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   Table of Contents - Current issue
Coverpage
November-December 2019
Volume 36 | Issue 6
Page Nos. 473-570

Online since Thursday, October 31, 2019

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EDITORIAL  

Vitamin D in chronic obstructive pulmonary disease and asthma in Indian population p. 473
Sanjeev Kumar Gupta, Sathiyamoorthy Ramadass
DOI:10.4103/lungindia.lungindia_458_19  PMID:31670293
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ORIGINAL ARTICLES Top

Hypersensitivity pneumonitis: Clinical manifestations – Prospective data from the interstitial lung disease-India registry Highly accessed article p. 476
Sheetu Singh, Bridget F Collins, Bharat B Sharma, Jyotsana M Joshi, Deepak Talwar, Sandeep Katiyar, Nishtha Singh, Lawrence Ho, Jai K Samaria, Parthasarthi Bhattacharya, Sudhir Chaudhari, Tejraj Singh, Khushboo Pilania, Sudhakar Pipavath, Jitesh Ahuja, Ravindran Chetambath, Aloke G Ghoshal, Nirmal K Jain, HJ Gayathri Devi, Surya Kant, Parvaiz Koul, Raja Dhar, Rajesh Swarnakar, Subodh K Katiyar, Arpita Jindal, Daya K Mangal, Virendra Singh, Ganesh Raghu
DOI:10.4103/lungindia.lungindia_263_19  PMID:31670294
Context: Multiple environmental factors are associated with development of hypersensitivity pneumonitis (HP), and diagnostic algorithms for the diagnosis of HP have been proposed in recent perspectives. Aims: We analyzed the data of patients with HP from interstitial lung disease (ILD)-India registry. The analysis was performed to (1) find the prevalence of HP, (2) reclassify HP as per a recently proposed classification criterion to assess the level of diagnostic certainty, and (3) identify the causative agents for HP. Setting and Designs: This was a prospective multicenter study of consecutive, consenting adult patients with new-onset ILD from 27 centers across India (March 2012–April 2015). Materials and Methods: The diagnoses were based on prespecified working clinical criteria and multidisciplinary discussions. To assess strength of diagnosis based on available clinical information, patients with HP were subclassified into definite HP, HP with high level of confidence, and HP with low level of confidence using a recent classification scheme. Results: Five hundred and thirteen of 1084 patients with new-onset ILD were clinically diagnosed with HP and subclassified as HP with high level of confidence (380, 74.1%), HP with low level of confidence (106, 20.7%), and definite HP (27, 5.3%). Exposures among patients with HP were birds (odds ratios [OR]: 3.52, P < 0.001), air-conditioners (OR: 2.23, P < 0.001), molds (OR: 1.79, P < 0.001), rural residence (OR: 1.64, P < 0.05), and air-coolers (OR: 1.45, P < 0.05). Conclusions: About 47.3% of patients with new-onset ILD in India were diagnosed with HP, the majority of whom were diagnosed as HP with a high level of confidence. The most common exposures were birds, cooling devices, and visible molds.
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Effects of genetic polymorphisms in Vitamin D metabolic pathway on Vitamin D level and asthma control in South Indian patients with bronchial asthma p. 483
Manju Rajaram, Sandhiya Selvarajan, Revathy Neelamegan, Sadishkumar Kamalanathan, Vikneswaran Gunaseelan, Alphienes Stanley Xavier, Saibal Das, Vignesh Karthikeyan, Vinodkumar Saka, Adithan Chandrasekaran
DOI:10.4103/lungindia.lungindia_23_19  PMID:31670295
Objectives: The study was designed to evaluate the single-nucleotide polymorphisms (SNPs) of genes involved in Vitamin D actions (rs2228570) and metabolic pathways (rs2248137 and rs10766197) and their associations with serum 25-hydroxy Vitamin D (25(OH)D) level and asthma control in South Indian patients with bronchial asthma. Materials and Methods: One hundred and two patients of South Indian origin with bronchial asthma either naive to inhaled corticosteroids (ICSs) or not receiving ICS for ≥1 month were included and were treated with ICS (beclomethasone 200 μg twice daily) for 8 weeks. One hundred and one unrelated healthy South Indians were used as controls. Pulmonary function test and fractional exhaled nitric oxide were used to assess asthma control. Serum 25(OH)D levels (chemiluminescence immunoassay) and SNPs in Vitamin D pathway (real-time polymerase chain reaction) were assessed. The associations of SNPs and serum 25(OH)D with asthma control was determined using linear regression. All analyses were performed using SPSS (version 19) and “SNPStats.” P < 0.05 was considered as statistically significant. Results: Vitamin D receptor (VDR) polymorphism (rs2228570) was found to be protective against asthma (P = 0.022), while there were no significant associations between the other two SNPs and asthma. Similarly, poor correlation and insignificant associations between the SNPs and serum 25(OH)D levels were observed in both cases and controls. There were also insignificant associations between the SNPs and asthma control. Conclusion: VDR polymorphism (rs2228570) was found to be protective against asthma in South Indians, while other genes involved in the metabolic pathway of Vitamin D did not show associations with asthma.
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Should vitamin D be routinely checked for all chronic obstructive pulmonary disease patients? p. 492
Navin Kumar Mishra, Jai Kishan Mishra, GN Srivastava, D Shah, M Rahman, NA Latheef, A Maurya, Bhupendar K Rajak
DOI:10.4103/lungindia.lungindia_141_19  PMID:31670296
Aims and Objectives: This study aimed to compare the vitamin D levels between chronic obstructive pulmonary disease (COPD) patients and healthy controls and to describe the correlation between vitamin D levels and lung functions. Methods: Fifty COPD patients (cases) and 30 healthy volunteers (controls) were recruited and their serum vitamin D level was measured together with lung function (forced vital capacity and forced expiratory volume in 1 s [FEV1]) by spirometry. vitamin D was categorized as ≤20 nmol/l: deficient, 21–50 nmol/l: inadequate, and ≥51 nmol/l as sufficient. Results: In this case–control cross-sectional study, lower vitamin D levels were associated with lower lung function in both cases as well as controls, the effect being more pronounced in cases. Mean FEV1 at vitamin D ≤20 nmol/l (0.98 ± 0.40 vs. controls 1.93 ± 0.24 with P = 0.006), mean FEV1 at vitamin D 21–50 nmol/l (1.55 ± 0.54 vs. 2.20 ± 0.31 with P = 0.000), and mean FEV1 at vitamin D ≥51 nmol/l (2.06 ± 0.54 vs. 2.20 ± 0.31 with P = 0.002). Moreover, the severity of predicted postbronchodilator FEV1% was also much lower among COPD cohort versus healthy volunteers (mean FEV1%: cases 47.88 ± 14.22 vs. controls 58.76 ± 15.05 with P = 0.002). Conclusions: Importantly, lung function in both the groups was affected by decreased vitamin D level; decrease in FEV1 was more pronounced among COPD patients compared to controls showing more expiratory airflow limitation. Vitamin D levels are associated with changes in lung function in cases of COPD as well as healthy controls. Larger studies to confirm the association in Indian context are required and routine assessment of vitamin D may be undertaken to obviate the effects of low vitmain D level on lung function.
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Predictors of obesity hypoventilation syndrome among patients with sleep-disordered breathing in India p. 499
Mahismita Patro, Dipti Gothi, Umesh Chandra Ojha, Sameer Vaidya, Ram Babu Sah
DOI:10.4103/lungindia.lungindia_61_19  PMID:31670297
Introduction: No study has been done in India to evaluate obesity hypoventilation syndrome (OHS) among patients with sleep-disordered breathing (SDB). The known predictors of OHS, i.e., body mass index (BMI) >35 kg/m2 and forced vital capacity (FVC) <3.5 L for men and <2.3 L for women from western countries, cannot be applied to Indian patients. Objectives: To find out the prevalence of OHS and to determine the predictors of OHS among Indian SDB patients. Materials and Methods: It was a retrospective observational study conducted in a tertiary care institute from September 1, 2017, to August 31, 2018. All the patients who underwent polysomnography were analyzed for the presence of OHS. Of 85 patients referred for polysomnography, 76 had SDB. Thirteen patients were excluded because of hypoventilation due to other known causes or could not perform spirometry. Results: The prevalence of OHS among SDB after excluding the other causes of hypoventilation was 15.87% (10/63). The predictors were determined using univariate analysis between daytime partial pressure of carbon dioxide (PaCO2) and other predictors. PaCO2 significantly correlated with minimum nocturnal oxygen saturation by pulse oximetry (SpO2), FVC %predicted, BMI, daytime SpO2, forced expiratory volume %predicted, and partial pressure of oxygen (PaO2). Following a stepwise multiple regression, minimum nocturnal SpO2, FVC %predicted, and BMI were found to be independent predictors of OHS. A minimum nocturnal SpO2 threshold of 60%, FVC %predicted <74.5%, BMI >30.95 kg/m2, and absolute FVC <2.33 L for men and <1.68 L for women were found to be predictors of OHS. Conclusion: The prevalence of OHS in Indian patients is similar to Caucasians. OHS is seen in Indian patients even at a lower BMI and lower spirometric parameters.
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Predictors and microbiology of ventilator-associated pneumonia among patients with exacerbation of chronic obstructive pulmonary disease p. 506
Gopi C Khilnani, Dilip Dubey, Vijay Hadda, Satya Ranjan Sahu, Seema Sood, Karan Madan, Pawan Tiwari, Saurabh Mittal, Anant Mohan, Ravindra M Pandey, Randeep Guleria
DOI:10.4103/lungindia.lungindia_13_19  PMID:31670298
Background: Understanding the risk factors and microbiology of ventilator-associated pneumonia (VAP) among patients with chronic obstructive pulmonary disease (COPD) is important for the application of preventive and therapeutic interventions. Therefore, this study was planned to assess the clinical predictors and microbiological features of VAP among COPD patients. Materials and Methods: This prospective study involved patients with exacerbation of COPD who required mechanical ventilation and admitted in respiratory intensive care unit at a tertiary care teaching hospital. Various baseline demographic and clinical features were compared between patients with VAP and without VAP. Univariate and multivariable analyses were done to assess the impact of demographic and clinical features on the development of VAP. Results: The study included 100 intubated patients with age (mean ± standard deviation [SD]) of 62.45 ± 8.32 years, duration (median) of COPD of 6 years, and Acute Physiology, Age, and Chronic Health Evaluation score (mean ± SD) of 18.60 ± 4.30. In this cohort, 17 patients developed VAP. Multivariable analysis showed that Sequential Organ Failure Assessment (SOFA) score at admission, re-intubation, and history of previous hospitalization were independent predictors of VAP with odds ratio (95% confidence interval) of 2.70 (1.24, 5.63; P = 0.012), 66.96 (4.86, 922.72; P = 0.002), and 35.92 (2.84, 454.63; P = 0.006), respectively. Acinetobacter baumannii was the most frequent organism (n = 8; 47%), followed by Klebsiella pneumoniae (n = 5; 29%), Pseudomonas aeruginosa (n = 1; 6%), and Enterobacter spp. (n = 1; 6%). All organisms were multidrug resistant (MDR). Conclusions: SOFA score at admission, re-intubation, and history of previous hospitalization were independent predictors of VAP. Antimicrobial therapy for VAP should cover MDR Gram-negative organisms.
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Suboptimal compliance to aerosol therapy in pediatric asthma: A prospective cohort study from Eastern India p. 512
Rajasree Sinha, Sandeep Lahiry, Sibarjun Ghosh
DOI:10.4103/lungindia.lungindia_343_18  PMID:31670299
Background: Suboptimal compliance to aerosol medication is common in pediatric asthma. Accordingly, the objective of this study is to assess noncompliance to aerosol therapy in childhood asthma and determine contributory factors. Materials and Methods: A prospective cohort study was conducted among pediatric patients attending asthma clinic. Patients (n = 215) having “mild” and “moderate” asthma severity rating were included. The total study duration was 12 months (June 2016–June 2017), with an active recruitment phase of 6 months. The minimum period for follow-up was 90 days. Caregivers were instructed to maintain an “asthma diary” for daily dosages of inhalers. At follow-up, the diary entries were corroborated with the amount of inhaler medication unused. Subsequently, medication compliance ratio (CR) was calculated according to the following formula: CR = number of medication doses taken/number of medication doses prescribed. CR% >80 was considered as “good compliance”. Results: A total of 169 patients (78.6%) returned for follow-up. The mean compliance to asthma medication was suboptimal (75.3%). The children were primarily prescribed inhaled corticosteroids and short-acting beta-agonist (SABA)-based regimens on index visit. Leukotriene receptor antagonist was added in select cases (67.9%). Nearly 45.6% of the patients had “good compliance.” CR correlated with the sociodemographic profile and disease severity. Higher socioeconomic status and proper inhaler technique reflected better symptom control. Fear of side effects, behavioral difficulties, and economic restrictions were the identified causes of medication default. Conclusion: In the Eastern part of India, compliance to aerosol therapy in pediatric asthma is suboptimal. Sociodemographics, disease severity, and inhaler technique are important determinants.
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Prospective 1-year follow-up study of all cured, new sputum smear positive tuberculosis patients under the Revised National Tuberculosis Control Program in Hyderabad, Telangana State, India p. 519
Neeta Mathur, Chakrapani Chatla, Saba Syed, Yogesh Patel, Snigdha Pattnaik, Dilip Mathai, Adepu Rajesham
DOI:10.4103/lungindia.lungindia_143_19  PMID:31670300
Background: Tuberculosis (TB) is one of the leading causes of mortality in India. The Revised National Tuberculosis Control Program (RNTCP) is a robust public health system to deal with TB in India. Unless the treated patient comes back to the system with signs and symptoms of TB due to relapse or re-infection, there is no mechanism of follow-up or any method to know the relapse rate in the population. We attempted to follow the patients declared as “Cured” as per the RNTCP guidelines for 1–2 years to identify the health status of the index cases and their household contacts in posttreatment phase. Materials and Methods: In this prospective cohort study, 187 index cases, who were declared “Cured” in six randomly selected TB units of Hyderabad district, were followed up for 1–2 years through home visits by trained staff with structured data collection forms. Data were analyzed using SPSS v20.0. Results: The mean age of the index cases was 33.64 (±16.10) years, and there were 75 females and 112 males. The study sample was homogenous for gender, age, smear grade, religion, marital status, smoking status, alcohol consumption, and human immunodeficiency virus status, etc., At 1-year posttreatment follow-up of 187 index cases, 143 (76.47%) were healthy and working without any symptoms of TB. Symptoms of TB were present in 26 (13.90%) cases, and seven index cases (4.06%) were re-diagnosed with TB. The 2-year posttreatment survival was 92%. Conclusion: Long-term follow-up of cured, new smear-positive TB cases reinforce the effectiveness of anti-TB treatment under the RNTCP as assessed by improved health outcomes in more than two-thirds of cases and posttreatment survival of 92% of index cases. We recommend continuing such follow-up for all TB cases treated under the RNTCP for effective end-TB strategy.
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REVIEW ARTICLE Top

Management of community-acquired bacterial pneumonia in adults: Limitations of current antibiotics and future therapies Highly accessed article p. 525
Sandeep Nayar, Ashfaq Hasan, Pradyut Waghray, Srinivasan Ramananthan, Jaishid Ahdal, Rishi Jain
DOI:10.4103/lungindia.lungindia_38_19  PMID:31670301
Community-acquired bacterial pneumonia (CABP) is one of the leading causes of morbidity and mortality in India and worldwide. Evidence indicates that Gram-positive, Gram-negative, and atypical bacteria are encountered with near-equal frequency. Despite guideline recommendations and antibiotic options for the management of CABP, burden of morbidity and mortality is high, which is attributable to a variety of factors. Failure of empirical therapy, probably because of insufficient microbial coverage, increasing bacterial resistance, and adverse effects of existing treatments, underlies the unsuccessful treatment of CABP, especially in India. Multiple novel therapies that have entered clinical development phases have potential to address some of these issues. This article discusses the current treatment guidelines in CABP, management limitations, and emerging potential treatment options in the management of CABP.
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CASE REPORTS Top

Warfarin-induced diffuse alveolar hemorrhage: Case report and a review of the literature p. 534
Shekhar Kunal, Rajeev Bagarhatta, Sheetu Singh, Sohan Kumar Sharma
DOI:10.4103/lungindia.lungindia_8_19  PMID:31670302
Diffuse alveolar hemorrhage (DAH) refers to the intra-alveolar accumulation of blood originating from the pulmonary microvasculature. This life-threatening condition is a medical emergency as patients often develop acute respiratory failure requiring invasive mechanical ventilation. This mandates for an early diagnosis with prompt and aggressive management strategies. A host of clinical disorders are known to cause DAH; however, warfarin-induced alveolar hemorrhage is a distinct clinical rarity. A search of the literature reveals few reports documenting this entity. A 27-year-old male presented with complaints of recent-onset hemoptysis and dyspnea. One month back, he was diagnosed with lower-limb deep-venous thrombosis and pulmonary embolism. He had been taking oral anticoagulants irregularly since then without monitoring of prothrombin time. Chest radiograph, done on presentation, revealed bilateral upper-lobe infiltrates, whereas computed tomography of the chest was suggestive of bilateral upper-lobe ground-glass opacities. Serial bronchoscopic alveolar lavage yielded samples which became progressively bloodier, whereas cytological evaluation of the sample revealed numerous alveolar macrophages with intracytoplasmic hemosiderin. A diagnosis of DAH due to warfarin was made, and the patient was administered Vitamin K followed by infusion of fresh frozen plasma. There was a marked clinical recovery, and the patient has been asymptomatic since then.
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Removal of lung lavage fluid during whole-lung lavage using biphasic cuirass ventilation chest percussion in a patient with autoimmune pulmonary alveolar proteinosis p. 540
Kei Nakamura, Satoko Omura, Koichiro Kajiura, Masanobu Ishigaki
DOI:10.4103/lungindia.lungindia_289_18  PMID:31670303
Autoimmune pulmonary alveolar proteinosis (PAP) is a rare lung disease. Although recombinant human granulocyte macrophage colony-stimulating factor (GM-CSF) therapy has emerged as a new therapeutic modality, whole-lung lavage (WLL) with manual chest percussion has been a standard therapy in advanced cases. The application of biphasic cuirass ventilation (BCV) instead of chest percussion has rarely been reported. We describe the case of a patient with advanced PAP who recovered well in both lungs, without complication, after we performed WLL with BCV under anesthetic mechanical ventilation. Both radiographical chest findings and clinical symptoms were improved, and oxygen therapy was finally withdrawn. This case illustrates that BCV can enhance the effective removal of lavage fluid and is an alternative to manual percussion.
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Pulmonary T-cell lymphoma masquerading as eosinophilic pneumonitis p. 543
Najam Siddiqui, Kevin Charles, Ashley E Ferraro, Robert C Holladay, Jeremy C Johnson, Satish Kalanjeri
DOI:10.4103/lungindia.lungindia_43_19  PMID:31670304
Primary pulmonary T-cell lymphoma is an unusual subtype of peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS). This is a general term used to describe a diverse group of T-cell-type lymphomas that would otherwise not be classified as a PTCL. Among non-Hodgkin's lymphomas, PTCL accounts for 12% of cases. PTCL-NOS accounts for approximately 25% of all PTCL cases. Primary pulmonary T-cell lymphoma is associated with unfavorable outcomes and has a poor prognosis. Being a rare disease, epidemiological data regarding primary pulmonary T-cell lymphoma continues to be sparse at this time. We present a case of PTCL, which was misdiagnosed as eosinophilic pneumonitis (EP) based on samples obtained from transbronchial cryobiopsy. To our knowledge, this is the first reported case of PTCL masquerading as EP.
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Pulmonary alveolar microlithiasis: A rare disease treated with lung transplantation, first case from India p. 546
Apar Jindal, Vijil Rahulan, Govini Balasubramani, Prabhat Dutta, Sandeep Attawar
DOI:10.4103/lungindia.lungindia_50_19  PMID:31670305
Pulmonary alveolar microlithiasis (PAM) is a rare autosomal recessive condition characterized by widespread alveolar deposition of calcium microliths. A mutation in the SLC34A2 gene in the alveolar Type II pneumocytes is responsible for decreased phosphate clearance and accumulation of calcium as spherules in the alveoli. The presence of this gene in other organs is responsible for the systemic phenotype of the disease. PAM is characterized by the lack of defining symptoms such as cough and progressive dyspnea until it reaches the stage of cor pulmonale and presents with features of respiratory and right ventricular (RV) failure. Radiologically, it is characterized by intense calcification in the lung parenchyma producing specific signs such as the “sandstorm appearance” in the early stages to the “white out lung” with “black pleura sign” in the later stages of the disease. While conventional therapy has not been successful at treatment, bilateral lung transplantation offers to be the only effective remedy. In this report, we present the case of a 54-year-old female who presented in the stage of respiratory and RV failure, with oxygen and noninvasive ventilation (NIV) dependence. She was treated with bilateral lung transplantation. Postoperatively, she was monitored closely for immunosuppression, prophylactic anti-infective measures, and bronchoscopies to evaluate for airway complications. The patient gradually improved and was discharged from the hospital without any need for oxygen or NIV.
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“Necklace in the lung:” Multilocularis hydatid cyst mimicking left-sided massive pleural effusion p. 550
Jyoti Bajpai, Ayush Jain, Avishek Kar, Surya Kant, Darshan Kumar Bajaj
DOI:10.4103/lungindia.lungindia_76_19  PMID:31670306
Massive pleural effusions are commonly caused by malignancy, parapneumonic effusion, and tuberculosis. Parasitic infections are rare causes of massive pleural effusion. Echinococcosis or hydatid disease is a major public health problem in poor hygienic environments. The liver and lungs are the most frequently involved organs. Pulmonary disease appears to be more common in younger individuals. Echinococcus multilocularis causes alveolar echinococcosis, which accounts for <5% of all cases of hydatid liver disease and less frequently lung disease. Here, we present an unusual case of multilocular pulmonary hydatid cysts mimicking massive pleural effusion in a 25-year-old young male.
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COMMENTARY Top

An “Orphan” in search of a treatment: Pulmonary alveolar microlithiasis p. 553
Manjit Sharad Tendolkar
DOI:10.4103/lungindia.lungindia_437_19  PMID:31670307
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GENERAL PERSPECTIVE Top

Interpreting very low Mycobacterium tuberculosis detected on Xpert Mycobacterium tuberculosis/rifampicin p. 555
Kanchan Ajbani, Swapna Naik, Mubin Kazi, Anjali Shetty, Camilla Rodrigues
DOI:10.4103/lungindia.lungindia_463_18  PMID:31670308
The development and rollout of the Xpert® Mycobacterium tuberculosis/rifampicin assay for the GeneXpert platform is considered an important breakthrough in the fight against tuberculosis. Xpert though robust is known to have issues that occur with very low load of tuberculosis detection, wherein it is recommended to confirm resistance if resistance is not suspected using another genotypic test.
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PICTORIAL QUIZ Top

A young male with hemoptysis p. 558
Saurabh Mittal, Karan Madan, Anant Mohan, Vijay Hadda
DOI:10.4103/lungindia.lungindia_165_19  PMID:31670309
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CASE LETTERS Top

The sandwiched pleural effusion p. 560
Kavitha Venkatnarayan, Rishabh Raj, Uma Maheswari Krishnaswamy, Priya Ramachandran, Uma Devaraj, Anuradha Ananthamurthy
DOI:10.4103/lungindia.lungindia_122_19  PMID:31670310
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Acute pain abdomen after bronchial artery embolization p. 562
Kavitha Venkatnarayan, Senthil Dhanasekaran, Uma Maheswari Krishnaswamy, Priya Ramachandran, Uma Devaraj, Abhinandan Ruge
DOI:10.4103/lungindia.lungindia_151_19  PMID:31670311
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Patent foramen ovale: Connecting dots from massive pulmonary embolism to acute ischemic stroke p. 564
Ka U Lio, Maruti Kumaran, Parth Rali
DOI:10.4103/lungindia.lungindia_276_19  PMID:31670312
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LETTERS TO EDITOR Top

Use of Venturi to prevent desaturation during nebulization p. 567
Wasimul Hoda, Brajesh Kumar Ratre, Sachidanand Jee Bharti
DOI:10.4103/lungindia.lungindia_96_19  PMID:31670313
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Acute cardiogenic shock with paclitaxel use in a lung carcinoma patient p. 568
Shouvik Choudhury, Suparna Chatterjee, Sampath B K Pulakhandam
DOI:10.4103/lungindia.lungindia_298_19  PMID:31670314
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Saiphoklang et al.'s home mechanical ventilation in a developing country: What else can be done for an improved future program? p. 570
Habib Md Reazaul Karim, Antonio M Esquinas
DOI:10.4103/lungindia.lungindia_198_19  PMID:31670315
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