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Jackson TW, House JS, Henriquez AR, Schladweiler MC, Jackson KM, Fisher AA, Snow SJ, Alewel DI, Motsinger-Reif AA, Kodavanti UP. Multi-tissue transcriptomic and serum metabolomic assessment reveals systemic implications of acute ozone-induced stress response in male Wistar Kyoto rats. Metabolomics 2023; 19:81. [PMID: 37690105 DOI: 10.1007/s11306-023-02043-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/21/2023] [Indexed: 09/12/2023]
Abstract
Air pollutant exposures have been linked to systemic disease; however, the underlying mechanisms between responses of the target tissue and systemic effects are poorly understood. A prototypic inducer of stress, ozone causes respiratory and systemic multiorgan effects through activation of a neuroendocrine stress response. The goal of this study was to assess transcriptomic signatures of multiple tissues and serum metabolomics to understand how neuroendocrine and adrenal-derived stress hormones contribute to multiorgan health outcomes. Male Wistar Kyoto rats (12-13 weeks old) were exposed to filtered air or 0.8 ppm ozone for 4-hours, and blood/tissues were collected immediately post-exposure. Each tissue had distinct expression profiles at baseline. Ozone changed 1,640 genes in lung, 274 in hypothalamus, 2,516 in adrenals, 1,333 in liver, 1,242 in adipose, and 5,102 in muscle (adjusted p-value < 0.1, absolute fold-change > 50%). Serum metabolomic analysis identified 863 metabolites, of which 447 were significantly altered in ozone-exposed rats (adjusted p-value < 0.1, absolute fold change > 20%). A total of 6 genes were differentially expressed in all 6 tissues. Glucocorticoid signaling, hypoxia, and GPCR signaling were commonly changed, but ozone induced tissue-specific changes in oxidative stress, immune processes, and metabolic pathways. Genes upregulated by TNF-mediated NFkB signaling were differentially expressed in all ozone-exposed tissues, but those defining inflammatory response were tissue-specific. Upstream predictor analysis identified common mediators of effects including glucocorticoids, although the specific genes responsible for these predictors varied by tissue. Metabolomic analysis showed major changes in lipids, amino acids, and metabolites linked to the gut microbiome, concordant with transcriptional changes identified through pathway analysis within liver, muscle, and adipose tissues. The distribution of receptors and transcriptional mechanisms underlying the ozone-induced stress response are tissue-specific and involve induction of unique gene networks and metabolic phenotypes, but the shared initiating triggers converge into shared pathway-level responses. This multi-tissue transcriptomic analysis, combined with circulating metabolomic assessment, allows characterization of the systemic inhaled pollutant-induced stress response.
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Affiliation(s)
- Thomas W Jackson
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711, USA.
- Oak Ridge Institute for Science and Education Research Participation Program, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711, USA.
| | - John S House
- Division of Intramural Research, National Institute of Environmental Health Sciences, Department of Health and Human Services, National Institutes of Health, Research Triangle Park, NC, 27709, USA
| | - Andres R Henriquez
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711, USA
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, ON, K1A 0K9, Canada
| | - Mette C Schladweiler
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711, USA
| | | | - Anna A Fisher
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711, USA
| | - Sam J Snow
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711, USA
- ICF, Durham, NC, USA
| | - Devin I Alewel
- Oak Ridge Institute for Science and Education Research Participation Program, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711, USA
| | - Allison A Motsinger-Reif
- Oak Ridge Institute for Science and Education Research Participation Program, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711, USA
| | - Urmila P Kodavanti
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, NC, 27711, USA
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The dynamicity of acute ozone-induced systemic leukocyte trafficking and adrenal-derived stress hormones. Toxicology 2021; 458:152823. [PMID: 34051339 DOI: 10.1016/j.tox.2021.152823] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/06/2021] [Accepted: 05/24/2021] [Indexed: 12/16/2022]
Abstract
Ozone exposure induces neuroendocrine stress response, which causes lymphopenia. It was hypothesized that ozone-induced increases in stress hormones will temporally follow changes in circulating granulocytes, monocytes- and lymphocyte subpopulations. The goal of this study was to chronicle the changes in circulating stress hormones, cytokines, and leukocyte trafficking during 4 h exposure to ozone. Male Wistar Kyoto rats were exposed to air or ozone (0.4 or 0.8 ppm) for 0.5, 1, 2, or 4 h. After each time point, circulating stress hormones, cytokines, and lung gene expression were assessed along with live and apoptotic granulocytes, monocytes (classical and non-classical), and lymphocytes (B, Th, and Tc) in blood, thymus, and spleen using flow cytometry. Circulating stress hormones began to increase at 1 h of ozone exposure. Lung expression of inflammatory cytokines (Cxcl2, Il6, and Hmox1) and glucocorticoid-responsive genes (Nr3c1, Fkbp5 and Tsc22d3) increased in both a time- and ozone concentration-dependent manner. Circulating granulocytes increased at 0.5 h of ozone exposure but tended to decrease at 2 and 4 h, suggesting a rapid egress and then margination to the lung. Classical monocytes decreased over 4 h of exposure periods (∼80 % at 0.8 ppm). B and Tc lymphocytes significantly decreased after ozone exposure at 2 and 4 h. Despite dynamic shifts in circulating immune cell populations, few differences were measured in serum cytokines. Ozone neither increased apoptotic cells nor altered thymus and spleen lymphocytes. The data show that ozone-induced increases in adrenal-derived stress hormones precede the dynamic migration of circulating immune cells, likely to the lung to mediate inflammation.
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Henriquez AR, Snow SJ, Schladweiler MC, Miller CN, Dye JA, Ledbetter AD, Hargrove MM, Richards JE, Kodavanti UP. Exacerbation of ozone-induced pulmonary and systemic effects by β 2-adrenergic and/or glucocorticoid receptor agonist/s. Sci Rep 2019; 9:17925. [PMID: 31784596 PMCID: PMC6884479 DOI: 10.1038/s41598-019-54269-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/10/2019] [Indexed: 12/16/2022] Open
Abstract
Agonists of β2 adrenergic receptors (β2AR) and glucocorticoid receptors (GR) are prescribed to treat pulmonary diseases. Since ozone effects are mediated through the activation of AR and GR, we hypothesized that the treatment of rats with relevant therapeutic doses of long acting β2AR agonist (LABA; clenbuterol; CLEN) and/or GR agonist (dexamethasone; DEX) would exacerbate ozone-induced pulmonary and systemic changes. In the first study, male 12-week-old Wistar-Kyoto rats were injected intraperitoneally with vehicle (saline), CLEN (0.004 or 0.02 mg/kg), or DEX (0.02 or 0.1 mg/kg). Since dual therapy is commonly used, in the second study, rats received either saline or combined CLEN + DEX (each at 0.005 or 0.02 mg/kg) one day prior to and on both days of exposure (air or 0.8ppm ozone, 4 hr/day x 2-days). In air-exposed rats CLEN, DEX or CLEN + DEX did not induce lung injury or inflammation, however DEX and CLEN + DEX decreased circulating lymphocytes, spleen and thymus weights, increased free fatty acids (FFA) and produced hyperglycemia and glucose intolerance. Ozone exposure of vehicle-treated rats increased bronchoalveolar lavage fluid protein, albumin, neutrophils, IL-6 and TNF-α. Ozone decreased circulating lymphocytes, increased FFA, and induced hypeerglycemia and glucose intolerance. Drug treatment did not reverse ozone-induced ventillatory changes, however, lung effects (protein and albumin leakage, inflammation, and IL-6 increase) were exacerbated by CLEN and CLEN + DEX pre-treatment in a dose-dependent manner (CLEN > CLEN + DEX). Systemic effects induced by DEX and CLEN + DEX but not CLEN in air-exposed rats were analogous to and more pronounced than those induced by ozone. These data suggest that adverse air pollution effects might be exacerbated in people receiving LABA or LABA plus glucocorticoids.
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Affiliation(s)
- Andres R Henriquez
- Oak Ridge Institute for Science and Education, U.S. Department of Energy, Oak Ridge, Tennessee, United States of America
| | | | - Mette C Schladweiler
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina, United States of America
| | - Colette N Miller
- Oak Ridge Institute for Science and Education, U.S. Department of Energy, Oak Ridge, Tennessee, United States of America
| | - Janice A Dye
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina, United States of America
| | - Allen D Ledbetter
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina, United States of America
| | - Marie M Hargrove
- Oak Ridge Institute for Science and Education, U.S. Department of Energy, Oak Ridge, Tennessee, United States of America
| | - Judy E Richards
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina, United States of America
| | - Urmila P Kodavanti
- Public Health and Integrated Toxicology Division, Center for Public Health and Environmental Assessment, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina, United States of America.
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Snow SJ, Henriquez AR, Costa DL, Kodavanti UP. Neuroendocrine Regulation of Air Pollution Health Effects: Emerging Insights. Toxicol Sci 2019; 164:9-20. [PMID: 29846720 DOI: 10.1093/toxsci/kfy129] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Air pollutant exposures are linked to cardiopulmonary diseases, diabetes, metabolic syndrome, neurobehavioral conditions, and reproductive abnormalities. Significant effort is invested in understanding how pollutants encountered by the lung might induce effects in distant organs. The role of circulating mediators has been predicted; however, their origin and identity have not been confirmed. New evidence has emerged which implicates the role of neuroendocrine sympathetic-adrenal-medullary (SAM) and hypothalamic-pituitary-adrenal (HPA) stress axes in mediating a wide array of systemic and pulmonary effects. Our recent studies using ozone exposure as a prototypical air pollutant demonstrate that increases in circulating adrenal-derived stress hormones (epinephrine and cortisol/corticosterone) contribute to lung injury/inflammation and metabolic effects in the liver, pancreas, adipose, and muscle tissues. When stress hormones are depleted by adrenalectomy in rats, most ozone effects including lung injury/inflammation are diminished. Animals treated with antagonists for adrenergic and glucocorticoid receptors show inhibition of the pulmonary and systemic effects of ozone, whereas treatment with agonists restore and exacerbate the ozone-induced injury/inflammation phenotype, implying the role of neuroendocrine activation. The neuroendocrine system is critical for normal homeostasis and allostatic activation; however, chronic exposure to stressors may lead to increases in allostatic load. The emerging mechanisms by which circulating mediators are released and are responsible for producing multiorgan effects of air pollutants insists upon a paradigm shift in the field of air pollution and health. Moreover, since these neuroendocrine responses are linked to both chemical and nonchemical stressors, the interactive influence of air pollutants, lifestyle, and environmental factors requires further study.
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Affiliation(s)
- Samantha J Snow
- Environmental Public Health Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina, 27711
| | - Andres R Henriquez
- Oak Ridge Institute for Science and Education, Research Triangle Park, North Carolina, 27711
| | - Daniel L Costa
- Emeritus, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina, 27711
| | - Urmila P Kodavanti
- Environmental Public Health Division, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, North Carolina, 27711
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Johan Garssen, Leendert Van Bree &. OZONE-INDUCED IMPAIRMENT OF PULMONARY TYPE IV HYPERSENSITIVITY AND AIRWAY HYPERRESPONSIVENESS IN MICE. Inhal Toxicol 2008. [DOI: 10.1080/089583797198088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Banjoko SO, Sridhar Mynapelli KC, Ogunkola IO, Masheyi OO. Methylene chloride exposure and carboxyhemoglobin levels in cabinetmakers. Indian J Occup Environ Med 2007; 11:56-60. [PMID: 21938216 PMCID: PMC3168097 DOI: 10.4103/0019-5278.34529] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Methylene chloride (MeCl(2)) is a clear colorless volatile sweet smelling lipophilic solvent used as a constituent of wood vanishes and paints. Human exposure is mainly due to inhalation and its biotransformation by the hepatic mixed function oxidases (MFO) leads to formation of carbon monoxide (CO). Simultaneous exposure to MeCl(2) and increased ambient CO results in undesirably increased carboxyhemoglobin (COHb) formation, which predisposes to carboxyhemoglobinaemia with the central nervous system as the primary target organ of toxicity.In this study, ambient CO levels were determined using a CO personal monitor in different pasts of Ibadan Nigeria and work place microenvironment of 50 Cabinet makers (test group) and 50 volunteer (control) in non-furniture making occupations. Mann Whitney U and Kruskaal Wallis were the statistical methods of analysis used.Questionnaires were administered to both groups carboxyhaemoglobin levels were determined in venous blood drawn from individuals in the two groups by differential spectrophotometric method.Ambient CO levels in Ibadan were observed to be between 4 and 52 ppm with a mean of 20 ppm. Work environment CO levels were significantly higher in test subjects than controls at 5.2 ± 1.08 ppm and 2.08 ± 0.91 ppm respectively (P <0.001). COHb in cabinetmakers with mean working hours of 9.48 ± 2.9 per day was 3.95 ± 1.35 (%) while that of controls with mean working hours of 8.0 ± 0.8 per day was 2.08 ± 0.91 ppm (P <0.001). Smoking however did not significantly affect the COHb levels within the two groups (P >0.05).It is therefore imperative to substitute MeCl(2) for safer chemicals in wood vanish and paints and the use of protective gas masks and adequate ventilation should be mandatory whenever MeCl(2) is used.
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Affiliation(s)
- Sunny O. Banjoko
- Department of Chemical Pathology, College of Health Sciences, Obafemi Awolowo University, Ile-Ife, Nigeria
| | - K. C. Sridhar Mynapelli
- Department of Epidemiology, Medical Statistics and Environmental Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Isiah O. Ogunkola
- Department of Chemical Pathology, University College Hospital, Ibadan, Nigeria
| | - Olatunde O. Masheyi
- Department of Chemical Pathology, University College Hospital, Ibadan, Nigeria
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Feng R, He W, Ochi H, Castranova V. Ozone exposure impairs antigen-specific immunity but activates IL-7-induced proliferation of CD4-CD8- thymocytes in BALB/c mice. JOURNAL OF TOXICOLOGY AND ENVIRONMENTAL HEALTH. PART A 2006; 69:1511-26. [PMID: 16854782 DOI: 10.1080/15287390500468696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
It is well known that ozone (O3), a potent reactive oxidant and air pollutant, induces respiratory inflammation and hyperresponsiveness upon inhalation. It was previously shown that O3 exposure (0.6 ppm, 10 h/day for 15 days) not only results in local bronchial inflammation, but also affects the nervous system and thymocyte proliferation, and places mice under oxidative stress. In the present study, data showed that O3 exposure could impair both the natural killer (NK) cell activity and the proliferation potential of spleen T cells to a specific antigen stimulus. Immunological function assays indicated that O3 exposure attenuated the proliferation of spleen mononuclear cells induced by concanavalin A and decreased CD4+ and CD28+ lymphocyte subsets. However, supplementation with natural antioxidants protected mice from O3-induced dysfunction of splenocyte proliferation. Meanwhile, O3 exposure resulted in a decline of mitogen-induced IL-2 production in splenocytes. It was also found that O3 exposure dramatically enhanced the proliferation of CD4-CD8- thymocytes stimulated by recombinant mouse interleukin-7 (rmIL-7), which is usually observed during the mammal aging process. Taken together, data conclude that short-term repetitive O3 exposure damages both innate and acquired immunity via altering the lymphocyte subset and cytokine profile, and via impact on thymocyte early development. O3-induced oxidative damage is one of the key factors leading to immune dysfunction in this mouse model.
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Affiliation(s)
- Rentian Feng
- Department of Immunology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Dietert RR, Hedge A. Toxicological considerations in evaluating indoor air quality and human health: impact of new carpet emissions. Crit Rev Toxicol 1996; 26:633-707. [PMID: 8958468 DOI: 10.3109/10408449609037480] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
This review article considers evidence regarding the toxicological impact of new carpet emissions on indoor air quality and human health. It compares emissions data from several studies and describes the dominant compounds found in those emissions. The toxicity of each these compounds is assessed for animal and human data, with a focus on inhalation exposure. Data for acute and chronic exposures are presented, and synergistic effects are considered. Differences and similarities between health responses caused by toxicity and/or by immunological reactions are discussed. Possible neurogenic pathways and associations between these and immune changes are considered as they might relate to inflammatory-based human reactions. Additionally, factors affecting human odor responses are described. The roles that a variety of psychological factors may also play in the etiology of potentially related phenomena, such as the sick building syndrome, pathogenic illness, and multiple chemical sensitivity, are considered. Gaps in the literature are identified within the article and suggestions for future research are offered. In particular, it is noted that few, if any, prior studies have evaluated both neurogenic and immune-mediated inflammation status within the same study. Based on the present information available, it is concluded that under normal environmental circumstances, VOC emissions from new carpets are sufficiently low such that they should not adversely affect indoor air quality or pose significant health risk to people.
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Affiliation(s)
- R R Dietert
- Institute for Comparative and Environmental Toxicology, Cornell University, Ithaca, NY 14853, USA
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Cajigas A, Gayer M, Beam C, Steinberg JJ. Ozonation of DNA forms adducts: a 32P-DNA labeling and thin-layer chromatography technique to measure DNA environmental biomarkers. ARCHIVES OF ENVIRONMENTAL HEALTH 1994; 49:25-36. [PMID: 8117143 DOI: 10.1080/00039896.1994.9934411] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Little direct documented evidence of ozone's genotoxicity exists. Deoxyribonucleic acid (DNA) adducts are produced by environmental toxic agents, including ozone. We have described a modified thin-layer chromatography (TLC) technique that can assess adduct formation as a biomarker of ozone injury. This requires 32P-labeling DNA, digestion of deoxynucleotides (dNMPs), and separation in two-dimensional PEI-cellulose TLC. We have applied this technique to control DNAs, to control DNA in solution exposed to acute ambient ozone, and to control DNA exposed to acute bubbled-through ozone (2 ppm for 24 h). We detected stable DNA adducts, including hydroxymethyluracil (HMU), thymine glycol (TG), 8-hydroxyguanine (8-OHG), and demonstrated, as yet, unidentified adducts that may serve as a "fingerprint" pattern of DNA adduction. This technique quantifies low-molecular-mass DNA adducts, both in vivo and in vitro, with potential applications to environmental toxicology.
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Affiliation(s)
- A Cajigas
- Department of Pathology, Albert Einstein College of Medicine, New York, New York
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Sherwin RP. Air pollution: the pathobiologic issues. JOURNAL OF TOXICOLOGY. CLINICAL TOXICOLOGY 1991; 29:385-400. [PMID: 1920572 DOI: 10.3109/15563659109000365] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
In defining the adverse effects of ambient levels of ozone on the human lung, research has tended to emphasize direct cause and effect responses. However, disease is generally multicausative and the lung has relatively few ways to respond to injury. Moreover, all adult lungs have some disease. Thus, pathogenesis is more appropriately addressed by asking "What role does the agent in question play in the causation, promotion, facilitation, and/or exacerbation of disease that is present?" Our recent studies of the lungs of 107 ostensibly healthy youths between 14 and 25 years of age (violent death cases in Los Angeles County) add suggestive evidence to epidemiologic and experimental data indicating that air pollution is adversely affecting the human lung. We found 80% of the youths with some degree of presumably subclinical Centriacinar Region disease and, in 27%, the Centriacinar Region disease was severe and extensive. Centriacinar Region disease has been linked to infectious organisms, cigarette smoke, ozone, mineral dusts, and other noxious agents. Recently, a mild form of Centriacinar Region disease has been produced in primates exposed to a level of ozone (0.15 ppm) that is frequently exceeded in Los Angeles. Since there is suggestive evidence that air pollution in Los Angeles increases the rate of decline of lung function, we suspect that there has also been an increase in the rate of structural decline, manifest in part by accentuated Centriacinar Region disease. The health significance of Centriacinar Region disease is just beginning to be appreciated. At the very least, reserve depletion reflected in the Centriacinar Region disease implies some reduction in lung performance and some increase in susceptibility to disease in general. At worst, the unexpected severity of the Centriacinar Region disease may be a bellwether for an impending rise in clinically manifested lung disease for the general population. An urgent research need is the monitoring of health through inventories of the functional and structural units of the human lung, with special emphasis on subpopulations of cell societies of the lung. The feasibility of applying image analysis for large volume objective quantitations has been demonstrated and should be implemented. Multicity studies, in cooperation with Offices of the Medical Examiner-Coroner and autopsy services in general, can help meet the critical need for increased sensitivity in the monitoring of the public health in a changing environment.
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Affiliation(s)
- R P Sherwin
- Department of Pathology, University of Southern California, Los Angeles 90033
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