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*Corresponding Author: Xaver Baur, European Society for Environmental and Occupational Medicine, Berlin, Germany.
Citation: Xaver Baur and Arthur L. Frank, (2024), Lung Function Changes After Asbestos Exposure: Implications for Compensation, J. General Medicine and Clinical Practice, 7(18); DOI:10.31579/2639-4162/233
Copyright: 2024, Xaver Baur. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Received: 04 October 2024 | Accepted: 14 October 2024 | Published: 21 October 2024
Keywords: older adults; risk factors; diseases in older adults
Previous asbestos workers with normal radiography, including chest CT scans, through a literature review have been shown to have significant changes in pulmonary function. This is seen for static and dynamic parameters as well as the transfer factor of the lung for carbon monoxide (TLCO). Much of the literature is of low sensitivity due to the cross-section rather than longitudinal data and selection bias. These effects are greater in those with asbestos-related pleural abnormalities or asbestosis or with both. Many studies document the synergistic effect of smoking with regard to pulmonary function changes, but even dust exposure alone can be seen to lead to changes with negative radiology. Unfortunately, more detailed and sensitive investigations such as longitudinal studies with measurements of TLCO, lung compliance and exercise testing by use of ergospirometry have been very rarely performed or are not available in the study group of interest. Our findings indicate that even sensitive chest CT scanning cannot provide exact lung function data and replace specific pulmonary functional tests. However, by support of AI CT scanning may become more useful for estimation of functional data in the future.
PFT pulmonary function test, CXR chest X ray (radiography), CT computed tomography, FVC forced vital capacity, FEV1 forced expiratory volume in 1 second, TLC total lung capacity, TLCO transfer factor of the lung for carbon monoxide (CO diffusion capacity), VA alveolar volume, TLCO/VA Krogh index
Long-term intensive inhalation of all kinds of inorganic dusts has been shown to cause impairment of lung function, i.e. restrictive and obstructive ventilation patterns (Begin, Ostiguy et al. 1993, Glencross, Weinberg et al. 1997, American Thoracic 2004, Wang, Yano et al. 2006, Dement, Welch et al. 2010, Dement, Welch et al. 2015, Collegium-Ramazzini 2016). This can be explained by the deposition of the more or less biopersistant materials in peripheral airways and in lung tissue associated with ongoing inflammatory and fibrogenic reactions. With regard to asbestos, it has to be noted that a cumulative dose of 1 fiber-year corresponds to an inhalative uptake of about 2 billion asbestos fibers. Using a sheep model Begin et al. (Begin, Masse et al. 1982) demonstrated that heavy asbestos exposure causes inflammatory and fibrotic changes in small airways. Correspondingly, histological investigations of lung tissue of chrysotile-exposed mine workers exhibited generalized fibrosis of small airways of workers which extended the effects of cigarette smoking (Wright and Churg 1985). There is a growing body of evidence that pulmonary function changes caused by inorganic materials including asbestos can occur even in the absence of radiographic changes. Without doubt, compensation has been denied to some because this finding has not been recognized. However, some (Schikowsky, Felten et al. 2017) have denied that lung function can be affected in the absence of radiographic changes, including from CT evaluation.
The latter authors stated: “…we found no significant association between lung function and asbestos exposure. Our results confirm the well-known correlation between lung function, smoking habits, and BMI.” (Schikowsky, Felten et al. 2018). Because this statement has the potential to a cause false understanding of prevention and compensation issues the aim of this work is to review the available relevant literature and thus the veracity of this conclusion.
A literature review and search using PubMed/Medline with the MESH term asbestos plus the terms pulmonary function testing, radiography, CT, computed tomography, and meta-analysis. We combined our literature search findings with data from a metaanalysis (Wilken, Velasco Garrido et al. 2011), literature searches and reviews undertaken in preparing the German guidelines for diagnostics and expert opinion of ARD in which one of the authors (XB) was involved, and a literature-based previous commentary (Baur, Manuwald et al. 2010, Baur and Wilken 2010, Baur, Clasen et al. 2011, Baur, Terracini et al. 2018, AWMF 2020).
A. individual lung function parameters in cross-sectional studies of asbestos workers without abnormal chest CT scans (in brackets: % predicted); values of metaanalysis by Wilken et al. 2011 are given in bold blue letters.
1.Vital capacity (VC or FVC)
Various cross-sectional studies show reduction of -1.2 to -11.2 % of predicted vital capacity in previously asbestos-exposed subjects; in detail: (Oldenburg, Degens et al. 2001) (mean 88.8 + 13.9%; s.)*; (Rui, De Zotti et al. 2004) (mean 96 %, s.)*; (Harkin, McGuinness et al. 1996) (mean 98 %, n.s.)*; (Begin, Ostiguy et al. 1993) with Pleura score of 0-5 (mean 93 %, s.)*; (Clark, Flynn et al. 2014) (mean 90,8 %, n.s.);(Clark, Flynn et al. 2017) at 60 years mean 94.0% and at 80 years mean 84.4%); (Park, Yates et al. 2015) (mean 98.8 %, n.s.); (Neri, Antonelli et al. 1994) with normal PFT selected (mean 96.5 %, n.s.); (Miller, Szeinuk et al. 2018) (mean 93,5 %, n.s.), Schikowsky et al. (Schikowsky, Felten et al. 2018) (mean 98.5 %, n.s.)Lopatin et al. (Lopatin, Tsay et al. 2016, Lopatin, Tsay et al. 2016) found that 75% of the asbestos study group with normal CT scans exhibited significantly reduced vital capacity values. In one publication (Preisser 2020) vital capacity corresponded to the outdated references from Quanjer et al. from 1983/1993 (Quanjer, Tammeling et al. 1993)) (mean 100.1%).
In two publications increased values of vital capacity were reported: (Begin, Filion et al. 1995) (mean 102 %, n.s.); (Van Cleemput, De Raeve et al. 2001) (mean 109.8, s.; the latter also used the outdated references from Quanjer et al. from 1983/1993 (Quanjer, Tammeling et al. 1993)).
*included in the metaanalysis of publications till 2010 by Wilken et al. (Wilken, Velasco Garrido et al. 2011) and in the review by Baur et al. (Baur, Terracini et al. 2018); overall, in the metaanalysis mean FVC was 97.1% (p=0.51).
1. Forced expiratory volume in one second (FEV1)
In most cross-sectional studies FEV1 was reported to be reduced, range -3 to -13 % predicted. In detail: (Oldenburg, Degens et al. 2001) (87%, s.)*; (Harkin, McGuinness et al. 1996) (mean 94 %, n.s.)*; (Begin, Ostiguy et al. 1993) with Pleura score of 0-5 (mean 96 %, n.s.)*; (Begin,
Filion et al. 1995) (mean 95 %, n.s.) *; (Clark, Flynn et al. 2014) (80.5%); (Clark, Flynn et al. 2017) at 60 years mean 93.1%and at 80 years mean 87 %); (Neri, Antonelli et al. 1994) with normal PFT selected (mean 94.7 %, n.s.); (Miller, Szeinuk et al. 2018) (mean (95,7 %, n.s.), Schikowsky et al. (Schikowsky, Felten et al. 2018) (mean 95.8 %, n.s.). (Park, Yates et al. 2015) (mean 90.4 %, n.s.). In two studies using outdated reference values increased FEV1 was reported (Van Cleemput, De Raeve et al. 2001, Rui, De Zotti et al. 2004)* (mean 103.8 %, 103 % respectively, both n.s.)*. Lopatin et al. (Lopatin, Tsay et al. 2016, Lopatin, Tsay et al. 2016) found that FEV1 is significantly reduced in 62% of these subjects.
*Included in the metaanalysis of publications until 2010 by Wilken et al. (Wilken, Velasco Garrido et al. 2011) and in the review by (Baur, Terracini et al. 2018); overall, in the metaanalysis mean FEV1 was 90.4 % (n.s.).
2. FEV1/FVC
This is given in only a few studies showing small reductions. In detail: (Park, Yates et al. 2015) (mean 70.8 %, s.); (Oldenburg, Degens et al. 2001) (mean 94.9 %; n.s.)*, (Neri, Antonelli et al. 1994) with normal PFT selected (mean 98.6 %, n.s.).
*included in review by (Baur, Manuwald et al. 2010) and in the metaanalysis of publications till 2010 by Wilken et al. (Wilken, Velasco Garrido et al. 2011) and in the review by (Baur, Terracini et al. 2018); overall, mean FEV1/FVC was 94.9 %, n.s.).
3. Transfer factor of the lung for carbon monoxide (TLCO)
In all but one study mean reduction from predicted values ranged from 2.8 - to - 9.2%. In detail: (Miller, Szeinuk et al. 2018) (mean 95,7 %, n.s.), (Park, Yates et al. 2015) (mean 87.6 %, n.s.); (Begin, Ostiguy et al. 1993) with Pleura score of 0-5 (mean 95%); (Van Cleemput, De Raeve et al. 2001) (mean 97.2%, n.s.); (Preisser 2020 ) (mean 79.7%); (Neri, Antonelli et al. 1994) normal PFT selected (mean 118.4 %, n.s.); (Clark, Flynn et al. 2014) (mean 97.1%, n.s.) (with TLCO/VA mean 98.8%), (Clark, Flynn et al. 2017) (at 60 years mean 98.9% and at 80 years mean 91.3 %). Interestingly, the study by (Schikowsky, Felten et al. 2018) reports increased TLCO/VA (mean 111.4 % (n.s.) but did not provide TLCO data.
4. Longitudinal studies and other lung function parameters
The longitudinal study in Libby vermiculite asbestos workers by (Clark, Flynn et al. 2017) showed decreases of adjusted FEV1, FVC, TLC and TLCO percent predicted means at 40, 60 and 80 years of age also in the group with normal CT scan (- 12.3%, - 13.2, - 15.3%, - 22.6 %). Appropriate results from exercise testing by use of ergospirometry or from lung compliance were not available.
A) Influence of underlying asbestosis or asbestos-related pleural disorders or confounding factors
1. Asbestosis and/or asbestos-related pleural disorders
The literature shows that lung function impairment is typically greater in previously asbestos- exposed subjects with evidence of underlying asbestosis and/or asbestos-related pleural disorders than in those without such radiologically identified changes (Kilburn and Warshaw 1991, Kilburn and Warshaw 1994, Algranti, Freitas et al. 2000, Algranti, Mendonca et al. 2001, Lebedova, Dlouha et al. 2003, Ameille, Letourneux et al. 2010, Wang, Wang et al. 2010, Wilken, Velasco Garrido et al. 2011, Algranti, Mendonca et al. 2013, Kopylev, Christensen et al. 2015, Clark, Flynn et al. 2017, Miller, Szeinuk et al. 2018).
2. Smoking
Smoking has been shown to be a complicating factor (Kilburn and Warshaw 1994, Bagatin, Neder et al. 2005, Abejie, Wang et al. 2010, Wilken, Velasco Garrido et al. 2011, Algranti, Mendonca et al. 2013, Yang, Yan et al. 2018).
3. BMI
Algranti et al. (Algranti, Mendonca et al. 2001) mentioned that obstructive ventilation patterns and shortness of breath of asbestos workers are significantly associated with body mass index. However, as shown by Salome et al. even in the extremely obese spirometric variables and TLCO are rarely below the normal range (Salome, King et al. 2010).
B) Combined findings of the literature search
We identified many studies with CT scans in asbestos workers looking at data only with those who had evidence of non-malignant disease and were not useful for this analysis.
The scientific literature we could use documents that when sensitive CT is used to establish the presence or absence of underlying non-malignant disease, data shows that even those with negative CT scans still have pulmonary function impairment although these effects are lower than in those with asbestos-related pleural abnormalities or asbestosis or with both (Algranti, Freitas et al. 2000, Ameille, Letourneux et al. 2010, Wang, Wang et al. 2010, Algranti, Mendonca et al. 2013) (Kilburn and Warshaw 1991, Kilburn and Warshaw 1994, Algranti, Mendonca et al. 2001, Wilken, Velasco Garrido et al. 2011). This is especially documented in a meta-analysis (Fig.) and in the longitudinal study of workers exposed to Libby amphiboles in vermiculite who have decreases of pulmonary function values over time (Clark, Flynn et al. 2017).
Literature also shows that changes is typically greater with a history of smoking (Kilburn and Warshaw 1994, Bagatin, Neder et al. 2005, Abejie, Wang et al. 2010, Wilken, Velasco Garrido et al. 2011, Algranti, Mendonca et al. 2013, Yang, Yan et al. 2018).
B. individual lung function parameters in cross-sectional studies of asbestos workers without abnormal chest CT scans (in brackets: % predicted); values of metaanalysis by Wilken et al. 2011 are given in bold blue letters.
5. Vital capacity (VC or FVC)
Various cross-sectional studies show reduction of -1.2 to -11.2 % of predicted vital capacity in previously asbestos-exposed subjects; in detail: (Oldenburg, Degens et al. 2001) (mean 88.8 + 13.9%; s.)*; (Rui, De Zotti et al. 2004) (mean 96 %, s.)*; (Harkin, McGuinness et al. 1996) (mean 98 %, n.s.)*; (Begin, Ostiguy et al. 1993) with Pleura score of 0-5 (mean 93 %, s.)*; (Clark, Flynn et al. 2014) (mean 90,8 %, n.s.);(Clark, Flynn et al. 2017) at 60 years mean 94.0% and at 80 years mean 84.4%); (Park, Yates et al. 2015) (mean 98.8 %, n.s.); (Neri, Antonelli et al. 1994) with normal PFT selected (mean 96.5 %, n.s.); (Miller, Szeinuk et al. 2018) (mean 93,5 %, n.s.), Schikowsky et al. (Schikowsky, Felten et al. 2018) (mean 98.5 %, n.s.)Lopatin et al. (Lopatin, Tsay et al. 2016, Lopatin, Tsay et al. 2016) found that 75% of the asbestos study group with normal CT scans exhibited significantly reduced vital capacity values. In one publication (Preisser 2020 ) vital capacity corresponded to the outdated references from Quanjer et al. from 1983/1993 (Quanjer, Tammeling et al. 1993)) (mean 100.1%).
In two publications increased values of vital capacity were reported: (Begin, Filion et al. 1995) (mean 102 %, n.s.); (Van Cleemput, De Raeve et al. 2001) (mean 109.8, s.; the latter also used the outdated references from Quanjer et al. from 1983/1993 (Quanjer, Tammeling et al. 1993)).
*included in the metaanalysis of publications till 2010 by Wilken et al. (Wilken, Velasco Garrido et al. 2011) and in the review by Baur et al. (Baur, Terracini et al. 2018); overall, in the metaanalysis mean FVC was 97.1% (p=0.51).
6. Forced expiratory volume in one second (FEV1)
In most cross-sectional studies FEV1 was reported to be reduced, range -3 to -13 % predicted. In detail: (Oldenburg, Degens et al. 2001) (87%, s.)*; (Harkin, McGuinness et al. 1996) (mean 94
%, n.s.)*; (Begin, Ostiguy et al. 1993) with Pleura score of 0-5 (mean 96 %, n.s.)*; (Begin,
Filion et al. 1995) (mean 95 %, n.s.)*; (Clark, Flynn et al. 2014) (80.5% ); (Clark, Flynn et al. 2017) at 60 years mean 93.1%and at 80 years mean 87 %); (Neri, Antonelli et al. 1994) with normal PFT selected (mean 94.7 %, n.s.); (Miller, Szeinuk et al. 2018) (mean (95,7 %, n.s.), Schikowsky et al. (Schikowsky, Felten et al. 2018) (mean 95.8 %, n.s.). (Park, Yates et al. 2015) (mean 90.4 %, n.s.). In two studies using outdated reference values increased FEV1 was reported (Van Cleemput, De Raeve et al. 2001, Rui, De Zotti et al. 2004)* (mean 103.8 %, 103 % respectively, both n.s.)*. Lopatin et al. (Lopatin, Tsay et al. 2016, Lopatin, Tsay et al. 2016) found that FEV1 is significantly reduced in 62% of these subjects.
*Included in the metaanalysis of publications until 2010 by Wilken et al. (Wilken, Velasco Garrido et al. 2011) and in the review by (Baur, Terracini et al. 2018); overall, in the metaanalysis mean FEV1 was 90.4 % (n.s.).
7. FEV1/FVC
This is given in only a few studies showing small reductions. In detail: (Park, Yates et al. 2015) (mean 70.8 %, s.); (Oldenburg, Degens et al. 2001) (mean 94.9 %; n.s.)*, (Neri, Antonelli et al. 1994) with normal PFT selected (mean 98.6 %, n.s.).
*included in review by (Baur, Manuwald et al. 2010) and in the metaanalysis of publications till 2010 by Wilken et al. (Wilken, Velasco Garrido et al. 2011) and in the review by (Baur, Terracini et al. 2018); overall, mean FEV1/FVC was 94.9 %, n.s.).
8. Transfer factor of the lung for carbon monoxide (TLCO)
In all but one study mean reduction from predicted values ranged from 2.8 - to - 9.2%. In detail: (Miller, Szeinuk et al. 2018) (mean 95,7 %, n.s.), (Park, Yates et al. 2015) (mean 87.6 %, n.s.); (Begin, Ostiguy et al. 1993) with Pleura score of 0-5 (mean 95%); (Van Cleemput, De Raeve et al. 2001) (mean 97.2%, n.s.); (Preisser 2020 ) (mean 79.7%); (Neri, Antonelli et al. 1994) normal PFT selected (mean 118.4 %, n.s.); (Clark, Flynn et al. 2014) (mean 97.1%, n.s.) (with TLCO/VA mean 98.8%), (Clark, Flynn et al. 2017) (at 60 years mean 98.9% and at 80 years mean 91.3 %). Interestingly, the study by (Schikowsky, Felten et al. 2018) reports increased TLCO/VA (mean 111.4 % (n.s.) but did not provide TLCO data.
9. Longitudinal studies and other lung function parameters
The longitudinal study in Libby vermiculite asbestos workers by (Clark, Flynn et al. 2017) showed decreases of adjusted FEV1, FVC, TLC and TLCO percent predicted means at 40, 60 and 80 years of age also in the group with normal CT scan (- 12.3%, - 13.2, - 15.3%, - 22.6 %). Appropriate results from exercise testing by use of ergospirometry or from lung compliance were not available.
C) Influence of underlying asbestosis or asbestos-related pleural disorders or confounding factors
4. Asbestosis and/or asbestos-related pleural disorders
The literature shows that lung function impairment is typically greater in previously asbestos- exposed subjects with evidence of underlying asbestosis and/or asbestos-related pleural disorders than in those without such radiologically identified changes (Kilburn and Warshaw 1991, Kilburn and Warshaw 1994, Algranti, Freitas et al. 2000, Algranti, Mendonca et al. 2001, Lebedova, Dlouha et al. 2003, Ameille, Letourneux et al. 2010, Wang, Wang et al. 2010, Wilken, Velasco Garrido et al. 2011, Algranti, Mendonca et al. 2013, Kopylev, Christensen et al. 2015, Clark, Flynn et al. 2017, Miller, Szeinuk et al. 2018).
5. Smoking
Smoking has been shown to be a complicating factor (Kilburn and Warshaw 1994, Bagatin, Neder et al. 2005, Abejie, Wang et al. 2010, Wilken, Velasco Garrido et al. 2011, Algranti, Mendonca et al. 2013, Yang, Yan et al. 2018).
6. BMI
Algranti et al. (Algranti, Mendonca et al. 2001) mentioned that obstructive ventilation patterns and shortness of breath of asbestos workers are significantly associated with body mass index. However, as shown by Salome et al. even in the extremely obese spirometric variables and TLCO are rarely below the normal range (Salome, King et al. 2010).
A) Combined findings of the literature search
We identified many studies with CT scans in asbestos workers looking at data only with those who had evidence of non-malignant disease and were not useful for this analysis.
The scientific literature we could use documents that when sensitive CT is used to establish the presence or absence of underlying non-malignant disease, data shows that even those with negative CT scans still have pulmonary function impairment although these effects are lower than in those with asbestos-related pleural abnormalities or asbestosis or with both (Algranti, Freitas et al. 2000, Ameille, Letourneux et al. 2010, Wang, Wang et al. 2010, Algranti, Mendonca et al. 2013) (Kilburn and Warshaw 1991, Kilburn and Warshaw 1994, Algranti, Mendonca et al. 2001, Wilken, Velasco Garrido et al. 2011). This is especially documented in a meta-analysis (Fig.) and in the longitudinal study of workers exposed to Libby amphiboles in vermiculite who have decreases of pulmonary function values over time (Clark, Flynn et al. 2017).
Literature also shows that changes is typically greater with a history of smoking (Kilburn and Warshaw 1994, Bagatin, Neder et al. 2005, Abejie, Wang et al. 2010, Wilken, Velasco Garrido et al. 2011, Algranti, Mendonca et al. 2013, Yang, Yan et al. 2018).
Exposure to asbestos is well known to produce a wide variety of disorders, both non-malignant and malignant. Compensation issues vary around the world, as does access to other forms of legal redress.
As early as 1971 it was reported that previous asbestos workers have reduced pulmonary function values even in the absence of asbestosis (Jodoin, Gibbs et al. 1971). Our review confirms and broadens these initial findings showing decreases of spirometric and TLCO values not only in asbestos-exposed subjects with asbestosis or asbestos-associated pleural abnormalities but also in those with normal chest CT scans. This includes impairment of forced vital capacity (FVC) with some studies that are statistically significant (Oldenburg et al. 2001, Rui et al 2004, Begin et al. 1993, Harkin et al. 1996; Clark et al. 2014; Lopatin et al. 2016, Wilken et al. 2011). Also, there are many studies with changes in forced expiratory volume in 1 second (FEV1) (Oldenburg et al. 2001, Harkin et al. 1996, Begin et al.1993, Begin et al. 1995, Clark et al 2014, Lopatin et al 2016, Wilken et al 2011), and several of TLCO (Begin, Ostiguy et al. 1993, Van Cleemput, De Raeve et al. 2001, Clark, Flynn et al. 2014, Park, Yates et al. 2015, Miller, Szeinuk et al. 2018). Correspondingly, Lopatin et al. report that 75% of their subject group had decreased FVC values and 62% of them had decreased FEV1 values; in this publication no relationship with reference values is given. Studies not finding similar results are those of Rui et al. (Rui, De Zotti et al. 2004) for FEV1 and of van Cleemput et al. (Van Cleemput, De Raeve et al. 2001) for FVC and FEV1 [these authors applied questionable or outdated references from Quanjer et al. from 1983/1993 (Quanjer, Tammeling et al. 1993)], and of Schikowsky et al. (Schikowsky, Felten et al. 2018) for TLCO/VA.
CT scans are much more sensitive than CXR for the determination of morphological changes of the lungs and pleura due to asbestos and other harmful exposures (Neri, Antonelli et al. 1994, Preisser 2020). Nevertheless, as mentioned, when CT is used to establish the presence or absence of underlying non-malignant disease, data shows that those with negative CT scans one can still have pulmonary function changes (Wilken, Velasco Garrido et al. 2011). This indicates that CT scanning cannot provide detailed functional impairment insight. Copeley et al. (Copley, Wells et al. 2001) found that only 58 % and 57 % of TLC and TLCO variability of asbestos workers can be explained by combined CT morphological findings.
By referring to the questionable statement of Schikowsky et al. (Schikowsky,
Felten et al. 2017) indicating “the lung function parameters of FVC, FEV1, DLCO/VA, and airway resistance were significantly associated with the burden of smoking, BMI and years since end of exposure (only DLCO/VA). However, they were not affected by factors (e.g. cumulative exposure) or duration of asbestos exposure… We found no significant association between lung function and asbestos exposure” the aforementioned and further shortcomings (low statistical power, not considering individual available previous asbestos air concentrations and previous lung function data, citation of non-relevant references, obvious, but undeclared conflict of interest), were recently pinpointed (Baur, Terracini et al. 2018) and could not be clearly negated (Schikowsky, Felten et al. 2018).
It should be noted that the additive adverse effect of asbestos exposure to adverse smoking effect on lung function is well documented (Kilburn and Warshaw 1994, Bagatin, Neder et al. 2005, Abejie, Wang et al. 2010, Wilken, Velasco Garrido et al. 2011, Algranti, Mendonca et al. 2013, Yang, Yan et al. 2018) and that BMI has little or no influence on FVC, FEV1 and TLCO (Salome, King et al. 2010). As opposed to Schikowsky et al., there is convincing evidence that the dose of asbestos and duration of asbestos exposure is associated with functional impairment (Frank 1979, Begin, Ostiguy et al. 1993, Bagatin, Neder et al. 2005, Wang, Yano et al. 2006). In the more differentiating German guideline for expert opinion, diagnostics, and compensation of asbestos-related occupational diseases) it is mentioned: “According to experience with other inorganic dusts, several studies with chest x-rays indicate slight lung function limitations in groups exposed to asbestos that do not show any radiological changes (Miller et al. (Miller, Szeinuk et al. 2018) [63], and meta-analysis by Wilken et al. [118] …. A study based on X-ray [69]
(Bagatin, Neder et al. 2005) showed dependence of the FVC on the cumulative asbestos fiber dose…. Therefore, it has to be assumedthat the functional limitations in groups with normal chest x-rays cannot be fully explained by image morphology and that asbestos exposure can also be associated with slight functional limitations regardless of the radiological findings…. In CT studies, evidence of such functional limitations without asbestos-related changes in the CT can also be found in studies by Szeinuk et al. (Szeinuk, Noonan et al. 2017) and Lopatin et al. (Lopatin, Tsay et al. 2016, Lopatin, Tsay et al. 2016) (in the latter publication, heavy smokers exposed to asbestos were compared with and without CT changes) [80,81,103]. …However, overall, no or only very small, statistically insignificant changes in lung function are described when radiological findings did not show abnormalities” (cited references are (Ameille, Letourneux et al. 2010, Wilken, Velasco Garrido et al. 2011, Clark, Flynn et al. 2014, Lopatin, Tsay et al. 2016, Lopatin, Tsay et al. 2016, Szeinuk, Noonan et al. 2017, Schikowsky, Felten et al. 2018) 80, 81, 85, 86, 89, 102, 118).
It should be noted that the publications by Ameille et al. 2010 (Ref. 86) which is cited in the aforementioned guideline does not present relationship of chest CT scan findings and lung function parameters; thus, this work does not allow any conclusion regarding the question, whether the subjects’ lung function parameters differ from reference values. All the other cited publications show mild functional impairments as given above. Furthermore, various studies with similar effects (see Result section above) are not mentioned in this guideline and the severe limitations with underestimation of the effects of asbestos especially due to the healthy worker effect are not taken into consideration.
Interestingly, the Draft Opinion of The Advisory Committee on Safety and Health at Work to the European Union for an Update of Commission Recommendation (EU) 2022/2337 concerning the European schedule of occupational disease includes in the new list of occupational diseases among others (ovary cancer and larynx cancer due to asbestos) pleural plaques with functional impairment of the lungs as well as non-malignant pleural effusion caused by asbestos exposure (listed in Annex I). However, the mostly small impairments of routinely measured spirometric values of previous asbestos workers with normal chest CT scans do not fulfil occupational disease criteria of European countries, although a significant proportion of them suffer from chronic bronchitis, COPD, and/or shortness of breath during exercise, and in some of them a significant asbestos-related decline of FVC and FEV1 over time can be documented, i.e. of at least 20
It is clear from the scientific literature over many years that individuals exposed to asbestos, even with normal radiology, by either CXR or CT, can still be shown to have negative alterations in their pulmonary function test results that can be ascribed to their prior exposures. Obviously, these alterations are underestimated in most available studies due to the healthy worker effect and the consideration of only spirometric data which are of much lower sensitive than measurement of CO diffusing capacity (Garcia, Griffith et al. 1990, Baur and Wilken 2010, Preisser, Velasco Garrido et al. 2011, Miller, Szeinuk et al. 2018, Modi and Cascella 2020) or ergospiromtry parameters (Wasserman, Hansen et al. 2011). Many studies document the synergistic effect of smoking with regard to pulmonary function changes, but even dust exposure alone can be seen to lead to changes with negative radiology.
These facts have significant implications for individuals who may be denied compensation following asbestos exposure when their radiographic findings do not show evidence of non- malignant disease. In fairness to such individuals.
Conflict of interests
XB has performed medical expert opinions for various German social courts and statutory accident institutions. ALF regularly participates in asbestos-related medical-legal activities, primarily for plaintiffs.
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Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.
Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.
Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.
Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.
This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.
Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.
As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.
Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.
International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.
Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.
Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.
I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!
"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".
I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.
We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.
I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.
I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.
I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.
Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.
“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.
Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.
Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.
Clinical Cardiology and Cardiovascular Interventions, we deeply appreciate the interest shown in our work and its publication. It has been a true pleasure to collaborate with you. The peer review process, as well as the support provided by the editorial office, have been exceptional, and the quality of the journal is very high, which was a determining factor in our decision to publish with you.
The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews journal clinically in the future time.
Clinical Cardiology and Cardiovascular Interventions, I would like to express my sincerest gratitude for the trust placed in our team for the publication in your journal. It has been a true pleasure to collaborate with you on this project. I am pleased to inform you that both the peer review process and the attention from the editorial coordination have been excellent. Your team has worked with dedication and professionalism to ensure that your publication meets the highest standards of quality. We are confident that this collaboration will result in mutual success, and we are eager to see the fruits of this shared effort.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, I hope this message finds you well. I want to express my utmost gratitude for your excellent work and for the dedication and speed in the publication process of my article titled "Navigating Innovation: Qualitative Insights on Using Technology for Health Education in Acute Coronary Syndrome Patients." I am very satisfied with the peer review process, the support from the editorial office, and the quality of the journal. I hope we can maintain our scientific relationship in the long term.
Dear Monica Gissare, - Editorial Coordinator of Nutrition and Food Processing. ¨My testimony with you is truly professional, with a positive response regarding the follow-up of the article and its review, you took into account my qualities and the importance of the topic¨.
Dear Dr. Jessica Magne, Editorial Coordinator 0f Clinical Cardiology and Cardiovascular Interventions, The review process for the article “The Handling of Anti-aggregants and Anticoagulants in the Oncologic Heart Patient Submitted to Surgery” was extremely rigorous and detailed. From the initial submission to the final acceptance, the editorial team at the “Journal of Clinical Cardiology and Cardiovascular Interventions” demonstrated a high level of professionalism and dedication. The reviewers provided constructive and detailed feedback, which was essential for improving the quality of our work. Communication was always clear and efficient, ensuring that all our questions were promptly addressed. The quality of the “Journal of Clinical Cardiology and Cardiovascular Interventions” is undeniable. It is a peer-reviewed, open-access publication dedicated exclusively to disseminating high-quality research in the field of clinical cardiology and cardiovascular interventions. The journal's impact factor is currently under evaluation, and it is indexed in reputable databases, which further reinforces its credibility and relevance in the scientific field. I highly recommend this journal to researchers looking for a reputable platform to publish their studies.
Dear Editorial Coordinator of the Journal of Nutrition and Food Processing! "I would like to thank the Journal of Nutrition and Food Processing for including and publishing my article. The peer review process was very quick, movement and precise. The Editorial Board has done an extremely conscientious job with much help, valuable comments and advices. I find the journal very valuable from a professional point of view, thank you very much for allowing me to be part of it and I would like to participate in the future!”
Dealing with The Journal of Neurology and Neurological Surgery was very smooth and comprehensive. The office staff took time to address my needs and the response from editors and the office was prompt and fair. I certainly hope to publish with this journal again.Their professionalism is apparent and more than satisfactory. Susan Weiner
My Testimonial Covering as fellowing: Lin-Show Chin. The peer reviewers process is quick and effective, the supports from editorial office is excellent, the quality of journal is high. I would like to collabroate with Internatioanl journal of Clinical Case Reports and Reviews.
My experience publishing in Psychology and Mental Health Care was exceptional. The peer review process was rigorous and constructive, with reviewers providing valuable insights that helped enhance the quality of our work. The editorial team was highly supportive and responsive, making the submission process smooth and efficient. The journal's commitment to high standards and academic rigor makes it a respected platform for quality research. I am grateful for the opportunity to publish in such a reputable journal.
My experience publishing in International Journal of Clinical Case Reports and Reviews was exceptional. I Come forth to Provide a Testimonial Covering the Peer Review Process and the editorial office for the Professional and Impartial Evaluation of the Manuscript.
