A mathematical model for breath gas analysis of volatile organic compounds with special emphasis on acetone

Determination of the two-compartment model parameters of exhaled HCN by fast negative photoionization mass spectrometry

Breath exhaled hydrogen cyanide (HCN) has been identified to be associated with several respiratory diseases. Accurately distinguishing the concentration and release rate of different HCN sources is of great value in clinical research. However, there are still significant challenges due to the high adsorption and low concentration characteristics of exhaled HCN. In this study, a two-compartment kinetic model method based on negative photoionization mass spectrometry was developed to simultaneously determine the kinetic parameters including concentrations and release rates in the airways and alveoli. The influences of the sampling line diameter, length, and temperature on the response time of the sampling system were studied and optimized, achieving a response time of 0.2 s. The negative influence of oral cavity-released HCN was reduced by employing a strategy based on anatomical lung volume calculation. The calibration for HCN in the dynamic range of 0.5-100 ppbv and limit of detection (LOD) at 0.3 ppbv were achieved. Subsequently, the experiments of smoking, short-term passive smoking, and intake of bitter almonds were performed to examine the influences of endogenous and exogenous factors on the dynamic parameters of the model method. The results indicate that compared with steady-state concentration measurements, the kinetic parameters obtained using this model method can accurately and significantly reflect the changes in different HCN sources, highlighting its potential for HCN-related disease research.

Diabetes noninvasive diagnostics and monitoring through volatile biomarkers analysis in the exhaled breath using optical absorption spectroscopy

The review is aimed on the analysis the abilities of noninvasive diagnostics and monitoring of diabetes mellitus (DM) and DM-associated complications through volatile molecular biomarkers detection in the exhaled breath. The specific biochemical reactions in the body of DM patients and their associations with volatile molecular biomarkers in the breath are considered. The applications of optical spectroscopy methods, including UV, IR, and terahertz spectroscopy for DM-associated volatile molecular biomarkers measurements, are described. The applications of similar technique combined with machine learning methods in DM diagnostics using the profile of DM-associated volatile molecular biomarkers in exhaled air or "pattern-recognition" approach are discussed.

Research progress of electronic nose technology in exhaled breath disease analysis

Exhaled breath analysis has attracted considerable attention as a noninvasive and portable health diagnosis method due to numerous advantages, such as convenience, safety, simplicity, and avoidance of discomfort. Based on many studies, exhaled breath analysis is a promising medical detection technology capable of diagnosing different diseases by analyzing the concentration, type and other characteristics of specific gases. In the existing gas analysis technology, the electronic nose (eNose) analysis method has great advantages of high sensitivity, rapid response, real-time monitoring, ease of use and portability. Herein, this review is intended to provide an overview of the application of human exhaled breath components in disease diagnosis, existing breath testing technologies and the development and research status of electronic nose technology. In the electronic nose technology section, the three aspects of sensors, algorithms and existing systems are summarized in detail. Moreover, the related challenges and limitations involved in the abovementioned technologies are also discussed. Finally, the conclusion and perspective of eNose technology are presented.

Dynamic Modeling of Carbon Dioxide Transport through the Skin Using a Capnometry Wristband

The development of a capnometry wristband is of great interest for monitoring patients at home. We consider a new architecture in which a non-dispersive infrared (NDIR) optical measurement is located close to the skin surface and is combined with an open chamber principle with a continuous circulation of air flow in the collection cell. We propose a model for the temporal dynamics of the carbon dioxide exchange between the blood and the gas channel inside the device. The transport of carbon dioxide is modeled by convection-diffusion equations. We consider four compartments: blood, skin, the measurement cell and the collection cell. We introduce the state-space equations and the associated transition matrix associated with a Markovian model. We define an augmented system by combining a first-order autoregressive model describing the supply of carbon dioxide concentration in the blood compartment and its inertial resistance to change. We propose to use a Kalman filter to estimate the carbon dioxide concentration in the blood vessels recursively over time and thus monitor arterial carbon dioxide blood pressure in real time. Four performance factors with respect to the dynamic quantification of the CO₂ blood concentration are considered, and a simulation is carried out based on data from a previous clinical study. These demonstrate the feasibility of such a technological concept.

Smelling the Disease: Diagnostic Potential of Breath Analysis

Breath analysis is a relatively recent field of research with much promise in scientific and clinical studies. Breath contains endogenously produced volatile organic components (VOCs) resulting from metabolites of ingested precursors, gut and air-passage bacteria, environmental contacts, etc. Numerous recent studies have suggested changes in breath composition during the course of many diseases, and breath analysis may lead to the diagnosis of such diseases. Therefore, it is important to identify the disease-specific variations in the concentration of breath to diagnose the diseases. In this review, we explore methods that are used to detect VOCs in laboratory settings, VOC constituents in exhaled air and other body fluids (e.g., sweat, saliva, skin, urine, blood, fecal matter, vaginal secretions, etc.), VOC identification in various diseases, and recently developed electronic (E)-nose-based sensors to detect VOCs. Identifying such VOCs and applying them as disease-specific biomarkers to obtain accurate, reproducible, and fast disease diagnosis could serve as an alternative to traditional invasive diagnosis methods. However, the success of VOC-based identification of diseases is limited to laboratory settings. Large-scale clinical data are warranted for establishing the robustness of disease diagnosis. Also, to identify specific VOCs associated with illness states, extensive clinical trials must be performed using both analytical instruments and electronic noses equipped with stable and precise sensors.

Millimeter-wave gas spectroscopy for breath analysis of COPD patients in comparison to GC-MS

The analysis of human breath is a very active area of research, driven by the vision of a fast, easy, and non-invasive tool for medical diagnoses at the point of care. Millimeter-wave gas spectroscopy (MMWGS) is a novel, well-suited technique for this application as it provides high sensitivity, specificity and selectivity. Most of all, it offers the perspective of compact low-cost systems to be used in doctors' offices or hospitals. In this work, we demonstrate the analysis of breath samples acquired in a medical environment using MMWGS and evaluate validity, reliability, as well as limitations and perspectives of the method. To this end, we investigated 28 duplicate samples from chronic obstructive lung disease patients and compared the results to gas chromatography-mass spectrometry (GC-MS). The quantification of the data was conducted using a calibration-free fit model, which describes the data precisely and delivers absolute quantities. For ethanol, acetone, and acetonitrile, the results agree well with the GC-MS measurements and are as reliable as GC-MS. The duplicate samples deviate from the mean values by only 6% to 18%. Detection limits of MMWGS depend strongly on the molecular species. For example, acetonitrile can be traced down to 1.8 × 10^-12mol by the MMWGS system, which is comparable to the GC-MS system. We observed correlations of abundances between formaldehyde and acetaldehyde as well as between acetonitrile and acetaldehyde, which demonstrates the potential of MMWGS for breath research.

Modelling of Breath and Various Blood Volatilomic Profiles—Implications for Breath Volatile Analysis

Researchers looking for biomarkers from different sources, such as breath, urine, or blood, frequently search for specific patterns of volatile organic compounds (VOCs), often using pattern recognition or machine learning techniques. However, they are not generally aware that these patterns change depending on the source they use. Therefore, we have created a simple model to demonstrate that the distribution patterns of VOCs in fat, mixed venous blood, alveolar air, and end-tidal breath are different. Our approach follows well-established models for the description of dynamic real-time breath concentration profiles. We start with a uniform distribution of end-tidal concentrations of selected VOCs and calculate the corresponding target concentrations. For this, we only need partition coefficients, mass balance, and the assumption of an equilibrium state, which avoids the need to know the volatiles’ metabolic rates and production rates within the different compartments.

Breath acetone concentration: too heterogeneous to constitute a diagnosis or prognosis biomarker in heart failure? A systematic review and meta-analysis

Introduction. Exhaled breath acetone (ExA) has been investigated as a biomarker for heart failure (HF). Yet, barriers to its use in the clinical field have not been identified. The aim of this systematic review and meta-analysis was to assess the ExA heterogeneity and factors of variability in healthy controls (HC), to identify its relations with HF diagnosis and prognostic factors and to assess its diagnosis and prognosis accuracy in HF patients.Methods. A systematic search was conducted in PUBMED and Web of Science database. All studies with HC and HF patients with a measured ExA were included and studies providing ExA's diagnosis and prognosis accuracy were identified.Results. Out of 971 identified studies, 18 studies involving 833 HC and 1009 HF patients were included in the meta-analysis. In HC, ExA showed an important heterogeneity (I²= 99%). Variability factors were fasting state, sampling type and analytical method. The mean ExA was 1.89 times higher in HF patients vs. HC (782 [531-1032] vs. 413 [347-478] ppbv;p< 0.001). One study showed excellent diagnosis accuracy, and one showed a good prognosis value. ExA correlated with New York Heart Association (NYHA) dyspnea (p< 0.001) and plasma brain natriuretic peptide (p< 0.001). Studies showed a poor definition and reporting of included subjects.Discussion. Despite the between-study heterogeneity in HC, the evidence of an excellent diagnosis and prognosis value of ExA in HF from single studies can be extended to clinical populations worldwide. Factors of variability (ExA procedure and breath sampling) could further improve the diagnosis and prognosis values of this biomarker in HF patients.

Breath volatile organic compound analysis: an emerging method for gastric cancer detection

Gastric cancer is a common malignancy, being the fifth most frequently diagnosed cancer and the fourth leading cause of cancer-related deaths worldwide. Diagnosis of gastric cancer at the early stage is critical to effectively improve the survival rate. However, a substantial proportion of patients with gastric cancer in the early stages lack specific symptoms or are asymptomatic. Moreover, the imaging techniques currently used for gastric cancer screening, such as computed tomography and barium examination, are usually radioactive and have low sensitivity and specificity. Even though endoscopy has high accuracy for gastric cancer screening, its application is limited by the invasiveness of the technique. Breath analysis is an economic, effective, easy to perform, non-invasive detection method, and has no undesirable side effects on subjects. Extensive worldwide research has been conducted on breath volatile organic compounds (VOCs), which reveals its prospect as a potential method for gastric cancer detection. Many interesting results have been obtained and innovative methods have been introduced in this subject; hence, an extensive review would be beneficial. By providing a comprehensive list of breath VOCs identified by gastric cancer would promote further research in this field. This review summarizes the commonly used technologies for exhaled breath analysis, focusing on the application of analytical instruments in the detection of breath VOCs in gastric cancers, and the alterations in the profile of breath biomarkers in gastric cancer patients are discussed as well.

Volatile Organic Compounds in Human Exhaled Breath to Diagnose Gastrointestinal Cancer: A Meta-Analysis

Introduction

Human exhaled volatile organic compounds (VOCs) are being extensively studied for the purposes of noninvasive cancer diagnoses. This article was primarily to assess the feasibility of utilizing exhaled VOCs analysis for gastrointestinal cancer (GIC) diagnosis.

Methods

PRISMA-based system searches were conducted for related studies of exhaled VOCs in GIC diagnosis based on predetermined criteria. Relevant articles on colorectal cancer and gastroesophageal cancer were summarized, and meta analysis was performed on articles providing sensitivity and specificity data.

Results

From 2,227 articles, 14 were found to meet inclusion criteria, six of which were on colorectal cancer (CRC) and eight on Gastroesophageal cancer(GEC). Five articles could provide specific data of sensitivity and specificity in GEC, which were used for meta-analysis. The pooled sensitivity, specificity, diagnostic odds ratio (DOR), and area under the curve (AUC) were calculated based on the combination of these data, and were 85.0% [95% confidence interval (CI): 79.0%-90.0%], 89.0% (95%CI: 86.0%-91.0%), 41.30 (21.56-79.10), and 0.93, respectively.

Conclusion

VOCs can distinguish gastrointestinal cancers from other gastrointestinal diseases, opening up a new avenue for the diagnosis and identification of gastrointestinal cancers, and the analysis of VOCs in exhaled breath has potential clinical application in screening. VOCs are promising tumor biomarkers for GIC diagnosis. Furthermore, limitations like the heterogeneity of diagnostic VOCs between studies should be minded.

Assessing the feasibility and acceptability of online measurements of exhaled volatile organic compounds (VOCs) in children with preschool wheeze: a pilot study

BACKGROUND

Investigating airway inflammation and pathology in wheezy preschool children is both technically and ethically challenging. Identifying and validating non-invasive tests would be a huge clinical advance. Real-time analysis of exhaled volatile organic compounds (VOCs) in adults is established, however, the feasibility of this non-invasive method in young children remains undetermined.

AIM

To determine the feasibility and acceptability of obtaining breath samples from preschool children by means of real-time mass spectrometry analysis of exhaled VOCs.

METHODS

Breath samples from preschool children were collected and analysed in real time by proton transfer reaction-time of flight-mass spectrometry (PTR-TOF-MS) capturing unique breath profiles. Acetone (mass channel m/z 59) was used as a reference profile to investigate the breath cycle in more detail. Dynamic time warping (DTW) was used to compare VOC profiles from adult breath to those we obtained in preschool children.

RESULTS

16 children were recruited in the study, of which eight had acute doctor-diagnosed wheeze (mean (range) age 3.2 (1.9-4.5) years) and eight had no history of wheezing (age 3.3 (2.2-4.1) years). Fully analysable samples were obtained in 11 (68%). DTW was used to ascertain the distance between the time series of mass channel m/z 59 (acetone) and the other 193 channels. Commonality of 12 channels (15, 31, 33, 41, 43, 51, 53, 55, 57, 60, 63 and 77) was established between adult and preschool child samples despite differences in the breathing patterns.

CONCLUSION

Real-time measurement of exhaled VOCs by means of PTR-MS is feasible and acceptable in preschool children. Commonality in VOC profiles was found between adult and preschool children.

Breath isoprene excretion during rest and low-intensity cycling exercise is associated with skeletal muscle mass in healthy human subjects

The physiological roles of isoprene, which is one of the many endogenous volatile organic compounds contained in exhaled breath, are not well understood. In recent years, exhaled isoprene has been associated with the skeletal muscle. Some studies have suggested that the skeletal muscle produces and/or stores some of the isoprene. However, the evidence supporting this association remains sparse and inconclusive. Furthermore, aging may affect breath isoprene response because of changes in the skeletal muscle quantity and quality. Therefore, we investigated the association between the breath isoprene excretion ([Formula: see text]) and skeletal muscle mass in young (n = 7) and old (n = 7) adults. The participants performed an 18 min cycling exercise after a 3 min rest. The workload corresponded to an intensity of 30% of the heart rate reserve, as calculated by the Karvonen formula. The exhaled breath of each participant was collected during the exercise test. We calculated [Formula: see text] from the product minute ventilation and isoprene concentration and, then, investigated the relationships between [Formula: see text] and muscle mass, which was measured by multi-frequency bioelectrical impedance analysis. Importantly, muscle mass persisted as a significant determinant that explained the variance in [Formula: see text] at rest even after adjusting for age. Furthermore, the muscle mass was a significant determinative factor for [Formula: see text] response during exercise, regardless of age. These data indicated that skeletal muscle mass could be one of the determinative factors for [Formula: see text] during rest and response to exercise. Thus, we suggest that the skeletal muscle may play an important role in generating and/or storing some of the endogenous isoprene. This new knowledge will help to better understand the physiological functions of isoprene in humans (Approval No. 20190079).

Determination of peppermint compounds in breath by needle trap micro-extraction coupled with gas chromatography-tandem mass spectrometry

Breath analysis is an alternative approach for disease diagnosis and for monitoring therapy. The lack of standardized procedures for collecting and analysing breath samples currently limits its use in clinical practice. In order to overcome this limitation, the "Peppermint Consortium" was established within the breath community to carry out breath wash-out experiments and define reference values for a panel of compounds contained in the peppermint oil capsule. Here, we present a needle trap micro-extraction technique coupled with gas chromatography and tandem mass spectrometry for a rapid and accurate determination of alpha-pinene, beta-pinene, limonene, eucalyptol, menthofuran, menthone, menthol and menthyl acetate in mixed breath samples. Detection limits between 1 and 20 pptv were observed when 25 mL of a humidified standard gas mixture were loaded into a needle trap device at a flow rate of 10 mL/min. Inter- and intra-day precisions were lower than 15%, thus confirming the reliability of the assay. Our procedure was used to analyse breath samples taken from a nominally healthy volunteer who were invited to swallow a 200 mg capsule of peppermint oil. Six samples were collected at various times within six hours of ingestion. Analyte concentrations were not affected by the sampling mode (i.e. mixed vs. end-tidal fraction), whereas respiratory rate and exhalation flow rate values slightly influenced the concentration of the target compounds in breath samples.

Breath acetone change during aerobic exercise is moderated by cardiorespiratory fitness

Exhaled breath acetone (BrAce) was investigated during and after submaximal aerobic exercise as a volatile biomarker for metabolic responsiveness in high and lower-fit individuals in a prospective cohort pilot-study. Twenty healthy adults (19-39 years) with different levels of cardiorespiratory fitness (VO_2peak), determined by spiroergometry, were recruited. BrAce was repeatedly measured by proton-transfer-reaction time-of-flight mass spectrometry (PTR-TOF-MS) during 40-55 min submaximal cycling exercise and a post-exercise period of 180 min. Activity of ketone and fat metabolism during and after exercise were assessed by indirect calorimetric calculation of fat oxidation rate and by measurement of venous β-hydroxybutyrate (βHB). Maximum BrAce ratios were significantly higher during exercise in the high-fit individuals compared to the lower-fit group (t-test; p= 0.03). Multivariate regression showed 0.4% (95%-CI = -0.2%-0.9%, p= 0.155) higher BrAce change during exercise for every ml kg^-1 min^-1 higher VO_2peak. Differences of BrAce ratios during exercise were similar to fat oxidation rate changes, but without association to respiratory minute volume. Furthermore, the high-fit group showed higher maximum BrAce increase rates (46% h^-1) in the late post-exercise phase compared to the lower-fit group (29% h^-1). As a result, high-fit young, healthy individuals have a higher increase in BrAce concentrations related to submaximal exercise than lower-fit subjects, indicating a stronger exercise-related activation of fat metabolism.

Spatial mapping of VOC exhalation by means of bronchoscopic sampling

Breath analysis holds promise for non-invasive in vivo monitoring of disease related processes. However, physiological parameters may considerably affect profiles of exhaled volatile organic substances (VOCs). Volatile substances can be released via alveoli, bronchial mucosa or from the upper airways. The aim of this study was the systematic investigation of the influence of different sampling sites in the respiratory tract on VOC concentration profiles by means of a novel experimental setup. After ethical approval, breath samples were collected from 25 patients undergoing bronchoscopy for endobronchial ultrasound or bronchoscopic lung volume reduction from different sites in the airways. All patients had total intravenous anaesthesia under pressure-controlled ventilation. If necessary, respiratory parameters were adjusted to keep P_ETCO₂ = 35-45 mm Hg. 30 ml gas were withdrawn at six sampling sites by means of gastight glass syringes: S1 = Room air, S2 = Inspiration, S3 = Endotracheal tube, S4 = Trachea, S5 = Right B6 segment, S6 = Left B6 segment (S4-S6 through the bronchoscope channel). 10 ml were used for VOC analysis, 20 ml for PCO₂ determination. Samples were preconcentrated by solid-phase micro-extraction (SPME) and analysed by gas chromatography-mass spectrometry (GC-MS). PCO₂ was determined in a conventional blood gas analyser. Statistically significant differences in substance concentrations for acetone, isoprene, 2-methyl-pentane and n-hexane could be observed between different sampling sites. Increasing substance concentrations were determined for acetone (15.3%), 2-methyl-pentane (11.4%) and n-hexane (19.3%) when passing from distal to proximal sampling sites. In contrast, isoprene concentrations decreased by 9.9% from proximal to more distal sampling sites. Blank bronchoscope measurements did not show any contaminations. Increased substance concentrations in the proximal respiratory tract may be explained through substance excretion from bronchial mucosa while decreased concentrations could result from absorption or reaction processes. Spatial mapping of VOC profiles can provide novel insights into substance specific exhalation kinetics and mechanisms.

Inhalation of molecular hydrogen increases breath acetone excretion during submaximal exercise: a randomized, single-blinded, placebo-controlled study

Aerobic exercise is widely accepted as a beneficial option for reducing fat in humans. Recently, it has been suggested that molecular hydrogen (H₂) augments mitochondrial oxidative phosphorylation. Therefore, the hypothesis that inhaling H₂ could facilitate lipid metabolism during aerobic exercise was investigated in the current study by measuring the breath acetone levels, which could be used as non-invasive indicators of lipid metabolism. This study aimed to investigate the effect of inhaling H₂ on breath acetone output during submaximal exercise using a randomized, single-blinded, placebo-controlled, and cross-over experimental design. After taking a 20-minute baseline measurement, breath acetone levels were measured in ten male subjects who performed a 60% peak oxygen uptake-intensity cycling exercise for 20 minutes while inhaling either 1% H₂ or a control gas. In another experiment, six male subjects remained in a sitting position for 45 minutes while inhaling either 1% H₂ or a control gas. H₂ significantly augmented breath acetone and enhanced oxygen uptake during exercise (P < 0.01). However, it did not significantly change oxidative stress or antioxidant activity responses to exercise, nor did it significantly alter the breath acetone or oxygen uptake during prolonged resting states. These results suggest that inhaling H₂ gas promotes an exercise-induced increase in hepatic lipid metabolism. The study was approved by the Ethical Committee of Chubu University, Japan (approved No. 260086-2) on March 29, 2018.

Real-Time Monitoring of 13C- and 18O-Isotopes of Human Breath CO2 Using a Mid-Infrared Hollow Waveguide Gas Sensor

Real-time measuring of CO₂ isotopes (¹³CO₂, ¹²CO₂, and ¹⁸OC¹⁶O) in exhaled breath using a mid-infrared hollow waveguide gas sensor incorporating a 2.73 μm distributed feedback laser was proposed and demonstrated for the first time based on calibration-free wavelength modulation spectroscopy. The measurement precisions for δ¹³C and δ¹⁸O were, respectively, 0.26 and 0.57‰ for an integration time of 131 s by Allan variance analysis. These measurement precisions achieved in the present work were at least 3.5 times better than those reported using direct absorption spectroscopy and 1.3 times better than those obtained by calibration-needed wavelength modulation absorption spectroscopy. Continuous measurement of three isotopes in the breathing cycle was performed. Alveolar gas from the expirogram was identified, and the ¹³C/¹²C and ¹⁸O/¹⁶O ratios were found to be almost constant during the alveolar plateau, which enables optimization of breath sampling and provides accurate information on metabolic processes. The ¹³C/¹²C and ¹⁸O/¹⁶O isotope ratios at the alveolar plateau of five breath cycles were averaged, yielding δ¹³C and δ¹⁸O values of (-24.3 ± 3.4) and (-30.7 ± 2.6) ‰, respectively. This study demonstrates the feasibility of real-time analysis of ¹³C- and ¹⁸O-isotopes of human breath CO₂ in clinical applications and shows its potential for diagnosing respiratory-related diseases with high sensitivity, selectivity, and specificity.

Effect of inhaled acetone concentrations on exhaled breath acetone concentrations at rest and during exercise

Real-time measurements of the differences in inhaled and exhaled, unlabeled and fully deuterated acetone concentration levels, at rest and during exercise, have been conducted using proton transfer reaction mass spectrometry. A novel approach to continuously differentiate between the inhaled and exhaled breath acetone concentration signals is used. This leads to unprecedented fine grained data of inhaled and exhaled concentrations. The experimental results obtained are compared with those predicted using a simple three compartment model that theoretically describes the influence of inhaled concentrations on exhaled breath concentrations for volatile organic compounds with high blood:air partition coefficients, and hence is appropriate for acetone. An agreement between the predicted and observed concentrations is obtained. Our results highlight that the influence of the upper airways cannot be neglected for volatiles with high blood:air partition coefficients, i.e. highly water soluble volatiles.

Modeling the bioaccessibility of inhaled semivolatile organic compounds in the human respiratory tract

The bioaccessibility of semivolatile organic compounds (SVOCs) via inhalation has rarely been studied, as indicated by the literature. There is no model to calculate the SVOC bioaccessibility following inhalation, and measurement data have focused on only a few polycyclic aromatic hydrocarbons (PAHs) in the particle phase. The present work developed a mechanistic model to address the mass transfer of inhaled SVOCs among the gas, particle and mucus phases in the human respiratory tract. The model considers (1) the SVOC partitioning between the gas and particle phases as well as between the gas and mucus phases and (2) the deposition of gas- and particle-phase SVOCs in the mucus of the respiratory tract. Based on the model, the inhalation bioaccessibility for 72 SVOCs was calculated. The SVOCs were measured in French dwellings at the nationwide scale, and their median concentrations in both the gas and particle phases were used for the bioaccessibility calculations. The results show that the inhalation bioaccessibility varies considerably from one compound to another, e.g., between 0.62 and 1.00 for phthalates, between 0.71 and 0.79 for polybrominated diphenyl ethers (PBDEs), between 0.48 and 0.56 for polychlorinated biphenyls (PCBs), between 0.48 and 1.00 for different chemical families of pesticides and between 0.48 and 0.90 for PAHs.

Highly Sensitive Room-Temperature Sensor Based on Nanostructured K₂W₇O22 for Application in the Non-Invasive Diagnosis of Diabetes

Diabetes is one of the most rapidly-growing chronic diseases in the world. Acetone, a volatile organic compound in exhaled breath, shows a positive correlation with blood glucose and has proven to be a biomarker for type-1 diabetes. Measuring the level of acetone in exhaled breath can provide a non-invasive, low risk of infection, low cost, and convenient way to monitor the health condition of diabetics. There has been continuous demand for the improvement of this non-invasive, sensitive sensor system to provide a fast and real-time electronic readout of blood glucose levels. A novel nanostructured K₂W₇O₂₂ has been recently used to test acetone with concentration from 0 parts-per-million (ppm) to 50 ppm at room temperature. The results revealed that a K₂W₇O₂₂ sensor shows a sensitive response to acetone, but the detection limit is not ideal due to the limitations of the detection system of the device. In this paper, we report a K₂W₇O₂₂ sensor with an improved sensitivity and detection limit by using an optimized circuit to minimize the electronic noise and increase the signal to noise ratio for the purpose of weak signal detection while the concentration of acetone is very low.

Modeling Pulmonary Gas Exchange and Single-Exhalation Profiles of Carbon Monoxide

Exhaled breath carbon monoxide (eCO) is a candidate biomarker for non-invasive assessment of oxidative stress and respiratory diseases. Standard end-tidal CO analysis, however, cannot distinguish, whether eCO reflects endogenous CO production, lung diffusion properties or exogenous sources, and is unable to resolve a potential airway contribution. Coupling real-time breath gas analysis to pulmonary gas exchange modeling holds promise to improve the diagnostic value of eCO. A trumpet model with axial diffusion (TMAD) is used to simulate the dynamics of CO gas exchange in the respiratory system and corresponding eCO concentrations for the first time. The mass balance equation is numerically solved employing a computationally inexpensive routine implementing the method of lines, which provides the distribution of CO in the respiratory tract during inhalation, breath-holding, and exhalation with 1 mm spatial and 0.01 s temporal resolution. Initial estimates of the main TMAD parameters, the maximum CO fluxes and diffusing capacities in alveoli and airways, are obtained using healthy population tissue, blood and anatomical data. To verify the model, mouth-exhaled expirograms from two healthy subjects, measured with a novel, home-built laser-based CO sensor, are compared to single-exhalation profiles simulated using actual breath sampling data, such as exhalation flow rate (EFR) and volume. A very good agreement is obtained in exhalation phases I and III for EFRs between 55 and 220 ml/s and after 10 and 20 s of breath-holding, yielding a unique set of TMAD parameters. The results confirm the recently observed EFR dependence of CO expirograms and suggest that measured end-tidal eCO is always lower than alveolar and capillary CO. Breath-holding allows the observation of close-to-alveolar CO concentrations and increases the sensitivity to the airway TMAD parameters in exhalation phase I. A parametric simulation study shows that a small increase in airway flux can be distinguished from an increase in alveolar flux, and that slight changes in alveolar flux and diffusing capacity have a significantly different effect on phase III of the eCO profiles.

Prospects and Challenges of Volatile Organic Compound Sensors in Human Healthcare

The chemical signatures of volatile organic compounds (VOCs) in humans can be utilized for point-of-care (POC) diagnosis. Apart from toxic exposure studies, VOCs generated in humans can provide insights into one's healthy and diseased metabolic states, acting as a biomarker for identifying numerous diseases noninvasively. VOC sensors and the technology of e-nose have received significant attention for continuous and selective monitoring of various physiological and pathophysiological conditions of an individual. Noninvasive detection of VOCs is achieved from biomatrices of breath, sweat and saliva. Among these, detection from sweat and saliva can be continuous in real-time. The sensing approaches include optical, chemiresistive and electrochemical techniques. This article provides an overview of such techniques. These, however, have limitations of reliability, precision, selectivity, and stability in continuous monitoring. Such limitations are due to lack of sensor stability and complexity of samples in a multivariate environment, which can lead to false readings. To overcome selectivity barriers, sensor arrays enabling multimodal sensing, have been used with pattern recognition techniques. Stability and precision issues have been addressed through advancements in nanotechnology. The use of various forms of nanomaterial not only enhance sensing performance, but also plays a major role in detection on a miniaturized scale. The rapid growth in medical Internet of Things (IoT) and artificial intelligence paves a pathway for improvements in human theranostics.

Propofol Breath Monitoring as a Potential Tool to Improve the Prediction of Intraoperative Plasma Concentrations

INTRODUCTION

Monitoring of drug concentrations in breathing gas is routinely being used to individualize drug dosing for the inhalation anesthetics. For intravenous anesthetics however, no decisive evidence in favor of breath concentration monitoring has been presented up until now. At the same time, questions remain with respect to the performance of currently used plasma pharmacokinetic models implemented in target-controlled infusion systems. In this study, we investigate whether breath monitoring of propofol could improve the predictive performance of currently applied, target-controlled infusion models.

METHODS

Based on data from a healthy volunteer study, we developed an addition to the current state-of-the-art pharmacokinetic model for propofol, to accommodate breath concentration measurements. The potential of using this pharmacokinetic (PK) model in a Bayesian forecasting setting was studied using a simulation study. Finally, by introducing bispectral index monitor (BIS) measurements and the accompanying BIS models into our PK model, we investigated the relationship between BIS and predicted breath concentrations.

RESULTS AND DISCUSSION

We show that the current state-of-the-art pharmacokinetic model is easily extended to reliably describe propofol kinetics in exhaled breath. Furthermore, we show that the predictive performance of the a priori model is improved by Bayesian adaptation based on the measured breath concentrations, thereby allowing further treatment individualization and a more stringent control on the targeted plasma concentrations during general anesthesia. Finally, we demonstrated concordance between currently advocated BIS models, relying on predicted effect-site concentrations, and our new approach in which BIS measurements are derived from predicted breath concentrations.

Mining the Volatilomes of Plant-Associated Microbiota for New Biocontrol Solutions

Microbial lifeforms associated with land plants represent a rich source for crop growth- and health-promoting microorganisms and biocontrol agents. Volatile organic compounds (VOCs) produced by the plant microbiota have been demonstrated to elicit plant defenses and inhibit the growth and development of numerous plant pathogens. Therefore, these molecules are prospective alternatives to synthetic pesticides and the determination of their bioactivities against plant threats could contribute to the development of control strategies for sustainable agriculture. In our previous study we investigated the inhibitory impact of volatiles emitted by Pseudomonas species isolated from a potato field against the late blight-causing agent Phytophthora infestans. Besides the well-documented emission of hydrogen cyanide, other Pseudomonas VOCs impeded P. infestans mycelial growth and sporangia germination. Current advances in the field support the emerging concept that the microbial volatilome contains unexploited, eco-friendly chemical resources that could help select for efficient biocontrol strategies and lead to a greener chemical disease management in the field.

Exposure to SVOCs from Inhaled Particles: Impact of Desorption

Inhaled semivolatile organic compounds (SVOCs) are simultaneously present in gas and particle phases. Particles desorb a fraction of their SVOCs moving through the human respiratory tract (RT). Quantifying such desorption is challenging but important since gas- and particle-phase SVOCs deposit in different locations in the RT, encountering different cell populations with varying health consequences. This paper presents a mass transfer model to quantify this desorption process in the head, tracheobronchial, and alveolar regions of the RT. The desorption of SVOCs from inhaled particles can be gauged using the ratio of particle residence time to the time required to achieve particle/gas equilibrium. Results indicate that the larger this ratio is, the more likely particles desorb the SVOCs they carry. For particles smaller than 0.5 μm diameter and SVOCs with a particle/gas partition coefficient (unitless) of 10¹⁰, accounting for desorption reduces the estimated particle-phase SVOC concentrations in the alveolar region by more than 35%; the reduction is almost 700% for 0.05 μm diameter particles. In hypothetical scenarios representing common indoor and outdoor situations, neglecting desorption significantly overestimates the concentration of ultrafine particle associated SVOCs in the alveolar region. This model is a preliminary step toward more nuanced estimates of exposure to inhaled SVOCs.

Doping-assisted low-pressure photoionization mass spectrometry for the real-time detection of lung cancer-related volatile organic compounds

Real-time detection of lung cancer-related volatile organic compounds (VOCs) is a promising, non-intrusive technique for lung cancer (LC) prescreening. In this study, a novel method was designed to enhance the detection selectivity and sensitivity of LC-related polar VOCs by dichloromethane (CH₂Cl₂) doping-assisted low-pressure photoionization mass spectrometry (LPPI-MS). Compared with conventional LPPI-MS, CH₂Cl₂ doping-assisted LPPI-MS boosted the peak intensities of n-propanol, n-pentanal, acetone, and butyl acetate in nitrogen specifically by 53, 18, 16, and 43 times, respectively. The signal intensities of their daughter ions were inhibited or reduced. At relative humidity (RH) of 20%, the sensitivities of n-propanol, n-pentanal, acetone, and butyl acetate detection ranged from 116 to 452 counts/ppbv with a detection time of 10s and R² >0.99 for the linear calibration curves. The method was also applicable under higher RH levels of 50% and 90%. Breath samples obtained from 10 volunteers and spiked samples were investigated. Eight-fold enhancements in the signal intensities of polar VOCs were observed in the normal and spiked samples. These preliminary results demonstrate the efficacy of the dichloromethane doping-assisted LPPI technique for the detection of LC-related polar VOCs. Further studies are indispensible to illustrating the detailed mechanism and applying the technique to breath diagnosis.

Significance of Exhaled Breath Test in Clinical Diagnosis: A Special Focus on the Detection of Diabetes Mellitus

Analysis of volatile organic compounds (VOCs) emanating from human exhaled breath can provide deep insight into the status of various biochemical processes in the human body. VOCs can serve as potential biomarkers of physiological and pathophysiological conditions related to several diseases. Breath VOC analysis, a noninvasive and quick biomonitoring approach, also has potential for the early detection and progress monitoring of several diseases. This paper gives an overview of the major VOCs present in human exhaled breath, possible biochemical pathways of breath VOC generation, diagnostic importance of their analysis, and analytical techniques used in the breath test. Breath analysis relating to diabetes mellitus and its characteristic breath biomarkers is focused on. Finally, some challenges and limitations of the breath test are discussed.

Real-Time Quantification of Amino Acids in the Exhalome by Secondary Electrospray Ionization–Mass Spectrometry: A Proof-of-Principle Study

BACKGROUND

Amino acids are frequently determined in clinical chemistry. However, current analysis methods are time-consuming, invasive, and suffer from artifacts during sampling, sample handling, and sample preparation. We hypothesized in this proof-of-principle study that plasma concentrations of amino acids can be estimated by measuring their concentrations in exhaled breath. A novel breath analysis technique described here allows such measurements to be carried out in real-time and noninvasively, which should facilitate efficient diagnostics and give insights into human physiology.

METHODS

The amino acid profiles in 37 individuals were determined by ion-exchange HPLC in blood plasma and simultaneously in breath by secondary electrospray ionization coupled to high-resolution mass spectrometry. Participants were split into training and test sets to validate the analytical accuracy. Longitudinal profiles in 3 individuals were additionally obtained over a 12-h period.

RESULTS

Concentrations of 8 slightly volatile amino acids (A, V, I, G, P, K, F, Orn) could be determined in exhaled breath with a CV of &lt;10%. Exhalome validation studies yielded high accuracies for each of these amino acids, on average only 3% less compared to plasma concentrations (95% CI ±13%). Higher variations were found only for amino acids with a low plasma concentration.

CONCLUSIONS

This study demonstrates for the first time that amino acids can be quantified in the human breath and that their concentrations correlate with plasma concentrations. Although this noninvasive technique needs further investigation, exhalome analysis may provide significant benefits over traditional, offline analytical methods.

FEV manoeuvre induced changes in breath VOC compositions: an unconventional view on lung function tests

Breath volatile organic compound (VOC) analysis can open a non-invasive window onto pathological and metabolic processes in the body. Decades of clinical breath-gas analysis have revealed that changes in exhaled VOC concentrations are important rather than disease specific biomarkers. As physiological parameters, such as respiratory rate or cardiac output, have profound effects on exhaled VOCs, here we investigated VOC exhalation under respiratory manoeuvres. Breath VOCs were monitored by means of real-time mass-spectrometry during conventional FEV manoeuvres in 50 healthy humans. Simultaneously, we measured respiratory and hemodynamic parameters noninvasively. Tidal volume and minute ventilation increased by 292 and 171% during the manoeuvre. FEV manoeuvre induced substance specific changes in VOC concentrations. pET-CO2 and alveolar isoprene increased by 6 and 21% during maximum exhalation. Then they decreased by 18 and 37% at forced expiration mirroring cardiac output. Acetone concentrations rose by 4.5% despite increasing minute ventilation. Blood-borne furan and dimethyl-sulphide mimicked isoprene profile. Exogenous acetonitrile, sulphides, and most aliphatic and aromatic VOCs changed minimally. Reliable breath tests must avoid forced breathing. As isoprene exhalations mirrored FEV performances, endogenous VOCs might assure quality of lung function tests. Analysis of exhaled VOC concentrations can provide additional information on physiology of respiration and gas exchange.

Alcohol breath test: gas exchange issues

The alcohol breath test is reviewed with a focus on gas exchange factors affecting its accuracy. The basis of the alcohol breath test is the assumption that alveolar air reaches the mouth during exhalation with no change in alcohol concentration. Recent investigations have shown that alcohol concentration is altered during its transit to the mouth. The exhaled alcohol concentration is modified by interaction with the mucosa of the pulmonary airways. Exhaled alcohol concentration is not an accurate indicator of alveolar alcohol concentration. Measuring alcohol concentration in the breath is very different process than measuring a blood level from air equilibrated with a blood sample. Airway exchange of alcohol leads to a bias against certain individuals depending on the anatomic and physiologic characteristics. Methodological modifications are proposed to improve the accuracy of the alcohol breath test to become fair to all.

Breath Biomarkers to Measure Uptake of Volatile Organic Compounds by Bicyclists

Breath biomarkers were used to study uptake of traffic-related volatile organic compounds (VOCs) from urban bicycling. Breath analysis was selected because it is one of the least invasive methods to assess urban traveler exposure. Research hurdles that were overcome included considering that factors other than on-road exposure can influence concentrations in the body, and absorbed doses during a trip can be small compared to baseline body burdens. Pre-trip, on-road, and post-trip breath concentrations and ambient air concentrations were determined for 26 VOCs for bicyclists traveling on different path types. Statistical analyses of the concentration data identified eight monoaromatic hydrocarbons potentially useful as breath biomarkers to compare differences in body levels brought about by urban travel choices. Breath concentrations of the biomarker compounds were significantly higher than background levels after riding on high-traffic arterial streets and on a path through a high-exposure industrial area, but not after riding on low-traffic local streets or on other off-street paths. Modeled effects of high-traffic streets on ambient concentrations were 100-200% larger than those of low-traffic streets; modeled effects of high-traffic streets on breath concentrations were 40-100% larger than those of low-traffic streets. Similar percentage increases in breath concentrations are expected for bicyclists in other cities.

Bacterial volatiles and diagnosis of respiratory infections

Breath testing has enormous potential in the medical diagnostic field. The underlying complexity and perceived availability of adequate specimens, combined with a lack of knowledge of the metabolic pathways that give rise to compounds that are sources of analytes detectable in breath, has greatly slowed development. These real obstacles have recently been largely overcome in the use of breath testing to identify patients with cystic fibrosis associated Pseudomonas aeruginosa infection and tuberculosis. This review summarizes progress made in the characterization of microbial volatiles produced by major lower respiratory tract bacterial pathogens, and their potential use as diagnostic markers in patient breath testing.

Modeling of breath methane concentration profiles during exercise on an ergometer

We develop a simple three compartment model based on mass balance equations which quantitatively describes the dynamics of breath methane concentration profiles during exercise on an ergometer. With the help of this model it is possible to estimate the endogenous production rate of methane in the large intestine by measuring breath gas concentrations of methane.

Prediction of blood:air and fat:air partition coefficients of volatile organic compounds for the interpretation of data in breath gas analysis

In this article, a database of blood:air and fat:air partition coefficients (λ b:a and λ f:a) is reported for estimating 1678 volatile organic compounds recently reported to appear in the volatilome of the healthy human. For this purpose, a quantitative structure-property relationship (QSPR) approach was applied and a novel method for Henry's law constants prediction developed. A random forest model based on Molecular Operating Environment 2D (MOE2D) descriptors based on 2619 literature-reported Henry's constant values was built. The calculated Henry's law constants correlate very well (R(2) test  =  0.967) with the available experimental data. Blood:air and fat:air partition coefficients were calculated according to the method proposed by Poulin and Krishnan using the estimated Henry's constant values. The obtained values correlate reasonably well with the experimentally determined ones for a test set of 90 VOCs (R(2)  =  0.95). The provided data aim to fill in the literature data gap and further assist the interpretation of results in studies of the human volatilome.

Quantification of selected volatile organic compounds in human urine by gas chromatography selective reagent ionization time of flight mass spectrometry (GC-SRI-TOF-MS) coupled with head-space solid-phase microextraction (HS-SPME)

Selective reagent ionization time of flight mass spectrometry with NO⁺as the reagent ion in conjunction with gas chromatography and head-space solid-phase microextraction was used to determine 16 volatiles in human urine.

Secondary electrospray ionization coupled to high-resolution mass spectrometry reveals tryptophan pathway metabolites in exhaled human breath

A real-time non-invasive breath analysis technique (secondary ESI-HRMS) reveals the hitherto unknown occurrence of tryptophan pathway metabolites in breath.

Nanoscale Sensor Technologies for Disease Detection via Volatolomics

The detection of many diseases is missed because of delayed diagnoses or the low efficacy of some treatments. This emphasizes the urgent need for inexpensive and minimally invasive technologies that would allow efficient early detection, stratifying the population for personalized therapy, and improving the efficacy of rapid bed-side assessment of treatment. An emerging approach that has a high potential to fulfill these needs is based on so-called "volatolomics", namely, chemical processes involving profiles of highly volatile organic compounds (VOCs) emitted from body fluids, including breath, skin, urine and blood. This article presents a didactic review of some of the main advances related to the use of nanomaterial-based solid-state and flexible sensors, and related artificially intelligent sensing arrays for the detection and monitoring of disease with volatolomics. The article attempts to review the technological gaps and confounding factors related to VOC testing. Different ways to choose nanomaterial-based sensors are discussed, while considering the profiles of targeted volatile markers and possible limitations of applying the sensing approach. Perspectives for taking volatolomics to a new level in the field of diagnostics are highlighted.

Instant effects of changing body positions on compositions of exhaled breath

Concentrations of exhaled volatile organic compounds (VOCs) may depend not only on biochemical or pathologic processes but also on physiological parameters. As breath sampling may be done in different body positions, effects of the sampling position on exhaled VOC concentrations were investigated by means of real-time mass spectrometry. Breaths from 15 healthy volunteers were analyzed in real-time by PTR-ToF-MS-8000 during paced breathing (12/min) in a continuous side-stream mode. We applied two series of body positions (setup 1: sitting, standing, supine, and sitting; setup 2: supine, left lateral, right lateral, prone, and supine). Each position was held for 2 min. Breath VOCs were quantified in inspired and alveolar air by means of a custom-made algorithm. Parallel monitoring of hemodynamics and capnometry was performed noninvasively. In setup 1, when compared to the initial sitting position, normalized mean concentrations of isoprene, furan, and acetonitrile decreased by 24%, 26%, and 9%, respectively, during standing and increased by 63%, 36%, and 10% during lying mirroring time profiles of stroke volume and pET-CO2. In contrast, acetone and H2S concentrations remained almost constant. In setup 2, when compared to the initial supine position, mean alveolar concentrations of isoprene and furan increased significantly up to 29% and 16%, respectively, when position was changed from lying on the right side to the prone position. As cardiac output and stroke volume decreased at that time, the reasons for the observed concentrations changes have to be linked to the ventilation/perfusion ratio or compartmental distribution rather than to perfusion alone. During final postures, all VOC concentrations, hemodynamics, and pET-CO2 returned to baseline. Exhaled blood-borne VOC profiles changed due to body postures. Changes depended on cardiac stroke volume, origin, compartmental distribution and physico-chemical properties of the substances. Patients' positions and cardiac output have to be controlled when concentrations of breath VOCs are to be interpreted in terms of biomarkers.

Hybrid volatolomics and disease detection

This Review presents a concise, but not exhaustive, didactic overview of some of the main concepts and approaches related to "volatolomics"-an emerging frontier for fast, risk-free, and potentially inexpensive diagnostics. It attempts to review the source and characteristics of volatolomics through the so-called volatile organic compounds (VOCs) emanating from cells and their microenvironment. It also reviews the existence of VOCs in several bodily fluids, including the cellular environment, blood, breath, skin, feces, urine, and saliva. Finally, the usefulness of volatolomics for diagnosis from a single bodily fluid, as well as ways to improve these diagnostic aspects by "hybrid" approaches that combine VOC profiles collected from two or more bodily fluids, will be discussed. The perspectives of this approach in developing the field of diagnostics to a new level are highlighted.

Modeling-based determination of physiological parameters of systemic VOCs by breath gas analysis: a pilot study

In this paper we develop a simple two compartment model which extends the Farhi equation to the case when the inhaled concentration of a volatile organic compound (VOC) is not zero. The model connects the exhaled breath concentration of systemic VOCs with physiological parameters such as endogenous production rates and metabolic rates. Its validity is tested with data obtained for isoprene and inhaled deuterated isoprene-D5.

Advances in electronic-nose technologies for the detection of volatile biomarker metabolites in the human breath

Recent advancements in the use of electronic-nose (e-nose) devices to analyze human breath profiles for the presence of specific volatile metabolites, known as biomarkers or chemical bio-indicators of specific human diseases, metabolic disorders and the overall health status of individuals, are providing the potential for new noninvasive tools and techniques useful to point-of-care clinical disease diagnoses. This exciting new area of electronic disease detection and diagnosis promises to yield much faster and earlier detection of human diseases and disorders, allowing earlier, more effective treatments, resulting in more rapid patient recovery from various afflictions. E-nose devices are particularly suited for the field of disease diagnostics, because they are sensitive to a wide range of volatile organic compounds (VOCs) and can effectively distinguish between different complex gaseous mixtures via analysis of electronic aroma sensor-array output profiles of volatile metabolites present in the human breath. This review provides a summary of some recent developments of electronic-nose technologies, particularly involving breath analysis, with the potential for providing many new diagnostic applications for the detection of specific human diseases associated with different organs in the body, detectable from e-nose analyses of aberrant disease-associated VOCs present in air expired from the lungs.

Exhaled nitric oxide and other exhaled biomarkers in bronchial challenge with exercise in asthmatic children: current knowledge

The fractional concentration of exhaled nitric oxide (FENO), a known marker of atopic-eosinophilic inflammation, may be used as a surrogate to assess exercise-induced bronchoconstriction (EIB) in asthmatic children. The predictive value of baseline FENO for EIB appears to be influenced by several factors, including age, atopy, current therapy with corticosteroids and measurement technique. Nonetheless, FENO cut-off values appear to be able to rule out EIB. FENO levels decrease during EIB, apparently through neural mechanisms rather than by decreased airway-epithelial surface. Partition of FENO into proximal and peripheral contributions of the respiratory tract may improve our understanding on NO exchange during exercise and help to screen subjects prone to EIB. Other biomarkers of inflammation and oxidative stress contained in exhaled gases and exhaled breath condensate (EBC) may shed light on the pathophysiology of EIB. Exhaled breath temperature is a promising real-time measurement whose routine use for assessing EIB warrants further investigation.

Non-(13)CO2 targeted breath tests: a feasibility study

Breath tests allow a non-invasive and fast diagnostic of different specific enzymes' phenotypic functionality. Over the last decade several 13C-breath tests were successfully tested, with the (13)C-urea breath test being approved by the US Food and Drug Administration (FDA) and the European Medicines Agency (EMA). The use of other targets than labeled (13)CO2 in exhaled breath offers additional possibilities. High sensitivity analytical technologies, such as proton-transfer reaction time-of-flight mass spectrometry, enable the detection of different volatile targets in the low ppb (parts per billion) range in real-time.In the current study volunteers received 0.8 mg deuterated 2-propanol, which was converted to d3-acetone (m/z 62.08) by alcohol dehydrogenase. D3-acetone (m/z 62.08) appeared in exhaled breath concentrations up to 30 ppb (at maximum). Parallel consumption of ethanol seems to reduce the activity of the enzyme, resulting in approximately 15-30% reduction of the produced d3-acetone. Phenotypic determination of enzyme activities is important, since the functionality of enzymes is influenced by factors such as age, sex, life-style, diet, organ function, metabolism, etc, which cannot be entirely accounted for by genetic factors.