The types of logic and implications of professional responsibility and accountability [18].
\\n\\n
These books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\\n\\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\\n\\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
\\n\\n\\n\\n\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
IntechOpen and Knowledge Unlatched formed a partnership to support researchers working in engineering sciences by enabling an easier approach to publishing Open Access content. Using the Knowledge Unlatched crowdfunding model to raise the publishing costs through libraries around the world, Open Access Publishing Fee (OAPF) was not required from the authors.
\n\nInitially, the partnership supported engineering research, but it soon grew to include physical and life sciences, attracting more researchers to the advantages of Open Access publishing.
\n\n\n\nThese books synthesize perspectives of renowned scientists from the world’s most prestigious institutions - from Fukushima Renewable Energy Institute in Japan to Stanford University in the United States, including Columbia University (US), University of Sidney (AU), University of Miami (USA), Cardiff University (UK), and many others.
\n\nThis collaboration embodied the true essence of Open Access by simplifying the approach to OA publishing for Academic editors and authors who contributed their research and allowed the new research to be made available free and open to anyone anywhere in the world.
\n\nTo celebrate the 50 books published, we have gathered them at one location - just one click away, so that you can easily browse the subjects of your interest, download the content directly, share it or read online.
\n\n\n\n\n'}],latestNews:[{slug:"intechopen-supports-asapbio-s-new-initiative-publish-your-reviews-20220729",title:"IntechOpen Supports ASAPbio’s New Initiative Publish Your Reviews"},{slug:"webinar-introduction-to-open-science-wednesday-18-may-1-pm-cest-20220518",title:"Webinar: Introduction to Open Science | Wednesday 18 May, 1 PM CEST"},{slug:"step-in-the-right-direction-intechopen-launches-a-portfolio-of-open-science-journals-20220414",title:"Step in the Right Direction: IntechOpen Launches a Portfolio of Open Science Journals"},{slug:"let-s-meet-at-london-book-fair-5-7-april-2022-olympia-london-20220321",title:"Let’s meet at London Book Fair, 5-7 April 2022, Olympia London"},{slug:"50-books-published-as-part-of-intechopen-and-knowledge-unlatched-ku-collaboration-20220316",title:"50 Books published as part of IntechOpen and Knowledge Unlatched (KU) Collaboration"},{slug:"intechopen-joins-the-united-nations-sustainable-development-goals-publishers-compact-20221702",title:"IntechOpen joins the United Nations Sustainable Development Goals Publishers Compact"},{slug:"intechopen-signs-exclusive-representation-agreement-with-lsr-libros-servicios-y-representaciones-s-a-de-c-v-20211123",title:"IntechOpen Signs Exclusive Representation Agreement with LSR Libros Servicios y Representaciones S.A. de C.V"},{slug:"intechopen-expands-partnership-with-research4life-20211110",title:"IntechOpen Expands Partnership with Research4Life"}]},book:{item:{type:"book",id:"7994",leadTitle:null,fullTitle:"Metformin",title:"Metformin",subtitle:null,reviewType:"peer-reviewed",abstract:"The book “Metformin” aims to bring to light new concepts and trends related to the many metformin therapeutic features. After a history of over 60 years, with moments of decline and spectacular returns, metformin can now be regarded as a universal panacea, the valences of its therapeutics being increasingly appreciated, both in the background treatment of diabetes and pre-diabetes, but also in reproductive pathology, cancer, cardiovascular disease, and antiageing. In this respect, the mechanisms of action and the pharmacodynamics of metformin seem to be incompletely known, a number of current studies have revealed new action valences.",isbn:"978-1-83880-428-2",printIsbn:"978-1-83880-427-5",pdfIsbn:"978-1-83880-760-3",doi:"10.5772/intechopen.77824",price:119,priceEur:129,priceUsd:155,slug:"metformin",numberOfPages:242,isOpenForSubmission:!1,isInWos:null,isInBkci:!1,hash:"4763270256096f776a58d75658fe1d9b",bookSignature:"Anca Mihaela Pantea Stoian and Manfredi Rizzo",publishedDate:"May 27th 2020",coverURL:"https://cdn.intechopen.com/books/images_new/7994.jpg",numberOfDownloads:10555,numberOfWosCitations:8,numberOfCrossrefCitations:12,numberOfCrossrefCitationsByBook:1,numberOfDimensionsCitations:22,numberOfDimensionsCitationsByBook:1,hasAltmetrics:1,numberOfTotalCitations:42,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 18th 2019",dateEndSecondStepPublish:"September 30th 2019",dateEndThirdStepPublish:"November 29th 2019",dateEndFourthStepPublish:"February 17th 2020",dateEndFifthStepPublish:"April 17th 2020",currentStepOfPublishingProcess:5,indexedIn:"1,2,3,4,5,6",editedByType:"Edited by",kuFlag:!1,featuredMarkup:null,editors:[{id:"243049",title:"Dr.",name:"Anca",middleName:null,surname:"Pantea Stoian",slug:"anca-pantea-stoian",fullName:"Anca Pantea Stoian",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,position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"6",totalChapterViews:"0",totalEditedBooks:"2",institution:{name:"Carol Davila University of Medicine and Pharmacy",institutionURL:null,country:{name:"Romania"}}}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,coeditorOne:{id:"303184",title:"Dr.",name:"Manfredi",middleName:null,surname:"Rizzo",slug:"manfredi-rizzo",fullName:"Manfredi Rizzo",profilePictureURL:"https://mts.intechopen.com/storage/users/303184/images/system/303184.png",biography:"Prof. Manfredi Rizzo, MD, PhD. Prof. Rizzo studied medicine and received training in Internal Medicine in Italy. He spent several years in the United States, working at the University of California. There he was able to gain clinical and research experience on patients with different metabolic disorders, including dyslipidemia, diabetes, obesity, and metabolic syndrome. He is also the Head of the Cardiometabolic Research Laboratory of the Department of Internal Medicine at the University of Palermo. Prof. Rizzo maintains a faculty position in the USA, where he is Adjunct Associate Professor of Internal Medicine at the School of Medicine, University of South Carolina, with a research position in the Division of Endocrinology, Diabetes, and Metabolism. Currently, Prof. Rizzo is on sabbatical leave since he joined Novo Nordisk in 2019 as a Director of the Clinical, Medical & Regulatory Department, Novo Nordisk Europe East and South. Prof. Rizzo sits on the editorial board of 10 international journals. The research work of Prof. Rizzo combines translational and primary research, with 250+ scientific publications in international journals. Finally, Prof. Rizzo has been the Coordinator, Vice-Chairman or Co-Chairman of international expert panel documents in the field of dyslipidemia, diabetes, and metabolic syndrome. He is currently a National Board Member of the Italian Society of Nutraceuticals (SINUT) and Executive Board Member of the Mediterranean Group for the Study of Diabetes (MGSD).",institutionString:"University of Palermo",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Palermo",institutionURL:null,country:{name:"Italy"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"1197",title:"Pharmaceutical Drug",slug:"pharmaceutical-drug"}],chapters:[{id:"68829",title:"Metformin Indications, Dosage, Adverse Reactions, and Contraindications",doi:"10.5772/intechopen.88675",slug:"metformin-indications-dosage-adverse-reactions-and-contraindications",totalDownloads:1351,totalCrossrefCites:0,totalDimensionsCites:2,hasAltmetrics:0,abstract:"Metformin or dimethyl biguanide is the oral antidiabetic drug with the most extensive experience of prescribing in the clinical practice of type 2 diabetes mellitus. In this chapter, we reviewed the indications, contraindications, and adverse drug reactions (ADR) of metformin. The most significant adverse drug reactions of metformin are lactic acidosis, allergies, hypoglycemia, vitamin B12 deficiency, altered taste, and gastrointestinal intolerance. Metformin is contraindicated in severe chronic diseases (hepatic, renal, and cardiac failure) or acute complications of diabetes (ketoacidosis and hyperosmolar state). Metformin is considered by all international guidelines the first-line treatment in type 2 diabetes mellitus (T2DM) together with medical, nutritional therapy. It is one of the most prescribed molecules worldwide. Furthermore, metformin can also be prescribed for other diseases like polycystic ovary syndrome or prediabetes (impaired glucose tolerance/fasting hyperglycemia). Recent studies have shown positive results concerning the use of metformin for cardiovascular or neuroprotective effects; also, several scientific papers are suggesting an antitumor or antiaging effect of metformin. Having such an excellent efficiency in practice, thus predicting its sustainability on the pharmaceutical market, research is directed toward characterizing metformin action on bacteria genera in the gut. Modifying the microbiota composition by pre- and probiotics could improve metformin action.",signatures:"Roxana Adriana Stoica, Diana Simona Ștefan, Manfredi Rizzo, Andra Iulia Suceveanu, Adrian Paul Suceveanu, Cristian Serafinceanu and Anca Pantea-Stoian",downloadPdfUrl:"/chapter/pdf-download/68829",previewPdfUrl:"/chapter/pdf-preview/68829",authors:[null],corrections:null},{id:"71037",title:"New Insight into Metformin Mechanism of Action and Clinical Application",doi:"10.5772/intechopen.91148",slug:"new-insight-into-metformin-mechanism-of-action-and-clinical-application",totalDownloads:1260,totalCrossrefCites:4,totalDimensionsCites:6,hasAltmetrics:0,abstract:"Metformin is the first-line medication for Type 2 diabetes (T2D) treatment, and it is the only US FDA approved oral antidiabetic medication for pediatric patients with T2D 10 years and older. Metformin is also used to treat polycystic ovary syndrome (PCOS), another condition with underlying insulin resistance. The clinical applications of metformin are continuing to expand into other fields including cancer, aging, cardiovascular diseases, and neurodegenerative diseases. Metformin modulates multiple biological pathways. Its novel properties and effects continue to evolve; however, its molecular mechanism of action remains incompletely understood. In this chapter, we focus on the recent translational research and clinical data on the molecular action of metformin and the evidence linking the effects of metformin on insulin resistance, prediabetes, diabetes, aging, cancer, PCOS, cardiovascular diseases, and neurodegenerative diseases.",signatures:"Yun Yan, Karen L. Kover and Wayne V. Moore",downloadPdfUrl:"/chapter/pdf-download/71037",previewPdfUrl:"/chapter/pdf-preview/71037",authors:[null],corrections:null},{id:"68972",title:"Metformin and Its Benefits in Improving Gut Microbiota Disturbances in Diabetes Patients",doi:"10.5772/intechopen.88749",slug:"metformin-and-its-benefits-in-improving-gut-microbiota-disturbances-in-diabetes-patients",totalDownloads:896,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"The human gastrointestinal tract presents a vastly population of microorganisms, called the microbiota. The presence of these microorganisms offers many benefits to the host, through a range of physiological functions. However, there is a potential for these mechanisms to be disrupted condition, known as dysbiosis. Recent results are showing important associations between diabetes and the gut microbiota and how the intestinal flora can influence the prognosis of this illness. Microbial intestinal imbalance has been linked to alterations in insulin sensitivity and in glucose metabolism and may play an important role in the development of diabetes. Metformin is one of the most important and widely used first-line medications for the management of type 2 diabetes (T2D). It is a complex drug with multiple sites of action and multiple molecular mechanisms. In recent years, attention has been directed to other modes of action, other than the classic ones, with increasing evidence of a major key role of the intestine. By analysing the effects of metformin on the homeostasis of the microbiota of diabetes patients, our present topic becomes one of the major importance in understanding how metformin therapy can improve gut microbiota dysbiosis and thus provide a better outcome for this illness.",signatures:"Andra Iulia-Suceveanu, Sergiu Ioan Micu, Claudia Voinea, Madalina Elena Manea, Doina Catrinoiu, Laura Mazilu, Anca Pantea Stoian, Irinel Parepa, Roxana Adriana Stoica and Adrian-Paul Suceveanu",downloadPdfUrl:"/chapter/pdf-download/68972",previewPdfUrl:"/chapter/pdf-preview/68972",authors:[null],corrections:null},{id:"71185",title:"Potential Protective Effects of Metformin on Ocular Complications in Patients with Type 2 Diabetes",doi:"10.5772/intechopen.91263",slug:"potential-protective-effects-of-metformin-on-ocular-complications-in-patients-with-type-2-diabetes",totalDownloads:744,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:1,abstract:"Diabetes mellitus (DM) as a chronic condition is a growing global problem. Its numerous complications, including ocular diseases, affect patients’ quality and length of life. Metformin is an effective, safe, and inexpensive first-line pharmacotherapy for type 2 diabetes (T2D). The current evidence indicates metformin’s multiple sites of action and multiple molecular mechanisms leading to its beneficial impact on metabolism, inflammation, oxidative stress, aging, as well as to its cardiovascular, neurological, bone, and antiproliferative properties. These impacts are the result of its acting on adenosine monophosphate-activated protein kinase (AMPK)-dependent and AMPK-independent pathways. Limited data suggest the protective role of metformin on microvascular ocular complications, including retinopathy, glaucoma, and age-related macular degeneration in patients with T2D. However, to confirm its mentioned protective and therapeutic effects, more large, randomized, double-blind, and placebo-controlled clinical studies are needed.",signatures:"Jasna Kusturica, Aida Kulo, Maida Rakanović-Todić, Lejla Burnazović-Ristić and Sanita Maleškić",downloadPdfUrl:"/chapter/pdf-download/71185",previewPdfUrl:"/chapter/pdf-preview/71185",authors:[null],corrections:null},{id:"69914",title:"Galega officinalis L. and Immunological Status in Diabetes Mellitus",doi:"10.5772/intechopen.88802",slug:"-em-galega-officinalis-em-l-and-immunological-status-in-diabetes-mellitus",totalDownloads:616,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Under diabetes mellitus, the administration of Galega officinalis promotes restoration of leukocyte precursors’ bone marrow pool and normalizes their proliferative activity. This plant protects the functional state of leukocytes by modulating actin cytoskeleton formation and through quantitative redistribution of leukocyte membrane glycoconjugates. Galega officinalis prevents the development of diabetes-associated oxidative stress which results in antiapoptotic activity. The normalization of leukocytes’ proliferative and functional capacity by Galega officinalis, along with its antiapoptotic and hypoglycemic effects, can improve the course of the disease and may prevent the development of complications of diabetes.",signatures:"Mariia Nagalievska, Halyna Hachkova and Nataliia Sybirna",downloadPdfUrl:"/chapter/pdf-download/69914",previewPdfUrl:"/chapter/pdf-preview/69914",authors:[null],corrections:null},{id:"70597",title:"Metformin in Health Issues and Reproductive System",doi:"10.5772/intechopen.90465",slug:"metformin-in-health-issues-and-reproductive-system",totalDownloads:655,totalCrossrefCites:1,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Metformin is one of oldest drug in reproductive medicine era; but most of times it is equal to polycystic ovary (PCO) syndrome especially obese patients. If it is still valuable or not, could have another health benefit or new fertility roles, and could be effective as well in male reproductive system will be discussed. According to increased rate of metabolic disorders and cardiovascular problems and cancers, there are several investigations on this old used drug. Those studies had been magnified its role as “the aspirin of current century,” which might have a promising role in longevity of the life. So, the chapter will be interesting.",signatures:"Elham Pourmatroud",downloadPdfUrl:"/chapter/pdf-download/70597",previewPdfUrl:"/chapter/pdf-preview/70597",authors:[{id:"79982",title:"Dr.",name:"Elham",surname:"Pourmatroud",slug:"elham-pourmatroud",fullName:"Elham Pourmatroud"}],corrections:null},{id:"68621",title:"Metformin and Its Implication in Cancer Therapy",doi:"10.5772/intechopen.88803",slug:"metformin-and-its-implication-in-cancer-therapy",totalDownloads:864,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"Metformin has been used for almost half a century as the first line of treatment for type 2 diabetes. Mechanisms of action are still incompletely known, recent studies have shown that metformin exerts its effects through several mechanisms, including the stimulation of AMP-activated protein kinase, decreasing production of cyclic AMP, inhibition of mitochondrial complex I of the electron transport chain, targeting glycerophosphate dehydrogenase and altering gut microbiota. In recent years, studies have shown that patients with type 2 diabetes mellitus have a lower risk of developing cancer, and patients with cancer and type 2 diabetes have a lower mortality. Experimental studies have demonstrated that metformin has anti-tumor activity by inhibiting mTORC1 signaling pathway and mitochondrial complex, inhibiting tumor growth and proliferation, and inducing cellular apoptosis. There are multiple studies showing that combination of metformin with different types of anti-cancer therapies may reduce toxicities and tumor resistance. This chapter is focused on the progress made in understanding the anti-tumor effect of metformin and its association with cancer therapy.",signatures:"Laura Mazilu, Dana Stanculeanu, Andreea Gheorghe, Adrian-Paul Suceveanu, Irinel Parepa, Felix Voinea, Doina Catrinoiu and Andra-Iulia Suceveanu",downloadPdfUrl:"/chapter/pdf-download/68621",previewPdfUrl:"/chapter/pdf-preview/68621",authors:[null],corrections:null},{id:"71132",title:"Preventive and (Neo)Adjuvant Therapeutic Effects of Metformin on Cancer",doi:"10.5772/intechopen.91291",slug:"preventive-and-neo-adjuvant-therapeutic-effects-of-metformin-on-cancer",totalDownloads:763,totalCrossrefCites:3,totalDimensionsCites:4,hasAltmetrics:1,abstract:"Metformin, the first-line antidiabetic drug, has become an attractive candidate in cancer therapy since retrospective clinical investigations reported that patients with type 2 diabetes receiving metformin had lower incidence of cancer than those with other glucose lowering drugs. In line with this, preclinical studies have demonstrated that the antitumor activity of metformin could proceed through several mechanisms. Thus far, metformin has been used in cancer prevention with reduced risk as consequence and treatment of various cancers as an adjuvant or neoadjuvant drug. Thus, existing data support the beneficial effects of metformin on many types of cancers such as reducing metastasis and mortality and improving pathological responses and survival rates. However, some reports do not support this and even show adverse effects. The discrepancy may be attributed to expression levels of its transporters or genetic background. Hence, this chapter briefly reviews information on the mechanism of metformin action and summarizes both completed and ongoing clinical trials in an attempt to evaluate the value of metformin in prevention and treatment of various cancer types.",signatures:"Yile Jiao, Xiaochen Wang and Zhijun Luo",downloadPdfUrl:"/chapter/pdf-download/71132",previewPdfUrl:"/chapter/pdf-preview/71132",authors:[null],corrections:null},{id:"68869",title:"Metformin in Cervical Cancer: Metabolic Reprogramming",doi:"10.5772/intechopen.88930",slug:"metformin-in-cervical-cancer-metabolic-reprogramming",totalDownloads:864,totalCrossrefCites:0,totalDimensionsCites:0,hasAltmetrics:0,abstract:"The reprogrammed metabolism plays a crucial role in intensively proliferating tumor cells to meet high energetic demands and adapt to metastasis and invasion. Metformin may counteract flexible metabolic phenotype of cervical cancer cells by restraining aerobic glycolysis (Warburg effect) and promoting mitochondrial-based metabolism. Metformin inhibits master oncogene c-Myc as well as hypoxia-inducible factor 1 (HIF-1α) and suppresses its downstream glycolytic regulatory enzymes and glucose transporters. Metformin targets bioenergetics of cervical cancer cells with aggressive phenotype and regulates the expression of enzymes controlling tricarboxylic acid cycle (TCA cycle) supplementation with substrates, glucose, and glutamine. The exposition of cervical tumor cells to Metformin alleviates their migratory capacity, restrains epithelial-to-mesenchymal transition (EMT) program implementation, and elucidates oxidative stress, which results in massive cell death due to apoptosis. The metabolic alterations caused by Metformin are specific to cancer cells. In summary, Metformin exerts antitumor effect in cervical cancer cells by regulating specific molecular targets in reprogrammed metabolism. Metformin selectively modulates metabolic pathways and thus may be potentially used in new precisely targeted therapeutic strategies for cervical cancer.",signatures:"Malgorzata Tyszka-Czochara and Marcin Majka",downloadPdfUrl:"/chapter/pdf-download/68869",previewPdfUrl:"/chapter/pdf-preview/68869",authors:[null],corrections:null},{id:"68916",title:"Antitumoral Effects of Metformin in Ovarian Cancer",doi:"10.5772/intechopen.88911",slug:"antitumoral-effects-of-metformin-in-ovarian-cancer",totalDownloads:870,totalCrossrefCites:1,totalDimensionsCites:2,hasAltmetrics:0,abstract:"In the last years, the antidiabetic drug metformin has received considerable attention in pursuing new drugs for anticancer treatments. Several reports have shown that metformin would have antitumor effects, not only attributable to its systemic effects but also due to direct effects on tumor cells. It has been proposed that metformin could be a suitable alternative for the treatment of gynecological cancers, such as ovarian cancer. This disease is characterized by high cell proliferation and angiogenesis potential, because ovarian cancer cells overexpress most oncogenic molecules including growth factors. The aim of the present chapter is to discuss the molecular mechanism by which metformin would affect tumor cells, with focus on epithelial ovarian cancer.",signatures:"Maritza P. Garrido, Margarita Vega and Carmen Romero",downloadPdfUrl:"/chapter/pdf-download/68916",previewPdfUrl:"/chapter/pdf-preview/68916",authors:[{id:"203972",title:"Prof.",name:"Carmen",surname:"Romero",slug:"carmen-romero",fullName:"Carmen Romero"},{id:"210291",title:"Dr.",name:"Maritza",surname:"Garrido",slug:"maritza-garrido",fullName:"Maritza Garrido"}],corrections:null},{id:"71075",title:"Metformin Activity against Breast Cancer: Mechanistic Differences by Molecular Subtype and Metabolic Conditions",doi:"10.5772/intechopen.91183",slug:"metformin-activity-against-breast-cancer-mechanistic-differences-by-molecular-subtype-and-metabolic-",totalDownloads:869,totalCrossrefCites:2,totalDimensionsCites:3,hasAltmetrics:0,abstract:"Obesity and type 2 diabetes increase the risk of and reduce survival in breast cancer (BC) patients. Metformin is the only anti-diabetic drug that alters this risk, with a reduction in BC incidence and improved outcomes. Metformin has AMP-kinase (AMPK) dependent and independent mechanisms of action, most notably affecting the liver and skeletal muscle. We and others have shown that metformin also downregulates protein and lipid synthesis; deactivates various receptor tyrosine kinases; alters cell cycle transcription/translation; modulates mitochondrial respiration and miRNA activation; targets key metabolic molecules; induces stem cell death and may induce apoptosis or autophagy in BC cells. Many of these anti-cancer effects are molecular subtype-specific. Metformin is most potent against triple negative (basal), followed by luminal BCs. The efficacy of metformin, as well as dose needed for the activity, is also modulated by the extracellular glucose concentration, cellular expression of the glucose transporter protein 1 (GLUT1), and the organic cation transporter protein 1 (OCT1, which transports metformin into cells). This chapter summarizes the diverse clinical and preclinical data related to the anti-cancer effects of metformin, focused against breast cancer.",signatures:"Reema S. Wahdan-Alaswad and Ann D. Thor",downloadPdfUrl:"/chapter/pdf-download/71075",previewPdfUrl:"/chapter/pdf-preview/71075",authors:[null],corrections:null},{id:"70414",title:"Metformin Modulates the Mechanisms of Ageing",doi:"10.5772/intechopen.89431",slug:"metformin-modulates-the-mechanisms-of-ageing",totalDownloads:809,totalCrossrefCites:0,totalDimensionsCites:1,hasAltmetrics:0,abstract:"Living in a time when population is continuously ageing, the challenge and demand for assessing the age-related pathways, potential diseases and longevity have become of major interest. The pharmaceutical industry possesses huge resources in this field, mainly due to the recent discoveries of novel mechanisms of action of old-established, classical drugs. Here we find metformin, a well-established antidiabetic medicine but with new potential benefits, as the most recent reports quote. We present the main pathways of the possible implications of metformin in the modulation of ageing processes, evolution and diseases, focussing on its ageing counteraction, based on the latest scientifically based biochemical reports.",signatures:"Adriana Florinela Cӑtoi, Andra Diana Andreicuț, Dan Cristian Vodnar, Katalin Szabo, Andreea Corina, Andreea Arsene, Simona Diana Stefan, Roxana Adriana Stoica and Manfredi Rizzo",downloadPdfUrl:"/chapter/pdf-download/70414",previewPdfUrl:"/chapter/pdf-preview/70414",authors:[null],corrections:null}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},subseries:null,tags:null},relatedBooks:[{type:"book",id:"9517",title:"Type 2 Diabetes",subtitle:"From Pathophysiology to Cyber Systems",isOpenForSubmission:!1,hash:"8c1eb0e29f87477ff2bc926cc3b695ea",slug:"type-2-diabetes-from-pathophysiology-to-cyber-systems",bookSignature:"Anca Pantea Stoian",coverURL:"https://cdn.intechopen.com/books/images_new/9517.jpg",editedByType:"Edited by",editors:[{id:"243049",title:"Dr.",name:"Anca",surname:"Pantea Stoian",slug:"anca-pantea-stoian",fullName:"Anca Pantea Stoian"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"2509",title:"Recent Advances in Novel Drug Carrier Systems",subtitle:null,isOpenForSubmission:!1,hash:"57c10c8e0b4bb01a815f2c42db01956e",slug:"recent-advances-in-novel-drug-carrier-systems",bookSignature:"Ali Demir Sezer",coverURL:"https://cdn.intechopen.com/books/images_new/2509.jpg",editedByType:"Edited by",editors:[{id:"62389",title:"PhD.",name:"Ali Demir",surname:"Sezer",slug:"ali-demir-sezer",fullName:"Ali Demir Sezer"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"5525",title:"Pain Relief",subtitle:"From Analgesics to Alternative Therapies",isOpenForSubmission:!1,hash:"5ffdba8a1f402fe1b279cf05e2fa0aae",slug:"pain-relief-from-analgesics-to-alternative-therapies",bookSignature:"Cecilia Maldonado",coverURL:"https://cdn.intechopen.com/books/images_new/5525.jpg",editedByType:"Edited by",editors:[{id:"73432",title:"Dr.",name:"Cecilia",surname:"Maldonado",slug:"cecilia-maldonado",fullName:"Cecilia Maldonado"}],equalEditorOne:null,equalEditorTwo:null,equalEditorThree:null,productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"9086",title:"Drug Repurposing",subtitle:"Hypothesis, Molecular Aspects and Therapeutic Applications",isOpenForSubmission:!1,hash:"5b13e06123db7a16dcdae682eb47ac66",slug:"drug-repurposing-hypothesis-molecular-aspects-and-therapeutic-applications",bookSignature:"Farid A. 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\r\n\tThe pipeline system is an integral part of our current civilization. All across the globe, it ensures the economical transmission of essential fluids to different industries, including oil and gas production, food processing, residential and industrial buildings, water supply, pulp and paper mills, pharmaceutical/medical manufacturing, and chemical manufacturing. Pipeline transportation plays a significant role in running the world economy, similar to the contribution of blood vessels in ensuring life. In this background, it is imperative to disseminate a comprehensive understanding of the fundamental and advanced knowledge in various disciplines of pipeline engineering. The successful design, construction, and operation of a pipeline require establishing a balance of production, cost, safety, and integrity. This book intends to provide the reader with a comprehensive overview of the current state-of-the-art in technology, networks, modeling, and management with a specific focus on the most important evidence-based developments in this important area. The exploration of the technological details would competently support the decision-making process.
",isbn:"978-1-83768-000-9",printIsbn:"978-1-83769-993-3",pdfIsbn:"978-1-83768-001-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"a01da9c63fd3825818d1215bd7c283ff",bookSignature:"Dr. Sayeed Rushd, Dr. Mohamed Ismail and Dr. Kofi Freeman Adane",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11928.jpg",keywords:"Welding, Control, Coating, Inspection, Leak Detection, Valves, Oil, Gas, Hydraulic System, Hazard, Modeling, Management",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"May 6th 2022",dateEndSecondStepPublish:"July 7th 2022",dateEndThirdStepPublish:"September 5th 2022",dateEndFourthStepPublish:"November 24th 2022",dateEndFifthStepPublish:"January 23rd 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"a month",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"An active researcher in different fields, including pipeline engineering, computational fluid mechanics, artificial intelligence, and separations processes, and a member of the society of petroleum engineers (SPE).",coeditorOneBiosketch:"Dr. Mohamed Anwar Ismail is involved in multiple research projects in pipeline engineering, biomass combustion and pyrolysis, fire dynamics, renewable energy, and emission reduction from diesel engines. 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He obtained his BSc in Mechanical Engineering from the University of Science & Technology, Ghana, in 2000, and MSc (2005) & Ph.D. (2009) in Mechanical Engineering from the University of Manitoba, Winnipeg, where he specialized in heat transfer and fluid engineering.",coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"267670",title:"Dr.",name:"Sayeed",middleName:null,surname:"Rushd",slug:"sayeed-rushd",fullName:"Sayeed Rushd",profilePictureURL:"https://mts.intechopen.com/storage/users/267670/images/system/267670.jpg",biography:"Dr. Sayeed Rushd is an Assistant Professor in the Department of Chemical Engineering at King Faisal University, Saudi Arabia. He obtained his Ph.D. in Chemical Engineering from the University of Alberta, Canada. In addition to teaching, Dr. Rushd is heavily involved in multiple research projects in the fields of pipeline engineering, dynamics of multiphase-flows, rheology, water treatment, and desalination. He has authored or co-authored more than thirty-five technical papers. He works as a reviewer of different reputed journals, such as Chemical Engineering Science, Engineering Applications of Computational Fluid Mechanics, Journal of Petroleum Science and Engineering, and Journal of Clean Production. 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They are derived from glial cells. They are the most common cause of solid tumors in the intracranial space in children [1]. Nearly 70,000 new cases of malignant primary and benign brain tumors of the central nervous system (CNS) are diagnosed in the United States each year. Of these, approximately 28% are gliomas, and 36% are meningiomas. Gliomas represent 80% of the primary malignant brain tumors. The incidence rates of brain tumors have increased in the last three decades. For all CNS tumors, of which brain tumors account for approximately 88%, the average annual incidence rate adjusted for age (2006 to 2010) for women (22.8 per 100,000) is higher than for men (19.1 per 100,000) [1, 2].
According to the World Health Organization (WHO) classification of brain tumors, they are divided into gliomas of the low and high degree of malignancy. Low-grade gliomas - I and II, are represented by pilocytic astrocytoma, diffuse glioma, and gemistocytic astrocytoma. They have a benign clinical course with a long survival time. High-grade gliomas, anaplastic astrocytoma (grade III) and glioblastoma multiforme (grade IV), are characterized by a rapid growth rate, extensive white matter infiltration, and poor short-term prognosis [3, 4]. Therefore, the histopathological diagnosis and its proper classification are crucial for treating patients. Diffuse astrocytoma (WHO grade II) is characterized by slow growth and infiltration of neighboring brain structures Figure 1 [5, 6, 7].
Intraoperative cerebral edema during emergency surgery in a patient with neurological deterioration secondary to a brain tumor bleeding.
In pediatric patients, the central nervous system’s tumors represent the second cause of cancer mortality after leukemia. The magnetic resonance imaging technique renders the integration of different structural images (FLAIR, diffusion, perfusion, SPGR, TRUFFI), functional aspects (DTI, BOLD), and metabolic profile (spectroscopy). They evaluated peritumoral edema by diffusion and perfusion sequences [8, 9]. The use of sequences that provide functional information allows the early identification of the risks associated with neurosurgical treatment and each case’s functional prognosis [10]. Some reports show a characteristic uptake pattern for the degree of malignancy of different neoplasms. In the case of primary tumors of the CNS, significant alterations can be observed in the uptake of glucose, methionine, and tyrosine. One of the technological resources that have changed the treatment of patients with CNS neoplasms is neuronavigation.
The radiological evaluation of brain tumors makes it possible to identify the structural, functional, and metabolic characteristics of neoplastic lesions and, for prognostic purposes, their relationship with healthy brain tissue by combining diverse image acquisition techniques.
The MRI imaging modalities currently used in presurgical planning for brain tumor resection are functional magnetic resonance imaging (fMRI), diffusion tensioner (DTI) imaging, diffusion tension tractography, and BOLD [2].
The diffusion tensor images allow the visualization and characterization of white matter tracts [11, 12, 13]. DTI images have been used to study the architecture of white matter and the integrity of normal and diseased brains. This magnetic resonance technique is based on the general principle that the anatomical microstructure directs water diffusion, being an echo-planar technique that maps the diffusion speed [14]. In brain tissue, diffusion rates are slower due to the typical parenchyma components that impede water movement. In specific pathological processes, water diffusion is restricted, which reduces the apparent diffusion coefficient (ADC), as in acute infarcts secondary to cytotoxic edema, abscess, lymphoma [12, 15]. Fiber tracking is the only non-invasive method to visualize the course, displacement, or interruption of white matter’s main tracts according to the DTI technique. Multiple studies have shown that fiber tracking can reconstruct white matter’s major fiber structures in the brain. Identifying the tracts is done by defining a rectangular interest volume (VOI) in the registered standard T1 anatomical datasets. A fast acquisition gradient echo sequence prepared with 3D magnetization weighted in T1 is used to acquire the images. T2-weighted images are acquired, inversion recovery images attenuated by T2 fluid, and 3D images weighted in T1 postcontrast are scanned. Intraoperative examinations are performed immediately when the operator considers that the lesion has been resected or intraoperative exploration was necessary to correct the cerebral displacement. For DTI, applies a sequence of echo-planar images weighted by spin-echo diffusion of a single shot (echo time, 147 milliseconds, repetition time, 9400 milliseconds, matrix size, 128 × 128, the field of view, 251 × 251 mm, the thickness of cut, 3 mm, bandwidth, 1502 Hz per pixel, diffusion encoding gradients in 12 directions with b values of 0 and 1000 s/mm2, and voxel size, 1.9 × 1.9 × 3 mm) [12, 13, 16]. The 3D segmental reconstruction of the tumor is performed based on the high-resolution 3D postcontrast anatomical data set.
In the case of tumors with high uptake of contrast medium - glioblastoma multiforme, metastasis, the edge of the outermost lesion that enhances post-contrast, for example, glioblastoma, and the edge of hyperintensity or mixed hypointensity in the lesion, such as the non-malignant entity, cavernoma, represented the limit of segmentation. In non-enhancing lesions such as low-grade glioma, the T2-weighted image is used to determine the tumor’s edge. For this reason, most tumors that do not have post-contrast enhancement have optimal visibility in this sequence. The existence of significant edema, which cannot be clearly distinguished from the low-grade glioma, was ruled out based on the findings of inversion recovery images with T2 fluid. The segmentation of the tumor is performed by cutting in a mode of 3D anatomical data. After profiling all the sections that contained the lesion, the three-dimensional reconstruction of the lesion was performed [13].
The techniques of DTI and tractography have overcome this obstacle and are now widely used to study the white matter in vivo. Diffusion images calculate the local direction of white matter from water diffusion measurements. Tractography takes this a step further to evaluate the functional connection between several different areas inside the same or contralateral hemisphere. The identification of water molecule’s movement in all directions is known as isotropic diffusion. In the central nervous system, anisotropic diffusion is used to define water’s movement in a parallel sense in the withe matter tracts defined by axons’ groups. Thus, creating maps of movement of water that define the structure and orientation of with matter tracts [2, 3].
Three-dimensional visualization of white substance fibers, such as the corticospinal (pyramidal) tract, corpus callosum, cerebellar peduncles, optical radiation, and arcuate fascicle, is of great value at the preoperative evaluation and intraoperative navigation Figure 2 [4].
3D reconstructions for white matter tracts with DTI-MRI technique. (A) Thalamic high-grade glioma and his relationship with the pyramidal tract. (B) Parasagittal meningioma and its relationship with corpus callosum and pyramidal tract. (C) Supratentorial Ependymoma and its relations with Corpus callosum. (D) Fourth ventricle tumor and middle cerebellar peduncle displacement.
There are three main techniques for perfusion imaging: T2 * enhanced dynamic magnetic susceptibility enhanced perfusion in T1-enhanced dynamic contrast, and arterial spin marking techniques, involving repetitive serial images through the tumor during blood passage been marked with contrast material. Theoretically, the degree of a signal drop is proportional to the concentration of gadolinium in the tissue, obtaining relative curves of concentration - time. Dynamic contrast images weighted in T1, where the main focus is estimating tumor permeability, allow the contrast to filter into the extravascular space and reach equilibrium during multiple contrast bolus passes through the tumor bed. An arterial spin is a form of perfusion without the use of intravenous contrast; a powerful magnetic gradient is applied to the blood inlet to reverse the magnetization, effectively labeling the blood that flows upward, have impeded its application for long periods of imaging and decrease in spatial resolution compared to gadolinium [16]. Different types of tumors and grades differ in their perfusion characteristics. For example, there is a strong correlation between the degree of astrocytoma and the relative measurements of cerebral blood volume (CBV) [17]. However, low-grade astrocytomas tend to have a high cerebral blood volume, associated with the process of angiogenesis and dense capillary networks that characterize these tumors.
It provides an analysis of the different metabolites in a delimited area within the brain and may be useful in the initial diagnosis of brain tumors. It can be done with a single voxel technique, in which a single spectrum is produced for a tissue volume, or a multivoxel technique, in which a greater volume of tissue is evaluated [18]. The primary metabolites evaluated include N-acetyl aspartate (NAA) (typical neuronal marker), choline (cell membrane marker), creatine (energy marker), lactate (metabolic acidosis), and lipids (tissue breakdown and cell death). The spectral patterns of intracranial neoplasms vary significantly due to differences in tumor types and grades. However, most CNS tumors manifest with elevated choline-creatine and co-NAA ratios caused by increases in cellularity (choline elevation) and a relative decrease in normal neurons (reduction of NAA).
Functional MRI (fMRI) mapping of eloquent language cortex in patients with brain tumors after surgery is feasible and may serve as a useful reference assessment for preoperative neurosurgical planning [19].
Functional magnetic resonance imaging (MR) is an advanced tool for studying brain functions in healthy subjects and neuropsychiatric patients, identifying and locating specific metabolism and neural activity phenomena [20].
BOLD is a measure of changes in oxygenated and deoxygenated blood proportion during a particular paradigm’s execution. The most commonly mapped functions during functional MRI studies include motor, auditory, somatosensory, visual perception, and language production and comprehension. When evaluating motor centers, typical tasks include tapping with fingers, pouting with lips, and flexing and extending toes [21]. Patients with mild to severe motor paresis of the hand may clench their fists instead of tapping with their fingers.
Several reports mention that a silent area around a brain tumor could recover his eloquence after the surgical resection of malignant tissue [22]. There is a latency of several seconds in the signal change observed in BOLD images, making the temporal resolution of functional MRI poor compared to other techniques such as DES or electroencephalography [23]. Because of the “delay of hemodynamic response” given the time required for the production and diffusion of vascular signal substances to dilate the vascular bed and cause a deoxygenated hemoglobin wash. Another consideration is that BOLD fMRI does not directly measure neural activity but changes in the region’s hemodynamic properties. So, the variability between functional localization among subjects may result from physiological differences in the BOLD signal without differences in neuronal activity per se. It has been found that several pharmacological agents may influence the BOLD signal [24].
The use of fMRI in conjunction with DTI for presurgical planning is currently the most established clinical application of these neuroimaging techniques. The aim is to provide the surgeon with functional information about the tumor’s area and its connections to adjacent areas. The regions of interest can be defined anatomically. However, the advance of functional imaging techniques allows us to define white matter tracts more precisely. Some reports mention that it is reliable in healthy ones but maybe inaccurate in those who harbor brain injuries Figure 3 [21].
The utility of fMRI and tractography for surgical planning. An 8-years-old boy presents at the emergency unit with a history of intermittent language disturbances and right-hemiparesis. fMRI (language paradigm) and DTI (Pyramidal tract, Corpus callous, Arcuate fascicle) images were performed. A 3D reconstruction at the Brainlab neuronavigation station was performed. (A) Pyramidal tract reconstruction and his relationship with a neoplastic lesion (Yellow) and language areas visualized with fMRI (Red). (B) Arcuate fascicle reconstruction and language areas and their relation to the neoplastic lesion. (C) 3D reconstruction of arcuate fascicle (Yellow), language areas (Red), and neoplastic lesion (Cyan).
In Mexico, PET positron emission tomography equipment began with opening the PET-Cyclotron Unit of the National Autonomous University of Mexico in 2002. We use nuclear medicine to determine the degree of malignancy of the lesions, evaluate the response to treatment, identify early recurrence, and radiotherapy planning.
By obtaining functional information of cellular and biological processes like glucose metabolism, protein synthesis, the PET with 18 fluoro-deoxy-glucose (FDG) PET was initially used to detect and distinguish tumors of a low and high degree of malignancy. 18 Fluoro-ethyl-tyrosine (18 F FET) evaluates the metabolism of amino acids. It provides well-contrasted images in both high and low-grade tumors. It is beneficial to take biopsies guided by image to establish a primary brain tumor diagnosis in the planning of radiotherapy treatments and distinguish between tumor recurrence or radionecrosis after initial therapy Figure 4 [4].
MRI and PET/CT 18F -FET fusion for brain tumor recurrence resection.
It has a sensitivity of 94% and specificity of 88% for the diagnosis of brain tumors. Although the 18-FDG and 18-FET quantitative parameters allow the distinction between low and high-grade tumors, only the 18-F FET values can distinguish between tumor and non-tumor lesions, confirming the superiority of 18-F FET over 18 FDG for the characterization of brain lesions. Since 18-FDG is unreliable for predicting the neoplastic nature due to absorption by inflammatory lesions, amino acid tracers such as FET have been developed in recent decades to increase specificity. However, to date, only a few studies limited to small population of patients compared the diagnostic value of 18-FDG and 18-FET. Goldman and Pirotte thoroughly reviewed the clinical management, images, and PET role [25].
On average, glioblastoma multiforme and medulloblastoma had a uniform and intense uptake throughout the tumor, while brainstem gliomas had a low uptake in less than 50% of the tumor and ependymoma had a low uptake throughout the tumor. When more than 50% of the tumor had uptake, the apparent diffusion coefficient was lower, which agrees with the increase in cellularity. In refractory/recurrent brain gliomas, the low correlation between uptake and enhancement is associated with decreased patient survival. It may reflect concurrent tissue degradation in the disease sites that received treatment and the development of new malignancy sites characterized by increased uptake of 18-F-FDG [26, 27].
The PET/MRI fusion tool in evaluating postoperative and radiooncological treatments provides information for tumor response, progression, and necrosis by radiation, affording the patients’ oncological and functional prognosis Figure 5.
The utility of Multimodal Neuronavigation for brain tumor resection. A 15-years-old girl was received with a history of left hemiparesis and tonic–clonic seizures. MRI was performed, and a low-grade glioma was suspected. DTI sequences were obtained. A PET-CT 18F-FET was obtained, and fusion with structural and DTI images was performed at the Brainlab workstation. (A) Structural MRI, 18F-FET PET-CT, and DTI for pyramidal tract were fused during neuronavigation planning. (B) Right, Transoperative 3D ultrasonographic images were obtained and fused with the previous neuronavigational plan. Left, Histopathological analysis reveals a diffuse glioma. (C) At 48 months of follow-up, a new 18F-FET PET-CT was performed, no metabolic activity was detected.
Neuronavigation systems provide intraoperative guidance to the surgeon. Nevertheless, its real advantage is also to help them plan a proper surgical approach to avoid injury and incorporates functional data provided by preoperative images of magnetic resonance imaging, nuclear medicine, intraoperative sonographic studies, and in some places, magnetoencephalography (MEG) to prevent damage to eloquent areas during brain surgery [1].
Image-guided neuronavigation uses the principle of stereotaxy. The brain is considered a geometric entity divided into three imaginary spatial planes that intersect, orthogonal to each other (axial, coronal, and sagittal). Theoretically, any point within the brain is designated by a specific series of coordinates in each plane.
Neuronavigation platforms provide the unique opportunity to translate the two-dimensional information obtained from several imaging techniques – CT scan, MRI, fMRI, PET-CT, into 3D information in the patient’s brain of a computational interface at the operating room [16]. The predefined targets on the navigational plan increase the chance to perform a safe and functional gross total resection of malignant primary brain tumors.
Its main objective is to facilitate the extensive resection of the lesion, minimize the risk of neurological sequelae, and favor the prognosis of survival. After registering the patient, the system’s accuracy is checked by identifying constant anatomical references or craniometric points. The contour of the lesion and the functional data are fused on the reference structures. In some cases, it is possible to transfer the images to the surgical microscope’s eyepieces during surgery.
The intraoperative accuracy of neuronavigation can be affected by changes in intracranial volume caused by tumor resection, brain inflammation, and cerebrospinal fluid flow Figure 1. Nevertheless, transoperative images can be combined with ultrasound, tomography, or magnetic resonance images. The intraoperative images offer the possibility of evaluating the residual tumor volume as the surgery progresses Figure 6.
3D intraoperative ultrasonographic reconstruction increases the usefulness of multimodal neuronavigation for brain tumor resection. A 17-years-old boy with a history of neurofibromatosis type 1 arrives at the emergency department with a headache and left hemiparesis. On an MRI study, a glioblastoma multiforme was suspected.
Neuronavigation is currently applied in brain surgery, and it is a regular technological resource to increase safety in most neurosurgical procedures (27).
The functional navigation was described as a technological tool for brain tumor resection. It results from the merging of structural, DTI, and BOLD information concerning a malignant tumor’s localization. It allows us to know the precise location of functional areas in the human brain [28].
Clinical articles have suggested that the brain shift observed after the opening of the dura and cerebrospinal fluid depletion is the main disadvantage for neuronavigation precision. Nevertheless, several reports suggest that intraoperative MRI use can solve this consequence of brain displacement satisfactorily [29]. In our country, these facilities are not available. To solve it, we correct the brain shit with three-dimensional ultrasound (3D-US) scans before the dural opening, after the dural opening, and at the end of the resective surgery. Taking advantage of merging this new 3D-US information with previously developed navigation plans with information on the different modalities of structural, functional, and metabolic information tumor and the neighboring tissue. In order to preserve and restore the functional status of each patient. Some limitations to consider for applying these techniques are the biological variability among individuals, the displacement of deep brain structures, and the previously mentioned brain-shift.
Prof. Hugues Duffau considers the brain as an entirely eloquent organ; every millimeter of the cerebral cortex represents, sometimes a well-recognized function, and others the association area for several complex functions as language and his diverse characteristics that sometimes define a person, visuospatial perception, auditive integration, and so forth.
In the pediatric patient, the patient’s age determines a more complex scenario because the stage of neurodevelopment at the time of brain tumor surgery determines the functions’ profile to evaluate. Some functions depend on the correct integration of cortical and subcortical areas in the developing brain. Thus, the extensive evaluation and integration in neuronavigation devices of structural, functional, and metabolic imaging techniques are essential to reduce the chance to produce functional sequels.
Undoubtedly, DTI has contributed substantially to the intraoperative identification of withe matter tracts. Perhaps the most studied are those related to motor function. It has been widely described that subcortical continuous monopolar stimulation can help identify the pyramidal pathway with a comprehensive concordance with its counterpart visualized by DTI.
Transoperative electrical stimulation is one more of the resources available to promote extensive glioma resection. The purpose is to preserve the patient’s functionality while attempting to dry out as much of the injury as possible [30].
In our experience, the integration of neuronavigation with intraoperative electrical stimulation and brain mapping considerably reduces the risk of lesions secondary to brain tumor resection.
Monopolar continuous stimulation seems to be the most useful and reproducible procedure for the pyramidal tract’s subcortical characterization. With the aid of DTI, it is possible to identify the modifications preoperatively in the trajectory, density, and resultant distortion secondary to a CNS malignancy. The neuronavigation plan defines precisely the location of the pyramidal tract. In the operative field, the neuronavigation tools and the intraoperative monopolar stimulation can effectively identify its location at subcortical, thalamic, and peduncular regions.
Recently advances suggest that intraoperative acquisition of DTI images can reduce the risk of sequelae.
The current neuronavigational technologies allow us to reach deep regions inside the human brain without an increased risk of disability.
The interrelation of different radiological information modalities – structural, functional, and metabolic, in the planning phase of the case and during the surgical procedure permit us to increase the gross-total resection rate for brain tumor resection.
The integration of neurophysiological information into the neuronavigational platform during the neurosurgical procedure reduces complications by monitoring and stimulating withe matter tracts related to language and motor functions.
All multidisciplinary effort is directed to increase surgical techniques’ safety to benefit the quality of life of children who suffer from brain tumor disease.
Many people have changed my life, mom, sister, wife, son, and teachers. We acknowledge the incredible patient’s confidence; thank you for touching my life, by improving yours.
This work is dedicated to respect and honor relatives and all medical staff members who fell during the COVID-19 pandemic.
“The authors declare no conflict of interest.”
In very recent educational literature, Covid 19 is most frequently represented as a ‘game changer’ [1]; seriously disruptive of schooling as we have come to know and recognise it, while hastening clarion calls for reform of the status quo [2, 3, 4, 5, 6]. Notwithstanding the import of the word ‘pandemic’, throughout the twentieth century, there have been repeated cries of ‘crisis’ in education, ‘A Nation At Risk’ [7] comes to mind, pre-dated by the ‘Sputnik’ (1957) shock (see [8]), perhaps foreshadowing more contemporary pre-occupations with STEM, and more recent systemic tremors in the form of ‘PISA shock’ [9] as it impacted in Germany, and elsewhere. Perhaps, more than many other research ‘Powerful Reforms and Shallow Roots’ [10] captures the manner in which repeated efforts at systemic reform have failed to ignite the radical change that was envisaged [11]. Rather, such efforts, frequently flounder on the rocks of school realities, while repeatedly re-learning that attempting ‘teacher proof’ curricula as a means of bypassing teacher competence and capacities, thus providing a short cut to ‘school improvement’ seeks to downplay or ignore the recurring lesson that ‘teachers matter’ [12], and are most likely to be central to educational processes into the future. There are compelling reasons for this that provide solid ground on which to build the argument presented in this chapter.
First, the pandemic (still with us) has very definitely reinforced the message that ‘home schooling’ when combined with ‘working from home’ is not a sustainable ‘bargain’ between the public and the state; schooling in various forms will need to be sustained into the future. Thus, while flexible working from home arrangements are likely to continue after various vaccines ride to the rescue, respect for teachers, and what schooling in general manages to achieve, has been enhanced in the eyes of parents and public, and maybe even policy-makers. Second, while versions of ‘lockdown’ necessitated that schools go online, with varying degrees of success, in general, teachers have had to get to grips with technologies to an unprecedented extent, extended by higher education institutions that provide professional support to the profession online, thus ‘alien’ technologies have become familiar to many; a benefit that provides experience on calibrating the use and effectiveness of various platforms for student engagement, teaching, learning and leading—spawning ongoing reflection and debate. Yet, these actual and potential benefits have made all concerned yearn for face-to-face interactions, formal and informal, as the lifeblood of communication, community, and holistic education. Third, these recent experiences have increased awareness of inequalities due to concern regarding access to: hardware, software, as well as quiet spaces for work and learning, providing further evidence of the necessity for schools as ‘safe havens’ of challenge, respect and caring. Fourth, such considerations have accentuated the necessity to revisit schooling as a ‘public good’ [13], something to which Governments need to be committed, providing sustained and adequate resources and in the process, preventing those who see the potential of technologies for profit and the privatisation of teaching and learning, thus exacerbating rather than diminishing inequalities that, in recent years, have been shown repeatedly to have increased [14]. While we readily recognise that, at a time of rapid change, predicting the future has never been more precarious, it is essential to salvage from past and present ‘bricolage’ [15] as the building blocks of possible futures. Thus, we ask: What pedagogical repertoires provide the most likely prospect of achieving and sustaining educational development goals?
Two eminent economists recently stated that “a healthy society is a vast web of cooperative activity sustained by mutual kindness and obligations” [16]. After decades of neoliberalism, some strains more virulent than others, there has been a considerable rise in ‘
Responsibility | Accountability |
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based in professional mandate situated judgement trust moral rationale internal evaluation negotiated standards implicit language framed by professions relative autonomy and personally inescapable proactive | defined by current governance standardised by contract control economic/legal rationale external auditing predetermined indicators transparent language framed by political goals compliance with employers’/ politicians’ decisions reactive |
The types of logic and implications of professional responsibility and accountability [18].
This categorisation recognises that accountability language and logic espouses the market assumptions and norms, whereas the language and logic of responsibility include degrees of relative autonomy and professional judgement. As part of our value stance in dealing with the tensions created by these competing and contradictory logics we recognise that it is possible to be accountable while not behaving in a professionally responsible manner; there is a moral dimension to the latter that, for an individual and a member of a profession, is inescapable. Additionally, while asserting that public good should prevail over private gain, from a professional responsibility perspective, it is necessary to recognise that “decision-by-rulebook intentionally eliminates judgement based on tacit knowledge”, something that is part of the lifeblood of the teacher-learner encounter [16]. We are obliged to be accountable, this is inescapable, while behaving in a professionally responsible manner is a choice, an inescapable responsibility as professionals. Sustainable futures, even pedagogical futures, depend upon it. Sustainable development necessitates doing things differently to avoid the inadequacies of previous initiatives, while remaining open to the possibilities of what sustainable futures may look like. Moreover, education for sustainable development (ESD) is an approach to education that requires changes in knowledge, skills, values and attitudes to enable a more just and sustainable society for all [19].
National educational policies are part of a wider international framework which requires states to respond to the challenges of the 21st century. Obligations arise from the United Nations Framework Convention on Climate Change (UNFCCC) that was established in 1994 and the adoption of the Sustainable Development Goals (SDGs) by 193 United Nations (UN) member states in 2015 [20]. Education for sustainable development is also supported by international policy initiatives such as the Organisation for Economic Co-operation and Development’s (OECD)
For the purposes of this chapter, we draw on qualitative research that involved a content analysis of the education policies of the OECD and UNESCO since 2014, the year that marked a decade of education for sustainable development [19], while also drawing on international literature and other related empirical work of the authors [13, 26]. This provided a backdrop to the evidence-based recommendations on the future of education by such think tanks as the World Economic Forum [27], the World Bank [28] and the Economists Intelligence Unit, [29]. While the aforementioned are all economic agencies, pre-occupied with preparation for the world of work, rather than providing a ‘good’ education they are influencing education policy on a global scale by publishing recommendations on pedagogical approaches required for 21st century schooling. Themes discussed below have emerged from a meta-analysis of documents selected from searches undertaken using various combinations of key words such as: trends facing education, education for sustainable development, 21st century skills, digital technology in education and 21st century teacher competencies. The most prominent of these documents are summarised in Table 2 and are included in the reference list. A systematic examination of these policy documents revealed a number of recurring considerations as pivotal triggers for change in education and the expectations regarding teachers’ capacity and competencies within this reform agenda.
Year | Organisation | Title | Reference |
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2014 | UNESCO | Shaping the Future We Want - UN Decade of Education for Sustainable Development | [19] |
2015 | United Nations | Transforming Our World: The 2030 Agenda for Sustainable Development | [20] |
2015 | UNESCO | Global Citizenship Education | [22] |
2015 | OECD | Students, computers and learning: Making the connection | [30] |
2015 | OECD | Education policy outlook 2015: making reforms happen | [31] |
2017 | OECD | Education for Sustainable Development | [23] |
2018 | OECD | Global Competency for an Inclusive World | [21] |
2018 | OECD | Education 2030: The future of education and skills | [32] |
2018 | UNESCO | ICT Competency Framework for Teachers V03 | [33] |
2019 | OECD | Trends Shaping Education | [34] |
2019 | UNESCO | Education for Sustainable Development. A roadmap | [35] |
2019 | OECD | TALIS 2018 Results (Volume I): Teachers and School Leaders as Lifelong Learners | [36] |
2019 | World Bank | World Development Report 2019: The Changing Nature of Work | [28] |
2019 | The Economist Intelligence Unit | Worldwide Educating for the Future Index 2019: From policy to practice | [29] |
2020 | OECD | PISA 2018 Results (Volume VI): Are Students Ready to Thrive in an Interconnected World? | [37] |
2020 | World Economic Forum | The Future of Jobs Report | [27] |
Chronology of salient policies analysed as part of this study.
Using inductive analysis, three main pedagogical themes emerged from the research, teachers’ capacity for: a) adaptive expertise and collaborative practice; b) technology enhanced learning and c) the fostering of 21st century skills, while these are considered through the lens of accountability-professional responsibility and sustainable development. Analysis here gains in significance by providing in-depth scrutiny of policy content, not for the purposes of generalisation, but rather to influence future deliberations on policy and practice as a contribution to shaping possible futures, in an open-ended rather than a prescriptive manner, leaving room for other voices as to how such policy items may be tailored to particular needs, while seeking to build and expand pedagogical repertoires through practical know how, thus sustaining development.
There are many ‘trends’ shaping education including: increasing global population climate change, pressure on living space for humans, increased risks of pandemics, income inequality, globalisation, and increased pervasiveness of technology in our lives all of which demand a systemic and rapid response from education systems all around the world [34]. UNESCO is entrusted to lead and coordinate the
I. Supportive Environment | ||
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Structures of Effective Caring | Classroom Learning Communities | Connections among staff and families |
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Student-centred Instruction | Conceptual Understanding and Motivation | Learning how to learn |
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Integration of Social Emotional Skills | Development of Habits and Mindsets | Educative and Restorative Behavioural Supports |
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Multi-tiered systems of support (MTSS) | Coordinated access to integrated services | Extended learning opportunities |
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Practices aligned with the science of learning and development. Adapted from [38].
Making the most of these advances, however, requires assimilating insights across multiple fields and connecting them to knowledge of successful approaches that are emerging in education [38]. Enabling teachers to acquire ‘adaptive expertise’ or ‘adaptive competence” required to apply meaningfully learned knowledge and skills flexibly and creatively across different contexts in a globalised society [39] is important and will require teachers to work with other stakeholders. This is not a new concept however, and there is a considerable literature that recognises the importance of ‘improvisation’ as an integral dimension of the teaching-learning encounter [40]. More than a century ago, Dewey [41, 42] not only re-conceived the way that learning should happen, but also the role that the teacher should play in the process of learning [43, 44]. For Dewey, it is not enough for the classroom teacher to be a lifelong learner of the techniques and subject-matter of education; they must aspire to share what they know with others in their learning community [45]. Freire [46], like Dewey, believed that each student should play an active role in their own learning, instead of being the passive recipients of knowledge. Consequently, both authors are in agreement that the ideal teacher would be open-minded and confident—confident in their competence while also open-minded to sharing and learning from his or her students [47]. A recent study by Farrell and Marshall [26] in the context of initial teacher education (ITE) found that some student teachers’ use of digital pedagogy toppled the typical co-operating teacher/student teacher hierarchy, placing the student teacher as mentor to the co-operating teacher. This was particularly true of the recent move to remote learning as a result of Covid 19. The pandemic is also a powerful reminder that education plays a significant role in facilitating not just academic learning, but also in supporting physical, social and emotional well-being. The key, in these instances, is a willingness to collaborate for mutual gain, thus building pedagogical capacity, as well as enhancing pedagogical repertoires through adapting technologies.
Balancing traditional forms of education and learning with wider social and personal development means new roles for all involved in education while seeking simultaneously to provide a holistic education, frequently against the grain of external policies more pre-occupied with preparation for the world of work. Such challenges necessitate melding the old with new, a multi-disciplinary approach to education and requiring “Democratic Pedagogical Partnership” whereby “formal but flexible arrangement between teacher educators and stakeholders who engage in ‘collaborative professionalism’ improve learning for all students in a variety of contexts through effective pedagogy and practice” [48]. One of the four Common European Principles for Teacher Competences and Qualifications [49] is that teaching is a ‘profession based on partnership: institutions providing teacher education should organise their work collaboratively in partnership with schools, local work environments, work-based training providers and other stakeholders” In further recognition of the role of partnerships in education, the Council of the European Union [50] observes that:
Teacher education programmes should draw on teachers’ own experience and seek to foster cross disciplinary and collaborative approaches, so that education institutions and teachers regard it as part of their task to work in cooperation with relevant stakeholders such as colleagues, parents and employers.
In support of this, the OECD [31] advocates that partnerships are central to the fostering of innovative teaching and learning-communities in which there is a bridge between theory and practice and between practitioners and those engaged in academic research. Making this rhetoric a reality will be a challenge even in the most advanced economies. Culture and context matter along with access to the continuing professional development of teachers [36]. Therefore, if governments are to harness the potential of education to have a positive impact on sustainable development, they need to invest in cultivating the most accomplished aspects of pedagogy that exists and can be enhanced by the transformative digital technology increasingly at our disposal. It will be difficult to achieve, and, in the first instance, it will be necessary for the research and policy communities, even in the most advanced economies, to address why pedagogical reform failure, reform fatigue or overload, are getting in the way of more sustainable transformations, more rooted in teacher-learner engagement, and the efforts necessary to overcome such challenges.
As indicated above, the Covid 19 pandemic has lent renewed urgency to being adaptive, while also extending pedagogical repertoires to embrace the potential offered by various technologies. More generally, the rapid pace of change and challenges facing the 21st century provides opportunities “and a window for action, as evidenced by the power of digitalisation to transform, connect and empower” [34]. Digital technology is playing a pivotal role in the development of modern economies and societies. This has profound implications for education, both because digital technology can enable new forms of learning and because it has become important for young people to master digital technology in preparation for adult life [37]. While schools are key sites for the building of adaptive competences [51], including the competences to embed digital technology in teaching, learning and assessment [33], a recent OECD report [30] notes that “the reality in our schools lags considerably behind the promise of technology.” While there is an expectation that teachers are proficient in the use of digital technology, in teaching, learning and assessment, the reality is that this is not always the case [52]. Provision of continuing professional development for teacher educators [53] is fundamental to developing digital competence, as is collaboration with leading experts including those from industry [54].
In order to develop a coherent professional learning plan for teachers, it is import to establish an agreed framework for digital competences that teachers need in order to harness the potential of digital technology in teaching, learning and assessment. However, given the pace of development of evolving technologies, this too is a tall order. McGarr and McDonagh [55] synthesised digital learning frameworks from around the world into a four-part model encompassing Technical skills, Pedagogical skills, Cyber-ethics and Attitudes (PEAT) (see Figure 1 below).
Synthesised model of teachers’ digital competence – The PEAT model [
Their model encapsulates the necessary technical, pedagogical and ethical competencies that are required for teacher education in the 21st century. According to Brox [57] there is currently a narrow utilitarian adoption of technology by teachers and she argues that “teacher education should encourage a deeper understanding of technology, in which both human and technological agency are explored and problematized”. Tsvetkova and Kiryukhin [58] assert that there is.
…a triad of digital competencies that create a stable structure for their development including: Vital (custom) digital competencies that enable teachers to keep up with the world of digital devices and services; profile and professional competencies that will determine the adaptability and success in the conditions of digitalization of professions and social digital competence of citizens that will help to preserve our delicate world on the principles of humanism and creative development of our children, to avoid atomisation of digital society.
Digital enhanced learning is an ambitious agenda and in the absence of time, resources and continuing professional development teachers are in danger of becoming scapegoats for lack of progress in this regard. Additionally, by focusing on a more technicist approach to skills, there is an underlying assumption that these are easily grafted on to teachers’ existing pedagogical repertoires, when there are more fundamental epistemic and identity considerations in play that take time to ferment as part of transforming not only the knowledge base of teaching that is crucial also forging 21st century teacher identities.
Another aspect of this challenge is equality of access to adequate infrastructure to support digital enhanced pedagogy. There is a case to be made for broadband to be made a public good if all education stakeholders are to have parity of access to digital enhanced learning opportunities. A further concern is the influence of the corporate sector that is currently filling the gap in continuing professional development by providing free online courses to teachers who wish to increase their level of competence in the area. However, creative and constructive engagement with the best forms of adaptive pedagogy, in whatever shape or form, has the potential to provide a sense of optimism for building a better future. Enthusiasm for promoting technologies for the benefit of already wealthy technology entrepreneurs is no substitute for sustained engagement that recognises the complexities of teaching and learning.
The rhetoric of 21st century skills orients toward the world of work at a time when we also need an emphasis on the promotion of education to foster broader objectives such preparing young people for “a rapidly changing, uncertain, risky and possibly dangerous future” [63]. Moreover, a predominantly economic focus on education has inherent contradictions [64] regarding teachers’ vital role in promoting the necessary “transformative shifts in how we think and act” [65] that are required for the changes in human behaviour essential for sustainable living. The capacity for transformative models of education to take root is dependent on a range of factors including preparedness of schools and teachers to embrace such approaches [66].
Education systems around the world are responding to the changing economic, environment, social and political global landscape by reviewing their curricula to include key skills and competencies. Thijs and van den Akker’s [67] description of curricular strata, where the supra level begins with transnational discourses about education, leading to the macro level of national level policy intentions and on to the meso level of policy guidance and facilitation to the micro level of school-level curricular practices and finally to the nano level of classroom interactions, demonstrates the complexities of implementing changes in the education sphere. While such a tiered approach to policy framing may well be necessary and appropriate, such a trickle down approach to trans-formation needs to give considerably more recognition to ‘continuous adaptation’ [68], thus also, considerably more dependent on micro capacities to extend the knowledge base of teaching, from a content and pedagogical perspective.
Lehtonen et al. [69] concur that the educational space is both complex and contested, presenting educators with the challenge of addressing difficult knowledge in a politicised and, at times, divisive context. The ability of teachers to critically form their responses to challenging and intricate situations, activating prior experience to move between repertoires for action in the light of reflection on alternative futures will be very varied across different contexts [70]. At the core of this dilemma is the concept of professional agency, whereby practitioners have the capacity to act in particular circumstances making sense of policies and of the multiple nuanced factors that influence the process by which these policies are realised. Agency and professional responsibility are not fixed capacities but rather an achievement resulting from the interplay of individual efforts and capabilities within contextual and structural factors in concrete situations [71], while responsibility implicitly contains a moral dimension. Thus, cultivating professional agency and responsibility in the teaching profession is central to understanding how educational policies are translated into contextually relevant teaching practices [72]. Important and all as teacher agency and professional responsibility may be, the days of ‘heroic’ performance are long since passed, thus there needs to be a significantly stronger sense of collective agency, collaborative professionalism, that takes professional responsibility seriously, while this too entails calling out systemic failures and inadequacies in terms of necessary and sustained support for teacher learning, and ongoing tailored 21st century ‘formation’ [73].
Another important factor in building sustainable teacher capacity is teacher professional identity and how it is inextricably linked to their chosen disciplines. The attempts by policy makers around the globe to progress the skills and competency agenda has been thwarted in some respects due to the lack of connection to subject discipline and pedagogical content knowledge (PCK) [74]. Skills cannot be learned in a content free zone. If teachers are to build their pedagogical repertoire for 21st century education they need to be supported and encouraged to broaden their horizons sufficiently to merge skill development and PCK in their practice [75]. However, if the rate of educational change persists without adequate resourcing and support, there is a serious danger of teacher burnout and attrition from the profession. We must learn from the sins of the past where rapid and radical reform did not achieve their intended outcomes [59]. There needs to be a systemic recognition by policy makers that we do not have to invent the future out of nothing, as well as increasing power asymmetries due to the expansion in influence of international agencies with their own agendas. Furthermore, teachers who are at the coal face of reform need to challenge the rhetoric surrounding the novelty of 21st century skills and competences. Seminal thinkers like Dewey and Freire have espoused the educational virtues of democratic and citizenship education, critical thinking and collaboration for decades. There is no denying that teacher capacity and competency to foster these skills are important agenda items. If we are to succeed in building this capacity and embedding these skills across the continuum of education, we need to approach it differently than heretofore in an incremental and non-threatening way that is achievable and sustainable. Slowing the process of change sufficiently to enable capacity to be enhanced incrementally is necessary; capacity building can only occur from where teachers’ expertise is rather than where it ought to be. There needs to be recognition also that the intellectual capacities of teachers vary considerably also from one jurisdiction to another, while this is already reflected in PISA results—particularly in Finland and Signapore [76]. While public partnerships have considerable potential to enhance teacher capacities, vigilance too is necessary in order to maintain schooling as a public good, a state responsibility that eschews profit in favour of society. Maintaining education as a public good to avoid the for profit sector dominating the agenda is essential. Moreover, making structural changes to the school year is also essential for educational reform to be more than a mere aspiration. Elongating the school year to facilitate sustained teacher learning at the site of the practice [77] and during the working day is a possible solution that, though a challenge to the profession will be necessary to consider.
Assessment is probably one of the most important aspects of the education process and has often been described as “the tail that wags the curriculum dog” [78]. Any attempts to embed key skills and competencies across the continuum of education must include a more holistic approach to assessment. This is easier said than done. Approaches to the assessment of skills and competencies will require more teacher and school-based assessment and less dependence on high stakes terminal exams. However, the controversy surrounding the examination process in many developed countries during COVID-19 crisis demonstrates the complex nature of assessment and the tension between transparency and fairness on the one hand and teacher autonomy and professional judgement on the other.
It is abundantly evident from the brief analysis and foray into aspects of building teacher capacity that the agenda is ambitious. As indicated in the introduction, even in the most developed economies, past experience indicates that this is an enormous challenge. When viewed from the perspective of cultures and contexts that continue to struggle with ‘basic’ education, the challenges appear as Sisyphean, and serves to disenfranchise, and demoralise rather than enhance teachers sense of agency and responsibility, and the quality of teaching and learning. Such a considerable educational change agenda is open to the accusation of policy elites talking among themselves. Unless and until the voices of teachers, learners, their parents and communities become part of that reform conversation in a meaningful and sustained manner, hope will drain away. There is no Valhalla, no ‘promised land’ to which teachers and their learners may easily migrate. Rather, they have to build and pave the way to that future. Without the support and resources necessary to match the ambition, professional agency, and professional responsibility are likely to decline rather than enjoy enhancement, and pedagogical repertoires more likely to become retrenched as Governments exert pressures to improve performance, resulting in impoverishment of teaching and learning, expanding disparities in learning outcomes, sustainability agendas shredded, to the detriment of the attractiveness of the teaching profession in many context where it is critically necessary. Policy-makers too have a responsibility to do more than merely enunciate lofty ambitions. These need to be matched by transformation strategies that are tailored to evident needs with resources that are equal to the challenge if even partial sustainability is to be achieved, the teaching profession enhanced, and the quality of teaching and learning improved. For too long, educational ‘change agents’ have been content to settle for less. While the influence of international agencies, their policy rhetorics, have grown more numerous, and demanding, no matter how laudable their advocacy, this does little for the capacities of teachers
The authors declare no conflict of interest.
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