So, thanks to Dr. Piacentino. Big hand for Dr. Piacentino. So, welcome to our first session today, and we'll be doing an update on radiographic screening for pneumoconiosis. And let's see if I can do this without killing it. I've got... Can you hear that? Can you hear me now? All right. So, I've got no conflicts of interest to disclose. Here's an outline of the presentation today, and we'll start out with an introduction. Then we'll do a bit of an update on chest radiography. We'll do an update on using high-res chest computed tomography for screening and surveillance, and then a bit of a conclusion. Here are learning objectives for today. To be aware of the new update to the ILO classification system. To learn some recent findings about chest radiographic appearances of pneumoconiosis. To learn about some aspects of HRCT screening, including its performance relative to chest X-ray, and a little bit about the ICO-ERD classification system, which kind of parallels the ILO classification system. To be aware of some recent updates to recommendations for lung cancer screening with low-dose chest CT, which is relevant to our patients with pneumoconiosis. To be aware of technological advancements, such as the use of AI machine learning for evaluating chest radiographs, and also the use of ultra-low-dose chest HRCT, which really is exciting because it allows you to use about the same amount of radiation as is used in a regular chest X-ray. So this slide is just to sort of frame things in terms of where chest radiographic, chest imaging screening sits as a type of prevention. And really, I think we all know that it's mostly secondary prevention. It's trying to catch disease at an early stage when interventions can still be effective. But as we'll see on the next slide, it can have an impact on primary prevention. And of course, chest imaging plays a critical role in diagnosis and treatment and looking for complications and that kind of thing, so very important for tertiary prevention. So chest imaging screening is really a type of medical surveillance where you do initial and periodic health evaluation of exposed people, including exposed people who may not necessarily look to be ill. And as we talked about in the previous slide, this type of screening, although it's really secondary prevention, it can have an impact on primary prevention. Because if you identify sentinel cases, or if you do an evaluation of aggregated data of a population, and you identify cases of pneumoconiosis that have slipped through your primary prevention, you can focus your primary prevention efforts to fix what went wrong to better control exposures. If medical surveillance is done for the purposes of secondary prevention to identify early stages of diseases, it's often referred to as medical screening or medical monitoring. So now we're going to talk a little bit specifically about chest radiography, plain chest imaging. And we'll start by talking about the update to the ILO classification system. And a bit of background about the ILO classification of chest radiographs, and here we're talking about just the PA chest radiograph, just that view. And the ILO system is long established for assessing the presence and severity of findings of pneumoconiosis on chest X-rays. The last version of the guidebook is shown here on your left. It's from 2011. There's a new guidebook that's out. It's dated 2022, as you can see on the slide here. But it was actually first posted in 2023. And there are five parts to classifying chest X-rays using the ILO system. There's technical quality. There's parenchymal abnormalities. There's plural abnormalities. There's other symbols. And there's comments. And I'm not going to get super detailed into this system because many are familiar with it. But just a little bit of overview. Many are familiar with this categorization of small opacities. So the level of profusion or density of small opacities on the chest X-ray on a 12-point scale running from zero minus to three plus. And the first number in the slash, you compare the examinee image to the image on a standard film. And the first number is the one that you think your examinee image most closely resembles. And the second one is if you seriously considered another one. And those small opacities go up to one centimeter in size. If something is greater than one centimeter in size, we term it a large opacity. And there are three types of large opacities, A, B, and C, representing progressively larger types of large opacities. So that's a basic overview in terms of what we call the small opacities. There are two types. There are rounded and there are irregular. And then we call the rounded ones PQR and the irregular ones STU, based on either how much of a diameter they have or how fat they are at the thickest part of the opacity. So less than 1.5, 1.5 to 3, and 3 to 10, as shown here. So a really well-established system, but one issue with the system in the past is that the comparison images, the standard images, were all old film screen radiographs done the old-fashioned way with film. Basically, nobody, hardly anybody in the U.S. uses film screen radiography anymore. We've transitioned almost entirely to digital radiography, and that's true worldwide as well for many reasons. So NIOSH and the ILO partnered together. They formed a memorandum of understanding to work together to update the standard images to be modern, digitally acquired images. And so under this memorandum of understanding, we worked together to compile candidate images, to conduct controlled reading trials, to summarize the findings, and to conduct a technical meeting to choose the final image set to be used as standard images. And it was really a major effort. It was a major international effort. More than 1,000 images were collected from across the world. And as you can see, they reflected all kinds of different workers, all kinds of different exposures that caused pneumoconiosis. And it was interesting. When we looked at the images that had the tightest range of classifications that were, you know, tightly gathered together when multiple qualified readers looked at them, we found that there were no U images. There were no U small opacities identified out of all these images, zero. And also for P opacities, there were very few images that had P opacities, particularly high perfusion P opacities. So it looked like in contemporary pneumoconiosis that U opacities really don't seem to happen much, if at all, and P opacities rarely. So here's the current status of the effort. So new standard images have been selected and were recently posted on the ILO website. There are JPEG images, which aren't to be used for classification. They're to be used for presentations or teaching. They're there for that purpose. The DICOM format images, which you would look at on a PAC system, are the ones that are to be used for classification for comparison with examinee images. All the standard images are new. They're all new digitally acquired images, except for the standards for U opacities. For that, we kept the old film screen radiography images because we couldn't identify any U opacity images in the image set that we collected. There's a new image that's been added specifically to assess for blunting of the costophrenic angle. There's an updated guidebook. This bullet is a little bit out of date. It's posted now. It's on the ILO website. And ILO is making the new guidebook and standard digital chest images available free without charge. So basically, anybody can go to these links that are both on the presentation and on the PDF handout to download these images. You don't have to pay for them anymore. And I included the links because they're a little bit hard to Google and find. So next, I'm going to talk a little bit about modern view of the radiographic appearance of pneumoconiosis. And again, I'll turn back to the slide that I showed before where we were screening for new standard images. And it really looks like U opacities don't happen much, if at all, due to pneumoconiosis. Maybe there are other pathologies that cause U opacities. Maybe if somebody has lymphogenic spread of carcinoma or something like that, perhaps that would cause U opacities. But it doesn't appear that pneumoconiosis by itself really causes them much, if at all. Next, I'm going to show a couple of images from the NIOSH Coal Workers Health Surveillance Program derived from data. That program provides active working coal miners with images at about five-year intervals while they're actively working. And the images are classified using the ILO system by at least two classifiers. And so in this paper, they looked at 2,500 images of small lung opacities in United States coal miners. And again, as you can see there in red, U opacities, there were very few U opacities identified. This goes along with the data that I already showed you. In addition, when people think of people who are exposed to coal mine dust or silica, which is also really important in exposures of coal miners, people think about rounded opacities. But in our experience, about 62% of the images had small opacities that were rounded. And about 38% had small opacities that were irregular. So irregular opacities do happen in dust-exposed coal miners. This image shows the distribution of the either rounded opacities or the irregular opacities. And as you can see here, when you either have two zones involved or one zone involved, you're more likely to have upper zone distribution for rounded opacities and lower zone distribution for irregular opacities. Another thing that's been seen in coal miners in recent years is with the resurgence of pneumoconiosis and the occurrence of PMF, we've identified silica exposure as an important issue. And with this increasing silica exposure over the last couple of decades, we've seen more R opacities. Those are the largest type of small opacity that's rounded. And as you can see, there's been, over the past several decades, a progressive increase in the proportion of miners who have these R opacities, although I would direct your attention to the scale. And the highest one is about 2%. So it's not the vast majority of miners, but certainly an increase in R opacities, consistent with silica playing an important role. So now we're going to switch gears and we're going to talk a little bit about large opacities. And again, this is a study of large opacities in U.S. coal miners and 204 cases of PMF evaluated by three qualified readers. And as you can see, the readers saw the large opacities differently. So there is a certain amount of normal variability in seeing even large opacities. There's inter-reader variability, which is normal. People perceive things differently. In terms of the distribution of large opacities, if you look at the top row, you can see that when there is one large opacity in the image, by far they most often occur in the right upper zone. And the thinking is that's because that's where a lot of dust deposits and also because of poor lymphatic drainage from the right upper zone. So the thought is that that's why there's increased likelihood to see large opacities there. As you look across, you can see that large opacities also occur in the left upper zone. And though uncommon, large opacities can occur in the mid and lower zone. And you see sort of the same pattern when you have two large opacities. The most common is both upper zones or two of them in the right upper zone. But then you can see that they also occur in mid and lower zones as well. So looking in aggregate at the distribution of all opacities, about 41 percent occurred in the right upper zone for the reasons that I talked about, 28 percent in the left upper zone, and then 31 percent in the mid or lower zones. And 6.8 percent of readings had only middle and or lower zone involvement. So not as common, but it can happen. Unilateral involvement occurred in 34 percent of the time, 82 percent on the right. And 53 percent of the large opacities were rounded, 47 percent polygonal. And the median background small opacity perfusion was 2.1. But the number of large opacities didn't correlate with the perfusion of small opacities. This is a really interesting study that came from Turkey last year in 2022, where the investigators looked at pneumoconiosis patients seen in an occupational diseases training clinic in a tertiary care hospital. They looked at 90 PMF patients with CT, used modern CT, a one millimeter section thickness high res, and you can see the range of different occupations in these patients. And then they characterized what the PMF lesions and what the chest imaging looked like. And 90 percent had bilateral large opacities on HRCT, 88.5 percent of the unilateral cases were in the right upper lobe. So it was similar to the plain chest radiograph data that I showed you earlier. 83.3 percent had enlarged lymph nodes, 63 percent with calcification, and 24 percent with eggshell classification. And this is a really important point. You know, CT, you can see lymph nodes, you can see structures like that really well that you can't see very well with chest X-ray. So one of the big advantages to CT, 86 percent had band structures where the PMF lesion attached to adjacent pleura, and 39 percent had pericitrical emphysema, and I'll show you a picture of that on the next slide. And so here on the left, you can see the pericitrical emphysema, so you can see those emphysema blebs between the large, you know, opacity of the PMF lesion and the pleura there, and the left image of the sandblaster, and the right image of the lead miner, you can see bands connecting the PMF lesions to the adjacent pleura. So nice examples of that. All right, so next I'm going to talk a little bit about the emerging role of artificial intelligence, and it's useful to kind of know what the definitions are. So intelligence is defined as the ability to learn and perform suitable techniques to solve problems and achieve goals appropriate to the context in an uncertain, ever-varying world. Artificial intelligence is the science and engineering of making intelligent machines. Machine learning is the part of AI studying how computer agents can improve their perception, knowledge, thinking, or actions based on experience or data. And in terms of machine learning, some terms that are useful are supervised learning, where a computer learns to predict human given labels. So an example would be asking the computer to do an ILO classification and assign ILO categories to x-rays. That would be supervised learning. Unsupervised learning would be if we gave a pile of x-rays to the computer and let the computer decide how it wanted to categorize them. Deep learning is the use of large multi-layer artificial neural networks that really kind of function like the human brain. So the future is here. As of 2021, a couple years ago, there were at least 100 AI software products that were approved for use in the EU. And of these, at least 51 of them also had FDA clearance at that time. And for a current list, there is a link there you can go to to look at. But as you can see, if you look at subspecialty, about 31% of these applications were for chest. If you look at modality, the largest proportion were for CT, but there were some for plain chest x-ray. And you can see what these AI programs are for, quantification, detection, diagnosis, triage, some for image enhancement. A 2022 systematic literature review looked at the use of deep learning to evaluate chest radiographs for CWP. And that review identified eight studies that used deep learning and 32 that used kind of older approaches. And this table shows the eight studies that used deep learning. And as you can see, in terms of identifying CWP, they really had high specificity and sensitivity. The column here is called recall, and that literature, recall, and sensitivity are the same thing. So they achieved sensitivities and specificities, often the 80, 90% range, for using AI to detect findings of pneumoconiosis, of co-workers' pneumoconiosis in chest x-rays. So I don't think it'll replace humans, but it may well be useful for screening whether an image needs additional follow-up evaluation by a human. So now I'm going to switch gears and talk about HRCT of the chest. And we'll start out with a little bit of an overview. And basically, HRCT has a lot of advantages relative to chest x-ray. Chest HRCT scans are more sensitive in identifying small and large opacities than plain chest x-rays. They're really useful in assessing symptomatic patients with borderline or atypical radiologic findings. HRCT scans provide better visualization of chest anatomy, and they allow you to see not just the lungs, but also structures like lymph nodes and pleura and vascular structures. So CTs are really useful for getting a better picture of the full chest anatomy. And in Australia, as we'll see, they've really gone largely to using low-dose and ultra-low-dose CT for screening for silicosis instead of chest x-ray. So here's an example. There's been an outbreak of silicosis among artificial stone workers in Australia. So in health screening for stone masons in Queensland, Australia, 2018-2019, 29 of 67 stone masons diagnosed with silicosis were positive by HRCT but negative by chest radiograph. And you can see this here, the ILO grade zero and 29, they had changes of pneumoconiosis by HRCT. And that's really not a new finding. You can go back to 88-89 to the study of 170 French coal miners, and they did older tech CT at that time. They did 10-millimeter sections as opposed to the 1-millimeter sections we do now. But they did 1.2-millimeter sections in this study at five levels of the chest. And they concluded that the findings showed the superior of CT over chest radiography in the evaluation of small opacities. So as you can see here, among the 48 patients in their study who were ILO category zero, these were exposed coal miners, there were seven that were CT category one and five that were CT category two. So they found pneumoconiosis in coal miners who were negative by chest X-ray. And the reverse happened too. So there were some that were chest X-ray category one, so there were 65 that they classified as category one by chest X-ray, but 31 of those were CT category zero. So it goes both ways, where you can have people that are negative by chest X-ray but positive by CT or positive by chest X-ray but negative by CT. Here's another study that was done in Turkish coal miners in 2002, showing disagreement between HRCT and chest radiography. And as you can see here, they had 16 folks who were chest X-ray category zero. And of those, nine were HRCT category one. And they had 43 who were chest X-ray category one, of which 11 were HRCT category zero. So again, you see this discordance. This is a more recent study from China, with Chinese coal miners who were diagnosed with CWP from 2000 to 2011. This study also mixed in healthy coal miners who were randomly selected from the same mine. And basically what they showed was among film screen positives, there were three that were negative by CT. And among those that were negative by film screen, there were 15 that were positive by HRCT. So again, it can go both ways. There are discordances with large opacities too. So this was a study that was done in Spain, looking at 106 Spanish patients with artificial stone silicosis, followed for a mean of four years. And at the end of follow-up, chest radiograph identified 31 cases with PMF, and HRCT identified 40. And the nine additional cases all were classified as having just small opacity disease by chest radiograph. So CT was more sensitive in finding PMF. It was also more sensitive in earlier stages at initial diagnosis, when 19 cases were ILO category zero by chest radiograph, but did have findings of micro-nodular patterns by CT, by HRCT. One more study from Brazilian shipyard sandblasters and stone carvers. And here you can see among 25 sandblasters that were evaluated, there were 19 that had PMF by chest X-ray, but there were 23 that had PMF by CT. And similarly for the stone carvers, there were three that had PMF by chest X-ray, seven PMF by CT. So again, CT was more sensitive for identifying large opacities in PMF. A little bit about asbestos and asbestos-related disease. This is a study from the University of Japan looking at construction workers, 97 construction workers that were evaluated with low-dose, less than two millisievert CT within sections. And you can see their findings by CT in the table on the right, including irregular opacities and pleuroplax. And then they had four readers who did ILO classifications of X-rays in parallel to these CT evaluations. And as you can see, the sensitivity of ILO classification for small opacities and for pleuroplax in these asbestos-exposed individuals wasn't that great. The specificity was good, so when they found abnormalities, they also showed up on CT by and large, but the sensitivity wasn't that great. So in terms of summarizing the performance of CT versus chest X-ray, among individuals with histories of substantial exposure to mineral dust, small opacities are often demonstrated by HRCT, among those apparently without small opacities on chest X-ray. HRCT sometimes doesn't confirm pneumoconiosis among those with borderline findings of small opacities consistent with pneumoconiosis by chest radiograph. HRCT has greater sensitivity for detecting large opacities than chest radiograph in several studies. And HRCT has greater sensitivity and specificity for detecting pleuroplax. And one additional tidbit is that in evaluation of folks exposed to Livy Amphibole, it's been published, that you have more false positives by chest X-ray for pleural findings as the body mass index increases because you're seeing pleural flat pads as pleural plaques. So one thing that's been raised as a issue with doing CT is the problem of radiation risk and the problem of getting lung cancer from the radiation. And this table shows the risk of radiation, and it's, as you can see, the risk from a single procedure increases as someone gets lower. And the risk of a procedure is greater if you're a woman than if you're a man. And as you can see here, these lifetime risks may seem pretty high because this is a model from the NCI website that assumes that people live to age 95. So if you live to age 95, you have that baseline risk in the top row there. And then you can see the excess risks that are displayed on the table depending on what type of procedure you get at what age and whether you're a man or a woman. And as you can see, a routine chest X-ray at 0.1 millisievert really has pretty low excess risk for a single procedure. And the risk isn't that much different, you know, makes sense, if you have an ultra low-dose CT that's done that's almost the same amount of radiation as a chest X-ray. And then the risk goes up as you go to procedures that have more and more radiation associated with them. So ultra low-dose chest CT really is attractive from the standpoint of limiting radiation exposure. And this study looked at whether it could perform well diagnostically relative to conventional CT. So it looked at 55 French workers with a history of at least 15 years asbestos exposure. They did ultra low CT with a radiation dose of just 0.25 millisieverts. Remember an X-ray is 0.1 millisievert compared against a standard CT at 4 millisieverts. And the prevalence of abnormalities in the population was 20%. And then they found for global pleural pulmonary findings, the sensitivity of the ultra low-dose CT was almost 91%, specificity 100%. For lung nodules, diffuse pleural thickening and calcified pleural plaques, the sensitivity, specificity, positive predictive value and negative predictive value were all 100%. And then for asbestosis, for making a call for asbestosis, the sensitivity of the ultra low-dose was 75% and the specificity was 100%. So really going to the ultra low-dose, you lose a little bit but you don't lose that much. And really what enables this is the improved computing capability. So with less radiation, you can now reconstruct an image that has clarity and definition and allows you to see things much better than in the past. Another thing that's been raised against CT is cost. And here are the Medicare costs for HRCT and chest X-ray. As of March, a reimbursement for a CT without contrast was $163. And reimbursement for a chest X-ray was $90. So there is a difference in cost, although that's somewhat an artifact of our healthcare system. So now I'm going to talk a little bit about the international classification of high-resolution computed tomography for occupational environmental respiratory disease or the ICO-ERD. And so if you're going to do HRCT for screening and surveillance, this is a system that was developed to parallel the ILO system, except instead of being for PHS radiographs, it's for CTs. And the classification consists of three parts. Again, this is a lot like ILO. A guideline, a reading sheet, and reference films. And in this initial study, it was validated by seven independent readers, evaluating HRCTs from 27 pneumoconiosis patients and seven normal controls. Here's some screenshots of the evaluation form, which is really very reminiscent of the ILO evaluation form. You classify rounded opacities, irregular opacities, you know, whether they're thickness and their distribution and their perfusion. There's also information about other findings, like ground glass. And you can look for honeycombing, emphysema, large opacities, plural findings. And when they did their validation study, they found pretty good kappa values between the seven different readers, except for ground glass. The reproducibility for ground glass wasn't as good as for the other things. And there is a relationship between ICO-ERD HRCT classifications and ILO chest x-ray classifications. This was a study of 46 Japanese subjects with substantial mineral dust exposure. There were 21 minors and 28 controls. And they plotted here the relationship between rounded opacity score by ICO-ERD versus ILO perfusion. And again, there was a pretty good correlation. So there is correlation here between these two approaches. So now I'm going to switch gears a little bit, and I'm going to talk about eligibility criteria for lung cancer screening with low-dose HRCT. And the reason I'm doing what seems like a little bit of a digression is that many patients who are dust-exposed and potentially eligible for surveillance also meet the U.S. Preventative Services Task Force criteria for low-dose lung cancer screening. And those were updated in 2021. So I just wanted to mention those. So adults who are 50 to 80 years old who have a 20-pack year smoking history and currently smoke or have quit within the past 15 years are eligible for annual lung cancer screening. And they fall off of that. They're not eligible if they have a condition, if they have a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery if lung cancer is found. And the reason I'm mentioning this is this is a change from the original, which had a lowest age of 55 and had a lowest pack year of 30 years that's now 50 and 20 instead. And Medicare pays to age 77, so Medicare doesn't pay all the way to age 80. They go 50 to 77. In any event, the U.S. Preventative Services Task Force recommends this as a B recommendation, which means there's high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial. And they do recommend that the service be provided. And lung cancer screening, it's really underutilized. So this is a map of the U.S. showing how well different states are doing at low-dose lung cancer screening with CT. And the darkest states, which are the states that have the highest proportion of people getting screening, they're only 12.75 percent of eligible people getting screening. So we're not doing a great job at screening folks. And many of these could be dust-exposed folks who might benefit from the screening from the standpoint of identifying pneumoconiosis, too. So finally, I'm going to finish up by talking a little bit practically about the application of HRCT in pneumoconiosis prevention, and then there'll be a bit of time to answer questions. And really kind of the future is here in Australia. As I was saying earlier, in Australia, they've really transitioned much more to CT instead of chest X-ray. And in 2021, the Western Australian government passed legislation requiring the use of low-dose HRCT imaging for silica health surveillance to assist in early detection and prevention. And this was in response to their epidemic of silicosis in artificial stone countertop workers. And here's the specific language that they used. Low dose, high resolution, computed tomography of the chest at less than one millisievert equivalent dose for the entire study. The study must image the whole of each lung on inspiration at 1.5 millimeter slice thickness or less without an inner slice gap and must include expiratory imaging. The images must be of adequate quality to detect subtle abnormalities, including ground glass opacities in small nodules. So the future is here, if you're in Australia, at least. And here are the appropriateness criteria from the American College of Radiology. These are from 2020, the most recent version. So it's a couple of years old at this point. But variant one, they talk about occupational exposure, screening, and surveillance of lung disease, initial imaging. So this would be folks that might be apparently normal without symptoms, but dust exposed or being screened. ACR said that chest radiography was usually appropriate and CT of the chest without contrast might be appropriate. And I'd suggest that as our health system transitions and ultra low dose CT becomes more common, maybe it'll be more positive towards CT. And the next variant they talk about is suspected interstitial lung disease initial imaging. So these might be people that have symptoms that you're evaluating. And here they say usually appropriate for both CT without IV contrast, which they put first, and chest radiography, which they put second. So if you suspect clinical disease is there for the many reasons that we talked about earlier, CT really is the better modality. And the third variant was occupational exposure, suspected interstitial lung disease based on a chest radiograph that's already been obtained. And of course, a CT is appropriate there. They also touched on airway disease. And they suggested CT chest without IV contrast is usually appropriate with suspected airway disease. Again, you can get inspiratory and expiratory, you know, views and look for inhomogeneous distribution. Chest X-ray is also usually appropriate, they say. And again, if you get into clinical disease where people are actually sick, CT is really the preferable modality. So we'll finish up with a few final comments. So in terms of screening recommendations, certainly dust exposed workers who are eligible according to the U.S. Preservative Services Task Force criteria should be offered annual screening for lung cancer with low-dose chest CT. And again, the criteria are age 50 to 80 years, 20-pack year smoking history. Current smokers are quit within the past 15 years. For low-dose lung cancer screening, shared decision-making is important, discussing it, deciding together. Screening can also detect pneumoconiosis. And be prepared to provide follow-up. In the National Lung Screening Trial, about 24 percent of low-dose CT scans required follow-up. And I would expect in dust exposed minors or dust exposed construction workers or other folks at risk for pneumoconiosis, the number needing follow-up might be even substantially higher. Screening apparently healthy workers at risk for pneumoconiosis from occupational exposures with chest radiography, it's still appropriate. Computer-assisted detection using AI machine learning techniques will hopefully improve the performance of that screening and improve the efficiency. Again, one role for AI might be to screen out x-rays that require more human attention. Also as ultra-low-dose chest CT becomes more widely available, the role of chest radiography will really need to be reassessed. Because if we remove the radiation difference and we have one modality that's superior to another, probably you should go for the better imaging modality. Lower-dose chest CT, low-dose chest CT is appropriate for evaluating workers at high risk for pneumoconiosis. And some things to consider that might weigh in favor of CT would be suggestive symptoms, diagnostic findings, pulmonary function abnormalities, especially in people with a history of substantial exposure, outbreak situations. So the Australian situation with the Stonemasons was an outbreak situation where there were lots of people with disease. And so if you're screening workers in an outbreak situation, CT might be the more appropriate modality. And then finally, the ICO-ERD's classification system provides a standardized way to report results. So radiographic screening for pneumoconiosis with plain chest X-ray will continue to be important for identifying sentinel cases, allowing unexpected failures in controlling hazardous exposures to be identified and controlled. So it'll continue to be important for primary prevention. It'll continue to be important for early detection so that interventions can be done to improve clinical outcomes, like ceasing dust exposures or lowering them. New technologies are likely to augment or replace older approaches, so computer-assisted detection of pneumoconiosis findings, artificial intelligence and machine learning, more use of ultra-low-dose CT, and more use of low-dose CT. So I'll stop there. Thank you very much. And I'll try to answer any questions. Great talk. Question about that co-workers in pneumoconiosis and U-opacities. Were those usually accompanied by rounded opacities? And were those upper, mid, lower zone? What's the story? That's so interesting. Yeah. So that .9 percent that had U-opacities, I can't tell you more about those few images that had U-opacities. I will say that it really, there's a pathologic condition called dust-related diffuse fibrosis that looks a lot like IPF that happens in dust-exposed individuals, and it happens both with coal exposure and with silica exposure. And so those folks that have lower zone irregulars, many of them pathologically, when you look at them, they'll have dust-related diffuse fibrosis. Hi. My name is Haramaya from Denmark, and thank you for a nice presentation. And please excuse me if my question is too basic. I was wondering, this definition of irregular or regular opacities, is that actually associated with clinical symptoms or prognosis? Sure. So classically, when people talk about the rounded opacities, they talk about coal dust or silica exposure, and rounded opacities tend to occur in the upper zones. And when people talk about, like, irregular opacities, the type of exposure they're most associated with are things like asbestos. You know, asbestosis looks a lot like IPF. You can get that lower zone irregular opacity, you know, kind of appearance that's IPF-like, that diffuse dust-related fibrosis appearance in a proportion of people that have silica or coal exposure. So that's kind of the difference. I hope that answers the question. Good morning. Thank you for a very interesting talk. I'm Carl Auerbach from Albany, New York. As you said, the future is here in some areas, and the ultra-low-dose CTs are obviously looking like they're going to start replacing chest X-rays. But that said, in one of your last slides, you had MRI listed in there. Will MRI be able to do the technical classification, and will it be better than CT? Obviously, MRIs are not as common and not as available, and certainly much more expensive. But that is now. So in the future, as these technologies become more available and lower cost, is there a role for MRI in this process? Because of all the air spaces in the lung, for that particular organ, MRI is generally not as good. But one place where MRI is potentially useful is if you have a large opacity that you're worried might be cancer. There's some recent literature that suggests that MRI can help you to differentiate between large opacities that are actually cancer versus large opacities that are pneumoconiosis. So MRI, good for looking at the mediastinum, good for that purpose, but maybe not so good for the lung. Thank you so much for a wonderful presentation. My name is Sonny. I work at Gundersen Health System in Wisconsin. I wanted to find out from you, is there a way of helping occupational health physicians to have a better basic knowledge about B reading? I tried to go for the exam, and it was really, really radiological-based. And throughout our trainings, throughout our practices, for my practice in Wisconsin, we do these x-rays, then we send it somewhere, and then they read it, they send it back. But we are the people who see these patients come to us. So that knowledge of B reading and having seen the patient, kind of, is very complementary. But still, we don't have that expertise to read these x-rays properly. We might know what it is, but we are not qualified, we are not B readers. Can we make B reading part of these sections, maybe once a year when we come for this, so we can begin to learn how to become qualified as a B reader? I love that idea. We actually recently posted a new online syllabus for self-study and images for learning about ILO classification and preparing for taking the B reader examination. So that's available. We're planning to pilot with some of our education and research centers. We're going to start with the one in Illinois to try to offer the examination in more sites, so people don't have to come to Morgantown to take the exam. We've also worked with the American College of Radiology. They've developed a new course based on the digital radiography. And they've offered several courses, and depending on funding, hopefully we'll be able to work with them to have more courses where they teach to the exam and then offer the exam right there. So we're working to make it more available. And a lot of these things are sort of related to how much funding and bandwidth we have, but we certainly want to disseminate that knowledge and make it available to more people. Hi, good morning. Thank you for the excellent talk. I'm Dr. Katlani from Queens College, New York, and I work for the Former Worker Program, Department of Energy Medical Screening Program for the nuclear industry workers. So we've been, we've screened between 2,000 and 2,000, and 2020 to 14,000 people and offered them annual low-dose CT scan, and of those 14,000 people screened, we've detected 205 lung cancers. Sorry, and that's my boss. Seventy-three percent of these lung cancers were detected during their, at an early stage. So we've been using this 20-pack year smoking criterion before, for a few years, before U.S. Preventive Services Task Force came up with this recommendation. And here's my question, and this is something we've been thinking of. For a person who has significant occupational exposure history and who's been a smoker, should this criterion be any different and not just 20-pack year? Should it be a person with substantial smoking history, occupational history? Is that person's risk of lung cancer the same person with occupational history, 10-pack year history, and somebody with no occupational history, 20-pack year smoking history, are their risks about the same or not? And that's my question for you, your opinion. That's a great question, and, you know, it's an area where I can't give you a definitive answer. You know, I think that that's an area, so say you have somebody with 19 years of smoking history, but they've been an asbestos worker, right? You know, and what do you do with that person? You know, I think that's shared decision-making. I think you sit down with the patient, you talk with the patient, you know, about the potential risks, you know, and then, you know, that might or might not be compensated by Medicare is the other thing, is getting the third-party payer, you know, to pay for it. You know, so not a straightforward question. Until we have more data, it's hard to really be definitive about that, but I think if the insurance will cover, if it's available, it's a shared decision-making, and I think it's reasonable for that type of patient to be offered lung cancer screening if based on meeting with them, you decide together it's appropriate. Good morning, Prof. Eisman, and colleagues, thank you for that enlightening talk. I'm just trying to understand the ultra-low-dose CT, and I don't quite understand why it's not as easily available and accessible, especially in countries where I come from, South Africa, and also to understand its application and benefit where there's an overlay of TB, such as, you know, where there's high incidence of HIV as well. So as well as the silicosis and the other pneumoconiosis and PMF and lung cancer. So just what's your experience with that? Thank you so much. Yeah, and I think the penetration of the ultra-low-dose CT, you know, it's like any other technology, people buy CT scanners and they're expensive, you know, and then, you know, until you can go to the, you know, you don't go to the newer technology until the finances allow it, right? So hopefully there'll be broader penetration of ultra-low-dose CT, you know, in multiple countries over time. And I think we have time for maybe one more question. Mark Boto from Seattle. My question is with regard to chest X-rays, are the obliques more sensitive for pleural plaques? And were the standard X-rays with obliques used for comparison for the high-dose CT for comparison? I mean high-resolution CT for comparison? So you're a person after my own heart. You remember oblique CTs, or oblique chest X-rays. And no, I don't think RIOs and LAOs were used in that study. But in fact, though, our standard X-rays with chest X-rays, obliques are more sensitive for pleural plaques, correct? Yeah, and gosh, I can't quote you a paper on that, but I know that in the pre-CT era that that was standard practice to get obliques. And certainly obliques will allow you to catch things in profile that you wouldn't catch, you know, with just a PAN lateral. So if you're working, you know, just with chest X-ray, you know, obliques probably still have a role. Thank you. Thank you. All right, well, thank you very much. Have a great meeting.

radiographic screening

pneumoconiosis

chest radiography

high-resolution chest computed tomography

ILO classification system

AI and machine learning

ultra-low-dose chest HRCT

lung cancer screening

MRI