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   Table of Contents - Current issue
Coverpage
November-December 2018
Volume 35 | Issue 6
Page Nos. 459-543

Online since Tuesday, October 30, 2018

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EDITORIAL  

Respiratory disease burden in India: Indian chest society SWORD survey Highly accessed article p. 459
Virendra Singh, Bharat Bhushan Sharma
DOI:10.4103/lungindia.lungindia_399_18  PMID:30381552
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ORIGINAL ARTICLES Top

Home return following invasive mechanical ventilation for the oldest-old patients in medical intensive care units from two US hospitals p. 461
Puthiery Va, Parth Rali, Harshitha Kota, Vivian Keenan, Sobia Mujtaba, Win Naing, Reka Salgunan, Irene Galperin, Oleg Epelbaum
DOI:10.4103/lungindia.lungindia_76_18  PMID:30381553
Background: The aging of the US population has been associated with an increase in intensive care unit (ICU) utilization and correspondingly, invasive mechanical ventilation (IMV) among the oldest-old (age ≥80 years). While previous studies have examined ICU and IMV outcomes in the elderly, very few have focused on patient-centered outcomes, specifically home return, in the oldest-old. We investigated the rate of immediate home return following IMV in the medical ICU in previously home-dwelling oldest-old patients relative to that of a comparison group of 50–70-year olds. Methods: Data were extracted retrospectively from patient records at Elmhurst Hospital Center in Elmhurst, NY, USA, encompassing the period from January 2009 to May 2014 and Jacobi Medical Center in the Bronx, NY, USA, from January 2010 to March 2014. Medical ICU admissions within those date ranges were screened for possible inclusion into one of two study groups based on age: ≥80 years old and 50–70 years old. The primary end point was hospital discharge: home return versus no home return (death or nonhome discharge). Cox proportional hazards' regression models were used to estimate crude and multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for failure to return home. Results: A total of 375 patients were included in the analysis: 279 (74%) patients aged 50–70 years and 96 (26%) patients aged ≥80 years. Compared to 50–70-year olds, being ≥80 years old was associated with a nearly two-fold greater risk of no home return: adjusted HR: 1.96; 95% CI 1.43–2.67. The oldest-old was at significantly increased risk of both being discharged to a skilled nursing facility or subacute rehabilitation (adjusted HR: 2.19; 95% CI 1.33–3.59) as well as of dying in the hospital (adjusted HR: 1.81; 95% CI 1.21–2.71). Conclusion: Previously home-dwelling oldest-old are at significantly increased risk of failing to return home immediately following medical ICU admission with IMV as compared to patients aged 50–70 years. These results can help medical ICU staff establish appropriate expectations when addressing the families of their oldest patients. Further studies are needed to evaluate the potential for delayed home return among the oldest old and to assess the ability of frailty indices to predict home return within this ICU population.
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1% versus 2% lignocaine for airway anesthesia in endobronchial ultrasound-guided transbronchial needle aspiration: A pilot, double-blind, randomized controlled trial p. 467
Shiba Kalyan Biswal, Saurabh Mittal, Vijay Hadda, Anant Mohan, Gopi C Khilnani, Ravindra M Pandey, Randeep Guleria, Karan Madan
DOI:10.4103/lungindia.lungindia_148_18  PMID:30381554
Background and Objectives: No previous study has compared different concentrations of lignocaine for topical anesthesia during endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA). In this pilot study, we compared 1% versus 2% lignocaine for topical airway anesthesia during EBUS-TBNA. Methods: In this double-blind, randomized trial, subjects were randomized to receive either 1% or 2% lignocaine for “spray-as-you-go” administration. All received combined moderate intravenous sedation (midazolam and fentanyl). Ten percent pharyngeal lignocaine spray (two sprays) and nebulized lignocaine (2.5 ml of 4% solution) were administered to all subjects. Administration of additional lignocaine was allowed at operator's discretion. The primary endpoints were operator-rated overall procedural satisfaction and cough, each assessed on visual analog scale (VAS), while the secondary outcomes included patient-rated faces pain scale scores, cumulative lignocaine dose, number of subjects receiving lignocaine >8.2 mg/kg, doses of midazolam/fentanyl between groups, and adverse events during procedure. Results: The mean (standard deviation [SD]) VAS scores for operator-rated procedure satisfaction were 64.2 (25.6) and 68.7 (23.7) in 1% and 2% group, respectively (P = 0.35). The median (interquartile range) VAS scores for operator-rated cough were 48.4 (23.9–69.9) in 1% group and 38.7 (18.6–69.5) in 2% group (P = 0.24). The mean [SD] cumulative lignocaine received in the 2% lignocaine group (248.6 [29.1] mg) was significantly greater than in 1% lignocaine group (178.5 [14.6] mg) (P < 0.01). Conclusion: One percent lignocaine is equally efficacious as 2% lignocaine for topical anesthesia during EBUS-TBNA, at a significantly lower cumulative lignocaine dose.
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Years of life lost due to asthma in a population-based 10-year study in Yazd, Iran p. 472
Hamidreza Rahavi, Alexander S Taft, Mina Mirzaei
DOI:10.4103/lungindia.lungindia_66_18  PMID:30381555
Introduction: Asthma is a prevalent disease in both children and adults. Significant progress in the management of asthma and prevention of asthmatic attacks resulted in a reduction of asthma deaths, but there is a variation among different regions based on health-care access and environmental factors. We aimed to investigate the trend of asthma mortality during a 10-year period in Yazd Province, a region in the center of Iran. Methods: We obtained our data from the death registry of Yazd health center. This registry collects data from hospitals, clinics, forensic medicine department, and cemeteries. All deaths due to asthma from 2002 to 2011 were included in our study. We used the remaining life expectancy of each person at death and sex group to calculate the years of life lost (YLL) due to asthma. Results: Nearly 10,371 years of life was lost due to asthma in our study (M/F ratio of 1.29). Asthma mortality rate increased with age, rising sharply after age 50. Average YLL per death was 18.6 years. Asthma mortality rate decreased from 6.66/100,000 in 2002 to 3.97 in 2011. YLL from asthma among men decreased from 796 in 2002 to 338 in 2011, but among women, it showed an increase from 335 to 534 at the same time. Conclusion: The trend of reduction in asthma mortality is not similar between different age and gender groups. Further studies are needed to determine the cause of increasing trend among more vulnerable groups.
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Utility of forced expiratory time as a screening tool for identifying airway obstruction and systematic review of English literature p. 476
Ashutosh Nath Aggarwal, Sharmishtha Das, Ritesh Agarwal, Navneet Singh
DOI:10.4103/lungindia.lungindia_3_18  PMID:30381556
Setting: This study was conducted at a pulmonary function laboratory of a tertiary care hospital in North India. Objective: The objective was to study the diagnostic characteristics and clinically useful threshold of forced expiratory time (FET, measured by auscultation over trachea) as a screening tool for identifying airway obstruction and to substantiate the diagnostic utility of FET through a systematic review of English literature. Methods: FET was compared in seventy patients with airway obstruction (Group A) and seventy controls with normal spirometry (Group B). Within-subject reproducibility of FET, and its correlation with spirometric parameters, was assessed. Diagnostic accuracy of FET in detecting airway obstruction was evaluated at various time thresholds. A systematic review of English literature on FET was also carried out. Results: Median FET was significantly longer in Group A (7.04 s [interquartile range (IQR) 6.67–7.70 s] vs. 4.14 s [IQR 3.60–4.68 s], P < 0.001). At a threshold of 5 s, FET had high sensitivity (0.943) and reasonable specificity (0.814) in detecting airway obstruction. FET measurements were reproducible and correlated negatively with forced expiratory volume in first second (FEV1), FEV1/forced vital capacity, and peak expiratory flow. The systematic review yielded 13 publications. At a widely used threshold of 6 s to describe airway obstruction, pooled sensitivity and specificity from five datasets were 0.802 (95% confidence interval [CI] 0.668–0.890) and 0.837 (95% CI 0.570–0.952), respectively. Conclusion: FET of 5 s or more, rather than the commonly recommended threshold of 6 s, should be regarded as abnormal.
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Endobronchial ultrasound-guided transbronchial needle aspiration in the economically disadvantaged: A retrospective analysis of 1582 individuals p. 483
Kuruswamy Thurai Prasad, Sahajal Dhooria, Inderpaul Singh Sehgal, Valliappan Muthu, Babu Ram, Nalini Gupta, Ashutosh Nath Aggarwal, Ritesh Agarwal
DOI:10.4103/lungindia.lungindia_176_18  PMID:30381557
Background: Whether the indications and diagnostic yield of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) vary according to the socioeconomic status of the patient, remains unknown. Herein, we evaluate this aspect in participants who underwent EBUS-TBNA. Materials and Methods: This is a retrospective analysis of all participants who underwent EBUS-TBNA for the evaluation of intrathoracic lymphadenopathy. We evaluated the indications and outcome of EBUS-TBNA in participants with and without economic disadvantage (issuance of a below poverty line card by the government). Results: Of the EUBUS procedures performed on 1582 participants (mean [standard deviation] age, 46.1 [15.7] years; 593 [37.5%] women) performed during the study, 61 (3.9%) were done in the economically disadvantaged (ED) group. Individuals in the ED group were younger (median age, 40 vs. 46 years; P = 0.002) and more likely to have tuberculosis (42.6% vs. 26.2%, P = 0.005) or malignancy (39.3% vs. 26.9%, P = 0.032) as a presumptive diagnosis. The overall diagnostic yield of EBUS was 63% and was significantly lower in the ED group (49.2% vs. 63.5%, P = 0.023). Previously used EBUS-TBNA needles were more commonly employed in the ED participants (62.7% vs. 20.1%, P < 0.001). On multivariate logistic regression analysis, younger age, larger size, and number of nodes sampled, and the use of new (versus reused) needles were independent predictors of higher diagnostic yield. There was no difference in the complication rate between the two groups. Conclusion: The diagnostic yield of EBUS was significantly lower in the ED participants, which is due to the differences in the clinical and procedural characteristics.
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Utility of para-aminosalicylic acid in drug-resistant tuberculosis: Should it be classified as Group D3 or Group C? p. 488
Unnati Desai, Jyotsna M Joshi
DOI:10.4103/lungindia.lungindia_141_18  PMID:30381558
Background: The World Health Organization drug-resistant tuberculosis (DR-TB) 2016 guidelines reclassified para-aminosalicylic acid (PAS) as Group D3 “add-on” drug. We studied our DR-TB data wherein PAS was widely and preferably used as a substitute in the standardized regimen in varied situations and report its utility in DR-TB. Methodology: This retrospective observational study enrolled both pulmonary and extrapulmonary DR-TB patients receiving PAS in the programmatic management of DR-TB from March 2012 to June 2013. They were divided into seven subgroups on the basis of indication for PAS substitution in the standardized regimen for DR-TB cases. The clinical profile and outcomes were analyzed. Results: PAS was substituted in 250 cases (225 – pulmonary DR-TB and 25 – extrapulmonary DR-TB). PAS was used in (1) pre-extensively drug-resistant TB (XDR-TB) fluoroquinolones (FQs) – 136 (54.4%), (2) XDR-TB – 15 (6%), (3) substitute drug for serious adverse events – 3 (1.2%), (4) pregnant DR-TB patients – 5 (2%), (5) patients on successful private-based second-line therapy adopted under the Revised National Tuberculosis Control Program – 10 (4%), (6) substitute drug for previous FQ exposure – 5 (2%), and (7) Category V – 76 (30.4%). Although 51.2% had an unfavorable response (UFR) against 48.8% with FR, wide disparity was noted in subgroups. FR was observed in 68.4% pre-XDR-TB (FQ), 80% pregnant patients, 90% adopted from private on successful second-line therapy, 80% previous FQ exposure against 40% XDR-TB, 7.9% Category V, and 0% PAS substitution for adverse drug reactions (ADRs). UFR was seen in 31.6% pre-XDR-TB (FQ), 20% pregnant patients, 10% adopted from private on successful second-line therapy, 20% of previous FQ exposure against 60% XDR-TB, 92.1% Category V, and 100% on PAS substitution for ADR. Conclusion: In view of the safety and efficacy of PAS in our DR-TB patients except for XDR and Category V group, we recommend larger studies with PAS and consider its reclassification into Group C rather than Group D3.
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Correlation of chronic obstructive pulmonary disease assessment test and clinical chronic obstructive pulmonary disease questionnaire score with BODE index in patients of stable chronic obstructive pulmonary disease p. 494
Shashank Singh, Mradul Kumar Daga, HS Hira, Lalit Kumar, Govind Mawari
DOI:10.4103/lungindia.lungindia_93_18  PMID:30381559
Background: Chronic obstructive pulmonary disease (COPD) has a major impact on health status in accordance with disease severity. It is usually assessed by the various quality of life questionnaires. Objectives: The aim of this study is to assess the disease severity and health status in stable patients of COPD using COPD assessment test (CAT) and clinical COPD questionnaire (CCQ) scores and to correlate with BODE index and its components. Methods: One hundred patients of stable COPD were subjected to CAT, CCQ irrespective of the stage of COPD during their visit. BODE index was also calculated. Results: COPD severity status assessed using forced expiratory volume 1% (FeV1%) predicted values correlated significantly with individual scores (CAT and FeV1%; r = −0.67; P < 0.001 and CCQ and FeV1%; r = 0.61; P < 0.001). CAT and CCQ score also correlated significantly (r = 0.84, P < 0.001) and both with the BODE index (r = 0.80; CAT and r = 0.66; CCQ, P < 0.01). Individual components of BODE index significantly correlated with CAT and CCQ scores. Conclusions: The CAT and CCQ have similar psychometric as well physical properties to assess the health status of COPD patients and can be used as a reliable scientific research tool and can be used in clinical practise to study the disease state and plan an appropriate treatment plan. The BODE index which is more objective, correlated well.
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REVIEW ARTICLE Top

Childhood allergic bronchopulmonary aspergillosis Highly accessed article p. 499
Kana Ram Jat, Pankaj C Vaidya, Joseph L Mathew, Sunil Jondhale, Meenu Singh
DOI:10.4103/lungindia.lungindia_216_18  PMID:30381560
Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disease caused by Aspergillus induced hypersensitivity. It usually occurs in immunocompetent but susceptible patients with bronchial asthma and cystic fibrosis. If ABPA goes undiagnosed and untreated, it may progress to bronchiectasis and/or pulmonary fibrosis with significant morbidity and mortality. ABPA is a well-recognized entity in adults; however, there is lack of literature in children. The aim of the present review is to summarize pathophysiology, diagnostic criteria, clinical features, and treatment of ABPA with emphasis on the pediatric population. A literature search was undertaken through PubMed till April 30, 2018, with keywords “ABPA or allergic bronchopulmonary aspergillosis” with limitation to “title.” The relevant published articles related to ABPA in pediatric population were included for the review. The ABPA is very well studied in adults. Recently, it is increasingly being recognized in children. There is lack of separate diagnostic criteria of ABPA for children. Although there are no trials regarding treatment of ABPA in children, steroids and itraconazole are the mainstay of therapy based on studies in adults and observational studies in children. Omalizumab is upcoming therapy, especially in refractory ABPA cases. There is a need to develop the pediatric-specific cutoffs for diagnostic criteria in ABPA. Well-designed trials are required to determine appropriate treatment regimen in children.
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CASE REPORTS Top

Pulmonary tuberculosis presenting as diffuse alveolar hemorrhage: Believe it or not p. 508
Alkesh Kumar Khurana, Sourabh Jain, Abhishek Goyal, Saurabh Saigal, Ujjawal Khurana
DOI:10.4103/lungindia.lungindia_203_17  PMID:30381561
Diffuse alveolar hemorrhage (DAH) has been rarely reported with pulmonary infections and even rarer with pulmonary tuberculosis (PTB). We hereby report the case of a 31-year-old male, a known case of ankylosing spondylitis, who presented with clinical and radiological features consistent with DAH. Initial partial improvement with steroids was followed by a microbiological diagnosis of tuberculosis (TB). Starting of antituberculous treatment was followed by complete clinical improvement. This leads to a thought-provoking possible association between the two pathologies, DAH and PTB, if any.
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A rare case of squamous cell carcinoma lung with multiple locoregional recurrences and histological transformation p. 511
Ram Niwas, Shibdas Chakrabarti, Viswesvaran Balasubramanian, Manas Kamal Sen, Jagdish Chander Suri
DOI:10.4103/lungindia.lungindia_221_17  PMID:30381562
A 52-year-old female nonsmoker with localized squamous cell carcinoma (T3N1M0) of lung underwent lobectomy with adjuvant chemotherapy. Two years later, the patient had her first locoregional recurrence with adenosquamous cell carcinoma, and pneumonectomy with adjuvant chemotherapy rendered her disease free. Subsequent isolated locoregional recurrence with squamous cell carcinoma 18 months later was treated with chemoradiotherapy and had a complete response. Patient yet again had locoregional recurrence after 4 years and had progressive disease despite subsequent multiple line of treatment with platinum-based chemotherapy, stereotactic body radiation therapy, and nivolumab. This case is unique in presentation due to prolonged survival with multiple line of treatment of recurrent locoregional tumor without distant metastasis and alteration in the histology of tumor during illness.
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Pediatric inflammatory myofibroblastic tumor of the trachea: Imaging spectrum and review of literature p. 516
Richa Singh Chauhan, Kushaljit Singh Sodhi, Ritambhara Nada, Ramandeep Virk, Joseph Mathew
DOI:10.4103/lungindia.lungindia_405_17  PMID:30381563
Inflammatory myofibroblastic tumor of the airway is a very uncommon benign primary neoplasm in pediatric age group with increased local recurrence rate and potential metastatic spread. We describe a case of a 6-year boy who was brought to the pediatric emergency with severe respiratory distress, dry cough, and stridor. Contrast-enhanced computed tomography and magnetic resonance imaging (MRI) of the neck showed a polypoidal mass lesion in the right anterolateral trachea causing significant airway narrowing. Bronchoscopic findings correlated with the imaging. The lesion was confirmed at surgery and was completely removed by surgical excision. Histopathology revealed an inflammatory myofibroblastic tumor. MRI findings of this entity in a child have not been reported before.
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NEWER TECHNIQUES Top

Cryoprobe transbronchial lung biopsy: How we do it? p. 520
Karan Madan, Saurabh Mittal, Nishkarsh Gupta, Vijay Hadda, Anant Mohan, Randeep Guleria
DOI:10.4103/lungindia.lungindia_52_17  PMID:30381564
Transbronchial lung biopsy (TBLB) is commonly utilized for diagnosis of diffuse parenchymal lung diseases. TBLB has a high yield in granulomatous interstitial lung diseases like sarcoidosis, but small size of biopsies limits its utility in idiopathic interstitial pneumonia. Surgical lung biopsy provides large size tissue, but there is associated morbidity, longer hospital stay, the risk of air leak, and mortality. Cryoprobe-TBLB, a relatively newer diagnostic procedure, provides larger biopsies than TBLB that are usually crush artifact free and enable the pathologist to provide diagnosis with greater confidence. We describe our technique of performing cryoprobe-TBLB.
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CASE LETTERS Top

Antisynthetase syndrome: Initial and follow-up imaging features p. 523
Ashish Chawla, Tahira Kumar, Pratik Mukherjee
DOI:10.4103/lungindia.lungindia_4_18  PMID:30381565
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Excessive dynamic airway collapse presenting as intractable cough: A case report p. 525
Surendran Aneeshkumar, Milan Malik Thaha, S Varun
DOI:10.4103/lungindia.lungindia_89_18  PMID:30381566
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Concomitant expression of exon 19 mutation epidermal growth factor receptor and anaplastic lymphoma kinase gene rearrangement in metastatic adenocarcinoma lung responsive to crizotinib p. 527
Abhishek Purkayastha, Amul Kapoor, Harinder Pal Singh, Arti Sarin, Prasanta Sengupta, Sankalp Singh, Niharika Bisht, Azhar Husain
DOI:10.4103/lungindia.lungindia_30_18  PMID:30381567
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Bronchial artery embolization for treatment of hemoptysis caused by peripheral pulmonary hamartoma p. 530
Udit Chauhan, Subodh Kumar, Khanak K Nandolia, Rahul Dev, Sudhir Saxena
DOI:10.4103/lungindia.lungindia_236_18  PMID:30381568
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LETTERS TO EDITOR Top

A case of steroid-induced diffuse alveolar hemorrhage p. 532
Priyanka Makkar, Vishisht Mehta, Nicholas Vander Els
DOI:10.4103/lungindia.lungindia_206_18  PMID:30381569
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Bronchial purging: Atypical pulmonary sarcoidosis presenting with bronchorrhea p. 533
Shweta Mahapatra, Loveleen Mangla, Deepak Talwar
DOI:10.4103/lungindia.lungindia_232_18  PMID:30381570
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Pulmonary sequestration with aberrant arterial supply from right renal artery p. 535
Suprava Naik, Biswadeep Ray, Sudipta Mohakud, Nerbadyswari Deep
DOI:10.4103/lungindia.lungindia_253_18  PMID:30381571
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Factors influencing severe community-acquired pneumonia few points to ponder p. 536
A K Aswin Pius, Animesh Ray
DOI:10.4103/lungindia.lungindia_282_18  PMID:30381572
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Author's reply p. 538
M Mahendra, BS Jayaraj, Sneha Limaye, SK Chaya, Raja Dhar, PA Mahesh
DOI:10.4103/lungindia.lungindia_354_18  PMID:30381573
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Ambidexterity: A useful addition to the skillset of an endobronchial ultrasound operator? p. 539
Animesh Ray, Shankar J D B Kalum, Sanjeev Sinha
DOI:10.4103/lungindia.lungindia_250_18  PMID:30381574
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Asthma-chronic obstructive pulmonary disease overlap syndrome: Is prediction feasible? p. 540
Habi Md Reazaul Karim, Antonio M Esquinas
DOI:10.4103/lungindia.lungindia_142_18  PMID:30381575
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Reply to: Asthma-chronic obstructive pulmonary disease overlap syndrome: Is prediction feasible? p. 541
Irfan Ismail Ayub, Abdul Majeed Arshad, Prathipa Sekar, Natraj Manimaran, Dhanasekar Thangaswamy, Chandrasekar Chockalingam
DOI:10.4103/lungindia.lungindia_189_18  PMID:30381576
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