Cobalt-beer cardiomyopathy. A clinical and pathologic study of twenty-eight cases

Cobalt Toxicity Induces Retinopathy and Optic Neuropathy in Mice

Purpose

To explore the effect of cobalt toxicity on vision.

Methods

A total of 103 wild-type (WT) mice were injected with cobalt chloride by two routes in different concentrations: single intravenous (IV) high or low doses (total, n = 43); or daily repeated intraperitoneal (IP) high (three days) or low (28 days, 56 days) dose, and low-dose cobalt with added minocycline (56 days) (total, n = 60); 10 WT mice served as a control group. An additional group of 17 immunodeficient NOD scid gamma (NSG) mice were injected IV or IP with cobalt, and 10 NSG mice served as control. Cobalt levels were measured in blood, urine, and tears by particle-induced X-ray emission (PIXE). Macroscopic, immunohistochemical, electroretinography (ERG), and molecular studies were done.

Results

PIXE revealed cobalt elimination from the blood by two hours, with increased levels in urine but under the detection limit in tears. In the retina, ERG recordings showed decreased b-wave amplitude. Apoptosis mainly involved the inner retina, with inner retinal inflammatory reaction in both WT and less in the NSG mice. In the optic nerves, an increased microglial and astrocytic activation was noted.

Conclusions

This study demonstrated functional visual impairment with extensive inflammatory reaction secondary to cobalt toxicity in mice.

Investigating the association between blood cobalt and gallstones: a cross-sectional study utilizing NHANES data

Background

With the use of cobalt alloys in medical prosthetics, the risk of cobalt exposure has increased. The objective of this study was to investigate the correlation between blood cobalt levels and the occurrence of gallstones utilizing data from the National Health and Nutrition Examination Survey (NHANES).

Methods

Data collected between 2017 and 2020 were analyzed, encompassing a total of 5,610 participants. Cobalt concentrations in whole blood specimens were directly measured using inductively coupled plasma mass spectrometry (ICP-MS). The presence of gallstones was ascertained through a standardized questionnaire. To assess the association between blood cobalt levels and the presence of gallstones, logistic regression analysis, restricted cubic spline analysis, and subgroup analysis were utilized.

Results

The results of logistic regression analysis revealed a heightened risk of developing gallstones in the Quartiles 2 and Quartiles 4 groups based on blood cobalt levels when compared to the Quartiles 1 group (OR = 1.54, 95% CI: 1.15-2.07; OR = 1.35, 95% CI: 1.03-1.77). The restricted cubic spline analysis exhibited a positive linear correlation between blood cobalt levels and the occurrence of gallstones. Subgroup analyses further demonstrated a statistically significant correlation between the Quartiles 4 category of blood cobalt levels and an elevated risk of gallstones, particularly among individuals aged 60 years or older, females, those with a body mass index (BMI) equal to or exceeding 25, serum total cholesterol levels below 200 mg/dL, as well as individuals diagnosed with hypertension or diabetes.

Conclusion

Our study findings indicate a notable association between elevated blood cobalt levels and an increased risk of gallstones. To establish a causal relationship between blood cobalt levels and the elevated risk of developing gallstones, further prospective cohort studies are warranted.

Metalloporphyrins as Tools for Deciphering the Role of Heme Oxygenase in Renal Immune Injury

Renal immune injury is a frequent cause of end-stage renal disease, and, despite the progress made in understanding underlying pathogenetic mechanisms, current treatments to preserve renal function continue to be based mainly on systemic immunosuppression. Small molecules, naturally occurring biologic agents, show considerable promise in acting as disease modifiers and may provide novel therapeutic leads. Certain naturally occurring or synthetic Metalloporphyrins (Mps) can act as disease modifiers by increasing heme oxygenase (HO) enzymatic activity and/or synthesis of the inducible HO isoform (HO-1). Depending on the metal moiety of the Mp employed, these effects may occur in tandem or can be discordant (increased HO-1 synthesis but inhibition of enzyme activity). This review discusses effects of Mps, with varying redox-active transitional metals and cyclic porphyrin cores, on mechanisms underlying pathogenesis and outcomes of renal immune injury.

Possible Sources of Trace Metals in Obese Females Living in Informal Settlements near Industrial Sites around Gauteng, South Africa

Trace metals have been reported in the literature to be associated with obesity. Exposure to some trace metals such as Mn, Cr, Ni, Cd, and Pb may pose a serious health risk to individuals living around a polluted environment. The present study assessed the levels of trace metals in the blood of obese females living around industrial areas in Gauteng, South Africa. The study was carried out using a mixed method approach. Only females with a BMI ≥ 30.0 were considered. A total of 120 obese females participated in the study (site 1: 40-industrial area, site 2: 40-industrial area, and site 3: 40-residential area), aged 18-45 and not in menopause. Blood samples were analysed for trace metals content using inductively coupled plasma mass spectrometry (ICP-MS). The mean concentrations of trace metals were in the order Pb > Mn > Cr > Co > As > Cd (site 1), Pb > Mn > Co > As > Cd (site 2), and Mn > Cr > Co > As > Pb > Cd (site 3). The blood Mn from site 1 ranged from 6.79 µg/L-33.99 µg/L, and the mean differences obtained from the participants from different sites were significant (p < 0.01). The blood levels of Mn, Pb, Cr, Co, As, and Cd were above the recommended limits set by the WHO in some of the participants. The present study noted, among others, closeness to industrial areas, lifestyle decisions such as the use of tobacco products by their partners indoors, and the method used for cooking as factors that might have accounted for the blood levels of Mn, Pb, Cd and Co. The study showed that there is a need for constant monitoring of the levels of trace metals in the blood of those living in these areas.

Cobalt chloride postconditioning as myoprotective therapy in cardiac ischemia-reperfusion

Since damage induced by ischemia-reperfusion (I/R) involves alterations in Ca²⁺ homeostasis and is reduced by ischemic postconditioning (IP) and that CoCl₂ can trigger changes resembling the response to a hypoxic event in normoxia and its blockade on Ca²⁺ current in heart muscle, our aim was to evaluate CoCl₂ as an IP therapeutic tool. Mechanic and energetic parameters of isolated and arterially perfused male Wistar rat heart ventricles were simultaneously analyzed in a model of I/R in which 0.23 mmol/L CoCl₂ was introduced upon reperfusion and kept or withdrawn after 20 min or introduced after 20 min of reperfusion. The presence of CoCl₂ did not affect diastolic pressure but increased post-ischemic contractile recovery, which peaked at 20 min and decreased at the end of reperfusion. This decrease was prevented when CoCl₂ was removed at 20 min of reperfusion. Total heat release increased throughout reperfusion, while economy increased between 15 and 25 min. No effect was observed when CoCl₂ was introduced at 20 min of reperfusion. In addition, both the area under the contracture curve evoked by 10 mmol/L caffeine-36 mmol/L Na⁺ and the contracture tension relaxation rate were higher with CoCl₂.Furthermore, CoCl₂ decreased the number of arrhythmias during reperfusion and the ventricular damaged area. The presence of CoCl₂ in reperfusion induces cardioprotection consistent with the improvement in cellular calcium handling. The use of CoCl₂ constitutes a potential cardioprotective tool of clinical relevance.

Cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids in relation to sports: a position statement of the sport cardiology and exercise nucleus of the European Association of Preventive Cardiology

The use of substances and medications with potential cardiovascular effects among those practicing sports and physical activity has progressively increased in recent years. This is also connected to the promotion of physical activity and exercise as core aspects of a healthy lifestyle, which has led also to an increase in sport participation across all ages. In this context, three main users' categories can be identified, (i) professional and amateur athletes using substances to enhance their performance, (ii) people with chronic conditions, which include physical activity and sport in their therapeutic plan, in association with prescribed medications, and (iii) athletes and young individuals using supplements or ergogenic aids to integrate their diet or obtaining a cognitive enhancement effect. All the substances used for these purposes have been reported to have side effects, among whom the cardiovascular consequences are the most dangerous and could lead to cardiac events. The cardiovascular effect depends on the type of substance, the amount, the duration of use, and the individual response to the substances, considering the great variability in responses. This Position Paper reviews the recent literature and represents an update to the previously published Position Paper published in 2006. The objective is to inform physicians, athletes, coaches, and those participating in sport for a health enhancement purpose, about the adverse cardiovascular effects of doping substances, commonly prescribed medications and ergogenic aids, when associated with sport and exercise.

Interactions between heavy metals and bacteria in mangroves

Environmental heavy metal pollution has become a serious problem in recent years. Therefore, our study investigated seven heavy metal-contaminated mangroves (Beihai, Fangchenggang, Hainan, Hongkong, Shenzhen, Yunxiao, and Zhanjiang) in southern China, and found that they were particularly polluted with Zn and Pb. These heavy metals were mainly distributed in the surface sediments of the mangroves. Among these seven mangroves, the Shenzhen mangrove was the most polluted site, whereas the Beihai mangrove was the least polluted. Moreover, the bacterial communities in the mangroves were significantly associated with heavy metal contamination. For instance, Fusibacter was significantly correlated with Pb, Zn, Cu, Co, Ni, Cd, and Ag (P < 0.05, R = -0.47). Syntrophorhabdus was also significantly correlated with heavy metals (P < 0.05, R = 0.63). Furthermore, Geo-Chip analyses were conducted to demonstrate the involvement of many functional genes in heavy metal transport, particularly Ni transport. Our results also demonstrated that the heavy metals could be transported by various bacteria. For example, Pseudomonas and Burkholderia were involved in various heavy metal transportation mechanisms, particularly for Ni and Zn, suggesting that these bacteria could be used for heavy metal remediation. Therefore, our study provides insights into the interactions between bacterial communities and heavy metals, which could enable the development of novel mangrove protection strategies.

Cobalt-induced cardiomyopathy - do circulating cobalt levels matter?

Elevated levels of circulating cobalt ions have been linked with a wide range of systemic complications including neurological, endocrine, and cardiovascular symptoms. Case reports of patients with elevated blood cobalt ions have described significant cardiovascular complications including cardiomyopathy. However, correlation between the actual level of circulating cobalt and extent of cardiovascular injury has not previously been performed. This review examines evidence from the literature for a link between elevated blood cobalt levels secondary to metal-on-metal (MoM) hip arthroplasties and cardiomyopathy. Correlation between low, moderate, and high blood cobalt with cardiovascular complications has been considered. Elevated blood cobalt at levels over 250 µg/l have been shown to be a risk factor for developing systemic complications and published case reports document cardiomyopathy, cardiac transplantation, and death in patients with severely elevated blood cobalt ions. However, it is not clear that there is a hard cut-off value and cardiac dysfunction may occur at lower levels. Clinical and laboratory research has found conflicting evidence of cobalt-induced cardiomyopathy in patients with MoM hips. Further work needs to be done to clarify the link between severely elevated blood cobalt ions and cardiomyopathy.

Cite this article: Bone Joint Res 2021;10(6):340–347.

Bioelution, Bioavailability, and Toxicity of Cobalt Compounds Correlate

Based on the wide use of cobalt substances in a range of important technologies, it has become important to predict the toxicological properties of new or lesser-studied substances as accurately as possible. We studied a group of 6 cobalt substances with inorganic ligands, which were tested for their bioaccessibility (surrogate measure of bioavailability) through in vitro bioelution in simulated gastric and intestinal fluids. Representatives of the group also underwent in vivo blood kinetics and mass balance tests, and both oral acute and repeated dose toxicity (RDT) testing. We were able to show a good correlation between high in vitro bioaccessibility with high in vivo bioavailability and subsequent high in vivo toxicity; consequently, low in vitro bioaccessibility correlated well with low in vivo bioavailability and low in vivo toxicity. In vitro bioelution in simulated gastric fluid was the most precise predictor of the difference in the oral RDT lowest observed adverse effect levels of 2 compounds representing the highly and poorly bioaccessible subset of substances. The 2 compounds cobalt dichloride hexahydrate and tricobalt tetraoxide differed by a factor of 440 in their in vitro bioaccessibility and by a factor of 310 in their RDT lowest observed adverse effect level. In summary, this set of studies shows that solubility, specifically in vitro bioelution in simulated gastric fluid, is a good, yet conservative, predictor of in vivo bioavailability and oral systemic toxicity of inorganic cobalt substances. Bioelution data are therefore an invaluable tool for grouping and read across of cobalt substances for hazard and risk assessment.

Cobalt oxide nanoparticles induce oxidative stress and alter electromechanical function in rat ventricular myocytes

Background

Nanotoxicology is an increasingly relevant field and sound paradigms on how inhaled nanoparticles (NPs) interact with organs at the cellular level, causing harmful conditions, have yet to be established. This is particularly true in the case of the cardiovascular system, where experimental and clinical evidence shows morphological and functional damage associated with NP exposure. Giving the increasing interest on cobalt oxide (Co₃O₄) NPs applications in industrial and bio-medical fields, a detailed knowledge of the involved toxicological effects is required, in view of assessing health risk for subjects/workers daily exposed to nanomaterials. Specifically, it is of interest to evaluate whether NPs enter cardiac cells and interact with cell function. We addressed this issue by investigating the effect of acute exposure to Co₃O₄-NPs on excitation-contraction coupling in freshly isolated rat ventricular myocytes.

Results

Patch clamp analysis showed instability of resting membrane potential, decrease in membrane electrical capacitance, and dose-dependent decrease in action potential duration in cardiomyocytes acutely exposed to Co₃O₄-NPs. Motion detection and intracellular calcium fluorescence highlighted a parallel impairment of cell contractility in comparison with controls. Specifically, NP-treated cardiomyocytes exhibited a dose-dependent decrease in the fraction of shortening and in the maximal rate of shortening and re-lengthening, as well as a less efficient cytosolic calcium clearing and an increased tendency to develop spontaneous twitches. In addition, treatment with Co₃O₄-NPs strongly increased ROS accumulation and induced nuclear DNA damage in a dose dependent manner. Finally, transmission electron microscopy analysis demonstrated that acute exposure did lead to cellular internalization of NPs.

Conclusions

Taken together, our observations indicate that Co₃O₄-NPs alter cardiomyocyte electromechanical efficiency and intracellular calcium handling, and induce ROS production resulting in oxidative stress that can be related to DNA damage and adverse effects on cardiomyocyte functionality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12989-020-00396-6.

In vitro bioaccessibility of metals from tape tea - A low-cost emerging drug

BACKGROUND

An in vitro physiologically relevant test based on the standard Unified Bioaccessibility Method (UBM) combined with inductively coupled plasma mass spectrometry was performed in this study to ascertain the elemental bioaccessibility pools of tape tea as emerging low-cost abuse drug under fasted conditions.

METHODS

Elemental quantification in tape tea and body fluid extracts was performed by an inductively coupled plasma quadrupole mass spectrometer - ICP-MS, and for sample preparation of the bioaccessibility extracts prior to ICP-MS analysis, a microwave-assisted acid decomposition was applied by using a microwave oven. The Unified Bioaccessibility Method (UBM) was considered for investigation of elemental bioaccessibility in tape tea, required a full set of organic compounds, salts, and enzymes.

RESULTS

Considering total element evaluation through ICP-MS, Co, Ni, Mn, and Zn are found at the highest concentrations in the sample, namely 415 ± 36, 202 ± 55, 1389 ± 225 and 2397 ± 197 μg L^-1, respectively. Regarding the oral bioaccessibility test, after both gastric and gastrointestinal extractions Co, Ni, and Mn are fully bioaccessible while for Zn the bioaccessibility is ca. 66 %.

CONCLUSION

According to the first results in the literature proposed for these samples, the bioaccessibility results indicate an increment in day-to-day total element concentration and depending on the concentration of each element that an individual consumes in its usual diet, the total concentration can exceed the TDI. There are several possible toxic effects caused by the excess of Co, Ni and Mn, which might be expected by their high total concentrations.

Trace elements in different tissues in aging rats

BACKGROUND

Trace elements (TE) in the human body provide a connecting link between the environment, lifestyle and biochemical modulation of homeodynamics. On the other hand, many non-essential (toxic) elements are linked to numerous diseases. Our study tried to identify differences in TE levels between healthy old and young Wistar rats in blood and the tissues of kidney, liver, heart, and testicles. Furthermore, we wanted to see if there were age-related differences in correlations between essential and/or non-essential (toxic) TE within and between mentioned tissues.

METHODS

We used 28 healthy male Wistar rats which were divided into two age groups: young, aged 10 weeks (n = 15) and old, aged 36 months (n = 13). The animals were sacrificed under general anesthesia and the blood samples, and samples from the tissues of the heart, kidneys, testicles, and liver were used for the determination of TE content in them. Analysis of the 16 elements was performed by inductively coupled plasma mass spectrometry (ICP-MS).

RESULTS

Toxic elements in old rats (As, Hg, and Cd) were significantly higher in all of the tissues where the difference in levels of these elements was found. Tissues of the kidney and liver had the most correlations between TE in old and young rats, respectively. In both old and young rats, arsenic was the toxic element that had most of the correlations with other essential or non-essential elements. In old rats, most of the TE correlations were detected between the tissues of the kidney and heart (11 correlations), while in young rats most of the correlations were observed between the tissues of kidney and liver, and kidney and testicles (with 9 correlations both).

CONCLUSIONS

Our study has found significant changes in levels of trace elements in all of the mentioned tissues, with kidney and testicles being the tissues with the most TE differences between the two aged groups. This and other similar studies should encourage other investigators to evaluate the mutual connections between TE and physiological, or the "unhealthy" aging. More studies with more tissues included, more biomarkers of the systemic function, and even molecular methods are needed to provide the answers to numerous questions relating to TE and aging.

Cobalt Administration Causes Reduced Contractility with Parallel Increases in TRPC6 and TRPM7 Transporter Protein Expression in Adult Rat Hearts

Exposure to circulating cobalt (Co²⁺) in patients with metal-on-metal orthopaedic hip implants has been linked to cardiotoxicity but the underlying mechanism(s) remain undefined. The aim of the current study was to examine the effects of Co²⁺ on the heart in vivo and specifically on cardiac fibroblasts in vitro. Adult male rats were treated with CoCl₂ (1 mg/kg) for either 7 days or 28 days. Inductively coupled plasma mass spectrometry (ICP-MS) was used to measure Co²⁺ uptake into various organs of the body. Co²⁺ accumulated in the heart over time with significant levels evident after only 7 days of treatment. There was no evidence of cardiac remodelling following Co²⁺ treatment as assessed by heart weight:body weight and left ventricular weight:body weight. However, a decrease in fractional shortening, as measured using echocardiography, was observed after 28 days of Co²⁺ treatment. This was accompanied by increased protein expression of the ion transient receptor potential (TRP) channels TRPC6 and TRPM7 as assessed by quantitative immunoblotting of whole cardiac homogenates. Uptake of Co²⁺ specifically into rat cardiac fibroblasts was measured over 72 h and was shown to dramatically increase with increasing concentrations of applied CoCl₂. Expression levels of TRPC6 and TRPM7 proteins were both significantly elevated in these cells following Co²⁺ treatment. In conclusion, Co²⁺ rapidly accumulates to significant levels in the heart causing compromised contractility in the absence of any overt cardiac remodelling. TRPC6 and TRPM7 expression levels are significantly altered in the heart following Co²⁺ treatment and this may contribute to the Co²⁺-induced cardiotoxicity observed over time.

Is end-organ surveillance necessary in patients with well-functioning metal-on-metal hip resurfacings?

Aims

Cardiac magnetic resonance (CMR) was used to assess whether cardiac function or tissue composition was affected in patients with well-functioning metal-on-metal hip resurfacing arthroplasties (MoMHRA) when compared with a group of controls, and to assess if metal ion levels correlated with any of the functional or structural parameters studied.

Patients and Methods

In all, 30 participants with no significant cardiac history were enrolled: 20 patients with well-functioning MoMHRA at mean follow-up of 8.3 years post-procedure (ten unilateral, ten bilateral; 17 men, three women) and a case-matched control group of ten non-MoM total hip arthroplasty patients (six men, four women). The mean age of the whole cohort (study group and controls) at the time of surgery was 50.6 years (41.0 to 64.0). Serum levels of cobalt and chromium were measured, and all patients underwent CMR imaging, including cine, T2* measurements, T1 and T2 mapping, late gadolinium enhancement, and strain measurements.

Results

None of the MoMHRA patients showed clinically significant cardiac functional abnormality. The MoMHRA patients had larger indexed right and left end diastolic volumes (left ventricular (LV): 74 ml/m2 vs 67 ml/m2, p = 0.045; right ventricular: 80 ml/m2 vs 71 ml/m2, p = 0.02). There was a small decrease in T2 time in the MoMHRA patients (median 49 ms vs 54 ms; p = 0.0003). Higher metal ion levels were associated with larger LV volumes and with shorter T2 time.

Conclusion

Although cardiac function is not clinically adversely affected in patients with well-functioning MoMHRA, modern imaging is able to demonstrate subtle changes in structure and function of the heart. As these changes correlate with systemic ion measurements, they may be consequences of wear debris deposition. Longer, longitudinal studies are necessary to determine whether cardiac function will become affected. Cite this article: Bone Joint J 2019;101-B:540–546.

Severe Cardiomyopathy Due to Arthroprosthetic Cobaltism: Report of Two Cases with Different Outcomes

Cobalt-induced cardiomyopathy is a well-known but uncommon disease, and the physician must maintain a high index of suspicion in order to make a timely diagnosis. We report two patients with cobalt-induced cardiomyopathy. Both patients developed progressively worsening symptoms of cobalt toxicity following revision of a fractured ceramic-on-ceramic total hip replacement to a metal-on-polyethylene bearing. In both patients, echocardiography showed LV hypertrophy, biventricular systolic dysfunction, and a large amount of pericardial effusion. Due to decompensated heart failure, both patients were initially considered candidates for heart transplantation. One patient was diagnosed with cobalt-induced cardiomyopathy before transplantation. He received cobalt chelation therapy and revision surgery, which led to complete recovery of heart function. In the other patient, the diagnosis was not made until the time of heart transplantation. The gross examination of the explanted heart revealed typical features of cobalt cardiotoxicity, which was then diagnosed as cobalt-induced cardiomyopathy. These cases emphasise the importance of early diagnosis and prompt treatment of cobalt intoxication.

Metal-on-metal total hip arthroplasty is not associated with cardiac disease

AIMS

Many case reports and small studies have suggested that cobalt ions are a potential cause of cardiac complications, specifically cardiomyopathy, after metal-on-metal (MoM) total hip arthroplasty (THA). The impact of metal ions on the incidence of cardiac disease after MoM THA has not been evaluated in large studies. The aim of this study was to compare the rate of onset of new cardiac symptoms in patients who have undergone MoM THA with those who have undergone metal-on-polyethylene (MoP) THA.

PATIENTS AND METHODS

Data were extracted from the Standard Analytics Files database for patients who underwent MoM THA between 2005 and 2012. Bearing surface was selected using International Classification of Diseases ninth revision codes. Patients with a minimum five-year follow-up were selected. An age and gender-matched cohort of patients who underwent MoP THA served as a comparison group. New diagnoses of cardiac disease were collected during the follow-up period. Comorbidities and demographics were identified and routine descriptive statistics were used.

RESULTS

We identified 29 483 patients who underwent MoM THA and 24 175 matched patients who underwent MoP THA. Both groups had a mean Charlson comorbidity index score of 4. There were no statistically significant differences in 30 of 31 pre-existing comorbidities. Patients undergoing MoM THA had a slightly lower incidence of cardiac failure compared with those undergoing MoP THA at three years (6.60% versus 7.06%, odds ratio (OR) 0.93, 95% confidence interval (CI) 0.87 to 0.99) and four years (8.73% versus 9.49%, OR 0.91, 95% CI 0.86 to 0.97) postoperatively, with no difference in the incidence of new cardiac failure in between the groups at five years. There was no statistically significant difference in the incidence of arrhythmia, myocardial infarction and cardiomyopathy at any time between the two groups.

CONCLUSION

MoM THA is not associated with cardiac complications. Initial reports may have represented individual instances of cardiac disease in patients with a failing MoM articulation rather than an emerging epidemiological trend. Cite this article: Bone Joint J 2018;100-B:28-32.

Characteristics of Cobalt-Related Cardiomyopathy in Metal Hip Implant Patients: An Evaluation of 15 Published Reports

Over 300,000 hip replacements occurred in the USA in 2010, and the frequency is likely increasing annually. Blood Cobalt (Co) concentrations in patients with well-functioning cobalt-chromium (Co-Cr) hip implants are usually elevated above background concentrations relative to the general population. Excessive Co exposure, in rare cases, can result in cardiomyopathy. The purpose of this review was to identify cases of cardiomyopathy in metal-containing hip implant patients and to evaluate the possible cause of each patient's cardiomyopathy. We evaluated 15 cases published between 2009 and 2016, and, based on a review of the preexisting risk factors, blood Co concentrations, and histopathological information published for each patient, they were stratified into one of four categories regarding the association between Co exposure and the development of cardiomyopathy: (1) Co was causal (five cases); (2) Co was contributory (two cases); (3) Co was possibly contributory (six cases); and (4) Co was non-causal (two cases). In all 15 cases, blood Co concentrations (14-6521 μg/L) were elevated beyond levels associated with the majority of metal-containing implant patients (0.1-10 μg/L), and, in many cases, there was evidence of a malfunctioning implant. The data indicate that individuals with well-functioning implants, even those with preexisting risk factors, are at no risk of developing cardiac effects. We conclude that blood Co measurements are informative, but should be interpreted with caution, and in context of other factors evaluated in this analysis. The mere presence of elevated Co is not sufficient to indicate causation for a patient's cardiomyopathy.

Assessing for Cardiotoxicity from Metal-on-Metal Hip Implants with Advanced Multimodality Imaging Techniques

BACKGROUND

High failure rates of metal-on-metal (MoM) hip implants prompted regulatory authorities to issue worldwide safety alerts. Circulating cobalt from these implants causes rare but fatal autopsy-diagnosed cardiotoxicity. There is concern that milder cardiotoxicity may be common and underrecognized. Although blood metal ion levels are easily measured and can be used to track local toxicity, there are no noninvasive tests for organ deposition. We sought to detect correlation between blood metal ions and a comprehensive panel of established markers of early cardiotoxicity.

METHODS

Ninety patients were recruited into this prospective single-center blinded study. Patients were divided into 3 age and sex-matched groups according to implant type and whole-blood metal ion levels. Group-A patients had a ceramic-on-ceramic [CoC] bearing; Group B, an MoM bearing and low blood metal ion levels; and Group C, an MoM bearing and high blood metal-ion levels. All patients underwent detailed cardiovascular phenotyping using cardiac magnetic resonance imaging (CMR) with T2*, T1, and extracellular volume mapping; echocardiography; and cardiac blood biomarker sampling. T2* is a novel CMR biomarker of tissue metal loading.

RESULTS

Blood cobalt levels differed significantly among groups A, B, and C (mean and standard deviation [SD], 0.17 ± 0.08, 2.47 ± 1.81, and 30.0 ± 29.1 ppb, respectively) and between group A and groups B and C combined. No significant between-group differences were found in the left atrial or ventricle size, ejection fraction (on CMR or echocardiography), T1 or T2* values, extracellular volume, B-type natriuretic peptide level, or troponin level, and all values were within normal ranges. There was no relationship between cobalt levels and ejection fraction (R = 0.022, 95% confidence interval [CI] = -0.185 to 0.229) or T2* values (R = 0.108, 95% CI = -0.105 to 0.312).

CONCLUSIONS

Using the best available technologies, we did not find that high (but not extreme) blood cobalt and chromium levels had any significant cardiotoxic effect on patients with an MoM hip implant. There were negligible-to-weak correlations between elevated blood metal ion levels and ejection fraction even at the extremes of the 95% CI, which excludes any clinically important association.

LEVEL OF EVIDENCE

Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Acetazolamide and N-acetylcysteine in the treatment of chronic mountain sickness (Monge's disease)

Patients suffering from chronic mountain sickness (CMS) have excessive erythrocytosis. Low -level cobalt toxicity as a likely contributor has been demonstrated in some subjects. We performed a randomized, placebo controlled clinical trial in Cerro de Pasco, Peru (4380m), where 84 participants with a hematocrit (HCT) ≥65% and CMS score>6, were assigned to four treatment groups of placebo, acetazolamide (ACZ, which stimulates respiration), N-acetylcysteine (NAC, an antioxidant that chelates cobalt) and combination of ACZ and NAC for 6 weeks. The primary outcome was change in hematocrit and secondary outcomes were changes in PaO₂, PaCO₂, CMS score, and serum and urine cobalt concentrations. The mean (±SD) hematocrit, CMS score and serum cobalt concentrations were 69±4%, 9.8±2.4 and 0.24±0.15μg/l, respectively for the 66 participants. The ACZ arm had a relative reduction in HCT of 6.6% vs. 2.7% (p=0.048) and the CMS score fell by 34.9% vs. 14.8% (p=0.014) compared to placebo, while the reduction in PaCO₂ was 10.5% vs. an increase of 0.6% (p=0.003), with a relative increase in PaO₂ of 13.6% vs. 3.0%. NAC reduced CMS score compared to placebo (relative reduction of 34.0% vs. 14.8%, p=0.017), while changes in other parameters failed to reach statistical significance. The combination of ACZ and NAC was no better than ACZ alone. No changes in serum and urine cobalt concentrations were seen within any treatment arms. ACZ reduced polycythemia and CMS score, while NAC improved CMS score without significantly lowering hematocrit. Only a small proportion of subjects had cobalt toxicity, which may relate to the closing of contaminated water sources and several other environmental protection measures.

Heart failure after conventional metal-on-metal hip replacements

Background and purpose - It is unclear whether metal particles and ions produced by mechanical wear and corrosion of hip prostheses with metal-on-metal (MoM) bearings have systemic adverse effects on health. We compared the risk of heart failure in patients with conventional MoM total hip arthroplasty (THA) and in those with metal-on-polyethylene (MoP) THA. Patients and methods - We conducted a retrospective cohort study using data from the Australian Government Department of Veterans' Affairs health claims database on patients who received conventional THA for osteoarthritis between 2004 and 2012. The MoM THAs were classified into groups: Articular Surface Replacement (ASR) XL Acetabular System, other large-head (LH) (> 32 mm) MoM, and small-head (SH) (≤ 32 mm) MoM. The primary outcome was hospitalization for heart failure after THA. Results - 4,019 patients with no history of heart failure were included (56% women). Men with an ASR XL THA had a higher rate of hospitalization for heart failure than men with MoP THA (hazard ratio (HR) = 3.2, 95% CI: 1.6-6.5). No statistically significant difference in the rate of heart failure was found with the other LH MoM or SH MoM compared to MoP in men. There was no statistically significant difference in heart failure rate between exposure groups in women. Interpretation - An association between ASR XL and hospitalization for heart failure was found in men. While causality between ASR XL and heart failure could not be established in this study, it highlights an urgent need for further studies to investigate the possibility of systemic effects associated with MoM THA.

Cardiovascular Effects of Performance-Enhancing Drugs

Exercise and competitive sports should be associated with a wide range of health benefits with the potential to inspire a positive community health legacy. However, the reputation of sports is being threatened by an ever-expanding armamentarium of agents with real or perceived benefits in performance enhancement. In addition to the injustice of unfair advantage for dishonest athletes, significant potential health risks are associated with performance-enhancing drugs. Performance-enhancing drugs may have an effect on the cardiovascular system by means of directly altering the myocardium, vasculature, and metabolism. However, less frequently considered is the potential for indirect effects caused through enabling athletes to push beyond normal physiological limits with the potential consequence of exercise-induced arrhythmias. This review will summarize the known health effects of PEDs but will also focus on the potentially greater health threat posed by the covert search for performance-enhancing agents that have yet to be recognized by the World Anti-Doping Agency. History has taught us that athletes are subjected to unmonitored trials with experimental drugs that have little or no established efficacy or safety data. One approach to decrease drug abuse in sports would be to accept that there is a delay from when athletes start experimenting with novel agents to the time when authorities become aware of these drugs. This provides a window of opportunity for athletes to exploit with relative immunity. It could be argued that all off-label use of any agent should be deemed illegal.

Protective effects of kolaviron and gallic acid against cobalt-chloride-induced cardiorenal dysfunction via suppression of oxidative stress and activation of the ERK signaling pathway

Cobalt (Co) toxicity is a potential public health problem due to recent renewed use of Co in orthopedic implants, dietary supplements, and blood doping in athletes and horses. We investigated the protective roles of kolaviron (KV), a bi-flavonoid of Garcinia kola, and gallic acid (GA) on cobalt chloride (CoCl2)-induced cardiorenal damage in rats. CoCl2 caused significant increases (p < 0.05) in serum creatine kinase–myocardial band (CK-MB), lactate dehydrogenase (LDH), aspartate transaminase (AST), xanthine oxidase (XO), urea, creatinine, malondialdehyde, H2O2, nitric oxide, as well as C-reactive protein expression, along with significant (p < 0.05) reduction in cardiac and renal expression of extracellular signal regulated kinase (ERK) and the activities of superoxide dismutase, catalase, and glutathione S-transferase. KV and GA prevented the toxic effects of CoCl2 by stimulating ERK expression and reversing Co-induced biochemical changes. Administration of CoCl2 alone did not significantly alter ECG patterns in the rats, although co-treatment with KV (200 mg/kg) produced QT-segment prolongation and also appeared to potentiate Co hypotension. Histopathology of the heart and kidneys of rats treated with KV and GA confirmed the biochemical data. KV and GA thus protected against cardiac and renal damage in Co intoxication via antioxidant and (or) cell survival mechanisms, possibly involving ERK activation.

Cobalt Cardiomyopathy

Cobalt can cause a distinctive, rapidly progressive and reversible depression of cardiac systolic function, which is readily distinguished from other causes of cardiomyopathy. Patients present with the subacute onset of severe heart failure, which is accompanied by hypotension and cyanosis, pericardial effusion, low voltage on the electrocardiogram, marked elevation of serum enzymes, and lactic acidosis. They typically have a history of lethargy, anorexia, and weight loss in the months preceding the illness and exhibit other evidence of cobalt’s effects on the body (eg, polycythemia and goiter). The course of cobalt-related cardiomyopathy may be progressive and fatal, but those who survive and cease exposure generally demonstrate complete resolution of symptoms and recovery of cardiac function. Patients presenting with rapid onset of cardiomyopathy, who also exhibit polycythemia, pericardial effusion, or goiter should be evaluated for cobalt exposure. Exposure can be confirmed by the measurement of cobalt in the serum, but serum levels of the ion are not reliably predictive of clinical cardiotoxicity. The clinical emergence of cobalt cardiomyopathy seems to require the coexistence of one or more cofactors, particularly a low-protein diet, thiamine deficiency, alcoholism, and hypothyroidism. As the medicinal use of cobalt has waned and measures to reduce industrial exposure have been implemented, subacute cobalt-related cardiomyopathy had become rare. However, reports describing classical features of the disease have recently surged among patients with a malfunctioning cobalt-alloy hip prosthesis.

Human exposure to metals due to consumption of fish from an artificial lake basin close to an active mining area in Katanga (D.R. Congo)

The concentrations of 14 essential and nonessential trace elements were determined in fish from Lake Tshangalele, Katanga province, Democratic Republic of Congo. This province has been a place of intensive mining activities for centuries, which have increased in recent years, due to the use of metals such as copper and cobalt for the industries of fast-growing countries. Lake Tshangalele, which receives effluents from metallurgical and mining plants in Likasi, is home to several fish species that are an important part of the diet of the local population, and, therefore, it constitutes a relevant site for documenting the human exposure to metals as a result of a fish diet. The highest concentrations (median levels, dry weight) of cobalt (7.25mgkg(-1)), copper (88.1mgkg(-1)), iron (197.5mgkg(-1)), manganese (65.35mgkg(-1)), zinc (122.9mgkg(-1)) and aluminum (135.4mgkg(-1)) were found in fish collected closest to the copper mining plant, with decreasing concentrations along the lake, up to the dam. In the most contaminated fish samples, values of up to 270.1mgkg(-1) for Al, 173.1mgkg(-1) for Cu, 220.9mgkg(-1) for Zn, 211.0mgkg(-1) for Mn, 324.2mgkg(-1) for Fe, 15.1mgkg(-1) for Co, 4.2mgkg(-1) for Cr, 1.6mgkg(-1) for Cd, 1.9mgkg(-1) for Pb, and 1.8mgkg(-1) for Ni were found. Metal contamination from mining activity resulted in being of great concern because of potential health risks to the local inhabitants due to the consumption of heavily contaminated fish.

CAPSULE

High levels of metals, especially cobalt, aluminum, iron, manganese, zinc and cadmium were found in fish from Tshangalele water system.

Trace Metals in Noah's Ark Shells (Arca noae Linnaeus, 1758): Impact of Tourist Season and Human Health Risk

Commercially important bivalve Noah's Ark shell (Arca noae Linnaeus, 1758) represents a high-quality seafood product, but the data on levels of metal contaminants that could pose a human health risk and also on some essential elements that are important for health protection are lacking. This study examined the concentrations of Cd, Pb, Cr, Ni, Cu, Co, and Zn in the soft tissue of A. noae from harvesting area in the central Adriatic Sea, to survey whether heavy metals are within the acceptable limits for public health and whether tourism could have an impact on them. The concentrations of analysed metals varied for Cd: 0.15-0.74, Pb: 0.06-0.26, Cr: 0.11-0.34, Ni: 0.09-0.22, Cu: 0.65-1.95, Co: 0.04-0.09, and Zn: 18.3-74.7 mg/kg wet weight. These levels were lower than the permissible limits for safe consummation of seafood, and only for Cd, some precautions should be taken into account if older shellfish were consumed. Increase of Cd, Cr, and Cu in shell tissue was observed during the tourist season at the site closest to the marine traffic routes, indicating that metal levels in shellfish tissue should be monitored especially carefully during the peak tourist season to prevent eventual toxic effects due to increased intake of metals, specifically of Cd.

Alterations in blood pressure, antioxidant status and caspase 8 expression in cobalt chloride-induced cardio-renal dysfunction are reversed by Ocimum gratissimum and gallic acid in Wistar rats

The protective abilities of the chloroform extract of Ocimum gratissimum (COG) and gallic acid against cobalt chloride (CoCl2) - induced cardiac and renal toxicity were evaluated. Rats were exposed to CoCl2 (350ppm) for 7 days, either alone, or in combination with COG (100 and 200mg/kg) or gallic acid (120mg/kg). CoCl2 given alone, caused significant increases (p<0.05) in oxidative stress parameters (hydrogen peroxide, H2O2 and malondialdehyde, MDA) and increased expression of the apoptotic initiator caspase 8 in the heart and kidneys. There was significant reduction (p<0.05) in reduced glutathione (GSH) in cardiac and renal tissues; reduction in superoxide dismutase (SOD) activity in the kidneys and adaptive increases in Glutathione S-transferase (GST) and catalase (CAT). CoCl2 also produced significant reduction (p<0.05) in systolic (SBP), diastolic (DBP) and mean arterial (MAP) blood pressures. Oral COG and gallic acid treatment significantly reduced (p<0.05) the levels of H2O2 and MDA; with reduced expression of caspase 8 and restoration of GSH levels, GPx, SOD and CAT activities, howbeit, to varying degrees in the heart and kidneys. COG (200mg/kg) was most effective in restoring the blood pressures in the rats to near control levels. CoCl2-induced histopathological lesions including myocardial infarction and inflammation and renal tubular necrosis and inflammation were effectively ameliorated by the treatments administered. This study provides evidence for the protective roles of O. gratissimum and gallic acid by modulation of CoCl2-induced alterations in blood pressure, antioxidant status and pro-apoptotic caspase 8 in Wistar rats.

Cobalt use and regulation in horseracing: a review

Cobalt, atomic weight 58.9, is a metallic element and environmental substance found in the animal in microgram quantities, predominantly as vitamin B12, but is also a component of at least one mammalian enzyme unassociated with B12. Cobalt is a required trace mineral and has long been administered as a dietary supplement to humans and animals. Cobalt deficiency outside of its requirement in vitamin B12 has not been reported in humans. The administration of cobalt salts was once standard treatment for anaemia in humans, owing to its ability to stimulate red blood cell synthesis. Elemental cobalt acts by stabilising hypoxia inducible factor (HIF-1α), which activates the erythropoietin gene, which in turn increases haemoglobin/red blood cell synthesis, which had led to a presumption that cobalt may be performance enhancing in athletes. Administration of cobalt in amounts sufficient to significantly increase the haematocrit are associated with risk of toxicity in humans, and the only cobalt administration study in horses showed no effect on red blood cell parameters or toxicity. Because of the perception that cobalt administration may enhance athletic performance, racing regulators have recently begun to restrict cobalt use in horseracing which has led to the introduction of cobalt thresholds in several racing jurisdictions. The International Federation of Horseracing Authorities is considering an international regulatory threshold for cobalt of 100 ng/ml in urine, based on studies performed in five different countries. In the United States, the Racing Commissioners International has recently set a primary plasma threshold of 25 ng/ml and secondary threshold of 50 ng/ml. One New York and New Jersey racetrack owner has initiated testing for cobalt and has denied his facilities to trainers whose horses tested positive for excessive quantities of cobalt. This review seeks to summarise what is known about the use of cobalt in horse racing.

Systemic cobalt toxicity from total hip arthroplasties

As adverse events related to metal on metal hip arthroplasty have been better understood, there has been increased interest in toxicity related to the high circulating levels of cobalt ions. However, distinguishing true toxicity from benign elevations in cobalt levels can be challenging. The purpose of this review is to examine the use of cobalt alloys in total hip arthroplasty, to review the methods of measuring circulating cobalt levels, to define a level of cobalt which is considered pathological and to review the pathophysiology, risk factors and treatment of cobalt toxicity. To the best of our knowledge, there are 18 published cases where cobalt metal ion toxicity has been attributed to the use of cobalt-chromium alloys in hip arthroplasty. Of these cases, the great majority reported systemic toxic reactions at serum cobalt levels more than 100 μg/L. This review highlights some of the clinical features of cobalt toxicity, with the goal that early awareness may decrease the risk factors for the development of cobalt toxicity and/or reduce its severity.

Take home message: Severe adverse events can arise from the release of cobalt from metal-on-metal arthroplasties, and as such, orthopaedic surgeons should not only be aware of the presenting problems, but also have the knowledge to treat appropriately.

Cite this article: Bone Joint J 2016;98-B:14–20.

Systemic cobalt toxicity from total hip arthroplasties

Recently, the use of metal-on-metal articulations in total hip arthroplasty (THA) has led to an increase in adverse events owing to local soft-tissue reactions from metal ions and wear debris. While the majority of these implants perform well, it has been increasingly recognised that a small proportion of patients may develop complications secondary to systemic cobalt toxicity when these implants fail. However, distinguishing true toxicity from benign elevations in cobalt ion levels can be challenging.

The purpose of this two part series is to review the use of cobalt alloys in THA and to highlight the following related topics of interest: mechanisms of cobalt ion release and their measurement, definitions of pathological cobalt ion levels, and the pathophysiology, risk factors and treatment of cobalt toxicity. Historically, these metal-on-metal arthroplasties are composed of a chromium-cobalt articulation.

The release of cobalt is due to the mechanical and oxidative stresses placed on the prosthetic joint. It exerts its pathological effects through direct cellular toxicity.

This manuscript will highlight the pathophysiology of cobalt toxicity in patients with metal-on-metal hip arthroplasties.

Take home message: Patients with new or evolving hip symptoms with a prior history of THA warrant orthopaedic surgical evaluation. Increased awareness of the range of systemic symptoms associated with cobalt toxicity, coupled with prompt orthopaedic intervention, may forestall the development of further complications.

Cite this article: Bone Joint J 2016;98-B:6–13.

Metals exposures of residents living near the Akaki River in Addis Ababa, Ethiopia: a cross-sectional study

Background. The Akaki River in Ethiopia has been found to contain elevated levels of several metals. Our objectives were to characterize metals exposures of residents living near the Akaki River and to assess metal levels in their drinking water. Methods. In 2011, we conducted a cross-sectional study of 101 households in Akaki-Kality subcity (near the Akaki River) and 50 households in Yeka subcity (distant to the Akaki River). One willing adult in each household provided urine, blood, and drinking water sample. Results. Urinary molybdenum (p < 0.001), tungsten (p < 0.001), lead (p < 0.001), uranium (p < 0.001), and mercury (p = 0.049) were higher in Akaki-Kality participants compared to Yeka participants. Participants in both subcities had low urinary iodine; 45% met the World Health Organization (WHO) classification for being at risk of moderate iodine deficiency. In Yeka, 47% of households exceeded the WHO aesthetic-based reference value for manganese; in Akaki-Kality, only 2% of households exceeded this value (p < 0.001). There was no correlation between metals levels in water samples and clinical specimens. Conclusions. Most of the exposures found during this investigation seem unlikely to cause acute health effects based on known toxic thresholds. However, toxicity data for many of these metals are very limited.

Relationship between alcohol consumption and cardiac structure and function in the elderly: the Atherosclerosis Risk In Communities Study

BACKGROUND

Excessive alcohol consumption is associated with cardiomyopathy, but the influence of moderate alcohol use on cardiac structure and function is largely unknown.

METHODS AND RESULTS

We studied 4466 participants from visit 5 of the Atherosclerosis Risk in Communities (ARIC) study (76±5 years and 60% women) who underwent transthoracic echocardiography, excluding former drinkers and those with significant valvular disease. Participants were classified into 4 categories based on self-reported alcohol intake: nondrinkers, drinkers of ≤7, ≥7 to 14, and ≥14 drinks per week. We related alcohol intake to measures of cardiac structure and function, stratified by sex, and fully adjusted for covariates. In both genders, increasing alcohol intake was associated with larger left ventricular diastolic and systolic diameters and larger left atrial diameter (P<0.05). In men, increasing alcohol intake was associated with greater left ventricular mass (8.2±3.8 g per consumption category; P=0.029) and higher E/E' ratio (0.82±0.33 per consumption category; P=0.014). In women, increasing alcohol intake was associated with lower left ventricular ejection fraction (-1.9±0.6% per consumption category; P=0.002) and a tendency for worse left ventricular global longitudinal strain (0.45±0.25% per consumption category; P=0.07).

CONCLUSIONS

In an elderly community-based population, increasing alcohol intake is associated with subtle alterations in cardiac structure and function, with women appearing more susceptible than men to the cardiotoxic effects of alcohol.

Alcohol consumption and risk of heart failure: the Atherosclerosis Risk in Communities Study

AIM

Alcohol is a known cardiac toxin and heavy consumption can lead to heart failure (HF). However, the relationship between moderate alcohol consumption and risk for HF, in either men or women, remains unclear.

METHODS AND RESULTS

We examined 14 629 participants of the Atherosclerosis Risk in Communities (ARIC) study (54 ± 6 years, 55% women) without prevalent HF at baseline (1987-89) who were followed for 24 ± 1 years. Self-reported alcohol consumption was assessed as the number of drinks/week (1 drink = 14 g of alcohol) at baseline, and updated cumulative average alcohol intake was calculated over 8.9 ± 0.3 years. Using multivariable Cox proportional hazards models, we examined the relation of alcohol intake with incident HF and assessed whether associations were modified by sex. Overall, most participants were abstainers (42%) or former drinkers (19%), with 25% reporting up to 7 drinks per week, 8% reporting ≥7 to 14 drinks per week, and 3% reporting ≥14-21 and ≥21 drinks per week, respectively. Incident HF occurred in 1271 men and 1237 women. Men consuming up to 7 drinks/week had reduced risk of HF relative to abstainers (hazard ratio, HR 0.80, 95% CI 0.68-0.94, P = 0.006); this effect was less robust in women (HR 0.84, 95% CI 0.71-1.00, P = 0.05). In the higher drinking categories, the risk of HF was not significantly different from abstainers, either in men or in women.

CONCLUSION

In the community, alcohol consumption of up to 7 drinks/week at early-middle age is associated with lower risk for future HF, with a similar but less definite association in women than in men. These findings suggest that despite the dangers of heavy drinking, modest alcohol consumption in early-middle age may be associated with a lower risk for HF.

Systemic toxicity related to metal hip prostheses

INTRODUCTION

One in eight of all total hip replacements requires revision within 10 years, 60% because of wear-related complications. The bearing surfaces may be made of cobalt/chromium, stainless steel, ceramic, or polyethylene. Friction between bearing surfaces and corrosion of non-moving parts can result in increased local and systemic metal concentrations.

OBJECTIVES

To identify and systematically review published reports of systemic toxicity attributed to metal released from hip implants and to propose criteria for the assessment of these patients.

METHODS

Medline (from 1950) and Embase (from 1980) were searched to 28 February 2014 using the search terms (text/abstract) chrom* or cobalt* and [toxic* or intox* or poison* or adverse effect or complication] and [prosthes* or 'joint replacement' or hip or arthroplast*] and PubMed (all available years) was searched using the search term (("Chromium/adverse effects"[Mesh] OR "Chromium/poisoning"[Mesh] OR "Chromium/toxicity"[Mesh]) OR ("Cobalt/adverse effects"[Mesh] OR "Cobalt/poisoning"[Mesh] OR "Cobalt/toxicity"[Mesh])) AND ("Arthroplasty, Replacement, Hip"[Mesh] OR "Hip Prosthesis"[Mesh]). These searches identified 281 unique references, of which 23 contained original case data. Three further reports were identified from the bibliographies of these papers. As some cases were reported repeatedly the 26 papers described only 18 individual cases. Systemic toxicity. Ten of these eighteen patients had undergone revision from a ceramic-containing bearing to one containing a metal component. The other eight had metal-on-metal prostheses. Systemic toxicity was first manifest months and often several years after placement of the metal-containing joint. The reported systemic features fell into three main categories: neuro-ocular toxicity (14 patients), cardiotoxicity (11 patients) and thyroid toxicity (9 patients). Neurotoxicity was manifest as peripheral neuropathy (8 cases), sensorineural hearing loss (7) and cognitive decline (5); ocular toxicity presented as visual impairment (6). All these neurological features, except cognitive decline, have been associated with cobalt poisoning previously. Type of prosthesis and blood metal concentrations. Where blood or serum metal concentrations were reported (n = 17 for cobalt and n = 14 for chromium), the median cobalt concentration was 398 (range, 13.6-6521) μg/L and the median chromium concentration was 48 μg/L (in whole blood) (range, 4.1-221 μg/L including serum and blood values). Those patients reported to have systemic features who had received a metal-on-metal prosthesis (n = 8) had a median peak blood cobalt concentration of 34.5 (range, 13.6-398.6) μg/L; those with a metal-containing revision of a failed ceramic prosthesis (n = 10) had a median blood cobalt concentration of 506 (range, 353-6521) μg/L. Management. The most common treatment was removal of the metal-containing prosthesis, undertaken in all but 2 patients. This was usually associated with a fall in circulating cobalt concentration and improvement in some or all features. Clinical and toxicological assessment of systemic features. We propose the following criteria for assessing the likelihood that clinical features are related to cobalt toxicity: clinical effects consistent with the known neurological, cardiac, or thyroidal effects of cobalt, and for which any other explanation is less likely; increased blood cobalt concentrations (substantially higher than those in patients with well-functioning prostheses) several months after hip replacement; a fall in the blood cobalt concentration, usually accompanied by signs of improvement in features. When judged by these criteria, the systemic features in 10 of the reported cases are likely to be related to cobalt exposure from a metal-containing hip prosthesis.

CONCLUSIONS

Rarely, patients exposed to high circulating concentrations of cobalt from failed hip replacements develop neurological damage, hypothyroidism and/or cardiomyopathy, which may not resolve completely even after removal of the prosthesis. The greatest risk of systemic cobalt toxicity seems to result from accelerated wear of a cobalt-containing revision of a failed ceramic prosthesis, rather than from primary failure of a metal-on-metal prosthesis.

Pathways of human exposure to cobalt in Katanga, a mining area of the D.R. Congo

Human exposure biomonitoring in the African Copperbelt (Katanga, southern D.R. Congo) revealed elevated cobalt (Co) exposure in the general population. This study was designed to identify the Co exposure routes for the non-occupationally exposed population in that area. The concentration of Co was measured in environmental and urine samples collected in urban and rural communities close to metal mining and/or refining plants, villages near a lake receiving effluents from metal refining plants, and control rural areas without industrial pollution. Drinking water, uncooked food items (maize flour, washed vegetables, fish and meat), indoor and outdoor dust samples were collected at each location. A food questionnaire was used to estimate dietary Co intake for adults and children. Geometric mean urine-Co (U-Co) concentrations were 4.5-fold (adults) and 6.6-fold (children) higher in the polluted than in the control area, with U-Co values being intermediate in the lakeside area. Average Co concentrations in environmental samples differed 6-40-fold between these areas. U-Co was positively correlated with most environmental Co concentrations, the highest correlations being found with Co in drinking water, vegetables and fruit. Estimated average total Co intake for adults was 63 (±42) μg/day in the control area, 94 (±55) μg/day in the lakeside villages and 570 (±100) μg Co/day in the polluted areas. U-Co was significantly related to modelled Co intake (R(2)=0.48, adults and R(2)=0.47, children; log-log relationship). Consumption of legumes, i.e. sweet potato leaves (polluted) and cereals+fish (lakeside) was the largest contributor to Co intake in adults, whereas dust ingestion appeared to contribute substantially in children in the polluted area. In conclusion, dietary Co is the main source of Co exposure in the polluted area and Co is efficiently transferred from soil and water in the human food chain.

Effects and blood concentrations of cobalt after ingestion of 1 mg/d by human volunteers for 90 d

BACKGROUND

Over-the-counter cobalt supplements are available for sale in the United States, but little is known regarding their clinical effects and biokinetic distribution with long-term use.

OBJECTIVE

We assessed blood kinetics, biochemical responses, and clinical effects in 5 adult men and 5 adult women who voluntarily ingested ∼ 1.0 mg Co/d (0.080-0.19 mg Co · kg⁻¹ · d⁻¹) of a commercially available cobalt supplement over a 3-mo period.

DESIGN

Volunteers were instructed to take the cobalt dietary supplement in the morning according to the manufacturer's label. Blood samples were collected and analyzed for a number of biochemical variables before, during, and after dosing. Hearing, vision, cardiac, and neurologic functions were also assessed in volunteers before, during, and after dosing.

RESULTS

After ∼ 90 d of dosing, mean cobalt blood concentrations were lower in men than in women. Mean cobalt whole blood and serum concentrations in men were 20 μg/L (range: 12-33 μg/L) and 25 μg/L (range: 15-46 μg/L), respectively. In women, mean cobalt whole blood and serum concentrations were 53 μg/L (range: 6-117 μg/L) and 71 μg/L (range: 9-149 μg/L), respectively. Estimated red blood cell (RBC) cobalt concentrations suggested that cobalt was sequestered in RBCs during their 120-d life span, which resulted in a slower whole blood clearance compared with serum. The renal clearance of cobalt increased with the serum concentration and was, on average, lower in women (3.5 ± 1.3 mL/min) than in men (5.5 ± 1.9 mL/min). Sex-specific differences were observed in cobalt absorption and excretion. There were no clinically significant changes in biochemical, hematologic, and clinical variables assessed in this study.

CONCLUSION

Peak cobalt whole blood concentrations ranging between 9.4 and 117 μg/L were not associated with clinically significant changes in basic hematologic and clinical variables.

Intolerability of cobalt salt as erythropoietic agent

Unfair athletes seek ways to stimulate erythropoiesis, because the mass of haemoglobin is a critical factor in aerobic sports. Here, the potential misuse of cobalt deserves special attention. Cobalt ions (Co(2+) ) stabilize the hypoxia-inducible transcription factors (HIFs) that increase the expression of the erythropoietin (Epo) gene. Co(2+) is orally active, easy to obtain, and inexpensive. However, its intake can bear risks to health. To elaborate this issue, a review of the pertinent literature was retrieved by a search with the keywords 'anaemia', 'cobalt', 'cobalt chloride', 'erythropoiesis', 'erythropoietin', 'Epo', 'side-effects' and 'treatment', amongst others. In earlier years, cobalt chloride was administered at daily doses of 25 to 300 mg for use as an anti-anaemic agent. Co(2+) therapy proved effective in stimulating erythropoiesis in both non-renal and renal anaemia, yet there were also serious medical adverse effects. The intake of inorganic cobalt can cause severe organ damage, concerning primarily the gastrointestinal tract, the thyroid, the heart and the sensory systems. These insights should keep athletes off taking Co(2+) to stimulate erythropoiesis.