Gene–environment interactions reported in ASD. Listed are gene-environment interactions pairs associated with ASD as identified by the systematic literature review using PRISMA guidelines.
\\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\\nWe 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
\\n"}]',published:!0,mainMedia:{caption:"Highly Cited",originalUrl:"/media/original/117"}},components:[{type:"htmlEditorComponent",content:'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\nThroughout 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\nReleased 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\nWe 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
\n'}],latestNews:[{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"},{slug:"introducing-intechopen-book-series-a-new-publishing-format-for-oa-books-20210915",title:"Introducing IntechOpen Book Series - A New Publishing Format for OA Books"}]},book:{item:{type:"book",id:"911",leadTitle:null,fullTitle:"Water Stress",title:"Water Stress",subtitle:null,reviewType:"peer-reviewed",abstract:"Plants experience water stress either when the water supply to their roots becomes limiting, or when the transpiration rate becomes intense. Water stress is primarily caused by a water deficit, such as a drought or high soil salinity. Each year, water stress on arable plants in different parts of the world disrupts agriculture and food supply with the final consequence: famine. Hence, the ability to withstand such stress is of immense economic importance. Plants try to adapt to the stress conditions with an array of biochemical and physiological interventions. This multi-authored edited compilation puts forth an all-inclusive picture on the mechanism and adaptation aspects of water stress. The prime objective of the book is to deliver a thoughtful mixture of viewpoints which will be useful to workers in all areas of plant sciences. We trust that the material covered in this book will be valuable in building strategies to counter water stress in plants.",isbn:null,printIsbn:"978-953-307-963-9",pdfIsbn:"978-953-51-4375-8",doi:"10.5772/1419",price:139,priceEur:155,priceUsd:179,slug:"water-stress",numberOfPages:314,isOpenForSubmission:!1,isInWos:1,isInBkci:!0,hash:"639300ffd325d217a7b6ec2261ff26e0",bookSignature:"Ismail Md. 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Rahman) assumed his current responsibilities as an Associate Professor at the Institute of Environmental Radioactivity, Fukushima University, Japan, in Oct 2015. He also has an honorary appointment to serve as a Collaborative Professor at Kanazawa University, Japan, from Mar 2015 to the present. \nFormerly, Dr. Rahman was a faculty member of the University of Chittagong, Bangladesh, affiliated with the Department of Chemistry (Oct 2002 to Mar 2012) and the Department of Applied Chemistry and Chemical Engineering (Mar 2012 to Sep 2015). Dr. Rahman was also adjunctly attached with Kanazawa University, Japan (Visiting Research Professor, Dec 2014 to Mar 2015; JSPS Postdoctoral Research Fellow, Apr 2012 to Mar 2014), and Tokyo Institute of Technology, Japan (TokyoTech-UNESCO Research Fellow, Oct 2004–Sep 2005). \nHe received his Ph.D. degree in Environmental Analytical Chemistry from Kanazawa University, Japan (2011). 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Besides, he has an M.Sc. degree in Applied Chemistry and a B.Sc. degree in Chemistry, all from the University of Chittagong, Bangladesh. \nDr. Rahman’s research interest includes the study of the fate and behavior of environmental pollutants in the biosphere; design of low energy and low burden environmental improvement (remediation) technology; implementation of sustainable waste management practices for treatment, handling, reuse, and ultimate residual disposition of solid wastes; nature and type of interactions in organic liquid mixtures for process engineering design applications.",institutionString:null,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Fukushima University",institutionURL:null,country:{name:"Japan"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"201022",title:"Dr.",name:"Hiroshi",middleName:null,surname:"Hasegawa",slug:"hiroshi-hasegawa",fullName:"Hiroshi Hasegawa",profilePictureURL:"https://mts.intechopen.com/storage/users/201022/images/4967_n.jpg",biography:"Hiroshi Hasegawa received his D.Sc. 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ASD has a particularly complex genetic architecture, with implicated genes accumulating thanks to more accessible and less costly high-throughput genotyping and sequencing technologies. Between 15 to 25% of ASD cases occur in the context of clinically defined monogenic syndromes and chromosomal rearrangements [2], and therefore have a genetic diagnosis. However, most patients still do not have a clearly identified genetic cause. Genome-wide association studies (GWAS), carried out in large cohorts using SNP arrays, did not find consistently associated ASD genes [3], but showed that individuals with ASD carry a significantly higher burden of
Recent ASD heritability estimates vary between 64 and 85% [8, 9], and incomplete concordance rates between monozygotic twins are reported [10, 11]. These observations suggest that ASD, and its hallmark clinical heterogeneity, is not solely determined by genetics, and that environmental factors may contribute to its risk. Due to the extreme vulnerability of the developing brain to environmental stressors [12], the impact of environmental factors in this neurodevelopmental pathology is of particular concern. In this context, the environment comprises all non-genetic factors that can influence the onset or progression of the disease. Generally, environmental factors include xenobiotics,
From conception to death, individuals are to some degree shaped by an ever-changing environment. However, its impact in health and disease through the life course is still mostly unexplored. Given the early onset of ASD, environmental exposure during the prenatal period to the second year of life is of particular relevance, while at later stages it may still modulate disease progression and possibly treatment efficacy [13, 15]. In this review we focus specifically on the role of xenobiotics in ASD, and on the impact of interactions between genetic variants and xenobiotic exposure. Literature reporting xenobiotic exposure in ASD is already extensive. We expect this systematic review may guide and encourage further studies to elucidate the impact of gene–environment interactions in ASD.
We systematically reviewed studies in two categories: (a) studies reporting xenobiotic exposure implicated in ASD; (b) studies reporting interactions between the previously defined xenobiotics and any genetic factor. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standard checklist [16]. Systematic reviews of the literature were performed successively for categories (a) and (b).
PubMed and EBSCO were queried from inception to November 2020, for records published in peer-reviewed English-language journals.
For records in category (a) PubMed and EBSCO were interrogated using updated and dropped clinical terms (“autis*”; “asperger” and “pervasive developmental disorder”) in combination with the terms “environment*”, or “xenobiotic”, or “toxin” or with terms for xenobiotics’ names (“antidepressants”; “air pollutants”; “bisphenol A”; “folic acid”; “metal”; “PBDE”; “PCB”; “pesticide”; “PFC”; “phthalate”; “vitamin D”). Regarding category (b) the query was done using the same clinical terms in combination with “gene–environment” term and with terms for xenobiotics names identified in previous search.
All identified records were imported to the Mendeley reference manager. PRISMA flowcharts for (a) and (b) categories are shown in Figure 1. For record screening, the following exclusion criteria were applied: 1) review articles and letters to editor; 2) articles where the participants’ diagnosis of ASD was not confirmed according to criteria from
PRISMA flowcharts for (1A) the identification of articles reporting associations between xenobiotic exposure and ASD; (1B) the identification of articles reporting associations between gene–environment interactions and ASD.
After screening, for category (a) eligible articles were included in the final results if they reported statistically significant associations between xenobiotic exposure and ASD risk. Prenatal to early postnatal (
Figure 1A shows the flowchart for the identification of relevant publications. After removing duplicates, a total of 4108 unique records were screened using the defined exclusion criteria, resulting in 130 eligible research papers. Application of the inclusion criterion (
The identified xenobiotics were categorized in seven major groups: Air Pollutants, Toxic Heavy Metals, Non-Persistent Organic Pollutants (non-POPs), Persistent Organic Pollutants (POPs), Pesticides, Pharmacological Drugs and Nutritional Factors (Figure 2). POPs include bisphenol A and phthalates, while non-POPs include polybrominated diphenyl ethers (PBDEs), polychlorinated biphenyls (PCBs) and perfluorinated compounds (PFCs). The first five groups comprise ubiquitous toxins present in air, daily use products and the food chain, while exposure to the last two groups occurs through ingestion.
Number of studies reporting negative and positive associations between exposure to xenobiotics and ASD, including prenatal to early postnatal and childhood to early adulthood exposures. NO2 – Nitrogen dioxide; O3 – Ozone; PM2.5 – Particulate matter with a diameter less than 2.5 μm; PM10 – Particulate matter with a diameter between 2.5 and 10 μm; SO2 – Sulfur dioxide; PAHs – Polycyclic aromatic hydrocarbons; BPA – Bisphenol a; PBDEs – Polybrominated diphenyl ethers; PCBs – Polychlorinated biphenyls; PFCs – Perfluorinated compounds; OC pesticides – Organochlorine pesticides; OP pesticides – Organophosphate pesticides.
Historical proof-of-concept evidence for a role of xenobiotic exposure in ASD comes from three studies, which reported for the first time a very high prevalence of the disorder among subjects prenatally exposed to teratogens. Specifically, these studies reported an ASD prevalence of 4% among individuals exposed to thalidomide [63], of 8.8% in subjects exposed to valproic acid [59] and of 21.4% in individuals exposed to misoprostol [64] (Table S1).
Evidence supporting an association with ASD is stronger for exposure to air pollutants and pesticides, as all studies examining these toxins report an increased risk for the disorder (Table S1). Usually, these studies gather air quality or pesticide application data for large geographical areas and, by applying geocoding methods, investigate how exposure patterns relate to ASD prevalence. Each of these studies includes, at least, one hundred cases, with larger ones examining exposure in thousands of subjects [18, 22, 23, 29, 30, 52]. Environmental agencies are instrumental for collection of airborne pollutant and pesticide data in large populations from geographically defined areas, enabling valuable geocoding approaches. Because heavy metals can circulate in the air, large population geocoding studies, involving hundreds of subjects, are also applied to assess exposure to these chemicals [31, 32, 34]. Some studies quantifying exposure to heavy metals, as well as those that analyze POPs, non-POPs or vitamin D, need to resort to biological matrices. Because this data is so labor intensive to collect, most evidence comes from small datasets of less than one hundred subjects. For instance, this review identified 4 studies assessing heavy metals in biological matrices like hair, nails and teeth, all carried out in small numbers of subjects [33, 35, 36, 38]. Regarding POPs and non-POPs, evidence for an association with ASD is still limited, as fewer reports addressed these chemicals (Table S1). Two studies provide evidence for an increased risk of ASD from prenatal exposure to PCBs [43, 44] while, in other two, PFCs prenatal exposure was found to decrease ASD risk [45, 46]. Concerning PBDEs, the only study reporting associations with the disorder observed a decreased risk due to exposure to BDE-153 and BDE-100 congeners, but an increased risk, only in girls, due to exposure to BDE-47 [42]. For bisphenol A and phthalates, two small size studies for each chemical report an increased risk of ASD associated with childhood exposure [39, 40, 41]. All studies on antidepressants report an increased risk of ASD (Table S1) and, as these usually resort to medical records to assess exposure, include thousands of subjects. A decreased risk of the pathology due to folic acid supplementation is observed by assessing medical records from large samples [68, 69]. However, two recent small size reports, which measured folic acid levels in maternal serum, show an increased risk of ASD associated with prenatal folic acid intake at very high concentrations [70, 71]. In case–control datasets a decreased risk for the disorder is associated with higher prenatal and childhood blood concentrations of 25-hydroxyvitamin D, the main circulating form of this nutrient, with mean serum concentrations values ranging from 9.9 ng/ml to 28.5 ng/ml in cases and 15.0 ng/ml to 40.1 ng/ml in controls [72, 73, 74, 75, 76, 77, 78, 79, 83, 85, 86, 87, 88]. Most of these studies comprise less than one hundred subjects, however 3 studies examining dried blood spots [84, 86] or medical records [81] were carried out in hundreds or thousands of subjects.
Figure 1B shows a flowchart for the identification of relevant publications. The query revealed 392 unique records, of which 15 remained after application of exclusion criteria. Nine research articles reported gene–environment interactions in ASD (Table 1). The environmental component of these interactions included air pollutants (PM10, NO2 and O3), PCBs, manganese and nutritional factors (folic acid and vitamin D), while the genetic component was a specific genotype or, in one study, the overall burden of copy number duplications (Table 1).
Study | Genetic factor | Xenobiotic | Ncases|Ncontrols | Main conclusion |
---|---|---|---|---|
Schmidt et al 2012 [65] | 677 C > T genotype in | Folic acid | 272|154 | Daily prenatal maternal folic acid intake >600 μg was associated with a reduced ASD risk when the mother, the child or both had the low-activity 677 C > T variant. |
Volk et al 2014 [21] | rs1858830 CC genotype in | NO2 and PM10 | 251|156 | Carriers of the CC genotype with higher prenatal exposure to NO2 or to PM10 were at increased risk of ASD when compared to subjects with CG or GG genotypes and lower exposure. |
Rahbar et al 2015 [90]; and Rahbar et al 2018 [91] | Ile/Ile genotype of | Manganese | 100|100 [90]; 163|163 [91] | Among carriers of Ile/Ile |
Schmidt et al 2015 [92] | rs10741657 AA genotype in | Vitamin D | 384|234 | AA genotype associated with a decreased ASD risk when maternal vitamin D intake was <400 IU. |
Coşkun et al 2016 [93] | rs2228570 TT genotype in | Vitamin D | 237|243 | Trend for an association of the TT genotype with elevated circulating 25(OH)D levels in children with ASD. |
Kim et al 2017 [94] | Copy number duplications burden | O3 | 158|147 | Higher burden of CNVs, namely duplications, and O3 exposure increases ASD risk. |
Mandic-Maravic et al 2019 [95] | Any medication | 113|114 | Maternal use of medication during pregnancy associated with high ASD risk in offspring with a | |
Bach et al. 2020 [96] | PCB-153 | 169|169 | Positive association between PCB-153 levels and ASD risk among carriers of |
Gene–environment interactions reported in ASD. Listed are gene-environment interactions pairs associated with ASD as identified by the systematic literature review using PRISMA guidelines.
25(OH)D – 25-hydroxyvitamin D;
Most of the genes assessed in these studies are involved in the metabolism of xenobiotics.
Five attributes that are transversal to many of the xenobiotics reviewed in this study, including air pollutants, toxic heavy metals, POPs, non-POPs and pesticides, likely account for the increased risk of ASD associated with their exposure: 1) ubiquitous exposure; 2) bioaccumulation potential; 3) neurotoxicity; 4) endocrine-disrupting potential and 5) ability to cross physiological barriers.
Exposure to these toxins is ubiquitous, since they are present in the environment, in everyday household and industrial products, and in food. For airborne toxins, this ubiquity is exacerbated by transboundary flows of pollutants, a phenomenon in which toxins circulate long distances and deposit on land and water bodies far from their sources [98]. POPs exhibit high lipid solubility and low hydrophilicity, and are resistant to environmental degradation through chemical or biological processes, increasing their risk of bioaccumulation in human adipose tissue, the ecosystem and in the food chain [99]. Some air pollutants (
Most of these toxins have well established neurotoxic properties [102]. Many, including bisphenol A, phthalates, pesticides, PAHs, PCBs, PBDEs and lead, are also endocrine-disrupting chemicals (EDCs), defined as any “
Given the awareness regarding the hazardous health effects of exposure to these toxins, restrictive policies or bans on their use are often legislated. These include bans on the agricultural application of harmful pesticides [111], the widespread production of bisphenol A-free baby bottles [112] and regulations on PCBs, PBDEs and PFCs production [113]. However, such legislations are not always fully effective. For instance, despite bans, exposure to POPs is still ubiquitous because of their resistance to degradation [113]. Restrictions on bisphenol A use led to replacement by analogues (bisphenol F and bisphenol S) for which harmful effects are also reported [114], and are therefore regrettable substitutions. The transgenerational effects of these toxins are also important, as they can affect not only the exposed individual, but also subsequent generations, through epigenetic mechanisms [99, 104]. Most of the identified chemicals have been persistently used since the 1950s, leading to a growing environmental burden and accumulation of insults over several generations. Consequently, some authors speculate that these delayed effects may account in part for the steady prevalence increase in ASD reported in the last decades [115].
The increased prevalence of ASD among subjects prenatally exposed to three pharmaceutical drugs (thalidomide, valproic acid and misoprostol) provided the first strong evidence for the involvement of environmental risk factors in ASD. Thalidomide is an immunomodulatory drug, widely prescribed to alleviate morning sickness in pregnant women during the 50s, while misoprostol is a prostaglandin analogue used as an abortion inductor and valproic acid is prescribed for epilepsy and bipolar disorder. These drugs are teratogens (
We also identified 5 research articles associating maternal antidepressant intake during pregnancy with ASD risk, particularly for Selective Serotonin Reuptake Inhibitors (SSRIs). SSRIs act by increasing the extracellular levels of serotonin and are known to cross the placenta [117] and to be secreted through breast milk at low levels [118]. Increased serotonin levels have repeatedly been found in blood samples from ASD subjects [119]. While individual research studies report associations between prenatal exposure to antidepressants and ASD, a recent meta-analysis [120] underpins the inconsistency of overall findings. Thus, a clinical balance between the risks of untreated maternal depression and unclear neurodevelopmental risks of antidepressant exposure for the offspring is warranted.
The most encouraging results for protective factors for ASD come from studies examining disease risk and nutrient sufficiency. Overall, there is significant evidence that folic acid and vitamin D supplementation during pregnancy and childhood are prophylactic for neurodevelopmental disorders.
Folic acid promotes the closure of the neural tube, reducing the risk of early neurodevelopmental problems: periconceptional folic acid intake prevents up to 70% of neural tube defects, with national health agencies recommending that women of childbearing age take 0.4 to 1 mg folic acid daily prior and during gestation [121]. However, while the natural folate is initially metabolized in the gut, folic acid is mainly metabolized in the liver, where the activity of dihydrofolate reductase (DHFR), the enzyme that converts folic acid to its biologically active form tetrahydrofolate, is reduced [122]. Thus, sustained high folic acid supplementation may eventually become noxious due to the accumulation of unmetabolized folic acid [122]. In agreement, two studies have observed a higher risk of ASD when mothers consume extremely high levels of this nutrient during pregnancy [70, 71].
Vitamin D plays a fundamental role in calcium and phosphorus metabolism, and is therefore crucial for various biological processes, among which the maintenance of brain homeostasis. Animal studies have also shown that the vitamin D receptor (VDR) is expressed in the brain since early in development [123]. Despite the growing number of studies reporting insufficiency of vitamin D in children with ASD, ambiguous cut-off levels for vitamin D insufficiency render difficult comparisons between studies [124].
The identification of consistent environmental risk factors for ASD is very relevant in view of the failure of genetics to fully explain the disease etiology and the clinical spectrum. However, integrating the emergent data on environmental risk factors for ASD with established genetic findings has been challenging. In this systematic review we identified 9 studies reporting specific gene–environment interaction pairs in ASD.
Because most of the identified genes cluster in biotransformation processes, their dysregulation may result in a deficient metabolism of xenobiotics, inducing pathological mechanisms that contribute to ASD onset.
While relatively scarce, the identified studies already offer valuable insights supporting the potential for preventive strategies based on environmental predictors for subjects carrying a genetic susceptibility variant. For example, controlling exposure to high levels of NO2 or PM10 of carriers of the
In 2005, Wild introduced the term “
To assess environmental exposure in ASD, the prospective cohort study MARBLES [129] recruits pregnant women who already have a biological child with the disorder, and are therefore at higher risk of a second child with ASD. The MARBLES study collects longitudinal information from the children, up to 36 months old, including environmental exposure, genetic and clinical data. This design allows the assessment of pre and early post-natal exposure to risk factors that may contribute to ASD risk. Because participants are recruited before or during pregnancy, monitoring of gestation and early childhood offers a chance to accurately measure exposures, allowing for the identification of early biomarkers.
Other studies with similar designs apply spectrometric methods to quantify the levels of toxins or their metabolites in biological matrices, usually through the collection of blood [42, 43, 44, 45], urine [39, 41, 51] or hair [33, 38] samples. However, prospective designs are not always possible, and cross-sectional studies do not allow assessment of past exposures. Retrospective studies are a viable alternative, benefiting from new methods that allow assessment of previous exposure [14]. For instance, vanguard studies are now using naturally shed deciduous teeth [35] to retrospectively quantify exposure to xenobiotics in ASD subjects. During odontogenesis, deciduous teeth store signatures of exposure to chemicals, from the second trimester
Another promising matrix takes advantage of archived dried blood spots collected through population-wide newborn-screenings for metabolic and congenital diseases. Chemicals relevant for ASD have been successfully detected in archived blood spots, including bisphenol A, PFCs, lead, mercury, PBDEs and PCBs [130, 131]. When correctly collected and stored, analytes remain stable in neonatal spots for years.
Other retrospective studies employ geo-referencing methods to collect information regarding exposure to air pollutants, pesticides and some heavy metals [18, 19, 24, 27, 32, 34, 49, 52]. These studies leverage indoor and outdoor air quality data, usage of agricultural pesticides or the location of environmentally-significant sites (
Overall, a comprehensive analysis of the exposome must address a multiplicity of factors that includes not only exposure to chemicals in variable settings and situations, but also medical procedures, events and lifestyle, psychosocial and cultural variables.
All research studies identified in this review that report gene–environment interactions in ASD, published up to November 2020, examined specific xenobiotics (Table 1). Knowledge regarding interactions between genetics and the environment is vast outside of ASD context, and might be the basis to define what specific interactions to analyze. Leveraging from public, manually curated, literature-based resources, such as the
Given the emerging evidence highlighted by this literature review, there is a clear need to shift from studies that separately address the role of genetics and the environment towards multidisciplinary strategies that explore both components as interacting risk factors. Such strategies will inform about the mechanisms through which environmental exposure interacts with genetic background, contributing to ASD onset. Models must further consider ASD phenotypic and genetic heterogeneity. To fully understand the etiology of this very complex disorder, genetic, environmental exposure, epigenetic and clinical data needs to be collected simultaneously for the same group of individuals. It is possible that different gene–gene and gene–environment interactions are associated with distinct clinical subgroups of individuals with ASD and, consequently, phenotypic stratification may also be incorporated into study design. Conceiving such designs is challenging, especially given the large population datasets that are needed to achieve statistical power for the discovery of small-effect variables associated with the disorder [136, 137]. Artificial Intelligence (AI) methods, including data mining and machine learning algorithms, will be crucial to overcome the challenge of integrating substantial amounts of data, allowing the detection of environmental exposure patterns contributing to ASD onset.
Understanding the biological mechanisms underlying gene–environment interactions that contribute to ASD is fundamental to distinguish between causal and non-causal exposures identified through association studies. While knowledge on this is still limited, given the diversity of risk factors it is likely that multiple mechanisms converge in ASD etiology.
Genetic mutations rendering some individuals more susceptible to certain xenobiotics is the simplest gene–environment interaction mechanism. For instance, a gene functional polymorphism that inhibits the enzymatic degradation of a given toxin may lead to its detrimental accumulation in the organism. Many xenobiotic-responding enzymes, like cytochrome P450 enzymes and GSTs, are expressed in the brain, suggesting the occurrence of metabolic processes that inactivate toxins locally [108].
Epigenetics, a gene expression regulatory process that involves heritable and reversible biochemical modifications of DNA or histones, independent of the DNA sequence, acts at the interface between genes and the environment. These processes include DNA methylation, histone methylation and acetylation events, and post-transcriptional regulation by non-coding RNAs, which are known to be involved in brain development [138]. Environmental factors can modulate genetics through epigenetic mechanisms and xenobiotics implicated ASD are known to alter epigenetic patterns. For instance, valproic acid inhibits histone deacetylases up-regulating the expression of various genes [139]. 5-MethylTHF, a metabolite of folic acid produced by MTHFR enzymatic activity, is a donor of the carbon group used to methylate DNA [140]. Consequently,
Neuropathological mechanisms that putatively lead to ASD, such as oxidative stress, neuro-inflammation, hypoxic damage, abnormal signaling pathways and endocrine disruption, can be induced by exposure to xenobiotics. Reduced brain levels of glutathione, the major endogenous cellular antioxidant responsible for the detoxification of xenobiotics, and other oxidative stress biomarkers have been observed in ASD subjects [145]. Evidence for increased levels of neuro-inflammation biomarkers in ASD, including brain levels of pro-inflammatory cytokines and microglia activation, which may be stimulated by allergens such as pesticides, has been reported [146]. Proxies for fetal and newborn hypoxia, indicating a deprivation of oxygen supply, have been reported in neonates that later develop ASD [26] and may be elicited by early-life events. Xenobiotics also interact directly with intracellular neurotransmitter pathways [108] leading to signaling impairments. For example, acetylcholinesterase, the enzyme that catalyzes the acetylcholine neurotransmitter breakdown, is the primary target of inhibition by organophosphate pesticides [147] Most of the identified xenobiotics are endocrine disruptors and a role for hormonal imbalances in the disorder is plausible, particularly given the male skewness in ASD diagnoses. Atypical steroidogenic activity, namely increased androgen [148] and estrogen [149] levels in the amniotic fluid, has been reported in affected males. Gender-specific effects of environmental toxins [110] and consequent hormonal imbalances may also be implicated in the female protective effect, a hypothesis proposed to explain the ASD male bias.
A novel area of interest in ASD is the role of gut-brain axis, which refers to biochemical signaling connections between the gastrointestinal tract and the central nervous system. Dysbiosis of the gut microbiome likely accounts for a high comorbidity of gastrointestinal symptoms in ASD patients [150]. While the liver is the predominant site of xenobiotic metabolism, the gastrointestinal tract is the first line of defense against ingested compounds, and is rich in both host and microbial enzymes. As the gut microbiota metabolize hundreds of dietary, pharmaceutical and industrial chemicals, dysbiosis could lead to impairments in the gut-brain axis resulting in neurological insults.
This review highlights the accumulating evidence for a role of exposure to xenobiotics in ASD risk, and reinforces the need of developing strategies that consider genetics and the environment as interacting components in ASD etiology. This is further supported by the still limited but promising results originating from studies that explore gene–environment interactions.
However, the current knowledge is likely just the tip of the iceberg. Given the enormous progress in high throughput methodologies for analysis of biomolecules (genomics, transcriptomics, proteomics, metabolomics), together with the development of comprehensive surveys on environmental exposure and advances in artificial intelligence methods for the integrative analysis of large amounts of data, the field is ripe for new discoveries. The expectation is that knowledge of the exposome of individuals can be integrated with their genomes to define patterns of interactions that cause their particular configuration of behaviors in the autism spectrum. There are however many challenges ahead, particularly concerning the collection of such extensive information from patients in sufficient numbers for integrative analysis.
Because environmental exposure is amenable to adjustment or avoidance, the most important clinical outcome of better understanding gene–environment interactions in ASD is the potential for mitigating risk by controlling exposure of individuals with a genetic vulnerability. This line of research thus opens novel and important perspectives to future prevention and personalized interventions for ASD.
This work was supported by Foundation for Science and Technology (FCT), through funding of the project “Gene-environment interactions in Autism Spectrum Disorder” [Grant PTDC/MED-OUT/28937/2017]. JXS was supported by a BioSys PhD programme fellowship from FCT (Portugal) with reference PD/BD/114386/2016. CR was supported by a grant from FCT (Ref: POCI- 01-0145-FEDER-016428).
The authors declare no conflict of interest.
Xenobiotic | Study | Ncases/ Ncontrols | Time of exposure | Exposure assessment | Risk |
---|---|---|---|---|---|
NO2 | Becerra et al. 2013 | 7421/ 72253 | Prenatal | Geocoding/air quality | Increased |
Volk et al. 2013 | 279/ 245 | Prenatal to postnatal | Geocoding/air quality | Increased | |
Jung et al. 2013 | 342/ 48731 | Prenatal to childhood | Geocoding/air quality | Increased | |
Volk et al. 2014 | 251/156 | Prenatal | Geocoding/air quality | Increased | |
Raz et al. 2017 | 2098/ 54191 | Postnatal (9 m) | Geocoding/air quality | Increased | |
Ritz et al. 2018 | 15387/ 68139 | Postnatal (9 m) | Geocoding/air quality | Increased | |
O3 | Becerra et al. 2013 | 5839/ 55757 | Prenatal | Geocoding/air quality | Increased |
Jung et al. 2013 | 342/ 48731 | Prenatal to childhood | Geocoding/air quality | Increased | |
Kaufman et al. 2019 | 428/ 6420 | Postnatal | Geocoding/air quality | Increased | |
McGuinn et al. 2020 | 674/855 | Prenatal 3rdtrimester | Geocoding/air quality | Increased | |
PM2.5 | Becerra et al. 2013 | 5839/ 55757 | Prenatal | Geocoding/air quality | Increased |
Volk et al. 2013 | 279/245 | Prenatal to postnatal | Geocoding/air quality | Increased | |
Volk et al. 2014 | 251/156 | Prenatal | Geocoding/air quality | Increased | |
Raz et al. 2015 | 245/ 1522 | Prenatal | Geocoding/air quality | Increased | |
Talbott et al. 2015 | 217/226 | Prenatal | Geocoding/air quality | Increased | |
Chen et al. 2018 | 124/ 1240 | Postnatal to childhood | Geocoding/air quality | Increased | |
Ritz et al. 2018 | 15387/ 68139 | Postnatal (9 m) | Geocoding/air quality | Increased | |
Kaufman et al. 2019 | 428/ 6420 | Prenatal to Postnatal | Geocoding/air quality | Increased | |
Jo et al. 2019 | 2471/ 243949 | Prenatal 1sttrimester | Geocoding/air quality | Increased | |
McGuinn et al. 2020 | 674/855 | Postnatal (1st year) | Geocoding/air quality | Increased | |
PM10 | Volk et al. 2013 | 279/245 | Prenatal to postnatal | Geocoding/air quality | Increased |
Volk et al. 2014 | 251/156 | Prenatal | Geocoding/air quality | Increased | |
Kalkbrenner et al. 2015 | 979/ 14666 | Prenatal 3rdtrimester | Geocoding/air quality | Increased | |
Chen et al. 2018 | 124/ 1240 | Postnatal to childhood | Geocoding/air quality | Increased | |
Ritz et al. 2018 | 15387/ 68139 | Postnatal (9 m) | Geocoding/air quality | Increased | |
SO2 | Jung et al. 2013 | 342/ 48731 | Prenatal to childhood | Geocoding/air quality | Increased |
Ritz et al. 2018 | 15387/ 68139 | Postnatal (9 m) | Geocoding/air quality | Increased | |
PAHs | von Ehrenstein et al. 2014 | 104/ 53181 | Prenatal | Geocoding/air quality | Increased |
Talbott et al. 2015 (2) | 215/ 4856 | Prenatal | Geocoding/air quality | Increased | |
Lead | Priya and Geetha 2011 | 45/50 | Childhood (4-12y) | Hair and nails | Increased |
Roberts et al. 2013 | 325/ 22101 | Perinatal (at birth) | Geocoding/air quality | Increased | |
von Ehrenstein et al. 2014 | 348/ 78373 | Prenatal | Geocoding/air quality | Increased | |
Talbott et al. 2015 (2) | 215/ 4856 | Prenatal | Geocoding/air quality | Increased | |
Arora et al. 2017 | 22/54 | Postnatal (15w) | Deciduous teeth | Increased | |
El-Ansary et al. 2017 | 35/30 | Childhood (3-12y) | Red blood cells | Increased | |
Manganese | Roberts et al. 2013 | 325/ 22101 | Perinatal (at birth) | Geocoding/air quality | Increased |
Arora et al. 2017 | 22/54 | Postnatal (15w) | Deciduous teeth | Decreased | |
Mercury | Windham et al. 2006 | 284/657 | Perinatal (at birth) | Geocoding/air quality | Increased |
Obrenovich et al. 2011 | 26/39 | Childhood (up to 6y) | Hair | Decreased | |
Roberts et al. 2013 | 325/ 22101 | Perinatal (at birth) | Geocoding/air quality | Increased | |
Priya and Geetha 2011 | 45/50 | Childhood (4-12y) | Hair and nailS | Increased | |
El-Ansary et al. 2017 | 35/30 | Childhood (3-12y) | Red blood cells | Increased | |
BPA | Stein et al. 2015 | 46/52 | Childhood (10.1 ± 3.7y) | Urine | Increased |
Kardas et al. 2016 | 48/41 | Childhood (7.5 ± 2.9y) | Serum | Increased | |
Phthalates | Testa et al. 2012 | 48/45 | Childhood (11.0 ± 5y) | Urine | Increased |
Kardas et al. 2016 | 48/41 | Childhood (7.5 ± 2.9y) | Serum | Increased | |
PBDEs | Lyall et al. 2017 (1) | 545/418 | Prenatal 2ndtrimester | Maternal serum | Increased Decreased |
PCBs | Cheslack-Postava et al. 2013 | 75/75 | Prenatal (early pregnancy) | Maternal serum | Increased |
Lyall et al. 2017 (2) | 545/418 | Prenatal (2nd trimester) | Maternal serum | Increased | |
PFCs | Lyall et al. 2018 | 553/443 | Prenatal 2ndtrimester | Maternal serum | Decreased |
Long et al. 2019 | 75/135 | Prenatal | Amniotic fluid | Decreased | |
OC pesticides | Roberts et al. 2007 | 465/ 6975 | Prenatal 1sttrimester | Geocoding/pesticides data | Increased |
Cheslack-Postava et al. 2013 | 75/75 | Prenatal 1sttrimester | Maternal serum | Increased | |
Brown et al. 2018 | 778/778 | Prenatal 1st or 2nd trimesters | Maternal serum | Increased | |
OP pesticides | Shelton et al. 2014 | 486/ 315 | Prenatal | Geocoding/pesticides data | Increased |
Schmidt et al. 2017 | 296/ 220 | Prenatal | Survey | Increased | |
Philippat et al. 2018 | 46/102 | Prenatal | Maternal urine | Increased | |
von Ehrenstein et al. 2019 | 2961/ 35370 | Prenatal to postnatal | Geocoding/pesticides data | Increased | |
Pyrethroids | Shelton et al. 2014 | 486/315 | Prenatal | Geocoding/pesticides data | Increased |
Hicks et al. 2017 | 159/298 | Prenatal | Geocoding/pesticides data | Increased | |
von Ehrenstein et al. 2019 | 2961/ 35370 | Prenatal to postnatal | Geocoding/pesticides data | Increased | |
Glyphosate | von Ehrenstein et al. 2019 | 2961/ 35370 | Prenatal to postnatal | Geocoding/pesticides data | Increased |
Antidepressants | Croen et al. 2011 | 298/ 1507 | Prenatal | Medical records | Increased |
Rai et al. 2013 | 4429/ 43277 | Prenatal | Medical records | Increased | |
Gidaya et al. 2014 | 5215/ 52150 | Prenatal | Medical records | Increased | |
Harrington et al. 2015 | 421/ 464 | Prenatal | interview and medical records | Increased | |
Rai et al. 2017 | 5378/ 249232 | Prenatal | Interview and medical records | Increased | |
Valproic Acid | Moore et al. 2000 | 52 | Prenatal | Survey | Increased |
Bromley et al. 2008 | 10/622 | Prenatal | Interview and medical records | Increased | |
Bromley et al. 2013 | 12/509 | Prenatal | Interview and medical records | Increased | |
Christensen et al. 2013 | 5437/ 630178 | Prenatal | Medical records | Increased | |
Thalidomide | Stromland et al. 1994 | 100 | Prenatal 1sttrimester | Medical records | Increased |
Misoprostol | Bandim et al. 2003 | 23 | Prenatal 1sttrimester | Interview | Increased |
Folic Acid | Schmidt et al. 2012 | 429/ 278 | Prenatal (early pregnancy) | Interview | Decreased |
Surén et al. 2013 | 270/ 84906 | Prenatal (early pregnancy) | Survey | Decreased | |
Al-Farsi et al. 2013 | 40/40 | Childhood (3-5y) | Serum | Decreased | |
Nilsen et al. 2013 | 234/89602 | Prenatal | Medical records | Decreased | |
Levine et al. 2018 | 572/ 44728 | Prenatal | Medical records | Decreased | |
Raghavan et al. 2018 | 86/1171 | Postnatal (2-3d) | Maternal plasma | Increased | |
Egorova et al. 2020 | 100/100 | Prenatal | Maternal serum | Increased | |
Vitamin D | Meguid et al. 2010 | 70/42 | Childhood (5.3 ± 2.8y) | Serum | Decreased |
Tostes et al. 2012 | 24/24 | Childhood (7.4 ± 2.7y) | Serum | Decreased | |
Mostafa and AL-Ayadhi 2012 | 50/30 | Childhood (8.2 ± 2.4y) | Serum | Decreased | |
Neumeyer et al. 2013 | 18/19 | Childhood (10.6 ± 0.4y) | Serum | Decreased | |
Gong et al. 2014 | 48/48 | Childhood (3.7 ± 1.2y) | Serum | Decreased | |
Bener et al. 2014 | 254/254 | Childhood (5.5 ± 1.6y) | Serum | Decreased | |
Kocovska et al. 2014 | 40/40 | Early adulthood (18.9 ± 2.9y) | Serum | Decreased | |
Fernell et al. 2015 | 58/58 | Neonatal | Dried Blood Spots | Decreased | |
Magnusson et al. 2016 | 9882/ 499757 | Prenatal to childhood | Medical records | Decreased | |
Bener et al. 2017 | 308/ 308 | Childhood (5.4 ± 1.7y) | Serum | Decreased | |
El-Ansary et al. 2018 | 28/27 | Childhood (7.0 ± 2.3y) | Plasma | Decreased | |
Guo et al. 2018 | 332/197 | Childhood (4.9 ± 1.5y) | Serum | Decreased | |
Wu et al. 2018 | 310/ 1240 | Neonatal | Dried Blood Spots | Decreased | |
Arastoo et al. 2019 | 31/31 | Childhood | Serum | Decreased | |
Lee et al. 2019 | 1399/ 1607 | Neonatal | Dried blood spots | Decreased | |
Alzghoul et al. 2019 | 83/106 | Childhood | Serum | Decreased | |
Sengenc et al. 2020 | 100/100 | Childhood | Serum | Decreased | |
Petruzzelli et al. 2020 | 54/36 | Childhood | Serum | Decreased |
Studies reporting xenobiotic exposure associated with ASD, identified through systematic literature review. For each study the numbers of ASD cases (Ncases) and controls (Ncontrols), the timing of exposure (specific time-points of prenatal, postnatal or childhood periods are shown when stated by the referenced authors), the exposure assessment method, and the direction of association are listed (increased or decreased risk by exposure).
BPA – bisphenol A; d – days old; m – months old; NO2 – nitrogen dioxide; O3 – ozone; OC pesticides – organochlorine pesticides; OP pesticides – organophosphate pesticides; PAHs – polycyclic aromatic hydrocarbons; PBDEs – polybrominated diphenyl ethers; PCBs – polychlorinated biphenyls; PFCs – perfluorinated compounds; PM2.5 – particulate matter with a diameter less than 2.5 μm; PM10 – particulate matter with a diameter between 2.5 and 10 μm; SO2 – sulfur dioxide; w – weeks old; y – years old.
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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. 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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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He is also a faculty member in the Molecular Oncology Program. He obtained his MSc and Ph.D. at Oregon State University and Texas Tech University, respectively. He pursued his postdoctoral studies at Rutgers University Medical School and the National Institutes of Health (NIH/NIDDK), USA. His research focuses on biochemistry, biophysics, genetics, molecular biology, and molecular medicine with specialization in the fields of drug design, protein structure-function, protein folding, prions, microRNA, pseudogenes, molecular cancer, epigenetics, metabolites, proteomics, genomics, protein expression, and characterization by spectroscopic and calorimetric methods.",institutionString:"University of Health Sciences",institution:null},{id:"180528",title:"Dr.",name:"Hiroyuki",middleName:null,surname:"Kagechika",slug:"hiroyuki-kagechika",fullName:"Hiroyuki Kagechika",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180528/images/system/180528.jpg",biography:"Hiroyuki Kagechika received his bachelor’s degree and Ph.D. in Pharmaceutical Sciences from the University of Tokyo, Japan, where he served as an associate professor until 2004. He is currently a professor at the Institute of Biomaterials and Bioengineering (IBB), Tokyo Medical and Dental University (TMDU). From 2010 to 2012, he was the dean of the Graduate School of Biomedical Science. Since 2012, he has served as the vice dean of the Graduate School of Medical and Dental Sciences. He has been the director of the IBB since 2020. Dr. Kagechika’s major research interests are the medicinal chemistry of retinoids, vitamins D/K, and nuclear receptors. He has developed various compounds including a drug for acute promyelocytic leukemia.",institutionString:"Tokyo Medical and Dental University",institution:{name:"Tokyo Medical and Dental University",country:{name:"Japan"}}},{id:"268659",title:"Ms.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/268659/images/8143_n.jpg",biography:"Dr. Zhan received his undergraduate and graduate training in the fields of preventive medicine and epidemiology and statistics at the West China University of Medical Sciences in China during 1989 to 1999. He received his post-doctoral training in oncology and cancer proteomics for two years at the Cancer Research Institute of Human Medical University in China. In 2001, he went to the University of Tennessee Health Science Center (UTHSC) in USA, where he was a post-doctoral researcher and focused on mass spectrometry and cancer proteomics. Then, he was appointed as an Assistant Professor of Neurology, UTHSC in 2005. He moved to the Cleveland Clinic in USA as a Project Scientist/Staff in 2006 where he focused on the studies of eye disease proteomics and biomarkers. He returned to UTHSC as an Assistant Professor of Neurology in the end of 2007, engaging in proteomics and biomarker studies of lung diseases and brain tumors, and initiating the studies of predictive, preventive, and personalized medicine (PPPM) in cancer. In 2010, he was promoted to Associate Professor of Neurology, UTHSC. Currently, he is a Professor at Xiangya Hospital of Central South University in China, Fellow of Royal Society of Medicine (FRSM), the European EPMA National Representative in China, Regular Member of American Association for the Advancement of Science (AAAS), European Cooperation of Science and Technology (e-COST) grant evaluator, Associate Editors of BMC Genomics, BMC Medical Genomics, EPMA Journal, and Frontiers in Endocrinology, Executive Editor-in-Chief of Med One. He has\npublished 116 peer-reviewed research articles, 16 book chapters, 2 books, and 2 US patents. His current main research interest focuses on the studies of cancer proteomics and biomarkers, and the use of modern omics techniques and systems biology for PPPM in cancer, and on the development and use of 2DE-LC/MS for the large-scale study of human proteoforms.",institutionString:null,institution:{name:"Xiangya Hospital Central South University",country:{name:"China"}}},{id:"40482",title:null,name:"Rizwan",middleName:null,surname:"Ahmad",slug:"rizwan-ahmad",fullName:"Rizwan Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/40482/images/system/40482.jpeg",biography:"Dr. Rizwan Ahmad is a University Professor and Coordinator, Quality and Development, College of Medicine, Imam Abdulrahman bin Faisal University, Saudi Arabia. Previously, he was Associate Professor of Human Function, Oman Medical College, Oman, and SBS University, Dehradun. Dr. Ahmad completed his education at Aligarh Muslim University, Aligarh. He has published several articles in peer-reviewed journals, chapters, and edited books. His area of specialization is free radical biochemistry and autoimmune diseases.",institutionString:"Imam Abdulrahman Bin Faisal University",institution:{name:"Imam Abdulrahman Bin Faisal University",country:{name:"Saudi Arabia"}}},{id:"41865",title:"Prof.",name:"Farid A.",middleName:null,surname:"Badria",slug:"farid-a.-badria",fullName:"Farid A. Badria",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41865/images/system/41865.jpg",biography:"Farid A. Badria, Ph.D., is the recipient of several awards, including The World Academy of Sciences (TWAS) Prize for Public Understanding of Science; the World Intellectual Property Organization (WIPO) Gold Medal for best invention; Outstanding Arab Scholar, Kuwait; and the Khwarizmi International Award, Iran. He has 250 publications, 12 books, 20 patents, and several marketed pharmaceutical products to his credit. 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He pursued post-doctoral research at College of Pharmacy, Health Science Center, Texas A & M University and was involved in another postdoctoral research at Department of Translational Neurosciences and Neurotherapeutics, John Wayne Cancer Institute, Santa Monica, California. In 2015, he worked in Harvard-MIT Health Sciences & Technology as a visiting scientist. He has substantial experience in nanotechnology-based formulation development and successfully served various Indian organizations to develop pharmaceuticals and nutraceutical products. He is an inventor in many US patents and an author in many peer-reviewed articles, book chapters and books published in various media of international repute. Dr. Mukherjee is currently serving as Principal Scientist, R&D at Esperer Onco Nutrition (EON) Pvt. Ltd. and heads the Hyderabad R&D center of the organization.",institutionString:"Esperer Onco Nutrition Pvt Ltd.",institution:null},{id:"319365",title:"Assistant Prof.",name:"Manash K.",middleName:null,surname:"Paul",slug:"manash-k.-paul",fullName:"Manash K. Paul",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/319365/images/system/319365.png",biography:"Manash K. Paul is a Principal Investigator and Scientist at the University of California Los Angeles. He has contributed significantly to the fields of stem cell biology, regenerative medicine, and lung cancer. His research focuses on various signaling processes involved in maintaining stem cell homeostasis during the injury-repair process, deciphering lung stem cell niche, pulmonary disease modeling, immuno-oncology, and drug discovery. He is currently investigating the role of extracellular vesicles in premalignant lung cell migration and detecting the metastatic phenotype of lung cancer via machine-learning-based analyses of exosomal signatures. Dr. Paul has published in more than fifty peer-reviewed international journals and is highly cited. He is the recipient of many awards, including the UCLA Vice Chancellor’s award, a senior member of the Institute of Electrical and Electronics Engineers (IEEE), and an editorial board member for several international journals.",institutionString:"University of California Los Angeles",institution:{name:"University of California Los Angeles",country:{name:"United States of America"}}},{id:"311457",title:"Dr.",name:"Júlia",middleName:null,surname:"Scherer Santos",slug:"julia-scherer-santos",fullName:"Júlia Scherer Santos",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311457/images/system/311457.jpg",biography:"Dr. Júlia Scherer Santos works in the areas of cosmetology, nanotechnology, pharmaceutical technology, beauty, and aesthetics. Dr. Santos also has experience as a professor of graduate courses. Graduated in Pharmacy, specialization in Cosmetology and Cosmeceuticals applied to aesthetics, specialization in Aesthetic and Cosmetic Health, and a doctorate in Pharmaceutical Nanotechnology. Teaching experience in Pharmacy and Aesthetics and Cosmetics courses. She works mainly on the following subjects: nanotechnology, cosmetology, pharmaceutical technology, aesthetics.",institutionString:"Universidade Federal de Juiz de Fora",institution:{name:"Universidade Federal de Juiz de Fora",country:{name:"Brazil"}}},{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",slug:"abdulsamed-kukurt",fullName:"Abdulsamed Kükürt",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/219081/images/system/219081.png",biography:"Dr. Kükürt graduated from Uludağ University in Turkey. He started his academic career as a Research Assistant in the Department of Biochemistry at Kafkas University. In 2019, he completed his Ph.D. program in the Department of Biochemistry at the Institute of Health Sciences. He is currently working at the Department of Biochemistry, Kafkas University. He has 27 published research articles in academic journals, 11 book chapters, and 37 papers. He took part in 10 academic projects. He served as a reviewer for many articles. He still serves as a member of the review board in many academic journals.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"178366",title:"Associate Prof.",name:"Volkan",middleName:null,surname:"Gelen",slug:"volkan-gelen",fullName:"Volkan Gelen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178366/images/system/178366.jpg",biography:"Volkan Gelen is a Physiology specialist who received his veterinary degree from Kafkas University in 2011. Between 2011-2015, he worked as an assistant at Atatürk University, Faculty of Veterinary Medicine, Department of Physiology. In 2016, he joined Kafkas University, Faculty of Veterinary Medicine, Department of Physiology as an assistant professor. Dr. Gelen has been engaged in various academic activities at Kafkas University since 2016. There he completed 5 projects and has 3 ongoing projects. He has 60 articles published in scientific journals and 20 poster presentations in scientific congresses. His research interests include physiology, endocrine system, cancer, diabetes, cardiovascular system diseases, and isolated organ bath system studies.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"418963",title:"Dr.",name:"Augustine Ododo",middleName:"Augustine",surname:"Osagie",slug:"augustine-ododo-osagie",fullName:"Augustine Ododo Osagie",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/418963/images/16900_n.jpg",biography:"Born into the family of Osagie, a prince of the Benin Kingdom. I am currently an academic in the Department of Medical Biochemistry, University of Benin. Part of the duties are to teach undergraduate students and conduct academic research.",institutionString:null,institution:{name:"University of Benin",country:{name:"Nigeria"}}},{id:"192992",title:"Prof.",name:"Shagufta",middleName:null,surname:"Perveen",slug:"shagufta-perveen",fullName:"Shagufta Perveen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192992/images/system/192992.png",biography:"Prof. Shagufta Perveen is a Distinguish Professor in the Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia. Dr. Perveen has acted as the principal investigator of major research projects funded by the research unit of King Saud University. She has more than ninety original research papers in peer-reviewed journals of international repute to her credit. She is a fellow member of the Royal Society of Chemistry UK and the American Chemical Society of the United States.",institutionString:"King Saud University",institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"49848",title:"Dr.",name:"Wen-Long",middleName:null,surname:"Hu",slug:"wen-long-hu",fullName:"Wen-Long Hu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49848/images/system/49848.jpg",biography:"Wen-Long Hu is Chief of the Division of Acupuncture, Department of Chinese Medicine at Kaohsiung Chang Gung Memorial Hospital, as well as an adjunct associate professor at Fooyin University and Kaohsiung Medical University. Wen-Long is President of Taiwan Traditional Chinese Medicine Medical Association. He has 28 years of experience in clinical practice in laser acupuncture therapy and 34 years in acupuncture. He is an invited speaker for lectures and workshops in laser acupuncture at many symposiums held by medical associations. He owns the patent for herbal preparation and producing, and for the supercritical fluid-treated needle. Dr. Hu has published three books, 12 book chapters, and more than 30 papers in reputed journals, besides serving as an editorial board member of repute.",institutionString:"Kaohsiung Chang Gung Memorial Hospital",institution:{name:"Kaohsiung Chang Gung Memorial Hospital",country:{name:"Taiwan"}}},{id:"298472",title:"Prof.",name:"Andrey V.",middleName:null,surname:"Grechko",slug:"andrey-v.-grechko",fullName:"Andrey V. Grechko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/298472/images/system/298472.png",biography:"Andrey Vyacheslavovich Grechko, Ph.D., Professor, is a Corresponding Member of the Russian Academy of Sciences. He graduated from the Semashko Moscow Medical Institute (Semashko National Research Institute of Public Health) with a degree in Medicine (1998), the Clinical Department of Dermatovenerology (2000), and received a second higher education in Psychology (2009). Professor A.V. Grechko held the position of Сhief Physician of the Central Clinical Hospital in Moscow. He worked as a professor at the faculty and was engaged in scientific research at the Medical University. Starting in 2013, he has been the initiator of the creation of the Federal Scientific and Clinical Center for Intensive Care and Rehabilitology, Moscow, Russian Federation, where he also serves as Director since 2015. He has many years of experience in research and teaching in various fields of medicine, is an author/co-author of more than 200 scientific publications, 13 patents, 15 medical books/chapters, including Chapter in Book «Metabolomics», IntechOpen, 2020 «Metabolomic Discovery of Microbiota Dysfunction as the Cause of Pathology».",institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"199461",title:"Prof.",name:"Natalia V.",middleName:null,surname:"Beloborodova",slug:"natalia-v.-beloborodova",fullName:"Natalia V. Beloborodova",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/199461/images/system/199461.jpg",biography:'Natalia Vladimirovna Beloborodova was educated at the Pirogov Russian National Research Medical University, with a degree in pediatrics in 1980, a Ph.D. in 1987, and a specialization in Clinical Microbiology from First Moscow State Medical University in 2004. She has been a Professor since 1996. Currently, she is the Head of the Laboratory of Metabolism, a division of the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation. N.V. Beloborodova has many years of clinical experience in the field of intensive care and surgery. She studies infectious complications and sepsis. She initiated a series of interdisciplinary clinical and experimental studies based on the concept of integrating human metabolism and its microbiota. Her scientific achievements are widely known: she is the recipient of the Marie E. Coates Award \\"Best lecturer-scientist\\" Gustafsson Fund, Karolinska Institutes, Stockholm, Sweden, and the International Sepsis Forum Award, Pasteur Institute, Paris, France (2014), etc. Professor N.V. Beloborodova wrote 210 papers, five books, 10 chapters and has edited four books.',institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"354260",title:"Ph.D.",name:"Tércio Elyan",middleName:"Azevedo",surname:"Azevedo Martins",slug:"tercio-elyan-azevedo-martins",fullName:"Tércio Elyan Azevedo Martins",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/354260/images/16241_n.jpg",biography:"Graduated in Pharmacy from the Federal University of Ceará with the modality in Industrial Pharmacy, Specialist in Production and Control of Medicines from the University of São Paulo (USP), Master in Pharmaceuticals and Medicines from the University of São Paulo (USP) and Doctor of Science in the program of Pharmaceuticals and Medicines by the University of São Paulo. Professor at Universidade Paulista (UNIP) in the areas of chemistry, cosmetology and trichology. Assistant Coordinator of the Higher Course in Aesthetic and Cosmetic Technology at Universidade Paulista Campus Chácara Santo Antônio. Experience in the Pharmacy area, with emphasis on Pharmacotechnics, Pharmaceutical Technology, Research and Development of Cosmetics, acting mainly on topics such as cosmetology, antioxidant activity, aesthetics, photoprotection, cyclodextrin and thermal analysis.",institutionString:null,institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"334285",title:"Ph.D. Student",name:"Sameer",middleName:"Kumar",surname:"Jagirdar",slug:"sameer-jagirdar",fullName:"Sameer Jagirdar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334285/images/14691_n.jpg",biography:"I\\'m a graduate student at the center for biosystems science and engineering at the Indian Institute of Science, Bangalore, India. I am interested in studying host-pathogen interactions at the biomaterial interface.",institutionString:null,institution:{name:"Indian Institute of Science Bangalore",country:{name:"India"}}},{id:"329248",title:"Dr.",name:"Md. Faheem",middleName:null,surname:"Haider",slug:"md.-faheem-haider",fullName:"Md. Faheem Haider",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329248/images/system/329248.jpg",biography:"Dr. Md. Faheem Haider completed his BPharm in 2012 at Integral University, Lucknow, India. In 2014, he completed his MPharm with specialization in Pharmaceutics at Babasaheb Bhimrao Ambedkar University, Lucknow, India. He received his Ph.D. degree from Jamia Hamdard University, New Delhi, India, in 2018. He was selected for the GPAT six times and his best All India Rank was 34. Currently, he is an assistant professor at Integral University. Previously he was an assistant professor at IIMT University, Meerut, India. He has experience teaching DPharm, Pharm.D, BPharm, and MPharm students. He has more than five publications in reputed journals to his credit. Dr. Faheem’s research area is the development and characterization of nanoformulation for the delivery of drugs to various organs.",institutionString:"Integral University",institution:{name:"Integral University",country:{name:"India"}}},{id:"329795",title:"Dr.",name:"Mohd Aftab",middleName:"Aftab",surname:"Siddiqui",slug:"mohd-aftab-siddiqui",fullName:"Mohd Aftab Siddiqui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329795/images/15648_n.jpg",biography:"Dr. Mohd Aftab Siddiqui is currently working as Assistant Professor in the Faculty of Pharmacy, Integral University, Lucknow for the last 6 years. He has completed his Doctor in Philosophy (Pharmacology) in 2020 from Integral University, Lucknow. He completed his Bachelor in Pharmacy in 2013 and Master in Pharmacy (Pharmacology) in 2015 from Integral University, Lucknow. He is the gold medalist in Bachelor and Master degree. He qualified GPAT -2013, GPAT -2014, and GPAT 2015. His area of research is Pharmacological screening of herbal drugs/ natural products in liver and cardiac diseases. He has guided many M. Pharm. research projects. He has many national and international publications.",institutionString:"Integral University",institution:null},{id:"333824",title:"Dr.",name:"Ahmad Farouk",middleName:null,surname:"Musa",slug:"ahmad-farouk-musa",fullName:"Ahmad Farouk Musa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333824/images/22684_n.jpg",biography:"Dato’ Dr Ahmad Farouk Musa\nMD, MMED (Surgery) (Mal), Fellowship in Cardiothoracic Surgery (Monash Health, Aust), Graduate Certificate in Higher Education (Aust), Academy of Medicine (Mal)\n\n\n\nDato’ Dr Ahmad Farouk Musa obtained his Doctor of Medicine from USM in 1992. He then obtained his Master of Medicine in Surgery from the same university in the year 2000 before subspecialising in Cardiothoracic Surgery at Institut Jantung Negara (IJN), Kuala Lumpur from 2002 until 2005. He then completed his Fellowship in Cardiothoracic Surgery at Monash Health, Melbourne, Australia in 2008. He has served in the Malaysian army as a Medical Officer with the rank of Captain upon completing his Internship before joining USM as a trainee lecturer. He is now serving as an academic and researcher at Monash University Malaysia. He is a life-member of the Malaysian Association of Thoracic & Cardiovascular Surgery (MATCVS) and a committee member of the MATCVS Database. He is also a life-member of the College of Surgeons, Academy of Medicine of Malaysia; a life-member of Malaysian Medical Association (MMA), and a life-member of Islamic Medical Association of Malaysia (IMAM). Recently he was appointed as an Interim Chairperson of Examination & Assessment Subcommittee of the UiTM-IJN Cardiothoracic Surgery Postgraduate Program. As an academic, he has published numerous research papers and book chapters. He has also been appointed to review many scientific manuscripts by established journals such as the British Medical Journal (BMJ). He has presented his research works at numerous local and international conferences such as the European Association for Cardiothoracic Surgery (EACTS) and the European Society of Cardiovascular Surgery (ESCVS), to name a few. He has also won many awards for his research presentations at meetings and conferences like the prestigious International Invention, Innovation & Technology Exhibition (ITEX); Design, Research and Innovation Exhibition, the National Conference on Medical Sciences and the Annual Scientific Meetings of the Malaysian Association for Thoracic and Cardiovascular Surgery. He was awarded the Darjah Setia Pangkuan Negeri (DSPN) by the Governor of Penang in July, 2015.",institutionString:null,institution:{name:"Monash University Malaysia",country:{name:"Malaysia"}}},{id:"30568",title:"Prof.",name:"Madhu",middleName:null,surname:"Khullar",slug:"madhu-khullar",fullName:"Madhu Khullar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/30568/images/system/30568.jpg",biography:"Dr. Madhu Khullar is a Professor of Experimental Medicine and Biotechnology at the Post Graduate Institute of Medical Education and Research, Chandigarh, India. She completed her Post Doctorate in hypertension research at the Henry Ford Hospital, Detroit, USA in 1985. She is an editor and reviewer of several international journals, and a fellow and member of several cardiovascular research societies. Dr. Khullar has a keen research interest in genetics of hypertension, and is currently studying pharmacogenetics of hypertension.",institutionString:"Post Graduate Institute of Medical Education and Research",institution:{name:"Post Graduate Institute of Medical Education and Research",country:{name:"India"}}},{id:"223233",title:"Prof.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/223233/images/system/223233.png",biography:"Xianquan Zhan received his MD and Ph.D. in Preventive Medicine at West China University of Medical Sciences. He received his post-doctoral training in oncology and cancer proteomics at the Central South University, China, and the University of Tennessee Health Science Center (UTHSC), USA. He worked at UTHSC and the Cleveland Clinic in 2001–2012 and achieved the rank of associate professor at UTHSC. Currently, he is a full professor at Central South University and Shandong First Medical University, and an advisor to MS/PhD students and postdoctoral fellows. He is also a fellow of the Royal Society of Medicine and European Association for Predictive Preventive Personalized Medicine (EPMA), a national representative of EPMA, and a member of the American Society of Clinical Oncology (ASCO) and the American Association for the Advancement of Sciences (AAAS). He is also the editor in chief of International Journal of Chronic Diseases & Therapy, an associate editor of EPMA Journal, Frontiers in Endocrinology, and BMC Medical Genomics, and a guest editor of Mass Spectrometry Reviews, Frontiers in Endocrinology, EPMA Journal, and Oxidative Medicine and Cellular Longevity. He has published more than 148 articles, 28 book chapters, 6 books, and 2 US patents in the field of clinical proteomics and biomarkers.",institutionString:"Shandong First Medical University",institution:{name:"Affiliated Hospital of Shandong Academy of Medical Sciences",country:{name:"China"}}},{id:"297507",title:"Dr.",name:"Charles",middleName:"Elias",surname:"Assmann",slug:"charles-assmann",fullName:"Charles Assmann",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/297507/images/system/297507.jpg",biography:"Charles Elias Assmann is a biologist from Federal University of Santa Maria (UFSM, Brazil), who spent some time abroad at the Ludwig-Maximilians-Universität München (LMU, Germany). He has Masters Degree in Biochemistry (UFSM), and is currently a PhD student at Biochemistry at the Department of Biochemistry and Molecular Biology of the UFSM. His areas of expertise include: Biochemistry, Molecular Biology, Enzymology, Genetics and Toxicology. He is currently working on the following subjects: Aluminium toxicity, Neuroinflammation, Oxidative stress and Purinergic system. Since 2011 he has presented more than 80 abstracts in scientific proceedings of national and international meetings. Since 2014, he has published more than 20 peer reviewed papers (including 4 reviews, 3 in Portuguese) and 2 book chapters. He has also been a reviewer of international journals and ad hoc reviewer of scientific committees from Brazilian Universities.",institutionString:"Universidade Federal de Santa Maria",institution:{name:"Universidade Federal de Santa Maria",country:{name:"Brazil"}}},{id:"217850",title:"Dr.",name:"Margarete Dulce",middleName:null,surname:"Bagatini",slug:"margarete-dulce-bagatini",fullName:"Margarete Dulce Bagatini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/217850/images/system/217850.jpeg",biography:"Dr. Margarete Dulce Bagatini is an associate professor at the Federal University of Fronteira Sul/Brazil. She has a degree in Pharmacy and a PhD in Biological Sciences: Toxicological Biochemistry. She is a member of the UFFS Research Advisory Committee\nand a member of the Biovitta Research Institute. She is currently:\nthe leader of the research group: Biological and Clinical Studies\nin Human Pathologies, professor of postgraduate program in\nBiochemistry at UFSC and postgraduate program in Science and Food Technology at\nUFFS. She has experience in the area of pharmacy and clinical analysis, acting mainly\non the following topics: oxidative stress, the purinergic system and human pathologies, being a reviewer of several international journals and books.",institutionString:"Universidade Federal da Fronteira Sul",institution:{name:"Universidade Federal da Fronteira Sul",country:{name:"Brazil"}}}]}},subseries:{item:{id:"23",type:"subseries",title:"Computational Neuroscience",keywords:"Single-Neuron Modeling, Sensory Processing, Motor Control, Memory and Synaptic Pasticity, Attention, Identification, Categorization, Discrimination, Learning, Development, Axonal Patterning and Guidance, Neural Architecture, Behaviours and Dynamics of Networks, Cognition and the Neuroscientific Basis of Consciousness",scope:"Computational neuroscience focuses on biologically realistic abstractions and models validated and solved through computational simulations to understand principles for the development, structure, physiology, and ability of the nervous system. This topic is dedicated to biologically plausible descriptions and computational models - at various abstraction levels - of neurons and neural systems. This includes, but is not limited to: single-neuron modeling, sensory processing, motor control, memory, and synaptic plasticity, attention, identification, categorization, discrimination, learning, development, axonal patterning, guidance, neural architecture, behaviors, and dynamics of networks, cognition and the neuroscientific basis of consciousness. Particularly interesting are models of various types of more compound functions and abilities, various and more general fundamental principles (e.g., regarding architecture, organization, learning, development, etc.) found at various spatial and temporal levels.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/23.jpg",hasOnlineFirst:!1,hasPublishedBooks:!0,annualVolume:11419,editor:{id:"14004",title:"Dr.",name:"Magnus",middleName:null,surname:"Johnsson",slug:"magnus-johnsson",fullName:"Magnus Johnsson",profilePictureURL:"https://mts.intechopen.com/storage/users/14004/images/system/14004.png",biography:"Dr Magnus Johnsson is a cross-disciplinary scientist, lecturer, scientific editor and AI/machine learning consultant from Sweden. \n\nHe is currently at Malmö University in Sweden, but also held positions at Lund University in Sweden and at Moscow Engineering Physics Institute. \nHe holds editorial positions at several international scientific journals and has served as a scientific editor for books and special journal issues. \nHis research interests are wide and include, but are not limited to, autonomous systems, computer modeling, artificial neural networks, artificial intelligence, cognitive neuroscience, cognitive robotics, cognitive architectures, cognitive aids and the philosophy of mind. \n\nDr. Johnsson has experience from working in the industry and he has a keen interest in the application of neural networks and artificial intelligence to fields like industry, finance, and medicine. \n\nWeb page: www.magnusjohnsson.se",institutionString:null,institution:{name:"Malmö University",institutionURL:null,country:{name:"Sweden"}}},editorTwo:null,editorThree:null,series:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403"},editorialBoard:[{id:"13818",title:"Dr.",name:"Asim",middleName:null,surname:"Bhatti",slug:"asim-bhatti",fullName:"Asim Bhatti",profilePictureURL:"https://mts.intechopen.com/storage/users/13818/images/system/13818.jpg",institutionString:null,institution:{name:"Deakin University",institutionURL:null,country:{name:"Australia"}}},{id:"151889",title:"Dr.",name:"Joao Luis Garcia",middleName:null,surname:"Rosa",slug:"joao-luis-garcia-rosa",fullName:"Joao Luis Garcia Rosa",profilePictureURL:"https://mts.intechopen.com/storage/users/151889/images/4861_n.jpg",institutionString:null,institution:{name:"University of Sao Paulo",institutionURL:null,country:{name:"Brazil"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",institutionURL:null,country:{name:"Turkey"}}}]},onlineFirstChapters:{paginationCount:4,paginationItems:[{id:"82367",title:"Spatial Variation and Factors Associated with Unsuppressed HIV Viral Load among Women in an HIV Hyperendemic Area of KwaZulu-Natal, South Africa",doi:"10.5772/intechopen.105547",signatures:"Adenike O. 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