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PURPOSE: To compare preoperative contrast-enhanced spectral mammography (CEM) versus digital mammography plus digital breast tomosynthesis (DM + DBT) in detecting breast cancer (BC) and assessing its size. MATERIAL AND METHODS: We retrospectively included 78 patients with histological diagnosis of BC who underwent preoperative DM, DBT, and CEM over one year. Four readers, blinded to pathology and clinical information, independently evaluated DM + DBT versus CEM to detect BC and measure its size. Readers' experience ranged 3-10 years. We calculated the per-lesion cancer detection rate (CDR) and the complement of positive predictive value (1-PPV) of both methods, stratifying analysis on the total of lesions, index lesions, and additional lesions. The agreement in assessing cancer size versus pathology was assessed with Bland-Altman analysis. RESULTS: 100 invasive BCs (78 index lesions and 22 additional lesions) were analyzed. Compared to DM + DBT, CEM showed higher overall CDR in less experienced readers (range 0.85-0.90 vs. 0.95-0.96), and higher CDR for additional lesions, regardless of the reader (range 0.54-0.68 vs. 0.77-0.86). CEM increased the detection of additional disease in dense breasts in all readers and non-dense breasts in less experienced readers only. The 1-PPV of CEM (range 0.10-0.18) was comparable to that of DM + DBT (range 0.09-0.19). At Bland-Altman analysis, DM + DBT and CEM showed comparable mean differences and limits of agreement in respect of pathologic cancer size. CONCLUSION: Preoperative CEM improved the detection of additional cancer lesions compared to DM + DBT, particularly in dense breasts. CEM and DM + DBT achieved comparable performance in cancer size assessment.
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Neoplasias de la Mama/diagnóstico por imagen , Medios de Contraste , Mamografía/métodos , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/cirugía , Femenino , Humanos , Persona de Mediana Edad , Variaciones Dependientes del Observador , Periodo Preoperatorio , Intensificación de Imagen Radiográfica , Estudios RetrospectivosRESUMEN
BACKGROUND: Old durum wheat varieties are being appreciated again because of their interesting genetic diversity and low fertilizer needs. RESULTS: The agronomic and bread-making performances of 14 old Italian durum wheat varieties grown under two low nitrogen (N) inputs (46 and 86 kg ha-1 ) were determined and the relationships among grain, semolina, dough and bread quality parameters were established. The old varieties yielded similarly to the check modern variety Svevo under both N levels. Increasing N fertilization from 46 to 86 kg ha-1 did not increase grain yield or the mg of N in the grain, although grain protein percentage increased as a result of a decrease in grain weight and an increase in gliadin content. Despite the resulting decrease in the gluten index, dough and bread quality improved at the higher N rate, highlighting the influential role of protein percentage and gliadin in bread quality. The genotypic variation in grain protein percentage among old varieties was more strongly associated with glutenin than with gliadin content. Variation in the gluten index was high (4-54); indeed, it was the most variable semolina parameter, and proved to contribute the most to variation in bread quality. This variation was independent of the glutenin alleles (HMW 20, 20*, 7, 13+16, 6+8) and was linked to the quality of the grain in terms of grain weight and the associated mg of N per grain. Remarkably, two old varieties, namely Calabria and Cappelli, were able to produce both a good yield and high-quality bread. CONCLUSION: Old Italian durum wheats continue to boast significant biodiversity and are worth exploring in low-input production systems. © 2019 Society of Chemical Industry.
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Pan/análisis , Triticum/química , Fertilizantes/análisis , Harina/análisis , Genotipo , Gliadina/metabolismo , Glútenes/metabolismo , Italia , Nitrógeno/análisis , Nitrógeno/metabolismo , Semillas/química , Semillas/genética , Triticum/clasificación , Triticum/genéticaRESUMEN
Following the boom in durum wheat breeding, ancient wheat disappeared from the human diet and old durum wheat varieties were replaced by what is believed to be their better versions: higher yielding modern varieties grown in high-input systems. Breeders have worked intensely ever since to improve the quality of durum wheat traits - mainly gluten subunit alleles - to obtain superior technological quality in the main durum wheat end products (first pasta and then bread) but conflicts about predicting their quality still exist. This is because quality is neither governed by one trait alone nor conditioned by a single controllable factor. This review discusses the evolution of wheat varieties from ancient to old, and then modern durum wheat in terms of agronomy, genetics, technological, and end-product qualities. Environmental effects will not be discussed. Moving from ancient to modern durum wheat varieties, grain yield increased, grain protein concentration decreased, and gluten strength and dough toughness improved, ameliorating the quality of pasta but decreasing the durum wheat versatility. © 2018 Society of Chemical Industry.
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Carácter Cuantitativo Heredable , Triticum/genética , Fitomejoramiento , Triticum/química , Triticum/clasificación , Triticum/crecimiento & desarrolloRESUMEN
The upcycling of agricultural by-products and the extension of the shelf-life of staple foods represent crucial strategies for mitigating the consequences of food losses and enhancing the competitiveness of the agri-food industry, thus facilitating the attainment of higher financial revenues. This is particularly relevant for global artichoke cultivation, where 60-80% of its biomass is discarded annually. The present study investigated the potential of using non-stabilized polyphenol-rich extracts from the main artichoke by-products (bracts, leaves, and stems) to fortify and extend the shelf-life of breadsticks. The incorporation of hydroalcoholic extracts at two addition levels (1000-2000 ppm) resulted in an increased antioxidant capacity and oxidative stability of fortified breadsticks. Rheological tests revealed that the fortification did not affect the dough's workability, with the exception of the leaf extract. While a slight deterioration in texture was observed, the shelf-life of breadsticks was significantly extended, particularly at the highest levels of addition, without any visible alteration in their appearance. The stem extract demonstrated the most promising outcomes, exhibiting a maximum increase of 69% in antioxidant capacity (DPPH) and an extension of the estimated shelf-life by 62% in the resulting breadsticks, prompting the potential for utilizing them to develop nutritious and healthy snacks with extended shelf-life.
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The conservation and characterization of landraces have key roles in the safeguarding and valorization of agrobiodiversity. Indeed, these plant genetic resources represent an important crop heritage with quality and sensory characteristics that can be of great use to consumers and industry. In addition, the preservation of genetic resources from the risk of progressive genetic erosion, and the enhancement of their potential can contribute to food security and improve the nutritional value of food. Accordingly, this study aimed to investigate a collection of Sardinian tomato landraces for parameters that have determinant roles in evaluating their responses to conservation, and therefore to consumer acceptance. Six Sardinian landraces and two commercial varieties were cultivated in a two-years off-season trial, harvested at two different maturity stages (turning, red-ripe) and characterized using 14 fruit-related quality parameters that define the marketability, nutritional value, and flavor of the fruit. Data were collected at intervals of 10 days, starting from the harvest date and over 30 days of storage under refrigeration. The simultaneous analysis of all the qualitative characteristics for the different genotypes allowed to clearly differentiate the local varieties from the commercial varieties and a few landraces emerged for their satisfactory performances, e.g. "Tamatta kaki" ad "Tamatta groga de appiccai". In particular, the "Tamatta groga de appiccai" showed satisfactory lycopene content at marketable stages (average 5.65 mg 100g-1 FF), a peculiar orange-pink color with the highest hue angle values (range: H°T0 = 72.55-H°T30 = 48.26), and the highest firmness among the landraces of the red-ripe group (range: EpT0 = 1.64-EpT30 = 0.54 N mm-1). These results highlight the potential of some of the Sardinian tomato landraces for developing new varieties or promoting their direct valorization in local markets and could considerably increase the effectiveness and efficiency of agrobiodiversity conservation strategies.
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Frutas , Solanum lycopersicum , Frutas/genética , Solanum lycopersicum/genética , Licopeno , GenotipoRESUMEN
Authentication of extra virgin olive oils is a key strategy for their valorization and a way to preserve olive biodiversity. Physical and thermal analysis have been proposed in this study as fast and green techniques to reach this goal. Thirteen extra virgin olive oils (EVOOs) obtained from minor olive cultivars, harvested at three different ripening stages, in four Italian regions (Abruzzo, Apulia, Sardinia, and Calabria) have been studied. Thermal properties, viscosity and color, as influenced by fatty acid composition and chlorophyll content, have been investigated. The thermal curves of EVOOs, obtained by differential scanning calorimetry, were mostly influenced by the oleic acid content: a direct correlation with the cooling and heating enthalpy and an indirect correlation with the cooling transition range were observed. The minor fatty acids, and particularly arachidic acid, showed an influence, mostly on the heating thermograms. Viscosity and color showed respectively a correlation with fatty acids composition and chlorophyll content, however they didn't result able to discriminate between the samples. Thanks to the principal component analysis, the most influencing thermal parameters and fatty acids were used to cluster the samples, based on their botanical and geographical origin, resulting instead the harvesting time a less influential variable.
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BACKGROUND: Extended focused abdominal sonography for trauma (e-FAST) is part of the primary survey in patients with high-energy trauma. However, it does not identify patients with retroperitoneal haemorrhage associated with significant pelvic trauma. A traumatic diastasis of pubic symphysis, as well as an 'open book' (OB) pelvic injury, is a diagnostic clue to recognize unstable pelvis with higher risk of bleeding. FAST-PLUS (FAST-PL pleural -US ultrasound of symphysis) protocol is an addendum to the e-FAST, which takes into account the study of the pubic symphysis in a single transverse scan after the traditional focused evaluation of the abdomen and thorax. OBJECTIVES: The aim of this study is to determine the value of FAST-PLUS protocol in the evaluation of pubic symphysis injuries and the identification of 'open book' (OB) unstable pelvic fractures. METHODS: Between January 2018 and December 2019, we retrospectively reviewed 67 polytraumatised patients with clinical suspicion of pelvic instability and with known anteroposterior pelvis compression injuries who underwent e-FAST with an additional transverse scan of the pubic symphysis, named the FAST-PLUS protocol and computed tomography (CT) exam in order to assess the correlation between them in defining the presence or absence of pubic symphyseal widening (SW). A cutoff value of 2.5 cm in transverse diameter was used to diagnose OB unstable pelvic injury. The results were analysed using Cohen's test, which uses the Kappa value as the reference index. RESULTS: The analysis carried out to assess the degree of agreement between FAST-PLUS and CT showed 5/67 patients (7.5%) with a critical pubic SW (> 2.5 cm transverse diameter) suggestive of unstable OB pelvic injury and 62/67 (92,5%) without any signs of SW at FAST-PLUS. At CT, findings of unstable OB pelvic fracture were confirmed in all patients with positive results at FAST-PLUS. Similarly, all patients with negative results for critical pubic SW (< 2.5 cm in transverse diameter) at FAST-PLUS were found to be negative at CT exam. The level of correlation between the two methods was high (Kappa value = 1) CONCLUSION: The FAST-PLUS protocol shows a high correlation with CT exam, which is the gold standard for the detection of unstable pubic SW, as well as OB pelvic injury, in polytraumatised patients. Inclusion of FAST-PLUS in patient management in the shock room may lead to a quicker identification of patients with unstable pelvis and to faster therapeutic work-up.
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Evaluación Enfocada con Ecografía para Trauma , Fracturas Óseas , Traumatismo Múltiple , Sínfisis Pubiana , Abdomen , Fracturas Óseas/diagnóstico por imagen , Humanos , Traumatismo Múltiple/diagnóstico por imagen , Pelvis/diagnóstico por imagen , Pelvis/lesiones , Sínfisis Pubiana/diagnóstico por imagen , Sínfisis Pubiana/lesiones , Estudios RetrospectivosRESUMEN
Poorly emphasized aspects for a sustainable olive oil system are chemical analysis replacement and quality design of the final product. In this context, near infrared spectroscopy (NIRS) can play a pivotal role. Thus, this study aims at comparing performances of different NIRS systems for the prediction of moisture, oil content, soluble solids, total phenolic content, and antioxidant activity of intact olive drupes. The results obtained by a Fourier transform (FT)-NIR spectrometer, equipped with both an integrating sphere and a fiber optic probe, and a Vis/NIR handheld device are discussed. Almost all the partial least squares regression models were encouraging in predicting the quality parameters (0.64 < R2pred < 0.84), with small and comparable biases (p > 0.05). The pair-wise comparison between the standard deviations demonstrated that the FT-NIR models were always similar except for moisture (p < 0.05), whereas a slightly lower performance of the Vis/NIR models was assessed. Summarizing, while on-line or in-line applications of the FT-NIR optical probe should be promoted in oil mills in order to quickly classify the drupes for a better quality design of the olive oil, the portable and cheaper Vis/NIR device could be useful for preliminary quality evaluation of olive drupes directly in the field.
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This research focuses on the exploration, recovery and valorization of some minor Italian olive cultivars, about which little information is currently available. Autochthonous and unexplored germplasm has the potential to face unforeseen changes and thus to improve the sustainability of the whole olive system. A pattern of nine minor genotypes cultivated in three Italian regions has been molecularly fingerprinted with 12 nuclear microsatellites (SSRs), that were able to unequivocally identify all genotypes. Moreover, some of the principal phenolic compounds were determined and quantified in monovarietal oils and the expression levels of related genes were also investigated at different fruit developmental stages. Genotypes differed to the greatest extent in the content of oleacein (3,4-DHPEA-EDA) and total phenols. Thereby, minor local genotypes, characterized by stable production and resilience in a low-input agro-system, can provide a remarkable contribution to the improvement of the Italian olive production chain and can become very profitable from a socio-economic point of view.
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Celiac disease is increasing all over the world. In this context, most recent research in this area is addressing and attempting to improve the nutritional value and sensory characteristics of gluten-free (GF) food products and to enhance their technological properties. Here, amaranth flour was studied as a potential healthy ingredient for the development of an innovative GF flat bread. Starting from two different basic formulations (rice flour:corn starch and rice flour:tapioca starch, 50:50), the impact of partially replacing rice flour (6%) and starch (6%) with amaranth on the nutritional characteristics, polyphenol composition, textural, and sensory properties of the resulting GF flat breads was explored. The substitution with amaranth led to detrimental effects on the doughs' viscometric properties, especially in the case of tapioca starch, but significantly improved the doughs' textural properties. All the amaranth-enriched flat breads showed a better color and a significant increase in all polyphenols fractions but lower antioxidant activity. During bread storage for three days, a detrimental effect on both starch retrogradation, toughness, and extensibility properties were observed, especially when tapioca starch was used. Check-all-that-apply (CATA) sensory test results showed that the incorporation of amaranth increased yeast odor and yeast flavor perception and decreased the softness in mouth-only in tapioca-based samples. A better compromise among technological, nutritional, and sensory properties was achieved when amaranth flour was added to the basic rice and corn formulation.
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The nutritional and physicochemical properties of sorghum proteins and starch make the use of this cereal for food production challenging. Sprouting is a cost-effective technology to improve the nutritional and functional profile of grains. Two drying treatments were used after sorghum sprouting to investigate whether the drying phase could improve the protein and starch functionalities. Results showed that the drying treatment at lower temperature/longer time (40 °C for 12 h) extended the enzymatic activity that started during sprouting compared to the one performed at higher temperature/shorter time (50 °C for 6 h). An increased protein hydrolysis and water- and oil-holding capacity were found in the flour obtained by the former treatment. Higher protein matrix hydrolysis caused high exposure of starch to enzymes, thus increasing its digestibility, while worsening the technological functionality. Overall, modulating drying conditions could represent a further way, in addition to sprouting, to improve sorghum flour's nutritional profile.
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Reducing food waste as well as converting waste products into second-life products are global challenges to promote the circular economy business model. In this context, the aim of this study is to quantify the environmental impact of lab-scale food preparations enriched with phenolic extracts from olive oil mill waste, i.e., wastewater and olive leaves. Technological (oxidation induction time) and nutritional (total phenols content) parameters were considered to assess the environmental performance based on benefits deriving by adding the extracts in vegan mayonnaise, salad dressing, biscuits, and gluten-free breadsticks. Phenolic extraction, encapsulation, and addiction to the four food preparations were analyzed, and the input and output processes were identified in order to apply the life cycle assessment to quantify the potential environmental impact of the system analyzed. Extraction and encapsulation processes characterized by low production yields, energy-intensive and complex operations, and the partial use of chemical reagents have a non-negligible environmental impact contribution on the food preparation, ranging from 0.71% to 73.51%. Considering technological and nutritional aspects, the extraction/encapsulation process contributions tend to cancel out. Impacts could be reduced approaching to a scale-up process.
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Nowadays, food processing by-products, which have long raised serious environmental concerns, are recognized to be a cheap source of valuable compounds. In the present study, incorporation of phenolic-rich extracts (500 and 1000 mg kg-1) from olive leaves (OL) and olive mill wastewater (OMW) into conventional gluten-free formulations has been exploited as a potential strategy for developing nutritious and healthy breadsticks with extended shelf-life. To this end, moisture, water activity (aw), visual and textural properties, the composition of biologically active compounds (soluble, insoluble, and bio-accessible polyphenols), antioxidant activity, oxidation stability, and consumer preference of the resulting breadsticks were investigated. Fortified breadsticks had higher moisture and aw, lower hardness, and similar color in comparison to the control, especially in the case of OL extract supplementation. All enriched formulations significantly affected the phenolic composition, as evidenced by the decrease in insoluble/soluble polyphenols ratio (from 7 in the control up to 3.1 and 4.5 in OL and OMW, respectively), and a concomitant increase in polyphenol bio-accessibility (OL: 14.5-23% and OMW: 10.4-15% rise) and antioxidant activity (OL: 20-36% and OMW: 11-16% rise). Moreover, a significant shelf-life extension was observed in all fortified breadsticks (especially in case of OMW supplementation). Sensory evaluation evidenced that 61% of the assessors showed a marked, but not significant, tendency to consider the sample supplemented with high levels of OL as a more palatable choice.
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Table olives are a pickled food product obtained by a partial/total debittering and subsequent fermentation of drupes. Their peculiar sensory properties have led to a their widespread use, especially in Europe, as an appetizer or an ingredient for culinary use. The most relevant literature of the last twenty years has been analyzed in this review with the aim of giving an up-to-date overview of the processing and storage effects on the nutritional and sensory properties of table olives. Analysis of the literature has revealed that the nutritional properties of table olives are mainly influenced by the processing method used, even if preharvest-factors such as irrigation and fruit ripening stage may have a certain weight. Data revealed that the nutritional value of table olives depends mostly on the balanced profile of polyunsaturated and monounsaturated fatty acids and the contents of health-promoting phenolic compounds, which are best retained in natural table olives. Studies on the use of low salt brines and of selected starter cultures have shown the possibility of producing table olives with an improved nutritional profile. Sensory characteristics are mostly process-dependent, and a relevant contribute is achieved by starters, not only for reducing the bitterness of fruits, but also for imparting new and typical taste to table olives. Findings reported in this review confirm, in conclusion, that table olives surely constitute an important food source for their balanced nutritional profile and unique sensory characteristics.
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The effects of ball milling treatment on both the structure and properties of guar gum (GG), tara gum (TG), and methylcellulose (MC) were analyzed prior to assessing their potential interactions with starch components when they are used alone or in blends in a corn starch-rice flour system. X-ray diffraction profiles showed that the ball milling caused a reduction in the crystallin domain and, in turn, a diminished viscosity of the GG aqueous solutions. Despite an increase in its viscosity properties, effects on TG were minimal, while the milled MC exhibited reduced crystallinity, but similar viscosity. When both milled and un-milled hydrocolloids were individually added to the starch-flour system, the pasting properties of the resulting mixtures seemed to be affected by the type of hydrocolloid added rather than the structural changes induced by the treatment. All hydrocolloids increased the peak viscosity of the binary blends (especially pure GG), but only milled and un-milled MC showed values of setback and final viscosity similar to those of the individual starch. Ball milling seemed to be more effective when two combined hydrocolloids (milled GG and MC) were simultaneously used. No significant differences were observed in the viscoelastic properties of the blends, except for un-milled GG/starch, milled TG/starch, and milled MC/milled TG/starch gels.
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The present study investigates the effect of partial or total substitution of rice flour (RF) with quinoa flour (QF) (at 25%, 50%, 75% and 100%) on the chemical-physical, nutritional, and sensory characteristics, as well as the volatile compounds, of ladyfinger biscuits. All quinoa-based formulations positively affected the crust colour, endowing it with lower 'lightness' and higher 'redness' values, giving the biscuits a more appealing crust colour. Biscuits with higher percentages of QF also had better structure, as they were softer. The substitution of RF with QF significantly improved the nutritional profile of the biscuits, as a result of the increase in protein, lipid, ash, total soluble (SP) and insoluble polyphenol (IP), flavonoid, and antioxidant activity levels, which increased linearly with the substitution rate. Quinoa supplementation led to an increase in volatile compounds that were nearly always characterised by positive olfactory attributes. Sensory analysis revealed that the maximal substitution rate of QF able to maintain an adequate consumer acceptability rating is probably 50%, as higher percentages impaired acceptability due to the presence of herbaceous and bitter tastes, even if the consumers also rated these samples as healthier and softer to touch.
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Advances in the adoption of technological innovations represent a great driver to improve the competitiveness of the Italian extra virgin olive oil (EVOO) industry. This work assesses the efficiency of an innovative extraction plant (with low oxidative impact, heating of paste before malaxation and a special decanter that avoids the final vertical centrifugation) in terms of oil yield and quality, and economic and environmental impacts. Economic and environmental impacts were evaluated by using both life cycle costing and life cycle assessment methodologies. A sensitivity analysis was also performed to highlight the uncertain factors that may strongly affect the results. Findings showed that olive milling with the innovative plant resulted in olive oil with a significant increase in quality, although the extraction yield was significantly higher when using conventional technology. In terms of environmental results, an average growth of 4.5% of the impacts in all categories was reached. The economic results revealed the highest extraction cost for the innovative scenario as well as the lower profitability, although a positive return in investment feasibility can be achieved due to an increase in the olive oil selling price. These findings could be useful to highlight the main hotspots in EVOO production and to suggest improvements for more sustainable management.
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The use of pseudocereals, legumes and ancient grains for breadmaking applications is receiving particular attention since they involve nutrient dense grains with proven health-promoting attributes. Dilution up to 45% of the basic wheat flour matrix by accumulative ternary addition of teff, green pea and buckwheat flours did significantly impact both the extractability and distribution of lipid subfractions in composite flours, doughs and breads, and induced differentiated dynamics in lipid binding along breadmaking. During mixing, a preferential covalent lipid binding to the inside part of the starch granules takes place at the expenses of both accessible free lipids and lipids initially bound non-covalently to the gluten/non-gluten proteins and to the outside part of the starch granules. During fermentation and later baking a preferential lipid binding to the gluten/non-gluten proteins and to the outside and inside starch granules takes place at the expenses of both a free lipid displacement and a bound lipid translocation to new protein and starch active sites. It can be noticed that the larger the accumulation of both protein- and starch-bound lipids over fermentation and baking, the higher physic-chemical and sensory profiles, and the slower starch hydrolysis, firming and retrogradation kinetics of composite breads were obtained.
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Pan/análisis , Harina/análisis , Triticum/química , Adulto , Grasas de la Dieta/análisis , Digestión , Fabaceae/química , Fagopyrum/química , Femenino , Fermentación , Manipulación de Alimentos , Glútenes/análisis , Humanos , Hidrólisis , Masculino , Persona de Mediana Edad , Valor Nutritivo , Pisum sativum/química , Almidón/química , Gusto , Adulto JovenRESUMEN
In recent years, the growing interest for well-being and healthy lifestyle together with an increasing awareness of the close relationship between food and health have boosted the production of an increasing number of novel goods to be placed in both gluten-containing and gluten-free products market. The objective of this study was to provide a realistic and detailed overview of the current bread-market supply in order to evaluate the overall quality of the available offer in this prioritized food industry area. Twenty commercial breads consisting of gluten (n = 10) and gluten-free (n = 10) samples currently available in the European market have been assessed by physical-chemical, technological, nutritional, and sensory determinations. The quality parameters obtained were related to each other by using Pearson correlations, while sample classification was achieved by applying factor analysis. Higher values for protein and bio-accessible polyphenols content, aroma and taste quality, and low and moderate expected glycaemic index corresponded to gluten containing breads. Although the main distinction was between gluten and gluten-free samples as it was expected, classification of breads allowed differentiating samples with different formulations in terms of presence/absence of alternative, innovative, and nutrient-dense raw materials.
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Pan/análisis , Análisis de los Alimentos , Manipulación de Alimentos , Valor Nutritivo , Adulto , Color , Fibras de la Dieta/análisis , Proteínas en la Dieta/análisis , Grano Comestible/química , Europa (Continente) , Femenino , Glútenes/análisis , Índice Glucémico , Humanos , Masculino , Persona de Mediana Edad , Odorantes/análisis , Gusto , Adulto JovenRESUMEN
OBJECTIVES: To examine the relationship among different indicators of pain and distress, including self-report, behavioral observations, and physiological parameters, in children with cancer undergoing invasive procedures. METHODS: Forty-eight children between the ages of 3.1 and 17.7 years were evaluated while undergoing lumbar punctures. Self-report measures assessed anxiety, pain, self-efficacy, expectations of coping strategies, and coping self-efficacy. Parents reported on their own and their child's levels of anxiety, and physicians estimated their own level of stress and technical difficulty in completing the procedure. Behavioral observations were made prior to, during, and after the procedure. Physiological parameters included heart rate, cardiac vagal tone, and salivary cortisol. At the discretion of attending physicians, 32 children received deep sedation, 9 received light sedation, and 7 received cognitive-behavioral strategies with topical anesthetic as interventions to manage procedural distress. RESULTS: There was a high degree of consistency within self-report, behavioral, and physiological parameters, but correlations between measures in different modalities were low. There were floor effects for most behavioral and self-report measures of distress. Cortisol showed marked changes preprocedure to postprocedure, demonstrating high levels of physiological response despite lack of apparent or perceived discomfort. Heart rate was significantly lower in the group using cognitive-behavioral techniques, especially at the point of needle insertion. DISCUSSION: Self-report measures, behavioral indicators, and physiological changes are not interchangeable outcomes. Treatment strategies were effective for minimizing subjective and behavioral distress, but not necessarily for physiological reactions. Future research should focus on individual differences in these responses, and treatment outcome studies aimed at reducing distress must be clear about the specific goals of intervention.