Quality Control Strains Suggested for Antimicrobial Susceptibility Testing by CLSI
\r\n\tAn update on clinical manifestations, their assessment, monitoring, and imagiology, including peripheral arthritis, enthesopathy, and extra-articular findings, and, the differential diagnosis with other diseases which evolves with axial and peripheral calcifications will be provided.
\r\n\r\n\t
\r\n\tAn important component of this book must be dedicated to the more recent treatments namely with biologic therapies but focusing also on new small molecule inhibitors and experimental therapies.
Most of the clinically important bacteria causing infections in humans are capable of exhibiting resistance to antimicrobial agents commonly used for the treatment. Therefore, upon isolation of the organism in the clinical microbiology laboratory, characterization frequently also employs tests to detect its antimicrobial susceptibility. Thus, the report produced by clinical microbiology laboratory for the physician, also includes organism’s susceptibility profile to different antimicrobials along with its identification [1]. Antimicrobial susceptibility testing (AST) is performed on bacteria that are isolated from clinical specimens to determine if the bacterial etiology of concern can be killed or inhibited by antimicrobial drugs that are potential choices for therapy, at the concentrations of the drugs that are attainable at the site of infection using the dosing regimen indicated in the drug product’s labeling. The results of AST are generally reported with interpretive categories. The category “susceptible” indicates that the bacteria are inhibited by the usually achievable concentrations of antimicrobial agent when the dosage recommended to treat the site of infection is used. The “intermediate” category defines the bacteria for which the response rates to usually attainable blood and tissue levels of antimicrobial agent are lower compared to susceptible isolates. The intermediate category plays the role of a buffer zone between the susceptible and resistant categories, but also indicates a number of other possibilities; the antimicrobials which are concentrated at the site of infection may be regarded as options for treatment (e.g., nitrofurantoin for the urinary tract infections). The “resistant” category, however, defines the bacteria which are not inhibited by the usually achievable concentrations of the agent with normal dosage regimens and that the clinical efficacy of the agent against the isolate may not be sufficient [2]. Clinicians consider these interpretations to determine which antimicrobial agent might be effective in treating the particular patient. The primary role of routine microbiology laboratories is to provide accurate and timely antimicrobial susceptibility test results for guiding the treatment of infectious diseases. In order to achieve that, the microbiologist should inform the clinician about whether an infectious agent is present in the patient’s specimen and which antimicrobial agent should provide the optimum therapy. Although the importance of antimicrobial susceptibility testing is well established, the procedure itself is very sensitive to changes in the environment and test conditions. Therefore, it is crucial that each variable in the procedure should be standardized and carefully controlled. With more reliable susceptibility results, infectious disease specialists and public health leaders can be able to recognize emerging resistance and novel resistance patterns. Additionally, the results of AST can be applied to define the agent of choice for empirical therapy, establish institutional or nationwide policies for prescribing of antibiotics, conduct epidemiological studies or resistance surveillance, and to evaluate the efficacy of newly developed agents. Owing to numerous variables that may affect the results, rigorous quality control is of utmost importance for susceptibility testing. Properly performed quality control would aid in providing accurate, reproducible and timely results. In this chapter the components of a quality assurance program for antimicrobial susceptibility testing will be highlighted.
\n\t\tFleming was first to report the inhibitory effect of penicillin on agar by observing a zone of growth inhibition of staphylococcal colonies grown next to a
Nationwide attempts were made to standardize AST methodologies; Clinical and Laboratory Standards Institute (CLSI, formerly NCCLS) (USA) [11], Werkgroep Richtlijnen Gevoeligheidsbepalingen (Netherlands) [12], Comité de l’Antibiogramme de la Société Française de Microbiologie (France) [13], the Swedish Reference Group for Antibiotics (Sweden) [14], Deutsches Institut für Normung (Germany) [15], the British Society for Antimicrobial Chemotherapy (UK) [16], they all published guidelines to improve the methodology and interpretation of AST. Recently, the European Committee on Antimicrobial Susceptibility Testing (EUCAST), a non-profit organization under the auspices of European Society of Clinical Microbiology and Infectious Diseases (ESCMID), developed and published AST guidelines. Breakpoint and QC tables for disk diffusion and minimum inhibitory concentration (MIC) testing can freely be accessed on organization’s website [17].
In clinical laboratories, widely adopted AST methods are disk diffusion and broth dilution methods. In disk diffusion method, disks impregnated with antimicrobial agents are used. The disks are placed onto agar plates which are preinoculated with the suspension of the microorganism being tested. The basic principle of the disk diffusion method is the diffusion of the antimicrobial agent into the medium which occurs when the disks come into contact with the moist surface of the plate. The concentration of the agent reduces logarithmically as the distance from the disk is increased. After the incubation period the plates are observed for the circular inhibiton zone created around the disk which is due to the inhibitory effect of the antimicrobial agent on the microorganism. Within the zone the concentration of the agent is sufficient to inhibit growth, whereas at the point where the concentration of the agent is no longer enough to inhibit growth, the organism is able to grow and forms a lawn of bacteria around the disk. To interprete the test results, the radius of the inhibition zone is measured and compared against the predefined values provided by the guidelines [18]. The most widely used guidelines are the CLSI and EUCAST guidelines [2, 17]. CLSI divides the results into three categories for most of the organism-agent combinations; susceptible, intermediate and resistant, whereas EUCAST uses only two categories, susceptible and resistant.
In the dilution methods, however, the susceptibility of the microorganisms to antimicrobial agents is determined whether in tubes (macrobroth dilution method) or in microtube wells molded into a plastic plate (microbroth dilution method). Both broth dilution methods use the same principle; first serial two-fold dilutions of the antimicrobial agent to be tested are made in the tubes/wells containing broth, and then same amount of bacterial suspension is distributed on each tube/well. At the end of the incubation period, the tubes/wells are examined for turbidity which is the indicator of bacterial growth in broth. The tubes/wells remain clear where the concentration of the agent is high enough to inhibit the bacterial growth, whereas at lower concentrations of the agent, the bacteria may grow which causes the tube/well become turbid. The lowest concentration of antimicrobial agent that prevents the
Clinical microbiology laboratories are an integral part of the total healthcare delivery system. Quality assurance (QA) is the overall process by which a laboratory can verify that a laboratory does its job well. While QA and quality control (QC) share the similar purposes, their meanings and functions are different [19]. QA can be defined as the overall program by which the quality of the test results can be guaranteed [20]. It evaluates and ensures that procedures provide relevant and timely data in the delivery of healthcare services. QA is primarily concerned with broader measures and monitors the performance of laboratory in total and covers all three phases of testing; pre-analytical, analytical and post-analytical. QC, in the other hand, is responsible for monitoring of the analytical phase of testing only and ensures that the daily tests are working properly [21]. QC and QA, only together provide measures for controlling how correct the tests are being performed because QC by itself often does not detect problems in time to prevent harmful results. For example, if >5% of
Standard processes are required to establish quality measures to be monitored. Standardization of AST has been achieved by CLSI, and in part by EUCAST. The processes defined in CLSI guidelines help clinical laboratories to perform QC tests, measure their results and provide corrective action recommendations covering a broad spectrum of error types. Each laboratory should establish its own quality requirements for testing processes. Only with established quality goals, laboratories can determine whether acceptable quality is being achieved, identify processes that are not performing satisfactorily and are in need of improvement, or to plan new processes to reach a specified level of quality [21]. And to ensure that all the established quality goals are achieved, a comprehensive QA program should be functional in a clinical laboratory.
The major components of a comprehensive QA program for AST, with the relative amount of effort required to be spent on each component given in parantheses, can be listed as follows [23]:
\n\t\t\tClinically relevant testing strategies (15%)
Testing of reference QC strains (15%)
Technical competency (15%)
Organism antibiogram verification (15%)
Supervisor review of results (15%)
Procedure manual (10%)
Cumulative antibiogram (5%)
Proficiency surveys (5%)
Other (5%)
The goals of the QC program as set by the CLSI [24, 25] includes to monitor the following:
\n\t\t\tthe precision (repeatability) and accuracy of AST procedures
the performance of reagents used in the tests
the performance of persons who carry out the tests and read the results
The continuous monitorization of the performance is best achieved, but not limited to, by the testing of QC strains.
\n\t\t\tOnly organisms likely to be the cause of an infection should be tested for antimicrobial susceptibility which necessitates the differentiation should be done between the normal flora that resides at the site of the infection and the actual organism causing the infection. Some important factors are to be considered to decide which bacterium or bacteria from a clinical specimen must be included in the AST; such as the body site from which the organism was isolated, the presence of other bacteria and the quality of the specimen from which the organism was grown, the host’s status, the ability of the bacterial species to cause infection at the body site from which the specimen was obtained, etc. [1, 26].
\n\t\t\tEach laboratory is unique in its capability, resources, level of experience or institutional needs. Therefore, the decision of which antimicrobials to test depends on each laboratory’s specifications and cannot be generalized. The decision involves the opinions of infectious diseases specialist and the pharmacist and should also be in concordance with the hospital formulary. Generally, a laboratory defines 10 to 15 antimicrobial agents for routine testing against various organisms or organism groups, which is called antimicrobial panel or battery. In CLSI’s M100 documents Table 1A (Suggested Groupings of Antimicrobial Agents With FDA Clinical Indications That Should Be Considered for Routine Testing and Reporting on Nonfastidious Organisms by Clinical Microbiology Laboratories in the United States) is a valuable source of information to refer to when such tables are to be created at the local level [2]. Because the identity of the bacterial isolate is often not known at the time the AST is performed, some drugs, which are inappropriate to report for that particular isolate, may be tested. These results, however, should be supressed in the final report.
The goal of the clinical microbiology laboratory is to create a report which will direct the clinician to use the least toxic, most cost-effective and most clinically effective agent that is available. This is accomplished by using the selective-reporting protocol provided by the CLSI. CLSI categorizes antimicrobial agents generally into four groups, Group A, B, C and U. Group A includes the primary agents whose results to be reported first. The results of Group B drugs should be selectively reported because these are generally broader spectrum agents. However, if the isolate is resistant to the primary agents, the patient cannot tolerate drugs in Group A, the infection has not responded to the therapy with the primary agents, a secondary agent would be a better clinical choice for the particular infection or that the patient has organisms isolated from another site also, and a secondary agent might be more appropriate for treating both organisms, then the results of Group B drugs can be reported [26]. Group C includes alternative or supplemental agents for special cases; such as resistant strains, for patients allergic to primary drugs, for treatment of unusual isolates or for epidemiological purposes. And finally, Group U, includes the agents that are used only or primarily in the treatment of urinary tract infections (e.g., nitrofurantoin, norfloxacin).
Selective-reporting, also called cascade-reporting, improves the clinical relevance of the reports produced and minimizes the selection of multiresistant strains by avoiding the use of broad spectrum agents when narrow spectrum option is susceptible.
\n\t\t\tThe procedural steps of each method must be followed strictly in order to obtain reproducible results. Standardization of AST methodology helps to optimize bacterial growth conditions so that the inhibition of growth can be attributed to the antimicrobial agent and the effects of nutrient limitations, temperature differences or other environmental conditions can be eliminated. And it also optimizes conditions for maintaining antimicrobial integrity and activity so that the failure to inhibit bacterial growth can be attributed to the organism’s resistance mechanisms [1].
The standardized components of AST include:
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t\t
Routine QC testing with a range of QC strains is the backbone of the internal QC testing. QC strains are well characterized organisms with defined susceptibility or resistance mechanisms to the antimicrobial agent(s) tested. Testing of QC strains helps to concurrently monitor the performance of the test and ensures that the test is being performed properly. The results obtained with the QC strains should be in predefined, acceptable ranges; for disk diffusion test, between the predefined inhibition zone diameters, and for MIC tests in predefined MIC ranges. If deviations from the acceptable limits are observed, it indicates unacceptable performance and the source(s) of the error should be investigated. CLSI recommends to use various QC strains for different aspects of AST. The list of QC strains can be found in the M100 tables which are updated on a yearly basis. Because of the introduction of new drugs, the changes effecting the existing drugs, or the emergence of new resistance mechanisms which should be investigated by the laboratory, the users are always referred to the latest update available. The QC strains recommended by CLSI are divided in two as being regular „QC strains“ and „supplemental QC strains“. Each laboratory performing AST with CLSI’s reference methods should include QC strains in regular QC tests, however, the supplemental strains are only required if they are used to assess a new test, for training new personnel, investigation of special susceptibility or resistance characteristics, etc., and are not required to be included in the routine QC of AST [2].
CLSI’s European counterpart, EUCAST, also publishes guidelines for the use of QC strains for AST, however, compared with the comprehensive battery of QC strains suggested by the CLSI, EUCAST is limited to six QC strains at the moment [27]. The guidelines of EUCAST are continously evolving and on areas where EUCAST’s experience is not able to cover yet, EUCAST does not refrain from making referrals to relevant CLSI documents. However, one big difference between the QC strains recommended by CLSI and EUCAST is that, EUCAST‘s recommendation for
\n\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tDisk diffusion and MIC of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | MIC of other non- | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening and confirmatory tests for ESBLs (negative) | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Disk diffusion and MIC of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tDisk diffusion and MIC for β-lactam/β-lactamase inhibitor combination drugs of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | MIC for β-lactam/β-lactamase inhibitor combination drugs of other non- | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Testing of amoxicillin-clavulanic acid for | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tScreening and confirmatory tests for ESBLs (positive) | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tConfirmatory test for suspected carbapenemase production in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tConfirmatory test for suspected carbapenemase production in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tDisk diffusion and MIC of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tDisk diffusion of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for β-lactamase production of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for inducible clindamycin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for high-level mupirocin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tMIC of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for β-lactamase production in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for oxacillin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for inducible clindamycin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for high-level mupirocin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tScreening test for oxacillin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tScreening test for inducible clindamycin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tScreening test for inducible clindamycin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tScreening test for high-level mupirocin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tMIC of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for vancomycin MIC ≥8 µg/mL in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for high-level aminoglycoside resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for vancomycin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tScreening test for vancomycin MIC ≥8 µg/mL for | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for high-level aminoglycoside resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for vancomycin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tDisk diffusion and MIC of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tDisk diffusion and MIC of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tChecking growth capabilities of medium used for disk diffusion and MIC tests for | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tDisk diffusion and MIC of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tDisk diffusion and MIC of | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Screening test for inducible clindamycin resistance in | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tMIC of anaerobes | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tMIC of anaerobes | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tMIC of anaerobes | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tMIC of anaerobes | \n\t\t\t\t\t\t
Quality Control Strains Suggested for Antimicrobial Susceptibility Testing by CLSI
When selecting QC strains for routine internal QC testing; the strains that most closely resemble the patient’s isolate should be tested [23]. This will provide that the drugs planned to be tested for the patient can be concomitantly tested with the QC strain. Additionally, same materials and testing conditions used for the clinical isolates can be evaluated. Before obtaining the QC strains, laboratories should decide which strains do fit best to the laboratory‘s procedures. For example, if a laboratory does not perform Modified Hodge Test (MHT) to confirm suspected carbapenemase production in
The QC strains can be obtained from various suppliers and in many formats. What important is, no matter in what format the strain has been received, the initial reconstitution should be performed according to supplier’s recommendations. For long term storage, stock cultures can be stored in a suitable stabilizer (e.g., trypticase soy broth with 10 to 15% glycerol, 50% fetal calf serum in broth, defibrinated sheep blood or skim milk) at -20°C or below (preferably at -60°C or below). To obtain working control cultures, subcultures from the permanent stock culture are made onto agar plates. Isolated colonies (4 to 5) are selected and subcultured to an agar slant (trypticase soy agar slants for non-fastidious organisms and chocolate agar slants for fastidious organisms) and incubated overnight. These working cultures on agar slants are stored at 2 – 8°C, for no more than three successive weeks. New working control cultures should be prepared at least monthly from permanent stock cultures. Prior to QC testing, growth from an agar slant is subcultured to agar plates and incubated overnight. To use for QC testing, 4 to 5 isolated colonies from the plate are selected. A new working culture should be prepared each day the QC test is being performed [2, 23].
Working control cultures can be used to monitor precision (repeatability) and accuracy of the AST as long as no significant change in the mean zone diameter or MIC value, not attributable to faulty methodology, is observed. Laboratories usually do not have problems with the maintenance of susceptible QC strains owing to the stability of these strains, however, QC strains with particular resistance mechanisms are harder to maintain since they may be less genetically stable. Repeated subcultures can cause the loss of resistance mechanisms and unsatisfactory performances can be experienced. Documented problems have arisen with the QC strains which carry their specific resistance mechanism on a plasmid (e.g.,
Appropriate QC organisms should be tested daily for all antimicrobial agents routinely included in the antimicrobial battery until a laboratory achieves “satisfactory performance“. CLSI makes the definition of “satisfactory performance“ as obtaining unacceptable results in no more than 1 out of 20 or 3 out of 30 results obtained in consecutive test days for each antimicrobial agent/organism combination. Once this satisfactory performance is obtained, a laboratory can convert from daily QC testing to weekly QC testing. As long as all QC test results are within the acceptable limits, the laboratory can continue weekly testing, however on occasions when a modification in the test is made, consecutive QC testing is required (Table 2., adapted from reference 2).
\n\t\t\t\t\n\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tStart to use new shipment or lot number of disks/MIC panels or prepared agar plates | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Start to use disks from a new manufacturer | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Expand or reduce the dilution range in MIC testing | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Repair of instrument that affects the AST results | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tStart to use prepared agar plates (disk diffusion), broth or agar (MIC) from a new manufacturer | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Convert inoculum preparation/standardization method from visual adjustment of turbidity to use a photometric device which has its own QC protocol | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Update of the software which affects the AST results | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tUse new method for MIC test (e.g., convert from visual reading to instrument reading of panel, convert from overnight to rapid MIC test) | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Use new manufacturer of MIC test | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Change method of measuring zones in disk diffusion test (e.g., start using an automated zone reader) | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Convert inoculum preparation/standardization method to a method that is dependent on user technique | \n\t\t\t\t\t\t
Required Quality Control Frequency after Modifications in the Test
* Number of days of consecutive QC testing required
For both, disk diffusion and MIC testing, addition of any new antimicrobial agent to the existing panel requires 20 or 30 consecutive days of satisfactory testing before it can be tested on a weekly schedule.
\n\t\t\tCorrective action is defined as the “action to eliminate the cause of a detected nonconformity or other undesirable situation“ [28] and in regard to AST, is needed whenever any of the weekly QC results are not within the acceptable limits. The factors causing for the deviation in the results are various but can be divided in two as being results due to identifiable errors and results with no error identified [24, 25]. Identifiable errors, also named obvious errors, are easy to detect and also easy to correct. Most usual reasons causing for identifiable errors include; use of the wrong disk, use of the wrong QC strain, contamination of the strain or media, use of the wrong incubation temperature or conditions. If the reason causing the out-of-range results is one of the identifiable errors, the test must be carried out again the day the error is observed. If results of the repeat test are in acceptable limits, no further corrective action is necessary. On the other hand, if the reason causing for the error cannot be identified, the test must be carried out again the day the error is observed, preferably with a new working culture or subculture, but should also be monitored for a total of five consecutive test days. During five consecutive days, if all results are within the acceptable limits no additional corrective action is required. However, if any of the results are outside the acceptable limits, additional corrective action is required. At this point, a systematic error, rather than a random should be suspected and the components of AST should be thoroughly investigated. The reasons include; wrong measurement, clerical errors, problems in the adjustment of turbidity, past expiration date materials, failure in providing proper growth conditions (temperature, atmosphere), improper storage of disks, contamination of QC strain, loss of characteristics, inoculum prepared from an old plate (> 24 hours), etc.. In order to start to routine QC testing, satisfactory performance for another 20 or 30 consecutive days is required once the reason causing the error is detected and corrected.
When an out-of-range QC results necessitates a corrective action, the factors listed in Table 3 should be considered for troubleshooting (Table 3., adapted from references 24 and 25).
\n\t\t\t\t\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\tUse of the wrong QC strain | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Improper storage | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | Inadequate maintenance (e.g., use of the same working culture for >1 month) | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Contamination | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Nonviability | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Changes in the organisms (e.g., mutation, loss of plasmid) | \n\t\t\t\t\t
\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\tImproper storage or shipping conditions | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Contamination | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Use of a defective agar plate (too thick or too thin) | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Inadequate volume of broth in tubes or wells | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Use of damaged plates, panels, cards, tubes (e.g., cracked, leaking) | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Use of expired materials | \n\t\t\t\t\t
\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\tUse of the wrong incubation temperature or conditions | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Inoculum suspensions were incorrectly prepared or adjusted | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Inoculum prepared from a plate incubated for the incorrect length of time | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Inoculum prepared from differential or selective media containing anti-infective agents or other growth-inhibiting compounds | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Use of wrong disk/reagents, ancillary supplies | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Improper disk placement (e.g., inadequate contact with the agar) | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Incorrect reading or interpretation of test results | \n\t\t\t\t\t
\n\t\t\t\t\t\t | Transcription error | \n\t\t\t\t\t
\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\tNot functioning properly or out of calibration (e.g., pipettes) | \n\t\t\t\t\t
Factors Frequently Causing Out-of-range Results
Results from all QC tests should be documented on a QC log sheet [23]. On this log sheet information regarding the following are required: the date, the technician who performed the test, antimicrobial agents used (potency, lot, expiration date, etc.), media used (lot, expiration date, etc.). Once the log sheet has been filled by the technician who performed and read the test, a second technician, or the supervisor, should check the results. Also, corrective actions taken, if any, and their outcomes should be noted.
A useful and simple way of monitoring QC results is to use the Shewhart diagram, in which the daily readings are plotted on a chart with upper and lower control limits marked [29]. It provides the visual assessment of the results but can also provide in depth information if a more formal mathematical approach is followed [20]. An example of presenting daily QC results on a Shewhart diagram is given in Figure 1. The famous rules of Westgard and Klee [30] can be easily adopted to the QC of disk diffusion test in which the control diameters are treated as mean ±2 SD [20].
One QC result lies outside the limits (Westgard rule 12s): It is a warning, whether it’s a random error or the beginning of an emerging problem. Routine test results for that day may be reported if there is no other evidence of problems in the current tests. It does not require corrective action by itself, unless the result is far out of range or there are other indications of a problem.
Two consecutive QC results are outside the limits in the same side of the mean of the range (Westgard rule 22s): Indicates an error in the test methodology (a systematic error), corrective action is required.
Ten consecutive QC results falling on one side of the mean (Westgard rule 10Ẍ): Results may be accepted but this likely indicates a systematic problem which should be acted on.
\n\t\tExample for daily disk diffusion QC results for
One of the most widely used supplemental QC measure is the use of susceptibility test results to verify results generated on patient results. Species with „typical“ antibiograms are useful in verification of the identification as well as the susceptibility results. CLSI suggests some results to be confirmed before they are reported, these mostly include rare resistance phenotypes. The rare resistance phenotypes are divided in three categories; Category I; not reported or only rarely reported to date, Category II; uncommon in most institutions, and Category III; may be common, but is generally considered of epidemiological concern. Since category I includes the least encountered and most significant results, it is highly important to detect these results before being reported unnoticed and to follow the necessary steps for the verification. Unusual resistance phenotypes which require confirmation are given in Table 3 (adapted from reference 2).
\n\t\t\t\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t\t\n\t\t\t\t\t\t\t\t | \n\t\t\t\t\t\t
\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\tNS to carbapenems, extended-spectrum cephalosporins or fluoroquinolones in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | NS to extended-spectrum cephalosporins, meropenem or minocycline, R to ampicillin or penicillin in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | NS to linezolid or vancomycin in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | NS to ampicillin, penicillin, extended-spectrum cephalosporins, daptomycin, ertapenem, meropenem, linezolid or vancomycin in β-hemolytic group | \n\t\t\t\t\t
\n\t\t\t\t\t\t | NS to daptomycin, ertapenem, meropenem, linezolid, or vancomycin, R to quinupristin-dalfopristin in viridans group | \n\t\t\t\t\t
\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\tI or R to carbapenems in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | I or R to 3rd generation cephalosporins or fluoroquinolones in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | R to colistin/polymyxin in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | I or R to colistin/polymyxin in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | I or R to trimethoprim-sulfamethoxazole in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | R to amoxicillin-clavulanic acid, R to ampicillin without accompanying β-lactamase production in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | NS to extended spectrum cephalosporins in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | I to ampicillin, penicillin, I or R to rifampin, NS to azithromycin in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | R to linezolid, NS to daptomycin for | \n\t\t\t\t\t
\n\t\t\t\t\t\t | NS to daptomycin, R to linezolid, I or R to quinupristin-dalfopristin, vancomycin MIC = 4 µg/mL or vancomycin MIC ≥ 8 µg/mL for | \n\t\t\t\t\t
\n\t\t\t\t\t\t | NS to daptomycin, I or R to quinupristin-dalfopristin or vancomycin, R to daptomycin in coagulase-negative | \n\t\t\t\t\t
\n\t\t\t\t\t\t | I or R to fluoroquinolone, imipenem, meropenem, quinupristin-dalfopristin, rifampin in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | I or R to quinupristin-dalfopristin in β-hemolytic group | \n\t\t\t\t\t
\n\t\t\t\t\t\t\t | \n\t\t\t\t\t\tR to amikacin, gentamicin, and tobramycin in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | I or R to extended spectrum cephalosporins in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | I or R to carbapenem in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | R to amikacin, gentamicin, and tobramycin, or carbapenem in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | I or R to fluoroquinolone in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | I or R to chloramphenicol or fluoroquinolone in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | R to vancomycin or high-level aminoglycoside in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | R to oxacillin in | \n\t\t\t\t\t
\n\t\t\t\t\t\t | R to amoxicillin, penicillin or extended spectrum cephalosporins in | \n\t\t\t\t\t
Unusual Resistance Phenotypes Which Require Confirmation
NS; nonsusceptible, I; intermediate, R; resistant
The general approach to be followed is, for all three categories, to confirm the identification of the organism and the AST. If the results are confirmed, the infection control should be informed about the case.
\n\t\tAccuracy of the susceptibility test results should be continously monitored. This is mostly accomplished by daily reviewing of the data that is being produced. Profiles which are likely, somewhat likely, somewhat unlikely and nearly impossible should be identified, whether manually or with the help of a software programmed to recognize different patterns of susceptibility data [1]. Prompt recognition of unusual resistance or inconsistent susceptibility helps the laboratory to timely confirm the susceptibility results. In order to confirm the results, first step is to exclude the transcriptional and reading errors and make sure of the purity of the inoculum which has been tested. If no errors are found in the previous steps, the identification of the organism should be confirmed and the susceptibility test be repeated, preferably with another method. In cases where no errors are detected and the unusual resistance is confirmed, the clinician may be warned and measures can be taken to limit the spread of this unusual resistance.
\n\t\tEducation is an important component of the QA process. Having knowledge about the methods also provides the understanding of their limitations and pitfalls. A well-educated technician may timely recognize atypical results and is aware of the approach to follow for the resolution and avoidance of errors [20]. A very efficient way of training in-service personnel is the end-point interpretation control [24, 25]. Laboratory workers, who perform AST, are provided with a set of selected disk diffusion plates and are asked to read the results. The recorded results are then compared by an experienced reader, e.g., the laboratory director, and the individual performances of each technician is evaluated and if necessary, corrected. It significantly helps to minimize variation in the interpretation of zone sizes among laboratory workers.
\n\t\tIn external quality assessment (EQA) programs, a central laboratory distributes test strains with known susceptibility profiles to all participant laboratories. Each participating laboratory tests and reports the results to the central laboratory. Once all the results are returned from participants, the central laboratory evaluates the results and prepares a feedback report. The benefit of participating in such program is that each individual laboratory can assess ist own performance compared with other laboratories, at national and international levels, it functions as an educational tool, and also provides the evidence of performance required by the accrediting bodies. On the other hand, the number of strains distributed in a year is relatively small, which brings the disadvantage of the rare errors going unnoticed [20]. Also, in contrast to internal QC, which is capable of acting on problems encountered on daily basis, it takes quite a while for the EQA feedback reports to be sent to the participating laboratories, thus corrective action is delayed.
\n\t\tInternal quality assessment (IQA) is a complementary activity to EQA in which routine tests are repeated on the same day as the original, but this time, with the identity of the specimen blinded. After the reports are produced, the results are compared and discrepancies noted. This activity helps to monitor the precision and accuracy of the test procedure and may highlight problem areas not detected by other QC methods. It monitors not only the performance of the test and reagents, but also the performance of the persons carrying out the tests [20]. The EQA and the IQA are complementary activities, while IQA focuses on monitoring a single laboratory on a daily basis, EQA compares the performance of different laboratories and is important for maintaining long-term accuracy of the AST methods employed [21].
\n\t\tThey are a type of EQA in which simulated patient specimens are sent to participating laboratories. Again, the reports are produced by each laboratory, and returned to the central laboratory for evaluation. In the United States, government mandates that clinical laboratories be accredited and licensed. The government and licensing agencies are using proficiency testing as an objective method for the accreditation of laboratories [21]. In 1988, the U.S. Congress passed the Clinical Laboratory Improvement Amendment (CLIA ‘88) which mandated proficiency testing (PT) as a major part of the laboratory accreditation process [31]. The initial CLIA ’88 proposal called for two PT specimens per year but final legislative rule, published in 2003, expanded this to study five samples three times per year. The definition of failure is defined as two of five incorrect results on two of the three consecutive PT surveys [32].
\n\t\tAccording to the work load and the resources a laboratory has, a laboratory can choose to use one of many types of commercial automated antimicrobial susceptibility test systems. Most of these systems use the principle of turbidimetric detection of bacterial growth in a broth medium by use of a photometer which periodically examines the test wells [26]. The most widely used systems in the world are VITEK 2 System (bioMérieux Vitek, Hazelwood, MO), BD Phoenix System (BD Diagnostic Systems, Sparks, MD), MicroScan WalkAway SI (Siemens Healthcare Diagnostics, Sacramento, CA) and TREK Sensititre (ARIS 2X, Trek Diagnostic Systems, Cleveland, OH). Each device has its own QC procedure and commercial susceptibility testing devices are not addressed in CLSI standards. CLSI only describes methods regarding generic reference procedures, however these reference methods are used by the US Food and Drug Administration before clearence is given to a commercial system for marketing in the US to evaluate its performance.
\n\tAlthough great improvement has been done in AST methodology and automated susceptibility systems have been introduced which provide same-day results, it should be considered that there are still many variables not covered by the standard methods. First of all, the laboratory test conditions are far different from
Highlighted by recent world-conflicts, such as the wars in Afghanistan and Iraq, it has become evident that a better and more comprehensive understanding of the relationship between stress-related psychological disorders and traumatic brain injury is much-needed, in both military and civilian populations. For the purposes of this chapter, we will focus on posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI); however, this is not to underplay the crucial need to better understand the wide range of stress-related psychological conditions and brain injury. The prevalence rates of PTSD and mTBI in American military personnel returning from Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) has been reportedly as high as approximately 14 and 20%, respectively [1]. Despite both PTSD and mTBI conditions being “invisible injuries” (injuries not outwardly observable), they are both capable of creating significant disruptions in normal living for individuals. Further, what little we know about the co-occurrence of these conditions suggests that, when combined, they are more difficult to treat and often result in poorer prognoses [2, 3, 4]. This understanding is a significant advancement, as it was once thought that the loss of consciousness or altered mental status that is often observed with brain injury offered protection from the development of stress disorders [5]. Although it is recent military engagements that have highlighted the need for a better understanding of concomitant PTSD and mTBI, these conditions are prevalent in both military and civilian contexts and are therefore issues of broad public health on a global scale.
Approximately 3.5–7.0% of adults within the United States develop PTSD every year. When examining military personnel, this number increases to anywhere between 33 and 65% [6]. On the global scale, approximately 25% of the world’s population has been affected by PTSD, making it the most prevalent psychiatric disorder [7]. Traumatic brain injuries are also very commonplace, and well over one-million people within the U.S. seek care annually for brain injury [8], with the majority of these being classified as mild [9, 10]. Worldwide, up to 50-million people annually seek treatment [6]. However, this number is likely an underestimation as many individuals who suffer an mTBI do not seek medical care. Furthermore, those that do seek medical attention oftentimes are misdiagnosed or underdiagnosed, especially if symptoms are mild or transient and loss of consciousness is limited to a short period of time [11]. When examining PTSD comorbid with mTBI, it becomes clear that many of those that have been affected by trauma have also experienced mTBI. Within civilian populations, PTSD following accidents such as falls or automotive collisions in which an mTBI occurs, range from approximately 20–36% [12]. Within a military context, this number increases to roughly 34–44% [13, 14]. However, like the reporting of each condition in isolation, the potential for misdiagnosis or underdiagnosis is large.
The prevalence and impact of both mTBI and PTSD (whether it be together or in isolation) result in a high cost of treatment, increased suicide rates, and lost work, all of which place a substantial burden on healthcare systems. Although the true costs are difficult to quantify, estimates for the health services cost associated with an mTBI alone range from $10,000USD to $100,000+ per patient depending on severity, length of hospital stay, and costs of rehabilitation [15, 16, 17, 18, 19], with a mean cost of $96,000USD [20]. The numbers are equally startling for the treatment costs associated with PTSD, with annual costs in excess of 200 million USD in US military personnel alone [21], and civilian costs estimated at even greater levels [22, 23, 24]. This estimate does not include the loss of productivity associated with this condition, which easily exceeds billions of dollars at a national level [25]. Although both PTSD and mTBI have substantial costs of care in isolation, when combined, healthcare costs are certainly increased, largely due to the complexity of treating comorbid conditions.
Posttraumatic stress disorder and mild traumatic brain injury have overlapping symptomology yet require different therapeutic approaches. In classical diagnoses, detailed information is collected about the onset and progression of symptoms to arrive at a probable diagnosis, which is then further refined. When dealing with an individual that may meet diagnostic criteria for both conditions, this process becomes much more difficult. In theory, a pattern of symptom overlap and divergence could help differentiate etiologies when dealing with comorbid PTSD and mTBI, however, recent evidence suggests this is not the case. In a 2009 study, eight symptoms that are related to both PTSD and mTBI (fatigue, irritability, concentration problems, memory problems, depression, anxiety, insomnia, and dizziness) were examined and compared between patients who had experienced a recent mTBI or PTSD, revealing substantial overlap between both clinical groups. Although it was found that patients with PTSD had greater overall symptom severity, the degree of overlap prevented differential diagnoses based on the pattern of symptoms reported [26]. A meta-analysis conducted the same year [27] provided some evidence that there are symptoms unique to each when occurring in isolation (PTSD—shame, guilt, re-experiencing symptoms; mTBI—headache, sensitivity to light, dizziness, memory deficits), however, this information does not assist in the diagnosis of those that experience both mTBI and PTSD. Therefore, it remains unclear which aspects of these disorders play significant roles in disease onset following event exposure (whether it be set individual traits, epigenetic changes, alterations to specific brain area structure and function, or a combination of these and other factors), and ultimately which set of symptoms will manifest that are linked to the genuine presence of PTSD, mTBI, or both.
The objective of this chapter is to review our current understanding of comorbid mTBI and PTSD, with an emphasis on reviewing the current state of biomarkers used to diagnose comorbid mTBI and PTSD that offer promise on a single-patient basis. To best accomplish these goals, we will begin with providing definitions of what is meant by the terms PTSD and mTBI. Following, we will review the current understanding of the neurological underpinnings of each condition, with a focus on areas of overlap, and examine currently accepted methods of diagnosis and treatment options. Lastly, we will provide an account of the current researchers utilizing biomarkers for either diagnosis or prognosis of PTSD and mTBI, as well as discuss implications for future research and treatment.
The lack of consistent definitions and assessments of mTBI and PTSD complicates the ability to capture accurate statistics for each condition. We focus on mild traumatic brain injury, as this is both the most common traumatic brain injury in civilian [28] and military populations [29], and is also the most likely to co-occur with PTSD [30]. Additionally, as mTBI is often the hardest to diagnose, the pursuit of biomarkers with clinical utility is of great importance. However, when it comes to describing what constitutes an mTBI, a large amount of ambiguity becomes apparent. What is clear is that for a diagnosis of mTBI, two things need to occur: (1) An external force must be exerted to the head; and (2) there must be a temporary change of mental status and/or other evidence of brain injury. Of course, for a traumatic brain injury to be classified as mild, there also needs to be an upper limit for the severity. This includes: (1) a loss of consciousness that does not exceed 30 minutes; and (2) posttraumatic amnesia that does not exceed 24 hrs. These criteria are largely accepted on a global scale [31, 32, 33] and will be used for this chapter as well.
Formal methods for the diagnosis of PTSD currently exist, making the definitions regarding the psychiatric condition somewhat consistent. In general, PTSD is characterized by four symptom clusters that develop in response to a traumatic event. The traumatic event must involve exposure to actual or perceived death, serious injury, or sexual violation. Furthermore, the event must be directly experienced or witnessed by the individual, or indirectly experienced by subsequently learning about the event after it happened to a close family member or friend. Specific clinical criteria include: (1) intrusive symptoms related to re-experiencing the trauma; (2) avoidance of the traumatic memory or cues; (3) negative mood and thoughts including emotional numbing and anhedonia; and (4) altered arousal including hypervigilance, irritability, aggression, and sleep disturbances [7, 34]. Additionally, symptoms result in significant social, personal, and vocational impairment [7]. PTSD is commonly comorbid with other anxiety or mood disorders, further complicating diagnosis, and is also associated with increased risk for numerous negative behavioral and health conditions, including substance use disorder, type II diabetes, and Alzheimer’s disease [35, 36, 37, 38], significantly expanding the costs of treatment. Although the criteria for diagnosing PTSD are rather straightforward, this does not mean that PTSD is a static phenomenon without gradation. It is known that PTSD symptoms appear on a continuum and can fluctuate in terms of their functional impact and presence across time. Furthermore, although the precipitating traumatic event is a critical component of PTSD, it is how an individual responds to that trauma that is essential in the diagnosis. An identical traumatic event for one individual may result in PTSD, whereas another person experiencing an identical event may not. Therefore, it is as much about the symptoms and functional impairment as it is about the event itself.
Research has shown that both mTBI and PTSD are correlated with both structural and functional changes in the brain, as evidenced by advanced neuroimaging. As can be seen in Figure 1, there are many regions of the brain that are known to be particularly susceptible to both mTBI and PTSD.
Multiple brain regions have been suggested as vulnerable to mTBI (green), including the dorsolateral prefrontal cortex, the temporal pole, cerebellum, and frontal white matter tracts connecting the amygdala and medial prefrontal cortex. PTSD has been correlated with numerous brain regions as well (red) including the amygdala, hippocampus, dorsolateral and dorsomedial prefrontal cortex, and orbitofrontal cortex. Areas in common to both PTSD and mTBI are displayed in yellow.
Within PTSD, structural and functional imaging studies have shown a wide range of brain regions that are affected. These regions include the amygdala, hippocampus, dorsolateral and dorsomedial prefrontal cortex, and the orbitofrontal cortex. As should be apparent, many of these regions have functional implications for the onset and maintenance of PTSD symptomology [39, 40]. When examining brain structure, many studies (including two large meta-analyses) have shown reduced volume in the hippocampus, a brain area that is known to mediate declarative memories [41, 42]. Similarly, reduced volume within the anterior cingulate cortex and insula have also been shown to be related to PTSD onset [43]. When examining the functional neuroimaging data related to PTSD, exposure to stimuli related to an individual’s trauma is associated with increased PTSD symptoms in concert with decreased activity within the medial prefrontal cortex and anterior cingulate [44, 45, 46]. Additional areas of decreased function during exposure to trauma-related stimuli include the inferior frontal gyrus, parietal cortex, visual association cortex, and hippocampus [44, 47, 48]. In contrast, areas of increased activity relative to controls include the amygdala [49, 50], parahippocampal gyrus [44, 51], and posterior cingulate [44, 45, 51]. Taken together, the existing literature provides strong evidence of dysfunction within a network of brain regions that are highly related to PTSD symptoms including the hippocampus and amygdala, cingulate cortex, and medial prefrontal cortex [52].
When examining the neurological correlates of mTBI, brain regions are most often damaged if the shearing forces that the brain undergoes during an mTBI are of sufficient magnitude to deform neural cells beyond normal tolerance levels [53]. If this deformation is of sufficient force to cause axonal tearing, the effects of the mTBI are likely to consist of longer-lasting neurological sequelae resulting from alterations to functional connectivity or difficulty with neuronal processing of information [54]. In comparison, if such forces are of a lesser magnitude, the neurological, cognitive, and behavioral symptoms are more likely to be short lived. In general, these forces particularly affect the longer white-matter tracts of the brain including the hypothalamic-pituitary–adrenal (HPA) axis, frontal, temporal, and limbic areas [55]. Specifically, these include the dorsolateral prefrontal cortex, the temporal pole, cerebellum, and frontal white matter tracts connecting the amygdala and medial prefrontal cortex [39, 40, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67]—all aforementioned areas that are also implicated in PTSD.
Although the role each of these regions play in the formation of cognition is beyond the scope of this chapter, it is apparent that many of these regions are involved in both emotional regulation and executive function, especially those that are affected in both PTSD and mTBI, including the prefrontal cortex and hippocampus [58, 68]. Perhaps not surprisingly, with the large amount of overlap in the neural substrates that are affected by both PTSD and mTBI, there is a fair degree of overlapping symptomology that has a significant impact on optimal methods for both diagnosing and treating PTSD concurrent with mTBI.
As stated previously, due to the overlap of symptoms in both PTSD and mTBI (Table 1), it is more difficult to both diagnose and treat PTSD when comorbid with mTBI. For example, in a recent study of 630,000+ veterans diagnosed with PTSD, only 30% had PTSD alone, with most suffering from concurrent psychiatric conditions, of which mTBI was a prominent co-condition [69].
PTSD | mTBI | PTSD/mTBI | |
---|---|---|---|
Behavioral symptoms | Aggression Agitation Avoidance of cues Hostility Hypervigilance Irritability Self-Destructive Behavior | Aggression Impulsivity Irritability | Aggression Impulsivity/Self Destructive Behaviors Irritability |
Physical/cognitive symptoms | Inability to concentrate or focus on tasks Insomnia Nightmares Sensitivity to sound | Coordination problems/loss of balance Amnesia Disorientation Dizziness Fatigue Headache Inability to concentrate or focus on tasks Insomnia Sensitivity to sound | Inability to concentrate or focus on tasks Insomnia Sensitivity to sound |
Psychological Symptoms | Anhedonia/loss of interest Anxiety Depression Intrusive thoughts/Unwanted thoughts Reexperiencing the event/Flashbacks Shame/Guilt Social Isolation/Loneliness | Anxiety Apathy Depression | Anhedonia/Apathy Anxiety Depression |
Symptomologies of PTSD and mTBI.
Diagnosis of PTSD usually consists of a combination of self-report measures and structured and/or semi-structured interview procedures. These procedures are often based on soliciting the information required to determine whether DSM-5 criteria [34] (or alternatives such as the ICD-10 [70]) have been met and include components of the trauma, symptoms/symptom clusters, and subtypes of the disorder. Common structured interviews, such as the Clinician-Administered PTSD Scale (CAPS), are considered both reliable and valid, however, they are time intensive [71]. Furthermore, due to upwards of 93% of PTSD cases co-reporting another psychiatric disorder, it can become difficult to differentiate between disorders with overlapping symptoms [6].
Unlike the diagnosis of TBI, where CT and MRI structural images readily demonstrate contusions or bleeds verifying their presence, there is a lack of interdisciplinary consensus as to what constitutes an mTBI. Although some criteria have been generally accepted (such as those described within the introduction of this chapter), there are diagnostic criteria available from the American Congress of Rehabilitation Medicine (ACRM), the US Centers for Disease Control and Prevention (CDC), and the World Health Organization (WHO) [72]. Therefore, the utility of a consistent and universally accepted measure of mTBI presence would be of great benefit when diagnosing a mTBI in isolation, and especially when attempting to diagnose in the presence of the overlapping symptoms commonly reported in PTSD.
As should be apparent from this cursory examination, the current process of diagnosing both PTSD and mTBI is largely reliant on often erroneous self-report techniques and arduous clinical interviews that have an inherent lack of consensus, necessitating improvements in both speed of diagnosis and consistency to best offer care and interventions to patients with PTSD and mTBI. One such avenue of providing this information may be found through the discovery of diagnostic biomarkers, which will be the primary focus of discussion for the remainder of this chapter. Before such a discussion takes place, it is important to further highlight the need for improved methods of diagnosing comorbid mTBI and PTSD by examining the implications such discoveries may have on treatment of each condition.
Although there are recognized “gold-standard” treatments for PTSD, there is still much room for improvement. For PTSD, Cognitive Behavioral Therapy (CBT) [73] and psychopharmacological treatment with selective serotonin reuptake inhibitors (SSRIs) and/or serotonin noradrenaline reuptake inhibitors (SNRIs) are often used for treatment. Similarly, both psychological and pharmacological treatments are recommended for the treatment of mTBI, such as CBT [74] in conjunction with pharmacological treatment of the sequalae associated with mTBI [75]. However, in a recent study of the evaluations of 41 guidelines related to the treatment of mTBI, only three were founded in what was determined to be an evidenced-based fashion [76], highlighting the need for more rigorous and evidence-based treatment regimens. There is even less evidence-based guidance when it comes to the treatment of comorbid mTBI and PTSD, making research on how to best identify multimorbidity in PTSD patients critical to developing effective treatment strategies.
As should be evident from the previous sections from this chapter, both the ability to diagnose PTSD comorbid with mTBI and the ability to effectively monitor treatment of the concurrent conditions would benefit from the identification of biomarkers. For this discussion we adapt the definition of a biomarker using a conceptual framework that is useful for clinical research and treatment purposes. This may include any information that can be used as an objective indication of a relevant medical state observed from outside the patient. Importantly, these signs must be able to be measured accurately and have high levels of replicability. This is captured in the WHO’s definition of a biomarker as “any substance, structure, or process that can be measured in the body or its products and influence or predict the incidence of outcome or disease” [77] and can be expanded to “… almost any measurement reflecting an interaction between a biological system and a potential hazard…[and] may be functional and physiological, biochemical at the cellular level, or a molecular interaction.” [78]. In alignment with these requirements, our discussion will focus on the relevance and validity of the suggested biomarkers, allowing for it to be used as a surrogate endpoint [79]. There are a wide range of biomarkers and targets currently being researched for roles in both mTBI and PTSD. A summary of biomarkers currently undergoing research that meet the criteria previously discussed can be seen in Table 2, with in-depth discussion of each following.
HPA axis dysregulation | Cortisol | Adrenal glucocorticoid hormone that modulates the HPA axis | PTSD |
Monoamine Dysfunction | Norepinephrine (NE) | Endogenous neurotransmitter and stress hormone | PTSD |
Serotonin (5-HT) | Monoamine neurotransmitter | PTSD | |
Inflammatory and immune function | Interleukin-1ß (IL-1ß) Interleukin-2 (IL-2) Interleukin-6 (IL-6) Interleukin-8 (IL-8) Interleukin-10 (IL-10) | Cytokine protein involved in inflammation Cytokine protein involved in immune function regulation Cytokine protein with pro- and antiinflammatory actions Cytokine protein involved in inflammation Cytokine protein with anti-inflammatory actions | PTSD PTSD PTSD and mTBI mTBI mTBI |
C-reactive protein (CRP) | Circulating protein released in response to inflammation | PTSD | |
Tumor Necrosis Factor alpha subunit (TNF-α) | Cytokine protein with pro-inflammatory actions | PTSD | |
Interferon gamma (IFN-γ) | Cytokine protein involved in immune function regulation | PTSD | |
Marinobufagenin (MBG) | Endogenous steroid related to myocardial infarction, heart failure, and kidney failure | mTBI | |
Genetic variation | FKBP Prolyl Isomerase 5 (FKBP5) Serotonin transporter gene linked polymorphic region (5-HTTLPR) | Protein coding gene regulating neuroendocrine stress Gene promotor region on the serotonin transporter gene linked to neuropsychiatric disorders | PTSD PTSD |
Nuclear receptor subfamily 3 group C, member 1 (NR3C-1) | Promotor region of the glucocorticoid receptor gene related to metabolism and immune response | PTSD | |
Apolipoprotein E (APOE) | Protein coding gene that regulates fat metabolism | mTBI | |
brain-derived neurotrophic factor (BDNF) | Protein coding gene that promotes neuronal survival | PTSD and mTBI | |
Functional and structural neuroimaging | Amygdala Medial Prefrontal Cortex Rostral Anterior Cingulate Cortex Hippocampus | Involved in emotional processing, and conditioned fear Involved in inhibition and goal-directed behaviors Cortical structure involved in mediating emotion and cognitive function Involved in memory and cognition | PTSD PTSD PTSD PTSD |
Diffusion weighted imaging (DWI) | Noninvasive technique using a specific form of Magnetic Resonance Imaging (MRI) to view water diffusion in images | mTBI | |
Magnetic resonance spectroscopy (MRS) | Noninvasive technique to analyze metabolic changes in tissue | mTBI | |
Neuronal and axonal injury | Tau Protein Ubiquitin C-terminal hydrolase isozyme L1 (UCHL1) Neuron-specific enolase (NSE) | Protein expressed primarily in neurons, involved in stabilizing microtubules Enzyme involved in axonal transport and integrity Enzyme involved in glycolytic metabolism in the brain | mTBI mTBI mTBI |
Neutrophil gelatinaseassociated lipocalin (NGAL) | Polypeptide released in response to systemic inflammation | mTBI | |
Blood Brain Barrier Disturbances | CSF/serum albumin ratio Astrocyte-specific SNS protein S100B | Measure of cerebrospinal fluid components in the periphery following injury Binding protein produced by astrocytes involved in intracellular functions | mTBI mTBI |
PrPc-cellular prion protein | Glycoprotein typically anchored to plasma membranes, proposed to be involved in neurodegenerative prion disease | mTBI | |
Cerebral Blood Flow Changes | Vasoreactivity | MRI measurable changes that could impair smooth muscle and affect cognition | mTBI |
Summary of current biomarker research.
Most of the promising biomarkers for the presence of PTSD are related to either dysfunction of the HPA axis, monoamine systems, heightened inflammation, genetic and epigenetic changes thought to be a result of methylation brought about through exposure to prolonged stress, or functional and structural neuroimaging. There has also been growing interest and research in the examination of psychophysical biomarkers of PTSD, such as indicators of hyperarousal (heart rate, blood pressure, skin conductance, etc.). However, examination of these forms of hyperactivity through psychological testing is beyond the scope of this chapter.
As has become apparent, many (if not all) of these genetic regions have been associated with other psychiatric conditions and may therefore be a better marker of stress-induced psychopathology in general rather than PTSD specifically, and there has yet to be a single genetic or epigenetic factor that reliably predicts the presence or severity of PTSD in isolation of other psychiatric conditions.
In addition to functional studies, a number of structural examinations of PTSD have taken place using neuroimaging techniques. Early studies examining structural differences between PTSD and non-PTSD patients demonstrated that smaller hippocampal volume may be associated with an increased risk of developing PTSD [112], though this finding has more recently been questioned with hippocampal volume reductions being acquired with trauma exposure [113]. When examining specific regions of the hippocampus using structural MRI, it appears as though reductions in specific subregions can be associated with PTSD symptoms. Specifically, reductions within the cornu ammonis 3 (CA3) layer of the hippocampus and the dentate gyrus are related to PTSD symptomology [114].
Currently, mTBI is typically diagnosed based solely on clinical presentation, in comparison to TBI which has prominent and objective neuroimaging findings. This has several implications as to the utility of biomarkers of mTBI. Perhaps of primary concern is the fact that any biomarker that would offer clinical benefits must be correlated with clinical symptom presentation. For example, a marker that elevates with impacts to the head without observable changes in clinical presentation in the patient would be of little clinical use. Potential biomarkers for mTBI are most often related to, or spawned, by the axonal injury that occurs following the much smaller forces related to a mTBI. These can be broadly categorized as those that are related to neuronal and axonal injury, blood brain barrier disturbances, neuroinflammation, cerebral blood flow changes, and genetic variation.
A further drawback to most biofluid based biomarkers of mTBI is the timescale at which they can be detected, necessitating their examination within the acute stage of the injury as they return to baseline levels rather quickly (though PrPc is an exception to this). As an alternative, potentially longer-lasting biomarker, advanced neuroimaging techniques such as diffusion weighted imagery (DWI) and magnetic resonance spectroscopy (MRS) for diagnosing the presence of an mTBI at a timescale that extends beyond the acute stage. Genetic information may offer additional information not available through the other methods discussed, such as the susceptibility to mTBI following head trauma, reflected in the likelihood of developing symptoms based on genetic variation.
Differential features of biomarkers specific to PTSD
HPA Axis Dysregulation (cortisol)
Monoamine Dysfunction (norepinephrine and serotonin)
Inflammatory and Immune Function (interleukins 2 and 1ß, C-reactive protein)
Genetic Variation (polymorphisms and methylation on genes FKBP5, 5-HTTLPR, and NR3C1)
Functional and Structural Neuroimaging (differential activation in amygdala, prefrontal cortex, hippocampus and rostral anterior cingulate cortex)
Differential features of biomarkers specific to mTBI
Neuronal and Axonal Injury (Tau protein, ubiquitin carboxyl-terminal hydrolase, neuron-specific enolase, neutrophil gelatinase-associated lipocalin)
Blood Brain Barrier Disturbances (CSF/serum albumin ratio, S100B, PrPC levels)
Neuroinflammation (interleukins 8 and 10, marinobufagenin)
Cerebral Blood Flow Changes (magnetic resonance imaging techniques to detect hypoperfusion)
In summary, posttraumatic stress disorder and mTBI are both significant problems that lead to reduced quality of life for a wide range of people. Due to the nature of symptoms, diagnosis and treatment is inefficient and often delayed, resulting in additional complications in patient outcomes. Determining consistent and accurate biomarkers to improve diagnostic measures of both PTSD and mTBI as well as to differentiate between the two would improve outcomes for both disorders. In the near future, the combination of a selection of the individual biomarkers discussed could be used to design a comprehensive screening tool for individuals following a traumatic event. Additionally, identification of biomarkers involved in the transition post-injury to long-term post-concussive symptoms could allow for early intervention and prevent development of PTSD following trauma. Further, the monitoring and classification of individual responses to screening arrays could dictate the best treatment options, and inform recommendations of medication, therapies, neuromodulation techniques and various combinations from those currently available. Ultimately, this could allow patients and physicians to better direct treatment and response measures based on the individual’s biological makeup.
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In this context, this chapter presents key subjects while implementing a quality management system at materials science laboratories and some considerations on strategies for effectively implementing such systems.",book:{id:"5486",slug:"quality-control-and-assurance-an-ancient-greek-term-re-mastered",title:"Quality Control and Assurance",fullTitle:"Quality Control and Assurance - An Ancient Greek Term Re-Mastered"},signatures:"Rodrigo S. Neves, Daniel P. Da Silva, Carlos E. C. Galhardo, Erlon H.\nM. Ferreira, Rafael M. Trommer and Jailton C. Damasceno",authors:[{id:"20571",title:"Prof.",name:"Erlon H.",middleName:null,surname:"Martins Ferreira",slug:"erlon-h.-martins-ferreira",fullName:"Erlon H. 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The quality practices or quality management systems adopted by industries will further evolve due to the changes of quality concepts as time goes by. This chapter discusses the change of quality concepts and the related revolution of quality management systems in the past century. The quality concepts were gradually changed from the achievement of quality standards, satisfaction of customer needs, and expectations to customer delight. Since merely satisfying customers is not enough to ensure customer loyalty, the enterprises gradually focus on customers’ emotional responses and their delight in order to pursue their loyalty. The emotion of “delight” is composed of “joy” and “surprise,” which can be achieved as the customers’ latent requirements are satisfied. Thus, the concept of “customer delight” and the means to provide the innovative quality so as to meet the unsatisfied customers’ latent needs are elaborated on. Finally, a framework of innovation creation is developed that is based on the mining of customer's latent requirements. This outline will manifest the essential elements of the related operation steps.",book:{id:"5486",slug:"quality-control-and-assurance-an-ancient-greek-term-re-mastered",title:"Quality Control and Assurance",fullTitle:"Quality Control and Assurance - An Ancient Greek Term Re-Mastered"},signatures:"Ching-Chow Yang",authors:[{id:"11862",title:"Prof.",name:"Ching-Chow",middleName:null,surname:"Yang",slug:"ching-chow-yang",fullName:"Ching-Chow Yang"}]},{id:"62915",title:"Advanced Methods of PID Controller Tuning for Specified Performance",slug:"advanced-methods-of-pid-controller-tuning-for-specified-performance",totalDownloads:3468,totalCrossrefCites:10,totalDimensionsCites:16,abstract:"This chapter provides a concise survey, classification and historical perspective of practice-oriented methods for designing proportional-integral-derivative (PID) controllers and autotuners showing the persistent demand for PID tuning algorithms that integrate performance requirements into the tuning algorithm. The proposed frequency-domain PID controller design method guarantees closed-loop performance in terms of commonly used time-domain specifications. One of its major benefits is universal applicability for both slow and fast-controlled plants with unknown mathematical model. Special charts called B-parabolas were developed as a practical design tool that enables consistent and systematic shaping of the closed-loop step response with regard to specified performance and dynamics of the uncertain controlled plant.",book:{id:"6323",slug:"pid-control-for-industrial-processes",title:"PID Control for Industrial Processes",fullTitle:"PID Control for Industrial Processes"},signatures:"Štefan Bucz and Alena Kozáková",authors:[{id:"21933",title:"Ms.",name:"Alena",middleName:null,surname:"Kozakova",slug:"alena-kozakova",fullName:"Alena Kozakova"},{id:"213658",title:"Dr.",name:"Štefan",middleName:null,surname:"Bucz",slug:"stefan-bucz",fullName:"Štefan Bucz"}]},{id:"75699",title:"Data Clustering for Fuzzyfier Value Derivation",slug:"data-clustering-for-fuzzyfier-value-derivation",totalDownloads:291,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"The fuzzifier value m is improving significant factor for achieving the accuracy of data. Therefore, in this chapter, various clustering method is introduced with the definition of important values for clustering. To adaptively calculate the appropriate purge value of the gap type −2 fuzzy c-means, two fuzzy values m1 and m2 are provided by extracting information from individual data points using a histogram scheme. Most of the clustering in this chapter automatically obtains determination of m1 and m2 values that depended on existent repeated experiments. Also, in order to increase efficiency on deriving valid fuzzifier value, we introduce the Interval type-2 possibilistic fuzzy C-means (IT2PFCM), as one of advanced fuzzy clustering method to classify a fixed pattern. In Efficient IT2PFCM method, proper fuzzifier values for each data is obtained from an algorithm including histogram analysis and Gaussian Curve Fitting method. Using the extracted information form fuzzifier values, two modified fuzzifier value m1 and m2 are determined. These updated fuzzifier values are used to calculated the new membership values. Determining these updated values improve not only the clustering accuracy rate of the measured sensor data, but also can be used without additional procedure such as data labeling. 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Buchholz",profilePictureURL:"https://mts.intechopen.com/storage/users/89438/images/6463_n.jpg",institutionString:null,institution:{name:"Loma Linda University",institutionURL:null,country:{name:"United States of America"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null}]},subseriesFiltersForPublishedBooks:[{group:"subseries",caption:"Plant Physiology",value:13,count:1},{group:"subseries",caption:"Human Physiology",value:12,count:2},{group:"subseries",caption:"Cell Physiology",value:11,count:8}],publicationYearFilters:[{group:"publicationYear",caption:"2022",value:2022,count:1},{group:"publicationYear",caption:"2020",value:2020,count:4},{group:"publicationYear",caption:"2019",value:2019,count:5},{group:"publicationYear",caption:"2018",value:2018,count:1}],authors:{paginationCount:303,paginationItems:[{id:"313921",title:"Dr.",name:"Hassan M.",middleName:null,surname:"Heshmati",slug:"hassan-m.-heshmati",fullName:"Hassan M. Heshmati",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/313921/images/system/313921.jpg",biography:"Dr. Hassan Massoud Heshmati is an endocrinologist with 46 years of experience in clinical research in academia (university-affiliated hospitals, Paris, France; Mayo Foundation, Rochester, MN, USA) and pharmaceutical companies (Sanofi, Malvern, PA, USA; Essentialis, Carlsbad, CA, USA; Gelesis, Boston, MA, USA). His research activity focuses on pituitary tumors, hyperthyroidism, thyroid cancers, osteoporosis, diabetes, and obesity. He has extensive knowledge in the development of anti-obesity products. Dr. Heshmati is the author of 299 abstracts, chapters, and articles related to endocrinology and metabolism. He is currently a consultant at Endocrinology Metabolism Consulting, LLC, Anthem, AZ, USA.",institutionString:"Endocrinology Metabolism Consulting, LLC",institution:null},{id:"198499",title:"Dr.",name:"Daniel",middleName:null,surname:"Glossman-Mitnik",slug:"daniel-glossman-mitnik",fullName:"Daniel Glossman-Mitnik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/198499/images/system/198499.jpeg",biography:"Dr. Daniel Glossman-Mitnik is currently a Titular Researcher at the Centro de Investigación en Materiales Avanzados (CIMAV), Chihuahua, Mexico, as well as a National Researcher of Level III at the Consejo Nacional de Ciencia y Tecnología, Mexico. His research interest focuses on computational chemistry and molecular modeling of diverse systems of pharmacological, food, and alternative energy interests by resorting to DFT and Conceptual DFT. He has authored a coauthored more than 255 peer-reviewed papers, 32 book chapters, and 2 edited books. He has delivered speeches at many international and domestic conferences. He serves as a reviewer for more than eighty international journals, books, and research proposals as well as an editor for special issues of renowned scientific journals.",institutionString:"Centro de Investigación en Materiales Avanzados",institution:{name:"Centro de Investigación en Materiales Avanzados",country:{name:"Mexico"}}},{id:"76477",title:"Prof.",name:"Mirza",middleName:null,surname:"Hasanuzzaman",slug:"mirza-hasanuzzaman",fullName:"Mirza Hasanuzzaman",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/76477/images/system/76477.png",biography:"Dr. Mirza Hasanuzzaman is a Professor of Agronomy at Sher-e-Bangla Agricultural University, Bangladesh. He received his Ph.D. in Plant Stress Physiology and Antioxidant Metabolism from Ehime University, Japan, with a scholarship from the Japanese Government (MEXT). Later, he completed his postdoctoral research at the Center of Molecular Biosciences, University of the Ryukyus, Japan, as a recipient of the Japan Society for the Promotion of Science (JSPS) postdoctoral fellowship. He was also the recipient of the Australian Government Endeavour Research Fellowship for postdoctoral research as an adjunct senior researcher at the University of Tasmania, Australia. Dr. Hasanuzzaman’s current work is focused on the physiological and molecular mechanisms of environmental stress tolerance. Dr. Hasanuzzaman has published more than 150 articles in peer-reviewed journals. He has edited ten books and written more than forty book chapters on important aspects of plant physiology, plant stress tolerance, and crop production. According to Scopus, Dr. Hasanuzzaman’s publications have received more than 10,500 citations with an h-index of 53. He has been named a Highly Cited Researcher by Clarivate. He is an editor and reviewer for more than fifty peer-reviewed international journals and was a recipient of the “Publons Peer Review Award” in 2017, 2018, and 2019. He has been honored by different authorities for his outstanding performance in various fields like research and education, and he has received the World Academy of Science Young Scientist Award (2014) and the University Grants Commission (UGC) Award 2018. He is a fellow of the Bangladesh Academy of Sciences (BAS) and the Royal Society of Biology.",institutionString:"Sher-e-Bangla Agricultural University",institution:{name:"Sher-e-Bangla Agricultural University",country:{name:"Bangladesh"}}},{id:"187859",title:"Prof.",name:"Kusal",middleName:"K.",surname:"Das",slug:"kusal-das",fullName:"Kusal Das",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSBDeQAO/Profile_Picture_1623411145568",biography:"Kusal K. Das is a Distinguished Chair Professor of Physiology, Shri B. M. Patil Medical College and Director, Centre for Advanced Medical Research (CAMR), BLDE (Deemed to be University), Vijayapur, Karnataka, India. Dr. Das did his M.S. and Ph.D. in Human Physiology from the University of Calcutta, Kolkata. His area of research is focused on understanding of molecular mechanisms of heavy metal activated low oxygen sensing pathways in vascular pathophysiology. He has invented a new method of estimation of serum vitamin E. His expertise in critical experimental protocols on vascular functions in experimental animals was well documented by his quality of publications. He was a Visiting Professor of Medicine at University of Leeds, United Kingdom (2014-2016) and Tulane University, New Orleans, USA (2017). For his immense contribution in medical research Ministry of Science and Technology, Government of India conferred him 'G.P. Chatterjee Memorial Research Prize-2019” and he is also the recipient of 'Dr.Raja Ramanna State Scientist Award 2015” by Government of Karnataka. He is a Fellow of the Royal Society of Biology (FRSB), London and Honorary Fellow of Karnataka Science and Technology Academy, Department of Science and Technology, Government of Karnataka.",institutionString:"BLDE (Deemed to be University), India",institution:null},{id:"243660",title:"Dr.",name:"Mallanagouda Shivanagouda",middleName:null,surname:"Biradar",slug:"mallanagouda-shivanagouda-biradar",fullName:"Mallanagouda Shivanagouda Biradar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/243660/images/system/243660.jpeg",biography:"M. S. Biradar is Vice Chancellor and Professor of Medicine of\nBLDE (Deemed to be University), Vijayapura, Karnataka, India.\nHe obtained his MD with a gold medal in General Medicine and\nhas devoted himself to medical teaching, research, and administrations. He has also immensely contributed to medical research\non vascular medicine, which is reflected by his numerous publications including books and book chapters. Professor Biradar was\nalso Visiting Professor at Tulane University School of Medicine, New Orleans, USA.",institutionString:"BLDE (Deemed to be University)",institution:{name:"BLDE University",country:{name:"India"}}},{id:"289796",title:"Dr.",name:"Swastika",middleName:null,surname:"Das",slug:"swastika-das",fullName:"Swastika Das",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/289796/images/system/289796.jpeg",biography:"Swastika N. Das is Professor of Chemistry at the V. P. Dr. P. G.\nHalakatti College of Engineering and Technology, BLDE (Deemed\nto be University), Vijayapura, Karnataka, India. She obtained an\nMSc, MPhil, and PhD in Chemistry from Sambalpur University,\nOdisha, India. Her areas of research interest are medicinal chemistry, chemical kinetics, and free radical chemistry. She is a member\nof the investigators who invented a new modified method of estimation of serum vitamin E. She has authored numerous publications including book\nchapters and is a mentor of doctoral curriculum at her university.",institutionString:"BLDEA’s V.P.Dr.P.G.Halakatti College of Engineering & Technology",institution:{name:"BLDE University",country:{name:"India"}}},{id:"248459",title:"Dr.",name:"Akikazu",middleName:null,surname:"Takada",slug:"akikazu-takada",fullName:"Akikazu Takada",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/248459/images/system/248459.png",biography:"Akikazu Takada was born in Japan, 1935. After graduation from\nKeio University School of Medicine and finishing his post-graduate studies, he worked at Roswell Park Memorial Institute NY,\nUSA. He then took a professorship at Hamamatsu University\nSchool of Medicine. In thrombosis studies, he found the SK\npotentiator that enhances plasminogen activation by streptokinase. He is very much interested in simultaneous measurements\nof fatty acids, amino acids, and tryptophan degradation products. By using fatty\nacid analyses, he indicated that plasma levels of trans-fatty acids of old men were\nfar higher in the US than Japanese men. . He also showed that eicosapentaenoic acid\n(EPA) and docosahexaenoic acid (DHA) levels are higher, and arachidonic acid\nlevels are lower in Japanese than US people. By using simultaneous LC/MS analyses\nof plasma levels of tryptophan metabolites, he recently found that plasma levels of\nserotonin, kynurenine, or 5-HIAA were higher in patients of mono- and bipolar\ndepression, which are significantly different from observations reported before. In\nview of recent reports that plasma tryptophan metabolites are mainly produced by\nmicrobiota. He is now working on the relationships between microbiota and depression or autism.",institutionString:"Hamamatsu University School of Medicine",institution:{name:"Hamamatsu University School of Medicine",country:{name:"Japan"}}},{id:"137240",title:"Prof.",name:"Mohammed",middleName:null,surname:"Khalid",slug:"mohammed-khalid",fullName:"Mohammed Khalid",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/137240/images/system/137240.png",biography:"Mohammed Khalid received his B.S. in Chemistry in July 2000, and his Ph.D. in Physical Chemistry in 2007 from the University of Khartoum, Sudan. In 2009 he joined the Dr. Ron Clarke research group at the School of Chemistry, Faculty of Science, University of Sydney, Australia as a postdoctoral fellow where he worked on the Interaction of ATP with the phosphoenzyme of the Na+, K+-ATPase, and Dual mechanisms of allosteric acceleration of the Na+, K+-ATPase by ATP. He then worked as Assistant Professor at the Department of Chemistry, University of Khartoum, and in 2014 was promoted to Associate Professor ranking. In 2011 he joined the staff of the Chemistry Department at Taif University, Saudi Arabia, where he is currently active as an Assistant Professor. His research interests include:\r\n(1) P-type ATPase Enzyme Kinetics and Mechanisms; (2) Kinetics and Mechanism of Redox Reactions; (3) Autocatalytic reactions; (4) Computational enzyme kinetics; (5) Allosteric acceleration of P-type ATPases by ATP; (6) Exploring of allosteric sites of ATPases and interaction of ATP with ATPases located in the cell membranes.",institutionString:"Taif University",institution:{name:"Taif University",country:{name:"Saudi Arabia"}}},{id:"63810",title:"Prof.",name:"Jorge",middleName:null,surname:"Morales-Montor",slug:"jorge-morales-montor",fullName:"Jorge Morales-Montor",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/63810/images/system/63810.png",biography:"Dr. Jorge Morales-Montor was recognized with the Lola and Igo Flisser PUIS Award for best graduate thesis at the national level in the field of parasitology. He received a fellowship from the Fogarty Foundation to perform postdoctoral research stay at the University of Georgia. He has 153 journal articles to his credit. He has also edited several books and published more than fifty-five book chapters. He is a member of the Mexican Academy of Sciences, Latin American Academy of Sciences, and the National Academy of Medicine. He has received more than thirty-five awards and has supervised numerous bachelor’s, master’s, and Ph.D. students. Dr. Morales-Montor is the past president of the Mexican Society of Parasitology.",institutionString:"National Autonomous University of Mexico",institution:{name:"National Autonomous University of Mexico",country:{name:"Mexico"}}},{id:"217215",title:"Dr.",name:"Palash",middleName:null,surname:"Mandal",slug:"palash-mandal",fullName:"Palash Mandal",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/217215/images/system/217215.jpeg",biography:null,institutionString:"Charusat University",institution:null},{id:"49739",title:"Dr.",name:"Leszek",middleName:null,surname:"Szablewski",slug:"leszek-szablewski",fullName:"Leszek Szablewski",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49739/images/system/49739.jpg",biography:"Leszek Szablewski is a professor of medical sciences. He received his M.S. in the Faculty of Biology from the University of Warsaw and his PhD degree from the Institute of Experimental Biology Polish Academy of Sciences. He habilitated in the Medical University of Warsaw, and he obtained his degree of Professor from the President of Poland. Professor Szablewski is the Head of Chair and Department of General Biology and Parasitology, Medical University of Warsaw. Professor Szablewski has published over 80 peer-reviewed papers in journals such as Journal of Alzheimer’s Disease, Biochim. Biophys. Acta Reviews of Cancer, Biol. Chem., J. Biomed. Sci., and Diabetes/Metabol. Res. Rev, Endocrine. He is the author of two books and four book chapters. He has edited four books, written 15 scripts for students, is the ad hoc reviewer of over 30 peer-reviewed journals, and editorial member of peer-reviewed journals. Prof. Szablewski’s research focuses on cell physiology, genetics, and pathophysiology. He works on the damage caused by lack of glucose homeostasis and changes in the expression and/or function of glucose transporters due to various diseases. He has given lectures, seminars, and exercises for students at the Medical University.",institutionString:"Medical University of Warsaw",institution:{name:"Medical University of Warsaw",country:{name:"Poland"}}},{id:"173123",title:"Dr.",name:"Maitham",middleName:null,surname:"Khajah",slug:"maitham-khajah",fullName:"Maitham Khajah",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/173123/images/system/173123.jpeg",biography:"Dr. Maitham A. Khajah received his degree in Pharmacy from Faculty of Pharmacy, Kuwait University, in 2003 and obtained his PhD degree in December 2009 from the University of Calgary, Canada (Gastrointestinal Science and Immunology). Since January 2010 he has been assistant professor in Kuwait University, Faculty of Pharmacy, Department of Pharmacology and Therapeutics. His research interest are molecular targets for the treatment of inflammatory bowel disease (IBD) and the mechanisms responsible for immune cell chemotaxis. He cosupervised many students for the MSc Molecular Biology Program, College of Graduate Studies, Kuwait University. Ever since joining Kuwait University in 2010, he got various grants as PI and Co-I. He was awarded the Best Young Researcher Award by Kuwait University, Research Sector, for the Year 2013–2014. He was a member in the organizing committee for three conferences organized by Kuwait University, Faculty of Pharmacy, as cochair and a member in the scientific committee (the 3rd, 4th, and 5th Kuwait International Pharmacy Conference).",institutionString:"Kuwait University",institution:{name:"Kuwait University",country:{name:"Kuwait"}}},{id:"195136",title:"Dr.",name:"Aya",middleName:null,surname:"Adel",slug:"aya-adel",fullName:"Aya Adel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/195136/images/system/195136.jpg",biography:"Dr. Adel works as an Assistant Lecturer in the unit of Phoniatrics, Department of Otolaryngology, Ain Shams University in Cairo, Egypt. Dr. Adel is especially interested in joint attention and its impairment in autism spectrum disorder",institutionString:"Ain Shams University",institution:{name:"Ain Shams University",country:{name:"Egypt"}}},{id:"94911",title:"Dr.",name:"Boulenouar",middleName:null,surname:"Mesraoua",slug:"boulenouar-mesraoua",fullName:"Boulenouar Mesraoua",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94911/images/system/94911.png",biography:"Dr Boulenouar Mesraoua is the Associate Professor of Clinical Neurology at Weill Cornell Medical College-Qatar and a Consultant Neurologist at Hamad Medical Corporation at the Neuroscience Department; He graduated as a Medical Doctor from the University of Oran, Algeria; he then moved to Belgium, the City of Liege, for a Residency in Internal Medicine and Neurology at Liege University; after getting the Belgian Board of Neurology (with high marks), he went to the National Hospital for Nervous Diseases, Queen Square, London, United Kingdom for a fellowship in Clinical Neurophysiology, under Pr Willison ; Dr Mesraoua had also further training in Epilepsy and Continuous EEG Monitoring for two years (from 2001-2003) in the Neurophysiology department of Zurich University, Switzerland, under late Pr Hans Gregor Wieser ,an internationally known epileptologist expert. \n\nDr B. Mesraoua is the Director of the Neurology Fellowship Program at the Neurology Section and an active member of the newly created Comprehensive Epilepsy Program at Hamad General Hospital, Doha, Qatar; he is also Assistant Director of the Residency Program at the Qatar Medical School. \nDr B. Mesraoua's main interests are Epilepsy, Multiple Sclerosis, and Clinical Neurology; He is the Chairman and the Organizer of the well known Qatar Epilepsy Symposium, he is running yearly for the past 14 years and which is considered a landmark in the Gulf region; He has also started last year , together with other epileptologists from Qatar, the region and elsewhere, a yearly International Epilepsy School Course, which was attended by many neurologists from the Area.\n\nInternationally, Dr Mesraoua is an active and elected member of the Commission on Eastern Mediterranean Region (EMR ) , a regional branch of the International League Against Epilepsy (ILAE), where he represents the Middle East and North Africa(MENA ) and where he holds the position of chief of the Epilepsy Epidemiology Section; Dr Mesraoua is a member of the American Academy of Neurology, the Europeen Academy of Neurology and the American Epilepsy Society.\n\nDr Mesraoua's main objectives are to encourage frequent gathering of the epileptologists/neurologists from the MENA region and the rest of the world, promote Epilepsy Teaching in the MENA Region, and encourage multicenter studies involving neurologists and epileptologists in the MENA region, particularly epilepsy epidemiological studies. \n\nDr. Mesraoua is the recipient of two research Grants, as the Lead Principal Investigator (750.000 USD and 250.000 USD) from the Qatar National Research Fund (QNRF) and the Hamad Hospital Internal Research Grant (IRGC), on the following topics : “Continuous EEG Monitoring in the ICU “ and on “Alpha-lactoalbumin , proof of concept in the treatment of epilepsy” .Dr Mesraoua is a reviewer for the journal \"seizures\" (Europeen Epilepsy Journal ) as well as dove journals ; Dr Mesraoua is the author and co-author of many peer reviewed publications and four book chapters in the field of Epilepsy and Clinical Neurology",institutionString:"Weill Cornell Medical College in Qatar",institution:{name:"Weill Cornell Medical College in Qatar",country:{name:"Qatar"}}},{id:"282429",title:"Prof.",name:"Covanis",middleName:null,surname:"Athanasios",slug:"covanis-athanasios",fullName:"Covanis Athanasios",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/282429/images/system/282429.jpg",biography:null,institutionString:"Neurology-Neurophysiology Department of the Children Hospital Agia Sophia",institution:null},{id:"190980",title:"Prof.",name:"Marwa",middleName:null,surname:"Mahmoud Saleh",slug:"marwa-mahmoud-saleh",fullName:"Marwa Mahmoud Saleh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/190980/images/system/190980.jpg",biography:"Professor Marwa Mahmoud Saleh is a doctor of medicine and currently works in the unit of Phoniatrics, Department of Otolaryngology, Ain Shams University in Cairo, Egypt. She got her doctoral degree in 1991 and her doctoral thesis was accomplished in the University of Iowa, United States. Her publications covered a multitude of topics as videokymography, cochlear implants, stuttering, and dysphagia. She has lectured Egyptian phonology for many years. Her recent research interest is joint attention in autism.",institutionString:"Ain Shams University",institution:{name:"Ain Shams University",country:{name:"Egypt"}}},{id:"259190",title:"Dr.",name:"Syed Ali Raza",middleName:null,surname:"Naqvi",slug:"syed-ali-raza-naqvi",fullName:"Syed Ali Raza Naqvi",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259190/images/system/259190.png",biography:"Dr. Naqvi is a radioanalytical chemist and is working as an associate professor of analytical chemistry in the Department of Chemistry, Government College University, Faisalabad, Pakistan. Advance separation techniques, nuclear analytical techniques and radiopharmaceutical analysis are the main courses that he is teaching to graduate and post-graduate students. In the research area, he is focusing on the development of organic- and biomolecule-based radiopharmaceuticals for diagnosis and therapy of infectious and cancerous diseases. Under the supervision of Dr. Naqvi, three students have completed their Ph.D. degrees and 41 students have completed their MS degrees. He has completed three research projects and is currently working on 2 projects entitled “Radiolabeling of fluoroquinolone derivatives for the diagnosis of deep-seated bacterial infections” and “Radiolabeled minigastrin peptides for diagnosis and therapy of NETs”. He has published about 100 research articles in international reputed journals and 7 book chapters. Pakistan Institute of Nuclear Science & Technology (PINSTECH) Islamabad, Punjab Institute of Nuclear Medicine (PINM), Faisalabad and Institute of Nuclear Medicine and Radiology (INOR) Abbottabad are the main collaborating institutes.",institutionString:"Government College University",institution:{name:"Government College University, Faisalabad",country:{name:"Pakistan"}}},{id:"58390",title:"Dr.",name:"Gyula",middleName:null,surname:"Mozsik",slug:"gyula-mozsik",fullName:"Gyula Mozsik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/58390/images/system/58390.png",biography:"Gyula Mózsik MD, Ph.D., ScD (med), is an emeritus professor of Medicine at the First Department of Medicine, Univesity of Pécs, Hungary. He was head of this department from 1993 to 2003. His specializations are medicine, gastroenterology, clinical pharmacology, clinical nutrition, and dietetics. His research fields are biochemical pharmacological examinations in the human gastrointestinal (GI) mucosa, mechanisms of retinoids, drugs, capsaicin-sensitive afferent nerves, and innovative pharmacological, pharmaceutical, and nutritional (dietary) research in humans. He has published about 360 peer-reviewed papers, 197 book chapters, 692 abstracts, 19 monographs, and has edited 37 books. He has given about 1120 regular and review lectures. He has organized thirty-eight national and international congresses and symposia. He is the founder of the International Conference on Ulcer Research (ICUR); International Union of Pharmacology, Gastrointestinal Section (IUPHAR-GI); Brain-Gut Society symposiums, and gastrointestinal cytoprotective symposiums. He received the Andre Robert Award from IUPHAR-GI in 2014. Fifteen of his students have been appointed as full professors in Egypt, Cuba, and Hungary.",institutionString:"University of Pécs",institution:{name:"University of Pecs",country:{name:"Hungary"}}},{id:"277367",title:"M.Sc.",name:"Daniel",middleName:"Martin",surname:"Márquez López",slug:"daniel-marquez-lopez",fullName:"Daniel Márquez López",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/277367/images/7909_n.jpg",biography:"Msc Daniel Martin Márquez López has a bachelor degree in Industrial Chemical Engineering, a Master of science degree in the same área and he is a PhD candidate for the Instituto Politécnico Nacional. His Works are realted to the Green chemistry field, biolubricants, biodiesel, transesterification reactions for biodiesel production and the manipulation of oils for therapeutic purposes.",institutionString:null,institution:{name:"Instituto Politécnico Nacional",country:{name:"Mexico"}}},{id:"196544",title:"Prof.",name:"Angel",middleName:null,surname:"Catala",slug:"angel-catala",fullName:"Angel Catala",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/196544/images/system/196544.jpg",biography:"Angel Catalá studied chemistry at Universidad Nacional de La Plata, Argentina, where he received a Ph.D. in Chemistry (Biological Branch) in 1965. From 1964 to 1974, he worked as an Assistant in Biochemistry at the School of Medicine at the same university. From 1974 to 1976, he was a fellow of the National Institutes of Health (NIH) at the University of Connecticut, Health Center, USA. From 1985 to 2004, he served as a Full Professor of Biochemistry at the Universidad Nacional de La Plata. He is a member of the National Research Council (CONICET), Argentina, and the Argentine Society for Biochemistry and Molecular Biology (SAIB). His laboratory has been interested for many years in the lipid peroxidation of biological membranes from various tissues and different species. Dr. Catalá has directed twelve doctoral theses, published more than 100 papers in peer-reviewed journals, several chapters in books, and edited twelve books. He received awards at the 40th International Conference Biochemistry of Lipids 1999 in Dijon, France. He is the winner of the Bimbo Pan-American Nutrition, Food Science and Technology Award 2006 and 2012, South America, Human Nutrition, Professional Category. In 2006, he won the Bernardo Houssay award in pharmacology, in recognition of his meritorious works of research. Dr. Catalá belongs to the editorial board of several journals including Journal of Lipids; International Review of Biophysical Chemistry; Frontiers in Membrane Physiology and Biophysics; World Journal of Experimental Medicine and Biochemistry Research International; World Journal of Biological Chemistry, Diabetes, and the Pancreas; International Journal of Chronic Diseases & Therapy; and International Journal of Nutrition. He is the co-editor of The Open Biology Journal and associate editor for Oxidative Medicine and Cellular Longevity.",institutionString:"Universidad Nacional de La Plata",institution:{name:"National University of La Plata",country:{name:"Argentina"}}},{id:"186585",title:"Dr.",name:"Francisco Javier",middleName:null,surname:"Martin-Romero",slug:"francisco-javier-martin-romero",fullName:"Francisco Javier Martin-Romero",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSB3HQAW/Profile_Picture_1631258137641",biography:"Francisco Javier Martín-Romero (Javier) is a Professor of Biochemistry and Molecular Biology at the University of Extremadura, Spain. He is also a group leader at the Biomarkers Institute of Molecular Pathology. Javier received his Ph.D. in 1998 in Biochemistry and Biophysics. At the National Cancer Institute (National Institute of Health, Bethesda, MD) he worked as a research associate on the molecular biology of selenium and its role in health and disease. After postdoctoral collaborations with Carlos Gutierrez-Merino (University of Extremadura, Spain) and Dario Alessi (University of Dundee, UK), he established his own laboratory in 2008. The interest of Javier's lab is the study of cell signaling with a special focus on Ca2+ signaling, and how Ca2+ transport modulates the cytoskeleton, migration, differentiation, cell death, etc. He is especially interested in the study of Ca2+ channels, and the role of STIM1 in the initiation of pathological events.",institutionString:null,institution:{name:"University of Extremadura",country:{name:"Spain"}}},{id:"217323",title:"Prof.",name:"Guang-Jer",middleName:null,surname:"Wu",slug:"guang-jer-wu",fullName:"Guang-Jer Wu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/217323/images/8027_n.jpg",biography:null,institutionString:null,institution:null},{id:"148546",title:"Dr.",name:"Norma Francenia",middleName:null,surname:"Santos-Sánchez",slug:"norma-francenia-santos-sanchez",fullName:"Norma Francenia Santos-Sánchez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/148546/images/4640_n.jpg",biography:null,institutionString:null,institution:null},{id:"272889",title:"Dr.",name:"Narendra",middleName:null,surname:"Maddu",slug:"narendra-maddu",fullName:"Narendra Maddu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272889/images/10758_n.jpg",biography:null,institutionString:null,institution:null},{id:"242491",title:"Prof.",name:"Angelica",middleName:null,surname:"Rueda",slug:"angelica-rueda",fullName:"Angelica Rueda",position:"Investigador Cinvestav 3B",profilePictureURL:"https://mts.intechopen.com/storage/users/242491/images/6765_n.jpg",biography:null,institutionString:null,institution:null},{id:"88631",title:"Dr.",name:"Ivan",middleName:null,surname:"Petyaev",slug:"ivan-petyaev",fullName:"Ivan Petyaev",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Lycotec (United Kingdom)",country:{name:"United Kingdom"}}},{id:"423869",title:"Ms.",name:"Smita",middleName:null,surname:"Rai",slug:"smita-rai",fullName:"Smita Rai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Integral University",country:{name:"India"}}},{id:"424024",title:"Prof.",name:"Swati",middleName:null,surname:"Sharma",slug:"swati-sharma",fullName:"Swati Sharma",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Integral University",country:{name:"India"}}},{id:"439112",title:"MSc.",name:"Touseef",middleName:null,surname:"Fatima",slug:"touseef-fatima",fullName:"Touseef Fatima",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Integral University",country:{name:"India"}}},{id:"424836",title:"Dr.",name:"Orsolya",middleName:null,surname:"Borsai",slug:"orsolya-borsai",fullName:"Orsolya Borsai",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Agricultural Sciences and Veterinary Medicine of Cluj-Napoca",country:{name:"Romania"}}}]}},subseries:{item:{id:"28",type:"subseries",title:"Animal Reproductive Biology and Technology",keywords:"Animal Reproduction, Artificial Insemination, Embryos, Cryopreservation, Conservation, Breeding, Epigenetics",scope:"The advances of knowledge on animal reproductive biology and technologies revolutionized livestock production. Artificial insemination, for example, was the first technology applied on a large scale, initially in dairy cattle and afterward applied to other species. Nowadays, embryo production and transfer are used commercially along with other technologies to modulate epigenetic regulation. Gene editing is also emerging as an innovative tool. 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She has over 25 years of experience working in reproductive biology and biotechnology areas with a special emphasis on embryo and gamete cryopreservation, for research and animal genetic resources conservation, leading research projects with several peer-reviewed papers. Rosa Pereira is member of the ERFP-FAO Ex situ Working Group and of the Management Commission of the Portuguese Animal Germplasm Bank.",institutionString:"The National Institute for Agricultural and Veterinary Research. 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