**[Lead Grand Rounds STORYBOARD]{.underline}**

+---------------------------------------------------+------------------+
| SCRIPT                                            | GRAPHICS         |
+---------------------------------------------------+------------------+
| None                                              | Slide 1: Lead    |
|                                                   | Medical Grand    |
|                                                   | Rounds Title     |
|                                                   | Slide            |
|                                                   |                  |
|                                                   | (CHAPTER -       |
|                                                   | Introduction)    |
|                                                   |                  |
|                                                   | ![               |
|                                                   | ](media/image1.w |
|                                                   | mf){width="1.663 |
|                                                   | 1944444444444in" |
|                                                   | height="1.3319   |
|                                                   | 444444444444in"} |
+---------------------------------------------------+------------------+
| Hello. My name is Dr. Kim Gehle and I come to you | ##### CAMERA     |
| from the Centers for Disease Control and          |                  |
| Prevention, Agency for Toxic Substances and       |                  |
| Disease Registry, Division of Toxicology and      |                  |
| Environmental Medicine. I'm a physician, board    |                  |
| certified in occupational medicine. This is the   |                  |
| Environmental Medicine Grand Rounds on Lead       |                  |
| Toxicity.                                         |                  |
|                                                   |                  |
| If you'd like to receive continuing education     |                  |
| credits for this seminar, please go to the web    |                  |
| page where this web cast is located and click on  |                  |
| the course hyperlink for continuing education.    |                  |
| There you can view the types and amounts of CE    |                  |
| available. These include CME, CNE, CEUs, and CECH |                  |
| credits.                                          |                  |
|                                                   |                  |
| After completing the assessment questionnaire and |                  |
| post test online, you can immediately print your  |                  |
| continuing education certificate.                 |                  |
|                                                   |                  |
| The goal of this seminar is to increase your      |                  |
| knowledge of lead toxicity and your ability to    |                  |
| evaluate potentially exposed patients. By the end |                  |
| of this seminar, you will be able to meet the     |                  |
| full list of objectives which cover the general   |                  |
| areas of:                                         |                  |
+---------------------------------------------------+------------------+
| • what lead is,                                   | Slide 2:         |
|                                                   | Learning         |
| • where it\'s found,                              | Objectives       |
|                                                   |                  |
| • how persons are exposed, and                    | ![               |
|                                                   | ](media/image2.w |
| • populations at risk,                            | mf){width="1.663 |
|                                                   | 1944444444444in" |
| You'll become familiar with CDC's concern for     | height="1.3319   |
| blood lead and recommendations for screening, as  | 444444444444in"} |
| well as the OSHA standards and regulations for    |                  |
| lead exposure.                                    |                  |
+---------------------------------------------------+------------------+
| You'll be able to:                                | Slide 3:         |
|                                                   | Learning         |
| • Describe the way lead is absorbed, distributed, | Objectives,      |
| and stored throughout the body,                   | Con't            |
|                                                   |                  |
| • Describe the major physiologic effects of lead, | ![               |
|                                                   | ](media/image3.w |
| • Describe the symptoms of mild and acute lead    | mf){width="1.663 |
| toxicity,                                         | 1944444444444in" |
|                                                   | height="1.3319   |
| • Describe the most useful test for lead          | 444444444444in"} |
| toxicity,                                         |                  |
+---------------------------------------------------+------------------+
| • List steps that should be taken at various      | Slide 4:         |
| blood lead levels,                                | Learning         |
|                                                   | Objectives,      |
| • And finally, list steps patients with domestic  | Con't            |
| and occupational exposures can take to protect    |                  |
| themselves from further exposure.                 | ![               |
|                                                   | ](media/image4.w |
|                                                   | mf){width="1.663 |
|                                                   | 1944444444444in" |
|                                                   | height="1.3319   |
|                                                   | 444444444444in"} |
+---------------------------------------------------+------------------+
| Okay, so what is lead and how are people exposed? | CAMERA           |
|                                                   |                  |
| People have used lead almost since the beginning  | (CHAPTER -- Lead |
| of civilization. Human activities have spread     | Exposure Routes) |
| lead widely throughout the environment, including |                  |
| air, water, soil, plants, animals, and man-made   |                  |
| constructions. Because lead is spread so widely   |                  |
| throughout the environment, it can be found in    |                  |
| everyone's body today.                            |                  |
+---------------------------------------------------+------------------+
| Lead is a soft gray metal which occurs naturally, | Slide 5: What is |
| but much of its presence in the environment stems | Lead?            |
| from its historic use in paint and gasoline and   |                  |
| from ongoing or historic mining and commercial    | ![               |
| operations.                                       | ](media/image5.w |
|                                                   | mf){width="1.663 |
| People used to be exposed to organic lead from    | 1944444444444in" |
| leaded gasoline, also known as tetraethyl lead.   | height="1.3319   |
|                                                   | 444444444444in"} |
| Imported canned food, jewelry, and some home      |                  |
| remedies may also contain lead.                   |                  |
+---------------------------------------------------+------------------+
| The biggest concern in the U.S. today regarding   | Slide 6: How     |
| lead is the use of leaded paint in housing before | does lead get    |
| 1978 which is now cracked or peeling on doors and | into the         |
| window sills.                                     | environment?     |
|                                                   |                  |
| This lead can get into household dust from        | ![               |
| activities like friction created by windows and   | ](media/image6.w |
| doors as they open and close. In addition, home   | mf){width="1.663 |
| renovations that disturb old paint can easily     | 1944444444444in" |
| spread lead dust throughout the home. Outside     | height="1.3319   |
| these homes, lead may enter soil from paint chips | 444444444444in"} |
| that are ground into the surrounding soil over    |                  |
| time.                                             |                  |
|                                                   |                  |
| In addition, soil may have been contaminated by   |                  |
| lead used in gasoline before 1976. This lead      |                  |
| doesn\'t go away, but instead remains in soil. If |                  |
| this has happened, bare soil can pose a hazard.   |                  |
|                                                   |                  |
| Lead may enter the dust or air in work            |                  |
| environments which involve lead.                  |                  |
|                                                   |                  |
| Finally, in mining and smelting areas, deposited  |                  |
| lead from the air may result in high soil levels. |                  |
+---------------------------------------------------+------------------+
| Today, everyone is exposed to environmental lead. | CAMERA           |
| Exposure                                          |                  |
|                                                   |                  |
| to lead occurs through inhalation, ingestion and  |                  |
| dermal contact. Examples include drinking lead    |                  |
| contaminated water, eating contaminated foods,    |                  |
| and swallowing or touching dust or dirt that      |                  |
| contains lead.                                    |                  |
|                                                   |                  |
| Lead exposure in the general population,          |                  |
| including children, occurs primarily through      |                  |
| ingestion, although inhalation also contributes   |                  |
| to lead body burden and may be the major          |                  |
| contributor for workers in lead-related           |                  |
| occupations.                                      |                  |
+---------------------------------------------------+------------------+
| Lead paint is the major source of lead exposure   | Slide 7: How are |
| for children in the U.S. As lead paint            | people exposed   |
| deteriorates, peels, chips, or is removed by      | to lead?         |
| renovation, or pulverizes due to friction, such   |                  |
| as in windowsills, house dust and surrounding     | ![               |
| soil may become contaminated. Lead then enters    | ](media/image7.w |
| the body through normal hand-to-mouth activity    | mf){width="1.663 |
| and inhalation.                                   | 1944444444444in" |
|                                                   | height="1.3319   |
| Ingestion of contaminated food, water or alcohol  | 444444444444in"} |
| may be significant for some populations.          |                  |
|                                                   |                  |
| In addition, ingesting certain home remedy        |                  |
| medicines may expose people to lead or lead       |                  |
| compounds.                                        |                  |
|                                                   |                  |
| It\'s important to remember that once lead is     |                  |
| absorbed into the body, it may be stored for long |                  |
| periods in mineralizing tissue, such as teeth and |                  |
| bones. It can then be released into the           |                  |
| bloodstream, especially in times of calcium       |                  |
| stress, such as pregnancy, lactation,             |                  |
| osteoporosis, or calcium deficiency.              |                  |
|                                                   |                  |
| This endogenous exposure can be significant,      |                  |
| especially for individuals with a long history of |                  |
| lead exposure.                                    |                  |
+---------------------------------------------------+------------------+
| As noted earlier, lead paint is the major source  | CAMERA           |
| of lead exposure in the United States, especially |                  |
| for children. Lead was banned from paint in the   |                  |
| U.S. in 1978.                                     |                  |
|                                                   |                  |
| Even though leaded paint may have been covered    |                  |
| with non-leaded paint, it may still be released   |                  |
| into the home environment                         |                  |
|                                                   |                  |
| by peeling, chipping, chalking, friction, impact, |                  |
| or by home renovation.                            |                  |
+---------------------------------------------------+------------------+
| In fact, between 83 and 86% of all homes built in | ##### Sli        |
| the U.S. before 1978 have lead-based paint in     | de 8: Lead in ho |
| them. The older the house, the more likely it is  | me environments. |
| to contain lead-based paint and to have a higher  |                  |
| concentration of lead in the paint. Before 1955,  | ##### !          |
| most white house paint contained up to 50% lead.  | [](media/image8. |
|                                                   | wmf){width="1.66 |
| Many people think that children will be safe if   | 31944444444444in |
| they are prevented from eating paint chips.       | " height="1.3319 |
| Children with pica are certainly at higher risk.  | 444444444444in"} |
| However, significant blood lead elevations can    |                  |
| result from invisible, lead contaminated dust or  |                  |
| soil ingested through normal hand to mouth        |                  |
| behaviors.                                        |                  |
|                                                   |                  |
| As this slide shows, children may ingest leaded   |                  |
| paint, dust, or soil from many sources in their   |                  |
| homes. Windows, porches, and doors are usually    |                  |
| the most significant contributors of lead dust to |                  |
| the home environment.                             |                  |
|                                                   |                  |
| Playing in, or the tracking indoors of            |                  |
| contaminated exterior soil, can also be a major   |                  |
| source of lead exposure.                          |                  |
|                                                   |                  |
| Any home renovation that disturbs lead paint can  |                  |
| create hazardous levels of lead in dust that may  |                  |
| not be visible to the eye.                        |                  |
|                                                   |                  |
| The amount of dust in the home environment is     |                  |
| directly correlated with children's blood lead    |                  |
| levels. There is no safe threshold for lead.      |                  |
+---------------------------------------------------+------------------+
| Most adult exposures are occupational and occur   | ###              |
| in lead-related industries, through inhalation,   | ## Slide 9: How  |
| ingestion, and dermal contact with lead.          | are people expos |
|                                                   | ed to lead in Wo |
| If showers and a change of clothing are not       | rk Environments? |
| provided, workers can bring lead dust home on     |                  |
| their skin, shoes, and clothing, inadvertently    | ##### !          |
| exposing family members.                          | [](media/image9. |
|                                                   | wmf){width="1.66 |
| In addition to direct ingestion of lead dust      | 31944444444444in |
| during their work, workers may inhale lead dust   | " height="1.3319 |
| and lead oxide fumes, as well as eat, drink, and  | 444444444444in"} |
| smoke in or near contaminated areas, thereby      |                  |
| increasing their probability of lead ingestion.   |                  |
| Between point five and one point five million     |                  |
| workers are exposed to lead in the workplace.     |                  |
+---------------------------------------------------+------------------+
| Activities that involve lead include: lead        | ##### S          |
| smelting, refining, and manufacturing industries. | lide 10: What jo |
| Other jobs that may involve lead include:         | bs involve lead? |
| construction, automobile repair, plumbing,        |                  |
|                                                   | ##### ![         |
| printing, and work involving fire arms.           | ](media/image10. |
|                                                   | wmf){width="1.66 |
|                                                   | 31944444444444in |
|                                                   | " height="1.3319 |
|                                                   | 444444444444in"} |
+---------------------------------------------------+------------------+
| Adults can also be exposed during hobbies and     | CAMERA           |
| activities where lead is used. Certain hobbies,   |                  |
| home activities,                                  | (CHAPTER -- How  |
|                                                   | Exposure Occurs) |
+---------------------------------------------------+------------------+
| and car repairs, such as radiator repair, can     | ##### Slid       |
| contribute to lead exposure. Some common hobbies  | e 11: What hobbi |
| include glazed pottery                            | es involve Lead? |
|                                                   |                  |
| making; artistic painting; stained-glass making;  | ##### ![         |
| glass or metal soldering; target shooting;        | ](media/image11. |
| electronics soldering; and molding of bullets,    | wmf){width="1.66 |
| slugs, or fishing sinkers.                        | 31944444444444in |
|                                                   | " height="1.3319 |
| One frequent source of lead exposure is house     | 444444444444in"} |
| renovation that involves scraping, remodeling, or |                  |
| otherwise disturbing lead-based paint. Renovation |                  |
| involving lead-based paint should only be         |                  |
| undertaken after proper training.                 |                  |
+---------------------------------------------------+------------------+
| Lead occurs in drinking water through leaching    | Slide 12: Lead   |
| from lead-containing pipes, faucets, and solder,  | in drinking      |
| which can be found in the plumbing of older       | water.           |
| buildings. Other potential sources of lead        |                  |
| contamination include brass fixtures, older       | ![]              |
| drinking water coolers, and older coffee urns.    | (media/image12.w |
|                                                   | mf){width="1.663 |
| Leaching rates accelerate when water is acidic or | 1944444444444in" |
| hot, or when it\'s been standing in the pipes for | height="1.3319   |
| extended periods, such as overnight. Boiling      | 444444444444in"} |
| water will not get rid of lead. Flushing standing |                  |
| water from lines and faucets for a few minutes    |                  |
| before use, and using cold water for drinking may |                  |
| reduce exposure.                                  |                  |
+---------------------------------------------------+------------------+
| Lead is still used in commercial products, such   | ##### Slide      |
| as bridge paint, computers, solder, pewter, some  | 13: Lead in comm |
| ceramic glazes, jewelry, and automotive           | ercial products. |
| batteries.                                        |                  |
|                                                   | ##### ![         |
| While lead may be prohibited from many of these   | ](media/image13. |
| products in the U.S., imported or pre-regulation  | wmf){width="1.66 |
| products may still pose a risk.                   | 31944444444444in |
|                                                   | " height="1.3319 |
|                                                   | 444444444444in"} |
+---------------------------------------------------+------------------+
| Lead may also contaminate food or beverages       | Slide 14: Lead   |
| through production, packaging, or storage.        | in food          |
|                                                   | products.        |
| Production sources may include the uptake of lead |                  |
| from soil by root vegetables or atmospheric lead  | ![]              |
| deposition onto leafy vegetables. Homemade        | (media/image14.w |
| "moonshine" that was distilled and/or stored in   | mf){width="1.663 |
| leaded containers is another example of a         | 1944444444444in" |
| production source.                                | height="1.3319   |
|                                                   | 444444444444in"} |
| Packaging may also pose a risk. Until the         |                  |
| phase-out in the United States of lead-soldered   |                  |
| food cans during the 1980s, canned food was the   |                  |
| major source of lead in our diet. Although some   |                  |
| plastic food wrappers may be printed with         |                  |
| lead-containing pigments, and although some food  |                  |
| cans produced and sold in foreign countries may   |                  |
| be lead-soldered, the amount of lead in the       |                  |
| American diet has declined substantially.         |                  |
|                                                   |                  |
| Storage or serving of food or beverages in        |                  |
| lead-containing vessels may cause contamination,  |                  |
| including some ceramic tableware, especially if   |                  |
| it\'s imported, as well as leaded-crystal         |                  |
| glassware.                                        |                  |
+---------------------------------------------------+------------------+
| Lead-glazed pottery, particularly if it\'s        | CAMERA           |
| imported, is a potential source of exposure       |                  |
| that\'s often overlooked. Even \"safe\" pottery   |                  |
| and ceramic-ware can become harmful to human      |                  |
| health. For example, dishwashing may chip or wear |                  |
| off the protective glaze and expose people to     |                  |
| lead-containing pigments.                         |                  |
|                                                   |                  |
| Certain ethnic groups may use products that       |                  |
| contain lead. Examples include some remedies and  |                  |
| cosmetics of Mexican, Asian, and Middle Eastern   |                  |
| origin.                                           |                  |
+---------------------------------------------------+------------------+
| Azarcon and greta, which are Mexican folk         | Slide 15: Lead   |
| remedies used to treat the colic-like illness     | in Ethnic        |
| \"empacho,\" may contain lead. Azarcon and greta  | products.        |
| are also known as: liga, Maria Luisa, alarcon,    |                  |
| coral,and rueda.                                  | ![]              |
|                                                   | (media/image15.w |
| Lead containing remedies used by some Asian       | mf){width="1.663 |
| communities include chuifong, tokuwan, ghasard,   | 1944444444444in" |
| bali goli, kandu, surma, and ba-baw-san.          | height="1.3319   |
|                                                   | 444444444444in"} |
| Middle Eastern remedies and cosmetics include:    |                  |
| alkohl, saoott, and cebagin.                      |                  |
|                                                   |                  |
| A web site has been provided on the slide where   |                  |
| you may go to find more listings.                 |                  |
+---------------------------------------------------+------------------+
| Because of widespread human use of lead, lead is  | Slide 16: Lead   |
| ubiquitous in the environment. These background   | in the           |
| levels vary, depending on historic uses in the    | environment.     |
| area. The past use of lead in gasoline has        |                  |
| contaminated soil, especially along roadways.     | ![]              |
|                                                   | (media/image16.w |
| Industries, such as mining and lead smelting,     | mf){width="1.663 |
| have also contributed to high levels of lead in   | 1944444444444in" |
| the soil, water, and air around such facilities.  | height="1.3319   |
| This applies to both present-day and historic     | 444444444444in"} |
| facilities.                                       |                  |
|                                                   |                  |
| Smaller businesses, such as auto repair shops,    |                  |
| can contribute to elevations of lead in adjacent  |                  |
| areas.                                            |                  |
+---------------------------------------------------+------------------+
| While children's lead levels have declined in     | CAMERA           |
| recent decades, children who reside in housing    |                  |
| built before 1978, particularly those in the      | (CHAPTER -- How  |
| inner cities or those built before the 1950s are  | Lead Effects The |
| at greater risk.                                  | Body)            |
|                                                   |                  |
| These children are more likely to be poor and     |                  |
| from racial or ethnic minority groups.            |                  |
+---------------------------------------------------+------------------+
| Because of their behavior and physiology,         | Slide 17: Who is |
| children are more affected by exposure to lead    | most at risk of  |
| than adults. For example, children generally      | lead exposure?   |
| ingest lead-contaminated soil and house dust at   |                  |
| higher rates than adults because of mouthing and  | ![]              |
| hand-to-mouth behaviors. This is especially true  | (media/image17.w |
| for children who exhibit pica, a compulsive       | mf){width="1.663 |
| hand-to-mouth behavior and repeated eating of     | 1944444444444in" |
| nonfood items.                                    | height="1.3319   |
|                                                   | 444444444444in"} |
| Being closer to the ground than adults, children  |                  |
| also breathe lead-contaminated dust and soil, as  |                  |
| well as fumes or vapors that are close to the     |                  |
| ground, and they ingest more food and water than  |                  |
| adults per body weight.                           |                  |
|                                                   |                  |
| Although children are at greater risk for harmful |                  |
| health effects from lead exposure, adult          |                  |
| exposures can also result in harmful effects.     |                  |
|                                                   |                  |
| Pregnant women and developing fetuses are also at |                  |
| risk. The mother\'s blood lead level is an        |                  |
| important indication of risk to the fetus. In     |                  |
| addition, mothers who had exposure to lead in the |                  |
| past may store lead in their bones. Lead may be   |                  |
| released from bones during times of calcium       |                  |
| stress, such as pregnancy and lactation.          |                  |
+---------------------------------------------------+------------------+
| Now let\'s talk about what happens when lead is   | CAMERA           |
| absorbed.                                         |                  |
+---------------------------------------------------+------------------+
| Most of the lead that\'s absorbed is excreted     | Slide 18:        |
| through urine or through biliary clearance in the | Biologic Fate.   |
| feces. The absorption and biologic fate of lead,  |                  |
| once it enters the human body, depends on a       | ![]              |
| variety of factors, including nutritional status, | (media/image18.w |
| health, and age.                                  | mf){width="1.663 |
|                                                   | 1944444444444in" |
| Children and pregnant women absorb more of the    | height="1.3319   |
| lead they ingest than others. They can absorb up  | 444444444444in"} |
| to seventy percent of ingested lead, whereas      |                  |
| nonpregnant females and male adults typically     |                  |
| absorb up to twenty percent.                      |                  |
|                                                   |                  |
| Absorbed lead is exchanged between blood, soft    |                  |
| tissues, and mineralizing tissues. Although the   |                  |
| blood generally carries only a small fraction of  |                  |
| total lead body burden, it does serve as the      |                  |
| initial receptacle of absorbed lead and           |                  |
| distributes lead throughout the body, making it   |                  |
| available to other tissues (or for excretion).    |                  |
|                                                   |                  |
| Blood lead is also important because the BLOOD    |                  |
| LEAD LEVEL is the most widely used measure of     |                  |
| lead exposure. The half-life of lead in adult     |                  |
| human blood has been estimated to be 28 days.     |                  |
+---------------------------------------------------+------------------+
| The brain is also a site of distribution. Lead in | CAMERA           |
| soft tissues has an approximate half-life of 40   |                  |
| days.                                             |                  |
|                                                   |                  |
| Under certain circumstances the lead will leave   |                  |
| the bones and reenter the blood and soft tissue   |                  |
| organs. Bone-to-blood lead mobilization increases |                  |
| during periods of pregnancy, lactation,           |                  |
| menopause, physiologic stress, chronic disease,   |                  |
| hyperthyroidism, kidney disease, broken bones,    |                  |
| and advanced age, which is exacerbated by calcium |                  |
| deficiency.                                       |                  |
|                                                   |                  |
| Consequently, the normally inert pool of stored   |                  |
| lead poses a special risk because it is a         |                  |
| potential endogenous source of lead that can      |                  |
| maintain blood lead levels long after exposure    |                  |
| has ended.                                        |                  |
+---------------------------------------------------+------------------+
| Lead serves no useful purpose in the human body,  | Slide 19:        |
| but its presence in the body can lead to toxic    | Physiologic      |
| effects, regardless of exposure pathway. Lead     | Effects of Lead. |
| toxicity can affect every organ system. It must   |                  |
| be emphasized that, for children, there may be no | ![]              |
| threshold for developmental effects.              | (media/image19.w |
|                                                   | mf){width="1.663 |
| While the immediate health effect of concern in   | 1944444444444in" |
| children is typically neurologic, it is important | height="1.3319   |
| to remember that childhood lead poisoning can     | 444444444444in"} |
| lead to health effects later in life including    |                  |
|                                                   |                  |
| renal effects, hypertension, reproductive         |                  |
| effects, and developmental problems in offspring. |                  |
| These effects may occur as a result of lead       |                  |
| exposure as an adult, but usually from higher     |                  |
| (such as occupational) levels than those levels   |                  |
| that affect children.                             |                  |
+---------------------------------------------------+------------------+
| The nervous system is the most sensitive target   | CAMERA           |
| of lead exposure. Because otherwise asymptomatic  |                  |
| individuals may experience neurological effects   |                  |
| from lead exposure, clinicians should have a high |                  |
| index of suspicion for lead exposure, especially  |                  |
| in the case of children.                          |                  |
+---------------------------------------------------+------------------+
| Children may suffer neurological effects at low   | ##### Slide      |
| exposure doses, including a decrement in IQ       |  20: Neurologic  |
| performance and other neuropsychologic defects.   | Effects of Lead. |
| Some studies have found, for example, that for    |                  |
| every 10 mcg/dL increase in BLOOD LEAD LEVEL,     | ##### ![         |
| children's IQs fell four to seven points.         | ](media/image20. |
|                                                   | wmf){width="1.66 |
| There is also evidence that attention deficit     | 31944444444444in |
| hyperactivity disorder or (ADHD) and hearing      | " height="1.3319 |
| impairment in children increase with increasing   | 444444444444in"} |
| BLOOD LEAD LEVEL, and that lead exposure may      |                  |
| disrupt balance and impair peripheral nerve       |                  |
| function.                                         |                  |
|                                                   |                  |
| In children, a high lead exposure dose may        |                  |
| produce encephalopathy and other attendant signs  |                  |
| such as hyperirritability, ataxia, convulsions,   |                  |
| stupor, coma and death. Some of the neurological  |                  |
| effects of lead in children may persist into      |                  |
| adulthood.                                        |                  |
|                                                   |                  |
| The BLOOD LEAD Levels associated with             |                  |
| encephalopathy in children vary from study to     |                  |
| study, but BLOOD LEAD Levels of 70 to 80          |                  |
| micrograms per deciliter or greater appear to     |                  |
| indicate a serious risk.                          |                  |
|                                                   |                  |
| Adults with current lead exposure may have        |                  |
| similar neurologic effects to children, but       |                  |
| normally these occur at higher exposure dose      |                  |
| levels. Slowed nerve conduction and forearm       |                  |
| extensor weakness (or wrist drop), as late signs  |                  |
| of lead intoxication, are more classic signs in   |                  |
| workers chronically exposed to high lead levels.  |                  |
+---------------------------------------------------+------------------+
| Acute, high dose lead-induced impairment of       | #####            |
| proximal tubular function manifests in            | Slide 21: Renal  |
| aminoaciduria, glycosuria, and hyperphosphaturia  | Effects of Lead. |
| (a Fanconi-like syndrome); these effects appear   |                  |
| to be reversible. However, continued or           | ##### ![         |
| repetitive exposures can cause a toxic stress on  | ](media/image21. |
| the kidney that, if unrelieved, may develop into  | wmf){width="1.66 |
| chronic and often irreversible lead nephropathy   | 31944444444444in |
| (for example, chronic interstitial nephritis).    | " height="1.3319 |
|                                                   | 444444444444in"} |
| Some chronic advanced renal disease or decrement  |                  |
| in renal function may be caused by latent effects |                  |
| of lead exposure that occurred years earlier in   |                  |
| childhood.                                        |                  |
+---------------------------------------------------+------------------+
| Because past or ongoing excessive lead exposure   | CAMERA           |
| may also be a causative agent in kidney disease   |                  |
| associated with essential hypertension, primary   |                  |
| care providers should follow closely the renal    |                  |
| function of patients with hypertension and a past |                  |
| history of lead exposure.                         |                  |
+---------------------------------------------------+------------------+
| Lead inhibits the body\'s ability to make         | Slide 22:        |
| hemoglobin by interfering with several enzymatic  | Hematologic      |
| steps in the heme pathway.                        | Effects of Lead. |
|                                                   |                  |
| Lead can induce two types of anemia, often        | ![]              |
| accompanied by basophilic stippling of the        | (media/image22.w |
| erythrocytes.                                     | mf){width="1.663 |
|                                                   | 1944444444444in" |
| • First, Acute, high-dose lead exposure has been  | height="1.3319   |
| associated                                        | 444444444444in"} |
|                                                   |                  |
| with hemolytic anemia.                            |                  |
|                                                   |                  |
| • In chronic lead exposure, lead induces anemia   |                  |
| by both interfering with heme biosynthesis and by |                  |
| diminishing red blood cell survival.              |                  |
+---------------------------------------------------+------------------+
| Studies of children with high lead exposure have  | ##### Slid       |
| found that a strong inverse correlation exists    | e 23: Endocrine  |
| between BLOOD LEAD LEVEL and vitamin D levels.    | Effects of Lead. |
| Lead impedes vitamin D conversion into its        |                  |
| hormonal form, 1,25-dihydroxyvitamin D, which is  | ##### ![         |
| largely responsible for the maintenance of extra- | ](media/image23. |
|                                                   | wmf){width="1.66 |
| and intra-cellular calcium homeostasis.           | 31944444444444in |
|                                                   | " height="1.3319 |
| Minimizing lead exposure, and assuring sufficient | 444444444444in"} |
| calcium in the diet throughout all stages of      |                  |
| life, can help individual patients to ensure peak |                  |
| bone densities and diminish osteoporosis risk     |                  |
| factors.                                          |                  |
|                                                   |                  |
| The effects of lead exposure on thyroid function  |                  |
| have been examined in occupationally exposed      |                  |
| adult workers and in children.                    |                  |
+---------------------------------------------------+------------------+
| Hypertension is a complex condition with many     | CAMERA           |
| different causes and risk factors, including age, |                  |
| weight, diet, and exercise habits.                |                  |
+---------------------------------------------------+------------------+
| Lead exposure is one factor of many that may      | Slide 24:        |
| contribute to the onset and development of        | Cardiovascular   |
| hypertension.                                     | Effects of Lead. |
|                                                   |                  |
| Although low lead level exposures (resulting in   | ![]              |
| BLOOD LEAD LEVELs \<30 micrograms per deciliter)  | (media/image24.w |
| show less of an association with hypertension,    | mf){width="1.663 |
| studies show that greater lead level exposures    | 1944444444444in" |
| (primarily occupational) increase the risk for    | height="1.3319   |
| hypertensive heart disease and cerebrovascular    | 444444444444in"} |
| disease as latent effects.                        |                  |
|                                                   |                  |
| On a population basis, this could increase the    |                  |
| incidence of hypertension a substantial amount,   |                  |
| due to the high prevalence of hypertension of all |                  |
| causes in general populations.                    |                  |
+---------------------------------------------------+------------------+
| Lead readily crosses the placenta and             | ##### Slide 25   |
| developmental effects include pregnancy outcomes  | : Developmental  |
| (such as premature births and                     | Effects of Lead. |
|                                                   |                  |
| low birth weights), congenital abnormalities, and | ##### ![         |
| post birth effects on growth or neurologic        | ](media/image25. |
| development.                                      | wmf){width="1.66 |
|                                                   | 31944444444444in |
| In a retrospective study, a higher proportion of  | " height="1.3319 |
| learning disabilities were found among            | 444444444444in"} |
| school-aged children with biological parents who  |                  |
| were lead poisoned as children 50 years           |                  |
| previously.                                       |                  |
|                                                   |                  |
| This suggests that the children of parents who    |                  |
| experienced overt lead poisoning as children      |                  |
| could be at greater risk for neurologic           |                  |
| development impairment.                           |                  |
+---------------------------------------------------+------------------+
| I have discussed what lead is, who is at risk for | CAMERA           |
| exposure, and the health effects that are         |                  |
| associated with lead, I will now discuss what     | (CHAPTER --      |
| happens in the clinical setting. As you know,     | Determining If   |
| lead toxicity is irreversible. However, an early  | Lead Exposure    |
| and accurate diagnosis can greatly improve the    | Has Occurred)    |
| patient's prognosis.                              |                  |
+---------------------------------------------------+------------------+
| Because lead poisoning is often asymptomatic,     | ####             |
| preventive screening is very important. This      | # Slide 26: Clin |
| includes asking questions to evaluate the risk of | ical Evaluation. |
| lead exposure and, if indicated, blood sampling.  |                  |
|                                                   | ##### ![         |
| Whether a patient has been exposed to lead but is | ](media/image26. |
| asymptomatic, or the patient is already           | wmf){width="1.66 |
| exhibiting symptoms that may be related to a past | 31944444444444in |
| or current exposure, it is important to perform a | " height="1.3319 |
| thorough exposure history and physical            | 444444444444in"} |
| evaluation.                                       |                  |
|                                                   |                  |
| In order to correctly interpret the physical      |                  |
| evaluation, it is important to be familiar with   |                  |
| the signs and symptoms of lead poisoning and the  |                  |
| lead exposure history.                            |                  |
+---------------------------------------------------+------------------+
| Because lead poisoning is often asymptomatic,     | #####            |
| recognition of lead exposure often depends on the |  Slide 27: Preve |
| initial reporting of high BLOOD LEAD Levels by    | ntive Screening. |
| primary care providers.                           |                  |
|                                                   | ##### ![         |
| In the case of children, CDC recommends that      | ](media/image27. |
| states develop statewide plans for BLOOD LEAD     | wmf){width="1.66 |
| LEVEL screening. Contact your state or local      | 31944444444444in |
| health department to see if your state has a lead | " height="1.3319 |
| screening plan.                                   | 444444444444in"} |
|                                                   |                  |
| In the absence of a local plan, CDC recommends    |                  |
| screening at one and two years of age, and        |                  |
| annually up to age 6 if there is an identified    |                  |
| lead risk.                                        |                  |
|                                                   |                  |
| For occupationally exposed adults, consult the    |                  |
| federal lead standard for the mandated type and   |                  |
| frequency of lead screening.                      |                  |
|                                                   |                  |
| Asking lead exposure risk questions through an    |                  |
| environmental exposure history can assist you in  |                  |
| determining if a child or adult has been exposed  |                  |
| to lead in the environment.                       |                  |
+---------------------------------------------------+------------------+
| In the absence of health department guidance on   | CAMERA           |
| screening, the first step in identifying          |                  |
| individuals with potential lead exposure is to    |                  |
| determine through appropriate questioning whether |                  |
| or not any of the typical lead exposure pathways  |                  |
| are cause for heightened concern. Many health     |                  |
| departments can provide physicians with personal  |                  |
| risk or lead exposure history questionnaires      |                  |
| and/or localized risk information to help in this |                  |
| process.                                          |                  |
+---------------------------------------------------+------------------+
| Some of the issues a physician might discuss with | ##### Slide 28   |
| the patient and/or family include the patient's   | : Environmental  |
| location, age, the physical condition of current  | Exposure History |
| and past residences, schools, day-care centers as |                  |
| applicable, to identify potential for lead paint  | ##### ![         |
| exposure as well as proximity to industrial       | ](media/image28. |
| facilities, hazardous waste sites, and other      | wmf){width="1.66 |
| potential lead sources.                           | 31944444444444in |
|                                                   | " height="1.3319 |
| It is also important to ask about any home        | 444444444444in"} |
| remodeling activities current or past. Questions  |                  |
| about the occupations and hobbies of all home     |                  |
| occupants should also be included. In addition,   |                  |
| the patient's family history, including the       |                  |
| possibility of maternal/family lead exposure and  |                  |
| the potential use of unusual medicines or home    |                  |
| remedies should be asked.                         |                  |
|                                                   |                  |
| Other questions to ask relate to the use of       |                  |
| imported or glazed ceramics and leaded crystal.   |                  |
| If your patient is a child, have any of their     |                  |
| siblings or playmates been diagnosed with lead    |                  |
| poisoning?                                        |                  |
|                                                   |                  |
| If any of these questions indicate a risk of lead |                  |
| exposure, a blood test should be ordered.         |                  |
+---------------------------------------------------+------------------+
| In addition to the environmental and family       | #####            |
| exposure history and BLOOD LEAD LEVEL screening   |  Slide 29: Physi |
| just mentioned, physicians should conduct a       | cal Examination. |
| complete physical examination of patients with    |                  |
| potential exposure to lead. It is important to    | ##### ![         |
| keep in mind, however, that even a complete       | ](media/image29. |
| physical examination may not identify subtle      | wmf){width="1.66 |
| neurological effects that may be associated with  | 31944444444444in |
| low-dose lead exposure in children.               | " height="1.3319 |
|                                                   | 444444444444in"} |
| The physical examination should include special   |                  |
| attention to the                                  |                  |
|                                                   |                  |
| • neurologic,                                     |                  |
|                                                   |                  |
| • hematologic,                                    |                  |
|                                                   |                  |
| • cardiovascular,                                 |                  |
|                                                   |                  |
| • gastrointestinal,                               |                  |
|                                                   |                  |
| • and renal systems.                              |                  |
|                                                   |                  |
| The health care provider should be certain to     |                  |
| check blood pressure to evaluate whether the      |                  |
| patient is hypertensive and pay special attention |                  |
| to the renal system in those who are positive for |                  |
| hypertension. Careful evaluation of the nervous   |                  |
| system, including behavioral changes should be    |                  |
| noted. In addition, check for a purplish or       |                  |
| blue/black line on the gingival tissues also      |                  |
| known as the (lead line). This is rarely seen     |                  |
| today, but if present, usually indicates severe   |                  |
| and prolonged lead poisoning.                     |                  |
|                                                   |                  |
| For children the physical exam should include:    |                  |
| hearing, speech, and other developmental          |                  |
| milestones, in addition to the nutritional        |                  |
| status, which should be carefully evaluated and   |                  |
| documented. When the neurologic exam, milestones, |                  |
| or behavior suggest it, further neurobehavioral   |                  |
| testing, or evaluation for ADHD, may be           |                  |
| indicated.                                        |                  |
|                                                   |                  |
| Since iron and calcium deficiencies are known to  |                  |
| enhance the absorption of lead and to aggravate   |                  |
| pica, it is especially important to assess the    |                  |
| nutritional status of young children.             |                  |
+---------------------------------------------------+------------------+
| Most patients who suffer from lead poisoning are  | ###              |
| asymptomatic, hence the importance of exposure    | ## Slide 30: Sig |
| assessment and screening. There is a continuum of | ns and Symptoms. |
| signs and symptoms depending on the level and     |                  |
| duration of lead exposure (or lead exposure       | ##### ![         |
| dose). Because of differences in individual       | ](media/image30. |
| susceptibility, symptoms of lead exposure and     | wmf){width="1.66 |
| their onset may vary.                             | 31944444444444in |
|                                                   | " height="1.3319 |
| At the lowest lead exposure dose, patients may    | 444444444444in"} |
| appear asymptomatic with impaired abilities. This |                  |
| may occur at BLOOD LEAD LEVELs ranging from 10 to |                  |
| 25 micrograms per deciliter and may include:      |                  |
| decreased learning and memory; lowered IQ,        |                  |
| decreased verbal ability, impaired speech and     |                  |
| hearing functions; and early signs of             |                  |
| hyperactivity or ADHD. The symptoms vary by       |                  |
| exposure level.                                   |                  |
+---------------------------------------------------+------------------+
| In symptomatic lead intoxication, BLOOD LEAD      | Slide 31: Signs  |
| LEVELs generally range from thirty five to fifty  | and Symptoms:    |
| micrograms per deciliter in children and forty to | low toxicity.    |
| sixty micrograms per deciliter in adults.         |                  |
|                                                   | ![]              |
| At low lead exposure dose, symptoms may include:  | (media/image31.w |
|                                                   | mf){width="1.663 |
| • myalgia or paresthesia,                         | 1944444444444in" |
|                                                   | height="1.3319   |
| • mild fatigue                                    | 444444444444in"} |
|                                                   |                  |
| • irritability                                    |                  |
|                                                   |                  |
| • lethargy, and                                   |                  |
|                                                   |                  |
| • occasional abdominal discomfort.                |                  |
+---------------------------------------------------+------------------+
| Signs and symptoms of moderate lead exposure dose | Slide 32: Signs  |
| may include:                                      | and Symptoms:    |
|                                                   | moderate         |
| • arthralgia,                                     | toxicity.        |
|                                                   |                  |
| • general fatigue,                                | ![]              |
|                                                   | (media/image32.w |
| • difficulty concentrating,                       | mf){width="1.663 |
|                                                   | 1944444444444in" |
| • muscular exhaustibility,                        | height="1.3319   |
|                                                   | 444444444444in"} |
| • tremor,                                         |                  |
|                                                   |                  |
| • headache,                                       |                  |
|                                                   |                  |
| • diffuse abdominal pain,                         |                  |
|                                                   |                  |
| • vomiting,                                       |                  |
|                                                   |                  |
| • weight loss, and                                |                  |
|                                                   |                  |
| • constipation.                                   |                  |
+---------------------------------------------------+------------------+
| High exposure dose is frequently found in         | CAMERA           |
| association with BLOOD LEAD LEVELs of seventy     |                  |
| micrograms per deciliter or more in children and  |                  |
| one hundred micrograms per deciliter or more in   |                  |
| adults.                                           |                  |
|                                                   |                  |
| Signs and symptoms may include:                   |                  |
+---------------------------------------------------+------------------+
| • paresis or paralysis,                           | Slide 33: Signs  |
|                                                   | and Symptoms:    |
| • encephalopathy which may abruptly lead to       | severe toxicity. |
| seizures,                                         |                  |
|                                                   | ![]              |
| • changes in consciousness,                       | (media/image33.w |
|                                                   | mf){width="1.663 |
| • coma, and death,                                | 1944444444444in" |
|                                                   | height="1.3319   |
| • presence of a lead line, and                    | 444444444444in"} |
|                                                   |                  |
| • colic (or intermittent, severe abdominal        |                  |
| cramps).                                          |                  |
|                                                   |                  |
| Keep in mind that the signs and symptoms          |                  |
| generally relate to exposure dose levels but may  |                  |
| also appear at variance with these designations.  |                  |
|                                                   |                  |
| The importance for the clinician is to recognize  |                  |
| ongoing lead exposure, stop that exposure, and    |                  |
| treat the patient as appropriate.                 |                  |
+---------------------------------------------------+------------------+
| Now let's look at biologic testing. I will be     | CAMERA           |
| discussing biologic indicators of exposure and    |                  |
| biologic indicators of effect from lead exposure. | (CHAPTER --      |
|                                                   | Tests to         |
|                                                   | Determine Level  |
|                                                   | of Exposure)     |
+---------------------------------------------------+------------------+
| Venous BLOOD LEAD LEVEL testing is the most       | Slide 34:        |
| useful screening and diagnostic test for recent   | Laboratory       |
| or ongoing lead exposure as opposed to past       | Tests.           |
| exposures. Given the greater risk of              |                  |
| contamination using the finger-stick method, an   | ![]              |
| elevated BLOOD LEAD LEVEL obtained by             | (media/image34.w |
| finger-stick should always be confirmed through   | mf){width="1.663 |
| venipuncture.                                     | 1944444444444in" |
|                                                   | height="1.3319   |
| BLOOD LEAD LEVELs respond quickly to abrupt or    | 444444444444in"} |
| intermittent changes in lead intake.              |                  |
|                                                   |                  |
| For individuals with high or chronic past         |                  |
| exposure, however, BLOOD LEAD LEVELs often        |                  |
| under-represent the total body burden because     |                  |
| most lead is stored in the bone. In some cases,   |                  |
| Blood lead levels may even be "normal".           |                  |
|                                                   |                  |
| For higher exposure levels, the Erythrocyte       |                  |
| protoporphyrin                                    |                  |
|                                                   |                  |
| (also called EP) may be useful. EP, which is      |                  |
| commonly assayed as zinc protoporphyrin (or ZPP), |                  |
| was previously considered the best test for       |                  |
| screening for asymptomatic children. However, the |                  |
| ZPP assay is not sufficiently sensitive at lower  |                  |
| BLOOD LEAD LEVELs and therefore is not as useful  |                  |
| a screening test for lead exposure as previously  |                  |
| thought.                                          |                  |
+---------------------------------------------------+------------------+
| Lab testing may also appropriately include        | CAMERA           |
| biologic markers of effect, such as renal         |                  |
| function or secondary testing, such as a          |                  |
| neurobehavioral and psychological evaluation for  |                  |
| children with indicative findings on exam.        |                  |
|                                                   |                  |
| In lead-exposed patients, the hemocrit and        |                  |
| hemoglobin values may be slightly to moderately   |                  |
| low in the complete blood count or CBC, and the   |                  |
| peripheral smear may be either normochromic/      |                  |
| normocytic or hypochromic/microcytic.             |                  |
+---------------------------------------------------+------------------+
| There may be basophilic stippling in patients who | Slide 35:        |
| have been significantly poisoned for a prolonged  | Complete Blood   |
| period. However, because these results are not    | Count.           |
| specific to lead exposure, the CBC test is not as |                  |
| valuable for detecting lead exposure as is the    | ![]              |
| BLOOD LEAD LEVEL and ZPP assays.                  | (media/image35.w |
|                                                   | mf){width="1.663 |
| In addition, a hypochromic, microcytic anemia     | 1944444444444in" |
| should be appropriately differentiated from other | height="1.3319   |
| causes of anemia, especially iron-deficiency      | 444444444444in"} |
| anemia, by the use of testing for iron, iron      |                  |
| binding capacity, and ferritin.                   |                  |
+---------------------------------------------------+------------------+
| Abdominal radiographs may show the presence of    | Slide 36:        |
| radiodense lead foreign bodies in the             | Abdominal        |
| gastrointestinal tract. These are helpful only in | radiographs.     |
| cases of acute ingestion of lead sinkers, curtain |                  |
| weights, jewelry, or paint chips or unusual       | ![]              |
| persistence of high blood lead values.            | (media/image36.w |
|                                                   | mf){width="1.663 |
| The picture on the right was taken in 2004 and    | 1944444444444in" |
| shows a radiograph of a child who had swallowed a | height="1.3319   |
| pendant containing lead. The child's blood lead   | 444444444444in"} |
| level was over twenty micrograms per deciliter,   |                  |
| but no environmental sources could be found.      |                  |
|                                                   |                  |
| This radiograph was able to detect the source of  |                  |
| ongoing lead exposure.                            |                  |
+---------------------------------------------------+------------------+
| Longbone radiographs may show the presence of     | Slide 37:        |
| "lead lines" which are denser areas of bone near  | Longbone         |
| the growth plate. Lead lines indicate prolonged   | radiographs.     |
| exposure to lead while growing. This radiograph   |                  |
| shows "Lead Lines" in a five year old male with   | ![]              |
| radiological growth retardation and a blood lead  | (media/image37.w |
| level of thirty seven point seven micrograms per  | mf){width="1.663 |
| deciliter.                                        | 1944444444444in" |
|                                                   | height="1.3319   |
|                                                   | 444444444444in"} |
+---------------------------------------------------+------------------+
| This x-ray shows "Lead Lines" in a three-year old | Slide 38:        |
| girl with a Blood lead level of ten point six     | Longbone         |
| micrograms per deciliter.                         | radiographs.     |
|                                                   |                  |
| Notice the increased density on the metaphysis    | ![]              |
| growth plate of the knee.                         | (media/image38.w |
|                                                   | mf){width="1.663 |
|                                                   | 1944444444444in" |
|                                                   | height="1.3319   |
|                                                   | 444444444444in"} |
+---------------------------------------------------+------------------+
| The CDC currently considers children to have an   | Slide 39: U.S.   |
| elevated level of lead if their BLOOD LEAD LEVEL  | Standards for    |
| is ten micrograms per deciliter or higher. In     | Lead.            |
| many states, there is a requirement for reporting |                  |
| BLOOD LEAD LEVELs over ten micrograms per         |                  |
| deciliter to the local or state health            |                  |
| department. As mentioned earlier, however, health |                  |
| effects of lead have been shown to occur below    |                  |
| this level.                                       |                  |
|                                                   |                  |
| For adults in the workplace, OSHA considers an    |                  |
| average BLOOD LEAD LEVEL of fifty micrograms per  |                  |
| deciliter as cause for removal from the job and a |                  |
| BLOOD LEAD LEVEL of forty micrograms per          |                  |
| deciliter as cause for mandatory notification.    |                  |
+---------------------------------------------------+------------------+
| An attempt should be made to identify and         | CAMERA           |
| minimize lead exposures when BLOOD LEAD LEVELs    |                  |
| indicate that they are occurring at any blood     | (CHAPTER --      |
| lead level above background population levels.    | Treatment and    |
|                                                   | Instructions For |
| The average BLOOD LEAD LEVEL for children 1 to 5  | Patients)        |
| years of age was two point seven micrograms per   |                  |
| deciliter from 1991 to 1994. The average BLOOD    |                  |
| LEAD LEVEL for adults eighteen to seventy four    |                  |
| years of age, from 1988 to 1991, was three        |                  |
| micrograms per deciliter.                         |                  |
|                                                   |                  |
| It\'s important to remember that the average      |                  |
| population BLOOD LEAD LEVEL may vary from place   |                  |
| to place, depending on the extent of              |                  |
| environmental lead in that area.                  |                  |
+---------------------------------------------------+------------------+
| In general, the most important management tool    | Slide 40:        |
| for lead-associated health effects is to remove   | Clinical         |
| the source of                                     | Management.      |
|                                                   |                  |
| lead exposure. It\'s important to refer patients  |                  |
| to local or state health departments which can    |                  |
| help determine the sources of lead exposure.      |                  |
|                                                   |                  |
| Health departments often provide environmental    |                  |
| investigations for children with elevated blood   |                  |
| lead levels. These may include looking for lead   |                  |
| hazards in their homes and other places where     |                  |
| they spend time. If this isn\'t offered, refer    |                  |
| patients to private risk assessors or information |                  |
| on home lead hazards, available from health       |                  |
| departments or agencies such as the U.S.          |                  |
| Department of Housing and Urban Development.      |                  |
|                                                   |                  |
| Health departments can also help patients by      |                  |
| looking for other sources of lead exposure, such  |                  |
| as ceramics with leaded glaze, home remedies, or  |                  |
| foods containing lead, and family members'        |                  |
| occupations or hobbies.                           |                  |
|                                                   |                  |
| Health departments can also provide education.    |                  |
| Patients with elevated BLOOD LEAD LEVELs, and     |                  |
| their families, should receive education about    |                  |
| the potential health effects of lead exposure,    |                  |
| environmental and behavioral interventions to     |                  |
| reduce potential for lead exposure, and the       |                  |
| importance of good nutrition in reducing the      |                  |
| absorption and effects of lead.                   |                  |
|                                                   |                  |
| Health departments can often furnish educational  |                  |
| materials to health-care providers, and many      |                  |
| times have an established program for education   |                  |
| and coordination of care and case management.     |                  |
+---------------------------------------------------+------------------+
| In addition to education and aggressive           | ##               |
| intervention, chelation may be indicated for      | ### Slide 41: Ch |
| children with blood lead levels over forty        | elation Therapy. |
| micrograms per deciliter.                         |                  |
|                                                   |                  |
| Because there are potential side effects          |                  |
| associated with each chelation drug, and because  |                  |
| treatment protocols differ for each, it is vital  |                  |
| that physicians with experience in chelation      |                  |
| therapy be consulted before any chelation therapy |                  |
| is begun.                                         |                  |
|                                                   |                  |
| An accredited regional poison control center, a   |                  |
| university medical center, or a state or local    |                  |
| health department can help identify an            |                  |
| experienced physician.                            |                  |
+---------------------------------------------------+------------------+
| Now, what to tell your patients. People who are   | CAMERA           |
| exposed to lead may be exposed through a variety  |                  |
| of sources, including deteriorating paint or      |                  |
| contaminated soil, water, or other products.      |                  |
|                                                   |                  |
| There may be multiple sources of exposure.        |                  |
| Therefore, it\'s important to encourage patients  |                  |
| to address all potential sources of lead and to   |                  |
| continue blood lead monitoring to help confirm    |                  |
| that the source or sources have been effectively  |                  |
| eliminated. In all cases,                         |                  |
+---------------------------------------------------+------------------+
| patients should be advised to: reduce sources of  | Slide 42:        |
| lead exposure, consume a diet high in calcium and | Instructions to  |
| iron, and continue to monitor BLOOD LEAD LEVELS.  | Patients.        |
|                                                   |                  |
| If a patient is concerned about exposure to lead  |                  |
| at work, they should talk to their employer's     |                  |
| health and safety officer about removal from      |                  |
| exposure. They may also contact OSHA.             |                  |
+---------------------------------------------------+------------------+
| Patients also need to understand when and why     | CAMERA           |
| they should call you for further medical          |                  |
| attention. In particular, they should know to     |                  |
| have their blood lead monitored on an ongoing     |                  |
| basis to confirm removal from the source of       |                  |
| exposure.                                         |                  |
|                                                   |                  |
| The Agency for Toxic Substances and Disease       |                  |
| Registry has developed a patient education sheet  |                  |
| on lead toxicity that can help you explain this   |                  |
| to patients. I will provide the web link to       |                  |
| obtain this and other related products and        |                  |
| information at the end of the program.            |                  |
+---------------------------------------------------+------------------+
| If your patient lives in a home built before      | Slide 43:        |
| 1978, advise them to consider the following:      | Instructions to  |
|                                                   | Patients with    |
| • test for lead hazards,                          | pre-1978 homes.  |
|                                                   |                  |
| • assume the paint has lead,                      |                  |
|                                                   |                  |
| • make sure all paint is in good condition, and   |                  |
|                                                   |                  |
| • fix lead paint hazards safely.                  |                  |
+---------------------------------------------------+------------------+
| In addition, they should use "lead-safe" work     | Slide 44:        |
| practices when disturbing paint, which includes   | Instructions to  |
| "working wet", containing dust and debris,        | Patients with    |
| keeping the children away, using proper equipment | pre-1978 homes,  |
| and materials, and using specialized clean up and | Con't.           |
| testing techniques after work is done.            |                  |
+---------------------------------------------------+------------------+
| It\'s important to avoid sources of lead by not   | Slide 45:        |
| allowing children to chew painted surfaces, wet   | Instructions to  |
| cleaning surfaces weekly, cleaning window sills   | Patients with    |
| and wells, not letting children play in bare      | pre-1978 homes,  |
| soil, and covering bare silt in the yard with     | Con't            |
| grass or 6 inches of mulch.                       |                  |
+---------------------------------------------------+------------------+
| Other measures include:                           | Slide 46:        |
|                                                   | Instructions to  |
| running cold water for one to two minutes before  | Patients with    |
| using                                             | pre-1978 homes,  |
|                                                   | Con't            |
| , washing children's hands and faces frequently,  |                  |
| washing toys with soap and water                  |                  |
|                                                   |                  |
| , and feeding children plenty of calcium          |                  |
|                                                   |                  |
| and iron rich foods                               |                  |
+---------------------------------------------------+------------------+
| Now I'd like to review some of the information    | CAMERA           |
| discussed in this program. Lead was widely used   |                  |
| in gasoline and paint throughout the United       | (CHAPTER --      |
| States until the mid 1970s. Because of this, lead | Summary)         |
| is common in the environment.                     |                  |
+---------------------------------------------------+------------------+
| The most common route of exposure is ingestion of | ##### Sl         |
| lead-contaminated dust in housing built before    | ide 47: Summary. |
| 1978. Both normal wear and tear and renovation    |                  |
| can create dangerous levels of lead dust.         |                  |
|                                                   |                  |
| Because of their physiology and behavior,         |                  |
| children are at greatest risk of lead poisoning.  |                  |
| Lead poisoning is often asymptomatic, even at     |                  |
| levels that can cause harm. Therefore, children's |                  |
| blood should be tested for lead at ages one and   |                  |
| two, and annually up to age six, if they are at   |                  |
| risk of lead poisoning.                           |                  |
|                                                   |                  |
| Occupations, including construction workers,      |                  |
| automobile repair workers, and people working in  |                  |
| lead mining                                       |                  |
|                                                   |                  |
| or smelting may be exposed to high levels of      |                  |
| lead.                                             |                  |
|                                                   |                  |
| The most important step in managing lead          |                  |
| poisoning is removal of the source of exposure.   |                  |
| Local or state health departments often offer     |                  |
| services that can assist with this aspect of case |                  |
| management.                                       |                  |
+---------------------------------------------------+------------------+
| Patients should receive education about how to    | ##### Slide 48:  |
| reduce or avoid future exposures.                 |  Summary, Con't. |
+---------------------------------------------------+------------------+
| You can get more information from your regional   | ##### Slide 49:  |
| poison control center; State, county or local     |  How can I get m |
| health departments; EPA National Lead Information | ore Information? |
| Center; and the Alliance for Healthy Homes.       |                  |
+---------------------------------------------------+------------------+
| For more information please contact the resources | CAMERA           |
| listed on the slide.                              |                  |
|                                                   |                  |
| This concludes the Environmental Medicine Grand   |                  |
| Rounds on Lead Toxicity.                          |                  |
|                                                   |                  |
| Thank you.                                        |                  |
+---------------------------------------------------+------------------+
| None.                                             | #                |
|                                                   | #### Slide 50: I |
|                                                   | nformation on ho |
|                                                   | me environments. |
+---------------------------------------------------+------------------+