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Exhaled nitric oxide in the clinical management of asthma.

Management of asthma has gradually evolved from the concept of controlling bronchial hyperresponsiveness to focusing on control of inflammation. The awareness of airway remodeling, and the emergence of data suggesting irreversibility of some of these changes, despite standard-of-care pharmacotherapies such as inhaled steroids, has highlighted the need for early detection; effective diagnosis and treatment; monitoring responses and adhering to treatment; and predicting exacerbations. Pre-clinical intervention strategies targeted toward picking up early suggestions of asthma before irreversible airway changes occur may open the door to primary prevention approaches. Although invasive methods, such as bronchial biopsy, remain the gold standard to understanding and treating asthma, there is a preference for noninvasive techniques for reasons of convenience, ease of use, and patient comfort. In this article, recent data that support the use of exhaled nitric oxide as a noninvasive biomarker of inflammation in clinical practice are reviewed.

Anti-Inflammatory Agents↗

Evaluation of two biological markers of tobacco exposure. MRFIT Research Group.

This study assesses serum thiocyanate and expired-air carbon monoxide based on findings for 8,895 participants in the Multiple Risk Factor Intervention Trial. For each marker and combination of markers, a logistic probability model was used to generate a plot of true positive vs false positive rates (an operating characteristic curve), an optimal cutpoint, and the positive predictive value for discriminating tobacco smokers (cigarettes, pipes, cigars, or cigarillos) from non-tobacco smokers. Optimal cutpoints were 83 mumols/liter for thiocyanate and 10 ppm for carbon monoxide. These cutpoints were applied to the entire group to evaluate accuracy. Specificity was higher for carbon monoxide than for thiocyanate (91.8 vs 87.3%) and sensitivity was lower (85.7% for carbon monoxide vs 88.8% for thiocyanate). When carbon monoxide and thiocyanate were both used, specificity was 92.7% and sensitivity was 89.1%. The estimated cutpoints derived from the Multiple Risk Factor Intervention Trial result in predictive values greater than 87% when the prevalence of smokers is greater than 50%. Cutpoints should be modified to maximize the predictive value when the prevalence of smokers is less than 50%. Both serum thiocyanate and carbon monoxide are good markers of smoking exposure. Serum thiocyanate may be preferable to carbon monoxide because of its longer half-life.

Adult↗

Effects of riboflavin deficiency and riboflavin administration on carcinogen-DNA binding.

A study was conducted to assess the effects of riboflavin deficiency and riboflavin supplementation on carcinogen-DNA binding. After 12 wk on a riboflavin-sufficient or a riboflavin-deficient diet male Wistar rats were administered 3H-labelled benzo[a]pyrene (BP) ip. [3H]BP was given either at a uniform dose of 450 muCi/rat irrespective of body weight or at a dose adjusted to body weight. After 17 hr the animals were killed, various organs were dissected and the level of [3H]BP bound to DNA was quantified in organs that are known to be the seats of drug metabolism (i.e. the liver, lungs and intestinal mucosa). In a separate experiment, the effect of riboflavin supplementation on BP-DNA binding was also investigated. When [3H]BP was administered at 450 microCi/rat, BP-DNA binding was markedly increased in the livers and intestinal mucosae of the pair-fed and deficient groups compared with controls. With the administration of [3H]BP adjusted to body weight, no differences in BP-DNA binding between groups were observed in any tissue. However, on administration of riboflavin there was a decrease in the level of [3H]BP bound to DNA in almost all tissues, especially in the lungs, where the reduction was significant. The results suggest that undernutrition/riboflavin deficiency may increase the risk of carcinogenesis by way of an increase in carcinogen binding, which however can be reversed by riboflavin supplementation.

Animals↗

Smoking characteristics and inhalation biochemistry in the Scottish population.

Data from a cross-sectional random population sample of 10,359 middle-aged Scottish men and women are used to investigate the relationships between self-reported tobacco consumption and three biochemical markers of tobacco inhalation: expired air carbon monoxide (CO), serum thiocyanate and serum cotinine. These data represent one of the largest samples of these biochemical markers yet analysed. The results show that, for each sex, the biochemical markers are highly correlated for smokers and for the entire sample of mixed smokers and non-smokers. CO is the preferred biochemical marker, in such groups, because it is the cheapest, is non-invasive and gives virtually instantaneous results. Self-reported daily cigarette consumption also correlates well with each of these biochemical markers, and so it appears that people are, in the context of population studies, mainly truthful about their smoking. The relationships with self-reported cigarette consumption are curvilinear with apparent levelling out of the gradient at around 25 cigarettes/day for cotinine and thiocyanate and at greater than 40 cigarettes/day for CO. Sex differences are small, although thiocyanate is generally higher and cotinine generally lower in women with the same self-reported cigarette consumption as men. Amongst non-smokers, only cotinine is able to discriminate between self-reported levels of exposure to passive smoking. CO and thiocyanate are not suitable for measuring low levels of smoke inhalation, such as found in passive smokers.

Adult↗

Verification of adolescent self-reported smoking.

Smoking and the validity of information obtained on it is often questioned in view of the widespread belief that adolescents tend to under- or over-report the habit. The aim here was to verify smoking habits as reported in a questionnaire given in conjunction with dental examinations by asking participants directly whether they smoked or not and performing biochemical measurements of thiocyanate in the saliva and carbon monoxide in the expired air. The series consisted of 150 pupils in the ninth grade (age 15 years). The reports in the questionnaires seemed to provide a reliable estimate of adolescent smoking, the sensitivity of the method being 81-96%, specificity 77-95%. Biochemical verification or control of smoking proved needless in normal dental practice. Accepting information offered by the patient provides a good starting point for health education and work motivating and supporting of self-directed breaking of the habit.

Adolescent↗

Substance use among emergency room patients: Is self-report preferable to biochemical markers?

AIM OF STUDY: To explore the validity of self-reported substance use among emergency room populations and the processes of sample selection bias, to establish their influence on the prevalence rates found. METHODS: Self-reported alcohol and illicit drug use of patients in the emergency room is compared with results from an alcohol breath analyser and urine toxicology. RESULTS: Variations in reported substance use occur when comparing self-report measures with alcohol breath analyser results and urine toxicology. Self-reported alcohol use was found among 7.5% of the patients compared with 4.7% based on alcohol breath analysers. Illicit drug use was reported by 9.0% of the patients whereas urine toxicology resulted in 30% patients positive for illicit drug use. Patients that voluntarily participate in the study differ from those that do not participate. Patients who refuse an alcohol breath analyser report slightly more alcohol use prior to the injury (difference not significant), and patients who provide a urine sample report more illicit drug use prior to the injury compared to those that refuse. DISCUSSION: Differences in prevalence rates can be explained partly by the measurements used and partly by sample selection bias. Self-reported alcohol use and self-reported illicit drug use are preferable to the "gold standard" when used among emergency room patients, because both measures provide more accurate information on the actual use. Sample selection bias also influences the prevalence rates.

Adolescent↗

Disruption in Th1/Th2 immune response in young adult smokers.

Interferon (IFN)-gamma and IL-10 cytokines, measures of Th1 and Th2 immunity, were examined in 20 healthy nonsmokers (12 males, 8 females) and 19 smokers (11 males, 8 females), aged 19-41 years (23.46+/-0.82 years). Nonsmokers came to the laboratory once; smokers came to the laboratory after ad lib smoking and following 24-h smoking abstinence. Salivary cotinine and expired CO confirmed smoking status. Plasma was collected at the end of each lab session and assayed for peripheral IFN-gamma and IL-10 levels. Among smokers, peripheral IFN-gamma, IL-10, or IFN-gamma/IL-10 ratio levels did not change in response to 24-h smoking abstinence. IFN-gamma levels and IFN-gamma/IL-10 ratios were higher among female smokers while smoking and following 24-h abstinence compared to male smokers in both conditions and compared to male and female nonsmokers. There was no sex or smoking status difference in IL-10 levels. Results suggest that cigarette smoking may have at least short-term damaging effects on the body's normal immune balance, particularly for women.

Adult↗

The strong induction of metallothionein gene following cadmium exposure transiently affects the expression of many genes in Eisenia fetida: a trade-off mechanism?

Metal pollution causes disturbances at various levels of biological organization in most species. Important physiological functions could be affected in the exposed individuals and among the main physiological functions, immunity may provide one (or more) effector(s) whose expression can be directly affected by a metal exposure in various macroinvertebrates. Protein expressions were studied in order to test them as molecular biomarkers of metal exposure in Eisenia fetida. Selected effectors were calmodulin, heat shock proteins, superoxide dismutase, catalase, metallothionein, beta-adrenergic receptor kinase, pyruvate carboxylase, transcriptionally controlled tumor protein, protein kinase C, ubiquitin and cyclophilin-A. The level of expression of each gene was analysed in whole organism following exposures to cadmium in soil using real-time PCR. Metallothionein, transcriptionally controlled tumor protein and cyclophilin-A expression were also measured following copper exposures in soil because these genes seemed to be sensitive to copper. This work enabled to distinguish metallothionein and cyclophilin-A among the 15 selected effectors. A strong decrease of the number of transcripts was also detected for most effectors soon after the exposure to cadmium suggesting that a trade-off mechanism occurs.

Animals↗

Increased breath biomarkers of oxidative stress in diabetes mellitus.

BACKGROUND: Oxidative stress has been implicated in the major complications of diabetes mellitus, including retinopathy, nephropathy, neuropathy and accelerated coronary artery disease. There is a clinical need for a marker of oxidative stress which could potentially identify diabetic patients at increased risk for these complications. We measured oxidative age, a new breath marker of oxidative stress, in diabetic patients. METHODS: Three groups were studied: type 1 diabetes mellitus (n=9), type 2 diabetes mellitus (n=53) and non-diabetic normals (n=39). Volatile organic compounds (VOCs) in breath were assayed by gas chromatography and mass spectroscopy to construct the breath methylated alkane contour (BMAC), a three-dimensional display of oxidative stress markers, C4-C20 alkanes and monomethylated alkanes. The collective abundance of these VOCs was reduced to a single value, the oxidative age, comprising the volume under the curve of the BMAC corrected for chronological age. RESULTS: Oxidative age was significantly increased in type 1 diabetes (mean=0.103, S.E.M.=0.119, p<0.01) and type 2 diabetes (mean=0.103, S.E.M.=0.047, p<0.05) compared to age-matched normals (mean=-0.248, S.E.M.=0.079). No significant correlation between oxidative age and blood glucose or hemoglobin A1C was observed in either group. CONCLUSIONS: Oxidative age, a marker of oxidative stress, was significantly increased in both type 1 and type 2 diabetes mellitus. Oxidative age merits further study as a candidate marker of risk for the complications of diabetes mellitus.

Adult↗

Diagnostic potential of breath analysis--focus on volatile organic compounds.

Breath analysis has attracted a considerable amount of scientific and clinical interest during the last decade. In contrast to NO, which is predominantly generated in the bronchial system, volatile organic compounds (VOCs) are mainly blood borne and therefore enable monitoring of different processes in the body. Exhaled ethane and pentane concentrations were elevated in inflammatory diseases. Acetone was linked to dextrose metabolism and lipolysis. Exhaled isoprene concentrations showed correlations with cholesterol biosynthesis. Exhaled levels of sulphur-containing compounds were elevated in liver failure and allograft rejection. Looking at a set of volatile markers may enable recognition and diagnosis of complex diseases such as lung or breast cancer. Due to technical problems of sampling and analysis and a lack of normalization and standardization, huge variations exist between results of different studies. This is among the main reasons why breath analysis could not yet been introduced into clinical practice. This review addresses the basic principles of breath analysis and the diagnostic potential of different volatile breath markers. Analytical procedures, issues concerning biochemistry and exhalation mechanisms of volatile substances, and future developments will be discussed.

Air↗

Exhaled markers in the monitoring of airways inflammation and its response to steroid's treatment in mild persistent asthma.

The measure of inflammatory cytokines in the exhaled breath condensate has been recently proposed for use in monitoring asthma and the therapeutic response to steroids. The aim of the present study was to investigate the usefulness of measuring exhaled IL-6, IL-4 and pH in mild persistent asthma. Furthermore the effects on these markers of inhaled steroids were assessed. The study enrolled 28 asthmatic (15 males, 38+/-12 years) and 15 healthy subjects (5 males, 35+/-6 years). IL-6, IL-4 and pH were measured in the exhaled breath condensate of the subjects studied. Significantly higher concentrations of IL-6 and IL-4 were observed in the breath condensate of asthmatic patients (7.1+/-1.1 and 64.4+/-8.3 pg/ml) compared to controls (2.7+/-0.6 and 31.7+/-3.5 pg/ml), p<0.001. Furthermore, exhaled IL-4 fell significantly after treatment with inhaled steroids for 6 months (47.9+/-3.2 pg/ml, p<0.001) while exhaled IL-6 did not (6.4+/-1.0 pg/ml, p=0.8). The exhaled pH turned out to be lower in asthmatic subjects than in controls (7.39+/-0.11 vs. 7.85+/-0.14; P<0.001) but trended towards control levels after steroid treatment (7.65+/-0.16, P<0.001). We conclude that the measurement of exhaled IL-4 and pH in mild asthmatic subjects could be a useful way of monitoring their airway inflammation as well as their response to the treatment.

Administration, Inhalation↗

Carboxyhemoglobin and thiocyanate as biomarkers of exposure to carbon monoxide and hydrogen cyanide in tobacco smoke.

The determination of biomarkers in human body fluids is a useful tool, which allows the quantitative assessment of the exposure to chemicals or complex mixtures of chemicals and of early biological effects as a result of the exposure. Biomarkers require validation before their successful application in human studies. This review describes some general purposes of human biomonitoring and biomarkers including the requirements for validation. Risk assessment and harm reduction of smoking and tobacco products, respectively, is a very suitable field for the application of biomarkers. A brief historical review shows that the application of biomarkers of exposure and effect in human smoking goes back more than 150 years. Two 'classical' biomarkers of exposure to tobacco, namely carboxyhemoglobin (COHb and its equivalent carbon monoxide in exhalate, COex) and thiocyanate (SCN) in body fluids are discussed in terms of sources of exposure, metabolism, disposition kinetics and influencing host factors. Data on COHb/COex and SCN in nonsmokers and smokers as well as the power to discriminate between smokers and nonsmokers are presented. Both biomarkers are significantly correlated with the daily cigarette consumption. Smoking machine-derived yields of the precursors carbon monoxide and hydrogen cyanide were not correlated with COHb/COex and SCN, respectively. It is concluded that, while COHb/COex is a useful biomarker for assessing the smoke inhalation, preferably in controlled studies, the application of SCN in body fluids as a biomarker for smoking is limited, mainly due to the abundance of other sources for SCN.

Biomarkers↗

Usefulness of biomarkers in population studies: from exposure to susceptibility and to prediction of cancer.

From a review of decades of intensive biomarker research and prospective validation studies, it becomes clear that only a limited number of biomarkers can be used to provide reliable documentation of excessive exposure to environmental mutagenic agents, expression of detrimental biological effects from the exposure and increased risk for cancer. These studies also demonstrate that expression of each biomarker represents an integrated response to the exposure that is influenced by susceptibility factors, and an integral component of the complex carcinogenic pathway. A current interest is in the use of phenotypic functional assays to improve and complement the assessment of cancer risk. A recommended approach includes assays that indicate DNA repair deficiency, i.e. host-cell-mediated reporter gene and challenge (mutagen-sensitivity) assays. The usefulness and limitations in biomarker investigations will be discussed. The review emphasizes the need for carefully designed investigations that involve adequate sample sizes and a combination of appropriate biomarkers to generate reproducible results that can be translated into more reliable cancer risk assessment. The assessment can be used to drive the implementation of disease prevention and intervention activities. Such an approach is consistent with the current priority in translating basic science knowledge into health applications.

Biomarkers↗

Leukotrienes and 8-isoprostane in exhaled breath condensate of children with stable and unstable asthma.

BACKGROUND: Cysteinyl-leukotrienes (cys-LTs) and 8-isoprostane are biomarkers of airway inflammation and oxidative stress. OBJECTIVE: The aim of this study was to evaluate cys-LT and 8-isoprostane levels in exhaled breath condensate (EBC) of children with different degrees of asthma severity. METHODS: EBC was collected from 14 steroid-naive children with mild persistent asthma, 13 children with stable mild- to-moderate persistent asthma treated with inhaled corticosteroids (ICS), 9 ICS-treated children with unstable asthma, and 19 healthy children. RESULTS: In the three groups of asthmatic children, EBC concentrations of cys-LTs and 8-isoprostane were significantly higher than in control children (steroid-naive asthmatic children: cys-LTs median, 10.8 pg/mL, P <.001, 8-isoprostane, 16.2 pg/mL, P <.001; ICS-treated stable asthmatic children: cys-LTs, 12.7 pg/mL, P <.001, 8-isoprostane, 18.1 pg/mL, P <.001; children with unstable asthma: cys-LTs, 106.0 pg/mL, P <.01, 8-isoprostane, 29.7 pg/mL, P <.01; control children: cys-LTs, 4.3 pg/mL, 8-isoprostane, 3.5 pg/mL). Cys-LT levels were higher in children with unstable asthma than in the other two asthmatic groups (P <.05). FE(NO) levels were significantly higher in steroid-naive and in children with unstable asthma compared with ICS-treated children with stable asthma (P <.01). CONCLUSIONS: Our study shows that EBC cys-LTs and 8-isoprostane concentrations are higher in asthmatic children than in healthy control children, with scattered values in patients with unstable asthma. These findings suggest that EBC eicosanoid measurement may have useful clinical implications for investigating phenotype differences among asthmatic patients.

Adolescent↗

Effects of a leukotriene receptor antagonist on exhaled leukotriene E4 and prostanoids in children with asthma.

BACKGROUND: Leukotriene (LT) E(4) and 8-isoprostane concentrations are elevated in exhaled breath condensate in children with asthma. The effects of leukotriene receptor antagonists (LTRAs) on exhaled leukotriene and prostanoids in children with asthma are unknown. OBJECTIVE: (1) To study the effect of montelukast, a LTRA, on exhaled LTE(4), 8-isoprostane, and prostaglandin E(2) in children with asthma and atopic children; (2) to measure exhaled nitric oxide. METHODS: An open-label study with oral montelukast (5 mg once daily for 4 weeks) was undertaken in 17 atopic children with asthma and 16 atopic children without asthma. RESULTS: Pretreatment exhaled LTE(4) (P < .0001) and 8-isoprostane (P < .0001) values were higher in atopic children with asthma than in atopic children without asthma. In atopic children with asthma, montelukast reduced exhaled LTE(4) by 33% (P < .001), and this reduction was correlated with pretreatment LTE(4) values (r = -0.90; P = .0001). Posttreatment exhaled LTE(4) levels in children with asthma were higher than pretreatment LTE(4) values in atopic children without asthma (P < .004). Montelukast had no effect on exhaled LTE(4) in atopic children without asthma (P = .74), or on exhaled 8-isoprostane (atopic children with asthma, P = .94; atopic children without asthma, P = .55) and PGE(2) (atopic children with asthma, P = .56; atopic children without asthma, P = .93) in both groups. In atopic children with asthma, exhaled nitric oxide concentrations were reduced by 27% (P < .05) after montelukast. CONCLUSION: Leukotriene receptor antagonists decrease exhaled LTE(4) in atopic children with asthma. This reduction is dependent on baseline exhaled LTE(4) values. CLINICAL IMPLICATIONS: Measurement of exhaled LTE(4) might help identify children with asthma most likely to benefit from LTRAs.

Acetates↗