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Groot Lipman KB, Boellaard TN, de Gooijer CJ, Bogveradze N, Hong EK, Landolfi F, Castagnoli F, Vakhidova N, Smesseim I, van der Heijden F, Beets-Tan RG, Wittenberg R, Bodalal Z, Burgers JA, Trebeschi S. Artificial Intelligence-based Quantification of Pleural Plaque Volume and Association With Lung Function in Asbestos-exposed Patients. J Thorac Imaging 2024; 39:165-172. [PMID: 37905941 PMCID: PMC11027965 DOI: 10.1097/rti.0000000000000759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
PURPOSE Pleural plaques (PPs) are morphologic manifestations of long-term asbestos exposure. The relationship between PP and lung function is not well understood, whereas the time-consuming nature of PP delineation to obtain volume impedes research. To automate the laborious task of delineation, we aimed to develop automatic artificial intelligence (AI)-driven segmentation of PP. Moreover, we aimed to explore the relationship between pleural plaque volume (PPV) and pulmonary function tests. MATERIALS AND METHODS Radiologists manually delineated PPs retrospectively in computed tomography (CT) images of patients with occupational exposure to asbestos (May 2014 to November 2019). We trained an AI model with a no-new-UNet architecture. The Dice Similarity Coefficient quantified the overlap between AI and radiologists. The Spearman correlation coefficient ( r ) was used for the correlation between PPV and pulmonary function test metrics. When recorded, these were vital capacity (VC), forced vital capacity (FVC), and diffusing capacity for carbon monoxide (DLCO). RESULTS We trained the AI system on 422 CT scans in 5 folds, each time with a different fold (n = 84 to 85) as a test set. On these independent test sets combined, the correlation between the predicted volumes and the ground truth was r = 0.90, and the median overlap was 0.71 Dice Similarity Coefficient. We found weak to moderate correlations with PPV for VC (n = 80, r = -0.40) and FVC (n = 82, r = -0.38), but no correlation for DLCO (n = 84, r = -0.09). When the cohort was split on the median PPV, we observed statistically significantly lower VC ( P = 0.001) and FVC ( P = 0.04) values for the higher PPV patients, but not for DLCO ( P = 0.19). CONCLUSION We successfully developed an AI algorithm to automatically segment PP in CT images to enable fast volume extraction. Moreover, we have observed that PPV is associated with loss in VC and FVC.
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Affiliation(s)
- Kevin B.W. Groot Lipman
- Department of Radiology
- Department of Thoracic Oncology, Netherlands Cancer Institute, Amsterdam
- Technical Medicine, University of Twente, Enschede
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht
| | | | | | - Nino Bogveradze
- Department of Radiology
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht
- Academic Pridon Todua Medical Center, Research Institute of Clinical Medicine, Tbilisi, GA
| | - Eun Kyoung Hong
- Department of Radiology
- Seoul National University Hospital, Seoul, South Korea
| | - Federica Landolfi
- Department of Radiology
- Radiology Unit, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Francesca Castagnoli
- Department of Radiology
- Department of Radiology, University of Brescia, Brescia, IT
- Department of Radiology, Royal Marsden Hospital, London, UK
- Division of Radiotherapy and Imaging, The Institute of Cancer Research, London, UK
| | | | - Illaa Smesseim
- Department of Thoracic Oncology, Netherlands Cancer Institute, Amsterdam
| | - Ferdi van der Heijden
- Department of Robotics and Mechatronics, University of Twente, Enschede, The Netherlands
| | - Regina G.H. Beets-Tan
- Department of Radiology
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht
- Faculty of Health Sciences, University of Southern Denmark, Odense, DK
| | | | - Zuhir Bodalal
- Department of Radiology
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht
| | - Jacobus A. Burgers
- Department of Thoracic Oncology, Netherlands Cancer Institute, Amsterdam
| | - Stefano Trebeschi
- Department of Radiology
- GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht
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Progression of Pulmonary Fibrosis According to Radiological Pattern in Asbestosis. Ann Am Thorac Soc 2023; 20:328-330. [PMID: 36322448 DOI: 10.1513/annalsats.202206-474rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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Shimonovich M, Pearce A, Thomson H, Katikireddi SV. Causal assessment in evidence synthesis: A methodological review of reviews. Res Synth Methods 2022; 13:405-423. [PMID: 35560730 PMCID: PMC9543433 DOI: 10.1002/jrsm.1569] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 03/11/2022] [Accepted: 05/07/2022] [Indexed: 11/10/2022]
Abstract
In fields (such as population health) where randomised trials are often lacking, systematic reviews (SRs) can harness diversity in study design, settings and populations to assess the evidence for a putative causal relationship. SRs may incorporate causal assessment approaches (CAAs), sometimes called 'causal reviews', but there is currently no consensus on how these should be conducted. We conducted a methodological review of self-identifying 'causal reviews' within the field of population health to establish: (1) which CAAs are used; (2) differences in how CAAs are implemented; (3) how methods were modified to incorporate causal assessment in SRs. Three databases were searched and two independent reviewers selected reviews for inclusion. Data were extracted using a standardised form and summarised using tabulation and narratively. Fifty-three reviews incorporated CAAs: 46/53 applied Bradford Hill (BH) viewpoints/criteria, with the remainder taking alternative approaches: Medical Research Council guidance on natural experiments (2/53, 3.8%); realist reviews (2/53, 3.8%); horizontal SRs (1/53, 1.9%); 'sign test' of causal mechanisms (1/53, 1.9%); and a causal cascade model (1/53, 1.9%). Though most SRs incorporated BH, there was variation in application and transparency. There was considerable overlap across the CAAs, with a trade-off between breadth (BH viewpoints considered a greater range of causal characteristics) and depth (many alternative CAAs focused on one viewpoint). Improved transparency in the implementation of CAA in SRs in needed to ensure their validity and allow robust assessments of causality within evidence synthesis.
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Affiliation(s)
- Michal Shimonovich
- MRC/CSO Social & Public Health Sciences UnitUniversity of GlasgowGlasgowUK
| | - Anna Pearce
- MRC/CSO Social & Public Health Sciences UnitUniversity of GlasgowGlasgowUK
| | - Hilary Thomson
- MRC/CSO Social & Public Health Sciences UnitUniversity of GlasgowGlasgowUK
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Brueckner U, Schulze AS, Walter D, Kampschulte M, Schneider J. Rounded atelectasis after exposure to refractory ceramic fibres (RCF). Part Fibre Toxicol 2021; 18:48. [PMID: 34965858 PMCID: PMC8715575 DOI: 10.1186/s12989-021-00441-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 12/14/2021] [Indexed: 11/24/2022] Open
Abstract
Background Refractory Ceramic fibres (RCF) are man-made mineral fibres used in high performance thermal insulation applications. Analogous to asbestos fibres, RCF are respirable, show a pleural drift and can persist in human lung tissue for more than 20 years after exposure. Pleural changes such as localised or diffuse pleural thickening as well as pleural calcification were reported. Result A 45 years old man worked in high performance thermal insulation applications using refractory ceramic fibres (RCF) for almost 20 years. During a occupational medical prophylaxis to ensure early diagnosis of disorders caused by inhalation of aluminium silicate fibres with X-ray including high-resolution computed tomography (HRCT), bilateral pleural thickening was shown and a pleural calcification next to a rounded atelectasis was detected. Asbestos exposure could be excluded. In pulmonary function test a restrictive lung pattern could be revealed. In work samples scanning electron microscopy (SEM) including energy dispersive X-ray analysis (EDX) classified used fibres as aluminium silicate fibres. X-ray powder diffraction (XRD) and transmission electron microscopy (TEM) showed crystalline as well as amorphous fibres. Conclusions A comprehensive lung function analysis and in case of restrictive lung disorders additional CT scans are needed in RCF exposed workers in accordance to the guidelines for medical occupational examinations comparable to asbestos exposed workers.
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Affiliation(s)
- Ulrike Brueckner
- Institute and Outpatient Clinic for Occupational and Social Medicine, Justus-Liebig-University, Aulweg 129, 35392, Giessen, Germany.
| | - Anne S Schulze
- Institute and Outpatient Clinic for Occupational and Social Medicine, Justus-Liebig-University, Aulweg 129, 35392, Giessen, Germany
| | - Dirk Walter
- Institute and Outpatient Clinic for Occupational and Social Medicine, Justus-Liebig-University, Aulweg 129, 35392, Giessen, Germany.,Institute of Inorganic and Analytical Chemistry, Justus-Liebig-University, Heinrich-Buff-Ring 17, 35392, Giessen, Germany
| | - Marian Kampschulte
- Clinic for Diagnostic and Interventional Radiology, University Hospital, Justus-Liebig-University, Klinikstrasse 33, 35392, Giessen, Germany
| | - Joachim Schneider
- Institute and Outpatient Clinic for Occupational and Social Medicine, Justus-Liebig-University, Aulweg 129, 35392, Giessen, Germany
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Peterson MK, Mohar I, Lam T, Cook TJ, Engel AM, Lynch H. Critical review of the evidence for a causal association between exposure to asbestos and esophageal cancer. Crit Rev Toxicol 2020; 49:597-613. [PMID: 31965908 DOI: 10.1080/10408444.2019.1692190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Esophageal cancers comprise about 1% of all cancers diagnosed in the US but are more prevalent in other regions of the world. Several regulatory agencies have classified asbestos as a known human carcinogen, and it is linked to multiple diseases and malignancies, including lung cancer and mesothelioma. In a 2006 review of the epidemiological literature, the Institute of Medicine (IOM) did not find sufficient evidence to demonstrate a causal relationship between asbestos exposure and esophageal cancer. To reevaluate this conclusion, we performed a critical review of the animal toxicological, epidemiological, and mechanism of action literature on esophageal cancer and asbestos, incorporating studies published since 2006. Although there is some evidence in the epidemiological literature for an increased risk of esophageal cancer in asbestos-exposed occupational cohorts, these studies generally did not control for critical esophageal cancer risk factors (e.g. smoking, alcohol consumption). Furthermore, data from animal toxicological studies do not indicate that asbestos exposure increases esophageal cancer risk. Based on our evaluation of the literature, and reaffirming the IOM's findings, we conclude that there is insufficient evidence to demonstrate a causal link between asbestos exposure and esophageal cancer.
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Poland CA, Duffin R. The toxicology of chrysotile-containing brake debris: implications for mesothelioma. Crit Rev Toxicol 2019; 49:11-35. [DOI: 10.1080/10408444.2019.1568385] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Craig A. Poland
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
- Institute of Occupational Medicine, Edinburgh, UK
| | - Rodger Duffin
- Centre for Inflammation Research, Queen's Medical Research Institute, The University of Edinburgh, Edinburgh, UK
- Concept Life Sciences, Dundee, UK
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Maxim LD, Utell MJ. Review of refractory ceramic fiber (RCF) toxicity, epidemiology and occupational exposure. Inhal Toxicol 2018; 30:49-71. [PMID: 29564943 DOI: 10.1080/08958378.2018.1448019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
This literature review on refractory ceramic fibers (RCF) summarizes relevant information on manufacturing, processing, applications, occupational exposure, toxicology and epidemiology studies. Rodent toxicology studies conducted in the 1980s showed that RCF caused fibrosis, lung cancer and mesothelioma. Interpretation of these studies was difficult for various reasons (e.g. overload in chronic inhalation bioassays), but spurred the development of a comprehensive product stewardship program under EPA and later OSHA oversight. Epidemiology studies (both morbidity and mortality) were undertaken to learn more about possible health effects resulting from occupational exposure. No chronic animal bioassay studies on RCF have been conducted since the 1980s. The results of the ongoing epidemiology studies confirm that occupational exposure to RCF is associated with the development of pleural plaques and minor decrements in lung function, but no interstitial fibrosis or incremental lung cancer. Evidence supporting a finding that urinary tumors are associated with RCF exposure remains, but is weaker. One reported, but unconfirmed, mesothelioma was found in an individual with prior occupational asbestos exposure. An elevated SMR for leukemia was found, but was absent in the highly exposed group and has not been observed in studies of other mineral fibers. The industry will continue the product stewardship program including the mortality study.
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Affiliation(s)
- L Daniel Maxim
- a Everest Consulting Associates , West Windsor , NJ , USA
| | - Mark J Utell
- b University of Rochester School of Medicine and Dentistry , Rochester , NY , USA
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Dement JM, Welch LS, Ringen K, Cranford K, Quinn P. Longitudinal decline in lung function among older construction workers. Occup Environ Med 2017; 74:701-708. [DOI: 10.1136/oemed-2016-104205] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 04/12/2017] [Accepted: 04/21/2017] [Indexed: 11/04/2022]
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Schikowsky C, Felten MK, Eisenhawer C, Das M, Kraus T. Lung function not affected by asbestos exposure in workers with normal Computed Tomography scan. Am J Ind Med 2017; 60:422-431. [PMID: 28370144 DOI: 10.1002/ajim.22717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND It has been suggested that asbestos exposure affects lung function, even in the absence of asbestos-related pulmonary interstitial or pleural changes or emphysema. METHODS We analyzed associations between well-known asbestos-related risk factors, such as individual cumulative asbestos exposure, and key lung function parameters in formerly asbestos-exposed power industry workers (N = 207) with normal CT scans. For this, we excluded participants with emphysema, fibrosis, pleural changes, or any combination of these. RESULTS The lung function parameters of FVC, FEV1, DLCO/VA, and airway resistance were significantly associated with the burden of smoking, BMI and years since end of exposure (only DLCO/VA). However, they were not affected by factors directly related to amount (eg, cumulative exposure) or duration of asbestos exposure. CONCLUSIONS Our results confirm the well-known correlation between lung function, smoking habits, and BMI. However, we found no significant association between lung function and asbestos exposure.
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Affiliation(s)
- Christian Schikowsky
- Institute for Occupational and Social Medicine; RWTH Aachen University; Aachen Germany
| | - Michael K. Felten
- Institute for Occupational and Social Medicine; RWTH Aachen University; Aachen Germany
| | - Christian Eisenhawer
- Institute for Occupational and Social Medicine; RWTH Aachen University; Aachen Germany
| | - Marco Das
- Department of Diagnostic Radiology; RWTH Aachen University; Aachen Germany
- Department of Radiology; Maastricht University Medical Center; Maastricht The Netherlands
| | - Thomas Kraus
- Institute for Occupational and Social Medicine; RWTH Aachen University; Aachen Germany
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Clark KA, Flynn JJ, Karmaus WJJ, Mohr LC. The Effects of Pleural Plaques on Longitudinal Lung Function in Vermiculite Miners of Libby, Montana. Am J Med Sci 2017. [PMID: 28641716 DOI: 10.1016/j.amjms.2017.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND This study was conducted to assess associations of pleural plaques (PP) and longitudinal lung function in vermiculite miners of Libby, Montana who are occupationally exposed to asbestos. High-resolution computed tomography (HRCT) was used to identify asbestos-related findings in former Libby vermiculite miners. We investigated annual lung function decline in miners with PP only and compared them to miners with normal HRCT findings. MATERIALS AND METHODS HRCTs from 128 miners were categorized into the following 4 diagnostic groups: (1) normal computed tomography scan (n = 9); (2) PP only (n = 72); (3) PP and interstitial fibrosis (n = 26) and (4) additional HRCT abnormalities (n = 21) such as rounded atelectasis, diffuse pleural thickening, pleural effusions or pulmonary nodules or tumor >1cm in diameter. Random intercept and slope linear mixed-effect regression models identified differences in lung function decline between miners with asbestos-associated outcomes and those with normal HRCT. Models were adjusted for follow-up time, body mass index, smoking status, latent exposure period and employment years. Interactions for smoking status with age and smoking status with pleural plaque severity were examined. RESULTS Miners with PP only did not have an accelerated decline in lung function between 40 and 80 years. Miners with PP and additional HRCT abnormalities displayed significantly accelerated declines in forced expiratory volume in 1 second and diffusing capacity of the lungs for carbon monoxide (P = 0.05 and P < 0.01, respectively). Plaque severity did not affect lung function decline. However, smokers with extensive plaques displayed accelerated loss in diffusing capacity of the lungs for carbon monoxide and forced expiratory volume in 1 second when compared to nonsmoking miners with mild plaque formation. CONCLUSIONS PP alone did not significantly affect lung function decline in vermiculite miners of Libby, Montana.
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Affiliation(s)
- Kathleen A Clark
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.
| | - J Jay Flynn
- Health Network America, Tinton Falls, New Jersey
| | - Wilfried J J Karmaus
- Division of Epidemiology, Biostatistics and Environmental Health, University of Memphis, Memphis, Tennessee
| | - Lawrence C Mohr
- Department of Medicine, Medical University of South Carolina, Charleston, South Carolina; Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina; Environmental Biosciences Program, Medical University of South Carolina, Charleston, South Carolina
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Dodge DG, Beck BD. Historical state of knowledge of the health risks of asbestos posed to seamen on merchant ships. Inhal Toxicol 2016; 28:637-657. [DOI: 10.1080/08958378.2016.1244228] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Comment on “Exposure-response modeling of non-cancer effects in humans exposed to Libby Amphibole Asbestos; update” by Benson et al. (2015). Regul Toxicol Pharmacol 2016; 80:268-9. [DOI: 10.1016/j.yrtph.2016.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 03/01/2016] [Accepted: 05/11/2016] [Indexed: 11/17/2022]
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Zu K, Tao G, Goodman JE. Pleural plaques and lung function in the Marysville worker cohort: a re-analysis. Inhal Toxicol 2016; 28:514-9. [DOI: 10.1080/08958378.2016.1210704] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Ke Zu
- Gradient, Cambridge, MA, USA
| | - Ge Tao
- Gradient, Cambridge, MA, USA
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Exposure-response modeling of non-cancer effects in humans exposed to Libby Amphibole Asbestos; update. Regul Toxicol Pharmacol 2015; 73:780-9. [PMID: 26524929 DOI: 10.1016/j.yrtph.2015.10.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 10/19/2015] [Accepted: 10/20/2015] [Indexed: 11/22/2022]
Abstract
The United States Environmental Protection Agency (EPA) developed a quantitative exposure-response model for the non-cancer effects of Libby Amphibole Asbestos (LAA) (EPA, 2014). The model is based on the prevalence of localized pleural thickening (LPT) in workers exposed to LAA at a workplace in Marysville, Ohio (Lockey et al., 1984; Rohs et al., 2008). Recently, Lockey et al. (2015a) published a follow-up study of surviving Marysville workers. The data from this study increases the number of cases of LPT and extends the observation period for a number of workers, thereby providing a strengthened data set to define and constrain the optimal exposure-response model for non-cancer effects from inhalation exposure to LAA. The new data were combined with the previous data to update the exposure-response modeling for LPT. The results indicate that a bivariate model using cumulative exposure and time since first exposure is appropriate, and the benchmark concentration is similar to the findings previously reported by EPA (2014). In addition, the data were also used to develop initial exposure-response models for diffuse pleural thickening (DPT) and small interstitial opacities (SIO).
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Kopylev L, Christensen KY, Brown JW, Cooper GS. Authors' response: A systematic review of the association between pleural plaques and changes in lung function. Occup Environ Med 2015. [PMID: 26203101 PMCID: PMC4552904 DOI: 10.1136/oemed-2015-103063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Leonid Kopylev
- National Center for Environmental Assessment, Office of Research and Development, United States Environmental Protection Agency, Washington DC, USA
| | - Krista Y Christensen
- National Center for Environmental Assessment, Office of Research and Development, United States Environmental Protection Agency, Washington DC, USA
| | - James W Brown
- National Center for Environmental Assessment, Office of Research and Development, United States Environmental Protection Agency, Washington DC, USA
| | - Glinda S Cooper
- National Center for Environmental Assessment, Office of Research and Development, United States Environmental Protection Agency, Washington DC, USA
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Comment on "HRCT/CT and Associated Spirometric Effects of Low Libby Amphibole Asbestos Exposure" by Lockey et al (2015). J Occup Environ Med 2015; 57:e80. [PMID: 26147559 DOI: 10.1097/jom.0000000000000463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Maxim LD, Niebo R, Utell MJ. Are pleural plaques an appropriate endpoint for risk analyses? Inhal Toxicol 2015; 27:321-34. [DOI: 10.3109/08958378.2015.1051640] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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