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   Table of Contents - Current issue
Coverpage
September-October 2020
Volume 37 | Issue 5
Page Nos. 379-466

Online since Monday, August 31, 2020

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EDITORIALS  

With gain and gratitude, I am retiring Highly accessed article p. 379
Virendra Singh
DOI:10.4103/lungindia.lungindia_682_20  PMID:32883894
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Management of lung cancer during the COVID-19 pandemic: Practical solutions for resource-constrained settings from adaptions of an international consensus Highly accessed article p. 381
Navneet Singh
DOI:10.4103/lungindia.lungindia_379_20  PMID:32883895
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ORIGINAL ARTICLES Top

Comparison of spray catheter with “spray-as-you-go” technique for airway anesthesia during flexible bronchoscopy – A randomized trial p. 384
Kavitha Venkatnarayan, Uma Devaraj, Uma Maheswari Krishnaswamy, Priya Ramachandran, Tinku Thomas, George D’Souza
DOI:10.4103/lungindia.lungindia_528_19  PMID:32883896
Background: Administration of local airway anesthesia is the principal determinant of procedural comfort during flexible bronchoscopy. However, the ideal method of administration is still unknown. In this study, we compared lignocaine administration using a spray catheter (SC) with “spray-as-you-go” technique. Methods: Patients undergoing bronchoscopy were randomized to receive airway anesthesia with 2% lignocaine through the SC (SC group) or “spray-as-you-go” technique through the working channel (WC group). The primary outcome parameter was cough count, and the secondary outcome parameters compared were need for sedation, operator-rated procedural satisfaction and cough, and patient-rated comfort on a Visual Analog Scale (VAS). Results: One hundred and thirty patients were randomized with comparable baseline parameters. The median (interquartile range [IQR]) cough count was 28 (19, 37) in the WC group and 15 (9, 23) in the SC group (P < 0.001). Requirement for sedation was lower in the SC group (5 vs. 18; P = 0.003). The mean (standard deviation [SD]) VAS score for operator-rated satisfaction was 66.5 (16.8) in the WC group and 80.6 (14.2) in the SC group; P < 0.001. The median (IQR) VAS score for operator-rated cough was 35 (23, 44) in the WC group and 18 (11, 28) in the SC group; P < 0.001. However, there was no difference in the patient-rated comfort VAS (mean [SD] of 66.4 [14.5] in the WC group and 69.9 [13.0] in the SC group; P = 0.07). Conclusion: Lignocaine instillation using the SC during bronchoscopy reduced cough, need for sedation, and improved operator satisfaction.
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Microbiological profile of tubercular and nontubercular empyemas and its impact on clinical outcomes: A retrospective analysis of 285 consecutively operated cases p. 389
Mohan Venkatesh Pulle, Belal Bin Asaf, Arvind Kumar, Harsh Vardhan Puri, CL Vijay, Sukhram Bishnoi
DOI:10.4103/lungindia.lungindia_553_19  PMID:32883897
Background: Empyema thoracis is an entity seen across all age groups. This study aims at reporting a detailed microbiological profile of “pus and pleural tissue” in patients operated for empyema thoracis and also correlating it with perioperative clinical outcomes. Materials and Methods: Patients operated for empyema thoracis between 2012 and 2016 were included in the study. Patients were taken up for surgery after thorough preoperative evaluation. Perioperative outcomes were correlated with the results of microbiological analysis to evaluate their effect on clinical outcomes. Results: In the study, 285 patients were operated. There were 215 males (75.4%) and 70 females (24.6%). Tuberculosis (TB) was responsible for 58.2% of the cases (n = 166). Of 166, 32 patients were mycobacterial culture positive, suggesting 19.28% mycobacterial culture positivity rate. 21.8% of the total mycobacterial cultures were multidrug resistant. TB culture-positive patients had a significantly higher incidence of air leak (P = 0.03), inter-costal drain (ICD) duration (P = 0.03), and higher rates of recurrence (P = 0.03). Nontubercular empyema constituted 119 cases (41.8%). Forty-seven (39.5%) cases were culture positive. Gram-negative organisms were cultured in 30 (63.8%). Pseudomonas aeruginosa was the predominant isolate. Bacterial culture-positive patients had significantly higher conversions (P = 0.03), prolonged postoperative air leak (P = 0.04), and postoperative wound infections. Conclusions: This study highlights the emergence of Gram-negative organisms in bacterial empyema and emergence of multidrug resistance in tubercular empyema. Clinical outcome correlation revealed increased complications in culture-positive cases in both tubercular and nontubercular empyemas.
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Comparison of fractional exhaled nitric oxide, spirometry, and Asthma Control Test, in predicting asthma exacerbations: A prospective cohort study p. 394
Chandrashekar Y Kriti, Aswini K Mohapatra, Mohan K Manu, Asha Kamath
DOI:10.4103/lungindia.lungindia_546_19  PMID:32883898
Context: Fractional exhaled nitric oxide (FeNO) is a noninvasive test for airway inflammation in asthma. The usefulness of FeNO in predicting exacerbations is uncertain. Aims: The study aims to assess and compare the ability of FeNO, spirometry, and asthma control test (ACT) in predicting future exacerbations of asthma and their correlation with each other. Settings and Design: This prospective, cohort study was conducted at the Department of Respiratory Medicine, Kasturba Medical College, Manipal. Materials and Methods: Adult asthma patients of age 18–65 years were included. Patients with a smoking history of >10 pack-years and those in whom spirometry was contraindicated were excluded. Patients who consented underwent FeNO and spirometry. The control of asthma was assessed using the ACT questionnaire. We captured the number of exacerbations in the follow-up period of 4 months. Statistical Analysis Used: Mann–Whitney test was used to compare the utility of FeNO, spirometry, ACT in predicting exacerbations and Spearman's correlation coefficient was used to ascertain the correlation among them. Results: Of 154 study patients, 28% had exacerbations. We found that there was no significant difference in FeNO in patients with and without exacerbations. The median (interquartile range [IQR]) FEV1% in the patients with and without exacerbations were 68 (55–79) and 75 (65–88), respectively (P = 0.013). The median (IQR) ACT score in patients with exacerbations was 12 (10–16) which was significantly lower than in those without exacerbation in whom it was 16 (14–18) (P = 0.003). There was a negative correlation of ACT with FeNO (Correlation coefficient: −0.167, P = 0.038). The median (IQR) FeNO level (ppb) was lower in patients who were on inhaled corticosteroid (ICS) than in the other group values being 22 (14–38) and 30 (17–58), respectively (P = 0.05). Conclusions: In our study, FEV1% and ACT score could predict exacerbations of asthma whereas FeNO could not. FeNO level correlated inversely with ACT score. FeNO level decreased with inhaled corticosteroid usage.
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Transthoracic ultrasonography in patients with interstitial lung disease p. 400
Govind Narayan Srivastava, Aarushi Chokhani, Ashish Verma, Zeeshan Siddiqui
DOI:10.4103/lungindia.lungindia_112_20  PMID:32883899
Background: Transthoracic ultrasonography (TUS) is suggested as a noninvasive, radiation-free method for the assessment of interstitial lung disease (ILD). This study was designed to study TUS features of ILD. Furthermore, possible correlations of these features with parameters of spirometry, arterial blood gas (ABG) analysis and 6-min walk test (6MWT) were assessed. Materials and Methods: Fifty patients with ILD were diagnosed based on history, examination, chest X-ray/high-resolution computed tomography, and spirometry. Each patient underwent 6MWT, ABG analysis, and TUS. TUS was also performed on 20 healthy volunteering controls. Results: The TUS features among patients were B pattern in 40 patients (80.0%, P < 0.001), decreased lung sliding in 22 patients (44.0%, P < 0.001), pleural line thickening in 28 patients (56.0%, P < 0.001), pleural line irregularity in 39 patients (78.0%, P < 0.001) and subpleural changes in 22 patients (44.0%, P < 0.01). Increasing pleural line thickness was inversely correlated with forced vital capacity (FVC) percent predicted (r = −0.345, P < 0.05), pO2 (r = −0.335, P < 0.01), SpO2 at rest (r = −0.444, P < 0.01), 6-min walk distance (6MWD) (r = −0.554, P < 0.001) and distance-saturation product (DSP) (r = −0.572, P < 0.001). Increasing distance between B lines also correlated inversely with FVC percent predicted (r = −0.278), pO2 (r = −0.207), SpO2 at rest (r = −0.170), 6MWD (r = −0.209), and DSP (r = −0.214); however these correlations were not statistically significant (P > 0.05). Conclusion: TUS seems to be a useful imaging method for the diagnosis of ILD. It can be used to estimate the severity of ILD. It is simple, bedside, cost-effective, and radiation-free. It may be especially useful in the follow up of patients in low resource settings, pregnant females, and bed-ridden or unstable patients who cannot be shifted to radiology suite.
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Safety of chronic obstructive pulmonary disease patients undergoing carbon dioxide insufflation in extended endoscopic procedures p. 407
Scott A Helgeson, Kristyn L Lewis, Laurel E Carter, Hollie Saunders, Neal M Patel
DOI:10.4103/lungindia.lungindia_74_20  PMID:32883900
Introduction: Carbon dioxide (CO2) insufflation for endoscopies has been shown to be more comfortable and safe, but only in patients without underlying chronic obstructive pulmonary disease (COPD). The aim of this study was to show that using CO2 is safe in COPD patients. Methods: Patients were retrospectively identified who underwent extended endoscopic procedures during the time period of January 2012 to December 2017. Patients were included if they also had COPD. A matched control group without COPD was created during the same timeframe. All the patients were sedated with continuous monitoring of their CO2 levels by end-tidal CO2 (EtCO2). Results: One hundred and ten patients had COPD and underwent an extended endoscopic procedure. These patients had a higher severity of their comorbidities (American Society of Anesthesiologists class 3 or 4) (93.6% [95% confidence interval [CI], 87.4%–96.9%] vs. 60.3% [95% CI, 51.1%–69.0%]; P < 0.01) and an increase of co-existing obstructive sleep apnea (33.6% vs. 6.3%, P < 0.01). There was no difference in baseline EtCO2, but the peak EtCO2 and postprocedure EtCO2 were both significantly higher in the COPD group. The only postprocedural complication found was an inability to be extubated immediately following the procedure with subsequent need to hospitalize the patient, which occurred in three patients (2.8%; 95% CI, 0.9%–7.9%) in the COPD group and one (0.9%; 95% CI, 0.2%–4.9%) in the non-COPD group (P = 0.37). Conclusion: The present study, which was the only study looking at CO2 insufflation specifically in COPD patients, provides evidence that CO2 insufflation is safe in COPD despite a slight increase in EtCO2.
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Determination of equation for estimating continuous positive airway pressure in patients with obstructive sleep apnea for the Indian population p. 411
Latha Sarma, Nandan Putti, Kapil Alias, Mohit Chilana
DOI:0.4103/lungindia.lungindia_322_19  PMID:32883901
Background: Continuous positive airway pressure (CPAP) is the treatment of obstructive sleep apnea (OSA). The CPAP pressure is generally estimated by manual titration or an auto CPAP device. An alternative method involves the use of the predictive equation. Aim and Objective: There is no equation developed, taking into account the Indian population. The aim is to develop a predictive equation for optimal CPAP pressure in patients with OSA and to validate the equation by comparing it with manual titration pressure. Materials and Methods: A total of 250 patients with OSAS who underwent successful manual titration for CPAP treatment in a tertiary care center were included in this study and divided randomly into two groups A and B with 150 and 100 patients, respectively. Stepwise multiple regression analysis was applied to anthropometric and polysomnographic variables of group A and the predictive equation for estimating CPAP was developed using SPSS. This equation was validated by comparing the estimated pressure with that of manual titration pressure in Group B. Results: The mean age was 55.09 ± 11.43 and mean body mass index (BMI) was 33.69 ± 6.56. CPAP pressure in patients with OSA was 11.13 ± 1.83 cm H2O. The Apnea Hypopnea index (AHI) (r = 0.595, P < 0.001), minimal; SpO2 (r = −0.502, P < 0.001), BMI (r = 0.494, P < 0.001) significantly correlated with optimal CPAP level. A predictive equation for optimal CPAP level in patients with OSA was developed using AHI, BMI, and minimal SpO2, which can be easily measured during the diagnostic process. Optimal CPAP level (cm H2O) =8.401+ (0.053 × BMI) + (0.020 × AHI) − (0.031 × lowest oxygen). Twenty-six percent of the variance in the optimal CPAP level was explained by this equation (R2 = 0.26, P < 0.001) and the equation showed 86% of optimal estimation. Conclusion: The results suggest that manual titration pressure correlates with the pressure derived from the predictive equation in our study.
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Prevalence and profile of sleep-disordered breathing and obstructive sleep apnea in patients with interstitial lung disease at the pulmonary medicine department of a tertiary care hospital in Mumbai p. 415
Ketaki Utpat, Abhishek Gupta, Unnati Desai, Jyotsna M Joshi, Ramesh N Bharmal
DOI:10.4103/lungindia.lungindia_6_20  PMID:32883902
Background: Sleep-disordered breathing (SDB), predominantly obstructive sleep apnea (OSA), is a frequent phenomenon in interstitial lung disease (ILD) and may be associated with significant morbidity and mortality. Methodology: A prospective, observational, hospital-based study was conducted in a tertiary care hospital after ethics committee permission. The study group consisted of 100 consecutive ILD patients diagnosed by a multidisciplinary diagnosis. They were evaluated for the prevalence of SDB with a polysomnography after a comprehensive history, detailed clinical examination, calculation of various pretest probability scores, and relevant prerequisite workup. Results: Out of the total 100 ILD patients, 44 were male (44%) and 56 were female (56%). SDB was present in 57 (57%) patients. Of these, 29 (29%) were found to have only nocturnal oxygen desaturation (NOD), while 28 (28%) had OSA. The 28 cases of OSA were distributed as 15 mild OSA (53.57%), 10 moderate OSA (35.71%), and 3 severe OSA (10.71%). The patients were divided into the following four groups: total study Group (A), patients with OSA (Group B), patients with NOD without OSA (Group C), and no SDB (Group D). The mean forced vital capacity values predicted in the four groups were 53.67%, 50%, 45.56%, and 57.87%, respectively. The mean body mass index in the four groups was 24.56, 27, 26.98, and 24.89 kg/m2, respectively. The mean 6-min walk distance in the four groups was 280.7, 250, 256.65, and 311.4 m, respectively. The mean partial pressure of oxygen in the four groups was 65.65, 60, 62.10, and 75.66 mmHg, respectively. The mean apnea–hypopnea index in the study group was 2.98/h, 8.6/h with mild OSA, 21.69/h with moderate OSA, 48.78/h with severe OSA, 3.89/h in patients having NOD without OSA, and 2.54/h in patients with no SDB. Conclusion: SDB in ILD is associated with a significant impact on the cardinal determinants of functional capacity, lung function, and quality of life.
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REVIEW ARTICLES Top

Respiratory infections: Role of Vitamin D and surfactant proteins A and D p. 421
Rachel Poorna, Niranjan Biswal
DOI:10.4103/lungindia.lungindia_369_18  PMID:32883903
Respiratory tract infection is the common viral infection and the principal cause of death among children under 5 years of age. It damages lung epithelium and increases mucus production and inflammation, leading to dyspnea. The sunshine vitamin (Vitamin D) and surfactant protein (SP) A and D along with their usual function play an important role in host defense. This article reviews with immune role of Vitamin D and SP A and D which aids excessive cytokines production, boosts phagocytosis, hinders inflammatory activity, and thus acts as a first-line defense against lung pathogens.
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Catch the rainbow: Prognostic factor of sarcoidosis p. 425
Senol Kobak
DOI:10.4103/lungindia.lungindia_380_19  PMID:32883904
Sarcoidosis is a systemic, chronic, inflammatory disease characterized by noncaseating granuloma formations. The fact that the etiopathogenesis of the disease has not been elucidated yet brings it many theories and assumptions. Being a systemic disease and ability to involve many organs and systems, it attracts the attention of physicians from different branches. In addition to lung involvement, skin, eye, heart, and locomotor system involvement is an important clinical finding. Sarcoidosis may present with very different clinical presentations, and therefore, it is one of the important “imitators” in the medical literature. I like sarcoidosis as a “rainbow,” it is a disease that contains the characteristics of many diseases. Different clinical, radiological, and laboratory prognostic factors (lupus pernio, chronic uveitis, late-onset disease, chronic hypercalcemia, nephrocalcinosis, Afro-American race, progressive pulmonary sarcoidosis, radiologic Stage 4, bone involvement, neurosarcoidosis, cardiac involvement, and chronic respiratory failure) have been defined in this “rainbow.” Early identification of these factors plays an important role in the determination of treatment strategies, morbidity, and mortality of the disease. In this article, clinical, genetic, laboratory, and radiological factors that determine the prognosis of sarcoidosis are discussed in light of the latest data in the literature.
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CASE REPORTS Top

Rosai–Dorfman disease presenting as internal jugular vein thrombosis and middle lobe collapse-consolidation p. 433
Ambika Sharma, Deepika Hemrajani, Sheetu Singh, Kapil Bhardwaj, Chand Bhandari, RK Jenaw
DOI:10.4103/lungindia.lungindia_150_19  PMID:32883905
Rosai–Dorfman disease, also known as sinus histiocytosis with massive lymphadenopathy, is a rare and benign disease that usually presents as massive and painless cervical lymphadenopathy. We are reporting this rare disease with systemic manifestations and causing internal jugular vein thrombosis and middle lobe collapse-consolidation.
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A red herring, a wild-goose chase, and an unexpected diagnosis of concomitant malignancy and sarcoidosis p. 437
Ponnuthurai Bala, Padmanabhan Arjun, Liju Varghese, SR Sudin, Sandeep Pillai, Cherian Thampy, Shaji Palangadan, KA Biji
DOI:10.4103/lungindia.lungindia_378_19  PMID:32883906
A 49-year-old male was evaluated in our hospital for chronic cough, cervical lymphadenopathy, and a testicular mass. As a part of the management, he underwent a cervical lymph node biopsy, which showed metastatic deposits from papillary carcinoma thyroid. Subsequently, he underwent orchidectomy for suspected testicular malignancy, but the biopsy showed discrete granulomatous inflammation consistent with sarcoidosis. This was followed by total thyroidectomy with neck node dissection. Nodal histopathological examination, this time, revealed a single node containing both malignancy and granulomas. Prior to the thyroid surgery, he underwent a mediastinoscopic sampling of the mediastinal nodes, which also showed granulomatous inflammation consistent with sarcoidosis. Sarcoidosis affecting the genitourinary system is a rare entity. The coexistence of sarcoidosis and thyroid malignancy poses a diagnostic challenge. A thorough review of the literature was done, and there are no reports from India on the above association. This is a unique case, which could possibly suggest an association between sarcoidosis and malignancy and highlights the importance of obtaining a tissue diagnosis in such cases.
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Organizing pneumonia secondary to Pneumocystis jirovecii infection in a kidney transplant recipient: Case report and review of literature p. 441
Rakesh Kodati, Anuradha Tadepalli, Chandana Reddy, Rajasekhara Chakravarthi, Girish Kumthekar, Ravindranath Tagore
DOI:10.4103/lungindia.lungindia_487_19  PMID:32883907
Organizing pneumonia (OP), previously known as bronchiolitis obliterans OP, is a diffuse parenchymal lung disease affecting the distal bronchioles, alveolar ducts, and alveolar walls. Pulmonary infections, especially bacterial and viral diseases, are known to be associated with the secondary form of OP. OP secondary to fungal infections is less common. Here, we report a case of OP associated with pneumocystis pneumonia (PCP) in a kidney transplant recipient on tacrolimus-based triple immunosuppression. The index case had developed new lung consolidation toward the end of trimethoprim-sulfamethoxazole therapy for PCP. Spontaneous clinical and radiographic resolution was seen without any increment in the dose of corticosteroids. We review the literature and present a summary of all reported cases of OP associated with PCP to date.
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Endobronchial capillary hemangioma a rare cause of hemoptysis p. 445
Aditya Kumar Chawla, Gaurav Chaudhary, Manish Aggarwal, Madhav Kumar Chawla, Rakesh Kumar Chawla
DOI:10.4103/lungindia.lungindia_508_19  PMID:32883908
Endobronchial capillary hemangioma is a very rare benign tumor in adults. The clinical presentation and management of adult capillary hemangiomas involving the tracheobronchial tree are not yet established. We present a case of an isolated capillary hemangioma of the right main bronchus detected during the evaluation of an adult male presented with hemoptysis.
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COMMENTARY Top

Lignocaine delivery for topical anesthesia during bronchoscopy: Recent advances p. 449
Karan Madan, Saurabh Mittal, Anant Mohan
DOI:10.4103/lungindia.lungindia_558_20  PMID:32883909
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PICTORIAL CME Top

Pulmonary arteriovenous malformation p. 451
Padmanabhan Arjun, Muhammed Semeer, Manish Kumar Yadav
DOI:10.4103/lungindia.lungindia_539_19  PMID:32883910
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CASE LETTER Top

Obstructive fibrinous tracheal pseudomembrane following tracheal stent placement: An underrecognized entity p. 453
Satya Ranjan Sahu, Karan Madan, Anant Mohan, Saurabh Mittal
DOI:10.4103/lungindia.lungindia_1_20  PMID:32883911
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RESEARCH LETTERS Top

Safety of Rifabutin in patients with rifampicin-induced thrombocytopenia p. 455
Trina Sarkar, Niccolò Riccardi, Haresh Wagh, Zarir F Udwadia
DOI:10.4103/lungindia.lungindia_401_20  PMID:32883912
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Who is an interventional pulmonologist in India? – Time to bell the cat p. 456
Arjun Khanna, Deepak Talwar
DOI:10.4103/lungindia.lungindia_445_20  PMID:32883913
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Virtual bronchoscopy using Horos p. 457
Atsushi Sano
DOI:10.4103/lungindia.lungindia_110_20  PMID:32883914
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Vitamin D, lung functions, and chronic obstructive pulmonary disease: Quod non erat demonstrandum p. 459
Mouna Manjunath, Animesh Ray
DOI:10.4103/lungindia.lungindia_51_20  PMID:32883915
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Lichen scrofulosorum: An uncommon manifestation of a common disease p. 461
Nirmal Chand Kajal, P Prasanth, Ritu Dadra
DOI:10.4103/lungindia.lungindia_125_20  PMID:32883916
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Barrier enclosure device during patient preparation for flexible bronchoscopy p. 463
Inderpaul Singh Sehgal, Sahajal Dhooria, Kuruswamy Thurai Prasad, Valliappan Muthu, Ashutosh Nath Aggarwal, Ritesh Agarwal
DOI:10.4103/lungindia.lungindia_482_20  PMID:32883917
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OBITUARY Top

Prof. Subramanian Chandrasekaran (Prof. SCS) President of Indian Chest Society 1998 p. 465
Vijayalakshmi Thanasekaran
DOI:10.4103/lungindia.lungindia_684_20  PMID:32883918
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