|Year : 2014 | Volume
| Issue : 4 | Page : 342-347
Correlation of exhaled nitric oxide, nasal nitric oxide and atopic status: A cross-sectional study in bronchial asthma and allergic rhinitis
Nitesh Gupta, Nitin Goel, Raj Kumar
Department of Respiratory Allergy and Applied Immunology, National Centre of Respiratory Allergy, Asthma and Immunology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
|Date of Web Publication||1-Oct-2014|
Dr. Raj Kumar
Department of Respiratory Allergy and Applied Immunology, National Centre of Respiratory Allergy, Asthma and Immunology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi - 110 007
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: Exhaled nitric oxide (FE NO ) and nasal nitric oxide (n NO) measurement is an area of ongoing research in the study of airway inflammation. The atopic status is known to influence the levels of FE NO and n NO. This study was undertaken to study the relationship between nitric oxide measurements in bronchial asthma and allergic rhinitis along with their correlation with atopic profile of Indian population. Materials and Methods: Ninety subjects were recruited for the study comprising of 25 each of bronchial asthma (BA), allergic rhinitis (AR), bronchial asthma with allergic rhinitis (BA-AR) and 15 healthy controls. These were assessed for atopy and exhaled breath analysis of nitric oxide. The measurements of FE NO and n NO levels were done using NIOX chemiluminescence analyzer. Atopy was assessed by skin prick testing (SPT) against 58 common aero-allergens and subjects with ≥1 positive SPT were labeled as atopic. Results: The BA-AR and BA groups had higher FE NO levels in comparison to the control (P < 0.05) and AR group (P < 0.05). The AR and BA-AR groups had higher n NO levels compared to the control group (P < 0.05) and BA group (P < 0.05). The increasing FE NO levels significantly correlated with the increase in the number of allergen sensitization in patients suffering from BA-AR (P < 0.05). However, the BA group showed a weaker positive correlation (P = 0.07). Conclusion: FE NO is a non-invasive marker of airway inflammation. Also, FE NO levels correlate with presence and degree of atopy in BA and AR. Simultaneously, n NO could be a surrogate marker of rhinitis.
Keywords: Asthma, atopy, nitric oxide, rhinitis, skin prick testing
|How to cite this article:|
Gupta N, Goel N, Kumar R. Correlation of exhaled nitric oxide, nasal nitric oxide and atopic status: A cross-sectional study in bronchial asthma and allergic rhinitis. Lung India 2014;31:342-7
|How to cite this URL:|
Gupta N, Goel N, Kumar R. Correlation of exhaled nitric oxide, nasal nitric oxide and atopic status: A cross-sectional study in bronchial asthma and allergic rhinitis. Lung India [serial online] 2014 [cited 2020 Jul 5];31:342-7. Available from: http://www.lungindia.com/text.asp?2014/31/4/342/142107
| Introduction|| |
The nitric oxide (NO) in the lung/airways has a key role as a vasodilator, bronchodilator, neurotransmitter and inflammatory mediator. ,,, Exhaled nitric oxide (FE NO ) and nasal nitric oxide (n NO) measurement is an area of ongoing research in the study of airway inflammation.
The FE NO level measurement has been validated and standardized for supporting the diagnosis in cases of eosinophilic inflammation of airways, bronchial hyperreactivity and asthma. 
FE NO levels have been higher in atopic than non-atopic bronchial asthma patients and some studies also reported that healthy atopic subjects without symptoms or signs of airway disorders have higher FE NO levels than non-atopic subjects. , Similarly the effect of clinical atopy, with atopic cases having higher levels as compared to non-atopic cases. 
To the best of our knowledge, the literature on exhaled breath and nasal nitric oxide from India is lacking. Hence, this study was undertaken to answer the question about the relationship between the noninvasive methods of nitric oxide measurements in bronchial asthma and allergic rhinitis and their correlation with atopic profile of Indian population.
| Materials and Methods|| |
Study design and demographics
The diagnosed patients of bronchial asthma (BA), allergic rhinitis (AR) and bronchial asthma with allergic rhinitis (BA-AR) were enrolled for the study from the outpatient clinics. A total of 90 subjects (36 females and 54 males) aged between 6-38 years were evaluated and they were divided into 4 groups: Group A - 25 Bronchial asthma (without allergic rhinitis); Group B - 25 Allergic rhinitis (without bronchial asthma); Group C - 25 Bronchial asthma with allergic rhinitis and Group D - 15 controls. Patients from all the 4 groups were further subdivided into atopic and non-atopic subgroups based on the skin prick test results for the purpose of analysis. The diagnosis of asthma and allergic rhinitis were based on Global Initiative for Asthma (GINA)  and Allergic Rhinitis and its Impact on Asthma (ARIA) (2008)  respectively. The subjects with inability to satisfactorily perform the nitric oxide maneuver were excluded. Other exclusion criterion were 1) Smoker (Former and current smokers) 2) Inhaled/nasal/oral steroid intake in preceding one month 3) Episode of upper or lower respiratory tract infection in the preceding one month and 4) History of urticaria/eczema. All the 90 subjects underwent a battery of investigations including baseline spirometry, FE NO and n NO measurements, skin prick tests and blood sampling, absolute eosinophil counts and serum total IgE levels.
Written informed consent was obtained from all subjects/parents (in case of subject's age <18 years) to participate in the study. The study protocol was approved by institutional ethical committee.
Measurement of FE NO and n NO
The measurements of exhaled nitric oxide and nasal nitric oxide was performed using NIOX chemiluminescence analyzer (Aerocrine AB, Solna, Sweden) in accordance with the 2005 ATS/ERS recommendations. 
The patient was inserted the mouthpiece, inhaled through mouth to total lung capacity (TLC) and then immediately exhaled at a constant flow rate (50 mL/s) to residual volume without breath-holding. The duration of exhalation had to be sufficient (>4 seconds in subjects <12 years and >6 seconds in subjects >12 years). Repeated, reproducible exhalations were performed to obtain at least two NO plateau values that agreed with in 10% of each other. The mean level of two reproducible recordings was used as the result value. The n NO measurement was done using the same analyzer by the nasal aspiration method. The measurements were always performed at the same place and the sampling timing was between 10-11 am.
Skin prick testing
Skin prick testing (SPT) to 58 common aeroallergens was performed in all the patients as per standard guidelines.  These are the commonest aeroallergens in clinical practice of allergy in India as per the study by Singh et al.  Atopy was defined as a positive skin prick test (wheal diameter of >3 mm as compared to buffer saline as control) for at least ≥1 aeroallergen. 
Measurement of serum total IgE and absolute eosinophil counts
Serum Total IgE was estimated by ELISA method using MINILYSER - TECAN, Austria, Calbiotech kit as per manufacturer's instructions. The number of peripheral blood eosinophils was counted in EDTA containing blood samples using an automated analyzer.
Spirometry with reversibility
Spirometry was performed on a dry, rolling-seal spirometer of the Benchmark model lung function machine (P.K. Morgan, Kent, UK). Maximal expiratory flow volume curves were obtained as per the ATS recommendations. 
All data analysis was performed using SPSS statistical package version 16.0 for windows (SPSS, Chicago, IL, USA). The data was examined for distribution and homogeneity of variances was checked before applying parametric tests. The data on FE NO and n NO were expressed as mean ± SD. The variables were compared between the four groups using one-way analysis of variance (ANOVA) and the post hoc Bonferroni alpha significant difference test for multiple comparisons. The univariate analyses of factors associated with FE NO was done using Pearson correlation. The conventional 5% level (P < 0.05) was considered to be statistically significant.
| Results|| |
The demographic characteristics of all the four groups are shown in [Table 1]. Of the total 90 subjects, 54 were males and rests of 36 subjects were females. Overall there were 54 atopic and 36 non-atopic patients in the study. The mean ages, age distribution, anthropometric variables (height, weight, BMI) were normally distributed amongst all the groups.
Exhaled nitric oxide (FE NO)
The mean levels of FE NO in all the four groups are depicted in [Table 1]. All the three groups had higher FE NO levels compared to the control group [Table 1]. The BA and BA-AR groups had significantly higher levels than the AR group [Figure 1]a. Also, the BA-AR group had higher FE NO levels when compared to the BA group although the comparison failed to reach statistical significance.
Nasal nitric oxide (n NO)
The mean levels of n NO in all the four groups are shown in [Table 1]. The AR group and BA-AR group had significantly higher n NO levels as compared to the control and BA groups [Figure 1]b. However, the BA group had n NO levels lower than the control group.
Atopic profile and nitric oxide levels
The control group had 8 atopic subjects and 7 non-atopic subjects. The FE NO levels between the atopic and non-atopic control subjects did not differ significantly (P = 0.771). The atopic patients suffering from BA, AR and BA-AR had statistically significant higher levels of FE NO in comparison to non-atopic patients of same group [Figure 2]. However, in comparison the mean n NO levels did not differ significantly; between the atopic and non-atopic patients in all the four groups.
|Figure 2: Intragroup comparison of FENO levels between atopic and non-atopic patients; P < 0.05 - statistically significant BA- Bronchial asthma; AR- Allergic rhinitis: BA-AR- Bronchial asthma with allergic rhinitis|
Click here to view
Number of positive responses on skin prick test and nitric oxide levels
The patients in all the four groups were further subdivided into 3 sub-groups on the basis of number of positive responses on SPT; 0, 1-3 and >3. The FE NO and n NO levels were analyzed in these subgroups [Table 2]. The FE NO levels positively and significantly correlated with the number of positive responses on SPT in patients suffering from BA-AR (P < 0.05). The BA group and AR group also showed a positive correlation albeit a weaker one (P = 0.07). However, no significant correlation of n NO levels and number of positive response on SPT were found in any of the four groups.
|Table 2: Correlation of FENO and n NO with SPT positivity of number of allergens|
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Serum total IgE, AEC, spirometry and nitric oxide levels
The serum total IgE and AEC levels were significantly higher in BA, AR and BA-AR groups when compared to the control group. However, no significant difference was found in their levels in atopic and non-atopic patients in each of the four groups. In the study, overall FE NO levels correlated significantly with serum total IgE levels (P = 0.002), however n NO levels were not significantly correlated with serum total IgE levels (P = 0.254). The AEC levels also correlated positively and significantly with FE NO levels (P = 0.004) and n NO levels (P = 0.01). The PFT parameters FEV 1 , FVC and FEV 1 /FVC did not show a significant correlation with either FE NO or n NO levels.
| Discussion|| |
Exhaled nitric oxide (FE NO ) measurement is non-invasive, simple and well tolerated method and is now used as a clinical biomarker for assessment of airway inflammation.  Similarly, nasal nitric oxide (n NO) measurement is useful in the diagnosis, treatment and follow-up of patients with nasal pathology, especially because as it is noninvasive. 
In the present study we have demonstrated that healthy individuals had mean FE NO levels of 12.73 ± 7.8 ppb whereas other studies on Chinese, African population and data from asthma and allergy research group had mean FE NO levels ranging from 20-39ppb. ,,, In a study by Ciprandi et al.,  the children suffering from asthma and rhinitis had mean FE NO levels of 41 ppb, with asthma had 37 ppb and those with rhinitis had 31 ppb (P < 0.001). We also found that FE NO levels were highest in BA-AR group (41.44 ± 29.9 ppb) followed by BA group (34.96 ± 17.2 ppb) and AR group (16.40 ± 10.3 ppb). In agreement with the literature, we observed higher FE NO levels in BA and BA-AR groups in comparison to the control group (P < 0.05) and AR group (P < 0.05). No statistical difference was found among any other groups for FE NO levels. The findings are consistent with previous studies. ,
The measurement of nasal inflammation in AR would rely on detecting increased levels of nasal NO resulting from increased expression of iNOS (inducible nitric oxide synthase), akin to the increase of exhaled nitric oxide levels in bronchial asthma.  In a study by Stewart et al.,  the mean n NO levels of 853.3 ppb in AR and 763.4 ppb in BA-AR groups were higher in comparison to 674.1 ppb levels in BA group. In our study also the n NO levels in AR (271.44 ± 120.3 ppb) and BA-AR groups (336.42 ± 124.6 ppb) were significantly higher in comparison to BA group (100.58 ± 111.2 ppb) and control group (114.50 ± 76.0 ppb). The above findings are attributed to increase in local production of nitric oxide in nasal epithelium in patients suffering from allergic rhinitis. , We did not find any statistical difference among any other groups for n NO levels. These results were in agreement with the previous studies by Kharitonov et al.,  and Lee et al. 
The effect of presence and degree of clinical atopic conditions on FE NO levels has been addressed in the literature. The higher FE NO levels in atopic asthmatics has been documented, however the effect of atopy on FE NO levels of healthy subjects requires further validation. , Rouhos et al.,  in his study showed atopic constitution, defined as positive skin prick test results,which does not increase FE NO levels in healthy nonsmoking adults with no signs or symptoms of airway disorders. Similar to this study, we also found no significant difference in FE NO levels with respect to atopic status in the control group.
In the present study the atopic BA, AR and BA-AR subjects had significantly higher FE NO levels in comparison to non-atopic subjects of the same group. Previous studies by Jouvaville et al.  and Gratziou et al.  have also found the similar result. In a study by Kumar et al.  the atopic allergic rhinitis subjects had statistically significant higher FE NO levels when compared to non-atopic subjects. Similar result was observed in the present study and this supports the hypothesis of a presence of subclinical inflammation of lower airways, and may predict development of asthma in future.
We found higher levels of nNO in atopic subjects of BA, AR and BA-AR in comparison to non-atopic subjects; though the relationship was statistically not significant. Olin et al.  and Kharitonov et al.  in their studies observed similar results.
The association between the degree of atopy and FE NO levels has been studied by Ho et al.  and Strunk et al.,  and they concluded that as number of positive responses on skin prick test increases, the FE NO levels also increases. We also found the similar positive correlation between FE NO levels and number of positive responses on SPT in BA-AR group (P < 0.05). Similarly, atopic BA subjects also showed a positive correlation albeit a weaker one (P = 0.07). The plausible explanation for this finding has been attributed to difference of inflammatory cells recruitment in atopics (eosinophilic) and non-atopic asthmatics (neutrophilic) as well as to cell activity of NO producing cells.  However, in a study by Moore et al.,  in asthmatics FE NO was not always associated with the number of positive skin prick test response. Thus, there exists a complex relationship between atopic profile and FE NO levels which requires further evaluation. Also, we found no significant association between n NO levels and the number of allergens positive on SPT in any of the groups of our study.
The higher FE NO and n NO levels in atopic subjects could be attributed to induction of iNOS enzyme. iNOS is the characteristic enzyme found in association with mucosal mast cells, eosinophils, and T-lymphocyte activation as described in cases of allergic rhinitis and bronchial asthma. , In bronchial biopsies of asthmatics an up regulation of expression of iNOS has been observed and immuno-cytochemical studies have also demonstrated expression of NOSs in human nasal mucosa. ,,
The FE NO and n NO levels are known to be influenced by age, sex, height, smoking and atopy status of the individual.  In current study, all the groups (AR, BA, BA with AR and Controls) were comparable with respect to all these factors except the atopic status. Hence, we could evaluate correlation of atopic status with FE NO and n NO levels. This was the strength of our study.
The work is limited by the small number of subjects enrolled. Hence, a further large-scale population based study is required for assessing applicability of FE NO and n NO levels in evaluation of BA and/or AR patients.
FeNO and nNo may serve as non-invasive marker of airway inflammation and atopy. Hence, they can be used for early recognition of airway inflammation and also as a guide for follow-up and management of BA and AR. This requires further large scale studies to validate the levels of FE NO and n NO and simultaneously confirm the correlation with atopic status.
| Conclusions|| |
In conclusion, the FE NO levels reflect the inflammatory activity of the airway epithelium and is associated with presence as well as degree of atopy in a sensitized patient, determined by positive skin prick test results to common aeroallergens. The study also highlights the need for evaluation of patient for the existence of allergic rhinitis or bronchial asthma in cases with higher FE NO levels. The n NO levels can be used as an inflammatory marker for supporting the diagnosis of coexisting allergic rhinitis in bronchial asthma patients. Further, large scale studies are required to develop reference equations and cutoff values for FE NO and n NO levels to aid in diagnosis and follow-up in Indian population.
| Acknowledgments|| |
The authors thank the Indian Council of Medical Research (ICMR) for the award under the MD/MS/DM/MCH thesis financial assistance program of ICMR, Human Resource Development for the present work.
| References|| |
|1.||Dweik RA, Comhair SA, Gaston B, Thunnissen FB, Farver C, Thomassen MJ, et al. NO chemical events in the human airway during the immediate and late antigen-induced asthmatic response. Proc Natl Acad Sci USA 2001;98:2622-7. |
|2.||Ricciardolo FL. Multiple roles of nitric oxide in the airways. Thorax 2003;58:175-82. |
|3.||Jain B, Rubenstein I, Robbins R, Leise R, Sisson J. Modulation of airway epithelial cell ciliary beat frequency by nitric oxide. Biochem Biophys Res Comm 1993;191:83-8. |
|4.||Kharitonov SA, Rajakulasingam K, O'Connor B, Durham SR, Barnes PJ. Nasal nitric oxide is increased in patients with asthma and allergic rhinitis and may be modulated by nasal glucorticoids. J Allergy Clin Immunol 1997;99:58-64. |
|5.||An Official ATS Clinical Practice Guideline: Interpretation of Exhaled Nitric Oxide Levels (FE NO ) for Clinical Applications. Am J Respir Crit Care Med 2011;184:602-15. |
|6.||Olin AC, Alving K, Torén K. Exhaled nitric oxide: Relation to sensitization and respiratory symptoms. Clin Exp Allergy 2004;34:221-6. |
|7.||Travers J, Marsh S, Aldington S, Williams M, Shirtcliffe P, Pritchard A, et al. Reference ranges for exhaled nitric oxide derived from random community survey of adults. Am J Respir Crit Care Med 2007;176:238-4. |
|8.||GINA Report, Global Strategy for Asthma Management and Prevention. [place unknown] The Global Initiative for Asthma (GINA); 2009 May [Last updated on 2010 Jan 12, cited on 2010 Aug 23]. pdf 1.0Mb. Available from: http://www.ginasthma.com/Guidelineitem.asp??l1=2andl2=1andintId=1561.[Last accessed on 2010 Aug 23]. |
|9.||Bosquet J, Khaltev N, Cruz AA, Denberg J, Fokkens WJ, Togias A, et al. Allergic Rhinitis and its Impact on Asthma 2008 update. Allergy 2008;86:8-160. |
|10.||American Thoracic Society; European Respiratory Society. ATS/ERS Recommendations for Standardized Procedures for the Online and Offline Measurement of Exhaled Lower Respiratory Nitric Oxide and Nasal Nitric Oxide, 2005. Am J Respir Crit Care Med 2005;171:912-30. |
|11.||Gaur SN, Singh BP, Singh AB, Vijayan VK, Agarwal MK. Guidelines for practice of allergen immunotherapy in India. Ind J Allergy Asth Appl Immunol 2009;23:1-20. |
|12.||Singh AB, Shahi S. Aeroallergens in Clinical Practice of Allergy in India- ARIA Asia Pacific Work-shop Report. Asian Pac J Allergy Immunol 2008;26:245-56. |
|13.||American Thoracic Society 1995. Update standardisation of spirometry. Am J Respir Crit Care Med 1995;152:1107-36. |
|14.||Serrano C, Valero A, Picado C. Nasal Nitric Oxide. Arch Bronconeumol 2004;40:222-30. |
|15.||Smith AD, Cowan JO, Filsell S, McLachlan C, Monti-Sheehan G, Jackson P, et al. Diagnosing asthma: Comparisons between exhaled nitric oxide measurements and conventional tests. Am J Respi Crit Care Med 2004;169:473-8. |
|16.||Dupont LJ, Demedts MG, Verleden GM. Prospective evaluation of the validity of exhaled nitric oxide for the diagnosis of asthma. Chest 2003;123:751-6. |
|17.||Stewart M, Clearie KL, Vaidyanathan S, Williamson AP, Lipworth BJ. Relationship between fractional exhaled nitric oxide and nasal nitric oxide in airway diseases. Ann Allergy Asthma Immunol 2010;105:162-7. |
|18.||Jouaville LF, Annesi-Maesonao I, Nguyen LT, Bocage AS, Bedu M, Caillaud D. Interrelationships among asthma, atopy, rhinitis, and exhaled nitric oxide in a population-based sample of children. Clin Exp Allergy 2003;33:1506-11. |
|19.||Ciprandi G, Tosca MA, Capasso M. Exhaled Nitric Oxide in Children with Allergic Rhinitis and/or Asthma: A Relationship with Bronchial Hyperreactivity. J Asthma 2010;47:1142-7. |
|20.||Alvarez MJ, Olaguibel JM, Garcia BE, Rodríquez A, Tabar AI, Urbiola E. Airway inflammation in asthma and perennial allergic rhinitis. Relationship with nonspecific bronchial responsiveness and maximal airway narrowing. Allergy 2000;55:355-62. |
|21.||Barnes PJ, Kharitonov SA. Exhaled nitric oxide: A new lung function test. Thorax 1996;51:233-7. |
|22.||Kharitonov SA, Gonio F, Kelly C, Meah S, Barnes PJ. Reproducibility of exhaled nitric oxide measurements in healthy and asthmatic adults and children. Eur Respir J 2003;21:433-8. |
|23.||Lee KJ, Cho SH, Lee SH, Tae K, Yoon HJ, Kim SH, et al. Nasal and Exhaled Nitric Oxide in Allergic Rhinitis. Clin Exp Otorhinolaryngol 2012;5:228-33. |
|24.||Franklin PJ, Stick SM, LeSouëf PN, Ayres JG, Turner SW. Measuring exhaled nitric oxide levels in adults. The importance of atopy and airway hyper responsiveness. Chest 2004;126:1540-5. |
|25.||Rouhos A, Kainu A, Karjalainen J, Lindqvist A, Piirilä P, Sarna S, et al. Atopic sensitization to common allergens without symptoms or signs of airway disorders does not increase exhaled nitric oxide. Clin Respir J 2008;2:141-8. |
|26.||Gratziou Ch, Lignos M, Dassiou M, Roussos C. Influence of atopy on exhaled nitric oxide in patients with stable asthma and rhinitis. Eur Respir J 1999;14:897-901. |
|27.||Ho L-P, Wood FT, Robson A, Innes JA, Greening AP. Atopy influences exhaled nitric oxide levels in adult asthmatics. Chest 2000;118:1327-31. |
|28.||Kumar R, Gupta N, Goel N. Correlation of Atopy and FE NO in Allergic Rhinitis: An Indian Study. Indian J Chest Dis Allied Sci 2013;55:79-83. |
|29.||Strunk RC, Szefler SJ, Philips BR, Zeiger RS, Chinchilli VM, Larsen G, et al. Childhood Asthma Research and Education Network of the National Heart, Lung, and Blood Institute. Relationship of exhaled nitric oxide to clinical and inflammatory markers of persistent asthma in children. J Allergy Clin Immunol 2003;112:883-92. |
|30.||Morre WC, Bleecker ER, Curran-Everett D, Erzurum SC, Ameredes RA, Bacharier L, et al. National Heart, Lung, and Blood Institute`s Severe Asthma Research Program. Characterization of the severe asthma phenotype by the National Heart, Lung, and Blood Institute`s Severe Asthma Research Program. J Allergy Clin Immunol 2007;119:405-13. |
|31.||Jatakanon A, Lim S, Kharitonov SA, Chung KF, Barnes PJ. Correlation between exhaled nitric oxide, sputum eosinophils, and methacholine responsiveness in patients with mild asthma. Thorax 1998;53:91-5. |
|32.||Howarth PH, Wilson J, Djukanovic R, Wilson S, Britten K, Walls A, et al. Airway inflammation and atopic asthma: A comparative bronchoscopic investigation. Int Arch Allergy Appl Immunol 1991;4:266-9. |
|33.||Hamid Q, Springall DR, Riveros-Moreno V, Chanez P, Howarth P, Redington A, et al. Induction of nitric oxide synthase in asthma. Lancet 1993;342:1510-3. |
|34.||Robbins RA, Barnes PJ, Springall DR, Warren JB, Kwon OJ, Buttery LK, et al. Expression of inducible nitric oxide synthase in human bronchial epithelial cells. Biochem Biophys Res Commun 1994;203:209-18. |
|35.||Furukawa K, Harrison D, Saleh D, Shennib H, Chagnon F, Giaid A. Expression of nitric oxide synthase in human nasal mucosa. Am J Respir Crit Care Med 1996;153:847-50. |
[Figure 1], [Figure 2]
[Table 1], [Table 2]