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After 25 years of declines in coal workers' pneumoconiosis (thanks to federal regulation of tolerable concentrations of coal dust and radiographic surveillance of miners), CWP and progressive massive fibrosis have been on the upswing since 2001, killing or disabling dozens of relatively young miners. Wade et al describe the trend in a cohort of 138 West Virginian coal miners with PMF (average age 52; mean time from normal chest X-ray to PMF: 12 years; mean time from onset of symptoms to PMF: 8 years). CHEST 2011;139:1458-1462.