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Yammine L, Tovar M, Yammine NA, Becker C, Weaver MF. E-cigarettes and Youth: The Known, the Unknown, and Implications for Stakeholders. J Addict Med 2024:01271255-990000000-00298. [PMID: 38498621 DOI: 10.1097/adm.0000000000001304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
ABSTRACT Despite the decline in the prevalence of e-cigarette use among youth during the coronavirus disease 2019 pandemic, more than 2.5 million of US high and middle schoolers are still using e-cigarettes. Furthermore, those who use e-cigarettes are starting at a younger age and are using them more intensely, reflecting, at least in part, a high addiction liability of modern e-cigarettes. Beyond addiction, accumulating evidence suggests that, in the short-term, e-cigarettes are associated with cardiovascular and pulmonary effects, whereas the long-term effects of e-cigarette use are yet to be established. The aim of this review is to synthesize current knowledge on e-cigarette use among youth, including established and potential risks and efforts to date to curb youth exposure to e-cigarettes. In addition, we provide recommendations for health care providers, researchers, and other stakeholders to address this significant public health issue.
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Affiliation(s)
- Luba Yammine
- From the Louis A. Faillace, MD, Department of Psychiatry and Behavioral Sciences, UTHealth McGovern Medical School, Houston, TX (LY, MFW); University of Texas Health Science Center at Houston, Houston, TX (MT, CB); and University of Texas Health Science Center at San Antonio, San Antonio, TX (NAY)
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2
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House EL, Kim SY, Chalupa D, Hernady E, Groves AM, Johnston CJ, McGraw MD. IL-17A neutralization fails to attenuate airway remodeling and potentiates a proinflammatory lung microenvironment in diacetyl-exposed rats. Am J Physiol Lung Cell Mol Physiol 2023; 325:L434-L446. [PMID: 37642674 PMCID: PMC10639012 DOI: 10.1152/ajplung.00082.2023] [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: 03/16/2023] [Revised: 08/04/2023] [Accepted: 08/09/2023] [Indexed: 08/31/2023] Open
Abstract
Bronchiolitis obliterans (BO) is a devastating lung disease that can develop following inhalation exposure to certain chemicals. Diacetyl (DA) is one chemical commonly associated with BO development when inhaled at occupational levels. Previous studies in rats have shown that repetitive DA vapor exposures increased lung CD4+CD25+ T cells and bronchoalveolar (BAL) interleukin-17A (IL-17A) concentrations concurrent with the development of airway remodeling. We hypothesized that IL-17A neutralization would attenuate the severity of airway remodeling after repetitive DA vapor exposures. Sprague-Dawley rats were exposed to 200 parts-per-million DA vapor or filtered air (RA) for 6 h/day × 5 days and monitored for 2 wk postexposure. Treatment with IL-17A neutralization (αIL-17A) or IgG (control) began immediately following exposures and continued twice weekly until study's end. Lungs were harvested for histology, flow cytometry, and BAL analyses. Survival, oxygen saturations, and percent weight change decreased significantly in DA-exposed versus RA-exposed rats, but did not differ significantly between DA + αIL-17A versus DA + IgG. Similarly, the number nor severity of airway lesions did not differ significantly between DA + αIL-17A versus DA + IgG rats despite the percentage of lung regulatory T cells increasing with decreased BAL IL-17A concentrations. Ashcroft scoring of the distal lung parenchyma suggested worse parenchymal remodeling in DA + αIL-17A versus DA + IgG rats with increased expression of tumor necrosis factor-alpha (TNF-α), interleukin-1 beta (IL-1β), and nuclear factor-kappa B (NF-κB). Collectively, IL-17A neutralization in DA-exposed rats failed to attenuate airway remodeling with increased expression of pro-inflammatory cytokines TNF-α, IL-1β, and NF-κB.NEW & NOTEWORTHY Interleukin-17A (IL-17A) neutralization has shown benefit previously in preclinical models of transplant-associated bronchiolitis obliterans (BO), yet it remains unknown whether IL-17A neutralization has similar benefit for other forms of BO. Here, IL-17A neutralization fails to prevent severe airway remodeling in rats exposed repetitively to the flavoring chemical diacetyl, and instead, promotes a proinflammatory microenvironment with increased expression of TNF-α, IL-1β, and NF-κB within the lung.
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Affiliation(s)
- Emma L House
- Department of Pathology, University of Rochester Medical Center, Rochester, New York, United States
- Department of Pediatrics, Division of Pediatric Pulmonology, University of Rochester Medical Center, Rochester, New York, United States
| | - So-Young Kim
- Department of Pediatrics, Division of Pediatric Pulmonology, University of Rochester Medical Center, Rochester, New York, United States
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, New York, United States
| | - David Chalupa
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, New York, United States
| | - Eric Hernady
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, New York, United States
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York, United States
| | - Angela M Groves
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, New York, United States
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York, United States
- Department of Pediatrics, Division of Neonatology, University of Rochester Medical Center, Rochester, New York, United States
| | - Carl J Johnston
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, New York, United States
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, New York, United States
- Department of Pediatrics, Division of Neonatology, University of Rochester Medical Center, Rochester, New York, United States
| | - Matthew D McGraw
- Department of Pediatrics, Division of Pediatric Pulmonology, University of Rochester Medical Center, Rochester, New York, United States
- Department of Environmental Medicine, University of Rochester Medical Center, Rochester, New York, United States
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3
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Gutor SS, Miller RF, Blackwell TS, Polosukhin VV. Environmental and occupational bronchiolitis obliterans: new reality. EBioMedicine 2023; 95:104760. [PMID: 37598462 PMCID: PMC10458287 DOI: 10.1016/j.ebiom.2023.104760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 07/10/2023] [Accepted: 08/02/2023] [Indexed: 08/22/2023] Open
Abstract
Patients diagnosed with environmental/occupational bronchiolitis obliterans (BO) over the last 2 decades often present with an indolent evolution of respiratory symptoms without a history of high-level, acute exposure to airborne toxins. Exertional dyspnea is the most common symptom and standard clinical and radiographic evaluation can be non-diagnostic. Lung biopsies often reveal pathological abnormalities affecting all distal lung compartments. These modern cases of BO typically exhibit the constrictive bronchiolitis phenotype of small airway remodeling, along with lymphocytic inflammation. In addition, hypertensive-type remodeling of intrapulmonary vasculature, diffuse fibroelastosis of alveolar tissue, and fibrous thickening of visceral pleura are frequently present. The diagnosis of environmental/occupational BO should be considered in patients who present with subacute onset of exertional dyspnea and a history compatible with prolonged or recurrent exposure to environmental toxins. Important areas for future studies include development of less invasive diagnostic approaches and testing of novel agents for disease prevention and treatment.
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Affiliation(s)
- Sergey S Gutor
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert F Miller
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Timothy S Blackwell
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA; Veterans Affairs Medical Center, Nashville, TN, USA
| | - Vasiliy V Polosukhin
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
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Salama M, Mohammed DM, Fahmy K, Al-Senosy NK, Ebeed NM, Farouk A. Evaluation of the cytotoxicity and genotoxicity potential of synthetic diacetyl food flavoring in silico, in vivo, and in vitro. Food Chem Toxicol 2023:113923. [PMID: 37399938 DOI: 10.1016/j.fct.2023.113923] [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: 04/20/2023] [Revised: 06/24/2023] [Accepted: 06/28/2023] [Indexed: 07/05/2023]
Abstract
Diacetyl is a common ingredient that creates a buttery flavor in baked goods and other food products. The cytotoxic impact of diacetyl on a normal human liver cell line (THLE2) indicated an IC50 value of 41.29 mg/ml through MTT assay and a cell cycle arrest in the G0/G1 phase relative to the control. Administration of diacetyl at two-time points (acute-chronic) led to a significant increase in DNA damage indicated by the increase in tail length, tail DNA%, and tail moment. The mRNA and protein expression levels of genes in the rats' livers were then measured using real-time PCR and western blotting. The results showed an activation of the apoptotic and necrosis mechanism, with an upregulation of p53, Caspase 3, and RIP1 and a downregulation of Bcl-2 at the mRNA level. The ingestion of diacetyl disrupted the liver's oxidant/antioxidant balance, as evidenced by alterations in levels of GSH, SOD, CAT, GPx, GR, MDA, NO, and peroxynitrite. Additionally, heightened levels of inflammatory cytokines were shown. Histopathological examinations revealed necrotic foci and congested portal areas in the rats' liver cells after treatment with diacetyl. Diacetyl may interact moderately with Caspase, RIP1, and p53 core domain through In-silico, possibly resulting in upregulated gene expression.
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Affiliation(s)
- Mohamed Salama
- Preventive Medicine Dept, Health Affairs Directorate, Ministry of Health, Ataba, 11511, Cairo, Egypt
| | - Dina Mostafa Mohammed
- Nutrition and Food Sciences Department, National Research Centre, Cairo, 12622, Egypt
| | - Khaled Fahmy
- Genetics Department, Faculty of Agriculture, Ain Shams University, Hadayek Shoubra, 11241, Cairo, Egypt
| | - Neima K Al-Senosy
- Genetics Department, Faculty of Agriculture, Ain Shams University, Hadayek Shoubra, 11241, Cairo, Egypt
| | - Naglaa M Ebeed
- Genetics Department, Faculty of Agriculture, Ain Shams University, Hadayek Shoubra, 11241, Cairo, Egypt
| | - Amr Farouk
- Flavour and Aroma Chemistry Department, National Research Centre, Cairo, 12622, Egypt.
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Kim MD, Chung S, Baumlin N, Sun L, Silswal N, Dennis JS, Yoshida M, Sabater J, Horrigan FT, Salathe M. E-cigarette aerosols of propylene glycol impair BK channel activity and parameters of mucociliary function. Am J Physiol Lung Cell Mol Physiol 2023; 324:L468-L479. [PMID: 36809074 PMCID: PMC10042605 DOI: 10.1152/ajplung.00157.2022] [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: 05/16/2022] [Revised: 01/26/2023] [Accepted: 02/13/2023] [Indexed: 02/23/2023] Open
Abstract
Propylene glycol (PG) is a common delivery vehicle for nicotine and flavorings in e-cigarette (e-cig) liquids and is largely considered safe for ingestion. However, little is known about its effects as an e-cig aerosol on the airway. Here, we investigated whether pure PG e-cig aerosols in realistic daily amounts impact parameters of mucociliary function and airway inflammation in a large animal model (sheep) in vivo and primary human bronchial epithelial cells (HBECs) in vitro. Five-day exposure of sheep to e-cig aerosols of 100% PG increased mucus concentrations (% mucus solids) of tracheal secretions. PG e-cig aerosols further increased the activity of matrix metalloproteinase-9 (MMP-9) in tracheal secretions. In vitro exposure of HBECs to e-cig aerosols of 100% PG decreased ciliary beating and increased mucus concentrations. PG e-cig aerosols further reduced the activity of large conductance, Ca2+-activated, and voltage-dependent K+ (BK) channels. We show here for the first time that PG can be metabolized to methylglyoxal (MGO) in airway epithelia. PG e-cig aerosols increased levels of MGO and MGO alone reduced BK activity. Patch-clamp experiments suggest that MGO can disrupt the interaction between the major pore-forming BK subunit human Slo1 (hSlo1) and the gamma regulatory subunit LRRC26. PG exposures also caused a significant increase in mRNA expression levels of MMP9 and interleukin 1 beta (IL1B). Taken together, these data show that PG e-cig aerosols cause mucus hyperconcentration in sheep in vivo and HBECs in vitro, likely by disrupting the function of BK channels important for airway hydration.
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Affiliation(s)
- Michael D Kim
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Samuel Chung
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Nathalie Baumlin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Liang Sun
- Department of Integrative Physiology, Baylor College of Medicine, Houston, Texas, United States
| | - Neerupma Silswal
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - John S Dennis
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Makoto Yoshida
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Juan Sabater
- Department of Research, Mount Sinai Medical Center, Miami Beach, Florida, United States
| | - Frank T Horrigan
- Department of Integrative Physiology, Baylor College of Medicine, Houston, Texas, United States
| | - Matthias Salathe
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States
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Kreuter M, Behr J, Bonella F, Costabel U, Gerber A, Hamer OW, Heussel CP, Jonigk D, Krause A, Koschel D, Leuschner G, Markart P, Nowak D, Pfeifer M, Prasse A, Wälscher J, Winter H, Kabitz HJ. [Consensus guideline on the interdisciplinary diagnosis of interstitial lung diseases]. Pneumologie 2023; 77:269-302. [PMID: 36977470 DOI: 10.1055/a-2017-8971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
The evaluation of a patient with interstitial lung disease (ILD) includes assessment of clinical, radiological, and often histopathological data. As there were no specific recommendations to guide the evaluation of patients under the suspicion of an ILD within the German practice landscape, this position statement from an interdisciplinary panel of ILD experts provides guidance related to the diagnostic modalities which should be used in the evaluation of ILD. This includes clinical assessment rheumatological evaluation, radiological examinations, histopathologic sampling and the need for a final discussion in a multidisciplinary team.
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Affiliation(s)
- Michael Kreuter
- Universitäres Lungenzentrum Mainz, Abteilungen für Pneumologie, ZfT, Universitätsmedizin Mainz und Pneumologie, Beatmungs- und Schlafmedizin, Marienhaus Klinikum Mainz
- Zentrum für interstitielle und seltene Lungenerkrankungen, Thoraxklinik, Universitätsklinikum Heidelberg und Klinik für Pneumologie, Klinikum Ludwigsburg
- Deutsches Zentrum für Lungenforschung
| | - Jürgen Behr
- Medizinische Klinik und Poliklinik V, LMU Klinikum der Universität München
- Deutsches Zentrum für Lungenforschung
| | - Francesco Bonella
- Zentrum für interstitielle und seltene Lungenerkrankungen, Ruhrlandklinik, Universitätsmedizin Essen
| | - Ulrich Costabel
- Zentrum für interstitielle und seltene Lungenerkrankungen, Ruhrlandklinik, Universitätsmedizin Essen
| | - Alexander Gerber
- Rheumazentrum Halensee, Berlin und Institut für Arbeits- Sozial- und Umweltmedizin, Goetheuniversität Frankfurt am Main
| | - Okka W Hamer
- Institut für Röntgendiagnostik, Universitätsklinikum Regensburg und Abteilung für Radiologie, Klinik Donaustauf, Donaustauf
| | - Claus Peter Heussel
- Diagnostische und interventionelle Radiologie, Thoraxklinik Heidelberg, Universitätsklinikum Heidelberg
- Deutsches Zentrum für Lungenforschung
| | - Danny Jonigk
- Institut für Pathologie, Medizinische Hochschule Hannover und Institut für Pathologie, RWTH Universitätsklinikum Aachen
- Deutsches Zentrum für Lungenforschung
| | - Andreas Krause
- Abteilung für Rheumatologie, klinische Immunologie und Osteologie, Immanuel Krankenhaus Berlin
| | - Dirk Koschel
- Abteilung für Innere Medizin und Pneumologie, Fachkrankenhaus Coswig, Lungenzentrum, Coswig und Bereich Pneumologie der Medizinischen Klinik, Carl Gustav Carus Universitätsklinik, Dresden
| | - Gabriela Leuschner
- Medizinische Klinik und Poliklinik V, LMU Klinikum der Universität München
- Deutsches Zentrum für Lungenforschung
| | - Philipp Markart
- Medizinische Klinik V, Campus Fulda, Universitätsmedizin Marburg und Medizinische Klinik und Poliklinik, Universitätsklinikum Gießen
- Deutsches Zentrum für Lungenforschung
| | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU Klinikum, München
| | - Michael Pfeifer
- Klinik für Pneumologie und konservative Intensivmedizin, Krankenhaus Barmherzige Brüder Regensburg
| | - Antje Prasse
- Klinik für Pneumologie und Infektionsmedizin, Medizinische Hochschule Hannover und Abteilung für Fibroseforschung, Fraunhofer ITEM
- Deutsches Zentrum für Lungenforschung
| | - Julia Wälscher
- Zentrum für interstitielle und seltene Lungenerkrankungen, Ruhrlandklinik, Universitätsmedizin Essen
| | - Hauke Winter
- Abteilung für Thoraxchirurgie, Thoraxklinik, Universität Heidelberg, Heidelberg
- Deutsches Zentrum für Lungenforschung
| | - Hans-Joachim Kabitz
- II. Medizinische Klinik, Pneumologie und Internistische Intensivmedizin, Klinikum Konstanz, GLKN, Konstanz
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de Almeida GC, Mizutani RF, Terra-Filho M, Santos UDP. Constrictive bronchiolitis secondary to exposure to flavoring agents: a little known occupational hazard. J Bras Pneumol 2023; 49:e20220328. [PMID: 36700574 PMCID: PMC9970363 DOI: 10.36416/1806-3756/e20220328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Gustavo Corrêa de Almeida
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clinicas Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Rafael Futoshi Mizutani
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clinicas Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Mario Terra-Filho
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clinicas Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Ubiratan de Paula Santos
- . Divisão de Pneumologia, Instituto do Coração - InCor - Hospital das Clinicas Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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Alhadyan SK, Sivaraman V, Onyenwoke RU. E-cigarette Flavors, Sensory Perception, and Evoked Responses. Chem Res Toxicol 2022; 35:2194-2209. [PMID: 36480683 DOI: 10.1021/acs.chemrestox.2c00268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The chemosensory experiences evoked by flavors encompass a number of unique sensations that include olfactory stimuli (smell), gustatory stimuli (taste, i.e., salty, sweet, sour, bitter, and umami (also known as "savoriness")), and chemesthesis (touch). As such, the responses evoked by flavors are complex and, as briefly stated above, involve multiple perceptive mechanisms. The practice of adding flavorings to tobacco products dates back to the 17th century but is likely much older. More recently, the electronic cigarette or "e-cigarette" and its accompanying flavored e-liquids emerged on to the global market. These new products contain no combustible tobacco but often contain large concentrations (reported from 0 to more than 50 mg/mL) of nicotine as well as numerous flavorings and/or flavor chemicals. At present, there are more than 400 e-cigarette brands available along with potentially >15,000 different/unique flavored products. However, surprisingly little is known about the flavors/flavor chemicals added to these products, which can account for >1% by weight of some e-liquids, and their resultant chemosensory experiences, and the US FDA has done relatively little, until recently, to regulate these products. This article will discuss e-cigarette flavors and flavor chemicals, their elicited responses, and their sensory effects in some detail.
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Affiliation(s)
- Shatha K Alhadyan
- Department of Pharmaceutical Sciences, North Carolina Central University, Durham, North Carolina 27707, United States
| | - Vijay Sivaraman
- Department of Biological and Biomedical Sciences, North Carolina Central University, Durham, North Carolina 27707, United States
| | - Rob U Onyenwoke
- Department of Pharmaceutical Sciences, North Carolina Central University, Durham, North Carolina 27707, United States.,Biomanufacturing Research Institute and Technology Enterprise (BRITE), North Carolina Central University, Durham, North Carolina 27707, United States
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Card JW, Scaife KM, Haighton LA. Review of evidence relating to occupational exposure limits for alpha-diketones and acetoin, and considerations for deriving an occupational exposure limit for 2,3-pentanedione. Crit Rev Toxicol 2022; 52:715-730. [PMID: 36803409 DOI: 10.1080/10408444.2023.2168175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
Alpha-diketones, notably diacetyl, have been used as flavoring agents. When airborne in occupational settings, exposures to diacetyl have been associated with serious respiratory disease. Other α-diketones, such as 2,3-pentanedione, and analogues such as acetoin (a reduced form of diacetyl), require evaluation, particularly, in light of recently available toxicological studies. The current work reviewed mechanistic, metabolic, and toxicology data available for α-diketones. Data were most available for diacetyl and 2,3-pentanedione, and a comparative assessment of their pulmonary effects was performed, and an occupational exposure limit (OEL) was proposed for 2,3-pentanedione. Previous OELs were reviewed and an updated literature search was performed. Respiratory system histopathology data from 3-month toxicology studies were evaluated with benchmark dose (BMD) modelling of sensitive endpoints. This demonstrated comparable responses at concentrations up to 100 ppm, with no consistent overall pattern of greater sensitivity to either diacetyl or 2,3-pentanedione. In contrast, based on draft raw data, no adverse respiratory effects were observed in comparable 3-month toxicology studies that evaluated exposure to acetoin at up to 800 ppm (highest tested concentration), indicating that acetoin does not present the same inhalation hazard as diacetyl or 2,3-pentanedione. To derive an OEL for 2,3-pentanedione, BMD modelling was conducted for the most sensitive endpoint from 90-day inhalation toxicity studies, namely, hyperplasia of nasal respiratory epithelium. On the basis of this modelling, an 8-hour time-weighted average OEL of 0.07 ppm is proposed to be protective against respiratory effects that may be associated with chronic workplace exposure to 2,3-pentanedione.
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Affiliation(s)
- Jeffrey W Card
- Intertek Health Sciences Inc., Mississauga, Ontario, Canada
| | - Kevin M Scaife
- Intertek Health Sciences Inc., Mississauga, Ontario, Canada
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Virji MA, Fechter-Leggett ED, Groth CP, Liang X, Blackley BH, Stanton ML, LeBouf RF, Harvey RR, Bailey RL, Cummings KJ, Cox-Ganser JM. Decrements in lung function and respiratory abnormalities associated with exposure to diacetyl and 2,3-pentanedione in coffee production workers. Front Public Health 2022; 10:966374. [PMID: 36033819 PMCID: PMC9412051 DOI: 10.3389/fpubh.2022.966374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 07/18/2022] [Indexed: 01/24/2023] Open
Abstract
Coffee production workers are exposed to complex mixtures of gases, dust, and vapors, including the known respiratory toxins, diacetyl, and 2,3-pentanedione, which occur naturally during coffee roasting and are also present in flavorings used to flavor coffee. This study evaluated the associations of these two α-diketones with lung function measures in coffee production workers. Workers completed questionnaires, and their lung function was assessed by spirometry and impulse oscillometry (IOS). Personal exposures to diacetyl, 2,3-pentanedione, and their sum (SumDA+PD) were assigned to participants, and metrics of the highest 95th percentile (P95), cumulative, and average exposure were calculated. Linear and logistic regression models for continuous and binary/polytomous outcomes, respectively, were used to explore exposure-response relationships adjusting for age, body mass index, tenure, height, sex, smoking status, race, or allergic status. Decrements in percent predicted forced expiratory volume in 1 second (ppFEV1) and forced vital capacity (ppFVC) were associated with the highest-P95 exposures to 2,3-pentanedione and SumDA+PD. Among flavoring workers, larger decrements in ppFEV1 and ppFVC were associated with highest-P95 exposures to diacetyl, 2,3-pentanedione, and SumDA+PD. Abnormal FEV1, FVC, and restrictive spirometric patterns were associated with the highest-P95, cumulative, and average exposures for all α-diketone metrics; some of these associations were also present among flavoring and non-flavoring workers. The combined category of small and peripheral airways plus small and large airways abnormalities on IOS had elevated odds for highest-P95 exposure to α-diketones. These results may be affected by the small sample size, few cases of abnormal spirometry, and the healthy worker effect. Associations between lung function abnormalities and exposure to α-diketones suggest it may be prudent to consider exposure controls in both flavoring and non-flavoring settings.
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Affiliation(s)
- Mohammed Abbas Virji
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, United States,*Correspondence: Mohammed Abbas Virji
| | - Ethan D. Fechter-Leggett
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, United States
| | - Caroline P. Groth
- Department of Epidemiology and Biostatistics, West Virginia University School of Public Health, Morgantown, WV, United States
| | - Xiaoming Liang
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, United States
| | - Brie H. Blackley
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, United States
| | - Marcia L. Stanton
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, United States
| | - Ryan F. LeBouf
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, United States
| | - R. Reid Harvey
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, United States
| | - Rachel L. Bailey
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, United States
| | - Kristin J. Cummings
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, United States
| | - Jean M. Cox-Ganser
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, WV, United States
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11
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Tabaa MME, Aboalazm HM, Shaalan M, Khedr NF. Silymarin constrains diacetyl-prompted oxidative stress and neuroinflammation in rats: involvements of Dyn/GDNF and MAPK signaling pathway. Inflammopharmacology 2022; 30:961-980. [PMID: 35366745 PMCID: PMC9135832 DOI: 10.1007/s10787-022-00961-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 02/25/2022] [Indexed: 11/26/2022]
Abstract
Neuroinflammation, a major component of many CNS disorders, has been suggested to be associated with diacetyl (DA) exposure. DA is commonly used as a food flavoring additive and condiment. Lately, silymarin (Sily) has shown protective and therapeutic effects on neuronal inflammation. The study aimed to explore the role of Sily in protecting and/or treating DA-induced neuroinflammation. Neuroinflammation was induced in rats by administering DA (25 mg/kg) orally. Results revealed that Sily (50 mg/kg) obviously maintained cognitive and behavioral functions, alleviated brain antioxidant status, and inhibited microglial activation. Sily enhanced IL-10, GDNF and Dyn levels, reduced IFN-γ, TNFα, and IL-1β levels, and down-regulated the MAPK pathway. Immunohistochemical investigation of EGFR and GFAP declared that Sily could conserve neurons from inflammatory damage. However, with continuing DA exposure during Sily treatment, oxidative stress and neuroinflammation were less mitigated. These findings point to a novel mechanism involving the Dyn/GDNF and MAPK pathway through which Sily might prevent and treat DA-induced neuroinflammation.
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Affiliation(s)
- Manar Mohammed El Tabaa
- Pharmacology & Environmental Toxicology, Environmental Studies & Research Institute (ESRI), University of Sadat City, Minofia Governorate, Sadat city, Egypt
| | - Hamdi M. Aboalazm
- Biochemistry, Environmental Studies & Research Institute (ESRI), University of Sadat City, Sadat City, Egypt
| | - Mohamed Shaalan
- Pathology Department, Faculty of Veterinary Medicine, Cairo University, Giza, Egypt
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12
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Attfield KR, Zalay M, Zwack LM, Glassford EK, LeBouf RF, Materna BL. Assessment of worker chemical exposures in California vape shops. JOURNAL OF OCCUPATIONAL AND ENVIRONMENTAL HYGIENE 2022; 19:197-209. [PMID: 35156905 PMCID: PMC8989644 DOI: 10.1080/15459624.2022.2036341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
E-cigarettes are battery-operated devices that heat a liquid mixture to make an aerosol that is inhaled, or vaped, by the user. Vape shops are retail environments designed to fulfill customer demand for diverse e-liquid flavors and hardware options, which create unique worker exposure concerns. To characterize exposures to vape shop workers, especially to flavoring chemicals associated with known respiratory toxicity, this study recruited vape shops from the San Francisco Bay Area. In six shops, we measured air concentrations for volatile organic compounds, formaldehyde, flavoring chemicals, and nicotine in personal and/or area samples; analyzed components of e-liquids vaped during field visits; and assessed metals on surface wipe samples. Interviews and observations were conducted over the course of a workday in the same six shops and interviews were performed in an additional six where sampling was not conducted. Detections of the alpha-diketone butter flavoring chemicals diacetyl and/or 2,3-pentanedione were common: in the headspace of purchased e-liquids (18 of 26 samples), in personal air samples (5 of 16), and in area air samples (2 of 6 shops). Two exceedances of recommended exposure limits for 2,3-pentanedione (a short-term exposure limit and an 8-hr time-weighted average) were measured in personal air samples. Other compounds detected in the area and personal air samples included substitutes for diacetyl and 2,3-pentanedione (acetoin and 2,3-hexanedione) and compounds that may be contaminants or impurities. Furthermore, a large variety (82) of other flavoring chemicals were detected in area air samples. None of the 12 shops interviewed had a health and safety program. Six shops reported no use of any personal protective equipment (PPE) (e.g., gloves, chemical resistant aprons, eye protection) and the others stated occasional use; however, no PPE use was observed during any field investigation day. Recommendations were provided to shops that included making improvements to ventilation, hygiene, use of personal protective equipment, and, if possible, avoidance of products containing the alpha-diketone flavoring chemicals. Future research is needed to evaluate the long-term health risks among workers in the vape shop retail industry and for e-cigarette use generally. Specific areas include further characterizing e-liquid constituents and emissions, evaluating ingredient health risks, evaluating the contributions of different routes of exposure (dermal, inhalation, and ingestion), and determining effective exposure mitigation measures.
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Affiliation(s)
- Kathleen R Attfield
- Environmental Health Investigations Branch, California Department of Public Health, Richmond, California
| | | | - Leonard M Zwack
- Hazard Evaluations and Technical Assistance Branch, National Institute for Occupational Safety and Health, Cincinnati, Ohio
| | - Eric K Glassford
- Hazard Evaluations and Technical Assistance Branch, National Institute for Occupational Safety and Health, Cincinnati, Ohio
| | - Ryan F LeBouf
- Field Studies Branch, Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, West Virginia
| | - Barbara L Materna
- Occupational Health Branch, California Department of Public Health, Richmond, California
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13
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Goel R, Reilly SM, Valerio LG. A Computational Approach for Respiratory Hazard Identification of Flavor Chemicals in Tobacco Products. Chem Res Toxicol 2022; 35:450-458. [PMID: 35239324 DOI: 10.1021/acs.chemrestox.1c00361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Flavor chemicals contribute to the appeal and toxicity of tobacco products, including electronic nicotine delivery systems (ENDS). The assortment of flavor chemicals available for use in tobacco products is extensive. In this study, a chemistry-driven computational approach was used to evaluate flavor chemicals based on intrinsic hazardous structures and reactivity of chemicals. A large library of 3012 unique flavor chemicals was compiled from publicly available information. Next, information was computed and collated based on their (1) physicochemical properties, (2) global harmonization system (GHS) health hazard classification, (3) structural alerts linked to the chemical's reactivity, instability, or toxicity, and (4) common substructure shared with FDA's harmful and potentially harmful constituents (HPHCs) flavor chemicals that are respiratory toxicants. Computational analysis of the constructed flavor library flagged 638 chemicals with GHS classified respiratory health hazards, 1079 chemicals with at least one structural alert, and 2297 chemicals with substructural similarity to FDA's established and proposed list of HPHCs. A subsequent analysis was performed on a subset of 173 chemicals in the flavor library that are respiratory health hazards, contain structural alerts as well as flavor HPHC substructures. Four general toxicophore structures with an increased potential for respiratory toxicity were then identified. In summary, computational methods are efficient tools for hazard identification and understanding structure-toxicity relationship. With appropriate context of use and interpretation, in silico methods may provide scientific evidence to support toxicological evaluations of chemicals in or emitted from tobacco products.
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14
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LeBouf RF, Ranpara A, Ham J, Aldridge M, Fernandez E, Williams K, Burns DA, Stefaniak AB. Chemical Emissions From Heated Vitamin E Acetate—Insights to Respiratory Risks From Electronic Cigarette Liquid Oil Diluents Used in the Aerosolization of Δ9-THC-Containing Products. Front Public Health 2022; 9:765168. [PMID: 35127617 PMCID: PMC8814346 DOI: 10.3389/fpubh.2021.765168] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 12/14/2021] [Indexed: 11/30/2022] Open
Abstract
As of February 18, 2020, the e-cigarette, or vaping, product use associated lung injury (EVALI) outbreak caused the hospitalization of a total of 2,807 patients and claimed 68 lives in the United States. Though investigations have reported a strong association with vitamin E acetate (VEA), evidence from reported EVALI cases is not sufficient to rule out the contribution of other chemicals of concern, including chemicals in either THC or non-THC products. This study characterized chemicals evolved when diluent oils were heated to temperatures that mimic e-cigarette, or vaping, products (EVPs) to investigate production of potentially toxic chemicals that might have caused lung injury. VEA, vitamin E, coconut, and medium chain triglyceride (MCT) oil were each diluted with ethanol and then tested for constituents and impurities using a gas chromatograph mass spectrometer (GC/MS). Undiluted oils were heated at 25°C (control), 150°C, and 250°C in an inert chamber to mimic a range of temperatures indicative of aerosolization from EVPs. Volatilized chemicals were collected using thermal desorption tubes, analyzed using a GC/MS, and identified. Presence of identified chemicals was confirmed using retention time and ion spectra matching with analytic standards. Direct analysis of oils, as received, revealed that VEA and vitamin E were the main constituents of their oils, and coconut and MCT oils were nearly identical having two main constituents: glycerol tricaprylate and 2-(decanoyloxy) propane-1,3-diyl dioctanoate. More chemicals were measured and with greater intensities when diluent oils were heated at 250°C compared to 150°C and 25°C. Vitamin E and coconut/MCT oils produced different chemical emissions. The presence of some identified chemicals is of potential health consequence because many are known respiratory irritants and acute respiratory toxins. Exposure to a mixture of hazardous chemicals may be relevant to the development or exacerbation of EVALI, especially when in concert with physical damage caused by lung deposition of aerosols produced by aerosolizing diluent oils.
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Affiliation(s)
- Ryan F. LeBouf
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
- *Correspondence: Ryan F. LeBouf
| | - Anand Ranpara
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
| | - Jason Ham
- Health Effects Laboratory Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
| | - Michael Aldridge
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
| | - Elizabeth Fernandez
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
| | - Kenneth Williams
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
| | - Dru A. Burns
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
| | - Aleksandr B. Stefaniak
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
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15
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Nowak D, Ochmann U, Mueller-Lisse UG. Berufskrankheiten der Atemwege und der Lunge. PNEUMO NEWS 2022; 14:28-41. [PMID: 36281236 PMCID: PMC9581555 DOI: 10.1007/s15033-022-3415-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Dennis Nowak
- Inst. u. Poliklinik f. Arbeits-u. Umweltmedizin LMU München, Ziemssenstr. 1, 80336 München, Deutschland
| | - Uta Ochmann
- Klinikum Innenstadt der LMU, Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, Ziemssenstr. 1, 80336 München, Deutschland
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16
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House EL, Kim SY, Johnston CJ, Groves AM, Hernady E, Misra RS, McGraw MD. Diacetyl Vapor Inhalation Induces Mixed, Granulocytic Lung Inflammation with Increased CD4 +CD25 + T Cells in the Rat. TOXICS 2021; 9:359. [PMID: 34941793 PMCID: PMC8707442 DOI: 10.3390/toxics9120359] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 11/16/2022]
Abstract
Diacetyl (DA) is a highly reactive alpha diketone associated with flavoring-related lung disease. In rodents, acute DA vapor exposure can initiate an airway-centric, inflammatory response. However, this immune response has yet to be fully characterized in the context of flavoring-related lung disease progression. The following studies were designed to characterize the different T cell populations within the lung following repetitive DA vapor exposures. Sprague-Dawley rats were exposed to 200 parts-per-million DA vapor for 5 consecutive days × 6 h/day. Lung tissue and bronchoalveolar lavage fluid (BALF) were analyzed for changes in histology by H&E and Trichrome stain, T cell markers by flow cytometry, total BALF cell counts and differentials, BALF IL17a and total protein immediately, 1 and 2 weeks post-exposure. Lung histology and BALF cell composition demonstrated mixed, granulocytic lung inflammation with bronchial lymphoid aggregates at all time points in DA-exposed lungs compared to air controls. While no significant change was seen in percent lung CD3+, CD4+, or CD8+ T cells, a significant increase in lung CD4+CD25+ T cells developed at 1 week that persisted at 2 weeks post-exposure. Further characterization of this CD4+CD25+ T cell population identified Foxp3+ T cells at 1 week that failed to persist at 2 weeks. Conversely, BALF IL-17a increased significantly at 2 weeks in DA-exposed rats compared to air controls. Lung CD4+CD25+ T cells and BALF IL17a correlated directly with BALF total protein and inversely with rat oxygen saturations. Repetitive DA vapor exposure at occupationally relevant concentrations induced mixed, granulocytic lung inflammation with increased CD4+CD25+ T cells in the rat lung.
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Affiliation(s)
- Emma L. House
- Department of Pathology, University of Rochester Medical Center, Rochester, NY 14642, USA;
- Division of Pediatric Pulmonology, Department of Pediatrics, School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA; (S.-Y.K.); (A.M.G.)
| | - So-Young Kim
- Division of Pediatric Pulmonology, Department of Pediatrics, School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA; (S.-Y.K.); (A.M.G.)
- Department of Environmental Medicine, School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA; (C.J.J.); (E.H.)
| | - Carl J. Johnston
- Department of Environmental Medicine, School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA; (C.J.J.); (E.H.)
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY 14642, USA
- Division of Neonatology, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY 14642, USA;
| | - Angela M. Groves
- Division of Pediatric Pulmonology, Department of Pediatrics, School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA; (S.-Y.K.); (A.M.G.)
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Eric Hernady
- Department of Environmental Medicine, School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA; (C.J.J.); (E.H.)
- Department of Radiation Oncology, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Ravi S. Misra
- Division of Neonatology, Department of Pediatrics, University of Rochester Medical Center, Rochester, NY 14642, USA;
| | - Matthew D. McGraw
- Division of Pediatric Pulmonology, Department of Pediatrics, School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA; (S.-Y.K.); (A.M.G.)
- Department of Environmental Medicine, School of Medicine & Dentistry, University of Rochester Medical Center, Rochester, NY 14642, USA; (C.J.J.); (E.H.)
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17
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Virji MA, Cummings KJ, Cox-Ganser JM. A Strategy for Field Evaluations of Exposures and Respiratory Health of Workers at Small- to Medium-Sized Coffee Facilities. Front Public Health 2021; 9:705225. [PMID: 34858915 PMCID: PMC8631862 DOI: 10.3389/fpubh.2021.705225] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
Coffee production is a global industry with roasteries throughout the world. Workers in this industry are exposed to complex mixtures of gases, dusts, and vapors including carbon monoxide, carbon dioxide, coffee dust, allergens, alpha-diketones, and other volatile organic compounds (VOCs). Adverse respiratory health outcomes such as respiratory symptoms, reduced pulmonary function, asthma, and obliterative bronchiolitis can occur among exposed workers. In response to health hazard evaluations requests received from 17 small- to medium-sized coffee facilities across the United States, the National Institute for Occupational Safety and Health conducted investigations during 2016-2017 to understand the burden of respiratory abnormalities, exposure characteristics, relationships between exposures and respiratory effects, and opportunities for exposure mitigation. Full-shift, task-based, and instantaneous personal and area air samples for diacetyl, 2,3-pentanedione and other VOCs were collected, and engineering controls were evaluated. Medical evaluations included questionnaire, spirometry, impulse oscillometry, and fractional exhaled nitric oxide. Exposure and health assessments were conducted using standardized tools and approaches, which enabled pooling data for aggregate analysis. The pooled data provided a larger population to better address the requestors' concern of the effect of exposure to alpha-diketones on the respiratory heath of coffee workers. This paper describes the rationale for the exposure and health assessment strategy, the approach used to achieve the study objectives, and its advantages and limitations.
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Affiliation(s)
| | | | - Jean M. Cox-Ganser
- Respiratory Health Division, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, Morgantown, WV, United States
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18
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Ghio AJ, Soukup JM, Dailey LA, Roggli VL, Crumbliss AL, Palmer SM. Diacetyl exposure disrupts iron homeostasis in animals and cells. Inhal Toxicol 2021; 33:268-274. [PMID: 34752160 DOI: 10.1080/08958378.2021.1989092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Several mechanisms have been proposed for the biological effect of diacetyl. We tested the postulate that animal and cell exposures to diacetyl are associated with a disruption in iron homeostasis. MATERIALS AND METHODS Male, Sprague-Dawley rats were intratracheally-instilled with either distilled water or diacetyl. Seven days after treatment, animals were euthanized and the lungs removed, fixed, and embedded. Sections were cut and stained for iron, collagen, and ferritin. Human epithelial (BEAS-2B) and monocytic (THP-1) cells were exposed in vitro to ferric ammonium citrate (FAC), diacetyl, and both FAC and diacetyl. Cell non-heme iron concentrations and ferritin levels were quantified using inductively coupled plasma optical emission spectroscopy and an immunoassay respectively. RESULTS After exposure of animals to diacetyl, there were airway polypoid lesions which stained positively for both iron and the intracellular storage protein ferritin. Trichrome stain showed a deposition of collagen immediately adjacent to accumulated metal following diacetyl exposure. In in vitro cell exposures, FAC increased non-heme iron concentration but co-incubations of FAC and diacetyl elevated levels to significantly greater values. Levels of ferritin were increased with exposures of BEAS-2B and THP-1 cells to FAC but were similarly greater after co-exposure with FAC and diacetyl. CONCLUSIONS Results of animal and cell studies support a disruption of iron homeostasis by diacetyl. It is proposed that, following internalization, diacetyl complexes intracellular sources of iron. The cell recognizes a loss of its requisite iron to diacetyl and imports greater concentrations of the metal.
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Affiliation(s)
- Andrew J Ghio
- US Environmental Protection Agency, Chapel Hill, NC, USA
| | | | - Lisa A Dailey
- US Environmental Protection Agency, Chapel Hill, NC, USA
| | - Victor L Roggli
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | | | - Scott M Palmer
- Deparment of Medicine, Duke University Medical Center, Durham, NC, USA
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19
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Nowak D, Ochmann U, Mueller-Lisse UG. [Occupational diseases of the airways and the lungs]. Internist (Berl) 2021; 62:906-920. [PMID: 34387701 PMCID: PMC8361830 DOI: 10.1007/s00108-021-01109-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 11/10/2022]
Abstract
The attributable proportion of occupation-related influences on airway and lung diseases is 10-30%. In patients with obstructive airway diseases it is extremely important to sufficiently document findings during the period of activities burdening the airway as compared to periods off work. Chronic obstructive pulmonary disease (COPD) can have a work-related (partial) cause even in smokers. Regarding occupational infectious diseases, the main cause up to 2019 was tuberculosis but the corona pandemic has led to coronavirus disease 2019 (COVID-19) being the most frequent occupational disease. For the occupational medical assessment of interstitial and malignant pulmonary diseases, checklists can be helpful to support the medical history.
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Affiliation(s)
- Dennis Nowak
- Institut und Poliklinik für Arbeits‑, Sozial- und Umweltmedizin, LMU Klinikum, Ziemssenstr. 1, 80336, München, Deutschland.
- Comprehensive Pneumology Center (CPC) München, Deutsches Zentrum für Lungenforschung (DZL), München, Deutschland.
| | - Uta Ochmann
- Institut und Poliklinik für Arbeits‑, Sozial- und Umweltmedizin, LMU Klinikum, Ziemssenstr. 1, 80336, München, Deutschland
- Comprehensive Pneumology Center (CPC) München, Deutsches Zentrum für Lungenforschung (DZL), München, Deutschland
| | - Ullrich G Mueller-Lisse
- Klinik und Poliklinik für Radiologie, LMU Klinikum, München, Deutschland
- Comprehensive Pneumology Center (CPC) München, Deutsches Zentrum für Lungenforschung (DZL), München, Deutschland
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20
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Park HR, Vallarino J, O'Sullivan M, Wirth C, Panganiban RA, Webb G, Shumyatcher M, Himes BE, Park JA, Christiani DC, Allen J, Lu Q. Electronic cigarette smoke reduces ribosomal protein gene expression to impair protein synthesis in primary human airway epithelial cells. Sci Rep 2021; 11:17517. [PMID: 34471210 PMCID: PMC8410828 DOI: 10.1038/s41598-021-97013-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 08/05/2021] [Indexed: 12/27/2022] Open
Abstract
The widespread use of electronic cigarettes (e-cig) is a serious public health concern; however, mechanisms by which e-cig impair the function of airway epithelial cells-the direct target of e-cig smoke-are not fully understood. Here we report transcriptomic changes, including decreased expression of many ribosomal genes, in airway epithelial cells in response to e-cig exposure. Using RNA-seq we identify over 200 differentially expressed genes in air-liquid interface cultured primary normal human bronchial epithelial (NHBE) exposed to e-cig smoke solution from commercial e-cig cartridges. In particular, exposure to e-cig smoke solution inhibits biological pathways involving ribosomes and protein biogenesis in NHBE cells. Consistent with this effect, expression of corresponding ribosomal proteins and subsequent protein biogenesis are reduced in the cells exposed to e-cig. Gas chromatography/mass spectrometry (GC/MS) analysis identified the presence of five flavoring chemicals designated as 'high priority' in regard to respiratory health, and methylglyoxal in e-cig smoke solution. Together, our findings reveal the potential detrimental effect of e-cig smoke on ribosomes and the associated protein biogenesis in airway epithelium. Our study calls for further investigation into how these changes in the airway epithelium contribute to the current epidemic of lung injuries in e-cig users.
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Affiliation(s)
- Hae-Ryung Park
- Program in Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02215, USA
| | - Jose Vallarino
- Program in Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02215, USA
| | - Michael O'Sullivan
- Program in Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02215, USA
| | - Charlotte Wirth
- Program in Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02215, USA
| | - Ronald A Panganiban
- Program in Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02215, USA
| | - Gabrielle Webb
- Program in Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02215, USA
| | - Maya Shumyatcher
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Blanca E Himes
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Jin-Ah Park
- Program in Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02215, USA
| | - David C Christiani
- Program in Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02215, USA
| | - Joseph Allen
- Program in Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02215, USA.
- Harvard T.H. Chan School of Public Health, Room 404-L401 Park Drive, Boston, MA, 02215, USA.
| | - Quan Lu
- Program in Molecular and Integrative Physiological Sciences, Department of Environmental Health, Harvard T.H. Chan School of Public Health, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA, 02215, USA.
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21
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Harvey RR, Blackley BH, Korbach EJ, Rawal AX, Roggli VL, Bailey RL, Cox-Ganser JM, Cummings KJ. Case Report: Flavoring-Related Lung Disease in a Coffee Roasting and Packaging Facility Worker With Unique Lung Histopathology Compared With Previously Described Cases of Obliterative Bronchiolitis. Front Public Health 2021; 9:657987. [PMID: 34095061 PMCID: PMC8173047 DOI: 10.3389/fpubh.2021.657987] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 04/14/2021] [Indexed: 11/13/2022] Open
Abstract
Occupational exposure to diacetyl, a butter flavor chemical, can result in obliterative bronchiolitis. Obliterative bronchiolitis is characterized by exertional dyspnea, fixed airflow obstruction, and histopathologic constrictive bronchiolitis, with bronchiolar wall fibrosis leading to luminal narrowing and obliteration. We describe a case of advanced lung disease with histopathology distinct from obliterative bronchiolitis in a 37-year-old male coffee worker following prolonged exposure to high levels of diacetyl and the related compound 2,3-pentanedione, who had no other medical, avocational, or occupational history that could account for his illness. He began working at a coffee facility in the flavoring room and grinding area in 2009. Four years later he moved to the packaging area but continued to flavor and grind coffee at least 1 full day per week. He reported chest tightness and mucous membrane irritation when working in the flavoring room and grinding area in 2010. Beginning in 2014, he developed dyspnea, intermittent cough, and a reduced sense of smell without a work-related pattern. In 2016, spirometry revealed a moderate mixed pattern that did not improve with bronchodilator. Thoracoscopic lung biopsy results demonstrated focal mild cellular bronchiolitis and pleuritis, and focal peribronchiolar giant cells/granulomas, but no evidence of constrictive bronchiolitis. Full-shift personal air-samples collected in the flavoring and grinding areas during 2016 measured diacetyl concentrations up to 84-fold higher than the recommended exposure limit. Medical evaluations indicate this worker developed work-related, airway-centric lung disease, most likely attributable to inhalational exposure to flavorings, with biopsy findings not usual for obliterative bronchiolitis. Clinicians should be aware that lung pathology could vary considerably in workers with suspected flavoring-related lung disease.
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Affiliation(s)
- R Reid Harvey
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
| | - Brie H Blackley
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
| | | | | | - Victor L Roggli
- Department of Pathology, Duke University, Durham, NC, United States
| | - Rachel L Bailey
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
| | - Jean M Cox-Ganser
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
| | - Kristin J Cummings
- Respiratory Health Division, National Institute for Occupational Safety and Health, Morgantown, WV, United States
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22
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Azimi P, Keshavarz Z, Lahaie Luna M, Cedeno Laurent JG, Vallarino J, Christiani DC, Allen JG. An Unrecognized Hazard in E-Cigarette Vapor: Preliminary Quantification of Methylglyoxal Formation from Propylene Glycol in E-Cigarettes. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:E385. [PMID: 33419122 PMCID: PMC7825490 DOI: 10.3390/ijerph18020385] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 12/26/2020] [Accepted: 12/27/2020] [Indexed: 02/01/2023]
Abstract
Up to 95% of the liquid volume in an e-cigarette consists of propylene glycol. Previous research has shown that propylene glycol can generate diacetyl and formaldehyde when heated. New research shows that propylene glycol can also generate methylglyoxal, an alpha di-carbonyl compound recently shown to cause epithelial necrosis at even lower concentrations than diacetyl, the flavoring chemical associated with bronchiolitis obliterans ("Popcorn Lung"). We analyzed chemical emissions from 13 JUUL pod flavors. Diacetyl and methylglyoxal was detected in 100% of samples with median concentration (range) of 20 µg/m3 (less than limit of quantification: 54 µg/m3) and 4219 µg/m3 (677-15,342 µg/m3), respectively. We also detected acetaldehyde (median concentration: 341 µg/m3) and propionaldehyde (median concentration: 87 µg/m3) in all samples. The recent evidence that methylglyoxal is more cytotoxic to airway epithelial cells than diacetyl makes this an urgent public health concern. Current smokers considering e-cigarettes as a smoking cessation tool, and never users, who may be under the impression that e-cigarettes are harmless, need information on emissions and potential risks to make informed decisions.
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Affiliation(s)
- Parham Azimi
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA; (P.A.); (Z.K.); (M.L.L.); (J.G.C.L.); (J.V.); (D.C.C.)
| | - Zahra Keshavarz
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA; (P.A.); (Z.K.); (M.L.L.); (J.G.C.L.); (J.V.); (D.C.C.)
| | - Marianne Lahaie Luna
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA; (P.A.); (Z.K.); (M.L.L.); (J.G.C.L.); (J.V.); (D.C.C.)
- Occupational & Environmental Health Division, Dalla Lana School of Public Health, University of Toronto, Toronto, ON M5T 3M7, Canada
| | - Jose Guillermo Cedeno Laurent
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA; (P.A.); (Z.K.); (M.L.L.); (J.G.C.L.); (J.V.); (D.C.C.)
| | - Jose Vallarino
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA; (P.A.); (Z.K.); (M.L.L.); (J.G.C.L.); (J.V.); (D.C.C.)
| | - David C. Christiani
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA; (P.A.); (Z.K.); (M.L.L.); (J.G.C.L.); (J.V.); (D.C.C.)
| | - Joseph G. Allen
- Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA; (P.A.); (Z.K.); (M.L.L.); (J.G.C.L.); (J.V.); (D.C.C.)
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23
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Reagan-Steiner S, Gary J, Matkovic E, Ritter JM, Shieh WJ, Martines RB, Werner AK, Lynfield R, Holzbauer S, Bullock H, Denison AM, Bhatnagar J, Bollweg BC, Patel M, Evans ME, King BA, Rose DA, Baldwin GT, Jones CM, Krishnasamy V, Briss PA, Weissman DN, Meaney-Delman D, Zaki SR, Jatlaoui T, Koumans E, Kiernan E, Petersen E, Karwowski MP, Valentin-Blasini L, Blount BC, Cummings KJ, Ghinai I, Feder K, Wells EV, Turabelidze G, Byers P, Tanz LJ, Navarette KA, Ramadugu K, Dewart C, Miller J, Squires K, Marsden L, Fields CA. Pathological findings in suspected cases of e-cigarette, or vaping, product use-associated lung injury (EVALI): a case series. THE LANCET RESPIRATORY MEDICINE 2020; 8:1219-1232. [DOI: 10.1016/s2213-2600(20)30321-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 12/12/2022]
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24
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Abstract
Occupational bronchiolitis is characterized by inflammation of the small airways, and represents a heterogeneous set of lung conditions that can occur following a range of inhalation exposures related to work. The most common clinical presentation includes insidious onset of exertional dyspnea and cough. Multiple reports in recent years have drawn attention to previously unrecognized risk factors for occupational bronchiolitis following exposures in several settings. Both current and past occupational exposures, including prior military deployment-related exposures, should be considered in patients undergoing evaluation for unexplained dyspnea. Diagnostic testing for potential bronchiolitis should include a thorough assessment of the small airways.
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25
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Bhatt JM, Ramphul M, Bush A. An update on controversies in e-cigarettes. Paediatr Respir Rev 2020; 36:75-86. [PMID: 33071065 PMCID: PMC7518964 DOI: 10.1016/j.prrv.2020.09.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/17/2020] [Indexed: 12/12/2022]
Abstract
E-cigarettes are electronic nicotine delivery systems (ENDS) which mimic tobacco smoking without the combustion of tobacco. These devices have been misleadingly marketed as "less harmful" alternatives to conventional smoking tobacco products. The e-liquid in e-cigarettes include nicotine, a humectant and other additives including flavourings, colourants, or adulterants such as bacterial and fungal products. In this review, we discuss the contrasting views of the tobacco lobby and most professional societies. We describe the epidemiology of the use of these devices, with a widespread and significant rise in youth e-cigarette use seen in both the USA and Europe. We also describe what is known about the toxicity and mechanisms of EVALI (e-cigarette or vaping associated lung injury). This characterised by respiratory failure with an intense inflammatory response. The presentations are diverse and clinicians should consider vaping as a possible cause of any unusual respiratory illness in patients who have a history of vaping or other use of e-cigarette-related products. Second hand exposure to e-cigarettes is also harmful through respiration and transdermal absorption. E-cigarettes have a worse acute toxicity than tobacco and their long-term toxicity is unknown, and we advocate for the immediate, most vigorous anti-vaping legislation possible.
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Affiliation(s)
- Jayesh Mahendra Bhatt
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom.
| | - Manisha Ramphul
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, NG7 2UH, United Kingdom.
| | - Andrew Bush
- Paediatrics and Paediatric Respirology, National Heart and Lung Institute, United Kingdom; Paediatric Chest Physician, Royal Brompton & Harefield NHS Foundation Trust, United Kingdom; Imperial Centre for Paediatrics and Child Health, United Kingdom; Royal Brompton Hospital, Sydney Street, London SW3 6NP, United Kingdom.
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26
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Ghosh A, Beyazcicek O, Davis ES, Onyenwoke RU, Tarran R. Cellular effects of nicotine salt-containing e-liquids. J Appl Toxicol 2020; 41:493-505. [PMID: 33034066 DOI: 10.1002/jat.4060] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 12/30/2022]
Abstract
"Pod-based" e-cigarettes such as JUUL are currently the most prevalent electronic nicotine delivery systems (ENDS) in the United States. JUUL-type ENDS utilize nicotine salts protonated with benzoic acid rather than freebase nicotine. However, limited information is available on the cellular effects of these products. Cytoplasmic Ca2+ is a universal second messenger that controls many cellular functions including cell growth and cell death. Of note, dysregulation of cell Ca2+ homeostasis has been linked with several disease processes including autoimmune disease and several types of cancer. We exposed HEK293T cells and THP-1 macrophage-like cells to different JUUL e-liquids. We evaluated their effects on cellular viability and Ca2+ signaling by measuring fluorescence from calcein-AM/propidium iodide and Fluo-4, respectively. E-liquid autofluorescence was used to look for e-liquid permeation into cells. To identify the mechanisms behind the Ca2+ responses, different inhibitors of Ca2+ channels and phospholipase C signaling were used. JUUL e-liquids caused significant cytotoxic effects, with "Mint" flavor being the most cytotoxic. The Mint flavored e-liquid also caused a significant elevation in cytoplasmic Ca2+ . Using autofluorescence, the permeation of JUUL e-liquids into live cells was confirmed, indicating that intracellular organelles are directly exposed to e-liquids. Further studies identified the endoplasmic reticulum as being the source of e-liquid-induced changes in cytoplasmic Ca2+ . Nicotine salt-based e-liquids cause cytotoxicity and elevate cytoplasmic Ca2+ , indicating that they can exert biological effects beyond what would be expected with nicotine alone. These effects are flavor-dependent, and we propose that flavored e-liquids be reassessed for potential lung toxicity.
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Affiliation(s)
- Arunava Ghosh
- Department of Cell Biology & Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ozge Beyazcicek
- Department of Cell Biology & Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Eric S Davis
- Department of Cell Biology & Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rob U Onyenwoke
- Biomanufacturing Research Institute and Technology Enterprise, North Carolina Central University, Durham, North Carolina, USA
| | - Robert Tarran
- Department of Cell Biology & Physiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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27
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Nena E, Steiropoulos P, Voulgaris A, Froudarakis M, Karpathiou G. Occupational exposures in constrictive bronchiolitis. Pathol Res Pract 2020; 216:153069. [PMID: 32825942 DOI: 10.1016/j.prp.2020.153069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/12/2020] [Accepted: 06/17/2020] [Indexed: 11/30/2022]
Abstract
Bronchiolitis obliterans is a clinical entity which results from a variety of etiologies and has a detrimental impact on patients' quality of life when it remains undiagnosed and untreated. Due to its non-pathognomic clinical symptoms and signs, physicians often proceed to radiological examination, especially with high resolution chest tomography. Histological examination reveals constrictive bronchiolitis, the pathological definition of bronchiolitis obliterans. Due to an almost normal aspect of the lung parenchyma this condition can be missed. However, its recognition and the identification of a possible exposure are important for removing the patient from the incriminating agent. We present a case of constrictive bronchiolitis in a metal-cutting worker, highlighting the principal findings of this disease.
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Affiliation(s)
- Evangelia Nena
- Laboratory of Hygiene and Environmental Protection, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Paschalis Steiropoulos
- Department of Pneumonology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Athanasios Voulgaris
- Department of Pneumonology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Marios Froudarakis
- Department of Pneumonology, Medical School, Democritus University of Thrace, Alexandroupolis, Greece
| | - Georgia Karpathiou
- Department of Pathology, University Hospital of Saint-Etienne, CEDEX 2, St-Etienne, 42055, France.
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