ligand structures in metalloenzymes, many researchers have proposed that transition metal sulfide minerals could have served as structural analogs of metalloenzymes for catalyzing prebiotic redox conversions. This assumption has been tested and verified to some extent by several studies, which focused on using Earth-abundant transition metal sulfides as catalysts for multi-electron C and N conversions. The progress in this field will be introduced, with a focus on the CO2 fixation and ammonia synthesis from nitrate/nitrite reduction and N2 reduction. Recently developed methods for screening effective mineral catalysts were also reviewed.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Yamei Li"},{id:"80338",title:"Ionic Conductivity of Strontium Fluoroapatites Co-doped with Lanthanides",slug:"ionic-conductivity-of-strontium-fluoroapatites-co-doped-with-lanthanides",totalDownloads:54,totalDimensionsCites:0,doi:"10.5772/intechopen.102410",abstract:"Britholites derivatives of apatite’s that contain lanthanium and neodymium in the serial compounds Sr8La2−xNdx(PO4)4(SiO4)2F2 with 0 ≤ x ≤ 2 were subject of the present investigation. The solid state reaction was the route of preparing these materials. Several techniques were employed for the analysis and characterization of the synthesized powders. The chemical analysis results indicated that molar ratio Sr+La+NdP+Si was of about 1.67 value of a stoichiometric powder. The X-ray diffraction data showed single-phase apatites crystallizing in hexagonal structure with P63/m space group were successively obtained. Moreover, the substitution of lanthanium by neodymium in strontium phosphosilicated fluorapatite was total. This was confirmed by the a and c lattice parameters contraction when (x) varies coherently to the sizes of the two cations. The infrared spectroscopy and the 31P NMR (MAS) exhibited the characteristic bands of phosphosilicated fluorapatite. The pressureless sintering of the material achieved a maximum of 89% relative density. The sintered specimens indicated that the Nd content as well as the heating temperature affected the ionic conduction of the materials and the maximum was 1.73 × 10−6 S cm−1 obtained at 1052 K for x = 2.",book:{id:"11137",title:"Mineralogy",coverURL:"https://cdn.intechopen.com/books/images_new/11137.jpg"},signatures:"Khouloud Kthiri, Mohammed Mehnaoui, Samira Jebahi, Khaled Boughzala and Mustapha Hidouri"}],onlineFirstChaptersTotal:10},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:89,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:104,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:32,numberOfPublishedChapters:318,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:12,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:11,numberOfPublishedChapters:141,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:8,numberOfPublishedChapters:129,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:113,numberOfOpenTopics:3,numberOfUpcomingTopics:1,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:106,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:5,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:0,numberOfPublishedChapters:15,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:null,doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"11",title:"Biochemistry",doi:"10.5772/intechopen.72877",issn:"2632-0983",scope:"Biochemistry, the study of chemical transformations occurring within living organisms, impacts all areas of life sciences, from molecular crystallography and genetics to ecology, medicine, and population biology. Biochemistry examines macromolecules - proteins, nucleic acids, carbohydrates, and lipids – and their building blocks, structures, functions, and interactions. Much of biochemistry is devoted to enzymes, proteins that catalyze chemical reactions, enzyme structures, mechanisms of action and their roles within cells. Biochemistry also studies small signaling molecules, coenzymes, inhibitors, vitamins, and hormones, which play roles in life processes. Biochemical experimentation, besides coopting classical chemistry methods, e.g., chromatography, adopted new techniques, e.g., X-ray diffraction, electron microscopy, NMR, radioisotopes, and developed sophisticated microbial genetic tools, e.g., auxotroph mutants and their revertants, fermentation, etc. More recently, biochemistry embraced the ‘big data’ omics systems. Initial biochemical studies have been exclusively analytic: dissecting, purifying, and examining individual components of a biological system; in the apt words of Efraim Racker (1913 –1991), “Don’t waste clean thinking on dirty enzymes.” Today, however, biochemistry is becoming more agglomerative and comprehensive, setting out to integrate and describe entirely particular biological systems. The ‘big data’ metabolomics can define the complement of small molecules, e.g., in a soil or biofilm sample; proteomics can distinguish all the comprising proteins, e.g., serum; metagenomics can identify all the genes in a complex environment, e.g., the bovine rumen. This Biochemistry Series will address the current research on biomolecules and the emerging trends with great promise.",coverUrl:"https://cdn.intechopen.com/series/covers/11.jpg",latestPublicationDate:"June 29th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:32,editor:{id:"31610",title:"Dr.",name:"Miroslav",middleName:null,surname:"Blumenberg",slug:"miroslav-blumenberg",fullName:"Miroslav Blumenberg",profilePictureURL:"https://mts.intechopen.com/storage/users/31610/images/system/31610.jpg",biography:"Miroslav Blumenberg, Ph.D., was born in Subotica and received his BSc in Belgrade, Yugoslavia. He completed his Ph.D. at MIT in Organic Chemistry; he followed up his Ph.D. with two postdoctoral study periods at Stanford University. Since 1983, he has been a faculty member of the RO Perelman Department of Dermatology, NYU School of Medicine, where he is codirector of a training grant in cutaneous biology. Dr. Blumenberg’s research is focused on the epidermis, expression of keratin genes, transcription profiling, keratinocyte differentiation, inflammatory diseases and cancers, and most recently the effects of the microbiome on the skin. He has published more than 100 peer-reviewed research articles and graduated numerous Ph.D. and postdoctoral students.",institutionString:null,institution:{name:"New York University Langone Medical Center",institutionURL:null,country:{name:"United States of America"}}},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"14",title:"Cell and Molecular Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/14.jpg",isOpenForSubmission:!0,editor:{id:"165627",title:"Dr.",name:"Rosa María",middleName:null,surname:"Martínez-Espinosa",slug:"rosa-maria-martinez-espinosa",fullName:"Rosa María Martínez-Espinosa",profilePictureURL:"https://mts.intechopen.com/storage/users/165627/images/system/165627.jpeg",biography:"Dr. Rosa María Martínez-Espinosa has been a Spanish Full Professor since 2020 (Biochemistry and Molecular Biology) and is currently Vice-President of International Relations and Cooperation development and leader of the research group 'Applied Biochemistry” (University of Alicante, Spain). Other positions she has held at the university include Vice-Dean of Master Programs, Vice-Dean of the Degree in Biology and Vice-Dean for Mobility and Enterprise and Engagement at the Faculty of Science (University of Alicante). She received her Bachelor in Biology in 1998 (University of Alicante) and her PhD in 2003 (Biochemistry, University of Alicante). She undertook post-doctoral research at the University of East Anglia (Norwich, U.K. 2004-2005; 2007-2008).\nHer multidisciplinary research focuses on investigating archaea and their potential applications in biotechnology. She has an H-index of 21. She has authored one patent and has published more than 70 indexed papers and around 60 book chapters.\nShe has contributed to more than 150 national and international meetings during the last 15 years. Her research interests include archaea metabolism, enzymes purification and characterization, gene regulation, carotenoids and bioplastics production, antioxidant\ncompounds, waste water treatments, and brines bioremediation.\nRosa María’s other roles include editorial board member for several journals related\nto biochemistry, reviewer for more than 60 journals (biochemistry, molecular biology, biotechnology, chemistry and microbiology) and president of several organizing committees in international meetings related to the N-cycle or respiratory processes.",institutionString:null,institution:{name:"University of Alicante",institutionURL:null,country:{name:"Spain"}}},editorTwo:null,editorThree:null},{id:"15",title:"Chemical Biology",coverUrl:"https://cdn.intechopen.com/series_topics/covers/15.jpg",isOpenForSubmission:!0,editor:{id:"441442",title:"Dr.",name:"Şükrü",middleName:null,surname:"Beydemir",slug:"sukru-beydemir",fullName:"Şükrü Beydemir",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003GsUoIQAV/Profile_Picture_1634557147521",biography:"Dr. Şükrü Beydemir obtained a BSc in Chemistry in 1995 from Yüzüncü Yıl University, MSc in Biochemistry in 1998, and PhD in Biochemistry in 2002 from Atatürk University, Turkey. He performed post-doctoral studies at Max-Planck Institute, Germany, and University of Florence, Italy in addition to making several scientific visits abroad. He currently works as a Full Professor of Biochemistry in the Faculty of Pharmacy, Anadolu University, Turkey. Dr. Beydemir has published over a hundred scientific papers spanning protein biochemistry, enzymology and medicinal chemistry, reviews, book chapters and presented several conferences to scientists worldwide. He has received numerous publication awards from various international scientific councils. He serves in the Editorial Board of several international journals. 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He is a member of the Turkish Biochemical Society, American Chemical Society, and German Genetics society. Dr. Ekinci published around ninety scientific papers, reviews and book chapters, and presented several conferences to scientists. He has received numerous publication awards from several scientific councils. 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He worked on the structure-function relationships of glycoconjugates and his main project was the investigations on the biological roles of the de-N-glycosylation enzymes (Endo-N-acetyl-β-D-glucosaminidase and peptide-N4-(N-acetyl-β-glucosaminyl) asparagine amidase). From 2002 he contributes to the understanding of the Blood-brain barrier functioning using proteomics approaches. He has published more than 70 papers. 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Since then, he has been working as an Adjunct Professor in the same Department at the University of Pavia. His research activity during the first years was primarily focused on the purification and structural characterization of enzymes from animal and plant sources. During this period, Prof. Iadarola familiarized himself with the conventional techniques used in column chromatography, spectrophotometry, manual Edman degradation, and electrophoresis). Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. More recently, Prof. Iadarola was involved in developing techniques such as two-dimensional electrophoresis coupled to liquid chromatography/mass spectrometry (2DE-LC/MS) for the proteomic analysis of biological fluids aimed at the identification of potential biomarkers of different lung diseases. He is the author of about 150 publications (According to Scopus: H-Index: 23; Total citations: 1568- According to WOS: H-Index: 20; Total Citations: 1296) of peer-reviewed international journals. 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She gained considerable experience in developing and validating new methodologies whose applications allowed her to determine both the amount of biomarkers (Desmosine and Isodesmosine) in the urine of patients affected by COPD, and the activity of proteolytic enzymes (HNE, Cathepsin G, Pseudomonas aeruginosa elastase) in the sputa of these patients. Simona Viglio was also involved in research dealing with the supplementation of amino acids in patients with brain injury and chronic heart failure. She is presently engaged in the development of 2-DE and LC-MS techniques for the study of proteomics in biological fluids. The aim of this research is the identification of potential biomarkers of lung diseases. 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He also obtained an MSc in Molecular and Genetic Medicine, and a Ph.D. in Clinical Immunology and Human Genetics from the University of Sheffield, UK. He also completed a short-term fellowship in Pediatric Clinical Immunology and Bone Marrow Transplantation at Newcastle General Hospital, England. Dr. Rezaei is a Full Professor of Immunology and Vice Dean of International Affairs and Research, at the School of Medicine, Tehran University of Medical Sciences, and the co-founder and head of the Research Center for Immunodeficiencies. He is also the founding president of the Universal Scientific Education and Research Network (USERN). Dr. Rezaei has directed more than 100 research projects and has designed and participated in several international collaborative projects. He is an editor, editorial assistant, or editorial board member of more than forty international journals. He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. 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Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. 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His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. 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He received grants from Alianza del Pacifico for a stay at the University of Magallanes, Chile, in 2014, and from Consejo Nacional de Ciencia y Tecnología (CONACyT) to work in the Food and Agriculture Organization’s Animal Production and Health Division (AGA), Rome, Italy, in 2014–2015. He has collaborated with researchers from different countries and published ninety-eight journal articles. 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