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Use of carboxyhemoglobin as a biomarker of environmental CO exposure: critical evaluation of the literature

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Abstract

Carbon monoxide (CO) poisoning is the primary cause for access to emergency department (ED) services for more than 50,000 persons in Europe and the USA every year. CO poisoning diagnosis is based on multiple factors and is usually confirmed by high carboxyhemoglobin (COHb) levels in the blood. We conducted a systematic evaluation of literature to investigate the usefulness of COHb as a biomarker of environmental CO exposure. We conducted an electronic search in Medline, Embase, and the Cochrane Library databases. We selected studies reporting high or low environmental CO concentrations, as well as COHb levels in exposed subjects presenting in ED or staying at home. We included 19 studies, but only 7 studies reported environmental CO concentration and proved a correlation between COHb and CO exposure in healthy and non-smoker subjects only. However, confounding factors were often incompletely assessed. The main symptoms reported were headache, nausea, vertigo and vomiting. COHb data stored in healthcare databases were used in six studies and provided useful information about symptoms, CO sources and patient characteristics. Most studies were classified at risk of bias. This review indicates that COHb is the most commonly used biomarker to assess CO exposure and seems to be useful. Further studies are needed to establish the reliability of COHb as a biomarker and/or explore other possible biomarkers. Surveillance systems of the general population, correlated with geographical locations and other confounding factors, could be important for CO exposure monitoring and the development of focused prevention programs.

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Acknowledgements

The authors would like to thank Johanna Chester for her critical revision and editing assistance.

Funding

No specific funding was received for this study.

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Authors and Affiliations

  1. Department of Laboratory Medicine-Laboratory of Toxicology, Clinical Pathology and Advanced Diagnostic, Ospedale Civile Sant’Agostino Estense, Via Giardini 1355, 41126, Modena, Italy

    Agnese Veronesi, Valentina Pecoraro & Tommaso Trenti

  2. Regional Centre for Environment and Health, Arpae Emilia-Romagna, Modena, Italy

    Stefano Zauli, Marta Ottone & Paolo Lauriola

  3. Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Chilton, Didcot, Oxfordshire, OX11 0RQ, UK

    Giovanni Leonardi

Authors
  1. Agnese Veronesi
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  2. Valentina Pecoraro
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  3. Stefano Zauli
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  4. Marta Ottone
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  5. Giovanni Leonardi
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  6. Paolo Lauriola
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  7. Tommaso Trenti
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Contributions

All authors contributed to the execution of the review. AV, VP, SZ, MO, PL and TT conceived and designed the study. VP designed and implemented the search strategies. AV and VP selected studies, assessed validity and extracted data. AV and VP evaluated the data. All authors interpreted the data, prepared the full review and contributed to its revision, interpretation of results and approval.

Corresponding author

Correspondence to Agnese Veronesi.

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The authors declare that they have no conflicts of interest.

Additional information

Responsible editor: Philippe Garrigues

Appendix. Medline search strategy

Appendix. Medline search strategy

(((((((((carboxyhemoglobin) OR ((“Carboxyhemoglobin/analysis”[Mesh] OR “Carboxyhemoglobin/blood”[Mesh] OR “Carboxyhemoglobin/diagnostic use”[Mesh] OR “Carboxyhemoglobin/etiology”[Mesh] OR “Carboxyhemoglobin/toxicity”[Mesh])))) OR ((carbon monoxide poisoning) OR ((“Carbon Monoxide Poisoning/analysis”[Mesh] OR “Carbon Monoxide Poisoning/blood”[Mesh] OR “Carbon Monoxide Poisoning/diagnosis”[Mesh] OR “Carbon Monoxide Poisoning/etiology”[Mesh])))) OR carbon monoxide exposure) OR ((biological marker*) OR ((“Biological Markers/blood”[Mesh] OR “Biological Markers/diagnostic use”[Mesh]))))) OR (((((((blood oxygenation) OR blood oxygen level)) OR (((blood oxygen saturation) OR oxymetry) OR “Oximetry/utilization”[Mesh]))) OR ((hemoglobinometry) OR “Hemoglobinometry/utilization”[Mesh])) OR ((“Blood Gas Analysis/utilization”[Mesh]) OR “blood gas analysis”)))) AND ((((((“Population Surveillance”[Mesh]) OR “population surveillance”)) OR ((“Public Health Surveillance”) OR “Public Health Surveillance”[Mesh]))) OR ((((“home accidents”) OR “Accidents, Home”[Mesh])) OR ((“Air Pollution, Indoor”[Mesh]) OR “indoor air pollution”))).

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Veronesi, A., Pecoraro, V., Zauli, S. et al. Use of carboxyhemoglobin as a biomarker of environmental CO exposure: critical evaluation of the literature. Environ Sci Pollut Res 24, 25798–25809 (2017). https://doi.org/10.1007/s11356-017-0270-1

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