Analysis of serum CA125 and related influencing factors in silicosis patients with pulmonary heart disease / 中华劳动卫生职业病杂志

Objective: To analyze the serum carbohydrate antigen 125 (CA125) level and its influencing factors in male silicosis patients with pulmonary heart disease. Methods: In October 2021, data of 38 male patients with simple silicosis (silicosis group), 28 cases of silicosis with pulmonary heart disease (pulmonary heart disease group), and 27 healthy controls (control group) in the same age group were collected in inpatient and outpatient of Nanjing Occupational Disease Prevention and Control Hospital from January 2017 to December 2020. The serum CA125 levels of the three groups were compared, and the correlation between disease-related indexes and serum CA125 in silicosis patients with pulmonary heart disease was analyzed, as well as the influencing factors of pulmonary heart disease and serum CA125 levels in silicosis patients. Results: The serum CA125 level[ (19.95±7.52) IU/ml] in pulmonary heart disease group was higher than that in silicosis group[ (12.98±6.35) IU/ml] and control group[ (9.17±5.32) IU/ml] (P<0.05). There was no significant difference in serum CA125 level between the silicosis group and the control group (P>0.05). Serum CA125 levels were positively correlated with blood uric acid and fasting blood glucose in silicosis patients with pulmonary heart disease (r=0.39, 0.46, P<0.05). Serum CA125 level was a risk factor for silicosis patients with pulmonary heart disease (OR=1.13, 95%CI: 1.02-1.24, P<0.05). Dust exposure time, lactate dehydrogenase and smoking history were positively correlated with serum CA125 level in silicosis patients (P<0.05) . Conclusion: The serum CA125 level of male silicosis patients with pulmonary heart disease is significantly increased, and the level of CA125 is correlated with the level of fasting blood glucose and blood uric acid.

The influencing factors of cognitive impairment in patients with silicosis / 中华劳动卫生职业病杂志

Objective: To explore the influencing factors of cognitive impairment in patients with silicosis, and to analyze the effect of brain-derived neurotrophic factor (BDNF) on cognitive function. Methods: In March 2021, 484 silicosis patients from April 2018 to April 2020 were included in the study. The Montreal Cognitive Assessment Scale of Chinese version was used to evaluate their cognitive function, and they were divided into the cognitive impairment group (n=282) and the non cognitive impairment group (n=202) , another 30 healthy persons from body check were served as control group. The concentrations of BDNF were compared between the three groups. And the receiver operating characteristic (ROC) curve was drawed to analyze the value of BDNF in predicting cognitive impairment in silicosis patients. And the logistic regression analysis was used to explore the risk factors of cognitive impairment. Results: The incidence of cognitive impairment in silicosis patients was 58.26% (282/484) . The level of BDNF in the cognitive impairment group[ (10.32±2.11) mg/L] was significantly lower than that in the non cognitive impairment group[ (13.43±3.45) mg/L] (t=-12.27, P<0.001) . The results of ROC curve analysis showed that the area unde the curve of BDNF in predicting cognitive impairment of silicosis patients was 0.763 (95%CI: 0.613-0.874, P=0.024) , the cut off value was 10 mg/L, the sensitivity was 0.88, and the specificity was 0.84. Logistic regression analysis showed that the level of BDNF (≤10 mg/L) , age (≥65 years old) , course of disease (≥5 years) and diabetes mellitus were the risk factors of cognitive impairment in silicosis patients (OR=2.346, 95%CI: 1.654-3.103; OR=1.757, 95%CI: 1.214-1.998; OR=1.346, 95%CI: 1.112-1.564; OR=1.165, 95%CI: 1.102-1.542, P=0.001, 0.012, 0.027, 0.036) . Conclusion: BDNF may be one of the indicator to predict the risk of cognitive impairment in patients with silicosis.

Enfermeiro do trabalho na prevenção da silicose: uma revisão integrativa / Enfermero de trabajo en prevención de la silicosis: una revisión integradora / Occupational health nurse in the prevention of silicosis: an integrative review

Objective: to investigate the spread of knowledge regarding silicosis and to identify the occupational health nurse course of action to prevent it. Method: It is an integrative review of the literature held in the databases: LILACS, SciELO, BDENF and PubMed. The employed keywords were “silicosis”, “occupational health nursing” and “pneumoconiosis”, published in Portuguese, Spanish and English, in the years of 2004 to 2014. Eight articles met the inclusion criteria were selected and answered the guiding questions. Results:The selected articles seek to deepen the knowledge on silicosis, to estimate its prevalence, to establish the patient’s profile, to describe the major symptoms, to identify the major risk factors associated with the disease and to evaluate the quality of living of those afflicted by it. Conclusion: Silicosis is a public health problem with high prevalence and which requires very specific strategies to its prevention and control, especially those developed in occupational health nursing.

Objetivo: averiguar a divulgação do conhecimento sobre silicose e identificar ações do enfermeiro do trabalho para sua prevenção. Métodos: Trata-se de uma revisão integrativa da literatura realizada nas bases dedados LILACS, SciELO, BDENF e PubMed, utilizando-se os descritores “silicose”, “enfermagem do trabalho” e “pneumoconiose”, nos idiomas português, inglês e espanhol, dos anos de 2004 a 2014. Foram selecionados oito artigos que atenderam aos critérios de inclusão e responderam as questões norteadoras. Resultados: Os artigos selecionados abordam a silicose, estimam sua prevalência, delineiam o perfil dos portadores, descrevem os principais sintomas, identificam fatores de risco associados e avaliam a qualidade de vida dos acometidos. Conclusão: A silicose é um problema de saúde pública com alta prevalência, que necessita de estratégias específicas para seu controle e prevenção, especialmente aquelas desenvolvidas no âmbito da enfermagem do trabalho.

Objetivo: investigar la difusión del conocimiento sobre la silicosis e identificar las acciones del enfermero trabajo para su prevención. Método: Se trata de una revisión integradora de la literatura realizada en las bases de dados LILACS, SciELO, BDENF y PubMed utilizando las palabras clave “silicosis”, “enfermería de trabajo” y “neumoconiosis”, en Portugués, Inglés y Español. Fueron seleccionados de los años 2004 a 2014 ocho artículos que cumplieron con los criterios de inclusión y respondieron a las preguntas de orientación. Resultados: Los artículos seleccionados cubren silicosis, valorar su prevalencia, definir el perfil de los pacientes, describir los síntomas principales, identificar los factores de riesgo asociados y evaluar la calidad de vida de los afectados. Conclusión: La silicosis es un problema de salud pública con una alta prevalencia, que requiere estrategias específicas para su control y prevención, especialmente las desarrolladas en la enfermería de trabajo.

Síndrome de Erasmus: silicose e esclerose sistêmica / Erasmus syndrome: silicosis and systemic sclerosis

A silicose é a pneumoconiose mais frequente, decorrente da inalação de sílica ou de poeiras minerais contendo silicatos, caracterizada principalmente pela fibrose pulmonar de caráter irreversível. Está associada com o desenvolvimento de outras doenças, incluindo tuberculose pulmonar, câncer pulmonar e doenças autoimunes. A doença do tecido conjuntivo posterior à exposição à sílica ocorre geralmente após 15 anos do início da exposição. A síndrome de Erasmus refere-se ao desenvolvimento de esclerose sistêmica em indivíduos previamente expostos à sílica e que apresentavam ou não silicose. Os autores relatam dois casos de pacientes com diagnóstico de silicose que desenvolveram esclerose sistêmica.

The silicosis is the pneumoconiosis more frequent, resulting from the inhalation of silica or silicates containing mineral dust, mainly characterized by irreversible lung fi brosis. It is associated with the development of other diseases, including pulmonary tuberculosis, lung cancer and autoimmune diseases. The connective tissue disease after exposure to silica occurs usually after 15 years of initial exposure.The Erasmus syndrome describes the association of systemic sclerosis following exposure to silica with or without silicosis. The authors report two cases of patients with diagnosis of silicosis who developed systemic sclerosis.

Silicose e Esclerose Sistêmica – Síndrome de Erasmus: relato de um caso / Silicosis and systemic sclerosis – Erasmus' syndrome: case report

A silicoesclerodermia, descrita inicialmente por Erasmus em 1957, é o resultado da interferência na imunidade celular relacionada à citotoxicidade da sílica, responsável pelas reações auto-imunes e pela formação de imunocomplexos circulantes. Neste relato, os autores descrevem o caso de um homem de 61 anos com antecedentes de exposição à sílica e que desenvolveu Síndrome de Erasmus.

Silicoscleroderma, described by Erasmus in 1957, is the result of cellular immunity interference related to the cytotoxicity of silica, and it is responsible for autoimmune reactions and formation of circulating immunecomplexes. In this text, the authors describe a 61-years-old man with previous exposure to silica, and who developed Erasmus’ syndrome.

Pneumoconiose: relato de caso / Case report: pneumoconiosis

VDVB, 38 anos, masculino, há 5 anos trabalha com jatos de areia. Em julho/2007 paciente referiu dispnéiade instalação súbita, associada à tosse seca, sudorese noturna e astenia. Há 4 meses teve perda ponderal de 10 quilos. Foi internado em franca insuficiência respiratória. Não apresenta comorbidades nem faz uso de medicações. Ao exame físico apresentou taquidispnéia (freqüência respiratória: 40mpm), taquicardia (freqüência cardíaca: 135bpm), tiragens intercostais, estertoração crepitanteem bases pulmonares, diminuição de murmúrios vesiculares à direita e saturação de oxigênio de 86%.Ao RX de tórax havia condensações alveolares difusas bilaterais e de aspecto confluente peri-hilar e basal direito. BAAR negativo. PPD não-reator. Ecocardiograma mostrou tronco da artéria pulmonar e calibre mantidos,fração de ejeção de 59% e prolapso de válvula mitral. À tomografia computadorizada, firmou-se o diagnóstico de pneumoconiose, devido à presença de micronódulosconfluentes formando massas parenquimatosas e subpleurais, com presença de adenomegalia para-hilar;cavitações ausentes. Medicações em uso no momento da internação: atrovent, berotec, meticorten, talofilina.Após compensação da insuficiência respiratória e paciente teve alta hospitalar e foi orientado quanto à irreversibilidade caso e a possibilidade de transplante pulmonar.

Silicose: exposição ocupacional e medidas preventivas / Silicosis: occupational exposure and preventive measures

A silicose é uma doença crônica e incapacitante com altas taxas de mortalidade e morbidade tornando-se uma preocupação não só no território nacional mas a n´vel internacional. A silicose é a pneumoconiose mais antiga e mesmo assim, medidas preventivas e tecnologia disponível nas indústrias não são suficientes para diminuir sua incidência. Mesmo com desenvolvimento de sistemas legislativos mais eficientes e conscientes, surtos de silicose aguda continuam a ocorrer em indústrias mesmo nos países mais desenvolvidos. Uma vez estabelecida a doença é irreversível tendo como única alternativa evitar a progressão da doença e o surgimento de complicações . Este trabalho foi realizado através de uma extensa revisão da literatura nacional e internacional, utilizando livros texto e artigos publicados nas principais revistas médicas com o objetivo de conhecer melhor a doença e sua epidemiologia, diferentes apresentações e possíveis formas de manejo terapêutico.

Tuberculose e silicose: epidemiologia, diagnóstico e quimioprofilaxia / Tuberculosis and silicosis: epidemiology, diagnosis and chemoprophylaxis

A silicose, a mais prevalente das pneumoconioses, é provocada pela inalação de partículas de sílica cristalina. Indivíduos expostos à sílica, com ou sem silicose, apresentam risco aumentado de tuberculose e de micobacterioses não-tuberculosas. O risco de silicóticos desenvolverem tuberculose em relação a controles sadios varia de 2,8 a 39 vezes, em conformidade com a gravidade da doença de base. Têm sido estudados diferentes esquemas de quimioprofilaxia para tuberculose em silicóticos, todos com eficácia semelhante e com redução final de risco para cerca da metade em relação ao uso de placebo. São, no entanto, esquemas de longa duração, o que, acrescido dos possíveis efeitos colaterais (particularmente hepatotoxicidade), podem prejudicar a aderência. As diretrizes atuais recomendam a realização de prova tuberculínica e, se positiva, a instituição de quimioprofilaxia. São vários os esquemas possíveis, tanto em termos de drogas quanto de duração. Nossa recomendação é de que se use isoniazida na dose de 300 mg/dia (ou 10 mg/kg/dia) por seis meses para os indivíduos com silicose ou sadios com exposição superior a 10 anos, se forem reatores fortes à prova tuberculínica (induração > 10 mm). São necessários, no entanto, novos estudos para que indicações, drogas, doses e duração da profilaxia sejam definidas mais apropriadamente.

Silicosis, the most prevalent of the pneumoconioses, is caused by inhalation of crystalline silica particles. Silica-exposed workers, with or without silicosis, are at increased risk for tuberculosis and nontuberculous mycobacteria-related diseases. The risk of a patient with silicosis developing tuberculosis is higher (2.8 to 39 times higher, depending on the severity of the silicosis) than that found for healthy controls. Various regimens for tuberculosis chemoprophylaxis in patients with silicosis have been studied, all of which present similar efficacy and overall risk reduction to about one half of that obtained with placebo. Long-term regimens have potential side effects (particularly hepatotoxicity). In addition, the use of such regimens can jeopardize adherence to treatment. The current guidelines recommend that tuberculin skin tests be performed, and, if positive, that chemoprophylaxis be instituted. There are several possible regimens, varying in terms of the drugs prescribed, as well as in terms of treatment duration. We recommend the use of isoniazid at 300 mg/day (or 10 mg/kg/day) for six months for patients with silicosis, as well as for healthy patients with periods of exposure to silica longer than 10 years and strongly positive tuberculin skin test results (induration > 10 mm). Nevertheless, further studies are necessary so that indications, drugs, doses and duration of chemoprophylaxis regimens can be more properly defined.

Factors determining the severity of pulmonary function impairment in silicotic patients.

OBJECTIVE: Silicosis is the most common occupational lung disease in Thailand. Determinants of pulmonary function impairment in Thai silicotic patients have not been mentioned before. MATERIAL AND METHOD: The present study was conducted in silicotic patients who attended the Siriraj Occupational Lung Clinic in the year 2006. Patients were classified according to the forced expiratory volume in one second (FEV1) into the severe impairment group (< 50% predicted) and the non-severe group (FEV1 > 50% predicted) which includes normal FEV1. Comparison between the two groups in terms of demographic characteristics, smoking history, history of pulmonary tuberculosis, and radiographic features were assessed. RESULTS: Thirty-four patients of which 24 were female (70.6%) had an overall mean age of 53.7 years. Seven patients (20.6%) had severe impairment, four were female, three were smokers, and two had a history of pulmonary tuberculosis. All of the severe impairment patients had nodule profusion in category 2 and had large opacity. Only the presence of large opacity was significantly associated with the severity of pulmonary function impairment (p = 0.002). CONCLUSION: Only the presence of large opacity in a chest radiograph can determine the severity of pulmonary function impairment in Thai silicotic patients.

Fibrose maciça progressiva em trabalhadores expostos à sílica: achados na tomografia computadorizada de alta resolução / Progressive massive fibrosis in silica-exposed workers: high-resolution computed tomography findings

OBJETIVO: Avaliar as características radiológicas das massas conglomeradas pela tomografia computadorizada de alta resolução de tórax. MÉTODOS: Foram selecionados 75 pacientes silicóticos, a maioria jateadores de areia, portadores de fibrose maciça progressiva, atendidos no Hospital Universitário Antônio Pedro entre 1986 e 2004. Os pacientes foram submetidos a avaliação clínica, radiografia simples de tórax e tomografia computadorizada de alta resolução. RESULTADOS: Mais da metade dos pacientes com silicose complicada mostrou na radiografia de tórax grandes opacidades dos tipos B e C, denotando a gravidade da doença nesses pacientes. Dos 75 casos, apenas um apresentou massa unilateral simulando câncer de pulmão. Quarenta e quatro pacientes realizaram tomografia computadorizada de alta resolução do tórax. As massas predominaram nos terços superiores e posteriores (88,6 por cento). Broncograma aéreo e calcificações no interior das massas foram observados em 70,4 por cento e 63,8 por cento dos casos, respectivamente. História de tuberculose foi relatada em 52 por cento dos pacientes estudados. CONCLUSÃO: Na grande maioria dos casos as massas eram bilaterais, predominando nas regiões póstero-superiores dos pulmões, com broncogramas aéreos e calcificações de permeio. Associação com calcificações linfonodais foi um achado freqüente. A exposição a elevadas concentrações de poeira e a tuberculose foram consideradas fatores de risco para o desenvolvimento da fibrose maciça progressiva.

OBJECTIVE: To evaluate the radiological characteristics of conglomerate masses using high-resolution computed tomography of the chest. METHODS: From among the patients treated between 1986 and 2004 at the Antonio Pedro University Hospital, 75 patients with silicosis and massive fibrosis, most working in the field of sandblasting, were selected for study. These patients were submitted to a clinical evaluation, chest X-ray and high-resolution computed tomography of the chest. RESULTS: In more than half of the patients with accelerated silicosis, the chest X-ray revealed large type B and C opacities, denoting the severity of the disease in those patients. In 1 case, a unilateral mass simulating lung cancer was observed. High-resolution computed tomography scans of the chest were acquired for 44 patients. In most cases (88.6 percent), the masses were located in the superior and posterior thirds of the lung. Common findings within the masses included air bronchograms (in 70.4 percent) and calcifications (in 63.6 percent). A history of tuberculosis was reported by 52 percent of the patients. CONCLUSION: In the vast majority of cases, the masses were bilateral, predominantly located in the superior and posterior regions of the lung, featuring air bronchograms and interposed calcifications. Concomitant calcification of the mediastinal and hilar lymph nodes was another common finding. Exposure to high concentrations of dust and having a history of tuberculosis were considered significant risk factors for the development of progressive massive fibrosis.

Bilateral spontaneous pneumothorax in silicosis.

Occurrence of pneumothorax in silicosis is rare and when it occurs, pneumothorax is usually unilateral. We report here a patient with accelerated silicosis who presented with bilateral spontaneous pneumothoraces occurring simultaneously. The rarity of its clinical presentation in the form of bilateral simultaneous spontaneous pneumothorax combined with the typical clinical and radiological features of accelerated silicosis with tuberculosis make us to report this case.

Avaliação das características resistivas do sistema respiratório de indivíduos portadores de silicose pela técnica de oscilações forçadas / Using the forced oscillation technique to evaluate respiratory resistance in individuals with silicosis

OBJETIVO: Avaliar o comportamento dos parâmetros resistivos obtidos por meio da técnica de oscilações forçadas em pacientes portadores de diferentes graus de obstrução respiratória em decorrência da silicose. MÉTODOS: Foram analisados 40 indivíduos não tabagistas, sendo 10 sadios, sem história de doença pulmonar e exposição à sílica, e 30 portadores de silicose. Os voluntários foram examinados por meio da técnica de oscilações forçadas e da espirometria, técnica utilizada como referência para se classificar os diferentes níveis de obstrução. Desta classificação resultou a separação dos indivíduos em cinco grupos: controle (n = 10); normal ao exame, composto por indivíduos com laudo clínico e radiológico de silicose, porém normais ao exame espirométrico (n = 7); com obstrução leve (n = 10); com obstrução moderada (n = 8); e com obstrução acentuada (n = 5). RESULTADOS: A redução dos parâmetros espirométricos correspondeu a um significativo aumento na resistência total do sistema respiratório (p < 0,001), assim como na resistência associada às vias aéreas (p < 0,003). Foi também observada uma significativa redução na homogeneidade do sistema respiratório (p < 0,004). CONCLUSÃO: As informações adicionais referentes às propriedades resistivas do sistema respiratório, obtidas por meio da técnica de oscilações forçadas, podem contribuir para a complementação dos dados obtidos a partir de exames espirométricos em indivíduos portadores de silicose, o que ressalta o elevado potencial desta técnica na análise desses pacientes.

OBJECTIVE: To evaluate the resistance values obtained through the use of the forced oscillation technique in patients with varying degrees of airway obstruction resulting from silicosis. METHODS: A total of 40 never-smoking volunteers were analyzed: 10 were healthy subjects with no history of pulmonary disease or silica exposure, and 30 had silicosis. The forced oscillation technique was used to examine the subjects, and spirometry was used as a reference in order to classify the obstruction by degree. This classification resulted in five groups: control (n = 10); normal exam, composed of individuals diagnosed clinically and radiologically with silicosis but presenting normal spirometry results (n = 7); mild obstruction (n = 10); moderate obstruction (n = 8); and severe obstruction (n = 5). RESULTS: The reduction observed in the spirometric values corresponded to a significant increase in the total respiratory resistance (p < 0.001), as well as in airway resistance (p < 0.003). A significant reduction in ventilation homogeneity was also observed (p < 0.004). CONCLUSION: In individuals with silicosis, the additional respiratory resistance-related data obtained through the use of the forced oscillation technique can complement spirometric data. Therefore, the forced oscillation technique presents great potential for the analysis of such patients.

Cavitação pulmonar infectada em pacientes com silicoesclerodermia (síndrome de Erasmus) / Infected pulmonary cavity in a patient with silica induced scleroderma (Erasmus' syndrome)

Inicialmente descrita em 1957, a associação entre silicose e esclerose sistêmica (síndrome de Erasmus) ocorre, possivelmente, por alterações humorais e celulares, desencadeadas pela toxicidade da sílica. Neste relato, os autores descrevem o caso de um homem de 41 anos, com síndrome de Erasmus, admitido com uma cavitação pulmonar infectada.

Chronic necrotising pulmonary aspergillosis: a rare complication in a case of silicosis.

Chronic necrotising pulmonary aspergillosis (CNPA) is a rare complication of silicosis whose diagnosis requires a high index of suspicion as it mimics tuberculosis. We report a case of a 52-year-old male with a long history of silica dust exposure and progressively increasing dyspnoea for the past eight years, productive cough, fever, weight loss for past three months and hemoptysis for preceding three weeks. Based on the clinical, radiological and microbiological evidence, he was diagnosed to be a case of CNPA with aspergilloma complicating silicosis.

Influence of colchicine on pulmonary silicotic fibrogenesis in rats.

With an aim to evaluate the antifibrotic action of colchicine in experimental model of pulmonary silicosis, the effect of colchicine on developing and developed pulmonary silicosis induced by quartz was studied in rats in vivo and on alveolar macrophages exposed to quartz particulates in vitro. A progressive increase in wet and dry weight of lungs exposed to quartz dust alone, and quartz dust and colchicine injected orally was investigated. An increase in collagen contents, with lapse in time, in animals exposed intratracheally to quartz dust, or exposed similarly to quartz dust but receiving colchicine simultaneously through oral route was observed. A blindfold evaluation of histological sections of lungs of silicotic animals with or without colchicine administration during development of lesions did not reveal any difference between two groups of silicotic rats. Administration of colchicine for 4 weeks after the lesions were developed neither inhibited nor retarded the laying down of collagen. The studies were extended to investigate the effect of colchicine on quartz-induced alveolar macrophage cytotoxicity. The presence of varying concentrations of colchicine in the culture medium did not significantly alter cytotoxic potential of quartz. The results reveal that colchicine administration during the development of and on developed silicosis does not significantly alter pathogenesis of silicotic lesions. At the cellular level colchicine does not modulate quartz-induced alveolar macrophage cytotoxicity, believed to be a significant event for the onset of pulmonary silicotic fibrogenesis.

Silicosis associated with systemic lupus erythematosus

The hypothesis that exposure to silica might be associated with a wide range of autoimmune diseases including SLE (Systemic Lupus Erythematosus) has been discussed over the last decade, but only few cases of silicosis and SLE were described in the literature. We report the case of a male patient in his fifth decade of life, with previous exposure to silica, who worked as a well digger for ten years. The patients's clinical picture started with articular symptoms, sporadic peaks of fever, anemia, positive anti-nuclear factor, peripheral (1/10) and homogeneous (1/500) standard, and productive cough. Computed tomography of the chest showed a diffuse interstitial process, bilateral nodules, para-aortic and para-tracheal hilar calcifications, compatible with pulmonary and ganglial silicosis. He developed acute respiratory distress syndrome (ARDS) and died.

Co-morbidade na silicose / Silicosis co morbidity

Em estudo retrospectivo de 168 casos de pacientes portadores de silicose, representando 42,4 por cento (168/396), atendidos no HUAP e INSS de Niterói entre 1985 e 1995, foram encontradas as seguintes entidades associadas: tuberculose pulmonar, DPOC, cor pulmonale, infecções respiratórias agudas, outras tuberculoses, fibroses pulmonares não-classificadas, outras pneumoconioses, sinusite crônica, outras pneumopatias não-classificadas, sarcoidose, micoses pulmonares, esclerodermia, câncer de pulmão e proteinose alveolar. A comparação dos dois qüinqüênios mostrou um crescimento no percentual da silicose de 43,4 por cento (73/168) para 56,5 por cento (95/168), com aumento da ocorrência de tuberculose, que passou de 31,5 por cento para 42,1 por cento e redução da incidência de DPOC de 41,0 por cento (30/73) para 38,9 por cento (37/95)