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Impact of the cardiac troponin testing algorithm on excessive and inappropriate troponin test requests.

Cardiac troponin (cTn) is a key biomarker for the assessment of myocardial injury, but overutilization of this test has increased workload and costs. We developed and implemented an algorithm to eliminate excessive utilization. Significant reduction was observed after the implementation of the algorithm in total cTnI requests (29.9%; P = .007), requests from outpatient clinics (70.7%; P = .003), and other wards (42.8%; P = .003). Stat requests, the number of third requests, and more than 3 requests per patient were reduced significantly by 42.8% (P = .004), 35.8% (P = .003), and 49.4% (P = .008), respectively. The test and labor costs each were reduced by 29.9% (P = .007 for each). There was no significant change in cTnI orders from emergency and critical care departments. The cTnI testing algorithm reduced unnecessary orders for cTnI tests with no reduction in meeting patients'critical needs. Reduction in unnecessary and inappropriate requests reduces labor and test costs.

Algorithms↗

Exhaled nitric oxide is reduced in infants with rhinorrhea.

In infants, the effect of colds and other respiratory tract infections (RTI) on exhaled nitric oxide (FE(NO)) is not clear. In this study, we measured FE(NO) in 24 infants (14 boys) who presented with rhinorrhea, with or without cough but not wheeze. Twelve of these infants had a history of recurrent wheeze. Levels were compared with a group of 23 healthy infants (13 boys). Further, 8 infants (5 with a history of recurrent wheeze) with rhinorrhea were tested after symptoms had resolved. Infants with rhinorrhea had significantly lower FE(NO) than the healthy infants (11.9 vs. 23.8 ppb, respectively, P < 0.0007). Levels increased from 7.5 ppb to 34.1 ppb in the 8 infants tested with and without symptoms (P = 0.0002). Infants with rhinorrhea have reduced FE(NO), irrespective of their respiratory history.

Airway Resistance↗

[Breath condensate as a method of noninvasive assessment of inflammation mediators from the lower airways].

The detection of mediators from the lower airways still depends on invasive or provoking sampling techniques like bronchoalveolar lavage (BAL) or induced sputum, respectively. Both methods affect the specimen itself. In contrast, the breathing condensate opens the possibility to get native specimens from lower airways during breathing at rest. The breathing condensate was obtained by freezing of exhaled air. The equipment was developed in the FILT Res. Soc. Ltd.. The method is applied for a patent. Leukotriene B4 and Leukotriene C4D4E4F4 were measured in the exhalation of asthmatics, patients with different airway disorders and healthy volunteers. In an additional study the condensate was obtained before and after of a non-specific bronchial challenge test. In asthmatics a close correlation between leukotriene concentration of the condensate and the degree of asthmatic disease according to "International Consensus Report" was found, but no correlation to lung function tests. Within a bronchial challenge test applying histamine the release of leukotrienes was shown to be more sensitive to the challenge test than a lung function test. The results of the study indicate new diagnostic possibilities in lung diseases using the detection of non volatile substances in the exhaled air.

Asthma↗

The detection of minimal alcoholic liver disease by three methods.

The serum aspartate transaminase, 2-h post-prandial bile acids and the aminopyrine breath test were measured in 14 alcoholics with histologically proved minimal liver damage. A raised aspartate transaminase value was found in 64% (9/14) of the patients and was the commonest abnormality found. In three patients all three tests were normal. Six patients stopped abusing alcohol and, when reassessed a mean of 33 days later, showed significant changes in the mean aspartate transaminase value and the mean value for the aminopyrine breath test. There was no significant change in the mean post-prandial bile acids value. The remaining eight patients continued to drink alcohol and, when reassessed at a mean of 118 days, showed no significant change in any of these indices. Of the methods assessed, the serum aspartate transaminase appeared to be the most useful for detecting and monitoring patients with minimal alcoholic liver disease. However, all three tests failed to detect an unacceptably high percentage of the patients, and liver biopsy therefore remains a more certain diagnostic method.

Alcoholism↗

Mechanistically identified suitable biomarkers of exposure, effect, and susceptibility for silicosis and coal-worker's pneumoconiosis: a comprehensive review.

Clinical detection of silicosis is currently dependent on radiological and lung function abnormalities, both late manifestations of disease. Markers of prediction and early detection of pneumoconiosis are imperative for the implementation of timely intervention strategies. Understanding the underlying mechanisms of the etiology of coal workers pneumoconiosis (CWP) and silicosis was essential in proposing numerous biomarkers that have been evaluated to assess effects following exposure to crystalline silica and/or coal mine dust. Human validation studies have substantiated some of these proposed biomarkers and argued in favor of their use as biomarkers for crystalline silica- and CWP-induced pneumoconiosis. A number of "ideal" biological markers of effect were identified, namely, Clara cell protein-16 (CC16) (serum), tumor necrosis factor-alpha (TNF-alpha) (monocyte release), interleukin-8 (IL-8) (monocyte release), reactive oxygen species (ROS) measurement by chemiluminescence (neutrophil release), 8-isoprostanes (serum), total antioxidant levels measured by total equivalent antioxidant capacity (TEAC), glutathione, glutathione peroxidase activity, glutathione S-transferase activity, and platelet-derived growth factor (PDGF) (serum). TNF-alpha polymorphism (blood cellular DNA) was identified as a biomarker of susceptibility. Further studies are planned to test the validity and feasibility of these biomarkers to detect either high exposure to crystalline silica and early silicosis or susceptibility to silicosis in gold miners in South Africa.

Air Pollutants, Occupational↗

Assessment of diagnostic markers by goodness-of-fit tests.

Receiver operating characteristic (ROC) curves are useful statistical tools used to assess the precision of diagnostic markers or to compare new diagnostic markers with old ones. The most common index employed for these purposes is the area under the ROC curve (theta) and several statistical tests exist that test the null hypotheses H(0): theta= 0.5 or H(0): theta1=theta2, in the case of two-marker comparisons, against alternatives of interest. In this paper we show that goodness-of-fit of uniformity of the distribution of the false positive (true positive) rates can be used instead of tests based on the area index. A semi-parametric approach is based on a completely specified distribution of marker measurements for either the healthy (F) or diseased (G) subjects, and this is extended to the two-marker case. We then extend to the one- and two-marker case when neither distribution is specified (the non-parametric case). In general, ROC-based tests are more powerful than goodness-of-fit tests for location differences between the distributions of healthy and diseased subjects. However ROC-based tests are less powerful when location-scale differences exist (producing ROC curves that cross the diagonal) and are incapable of discriminating between healthy and diseased samples when theta=0.5 but F not equal G. In these cases, goodness-of-fit tests have a distinct advantage over ROC-based tests. In conclusion, ROC methodology should be used with recognition of its potential limitations and should be replaced by goodness-of-fit tests when appropriate. The latter are a viable alternative and can be used as a 'black box' or as an exploratory first step in the evaluation of novel diagnostic markers.

Biomarkers↗

In vitro evaluation of matrix metalloproteinases as predictive testing for nickel, a model sensitizing agent.

The identification of potential damage due to chemical exposure in the workplace is a major health and regulatory concern. Traditional tests that measure both sensitization and elicitation responses require the use of animals. An alternative to this widespread use of experimental animals could have a crucial impact on risk assessment, especially for the preliminary screening of new molecules. We developed an in vitro model for the screening of potential toxic compounds. Human keratinocytes (HaCat) were used as target cells while matrix metalloproteinases (MMP) were selected as responders because they are key enzymes involved in extracellular matrix (ECM) degradation in physiological and pathological conditions. Chemical exposure was performed using nickel sulphate as a positive tester. Nickel contact induced upregulation of MMP-2 and IL-8 mRNA production. Molecular activation occurred even at very low nickel concentrations even though no phenotypic changes were observed. MMP-9 accumulation was found in the medium of treated cells with respect to controls. These observations led to the hypothesis that even minimal exposure can accumulate transcriptional activity resulting in long-term clinical signs after contact. Our simple in vitro model can be applied as a useful preliminary complement to the animal studies to screen the effects of new potential toxic compounds.

Animal Testing Alternatives↗

Expired breath hydrogen peroxide is a marker of acute airway inflammation in pediatric patients with asthma.

Airway inflammation is important in the development and progression of many pulmonary disorders, including asthma. We hypothesized that the hydrogen peroxide (H2O2) concentration in expired breath may be a marker of airway inflammation. Expired breath condensate was collected by cooling and the H2O2 concentration was measured fluorimetrically. Thirty-five samples were collected from 22 pediatric patients with asthma who were 7 to 18 yr of age and from 11 healthy, nonasthmatic controls. Asthmatic subjects were determined to be well or sick (acute disease of the upper or lower respiratory tract) by clinical examination. Pulmonary function tests were determined to be abnormal if there was a > 15% reduction in FEV1 or > 20% reduction in FEF25-75 compared with baseline values. Expired breath H2O2 was elevated in asthmatic subjects compared with controls (0.81 +/- 0.70 versus 0.25 +/- 0.27 mumol/L). The difference was primarily due to elevation of H2O2 in sick asthmatic subjects, whose expired breath H2O2 level of 1.5 +/- 0.5 (n = 10) was different from that of well asthmatics (0.54 +/- 0.56, n = 25). There was a high correlation between expired breath H2O2 and clinical status. Elevation of expired H2O2 occurred with either acute upper or lower respiratory tract disease. There was no statistically significant correlation between expired breath H2O2 level and pulmonary function test results. We conclude that elevation of H2O2 in the expired breath condensate is a simple, noninvasive method that can be used as a biochemical marker of airway inflammation.

Acute Disease↗

Biomarkers of genetic damage and inflammation in blood and bronchoalveolar lavage fluid among former German uranium miners: a pilot study.

Former East German uranium miners who are known to have been exposed to radon are estimated to be at high risk for lung carcinogenesis. Among these miners over 200 occupationally caused lung cancer cases are expected to occur each year, resulting in a total of 7,000-24,000 excess lung cancer cases in the coming years. It is still unknown whether there is a correlation between biomarkers and the exposure of the uranium miners to ionizing radiation that might enable us to trace those miners with high lung cancer risk. The primary aim of this pilot study was to test the possibility of performing a biomarker study in this unique cohort of former uranium miners in spite of several limitations that had to be taken into consideration when comparing them with healthy controls, such as old age, age-dependent diseases and potential confounding artefacts from dissimilar smoking patterns. The second aim was to test a range of biomarkers for DNA damage and inflammation in leukocytes and bronchoalveolar fluid for their ability to detect biological effects. In this cohort of miners we found an increased frequency of chromosomal aberrations in blood lymphocytes and an increased prevalence of both fibronectin and tumour necrosis factor alpha in the bronchoalveolar fluid.

Aged↗

8-Isoprostane, a marker of oxidative stress, is increased in the expired breath condensate of patients with pulmonary sarcoidosis.

STUDY OBJECTIVE: 8-Isoprostane is considered an index of oxidative stress. Measurement of 8-isoprostane in the expired breath condensate, a totally noninvasive method, has not been used to explore the level of inflammation in pulmonary sarcoidosis. Therefore, the aim of our study was to measure the levels of 8-isoprostane in the expired breath condensate of patients with sarcoidosis, and to investigate the relation of 8-isoprostane level to disease activity. PATIENTS: We investigated 30 patients with pulmonary sarcoidosis (active disease, n = 14; nonactive disease, n = 16) and 12 healthy subjects as control group. METHODS: 8-Isoprostane was measured in the expired breath condensate of all subjects, and its levels were compared between the control and sarcoidosis groups as well as between the subgroups of patients with active and nonactive disease. In the group with sarcoidosis, 8-isoprostane levels were further correlated with markers that may reflect disease activity, such as serum angiotensin-converting enzyme (sACE) level, serum calcium level, and pulmonary function test results. RESULTS: The concentration of 8-isoprostane was increased in patients with sarcoidosis compared to control subjects (mean, 64.23 pg/mL; 95% confidence interval [CI], 37.00 to 91.46 pg/mL; vs mean, 20.75 pg/mL; 95% CI, 16.06 to 25.44 pg/mL; p = 0.04). The difference was primarily due to the patients with active disease, who had significantly higher levels of 8-isoprostane (mean, 111.4 pg/mL; 95% CI, 62.56 to 160.30 pg/mL; p < 0.001) compared to patients with nonactive disease (mean, 22.94 pg/mL; 95% CI, 15.89 to 29.99 pg/mL) or healthy subjects. 8-Isoprostane levels in patients with nonactive disease did not differ from those in healthy subjects (p > 0.05). In the patients with sarcoidosis, 8-isoprostane levels were positively correlated with sACE level (p < 0.0001, r = 0.69), but was not correlated with serum calcium level or pulmonary function test values. CONCLUSIONS: Our data suggest that 8-isoprostane levels are increased in the expired breath condensate of patients with sarcoidosis and might serve as an index of disease activity.

Adult↗

Successful eradication of Helicobacter pylori as determined by ((13))C-urea breath test does not alter fibrinogen and acute phase response markers.

In this study we examined in 100 patients testing positive for Helicobacter pylori infection whether successful eradication therapy with pantoprazole, clarithromycin, and metronidazole alters fibrinogen and other acute phase response markers. Of 100 patients, only 11 showed a fibrinogen level above 300 mg/dL. Successful eradication proven by the 13C-urea breath test does not alter acute phase response markers. These findings indicate that Helicobacter pylori infection is unlikely to affect atherosclerosis unfavourably via acute phase response.

2-Pyridinylmethylsulfinylbenzimidazoles↗

The Helicobacter pylori breath test: a surrogate marker for peptic ulcer disease in dyspeptic patients.

BACKGROUND: There is interest in noninvasive H pylori testing as a means of predicting diagnosis and determining management in dyspeptic patients. AIMS: To assess the value of the 14C urea breath test as a predictor of peptic ulcer disease in patients presenting with dyspepsia. PATIENTS AND METHODS: 327 consecutive patients referred for investigation of dyspepsia had a 14C urea breath test performed before endoscopy. Patients were not included if they had previously confirmed ulcer disease, previous gastric surgery, or were taking non-steroidal anti-inflammatory drugs. RESULTS: Of the 182 patients with a positive 14C urea breath test, duodenal and/or gastric ulcers were present in 45% and erosive duodenitis in a further 2%. Oesophagitis was present in 12% of the breath test positive patients with two thirds of the oesophagitis patients having co-existent ulcer disease. The prevalence of ulcer disease in the H pylori positive dyspeptic patients was independently related to smoking and previous investigation status. If previously uninvestigated, the prevalence of ulcers was 67% in smokers and 46% in non-smokers. If previous upper gastrointestinal investigations were negative, the prevalence of ulcers was 53% in smokers and 28% in non-smokers. Of the 136 patients with a negative breath test, only 5% had peptic ulcers. The most frequent endoscopic finding in these H pylori negative subjects was oesophagitis, being present in 17%. CONCLUSIONS: This study demonstrates that a positive H pylori test is a powerful predictor of the presence of underlying ulcer disease in dyspeptic patients, especially if smokers, and that a negative H pylori test is a powerful predictor of the absence of ulcer disease. It also indicates that a negative upper gastrointestinal investigation does not preclude subsequent presentation with ulcer disease.

Adolescent↗

Nephroscreen: a diagnostic test for predicting acute renal failure?

Acute renal failure is a frequent and often fatal complication of hospitalized patients. While the risk of acute renal failure among select patient groups is well recognized, physicians currently rely on diagnostic tests such as changes of serum creatinine and indirect assessment of the glomerular filtration rate to diagnose acute renal failure. Although these parameters capture the degree of kidney function lost, they are not warning signs of evolving kidney injury. While the clinical emergence of acute renal failure is sudden, the pathologic changes preceding loss of kidney function are not so sudden. Nephroscreen is a fast and easy-to-use urine enzyme-linked immunosorbent assay test designed to quantify specific pathologic events preceding death of renal proximal tubule cells. It detects acute kidney damage days before serum creatinine rises and may open new avenues to defining acute renal failure as well as treating acute renal failure patients earlier and more effectively.

Acute Kidney Injury↗

Cadmium-induced colony disintegration of duckweed (Lemna paucicostata Hegelm.) and as biomarker of phytotoxicity.

The toxic effect of cadmium on Lemna paucicostata was investigated with hydroponic culture in a culture facility. Cadmium treatment (0.4-6.4 micromol L(-1) Cd) induced L. paucicostata to release daughter fronds from the mother frond before maturity, resulting in colony disintegration. The 8-h and 24-h EC(50) values for colony disintegration in L. paucicostata plants were 0.12 and 0.11 mg L(-1), respectively. The maximum permissible concentrations (MPCs) were 0.012 and 0.011 mg L(-1) accordingly (MPC = 10% x EC(50)). These values were lower than the values of most of these biomarkers in duckweed reported in the literature, suggesting that colony disintegration in L. paucicostata may serve as a sensitive biomarker for the phytotoxicity test. Nutrient concentrations (1/2, 1/10, 1/20, 1/40, and 0-fold concentrations of Hoagland's solution) and Cd salt form (CdCl(2) or CdSO(4)) did not have a significant effect on colony disintegration. In addition, resistance to Cd stress differed significantly among clones of the plants. Approximately 2% of colonies in the wild population of L. paucicostata were tolerant of cadmium. These results indicate that colony disintegration of L. paucicostata could be used as a sensitive, cost-effective, and valuable biomarker to assess the acute phytotoxicity of cadmium and other heavy metals.

Araceae↗

Analysis of expired air for oxidation products.

Chronic inflammation is a critical feature of chronic obstructive pulmonary disease, cystic fibrosis, and asthma. This inflammation is associated with the increased production of reactive oxygen species or oxidative stress in the lungs. Oxidative stress may have several adverse effects and may amplify the inflammatory process; however, monitoring oxidative stress is difficult and may not be reflected by changes in blood markers. We have therefore developed several noninvasive markers in the exhaled breath that may indicate oxidative stress in the lungs, and we studied these in relationship to the severity of chronic inflammatory lung diseases. We analyzed the exhaled breath for the content of nitric oxide as a marker of inflammation, carbon monoxide as a marker of oxidative stress, and ethane, which is one of the end products of lipid peroxidation. In addition, we measured the concentration of markers of oxidative stress such as isoprostanes in exhaled breath condensate. Our results confirm that there are increased inflammation, oxidative stress, and lipid peroxidation in lung disease, as shown by elevated levels of nitric oxide, carbon monoxide, and ethane, respectively. The finding of lower levels of these gases in patients on steroid treatment and of higher levels in those with more severe lung disease, as assessed by lung function tests and clinical symptoms, reinforces the hypothesis that the noninvasive measurement of exhaled gases maybe useful in monitoring the underlying pathologic pathways of lung disease. Longitudinal studies are required to assess the clinical usefulness of these measurements in the monitoring of chronic inflammatory lung disease.

Asthma↗

Heart allograft rejection: detection with breath alkanes in low levels (the HARDBALL study).

BACKGROUND: We evaluated a new marker of heart transplant rejection, the breath methylated alkane contour (BMAC). Rejection is accompanied by oxidative stress that degrades membrane polyunsaturated fatty acids, evolving alkanes and methylalkanes, which are excreted in the breath as volatile organic compounds (VOCs). METHODS: Breath VOC samples (n = 1,061) were collected from 539 heart transplant recipients before scheduled endomyocardial biopsy. Breath VOCs were analyzed by gas chromatography and mass spectroscopy, and BMAC was derived from the abundance of C4-C20 alkanes and monomethylalkanes. The "gold standard" of rejection was the concordant set of International Society for Heart and Lung Transplantation (ISHLT) grades in biopsies read by 2 reviewers. RESULTS: Concordant biopsies were: Grade 0, 645 of 1,061 (60.8%); 1A, 197 (18.6%); 1B, 84 (7.9%); 2, 93 (8.8%); and 3A, 42 (4.0%). A combination of 9 VOCs in the BMAC identified Grade 3 rejection (sensitivity 78.6%, specificity 62.4%, cross-validated sensitivity 59.5%, cross-validated specificity 58.8%, positive predictive value 5.6%, negative predictive value 97.2%). Site pathologists identified the same cases with sensitivity of 42.4%, specificity 97.0%, positive predictive value 45.2% and negative predictive value 96.7%. CONCLUSIONS: A breath test for markers of oxidative stress was more sensitive and less specific for Grade 3 heart transplant rejection than a biopsy reading by a site pathologist, but the negative predictive values of the 2 tests were similar. A screening breath test could potentially identify transplant recipients at low risk of Grade 3 rejection and reduce the number of endomyocardial biopsies.

Adult↗

Collagenolytic enzymes in gingival crevicular fluid as diagnostic indicators of periodontitis.

Periodontal diseases are associated with the production of several families of enzymes that are detectable in gingival crevicular fluid and that are released by stromal, epithelial or inflammatory cells. Measurement of collagen degrading enzymes in crevicular fluid could contribute to insights into pathogenesis of periodontal diseases and also provide a rational basis for the development of novel diagnostic tests. However, similar to the development of other diagnostic tests, the appropriate validation of collagenolytic enzymes as diagnostic indicators is dependent on clearcut demonstrations of the identity of the enzyme in the assay, and the reproducibility, diagnostic accuracy, and clinical utility of the test. If collagenolytic enzymes are to be of clinical usefulness, they should be easily measured over a broad range of disease severities and in varied clinical settings. Ideally, the diagnostic test should assay for an essential component of proposed pathogenic mechanisms. Neutrophil collagenase and gelatinase are promising enzymes for diagnostic tests because of (1) their apparently central role in periodontal attachment loss and disease progression; (2) demonstrations of positive associations between enzyme levels and attachment loss and inflammation; and (3) availability of sensitive and specific assays to quantify these enzymes. However, much less data exist on reproducibility, diagnostic accuracy, and clinical use in longitudinal studies. In the future, more emphasis must be placed on the importance of appropriate study design for establishing the efficacy of collagenolytic enzymes as diagnostic tests.

Amino Acid Sequence↗

Functional genomics and proteomics in the clinical neurosciences: data mining and bioinformatics.

The goal of this chapter is to introduce some of the available computational methods for expression analysis. Genomic and proteomic experimental techniques are briefly discussed to help the reader understand these methods and results better in context with the biological significance. Furthermore, a case study is presented that will illustrate the use of these analytical methods to extract significant biomarkers from high-throughput microarray data. Genomic and proteomic data analysis is essential for understanding the underlying factors that are involved in human disease. Currently, such experimental data are generally obtained by high-throughput microarray or mass spectrometry technologies among others. The sheer amount of raw data obtained using these methods warrants specialized computational methods for data analysis. Biomarker discovery for neurological diagnosis and prognosis is one such example. By extracting significant genomic and proteomic biomarkers in controlled experiments, we come closer to understanding how biological mechanisms contribute to neural degenerative diseases such as Alzheimers' and how drug treatments interact with the nervous system. In the biomarker discovery process, there are several computational methods that must be carefully considered to accurately analyze genomic or proteomic data. These methods include quality control, clustering, classification, feature ranking, and validation. Data quality control and normalization methods reduce technical variability and ensure that discovered biomarkers are statistically significant. Preprocessing steps must be carefully selected since they may adversely affect the results of the following expression analysis steps, which generally fall into two categories: unsupervised and supervised. Unsupervised or clustering methods can be used to group similar genomic or proteomic profiles and therefore can elucidate relationships within sample groups. These methods can also assign biomarkers to sub-groups based on their expression profiles across patient samples. Although clustering is useful for exploratory analysis, it is limited due to its inability to incorporate expert knowledge. On the other hand, classification and feature ranking are supervised, knowledge-based machine learning methods that estimate the distribution of biological expression data and, in doing so, can extract important information about these experiments. Classification is closely coupled with feature ranking, which is essentially a data reduction method that uses classification error estimation or other statistical tests to score features. Biomarkers can subsequently be extracted by eliminating insignificantly ranked features. These analytical methods may be equally applied to genetic and proteomic data. However, because of both biological differences between the data sources and technical differences between the experimental methods used to obtain these data, it is important to have a firm understanding of the data sources and experimental methods. At the same time, regardless of the data quality, it is inevitable that some discovered biomarkers are false positives. Thus, it is important to validate discovered biomarkers. The validation process may be slow; yet, the overall biomarker discovery process is significantly accelerated due to initial feature ranking and data reduction steps. Information obtained from the validation process may also be used to refine data analysis procedures for future iteration. Biomarker validation may be performed in a number of ways - bench-side in traditional labs, web-based electronic resources such as gene ontology and literature databases, and clinical trials.

Animals↗