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   Table of Contents - Current issue
March-April 2017
Volume 34 | Issue 2
Page Nos. 117-220

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Nonsmoker COPD: Is it a reality? p. 117
Bharat Bhushan Sharma, Virendra Singh
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India's fight against tuberculosis: How can chest physicians help? p. 120
Madhukar Pai, Parvaiz Koul
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Prevalence and etiological profile of chronic obstructive pulmonary disease in nonsmokers Highly accessed article p. 122
Tariq Mahmood, Ravindra Kumar Singh, Surya Kant, Amitabh Das Shukla, Alok Chandra, Rajneesh Kumar Srivastava
Background: Tobacco smoking has been recognized as the most important risk factor for chronic obstructive pulmonary disease (COPD) for a long time, but recent studies have shown that nonsmokers also contribute to a significant proportion of COPD. This study was performed to find out the proportion of nonsmoker individuals among COPD patients and to determine various etiologies in nonsmoker COPD patients. Materials and Methods: This study was an observational cross-sectional study conducted in Department of Pulmonary Medicine, MLN Medical College, Allahabad. A total of 200 COPD patients, aged >18 years of either gender with COPD, diagnosed by clinical and spirometric criteria (GOLD guideline) were included in the study. Results: Of the 200 COPD patients, the proportion of nonsmoker patients was 56.5%, and the smoker was 43.5%. Among 113 nonsmoker COPD patients, maximum number of patients (69.03%) belonged to low socioeconomic status but most important and statistically significant risk factor was exposure to biomass smoke (53.98%), other significant risk factors were treated pulmonary tuberculosis (32.74%), and long-standing asthma (14.16%). Risk factors that were not statistically significant were occupational exposure (9.73%), exposure to outdoor air pollution (3.54%), and lower respiratory tract infection during childhood (1.77%). The patients who were exposed to more than one risk factors, developed COPD at an earlier age. Conclusions: This study revealed that nonsmokers contribute a significant proportion of COPD patients. Multiple risk factors other than smoking also play a major role in the development of COPD, particularly exposure to biomass smoke, treated pulmonary tuberculosis, and long-standing asthma.
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Correlation of pollen counts and number of hospital visits of asthmatic and allergic rhinitis patients p. 127
Nishtha Singh, Udaiveer Singh, Dimple Singh, Mangal Daya, Virendra Singh
Aims and Objectives: Environmental pollens are known to cause exacerbation of symptoms of patients with allergic rhinitis (AR) and asthma. During pollen months, number of patients visiting hospital has been shown to increase in some studies. However, in India, such studies are lacking. Therefore, we aimed to study pollen counts and to find its correlation with number of new patients attending Asthma Bhawan for 2 years. Materialsx and Methods: Aerobiological sampling was done using Burkard 24 h spore trap system. The site selected for the entrapment of the air spore was the building of Asthma Bhawan situated at Vidhyadhar Nagar, Jaipur. New patients coming with problems of respiratory allergy such as AR or asthma were recruited in the study. Skin prick tests (SPTs) were carried out after obtaining consent in these patients. Monthly pollen counts of trees, weeds and grasses were correlated with the number of new patients. Pollen calendar was prepared for 2 years. Results: Average annual pollen count during 2011 and 2012 were 14,460.5. In the analysis, 37 types of species or families were identified. Pollen count showed two seasonal peaks during March–April and from August to October. January and June showed the lowest pollen counts in 2 years. Average monthly count of grass pollens showed significant correlation with number of new patients (r = 0.59). However, monthly pollen count of trees and weeds did not correlate. The correlation of the pollen count of individual pollen with the SPT positivity to that pollen showed significant correlation with Chenopodium album only. Conclusions: It can be concluded that there were two peaks of pollen count in a year during March–April and August–October. Average monthly pollen counts of grass were significantly correlated with the number of hospital visits of new patients.
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Fractional exhaled nitric oxide is a useful adjunctive modality for monitoring bronchial asthma p. 132
Venkatnarayan Kavitha, Anant Mohan, Karan Madan, Vijay Hadda, GC Khilnani, Randeep Guleria
Background and Objective: To evaluate the utility of fractional exhaled nitric oxide (FeNO) in monitoring asthma control. Materials and Methods: Steroid naïve nonsmoking asthmatics were recruited and followed for 6–8 weeks on standard treatment. Serial measurements of FeNO, peak expiratory flow rate (PEFR) variability, forced expiratory volume in 1 s (FEV1), bronchodilator reversibility (BDR), and asthma control test (ACT) score were measured at baseline and after 6–8 weeks of treatment. Results: One hundred and fifty-one patients were recruited over an 18-month period. These comprised 79 males (52.3%) with mean (standard deviation) age of 34.2 (11.6). Mean (SD) FeNO levels at baseline and after therapy were 45.4 (35.9) and 38.4 (23.7) ppb, respectively (P = 0.01). Baseline FeNO correlated strongly with FEV1 (r = −0.78, P < 0.001), ACT score (r = −0.76, P < 0.001), PEFR variability (r = −0.74, P < 0.001), and moderately with BDR (r = 0.50, P < 0.001). After treatment with inhaled steroids, the correlation remained strong with ACT score (r = −0.68, P < 0.001) but weakened with PEFR variability (r = −0.34, P = 0.01) and FEV1 (r = −0.36, P = 0.01). Conclusions: FeNO may be useful as an adjunctive noninvasive modality to assess asthma control in both steroid naïve asthmatics and asthmatics on treatment. However, the suboptimal sensitivity and specificity may limit its utility as a point-of-care single monitoring tool.
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Study the association of chronic obstructive pulmonary disease with early endothelial dysfunction and its impact on cardiovascular system by estimating urinary albumin creatinine ratio p. 138
Anand Agrawal, Renu Garg, Dibakar Sahu, Mukesh Kumar
Background: Chronic obstructive pulmonary disease (COPD) attribute to systemic inflammation which is responsible for microalbuminuria reflecting endothelial dysfunction, could be a significant surrogate marker of potential cardiovascular morbidity. Objective: The aim of our study was to find out the possible association of COPD with early cardiovascular changes in the form of renal endothelial dysfunction. Settings and Design: Case–control, multi-group, cross-sectional hospital-based study was designed and conducted in the Department of Respiratory Medicine of BPS Government Medical College for Women, Khanpur Kalan, Sonipat, Haryana. Subjects and Methods: The study included 150 subjects, comprising of three groups with each having 50 subjects: Group 1 – acute exacerbation of COPD, Group 2 – stable COPD patients, Group 3 – asymptomatic smokers. Pulmonary function test, urine albumin creatinine ratio (UACR) and brachio-ankle pulse wave velocity were measured in all the subjects. Statistical Analysis: Data were analyzed using SPSS ver 20 (IBM, USA) software. Continuous variables were compared by unpaired Student's t-test while correlation was measured by Pearson correlation test, P < 0.05 was considered statistically significant. Results: The mean urine albumin creatinine ratio UACR value in acute exacerbation of COPD (283.30 mg/g; standard deviation [SD] ±871.98) was found significantly higher compare to control subjects (24.17 mg/g; SD ± 32.105;) P = 0.038. Besides this COPD patients with Type 2 respiratory failure having robust positive correlation in between UACR and arterial blood pH (r = 0.559; P = 0.030) while it was inverse and moderate with partial pressure of arterial oxygen (r = −0.470; P = 0.077). Conclusions: Acute state of COPD with or without Type 2 respiratory failure is having a significant impact on cardiovascular system in the form of early microvascular changes.
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Cotton dust exposure: Analysis of pulmonary function and respiratory symptoms p. 144
Bharat M Dangi, Anjali R Bhise
Background: Cotton industry workers are exposed to various hazards in the different departments of textile factories. The major health problems associated with cotton dust are respiratory problems, byssinosis, bronchitis and asthma. Objective: To study the effect of cotton dust exposure on pulmonary function and respiratory symptoms. Settings and Design: This cross-sectional observational study was conducted at cotton mill in the Ahmedabad city. Materials and Methods: One hundred cotton mill workers of the weaving and spinning area participated in this study while 100 age- and gender-matched male subjects living in the residential area served as the control group. A questionnaire was used to inquire about respiratory symptoms and spirometry was done in both the groups. Statistical Analysis Used: Student's t-test was used to find the difference between spirometric parameters, and Chi-square test was used to find the difference between respiratory symptoms. Results: Respiratory symptoms were statistically significantly more common in the cotton mill workers compared to control group. Cotton mill workers group also showed significant (P < 0.0001) decrease in forced expiratory volume in 1 s (FEV1), ratio of FEV1 and forced vital capacity (FVC) and peak expiratory flow rate, and no significant difference of FVC between groups. There was an association of duration of exposure and symptoms with spirometric abnormality. Conclusion: Cotton mill workers showed a significant decrease in spirometric parameters and increase in respiratory symptoms. As the duration of exposure and symptoms increased, spirometric abnormality increased.
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Prevalence of Aspergillus hypersensitivity and allergic bronchopulmonary aspergillosis in patients with bronchial asthma at a tertiary care center in North India p. 150
Alok Nath, Ajmal Khan, Zia Hashim, Jeetendra Kumar Patra
Background: The prevalence of Aspergillus hypersensitivity (AH) and allergic bronchopulmonary aspergillosis (ABPA) has been variably reported. Systematic data regarding Aspergillus sensitization and ABPA are lacking from this part of the country. Objectives: The aim of this study was to evaluate the prevalence of AH and ABPA in Uttar Pradesh. Setting and Design: This was prospective observational study. All patients attending outpatient Department of Pulmonary Medicine of our institute were included in the study. Subjects and Methods: Consecutive asthmatic patients underwent screening for ABPA using Aspergillus skin test (AST). Those showing a positive response to AST were further evaluated for ABPA. Results: During the study, 350 patients (192 males, 158 females, mean ± standard deviation age: 38.3 ± 12.8) were screened with AST. One hundred and twenty-three patients (35.1%) were tested positive for AST and 21.7% of patients were diagnosed as ABPA. Conclusions: A high prevalence rate of ABPA was observed at our chest clinic. Although comparable with published data from other tertiary centers, it does not represent the true prevalence rates in asthmatics because of high chances of referral bias.
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Assess drug resistance pattern and genetic profile of Mycobacterium tuberculosis clinical isolates by molecular typing methods using direct repeats and IS6110 in pulmonary tuberculosis cases p. 155
Deepika Kalo, Surya Kant, Kanchan Srivastava, Ajay K Sharma
Background: Tuberculosis (TB), a highly contagious disease that sees no gender, age, or race is mainly a disease of lungs. According to World Health Organization, a TB patient can be completely cured with 6–9 months of anti-TB treatment under directly observed treatment short course. Objectives: The aim of this study was to check the mono, multi- and triple-drug resistance to first line drugs (FLDs) among TB patients and to access their genetic profile using DR 3074, DR 0270, DR 0642, DR 2068, and DR 4110 using molecular techniques. Material and Methods: To gain a better understanding of drug resistant TB, we characterized 121 clinical isolates recovered from 159 drug resistant pulmonary tuberculosis patients by IS6110 genotyping. MTB isolates recovered from HIV- negative, and smear positive cases of both genders, age varied from 18 to 70 years with drug resistant-TB that was refractory to chemotherapy given for > 12 months. Of a total of 159 sputum smear positive patients sum number of male and female patients was 121 (76.10%) and 38 (23.89%), respectively. Among these patients, number of literate and illiterate patients were 123 (77.3%) and 36 (22.6%). 25 (15.7%) patients had farming as their occupation, 80 (50.3%) had nonagricultural occupation and 54 (33.9%) women were housewives. Results: Mono drug resistant, multi-drug resistant, and totally drug resistant (TDR) cases of TB were calculated as 113.83%, 125.1%, and 67.9%. Isoniazid showed the highest percentage of resistance among the patients. Conclusion: Any noncompliance to TB medications, lack of knowledge, and poor management in health centers, etc., results in the emergence of deadly direct repeat forms of TB, which are further complicated and complex to treat.
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Diagnosis and management options in malignant pleural effusions p. 160
Ramakant Dixit, KC Agarwal, Archana Gokhroo, Chetan B Patil, Manoj Meena, Narender S Shah, Piyush Arora
Malignant pleural effusion (MPE) denotes an advanced malignant disease process. Most of the MPE are metastatic involvement of the pleura from primary malignancy at lung, breast, and other body sites apart from lymphomas. The diagnosis of MPE has been traditionally made on cytological examination of pleural fluid and/or histological examination of pleural biopsy tissue that still remains the initial approach in these cases. There has been tremendous advancement in the diagnosis of MPE now a day with techniques i.e. characteristic Ultrasound and computed tomography features, image guided biopsies, fluorodeoxyglucose-positron emission tomography imaging, thoracoscopy with direct biopsy under vision, tumor marker studies and immunocytochemical analysis etc., that have made possible an early diagnosis of MPE. The management of MPE still remains a challenge to pulmonologist and oncologist. Despite having various modalities with better tolerance such as pleurodesis and indwelling pleural catheters etc., for long-term control, all the management approaches remain palliative to improve the quality of life and reduce symptoms. While choosing an appropriate management intervention, one should consider the clinical status of the patient, life expectancy, overall cost, availability and comparative institutional outcomes, etc.
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Rare cause of paradoxical worsening of pleural effusion in a patient with tuberculosis p. 167
Paramasivan Duraikannan, S Saheer, T Balamugesh, DJ Christopher
A 33-year-old patient, Known case of chronic kidney disease on maintenance dialysis presented with complaints of low-grade fever and weight loss of 2 months duration. Computed tomography (CT) revealed bilateral mild pleural effusion with significant mediastinal and abdominal adenopathy. CT-guided fine-needle aspiration cytology of abdominal lymph nodes and bone marrow culture was suggestive of tuberculosis. The patient was started on four drug anti-tubercular therapy, post 6 weeks of initiation he developed new onset fever and chest X-ray revealed moderate right pleural effusion. Diagnostic thoracocentesis was suggestive of chylothorax. To the best of our knowledge, this is the first case report of chylothorax due to the paradoxical reaction in the HIV-negative tuberculous patient.
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Curious case of extraskeletal myxoid chondrosarcoma p. 170
Sushilkumar Satish Gupta, Neha Khanna, Adam Jacobi
Extraskeletal myxoid chondrosarcomas (EMC) are a rare entity of soft tissue tumors that have slow growth with metastatic potential. We discuss here a case of EMC presenting with right upper extremity pain and hemoptysis. Computed tomography scans chest showed diffuse metastatic numerous lung nodules bilaterally. Biopsy confirmed the diagnosis of the tumor. Chemotherapy was a bigger challenge for our patient due to sparse research and data in the literature about the disease.
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Air leak: An unusual manifestation of organizing pneumonia secondary to bleomycin p. 173
R Namitha, KP Nimisha, Nasser Yusuf, CP Rauf
Organizing pneumonia (OP) is a less common interstitial lung disease with varying clinical picture. The development of pulmonary air leak in a case of OP is an extremely rare complication. Here, we report the case of a 46-year-old female with carcinoma ovary, postchemotherapy who developed respiratory distress with pneumomediastinum, and subcutaneous emphysema. Lung biopsy showed evidence of OP. This turned out to be a rare case of OP, secondary to bleomycin chemotherapy, presenting with pulmonary air leak.
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Myelomatous pleural effusion: A rare case entity reported from a tertiary care cancer center in South India p. 176
Govind K Babu, Smitha C Saldanha, KN Lokesh, MC Suresh Babu, Akkamaha Devi Patil, Pretesh R Kiran, KC Lakshmaiah, D Lokanatha
Multiple myeloma (MM) is a plasma cell neoplasm and constitutes 10% of hematologic malignancies. Malignant myelomatous pleural effusions are very rare and occur in <1% of cases of MM. In this article, we report a rare case of a patient who initially presented with pleural effusion and was subsequently found to be secondary to MM with an underlying raised IgG paraprotein. The patient symptomatically improved and was in partial remission with palliative radiotherapy, VTD chemotherapy, and bisphosphonates.
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Pulmonary mucormycosis diagnosed by convex probe endobronchial ultrasound-guided fine needle aspiration of cavity wall p. 179
Vidya Nair, Rahul Kumar Sharma, Arjun Khanna, Deepak Talwar
Pulmonary mucormycosis is an opportunistic fungal infection in immunocompromised individuals. It is difficult to diagnose as it requires tissue biopsy, and generally these patients are unfit to undergo invasive lung biopsies. We describe a novel technique in a case with uncontrolled diabetes mellitus with nonresolving pulmonary cavitary disease where convex probe endobronchial ultrasound (EBUS)-guided aspiration of lung cavity wall showed classical histopathological picture establishing the diagnosis of mucorale infection. EBUS being real-time, minimally invasive technique with minimal risk of complications, led to early diagnosis, and prompt treatment. This appears to be a novel diagnostic modality in pulmonary mucormycosis with minimal complications as compared with other biopsy methods with very high complication risk.
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Thoracoscopic foreign body removal and repair of bronchus intermedius following injury during failed bronchoscopic retrieval p. 182
Belal Bin Asaf, CL Vijay, Sukhram Bishnoi, Naresh Dua, Arvind Kumar
Aspiration of foreign body (FB) into the airways is common in children and continues to be a cause for morbidity and mortality. We report herein, successful thoracoscopic management of a child who aspirated a large magnetic FB into his right bronchus and developed a tear of bronchus intermedius (BI) during an attempt at bronchoscopic retrieval using rigid bronchoscope. The impacted FB was successfully removed thoracoscopically followed by thoracoscopic BI repair.
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Management of locally advanced primary mediastinal synovial sarcoma p. 185
Ambarish S Chatterjee, Rajiv Kumar, Nilendu Purandare, Sabita Jiwnani, George Karimundackal, CS Pramesh
Primary mediastinal synovial sarcoma (PMSS) is a relatively rare disease, and patients are treated predominantly with surgery for resectable disease. Management of locally advanced borderline resectable and unresectable PMSS is not only challenging but also lacks standard guidelines. We present three patients with PMSS, who were unresectable or borderline resectable at presentation and were treated with neoadjuvant chemotherapy followed by surgery and postoperative radiotherapy.
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Recurrent endobronchial actinomycosis following an interventional procedure p. 189
Arjun Padmanabhan, Abin Varghese Thomas
Actinomycosis is an indolent, slowly progressive infection caused by anaerobic or microaerophilic bacteria, primarily from the genus Actinomyces. Thoracic involvement is observed in approximately 15% of cases of infection with actinomycosis. Here, we present a case of a 61-year-old male who presented with recurrent endobronchial actinomycosis. The case is being presented because of its rarity on three counts – endobronchial involvement, which is uncommon, recurrence in different sites in the bronchial tree, which is even rarer and development of the disease following an endobronchial procedure.
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An intra-thoracic follicular carcinoma of thyroid: An uncommon presentation p. 193
Surya Kant, Anand Srivastava, Rahul Kumar, Ajay Kumar Verma, Anand Kumar Mishra, Nuzhat Husain
Follicular carcinoma of thyroid is the second most common type of carcinoma of thyroid, and it may metastasize to bone, lung, brain, and skin. However, the initial presentation of follicular carcinoma of the thyroid as a large intrathoracic mass without any symptoms of thyroid gland enlargement and dysfunction is very rare. We hereby report a case of a 50-year-old male who presented with chief complaints of chest and low back pain. Preliminary evaluation led to the provisional diagnosis of left-sided intrathoracic mass with vertebral metastasis which was suspected to be a case of bronchogenic carcinoma with distant metastasis. Surprisingly, transthoracic biopsy and histopathology revealed metastasis from follicular carcinoma of thyroid. This prompted us for a retrograde evaluation for a primary thyroid malignancy for which an ultrasound and contrast enhanced computed tomography (CECT) of the neck was done which confirmed the presence of a solitary thyroid nodule. Ultrasonography-guided fine-needle aspiration cytology of the nodule revealed follicular carcinoma of thyroid. Histopathological evaluation subsequent to total thyroidectomy revealed follicular carcinoma thyroid, further confirming the diagnosis. The patient was then referred to Department of Nuclear Medicine and Radiotherapy for radionuclide ablation and chemotherapy. We chose to report this case because of its rare presentation as a large intrathoracic mass and the retrograde diagnosis of follicular carcinoma of thyroid. To the best of our knowledge, this is the first report of such a rare case.
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Intrathoracic Castleman's disease: “An important clinical mimicker” p. 197
Rajendra Prasad Takhar
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Eggshell calcification p. 200
Manu Madan, Richa Mittal, Pawan Gupta, Sunil K Chhabra
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Bronchoscopic management of critical central airway obstruction by thyroid cancer: Combination airway stenting using tracheal and inverted-Y carinal self-expanding metallic stents p. 202
Karan Madan, Prajowl Shrestha, Rakesh Garg, Vijay Hadda, Anant Mohan, Randeep Guleria
Central airway obstruction (CAO) can result from various benign and malignant etiologies. Anaplastic thyroid cancer (ATC) is the most aggressive form of thyroid cancer. Rapid airway compromise is the main cause of death in ATC. We report a patient with ATC who presented with a large neck mass leading to CAO with long segment tracheal and right main bronchial compression and respiratory failure. Urgent Rigid Bronchoscopy was performed for airway stabilization and patient was managed with a combination airway stenting approach. A combination of self expanding, metallic, covered inverted Y and straight tracheal stents was used to stabilize the near complete airway structure. We herein highlight the role of therapeutic rigid bronchoscopy with airway stenting as an efficacious treatment modality for management of malignant CAO.
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Hereditary hemorrhagic telangiectasia with hemothorax in pregnancy p. 206
Sagar Raiya, Amita Athavale, Jairaj Nair, Hemant Deshmukh
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Bronchoscopic instillation of liposomal amphotericin B in management of nonresponding endobronchial mucormycosis p. 208
Loganathan Nattusamy, Umasankar Kalai, Vijay Hadda, Anant Mohan, Randeep Guleria, Karan Madan
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Pulmonary inflammatory pseudotumor with jaundice and anemia: A case report p. 210
Avradip Santra, Abhishek Bandyopadhyay, Amitabha Sengupta, Saibal Mondal
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Hoarseness of voice as presenting complaint of idiopathic pulmonary arterial hypertension p. 212
Rajiv Garg, Anubhuti Singh, Kamal Kumar Sawlani, Ashwini Kumar Mishra
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Mapleson D continuous positive airway pressure system for weaning of mechanical ventilation in pediatric patients p. 215
Anirban Mandal, Puneet Kaur Sahi
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Mapleson D continuous positive airway pressure system for weaning of mechanical ventilation in pediatric patients: In response p. 216
Miguel Angel Palomero Rodriguez, Héctor Chozas de Arteaga, Yolanda Laporta Báez, Jesús de Vicente Sánchez, Antonio Pérez Ferrer
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Author's reply to concern on excessive dynamic airway collapse and wheeze p. 217
Girish Sindhwani, Rakhee Sodhi
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Methodological issues in article titled, “Prevalence and correlates of nicotine dependence among construction site workers: A cross-sectional study in Delhi” p. 218
MD Bashar
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Erratum: Mechanisms of hypoxemia p. 220

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