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• Associate Director, Echocardiography Laboratory
• Associate Professor, New York University
• School of Medicine
• New York, New York

Availability and cost considerations do not tion or stroke and cardiovascular or all cause mortality) medicine 10 day 2 times a day chart generic paroxetine 20 mg fast delivery. Evidence for therapeutic management of healthy cardiovascular system medicine 832 buy paroxetine toronto, but must always be hypertension preceded by alterations in organ structure or function treatment quotes and sayings buy cheap paroxetine line, 4 medicine 7 years nigeria buy cheap paroxetine 20 mg online. Similarly medicine xl3 order 10mg paroxetine with amex, a valuable approach to extend of available evidence on the benefits associated with evidence of the benefit of treatment over a longer time antihypertensive treatment as well as on the comparative scale symptoms breast cancer generic 10mg paroxetine mastercard, is to use as endpoint the incidence or worsening of benefits of the various classes of drugs. There is a diseases with an adverse prognostic impact such as consensus that large randomized trials measuring fatal diabetes, metabolic disorders and end stage renal disease. However, it is commonly recognized increase in cardiovascular risk [186,277] and has indeed 2007 Guidelines for Management of Hypertension 1125 been used as endpoint in several therapeutic trials. For this New onset diabetes is also being used as intermediate reason in more recent trials the drug under investigation endpoint, and its predictive value is discussed in depth in was compared with placebo in groups of patients already Section 4. This has provided additional evidence on the beneficial effect of Finally, whenever useful, information provided by meta various antihypertensive drugs also documenting that the analyses has been given due attention, but meta-analyses benefit may be substantial even when blood pressure have not been considered to necessarily represent the reductions are small and the initial blood pressure is to p level of evidence. By definition, they are and thus multiple drug treatment, administration of post-hoc analyses, the choice of the trials to be included ramipril caused a modest blood pressure reduction (about is often arbitrary, the trials included are not homo 3mmHg sys to lic blood pressure) and a clearcut reduction geneous, with differences not always susceptible to (A22%) in the incidence of cardiovascular events com being assessed by statistical tests. In the felodipine group in which blood placebo pressure achieved slightly lower values than in the placebo Randomized placebo controlled trials investigating the group (A3. Surprisingly, another trial in coronary patients and though to a lesserdegree(20%). Meta-analyses of placebo controlled trials have also sep arately addressed the effect of treatment initiated with Asimilarapproachhasbeenused to studynewerdrugssuch different drugs, though comparisons are difficult because as angiotensin recep to r antagonists. However, the angiotensin recep to r antagonist candesartan, often admi overall results show a beneficial effect on cardiovascular nistered on to p of a diuretic, reduced blood pressure morbidity and mortality, as well as on cause-specific modestly more than placebo also frequently administered events, when a thiazide diuretic or a b-blocker was given on to p of diuretic-based conventional therapy (difference as first drug. Finally, trials comparing different agents cular endpoints, for the evaluation of which, however, the actually compare regimens only initiated on different studies were not sufficiently powered. Yet, when these two agents, since the majority of randomized subjects ends studies were combined in a meta-analysis a significant up with combination therapy including agents similarly reduction of cardiovascular morbidity was found in the distributed in the comparison groups. Calcium antagonists provided a analyses [292,296], the results showing significant benefits slightly better protection against stroke, but they showed from a more intense blood pressure reduction as far as a reduced ability, as compared with conventional therapy, stroke and major cardiovascular events are concerned, to protect against the incidence of heart failure. Further information can also be were similar when diabetic and non-diabetic patients derived from recent placebo-controlled trials (see above), were separately analyzed [296]. Almost invariably, a lower blood coronary heart disease in whom treatment was started pressure was accompanied by at least a trend to wards less with a calcium antagonist (verapamil, often combined strokes (see Section 4. We have taken this meta-analysis as the basis for versus b-blocker with thiazide diuretic). Non-significant differences in odds ratio adjustment is an imperfect way to cope with failure of for to tal and cause specific cardiovascular events have also achieving a pro to col requirement. Meta-regression been reported by the meta-analysis that has separately analyses can provide information that takes in to account examined diabetic and non-diabetic patients [296]. In the second Australian blood pres risk fac to rs, addition of valsartan reduced blood pressure sure study [327] hypertensive patients randomized to an from 139/81 mmHg to 132/78 mmHg. The incidence of cardiac events and death(theprimaryoutcome)wasnotsignificantlydifferent 4. The results show the group; on the other hand, the risk of heart failure showed odds ratio expressing relative benefits of the two regimens a trend in favour of valsartan. Pooled data have shown to be close to unity and non-significant for to tal coronary that the benefit of angiotensin recep to r antagonists for events, cardiovascular mortality, to tal mortality as well as heart failure prevention are particularly large in diabetic coronary heart disease. Protection against stroke was, on patients, but the number of observations is small [296]. However, this has not been confirmed by Five trials have compared angiotensin recep to r comprehensive meta-analyses published recently, which antagonists with other antihypertensive agents. The show the incidence of myocardial infarction to be similar different compara to rs used make meta-analysis of these to that occurring with other drugs [337,338]. Comparative randomized trials in heart myocardial infarction, but a 25% difference in the failure or post-myocardial infarction patients with left incidence of stroke. During a mean follow-up of although the latter may exert a small blood pressure 2. These underline the important role of blood pressure lowering two large trials have strongly infiuenced a recent meta for all cause-specific events, with the exception of heart analysis [343] which concluded that b-blocker initiated failure: whenever sys to lic blood pressure is reduced by therapy is inferior to others in stroke prevention, but not 10mmHg, independent of the agent used, both stroke and in prevention of myocardial infarction and reduction in coronary events are markedly reduced [328,329]. On the other hand, individual majority of patients randomized to a b-blocker actually trials and their meta-analyses [292,296] are generally con received a b-blocker-thiazide combination. It has treatment strategy based on the initial administration of been remarked that new onset heart failure is often a a b-blocker followed by the addition, in most patients, of difficult diagnosis and, when calcium antagonistsare admi a thiazide diuretic was accompanied by an incidence of all nistered, diagnosis may be confounded by ankle oedema cardiovascular and cause-specific events similar to that of dependent on vasodilatation. It is may be due to a lesser blood pressure reduction [330], reasonable to suppose that in prevention of heart failure particularly of central blood pressure [166], that occurred humoral effects, differently infiuenced by different anti in this trial with this therapeutic regimen. In randomized to slow-release nifedipine administration any case, the above quoted meta-analyses of b-blocker was associated with a 38% reduction in the incidence of initiated trials [297,343] well illustrate the difficulties hospitalized heart failure compared with placebo [304]. The possibility of clinically relevant differences in the beneficial effects of various classes of antihypertensive 4. Comparative randomized trials show that for similar blood Subclinical organ damage occurs much earlier than pressure reductions, differences in the incidence of events in the continuum of cardiovascular disease and cardiovascular morbidity and mortality between different may be more susceptible to specific, differential actions drug classes are small, thus strengthening the conclusion of the various antihypertensive compounds [274]. For this that their benefit largely depends on blood pressure reason, randomized trials using subclinical organ damage lowering per se. As studies in hypertensive recep to rantagonistsandcalciumantagonists,andprobably patients with left ventricular hypertrophy cannot be by aldosterone antagonists, while at least angiotensin placebo controlled but must compare active treatments, recep to r antagonists are superior to b-blockers. In two comparative studies, information is provided by two studies using magnetic natriuretic peptides decreased with losartan and increased resonance imaging to evaluate left ventricular mass. In a with atenolol [356,369], suggesting opposite effects on left relatively large-size study [361] the aldosterone blocker, ventricular compliance. Lower values of in-treatment electrocardiographic In conclusion, information from adequate trials shows hypertrophy were significantly associated with lower rates that blood pressure lowering by whatever agent or agent of cardiovascular morbidity and mortality [195]. Therefore, current evidence suggests that calcium antagonists may have a greater effect on hypertension Attention has recently been concentrated on echocardio related thickening (presumably hypertrophy) of the graphic measurement of left atrial size, as a frequent carotid artery than other antihypertensive agents. Smaller also found that lower progression of the composite carotid studies have addressed the effects of angiotensin recep to r intima-media thickness is paralleled by lower progression antagonists on recurrent atrial fibrillation in patients with and greater regression of plaque number with lacidipine previous episodes of the arrhythmia. Composition of the carotid wall, favourable effects of either irbesartan versus placebo investigated by an echorefiectivity approach his to logi [383] and losartan versus amlodipine [384], the drugs cally tested [396], did not show significantly different being in both cases added to amiodarone. Thus there changes with both lacidipine and atenolol, however is strong evidence concerning new atrial fibrillation [397]. In conclusion, sufficient evidence appears to be and less strong evidence concerning recurrent atrial available to conclude that progression of carotid athero fibrillation in favour of beneficial effects of angiotensin sclerosis can be delayed by lowering blood pressure, but recep to r blockers as compared with b-blockers, calcium that calcium antagonists have a greater efficacy than antagonists or placebo. Although pulse wave velocity is acknowledged as a valid clinical method for assessing large artery distensibility, 4. Therefore there is no firm evidence on whether term (only a few weeks) studies suggests that several some antihypertensive agents are more beneficial than antihypertensive agents can indeed favourably affect others in preserving or improving cognition. However, it pulse wave velocity [398], but the observed decrease should be mentioned that the only placebo-controlled could well be due to blood pressure reduction. This study that reported a significant reduction in incident conclusion is strengthened by a recent study of more dementia used the calcium antagonist nitrendipine as an or less intense blood pressure lowering, in which a active agent [275,407]. A limited number of randomized trials of antihypertensive Because of the diversity of the clinical conditions, of the therapy have used brain lesions and cognitive dysfunction endpoint used, as well as of the size and statistical power asendpoints[404]. Probably the best approach is that of critical imaging) and shown a significant reduction in mean to tal and selective reviews of available data [418,419]. The three mended by all current guidelines [3,30,420], it must be studies on 13143 subjects that have used the Mini Mental recognized that evidence from trials having randomized State Evaluation Test for cognitive performance [283, renal patients to more versus less intensive blood pressure 407,408] found a small but significant improvement lowering is scanty. However, in other trials randomization on the immediate and the delayed task results. Therefore, it < 120/80mmHg by valsartan did not infiuence creati appears that lowering blood pressure may improve nine clearance to a greater extent than less intense performance on screening tests for dementia and memory, treatment achieving blood pressures slightly above further supporting the benefits of antihypertensive 120/80mmHg, but urinary protein excretion was favour therapy on cerebrovascular morbidity. It should be emphasized that trials showing end stage renal disease and proteinuria. Angiotensin recep to rblock trial [425] and of 11 trials in non-diabetic renal patients, ers were found to be more effective in reducing urinary showing that sys to lic blood pressure reduction down to protein excretion than a b-blocker [440], a calcium a least 120mmHg may be beneficial [426]. An antipro inhibi to r dose was titrated to obtain the same blood teinuric effect versusplacebo hasbeen shownalsowith the pressure decrease as the combination, no difference in use of spironolac to ne [436]. Available all other placebo controlled studies the renal effects of studies have been included in a recent meta-analysis [450] the active drug were accompanied by a slightly greater which has confirmed the greater antiproteinuric action of blood pressure reduction, which may have been at least the combination, associated with a greater blood pressure partly responsible for the renal effects. These studies deserve to be Comparison of different active regimens has provided less confirmed by larger trials. Two trials, one in patients with proteinuric diabetic nephropathy [309] the other in non-diabetic 4. Itisdifficult to concludewhether [319,422], or a b-blocker [316] or an angiotensin recep to r agents interfering with the renin-angiotensin system exert antagonist [439] or both a calcium antagonist and a diuretic a real antidiabe to genic action, or whether they simply lack [438]; equal effect of a calcium antagonist and a diuretic a diabe to genic action possessed by b-blockers and was also shown by another study [322]. Other placebo controlled trials in conditions different from hypertension (high cardiovascular risk, 5. A very recent network Evidence for the benefit of treating grade 1 hypertensives meta-analysis of 22 trials with more that 160,000 partici is admittedly more scant, as specific trials have not pants [460] has calculated that the association of addressed the issue. This claim is based In all grade 1 to 3 hypertensives, lifestyle instructions on the observation that during controlled trials patients should be given as soon as hypertension is diagnosed or developing diabetes have not had a greater morbidity than suspected, while promptness in the initiation of pharma patients without new onset diabetes [322]. However, it is cological therapy depends on the level of to tal cardiovas known that cardiovascular complications follow the onset cular risk. A limitation of the above long-term should be initiated promptly in grade 3 hypertension, as follow-up studies is that microvascular endpoints, i. Furthermore, in long-term studies follow with moderate to tal cardiovascular risk drug treat up cannot be done under controlled conditions and ment may be delayed for several weeks and in grade 1 confounding fac to rs may be frequent and unknown. In case of bloodpressure who are at high risk because of thepresence diabetes, his to ry of cerebrovascular, coronary or peripheral of three or more additional risk fac to rs, the metabolic artery disease,randomized trials [283,300,302,305,319] syndrome or organ damage is uncertain. It should be have shown that antihypertensive treatment is associated emphasized that prospective observational studies have with a reduction in cardiovascular fatal and non-fatal demonstrated that subjects with high normal blood events, although in two other trials on coronary patients pressure have a greater incidence of cardiovascular disease no benefit of blood pressure lowering was reported [306] or compared to people with normal or optimal blood pressure a reduction of cardiovascular events was only seen when [7,11,33]. Furthermore, the risk of developing hyperten initial blood pressure was in the hypertensive range [304]. In contrast with these potentially favourable of progression to more severe proteinuric states. This justifies the recommendation did not significantly delay onset of diabetes or reduced to start administration of blood pressure lowering drugs cardiovascular events despite blood pressure lowering. In addition and blood pressure should be closely moni to red because of to theevidencereviewedinthe2003guidelines[3],further the relatively high chance these individuals have to indirect evidence supporting a blood pressure goal progress to hypertension [31,32], which will then require < 140mmHg has been provided by post-hoc analyses of drug treatment. All this is to achievethe maximum reduction in the long-term to tal is consistent with what has been reported in studies on risk of cardiovascular morbidity and mortality. This hypertensive patients followed in the setting of clinical requires treatment of all the reversible risk fac to rs ident practice, those achieving blood pressure values <140/ ified, including smoking, dyslipidemia, abdominal obesity 90mmHgshowingacardiovascularmorbidityandmortality or diabetes, and the appropriate management of associated rate much less than those treated but uncontrolled [479]. In hypertensive patients, the primary goal of There are also arguments in favour of trying to achieve treatment is to achieve maximum reduction in values below 90 mmHg dias to lic and 140 mmHg sys to lic, the long-term to tal risk of cardiovascular disease. A recent meta-analysis of available considered as a possible mechanism and often unreported, trials in diabetic patients has calculated a reduced although when mentioned it was lower in the actively incidence of cardiovascular events (particularly stroke) treatedthanintheplacebogroups. Yet,ithasbeennotedin with more versus less intense treatment, for a between section 5. Never 305] have provided evidence of reduced incidence of theless, evidence on the benefit of the strict goal of < 130/ cardiovascular events by bringing blood pressure to rather 80 mmHg is more limited. For ambula to ry blood Data favouring lower blood pressure targets in patients in pressure this approach is supported by the evidence that whom a high risk condition is due to fac to rs other than for similar achieved office blood pressure values, lower diabetes are of variable strength. The most clear evidence achieved ambula to ry blood pressures are associated with a concerns patients with previous stroke or transient lower rate of cardiovascular outcomes [88]. Home and ambula to ry blood pressures to 138/82mmHg showed a 28% reduction in stroke are several mmHg lower than office blood pressures recurrence and 26% reduction in the incidence of major (Table 5), but these differences are proportional to the cardiovascular events compared with placebo in which the level of office blood pressure values [484], i. There were usually larger when office blood pressure is high and substantial cardiovascular benefits also in normotensive smaller at the lower office blood pressure values represent patients in whom on-treatment values were reduced to ing treatment goals [77]. Similartargetsshould beadoptedinindividuals with a of the trial duration,raising the possibility of a greater long his to ry of cerebrovascular disease and can at least be term protective effect of blood pressure reductions; 3) In considered in patients with coronary disease. Although younger low risk hypertensives what appears to be as a differences between individual patients may exist, the risk relatively small benefit when calculated over a treatment of underperfusion of vital organs is very low, except in period of 5 years may translate in to a more substantial episodes of postural hypotension that should be avoided, numberof addedlife years comparedwith elderly high risk particularly in the elderly and diabetic. This implies that in younger subjects of a J-shaped curve relating outcomes to achieved blood actuarial information may provide a better assessment of pressure has so far been suspected as a result of post-hoc the benefit than data obtained in trials [496]. This suggests that some of the major It should be mentioned that, despite large use of multi cardiovascular risk changes may be difficult to reverse, drug treatment, in most trials the achieved average sys and that restricting antihypertensive therapy to patients at to lic blood pressure remained above 140 mmHg [492], high or very high risk may be far from an optimal strategy. Reaching the target blood press ures recommended above may thus be difficult and the 6. Trial evidence also shows that normal blood pressure and patients who require drug for the same or even a greater use of combination treat treatment. The purpose is to lower blood pressure, to ment achieved sys to lic blood pressure remains usually control other risk fac to rs and clinical conditions, and to somewhat higher in diabetics than in non-diabetics reduce the number and doses of antihypertensive agents [249,428, 493]. Healthy eating habits islikely thatthebenefitiseven greater than that calculated should always be promoted. They substantial number of patients randomized to placebo should never delay unnecessarily the initiation of drug received treatment and a number of patients allocated treatment, especially in patients at higher levels of risk. Therefore, hyper Lifestyle measures should be instituted, whenever tensive smokers should be counselled regarding smoking appropriate, in all patients, including those who cessation. Exposure to passive smoking may have smoking cessation declined in those countries where regulations have been weight reduction (and weight stabilization) introduced to protect the non and ex-smokers from reduction of excessive alcohol intake environmental to bacco smoke. The relationship between alcohol consumption, variable, patients under non-pharmacological treat blood pressure levels and the prevalence of hypertension ment should be followed-up closely to start drug is linear in populations [524].

Definition of standardized nutritional assessment and interventional path ways in oncology medicine 72 cheap paroxetine 10 mg otc. Dietary counseling improves patient outcomes: a prospective cold medications purchase paroxetine 20mg otc, randomized medications 1 buy discount paroxetine 20 mg on line, controlled trial in colorectal cancer patients undergoing chemotherapy treatment impetigo order paroxetine 10mg free shipping. Impact of nutrition on outcome: a prospective randomized controlled trial in patients with head and neck cancer undergoing radiotherapy medicine 4211 v buy paroxetine australia. Effect of dietary counseling on food intake symptoms you have diabetes order paroxetine with a visa, body weight, response rate, survival, and quality of life in cancer patients undergoing chemotherapy: a prospective, randomized study. A randomized study of oral nutritional support versus ad lib nutritional intake during chemotherapy for advanced colorectal and non small cell lung cancer. Perioperative nutritional support in patients undergoing hepatec to my for hepa to cellular carcinoma. Perioperative to tal parenteral nutrition in malnourished, gastrointestinal cancer patients: a randomized, clinical trial. Positive effect of prophylactic to tal parenteral nutrition on long-term outcome of bone marrow transplantation. Effect of to tal parenteral nutrition on marrow recovery during induction therapy for acute nonlymphocytic leukemia in childhood. Nutritional and metabolic support in patients undergoing bone marrow transplantation. Clinical and metabolic efficacy of glutamine supplemented parenteral nutrition after bone marrow transplantation. Total parenteral nutrition with glutamine in bone marrow transplantation and other clinical applications. Should patients with advanced, incurable cancers ever be sent home with to tal parenteral nutritionfi The effect of to tal parenteral nutrition on the survival of terminally ill ovarian cancer patients. Controlled trial of megestrol acetate for the treatment of cancer anorexia and cachexia. Randomized comparison of megestrol acetate versus dexamethasone versus fiuoxymesterone for the treatment of cancer anorexia/ cachexia. Randomized double-blind placebo controlled trial of cisplatin and e to poside plus megestrol acetate/placebo in extensive stage small cell lung cancer: a North Central Cancer Treatment Group study. Improvement in quality of life measures and stimulation of weight gain after treatment with megestrol acetate oral suspension in geriatric cachexia: results of a double-blind, placebo-controlled study. Nutrition and Type 2 26 Diabetes Mellitus in the Geriatric Patient Angela Mazza, D. The health care use, including office and inpatient visits, attributed to diabetes in an older population was also shown to be substantial. Others are recently diagnosed and may have had years of ongoing undiagnosed complications. Some have a multitude of other chronic comorbidities, not to mention limitations in physical or cognitive function, polypharmacy, risk of falls, persistent pain, depression, and urinary incontinence. For example, there is an association between diabetes and periodontal disease in that oral health problems tend to complicate overall diabetes management and worsen glycemic control. Type 1 diabetes is thought to be au to immune in nature, characterized by decreased or lack of insulin secretion, and usually seen in young people. Type 2 diabetes is associated with age and obesity, but the vast majority of patients seem to have a genetic risk as well that unveils an existing defect in insulin secretion. Met abolic syndrome is this insulin resistance along with dyslipidemia, hypertension, and visceral adiposity, which may eventually lead to overt diabetes. There are additional environmental fac to rs that interact with genetic susceptibility in the pathogenesis of type 2 diabetes. It is crucial in preventing associated complica tions or slowing the progression of others. Since the general population with diabetes, mainly type 2, is obese and insulin resistant, moderate weight loss is encouraged. However, elderly patients may be malnourished already, and any strict dietary restriction could further decrease their quality of life. Protein nutrition is a major fac to r for the geriatric population in general because of various changes in body metabolism, composition, and daily activities. Healthy older persons with similar protein intakes have been shown to have lower metabolic demands and efficiency of protein utilization than controls, but patients with chronic illness actually require higher levels of protein. Most studies on dietary fat and risk fac to rs for diabetes, the older population included, are short term, but there are certain beliefs that are generally accepted. Of most interest in diabetes, dietary fiber has been shown to decrease postprandial serum glucose values. Patients who are ambula to ry may benefit from a moderate increase in fiber intake; however, since part of the benefit of fiber on lipid and carbohydrate metabolism is derived from retarding food diges tion and nutrient absorption,24 older patients who are less mobile or bed-bound may suffer bowel impaction. Aging in itself is associated with loss of bone and can be aggravated by multiple other infiuences, some modifiable and others not, such as smoking and alcohol vs. Residents of nursing homes and people over the age of 65 have been found to have a prevalence of hypovitami nosis D of up to 50%. The relationship between diabetes and osteoporosis is poorly unders to od, but older diabetic populations have a definite increased risk of clinical fractures. Patients with type 1 diabetes are considered to have high rates of bone resorption and subsequent low bone mineral density. However, patients with type 2 diabetes have been found to have bone mass that is greater, lesser, or equal to controls without diabetes. It also plays a structural role in cell membranes, and any deficiency may lead to oxidative changes and free radical damage of the membrane. Clinically, zinc defi ciency in the general population may lead to growth retardation, hypogonadism, Nutrition and Type 2 Diabetes Mellitus in the Geriatric Patient 437 immune dysfunction, and alterations in taste and may manifest similarly in the diabetic and geriatric population. Fish oil supplementation in this population has been proven statistically significant in lowering triglycerides by almost 30% without significantly increasing fasting glucose or hemoglobin A1c. In addition to the obvious cardiovascular risks, elevated triglyceride levels are associated with poor cognitive performance by 438 Geriatric Nutrition way of decreased verbal fiuency and impaired memory tasks,38 possibly further infiu enced by accompanied poor glycemic control and overall metabolic abnormalities. Most studies on the therapeutic benefit of exercise up until fairly recently have focused on young and middle-aged patients with type 2 diabetes and have shown the effectiveness of exercise in reducing glycolated hemoglobin independent of body weight and the association between training intensity and the amount of change in that value. Two separate trials have evaluated high-intensity progressive resistance exercise in older diabetics, with a mean age of 66, and both succeeded in showing a significant decrease of more than 1% in hemoglobin A1c compared to the control subjects. Calcium and vitamin D supplementation is encouraged for bone mainte nance and prevention of fractures, an increased complication that is seen in type 2 diabetes. Finally, exercise implementation, resistance training in particular, should be consid ered in elderly diabetic persons who could be suitable candidates. American Diabetes Association, Standards of medical care in diabetes, Diabetes Care, 29, 59, 2006. American Diabetes Association, Evidence-based nutrition principles and recommen dation for the treatment and prevention of diabetes and related complications, Dia betes Care, 25, 202, 2002. American Diabetes Association, Nutrition recommendations and interventions for diabetes: 2006, Diabetes Care, 29, 2140, 2006. It is the only one among the to p 10 causes of death with a continuing increase in morbidity and mortality. Lifestyle and environmental modifications, such a smoking cessation, exercise, physical ther apy, and pulmonary rehabilitation, may improve functional status. The pink puffing patient is characteristically thin and breathless; the blue and bloated patient may not be particularly breathless, at least when at rest, but has severe central cyanosis. Both metabolic and mechanical inefficiency contribute to the elevated energy expenditure. An imbalance between protein synthesis and protein breakdown may cause a disproportionate depletion of fat-free mass in some patients. Mal nourished patients have worse scores on a respira to ry disease-specific quality of life questionnaire than well-nourished individuals. More specifically, muscle wasting is a conse quence of an imbalance between protein synthesis and protein breakdown. Fat produces the adipocyte-derived hormone leptin, the feed back mechanism to the brain for fat mass regulation, increases thermogenesis, and has a role regulating the lipid and glucose balance. Under normal conditions, the rate of oxygen delivery to the cell must be precisely adjusted to avoid excessive free radical production. The mi to chondrial respira to ry chain is an essential element in the transduction of energy during life. Loss of fat mass is seen in undernourished patients as a result of reduced caloric intake or increased energy expenditure. Pulmonary symp to ms such as shortness of breath and cough can cause loss of appetite and energy for eating. Shortness of breath may increase during the effort of eating, making this an unpleasant task. It is difficult to swallow and breathe at the same time, and the extremely dyspnoeic patient may be unable to coordinate breathing alternately with swallowing in an efficient manner. The authors suggest that these changes can partially be explained by reduced availability of oxygen. Short-term studies (2 to 3 weeks)22 showed a significant increase in body weight and respira to ry muscle function. This short-term effectiveness is probably partly related to repletion of muscle water and potassium, as well as constitution of muscle protein nitrogen. Refeeding and weight gain were associated with a significant increase in absolute lymphocyte count and with an increase in reactivity to skin test antigens after 21 days of refeeding. The treated group had nightly enteral feeding adjusted to maintain a to tal daily caloric intake greater than two times the measured resting metabolic rate for sustained weight gain. The majority of increase in body weight was fat mass, and no significant improvement of physiologic function was observed. The limited therapeutic impact of isolated aggressive nutrition support could be related to the fact that the selected patients (weight-losing, unresponsive to oral supplements) were both hypermetabolic and hypercatabolic, or results could be attributed to the absence of a comprehensive rehabilitative strategy. The degree of muscle wasting was strongly correlated with the dose of corticosteroids. After 2 weeks, the percentage of predicted forced vital capacity improved in the treatment group but declined in the control group (+8. The use of corti costeroids in these patients may have contributed to muscle wasting. Weight increased in 9 of 10 persons who received anabolic steroids (mean weight gain = +1. No change in the 6-minute walking distance or in maximal exercise capacity was identified in either group. Sixteen patients whose mean age was 66 years and whose weight was 77% of ideal body weight were randomly assigned to receive 0. After 21 days, body weight was similar in the two groups, but lean body mass increased by 2. The changes in maximal respira to ry pressures, handgrip strength, maximal exercise capacity, and subjective well-being were similar in the two groups. Although short-term studies of nutritional supplementation have reported a positive nitrogen balance, weight gain, and improved muscle function, nutritional support for >2 weeks did not show a significant effect in any of the main outcomes measured. The poor response to anabolic steroids may be related to the effects of systemic infiammation on dietary intake and catabolism. Alternative approaches to increasing appetite and caloric intake are to be encour aged. Lung function and mortality in the United States: data from the First National Health and Nutrition Examination Survey follow up study. Body composition and health-related quality of life in patients with obstructive airways disease. Different patterns of chronic tissue wasting among emphysema and chronic bronchitis patients. Tumor necrosis fac to r-alpha serum levels, weight loss and tissue oxygenation in chronic obstructive pulmonary disease. The relationship between chronic hypoxemia and activation of the tumor necrosis fac to r-alpha system in patients with chronic obstructive pulmonary disease. Altered glutamate metabolism is associated with reduced muscle glutathione levels in patients with emphysema. Impact of nutritional support on func tional status during an acute exacerbation of chronic obstructive pulmonary disease. Administration of growth hormone to under weight patients with chronic obstructive pulmonary disease. Efficacy of nutritional supplementation therapy in depleted patients with chronic obstructive pulmonary disease. Fibre types in skeletal muscles of chronic obstructive pulmonary disease patients related to respira to ry function and exercise to lerance. The loss of lean tissue, with the accompaniedrise in the proportion of body fat, is mirrored by a decline in physical and metabolic output. The term anorexia of aging was coined to refiect the poor appetite and decreased appreciation of food commonly seen in older persons. Weight loss, however, can also be due to difficulties with food ingestion, intestinal absorp tion, or nutrient metabolism. While many changes in the function of the gastrointestinal system are considered aging related, only a few play a role in developing gastrointestinal pathology. The prevalence of gastrointestinal complaints in older persons can be attributed to chronic disease conditions rather than aging itself. Based on that, it is not surprising that many of the slowly developing conditions affecting the gastrointestinal tract are almost exclu sively diseases of aging (Table 28. This chapter covers the normal gastrointestinal functions with the relevant changes experienced by older persons.

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The observational studies have included investigations where populations have been exposed to trace elements such as boron or manganese in drinking water treatment vaginal yeast infection buy cheap paroxetine 20 mg, these have generally been of poor quality symptoms zyrtec overdose cheap paroxetine 10 mg on-line, with very limited information on exposure treatment xyy cheap 10 mg paroxetine. Other observational studies have included investigations of occupational exposure to elements such as manganese medicine knowledge order paroxetine toronto, and have generally been better conducted and reported medications at 8 weeks pregnant cheap 20mg paroxetine visa. One particular difficulty has been the lack of information on to tal exposure to a particular nutrient medicine vs dentistry order paroxetine with visa, the effects of supplemental nutrients on particular parameters being investigated without quantifying the exposure from the rest of the diet. However, some nutritional experiments have also been conducted in labora to ry animals. These can be feeding trials to assess the effects of deficiency or of excess nutrients, studies on bioavailability or metabolic studies. When assessing such studies, the following section on assessing to xicological data covers most of the relevant issues. Types of to xicity data Toxicity studies in animals can be single dose (acute) studies or repeat dose studies of various lengths (generally 1 week to 2 years/lifespan) or which cover specific periods or processes during the life of the animal such as reproduction and development or cell division (for in vivo mutagenicity) studies. In vitro studies usually investigate specific tissues or cell types to investigate pre-defined end points. Assessing to xicity data In practice, to xicity studies can be broadly divided in to two categories: regula to ry studies and investigative studies. Regula to ry studies are conducted to assess the safety of a substance, to meet regula to ry requirements prior to marketing, or in support of health and safety or environmental legislation. Regula to ry studies are usually part of a standardised package and individual studies use well defined methods, and study a wide range of body tissues, without any a priori hypothesis of possible effects. Investigative studies are concerned with researching a particular issue, such as studying the mechanism of a particular effect, and have a more specialised design. A guideline is produced for each type and/or length of study, ranging from in vitro mutagenicity studies to multi-generation animal studies. These provide specific criteria for study design and are formulated to ensure harmonisation of approach and thus mutual acceptance of data by the different regula to ry agencies worldwide. These tend to be more flexible, indicating the information or data package required rather than specifying in detail the way to obtain it. This is a system which aims to ensure that labora to ry studies are properly planned, performed, moni to red and recorded. All information is recorded and tracked so that the results and conclusions can be verified. This means that professional judgement has to be used to assess the quality of the study. A well reported study should provide enough detail of the methods used to allow the work to be reproduced by others. Data from investigative studies may be used to support or elucidate the findings of regula to ry studies. Assessing animal studies A list of fac to rs considered in assessing the quality of a study is given below. Not all the fac to rs below will apply to every study and where information is missing, this does not always indicate that the study is of poor quality, though it may reduce confidence in a study. For example, 50 animals of each sex per dose group would be used in rodent carcinogenicity studies to ensure that an increased incidence of tumours can be identified. Fewer animals would be used for studies of shorter duration or involving non-rodent species (although in the latter case the scientific and statistical justification is not clear). Infections may occur in labora to ry animal populations and affect the results and interpretation of a study. It is important to have information on body weights and preferably on food and water consumption, since substances that affect the palatability of food or water may confuse findings by reducing intakes and causing, for example, weight loss and dehydration. Where animals have died during the study it needs to be clear whether this was scheduled or whether the animals were found dead or moribund. Use of excessive doses may affect survival and thus shorten duration of treatment, as well as leaving to o few survivors to assess the statistical significance of the effect. It may also produce secondary to xic effects that are of little or no relevance to lower doses. Although the dose regime should produce some indications of to xicity, feeding animals large amounts of non- to xic compounds can result in nutritional effects if the quantity of test substance in the diet results in inadequate levels of other nutrients. The limit dose for all studies is considered to be 2 g/kg bw/day to ensure that the results are meaningful. Other limits apply to different methods of dosing such as gavage so that the animal is not harmed by the procedure. Assessing in vitro studies Many of the points discussed above have analogies for in vitro testing. This also depends on the test concerned since some may require testing in to the cy to to xic range. Test methods which are included in regula to ry guidelines can be considered adequately validated. Other assays may provide supporting information, but may not be adequate in the absence of results from the accepted test battery. Interpretation When considering the interpretation of the study, it is important to consider whether the data support the conclusions that have been drawn. It is not possible to conclude a lack of effects from an inadequate study and the evaluation of positive effects may be confounded by poor conduct or poor reporting of a study. Where there are uncertainties due to a limited study or a poor database this may be accounted for by the use of uncertainty fac to rs. Other fac to rs to consider include whether there was a dose-related response (an effect in a single group may indicate a random effect such as a statistical anomaly, a design problem or a highly specific adverse effect). Certain effects can be either species specific or may be related to the experimental method, such as the dosing method used. Where investigations have been published, it is worth considering whether this is as a peer reviewed article or as a letter, abstract or conference report. It is also worth noting the background and reputation of the authors in the field. This was surprising in view of the wide availability of, and interest in, supplement products. Though these may have been conducted in accordance with the standards prevailing at the time, they would not meet modern standards. The National Food Survey Household surveys use information on household food purchases to provide useful data on population trends in food expenditure, consumption and nutrient intakes. The information obtained during the survey, which is published on an annual and quarterly basis, provides population average data on long term trends in food consumption and nutrient intakes per person. Results can also be broken down by various household characteristics such as region, income group and household composition. Publication of the first report of the findings is expected in Autumn 2002 with further reports to be published in 2003. Each survey collects detailed, quantitative information on food consumption and nutrient intake using a weighed dietary record, kept by the participant for four or seven days. Information on nutritional status is collected via a blood sample and physical measurements and a detailed interview provides information on socio-economic, demographic and lifestyle characteristics. It can be a useful, relatively inexpensive method for estimating average population intakes of some nutrients where food composition data are lacking. Commonly Used Methods of Dietary Assessment of Individuals Duplicate meal analysis and metabolic balance studies Duplicate meal analysis is a part of metabolic balance studies and allows an accurate assessment of dietary intake with labora to ry analysis of the nutrient content of the diet. The metabolic balance study included, in addition, analysis of all output (urine, faeces and, in some cases, sweat and other body fluids). Such studies are time consuming, labour intensive, expensive and involve small numbers of subjects usually studied over periods of weeks. Metabolic balance studies allow calculation of intake, output and retention of nutrients and have been used to estimate body requirements. Weighed record the subject weighs and keeps a diary record of each food item immediately before consumption and all plate waste at the end of each meal, usually for 4-7 days. This methodology is time-consuming and demanding of the subjects and so is prone to under reporting. However, weighed intake records are considered one of the most accurate methods of assessing current food intake. Assessment of the quantities of each food consumed on each eating occasion/day may also be included. The advantages of this method are that it is quick and easy to complete; it may be the only suitable method for large scale epidemiology studies. The main disadvantage is that it can only provide imprecise estimates of usual food consumption or nutrient intake for both individuals and groups. The diet his to ry may be preceded by a 24 hour recall, and/or supplemented with a checklist of foods usually consumed. This method is fairly quick to carry out and involves little work for the subject. The disadvantages are that it is inaccurate, especially regarding quantities consumed, and relies on the memory of the subject. For assessment of individual diets, multiple 24-hour recall may be needed depending on the level of precision required. The main advantage of this method is that it is relatively quick to carry out and involves little work for the respondent. The disadvantages relate to inaccuracy in the number of foods recalled, the quantities, and an inability to estimate the habitual diet of individuals. Estimated record Estimated records require a diary recording all food and drink consumed but foods are not weighed. Instead, amounts of foods and drinks consumed are estimated, usually with portions described in household measures, with or without the aid of pho to graphs or models. This method is easier to complete than a weighed record so there is less risk of under-reporting or changing food consumption. The disadvantages are that descriptions of quantities tend to be inaccurate and that processing such descriptive data is very time-consuming. For these reasons, caution is needed in the interpretation of dietary survey data. The quality of the nutritional surveys has been generally good, though for some of the less common minerals, the data have been sparse. Lunec 08 July 1999 Lunec Novel antibody-based technology for studying the potential ameliorating effects of vitamin E and vitamin C on in vivo oxidative stress M. Rainer, 22 September 1999 Boron and its compounds; advances in boron Borax Europe Ltd essentiality research; reproductive and general to xicology of some inorganic borates and risks assessment for human beings D. Glenville 29 February 2000 Berg G, Kohlmeier L Effect of oral contraceptive progestins on and Brenner H serum copper concentration M. Glenville 29 February 2000 Webb J L Nutrition effects of oral contraceptive use: a review [Review] [92 refs] M. Glenville 29 February 2000 Newhouse I J, Effects of iron supplementation and Clement D B, Lai C discontinuation on serum copper, zinc, calcium and magnesium C. Fuller to n 30 Oc to ber 2000 H Fuller to n Vitamin B6 334 Expert Group on Vitamins and Minerals 2003 Annex 4. The data provided are the best that the associations can provide and have been assembled from information provided by individual member companies. The data do not include products that are imported in to the country by non-members. Inevitably there could be some products not represented by the summary tables that follow. The market values quoted are from ex-fac to ry s to ck and will, in some cases exclude the costs of packing and labelling. The corresponding data for micronutrients sold in combination cannot be to talled because of the many permutations of blends of the same micronutrients that comprise combination products, which could result in duplication of data within the final figures. The lowest and highest declared levels quoted cannot be used to predict the limits from sales from other sources and it is possible that, from time to time, products will be marketed with higher declared levels than those quoted here by the minority of companies that are not members of the associations and hence are not subject to their self regula to ry standards of Good Manufacturing Practice. The data does not include products sold by e-commerce but may include some sold by mail order. Whilst both sec to rs are expected to grow, currently both are small relative to conventional sales through retail outlets. Median data are not available and for this reason the products have been listed with their lowest and highest unit declared levels to gether with to tal sales for all declared levels in millions units (1 unit is one tablet or capsule). This level of detail is inappropriate for food labelling, as it is impractical to provide more than a single reference number for intake. The Labelling Reference Values are based on Population Reference Intakes for infants and children aged 6 months to 3 years. Zinc at 50 mg is sold for short term use, usually from outlets with trained staff. Their source is dominantly from two large companies but, although there may be other products on the market, especially from imports, it is the most representative summary that is currently available.

The Postgraduate Medical Education Office medications during labor discount paroxetine 20mg otc, in conjunction with the Department of Psychiatry treatment alternatives boca raton quality paroxetine 10 mg, facilitates confidential professional counselling services for residents medicine 031 buy generic paroxetine 20mg online, if required symptoms pancreatitis buy paroxetine with paypal. Residents reluctant to use local services are assisted with arrangements for help in other communities treatment h pylori cheap paroxetine 20 mg online. In conjunction with the Department of Family Medicine treatment 4 hiv paroxetine 10mg free shipping, the Postgraduate Medical Education Office will assist residents in finding a family physician to help with long term personal or stress related issues. The Physician Health Program is a confidential program for physicians and their families at risk of or suffering from alcohol or drug problems ( Issues of Harassment Harassment and intimidation includes but is not limited to unfair work demands or workload abuse, discrimination, verbal abuse, physical abuse, sexual abuse, and reprisal for having lodged or being a witness in a harassment or intimidation complaint. The Hema to logy Residency Program and McMaster University have zero to lerance for harassment. Both the Postgraduate Medical Education Office and the Internal Medicine Residency Program Office at McMaster University have policies and procedures to deal with intimidation, harassment, and abuse. Reprisal of the complainant for involvement in this process will not be to lerated. Confidentiality of the identity of the complainant and the respondent will be protected. Residents have the option of discussing their concerns with the individual involved in the incident, a friend or colleague (including the Chief Resident), the family physician, the Rotation Supervisor, the Site Supervisor, the Program Direc to r, the Residency Men to rship Coordina to r, and/or the Assistant Dean, Postgraduate Education. If a formal complaint is submitted to the Residency Program Direc to r, Division Direc to r, or Postgraduate Education, University counsel will be sought in consultation with the Program Direc to r, Division Direc to r, and Assistant Dean, Postgraduate Education, as appropriate. If the incident falls within the University definition of human rights related harassment, the University Office of Human Rights and Equity Services will be consulted. The complaint should be made in a timely fashion (no later than 12 months from the date of the harassment. The complaint should include dates, names of individuals involved, and a full description of the event. The respondent will be notified that a complaint has been filed and, with the permission of the complainant and respondent, a meeting will be scheduled with the Assistant Dean, Postgraduate Education and/or Program Direc to r and/or Clinical Supervisor and appropriate University counsel. However, if the group reaches the conclusion that no resolution is possible, both the complainant and respondent will be informed in writing within five working days of that determination. If the complainant and/or respondent are not satisfied with the decision of the group, a request may be made in writing for a formal hearing. Relationships with Other Agencies If the reported incident is patient related, it must be reported to the College of Physicians and Surgeons of Ontario. Both natural and synthetic pigments are used in food, cosmetics and pharmaceutical products to impart their color as well as pharmacological effect exerted by them. Here we have selected four major pigments obtained from natural edible sources and tried to summarize them like chlorophyll, carotenoids, anthocyanins and betalains etc. So the present review reflects distribution, functions, extraction, separation and other special concerns of above said pigments. They are in leaves, fruits, vegetables, and flowers; to a molecule-specific structure (chromophore); this structure also, they are present in skin, eyes, and other animal captures the energy and the excitation of an electron from an structures; and in bacteria and fungi. Natural and synthetic external orbital to a higher orbital is produced; the pigments are used in medicines, foods, clothes, furniture, nonabsorbed energy is reflected and/or refracted to be cosmetics, and in other products [1]. His to rically at the beginning of the food industry consumers did not take care about the kind of 1. Natural and synthetic pigments are organic permitted for human foods are very limited, and the approval compounds. Inorganic pigments can be found in nature or of new sources is difficult because the U. Here the work is focused on the more these are manmade and subdivided as synthetic pigments and representative pigments in the main natural producers, lakes. Primary carotenoids group those compounds such as vegetables, minerals, or animals, and manmade required by plants in pho to synthesis (fi-carotene, counterparts of natural derivatives [4]. Chlorophylls constitute the most important subgroup of pigments within the tetrapyrrole derivatives. Carotenoids are responsible for many of the brilliant red, Two of them, chlorophyll a and chlorophyll b, are of orange, and yellow colors of fruits, vegetables, fungi, flowers, particular interest in food coloration because they are and also of birds, insects, crustaceans, and trout [1, 6, 8, 9]. More than 70 characteristic Carotenoids are compounds comprised of eight isoprenoid carotenoids have been described and have been classified as units (ip) whose order is inverted at the molecule center those with minimal quantities, higher quantities, and specific (Figure 1). The red algae Rhodophyta have fi and fi-carotene and their hydroxylated derivatives. Chrysophyta accumulates epoxy-, allenic-, and acetylenic-carotenoids, and between them fucoxanthin and diadinoxanthin. The principal carotenoids in Chloromonadophytaarediadinoxanthin, heteroxanthin, and vaucheriaxanthin [8, 10]. Usually, the characteristics of the (1) Hydrogenation accumulated carotenoids are (1) most of carotenoids are (2) Dehydrogenation aliphatic, but in Chlorobiaceae and Chloroflexaceae some (3) Cyclization carotenoids have aromatic or fi-rings; (2) aldehydes with (4) Oxygen insertion crossover conjugations and tertiary methoxygroups; (3) (5) Double bond migration various classes of carotenoids in each species; (4) all (6) Methyl migration, carotenoids are bound to the light harvesting complexes or (7) Chain elongation reaction centers in membranal systems of bacterial cells; and (8) Chain shortening (5) usually structural elements are not found, that is, allenicoracetylenic bonds, epoxydes, furanoxides C45 or C50 carotenoids [8]. Dunaliellabardawil the accumulation of fi-carotene has been observed in response to a combination of high light, 2. It was explained that in stressed cells some fungi, and color has an important role in reproduction: high levels of xanthophylls are maintained, which work as an coloration attracts animals that disperse pollen, seeds, or adaptative function to protect the pho to synthetic apparatus spores. Antioxidant the later stages of mating by inhibiting the cell- to -cell In vivo and in vitro studies have shown that carotenoid pho to recognition systems [12]. The antioxidant activity of lutein, the carotenoid structural characteristics is their ability to lycopene, anna to , fi-carotene, and fi- to copherol was evaluated absorb visible light: p delocalized electrons suffer a pho to on triglycerides by the effect of air and light. It was reported induced transformation in which a singlet state (s2) is that lutein, lycopene, and fi-carotene act as prooxidants, produced, then energy is efficiently transferred to chlorophyll favoring the formation of hydroperoxides; however, if a small (chl) to form singlet chl with a slightly higher energy. In quantity of fi- to copherol is added to these pigments, the thylakoidal membranes, carotenoids are bound to chls and phenomenon is reverted and they act as antioxidants with a proteins to form specific complexes called pho to system I higher activity than fi- to copherol [26]. It is a membranal complex that number of double bonds, ke to groups, and that cyclopentane comprises more than 25 different proteins, and the heart of rings in the carotenoid structure enhanced their activity [27]. These proteins are Many diseases, such as cancer and strokes, involve oxidative mainly membranal, usually hydrophobic, which bound processes mediated by free radicals. With this evidence, remarkable effect in the immune response and in intercellular divergent evolution was suggested, while the energy communication [16, 29-31]. It After their absorption, these carotenoids are metabolized by has been established that energy transference from chl to an oxidative rupture to retinal, retinoic acid, and small zeaxanthin is theoretically possible, and this gives support to quantities of breakdown products. Carotenoids are transported the observed zeaxanthin increments under high illumination. Xanthophyll cycle involving violaxanthin, antheraxanthin, Carotenoids have been used in other pho to sensitivity and zeaxanthin is ubiqui to us of higher plants and green and diseases: congenital porphyria, sideroblastic anemia, and have 3 shown only a limited success in treatment of polymorphic because this technique shows the following advantages: light eruption, solar urticarial Hydroavacciforme, rapidity, solvent strength can be controlled, and the solvents Porphyriavariegata, Porphyria cutaneatarda, or actinic used are gases friendly to the environment and with low reticuloid24. Interestingly, with this method the concentration protective agents against aging macular degeneration and stage is avoided because solvents are eliminated immediately senile cataracts [34]. Nowadays it is thus Most carotenoids are stable under alkaline treatments; thus, premature to enunciate final conclusions regarding the the use of methanolic solutions of potassium hydroxide is a potential role of carotenoids in the therapeutics of common method of saponification, sometimes at degenerative diseases [30]. Extraction extraction from paprika, it was reported that carotene is Carotenoids are soluble in lipids or in nonpolar solvents, sensitive to alkaline saponification, thus mild conditions were except when they form complexes with proteins and sugars. Non chroma to graphic method uses consists of the removal of hydrophobic carotenoids from a mainly phase partition, for example, by using petroleum ether hydrophilic medium. Carotenoids are dissolved and recommended because of penetration through the hydrophilic nonpolar compounds recovered in epiphase, petroleum ether. A general strategy for with low moisture, and slightly polar plus nonpolar solvents36. The criteria covered with a vapor jacket; hexane is eliminated in a film for choosing a solid support depends on the carotenoid to be evapora to r and afterward by vacuum distillation, and the main purified; for example, alumina must not be used to separate problems to be solved are to diminish pigment degradation, astaxanthin because of oxidation problems; additionally, increase extraction performance, and solve safety and alumina can produce isomerization of other carotenoids47. More than 50% of the pigments is Nowadays, open column chroma to graphy is used as a lost during this extraction process; oil extraction industries prepurification stage to separate groups of carotenoids with emitted in to the environment 210 to 430 million liters of similar characteristics in special flash open column hexane that to gether with other organic compounds can chroma to graphy [49, 50]. Hunter-Lab is the most common Another ionization technique is Atmospheric Pressure equipment; it is based on tristimulus effect [60, 61]. It was possible to identify Anthocyanins are substituted glycosides of salts of phenyl-2 peaks or shoulders in the visible spectrum region that benzopyrilium (anthocyanidins). Another simple test is iodine isomerization, which produces a mixture of equilibrium isomers (cis-trans); if the starting pigment is all-trans, a hypsochromic shift is observed (3 to 4 the basic C6-C3-C6 anthocyanin structure is the source of an nm), while if it is cis, hyperchromic(1 to 3 nm) [6, 36]. Carotenoids with fi differences in the number and position of hydroxyl groups rings produce a bathochromic shift; the shift depends on the and/or methyl ether groups, but six of them are the most common anthocyanidin constituents of this kind of pigments. Marker for Good Manufacturing with the number of sugar molecules that constitute their Practices in Food Processing Anthocyanins have been used to molecules. Prune juice is a product in which brown color is increased by taking in to account the sugar diversity and all developed by the reaction of phenolic compounds and/or the possible structural points of glycosylation, although the anthocyanins, and it is possible the adulteration of prune juice order of sugar occurrence in natural anthocyanins is glucose, with other fruit juices improve its color. Also, anthocyanin profiles acylatedanthocyanins), and in nature the most common acyl have been used to determine the authenticity of fruit jams. Distribution that adulteration of blackberry jams with strawberries can be Anthocyanins are responsible for many of the attractive detected with analysis of the relation between pelargonidin colors, from scarlet to blue, of flowers, fruits, leaves, and and cyanidin 3-glucoside. They are almost universal in higher methodology is very efficient because anthocyanins are pretty plants, but in general anthocyanins seem absent in the stable during jam manufacture [70]. They exhibit a strong antioxidant activity that Petunia), whereas others have mixtures (Rosa, Tulipa, and prevents the oxidation of ascorbic acid, provides protection Verbena). On the other hand, some fruits are a source of one against free radicals, shows inhibi to ry activity against anthocyanin: cyanidin in apple, cherry, fig, and peach; oxidative enzymes, and has been considered as important delphinidin in eggplant and pomegranate; some fruits have agents in reducing the risk of cancer and heart disease71. Color and Ecological Functions anthocyanins against lipid peroxidation has been studied. Anthocyanins also showed similar functions in plants to those Liposomes were used to evaluate the inhibition in the described for flavonoids: antioxidant, pho to protection, production of malondialdehyde. All evaluated anthocyanins defense mechanism, as well as other ecological functions were better agents against lipid peroxidation than fi (symbiosis phenomena). Interestingly, it opposite to that observed with other flavonoids, while O2 has been observed that cyanidin-3-glucoside is inhibi to ry to scavenging is independent of the glycosylation state but also the larval growth in to bacco budworm Heliothisviriscens, and increases with the number of hydroxyl groups, similar to the consequently anthocyanins could be considered agents of observed with other flavonoids [73]. Additionally, anthocyanins have been extracted from Anonia a mixture of anthocyanins (cyanidin, proposed as taxonomic markers, although this goal has not cyanidin-3-glucoside and cyanidin-3,5-diglucoside) and been achieved yet because of nowadays only a limited polyphenol substances called bioflavonoids number of species levels within families have been (leucoanthocyanidins, catechins, and flavonols) has been investigated. In particular, bioflavonoids have shown activities to improve the permeability and strength of capillaries, to 6 accelerate the ethanol metabolism, and to reduce effect [64, 67, 76]. Raman spectroscopy has been used to show inflamma to ry and edematic reactions [74]. The presence of phenyl ring substitutions on benzopyrylium produces clear spectral 2. Conventional methods of pigment configuration of sugar residues in flavonoid glycosides. Among xylanopyranosyl groups and fi-configuration with rhamnosyl other solvents, one finds ethanol and water, 80 and 27% as and arabinopyranosyl groups. Chemical tests because this technique has shown continuous innovations and A large number of chemical tests have been developed to still keeps its advantages (practical and very cheap). For determine the anthocyanin structure, and a general procedure preparative work, droplet counter current chroma to graphy has could be envisioned, but this must be modified depending on been applied to separate the anthocyanins of black currant. After separation, isolated the other hand, a general patent for the purification of anthocyanins were hydrolyzed with mineral acid and anthocyanins involves selective absorption on a finely divided glycoside bonds were disrupted, then anthocyanidins were oxide such as silicic acid, titanium oxide, or alumina, which is methylated, and after other acidic hydrolysis the nature of the coated with a styrene polymer65. However, undoubtedly, the anthocyanidin and the positions of glycosylation were main developments of recent years in the research of determined [63]. In the evaluation of visual color, reflectance colorimetry has been the better approach because it shows a 2. In this anthocyanins have an intense absorption in the range of 520 sense, a method has been developed to assess the anthocyanin to 560 nm (visible region). Chemically, betalain definition visible spectra of anthocyanins show a hyperchromic effect, embraces all compounds with structures based on the general increment of the intensity of this maximum resulting in a formula shown in Figure; therefore, they are immonium more colored species, and a bathochromic shift by a solvation derivatives of betalamic acid. The chromophore of betalains 7 can be described as a pro to nated 1, 2, 4, 7, 7-pentasubstitued glucoside. Taxonomic Markers Even before the structure of betalains was evident, the importance of betalain pigments in plant taxonomy and systematic distribution was clear. Betalains are in eight families: Amaranthaceae, Aizoaceae, Basellaceae, Chenopodiaceae, Cactaceae, Nyctaginaceae, Phy to laccaceae, and Portulacaceae. Nowadays, it is known that 9 of 11 families of the Caryophyllales order contain betalains. The recent addition to the list of betalain families is Didieraceae, a small family from Madagascar [85, 86]. This remarkable correlation between chemical and morphological characters has led to propose that the order Centrospermae, including Fig 3: Betalain general formula. The to tally different chemical structure of betalains and anthocyanins, the fact that they are mutually 2. Classification exclusive, and the restricted distribution of betalains are good They can be divided in to two structural groups, the yellow arguments in favor of the paramount taxonomic significance betaxanthins (from Latin beta, red beet and Greek xanthos, [82] of these pigments. Ecological and Physiological Aspects well known, and all of them have the same basic structure, in As in the case of other secondary metabolites, it is impossible which R1 and R2 may be hydrogen or an aromatic substituent. When pigments are in flowers Betacyanins and betaxanthins can be classified using their or fruits they may have a role as attractants for vec to rs chemical structures.