Clinical statistics analysis on the characteristics of pneumoconiosis of Chinese miner population

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1 Originl Article Clinicl sttistics nlysis on the chrcteristics of pneumoconiosis of Chinese miner popultion Mei-Fng Wng 1 *, Run-Ze Li 2 *, Ying Li 2, Xue-Qin Cheng 1, Jun Yng 1, Wen Chen 3, Xing-Xing Fn 2, Hu- Dn Pn 2, Xio-Jun Yo 2, To Ren 1, Xin Qin 1, Ling Liu 2, Eline Li-Hn Leung 2, Yi-Jun Tng 1 1 Deprtment of Respirtory Medicine, Tihe Hospitl, Hubei University of Medicine, Shiyn , Chin; 2 Stte Key Lbortory of Qulity Reserch in Chinese Medicine/Mcu Institute for Applied Reserch in Medicine nd Helth, Mcu University of Science nd Technology, Mcu (SAR), Chin; 3 Deprtment of Medicl Imging, Tihe Hospitl, Hubei University of Medicine, Shiyn , Chin Contributions: (I) Conception nd design: L Liu, EL Leung, YJ Tng; (II) Administrtive support: L Liu, YJ Tng; (III) Provision of study mterils or ptients: YJ Tng; (IV) Collection nd ssembly of dt: MF Wng; (V) Dt nlysis nd interprettion: RZ Li; (VI) Mnuscript writing: All uthors; (VII) Finl pprovl of mnuscript: All uthors. *These uthors contributed eqully to this work. Correspondence to: Yi-Jun Tng. Respirtory Medicine deprtment of Tihe Hospitl, Hubei University of Medicine, Wuhn , Chin. Emil: tngyijun_799@163.com; Eline Li-Hn Leung. Stte Key Lbortory of Qulity Reserch in Chinese Medicine/Mcu Institute for Applied Reserch in Medicine nd Helth, Mcu University of Science nd Technology, Mcu (SAR), Chin. Emil: lhleung@must.edu.mo; Ling Liu. Stte Key Lbortory of Qulity Reserch in Chinese Medicine/Mcu Institute for Applied Reserch in Medicine nd Helth, Mcu University of Science nd Technology, Mcu (SAR), Chin. Emil: lliu@must.edu.mo. Bckground: Pneumoconiosis is one of the most common occuptionl diseses, which shows the progressive nd irreversible pthologicl chnges. It ultimtely cn induce pulmonry filure nd led to deth. To dte, these ptients hve no curtive tretment option under the current stndrd of cre, so it is especilly importnt to dely the onset of the disese nd slow down its progression. Therefore, understnding of clinicl fetures of pneumoconiosis is prticulrly criticl for medicl intervention. Methods: We collected the clinicl dt from 118 pneumoconiosis cses of miners dmitted in hospitl nd processed the sttistics nlysis by using the Chi-squre test nd the risk ssessment. Results: Compred to other types of miners, gold miners re lible to cuse Broncho-pulmonry coinfection with Chi-squre vlue nd the P vlue < However, unexpectedly, the smoking miners displyed better Activities of Dily Living (ADLs) compred to non-smokers, which showed of Chi-squre score nd less thn of P vlue. And this connection ws ssocited with the dust exposure time (P<0.05), showing the incresing risk of non-smoking miners occurred s the incresing time exposed to dust. In ddition, our nlysis indicted tht the probbility of smoking miners suffered from Bronchopulmonry co-infection ws less thn non-smoking miners with Chi-squre vlue nd P<0.01, which ws lso ssocited with the dust exposure time tendentiously, though P>0.05. Moreover, smoking history exhibited deteriorting effect to the overll survivl (OS) with of Chi-squre vlue nd P<0.05, in ccordnce with smoking reducing life time. Interestingly, pneumoconiosis drugs could extend the smokers OS, but not non-smokers. Conclusions: Our studies suggest tht the history of smoking nd exposure time of dust ply importnt roles in the development of pneumoconiosis nd smoking could be fctor tht determines the tretment options depending on ptients smoking history. Keywords: Pneumoconiosis; epidemiology (EP); prevention & control (PC) Submitted My 10, Accepted for publiction Jun 26, doi: /jtd View this rticle t:

2 2204 Wng et l. Chrcteristics of pneumoconiosis Introduction Pneumoconiosis is one of the most common diseses in the miners, which is chrcterized by the progressive nd irreversible pthologic fetures. The min cuse of this disese is the excessive inhltion of dust in working process, which cn led to repeted inflmmtion, progressive pulmonry fibrosis, reducing the ptients survivl time, lung function filure nd eventully cuse deth (1). Epidemiologicl investigtion on the globl lung diseses showed tht the prevlence of pneumoconiosis rnked the top of occuptionl lung diseses, especilly in developing countries, where this phenomenon is more serious (2). Chinese is one of popultions exposed to dust most widely with the highest prevlence of pneumoconiosis every yer (3,4). According to the reports of 2014 Ntionl Occuptionl Disese published by Ntionl Helth nd Fmily Plnning Commission (NHFPC) of the People s Republic of Chin, there were 29,972 new cses of occuptionl lung diseses dignosed in 2014, 90% of which ws pneumoconiosis, nmely 26,873 cses. When clssified by types of jobs, col mining, wshing industry nd nonferrous metl mining industry were rnked the top three with 11,396 cses, 2,935 cses nd 4,408 cses, respectively, ccounting for 62.52% of ll new diseses (5). The direct economic loss for the country reched 8 billion per yer, nd the indirect economic losses even reched 20 billion (6,7). However, the pneumoconiosis is still not curble s there is no effective tretment or control drug to slow down the disese progression. Currently the most effective wy to retrd the disese is prevention. Studies hve shown tht reducing the worker s dily brething concentrtion of dust cn effectively reduce the chnce of suffering from pneumoconiosis (8,9). According to the rules of Americn Conference of Governmentl Industril Hygienists (ACGIH), they defined the dngerous levels of work conditions by cler principle on working hours nd dust concentrtion. And more specificlly, the dngerous levels were different from ech type of dust becuse the mximum llowble levels were different (10,11). The methods currently pplied to control the concentrtion of dust re: technologicl innovtion, wet field opertions, ventiltion dust, individul protective equipment, occuptionl helth mngement, helth eduction, monitoring nd inspection (12). With the rpid development of economy nd industry, nd the insufficient protection of the environment, there re more thn 6 million underground mining workers under the thret of Pneumoconiosis in Chin (13). So the finncil burden for inititing preventive efforts is extremely serious (14). Therefore, it is very essentil to lern the bsic condition of pneumoconiosis ptients, effectively find out the chrcteristics of Chinese miners pneumoconiosis, nd develop effective tretment strtegies to prevent nd control this illness. In this study, we hve collected ptient informtion of 118 clinicl cses from the Tihe Hospitl. We nlyzed the clinicl dt of pneumoconiosis ptients by using the sttisticl methods of the Chi-squre test, the multilyer Chisqure test nd the risk rtio (RR) test, nd identified the chrcteristics of this disese to develop useful prevention nd tretment strtegies for the clinicl ptient cre. Methods Bsic subjects According to the dignostic criteri of pneumoconiosis (15,16), 118 pneumoconiosis ptients (117 mles nd 1 femle) from Tihe Hospitl were retrospective nlyzed since 2010, nd 50 (42.4%) of col miners, 19 (16.1%) of gold miners, 12 (10.2%) of mixer of both nd 37 (31.4%) of other miners were included. According to lung imging dignosis of pneumoconiosis ptients (16), there were 18 (15.3%) ptients in stge I, 83 (70.3%) in stge II, nd 17 (14.4%) in stge III, who were dignosed when first dmitted to Tihe hospitl. We lso clssified these ptients into different groups: groups ccording to ge, <50 yers old of 83 (70.3%) nd >50 yers old of 35 (29.7%); groups ccording to smoking history, 55 (46.6%) of smokers nd non-smokers of 63 (53.4%). In ddition, they were divided by dust exposure time: 16 (13.6%) <3 yers, 17 (14.4%) between 3 5 yers, 41 (34.7%) between 5 10 yers, nd 44 (37.3%) >10 yers. Among them, except one ptient without ny tretment, 15 (12.7%) of these ptients were treted with drugs specificlly used for pneumoconiosis, 22 (18.6%) of them were subjected to lung lvge therpy, nd combintion of both tretments pplied to other 80 (67.8%) ptients. The study protocol ws pproved by the Deprtment of ethnics committee, Shiyn Tihe Hospitl (ID: ) nd ws conducted in ccordnce with the Helsinki Declrtion of 1964 (revised 2008). Observtion subjects To lern the pthologicl chrcteristics of pneumoconiosis, mnifold investigtion nd observtion were included in this

3 Journl of Thorcic Disese, Vol 8, No 8 August Tble 1 Risk ssessment nd comprison between Broncho-pulmonry co-infection history nd types of miners in different conditions Bsic nd Broncho-pulmonry co-infection history observtion >3 times/yer <3 times/yer BD vlue b subjects Gold miner Col miner Mixer Other miners Gold miner Col miner Mixer Other miners Ages P>0.05 <50 yers old >50 yers old Dust exposure time P>0.05 <3 yers yers yers >10 yers Tretments P>0.05 Drugs c Lung lvge Combintion d Totl number (percentge of ll) 9 (7.6%) 7 (5.9%) 2 (1.7%) 6 (5.1%) 10 (8.5%) 43 (36.4%) 10 (8.5%) 31 (26.3%) F/χ (P=0.005) RR e (95% CI f ) ( ) g ( ) g ( ) g RR, risk rtio., mix of col nd gold mine; b, Breslow-Dy P vlue (test of conditionl independence); in this tble, becuse of the qudruple-observtion objects, it cnnot provide exct P vlue; c, drugs specificlly used for pneumoconiosis; d, combintion of drugs nd lung lvge; f, confidence intervl; g, risk rtio of co-infection >3 times/yer compred to gold miner. study: overll survivl (OS), Activities of Dily living (ADLs, term used in helthcre refer to people s dily self-cre ctivities, which ws clssified into two phses in this reserch: living independently nd living with help) (17), smoking history, syndromes including concurrent tuberculosis, concurrent hemoptysis, pneumothorx nd Bronchopulmonry infection cses. Ptients signed n informed consent, nd their other personl informtion will not be published to protect ptient privcy. Dignostic criteri According to the Chin Ntionl pneumoconiosis dignostic criteri, pneumoconiosis ptients should hve dust exposure history records nd pproprite chest X-ry exmintion (18). Sttisticl nlysis Becuse the dignosis time could not correspond to the rel disese time, the initil exposure time to dust ws used s sttisticl trget. All the sttisticl nlysis procedures were performed by using SPSS 22.0 (SPSS Institute, Inc., Chicgo, IL, USA). Differences between different groups of ptients were ccessed by using Chi-squre tests ssuming vrinces. In ddition, further nlysis ws performed by the multilyer Chi-squre test to confirm the conditionl independence with the Breslow-Dy vlue. P vlues of less thn 0.05 (2 tiled) re considered significntly different (19,20). Finlly, the risk ssessment of ptients ws predicted by using the RR test, nd it is considered sttisticl significnce s the rtio devited from 1, more devition nd more difference. Results We compred types of miners with different syndromes including concurrent tuberculosis, concurrent hemoptysis, pneumothorx nd Broncho-pulmonry infection by using Chi-squre tests, nd we found tht gold miners re lible to cuse Broncho-pulmonry co-infection with Chi-squre vlue nd the P vlue <0.001 (Tble 1). Moreover,

4 2206 Wng et l. Chrcteristics of pneumoconiosis Tble 2 Risk ssessment nd comprison between smoking history nd ADL in different conditions ADLs Bsic nd observtion subjects Living independently Living with help Smoker Non-smoker Smoker Non-smoker Jobs Gold mine Col mine Mix Other mine Ages <50 yers old >50 yers old Dust exposure time <3 yers yers yers >10 yers Tretments Drugs Lung lvge Combintion Totl number (percentge of ll) 24 (20.3%) 8 (6.8%) 31 (26.3%) 55 (46.6%) F/χ (P=0.004) RR (95% CI) ( ), risk rtio of living independently compred to non-smoker. ADLs, Activities of Dily. BD vlue P=0.118 P=0.696 P=0.038 P=0.972 further risk ssessment predicted tht the risk of gold miners suffered from Broncho-pulmonry co-infection ws lmost 5 times more thn other types of miners (Tble 1). In ddition, we compred vrious types of miners with Broncho-pulmonry co-infection in different conditions of multiple fctors, including ges, dust exposure time nd therpeutic methods by using multilyer Chisqure test, which showed no sttisticl significnce with P>0.05 (Tble 1). Becuse of its specificity, smoking hs been one of the key elements of clinicl concern in lung diseses. Sttisticl nlysis exhibited tht lung functions of smokers declined fster with the incresing smoking yers compred to the non-smokers (21,22). Due to excessive dust exposure, progressive pulmonry fibrosis nd pulmonry filure re esily ppered in miner ptients following pthologicl chnges. To determine whether smoking could worsen pneumoconiosis of miners, we nlyzed the clinicl dt of smoking history nd their ADLs. However, unexpectedly, the smoking miners displyed better ADLs compred to non-smokers, which showed of Chi-squre score nd less thn of P vlue (Tble 2). About 20.3% (24/118) of smokers lived independently compred to 6.8% (8/118) of non-smoking miners, which showed significntly different by using Chi-squre tests. Moreover, the risk ssessment exhibited non-smokers hd 5 times more risk with worse ADLs compred to smokers (Tble 2). We found tht this connection ws ssocited with the dust exposure time with P<0.05, nlyzed by further multilyer Chisqure test in vrious conditions, including jobs, ges, dust exposure time nd tretments (Tble 2). An dditionl risk ssessment indictes tht the incresing risk of nonsmoking miners occurred s the incresing time exposed to dust (Tble 3). The RR vlue ws rising shrply yer by yer, which ws up to fter exposing to dust more thn 10 yers, wheres it ws only when exposure time ws less thn 3 yers. Next, we studied the connection between smoking

5 Journl of Thorcic Disese, Vol 8, No 8 August Tble 3 Risk ssessment between smoking history nd ADLs under different exposure time to dust Dust exposure time ADLs (%) Living independently <3 yers 3 5 yers 5 10 yers >10 yers Totl Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker 1 (11.1) 2 (28.6) 4 (44.4) 2 (25.0) 11 (50.0) 2 (10.5) 8 (53.3) 2 (6.9) 24 (43.6) 8 (12.7) Living with help 8 (88.9) 5 (71.4) 5 (55.6) 6 (75.0) 11 (50.0) 17 (89.5) 7 (46.7) 27 (93.1) 31 (53.4) 55 (87.3) Totl 9 (100.0) 7 (100.0) 9 (100.0) 8 (100.0) 22 (100.0) 19 (100.0) 15 (100.0) 29 (100.0) 55 (100.0) 63 (100.0) RR (95% CI) ( ) ( ), risk rtio of living independently compred to non-smoker ( ) ( ) ( ) Tble 4 Risk ssessment nd comprison between Broncho-pulmonry co-infection history nd smoking history in different conditions Broncho-pulmonry co-infection history Bsic nd observtion subjects <3 times/yer >3 times/yer BD vlue Smoker Non-smoker Smoker Non-smoker Jobs P=0.777 Gold mine Col mine Mix Other mine Ages P=0.450 <50 yers old >50 yers old Dust exposure time P=0.604 <3 yers yers yers >10 yers Tretments P=0.176 Drugs Lung lvge Combintion Totl number (percentge of ll) 50 (42.4) 43 (36.4) 5 (4.2) 19 (16.1) F/χ (P=0.039) RR (95% CI) ( ), risk rtio of co-infection >3 times/yer compred to non-smoker. history nd other co-infection diseses, including concurrent tuberculosis, concurrent hemoptysis, pneumothorx nd Broncho-pulmonry infection. As result, our nlysis indictes tht the probbility of smoking miners suffered from Broncho-pulmonry co-infection ws less thn nonsmoking miners with Chi-squre vlue nd P<0.01 (Tble 4). About 16.1% (19/118) of smoking miners coinfected with Broncho-pulmonry, showing significntly different compred to 4.2% (5/118) of non-smokers, which ws not relted with other fctors, such s jobs, ges nd

6 2208 Wng et l. Chrcteristics of pneumoconiosis Tble 5 Risk ssessment nd comprison between smoking history nd overll survivl in different conditions OS Bsic nd observtion subjects <5 yers >5 yers Smoker Non-smoker Smoker Non-smoker Jobs Gold mine Col mine Mix Other mine Ages <50 yers old >50 yers old Dust exposure time <3 yers yers yers >10 yers Tretments Drugs Lung lvge Combintion Totl number (percentge of ll) 47 (39.8) 47 (39.8) 8 (3.8) 16 (13.6) F/χ (P=0.049) RR (95% CI) ( ) b, mix of col nd gold mine; b, risk rtio of OS <5 yers compred to non-smoker. OS, overll survivl. BD vlue P=0.785 P=0.744 P=0.888 P=0.048 tretments (Tble 4). A further risk ssessment reveled tht the RR of smoking ptients suffered from Bronchopulmonry co-infection ws times of non-smokers, which indicted tht non-smokers my be susceptible to this co-infection. However, this result is quite different from the common sense tht smoking nd dust exposure cn increse the probbility of lung infection. Therefore, we further nlyzed the conditions independence on this result by using multilyer Chi-squre test, s dust exposure time plyed criticl role in the reltionship between ADLs nd smoking history (Tbles 2,3). Although, there ws no sttisticl significnce on the condition of different dust exposure time, the trend still showed tht with the incresing dust time, the non-smokers would hve more probbility to get Broncho-pulmonry co-infection (dt not shown). Finlly, expectedly, smoking history exhibited deteriorting effect to OS with of Chi-squre vlue nd P<0.05 (Tble 5), compring 3.8% of smoking ptients with 13.6% of non-smokers when OS time ws more thn 5 yers. Moreover, the RR indicted tht the non-smokers hd 2 times of probbility to rech more thn 5 yers of OS compred to smokers (Tble 5). Further multilyer Chisqure tests reveled tht the link between smoking history nd OS ws ssocited with therpeutic methods (Tble 5). An dditionl risk ssessment showed tht pneumoconiosis drugs were more beneficil to the smokers for extending OS with RR of (Tble 6), implying tht these drugs my hve side effects to non-smokers nd the drugs therpy my be not pproprite to them. Conversely, lung lvge therpy ws better to non-smokers with RR of (Tble 6). Therefore, these results suggested tht the ptients with the smoking history should select pneumoconiosis drugs therpy lone, nd non-smokers

7 Journl of Thorcic Disese, Vol 8, No 8 August Tble 6 Risk ssessment between smoking history nd overll survivl under different therpeutic methods Tretments OS Pneumoconiosis drugs Lung lvge therpy Combintion of drugs nd lvge Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker Smoker Non-smoker >5 yers 1 (20.0) 1 (10.0) 0 (0) 5 (50.0) 7 (18.4) 10 (23.8) 8 (14.5) 16 (25.4) <5 yers 4 (80.0) 9 (90.0) 12 (100.0) 5 (50.0) 31 (81.6) 32 (76.2) 47 (85.5) 47 (74.6) Totl 5 (100.0) 10 (100.0) 12 (100.0) 10 (100.0) 38 (100.0) 42 (100.0) 55 (100.0) 63 (100.0) RR (95% CI) ( ) ( ) ( ) ( ), risk rtio of OS <5 yers compred to non-smoker. Totl should choose lung lvge therpy lone. Discussion In 1987, Chin encted nd implemented principle entitled Pneumoconiosis disese prevention nd disese control of the People s Republic of Chin, nd in 2001 nother principle ws promulgted: Occuptionl disese prevention nd control of the People s Republic of Chin (23). Although the lws permit the cceptble dust concentrtion of 1 mg/m 3 nd provide the methods to reduce dust concentrtion, the prevlence of pneumoconiosis in Chin hs not yet significntly reduced due to the rpid economic nd industril development. Therefore, understnding of the chrcteristics of pneumoconiosis is prticulrly criticl to effectively control the progress of the pneumoconiosis. Here we compred nd nlyzed the clinicl dt of 118 pneumoconiosis cses from the Tihe Hospitl, which included ll kinds of ptients with different tretment options, co-infection history, ge, dust exposure times, smoking history, working condition nd ADLs. Compred to other types of miners, gold miners re lible to cuse Broncho-pulmonry co-infection (Tble 1). Therefore, it is importnt to strictly control the dust concentrtion especilly in the gold mine re, build nd rise self-protection wreness of miners, nd increse the chnces of physicl exmintion, which will be helpful to lower the morbidity of pneumoconiosis s well s medicl expenses. In trditionl Chinese medicine science, the pneumoconiosis is considered s type of chronic diseses, nd the dust s dryness fctor could block the min nd collterl chnnels of lung, ultimtely leding to the Qi nd Yin deficiency in the body. Consequently, to investigte the tretment of Chinese medicine will be beneficil to invigorte the primordil Qi nd Yin nd improve physicl helth, such s Bu Zhong Yi Qi formul, Sh Shen Mi Dong formul (24) nd tetrndrine (25). Smoking is one of the common fctors leding to pneumoni. The reltionship between pneumoconiosis nd smoking history could be criticl fctor ffecting the medicl dvice nd tretments (26). Unexpectedly (27), our nlyticl dt indicted tht there ws negtive correltivity between smoking history nd Bronchopulmonry co-infection, which showed tht the probbility of smoking miners suffered from Broncho-pulmonry co-infection ws less thn non-smoking miners (Tble 4) which ws concerned with the dust exposure time fctor. Moreover, if the dust exposure time ws less thn 3 yers, non-smokers kept better ADLs thn the smoking miners. Reversely, s the incresing time exposed to dust, there ws n incresing risk of non-smoking miners (Tble 3). Unfortuntely, the smoking miners OS ws still shorter thn non-smokers (Tble 5), in ccordnce with smoking reducing life time (28). Interestingly, pneumoconiosis drugs could only extend the smokers OS, but not the nonsmoking miners (Tble 6). One possibility is tht these drugs could relieve the lung filure due to smoking nd hve side effects on non-smokers. Therefore, compred to these different tretments, we recommended tht the ptients with the smoking history should select pneumoconiosis drugs therpy lone, nd non-smoking ptients should choose lung lvge therpy lone without pneumoconiosis drugs. In conclusion, the smoking history nd dust exposure time ply importnt roles in the progression of pneumoconiosis. However, the stge of disese s nother fctor need to be excluded if we wnt to confirm this conclusion. Coinfections often hppened in stge III of pneumoconiosis,

8 2210 Wng et l. Chrcteristics of pneumoconiosis but the most ptients dmitted to the hospitl were in stge II. Hence, we need to collect more stge III ptients nd observe their condition. Moreover, we will further focus on finding out the biologicl fctors tht my chnge the possibility of co-infection rtio in the different dust exposure time. To dte, there is no vilble tretment for pneumoconiosis provided by ny institution or rndomized controlled tril (RCT). The reserch on this disese is lmost bout the prevlence, risk ssessment nd clinicl experiments. Dr. Wng chose six different Chinese medicine formuls to tret the pneumoconiosis, nd observed the ptients relief from the symptoms (24). Dr. To divided pneumoconiosis into four syndromes nd gve different formuls. The two results bove suggested tht their therpies hd efficcy, however, their experiments did not use rndomized control method nd not evluted by sttisticl nlysis. More probble, it is essentil to set up pneumoconiosis clinicl reserch criterion to further study nd tret this disese. Here we found the fundmentl properties of pneumoconiosis, but we still hve long wy to go to prevent nd control this disese, nd the discovery of effective drugs nd other efficient tretments pper especilly importnt. Ptients of stge II were dominted in this retrospective study, so further vlidtion nlyzes with more popultions of other stges re needed to confirm our findings. In ddition, more mechnism nd functionl study is needed to promote drugs development in the future. Acknowledgements Funding: This work ws supported by Mcu Science (021/2013/A1), Technology Development Found (005/2014/AMJ), Ntionl Nturl Science Foundtion of Chin ( ), Eductionl Commission of Hubei Province of Chin (D ) nd Science nd technology Progrm of Shiyn, Chin (15Y20). Footnote Conflicts of Interest: The uthors hve no conflicts of interest to declre. Ethicl Sttement: The study protocol ws pproved by the Deprtment of ethnics committee, Shiyn Tihe Hospitl (ID: ) nd ws conducted in ccordnce with the Helsinki Declrtion of 1964 (revised 2008). Ptients signed n informed consent, nd their other personl informtion will not be published to protect ptient privcy. References 1. Chen W, Liu Y, Wng H, et l. Long-term exposure to silic dust nd risk of totl nd cuse-specific mortlity in Chinese workers: cohort study. PLoS Med 2012;9:e Pingle S. Occuptionl sfety nd helth in Indi: now nd the future. Ind Helth 2012;50: Anto VC, Petsonk EL, Sokolow LZ, et l. Rpidly progressive col workers' pneumoconiosis in the United Sttes: geogrphic clustering nd other fctors. Occup Environ Med 2005;62: Hn L, Hn R, Ji X, et l. Prevlence Chrcteristics of Col Workers' Pneumoconiosis (CWP) in Stte-Owned Mine in Estern Chin. Int J Environ Res Public Helth 2015;12: Chin NHFPCotPsRo. The Ntionl Occuptionl Disese Report of Ministry of Lnd nd Resources of the People's Republic of Chin; 8, DEC, Avilble online: t _ htm 6. Shi ZC. Whole lung lvge for tretment of pneumoconiosis. Zhonghu Lo Dong Wei Sheng Zhi Ye Bing Z Zhi 2010;28: Xi Y, Liu J, Shi T, et l. Prevlence of pneumoconiosis in Hubei, Chin from 2008 to Int J Environ Res Public Helth 2014;11: Shen F, Yun J, Sun Z, et l. Risk identifiction nd prediction of col workers' pneumoconiosis in Kilun Colliery Group in Chin: historicl cohort study. PLoS One 2013;8:e Petsonk EL, Rose C, Cohen R. Col mine dust lung disese. New lessons from old exposure. Am J Respir Crit Cre Med 2013;187: Torres Rey CH, Ibñez Pinill M, Briceño Ayl L, et l. Underground col mining: reltionship between col dust levels nd pneumoconiosis, in two regions of Colombi, Biomed Res Int 2015;2015: Gun HY, Zhng H, Su LP, et l. The study of the chrcteristics nd influencing fctors of pneumoconiosis mong workers exposed to dusts in n iron mine. Zhonghu Lo Dong Wei Sheng Zhi Ye Bing Z Zhi 2012;30: Shen F, Liu H, Yun J, et l. Cost-Effectiveness of col workers' pneumoconiosis prevention bsed on its predicted incidence within the Dtong Col Mine Group in Chin.

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