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Easwaran M, Maria CS, Martinez JD, Hung B, Yu X, Soo J, Kimura A, Gross ER, Erickson-DiRenzo E. Effects of Short-term Electronic(e)-Cigarette Aerosol Exposure in the Mouse Larynx. Laryngoscope 2024; 134:1316-1326. [PMID: 37698394 PMCID: PMC10922082 DOI: 10.1002/lary.31043] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 08/17/2023] [Accepted: 08/29/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES The effects of electronic cigarettes (e-cigarettes) on the larynx are relatively unknown. This study examined the short-term effects of e-cigarette inhalation on cellular and inflammatory responses within the mouse laryngeal glottic and subglottic regions after exposure to pod-based devices (JUUL). METHODS Male C57BL6/J mice (8-9 weeks) were assigned to control (n = 9), JUUL flavors Mint (JMi; n = 10) or Mango (JMa; n = 10). JUUL mice were exposed to 2 h/day for 1, 5, and 10 days using the inExpose inhalation system. Control mice were in room air. Vocal fold (VF) epithelial thickness, cell proliferation, subglandular area and composition, inflammatory cell infiltration, and surface topography were evaluated in the harvested larynges. Mouse body weight and urinary nicotine biomarkers were also measured. Chemical analysis of JUUL aerosols was conducted using selective ion flow tube mass spectrometry. RESULTS JUUL-exposed mice had reduced body weight after day 5. Urinary nicotine biomarker levels indicated successful JUUL exposure and metabolism. Quantitative analysis of JUUL aerosol indicated that chemical constituents differ between JMi and JMa flavors. VF epithelial thickness, cellular proliferation, glandular area, and surface topography remained unchanged after JUUL exposures. Acidic mucus content increased after 1 day of JMi exposure. VF macrophage and T-cell levels slightly increased after 10 days of JMi exposures. CONCLUSIONS Short-term e-cigarette exposures cause minimal flavor- and region-specific cellular and inflammatory changes in the mouse larynx. This work provides a foundation for long-term studies to determine if these responses are altered with multiple e-cigarette components and concentrations. LEVEL OF EVIDENCE N/A Laryngoscope, 134:1316-1326, 2024.
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Affiliation(s)
- Meena Easwaran
- Department of Otolaryngology - Head & Neck Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Chloe Santa Maria
- Department of Otolaryngology - Head & Neck Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Joshua D. Martinez
- Department of Otolaryngology - Head & Neck Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Barbara Hung
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Xuan Yu
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Joanne Soo
- Department of Otolaryngology - Head & Neck Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Akari Kimura
- Department of Otolaryngology - Head & Neck Surgery, School of Medicine, Stanford University, Stanford, CA
| | - Eric R. Gross
- Department of Anesthesiology, Perioperative and Pain Medicine, School of Medicine, Stanford University, Stanford, CA
| | - Elizabeth Erickson-DiRenzo
- Department of Otolaryngology - Head & Neck Surgery, School of Medicine, Stanford University, Stanford, CA
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Mercier C, Pourchez J, Leclerc L, Forest V. In vitro toxicological evaluation of aerosols generated by a 4th generation vaping device using nicotine salts in an air-liquid interface system. Respir Res 2024; 25:75. [PMID: 38317149 PMCID: PMC10845662 DOI: 10.1186/s12931-024-02697-2] [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: 10/13/2023] [Accepted: 01/22/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Electronic cigarettes (EC) have gained popularity, especially among young people, with the introduction of fourth-generation devices based on e-liquids containing nicotine salts that promise a smoother vaping experience than freebase nicotine. However, the toxicological effects of nicotine salts are still largely unknown, and the chemical diversity of e-liquids limits the comparison between different studies to determine the contribution of each compound to the cytotoxicity of EC aerosols. Therefore, the aim of this study was to evaluate the toxicological profile of controlled composition e-liquid aerosols to accurately determine the effects of each ingredient based on exposure at the air-liquid interface. METHODS Human lung epithelial cells (A549) were exposed to undiluted aerosols of controlled composition e-liquids containing various ratios of propylene glycol (PG)/vegetable glycerin (VG) solvents, freebase nicotine, organic acids, nicotine salts, and flavoured commercial e-liquids. Exposure of 20 puffs was performed at the air-liquid interface following a standard vaping regimen. Toxicological outcomes, including cytotoxicity, inflammation, and oxidative stress, were assessed 24 h after exposure. RESULTS PG/VG aerosols elicited a strong cytotoxic response characterised by a 50% decrease in cell viability and a 200% increase in lactate dehydrogenase (LDH) production, but had no effects on inflammation and oxidative stress. These effects occurred only at a ratio of 70/30 PG/VG, suggesting that PG is the major contributor to aerosol cytotoxicity. Both freebase nicotine and organic acids had no greater effect on cell viability and LDH release than at a 70/30 PG/VG ratio, but significantly increased inflammation and oxidative stress. Interestingly, the protonated form of nicotine in salt showed a stronger proinflammatory effect than the freebase nicotine form, while benzoic acid-based nicotine salts also induced significant oxidative stress. Flavoured commercial e-liquids was found to be cytotoxic at a threshold dose of ≈ 330 µg/cm². CONCLUSION Our results showed that aerosols of e-liquids consisting only of PG/VG solvents can cause severe cytotoxicity depending on the concentration of PG, while nicotine salts elicit a stronger pro-inflammatory response than freebase nicotine. Overall, aerosols from fourth-generation devices can cause different toxicological effects, the nature of which depends on the chemical composition of the e-liquid.
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Affiliation(s)
- Clément Mercier
- Mines Saint-Etienne, Université Jean Monnet, INSERM, U1059 Sainbiose, Centre CIS, Saint-Etienne, 42023, France.
| | - Jérémie Pourchez
- Mines Saint-Etienne, Université Jean Monnet, INSERM, U1059 Sainbiose, Centre CIS, Saint-Etienne, 42023, France
| | - Lara Leclerc
- Mines Saint-Etienne, Université Jean Monnet, INSERM, U1059 Sainbiose, Centre CIS, Saint-Etienne, 42023, France
| | - Valérie Forest
- Mines Saint-Etienne, Université Jean Monnet, INSERM, U1059 Sainbiose, Centre CIS, Saint-Etienne, 42023, France
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Wang J, Wang Y, Wang P, Shen X, Wang L, He D. Construction and evaluation of a nomogram prediction model for aspiration pneumonia in patients with acute ischemic stroke. Heliyon 2023; 9:e22048. [PMID: 38034684 PMCID: PMC10682132 DOI: 10.1016/j.heliyon.2023.e22048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/02/2023] [Accepted: 11/02/2023] [Indexed: 12/02/2023] Open
Abstract
Background Aspiration Pneumonia (AP) is a leading cause of death in patients with Acute Ischemic Stroke (AIS). Early detection, diagnosis and effective prevention measures are crucial for improving patient prognosis. However, there is a lack of research predicting AP occurrence after AIS. This study aimed to identify risk factors and develop a nomogram model to determine the probability of developing AP after AIS. Method A total of 3258 AIS patients admitted to Jinshan Hospital of Fudan University between January 1, 2016, and August 20, 2022, were included. Among them, 307 patients were diagnosed with AP (AP group), while 2951 patients formed the control group (NAP group). Univariate and multivariate logistic regression analyses were conducted to identify relevant risk factors for AP after AIS. These factors were used to establish a scoring system and develop a nomogram model using R software. Results Univariate analysis revealed 20 factors significantly associated (P < 0.05) with the development of AP after AIS. These factors underwent multivariate logistic regression analysis, which identified age (elderly), National Institute of Health Stroke Scale (NIHSS) score, dysphagia, atrial fibrillation, cardiac insufficiency, renal insufficiency, hepatic insufficiency, elevated Fasting Blood Glucose (FBG), elevated C-Reactive Protein (CRP), elevated Neutrophil percentage (NEUT%), and decreased prealbumin as independent risk factors. A nomogram model incorporating these 11 risk factors was constructed, with a C-index of 0.872 (95 % CI: 0.845-0.899), indicating high accuracy. Calibration and clinical decision analyses demonstrated the model's reliability and clinical value. Conclusion A nomogram model incorporating age, NIHSS score, dysphagia, atrial fibrillation, cardiac insufficiency, renal insufficiency, hepatic insufficiency, FBG, CRP, NEUT%, and prealbumin effectively predicts AP risk in AIS patients. This model provides guidance for early intervention strategies, enabling the identification of high-risk individuals for timely preventive measures.
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Affiliation(s)
- Junming Wang
- Center of Emergency and Critical Care Medicine, Jinshan Hospital, Fudan University, Shanghai, 201508, China
- Research Center for Chemical Injury, Emergency and Critical Medicine of Fudan University, Shanghai, 201508, China
- Key Laboratory of Chemical Injury, Emergency and Critical Medicine of Shanghai Municipal Health Commission, Shanghai, 201508, China
| | - Yuntao Wang
- Department of General Practice, Jinshan Hospital, Fudan University, Shanghai, 201508, China
| | - Pengfei Wang
- Center of Emergency and Critical Care Medicine, Jinshan Hospital, Fudan University, Shanghai, 201508, China
- Research Center for Chemical Injury, Emergency and Critical Medicine of Fudan University, Shanghai, 201508, China
- Key Laboratory of Chemical Injury, Emergency and Critical Medicine of Shanghai Municipal Health Commission, Shanghai, 201508, China
| | - Xueting Shen
- Department of General Practice, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Lina Wang
- Department of General Practice, Jinshan Hospital, Fudan University, Shanghai, 201508, China
| | - Daikun He
- Department of General Practice, Jinshan Hospital, Fudan University, Shanghai, 201508, China
- Department of General Practice, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
- Center of Emergency and Critical Care Medicine, Jinshan Hospital, Fudan University, Shanghai, 201508, China
- Research Center for Chemical Injury, Emergency and Critical Medicine of Fudan University, Shanghai, 201508, China
- Key Laboratory of Chemical Injury, Emergency and Critical Medicine of Shanghai Municipal Health Commission, Shanghai, 201508, China
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Polosa R, Emma R, Cibella F, Caruso M, Conte G, Benfatto F, Ferlito S, Gulino A, Malerba M, Caponnetto P. Impact of exclusive e-cigarettes and heated tobacco products use on muco-ciliary clearance. Ther Adv Chronic Dis 2021; 12:20406223211035267. [PMID: 34422253 PMCID: PMC8371723 DOI: 10.1177/20406223211035267] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Tobacco smoking impairs mucociliary clearance (MCC) efficiency as shown by
prolonged saccharin test transit time (STTT). Avoiding exposure to tobacco
smoke from combustible cigarettes may restore MCC function and former
smokers have been shown to exhibit similar STTT as never smokers. The impact
on STTT of switching from smoking to combustion-free tobacco products such
as e-cigarettes (ECs) and heated tobacco products (HTPs) is not known. Methods: We report STTT of exclusive EC and HTP users. Test results were compared with
those obtained in current, former, and never smokers. Results: STTT were obtained from 39 current, 40 former, 40 never smokers, and from 20
EC and 20 HTP users. Comparison of STTT values showed significant difference
among the five study groups (p < 0.00001) with current
smokers having a median [interquartile range (IQR)] STTT of 13.15 min, which
was significantly longer compared with that of all other study groups. In
particular, compared with former (7.26 min) and never smokers (7.24 min),
exclusive EC users and exclusive HTP users had similar STTT at 7.00 and
8.00 min, respectively. Conclusion: Former smokers who have switched to exclusive regular use of combustion-free
nicotine delivery systems (i.e., ECs and HTPs) exhibit similar saccharin
transit time as never and former smokers. This suggests that combustion-free
nicotine delivery technologies are unlikely to have detrimental effects on
MCC function.
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Affiliation(s)
- R Polosa
- Centre for the Prevention and Treatment of Tobacco Addiction (CPCT), Teaching Hospital Policlinico - V. Emanuele, University of Catania, Catania, Italy Center of Excellence for the Acceleration of Harm Reduction (CoEHAR), University of Catania, Italy Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - R Emma
- Centre for the Prevention and Treatment of Tobacco Addiction (CPCT), Teaching Hospital Policlinico - V. Emanuele, University of Catania, Catania, Italy, Center of Excellence for the Acceleration of Harm Reduction (CoEHAR), University of Catania, Catania, Italy
| | - F Cibella
- National Research Council of Italy, Institute of Biomedicine and Molecular Immunology, Palermo, Italy
| | - M Caruso
- Centre for the Prevention and Treatment of Tobacco Addiction (CPCT), Teaching Hospital Policlinico - V. Emanuele, University of Catania, Catania, Italy, Center of Excellence for the Acceleration of Harm Reduction (CoEHAR), University of Catania, Catania, Italy
| | - G Conte
- Centre for the Prevention and Treatment of Tobacco Addiction (CPCT), Teaching Hospital Policlinico - V. Emanuele, University of Catania, Catania, Italy
| | - F Benfatto
- Centre for the Prevention and Treatment of Tobacco Addiction (CPCT), Teaching Hospital Policlinico - V. Emanuele, University of Catania, Catania, Italy
| | - S Ferlito
- Department of Medical Science, Surgical Science and advanced Technologies G.F, Ingrassia, University of Catania, Catania, Italy
| | - A Gulino
- Department of Medical Science, Surgical Science and advanced Technologies G.F, Ingrassia, University of Catania, Catania, Italy
| | - M Malerba
- Translational Medicine Department, Eastern Piedmont University (UPO), Novara, Italy
| | - P Caponnetto
- Centre for the Prevention and Treatment of Tobacco Addiction (CPCT), Teaching Hospital Policlinico - V. Emanuele, University of Catania, Catania, Italy, Center of Excellence for the Acceleration of Harm Reduction (CoEHAR), University of Catania, Catania, Italy
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5
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Objective assessment of nasal resistance among electronic cigarette users. The Journal of Laryngology & Otology 2021; 135:616-619. [PMID: 34078481 DOI: 10.1017/s0022215121001432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Electronic cigarettes have been a popular alternative to tobacco smoking. The effect of tobacco smoking on nasal airway resistance has been investigated before; however, the effect of the aerosol generated by electronic cigarettes is still unknown. This study aimed to evaluate the short-term effects of e-cigarettes on nasal airway resistance. METHODS Sixty-one participants were recruited into a vapers group and a control group. The vapers group was instructed to smoke for 5 minutes, and their nasal resistance was measured pre-procedure and at 1 and 5 minutes post-procedure. The results were compared between both groups. RESULTS Repeated measures analysis of variance demonstrated that vaping has no statistically significant effect on total nasal airway resistance. CONCLUSION Although the differences between both groups were not statistically significant overall, the vapers group showed a reduction in nasal airway resistance in the short term.
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Phillips G, Czekala L, Behrsing HP, Amin K, Budde J, Stevenson M, Wieczorek R, Walele T, Simms L. Acute electronic vapour product whole aerosol exposure of 3D human bronchial tissue results in minimal cellular and transcriptomic responses when compared to cigarette smoke. TOXICOLOGY RESEARCH AND APPLICATION 2021. [DOI: 10.1177/2397847320988496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
The use of electronic vapour products (EVPs) continues to increase worldwide and with advances in cell culture systems, molecular biology and the computational sciences there is also accumulating evidence of their potential reduced toxicity and reduced potential harm when compared to cigarette smoke. To further understand the potential risks and health effects associated with exposure to EVP aerosols we have assessed the cellular and transcriptomic response from a commercially available lung tissue culture system (MucilAirTM) following a single sub-cytotoxic exposure to cigarette smoke and the equivalent nicotine delivered dose of EVP aerosol. The transcriptomic, cellular (cilia beat frequency (CBF) and percent active area (%AA), trans epithelial electrical resistance (TEER), histology) and cytokine release were assessed at 4- and 48- hours following recovery from air, EVP aerosol (8.4% V/V: mybluTM blueberry flavour, 2.4% nicotine) and 3R4F smoke (3.5% V/V: exposure). No pathological changes were observed at either recovery time point from any exposure. Air and EVP aerosol exposure had no effect on CBF, %AA nor TEER at 48 hours. Exposure to cigarette smoke resulted in a decrease in TEER, an increase in CBF and the release of proinflammatory cytokines at both recovery time points. Although the number of significantly expressed genes was minimal following exposure to EVP aerosol, exposure to 3R4F smoke resulted in a significant upregulation of several disease relevant pathways. These data provide evidence that following an acute exposure to EVP aerosol there is significantly less damage to lung cells in culture than the equivalent, nicotine based, dose of cigarette smoke.
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Affiliation(s)
- Gary Phillips
- Group Science and Regulatory Affairs, Imperial Brands PLC, Bristol, United Kingdom
| | - Lukasz Czekala
- Group Science and Regulatory Affairs, Imperial Brands PLC, Bristol, United Kingdom
| | - Holger P Behrsing
- Respiratory Toxicology, Institute for In Vitro Sciences, Inc., Gaithersburg, MD, USA
| | - Khalid Amin
- University of Minnesota Medical Center, Minneapolis, MN, USA
| | - Jessica Budde
- Reemtsma Cigarettenfabriken GmbH, An Imperial Brands PLC Company, Hamburg, Germany
| | - Matthew Stevenson
- Group Science and Regulatory Affairs, Imperial Brands PLC, Bristol, United Kingdom
| | - Roman Wieczorek
- Reemtsma Cigarettenfabriken GmbH, An Imperial Brands PLC Company, Hamburg, Germany
| | - Tanvir Walele
- Group Science and Regulatory Affairs, Imperial Brands PLC, Bristol, United Kingdom
| | - Liam Simms
- Group Science and Regulatory Affairs, Imperial Brands PLC, Bristol, United Kingdom
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Abstract
PURPOSE OF REVIEW Electronic cigarettes have quickly risen to be the leading alternative nicotine source to tobacco. E-cigarette use is hard to research and regulate because of the novelty and rapid evolution of the devices and E-liquids. Epidemiological data on long-term usage is currently lacking, but in smaller cohort studies we are starting to understand the usage patterns and demographics of users, which differ depending on where the study takes place and the regulatory environment. The present review describes the current knowledge of the effects of E-cigarettes on the pulmonary system and knowledge of their usage patterns worldwide. RECENT FINDINGS E-cigarette use is continuing to rise in young adults in United States and Canada, but not in United Kingdom. These suggest that regulation is influencing uptake in young adults. If E-cigarettes are to be considered as a harm minimisation smoking cessation product, use in young never smokers must be factored into the risk assessment. A recent surge in cases of lung injury associated with vaping in America has resulted in the definition of vaping associated pulmonary injury, although the exact cause remains unknown. SUMMARY It is our opinion that E-cigarettes can no longer be defined as harmless. Further studies are needed to determine the risks for all populations as it is evident that a large proportion of E-cigarette users are never-smokers, meaning they cannot only be considered from a harm reduction perspective.
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Pinkston R, Zaman H, Hossain E, Penn AL, Noël A. Cell-specific toxicity of short-term JUUL aerosol exposure to human bronchial epithelial cells and murine macrophages exposed at the air-liquid interface. Respir Res 2020; 21:269. [PMID: 33069224 PMCID: PMC7568376 DOI: 10.1186/s12931-020-01539-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/08/2020] [Indexed: 01/09/2023] Open
Abstract
Backgroud JUUL, an electronic nicotine delivery system (ENDS), which first appeared on the US market in 2015, controled more than 75% of the US ENDS sales in 2018. JUUL-type devices are currently the most commonly used form of ENDS among youth in the US. In contrast to free-base nicotine contained in cigarettes and other ENDS, JUUL contains high levels of nicotine salt (35 or 59 mg/mL), whose cellular and molecular effects on lung cells are largely unknown. In the present study, we evaluated the in vitro toxicity of JUUL crème brûlée-flavored aerosols on 2 types of human bronchial epithelial cell lines (BEAS-2B, H292) and a murine macrophage cell line (RAW 264.7). Methods Human lung epithelial cells and murine macrophages were exposed to JUUL crème brûlée-flavored aerosols at the air–liquid interface (ALI) for 1-h followed by a 24-h recovery period. Membrane integrity, cytotoxicity, extracellular release of nitrogen species and reactive oxygen species, cellular morphology and gene expression were assessed. Results Crème brûlée-flavored aerosol contained elevated concentrations of benzoic acid (86.9 μg/puff), a well-established respiratory irritant. In BEAS-2B cells, crème brûlée-flavored aerosol decreased cell viability (≥ 50%) and increased nitric oxide (NO) production (≥ 30%), as well as iNOS gene expression. Crème brûlée-flavored aerosol did not affect the viability of either H292 cells or RAW macrophages, but increased the production of reactive oxygen species (ROS) by ≥ 20% in both cell types. While crème brûlée-flavored aerosol did not alter NO levels in H292 cells, RAW macrophages exposed to crème brûlée-flavored aerosol displayed decreased NO (≥ 50%) and down-regulation of the iNOS gene, possibly due to increased ROS. Additionally, crème brûlée-flavored aerosol dysregulated the expression of several genes related to biotransformation, inflammation and airway remodeling, including CYP1A1, IL-6, and MMP12 in all 3 cell lines. Conclusion Our results indicate that crème brûlée-flavored aerosol causes cell-specific toxicity to lung cells. This study contributes to providing scientific evidence towards regulation of nicotine salt-based products.
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Affiliation(s)
- Rakeysha Pinkston
- Department of Environmental Toxicology, College of Sciences and Engineering, Southern University and A&M College, Baton Rouge, LA, 70813, USA.,Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, 1909 Skip Bertman Drive, Baton Rouge, LA, 70803, USA
| | - Hasan Zaman
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, 1909 Skip Bertman Drive, Baton Rouge, LA, 70803, USA
| | - Ekhtear Hossain
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, 1909 Skip Bertman Drive, Baton Rouge, LA, 70803, USA
| | - Arthur L Penn
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, 1909 Skip Bertman Drive, Baton Rouge, LA, 70803, USA
| | - Alexandra Noël
- Department of Comparative Biomedical Sciences, School of Veterinary Medicine, Louisiana State University, 1909 Skip Bertman Drive, Baton Rouge, LA, 70803, USA.
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9
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Prasetyo A, Sadhana U, Budiman J. Nasal Mucociliary Clearance in Smokers: A Systematic Review. Int Arch Otorhinolaryngol 2020; 25:e160-e169. [PMID: 33542766 PMCID: PMC7851360 DOI: 10.1055/s-0040-1702965] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/18/2019] [Indexed: 11/02/2022] Open
Abstract
Introduction Smoking is one of the most important causes of mortality and morbidity in the world, as it is related to the risk factor and etiology of respiratory-tract diseases. Long-term smoking causes both structural and functional damage in the respiratory airways, leading to changes in nasal mucociliary clearance (NMC). Objectives The aim of the present study was to look systematically into the current literature and carefully collect and analyze results to explore NMC in smokers. Data Synthesis Two independent reviewers conducted a literature search on some Electronic database: Pubmed, Medline, Ebsco, Springer Link, Science Direct, Scopus, and Proquest searching for articles fulfilling the inclusion and exclusion criteria. The lead author independently assessed the risk of bias of each of the included studies and discussed their assessments with the other two authors to achieve consensus. Of the 1,654 articles identified in the database search, 16 met the criteria for this review. Most of the articles (15 out of 16) showed the impairment of NMC in smokers. Conclusion The present systematic review suggests that there is an impairment of NMC in smokers. The impairment is not only observed in cigarette smoking, but also in passive smoking, bidi smoking, electronic smoking, and hookah smoking. The impairment of NMC in chronic exposure to smoking is caused by the ciliotoxic effect, hypersecretion and viscoelastic change of mucous, airway surface liquid depletion, increased oxidative stress, and deteriorations in the inflammatory and immune systems.
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Affiliation(s)
- Awal Prasetyo
- Department of Biomedical Science, Faculty of Medicine, Diponegoro University, Semarang, Indonesia.,Department of Anatomic Pathology, Faculty of Medicine, Diponegoro University - Dr. Kariadi Hospital, Semarang, Indonesia
| | - Udadi Sadhana
- Department of Anatomic Pathology, Faculty of Medicine, Diponegoro University - Dr. Kariadi Hospital, Semarang, Indonesia
| | - Jethro Budiman
- Department of Biomedical Science, Faculty of Medicine, Diponegoro University, Semarang, Indonesia.,Department of Anatomic Pathology, Faculty of Medicine, Diponegoro University - Dr. Kariadi Hospital, Semarang, Indonesia.,Department of Emergency Unit, Panti Wilasa Citarum Hospital, Semarang, Indonesia
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10
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Chaumont M, Tagliatti V, Channan EM, Colet JM, Bernard A, Morra S, Deprez G, Van Muylem A, Debbas N, Schaefer T, Faoro V, van de Borne P. Short halt in vaping modifies cardiorespiratory parameters and urine metabolome: a randomized trial. Am J Physiol Lung Cell Mol Physiol 2019; 318:L331-L344. [PMID: 31721596 PMCID: PMC7052663 DOI: 10.1152/ajplung.00268.2019] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Propylene glycol and glycerol are e-cigarette constituents that facilitate liquid vaporization and nicotine transport. As these small hydrophilic molecules quickly cross the lung epithelium, we hypothesized that short-term cessation of vaping in regular users would completely clear aerosol deposit from the lungs and reverse vaping-induced cardiorespiratory toxicity. We aimed to assess the acute effects of vaping and their reversibility on biological/clinical cardiorespiratory parameters [serum/urine pneumoproteins, hemodynamic parameters, lung-function test and diffusing capacities, transcutaneous gas tensions (primary outcome), and skin microcirculatory blood flow]. Regular e-cigarette users were enrolled in this randomized, investigator-blinded, three-period crossover study. The periods consisted of nicotine-vaping (nicotine-session), nicotine-free vaping (nicotine-free-session), and complete cessation of vaping (stop-session), all maintained for 5 days before the session began. Multiparametric metabolomic analyses were used to verify subjects' protocol compliance. Biological/clinical cardiorespiratory parameters were assessed at the beginning of each session (baseline) and after acute vaping exposure. Compared with the nicotine- and nicotine-free-sessions, a specific metabolomic signature characterized the stop-session. Baseline serum club cell protein-16 was higher during the stop-session than the other sessions (P < 0.01), and heart rate was higher in the nicotine-session (P < 0.001). Compared with acute sham-vaping in the stop-session, acute nicotine-vaping (nicotine-session) and acute nicotine-free vaping (nicotine-free-session) slightly decreased skin oxygen tension (P < 0.05). In regular e-cigarette-users, short-term vaping cessation seemed to shift baseline urine metabolome and increased serum club cell protein-16 concentration, suggesting a decrease in lung inflammation. Additionally, acute vaping with and without nicotine decreased slightly transcutaneous oxygen tension, likely as a result of lung gas exchanges disturbances.
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Affiliation(s)
- Martin Chaumont
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Institute for Translational Research in Cardiovascular and Respiratory Sciences, Université Libre de Bruxelles, Brussels, Belgium
| | - Vanessa Tagliatti
- Department of Human Biology and Toxicology, University of Mons, Mons, Belgium
| | - El Mehdi Channan
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Institute for Translational Research in Cardiovascular and Respiratory Sciences, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean-Marie Colet
- Department of Human Biology and Toxicology, University of Mons, Mons, Belgium
| | - Alfred Bernard
- Laboratory of Toxicology and Applied Pharmacology, Institute of Experimental and Clinical Research, Université Catholique de Louvain, Brussels, Belgium
| | - Sofia Morra
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Institute for Translational Research in Cardiovascular and Respiratory Sciences, Université Libre de Bruxelles, Brussels, Belgium
| | - Guillaume Deprez
- Department of Clinical Chemistry, Université Libre de Bruxelles, Brussels, Belgium
| | - Alain Van Muylem
- Chest Department, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Nadia Debbas
- Department of Cardiology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Thomas Schaefer
- Cardio-Pulmonary Exercise Laboratory, Université Libre de Bruxelles, Brussels, Belgium
| | - Vitalie Faoro
- Cardio-Pulmonary Exercise Laboratory, Université Libre de Bruxelles, Brussels, Belgium
| | - Philippe van de Borne
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Institute for Translational Research in Cardiovascular and Respiratory Sciences, Université Libre de Bruxelles, Brussels, Belgium
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11
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Iskandar AR, Zanetti F, Kondylis A, Martin F, Leroy P, Majeed S, Steiner S, Xiang Y, Ortega Torres L, Trivedi K, Guedj E, Merg C, Frentzel S, Ivanov NV, Doshi U, Lee KM, McKinney WJ, Peitsch MC, Hoeng J. A lower impact of an acute exposure to electronic cigarette aerosols than to cigarette smoke in human organotypic buccal and small airway cultures was demonstrated using systems toxicology assessment. Intern Emerg Med 2019; 14:863-883. [PMID: 30835057 PMCID: PMC6722047 DOI: 10.1007/s11739-019-02055-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 02/12/2019] [Indexed: 12/11/2022]
Abstract
In the context of tobacco harm-reduction strategy, the potential reduced impact of electronic cigarette (EC) exposure should be evaluated relative to the impact of cigarette smoke exposure. We conducted a series of in vitro studies to compare the biological impact of an acute exposure to aerosols of "test mix" (flavors, nicotine, and humectants), "base" (nicotine and humectants), and "carrier" (humectants) formulations using MarkTen® EC devices with the impact of exposure to smoke of 3R4F reference cigarettes, at a matching puff number, using human organotypic air-liquid interface buccal and small airway cultures. We measured the concentrations of nicotine and carbonyls deposited in the exposure chamber after each exposure experiment. The deposited carbonyl concentrations were used as representative measures to assess the reduced exposure to potentially toxic volatile substances. We followed a systems toxicology approach whereby functional biological endpoints, such as histopathology and ciliary beating frequency, were complemented by multiplex and omics assays to measure secreted inflammatory proteins and whole-genome transcriptomes, respectively. Among the endpoints analyzed, the only parameters that showed a significant response to EC exposure were secretion of proteins and whole-genome transcriptomes. Based on the multiplex and omics analyzes, the cellular responses to EC aerosol exposure were tissue type-specific; however, those alterations were much smaller than those following cigarette smoke exposure, even when the EC aerosol exposure under the testing conditions resulted in a deposited nicotine concentration approximately 200 times that in saliva of EC users.
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Affiliation(s)
- Anita R Iskandar
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland.
| | - Filippo Zanetti
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Athanasios Kondylis
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Florian Martin
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Patrice Leroy
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Shoaib Majeed
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Sandro Steiner
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Yang Xiang
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Laura Ortega Torres
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Keyur Trivedi
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Emmanuel Guedj
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Celine Merg
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Stefan Frentzel
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Nikolai V Ivanov
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Utkarsh Doshi
- Altria Client Services LLC, Richmond, VA, 23219, USA
| | | | | | - Manuel C Peitsch
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
| | - Julia Hoeng
- Philip Morris International R&D, Philip Morris Products S.A., Quai Jeanrenaud 5, 2000, Neuchâtel, Switzerland
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12
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Cuadra GA, Smith MT, Nelson JM, Loh EK, Palazzolo DL. A Comparison of Flavorless Electronic Cigarette-Generated Aerosol and Conventional Cigarette Smoke on the Survival and Growth of Common Oral Commensal Streptococci. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:E1669. [PMID: 31091650 PMCID: PMC6572406 DOI: 10.3390/ijerph16101669] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/26/2019] [Accepted: 05/08/2019] [Indexed: 12/15/2022]
Abstract
Background: The use of electronic cigarettes (ECIG) has become very common. Consequently, critical analysis of the biological effects of ECIG aerosol deserves attention. Flavorless ECIG aerosol is known to comprise fewer harmful constituents than cigarette smoke. Therefore, we hypothesize that aerosol has less immediate effect on the viability of oral commensal streptococci than smoke. Methods: Survival and growth of four strains of commensal streptococci were measured after exposure to flavorless ECIG aerosol ± nicotine and smoke. Peristaltic pumps were used to transport aerosol or smoke into chambers containing recently seeded colony-forming units (CFUs) of the oral commensal streptococci on agar plates. Bacterial survival and growth, based on colony counts and sizes, were determined 24 h post-exposure. Additionally, aerosol or smoke were delivered into chambers containing pre-adhered streptococci to plastic coverslips and biofilm formation was determined 24 h post-exposure via scanning electron microscopy. Results: The results suggest that flavorless aerosol ± nicotine has a modest effect on bacterial growth both as colonies on agar and as biofilms. In contrast, smoke dramatically decreased bacterial survival and growth in all parameters measured. Conclusion: Unlike cigarette smoke, flavorless ECIG aerosol has only a small effect on the survival and growth of oral commensal streptococci.
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Affiliation(s)
| | - Maxwell T Smith
- Department of Medical Laboratory Science, School of Allied Health Sciences, Lincoln Memorial University, Harrogate, TN 37752, USA.
| | - John M Nelson
- Department of Biology, School of Mathematics and Sciences, Lincoln Memorial University, Harrogate, TN 37752, USA.
| | - Emma K Loh
- Department of Biology, Muhlenberg College, Allentown, PA 18104, USA.
| | - Dominic L Palazzolo
- Department of Physiology, DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Harrogate, TN 37752, USA.
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13
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Chaumont M, van de Borne P, Bernard A, Van Muylem A, Deprez G, Ullmo J, Starczewska E, Briki R, de Hemptinne Q, Zaher W, Debbas N. Fourth generation e-cigarette vaping induces transient lung inflammation and gas exchange disturbances: results from two randomized clinical trials. Am J Physiol Lung Cell Mol Physiol 2019; 316:L705-L719. [PMID: 30724099 PMCID: PMC6589591 DOI: 10.1152/ajplung.00492.2018] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
When heated by an electronic cigarette, propylene glycol and glycerol produce a nicotine-carrying-aerosol. This hygroscopic/hyperosmolar aerosol can deposit deep within the lung. Whether these deposits trigger local inflammation and disturb pulmonary gas exchanges is not known. The aim of this study was to assess the acute effects of high-wattage electronic cigarette vaping with or without nicotine on lung inflammation biomarkers, transcutaneous gas tensions, and pulmonary function tests in young and healthy tobacco smokers. Acute effects of vaping without nicotine on arterial blood gas tensions were also assessed in heavy smokers suspected of coronary artery disease. Using a single-blind within-subjects study design, 25 young tobacco smokers underwent three experimental sessions in random order: sham-vaping and vaping with and without nicotine at 60 W. Twenty heavy smokers were also exposed to sham-vaping (n = 10) or vaping without nicotine (n = 10) in an open-label, randomized parallel study. In the young tobacco smokers, compared with sham-vaping: 1) serum club cell protein-16 increased after vaping without nicotine (mean ± SE, −0.5 ± 0.2 vs. +1.1 ± 0.3 µg/l, P = 0.013) and vaping with nicotine (+1.2 ± 0.3 µg/l, P = 0.009); 2) transcutaneous oxygen tension decreased for 60 min after vaping without nicotine (nadir, −0.3 ± 1 vs. −15.3 ± 2.3 mmHg, P < 0.001) and for 80-min after vaping with nicotine (nadir, −19.6 ± 2.8 mmHg, P < 0.001). Compared with sham vaping, vaping without nicotine decreased arterial oxygen tension for 5 min in heavy-smoking patients (+5.4 ± 3.3 vs. −5.4 ± 1.9 mmHg, P = 0.012). Acute vaping of propylene glycol/glycerol aerosol at high wattage with or without nicotine induces airway epithelial injury and sustained decrement in transcutaneous oxygen tension in young tobacco smokers. Intense vaping conditions also transiently impair arterial oxygen tension in heavy smokers.
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Affiliation(s)
- Martin Chaumont
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles , Brussels , Belgium
| | - Philippe van de Borne
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles , Brussels , Belgium
| | - Alfred Bernard
- Laboratory of Toxicology and Applied Pharmacology, Institute of Experimental and Clinical Research, Université Catholique de Louvain , Brussels , Belgium
| | - Alain Van Muylem
- Department of Respiratory Medicine, Erasme University Hospital, Université Libre de Bruxelles , Brussels , Belgium
| | - Guillaume Deprez
- Department of Clinical Chemistry, Erasme University Hospital, Université Libre de Bruxelles , Brussels , Belgium
| | - Julien Ullmo
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles , Brussels , Belgium
| | - Eliza Starczewska
- Department of Cardiology, Erasme University Hospital, Université Libre de Bruxelles , Brussels , Belgium
| | - Rachid Briki
- Department of Cardiology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles , Brussels , Belgium
| | - Quentin de Hemptinne
- Department of Cardiology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles , Brussels , Belgium
| | - Wael Zaher
- Department of Cardiology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles , Brussels , Belgium
| | - Nadia Debbas
- Department of Cardiology, Centre Hospitalier Universitaire Saint-Pierre, Université Libre de Bruxelles , Brussels , Belgium
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14
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Sosnowski TR, Odziomek M. Particle Size Dynamics: Toward a Better Understanding of Electronic Cigarette Aerosol Interactions With the Respiratory System. Front Physiol 2018; 9:853. [PMID: 30038580 PMCID: PMC6046408 DOI: 10.3389/fphys.2018.00853] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 06/15/2018] [Indexed: 11/17/2022] Open
Abstract
The knowledge of possible acute and long-term health effects of aerosols inhaled from electronic cigarettes (ECs) is still limited partially due to incomplete awareness of physical phenomena related to EC-aerosol dynamics. This short review discusses the basic processes of aerosol transformation (dynamics) upon inhalation, indicating also the need for the accurate determination of the size of droplets in the inhaled EC-mist. The significance of differences in the aerosol particle size distribution for the prediction of regional deposition of inhaled mist in the respiratory system is highlighted as a decisive factor in the interactions of inhaled EC-aerosols with the organism.
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Affiliation(s)
- Tomasz R Sosnowski
- Faculty of Chemical and Process Engineering, Warsaw University of Technology, Warsaw, Poland
| | - Marcin Odziomek
- Faculty of Chemical and Process Engineering, Warsaw University of Technology, Warsaw, Poland
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15
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Chaumont M, Bernard A, Pochet S, Mélot C, El Khattabi C, Reye F, Boudjeltia KZ, Van Antwerpen P, Delporte C, van de Borne P. High-Wattage E-Cigarettes Induce Tissue Hypoxia and Lower Airway Injury: A Randomized Clinical Trial. Am J Respir Crit Care Med 2018; 198:123-126. [DOI: 10.1164/rccm.201711-2198le] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Cobb E, Hall J, Palazzolo DL. Induction of Metallothionein Expression After Exposure to Conventional Cigarette Smoke but Not Electronic Cigarette (ECIG)-Generated Aerosol in Caenorhabditis elegans. Front Physiol 2018; 9:426. [PMID: 29740339 PMCID: PMC5925786 DOI: 10.3389/fphys.2018.00426] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/05/2018] [Indexed: 11/21/2022] Open
Abstract
Aim: With the invention of electronic cigarettes (ECIG), many questions have been raised regarding their safety as an alternative to smoking conventional cigarettes. Conventional cigarette smoke contains a variety of toxicants including heavy metals. However, ECIG-generated aerosol contains only trace amounts of metals, adding to the argument for it being a safer alternative. In response to heavy metal exposure, metallothioneins are induced in cells to help store the metal, detoxify the body, and are also known responders to oxidative stress. In an attempt to add to the evaluation of the safety of ECIGs, metallothionein expression was quantified using the nematode Caenorhabditis elegans as an assessment of stress induced cellular damage caused by exposure. Methods: Adult nematodes were exposed to either ECIG aerosol or conventional cigarette smoke at doses of 15, 30, and 45 puffs, the equivalent of one, two, and three cigarettes, respectively. Movement, survival, and stress-induced sleep were assessed for up to 24 h after exposure. Relative expression levels for mtl-1 and mtl-2, C. elegans metallothionein genes, were analyzed after 1, 5, and 24 h post exposure using quantitative RT-PCR. Results: Nematodes exposed to conventional cigarette smoke underwent stress-induced sleep in a dose dependent manner with animals recovering to values within the range of air control after 5 h post exposure. Those exposed to ECIG aerosol did not undergo stress-induced sleep and were indistinguishable from controls. The expression of mtl-1 increased in a dose and time dependent manner in C. elegans exposed to conventional cigarette smoke, with a maximum expression observed at 5 h post exposure of 45 puffs. No induction of mtl-2 was observed in any animals. Additionally, ECIG aerosol did not induce expression of mtl-1 and mtl-2 at levels different than those of untreated. Conclusion: ECIG aerosol failed to induce a stress response in C. elegans. In contrast, conventional cigarette smoke induced the production of mtl-1 in a manner that correlates with the induction of stress-induced sleep suggesting a stress response to damage. The lack of cellular stress response to ECIG aerosol suggests it may be a safer alternative to conventional cigarettes.
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Affiliation(s)
- Eric Cobb
- School of Mathematics and Sciences, Lincoln Memorial University, Harrogate, TN, United States.,DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Harrogate, TN, United States
| | - Julie Hall
- Department of Biology, School of Mathematics and Sciences, Lincoln Memorial University, Harrogate, TN, United States
| | - Dominic L Palazzolo
- Department of Physiology, DeBusk College of Osteopathic Medicine, Lincoln Memorial University, Harrogate, TN, United States
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