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   Table of Contents - Current issue
Coverpage
March-April 2021
Volume 38 | Issue 2
Page Nos. 107-207

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EDITORIAL  

Pleura – The quest within p. 107
Dharmesh Patel
DOI:10.4103/lungindia.lungindia_851_20  PMID:33687001
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ORIGINAL ARTICLES Top

Safety and diagnostic yield of transbronchial lung cryobiopsy by flexible bronchoscopy using laryngeal mask airway in diffuse and localized peripheral lung diseases: A single-center retrospective analysis of 326 cases Highly accessed article p. 109
Manoj Kumar Goel, Ajay Kumar, Gargi Maitra, Balkar Singh, Sunita Ahlawat, Priti Jain, Neeraj Garg, RK Verma
DOI:10.4103/lungindia.lungindia_220_20  PMID:33687002
Background: Intubation with either an endotracheal tube or a rigid bronchoscope is generally preferred to provide airway protection as well as to manage unpredictable complications during transbronchial lung cryobiopsy (TBLC). The laryngeal mask airway has been described as a safe and convenient tool for airway control during bronchoscopy. Aims and Objectives: In this study, we evaluated the safety and outcome of using a laryngeal mask airway (LMA) as a conduit for performing TBLC by flexible video bronchoscopy (FB). Methods: We retrospectively analyzed the database of the patients who underwent TBLC between November 2015 and September 2019. The procedure was performed using FB through LMA under general anesthesia. Prophylactic occlusion balloon was routinely used starting January 2017 onwards. Radial endobronchial ultrasound (R-EBUS) guidance was used for TBLC in the localized lung lesions when deemed necessary. Multidisciplinary consensus diagnostic yield was determined and periprocedural complications were recorded. Results: A total of 326 patients were analysed. The overall diagnostic yield was 81.60% (266/326) which included a positive yield of 82.98% (161/194) in patients with diffuse lung disease and 79.54% (105/132) in patients with localized disease. Serious bleeding complication occurred in 3 (0.92%) cases. Pneumothorax was encountered in 8 (2.45%) cases. A total of 9 (2.76%) cases had at least 1 major complication. Conclusion: This study demonstrates that the use of LMA during TBLC by flexible bronchoscopy allows for a convenient port of entry, adequate airway support and effective endoscopic management of intrabronchial haemorrhage especially with the use of occlusion balloon.
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Clinical analysis of adenovirus postinfectious bronchiolitis obliterans and nonadenovirus postinfectious bronchiolitis obliterans in children Highly accessed article p. 117
Fei Huang, Yu-Cong Ma, Fang Wang, Ya-Nan Li
DOI:10.4103/lungindia.lungindia_374_20  PMID:33687003
Background and Objective: Postinfectious bronchiolitis obliterans (PIBO) is an uncommon and severe form of chronic obstructive lung disease in children. Adenovirus (ADV) is the main pathogen of PIBO in children. However, the risk factors of ADV-PIBO are not fully understood. This study aims to analyze the clinical characteristics of PIBO caused by ADV and compared with non-ADV-PIBO. Materials and Methods: A retrospective study of children under the age of 14 years diagnosed PIBO was performed in 56 ADV-PIBO cases, 29 non-ADV-PIBO, and 39 healthy controls to determine clinical characteristics of PIBO. Results: There was no difference between ADV-PIBO and non-ADV-PIBO cases in gender, age, individual and family atopy or history of asthma, and previous history of wheezing and no difference in the clinical manifestations and signs between the two groups. However, the hospital stay, duration of ventilator use, and multifocal pneumonia incidence of ADV-PIBO group have a significant differences compared with non-ADV-PIBO. Notably, inflammatory markers lactic dehydrogenase (LDH), interleukin 8 (IL-8), and interferon-gamma (IFN-γ) were significantly increased in PIBO patients, and those expressed in ADV-PIBO patients were higher than those in non-ADV-PIBO patients. In addition, ADV-PIBO children required a longer duration of oral prednisone and azithromycin than non-ADV-PIBO cases. Conclusions: Compared with non-ADV-PIBO, ADV-PIBO has a longer hospital stay, longer duration of ventilator use, increased LDH, IL-8, and IFN-γ expressions, and longer duration of oral prednisone and azithromycin treatment. Further research is needed to determine why PIBO caused by ADVs are more severe than those caused by other pathogens.
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Performance of cytology, acid-fast bacilli smear, gene Xpert and mycobacterial cultures in endobronchial ultrasound-transbronchial needle aspiration aspirate in diagnosing mediastinal tuberculous lymphadenitis p. 122
V Frank Mohan, Vivek Nangia, AK Singh, Rahul Behl, Nitin Dumeer
DOI:10.4103/lungindia.lungindia_128_20  PMID:33687004
Background: Diagnosis of isolated mediastinal tuberculosis (TB) can be challenging. Endobronchial ultrasound (EBUS) increases the diagnostic yield by direct sonographic visualization of mediastinal and hilar lymph nodes. With the advent of molecular techniques such as Gene Xpert, their addition to the cytology and cultures increases the diagnostic yield and detection of rifampicin resistance (RR) which helps change the effective therapeutic regimen immediately. Materials and Methods: Prospective analysis of all patients undergoing EBUS-guided transbronchial needle aspiration (EBUS-TBNA) with a clinical possibility of TB in isolated mediastinal lymphadenopathy patients at a tertiary care referral center between June 2016 and January 2018. All patients had at least five passes from each node of which two passes from each lymph node sampled in 2 ml of saline for culture and Gene Xpert for microbiologic, pathologic, and molecular analysis as per hospital protocol. Results: Out of 60 patients, 44 were diagnosed to have mediastinal tuberculous lymphadenitis, 8 sarcoidosis, 2 malignancies, and 6 reactive lymphadenitis. TBNA cytology was positive in 40/44 patients (90.9%), out of which 18 patients were culture positive with the sensitivity of 100%, specificity 47.6%, positive predictive value (PPV) 45%, and negative predictive value (NPV) 100%, (P value 0.011). TBNA acid-fast bacilli (AFB) smear was positive in 20/44 patients (45.45%) out of which 12 were culture positive, with sensitivity of 67%, specificity 80.95%, PPV 60%, NPV 85% (P value 0.011). TBNA Gene Xpert was positive in 30/44 patients (68.2%), out of which 6 (13.63%) showed RR-TB and two were cytology negative. Sixteen patients where culture positive with sensitivity of 88.89%, specificity 66.67%, PPV 53.33%, NPV 93.33% (P value of 0.005). TBNA AFB culture was positive in 18/44 patients (40.9%). Conclusion: EBUS-TBNA is an effective and safe diagnostic tool for intrathoracic TB, especially for mediastinal tuberculous lymphadenitis. The combination of various tests increases the diagnostic yield. Mediastinal nodal aspirates traditionally believed to be paucibacillary can still be captured by Gene Xpert.
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Factors determining surgical outcome after bronchial re-implantation for traumatic main bronchus transection p. 128
Mohan Venkatesh Pulle, Belal Bin Asaf, Harsh Vardhan Puri, Sumit Bangeria, Sukhram Bishnoi, Arvind Kumar
DOI:10.4103/lungindia.lungindia_306_20  PMID:33687005
Objectives: The diagnosis of traumatic transection of main bronchus is often delayed, resulting in attempts at surgical repair sometimes even months after the injury. Our aim is to analyze the factors affecting surgical outcome in patients undergoing lung preserving bronchial re-implantation for bronchial transection. Materials and Methods: This is a retrospective analysis of prospectively maintained data of 10 cases of traumatic transection of main bronchus who underwent bronchial re-implantation at a tertiary thoracic surgery center in India. Patients were divided into two groups based on their total length of hospital stay. Occurrence of postoperative complications and/or hospital stay >7 days were considered poor surgical outcomes. Results: Out of 10 patients, 6 were left main bronchus transections and 4 right main bronchus transections. The male-female ratio was 7:3. Right-sided bronchial injury and higher preoperative Injury Severity Score (ISS) were associated with poor surgical outcomes (P < 0.01). These patients also had significantly higher anastomotic complications, chest tube duration, and prolonged postoperative air leak. Age of the patient, preoperative hemoglobin or albumin levels, and time of referral did not influence the surgical outcomes. Conclusions: Poorer surgical outcomes were observed in patients who had right-sided main bronchus injury and higher ISSs. Time of referral did not influence the outcome. This study is limited by small sample size and retrospective nature. As no single center will have large numbers of this uncommon injury, multicenter pooled data are needed to re-affirm the findings of this study.
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Clinicopathological and immunohistochemical study of pulmonary neuroendocrine tumors – A single-institute experience p. 134
Uma Jyothi Swaroopa Pasala, Monalisa Hui, Shantveer G Uppin, N Narendra Kumar, K Bhaskar, GK Paramjyothi
DOI:10.4103/lungindia.lungindia_482_19  PMID:33687006
Introduction: Pulmonary neuroendocrine tumors (NETs) comprise a spectrum of tumors ranging from indolent to highly aggressive neoplasm. This study aims to study the clinicopathological and immunohistochemical features of NETs and assess the sensitivity of various IHC markers. Materials and Methods: All consecutive cases of pulmonary NETs diagnosed from January 2016 to June 2019 were analyzed retrospectively. The routine hematoxylin- and eosin-stained sections along with immunohistochemistry (IHC) slides were reviewed. IHC was done using a panel of markers which included synaptophysin, chromogranin, CD56, thyroid transcription factor-1 (TTF-1), p-40, napsin-A, and ki67. Results: Of total number of 53 patients, diagnosis was made on biopsy in 40 patients and resection specimen in 13 patients. Small cell lung carcinoma was the most common (31 cases), followed by 16 cases of typical carcinoid, 5 cases of atypical carcinoid, and 1 case of combined SCLC. Both synaptophysin and chromogranin were positive in all the cases of typical carcinoid. Synaptophysin had better sensitivity than chromogranin in atypical carcinoid and small cell carcinoma. CD56 was positive in 8 out of 9 cases done. TTF-1 was negative in all the cases of typical carcinoid. The sensitivity of TTF-1 in small cell carcinoma was 85.19%. The mean Ki67 labeling index was 1.4%, 6.6%, and 65.6% in typical, atypical carcinoid, and small cell carcinomas, respectively. Conclusion: Synaptophysin was more sensitive than chromogranin, especially in atypical carcinoid and small cell carcinoma. TTF-1 along with high Ki67 differentiates small cell carcinoma from carcinoid.
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Diagnostic utility of pleural fluid carcinoembryonic antigen in patients with exudative pleural effusion p. 139
Vishnu G Krishnan, Akhilesh Kunoor, Pavithran Keechilath, Asmita Anilkumar Mehta
DOI:10.4103/lungindia.lungindia_196_20  PMID:33687007
Background: Pleural effusion (PE) is presenting symptoms of many different diseases and is often a diagnostic challenge. Negative cytology in the malignant PE requires more complicated diagnostic procedures, such as closed pleural biopsy or thoracoscopic pleural biopsy. Not all the patients will be fit for such invasive procedures due to high risk. Tumor markers seem to be a promising alternative and have been proposed to aid in the differentiation of the PE etiology. Objective: The objective of the study was to evaluate the diagnostic value of pleural fluid carcinoembryonic antigen (CEA) in differentiation between malignant and nonmalignant PEs and to compare adenosine deaminase (ADA) levels with respect to malignant and nonmalignant PE. Methodology: It was a prospective observational study. Patients who presented with undiagnosed exudative PE during the time period 2016–2018 were studied. Pleural fluid was subjected to all routine investigations such as sugar, protein, lactate dehydrogenase, ADA, and CEA. Results: A total of 100 patients were included in the study. Fifty-one patients had malignancy. Univariate analysis showed that smoker, previous history of cancer, ADA <20, and CEA of >2.15 were variables associated with malignancy. Multivariate analysis showed pleural fluid CEA >2.15 as only independent risk factor associated with malignancy. The sensitivity of 91.5% and 65% and specificity of 92.5% and 81.4%, respectively, were found for CEA 2.15 ng/dl and ADA <16.5 U/L as plotted from receiver operating characteristic curve. The combined CEA and ADA (2.39 ng/ml and 16.5 U/L) values in pleural fluid had higher sensitivity of 100%. Conclusion: Our study demonstrated that pleural fluid CEA levels have a sensitivity of 93.5% and specificity of 73% in diagnosing of malignant PE. ADA levels lesser than 16.5 U/L were seen in patients with malignant PE, but less sensitive and specific compared to CEA. Combined ADA and CEA levels had higher sensitivity than CEA alone.
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Clinico-etiological characteristics of organizing pneumonia: A retrospective study p. 144
Vikas Marwah, Deepu K Peter, Neeraj Sharma, Saikat Bhattacharjee, Arun Hegde, Divya Shelly, Virender Malik, Gaurav Bhati, Shalendra Singh
DOI:10.4103/lungindia.lungindia_105_20  PMID:33687008
Introduction: Organizing pneumonia (OP) is an idiopathic interstitial pneumonia characterized radiologically by the patchy peripheral areas of ground-glass opacities and consolidation. It is commonly associated with a variety of conditions such as connective tissue diseases (CTD), drugs, infections, malignancy, radiation exposure, post-transplant, and other interstitial pneumonia. There are no specific clinical manifestations unless there is an underlying etiology. We present a series of such cases. Aims and Objectives: The aim of the study was to identify the clinical characteristics and etiological spectrum of patients manifesting radiologically with OP pattern. Materials and Methods: This was a retrospective analysis of clinico-radiological profile and etiological diagnosis of 23 patients, who had a radiological diagnosis of OP during the period of January 2017–September 2019. Results: Our patients presented with nonspecific symptoms of cough, fever, breathlessness, and occasionally with hemoptysis. The various etiologies identified were CTD (n = 4), infection (n = 2), drugs (n = 4), radiation (n = 1), chronic aspiration syndrome (n = 1), malignancy (n = 2), hypersensitivity pneumonitis (n = 1), and chronic heart failure (n = 2), and in majority (n = 7), no underlying etiology was evident and were labeled as cryptogenic organizing pneumonia. Conclusion: OP is an underdiagnosed entity and is associated with numerous diseases varying from pulmonary tuberculosis to malignancy. Identification of the underlying disease process is of paramount importance as it enables the treating physician to implement necessary therapeutic interventions.
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Role of medical thoracoscopy in the treatment of complicated parapneumonic effusions p. 149
Ramanjaneya Ranganatha, Syed Zulkharnain Tousheed, Bangalore Venkatraman MuraliMohan, Muhammed Zuhaib, Deepika Manivannan, BR Harish, Poojaramuddanahally Hanumantharayappa Manjunath, Kedar R Hibare, Hemanth Kumar, Chandrasekar Sagar, Vellaichamy Muthupandi Annapandian
DOI:10.4103/lungindia.lungindia_543_20  PMID:33687009
Objective: The role of medical thoracoscopy in the treatment of pleural infections is increasingly being recognized. This study was done to assess the role of medical thoracoscopy in the management of carefully selected subset of patients with complicated parapneumonic effusions (PPEs). Materials and Methods: We analyzed retrospective data of 164 thoracoscopic procedures performed at our center on patients with complicated PPE in the past 10 years. Patients were subjected to medical thoracoscopy based on ultrasonographic stratification and a computed tomography (CT) thorax. Medical thoracoscopy was performed after an intercostal block under conscious sedation with midazolam (2 mg) and fentanyl (50 mcg) and local anesthesia with lignocaine 2% (10–15 ml), through a single port 10 mm diameter thoracoscope. Results: A total of 164 patients (119 males and 45 females) underwent medical thoracoscopy during the study period. The mean age was 47.4 ± 15.9 (median, 50; range, 16–86). The final diagnosis by thoracoscopy was bacterial empyema in 93 patients and tuberculosis in 71 patients. Medical thoracoscopy was successful without subsequent intervention in 160 (97.5%) patients, two patients underwent a second procedure, in the form of decortication, and two patients died due to sepsis. There were no major procedure-related complications that required intervention. Conclusion: Early adhesiolysis and drainage of fluid using medical thoracoscopy should be considered in patients with multiloculated complicated PPE after careful radiological (ultrasonography and CT) stratification, as a more cost-effective and safe method of management.
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Chylothorax - Modalities of management and outcomes: A case series p. 154
Mohan Venkatesh Pulle, Harsh Vardhan Puri, Belal Bin Asaf, Sukhram Bishnoi, Ajit Yadav, Arvind Kumar
DOI:10.4103/lungindia.lungindia_526_20  PMID:33687010
Background: At present, there are no universally accepted protocols for the management of chylothorax. This study aims at reporting the clinical experience and presenting our institutional protocol for managing chylothorax. Materials and Methods: This is a retrospective analysis of chylothorax patients managed at a dedicated thoracic surgical unit over 8 years. A detailed analysis of demography and perioperative variables including complications was carried out. Factors influencing failure of conservative and surgical therapy were analyzed. Results: A total of 26 patients were included with a mean age of 42.4 years (range, 2–72 years). Postsurgical chylothorax was the most common variant (53.8%). Majority (46.1%) of the patients had >1000 ml/24 h intercostal tube drainage at presentation. All patients were initially subjected to conservative management, of which 11 (42.4%) patients were managed successfully with conservative therapy alone. Rest 15 (57.6%) patients required video-assisted thoracoscopic thoracic duct ligation, which was successful in 10/15 (66.7%) patients, whereas additional intervention was required in 5/15 (33.3%) patients. Drain output of >1000 ml/day was an independent predictor of failure of conservative therapy. Nontraumatic bilateral chylothorax was associated with high probability of failure of surgical therapy in the first attempt and may require additional treatment modality. Conclusions: Initial conservative management is recommended for all chylothorax patients, which is unlikely to succeed if daily drainage is >1000 ml/24 h. VATS thoracic duct ligation is recommended in such cases. Nontraumatic bilateral chylothorax has higher surgical failure rates. In such cases, additional procedures in the form of pleurodesis and/or thoracic duct embolization/disruption should be considered.
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REVIEW ARTICLES Top

Computer-Aided quantitative analysis in interstitial lung diseases – A pictorial review using CALIPER p. 161
Bhavin G Jankharia, Bhoomi A Angirish
DOI:10.4103/lungindia.lungindia_244_20  PMID:33687011
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The emerging role of nebulization for maintenance treatment of chronic obstructive pulmonary disease at home p. 168
Deepak Talwar, R Ramanathan, Meena Lopez, Rashmi Hegde, Jaideep Gogtay, Geeta Goregaonkar
DOI:10.4103/lungindia.lungindia_68_20  PMID:33687012
Inhalation therapy is the cornerstone of chronic obstructive pulmonary disease (COPD) management. However, for many COPD patients who are managed at home, nebulization therapy offers an effective alternative treatment and fulfills the gap of catering to the specific population of patients who are unable to use handheld inhaler devices appropriately. The present review highlights key aspects, namely selection of the right beneficiaries for home nebulization, available drugs in nebulized formulations for the treatment of COPD, and the importance of care, cleaning, and maintenance, which are prerequisites for ensuring successful nebulization therapy.
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RECOMMENDATIONS Top

Expert recommendations on the role of macrolides in chronic respiratory diseases p. 174
Raja Dhar, Deepak Talwar, Virendra Singh, Harjit Dumra, Sujeet Rajan, SK Jindal
DOI:10.4103/lungindia.lungindia_498_19  PMID:33687013
Background: India contributes to 32% of the total global disability-adjusted life years, due to chronic respiratory diseases. This has led to a high rate of health loss from these diseases. Antibiotics are commonly used in the management of respiratory disorders. With excellent tissue penetration, prolonged tissue persistence, and favorable side effect profile, macrolides are one of the best treatment options being recommended for respiratory, urogenital, dermal, and other bacterial infections. Still, there is a lack of clinical trial data on the use of macrolides in the management of respiratory chronic disease, and hence, there is a need for clinical guidance on their use in Indian setting. Methods: A systematic review of the literature was conducted on PubMed, Cochrane database, and Google Scholar. Existing guidelines, meta-analyses, systematic reviews, randomized controlled trials (RCTs), non-RCTs, landmark studies, and key-cited articles were selected. Recommendations were based on available evidence and expert panel's logical empiricism and consensus. Results and Discussion: This article discusses evidence-based and clinical practice based management of chronic respiratory conditions including chronic obstructive pulmonary disease, asthma, bronchiectasis, diffusive panbronchiolitis, and organizing pneumonia. The authors reviewed different respiratory conditions, role of macrolides in their management, adverse events and antimicrobial resistance associated with macrolides, evidence review of various clinical trials, guideline recommendations, and clinical recommendations.
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CASE REPORTS Top

Pleural schistosomiasis masquerading as tubercular pyopneumothorax: World’s first case report p. 183
Rohit Vadala, Imran Shamsi, Charul Dabral, Dhruv Talwar, Deepak Talwar
DOI:10.4103/lungindia.lungindia_232_20  PMID:33687014
Schistosomiasis is an uncommon waterborne helminthic infection that infects humans. Although it is not prevalent in India, many cases are reported due to contact with infested water bodies. Schistosomiasis primarily involves the lower urinary tract and colorectal region. Pulmonary schistosomiasis, although very unusual, has been described with the systemic manifestation of the disease; however, pleural involvement with schistosomiasis has never been described before in the literature. We report this first case of pleural schistosomiasis masquerading as tuberculosis, which posed a diagnostic challenge and later a new learning point in the presentation of the disease.
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Fetal lung interstitial tumor: An uncommon pediatric pulmonary neoplasm p. 186
Saloni Naresh Shah, N Geetha, Radhakrishnan Satheesan, Ashok Parameswaran
DOI:10.4103/lungindia.lungindia_646_20  PMID:33687015
Fetal lung interstitial tumor (FLIT) is a rare pediatric lung tumor with radiological features similar to developmental pulmonary malformations and other congenital lung neoplasms. There are about 17 cases of FLIT reported worldwide till date. We report the first case of FLIT in the Indian literature which was diagnosed in the early postnatal period (at the 21st day of life) by pathological examination. The tumor exhibited a novel focal micropapillary architecture, in addition to the previously described microscopic features. We discuss the pathogenesis and differential diagnoses of FLIT and review the literature.
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COMMENTARY Top

Coexistent obstructive sleep apnea in patients with chronic obstructive pulmonary disease: Several unanswered questions need to be addressed p. 191
Athanasios Voulgaris, Paschalis Steiropoulos
DOI:10.4103/lungindia.lungindia_580_20  PMID:33687016
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PICTORIAL QUIZ Top

A patient with gastroesophageal junction carcinoma and cough p. 193
Priyanka S Makkar, Vishisht Mehta, Miranda Tan
DOI:10.4103/lungindia.lungindia_520_19  PMID:33687017
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PICTORIAL CME Top

Gastric distention: A common complication of noninvasive ventilation p. 195
Saurabh Mittal, Karan Madan, Anant Mohan, Vijay Hadda
DOI:10.4103/lungindia.lungindia_535_19  PMID:33687018
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RADIOLOGY QUIZ Top

An unusual cause of “reverse batwing” sign p. 196
Kadli Shirish Kumar, Rohit Vadala, Deepak Talwar
DOI:10.4103/lungindia.lungindia_212_20  PMID:33687019
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CASE LETTER Top

Foreign body removed using curette and retrieval net after tracheostomy p. 199
Kazuaki Nishiki, Yoko Ishige, Yasutaka Kawasaki, Shiro Mizuno
DOI:10.4103/lungindia.lungindia_957_20  PMID:33687020
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LETTERS TO EDITOR Top

Pseudomonas-associated mycotic pulmonary artery aneurysm with endovascular management p. 201
Rahul Tyagi, Manjit Sharad Tendolkar, Rajeev Sivasankar
DOI:10.4103/lungindia.lungindia_906_20  PMID:33687021
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Radiological quandary: Unilateral interstitial lung disease – Truth or dare p. 202
Loveleen Mangla, Imran Shamsi, Dhruv Talwar, Deepak Talwar
DOI:10.4103/lungindia.lungindia_227_20  PMID:33687022
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Profile of sleep-disordered breathing in ILD: Could be better with study design? p. 204
Deependra Kumar Rai
DOI:10.4103/lungindia.lungindia_838_20  PMID:33687023
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OBITUARY Top

Remembrance – Dr. V. K. Vijayan (19.06.1948 to 28.01.2019) p. 206
Nasser Yusuf, Parvaiz A Koul
DOI:10.4103/lungindia.lungindia_65_21  PMID:33687024
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