Socio-demographic characteristics of participants.
\r\n\t
",isbn:"978-1-80355-403-7",printIsbn:"978-1-80355-402-0",pdfIsbn:"978-1-80355-404-4",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,hash:"360fe5dabd12a1f91a5658a5fe3eff66",bookSignature:"Associate Prof. Murat Eyvaz and Dr. Ahmed Albahnasawi",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11934.jpg",keywords:"Hydrogen Sources, Hydrogen Production, Hydrogen Safety, Hydrogen Storage Methods, Environmental Impacts of Hydrogen, Synthetic Fertilizer Production, Aromatization, Hydrocracking, Hydrodesulfurization, Fuel Cells, Gas Turbines, Hydrogen Driven Vehicles",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"February 18th 2022",dateEndSecondStepPublish:"March 18th 2022",dateEndThirdStepPublish:"May 17th 2022",dateEndFourthStepPublish:"August 5th 2022",dateEndFifthStepPublish:"October 4th 2022",remainingDaysToSecondStep:"2 months",secondStepPassed:!0,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Eyvaz is a pioneering researcher in environmental sciences and engineering, who has co-authored numerous journal articles and conference papers and has four patents on wastewater treatment systems.",coeditorOneBiosketch:"Dr. Albahnasawi is a pioneering researcher in environmental sciences and engineering, who has co-authored numerous journal articles and conference papers on water and wastewater treatment and waste remediation.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"170083",title:"Associate Prof.",name:"Murat",middleName:null,surname:"Eyvaz",slug:"murat-eyvaz",fullName:"Murat Eyvaz",profilePictureURL:"https://mts.intechopen.com/storage/users/170083/images/system/170083.png",biography:"Dr. Murat Eyvaz is an associate professor in the Environmental Engineering Department, Gebze Technical University, Turkey. His research interests include applications in water and wastewater treatment facilities, electrochemical treatment processes, filtration systems at the lab and pilot-scale, membrane processes (forward osmosis, reverse osmosis, membrane bioreactors), membrane manufacturing methods (polymeric membranes, nanofiber membranes, electrospinning), spectrophotometric analyses (UV, atomic absorption spectrophotometry), chromatographic analyses (gas chromatography, high-pressure liquid chromatography). He has co-authored many journal articles and conference papers and has taken part in many national projects. He serves as an editor and reviewer for many indexed journals. 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Venkateswarlu",coverURL:"https://cdn.intechopen.com/books/images_new/371.jpg",editedByType:"Edited by",editors:[{id:"58592",title:"Dr.",name:"Arun",surname:"Shanker",slug:"arun-shanker",fullName:"Arun Shanker"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}}]},chapter:{item:{type:"chapter",id:"65944",title:"The Potential Contribution of Nanoparticles in the Treatment of Inflammatory Diseases",doi:"10.5772/intechopen.84776",slug:"the-potential-contribution-of-nanoparticles-in-the-treatment-of-inflammatory-diseases",body:'\nAlong with the advances in drug development recently, a new technology has gained a lot of attention in the last decades; this technology is nanotechnology [1]. Pharmaceutical industries have become increasingly interested in nanomedicine, due to the huge advantages this technology provides. Nanomedicine is the application of nanotechnology to diagnose and treat biological systems in health and disease [2]. Nanomedicine has led to the development of powerful tools for biological and medical research; these developments include targeted drug delivery, implantable materials for tissue engineering, and creating nanoscale probes for medical diagnostics and tracking cell movements [3]. At times of infection or injury, inflammation plays a very important role in protecting the injured tissue from further infection by starting the healing process [4]. It does this by increasing blood flow to the damaged tissue, which increases the activity of the cells and makes the tissue appear red, hot, and swelling. So, inflammation is actually the body’s own response to any damage occurred in the body, which makes it an important part of the healing process. However, if inflammation occurs by mistake, for example, in autoimmune diseases where the body attacks itself or if the inflammation stays too long, even after the infection or injury had passed, then this could cause an inflammatory disease. Therefore, short periods of inflammation, such as with an allergic reaction or with an infection, are generally fully treatable and leave no long-term problems. On the other hand, if inflammation lasts more than several months or years, then it is particularly severe and may cause lasting damage to the affected area or organ, for example, deformed joints. Although, there are an extensive number of medications that are available for the treatment of acute and chronic inflammation in the market. However, scientists have recently started to guide their research toward nanomedicine treatments for inflammatory diseases. Many researches have been studied in vivo and in vitro regarding the treatment of inflammatory diseases with different kinds of nanoparticles. The results of most of the studies reveal a lot of promising and very successful developments. The focus of this chapter is to provide an overview in nanotechnology contribution in treating inflammatory diseases.
\nWhen a body is injured or attacked by microbial organisms such as bacteria, viruses, or fungi, the immune system is signaled for invaders by the process of inflammation. Inflammation is simply the body’s mechanism of defending itself by responding to stimuli to repair and heal any signs of damaged cells or tissues. That’s why inflammation is an important part of the immune system’s physiological response, without which, infections and injuries could become fatal. However, if the inflammatory process is not working as it should be, it can turn into a disease. Inflammatory diseases include a massive number of disorders and conditions [4, 5, 6]. Examples include allergy, asthma, glomerulonephritis, hepatitis, and inflammatory bowel disease [5]. Chronic inflammation has been linked to certain diseases such as heart disease or stroke and may also lead to autoimmune disorders, such as rheumatoid arthritis or cancer [4].
\nAn infection or injury affecting the body will most probably trigger a number of physical reactions by the immune system that will eventually cause inflammation [5]. On the other hand, inflammation in any part of the body does not necessarily mean that there is a microbial infection.
\nThe most common causes of inflammation are:
Pathogens like viruses, bacteria, or fungi
Injuries like external cuts or wounds
Chemicals or radiation affecting the lungs or body
Diseases or conditions that can cause inflammation:
Cystitis: an inflammation of the bladder
Bronchitis: an inflammation of the bronchi in the lungs
Otitis media: an inflammation in the middle ear
Dermatitis: an inflammation of the skin
Acute inflammation is a short-term response with localized effects that means it works at a specific place where the problem exists. It usually occurs after an injury or wound on the skin, a sprained ankle, or a sore throat due to a bacterial infection. It starts rapidly, and symptoms are usually severe, but they subside in a couple of days or weeks. During an acute inflammation episode, the blood vessels in the area affected dilate, and therefore blood flow increases, and the white blood cells cover the injured area to promote healing. This response is what causes the injured area to turn red and become swollen [5].
\nChronic inflammation is a long-term response; it’s mostly a persistent, low-level inflammation that can last for months or even a lifetime [7]. Inflammation begins as a defensive process in which the body is ready to protect itself from harmful pathogens or chemicals that were exposed to the body for a long period of time. However, sometimes, this defense mechanism can become uncontrolled, and hence, damage to vital organs, nervous and musculoskeletal systems, and blood vessels could occur. In some diseases the immune system might attack its own normal cells mistaking it for a foreign organism or pathogen, such as in autoimmune disorders, causing harmful inflammatory responses.
\nChronic inflammatory diseases include:
Rheumatoid arthritis, where many joints throughout the entire body are permanently inflamed
Psoriasis, a chronic skin disease
Inflammations of the bowel such as ulcerative colitis
Active hepatitis
Signs and symptoms of inflammation can be uncomfortable, but they show that the body is trying to heal itself. They vary in severity and intensity depending whether the inflammation is acute or chronic. The most important signs that may indicate an acute inflammation are [5, 6]:
Redness: this occurs because the capillaries in the area are filled with more blood than usual.
Heat: this occurs because more blood flows to the affected area, and this makes it feel warm to the touch.
Swelling: this is caused by a buildup of fluid.
Pain: this is due to the release of chemicals during inflammation that stimulate nerve endings, making the area more sensitive to the touch.
Immobility: there may be some loss of function in the region of the inflammation.
Not all of the signs must occur simultaneously; some might appear before the others. Some inflammations, however, could occur silently without any symptoms, especially when the inflammation is deep inside the body such as in an internal organ. The loss of function symptom, for example, is when you cannot breathe properly if you have asthma, when an inflamed arm or leg is difficult to move or when the sense of smell is lost during a nasal allergy. Inflammation does not necessarily start exactly when a person has been infected by a virus or bacteria, but it actually begins when the body starts to fight against the harmful stimulus or the infection.
\nSymptoms of chronic inflammation present in a different way [5, 7]. These can include:
Constant fatigue
Mouth sores
Joint, chest, or abdominal pain
Rash
Fever
When people have inflammation, they will feel pain, discomfort, distress, and stiffness in the inflamed area, depending on the severity of the inflammation; the type of pain varies. Although inflammation, in most cases, does indicate that the immune system is working properly, the symptoms are still an unpleasant feeling and usually need treatment to ease the pain.
\nThe treatment of inflammatory disorders must rely on targets present in the diseased tissues [8]. To achieve the desired therapeutic effect on inflammatory cells, high drug doses will be required which sometime can induce unwanted effects on healthy tissues. The main anti-inflammatory drugs are either steroidal such as betamethasone, prednisone, and dexamethasone or nonsteroidal anti-inflammatory drugs (NSAIDS) such as aspirin, ibuprofen, and naproxen [4]. NSAIDs are available in low doses over the counter mostly to treat the pain associated with inflammation, while higher doses of NSAIDs and steroidal medication are available as prescription medications [5]. Both are used to treat acute and chronic inflammatory diseases. However, their prolonged use is associated with a lot of side effects. Steroidal drugs can cause adrenal atrophy, fluid retention, thinning of bones which can lead to osteoporosis, and increased risk of infection or injury. NSAIDS can cause peptic ulcers, allergies, high blood pressure, or liver and kidney problems. Thus, the search for new anti-inflammatory agents is getting popular with the objective to obtain greater safety, better efficacy, and a more economical way to treat inflammation [5].
\nNanomedicine has grown rapidly due to the need for improved therapies for inflammatory, developmental, infectious, and degenerative nervous system disorders [9]. These disorders are a significant burden due to the increased number of people affected, disease severity, and financial cost. Therefore, the need for an improved diagnosis and treatment is urgent. Nanotechnology has been widely studied in the last decade and proved to be an encouraging strategy in the healthcare system and the medical field. This novel technology provides a vast number of nanomaterials and tools that could actually diagnose and treat different inflammatory disorders and conditions. This chapter focuses on the current and future potential of nanomedicine to positively treat inflammatory disorders.
\nThe last decade has been a tremendous growth for nanotechnology; it encompasses different scientific disciplines. This field aims at designing materials with new functions and beneficial properties at the nanometer level [10]. The nanomaterials designed are mostly any shape with a size in the range of 1–100 nm [11]. The huge and unique advantages that nanoparticles (NPs) offer made them an important research in the medical field, which created a new field called nanomedicine [12]. They can be used for the prevention, diagnosis, and treatment of many diseases, due to their very small size and large surface area. In addition to their easy preparation, NPs can be used to encapsulate and protect drugs, genes, or proteins in which they are carrying from degradation, thus, enhancing their biodistribution and allowing sustained release [13]. They also improve the bioavailability of hydrophobic molecules and can be modulated for site-specific targeting, hence, decreasing the side effects of drugs. Moreover, their unique ability to pass through the physiological barriers and intercellular spaces through different mechanisms due to their small size is an important property in the treatment of different kinds of diseases such as brain disorders [13]. In many cases nowadays, current treatments are simply inadequate to decrease disease progression or even remove symptoms and signs of inflammation [9]. However, nanoparticles can solve such problems, for example, increasing drug penetration into sites of active microbial infection while decreasing its side effects by working as drug carriers. In recent years, the goal for nanoparticle development was for the treatment, detection, and prevention of inflammatory and infected sites [14, 15, 16].
\nDifferent types of nanocarriers are available, and they are fabricated and chosen depending on different aspects such as the kind of application, what is carried by the nanoparticles whether it’s a drug or gene, way of administration, materials used, and method of fabrication. Types of nanoparticles include, but not limited to, polymeric nanoparticles, solid lipid nanoparticles (SLNs), liposomes, metallic nanoparticles, and dendrimers [1]. Below are the different types of nanoparticles that are mostly used.
\nPolymeric nanoparticles are made from natural or artificial biodegradable and biocompatible polymers; they represent a promising formulation for drug delivery [17]. They work as carriers to control drug release and target specific locations. When compared to conventional formulations, polymeric nanoparticles can increase the solubility of the drug, hence, increasing its absorption and reducing the therapeutic dose. Furthermore, these nanoparticles are stable and safe. Polymeric nanoparticles can be fabricated using various methods of synthesis, according to their intended application. They can be designed as nanocapsules or nanospheres and range from 10 to 1000 nm in diameter, differing in their composition and structural organization [1]. A nanocapsule has a polymeric membrane surrounding an oily core in which the active ingredient can be adsorbed to the membrane and/or dissolved in the oily core. Nanospheres, on the other hand, are made only from a polymeric structure, where the active constituent is adsorbed or retained. Polymeric materials that have been used extensively for nanoparticles include poly-lactic-acid (PLA) and poly-lactic-co-glycolic acid (PLGA) [1, 18].
\nSolid lipid nanoparticles (SLNs) are colloidal carrier systems that contain highly purified triglycerides, composed mainly of lipids. These structures are produced from solid lipids and are stabilized by surfactants. They combine the advantages of other colloidal systems such as liposomes and polymeric nanoparticles, in their biodegradability, biocompatibility, and low toxicity [19]. SLNs can be produced on a large scale; they have high physicochemical stability and offer good protection against drug degradation [1, 19]. Their size ranges from 50 to 1000 nm and may be used in the pharmaceutical field for the delivery of drugs using different routes of administration such as oral and parenteral routes [1].
\nLiposomes for drug delivery are spherical small-sized vesicles composed of natural or synthetic lipid bilayers, separated by an aqueous medium in their core [1, 2, 17]. Hydrophilic substances are encapsulated inside the aqueous compartment, while lipophilic substances are adsorbed or incorporated in the lipid bilayers. Liposomes are classified according to their surface charge, size, lipid composition, and method of preparation. The surface charge could be anionic, cationic, or neutral. According to the size and number of lamellae, liposomes can be classified as small, large, or giant and oligo-, uni- or multi-lamellar, respectively [1]. Liposomes have helped decrease the side effects of different drugs such as anticancer and antifungal drugs, simultaneously with improving their efficacy [2]. Liposomal drug delivery preparations have also been studied in various chronic inflammatory diseases. This is a promising approach since it limits the side effects of anti-inflammatory drugs on healthy tissues [2].
\nMetallic nanoparticles comprise a class of materials that are made from metals such as titanium, gold, and platinum. They exhibit remarkable optical and electronic properties, which make them very useful in the medical field [20]. These nanoparticles are ranged in size from 1 to 100 nm, and they can be fabricated and modulated with several functional groups, due to their high surface area to volume ratio that allows them to be conjugated with antibodies, ligands, and vehicles for gene drug delivery and diagnostic imaging [17, 19, 21]. Moreover, metallic nanoparticles have the potential to carry large doses of drugs and increase their circulatory half-life [19]. Examples of metallic nanoparticles used in research nowadays include but are not limited to gold, silver, zinc oxide, and iron nanoparticles.
\nDendrimers, one of the most interesting classes of nanoparticles, are synthetic polymers with repetitively branched molecules ranging in size from 1 to 100 nm [22]. Dendrimers are radially symmetrical molecules with well-defined and homogeneous structure consisting of treelike branches [23]. A typical dendrimer is composed of different parts; it is composed of a central core surrounded by repeated units that start from the inside and grow outward like branches with multiple peripheral functional groups [24]. The functional groups have a high degree of molecular uniformity and could be adjusted in size, valency, solubility, and biodegradation [17]. The dendrimers have very high stability and huge surface area, which made them gain a lot of interest and have a wide number of applications in the biomedical field.
\nPharmacists, physicians, and patients have long desired better pharmaceutical formulations to improve drug efficacy, reduce toxicity, and reduce the costs of preparation and treatment [2]. The conventional treatments available for inflammatory diseases involve nontargeted treatment options with extensive adverse effects. However, nanodrug delivery has shown, in many studies over the years, a numerous number of promising approaches for delivery of therapeutic agents, and most of them proved to reduce side effects and toxicity, increase a drug’s bioavailability and effectiveness at the site, and reduce cost. The focus of this section is to highlight the contribution of several nanoparticle applications that have made an immediate major impact in the treatment of different inflammatory disorders.
\nRheumatoid arthritis (RA) is the most common inflammatory disease and is the major cause of disability of the joints [13, 17, 25]. This disease is associated with progressive disability, systemic complications, and socioeconomic costs [13, 17]. To deliver drugs to the target site directly is still a major problem nowadays. Thus, bounding drugs to carriers, like nanoparticles, can make cell-specific targeting become more achievable. The drugs available conventionally for the treatment of RA include three main groups; these are disease-modifying antirheumatic drugs (DMARDs), steroids, and anti-inflammatory drugs such as NSAIDS. Discussed below are examples for the contribution of nanoparticles to each group.
\nIn one study scientists explored the use of multifunctional nanoparticles in the treatment of RA that involves small synovial joints. This study used near-infrared (NIR) light technology along with the nanoparticles [25]. In this study methotrexate (MTX), which is a DMARD, was loaded to a PLGA polymer-gold (Au) half shell nanoparticle. Then arginine-glycine-aspartic acid (RGD) peptide was conjugated to the surface of the Au NP forming a multifunctional NP (RGD-MTX-PLGA-Au). The RGD peptide was used as a targeting moiety for inflammation, the Au half shell was used to generate heat, and MTX was used for the treatment of RA. The NPs were injected into collagen-induced arthritic (CIA) mice. They were effectively delivered and accumulated in the inflamed joints due to RGD peptides. After delivery, heat was generated upon NIR exposure due to Au, and the MTX was then rapidly released from PLGA nanoparticles. The application of this multifactorial NP in CIA mice had better therapeutic efficacy with a much smaller dose of MTX, when compared to conventional treatment [25]. These results demonstrate that the targeted NPs treatment is a useful and effective strategy for increasing the therapeutic efficacy and decreasing side effects of drugs used in the treatment of RA.
\nSteroids have been used for the treatment of chronic inflammatory disorders for decades [26]. Normally, to reach efficacious concentrations in the blood, they are frequently injected in high doses due to their rapid clearance from the body. However, the chronic use of corticosteroids is associated with severe side effects such as osteoporosis, hypertension, and weight gain. Therefore, current corticosteroids should have active targeting, controlled release and retention in the inflamed tissue. This could be done using engineered nanomaterials as delivery vehicles. In one study, glucocorticoids were loaded into liposomes to prolong the drug circulation time and change drug distribution. As a consequence, number of injections and doses were reduced while still achieving similar efficacy to that of free glucocorticoid in rat models of rheumatoid arthritis [26].
\nNano-carriers that were also successful in delivering anti-inflammatory drugs were PAMAM dendrimers [17, 26]. In one study, they have been used to deliver indomethacin to reduce inflammation in the rat model of arthritis. The polyethylene glycol (PEG) dendrimers were functionalized with folate as a targeting ligand to target only activated macrophages, since folate receptor is expressed on activated macrophages only and not on resting ones. This folate-PEG-PAMAM dendrimer was loaded with indomethacin to study its anti-inflammatory effect. This conjugation resulted in a 10–20-fold increase in drug loading efficiency and was found to release indomethacin in the joints in a sustained manner [17].
\nDermatologic therapy is mainly aimed to prevent or decrease inflammation in the skin. Topical corticosteroids are the keystone of dermatologic therapy and have been used for various inflammatory conditions for their treatment or prevention [11]. Corticosteroids are often prescribed, though their use can carry significant side effects, as mentioned earlier.
\nIn several studies, SLN corticosteroid formulations showed increased penetration compared to its traditional counterparts, resulting in penetration beyond the epidermis and into the dermis [11]. Moreover, SLN provide the added benefit of sustained release, which is a desirable feature for controlling concentration of drug in tissue over time; these properties may improve side effect profiles and dosing schedules of drugs.
\nNSAIDs are another main drug used in the treatment of inflammatory diseases because of their excellent anti-inflammatory and analgesic actions [10]. However, NSAIDs are associated with serious adverse effects. Therefore, whenever possible, drugs are used topically for dealing with local inflammatory diseases. Topical ointments that contain NSAIDs nanoparticles were studied for skin penetration, safety, and anti-inflammatory effects in animal models of acute and chronic inflammation. In one study, two ointments, one with normal NSAIDs and the other containing NSAIDs in nanoform, were compared [10]. Following the application of both, the study revealed that NSAID in the nanoform had increased penetration of the drug into the skin compared with the normal NSAID, suggesting a higher local activity of NSAID nanoform when applied to the skin. In chronic inflammation model, both formulations decreased foot swelling in a time-dependent manner. However, the healing rate at 7 days of post treatment was significantly higher following treatment with NSAID nanoform compared with the normal NSAID [10]. Moreover, the concentration of NSAID nanoform was much lower than those required of the normal NSAID. Hence, the potency of the nanoformulations is much higher than normal treatment [10]. NSAID nanoformulations are expected to be the basis for new dermatological products, due to their effective treatment and low side effects.
\nAnother major dermatological product that is used by many consumers is sunscreen. Sunscreens are important tools for skincare and the first line of choice for the prevention of inflammation caused by ultraviolet (UV) rays. UV filters are crucial for the prevention of sunburn and UV-induced mutations that may lead to skin cancer. Inorganic UV filters such as titanium oxide (TiO2) and zinc oxide (ZnO) have been used in sunscreen formulations for a long time, and they are effective in protecting against both UVA and UVB rays. Despite that, TiO2 and ZnO filters leave an opaque white residue on the skin, which limits its use by many customers [11]. However, by reducing TiO2 and ZnO sizes to the nanoscale, the production of translucent products is possible rather than the white coarse raw material. It has been shown that sunscreens using particles between 40 and 60 nm are capable of providing good transparency without weakening UVA and UVB protection [27]. Although there has been some concern about the use of nanomaterials in sunscreens, there is no indication that the use of TiO2 or ZnO holds any danger, and studies showed that nanoparticle preparations do not penetrate past the stratum corneum [28]. Therefore, further study is still needed to fully evaluate the safety of these filters and fully prove their safety.
\nAsthma is a chronic inflammatory condition characterized by narrowing and swelling of the airways with extra production of mucus, which makes it difficult for the person to breathe [29]. Theophylline is a drug that had been used conventionally worldwide for the treatment of allergic asthma for several years [30]. Although it’s still widely prescribed, its use has decreased due to the use of inhaled glucocorticoids instead. Moreover, theophylline has severe side effects due to its low therapeutic window, such as nausea, headache, and cardiac arrhythmias, which limits its use. The adsorption of theophylline to chitosan nanoparticles, modified by the addition of thiol groups, was studied in vivo using mouse models of allergic asthma [29].
\nChitosan is a polymer derived from chitin that has been used for nanodrug delivery due to its beneficial properties such as biocompatibility, biodegradability, and bio-adhesiveness [31]. The mice were treated intranasally with theophylline alone, chitosan nanoparticles alone, or theophylline adsorbed to chitosan nanoparticles [29]. The effects of theophylline on cellular infiltration, histopathology of lung sections, and apoptosis of lung cells were investigated to determine the effectiveness of theophylline chitosan NPs as a drug-delivery vehicle for theophylline. Intranasal delivery of theophylline conjugated nanoparticles augmented the anti-inflammatory effects of the drug compared to theophylline administered alone [29]. Thus, the clinical effects of theophylline in treating asthma could be enhanced through the use of nanodrug delivery system. Nasal drug delivery is indeed a promising technique because of the large surface area in the nose, high blood flow, avoidance of first-pass metabolism, and the quick onset of pharmacological activity. Furthermore, it is reasonable to point out that the bioavailability, adsorption, and residence time of drugs administered through the nasal route would be increased using drug delivery carriers such as nanoparticles [32].
\nUlcerative colitis (UC) and Crohn’s disease (CD) are the two major types of inflammatory bowel disease (IBD). IBD is a chronic but relapsing inflammatory disorder of the gastrointestinal tract [33]. UC is characterized by inflammation that is limited to the colon, while CD involves any part of the gastrointestinal tract. Abdominal pain, diarrhea, and rectal bleeding are frequent symptoms in patients suffering from IBD [33]. For years, the conventional treatment of IBD consisted of anti-inflammatory medications, such as corticosteroids, aminosalicylates, and immune suppressants. However, these drugs have several side effects due to their unspecific targeting upon administration. A promising strategy toward IBD treatment would be to selectively target the inflamed colonic tissue in order to decrease side effects and increase therapeutic efficacy of the drug administered.
\nIn one study they used mesalamine, an anti-inflammatory medication used conventionally to treat UC, in a nanoparticle formulation [34]. Free mesalamine undergoes rapid and almost complete systemic absorption from the intestine, which causes side effects and drug loss, lowering the therapeutic effect of the medication. The drug then undergoes extensive metabolism. Therefore, it is important to deliver mesalamine (5ASA) locally to the colon, in order to reduce the systemic drug absorption and thus slow down the metabolism. The drug was covalently bound to a NP matrix polymer. Experiments in mice with colon inflammation showed a distinct retention of the mesalamine inside the NP matrix, which allowed efficient colonic targeting and slowed down the release of the drug. This approach elevated the selectivity of the drug toward the inflammation site by decreasing the rapid drug release in the proximal intestine after oral administration [34].
\nNano-drug delivery represents a promising approach in inflammatory disorders, mostly due to their accumulation in the inflamed regions [33]. In another study, the drug release was triggered by the sensitivity of polymer to pH during gastrointestinal (GI) transit. Scientists combined PLGA nanoparticles with pH-triggered polymer, to provide both specific accumulation in inflamed tissue and selective drug release in the colon [33]. They used curcumin (C) as the drug of choice to treat IBD, which is known for decades for its anti-inflammatory, antioxidant, antimicrobial, anticarcinogenic, and hepato-protective effects. Anti-inflammatory effects of C have been studied in several diseases before, such as Alzheimer’s disease, Parkinson’s disease, multiple sclerosis, and cerebral injury [35]. However, we must note that raw C is known for its poor solubility and thus low bioavailability. Moreover, it has a high rate of metabolism and rapid elimination. Thus, an IBD-specific delivery system is needed to protect C from fast degradation. This study aimed to evaluate the effects of C loaded in polymeric pH-sensitive nanoparticles in the treatment of IBD. They were also compared to a C suspension to assess the selectivity and specific delivery of C to the colon. The negative charge of the surface of nanoparticles attracted them to positively charged ulcerated tissues [36]. Hence, C-NPs exhibited suitable physicochemical characteristics, due to their small size and opposite surface charge, for colonic delivery. In vitro studies reported that encapsulated C was found to cross through the epithelial barrier better than C suspension [33].
\nAD is a type of chronic low-level inflammation that mainly affects the elderly [37]. It’s considered as a progressive and devastating neurodegenerative disorder that is characterized by cognitive deterioration and decline in the quality of the patient’s life [38]. An enormous amount of in vivo and in vitro research was conducted by many groups to study the effect of NPs on the treatment of AD. The following are some examples of nanomaterials that are intended to target the brain and treat AD:
\nAlbumin NPs loaded with tacrine, which was an AD medication previously, was synthesized and administered through the intranasal route of sheep to avoid the first-pass metabolism of the drug and deliver it rapidly to the brain. Due to the small size and large surface area of albumin NPs, the delivery of tacrine was improved through the mucosa to the brain. This research was tested on sheep nasal mucosa in permeation cell [39].
\nDendrimers, as mentioned earlier, are globular macromolecular structures with a densely packed surface. It was found that dendrimers could block the aggregation of Amyloid β (Aβ), which is one of the causes of AD. This is by binding to the protofibrils and fibrils, therefore preventing the cytotoxic effect of Aβ plaques. In one study it was suggested that conjugated and unconjugated dendrimers had the ability to separate Aβ deposits in vitro [40].
\nGold (Au) NPs were designed to dissolve the Aβ aggregates by the use of local thermal energy at a molecular level and preventing further aggregation. When Au NPs attach to Aβ aggregates and a weak microwave field is applied, they produce thermal energy which dissolve the aggregation and prevent them from reforming. Au NPs are known to have the advantage of large surface area, biocompatibility, and small size which make them very suitable in this application [41].
\nPolymeric NPs such as PLGA have great biocompatibility and biodegradability properties. They have the ability to encapsulate different kind of drugs and transport them to the brain by surface modification. For example, curcumin has been encapsulated by PLGA in several studies. This formulation was found to be a potential candidate for the treatment of AD due to the great properties of curcumin as mentioned earlier. Curcumin was found to bind to the Aβ plaques and disaggregating them, due to its anti-amyloid property, which makes this C-NP formulation a very promising drug in the treatment of AD [41].
\nAnti-inflammatory effects of engineered nanomaterials can be intentionally achieved. This is by modulating the nanoparticle physicochemical properties and by using nanoparticles as carriers for anti-inflammatory agents. However, structure activity relationship (SAR) studies are needed to further improve this area of nanotechnology. Despite the huge amount of benefits that nanoparticle holds as drug carriers, there are still some disadvantages [13]. For example, NPs might generate toxicity due to their small size, which widen the biodistribution of the drug in the body. Hence, increasing the drugs’ potency, which although beneficial, also might affect the immune response of the body and trigger toxicity. Moreover, clinical researchers have mentioned some negative factors, such as high cost and the difficulty of scaling-up processes [1]. Therefore, future nanodrug delivery studies are recommended, and these studies should focus on toxicity and on identifying key elements like dose, route of administration, physicochemical properties, and composition that might provoke toxicity. Understanding what makes the same nanoparticle beneficial in one model and toxic in another model is critical. This will aid drug delivery formulation scientists in choosing appropriate nanoparticle carriers and will clearly enhance the rapidly growing field of nanodrug delivery.
\nMost drugs available nowadays are limited by their poor solubility, number of side effects, frequent dosing, and nonspecific delivery. Therefore, scientists have shifted their research to using nanoparticles for the delivery of drugs to avoid those limitations. NPs are now studied to deliver two or more drugs simultaneously for combination therapy, aiming to decrease frequency of dosing and number of medications a patient is receiving and thus increasing compliance. The main advantage of using NPs is that they could be modulated and specifically targeted to match the need. Therefore, the production of nanomaterials as drug delivery carriers can offer new opportunities to provide more focused and precise treatment of inflammatory diseases and improve the potential therapeutic effectiveness of available medications [17]. We covered in this chapter the advantages of nanotechnology in the medical field and the different kinds of NPs available. We also mentioned different kinds of inflammatory diseases such as arthritis, asthma, and Alzheimer’s disease and how nanoparticles were able to positively contribute in their treatment. Despite the many technical, regulatory, and legal challenges, the development of these technologies on a large scale would face, there is no doubt that there is enough desire to overcome these challenges to improve the quality of life and benefit the society [2].
\nAD | Alzheimer’s disease |
Aβ | amyloid β |
CD | Crohn’s disease |
CIA | collagen-induced arthritis |
C | curcumin |
DMARDs | disease-modifying antirheumatic drugs |
IBD | inflammatory bowel disease |
5ASA | mesalamine |
MTX | methotrexate |
NPs | nanoparticles |
NIR | near-infrared radiation |
NSAIDs | nonsteroidal anti-inflammatory drugs |
PLA | poly-lactic-acid |
PLGA | poly-lactic-co-glycolic-acid |
PEG | polyethylene glycol |
RA | rheumatoid arthritis |
SAR | structure activity relationship |
SLN | solid lipid nanoparticles |
TiO2 | titanium oxide |
UC | ulcerative colitis |
UV | ultraviolet |
ZnO | zinc oxide |
Hypertension is a major risk factor of cardiovascular diseases (CVD), and is highly prevalent in sub-Saharan Africa (SSA) [1, 2]. CVD including ischemic heart disease and stroke are the world’s biggest killers, having killed 15.2 million people in 2016 alone [3], and being responsible for 17.9 million (31%) of global deaths annually [4]. To limit CVD, World health organization (WHO) advocated preventive management of hypertension and other CVD risk factors [4]. In Nigeria where the age-standardized prevalence of Hypertension is 19.3%, only 8% of hypertensive patients are aware, 3% controlled and just 5% are covered by treatment [5]. Fortunately though, willingness to adopt recommended lifestyle measures is encouraging among hypertensive patients [6].
In African rural settings deep-routed cultural orientations can manifest in beliefs and perceptions about health that vary with modern medical perceptions. It is beneficial to re-orientate people in such deeply cultural settings to acquire well informed modern health perspectives. This can be achieved by introducing culturally appropriate behavioral health interventions that have undergone cultural adaptation based on the people’s traditional health practices and cultural beliefs.
An ideal behavioral treatment intervention should be adapted culturally by following standard procedures. Studies have shown that guideline-based cultural adaptation process has potential to increase acceptability, attractiveness and effectiveness of treatment support programs among target populations [9, 10, 11]. Furthermore evidence abounds that systematic cultural adaptation of behavioral treatments offer intrinsic self-efficacy benefits for patients [12, 13, 14]. Reports further suggests that cultural adaptation of health interventions can enhance service delivery when implemented as a living process with dynamism for continuous feedback, replicability and improvement [11]. Conversely other interventions that are not culturally adapted can unwittingly discourage uptake of recommended lifestyles by patients at risk of CVD [15]. Systematic review evidence from global perspective have also highlighted usefulness of culturally adapted interventions in control of CVD risk factors [16]. Currently however, there is a dearth of regional studies investigating usefulness and exploitability of cultural adaptation of treatment interventions in SSA settings.
To implement standard cultural adaptation, Barrera et al. identified five guideline-based sequential stages involved from a Consensus on Updates of Models for Effective Cultural Adaptation as follows:
The effectiveness of culturally adapted interventions can be evaluated using standard testing procedures. Studies suggest that goal setting and pursuance among patients can be effective in promoting acculturation and adoption of adapted interventions among populations at risk of CVD. Similar evidence abounds that goal setting is useful in evaluating effectiveness of culturally adapted interventions including acquisition of behavioral self-management skills [18, 19, 20, 21]. Indeed the setting and pursuing of culturally adapted goals to stimulate healthy behavior have enhanced chronic disease self-management skills [18, 20]. Available evidence further suggests that the more frequently goals are set and pursued, the easier and faster patients learn and acquire targeted self-management skills [19].
In this study, following standard guidelines and procedures we culturally adapted an existing hypertension education program to produce a similar variant with enhanced cultural content and sensitivity using the first three out of five sequential steps. We proceeded further to evaluate the adapted program for
A mixed methods study in two phases: in
Cultural adaptation study in relation to QUICK-1 and QUICK-2 studies.
In the current study, our focus is to describe the
Our study was implemented at a primary healthcare center,
In the following section we describe the steps taken in adapting CHEP from CAHE and in evaluating the former, based on designs, measures, procedures and analysis adopted.
In the
Beyond what was already known from CAHE, CHEP specifically sought to know the local, cultural and contextual factors the Nigerian hypertensive patients perceive as inhibitors or enablers of prescribed hypertension care and self-management: what hypertension is and how it presents; what situations make hypertension easy or difficult for patients to manage as advised; how patients’ finances affect their treatment goals; and how patients’ native customs and social environment affect their use of medications, food selection, exercise or weight management. During a follow-up focused group discussion (FGD) after CHEP counseling sessions, participants were further asked: how they view CHEP counseling on pills use, healthy diet, salt reduction/substitution and exercise; what was particularly helpful, or frustrating about CHEP counseling; how much they have been able to meet their hypertension self-management goals; and ways in which the education program can be improved upon in future.
In addition to the qualitative interviews, at a later stage we conducted FGD with participants to get their views about usefulness, acceptability, sustainability and effectiveness or otherwise of CHEP. As was done in CAHE, the CHEP development interviews began with the interviewer familiarizing with respondents to determine preferred language of communication. Thereafter we introduced participants to the research objectives: to elicit patients’ explanatory model of hypertension regarding cause, presentation, course, duration, consequence, treatment, self-management and contextual factors relating to hypertension including social, cultural, religious, and financial factors. Furthermore, while CAHE sought to know the effect migration had on hypertension self-management efforts of its immigrant participants, CHEP explored how peculiar local features of Nigeria’s rural, social and cultural environments can be exploited to optimize hypertension self-care.
We used MAXQDA data management software [29], and Grounded Theory [30] to analyze our data. The analytic process was at first carried out by two researchers independently, thereafter the interview transcripts were exchanged and coding and analytic steps repeated all over by individual researcher. Following this, areas of disagreement were jointly resolved by discussing the data further. In analyzing, we repeatedly examined, compared, verified and reordered the data in line with identified themes and concepts. This produced a matrix of concepts, sub-categories and categories from multi-level coding along thematic lines as follows: a) first we identified clusters of similar concepts in each interview transcript by assigning series of open codes to similar text fragments and emerging themes that reflected same ideas. To produce a code list we inductively coded sections of each transcript that provided information on respondents’ ideas about hypertension and hypertension self-management; b) next we reviewed the code list to eliminate duplicates and streamline similar concepts to produce a smaller set of mutually exclusive concepts; and c) we scrutinized the data further and grouped streamlined concepts and related text fragments under four major themes to address our core research question: what social, cultural or native factors affect compliance with prescribed pills, diet and healthy behavior among hypertensive primary care patients from rural Nigeria?
In the preliminary adaptation stage, we tailored CHEP culturally using information collected in the
Both CHEP and CAHE had notable similarities in forms and contents; each was implemented in three modules over 6 months among hypertensive patients in Europe (
Excluding goals setting and few self-report measures, many other measures were assessed in both CAHE and CHEP including patient demographics and physiological measures. Other measures include perceived stress, social support, and illness perception, beliefs about medicines, self efficacy, medication adherence, lifestyle adherence and satisfaction with care. Unlike CHEP however, a measure of ‘discrimination’ was deemed relevant and included in CAHE whose participants had migrated to Europe and could possibly experience social exclusion.
A CHEP counseling visit usually began with participants familiarizing with others and the trainers. This is followed by: group interactive counseling on hypertension and hypertension self-management; poster teaching on culturally relevant exercises; a visit to the local market to familiarize with healthy foods; an audiovisual viewing session on pills use, healthy diet and lifestyle; a field practical exercise session; and a goal setting and assessment session. CAHE on the other hand was delivered in one-on-one teaching sessions, featured no audiovisual session, and did not involve teaching visits to local market or grocery store but nevertheless deployed a specially prepared take-home hypertension handbook to teach her relatively more literate participants about healthy food choices, food preparation methods, pills use and healthy lifestyle. Both CAHE and CHEP counseling trainings were structured into 3 modules and delivered on 3 occasions few weeks apart, over six months in between a baseline and a final assessment visit. In both programs, every participant had physiological, anthropometric and self-report measurements at baseline and final visits. However, CHEP additionally had these measures taken during each of the 3 intervening educational visits because it was observed during pre-baseline information visits that the patients valued such interim measurements if the results are immediately communicated to motivate their self-management efforts.
The
We measured and recorded participants’ socio-demographic parameters (age, gender, ethnicity, marital status, income level, employment status, educational status, alcohol use and tobacco use) and assessed their hypertension treatment outcomes including blood pressure control, body mass index, medication adherence, behavioral adherence as well as social support, satisfaction with care, illness perception, beliefs about medicines, and medication adherence self efficacy. Furthermore we asked participants specific questions on physical activity and exercise, use of salt, alcohol and smoking and graded their responses on a Likert Scale. Finally we asked participants to set and practice preferred culturally adapted behavioral health goals and graded their performances of set goals as a measure of ‘cultural fitness.
Each of the 149 participants individually had an initial baseline assessment, followed by 3 modules of CHEP training in groups of 12–15 at 6 weeks, 10 weeks and 14 weeks past baseline. They were later disaggregated to have final individual assessments at 6 months past baseline. In essence, each participant had five study visits including a baseline assessment visit, a final assessment visit and three intervening group educational and goals setting assessment visits. Following the baseline visit (1st study visit) each participant was guided to set 3 culturally adapted behavioral goals during the first training session (2nd study visit), and to practice the selected goals at home until he/she revisits for the second training session (3rd study visit). The same goals setting instructions were repeated at the end of second training towards the third and final training session (4th study visit). Participants were additionally guided to practice preferred physical exercises for 20 minutes during the 3rd training session only, and they were encouraged to continue the exercises at home until the final visits at 6 months (5th study visit). In the section on assessment of set goals, participants’ goals related performances were rated on a Likert scale and compared over 6 months before and after the intervention. Full details of the effectiveness of CHEP evaluation study are available in a related study [13].
Data were analyzed based on: 1) qualitative self-report from each of the 149 participants on performance of set goals as instructed; and 2) quantitative ‘before-, and after’ comparison of changes in treatment outcomes of participants following intervention.
In assessing performance of set goals, we recorded the number and types of goals set by each participant during a current visit following practice of such goals at home as instructed during previous visit. Using a Likert scale we inquired and got qualitative responses from each participant on the extent to which they practiced selected goals at home. For the CHEP effectiveness study we employed descriptive statistics and regression analysis to evaluate changes in BP control, Body Mass Index, behavioral adherence and medication adherence and got promising improvements as reported in Odusola, et al. [13].
By design we have reserved the last two stages of the cultural adaptation process, ‘
Approval for Ethical conduct of the main study was obtained from the Ethics Committee of University of Ilorin Teaching Hospital on 30th March 2010. The current study is one of the sub-studies of the main study.
We collected qualitative information from 40 hypertensive patients (systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg). Most of them were 50 years or older, two third were Christians, almost all (80%) earn less than 5USD per day while 70% had only primary school education, and most were artisans engaged in farming, fishing, or petty trading (Table 1).
Hereunder we describe our results based on the first three out of five guideline-based cultural adaptation stages.
The results are in two streams: a)
Our data showed that a people’s culture, customs and beliefs have capacity to discourage uptake and practice of healthy behavior (Table 2).
Our data yielded a rich mix of information on factors encouraging healthy behavior among participants (Table 2). Many felt cultural adaptation of certain local practices made it easier, cheaper and more attractive to practice healthy behavior.
Characteristics | N (%) |
---|---|
Age group (years) | |
• 30–50 | 9 (22.5%) |
• 50–70 | 26 (65%) |
• 70–90 | 5 (12.5%) |
Gender | |
• Male | 16 (40%) |
• Female | 24 (60%) |
Educational level | |
• None or primary education | 28 (70%) |
• Secondary education | 9 (22.5%) |
• Tertiary education | 3 (7.5%) |
Ethnicity | |
• Nupe | 6 (15%) |
• Yoruba | 31 (77.5%) |
• Others | 3 (7.5%) |
Socio-demographic characteristics of participants.
Category | Sub-category | Concepts and Examples | |
---|---|---|---|
Factors motivating healthy behavior | Factors inhibiting healthy behavior | ||
Food related practices: Salt use | Food conservation practices | Salt can preserve food stocks against microbial degradation [n = 3]* | |
Food preparation practices | A salt-less diet is repulsive to the African mindset [n = 7] | ||
Salt and salt products (e.g.maggi) are substantially used in meals preparation [n = 14] | |||
Medicinal use of salt | Salted water (salt solution) is a sure panacea for abdominal/stomach discomfort [n = 3] | ||
Food related practices: Salt use | Availability of suitable salt substitute | Following health counseling, I found out that meals prepared with | |
Food related practices: Fruits and vegetables consumption | Endowment of rural environments with health-promoting possibilities and practices: arable land for vegetable and fruit farming and poultry; and streams and rivers for fishing | I now get enough vegetables in my regular diet from vegetable gardening at my backyard [n = 5] | |
Societal socio-cultural perceptions: weight gain | Increase in body size perceived as wealth, affluence, comfort | The bigger one is the wealthier, affluent and more comfortable he/she is perceived [n = 12] | |
Decrease in body size perceived as illness, disease | Deliberate weight loss or slimming down perceived as being caused by serious internal disease [n = 13] | ||
Increase in body size (bigness) perceived as a woman’s beauty or sexual attractiveness | The fatter a woman is, the more beautiful and attractive she is viewed [n = 7] | ||
Weight gain or Obesity perceived inherited or natural in some families | Heaviness or fatness runs in my family; we normally have big sizes [n = 3] | ||
Some local delicacies have fattening tendency | Popular local meals are often heavily starch-based, e.g. Pounded yam, Garri-eba [n = 5] | ||
Red Palm-oil, Groundnut oil readily available in our environment [n = 11] | |||
Popular local goat-breeding practice makes red meat readily available [n = 2] | |||
Socio-cultural perceptions: weight reduction | Cultural perceptions and orientations: being fat is tantamount to ugliness, sluggishness and physical unfitness | People will say: look at him, ‘big for nothing’, he will not be able to enjoy breathing, worse still [n = 3]. | |
Socio-cultural perceptions: lack of exercise | Perception of exercise as related to elderly “fragile” health and wellbeing | Popular view: exercising is dangerous with increasing age, and to health the elderly [n = 7] | |
Perception of exercise as related to perceived necessity | Popular view: walking long distances just to exercise could only mean one is unserious and greedy to avoid spending travel costs [n = 5] | ||
Socio-cultural perceptions: exercise and physical fitness | Cultural practices and environmental possibilities to achieve physical fitness | Brisk trekking to farm, other destinations; dancing and clapping in church; drumming during festivals; food grains grinding and yam pounding; farming and gardening activities; laundry (washing clothes), sweeping floors,; and where feasible canoe paddling on rivers | |
Socio-cultural perceptions: social habits | Smoking and non-smoking tobacco and Snuff uses are wrongly perceived beneficial to health | Cigarette smoking and Snuff sniffing relieve tension and aid work [n = 1] | |
There’s a perception that local alcoholic beverage (Palm wine) and Kola nuts are beneficial to health | Palm wine makes vision clearer [n = 1], chewing kola nuts stimulate task performance and it’s a social standard for elders to chew kola nuts [n = 2] | ||
Socio-cultural perceptions: social habits | Faith-based and gender-based considerations that discourages use of alcohol and tobacco | Faith-based and gender-based abhorrence of smoking, alcohol and tobacco by women; society frowns seriously at sight of a woman smoking cigarette |
Motivational and inhibitory factors of healthy behavior: Thematic matrix of categories, sub-categories and concepts.
Notes: n refers to the number of respondents who expressed the implied view.
Cultural adaptation of the Education Program was accomplished based on the conceptual framework of formative research using information obtained from qualitative interviews with patients. The other anticipated source of information, literature review, did not yield much useful information on the topic from the study region. Osuna et al. similarly relied substantially on information from a Focus Group Discussion with participants to achieve cultural adaptation design of a diabetes Intervention program among Latinas in the United States [11]. The adaptation in our study was achieved through cultural modification of existing behavioral health practices among the local population. This involved modifying the
Furthermore, in Table 4 we highlight the thematic categories of the relationships existing between traditional local perspectives and cultural practices, and their adaptability following educational counseling drawing from newly available culturally relevant information.
Program Content & Procedure | CAHE | CHEP |
---|---|---|
Type of program | Hypertension education program | Hypertension education program |
Focus of program | Hypertension self-management | Hypertension self-management |
Implementation setting | Urban Amsterdam, Netherlands | Rural Kwara, Nigeria |
Study population | Hypertensive Primary care African immigrants (mostly literate) | Hypertensive primary care native Africans (mostly illiterate) |
Language of communication | English | Native Yoruba and Nupe |
Cultural familiarity of education counselors or trainers | Used Dutch nurse Practitioner | Used native African medical and nurse practitioners |
Information gathering method | Qualitative interviews with hypertensive participants | FGD and Qualitative interviews with hypertensive participants |
Cultural exploratory content | Exploratory from a perspective of European urban/city environment | More deeply exploratory from a perspective of rural African socio-cultural environment |
Behavioral health facilities available to support physical fitness and exercise habits | Promoted use of lifestyle referral facilities like gyms, swimming pool, walking out etc. | Promoted use of cultural and environmental possibilities like household chores, farm work, food preparation activities etc. |
Adapted component of dietary counseling | Counseled participants to reduce dietary salt consumption | Supported dietary salt reduction counseling with possibility to replace salt with a suitable local substitute |
Assessment of cultural fitness | Did not assess participants for cultural fitness | Assessed participants for cultural fitness using culturally tailored behavioral health goals |
Effect on hypertension treatment outcome | Significant improvements in diastolic blood pressure and lifestyle adherence | Significant improvements in blood pressure control, medication adherence and lifestyle adherence |
Contents and procedural variances and similarities between culturally adapted CHEP and CAHE.
Notes: CAHE – Culturally appropriate hypertension education; CHEP – Cardiovascular health education program.
Category | Sub-category | Cultural perspectives and linkages | Cultural adaptation and tailoring |
---|---|---|---|
Cultural endowments towards healthy behavior – Diet | Rural African food preservation and preparation practices | Africans are naturally accustomed to high-salt diet | Ability to replace salt with Iru, a suitable local substitute |
Medicinal use of salt | Health-driven ignorant use of salt further diminishes health | Provide enlightenment information about avoidable use of salt | |
Cultural awareness towards healthy behavior – Weight | Local perceptions about body image and size | Societal perception driven preference for big body sizes | Provide useful information to situate body size within health perspectives |
Cultural re-orientation towards healthy behavior – Exercise | Perceived danger of exercise to health | Health-driven concerns about older age-related dangers of exercise | Re-orientate about benefits/risks of age-tailored exercising |
Cultural practices and environmental endowments towards healthy behavior – Physical activity | Perceptions that it is difficult, expensive and time wasting to achieve physical fitness | Realizations that physical fitness is also achievable using usual everyday household chores, cultural and occupational activities, leisure and faith-based activities | Re-orientate patients about the possibility and practicability of cheap, user-friendly, attractive and acceptable cultural and environmental activities as exercise |
Faith-based and societal perspectives and norms | Societal perceptions of certain behaviors as ‘unfaithful’ and ‘anti-social’ e.g. smoking and use of alcohol | Health-driven exploitation of faith-based abhorrence of certain norms to drive healthy behavior | Provide useful information to exploit faith-based and gender-based socio-cultural practices |
Culturally adapted components of existing behavioral practices: Categories, sub-categories, concepts and thematic linkages.
Preliminary evaluation of the culturally adapted educational intervention was implemented in two arms: 1) cultural fitness assessment based on performance of set behavioral health goals; and 2) assessment of effectiveness based on changes in participants’ hypertension treatment outcomes.
To assess cultural fitness, we examined and recorded serial performance of set goals as reported by participants themselves over six 6 months.
Simultaneously, the effectiveness assessment study took place over same period but this not being the focus of the current study, is reported fully elsewhere [13]. Briefly it involved before-, and after assessments of changes in blood pressure (BP) control, medication adherence, behavioral adherence, and body mass index (BMI). Out of an initial 149 included participants, 140 (94%) completed the study. More participants reported high adherence to prescribed medications and behavioral advice at 6 months compared to baseline: respectively, 101 (72%) at 6 months versus 70 (50%) at baseline, (p < 0.001) and 126 (90%) at 6 months versus 106 (76%) at baseline, (p < 0.001). Similarly, participants with controlled BP doubled from 34 (24%) at baseline to 65 (46%) at 6 months, (p = 0.001). The median SBP and DBP decreased from 129.0 to 122.0 mmHg, (p = 0.002) and from 80.0 to 73.5 mmHg, (p < 0.001), respectively. However, BMI did not change (p = 0.444). The improvement in medication adherence was associated with a decrease in medication concerns (p = 0.045) and improvement in medication self-efficacy (p < 0.001).
As indicated in the methods each participant made 5 visits over 6 months: a baseline assessment visit, three intervening group education visits, and a final assessment visit. Hereunder we report the performance of set goals by participants based on self-reports. Using information from our interview data we structured existing local behavioral health practices of the region into 12 distinct culturally tailored goals (Box 1). We guided participants to select, set and practice three preferred goals during the three intervening group visits as well as at home in the weeks that followed their current visit. Their performances were assessed qualitatively during the subsequent visits.
Culturally tailored behavioral health goals set by participants
To reduce amount of salt and salt-containing condiments I currently use in food preparation and/or preservation by half before my next visit
To completely replace salt with
To increase my consumption of healthy foods by eating more fish and at least 3 servings of vegetables and fruits daily before my next visit
To decrease my consumption of unhealthy foods by eating less of red palm oil, groundnut oil, goat meat and other fatty food daily before my next visit
To stop smoking completely if I do, or at least reduce the number of cigarette sticks I smoke daily by half before my next visit
To completely discontinue the use of all socially acceptable non-smoking forms of tobacco (Taba/Snuff), and Kola nuts, or reduce the quantity I use daily by half before my next visit
To completely discontinue consumption of Alcohol and other alcoholic beverages (Spirit, Palm wine, Gin, Ogogoro) perceived as culturally acceptable, or at least reduce the quantities I consume daily by half before my next visit
To exercise more regularly using locally available methods like brisk walking, canoe paddling, cycling or others, to and from my destinations for at least 30 minutes everyday
To exercise more regularly using food preparation processes such as yam/grain pounding in mortars whenever feasible over at least 30 minutes per session before my next visit
To exercise more regularly using usual household chores such as sweeping floors, laundry (washing clothes), pulling/fetching water from wells or others over at least 30 minutes daily before my next visit
To exercise more regularly using usual farming activities such as ground hoeing, shoveling, bush clearing, manual harvesting, gardening etc. over at least 30 minutes daily before my next visit
To exercise more regularly using usual leisurely or faith-related activities such as clapping, dancing, singing, drumming, gaming or others for at least 30 minutes daily before my next visit
We inquired verbally from participants about how well they practiced selected goals during a subsequent visit and graded their responses on a Likert scale as follows:
For how many days in a week did you perform the selected goal?
Response grading: 0-1 day (poor); 2–3 days (fair); 4–5 days (good); 6–7 days (very good)
For how many minutes in a day did you perform the selected goal?
Response grading: 0–10 mins (poor); 11–20 mins (fair); 21–30 mins (good); > 30 mins (very good)
How seriously did you perceive any challenges or difficulties encountered in performing the goals you selected and how well did you resolve the challenges?
Response grading: serious challenges, not resolved (poor); moderate challenges, partly resolved (fair); minor challenges, fully resolved (good); encountered no challenges (very good)
On a scale of 1 to 4 (1 – poor, 2 – fair, 3 – good, 4 – very good), how would you rate yourself on degree of performance (effectiveness), of set goals?
Response: not performed at all (poor); sometimes performed (fair); often performed (good); always performed (very good).
Following this we graded self-rated performances of participants on a Likert scale (Table 5), and found that an overwhelming majority of them performed the selected goals reasonably well. At least 49% and 28% of participants were graded ‘good’ and ‘very good’ respectively on the number of minutes they performed selected goals daily. Furthermore, regarding number of days per week they performed selected goals, about 61% and 11% were graded ‘good’ and ‘very good’ respectively. On their abilities to resolve potential challenges faced, 18% and 56% of participants were graded ‘good’ and ‘very good’ respectively. Finally 30% and 53% of participants were graded ‘good’ and ‘very good’ respectively regarding their perceived effectiveness in performing selected goals.
Performance scale | Participants’ graded performance (Minutes/day) | Participants’ graded performance (Days/week) | Participants’ graded performance (Resolution of challenges) | Participants’ self-rated goals performance (Effectiveness) |
---|---|---|---|---|
N (%) | N (%) | N (%) | N (%) | |
Poor | 23 (16) | 21 (15) | 11 (8) | 0 |
Fair | 10 (7) | 19 (14) | 25 (18) | 24 (17) |
Good | 68 (49) | 85 (61) | 25 (18) | 42 (30) |
Very good | 39 (28) | 15 (11) | 79 (56) | 74 (53) |
Total | 140 (100) | 140 (100) | 140 (100) | 140 (100) |
Assessment of performance of set goals by participants.
The particular types of culturally adapted goals participants preferred to set and pursue yielded interesting information from our data. Viewed against the background of attractiveness and acceptability, such information can be useful in guiding physicians and care givers on behavioral health practices likely to be accepted and complied with by hypertensive patients. This type of information can predict areas in need of counseling reinforcement for patients in efforts to improve hypertension self-management skills. Extracts from our data (Table 6) reveals that the three most preferred and set goals are dietary salt reduction, exercising and compliance with pills use. Similarly, the three least preferred and set goals are stopping tobacco use, limiting alcohol use and stopping kola nuts consumption. Finally, important considerations that guided participants in selecting particular goals include funding performance of the goals, ease/rigor of performance, and access to practicing the goals.
Types of Goals | Educational Sessions | ||
---|---|---|---|
CHEP 1, N (%) | CHEP 2, N (%) | CHEP 3, N (%) | |
Diet (salt restriction) | 124 (89) | 97 (69) | 66 (47) |
Diet (fat restriction) | 23 (16) | 12 (9) | 27 (19) |
Diet (vegetables & fruits consumption) | 16 (11) | 9 (6) | 8 (6) |
Physical fitness & exercise | 121 (86) | 100 (71) | 93 (66) |
Weight reduction | 59 (42) | 47 (34) | 32 (23) |
Quit smoking | 4 (3) | 4 (3) | 2 (1) |
Quit non-smoked tobacco | 5 (4) | 2 (1) | 0 (0) |
Quit Kola nut | 14 (10) | 4 (3) | 7 (5) |
Restrict alcohol | 13 (9) | 10 (7) | 7 (5) |
Comply with pills use | 92 (66) | 78 (56) | 59 (42) |
Comply with clinic appointments | 13 (9) | 19 (14) | 15 (11) |
Frequency and types of behavioral goals set during educational sessions.
We examined the proceedings and results of cultural adaptation of a behavioral treatment program following standard guidelines, among primary care patients with hypertension from rural Nigeria highlighting cultural fitness and effectiveness of the adapted program on their hypertension self-management. Based on theoretical and conceptual framework of formative research described by Resnicow et al. [7], we combined information from exploratory interviews with hypertensive patients with extracts from a review of literature on the topic to adapt a Cardiovascular Health Education Program (CHEP) from an existing Culturally Appropriate Hypertension Education (CAHE) previously deployed among hypertensive African immigrants in the Netherlands [12]. The literature review however did not yield enough relevant information. Our goal was to increase cultural sensitivity and contents of CHEP relative to CAHE and to make the adapted CHEP relevant to specific needs of hypertensive patients from rural Nigeria. Resnicow et al. had proposed combining: a)
Following debates on the most appropriate process for cultural adaptation, researchers arrived at a consensus aggregating various approaches to establish a standard guideline involving five sequential stages: 1) information gathering, stage one; 2) preliminary adaptation design, stage two; 3) preliminary adaptation testing, stage three; 4) adaptation refinement, stage four; and 5) adaptation trial, stage five [10, 17]. In the current study however, by design we opted to adapt CHEP from CAHE using the first three of five guideline-based stages, deferring the last two stages for a future CHEP efficacy trial. A diabetes lifestyle intervention program was similarly adapted for Latinas in the USA using stages one to three only [11].
The local and cultural environments of patients in our study are endowed with materials and possibilities that influenced their hypertension self-management capacities. We found that locally grown Locust Beans ‘
Cultural fitness is determined by the extent to which a people accept and use the language, values, beliefs and materials characteristics of newly introduced culturally tailored interventions targeting their self-management skills. We assessed the adapted intervention for cultural fitness by conducting a goals setting and performance exercise among participants and got promising results on performances by most participants. Similar findings have also been reported from other studies [19, 20, 21]. Moreover during a follow-up FGD participants spoke excitedly and expressed desires to continue to use the education program even after the study. Interestingly we observed that the three most common behavioral goals practiced by participants were
Limitations encountered in this study include:
Participants could have been biased in recalling events and they may have given socially desirable answers on some aspects of our results that are based on self-reports
Without prejudice to results obtained, logistics and funding constraints limited our ability to implement all the five guideline-based cultural adaptation stages
We followed standard guidelines to culturally adapt an existing behavioral health intervention among hypertensive patients from rural Nigeria. Modeled after a similar intervention from Europe we systematically developed and adapted the new intervention using frameworks of formative research. We got quite promising results on evaluating the adapted intervention for cultural fitness and effectiveness. We submit that guide-line based culturally adapted behavioral treatments have potential to improve hypertension treatment outcomes and limit cardiovascular diseases.
The successful control of risk factors among patients at risk of cardiovascular diseases is a major goal of every attending physician. But a major obstacle to this goal is the difficulties faced by patients in adhering to prescribed pills and behavioral advices. Innovations like the current intervention which provides unique information on behavioral practices preferred and disliked by patients can guide physicians on acceptable and adoptable behaviors.
Authors are grateful to the staff of Ogo Oluwa hospital and the health insurance company. We thank Health Insurance Fund, PharmAccess Foundation, and NUFFIC for supporting the study.
The authors declare no conflict of interest.
AO drafted the manuscript, designed and conducted the study. AA revised versions of the draft. Both authors approved the final draft.
Ove Odredbe i uvjeti ističu pravila i regulacije u svezi korištenja IntechOpenove stranice www.intechopen.com i svih poddomena u vlasništvu IntechOpena, tvrtke sa sjedištem u 5 Princes Gate Court, London, SW7 2QJ, Ujedinjeno Kraljevstvo.
',metaTitle:"Odredbe i uvjeti",metaDescription:"Ove Odredbe i uvjeti ističu pravila i regulacije u svezi korištenja IntechOpenove stranice www.intechopen.com i svih poddomena u vlasništvu IntechOpena, tvrtke sa sjedištem u 5 Princes Gate Court, London, SW7 2QJ, Ujedinjeno Kraljevstvo.",metaKeywords:null,canonicalURL:"/page/cro-terms-and-conditions",contentRaw:'[{"type":"htmlEditorComponent","content":"Pristupom na stranicu www.intechopen.com slažete se s ovim odredbama, sa svim primjenjivim zakonskim odredbama, te se slažete s poštovanjem svih lokalnih zakona. Korištenje i/ili pristup ovoj stranici temelji se na potpunom prihvaćanju ovih odredbi. Svi materijali na ovoj stranici zaštićeni su primjenjivim zakonima o autorskim pravima i žigu.
\\n\\nSljedeća terminologija odnosi se na Odredbe i uvjete, te na sve naše ugovore:
\\n\\nKlijent, stranka, vi, vaš odnosi se na vas, osobu koja pristupa ovoj stranici i prihvaća IntechOpenove Odredbe i uvjete;
\\n\\nKompanija, tvrtka, mi, naše odnosi se na tvrtku IntechOpen;
\\n\\nStranke, strane odnosi se na klijenta i na nas, ili samo na klijenta ili nas.
\\n\\nSve odredbe koje se odnose na ponudu, prihvat ili razmatranje plaćanja, a za koja mi pružamo asistenciju klijentu, bilo na ugovoreni ili fiksni način, a s ciljem da se ostvare potrebe i želje klijenta u svezi s našim uslugama, su podložne zakonskim odredbama Ujedinjenog Kraljevstva.
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\\n\\nMi koristimo kolačiće. Korištenjem IntechOpenove stranice slažete se s korištenjem kolačića u skladu s IntechOpenovom Politikom privatnosti. Većina modernih, interaktivnih stranica koristi kolačiće kako bi omogućila ponovno pronalaženje korisničkih detalja kod svakog posjeta. Na našoj stranici kolačići se uglavnom koriste kako bi omogućili funkcionalnost i olakšali posjetiteljima korištenje stranice.
\\n\\nIntechOpen ili njegovi suradnici niti u jednom slučaju neće biti odgovorni za štete (štete uključuju gubitak podataka ili profita, druge poslovne prekide, te sve ostale štete) koje nastanu zbog korištenja materijala na IntechOpenovoj stranici ili nemogućnosti da se iste koriste, čak i ako je IntechOpen ili njegov predstavnik o takvoj šteti obaviješten pismenim ili usmenim putem. Neke jurisdikcije ne dozvoljavaju ograničenja garancija ili ograničenja obveza za posljedične ili slučajne štete pa se u tom slučaju ova ograničenja možda ne odnose na vas.
\\n\\nMaterijali koji se pojavljuju na IntechOpenovoj stranici mogu sadržavati manje greške, tipfelere ili fotografske greške. IntechOpen može napraviti promjene na bilo kojem materijalu koji se nalazi na stranici u bilo koje vrijeme.
\\n\\nIntechOpen nije formalno povezan niti s jednom vanjskom stranicom čije poveznice vode na www.intechopen.com, osim ako to nije izravno navedeno. Iz tog razloga IntechOpen nije odgovoran za sadržaj koji se pojavljuje na takvim stranicama. Poveznica na IntechOpenovu stranicu ne implicira povezanost sa IntechOpenom. Korištenje takvih poveznica isključiva je odgovornost korisnika.
\\n\\nZadržavamo pravo vlasništva nad cjelokupnom stranicom www.intechopen.com i nad svim materijalom na toj stranici. Koristeći se našim uslugama, slažete se da maknete sve poveznice na našu stranicu odmah nakon što to od vas zatražimo. Također, zadržavamo pravo da ove Odredbe i uvjete, i politiku o poveznicama izmjenimo u bilo koje vrijeme. Koristeći se poveznicama na naše stranice slažete se s ovim Odredbama i uvjetima.
\\n\\nAko smatrate da je bilo koja poveznica na našoj stranici sumnjiva iz bilo kojeg razloga, molimo vas da nas kontaktirate. U tom slučaju razmotrit ćemo micanje poveznice s naše stranice, iako nismo obvezni to napraviti.
\\n\\nBez prethodne privole i izričite pisane dozvole, ne možete stvarati okvire oko naših stranica ili koristiti druge tehnike koje na bilo koji način mogu promijeniti prezentaciju ili izgled naše stranice.
\\n\\nIntechOpen može ove Odredbe izmijeniti u bilo koje vrijeme i bez prethodne obavijesti. Koristeći ovu stranicu vi se slažete s trenutnim Odredbama i uvjetima koje su na snazi.
\\n\\nOve Odredbe i uvjeti su sastavljeni u skladu s odredbama prava Ujedinjenog Kraljevstva, a za sve sporove nadležan je sud u Londonu, Ujedinjeno Kraljevstvo.
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\n\nSljedeća terminologija odnosi se na Odredbe i uvjete, te na sve naše ugovore:
\n\nKlijent, stranka, vi, vaš odnosi se na vas, osobu koja pristupa ovoj stranici i prihvaća IntechOpenove Odredbe i uvjete;
\n\nKompanija, tvrtka, mi, naše odnosi se na tvrtku IntechOpen;
\n\nStranke, strane odnosi se na klijenta i na nas, ili samo na klijenta ili nas.
\n\nSve odredbe koje se odnose na ponudu, prihvat ili razmatranje plaćanja, a za koja mi pružamo asistenciju klijentu, bilo na ugovoreni ili fiksni način, a s ciljem da se ostvare potrebe i želje klijenta u svezi s našim uslugama, su podložne zakonskim odredbama Ujedinjenog Kraljevstva.
\n\nOsim ako nije suprotno navedeno, IntechOpen i/ili svi davatelji licence vlasnici su intelektualnog vlasništva nad svim materijalima na www.intechopen.com. Sva prava intelektualnog vlasništva su pridržana. Stranice sa www.intechopen.com možete gledati, preuzimati, dijeliti, dijeliti poveznice i printati za osobnu uporabu, a temeljem pravila sadržanih u ovim Odredbama i uvjetima.
\n\nMi koristimo kolačiće. Korištenjem IntechOpenove stranice slažete se s korištenjem kolačića u skladu s IntechOpenovom Politikom privatnosti. Većina modernih, interaktivnih stranica koristi kolačiće kako bi omogućila ponovno pronalaženje korisničkih detalja kod svakog posjeta. Na našoj stranici kolačići se uglavnom koriste kako bi omogućili funkcionalnost i olakšali posjetiteljima korištenje stranice.
\n\nIntechOpen ili njegovi suradnici niti u jednom slučaju neće biti odgovorni za štete (štete uključuju gubitak podataka ili profita, druge poslovne prekide, te sve ostale štete) koje nastanu zbog korištenja materijala na IntechOpenovoj stranici ili nemogućnosti da se iste koriste, čak i ako je IntechOpen ili njegov predstavnik o takvoj šteti obaviješten pismenim ili usmenim putem. Neke jurisdikcije ne dozvoljavaju ograničenja garancija ili ograničenja obveza za posljedične ili slučajne štete pa se u tom slučaju ova ograničenja možda ne odnose na vas.
\n\nMaterijali koji se pojavljuju na IntechOpenovoj stranici mogu sadržavati manje greške, tipfelere ili fotografske greške. IntechOpen može napraviti promjene na bilo kojem materijalu koji se nalazi na stranici u bilo koje vrijeme.
\n\nIntechOpen nije formalno povezan niti s jednom vanjskom stranicom čije poveznice vode na www.intechopen.com, osim ako to nije izravno navedeno. Iz tog razloga IntechOpen nije odgovoran za sadržaj koji se pojavljuje na takvim stranicama. Poveznica na IntechOpenovu stranicu ne implicira povezanost sa IntechOpenom. Korištenje takvih poveznica isključiva je odgovornost korisnika.
\n\nZadržavamo pravo vlasništva nad cjelokupnom stranicom www.intechopen.com i nad svim materijalom na toj stranici. Koristeći se našim uslugama, slažete se da maknete sve poveznice na našu stranicu odmah nakon što to od vas zatražimo. Također, zadržavamo pravo da ove Odredbe i uvjete, i politiku o poveznicama izmjenimo u bilo koje vrijeme. Koristeći se poveznicama na naše stranice slažete se s ovim Odredbama i uvjetima.
\n\nAko smatrate da je bilo koja poveznica na našoj stranici sumnjiva iz bilo kojeg razloga, molimo vas da nas kontaktirate. U tom slučaju razmotrit ćemo micanje poveznice s naše stranice, iako nismo obvezni to napraviti.
\n\nBez prethodne privole i izričite pisane dozvole, ne možete stvarati okvire oko naših stranica ili koristiti druge tehnike koje na bilo koji način mogu promijeniti prezentaciju ili izgled naše stranice.
\n\nIntechOpen može ove Odredbe izmijeniti u bilo koje vrijeme i bez prethodne obavijesti. Koristeći ovu stranicu vi se slažete s trenutnim Odredbama i uvjetima koje su na snazi.
\n\nOve Odredbe i uvjeti su sastavljeni u skladu s odredbama prava Ujedinjenog Kraljevstva, a za sve sporove nadležan je sud u Londonu, Ujedinjeno Kraljevstvo.
\n"}]},successStories:{items:[]},authorsAndEditors:{filterParams:{},profiles:[{id:"396",title:"Dr.",name:"Vedran",middleName:null,surname:"Kordic",slug:"vedran-kordic",fullName:"Vedran Kordic",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/396/images/7281_n.png",biography:"After obtaining his Master's degree in Mechanical Engineering he continued his education at the Vienna University of Technology where he obtained his PhD degree in 2004. He worked as a researcher at the Automation and Control Institute, Faculty of Electrical Engineering, Vienna University of Technology until 2008. His studies in robotics lead him not only to a PhD degree but also inspired him to co-found and build the International Journal of Advanced Robotic Systems - world's first Open Access journal in the field of robotics.",institutionString:null,institution:{name:"TU Wien",country:{name:"Austria"}}},{id:"441",title:"Ph.D.",name:"Jaekyu",middleName:null,surname:"Park",slug:"jaekyu-park",fullName:"Jaekyu Park",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/441/images/1881_n.jpg",biography:null,institutionString:null,institution:{name:"LG Corporation (South Korea)",country:{name:"Korea, South"}}},{id:"465",title:"Dr",name:"Christian",middleName:null,surname:"Martens",slug:"christian-martens",fullName:"Christian Martens",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:null},{id:"479",title:"Dr.",name:"Valentina",middleName:null,surname:"Colla",slug:"valentina-colla",fullName:"Valentina Colla",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/479/images/358_n.jpg",biography:null,institutionString:null,institution:{name:"Sant'Anna School of Advanced Studies",country:{name:"Italy"}}},{id:"494",title:"PhD",name:"Loris",middleName:null,surname:"Nanni",slug:"loris-nanni",fullName:"Loris Nanni",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/494/images/system/494.jpg",biography:"Loris Nanni received his Master Degree cum laude on June-2002 from the University of Bologna, and the April 26th 2006 he received his Ph.D. in Computer Engineering at DEIS, University of Bologna. On September, 29th 2006 he has won a post PhD fellowship from the university of Bologna (from October 2006 to October 2008), at the competitive examination he was ranked first in the industrial engineering area. He extensively served as referee for several international journals. He is author/coauthor of more than 100 research papers. He has been involved in some projects supported by MURST and European Community. His research interests include pattern recognition, bioinformatics, and biometric systems (fingerprint classification and recognition, signature verification, face recognition).",institutionString:null,institution:null},{id:"496",title:"Dr.",name:"Carlos",middleName:null,surname:"Leon",slug:"carlos-leon",fullName:"Carlos Leon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Seville",country:{name:"Spain"}}},{id:"512",title:"Dr.",name:"Dayang",middleName:null,surname:"Jawawi",slug:"dayang-jawawi",fullName:"Dayang Jawawi",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Technology Malaysia",country:{name:"Malaysia"}}},{id:"528",title:"Dr.",name:"Kresimir",middleName:null,surname:"Delac",slug:"kresimir-delac",fullName:"Kresimir Delac",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/528/images/system/528.jpg",biography:"K. Delac received his B.Sc.E.E. degree in 2003 and is currentlypursuing a Ph.D. degree at the University of Zagreb, Faculty of Electrical Engineering andComputing. His current research interests are digital image analysis, pattern recognition andbiometrics.",institutionString:null,institution:{name:"University of Zagreb",country:{name:"Croatia"}}},{id:"557",title:"Dr.",name:"Andon",middleName:"Venelinov",surname:"Topalov",slug:"andon-topalov",fullName:"Andon Topalov",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/557/images/1927_n.jpg",biography:"Dr. Andon V. Topalov received the MSc degree in Control Engineering from the Faculty of Information Systems, Technologies, and Automation at Moscow State University of Civil Engineering (MGGU) in 1979. He then received his PhD degree in Control Engineering from the Department of Automation and Remote Control at Moscow State Mining University (MGSU), Moscow, in 1984. From 1985 to 1986, he was a Research Fellow in the Research Institute for Electronic Equipment, ZZU AD, Plovdiv, Bulgaria. In 1986, he joined the Department of Control Systems, Technical University of Sofia at the Plovdiv campus, where he is presently a Full Professor. He has held long-term visiting Professor/Scholar positions at various institutions in South Korea, Turkey, Mexico, Greece, Belgium, UK, and Germany. And he has coauthored one book and authored or coauthored more than 80 research papers in conference proceedings and journals. His current research interests are in the fields of intelligent control and robotics.",institutionString:null,institution:{name:"Technical University of Sofia",country:{name:"Bulgaria"}}},{id:"585",title:"Prof.",name:"Munir",middleName:null,surname:"Merdan",slug:"munir-merdan",fullName:"Munir Merdan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/585/images/system/585.jpg",biography:"Munir Merdan received the M.Sc. degree in mechanical engineering from the Technical University of Sarajevo, Bosnia and Herzegovina, in 2001, and the Ph.D. degree in electrical engineering from the Vienna University of Technology, Vienna, Austria, in 2009.Since 2005, he has been at the Automation and Control Institute, Vienna University of Technology, where he is currently a Senior Researcher. His research interests include the application of agent technology for achieving agile control in the manufacturing environment.",institutionString:null,institution:null},{id:"605",title:"Prof",name:"Dil",middleName:null,surname:"Hussain",slug:"dil-hussain",fullName:"Dil Hussain",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/605/images/system/605.jpg",biography:"Dr. Dil Muhammad Akbar Hussain is a professor of Electronics Engineering & Computer Science at the Department of Energy Technology, Aalborg University Denmark. Professor Akbar has a Master degree in Digital Electronics from Govt. College University, Lahore Pakistan and a P-hD degree in Control Engineering from the School of Engineering and Applied Sciences, University of Sussex United Kingdom. Aalborg University has Two Satellite Campuses, one in Copenhagen (Aalborg University Copenhagen) and the other in Esbjerg (Aalborg University Esbjerg).\n· He is a member of prestigious IEEE (Institute of Electrical and Electronics Engineers), and IAENG (International Association of Engineers) organizations. \n· He is the chief Editor of the Journal of Software Engineering.\n· He is the member of the Editorial Board of International Journal of Computer Science and Software Technology (IJCSST) and International Journal of Computer Engineering and Information Technology. \n· He is also the Editor of Communication in Computer and Information Science CCIS-20 by Springer.\n· Reviewer For Many Conferences\nHe is the lead person in making collaboration agreements between Aalborg University and many universities of Pakistan, for which the MOU’s (Memorandum of Understanding) have been signed.\nProfessor Akbar is working in Academia since 1990, he started his career as a Lab demonstrator/TA at the University of Sussex. After finishing his P. hD degree in 1992, he served in the Industry as a Scientific Officer and continued his academic career as a visiting scholar for a number of educational institutions. In 1996 he joined National University of Science & Technology Pakistan (NUST) as an Associate Professor; NUST is one of the top few universities in Pakistan. In 1999 he joined an International Company Lineo Inc, Canada as Manager Compiler Group, where he headed the group for developing Compiler Tool Chain and Porting of Operating Systems for the BLACKfin processor. The processor development was a joint venture by Intel and Analog Devices. In 2002 Lineo Inc., was taken over by another company, so he joined Aalborg University Denmark as an Assistant Professor.\nProfessor Akbar has truly a multi-disciplined career and he continued his legacy and making progress in many areas of his interests both in teaching and research. 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This problematic is particularly relevant with medical imaging data, where linear techniques are frequently unsuitable for capturing variations in anatomical structures. In many cases, there is enough structure in the data (CT, MRI, ultrasound) so a lower dimensional object can describe the degrees of freedom, such as in a manifold structure. Still, complex, multivariate distributions tend to demonstrate highly variable structural topologies that are impossible to capture with a single manifold learning algorithm. This chapter will present recent techniques developed in manifold theory for medical imaging analysis, to allow for statistical organ shape modeling, image segmentation and registration from the concept of navigation of manifolds, classification, as well as disease prediction models based on discriminant manifolds. We will present the theoretical basis of these works, with illustrative results on their applications from various organs and pathologies, including neurodegenerative diseases and spinal deformities.",book:{id:"7342",slug:"manifolds-ii-theory-and-applications",title:"Manifolds II",fullTitle:"Manifolds II - Theory and Applications"},signatures:"Samuel Kadoury",authors:null},{id:"52886",doi:"10.5772/65903",title:"Head Pose Estimation via Manifold Learning",slug:"head-pose-estimation-via-manifold-learning",totalDownloads:1793,totalCrossrefCites:4,totalDimensionsCites:3,abstract:"For the last decades, manifold learning has shown its advantage of efficient non-linear dimensionality reduction in data analysis. Based on the assumption that informative and discriminative representation of the data lies on a low-dimensional smooth manifold which implicitly embedded in the original high-dimensional space, manifold learning aims to learn the low-dimensional representation following some geometrical protocols, such as preserving piecewise local structure of the original data. Manifold learning also plays an important role in the applications of computer vision, i.e., face image analysis. According to the observations that many face-related research is benefitted by the head pose estimation, and the continuous variation of head pose can be modelled and interpreted as a low-dimensional smooth manifold, we will focus on the head pose estimation via manifold learning in this chapter. Generally, head pose is hard to directly explore from the high-dimensional space interpreted as face images, which is, however, can be efficiently represented in low-dimensional manifold. Therefore, in this chapter, classical manifold learning algorithms are introduced and the corresponding application on head pose estimation are elaborated. Several extensions of manifold learning algorithms which are developed especially for head pose estimation are also discussed and compared.",book:{id:"5488",slug:"manifolds-current-research-areas",title:"Manifolds",fullTitle:"Manifolds - Current Research Areas"},signatures:"Chao Wang, Yuanhao Guo and Xubo Song",authors:[{id:"190308",title:"Dr.",name:"Chao",middleName:null,surname:"Wang",slug:"chao-wang",fullName:"Chao Wang"},{id:"190461",title:"Prof.",name:"Xubo",middleName:null,surname:"Song",slug:"xubo-song",fullName:"Xubo Song"},{id:"191562",title:"MSc.",name:"Yuanhao",middleName:null,surname:"Guo",slug:"yuanhao-guo",fullName:"Yuanhao Guo"}]},{id:"62804",doi:"10.5772/intechopen.79383",title:"Recent Advances of Manifold Regularization",slug:"recent-advances-of-manifold-regularization",totalDownloads:1070,totalCrossrefCites:0,totalDimensionsCites:3,abstract:"Semi-supervised learning (SSL) that can make use of a small number of labeled data with a large number of unlabeled data to produce significant improvement in learning performance has been received considerable attention. Manifold regularization is one of the most popular works that exploits the geometry of the probability distribution that generates the data and incorporates them as regularization terms. There are many representative works of manifold regularization including Laplacian regularization (LapR), Hessian regularization (HesR) and p-Laplacian regularization (pLapR). Based on the manifold regularization framework, many extensions and applications have been reported. In the chapter, we review the LapR and HesR, and we introduce an approximation algorithm of graph p-Laplacian. We study several extensions of this framework for pairwise constraint, p-Laplacian learning, hypergraph learning, etc.",book:{id:"7342",slug:"manifolds-ii-theory-and-applications",title:"Manifolds II",fullTitle:"Manifolds II - Theory and Applications"},signatures:"Xueqi Ma and Weifeng Liu",authors:null},{id:"53713",doi:"10.5772/67008",title:"An Intrinsic Characterization of Bonnet Surfaces Based on a Closed Differential Ideal",slug:"an-intrinsic-characterization-of-bonnet-surfaces-based-on-a-closed-differential-ideal",totalDownloads:1459,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"The structure equations for a two‐dimensional manifold are introduced and two results based on the Codazzi equations pertinent to the study of isometric surfaces are obtained from them. Important theorems pertaining to isometric surfaces are stated and a theorem due to Bonnet is obtained. A transformation for the connection forms is developed. It is proved that the angle of deformation must be harmonic, and that the differentials of many of the important variables generate a closed differential ideal. This implies that a coordinate system exists in which many of the variables satisfy particular ordinary differential equations, and these results can be used to characterize Bonnet surfaces.",book:{id:"5488",slug:"manifolds-current-research-areas",title:"Manifolds",fullTitle:"Manifolds - Current Research Areas"},signatures:"Paul Bracken",authors:[{id:"92883",title:"Prof.",name:"Paul",middleName:null,surname:"Bracken",slug:"paul-bracken",fullName:"Paul Bracken"}]},{id:"72257",doi:"10.5772/intechopen.92441",title:"Quasiconformal Reflections across Polygonal Lines",slug:"quasiconformal-reflections-across-polygonal-lines",totalDownloads:419,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"An important open problem in geometric complex analysis is to establish algorithms for explicit determination of the basic curvelinear and analytic functionals intrinsically connected with conformal and quasiconformal maps, such as their Teichmüller and Grunsky norms, Fredholm eigenvalues and the quasireflection coefficient. This has not been solved even for convex polygons. This case has intrinsic interest in view of the connection of polygons with the geometry of the universal Teichmüller space and approximation theory. This survey extends our previous survey of 2005 and presents the new approaches and recent essential progress in this field of geometric complex analysis, having various important applications. Another new topic concerns quasireflections across finite collections of quasiintervals.",book:{id:"8760",slug:"structure-topology-and-symplectic-geometry",title:"Structure Topology and Symplectic Geometry",fullTitle:"Structure Topology and Symplectic Geometry"},signatures:"Samuel L. 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Clifford algebra unifies and generalizes real number, complex, quaternion, and vector algebra and converts complicated relations and operations into intuitive matrix algebra independent of coordinate systems. By localizing the basis or frame of space-time and introducing differential and connection operators, Clifford algebra also contains Riemann geometry. Clifford algebra provides a unified, standard, elegant, and open language and tools for numerous complicated mathematical and physical theories. Clifford algebra calculus is an arithmetic-like operation that can be well understood by everyone. This feature is very useful for teaching purposes, and popularizing Clifford algebra in high schools and universities will greatly improve the efficiency of students to learn fundamental knowledge of mathematics and physics. So, Clifford algebra can be expected to complete a new big synthesis of scientific knowledge.",book:{id:"8760",slug:"structure-topology-and-symplectic-geometry",title:"Structure Topology and Symplectic Geometry",fullTitle:"Structure Topology and Symplectic Geometry"},signatures:"Ying-Qiu Gu",authors:[{id:"314607",title:"Dr.",name:"Ying-Qiu",middleName:null,surname:"Gu",slug:"ying-qiu-gu",fullName:"Ying-Qiu Gu"}]},{id:"52596",title:"Symplectic Manifolds: Gromov-Witten Invariants on Symplectic and Almost Contact Metric Manifolds",slug:"symplectic-manifolds-gromov-witten-invariants-on-symplectic-and-almost-contact-metric-manifolds",totalDownloads:1496,totalCrossrefCites:0,totalDimensionsCites:0,abstract:"In this chapter, we introduce Gromov-Witten invariant, quantum cohomology, Gromov-Witten potential, and Floer cohomology on symplectic manifolds, and in connection with these, we describe Gromov-Witten type invariant, quantum type cohomology, Gromov-Witten type potential and Floer type cohomology on almost contact metric manifolds. On the product of a symplectic manifold and an almost contact metric manifold, we induce some relations between Gromov-Witten type invariant and quantum cohomology and quantum type invariant. We show that the quantum type cohomology is isomorphic to the Floer type cohomology.",book:{id:"5488",slug:"manifolds-current-research-areas",title:"Manifolds",fullTitle:"Manifolds - Current Research Areas"},signatures:"Yong Seung Cho",authors:[{id:"62522",title:"Prof.",name:"Yong Seung",middleName:null,surname:"Cho",slug:"yong-seung-cho",fullName:"Yong Seung Cho"}]},{id:"62804",title:"Recent Advances of Manifold Regularization",slug:"recent-advances-of-manifold-regularization",totalDownloads:1070,totalCrossrefCites:0,totalDimensionsCites:3,abstract:"Semi-supervised learning (SSL) that can make use of a small number of labeled data with a large number of unlabeled data to produce significant improvement in learning performance has been received considerable attention. Manifold regularization is one of the most popular works that exploits the geometry of the probability distribution that generates the data and incorporates them as regularization terms. There are many representative works of manifold regularization including Laplacian regularization (LapR), Hessian regularization (HesR) and p-Laplacian regularization (pLapR). Based on the manifold regularization framework, many extensions and applications have been reported. In the chapter, we review the LapR and HesR, and we introduce an approximation algorithm of graph p-Laplacian. We study several extensions of this framework for pairwise constraint, p-Laplacian learning, hypergraph learning, etc.",book:{id:"7342",slug:"manifolds-ii-theory-and-applications",title:"Manifolds II",fullTitle:"Manifolds II - Theory and Applications"},signatures:"Xueqi Ma and Weifeng Liu",authors:null},{id:"53552",title:"Sub-Manifolds of a Riemannian Manifold",slug:"sub-manifolds-of-a-riemannian-manifold",totalDownloads:1734,totalCrossrefCites:1,totalDimensionsCites:1,abstract:"In this chapter, we introduce the theory of sub-manifolds of a Riemannian manifold. The fundamental notations are given. The theory of sub-manifolds of an almost Riemannian product manifold is one of the most interesting topics in differential geometry. According to the behaviour of the tangent bundle of a sub-manifold, with respect to the action of almost Riemannian product structure of the ambient manifolds, we have three typical classes of sub-manifolds such as invariant sub-manifolds, anti-invariant sub-manifolds and semi-invariant sub-manifolds. In addition, slant, semi-slant and pseudo-slant sub-manifolds are introduced by many geometers.",book:{id:"5488",slug:"manifolds-current-research-areas",title:"Manifolds",fullTitle:"Manifolds - Current Research Areas"},signatures:"Mehmet Atçeken, Ümit Yıldırım and Süleyman Dirik",authors:[{id:"191326",title:"Prof.",name:"Mehmet",middleName:null,surname:"Atceken",slug:"mehmet-atceken",fullName:"Mehmet Atceken"},{id:"196148",title:"Dr.",name:"Umit",middleName:null,surname:"Yildirim",slug:"umit-yildirim",fullName:"Umit Yildirim"}]},{id:"52886",title:"Head Pose Estimation via Manifold Learning",slug:"head-pose-estimation-via-manifold-learning",totalDownloads:1793,totalCrossrefCites:4,totalDimensionsCites:3,abstract:"For the last decades, manifold learning has shown its advantage of efficient non-linear dimensionality reduction in data analysis. Based on the assumption that informative and discriminative representation of the data lies on a low-dimensional smooth manifold which implicitly embedded in the original high-dimensional space, manifold learning aims to learn the low-dimensional representation following some geometrical protocols, such as preserving piecewise local structure of the original data. Manifold learning also plays an important role in the applications of computer vision, i.e., face image analysis. According to the observations that many face-related research is benefitted by the head pose estimation, and the continuous variation of head pose can be modelled and interpreted as a low-dimensional smooth manifold, we will focus on the head pose estimation via manifold learning in this chapter. Generally, head pose is hard to directly explore from the high-dimensional space interpreted as face images, which is, however, can be efficiently represented in low-dimensional manifold. 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Dr. Koprowski has authored more than a hundred research papers with dozens in impact factor (IF) journals and has authored or co-authored six books. Additionally, he is the author of several national and international patents in the field of biomedical devices and imaging. Since 2011, he has been a reviewer of grants and projects (including EU projects) in biomedical engineering.",institutionString:null,institution:{name:"University of Silesia",institutionURL:null,country:{name:"Poland"}}},subseries:[{id:"7",title:"Bioinformatics and Medical Informatics",keywords:"Biomedical Data, Drug Discovery, Clinical Diagnostics, Decoding Human Genome, AI in Personalized Medicine, Disease-prevention Strategies, Big Data Analysis in Medicine",scope:"Bioinformatics aims to help understand the functioning of the mechanisms of living organisms through the construction and use of quantitative tools. The applications of this research cover many related fields, such as biotechnology and medicine, where, for example, Bioinformatics contributes to faster drug design, DNA analysis in forensics, and DNA sequence analysis in the field of personalized medicine. Personalized medicine is a type of medical care in which treatment is customized individually for each patient. Personalized medicine enables more effective therapy, reduces the costs of therapy and clinical trials, and also minimizes the risk of side effects. Nevertheless, advances in personalized medicine would not have been possible without bioinformatics, which can analyze the human genome and other vast amounts of biomedical data, especially in genetics. The rapid growth of information technology enabled the development of new tools to decode human genomes, large-scale studies of genetic variations and medical informatics. The considerable development of technology, including the computing power of computers, is also conducive to the development of bioinformatics, including personalized medicine. In an era of rapidly growing data volumes and ever lower costs of generating, storing and computing data, personalized medicine holds great promises. Modern computational methods used as bioinformatics tools can integrate multi-scale, multi-modal and longitudinal patient data to create even more effective and safer therapy and disease prevention methods. Main aspects of the topic are: Applying bioinformatics in drug discovery and development; Bioinformatics in clinical diagnostics (genetic variants that act as markers for a condition or a disease); Blockchain and Artificial Intelligence/Machine Learning in personalized medicine; Customize disease-prevention strategies in personalized medicine; Big data analysis in personalized medicine; Translating stratification algorithms into clinical practice of personalized medicine.",annualVolume:11403,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/7.jpg",editor:{id:"351533",title:"Dr.",name:"Slawomir",middleName:null,surname:"Wilczynski",fullName:"Slawomir Wilczynski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000035U1loQAC/Profile_Picture_1630074514792",institutionString:null,institution:{name:"Medical University of Silesia",institutionURL:null,country:{name:"Poland"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"5886",title:"Dr.",name:"Alexandros",middleName:"T.",surname:"Tzallas",fullName:"Alexandros Tzallas",profilePictureURL:"https://mts.intechopen.com/storage/users/5886/images/system/5886.png",institutionString:"University of Ioannina, Greece & Imperial College London",institution:{name:"University of Ioannina",institutionURL:null,country:{name:"Greece"}}},{id:"257388",title:"Distinguished Prof.",name:"Lulu",middleName:null,surname:"Wang",fullName:"Lulu Wang",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRX6kQAG/Profile_Picture_1630329584194",institutionString:null,institution:{name:"Shenzhen Technology University",institutionURL:null,country:{name:"China"}}},{id:"225387",title:"Prof.",name:"Reda",middleName:"R.",surname:"Gharieb",fullName:"Reda Gharieb",profilePictureURL:"https://mts.intechopen.com/storage/users/225387/images/system/225387.jpg",institutionString:"Assiut University",institution:{name:"Assiut University",institutionURL:null,country:{name:"Egypt"}}}]},{id:"8",title:"Bioinspired Technology and Biomechanics",keywords:"Bioinspired Systems, Biomechanics, Assistive Technology, Rehabilitation",scope:'Bioinspired technologies take advantage of understanding the actual biological system to provide solutions to problems in several areas. Recently, bioinspired systems have been successfully employing biomechanics to develop and improve assistive technology and rehabilitation devices. The research topic "Bioinspired Technology and Biomechanics" welcomes studies reporting recent advances in bioinspired technologies that contribute to individuals\' health, inclusion, and rehabilitation. Possible contributions can address (but are not limited to) the following research topics: Bioinspired design and control of exoskeletons, orthoses, and prostheses; Experimental evaluation of the effect of assistive devices (e.g., influence on gait, balance, and neuromuscular system); Bioinspired technologies for rehabilitation, including clinical studies reporting evaluations; Application of neuromuscular and biomechanical models to the development of bioinspired technology.',annualVolume:11404,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/8.jpg",editor:{id:"144937",title:"Prof.",name:"Adriano",middleName:"De Oliveira",surname:"Andrade",fullName:"Adriano Andrade",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRC8QQAW/Profile_Picture_1625219101815",institutionString:null,institution:{name:"Federal University of Uberlândia",institutionURL:null,country:{name:"Brazil"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"49517",title:"Prof.",name:"Hitoshi",middleName:null,surname:"Tsunashima",fullName:"Hitoshi Tsunashima",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYTP4QAO/Profile_Picture_1625819726528",institutionString:null,institution:{name:"Nihon University",institutionURL:null,country:{name:"Japan"}}},{id:"425354",title:"Dr.",name:"Marcus",middleName:"Fraga",surname:"Vieira",fullName:"Marcus Vieira",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00003BJSgIQAX/Profile_Picture_1627904687309",institutionString:null,institution:{name:"Universidade Federal de Goiás",institutionURL:null,country:{name:"Brazil"}}},{id:"196746",title:"Dr.",name:"Ramana",middleName:null,surname:"Vinjamuri",fullName:"Ramana Vinjamuri",profilePictureURL:"https://mts.intechopen.com/storage/users/196746/images/system/196746.jpeg",institutionString:"University of Maryland, Baltimore County",institution:{name:"University of Maryland, Baltimore County",institutionURL:null,country:{name:"United States of America"}}}]},{id:"9",title:"Biotechnology - Biosensors, Biomaterials and Tissue Engineering",keywords:"Biotechnology, Biosensors, Biomaterials, Tissue Engineering",scope:"The Biotechnology - Biosensors, Biomaterials and Tissue Engineering topic within the Biomedical Engineering Series aims to rapidly publish contributions on all aspects of biotechnology, biosensors, biomaterial and tissue engineering. We encourage the submission of manuscripts that provide novel and mechanistic insights that report significant advances in the fields. Topics can include but are not limited to: Biotechnology such as biotechnological products and process engineering; Biotechnologically relevant enzymes and proteins; Bioenergy and biofuels; Applied genetics and molecular biotechnology; Genomics, transcriptomics, proteomics; Applied microbial and cell physiology; Environmental biotechnology; Methods and protocols. Moreover, topics in biosensor technology, like sensors that incorporate enzymes, antibodies, nucleic acids, whole cells, tissues and organelles, and other biological or biologically inspired components will be considered, and topics exploring transducers, including those based on electrochemical and optical piezoelectric, thermal, magnetic, and micromechanical elements. Chapters exploring biomaterial approaches such as polymer synthesis and characterization, drug and gene vector design, biocompatibility, immunology and toxicology, and self-assembly at the nanoscale, are welcome. Finally, the tissue engineering subcategory will support topics such as the fundamentals of stem cells and progenitor cells and their proliferation, differentiation, bioreactors for three-dimensional culture and studies of phenotypic changes, stem and progenitor cells, both short and long term, ex vivo and in vivo implantation both in preclinical models and also in clinical trials.",annualVolume:11405,isOpenForSubmission:!0,coverUrl:"https://cdn.intechopen.com/series_topics/covers/9.jpg",editor:{id:"126286",title:"Dr.",name:"Luis",middleName:"Jesús",surname:"Villarreal-Gómez",fullName:"Luis Villarreal-Gómez",profilePictureURL:"https://mts.intechopen.com/storage/users/126286/images/system/126286.jpg",institutionString:null,institution:{name:"Autonomous University of Baja California",institutionURL:null,country:{name:"Mexico"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"35539",title:"Dr.",name:"Cecilia",middleName:null,surname:"Cristea",fullName:"Cecilia Cristea",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYQ65QAG/Profile_Picture_1621007741527",institutionString:null,institution:{name:"Iuliu Hațieganu University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}},{id:"40735",title:"Dr.",name:"Gil",middleName:"Alberto Batista",surname:"Gonçalves",fullName:"Gil Gonçalves",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYRLGQA4/Profile_Picture_1628492612759",institutionString:null,institution:{name:"University of Aveiro",institutionURL:null,country:{name:"Portugal"}}},{id:"211725",title:"Associate Prof.",name:"Johann F.",middleName:null,surname:"Osma",fullName:"Johann F. Osma",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSDv7QAG/Profile_Picture_1626602531691",institutionString:null,institution:{name:"Universidad de Los Andes",institutionURL:null,country:{name:"Colombia"}}},{id:"69697",title:"Dr.",name:"Mani T.",middleName:null,surname:"Valarmathi",fullName:"Mani T. Valarmathi",profilePictureURL:"https://mts.intechopen.com/storage/users/69697/images/system/69697.jpg",institutionString:"Religen Inc. | A Life Science Company, United States of America",institution:null},{id:"205081",title:"Dr.",name:"Marco",middleName:"Vinícius",surname:"Chaud",fullName:"Marco Chaud",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSDGeQAO/Profile_Picture_1622624307737",institutionString:null,institution:{name:"Universidade de Sorocaba",institutionURL:null,country:{name:"Brazil"}}}]}]}},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"profile.detail",path:"/profiles/322965",hash:"",query:{},params:{id:"322965"},fullPath:"/profiles/322965",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()