Professional Documents
Culture Documents
+, 2,2
-
azinobis-(3-ethylbenzothiazole-6-sulphonate) radical cation; FRAP, ferric reducing antioxidant power; CUPRAC, cupric ion reducing antioxidant capacity; ORAC, oxygen
radical absorbance capacity; TRAP, total radical-trapping antioxidant parameter; LDL, lowdensity lipoprotein; ESR, electronspinresonance; HepG2, humanhepatocarcinoma;
DCFH
2
, dihydrodichlorouorescein; DCFH
2
-DA, dihydrodichlorouorescein diacetate; CAA, cellular antioxidant activity; RBC, red blood cells; NOx, NADPH oxidases; NOS,
nitric oxide synthase; Nrf-2, nuclear factor E2-related protein 2; NF-B, nuclear factor kappa B.
, ABTS
+) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.1.2. Reduction of metal ions (FRAP and CUPRAC assays) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.1.3. Competitive methods (ORAC and TRAP assays) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
2.1.4. Oxidation of low density lipoprotein (LDL) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.1.5. Nanoparticles-based assays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
2.1.6. Other chemical assays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.2. Evaluation of the antioxidant activity at cellular level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
2.2.1. Cellular antioxidant activity (CAA) assay. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
2.2.2. Expression of antioxidant enzymes vs inhibition of pro-oxidant enzymes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2.2.3. Activation vs repression of redox transcription factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
3. Correlation between chemical-based antioxidant capacity indexes and cellular-based assays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
4. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Ana Denicola is Head of the Physical Biochemistry
laboratory at the Chemical Biology Institute of Fac-
ulty of Science, University of the Republic (UdelaR),
Uruguay. She graduated inChemistry/Pharmaceutical
Chemistry at the UdelaR, Uruguay, and received her
PhD in Biochemistry at Virginia Tech, Va, USA. She is
nowFull Professor of Physical Biochemistryat the Fac-
ulty of Science, UdelaR. Her major research interests
concern mechanisms of bioproduction and reactivity
of oxygen and nitrogen species, structural and func-
tional characterization of oxidative modications of
proteins, synthetic and natural antioxidants.
Camilo Lpez Alarcn received his Doctorate in
Chemistry in 2004 fromthe University of Chile, Chile.
He then gained a posdoctoral position at Dr. Eduardo
Lissis laboratory at University of Santiago of Chile,
where he focused on free radicals and antioxidants
chemistry. At present, he is Associate Professor at
Ponticial Catholic University of Chile, where he is
studying new methodologies to evaluate in vitro
antioxidant capacity of foods, beverages and human
uids. His current research focuses on the interac-
tionof biologically-relevant compounds withreactive
species such as nitrous acid, peroxyl radicals, super-
oxide, hypochlorite and nitrogen dioxide.
1. Introduction
During the last decades it has been proposed that oxidative
stress, denedas theunbalancebetweenreactiveoxygenandnitro-
gen species (ROS/RNS) production and the antioxidant defense,
plays a pivotal role in different pathophysiological conditions [1,2].
Oxidative stress, originated from an increase in ROS/RNS produc-
tion or froma decrease in the antioxidant network, is characterized
bytheinabilityof endogenous antioxidants tocounteract theoxida-
tive damage on biological targets [3]. In this context, it has been
suggested that an intake of a rich antioxidant diet is inversely
associated with the risk to develop some pathologies like car-
diovascular diseases [46]. Thus, attention has been paid on the
antioxidant capacity of natural products, with particular interest
on those that are frequently (or potentially) consumed by peo-
ple. Different in vitro chemical-based assays have been developed
to determine the antioxidant capacity of natural products, includ-
ing the popular ORAC, DPPH
+FRH (1)
where AH and FR
onlipids, proteins,
or DNA. However, Reaction (1) does not represent all the factors
affecting the antioxidant activity of a compound or an antioxidant-
containingmixture. Amongthese factors, the most relevant are: the
reactivity of antioxidants toward FR
, the number of FR
molecules
neutralizedby eachantioxidant molecule (stoichiometric factor, n),
the liposolubility of the antioxidant, and the presence of secondary
reactions.
1.1.1.1. Reactivity and stoichiometric factor. Taking into account
Reaction (1) as a bimolecular process, the rate of the reaction, r,
expressed as:
r = k
1
[AH] [FR
]
ss
(1)
depends on the kinetic rate constant k
1
, the antioxidant concen-
tration [AH], and the steady state concentration of FR
([FR
]
ss
).
Accordingly, froma kinetic point of view, a compound with a high
k
1
value wouldbe a goodantioxidant. Nonetheless, for antioxidants
expected to act in biological environments (for example human
blood plasma) the latter is relevant only if their reactions with FR
.
In that case, the stoichiometry of Reaction (1), dened as the num-
ber of FR
incompart-
mentalized systems. This is a pivotal point when trying to inhibit
lipid peroxidation processes in cell membranes, where antioxi-
dants should have an appropriate liposolubility to be incorporated
into the membrane and to react with FR
through chain-breaking
reactions [16]. For instance, -tocopherol is liposoluble and is
the most important biological antioxidant in membranes, but its
solubility in water is very low. One particular case is ascorbic
acid, which in spite of its well-known hydrophilic character is
able to work additively with membrane-immersed -tocopherol
to prevent lipid peroxidation, by reducing the surface-exposed -
tocopheroxyl radical back to -tocopherol [17].
1.1.1.3. Secondary reactions. Other aspect toconsider inthe antiox-
idant behavior of a particular sample is the ability of secondary free
radicals (A
+BTH AH+BT
(2)
It has been observed that secondary phenoxyl radicals can, in
some conditions, trigger oxidative modications on proteins, DNA,
as well as on cell membrane lipids [18]. Furthermore, depending on
the antioxidant compound and/or the place where A
is generated,
it can react with O
2
to forma secondary peroxyl radical or superox-
ide anion (Reaction (3) and Reaction (4), respectively). In the latter
case, dismutation of superoxide (usually catalyzed by superoxide
dismutase, SOD) yields hydrogen peroxide (H
2
O
2
), which in the
presenceof metals generates hydroxyl radical (Fentonmechanism),
a strongly oxidant free radical.
A
+O
2
AOO
(3)
A
+O
2
A
ox
+O
2
(4)
1.1.2. New mechanisms based on redox signaling
In 1985 Helmut Sies introduced the concept of oxidative stress
as a disturbance in the prooxidant-antioxidant balance in favor
of the former [3]. Experimental evidence supported the idea that
oxidative stress contributes to the development of several patholo-
gies including cardiovascular disease, neurodegenerative diseases,
cancer andalsoaging. ROS suchas superoxide, singlet oxygen, H
2
O
2
and hydroxyl radical were mainly considered responsible for these
damaging oxidative reactions. More recently, new radical species
were identied, now centered on nitrogen, thus termed reactive
nitrogen species RNS, derived fromthe biologically produced rad-
ical, nitric oxide (
,
ABTS
+)
DPPH
-
Azinobis-(3-ethylbenzothiazole-6-sulphonate) radical cation,
ABTS
+) are two stable and colored free radicals that have been
widely employed to determine antioxidant capacity [26,27]. DPPH
+ must be generated
from the oxidation of ABTS by oxidants such as K
2
S
2
O
8
, MnO
2
or peroxyl radicals [28]. DPPH
and polyphenols.
The shortcomings of these assays are the complexity of the
mechanisms of reaction, the dependence of the index with the
experimental conditions, and the poor correlation between DPPH
and ABTS
and ABTS
+ -based
assays, FRAP and CUPRAC indexes depend on the reaction time.
Depending on the sample under study, different endpoints of the
reaction can be registered. In this context, it has recently been pro-
posed a kinetic matching approach to express antioxidant capacity
in a more standardized way [34].
2.1.3. Competitive methods (ORAC and TRAP assays)
These methodologies evaluate the ability of a particular sam-
ple to inhibit the consumption of a target molecule (usually
followed by UVvisible absorption or uorescence spectroscopy)
mediated by peroxyl radicals. Usually, AAPH (2,2
-Azobis (2-
methylpropionamidine) hydrochloride, also abbreviated ABAP) is
employed as peroxyl radical (ROO
) elicited by Peumus-
boldus extract. Control experiment (in the absence of extract, ), Peumusboldus
0.1 L/mL (); 0.3L/mL (); 0.5L/mL (). Data taken from[40].
at a known rate in the rst hours of incubation in aqueous media,
according to Reaction (5) [35]
AAPH+O
2
2ROO
+N
2
(5)
The incubation of AAPH with a particular target molecule (TM)
leads to a change in the UVvisible absorption or uorescence
intensity of that TM. Thus, the co-incubation of TM, AAPHand pure
antioxidants or their complex mixtures (XH) usually leads to the
inhibition of TM consumption. The minimal reactions involved in
these assays are:
ROO
+TMconsumption (6)
ROO
+XH X
+ROOH (7)
2ROO
can be followed
by uorescence [44,45]. It is important to consider that TRAP
index reects mainly the number of ROO
-antioxidant reaction.
2.1.4. Oxidation of low density lipoprotein (LDL)
The oxidation of LDL mediated by ROS/RNS has been studied
since many years ago. At present, it is well known that ROS play a
pivotal role inthe initiation, propagationandterminationreactions
of the LDL lipid peroxidation processes [2]. In vitro assays usually
employ cupric sulfate as initiator of LDL oxidationandthe lipidper-
oxidation processes are easily followed by UV spectroscopy and/or
chemiluminiscence techniques [46]. In the rst case, the formation
of diene conjugates at 234nmis followed, while in the second one,
the emission of photons related to the formation of nal oxida-
tive products is measured. When cupric sulfate is added to a LDL
solution, the kinetic proles are characterized by the presence of a
lag time associated with the presence of endogenous antioxidants
(mainly vitamin E and coenzyme Q) in the LDL particle. After that
period, the peroxidation of lipids is evidenced as an increase in
the absorbance at 234nm that eventually reaches a plateau, after
minutes or hours. In the presence of antioxidants, this lag time is
increased, implying an additional protection of LDL given by the
sample. Thus, measurement of the lag time has been frequently
used to evaluate antioxidant capacity.
The main advantage of this in vitro assay is the use of a biologi-
cal relevant target. One of the most important shortcomings of this
methodis the variabilitybetweenlot tolot of the LDL sample. This is
a consequence of the complexity of the LDL particle, whichincludes
proteins (apoB), lipids (phospholipids, saturated and unsaturated
lipids, triglycerides, free and esteried cholesterol), and endoge-
nous antioxidants (vitamin E, coenzyme-Q), that can vary from
donor to donor. Also, when cupric sulfate is employed as initia-
tor of oxidation, it should be considered that the antioxidant effect
can also derive fromthe copper-chelating capacity of the sample.
2.1.5. Nanoparticles-based assays
More recently, novel chemical assays based on nanotechnology,
in particular the use of nanoparticles, have been proposed to evalu-
ate antioxidant capacity. Inpioneeringwork, Scampicchioet al. [13]
estimated the antioxidant power of several phenolic acids fromthe
generation and growth of gold nanoparticles (AuNPs) from a Au
III
solution (HAuCl
4
) by the appearance of a sharp plasmon absorp-
tion band at 555nm. The optical properties of the generated AuNPs
correlated well with the reduction potential of the phenolic acids
as measured by cyclic voltametry, and it was proposed as a form
6 C. Lpez-Alarcn, A. Denicola / Analytica Chimica Acta 763 (2013) 110
to evaluate the antioxidant capacity of pure compounds and com-
plex mixtures. For example, this experimental approach has been
recently employed by Liu et al. [47] to evaluate the antioxidant
capacity of chrysanthemum extracts and tea beverages. In addi-
tion, Vilela andcollaborators [14], following the generationof AuNP
at 540nm (A
540
) described a sigmoidal behavior as a function of
polyphenol concentration (X) that t the equation:
A
540
=
A max
1 +e
KAuNPs
XX
50
C
(3)
where Xc
50
represents the concentration of polyphenol that gives
half maximum plasmon resonance absorption and K
AuNPs
the
number of AuNPs produced per polyphenol concentration unit.
The authors proposed to use K
AuNPs
as a parameter to estimate
antioxidant capacity. The assay has been applied to evaluate the
antioxidant activity of natural products such as tea, apples, pears,
red wines and honey. Interestingly, a good correlation between
K
AuNPs
and total phenolic content has been observed [14].
Inadditiontothe latter studies, zyreket al. [12] have reported
a novel methodology employing silver nanoparticles to assess
antioxidant capacity. The method, namedSNPAC(Silver NanoParti-
cle Antioxidant Capacity) employs Trolox as standard antioxidant,
andreects thetotal antioxidant capacity(TAC) of thesampleunder
study. The assay is based on the ability of polyphenols to reduce
Ag
+
ions in the presence of citrate-stabilized silver seeds, and eval-
uates the intensity of the plasmon visible-absorbance at 423nmto
quantitatively determine antioxidant capacity. In comparison with
previous reports the novelty of this assay is to employ a rst step
reductionof Ag
+
ions by citrate to formsilver seeds. Afterwards, the
addition of the polyphenol-containing sample increase the plas-
mon absorption intensity. The role of polyphenols as secondary
reducing agents would imply a more robust and reproducible
methodology than the assays employing a direct reduction of
metal ions by antioxidants. Interestingly, the authors describe that
growth but not nucleation of silver nanoparticles showed a linear
concentration-dependent response. The SNPAC method has been
applied to a wide variety of pure antioxidants and complex mix-
tures suchas fruit juices andherbal teas. As advantages, the method
has shown good linearity with polyphenol concentration and has
not been affected by the presence of reducing sugars, fruits acids,
nor amino acids present in the extracts.
These newnanoparticles-basedassays todetermine antioxidant
capacity of natural products comprise a novel and promising area
combining nanoscience with food and health research.
2.1.6. Other chemical assays
In addition to the above discussed assays, other methodologies
have also been proposed to evaluate antioxidant capacity. These
methods aim to evaluate scavenging activity toward ROS/RNS
formed in vivo like superoxide anion, hydroxyl radical, peroxyni-
trite and hypochlorite.
The classical approach to determine antioxidant capacity
toward superoxide employs the xanthine-xanthine oxidase sys-
temas the superoxide source and probes such as ferricytochrome
c or nitrobluetetrazolium (NBT) [2,7,9]. The reduction of both
probes, mediated by superoxide, is followed by visible absorbance,
assessing the formation of ferrocytochrome c or formazan, respec-
tively. Alternatively or in conjunction, the reactivity toward
superoxideis determinedbyelectronspinresonance(ESR) employ-
ing 5,5-dimethyl-1-pyrroline-N-oxide (DMPO) as spin-trap [2,7].
In the presence of an antioxidant-containing sample, the reduction
of ferricytochrome c, NBT or the formation of DMPO-OH adduct
is inhibited. These assays have been widely employed, however,
it is important to consider that some antioxidants, particularly
avonoids, can inhibit xanthine oxidase leading to overestimation
of the antioxidant capacity index [48]. For instance, polyphenols
have been observed to inhibit xanthine oxidase activity using a
parallel CUPRAC assay [49].
Hydroxyl radical (
em
=535nm) and the results are expressed in moles of quercetin
equivalents. The CAA assay is an important tool for screening
antioxidant activity in natural products extracts that evaluates its
potential to exert an antioxidant response at the cellular level,
not just its capacity as a reducing agent. The principle of the
method is depicted in Fig. 3. ROO
but alsoother
biologically-produced ROS/RNS are capable to performthis oxida-
tion, like H
2
O
2
in the presence of peroxidases (not H
2
O
2
alone),
peroxynitrite or hydroxyl radical [51]. The antioxidant compound
can prevent DCHF
2
oxidation, thus reduce uorescence levels in
different ways, either directly reacting with ROO
or secondary
oxidants ROS/RNS, or indirectly, inducing an antioxidant cellular
response that in sum reduce the levels of oxidant cellular status.
The CAA assay protocol is detailed in [54]. Briey, HepG2 cells are
seededonamicroplateat adensityof 610
4
cell/100L/well. After
24h of growth, cells are incubated with the natural product extract
and the probe dichloro-dihydrouorescein diacetate (DCFH
2
-DA,
25M) for 1h at 37
SA
CA
(4)
where SA is the integrated area under the curve sample uores-
cence vs time and CA is the integrated area fromthe control curve.
Quercetin is used as standard and CAA values are expressed as
mol equivalents of quercetin per 100mol of compound (pure
avonoid) or 100g product (fruit, vegetable) or per 100mol of
total phenolics (considering all phenol content as expressed as gal-
lic acid equivalents).
Among the pure compounds examined in the CAA assay,
quercetinshowedthehighest CAAactivity, followedbykaempferol,
myricetin, epigallocatechin gallate and luteolin. In contrast, caffeic
acid, gallic acid and ascorbic acid showed less than 1% CAA activity
[54].
Cellular uptake of DCFH
2
-DA is rapid and relatively stable
although leakage is observed after 1h, thus long runs should be
avoided [55]. Exposure of loaded cells to light should be minimized
to avoid artifactual generation of superoxide and oxidation of the
probe[56]. Theuseof darkmicroplates is recommended. We should
not forget that working with cells is not like isolated chemical reac-
tions. The cell response is quite complex, thus, more variable results
are expected depending on the assay conditions like growth status
of the cell line, endogenous antioxidant levels and initial ROS/RNS
production. Several replicas should be performed in order to mini-
mize these variables.
Since the publication of the CAA assay by Wolfe and Liu in
2007 [54], this method has been applied to several natural prod-
uct extracts, food and dietary supplements. Among fruits analyzed,
the ones with higher phenolics content were the ones display-
ing higher CAA values; berries (blueberry, cranberry, etc.) with
>50mol quercetin/100g followed by apples, and grapes with less
than 10mol quercetin/100g [57].
Different cell types have been used for the CAA assay besides
HepG2, including Caco-2 matured differentiated intestinal cells
[58], human gastric adenocarcinoma cell line AGS with rapid pro-
liferation properties [59], vascular endothelial cells EA.hy926 [60],
human macrophage cell line U937 [61], human lung broblasts
(WI38, IMR-90) [62]. An interesting one is erythrocytes, since it
is easily available and testing the potential protection of red blood
cells (RBC) is biologically relevant per se as RBC play a critical role
in reducing oxidative stress in the vasculature [63,64]. The same
principle is used, i.e., cells are loaded with the redox probe DCFH
2
,
incubated with the antioxidant to be tested and exposed to oxida-
tive stress via generation of ROO
C/160rpmwith 0.75mM H
2
O
2
). Pretreatment with isolated
avonoids [6769] or complex polyphenolic mixtures like wine
[70,71] partially suppressed the damage triggered by H
2
O
2
.
2.2.2. Expression of antioxidant enzymes vs inhibition of
pro-oxidant enzymes
The previous CAA assay evaluates the capacity of individual
compounds or complex mixtures to effectively reduce the intracel-
lular oxidative state (the levels of the internal biomarker oxidized
uorescein are lower) but it does not say about the mechanismthe
antioxidant compound(s) used to reduce the oxidative stress: is it
reacting directly with a radical oxidant?, which one?, inhibiting the
production of more radical oxidants?, repairing the biomolecules
oxidized by a radical oxidant?. Nevertheless, it is an index that bet-
ter reects the new concept of an antioxidant: a compound (or
mixture) that modulates the cellular redox state. But we can go
further and investigate if the compound displaying a good CAA
is in fact inhibiting an oxidase (for example NADPH oxidase that
produces superoxide) or inducing the expression of an antioxidant
enzyme (for example SOD), resulting in both cases in the reduction
of superoxide/H
2
O
2
levels.
NADPHoxidases are heme-avoenzymes that produce ROS [72].
Theclassical Nox(gp91
phox
) alsotermedNox2, is foundinthemem-
brane of phagocytes and forms an active complex with the other
membrane subunit p22
phox
as well as soluble regulatory proteins,
to catalyze the production of superoxide anion that plays a crucial
role in host defense. We now know that there is an entire family
of NADPH oxidases (Nox) that mediate diverse functions including
cell growth, apoptosis, innate immunity, angiogenesis, regulation
of the extracellular matrix and thyroid hormone biosynthesis. Nox
15 produce superoxide from molecular oxygen at the expense
of NAD(P)H, whereas Duox enzymes are known to release H
2
O
2
without forming detectable amounts of superoxide.
Certain polyphenols and metabolites are able to inhibit Nox
activity reducing the endogenous production of ROS [73,74]. In
addition, complex mixtures from plant extracts or natural prod-
ucts like wine, cocoa, propolis, have been demonstrated to inhibit
this enzyme, in particular the Nox1 and/or Nox 4 isoforms, respon-
sible for the constant production of superoxide at the endothelium
[7579].
Further examples of inhibition of key pro-oxidant enzymes by
polyphenols have been given, e.g., with 5-lipoxygenase and xan-
thine oxidase [49,77,79].
Nitric oxide synthases (NOS) are a family of heme-avoenzymes
that produce the radical
NO from l-arginine using NADPH and
molecular oxygen (also requires tetrahydrobiopterine BH
4
and
Ca
2+
/calmodulin) [80]. Different isoforms have been identied:
NOS1 (neuronal nNOS), NOS2 (inducible iNOS present in phago-
cytes) and NOS3 (endothelial eNOS). A prolonged high production
of
NO from iNOS should be avoided to diminish the inamma-
tory state, while active production fromeNOS at the endothelium
is desirable to promote a healthy vascular function.
The benecial effect of some polyphenols to increase eNOS
activity and at the same time inhibit endothelial Nox, translates
into an effective increase of
NO bioavailability, since not only
more
NO is been produced by eNOS but also the formation of
peroxynitrite from the reaction of
NO with superoxide is being
prevented [78,81,82]. Increased