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1. Introduction
Gastroesophageal reflux disease (GERD) is a chronic condition in which patients suffer troublesome symptoms and/or complications as the reflux of stomach contents occurs. GERD is a common disease worldwide with the range of an estimated prevalence of 18.1–27.8% in North America, 8.8–25.9% in Europe, 2.5–7.8% in East Asia, 8.7–33.1% in the Middle East, 11.6% in Australia, and 23.0% in South America [1]. It causes significant morbidity, considerable decrease of quality of life, and high costs of exams and treatment derived from repeated visits to the doctor.
The patients with GERD suffer from typical symptoms, such as heartburn and regurgitation, as well as other atypical symptoms including chest pain, cough, asthma, and hoarseness. With the usage of proton pump inhibitors (PPIs) in the clinic, a dramatic improvement in symptom resolution and life quality, as well as in mucosal healing, is expected.
However, the treatment of GERD fails in a proportion of patients despite the high efficacy of PPIs. This situation is referred as to refractory GERD symptoms. What is worse, it is getting more and more common in clinical practices. In this chapter, we will discuss about this difficult situation, emphasizing on diagnosis and treatment, combined with suggested management of these patients.
2. Definition of refractory GERD symptom
The definition of “refractory GERD” has traditionally been described as a group of varying symptom presentations related to GERD, which persists even though the patients accepted the standard daily PPI therapy for at least 12 weeks. Some researchers referred to a failure to achieve satisfactory symptomatic response, for example, less than 50% improvement of relief of symptoms and life quality, to once-daily PPI to be classified as “refractory GERD” or “refractory reflux symptoms” [2]. The continued symptoms must be to a degree that impairs quality of life, and symptoms must be “reflux-related,” which are supposed to be influenced by sex, age, ethnicity, social status, comorbidity, and cultural background. However, there is a controversy of the PPI dose for the definition of “refractory GERD.” Some investigators prefer that inadequate response to twice-daily PPI treatment as refractory disease [3]. Moreover, the patient’s remaining symptoms are subjective to and dependent on the patient’s expectations of the therapy. It needs more clinical practice and further researches to supplement the definition in the future.
3. Causes of refractory GERD symptom
There are some underlying causes of refractory GERD. Firstly, poor compliance and adherence should be excluded before further evaluation is pursued. There are some key points of medication administration for patients, such as taking PPIs at the optimal 30–60 minutes prior to meal; avoiding discontinued PPIs without doctors’ instruction even though the symptoms are relieved; receiving enough information about PPIs therapy. These points are initial important considerations for resolving the refractory GERD. Then, other disorders with GERD-like symptoms, such as esophageal disorders and functional gastrointestinal disorders, should be considered in the differential diagnosis of patients with persistent symptoms (Figure 1).
Figure 1.
Causes of refractory GERD symptom.
Additionally, obesity and overeating are other common factors associated with PPI failure in patients initially diagnosed with GERD.
4. Diagnosis of refractory GERD symptom
4.1 Symptom evaluation
The first important step is to identify the actual nature of the persisting symptoms. It can help a physician to choose the correct equipment for the next step of diagnosis. The typical symptoms of GERD are heartburn and regurgitation, which can be recognized by the GerdQ questionnaire. It is a revision of the Reflux Disease Questionnaire (RDQ) with positive predictor questions about heartburn and regurgitation as well as negative predictors about epigastric pain and nausea. It is reported that there is a sensitivity of 65% and specificity of 71% with GerdQ, which is close to the efficiency done by the clinical judgment of gastroenterologists [4]. However, presenting regurgitation should also be differentiated to gastroparesis or rumination syndrome. Except that, the physician should be aware of the proportion of patients with the atypical symptoms, such as retrosternal discomfort and pain, cough, asthma, hoarseness, throat discomfort, foreign body sensation in throat, globus sensation, belching, dysphagia, and epigastric pain and epigastric discomfort.
A recent study shows that there is about half of patients with atypical symptom, combined or uncombined with typical symptom [5]. In short, it is essential to figure out which symptoms respond and which do not respond to PPI therapy. More detailed questioning about symptom often help clarify the cause for a patient’s persistent symptoms. Especially, the patients with atypical symptom might have poor response to PPI therapy because there are probably other causes or diseases that overlapped GERD.
4.2 Endoscopy
Upper endoscopy should be taken principally to exclude non-reflux esophageal disorders and other gastric diseases and to check whether erosive esophagitis exists, which can provide evidence of ongoing acid reflux. However, endoscopy is of limited value for diagnosis of refractory GERD symptom. It is because that most patients have normal endoscopy. The potential reasons are that most patients with refractory GERD symptom have other esophageal motility problem; they have non-erosive reflux disease (NERD); or PPIs they taken has healed the mucosal injury.
4.3 Esophageal manometry
All patients with refractory GERD symptom are strongly recommended to undergo esophageal manometry. The purpose mainly is to find esophageal motor disorders, for example, achalasia, weak peristalsis, hypertensive esophageal dysmotility, diffuse esophageal spasm (DES), hiatus hernias (HH), high UES pressure, and abnormal lower esophageal sphincter (LES) pressure. Secondly, but more important, esophageal manometry is applied for identifying the accurate location of LES in order to place reflux monitoring pH sensors.
4.4 Ambulatory monitoring for reflux
There are two methods for esophageal reflux monitoring, called as On-PPI and Off-PPI. In off-PPI (7 days after cessation of PPI), the presence of abnormal acid reflux and/or positive symptom-reflux relationship can be confirmed. The relevant parameter to be observed is esophageal acid exposure, which is the proportion of time (in minutes or percentage of time) spent below pH 4, as well as correlation between symptoms and reflux events (symptom index (SI) and/or symptom association probability (SAP)). Positive symptom association with normal esophageal acid exposure is considered hypersensitive esophagus (HE), reflecting an underlying visceral hypersensitivity. For on-PPI reflux monitoring, impedance-pH monitoring should reasonably be proposed as the preferred investigation. It can detect nonacid reflux during the PPI therapy period, which is one of causes for persistent GERD symptom. It also can figure out whether acid reflux is controlled or not by the treatment (Table 1).
Nonerosive reflux disease (NERD)
No mucosal break Normal esophageal acid exposure
Hypersensitive esophagus (HE)
No mucosal break Normal esophageal acid exposure SI > 50%, SAP > 95%
Functional heartburn (FH)
Heartburn refractory to PPIs, no mucosal break, normal esophageal acid exposure SI < 50%, SAP < 95%
Table 1.
Diagnosis based on endoscopy, esophageal manometry, and ambulatory monitoring for reflux.
4.5 Assessment and evaluation for psychological status
Psychological disorders such as hysteria, anxiety, and distress should also be evaluated in patients with refractory symptoms. Weak correlation of symptoms with acid reflux events might indicate a high level of anxiety and hysteria as compared with patients who demonstrate a close correlation between symptoms and acid reflux event [6]. Anxiety and depression have been shown to increase reflux symptoms reported in population-based studies. A study has reported that patients who did not respond to PPI treatment were suffered from more psychosocial problem [7].
5. Management of refractory GERD symptom
5.1 Lifestyle modifications
Weight loss, head of bed elevation, and avoiding late-night meals, which have been shown as effective interventions for GERD, have not been demonstrated yet equally useful in patients with refractory reflux symptoms. The value of lifestyle modifications in patients with refractory symptoms lies in avoidance of specific lifestyle activities that have been identified by patients or physicians to trigger symptoms. A low-bulk and low-fat diet along with small but more frequent meals should surely be recommended.
5.2 Medicine
Increasing the PPI dose or to change to an alternative PPI improved the symptom in some patients [8]. However, this dosing strategy should be used for a short time period (2–3 months) and should be tapered if it does not result in improvement of symptoms. The addition of an H2RA at bedtime was shown to significantly reduce the duration of nocturnal acid breakthrough (NAB) pain modulators. Transient lower esophageal sphincter relaxation (TLESR) reducers can be considered for patients with abnormal frequency of nonacid reflux. The drugs that can reduce the number of reflux events regardless of their acidity are theoretically desirable because of the potential for weakly acidic or bile reflux to cause symptoms. Nevertheless, high-quality controlled trials are needed to demonstrate its efficacy in patients with refractory symptoms.
Visceral pain modulator therapy has been another option for patients with an acid-hypersensitive esophagus or functional heartburn. A randomized, placebo-controlled trial has demonstrated citalopram 20 mg/day to be of symptomatic benefit in patients with acid-hypersensitive esophagus and refractory GERD symptoms [9].
5.3 Endoscopic therapy
Stretta procedure and EsophyX transoral incisionless fundoplication are two antireflux endoscopic devices which are clinically available. The Stretta procedure showed clinical improvement of esophageal symptoms and a decrease in PPI use but no significant effect on esophageal acid exposure [10]. EsophyX offers a less invasive alternative to laparoscopic fundoplication for PPI-dependent GERD patients, which still needs further studies to demonstrate its efficiency.
5.4 Antireflux surgery
Comparing with patients with adequate PPI symptom control, antireflux surgery might have a less favorable clinical outcome for the patients with refractory GERD symptom. Normal acid exposure and the presence of atypical reflux symptoms and persisting symptoms despite PPI therapy are predictors of a poor postoperative outcome. It is important to confirm pathological reflux before considering antireflux surgery if there is no proven esophagitis. Summarily, surgery can be a valuable option in patients with typical reflux symptoms with inadequate response to PPIs, provided abnormal esophageal acid exposure and/or positive symptom association analysis in off-PPI test [11].
5.5 Psychological treatment
According to a recent research, perceptions of reflux symptoms are associated with psychosocial distress in these patients with refractory GERD symptom who have normal impedance-pH results. Furthermore, patient-reported symptom severity is associated with physiological differences, as opposed to psychosocial factors [11]. In these patients with psychological disorders, treatment-targeted psychosocial abnormality may improve patient response to PPI therapy [2]. Psychological treatment should be a potential consideration in the case of the patients without other identifiable causes. In many clinical experiences, psychological disorders may be an underlying etiology in many patients with refractory symptoms (Figure 2).
Figure 2.
Diagnostic and treatment algorithm for patients with refractory GERD symptom.
\n',keywords:"gastroesophageal reflux disease (GERD), refractory proton pump inhibitor (PPI) symptoms, high-resolution manometry (HRM), impedance-pH monitoring, refractory reflux symptoms",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/63508.pdf",chapterXML:"https://mts.intechopen.com/source/xml/63508.xml",downloadPdfUrl:"/chapter/pdf-download/63508",previewPdfUrl:"/chapter/pdf-preview/63508",totalDownloads:1309,totalViews:224,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:0,impactScore:0,impactScorePercentile:39,impactScoreQuartile:2,hasAltmetrics:0,dateSubmitted:"March 12th 2018",dateReviewed:"August 8th 2018",datePrePublished:"December 19th 2018",datePublished:"April 3rd 2019",dateFinished:"September 11th 2018",readingETA:"0",abstract:"Gastroesophageal reflux disease (GERD) is a chronic condition in which patients suffer troublesome symptoms and/or complications as the reflux of stomach contents occurs. GERD is a common disease worldwide with the range of estimated prevalence 18.1–27.8% in North America, 8.8–25.9% in Europe, 2.5–7.8% in East Asia, 8.7–33.1% in the Middle East, 11.6% in Australia and 23.0% in South America. It causes significant morbidity, considerable decrease of quality of life and high costs of exams and treatment derived from repeated visit doctor. The patients with GERD suffer from typical symptoms such as heartburn and regurgitation, as well as other atypical symptoms including chest pain, cough, asthma, and hoarseness. With the usage of pump inhibitors (PPIs) in clinic, a dramatic improvement in symptom resolution and life quality, as well as in mucosal healing is expected. However, the treatment of GERD fails in a proportion of patients despite the high efficacy of PPIs. This situation is getting more and more common in clinical practices. In this chapter, we will discuss about this difficult situation, emphasizing diagnosis and treatment, combined with suggested management of these patients.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/63508",risUrl:"/chapter/ris/63508",book:{id:"7104",slug:"gastroesophageal-reflux-disease-theory-and-research"},signatures:"Xia Chen and Fei Wang",authors:[{id:"250058",title:"Dr.",name:"Xia",middleName:null,surname:"Chen",fullName:"Xia Chen",slug:"xia-chen",email:"xiac6686@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Definition of refractory GERD symptom",level:"1"},{id:"sec_3",title:"3. Causes of refractory GERD symptom",level:"1"},{id:"sec_4",title:"4. Diagnosis of refractory GERD symptom",level:"1"},{id:"sec_4_2",title:"4.1 Symptom evaluation",level:"2"},{id:"sec_5_2",title:"4.2 Endoscopy",level:"2"},{id:"sec_6_2",title:"4.3 Esophageal manometry",level:"2"},{id:"sec_7_2",title:"4.4 Ambulatory monitoring for reflux",level:"2"},{id:"sec_8_2",title:"4.5 Assessment and evaluation for psychological status",level:"2"},{id:"sec_10",title:"5. Management of refractory GERD symptom",level:"1"},{id:"sec_10_2",title:"5.1 Lifestyle modifications",level:"2"},{id:"sec_11_2",title:"5.2 Medicine",level:"2"},{id:"sec_12_2",title:"5.3 Endoscopic therapy",level:"2"},{id:"sec_13_2",title:"5.4 Antireflux surgery",level:"2"},{id:"sec_14_2",title:"5.5 Psychological treatment",level:"2"}],chapterReferences:[{id:"B1",body:'El-Serag HB, Sweet S, Winchester CC, Dent J. Update on the epidemiology of gastro-oesophageal reflux disease: A systematic review. Gut. 2014;63:871-880'},{id:"B2",body:'Sifrim D, Zerbib F. Diagnosis and management of patients with reflux symptoms refractory to proton pump inhibitors. Gut. 2012;61:1340-1354'},{id:"B3",body:'Martinez SD, Malagon IB, Garewal HS, Cui H, Fass R. Nonerosive reflux disease (NERD)—Acid reflux and symptom patterns. Alimentary Pharmacology & Therapeutics. 2003;17:537-545'},{id:"B4",body:'Jones R, Junghard O, Dent J, Vakil N, Halling K, Wernersson B, et al. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. Alimentary Pharmacology & Therapeutics. 2009;30:1030-1038'},{id:"B5",body:'Wang F, Li P, Ji GZ, Miao L, Fan Z, You S, et al. An analysis of 342 patients with refractory gastroesophageal reflux disease symptoms using questionnaires, high-resolution manometry, and impedance-pH monitoring. Medicine. 2017;96(5):e5906'},{id:"B6",body:'Becher A, El-Serag H. Systematic review: The association between symptomatic response to proton pump inhibitors and health-related quality of life in patients with gastro-oesophageal reflux disease. Alimentary Pharmacology & Therapeutics. 2011;34:618-627'},{id:"B7",body:'Chen X, Li P, Wang F, Ji G, Miao L, You S. Psychological results of 438 patients with persisting gastroesophageal reflux disease symptoms by symptom checklist 90-revised questionnaire. Euroasian Journal of Hepato-Gastroenterology. 2017;7:117-121'},{id:"B8",body:'Fass R, Sontag SJ, Traxler B, Sostek M. Treatment of patients with persistent heartburn symptoms: A double-blind, randomized trial. Clinical Gastroenterology and Hepatology. 2006;4:50-56'},{id:"B9",body:'Viazis N, Keyoglou A, Kanellopoulos AK, Karamanolis G, Vlachogiannakos J, Triantafyllou K, et al. Selective serotonin reuptake inhibitors for the treatment of hypersensitive esophagus: A randomized, double-blind, placebo-controlled study. The American Journal of Gastroenterology. 2012;107:1662-1667'},{id:"B10",body:'Arts J, Sifrim D, Rutgeerts P, Lerut A, Janssens J, Tack J. Influence of radiofrequency energy delivery at the gastroesophageal junction (the Stretta procedure) on symptoms, acid exposure, and esophageal sensitivity to acid perfusion in gastroesophageal reflux disease. Digestive Diseases and Sciences. 2007;52:2170-2177'},{id:"B11",body:'Yadlapati R, Tye M, Keefer L, Kahrilas PJ, Pandolfino JE. Psychosocial distress and quality of life impairment are associated with symptom severity in PPI non-responders with normal impedance-pH profiles. The American Journal of Gastroenterology. 2018;113:31-38'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Xia Chen",address:"xiac6686@gmail.com",affiliation:'
Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
Medical Center for Digestive Diseases, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, China
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1. Introduction
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Leiomyomas also called uterine myomas, uterine fibroids, or fibromyomas are discrete, rounded, firm, white to pale pink, benign myometrial tumours composed mostly of smooth muscle with varying amounts of fibrous connective tissues [1]. Uterine fibroids or leiomyomas are benign tumours of the uterine smooth muscles. They are benign clonal neoplasms that contain an increased amount of extracellular collagen, elastin and are surrounded by a thin pseudo-capsule. They may enlarge to cause significant distortion of the uterine surface or cavity. Their size will then be described in menstrual weeks, as in a pregnant uterus [2].
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Most fibroids are asymptomatic; usually asymptomatic in pregnancy but may interfere with conception and may cause spontaneous abortion, missed abortions, painful red degeneration or infarction of the fibroids, abnormal foetal presentation, obstructed labour, and an increased likelihood of premature deliveries, caesarean deliveries, postpartum haemorrhage and, whereas, in the non-pregnant state its signs and symptoms are menorrhagia, metorrhagia, menometorrhagia, infertility, constipation, urinary incontinence, and leiosarcoma transformation [3]. Uterine fibroids can occur in the non-pregnant woman and then continue into pregnancy/may develop de novo in pregnancy. In both circumstances, the physiopathology is the same but specific considerations may be taken in its management.
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2. Epidemiology
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Evidence from the contemporary literature reports that the prevalence rate of uterine fibroid varies between 16.7% - 30% of reproductive-age women and there is a two-fold increase in the prevalence in Afro American women [4, 5]. Also, their incidence tends to peak at the age of 35 years and almost 50% of African women will have uterine fibroid by their 5th decade of life [1]. Leiomyomas are the most frequent pelvic tumours and occur in about 20 to 25% of reproductive-age women. Uterine fibroids and the severity of their symptoms have a predilection for the black ethnicity. Huyck KL et al. in 2008 demonstrated that the odds of having severe symptoms from uterine fibroids are more than five times greater in black African women than in Caucasians [6]. Furthermore, black women develop the disease five to six years earlier and their peak age at diagnosis is 40–44 years [7] as opposed to a to peak age of incidence of 35 years observed in Caucasians [1]. Also, almost 50% of African women will have uterine fibroid by their 5th decade of life [1].
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Risks factors of uterine fibroids include African-American ethnicity, early menarche (less than 11 years) and high body mass index [8, 9]. Moreover, the length of the menstrual cycle has an inversely proportional relationship with fibroids: a shorter cycle is positively correlated with an increased likelihood to develop fibroids [10, 11]. A similar inverse association is observed with use of oral contraceptives, the duration of tobacco smoking and the development of fibroids [12]. On the other hand, multiparity and the late ages of last pregnancy are other protective factors for uterine fibroids [11].
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3. Anatomical Classification of Uterine Fibroids
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According to their anatomic locations, there are three different types of leiomyomas:
Subserosal or subperitoneal leiomyomata are the most common and are usually asymptomatic unless very large. They originate in the myometrium and grow out toward the serosal surface of the uterus, lying beneath the peritoneum [1]. They may lie just at the serosal surface of the uterus or may become pedunculated. They become parasitic when they derive their entire blood supply outside of the uterus, from omental vessels. Sometimes, their pedicles may atrophy and resorb. When they arise laterally, subserous tumours may extend between the two peritoneal layers of the broad ligament to become intraligamentary leiomyomas.
Intramural or interstitial myomas are located within the uterine wall of the myometrium and may distort the shape of the uterine cavity and surface. They may manifest with swelling of the abdomen, menorrhagia and infertility.
Submucosal fibroids are the most symptomatic. They originate in the myometrium and grow toward the endometrial cavity, protruding into the uterine cavity that they tend to compress. Their impact on the endometrium and its blood supply most often lead to irregular uterine bleeding. Other symptoms commonly associated are dysmenorrhea, infertility and recurrent abortions [13]. This type of fibroids may also develop pedicles and protrude fully into the uterine cavity. Occasionally they pass through the cervical canal while still attached within the corpus by a long stalk. There, they are subject to torsion or infection.
Cervical leiomyomas are a rare type. They are sometimes mistaken to vaginal leiomyomas, which may present with the same clinical features [14]. They cause early pressure effects in regions of bladder neck, infection, dyspareunia and infertility.
With respect to the location of the fibroids, 89.4% submucous, 10.6% subserous and 74.5% were intramural according to a study done in Cameroon [15].
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FIGO classification of uterine fibroids (PALM-COEIN)
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Stage 0: a sub-mucosal pedunculated intra-uterine cavity fibroid
Stage 1: a sub-mucosal located less than 50% intra-murally
Stage 2: a sub-mucosal located greater than 50% intra-murally
Stage 3: a fibroid which is 100% interstitially or intra-murally located in contact with the endometrium
Stage 4: a fibroid which is completely interstitially or intra-murally located
Stage 5: a sub-serosal fibroid which is greater than or equall to 50% intra-murally located
Stage 6: a sub-serosal fibroid which is less than 50% intra-murally located
Stage 7: a sub-serosal pedunculated fibroid
Stage 8: others, parasite (round cervical ligament, large ligament).
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4. Physiopathology of Uterine Fibroids
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The cause of uterine leiomyomata is idiopathic till date. However, several hypotheses have been postulated, namely:
Glucose-6-phosphate dehydrogenase studies suggest that each individual leiomyoma is unicellular in origin that is monoclonal [2]. Hence, this implies a genetic probability for the growth of uterine.
In increment in the exposure of circulating oestrogens is another hypothesis for the growth of uterine fibroids. Effectively, leiomyomas contain oestrogen receptors in higher concentrations than the surrounding myometrium. But at lower concentrations than the endometrium, this oestrogen may contribute to tumour enlargement by increasing the production of extracellular matrix. On the other hand, progesterone increases the mitotic activity of myomas in young women. It may allow for tumour enlargement by down-regulating apoptosis in the fibroids [16]. They usually decrease in size after menopause and whenever myomas grow after menopause, malignancy must be seriously considered [17].
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Malignant transformation of leiomyomas is very rare, seen in 0.04% women having uterine fibroids. In a review of 13,000 leiomyomas, 38 cases (0.29%) demonstrated malignant manifestations. A second study reported that malignant change developed in less than 0.13% of uterine leiomyomas [17]. The diagnosis of leiomyosarcomas is based on the counts of 10 or more mitotic figures per 10 HPFs. Atypical leiomyoma is differentiated from leiomyosarcoma by a lack of necrotizing tumour cells and a mitotic count less than 7 per 10 HPFs. Nuclear atypia makes the difference with mitotically active leiomyoma [18]. Secondary changes may occur when the fibroids tend to outgrow their blood supply. These degenerations include necrotic, haemorrhagic (red degeneration) or septic for the acute ones. Chronic degeneration may be atrophic, hyaline (65%), cystic, calcific (10%), myxomatous (15%), or fatty [1].
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5. Diagnoses
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5.1 Clinical features
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Most at times, leiomyomas are asymptomatic. Symptoms are found only in about 35–50% of the patients. They vary according to the type, location, size, number and vascular supply of the fibroids. These include:
Abnormal bleeding from the uterus
Pain symptoms
Pressure effects
Reproductive dysfunction
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Bleeding from the uterus is the most common symptom. It may either be during the menstrual periods when the patient will have heavy and prolonged menses called menometorrhagia [16] or it may manifest as light spotting before and after the menses. The incidence of abnormal uterine bleeding was 47.7% in a study done by Okogbo et al. in 2011 in Nigeria [19]. This abnormal bleeding is due to the development or dilatation of endometrial venules which increase the flow during cyclical sloughing or to the increase in size of the uterine cavity by the fibromyomas [17].
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Pain may either be due to red degeneration, infarction or torsion of a uterine fibroid, or mat stem from attempts to expel a pedunculated submucousal fibroid [1]. A sensation of pelvic heaviness or fullness or a feeling of a mass in the pelvis is particularly characteristic of large tumours. These may press on nerves within the bony pelvis, creating pain that radiates to the back or lower extremities.
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Pressure effects may either be anteriorly on the bladder, causing mainly frequent micturation, and urinary incontinence. Laterally, myomas may compress the ureters, leading to hydroureters. When the base of the bladder is involved, urinary retention may occur. Posteriorly, fibroids may increase the rectal pressure or cause constipation or tenesmus. It should be noted that these pressure symptoms are quite unusual and are difficult to directly relate to fibroids.
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The relationship between fibroids and infertility is not clear. Fibroids may have a detrimental effect on fertility in up to 10% of the cases [20]. Infertility may result because of impaired implantation, tubal function or sperm transport.
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5.2 Diagnostic tests
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The diagnosis of uterine fibroids is made from the signs and symptoms, pelvic examination, laboratory investigations and imaging.
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Most leiomyomas are discovered by routine pelvic examination, when a firm mass of an irregular shape is felt in the uterus. To confirm the diagnosis different types of imaging techniques are used:
A Pelvic ultrasound scan is the test of first choice. Here, three-dimensional scan is preferred to a two-dimensional scan due its higher resolution which helps to rule out a pregnancy, other pelvic masses, a congenital uterine malformation [21].
A magnetic resonance imaging is the gold standard test which is highly accurate in depicting the size, number and location of myomas to choose the therapeutical modality.
Saline sonohysterography can identify and characterise the location of submucosal myomas missed on classical abdominal or transvaginal ultrasound.
Plain X-Rays of the lower abdomen and pelvis usually identify only calcified fibroids and sometimes large fibroids may be seen as soft tissue or calcified masses displacing bowel gas [22].
Hysterosalpingography may be useful in the infertile patient. It evaluates the contour of the uterine cavity and the patency of fallopian tubes but does not evaluate the exact location of fibroids.
CT scan is not the investigation of choice, fibroids may be detected incidentally while investigating for another condition.
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Laboratory investigations may reveal anaemia as a consequence of the menometrorrhagia of fibroids and depletion of iron stores or leucocytosis and raised C-reactive proteins in case of acute degeneration or infection.
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Differential diagnoses of leiomyomas include pregnancy, adenomyosis, leiomyosarcoma, or solid ovarian neoplasms. Other conditions to be considered include sub involution, congenital anomalies, adherent adnexa, omentum or bowel benign hypertrophy, and sarcoma or carcinoma of the uterus [1]. The most common symptom of leiomyomata, recurrent abnormal bleeding, may be caused by any of the numerous conditions that affect the uterus. The definitive diagnosis in cases of uterine bleeding usually can be established by endometrial biopsy or fractional D&C [16].
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6. Management
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When uterine fibroids become symptomatic, medical or surgical treatment is offered to the patient, depending on her age, symptoms and future fertility desires.
Medical therapy includes:
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Progestins: Progestational therapy using norethindrone, medrogestone, and medroxyprogesterone acetate has been successful. These compounds produce a hypo-estrogenic effect by inhibiting gonadotropin secretion and suppressing ovarian function [17]. A small randomised controlled trial presented weak evidence of a reduction in fibroid size among women receiving lynestrenol compared with women receiving leuprolide acetate [13].
25 mg mifepristone produces reduction in leiomyoma size and uterine volume and produces symptomatic improvement in women with fibroids [23].
Gonadotrophin Releasing Hormone (GnRH) agonists have proven very useful for limiting growth or temporarily decreasing uterine fribroid’s size. GnRH agonists induce hypogonadism through pituitary desensitisation, down-regulation of receptors, and inhibition of gonadotropins. They are however not suitable for long term use because they are associated with menopausal symptoms and bone loss but are likely to be beneficial preoperatively [24].
Oestrogen Receptors Modulators and Antagonists: Because co-administration of oestrogen with progesterone was essential for growth and maintenance, inhibition of oesytogen receptors should also be an effective treatment for Leiomyomas [22].
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Surgical therapies include:
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Myomectomy: There may be a beneficial effect of surgical resection of myomas to enhance fertility or successful pregnancy outcome [25]. It can be achieved using the following surgical procedures: open surgery, laparoscopy, robotic, transvaginal, and hysteroscopic surgery. The location and size of the myoma(s) dictates the specific surgical approach. Total abdominal myomectomy maintains fertility compared with hysterectomy but increases recovery time and postoperative pain compared with laparoscopic myomectomy [24]. However, there is high chance of recurrence with myomectomy, while hysterectomy is definitive. A rare complication of laparoscopic myomectomy is the occurrence of parasitic leiomyomas. They usually regress after menopause but in extremely rare cases they can calcify and present in a post-menopausal woman with atypical signs and symptoms [26].
Hysterectomy: It is the procedure of choice whenever surgery is indicated for leiomyomas and when childbearing has been completed. It should also be considered in the event of a rapidly enlarging fibroids, in which a reasonable likelihood of malignancy exists. Different types of hysterectomies exist: laparoscopically-assisted vaginal hysterectomy, total vaginal hysterectomy, total abdominal hysterectomy and total laparoscopic hysterectomy. Total abdominal hysterectomy is considered to be beneficial in reducing fibroid-related symptoms, but total vaginal hysterectomy and total laparoscopic hysterectomy may have lower risks of complications, and shorter recovery times [18]. In 2010 Demir RH and Marchand GJ published a case report in which they resected a huge uterus weighing 3200 g via laparoscopic-assisted hysterectomy, laparotomy can be avoided in almost all instances of hysterectomy for benign disease for an experienced laparoscopic surgeon [27].
Uterine artery embolization (UAE): It is the occlusion of the uterine artery, which reduces the blood supply to the uterus and ultimately to the uterine fibroids. There is evidence that uterine artery embolization patients are more likely to report greater improvements in symptoms, fewer complications and less additional interventions than myomectomy. Meanwhile, patients who undergo a myomectomy are more likely to have a conserved fertility [28, 29]. Complications of the technique include infections, complications of angiography and very rarely, uterine ischemia. However, there are no increased serious complications after UAE in patients with a large fibroid burden [30].
Laparoscopic occlusion of the uterine vessel: It consists of cauterising the uterine artery at laparoscopy, with or without concurrent myomectomy. Based on the study of Helal et al. in 2010, both laparoscopic occlusions of the uterine vessel and embolization improve symptoms associated with uterine fibroids [31]. The laparoscopic procedure resulted in less postoperative pain and nausea and shorter hospital stays, although significantly more participants experienced heavy menstrual bleeding six months after laparoscopic occlusion, indicating a more favourable effect after uterine leiomyoma embolization. Thus, laparoscopic uterine artery occlusion is likely to attract considerable interest as an effective alternative to hysterectomy treatment of symptomatic uterine leiomyomata.
MRI- guided focused ultrasound surgery. It was approved by the Food and Drug Administration (FDA) in October 2004 for the treatment of leiomyoma in premenopausal women who have completed childbearing. This outpatient procedure uses MRI for real-time thermal monitoring of the thermoablative technique, which concentrates multiple waves of ultrasound energy on a small volume of tissue to be destroyed [16]. Careful patient selection and use of pre-treatment imaging are important components for predicting the success of MR-guided focused ultrasound surgery of uterine leiomyomas [32]. Overall, there is reasonable tolerance, improvement in quality of life, and modest change in fibroid size. However, 11% of women experience worsened symptoms during more than a year of follow-up and 28% elect further treatment including myomectomy and hysterectomy [13].
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7. Uterine Fibroids and Pregnancy.
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The prevalence of leiomyomas in pregnancy varies between 10.7% to 16.7% [5, 33]. It’s higher in African American women followed by Caucasians, Hispanic and Asian women [33]. According to a study done by Hasan et al. in 2010, fibroids are part of the factors predictive of bleeding in the first trimester of pregnancy and are also potential important predictors of heavy menstrual bleeding heaviness [34]. This is due to the oedema, increased vascularity and hypertrophy of uterine muscles that lead to the increase in size of fibroids during pregnancy. However, Laughlin et al. in 2010 think there could be a direct protective effect of pregnancy on fibroids after delivery. In their study of 171 postpartum women, they found that 36% of fibroids resolved to an undetectable level and those that remain were reduced in diameter by a median of 0.5 cm [35].
\n
Generally, the effects of fibroids on pregnancy and labour are:
Spontaneous abortion, especially with sub-mucousal leiomyomas due to the distortion of the uterine cavity and impairment of the vascular supply to the implanted ovum [36].
Ectopic pregnancy if it interferes with the passage of the ovum.
Incarceration of a retroverted gravid uterus in case of posterior wall uterine fibroid.
Placenta praevia due to interference with implantation of the ovum in the upper uterine segment.
Malpresentations; in the study of Tchente et al. in 2008, breech presentation was two times more encountered in pregnant women with fibroids [15].
Abdominal discomfort if the tumour is large.
Torsion of the uterus which is very rare and is found in subserousal fundal myoma.
Premature or threatening premature delivery probably due to the stretching of the uterus by the fibroids or the liberation of prostaglandins and fever in red degeneration [15].
Prolonged labour due to inertia from interference with normal uterine contractions.
Obstructed labour in cervical myoma or pedunculated subserous myoma impacted in the pelvis.
Postpartum haemorrhage due to interference with sub involution of the uterus and increased vascularity.
Puerperal sepsis.
\n\n
The management of uterine fibroids in pregnancy depends on the signs and symptoms:
\n
In the majority of cases, no treatment is required. In case of pain, bed rest and narcotics are almost always successful [16]. Tocolytics may be necessary to control the uterine contractions in threatening premature labour. Myomectomy is generally contraindicated during pregnancy due to increased vascularity that may lead to haemorrhagic complications. However, laparoscopic myomectomy may be considered safe if done in early pregnancy but only in the hands of experienced laparoscopic surgeons [37]. Indications for it include red degeneration not responding to medical therapy, torsion of a pedunculated myoma or internal haemorrhage from rupture of a surface vein [36]. In case of obstructed labour, caesarean section is indicated but myomectomy is contraindicated. In the post-partum period, prophylactic antibodies should be given. Also, the women should be carefully observed for post-partum haemorrhage.
\n
\n
\n
8. Conclusion
\n
Uterine fibroids are the most frequent benign uterine tumours in females of reproductive age. Although benign in character they are associated with adverse outcomes such as miscarriages, aseptic necrobiosis, foetal mal-presentation, obstructed labour, premature births, caesarean sections, postpartum haemorrhage in pregnancy, and an altered menstrual cycle, heavy menstrual bleeding, infertility, constipation, urinary incontinence, and malignant transformation in non-pregnant women. Through this chapter the authors sought to contribute to the scarce evidence on its idiopathic pathophysiology and present all its available management options.
\n
\n\n',keywords:"uterine fibroid, leiomyoma, pathophysiology, management",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/73825.pdf",chapterXML:"https://mts.intechopen.com/source/xml/73825.xml",downloadPdfUrl:"/chapter/pdf-download/73825",previewPdfUrl:"/chapter/pdf-preview/73825",totalDownloads:637,totalViews:0,totalCrossrefCites:2,dateSubmitted:"July 1st 2020",dateReviewed:"September 23rd 2020",datePrePublished:"December 8th 2020",datePublished:"March 24th 2021",dateFinished:"October 30th 2020",readingETA:"0",abstract:"Uterine fibroid is the most encountered benign tumour in women of reproductive age. It causes spontaneous abortions, missed abortions, painful red degeneration or infarction of the fibroids, abnormal foetal presentation, obstructed labour, and an increased likelihood of premature deliveries, caesarean deliveries, postpartum haemorrhage in pregnancy, whereas, in the non-pregnant women it is associated an irregular menstrual cycle sometimes associated with heavy menstrual bleeding, infertility, constipation, urinary incontinence, and leiosarcoma transformation. Till date is pathophysiology and management both in the non-pregnant and pregnant woman have not been well described. In this chapter, we present contemporary evidence to help elucidate this enigma.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/73825",risUrl:"/chapter/ris/73825",signatures:"Joel Noutakdie Tochie, Gaelle Therese Badjang, Gregory Ayissi and Julius Sama Dohbit",book:{id:"10485",type:"book",title:"Fibroids",subtitle:null,fullTitle:"Fibroids",slug:"fibroids",publishedDate:"March 24th 2021",bookSignature:"Hassan Abduljabbar",coverURL:"https://cdn.intechopen.com/books/images_new/10485.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83962-996-9",printIsbn:"978-1-83962-995-2",pdfIsbn:"978-1-83968-011-3",isAvailableForWebshopOrdering:!0,editors:[{id:"68175",title:"Prof.",name:"Hassan",middleName:"S",surname:"Abduljabbar",slug:"hassan-abduljabbar",fullName:"Hassan Abduljabbar"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"270799",title:"Dr.",name:"Julius",middleName:null,surname:"Dohbit Sama",fullName:"Julius Dohbit Sama",slug:"julius-dohbit-sama",email:"dohbit@yahoo.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"326000",title:"Dr.",name:"Joel Noutakdie",middleName:null,surname:"Tochie",fullName:"Joel Noutakdie Tochie",slug:"joel-noutakdie-tochie",email:"joeltochie@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"326072",title:"Dr.",name:"Gregory",middleName:null,surname:"Ayissi",fullName:"Gregory Ayissi",slug:"gregory-ayissi",email:"ayissigregory@yahoo.fr",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Catholic University of Cameroon",institutionURL:null,country:{name:"Cameroon"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Epidemiology",level:"1"},{id:"sec_3",title:"3. Anatomical Classification of Uterine Fibroids",level:"1"},{id:"sec_4",title:"4. Physiopathology of Uterine Fibroids",level:"1"},{id:"sec_5",title:"5. Diagnoses",level:"1"},{id:"sec_5_2",title:"5.1 Clinical features",level:"2"},{id:"sec_6_2",title:"5.2 Diagnostic tests",level:"2"},{id:"sec_8",title:"6. Management",level:"1"},{id:"sec_9",title:"7. Uterine Fibroids and Pregnancy.",level:"1"},{id:"sec_10",title:"8. Conclusion",level:"1"}],chapterReferences:[{id:"B1",body:'\nPernoll ML. Benson and Pernoll’s handbook of Obstetrics and Gynecology: Mc-Graw Hill Companies; 2001.\n'},{id:"B2",body:'\nStewart EA. Uterine fibroids. Lancet. 2001;357(9252):293-8.\n'},{id:"B3",body:'\nDohbit JS, Meka ENU, Tochie JN, Kamla I, Danwang C, Tianyi FL, Foumane P, Andze GO. Diagnostic ambiguity of aseptic necrobiosis of a uterine fibroid in a term pregnancy: a case report. BMC Pregnancy Childbirth. 2019 J;19(1):9.\n'},{id:"B4",body:'\nLee CJ, Miller, E.S. DEJA REVIEW Obstetrics and Gynaecology: McGraw-Hill Companies; 2008.\n'},{id:"B5",body:'\nEgbe TO, Badjang TG, Tchounzou R, Egbe E-N, Ngowe MN. Uterine fibroids in pregnancy: prevalence, clinical presentation, associated factors and outcomes at the Limbe and Buea Regional Hospitals, Cameroon: a cross-sectional study. BMC Res Notes 2018;11:889.\n'},{id:"B6",body:'\nHuyck KL, Panhuysen CI, Cuenco KT, Zhang J, Goldhammer H, Jones ES, et al. The impact of race as a risk factor for symptom severity and age at diagnosis of uterine leiomyomata among affected sisters. Am J Obstet Gynecol. 2008;198(2):168 e1-9.\n'},{id:"B7",body:'\nWise LA, Palmer JR, Stewart EA, Rosenberg L. Age-specific incidence rates for self-reported uterine leiomyomata in the Black Women’s Health Study. Obstet Gynecol. 2005 ;105(3):563-8.\n'},{id:"B8",body:'\nWise LA, Palmer JR, Spiegelman D, Harlow BL, Stewart EA, Adams-Campbell LL, et al. Influence of body size and body fat distribution on risk of uterine leiomyomata in U.S. black women. Epidemiology. 2005;16(3):346-54.\n'},{id:"B9",body:'\nFaerstein E, Chor D, Lopes Cde S. Reliability of the information about the history of diagnosis and treatment of hypertension. Differences in regard to sex, age, and educational level. The Pro-Saude study. Arq Bras Cardiol. 2001;76(4):301-4.\n'},{id:"B10",body:'\nTerry KL, De Vivo I, Hankinson SE, Missmer SA. Reproductive characteristics and risk of uterine leiomyomata. Fertil Steril. 2010;94(7):2703-7.\n'},{id:"B11",body:'\nAmanti L. S-BH, Abdollahi H., Ehdaeivand F. Uterine Leiomyoma and its association with menstrual pattern and history of progesterone acetate injections. International Journal of General Medicine. 2011;4:533-8.\n'},{id:"B12",body:'\nRoss RK, Pike MC, Vessey MP, Bull D, Yeates D, Casagrande JT. Risk factors for uterine fibroids: reduced risk associated with oral contraceptives. Br Med J (Clin Res Ed). 1986:9;293(6543):359-62.\n'},{id:"B13",body:'\nViswanathan M, Hartmann K, McKoy N, Stuart G, Rankins N, Thieda P, et al. Management of uterine fibroids: an update of the evidence. Evid Rep Technol Assess (Full Rep). 2007;(154):1-122.\n'},{id:"B14",body:'\nIndranil CA, Shyamaoada D. Vaginal leiomyoma. Journal of Mid-Life Health. 2011;2(1):42-3.\n'},{id:"B15",body:'\nTchente Nguefack C, Fogaing AD, Tejiokem MC, Nana Njotang P, Mbu R, Leke R. [Pregnancy outcome in a group of Cameroonian women with uterine fibroids]. J Gynecol Obstet Biol Reprod (Paris). 2009 ;38(6):493-9.\n'},{id:"B16",body:'\nDeCherney AHNL, Godwin TM, Laufer N, editor. Current diagnosis and treatments in Obstetrics and Gynaecology. Tenth ed: The Mc Graw-Hill Companies, Inc; 2007.\n'},{id:"B17",body:'\nFortner KBSLM, Fox HE, Wallach EE, editor. The Johns Hopkins Manual of Gynaecology and Obstetrics. Third ed: Lippincott Williams and Wilkins; 2007.\n'},{id:"B18",body:'\nHosseini H, Jacquemyn Y, Goossens K, Van Marck V. Atypical uterine leiomyoma: a rare variant of a common problem. BMJ Case Rep. 2009;2009.\n'},{id:"B19",body:'\nOkogbo FO, Ezechi OC, Loto OM, Ezeobi PM. Uterine Leiomyomata in South Western Nigeria: a clinical study of presentations and management outcome. Afr Health Sci. 2011;11(2):271-8.\n'},{id:"B20",body:'\nHart R. Unexplained infertility, endometriosis, and fibroids. BMJ. 2003;327(7417):721-4.\n'},{id:"B21",body:'\nDohbit JS, Meka E, Tochie JN, Kamla I, Mwadjie D, Foumane P. A case report of bicornis bicollis uterus with unilateral cervical atresia: an unusual aetiology of chronic debilitating pelvic pain in a Cameroonian teenager. BMC Womens Health 217;17(1):39.\n'},{id:"B22",body:'\nWilde S, Scott-Barrett S. Radiological appearances of uterine fibroids. Indian J Radiol Imaging. 2009;19(3):222-31.\n'},{id:"B23",body:'\nMukherjee S, Chakraborty S. A study evaluating the effect of mifepristone (RU-486) for the treatment of leiomyomata uteri. Niger Med J. 2011;52(3):150-2.\n'},{id:"B24",body:'\nLethaby AE, Vollenhoven BJ. Fibroids (uterine myomatosis, leiomyomas). Clin Evid (Online). 2007;2007.\n'},{id:"B25",body:'\nSinclair D, Gaither K, Mason TC. Fertility outcomes following myomectomy in an urban hospital setting. J Natl Med Assoc. 2005;97(10):1346-8.\n'},{id:"B26",body:'\nHwang JH, Modi GV, Jeong Oh M, Lee NW, Hur JY, Lee KW, et al. An unusual presentation of a severely calcified parasitic leiomyoma in a postmenopausal woman. JSLS. 2010;14(2):299-302.\n'},{id:"B27",body:'\nDemir RH, Marchand GJ. Safe laparoscopic removal of a 3200 gram fibroid uterus. JSLS. 2010;14(4):600-2.\n'},{id:"B28",body:'\nMara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol. 2008;31(1):73-85.\n'},{id:"B29",body:'\nNarayan A, Lee AS, Kuo GP, Powe N, Kim HS. Uterine artery embolization versus abdominal myomectomy: a long-term clinical outcome comparison. J Vasc Interv Radiol. 2010 ;21(7):1011-7.\n'},{id:"B30",body:'\nSmeets AJ, Nijenhuis RJ, Boekkooi PF, Vervest HA, van Rooij WJ, de Vries J, et al. Safety and effectiveness of uterine artery embolization in patients with pedunculated fibroids. J Vasc Interv Radiol. 2009;20(9):1172-5.\n'},{id:"B31",body:'\nHelal A, Mashaly Ael M, Amer T. Uterine artery occlusion for treatment of symptomatic uterine myomas. JSLS. 2010;14(3):386-90.\n'},{id:"B32",body:'\nLenard ZM, McDannold NJ, Fennessy FM, Stewart EA, Jolesz FA, Hynynen K, et al. Uterine leiomyomas: MR imaging-guided focused ultrasound surgery--imaging predictors of success. Radiology. 2008;249(1):187-94.\n'},{id:"B33",body:'\nLaughlin SK, Baird DD, Savitz DA, Herring AH, Hartmann KE. Prevalence of uterine leiomyomas in the first trimester of pregnancy: an ultrasound-screening study. Obstet Gynecol. 2009;113(3):630-5.\n'},{id:"B34",body:'\nHasan R, Baird DD, Herring AH, Olshan AF, Jonsson Funk ML, Hartmann KE. Patterns and predictors of vaginal bleeding in the first trimester of pregnancy. Ann Epidemiol. 2010;20(7):524-31.\n'},{id:"B35",body:'\nLaughlin SK, Schroeder JC, Baird DD. New directions in the epidemiology of uterine fibroids. Semin Reprod Med. 2010 ;28(3):204-17.\n'},{id:"B36",body:'\nEl-Mowafi DM. Obstetrics Simplified. El-Happy Land Square, El-Mansoura, Egypt: Burg Abu-Samr; 1997.\n'},{id:"B37",body:'\nArdovino M, Ardovino I, Castaldi MA, Monteverde A, Colacurci N, Cobellis L. Laparoscopic myomectomy of a subserous pedunculated fibroid at 14 weeks of pregnancy: a case report. J Med Case Rep. 2011;5(1):545.\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Joel Noutakdie Tochie",address:"joeltochie@gmail.com",affiliation:'
Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon
Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon
'},{corresp:null,contributorFullName:"Julius Sama Dohbit",address:null,affiliation:'
Department of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Cameroon
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The Igbo states in Nigeria has the average prevalence of 711 cases of COVID-19 with the highest 1096 (Enugu) and least 207 (Anambra) as at 26th August, 2020. This chapter studied some Igbo indigenous plants in use since the outbreak and presents Bitter kola, Garlic, Giloy, Ginger, Lime, and Turmeric which are having anti-COVID-19 properties. The authors suggest that these plants have the properties that alter the PH on the interface between the virus spike proteins and the human respiratory surfaces causing a brake on the interaction with human ACE-2 and where interaction has taken place, the replication and translation stages are disrupted. The plants thus are potential modifiers of this milieu and inhibitor of the main protease and endoribonuclease via epigenetics and homeostasis. These plants consumption should be encouraged as prophylactic or curative measures pending the discovery of a definitive cure. The chapter recommends that the search for COVID-19 cure should not be limited to conventional medicines, rather should be extended to some indigenous plants in Igbo land.",book:{id:"9445",slug:"alternative-medicine-update",title:"Alternative Medicine",fullTitle:"Alternative Medicine - Update"},signatures:"Obeta M. Uchejeso, Ikeagwulonu R. Chinaza, Ohanube A.K. Goodluck and Jwanse I. Rinpan",authors:[{id:"329113",title:"Dr.",name:"Obeta",middleName:"Mark",surname:"M. Uchejeso",slug:"obeta-m.-uchejeso",fullName:"Obeta M. Uchejeso"},{id:"331227",title:"MSc.",name:"Ohanube",middleName:null,surname:"A.K. Goodluck",slug:"ohanube-a.k.-goodluck",fullName:"Ohanube A.K. Goodluck"},{id:"331228",title:"MSc.",name:"Ikeagwulonu",middleName:null,surname:"R. Chinaza",slug:"ikeagwulonu-r.-chinaza",fullName:"Ikeagwulonu R. Chinaza"},{id:"331230",title:"MSc.",name:"Jwanse",middleName:null,surname:"I. Rinpan",slug:"jwanse-i.-rinpan",fullName:"Jwanse I. 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However, this toxic plant is reported to possess anti-inflammatory activity, anti-arthritic effect, antioxidant activity, antimicrobial activity, anti- carcinogenic activity, hypoglycemic activity, cardioprotective, hepatoprotective, neuroprotective, and hypolipidemic activity etc. All these activities are attributed to its various constituents like phenolic compounds, flavonoids, carbohydrates, alkaloids, steroids, etc. In Ayurveda, a series of pharmaceutical procedures which converts a poisonous drug into a safe and therapeutically effective medicine is termed as Shodhana. Shodhana improves the yield, decreases the phenolic and flavonoid content; and converts toxic urushiol into nontoxic anacardol derivative thereby reducing toxicity of nuts of Semecarpus anacardium. 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\r\n\tTransforming our World: the 2030 Agenda for Sustainable Development endorsed by United Nations and 193 Member States, came into effect on Jan 1, 2016, to guide decision making and actions to the year 2030 and beyond. Central to this Agenda are 17 Goals, 169 associated targets and over 230 indicators that are reviewed annually. The vision envisaged in the implementation of the SDGs is centered on the five Ps: People, Planet, Prosperity, Peace and Partnership. This call for renewed focused efforts ensure we have a safe and healthy planet for current and future generations.
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\r\n
\r\n\tThis Series focuses on covering research and applied research involving the five Ps through the following topics:
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\r\n\t1. Sustainable Economy and Fair Society that relates to SDG 1 on No Poverty, SDG 2 on Zero Hunger, SDG 8 on Decent Work and Economic Growth, SDG 10 on Reduced Inequalities, SDG 12 on Responsible Consumption and Production, and SDG 17 Partnership for the Goals
\r\n
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\r\n\t2. Health and Wellbeing focusing on SDG 3 on Good Health and Wellbeing and SDG 6 on Clean Water and Sanitation
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\r\n\t3. Inclusivity and Social Equality involving SDG 4 on Quality Education, SDG 5 on Gender Equality, and SDG 16 on Peace, Justice and Strong Institutions
\r\n
\r\n\t
\r\n
\r\n\t4. Climate Change and Environmental Sustainability comprising SDG 13 on Climate Action, SDG 14 on Life Below Water, and SDG 15 on Life on Land
\r\n
\r\n\t
\r\n
\r\n\t5. Urban Planning and Environmental Management embracing SDG 7 on Affordable Clean Energy, SDG 9 on Industry, Innovation and Infrastructure, and SDG 11 on Sustainable Cities and Communities.
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\r\n\tThe series also seeks to support the use of cross cutting SDGs, as many of the goals listed above, targets and indicators are all interconnected to impact our lives and the decisions we make on a daily basis, making them impossible to tie to a single topic.
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He is also a faculty member in the Molecular Oncology Program. He obtained his MSc and Ph.D. at Oregon State University and Texas Tech University, respectively. He pursued his postdoctoral studies at Rutgers University Medical School and the National Institutes of Health (NIH/NIDDK), USA. His research focuses on biochemistry, biophysics, genetics, molecular biology, and molecular medicine with specialization in the fields of drug design, protein structure-function, protein folding, prions, microRNA, pseudogenes, molecular cancer, epigenetics, metabolites, proteomics, genomics, protein expression, and characterization by spectroscopic and calorimetric methods.",institutionString:"University of Health Sciences",institution:null},{id:"180528",title:"Dr.",name:"Hiroyuki",middleName:null,surname:"Kagechika",slug:"hiroyuki-kagechika",fullName:"Hiroyuki Kagechika",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180528/images/system/180528.jpg",biography:"Hiroyuki Kagechika received his bachelor’s degree and Ph.D. in Pharmaceutical Sciences from the University of Tokyo, Japan, where he served as an associate professor until 2004. He is currently a professor at the Institute of Biomaterials and Bioengineering (IBB), Tokyo Medical and Dental University (TMDU). From 2010 to 2012, he was the dean of the Graduate School of Biomedical Science. Since 2012, he has served as the vice dean of the Graduate School of Medical and Dental Sciences. He has been the director of the IBB since 2020. Dr. Kagechika’s major research interests are the medicinal chemistry of retinoids, vitamins D/K, and nuclear receptors. He has developed various compounds including a drug for acute promyelocytic leukemia.",institutionString:"Tokyo Medical and Dental University",institution:{name:"Tokyo Medical and Dental University",country:{name:"Japan"}}},{id:"40482",title:null,name:"Rizwan",middleName:null,surname:"Ahmad",slug:"rizwan-ahmad",fullName:"Rizwan Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/40482/images/system/40482.jpeg",biography:"Dr. Rizwan Ahmad is a University Professor and Coordinator, Quality and Development, College of Medicine, Imam Abdulrahman bin Faisal University, Saudi Arabia. Previously, he was Associate Professor of Human Function, Oman Medical College, Oman, and SBS University, Dehradun. Dr. Ahmad completed his education at Aligarh Muslim University, Aligarh. He has published several articles in peer-reviewed journals, chapters, and edited books. His area of specialization is free radical biochemistry and autoimmune diseases.",institutionString:"Imam Abdulrahman Bin Faisal University",institution:{name:"Imam Abdulrahman Bin Faisal University",country:{name:"Saudi Arabia"}}},{id:"41865",title:"Prof.",name:"Farid A.",middleName:null,surname:"Badria",slug:"farid-a.-badria",fullName:"Farid A. Badria",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/41865/images/system/41865.jpg",biography:"Farid A. Badria, Ph.D., is the recipient of several awards, including The World Academy of Sciences (TWAS) Prize for Public Understanding of Science; the World Intellectual Property Organization (WIPO) Gold Medal for best invention; Outstanding Arab Scholar, Kuwait; and the Khwarizmi International Award, Iran. He has 250 publications, 12 books, 20 patents, and several marketed pharmaceutical products to his credit. He continues to lead research projects on developing new therapies for liver, skin disorders, and cancer. Dr. Badria was listed among the world’s top 2% of scientists in medicinal and biomolecular chemistry in 2019 and 2020. He is a member of the Arab Development Fund, Kuwait; International Cell Research Organization–United Nations Educational, Scientific and Cultural Organization (ICRO–UNESCO), Chile; and UNESCO Biotechnology France",institutionString:"Mansoura University",institution:{name:"Mansoura University",country:{name:"Egypt"}}},{id:"329385",title:"Dr.",name:"Rajesh K.",middleName:"Kumar",surname:"Singh",slug:"rajesh-k.-singh",fullName:"Rajesh K. Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329385/images/system/329385.png",biography:"Dr. Singh received a BPharm (2003) and MPharm (2005) from Panjab University, Chandigarh, India, and a Ph.D. (2013) from Punjab Technical University (PTU), Jalandhar, India. He has more than sixteen years of teaching experience and has supervised numerous postgraduate and Ph.D. students. He has to his credit more than seventy papers in SCI- and SCOPUS-indexed journals, fifty-five conference proceedings, four books, six Best Paper Awards, and five projects from different government agencies. He is currently an editorial board member of eight international journals and a reviewer for more than fifty scientific journals. He received Top Reviewer and Excellent Peer Reviewer Awards from Publons in 2016 and 2017, respectively. He is also on the panel of The International Reviewer for reviewing research proposals for grants from the Royal Society. He also serves as a Publons Academy mentor and Bentham brand ambassador.",institutionString:"Punjab Technical University",institution:{name:"Punjab Technical University",country:{name:"India"}}},{id:"142388",title:"Dr.",name:"Thiago",middleName:"Gomes",surname:"Gomes Heck",slug:"thiago-gomes-heck",fullName:"Thiago Gomes Heck",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/142388/images/7259_n.jpg",biography:null,institutionString:null,institution:{name:"Universidade Regional do Noroeste do Estado do Rio Grande do Sul",country:{name:"Brazil"}}},{id:"336273",title:"Assistant Prof.",name:"Janja",middleName:null,surname:"Zupan",slug:"janja-zupan",fullName:"Janja Zupan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/336273/images/14853_n.jpeg",biography:"Janja Zupan graduated in 2005 at the Department of Clinical Biochemistry (superviser prof. dr. Janja Marc) in the field of genetics of osteoporosis. Since November 2009 she is working as a Teaching Assistant at the Faculty of Pharmacy, Department of Clinical Biochemistry. In 2011 she completed part of her research and PhD work at Institute of Genetics and Molecular Medicine, University of Edinburgh. She finished her PhD entitled The influence of the proinflammatory cytokines on the RANK/RANKL/OPG in bone tissue of osteoporotic and osteoarthritic patients in 2012. From 2014-2016 she worked at the Institute of Biomedical Sciences, University of Aberdeen as a postdoctoral research fellow on UK Arthritis research project where she gained knowledge in mesenchymal stem cells and regenerative medicine. She returned back to University of Ljubljana, Faculty of Pharmacy in 2016. She is currently leading project entitled Mesenchymal stem cells-the keepers of tissue endogenous regenerative capacity facing up to aging of the musculoskeletal system funded by Slovenian Research Agency.",institutionString:null,institution:{name:"University of Ljubljana",country:{name:"Slovenia"}}},{id:"357453",title:"Dr.",name:"Radheshyam",middleName:null,surname:"Maurya",slug:"radheshyam-maurya",fullName:"Radheshyam Maurya",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/357453/images/16535_n.jpg",biography:null,institutionString:null,institution:{name:"University of Hyderabad",country:{name:"India"}}},{id:"311457",title:"Dr.",name:"Júlia",middleName:null,surname:"Scherer Santos",slug:"julia-scherer-santos",fullName:"Júlia Scherer Santos",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/311457/images/system/311457.jpg",biography:"Dr. Júlia Scherer Santos works in the areas of cosmetology, nanotechnology, pharmaceutical technology, beauty, and aesthetics. Dr. Santos also has experience as a professor of graduate courses. Graduated in Pharmacy, specialization in Cosmetology and Cosmeceuticals applied to aesthetics, specialization in Aesthetic and Cosmetic Health, and a doctorate in Pharmaceutical Nanotechnology. Teaching experience in Pharmacy and Aesthetics and Cosmetics courses. She works mainly on the following subjects: nanotechnology, cosmetology, pharmaceutical technology, aesthetics.",institutionString:"Universidade Federal de Juiz de Fora",institution:{name:"Universidade Federal de Juiz de Fora",country:{name:"Brazil"}}},{id:"219081",title:"Dr.",name:"Abdulsamed",middleName:null,surname:"Kükürt",slug:"abdulsamed-kukurt",fullName:"Abdulsamed Kükürt",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRNVJQA4/Profile_Picture_2022-03-07T13:23:04.png",biography:"Dr. Kükürt graduated from Uludağ University in Turkey. He started his academic career as a Research Assistant in the Department of Biochemistry at Kafkas University. In 2019, he completed his Ph.D. program in the Department of Biochemistry at the Institute of Health Sciences. He is currently working at the Department of Biochemistry, Kafkas University. He has 27 published research articles in academic journals, 11 book chapters, and 37 papers. He took part in 10 academic projects. He served as a reviewer for many articles. He still serves as a member of the review board in many academic journals. His research interests include biochemistry, oxidative stress, reactive species, antioxidants, lipid peroxidation, inflammation, reproductive hormones, phenolic compounds, female infertility.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"178366",title:"Associate Prof.",name:"Volkan",middleName:null,surname:"Gelen",slug:"volkan-gelen",fullName:"Volkan Gelen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/178366/images/system/178366.jpg",biography:"Volkan Gelen is a Physiology specialist who received his veterinary degree from Kafkas University in 2011. Between 2011-2015, he worked as an assistant at Atatürk University, Faculty of Veterinary Medicine, Department of Physiology. In 2016, he joined Kafkas University, Faculty of Veterinary Medicine, Department of Physiology as an assistant professor. Dr. Gelen has been engaged in various academic activities at Kafkas University since 2016. There he completed 5 projects and has 3 ongoing projects. He has 60 articles published in scientific journals and 20 poster presentations in scientific congresses. His research interests include physiology, endocrine system, cancer, diabetes, cardiovascular system diseases, and isolated organ bath system studies.",institutionString:"Kafkas University",institution:{name:"Kafkas University",country:{name:"Turkey"}}},{id:"418963",title:"Dr.",name:"Augustine Ododo",middleName:"Augustine",surname:"Osagie",slug:"augustine-ododo-osagie",fullName:"Augustine Ododo Osagie",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/418963/images/16900_n.jpg",biography:"Born into the family of Osagie, a prince of the Benin Kingdom. I am currently an academic in the Department of Medical Biochemistry, University of Benin. Part of the duties are to teach undergraduate students and conduct academic research.",institutionString:null,institution:{name:"University of Benin",country:{name:"Nigeria"}}},{id:"192992",title:"Prof.",name:"Shagufta",middleName:null,surname:"Perveen",slug:"shagufta-perveen",fullName:"Shagufta Perveen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/192992/images/system/192992.png",biography:"Prof. Shagufta Perveen is a Distinguish Professor in the Department of Pharmacognosy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia. Dr. Perveen has acted as the principal investigator of major research projects funded by the research unit of King Saud University. She has more than ninety original research papers in peer-reviewed journals of international repute to her credit. She is a fellow member of the Royal Society of Chemistry UK and the American Chemical Society of the United States.",institutionString:"King Saud University",institution:{name:"King Saud University",country:{name:"Saudi Arabia"}}},{id:"49848",title:"Dr.",name:"Wen-Long",middleName:null,surname:"Hu",slug:"wen-long-hu",fullName:"Wen-Long Hu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49848/images/system/49848.jpg",biography:"Wen-Long Hu is Chief of the Division of Acupuncture, Department of Chinese Medicine at Kaohsiung Chang Gung Memorial Hospital, as well as an adjunct associate professor at Fooyin University and Kaohsiung Medical University. Wen-Long is President of Taiwan Traditional Chinese Medicine Medical Association. He has 28 years of experience in clinical practice in laser acupuncture therapy and 34 years in acupuncture. He is an invited speaker for lectures and workshops in laser acupuncture at many symposiums held by medical associations. He owns the patent for herbal preparation and producing, and for the supercritical fluid-treated needle. Dr. Hu has published three books, 12 book chapters, and more than 30 papers in reputed journals, besides serving as an editorial board member of repute.",institutionString:"Kaohsiung Chang Gung Memorial Hospital",institution:{name:"Kaohsiung Chang Gung Memorial Hospital",country:{name:"Taiwan"}}},{id:"298472",title:"Prof.",name:"Andrey V.",middleName:null,surname:"Grechko",slug:"andrey-v.-grechko",fullName:"Andrey V. Grechko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/298472/images/system/298472.png",biography:"Andrey Vyacheslavovich Grechko, Ph.D., Professor, is a Corresponding Member of the Russian Academy of Sciences. He graduated from the Semashko Moscow Medical Institute (Semashko National Research Institute of Public Health) with a degree in Medicine (1998), the Clinical Department of Dermatovenerology (2000), and received a second higher education in Psychology (2009). Professor A.V. Grechko held the position of Сhief Physician of the Central Clinical Hospital in Moscow. He worked as a professor at the faculty and was engaged in scientific research at the Medical University. Starting in 2013, he has been the initiator of the creation of the Federal Scientific and Clinical Center for Intensive Care and Rehabilitology, Moscow, Russian Federation, where he also serves as Director since 2015. He has many years of experience in research and teaching in various fields of medicine, is an author/co-author of more than 200 scientific publications, 13 patents, 15 medical books/chapters, including Chapter in Book «Metabolomics», IntechOpen, 2020 «Metabolomic Discovery of Microbiota Dysfunction as the Cause of Pathology».",institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"199461",title:"Prof.",name:"Natalia V.",middleName:null,surname:"Beloborodova",slug:"natalia-v.-beloborodova",fullName:"Natalia V. Beloborodova",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/199461/images/system/199461.jpg",biography:'Natalia Vladimirovna Beloborodova was educated at the Pirogov Russian National Research Medical University, with a degree in pediatrics in 1980, a Ph.D. in 1987, and a specialization in Clinical Microbiology from First Moscow State Medical University in 2004. She has been a Professor since 1996. Currently, she is the Head of the Laboratory of Metabolism, a division of the Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, Moscow, Russian Federation. N.V. Beloborodova has many years of clinical experience in the field of intensive care and surgery. She studies infectious complications and sepsis. She initiated a series of interdisciplinary clinical and experimental studies based on the concept of integrating human metabolism and its microbiota. Her scientific achievements are widely known: she is the recipient of the Marie E. Coates Award \\"Best lecturer-scientist\\" Gustafsson Fund, Karolinska Institutes, Stockholm, Sweden, and the International Sepsis Forum Award, Pasteur Institute, Paris, France (2014), etc. Professor N.V. Beloborodova wrote 210 papers, five books, 10 chapters and has edited four books.',institutionString:"Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology",institution:null},{id:"354260",title:"Ph.D.",name:"Tércio Elyan",middleName:"Azevedo",surname:"Azevedo Martins",slug:"tercio-elyan-azevedo-martins",fullName:"Tércio Elyan Azevedo Martins",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/354260/images/16241_n.jpg",biography:"Graduated in Pharmacy from the Federal University of Ceará with the modality in Industrial Pharmacy, Specialist in Production and Control of Medicines from the University of São Paulo (USP), Master in Pharmaceuticals and Medicines from the University of São Paulo (USP) and Doctor of Science in the program of Pharmaceuticals and Medicines by the University of São Paulo. Professor at Universidade Paulista (UNIP) in the areas of chemistry, cosmetology and trichology. Assistant Coordinator of the Higher Course in Aesthetic and Cosmetic Technology at Universidade Paulista Campus Chácara Santo Antônio. Experience in the Pharmacy area, with emphasis on Pharmacotechnics, Pharmaceutical Technology, Research and Development of Cosmetics, acting mainly on topics such as cosmetology, antioxidant activity, aesthetics, photoprotection, cyclodextrin and thermal analysis.",institutionString:null,institution:{name:"University of Sao Paulo",country:{name:"Brazil"}}},{id:"334285",title:"Ph.D. Student",name:"Sameer",middleName:"Kumar",surname:"Jagirdar",slug:"sameer-jagirdar",fullName:"Sameer Jagirdar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334285/images/14691_n.jpg",biography:"I\\'m a graduate student at the center for biosystems science and engineering at the Indian Institute of Science, Bangalore, India. I am interested in studying host-pathogen interactions at the biomaterial interface.",institutionString:null,institution:{name:"Indian Institute of Science Bangalore",country:{name:"India"}}},{id:"329795",title:"Dr.",name:"Mohd Aftab",middleName:"Aftab",surname:"Siddiqui",slug:"mohd-aftab-siddiqui",fullName:"Mohd Aftab Siddiqui",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/329795/images/15648_n.jpg",biography:"Dr. Mohd Aftab Siddiqui is currently working as Assistant Professor in the Faculty of Pharmacy, Integral University, Lucknow for the last 6 years. He has completed his Doctor in Philosophy (Pharmacology) in 2020 from Integral University, Lucknow. He completed his Bachelor in Pharmacy in 2013 and Master in Pharmacy (Pharmacology) in 2015 from Integral University, Lucknow. He is the gold medalist in Bachelor and Master degree. He qualified GPAT -2013, GPAT -2014, and GPAT 2015. His area of research is Pharmacological screening of herbal drugs/ natural products in liver and cardiac diseases. He has guided many M. Pharm. research projects. He has many national and international publications.",institutionString:"Integral University",institution:null},{id:"255360",title:"Dr.",name:"Usama",middleName:null,surname:"Ahmad",slug:"usama-ahmad",fullName:"Usama Ahmad",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/255360/images/system/255360.png",biography:"Dr. Usama Ahmad holds a specialization in Pharmaceutics from Amity University, Lucknow, India. He received his Ph.D. degree from Integral University. Currently, he’s working as an Assistant Professor of Pharmaceutics in the Faculty of Pharmacy, Integral University. From 2013 to 2014 he worked on a research project funded by SERB-DST, Government of India. He has a rich publication record with more than 32 original articles published in reputed journals, 3 edited books, 5 book chapters, and a number of scientific articles published in ‘Ingredients South Asia Magazine’ and ‘QualPharma Magazine’. He is a member of the American Association for Cancer Research, International Association for the Study of Lung Cancer, and the British Society for Nanomedicine. Dr. Ahmad’s research focus is on the development of nanoformulations to facilitate the delivery of drugs that aim to provide practical solutions to current healthcare problems.",institutionString:"Integral University",institution:{name:"Integral University",country:{name:"India"}}},{id:"30568",title:"Prof.",name:"Madhu",middleName:null,surname:"Khullar",slug:"madhu-khullar",fullName:"Madhu Khullar",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/30568/images/system/30568.jpg",biography:"Dr. Madhu Khullar is a Professor of Experimental Medicine and Biotechnology at the Post Graduate Institute of Medical Education and Research, Chandigarh, India. She completed her Post Doctorate in hypertension research at the Henry Ford Hospital, Detroit, USA in 1985. She is an editor and reviewer of several international journals, and a fellow and member of several cardiovascular research societies. Dr. Khullar has a keen research interest in genetics of hypertension, and is currently studying pharmacogenetics of hypertension.",institutionString:"Post Graduate Institute of Medical Education and Research",institution:{name:"Post Graduate Institute of Medical Education and Research",country:{name:"India"}}},{id:"223233",title:"Prof.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/223233/images/system/223233.png",biography:"Xianquan Zhan received his MD and Ph.D. in Preventive Medicine at West China University of Medical Sciences. He received his post-doctoral training in oncology and cancer proteomics at the Central South University, China, and the University of Tennessee Health Science Center (UTHSC), USA. He worked at UTHSC and the Cleveland Clinic in 2001–2012 and achieved the rank of associate professor at UTHSC. Currently, he is a full professor at Central South University and Shandong First Medical University, and an advisor to MS/PhD students and postdoctoral fellows. He is also a fellow of the Royal Society of Medicine and European Association for Predictive Preventive Personalized Medicine (EPMA), a national representative of EPMA, and a member of the American Society of Clinical Oncology (ASCO) and the American Association for the Advancement of Sciences (AAAS). He is also the editor in chief of International Journal of Chronic Diseases & Therapy, an associate editor of EPMA Journal, Frontiers in Endocrinology, and BMC Medical Genomics, and a guest editor of Mass Spectrometry Reviews, Frontiers in Endocrinology, EPMA Journal, and Oxidative Medicine and Cellular Longevity. He has published more than 148 articles, 28 book chapters, 6 books, and 2 US patents in the field of clinical proteomics and biomarkers.",institutionString:"Shandong First Medical University",institution:{name:"Affiliated Hospital of Shandong Academy of Medical Sciences",country:{name:"China"}}},{id:"297507",title:"Dr.",name:"Charles",middleName:"Elias",surname:"Assmann",slug:"charles-assmann",fullName:"Charles Assmann",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/297507/images/system/297507.jpg",biography:"Charles Elias Assmann is a biologist from Federal University of Santa Maria (UFSM, Brazil), who spent some time abroad at the Ludwig-Maximilians-Universität München (LMU, Germany). He has Masters Degree in Biochemistry (UFSM), and is currently a PhD student at Biochemistry at the Department of Biochemistry and Molecular Biology of the UFSM. His areas of expertise include: Biochemistry, Molecular Biology, Enzymology, Genetics and Toxicology. He is currently working on the following subjects: Aluminium toxicity, Neuroinflammation, Oxidative stress and Purinergic system. Since 2011 he has presented more than 80 abstracts in scientific proceedings of national and international meetings. Since 2014, he has published more than 20 peer reviewed papers (including 4 reviews, 3 in Portuguese) and 2 book chapters. He has also been a reviewer of international journals and ad hoc reviewer of scientific committees from Brazilian Universities.",institutionString:"Universidade Federal de Santa Maria",institution:{name:"Universidade Federal de Santa Maria",country:{name:"Brazil"}}},{id:"217850",title:"Dr.",name:"Margarete Dulce",middleName:null,surname:"Bagatini",slug:"margarete-dulce-bagatini",fullName:"Margarete Dulce Bagatini",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/217850/images/system/217850.jpeg",biography:"Dr. Margarete Dulce Bagatini is an associate professor at the Federal University of Fronteira Sul/Brazil. She has a degree in Pharmacy and a PhD in Biological Sciences: Toxicological Biochemistry. She is a member of the UFFS Research Advisory Committee\nand a member of the Biovitta Research Institute. She is currently:\nthe leader of the research group: Biological and Clinical Studies\nin Human Pathologies, professor of postgraduate program in\nBiochemistry at UFSC and postgraduate program in Science and Food Technology at\nUFFS. She has experience in the area of pharmacy and clinical analysis, acting mainly\non the following topics: oxidative stress, the purinergic system and human pathologies, being a reviewer of several international journals and books.",institutionString:"Universidade Federal da Fronteira Sul",institution:{name:"Universidade Federal da Fronteira Sul",country:{name:"Brazil"}}},{id:"226275",title:"Ph.D.",name:"Metin",middleName:null,surname:"Budak",slug:"metin-budak",fullName:"Metin Budak",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226275/images/system/226275.jfif",biography:"Metin Budak, MSc, PhD is an Assistant Professor at Trakya University, Faculty of Medicine. He has been Head of the Molecular Research Lab at Prof. Mirko Tos Ear and Hearing Research Center since 2018. His specializations are biophysics, epigenetics, genetics, and methylation mechanisms. He has published around 25 peer-reviewed papers, 2 book chapters, and 28 abstracts. He is a member of the Clinical Research Ethics Committee and Quantification and Consideration Committee of Medicine Faculty. His research area is the role of methylation during gene transcription, chromatin packages DNA within the cell and DNA repair, replication, recombination, and gene transcription. His research focuses on how the cell overcomes chromatin structure and methylation to allow access to the underlying DNA and enable normal cellular function.",institutionString:"Trakya University",institution:{name:"Trakya University",country:{name:"Turkey"}}},{id:"243049",title:"Dr.",name:"Anca",middleName:null,surname:"Pantea Stoian",slug:"anca-pantea-stoian",fullName:"Anca Pantea Stoian",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/243049/images/system/243049.jpg",biography:"Anca Pantea Stoian is a specialist in diabetes, nutrition, and metabolic diseases as well as health food hygiene. She also has competency in general ultrasonography.\n\nShe is an associate professor in the Diabetes, Nutrition and Metabolic Diseases Department, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania. She has been chief of the Hygiene Department, Faculty of Dentistry, at the same university since 2019. Her interests include micro and macrovascular complications in diabetes and new therapies. Her research activities focus on nutritional intervention in chronic pathology, as well as cardio-renal-metabolic risk assessment, and diabetes in cancer. She is currently engaged in developing new therapies and technological tools for screening, prevention, and patient education in diabetes. \n\nShe is a member of the European Association for the Study of Diabetes, Cardiometabolic Academy, CEDA, Romanian Society of Diabetes, Nutrition and Metabolic Diseases, Romanian Diabetes Federation, and Association for Renal Metabolic and Nutrition studies. She has authored or co-authored 160 papers in national and international peer-reviewed journals.",institutionString:null,institution:{name:"Carol Davila University of Medicine and Pharmacy",country:{name:"Romania"}}},{id:"279792",title:"Dr.",name:"João",middleName:null,surname:"Cotas",slug:"joao-cotas",fullName:"João Cotas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/279792/images/system/279792.jpg",biography:"Graduate and master in Biology from the University of Coimbra.\n\nI am a research fellow at the Macroalgae Laboratory Unit, in the MARE-UC – Marine and Environmental Sciences Centre of the University of Coimbra. My principal function is the collection, extraction and purification of macroalgae compounds, chemical and bioactive characterization of the compounds and algae extracts and development of new methodologies in marine biotechnology area. \nI am associated in two projects: one consists on discovery of natural compounds for oncobiology. The other project is the about the natural compounds/products for agricultural area.\n\nPublications:\nCotas, J.; Figueirinha, A.; Pereira, L.; Batista, T. 2018. An analysis of the effects of salinity on Fucus ceranoides (Ochrophyta, Phaeophyceae), in the Mondego River (Portugal). Journal of Oceanology and Limnology. in press. DOI: 10.1007/s00343-019-8111-3",institutionString:"Faculty of Sciences and Technology of University of Coimbra",institution:null},{id:"279788",title:"Dr.",name:"Leonel",middleName:null,surname:"Pereira",slug:"leonel-pereira",fullName:"Leonel Pereira",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/279788/images/system/279788.jpg",biography:"Leonel Pereira has an undergraduate degree in Biology, a Ph.D. in Biology (specialty in Cell Biology), and a Habilitation degree in Biosciences (specialization in Biotechnology) from the Faculty of Science and Technology, University of Coimbra, Portugal, where he is currently a professor. In addition to teaching at this university, he is an integrated researcher at the Marine and Environmental Sciences Center (MARE), Portugal. His interests include marine biodiversity (algae), marine biotechnology (algae bioactive compounds), and marine ecology (environmental assessment). Since 2008, he has been the author and editor of the electronic publication MACOI – Portuguese Seaweeds Website (www.seaweeds.uc.pt). He is also a member of the editorial boards of several scientific journals. Dr. Pereira has edited or authored more than 20 books, 100 journal articles, and 45 book chapters. He has given more than 100 lectures and oral communications at various national and international scientific events. He is the coordinator of several national and international research projects. In 1998, he received the Francisco de Holanda Award (Honorable Mention) and, more recently, the Mar Rei D. Carlos award (18th edition). He is also a winner of the 2016 CHOICE Award for an outstanding academic title for his book Edible Seaweeds of the World. In 2020, Dr. Pereira received an Honorable Mention for the Impact of International Publications from the Web of Science",institutionString:"University of Coimbra",institution:{name:"University of Coimbra",country:{name:"Portugal"}}},{id:"61946",title:"Dr.",name:"Carol",middleName:null,surname:"Bernstein",slug:"carol-bernstein",fullName:"Carol Bernstein",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/61946/images/system/61946.jpg",biography:"Carol Bernstein received her PhD in Genetics from the University of California (Davis). She was a faculty member at the University of Arizona College of Medicine for 43 years, retiring in 2011. Her research interests focus on DNA damage and its underlying role in sex, aging and in the early steps of initiation and progression to cancer. In her research, she had used organisms including bacteriophage T4, Neurospora crassa, Schizosaccharomyces pombe and mice, as well as human cells and tissues. She authored or co-authored more than 140 scientific publications, including articles in major peer reviewed journals, book chapters, invited reviews and one book.",institutionString:"University of Arizona",institution:{name:"University of Arizona",country:{name:"United States of America"}}},{id:"182258",title:"Dr.",name:"Ademar",middleName:"Pereira",surname:"Serra",slug:"ademar-serra",fullName:"Ademar Serra",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/182258/images/system/182258.jpeg",biography:"Dr. Serra studied Agronomy on Universidade Federal de Mato Grosso do Sul (UFMS) (2005). He received master degree in Agronomy, Crop Science (Soil fertility and plant nutrition) (2007) by Universidade Federal da Grande Dourados (UFGD), and PhD in agronomy (Soil fertility and plant nutrition) (2011) from Universidade Federal da Grande Dourados / Escola Superior de Agricultura Luiz de Queiroz (UFGD/ESALQ-USP). Dr. Serra is currently working at Brazilian Agricultural Research Corporation (EMBRAPA). His research focus is on mineral nutrition of plants, crop science and soil science. Dr. Serra\\'s current projects are soil organic matter, soil phosphorus fractions, compositional nutrient diagnosis (CND) and isometric log ratio (ilr) transformation in compositional data analysis.",institutionString:"Brazilian Agricultural Research Corporation",institution:{name:"Brazilian Agricultural Research Corporation",country:{name:"Brazil"}}}]}},subseries:{item:{id:"18",type:"subseries",title:"Proteomics",keywords:"Mono- and Two-Dimensional Gel Electrophoresis (1-and 2-DE), Liquid Chromatography (LC), Mass Spectrometry/Tandem Mass Spectrometry (MS; MS/MS), Proteins",scope:"With the recognition that the human genome cannot provide answers to the etiology of a disorder, changes in the proteins expressed by a genome became a focus in research. Thus proteomics, an area of research that detects all protein forms expressed in an organism, including splice isoforms and post-translational modifications, is more suitable than genomics for a comprehensive understanding of the biochemical processes that govern life. The most common proteomics applications are currently in the clinical field for the identification, in a variety of biological matrices, of biomarkers for diagnosis and therapeutic intervention of disorders. From the comparison of proteomic profiles of control and disease or different physiological states, which may emerge, changes in protein expression can provide new insights into the roles played by some proteins in human pathologies. Understanding how proteins function and interact with each other is another goal of proteomics that makes this approach even more intriguing. Specialized technology and expertise are required to assess the proteome of any biological sample. Currently, proteomics relies mainly on mass spectrometry (MS) combined with electrophoretic (1 or 2-DE-MS) and/or chromatographic techniques (LC-MS/MS). MS is an excellent tool that has gained popularity in proteomics because of its ability to gather a complex body of information such as cataloging protein expression, identifying protein modification sites, and defining protein interactions. The Proteomics topic aims to attract contributions on all aspects of MS-based proteomics that, by pushing the boundaries of MS capabilities, may address biological problems that have not been resolved yet.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/18.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11414,editor:{id:"200689",title:"Prof.",name:"Paolo",middleName:null,surname:"Iadarola",slug:"paolo-iadarola",fullName:"Paolo Iadarola",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bSCl8QAG/Profile_Picture_1623568118342",biography:"Paolo Iadarola graduated with a degree in Chemistry from the University of Pavia (Italy) in July 1972. He then worked as an Assistant Professor at the Faculty of Science of the same University until 1984. In 1985, Prof. Iadarola became Associate Professor at the Department of Biology and Biotechnologies of the University of Pavia and retired in October 2017. Since then, he has been working as an Adjunct Professor in the same Department at the University of Pavia. His research activity during the first years was primarily focused on the purification and structural characterization of enzymes from animal and plant sources. During this period, Prof. Iadarola familiarized himself with the conventional techniques used in column chromatography, spectrophotometry, manual Edman degradation, and electrophoresis). Since 1995, he has been working on: i) the determination in biological fluids (serum, urine, bronchoalveolar lavage, sputum) of proteolytic activities involved in the degradation processes of connective tissue matrix, and ii) on the identification of biological markers of lung diseases. In this context, he has developed and validated new methodologies (e.g., Capillary Electrophoresis coupled to Laser-Induced Fluorescence, CE-LIF) whose application enabled him to determine both the amounts of biochemical markers (Desmosines) in urine/serum of patients affected by Chronic Obstructive Pulmonary Disease (COPD) and the activity of proteolytic enzymes (Human Neutrophil Elastase, Cathepsin G, Pseudomonas aeruginosa elastase) in sputa of these patients. More recently, Prof. Iadarola was involved in developing techniques such as two-dimensional electrophoresis coupled to liquid chromatography/mass spectrometry (2DE-LC/MS) for the proteomic analysis of biological fluids aimed at the identification of potential biomarkers of different lung diseases. He is the author of about 150 publications (According to Scopus: H-Index: 23; Total citations: 1568- According to WOS: H-Index: 20; Total Citations: 1296) of peer-reviewed international journals. He is a Consultant Reviewer for several journals, including the Journal of Chromatography A, Journal of Chromatography B, Plos ONE, Proteomes, International Journal of Molecular Science, Biotech, Electrophoresis, and others. He is also Associate Editor of Biotech.",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorTwo:{id:"201414",title:"Dr.",name:"Simona",middleName:null,surname:"Viglio",slug:"simona-viglio",fullName:"Simona Viglio",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRKDHQA4/Profile_Picture_1630402531487",biography:"Simona Viglio is an Associate Professor of Biochemistry at the Department of Molecular Medicine at the University of Pavia. She has been working since 1995 on the determination of proteolytic enzymes involved in the degradation process of connective tissue matrix and on the identification of biological markers of lung diseases. She gained considerable experience in developing and validating new methodologies whose applications allowed her to determine both the amount of biomarkers (Desmosine and Isodesmosine) in the urine of patients affected by COPD, and the activity of proteolytic enzymes (HNE, Cathepsin G, Pseudomonas aeruginosa elastase) in the sputa of these patients. Simona Viglio was also involved in research dealing with the supplementation of amino acids in patients with brain injury and chronic heart failure. She is presently engaged in the development of 2-DE and LC-MS techniques for the study of proteomics in biological fluids. The aim of this research is the identification of potential biomarkers of lung diseases. She is an author of about 90 publications (According to Scopus: H-Index: 23; According to WOS: H-Index: 20) on peer-reviewed journals, a member of the “Società Italiana di Biochimica e Biologia Molecolare,“ and a Consultant Reviewer for International Journal of Molecular Science, Journal of Chromatography A, COPD, Plos ONE and Nutritional Neuroscience.",institutionString:null,institution:{name:"University of Pavia",institutionURL:null,country:{name:"Italy"}}},editorThree:null,series:{id:"11",title:"Biochemistry",doi:"10.5772/intechopen.72877",issn:"2632-0983"},editorialBoard:[{id:"72288",title:"Dr.",name:"Arli Aditya",middleName:null,surname:"Parikesit",slug:"arli-aditya-parikesit",fullName:"Arli Aditya Parikesit",profilePictureURL:"https://mts.intechopen.com/storage/users/72288/images/system/72288.jpg",institutionString:null,institution:{name:"Indonesia International Institute for Life Sciences",institutionURL:null,country:{name:"Indonesia"}}},{id:"40928",title:"Dr.",name:"Cesar",middleName:null,surname:"Lopez-Camarillo",slug:"cesar-lopez-camarillo",fullName:"Cesar Lopez-Camarillo",profilePictureURL:"https://mts.intechopen.com/storage/users/40928/images/3884_n.png",institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",institutionURL:null,country:{name:"Mexico"}}},{id:"81926",title:"Dr.",name:"Shymaa",middleName:null,surname:"Enany",slug:"shymaa-enany",fullName:"Shymaa Enany",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRqB9QAK/Profile_Picture_1626163237970",institutionString:null,institution:{name:"Suez Canal University",institutionURL:null,country:{name:"Egypt"}}}]},onlineFirstChapters:{paginationCount:1,paginationItems:[{id:"81644",title:"Perspective Chapter: Ethics of Using Placebo Controlled Trials for Covid-19 Vaccine Development in Vulnerable Populations",doi:"10.5772/intechopen.104776",signatures:"Lesley Burgess, Jurie Jordaan and Matthew Wilson",slug:"perspective-chapter-ethics-of-using-placebo-controlled-trials-for-covid-19-vaccine-development-in-vu",totalDownloads:5,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"SARS-CoV-2 Variants - Two Years After",coverURL:"https://cdn.intechopen.com/books/images_new/11573.jpg",subseries:{id:"6",title:"Viral Infectious Diseases"}}}]},publishedBooks:{paginationCount:3,paginationItems:[{type:"book",id:"8977",title:"Protein Kinases",subtitle:"Promising Targets for Anticancer Drug Research",coverURL:"https://cdn.intechopen.com/books/images_new/8977.jpg",slug:"protein-kinases-promising-targets-for-anticancer-drug-research",publishedDate:"December 8th 2021",editedByType:"Edited by",bookSignature:"Rajesh Kumar Singh",hash:"6d200cc031706a565b554fdb1c478901",volumeInSeries:24,fullTitle:"Protein Kinases - Promising Targets for Anticancer Drug Research",editors:[{id:"329385",title:"Dr.",name:"Rajesh K.",middleName:"Kumar",surname:"Singh",slug:"rajesh-k.-singh",fullName:"Rajesh K. Singh",profilePictureURL:"https://mts.intechopen.com/storage/users/329385/images/system/329385.png",institutionString:"Punjab Technical University",institution:{name:"Punjab Technical University",institutionURL:null,country:{name:"India"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null},{type:"book",id:"9742",title:"Ubiquitin",subtitle:"Proteasome Pathway",coverURL:"https://cdn.intechopen.com/books/images_new/9742.jpg",slug:"ubiquitin-proteasome-pathway",publishedDate:"December 9th 2020",editedByType:"Edited by",bookSignature:"Xianquan Zhan",hash:"af6880d3a5571da1377ac8f6373b9e82",volumeInSeries:18,fullTitle:"Ubiquitin - Proteasome Pathway",editors:[{id:"223233",title:"Prof.",name:"Xianquan",middleName:null,surname:"Zhan",slug:"xianquan-zhan",fullName:"Xianquan Zhan",profilePictureURL:"https://mts.intechopen.com/storage/users/223233/images/system/223233.png",institutionString:"Shandong First Medical University",institution:{name:"Affiliated Hospital of Shandong Academy 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nutrition, leading to the development of new feeding strategies and food valuation while being more sustainable with the environment, allowing more readers to learn about the subject.",author:{id:"175967",name:"Manuel",surname:"Gonzalez Ronquillo",institutionString:null,profilePictureURL:"https://mts.intechopen.com/storage/users/175967/images/system/175967.png",slug:"manuel-gonzalez-ronquillo",institution:{id:"6221",name:"Universidad Autónoma del Estado de México",country:{id:null,name:"Mexico"}}}}]},submityourwork:{pteSeriesList:[{id:"14",title:"Artificial Intelligence",numberOfPublishedBooks:9,numberOfPublishedChapters:87,numberOfOpenTopics:6,numberOfUpcomingTopics:0,issn:"2633-1403",doi:"10.5772/intechopen.79920",isOpenForSubmission:!0},{id:"7",title:"Biomedical 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Fungal infectious illness prevalence and prognosis are determined by the exposure between fungi and host, host immunological state, fungal virulence, and early and accurate diagnosis and treatment. \r\nPatients with both congenital and acquired immunodeficiency are more likely to be infected with opportunistic mycosis. Fungal infectious disease outbreaks are common during the post- disaster rebuilding era, which is characterised by high population density, migration, and poor health and medical conditions.\r\nSystemic or local fungal infection is mainly associated with the fungi directly inhaled or inoculated in the environment during the disaster. The most common fungal infection pathways are human to human (anthropophilic), animal to human (zoophilic), and environment to human (soilophile). Diseases are common as a result of widespread exposure to pathogenic fungus dispersed into the environment. \r\nFungi that are both common and emerging are intertwined. In Southeast Asia, for example, Talaromyces marneffei is an important pathogenic thermally dimorphic fungus that causes systemic mycosis. Widespread fungal infections with complicated and variable clinical manifestations, such as Candida auris infection resistant to several antifungal medicines, Covid-19 associated with Trichoderma, and terbinafine resistant dermatophytosis in India, are among the most serious disorders. \r\nInappropriate local or systemic use of glucocorticoids, as well as their immunosuppressive effects, may lead to changes in fungal infection spectrum and clinical characteristics. Hematogenous candidiasis is a worrisome issue that affects people all over the world, particularly ICU patients. CARD9 deficiency and fungal infection have been major issues in recent years. Invasive aspergillosis is associated with a significant death rate. Special attention should be given to endemic fungal infections, identification of important clinical fungal infections advanced in yeasts, filamentous fungal infections, skin mycobiome and fungal genomes, and immunity to fungal infections.\r\nIn addition, endemic fungal diseases or uncommon fungal infections caused by Mucor irregularis, dermatophytosis, Malassezia, cryptococcosis, chromoblastomycosis, coccidiosis, blastomycosis, histoplasmosis, sporotrichosis, and other fungi, should be monitored. \r\nThis topic includes the research progress on the etiology and pathogenesis of fungal infections, new methods of isolation and identification, rapid detection, drug sensitivity testing, new antifungal drugs, schemes and case series reports. It will provide significant opportunities and support for scientists, clinical doctors, mycologists, antifungal drug researchers, public health practitioners, and epidemiologists from all over the world to share new research, ideas and solutions to promote the development and progress of medical mycology.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/4.jpg",keywords:"Emerging Fungal Pathogens, Invasive Infections, Epidemiology, Cell Membrane, Fungal Virulence, Diagnosis, Treatment"},{id:"5",title:"Parasitic Infectious Diseases",scope:"Parasitic diseases have evolved alongside their human hosts. In many cases, these diseases have adapted so well that they have developed efficient resilience methods in the human host and can live in the host for years. Others, particularly some blood parasites, can cause very acute diseases and are responsible for millions of deaths yearly. Many parasitic diseases are classified as neglected tropical diseases because they have received minimal funding over recent years and, in many cases, are under-reported despite the critical role they play in morbidity and mortality among human and animal hosts. The current topic, Parasitic Infectious Diseases, in the Infectious Diseases Series aims to publish studies on the systematics, epidemiology, molecular biology, genomics, pathogenesis, genetics, and clinical significance of parasitic diseases from blood borne to intestinal parasites as well as zoonotic parasites. We hope to cover all aspects of parasitic diseases to provide current and relevant research data on these very important diseases. In the current atmosphere of the Coronavirus pandemic, communities around the world, particularly those in different underdeveloped areas, are faced with the growing challenges of the high burden of parasitic diseases. At the same time, they are faced with the Covid-19 pandemic leading to what some authors have called potential syndemics that might worsen the outcome of such infections. Therefore, it is important to conduct studies that examine parasitic infections in the context of the coronavirus pandemic for the benefit of all communities to help foster more informed decisions for the betterment of human and animal health.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/5.jpg",keywords:"Blood Borne Parasites, Intestinal Parasites, Protozoa, Helminths, Arthropods, Water Born Parasites, Epidemiology, Molecular Biology, Systematics, Genomics, Proteomics, Ecology"},{id:"6",title:"Viral Infectious Diseases",scope:"The Viral Infectious Diseases Book Series aims to provide a comprehensive overview of recent research trends and discoveries in various viral infectious diseases emerging around the globe. The emergence of any viral disease is hard to anticipate, which often contributes to death. A viral disease can be defined as an infectious disease that has recently appeared within a population or exists in nature with the rapid expansion of incident or geographic range. This series will focus on various crucial factors related to emerging viral infectious diseases, including epidemiology, pathogenesis, host immune response, clinical manifestations, diagnosis, treatment, and clinical recommendations for managing viral infectious diseases, highlighting the recent issues with future directions for effective therapeutic strategies.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/6.jpg",keywords:"Novel Viruses, Virus Transmission, Virus Evolution, Molecular Virology, Control and Prevention, Virus-host Interaction"}],annualVolumeBook:{},thematicCollection:[],selectedSeries:{title:"Infectious Diseases",id:"6"},selectedSubseries:null},seriesLanding:{item:null},libraryRecommendation:{success:null,errors:{},institutions:[]},route:{name:"profile.detail",path:"/profiles/428324",hash:"",query:{},params:{id:"428324"},fullPath:"/profiles/428324",meta:{},from:{name:null,path:"/",hash:"",query:{},params:{},fullPath:"/",meta:{}}}},function(){var e;(e=document.currentScript||document.scripts[document.scripts.length-1]).parentNode.removeChild(e)}()