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   Table of Contents - Current issue
Coverpage
July-August 2017
Volume 34 | Issue 4
Page Nos. 309-403

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EDITORIAL  

Increased oxidative stress and depleted antioxidant capacity in chronic obstructive pulmonary disease: Searching for applications p. 309
Anurag Agrawal
DOI:10.4103/lungindia.lungindia_223_17  PMID:28671159
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ORIGINAL ARTICLES Top

Placement of tracheobronchial silicone Y-stents: Multicenter experience and systematic review of the literature p. 311
Inderpaul Singh Sehgal, Sahajal Dhooria, Karan Madan, Vallandramam Pattabhiraman, Ravindra Mehta, Rajiv Goyal, Jayachandra Akkaraju, Ritesh Agarwal
DOI:10.4103/0970-2113.209241  PMID:28671160
Background: Airway obstruction or tracheoesophageal fistula (TEF) near the tracheal carina requires placement of Y-shaped stents. Herein, we describe our multicenter experience with the placement of Dumon silicone Y-stents. We also conduct a systematic review for studies describing the deployment of airway silicone Y-stents. Methods: This was a retrospective analysis of consecutive subjects who underwent placement of silicone Y-stents. The clinical details including the underlying diagnosis, indication for the placement of silicone Y-stents, success of stent placement, and follow-up are presented. The PubMed and EMBASE databases were also reviewed for studies describing the placement of silicone Y-stents. Results: During the study, 27 silicone Y-stents were placed. The mean (standard deviation) age of the study population (85.2% males) was 57.7 (13.5) years. The stents were placed for airway obstruction in 77.8% and TEF in 29.6% of the patients. The most common underlying disease was carcinoma of the esophagus. The degree of airway obstruction was grade 3–4 in 18 subjects, and respiratory failure was encountered in 18 subjects. The stent was deployed successfully in all the subjects. No deaths were encountered during stent placement. Most subjects had rapid relief of symptoms following the procedure. Excessive secretions and mucostasis were the most common stent-related complications followed by the development of granulation tissue. The systematic review yielded nine studies (338 subjects with airway obstruction and/or TEF). The most common indication for silicone Y-stent placement was tracheobronchial obstruction and TEF due to malignancy. Benign disorders that necessitated stent placement included postintubation tracheal stenosis, airway malacia, and others. The stent was successfully placed in 98% with only one periprocedural death. Granulation tissue formation and mucostasis were the most common stent-related complications. Conclusion: Placement of silicone Y-stent is a safe and effective procedure that provides quick relief of symptoms in subjects presenting with airway obstruction and TEF at or near the tracheal carina.
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Video-assisted thoracoscopic surgery for pulmonary aspergilloma p. 318
Arvind Kumar, Belal Bin Asaf, Harsh Vardhan Puri, Vijay C Lingaraju, Shireen Siddiqui, Pulle Mohan Venkatesh, Jayashree Sood
DOI:10.4103/0970-2113.209232  PMID:28671161
Introduction: Surgical management of pulmonary aspergilloma in symptomatic patients offers a significant chance of cure. Video-assisted thoracic surgery is a valid alternative for properly selected cases. We herein report our experience with thoracoscopic management of pulmonary aspergilloma. Patient and Methods: This retrospective analysis was performed on 41 patients operated between 2012 to 2015. The patient records were thoroughly analyzed for demography, clinical presentation, computed tomography , the procedure performed , post-operative complications and course during 6 month's follow up. Results: Out of total 41 patients, 23 (56%) were treated by VATS and 18 (44%) by thoracotomy. Average intraoperative blood loss was 214 ml (±106) in VATS group and 461 ml (±167) in thoracotomy. Mean operative time was 162 (±14) minutes in VATS and 239 (±12) minutes in thoracotomy group. In VATS group, postoperative complications were found in 5 patients and in 11 patients in the thoracotomy group. Average duration of chest tube was 5.43 () days in VATS group and 8.94 () days in thoracotomy group. Average length of hospital stay was 5.04 in VATS group and 6.55 days in thoracotomy group. Conclusions: VATS for pulmonary aspergilloma, if applicable, may be a safe and efficacious option in experienced hands. Simple aspergilloma, in particular , is considered to be a good indication for VATS. Some cases of complex aspergilloma may also be amenable to VATS. However, the long term results need to be further analyzed using a larger study group.
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Study of oxidative stress biomarkers in chronic obstructive pulmonary disease and their correlation with disease severity in north Indian population cohort p. 324
Jyoti Bajpai, Ved Prakash, Surya Kant, Ajay Kumar Verma, Anand Srivastava, Darshan K Bajaj, MK Ahmad, Avinash Agarwal
DOI:10.4103/lungindia.lungindia_205_16  PMID:28671162
Background: Oxidant-antioxidant imbalance forms a prime component in pathogenesis of chronic obstructive pulmonary disease (COPD). Studies of oxidative stress markers in South Asians were sparse. Methods: One hundred and eighty COPD patients and eighty healthy nonsmokers were enrolled in the study. Serum malondialdehyde (MDA) and iron levels were estimated for oxidative stress. Three antioxidant markers evaluated-catalase, superoxide dismutase (SOD), and serum copper. Patients on antioxidant therapy and with sepsis and chronic illness were excluded from the study. Results: The mean age of COPD patients was 59.29 ± 10.3 years. Serum levels of MDA and iron were significantly higher in COPD patients compared to controls (5.21 ± 1.9 vs. 0.71 ± 0.29 nmol MDA/ml, P = 0.0001 and 69.85 ± 85.49 vs. 79.32 ± 24.39 μg/dl, P = 0.0001, respectively). Mean level of all antioxidant enzymes catalase, SOD, and copper were significantly diminished in cases when compared to control population (P = 0.001). Levels of MDA and iron were found to be significantly elevated in higher Global Initiative for Chronic Obstructive Lung Disease (GOLD) classes (III, IV) when compared to lower GOLD Classes (I, II). The levels of serum antioxidants were significantly depleted in higher GOLD grades too. COPD patients who were male and smoked had significantly higher levels of oxidants and depleted antioxidant levels compared to female and nonsmoking compatriots. Serum MDA levels negatively correlated with forced expiratory volume 1 s and forced vital capacity (r = −0.19 and r = −0.21, P ≤ 0.01). The presence of a cough significantly correlated with higher levels of MDA and iron (P = 0.001). The levels of MDA negatively correlated with SOD and catalase levels. Conclusion: Oxidative markers (MDA and iron) are higher whereas antioxidants (catalase, copper, and SOD) are significantly reduced in patients of COPD. Serum MDA levels correlate with lung functions and disease severity.
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Predictors of mortality of severe sepsis among adult patients in the medical Intensive Care Unit p. 330
Aziz Kallikunnel Sayed Mohamed, Asmita Anilkumar Mehta, Ponneduthamkuzhy James
DOI:10.4103/lungindia.lungindia_54_16  PMID:28671163
Background: Sepsis is an important cause of mortality in the Intensive Care Units (ICUs) worldwide. Information regarding early predictive factors for mortality and morbidity is limited. Aims and Objectives: The primary objective of the study was to estimate the mortality of severe sepsis among adult patients admitted into the medical ICU. The secondary objective was to identify the predictors associated with mortality. Materials and Methods: Adult patients admitted with severe sepsis in the medical ICU were studied. The primary outcome was the mortality among the study population. Baseline demographic, clinical, and laboratory data were recorded upon inclusion into the study. Risk factors associated with mortality were studied by univariate analysis. The variables having statistical significance were further included in multivariate analysis to identify the independent predictors of mortality. Results: Out of eighty patients, 54 (67.5%) died. Univariate analysis showed that age >60 years, tachycardia, hypotension, elevated C-reactive protein (CRP) and lactate, thrombocytopenia, need of mechanical ventilation, and high Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment scores were variables associated with high mortality. The independent predictors of mortality identified by multivariate regression analysis were platelet count below 1 lakhs, serum levels of CRP >100, APACHE II score >25 on the day of admission to the ICU with severe sepsis, and the need for invasive mechanical ventilation. Conclusions: Low platelet count, elevated serum levels of CRP, APACHE score >25, and the need for invasive mechanical ventilation were found to be independent predictors of mortality of severe sepsis among adult patients with severe sepsis in the medical ICU.
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Impact of chemotherapy on symptom profile, oxidant-antioxidant balance and nutritional status in non-small cell Lung Cancer p. 336
Anant Mohan, Rosemary Poulose, Tarang Gupta, Kalpana Luthra, Ravindra M Pandey, Karan Madan, Vijay Hadda, Randeep Guleria
DOI:10.4103/0970-2113.209230  PMID:28671164
Background: Lung cancer is associated with an oxidant-antioxidant imbalance that is implicated in tumor progression. However, the association of this imbalance on disease burden and treatment response is unclear. The effect of chemotherapy on oxidative stress, antioxidant status, and nutritional profile in patients with advanced nonsmall cell lung cancer (NSCLC) was prospectively evaluated. Subjects and Methods: Patients with confirmed cytological/histological diagnosis of NSCLC were recruited. Performance status was determined using the Eastern Cooperative Oncology Group grading and the Karnofsky Performance Scale. Skin fold anthropometry was done for nutritional assessment. All patients received chemotherapy with intravenous carboplatin and paclitaxel at three-weekly intervals. Response was assessed after four cycles by repeat imaging. Plasma levels of total antioxidant status (TAS), malondialdehyde (MDA), and glutathione peroxidase (GPx) levels were estimated using commercially available kits, and the change was correlated with clinical outcome, response to chemotherapy, performance status, and nutritional profile. Results: Thirty-five cases were studied (92% males), with a mean (SD) age of 56.2 (9.3) years. Following treatment, majority of patients demonstrated stable disease (n = 15 [42%]), followed by partial response (29%), progressive disease (22%), and complete remission (6%). Significant improvement occurred in respiratory symptoms. Body fat declined while subscapular skinfold thickness and 6-min walk distance increased. Spirometric values and performance status remained unchanged. GPx levels declined significantly while no notable change was observed in MDA and TAS levels. Conclusions: Chemotherapy for NSCLC improves symptoms, nutritional status, and exercise capacity but worsens the antioxidant status.
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Diagnostic evaluation of mediastinal lesions: Analysis of 144 cases p. 341
Ramakant Dixit, Narender Singh Shah, Mukesh Goyal, Chetan B Patil, Mukesh Panjabi, Rakesh C Gupta, Neeraj Gupta, Sabarigiri Vasan Harish
DOI:10.4103/lungindia.lungindia_311_16  PMID:28671165
Background: Mediastinum is a “Pandora's box” with many neoplastic and nonneoplastic lesions. The purpose of this study was to analyze our institutional experience of mediastinal lesions on fine-needle aspiration cytology (FNAC) and/or biopsy. Materials and Methods: This study was an analysis of 144 patients who had undergone ultrasound-guided FNAC and/or core biopsy for mediastinal lesions. Results: A total of 144 cases of suspected mediastinal masses were seen, and in 139 cases, tissue diagnosis was attempted. Out of 139 cases, 93 cases were neoplastic in nature (67%), 32 were nonneoplastic (23%), and 14 remained inconclusive (10%). Among neoplastic mediastinal lesions, metastatic carcinoma (37.4%) was the most common neoplastic lesion, followed by non-Hodgkin's lymphoma (12.2%), Hodgkin's lymphoma (7.1%), thymic lesions (3.5%), etc. Among nonneoplastic conditions, tuberculosis was the most common lesion (20.1%). An accurate tissue diagnosis was made in 89.9% cases by FNAC or core biopsy of mediastinal lesions in this study. Procedure-related mortality was nil. Complications were mostly minor and included chest pain in 24.5%, small pneumothorax in 13.6% requiring closed tube thoracostomy in 1.4%, and scanty hemoptysis in 9.3% cases. Conclusion: Neoplastic mediastinal lesions are more common than nonneoplastic lesions, with metastatic carcinoma being the most common cause followed by tuberculosis. A wide variety of lesions observed in this study stress on the importance of cytohistological diagnosis in all cases of mediastinal lesions for the final diagnosis and management planning. A guided FNAC or core biopsy is still accurate, well tolerated, and devoid of major complications.
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Effects of oral montelukast on airway function in acute asthma: A randomized trial p. 349
Alisha Chaudhury, Gajanan S Gaude, Jyothi Hattiholi
DOI:10.4103/0970-2113.209234  PMID:28671166
Background: The role of leukotriene receptor antagonist is well known in the management of chronic asthma, but their efficacy in acute exacerbation of asthma is unknown. The present study was done to evaluate the clinical efficacy of oral montelukast as an add on therapy to the usual standard therapy of acute attack of bronchial asthma. Materials and Methods: A randomized single-blinded controlled study was conducted in a tertiary care teaching hospital. A total of 162 patients with age >18 years of acute exacerbations due to bronchial asthma were included in the study. The patients were randomized into two study and control groups. The study group patients received oral montelukast (10 mg) once daily for 2 weeks, while the control group received a placebo. All the patients received standard therapy according to GINA guidelines. Improvements in lung function tests, clinical symptoms, and relapse rates were monitored at baseline, 1 week, 2 weeks, and 4 weeks. Side effects profile was also monitored. Results: A total of 160 patients were finally assessed. Seventy-eight patients belonged to study group and 82 in the control group. Baseline characteristics were similar and well matched in both groups. Mean age was 39.9 ± 15.8 years in the study group and 42.8 ± 12.8 in the control group and majority were female patients in both groups. At the end of 4 weeks, it was observed that the study group patients who received montelukast had better forced expiratory volume in 1 s (FEV1) improvement by 21% (0.21 L) as compared to the control group (P < 0.0033). It was also observed that there was a better improvement in peak expiratory flow rate (PEFR) at 2 weeks (0.4 L/s, 12%) and at 4 weeks (0.9 L/s, 23%) as compared to the control group (P < 0.0376 and P < 0.0003 respectively). There was no difference in forced vital capacity (FVC), FEV1/FVC ratio and relapse rates between the two groups. No serious adverse effects were observed during the study. Conclusions: In acute asthma exacerbations, the present study showed that additional administration of oral montelukast resulted in significantly higher FEV1at 4 weeks and PEFR at 2 weeks and 4 weeks as compared to the standard treatment alone. These findings should be confirmed by conducting a larger population-based clinical study.
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REVIEW ARTICLE Top

Vitamin D and asthma in children: A systematic review and meta-analysis of observational studies p. 355
Kana Ram Jat, Anju Khairwa
DOI:10.4103/0970-2113.209227  PMID:28671167
There is growing literature suggesting a link between Vitamin D deficiency and asthma in children, but systematic reviews are lacking. The aim of this study is to evaluate the prevalence of Vitamin D deficiency in asthmatic children and to assess the correlations of Vitamin D levels with asthma incidence, asthma control, and lung functions. PubMed, EMBASE, and Cochrane Library were searched for observational studies on asthma and Vitamin D. Two authors independently extracted data. Meta-analysis was performed using the Review Manager Software. A total of 23 (11 case–control, 5 cohort, and 7 cross-sectional) studies enrolling 13,160 participants were included in the review. Overall, Vitamin D deficiency and insufficiency were prevalent in 28.5% and 26.7% children with asthma, respectively. The mean 25-hydroxyvitamin D (25(OH)D) levels (10 studies) were significantly lower in asthmatic children as compared to nonasthmatic children with a mean difference of −9.41 (95% confidence interval [CI] −16.57, −2.25). The odds ratio of Vitamin D deficiency (eight case–control studies) was significantly higher among asthmatic children as compared to nonasthmatic children (odds ratio 3.41; 95% CI 2.04, 5.69). Correlations between Vitamin D levels and incidence of asthma, lung functions, and control of asthma had mixed results. To conclude, asthmatic children had lower 25(OH)D levels as compared to nonasthmatic children, but the correlations between 25(OH)D and asthma incidence, asthma control, and lung functions were varied. Well-designed randomized controlled trials are required to determine if children with asthma can benefit from Vitamin D supplementation.
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CASE REPORTS Top

Multidrug-resistant tuberculosis and leprosy: An unsolved mystery p. 364
Robin Gupta, Kranti Garg, Mala Bhalla, Ashok K Janmeja
DOI:10.4103/lungindia.lungindia_451_15  PMID:28671168
Tuberculosis (TB) and leprosy are two age-old infections, which we are facing even today. With drug-resistant TB on the rise, we report a case of multidrug-resistant TB with leprosy, which has never been reported previously. The peculiar course of this case forces us to rethink about the upcoming challenges due to their cooccurrence.
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Hemoptysis: Beyond routine chest computed tomography and bronchoscopy p. 368
Saurabh Mall, Rahul Kumar Sharma, Deepak Prajapat, Samir K Gupta, Deepak Talwar
DOI:10.4103/lungindia.lungindia_456_16  PMID:28671169
Hemoptysis is considered as a medical emergency which requires urgent stabilization with identification and correction of underlying etiology. Diagnosis of the cause of hemoptysis is not always readily identified after bronchoscopy and conventional computed tomography (CT) chest. Arteriovenous malformation (AVM) is a rare but important cause of massive hemoptysis which can be easily picked up by the use of double turn contrast CT chest. We here report a rare congenital AVM anomaly called Klippel-Trenaunay-Parks-Weber syndrome as a cause of massive hemoptysis and utility of double turn CT in diagnosing AVM as a cause of hemoptysis.
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Platypnea-orthodeoxia syndrome in idiopathic pulmonary fibrosis with Pneumocystis jiroveci pneumonia p. 372
R Swapna, Rahul Roshan, Sunil K Chhabra
DOI:10.4103/0970-2113.209236  PMID:28671170
Platypnea-orthodeoxia syndrome (POS), the occurrence of dyspnea and arterial desaturation on changing from supine to sitting position, is a very rare phenomenon. Most case reports have been in association with an intra-atrial communication, and observation of this unusual physiological abnormality in pulmonary conditions has been extremely rare. We present a case of idiopathic pulmonary fibrosis where the patient developed characteristic symptoms of POS when it was complicated by Pneumocystis jiroveci pneumonia. This was objectively confirmed. A similar association has not been reported earlier in literature.
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Early-onset de novo invasive pulmonary aspergillosis in an orthotopic heart transplant recipient p. 376
Zaw Min, Manik Veer, Parth Rali, Anil Singh, Nitin Bhanot
DOI:10.4103/lungindia.lungindia_454_16  PMID:28671171
Invasive aspergillosis generally occurs during the first 1–6 months after heart transplantation. It has been rarely seen in the first 2 weeks postcardiac transplant. We herein describe a unique case of invasive pulmonary aspergillosis (IPA) diagnosed on day 9 postorthotopic heart transplantation. The known risk factors for IPA in cardiac transplant recipients were not identified in our case. The organ recipients from the same donor did not report Aspergillus infection. Hospital environmental samplings failed to demonstrate Aspergillus spores in the patient's room and his adjacent rooms. A diagnosis of early-onset de novo IPA was made. The patient initially received combined antifungal therapy (voriconazole plus micafungin), followed by voriconazole maintenance monotherapy with favorable clinical outcome.
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Gastric and pulmonary sarcoidosis complicated by hypercalcemia and acute renal failure: Case report and literature review p. 380
AS Deepa, Vivek Anand Padegal, K S Poorna Chandra, HK Santhosh
DOI:10.4103/lungindia.lungindia_276_15  PMID:28671172
Gastric sarcoidosis is a very rare manifestation of sarcoidosis. Only few case reports have been described in the literature. We present a case of coexisting gastric and pulmonary sarcoidosis in a 56-year-old female, who presented with gastrointestinal symptoms. Gastric mucosal biopsies, transbronchial needle aspiration, and endobronchial mucosal biopsies revealed noncaseating granulomas. This case report emphasizes on early evaluation of other organ system and initiation of treatment.
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Metastatic renal carcinoid: To skin, lungs, and pancreas p. 383
Hammad Arshad, Parth Rali, Khalid Malik
DOI:10.4103/lungindia.lungindia_291_16  PMID:28671173
Carcinoid tumors rarely originate in the urogenital system. We represent a unique case of primary renal carcinoid tumor which was initially diagnosed as renal cell cancer and 10 years later correctly diagnosed as metastatic renal carcinoid.
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Case of postural complex sleep apnea: effect of gravitational forces p. 386
Kamender Singh Pawar, Abhishek Goyal, Alkesh Khurana, Senthil Kumar, Amit Kumar Sen
DOI:10.4103/lungindia.lungindia_374_16  PMID:28671174
We report a case of an elderly male with predominant obstructive sleep apnea and who developed or complex sleep apnea (CxSA) at the start of continuous positive airway pressure (CPAP) titration. This CxSA was more prominent in supine position, and he was not settling with either CPAP/bilevel positive airway pressure (PAP) in supine position. He finally settled with CPAP along with position therapy. This case highlights the importance of treating CxSA with basic PAP modes like CPAP along with positional therapy before switching to costlier therapies such as adaptive servo-ventilation.
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A rare cause of ventilatory failure in a patient with post-traumatic intracranial hemorrhage p. 390
Balamugesh Thangakunam, Shakti Kumar Bal, Ajay V Venkatapathy, Aparna Irodi, Devasahayam Jesudas Christopher
DOI:10.4103/0970-2113.209246  PMID:28671175
High minute ventilation is required to lower intracranial pressures in patients with intracranial bleed. Respiratory acidemia consequent to ventilatory difficulty is dangerous in such patients as it further raises intracranial tension. We describe such a case. A 24-year-old man had to be intubated and mechanically ventilated after he met with a road traffic accident and sustained extensive maxillofacial injuries and intracranial bleed. A tooth was accidentally aspirated in this injury and progressively resulted in left lower lobe collapse, pneumomediastinum, and consequent difficult ventilation. Under video bronchoscope guidance, the tooth was removed with grasping forceps. Pneumomediastinum temporarily increased after the tooth removal, but by 12 h postextraction, resolution of both the pneumomediastinum and left lower lobe collapse was observed. There was a 17 h delay postadmission before the cause of ventilatory failure was realized. Aspiration of foreign bodies, in general, and teeth, in particular, should be actively looked for in patients with ventilatory difficulties in the post-trauma setting.
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RADIOLOGY QUIZ Top

Progression of a rare multiple cystic lung disease p. 393
Kamal Gera, Ajay Lall, Ritu Kulshrestha, Kanika Singh, Nandini Chhabra
DOI:10.4103/lungindia.lungindia_530_16  PMID:28671176
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CLINICOPATHOLOGIC CONFERENCE Top

A 36-year-old man with breathlessness and anasarca p. 395
Syed Zulkharnain Tousheed, Tiyas Sen Dutt, BV Muralimohan, Binoy Chatturambil, Vimal Raj, Preeti Latha Raut
DOI:10.4103/lungindia.lungindia_16_15  PMID:28671177
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CASE LETTERS Top

Metastasis to parotid gland from primary bronchogenic carcinoma: A case letter p. 398
Durga J Lawande, Mongressa V Monteiro, Uday C Kakodkar, Sanjivani J Keny
DOI:10.4103/0970-2113.209233  PMID:28671178
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Adult right-sided thoracic kidney: A very rare form of renal ectopia p. 400
Rahul Gupta, Anchal Gupta, Mohd Ilyas, Kamal Singh Chauhan
DOI:10.4103/lungindia.lungindia_118_16  PMID:28671179
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BOOK REVIEW Top

Clinico radiological series: Imaging of interstitial lung disease p. 403
Sheetu Singh, Bhavin Jankharia
DOI:10.4103/lungindia.lungindia_124_17  
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