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Capuano R, Ciotti M, Catini A, Bernardini S, Di Natale C. Clinical applications of volatilomic assays. Crit Rev Clin Lab Sci 2024:1-20. [PMID: 39129534 DOI: 10.1080/10408363.2024.2387038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/23/2024] [Accepted: 07/29/2024] [Indexed: 08/13/2024]
Abstract
The study of metabolomics is revealing immense potential for diagnosis, therapy monitoring, and understanding of pathogenesis processes. Volatilomics is a subcategory of metabolomics interested in the detection of molecules that are small enough to be released in the gas phase. Volatile compounds produced by cellular processes are released into the blood and lymph, and can reach the external environment through different pathways, such as the blood-air interface in the lung that are detected in breath, or the blood-water interface in the kidney that leads to volatile compounds detected in urine. Besides breath and urine, additional sources of volatile compounds such as saliva, blood, feces, and skin are available. Volatilomics traces its roots back over fifty years to the pioneering investigations in the 1970s. Despite extensive research, the field remains in its infancy, hindered by a lack of standardization despite ample experimental evidence. The proliferation of analytical instrumentations, sample preparations and methods of volatilome sampling still make it difficult to compare results from different studies and to establish a common standard approach to volatilomics. This review aims to provide an overview of volatilomics' diagnostic potential, focusing on two key technical aspects: sampling and analysis. Sampling poses a challenge due to the susceptibility of human samples to contamination and confounding factors from various sources like the environment and lifestyle. The discussion then delves into targeted and untargeted approaches in volatilomics. Some case studies are presented to exemplify the results obtained so far. Finally, the review concludes with a discussion on the necessary steps to fully integrate volatilomics into clinical practice.
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Affiliation(s)
- Rosamaria Capuano
- Department of Electronic Engineering, University of Rome Tor Vergata, Roma, Italy
- Interdepartmental Center for Volatilomics, "A. D'Amico", University of Rome Tor Vergata, Rome, Italy
| | - Marco Ciotti
- Department of Laboratory Medicine, University Hospital Tor Vergata, Rome, Italy
| | - Alexandro Catini
- Department of Electronic Engineering, University of Rome Tor Vergata, Roma, Italy
- Interdepartmental Center for Volatilomics, "A. D'Amico", University of Rome Tor Vergata, Rome, Italy
| | - Sergio Bernardini
- Interdepartmental Center for Volatilomics, "A. D'Amico", University of Rome Tor Vergata, Rome, Italy
- Department of Laboratory Medicine, University Hospital Tor Vergata, Rome, Italy
- Department of Experimental Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Corrado Di Natale
- Department of Electronic Engineering, University of Rome Tor Vergata, Roma, Italy
- Interdepartmental Center for Volatilomics, "A. D'Amico", University of Rome Tor Vergata, Rome, Italy
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Haworth-Duff A, Smith BL, Sham TT, Boisdon C, Loughnane P, Burnley M, Hawcutt DB, Raval R, Maher S. Rapid differentiation of cystic fibrosis-related bacteria via reagentless atmospheric pressure photoionisation mass spectrometry. Sci Rep 2024; 14:17067. [PMID: 39048618 PMCID: PMC11269582 DOI: 10.1038/s41598-024-66851-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 07/04/2024] [Indexed: 07/27/2024] Open
Abstract
Breath analysis is an area of significant interest in medical research as it allows for non-invasive sampling with exceptional potential for disease monitoring and diagnosis. Volatile organic compounds (VOCs) found in breath can offer critical insight into a person's lifestyle and/or disease/health state. To this end, the development of a rapid, sensitive, cost-effective and potentially portable method for the detection of key compounds in breath would mark a significant advancement. Herein, we have designed, built and tested a novel reagent-less atmospheric pressure photoionisation (APPI) source, coupled with mass spectrometry (MS), utilising a bespoke bias electrode within a custom 3D printed sampling chamber for direct analysis of VOCs. Optimal APPI-MS conditions were identified, including bias voltage, cone voltage and vaporisation temperature. Calibration curves were produced for ethanol, acetone, 2-butanone, ethyl acetate and eucalyptol, yielding R2 > 0.99 and limits of detection < 10 pg. As a pre-clinical proof of concept, this method was applied to bacterial headspace samples of Escherichia coli (EC), Pseudomonas aeruginosa (PSA) and Staphylococcus aureus (SA) collected in 1 L Tedlar bags. In particular, PSA and SA are commonly associated with lung infection in cystic fibrosis patients. The headspace samples were classified using principal component analysis with 86.9% of the total variance across the first three components and yielding 100% classification in a blind-sample study. All experiments conducted with the novel APPI arrangement were carried out directly in real-time with low-resolution MS, which opens up exciting possibilities in the future for on-site (e.g., in the clinic) analysis with a portable system.
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Affiliation(s)
- Adam Haworth-Duff
- Department of Electrical Engineering and Electronics, University of Liverpool, Liverpool, UK
| | - Barry L Smith
- Department of Electrical Engineering and Electronics, University of Liverpool, Liverpool, UK
| | - Tung-Ting Sham
- Department of Electrical Engineering and Electronics, University of Liverpool, Liverpool, UK
| | - Cedric Boisdon
- Department of Electrical Engineering and Electronics, University of Liverpool, Liverpool, UK
| | - Paul Loughnane
- Department of Biochemistry and Systems Biology, University of Liverpool, Liverpool, UK
| | - Mark Burnley
- Department of Electrical Engineering and Electronics, University of Liverpool, Liverpool, UK
| | - Daniel B Hawcutt
- Department of Women's and Children's Health, University of Liverpool, Liverpool, UK
- NIHR Alder Hey Clinical Research Facility, Liverpool, UK
| | - Rasmita Raval
- Open Innovation Hub for Antimicrobial Surfaces, Department of Chemistry, University of Liverpool, Liverpool, UK
| | - Simon Maher
- Department of Electrical Engineering and Electronics, University of Liverpool, Liverpool, UK.
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Streckenbach B, Sakas J, Perkins N, Kohler M, Moeller A, Zenobi R. A gas-phase standard delivery system for direct breath analysis. J Breath Res 2022; 17. [PMID: 36579824 DOI: 10.1088/1752-7163/acab79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/14/2022] [Indexed: 12/15/2022]
Abstract
Applications for direct breath analysis by mass spectrometry (MS) are rapidly expanding. One of the more recent mass spectrometry-based approaches is secondary electrospray ionization coupled to high-resolution mass spectrometry (SESI-HRMS). Despite increasing usage, the SESI methodology still lacks standardization procedures for quality control and absolute quantification. In this study, we designed and evaluated a custom-built standard delivery system tailored for direct breath analysis. The system enables the simultaneous introduction of multiple gas-phase standard compounds into ambient MS setups in the lower parts-per-million (ppm) to parts-per-billion (ppb) range. To best mimic exhaled breath, the gas flow can be heated (37 °C-40 °C) and humidified (up to 98% relative humidity). Inter-laboratory comparison of the system included various SESI-HRMS setups, i.e. an Orbitrap and a quadrupole time-of-flight mass spectrometer (QTOF), and using both single- as well as multi-component standards. This revealed highly stable and reproducible performances with between-run variation <19% and within-run variation <20%. Independent calibration runs demonstrated high accuracy (96%-111%) and precision (>95%) for the single-compound standard acetone, while compound-specific performances were obtained for the multi-component standard. Similarly, the sensitivity varied for different compounds within the multi-component standard across all SESI-Orbitrap and -QTOF setups, yielding limits of detections from 3.1 ppb (forp-xylene) to 0.05 ppb (for 1,8-cineol). Routinely applying the standard system throughout several weeks, allowed us to monitor instrument stability and to identify technical outliers in exhaled breath measurements. Such routine deployment of standards would significantly improve data quality and comparability, which is especially important in longitudinal and multi-center studies. Furthermore, performance validation of the system demonstrated its suitability for reliable absolute quantification while it illustrated compound-dependent behavior for SESI.
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Affiliation(s)
- Bettina Streckenbach
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | - Justinas Sakas
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland.,EaStCHEM School of Chemistry, University of Edinburgh, Edinburgh, United Kingdom
| | - Nathan Perkins
- Division of Clinical Chemistry and Biochemistry, University Children's Hospital Zurich, Zurich, Switzerland
| | - Malcolm Kohler
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich, Zurich, Switzerland
| | - Renato Zenobi
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
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Drabińska N, Flynn C, Ratcliffe N, Belluomo I, Myridakis A, Gould O, Fois M, Smart A, Devine T, Costello BDL. A literature survey of all volatiles from healthy human breath and bodily fluids: the human volatilome. J Breath Res 2021; 15. [PMID: 33761469 DOI: 10.1088/1752-7163/abf1d0] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/24/2021] [Indexed: 02/06/2023]
Abstract
This paper comprises an updated version of the 2014 review which reported 1846 volatile organic compounds (VOCs) identified from healthy humans. In total over 900 additional VOCs have been reported since the 2014 review and the VOCs from semen have been added. The numbers of VOCs found in breath and the other bodily fluids are: blood 379, breath 1488, faeces 443, milk 290, saliva 549, semen 196, skin 623 and urine 444. Compounds were assigned CAS registry numbers and named according to a common convention where possible. The compounds have been included in a single table with the source reference(s) for each VOC, an update on our 2014 paper. VOCs have also been grouped into tables according to their chemical class or functionality to permit easy comparison. Careful use of the database is needed, as a number of the identified VOCs only have level 2-putative assignment, and only a small fraction of the reported VOCs have been validated by standards. Some clear differences are observed, for instance, a lack of esters in urine with a high number in faeces and breath. However, the lack of compounds from matrices such a semen and milk compared to breath for example could be due to the techniques used or reflect the intensity of effort e.g. there are few publications on VOCs from milk and semen compared to a large number for breath. The large number of volatiles reported from skin is partly due to the methodologies used, e.g. by collecting skin sebum (with dissolved VOCs and semi VOCs) onto glass beads or cotton pads and then heating to a high temperature to desorb VOCs. All compounds have been included as reported (unless there was a clear discrepancy between name and chemical structure), but there may be some mistaken assignations arising from the original publications, particularly for isomers. It is the authors' intention that this work will not only be a useful database of VOCs listed in the literature but will stimulate further study of VOCs from healthy individuals; for example more work is required to confirm the identification of these VOCs adhering to the principles outlined in the metabolomics standards initiative. Establishing a list of volatiles emanating from healthy individuals and increased understanding of VOC metabolic pathways is an important step for differentiating between diseases using VOCs.
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Affiliation(s)
- Natalia Drabińska
- Division of Food Sciences, Institute of Animal Reproduction and Food Research of Polish Academy of Sciences, Tuwima 10, 10-747 Olsztyn, Poland
| | - Cheryl Flynn
- Centre of Research in Biosciences, University of the West of England, Frenchay Campus, Coldharbour Lane, Bristol BS16 1QY, United Kingdom
| | - Norman Ratcliffe
- Centre of Research in Biosciences, University of the West of England, Frenchay Campus, Coldharbour Lane, Bristol BS16 1QY, United Kingdom
| | - Ilaria Belluomo
- Department of Surgery and Cancer, Imperial College London, St. Mary's Campus, QEQM Building, London W2 1NY, United Kingdom
| | - Antonis Myridakis
- Department of Surgery and Cancer, Imperial College London, St. Mary's Campus, QEQM Building, London W2 1NY, United Kingdom
| | - Oliver Gould
- Centre of Research in Biosciences, University of the West of England, Frenchay Campus, Coldharbour Lane, Bristol BS16 1QY, United Kingdom
| | - Matteo Fois
- Centre of Research in Biosciences, University of the West of England, Frenchay Campus, Coldharbour Lane, Bristol BS16 1QY, United Kingdom
| | - Amy Smart
- Centre of Research in Biosciences, University of the West of England, Frenchay Campus, Coldharbour Lane, Bristol BS16 1QY, United Kingdom
| | - Terry Devine
- Centre of Research in Biosciences, University of the West of England, Frenchay Campus, Coldharbour Lane, Bristol BS16 1QY, United Kingdom
| | - Ben De Lacy Costello
- Centre of Research in Biosciences, University of the West of England, Frenchay Campus, Coldharbour Lane, Bristol BS16 1QY, United Kingdom
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Volatile Organic Compounds in Exhaled Breath as Fingerprints of Lung Cancer, Asthma and COPD. J Clin Med 2020; 10:jcm10010032. [PMID: 33374433 PMCID: PMC7796324 DOI: 10.3390/jcm10010032] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/14/2020] [Accepted: 12/22/2020] [Indexed: 12/11/2022] Open
Abstract
Lung cancer, chronic obstructive pulmonary disease (COPD) and asthma are inflammatory diseases that have risen worldwide, posing a major public health issue, encompassing not only physical and psychological morbidity and mortality, but also incurring significant societal costs. The leading cause of death worldwide by cancer is that of the lung, which, in large part, is a result of the disease often not being detected until a late stage. Although COPD and asthma are conditions with considerably lower mortality, they are extremely distressful to people and involve high healthcare overheads. Moreover, for these diseases, diagnostic methods are not only costly but are also invasive, thereby adding to people’s stress. It has been appreciated for many decades that the analysis of trace volatile organic compounds (VOCs) in exhaled breath could potentially provide cheaper, rapid, and non-invasive screening procedures to diagnose and monitor the above diseases of the lung. However, after decades of research associated with breath biomarker discovery, no breath VOC tests are clinically available. Reasons for this include the little consensus as to which breath volatiles (or pattern of volatiles) can be used to discriminate people with lung diseases, and our limited understanding of the biological origin of the identified VOCs. Lung disease diagnosis using breath VOCs is challenging. Nevertheless, the numerous studies of breath volatiles and lung disease provide guidance as to what volatiles need further investigation for use in differential diagnosis, highlight the urgent need for non-invasive clinical breath tests, illustrate the way forward for future studies, and provide significant guidance to achieve the goal of developing non-invasive diagnostic tests for lung disease. This review provides an overview of these issues from evaluating key studies that have been undertaken in the years 2010–2019, in order to present objective and comprehensive updated information that presents the progress that has been made in this field. The potential of this approach is highlighted, while strengths, weaknesses, opportunities, and threats are discussed. This review will be of interest to chemists, biologists, medical doctors and researchers involved in the development of analytical instruments for breath diagnosis.
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Peel AM, Wilkinson M, Sinha A, Loke YK, Fowler SJ, Wilson AM. Volatile organic compounds associated with diagnosis and disease characteristics in asthma - A systematic review. Respir Med 2020; 169:105984. [PMID: 32510334 DOI: 10.1016/j.rmed.2020.105984] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 03/30/2020] [Accepted: 04/19/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Metabolomics refers to study of the metabolome, the entire set of metabolites produced by a biological system. The application of metabolomics to exhaled breath samples - breathomics - is a rapidly growing field with potential application to asthma diagnosis and management. OBJECTIVES We aimed to review the adult asthma breathomic literature and present a comprehensive list of volatile organic compounds identified by asthma breathomic models. METHODS We undertook a systematic search for literature on exhaled volatile organic compounds in adult asthma. We assessed the quality of studies and performed a qualitative synthesis. RESULTS We identified twenty studies; these were methodologically heterogenous with a variable risk of bias. Studies almost universally reported breathomics to be capable of differentiating - with moderate or greater accuracy - between samples from healthy controls and those with asthma; and to be capable of phenotyping disease. However, there was little concordance in the compounds upon which discriminatory models were based. CONCLUSION Results to-date are promising but validation in independent prospective cohorts is needed. This may be challenging given the high levels of inter-individual variation. However, large-scale, multi-centre studies are underway and validation efforts have been aided by the publication of technical standards likely to increase inter-study comparability. Successful validation of breathomic models for diagnosis and phenotyping would constitute an important step towards personalised medicine in asthma.
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Affiliation(s)
- Adam M Peel
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK.
| | - Maxim Wilkinson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester; Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Ashnish Sinha
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Yoon K Loke
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
| | - Stephen J Fowler
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester; Manchester Academic Health Science Centre and NIHR Manchester Biomedical Research Centre, Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Andrew M Wilson
- Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich, NR4 7TJ, UK
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Ratiu IA, Ligor T, Bocos-Bintintan V, Szeliga J, Machała K, Jackowski M, Buszewski B. GC-MS application in determination of volatile profiles emitted by infected and uninfected human tissue. J Breath Res 2019; 13:026003. [PMID: 30530935 DOI: 10.1088/1752-7163/aaf708] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Volatile organic compounds (VOCs) released into the headspace air over human tissues infected with different bacteria were investigated in this work. The above-mentioned VOCs result both from bacterial metabolic processes (pathogen-specific signals) and from the matrix (tissue samples themselves). The objective of this study was to investigate whether one could reliably identify various microorganism strains that exist inside infected tissue samples by direct monitoring of the headspace atmosphere above their cultures. Headspace samples were directly interrogated using a GC-MS system, which produced distinct profiles for samples contaminated with single bacterial strains or with multiple strains (mixed infections). Principal component analysis (PCA) and predictive analysis based on receiver operating characteristics curves (ROC) were the statistical procedures utilized for differentiating between infected and uninfected samples, while network analysis and heat-mapping were used to highlight the connections between emitted volatiles and infectious pathogens. By using ROC curves, obtained results demonstrated that the area under the ROC (95% probability interval) was 0.86 in case of infected samples and 0.48 for uninfected samples. On the other hand, PCA highlighted separation between components coming from infected and uninfected patients, where 67% of variance was described from the first 2 principal components. The biomarker chemicals documented from this work, as well as the developed methodology may ultimately be applied to identify bacterial infections by analyzing exhaled breath.
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Affiliation(s)
- Ileana-Andreea Ratiu
- Department of Environmental Chemistry and Bioanalytics, Faculty of Chemistry, Interdisciplinary Centre of Modern Technologies, Nicolaus Copernicus University, 7 Gagarina Str., 87-100 Torun, Poland. Faculty of Chemistry and Chemical Engineering, Babeş-Bolyai University, 11 Arany Janos, RO-400028, Cluj-Napoca, Romania
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Romano A, Doran S, Belluomo I, Hanna GB. High-Throughput Breath Volatile Organic Compound Analysis Using Thermal Desorption Proton Transfer Reaction Time-of-Flight Mass Spectrometry. Anal Chem 2018; 90:10204-10210. [DOI: 10.1021/acs.analchem.8b01045] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Andrea Romano
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary’s Hospital, South Wharf Road, London W2 1NY, United Kingdom
| | - Sophie Doran
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary’s Hospital, South Wharf Road, London W2 1NY, United Kingdom
| | - Ilaria Belluomo
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary’s Hospital, South Wharf Road, London W2 1NY, United Kingdom
| | - George Bushra Hanna
- Department of Surgery and Cancer, Imperial College London, 10th Floor QEQM Building, St. Mary’s Hospital, South Wharf Road, London W2 1NY, United Kingdom
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Tejero Rioseras A, Singh KD, Nowak N, Gaugg MT, Bruderer T, Zenobi R, Sinues PML. Real-Time Monitoring of Tricarboxylic Acid Metabolites in Exhaled Breath. Anal Chem 2018; 90:6453-6460. [DOI: 10.1021/acs.analchem.7b04600] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Alberto Tejero Rioseras
- Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland
- SEADM, S.L., 28036 Madrid, Spain
- Department of Analytical Chemistry, University of Cordoba, 14005 Cordoba, Spain
| | - Kapil Dev Singh
- University Children’s Hospital Basel, University of Basel, 4056 Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland
| | - Nora Nowak
- Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland
| | - Martin T. Gaugg
- Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland
| | - Tobias Bruderer
- Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland
| | - Renato Zenobi
- Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland
| | - Pablo M.-L. Sinues
- Department of Chemistry and Applied Biosciences, ETH Zurich, 8093 Zurich, Switzerland
- University Children’s Hospital Basel, University of Basel, 4056 Basel, Switzerland
- Department of Biomedical Engineering, University of Basel, 4123 Allschwil, Switzerland
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Dutta D, Chong NS, Lim SH. Endogenous volatile organic compounds in acute myeloid leukemia: origins and potential clinical applications. J Breath Res 2018; 12:034002. [PMID: 29463782 DOI: 10.1088/1752-7163/aab108] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Not unlike many cancer types, acute myeloid leukemia (AML) exhibits many metabolic changes and reprogramming, causing changes in lipid metabolism. Some of the distinct molecular abnormalities associated with AML also modify the metabolic changes. Both processes result in changes in the production of endogenous volatile organic compounds (VOCs). The increasing availability of highly sensitive methods for detecting trace chemicals provides the opportunity to investigate the role of patient-specific VOC finger-prints as biomarkers for detecting early relapse or minimal residual disease in AML. Since VOC production is reliant on metabolic activities, when combined with currently available methods, VOC analysis may identify within a group of patients with flow cytometric or molecular evidence of residual disease those most at risk for disease relapse.
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Affiliation(s)
- Dibyendu Dutta
- Department of Professional Sciences, Middle Tennessee State University, Murfreesboro, Tennessee, United States of America
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Singh KD, Del Miguel GV, Gaugg MT, Ibañez AJ, Zenobi R, Kohler M, Frey U, Sinues PML. Translating secondary electrospray ionization-high-resolution mass spectrometry to the clinical environment. J Breath Res 2018; 12:027113. [PMID: 29411710 DOI: 10.1088/1752-7163/aa9ee3] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
While there has been progress in making use of breath tests to guide clinical decision making, the full potential of exhaled breath analysis still remains to be exploited. Here we summarize some of the reasons why this is the case, what we have done so far to overcome some of the existing obstacles, and our vision of how we think breath analysis will play a more prominent role in the coming years. In particular, we envision that real-time high-resolution mass spectrometry will provide valuable information in biomarker discovery studies. However, this can only be achieved by a coordinated effort, using standardized equipment and methods in multi-center studies to eventually deliver tangible advances in the field of breath analysis in a clinical setting. Concrete aspects such as sample integrity, compound identification, quantification and standardization are discussed. Novel secondary electrospray ionization developments with the aim of facilitating inter-groups comparisons and biomarker validation studies are also presented.
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Affiliation(s)
- Kapil Dev Singh
- University of Basel Children's Hospital, Basel, Switzerland. Department of Biomedical Engineering, University of Basel, Basel, Switzerland
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12
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Bregy L, Nussbaumer-Ochsner Y, Martinez-Lozano Sinues P, García-Gómez D, Suter Y, Gaisl T, Stebler N, Gaugg MT, Kohler M, Zenobi R. Real-time mass spectrometric identification of metabolites characteristic of chronic obstructive pulmonary disease in exhaled breath. CLINICAL MASS SPECTROMETRY (DEL MAR, CALIF.) 2018; 7:29-35. [PMID: 39193555 PMCID: PMC11322756 DOI: 10.1016/j.clinms.2018.02.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 01/08/2018] [Accepted: 02/07/2018] [Indexed: 12/12/2022]
Abstract
Background New mass spectrometry (MS) techniques analysing exhaled breath have the potential to better define airway diseases. Here, we present our work to profile the volatile organic compounds (VOCs) in exhaled breath from patients with chronic obstructive pulmonary disease (COPD), using real-time MS, and relate this disease-specific breath profile to functional disease markers. Methods In a matched cohort study, patients with COPD, according to GOLD criteria, were recruited. Exhaled breath analysis by untargeted MS was performed using secondary electrospray ionization - high-resolution MS (SESI-HRMS). Results Exhaled breath from 22 patients with COPD (mean age 58.6 ± 6.9 years, FEV1 58.5 ± 19.9% predicted, 32.4 ± 19.2 pack years smoking) and 14 controls (mean age 58.1 ± 8.1 years, FEV1 102.5 ± 11.3% predicted, 23.6 ± 12.5 pack years smoking) was analysed using SESI-HRMS. From 1441 different features, 43 markers were identified that allowed discrimination between the two groups with an accuracy of 89% (CI 74-97%), a sensitivity of 93%, and a specificity of 86%. The markers were determined to be metabolites of oxidative stress processes, such as fatty acids, aldehydes and amino acids, resulting from lung muscle degradation. Conclusion Real-time breath analysis by SESI-MS allows molecular profiling of exhaled breath, can distinguish patients with COPD from matched healthy controls and provides insights into the disease pathogenesis.
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Affiliation(s)
- Lukas Bregy
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | | | - Pablo Martinez-Lozano Sinues
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
- Department of Biomedical Engineering, University of Basel, Basel, Switzerland
- University Children’s Hospital Basel, Basel, Switzerland
| | - Diego García-Gómez
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | - Yannick Suter
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | - Thomas Gaisl
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Nina Stebler
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
| | - Martin Thomas Gaugg
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
| | - Malcolm Kohler
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Renato Zenobi
- Department of Chemistry and Applied Biosciences, ETH Zurich, Zurich, Switzerland
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Perez‐Hurtado P, Palmer E, Owen T, Aldcroft C, Allen M, Jones J, Creaser C, Lindley M, Turner M, Reynolds J. Direct analysis of volatile organic compounds in foods by headspace extraction atmospheric pressure chemical ionisation mass spectrometry. RAPID COMMUNICATIONS IN MASS SPECTROMETRY : RCM 2017; 31:1947-1956. [PMID: 28857369 PMCID: PMC5656932 DOI: 10.1002/rcm.7975] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/22/2017] [Accepted: 08/23/2017] [Indexed: 06/01/2023]
Abstract
RATIONALE The rapid screening of volatile organic compounds (VOCs) by direct analysis has potential applications in the areas of food and flavour science. Currently, the technique of choice for VOC analysis is gas chromatography/mass spectrometry (GC/MS). However, the long chromatographic run times and elaborate sample preparation associated with this technique have led a movement towards direct analysis techniques, such as selected ion flow tube mass spectrometry (SIFT-MS), proton transfer reaction mass spectrometry (PTR-MS) and electronic noses. The work presented here describes the design and construction of a Venturi jet-pump-based modification for a compact mass spectrometer which enables the direct introduction of volatiles for qualitative and quantitative analysis. METHODS Volatile organic compounds were extracted from the headspace of heated vials into the atmospheric pressure chemical ionization source of a quadrupole mass spectrometer using a Venturi pump. Samples were analysed directly with no prior sample preparation. Principal component analysis (PCA) was used to differentiate between different classes of samples. RESULTS The interface is shown to be able to routinely detect problem analytes such as fatty acids and biogenic amines without the requirement of a derivatisation step, and is shown to be able to discriminate between four different varieties of cheese with good intra and inter-day reproducibility using an unsupervised PCA model. Quantitative analysis is demonstrated using indole standards with limits of detection and quantification of 0.395 μg/mL and 1.316 μg/mL, respectively. CONCLUSIONS The described methodology can routinely detect highly reactive analytes such as volatile fatty acids and diamines without the need for a derivatisation step or lengthy chromatographic separations. The capability of the system was demonstrated by discriminating between different varieties of cheese and monitoring the spoilage of meats.
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Affiliation(s)
- P. Perez‐Hurtado
- Centre for Analytical Science, Department of ChemistryLoughborough UniversityAshby RoadLoughboroughLE11 3TUUK
| | - E. Palmer
- Centre for Analytical Science, Department of ChemistryLoughborough UniversityAshby RoadLoughboroughLE11 3TUUK
| | - T. Owen
- Centre for Analytical Science, Department of ChemistryLoughborough UniversityAshby RoadLoughboroughLE11 3TUUK
| | - C. Aldcroft
- Advion LtdKao Hockham Building, Edinburgh WayHarlowCM20 2NQUK
| | - M.H. Allen
- Advion LtdKao Hockham Building, Edinburgh WayHarlowCM20 2NQUK
| | - J. Jones
- Advion Inc.10 Brown Road, Suite 101IthacaNY14850USA
| | - C.S. Creaser
- Centre for Analytical Science, Department of ChemistryLoughborough UniversityAshby RoadLoughboroughLE11 3TUUK
| | - M.R. Lindley
- School of Sports, Exercise and Health SciencesLoughborough UniversityAshby RoadLoughboroughLE11 3TUUK
| | - M.A. Turner
- Centre for Analytical Science, Department of ChemistryLoughborough UniversityAshby RoadLoughboroughLE11 3TUUK
| | - J.C. Reynolds
- Centre for Analytical Science, Department of ChemistryLoughborough UniversityAshby RoadLoughboroughLE11 3TUUK
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Neerincx AH, Geurts BP, van Loon J, Tiemes V, Jansen JJ, Harren FJM, Kluijtmans LAJ, Merkus PJFM, Cristescu SM, Buydens LMC, Wevers RA. Detection of Staphylococcus aureus in cystic fibrosis patients using breath VOC profiles. J Breath Res 2016; 10:046014. [PMID: 27902490 DOI: 10.1088/1752-7155/10/4/046014] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Staphylococcus aureus (S. aureus) is a common bacterium infecting children with cystic fibrosis (CF). Since current detection methods are difficult to perform in children, there is need for an alternative. This proof of concept study investigates whether breath profiles can discriminate between S. aureus infected and non-infected CF patients based on volatile organic compounds (VOCs). We collected exhaled breath of CF patients with and without S. aureus airways infections in which VOCs were identified using gas chromatography-mass spectrometry. We classified these VOC profiles with sparse partial least squares discriminant analysis. Multivariate breath VOC profiles discriminated infected from non-infected CF patients with high sensitivity (100%) and specificity (80%). We identified the nine compounds most important for this discrimination. We successfully detected S. aureus infection in CF patients, using breath VOC profiles. Nine highlighted compounds can be used as a focus point in further biomarker identification research. The results show considerable potential for non-invasive diagnosis of airway infections.
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Affiliation(s)
- A H Neerincx
- Department of Molecular and Laser Physics, Institute for Molecules and Materials, Radboud University, Nijmegen, The Netherlands. Department of Paediatrics, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, The Netherlands. Authors contributed equally to this work
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15
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Martin HJ, Turner MA, Bandelow S, Edwards L, Riazanskaia S, Thomas CLP. Volatile organic compound markers of psychological stress in skin: a pilot study. J Breath Res 2016; 10:046012. [DOI: 10.1088/1752-7155/10/4/046012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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16
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Real-time monitoring of exhaled volatiles using atmospheric pressure chemical ionization on a compact mass spectrometer. Bioanalysis 2016; 8:1325-36. [DOI: 10.4155/bio-2016-0045] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Aim: Breath analyses have potential to detect early signs of disease onset. Ambient ionization allows direct combination of breath gases with MS for fast, on-line analysis. Portable MS systems would facilitate field/clinic-based breath analyses. Results & methodology: Volunteers ingested peppermint oil capsules and exhaled volatile compounds were monitored over 10 h using a compact mass spectrometer. A rise and fall in exhaled menthone was observed, peaking at 60–120 min. Real-time analysis showed a gradual rise in exhaled menthone postingestion. Sensitivity was comparable to established methods, with detection in the parts per trillion range. Conclusion: Breath volatiles were readily analyzed on a portable mass spectrometer through a simple inlet modification. Induced changes in exhaled profiles were detectable with high sensitivity and measurable in real-time.
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17
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Techniques and issues in breath and clinical sample headspace analysis for disease diagnosis. Bioanalysis 2016; 8:677-90. [PMID: 26978667 DOI: 10.4155/bio.16.22] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Analysis of volatile organic compounds (VOCs) from breath or clinical samples for disease diagnosis is an attractive proposition because it is noninvasive and rapid. There are numerous studies showing its potential, yet there are barriers to its development. Sampling and sample handling is difficult, and when coupled with a variety of analytical instrumentation, the same samples can give different results. Background air and the environment a person has been exposed to can greatly affect the VOCs emitted by the body; however, this is not an easy problem to solve. This review investigates the use of VOCs in disease diagnosis, the analytical techniques employed and the problems associated with sample handling and standardization. It then suggests the barriers to future development.
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18
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Barrios-Collado C, García-Gómez D, Zenobi R, Vidal-de-Miguel G, Ibáñez AJ, Martinez-Lozano Sinues P. Capturing in Vivo Plant Metabolism by Real-Time Analysis of Low to High Molecular Weight Volatiles. Anal Chem 2016; 88:2406-12. [PMID: 26814403 DOI: 10.1021/acs.analchem.5b04452] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We have deployed an efficient secondary electrospray ionization source coupled to an Orbitrap mass analyzer (SESI-MS) to investigate the emissions of a Begonia semperflorens. We document how hundreds of species can be tracked with an unparalleled time resolution of 2 min during day-night cycles. To further illustrate the capabilities of this system for volatile organic compounds (VOCs) analysis, we subjected the plant to mechanical damage and monitored its response. As a result, ∼1200 VOCs were monitored displaying different kinetics. To validate the soundness of our in vivo measurements, we fully characterized some key compounds via tandem mass spectrometry (MS/MS) and confirmed their expected behavior based on prior gas chromatography/mass spectrometry (GC/MS) studies. For example, β-caryophyllene, which is directly related to photosynthesis, was found to show a periodic day-night pattern with highest concentrations during the day. We conclude that the capability of SESI-MS to capture highly dynamic VOC emissions and wide analyte coverage makes it an attractive tool to complement GC/MS in plant studies.
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Affiliation(s)
- César Barrios-Collado
- Department of Energy Engineering and Fluid Dynamics, University of Valladolid , 47002 Valladolid, Spain.,SEADM S.L., 28036 Madrid, Spain.,Department of Chemistry and Applied Biosciences, ETH Zurich , 8093 Zurich, Switzerland
| | - Diego García-Gómez
- Department of Chemistry and Applied Biosciences, ETH Zurich , 8093 Zurich, Switzerland
| | - Renato Zenobi
- Department of Chemistry and Applied Biosciences, ETH Zurich , 8093 Zurich, Switzerland
| | - Guillermo Vidal-de-Miguel
- Department of Chemistry and Applied Biosciences, ETH Zurich , 8093 Zurich, Switzerland.,Fossil Ion Technology S.L., 28036 Madrid, Spain
| | - Alfredo J Ibáñez
- Department of Chemistry and Applied Biosciences, ETH Zurich , 8093 Zurich, Switzerland.,Science Zurich - Zurich PhD Program Molecular Life Sciences, 8093 Zurich, Switzerland
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Cavaleiro Rufo J, Madureira J, Oliveira Fernandes E, Moreira A. Volatile organic compounds in asthma diagnosis: a systematic review and meta-analysis. Allergy 2016; 71:175-88. [PMID: 26476125 DOI: 10.1111/all.12793] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 01/01/2023]
Abstract
We aimed to assess the value and classification rate of exhaled volatile organic compounds (VOCs) in asthma diagnosis. A PRISMA-oriented systematic search for published studies regarding exhaled VOCs in asthma diagnosis was conducted based on predefined criteria. Studies presenting sensitivity and specificity values for the test were included in the meta-analysis. Pooled diagnosis odds ratios (DOR), area under the curve (AUC) and positive and negative likelihood ratios (LR) for exhaled VOC profiles were calculated; and publication bias, threshold effect and heterogeneity were estimated. Eighteen studies were selected for the qualitative analysis and six met the criteria for inclusion in the quantitative analysis. Mean (95% CI) pooled DOR, positive and negative LR were 49.3 (15.9-153.3), 5.86 (3.07-11.21) and 0.16 (0.10-0.26), respectively. The AUC value was 0.94. Only three of the 18 reviewed studies performed an external validation of the model using a different data set. The results from the revised studies suggest that exhaled VOCs are promising biomarkers for asthma diagnosis and that several compounds, mainly alkanes, may be significantly associated with asthma inflammation. However, there are still various constraints associated with standardization and externally validated studies are needed to introduce exhaled VOC profiling in a clinical scenario.
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Affiliation(s)
- J. Cavaleiro Rufo
- GEAC; INEGI - Institute of Science and Innovation in Mechanical Engineering and Industrial Management; Porto Portugal
- Faculty of Medicine of the University of Porto; Portugal & Centro Hospitalar São João E.P.E.; Porto Portugal
| | - J. Madureira
- GEAC; INEGI - Institute of Science and Innovation in Mechanical Engineering and Industrial Management; Porto Portugal
| | - E. Oliveira Fernandes
- GEAC; INEGI - Institute of Science and Innovation in Mechanical Engineering and Industrial Management; Porto Portugal
| | - A. Moreira
- Faculty of Medicine of the University of Porto; Portugal & Centro Hospitalar São João E.P.E.; Porto Portugal
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20
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Tien HW, Ou YM, Hsu RY, Wang TS, Her GR. Letter: The formation of a M + 2 compound in the analysis of a trimethylsilyl derivative of monocarboxylic acids by gas chromatography electrospray ionization mass spectrometry. EUROPEAN JOURNAL OF MASS SPECTROMETRY (CHICHESTER, ENGLAND) 2016; 22:145-150. [PMID: 27553737 DOI: 10.1255/ejms.1418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
The trimethylsilyl (TMS) derivative is one of the most widely utilized derivatives for analyzing polar compounds by gas chromatography. An ion two mass units higher than the protonated molecular ion was observed in analyzing TMS-monocarboxylic acids by using gas chromatography electrospray ionization mass spectrometry (GC-ESI/MS). The structure of the M + 2 compound was investigated using tandem mass spectrometry and high-resolution mass spectrometry. The results suggest that one methyl group bound to the silicon atom was replaced by a hydroxyl group during the ESI process. One possible mechanism for the formation of the M + 2 compound is proposed. This observation suggests the possibility of synthesizing an organic compound by using ESI.
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Affiliation(s)
- Hsin-Wen Tien
- Department of Chemistry, National Taiwan University, Taipei, Taiwan
| | - Yu-Meng Ou
- Department of Chemistry, National Taiwan University, Taipei, Taiwan
| | - Ren-Yu Hsu
- Department of Chemistry, National Taiwan University, Taipei, Taiwan
| | - Tsung-Shing Wang
- Department of Chemistry, National Taiwan University, Taipei, Taiwan
| | - Guor-Rong Her
- Department of Chemistry, National Taiwan University, Taipei, Taiwan.
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21
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Li DX, Gan L, Bronja A, Schmitz OJ. Gas chromatography coupled to atmospheric pressure ionization mass spectrometry (GC-API-MS): Review. Anal Chim Acta 2015; 891:43-61. [DOI: 10.1016/j.aca.2015.08.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/20/2015] [Accepted: 08/02/2015] [Indexed: 10/23/2022]
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Pereira J, Porto-Figueira P, Cavaco C, Taunk K, Rapole S, Dhakne R, Nagarajaram H, Câmara JS. Breath analysis as a potential and non-invasive frontier in disease diagnosis: an overview. Metabolites 2015; 5:3-55. [PMID: 25584743 PMCID: PMC4381289 DOI: 10.3390/metabo5010003] [Citation(s) in RCA: 149] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 12/12/2014] [Indexed: 02/06/2023] Open
Abstract
Currently, a small number of diseases, particularly cardiovascular (CVDs), oncologic (ODs), neurodegenerative (NDDs), chronic respiratory diseases, as well as diabetes, form a severe burden to most of the countries worldwide. Hence, there is an urgent need for development of efficient diagnostic tools, particularly those enabling reliable detection of diseases, at their early stages, preferably using non-invasive approaches. Breath analysis is a non-invasive approach relying only on the characterisation of volatile composition of the exhaled breath (EB) that in turn reflects the volatile composition of the bloodstream and airways and therefore the status and condition of the whole organism metabolism. Advanced sampling procedures (solid-phase and needle traps microextraction) coupled with modern analytical technologies (proton transfer reaction mass spectrometry, selected ion flow tube mass spectrometry, ion mobility spectrometry, e-noses, etc.) allow the characterisation of EB composition to an unprecedented level. However, a key challenge in EB analysis is the proper statistical analysis and interpretation of the large and heterogeneous datasets obtained from EB research. There is no standard statistical framework/protocol yet available in literature that can be used for EB data analysis towards discovery of biomarkers for use in a typical clinical setup. Nevertheless, EB analysis has immense potential towards development of biomarkers for the early disease diagnosis of diseases.
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Affiliation(s)
- Jorge Pereira
- CQM-Centro de Química da Madeira, Universidade da Madeira, Campus Universitário da Penteada, Funchal 9000-390, Portugal.
| | - Priscilla Porto-Figueira
- CQM-Centro de Química da Madeira, Universidade da Madeira, Campus Universitário da Penteada, Funchal 9000-390, Portugal.
| | - Carina Cavaco
- CQM-Centro de Química da Madeira, Universidade da Madeira, Campus Universitário da Penteada, Funchal 9000-390, Portugal.
| | - Khushman Taunk
- Proteomics Lab, National Centre for Cell Science, Ganeshkhind, Pune 411007, India.
| | - Srikanth Rapole
- Proteomics Lab, National Centre for Cell Science, Ganeshkhind, Pune 411007, India.
| | - Rahul Dhakne
- Laboratory of Computational Biology, Centre for DNA Fingerprinting & Diagnostics, Hyderabad, Andhra Pradesh 500 001, India.
| | - Hampapathalu Nagarajaram
- Laboratory of Computational Biology, Centre for DNA Fingerprinting & Diagnostics, Hyderabad, Andhra Pradesh 500 001, India.
| | - José S Câmara
- CQM-Centro de Química da Madeira, Universidade da Madeira, Campus Universitário da Penteada, Funchal 9000-390, Portugal.
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Beauchamp J, Risby TH. A recognition of David Smith's unique contributions to the field of breath analysis. J Breath Res 2014; 8:030201. [PMID: 25189283 DOI: 10.1088/1752-7155/8/3/030201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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