Is there an advantage in normalising the results of the Helicobacter Pylori [13C]Urea breath test for CO2 production rate in children?

The urea breath test (UBT) is a non-invasive diagnostic test to detect the presence of Helicobacter pylori in the stomach, and is the simplest way to confirm eradication after treatment. The test is based on the capacity of H. pylori to secrete the enzyme urease, which hydrolyses urea to ammonia and carbon dioxide. The aim of this study was to determine whether there is an advantage in expressing the results of UBTs in terms of urea hydrolysis rate (UHR), rather than breath ¹³C enrichment alone. Retrospective analysis of data collected between 1995 and 2002 from 260 patients undergoing UBTs was performed. The cut-offs for positive tests using breath 30-minute enrichment (E30), UHR calculated using VCO₂ estimated from height and weight (H/WT) and VCO₂ estimated from weight only were determined using two-graph receiver operator characteristic (TG-ROC) analysis. The cut-off points were 3.5‰ or 38.7?ppm ¹³C excess, 7.04?µmol/h and 7.08?µmol/h, respectively. There was no advantage in expressing the results as UHR (θ₀, Theta-zero, where sensitivity?=?specificity?=?0.97 (UHR H/WT), 0.98 (UHR WT) and 1.00 (E30)) rather than breath ¹³CO₂ enrichment alone. Differences in the extent of H. pylori colonisation and urease activity are more important than variation in VCO₂ in determining breath ¹³CO₂ enrichment in the UBT.     

Towards an Inhalative 13C Breath Test Method

Abstract

Customary ¹³CO₂ breath tests—and also ¹⁵N urine tests—always start with an oral administration of a test substrate. The test person swallows a stable isotope labelled diagnostic agent. This technique has been used to study several pathophysiological changes in gastrointestinal organs. However, to study pathophysiological changes of the bronchial and lung epithelium, the inhalative administration of a stable isotope labelled agent appeared more suitable to us. [1-¹³C]Hexadecanol and [1-¹³C]glucose were chosen. Inhaled [1-¹³C]hexadecanol did not yield ¹³CO₂ in the exhaled air, but [1-¹³C]glucose did. To study the practicability of the [1-¹³C]glucose method and the reproducibility of the results, 18 inhalation tests were performed with healthy subjects. In 6 self-tests, the optimum inhalative dose of [¹³C]glucose was determined to be 205 mg. Using the APS aerosol provocation system with the nebulizer ‘Medic Aid’ (Erich Jaeger Würzburg), a 25% aqueous solution was inhaled. Then, breath samples were collected at 15 min. intervals and analysed for ¹³CO₂. 75–120min after the end of inhalation a well-reproducible maximum δ¹³C value of 6‰ over baseline (DOB) was detected for 12 healthy probands.

Speculating that the pulmonary resorption of the [¹³C]glucose is the rate-limiting step of elimination, decompensations in the epithelium ought to be reflected in changed [1-¹³C]glucose resorption rates and changed ¹³CO₂ output.

Therefore, we speculate that the inhalation of suitable ¹³C-labelled substrates will pave the way for a new group of ¹³CO₂ breath tests aiding investigations of specific pathophysiological changes in the pulmonary tract, such as inflammations of certain sections and decompensations of cell functions.     

Breath water-based doubly labelled water method for the noninvasive determination of CO2 production and energy expenditure in mice

ABSTRACT

We explored a novel doubly labelled water (DLW) method based on breath water (BW-DLW) in mice to determine whole body CO₂ production and energy expenditure noninvasively. The BW-DLW method was compared to the DLW based on blood plasma. Mice (n?=?11, 43.5?±?4.6?g body mass (BM)) were administered orally a single bolus of doubly labelled water (1.2?g H₂¹⁸O kg BM^?1 and 0.4?g ²H₂O kg BM^?1, 99 atom% (AP) ¹⁸O or ²H). To sample breath water, the mice were placed into a respiration vessel. The exhaled water vapour was condensed in a cold-trap. The isotope enrichments of breath water were compared with plasma samples. The ²H/¹H and ¹⁸O/¹⁶O isotope ratios were measured by means of isotope ratio mass spectrometry. The CO₂ production (RCO₂) was calculated from the ²H and ¹⁸O enrichments in breath water and plasma over 5 days. The isotope enrichments of breath water vs. plasma were correlated (R²?=?0.89 for ²H and 0.95 for ¹⁸O) linearly. The RCO₂ determined based on breath water and plasma was not different (113.2?±?12.7 vs. 111.4?±?11.0?mmol?d^–1), respectively. In conclusion, the novel BW-DLW method is appropriate to obtain reliable estimates of RCO₂ avoiding blood sampling.     

Compact laser difference-frequency spectrometer for multicomponent trace gas detection

2 O), carbon dioxide (CO₂), and sulfur dioxide (SO₂). Real-time detection of CO, N₂O, and CO₂ was performed in open air over a path length of 5 to 18 m. The feasibility of DFG spectroscopic measurement of the ¹³C/¹²C and ¹⁸O/¹⁷O/¹⁶O isotopic ratios in atmospheric carbon dioxide was also investigated. We report what to our knowledge is the first simultaneous spectroscopic measurement of all three isotopes of oxygen in ambient CO₂. Received: 14 August 1997/Revised version: 3 November 1997     

Exact profiles of 13CO2 recovery in breath air after per oral administration of [13C]methacetin in two groups of different ages

The aim of this study is to determine if age is a factor influencing the results of a [¹³C]methacetin breath test (¹³C-MBT). Two groups of healthy volunteers, each comprising six men and six women, but differing in average age (Y=young, 25.1±0.6 years, MA=middle-aged;, 46.0±2.1 years) orally took 75 mg [¹³C]methacetin. Samples of expiratory air for ¹³CO₂ measurement were collected up to 48 h after intake of the substrate. A maximum momentary ¹³CO₂ breath exhalation of 37.0±2.6%dose/h was observed at 18 min (median, range: 9–30 min) in the young subjects and of 38.4±2.5%dose/h at 18 min (median, range: 12–30 min) in the middle-age volunteers. The cumulative ¹³C elimination in expiratory air was statistically significantly higher in the MA compared with the Y group as from 75 min up to 180 min, indicating a greater microsomal metabolic efficiency of the liver in the middle-aged healthy subjects. Gender, use of hormonal contraception, cigarette smoking, or body mass index did not modify the age-related effect on the cumulative ¹³C elimination in breath air. The study results imply a necessity of composing control groups well matched with regard to the age structure for a proper interpretation of clinical ¹³C-MBT results.     

In situ measurement of CO2 and water vapour isotopic compositions at a forest site using mid-infrared laser absorption spectroscopy

We conducted continuous, high time-resolution measurements of CO₂ and water vapour isotopologues (¹⁶O¹²C¹⁶O, ¹⁶O¹³C¹⁶O and ¹⁸O¹²C¹⁶O for CO₂, and H₂¹⁸O for water vapour) in a red pine forest at the foot of Mt. Fuji for 9 days from the end of July 2010 using in situ absorption laser spectroscopy. The δ¹⁸O values in water vapour were estimated using the δ²H–δ¹⁸O relationship. At a scale of several days, the temporal variations in δ¹⁸O-CO₂ and δ¹⁸O-H₂O are similar. The orders of the daily Keeling plots are almost identical. A possible reason for the similar behaviour of δ¹⁸O-CO₂ and δ¹⁸O-H₂O is considered to be that the air masses with different water vapour isotopic ratios moved into the forest, and changed the atmosphere of the forest. A significant correlation was observed between δ¹⁸O-CO₂ and δ¹³C-CO₂ values at nighttime (r²≈0.9) due to mixing between soil (and/or leaf) respiration and tropospheric CO₂. The ratios of the discrimination coefficients (Δ_a/Δ) for oxygen (Δ_a) and carbon (Δ) isotopes during photosynthesis were estimated in the range of 0.7–1.2 from the daytime correlations between δ¹⁸O-CO₂ and δ¹³C-CO₂ values.     

Production of 13C Labelled Pea Flour for Use in Human Digestion and Fermentation Studies

Abstract

Stable isotope breath tests offer a new approach to the study of digestion and fermentation of carbohydrates in man. In this study, ¹³C labelled peas were grown by pulsing 250ml ¹³CO₂ into a sealed growth chamber. A second pulse was added to a portion of the peas to increase the ¹³C enrichment. This generated pea flour with an enrichment of 2.36 at.% excess (range 2.09–2.71 n = 3) and 8.64 atom % excess (range 7.37–9.78 n = 3) respectively. This represented incorporation of an absolute yield of 3.8% of the ¹³CO₂ into peas in the ‘once-labelled’ treatment and 7.5% in the ‘twice-labelled’ treatment. Ingestion of a mixture of the labelled pea flour (300 mg) by two volunteers generated measurable ¹³CO₂ excretion for breath test analysis. The profile of breath ¹³CO₂ enrichment increased to a maximum within three hours after consuming the pea flour followed by a decrease almost back to baseline by 13 hours. Breath ¹³CO₂ appeared to rise again after this apparent nadir at 13 hours until the end of the sampling period. Mathematical analysis of the data suggested that two peaks best described the profile of breath ¹³CO₂ up to 13 hours. A third peak was necessary to describe the late rise in breath ¹³CO₂ enrichment. This use of ¹³C enriched pea flour may provide a useful non invasive method for measurement of digestion and fermentation in vivo.     

13C Basal Abundance of Expired CO2 -Definition of Pre-Requisites for Kinetic Breath Tests

Abstract

A sufficiently stable rate of ¹³CO₂ exhalation is necessary when the diagnostic ¹³CO₂ breath tests are performed in healthy subjects and patients. The aim of the research was to define prerequisite conditions for kinetic breath tests in order to ensure a stable ¹³CO₂ background. A 3-part protocol was developed. Part I: a study of the one-day variation of ¹³CO₂ abundance in expired CO₂ confirmed that shifts of the basal ¹³C abundance in breath are inherent in nature. Part II: a study of the variations of ¹³C enrichment after the ingestion of different meals and beverages showed that ingestion of food items containing C₄ plant sugars, such as maize, induces a significant increase in isotopic abundance. Part III: a new test breakfast containing rice grain cereal, milk and orange juice was tested. This test meal induces no significant change on the basal ¹³CO₂ abundance in healthy subjects. This new finding allows to avoid the fasting period normally required prior to a breath test which is sometimes difficult for children and pregnant women.     

The 13C bicarbonate method: an inverse end product method for measuring CO2 production and energy expenditure

We reconsider the principle of the ¹³C bicarbonate (NaH¹³CO₃) method (¹³C-BM) for the determination of the CO₂ production to obtain an estimate of energy expenditure (EE). Its mathematical concept based on a three-compartmental model is related to the [¹⁵N]glycine end product method. The CO₂ production calculated by the ¹³C-BM, R_aCO₂(¹³C) is compared to the result from the indirect calorimetry, RCO₂(IC). In an interspecies comparison (dog, goat, horse, cattle, children, adult human; body mass ranging from 15 to 350?kg, resting and fasting conditions) we found an excellent correlation between the results of ¹³C-BM and IC with RCO₂(IC)?=?0.703?×?R_aCO₂(¹³C), (R²?=?0.99). The slope of this correlation corresponds to the fractional ¹³C recovery (RF(¹³C)) of ¹³C in breath CO₂ after administration of NaH¹³CO₃. Significant increase in RF(¹³C) was found in physically active dogs (0.95?±?0.14; n?=?5) vs. resting dogs (0.71?±?0.10, n?=?17; p?=?.015). The ¹³C recovery in young bulls was greater in blood CO₂ (0.81?±?0.05) vs. breath CO₂ (0.73?±?0.05, n?=?12, p?<?.001) and in ponies with oral (0.76?±?0.03, n?=?8) vs. intravenous administration of NaH¹³CO₃ (0.69?±?0.07; n?=?8; p?=?.026). We suggest considering the ¹³C-BM as a ‘stand-alone’ method to provide information on the total CO₂ production as an index of EE.     

Use of the optogalvanic effect (OGE) for isotope ratio spectrometry of 13CO2 and 14CO2

The use of isotopic carbon dioxide lasers for determination of carbon (and oxygen) isotope ratios was first demonstrated in 1994. Since then a commercial device called LARA^?, has been manufactured and used for Helicobacter pylori breath tests using ¹³C-labelled urea. The major advantages of the optogalvanic effect compared with other infrared absorption isotope ratio measurement techniques are its lack of optical background and its high sensitivity resulting from a signal gain proportional to laser power. Continuous normalisation using two cells, a standard and sample, lead to high accuracy as well as precision. Recent advances in continuous flow measurement of ¹³C/¹²C ratios of CO₂ in air and extensions of the technique to ¹⁴C, which can be analysed as a stable isotope, are described.     

Helicobacter pylori determination in non-municipal drinking water and epidemiological findings

Background.?Studies conducted in Europe as well as in North and South America have tried to link Helicobacter pylori colonization with the drinking water supply, especially since H. pylori is known to survive quite well in water.

Methods.?In 2000, a cohort of 1884 grade-two children from two rural counties surrounding the city of Leipzig, Germany (77.4% of the 1991/1992 birth cohort) were tested for H. pylori colonization using the [¹³C]urea breath test. A parent-completed questionnaire elicited details on living conditions and lifestyle habits including questions on the children's drinking water from sources other than public water supplies, swimming in natural waters, etc.

In a second independent study, samples of well water, taken from 157 private wells still used in the two counties, were being tested for the presence of H. pylori, using polymerase chain reaction (PCR) method to determine relevant target DNA fragments of H. pylori.

Results.?In county I, 5.7% of the children and in county II 6.6% tested H. pylori-positive. Cluster analyses of the questionnaire data in both counties pointed to ‘drinking water from other than municipal sources’, as the closest H. pylori-associated cluster variable. The cluster estimations were supported by odds ratio (OR) calculations with an OR?=?16.4 (95% confidence interval (CI) 3.1,…,88.5) for county I and OR?=?4.0 (95% CI 1.3,…,12.4) for county II.

The PCR analyses showed H. pylori DNA fragments in 10.8% of the wells in county I and 9.2% in county II. The detection limit was set at 10 DNA copies corresponding to 125?bacteria/L, the average infestation of these wells was 931?bacteria/L.

Conclusion.?Despite the fact that the microbiological and epidemiological data do not correspond except that both studies were conducted in the same geographical areas, the independent findings of H. pylori in well water in the same general areas where children do seem to drink water other than from the public water supply suggests that water may be an important source of H. pylori infection.     

Isotope analysis by infrared laser absorption spectroscopy

The feasibility of IR laser spectroscopy as a technique for the measurement of small abundances of stable and radioactive isotopes has been examined. Theoretical considerations and first experimental results with two laser systems are presented: 1) Coincidences between emission lines of a CO₂-laser and absorption lines of¹³C-substituted ethylene can be used to determine the¹³C-concentration of C₂H₄. 2) A tunable PbS-diode laser emitting in the 4.3 μm-spectral region of the rotation-vibration bands of CO₂ can be used to determine abundances of¹²C,¹³C,¹⁶O,¹⁷O and¹⁸O in small samples of CO₂. With optimized performance, sensitivities up to 10⁻⁹–10⁻¹⁰ seem possible, and for higher abundances an accuracy of 10⁻³. This should allow geophysical isotope studies to be performed and it is hoped that the technique will eventually be applicable to measuring the activity of long-lived radioisotopes.     

Comparison of two dosage regimens of the substrate for the [13C]methacetin breath test

The [¹³C]methacetin breath test ([¹³C]MBT) – a valuable non-invasive tool dedicated to the assessment of the liver metabolic capacity – still needs standardisation. The aim of this study was to check whether currently used dosage regimens of [¹³C]methacetin provide concordant [¹³C]MBT results in subjects with an atypical body constitution. Healthy volunteers: low body mass<55 kg (eight women), and high body mass>95 kg (eight large body frame men) were recruited. They underwent [¹³C]MBT on separate days, taking in random order [¹³C]methacetin: a fixed 75 mg dose (FX75), or a 1 mg kg^?1 body mass-adjusted dose (BMAD). Samples of expiratory air for ¹³CO₂ measurement were collected over 3 h. The maximum momentary ¹³C elimination in breath air occurred earlier and was higher following BMAD than with FX75 in the low body mass females (T _max 14.6±1.0 min vs. 22.1±2.4 min, p=0.019; D _max 41.9±2.9 % dose h^?1 vs. 36.6±3.6 % dose h^?1, p=0.071). In the high body mass men, T _max remained unchanged, whereas D _max was slightly higher with BMAD compared to FX75 (21.5±3.2 min vs. 23.0±3.0 min; 38.5±2.9 % dose h^?1 vs. 32.3±2.5 % dose h^?1). It is concluded that in subjects with a body constitution outside the general population average, the dosage of the substrate may affect some results of the [¹³C]MBT. The dosage-related differences appear, however, to be insignificant if the result of the [¹³C]MBT is reported as a cumulative ¹³C recovery in breath air.     

Sensitive measurements of stable carbon isotopes of CO<Subscript>2</Subscript> with wavelength modulation spectroscopy near 2 μm

We performed highly sensitive measurements of stable carbon isotopes of CO₂ using wavelength modulation spectroscopy with a distributed feedback laser diode in the 2-μm wavelength range. Ro-vibrational transitions, which belong to the different combination bands, were selected to measure the ¹³CO₂/¹²CO₂ carbon isotope ratio. The δ ¹³C value was determined through the signals obtained in a Herriott-type multipass cell with an optical path length of 29.9 m. The limit of detection for CO₂ using our measurement system was 16±1 parts per billion by volume at the strongest absorption peak that is assigned to the 2ν ₁+ν ₃ R(16) line within the laser emitting frequency region. The 10-h long term precision was a δ ¹³C standard deviation of 0.24‰ (1σ) with the best suited line pairs of ¹²CO₂ and ¹³CO₂ and with careful temperature and pressure control in the cell. The 3-min response and high precision of this measurement allows for precise continuous measurements of stable carbon isotopes in ambient CO₂.     

Analysis of 13C-mixed Triacylglycerol in Stool by Bulk (Ea-IRMS) and Compound Specific (GC/MS) Methods

Abstract

This paper was presented in poster form at the 17th International Congress of Nutrition, August 27-31, Vienna. Austria (Annals of Nutrition & Metabolism 2001; 45(Suppl.1):349). Some of the data were also presented in poster form at the British Society of Gastroenterology Meeting, March 18-21, Glasgow, UK (Gut 2001; 48(Suppl.1):A91).

The ¹³C-mixed triacylglycerol (MTG) breath test is used to measure intraluminal fat digestion. In normal digestion. 20–40% of the ingested ¹³C label is recovered in breath CO₂. We aimed to identify the proportions of ingested label excreted in stool, as well as breath following ingestion of ¹³C-MTG by children with impaired exocrine pancreatic function and healthy controls. ¹³C enrichment of breath samples was measured by continuous flow isotope ratio mass spectrometry (IRMS) and cumulative percent dose recovered (cPDR) in 10 h was calculated. Total ¹³C of a faecal fat extract from each stool was measured by elemental analyser-IRMS, and ¹³C enrichment and concentration of the TBDMS derivative of octanoic acid was measured by GC/MS after hydrolysis of the fat extract. Stool 5-day cPDR was calculated. Mean breath cPDR was 35%. Mean cPDR in stool by combustion-IRMS and GC/ MS, respectively, was 0.8% and 1.0%. Therefore, the remaining 64% of the ¹³C label must remain in the body and variability in breath cPDR is due to postabsorptive rather than predigestive factors.     

The MICE facility – a new tool to study plant–soil C cycling with a holistic approach

Plant–soil interactions are recognized to play a crucial role in the ecosystem response to climate change. We developed a facility to disentangle the complex interactions behind the plant–soil C feedback mechanisms. The MICE (‘Multi-Isotope labelling in a Controlled Environment’) facility consists of two climate chambers with independent control of the atmospheric conditions (light, CO₂, temperature, humidity) and the soil environment (temperature, moisture). Each chamber holds 15 plant–soil systems with hermetical separation of the shared above ground (shoots) from the individual belowground compartments (roots, rhizosphere, soil). Stable isotopes (e.g. ¹³C, ¹⁵N, ²H, ¹⁸O) can be added to either compartment and traced within the whole system. The soil CO₂ efflux rate is monitored, and plant material, leached soil water and gas samples are taken frequently. The facility is a powerful tool to improve our mechanistic understanding of plant–soil interactions that drive the C cycle feedback to climate change.     

Biomedical Application of an Isotope Selective Nondispersive Infrared Spectrometer for 13CO2 and 12CO2 Concentration Measurements in Breath Samples

A newly developed isotope selective nondispersive infrared (NDIR) spectrometer for the measurement of ¹³CO₂ and ¹²CO₂ concentrations in breath samples was applied as a low cost and very simple to operate alternative to isotope ratio mass spectrometry (IRMS). We used this device for several biomedical applications ([¹³C]urea breath test, [¹³C]leucine metabolism, [¹³C]methacetin catabolism of rats) and found that the results agree very well with IRMS.     

Investigations of multiphoton selective dissociation of (CH3)2O in the field of a pulsed CO2 laser

Experimental investigations of multiphoton selective dissociation of (CH₃)₂O induced by a pulsed CO₂ laser have been conducted. Separation of H, C, and O isotopes was performed in enriched mixtures and in samples with the natural abundance. The following coefficients of selectivity have been obtained:K _D/K_H=4.0,K ₁₃/K₁₂=1.7, andK ₁₈/K₁₆≧1.6. We studied the dependences of the selectivity coefficient on ether pressure, on the laser energy and frequency as well as the influence of secondary chemical reactions on the dissociation selectivity. Estimations made by using the RRKM theory have indicated that ether molecules that decompose have an average excitation energy above the dissociation threshold of ∼1.5 kcal/mole.     

Postnatal development of urea synthesis in VLBW-infants as estimated by 15N-ammonium chloride urine test: Differences between AGA- and SGA-Infants

A prototype off-axis integrated cavity output spectrometer (OA-ICOS) utilizing two identical cavities together with a near-infrared (1.63 μm) external cavity tunable diode laser is described. The two-cavity design—one for a reference gas and one for a sample gas—takes advantage of classical double-beam infrared spectrometer characteristics in reducing uncertainties due to laser scan or power instabilities and major temperature variations by a factor of three or better compared with a single-cavity scheme. This is the first OA-ICOS instrument designed to determine ¹³C/¹²C and ¹⁸O/¹⁶O ratios from CO₂ rotation/vibration fine structure in three different combination bands. Preliminary results indicate that at 0.8 Hz a precision of 3.3 and 2.8 \permil\ is obtained for δ¹³C and δ¹⁸O, respectively, over a period of 10 h and a pure CO₂ gas sample at 26 hPa. By averaging 100 spectra over a subset of the data, we achieved a precision of 1.6 and 0.8 \permil\ for δ¹³C and δ¹⁸O, respectively.     

Field-deployable measurements of free-living individuals to determine energy balance: fuel substrate usage through δ13C in breath CO2 and diet through hair δ13C and δ15N values

Carbon isotopes of breath CO₂ vary depending on diet and fuel substrate used. This study examined if exercise-induced δ¹³C-CO₂ changes in substrate utilization were distinguishable from baseline δ¹³C-CO₂ variations in a population with uncontrolled diet, and compared hair isotope values and food logs to develop an isotope model of diet. Study participants included nine women with diverse Body Mass Index (BMI), age, ancestry, exercise history, and diet. Breath samples were collected prior to and up to 12?h after a 5- or 10?K walk/run. Indirect calorimetry was measured with a smartphone-enabled mobile colorimetric device, and a field-deployable isotope analyzer measured breath δ¹³C-CO₂ values. Diet was assessed by food logs and δ¹³C, δ¹⁵N of hair samples. Post-exercise δ¹³C-CO₂ values increased by 0.54?±?1.09‰ (1 sd, n?=?9), implying enhanced carbohydrate burning, while early morning δ¹³C-CO₂ values were lower than daily averages (p?=?0.0043), indicating lipid burning during overnight fasting. Although diurnal δ¹³C-CO₂ variation (1.90?±?0.77‰) and participant baseline range (3.06‰) exceeded exercise-induced variation, temporal patterns distinguished exercise from dietary isotope effects. Hair δ¹³C and δ¹⁵N values were consistent with a new dietary isotope model. Notwithstanding the small number of participants, this study introduces a novel combination of techniques to directly monitor energy balance in free-living individuals.