The dose response principle from philosophy to modern toxicology: The impact of ancient philosophy and medicine in modern toxicology science.

Since ancient times the concept of dose response, from a toxicological perspective, has been a matter of concern. Already by the 8th century BC and over the years, many enlightened people have attempted to interpret this phenomenon, observing and coming across its results and practical implementation through exposure to chemical substances, either from natural or synthetic sources. Nowadays, the environmental exposure of human populations to chemicals in terms of quantity and quality might differ. Nevertheless, dose response still remains an issue joining hands with scientific and technological progress. The aim of the present review is not only to briefly recount the history of the dose response concept, from ancient time theories to novel approaches, but also to draw the outline of challenges and requirements toxicology science needs to fulfill.

Simulating real-life exposures to uncover possible risks to human health: A proposed consensus for a novel methodological approach.

In real life, consumers are exposed to complex mixtures of chemicals via food, water and commercial products consumption. Since risk assessment usually focuses on individual compounds, the current regulatory approach doesn't assess the overall risk of chemicals present in a mixture. This study will evaluate the cumulative toxicity of mixtures of different classes of pesticides and mixtures of different classes of pesticides together with food additives (FAs) and common consumer product chemicals using realistic doses after long-term exposure. Groups of Sprague Dawley (CD-SD) rats (20 males and 20 females) will be treated with mixtures of pesticides or mixtures of pesticides together with FAs and common consumer product chemicals in 0.0, 0.25 × acceptable daily intake (ADI)/tolerable daily intake (TDI), ADI/TDI and 5 × ADI/TDI doses for 104 weeks. All animals will be examined every day for signs of morbidity and mortality. Clinical chemistry hematological parameters, serum hormone levels, biomarkers of oxidative stress, cardiotoxicity, genotoxicity, urinalysis and echocardiographic tests will be assessed periodically at 6 month intervals. At 3-month intervals, ophthalmological examination, test for sensory reactivity to different types of stimuli, together with assessment of learning abilities and memory performance of the adult and ageing animals will be conducted. After 24 months, animals will be necropsied, and internal organs will be histopathologically examined. If the hypothesis of an increased risk or a new hazard not currently identified from cumulative exposure to multiple chemicals was observed, this will provide further information to public authorities and research communities supporting the need of replacing current single-compound risk assessment by a more robust cumulative risk assessment paradigm.

Hair nicotine/cotinine concentrations as a method of monitoring exposure to tobacco smoke among infants and adults.

In this pilot study, we examined the validity and usefulness of hair nicotine-cotinine evaluation as a biomarker of monitoring exposure to tobacco. Head hair samples were collected from 22 infants (<2 years of age) and 44 adults with different exposures to tobacco (through either active or passive smoking) and analyzed by liquid chromatography-mass spectrometry (LC-MS) for nicotine and cotinine. Hair samples were divided into three groups, infants, passive smoker adults and active smoker adults, and into eight subgroups according to the degree of exposure. The limit of quantification (LOQ) was 0.1 ng/mg for nicotine and 0.05 ng/mg for cotinine. Mean recovery was 69.15% for nicotine and 72.08% for cotinine. The within- and between-day precision for cotinine and nicotine was calculated at different concentrations. Moreover, hair nicotine and cotinine concentrations were highly correlated among adult active smokers (R (2) = 0.710, p < 0.001), among adult nonsmokers exposed to secondhand smoke (SHS; R (2) = 0.729, p < 0.001) and among infants (R (2) = 0.538, p = 0.01). Among the infants exposed to SHS from both parents the noted correlations were even stronger (R (2) = 0.835, p = 0.02). The above results identify the use of hair samples as an effective method for assessing exposure to tobacco, with a high association between nicotine and cotinine especially among infants heavily exposed to SHS.

Effects of pesticide exposure on the human immune system.

Epidemiological evidence from Western countries indicates that the prevalence of diseases associated with alterations in the immune response, such as asthma, certain autoimmune diseases and cancer, are increasing to such an extent that it cannot be attributed to improved diagnostics alone. There is some concern that this trend could be, at least, partially attributable to new or modified patterns of exposures to chemicals, including pesticides. The purpose of this article is to review the evidence on pesticide immunotoxicity in humans. Overall, the available data are inadequate to draw firm conclusions on the immunotoxic risk associated with pesticide exposure. The available studies on the effects of pesticides on the human immune system have several limitations, including limited data on exposure levels, heterogeneity of the applied methods, and difficulties in assessing the prognostic significance of observed slight changes and in the interpretation of the reported findings. Further studies are needed and preferably as prospective studies, comparing pre- and post-exposure data in the same group of subjects and including an appropriate non-exposed control group. More knowledge is required regarding the prognostic significance of the small changes observed.

Biological monitoring and questionnaire for assessing exposure to ethylenebisdithiocarbamates in a multicenter European field study.

This study deals with pesticide exposure profile in some European countries with a specific focus on ethylenebisdithiocarbamates (EBDC). In all, 55 Bulgarian greenhouse workers, 51 Finnish potato farmers, 48 Italian vineyard workers, 42 Dutch floriculture farmers, and 52 Bulgarian zineb producers entered the study. Each group was matched with a group of not occupationally exposed subjects. Exposure data were gained through self-administered questionnaires and measuring ethylenethiourea (ETU) in two spot urine samples collected, respectively, before the beginning of seasonal exposure (T0), and after 30 days, at the end of the exposure period (T30). Controls underwent a similar protocol. Study agriculture workers were involved in mixing and loading pesticides, application of pesticide mixture with mechanical or manual equipments, re-entry activities, and cleaning equipments. Chemical workers were involved in synthesis, quality controls, and packing activities. The number of pesticides to whom these subjects were exposed varied from one (zineb production) to eight (potato farmers). The use of personal protective devices was variegate and regarded both aerial and dermal penetration routes. EBDC exposure, assessed by T30 urinary ETU, was found to follow the order: greenhouse workers, zineb producers, vineyard workers, potato farmers, floriculture farmers with median levels of 49.6, 23.0, 11.8, 7.5, and 0.9 microg/g creatinine; the last group having ETU at the same level of controls (approximately 0.5 microg/g creatinine). Among agriculture workers, pesticide application, especially using manual equipment, seems to be the major determinant in explaining internal dose. Although the analysis of self-administered questionnaires evidenced difficulties especially related to lack and/or poor quality of reported data, biological monitoring confirms to be a powerful tool in assessing pesticide exposure.

Immune effects and exposure to ethylenebisdithiocarbamate pesticides in re-entry workers in the Netherlands.

Ethylenebisdithiocarbamates are widely used as fungicides in agriculture. Although EBDC's have a low acute toxicity, they are suspected to have immune effects at low doses. However, little human studies on these effects have been published. In the Netherlands, a study was conducted among pesticide exposed workers aimed at evaluating the short-term and long-term immune effects of exposure and the relation between ethylenebisdithiocarbamate and immune effects. Forty-one re-entry workers and 40 nonexposed controls were medically examined; furthermore, immune parameters were determined in blood, and all participants filled in a questionnaire regarding exposure and outcome parameters. The level of ethylenethiourea in urine was determined as indicator of exposure. No relevant adverse immune effects were found in the pesticide exposed workers compared with the nonexposed controls. Also no exposure response relationship between immune effects and ethylenebisdithiocarbamate in urine was found. This finding might be due to very low exposure levels of the re-entry work but might also be due to a lack of immunotoxicity of ethylenebisdithiocarbamate at normal exposure levels.

Toxicological evaluation of the immune function of pesticide workers, a European wide assessment.

In this study, the prolonged low-dose exposure of mixtures of pesticides has been examined on hematological parameters and components of the immune defense in occupationally exposed humans. This investigation was carried out in five field studies in: the Netherlands (flower bulb growers, mainly re-entry workers), Italy (vineyard workers), Finland (potato farmers), and Bulgaria (workers from a zineb factory and greenhouse workers). Immunotoxicity was studied by measuring hematological parameters, complement, immunoglobulins, lymphocyte subpopulations, natural killer cells, autoimmunity, and antibody responses to hepatitis B vaccination. The total study population consisted of 248 pesticide-exposed and 231 non-occupationally exposed workers. As a surrogate measure of pesticide exposure the urinary excretion of ethylenethiourea (ETU), the main metabolite ethylenebisdithiocarbamates was measured. A significantly higher level of ETU in occupationally exposed subjects compared with controls (2.7 +/- 8.1 microg/g vs 0.5 +/- 3.7 microg/g creatinine) was found. Statistically significant differences, albeit very low, were found for complement C3 and C4 and the immunoglobulin classes IgG4 and IgA. For complement and IgG4, the levels were slightly increased and the level of IgA was decreased. In the lymphocyte populations, the CD8 subpopulation was increased. No effects were found on autoimmune antibodies and antibody response to hepatitis vaccination. In conclusion, pesticide exposure under various work place conditions in Europe was associated only with some subtle effects on the immune system, which may suggest that occupational exposure to pesticides does not influence the immunologic system in a clinically significant fashion, and does not pose a significant health risk to the exposed subjects.

Association of pesticide exposure, vaccination response, and interleukin-1 gene polymorphisms.

We performed a cross-sectional study involving workers from four European countries in which exposure to pesticides and immune parameters were evaluated over a short period of time. The total study population consisted of 238 workers occupationally exposed to pesticides and 198 nonoccupationally exposed workers. The study showed that pesticide exposure at levels encountered by workers under different conditions in Europe did not affect the ability of the immune system to respond to vaccination. We could, however, identify individuals within the group of pesticide exposed workers who were genetically characterized by the 2.2 IL-1alpha polymorphism and who showed a lower antibody response, pointing out the importance of the understanding of genetic variability and the interaction between genetic and environmental factors in the identification of high-risk individuals, which may eventually lead to preventive measures.

Occupational exposure to ethylenebisdithiocarbamates in agriculture and allergy: results from the EUROPIT field study.

This epidemiological study was carried out to evaluate the possible association between occupational exposure to ethylenebisdithiocarbamates (EDBC) and allergy. The study was conducted in four countries in the European Union: The Netherlands, Finland, Italy and Bulgaria. A total of 248 workers exposed to EDBC and 231 non-occupationally exposed subjects entered the study. Exposure to EDBC was measured as urinary ethylenethiourea (ETU) in urinary samples collected at baseline and after 30 days of exposure. Several effect parameters were evaluated including questionnaire data on allergy, Phadiatop, a general allergy test, and specific IgE parameters. These data were also collected at baseline and after 30 days of exposure. Cross-sectional as well as longitudinal comparisons were made, adjusted for potential confounding factors. No association was found between exposure status, EDBC levels and allergic contact dermatitis, allergic rhinitis, food allergy or atopy as measured by the Phadiatop. The prevalence of skin irritation was elevated in the Dutch field study only and is more likely a result of plant contact rather than EDBC exposure. Occupational exposure to sunlight was noted to have a protective effect on atopy in terms of IgE positivity. We conclude that the EDBC exposure levels experienced in our field study are not associated with increased prevalence of allergic symptoms or allergy.

Asthmatic symptoms after exposure to ethylenebisdithiocarbamates and other pesticides in the Europit field studies.

We conducted a multicenter prospective study to assess the effects of occupational exposure to ethylenebisdithiocarbamate fungicides and/or other pesticides on self-reported asthma and asthmatic symptoms. This multicenter study was conducted among 248 workers exposed to pesticides and 231 non-exposed workers from five field studies. The five field studies were carried out in The Netherlands, Italy, Finland, and two studies in Bulgaria. Subjects constituting this cohort completed a self-administered questionnaire at baseline (before the start of exposure). Ethylenethiourea in urine was determined to assess exposure to ethylenebisdithiocarbamates. In multivariate analyses adjusted for all potential confounders (age, education, residence, smoking, gender, and field study), we found inverse associations, all not statistically significant, between occupational exposure to pesticides and asthma diagnosis (OR 0.41; 95% CI 0.15-1.11), complains of chest tightness (OR 0.60; 95% CI 0.36-1.02), wheeze (OR 0.56; 95% CI 0.32-0.98), asthma attack (OR 0.52; 95% CI 0.12-2.25), and asthma medication (OR 0.79; 95% CI 0.25-2.53). Furthermore, we reported null associations for multivariate analysis using ethylenethiourea as determinant for exposure. Although exposure to pesticides remains a potential health risk, our results do not suggest an association between exposure to ethylenebisdithiocarbamates and/or other pesticides used in our study on asthma and asthmatic symptoms.

A controlled study of tryptophan and cortisol in violent offenders.

Changes in the metabolism of tryptophan, other amino acids, and steroid hormones have been implicated in aggression. We compared tryptophan, competing long amino acids (CAAs), and cortisol in serum (S) and CSF in 22 violent offenders and 15 healthy controls. Offenders had significantly increased S-L-tryptophan, S-free tryptophan, S-CAAs, S-cortisol and CSF-cortisol, indicating abnormal neurophysiological processes. Larger studies on the interplay between violence, serotonin precursors, and stress hormones need to integrate personality traits, life situations, and physiological adaptation.

Total plasma l-tryptophan, free l-tryptophan and competing amino acid levels in a homicidal male adolescent with conduct disorder.

OBJECTIVE: Several studies have shown abnormal findings in human serotonin metabolism, such as increased total plasma l-tryptophan and free l-tryptophan levels among habitually violent antisocial offenders. It is not clear if these increased l-tryptophan levels are associated with adult antisocial personality disorder (ASP) or history of substance abuse, or if these levels are already present in adolescent subjects with conduct disorder (CD). METHOD: Total plasma and free l-tryptophan and competing amino acids (CAAs) were measured in a 15-year-old adolescent offender, who was convicted for two homicides, and in 10 healthy male controls of similar age and body mass index (BMI). RESULTS: In the juvenile offender, plasma total l-tryptophan/CAA was 84% and free l-tryptophan/CAA 143% higher than average mean among controls. CONCLUSION: From this very aggressive boy with CD, findings of free l- and total l-tryptophan/CAA values were similar to those of habitually violent adult ASP offenders. As severe CDs in adolescence tend to develop into adults with ASP, increased l-tryptophan/CAA and free l-tryptophan/CAA values may serve as early indicators for the development of habitually violent adult offenders.

The effects of wood dusts on the redox status and cell death in mouse macrophages (RAW 264.7) and human leukocytes in vitro.

Wood dusts are classified as carcinogenic to humans and also produce other toxic, allergic, and acute effects in woodworkers. However, little is known about causative agents in wood dusts and their mechanisms of action. The effects of different tree species and particle size for biological activity were studied. The differences in the production of reactive oxygen species (ROS) and cell death (necrotic and apoptotic) between mouse macrophage (RAW 264.7) cells and human polymorphonuclear leukocytes (PMNL) for pine, birch, and beech dust exposures were investigated in vitro. The pine and birch dust exposure (1-100 microg/ml) produced concentration-dependent ROS production in both the cells, which was one order of magnitude higher with pine dust. The ROS production was faster in human PNML than murine RAW cells. The higher concentrations (500 and/or 1000 microg/ml) decreased ROS formation. With pine and birch dust exposure, this was probably due to the necrotic cell death. The pine dust concentrations of 500 and 1000 microg/ml were cytotoxic to human PMNL. The beech dust exposure activated the ROS production and decreased the cell viability only at the highest concentrations, being least potent of the three dusts. A sign of the apoptotic cell death in the murine RAW cells was observed at the pine dust concentration of 100 microg/ml. The exposure to the birch and beech dusts with a smaller particle size (<5 microm) produced greater ROS production than exposure to the corresponding dust with a wide range of particle sizes. However, changing the particle size did not affect the cell viability. The results indicate that the type of wood dust (tree species and possibly particle size) has a significant impact on the function and viability of phagocytic cells.

The 3-year follow-up study in a block of flats - experiences in the use of the Finnish indoor climate classification.

Indoor climate of two new blocks of flats was investigated. The case building was built for people with respiratory diseases by following the instructions of the Finnish Classification of Indoor Climate, Construction and Finishing Materials, while the control building was built using conventional building technology. The main indoor air parameters (temperature, relative humidity and levels of CO, CO2, ammonia, total volatile organic compounds, total suspended particles, fungal spores, bacteria and cat, dog and house dust mite allergens) were measured in six apartments of both the buildings on five occasions during the 3-year occupancy. In addition, a questionnaire to evaluate symptoms of the occupants and their satisfaction with their home environment was conducted in connection with indoor air quality (IAQ) measurements. The levels of indoor air pollutants in the case building were, in general, lower than those in the control building. In addition, the asthmatic occupants informed that their symptoms had decreased during the occupancy in the case building. This case study showed that high IAQ is possible to reach by careful design, proper materials and equipment and on high-quality construction with reasonable additional costs. In addition, the study indicated that good IAQ can also be maintained during the occupancy, if sufficient information on factors affecting IAQ and guidance on proper use and care of equipment are available for occupants.

Free L-tryptophan plasma levels in antisocial violent offenders.

RATIONALE: Several studies have shown that impulsive violent behavior is associated with reduced serotonin metabolism in the brain, but no data exist on possible alterations of the serotonin precursor (free L-tryptophan) levels among violent offenders. OBJECTIVES: To study free L-tryptophan and kynurenine plasma levels among antisocial violent offenders. METHODS: Free L-tryptophan and competing amino acid (CAA) plasma levels were measured among 19 male impulsive antisocial violent offenders and 19 age-matched healthy male controls. RESULTS: Mean free L-tryptophan/(CAA) plasma levels were 160% (95% CI 116%-204%) higher among offenders than controls (P=0.000). Seventeen of the 19 offenders (89.5%) had values of more than 2 SD above the mean value of controls. The levels of kynurenine, the major metabolite of tryptophan, were slightly increased in offenders. CONCLUSION: Free plasma L-tryptophan/CAA levels were markedly increased among antisocial violent offenders indicating a disturbed tryptophan metabolism.

Indicators of L-arginine metabolism and cardiovascular risk factors--a cross-sectional study in healthy middle-aged men.

This study examines the relationship between traditional risk factors of coronary artery disease and indicators involved in the metabolism of L-arginine (plasma and urine L-arginine, plasma L-citrulline, serum creatinine and urine orotic acid). Our study population consisted of 40 healthy male volunteers aged between 35 and 55 years. We found an inverse association between serum creatinine and blood pressure, between plasma L-citrulline and blood pressure, as well as between urine L-arginine and blood pressure. We also found a positive association between plasma LDL-cholesterol and urine L-arginine and a negative correlation between plasma L-arginine and LDL-cholesterol. Orotic acid measured from urine was not associated with any of the indicators of L-arginine metabolism. Our results indicate that L-arginine metabolism is of profound significance for cardiovascular health. However, our study does not answer questions relating to causality. Further studies are needed to clarify the causal relationship between cardiovascular risk factors, especially elevated blood pressure and high LDL-cholesterol, and indicators of L-arginine metabolism.

Preliminary report on the results of the second phase of a round- robin endotoxin assay study using cotton dust.

In an on-going endotoxin assay study, a two-part interlaboratory endotoxin assay study has been completed. The purpose of the study was to compare the variation in assay results between different laboratories, and, if the variation was high, to see if a common protocol would reduce the variation. In both parts of the study, membrane filters laden with the same approximate amount and type of cotton dust were sent for analysis to laboratories that "routinely" perform endotoxin analyses. First, each of these laboratories performed the analysis using the methodology common to its laboratory. In the second part of the study, membrane filters with cotton dust were again sent to the same laboratories where the analyses were performed as before but with a common extraction protocol. The preliminary results from the first phase of the study have been collected and showed that intra-laboratory variations were small, but large and significant interlaboratory variation was observed. The results were reported elsewhere. The preliminary results from the second part of the study consisting of the data currently collected are presented here. Again, intra-laboratory variations were small, but, also again, large and significant inter-laboratory variation was observed. However, in this part of the study, the range between the highest and lowest average results was narrower than in the first part of the study. Influence of the assay kit type was examined. The variation within assay kit type was small but significant differences in results were observed between assay kit types. The findings suggest that endotoxin concentration in samples can be ranked within laboratories, but not necessarily between laboratories. However, some of the variation between laboratories has been reduced by a common extraction protocol which suggests the possibility of further standardization that may lead to better comparability between laboratories.

Occupational exposure to alkoxysilanes in a fibreglass manufacturing plant.

OBJECTIVE: To assess the exposure of workers to alkoxysilanes and to determine the main route of exposure during the manufacture of fibreglass. METHODS: Occupational hygiene samples were taken from workers and their environment in a fibreglass factory during filament forming and the handling of coated fibres. The total exposure of workers to silanes was assessed by the collection of air samples into impinger flasks at stationary sampling sites, by the use of absorbent patch samples on workers' clothes or skin and from handwash samples. During the time of our field survey, 3-aminopropyltriethoxysilane, 3-glycidoxypropyltrimethoxysilane and 3-methacryloxypropyltrimethoxysilane were being used in different sizing mixtures. The samples were analysed by gas and liquid chromatography. RESULTS: The silane concentrations in the air samples were below the detection limits of the analytical methods. The mean dermal exposure to 3-glycidoxypropyltrimethoxysilane, analysed from the patch samples, was 2,800 mg h(-1) in the forming room and 800 mg h(-1) in the winder room. The corresponding figures for 3-methacryloxypropyl-trimethoxysilane were 3 and 9 mg h(-1). As determined in the handwash samples, the mean exposure to 3-glycidoxypropyltrimethoxysilane through the hands was 1,500 mg h(-1) in the forming room and 1,800 mg h(-1) in the winder room, the respective values for 3-methacryloxypropyltrimethoxysilane being 110 mg h(-1) and 90 mg h(-1). Only small quantities of 3-aminopropyltriethoxysilane were found in a few handwash samples. CONCLUSIONS: Our results showed that the workers in the fibreglass factory were clearly exposed to silanes. The main route of potential exposure was through the skin, especially the hands, which emphasised the importance of wearing appropriate protective gloves. According to the patch sampling, on average two thirds of the total dermal exposure was caused by exposure of the forearm, as indicated by the amounts of silanes analysed in the forearm patches. Since almost every worker was wearing protective gloves, the main occupational health finding concerning exposure to silanes was that short-sleeved T-shirts did not provide any protection to the arms.

Endotoxins and IgG antibodies as indicators of occupational exposure to the microbial contaminants of metal-working fluids.

OBJECTIVES: The aim of this study was to evaluate workers' exposure to microbes and bacterial endotoxins during the use of metal-working fluids (MWF). METHODS: Air and bulk sampling with biomonitoring of workers' serum IgG antibodies were used to estimate the exposure to biological agents at 18 workplaces. The types of emulsified MWF used were synthetic fluid, mineral oil or rape seed oil, in grinding, turning and drilling work. RESULTS: The endotoxin concentrations in the air ranged from 0.04 to 600 ng/m(3) when the endotoxin levels in MWF were 0.03-25,000 ng/ml. A high correlation was found between the endotoxin levels and the bacterial counts from MWF, as well as between the total culturable bacteria and the gram-negative bacteria concentrations in the air. Comamonas testosteroni and C. acidovorans were the most common strains in the samples but also colonies of Ochrobactrum anthropi, Pantoea agglomerans and Stenotrophomonas maltophilia were isolated from the workplaces. Fungi like Aspergillus, Cladosporium and Penicillium species were identified in the air but only rarely in the MWF. Positive IgG antibodies were found in the sera of 22 of the 25 MWF workers examined. Antibodies against S. maltophilia, P. agglomerans and C. acidovorans were the most common, appearing in 72%, 64% and 64%, respectively, of the cases. The MWF workers showed significantly higher IgG antibody responses to bacterial antigens than did the controls. CONCLUSIONS: The results clearly proved that in occupational hygiene measurements, endotoxins serve as excellent indicators of exposure to the microbial contaminants of MWF. IgG antibodies against antigens identified from workplace samples could be a practical tool for occupational health physicians.

Rat model for renal effects of 2-alkoxyalcohols and their acetates.

Male Wistar rats were given ethanediol (9.4 g/l), 2-ethoxyethylacetate (5.4 g/l), 2-butoxyethylacetate (2.9 g/l) and 1,2-propanediol (40 g/l) respectively in their drinking water for 2 weeks. Urine was collected during the last 24 h of the exposure. There was a marked increase in the oxalic acid excretion by the rats given ethanediol while rats given the alkoxyacetates excreted large amounts of ethoxyacetic and butoxyacetic acid, respectively. While not increased compared with controls, the excretion of oxalic acid by the latter group of rats was correlated to the excretion of the respective alkoxyacetic acids. The ammonia and glycosaminoglycan excretion was also smaller than that of controls. The urinary activity of succinate dehydrogenase was decreased in rats given the alkoxyacetates but not in animals exposed to ethanediol or propanediol. The data show that oxalic acid is actually a minor metabolite of the alkoxyacetates while the biochemical effects in kidney are associated more with the alkoxyacetic acid load. Alkoxyacetic acids seem to be inhibitors of renal succinate dehydrogenase, which may account for the decreased ammonia and glycosaminoglycan excretion.