Non-malignant silica-related diseases in a specialized outpatient clinic.

BACKGROUND: Uncontrolled occupational exposure to silica is still frequent in Brazil, with several recent records in the state of Minas Gerais. However, few national studies have addressed silica-related diseases other than silicosis. AIMS: To describe the occurrence of the main non-malignant silica-related diseases: silicosis, tuberculosis (TB), chronic obstructive pulmonary disease (COPD), and autoimmune diseases in a specialized outpatient clinic. METHODS: Case series study of 1525 patients exposed to silica, seen between 1984 and 2021, with descriptive findings of clinical and occupational data from the first medical evaluation. RESULTS: Medians of age and exposure time were 47 and 15 years, respectively, and 97% of patients were male. The prevalence of silicosis was 44%, of which 27% had large opacities. The main occupational sectors were underground gold mining (28%), precious and semi-precious stone work (20%), and artisanal mining (9%). Spirometries were abnormal in 55%, with obstructive disorder being the most common finding. COPD (25%), active TB or sequelae (12%), and connective tissue diseases (6%) were diagnosed in patients with and without silicosis. CONCLUSIONS: The percentage of silicosis appears to be alarming, even considering the biases of selective referrals. The patients were relatively young and already had a functional impact, caused not only by silicosis but by one or more silica-related diseases. COPD, TB, and connective tissue diseases proved to be frequent, leading to the need for specifics protocols to investigate them in individuals exposed to silica. By adopting strategies to combat silicosis, the prevention of other silica-related diseases is concomitantly promoted.

Underreporting of mesothelioma, asbestosis and pleural plaques in Brazil.

BACKGROUND: Brazil has a long history of heavy asbestos consumption. However, the number of asbestos-related diseases (ARDs) falls far below the one expected compared with other asbestos consumer countries. AIMS: To examine underreporting of ARDs, that is mesothelioma, asbestosis and pleural plaques, in Brazil's Mortality Information System (SIM). METHODS: Health information systems (HIS) were mapped, datasets retrieved and records of ARD deaths extracted. Records were pair-matched using anonymous linkage to create a single database. ARD-reported cases missing in SIM were considered unreported. The study's period ranged from 2008 to 2014, when every HIS contributed to the ARD records pool. RESULTS: A total of 1298 registered ARD deaths were found, 996 cases of mesothelioma (77%) and 302 (23%) of asbestosis and pleural plaques. SIM was the major single data source of ARD but 335 mesothelioma deaths were missing, an average underreporting of 33%, with no clear time trend. For asbestosis and pleural plaques, underreporting of ARD oscillated from 55% in 2010 to 25% in 2014, a declining trend. ARD underreporting was not associated with sex or age. CONCLUSIONS: One-third of underreported ARD deaths in the universal SIM is unacceptably high and, apparently, it has not been improving substantially over time. After recoveries from multiple databases, the number of cases is still below, which could be expected based on asbestos consumption. Interoperability of multiple information systems could enhance case detection and improve the precision of mortality estimates, which are crucial for surveillance and for evaluation of remedial policies.

Does exposure to inflammatory particles modify the pattern of anion in exhaled breath condensate?

Exposure to environmental and occupational particulate matter (PM) induces health effects on the cardio-pulmonary system. In addition, associations between exposure to PM and metabolic syndromes like diabetes mellitus or obesity are now emerging in the literature. Collection of exhaled breath condensate (EBC) is an appealing non-invasive technique to sample pulmonary fluids. This hypothesis-generating study aims to (1) validate an ion chromatography method allowing the robust determination of different metabolism-related molecules (lactate, formate, acetate, propionate, butyrate, pyruvate, nitrite, nitrate) in EBC; (2) apply this method to EBC samples collected from workers exposed to quartz (a known inflammatory particle), to soapstone (a less inflammatory particle than quartz), as well as to controls. A multi-compound standard solution was used to determine the linearity range, detection limit, repeatability and bias from spiked EBC. The biological samples were injected without further treatment into an ion chromatograph with a conductivity detector. RTube® were used for field collection of EBC from 11 controls, 55 workers exposed to soapstone and 12 volunteers exposed to quartz dust. The analytical method used proved to be adequate for quantifying eight anions in EBC samples. Its sub-micromolar detection limits and repeatability, combined with a very simple sample preparation, allowed an easy and fast quantification of different glycolysis or nitrosative stress metabolites. Using multivariate discriminant analysis to maximize differences between groups, we observed a different pattern of anions with a higher formate/acetate ratio in the EBC samples for quartz exposed workers compared to the two other groups. We hypothesize that a modification of the metabolic signature could be induced by exposure to inflammatory particles like quartz and might be observed in the EBC via a change in the formate/acetate ratio.

Respiratory impairment in Brazilian foundry workers exposed to sand.

OBJECTIVE: Foundries date back to the 16th century in Brazil and still constitute a strong economic activity today. Workers are at risk of respiratory diseases due to various exposures such as polycyclic aromatic hydrocarbons, pyrolysis degradation products, mineral dust, organic dust, resin, and isocyanates. We evaluate respiratory morbidity among workers in foundries using sand. METHODS: Six foundries with sand molding operations were selected. Length of exposure in years was utilized as a surrogate for exposure. The medical evaluation consisted of a respiratory symptoms questionnaire, occupational history, spirometry, and chest X-rays. Additionally, workers exposed to resins and a control group underwent bronchial provocation tests. RESULTS: A sample of 598 male workers with a mean age of 36.5 years (SD = 10.0) was analyzed. The mean length of exposure was 10.1 years (SD = 7.4). The overall prevalence of pneumoconiosis was 4.5%. Chronic bronchitis (CB) and X-ray profusion were significantly related to the quartiles of length of exposure (trend tests: P = 0.0055 and P < 0.001, respectively). There was a significant risk of having an abnormal FVC and FEV(1) with the presence of pneumoconiosis (OR = 4.63 CI 1.40-13-23, OR 3.34 CI 1.03-9.26, respectively). Workers exposed to resins compared with controls showed no differences in relation to spirometry, respiratory symptoms and bronchial reactivity. CONCLUSIONS: There were significant associations between length of exposure CB and prevalence of profusion 1/0 or above. There was also a significant association for pneumoconiosis versus and abnormal FVC and FEV(1). Foundry workers currently exposed to resins did not show an excess of respiratory symptoms, abnormal spirometry or increased bronchial reactivity.

Occupational asthma caused by Ipe (Tabebuia spp) dust.

BACKGROUND: Ipe is a resistant hardwood that contains naphtoquinones. It is easily found and frequently used in South and Central America. Naphtoquinones are skin sensitizers. OBJECTIVE: To describe a case of occupational asthma related to Ipe wood dust. METHODS: The patient was submitted to a clinical evaluation consisting of a respiratory symptom questionnaire, occupational history, serial measurements of lung function by spirometry, skin prick tests, patch tests, specific IgE and specific bronchial provocation tests to Ipe dust. RESULTS: Serial lung function measurements showed sustained regression of obstruction following removal from exposure. Skin prick tests, but not patch tests, were positive to Ipe, and a specific bronchial challenge showed a late asthmatic reaction. Specific IgE search was negative. CONCLUSIONS: Exposure to Ipe wood dust can lead to occupational asthma. The underlying mechanism should be investigated.

Pneumoconiosis after sericite inhalation.

BACKGROUND: Between 1997 and 1999 three sericite plant workers in Parana, Brazil, were diagnosed with pneumoconiosis. AIMS: To investigate and describe the radiological, clinical, and pathological changes in miners and millers exposed to sericite dust with mineralogical characteristics of inhaled dust. METHODS: The working premises were visited to examine the sericite processing and to classify the jobs according to make qualitative evaluation. Respirable dust was collected and the amount of crystalline silica and particle size distribution were measured. Forty four workers were examined by a standard questionnaire for respiratory symptoms, spirometry, and chest x ray. Material from an open lung biopsy was reviewed for histopathological and mineralogical analysis, together with sericite samples from the work site to compare the mineral characteristics in lung lesions and work area. RESULTS: Respirable dust contained 4.5-10.0% crystalline silica. Particle size distribution showed a heavy burden of very fine particles (23-55%) with a mean diameter of <0.5 microm. Mean age of sericite miners was 41.0 (11.9) and mean number of years of exposure was 13.5 (10.1). In 52.3% of workers (23/44), chest radiographs presented a median category of 1/0 or above, and 18.2% (8/44) had a reduced FEV1. There was a significant association between exposure indices and x ray category. Histological studies of the lung biopsy showed lesions compatible with mixed dust fibrosis with no silicotic nodules. x Ray diffraction analysis of the lung dust residue and the bulk samples collected from work area showed similar mineralogical characteristics. Muscovite and kaolinite were the major mineral particle inclusions in the lung. CONCLUSION: Exposure to fine sericite particles is associated with the development of functional and radiological changes in workers inducing mixed dust lesions, which are distinct histologically from silicosis.

Exposición a sílice y silicosis en el Programa Nacional de Eliminación de Silicosis en Brasil (PNES) / Exhibition to silica and silicosis in the National Program of Elimination of Silicosis in Brazil (PNES)

La silicosis es la principal neumoconiosis en Brasil. El número de trabajadores registrados ocupacionalmente expuestos por más de 30 por ciento de la jornada de trabajo es superior a 2.000.000, concentrados en los sectores de industrias de la construcción, minería, transformación de minerales no metálicos y metalúrgica. El número real de expuestos es mayor pues la informalidad del trabajo actualmente es superior al 50 por ciento. El límite de tolerancia a la sílice es 0,1 mg por m3 para una jornada de 48 horas semanales y están previstos exámenes médicos y de laboratorio periódicos para todos los expuestos a sílice. Hay datos disponibles para algunos sectores como: cerámicas, minería de carbón y mármol, que apuntan a situaciones frecuentes de exposición que sobrepasan el límite de tolerancia. Hay también datos médicos sobre la ocurrencia de silicosis, que es un grave problema en actividades ligadas a la industria naval, extracción de material de relleno y cavado de pozos. El año 2001 fue lanzado el Programa Nacional para la Eliminación de la Silicosis (PNES), en consonancia con la propuesta Internacional del Programa de la Organización Internacional del Trabajo (OIT) y la Organización Mundial de la Salud (OMS), con el objetivo de disminuir la incidencia de silicosis para el 2015 y eliminarla como problema de Salud Pública para el 2030.

Non-malignant asbestos-related diseases in Brazilian asbestos-cement workers.

BACKGROUND: Production of asbestos-cement products in Brazil started in the 1940s, peaked in the 60-70s and is still an active industry. This study was designed to assess the non-malignant effects of asbestos exposure in the asbestos-cement industry in Brazil. METHODS: A group of 828 former asbestos-cement workers enrolled in a cross-sectional and cohort study of respiratory morbidity, submitted to a detailed occupational history, respiratory symptoms questionnaire, spirometry, PA chest x-ray, and high resolution computed chest tomography (HRCT). Asbestos exposure was assessed by years of exposure, cumulative exposure (a semi-quantitative method), and latency time from first exposure. Asbestosis and pleural thickening were assessed according to HRCT criteria. RESULTS: Asbestosis was present in 74 (8.9%) and pleural thickening in 246 (29.7%). Using the HRCT as the "best available evidence", it was shown that were more false negatives than false positives in the x-ray readings for parenchymal (21.6% false negatives, 4.2% false positives) and pleural (26.0% false negatives, 14.4% false positives) diseases due to asbestos. Latency time from first exposure was the best predictor for both asbestosis and pleural thickening. Subjects in the higher exposure groups presented lower levels of lung function. Obstructive defects were significantly related to smoking, shortness of breath, body mass index, and age, whereas restrictive defects were related to asbestosis, shortness of breath, and latency time. Chronic bronchitis increased with latency time in the three smoking groups and was significantly related to pleural thickening (OR 1.56 (1.00-2.42)). Shortness of breath was significantly associated with body mass index and pleural thickening (OR 1.30 (1.24-2.09)). CONCLUSIONS: Pleural thickening and asbestosis showed a significant association with latency time and exposure. FVC and FEV(1) decreased across increasing profusion with an added effect of pleural thickening. There was a significant and independent effect of exposure on lower levels of FVC and FEV(1). Obstructive defects were mainly related to smoking and restriction to asbestosis. Dust exposure and smoking were synergistic in increasing chronic bronchitis and shortness of breath report. Shortness of breath report was also related to pleural thickening and higher body mass index.

Lung cancer in Brazil.

Lung cancer is the second leading cause of death in Brazil, after exclusion of external causes. Registries in the country are not reliable because of under-registration and limited coverage. Incidence rates for Brazil are less then half those for selected areas with good registries. Crude and adjusted incidence and mortality rates for lung cancer are rising, particularly among women. The main reason is the acceleration in tobacco consumption and the spread of smoking among women. At present, approximately 40% of men and 25% of women, 15 years of age or older, are current smokers. In the state of Rio Grande do Sul, where registries are reliable, incidence and mortality for males are similar to US data and the figures for women are rapidly approaching those for men. Occupations associated with risks of exposure to respiratory carcinogens show a rise in the incidence of lung cancer in the industrialized area of São Paulo. The main occupational risk in Brazil is exposure to mineral dusts, silica, or asbestos. Although about 15 million Brazilians are exposed to pesticides, agricultural workers were not a risk group for lung cancer in a case-control study. Pesticides containing arsenic and dichlorodiphenyltrichloroethane (DDT) are banned. In recent years, a trend towards a decrease in male smoking has been noted, but there is still a high tobacco exposure burden in both males and females, with a forecast of a further increase in rates of lung cancer incidence and deaths. Control of respiratory carcinogens at work continues to be a problem, particularly in the present scenario of economic and political pressures on Brazil and other developing nations. Semin Oncol 28:143-152.

Asbestos-Related Pleural Thickening is Independently Associated With Lower Levels of Lung Function and with Shortness of Breath.

This study investigated the relative contribution of asbestos-related pleural thickening (PT) to lung function indices and to respiratory symptoms. A group of 828 former asbestos cement workers enrolled in a cross-sectional and cohort study of respiratory morbidity and submitted to a detailed occupational history, respiratory symptoms questionnaire, spirometry, postero-anterior chest x-ray, and high-resolution computed chest tomography (HRCT). Asbestos exposure was assessed by years of exposure (a semi-quantitative method), cumulative exposure, and latency time from first exposure. Smoking was assessed in pack-years. PT and asbestosis were assessed according to HRCT criteria. Statistical analysis included descriptive analysis, univariate and multivariate analysis of variance for comparisons of factors related to PT, stepwise multiple regression analysis for continuous dependent variables, and logistic regression analysis for dichotomous dependent variables. Mean age was 51.4 (SD 10.5) years, mean years of exposure 12.4 (SD 8.8), mean cumulative exposure 79.9 (SD 68.5), and mean latency time 25.2 yr (SD 10.4). Of the 828, 238 (28.7%) were smokers, 288 (34.8%) former smokers, and 302 (36.2%) nonsmokers. PT was present in 246 (29.7%) and asbestosis in 74 (8.9%); 97 (11.9%) had shortness of breath of Grade III or more. PT subjects had lower height-adjusted forced vital capacity (FVC) and forced expiratory volume in I s (FEV1) and lower FEV1/FVC% (p < .00001 for all). Variables significantly related to PT were age (p < .000 1), years of exposure (p < .0000 1), cumulative exposure (p < .00001), latency time (p < .00001), pack-years (p < .0000 1), and asbestosis (p < .00 1). In a multiple stepwise regression model, after controlling for confounders, height adjusted FEV1 and FVC were in versely and significantly associated with PT, mainly when associated with asbestosis. A logistic regression model with shortness of brea th as the dependent va riable, con trolled for confounders, showed that PT was significa ntly associated with the symptom, even without asbestosis. In conclusion, PT is independently associated with lower va lues of FEV1 and FVC. PT is also independently associated with an increased risk of shortn ess of breath report. PT should be considered as a disease for clinical follow up and for compensa tion claims.

Asbestos: current issues related to cancer and to uses in developing countries.

Asbestos is one of the main occupational carcinogens recognized and studied in the literature. Its uses have undergone major changes in recent decades, with severe restrictions on commercial amphiboles according to different patterns: in developed countries asbestos is strictly controlled or banned, except in Japan, while in developing countries consumption has leveled off or increased. As an example, Brazil is one the seven world leaders in asbestos production and consumption. Although there is a clear excess of mesotheliomas linked to amphibole exposure, mainly to crocidolite, there is no evidences that chrysotile is harmless to the pleura. Also, the relationship between fibrogenesis and carcinogenesis is not sufficiently understood to defend the concept that there are protective exposure limits to both diseases. "Controlled use" policy may be effective at the occupational level in a select group of companies, representing only a fraction of the exposed population. In developing countries subject to economic pressures, these issues merit proper discussion to avoid unnecessary disease and death.

Occupational health in Brazil.

Brazil is a recently industrialised country with marked contrasts in social and economic development. The availability of public/private services in its different regions also varies. Health indicators follow these trends. Occupational health is a vast new field, as in other developing countries. Occupational medicine is a required subject in graduation courses for physicians. Specialisation courses for university graduated professionals have more than 700 hours of lectures and train occupational health physicians, safety engineers and nursing staff. At the technical level, there are courses with up to 1300 hours for the training of safety inspectors. Until 1986 about 19,000 occupational health physicians, 18,000 safety engineers and 51,000 safety inspectors had been officially registered. Although in its infancy, postgraduation has attracted professionals at university level, through residence programmes as well as masters and doctors degrees, whereby at least a hundred good-quality research studies have been produced so far. Occupational health activities are controlled by law. Undertakings with higher risks and larger number of employees are required to hire specialised technical staff. In 1995 the Ministry of Labour demanded programmes of medical control of occupational health (PCMSO) for every worker as well as a programme of prevention of environmental hazards (PPRA). This was considered as a positive measure for the improvement of working conditions and health at work. Physicians specialising in occupational medicine are the professionals more often hired by the enterprises. Reference centres (CRSTs) for workers' health are connected to the State or City Health Secretariat primary health care units. They exist in more populated areas and are accepted by workers as the best way to accomplish the diagnosis of occupational diseases. There is important participation by the trade unions in the management of these reference centres. For 30 years now employers organisations have also kept specialised services for safety and occupational health. Although they are better equipped they are less well used by the workers than the CRSTs. At the federal level, activities concerned with occupational health are connected to three ministries: Labour, Health and Social Security. The Ministry of Labour enacts legislation on hygiene, safety and occupational medicine, performs inspections through its regional units and runs a number of research projects. The Ministry of Health provides medical care for workers injured or affected by occupational diseases and also has surveillance programmes for certain occupational diseases. The Ministry of Social Security provides rehabilitation and compensation for registered workers. In spite of a decrease in the number of accidents at work during the past 25 years, working conditions have not improved. Changes in the laws of social security in the 1970s discouraged registration and reporting of occupational injuries and diseases. In consequence death rates due to accidents increased. With the implementation of the CRSTs, the recorded incidence of occupational diseases has risen, not only because of improved diagnosis, but also because of stronger pressure from the unions and better organisation of public services and enterprises.

Pneumoconiose em trabalhadores de industria de abrasivos / Pneumoconiosis in workers of abrasive industry

O desenvolvimento de pneumopatia profissional em operarios de industrias de material abrasivo e incomun, sendo ate recentemente considerada a silica como causadora da pneumoconiose. Analisamos 22 operarios destas industrias em que se detectaram alteracoes radiograficas de torax. Todos eram do sexo masculino, com idades variando de 29 a 59 anos. Dezenove trabalhavam na producao de carbeto de silicio, tres na producao de oxido de aluminio e um em ambos, tendo ficado expostos por um periodo de 8 a 27 anos. As alteracoes radiologicas (ILO-80) predominantes foram pequenas opacidades em 20 pacientes. Associacao de grandes e pequenas opacidades foram observadas em um caso e grandes opacidades isoladamente em um. As pequenas opacidades foram predominantemente difusas e arredondadas. Nos dois doentes com grandes opacidades, estas se enquadravam como categoria B. Conclui-se que operarios em industrias de abrasivos encontram-se sob risco de desenvolvimento de pneumopatia profissional mais provavelmente desencadeada pela inalacao de carbeto de silicio.

[Pneumoconiosis in abrasive industry workers]. / Pneumoconiose em trabalhadores de indústria de abrasivos.

Occupational lung disease is uncommon in workers of abrasive industries. Twenty-two workers of these industries presenting radiological lung lesions were analysed. All were males with ages ranging from 29 to 59 years. Nineteen worked in the production of silicon carbide, three in the production of aluminum dioxide and one in both for a period of 8 to 27 years. In 20 patients the predominant radiological changes (ILO-80) were small opacities. Association of small and large opacities was observed in one case and isolated large opacities in another one. The small opacities were predominantly round and diffuse. The large opacities in both patients were classified as being of category B. It is concluded that the workers in abrasive industries are at a higher risk of developing occupational lung disease produced by silicon carbide.

[Asbestos and bronchogenic carcinoma: a search for fibers in the pulmonary tissue of 3 patients with bronchogenic carcinoma]. / Asbesto e carcinoma broncogênico: pesquisa de fibras em tecido pulmonar de três pacientes portadores de carcinoma broncogênico.

Based on the highly suspicious radiological findings of exposure to asbestos (case 1) or on a positive occupational history (cases 2 and 3), the authors looked for the presence of fibers in blocks of lung tissue removed in autopsy or surgical biopsies of three cases of bronchogenic carcinoma. The blocks were submitted to sodium hypochloride digestion followed by fiber identification in phase contrast light microscopy. The authors were able to demonstrate the presence of fibres in the three cases. The likelyhood of those carcinomas being caused by exposure to asbestos is very high, as two out of the three cases showed pulmonary fibrosis (cases 1 and 2) and the other case showed typical parietal pleural plaques at thoracotomy.

Pleural biopsy with Cope and Abrams needles.

The object of this study was to compare the diagnostic yield of Abrams and Cope needles. Pleural biopsies were performed in 24 patients with both needles. In two patients, the procedure was repeated within a few days. All patients had pleural effusion. The biopsies were performed at the same time; the biopsy sites were no more than 5 cm distant from each other. Diagnoses were exclusively pathologic. There was no difference between the needles in relation to diagnosis; greater size of the fragment, mesothelial cells, and fibrin were most frequently obtained by Abrams needle, while muscle was better obtained with the Cope needle. The biopsies with both needles were very similar regarding chronic inflammation, granuloma, caseous necrosis, neoplastic tissue, granulation, neutrophils, hemorrhage, vessels, nerves, adipose tissue and epidermis. The advantages of more pleural tissue obtained with the Abrams needle was not translated into better diagnostic yield in the present series.

[Immunopathological studies in herpes gestationis]. / Estudos de inmunopatologia no herpes gestationis.

Immunologic studies were made in two patients with "herpes gestationis". Direct and indirect immunofluorescence studies lead to the following results: 1. DIF was done with antisera against IgG, IgM, IgA, IgE and C3. Only the deposit of C3 was detected on the basal membrane zone of the lesioned skin. In one of the patients the deposit was found also on healthy skin. 2. IIF did not show immunoglobulins against the basal membrane in sera but in both patients a termolabil factor (factor HG) which activates the fixation of the complement onto the basal membrane zone was detected. No correlation between the immunopathologic pattern of Herpes gestationis and that of the other bullous diseases which cause subepidermic bullae was found. However there was a significant similarity between the immunologic pattern of Herpes gestationis and Bullous pemphigoid.