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Original Research: Occupational and Environmental Lung Diseases |

Artificial Stone SilicosisSilicosis Resurgence Among Stone Workers: Disease Resurgence Among Artificial Stone Workers FREE TO VIEW

Mordechai R. Kramer, MD, FCCP; Paul D. Blanc, MD, MSPH, FCCP; Elizabeth Fireman, PhD; Anat Amital, MD, FCCP; Alexander Guber, MD, FCCP; Nader Abdul Rhahman, MD; David Shitrit, MD
Author and Funding Information

From the Pulmonary Institute (Drs Kramer, Amital, and Rhahman), Rabin Medical Center, Beilinson Campus, Petach Tikva; the Pulmonary Department (Drs Guber and Shitrit), Meir Medical Center, Kfar Saba, affiliated with Sackler Faculty of Medicine, Tel Aviv University; the Institute of Pulmonary and Allergic Diseases (Dr Fireman), National Service for Interstitial Lung Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; and the Division of Occupational and Environmental Medicine (Dr Blanc), Department of Medicine, University of California, San Francisco, San Francisco, CA.

Correspondence to: David Shitrit, MD, Pulmonary Department, Meir Medical Center, Kfar Saba 49100, Israel; e-mail: davids3@clalit.org.il


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

Funding/Support: The authors have reported to CHEST that no funding was received for this study.


Chest. 2012;142(2):419-424. doi:10.1378/chest.11-1321
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Background:  Silicosis is a progressive, fibrotic, occupational lung disease resulting from inhalation of respirable crystalline silica. This disease is preventable through appropriate workplace practices. We systematically assessed an outbreak of silicosis among patients referred to our center for lung transplant.

Methods:  This retrospective cohort analysis included all patients with a diagnosis of silicosis who were referred for evaluation to the National Lung Transplantation Program in Israel from January 1997 through December 2010. We also compared the incidence of lung transplantation (LTX) due to silicosis in Israel with that of the International Society for Heart and Lung Transplantation (ISHLT) registry.

Results:  During the 14-year study period, 25 patients with silicosis were referred for evaluation, including 10 patients who went on to undergo LTX. All patients were exposed by dry cutting a relatively new, artificial, decorative stone product with high crystalline silica content used primarily for kitchen countertops and bathroom fixtures. The patients had moderate-to-severe restrictive lung disease. Two patients developed progressive massive fibrosis; none manifested acute silicosis (silicoproteinosis). Three patients died during follow-up, without LTX. Based on the ISHLT registry incidence, 0.68 silicosis cases would have been expected instead of the 10 observed (incidence ratio, 14.6; 95% CI, 7.02-26.8).

Conclusions:  This silicosis outbreak is important because of the worldwide use of this and similar high-silica-content, artificial stone products. Further cases are likely to occur unless effective preventive measures are undertaken and existing safety practices are enforced.

Figures in this Article

Silicosis is a progressive, fibrotic, occupational lung disease resulting from inhalation of respirable crystalline silica. This disease is preventable through appropriate workplace practices.1,2 Mineral sources of silica are abundant, and include quartz, granite, sandstone, slate, and sand.3 Occupations traditionally associated with increased risk of silicosis include glass and pottery making, mining and quarrying, sandblasting, and any construction trades that generate silica dust through stone or concrete work.4,5 There is no established effective treatment regimen for silicosis other than supportive care. Although corticosteroid therapy has been used for acute silicosis, it is of unproven benefit.6 In recent years, lung transplantation (LTX) has emerged as a potential intervention for end-stage disease.79

We noted a dramatic increase in the number of patients with silicosis referred for evaluation to the National Lung Transplantation Center in Israel. Detailed routine evaluation of the LTX candidates, including an occupational exposure history, revealed that all cases were decorative stone workers whose employment involved cutting a new, high-silica-content, artificial stone product used primarily for kitchen and bathroom countertops. We systematically investigated this silicosis outbreak, conducting a retrospective analysis of all cases of silicosis referred to our center for LTX evaluation over a 14-year period.

Study Population

We conducted a retrospective analysis of all patients referred to our outpatient LTX evaluation center with a diagnosis of silicosis from January 1997 through December 2010. This is the sole national referral site for LTX in Israel. All case subjects received a diagnosis prior to LTX during the initial evaluation, which included biopsy material in all but two cases. Histologic reconfirmation in all transplanted cases was carried out using explanted lung tissue. In addition to analyzing our own experience, including comparison with overall survival for all LTX cases regardless of diagnosis, we compared the frequency of LTX cases for silicosis in Israel with data from the International Society for Heart and Lung Transplantation (ISHLT) registry. The institutional review board of Rabin Medical Center approved the study protocol (IRB number 6313-2011).

Diagnosis of Silicosis

A pretransplant diagnosis of silicosis was based on criteria consistent with those of the US National Institute for Occupational Safety and Health (NIOSH), including an occupational history indicating a high likelihood of exposure to respirable silica dust and radiographic evidence of fibrotic lung disease in a pattern supportive of this diagnosis.4 Histologic confirmation was also obtained in all but two cases that relied solely on the NIOSH algorithm. Based on the extent of disease and the time that had elapsed since first exposure, we classified patients into those with accelerated disease with progressive massive fibrosis (PMF) or chronic silicosis.

We analyzed several CaesarStone samples of various colors using x-ray powder diffraction at the Analytical Research Services and Instrumentation Unit of Ben Gurion University of the Negev (Philips 1050/70 powder diffractometer, with a graphite monochromator on diffracted beam providing K-alpha radiation [1.541Å], operating at v = 40 kV, I = 30 mA). Phase identification was performed using the Bede ZDS computer search/match program coupled with the International Centre for Diffraction Data Powder Diffraction File database (1999).

Transplant Evaluation and Statistical Analysis

All referrals underwent a complete standardized evaluation as part of the assessment for potential LTX candidacy, including a detailed occupational exposure history, pulmonary function testing (yielding lung volumes and flows and a diffusing capacity for carbon monoxide), a 6-min walking test, and a full cardiopulmonary exercise test. In addition, all patients underwent high-resolution CT imaging of the thorax. Invasive diagnostic procedures, including fiberoptic bronchoscopy and/or video-assisted thoracoscopic surgery, were performed, depending on the clinical diagnostic context. Routine follow-up included monthly outpatient visits. Interval deterioration in clinical status or lung function guided additional pre-LTX testing.

Standard operative techniques were used for LTX. All patients were followed closely posttransplant, with at least monthly outpatient evaluations and standard bronchoscopic surveillance. No transplanted patient was lost to follow-up. A median follow-up of 23 months was accrued through December 31, 2010. The incidence of silicosis-related LTX in Israel was compared with the expected rate in the IHSLT registry and tested as the ratio of a Poisson variable to its expected value.10

During the 14-year study period, we gave 25 patients a diagnosis of silicosis. All cases were diagnosed based on detailed occupational history. Histologic confirmation that relied solely on the NIOSH algorithm was also obtained in all but two cases. Of these, 15 (60%) were determined to be potential candidates for LTX, 12 were listed, and 10 (40%) ultimately underwent transplant. Among them were a father and son, both of whom developed silicosis after working together. The father underwent LTX, and the son is currently listed for LTX. Over the same period, 320 other patients underwent LTX at this center. Figure 1 shows the frequency by year of 25 case referrals for transplant evaluation between 1997 and 2010.

Figure Jump LinkFigure 1. Reported cases of silicosis due to engineered stone among lung transplant candidates in Israel.Grahic Jump Location

We found that all 25 patients shared an exposure history of working with the same commercial brand of decorative, synthetic stone material, performing a similar work task of dry cutting the stone for end-use in construction, predominantly for kitchens and other countertop applications. Review of the manufacturer’s material safety data sheet for product information documented that this material, CaesarStone, contains > 85% crystalline silica.11 Although the first cases were recognized between 1997 and 2001 (Fig 1), these were scattered events. Thus, we did not appreciate the nature of the outbreak until the accumulated 10-case cluster was fully manifested.

All 25 patients reported that > 90% of their typical work duties involved handling CaesarStone. Less than 10% included other potential exposure sources of silica, primarily natural granite. In 1987, CaesarStone became the world’s first company to use quartz as the main component in its new surfacing material. It contains at least 85% natural quartz aggregates and a small amount of pigments and enhanced polymer resins.11

The patients all reported that their work was performed without dust suppression (eg, wet as opposed to dry cutting or effective local ventilation), typically working without any personal respiratory protection, an average of 10 to 12 h daily. We are not aware of any industrial hygiene measurements or other assessments carried out by governmental inspectors at the workplaces implicated in this outbreak; thus, there are no data quantifying the airborne dust concentrations that occurred.

Table 1 presents the demographic and clinical characteristics of the transplant candidates and recipients with silicosis. As shown, most of the patients were middle-aged men with a BMI < 25 m2/kg; the majority smoked. Occupational exposure ranged from 17 ± 9 years to 22.0 ± 7 years. All had moderate-to-severe restrictive lung disease, and most (including the LTX recipients) were dependent on oxygen supplementation. Two candidates manifested characteristics of PMF consistent with accelerated silicosis; all others were classified as chronic silicosis. There were no cases of acute silicosis (silicoproteinosis) among the 25 patients.

Table Graphic Jump Location
Table 1 —Demographic and Clinical Characteristics of 15 Patients Determined to be Transplant Candidates and of 10 Patients Who Underwent LTX for Artificial Stone Silicosis

Data are presented as mean ± SD or No. (%) unless indicated otherwise. Dlco = diffusing capacity of the lung for carbon monoxide; LTX = lung transplant; Sao2 = arterial oxygen saturation; TLC = total lung capacity; Va = alveolar volume; VATS = video-assisted thoracoscopic surgery.

Most of the candidate patients (86%) underwent diagnostic procedures (video-assisted thoracoscopic surgery in seven and bronchoscopy in six) to confirm the silicosis diagnosis with tissue. Similar procedures were done presurgically in the LTX recipients. Most were treated with oral steroids prior to further surgical intervention, but none had a clinically significant response. Mean waiting time from listing until the LTX was 10 ± 4 months.

Figure 2 shows CT scans of the lung in two transplant candidates with advanced silicosis from this series. Figure 2A presents a patient with diffuse micronodular pattern, and Figure 2B presents a patient with PMF.

Figure Jump LinkFigure 2. A, CT scan of lung transplant candidate with advanced silicosis with diffuse micronodular pattern. B, CT scan of lung transplant candidate with advanced silicosis due to Artificial Stone with progressive massive fibrosis at presentation.Grahic Jump Location

The typical histologic findings from the explanted lung of a patient with silicosis included severe patchy pulmonary fibrosis, mainly peripheral and centrilobular, with conglomerates of rounded scars compatible with silicotic nodules. Birefringent particles consistent with silica were present in the nodules.

All CaesarStone samples were analyzed using an x-ray powder diffraction method and were found to have high silica content. Silica particles were present on imaging and confirmed through phase identification.

Seven of the 10 LTX recipients underwent a single LTX, whereas the remaining three underwent bilateral LTX. The 1-year survival of the patients with silicosis after LTX was similar to that of other LTX recipients in our center during this period (83% ± 4% vs 81% ± 7%, respectively; P = .64). Two LTX candidates died a mean of 18 ± 4 months after diagnosis, both from acute respiratory failure.

Based on cumulative ISHLT registry data for 1997 through 2010, 50 of 24,090 patients (0.2%) underwent LTX because of silicosis, compared with 10 of 330 patients (3.0%) in our experience over a comparable interval. Using the ISHLT rate, we would have anticipated less than one case (0.684), yielding a ratio of observed to expected of 14.6 (95% CI, 7.0-26.8). The sources of silica exposure are not reported in the ISHLT data. As noted, all of these cases were related to work with the same synthetic stone product.

We report here an unusually high incidence of advanced, life-threatening silicosis linked to a specific, relatively new, engineered product with a high silica content. This cause-and-effect relationship is supported by the extraordinary case incidence we observed over a short period linked to a single exposure scenario, a nearly 15-fold increase in the expected transplant rate for this condition. This relationship is strengthened by the similar occupational histories of the patients; the known high silica content composition of the product; the likelihood (based on standard industrial hygiene principles) that levels of respirable silica in excess of recommended standards would have been generated by the practice of dry cutting stone, as was described by the patients; and the time of disease presentation in relation to the commercial introduction of this product, which occurred in the late 1980s, approximately 10 years before our first index case.

Silicosis is one of the oldest occupational diseases known to humankind, recognized as miner’s phthisis centuries ago.12,13 Unfortunately, the disease is still endemic worldwide, and lethal outbreaks that could have been prevented continue to be reported. An example in another industry was an epidemic of silicosis among young garment factory workers in Turkey who sandblasted blue jeans.14 In the 20th century, one of the most infamous silicosis outbreaks was linked to tunneling at Gauley Bridge in the United States, which claimed hundreds of lives.15

CaesarStone is based on a synthetic polymer resin bound with a high (≥ 85%) silica content.11 Its physical properties of strength, water resistance, and pigment options present advantages over natural granite. In contrast to CaesarStone, granite carries a lower silica exposure risk. CaesarStone was the first commercial synthetic decorative stone of its type that was marketed widely, but since its introduction in 1987, other similar products have been introduced. The two most prevalent of these are Silestone (manufactured in Spain) and Zodiaq, a DuPont product from the United States. Silestone has been associated recently with two separate case clusters of silicosis totaling nine individuals (one of whom was reported to have PMF), although none was reported to have LTX.16,17

It is likely that many other cases of Artificial Stone silicosis and related synthetic stone lung diseases are yet to be diagnosed. Indeed, there are many small workshops in Israel using high-silica-content artificial stone with inadequate worker protection. It is also important to emphasize that we have described only cases that both came to medical attention and were referred for transplant evaluation; thus, the true national case incidence of silicosis in Israel is probably higher. Another limitation of this report is that we do not have dust exposure measurements (eg, characterizing particle size distributions) quantifying exposures that occurred. There can be little doubt, however, that the practices described resulted in overexposure. A recent serious US Occupational Safety and Health Administration citation for overexposure to silica among employees dry cutting stone, specifically including CaesarStone, Silestone, and Zodiaq, underscores this presumption.18

The 20% proportion of PMF (two of 10 transplanted cases) we report is difficult to contextualize and may or may not be generalizable. To our knowledge, the only other published series describing LTX for silicosis reported none with PMF among 11 cases.19

This report emphasizes the importance of routinely obtaining a detailed occupational exposure history during the initial evaluation of all LTX candidates. Once the nature of the outbreak was apparent, we used the media to increase public awareness of its root cause, emphasizing that silicosis is preventable. We also urged the Ministry of Health in Israel to enforce existing regulations to protect those working with CaesarStone. We believe that disease recognition and reporting, and the identification of disease clusters is critical for the prevention of silicosis. Awareness of the outbreak, and analyzing the information and acting on it, might lead to improved prevention and reduced risk of future disease.

Additionally, given the latency of the silicosis, additional cases may be discovered in the future as a result of the exposures. Moreover, delay in recognizing the problem may have led to ongoing hazardous exposures and more cases. It should be emphasized that many individuals with exposure-related disease and disability may not be seen on a transplant service, because most people with pulmonary impairment are not appropriate candidates for this intervention. In addition, the low numbers of patients with silicosis seen in transplant services should suggest that even two or three patients with the same exposure history should be a cause for concern and heightened investigation. It is not surprising that the authors and others on the service did not recognize this outbreak as it was manifesting itself initially, but this report may help others understand what might have been done to improve early identification of unusual disease patterns through analysis of the available data.

In summary, we report an outbreak of end-stage silicosis leading to LTX, a disease epidemic caused by dust generated through dry cutting engineered decorative stone with very high silica content. Strict enforcement of occupational safety and health regulations could have prevented this needless tragedy. Appropriate public health interventions to prevent future occurrences should be undertaken.

Author contributions: Dr Shitrit is the guarantor of the paper. He had full access to all of the study data and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Kramer: contributed to the study design, data collection, and manuscript review and approval.

Dr Blanc: contributed to the data analysis and manuscript writing and approval.

Dr Fireman: contributed to the data collection and manuscript review and approval.

Dr Amital: contributed to the data collection and manuscript review and approval.

Dr Guber: contributed to the data collection and manuscript review and approval.

Dr Rhahman: contributed to the data collection and manuscript review and approval.

Dr Shitrit: contributed to the study design, data collection, statistical analysis, and manuscript writing.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: The authors thank Faye Schreiber, MS, for editing the manuscript.

ISHLT

International Society for Heart and Lung Transplantation

LTX

lung transplantation

NIOSH

National Institute for Occupational Safety and Health

PMF

progressive massive fibrosis

Thomas CR, Kelley TR. A brief review of silicosis in the United States. Environ Health Insights. 2010;4:21-26.
 
Cowie RL, Murray J, Becklake MR. Pneumoconioses and other mineral dust-related diseases.. In:Mason RJ, Broaddus VC, Martin TR, et al., eds. Murray and Nadel’s Textbook of Respiratory Medicine.5th ed. Philadelphia, PA: Saunders Elsevier; 2010:1554-1586.
 
Langer AM. Mineralogy.. In:Merchant JA., ed. Occupational Respiratory Diseases.DHHS (NIOSH) Publication No. 86-102. Washington DC: US Department of Health and Human Services (Centers for Disease Control); 1986:3-40.
 
NIOSHNIOSH. NIOSH Hazard Review: Health Effects of Occupational Exposure to Respirable Crystalline Silica. DHHS Publication No. 2002-129. Washington, DC: US Department of Health and Human Services;2002http://www.cdc.gov/niosh/docs/2002-129/pdfs/02-129.pdf. Accessed December 5, 2009.
 
Bang KM, Mazurek JM. Centers for Disease Control and Prevention (CDC) Centers for Disease Control and Prevention (CDC). Silicosis mortality, prevention, and control—United States, 1968-2002. MMWR Morb Mortal Wkly Rep. 2005;54(16):401-405.
 
Fishman AP. Fishman’s Pulmonary Diseases and Disorders.4th ed. Philadelphia, PA: The McGraw-Hill Companies; 2008:978-979.
 
Lung Transplant GroupLung Transplant Group. Single lung transplantation for end-stage silicosis: report of a case. J Formos Med Assoc. 1992;91(9):926-932.
 
Demoulin AS, Hermans G, Gustin M. An unusual interstitial lung disease [in French]. Rev Med Liege. 2009;64(7-8):373-376.
 
Chida M, Fukuda H, Araki O, Tamura M, Umezu H, Miyoshi S. Lung transplantation for aspiration-induced silicosis of the lung. Gen Thorac Cardiovasc Surg. 2010;58(3):141-143.
 
Baillar JC III, Ederer F. Significance factors for the ratio of a Poisson variable to its expectation. Biometrics. 1964;20(3):639-643.
 
CaesarStoneCaesarStone. CasesarStone website.http://media.caesarstoneus.com/pdf/Caesarstone%20MSDS%2020Mar2010.pdf. Accessed April 10, 2012.
 
Rosen D. The History of Miners’ Diseases. New York, NY: Schuman’s; 1943.
 
Rosner D, Markowitz G. Deadly Dust: Silicosis and the On-going Struggle to Protect Workers’ Health. Ann Arbor, MI: The University of Michigan Press; 2006.
 
Akgun M, Araz O, Akkurt I, et al. An epidemic of silicosis among former denim sandblasters. Eur Respir J. 2008;32(5):1295-1303.
 
Cherniack M. The Hawk’s Nest Incident: America’s Worst Industrial Disaster. Binghamton, NY: Vail-Ballou Press; 1986.
 
García Vadillo C, Gómez JS, Morillo JR. Silicosis in quartz conglomerate workers [in English and Spanish]. Arch Bronconeumol. 2011;47(1):53.
 
Martínez C, Prieto A, García L, Quero A, González S, Casan P. Silicosis: a disease with an active present [in English and Spanish]. Arch Bronconeumol. 2010;46(2):97-100.
 
US Department of Labor Office of Public AffairsUS Department of Labor Office of Public Affairs. US Department of Labor’s OSHA cites Cherry Hill, NJ, company for worker exposure to silica, other health and safety hazards. Region 2 news release 11-78-New (OSHA 11-008). Occupational Safety and Health Administration website.http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=19161. Published January 26, 2011. Accessed April 10, 2012.
 
Di Giuseppe M, Gambelli F, Hoyle GW, et al. Systemic inhibition of NF-kappaB activation protects from silicosis. PLoS ONE. 2009;4(5):e5689.
 

Figures

Figure Jump LinkFigure 1. Reported cases of silicosis due to engineered stone among lung transplant candidates in Israel.Grahic Jump Location
Figure Jump LinkFigure 2. A, CT scan of lung transplant candidate with advanced silicosis with diffuse micronodular pattern. B, CT scan of lung transplant candidate with advanced silicosis due to Artificial Stone with progressive massive fibrosis at presentation.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Demographic and Clinical Characteristics of 15 Patients Determined to be Transplant Candidates and of 10 Patients Who Underwent LTX for Artificial Stone Silicosis

Data are presented as mean ± SD or No. (%) unless indicated otherwise. Dlco = diffusing capacity of the lung for carbon monoxide; LTX = lung transplant; Sao2 = arterial oxygen saturation; TLC = total lung capacity; Va = alveolar volume; VATS = video-assisted thoracoscopic surgery.

References

Thomas CR, Kelley TR. A brief review of silicosis in the United States. Environ Health Insights. 2010;4:21-26.
 
Cowie RL, Murray J, Becklake MR. Pneumoconioses and other mineral dust-related diseases.. In:Mason RJ, Broaddus VC, Martin TR, et al., eds. Murray and Nadel’s Textbook of Respiratory Medicine.5th ed. Philadelphia, PA: Saunders Elsevier; 2010:1554-1586.
 
Langer AM. Mineralogy.. In:Merchant JA., ed. Occupational Respiratory Diseases.DHHS (NIOSH) Publication No. 86-102. Washington DC: US Department of Health and Human Services (Centers for Disease Control); 1986:3-40.
 
NIOSHNIOSH. NIOSH Hazard Review: Health Effects of Occupational Exposure to Respirable Crystalline Silica. DHHS Publication No. 2002-129. Washington, DC: US Department of Health and Human Services;2002http://www.cdc.gov/niosh/docs/2002-129/pdfs/02-129.pdf. Accessed December 5, 2009.
 
Bang KM, Mazurek JM. Centers for Disease Control and Prevention (CDC) Centers for Disease Control and Prevention (CDC). Silicosis mortality, prevention, and control—United States, 1968-2002. MMWR Morb Mortal Wkly Rep. 2005;54(16):401-405.
 
Fishman AP. Fishman’s Pulmonary Diseases and Disorders.4th ed. Philadelphia, PA: The McGraw-Hill Companies; 2008:978-979.
 
Lung Transplant GroupLung Transplant Group. Single lung transplantation for end-stage silicosis: report of a case. J Formos Med Assoc. 1992;91(9):926-932.
 
Demoulin AS, Hermans G, Gustin M. An unusual interstitial lung disease [in French]. Rev Med Liege. 2009;64(7-8):373-376.
 
Chida M, Fukuda H, Araki O, Tamura M, Umezu H, Miyoshi S. Lung transplantation for aspiration-induced silicosis of the lung. Gen Thorac Cardiovasc Surg. 2010;58(3):141-143.
 
Baillar JC III, Ederer F. Significance factors for the ratio of a Poisson variable to its expectation. Biometrics. 1964;20(3):639-643.
 
CaesarStoneCaesarStone. CasesarStone website.http://media.caesarstoneus.com/pdf/Caesarstone%20MSDS%2020Mar2010.pdf. Accessed April 10, 2012.
 
Rosen D. The History of Miners’ Diseases. New York, NY: Schuman’s; 1943.
 
Rosner D, Markowitz G. Deadly Dust: Silicosis and the On-going Struggle to Protect Workers’ Health. Ann Arbor, MI: The University of Michigan Press; 2006.
 
Akgun M, Araz O, Akkurt I, et al. An epidemic of silicosis among former denim sandblasters. Eur Respir J. 2008;32(5):1295-1303.
 
Cherniack M. The Hawk’s Nest Incident: America’s Worst Industrial Disaster. Binghamton, NY: Vail-Ballou Press; 1986.
 
García Vadillo C, Gómez JS, Morillo JR. Silicosis in quartz conglomerate workers [in English and Spanish]. Arch Bronconeumol. 2011;47(1):53.
 
Martínez C, Prieto A, García L, Quero A, González S, Casan P. Silicosis: a disease with an active present [in English and Spanish]. Arch Bronconeumol. 2010;46(2):97-100.
 
US Department of Labor Office of Public AffairsUS Department of Labor Office of Public Affairs. US Department of Labor’s OSHA cites Cherry Hill, NJ, company for worker exposure to silica, other health and safety hazards. Region 2 news release 11-78-New (OSHA 11-008). Occupational Safety and Health Administration website.http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=19161. Published January 26, 2011. Accessed April 10, 2012.
 
Di Giuseppe M, Gambelli F, Hoyle GW, et al. Systemic inhibition of NF-kappaB activation protects from silicosis. PLoS ONE. 2009;4(5):e5689.
 
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