Recommendations for medical management of adult lead exposure

Exposure to lead in South African shooting ranges

INTRODUCTION

Lead exposure in shooting ranges has been under scrutiny for decades, but no information in this regard is available in respect of African settings, and in South Africa specifically. The aim of this study was to determine the blood lead levels in the users of randomly selected private shooting ranges in South Africa's Gauteng province.

METHODS

An analytical cross sectional study was conducted, with participants recruited from four randomly selected shooting ranges and three archery ranges as a comparator group.

RESULTS

A total of 118 (87 shooters and 31 archers) were included in the analysis. Shooters had significantly higher blood lead levels (BLL) compared to archers with 36/85 (42.4%) of shooters versus 2/34 (5.9%) of archers found to have a BLL ≥10μg/dl (p<0.001).

CONCLUSION

Shooting ranges may constitute an import site of elevated exposure to lead. Improved ventilation, low levels of awareness of lead hazards, poor housekeeping, and inadequate personal hygiene facilities and practices at South African shooting ranges need urgent attention.

The relationship between blood lead levels and occupational exposure in a pregnant population

Background

Pregnant women exposed to lead are at risk of suffering reproductive damages, such as miscarriage, preeclampsia, premature delivery and low birth weight. Despite that the workplace offers the greatest potential for lead exposure, there is relatively little information about occupational exposure to lead during pregnancy. This study aims to assess the association between blood lead levels and occupational exposure in pregnant women from Durango, Mexico.

Methods

A cross-sectional study was carried out in a population of 299 pregnant women. Blood lead was measured in 31 women who worked in jobs where lead is used (exposed group) and 268 who did not work in those places (control group). Chi-square test was applied to compare exposed and control groups with regard to blood lead levels. Odds ratio (OR) and 95% confidence intervals (CI) were calculated. Multivariable regression analysis was applied to determine significant predictors of blood lead concentrations in the exposed group.

Results

Exposed women had higher blood lead levels than those in the control group (4.00 ± 4.08 μg/dL vs 2.65 ± 1.75 μg/dL, p = 0.002). Furthermore, women in the exposed group had 3.82 times higher probability of having blood lead levels ≥ 5 μg/dL than those in the control group. Wearing of special workwear, changing clothes after work, living near a painting store, printing office, junkyard or rubbish dump, and washing the workwear together with other clothes resulted as significant predictors of elevated blood lead levels in the exposed group.

Conclusions

Pregnant working women may be at risk of lead poisoning because of occupational and environmental exposure. The risk increases if they do not improve the use of protective equipment and their personal hygiene.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3902-3) contains supplementary material, which is available to authorized users.

Elevated Blood Lead Levels Among Employed Adults - United States, 1994-2013

CDC's National Institute for Occupational Safety and Health (NIOSH) and state health departments collect data on laboratory-reported adult blood lead levels (BLLs). This report presents data on elevated BLLs among employed adults (defined as persons aged ≥16 years) in the United States for 1994-2013. This report is a part of the Summary of Notifiable Noninfectious Conditions and Disease Outbreaks - United States, which encompasses various surveillance years but is being published in 2016 (1). The Summary of Notifiable Noninfectious Conditions and Disease Outbreaks appears in the same volume of the Morbidity Mortality Weekly Report (MMWR) as the annual Summary of Notifiable Infectious Diseases (2).

Case of acute lead toxicity associated with Ayurvedic supplements

Use of traditional folkloric remedies not disclosed to the physician may be difficult to identify as a source of lead toxicity. This report illustrates the presentation of a 26-year-old man who, during his 1 month vacation in India, was treated for low back pain with Ayurvedic herbal medicine. On his return to the USA, he presented to the emergency department with epigastric pain, weight loss, dark stools, nausea and vomiting. He was admitted and noted to be anaemic with a blood lead level (BLL) of 94.8 µg/dL. Peripheral blood smear demonstrated basophilic stippling. Chelation therapy with succimer was initiated. The patient became asymptomatic within months. Three years later, he remained asymptomatic with BLL <20 µg/dL. Physicians should be cognisant of potential toxicity from these Ayurvedic medications and have a heightened level of suspicion for lead toxicity in the face of anaemia and abdominal pain without obvious cause.

Self-aliquoting micro-grooves in combination with laser ablation-ICP-mass spectrometry for the analysis of challenging liquids: quantification of lead in whole blood

We present a technique for the fast screening of the lead concentration in whole blood samples using laser ablation-inductively coupled plasma-mass spectrometry (LA-ICP-MS). The whole blood sample is deposited on a polymeric surface and wiped across a set of micro-grooves previously engraved into the surface. The engraving of the micro-grooves was accomplished with the same laser system used for LA-ICP-MS analysis. In each groove, a part of the liquid blood is trapped, and thus, the sample is divided into sub-aliquots. These aliquots dry quasi instantly and are then investigated by means of LA-ICP-MS. For quantification, external calibration against aqueous standard solutions was relied on, with iron as an internal standard to account for varying volumes of the sample aliquots. The (208)Pb/(57)Fe nuclide ratio used for quantification was obtained via a data treatment protocol so far only used in the context of isotope ratio determination involving transient signals. The method presented here was shown to provide reliable results for Recipe ClinChek® Whole Blood Control levels I-III (nos. 8840-8842), with a repeatability of typically 3 % relative standard deviation (n = 6, for Pb at 442 μg L(-1)). Spiked and non-spiked real whole blood was analysed as well, and the results were compared with those obtained via dilution and sectorfield ICP-MS. A good agreement between both methods was observed. The detection limit (3 s) for lead in whole blood was established to be 10 μg L(-1) for the laser ablation method presented here. Graphical Abstract Micro-grooves are filled with whole blood, dried, and analyzed by laser ablation ICP-mass spectrometry. Notice that the laser moves in perpendicular direction with regard to the micro-grooves.

Retained Lumbar Bullet: A Case Report of Chronic Lead Toxicity and Review of the Literature

BACKGROUND

Lead toxicity from retained bullet fragments is difficult to both predict and diagnose, but important to treat early, given the potential severity of disease. Blood lead levels > 25 μg/dL and 40 μg/dL are considered toxic in children and adults, respectively. Symptoms may range from nonspecific constitutional symptoms to seizures and coma. Chelation is the mainstay therapy for lead poisoning and levels to treat depend on patient age, blood lead levels, and the presence of symptoms. CASE 

REPORT

We present the case of a woman with symptoms of severe lead toxicity from 20-year-old retained bullet fragments. She had been seen by multiple providers for evaluation of each symptom, but a unifying diagnosis had not been found. After identifying this complication, she was treated appropriately and more serious complications were prevented. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We present this case to increase awareness among emergency physicians of lead toxicity in patients with a seemingly unrelated constellation of symptoms and a history of a previous gunshot wound with retained bullet or bullet fragments.

The attributable annual health costs of U.S. occupational lead poisoning

BACKGROUND

U.S. occupational lead standards have not changed for decades, while knowledge about lead's health effects has grown substantially.

OBJECTIVE

The objective of this analysis was twofold: to estimate the attributable annual societal costs of health damages associated with occupationally lead-exposed U.S. workers and, more broadly, to develop methods for a fuller valuation of health damages.

METHODS

I combined data voluntarily reported to NIOSH on the number of highly exposed workers with published literature on the health effects of lead in adults to estimate the potential health benefits of lowering the U.S. occupational limit. I developed simple algorithms for monetizing more fully both the direct medical and indirect (productivity) damages associated with those high lead exposures.

RESULTS

I estimated direct medical costs of $141 million (2014US$) per year for 16 categories of health endpoints, and combined direct and indirect costs of over $392 million (2014US$) per year for the 10,000 or so U.S. workers with high occupational lead exposures.

CONCLUSIONS

Reducing allowable occupational lead limits produces annual societal benefits of almost $40,000 per highly exposed worker. Given underreporting of actual exposures and the omission of important health effects, this is likely a severe underestimate.

Dose-Response Relationship between Cumulative Occupational Lead Exposure and the Associated Health Damages: A 20-Year Cohort Study of a Smelter in China

Long-term airborne lead exposure, even below official occupational limits, has been found to cause lead poisoning at higher frequencies than expected, which suggests that China's existing occupational exposure limits should be reexamined. A retrospective cohort study was conducted on 1832 smelting workers from 1988 to 2008 in China. These were individuals who entered the plant and came into continuous contact with lead at work for longer than 3 months. The dose-response relationship between occupational cumulative lead exposure and lead poisoning, abnormal blood lead, urinary lead and erythrocyte zinc protoporphyrin (ZPP) were analyzed and the benchmark dose lower bound confidence limits (BMDLs) were calculated. Statistically significant positive correlations were found between cumulative lead dust and lead fumes exposures and workplace seniority, blood lead, urinary lead and ZPP values. A dose-response relationship was observed between cumulative lead dust or lead fumes exposure and lead poisoning (p < 0.01). The BMDLs of the cumulative occupational lead dust and fumes doses were 0.68 mg-year/m³ and 0.30 mg-year/m³ for lead poisoning, respectively. The BMDLs of workplace airborne lead concentrations associated with lead poisoning were 0.02 mg/m³ and 0.01 mg/m³ for occupational exposure lead dust and lead fume, respectively. In conclusion, BMDLs for airborne lead were lower than occupational exposure limits, suggesting that the occupational lead exposure limits need re-examination and adjustment. Occupational cumulative exposure limits (OCELs) should be established to better prevent occupational lead poisoning.

Gunshot wound causing complete spinal cord injury without mechanical violation of spinal axis: Case report with review of literature

Penetrating spine injury (PSI) forms the third most common cause of spine injury, only next to road traffic accidents and fall. Gunshot wound (GSW) forms the major bulk of PSI. Due to easy availability of firearms and antisocial behavior, GSW which were predominant in military population is now increasingly seen in civilized society. Here, we present a detail case review of unique case of civilian GSW indirectly causing complete spinal cord injury due to shock wave generated by the bullet, along with its systematic management.

Possible Relationship between Chronic Telogen Effluvium and Changes in Lead, Cadmium, Zinc, and Iron Total Blood Levels in Females: A Case-Control Study

Introduction:

Hair loss is a common and distressing problem that can affect both males and females of all ages. Chronic telogen effluvium (CTE) is idiopathic diffuse scalp hair shedding of at least 6 months duration. Hair loss can be one of the symptoms of metal toxicity. Lead (Pb) and cadmium (Cd) are highly toxic metals that can cause acute and chronic health problems in human. The aim of the present study is to determine if there is a relationship between these metals and CTE in women and if CTE is also associated with changes in zinc (Zn) or iron (Fe) blood levels.

Materials and Methods:

Pb, Cd, Fe and Zn total blood levels were determined in 40 female patients fulfilling the criteria of CTH and compared with total blood levels of same elements in 30 well-matched healthy women.

Results:

Quantitative analysis of total blood Fe, Zn, Pb and Cd revealed that there were no significant differences between patients and controls regarding Fe, Zn, and Pb. Yet, Cd level was significantly higher in patients than controls. In addition, Cd level showed significant positive correlation with the patient's body weight.

Conclusion:

Estimation of blood Pb and Cd levels can be important in cases of CTE as Cd toxicity can be the underlying hidden cause of such idiopathic condition.

Blood Lead Levels and Cause-Specific Mortality of Inorganic Lead-Exposed Workers in South Korea

The objective of this study was to identify the association of blood lead level (BLL) with mortality in inorganic lead-exposed workers of South Korea. A cohort was compiled comprising 81,067 inorganic lead exposed workers working between January 1, 2000, and December 31, 2004. This cohort was merged with the Korean National Statistical Office to follow-up for mortality between 2000 and 2008. After adjusting for age and other carcinogenic metal exposure, all-cause mortality (Relative risk [RR] 1.36, 95% confidence interval [CI] 1.03-1.79), digestive disease (RR 3.23, 95% CI 1.33-7.86), and intentional self-harm (RR 2.92, 95% CI 1.07-7.81) were statistically significantly higher in males with BLL >20 μg/dl than of those with BLL ≤10μg/dl. The RR of males with BLL of 10-20 μg/dl was statistically higher than of those with BLL ≤10μg/dl in infection (RR 3.73. 95% CI, 1.06-13.06). The RRs of females with 10-20 μg/dl BLL was statistically significantly greater than those with BLL <10μg/dl in all-cause mortality (RR 1.93, 95% CI 1.16-3.20) and colon and rectal cancer (RR 13.42, 95% CI 1.21-149.4). The RRs of females with BLL 10-20 μg/dl (RR 10.45, 95% CI 1.74-62.93) and BLL ≥20 μg/dl (RR 12.68, 95% CI 1.69-147.86) was statistically significantly increased in bronchus and lung cancer. The increased suicide of males with ≥20 μg/dl BLLs, which might be caused by major depression, might be associated with higher lead exposure. Also, increased bronchus and lung cancer mortality in female workers with higher BLL might be related to lead exposure considering low smoking rate in females. The kinds of BLL-associated mortality differed by gender.

Autophagy plays a protective role in cell death of osteoblasts exposure to lead chloride

Lead (Pb) is a toxic heavy metal widespreadly used in industrial field. Prior studies showed that Pb exposure had detrimental effects on osteoblasts. The mechanisms underlying Pb-induced damage are complex. Autophagy can protect cells from various cytotoxic stimuli. In the present study, the aim of our research was to investigate whether Pb could activate autophagy to play a protective role against osteoblasts apoptosis. Our results indicated that PbCl2 induced autophagy and autophagic flux in MC3T3-E1 murine osteoblastic cell by RT-PCR, western blot, as well as fluorescence microscopy analysis of GFP-LC3, AO and MDC staining. Pb increased the apoptosis of osteoblasts, evidenced by western blot and Hoechst 33258 staining assessment. In addition, inhibiting autophagy by 3-MA further increased the osteoblasts apoptosis after Pb exposure, showed by flow cytometry and Hoechst 33258 staining. Furthermore, phosphorylation of mTOR and p70S6K was inhibited by Pb exposure, indicating that Pb might induce autophagy in osteoblasts via inhibiting mTOR pathway. Altogether, these evidence suggested that Pb exporsure promoted autophagy flux in osteoblasts. The activation of autophagy by Pb played a protective role in osteoblasts apoptosis, which might be mediated through the mTOR pathway.

Role of Lead in the Central Nervous System: Effect on Electroencephlography, Evoked Potentials, Electroretinography, and Nerve Conduction

The toxic effects of lead on the brain are well known, but its effects on EEG and evoked potentials (EPs) are not generally known in the neurodiagnostic community. Despite public health efforts, lead is still widely present at low levels in the environment. Even at low concentrations, lead is known to cause biochemical and physiological dysfunction. The present article reviews the effects of lead exposure on the central nervous system, with a special emphasis on the developing brain. Additionally, it describes the effects of lead on EEG, EPs, electroretinography, and nerve conduction studies.

Elevated Blood Lead Levels Among Fire Assay Workers and Their Children in Alaska, 2010-2011

In October 2010, an employee at Facility A in Alaska that performs fire assay analysis, an industrial technique that uses lead-containing flux to obtain metals from pulverized rocks, was reported to the Alaska Section of Epidemiology (SOE) with an elevated blood lead level (BLL) ≥10 micrograms per deciliter (μg/dL). The SOE initiated an investigation; investigators interviewed employees, offered blood lead screening to employees and their families, and observed a visit to the industrial facility by the Alaska Occupational Safety and Health Section (AKOSH). Among the 15 employees with known work responsibilities, 12 had an elevated BLL at least once from October 2010 through February 2011. Of these 12 employees, 10 reported working in the fire assay room. Four children of employees had BLLs ≥5 μg/dL. Employees working in Facility A's fire assay room were likely exposed to lead at work and could have brought lead home. AKOSH inspectors reported that they could not share their consultative report with SOE investigators because of the confidentiality requirements of a federal regulation, which hampered Alaska SOE investigators from fully characterizing the lead exposure standards.

Relationship between blood levels of heavy metals and lung function based on the Korean National Health and Nutrition Examination Survey IV-V

BACKGROUND

Heavy metal exposure may contribute to inflammation in the lungs via increased oxidative stress, resulting in tissue destruction and obstructive lung function (OLF). In this study, we evaluated the relationship between lead and cadmium levels in blood, and lung function in the Korean population.

METHODS

Pooled cross-sectional data from 5,972 subjects who participated in the Korean National Health and Nutrition Examination Survey 2008-2012 were used for this study. OLF was defined as forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) <0.7. Graphite-furnace atomic absorption spectrometry was used to measure levels of lead and cadmium in blood.

RESULTS

Adjusted means for age, sex, body mass index, and smoking status in blood lead and cadmium levels were increased with age and were higher in men and current smokers. The FEV1/FVC ratio was lower in the highest quartile group of lead (78.4% vs 79.0%; P=0.025) and cadmium (78.3% vs 79.2%; P<0.001) concentrations, compared with those in the lowest quartile groups. Multiple linear regression demonstrated an inverse relationship between the FEV1/FVC ratio and concentrations of lead (estimated -0.002; P=0.007) and cadmium (estimated -0.005; P=0.001). Of the 5,972 subjects, 674 (11.3%) were classified into the OLF group. Among current smokers, the risk of OLF was higher in subjects in the highest quartile group of cadmium concentration than in those in the lowest quartile group (odds ratio 1.94; 95% confidence interval 1.06-3.57).

CONCLUSION

We demonstrated a significant association between the FEV1/FVC ratio and blood concentrations of lead and cadmium in the Korean population. The risk for OLF was elevated with increasing concentrations of cadmium among current smokers.

More evidence of unpublished industry studies of lead smelter/refinery workers

BACKGROUND

Lead smelter/refinery workers in the US have had significant exposure to lead and are an important occupational group to study to understand the health effects of chronic lead exposure in adults. Recent research found evidence that studies of lead smelter/refinery workers have been conducted but not published. This paper presents further evidence for this contention.

OBJECTIVES

To present further evidence of industry conducted, unpublished epidemiologic studies of lead smelter/refinery workers and health outcomes.

METHODS

Historical research relying on primary sources such as internal industry documents and published studies.

RESULTS

ASARCO smelter/refinery workers were studied in the early 1980s and found to have increased risk of lung cancer and stroke in one study, but not in another.

CONCLUSIONS

Because occupational lead exposure is an on-going concern for US and overseas workers, all epidemiologic studies should be made available to evaluate and update occupational health and safety standards.

Lead toxicity: a review

Lead toxicity is an important environmental disease and its effects on the human body are devastating. There is almost no function in the human body which is not affected by lead toxicity. Though in countries like US and Canada the use of lead has been controlled up to a certain extent, it is still used vehemently in the developing countries. This is primarily because lead bears unique physical and chemical properties that make it suitable for a large number of applications for which humans have exploited its benefits from historical times and thus it has become a common environmental pollutant. Lead is highly persistent in the environment and because of its continuous use its levels rise in almost every country, posing serious threats. This article reviews the works listed in the literature with recent updates regarding the toxicity of lead. Focus is also on toxic effects of lead on the renal, reproductive and nervous system. Finally the techniques available for treating lead toxicity are presented with some recent updates.

Chronic lead exposure decreases the vascular reactivity of rat aortas: the role of hydrogen peroxide

We investigated whether exposure to small concentrations of lead alters blood pressure and vascular reactivity. Male Wistar rats were sorted randomly into the following two groups: control (Ct) and treatment with 100 ppm of lead (Pb), which was added to drinking water, for 30 days. Systolic blood pressure (BP) was measured weekly. Following treatment, aortic ring vascular reactivity was assessed. Tissue samples were properly stored for further biochemical investigation. The lead concentration in the blood reached approximately 8 μg/dL. Treatment increased blood pressure and decreased the contractile responses of the aortic rings to phenylephrine (1 nM–100 mM). Following N-nitro-L arginine methyl ester (L-NAME) administration, contractile responses increased in both groups but did not differ significantly between them. Lead effects on R_max were decreased compared to control subjects following superoxide dismutase (SOD) administration. Catalase, diethyldithiocarbamic acid (DETCA), and apocynin increased the vasoconstrictor response induced by phenylephrine in the aortas of lead-treated rats but did not increase the vasoconstrictor response in the aortas of untreated rats. Tetraethylammonium (TEA) potentiated the vasoconstrictor response induced by phenylephrine in aortic segments in both groups, but these effects were greater in lead-treated rats. The co-incubation of TEA and catalase abolished the vasodilatory effect noted in the lead group. The present study is the first to demonstrate that blood lead concentrations well below the values established by international legislation increased blood pressure and decreased phenylephrine-induced vascular reactivity. The latter effect was associated with oxidative stress, specifically oxidative stress induced via increases in hydrogen peroxide levels and the subsequent effects of hydrogen peroxide on potassium channels.

Role of delta-aminolevulinic acid in the symptoms of acute porphyria

BACKGROUND

Attacks of neuropathic pain, usually abdominal, are characteristic of the acute porphyrias and accompanied by overproduction of heme-precursor molecules, specifically delta-aminolevulinic acid and porphobilinogen. The basis for the acute symptoms in these diseases has been speculative.

METHODS

We review genetic acute porphyria, hereditary tyrosinemia, and an acquired condition, lead poisoning. All perturb heme synthesis and present with a similar pain syndrome.

RESULTS

Although each of these conditions has characteristic urine biochemistry, all exhibit excess delta-aminolevulinic acid. Moreover, in all, treatment with hemin reduces delta-aminolevulinic acid and relieves symptoms. In contrast, use of recombinant porphobilinogen deaminase to knock down porphobilinogen in acute porphyria was ineffective.

CONCLUSIONS

There is now convincing evidence that delta-aminolevulinic acid is the cause of pain in the acute porphyrias. The efficacy of hemin infusion is due mainly, if not entirely, to its inhibition of hepatic delta-aminolevulinic acid synthase-1, the enzyme that catalyzes delta-aminolevulinic acid formation. Delta-aminolevulinic acid synthase-1 is a rational target for additional therapies to control symptoms in acute porphyria.

Risk factors for lead exposure in adult population in southern Brazil

In Brazil there is no systematic evaluation to access blood lead levels (BLL) in the general population and few studies with adults have been published. The aim of this study was to examine the socioeconomic, environmental, and lifestyle determinants of BLL in the adult Brazilian population. In total, 959 adults, aged 40 years or more, were randomly selected in a city in southern Brazil. Information on socioeconomic, dietary, lifestyle, and occupational background was obtained by interviews. A spatial analysis was conducted to discern whether there were any identifiable sources of exposure. BLL were measured by inductively coupled plasma-mass spectrometry. There was an adjustment for gender, age, race, education, income class, smoking status, alcohol consumption, occupation, and red meat or cow milk consumption (Model 1), and for occupation and gender (Model 2). The geometric mean of BLL was 1.97 μg/dl (95% CI: 1.9-2.04 μg/dl). In Model 1, BLL were positively associated with male gender, older age, and drinking and smoking habits, and less frequently with milk consumption. In Model 2, data showed higher BLL in non-white than white participants, in former smokers and individuals with current or former employment in lead (Pb) industries. The participants living in the area with more Pb industries had higher BLL (3.3 μg/dl) compared with those residing in other areas with no or fewer Pb industries (1.95 μg/dl). Despite the low BLL found in adults living in an urban area, Pb industries need to be monitored and regulatory laws implemented to prevent metal contamination in urban settings.

Tremor secondary to neurotoxic exposure: mercury, lead, solvents, pesticides

Lead, mercury, solvents, and pesticide exposures are common in certain occupations and may cause nervous system dysfunction. Tremors may be the herald manifestation among a constellation of acute toxicity signs and symptoms. However, since tremors may also be the only sign on clinical presentation and since tremors also occur in other diseases, relating tremors to a specific occupational exposure can be challenging. Diagnosis of tremor etiology must be based on other findings on physical exam, laboratory results, and/or imaging. Discerning whether the tremor resulted from the occupational environment versus other etiologies requires knowledge of potential exposure sources, additional detail in history taking, and support of other health and industrial professionals. Reduction or removal from the exposure source remains the key first step in treating patients suffering from tremor that had resulted from occupational exposure toxicity.

A Pilot Assessment of Occupational Health Hazards in the US Electronic Scrap Recycling Industry

The National Institute for Occupational Safety and Health (NIOSH) surveyed a randomly selected sample of electronic scrap (e-scrap) recycling facilities nationwide to characterize work processes, exposures, and controls. Despite multiple attempts to contact 278 facilities, only 47 responded (17% response rate). Surveyed facilities reported recycling a wide variety of electronics. The most common recycling processes were manual dismantling and sorting. Other processes included shredding, crushing, and automated separation. Many facilities reported that they had health and safety programs in place. However, some facilities reported the use of compressed air for cleaning, a practice that can lead to increased employee dust exposures, and some facilities allowed food and drinks in the production areas, a practice that can lead to ingestion of contaminants. Although our results may not be generalizable to all US e-scrap recycling facilities, they are informative regarding health and safety programs in the industry. We concluded that e-scrap recycling has the potential for a wide variety of occupational exposures particularly because of the frequent use of manual processes. On-site evaluations of e-scrap recyclers are needed to determine if reported work processes, practices, and controls are effective and meet current standards and guidelines. Educating the e-scrap recycling industry about health and safety best practices, specifically related to safe handling of metal dust, would help protect employees.

Metal pollutants and cardiovascular disease: mechanisms and consequences of exposure

INTRODUCTION

There is epidemiological evidence that metal contaminants may play a role in the development of atherosclerosis and its complications. Moreover, a recent clinical trial of a metal chelator had a surprisingly positive result in reducing cardiovascular events in a secondary prevention population, strengthening the link between metal exposure and cardiovascular disease (CVD). This is, therefore, an opportune moment to review evidence that exposure to metal pollutants, such as arsenic, lead, cadmium, and mercury, is a significant risk factor for CVD.

METHODS

We reviewed the English-speaking medical literature to assess and present the epidemiological evidence that 4 metals having no role in the human body (xenobiotic), mercury, lead, cadmium, and arsenic, have epidemiologic and mechanistic links to atherosclerosis and CVD. Moreover, we briefly review how the results of the Trial to Assess Chelation Therapy (TACT) strengthen the link between atherosclerosis and xenobiotic metal contamination in humans.

CONCLUSIONS

There is strong evidence that xenobiotic metal contamination is linked to atherosclerotic disease and is a modifiable risk factor.

Metalloproteinase Inhibition Protects against Reductions in Circulating Adrenomedullin during Lead-induced Acute Hypertension

Intoxication with lead (Pb) results in increased blood pressure by mechanisms involving matrix metalloproteinases (MMPs). Recent findings have revealed that MMP type two (MMP-2) seems to cleave vasoactive peptides. This study examined whether MMP-2 and MMP-9 levels/activities increase after acute intoxication with low lead concentrations and whether these changes were associated with increases in blood pressure and circulating endothelin-1 or with reductions in circulating adrenomedullin and calcitonin gene-related peptide (CGRP). Here, we expand previous findings and examine whether doxycycline (a MMPs inhibitor) affects these alterations. Wistar rats received intraperitoneally (i.p.) 1st dose 8 μg/100 g of lead (or sodium) acetate, a subsequent dose of 0.1 μg/100 g to cover daily loss and treatment with doxycycline (30 mg/kg/day) or water by gavage for 7 days. Similar whole-blood lead levels (9 μg/dL) were found in lead-exposed rats treated with either doxycycline or water. Lead-induced increases in systolic blood pressure (from 143 ± 2 to 167 ± 3 mmHg) and gelatin zymography of plasma samples showed that lead increased MMP-9 (but not MMP-2) levels. Both lead-induced increased MMP-9 activity and hypertension were blunted by doxycycline. Doxycycline also prevented lead-induced reductions in circulating adrenomedullin. No significant changes in plasma levels of endothelin-1 or CGRP were found. Lead-induced decreases in nitric oxide markers and antioxidant status were not prevented by doxycycline. In conclusion, acute lead exposure increases blood pressure and MMP-9 activity, which were blunted by doxycycline. These findings suggest that MMP-9 may contribute with lead-induced hypertension by cleaving the vasodilatory peptide adrenomedullin, thereby inhibiting adrenomedullin-dependent lowering of blood pressure.

Blood lead levels of Korean lead workers in 2003-2011

OBJECTIVES

This study aimed to document the trend in blood lead levels in Korean lead workers from 2003 until 2011 and blood lead levels within each of the main industries.

METHODS

Nine years (2003-2011) of blood lead level data measured during a special health examination of Korean lead workers and collected by the Korea Occupational Safety and Health Agency were analyzed. Blood lead levels were determined by year, and a geometric mean (GM) was calculated for each industry division.

RESULTS

The overall GM blood lead level for all years combined (n = 365,331) was 4.35 μg/dL. The GM blood lead level decreased from 5.89 μg/dL in 2003 to 3.53 μg/dL in 2011. The proportion of the results ≥30 μg/dL decreased from 4.3% in 2003 to 0.8% in 2011. In the "Manufacture of Electrical Equipment" division, the GM blood lead level was 7.80 μg/dL, which was the highest among the industry divisions. The GM blood lead levels were 7.35 μg/dL and 6.77 μg/dL in the "Manufacturers of Rubber and Plastic Products" and the "Manufacture of Basic Metal Products" division, respectively.

CONCLUSIONS

The blood lead levels in Korean lead workers decreased from 2003 to 2011 and were similar to those in the US and UK. Moreover, workers in industries conventionally considered to have a high risk of lead exposure also tended to have relatively high blood lead levels compared to those in other industries.

Changing blood lead levels and oxidative stress with duration of residence among Taiwan immigrants

Immigrants lack appropriate health care access and other resources needed to reduce their exposure to preventable environmental health risks. Little is known about the impact of lead exposure and oxidative stress among immigrants. Thus, this study was to examine the differences between the blood lead levels (BLLs) and oxidative stress levels of immigrants and non-immigrants, and to investigate the determinants of increased BLLs or oxidative stress levels among immigrants. We collected demographic data of 239 immigrant women and 189 non-immigrant women who resettled in the central area of Taiwan. Each study participant provided blood samples for genotyping and for measuring blood metal levels and oxidative stress. Recent immigrants were at risk for elevated BLLs. Decreased BLLs, malondialdehyde (MDA), and increased blood selenium levels were significantly associated with duration of residence in Taiwan. Elevated BLLs and MDA in recent immigrants may serve as a warning sign for the health care system. The nation's health will benefit from improved regulation of living environments, thereby improving the health of immigrants.

Medical toxicology case presentations: to chelate or not to chelate, is that the question?

Four case studies described in this article were presented to a panel of physicians participating in the ACMT "Use and Misuse of Metal Chelation Therapy" Symposium in February 2012. The individuals who participated in the panel are listed in the appendix. These cases highlight some of the practical questions facing medical providers when issues of metal toxicity and its treatment arise. Medical toxicologists are valuable resources for information, public debate, consultation, and treatment of patients with concerns about heavy metal exposure.

Mortality among participants in a lead surveillance program

BACKGROUND

There is evidence that adult lead exposure increases cancer risk. IARC has classified lead as a 'probable' carcinogen, primarily based on stomach and lung cancer associations.

METHODS

We studied mortality among men in a lead surveillance program in 11 states,. categorized by their highest blood lead (BL) test (0-<5 µg/dl, 5-<25 µg/dl, 25-<40 µg/dl and 40+ µg/dl).

RESULTS

There were 58,368 men with a median 12 years of follow-up (6 to 17 years from lowest to higher BL category), and 3337 deaths. Half of the men had only one BL test. There was a strong healthy worker effect (all cause SMR=0.69, 95% CI: 0.66-0.71). The highest BL category had elevated lung and larynx cancer SMRs (1.20, 95% CI: 1.03-1.39, n=174, and 2.11, 95% CI: 1.05-3.77, n=11, respectively); there were no significant excesses of any other cause-specific SMR. Lung cancer RRs by increasing BL category were 1.0, 1.34, 1.88, and 2.79 (test for trend p=<0.0001), unchanged by adjustment for follow-up time. The lung cancer SMR in the highest BL category with 20+ years follow-up was 1.35 (95% CI: 0.92-1.90).

CONCLUSIONS

We found an association of blood lead level with lung cancer mortality. Our data are limited by lack of work history (precluding analyses by duration of exposure), and smoking data, although the strong positive trend in RRs by increasing blood lead category in internal analysis is unlikely to be caused by smoking differences. Other limitations include different lengths of follow-up in different lead categories, reliance on few blood lead tests to characterize exposure, and few deaths for some causes.

Intervention model for contaminated consumer products: a multifaceted tool for protecting public health

Lead-based paint and occupational lead hazards remain the primary exposure sources of lead in New York City (NYC) children and men, respectively. Lead poisoning has also been associated with the use of certain consumer products in NYC. The NYC Department of Health and Mental Hygiene developed the Intervention Model for Contaminated Consumer Products, a comprehensive approach to identify and reduce exposure to lead and other hazards in consumer products. The model identifies hazardous consumer products, determines their availability in NYC, enforces on these products, and provides risk communication and public education. Implementation of the model has resulted in removal of thousands of contaminated products from local businesses and continues to raise awareness of these hazardous products.

Indoor firing ranges and elevated blood lead levels - United States, 2002-2013

Indoor firing ranges are a source of lead exposure and elevated blood lead levels (BLLs) among employees, their families, and customers, despite public health outreach efforts and comprehensive guidelines for controlling occupational lead exposure. There are approximately 16,000-18,000 indoor firing ranges in the United States, with tens of thousands of employees. Approximately 1 million law enforcement officers train on indoor ranges. To estimate how many adults had elevated BLLs (≥10 µg/dL) as a result of exposure to lead from shooting firearms, data on elevated BLLs from the Adult Blood Lead Epidemiology and Surveillance (ABLES) program managed by CDC's National Institute for Occupational Safety and Health (NIOSH) were examined by source of lead exposure. During 2002-2012, a total of 2,056 persons employed in the categories "police protection" and "other amusement and recreation industries (including firing ranges)" had elevated BLLs reported to ABLES; an additional 2,673 persons had non-work-related BLLs likely attributable to target shooting. To identify deficiencies at two indoor firing ranges linked to elevated BLLs, the Washington State Division of Occupational Safety and Health (WaDOSH) and NIOSH conducted investigations in 2012 and 2013, respectively. The WaDOSH investigation found a failure to conduct personal exposure and biologic monitoring for lead and also found dry sweeping of lead-containing dust. The NIOSH investigation found serious deficiencies in ventilation, housekeeping, and medical surveillance. Public health officials and clinicians should ask about occupations and hobbies that might involve lead when evaluating findings of elevated BLLs. Interventions for reducing lead exposure in firing ranges include using lead-free bullets, improving ventilation, and using wet mopping or high-efficiency particulate air (HEPA) vacuuming to clean.

Low-dose chronic lead exposure increases systolic arterial pressure and vascular reactivity of rat aortas

Chronic lead exposure induces hypertension affecting endothelial function. We investigated whether low-concentration lead exposure alters blood pressure and vascular reactivity, focusing on the roles of NO, oxidative stress, cyclooxygenase-derived vasoconstrictor prostanoids, and the local angiotensin-renin system. Aortic rings from 3-month-old Wistar rats were treated daily with lead acetate (first dose 4mg/100g, subsequent doses 0.05mg/100g, im) or vehicle for 30 days. Treatment increased lead blood levels (12μg/dl), blood pressure, and aortic ring contractile response to phenylephrine (1nM-100mM). Contractile response after L-NAME administration increased in both groups but was higher after lead treatment. Lead effects on Rmax decreased more after apocynin and superoxide dismutase administration compared to control. Indomethacin reduced phenylephrine response more after lead treatment than in controls. The selective COX-2 inhibitor NS398, thromboxane A2/prostaglandin H2 receptor antagonist SQ 29,548, TXA2 synthase inhibitor furegrelate, EP1 receptor antagonist SC 19220, and ACE inhibitor and AT1 receptor antagonist losartan reduced phenylephrine responses only in vessels from lead-treated rats. Basal and stimulated NO release was reduced and local O2(-) liberation increased in the lead-treated group compared to controls. eNOS, iNOS, and AT1 receptor protein expression increased with lead exposure, but COX-2 protein expression decreased. This is the first demonstration that blood Pb(2+) (12µg/dl) concentrations below the WHO-established values increased systolic blood pressure and vascular phenylephrine reactivity. This effect was associated with reduced NO bioavailability, increased reactive oxygen species production, increased participation of COX-derived contractile prostanoids, and increased renin-angiotensin system activity.

Neurotoxic effect of lead on rats: Relationship to Apoptosis

BACKGROUND

Lead toxicity has been subjected to intensive research work, but some aspects of its mechanism needs to be elucidated.

OBJECTIVES

In the current study we aim to investigate the impact of lead toxicity on some different intermediates of apoptotic signaling pathway in experimental rats.

DESIGN AND METHODS

We measured caspase-8 and caspase-9 [by chemilumenescence], Bax and Bcl-2 [by ELISA] in Experimental rats, injected intraperitoneally with lead acetate for 7days at the dosage of 25, 50 and l00 mg/kg body weight and compared to control rats injected with deionized distilled water instead. instead.

RESULTS

Lead acetate significantly increased the levels of caspase 8, caspase 9 and Bax in liver, kidney and brain of experimental animals especially those with high doses. Meanwhile, caspase 8 and Bax significantly increased in brain tissue at low dose of lead, while Bcl-2 significantly increased only with advanced toxicity. Furthermore, Bax/bcl2 ratio was significantly high in kidney (p<0.05), liver (p<0.01) and brain (p<0.01) at higher doses of lead toxicity. However, brain tissues showed significant Bax/Bcl2 ratio (p<0.05) at low lead dose. A significant positive correlation was noticed between the blood level of lead and enzymatic level of caspase 8, caspase 9 and Bax in different tissues.

CONCLUSION

: we concluded that lead might have toxic effect through intrinsic and extrinsic induction of apoptotic pathway with prominent effect on brain tissue even at low dose.

Incident ESRD among participants in a lead surveillance program

BACKGROUND

Very high levels of lead can cause kidney failure; data about renal effects at lower levels are limited.

STUDY DESIGN

Cohort study, external (vs US population) and internal (by exposure level) comparisons.

SETTINGS & PARTICIPANTS

58,307 men in an occupational surveillance system in 11 US states.

PREDICTOR

Blood lead levels.

OUTCOME

Incident end-stage renal disease determined by matching the cohort with the US Renal Data System (n=302).

MEASUREMENTS

Blood lead categories were 0-<5, 5-<25, 25-<40, 40-51, and >51 μg/dL, defined by highest blood lead test result. One analysis for those with data for race (31% of cohort) and another for the whole cohort after imputing race.

RESULTS

Median follow-up was 12 years. Among those with race information, the end-stage renal disease standardized incidence ratio (SIR; US population as referent) was 1.08 (95% CI, 0.89-1.31) overall. The SIR in the highest blood lead category was 1.47 (95% CI, 0.98-2.11), increasing to 1.56 (95% CI, 1.02-2.29) for those followed up for 5 or more years. For the entire cohort (including those with race imputed), the overall SIR was 0.92 (95% CI, 0.82-1.03), increasing to 1.36 (95% CI, 0.99-1.73) in the highest blood lead category (SIR of 1.43 [95% CI, 1.01-1.85] in those with ≥5 years' follow-up). In internal analyses by Cox regression, rate ratios for those with 5 or more years' follow-up in the entire cohort were 1.0 (0-<5 and 5-<25 μg/dL categories combined) and 0.92, 1.08, and 1.96 for the 25-<40, 40-51, and >51 μg/dL categories, respectively (P for trend=0.003). The effect of lead was strongest in nonwhites.

LIMITATIONS

Lack of detailed work history, reliance on only a few blood lead tests per person to estimate level of exposure, lack of clinical data at time of exposure.

CONCLUSIONS

Data suggest that current US occupational limits on blood lead levels may need to be strengthened to avoid kidney disease.

Maternal blood, plasma, and breast milk lead: lactational transfer and contribution to infant exposure

BACKGROUND

Human milk is a potential source of lead exposure. Yet lactational transfer of lead from maternal blood into breast milk and its contribution to infant lead burden remains poorly understood.

OBJECTIVES

We explored the dose-response relationships between maternal blood, plasma, and breast milk to better understand lactational transfer of lead from blood and plasma into milk and, ultimately, to the breastfeeding infant.

METHODS

We measured lead in 81 maternal blood, plasma, and breast milk samples at 1 month postpartum and in 60 infant blood samples at 3 months of age. Milk-to-plasma (M/P) lead ratios were calculated. Multivariate linear, piecewise, and generalized additive models were used to examine dose-response relationships between blood, plasma, and milk lead levels.

RESULTS

Maternal lead levels (mean±SD) were as follows: blood: 7.7±4.0 μg/dL; plasma: 0.1±0.1 μg/L; milk: 0.8±0.7 μg/L. The average M/P lead ratio was 7.7 (range, 0.6-39.8) with 97% of the ratios being >1. The dose-response relationship between plasma lead and M/P ratio was nonlinear (empirical distribution function=6.5, p=0.0006) with the M/P ratio decreasing by 16.6 and 0.6 per 0.1 μg/L of plasma lead, respectively, below and above 0.1 μg/L plasma lead. Infant blood lead level (3.4±2.2 μg/dL) increased by 1.8 μg/dL per 1 μg/L milk lead (p<0.0001, R2=0.3).

CONCLUSIONS

The M/P ratio for lead in humans is substantially higher than previously reported, and transfer of lead from plasma to milk may be higher at lower levels of plasma lead. Breast milk is an important determinant of lead burden among breastfeeding infants.

Lead exposure and blood pressure among workers in diverse industrial plants in Kenya

The study evaluated airborne exposures and blood lead (BPb) levels in 233 production workers at six diverse industrial plants in Kenya. Blood and personal breathing zone air samples were collected and analyzed for lead (Pb) using atomic absorption spectroscopy. Blood pressure (BP) levels were measured using a standard mercury sphygmomanometer. The results indicated mean airborne Pb levels ± standard deviation (SD) as follows: 183.2 ± 53.6 μg/m(3) in battery recycling, 133.5 ± 39.6 μg/m(3) in battery manufacturing, 126.2 ± 39.9 μg/m(3) in scrap metal welding, 76.3 ± 33.2 μg/m(3) in paint manufacturing, 27.3 ± 12.1 μg/m(3) in a leather manufacturing, and 5.5 ± 3.6 μg/m(3) in a pharmaceutical plant. The mean airborne Pb levels exceeded the U.S. Occupational Safety and Health Administration (OSHA) 8-hr time-weighted average (TWA) permissible exposure limit (PEL) for Pb of 50 μg/m(3) in the battery manufacturing, battery recycling, welding, and paint manufacturing plants. Similarly, mean BPb concentrations exceeded the American Conference of Governmental Industrial Hygienists (ACGIH®) biological exposure index (BEI) for Pb of 30 μg/dl. A significant positive association was observed between BPb and breathing zone air Pb (R(2) = 0.73, P < 0.001). Approximately 30% of the production workers (N = 233) were in the hypertensive range with an average systolic and diastolic blood pressure (BP) of 134.7 ± 12.7 mmHg and 86.4 ± 8.9 mmHg, respectively. In the multivariate regression analysis, age, duration of work, airborne Pb and BPb levels were significantly associated (P < 0.05) with a change in BP. We recommend improved engineering controls, work practices, and personal hygiene to reduce Pb exposures. In addition, workers should undergo comprehensive medical surveillance to include BPb and BP testing, and airborne Pb assessments in all industries with significant lead exposures.