**2.1. Dysregulation of cell cycle checkpoints**

cancer [1]. For patients with HR+ve/HER2−ve metastatic breast cancer (MBC), the choice between chemotherapy versus endocrine therapy depends on the disease load especially the presence of visceral crisis – patients with impending visceral crisis should be treated with systemic chemotherapy, whereas patients with stable condition should be given endocrine therapy. As hormonal stimulation is known to be the underlying driving force and these tumors tend to be slow growing, endocrine therapy is considered the mainstay of treatment for most patients.

The first endocrine therapy described for treatment of MBC was tamoxifen which dated back in year 1971 [2]. It is a selective estrogen receptor modulator (SERMs) that binds competitively to estrogen receptors, and can have both antagonistic and agonistic effect depending on the tissue of action. Nowadays tamoxifen and raloxifen are the most commonly used SERMs clinically. SERMs can be used in both pre- and post-menopausal women. These drugs are well tolerated and have favorable toxicity profile. The use of aromatase inhibitor (AI) was started in early 2000s for post-menopausal women. AI blocks the action of peripheral aromatase, preventing conversion of androgens to estrogen. Letrozole and anastrozole are non-steroidal reversible AIs, whereas exemestane is a steroidal irreversible AI. The initial evidence to support the use of AI was by the TARGET trial, which showed equivalent efficacy of anastrozole and tamoxifen in the first line treatment of HR-positive MBC but with lower incidence of side effects such as thromboembolic events and vaginal bleeding [3]. Subsequently letrozole was demonstrated to have superior time to progression (9.4 versus 6.0 months, p < 0.0001), improved objective response rate (ORR) (32 versus 21%, p −0.0002) and a trend toward longer overall survival (OS) (34 versus 30 months) compared with tamoxifen [4]. The third class of endocrine therapy is selective estrogen-receptor degrader (SERD), and fulvestrant is the only SERD approved by the U.S. Food and Drug Administration (FDA) so far. In the CONFIRM trial, it has been defined that fulvestrant should be given at a higher dose of 500 mg instead of 250 mg for its better benefit in overall survival [5]. In the recently published phase 3 FALCON trial in which endocrine therapy-naïve patients were randomized to receive fulvestrant 500 mg monthly or anastrozole 1 mg daily [6]. The progression-free survival (PFS) in the fulvestrant group was 16.6 months compared with that of 13.8 months in the anastrozole group. The p-value was at a borderline of 0.0486 and the overall survival data is not available yet. As such, both AI and fulvestrant are acceptable option for initial treatment of HR+ve/HER2−ve MBC, yet the use of fulvestrant is often limited by the need for monthly intramuscular injection and its high cost. Traditional endocrine therapy at the frontline setting achieves an overall response rate in the range of 25–45% and median PFS around 8–10 months [3, 4, 7]. Second line endocrine therapy often yields unfavorable response. With improving understanding in this disease, more and more evidence suggests that combining endocrine therapy with targeted therapy could overcome endocrine resistance and significantly prolong the time on endocrine therapy, delaying the needs for chemotherapy. This chapter will discuss the latest development in the targeted

therapy for HR+ve/HER2−ve MBC and the future direction.

Endocrine resistance is a major obstacle for treatment of HR+ve/HER2−ve MBC. Multiple mechanisms have been implicated. Based on these knowledge we now have a number of

**2. Endocrine resistance**

162 Breast Cancer and Surgery

In mammalian cells, cell cycle progression is determined by the checkpoint regular retinoblastoma protein (Rb), which itself is controlled by a number of cyclin-dependent kinases (CDK) [8]. In quiescent state, Rb in its hypo-phosphorylated state suppresses the cell cycle progression from G1 phase into S (synthesis) phase. In proliferative state, CDK subtypes 4 and 6 complexes with cyclin D1, D2, or D3, triggering Rb phosphorylation [9]. Hyperphosphorylation of Rb leads to increased activity of the E2F family of transcription factors and promotes cell cycle progression. Cyclin D1 amplification is common in HR-positive breast cancer. Cyclin D1 is encoded by *CCDN1*. *CCND1* and cyclin D1 have been found to be amplified in 15–20 and 28–58% of luminal breast cancer respectively [10, 11]. Preclinical research suggested dysregulated cell cycle checkpoint regulation could lead to abnormal cell cycle progression and loss of endocrine responsiveness. Treatment of antiestrogen in breast cancer cells was associated with suppressed cyclin D1 expression, and emergence of endocrine resistance was accompanied by persistent cyclin D1 expression and Rb phosphorylation [12, 13]. Subsequent *in vitro* study further demonstrated that in breast cancer cell lines, CDK4/6 inhibitor palbociclib had preferential activity in reversing treatment resistance in luminal cells [14]. A number of CDK4/6 inhibitors have been tested clinically, and have become standard treatment of HR+ve/HER2−ve MBC.

## **2.2. Crosstalk growth factor receptor and PI3K/AKT/mTOR pathway**

Phosphatidylinositol-3-kinasd (PI3K)-Akt-mammalian target of rapamycin (mTOR) pathway is an important signal transduction system on which many growth factor receptors pathways converge. Crosstalk between the PI3K/Akt/mTOR pathway and growth factor receptors such as EGFR, HER2, HER2, FGFR1, and IGF1R have been described in endocrine resistance [15–18].

Abnormal activation of the PI3K pathway could result in factitious cell proliferation. The PI3K complex is composed of a regulatory subunit and a catalytic subunit p110. P110 has four isoforms – α, β, γ, and δ. *PIK3CA* mutation is found in up to 40% of breast cancer and is likely to be present in early cancer development [19, 20]. Abnormal PK3K signaling was found in up to 70% of breast cancers [21]. Besides *PIK3CA* mutation, hyperactivation of this pathway can result from aberration other PI3K subunits, mutation or phosphorylation of effectors Akt, loss of inhibitory signal from PTEN or INPPR4B, leading to activation of downstream effector mTOR protein. As hyperactivation of PI3K pathway could promote estrogen-independent ER transcriptional activation, inhibition of PI3K or its downstream effectors is an attractive target to overcome endocrine resistance [21, 22].

#### **2.3. Changes in the estrogen receptor (ER) and HER2 status**

Loss of HR expression, although uncommon, has been reported in hormone-resistant breast cancer. Study of paired primary and metastatic HR-positive breast cancer found a positive-tonegative change in HR status in 10% of metastatic breast tumor [23]. In the P024 neoadjuvant endocrine therapy trial that recruited 228 post-menopausal women with HR-positive stage 2 or 3 breast cancer, those who lost ER status after AI treatment had worse recurrence-free survival compared with those who had no change in ER status (HR of relapse = 2.4, p = 0.03) [24]. Another study of paired sample analysis of primary cancer and liver metastases posttreatment showed ER status and HER2 status change in 30% and 10% of patients [25]. How these changes in receptor status affect management and outcome is not well understood.

hormonal therapy, the type of recent hormonal therapy, or prior chemotherapy (HR ranges, 0.35–0.67). The ORR for all randomly assigned patients in palbociclib-letrozole group versus placebo-letrozole group was 42.1% (95% CI, 37.5–46.9) and 34.7% (95% CI, 28.4–41.3) (odds ratio 1.4, 95% CI, 0.98–2.01; p = 0.06). CBR among all patients randomized was 84.9% (95% CI, 81.2–88.1) for palbociclib-letrozole group and 70.3% (95% CI, 63.8–76.2) for placebo-letrozole group (odds ratio 2.39 (95% CI, 1.58–3.59; p < 0.0010). The most frequent grade 3 and 4 adverse event (AE) in the palbociclib-letrozole group was neutropenia (66%), but febrile neutropenia occurred in 1.8% of patients only. Other common AE included fatigue (37%), nausea (35%), arthralgia (33%), alo-

Management of Hormone Receptor-Positive Metastatic Breast Cancer

http://dx.doi.org/10.5772/intechopen.75759

165

PALAMO-3 is another indication-defining phase 3 study of palbociclib [30]. Patients with HR+ve/HER2−ve HER2-negative MBC who had relapsed or progressed during prior endocrine therapy were randomized to receive fulvestrant with placebo or fulvestrant with palbociclib. A total of 521 patients were randomized. The median PFS was 9.2 and 3.8 months in the fulvestrant-palbociclib and fulvestrant-placebo groups respectively (95% CI, 2.5–5.5) (HR 0.42, 95% CI, 0.32–0.56; p < 0.001). ORR was 10.4% with fulvestrant-palbociclib and 6.3% with fulvestrant-placebo, and the CBR was 34% with fulvestrant-palbociclib and 19% with fulvestrantplacebo. In the fulvestrant-palbociclib group, grade 3 or 4 neutropenia was found in 62%. Other common AEs were fatigue (38%), nausea (29%), anemia (26%), and headache (21%).

The results of PALOMA-2 echo those of PALOMA-1 that led to FDA approval. PALOMA-1 differs from PALOMA-2, besides being a phase 2 trial, in that it adopted a 1:1 randomization. There were also small differences in the subgroup analysis, such as inclusion of the newly diagnosed metastatic disease subgroup. Nevertheless, both studies showed significant sur-

Ribociclib is the second CDK 4/6 inhibitor received the U.S. FDA approval in March 2017. The first approval study was MONOLEESA-2 for first line setting. MONOLEESA-7, which is also a first line trial, had special interest in pre- and peri-menopausal women. The data also

MONOLEESA-2 is a double-blind, placebo-controlled, phase 3 study of ribociclib plus letrozole [31]. It mirrors PALOMA-2 for the target patient population. Patients were randomized 1:1 to ribociclib-letrozole or placebo-letrozole. The study demonstrated that the addition of ribociclib to letrozole significantly improved PFS from 14.5 months to over 25 months giving a HR of 0.56 for disease progression or death (95% CI, 0.43–0.72; p < 0.001). The ORR was 40.7% in the ribociclib group and 27.5% in the placebo group in the intention-to-treat population. The CBR was 79.6% in the ribociclib group and 72.8% in the placebo group (p = 0.02) respectively in the intention-to-treat population. The most common grade 3 and 4 AEs were neutropenia (60%), elevated alanine aminotransferase (9%), elevated aspartate aminotransferase

(6%), infection (4%) and vomiting (4%). Other common AEs were minor and mild.

pecia (33%) and diarrhea (26%) and all these were mild.

vival benefit of palbociclib and similar toxicity profiles.

*<IP_ADDRESS>. Key results of phase 3 MONOLEESA studies*

*3.1.2. Ribociclib*

became available recently.

### **2.4. Molecular changes secondary to the use of aromatase inhibitor**

Molecular changes in the target receptors after treatment causing treatment failure is a wellknown phenomenon in many malignancies. For HR-positive breast cancer, the target of interest is *ESR1*, which encodes for ERα. *ESR1* mutation has not been detected in sequencing analysis of 390 treatment-naïve primary breast cancer tissues in the Cancer Genome Atlas project [11]. In another study, tissue of patients with hormone-resistance breast cancer were sequenced, and showed 14 or 80 these cases showed *ESR1* mutations affecting the ligand-binding domain [26]. The mutations were the highly recurrent mutations encoding p.Tyr537Ser, p.Tyr537Asn and p.Asp538Gly alterations. p.Tyr537Ser and p.Asp538Gly play a role in hydrogen bonding of the mutant amino acid with Asp351 and favors the agonist conformation of the ER receptor. As a result the mutant ER becomes active in the absence of hormonal stimulation, and renders ER antagonists ineffective. The clinical significance of *ESR1* mutation will be further discussed in Section 3.4.


Preface

Chapter 7 **Examining Non‐Celiac Consumers of Gluten‐Free Products: An**

Tiziana de‐Magistris, Hind Belarbi and Wajdi Hellali

Ricardo Fueyo-Díaz, Santiago Gascón-Santos and Rosa Magallón-

**Empirical Evidence in Spain 101**

Botaya

**VI** Contents

Chapter 8 **I Can't Eat That! Sticking to a Gluten-Free Diet 115**

**Celiac disease (CD**) is described as a chronic, genetically based gluten-sensitive immunemediated enteropathic disease, primarily affecting the small intestinal mucosa. CD did not occur before the Neolithic period (beginning about 9500 BC) because the grains have been cultivated by humans only since this time, in the Fertile Crescent in Western Asia.

In 1930, during World War II, a Dutch pediatrician William Dicke observed that a lack of access to wheat improved the status of children with celiac disease, and in 1952, he was ac‐ knowledged for linking the ingestion of wheat proteins as the cause of celiac disease. The first biopsy technique of CD was developed by Margot Shiner, a pediatric gastroenterologist in 1950; she observed the small intestine and the pathologic changes in the celiac disease.

In 1966, dermatitis herpetiformis was linked to gluten sensitivity. In the 1980s, celiac disease was associated with other autoimmune diseases such as thyroid diseases, type 1 diabetes mellitus, and Down syndrome. In the 1990s, genetic markers HLA-DQ2 and HLA-DQ8 and the antitransglutaminase antibodies were identified.

The prevalence of CD is approximately 1% within the US and European populations and may be higher in Northern European countries, approximately 1.5%. CD is a common disor‐ der in North Africa, the Middle East, and India. The diagnostic rate is low in these countries due to low availability of diagnostic facilities and poor disease awareness. The highest CD prevalence in the world (5.6%) has been described in an African population originally living in Western Sahara, the Saharawi, of the Arab-Berber origin.

Initially, it was thought that exogenous gluten products were directly toxic to the mucosa in celiac disease. In contrast with earlier suggestions, intraepithelial lymphocytes (IELs) are now thought to actively contribute to mucosal damage. Antigen exposure in celiac disease causes rapid in situ activation of α/β T-cell IELs. These cells may then damage enterocytes through contributions from several possible mechanisms, including the NKG2D-major his‐ tocompatibility complex class I chain-related gene A pathway.

CD diagnosis includes three major steps: (1) blood tests (including serology) positive, (2) small bowel biopsy and histological confirmation, and (3) implementation and response to a gluten-free diet (GFD). At present, the only effective treatment available for CD individuals is a strict lifelong gluten-free diet (GFD). There is a need for an alternative, because GFD is costly and not universally available and compliance is difficult.

**Non-celiac gluten sensitivity (NCGS):** It is a new syndrome of gluten intolerance, a condi‐ tion where intestinal and extraintestinal symptoms are triggered by gluten ingestion, in the absence of CD and wheat allergy, as defined by discussions held at three different interna‐ tional consensus conferences. The clinical picture of NCGS is a combination of IBS-like

symptoms, behavior disturbances, and systemic manifestations. In the medical literature, some other names have been suggested for this disorder, such as gluten sensitivity (GS), gluten hypersensitivity, or nonceliac gluten intolerance.

This new entity was described around 30 years ago, but it was necessary to wait until 2011, when it was proposed by members of the First Expert Meeting on gluten sensitivity. The new defini‐ tion (the Oslo definition) of CD suggested that the disorder should be named NCGS, which made it distinguishable from CD. The Second Expert Meeting on GS that was held in Munich in 2012 decided to change the name of this disorder to NCGS in order to avoid confusion with CD. The first case reports of NCGS in children were described in 2012. NCGS can be diagnosed in those patients with gluten intolerance who do not develop antibodies that are typical neither of CD nor of wheat allergy (WA) and who do not suffer from lesions in the duodenal mucosa, which are characteristic of CD. The gluten-free diet leads to complete regression of symptoms in the same way and efficacy that is achieved in celiac patients.

The prevalence of NCGS is at least six times higher than that observed in CD. Half of the NCGS patients have the genes encoding DQ2 or DQ8 molecules in their HLA system. The genes encoding DQ2 or DQ8 molecules are present in 95% of the CD patients. Negative re‐ sults for both HLA-DQ2 and HLA-DQ8 excluded the diagnosis of CD in at least 95%. These genes are present in healthy people as well (30%), but less frequently than in the case of the NCGS patients (50%).

The adaptative immune response may play a role in the NCGS pathogenesis. Contrary to CD, where the secondary immune response is upregulation, the NCGS patients demonstrate mainly upregulation of the primary response, and there is no increased expression of the genes of the secondary immune response including IL-6, IL-21, and IFN-gamma, which is characteristic of CD. The NCGS patients' gastrointestinal tracts and their intestinal permea‐ bility are normal, and the lesions in the histological picture of their duodenal mucosa are minor (Marsh 0 classification, in the majority of cases).

NCGS treatment is identical to CD and consists in the prescription of a gluten-free diet, which must be followed in a strict form during long life, avoiding all the crossed contamina‐ tions and also the possible unannounced interruptions of the diet.

Finally, I want to thank all the authors for their wonderful contributions, as well as the speed and efficiency in the delivery of their chapters. A special gratitude should be men‐ tioned to all the excellent team from the Editorial Board of InTech, especially to Ms. Marija‐ na Francetic, for their continued support and final condition of this book.

> **Prof. Luis Rodrigo, MD** Emeritus Professor of Medicine University of Oviedo Oviedo, Spain

**Section 1**

## **Celiac Disease**

symptoms, behavior disturbances, and systemic manifestations. In the medical literature, some other names have been suggested for this disorder, such as gluten sensitivity (GS),

This new entity was described around 30 years ago, but it was necessary to wait until 2011, when it was proposed by members of the First Expert Meeting on gluten sensitivity. The new defini‐ tion (the Oslo definition) of CD suggested that the disorder should be named NCGS, which made it distinguishable from CD. The Second Expert Meeting on GS that was held in Munich in 2012 decided to change the name of this disorder to NCGS in order to avoid confusion with CD. The first case reports of NCGS in children were described in 2012. NCGS can be diagnosed in those patients with gluten intolerance who do not develop antibodies that are typical neither of CD nor of wheat allergy (WA) and who do not suffer from lesions in the duodenal mucosa, which are characteristic of CD. The gluten-free diet leads to complete regression of symptoms in

The prevalence of NCGS is at least six times higher than that observed in CD. Half of the NCGS patients have the genes encoding DQ2 or DQ8 molecules in their HLA system. The genes encoding DQ2 or DQ8 molecules are present in 95% of the CD patients. Negative re‐ sults for both HLA-DQ2 and HLA-DQ8 excluded the diagnosis of CD in at least 95%. These genes are present in healthy people as well (30%), but less frequently than in the case of the

The adaptative immune response may play a role in the NCGS pathogenesis. Contrary to CD, where the secondary immune response is upregulation, the NCGS patients demonstrate mainly upregulation of the primary response, and there is no increased expression of the genes of the secondary immune response including IL-6, IL-21, and IFN-gamma, which is characteristic of CD. The NCGS patients' gastrointestinal tracts and their intestinal permea‐ bility are normal, and the lesions in the histological picture of their duodenal mucosa are

NCGS treatment is identical to CD and consists in the prescription of a gluten-free diet, which must be followed in a strict form during long life, avoiding all the crossed contamina‐

Finally, I want to thank all the authors for their wonderful contributions, as well as the speed and efficiency in the delivery of their chapters. A special gratitude should be men‐ tioned to all the excellent team from the Editorial Board of InTech, especially to Ms. Marija‐

**Prof. Luis Rodrigo, MD**

University of Oviedo

Oviedo, Spain

Emeritus Professor of Medicine

gluten hypersensitivity, or nonceliac gluten intolerance.

the same way and efficacy that is achieved in celiac patients.

minor (Marsh 0 classification, in the majority of cases).

tions and also the possible unannounced interruptions of the diet.

na Francetic, for their continued support and final condition of this book.

NCGS patients (50%).

VIII Preface


*4.11. Immunohistochemistry Analysis*

MIP-2 and COX-2 expressions in hepatic tissue were evaluated by immunohistochemistry staining as previously described [96]. The prepared hepatic sections were recovered, and the endogenous peroxidase in tissues was inactivated with 0.1% hydrogen peroxide containing methanol for 15 min. Then, the sections were incubated with a rabbit polyclonal MIP-2 and COX-2 antibody at 4 ◦C overnight. Subsequently, the sections were washed with PBS and incubated with rabbit anti-mouse (1:1000) secondary antibody at

room temperature for 30 min. The sections were rinsed with PBS 3 times and stained with diaminobenzidine (DAB). Additionally, they were evaluated under an optical microscope (Olympus Optical Co., Ltd., Tokyo, Japan).


Estimation of Bioavailability

**65**

**Chapter 4**

**Abstract**

will be established.

**1. Introduction**

cross over study, area under curve

Studies

*Divvela Hema Nagadurga*

Bioavailability and Bioequivalence

*In vivo* bioavailability studies are performed for new drug to establish essential pharmacokinetic parameters including rate of absorption, extent of absorption, rates of excretion and metabolism and elimination half-life after a single and multiple dose administration. These essential pharmacokinetic parameters are useful in establishing dosage regimens. Bioequivalence used to assess the expected *in vivo* biological equivalence of two proprietary preparations of drug products. If two drugs are bioequivalent, it means that they are expected to be same for all intents and purposes. In determining bioequivalence between two drugs such as a reference drug or brand and potential to be test drug or marketed generic drug. Pharmacokinetic studies are conducted whereby each of the drugs is administered in a cross over study to healthy volunteer's subjects. Plasma is obtained at regular intervals and assayed for parent drug or metabolite concentration to compare the two drugs. For comparison purpose of two formulations, the plasma concentration data are used to assess key pharmacokinetic parameters. If 90% confidence interval for the ratio of the geometric least square means of peak plasma concentration, area under curve of test and reference drugs are within 80–125%, then bioequivalence

**Keywords:** bioavailability, bioequivalence studies, pharmacokinetic parameters,

Bioavailability is defined as relative amount of drug from an administered dosage which enters the systemic circulation and the rate at which the drug appears in the systemic circulation. The bioavailability studies are done by measuring the concentration of the drug in the plasma or blood after administration of drug following systemic protocol of studies and documented over time. The systemic protocol is helpful for clinical trials in the early drug development, and the data obtained are used in subsequent bioequivalence studies. Bioequivalence studies were carried out to distinguish between two pharmaceutical products containing the same active substance. One drug formulated into two different formulations if they show to be therapeutically equivalent to one another in order to be considered interchangeable. Pharmacokinetics of drug deals with the change in drug concentration in plasma and/or its metabolites in the human or animal body with respect to time following administration of the pharmaceutical product. Bioequivalence studies are used to assess the expected *in vivo* biological equivalence of two proprietary preparations of a drug. If two pharmaceutical products are said to be bioequivalent, then they


*3.3. Bariatric Surgery*

Bariatric surgery, also so-called metabolic surgery, refers to methods used to reduce obesity and improve metabolic abnormalities. The most used techniques are the vertical sleeve gastrectomy, Roux-en-Y gastric bypass, adjustable gastric banding, and biliopancreatic diversion/duodenal switch. Selection of the most appropriate procedure needs to consider not only the morbidity/mortality risk during the procedures but also the potential side effects during follow-up [82]. The surgical treatment of obesity improved management of diabetic and non-diabetic CKD and reduced the rate of renal decline toward ESKD. Once ESKD is established, absolute event rates are low and although complications can be present, it remains a safe intervention. Implementing one of the above surgeries pretransplant increases the potential access to transplantation and, in addition, improves the management of metabolic complications post-transplantation, including new-onset diabetes. Likewise, this may be beneficial as a treatment for potential obese donors [82].

A beneficial impact on obese patients with type 2 diabetes in kidney protection has been emphasized. A large metanalysis concluded that post-surgical reduction in albuminuria is independent of the changes in BMI, HbA1c, and systolic BP [106]. In nondiabetic subjects, randomized studies are not available, but many observational studies have demonstrated the beneficial impact in reducing incidence of albuminuria and the risk for ESKD after an 18 year follow-up [107]. In CKD patients, at the end of the first year post-surgery [108] and after 7 years of follow-up, improvement in the categories of CKD were observed in around half of the patients, and even in patients with very high risk at baseline a quarter of them improved [109].

In patients with ESKD in dialysis, before kidney transplantation, bariatric surgery had a reduction in mortality, incidence of diabetes, and around 60% of cardiac diseases. The preferred method in dialysis patients is the laparoscopic sleeve gastrectomy in which results are more effective with less complications and with the additional advantage of not interfering with pharmacokinetics of immunosuppression drugs [110].

Increment in the incidence of kidney stones has been reported associated with bariatric surgery. Among the factors that contribute to this association are the decrease in urinary volume and citrate, the increased urinary oxalate, and the calcium oxalate saturation. Procedure selection may be critical to mitigate the risks of oxalate nephropathy since more restrictive procedures reduce the risk [111].


**1. Introduction**

Leucine dehydrogenase (LeuDH; EC <IP_ADDRESS>), a NAD<sup>+</sup> dependent oxidoreductase, which catalyzes reversible L-leucine and other branched chain L-amino acids deamination reaction to the formation of the corresponding α-keto acid [1]. The enzyme was first identified in *Bacillus cereus* [2], and then was found in some microorganisms *Bacillus licheniformis* [3], *Bacillus sphaericus* [4], *Citrobacter freundii* [5], and *Laceyella sacchari* [6]. Moreover, crystal structures of the LeuDH from *Sporosarcina psychrophila* [7] and *Bacillus sphaericus* have been described [8].

LeuDH is used as a biocatalyst to format amino acids for using in the pharmaceutical industry by catalyzing the corresponding α-keto acids [9]. However, some of α-keto acids are unstable and degraded during prolonged incubation at moderate temperatures, such as 37 ◦C [10]. Importantly, cold-adapted enzymes that exhibit high levels of activity at room temperature (20–25 ◦C) should be

useful for converting such unstable α-keto acids. What is more, cold-adapted enzymes have better conversion rates, the specificity of substrate and product, fewer by-products, which are required in the modern industry [11]. Although many LeuDHs have already been characterized, only a few cold-adapted LeuDH have been reported, such as LeuDH from *Alcanivorax dieselolei* [12] and *Sporosarcina psychrophila* [7].

Antarctic sea-ice, due to its specific geographical location and climate, is considered as an extreme environment on the earth. To develop the ability to withstand the extreme environment, sea-ice microorganisms have evolved several adaptive strategies and would be the new and promising microbial sources of cold-adapted enzymes. In our previous studies, some cold-adapted enzymes were isolated from Antarctic sea-ice bacteria and had become interesting for industrial applications [13,14]. It is well-known that L-*tert*-leucine and its derivatives are useful as pharmaceutical active ingredients and chiral auxiliaries, while LeuDH is a key enzyme for the enzymatic production of L-*tert*-leucine. Here, we briefly describe the homology modeling, expression, and characterization of cold-adapted LeuDH from Antarctic sea-ice bacterium. This LeuDH had unique properties make it good candidate for future medical and pharmaceutical industry applications.


**Abstract**

The recreational seaport industry carries out many critical functions, including transport circulation, logistics, commercial, and spatial ones. They influence local economic growth and determine the quality of recreational seaport. However, the definition of recreational seaport quality has remained elusive among the community, at present. Hence, this chapter explores the current literature by using the Systematic Literature Review (SLR) to derive at the definition of seaport quality based on three categories: seaport effectiveness, seaport reliability, and seaport governance, which will be main pillars for the development of marinas. This chapter proposes the Seaport Quality System (SQS) and Spatial Interaction Model (SIM) as a way to develop approaches and strategies that support sustainable planning and management of recreational seaports and marinas in countries with extensive coastlines. It is proposed that in order to offer sustainable and quality services, marinas must adopt the SQS model based on identifying and managing quality and risks. In addition, SIM can be utilised to improve the marinas operations by adopting key components in cruise activities, economic corridors and seaport regionalisation. The combination of both models are essential to enhance the growth momentum of marinas in this country.

**Keywords:** recreational seaport, seaport quality system (SQS), sustainable development


**2.3.2 Biomarkers: Fatty acids, vitamin D and E**

The distribution of fatty acids in the plasma phospholipid fraction as well as Vit D and Vit E will be analyzed in plasma samples from the same aliquots at a commercial laboratory in Oslo (AS Vitas; http://www.vitas.no/) using solid phase extraction and gas chromatography.

## **2.4 Measurement of exposure to virus (viral infections)**


*<IP_ADDRESS> Mix-up of samples or sample related data*

• Wrong documentation in the internal database system

**Possible coping strategies**

*DOI: http://dx.doi.org/10.5772/intechopen.91463*

*Risk Management in Biobanks*

departments

**Possible reasons**

• IC is incorrect

• IC has been withdrawn

• IC has not been obtained

**Possible consequences**

**Possible coping strategies**

departments

**Possible reasons**

• Image loss

**95**

**Possible consequences**

• Samples are not usable for research projects

• Training of medical personnel of clinical partners

• Process control through a traffic light system

• Samples are not usable for research projects

• Integration of biobank processes into clinical processes of cooperating

*<IP_ADDRESS> The informed consent is invalid although it is marked as valid in the system*

• Invalidity of the informed consent cannot be detected when scanning

• Comprehensive IC in all clinical departments of the hospital

• IC is unscannable

• IC gets lost

• Problem discussions

• Training of medical personnel of the clinical partners

• Information and motivation of clinical personnel

• Expanding of personnel resources

• Current presentations and reporting about the biobank

*<IP_ADDRESS> No informed consent when including samples (serum, cryo)*

• Integration of biobank processes into clinical processes of cooperating


**1. Introduction**

Depression, clinically characterized by significant and persistent low mood symptoms, is a common and growing globally mental health issue linked with considerably diminished role-functioning and quality of life, medical comorbidity, and mortality [1]. In 2017, about 17.3 million adults aged 18 and over in the US had experienced at least one major depressive episode. The prevalence was about 7.1%, and highest among adults reporting two or more races [2]. According to the Depression and Other Common Mental Disorders: Global Health Estimates published by WHO in 2017, the total number of people living with depression in the world is 322 million. Nearly half of them live in the South-East Asia Region and Western Pacific Region, such as China and India. Meanwhile, the prevalence of depression varies by age, peaking in older adulthood, and was estimated above 7.5% among females aged 55–74 years [3]. A substantial number of researches have shown strong relationships between depression and physical health, including cardiovascular disease [4], Parkinson's disease [5], metabolic disease [6], dementia [7], type 2 diabetes [8], and cancer [9]. Out of the mental and addictive disorders, depressive disorders cause most disability-adjusted life years for both sexes, followed by anxiety disorders in women [10]. In 2015, depressive disorders led to a global total of over 50 million years lived with disability (YLD), more than

**Citation:** Wang, K.; Zhao, Y.; Nie, J.; Xu, H.; Yu, C.; Wang, S. Higher HEI-2015 Score Is Associated with Reduced Risk of Depression: Result from NHANES 2005–2016. *Nutrients* **2021**, *13*, 348. https://doi.org/ 10.3390/nu13020348

Received: 17 December 2020 Accepted: 19 January 2021 Published: 25 January 2021

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2021 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

80% of which occurred in low- and middle-income countries [4]. Studies in recent decades have shown associations between nutrient intake and the risk of depression, including minerals like zinc, omega-3 fatty acids, and vitamins such as vitamin D [11–14]. Many researchers also found adherence to a specific dietary pattern, such as "dietary approaches to stop hypertension", was correlated with lower depression risk [15–17]. While most of them focused on specific diet pattern or food intake, some research explored the relationship from a macroscopic view. To explore the effect of diet quality in a more macroscopic way, we adopted the latest edition of the Healthy Eating Index (HEI) to determine whether diet quality is related to depression. Through this research, we want to answer whether aligning with the Dietary Guidelines for Americans (DGA) reduces the risk of depression.


**4. Material and methods**

In this investigation a knowledge-based algorithm for the automated mapping of water bodies was developed based on a spectral database from five airborne hyperspectral datasets from the two German cities Berlin (two datasets) and Potsdam, and the German island Helgoland (two datasets) (Tab. 2). Five independent datasets were used for validation (Tab. 2). The selected scenes comprise urban, rural and coastal landscapes as well as different sensors to prove the wide applicability of the developed approach. The AISA Eagle sensor is an airborne VNIR pushbroom scanner (400 – 970 nm) with 12 bit radiometric resolution and variable spatial and spectral binning options, the latter resulting in mean spectral sampling intervals between 1.25 nm and 9.2 nm (Spectral Imaging Ltd., 2011) and

\* Datasets analyzed during algorithm development

° Independent datasets for validation

Table 2. Dataset-specific characteristics

Fig. 4. Location of the test sites within Germany

In this investigation a knowledge-based algorithm for the automated mapping of water bodies was developed based on a spectral database from five airborne hyperspectral datasets from the two German cities Berlin (two datasets) and Potsdam, and the German island Helgoland (two datasets) (Tab. 2). Five independent datasets were used for validation (Tab. 2). The selected scenes comprise urban, rural and coastal landscapes as well as different sensors to prove the wide applicability of the developed approach. The AISA Eagle sensor is an airborne VNIR pushbroom scanner (400 – 970 nm) with 12 bit radiometric resolution and variable spatial and spectral binning options, the latter resulting in mean spectral sampling intervals between 1.25 nm and 9.2 nm (Spectral Imaging Ltd., 2011) and

Test site Sensor Acquisition date, time (UTC) Pixel size (rounded)

Ammersee

Döberitzer Heide

Rheinsberg

Mönchsgut

Dresden

Potsdam Berlin

Potsdam (*urban*) HyMap 07.07.2004, 10:29 \* 4 m

Rheinsberg (rural) HyMap 20.06.1999, 10:46 ° 10 m Dresden (*urban*) HyMap 07.07.2004, 09:39 ° 4 m Mönchsgut (*coastal*) HyMap 03.09.1998, 13:47 ° 6 m Döberitzer Heide (*rural*) AISA Eagle 19.08.2009, 11:42 ° 2 m

20.06.2005, 10:12 \*

09.05.2008, 08:32 \* 09.05.2008, 09:26 ° 09.05.2008, 09:41 \* 4 m 4 m

1 m 1 m 1 m

Berlin (*urban*) HyMap 20.06.2005, 09:38 \*

Helgoland

AISA Eagle HyMap simulated EnMAP

Sensor types urban coastal rural Test site types

Fig. 4. Location of the test sites within Germany

**4. Material and methods**

Helgoland (*coastal*) AISA Eagle

\* Datasets analyzed during algorithm development

° Independent datasets for validation

Table 2. Dataset-specific characteristics

488 to 60 spectral bands, respectively. The mean spectral sampling interval of the analyzed datasets is 2.3 nm for "Döberitzer Heide" and 4.6 nm for "Helgoland". The HyMap sensor is an airborne VNIR-SWIR whiskbroom scanner with 16 bit radiometric resolution consisting of four detector modules with mean spectral sampling intervals of 15 nm (VIS and NIR), 13 nm (SWIR1) and 17 nm (SWIR2) (Cocks *et al.*, 1998). The 128 spectral bands cover the spectral region from 440 nm to 2500 nm.

Water detection is a trivial task as long as there are no other dark surfaces present in the image. Unfortunately, the most prominent spectral characteristic of water pixels – water pixels are very dark – also applies to a couple of other surfaces such as dark rocks (e.g., lava, basalt) or bituminous roofing materials and especially to pixels covered by shadow. To account for this, we developed a two-step approach that firstly masks low albedo pixels as potential water pixels (section 4.1) and secondly applies a process of elimination to consecutively remove false positives (sections 4.2 and 4.3).


**5. Conclusion**

*Ion Beam Techniques and Applications*

Indian cigarettes which was 0.4 μg/g (**Table 4**).

into the food chain through agricultural practices [21].

after their application [21].

in manures and many pesticides, so it becomes easily a part of the environment

Cadmium inhaled in its oxidized form as cadmium oxide while smoking. It is roughly estimated that 10% of cadmium deposit in lungs, and about 20–50% become a part of circulation [15, 7]. Cadmium accumulates in the circulation as well as deposits in kidney mainly in the cortex of the kidney by the late reaction of cadmium and metallothioneins. Although smoking generates small amount of copper which is unable to cause kidney failure, many studies stated that copper accumulates in kidney and is the main cause of renal end-stage failure and tubular dysfunction [17, 15, 18]. Many of other health disorders included emphysema, cataract, hypertension, as well as cardiovascular disease are also under investigation to know possible consequences of copper accumulation in these diseases [19, 20]. Copper mainly comes in air from fossil fuel burning and remains in the air for a long time. Usually, copper settles down in soil due to rain where it becomes bioavailable to plants. Naturally, copper comes from the soil through weathering of parent material, decaying of natural vegetation, forest fire, dust, windblown, and sea spray. Copper is also released into the environment by anthropogenic activities mainly by mining, metal production, wood production, and phosphate fertilizer. Human health is potentially affected by the soluble copper compounds which enter

The concentration of copper in the tobacco of local and imported brands was observed, ranging from 0.17 to 5.71 μg/g with an average of 0.97 μg/g (**Table 2**) and from 0.41 to 2.3 μg/g with an average of 1.14 μg/g (**Table 3**), respectively. In this study, copper is at the lowest level with respect to other studies was done in different places of the world (given in **Table 4**). Long-term exposure to a higher level of copper causes decline in intelligence in young adolescents. Industrial exposure to copper fumes, dust, or mists generated by industries cause metal fumes fever and atopic retardation in nasal mucous membranes. Copper deposit in cornea and chronic copper toxicity causes various diseases like Wilson's disease, characterized

by hepatic cirrhosis, renal disease, brain damage, and demyelination [22].

Nickel is present in low concentration in the environment and use in many things made by a human. Commonly nickel is used in steel and metal products as well as in jewelry [21]. The concentration of nickel in the tobacco of local and imported brands was observed, ranging from 0.08 to 1.03 μg/g with an average of 0.31 μg/g and from 0.33 to 0.5 μg/g with an average of 0.43 μg/g, respectively.

Nickel is a mutagen and carcinogen that causes many types of cancer in human especially related to the respiratory track. It induces sister chromatid exchanges by mutation [23]. Experiments showed the affected heart development in the unborn mice due to Nickel toxicity [24]. Although nickel is essential, but in excessive amount it is dangerous to health which causes sickness and enhance chances of various types of cancer like lung cancer, larynx cancer, prostate cancer, and nose cancer. Human exposure to nickel is usually through drinking water, breathing air, the food chain, and smoking of cigarettes [25]. The concentration of nickel measured in this

The local cigarettes had an average concentration of cadmium in tobacco which was 4.92 μg/g with standard deviation of 1.2. The minimum mean concentration of cadmium in a sample was 1.86 μg/g, and maximum concentration in a sample was 9.4 μg/g. In the imported cigarettes, the mean concentration of cadmium present in the tobacco was 4.88 μg/g with standard deviation of 0.74 (**Table 2**). The minimum concentration of cadmium observed in tobacco of imported brands was 4.2 μg/g, and maximum concentration was 5.85 μg/g (**Table 3**). The concentration of cadmium in this study is at the highest level as compared to other studies around the world (**Table 4**). The lowest cadmium concentration was observed in tobacco of

**96**

The available data on toxic metals in tobacco of Pakistani cigarettes was insufficient; this study will provide adequate data to all concerned departments. This study will also create awareness among people about the toxicity of metals present in tobacco of cigarettes.