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   Table of Contents - Current issue
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March-April 2020
Volume 37 | Issue 2
Page Nos. 97-186

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EDITORIAL  

Postoperative bronchopleural fistula: Does one size fit all? p. 97
Valliappan Muthu, Kuruswamy Thurai Prasad, Ritesh Agarwal
DOI:10.4103/lungindia.lungindia_89_20  PMID:32108591
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ORIGINAL ARTICLES Top

Methodology of Seasonal Waves of Respiratory Disorders survey conducted at respiratory outpatient clinics across India p. 100
Bharat Bhushan Sharma, Sheetu Singh, Krishna Kumar Sharma, KP Suraj, Tariq Mahmood, Kumar Utsav Samaria, Surya Kant, Nishtha Singh, Tejraj Singh, Aradhna Singh, Rajeev Gupta, Parvaiz A Koul, Sundeep Salvi, Virendra Singh, SWORD Study Group
DOI:10.4103/lungindia.lungindia_466_19  PMID:32108592
Background: Respiratory disorders are important contributors to disease burden across the world. The aim is to assess the proportionate burden of types of respiratory diseases and their seasonal patterns in India we are performing a field study. The present report describes methodological aspects of a respiratory disease point prevalence survey from India. Methods: A total of 4108 chest physicians were invited. Acceptance was received from 420 sites. Chest physicians were classified according to location of practice one as medical college, district government hospital, private hospital, and private clinics. Qualifications of practicing chest physicians were postgraduate in chest medicine, including Doctorate of Medicine (68.4%), diploma in chest medicine (22.1%), and Postgraduate in Medicine (9.5%). The study questionnaire was designed to record demographic data, comorbidities, risk factors, and respiratory conditions based on ICD-10. Results: A total of 366 sites provided baseline data, and the response rate of recruitment of the study sites was 8.9% in the baseline phase. However, government and private medical colleges, as well as government and private hospitals across India, were part of recruitment of respiratory patients for this survey. Conclusions: It is feasible to conduct a large multisite study to assess respiratory disease burden. Challenges include low response rate and logistic issues.
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Bronchoscopic device closure of postoperative bronchopleural fistulae: Novel devices and innovative techniques Highly accessed article p. 107
Vikas Marwah, C D S Katoch, Kunal Kumar, Kamal Pathak, Saikat Bhattacharjee, Prashant Jindamwar
DOI:10.4103/lungindia.lungindia_179_19  PMID:32108593
Background: Bronchoscopic device closure plays a significant role in the nonsurgical management of bronchopleural fistulae (BPF). Herein, we describe our 10-year experience in the management of postoperative BPF using various device closure modalities. This is the largest series of bronchoscopic device closure of BPF being reported from India. Materials and Methods: This was a retrospective analysis of data of patients who underwent bronchoscopic device closure with various techniques for the management of postoperative BPF. In total, 11 patients (six males and five females) with a mean age (±standard deviation) of 42.72 ± 14.40 years with BPFs were treated with various bronchoscopic interventions for BPF closure. We used various devices such as endobronchial coils, occluder devices, and covered tracheobronchial self-expandable stents for BPF closure depending on the size of air leaks. We describe the various devices used, technique, and outcome of bronchoscopic management of BPF. Results: All our patients had developed BPFs postoperatively. Pulmonary tuberculosis was the most common etiology seen in nine of our patients. All the devices were placed using a fiberoptic bronchoscope, and all patients were followed up for a minimum duration of 6 months. We successfully localized and closed BPFs in nine (81.81%) of our patients. Conclusions: Bronchoscopic device closure can be a successful strategy to manage postoperative BPF with minimal complications.
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Rigid bronchoscopic interventions for central airway obstruction – An observational study p. 114
Ajmal Khan, Zia Hashim, Mansi Gupta, Hira Lal, Aarti Agarwal, Alok Nath
DOI:10.4103/lungindia.lungindia_454_19  PMID:32108594
Background: Central airway obstruction (CAO) is a significant cause of morbidity and mortality in patients with thoracic malignancies. In this prospective study, we describe the role of rigid bronchoscopy (RB) in the multimodality management of CAO. Methods: Prospective description of different rigid bronchoscopic techniques used for CAO between July 2016 and July 2019. Results: A total of 152 procedures (124 therapeutic/palliative and 28 diagnostics) in 111 adults and 10 pediatric patients were performed. The mean age in 111 adults (66 males) and 10 pediatric (5 males) patients were 45.4 ± 15.8 (range 16–80) and 5.4 ± 3.6 (range 1–10) years, respectively. Palliation of the airway obstruction (48.8%) and establishment of diagnosis (23.2%) were the main indications of RB in our study. Mechanical debulking in 53 (57%) and airway dilatation in 40 (43%) patients were the most utilized interventions during the palliative or therapeutic RB. There was a significant decrease in mean (modified Medical Research Council) dyspnea scale from 3.9 ± 1.0 to 1.42 ± 0.63 and increase in mean Visual Analogue Scale from 2.06 ± 0.74 to 8.7 ± 0.54 after the procedure (P < 0.0001). Additional therapy was undertaken in 38 (31.4%) of 121 patients, and surgical excision was the primary form of definitive treatment in 17 patients Moderate bleeding was encountered in 13.3% of the procedures mainly in the diagnostic RB. The mean procedure duration was 28.4 (range, 11–49) min and 13.2 (7–22) min in the adults and pediatric patients, respectively. A total of 31 patients succumbed to the illness due to the progressive nature of their disease. Conclusions: An individualized approach to interventional procedures is safe and effective way to achieve and maintain palliation of CAO. RB with multimodality treatment achieves the goal in majority of the patients.
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A decade after introducing MPOWER, trend analysis of implementation of the WHO FCTC in the Eastern Mediterranean Region p. 120
Gholamreza Heydari
DOI:10.4103/lungindia.lungindia_388_19  PMID:32108595
Background: Perfect implementation of the six priority policies advocated by the MPOWER package is the most important challenge for member states (MS) to reach tobacco control goals. Methods: A validated checklist set according to the WHO Report on the Global Tobacco Epidemic was filled out five times based on biannual reports from 2011 to 2019 for 22 MS in the Eastern Mediterranean Region. It contained ten topics including smoking prevalence and seven elements of six MPOWER policies and compliances resulting with possible maximum score of 37. High score indicates better implementation. Results: The total score for the region increased from 416 in 2011 to 509 in 2019. Six countries (27% of the region) had more than 75% of total score, whereas 11 countries were between 50% and 75% and five countries had <50% of total score in 2019. In all five reports, Iran was ranked first in the region even in 2019, when it witnessed a 2 point decrease. Iran held the first place alongside with Pakistan and Saudi Arabia with 32 points. The highest score in the indicators was related to the monitoring, reaching from 35 in 2011 to 59 in 2019. The lowest score increase in the indicators was related to the Smoke-free Policy compliance and the prevalence of consumption, reaching from 18 to 20 and 44–48, respectively, between 2011 and 2019. Conclusions: Although several remarkable achievements have been made regarding tobacco control goals, many policy implementation challenges remain and require urgent action by member states in the Eastern Mediterranean region.
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Changes of serum adenosine deaminase level in new cases of pulmonary tuberculosis before and after intensive phase treatment p. 126
Soedarsono Soedarsono, Kana Wulung Arie Ichida Prinasetyo, Mayfanny Tanzilia, Jusak Nugraha
DOI:10.4103/lungindia.lungindia_395_19  PMID:32108596
Background and Objectives: Tuberculosis (TB) continues to be a public health crisis with an estimated 10 million people developing TB disease in 2017. Adenosine deaminase (ADA) level in serum and pleural fluid as a biomarker may be used to diagnose pulmonary TB (PTB), but it is not always easy to obtain those samples at the end of treatment. This study was conducted to analyze the changes of serum ADA level in the new case of PTB patients with acid-fast bacilli (AFB) smear-positive sputum and sputum conversion status as treatment monitoring in PTB patients. Materials and Methods: This was a prospective observational analytic study conducted in Dr. Soetomo General Hospital, Surabaya, from January 2018 to May 2018. Participants were all new cases of PTB patients with AFB smear-positive sputum, and a positive rapid molecular test for Mycobacterium tuberculosis. Blood serums were taken at the same time on the 1st day of TB treatment and also taken at the end of intensive phase treatment to analyze the changes of serum ADA level. Results: There were 26 TB patients and 26 healthy control people. Serum ADA level at the beginning of TB treatment was higher than the level at the end of intensive phase treatment. There was a significant difference between serum ADA level before and after the intensive phase of TB treatment (P < 0.001). Conclusions: The examination of serum ADA levels can be used to evaluate the PTB treatment response.
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Multidrug resistance in tubercular mediastinal adenopathy diagnosed by endobronchial ultrasound-transbronchial needle aspiration p. 130
Amit Dhamija, Saurabh Goyal, Abhinav Guliani, Reena Raveendran, Arup Kumar Basu
DOI:10.4103/lungindia.lungindia_421_19  PMID:32108597
Background: Drug resistance in tuberculosis (TB) is a major public health problem. It is easy to assess for drug resistance in pulmonary samples, but the resistance pattern of TB in the mediastinal nodes has not been studied. The aim of this study is to assess the incidence of multidrug resistance in tubercular mediastinal adenopathy with the help of endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration. Materials and Methods: This was a prospective study at a tertiary care teaching hospital in New Delhi where 102 patients with positive mycobacterial cultures from mediastinal lymph node aspirates taken with the help of EBUS were enrolled over 24 months and their drug sensitivity to the first-line antitubercular drugs analyzed. Results: There were 30 cases of drug resistance of 102 culture-positive cases. Of them, 8 patients had multidrug resistant TB (MDR-TB), 16 cases had only single drug resistance, and the remaining 6 cases had more than one drug resistance pattern but not MDR. In our study, the overall incidence of MDR-TB is 7.8% (8/102), although the incidence of MDR-TB in new and re-treatment cases is 2.2% (2/89) and 46.1% (6/13), respectively. Conclusion: Such a high percentage of drug-resistant patients is common in tertiary care hospitals; however, similar percentages may be found in other settings as well. Therefore, all efforts should be made to take samples for Mycobacterium tuberculosis culture from the involved nodes before commencing therapy to avoid treatment failures.
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Clinicopathological characteristics and treatment outcome in small cell lung cancer: A single institutional experience from India p. 134
Sandip Ganguly, Bivas Biswas, Sayanika Bhattacharjee, Joydeep Ghosh, Sumit Mukhopadhyay, Divya Midha, Deepak Dabkara
DOI:10.4103/lungindia.lungindia_370_19  PMID:32108598
Background and Objectives: Small cell lung cancer (SCLC) constitutes 14%–20% of all lung cancers. Clinical data on SCLC are scarce in literature. To report clinical features and treatment outcome of SCLC treated at our center. Materials and Methods: This is a single institutional data review of SCLC patients treated between June 2011 and December 2018. Patients were staged as either localized or extensive disease after appropriate staging work-up. Patients with localized disease were treated with concurrent chemoradiation with platinum-based chemotherapy. Those with extensive disease were treated with platinum based palliative chemotherapy. Clinicopathological characteristics, treatment details, and outcome were recorded in this study. Patients who received at least one cycle of chemotherapy were included for survival analysis as intent-to-treat analysis. Results: A total of 181 were patients registered with a median age of 62 years (range: 35–86 years) and male: female ratio of 166:15. Eighty-seven percent (n = 157) of patients had smoking history and 15% (n = 28) of patients had symptom of superior vena cava obstruction at baseline. Twenty-seven (15%) patients had localized disease at presentation. One hundred and twenty (66%) patients took systemic chemotherapy. Chemotherapy regimen was carboplatin only in 9 (7%), etoposide-carboplatin in 54 (45%), and cisplatin-etoposide in 57 (48%). Patients received median cycle number of 6 (range: 1–6). Of the evaluable 87 (73%) patients, initial response was complete response in 4, partial response in 57, stable disease in 20, and progressive disease in 6. Twenty patients received second-line chemotherapy at time of disease progression. After a median follow-up of 8.8 months (range: 0.3–46.1), median progression-free survival (PFS) of the whole population was 9.3 months. Conclusions: Small cell carcinoma in our series had a high incidence of advanced stage (85%) and 13% of patients were nonsmoker. Only 66% of patients received palliative chemotherapy and achieved high disease control rate (>75%) in the evaluable patients with median PFS of 9.3 months.
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Accidental inhalation of scarf pin: Presentation and management p. 140
Rachid Marouf, Sara Zerrouki, Ihsan Alloubi, Brahim Housni
DOI:10.4103/lungindia.lungindia_345_19  PMID:32108599
Background: The accidental aspiration of foreign bodies (FBs) is a rare occurrence in adults. However, inhalation of scarf pin is a phenomenon more and more common in the context of Muslim nations. The aim of our study was to describe the characteristics of this particular FB and illustrate the circumstances and consequences of inhalation. Methods: This retrospective study involved patients with a history of scarf pin aspiration admitted to the Thoracic Surgery Department of Mohammed VI University Hospital Center, Oujda, Morocco, over a period of 10 years. Their main presentation, diagnosis, treatment, and outcome were analyzed. Results: The average age of the 30 cases was 18 years (13–43). No antecedent was found in all cases. The penetration syndrome was found in all cases, with a transient moment of suffocation in 19 cases (63.33%), a dry cough in 15 cases (50%), minimal hemoptysis in 4 cases (13.33%), and purulent sputum in 3 cases (10%). The clinical examination was normal in all cases. The chest X-ray showed the FB in the form of linear right sided opacity in 14 cases (46.66%), left sided in 8 cases (26.66%), and in the trachea in 8 cases (26.66). Rigid bronchoscopy visualized the scarf pin at the level of the right basal pyramid in 5 cases (16.66%) and on the left side in 2 cases (6.66%), at the level of the main right and intermediate trunk in 7 cases (23.33%), at the level of the left main bronchus in 4 cases (13.33%) and in the trachea in 5 cases (16.66%). The pin was extracted by rigid bronchoscopy in 23 cases (76.66%) and was expelled spontaneously in 5 cases (16.66%). Thoracotomy was required in 2 cases (6.66%). Medical treatment, including antibiotic therapy and short-course oral corticosteroids, was administered in all cases. Conclusion: Scarf pin inhalation is common in women who wear the Islamic headscarf. Bronchoscopy is an important tool to manage these FBs, but the best prevention treatment is careful handling of these potentially sharp objects away from the mouth.
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Correlation of programmed death-ligand 1 expression with gene expression and clinicopathological parameters in Indian patients with non-small cell lung cancer p. 145
Manish Kumar, Bhupesh Guleria, Shivashankar Swamy, Sneha Soni
DOI:10.4103/lungindia.lungindia_488_19  PMID:32108600
Objectives: The aim of this study is to evaluate the incidence of programmed cell death-ligand 1 (PD-L1) expression in non-small cell lung cancer (NSCLC) cases and its correlation with gene mutation and clinicopathological parameters. Methods: Samples from NSCLCs patients were studied for PD-L1 expression through immunohistochemistry (IHC) using Rabbit anti-human PDL-1/CD274 Monoclonal Antibody. Genetic mutations were studied using IHC/fluorescence in situ hybridization (FISH) methods (for anaplastic lymphoma kinase [ALK]) or polymerase chain reaction/gene sequencing analysis (for epidermal growth factor receptor [EGFR]). Pearson's correlation coefficient (r) was used for correlation analysis. PD-L1 expression was analyzed for association with clinicopathological features. Results: Of the 101 NSCLC cases, PD-L1 expression was observed in 33.66% (34/101) cases; tumor proportion score of <50%: 67.65% (23/34) and ≥50%: 32.35% (11/34) cases. PD-L1 positivity was seen in; males: 35.5%, females: 28%, smokers: 37.7%, cases with brain metastasis: 20%, cases with pleural effusion: 20.8%, and histopathological evaluation (well-differentiated: 21.42%, moderately-differentiated: 13.79%, poorly-differentiated: 36.11%, and adenosquamous disease: 40.9%). Genetic mutation studies revealed PD-L1 positivity in 18.1% cases with EGFR mutation, 50% of ALK-IHC positive cases, and 33.3% ALK-FISH positive cases. No or very weak correlation (r < 0.3) in PD-L1 expression with gene mutations or clinicopathological parameters was observed. Conclusions: The study demonstrated PD-L1 expression in ~ 1/3rd cases of NSCLC patients. No or very weak correlation was observed for PD-L1 expression with genetic mutations and other parameters studied. The presence of gene mutations in PD-L1 expressed samples suggests further investigation on PD-L1 inhibitors in such patients for decisive treatments.
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REVIEW ARTICLE Top

The uses of overnight pulse oximetry p. 151
Shruti Singh, Sara Z Khan, Dilbagh Singh, Sameer Verma, Arunabh Talwar
DOI:10.4103/lungindia.lungindia_302_19  PMID:32108601
Overnight pulse oximetry (OPO) has proven to be an effective and beneficial technique to determine the cardiorespiratory status of patients in both the inpatient and outpatient settings. It is a cheap, safe, reliable, simple, and accurate method of patient monitoring as compared to the expensive and labor-intensive method of multichannel polysomnography for detecting sleep-disordered breathing. It provides accurate information about patient's oxygenation status and also helps in monitoring the response to continuous positive airway pressure and in the surgical treatment of obstructive sleep apnea (OSA). Nocturnal hypoxemia portends a poor prognosis in patients of chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), and neuromuscular diseases. OPO can help its early detection and management.
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CASE REPORTS Top

Obstructive lung disease secondary to compression of the bronchus by an enlarged pulmonary artery p. 158
Justin Panthappattu, Vidhu Sharma, Sameer Verma, Arunabh Talwar
DOI:10.4103/lungindia.lungindia_436_19  PMID:32108602
In clinical practice, the presence of wheezing generally indicates an airway disease. In rare circumstances, adjacent mediastinal structures may compress the tracheobronchial tree leading to obstructive physiology. Compression of the tracheobronchial region by an enlarged pulmonary artery (PA) is exceedingly rare. We present here a case of pulmonary hypertension, where the enlarged PA resulted in obstructive lung physiology with a relevant review of the literature.
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Successful treatment of allergic bronchopulmonary aspergillosis with posaconazole in a child with cystic fibrosis: Case report and review of the literature p. 161
Nurhayat Yakut, Eda Kepenekli Kadayifci, Ela Erdem Eralp, Yasemin Gokdemir
DOI:10.4103/lungindia.lungindia_288_19  PMID:32108603
Allergic bronchopulmonary aspergillosis (ABPA) is recognized as a rare, progressive, allergic disorder in patients with cystic fibrosis (CF) and asthma. Treatment of ABPA mainly includes systemic corticosteroids (CSs) and antifungal agents. Here, we report posaconazole treatment in a 9-year-old male child with ABPA and also review the literature on antifungal management of ABPA. The child with CF was admitted to the emergency room with complaints of fever, productive cough, and acute dyspnea. Auscultation of the lungs revealed obvious bilateral fine crackles and bilateral rhonchus. He was started with intravenous meropenem and amikacin for acute exacerbation. The patient was diagnosed with ABPA because of his failure to respond to antibiotherapy, elevated serum immunoglobulin (Ig) E, specific IgE, to Aspergillus fumigatus levels and sputum growth of A. fumigatus. He was successfully treated with posaconazole with marked clinical and laboratory improvement and no adverse effects. CSs and antifungal agents are the mainstay of therapy in patients with ABPA based on observational studies in children. Posaconazole is a useful treatment option for patients with ABPA.
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Unilateral pulmonary venous atresia: A rare cause of recurrent hemoptysis p. 164
Shagun Jyotin Shah, Chandrahas T Deshmukh, Jane J E David, Moushmi M Hosalkar
DOI:10.4103/lungindia.lungindia_369_19  PMID:32108604
Hemoptysis is a rare but distressing complaint in children. Pulmonary venous atresia (PVA) is a rare cause of recurrent hemoptysis in children. We report a 3-year-old boy with recurrent hemoptysis for 2 years. The child had tachycardia, tachypnea, tender hepatomegaly, and left-sided decreased air entry with crepitations. Coagulation and Koch's workup was negative. X-ray of the chest showed a small left hemithorax. Computed tomography with angiography showed left unilateral PVA with pulmonary artery hypoplasia and dysplastic left lung. The child has been posted for left pneumonectomy. Although uncommon, PVA should be diagnosed early to prevent life-threatening complications such as hemoptysis and pulmonary hypertension. The patient can be managed conservatively or surgically depending on the severity. Early diagnosis and intervention helps in reducing morbidity and mortality.
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RADIOLOGY QUIZ Top

Pulmonary arteries in a fix p. 167
Kavitha Venkatnarayan, Uma Maheswari Krishnaswamy, Uma Devaraj, Priya Ramachandran
DOI:10.4103/lungindia.lungindia_309_19  PMID:32108605
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GENERAL PERSPECTIVE Top

The global initiative for asthma guidelines (2019): change in the recommendation for the management of mild asthma based on the SYGMA-2 trial – A critical appraisal Highly accessed article p. 169
Sujeet Rajan, Nithya J Gogtay, Mahanjit Konwar, Urmila Mukund Thatte
DOI:10.4103/lungindia.lungindia_308_19  PMID:32108606
The Global Initiative for Asthma (GINA) recently released their updated Global Strategy for Asthma Management and Prevention Guide (2019). The pocket guide for practicing clinicians states that “the 2019 GINA strategy report represents the most important change in asthma management in 30 years.” An important recommendation is the change in treatment strategy for the management of mild asthma where the guideline recommends that” all adults and adolescents with asthma should receive either symptom driven (in mild asthma) or daily low dose inhaled corticosteroid (ICS) containing controller treatment to reduce the risk of serious exacerbations.” Our study critically appraises the SYGMA-2 trial, a key trial that largely formed the basis of this recommendation and discusses the potential consequences of using only long-acting beta-2-agonist + ICS as needed as against regular, daily low-dose ICS with as-needed short-acting beta-2-agonist. Our critique covers airway inflammation, disease heterogeneity, understanding the noninferiority margin and its consequences, the Hawthorne effect, and conflict of interest. It is our view that statement of this magnitude will have far-reaching implications for clinical practice which will be in the interests of some patients but also against the interests of others.
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CASE LETTERS Top

An unusual case of gastropleural fistula: Management dilemmas p. 174
Joseph Thomas Kathayanatt, Shaji Palangadan, Ratish Radhakrishnan, Jayakumar Thanath
DOI:10.4103/lungindia.lungindia_242_17  PMID:32108607
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Where there is a balloon, there is a way! p. 176
Valliappan Muthu, Sahajal Dhooria, Inderpaul Singh Sehgal, Kuruswamy Thurai Prasad, Ritesh Agarwal
DOI:10.4103/lungindia.lungindia_317_19  PMID:32108608
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Single-lung stereotactic body radiotherapy: A case report and discussion of therapeutic challenges p. 177
Meetakshi Gupta, Naveen Mummudi, Ritesh Mhatre, Jai Prakash Agarwal
DOI:10.4103/lungindia.lungindia_281_19  PMID:32108609
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Primary ciliary dyskinesia due to DRC1/CCDC164 gene mutation p. 179
Antony Terance Benjamin, Ram Ganesh, Jagdish Chinnappa, Ilin Kinimi, Jane Lucas
DOI:10.4103/lungindia.lungindia_361_19  PMID:32108610
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RESEARCH LETTERS Top

Response to “Endovascular glue embolisation for control of massive hemoptysis caused by peripheral pulmonary artery pseudoaneurysms: Report of 7 cases” p. 181
Vivek Agarwal, Ujjwal Gorsi
DOI:10.4103/lungindia.lungindia_387_19  PMID:32108611
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Reversed halo sign: Uncommon presentation of a common disease p. 182
Bijay Pattnaik, PB Sryma, Saurabh Mittal, Karan Madan
DOI:10.4103/lungindia.lungindia_360_19  PMID:32108612
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First report of pulmonary alveolar microlithiasis diagnosed by cryobiopsy p. 183
Manoj Kumar Goel, Ajay Kumar, Gargi Maitra
DOI:10.4103/lungindia.lungindia_497_19  PMID:32108613
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Bronchopleural fistula secondary to bronchoalveolar lavage-induced pneumothorax: A rare complication p. 185
Shalendra Singh, Shreyas Kate, Saurabh Sud, Deepak Dwivedi
DOI:10.4103/lungindia.lungindia_459_19  PMID:32108614
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