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Although exposure must always be investigated by anamnesis&#44; in many cases the information that patients provide may be insufficient or confusing&#46; Patients may have been unaware of the presence of asbestos in the workplace&#44; or may have difficulty remembering activities that they performed many years previously&#46; Therefore&#44; in these cases it is important to have access to objective data that prove exposure and permit a reliable diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The most objective proof of exposure to asbestos is its deposition in the lung&#44; which corresponds to the proportion of inhaled asbestos that could not be eliminated&#46; A safe method for determining the extent of this deposition is the analysis of lung samples&#44; for which&#44; obviously&#44; tissue samples are required&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;6</span></a> An alternative technique is to analyze asbestos content in the form of fibers&#44; or more commonly&#44; asbestos bodies in bronchoalveolar lavage &#40;BAL&#41;&#46; This technique has the advantage of being non-invasive&#44; and in several previous publications has shown a good correlation with the determination of asbestos in lung tissue&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">In Spain&#44; the number of recent scientific studies of ARD is limited&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#44;8&#8211;13</span></a> Even scarcer are studies that objectively analyze the pulmonary deposition of asbestos&#46;<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">5&#44;6</span></a> There is currently only 1 laboratory in Spain that carries out routine analysis of asbestos in biological samples&#46; Laboratory reference values for the Spanish population have been published<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">5</span></a> and can be used to establish cut-off points for different pathologies&#46; In the case of BAL&#44; however&#44; no study of this kind is currently available&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this study was to present an initial assessment of the usefulness of the analysis of asbestos bodies in BAL for diagnosing ARD in the city of Barcelona&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Study Population</span><p id="par0030" class="elsevierStylePara elsevierViewall">This retrospective-observational study included 39 patients exposed to asbestos who underwent a diagnostic BAL due to suspicion of ARD from 2007 until 2013&#46; Suspicion was based on the patient&#39;s report of prior asbestos exposure and&#47;or suggestive chest radiological images&#46; The study also included a second group of 33 patients who had not been exposed to asbestos&#44; in whom BAL was indicated in the diagnostic process&#46; Lung tissue samples were also available from 8 exposed and 15 non-exposed patients &#40;all of whom underwent surgical resection for lung cancer&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Fifty-eight patients in the study population were resident in the city of Barcelona&#44; 13 patients in the Barcelona metropolitan area&#44; and 1 in the city of Tarragona&#46; The patient&#39;s exposure was determined by anamnesis&#46; Jobs and activities were recorded chronologically and the presence of exposure was established by one of the authors&#46; The study was approved by our hospital&#39;s Ethics Committee &#40;PR&#40;AG&#41;20&#47;2007&#41;&#46; All patients gave written consent to participate in the study&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Clinical and Radiological Diagnosis</span><p id="par0040" class="elsevierStylePara elsevierViewall">All patients underwent anamnesis&#44; physical examination&#44; chest X-ray&#44; lung CT and blood analysis&#46; The diagnosis of asbestos-related disease was established on the basis of asbestos exposure plus a suggestive clinical and radiological profile&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Lung cancer was diagnosed on the basis of a histological exam performed by a pathologist&#46; The diagnosis of benign pleural ARD was based on radiologic images suggesting the presence of pleural plaques&#44; fibrosis&#44; effusions&#44; and on exclusion of other diseases&#46; Rounded atelectasis was diagnosed on the basis of typical radiological patterns on chest CT&#46; Mesothelioma was diagnosed by the pathologist from the available pleural biopsies using conventional and immunohistochemical techniques&#46; Patients with diffuse interstitial lung disease were evaluated&#46; Asbestosis was diagnosed in patients with a combination of an interstitial lung pattern&#44; asbestos exposure&#44; suggestive pleural alterations or high levels of asbestos bodies in BAL&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Sample Collection Protocol</span><p id="par0050" class="elsevierStylePara elsevierViewall">BAL samples&#58; Bronchoalveolar lavage was performed at the lingula or right middle lobe of the lung contralateral to the neoplasia&#46; One hundred fifty ml of saline serum were instilled&#44; and at least 10<span class="elsevierStyleHsp" style=""></span>ml of fluid was used for the asbestos study&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Lung tissue&#58; The size of the specimen was 2 cm&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">3</span></a> The region of the lung sampled depended on the tumor location&#46; Samples were fixed in formaldehyde&#46; All lung specimens were examined by a pathologist from our hospital&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Preparation of BAL Lung Samples</span><p id="par0060" class="elsevierStylePara elsevierViewall">Ten ml of BAL were obtained from each patient&#44; and centrifuged at 2000<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">g</span> for 20<span class="elsevierStyleHsp" style=""></span>min&#44; after which 30<span class="elsevierStyleHsp" style=""></span>ml of filtered sodium hypochlorite were added&#46; The mixture was shaken for 1<span class="elsevierStyleHsp" style=""></span>h to facilitate elimination of organic material&#44; and centrifuged at 2000<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">g</span> for 20<span class="elsevierStyleHsp" style=""></span>min&#46; Sodium hypochlorite was discarded and the sample resuspended in filtered distilled water&#46; The solution obtained was filtered through a 0&#46;45<span class="elsevierStyleHsp" style=""></span>&#956;m pore diameter membrane&#46; The filter was dried in an oven overnight at 37<span class="elsevierStyleHsp" style=""></span>&#176;C and transferred to a microscope slide by means of an acetone vaporizer &#40;JS Holdings 240v&#47;110v&#41; for subsequent study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Preparation of Tissue Lung Samples</span><p id="par0065" class="elsevierStylePara elsevierViewall">Two 0&#46;5<span class="elsevierStyleHsp" style=""></span>g fragments of lung tissue that did not contain pleura or vessels were obtained from each specimen&#46; One of these fragments was frozen&#44; lyophilized and weighed to determine the dry tissue weight&#44; in accordance with the international consensus on expressing AB results in terms of grams of dry lung tissue&#46; Once the dry weight was known&#44; the lyophilized sample was discarded&#44; as this technique can alter the concentration and size of asbestos bodies&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The non-lyophilized tissue section was divided into small fragments and washed for 16<span class="elsevierStyleHsp" style=""></span>h with filtered distilled water&#46; Then&#44; 35<span class="elsevierStyleHsp" style=""></span>ml of previously filtered sodium hypochlorite were added to the sample&#46; The fragments were left in this solution for 4<span class="elsevierStyleHsp" style=""></span>h to facilitate tissue digestion and removal of organic matter&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The sample was centrifuged at 2000<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">g</span> for 20<span class="elsevierStyleHsp" style=""></span>min&#46; After discarding the supernatant&#44; 30<span class="elsevierStyleHsp" style=""></span>ml of filtered distilled water were added&#46; After another centrifugation and elimination of the supernatant the sample was resuspended in 20<span class="elsevierStyleHsp" style=""></span>ml of filtered distilled water and sonicated for 10&#8243; using an ultrasonic bath &#40;UCI-50&#44; 300<span class="elsevierStyleHsp" style=""></span>W&#44; 50&#47;60<span class="elsevierStyleHsp" style=""></span>Hz&#44; Raypa S&#46;L&#46;&#41;&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Twenty ml of a 1&#58;1 ethanol &#40;Milipore Corporation&#44; Germany&#41; chloroform &#40;PanreacQuimicaSau&#44; Spain&#41; mixture were added to the solution and the sample was centrifuged&#46; After centrifugation&#44; the upper layer the resulting density gradient was discarded using a Pasteur pipette and the resulting solution was filtered using a 0&#46;45<span class="elsevierStyleHsp" style=""></span>&#956;m diameter membrane &#40;Millipore Membrane filters HAWP02500&#41;&#46; The filter was dried in an oven overnight at 37<span class="elsevierStyleHsp" style=""></span>&#176;C and transferred to a microscope slide by means of an acetone vaporizer &#40;JS Holdings 240v&#47;110v&#41; for subsequent study&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Asbestos Body Counting by Optic Microscopy</span><p id="par0085" class="elsevierStylePara elsevierViewall">The filters were viewed with an optic microscope &#40;CX21FS2&#59; Olympus Life Science Europe GMBH&#44; Hamburg&#44; Germany&#41; at &#215;400 magnification&#46; In accordance with the criteria established by the working group of the European Respiratory Society in 1998&#44; asbestos levels exceeding 1 AB&#47;ml BAL or 1000 AB&#47;g dry tissue were considered potentially pathological&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Statistical Analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">The data are expressed as median and range &#40;<span class="elsevierStyleItalic">r</span>&#41;&#46; In an initial analysis with the Kolmogorov&#8211;Smirnov test&#44; AB values did not follow a normal distribution&#59; hence&#44; the Wilcoxon test was used to determine the differences between groups&#46; The Spearman correlation coefficient was calculated to establish correlations between the parameters analyzed&#46; The consistency of levels of AB in BAL was estimated by evaluating the sensitivity &#40;SE&#41; and specificity &#40;SP&#41; of the method&#44; the positive &#40;PPV&#41; and negative &#40;NPV&#41; predictive values&#44; and the likelihood ratio of a positive &#40;LR&#43;&#41; and negative &#40;LR&#8722;&#41; value with 95&#37; confidence intervals &#40;95&#37; CI&#41; using the Wilson method&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a> Receiver-operating characteristic &#40;ROC&#41; curves were constructed to determine the most discriminating cut-off value of AB&#47;ml BAL for predicting ARD&#46; The statistical analysis was carried out with Graph Pad software &#40;2002&#8211;2005&#41;&#46;</p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Results</span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Clinical Characteristics of The Study Population</span><p id="par0095" class="elsevierStylePara elsevierViewall">The baseline characteristics of the 72 patients are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; There was a predominance of males and smokers or ex-smokers&#46; Thirty-three patients denied asbestos exposure&#46; Forty patients were diagnosed with carcinoma&#44; 10 with benign pleural disease&#44; 6 with asbestosis&#44; 1 with mesothelioma&#44; 5 with rounded atelectasis&#44; 4 with interstitial lung disease of unidentified origin&#44; 2 with tuberculosis and 4 with other pathologies &#40;bronchiectasis&#44; COPD&#44; aortic aneurysm&#44; esophageal squamous carcinoma&#41;&#46; Significant differences between exposed and non-exposed patients with regard to sex and smoking were observed &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;011 and &#46;015 respectively&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Asbestos Bodies in BAL</span><p id="par0100" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the levels of AB&#47;ml BAL and AB&#47;g dry lung tissue in exposed and non-exposed patients&#46; Of the 39 exposed patients&#44; 13 &#40;33&#37;&#41; presented values of AB above 1 AB&#47;ml BAL&#44; with a median value of 0&#46;06 &#40;<span class="elsevierStyleItalic">r</span>&#58; 0&#46;13&#8211;19&#46;4&#41;&#46; In the 33 non-exposed patients&#44; 5 &#40;15&#37;&#41; presented AB values above 1 AB&#47;ml BAL&#44; with a median value of 0&#46;03 &#40;<span class="elsevierStyleItalic">r</span>&#58; 0&#8211;9&#46;5&#41;&#46; One of these patients lived in Cerdanyola&#46; There was a significant difference between AB levels in exposed and non-exposed patients &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;006&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">The sensitivity&#44; specificity and positive and negative predictive values of AB in BAL for the diagnosis of ARD&#44; according to exposure determined by work records&#44; are shown in <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#46; AB levels above 1 AB&#47;ml BAL had a sensitivity of 33&#37; &#40;95&#37; CI&#58; 19&#8211;50&#41; and a specificity of 85&#37; &#40;95&#37; CI&#58; 67&#8211;94&#41; for diagnosing ARD&#46; The ROC curve showed the most relevant cut-off value of AB&#47;ml BAL for predicting ARD&#46; The area under the ROC curve was 0&#46;7&#46; A cut-off point of 0&#46;5 AB&#47;ml BAL achieved the most satisfactory sensitivity&#58; 46&#37; &#40;29&#8211;84&#41;&#44; with a specificity of 83&#37; &#40;68&#8211;96&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0110" class="elsevierStylePara elsevierViewall">AB levels in BAL in the different pathologies are shown in <a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#46; Six of the 40 patients with lung cancer &#40;15&#37;&#41; had high levels of AB in BAL&#58; 3 &#40;19&#37;&#41; of the 16 with asbestos exposure and 3 &#40;12&#37;&#41; of the 24 without&#46; Only 2 of the 10 patients with benign pleural asbestos diseases &#40;both non-exposed&#41; showed high AB levels in BAL&#46; Of the 6 patients diagnosed with asbestosis&#44; 4 &#40;all with asbestos exposure&#41; had high AB levels&#46; Three of 5 patients with rounded atelectasis &#40;all with previous asbestos exposure&#41; had high AB levels&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Asbestos Bodies in Lung Tissue and Correlation of AB in BAL and Lung Tissue</span><p id="par0115" class="elsevierStylePara elsevierViewall">Medians of 631 &#40;<span class="elsevierStyleItalic">r</span>&#58; 60&#8211;7499&#41; and 134 &#40;<span class="elsevierStyleItalic">r</span>&#58; 0&#8211;2149&#41; AB&#47;g dry tissue were obtained for exposed and non-exposed patients respectively &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Three &#40;37&#37;&#41; patients in the exposed group and 1 &#40;7&#37;&#41; patient in the non-exposed group presented values above 1000 AB&#47;g&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a> shows the correlation between levels of AB&#47;ml BAL and AB&#47;g lung tissue&#44; with a Spearman Rank Coefficient of 0&#46;633 &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;002&#41;&#46; None of the 4 patients with lung values above 1000 AB&#47;gr had values below 1 AB&#47;ml BAL&#44; while in 1 patient with lung adenocarcinoma who presented high BAL values this result was not confirmed in tissue&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0125" class="elsevierStylePara elsevierViewall">Our study found a good correlation &#40;0&#46;63&#41; between levels of AB in lung and bronchoalveolar lavage&#46; Moreover&#44; no clinically significant discrepancies were observed between these measurements&#59; there was only 1 patient with lung cancer in whom high AB levels in BAL were not confirmed in lung tissue&#46; A value of 0&#46;5 AB&#47;ml BAL showed the best sensitivity &#40;46&#37;&#44; range 29&#37;&#8211;84&#37;&#41;&#44; with a specificity of 83&#37; &#40;range 68&#37;&#8211;96&#37;&#41; for the diagnosis of ARD&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">The results of the present study confirm&#44; for the first time in Spain&#44; the diagnostic utility of the quantification of asbestos bodies in BAL&#46; Lung asbestos burden is considered to constitute objective evidence of past exposure to this silicate&#44; and its quantification has been proposed as a useful tool in patients with a suspected asbestos-related disease when a history of exposure is either lacking or inconclusive&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a> Because of the difficulty in obtaining lung samples for analysis&#44; certain less invasive diagnostic methods have been investigated&#46; While the sensitivity of sputum analysis is controversial&#44;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">16&#8211;19</span></a> BAL has been used by several authors to determine lung asbestos burden&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">7&#44;20&#8211;22</span></a> The present study supports this approach&#44; since a significant correlation was observed between the AB counts in BAL and in the lung&#46; Previous studies have found this correlation to be around 0&#46;7&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">23&#44;24</span></a> In our study the correlation was slightly lower&#44; at 0&#46;63&#44; probably due to the characteristics of the patient sample&#58; in previous studies the percentage of non-exposed patients was very low&#44; between 7&#37; and 8&#37;&#44; whereas in our series it was as high as 46&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">23&#44;24</span></a> The analysis of asbestos in biological samples loses sensitivity in patients with lower AB levels&#44; and results are highly variable owing to the recovery of lavage samples and the counting techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">In our series&#44; AB count in BAL was shown to be a reliable basis for diagnosis of ARD&#46; All patients with high AB counts in lung also had high AB counts in BAL&#44; and high levels in BAL were not confirmed in the lung in only 1 patient&#46; This patient&#44; who had worked as a chauffeur&#44; denied asbestos exposure&#46; The difference in lung and BAL results may have been due to variations in the analyses carried out&#44; which included different lung areas&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">17</span></a> In conclusion&#44; the experience at our laboratory shows that quantification of asbestos bodies in BAL is a good alternative to lung examination when determining asbestos exposure&#44; and offers the advantage of being less invasive for the patient&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The present study highlights the difficulties of ascertaining asbestos exposure in clinical practice&#46; Overall&#44; the diagnostic yield of BAL for determining exposure was moderate&#44; as reflected by a Youden index of 0&#46;18&#46; Although in this study we found the best threshold for AB counts in BAL to be 0&#46;5 in terms of sensitivity and specificity&#44; the accepted international threshold is 1&#44; and we calculated our diagnostic yield accordingly&#46; Only 33&#37; of the patients who reported some degree of asbestos exposure had AB counts above 1&#47;ml&#46; The low AB counts in BAL of exposed patients are surprising&#44; although this phenomenon has already been observed in previous studies&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> The most likely explanation is the difference between exposure and retention&#46; Most imported asbestos is in the form of chrysotile&#44; which is known to have faster clearance than other asbestos fibers&#46; According to this hypothesis&#44; the vast majority of inhaled asbestos would be eliminated&#44; thus explaining the negativity of BAL analyses performed many years later&#46; Indeed&#44; recent data from our group reveal that the vast majority of asbestos fibers retained in the lungs of the Spanish population are amphiboles &#40;unpublished data&#41;&#46; Moreover&#44; this limited sensitivity may increase in direct proportion to the latency time&#44;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a> suggesting that analyses of lung asbestos burden cannot substitute anamnesis in the initial evaluation of patients&#46; Consequently&#44; a history of exposure must continue to be the cornerstone for diagnosis of asbestos-related diseases&#46; BAL examination&#44; then&#44; remains a practical option for establishing definite exposure in patients in whom the anamnesis is inconclusive&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">However&#44; our results also highlight the limitations of anamnesis to reliably ascertain past asbestos exposures&#46; Fifteen per cent of our non-exposed patients had high levels of asbestos bodies in BAL&#46; As other authors<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> have noted&#44; unknown exposure&#44; be it occupational&#44; environmental or domestic&#44; may remain unrecognized and this is challenging for physicians diagnosing ARDs&#46; Patients can be unaware of past exposure to asbestos for several reasons&#44; including lack of information on the activities and products existing in the subject&#39;s workplace&#44; as well as his or her inability to remember specific information from the distant past&#46; An example of this is the case of a patient in our series who did not report asbestos exposure but had high levels of AB counts in BAL&#59; this patient had lived in Cerdanyola&#44; a town with well-documented&#44; high environmental levels of asbestos due to the vicinity of a fibrocement factory&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Levels of asbestos bodies in BAL varied according to the specific disease&#46; In lung cancer&#44; 15&#37; of patients had high AB counts&#44; suggesting that asbestos exposure should be investigated as a possible risk factor for lung cancer in our setting&#46; The supra-additive effect of asbestos and smoking constitutes a huge health concern in Spain&#44; where the percentage of smokers still remains high&#46; In addition&#44; diagnosing asbestos as the causative factor in lung cancer is particularly difficult in smokers&#44; and the issue often has legal implications&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">26&#44;27</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">The relevance of high AB counts in BAL depends on the disease under diagnosis&#46; In our series&#44; in patients with mesothelioma&#44; rounded atelectasis or benign pleural diseases&#44; high AB levels confirmed the diagnosis&#59; while in patients with asbestosis&#44; detection of high levels &#40;66&#37;&#41; supported a specific diagnosis and helped rule out other interstitial diseases&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">This study has several limitations&#46; Asbestos exposure could not be ascertained using the job-exposure matrix&#44; and the accuracy of self-reported exposure was probably low&#46; Additionally&#44; since the test results correspond to patients from Barcelona&#44; an industrial city&#44; they cannot be extrapolated to individuals living in rural areas&#46; Finally&#44; patients with mesothelioma were not included&#44; so our results do not apply to this pathology&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">In conclusion&#44; our results show that analysis of asbestos bodies in BAL could be a reliable method for determining the lung asbestos burden in the Spanish population&#46; Although its limited sensitivity means that it cannot replace anamnesis as the gold standard for establishing asbestos exposure&#44; the assessment of asbestos bodies in BAL represents a good option in patients with a confusing medical history&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Authorship</span><p id="par0170" class="elsevierStylePara elsevierViewall">Conception and design&#58; MJC and JF&#59; Analysis and interpretation&#58; DAS&#44; VC&#44; JG&#44; MC&#44; LP and ASF&#59; Drafting the manuscript for important intellectual content&#58; MJC and JF&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflict of interest statement</span><p id="par0175" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bronchoalveolar lavage &#40;BAL&#41; analysis has been proposed as an objective technique for confirming asbestos exposure&#46; However&#44; the reliability and diagnostic yield of this procedure has not been studied in Spain&#46; The aim of this study was to assess the usefulness of the analysis of asbestos bodies &#40;AB&#41; in bronchoalveolar lavage &#40;BAL&#41; for the diagnosis of asbestos-related diseases &#40;ARD&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">BAL samples from 72 patients &#40;66 male&#44; mean age 66 years&#41; undergoing bronchoscopy were analyzed&#46; Lung tissue from 23 of these patients was also analyzed&#46; Asbestos exposure was assessed by anamnesis and a review of the patient&#39;s medical records&#46; BAL and lung samples were processed and AB count was determined by light microscopy&#46; The accepted threshold value to diagnose asbestos-related diseases was 1 AB&#47;ml BAL or 1000 AB&#47;gr dry tissue&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Thirty-nine patients reported exposure to asbestos&#46; Of these&#44; 13 &#40;33&#37;&#41; presented AB values above 1 AB&#47;ml BAL&#46; In the 33 non-exposed patients&#44; 5 &#40;15&#37;&#41; presented AB values above 1 AB&#47;ml BAL&#46; There was a significant difference between the AB levels of exposed and non-exposed patients <span class="elsevierStyleItalic">&#40;P</span>&#61;&#46;006&#41;&#46; The ROC curve showed that a value of 0&#46;5 AB&#47;ml BAL achieved the most satisfactory sensitivity&#44; 46&#37;&#44; and a specificity of 83&#37;&#46; The correlation between AB levels in BAL and lung was 0&#46;633 <span class="elsevierStyleItalic">&#40;P</span>&#61;&#46;002&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">BAL study provides objective evidence of exposure to asbestos&#46; The good correlation between the AB counts in BAL and lung tissue indicates that both techniques are valid for the analysis of asbestos content&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
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          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">El an&#225;lisis del lavado broncoalveolar &#40;LBA&#41; se ha propuesto como t&#233;cnica objetiva para certificar la exposici&#243;n a amianto&#46; Sin embargo&#44; la fiabilidad y la productividad de este procedimiento diagn&#243;stico no se han analizado en Espa&#241;a&#46; El prop&#243;sito de este estudio fue evaluar la utilidad del an&#225;lisis de part&#237;culas de amianto &#40;PA&#41; en el LBA para el diagn&#243;stico de enfermedades relacionadas con el amianto &#40;ERA&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se analizaron muestras de LBA de 72 pacientes &#40;66 varones&#44; edad media de 66 a&#241;os&#41; sometidos a broncoscopia&#46; Tambi&#233;n se analiz&#243; el tejido pulmonar de 23 de estos pacientes&#46; La exposici&#243;n al amianto se evalu&#243; a partir de la anamnesis y la revisi&#243;n de las historias cl&#237;nicas de los pacientes&#46; Las muestras de LBA y de tejido pulmonar se procesaron&#44; y la cantidad de PA se determin&#243; mediante microscopia &#243;ptica&#46; El valor umbral aceptado para diagnosticar una enfermedad relacionada con el amianto fue de 1 PA&#47;ml de LBA o 1&#46;000 PA&#47;g de tejido seco&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Treinta y nueve pacientes refirieron exposici&#243;n a amianto&#46; En 13 &#40;33&#37;&#41; de estos pacientes&#44; los niveles de PA fueron superiores a 1 PA&#47;ml de LBA&#46; De los 33 pacientes no expuestos&#44; los valores de PA fueron superiores a 1 PA&#47;ml de LBA en 5 casos &#40;15&#37;&#41;&#46; La diferencia entre los niveles de PA de los pacientes expuestos y los no expuestos fue significativa &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;006&#41;&#46; La curva ROC indic&#243; que el nivel de 0&#44;5 PA&#47;ml de LBA era el que alcanzaba mayor sensibilidad &#40;46&#37;&#41;&#44; con un 83&#37; de especificidad&#46; El grado de correlaci&#243;n entre los niveles de PA en el LBA y el tejido pulmonar fue de 0&#44;633 &#40;p<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#44;002&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">El estudio del LBA ofrece una prueba objetiva de la exposici&#243;n a amianto&#46; La buena correlaci&#243;n observada entre los recuentos de PA en el LBA y en el tejido pulmonar indica la validez de ambas t&#233;cnicas para analizar el contenido de amianto&#46;</p></span>"
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            "titulo" => "M&#233;todos"
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
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    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as&#58; Cruz MJ&#44; Curull V&#44; Pijuan L&#44; &#193;lvarez-Sim&#243;n D&#44; S&#225;nchez-Font A&#44; de Gracia J&#44; et al&#46; Utilidad del lavado broncoalveolar en el diagn&#243;stico de enfermedades relacionadas con el amianto&#46; Arch Bronconeumol&#46; 2017&#59;53&#58;318&#8211;323&#46;</p>"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Receiver operating characteristic curve constructed to determine the most relevant value of AB&#47;ml BAL for predicting ARD&#46; The dot represents the optimal cut-off point&#46;</p>"
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      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">AB values in the BAL samples of the patients studied &#40;values higher than 0&#41;&#46; A&#58; Patients with reported exposure&#59; B&#58; Patients without reported exposure&#46; Dotted line&#58; levels above 1 AB&#47;ml BAL&#46;</p>"
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Correlation between levels of AB&#47;ml of BAL and AB&#47;g dry tissue&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Exposed<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a><br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Non exposed<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">&#42;</span></a><br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age&#44; yr</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">67&#46;8 &#40;9&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">64&#46;3 &#40;9&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;450&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Sex&#44; M&#47;F</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">39&#47;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#47;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Smoking habit&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">11 &#40;28&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">15 &#40;45&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Ex-smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">19 &#40;49&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;18&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Non-smoker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">9 &#40;23&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">12 &#40;37&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Diagnosis&#44; n &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bronchogenic carcinoma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">16 &#40;41&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">24 &#40;73&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;164&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Benign pleural disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;13&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;15&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Asbestosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">6 &#40;16&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mesothelioma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rounded atelectasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4 &#40;10&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Interstitial lung disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tuberculosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;2&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Other pathologies&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;8&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Exposed<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>39&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Non-exposed<br><span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>33&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">AB&#47;ml BAL</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;06 &#40;0&#46;13&#8211;19&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;03 &#40;0&#8211;9&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Values&#62;1 AB&#47;ml BAL</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">13 &#40;33&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 &#40;15&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Car mechanic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Textile industry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Thermal insulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Metallurgy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Docker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Automotive industry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bricklayer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Driver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Food industry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Painter&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">AB&#47;gr dry tissue</span><a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">&#42;&#42;</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">631 &#40;60&#8211;7499&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">134 &#40;0&#8211;2149&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;022&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Values&#62;1000 AB&#47;gr dry tissue</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3 &#40;37&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 &#40;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Metallurgy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Docker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Thermal insulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Food industry&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                  \t\t\t\t\tvoid\n
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:27 [
            0 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical aspects of asbestos-related diseases&#8212;what are the unresolved topics&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "D&#46;E&#46; Banks"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/JOM.0000000000000242"
                      "Revista" => array:7 [
                        "tituloSerie" => "J Occup Environ Med"
                        "fecha" => "2014"
                        "volumen" => "56"
                        "numero" => "Suppl 10"
                        "paginaInicial" => "S8"
                        "paginaFinal" => "S12"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25285978"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Asbestos and the lung in the 21st century&#58; an update"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "S1 Prazakova"
                            1 => "P&#46;S&#46; Thomas"
                            2 => "A&#46; Sandrini"
                            3 => "D&#46;H&#46; Yates"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/crj.12028"
                      "Revista" => array:6 [
                        "tituloSerie" => "Clin Respir J"
                        "fecha" => "2014"
                        "volumen" => "8"
                        "paginaInicial" => "1"
                        "paginaFinal" => "10"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23711077"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "Graus R&#44; Abat J&#44; Calleja A&#44; Freixa A&#44; Guardino X&#44; Hern&#225;ndez S&#46; Manual per a la diagnosi i el tractament de l&#8217;amiant a la construcci&#243;&#46; Editorial&#58; Col&#183;legi d&#8217;Aparelladors i Arquitectes T&#232;cnics de Barcelona&#46; Barcelona&#58; 1998&#46;"
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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