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Medical Toxicology of Occupational and Environmental Exposures is the only reference which comprehensively covers the clinical, analytical, and monitoring information needed by clinicians, students and investigators with interests in metals, radiation, and cancer. The information in all chapters is presented in a cogent, standardized format which greatly simplifies the use of the text as a reference. Reviewed by a distinguished panel of well-known toxicology experts, the information is critically evaluated and authoritative. The interdisciplinary, evidence-based approach is designed to reach beyond clinical settings to increase the scientific understanding of those in associated fields (analytical laboratories, universities, federal and state regulatory and environmental agencies) involved with decisions regarding metals, radiation, and chemical carcinogens. The consistent and concise style allows the reader to quickly locate the appropriate information necessary for informed decisions regarding the sources, host susceptibility, dose-response, clinical effect, health surveillance, and management of exposures to these substances. Additional information is readily available to the interested reader through the detailed bibliography at the end of each chapter.
Volume 1 "Metals and Metalloids: Clinical Assessment, Diagnostic Tests, and Therapeutics" is written to be clinically-oriented with a consistent template, allowing easier access to detailed information on specific metals.
Donald G. Barceloux, MD, Author: Dr. Barceloux is a Medical Toxicologist in the Department of Emergency Medicine at Pomona Valley Community Hospital. For over 30 years, he has served as a Clinical Professor of Medicine at the University of California, Los Angeles School of Medicine. He received his A.B. in Biology, B.S. in General Engineering, and M.S. in Engineering Science from Stanford University, and his medical training at the University of California, Los Angeles. He is a Consultant in Medical Toxicology including the diagnosis and treatment of poisoning, health surveillance, biological monitoring, interpretation of risk assessment and toxicological data, and determination of the medical effects of exposures to chemicals and drugs. He co-authored the First Edition of Medical Toxicology: Diagnosis and Treatment of Human Poisoning as well as various other toxicology related publications on metals, solvents, alcohols, natural substances, drugs of abuse, and the treatment of poisonings. This volume is the third book in his Medical Toxicology series, which provides concise, detailed coverage on the medical toxicology of metals, radiation, and chemical carcinogens. The first two volumes were Medical Toxicology of Natural Substances: Foods, Fungi, Medicinal Herbs, Plants, and Venomous Animals and Medical Toxicology of Drug Abuse: Synthetic Chemicals and Psychoactive Plants. His work in Medical Toxicology and Emergency Medicine has been recognized by fellowship in the American Academy of Clinical Toxicology, the American College of Medical Toxicology, and the American College of Emergency Medicine.
Robert B. Palmer, PhD, Editor: Dr. Palmer is a board-certified clinical toxicologist in private practice with Toxicology Associates, PLLC and is an attending toxicologist at the Rocky Mountain Poison and Drug Service in Denver, CO. He holds academic appointments at the University of Colorado and University of Wyoming. Dr. Palmer previously served on the Board of Directors of the American Board of Applied Toxicology (ABAT) and the Board of Trustees of the Academy of Clinical Toxicology (AACT) including serving as AACT president. He is a frequent author and speaker on many aspects of clinical and forensic toxicology.
Foreword xli
Preface xliii
Acknowledgments xlv
Review Panel xlvii
Volume 1 Metals and Metalloids: Clinical Assessment, Diagnostic Tests, and Therapeutics 1
1 Aluminum 3
2 Antimony 35
3 Arsenic 49
4 Barium 115
5 Beryllium 133
6 Bismuth 157
7 Boron and Boron Compounds 169
9 Chromium 225
10 Cobalt 271
11 Copper 319
12 Germanium 347
13 Gold 355
14 Indium 363
15 Iron 371
16 Lead 395
17 Lithium 499
18 Magnesium 527
19 Manganese 539
20 Mercury 573
21 Molybdenum 645
22 Nickel 657
23 Phosphorus and Phosphorus Compounds 689
24 Platinum and Related Metals 711
25 Potassium 731
26 Rare Earth Elements 747
27 Selenium 759
28 Silver 803
29 Tellurium 815
30 Thallium 823
31 Tin 843
32 Titanium 865
33 Tungsten 875
34 Vanadium 895
35 Zinc 917
36 Zirconium 941
Although the identification of aluminum as a metal occurred in 1827, the Romans used alum (hydrated aluminum sulfate) for the purification of water and the preparation and staining of hides.1 In Europe, the commercial production of aluminum as a metallic pigment began shortly after the development of the Hall-Heroult electrolytic process in 1886. This process became the major industrial process for smelting aluminum by dissolving aluminum oxide (alumina from bauxite ore) in molten cryolite and electrolyzing the molten salt bath.2 The first reported case associating aluminum toxicity with memory loss, ataxia, tremor, and muscle tics occurred in 1921.3 Massive exposure to finely divided pyrotechnical aluminum flake powders during World War II in Germany caused fibrotic lung disease (aluminosis); ~20?years later, McLaughlin et al. reported the case of a ball mill operator with an occupational exposure to aluminum and aluminum oxide (Al2O3) during the production of flake powders; he presented with pulmonary fibrosis and encephalopathy (poor memory, speech disorder, myoclonic jerks, convulsion, focal weakness).4
In the middle of the 20th century (1944-1979), aluminum powder (e.g., McIntyre powder) was released in mines as a prophylactic agent to coat silica particles and prevent silicon-induced fibrotic reactions. Mortality studies of Australian cohorts exposed to aluminum dust prophylactically did not support the effectiveness of aluminum as a protective agent for silicosis.5 This study suggested the possibility of increased risk of cardiovascular disease and Alzheimer's disease in the exposed cohort; however, the increase was small (SMR = 1.38) and not statistically significant with wide confidence intervals. An analysis of postmortem aluminum concentrations suggested pulmonary aluminum concentrations were similar in eight workers receiving McIntyre Powder and occupationally exposed workers.6 The medical use of aluminum increased significantly in the 1950s when aluminum was prescribed as a phosphate binder to patients with chronic renal failure. By 1972, Alfrey et al. recognized an encephalopathy in patients on dialysis characterized by progressive dementia, myoclonus, facial grimacing, diffuse pain, and seizures.7 This epidemic of dialysis dementia vanished when excess aluminum was eliminated from the dialysate.8 In the early 1980s, a syndrome of encephalopathy, metabolic bone disease, and microcytic anemia occurred in dialysis-dependent children receiving aluminum-containing antacids.9 Calcium carbonate gradually replaced aluminum-containing antacids in patients with chronic renal failure because of the lack of toxicity and the superior binding of calcium carbonate to phosphates compared with aluminum.10 Parenteral solutions (e.g., total parenteral nutrition) were recognized as sources of aluminum loading, particularly in children; in 1990, the US FDA recommended that the aluminum concentration of these solutions not exceed 25?µg/L followed in 2004 by a daily recommended intake of 5?µg/kg.
Aluminum is the third most abundant element in the earth's crust after oxygen and silicon, comprising about 8% of the earth's crust and belonging to Group 13 (Group IIIa) along with boron, gallium, indium, and thallium.11 Most aluminum compounds are solids with high melting points. Pure aluminum is a light, malleable, silvery-white metal that easily conducts both heat and electricity; however, the high reactivity of aluminum limits the existence of the metallic state in the earth's crust. The only natural oxidation state of aluminum is Al3+ with an ionic radius and chemical behavior similar to Fe3+. Because aluminum has a small radius and an avid affinity for oxygen, this metal exists almost exclusively as aluminum oxides (bauxite) or aluminosilicate compounds (clays, feldspars, and micas). The resistance of aluminum to corrosion results from the rapid formation of aluminum oxide following exposure to oxygen, water, or other oxidants.
The pH determines the solubility of aluminum compounds; therefore, the physiological milieu strongly affects the affinity of Al3+ for hydroxide ions and the subsequent precipitation of the complex. Only small amounts of free aluminum exist in solutions within pH?6.5-7.4. Aluminum salts of chloride, nitrate, and sulfate are water-soluble, whereas metallic aluminum, aluminum oxide, and other aluminum salts (hydroxide, phosphate, silicate) are very poorly water-soluble. Aluminum hydroxides and aluminum phosphates are some of the least soluble aluminum salts, but both compounds contribute to aluminum exposure.12 Aluminum oxide nanoparticles (<100?µm) more easily diffuse across biological membranes than larger particles.13 At pH?7.0, the solubility of aluminum hydroxide and aluminum sulfate is limited (2.5?mg/L);14 however, the solubility of aluminum salts increases as the pH deviates from neutral. Aluminum hydroxide binds hydrogen ions in an acid medium, whereas aluminum hydroxide releases hydrogen ions in an alkaline medium. In acidic aqueous conditions of the stomach (i.e., pH?2), aluminum occurs primarily as a monomolecular hexahydrate, Al(H2O)6, which is the "free" form of Al3+. As pH increases to near-neutral conditions in the intestines, the insoluble precipitate (aluminum hydroxide, Al(OH)3) forms. Table 1.1 lists the physical properties and identifying information of aluminum and common aluminum salts.
Aluminum exists naturally in bauxite, cryolite, feldspars, micas, and silicates. The major source of commercial aluminum is bauxite; this mineral contains aluminum hydroxide, silica, ferrous oxide, and smaller amounts of cryolite (Na3AlF6). The production of this metal via electrolytic reduction of the raw material involves the following: 1) the refining of bauxite (Bayer Process) under high temperature, pressure, and strong caustic solution to form alumina (aluminum oxide), 2) the electrolytic reduction of the hydrate by the Hall-Heroult process to produce aluminum in the reduction cells (pots), and 3) the casting of aluminum into ingots. During this chemical process, the aluminum leaches from the bauxite as sediment containing aluminum oxide (alumina). During the electrolysis of molten cryolite, the electrothermal process produces pure aluminum that precipitates on carbon cathodes in the furnace of a carbon-lined steel reservoir. Typically, ~200 pots are arranged in potlines within buildings called potrooms. Prebake technology has gradually replaced the older Søderberg pots, resulting in more efficient hooding, improved fume extraction, and reduced exposure to a variety of dust, fumes, and gases. Potential exposures to chemicals during the electrolysis of aluminum include tar oils, polyaromatic hydrocarbons (3,4-benzo(a)pyrene),15 carbon monoxide, sulfur dioxide, and airborne fluorides (F-, HF, sodium aluminum tetrafluoride).16 In a study of 17,089 aluminum smelter workers followed from 1950-2004, the incidence of lung, bladder, and buccal cancer increased significantly (P <?0.001) with exposure to benzo(a)pyrene.17
Aluminum is an extremely versatile metal with myriad of uses as a structural material in the manufacture of food containers, insulating materials, automobile and airplane manufacturing, machinery, electrical products, and cooking utensils. Because pure aluminum lacks strength, most aluminum used in metallurgy involves the production of aluminum-based alloy castings and wrought aluminum products. The wire form of aluminum is used in welding, whereas the powder form is a constituent of paints, pyrotechnic flakes, and solid rocket propellants. Other applications for aluminum compounds include the following: antacids (hydroxide, phosphate), deodorants (chloride hexahydrate, hydroxide, phosphate, carbonate, silicate), abrasives (trioxide), petroleum cracking (anhydrous chloride), water purification (sulfate, alums), leavening agent (acidic sodium phosphate), grain fumigant (aluminum phosphide), emulsifying agent (basic sodium phosphate), acidifying agent (sulfate), anti-caking agent (silicate), color additives (aluminum lakes), the brewing and paper industry (bentonite, zeolite), the catalyst for the manufacture of rubber and wood preservatives (chloride), glass and ceramic production (borate), soap and paint industry, and food processing. Alum is a series of double sulfate salts of monovalent cations (i.e., principally aluminum, potassium, other aluminum sulfates) used to reduce the turbidity of drinking water. The sulfate of aluminum dissolves in water to form aluminum hydroxide, resulting in precipitation along with suspended organic matter. Aluminum chloride (AlCl3) is a skin and mucous membrane irritant used as a fine powder in the petroleum cracking and polyisoprene production industries. Military applications have the greatest potential for aluminum nanoparticles, particularly coatings, fuels, and propellants.
TABLE 1.1 Physical properties and identifying information of aluminum and aluminum salts.
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