\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:{caption:"IntechOpen Maintains",originalUrl:"/media/original/113"}},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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He is the winner of the following awards: Pan-American Nutrition, Food Science, and Technology Award, in 2006 and 2012, South America.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"258231",title:"Dr.",name:"Michael",middleName:"Thomas",surname:"Fasullo",slug:"michael-fasullo",fullName:"Michael Fasullo",profilePictureURL:"https://mts.intechopen.com/storage/users/258231/images/system/258231.jpg",biography:"Michael Fasullo, Ph.D., is an associate professor at SUNY Polytechnic University, New York. He earned a BSc at the Massachusetts Institute of Technology and a Ph.D. at the Department of Biochemistry, Stanford University, California. He was an American Cancer Society fellow at Columbia University, New York, and held faculty positions at Loyola University Chicago and Albany Medical College, New York. He has authored more than forty peer-reviewed publications, book chapters, and review articles in the field of yeast genetics, DNA recombination and repair, oncolytic viruses, and toxicology. His present work focuses on profiling the yeast and mammalian genome for resistance to P450-activated mycotoxins and heterocyclic amines. His research has been funded by the National Institutes of Health, Department of Defense, March of Dimes, and Leukemia Research Foundation.",institutionString:"State University of New York Polytechnic Institute",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"State University of New York Polytechnic Institute",institutionURL:null,country:{name:"United States of America"}}}],coeditorOne:{id:"196544",title:"Prof.",name:"Angel",middleName:null,surname:"Catala",slug:"angel-catala",fullName:"Angel Catala",profilePictureURL:"https://mts.intechopen.com/storage/users/196544/images/system/196544.jpg",biography:"Angel Catalá studied chemistry at Universidad Nacional de La Plata, Argentina, where he received a Ph.D. in Chemistry (Biological Branch) in 1965. From 1964 to 1974, he worked as an Assistant in Biochemistry at the School of Medicine at the same university. From 1974 to 1976, he was a fellow of the National Institutes of Health (NIH) at the University of Connecticut, Health Center, USA. From 1985 to 2004, he served as a Full Professor of Biochemistry at the Universidad Nacional de La Plata. He is a member of the National Research Council (CONICET), Argentina, and the Argentine Society for Biochemistry and Molecular Biology (SAIB). His laboratory has been interested for many years in the lipid peroxidation of biological membranes from various tissues and different species. Dr. Catalá has directed twelve doctoral theses, published more than 100 papers in peer-reviewed journals, several chapters in books, and edited twelve books. He received awards at the 40th International Conference Biochemistry of Lipids 1999 in Dijon, France. He is the winner of the Bimbo Pan-American Nutrition, Food Science and Technology Award 2006 and 2012, South America, Human Nutrition, Professional Category. In 2006, he won the Bernardo Houssay award in pharmacology, in recognition of his meritorious works of research. Dr. Catalá belongs to the editorial board of several journals including Journal of Lipids; International Review of Biophysical Chemistry; Frontiers in Membrane Physiology and Biophysics; World Journal of Experimental Medicine and Biochemistry Research International; World Journal of Biological Chemistry, Diabetes, and the Pancreas; International Journal of Chronic Diseases & Therapy; and International Journal of Nutrition. 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There is now a worldwide epidemic of Type 2 Diabetes Mellitus. It is a condition associated with numerous complications, which may well be present even at the time of diagnosis. Effective treatments are available but there is no known cure. The focus therefore is on both prevention and early detection by screening, with a view to preventing or delaying complications.
\n\t\t\tThis chapter gives a brief overview of the evidence for prevention of Type 2 Diabetes (behavioural and pharmacological) and describes various approaches to screening, from an international perspective, together with their relative advantages and disadvantages. Clinical opportunistic screening will be discussed and compared with population screening. The international guidance for screening for Type 2 Diabetes will be reviewed and a summary of the evidence relating to the psychological effects of screening, as well as the costs and cost-effectiveness of the various types of screening programmes, will be presented.
\n\t\tThe prevalence of diabetes, particularly Type 2 Diabetes, is increasing on a worldwide scale. The greatest increases are being seen in developing countries such as those in South East Asia (International Diabetes Federation, 2003; Ramachandran et al., 2010). There are many reasons for this increase in prevalence but it is generally thought that increasing rates of obesity and lack of exercise predicated upon a pre-existing genetic tendency towards diabetes are fuelling the epidemic (Stumvoll et al., 2005).
\n\t\t\tDiabetes is a common condition affecting 5.4% of the UK population (over 2.3 million people) and the vast majority of these have Type 2 Diabetes (The NHS Information Centre, 2010) with a higher prevalence amongst older people. For example between 10% and 20% of patients aged 60 to 79 years in the European prevalence study (DECODE) had diabetes (DECODE Study Group, 2003). In our own study (Evans et al., 2008), over a period of 20 years, there had been a trebling of the prevalence of Type 2 Diabetes in one family practice in the UK (Figure 1).
\n\t\t\tType 2 Diabetes has a significant impact on life expectancy. It has been estimated that having diabetes reduces life expectancy by 17 years in males and 20 years in females, who are diagnosed with the condition at the age of 45 years (Yorkshire & Humber Public Health Observatory, 2007). It is also generally acknowledged that a large number of patients with Type 2 Diabetes remain undiagnosed. For example in the US, one third to one half of people with Type 2 Diabetes are undiagnosed and thus untreated (Engelgau et al., 2000).
\n\t\t\tIncreasing prevalence of Type 2 Diabetes in one UK family practiceFrom: Evans, P., Langley, P., Pereira Gray, D. Diagnosing Type 2 diabetes before patients complain of diabetic symptoms – clinical opportunistic screening in a single general practice.
Type 2 Diabetes is a relatively unusual chronic disease in that it can have a long latent period prior to clinical diagnosis, perhaps up to 10 years (Harris et al., 1992). Patients who eventually develop Type 2 Diabetes often pass through a phase of intermediate hyperglycaemia when their blood glucose levels are elevated but not above the diagnostic threshold for Type 2 Diabetes. These intermediate states are collectively called Prediabetes and include Impaired Fasting Glucose diagnosed on a fasting plasma glucose test or Impaired Glucose Tolerance diagnosed on an oral glucose tolerance test. More recently the term Impaired Glucose Regulation has been proposed to include these borderline hyperglycaemic states (Diabetes UK, 2009).
\n\t\t\tBoth conditions are increasingly prevalent and it has been estimated that 5.1% of the UK population aged 20 to 79 may have Impaired Glucose Tolerance (International Diabetes Federation, 2003). Prediabetes carries an increased risk of progression to Type 2 Diabetes although this can vary widely, dependent on ethnicity and other factors (Unwin et al., 2002). Nevertheless, it is widely accepted that patients with these conditions are at greater risk of both Type 2 Diabetes and cardiovascular disease (Cautinho et al., 1999), and interventions designed to prevent diabetes have, in the main, been targeted at this group (Tuomilehto et al., 2001).
\n\t\t\tType 2 Diabetes is also unusual in that, unlike other conditions such as hypertension, a large proportion of patients have complications at clinical diagnosis. In the Hoorn Study, for example, at entry into the study, 39.5% of patients had ischaemic heart disease (Spijkerman et al., 2004) and 48.1% had impaired foot sensitivity (Spijkerman et al., 2003). In addition, since it is likely that having a high blood glucose for years on end may represent a harmful “legacy effect” (Del Prato, 2009), there is a greater imperative to diagnose early and theoretically reduce diabetic complications in later years.
\n\t\t\tThese characteristics raise the logical possibility of preventing patients progressing to Type 2 Diabetes during this latent phase and hence reducing the complications associated with Type 2 Diabetes, both at diagnosis and afterwards.
\n\t\t\tThere is now substantial evidence that progression to Type 2 Diabetes can be prevented or delayed in patients at high risk of Type 2 Diabetes (including those with Impaired Glucose Tolerance or Impaired Fasting Glucose), both by behavioural interventions (Knowler et al., 2002; Ramachandran et al., 2006; Tuomilehto et al., 2001) and by pharmacological interventions (Gillies et al., 2007; Salpeter et al., 2008).
\n\t\t\t\tBehavioural interventions included lifestyle interventions promoting weight loss, increased physical activity and dietary modification (Tuomilehto et al., 2001). In the Finnish Diabetes Prevention Study, this was achieved by offering detailed and individualised counselling to achieve set lifestyle goals. Prolonged engagement with a dietary counsellor was needed – for example, the median number of sessions per participant was 20 (Tuomilehto et al., 2001).
\n\t\t\t\tPharmacological interventions have included rosiglitazone (Gerstein et al., 2006), troglitazone (Buchanan et al., 2002), acarbose (Chiasson et al., 2003), metformin (Knowler et al., 2002), and orlistat (Torgerson, 2004). A recent meta-analysis has shown that lifestyle interventions can produce a 50% relative risk reduction in the incidence of Type 2 Diabetes at one year (Yamaoka & Tango, 2005). Typically these interventions are in high-risk individuals such as those with Prediabetes (usually Impaired Glucose Tolerance) and interventions are targeted at halting or slowing β-cell dysfunction and hence incident cases of Type 2 Diabetes.
\n\t\t\t\tOur previous work in defining an effective pragmatic strategy for diabetes prevention using general practitioner (GP) databases identified a large proportion of patients with Prediabetes (Greaves et al., 2004). We subsequently developed an educational package for patients with Prediabetes and their healthcare professionals. This package known as WAKEUP (Ways of Addressing Knowledge Education and Understanding in Prediabetes) was found to be acceptable to both patients and health professionals (Evans et al., 2007).
\n\t\t\t\tAs well as issues relating to clinician education, there are also many practical issues in delivering a national diabetes prevention programme. It is generally acknowledged that the intensity of the lifestyle intervention delivered in these trials is just not feasible in routine practice (Heneghan et al., 2006). A more pragmatic, yet effective, intervention is needed and several research groups in the UK are working on this issue, as are colleagues in Australia (Kilkkinen et al., 2007; Laatikainen et al., 2007).
\n\t\t\tOnce a patient has developed Type 2 Diabetes, the major aim of clinical care is to prevent complications and morbidity related to the disease. The commonest complication of Type 2 Diabetes is cardiovascular disease (American Diabetes Association, 2011) manifested as coronary artery disease, peripheral vascular disease or carotid artery and other cerebrovascular diseases. It is generally acknowledged that patients with Type 2 Diabetes have a raised cardiovascular risk and this may well be present before a clinical diagnosis is made (Hu et al., 2002). Some studies have shown that this risk is equivalent to that of a patient of the same age who does not have diabetes but has already had a coronary event (Haffner et al., 1998). Hence, Type 2 Diabetes is often termed a “coronary risk equivalent“, although this has been contradicted recently in a systematic review and meta-analysis (Bulugahapitiya et al., 2009).
\n\t\t\t\tReducing cardiovascular risk in patients with Type 2 Diabetes is therefore a priority. However, what has yet to be definitively established with regard to screening is whether early diagnosis reduces the risk of complications developing. Our previous work (Evans et al., 2008) showed that patients diagnosed by screening had a significantly lower median HbA1c (1.1% lower) than those presenting with symptoms. As the HbA1c is so closely related to outcomes in Type 2 Diabetes (UK Prospective Diabetes Study (UKPDS) Group, 1998), it is likely that health benefit will ensue for those patients diagnosed by screening - however this is not proven as yet.
\n\t\t\tEffective treatments for the disease are available through lifestyle advice, oral hypoglycaemic drugs, and insulin. Most of the health economic models (e.g. Gillies et al., 2008; Hoerger et al., 2004; Waugh et al., 2007) developed to assess the cost-effectiveness of screening for diabetes include an assessment of the effectiveness of treatment for Type 2 Diabetes, comparing the screened and unscreened groups. As yet, there are no long-term studies of the effectiveness of treatment after diagnosis of Type 2 Diabetes in screened and unscreened groups, so health economic simulations are needed - with their accompanying assumptions.
\n\t\t\t\tThese models use data from the UK Prospective Diabetes Study (UKPDS, 1998) which showed that intensive treatment of Type 2 Diabetes reduced the risks of microvascular complications but not macrovascular events. However, subsequent follow up after the trial had finished did show a reduction in macrovascular events in the intensive arm (Holman et al., 2008).
\n\t\t\t\tNational guidance for the effective treatment of Type 2 Diabetes in primary and secondary care exists in the UK (National Collaborating Centre for Chronic Conditions, 2008; National Institute for Health and Clinical Excellence, 2009) and in the US (American Diabetes Association, 2011). These guidelines are evidence-based and should improve outcomes in patients with Type 2 Diabetes. Effective treatments are targeted at optimising cardiovascular risk factors, including serum lipids, HbA1c and blood pressure. In addition, GPs in the UK also receive incentivised payments under the Quality and Outcome Framework when patients with Type 2 Diabetes reach the glycaemic, blood pressure and lipid targets (Roland, 2004).
\n\t\t\tScreening in medicine is a search process. An examination or a test is offered to asymptomatic people “to classify them as likely or unlikely to have the disease that is the object of screening” (Morrison, 1998). People who are likely to have the disease are then investigated further to arrive at the final diagnosis. The assumption is that an effective intervention is available.
\n\t\t\tAn early diagnosis and treatment activity applied in large groups is often described as ‘mass screening’ or ‘population screening’ (Morrison, 1998). Population screening in medicine was introduced in the mid-twentieth century and was applied to a number of diseases including tuberculosis, and more recently to cervical cancer, breast cancer and colon cancer. It was also attempted for diabetes.
\n\t\t\tThere are two inevitable consequences of all screening programmes, namely the occurrence of what are called ‘false positive’ or ‘false negative’ results. False positives are people whose test is positive for the disease being sought but who prove not to have the disease. Patients suffer additional investigations and anxiety. People classified as false negative are those who actually have the disease but the test fails to detect it. The patient then suffers the consequences of undiagnosed disease.
\n\t\t\tBefore any screening programme is introduced, its advantages and disadvantages must be carefully assessed. The general principles of screening were initially set out in the late 1960s (Wilson & Jungner, 1968). Since then, the criteria have been updated (UK National Screening Committee, 1998) and programmes now need to meet a number of criteria. These broadly relate to the health condition, the screening test, the availability of effective treatment, and the screening programme itself. Figure 2 outlines our summary of the criteria currently used by a variety of international health organisations to evaluate population screening. Based on such criteria, there is as yet no justification for population-based screening for Type 2 Diabetes (Borch-Johnsen et al., 2003; Waugh et al., 2007; Wareham & Griffin, 2001), although the case is becoming stronger. Whilst Type 2 Diabetes meets many of the criteria for screening, the main argument against population-based screening is that uncertainty remains about the true benefits arising from the early detection of Type 2 Diabetes through such programmes. In addition, it is unclear whether the economic cost of screening can be justified
The results of the ADDITION study (Echouffo-Tcheugui et al, 2009 ; Lauritzen et al., 2000; Sandbaek et al., 2008), which will assess the effectiveness of screening for Type 2 Diabetes combined with the provision of intensive treatment to newly-diagnosed patients, will be available soon and will provide much-needed evidence for or against screening.
\n\t\t\tType 2 Diabetes may well be a suitable disease for screening - it is a serious disease, being associated with many complications, especially in the eyes, heart, kidneys, and limbs and it shortens the expectation of life considerably. Screening tests consist of blood glucose tests and/or oral glucose tolerance tests. These tests are relatively cheap with a blood glucose test costing only £0.48 (US$0.77) in the UK National Health Service. Blood glucose tests and oral glucose tolerance tests have no adverse effects for the patient apart from the inconvenience of having blood tests and the very rare complications of venepuncture.
\n\t\t\tThere are two broad approaches to screening for Type 2 Diabetes – population or opportunistic screening. They have different advantages and disadvantages.
\n\t\t\tPopulation screening, as its name implies, is based on a defined population and aims to screen every person in this population (Engelgau et al., 2000). It includes ‘universal’ screening, which attempts to define the prevalence of diabetes by screening a whole community (Knowler et al., 1978; Sharp, 1964), and ‘targeted’ or ‘selective’ screening, which attempts to screen a defined sub-group of the population (Engelgau et al., 2000). In either case, a suitable test such as a screening blood glucose test is offered to a defined population.
\n\t\t\t\tCriteria for assessing the value of screening programmes(Criteria adopted by: a UK National Screening Committee; b American Diabetes Association; c World Health Organization).
Historically, screening was offered directly to people in communities and sometimes directly to people in the street – UK examples include surveys undertaken in Bedford (Sharp, 1964), Rotherham (Girt et al., 1969), and Birmingham (Birmingham Diabetes Survey Working Party, 1976). However, the yield was small as many people at low risk were approached and some of those detected failed to consult their GP. Costs per new case detected were therefore high and this approach was abandoned. Community screening could be cost-effective if the prevalence of Type 2 Diabetes in the community was extremely high, although this is rarely the case.
\n\t\t\t\tThe populations most often identified for screening include people selected because they have one or more risk factors for Type 2 Diabetes. These most commonly include older age, obesity, a family history of diabetes, and hypertension. This approach increases the likelihood of finding new cases and so improves the efficiency of the screening process.
\n\t\t\t\tRisk factors are most commonly known to GPs. They are not known to hospitals, as they do not hold the medical records of populations, only those people referred to them. Hence, population screening nowadays is most commonly based on people selected from the population registers of people registered with family practices. This has meant that most of the research reports have come from those countries in which the health system is based on family practices, i.e. Australia, Canada, New Zealand, the Netherlands, the UK, Denmark, and registration-based systems in the USA.
\n\t\t\t\tPopulation screening has several important advantages. It is mathematically precise, readily reproducible, and can operate largely independent of the clinical skills of the doctors and nurses in the family practices. It is easy to transpose arrangements across areas and countries.
\n\t\t\t\tPopulation screening has several important disadvantages. Unless whole community populations are used, various techniques have to be employed to determine potential sub-groups at risk. Selection has to be made on the basis of various clinical risk factors as set out below. This can involve searching of medical records or extraction of risk factors such as age and Body Mass Index (BMI) (Greaves et al., 2004) directly from the GP database or applying external criteria such as those of the American Diabetes Association to the GP’s electronic record (Woolthuis et al., 2007). However, there are always people, including those at risk, who decline to accept the offer of screening for a variety of reasons.
\n\t\t\t\tThe process then involves communication with the people in the target population, usually by writing to them and offering them an appointment. Some people will want to change their appointment and staff of the practice need to accommodate this. Some people will not come and may need to be sent a further appointment. Those who do come need to be recorded. Then, if the screening process is separate from the clinician, the clinician has to be informed and take action. In some US studies, primary care clinicians have not always responded appropriately (Ealovega et al., 2004). There may be a difference in attitude to those tests initiated by clinicians themselves and those tests initiated by others.
\n\t\t\t\tIt is inevitable that population screening carries administrative costs over and above the cost of the screening investigations. Nevertheless, in the UK, the National Health Service has recently instituted a comprehensive vascular risk assessment programme, known as ‘NHS Health Checks’ (Department of Health, 2008). These checks are offered to patients aged 40 to 74 years old who do not have existing vascular disease or diabetes. This is a two-step process and diabetes risk is estimated using a self-completed questionnaire, followed by a blood test if appropriate. It is envisaged that the whole of this age group in the population will be screened once every five years. Although it is considered reasonable to include a diabetes assessment within a global cardiovascular risk assessment, there is some current concern about the implementation of this programme (Khunti et al., 2011).
\n\t\t\t\tIn summary, therefore, population screening, usually of high-risk sub-groups, is the commonest form of screening performed world wide, but in practice is undertaken only in richer and developed countries. Hence, one profound implication is that population screening may well be too costly to be undertaken in developing countries and this is doubly serious as many Asian countries have some of the highest levels of prevalence of Type 2 Diabetes in the world, e.g. 10% in China (Ramachandran et al., 2010).
\n\t\t\tClinical opportunistic screening is quite different from population screening and is a form of clinical case finding. It is essentially an extension of ordinary clinical care in family practice. The key difference from population screening is that the patient, rather than the clinician, makes the appointment. In clinical opportunistic screening, the patient makes the appointment to go to the family practice and then the clinically alert doctor or nurse takes advantage of the patient’s presence in the consulting room to offer screening, based on their risk factor profile.
\n\t\t\t\tThis process has a long tradition in family practice and the whole basis of determining how many people smoke, drink heavily, are overweight or obese, or have raised cholesterol levels has been done in family practices without any national screening programmes. Since more clinical conditions are screened for opportunistically than are screened for by formal population programmes, opportunistic screening can be seen as the usual method of screening. It has just not been recognised as such.
\n\t\t\t\tThe introduction of computer systems in UK family practices (since the 1980s) has enabled generalist doctors and nurses – for the first time – to organise, handle, and retrieve data live during consultations. Computers have made the family practice consultation much more efficient and opportunistic screening is one aspect of this.
\n\t\t\t\tClinical opportunistic screening has several advantages. Firstly, this process eliminates most of the costly administrative overheads associated with population screening. Secondly, since the offer of screening is made within a therapeutic and trusting patient-doctor relationship, acceptance rates are generally high. An important advantage is that the screening process is offered by the doctor who will care for the patient if the disease is diagnosed, so that, if the test is positive, treatment can start immediately. Thirdly, the relatively high contact rate that people have with their primary health care team underpins clinical opportunistic screening. In the UK, The NHS Information Centre for Health and Social Care (2009) reports that the average contact for adults with their family practice is 5.5 encounters per year of which 3.4 per patient per year are with the doctor. This is important in that the health system offers the doctor repeated opportunities to screen; if a test is missed on one occasion when the patient is distressed or in no state to be screened, or if the doctor simply forgets, then the doctor can be confident that the average patient will be seen again within about four months.
\n\t\t\t\tFourthly, clinical opportunistic screening exploits the key fact that it is family practice, and only family practice, which has the risk factor data and often knows it very well. For example, GPs are spending more and more of their time seeking to alter risk factors for disease. They screen for and increasingly find and then treat hypertension, itself a risk factor for Type 2 Diabetes and also for obesity which is all too obvious to the clinician. Other risk factors such as a positive family history may be very well known too as the family doctor will have often treated the older family members for diabetes and may still be doing so. Fifthly, this is the only system which can be undertaken in developing countries and is possible wherever there are generalist doctors. Fortunately, family medicine and computerisation of family practice records is spreading steadily around the world, hence the potential for this approach is increasing rapidly worldwide.
\n\t\t\t\tIn one recent method, university staff determined the risk groups and worked with a group of associated family practices to develop a ‘flagging system’ which jogged the doctor’s memory when at risk patients are seen (Woolthuis et al., 2009). The authors concluded that because it was ‘embedded within daily care’ and achieved a high uptake rate, this approach was feasible and inexpensive; however, no estimate of the screening costs was reported.
\n\t\t\t\tClinical opportunistic screening has some important disadvantages. Realistically, it cannot be expected to cover the entire at-risk population and it is dependent on the patient consulting for some reason. It also depends on the clinical alertness of the family physicians and practice nurses. This is not standard, and there are inevitable variations in clinical skills, which means variations in the screening process being delivered. The offer of clinical opportunistic screening is a judgement and different clinicians will make different judgements at different times. These types of interventions therefore cannot be completely standardised. Hence, they have been criticised by some as inefficient (Law, 1994) and can be seen as untidy, and potentially unpredictable. Furthermore, patients vary greatly in their emotional state in consultations and, if they are upset with anxiety, depression or having just received bad news, it becomes inappropriate to offer screening.
\n\t\t\tWhilst there is not yet sufficient evidence to support the introduction of general population screening, there is broad support for screening programmes that focus on defined sub-groups of the population who are at higher risk of developing Type 2 Diabetes. A number of organisations have issued position statements relating to targeted or opportunistic screening for Type 2 Diabetes (e.g. American Diabetes Association, 2011; Diabetes UK, 2006; World Health Organization, 2003). These make recommendations about the patient sub-groups that should be considered for screening, the frequency of screening, where screening should take place, and the preferred screening test.
\n\t\t\t\tIt is generally accepted (American Diabetes Association, 2011; Diabetes UK, 2006) that clinical judgement and patient preference should guide decisions about screening for Type 2 Diabetes. Several organisations in the UK, Europe and USA (American Diabetes Association, 2011; Diabetes UK, 2006; Paulweber et al., 2010) have made recommendations about the risk factors that might indicate a need for screening and these are summarised in Figure 3.
\n\t\t\t\t\tThe optimal frequency of screening is not known. However, Diabetes UK (2006) and the American Diabetes Association (2011) recommend that health professionals should consider proactively screening adults at risk of developing the condition every three years. Both organisations note that it may be necessary to screen more frequently, for example, where individuals are overweight and have one or more of the other risk factors shown in Figure 3.
\n\t\t\t\tCurrently, the consensus view is that screening should take place in a clinical setting, with testing offered by health care providers, based on an assessment of the individual patient. Diabetes UK argue that “screening is probably most-effective when performed as part of a general health review in primary and community care services, when other cardiovascular risks can be measured … and appropriate advice is immediately available” (Diabetes UK, 2006; p.6).
\n\t\t\t\t\tTo achieve screening in ‘hard-to-reach’ groups, particularly ethnic minorities in developed countries, other locations have been suggested, including religious and community venues or assessments in the workplace (Grant et al., 2004; Oberlinner et al., 2008; Porterfield et al., 2004; Somannavar et al., 2008; Tabaei et al., 2003), although the evidence base for screening in these settings is limited at present.
\n\t\t\t\t\tOne potential disadvantage is that community screening of this nature does not reach the groups who are most at risk of developing the condition, and may inappropriately test those who are at low risk or those already diagnosed with diabetes. Diabetes UK (2006) supports community screening for patient groups who do not routinely access family practice services,
There is insufficient evidence to identify a single ideal screening test (Waugh et al., 2007). A range of tests exist which might be used for screening purposes and these vary in their sensitivity and specificity, as well as their convenience, acceptability and cost (Cox & Edelman, 2009). Sensitivity is the “proportion of true positives that are correctly identified by the test”, while specificity is the “proportion of true negatives that are correctly identified by the test” (Altman & Bland, 1994).
\n\t\t\t\t\tUK, European and US Guidance on who should be screened for Type 2 Diabetes
Options include the fasting blood glucose test, the oral glucose tolerance test, random (or casual) blood glucose test, or a fasting capillary blood glucose test. More recently, it has been suggested that the glycated haemoglobin (HbA1c) test might also be appropriate for screening, because it does not require fasting and reflects longer-term glycaemia rather than a value at a single time point (American Diabetes Association, 2011; Bennett et al., 2007; Saudek et al., 2008). HbA1c may also have more relevance to clinicians dealing with patients who have diabetes. Urine testing is not strongly recommended for screening purposes, because it is less sensitive than the blood tests.
\n\t\t\t\t\tCurrently, a fasting blood glucose test is recommended as the screening test for Type 2 Diabetes in the UK and the USA (American Diabetes Association, 2011; Diabetes UK, 2006). It is easier and faster to perform in clinical settings, more convenient and acceptable to patients, and less expensive than other tests. The latest US guidance (American Diabetes Association, 2011) also states that the HbA1c and 2-hour 75g oral glucose tolerance test are appropriate tests to screen for diabetes. European guidance has tended to encourage the use of the oral glucose tolerance test as the gold standard diagnostic test (Waugh et al., 2007).
\n\t\t\t\t\t\n\t\t\t\t\t\tDiabetes UK (2006) suggest a fasting capillary blood test can be used for initial screening purposes, although this has lower sensitivity and specificity than venous blood glucose measurement and requires careful interpretation and feedback to the patient. Random (or casual) blood or plasma glucose testing can also be carried out if the patient has taken food or drink prior to the screening test; in this sense, it is practical but the results can be more difficult to interpret than those obtained via fasting tests.
\n\t\t\t\t\tWhere a screening test result is suggestive of diabetes, it is recommended that a second, fasting test be repeated on a different day to exclude the possibility of laboratory error, unless the patient has classic symptoms of diabetes. Guidance (American Diabetes Association, 2011; Diabetes UK, 2006) exists for health professionals with regard to the interpretation of test results. This includes the action needed (e.g. further testing, appropriate referrals) as well as the patient education that is required when positive, borderline, or normal test results are received.
\n\t\t\t\tA number of targeted screening programmes have been piloted in the UK, Europe and the USA in the last decade (e.g. Echouffo-Tcheugui et al., 2009; Edelman et al., 2002a; Franciosi et al., 2005; Greaves et al., 2004; Goyder et al., 2008; Janssen et al., 2007; O’Connor et al., 2001; Woolthuis et al., 2009).
\n\t\t\t\tMany have employed a ‘stepwise’ approach, whereby participants progress through increasingly invasive screening procedures until they are diagnosed with diabetes or found not to have the condition. The number of steps in the screening process varies across studies.
\n\t\t\t\tTypically, in the first step, potential screening participants are identified by:
\n\t\t\t\ttheir responses on a self-completed questionnaire that assesses their risk of diabetes, such as the FINDRISC (Saaristo et al., 2005), the Symptom Risk Questionnaire (Adriaanse et al., 2002) or the Diabetes Risk Score (Franciosi et al., 2005); or
using the GP electronic medical records to search for people who match specific risk criteria (e.g. Greaves et al., 2004); or
using a standardised risk calculator based on clinical data held on the computerised medical record to assess the patient’s risk of diabetes, such as the Cambridge Risk Score (Griffin et al., 2000) or QDRISK (Hippisley-Cox et al., 2009).
A recent alternative approach has been the use of online self-completion risk tools to determine a person’s risk of diabetes and hence the need for further action. Both the American Diabetes Association and Diabetes UK have online risk calculators available for the public to use (http://www.diabetes.org/diabetes-basics/prevention/diabetes-risk-test/; and http://www.diabetes.org.uk/riskscore respectively).
\n\t\t\t\tIndividuals who are identified as being ‘at risk’ of diabetes after the first step are offered (by invitation letter or during a GP consultation) a blood test to directly measure their glucose levels. The initial test tends to be relatively simple and convenient; in some studies, this has been a random blood glucose or HbA1c sample (which do not require prior fasting); in others, a capillary blood sample (‘finger prick’ test) has been used.
\n\t\t\t\tIf the results of the initial blood test fall within the normal range, the participant does not progress to the next level, but may receive lifestyle advice. If the results of the initial test reveal glucose levels above a specified threshold, participants are invited back for further testing. At that stage, the screening test may require the patient to fast for a prescribed period prior to the blood sample or undergo a more complex and lengthy screening process, such as the oral glucose tolerance test.
\n\t\t\t\tUptake of screening has varied across the studies and this may be a reflection of the type of test offered, how the invitation is made and where the testing takes place. In one study (O’Connor et al., 2001), the uptake of an initial random blood glucose test (offered via letter) was 44%. Where random capillary blood tests were offered, however, uptake was around 60-70% (Echouffo-Tcheugui et al., 2009). In one study, the reported uptake of a fasting capillary blood glucose test offered directly by the GP was 90% (Woolthuis et al., 2009). Further dropout is evident at the later stages of many of the stepwise screening processes, whereby individuals who have abnormal results in initial tests fail to return for further tests (Woolthuis et al., 2009), particularly where this involves more invasive or complex tests or where the patient is referred to an outpatient clinic (e.g. Franciosi et al., 2005; Janssen et al., 2007; O’Connor et al., 2001).
\n\t\t\tThe system of screening for Type 2 Diabetes in the St Leonard’s Practice, Exeter, UK is one special form of clinical opportunistic screening (Evans et al., 2008). It does not employ any external resources to screen for risk factors. The process relies on the clinical alertness of the GPs and practice nurses, and the efficient protocol-driven screening of patients with chronic conditions known to be associated with Type 2 Diabetes. The doctors and nurses screen adult patients with cardiovascular or cerebrovascular disease, hypertension, hypercholesterolaemia, obesity, recurrent skin infections, or a positive family history of diabetes.
\n\t\t\t\tIts advantages are that it eliminates another layer of costs that arise from the involvement of an external agency, such as a university or medical school. It also means that people from external organisations do not see confidential medical records. It fosters professional interest amongst GPs in patients as people with individual risks. It also fosters professional pride in GPs in ultra-early diagnosis. It is possible to maintain the system year after year and it has been so maintained in this practice since 1987 (Evans et al., 2008). Clinical opportunistic screening has the advantage that, since so many blood tests are taken nowadays in family practice, it is often possible to add the blood glucose screening test to samples being taken already, thus saving the patient an additional blood test.
\n\t\t\t\tThe main advantage of this system is that it can identify, year after year, two-thirds of all new cases of Type 2 Diabetes before a single symptom of diabetes has been reported by a patient (Evans et al., 2008).
\n\t\t\t\tSome family practices, including St Leonard’s, operate personal lists (Pereira Gray, 1979). When these are in use, it is also possible to compare the performance between doctors. Its main advantage internationally is that the method is more easily reproducible in family practices around the world. All that is needed is an enthusiastic family practitioner or nurse and an efficient computerised medical record system. Both family practice and computer systems are spreading rapidly.
\n\t\t\t\tThe disadvantages of the St Leonard’s system are that the intervention is not standardised and that there are variations between the six doctor partners operating it. It is not yet known how easy it will be to roll it out into other family practices more widely and it may be difficult where morale is low or burnout amongst the doctors is a serious problem (Soler et al., 2008).
\n\t\t\t\n\t\t\t\t\tMarteau (1990) notes that the receipt of an invitation to participate in a cancer or general health screening programme can be enough to evoke anxiety for some patients. As one might expect, receiving a ‘positive’ result after the screening test can also cause negative emotional reactions. People are not always reassured, even by a ‘normal’ result, and other adverse psychological effects can occur. For example, a ‘normal’ result may reinforce an unhealthy lifestyle or perceptions of invulnerability, and make patients less likely to return for future screening (Marteau 1989).
\n\t\t\t\tRecently, studies in Europe and the USA have specifically explored the psychological effects of undergoing screening for Type 2 Diabetes and these tend to support the conclusions of Marteau’s work. Some studies have assessed the impact of screening by asking patients to complete rating scales that measure their levels of anxiety, depression, and disease-specific worry (Eborall et al., 2007a; Park et al., 2008), or their health-related quality of life (Edelman et al., 2002b). Such studies have generally found no lasting or significant adverse psychological effects in terms of anxiety, depression, worry, or perceived quality of life after screening. However, there is some evidence that simply being invited for screening can increase state anxiety and that, six weeks after attending, anxiety is higher amongst people who have progressed further through the screening process, particularly those who were eventually diagnosed with diabetes (Park et al., 2008).
\n\t\t\t\tOther studies have explored patients’ experiences of screening in more depth. One study, which interviewed people shortly after they underwent screening tests (Adriaanse et al., 2002), found most participants had positive views of the screening process and had not found it burdensome. Most individuals who had been newly-diagnosed with diabetes did not feel alarmed or concerned about their results. Many appeared to believe they had a ‘mild’ version of the condition that they could control, although they felt the required lifestyle changes would have a significant impact on their life. People whose test results were normal reported feelings of relief or reassurance but saw no reason to change their lifestyle. Only a quarter of this group intended to have their blood glucose tested in future. Another study, which interviewed participants at different stages of a stepwise screening process (Eborall et al., 2007b), reported similar findings but noted that the stepped nature of the screening process appeared to help participants to adjust psychologically.
\n\t\t\t\tThe World Health Organization (2003) has cautioned that, as public awareness increases about the significance of a diagnosis of diabetes and its possible complications, the psychological effects of screening may become more marked. Marteau (1990) and Griffin et al. (2000) argue that some of the negative effects of screening can be avoided or reduced, if health professionals attend to the patient’s psychological and information needs at each stage of the screening process, including the point of invitation, the test procedure itself, discussing the results, and later follow-up.
\n\t\t\tEconomic modelling studies have been conducted to estimate the cost-effectiveness of screening for Type 2 Diabetes and Impaired Glucose Tolerance. In the UK, decisions about funding of interventions are made by the National Institute for Health and Clinical Excellence (NICE), based on cost-effectiveness. This body considers that interventions below an incremental cost-effectiveness ratio (ICER) threshold of £20,000 to £30,000 per quality-adjusted life-year (QALY) are cost-effective (National Institute for Health and Clinical Excellence, 2004).
\n\t\t\t\tOne systematic review and economic modelling exercise (Waugh et al., 2007), which included four studies, reached the conclusion that screening for diabetes appeared to be cost-effective for people aged 40-70 years. Whilst screening was more cost-effective for the older age bands (50-69 and 60-69 years), even for people aged 40-49 years, the ICER for screening (when compared to a policy of not screening) was £10,216 per QALY. Screening was found to be more cost-effective for people who were hypertensive and obese and, for many groups, the costs of screening were offset by lower treatment costs in the future. However, because the most comprehensive model in the review came from the USA (Hoerger et al., 2004), the applicability of these findings in the UK was questioned.
\n\t\t\t\tA more recent modelling study (Gillies et al., 2008), based on data derived from England and Wales, concluded that screening for Type 2 Diabetes and Impaired Glucose Tolerance – combined with appropriate lifestyle or pharmacological interventions for those found to have Impaired Glucose Tolerance to delay or prevent diabetes – appeared to be cost-effective in a population aged 45 years with \'above-average\' risk of developing diabetes. When comparing a policy of
The results of the above studies suggest that it may be more cost-effective to screen for Type 2 Diabetes
Other studies have attempted to determine the costs of targeted or opportunistic screening, based on the cost of identifying one new case of Type 2 Diabetes. In one US study (O’Connor et al., 2001), which used a two-step screening protocol (random blood glucose followed by oral glucose tolerance test), one new case of diabetes was identified for every 40 high-risk patients screened. The uptake of screening was relatively low (44% of patients who were invited attended) and the screening costs per new case were estimated at $4,064 per new case identified.
\n\t\t\t\tMore recently, a Danish study (Dalsgaard et al., 2010) has compared three different stepwise screening strategies for Type 2 Diabetes. In the first strategy, diabetes risk questionnaires were sent by the family practice to people aged 40-69 years and those found to be at high risk were asked to contact their GP to arrange a screening test. This strategy detected new cases of Type 2 Diabetes in 0.8% of the target population, at a cost of €1,058 (US$1,535)” per case. Two opportunistic screening programmes were also piloted. In these approaches, people who were consulting their GP were asked to complete the risk questionnaire in the waiting room and were either offered a screening test during the consultation (OP-direct) or asked to return for a fasting screening test at a subsequent consultation (OP-subsequent). The OP-direct strategy detected new cases of Type 2 Diabetes in 0.9% of the target population, at a cost of €707 (US$1,026) per case, while the OP-subsequent strategy detected Type 2 Diabetes in 0.5% of the target population, at a cost of €727 (US£1,055) per new case. The authors concluded that opportunistic screening can identify a similar proportion of new cases as mail-distributed questionnaires, but at lower cost.
\n\t\t\tThe worldwide epidemic of diabetes, mainly Type 2 Diabetes, calls for a major response as, in some countries, prevalence now exceeds 10% of the whole adult population. Clinicians are seeking to prevent the condition developing and to screen for undiagnosed cases. Since Type 2 Diabetes is increasingly managed in family practice or primary care, education and support is important.
\n\t\t\tPrevention of Type 2 Diabetes is now possible through lifestyle alteration but, so far, only after expensive interventions. Drugs can aid prevention but adverse effects are a big issue. Research on simplifying lifestyle interventions is urgent. Once Type 2 Diabetes is diagnosed, health professionals can then intervene as early as possible, before symptoms develop, in order to prevent complications.
\n\t\t\tIn the meanwhile, achieving earlier diagnosis of Type 2 Diabetes depends on screening. Population screening is likely to be introduced in richer countries and has recently started in the UK.
\n\t\t\tClinical opportunistic screening in family practice offers an important alternative approach since it may well be more cost-effective, provides the quickest route to treatment, and can detect two-thirds of all new cases of Type 2 Diabetes in a defined population. However, the effectiveness of this type of screening in routine care without extra resources has only been demonstrated in one practice and needs replication. If the early reports are confirmed, then clinical opportunistic screening warrants further consideration as an affordable alternative to population screening, particularly in the developing world.
\n\t\tWe acknowledge with thanks the assistance of Ms Beverley Berry, Information Manager at the Royal College of General Practitioners, London, who provided references for reports relating to early community screening programmes in Rotherham, Bedford and Birmingham. We also acknowledge with thanks the assistance of Dr Maurice Salzmann, Consultant Clinical Biochemist at the Royal Devon and Exeter NHS Foundation Trust, Exeter, who provided details of the local NHS laboratory cost of a blood glucose test.
\n\t\tDifferent fermented foods could be categorized according to fermentation products just like organic acids which consisting of acetic acid and lactic acid (dairy and vegetables); and peptides and amino acids resulted from protein (fish and other fermentations); CO2 (bread); and alcohol (wine and beer) [1, 2]. Food fermentation is one of an early the most precise innovations created and developed by people.
In Asia, coastal foragers during the age of primitive pottery (8000 to 3000 b.c.) were thought to have fermented vegetables before developing of crop-based agriculture [3]. It is possible that dairy fermentations in Middle East came after cattle domestication, alcohol was the first discovered fermented product from fruit fermentation. Many advanced fermentation procedures to produce alcohol by using the cereals were created nearly 4000 b.c., just like producing wine from rice in Asia and beer in Egypt [1]. In Asia, many composed references regarding fermentation innovation were found in historic poems Shijing Chinese book (1100 to 600 b.c.), that celebrates “the thousand wines of Yao,” in referring to a kingdom in China from 2300 b.c. Cucumber thought were first fermented nearly 2000b.c. in Middle East. Old composed records came from the remains of papers of a play (The Taxiarchs) by Eupolis a writer from Greece (429–412 b.c.), also in Christian Bible, pickles were repeated many times. The fermented cabbage and kimchi on the Korean style, is expected to have established in the primitive pottery age from the wizened vegetables ordinary fermentation stored in seawater [1].
Sauerkraut on European style is thought was established in China, while the technique might be transferred to Europe at the invasion time of Mongol to central Europe in the 13th century. Nowadays, the vegetable fermentation industry is conducting on an enormous scale. Companies in United States that working on cucumber pickles fermentations may have 1000 fermentation tanks of forty-thousand-liter capacity at one site.
Throughout the ages, it was believed that cucumber pickle as the fairly fermented cucumber to which spices, vinegar, salt, and sometimes sugar has been added. While the preservation was not required by using the heat. Recently, fresh packed pickles, manufactured by adding of spices, salt, and vinegar to the fresh cucumbers under pasteurized preservation, are representing a huge portion of pickle industry.
Industrial treatments tentatively preserve around 40% of crop through the fermentation in NaCI brines that contain fermentable carbohydrates which converting into acetic acids, ethanol, lactic acid, CO2, and other compounds by naturally existence lactic acid bacteria and yeast. This procedure uses to expand the using equipment packing line and workers to throughout the year operation in manufacturing of the final product.
Traditionally, fiberglass, wood, and polyethylene tanks are used for the fermentation that might require 10–21 days (period of storage in the same tanks is generally less than 1 year) and sometimes longer. Tanks are put outdoors to give the opportunity for sunlight ultraviolet irradiation to hit the surface of the brine and subsequently inhibiting yeasts and molds growing, and other microorganisms on the surface of the brine.
During the fermentation of cucumber pickles, brine storage and processing operations are liable to the reactions of oxidation which affect adversely on the quality properties. In spite of pickles are flooded in brine during fermentation and bulk-storage, while the containers are opening, which encourage the exposure to air and sunlight.
Additionally, pickle tanks’ brines are usually spread with air in order to mix the components and to release CO2, and at the time of transferring to processing operations, pickles are removed from brine and subsequently exposes to light and oxygen. Also, the brines and pickles content of traces prooxidant metals just like copper, zinc and iron which act together with oxygen and light to be in charge of pigments oxidation and developing undesirable flavors sometimes, and this may lead to considerable economic loss of the market value.
Cucumber (
Air purging may be stopped each day several hours to control aerobic microorganisms’ excessive growth. Usually, cucumber is fermented with
Fermentation is influenced by variables due to cucumbers, environmental conditions under which they are kept during fermentation, and microorganisms that are naturally present or intentionally added. Since it is so important to maintain the structural integrity of cucumbers, both physical and chemical factors are involved. The interactions between these factors lead to an extremely interesting and complex fermentation process [15]. A lot of research on the fermentation of cucumbers and other fruits and vegetables has been done. However, there is an incomplete understanding of the interactions between the microbiological, chemical, and physical factors involved.
Before the cucumber fermentation industry can take full advantage of the biotechnology revolution that looms for many fermentation industries, more understanding of these interactions is needed [16].
The production of CO2 in the cover brine of fermenting vegetables by heterofermentative LAB and fermentative species of yeasts has been linked with gas pockets formation inside the cucumber, which called formation of bloater (Figure 1). Homofermentative LAB capable of decarboxylating malic acid, as example
Steps brine fermentation of cucumber [
Oxidative yeasts may cause malodorous spoilage of fermented cucumbers to develop. The lactic acid generated during fermentation can be consumed by these microorganisms, with a subsequent increase in pH that facilitates the development of spoilage microorganisms [22, 23]. In cucumbers, lactic acid produced during primary fermentation can be catabolized by yeasts of the genera Pichia and Issatchenkia, causing an increase in pH.
Pectinolytic enzymes derived from plant material or microbes can cause the softening of brined vegetables (Figure 2).
Mold growth accompanying film-forming yeast growth on the brine surface can cause softening of cucumbers. In the absence of sunlight and the presence of minimal amounts of oxygen, heavy scum yeast and/or mold growth is generally the result of neglecting brine material during extended storage [25]. In order to maintain anaerobic conditions and to limit the growth of surface yeasts and molds, Pickled cucumber tanks are usually held indoors, with a seated plastic cover weighted down with water or brine. Mold polygalacturonases associated with cucumber flowers can also result in the softening of brined cucumbers [26]. By draining and rebrining the tank with calcium chloride, this problem can be reduced. 36 hours after the initial brining procedure. However, this solution is not about salt disposal. Recycled brines are instead treated to inactivate the softening enzymes, if necessary [14]. The addition of calcium chloride may slow down the rate of fermenting cucumbers’ enzymatic softening. This should not, however, be relied upon to eliminate problems with enzymatic softening. Care must be taken to minimize the contamination of flowers and plant debris by cucumbers, especially small fruits, which may be a source of contamination by pectinolytic molds. Due to the reduced amount of brine surface in contact with air compared to the total volume, softening is not a very serious problem in bulk Spanish-style cucumber fermentation. Yeasts and/or molds on the plastic drums used during the conditioning operations (sizing, grading, pitting, stuffing, etc.) can, however, cause softening [22]. Desalting is used to prepare non-pasteurized fermented cucumbers, followed by the addition of cover liquor, often containing acetic acid and preservatives. Sugar is added to sweet pickles at concentrations of up to 40 percent. The main spoilage organisms in such products are osmotolerant yeasts, and a preservation prediction chart, based on the concentration of acid and sugar required for shelf stability, has been developed. On the surface of the liquid, aerobic molds and film yeasts may grow, mainly as a result of defective jar closure. Spoilage microorganisms in sweet pickles include yeasts [27] and lactobacilli, particularly the heterofermentative
This can lead to a potentially dangerous situation triggered by an increase in pH as the spoilage microorganisms consume organic acids. Germination of
The refrigerated fresh-pack (non-fermented) products contain 2–3 percent NaCl and sometimes sodium benzoate or other preservatives and are acidified with vinegar at a balanced pH of around 3.7 [29]. The cucumbers are not heated, like the half-sour pickles, either before or after packing. The products will maintain an acceptable quality for several months if properly acidified, refrigerated, and preserved. However, recipes containing no vinegar or other acid in the initial cover liquor should be considered with caution. Quality assurance of cucumber products begins with the removal of the cucumber’s outer leaves and woody core. In addition to its undesirable texture, the existing sucrose in the core could be utilized by
Usually, fermentation is defined as an anaerobic process. Within the cucumber fermentation process, LAB and yeast convert glucose and fructose into lactic acid, ethanol, acetic acid, and CO2. The homofermentative LAB main pathway is breaking down of one six-carbon sugar (glucose) to produce two molecules of three-carbon lactic acid. More complex metabolism is used by Heterofermentative organisms. At the beginning, glucose is converted into CO2 five-carbon sugar phosphate, and furthermore degraded into lactic acid and a two-carbon compound, acetic acid or ethanol [32]. We shall concentrate here on vegetable fermentation biochemical features that link to quality of the product. So far, many researches are paying more attention in vegetables fermentation and storage, especially cucumbers, with reduced salt. Vegetable fermentations’ chloride waste can be extremely reduced in case of reducing the required salt for fermentation and storage in order to exclude the desalting step before the conversion to final products. Many research studied the relationship between concentration and type of the salt [33]. Replacing of NaCl with various cations and anions on fermentation of sugar in cucumber juice. The most interesting thing, fructose was the most preferred fermentable sugar to
Fleming et al. [21] showed the importance of calcium in keeping fermented cucumbers’ firmness. It was found that first-order kinetics is followed by the nonenzymatic softening of acidified, blanched cucumber tissue [37]. The mentioned kinetic manner made it reasonable to identify the activation of entropy and enthalpy of cucumbers’ nonenzymatic softening, although that the chemical reactions in charge of softening were not known. At 1.5 M NaCl, both activation of entropy and enthalpy were high. Cucumber softening was inhibited by calcium because it reduced activation entropy too much into a limit that activation overall free energy was reduced [38]. This behavior of thermodynamic is resembled to that which occurs when changing conformation of polymers, just like in denaturation of protein. It is totally differed from the observed properties of pectin acid hydrolysis [39]. Figured out that pectin’s acid hydrolysis rate was inefficient to be the reason for non-enzymatic softening the tissue of the cucumber [40]. Identified salt, temperature, and calcium concentrations combined effects on fermented cucumber tissue’s softening rate. The softening kinetics of fermented cucumbers did not follow the first-order simple reaction. Just like the tissues of many other plants, cucumber possesses enzymes that have the ability to degrade the ingredients of plant cell walls, which may lead to changing in the texture.
In cucumbers, many activities of enzymes have been found such as exopolygalacturonase, pectinesterase, and endopolygalacturonase [41]. When fermenting or acidifying of cucumber, methyl groups are removed from pectin by pectinesterase [42]. Nevertheless, pectin’s’ enzymatic hydrolysis by polygalacturonases from cucumber has not been identified if it is a significant factor in fermented cucumbers’ softening. Adding of fungal polygalacturonases into the tanks of fermentation, especially on the flowers attached to small cucumbers has been linked to the commercially importance of fermented cucumbers’ enzymatic softening. Buescher and Burgin [43] developed a sensitive new method of diffusion plate to determine the activity of polygalacturonase in the brines of fermentation and found that alumino-silicate clay has the ability of adsorbing and removing the activity of polygalacturonase from the brines of fermentation that are recycled. Enzymes which could hydrolyze polysaccharides of the cucumbers cell wall have not studied widely comparing with the enzymes that degrade pectin [45]. Showed that the activity of endo-β-1,4- gluconase in cucumber is inhibited under pH of 4.8 while endoglucomannan-splitting enzyme retains its activity under pH of 4.0 but is inhibited within the fermentation. In fresh cucumbers, they characterized 6 enzymes which hydrolyze p-nitrophenylglycosides of β-d-glucose, β-d-galactose, α-d-galactose, β-d-xylose, α-d-mannose, and α-l-arabinose, which were inhibited throughout the fermentation. The enzymes that have the ability to hydrolyze the synthetic substrates are widespread in plants. Resemble enzymatic activities were found in olives, pears, and Semillon grapes.
Maruvada [44] and Takayanagi et al. [45] discovered the same p-nitrophenyl glycosidases detected by [44] in cucumbers. She reported undetectable levels in 2% NaCl brines throughout the first week of fermentation [46, 47]. Gathered calcium addition, fresh cucumbers’ blanching relatively to enzyme inactivation, and a quick fermentation using a malolactic-negative
Compared to the fermentation of liquids such as beer, wine, and milk, unique problems are involved in the fermentation of whole vegetables. Structural integrity has to be preserved in whole vegetables, which is not a factor with liquids [52]. Tissue softening is also a serious defect that can be caused by pectinolytic enzymes of either microbial (primarily fungal) source [53] or of the cucumber fruit itself. Off-flavors and off-colors may result from improper methods of fermentation and handling.
The cucumber pickle industry is faced with waste disposal, in addition to spoilage problems. These wastes consist of the salt used to prevent softening during fermentation and storage, and the organic wastes. Salt concentrations used greatly exceed the 2–3 percent desired in the final product [54].
Thus, after storing the brine, the excess salt must be leached from the cucumbers before they are processed into finished products. Disposal of this non-biodegradable waste salt is a source of serious environmental concern. As the salt is extracted during leaching, soluble cucumbers, including desirable nutrients and flavor compounds, are also removed. These desirable components are not only lost, they must be degraded before being discharged into waterways. Discharge of salt and organic materials into municipal disposal systems typically entails an extra expense for pickle companies, since municipalities must charge for recovering the cost of handling such waste [55] (Figure 3).
Cucumber bloater defect caused by carbon dioxide microbiologically produced during fermentation by either yeasts or LAB [
Purge-and-trap analysis of cucumber slurries’ volatile ingredients in 2 percent reduced-salt salt brine before and after cucumber fermentation. Volatile components’ comparison before and after fermentation led to the derivation that the main influence of fermentation on volatile flavors was to prohibit the enzymatic production of E, Z-2,6-nonadienal and 2-nonenal enzymes in cucumbers [34]. These aldehydes are the major ingredients in charge of cucumbers’ fresh flavor [57]. Although, after a few days of cucumber fermentation, when tearing the tissue of cucumber, the pH descends low enough to deactivate the enzymes that forming these compounds. In fresh cucumber slurries, just benzaldehyde, ethyl benzene, and o-xylene were not found within the volatile ingredients characterized in the fermented cucumbers. Recently, the absence of flavor influence of volatile aldehydes is the main effect of the fermentation on flavor [35]. In fermented pickled cucumber brines, a low influence of volatility flavor compound was characterized. Adding of saturated salt to brine samples and heating to 50 °C, SPME (solid-phase microextraction) fiber sampling followed by GC-olfactometry resulted in the identification of a component with an odor close to that of the fermentation brine. The component with a fermentation brine odor was characterized as
IntechOpen implements a robust policy to minimize and deal with instances of fraud or misconduct. As part of our general commitment to transparency and openness, and in order to maintain high scientific standards, we have a well-defined editorial policy regarding Retractions and Corrections.
",metaTitle:"Retraction and Correction Policy",metaDescription:"Retraction and Correction Policy",metaKeywords:null,canonicalURL:"/page/retraction-and-correction-policy",contentRaw:'[{"type":"htmlEditorComponent","content":"IntechOpen’s Retraction and Correction Policy has been developed in accordance with the Committee on Publication Ethics (COPE) publication guidelines relating to scientific misconduct and research ethics:
\\n\\n1. RETRACTIONS
\\n\\nA Retraction of a Chapter will be issued by the Academic Editor, either following an Author’s request to do so or when there is a 3rd party report of scientific misconduct. Upon receipt of a report by a 3rd party, the Academic Editor will investigate any allegations of scientific misconduct, working in cooperation with the Author(s) and their institution(s).
\\n\\nA formal Retraction will be issued when there is clear and conclusive evidence of any of the following:
\\n\\nPublishing of a Retraction Notice will adhere to the following guidelines:
\\n\\n1.2. REMOVALS AND CANCELLATIONS
\\n\\n2. STATEMENTS OF CONCERN
\\n\\nA Statement of Concern detailing alleged misconduct will be issued by the Academic Editor or publisher following a 3rd party report of scientific misconduct when:
\\n\\nIntechOpen believes that the number of occasions on which a Statement of Concern is issued will be very few in number. In all cases when such a decision has been taken by the Academic Editor the decision will be reviewed by another editor to whom the author can make representations.
\\n\\n3. CORRECTIONS
\\n\\nA Correction will be issued by the Academic Editor when:
\\n\\n3.1. ERRATUM
\\n\\nAn Erratum will be issued by the Academic Editor when it is determined that a mistake in a Chapter originates from the production process handled by the publisher.
\\n\\nA published Erratum will adhere to the Retraction Notice publishing guidelines outlined above.
\\n\\n3.2. CORRIGENDUM
\\n\\nA Corrigendum will be issued by the Academic Editor when it is determined that a mistake in a Chapter is a result of an Author’s miscalculation or oversight. A published Corrigendum will adhere to the Retraction Notice publishing guidelines outlined above.
\\n\\n4. FINAL REMARKS
\\n\\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\\n\\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
\\n\\nThe general principles set out above apply to Retractions and Corrections issued in all IntechOpen publications.
\\n\\nAny suggestions or comments on this Policy are welcome and may be sent to permissions@intechopen.com.
\\n\\nPolicy last updated: 2017-09-11
\\n"}]'},components:[{type:"htmlEditorComponent",content:'IntechOpen’s Retraction and Correction Policy has been developed in accordance with the Committee on Publication Ethics (COPE) publication guidelines relating to scientific misconduct and research ethics:
\n\n1. RETRACTIONS
\n\nA Retraction of a Chapter will be issued by the Academic Editor, either following an Author’s request to do so or when there is a 3rd party report of scientific misconduct. Upon receipt of a report by a 3rd party, the Academic Editor will investigate any allegations of scientific misconduct, working in cooperation with the Author(s) and their institution(s).
\n\nA formal Retraction will be issued when there is clear and conclusive evidence of any of the following:
\n\nPublishing of a Retraction Notice will adhere to the following guidelines:
\n\n1.2. REMOVALS AND CANCELLATIONS
\n\n2. STATEMENTS OF CONCERN
\n\nA Statement of Concern detailing alleged misconduct will be issued by the Academic Editor or publisher following a 3rd party report of scientific misconduct when:
\n\nIntechOpen believes that the number of occasions on which a Statement of Concern is issued will be very few in number. In all cases when such a decision has been taken by the Academic Editor the decision will be reviewed by another editor to whom the author can make representations.
\n\n3. CORRECTIONS
\n\nA Correction will be issued by the Academic Editor when:
\n\n3.1. ERRATUM
\n\nAn Erratum will be issued by the Academic Editor when it is determined that a mistake in a Chapter originates from the production process handled by the publisher.
\n\nA published Erratum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n3.2. CORRIGENDUM
\n\nA Corrigendum will be issued by the Academic Editor when it is determined that a mistake in a Chapter is a result of an Author’s miscalculation or oversight. A published Corrigendum will adhere to the Retraction Notice publishing guidelines outlined above.
\n\n4. FINAL REMARKS
\n\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\n\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
\n\nThe general principles set out above apply to Retractions and Corrections issued in all IntechOpen publications.
\n\nAny suggestions or comments on this Policy are welcome and may be sent to permissions@intechopen.com.
\n\nPolicy last updated: 2017-09-11
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The motor of the society is the industry and the research of this topic has to be empowered in order to increase and improve the quality of our lives.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/22.jpg",hasOnlineFirst:!0,hasPublishedBooks:!0,annualVolume:11418,editor:{id:"27170",title:"Prof.",name:"Carlos",middleName:"M.",surname:"Travieso-Gonzalez",slug:"carlos-travieso-gonzalez",fullName:"Carlos Travieso-Gonzalez",profilePictureURL:"https://mts.intechopen.com/storage/users/27170/images/system/27170.jpeg",biography:"Carlos M. Travieso-González received his MSc degree in Telecommunication Engineering at Polytechnic University of Catalonia (UPC), Spain in 1997, and his Ph.D. degree in 2002 at the University of Las Palmas de Gran Canaria (ULPGC-Spain). He is a full professor of signal processing and pattern recognition and is head of the Signals and Communications Department at ULPGC, teaching from 2001 on subjects on signal processing and learning theory. His research lines are biometrics, biomedical signals and images, data mining, classification system, signal and image processing, machine learning, and environmental intelligence. He has researched in 52 international and Spanish research projects, some of them as head researcher. He is co-author of 4 books, co-editor of 27 proceedings books, guest editor for 8 JCR-ISI international journals, and up to 24 book chapters. He has over 450 papers published in international journals and conferences (81 of them indexed on JCR – ISI - Web of Science). He has published seven patents in the Spanish Patent and Trademark Office. He has been a supervisor on 8 Ph.D. theses (11 more are under supervision), and 130 master theses. He is the founder of The IEEE IWOBI conference series and the president of its Steering Committee, as well as the founder of both the InnoEducaTIC and APPIS conference series. He is an evaluator of project proposals for the European Union (H2020), Medical Research Council (MRC, UK), Spanish Government (ANECA, Spain), Research National Agency (ANR, France), DAAD (Germany), Argentinian Government, and the Colombian Institutions. He has been a reviewer in different indexed international journals (<70) and conferences (<250) since 2001. He has been a member of the IASTED Technical Committee on Image Processing from 2007 and a member of the IASTED Technical Committee on Artificial Intelligence and Expert Systems from 2011. \n\nHe has held the general chair position for the following: ACM-APPIS (2020, 2021), IEEE-IWOBI (2019, 2020 and 2020), A PPIS (2018, 2019), IEEE-IWOBI (2014, 2015, 2017, 2018), InnoEducaTIC (2014, 2017), IEEE-INES (2013), NoLISP (2011), JRBP (2012), and IEEE-ICCST (2005)\n\nHe is an associate editor of the Computational Intelligence and Neuroscience Journal (Hindawi – Q2 JCR-ISI). He was vice dean from 2004 to 2010 in the Higher Technical School of Telecommunication Engineers at ULPGC and the vice dean of Graduate and Postgraduate Studies from March 2013 to November 2017. 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