Enhanced H2S biogenesis followed by its postharvest application retarded senescence development by promoting multiple antioxidant protection systems in button mushroom during cold storage

Rapid postharvest quality deterioration of button mushroom as fruit body surface browning brings about senescence development and limits its distribution potential and postharvest storage. In this investigation, 0.5 mM of NaHS as the optimum concentration for H2S fumigation was applied to retain the quality of Agaricus bisporus mushrooms concerning some qualitative and biochemical attributes evaluation throughout 15 storage-day at 4°C and 80-90% relative humidity. In H2S fumigated mushrooms, pileus browning index, weight loss and softening decreased, concomitant with higher cell membrane stability as revealed by subsidiary electrolyte leakage, malondialdehyde (MDA) and H2O2 contents compared to the control during the cold storage period. H2S fumigation boosted total phenolics, as presented by the enhanced phenylalanine ammonia-lyase (PAL) activity and total antioxidant scavenging activity, while polyphenol oxidase (PPO) activity diminished. Moreover, in H2S fumigated mushrooms not only peroxidase (POD), catalase (CAT), superoxide dismutase (SOD), glutathione reductase (GR) and glutathione peroxidase (GPx) activities but also ascorbic acid and glutathione (GSH) contents increased, even though glutathione (GSSG) content declined. The raised endogenous H2S level prompted by greater cystathionine ß-synthase (CBS), cystathionine ?-lyase (CSE), cysteine synthase (CS), L-cysteine desulfhydrases (LCD) and D-cysteine desulfhydrases (DCD) enzymes activities until 10d in fumigated mushrooms. In general, the increase in endogenous H2S biogenesis promoted by H2S fumigation in button mushrooms resulted in retarding senescence development, maintaining redox balance by boosting multiple enzymatic and non-enzymatic antioxidants defense parameters.

Functional Quality, Antioxidant Capacity and Essential Oil Percentage in Different Mint Species Affected by Salinity Stress

Saline stress is responsible for significant reductions in the growth of plants, and it globally leads to limitations in the performance of crops, especially in drought-affected areas. However, a better understanding of the mechanisms involved in the resistance of plants to environmental stress can lead to a better plant breeding and selection of cultivars. Mint is one of the most important medicinal plants, and it has important properties for industry, and for the medicinal and pharmacy fields. The effects of salinity on the biochemical and enzymatic properties of 18 ecotypes of mint from six different species, that is, Mentha piperita, Mentha mozafariani, Mentha rotundifolia, Mentha spicata, Mentha pulegium and Mentha longifolia, have been examined in this study. The experimental results showed that salinity increased with increasing in stress integrity influenced the enzymatic properties, proline content, electrolyte leakage, and the hydrogen peroxide, malondialdehyde, and essential oil contents. Cluster analysis and principal component analysis were conducted, and they grouped the studied species on the basis of their biochemical characteristics. According to the obtained biplot results, M. piperita and M. rotundifolia showed better stress tolerance than the other varieties, and M. longifolia was identified as being salt sensitive. Generally, the results showed that H₂ O₂ and malondialdehyde had a positive connection with each other and showed a reverse relationship with all the enzymatic and non-enzymatic antioxidants. Finally, it was found that the M. spicata, M. rotundifolia and M. piperita ecotypes could be used for future breeding projects to improve the salinity tolerance of other ecotypes.

Understanding the Postharvest Phytochemical Composition Fates of Packaged Watercress (Nasturtium officinale R. Br.) Grown in a Floating System and Treated with Bacillus subtilis as PGPR

The physiological changes and phytochemical pathways of processed watercress (Nasturtium officinale R. Br.) undergone during storage are not well known. The objective of this work was to evaluate the respiration rate and the inherent and external quality of watercress inoculated with B. subtilis and packaged as a fresh-cut product and stored at 4 °C for 11 days. Watercress was grown using continuous flotation (FL) in a greenhouse using substrate disinfection and inoculated or not with Bacillus subtilis as a plant-growth-promoting rhizobacteria (PGPR). The fresh-cut watercress respiration rate and phytochemical profile changed during the shelf life. The inherent phytochemical compounds were retained during the storage of the fresh-cut salad bags. The best results were found in watercress grown in a disinfected substrate but were less satisfactory when seeds and substrates were inoculated with PGPR. In general, the external quality and the pigment contents progressively decreased during the shelf life and the browning enzyme activities responsible for phenolic oxidation increased at different intensities throughout storage. At the end of the shelf-life period, the fresh weight loss of the fresh-cut product was less than 1% of the original weight. The results demonstrated that watercress grown in FL is a standardised baby leaf vegetable that is suitable for processing in the fresh-cut industry and for storing for more than 10 days. Unclear results were obtained for Bacillus subtilis in the postharvest period due to the inconsistent responses of the different analysed parameters.

Investigation of yield, phytochemical composition, and photosynthetic pigments in different mint ecotypes under salinity stress

Salinity stress is one of the main limiting factors of medicinal plant growth and may affect their characteristics and chemical composition. In order to evaluate the response of different species of Iranian mint to salinity stress, an experiment was designed in greenhouse conditions. In this experiment, six Iranian mint species were cultivated in pots under different salinity stress including 0, 2.5, 5, and 7.5 dS/m. The chlorophyll indices (a, b, total, and a/b ratio), carotenoids, total anthocyanin, total phenolic and flavonoid content, antioxidant activity, dry matter yield, and essential oil content were measured in two different harvest stages. Salinity stress affected various measured traits. The results showed that despite the negative effect of salinity stress on photosynthetic pigments, in some ecotypes and species, photosynthetic pigments were not affected by salinity stress. The amount of total phenolic content, total flavonoid content, and total anthocyanin increased in response to salinity stress. The dry matter decreased under salinity stress, but the content of essential oil increased as a result of salinity stress increment. The results of PCA biplot showed that the E16 and E18 ecotypes were separated by a large distance. Among the various ecotypes, E18 had the most desirable traits which can be recognized as a salt-tolerant ecotype. Also, piperita species was the best among the species in all salinity stress levels.

How do essential oil composition and phenolic acid profile of Heracleum persicum fluctuate at different phenological stages?

Heracleum persicum, commonly named Persian hogweed, is a principal native medicinal plant in Iran. Collecting H. persicum at the most appropriate growing stage is the key factor to achieve the high phytochemical quality to meet consumer's needs. In the present experiment, the aerial parts of this plant were harvested at up to six different developmental stages during the growing season to determine the phytochemical profiles. Our results indicated that the highest essential oil content was obtained in the mid-mature seed stage (3.5%). The most elevated extract content was recorded in the floral budding stage (10.4%). In the vegetative stage, limonene (18.1%), in floral budding stage, caryophyllene (14.1%), anethole (14.6%), and β-bisabolene (12.7%), in the full flowering stage, myristicin (15.0%), and hexyl butyrate (9.1%), in the early development of seeds stage, hexyl butyrate (32.1%), and octyl acetate (11.7%), in the mid-mature seeds stage hexyl butyrate (38.8%), octyl acetate (14.5%), in the late-mature/ripe seeds stage, hexyl butyrate (23.6%), and octyl acetate (10.5%) are recorded as the main components. The highest phenolic acids content was obtained in the floral budding stage (287.40 mg/g dried extract). The analysis of phenolic acids demonstrated cinnamic acid (8.0-225.3 mg/g extract), p-coumaric acid (1.7-39.2 mg/g extract), p-hydroxybenzoic acid (0.8-16.8 mg/g extract), and ferulic acid (2.4-15.8 mg/g extract) as the main phenolic acids. Cinnamic acid was found as the major phenolic compound in the vegetative stage following by floral budding, the full flowering stage, the early development of seeds, and late-mature/ripe seeds stages. P-coumaric acid was the most abundant phenolic compounds in the mid-mature seeds stage. In this regard, the harvest time of H. persicum aerial parts can be selected to achieve the highest secondary metabolites of interest. The results of this study can be used as a guideline for grower to obtain the highest possible amount of desirable metabolites, beneficial in both food and pharmaceutical industries as well as their undeniable economical benefits.

Areca catechu-From farm to food and biomedical applications

The family Arecaceae includes 181 genera and 2,600 species with a high diversity in physical characteristics. Areca plants, commonly palms, which are able to grow in nearly every type of habitat, prefer tropical and subtropical climates. The most studied species Areca catechu L. contains phytochemicals as phenolics and alkaloids with biological properties. The phenolics are mainly distributed in roots followed by fresh unripe fruits, leaves, spikes, and veins, while the contents of alkaloids are in the order of roots, fresh unripe fruits, spikes, leaves, and veins. This species has been reputed to provide health effects on the cardiovascular, respiratory, nervous, metabolic, gastrointestinal, and reproductive systems. However, in many developing countries, quid from this species has been associated with side effects, which include the destruction of the teeth, impairment of oral hygiene, bronchial asthma, or oral cancer. Despite these side effects, which are also mentioned in this work, the present review collects the main results of biological properties of the phytochemicals in A. catechu. This study emphasizes the in vitro and in vivo antioxidant, antimicrobial, anticancer, and clinical effectiveness in humans. In this sense, A. catechu have demonstrated effectiveness in several reports through in vitro and in vivo experiments on disorders such as antimicrobial, antioxidant, or anticancer. Moreover, our findings demonstrate that this species presents clinical effectiveness on neurological disorders. Hence, A. catechu extracts could be used as a bioactive ingredient for functional food, nutraceuticals, or cosmeceuticals. However, further studies, especially extensive and comprehensive clinical trials, are recommended for the use of Areca in the treatment of diseases.

Rosmarinus plants: Key farm concepts towards food applications

Rosmarinus species are aromatic plants that mainly grow in the Mediterranean region. They are widely used in folk medicine, food, and flavor industries and represent a valuable source of biologically active compounds (e.g., terpenoids, flavonoids, and phenolic acids). The extraction of rosemary essential oil is being done using three main methods: carbon dioxide supercritical extraction, steam distillation, and hydrodistillation. Furthermore, interesting antioxidant, antibacterial, antifungal, antileishmanial, anthelmintic, anticancer, anti-inflammatory, antidepressant, and antiamnesic effects have also been broadly recognized for rosemary plant extracts. Thus the present review summarized data on economically important Rosmarinus officinalis species, including isolation, extraction techniques, chemical composition, pharmaceutical, and food applications.

Resource use efficiency of indoor lettuce (Lactuca sativa L.) cultivation as affected by red:blue ratio provided by LED lighting

LED lighting in indoor farming systems allows to modulate the spectrum to fit plant needs. Red (R) and blue (B) lights are often used, being highly active for photosynthesis. The effect of R and B spectral components on lettuce plant physiology and biochemistry and resource use efficiency were studied. Five red:blue (RB) ratios (0.5-1-2-3-4) supplied by LED and a fluorescent control (RB = 1) were tested in six experiments in controlled conditions (PPFD = 215 μmol m-2 s-1, daylength 16 h). LED lighting increased yield (1.6 folds) and energy use efficiency (2.8 folds) as compared with fluorescent lamps. Adoption of RB = 3 maximised yield (by 2 folds as compared with RB = 0.5), also increasing leaf chlorophyll and flavonoids concentrations and the uptake of nitrogen, phosphorus, potassium and magnesium. As the red portion of the spectrum increased, photosystem II quantum efficiency decreased but transpiration decreased more rapidly, resulting in increased water use efficiency up to RB = 3 (75 g FW L-1 H2O). The transpiration decrease was accompanied by lower stomatal conductance, which was associated to lower stomatal density, despite an increased stomatal size. Both energy and land surface use efficiency were highest at RB ≥ 3. We hereby suggest a RB ratio of 3 for sustainable indoor lettuce cultivation.

Physico-chemical properties and fatty acid composition of

Chrozophora tinctoria L., usually known as dyer’s Croton, Turnsole or Giradol, has been used in various medicinal and food products for many years. However, no comprehensive research has been undertaken to assess its potential as a new seed oil crop. Therefore, the current study examined the fatty acid composition, physico-chemical properties and antioxidant activity of C. tinctoria seeds, grown in the southwest of Iran. The seed oil content was found to be 26.40%. The extracted oil was analyzed for fatty acid composition using gas chromatography (GC). The results showed that unsaturated fatty acids accounted for almost 91% of the total fatty acids. Linoleic acid was the dominant fatty acid (76.68%), followed by oleic acid (13.99%) and palmitic acid (5.32%). δ-tocopherol was the major tocopherol in the oil, representing 70 mg/100 g oil. The total phenolic content (151.70 mg GAE per 100 g oil) and total flavonoid content (1.17 mg QE oil) were also determined in the extracted oil. The antioxidant activity was measured by a DPPH assay and expressed as 45% of the seed oil. Due to its high oil yield and high unsaturated fatty acid content, C. tinctoria could be regarded as a new source of edible oil.

Veronica Plants-Drifting from Farm to Traditional Healing, Food Application, and Phytopharmacology

The Veronica genus, with more than 200 species, belongs to the Plantaginaceae family and is distributed over most of the Northern Hemisphere and in many parts of Southern Hemisphere. These plants are traditionally used in medicine for wound healing, in the treatment of rheumatism, and in different human diseases. This paper reviews the chemical composition of some valuable Veronica species, the possibilities Veronica extracts have in food preservation and as food ingredients, and their functional properties. Veronica species represent a valuable source of biological active secondary metabolites, including iridoid glycosides and phenolic compounds. In particular, due to presence of these phytochemicals, Veronica species exhibit a wide spectrum of biological activities, including antimicrobial and antioxidant. In fact, some studies suggest that some Veronica extracts can inhibit foodborne pathogens, such as Listeria monocytogenes, but only a few of them were performed in food systems. Moreover, anticancer, anti-inflammatory, and other bioactivities were reported in vitro and in vivo. The bioactivity of Veronica plants was demonstrated, but further studies in food systems and in humans are required.

Physiochemical properties of petunia edible flowers grown under saline conditions and their postharvest performance under modified atmosphere packaging and ethanol application

BACKGROUND

Edible flowers have both great nutritional value and sensory appeal; however, their shelf-life is limited to a few days because they are highly perishable.

RESULTS

The impact of postharvest ethanol (ET) treatment and modified atmosphere packaging (MAP) on the quality and storage of edible flowers collected from short-term salt-stressed plants was tested. Hydroponically grown petunia (Petunia x hybrita L.) plants were subjected to salinity (0-50-100 mmol L^-1 NaCl) and harvested flowers were stored for up to 14 days in MAP and/ET vapours. The salinity of 100 mmol L^-1 NaCl decreased plant biomass and negatively affected physiological processes as a result of stomata closure. Flower polyphenols, antioxidants, carotenoids and anthocyanins increased with 50 mmol L^-1 of NaCl, indicating a higher nutritional value. Short-term exposure of petunia to salinity decreased the flower N, K and Ca concentrations. During storage for 7 days, salinity lead to deteriorated flowers that showed browning as a result of tissue breakdown, whereas CO₂ production and weight loss were unaffected by salinity. After 14 days of storage, salinity decreased flower respiration and increased weight loss, whereas ET application completely destroyed the flowers. Carotenoids and anthocyanins were decreased by a combination of salinity and ET. Petunia flowers revealed the induction of both non-enzymatic (i.e. proline content) and enzymatic (catalase) mechanisms to overcome the stress caused by salinity at harvest stage and/or ethanol at storage.

CONCLUSION

The results of the present study demonstrate that a short-stress salinity of 50 mmol L^-1 NaCl can be used for petunia growth and also that flowers of nutritional value can be stored for up to 7 days, whereas ET application failed to preserve petunia flowers. © 2019 Society of Chemical Industry.

Unraveling the Role of Red:Blue LED Lights on Resource Use Efficiency and Nutritional Properties of Indoor Grown Sweet Basil

Indoor plant cultivation can result in significantly improved resource use efficiency (surface, water, and nutrients) as compared to traditional growing systems, but illumination costs are still high. LEDs (light emitting diodes) are gaining attention for indoor cultivation because of their ability to provide light of different spectra. In the light spectrum, red and blue regions are often considered the major plants' energy sources for photosynthetic CO2 assimilation. This study aims at identifying the role played by red:blue (R:B) ratio on the resource use efficiency of indoor basil cultivation, linking the physiological response to light to changes in yield and nutritional properties. Basil plants were cultivated in growth chambers under five LED light regimens characterized by different R:B ratios ranging from 0.5 to 4 (respectively, RB0.5, RB1, RB2, RB3, and RB4), using fluorescent lamps as control (CK1). A photosynthetic photon flux density of 215 μmol m-2 s-1 was provided for 16 h per day. The greatest biomass production was associated with LED lighting as compared with fluorescent lamp. Despite a reduction in both stomatal conductance and PSII quantum efficiency, adoption of RB3 resulted in higher yield and chlorophyll content, leading to improved use efficiency for water and energy. Antioxidant activity followed a spectral-response function, with optimum associated with RB3. A low RB ratio (0.5) reduced the relative content of several volatiles, as compared to CK1 and RB ≥ 2. Moreover, mineral leaf concentration (g g-1 DW) and total content in plant (g plant-1) were influences by light quality, resulting in greater N, P, K, Ca, Mg, and Fe accumulation in plants cultivated with RB3. Contrarily, nutrient use efficiency was increased in RB ≤ 1. From this study it can be concluded that a RB ratio of 3 provides optimal growing conditions for indoor cultivation of basil, fostering improved performances in terms of growth, physiological and metabolic functions, and resources use efficiency.

Artemisia umbelliformis Lam. and Génépi Liqueur: Volatile Profile as Diagnostic Marker for Geographic Origin and To Predict Liqueur Safety

Artemisia umbelliformis, commonly known as "white génépi", is characterized by a volatile fraction rich in α- and β-thujones, two monoterpenoids; under European Union (EU) regulations these are limited to 35 mg/L in Artemisia-based beverages because of their recognized activity on the human central nervous system. This study reports the results of an investigation to define the geographical origin and thujone content of individual plants of A. umbelliformis from different geographical sites, cultivated experimentally at a single site, and to predict the thujone content in the resulting liqueurs through their volatile fraction. Headspace solid phase microextraction (HS-SPME) combined with gas chromatography-mass spectrometry (GC-MS) and non-separative HS-SPME-MS were used as analytical platforms to create a database suitable for chemometric description and prediction through linear discriminant analysis (LDA). HS-SPME-MS was applied to shorten analysis time. With both approaches, a diagnostic prediction of (i) plant geographical origin and (ii) thujone content of plant-related liqueurs could be made.

Abstract P6-16-08: The impact of genomic mutation on metastatic breast cancer treatment: A retrospective clinical trial

Background: Next-Generation Sequencing (NGS) has made genomic mutation-driven cancer medicine feasible. Recognizing the importance of pathway and biomarker-driven personalized therapy for patients with metastatic breast cancer (MBC), we frequently submit tumor tissue for FoundationOne® genomic sequencing. Here we report the results and clinical impact of this test in 44 patients with MBC.

Patients and Methods: An institution IRB protocol was established for this retrospective clinical trial performed at the City of Hope Comprehensive Cancer Center from January 2014 to May 2016 with available tumor genomic DNA mutation results through FoundationOne® testing. Patients' clinical characteristics including age, race, treatment history, clinical outcome and genomic mutation profiles were reviewed.

Results: We identified 44 patients with MBC submitted for FoundationOne® genomic profiling: 24 triple negative breast cancer (TNBC), 16 estrogen receptor positive (ER+) and 4 human epidermal growth factor receptor 2 positive (HER2+). A total of 23 patients received over 3 lines of chemotherapies prior to FoundationOne® testing. Actionable mutations were identified in 42 of the 44 patients and 23 patients (52%) initiated mutation-driven targeted therapies. Of these 23 patients treated, a total of 17 had accessible responses and 6 patients did not have accessible responses due to short exposure (<2 weeks) and transition to hospice. The remaining 19 patients failed to initiate targeted therapy: 7 transitioned to palliative care/hospice, 5 were placed on other chemotherapy by treating physician, 4 had exhausted all of the targeted therapies recommended, and 3 chose not to start on treatment. Of the 7 responders, 2 received pazopanib and 5 received everolimus containing regimen. Durable response was observed in 3 cases: two patients carried PIK3CA alterations and were treated with everolimus, and the other responder had FGFR1 amplification and was treated with pazopanib. Comparing the genomic mutation profiling with The Cancer Genome Atlas (TCGA) database which contains primary breast cancer, the heavily pretreated TNBC tumors carried higher percentage of PIK3CA mutations (29% vs. 8%, p<0.01).

Conclusion: Targeted genomic sequencing through FoundationOne® can identify effective therapy that has not generally been used based on pathology type. NGS should be performed early in patients with good performance status. This approach should be utilized in a setting where genomic mutation driven therapeutic trials are available.

Contact information: Yuan Yuan MD PhD, Department of Medical Oncology & Molecular Therapeutics; City of Hope Comprehensive Cancer Center; Duarte, CA 91030; Email: yuyuan@coh.org.

Citation Format: Yuan Y, Yost S, Yuan Y-C, Liu Z, Frankel P, Nicola S, Mortimer J. The impact of genomic mutation on metastatic breast cancer treatment: A retrospective clinical trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-16-08.

Th-17 cytokines and interstitial lung involvement in systemic sclerosis

The two phenotypes of both limited and diffuse systemic sclerosis (SSc) have different forms of pulmonary involvement: pulmonary arterial hypertension (limited phenotype) or interstitial lung disease (ILD) (diffuse phenotype). We aimed to investigate whether Th17-related cytokines, as measured in exhaled breath condensate (EBC) and in serum were connected to ILD in diffuse SSc patients. We found that for both limited and diffuse SSc, the EBC levels of all cytokines and most of the cytokine serum levels were significantly higher in patients than in controls, while, the EBC levels of Th-17 cytokines and the serum levels of IL-10 and TNF-α were significantly higher in diffuse than in limited SSc. Moreover, the thoracic CT-scan score of ILD was significantly associated with the EBC levels of IL-1 beta and with the serum IL-23, TNF-α and IL-10 levels, whereas lung carbon monoxide diffusing capacity was negatively related to the EBC levels of IL-1 beta, IL-17 and serum IL-10. Serum IL-23 was also inversely correlated with vital capacity. In conclusion, in diffuse SSc patients our results show a clear link between Th-17 cytokines measured both in EBC and in serum with interstitial lung involvement. This highlights how important it is to target Th-17 cytokines when developing new treatments for lung fibrosis.

Effects of water stress and light intensity on chlorophyll fluorescence parameters and pigments of Aloe vera L

Aloe vera L. is one of the most important medicinal plants in the world. In order to determine the effects of light intensity and water deficit stress on chlorophyll (Chl) fluorescence and pigments of A. vera, a split-plot in time experiment was laid out in a randomized complete block design with four replications in a research greenhouse. The factorial combination of three light intensities (50, 75 and 100% of sunlight) and four irrigation regimes (irrigation after depleting 20, 40, 60 and 80% of soil water content) were considered as main factors. Sampling time was considered as sub factor. The first, second and third samplings were performed 90, 180 and 270 days after imposing the treatments, respectively. The results demonstrated that the highest light intensity and the severe water stress decreased maximum fluorescence (Fm), variable fluorescence (Fv)/Fm, quantum yield of PSII photochemistry (ФPSII), Chl and photochemical quenching (qP) but increased non-photochemical quenching (NPQ), minimum fluorescence (F0) and Anthocyanin (Anth). Additionally, the highest Fm, Fv/Fm, ФPSII and qP and the lowest NPQ and F0 were observed when 50% of sunlight was blocked and irrigation was done after 40% soil water depletion. Irradiance of full sunlight and water deficit stress let to the photoinhibition of photosynthesis, as indicated by a reduced quantum yield of PSII, ФPSII, and qP, as well as higher NPQ. Thus, chlorophyll florescence measurements provide valuable physiological data. Close to half of total solar radiation and irrigation after depleting 40% of soil water content were selected as the most efficient treatments.

Postharvest management affects spearmint and calamint essential oils

BACKGROUND

The objectives of this work were to evaluate the phytomass yield, essential oil (EO) content and EO yield of Mentha spicata L. var. rubra, M. spicata L. var. viridis and Calamintha nepeta Savi in Piedmont (Italy), and to study how postharvest management (hydrodistillation of EO from fresh, dehumidified or oven-dried herbs) can affect the EO content and profile of the three species.

RESULTS

Mentha spicata L. var. rubra gave the greatest phytomass yield (1997 g m(-2)), which was statistically different from M. spicata L. var. viridis and C. nepeta. The highest EO yield was obtained from C. nepeta (3.75 g m(-2)), which was significantly different from the Mentha genus. Postharvest management significantly affected both the EO content and the EO profile of each species, with the dehumidifying process leading to a significantly higher EO content than the oven-drying process. The EO profile was different not only from species to species but also because of the postharvest management.

CONCLUSION

The dehumidifying process is a relatively new postharvest technology that has shown positive results in terms of EO yield, and it can be applied to species which have a high EO value, after evaluation of the resulting EO profile.

Hydrodistillation and in situ microwave-generated hydrodistillation of fresh and dried mint leaves: a comparison study

BACKGROUND

Hydrodistillation (HD) has been used since ancient times for the extraction of essential oils (EO). Despite the intrinsic limitations of this technique, it remains the most common method both in the laboratory and on an industrial scale. The main drawbacks are the long extraction time involved and the risk of thermal degradation. Over the last decade, microwave-assisted extraction (MAE) and in situ microwave-generated hydrodistillation (MGH) have been shown to be the most promising techniques in improving plant extraction and hydrodistillation.

RESULTS

In this study we compare HD with MGH in the extraction of several mint species cultivated in Piedmont: Mentha spicata L. var. rubra, Mentha spicata L. var. viridis and Mentha piperita L. MGH requires either fresh plant or rehydrated material, it is extremely fast and allows a reduction in energy consumption and overall cost. All the EO have been analyzed by gas chromatography-mass spectrometry. A mechanism of microwave-generated essential oil extraction has been proposed to explain the differences in the composition of the oil obtained from this environmentally friendly technique.

CONCLUSIONS

The yields and composition percentages of the EO obtained by HD and in situ MGH of fresh and dried mint leaves lie in a relatively narrow range, although MGH is faster. MW polarization effects and the water solubility of the components influence extract composition.

[Cytofluorimetric evaluation of peripheral blood dendritic cells in patients with Mediterranean Kaposi's sarcoma]

AIM

Kaposi's sarcoma (KS) is a lympho-angioproliferative disorder characterized by angiomatous nodules and plaques that mainly affect the skin. The disease is consistently associated with human herpesvirus-8 (HHV8) and with a state of preexistent immunosuppression. Dendritic cells (DCs) have an instrumental role in the activation and function of both innate and adaptative immune responses. At least 2 distinct subsets have been characterized in peripheral blood based on phenotypic markers: myeloid DCs (CD11c+), associated with Ag uptake, T cell activation and ability to secrete IL-12, and plasmacytoid DCs, high virus-induced IFN-alpha producing cells. Because of the role of both DC subtypes in antiviral and antitumor induced responses, we hypothesized that DCs could be involved in the onset and evolution of KS.

METHODS

Thirty-five patients with mediterranean KS assigned to different clinical stages were compared with 51 healthy control subjects. Peripheral blood DCs were quantified and functionally characterised by flow cytometry directly on whole blood samples. The production of the regulatory cytokines, IL-12 and IL-10, was assessed as intracellular accumulation after incubation with or without lipopolysaccharide (LPS).

RESULTS

Myeloid DCs identified as lineage-/HLA-DR+/CD11c+ cells were significantly lower in KS patients than in controls (0.54+/-0.25 vs 0.69 +/-0.26% of the peripheral blood mononuclear cells; p<0.017). Furthermore, CD11c+ DCs were lower in patients with more diffuse disease. Plasmacytoid DCs, identified as lineage-/HLA-DR+/CD123+ cells, were lower in KS patients (0.23+/-0.19 vs 0.36+/-0.17; p<0.001). DCs from KS patients were more mature, as assessed by expression of the maturation marker CD83, and showed an impaired ability to produce IL-12 upon LPS stimulation, as compared with controls.

CONCLUSION

The numerical and functional alterations of peripheral blood DCs observed in KS patients suggest an involvement of these cells in the onset and evolution of the disease.

Altered maturation of peripheral blood dendritic cells in patients with breast cancer

Tumours have at least two mechanisms that can alter dendritic cell (DC) maturation and function. The first affects the ability of haematopoietic progenitors to differentiate into functional DCs; the second affects their differentiation from CD14+ monocytes, promoting an early but dysfunctional maturation. The aim of this study was to evaluate the in vivo relevance of these pathways in breast cancer patients. For this purpose, 53 patients with invasive breast cancer were compared to 68 healthy controls. To avoid isolation or culture procedures for enrichment of DCs, analyses were directly performed by flow cytometry on whole-blood samples. The expression of surface antigens and intracellular accumulation of regulatory cytokines upon LPS stimulation were evaluated. The number of DCs, and in particular of the myeloid subpopulation, was markedly reduced in cancer patients (P<0.001). Patient DCs were characterized by a more mature phenotype compared with controls (P=0.016), and had impaired production of IL-12 (P<0.001). These alterations were reverted by surgical resection of the tumour. To investigate the possible role of some tumour-related immunoactive soluble factors, we measured the plasmatic levels of vascular endothelial growth factor, IL-10 and spermine. A significant inverse correlation between spermine concentration and the percentage of DCs expressing IL-12 was found. Evidence was also obtained that in vitro exposure of monocyte-derived DCs to spermine promoted their activation and maturation, and impaired their function. Taken together, our results suggest that both the above-described mechanisms could concomitantly act in breast cancer to affect DC differentiation, and that spermine could be a mediator of dysfunctional maturation of DCs.

[Gentamycin distribution volume in a mechanically ventilated patient-- pharmacokinetic and clinical aspects]

Mechanical ventilation (MV) of more than 32 hours may alter the gentamycin pharmacokinetic profile by increasing its volume of distribution (VD). As a result, the standard garamycin dosage regime has to be adjusted in order to obtain an adequate peak serum concentration, which is well correlated with the efficacy of garamycin therapy. Garamycin is a water-soluble drug with negligible binding to plasma albumin, so its VD approximates the volume of extra-cellular fluid, which may be expanded by MV. MV-related fluid retention is mediated via various homeostatic compensatory systems. They are activated to combat the decrease in cardiac output and central blood volume caused by MV, due to the increase in airway and intrathoracic pressure. These phenomena are more prominent during prolonged ventilation, PEEP or C-PAP ventilation, and in previously hypovolemic patients. Patients requiring MV for more than 32 hours had an average garamycin VD of 0.36 L/Kg compared with the mean VD of 0.25 L/Kg in normal adults. In the patient presented, a similar change in garamycin VD was seen, while conventional doses given during MV failed to reach suitable clinical peak levels.

Severe myocardial dysfunction and coronary revascularization

Severe myocardial dysfunction, characterized by global hypokinesis, or akinetic areas with hypokinesis of the remaining wall, and a very low ejection fraction (EF), has been considered to be a contraindication for coronary revascularization (CABG). However, myocardial scintigraphy and echo-stress data have shown that hypo- or akinetic areas can regain their contractility. Therefore, we expanded the indications for CABG, and performed operations even upon patients who were waiting for a heart transplant. Between January 1993 and June 1995, among 352 patients who underwent CABG, 85 had highly depressed left ventricular function. Their resting EF was lower than 0.35, and in 27 it was lower than 0.25. Viable areas of myocardium were found in all of the patients through the combination of scintigraphy and dobutamine-echocardiography: these areas depended on significant coronary lesions. The mean age of the patients was 48.2 years (range 33-62 years); angina was present in 62 patients. A mean of 3.1 grafts/patient were implanted; enoximone was used in all but 5 patients upon weaning from cardiopulmonary bypass; intra-aortic balloon pump was used in 9 cases. Operative mortality was 10.6% (9 patients), due to low-output syndrome in 5, acute myocardial infarction in 2, cerebral damage in 1, and respiratory failure in 1. At the 6-month follow-up, EF was improved in all but 7 patients, in whom it remained unchanged. Scintigraphic and echocardiographic tests revealed good function in most of the areas that had been previously recognized as hypo- or akinetic. These results suggest that the indications for standard myocardial revascularization can be expanded, and a promising option can be offered to patients who may otherwise be destined to wait for an uncertain transplantation.

The effect of work activity in pregnancy on the risk of fetal growth retardation

BACKGROUND

The relationship between physical activity at work and risk of fetal growth restriction is controversial. For the most part, previous studies investigated the effect of work activity on birthweight alone. We evaluated the impact of type of occupation and physical effort at work on the risk of ultrasonographically confirmed fetal growth retardation among nulliparous women.

METHODS

We compared the characteristics of work and the intensity of occupational fatigue (work posture, weekly working hours, physical effort at work) in 349 patients with ultrasonographically confirmed fetal growth retardation and 698 control pregnancies with appropriate fetal growth. Physical demands at work were evaluated by interview at birth. Logistic regression analysis was used to evaluate the association of employment status, type of occupation, and intensity of occupational fatigue with the risk of fetal growth retardation, correcting for potential confounders (maternal age, pre-pregnancy body mass index, mean weight gain in pregnancy, education, partner's social status, smoking in pregnancy, alcohol use, illicit drug use, time of stopping work, and hypertension).

RESULTS

After adjusting for confounding, the risk of fetal growth retardation was similar between unemployed and formally employed women at the beginning of pregnancy (OR = 1.26; 95% confidence interval = 0.86 - 1.83). However, manual workers were at slightly higher risk of IUGR than not formally employed women (OR = 1.81; 95% CI = 1.15 - 2.85). Among formally employed women, standing or walking at work, and working > or = 30 hours a week were not significantly associated with IUGR. Finally, the risk of IUGR was significantly higher (OR = 2.46; 95% CI = 1.36 - 4.21) among women reporting moderate-to-heavy as compared to light physical effort at work.

CONCLUSION

Formal employment at the beginning of pregnancy is not associated with an increased risk of IUGR. However, moderate-to-heavy physical effort at work seems to increase the risk of sonographically confirmed fetal growth retardation.

Effect measures for behavioral factors adversely affecting fetal growth

The purpose of this study was to estimate the proportion of ultrasonically diagnosed fetal growth retardation that may be attributable to potentially remediable factors (for example, cigarette smoking, alcohol use, and drug addition). We computed multivariate odds ratios for fetal growth retardation associated with cigarette smoking and alcohol and illicit drug consumption in 350 singleton pregnancies complicated by fetal growth retardation and 700 controls. The odds ratio of fetal growth retardation among women who smoked throughout pregnancy was 2.61 (95% confidence interval, 1.38 to 4.93) compared to women who claimed to have stopped smoking by the 18th week of gestation. The summary attributable risk of fetal growth retardation associated with behavioral variables measured during the first trimester and thereafter ranged from 18 to 21%. By implication, the maximum proportion of fetal growth retardation that could theoretically be prevented by eliminating these risk factors accounts for about 1% of all births. However, allowance for the limited modifiability of preventable factors and the consistent overlap between them would probably reduce such estimate to less than 1%. We conclude that only interventions to reduce the prevalence of strong risk factors (for example, preeclampsia, sociodemographic variables) may have a substantial effect on the incidence of impaired fetal growth and subsequent infant morbidity.

The effect of work activity in pregnancy on the risk of severe preeclampsia

The aim of this study was to evaluate the impact of type of employment and level of physical activity at work on the risk of severe preeclampsia. For this purpose, we carried out a case control study of 160 nulliparous pregnant women with severe preeclampsia and 320 normotensive nulliparous controls who received prenatal care from members of one medical staff. The type of employment and the level of physical activity sustained at work were ascertained at birth through an interview based on a standard questionnaire. The degree of physical activity at work was assessed by a 4-level activity score based on type of work, physical intensity, posture at work, and weekly working hours. In logistic regression analysis, after adjustment for potential confounders (maternal age, time of stopping work, prepregnancy body mass index, social status of the partner, history of previous abortion, and prepregnancy smoking status), clerical workers had a significantly lower risk of severe preeclampsia than women who were unemployed at the beginning of pregnancy (OR 0.53, 95% CI 0.30, 0.96). In multivariate analysis, there was a significant linear trend relating the degree of physical activity at work, to the risk of preeclampsia (likelihood chi-square = 9.38, 3 df, p = 0.002). We then restricted the analysis to women who had ever worked in pregnancy (n = 339) also adjusting for confounders, and found that clerical workers were still at significantly lower risk of severe preeclampsia than women not formally employed (OR 0.2, 95% CI 0.08, 0.49). In addition, moderate/high physical activity at work was associated with a 2-fold increase in the risk of severe preeclampsia compared to mild activity (OR 2.08, 95% CI 1.11, 3.88). We conclude that moderate to high physical activity at work seems to increase the risk of severe preeclampsia.

Sociodemographic and clinical variables modifying the smoking-related risk of low birth weight

OBJECTIVE

The purpose of the study was to evaluate the sociodemographic and clinical variables modifying the smoking-related risk of low birth weight (< 2500 g).

METHOD

This case-control study included a population of 967 singleton low birth weight deliveries and 967 selected controls. Unconditional logistic regression analysis was used to test statistical significance of the interactions between smoking in pregnancy and other risk factors for low birth weight.

RESULTS

Increasing maternal age and parity potentiate the smoking-related risk of a low birth weight infant. The effect of maternal smoking on the risk of low birth weight was significantly increased in patients with a history of previous spontaneous abortion (excess risk 2.30, 95% C.I. 1.24-4.27) and in patients of high compared with patients of intermediate or low social class (excess risk 1.97, 95% C.I. 1.1-3.57). Smokers with less than two prenatal visits per trimester were at significantly greater risk of delivering a low birth weight infant (excess risk 2.36, 95% C.I. 1.14-4.87) than their counterparts with more frequent prenatal visits. Among clinical variables, the effect of maternal smoking on the risk of low birth weight was significantly increased in women with a history of first trimester hemorrhage during the current pregnancy (excess risk 2.67, 95% C.I. 1.30-5.49).

CONCLUSIONS

The smoking-related risk of low birth weight is very high in some subgroups of women. Identification of these subgroups could be important for prenatal counseling.

Torulopsis glabrata vaginitis

OBJECTIVE

To study the sociodemographic risk factors and clinical features of Torulopsis glabrata vaginal infection.

METHODS

We evaluated the sociodemographic and clinical characteristics of 86 consecutive symptomatic women attending a vaginitis clinic and isolated T glabrata. Case patients were compared with a control group of 174 asymptomatic women with negative vaginal cultures and an additional group of 625 symptomatic women with vaginal cultures positive for Candida albicans. In addition, the sensitivity of the isolates to the more common antimycotic agents used was tested by the modified Kirby-Bauer method.

RESULTS

Patients with T glabrata vaginal infection were from lower socioeconomic backgrounds and had less education. They were more likely to use vaginal tampons and to be seropositive for human immunodeficiency virus than were negative controls. Compared with C albicans infection, T glabrata was more frequent among women over 38 years of age and in those with less education and of lower social class. In logistic regression analysis, T glabrata was associated more frequently with recurrent vaginal candidiasis than was C albicans (odds ratio 2.46, 95% confidence interval 1.33-4.54; P = .004). Six of the 86 (7%) T glabrata isolates and none of the C albicans isolates (P < .001 by Fisher exact test) were resistant to the imidazole derivatives tested.

CONCLUSION

Torulopsis glabrata was isolated in 10% of women with vulvovaginal candidiasis attending a vaginitis clinic. This infection was associated with recurrent vaginitis in almost one-third of case patients presenting with symptoms.

The impact of oral contraception on vulvovaginal candidiasis

To evaluate risk factors related to sociodemographic and clinical variables, oral contraception and sexual behavior of women with recurrent vulvovaginal candidiasis, we conducted a case-control study comparing 153 patients with recurrent vulvovaginal candidiasis with both asymptomatic women with negative vaginal cultures and patients with nonrecurrent symptomatic vulvovaginal candidiasis. In logistic regression analysis, patients with recurrent Candida vaginitis were more likely than negative controls to have used any contraceptive method in the year before evaluation, to have used antibiotics in the month preceding the visit, and to have a higher number of lifetime sex partners. Compared to patients with nonrecurrent Candida vaginitis, patients with recurrent infection were more likely to use oral contraception and to have a higher frequency of monthly intercourse. The proportion of recur rent disease attributable to the pill averages 11-12%. We conclude that oral contraceptives may influence the recurrence of symptomatic vulvovaginal candidiasis.

Pregnancies complicated by idiopathic intrauterine growth retardation. Severity of growth failure, neonatal morbidity and two-year infant neurodevelopmental outcome

We evaluated the impact of the severity of intrauterine growth retardation (IUGR) measured as the proportion of expected birth weight (birth weight x 100/median birth weight) on short-term neonatal complications and two-year infant neurodevelopmental outcome. The study was carried out on 236 singleton pregnancies complicated by idiopathic IUGR. The rates of bradycardia, respiratory distress syndrome, hypocalcemia, ventilatory support, apneic crises, transient neurologic signs and poor neonatal outcome (neonatal death or cerebral palsy) significantly correlated with the increasing severity of IUGR. In logistic regression analysis more severely growth retarded infants (< 67.5% of expected birth weight) had higher rates of bradycardia, respiratory distress syndrome, hypocalcemia and bacterial sepsis when compared with those less severely affected (84-67.5% of expected birth weight). In pregnancies complicated by idiopathic IUGR, most short-term neonatal complications are inversely related to the severity of growth failure as evaluated by the proportion of expected birth weight.

Interaction between fetal gender and risk factors for fetal growth retardation

OBJECTIVE

Our purpose was to evaluate the interactions between fetal gender and recognized risk factors of fetal growth retardation.

STUDY DESIGN

A case-control study of 530 singleton pregnancies complicated by fetal growth retardation and 782 control pregnancies with appropriately grown fetuses was conducted. Interactions were evaluated by logistic regression analysis.

RESULTS

In logistic regression analysis fetal growth retardation was more frequent in female than male fetuses (odds ratio 1.39, 95% confidence interval 1.06 to 1.82). In female fetuses hypertension-related fetal growth retardation was three times more common than in males. On the other hand, a low (< 50 kg) maternal prepregnancy weight and a low (< 18) body mass index (kg/m2) were significant risk factors for fetal growth retardation in male fetuses only. Although maternal smoking in pregnancy was a significant risk factor for growth retardation in both male and female fetuses, its effect was significantly stronger in male fetuses.

CONCLUSION

Fetal gender can affect the magnitude of the classic risk factors for fetal growth retardation.

Epidemiological correlates of preterm premature rupture of membranes

OBJECTIVE

To study the clinical risk factors for preterm premature rupture of membranes (PROM).

METHOD

We conducted a case-control study of 138 patients with PROM between 24 and 35 weeks' gestation and 267 control subjects.

RESULTS

In stepwise multiple logistic regression models, the population of cases was more likely to be of low social class. Other risk factors for PROM were smoking in pregnancy, 1st or 2nd-3rd trimester hemorrhages, cervical incompetence and a documented cervico-vaginal infection during index pregnancy. First trimester hemorrhage and a documented cervico-vaginal infection during index pregnancy were associated with preterm PROM both in nulliparous and in multiparous women.

CONCLUSION

Few potentially remediable risk factors are associated with the occurrence of preterm PROM.

Cigarette smoking in pregnancy and risk of pre-eclampsia

The relationship between smoking in pregnancy and the development of pre-eclampsia has not been well studied. Smoking habits were prospectively evaluated in 117 patients with pre-eclampsia and 468 normotensive control pregnancies. Twenty cases (17.1%) and 120 controls (25.6%) reported smoking at any time during pregnancy. In stepwise multiple logistic regression analysis, smoking in pregnancy was a significant protective factor against the occurrence of pre-eclampsia (adjusted odds ratio = 0.50; 95% confidence interval 0.28-0.80, P = 0.018). On the other hand, a history of pre-eclampsia in previous pregnancies, low (< 6th grade) educational level, a body mass index > 24 and maternal blood group AB were factors independently associated with an increased risk of pre-eclampsia. In conclusion, this study confirms that smoking in pregnancy reduces the risk of pre-eclampsia. However, the harmful consequences of smoking on pregnancy outcome far outweigh this risk reduction.

Clinical and microbiological characteristics of symptomatic vulvovaginal candidiasis in HIV-seropositive women

OBJECTIVES

To evaluate the clinical and microbiological characteristics of symptomatic vaginal candidiasis in Human Immunodeficiency Virus (HIV)-seropositive women attending a gynaecologic outpatient clinic for sexually transmitted diseases (STDs).

DESIGN

Vaginal, rectal and oral specimens from cases and controls were cultured for Candida spp.

SUBJECTS

Eighty-four consecutive HIV-seropositive and 384 HIV-seronegative women with clinical signs of vulvovaginitis.

SETTING

A gynaecological out-patient clinic in Pavia, Italy.

RESULTS

The overall prevalence of vaginal candidiasis was 61.9% (52/84) in the cases and 32.3% (124/384; p < .001) in the controls. After adjustment by logistic regression analysis for confounding factors (age at first intercourse, lifetime sex partners, new partner/s in the last 6 months, type of contraceptive used), HIV-seropositive patients were at higher risk for both Candida albicans (odds ratio = 2.5; 95% confidence interval 1.31-4.69; p = 0.006) and Torulopsis glabrata vaginitis (OR = 3.5; 95% CI = 1.05-11.60; p = 0.04) than controls. HIV-seropositive subjects had also increased rates of oral and rectal colonisation with Candida spp. Finally, the time to recurrence of vaginal infection was significantly shorter in HIV-seropositive patients than controls and was correlated with the severity of HIV-induced immunodepression.

CONCLUSIONS

Vulvovaginal candidiasis is very common in HIV-seropositive women and its prevalence is correlated with the immunological status of the host. These patients have higher frequencies of Torulopsis glabrata vaginal infection and are more prone to recurrence than HIV-seronegative controls.

Maternal high-risk factors and severity of growth deficit in small for gestational age infants

The relationship between maternal risk factors and severity of fetal growth deficit was evaluated in a population of 613 small for gestational age (SGA) infants and 784 appropriately grown controls. The severity of growth deficit among SGA infants was expressed as 'fetal growth ratio' (observed/expected birthweight, where expected birthweight is the mean birthweight of the Italian population for a given gestational age). In multivariate models, preeclampsia was the only maternal high-risk factor positively correlated with a more severe growth deficit among SGA infants. Chronic cardiac or renal maternal diseases and female fetal sex were associated with mild forms of SGA, thus showing an inverse relationship with severity of growth deficit. Finally, the association between maternal smoking in pregnancy, low (< 0.2 kg/week) maternal weight gain, low (< 50 kg) pre-pregnancy weight, severe (Hb, < 8 g/dl) maternal anaemia, low education (< 6th grade), history of a previous low birthweight infant or recurrent spontaneous abortion, nulliparity and SGA was homogeneous across the severity strata of fetal growth deficit.

Asymptomatic genitourinary Chlamydia trachomatis infection in women seropositive for human immunodeficiency virus infection

OBJECTIVE

To evaluate the prevalence of asymptomatic Chlamydia trachomatis genitourinary infection in women with human immunodeficiency virus (HIV) infection.

METHODS

The prevalence of asymptomatic chlamydial genitourinary infection in HIV-seropositive women was compared with both HIV-seronegative controls and women with unknown HIV status. Chlamydia trachomatis was isolated in cell culture from endocervical and urethral specimens.

RESULTS

The prevalence of genitourinary C trachomatis infection among HIV-seropositive women was 18.3% (21 of 115), a rate significantly higher than in both HIV-negative women (11 of 136; P = .016) and controls with unknown HIV status (18 of 326; P = .0001). Crude odds ratios for endocervical and urethral chlamydial infection in HIV-seropositive women compared to HIV-seronegative controls were 2.6 (95% confidence interval [CI] 1.13-6.08) and 3.3 (95% CI 1.15-9.67), respectively. After adjustment for variables related to sexual habits, there was no difference in the risk of cervical C trachomatis infection between HIV-seropositive cases and HIV-seronegative controls (Mantel-Haenszel odds ratio 1.04, 95% CI 0.93-1.14; P = .41). Finally, in HIV-seropositive patients, both the severity of immunosuppression evaluated by CD4+, CD8+, and total lymphocyte counts and the detection of p24 HIV-related antigen did not correlate with the presence of chlamydial infection.

CONCLUSIONS

Women infected with HIV are at high risk for asymptomatic genitourinary chlamydial colonization. To prevent a possible "epidemic" of pelvic inflammatory disease, appropriate screening programs and therapeutic strategies should be planned.

Factors associated with abruptio placentae in preterm deliveries

OBJECTIVE

To evaluate risk factors associated with occurrence of abruptio placentae in preterm deliveries.

METHODS

Risk factors were evaluated in 55 consecutive index cases of abruptio placentae and 726 control patients delivered between 24-36 weeks' gestation.

RESULTS

In logistic regression analysis abruptio placentae was associated with a low number of antenatal visits, smoking in pregnancy, hypertension, intravenous drug abuse and a history of recent abdominal trauma. Among hypertensive disorders of pregnancy, preeclampsia superimposed on chronic hypertension was associated with the highest risk of premature placental separation. Finally, there was a significant trend relating duration of premature rupture of membranes with abruptio placentae (chi-square for trend = 3.93, p = 0.047).

CONCLUSIONS

Several risk factors seem strongly associated with abruptio placentae in preterm deliveries; the presence of these risk factors should dictate intensive surveillance.