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   Table of Contents - Current issue
Coverpage
January-February 2019
Volume 36 | Issue 1
Page Nos. 1-90

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EDITORIAL  

In tuberculosis, “one size does not fit all” p. 1
Salil Bhargava, Monika Jain, Manoj Jain
DOI:10.4103/lungindia.lungindia_489_18  PMID:30604697
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ORIGINAL ARTICLES Top

Extrapulmonary drug-resistant tuberculosis at a drug-resistant tuberculosis center, Mumbai: Our experience – Hope in the midst of despair! p. 3
Unnati Desai, Jyotsna M Joshi
DOI:10.4103/lungindia.lungindia_192_18  PMID:30604698
Background: Drug-resistant tuberculosis (DR-TB) is a global problem with only 52% reported cure rate. Extrapulmonary (EP) DR-TB poses a formidable diagnostic, therapeutic challenge. We aimed to study their clinical profile and treatment outcomes under the programmatic setting. Materials and Methods: This retrospective observational study included the database of consecutive EPDR-TB cases enrolled at the DR-TB center from 2012 to 2014. The demographic, clinical details, drug susceptibility tests (DSTs), follow-up, therapy, adverse events (AEs), and outcome were reviewed. Statistical analysis was done using percentages and mean. Results: Of total 1743 DR-TB patients, 76 (4.4%) EPDR-TB cases were included. These consisted of 53 (69.7%) adults and 23 (30.3%) children, with female preponderance. The mean age in adults and children was 27.96 (9.63) and 12.56 (3.83), respectively. EP sites involved were lymph nodes in 39 (51.3%), spine in 15 (19.7%), other bones in 6 (7.9%), pleural effusion in 9 (11.9%), central nervous system in 2 (2.6%), and disseminated EP disease in 5 (6.6%). Forty-one (53.9%) had multi-DR-TB (MDR-TB), 29 (38.2%) MDR-TB with fluoroquinolone resistance {preextensively DR-TB (Pre-XDR-TB (FQ)), 1 (1.3%) MDR-TB with aminoglycoside resistance (Pre-XDR-TB (AM)), and 5 (6.6%) extensively DR-TB (XDR-TB) on DST. Thirteen (17.11%) had comorbidities. None had HIV. Two (2.63%) had DM. Patients were treated as per the revised TB control program – programmatic management of DR-TB guidelines. Duration of intensive (IP) was 6.55 (1.22) months. Ten (13.2%) received shorter regimens, wherein therapy was stopped at 12–18 months due to severe adverse drug reactions and treatment response. Sixty-two (81.6%) completed treatment, 8 (10.5%) defaulted, 3 (4%) died, 2 (2.6%) failed, and 1 (1.3%) was transferred out. Two-third of patients reported AE. Conclusion: The prevalence of EP cases in DR-TB was 4.4%. Treatment completion rate was very high (81.6%). Shorter regimens were efficacious.
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Endovascular glue embolization for control of massive hemoptysis caused by peripheral pulmonary artery pseudoaneurysms: Report of 7 cases p. 8
Suresh Giragani, Ankit Balani, Gangadhar R Mallu, Gopikrishna Yedlapati, Venkata N Maturu, V Lakshman Babu, Surendar Alwala
DOI:10.4103/lungindia.lungindia_458_17  PMID:30604699
Purpose: Pulmonary artery pseudoaneurysms are a rare cause of massive hemoptysis and need to be considered as a differential with prompt recognition preventing mortality from life-threatening hemorrhage. We report the clinical details and imaging findings for a series of patients presenting with massive haemoptysis due to peripheral pulmonary artery pseudoaneurysm, managed by endovascular glue embolization. Methods: Hospital based retrospective study wherein records and image database of patients presenting with massive hemoptysis between January 2014 and March 2016 were studied. The immediate technical success, reintervention rate, and recurrence of massive hemoptysis were recorded. Results: Among patients with massive hemoptysis who underwent endovascular management in our department, seven patients fulfilled the inclusion criteria. The mean age was 54.3 years; mean lesion diameter was 10.8 mm (range 6–14 mm); underlying pathology being infective (tuberculosis) in all cases (n = 7). All lesions were treated with endovascular glue embolization. The technical success was 100%. Mean follow-up was 11.7 months. There was no case of recurrence of massive hemoptysis. There were no major complications with a single case of minor complication (in the form of chest pain and discomfort) which resolved with medical management. Conclusion: The endovascular approach using glue (N-butyl cyanoacrylate) is a minimally invasive and technically feasible, effective technique for emergent management of pulmonary artery pseudoaneurysms presenting as massive hemoptysis.
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Burden of obstructive lung disease study in Iran: First report of the prevalence and risk factors of copd in five provinces p. 14
Hooman Sharifi, Mostafa Ghanei, Hamidreza Jamaati, Mohammad Reza Masjedi, Mohsen Aarabi, Ali Sharifpour, Golnar Radmand, A Sonia Buist
DOI:10.4103/lungindia.lungindia_129_18  PMID:30604700
Background: Chronic obstructive pulmonary disease (COPD) is a global health burden that affects 300 million people worldwide. Globally, COPD was reported as the fourth leading cause of death in 2004 and is projected to occupy the third position in 2030. The goal of the present project is to describe the prevalence and determine the causes and risk factors of COPD in five provinces of Iran. Methods: This study followed a stratified cluster sampling strategy with proportional allocation within strata. The target population is all noninstitutionalized inhabitants, aged 18 and over, who inhabit in different provinces in Iran in the year 2017. The stratification of the sample according to the 31 provinces of Iran is incorporated in the sampling process. The core questionnaire was developed from preexisting validated questionnaires. The single most important outcome measure obtained as part of this protocol was spirometry before and after the administration of 200 mg (two puffs) of salbutamol. Results: The most commonly reported respiratory symptoms were as follows: wheezing (N=217, 20.4%, 95% confidence interval [CI]: 18%–22.8%), sputum production (N=173, 16.5%, 95% CI: 14.3%–18.8%), and dyspnea (N=131, 12.3%, 95% CI: 10.3%–14.3%). The overall COPD prevalence defined by the postbronchodilator spirometric Global Initiative for Chronic Obstructive Lung Disease criteria was 4.9%, higher in men (6.4%) than in women (3.9%). The prevalence of COPD was strongly dependent on smoking status, age, and sex. Conclusion: COPD is considered a preventable disease, and avoidance of exposure to major risk factors can prevent the vast majority of cases. The present study findings add to the literature on the prevalence of COPD in Iran and will help policy-makers, specialists, and all stakeholders to strategize and evaluate medical services required for reducing the prevalence of respiratory diseases. The data from our present study will serve as baseline information for future national and regional studies of COPD.
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Nocturic obstructive sleep apnea as a clinical phenotype of severe disease p. 20
Abhishek Goyal, Abhijit Pakhare, Poonam Chaudhary
DOI:10.4103/lungindia.lungindia_153_18  PMID:30604701
Study Objectives: This study was done to find whether a history of nocturia is associated with severity of obstructive sleep apnea (OSA) and also whether patients with nocturia constitute a separate phenotype of OSA. Materials and Methods: Retrospective chart review was done in consecutive OSA patients who were diagnosed in sleep laboratory of our institute. Detailed sleep history, examination, biochemical investigations, and polysomnography reports were taken for the analysis. Nocturia was defined as urine frequency ≥2/night. Results: Of 172 OSA patients, 87 (50.5%) patients had nocturia. On multivariate analysis, a history of nocturia had 2.429 times (confidence interval 1.086–5.434) more chances of having very severe OSA (P = 0.031). Time between bedtime and first time for urination was significantly less in very severe OSA compared to severe OSA and mild-to-moderate OSA (2.4 ± 0.9, 3.1 ± 1.3, and 3.0 ± 1.1 h, respectively) (P = 0.021). Patients with nocturia were older (52.3 ± 11.9 vs. 47.6 ± 12.1 years; P = 0.012), had higher STOP BANG scores (P = 0.002), higher apnea–hypopnea index (AHI) (64.8 ± 35.9 vs. 43.9 ± 29.1; P < 0.001), and higher Epworth sleepiness scale (ESS) (9.2 ± 5.3 vs. 7.7 ± 4.4; P = 0.052) and were more likely to be fatigued during day (P = 0.001). Nocturics had higher body mass index (BMI) (P = 0.030), higher waist, and hip circumference (P = 0.001and 0.023, respectively). Nocturic patients had lower awake SpO2(P = 0.032) and lower nadir SpO2 during sleep (P = 0.002). Conclusions: A history of nocturia (≥2/night) predicts very severe OSA (AHI >60). Nocturic OSA is a phenotype of OSA with more severe AHI, lower oxygen levels, higher BMI, and higher ESS. We believe nocturia can be used for screening in OSA questionnaires, which needs to be validated in further community-based studies.
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Is it feasible to carry out active case finding for tuberculosis in community-based settings? p. 28
Mercy Mani, Muskura Riyaz, M Shaheena, Saravanan Vaithiyalingam, Velavan Anand, Kalaiselvi Selvaraj, Anil J Purty
DOI:10.4103/lungindia.lungindia_324_18  PMID:30604702
Introduction and Objective: To achieve elimination of tuberculosis by 2025, identifying the remaining 25% of missed cases would play a major role. But there is paucity of evidence on this statement. This study aimed to assess feasibility of active case finding for tuberculosis in selected region of Puducherry. Methods: Community based survey was conducted by groups of trained undergraduate medical students. During January 2018, all residents of study area were assessed for presence of presumptive symptoms related to tuberculosis. Presumptive cases of tuberculosis were identified as per the programme definition and the same were facilitated to undergo follow up necessary investigations to rule out tuberculosis through frequent domiciliary visits. The data collection was done using mobile based Epicollect open access app. Feasibility was assessed using indicators namely household coverage, proportions of presumptive cases identified and undergone follow up investigations, number needed to screen for presumptive and confirmed cases of tuberculosis and average time spent per person. Results: Of the 2252 houses, 1746 were covered resulting in a response rate of 77.5% and included 6606 residents. Of the 55 presumptive cases identified (55/6606) 51 underwent investigations (51/55). Two new cases of tuberculosis were diagnosed in this survey. To identify one presumptive and confirmed case 120, 3303 people need to be screened respectively. Conclusion: Active case finding for tuberculosis is feasible provided the health system is able to invest adequate human resources and referral linkages to support peripheral centres.
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Adverse effects observed in lung cancer patients undergoing first-line chemotherapy and effectiveness of supportive care drugs in a resource-limited setting p. 32
Valliappan Muthu, Badari Mylliemngap, Kuruswamy Thurai Prasad, Digambar Behera, Navneet Singh
DOI:10.4103/lungindia.lungindia_321_17  PMID:30604703
Background: Lung cancer (LC) chemotherapy results in several adverse events (AEs). Data regarding supportive care medications (SCMs) offered to prevent/treat AEs in resource-limited settings are lacking. A prospective observational study was carried out to find the effectiveness of SCMs in real-life setting. Methods: Newly diagnosed LC patients receiving first-line chemotherapy at a tertiary referral center in North India (from July 2014 to September 2015) were enrolled. Incidence, timing of onset, duration, and grades of chemotherapy-related AEs were recorded. We assessed compliance to mandatory SCMs using a structured questionnaire. Patients also recorded various symptoms, frequency of need-based SCMs, visits to local practitioners, and hospitalization (if any) during the intercycle period. Results: Of the 112 patients enrolled, majority were males (83.9%, n = 94), current/ex-smokers (82.1%, n = 92), had advanced stage (Stage IIIB = 33.9% [n = 38] and Stage IV = 46.4% [n = 52]), and were non-small cell lung cancer (72.3%, n = 81). AEs were reported in 566 cycles (94%) out of a total of 602 chemotherapy cycles. Diarrhea was the most common AE (180 cycles, 29.9%) developing after a mean (standard deviation) duration of 3.6 (2.5) days and lasting for 4 (3.3) days. Vomiting (138 cycles, 22.9%) and constipation (121 cycles, 20.1%) were other common AEs. Grade 3/4 AEs occurred in 6.9% (39/566) cycles. Need-based SCMs were required in 479 of the 566 cycles (84.6%). Proportion of patients with Grade 3/4 AEs and hospitalization was highest for mucositis (16.1% Grade 3/4 and 9.7% hospitalized); followed by vomiting (10.1% Grade 3/4 and 8.7% hospitalized). Anemia was seen in 441 of 602 chemotherapy cycles (73.3%). Frequency and severity of anemia continued to increase with each chemotherapy cycle. Conclusion: LC chemotherapy has a high prevalence of AEs. However, the majority are low grade recovering with need-based SCMs, without any need for hospitalization.
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REVIEW ARTICLE Top

Physical signs in patients with chronic obstructive pulmonary disease Highly accessed article p. 38
Malay Sarkar, Rajeev Bhardwaz, Irappa Madabhavi, Mitul Modi
DOI:10.4103/lungindia.lungindia_145_18  PMID:30604704
We reviewed the various physical signs of chronic obstructive pulmonary disease, their pathogenesis, and clinical importance. We searched PubMed, EMBASE, and the CINAHL from inception to March 2018. We used the following search terms: chronic obstructive pulmonary disease, physical examination, purse-lip breathing, breath sound intensity, forced expiratory time, abdominal paradox, Hoover's sign, barrel-shaped chest, accessory muscle use, etc. All types of studies were chosen. Globally, history taking and clinical examination of the patients is on the wane. One reason can be a significant development in the field of medical technology, resulting in overreliance on sophisticated diagnostic machines, investigative procedures, and medical tests as first-line modalities of patient's management. In resource-constrained countries, detailed history taking and physical examination should be emphasized as one of the important modalities in patient's diagnosis and management. Declining bedside skills and clinical aptitude among the physician is indeed a concern nowadays. Physical diagnosis of chronic obstructive pulmonary disease (COPD) is the quickest and reliable modalities that can lead to early diagnosis and management of COPD patients. Bedside elicitation of physical signs should always be the starting point for any diagnosis and therapeutic approach.
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GENERAL PERSPECTIVE Top

Bronchoscopic lung cryobiopsy: An Indian association for bronchology position statement p. 48
Sahajal Dhooria, Ritesh Agarwal, Inderpaul Singh Sehgal, Ashutosh Nath Aggarwal, Rajiv Goyal, Randeep Guleria, Pratibha Singhal, Shirish P Shah, Krishna B Gupta, Suresh Koolwal, Jayachandra Akkaraju, Shankar Annapoorni, Amanjit Bal, Avdhesh Bansal, Digambar Behera, Prashant N Chhajed, Amit Dhamija, Raja Dhar, Mandeep Garg, Bharat Gopal, Kedar R Hibare, Prince James, Aditya Jindal, Surinder K Jindal, Ajmal Khan, Nevin Kishore, Parvaiz A Koul, Arvind Kumar, Raj Kumar, Ajay Lall, Karan Madan, Amit Mandal, Ravindra M Mehta, Anant Mohan, Vivek Nangia, Alok Nath, Sandeep Nayar, Dharmesh Patel, Vallandaramam Pattabhiraman, Narasimhan Raghupati, Pralay K Sarkar, Virendra Singh, Mahadevan Sivaramakrishnan, Arjun Srinivasan, Rajesh Swarnakar, Deepak Talwar, Balamugesh Thangakunam
DOI:10.4103/lungindia.lungindia_75_18  PMID:30604705
Background: Bronchoscopic lung cryobiopsy (BLC) is a novel technique for obtaining lung tissue for the diagnosis of diffuse parenchymal lung diseases. The procedure is performed using several different variations of technique, resulting in an inconsistent diagnostic yield and a variable risk of complications. There is an unmet need for standardization of the technical aspects of BLC. Methodology: This is a position statement framed by a group comprising experts from the fields of pulmonary medicine, thoracic surgery, pathology, and radiology under the aegis of the Indian Association for Bronchology. Sixteen questions on various technical aspects of BLC were framed. A literature search was conducted using PubMed and EMBASE databases. The expert group discussed the available evidence relevant to each question through e-mail and a face-to-face meeting, and arrived at a consensus. Results: The experts agreed that patients should be carefully selected for BLC after weighing the risks and benefits of the procedure. Where appropriate, consideration should be given to perform alternate procedures such as conventional transbronchial biopsy or subject the patient directly to a surgical lung biopsy. The procedure is best performed after placement of an artificial airway under sedation/general anesthesia. Fluoroscopic guidance and occlusion balloon should be utilized for positioning the cryoprobe to reduce the risk of pneumothorax and bleeding, respectively. At least four tissue specimens (with at least two of adequate size, i.e., ≥5 mm) should be obtained during the procedure from different lobes or different segments of a lobe. The histopathological findings of BLC should be interpreted by an experienced pulmonary pathologist. The final diagnosis should be made after a multidisciplinary discussion. Finally, there is a need for structured training for performing BLC. Conclusion: This position statement is an attempt to provide practical recommendations for the performance of BLC in DPLDs.
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CASE REPORTS Top

Cavitary lung disease following transbronchial biopsy using cryoadhesion in a patient with diffuse parenchymal lung disease p. 60
Vikas Pathak, Christine Zhou, Ezmin George
DOI:10.4103/lungindia.lungindia_21_18  PMID:30604706
Transbronchial lung biopsy using cryoadhesion is a diagnostic technique gaining in popularity. Several studies have been performed on its diagnostic yield and safety profile. However, definitive conclusions are limited due to the heterogeneity of results. The most common complications described in the current literature are pneumothorax and hemorrhage. This case describes a 60-year-old female who developed a cavitary lung lesion shortly after undergoing transbronchial lung cryobiopsy, highlighting the need for further research on the rarer complications that may be associated with this promising procedure.
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Intercostal artery pseudoaneurysm in pulmonary tuberculosis – A rare cause of hemoptysis: A case report with review of the literature p. 63
Madhurima Sharma, Manphool Singhal, Rajeev Kamble, Ashish Bhalla, Ujjwal Gorsi, Niranjan Khandelwal
DOI:10.4103/lungindia.lungindia_87_18  PMID:30604707
Pulmonary tuberculosis (TB) is one of the common causes of life-threatening hemoptysis, particularly in developing countries. Bronchial and pulmonary arteries are the major source of hemoptysis in pulmonary TB. Intercostal artery pseudoaneurysm as a cause of hemoptysis in pulmonary TB is extremely rare, with only a few reported cases. We describe a case of intercostal artery pseudoaneurysm in a patient of pulmonary TB, presenting as massive hemoptysis. Computed tomography bronchial angiography (CTBA) revealed a contrast-filled outpouching in a left upper lobe cavity. Catheter angiography revealed a pseudoaneurysm arising from one of the left intercostal arteries, which was managed subsequently by endovascular embolization. Pseudoaneurysm from visceral arteries is an extremely rare but important cause of massive hemoptysis in pulmonary TB, which if not managed promptly may prove fatal.
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Experience of the first lung transplantation performed in public sector in India p. 66
Kuruswamy Thurai Prasad, Inderpaul Singh Sehgal, Sahajal Dhooria, Ritesh Agarwal, Rana Sandip Singh, Harkant Singh, Goverdhan Dutt Puri, Virendra Kumar Arya, Digambar Behera, Ashutosh Nath Aggarwal
DOI:10.4103/lungindia.lungindia_74_18  PMID:30604708
Lung transplantation is the only modality that offers a long-term solution for end-stage lung diseases. Few centers in India have an active lung transplant program. Preoperative and postoperative considerations in lung transplantation may be different in the developing countries when compared to the developed world. In the early posttransplant period, infection could be the major consideration in developing countries, unlike graft rejection, that is usually the primary concern in the developed world. Herein, we report the first lung transplantation from a public sector hospital in India. The patient was a 33-year-old female, who underwent bilateral lung transplantation at our center, but succumbed to surgical and infectious complications in the early posttransplant period.
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PICTORIAL QUIZ Top

A 58-year-old lady with cough and breathlessness p. 70
Saurabh Mittal, Karan Madan
DOI:10.4103/lungindia.lungindia_278_17  PMID:30604709
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CASE LETTERS Top

Not all hemoptysis is tuberculosis – It could be intralobar bronchopulmonary sequestration p. 72
Miti Aatish Shah, Ira Shah
DOI:10.4103/lungindia.lungindia_425_17  PMID:30604710
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Histoplasmosis presenting as an intrathoracic mass p. 74
Manoj Kumar Pandey, Jyoti Bajpai, Surya Kant, Poornima Mishra, Siddhant Verma
DOI:10.4103/lungindia.lungindia_41_18  PMID:30604711
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Idiopathic pleuroparenchymal fibroelastosis presenting as bilateral spontaneous pneumothorax: A case report p. 75
Venkata Nagarjuna Maturu, Prithiviraj Rajendran, Narendra Kumar Narahari
DOI:10.4103/lungindia.lungindia_248_18  PMID:30604712
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A rare complication of bedside tracheotomy: Thyroid crisis p. 77
Hariprasad Kalpakam, Sahajal Dhooria, Ritesh Agarwal, Soham Mukherjee, Inderpaul Singh Sehgal
DOI:10.4103/lungindia.lungindia_238_18  PMID:30604713
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LETTERS TO EDITOR Top

Nebulizer practices among paramedics in India p. 80
Randeep J Guleria, Khushboo Mahendra Thakkar
DOI:10.4103/lungindia.lungindia_147_18  PMID:30604714
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Introduction to indigenous technique of pleuroscopy p. 81
Hanmant Ganpati Varudkar
DOI:10.4103/lungindia.lungindia_319_18  PMID:30604715
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Visual analog scale for assessing the perception of short-acting β2-agonist use in clinical practice p. 82
Giorgio Ciprandi, Michela Silvestri, Maria Angela Tosca
DOI:10.4103/lungindia.lungindia_370_18  PMID:30604716
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Sticking to basics pays even today: Diagnosis of adenocarcinoma lung on sputum examination in patient reluctant to undergo biopsy – Providing opportunity for targeted therapy for palliation if not early detection p. 84
Rahul Khera, Rahul Kumar Sharma, Mohit Kaushal, Deepak Talwar
DOI:10.4103/lungindia.lungindia_337_18  PMID:30604717
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Correlating between chronic obstructive pulmonary disease assessment test and emPHasis score in Group III pulmonary hypertension patients p. 86
Sayoni Sengupta, Debkanya Dey, Parthasarathi Bhattacharyya
DOI:10.4103/lungindia.lungindia_71_18  PMID:30604718
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Chylothorax due to sarcoidosis: A unique occurrence p. 87
Abhishek Gupta, Ketaki Utpat, Unnati Desai, Jyotsna M Joshi
DOI:10.4103/lungindia.lungindia_408_18  PMID:30604719
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Serum magnesium levels and its correlation with level of control in patients with asthma: A hospital-based, cross-sectional, prospective study p. 89
Prawin Kumar, Jagdish Prasad Goyal
DOI:10.4103/lungindia.lungindia_418_18  PMID:30604720
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