Increased pentane and carbon disulfide in the breath of patients with schizophrenia

Dietary fatty acid and antioxidant intake in community-dwelling patients suffering from schizophrenia

INTRODUCTION

Brain phospholipids are uniquely rich in polyunsaturated fatty acids (PUFAs). Most PUFAs such as alpha-linolenic acid 18:3(n-3), eicosapentaenoic acid 20:5(n-3), and docosahexaenoic acid 22:6(n-3) are essential and must be provided through the diet. PUFAs are also very sensitive to oxidative stress. Decreased essential fatty acid content has been observed in cell membranes of various tissue types of schizophrenia patients, including neural cell membranes. A number of mechanisms may account for these deficits, such as inadequate dietary supply or increased oxidation. It is known that patients with schizophrenia make poor dietary choices. However, whether their dietary fatty acid or antioxidant intake is insufficient and contributes to the observed deficiencies has not been assessed.

METHODS

After obtaining informed consent, a 24-h diet recall was administered to elicit nutritional information in 146 outpatients with schizophrenia. Intake of fatty acids and antioxidants including vitamins A, C, and E was compared to U.S. population standards according to the National Health and Nutrition Examination Survey Cycle III (NHANES III) results.

RESULTS

Saturated and polyunsaturated fatty acid (PUFA) intake was significantly higher in schizophrenia patients than in controls (p<or=0.05; p<or=0.005, respectively). No differences were found with regard to dietary intake of gamma-linolenic acid (18:3n-3), eicosapentaenoic acid (20:5n-3) and docosahexaenoic acid (22:6n-3). Similarly, antioxidant intake was not different between schizophrenia patients and controls.

CONCLUSION

The observed cell membrane deficits in PUFA and essential fatty acid content do not appear to derive from decreased dietary supply. Rather, intrinsic membrane phospholipid metabolism abnormalities may be causative. Overall increased fat intake in schizophrenia patients may contribute to the development of serious medical comorbidities, and further advance the risk for cumbersome metabolic side effects of antipsychotic treatment such as new-onset diabetes mellitus.

Diagnosis of pneumonia with an electronic nose: correlation of vapor signature with chest computed tomography scan findings

OBJECTIVES/HYPOTHESIS

The electronic nose is a sensor of volatile molecules that is useful in the analysis of expired gases. The device is well suited to testing the breath of patients receiving mechanical ventilation and is a potential diagnostic adjunct that can aid in the detection of patients with ventilator-associated pneumonia.

STUDY DESIGN

A prospective study.

METHODS

We performed a prospective study of patients receiving mechanical ventilation in a surgical intensive care unit who underwent chest computed tomography (CT) scanning. A single attending radiologist reviewed the chest CT scans, and imaging features were recorded on a standardized form. Within 48 hours of chest CT scan, five sets of exhaled gas were sampled from the expiratory limb of the ventilator circuit. The gases were assayed with a commercially available electronic nose. Both linear and nonlinear analyses were performed to identify correlations between imaging features and the assayed gas signatures.

RESULTS

Twenty-five patients were identified, 13 of whom were diagnosed with pneumonia by CT scan. Support vector machine analysis was performed in two separate analyses. In the first analysis, in which a training set was identical to a prediction set, the accuracy of prediction results was greater than 91.6%. In the second analysis, in which the training set and the prediction set were different, the accuracy of prediction results was at least 80%, with higher accuracy depending on the specific parameters and models being used.

CONCLUSION

The electronic nose is a new technology that continues to show promise as a potential diagnostic adjunct in the diagnosis of pneumonia and other infectious diseases.

Lipid Peroxidation Early after Brain Injury

The role of lipid peroxidation after brain injury is still not completely understood, and results of different studies have been equivocal. In this study, three proposed peroxidation markers were determined in patients early after isolated head injury and results compared to healthy controls. Malondialdehyde (MDA) and thiobarbituric acid-reactive substances (TBARS) were measured in plasma, and n-pentane was determined in patients' exhaled air. For MDA and TBARS no significant differences could be shown (0.267 vs. 0.358 ng/mL, and 0.896 vs. 0.814 ng/mL in patients vs. healthy volunteers, respectively). n-Pentane, however, was significantly increased in the expired air of patients (0.471 vs. 0.118 nmol/L in healthy volunteers). Similar results for n-pentane were obtained when only male patients and volunteers were considered (0.510 vs. 0.113 nmol/L). Stratification according to clinical outcome showed significantly higher values for n-pentane in male patients with poor outcome (0.656 nmol/L) in comparison with healthy male volunteers (0.113 nmol/L). No difference was found when patients were stratified according to the presence or absence of subarachnoid hemorrhage. It is concluded that, only in a sub-population of patients with brain injury, lipid-peroxidation is a crucial mechanism. n-Pentane seems to be a valuable marker to detect lipid peroxidation early after brain trauma. Malondialdehyde may be of value only later in the course of the disease. TBARS are not a specific marker and should therefore not be used.

Increased breath markers of oxidative stress in normal pregnancy and in preeclampsia

OBJECTIVES

The purpose of this study was to compare the intensity of oxidative stress in normal pregnancy, preeclampsia, and nonpregnant women using a breath test.

STUDY DESIGN

We studied primiparous women in third trimester pregnancy (38 uncomplicated, 26 with preeclampsia) and 60 nonpregnant control subjects. Volatile organic compounds (VOCs) in alveolar breath were analyzed by gas chromatography/mass spectroscopy to construct the breath methylated alkane contour (BMAC), a 3-dimensional display of abundance of C4-C20 alkanes and monomethylated alkanes.

RESULTS

The mean volume under curve (VUC) of the BMAC was significantly higher in preeclampsia patients than in normal pregnant women (P < .003) and nonpregnant control subjects (P < .005). A predictive model employing 5 VOCs distinguished preeclampsia from uncomplicated pregnancy (sensitivity = 92.3%, specificity = 89.7%; cross-validated sensitivity = 88.5%, specificity = 79.3%).

CONCLUSION

A breath test significantly demonstrated greater oxidative stress in women with preeclampsia than in uncomplicated pregnancy and nonpregnant control subjects. The breath test accurately identified women with established preeclampsia, but further studies are required to determine if this test can predict the onset of disease.

Electronic noses and disease diagnostics

Rapid developments in sensor technology have facilitated the production of devices--known as electronic noses--that can detect and discriminate the production profiles of volatile compounds from microbial infections in situ. Such qualitative and semi-quantitative approaches could have a significant role in the early diagnosis and detection of microbial diseases. Using artificial intelligence and web-based knowledge systems, electronic noses might also have a valuable role in monitoring disease epidemiology.

Volatile markers of breast cancer in the breath

Breast cancer is accompanied by increased oxidative stress and induction of polymorphic cytochrome P-450 mixed oxidase enzymes (CYP). Both processes affect the abundance of volatile organic compounds (VOCs) in the breath because oxidative stress causes lipid peroxidation of polyunsaturated fatty acids in membranes, producing alkanes and methylalkanes which are catabolized by CYP. We performed a pilot study of breath VOCs, a potential new marker of disease in women with breast cancer. This was a combined case-control and cross-sectional study of women with abnormal mammograms scheduled for a breast biopsy. Breath samples were analyzed by gas chromatography and mass spectroscopy in order to determine the breath methylated alkane contour (BMAC), a three-dimensional display of the alveolar gradients (abundance in breath minus abundance in room air) of C4-C20 alkanes and monomethylated alkanes. BMACs in women with and without breast cancer were compared using forward stepwise discriminant analysis. Two hundred one breath samples were obtained from women with abnormal mammograms and biopsies read by two pathologists. There were 51 cases of breast cancer in 198 concordant biopsies. The breath test distinguished between women with breast cancer and healthy volunteers with a sensitivity of 94.1% (48/51) and a specificity of 73.8% (31/42) (cross-validated sensitivity 88.2% (45/51), specificity 73.8% (31/42)). Compared to women with abnormal mammograms and no cancer on biopsy, the breath test identified breast cancer with a sensitivity of 62.7% (32/51) and a specificity of 84.0% (42/50) (cross-validated sensitivity of 60.8% (31/51), specificity of 82.0% (41/50)). The negative predictive value (NPV) of a screening breath test for breast cancer was superior to a screening mammogram (99.93% versus 99.89%); the positive predictive value (PPV) of a screening mammogram was superior to a screening breath test (4.63% versus 1.29%). A breath test for markers of oxidative stress accurately identified women with breast cancer, with an NPV superior to a screening mammogram. This breath test could potentially be employed as a primary screen for breast cancer. Confirmatory studies in larger groups are required.

Breath markers of oxidative stress in patients with unstable angina

Cardiac chest pain is accompanied by oxidative stress, which generates alkanes and other volatile organic compounds (VOCs). These VOCs are excreted in the breath and could potentially provide a rational diagnostic marker of disease. The breath methylated alkane contour (BMAC), a 3-dimensional surface plot of C4-C20 alkanes and monomethylated alkanes, provides a comprehensive set of markers of oxidative stress. In this pilot study, we compared BMACs in patients with unstable angina pectoris and in healthy volunteers. Breath VOCs were analyzed in 30 patients with unstable angina confirmed by coronary angiography and in 38 age-matched healthy volunteers with no known history of heart disease (mean age +/- SD, 62.7 +/- 12.3 years and 62.5 +/- 10.0, not significant). BMACs in both groups were compared to identify the combination of VOCs that provided the best discrimination between the 2 groups. Forward stepwise entry discriminant analysis selected 8 VOCs to construct a predictive model that correctly classified unstable angina patients with sensitivity of 90% (27 of 30) and specificity of 73.7% (28 of 38). On cross-validation, sensitivity was 83.3% (25 of 30) and specificity was 71.1% (27 of 38). We conclude that the breath test distinguished between patients with unstable angina and healthy control subjects.

Breath markers and soluble lipid peroxidation markers in critically ill patients

Free radical-mediated inflammatory processes account for a great portion of morbidity and mortality in critically ill patients. The purpose of this study was to determine two plasma peroxidation markers and three volatile markers related to lipid peroxidation, metabolic activity and cholesterol metabolism, and to explore relationships between the different markers and patients' clinical status. Substances were analyzed in whole blood and in exhaled air in patients with head injury, acute respiratory distress syndrome (ARDS) and in those being at risk of developing ARDS. These results were compared with the baseline measurements in healthy individuals. Additionally, patients were assessed according to their inflammatory status. Concentrations of malondialdehyde and thiobarbituric acid-reactive substances in plasma as well as pentane concentrations in breath increased with increasing inflammatory status. Although these compounds are generated through peroxidation of fatty acids, concentrations of these markers were significantly different in patient groups. Isoprene concentrations were lowest in the ARDS group. Acetone concentrations were not different between patient groups. We conclude that for the assessment of lipid peroxidation and other inflammatory reactions a set of parameters has to be defined. More detailed insights into inflammatory processes can be obtained when the volatile markers and the serum markers are considered together.

Breath biomarkers for detection of human liver diseases: preliminary study

Chronic liver disease is initially occult, has multiple aetiologies, involves complex diagnostic questions, and requires follow-up because progression is likely. Blood tests and biopsies are generally used, but have disadvantages. We have developed a new test for liver disease based on abnormal concentrations of metabolic products detected in exhaled breath. This test can be used, in conjunction with other clinically accepted diagnostic protocols, to detect and classify chronic liver diseases. Samples of breath collected from spontaneously breathing human subjects (86 patients presenting with 13 liver diseases and 109 subjects with normal liver function) were concentrated cryogenically and analysed by wide-bore capillary gas chromatography using various detectors. The concentrations of various molecules in exhaled breath were examined for potential use as biomarkers of liver function. Subjects with chronic liver diseases could be differentiated from those with normal liver function by comparing levels of breath carbonyl sulphide, carbon disulphide and isoprene; these differences were confirmed and correlated by comparing the levels with standard clinical blood markers of liver damage. The presence of chronic liver failure can thus be detected with sensitivity and specificity by quantifying sulphur-containing compounds arising from the abnormal metabolism associated with liver disease. The breath test we have developed appears to distinguish between hepatocellular and biliary tract aetiologies, and allows staging for severity. This approach may provide the clinician with a simple, non-invasive technique for use in the screening of large populations and follow-up for patients with chronic liver disease.

Oxidative damage and schizophrenia: an overview of the evidence and its therapeutic implications

Free radicals are highly reactive chemical species generated during normal metabolic processes. which in excess can lead to membrane damage. Elaborate antioxidant defence systems exist to protect against oxidative stress. There is accumulating evidence of altered antioxidant capacity in schizophrenia. Membrane dysfunction can be secondary to free radical-mediated pathology, and may contribute to specific aspects of schizophrenic symptomatology and complications of its treatment. Specifically, free radical-mediated abnormalities may contribute to the development of a number of clinically significant consequences, including prominent negative symptoms, tardive dyskinesia, neurological 'soft' signs and parkinsonian symptoms. Our previous results showing altered membrane dynamics and antioxidant enzyme activities in schizophrenia, and findings from other investigators, are consistent with the notion of free radical-mediated neurotoxicity in schizophrenia. These findings provide a theoretical basis from which the development of novel therapeutic strategies such as fatty acid and antioxidant supplementation can occur in the future.

Carbon disulfide exposure assessment in a Chinese viscose filament plant

Carbon disulfide is a well-known occupational hazard in the viscose industry, and studies have shown considerable health effects when workers are exposed to high concentrations of this reagent. At exposure levels below the TLV-TWA(31 mg/m3), findings remain contradictory, probably due to deficient exposure data. The present study tries to identify the occupational hazards and thoroughly assess the exposure levels in a Chinese viscose rayon plant.

METHODS

An industrial hygienic field survey and a sampling campaign were carried out, including multi-gas monitoring, on-line measurements, and stationary assessment in the spinning hall as well as personal exposure sampling for spinners (by charcoal tube absorbing and GC-FPD analysis). All data was introduced into Foxpro database, and analyzed by Epi info (6.04) and SPSS.

RESULTS

On-line measurement showed that the geometric mean (GM) of carbon disulfide exposure amounted to 12.73 mg/m3 in 'exposure' and 0.08 mg/m3 in 'non-exposure' worksites. These concentrations in the air were related to the subject's activities showing the highest levels when they had to open the shield windows of the spinning machines. Stationary exposure measurements of carbon disulfide in the spinning hall amounted to 23.29 mg/m3 GM (range 5.8-97.94 mg/m3). Personal exposure of spinners was about 17.3 mg/m3 GM. Comparing these methods, the personal exposure sampling could exactly express the exposure levels of the worker's contacting situation. The on-line measurement by multi-gas monitor might also be recommended to the factory as it has its own advantages of rapid and independent assessment, but it under-estimates the exposure level.

Correlation of breath ammonia with blood urea nitrogen and creatinine during hemodialysis

We have spectroscopically determined breath ammonia levels in seven patients with end-stage renal disease while they were undergoing hemodialysis at the University of California, Los Angeles, dialysis center. We correlated these measurements against simultaneously taken blood samples that were analyzed for blood urea nitrogen (BUN) and creatinine, which are the accepted standards indicating the level of nitrogenous waste loading in a patient's bloodstream. Initial levels of breath ammonia, i.e., at the beginning of dialysis, are between 1,500 ppb and 2,000 ppb (parts per billion). These levels drop very sharply in the first 15-30 min as the dialysis proceeds. We found the reduction in breath ammonia concentration to be relatively slow from this point on to the end of dialysis treatment, at which point the levels tapered off at 150 to 200 ppb. For each breath ammonia measurement, taken at 15-30 min intervals during the dialysis, we also sampled the patient's blood for BUN and creatinine. The breath ammonia data were available in real time, whereas the BUN and creatinine data were available generally 24 h later from the laboratory. We found a good correlation between breath ammonia concentration and BUN and creatinine. For one of the patients, the correlation gave an R(2) of 0.95 for breath ammonia and BUN correlation and an R(2) of 0.83 for breath ammonia and creatinine correlation. These preliminary data indicate the possibility of using the real-time breath ammonia measurements for determining efficacy and endpoint of hemodialysis.

CO(2)-controlled sampling of alveolar gas in mechanically ventilated patients

A newly designed gas-sampling device using end-tidal CO(2) to separate dead space gas from alveolar gas was evaluated in 12 mechanically ventilated patients. For that purpose, CO(2)-controlled sampling was compared with mixed expiratory sampling. Alveolar sampling valves were easily controlled via CO(2) concentration. Concentrations of four volatile substances were determined in the expired and inspired gas. Isoflurane and isoprene, which did not occur in the inspired air, had ratios of end-tidal to mixed expired concentrations of 1.75 and 1.81, respectively. Acetone and pentane, found in both the inspired and expired air, showed ratios of 0.96 and 1.0, respectively. Precision of concentration measurements was between 2.4% (isoprene) and 11.2% (isoflurane); reproducibility (as coefficient of variation) was 5%. Because the only possible source of isoflurane and isoprene in this setting was patients' blood, selective enrichment of alveolar gas was demonstrated. By using the new sampling technique, sensitivity of breath analysis was nearly doubled.

Potential diagnostic aids for abnormal fatty acid metabolism in a range of neurodevelopmental disorders

Disorders of neurodevelopment include attention deficit hyperactivity disorder, dyspraxia, dyslexia and autism. There is considerable co-morbidity of these disorders and their identification often presents difficulties to those making a diagnosis. This is especially difficult when a multidisciplinary approach is not adopted. All of these disorders have been reported as associated with fatty acid abnormalities ranging from genetic abnormalities in the enzymes involved in phospholipid metabolism to symptoms reportedly improved following dietary supplementation with long chain fatty acids. If definitive disorders of lipid metabolism could be defined then the diagnosis and subsequent management of neurodevelopmental disorders might be transformed. In the identification of those disorders of development which involve lipid metabolism, there are now several tests, measures of lipid metabolism, which could be useful.

Schizophrenia: is the potato the environmental culprit?

The pathology and aetiology of schizophrenia are reviewed in the light of the most recent research into the genetic/sporadic occurrence of this disease complex of world-wide distribution but of variable incidence. Although the aetiology is still unknown, numerous hypotheses have been postulated including dietetic factors but never has the potato (Solanum tuberosum L.) been suspected. However, a strong case can be advanced incriminating this widely, in fact almost universally, consumed vegetable tuber with its variable content of steroidal glycoalkaloids (SGAs) with known toxic action on both animals and humans, including possible teratogenic and cell membrane-damaging properties, as a very likely aetiological contender in most but possibly not all cases.

Variation in volatile organic compounds in the breath of normal humans

We studied the variation in volatile organic compounds (VOCs) in the breath of 50 normal humans, using gas chromatography and mass spectroscopy. An average breath sample contained 204.2 VOCs (SD=19.8, range 157-241). The alveolar gradient of each VOC (abundance in breath minus abundance in air) varied with rate of synthesis minus rate of clearance. A total of 3481 different VOCs were observed: 1753 with positive alveolar gradients, 1728 with negative alveolar gradients. Twenty-seven VOCs were observed in all fifty subjects. This study confirmed previous reports of wide inter-individual variations. Two new findings were the comparatively small variation in total number of breath VOCs, and the presence of a 'common core' of breath VOCs in all subjects.

Method for analysis of exhaled air by microwave energy desorption coupled with gas chromatography-flame ionization detection-mass spectrometry

A method for chemical analysis of volatile constituents in exhaled air of mechanically ventilated patients is described. Exhaled substances are adsorbed and concentrated onto activated charcoal, desorbed by microwave energy and transferred into a gas chromatograph for separation without prior cryofocusing. Substances are identified by flame ionisation detection and mass spectrometry. This method yields reproducible results and is well suited for clinical studies.

Reduced level of plasma antioxidant uric acid in schizophrenia

There is evidence of dysregulation of the antioxidant defense system in schizophrenia. The purpose of the present study was to examine whether uric acid, a potent antioxidant, is reduced in the plasma of patients with schizophrenia. To this end, a within-subject, repeated measures, on-off-on haloperidol treatment design was utilized. Male schizophrenic patients with either a haloperidol treatment (n=47) or a drug-free condition (n=35) had significantly lower levels of plasma uric acid than the age- and sex-matched normal control subjects (n=34). Following haloperidol withdrawal, plasma uric acid levels were further reduced in schizophrenic patients (P=0.018; paired t-test, n=35). However, no relationship was found between uric acid levels and the length of the drug-free period (< 5 or > 5 weeks) or days drug free. In addition, the plasma levels of uric acid in patient groups were significantly and inversely correlated with psychosis. There was a trend for lower uric acid levels in relapsed patients relative to clinically stable patients. Smoking, which can modify plasma antioxidant capacity, was not found to have prominent effects on uric acid levels. The present finding of a significant decrease of a selective antioxidant provides additional support to the hypothesis that oxidative stress in schizophrenia may be due to a defect in the antioxidant defense system.

Reduced status of plasma total antioxidant capacity in schizophrenia

To examine whether antioxidant capacity is reduced in patients with schizophrenia, we determined plasma total antioxidant status (TAS) by quenching the absorbance of the radical cation formed by the reaction of 2,2'-azinobis-(3-ethylbenzothiazoline-6-sulfonic acid) with a metmyoglobin and hydrogen peroxide. TAS serves as an index of net antioxidant activity derived from various antioxidants in plasma. Male schizophrenic patients were compared with age- and sex-matched healthy control subjects, using a within-subject, repeated measures, on-off-on haloperidol treatment design. Drug-free patients were free of all psychotropic medications for an average of 32 days. Plasma TAS was significantly lower in patients with schizophrenia than in normal controls. Plasma TAS in patients was significantly and inversely correlated with symptom severity during the drug-free condition. There were no significant differences between on and off haloperidol-treatment conditions. When patients returned to haloperidol treatment after relapse, the plasma TAS remained fairly constant and was not significantly different from the same individuals during haloperidol-stabilization or drug-free periods. These findings are indicative of an impaired antioxidant defense system, not attributable to neuroleptic treatment, and lend further support to the notion that oxidative stress may have a pathophysiological role in schizophrenia.

The application of infrared spectroscopy to breath CO2 isotope ratio measurements and the risk of spurious results

Stable CO2 isotope breath tests are established as a valuable tool in diagnostic and investigative medicine with the potential to become more prominent in the future. However, their development and widespread clinical use is limited by the requirement of isotope ratio mass spectroscopic analysis. To overcome this restriction alternative analytical techniques have been developed; the most promising, offering relative simplicity and lower costs, are those instruments using infrared spectroscopy. Clinical investigations using such instruments show them to perform well but very little attention has been given to the possibility of interference from the infrared absorption spectrum of other compounds in the breath. To provide an unambiguous answer to this concern we have analysed literature on over 200 detected breath compounds and their infrared absorption spectra to identify any absorption bands coincident with the nu3 absorption band of CO2. It was found that only five breath trace compounds possess coincident fundamental absorption bands, none of which pose the risk of spurious results. We conclude that the 13C16O2/12C16O2 ratio can confidently be measured for isotopic breath tests using an infrared spectrometer, the position of the nu3 absorption band of CO2 in the infrared spectrum precluding any discernible risk of spurious measurements due to coincidental absorption bands.

The membrane phospholipid hypothesis as a biochemical basis for the neurodevelopmental concept of schizophrenia

The neurodevelopmental hypothesis of schizophrenia is becoming an important feature of research in the field. However, its major drawback is that it lacks any biochemical basis which might draw the diverse observations together. It is suggested that the membrane phospholipid hypothesis can provide such a biochemical basis and that the neurodevelopmental phospholipid concept offers a powerful paradigm to guide future research.

Superoxide anion production by neutrophils derived from peripheral blood of schizophrenic patients

Evidence indicates that excess free radicals formation may occur in patients with schizophrenia. A study comparing the production of superoxide anion by peripheral blood neutrophils of 29 schizophrenic patients with that of 17 healthy volunteers detected a significant statistical increase in superoxide anion production in schizophrenic patients compared to the healthy control group. Despite the fact that oxidative mechanisms may play a role in schizophrenia, further studies are needed to define their involvement. Such studies would shed light on the etiology and pathogenesis of schizophrenia and may lead to new therapeutic approaches using antioxidants, which might partially alleviate or prevent the symptoms of schizophrenia.

Method for the collection and assay of volatile organic compounds in breath

Breath testing for volatile organic compounds (VOCs) provides an intrinsically safe method for investigating human metabolism. An improved breath-collecting apparatus (BCA) is described which was acceptable to patients, simple to use, highly sensitive, and free from chemical contamination. VOCs in 10.0 L alveolar breath and 10.0 L room air were collected onto adsorptive traps. Using automated instrumentation, VOCs were thermally desorbed and assayed by gas chromatography/mass spectroscopy. Twenty normal volunteers were studied, and the alveolar gradient (concentration in breath minus concentration in air) was determined for the most abundant VOCs. A total of 1259 VOCs were observed and tentatively identified in the breath of normal subjects. The mean alveolar gradients were positive in 461 VOCs and negative in 798 VOCs. The method provided a sensitive and convenient assay for breath VOCs and permitted tentative determination of their origin from either inside or outside the body.

The lipid membrane hypothesis of schizophrenia: implications for possible clinical breath tests

The diagnosis of disease on the basis of an altered profile of breath volatiles is a new area of clinical biochemistry. The membrane hypothesis of schizophrenia leads to a number of predictions about possible volatile biochemical markers for this condition. These molecules would arise from autoxidation of arachidonic acid and possibly other unsaturated fatty acids. Preliminary experimental studies in this area are reviewed. The results are encouraging and developments in analytical methodology, especially mass spectrometry and electronic nose technology, hold promise for an objective test for monitoring the progress of the disease and possibly for diagnosis.

Essential fatty acid deficiency in erythrocyte membranes from chronic schizophrenic patients, and the clinical effects of dietary supplementation

There is now convincing evidence that membrane phospholipid metabolism is abnormal in schizophrenic patients. Our own studies, consistent with those of other research groups, have shown marked depletion of essential fatty acids, particularly arachidonic acid and docosahexanoic acid, in red blood cell membranes from schizophrenic patients relative to healthy control subjects. We also present preliminary evidence that similar abnormalities are present in first degree relatives of schizophrenic patients. Furthermore, it appears that changes in diet, which modify membrane levels of fatty acids, can have significant effects upon symptoms of schizophrenia and tardive dyskinesia (TD). Thus, we have found that schizophrenic patients who eat more (n-3) fatty acids in their normal diet have less severe symptoms. In a pilot study of (n-3) fatty acid supplementation we observed significant improvement in both schizophrenic symptoms and tardive dyskinesia over a 6 week period.

Reduced susceptibility to oxidative damage of erythrocyte membranes from medicated schizophrenic patients

Susceptibility to non-enzymatic peroxidation of erythrocyte membranes from medicated schizophrenic patients relative to healthy control subjects was investigated by measuring internalization into erythrocytes of ethylene glycol, cellobiotol or mannitol, with or without preincubation with cumene hydroperoxide or with chlorpromazine. The main finding was that erythrocytes from schizophrenic patients were less susceptible than those from control subjects to non-enzymatic oxidative damage from cumene hydroperoxide, as measured by internalization of cellobiotol and mannitol. At baseline before incubation, there was reduced internalization of cellobiotol and mannitol and this was reduced even further by preincubation with chlorpromazine. It is suggested that previous findings of fatty acid deficits in erythrocyte membranes from neuroleptic-treated schizophrenic patients are unlikely to have resulted from non-enzymatic oxidative damage of the membrane. Furthermore, it is suggested that depleted erythrocyte membrane essential fatty acids are more likely to be the result of the schizophrenic process rather than antipsychotic drug treatment, and that antipsychotic drugs may even offer protection against membrane lipid peroxidation.

Free radical pathology in schizophrenia: a review

There is evidence that free radicals are involved in membrane pathology, and may play a role in schizophrenia. Free radicals are reactive chemical species generated during normal metabolic processes, and, in excess, can damage lipids, proteins, and DNA. Regions of high oxygen consumption, lipid content, and transition metals are at particular risk. Hence, neuronal membranes are uniquely vulnerable to radical-mediated damage. Elaborate antioxidant defense systems exist to protect against oxidative stress. In schizophrenia there is evidence for dysregulation of free radical metabolism, as detected by abnormal activities of critical antioxidant enzymes and other indices of lipid peroxidation in plasma, red blood cells, and cerebrospinal fluid. Such abnormalities have been associated with tardive dyskinesia, negative symptoms, neurological signs, poor premorbid function, and CT scan abnormalities. Studies to date have generally been exploratory. Further elucidation of the role of free radicals and antioxidants in schizophrenia and its treatment will require systematic investigation.

Fatty acids and schizophrenia

In a controlled study of red cell membrane fatty acids in patients with schizophrenia, substantial depletions of fatty acids from both the n-6 and n-3 series were demonstrated. Arachidonic acid and docosahexaenoic acid were particularly depleted. In a separate study, dietary analysis revealed no deficiency of fatty acid intake in this patient group, but greater intake of n-3 fatty acids was associated with less severe symptomatology. Dietary supplementation for six weeks with 10 g per day of concentrated fish oil (MaxEPA) led to significant improvement in schizophrenic symptoms. This clinical improvement was related to the increased level of n-3 fatty acids in red cell membranes. These findings form part of a growing body of research data suggestive of an abnormality in cell membrane fatty acid composition in schizophrenia. The preliminary evidence for clinically effective dietary manipulation to correct such an abnormality opens up novel and exciting therapeutic possibilities.

The Nithsdale Schizophrenia Surveys. XIV: Plasma lipid peroxide and serum vitamin E levels in patients with and without tardive dyskinesia, and in normal subjects

BACKGROUND

Tardive dyskinesia (TD) may be mediated through free radical damage to neurons. Plasma lipid peroxide levels are a measure of radical damage to fats. Vitamin E is a free radical scavenger.

METHOD

One hundred and twenty-eight schizophrenic patients were examined for TD using the Abnormal Involuntary Movements Scale. Blood samples were taken to measure plasma lipid peroxide, serum vitamin E and cholesterol, and vitamin E:cholesterol ratios. Twenty-four patients were also examined in October 1993, January 1994, and April 1994. Biochemical results were compared in 81 patients and 79 normal subjects.

RESULTS

Patients with and without TD did not differ in median plasma lipid peroxide and serum vitamin E levels, or vitamin E:cholesterol ratios. Correlations between seasonal change scores in TD and biochemical measurements were low. Lipid peroxide levels were higher and vitamin E:cholesterol ratios lower in patients than in normal subjects. Vitamin E levels were lowest in in-patients and in those living in supported accommodation.

CONCLUSIONS

The results do not support the hypothesis that TD is mediated through free radical damage to neurons, but suggest increased free radical activity in schizophrenia.

Analytical technologies for lipid oxidation products analysis

Productive investigation of the contribution of oxidative stress to human disease is facilitated by the design and application of suitable analytical technologies for oxidation product analysis. Lipid oxidation, including polyunsaturated fatty acid and cholesterol oxidation, produces a variety of products that can function as indexes of the extent of oxidation. These products include fatty acid hydroperoxides and hydroxides, aldehydes, prostanoids, hydrocarbons, and cholesterol hydroperoxides and hydroxides, epoxides, and carbonyls. Some of these oxidation products have biological activities that can contribute to tissue damage in unique ways. This paper reviews the state-of-the-art for chromatographic analysis of these products through a discussion of advances that have taken place since 1990.

Collection of a single alveolar exhaled breath for volatile organic compounds analysis

Measurement of specific organic compounds in exhaled breath has been used as an indicator of recent exposure to pollutants or as an indicator of the health of an individual. A typical application involves the collection of multiple breaths onto a sorbent cartridge or into an evacuated canister with the use of a relatively complex sampling apparatus. A new method has been developed wherein a single exhaled breath is directly transferred from the mouth into an evacuated 1 l or 1.8 l stainless steel SUMMA canister. The single breath canister (SBC) method avoids the necessity for a complex sampling system requiring maintenance and cleaning and allows easy collection of samples. Additionally, it is possible to collect a rapid sequence of samples from a subject to establish the elimination curve subsequent to an exposure to specific volatile organic compounds with a theoretical resolution of adjacent breaths. The SBC method was compared to an accepted canister based sampling system to assure comparability and then used to demonstrate its utility by measuring the absorption and elimination of chloroform during and after exposure to chlorinated shower water.

Volatile organic compounds in the breath of patients with schizophrenia

AIMS

To analyse the breath of patients with schizophrenia for the presence of abnormal volatile organic compounds.

METHODS

A case comparison study was performed in two community hospitals in Staten Island, New York. Twenty five patients with schizophrenia, 26 patients with other psychiatric disorders, and 38 normal controls were studied. Alveolar breath samples were collected from all participants, and volatile organic compounds in the breath were assayed by gas chromatography with mass spectroscopy. Differences in the distribution of volatile organic compounds between the three groups were compared by computerised pattern recognition analysis.

RESULTS

Forty eight different volatile organic compounds were observed in the breath samples. Three separate pattern recognition methods indicated an increased differentiation capability between the patients with schizophrenia and the other subjects. Pattern recognition category classification models using 11 of these volatile organic compounds identified the patients with schizophrenia with a sensitivity of 80.0% and a specificity of 61.9%. Volatile organic compounds in breath were not significantly affected by drug therapy, age, sex, smoking, diet, or race.

CONCLUSIONS

Microanalysis of volatile organic compounds in breath combined with pattern recognition analysis of data may provide a new approach to the diagnosis and understanding of schizophrenia. The physiological basis of these findings is still speculative.

Depleted red cell membrane essential fatty acids in drug-treated schizophrenic patients

The fatty acid composition of red blood cell membranes from 23 drug-treated schizophrenic patients was measured and compared with a healthy control group. There were substantial depletions of fatty acids from the n6 and n3 series, particularly arachidonic and docosahexanoic acid. Significant negative correlations between depleted n6 fatty acids and plasma levels of thiobarbituric acid reactive substances suggests that depletion is caused by increased breakdown of these fatty acids rather than by impaired incorporation of fatty acids into membranes. Arachidonic and docosahexanoic acids appear to show a bimodal distribution. We propose that this may be a metabolic abnormality which is of aetiological importance in schizophrenia.

Measurement of volatile organic compounds in exhaled breath as collected in evacuated electropolished canisters

A set of three complementary analytical methods were developed specifically for exhaled breath as collected in evacuated stainless steel canisters using gas chromatographic-mass spectrometric detection. The first is a screening method to quantify the carbon dioxide component (generally at 4-5% concentration), the second method measures the very volatile high-level endogenous compounds [e.g. acetone and isoprene at 500-1000 parts per billion by volume (ppbv), methanol, ethanol, dimethylsulfide at 2-10 ppbv], and the third method is designed to measure trace-level environmental contaminants and other endogenous volatile organic compounds (VOCs) (sub-ppbv) in breath. The canister-based sample format allows all three methods to be applied to each individual sample for complete constituent characterization. Application of these methods is shown to be useful in the following ways: analysis of CO2 levels indicates the approximate quantity of alveolar breath collected (as opposed to whole breath) in a sample; levels of major endogenous compounds are shown to be influenced by physical activities and subsequent recovery periods; and environmental exposures to xenobiotic VOCs can be characterized by assessment of post-exposure breath elimination curves. The instrumentation and methodology are described and example chromatograms and quantitative data plots demonstrating the utility of the methods are presented.

Metabolic and environmental origins of volatile organic compounds in breath

Although more than 200 volatile organic compounds (VOCs) have been identified in human alveolar breath, their origins are still mostly unknown. An attempt was made to determine whether the major VOCs in breath were derived from inside or outside the body--that is, were they products of metabolism or contaminants from the environment? The concentrations were measured of the 24 most abundant VOCs in the alveolar breath of 12 normal volunteers and also in the air they inspired. The polarity of the mean alveolar gradient (concentration in breath minus concentration in inspired air) was positive in 15 VOCs and negative in nine. The mean alveolar gradient varied from strongly positive (for example, 2,3,3-trimethylpentane), consistent with a metabolite manufactured in the body, to strongly negative (for example, isoprene), consistent with ingestion of an air pollutant which was then catabolised in vivo or excreted via an extra-pulmonary pathway.

Alveolar gradient of pentane in normal human breath

Previous studies have raised the question of whether pentane is a normal constituent of human breath, since its concentrations in inspired room air and expired breath are often similar. Using a highly sensitive assay for volatile organic compounds, we studied 37 normal subjects in order to determine the alveolar gradient of pentane in their breath (i.e. concentration in alveolar breath minus concentration in the inspired air). The chemical identity of pentane was confirmed by mass spectroscopy. The alveolar gradient of pentane was zero +/- 0.175 nmol/l in 54.1% of subjects, and distributed in an approximately bell-shaped curve. Determination of the alveolar gradient divided the normal subjects into three groups: the "passive equilibrators" who did not appear to excrete pentane in the breath (the majority), "metabolizers" who actively catabolized inhaled pentane, and "manufacturers" who excreted more pentane than they inhaled.