Colorectal cancer mortality rate per 100,000 (ASR) by sex and regions, 2005–2006.
\r\n\tThis book will aim to survey the most recent diagnostic techniques as well as the most promising therapeutic options we can count on to deal with optic nerve disorders. The audience of the book is quite wide and it aims at being the main entry to this fascinating topic for students, clinicians, and researchers.
",isbn:"978-1-80356-774-7",printIsbn:"978-1-80356-773-0",pdfIsbn:"978-1-80356-775-4",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!1,isSalesforceBook:!1,isNomenclature:!1,hash:"e3d02512ccae0638a73c5c2839e50015",bookSignature:"Prof. Felicia M. 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She spent research periods at Virginio del Rocio hospital in Seville, San Carlos hospital in Madrid, the Royal Bolton Hospital in Manchester, and Universidade Fluminense in Rio de Janeiro. She served as co-investigator of many national and international clinical trials. Since 2002, she is an Assistant Professor in Ophthalmology at the University of Messina. Her research interests are in the areas of glaucoma, neuro-ophthalmology, pediatric ophthalmology, and cataract. 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Determining etiology and causality is difficult and research findings are inconsistent among populations, which lead us to the question of whether scientists’ observation was incorrect or risk factors of cancer are different in different populations. Although an estimated 80% of cancer cases, in general, and 98% of colorectal cancer cases, in particular, were associated with environmental factors [3], it is uncertain to determine what the situation will be in a defined population.
The culture of Vietnam is a combination between Chinese and French because the country was occupied by China for nearly 1000 years and by France for around 100 years in the past. As colorectal cancer is reported to have connection with Western dietary habits, it is a favorable condition to observe its distribution and etiologies in Vietnam.
Located in Southeast Asia, Vietnam is bordered by China to the north, Laos to the northwest, Cambodia to the southwest, and the East Sea to the east. With a population of approximately 96,491,142 people in 2018 [4], Vietnam is the 13th most populous country in the world. The Socialist Republic of Vietnam has placed a significant emphasis on economic development since the introduction of the “Doi moi” (the economic reform) in 1986. As a result, Vietnam has achieved significantly in a short amount of time. For example, the percentage of the population living on less than a dollar a day has decreased from 58–29% over 10 years, and the life expectancy of Vietnamese people has reached 71 years for men and 75 years for women [5, 6, 7]. These progressing economics and urbanizations have changed lifestyles, dietary habits, increasing pollutions in living and working environments, which might be associated with the occurrence of colorectal cancer.
Regarding the source of data of colorectal cancer, for many countries, civil registration and vital statistics systems are considered the main sources for mortality data [8]. Civil registration was initiated in Vietnam in 1956, and despite the 50 years of collecting data about cancer mortality, limited information was published [9]. However, a recent study assessed the civil registration and vital statistics system in Vietnam and reported that the system had significant restrictions including a lack of data particularly about early neonatal deaths, deaths of temporary residents, and/or migrants [9].
Beyond Vietnam’s civil registration and vital statistics system, a national mortality reporting system was introduced in 1992 and periodic updating guidelines to improve the quality of data collecting [10]. Under the auspices of the Ministry of Health (MOH), the A6 mortality reporting system relies on commune-level health officials providing basic demographic data and information on the cause of death, which is recorded in an official book referred to as the A6. The data from the A6 is collated by the district-level health service and the information is then sent to the provincial and central level governments. The community plays a significant role in maintaining the current mortality reporting system, and in turn, can actively use the information to plan commune-level health services. Using the A6 system, mortality data regarding cancer were collected and analyzed [11, 12, 13, 14]. Verbal autopsy designed by WHO was applied in the community to determine all causes of death, including cancer [15]. Using the verbal autopsy as a reference, the sensitivity and completeness of the system were observed to be about 80% and 94%, respectively [16]. These findings have suggested that the accuracy and completeness of cancer mortality are feasible, and therefore, it was a source of data for colorectal cancer presented in the present study. The A6 system, with the detailed recordings of deaths in all communes, can easily be conveniently used by health workers. In Vietnam, during the last decade, 7081 (65.1%) medical doctors were working at commune health stations (CHS) [6, 17, 18]. Health workers are trained and work at CHS and they will contribute to the improvement of the mortality data quality and registration completeness gradually soon. Cancer epidemiology and population-based cancer registration were introduced by IARC during the 1980s, focused in the two biggest cities, Hanoi and Ho Chi Minh, representing the north and south of Vietnam, respectively. Cancer incidence during 1988–1997 in the Hanoi city and 1995–1998 in the Ho Chi Minh city was published by IACR [19, 20, 21]. Data on colorectal cancer incidence produced by these two population-based cancer registries include a database of cancer mortality extracted from MOH’s national mortality reporting system that was also used to present in the study.
Cancer was observed to be the second most common cause of death nationwide during 2005–2006 (about 16%) [11, 12, 14], after vascular heart diseases (about 25%). Colorectal cancer (ICD-10: C18–20) has occurred at a national level in Vietnam. This study aims to generate a comprehensive picture of the fatal disease in the eight regions of Vietnam, with the hope to facilitate epidemiological studies in our country. For data of risk factors of colorectal cancer, we conducted a molecular epidemiological case–control study on the incident cases of the disease from 2002 to 2011. The study was designed by the leading experts of cancer epidemiologists from Japan and Vietnam. The protocol was approved by the scientific and ethics committees of the MONBUKAGAKUSHO (Japan) and the Ministry of Science and Technology (Vietnam). Initial results and findings were published elsewhere [22, 23, 24].
From 2005 to 2006, we reported 4646 cases of fatal colorectal cancer among all 93,719 cancer death cases. It was responsible for about 5% of all cancer cases. Colorectal cancer was distributed in all 671 districts within 63 provinces/cities of Vietnam. Among 4646 colorectal cases, there were 2450 men (52.7%). The average age at death was 62 in men and 66 in women [14]. In 2002, the estimated number of death from colorectal cancer was 1730 cases in men and 2401 cases in women, provided that the total number of cases was 4131 [25]. The average reported number per year was 2323 cases in 2005–2006, which was only 56% of the estimated number of 4131 cases. According to GLOBOCAN 2018, colon ranked the fifth in the incidence and mortality among malignant diseases, with 5457 new cases and 3183 deaths per year [4].
These characteristics suggest that an epidemiological study must be performed:
Colorectal cancer caused thousands of deaths in Vietnam, and it was considered as one of the most important public health problems in our country.
Causality and risk factors of colorectal cancer were presented at nationwide because the cancer was observed in all 671 districts within all 63 provinces/cities. Therefore, we should observe and examine etiology and causality at the household and community levels in identifying and controlling risk factors.
Registration of colorectal cancer mortality nationwide might be underreported for about 40% of total cases. Data on cancer mortality registration will promptly be improved and it will be used for cancer control and prevention in our country.
Using referred data of cancer from China to estimate the cancer incidence and mortality of all sites as well as of colorectal cancer, it might be an overestimated colorectal cancer in 2002 for Vietnam [25].
Colorectal cancer caused premature death for an average of 7.3 years [18].
In terms of colorectal cancer in under-18 year-old people, 52 cases (1.13% of 4646 cases) were found [14]. Children and adolescents are not employed and therefore they are not exposed to occupational carcinogens. They are also rarely exposed to tobacco smoking and alcoholic beverages, according to a recent report on student health surveillance by WHO [26], as well as to dioxins in herbicides during the Vietnam War. What were the risk factors that induced colorectal cancer during the 1990s in Vietnam among children and adolescents?
Two population-based cancer registrations have been running in the two prominent cities of Hanoi and Ho Chi Minh. The covered population was about 13 million (15% of the country population) in 2008 [6, 19, 21].
Age-standardized incidence rates per 100,000 (ASR) of colorectal cancer was 10.5 in men and 6.5 in women, during 1993–1997, in Hanoi and 12.4 in men and 9.0 in women, during 1995–1998, in Ho Chi Minh City [19, 21]. The incidence rate of colorectal cancer in Vietnam was one fifth of that in the United States (ASR 52.6 in men and 37.0 in women, respectively) [27].
Data on the cancer incidence rate in Vietnam might be deviated by 15–25% since the death certificate was not available at that time. During the 1990s, only 12% of Vietnamese had health insurance (HI). Thus, many cancer patients were not admitted to hospitals, which impacted directly on number of mortality in oncology patients [17]. According to GLOBOCAN 2018, 114,871 cancer patients in Vietnam are deceased in 2018, which takes up more than one third of the prevalent cases [4].
In eight regions, ASR colorectal cancer mortality rates were from 4.0 to 11.3 per 100,000 in men and from 3.0 to 7.8 per 100,000 in women (Table 1). The highest mortality rates were seen in both men (11.3 per 100,000) and women (7.8 per 100,000) in the region of the Mekong Delta River in the South of Vietnam.
Region | Men | Women | ||||
---|---|---|---|---|---|---|
Cases | Crude | ASR | Cases | Crude | ASR | |
Red Delta River | 68 | 5.5 | 6.9 | 75 | 5.8 | 5.2 |
Northeast | 20 | 3.1 | 4.4 | 34 | 5.0 | 5.0 |
Northwest | 7 | 2.8 | 4.7 | 9 | 3.4 | 5.0 |
North central coast | 29 | 3.3 | 4.0 | 34 | 3.7 | 3.0 |
South central coast | 18 | 5.4 | 7.7 | 13 | 3.7 | 4.1 |
Central highlands | 9 | 3.1 | 6.0 | 7 | 2.3 | 3.7 |
Northeast South | 34 | 4.0 | 6.3 | 24 | 2.7 | 3.4 |
Mekong Delta River | 83 | 7.5 | 11.3 | 78 | 6.8 | 7.8 |
Colorectal cancer mortality rate per 100,000 (ASR) by sex and regions, 2005–2006.
In a specific province population, the colorectal cancer mortality rate per 100,000 person-years during 2005-2018 was 5.8, men 6.9, and women 5.0. Men to women ratio was 1.4 in the Lang Son province located in North Vietnam, remote areas of the country (Table 2).
Sex | Year | Total | Crude rate& | ASR-Segi@ | % < 70# | ASR-WHO$ |
---|---|---|---|---|---|---|
Men | 2005–2018 | 201 | 4.4 | 6.2 | 66.7 | 6.9 |
Women | 2005–2018 | 203 | 4.5 | 4.3 | 55.2 | 5.0 |
Both genders | 2005–2018 | 404 | 4.5 | 5.1 | 60.9 | 5.8 |
Mortality due to colorectal cancer by sex during 2005–2018 in Lang Son province.
Crude rate per 100,000 person-years.
Age-standardized rate per 100,000 person-years using the SEGI World standard population (in the 1960s).
Proportion of death cases aged under 70 year-olds.
Age-standardized rate per 100,000 person-years using the World Health Organization standard population for 2000-2025. Men to women ratio (ASR-WHO) = 1.4 (6.9/5.0).
The age-specific rate per 100,000 sharply increased in the age group of 50–59 with a peak of age group of 80+ at as high as 346.6 and 275.3 per 100,000 in men and women at the region of the Mekong Delta River in the South Vietnam, respectively (Figure 1). It supported the mentioned statement of the average age at death of 62 in men and 66 in women.
Age-specific mortality rate per 100,000 in men and women, 2005–2006.
ASR colorectal cancer mortality rates per 100,000 in men ranged from 4.0 to 11.3 and it was lower than the rate in the developed countries, which was as high as 17.7 (Figure 2). Nationwide, it was estimated to be 5.6 per 100,000 (ASR) or it was one third when compared to that of the developed countries [25].
ASR mortality rates per 100,000 by regions and in Vietnamese men, 2005–2006.
ASR colorectal cancer mortality rates per 100,000 in women ranged from 3.0 to 7.8 and it was lower than the rate in the developed countries, which was as high as 12.3 (Figure 3). Nationwide, it was estimated to be 5.2 per 100,000 (ASR) or it was nearly half when compared to that of the developed countries [25].
ASR mortality rates per 100,000 by regions and in Vietnamese women, 2005–2006.
Regarding colorectal cancer survival, there was a lack of surveillance data for cases incidence and mortality to estimate the relative survival in Vietnam. Two population-based cancer registries have been running in Vietnam, one in Hanoi established in 1988, and the other in Ho Chi Minh city established in 1990 [19, 21]. These institutions collected data from medical records only and there was a lack of follow-up data, so the data of incidence rates might be underestimated. We analyzed the survival rate for fatal colorectal cancer cases: 1-year survival was 33.5% and 5-year survival was 4.3%, men and women combined [13].
These data of incidence, mortality, and survival (among fatal cases only) of colorectal cancer cases in Vietnam have suggested that:
Risk factors-induced colorectal cancer might slightly be related to sex’s lifestyles, we should examine the risk factors that affect both men and women.
Prevention of colorectal cancer should be prioritized because the diseases were estimated to be caused by 98% of environmental risk factors [3].
Between 2005 and 2018, the age-standardized mortality rate per 100,000 person-years (ASR-WHO) was increased from 3.4 to 9.8 in men and 2.2 to 3.9 in women (Figure 4). The significant increase trend was seen in both genders by 3.4% per year (Table 3). However, this significant increasing trend was observed in men only (5.2% per year, Table 4) but not in women (1.8% per year, Table 5).
The trend of colorectal cancer mortality from 2005 to 2018 by gender in the Lang Son province located in North Vietnam. Missing data in 2009-2010; ASR-WHO: Age-standardized rate per 100,000 person-years using the World Health Organization standard population for 2000-2025.
Year | Case | Crude rate& | % < 70# | ASR-WHO-$ | MRR (95% CI)$$ | p |
---|---|---|---|---|---|---|
2005 | 16 | 2.2 | 75.0 | 2.8 | 1 (Reference) | |
2006 | 23 | 3.1 | 69.6 | 3.9 | 1.413 (0.747, 2.675) | 0.288 |
2007 | 26 | 3.5 | 73.1 | 4.6 | 1.590 (0.853, 2.964) | 0.144 |
2008 | 31 | 4.2 | 45.2 | 5.4 | 1.869 (1.023, 3.418) | 0.042 |
2011 | 35 | 4.8 | 60.0 | 6.3 | 2.147 (1.188, 3.879) | 0.011 |
2012 | 47 | 6.3 | 59.6 | 8.3 | 2.831 (1.605, 4.992) | <0.001 |
2013 | 34 | 4.6 | 61.8 | 5.9 | 2.073 (1.144, 3.775) | 0.016 |
2014 | 47 | 6.0 | 55.3 | 8.1 | 2.706 (1.534, 4.772) | 0.001 |
2015 | 41 | 5.2 | 61.0 | 6.9 | 2.343 (1.315, 4.174) | 0.004 |
2016 | 41 | 5.2 | 68.3 | 6.8 | 2.349 (1.318, 4.186) | 0.004 |
2017 | 27 | 3.4 | 44.4 | 4.5 | 1.527 (0.823, 2.834) | 0.180 |
2018 | 36 | 4.6 | 66.7 | 6.3 | 2.065 (1.146, 3.721) | 0.016 |
Mortality due to colorectal cancer in both genders by year from 2005 to 2018 in Lang Son province.
Adjusted for age group (0–9, 10–19, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, and 80+) and sex. Per year increment MRR (95% CI): 1.034 (1.010, 1.059),
Crude rate per 100,000 person-years.
Age-standardized rate per 100,000 person-years using the World Health Organization standard population for 2000–2025.
Proportion of death cases aged under 70 years. When combined for all cases from 2005 to 2018, for both genders, WHO-ASR: 5.8 per 100,000 person-years.
The estimated proportion of deaths due to colorectal cancer was 0.82% (404 cases of colorectal cancer vs. 49,253 total cases), both genders.
Year | Case | Crude rate& | % < 70# | ASR-WHO-$ | MRR (95% CI)## | |
---|---|---|---|---|---|---|
2005 | 9 | 2.5 | 88.9 | 3.4 | 1 (reference) | |
2006 | 12 | 3.3 | 75.0 | 4.7 | 1.311 (0.552, 3.112) | 0.539 |
2007 | 11 | 3.0 | 63.6 | 4.7 | 1.196 (0.496, 2.886) | 0.691 |
2008 | 14 | 3.8 | 57.1 | 5.4 | 1.501 (0.650, 3.468) | 0.342 |
2011 | 15 | 4.1 | 53.3 | 6.6 | 1.636 (0.716, 3.739) | 0.243 |
2012 | 18 | 4.8 | 55.6 | 7.8 | 1.928 (0.866, 4.290) | 0.108 |
2013 | 17 | 4.6 | 76.5 | 6.8 | 1.843 (0.821, 4.134) | 0.138 |
2014 | 23 | 5.9 | 65.2 | 9.6 | 2.354 (1.089, 5.089) | 0.029 |
2015 | 19 | 4.9 | 68.4 | 7.9 | 1.930 (0.873, 4.267) | 0.104 |
2016 | 26 | 6.7 | 69.2 | 10.1 | 2.649 (1.241, 5.654) | 0.012 |
2017 | 14 | 3.5 | 64.3 | 5.7 | 1.408 (0.609, 3.252) | 0.424 |
2018 | 23 | 5.9 | 69.6 | 9.8 | 2.346 (1.085, 5.070) | 0.030 |
Mortality due to colorectal cancer in men by year from 2005 to 2018 in Lang Son province.
Adjusted for age group (0–9, 10–19, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, and 80+). Per year increment MRR (95% CI): 1.052 (1.017, 1.089),
Crude rate per 100,000 person-years.
Age-standardized rate per 100,000 person-years using the World Health Organization standard population for 2000–2025.
Proportion of death cases aged under 70 years. When combined for all cases from 2005 to 2018 in men, WHO-ASR: 6.9 per 100,000 person-years.
The estimated proportion of deaths due to colorectal cancer was 0.64% (201 cases of colorectal cancer vs. 31,262 total cases) in men.
Year | Case | Crude rate& | % < 70# | ASR-WHO$ | MRR (95% CI)## | p |
---|---|---|---|---|---|---|
2005 | 7 | 1.9 | 57.1 | 2.2 | 1 (reference) | |
2006 | 11 | 3.0 | 63.6 | 3.2 | 1.545 (0.599, 3.986) | 0.368 |
2007 | 15 | 4.1 | 80.0 | 4.7 | 2.097 (0.855, 5.144) | 0.106 |
2008 | 17 | 4.5 | 35.3 | 4.9 | 2.344 (0.972, 5.652) | 0.058 |
2011 | 20 | 5.4 | 65.0 | 6.3 | 2.805 (1.186, 6.633) | 0.019 |
2012 | 29 | 7.7 | 62.1 | 8.8 | 3.994 (1.749, 9.117) | 0.001 |
2013 | 17 | 4.6 | 47.1 | 5.0 | 2.369 (0.982, 5.714) | 0.055 |
2014 | 24 | 6.1 | 45.8 | 7.0 | 3.159 (1.361, 7.332) | 0.007 |
2015 | 22 | 5.6 | 54.5 | 6.2 | 2.874 (1.228, 6.727) | 0.015 |
2016 | 15 | 3.8 | 66.7 | 4.3 | 1.965 (0.800, 4.818) | 0.140 |
2017 | 13 | 3.3 | 23.1 | 3.5 | 1.681 (0.670, 4.212) | 0.268 |
2018 | 13 | 3.3 | 61.5 | 3.9 | 1.704 (0.680, 4.272) | 0.255 |
Mortality due to colorectal cancer in women by year from 2005 to 2018 in Lang Son province.
Adjusted for age group (0–9, 10–19, 20–29, 30–39, 40–49, 50–59, 60–69, 70–79, and 80+). Per year increment MRR (95% CI): 1.018 (0.985, 1.052),
Crude rate per 100,000 person-years.
Age-standardized rate per 100,000 person-years using the World Health Organization standard population for 2000–2025.
Proportion of death cases aged under 70 years. When combined for all cases from 2005 to 2018 in women, WHO-ASR: 5.0 per 100,000 person-years.
The estimated proportion of deaths due to colorectal cancer was 1.13% (203 cases of colorectal cancer vs. 17,990 total cases) in women.
Risk factors of colorectal cancer include certain unhealthy dietary regimens, precancerous lesions detected on colonoscopy, and genetic factors. According to the guideline for colorectal cancer diagnosis and treatment released by Vietnam’s Ministry of Health in 2018, screening should be conducted on high-risk patients with a history of inflammatory bowel disease (Crohn’s disease or ulcerative colitis) or colorectal polyps, or a family history of polyposis syndrome, colorectal polyps, or colorectal cancer. Fecal occult blood test (FOBT) and colonoscopy are pivotal in screening. During 2008–2010, the National Cancer Control Program organized a screening program for five malignant diseases in which 9634 people were screened for oral and colorectal cancer. However, stage I-II colorectal cancers accounted only for 32.2% [28].
Treatment is decided based on multiple factors including staging, tumor location, and histopathology. Available treatment modalities in Vietnam are surgery, radiotherapy, and chemotherapy (systemic and targeted) [29].
In terms of surgery strategy, it depends on the curative/non-curative approaches as well as the operation indication relates to the complications or not. Pham et al. (2020) conducted a study on patients who performed single-port laparoscopic right hemicolectomy. The mean survival time was 67.9 ± 3.3 months and the recurrence rate was 16.7%. The survival rates at 2, 3, and 5 years were 87.5, 79.9, and 66.7%, respectively. Survival was shown to be associated with age, tumor size, and TNM stage at 61.7 ± 3.9 months after treatment [30]. For advanced stages, three main agents were 5-fluoropyrimidines, oxaliplatin, and irinotecan, combined in common regimens including FOLFOX/XELOX, FOLFIRI/XELIRI, or FOLFOXIRI. Trinh et al. followed up with metastatic colon cancer patients treated with FOLFOXIRI. The mean disease-free survival time was 13.37 ± 9 months, with the response after 3 and 6 cycles being 82 and 79.4%, respectively [31]. Radiation therapy is indicated in patients who have metastatic lesions in the liver, bone, or lungs [29].
The surgery method for rectal cancer depends on the extent and location of the tumor [29]. Truong et al. conducted a cohort study during 2009–2016 on patients with low rectal cancer undergoing laparoscopic sphincter-saving resection. The local and distant recurrence rates were 10.4 and 20.8%, respectively. The overall survival was 52.7 ± 3.9 months and the disease-free survival was 38.3 ± 2.9 months [32]. In another study on rectal cancer patients who were treated with surgery, survival was reported to be associated with staging, lymph nodes metastasis, and tumor size. The mean overall survival time was 48.9 ± 52.7 months and the 3-year survival rate was 91.7%. Patients at stage I-II or having lymph nodes <10 mm in diameter had better prognosis [33]. Vi et al. conducted a study on metastatic rectal cancer patients who were treated with FOLFOX4 and bevacizumab. The median overall survival time was 19 months and the survival rates after 1 and 2 years were 56.9 and 27.6%, respectively. In this population, survival was associated with the CEA level, the number of organs having metastasis, histopathology, and response to bevacizumab [34]. The overall survival time in this study was similar to some studies using similar regimens in the world [35, 36].
Health insurance (HI) provides access to health examination and treatment for all patients, including those who cannot cover their medical expenses using out-of-pocket money, ensuring equity and social security. All public health establishments in Vietnam participate in the national health insurance scheme. Private hospitals, especially centers managing chronic diseases, are also encouraged to participate.
After enrolling in the national health insurance program, most of the general populations pay an annual amount of 1,117,000 VND (approximately 48.5 USD). Insurance fees can be waived for some special populations (e.g., poor households and veteran’s relatives). In 2018, 86.8% of Vietnamese people are covered with national HI, allowing them to access most health-care services in Vietnam [37].
The mean direct costs for an outpatient and inpatient with colorectal cancer were 13.594 million VND (588 USD) and 63.371 million VND (2741 USD), respectively. This renders a financial burden for people who are not covered by HI and creates a barrier to access to health care [38]. As 80–100% of treatment costs for colorectal cancer are covered by HI in public hospitals and private clinics, patients enrolling in the insurance program can access expensive diagnostics and treatments. However, some targeted drugs and bevacizumab are only covered 30–50% by HI [39]. In Vietnam, the primary care levels are communal health stations and district health centers/hospitals. People who are treated at these facilities are fully covered if they participate in the HI program. If they must be transferred to higher-level (provincial/central) hospitals, patients have to present valid official letters of referral to the insurance agency to maintain maximum insurance coverage. The maximum coverage for a general person who is admitted to a central hospital is 80%; this will be reduced to 40% if they fail to present valid letters of referral [40].
In Vietnam, a majority of colorectal cancer patients are detected at late stages. In a study in 2015, 67.8% of the patients were diagnosed at stage III/IV [28]. Early detection of colorectal cancer through screening may significantly increase the 5-year survival to 89.9%, compared with 13.8–71.1% in patients with regional and distant colorectal cancer metastasis [41].
Having acknowledged the situation, the Vietnamese Government issued the National Strategy for the Prevention and Control of Non-Communicable Disease (NCD) (2015–2025). One of the objectives of this strategy is to reduce late diagnosis and increase survival for colorectal cancer [42]. Colorectal cancer screening is conducted annually, supported by the National Cancer Control Program, and is accessible in many health-care facilities [28, 43]. For community screening, FOBT is applied in many health-care centers, with the advantage of being a noninvasive, quick, and reliable method. When the patients have positive FOBT, the next step to be performed would be colonoscopy. This strategy helps to screen mass population, especially the people with risk factors (family history, colon polyp history, or age), as well as save up the human and economic resources. Some preliminary data have shown the effectiveness of this approach in early colorectal cancer; however, the long-term benefits in national screening and management program requires bigger data from multicenters [44, 45].
Efforts have been made to raise the awareness of lifestyle and diet modification, including limiting alcohol consumption and smoking, promoting a healthy diet, and encouraging physical exercises [46, 47, 48].
A case-control study was performed for colorectal cancers admitted to Hanoi Cancer Hospital, Viet Duc Surgery Hospital, and Bach Mai General Hospital located in Hanoi. The ratio of case-control is 1:1 with the standards for matching are gender and age (±5). Cases and controls were interviewed to collect data in using demographic and lifestyle questionnaire and semiquantitative food frequency questionnaire. Blood samples were collected in the early morning on the day of operation [23, 24]. Most patients came from the provinces near Hanoi within the Red Delta River. They will be represented as Vietnamese in the north.
Distribution of blood ABO group in Vietnamese is 45.00, 21.20, 28.30, and 5.50% for types O, A, B, and AB, respectively [49]. In our study, the distribution is different, with 42.97, 23.67, 27.95, and 5.42% for types O, A, B, and AB, respectively [50]. The proportion of type A plus AB is 26.70% while type O plus B is 73.30% in Vietnamese. However, in our study, it is 29.10% and 70.90%, respectively. Distribution of blood ABO group in our study population is similar to that in Vietnamese. Blood ABO group was observed to be associated with cancer risk, whereas blood A was seen to increase the risk of stomach cancer in many studies [51]. Blood A, AB, and B have also increased the risk of pancreatic cancer [52].
In our study, blood type A plus AB was seen to increase the risk of colorectal cancer, with OR = 1.58, 95% CI = 1.05–2.38 [50] (Table 6). The mechanism of developing colorectal cancer in patients with blood types A and AB is unknown.
Blood type | Control | Case | OR | 95% CI | P | |
---|---|---|---|---|---|---|
O and B | 187 | 150 | 1.00 | |||
A and AB | 58 | 73 | 1.58 | 1.05 | 2.38 | 0.027 |
Blood ABO group and risk of colorectal cancer.
When we separated colon and rectal cancer, the estimated risk was significantly increased for colon cancer, with OR = 3.36, 95% CI = 1.91–5.92, but not significantly increased for rectal cancer, with OR = 0.84, 95% CI = 0.54–1.32.
CYP1A1 genotypes | Control | Case | OR | 95% CI | P | |
---|---|---|---|---|---|---|
AA | 57 | 32 | 1.00 | |||
AG and GG | 226 | 237 | 1.86 | 1.16 | 2.98 | 0.010 |
CYP1A1 genotypes and the risk of colorectal cancer.
The function of CYP1A1 is recognized to be a major chemical carcinogen-induced cancer, in general, and colorectal cancer, in particular, in humans. We found that CYP1A1 (A/G and G/G genotypes) increased the risk of colorectal cancer, with OR = 1.86, 95% CI = 1.16–2.98 (Table 7) [50].
When parents and close relatives suffered from cancer, the patients are at a higher risk of colorectal cancer, with OR = 3.00, 95% CI = 1.29–6.99, and OR = 3.63, 95% CI = 1.31–10.01, respectively. Patients with a past history of colorectal pain and inflammation are also at a higher risk of cancer, with OR = 3.68, 95% CI = 2.01–6.75. Regarding body mass index (BMI), three levels were categorized, including <18.5; 18.5- < 25, and 25- < 30. Patients with body mass index of 25- < 30 are also at a higher risk of cancer, with OR = 2.09, 95% CI = 0.79–5.51, and
Factors | Control | Case | OR | 95% CI | P | |
---|---|---|---|---|---|---|
No | 303 | 290 | 1.00 | |||
Yes | 8 | 21 | 3.00 | 1.29 | 6.99 | 0.011 |
No | 305 | 294 | 1.00 | |||
Yes | 5 | 17 | 3.63 | 1.31 | 10.01 | 0.013 |
No | 286 | 255 | 1.00 | |||
Yes | 15 | 48 | 3.68 | 2.01 | 6.75 | 0.000 |
<18.5 | 32 | 17 | 1.00 | |||
18.5- < 25 | 108 | 119 | 2.03 | .12 | 3.33 | 0.005 |
25- < 30 | 7 | 8 | 2.09 | .79 | 5.51 | 0.135 |
Family and personal history of health and risk of colorectal cancer.
Alcoholic beverages have been proven to be a major part of human’s diet [53]. Excluding the poisonous effect of heavy intake of alcohol, we considered alcoholic beverages as a promoter of cancer in human. Most carcinogenic chemicals have a higher solubility in alcohol than in water. For example, aflatoxin B is soluble in ethanol but has a limited water solubility [54].
There is sufficient evidence for the carcinogenicity of alcohol beverages in human but inadequate evidence for the carcinogenicity of ethanol and alcoholic beverages in experimental animals [55]. Based on these facts and figures, we hypothesized that alcoholic beverages are promoters for cancer in humans. In this study, three levels of alcoholic drinking were categorized, including not drinking, some drinking per week, and daily drinking. Those who daily consume alcoholic beverages were at a significantly higher risk of colorectal cancer, with OR = 1.91, 95% CI = 0.98–3.72, and
Alcohol and/or beer | Control | Case | OR | 95% CI | P | |
---|---|---|---|---|---|---|
Not drinking | 175 | 145 | 1.00 | |||
Some drinking per week | 29 | 33 | 1.61 | .90 | 2.87 | 0.110 |
Daily drinking | 21 | 27 | 1.91 | .98 | 3.72 | 0.058 |
Drinking habits and risk of colorectal cancer.
Referred to earlier statements regarding cancer occurrence in species, only human’s internal organs of lung, liver, stomach, and others are seriously exposed to risk factors and can develop cancer. In contrast, animals suffer from cancer with a very rare occurrence in the internal organs [1, 2]. Animals consume natural foods without any preparation, while humans consume both natural foods and prepared foods [56, 57]. Also, humans used at least 10,000 chemical additives, which serve as contaminants [58]. Besides, heat-generated carcinogens due to the cooking temperature were reported in many previous studies. One of such carcinogens is acrylamide, which was detected in heated foods. It was evaluated by IARC to be a potential carcinogen to humans (Group 2A) [59].
The concentration of acrylamide was 50 μg/kg in hamburgers prepared at the temperature of 240°C, while it was zero in the control [60]. With this evidence, we hypothesized that the intake of heated foods might be a contributor to the development of colorectal cancer in our study population. Three food items were categorized to be heated food items because they were heated in cooking temperature at 165°C or higher during preparation processing [56, 57]. The concentration of heat-generated carcinogens (acrylamide) was generated and significantly increased when the temperature increased from 100–240°C [60]. Daily and weekly intake of barbecued meats (Usual outside appearance: medium-, well-, and blackened/charred of cooked meats vs. lightly browned of cooked meats), bread, and biscuits significantly increased the risk of colorectal cancer, with OR = 1.70, 95% CI = 1.09–2.63; OR = 2.15, 95% CI = 1.36–3.40; and OR = 2.05, 95% CI = 1.03–4.07, respectively (Table 10) [50].
Heated food items and heated levels | Control | Case | OR | 95% CI | P | |
---|---|---|---|---|---|---|
Barbecued meats | ||||||
Usual outside appearance: lightly browned of cooked meats | 220 | 194 | 1.00 | Reference | ||
Usual outside appearance: medium-, well-, and blackened/charred of cooked meats | 43 | 62 | 1.70 | 1.09 | 2.63 | 0.019 |
Bread | ||||||
No intake or rare | 207 | 179 | 1.00 | Reference | ||
Some intake per month | 66 | 67 | 1.17 | 0.79 | 1.74 | 0.432 |
Daily or weekly intake | 35 | 65 | 2.15 | 1.36 | 3.40 | 0.001 |
P for trend = 0.002 | ||||||
Biscuits | ||||||
No intake or rare | 231 | 206 | 1.00 | Reference | ||
Some intake per month | 68 | 81 | 1.34 | 0.92 | 1.95 | 0.125 |
Daily or weekly intake | 14 | 25 | 2.05 | 1.03 | 4.07 | 0.040 |
Dietary habits and risk of colorectal cancer.
The heating and burning of tobacco products lead to the formation of mainstream smoke and sidestream smoke. Mainstream smoke from cigarettes and cigars is generated during puff-drawing in the burning cone and hot zones; it travels through the tobacco column and exits from the mouthpiece. Sidestream smoke is formed during puff-drawing and is emitted freely from the smoldering tobacco product into the ambient air. A variety of chemical and physical processes occur in the oxygen-deficient, hydrogen-rich environment of the burning cone at temperatures up to 950°C. Tobacco smoke contains more than 3800 constituents and many of them are chemical carcinogens to humans [61]. Tobacco smoking was reported to be responsible for about 25–35% of all cancer in humans [3]. In our study, daily smoking of 11 cigarettes or more increased the risk of colorectal cancer, with OR = 2.08, 95% CI = 0.62–6.91, but it is not significant (Table 11) [50].
Number of cigarettes per day | Controls | Cases | OR | 95% CI | P | |
---|---|---|---|---|---|---|
Nonsmoker | 151 | 140 | 1.00 | |||
1–10 | 22 | 15 | 0.82 | 0.37 | 1.82 | 0.618 |
11+ | 5 | 9 | 2.08 | 0.62 | 6.91 | 0.233 |
Number of cigarettes per day and colorectal cancer.
Both the burning of tobacco and heating of foods leads to the formation of chemical carcinogens, known as “heat-generated carcinogens” or “dietary carcinogens.” Thousands of chemicals were reported in the smoke of burning tobacco and heating foods. These chemicals were detected in the user’s blood and urine after the intake of these products [60, 61, 62, 63, 64, 65, 66, 67]. With this evidence, we should seriously consider the study of heat-generated carcinogens and dietary carcinogens to prevent the development of cancer in humans.
Humans cannot synthesize micronutrients to meet the body’s requirement, so supplement from outside is necessary. Good foods provide good materials for the body’s energy metabolism and for activities preventing cancer [68].
The refrigerator is the equipment providing good conditions to keep fresh micronutrients for humans’ daily life. An indirect beneficial factor that reduces the risk of colorectal cancer was observed for the refrigerator available at home, with OR = 0.69, 95% CI = 0.48–0.99 (Table 12) [50].
Refrigerator available at home | Controls | Cases | OR | 95% CI | P | |
---|---|---|---|---|---|---|
No | 123 | 145 | 1.00 | |||
Yes | 121 | 99 | 0.69 | 0.48 | 0.99 | 0.045 |
Refrigerator available at home and risk of colorectal cancer.
With the focus on clinical epidemiology studies on colorectal cancer, the specific risk factors for Vietnamese patients have been identified and they require further investigations to have an instruction on the diet and lifestyle modification. Based on multiple factors in pathological mechanism, the strategy to control this malignancy should have an impact on comprehensive sides: environmental factors, screening strategy, and personalized management. The integration of different diagnostic methods in community, hospital, and individual levels enhanced the improvement in detection of early colorectal cancer and should be invested more. Besides issuing guideline for colorectal cancer from the perspectives of specialists, it is important to have a strategy of prevention and screening in community and to foster educational activities.
In the near future, to identify the relationship between risk factors and colorectal cancer in Vietnam as well as to optimize the environmental factors, the microbiome studies in our population should be performed. It is necessary to have a database for healthy people to compare with the colorectal cancer patients, with the collecting of data on diet and lifestyle habits. Furthermore, the studies on health-care cost-effectiveness in this specific field should be performed to support for building up an effective approach in the prevention, screening, and treating of colorectal cancer patients.
Based on the observations in Vietnam for colorectal cancer, the distribution of this disease and its causality as well as risk factors were identified. With these findings, some points can be induced:
Colorectal cancer is related to unrecognized heat-generated carcinogens in our foods: we found that tobacco smoking, barbecued meats, bread, and biscuits intake increase the risk of the disease. Tobacco heated at 950oC and smoking carcinogens can generate as much as 3800 types of chemicals [56, 57, 61]. These findings were partly published [24]. Chemical is an independent factor inducing cancer, which was successfully performed and reported for the first time in 1967 by Dr. Sugimura [60, 69]. Our epidemiological observations in humans consisted of these numbers from previous studies.
Control of cooking temperature in both family’s kitchen as well as public restaurants in humans’ daily life should be a significant consideration to prevent colorectal cancer in particular and all cancer sites in general.
In our study, although alcoholic beverages play an integral role in humans’ diets worldwide, alcoholic consumption would be categorized as a promoting factor of colorectal cancer development. Because of the organic solution of chemical carcinogens, similar to tobacco smoking, barbecued meats, bread, and biscuits are promoting colorectal cancer in our body.
Host factors committed to developing colorectal cancer included blood types A and AB, CYP1A1 genotypes A/G and G/G, family history of cancer, body mass index, history of colorectal pain, and inflammation.
Three groups of risk factors were determined to develop colorectal cancer, including tobacco smoking, barbecued meats, bread, and biscuits intake as the first group; alcohol consumption as the second group; and the identified host factors as the third group. Possible management of identified risk factors in preventing colorectal cancer can be refrainment of smoking and reduction of intake of heated foods at unsafe cooking temperatures. A screening for colorectal polyp and cancer for people aged 40+ is highly recommended. Policy frameworks for cancer control in general and colorectal cancer in Vietnam are in place, but there is still a lack of proper financing and governing models necessary to support a sustainable program.
The authors deeply appreciate former Prof. Hiroshi Nozawa, Doctor of Laws and Honorary Member of the Institute for Science of Labor, Emeritus Professor of Kanazawa University for the support at the Institute for Science of Labor, Kawasaki, Japan in 1994.
Takeuchi and Shimizu Takeuchi first described Moyamoya disease, in 1957 [1]. The term “Moyamoya” was coined to this illness due to its angiographic appearance of “something hazy, like a puff of cigarette smoke” (Moyamoya in Japanese) [1] “Moyamoya disease” (MMD) and “Moyamoya syndrome” (MMS) are both chronic cerebrovascular diseases affecting distal internal carotid and proximal portions of the anterior and middle cerebral arteries [2]. Though Moyamoya disease and Moyamoya syndrome are used synonymously, a subtle distinction separates these two entities. Moyamoya vasculopathy in those with underlying risk factors are described under the umbrella term “Moyamoya syndrome”, thus a wide variety of conditions can incite a Moyamoya vasculopathy, however, if a similar angiographic appearance is evident in those with no risk factors, except for an underlying genetic predisposition, it is entitled as “Moyamoya disease” [2]. One more distinction is the” bilateral “angiographic appearance pathognomonic for Moyamoya disease, whilst” unilateral “vasculopathy always qualifies to a Moyamoya syndrome, even without an underlying associated risk factor [2].
We searched PubMed from 1968 to January 2021 with the words “Moyamoya disease”, “Moyamoya syndrome”, “population-based”, “epidemiology”, “risk factors”, “genetics”, “clinical aspects”,clinical features of Moyamoya, seizure and Moyamoya, headache and Moyamoya, paediatric Moyamoya, Adult Moyamoya, stroke and Moyamoya, neuropsychological profile of Moyamoya, Research studies on Moyamoya, Case reports of Moyamoya. Relevant articles were also searched in the national and International journals where the full article could be retrieved. Clinical manifestation and underlying pathophysiology was reviewed in the searched article to provide an extensive review ofclinical aspects of Moyamoya disease.
This disease entity was believed to affect Asian heritage, given their genetic predisposition. However, it is now a well-known fact that this disease entity can affect American and European ethnicities [3]. This disease has a bimodal distribution of age-specific incidence rates with two peaks in the age groups of 5 years in children andmid-40s in the adults [3, 4]. It is twice more common in females as in males [3]. The incidence estimates of 0.35–0.54/100,000 are found in the Japanese and Korean populations [5]. An incidence of 0.086 cases per 100,000 persons inAmericans, incidence-rate ratios are 4.6 for Asian Americans, 2.2 for blacks, and 0.5 for Hispanics [6].
Moyamoya disease has a genetic aetiology, as mentioned above. Many studies where total genome search linkage was performed found an association between the disease and markers located at 3p24.2–26 chromosome [7], a possible connection of the marker D6S441 located on chromosome 6 which also has HLA gene [8], linkage to chromosome 17 have also been reported.
Moyamoya syndrome is associated with many conditions, as described below: [8].
Chromosomal/Genetic disorder | Neurofibromatosis, “Down’s syndrome, Turner syndrome |
---|---|
Haematological disorders | Sickle cell anaemia, Thalassemia, Aplastic anaemia |
Infectious disease | Leptospirosis, Tuberculous meningitis |
Neoplasms | Craniopharyngioma, Wilms tumour |
Drug abuse | Phenobarbital |
Autoimmune diseases | “Behcet’s disease, “Sjögren’s syndrome, systemic lupus erythematosus (SLE), Henoch Scholein Purpura (HSP) and ‘Graves’ disease |
Others | Cardiomyopathy, Polycystic kidney, Pulmonary sarcoidosis, Irradiation, Trauma, Renal artery stenosis |
A role of fibroblast growth factor, prostaglandin, and activation of cox2 in the vascular smooth muscle, EBV DNA and propionibacteria have all been proposed as a possible mediator of the neovascular response [9].
Disease progression can be slow, with overlapping intermittent events, or it can be a fulminant course, with rapid neurologic decline [10]. It has been reported that symptomatic progression is observed for five years, and delay in the rap initiation may have catastrophic consequences [10].
Various guidelines have been published over time and again. In 1996 and 1997 Japan published diagnostic criteria for the pathology and treatment of MMD [11]. In 2012, Japan published the latest guidelines based on 1997 guidelines [11].
Though cerebral angiography remains the gold standard for the diagnosis (Table 1), novel guidelines added a staging based on scores of magnetic resonance (MR) angiography (MRA) [12].
Stage | Cerebral angiographic findings |
---|---|
I | Narrowing of the carotid fork |
II | Initiation of the moyamoya (dilated major cerebral artery and a slight moyamoya vessel network) |
III | Intensification of the moyamoya (disappearance of the middle and anterior cerebral arteries, and thick and distinct moyamoya vessels) |
IV | Minimization of the moyamoya (disappearance of the posterior cerebral artery, and narrowing of individual moyamoya vessels) |
V | Reduction of the moyamoya (disappearance of all the main cerebral arteries arising from the internal carotid artery system, further minimization of the moyamoya vessels, and an increase in the collateral pathways from the external carotid artery system) |
VI | Disappearance of the moyamoya (disappearance of the moyamoya vessels, with cerebral blood flow derived only from the external carotid artery and the vertebrobasilar artery systems) |
Stages and cerebral angiographic findings.
Stenosis or occlusion at the end of ICA and/or the initial segment of the ACA and/or MCA.
At least two obvious shadows of the blood flow are displayed on the same scan level at the basal ganglia region, suggesting the existence of an abnormal vascular network.
The above manifestations are bilateral, but bilateral lesions may be staged differently.
The total score was the sum total of MRA results and each side (right and left were scored individually) as shown in the Tables 2 and 3.
Scoring for each artery | |
---|---|
Score | MRA Findings |
Internal carotid artery | |
0 | Normal |
1 | Stenosis of C1 |
2 | Discontinuity of the C1 signal |
3 | Invisible |
Middle cerebral artery | |
0 | Normal |
1 | Stenosis of M1 |
2 | Discontinuity of the M1 signal |
3 | Invisible |
Anterior cerebral artery | |
0 | Normal A2 and blood vessels distal to A2 |
1 | Signal decrease A2 and its distal blood vessels |
2 | Invisible |
Posterior cerebral artery | |
0 | Normal P2 and blood vessels distal to P2 |
1 | Signal decrease P2 and its distal blood vessels |
2 | Invisible |
Classification and scoring based on the MRA findings.
MRA total score | MRA stage |
---|---|
0–1 | 1 |
2–4 | 2 |
5–7 | 3 |
8–10 | 4 |
Total score calculated individually for the right and left side.
As per the new guidelines, other diseases viz. atherosclerosis, autoimmune diseases, meningitis, brain tumours, Down syndrome, Recklinghausen’s disease, head injury and cerebrovascular damage after head irradiation, should be excluded [12].
Pathological findings suggestive of MMD are fibrocellular thickening of arterial intima, waviness of internal elastic lamina, thinning of the media, variable stenosis and occlusion of the implicated vessels, presence of anastomotic and perforating branches around the circle of Willis and pial reticular conglomerate of small blood vessels [12].
Definitive MMD: Either angiographic or MRA appearance of vessels bilaterally with the exclusion of alternative diagnosis [13].
Probable MMD: Either angiographic or MRA appearance of vessels unilaterally with the exclusion of alternative diagnosis [13]. Unilateral MMD may progress to bilateral MMD in 10 to 39% of the cases.
If the autopsy is performed with no previous angiography, pathological findings similar to those mentioned above may serve in the diagnosis of MMD [13].
Quasi MMD or Rui MMD:Evidence of stenosis or occlusion of distal ICA or proximal MCA or ACA with abnormal vascular network either unilateral or bilateral, in association with an underlying disease [13]. Concurrent occurrence of congenital disease is common in children, and acquired disorderis common in adults.
Unstable MMD: Defined as “rapid progression or repeated stroke”. It is a clinically challenging condition. It is more prevalent in patients younger than threeyears and those with an associated underlying disease. It is a possible risk factor associated with perioperative ischemic complication [14].
Moyamoya disease/syndrome symptoms can be broadly categorised into two, by the underlying mechanism (Figure 1). The first category of symptoms is oligemia like transient ischemic attack (TIA), stroke, and oligemia like transient ischemic attack (TIA), stroke, and seizures. Amongst the ischemic symptoms, completed strokes are more common in children, a possible explanation being their inability to identify and complain about TIAs [11]. The second category of symptoms are due to the compensatory mechanisms’ harmful consequences to ischemia like a haemorrhage from fragile collateral vessels and headaches from dilated transdural collaterals [10].
Flow chart showing the clinical manifestation of Moyamoya disease based on underlying pathogenic mechanism.
The research committee has identified nine types of initial episodes of MMD.
Hemorrhagic type.
Epileptic type.
Infarction type (can be same side or alternating hemiplegia).
TIA type.
Frequent TIA type (two or more attacks per month).
Headache type.
Asymptomatic type.
Other types.
Details unknown type.
Moyamoya disease presents with ischemic symptoms in children, an incidence of 68% and adults usually present with a hemorrhagic stroke, about 42% [10].
Amongst the ischemic symptoms, completed strokes are more common in children, a possible explanation being their inability to identify and complain about TIAs [15]. They can be transient or fixed. Most commonly occur in the territory of the internal carotid artery and proximal middle and anterior cerebral arteries [10].
Underlying mechanism:
Progressive stenosis of the internal carotid and middle cerebral arteries are responsible for most of the symptoms [10].
Maximally dilated cortical vessels in patients with chronic ischemia, constrict in response to the decreased carbon dioxide due to hyperventilation, resulting in reduced cerebral perfusion and thus exacerbating the symptoms [16].
Precipitating factors: [16].
Crying (In the paediatric population).
Hyperventilation (In paediatric population).
Exercise.
Anaesthesia.
Dehydration.
Altitude.
Eating a hot meal.
Focal Symptoms: [10].
Hemiparesis.
Dysarthria.
Aphasia.
Visual deficits.
Chorea.
Non-focal symptoms: [10].
Headache: Approximately 20% of the paediatric patients under the age of 14 years suffer from headache. Likely explanantion for the headache was the reduction of cerebral blood flow or cerebral blood flow reserve and diffusive cortical inhibition [17]. Dilatation of meningeal and leptomeningeal collateral vessels may stimulate dural nociceptors. Every refractory headache, especially in the paediatric population should be thoroughly worked up for moyamoya disease [17] Headaches can be migraine-like episodes which may respond to revascularization surgery or remain refractory to surgery [17].
Cognitive impairment, learning disability, and attention deficits.
Seizures.
Syncope.
Personality change, mistaken for a psychiatric illness like schizophrenia, acute transient psychosis, and mania [18].
Symptoms and signs which serve as biomarkers in MMD/MMS:
Orthostatic intolerance (also termed “orthostatic dysregulation”): [19] Orthostatic intolerance is defined as” a disturbance in the physiological adjustment mechanism compensating for physical stresses, such as standing, and causes a variety of symptoms associated with hemodynamic or autonomic nervous system compromise”. These symptoms can have a potential impact on the quality of life of paediatric MMD patients. In a study done by H. Uchino et al., 59% of children 10–15 years old suffered from orthostatic intolerance. These symptoms usually go unnoticed, and thus a thorough history from the patients and their caretakers become mandatory.
Symptoms which are suggestive of orthostatic intolerance:
Frequent headache.
Susceptibility to vertigo & dizziness on standing.
Fatigue.
Difficulty while getting out of bed.
Motion sickness.
Palpitation &/or dyspnea after mild exercise.
Tendency for fainting in the standing position.
Anorexia.
Occasional umbilical colic (severe abdominal pain).
Nausea on taking a hot bath or encountering unpleasant experiences.
Absent from school due to the above symptoms.
Pallor.
Fundus: Retinovascular anomalies and “morning glory disk” an enlargement of the optic disk should compel the clinician to look for moyamoya vasculopathy [20]. Morning glory syndrome or Morning glory disc anomaly is an unusual congenital optic disc anomaly characterised by a funnel-shaped excavation of the posterior globe that incorporates the optic disc [21]. Kindler described it in 1970 because it resembled the morning glory flower. The disc itself is enlarged, and orange or pink in colour within a surrounding area of peripapillary chorioretinal pigmentary changes. Alteration of lamina cribrosa and posterior sclera due to embryonic developmental defect leads to this fundus’s flowery appearanace. Presence of this sign indicates an association with systemic or intracranial vasculopathies such as MMD. Morning glory disc occurs in 50% of patients with the MMD (Figure 2).
Showing morning glory disc [courtesy:Indian J Radiol imaging. 2018 Apr-Jun] [
Showing funnel-shaped excavation of posterior globe [courtesy: Indian J Radiol imaging. 2018 Apr-Jun] [
Sequelae of MMD: [16].
Refractory headaches.
Recurrent TIAs.
Posterior cerebral artery (PCA) involvement.
Recurrent intracranial aneurysms.
Unstable MMD.
In children with MMD, recurrent ischemias can result in cerebral atrophy and thus emanate the onset of learning difficulties, cognitive impairment and mental retardation.
Hemorrhagic manifestations are more common in adults than in children. These haemorrhages are seen in 42% of the adults. The location of the bleeding can be intraventricular, intraparenchymal or subarachnoid.
Underlying mechanism:
Rupture of fragile collateral vessels as a result of chronic oligemia [23].
Development of cerebral aneurysms at the apex of the basilar artery and posterior communicating artery, areas of increased shear stress due to shifting circulatory pattern at the base of the brain is another source of haemorrhage [24].
Quasi MMD is common in adults, and the manifestations may range from asymptomatic to catastrophic haemorrhage and rebleeding with a moribund prognosis [13].
Ischemic symptoms are more common in the paediatric population, as described above. Amongst the ischemic symptoms transient ischemic attacks(TIA) are more common in the paediatric population with an incidence of 81% and infarctions are experienced by adults in approximately 51% [25].
Reason for the above observation could be due to better development of leptomeningeal collaterals (LMCs) in children than adults [25]. Various factors have been implicated in this observation: [25].
Ageing: Significant decrease in LMCs and increased tortuosity and vascular resistance in leptomeningeal vessels.
Concomitant diseases in adult MMD patients like hypertension may have an effect on the development of collaterals.
Focal cerebral ischemia may stimulate cytokines’ secretion, such as angiogenic peptides and vascular endothelial growth factor (VEGF). These cytokines levels are lower in adults.
Associated underlying conditions are commonly observed in adults with MMD.
Clinical clues for associated disorders: [10].
History of radiotherapy | Head and neck malignancies like optic gliomas, craniopharyngiomas, and pituitary tumours |
Endocrine insufficiency | Neurofibromas or tumours compressing hypothalamic–optic pathway and pituitary stalk |
Visual field defects | Tumours compressing hypothalamic–optic pathway, Strokes involving the visual pathway |
Anaemia | Sickle cell anaemia, Thalassemia, Aplastic anaemia |
Acute abdomen, bone crises | Sickle cell anaemia |
Neurocutaneous markers | Neurofibromatosis, Down’s syndrome,Turner syndrome |
Refractory hypertension | Renal Artery Stenosis |
Fever | Leptospirosis, CNS tuberculosis |
Recurrent falls (Especially in the Paediatric population) | TIAs |
Systemic symptoms like cutaneous rash, joint pains | SLE, Sjogren syndrome and HSP |
Special Precautions to be exercised:
EEG: Hyperventilation may precipitate an acute oligemic episode, thus caution has been exercised in patients with suspected moyamoya disease. Specific alterations in MMD/MMS have characteristic changes in EEG, consisting of the gradual decrease in frequency and amplitude activation after hyperventilation. These EEG changes are referred to as re-build-up phenomenon [2].
Anaesthesia and postop care.
Travelling to high altitudes.
Exercise.
A vast constellation of symptoms constitutes a repertoire in MMD. They may facilitate the diagnosis or add more confusion to the diagnosis. Fundus examination and characteristic angiogram findings clinch the diagnosis of MMD. A high index of clinical suspicion and an eye to recognise the disease’s common and unusual manifestations and inciting events may prevent delay in the diagnosis. Early recognition of illness with prompt treatment may halt the progression and allay catastrophic neurological deficits.
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Developing nations are a broad term that includes countries that are less industrialised and have lower per capita income levels than developed countries. This chapter will discuss clean water for drinking water purposes. Pollution concerns of water in developing countries will be categorised in terms of physical, chemical and biological pollutants such as turbidity, organic matter and bacteria. Natural and anthropogenic pollution concerns linking with seasonal factors will be outlined. The multi-barrier approach to drinking water treatment will be discussed. Abstraction points used will be researched. Water treatment systems, medium- to small-scale approaches, will be discussed. The processes involved in removing the contaminants including physical processes such as sedimentation, filtration such as slow-sand filtration, coagulation and flocculation, and disinfectant processes such as chlorination will be reviewed. Other important methods including solar disinfection, hybrid filtration methods and arsenic removal technologies using innovative solid phase materials will be included in this chapter. Rainwater harvesting technologies are reviewed. Safe storage options for treated water are outlined. Challenges of water treatment in rural and urban areas will be outlined.",book:{id:"6682",slug:"the-relevance-of-hygiene-to-health-in-developing-countries",title:"The Relevance of Hygiene to Health in Developing Countries",fullTitle:"The Relevance of Hygiene to Health in Developing Countries"},signatures:"Josephine Treacy",authors:[{id:"238173",title:"Dr.",name:"Josephine",middleName:null,surname:"Treacy",slug:"josephine-treacy",fullName:"Josephine Treacy"}]},{id:"44219",doi:"10.5772/54973",title:"Disaster Management Discourse in Bangladesh: A Shift from Post-Event Response to the Preparedness and Mitigation Approach Through Institutional Partnerships",slug:"disaster-management-discourse-in-bangladesh-a-shift-from-post-event-response-to-the-preparedness-and",totalDownloads:4117,totalCrossrefCites:4,totalDimensionsCites:27,abstract:null,book:{id:"3054",slug:"approaches-to-disaster-management-examining-the-implications-of-hazards-emergencies-and-disasters",title:"Approaches to Disaster Management",fullTitle:"Approaches to Disaster Management - Examining the Implications of Hazards, Emergencies and Disasters"},signatures:"C. Emdad Haque and M. Salim Uddin",authors:[{id:"163390",title:"Dr.",name:"C. Emdad",middleName:null,surname:"Haque",slug:"c.-emdad-haque",fullName:"C. Emdad Haque"},{id:"168399",title:"Mr.",name:"Mohammed S",middleName:null,surname:"Uddin",slug:"mohammed-s-uddin",fullName:"Mohammed S Uddin"}]},{id:"59705",doi:"10.5772/intechopen.74943",title:"Augmented Reality Trends in Education between 2016 and 2017 Years",slug:"augmented-reality-trends-in-education-between-2016-and-2017-years",totalDownloads:2502,totalCrossrefCites:19,totalDimensionsCites:27,abstract:"The aim of this chapter is to review literature regarding using augmented reality (AR) in education articles published in between 2016 and 2017 years. The literature source was Web of Science and SSCI, SCI-EXPANDED, A&HCI, CPCI-S, CPCI-SSH, and ESCI indexes. Fifty-two articles were reviewed; however, 14 of them were not been included in the study. As a result, 38 articles were examined. Level of education, field of education, and material types of AR used in education and reported educational advantages of AR have been investigated. All articles are categorized according to target groups, which are early childhood education, primary education, secondary education, high school education, graduate education, and others. AR technology has been mostly carried out in primary and graduate education. “Science education” is the most explored field of education. Mobile applications and marker-based materials on paper have been mostly preferred. The major advantages indicated in the articles are “Learning/Academic Achievement,” “Motivation,” and “Attitude”.",book:{id:"6543",slug:"state-of-the-art-virtual-reality-and-augmented-reality-knowhow",title:"State of the Art Virtual Reality and Augmented Reality Knowhow",fullTitle:"State of the Art Virtual Reality and Augmented Reality Knowhow"},signatures:"Rabia M. Yilmaz",authors:[{id:"225838",title:"Dr.",name:"Rabia",middleName:null,surname:"Yilmaz",slug:"rabia-yilmaz",fullName:"Rabia Yilmaz"}]},{id:"45760",doi:"10.5772/56967",title:"Parenting and Culture – Evidence from Some African Communities",slug:"parenting-and-culture-evidence-from-some-african-communities",totalDownloads:9624,totalCrossrefCites:10,totalDimensionsCites:25,abstract:null,book:{id:"3440",slug:"parenting-in-south-american-and-african-contexts",title:"Parenting in South American and African Contexts",fullTitle:"Parenting in South American and African Contexts"},signatures:"Patricia Mawusi Amos",authors:[{id:"162496",title:"Mrs.",name:"Patricia",middleName:"Mawusi",surname:"Mawusi Amos",slug:"patricia-mawusi-amos",fullName:"Patricia Mawusi Amos"}]}],mostDownloadedChaptersLast30Days:[{id:"58890",title:"Philosophy and Paradigm of Scientific Research",slug:"philosophy-and-paradigm-of-scientific-research",totalDownloads:14074,totalCrossrefCites:9,totalDimensionsCites:17,abstract:"Before carrying out the empirical analysis of the role of management culture in corporate social responsibility, identification of the philosophical approach and the paradigm on which the research carried out is based is necessary. Therefore, this chapter deals with the philosophical systems and paradigms of scientific research, the epistemology, evaluating understanding and application of various theories and practices used in the scientific research. The key components of the scientific research paradigm are highlighted. Theories on the basis of which this research was focused on identification of the level of development of the management culture in order to implement corporate social responsibility are identified, and the stages of its implementation are described.",book:{id:"5791",slug:"management-culture-and-corporate-social-responsibility",title:"Management Culture and Corporate Social Responsibility",fullTitle:"Management Culture and Corporate Social Responsibility"},signatures:"Pranas Žukauskas, Jolita Vveinhardt and Regina Andriukaitienė",authors:[{id:"179629",title:"Prof.",name:"Jolita",middleName:null,surname:"Vveinhardt",slug:"jolita-vveinhardt",fullName:"Jolita Vveinhardt"}]},{id:"74550",title:"School Conflicts: Causes and Management Strategies in Classroom Relationships",slug:"school-conflicts-causes-and-management-strategies-in-classroom-relationships",totalDownloads:2328,totalCrossrefCites:1,totalDimensionsCites:10,abstract:"Conflicts cannot cease to exist, as they are intrinsic to human beings, forming an integral part of their moral and emotional growth. Likewise, they exist in all schools. The school is inserted in a space where the conflict manifests itself daily and assumes relevance, being the result of the multiple interpersonal relationships that occur in the school context. Thus, conflict is part of school life, which implies that teachers must have the skills to manage conflict constructively. Recognizing the diversity of school conflicts, this chapter aimed to present its causes, highlighting the main ones in the classroom, in the teacher-student relationship. It is important to conflict face and resolve it with skills to manage it properly and constructively, establishing cooperative relationships, and producing integrative solutions. Harmony and appreciation should coexist in a classroom environment and conflict should not interfere, negatively, in the teaching and learning process. This bibliography review underscore the need for during the teachers’ initial training the conflict management skills development.",book:{id:"7827",slug:"interpersonal-relationships",title:"Interpersonal Relationships",fullTitle:"Interpersonal Relationships"},signatures:"Sabina Valente, Abílio Afonso Lourenço and Zsolt Németh",authors:[{id:"324514",title:"Ph.D.",name:"Sabina",middleName:"N.",surname:"Valente",slug:"sabina-valente",fullName:"Sabina Valente"},{id:"326375",title:"Prof.",name:"Abílio Afonso",middleName:"Afonso",surname:"Lourenço",slug:"abilio-afonso-lourenco",fullName:"Abílio Afonso Lourenço"},{id:"329177",title:"Dr.",name:"Zsolt",middleName:null,surname:"Németh",slug:"zsolt-nemeth",fullName:"Zsolt Németh"}]},{id:"52475",title:"Teenage Pregnancies: A Worldwide Social and Medical Problem",slug:"teenage-pregnancies-a-worldwide-social-and-medical-problem",totalDownloads:8293,totalCrossrefCites:6,totalDimensionsCites:8,abstract:"Teenage pregnancies and teenage motherhood are a cause for concern worldwide. From a historical point of view, teenage pregnancies are nothing new. For much of human history, it was absolutely common that girls married during their late adolescence and experienced first birth during their second decade of life. This kind of reproductive behavior was socially desired and considered as normal. Nowadays, however, the prevention of teenage pregnancies and teenage motherhood is a priority for public health in nearly all developed and increasingly in developing countries. For a long time, teenage pregnancies were associated with severe medical problems; however, most of data supporting this viewpoint have been collected some decades ago and reflect mainly the situation of per se socially disadvantaged teenage mothers. According to more recent studies, teenage pregnancies are not per se risky ones. A clear risk group are extremely young teenage mothers (younger than 15 years) who are confronted with various medical risks, such as preeclampsia, preterm labor, and small for gestational age newborns but also marked social disadvantage, such as poverty, unemployment, low educational level, and single parenting. In the present study, the prevalence and outcome of teenage pregnancies in Austria are focused on.",book:{id:"5392",slug:"an-analysis-of-contemporary-social-welfare-issues",title:"An Analysis of Contemporary Social Welfare Issues",fullTitle:"An Analysis of Contemporary Social Welfare Issues"},signatures:"Sylvia Kirchengast",authors:[{id:"188289",title:"Prof.",name:"Sylvia",middleName:null,surname:"Kirchengast",slug:"sylvia-kirchengast",fullName:"Sylvia Kirchengast"}]},{id:"58060",title:"Pedagogy of the Twenty-First Century: Innovative Teaching Methods",slug:"pedagogy-of-the-twenty-first-century-innovative-teaching-methods",totalDownloads:8832,totalCrossrefCites:17,totalDimensionsCites:22,abstract:"In the twenty-first century, significant changes are occurring related to new scientific discoveries, informatization, globalization, the development of astronautics, robotics, and artificial intelligence. This century is called the age of digital technologies and knowledge. How is the school changing in the new century? How does learning theory change? Currently, you can hear a lot of criticism that the classroom has not changed significantly compared to the last century or even like two centuries ago. Do the teachers succeed in modern changes? The purpose of the chapter is to summarize the current changes in didactics for the use of innovative teaching methods and study the understanding of changes by teachers. In this chapter, we consider four areas: the expansion of the subject of pedagogy, environmental approach to teaching, the digital generation and the changes taking place, and innovation in teaching. The theory of education, figuratively speaking, has two levels. At the macro-level, in the “education-society” relationship, decentralization and diversification, internationalization of education, and the introduction of digital technologies occur. At the micro-level in the “teacher-learner” relationship, there is an active mix of traditional and innovative methods, combination of an activity approach with an energy-informational environment approach, cognition with constructivism and connectivism.",book:{id:"5980",slug:"new-pedagogical-challenges-in-the-21st-century-contributions-of-research-in-education",title:"New Pedagogical Challenges in the 21st Century",fullTitle:"New Pedagogical Challenges in the 21st Century - Contributions of Research in Education"},signatures:"Aigerim Mynbayeva, Zukhra Sadvakassova and Bakhytkul\nAkshalova",authors:[{id:"201997",title:"Dr.",name:"Aigerim",middleName:null,surname:"Mynbayeva",slug:"aigerim-mynbayeva",fullName:"Aigerim Mynbayeva"},{id:"209208",title:"Dr.",name:"Zukhra",middleName:null,surname:"Sadvakassova",slug:"zukhra-sadvakassova",fullName:"Zukhra Sadvakassova"},{id:"209210",title:"Dr.",name:"Bakhytkul",middleName:null,surname:"Akshalova",slug:"bakhytkul-akshalova",fullName:"Bakhytkul Akshalova"}]},{id:"58894",title:"Research Ethics",slug:"research-ethics",totalDownloads:3371,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"Research ethics is closely related to the ethical principles of social responsibility. This research covers a wide context of working with people, so the researchers raised a task not only to gain confidence in the respondents’ eyes, to receive reliable data, but also to ensure the transparency of the science. This chapter discusses the theoretical and practical topics of research, after evaluation of which ethical principles of organization and conducting the research are presented. There is a detailed description of how and what ethical principles were followed on the different stages of the research.",book:{id:"5791",slug:"management-culture-and-corporate-social-responsibility",title:"Management Culture and Corporate Social Responsibility",fullTitle:"Management Culture and Corporate Social Responsibility"},signatures:"Pranas Žukauskas, Jolita Vveinhardt and Regina Andriukaitienė",authors:[{id:"179629",title:"Prof.",name:"Jolita",middleName:null,surname:"Vveinhardt",slug:"jolita-vveinhardt",fullName:"Jolita Vveinhardt"}]}],onlineFirstChaptersFilter:{topicId:"23",limit:6,offset:0},onlineFirstChaptersCollection:[{id:"83014",title:"Culture: A Pillar of Organizational Sustainability",slug:"culture-a-pillar-of-organizational-sustainability",totalDownloads:1,totalDimensionsCites:0,doi:"10.5772/intechopen.106523",abstract:"Sustainability is a concern that permeates all levels of society and is premised on meeting the needs of the present without compromising the ability of future generations to meet theirs. More recently, policies and research have emerged that guide organizations to align their activities with the broader sustainable development agendas, including cultural issues, not just economic, social, and environmental ones. Culture is the material and immaterial attribute of society. It incorporates social organizations, literature, religion, myths, beliefs, behaviors and entrepreneurial practices of the productive segment, use of technology, and expressive art forms on which future generations depend. Thus, cultural sustainability is a fundamental issue and is configured as the fourth pillar of sustainability, equal to social, economic, and environmental issues, which has to do with the ability to sustain or continue with cultural beliefs and practices, preserve cultural heritage as its entity, and try to answer whether any culture will exist in the future. The importance of cultural sustainability lies in its power to influence people. Their beliefs are in the decisions made by society. Thus, there can be no sustainable development without including culture.",book:{id:"11429",title:"Sustainability, Ecology, and Religions of the World",coverURL:"https://cdn.intechopen.com/books/images_new/11429.jpg"},signatures:"Clea Beatriz Macagnan and Rosane Maria Seibert"},{id:"82949",title:"Corruption and Deterioration of Democracy: The Brazilian Lesson",slug:"corruption-and-deterioration-of-democracy-the-brazilian-lesson",totalDownloads:2,totalDimensionsCites:0,doi:"10.5772/intechopen.106194",abstract:"Although it has emerged, nationally and internationally, as one of the largest investigations against political corruption, Operation Car Wash—at its peak of popular prestige—cleared the path for the political rise of Jair Bolsonaro to the Presidency of the Republic of Brazil. And by doing so, to a certain extent, it paved the way for a set of arbitrary practices that today threaten and weaken the main Brazilian democratic institutions. Brazilian democracy today pays a high price for the Judiciary’s lethargic and condescending response to the unorthodox and illegal practices of Federal Judge Sérgio Moro during the golden years of Operation Car Wash (2014–2018). The lesson that the Brazilian episode brings to the international legal community is that the constant disrespect for the rules of due criminal procedure in large cases of corruption erodes the institutional bases that support the proper confrontation of this type of crime. The pertinent fight against corruption in a democracy can only take place in strict obedience to the law.",book:{id:"11772",title:"Corruption - New Insights",coverURL:"https://cdn.intechopen.com/books/images_new/11772.jpg"},signatures:"Fabio Roberto D’Avila and Theodoro Balducci de Oliveira"},{id:"82903",title:"Walking Accessibility to Primary Healthcare Services: An Inequity Factor for Olders in the Lisbon Metropolitan Area (Portugal)",slug:"walking-accessibility-to-primary-healthcare-services-an-inequity-factor-for-olders-in-the-lisbon-met",totalDownloads:3,totalDimensionsCites:0,doi:"10.5772/intechopen.106265",abstract:"This chapter discusses the walking accessibility to primary healthcare by the olders in Lisbon Metropolitan Area (LMA), Portugal, and its contribution for age-friendly environments as a factor of inequity. Constrains emerged from the collation of the supply approach, represented by service catchment areas based on walking distance time, and the demand approach, through a survey. The location and density of primary health network are a major factor, as it is related to distinct land use patterns within the LMA. The settlement structure influences the potential walkability to primary healthcare. The discrepancy between the potential walking accessibility and the real options is notorious, as olders` choices are diversified in terms of transportation modes and destinations, but mostly keeping relatively short time distances. This phenomenon is also influenced by factors such as personal preference, difficulty to walk, negative perceptions about the surroundings, and insufficient care support. This debate is already an effective concern of local authorities with spatial planning, social and health competences, insofar as solutions in terms of service flexibility and new travel solutions adapted to the specific needs of the olders are a growing reality in the LMA, promoting more age-friendly, health, and inclusive environments, and hence an equitable metropolis.",book:{id:"11479",title:"Social Aspects of Ageing - Selected Challenges, Analyses, and Solutions",coverURL:"https://cdn.intechopen.com/books/images_new/11479.jpg"},signatures:"Eduarda Marques da Costa, Ana Louro, Nuno Marques da Costa, Mariana Dias and Marcela Barata"},{id:"82834",title:"Perspective Chapter: Social Work Education in University Curricula for Sustainable Development",slug:"perspective-chapter-social-work-education-in-university-curricula-for-sustainable-development",totalDownloads:4,totalDimensionsCites:0,doi:"10.5772/intechopen.106246",abstract:"Universities of both global North and South have been changing from the traditional teaching-learning centers to cater to sustainability issues of those countries. Yet, there is a remarkable difference between the universities in the developed and the developing world. It has been found out that the different disciplines of university curricula can be integrated to address and minimize the adverse effects of unsustainability issues. The graduates of the universities will be the future leaders who have to cater to the needs and cope with the challenges of the next generation. There is a dearth of professional social workers to provide the necessary services as numerous catastrophes occur. The global society needs individuals who are equally sound in the knowledge of theory and the experience of practice. As the contemporary global issues become complex, the world needs competent social workers who can serve in different fields of practice. Social work could be the pivotal discipline in understanding common tragedies of the people to apply problem-solving model with the practitioners who are equipped with twenty-first century skills. Social work has to take a transition from a unidisciplinary to a multi- and trans-disciplinary perspective in achieving this objective.",book:{id:"11095",title:"Social Work - Perspectives on Leadership and Organisation",coverURL:"https://cdn.intechopen.com/books/images_new/11095.jpg"},signatures:"Upul Lekamge"},{id:"82190",title:"Effects of the Changes of Curriculum on the Coverage of Environmental Content in Geography",slug:"effects-of-the-changes-of-curriculum-on-the-coverage-of-environmental-content-in-geography",totalDownloads:3,totalDimensionsCites:0,doi:"10.5772/intechopen.104988",abstract:"The South African education sector has experienced several shifts in the curriculum since 1994, thus affecting the coverage, teaching and examination of environmental impact topics in the South African Further Education and Training Phase (FET) phase. This chapter evaluates the effects of changes in curriculum on the coverage of education for sustainable development content in Geography. A qualitative research approach using an interpretative paradigm was employed in the documents used by Geography teachers in South Africa. The chapter used Margaret Archers, Realist Social Theory as a theoretical framework that guides data analysis and interpretation. Document analysis was the only method used where policy documents and examination papers were the instruments evaluated. The results show that environmental impact topics are covered in varying degrees in the South African CAPS curriculum. The level of coverage of environmental impact topics in the examination question papers fluctuates, sometimes to levels below those stipulated in the CAPS documents. The conclusion that can be reached is that the variable coverage of environmental impact topics in the examinations may have a negative effect on the way teachers address the topics of Geography. This resulted in an emergence of structural and cultural morphogenesis in the teaching of environmental content in Geography.",book:{id:"11429",title:"Sustainability, Ecology, and Religions of the World",coverURL:"https://cdn.intechopen.com/books/images_new/11429.jpg"},signatures:"Sikhulile Bonginkosi Msezane"},{id:"82093",title:"Perspective Chapter: Pedagogical Approaches and Access to Education Among Early Childhood Education Learners with Disabilities in Africa During the COVID-19 Pandemic - Review of Available Literature",slug:"perspective-chapter-pedagogical-approaches-and-access-to-education-among-early-childhood-education-l",totalDownloads:11,totalDimensionsCites:0,doi:"10.5772/intechopen.104921",abstract:"The COVID 19 pandemic suddenly hit the world disrupting access to education especially in Sub-Saharan Africa, threatening the future of millions of learners. This chapter discusses the effects of COVID-19 on early childhood education (ECE) for learners with disabilities in Africa, focusing on three questions: (1) What pedagogical approaches were used to enable access to education among ECE learners with disabilities during the COVID 19 pandemic? (2) How was access to education for ECE learners with disabilities, and what challenges and opportunities were experienced? (3) How can access to quality and equitable learning for ECE learners with disabilities during the crisis be improved? Literature revealed that the pandemic aggravated the hardships in accessing learning programs among learners with disabilities widening the gap between them and their counterparts. Countries resorted to remote and digital pedagogical approaches to enable continuity of learning; however, many did not cater for learners with disabilities. Where disabilities were catered for, the reach and utilization were limited by lack of resources and capacity. Concerted efforts promoting effective inclusive learning are critical for the current and future pandemics. Barriers to provision of equitable education, and long-term effects of COVID 19 on in ECE learners with disabilities should be investigated.",book:{id:"10912",title:"Psychosocial, Educational, and Economic Impacts of COVID-19",coverURL:"https://cdn.intechopen.com/books/images_new/10912.jpg"},signatures:"Margaret Nampijja, Lillian Ayiro and Ruth Nalugya"}],onlineFirstChaptersTotal:144},preDownload:{success:null,errors:{}},subscriptionForm:{success:null,errors:{}},aboutIntechopen:{},privacyPolicy:{},peerReviewing:{},howOpenAccessPublishingWithIntechopenWorks:{},sponsorshipBooks:{sponsorshipBooks:[],offset:8,limit:8,total:0},allSeries:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:90,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical Engineering",numberOfPublishedBooks:12,numberOfPublishedChapters:107,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2631-5343",doi:"10.5772/intechopen.71985",isOpenForSubmission:!0}],lsSeriesList:[{id:"11",title:"Biochemistry",numberOfPublishedBooks:33,numberOfPublishedChapters:330,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2632-0983",doi:"10.5772/intechopen.72877",isOpenForSubmission:!0},{id:"25",title:"Environmental Sciences",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2754-6713",doi:"10.5772/intechopen.100362",isOpenForSubmission:!0},{id:"10",title:"Physiology",numberOfPublishedBooks:14,numberOfPublishedChapters:145,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-8261",doi:"10.5772/intechopen.72796",isOpenForSubmission:!0}],hsSeriesList:[{id:"3",title:"Dentistry",numberOfPublishedBooks:9,numberOfPublishedChapters:139,numberOfOpenTopics:2,numberOfUpcomingTopics:0,issn:"2631-6218",doi:"10.5772/intechopen.71199",isOpenForSubmission:!0},{id:"6",title:"Infectious Diseases",numberOfPublishedBooks:13,numberOfPublishedChapters:122,numberOfOpenTopics:4,numberOfUpcomingTopics:0,issn:"2631-6188",doi:"10.5772/intechopen.71852",isOpenForSubmission:!0},{id:"13",title:"Veterinary Medicine and Science",numberOfPublishedBooks:11,numberOfPublishedChapters:112,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2632-0517",doi:"10.5772/intechopen.73681",isOpenForSubmission:!0}],sshSeriesList:[{id:"22",title:"Business, Management and Economics",numberOfPublishedBooks:1,numberOfPublishedChapters:21,numberOfOpenTopics:3,numberOfUpcomingTopics:0,issn:"2753-894X",doi:"10.5772/intechopen.100359",isOpenForSubmission:!0},{id:"23",title:"Education and Human Development",numberOfPublishedBooks:0,numberOfPublishedChapters:10,numberOfOpenTopics:1,numberOfUpcomingTopics:1,issn:null,doi:"10.5772/intechopen.100360",isOpenForSubmission:!0},{id:"24",title:"Sustainable Development",numberOfPublishedBooks:1,numberOfPublishedChapters:19,numberOfOpenTopics:5,numberOfUpcomingTopics:0,issn:"2753-6580",doi:"10.5772/intechopen.100361",isOpenForSubmission:!0}],testimonialsList:[{id:"6",text:"It is great to work with the IntechOpen to produce a worthwhile collection of research that also becomes a great educational resource and guide for future research endeavors.",author:{id:"259298",name:"Edward",surname:"Narayan",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/259298/images/system/259298.jpeg",slug:"edward-narayan",institution:{id:"3",name:"University of Queensland",country:{id:null,name:"Australia"}}}},{id:"13",text:"The collaboration with and support of the technical staff of IntechOpen is fantastic. The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"6",title:"Infectious Diseases",doi:"10.5772/intechopen.71852",issn:"2631-6188",scope:"This series will provide a comprehensive overview of recent research trends in various Infectious Diseases (as per the most recent Baltimore classification). Topics will include general overviews of infections, immunopathology, diagnosis, treatment, epidemiology, etiology, and current clinical recommendations for managing infectious diseases. Ongoing issues, recent advances, and future diagnostic approaches and therapeutic strategies will also be discussed. This book series will focus on various aspects and properties of infectious diseases whose deep understanding is essential for safeguarding the human race from losing resources and economies due to pathogens.",coverUrl:"https://cdn.intechopen.com/series/covers/6.jpg",latestPublicationDate:"August 2nd, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:13,editor:{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"3",title:"Bacterial Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/3.jpg",isOpenForSubmission:!0,editor:{id:"205604",title:"Dr.",name:"Tomas",middleName:null,surname:"Jarzembowski",slug:"tomas-jarzembowski",fullName:"Tomas Jarzembowski",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKriQAG/Profile_Picture_2022-06-16T11:01:31.jpg",biography:"Tomasz Jarzembowski was born in 1968 in Gdansk, Poland. He obtained his Ph.D. degree in 2000 from the Medical University of Gdańsk (UG). After specialization in clinical microbiology in 2003, he started studying biofilm formation and antibiotic resistance at the single-cell level. In 2015, he obtained his D.Sc. degree. His later study in cooperation with experts in nephrology and immunology resulted in the designation of the new diagnostic method of UTI, patented in 2017. He is currently working at the Department of Microbiology, Medical University of Gdańsk (GUMed), Poland. Since many years, he is a member of steering committee of Gdańsk branch of Polish Society of Microbiologists, a member of ESCMID. 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She is now a lecturer at the University of Witwatersrand, South Africa, and a principal researcher at the Health Economics and Epidemiology Research Office (HE2RO), South Africa. Dr. Moolla holds a Ph.D. in Psychology with her research being focused on mental health and resilience. In her professional work capacity, her research has further expanded into the fields of early childhood development, mental health, the HIV and TB care cascades, as well as COVID. She is also a UNESCO-trained International Bioethics Facilitator.",institutionString:"University of the Witwatersrand",institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"419588",title:"Ph.D.",name:"Sergio",middleName:"Alexandre",surname:"Gehrke",slug:"sergio-gehrke",fullName:"Sergio Gehrke",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y000038WgMKQA0/Profile_Picture_2022-06-02T11:44:20.jpg",biography:"Dr. Sergio Alexandre Gehrke is a doctorate holder in two fields. The first is a Ph.D. in Cellular and Molecular Biology from the Pontificia Catholic University, Porto Alegre, Brazil, in 2010 and the other is an International Ph.D. in Bioengineering from the Universidad Miguel Hernandez, Elche/Alicante, Spain, obtained in 2020. In 2018, he completed a postdoctoral fellowship in Materials Engineering in the NUCLEMAT of the Pontificia Catholic University, Porto Alegre, Brazil. He is currently the Director of the Postgraduate Program in Implantology of the Bioface/UCAM/PgO (Montevideo, Uruguay), Director of the Cathedra of Biotechnology of the Catholic University of Murcia (Murcia, Spain), an Extraordinary Full Professor of the Catholic University of Murcia (Murcia, Spain) as well as the Director of the private center of research Biotecnos – Technology and Science (Montevideo, Uruguay). Applied biomaterials, cellular and molecular biology, and dental implants are among his research interests. He has published several original papers in renowned journals. In addition, he is also a Collaborating Professor in several Postgraduate programs at different universities all over the world.",institutionString:null,institution:{name:"Universidad Católica San Antonio de Murcia",country:{name:"Spain"}}},{id:"342152",title:"Dr.",name:"Santo",middleName:null,surname:"Grace Umesh",slug:"santo-grace-umesh",fullName:"Santo Grace Umesh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/342152/images/16311_n.jpg",biography:null,institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"333647",title:"Dr.",name:"Shreya",middleName:null,surname:"Kishore",slug:"shreya-kishore",fullName:"Shreya Kishore",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333647/images/14701_n.jpg",biography:"Dr. Shreya Kishore completed her Bachelor in Dental Surgery in Chettinad Dental College and Research Institute, Chennai, and her Master of Dental Surgery (Orthodontics) in Saveetha Dental College, Chennai. She is also Invisalign certified. She’s working as a Senior Lecturer in the Department of Orthodontics, SRM Dental College since November 2019. She is actively involved in teaching orthodontics to the undergraduates and the postgraduates. Her clinical research topics include new orthodontic brackets, fixed appliances and TADs. She’s published 4 articles in well renowned indexed journals and has a published patency of her own. Her private practice is currently limited to orthodontics and works as a consultant in various clinics.",institutionString:null,institution:{name:"SRM Dental College",country:{name:"India"}}},{id:"323731",title:"Prof.",name:"Deepak M.",middleName:"Macchindra",surname:"Vikhe",slug:"deepak-m.-vikhe",fullName:"Deepak M. Vikhe",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/323731/images/13613_n.jpg",biography:"Dr Deepak M.Vikhe .\n\n\t\n\tDr Deepak M.Vikhe , completed his Masters & PhD in Prosthodontics from Rural Dental College, Loni securing third rank in the Pravara Institute of Medical Sciences Deemed University. He was awarded Dr.G.C.DAS Memorial Award for Research on Implants at 39th IPS conference Dubai (U A E).He has two patents under his name. He has received Dr.Saraswati medal award for best research for implant study in 2017.He has received Fully funded scholarship to Spain ,university of Santiago de Compostela. He has completed fellowship in Implantlogy from Noble Biocare. \nHe has attended various conferences and CDE programmes and has national publications to his credit. His field of interest is in Implant supported prosthesis. Presently he is working as a associate professor in the Dept of Prosthodontics, Rural Dental College, Loni and maintains a successful private practice specialising in Implantology at Rahata.\n\nEmail: drdeepak_mvikhe@yahoo.com..................",institutionString:null,institution:{name:"Pravara Institute of Medical Sciences",country:{name:"India"}}},{id:"204110",title:"Dr.",name:"Ahmed A.",middleName:null,surname:"Madfa",slug:"ahmed-a.-madfa",fullName:"Ahmed A. Madfa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204110/images/system/204110.jpg",biography:"Dr. Madfa is currently Associate Professor of Endodontics at Thamar University and a visiting lecturer at Sana'a University and University of Sciences and Technology. He has more than 6 years of experience in teaching. His research interests include root canal morphology, functionally graded concept, dental biomaterials, epidemiology and dental education, biomimetic restoration, finite element analysis and endodontic regeneration. Dr. Madfa has numerous international publications, full articles, two patents, a book and a book chapter. Furthermore, he won 14 international scientific awards. Furthermore, he is involved in many academic activities ranging from editorial board member, reviewer for many international journals and postgraduate students' supervisor. Besides, I deliver many courses and training workshops at various scientific events. Dr. Madfa also regularly attends international conferences and holds administrative positions (Deputy Dean of the Faculty for Students’ & Academic Affairs and Deputy Head of Research Unit).",institutionString:"Thamar University",institution:null},{id:"210472",title:"Dr.",name:"Nermin",middleName:"Mohammed Ahmed",surname:"Yussif",slug:"nermin-yussif",fullName:"Nermin Yussif",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/210472/images/system/210472.jpg",biography:"Dr. Nermin Mohammed Ahmed Yussif is working at the Faculty of dentistry, University for October university for modern sciences and arts (MSA). Her areas of expertise include: periodontology, dental laserology, oral implantology, periodontal plastic surgeries, oral mesotherapy, nutrition, dental pharmacology. She is an editor and reviewer in numerous international journals.",institutionString:"MSA University",institution:null},{id:"204606",title:"Dr.",name:"Serdar",middleName:null,surname:"Gözler",slug:"serdar-gozler",fullName:"Serdar Gözler",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/204606/images/system/204606.jpeg",biography:"Dr. Serdar Gözler has completed his undergraduate studies at the Marmara University Faculty of Dentistry in 1978, followed by an assistantship in the Prosthesis Department of Dicle University Faculty of Dentistry. Starting his PhD work on non-resilient overdentures with Assoc. Prof. Hüsnü Yavuzyılmaz, he continued his studies with Prof. Dr. Gürbüz Öztürk of Istanbul University Faculty of Dentistry Department of Prosthodontics, this time on Gnatology. He attended training programs on occlusion, neurology, neurophysiology, EMG, radiology and biostatistics. In 1982, he presented his PhD thesis \\Gerber and Lauritzen Occlusion Analysis Techniques: Diagnosis Values,\\ at Istanbul University School of Dentistry, Department of Prosthodontics. As he was also working with Prof. Senih Çalıkkocaoğlu on The Physiology of Chewing at the same time, Gözler has written a chapter in Çalıkkocaoğlu\\'s book \\Complete Prostheses\\ entitled \\The Place of Neuromuscular Mechanism in Prosthetic Dentistry.\\ The book was published five times since by the Istanbul University Publications. Having presented in various conferences about occlusion analysis until 1998, Dr. Gözler has also decided to use the T-Scan II occlusion analysis method. Having been personally trained by Dr. Robert Kerstein on this method, Dr. Gözler has been lecturing on the T-Scan Occlusion Analysis Method in conferences both in Turkey and abroad. Dr. Gözler has various articles and presentations on Digital Occlusion Analysis methods. He is now Head of the TMD Clinic at Prosthodontic Department of Faculty of Dentistry , Istanbul Aydın University , Turkey.",institutionString:"Istanbul Aydin University",institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"256417",title:"Associate Prof.",name:"Sanaz",middleName:null,surname:"Sadry",slug:"sanaz-sadry",fullName:"Sanaz Sadry",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256417/images/8106_n.jpg",biography:null,institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"240870",title:"Ph.D.",name:"Alaa Eddin Omar",middleName:null,surname:"Al Ostwani",slug:"alaa-eddin-omar-al-ostwani",fullName:"Alaa Eddin Omar Al Ostwani",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/240870/images/system/240870.jpeg",biography:"Dr. Al Ostwani Alaa Eddin Omar received his Master in dentistry from Damascus University in 2010, and his Ph.D. in Pediatric Dentistry from Damascus University in 2014. Dr. Al Ostwani is an assistant professor and faculty member at IUST University since 2014. \nDuring his academic experience, he has received several awards including the scientific research award from the Union of Arab Universities, the Syrian gold medal and the international gold medal for invention and creativity. Dr. Al Ostwani is a Member of the International Association of Dental Traumatology and the Syrian Society for Research and Preventive Dentistry since 2017. He is also a Member of the Reviewer Board of International Journal of Dental Medicine (IJDM), and the Indian Journal of Conservative and Endodontics since 2016.",institutionString:"International University for Science and Technology.",institution:{name:"Islamic University of Science and Technology",country:{name:"India"}}},{id:"42847",title:"Dr.",name:"Belma",middleName:null,surname:"Işik Aslan",slug:"belma-isik-aslan",fullName:"Belma Işik Aslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/42847/images/system/42847.jpg",biography:"Dr. Belma IşIk Aslan was born in 1976 in Ankara-TURKEY. After graduating from TED Ankara College in 1994, she attended to Gazi University, Faculty of Dentistry in Ankara. She completed her PhD in orthodontic education at Gazi University between 1999-2005. Dr. Işık Aslan stayed at the Providence Hospital Craniofacial Institude and Reconstructive Surgery in Michigan, USA for three months as an observer. She worked as a specialist doctor at Gazi University, Dentistry Faculty, Department of Orthodontics between 2005-2014. She was appointed as associate professor in January, 2014 and as professor in 2021. Dr. Işık Aslan still works as an instructor at the same faculty. She has published a total of 35 articles, 10 book chapters, 39 conference proceedings both internationally and nationally. Also she was the academic editor of the international book 'Current Advances in Orthodontics'. She is a member of the Turkish Orthodontic Society and Turkish Cleft Lip and Palate Society. She is married and has 2 children. Her knowledge of English is at an advanced level.",institutionString:"Gazi University Dentistry Faculty Department of Orthodontics",institution:null},{id:"202198",title:"Dr.",name:"Buket",middleName:null,surname:"Aybar",slug:"buket-aybar",fullName:"Buket Aybar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/202198/images/6955_n.jpg",biography:"Buket Aybar, DDS, PhD, was born in 1971. She graduated from Istanbul University, Faculty of Dentistry, in 1992 and completed her PhD degree on Oral and Maxillofacial Surgery in Istanbul University in 1997.\r\nDr. Aybar is currently a full-time professor in Istanbul University, Faculty of Dentistry Department of Oral and Maxillofacial Surgery. She has teaching responsibilities in graduate and postgraduate programs. Her clinical practice includes mainly dentoalveolar surgery.\r\nHer topics of interest are biomaterials science and cell culture studies. She has many articles in international and national scientific journals and chapters in books; she also has participated in several scientific projects supported by Istanbul University Research fund.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178412",title:"Associate Prof.",name:"Guhan",middleName:null,surname:"Dergin",slug:"guhan-dergin",fullName:"Guhan Dergin",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178412/images/6954_n.jpg",biography:"Assoc. Prof. Dr. Gühan Dergin was born in 1973 in Izmit. He graduated from Marmara University Faculty of Dentistry in 1999. He completed his specialty of OMFS surgery in Marmara University Faculty of Dentistry and obtained his PhD degree in 2006. In 2005, he was invited as a visiting doctor in the Oral and Maxillofacial Surgery Department of the University of North Carolina, USA, where he went on a scholarship. Dr. Dergin still continues his academic career as an associate professor in Marmara University Faculty of Dentistry. He has many articles in international and national scientific journals and chapters in books.",institutionString:null,institution:{name:"Marmara University",country:{name:"Turkey"}}},{id:"178414",title:"Prof.",name:"Yusuf",middleName:null,surname:"Emes",slug:"yusuf-emes",fullName:"Yusuf Emes",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178414/images/6953_n.jpg",biography:"Born in Istanbul in 1974, Dr. Emes graduated from Istanbul University Faculty of Dentistry in 1997 and completed his PhD degree in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery in 2005. He has papers published in international and national scientific journals, including research articles on implantology, oroantral fistulas, odontogenic cysts, and temporomandibular disorders. Dr. Emes is currently working as a full-time academic staff in Istanbul University faculty of Dentistry Department of Oral and Maxillofacial Surgery.",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"192229",title:"Ph.D.",name:"Ana Luiza",middleName:null,surname:"De Carvalho Felippini",slug:"ana-luiza-de-carvalho-felippini",fullName:"Ana Luiza De Carvalho Felippini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192229/images/system/192229.jpg",biography:null,institutionString:"University of São Paulo",institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"256851",title:"Prof.",name:"Ayşe",middleName:null,surname:"Gülşen",slug:"ayse-gulsen",fullName:"Ayşe Gülşen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/256851/images/9696_n.jpg",biography:"Dr. Ayşe Gülşen graduated in 1990 from Faculty of Dentistry, University of Ankara and did a postgraduate program at University of Gazi. \nShe worked as an observer and research assistant in Craniofacial Surgery Departments in New York, Providence Hospital in Michigan and Chang Gung Memorial Hospital in Taiwan. \nShe works as Craniofacial Orthodontist in Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi, Ankara Turkey since 2004.",institutionString:"Orthodontist, Assoc Prof in the Department of Aesthetic, Plastic and Reconstructive Surgery, Faculty of Medicine, University of Gazi",institution:null},{id:"255366",title:"Prof.",name:"Tosun",middleName:null,surname:"Tosun",slug:"tosun-tosun",fullName:"Tosun Tosun",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255366/images/7347_n.jpg",biography:"Graduated at the Faculty of Dentistry, University of Istanbul, Turkey in 1989;\nVisitor Assistant at the University of Padua, Italy and Branemark Osseointegration Center of Treviso, Italy between 1993-94;\nPhD thesis on oral implantology in University of Istanbul and was awarded the academic title “Dr.med.dent.”, 1997;\nHe was awarded the academic title “Doç.Dr.” (Associated Professor) in 2003;\nProficiency in Botulinum Toxin Applications, Reading-UK in 2009;\nMastership, RWTH Certificate in Laser Therapy in Dentistry, AALZ-Aachen University, Germany 2009-11;\nMaster of Science (MSc) in Laser Dentistry, University of Genoa, Italy 2013-14.\n\nDr.Tosun worked as Research Assistant in the Department of Oral Implantology, Faculty of Dentistry, University of Istanbul between 1990-2002. \nHe worked part-time as Consultant surgeon in Harvard Medical International Hospitals and John Hopkins Medicine, Istanbul between years 2007-09.\u2028He was contract Professor in the Department of Surgical and Diagnostic Sciences (DI.S.C.), Medical School, University of Genova, Italy between years 2011-16. \nSince 2015 he is visiting Professor at Medical School, University of Plovdiv, Bulgaria. \nCurrently he is Associated Prof.Dr. at the Dental School, Oral Surgery Dept., Istanbul Aydin University and since 2003 he works in his own private clinic in Istanbul, Turkey.\u2028\nDr.Tosun is reviewer in journal ‘Laser in Medical Sciences’, reviewer in journal ‘Folia Medica\\', a Fellow of the International Team for Implantology, Clinical Lecturer of DGZI German Association of Oral Implantology, Expert Lecturer of Laser&Health Academy, Country Representative of World Federation for Laser Dentistry, member of European Federation of Periodontology, member of Academy of Laser Dentistry. Dr.Tosun presents papers in international and national congresses and has scientific publications in international and national journals. He speaks english, spanish, italian and french.",institutionString:null,institution:{name:"Istanbul Aydın University",country:{name:"Turkey"}}},{id:"260116",title:"Dr.",name:"Mehmet",middleName:null,surname:"Yaltirik",slug:"mehmet-yaltirik",fullName:"Mehmet Yaltirik",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/260116/images/7413_n.jpg",biography:"Birth Date 25.09.1965\r\nBirth Place Adana- Turkey\r\nSex Male\r\nMarrial Status Bachelor\r\nDriving License Acquired\r\nMother Tongue Turkish\r\n\r\nAddress:\r\nWork:University of Istanbul,Faculty of Dentistry, Department of Oral Surgery and Oral Medicine 34093 Capa,Istanbul- TURKIYE",institutionString:null,institution:{name:"Istanbul University",country:{name:"Turkey"}}},{id:"171887",title:"Prof.",name:"Zühre",middleName:null,surname:"Akarslan",slug:"zuhre-akarslan",fullName:"Zühre Akarslan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/171887/images/system/171887.jpg",biography:"Zühre Akarslan was born in 1977 in Cyprus. She graduated from Gazi University Faculty of Dentistry, Ankara, Turkey in 2000. \r\nLater she received her Ph.D. degree from the Oral Diagnosis and Radiology Department; which was recently renamed as Oral and Dentomaxillofacial Radiology, from the same university. \r\nShe is working as a full-time Associate Professor and is a lecturer and an academic researcher. \r\nHer expertise areas are dental caries, cancer, dental fear and anxiety, gag reflex in dentistry, oral medicine, and dentomaxillofacial radiology.",institutionString:"Gazi University",institution:{name:"Gazi University",country:{name:"Turkey"}}},{id:"272237",title:"Dr.",name:"Pinar",middleName:"Kiymet",surname:"Karataban",slug:"pinar-karataban",fullName:"Pinar Karataban",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/272237/images/8911_n.png",biography:"Assist.Prof.Dr.Pınar Kıymet Karataban, DDS PhD \n\nDr.Pınar Kıymet Karataban was born in Istanbul in 1975. After her graduation from Marmara University Faculty of Dentistry in 1998 she started her PhD in Paediatric Dentistry focused on children with special needs; mainly children with Cerebral Palsy. She finished her pHD thesis entitled \\'Investigation of occlusion via cast analysis and evaluation of dental caries prevalance, periodontal status and muscle dysfunctions in children with cerebral palsy” in 2008. She got her Assist. Proffessor degree in Istanbul Aydın University Paediatric Dentistry Department in 2015-2018. ın 2019 she started her new career in Bahcesehir University, Istanbul as Head of Department of Pediatric Dentistry. In 2020 she was accepted to BAU International University, Batumi as Professor of Pediatric Dentistry. She’s a lecturer in the same university meanwhile working part-time in private practice in Ege Dental Studio (https://www.egedisklinigi.com/) a multidisciplinary dental clinic in Istanbul. Her main interests are paleodontology, ancient and contemporary dentistry, oral microbiology, cerebral palsy and special care dentistry. She has national and international publications, scientific reports and is a member of IAPO (International Association for Paleodontology), IADH (International Association of Disability and Oral Health) and EAPD (European Association of Pediatric Dentistry).",institutionString:null,institution:null},{id:"172009",title:"Dr.",name:"Fatma Deniz",middleName:null,surname:"Uzuner",slug:"fatma-deniz-uzuner",fullName:"Fatma Deniz Uzuner",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/172009/images/7122_n.jpg",biography:"Dr. Deniz Uzuner was born in 1969 in Kocaeli-TURKEY. After graduating from TED Ankara College in 1986, she attended the Hacettepe University, Faculty of Dentistry in Ankara. \nIn 1993 she attended the Gazi University, Faculty of Dentistry, Department of Orthodontics for her PhD education. After finishing the PhD education, she worked as orthodontist in Ankara Dental Hospital under the Turkish Government, Ministry of Health and in a special Orthodontic Clinic till 2011. Between 2011 and 2016, Dr. Deniz Uzuner worked as a specialist in the Department of Orthodontics, Faculty of Dentistry, Gazi University in Ankara/Turkey. In 2016, she was appointed associate professor. Dr. Deniz Uzuner has authored 23 Journal Papers, 3 Book Chapters and has had 39 oral/poster presentations. She is a member of the Turkish Orthodontic Society. Her knowledge of English is at an advanced level.",institutionString:null,institution:null},{id:"332914",title:"Dr.",name:"Muhammad Saad",middleName:null,surname:"Shaikh",slug:"muhammad-saad-shaikh",fullName:"Muhammad Saad Shaikh",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Jinnah Sindh Medical University",country:{name:"Pakistan"}}},{id:"315775",title:"Dr.",name:"Feng",middleName:null,surname:"Luo",slug:"feng-luo",fullName:"Feng Luo",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Sichuan University",country:{name:"China"}}},{id:"344229",title:"Dr.",name:"Sankeshan",middleName:null,surname:"Padayachee",slug:"sankeshan-padayachee",fullName:"Sankeshan Padayachee",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of the Witwatersrand",country:{name:"South Africa"}}},{id:"315727",title:"Ms.",name:"Kelebogile A.",middleName:null,surname:"Mothupi",slug:"kelebogile-a.-mothupi",fullName:"Kelebogile A. 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The endocrine and nervous systems play important roles in maintaining homeostasis in the human body. Integration, which is the biological basis of physiology, is achieved through communication between the many overlapping functions of the human body's systems, which takes place through electrical and chemical means. Much of the basis of our knowledge of human physiology has been provided by animal experiments. Because of the close relationship between structure and function, studies in human physiology and anatomy seek to understand the mechanisms that help the human body function. 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