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Faversani A, Favero C, Dioni L, Pesatori AC, Bollati V, Montoli M, Musso V, Terrasi A, Fusco N, Nosotti M, Vaira V, Palleschi A. An EBC/Plasma miRNA Signature Discriminates Lung Adenocarcinomas From Pleural Mesothelioma and Healthy Controls. Front Oncol 2021; 11:643280. [PMID: 34211838 PMCID: PMC8239300 DOI: 10.3389/fonc.2021.643280] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/27/2021] [Indexed: 12/27/2022] Open
Abstract
Background Despite significant improvement in screening programs for cancers of the respiratory district, especially in at-risk subjects, early disease detection is still a major issue. In this scenario, new molecular and non-invasive biomarkers are needed to improve early disease diagnosis. Methods We profiled the miRNome in exhaled breath condensate (EBC) and plasma samples from fourteen patients affected by lung AdCa, nine healthy subjects. miRNA signatures were then analyzed in another neoplasia of the respiratory district, i.e. pleural mesothelioma (n = 23) and subjects previously exposed to asbestos were used as controls for this cohort (n = 19). Selected miRNAs were analyzed in purified pulmonary neoplastic or normal epithelial and stromal cell subpopulation from AdCa patients. Finally, the plasmatic miRNA signature was analyzed in a publicly available cohort of NSCLC patients for data validation and in silico analysis was performed with predicted miRNA targets using the multiMiR tool and STRING database. Results miR-597-5p and miR-1260a are significantly over-expressed in EBC from lung AdCa and are associated with AdCa. Similarly, miR-1260a is also up-regulated in the plasma of AdCa patients together with miR-518f-3p and correlates with presence of lung cancer, whereas let-7f-5p is under-expressed. Analysis of these circulating miRNAs in pleural mesothelioma cases confirmed that up-regulation of miR-518f-3p, -597-5p and -1260a, is specific for lung AdCa. Lastly, quantification of the miRNAs in laser-assisted microdissected lung tissues revealed that miR-518f-3p, 597-5p and miR-1260a are predominantly expressed in tumor epithelial cells. Validation analysis confirmed miR-518f-3p as a possible circulating biomarker of NSCLC. In silico analysis of the potentially modulated biological processes by these three miRNAs, shows that tumor bioenergetics are the most affected pathways. Conclusions Overall, our data suggest a 3-miRNAs signature as a non-invasive and accurate biomarker of lung AdCa. This approach could supplement the current screening approaches for early lung cancer diagnosis.
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Affiliation(s)
- Alice Faversani
- Division of Pathology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Chiara Favero
- EPIGET Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Laura Dioni
- EPIGET Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Angela Cecilia Pesatori
- EPIGET Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Department of Preventive Medicine, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Bollati
- EPIGET Lab, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Matteo Montoli
- Division of Thoracic Surgery and Lung Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valeria Musso
- Division of Thoracic Surgery and Lung Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Terrasi
- Division of Molecular Biology, Biomedical Center, Faculty of Medicine, LMU Munich, Martinsried, Germany
| | - Nicola Fusco
- Division of Pathology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.,Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Mario Nosotti
- Division of Thoracic Surgery and Lung Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Valentina Vaira
- Division of Pathology, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alessandro Palleschi
- Division of Thoracic Surgery and Lung Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Koc A, Goksel T, Pelit L, Korba K, Dizdas TN, Baysal E, Uzun UC, Kaya OO, Ozyilmaz B, Kutbay YB, Ozdemir TR, Kirbiyik O, Erdogan KM, Guvenc MS, Kocal GC, Basbinar Y. cfDNA in exhaled breath condensate (EBC) and contamination by ambient air: toward volatile biopsies. J Breath Res 2019; 13:036006. [PMID: 30970343 DOI: 10.1088/1752-7163/ab17ff] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Exhaled breath is a source of volatile and nonvolatile biomarkers in the body that can be accessed non-invasively and used for monitoring. The collection of lung secretions by conventional methods such as bronchoalveolar lavage, induced sputum collection, and core biopsies is limited by the invasive nature of these methods. Non-invasive collection of exhaled breath condensate (EBC) provides fluid samples that are representative of airway lining fluids. Various volatile and nonvolatile biomarkers can be detected in volatile condensates, such as H2O2, nitric oxide, lipid mediators, cytokines, chemokines, DNA, and microRNAs. Studies have examined cell-free DNA (cfDNA) in plasma samples from non-small-cell lung cancer patients, offering to new insights and fostering development of the liquid biopsy. However, few studies have examined cfDNA in EBC samples. This study examined whether EBC is an appropriate source of cfDNA using housekeeping-gene-specific primer probes and quantitative real-time polymerase chain reaction in healthy subjects. Ambient (room) air is contaminated with DNA, so caution is needed. Preliminary studies indicated that volatile biopsies are becoming an important diagnostic tool in lung cancer.
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Affiliation(s)
- Altug Koc
- Department of Translational Oncology, Institute of Oncology, Dokuz Eylul University, Izmir, Turkey. Department of Medical Genetics, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey. Genetic Diagnosis Center, Izmir Tepecik Training and Research Hospital, Health Sciences University, Izmir, Turkey
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Temel MT, Demiryürek S, Temel L, Saracaloglu A, Eke N, Baysalman E, Mammadov A, Coskun ME, Demiryürek AT. Dynamic thiol/disulfide homeostasis in children with community-acquired pneumonia. Pediatr Int 2019; 61:252-257. [PMID: 30597683 DOI: 10.1111/ped.13773] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 12/09/2018] [Accepted: 12/28/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Alteration in thiol level under oxidative stress may contribute to community-acquired pneumonia (CAP). The goal of this study was to determine whether there are changes in thiol/disulfide homeostasis and nitric oxide (NO) in children with CAP. METHODS In total, 130 participants were involved in the study. Of these, 65 had been diagnosed with CAP on admission, and the remaining 65 were healthy individuals. Serum total thiol and native thiol were measured in each participant using a novel automated spectrophotometric method. The amount of dynamic disulfide bonds and related ratios were calculated from these values. Serum NO was measured on chemiluminescence assay. RESULTS Average native thiol, total thiol, and disulfide in the CAP group were significantly lower than in the healthy individuals (P < 0.0001, P < 0.0001, P = 0.0126, respectively). In addition, disulfide/native thiol (P = 0.0002), and disulfide/total thiol ratios (P = 0.0004) were significantly higher, whereas the native thiol/total thiol ratio (P = 0.0004) was lower in the CAP group. High serum NO was noted in the CAP group (P = 0.0003), but there was no marked correlation between thiol/disulfide and NO. CONCLUSION The changes in endogenous thiol levels under oxidative stress may be associated with the pathogenesis of CAP in pediatric patients.
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Affiliation(s)
| | - Seniz Demiryürek
- Department of Physiology, University of Gaziantep, Gaziantep, Turkey
| | - Levent Temel
- Pediatrics Clinic, Private Gaziantep Defa Life Hospital, Gaziantep, Turkey
| | - Ahmet Saracaloglu
- Department of Medical Pharmacology, University of Gaziantep, Gaziantep, Turkey
| | - Necmi Eke
- Faculty of Medicine, University of Gaziantep, Gaziantep, Turkey
| | - Elif Baysalman
- Department of Medical Pharmacology, University of Gaziantep, Gaziantep, Turkey
| | - Azad Mammadov
- Department of Medical Pharmacology, University of Gaziantep, Gaziantep, Turkey
| | - Mehmet E Coskun
- Department of Pediatrics, University of Gaziantep, Gaziantep, Turkey
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Hoyte FCL, Gross LM, Katial RK. Exhaled Nitric Oxide: An Update. Immunol Allergy Clin North Am 2018; 38:573-585. [PMID: 30342580 DOI: 10.1016/j.iac.2018.06.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Fractional concentration of exhaled nitric oxide (FENO) is a biomarker used to identify allergic airway inflammation. Because it is noninvasive and easy to obtain, its utility has been studied in the diagnosis and management of several respiratory diseases. Much of the research has been done in asthma, and many studies support the use of FENO in aiding diagnosing asthma, predicting steroid responsiveness, and preventing exacerbations by guiding medication dosage and assessing adherence.
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Affiliation(s)
- Flavia C L Hoyte
- Division of Allergy and Immunology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.
| | - Lara M Gross
- Division of Allergy and Immunology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA; Division of Allergy and Clinical Immunology, Department of Medicine, University of Colorado, 13001 E 17th Place, Aurora, CO 80045, USA
| | - Rohit K Katial
- Division of Allergy and Immunology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
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5
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Lu Z, Huang W, Wang L, Xu N, Ding Q, Cao C. Exhaled nitric oxide in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis 2018; 13:2695-2705. [PMID: 30214187 PMCID: PMC6124452 DOI: 10.2147/copd.s165780] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Fractional exhaled nitric oxide (FENO) is a useful and noninvasive biomarker for eosinophilic airway inflammation, particularly in asthma. However, its utility in chronic obstructive pulmonary disease (COPD) remains controversial. In this study, we performed a systematic review and meta-analysis to evaluate FENO levels in COPD. Methods A search of PubMed, Embase, Cochrane Library, and clinical trial registry was conducted from inception to January 2018. Studies were included if they reported FENO levels in patients with COPD and healthy controls. We then extracted relevant information and analyzed data. Standard mean difference (SMD) with 95% confidence interval (CI) was applied in this meta-analysis. Results A total of 2,073 studies were reviewed for eligibility, with 24 studies pooled for analysis. The FENO levels in patients with COPD were elevated mildly compared with healthy controls (SMD 1.28, 95% CI 0.60-1.96). A similar result was also observed in stable COPD, with an SMD of 1.21 (95% CI 0.47-1.96). On the other hand, we found no association between FENO levels and exacerbated COPD. Additionally, for patients with COPD, ex-smokers had higher levels of FENO than current smokers (SMD 2.05, 95% CI 1.13-2.97). Conclusion Our studies demonstrated a mild elevation of FENO in COPD, and the association between exacerbated COPD and FENO levels needs to be further explored. The potential mechanism is still unknown and conflicting.
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Affiliation(s)
- Zhiyu Lu
- Department of Respiratory Medicine, Ningbo First Hospital, Ningbo, People’s Republic of China, ,Ningbo University School of Medicine, Ningbo, People’s Republic of China
| | - Weina Huang
- Department of Respiratory Medicine, Ningbo First Hospital, Ningbo, People’s Republic of China,
| | - Linfeng Wang
- Department of Respiratory Medicine, Ningbo First Hospital, Ningbo, People’s Republic of China,
| | - Ning Xu
- Department of Respiratory Medicine, Ningbo First Hospital, Ningbo, People’s Republic of China,
| | - Qunli Ding
- Department of Respiratory Medicine, The Affiliated Hospital of Medical School of Ningbo University, Ningbo, People’s Republic of China, ,Qunli Ding, Department of Respiratory Medicine, The Affiliated Hospital of Medical School of Ningbo University, 247 Renmin Road, Ningbo, Zhejiang 315020, People’s Republic of China, Tel/fax +86 574 8703 5778, Email
| | - Chao Cao
- Department of Respiratory Medicine, Ningbo First Hospital, Ningbo, People’s Republic of China, ,Correspondence: Chao Cao, Department of Respiratory Medicine, Ningbo First Hospital, 59 Liuting Road, Ningbo, Zhejiang 315010, People’s Republic of China, Tel/fax +86 574 8708 9878, Email
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6
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Hayes SA, Haefliger S, Harris B, Pavlakis N, Clarke SJ, Molloy MP, Howell VM. Exhaled breath condensate for lung cancer protein analysis: a review of methods and biomarkers. J Breath Res 2016; 10:034001. [PMID: 27380020 DOI: 10.1088/1752-7155/10/3/034001] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Lung cancer is a leading cause of cancer-related deaths worldwide, and is considered one of the most aggressive human cancers, with a 5 year overall survival of 10-15%. Early diagnosis of lung cancer is ideal; however, it is still uncertain as to what technique will prove successful in the systematic screening of high-risk populations, with the strongest evidence currently supporting low dose computed tomography (LDCT). Analysis of exhaled breath condensate (EBC) has recently been proposed as an alternative low risk and non-invasive screening method to investigate early-stage neoplastic processes in the airways. However, there still remains a relative paucity of lung cancer research involving EBC, particularly in the measurement of lung proteins that are centrally linked to pathogenesis. Considering the ease and safety associated with EBC collection, and advances in the area of mass spectrometry based profiling, this technology has potential for use in screening for the early diagnosis of lung cancer. This review will examine proteomics as a method of detecting markers of neoplasia in patient EBC with a particular emphasis on LC, as well as discussing methodological challenges involving in proteomic analysis of EBC specimens.
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Affiliation(s)
- Sarah A Hayes
- Bill Walsh Translational Cancer Research Laboratory, Kolling Institute of Medical Research, Northern Sydney Local Health District, St. Leonards, New South Wales, Australia. Sydney Medical School Northern, University of Sydney, New South Wales, Australia
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7
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van Mastrigt E, de Jongste JC, Pijnenburg MW. The analysis of volatile organic compounds in exhaled breath and biomarkers in exhaled breath condensate in children - clinical tools or scientific toys? Clin Exp Allergy 2016; 45:1170-88. [PMID: 25394891 DOI: 10.1111/cea.12454] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Current monitoring strategies for respiratory diseases are mainly based on clinical features, lung function and imaging. As airway inflammation is the hallmark of many respiratory diseases in childhood, noninvasive methods to assess the presence and severity of airway inflammation might be helpful in both diagnosing and monitoring paediatric respiratory diseases. At present, the measurement of fractional exhaled nitric oxide is the only noninvasive method available to assess eosinophilic airway inflammation in clinical practice. We aimed to evaluate whether the analysis of volatile organic compounds (VOCs) in exhaled breath (EB) and biomarkers in exhaled breath condensate (EBC) is helpful in diagnosing and monitoring respiratory diseases in children. An extensive literature search was conducted in Medline, Embase and PubMed on the analysis and applications of VOCs in EB and EBC in children. We retrieved 1165 papers, of which nine contained original data on VOCs in EB and 84 on biomarkers in EBC. These were included in this review. We give an overview of the clinical applications in childhood and summarize the methodological issues. Several VOCs in EB and biomarkers in EBC have the potential to distinguish patients from healthy controls and to monitor treatment responses. Lack of standardization of collection methods and analysis techniques hampers the introduction in clinical practice. The measurement of metabolomic profiles may have important advantages over detecting single markers. There is a lack of longitudinal studies and external validation to reveal whether EB and EBC analysis have added value in the diagnostic process and follow-up of children with respiratory diseases. In conclusion, the use of VOCs in EB and biomarkers in EBC as markers of inflammatory airway diseases in children is still a research tool and not validated for clinical use.
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Affiliation(s)
- E van Mastrigt
- Department of Paediatric Respiratory Medicine, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - J C de Jongste
- Department of Paediatric Respiratory Medicine, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - M W Pijnenburg
- Department of Paediatric Respiratory Medicine, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
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Koen N, Du Preez I, Loots DT. Metabolomics and Personalized Medicine. ADVANCES IN PROTEIN CHEMISTRY AND STRUCTURAL BIOLOGY 2015; 102:53-78. [PMID: 26827602 DOI: 10.1016/bs.apcsb.2015.09.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Current clinical practice strongly relies on the prognosis, diagnosis, and treatment of diseases using methods determined and averaged for the specific diseased cohort/population. Although this approach complies positively with most patients, misdiagnosis, treatment failure, relapse, and adverse drug effects are common occurrences in many individuals, which subsequently hamper the control and eradication of a number of diseases. These incidences can be explained by individual variation in the genome, transcriptome, proteome, and metabolome of a patient. Various "omics" approaches have investigated the influence of these factors on a molecular level, with the intention of developing personalized approaches to disease diagnosis and treatment. Metabolomics, the newest addition to the "omics" domain and the closest to the observed phenotype, reflects changes occurring at all molecular levels, as well as influences resulting from other internal and external factors. By comparing the metabolite profiles of two or more disease phenotypes, metabolomics can be applied to identify biomarkers related to the perturbation being investigated. These biomarkers can, in turn, be used to develop personalized prognostic, diagnostic, and treatment approaches, and can also be applied to the monitoring of disease progression, treatment efficacy, predisposition to drug-related side effects, and potential relapse. In this review, we discuss the contributions that metabolomics has made, and can potentially still make, towards the field of personalized medicine.
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Affiliation(s)
- Nadia Koen
- School for Physical and Chemical Sciences, Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Ilse Du Preez
- School for Physical and Chemical Sciences, Human Metabolomics, North-West University, Potchefstroom, South Africa
| | - Du Toit Loots
- School for Physical and Chemical Sciences, Human Metabolomics, North-West University, Potchefstroom, South Africa.
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Malinovschi A, Ludviksdottir D, Tufvesson E, Rolla G, Bjermer L, Alving K, Diamant Z. Application of nitric oxide measurements in clinical conditions beyond asthma. Eur Clin Respir J 2015; 2:28517. [PMID: 26672962 PMCID: PMC4653314 DOI: 10.3402/ecrj.v2.28517] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 07/05/2015] [Indexed: 02/01/2023] Open
Abstract
Fractional exhaled nitric oxide (FeNO) is a convenient, non-invasive method for the assessment of active, mainly Th2-driven, airway inflammation, which is sensitive to treatment with standard anti-inflammatory therapy. Consequently, FeNO serves as a valued tool to aid diagnosis and monitoring in several asthma phenotypes. More recently, FeNO has been evaluated in several other respiratory, infectious, and/or immunological conditions. In this short review, we provide an overview of several clinical studies and discuss the status of potential applications of NO measurements in clinical conditions beyond asthma.
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Affiliation(s)
- Andrei Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden;
| | - Dora Ludviksdottir
- Department of Respiratory Medicine and Sleep, Landspitali University Hospital, Reykjavik, Iceland
| | - Ellen Tufvesson
- Department of Respiratory Medicine and Allergology, Institute for Clinical Science, Lund University, Lund, Sweden
| | - Giovanni Rolla
- Department of Medical Sciences, Allergology and Clinical Immunology, University of Torino, Torino, Italy
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, Institute for Clinical Science, Lund University, Lund, Sweden
| | - Kjell Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Zuzana Diamant
- Department of Respiratory Medicine and Allergology, Institute for Clinical Science, Lund University, Lund, Sweden.,Department of Clinical Pharmacy & Pharmacology, University Medical Centre Groningen, Groningen, The Netherlands.,Department of General Practice, University Medical Centre Groningen, Groningen, The Netherlands.,QPS Netherlands, Groningen, The Netherlands
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10
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Carraro S, Giordano G, Pirillo P, Maretti M, Reniero F, Cogo PE, Perilongo G, Stocchero M, Baraldi E. Airway metabolic anomalies in adolescents with bronchopulmonary dysplasia: new insights from the metabolomic approach. J Pediatr 2015; 166:234-9.e1. [PMID: 25294602 DOI: 10.1016/j.jpeds.2014.08.049] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 07/23/2014] [Accepted: 08/26/2014] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To assess a group of adolescents with bronchopulmonary dysplasia (BPD) from a biochemical-metabolic standpoint, applying the metabolomic approach to studying their exhaled breath condensate (EBC). STUDY DESIGN Twenty adolescents with BPD (mean age 14.8 years) and 15 healthy controls (mean age 15.2 years) were recruited for EBC collection, exhaled nitric oxide measurement, and spirometry. The EBC samples were analyzed using a metabolomic approach based on mass spectrometry. The obtained spectra were analyzed using multivariate statistical analysis tools. RESULTS A reliable Orthogonal Projections to Latent Structures-Discriminant Analysis model showed a clear discrimination between cases of BPD and healthy controls (R(2) = 0.95 and Q(2) = 0.92). The search for putative biomarkers identified an altered complex lipid profile in the adolescents with BPD. CONCLUSIONS The metabolomic analysis of EBC distinguishes cases of BPD from healthy individuals, suggesting that the lung of survivors of BPD is characterized by long-term metabolic abnormalities. The search for putative biomarkers indicated a possible role of an altered surfactant composition, which may persist far beyond infancy.
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Affiliation(s)
- Silvia Carraro
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | - Giuseppe Giordano
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | - Paola Pirillo
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | - Michela Maretti
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | - Fabiano Reniero
- European Commission, Joint Research Center, Institute for Health and Consumer Protection (IHCP), System Toxicology Unit (ST), Ispra (VA), Italy
| | - Paola E Cogo
- Anesthesia and Cardiac Intensive Care, Bambino Gesù Pediatric Hospital, Rome, Italy
| | - Giorgio Perilongo
- Women's and Children's Health Department, University of Padova, Padova, Italy
| | | | - Eugenio Baraldi
- Women's and Children's Health Department, University of Padova, Padova, Italy.
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11
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Warwick G, Thomas PS, Yates DH. Non-invasive biomarkers in exacerbations of obstructive lung disease. Respirology 2014; 18:874-84. [PMID: 23521049 DOI: 10.1111/resp.12089] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 12/07/2012] [Accepted: 01/14/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Current methods of diagnosing exacerbations of asthma and chronic obstructive pulmonary disease (COPD) shed little light on their aetiology or pathophysiology. This study aimed to define the inflammatory biomarker profile of subjects with obstructive lung disease and to compare these with control subjects also with respiratory infections, using exhaled breath condensate (EBC) and induced sputum biomarker analysis. METHODS EBC, induced sputum and C-reactive protein were collected from subjects with exacerbations of asthma (n = 28), exacerbations of COPD (n = 29) and otherwise healthy controls with symptoms of respiratory tract infection (n = 28). Subjects were tested again after recovery. EBC and induced sputum were analysed for protein, hydrogen peroxide, interferon gamma inducible protein-10 (IP-10), neopterin, interleukin (IL)-6, IL-8, leukotriene B4 and tumour necrosis factor (TNF)-α. Sputum cell counts and EBC pH were also analysed. RESULTS EBC pH was significantly lower in exacerbation compared with recovery (5.54 0.07 vs 6.04 ± 0.08; P < 0.001). The novel markers IP-10 and neopterin were significantly increased in induced sputum supernatant (pooled groups pre and post exacerbation: IP-10: 188.6 ± 102.1 vs 5.40 ± 1.28 pg/mL, P = 0.006; neopterin: 15.81 ± 2.50 vs 5.38 ± 0.45 nmol/L, P < 0.0001), as was TNF-α (137.8 ± 49.64 vs 71.56 ± 45.03 pg/mL, P = 0.018). Few other biomarkers proved significantly different in exacerbation, although C-reactive protein was raised. CONCLUSIONS Non-invasive biomarker assessment may provide useful information in exacerbation of obstructive lung diseases, particularly sputum IP-10 and neopterin and EBC pH.
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Affiliation(s)
- Geoffrey Warwick
- Department of Thoracic Medicine, St Vincent's Hospital, Sydney, Australia.
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12
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Carraro S, Giordano G, Piacentini G, Kantar A, Moser S, Cesca L, Berardi M, Di Gangi IM, Baraldi E. Asymmetric dimethylarginine in exhaled breath condensate and serum of children with asthma. Chest 2014; 144:405-410. [PMID: 23412513 DOI: 10.1378/chest.12-2379] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor and uncoupler of nitric oxide synthase. By promoting the formation of peroxynitrite, ADMA is believed to contribute to several aspects of asthma pathogenesis (ie, airway inflammation, oxidative stress, bronchial hyperresponsiveness, and collagen deposition). The aim of the present study was to compare this mediator in healthy children and children with asthma using the completely noninvasive exhaled breath condensate (EBC) technique. METHODS We recruited 77 children with asthma (5-16 years of age) and 65 healthy children (5-15 years of age) who underwent EBC collection and spirometry. Serum ADMA levels and fractional exhaled nitric oxide levels were measured on the same day in a subgroup of children with asthma. EBC was collected using the Turbo-Deccs (Medivac). ADMA levels were measured using the ultra-performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) technique. RESULTS ADMA could be detected in the EBC of 71 subjects with asthma and 64 healthy subjects. ADMA levels in the EBC of children with asthma were significantly higher than in the healthy control subjects (median, 0.12 [interquartile range, 0.05-0.3] vs 0.07 [0.05-0.12]; P = .017), whereas no difference emerged between the children with asthma who were or were not receiving inhaled steroid treatment. No correlation was found between serum and EBC ADMA levels (P > .5). CONCLUSIONS We measured ADMA in EBC by UPLC-MS/MS, a reference analytical technique. Higher ADMA levels were found in children with asthma, supporting a role for this mediator in asthma pathogenesis. This oxidative stress-related mediator also seems to be scarcely affected by steroid therapy. We speculate that ADMA might be a target for new therapeutic strategies designed to control oxidative stress in asthma.
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Affiliation(s)
- Silvia Carraro
- Women's and Children's Health Department, University of Padova, Padova
| | - Giuseppe Giordano
- Women's and Children's Health Department, University of Padova, Padova
| | | | - Ahmad Kantar
- Paediatric Asthma Centre, Misurina Pio XII Institute, Belluno, Italy
| | - Serena Moser
- Department of Pediatrics, University of Verona, Verona
| | - Laura Cesca
- Women's and Children's Health Department, University of Padova, Padova
| | | | - Iole M Di Gangi
- Women's and Children's Health Department, University of Padova, Padova
| | - Eugenio Baraldi
- Women's and Children's Health Department, University of Padova, Padova.
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Chiappini E, Venturini E, Galli L, Novelli V, de Martino M. Diagnostic features of community-acquired pneumonia in children: what's new? Acta Paediatr 2013; 102:17-24. [PMID: 24330269 DOI: 10.1111/apa.12502] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIM To critically summarise the available data on diagnosis of CAP in children, focusing on the newest findings and on the need for new studies. METHODS Eighty studies on the diagnosis of paediatric community-acquired pneumonia were scrutinised. RESULTS We found no significant associations between the signs or symptoms and aetiology of pneumonia and concluded that chest radiographs remain controversial and real-time polymerase chain reaction appears more sensitive than blood cultures. CONCLUSION Antibiotic overuse could make it difficult to differentiate viral and bacterial causes. Molecular methods provide promising tools for diagnosing infection by atypical bacteria, but are expensive and should be used selectively.
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Affiliation(s)
- Elena Chiappini
- Department of Health Sciences; University of Florence; Anna Meyer Children's University Hospital; Florence Italy
| | - Elisabetta Venturini
- Department of Health Sciences; University of Florence; Anna Meyer Children's University Hospital; Florence Italy
| | - Luisa Galli
- Department of Health Sciences; University of Florence; Anna Meyer Children's University Hospital; Florence Italy
| | - Vas Novelli
- Department of Infectious Diseases; Great Ormond Street Hospital for Children NHS Trust; London UK
| | - Maurizio de Martino
- Department of Health Sciences; University of Florence; Anna Meyer Children's University Hospital; Florence Italy
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Carraro S, Giordano G, Reniero F, Carpi D, Stocchero M, Sterk P, Baraldi E. Asthma severity in childhood and metabolomic profiling of breath condensate. Allergy 2013; 68:110-7. [PMID: 23157191 DOI: 10.1111/all.12063] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Asthma is a heterogeneous disease and its different phenotypes need to be better characterized from a biochemical-inflammatory standpoint. This study aimed to apply the metabolomic approach to exhaled breath condensate (breathomics) to discriminate different asthma phenotypes, with a particular focus on severe asthma in children. METHODS In this cross-sectional study, we recruited 42 asthmatic children (age, 8-17 years): 31 with nonsevere asthma (treated with inhaled steroids or not) and 11 with severe asthma. Fifteen healthy children were enrolled as controls. Children performed exhaled nitric oxide measurement, spirometry, exhaled breath condensate (EBC) collection. Condensate samples were analyzed using a metabolomic approach based on mass spectrometry. RESULTS A robust Bidirectional-Orthogonal Projections to Latent Structures-Discriminant Analysis (O2PLS-DA) model was found for discriminating both between severe asthma cases and healthy controls (R(2) = 0.93; Q(2) = 0.75) and between severe asthma and nonsevere asthma (R(2) = 0.84; Q(2) = 0.47). The metabolomic data analysis leads to a robust model also when the 3 groups of children were considered altogether (K = 0.80), indicating that each group is characterized by a specific metabolomic profile. Compounds related to retinoic acid, adenosine and vitamin D (Human Metabolome Database) were relevant for the discrimination between groups. CONCLUSION The metabolomic profiling of EBC could clearly distinguish different biochemical-metabolic profiles in asthmatic children and enabled the severe asthma phenotype to be fully discriminated. The breathomics approach may therefore be suitable for discriminating between different asthma metabolic phenotypes.
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Affiliation(s)
- S. Carraro
- Department of Women‘s and Children‘s Health; University of Padova; Padova; Italy
| | - G. Giordano
- Department of Women‘s and Children‘s Health; University of Padova; Padova; Italy
| | - F. Reniero
- European Commission, Joint Research Centre; Institute for Health and Consumer Protection (IHCP), System Toxicology Unit (ST); Ispra; Italy
| | - D. Carpi
- European Commission, Joint Research Centre; Institute for Health and Consumer Protection (IHCP), System Toxicology Unit (ST); Ispra; Italy
| | | | - P.J. Sterk
- Department of Respiratory Medicine, Academic Medical Centre; University of Amsterdam; Amsterdam; the Netherlands
| | - E. Baraldi
- Department of Women‘s and Children‘s Health; University of Padova; Padova; Italy
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15
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Manna A, Caffarelli C, Varini M, Dascola CP, Montella S, Maglione M, Sperlì F, Santamaria F. Clinical application of exhaled nitric oxide measurement in pediatric lung diseases. Ital J Pediatr 2012; 38:74. [PMID: 23273317 PMCID: PMC3545741 DOI: 10.1186/1824-7288-38-74] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/19/2012] [Indexed: 12/18/2022] Open
Abstract
Fractional exhaled nitric oxide (FeNO) is a non invasive method for assessing the inflammatory status of children with airway disease. Different ways to measure FeNO levels are currently available. The possibility of measuring FeNO levels in an office setting even in young children, and the commercial availability of portable devices, support the routine use of FeNO determination in the daily pediatric practice. Although many confounding factors may affect its measurement, FeNO is now widely used in the management of children with asthma, and seems to provide significantly higher diagnostic accuracy than lung function or bronchial challenge tests. The role of FeNO in airway infection (e.g. viral bronchiolitis and common acquired pneumonia), in bronchiectasis, or in cases with diffuse lung disease is less clear. This review focuses on the most recent advances and the current clinical applications of FeNO measurement in pediatric lung disease.
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Affiliation(s)
- Angelo Manna
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Carlo Caffarelli
- Department of Pediatrics, University Hospital of Parma, Parma, Italy
| | - Margherita Varini
- Department of Pediatrics, University Hospital of Parma, Parma, Italy
| | | | - Silvia Montella
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Marco Maglione
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Francesco Sperlì
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
| | - Francesca Santamaria
- Department of Pediatrics, Federico II University, Via Sergio Pansini, 5 80131, Naples, Italy
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Abstract
Nitric oxide (NO) is now considered an important biomarker for respiratory disease. Studies have confirmed that the fractional concentration of exhaled nitric oxide (FENO) is elevated in the airways of patients who have asthma in comparison with controls. The level of FENO correlates well with the presence and level of inflammation, and decreases with glucocorticoid treatment. NO has potential to be used not only as a diagnostic aid but also as a management tool for assessing severity, monitoring response to therapy, and gaining control of asthma symptoms. This article reviews the biology of NO and its role in respiratory disease.
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Affiliation(s)
- Lora Stewart
- Allergy & Asthma Care and Prevention Center, Lone Tree, CO 80204, USA
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Hammitt LL, Murdoch DR, Scott JAG, Driscoll A, Karron RA, Levine OS, O'Brien KL. Specimen collection for the diagnosis of pediatric pneumonia. Clin Infect Dis 2012; 54 Suppl 2:S132-9. [PMID: 22403227 PMCID: PMC3693496 DOI: 10.1093/cid/cir1068] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Diagnosing the etiologic agent of pneumonia has an essential role in ensuring the most appropriate and effective therapy for individual patients and is critical to guiding the development of treatment and prevention strategies. However, establishing the etiology of pneumonia remains challenging because of the relative inaccessibility of the infected tissue and the difficulty in obtaining samples without contamination by upper respiratory tract secretions. Here, we review the published and unpublished literature on various specimens available for the diagnosis of pediatric pneumonia. We discuss the advantages and limitations of each specimen, and discuss the rationale for the specimens to be collected for the Pneumonia Etiology Research for Child Health study.
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Affiliation(s)
- Laura L Hammitt
- International Vaccine Access Center, Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland 21205, USA.
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Abstract
The collection and analysis of exhaled breath condensate (EBC) may be useful for the management of patients with chronic respiratory disease at all ages. It is a promising technique due to its apparent simplicity and non-invasiveness. EBC does not disturb an ongoing respiratory inflammation. However, the methodology remains controversial, as it is not yet standardized. The current diversity of the methods used to collect and preserve EBC, the analytical pitfalls and the high degree of within-subject variability are the main issues that hamper further development into a clinical useful technique. In order to facilitate the process of standardization, a simplified schematic approach is proposed. An update of available data identified open issues on EBC methodology. These issues were then classified into three separate conditions related to their influence before, during or after the condensation process: (1) pre-condenser conditions related to subject and/or environment; (2) condenser conditions related to condenser equipment; and (3) post-condenser conditions related to preservation and/or analysis. This simplified methodological approach highlights the potential influence of the many techniques used before, during and after condensation of exhaled breath. It may also serve as a methodological checklist for a more systematical approach of EBC research and development.
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Affiliation(s)
- Philippe Rosias
- Department of Paediatrics, Orbis Medical Center, Sittard, The Netherlands.
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Abstract
OBJECTIVE Aspiration of oropharyngeal or gastric contents into the lower respiratory tract is a common event in critically ill patients and can lead to pneumonia or pneumonitis. Aspiration pneumonia is the leading cause of pneumonia in the intensive care unit and is one of the leading risk factors for acute lung injury and acute respiratory distress syndromes. Despite its frequency, it remains largely a disease of exclusion characterized by ill-defined infiltrates on the chest radiograph and hypoxia. An accurate ability to diagnose aspiration is paramount because different modalities of therapy, if applied early and selectively, could change the course of the disease. This article reviews definitions, diagnosis, epidemiology, pathophysiology, including animal models of aspiration-induced lung injury, and evidence-based clinical management. Additionally, a review of current and potential biomarkers that have been tested clinically in humans is provided. DATA SOURCES Data were obtained from a PubMed search of the medical literature. PubMed "related articles" search strategies were used. SUMMARY AND CONCLUSIONS Aspiration in the intensive care unit is a clinically relevant problem requiring expertise and awareness. A definitive diagnosis of aspiration pneumonitis or pneumonia is challenging to make. Advances in specific biomarker profiles and prediction models may enhance the diagnosis and prognosis of clinical aspiration syndromes. Evidence-based management is supportive, including mechanical ventilation, bronchoscopy for particulate aspiration, consideration of empiric antibiotics for pneumonia treatment, and lower respiratory tract sampling to define pathogenic bacteria that are causative.
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Barreto M, Bonafoni S, Barberi S, La Penna F, Zambardi R, Martella S, Villa MP. Does a parent-reported history of pneumonia increase the likelihood of respiratory symptoms needing therapy in asthmatic children and adolescents? J Asthma 2011; 48:714-20. [PMID: 21793780 DOI: 10.3109/02770903.2011.601779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Asthmatic children and adolescents attending outpatient clinics often have a history of pneumonia. Whether respiratory symptoms, lung function, and airway inflammation differ in asthmatic patients with and without a history of pneumonia remains controversial. AIMS To compare clinical, lung functional, and inflammatory variables in asthmatic outpatients with and without a history of pneumonia. Methods. In 190 asthmatic outpatients, aged 6-18 years, we assessed respiratory symptoms, lung function (flows, volumes, and pulmonary diffusion capacity, DLCO/VA), and atopic-airway inflammation as measured by the fractional concentration of exhaled nitric oxide (FE(NO)). A previous medical and radiological diagnosis of pneumonia was defined as "recurrent pneumonia" if subjects had at least three pneumonia episodes or two episodes within a year. RESULTS Of the 190 outpatients studied, 38 (20%) had a history of pneumonia. These patients had more frequent upper-respiratory symptoms, nighttime awakenings in the past 4 weeks, daily use of inhaled corticosteroids, and lower FE(NO) than the 152 asthmatic children without previous pneumonia (FE(NO): 20.6 ppb, 95% CI: 15.2-28.0 vs. 31.1 ppb, 95% CI: 27.0-35.8; p < .05). Of the 38 patients with previous pneumonia, 14 had recurrent pneumonia. Despite comparable lung volumes and flows, they also had lower DLCO/VA than asthmatic children with no recurrent pneumonia and asthmatic children without previous pneumonia (DLCO/VA%: 91.2 ± 11.3 vs. 108.5 ± 14.7 vs. 97.9 ± 18.6, p < .05). CONCLUSION Respiratory assessment in asthmatic children and adolescents with a history of pneumonia, especially recurrent pneumonia, often discloses symptoms needing corticosteroid therapy, and despite normal lung volumes and flows, mild reductions in the variables reflecting gas diffusion and atopic-airway inflammation (DLCO/VA and FE(NO)). Whether these respiratory abnormalities persist in adulthood remains an open question.
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Affiliation(s)
- Mario Barreto
- NESMOS Department, Faculty of Medicine and Psychology, Pediatric Unit Sant'Andrea Hospital, University La Sapienza, Rome, Italy.
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Abstract
OBJECTIVE To evaluate the safety and feasibility of exhaled breath condensate (EBC) collection in children recovering from status asthmaticus (SA) in a pediatric intensive care unit (PICU); and to investigate whether 8-isoprostane (8-Iso) could be detected in the EBC of these children and to compare its concentration with that in the EBC collected from healthy children. DESIGN Prospective study. SETTING Multidisciplinary PICU in a teaching hospital. PATIENTS Sixteen consecutive patients (7-18 yrs of age) with SA and 16 age- and sex-matched controls. INTERVENTIONS The Wood clinical asthma score and the pulmonary index were used to assess the clinical severity of patients with SA upon admission to the PICU. EBC samples were collected within 24 hrs of admission to the PICU and were analyzed for the concentration of 8-Iso. MEASUREMENTS AND MAIN RESULTS Data are presented as mean ± sd values. There were no differences in age (12 ± 3.3 yrs vs.12 ± 2 yrs, p > .05) or sex (n = 10 males and n = 6 females in each group), between SA patients and controls. All patients with SA and the controls completed the EBC collection without complications. There was no statistically significant difference in the pulmonary index (3.2 ± 2.7 vs. 3.1 ± 2.8, p 0.9) post collection of EBC compared with the baseline values. There was a statistically significant correlation between Wood score and pulmonary index at the time of admission to the PICU in children with SA (r = .7, p < .01). The concentration of 8-Iso was significantly higher in the EBC of children with SA compared with controls (14.3 ± 1.8 pg/mL vs. 5.2 ± 0.7 pg/mL, p < .001). The correlation between the concentration 8-Iso and either the pulmonary index or Wood score at the time admission to the PICU was not statistically significant. CONCLUSIONS EBC collection is well tolerated by children aged 7-18 yrs who are recovering from SA in a PICU. 8-Iso is elevated in the EBC from children with SA and may provide insight into the biochemical changes of oxidative stress in children in this clinical setting.
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Current world literature. Curr Opin Allergy Clin Immunol 2010; 10:87-92. [PMID: 20026987 DOI: 10.1097/aci.0b013e3283355458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Jaoude PA, Knight PR, Ohtake P, El-Solh AA. Biomarkers in the diagnosis of aspiration syndromes. Expert Rev Mol Diagn 2010; 10:309-19. [PMID: 20370588 PMCID: PMC2882092 DOI: 10.1586/erm.10.7] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Recognizing and managing the different types of aspiration events remain a challenging task due to the lack of distinguishing clinical or laboratory characteristics. Numerous biomarkers in serum, sputum and bronchoalveolar lavage have been studied, and their role in the recognition of aspiration remains controversial at this time. Recent animal investigations using an array of biomarkers based on distinct pathogenic features of each aspiration event have produced promising results; however, they have not been validated in humans. Newer markers are being introduced as diagnostic and prognostic tools in conditions such as community-acquired pneumonia and sepsis, but they have not been examined in aspiration. The present review summarizes the different biomarkers that have been studied in aspiration and those who might have a potential clinical use in the future.
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Affiliation(s)
- Philippe Abou Jaoude
- The Veterans Affairs Western New York, Healthcare System, Buffalo, NY, USA and Western New York Respiratory Research Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NY, USA
| | - Paul R Knight
- The Veterans Affairs Western New York, Healthcare System, Buffalo, NY, USA and Department of Anesthesiology, State University of New York at Buffalo School of Medicine and Biomedical Sciences and School of Public Health and Health Professions, NY, USA
| | - Patricia Ohtake
- Department of Rehabilitation Science, State University of New York at Buffalo School of Medicine and Biomedical Sciences and School of Public Health and Health Professions, NY, USA
| | - Ali A El-Solh
- Medical Research, Bldg 20 (151) VISN02, VA Western New York Healthcare System, 3495 Bailey Avenue, Buffalo, NY, 14215-1199, USA and Western New York Respiratory Research Center, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NY, USA and Department of Social and Preventive Medicine State University of New York at Buffalo School of Medicine and Biomedical Sciences and School of Public Health and Health Professions, NY, USA, Tel.: +1 716 862 7366, Fax: +1 425 675 4502
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