[Analysis on results of occupational health examination in 677 workers exposed to inorganic fluorine].

Objective: To analyze the health hazards of fluorine and its inorganic compounds to workers exposed to fluorine, and to provide technical support for the protection of workers exposed to fluorine and the revision of occupational disease diagnostic standards. Methods: In January 2019, 677 workers exposed to fluorine in a fluorine chemical company in Hunan Province were selected by cluster sampling, and occupational health examination was conducted. The suspected occupational poisoning workers were diagnosed as occupational diseases, which were divided into poisoning group and non-poisoning group. T test and Pearson χ(2) test were used for statistical analysis. Results: A total of 73 occupational chronic fluorosis patients were diagnosed. 93.15% (68/73) of the skeletal lesions were multiple, and the most frequent sites were the upper tibia and fibula. 35.00% (21/60) , 50.00% (18/36) and 58.82% (10/17) of the tibia, fibula, ulna and radius had periosteal changes only on one side. Other abnormal results were mainly dental calculus (60.71%, 411/677) , fatty liver (48.89%, 331/677) , abnormal electrocardiogram (44.17%, 299/677) , decreased bone mass (33.53%, 227/677) and increased ALT (13.15%, 89/677) . Compared with non-poisoning group, the age, length of service exposed to fluoride and fatty liver detection rate of poisoning group were higher, and the differences were statistically significant (P<0.01) . Conclusion: The changes of long bone caused by inorganic fluoride only occur in one side, so the basic location of occupational health examination should include bilateral long bone to avoid missed diagnosis. It is difficult to diagnose occupational poisoning with single slight periosteal ossification, it is suggested that the standard should be revised to specify the degree.

Notes from the Field: Acute Sulfuryl Fluoride Poisoning in a Family - Florida, August 2015.

On August 19, 2015, the Florida Department of Health (FDOH) was notified by the Florida Poison Information Center Network and a local hospital of possible sulfuryl fluoride poisonings affecting a family in Martin County, in southeastern Florida. Sulfuryl fluoride is a highly toxic (toxicity category I) gas fumigant used for termite control of homes and buildings.* FDOH personnel in Martin County commenced an investigation and identified a family of five (a grandmother, mother, father, son, and daughter) exposed to sulfuryl fluoride after their house was fumigated. The Florida Department of Agriculture and Consumer Services (FDACS), and the U.S. Environmental Protection Agency (EPA) Criminal Investigation Division also conducted an investigation after being notified by FDOH. Medical records were reviewed, and the father was interviewed by FDOH.

AS, DISH or something else?

A 68-year-old farmer presented with progressively worsening pain in multiple joints associated with stiffening for 9 months. Locomotor examination revealed grossly restricted movement of the axial skeleton. There were no neurological deficits. Radiological evaluation demonstrated diffuse bone densification and extraspinal calcification with bony ankylosis reminiscent of ankylosing spondylitis. Laboratory tests subsequently yielded the true diagnosis. The patient was counselled accordingly and started on appropriate therapy.

[Dermal and inhalation poisoning. Rare guests in our intensive care units?]. / Dermale und inhalative Intoxikationen. Seltene Gäste auf unseren Intensivstationen?

Patients with dermal and inhalation poisoning are uncommon in intensive care treatment. We describe the diagnostics and specific toxicological treatment of patients with hydrofluoric acid burns. For inhalation poisoning, we focus on smoke inhalation, especially the management of cyanide and carbon monoxide poisoning. Special attention is given to the use of hyperbaric oxygenation for the treatment of carbon monoxide poisoning.

Evaluation of total oxidative status and total antioxidant capacity in patients with endemic fluorosis.

The objective of the present study was to determine the plasma total oxidative status (TOS) and total antioxidant capacity (TAC) in patients with endemic fluorosis. A total of 79 (35 males and 44 females; mean age 44.0 ± 11.9 years) patients with endemic fluorosis and 55 (23 males and 32 females; mean age 48.3 ± 8.5 years) age-, sex- and body mass index-matched healthy controls were included in this study. The urine fluoride levels and plasma TOS and TAC levels were measured. The urine fluoride levels of fluorosis patients were significantly higher than control subjects as expected (1.91 ± 0.15 vs. 0.49 ± 0.13 mg/L, respectively; p < 0.001). TOS was significantly higher in fluorosis group than in control group (17.55 ± 3.82 vs. 15.06 ± 4.31 µmol H(2)O(2) Eq/L, respectively; p = 0.001). TAC was significantly lower in fluorosis group than in control group (1.60 ± 0.36 vs. 1.82 ± 0.51 mmol Trolox Eq/L, respectively; p = 0.004). Oxidative stress index (OSI) was significantly higher in fluorosis group than in control group (11.5 ± 3.8 vs. 8.8 ± 3.7, respectively; p < 0.001). Correlation analysis in all the groups indicated that TAC was negatively correlated with urine fluoride (r = -0.25, p = 0.003), TOS was positively correlated with urine fluoride (r = 0.34, p < 0.001) and OSI was positively correlated with urine fluoride (r = 0.36, p < 0.001). The results of our study demonstrate that oxidative stress plays an important role in the pathogenesis of the endemic fluorosis.

[Clinical and pathogenetic aspects of the chronic occupational intoxication with fluorine compounds in modern reality].

Multi-year follow-up of 358 workers of aluminum pot rooms, including 165 individuals suffering from fluorosis, has shown significant changes in the clinical picture of the chronic occupational fluorine intoxication, developed under modern conditions of production, at lower concentrations of fluorine compounds in the air of working area. In this connection, the pathology of the musculoskeletal system plays the dominating role in this clinical picture and has the large variability of combinations of the individual sections destructions of the bone tissue. The main criterion to establish the phase of the disease is still the number and severity of the signs of this destruction. The visceral pathology in contemporary production circumstances is registered with less frequency and loses a number of the previously described clinical manifestations, however, is still of some importance to identify the early signs of the disease and to prevent the dental fluorosis on time.

[The experimental search of immunological criteria for identifying stages of development of chronic fluoride intoxication].

The experiment has shown the staging of the development of immune response to the chronic fluoride intoxication. Diagnostic criteria of the initial compensation stage are: leukocytosis against the background of reduced number of lymphocytes and increased one of monocytes; high levels of ceruloplasmin in blood plasma, a progressive increase in TNFalpha and cytokine IL-10. At the decompensation stage there are: leukocytosis with increased number of neutrophils; low levels of ceruloplasmin and the cytokines IL-1beta, IL-4 and the high level of TNFalpha, IL-6, IL-10. At the stage of exhaustion there are: leukopenia against the background of lymphocytosis, a high level of Hp, the low values of the level of IgM, IgG.

Acute toxicity of ingested fluoride.

This chapter discusses the characteristics and treatment of acute fluoride toxicity as well as the most common sources of overexposure, the doses that cause acute toxicity, and factors that can influence the clinical outcome. Cases of serious systemic toxicity and fatalities due to acute exposures are now rare, but overexposures causing toxic signs and symptoms are not. The clinical course of systemic toxicity from ingested fluoride begins with gastric signs and symptoms, and can develop with alarming rapidity. Treatment involves minimizing absorption by administering a solution containing calcium, monitoring and managing plasma calcium and potassium concentrations, acid-base status, and supporting vital functions. Approximately 30,000 calls to US poison control centers concerning acute exposures in children are made each year, most of which involve temporary gastrointestinal effects, but others require medical treatment. The most common sources of acute overexposures today are dental products - particularly dentifrices because of their relatively high fluoride concentrations, pleasant flavors, and their presence in non-secure locations in most homes. For example, ingestion of only 1.8 ounces of a standard fluoridated dentifrice (900-1,100 mg/kg) by a 10-kg child delivers enough fluoride to reach the 'probably toxic dose' (5 mg/kg body weight). Factors that may influence the clinical course of an overexposure include the chemical compound (e.g. NaF, MFP, etc.), the age and acid-base status of the individual, and the elapsed time between exposure and the initiation of treatment. While fluoride has well-established beneficial dental effects and cases of serious toxicity are now rare, the potential for toxicity requires that fluoride-containing materials be handled and stored with the respect they deserve.

Skeletal fluorosis due to excessive tea and toothpaste consumption.

We describe the case of a 53-year-old woman who presented with a metatarsal fracture and was found to have a bone mineral density (BMD) T-score of +11 in the lumbar spine and +7.6 in the hip. Subsequent investigation revealed very high serum, urine and tissue fluoride levels, associated with excessive tea and toothpaste consumption. The case emphasises the need to exclude fluorosis in individuals with unexpectedly high BMD levels.

Use of the Rey-Osterrieth Complex Figure Test for neurotoxicity evaluation of mixtures in children.

The aim of this study was to assess the value of the children's version of the Rey-Osterrieth Complex Figure Test as a screening test in a population exposed to different mixtures of neurotoxicants. Copy and Immediate Recall scores were evaluated through the test. Children were recruited from three sites; an area with natural contamination by fluoride and arsenic (F-As), a mining-metallurgical area with lead and arsenic contamination (Pb-As) and a malaria zone with the evidence of fish contaminated with dichlorodiphenyltrichloroethane (DDT) and polychlorinated biphenyls (PCBs). Children aged 6-11 years old, living in one of the three polluted sites since birth were recruited (n=166). The exposure was evaluated as follows: fluoride and arsenic in urine, lead in blood and DDT, dichlorodiphenyldichloroethylene (DDE) and PCBs in serum. To evaluate the test performance, z-scores for Copy and Immediate Recall were calculated. The proportion of children by residence area with performance lower than expected by age (below -1 SD) for Copy and Immediate Recall was in the F-As area (88.7% and 59%) and in the DDT-PCBs area (73% and 43.8%), respectively. In the Pb-As area, the proportion was 62% for both tests. After adjustment, Copy correlated inversely with fluoride in urine (r=-0.29; p<0.001) and Immediate Recall correlated inversely with fluoride in urine (r=-0.27; p<0.05), lead in blood (r=-0.72; p<0.01), arsenic in urine (r=-0.63; p<0.05) and DDE (r=-0.25; p<0.05). This study provided evidence that children included in this research are living in high risk areas and were exposed to neurotoxicants. Poor performance in the test could be explained in some way by F, Pb, As or DDE exposure, however social factors or the low quality of school education prevalent in the areas could be playing an important role.

A case of distal renal tubular acidosis, Southeast Asian ovalocytosis and possible fluorosis.

A 39-year old man had periodic paralysis due to hypokalaemia. Investigations led to the diagnosis of distal renal tubular acidosis (dRTA) and Southeast Asian ovalocytosis (SAO). Both can originate in mutations of the anion-exchanger 1 gene (AE1), which codes for band 3, the bicarbonate/chloride exchanger in both the red cell membrane and the basolateral membrane of the collecting tubule alpha-intercalated cell. The finding of diffuse osteosclerosis led to the suspicion of coexisting fluorosis.

[Justifying the use of primary tissue culture method for evaluation of sodium fluoride safety in nutrition products].

Toxicity of sodium fluoride added to nutrition products is assessed through peculiarities of kidney tissue culture growth in vitro--over 75% inhibition of cell clumps growth supports high toxic influence of sodium fluoride, the growth decrease from 63% to 74% signifies lower degree, the growth inhibition less than 62% demonstrates very low toxicity of the chemical.

Fluorosis as a probable cause of chronic lameness in free ranging eastern grey kangaroos (Macropus giganteus).

A population of eastern grey kangaroos (Macropus giganteus) inhabiting heathland and farmland surrounding an aluminum smelter at Portland, Victoria, Australia, exhibited clinical signs of lameness. An investigation was undertaken to determine the cause of this lameness. Hematology, necropsy, histopathology, fecal egg count, total worm count, reproductive status, and the population age range were examined and failed to reveal any additional underlying disease state. The specific problem of lameness was addressed with bone histopathology, radiography, quantitative ultrasonography, microradiography, and multielement analysis of bone ash samples. The significant lesions observed were: osteophytosis of the distal tibia and fibula, tarsal bones, metatarsus IV, and proximal coccygeal vertebrae; osteopenia of the femur, tibia, and metatarsus IV; incisor enamel hypoplasia; stained, uneven, and abnormal teeth wear; abnormal bone matrix mineralization and mottling; increased bone density; and elevated bone fluoride levels. Microradiography of affected kangaroos exhibited "black osteons," which are a known manifestation of fluorosis. Collectively, these lesions were consistent with a diagnosis of fluorosis.

[Determination of the contents of fourteen elements in urine of Xinjiang kuitun fluorine poisoning and arsenic-fluoride poisoning patients by ICP-AES].

A method of determining the contents of K, Na, Ca, Mg, P, Zn, Al, Ba, Co, Cu, Ni, Sr, Cr and Ti, fourteen elements, in urine of Xinjiang Kuitun fluorine poisoning and arsenic-fluoride poisoning patients was developed. The operation conditions of ICP-AES, and the lowest test concentration, precision and linear ranges were studied. The relative standard deviation of the method was 0.24%-2.47% (n=10), the average recoveries were 90.4%-00.5%. The contents of K and Na in urine of fluorine poisoning and arsenic-fluoride poisoning patients were higher than those of healthy contrast group. The contents of Ba, Co, Cu, Ni and Cr in the urine of arsenic-fluoride poisoning patients were higher than those of fluorine poisoning patients and healthy contrast group (P < 0.05). The contents of P, Ca, Mg, Zn, Al, Sr and Ti do not have statistic significance (P > 0.05). The method was sensitive, simple and accurate. The experiment data was reliable.

Fluorosis-induced hyperparathyroidism mimicking a giant-cell tumour of the femur.

We report the case of a young woman who, over a period of five years was diagnosed and treated for a giant-cell tumour of bone, osteomalacia and fluorosis. A review of the literature revealed a correlation between these three diagnoses, the primary pathology being fluorosis and the remaining symptoms being secondary manifestations. It is important to be aware of this association, especially in regions with endemic skeletal fluorosis.

Ossification of the transverse atlantal ligament associated with fluorosis: a report of two cases and review of the literature.

STUDY DESIGN: Two cases of ossification of the transverse atlantal ligament (OTAL) are reported, and the literature is reviewed. OBJECTIVE: To report two cases of OTAL, which share fluorosis as a possible etiologic link. SUMMARY OF BACKGROUND DATA: OTAL, a rare phenomenon, may cause upper cervical canal stenosis and spastic quadriparesis. However, the incidence, etiology, and the best therapeutic options are currently unclear. METHODS: Two cases are reported. Included are pertinent history, physical examination, radiographic evaluation, nonsurgical interventions, and outcomes. The available literature is also reviewed. RESULTS: On systemic examination, these two cases were found to have ossification of many ligaments and interosseous membranes, i.e., the atlantal transverse ligament, posterior longitudinal ligament, and interosseous membranes of ribs, forearm, and leg. These findings were coupled with a history of high fluoride intake and dental fluorosis; the diagnosis of fluorosis was made. After 2 weeks of treatment with halo ring traction, and protection and stabilization with a hard cervical collar, the clinical symptoms significantly improved. CONCLUSION: The incidence of OTAL may be not as rare as has been thought. Although the complete etiology of OTAL is not known, fluorosis may be one of the etiologic factors related to OTAL, as well as the ossification of other ligaments and interosseous membranes. Nonsurgical treatment may be safe and effective.