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   Table of Contents - Current issue
September 2020
Volume 152 | Issue 3
Page Nos. 169-323

Online since Saturday, October 17, 2020

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COVID cardiomyopathy: Is it time to involve the cardiologists? Highly accessed article p. 169
Mohammed Chowdhury, Valmiki R Maharaj, Gary S Francis, Tamas Alexy, Meg Fraser
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Testing for hepatitis in view of treatment: A universal health coverage service that can advance elimination of mother-to-child transmission of hepatitis B virus p. 172
Yvan Hutin, BB Rewari, Meg Doherty
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Antifibrotic drugs for idiopathic pulmonary fibrosis: What we should know? Highly accessed article p. 177
Vijay Hadda, Randeep Guleria
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Recent HIV infection testing algorithms p. 181
KG Murugavel, Madhuri Thakar, Sanjay Mehendale
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Epidemiology, diagnosis & treatment of non-tuberculous mycobacterial diseases p. 185
Surendra K Sharma, Vishwanath Upadhyay
Non-tuberculous mycobacteria (NTM) are ubiquitously present in the environment, but NTM diseases occur infrequently. NTM are generally considered to be less virulent than Mycobacterium tuberculosis, however, these organisms can cause diseases in both immunocompromised and immunocompetent hosts. As compared to tuberculosis, person-to-person transmission does not occur except with M. abscessus NTM species among cystic fibrosis patients. Lung is the most commonly involved organ, and the NTM-pulmonary disease (NTM-PD) occurs frequently in patients with pre-existing lung disease. NTM may also present as localized disease involving extrapulmonary sites such as lymph nodes, skin and soft tissues and rarely bones. Disseminated NTM disease is rare and occurs in individuals with congenital or acquired immune defects such as HIV/AIDS. Rapid molecular tests are now available for confirmation of NTM diagnosis at species and subspecies level. Drug susceptibility testing (DST) is not routinely done except in non-responsive disease due to slowly growing mycobacteria ( M. avium complex, M. kansasii) or infection due to rapidly growing mycobacteria, especially M. abscessus. While the decision to treat the patients with NTM-PD is made carefully, the treatment is given for 12 months after sputum culture conversion. Additional measures include pulmonary rehabilitation and correction of malnutrition. Treatment response in NTM-PD is variable and depends on isolated NTM species and severity of the underlying PD. Surgery is reserved for patients with localized disease with good pulmonary functions. Future research should focus on the development and validation of non-culture-based rapid diagnostic tests for early diagnosis and discovery of newer drugs with greater efficacy and lesser toxicity than the available ones.
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Immunological markers for identifying recent HIV infection in North-West India p. 227
Chandar Kanta Chauhan, P.V.M. Lakshmi, Vivek Sagar, Aman Sharma, Sunil K Arora, Rajesh Kumar
Background & objectives: Being more efficient and widely used, limiting antigen (LAg)-avidity enzyme immunoassay (EIA) based on the recent infection testing algorithm (RITA) has been developed for differentiating recent and established HIV-1 infection. So far, LAg-avidity EIA has not been validated among the Indian population. Hence, the present study was planned to identify recent HIV infections in high risk patients in the North-West region of India using modified LAg-avidity RITA. Methods: Four hundred HIV-positive high risk patients registered on pre-antiretroviral therapy (ART) programme in the last one year, from five ART centres in North-Western States of India, were included for identifying the recent HIV infections. One hundred HIV-positive cases registered for pre-ART for greater than two years in ART centres were included for estimating false recent rate (FRR). Single-well LAg-avidity EIA-based modified RITA was used to identify recent HIV infection cases. Results: Of the 400 HIV-1-positive samples, 64 (16%) were found to have been infected within the past 130 days. The proportion of recent HIV infections was 16.8 per cent (18/107) among female sex workers, 10.7 per cent (9/84) among men who have sex with men and 17.7 per cent (37/209) among injecting drug users. The FRR was one per cent (1/100). Interpretation & conclusions: LAg-avidity EIA-based modified RITA provided good discrimination between recent and non-recent HIV infection, hence, it could be considered suitable for estimating HIV incidence in sentinel surveillance system in India.
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Potential of neutrophil to lymphocyte ratio in predicting sustained remission in rheumatoid arthritis compared to other immune activation markers p. 234
S Chandrashekara, Deepak Chikkulikere Lingaraju, P Renuka, KR Anupama
Background & objectives: Cells and cell proportions may indicate the equilibrium status of the immune system. The present study was conducted to evaluate the role of cytokines and the immunocompetent cells as biomarkers of remission in rheumatoid arthritis (RA) patients intended to withdraw or reduce disease-modifying anti-rheumatic drug (DMARD) treatment. Methods: This prospective observational study involved newly diagnosed and treated RA patients who fulfilled 2010 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria. The patients were classified based on disease activity score (DAS)28-C-reactive protein (CRP)(3) score into remission (≤2.6) and treatment-naïve/active (>2.6) groups. Remission patients were followed up for six months and were reclassified into those in sustained remission (≤2.6) and relapse (>2.6) based on the DAS28-CRP(3) score. Various cytokines and cell surface markers were quantitated using whole blood samples, and the CD3+/CD19+ and FOXP3+/CD4+ ratios were calculated. The clinical, demographic, cytokine and cellular phenotype characteristics were compared between remission and treatment-naïve groups. The factors associated with sustained remission were verified. Results: Of the 72 patients, 52 were in remission and 20 were DMARD naïve and had active disease. Duration of illness, interleukin-6 (IL-6) and IL-10 were significantly different between remission and treatment naïve/active disease patients. Increased likelihood for achieving sustained remission was noted in RA patients with baseline NLR ≤2. Other demographic/clinical variables and cell phenotypes, namely age, gender, duration of illness, CD3+, CD4+, FOXP3+, CD19+, CD3+/CD19+, FOXP3+/CD4+ and cytokines - IL-6 and IL-10 were not associated with sustained remission. Interpretation & conclusions: The present preliminary study highlighted the potential of NLR in predicting sustained remission in RA patients with a cut-off <2. Further study with a large sample size should be done to confirm this finding.
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Study of long non-coding RNA highly upregulated in liver cancer (HULC) in breast cancer: A clinical & in vitro investigation p. 244
Reyhaneh Ravanbakhsh Gavgani, Esmaeil Babaei, Mohammad Ali Hosseinpourfeizi, Ashraf Fakhrjou, Vahid Montazeri
Background & objectives: Breast cancer remains the most common malignancy among women worldwide. Long non-coding RNAs (lncRNAs) have been shown to play critical roles in tumour initiation and progression. This study was aimed to evaluate the potential role of lncRNA highly upregulated in liver cancer (HULC) in breast cancer. Methods: The expression of HULC was evaluated in breast cancer patients and cell lines using real-time quantitative reverse transcription polymerase chain reaction. Small interfering RNA-based knockdown was also employed to study the potential role of HULC in breast cancer cell lines including ZR-75-1, MCF7 and MDA-MB-231. Results: HULC was significantly upregulated in tumour tissues compared to non-tumoural margins (P <0.001). The receiver operating characteristic (ROC) curve analysis demonstrated the biomarker potential of HULC (ROCAUC=0.78, P <0.001). The HULC knockdown induced apoptosis and suppressed cellular migration in breast cancer cell lines. Interpretation & conclusions: Our results indicated that HULC was upregulated in breast cancer and might play a role in tumourigenesis. The HULC may have a potential to be exploited as a new biomarker and therapeutic target in breast cancer.
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Evaluation of multiparametric flow cytometry in diagnosis & prognosis of myelodysplastic syndrome in India p. 254
Gaurav Dhingra, Jasmita Dass, Vandana Arya, Nitin Gupta, Amrita Saraf, Sabina Langer, Shyam Aggarwal, Jyoti Kotwal, Manorama Bhargava
Background & objectives: Diagnosis of myelodysplastic syndromes (MDS) is subjective in low-grade cases with <5 per cent blasts or <15 per cent ring sideroblasts. Flow cytometry (FCM) has been used to diagnose MDS; but, it still has only an adjunctive role. This study was conducted to evaluate the role of FCM to diagnose MDS and correlate the number of aberrancies with revised international prognostic scoring system (R-IPSS). Methods: This study included 44 consecutive clinically suspected cases of MDS with refractory cytopenia(s) and 10 controls. Patients were divided into two groups: (i) proven MDS cases (n=26), and (ii) suspected MDS (n=18). Ogata quantitative approach, pattern analysis and aberrant antigen expression were studied. Results: Ogata score ≥2 correctly diagnosed 80.7 per cent (21/26) while aberrant antigen and pattern analysis with flow score of ≥3 could diagnose 92.3 per cent (24/26) patients with proven MDS. Combination of both with flow score ≥3 could diagnose 100 per cent patients. Eight patients in suspected MDS group with persistent cytopenia on follow up were labelled as probable MDS. Ogata score ≥2 was present in 5 of 8 and pattern analysis score ≥3 was present in six probable MDS patients. Combination of both with flow score ≥3 was present in seven of eight patients. Spearman's correlation between Ogata score and R-IPSS, pattern analysis and R-IPSS and combination of both scores and R-IPSS showed significant positive correlation in proven MDS as well as when proven and probable MDS patients were combined. Interpretation & conclusions: Our results showed that combined Ogata approach and pattern analysis, demonstration of ≥3 aberrancies in >1 cell compartment could diagnose most MDS patients. Patients with high flow scores had high R-IPSS scores. Patient with flow score ≥3 and borderline cytomorphology should be observed closely for the development of MDS.
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Clinical profile & long-term natural history of symptomatic coronary artery disease in young patients (<30 yr) p. 263
Arun Gopalakrishnan, Harikrishnan Sivadasanpillai, Sanjay Ganapathi, Krishna Kumar Mohanan Nair, Sivasankaran Sivasubramonian, Ajitkumar Valaparambil
Background & objectives: Several studies have shown a high prevalence of cardiovascular risk factors in patients in the age group of 30-74 yr, but there is a paucity of data in young patients below 30 yr. We analyzed the clinical and coronary angiographic profile of patients <30 yr of age with symptomatic coronary artery disease (CAD) and also assessed their intermediate and long-term outcomes. Methods: All patients less than 30 yr of age who presented with symptomatic CAD from 1978 to 2017 in the department of Cardiology of a tertiary care hospital in south India, were studied for coronary risk factors and angiographic and treatment patterns, and the follow up data were collected. Results: The mean age of the 159 patients <30 yr of age was 26.7±3.29 yr. Male preponderance was observed (91.8%), 63.5 per cent patients were smokers and 88.3 per cent were dyslipidaemic. Acute myocardial infarction was the most common mode of presentation. Forty one per cent patients were non-adherent to medications. Risk factor control was inadequate with respect to smoking cessation, alcoholism, physical activity and dietary regulation. The predictors of long-term mortality were multivessel CAD [hazard ratio (HR): 1.927, 95% confidence interval (CI): 1.003-3.701] and reduction in ejection fraction (EF) (10% decrease in EF; HR: 1.349, 95% CI: 1.096-1.662). Overall mortality was 30 per cent at 10 yr and 48 per cent at 20 yr. Interpretation & conclusions: Decreasing EF and multivessel involvement were found to be the strong correlates for long-term mortality in young patients below 30 yr of age with CAD. High long-term mortality rates and poor risk factor control suggest the vast scope for the improvement of outcomes in these patients with aggressive risk factor control.
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Red cell antigen phenotypes in blood donors & thalassaemia patients for creation of red cell antigen-matched inventory p. 273
Swati Kulkarni, Bhavika Choudhary, Harita Gogri, Jayashree Sharma, Manisha Madkaikar
Background & objectives: Patients with thalasssaemia are at a risk of alloimmunization and the presence of RBC alloantibodies further complicates transfusion therapy. Matching for the critical antigens of Rh, Kell, Kidd and Duffy blood group systems has been shown to minimize alloimmunization. The aim of the present study was to create a database of extensively typed donors for clinically significant and common blood group antigens of Rh, Kidd, Kell and Duffy systems for transfusion therapy of multitransfused thalassaemic patients. Methods: Five hundred O group regular blood donors were phenotyped for Rh, Kell, Duffy and Kidd blood group antigens using haemagglutination technique. Eighty four non-alloimmunized and 15 alloimmunized thalassaemia major patients with known antigenic profiles (determined by polymerase chain reaction with sequence-specific primers) were selected for this study. Results: By analyzing antigen profiles of 500 O group regular donors, a database of 193 donors matching perfectly for Rh, Duffy, Kell and Kidd antigens was prepared for 15 alloimmunized patients. For non-alloimmunized 84 thalassaemic patients, a database of 405 donors was created. Interpretation & conclusions: A database of 500 regular blood donors phenotyped for common antigens of Rh, Duffy, Kell and Kidd blood group systems was created, which would be useful in providing extended antigen-matched RBCs for thalassaemia patients. This will improve the quality and effectiveness of transfusion therapy.
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Prevalence of red blood cell antibodies in whole blood donors: A single-centre experience in north India p. 280
Archana Solanki, Tulika Chandra, Ashutosh Singh
Background & objectives: Blood transfusion therapy involves multiple steps to ensure selection of safe blood component for transfusion. This includes testing for infectious markers, full ABO compatibility, free from any clinically significant red cell antibodies and acceptable donor's red cell survival rates without destruction of recipient's red cells. The red cell antibodies present in healthy blood donors can cause severe haemolytic transfusion reaction, especially in massive blood transfusion recipients and paediatric patients. Hence, screening of red cell antibodies in donor blood is important to provide compatible blood products and to avoid haemolytic transfusion reactions in susceptible patient population. This study was planned to assess prevalence, aetiology and type of unexpected red cell antibodies in a large number of whole blood donor population in north India. Methods: This three-year prospective observational study included blood donor samples for antibody screening from January 2015 to December 2017. A total of 166,803 healthy blood donors including 156,128 (93.6%) males and 10,675 (6.4%) females were screened. Results: The prevalence of red cell antibodies was 0.17 per cent in our donor population. Of the total 286 donors with red cell antibodies, 248 (86.7%) had alloantibodies, 30 (10.5%) had autoantibodies and eight donors (2.8%) showed positive antibody screening with inconclusive results. Interpretation & conclusions: Alloimmunization to red cell antigens is a challenging task for current transfusion practices. The antibody screening in blood donors may improve the quality and safety of blood transfusion in the recipients. It also reduces the risk of complications from incompatible blood transfusions.
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Therapeutic potential of xanthones from Swertia chirata in breast cancer cells p. 285
Atish Barua, Pritha Choudhury, Suvra Mandal, Chinmay Kumar Panda, Prosenjit Saha
Background & objectives: Medicinal plants like Swertia chirata are rich sources of different xanthones. This study was aimed to assess the cytotoxic potential of four most abundant xanthones present in S. chirata both in vivo and in vitro in Ehrlich ascites carcinoma (EAC), a mouse transplantable breast carcinoma cell line and two human breast carcinoma cell lines (MCF-7 and MDA-MB-231). Methods: Four xanthones derived from S. chirata namely 1-hydroxy-3,7,8-trimethoxyxanthone (XA), 1,8-dihydroxy-3,5-dimethoxyxanthone (XB), 1-hydroxy-3,5,8-trimethoxyxanthone (XC) and 1,5,8-trihydroxy-3-methoxyxanthone (XD) were used for determination of sub-lethal dose on the cell lines EAC, MCF-7, MDA-MB-231 and verified toxicity of sub-lethal dose on normal murine fibroblast cells. Cytotoxicity was measured in vivo and survivability of mice was plotted accordingly. Therapeutic efficacy of XD was evaluated both in vivo and in vitro by determination of lipid peroxidation (LPO), reactive oxygen species (ROS) generation and by quantitating the enzyme status (GSH, catalase, superoxide dismutase) in treated and untreated samples. DNA damage was evaluated using comet and DNA fragmentation assays. Furthermore, apoptotic effect was analyzed by flow cytometry and validated by TUNEL assay and Western blotting. Results: Among all the xanthones tested XD showed IC50at the lowest dose, and normal cells were unaffected at this dose. Survivability of mice increased significantly when treated with XD compared to other xanthones and cisplatin. Significantly increased ROS and LPO were found in cancer cells as a result of XD treatment which was unaltered in normal cell line. XD induced DNA damage and apoptosis in cancer cell lines. Interpretation & conclusions: Our experimental data indicate that XD may potentially act as a chemotherapeutic agent by enhancing ROS in breast cancer cells thereby leading to apoptosis.
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Effect of zinc supplementation on relative expression of immune response genes in neonates with sepsis: A preliminary study p. 296
Newton Banupriya, Ballambattu Vishnu Bhat, Vinayagam Vickneshwaran, Magadi Gopalakrishna Sridhar
Background & objectives: Zinc alters gene expression mainly by binding to a site on the transcription factor. Genome-wide expression studies have shown early repression of genes related to zinc and immunity in adult patients with sepsis. The present study was conducted to evaluate the role of zinc supplementation on relative expression of immune response genes in neonatal sepsis. Methods: In the present study, a sample of convenience of 22 neonates each was selected from the zinc supplemented and control groups using random numbers for expression of immune-related genes by zinc supplementation. These neonates with sepsis were earlier randomized into two groups: with and without zinc supplementation in addition to standard antibiotics and supportive care. Relative expression of immune response genes were analyzed for 22 neonates in each group using quantitative real-time PCR for calprotectin (S100A8/A9), tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), toll-like receptor-4 (TLR-4), cluster of differentiation 14 (CD14) and lipopolysaccharide-binding protein (LBP) genes. Results: An increase in serum zinc levels was observed in zinc-supplemented group compared to controls. S100A8 gene showed downregulation by three-fold (P <0.001) and S100A9 gene showed upregulation by two-fold (P <0.05) in zinc group compared to controls. CD14 gene showed upregulation by one-fold in zinc-supplemented group compared to controls (P <0.05). No significant fold changes were observed with respect to TNF-α, IL-6, LBP and TLR-4 genes between the two groups. Interpretation & conclusions: The results of our preliminary study showed that the zinc supplementation might modulates the relative expression of immune-related genes involved in sepsis pathway among neonates. However, studies with larger sample size are needed to be done to provide a better picture on the outcome by gene expression in neonatal sepsis by zinc supplementation.
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Quality of anticoagulation with warfarin in rural Chhattisgarh, India p. 303
Puja Chebrolu, Sushil Patil, Timothy S Laux, Noor Al-Hammadi, Yogesh Jain, Brian Gage
Background & objectives: In most of rural India, warfarin is the only oral anticoagulant available. Among patients taking warfarin, there is a strong association between poor control of the international normalized ratio (INR) and adverse events. This study was aimed to quantify INR control in a secondary healthcare system in rural Chhattisgarh, India. Methods: The INR data were retrospectively obtained from all patients taking warfarin during 2014-2016 at a secondary healthcare system in rural Chhattisgarh, India. Patients attending the clinic had their INR checked at the hospital laboratory and their warfarin dose adjusted by a physician on the same day. The time in therapeutic range (TTR) was calculated for patients who had at least two INR visits. Results: The 249 patients had 2839 INR visits. Their median age was 46 yr, and the median body mass index was 17.7 kg/m[2]. They lived a median distance of 78 km (2-3 h of travel) from the hospital. The median INR was 1.7 for a target INR of 2.0-3.0 (n=221) and 2.1 for a target of 2.5-3.5 (n=28). The median TTR was 13.0 per cent, and INR was subtherapeutic 66.0 per cent of the time. Distance from the hospital was not correlated with TTR. Interpretation & conclusions: INR values were subtherapeutic two-thirds of the time, and TTR values were poor regardless of distance from the health centre. Future studies should be done to identify interventions to improve INR control.
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Risk of type 2 diabetes mellitus among urban slum population using Indian Diabetes Risk Score p. 308
Sreeja Nittoori, Vidhya Wilson
Background and objectives: Diabetes has emerged as a major health challenge in India due to a rapid rise in the number of diabetes cases. Early identification of high risk individuals through screening and early interventions in the form of lifestyle modifications and treatment would help in the prevention of diabetes and its complications. This study was done to assess the risk of type 2 diabetes mellitus (T2DM) in an urban slum population using the Indian Diabetes Risk Score (IDRS) and to determine the factors associated with high risk score. Methods: A community-based cross-sectional study was conducted among the urban slum population in North Telangana, India. A total of 136 study participants were selected randomly from the records. A pre-designed and pre-tested structured questionnaire was used for data collection. Assessment of risk of T2DM was done using the IDRS. Results: Of the 136 study participants, 101 (74.3%) were at high risk (IDRS ≥60) followed by 32 (23.5%) at moderate risk (IDRS 30-50) and three (2.2%) at low risk (IDRS <30). Sixty two (92.5%) individuals in the age group ≥50 yr were at high risk compared to 34 (63%) in 35-49 yr age group. Most (n=35, 87.5%) of sedentary workers were at high risk compared to those employed in moderate (n=52, 75.4%) and strenuous work (n=14, 51.9%). Interpretation & conclusions: Nearly three-fourth (74.3%) of the study participants were at a high risk of developing T2DM. Age, type of occupation, abdominal obesity, general obesity and high blood pressure were the factors significantly associated with high risk IDRS score.
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Study of fine-needle aspiration microbiology versus wound swab for bacterial isolation in diabetic foot infections p. 312
KM Abdulbasith, Maanasa M Bhaskar, Malathi Munisamy, Raj Kumar Nagarajan
Background & objectives: Proper identification of the infection causing microbe in diabetic foot infections (DFIs) is essential for starting appropriate treatment. The objectives of this study were to compare fine-needle aspiration microbiology (FNAM) with wound swab as methods of sample collection in isolating microorganisms causing DFIs and also to compare the microbiological profile and sensitivity pattern of the infecting organisms. Methods: This study was conducted targeting all consecutive patients with DFIs with perfusion, extent, depth, infection and sensation (PEDIS) grade 2, 3, and 4 infections admitted in the department of Surgery of a tertiary care hospital in south India during July to August 2017. A superficial wound swab and an FNAM were collected from all the patients. These swabs are analyzed using standard microbiological techniques. Results: Eighty patients with DFI were included. Bacterial culture using FNAM samples yielded growth in 58.75 per cent samples, whereas wound swab samples yielded growth in 93.8 per cent cultures done. Measure of agreement between the two techniques using Kappa statistics was 0.069 (P=0.28). Interpretation & conclusions: In diabetic wound infections, wound swabs were sufficient to identify organisms in all grades of infection. However, in deeper infections (grade 3 and 4), FNAM would be a reliable investigation than wound swab.
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Insights from pre-treatment attrition & dropouts in an effectiveness trial of methylphenidate in children p. 316
Ruchita Shah, Susanta Padhy, Adarsh Kohli, Samita Sharma
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Klebsiella pneumoniae with pathological intercostal lung herniation p. 320
Madhusmita Mohanty Mohapatra, Devi Prasad Mohapatra
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Nontuberculous mycobacteria (NTM): Microbiological, clinical and geographical distribution p. 322
Surendra K Sharma
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Erratum: Clinicopathologic features of undifferentiated round cell sarcomas of bone & soft tissues: An attempt to unravel the BCOR-CCNB3- & CIC-DUX4-positive sarcomas p. 323

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