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1.
Article in English | WPRIM | ID: wpr-197496

ABSTRACT

Asthma is a prevalent and serious health problem in Korea. Recently, the Korean Asthma Guideline has been updated by The Korean Academy of Tuberculosis and Respiratory Diseases (KATRD) in an effort to improve the clinical management of asthma. This guideline focuses on adult patients with asthma and aims to deliver up to date scientific evidence and recommendations to general physicians for the management of asthma. For this purpose, this guideline was updated following systematic review and meta-analysis of recent studies and adapting some points of international guidelines (Global Initiative for Asthma [GINA] report 2014, National Asthma Education and Prevention Program [NAEPP] 2007, British Thoracic Society [BTS/SIGN] asthma guideline 2012, and Canadian asthma guideline 2012). Updated issues include recommendations derived using the population, intervention, comparison, and outcomes (PICO) model, which produced 20 clinical questions on the management of asthma. It also covers a new definition of asthma, the importance of confirming various airflow limitations with spirometry, the epidemiology and the diagnostic flow of asthma in Korea, the importance and evidence for inhaled corticosteroids (ICS) and ICS/formoterol as a single maintenance and acute therapy in the stepwise management of asthma, assessment of severity of asthma and management of exacerbation, and an action plan to cope with exacerbation. This guideline includes clinical assessments, and treatment of asthma-chronic obstructive pulmonary disease overlap syndrome, management of asthma in specific conditions including severe asthma, elderly asthma, cough variant asthma, exercise-induced bronchial contraction, etc. The revised Korean Asthma Guideline is expected to be a useful resource in the management of asthma.


Subject(s)
Adrenal Cortex Hormones , Adult , Aged , Asian Continental Ancestry Group , Asthma , Asthma, Exercise-Induced , Cough , Education , Epidemiology , Humans , Korea , Lung Diseases, Obstructive , Spirometry , Tuberculosis
2.
Article in English | WPRIM | ID: wpr-770881

ABSTRACT

A 46-year-old female patient was admitted to the intensive care unit (ICU) after liver transplantation. About an hour later after the ICU admission, she had no pupillary light reflex. Both pupils were also fixed at 5 mm. Patients who undergo liver transplantation are susceptible to neurologic disorders including hepatic encephalopathy, thromboembolism and intracranial hemorrhage. Abnormal pupillary light reflex usually indicates a serious neurologic emergency in these patients; however, benign neurologic disorders such as peripheral autonomic neuropathy or Holmes-Adie syndrome should also be considered. We experienced a case of fixed pupillary light reflex after liver transplantation diagnosed as peripheral autonomic neuropathy.


Subject(s)
Adie Syndrome , Emergencies , Female , Hepatic Encephalopathy , Humans , Intensive Care Units , Intracranial Hemorrhages , Liver Transplantation , Liver , Middle Aged , Nervous System Diseases , Peripheral Nervous System Diseases , Pupil , Reflex , Reflex, Pupillary , Thromboembolism
3.
Article in English | WPRIM | ID: wpr-770864

ABSTRACT

Although the incidence is not high in the general surgical population, pulmonary aspiration of gastric contents can result in serious long-term morbidity and mortality. We report a case of early use of extracorporeal membrane oxygenation (ECMO) to correct severe hypoxemia refractory to conventional mechanical ventilation in a patient with massive aspiration of gastric contents immediately followed by acute lung injury during general anesthesia induction. A 64-year-old woman diagnosed with stomach cancer was scheduled for elective diagnostic laparoscopy. Although there was no sign of gastrointestinal tract obstruction and midnight Nil per Os (NPO) was performed before the operation, pulmonary aspiration occurred during the induction of anesthesia. Despite the endotracheal intubation with mechanical ventilation, severe hypoxemia with hypercapnea persisted. Medical team agreed with applying veno-venous (VV) ECMO, and her blood gas analysis results became stable. ECMO was weaned successfully 9 days after the first aspiration event had occurred. Based on this case, early application of extracorporeal life support can have survival benefits.


Subject(s)
Acute Lung Injury , Anesthesia , Anesthesia, General , Hypoxia , Blood Gas Analysis , Extracorporeal Membrane Oxygenation , Female , Gastrointestinal Tract , Humans , Incidence , Intubation, Intratracheal , Laparoscopy , Middle Aged , Mortality , Pneumonia, Aspiration , Respiration, Artificial , Stomach Neoplasms
4.
Article in English | WPRIM | ID: wpr-96077

ABSTRACT

A 46-year-old female patient was admitted to the intensive care unit (ICU) after liver transplantation. About an hour later after the ICU admission, she had no pupillary light reflex. Both pupils were also fixed at 5 mm. Patients who undergo liver transplantation are susceptible to neurologic disorders including hepatic encephalopathy, thromboembolism and intracranial hemorrhage. Abnormal pupillary light reflex usually indicates a serious neurologic emergency in these patients; however, benign neurologic disorders such as peripheral autonomic neuropathy or Holmes-Adie syndrome should also be considered. We experienced a case of fixed pupillary light reflex after liver transplantation diagnosed as peripheral autonomic neuropathy.


Subject(s)
Adie Syndrome , Emergencies , Female , Hepatic Encephalopathy , Humans , Intensive Care Units , Intracranial Hemorrhages , Liver Transplantation , Liver , Middle Aged , Nervous System Diseases , Peripheral Nervous System Diseases , Pupil , Reflex , Reflex, Pupillary , Thromboembolism
5.
Article in English | WPRIM | ID: wpr-71282

ABSTRACT

Although the incidence is not high in the general surgical population, pulmonary aspiration of gastric contents can result in serious long-term morbidity and mortality. We report a case of early use of extracorporeal membrane oxygenation (ECMO) to correct severe hypoxemia refractory to conventional mechanical ventilation in a patient with massive aspiration of gastric contents immediately followed by acute lung injury during general anesthesia induction. A 64-year-old woman diagnosed with stomach cancer was scheduled for elective diagnostic laparoscopy. Although there was no sign of gastrointestinal tract obstruction and midnight Nil per Os (NPO) was performed before the operation, pulmonary aspiration occurred during the induction of anesthesia. Despite the endotracheal intubation with mechanical ventilation, severe hypoxemia with hypercapnea persisted. Medical team agreed with applying veno-venous (VV) ECMO, and her blood gas analysis results became stable. ECMO was weaned successfully 9 days after the first aspiration event had occurred. Based on this case, early application of extracorporeal life support can have survival benefits.


Subject(s)
Acute Lung Injury , Anesthesia , Anesthesia, General , Hypoxia , Blood Gas Analysis , Extracorporeal Membrane Oxygenation , Female , Gastrointestinal Tract , Humans , Incidence , Intubation, Intratracheal , Laparoscopy , Middle Aged , Mortality , Pneumonia, Aspiration , Respiration, Artificial , Stomach Neoplasms
7.
Article in English | WPRIM | ID: wpr-41599

ABSTRACT

BACKGROUND: The objective of this study was to investigate the association between A118G single nucleotide polymorphism (SNP) of human micro-opioid receptor (OPRM1) gene and the postoperative pain response in Korean patients undergoing thyroidectomy. METHODS: Fifty two adult patients undergoing thyroidectomy were enrolled in this study. Their blood samples were genotyped for the A118G polymorphism. Pain intensity was assessed by a verbal numerical rating scale (VNRS) at postanesthesia care unit, postoperative 6, 24, and 48 hours. Mechanical pain threshold was assessed using electronic von Frey preoperatively and repeated at postoperative 24 and 48 hours on the forearm and periincisional regions. RESULTS: Of the 50 patients, 23 patients were A118 homozygous (AA), 19 patients were heterozygous (AG), and 8 patients were 118G homozygous (GG). The VNRS score was higher in patients with GG genotype than other genotypes at PACU (P < 0.05). Mechanical pain thresholds on the forearm and periincisional area were decreased at postoperative 24 and 48 hours from the preoperative values in all genotypes (P < 0.05). However, the changes in pain thresholds were similar among the genotypes. CONCLUSIONS: A118G SNP of OPRM1 gene is associated with inter-individual difference in immediate postoperative pain score in Korean population.


Subject(s)
Adult , Electronics , Electrons , Forearm , Genotype , Humans , Pain Threshold , Pain, Postoperative , Polymorphism, Single Nucleotide , Receptors, Opioid , Thyroidectomy
8.
Article in English | WPRIM | ID: wpr-7836

ABSTRACT

Evidence suggests that diabetes mellitus (DM) is associated with idiopathic pulmonary fibrosis (IPF). According to the new IPF guidelines, high-resolution computed tomography (HRCT) is an essential means of diagnosing IPF. We investigated the relationship between IPF and DM in patients treated between 2003 and 2007. Newly diagnosed IPF patients in large university teaching hospitals in Korea were enrolled from January 2003 to December 2007. We retrospectively analyzed 1,685 patients using the interstitial lung disease (ILD) registry. In total, 299 IPF patients (17.8%) also had DM. The mean age of our subjects was 68.0 +/- 9.4 yr. HRCT showed significantly more reticular and honeycomb patterns in IPF patients with DM than in IPF patients without DM (P = 0.014, P = 0.028, respectively). Furthermore, significantly higher incidences of hypertension, cardiovascular diseases, and other malignancies (except lung cancer) were found in IPF patients with DM than in IPF patients without DM. In conclusion, IPF patients with DM are more likely to have the usual interstitial pneumonia (UIP) pattern, including reticular and honeycomb patterns, on HRCT than are those without DM.


Subject(s)
Aged , Cardiovascular Diseases/epidemiology , Diabetes Mellitus, Type 2/complications , Female , Humans , Hypertension/epidemiology , Idiopathic Pulmonary Fibrosis/complications , Incidence , Male , Middle Aged , Neoplasms/epidemiology , Registries , Republic of Korea/epidemiology , Retrospective Studies , Tomography, X-Ray Computed
9.
Article in English | WPRIM | ID: wpr-27756

ABSTRACT

CXC chemokine receptor 4 (CXCR4), which binds the stromal cell-derived factor-1 (SDF-1), has been shown to play a critical role in mobilizing the bone marrow (BM)-derived stem cells and inflammatory cells. We studied the effects of AMD3100, CXCR4 antagonist, on a murine bleomycin-induced pulmonary fibrosis model. Treatment of mice with AMD3100 in bleomycin-treated mice resulted in the decrease of SDF-1 in bronchoalveolar lavage (BAL) fluids at an early stage and was followed by the decrease of fibrocytes in the lung. AMD3100 treatment decreased the SDF-1 mRNA expression, fibrocyte numbers in the lung at an early stage (day 3) and CXCR4 expression at the later stage (day 7 and 21) after bleomycin injury. The collagen content and pulmonary fibrosis were significantly attenuated by AMD3100 treatment in later stage of bleomycin injury. AMD3100 treatment also decreased the murine mesenchymal and hematopoietic stem cell chemotaxis when either in the stimulation with bleomycin treated lung lysates or SDF-1 in vitro. In BM stem cell experiments, the phosphorylation of p38 MAPK which was induced by SDF-1 was significantly blocked by addition of AMD3100. Our data suggest that AMD3100 might be effective in preventing the pulmonary fibrosis by inhibiting the fibrocyte mobilization to the injured lung via blocking the SDF-1/CXCR4 axis.


Subject(s)
Animals , Bleomycin , Bronchoalveolar Lavage Fluid/chemistry , Cell Movement/drug effects , Cells, Cultured , Chemokine CXCL12/chemistry , Cytoprotection/drug effects , Down-Regulation/drug effects , Drug Evaluation, Preclinical , Female , Heterocyclic Compounds/pharmacology , Lung/drug effects , Mice , Mice, Inbred C57BL , Pulmonary Fibrosis/chemically induced , Receptors, CXCR4/antagonists & inhibitors
10.
Yonsei Medical Journal ; : 569-575, 2009.
Article in English | WPRIM | ID: wpr-178603

ABSTRACT

PURPOSE: Tumor necrosis factor-alpha (TNF-alpha) is a proinflammatory cytokine that has been implicated in many aspects of the airway pathology in asthma. TNF-alpha blocking strategies are now being tried in asthma patients. This study investigated whether TNF-alpha blocking therapy inhibits airway inflammation and airway hyperresponsiveness (AHR) in a mouse model of asthma. We also evaluated the effect of TNF-alpha blocking therapy on cytokine production and adhesion molecule expression. MATERIALS AND METHODS: Ovalbumin (OVA) sensitized BALB/c female mice were exposed to intranasal OVA administration on days 31, 33, 35, and 37. Mice were treated intraperitoneally with soluble TNF-alpha receptor (sTNFR) during the OVA challenge. RESULTS: There were statistically significant decreases in the numbers of total cell and eosinophil in bronchoalveolar lavage fluid (BALF) in the sTNFR treated group compared with the OVA group. However, sTNFR-treatment did not significantly decrease AHR. Anti-inflammatory effect of sTNFR was accompanied with reduction of T helper 2 cytokine levels including interleukin (IL)-4, IL-5 and IL-13 in BALF and vascular cell adhesion molecule 1 expression in lung tissue. CONCLUSION: These results suggest that sTNFR treatment can suppress the airway inflammation via regulation of Th2 cytokine production and adhesion molecule expression in bronchial asthma.


Subject(s)
Animals , Anti-Asthmatic Agents/therapeutic use , Asthma/drug therapy , Blotting, Western , Bronchi/drug effects , Bronchial Hyperreactivity , Bronchoalveolar Lavage Fluid/immunology , Enzyme-Linked Immunosorbent Assay , Female , Immunohistochemistry , Inflammation/drug therapy , Interleukin-13/metabolism , Interleukin-4/metabolism , Interleukin-5/metabolism , Mice , Mice, Inbred BALB C , Ovalbumin/pharmacology , Tumor Necrosis Factor-alpha/therapeutic use
11.
Article in Korean | WPRIM | ID: wpr-160397

ABSTRACT

Pseudomembranous colitis is a rare disease and is caused by abnormal overgrowth of toxin producing Clostridium difficile colonizing the large bowel of patients undergoing antibiotic therapy. Rifampicin is one of the first line anti-tuberculous agents, used worldwide. However, pseudomembranous colitis related to rifampicin usage is rare. We report a case of pseudomembranous colitis which developed in a 70-year-old male patient during the first line anti-tuberculous therapy including rifampicin. The patient was diagnosed with active pulmonary tuberculosis thirty days earlier. On admission, he suffered watery diarrhea and intermittent abdominal pain for 10 days. Sigmoidoscopic examination revealed diffusely scattered whitish to yellowish pseudomembrane with skipped areas or edematous hyperemic mucosa from rectum to descending colon, and histopathologic findings were consistent with pseudomembranous colitis with typical volcano-like exudate. Symptoms improved after excluding rifampicin and treatment with metronidazole. In patients with persistent diarrhea and abdominal pain receiving anti-tuberculous therapy including rifampicin, rifampicin-associated pseudomembranous colitis should be considered.


Subject(s)
Abdominal Pain , Aged , Clostridioides difficile , Colon , Colon, Descending , Diarrhea , Enterocolitis, Pseudomembranous , Exudates and Transudates , Humans , Male , Metronidazole , Mucous Membrane , Rare Diseases , Rectum , Rifampin , Tuberculosis, Pulmonary
12.
Article in Korean | WPRIM | ID: wpr-163919

ABSTRACT

OBJECTIVES: The matrix metalloproteinases (MMPs) that participate in the extracellular matrix metabolism play a important role in the progression of pulmonary fibrosis. The effects of the MMPs are regulated by several factors including Th-1 cytokines, interferon-gamma (IFN-gamma). Up to now, IFN-gamma is known to inhibit pulmonary fibrosis, but little is known regarding the exact effect of IFN-gamma on the regulation of the MMPs. This study investigated the effects of interferon-gamma on the pulmonary fibrosis and the expression of the lung MMP-2,-9, TIMP-1,-2, and Th-2 cytokines in aa rat model of bleomycin induced pulmonary fibrosis. MATERIALS AND METHODS: Male, specific pathogen-free Sprague-Dawley rats were subjected to an intratracheal bleomycin instillation. The rats were randomized to a saline control, a bleomycin treated, and a bleomycin+IFN-gamma treated group. The bleomycin+IFN-gamma treated group was subjected to an intramuscular injection of IFN-gamma for 14 days. At 3, 7, 14, and 28 days after the bleomycin instillation, the rats were sacrificed and the lungs were harvested. In order to evaluate the effects of the IFN-gamma on lung fibrosis and inflammation, the lung hydroxyproline content, inflammation and fibrosis score were measured. Western blotting, zymography and reverse zymography were performed at 3, 7, 14, 28 days after bleomycin instillation in order to evaluate the MMP-2,-9, and TIMP-1,-2 expression level. ELISA was performed to determine the IL-4 and IL-13 level in a lung homogenate. RESULTS: 1.7 days after bleomycin instillation, inflammatory changes were more severe in the bleomycin+IFN-gamma group than the bleomycin group (bleomycin group : bleomycin+IFN-gamma group=2.08 +/- 0.15 : 2.74 +/- 0.29, P<0.05), but 28 days after bleomycin instillation, lung fibrosis was significantly reduced as a result of the IFN-gamma treatment (bleomycin group : bleomycin+IFN-gamma group=3.94 +/- 0.43 : 2.46 +/- 0.13, P<0.05). 2. 28 days after bleomycin instillation, the lung hydroxyproline content was significantly reduced as a result of IFN-gamma treatment (bleomycin group : bleomycin+IFN-gamma group=294.04 +/- 31.73 micro gram/g : 194.92 +/- 15.51 micro gram/g, P<0.05). 3.Western blotting showed that the MMP-2 level was increased as a result of the bleomycin instillation and highest in the 14 days after bleomycin instillation. 4.In zymography, the active forms of MMP-2 were significantly increased as a result of the IFN-gamma treatment 3 days after the bleomycin instillation, bleomycin+IFN-gamma group (bleomycin group : bleomycin+IFN-gamma group=209.63 +/- 7.60% : 407.66 +/- 85.34%, P<0.05), but 14 days after the bleomycin instillation, the active forms of MMP-2 were significantly reduced as a result of the IFN-gamma treatment (bleomycin group : bleomycin+IFN-gamma group=159.36 +/- 20.93% : 97.23 +/- 12.50%, P<0.05). 5.The IL-4 levels were lower in the bleomycin and bleomycin+IFN-gamma groups but this was not significant, and the IL-13 levels showed no difference between the experiment groups. CONCLUSION: The author found that lung inflammation was increased in the early period but the pulmonary fibrosis was inhibited in the late stage as a result of IFN-gamma. The inhibition of pulmonary fibrosis by IFN-gamma appeared to be associated with the inhibition of MMP-2 activation by IFN-gamma. Further studies on the mechanism of the regulation of MMP-2 activation and the effects of MMP-2 activation on pulmonary fibrosis is warranted in the future.


Subject(s)
Animals , Bleomycin , Blotting, Western , Cytokines , Enzyme-Linked Immunosorbent Assay , Extracellular Matrix , Fibrosis , Humans , Hydroxyproline , Inflammation , Injections, Intramuscular , Interferon-gamma , Interleukin-13 , Interleukin-4 , Lung , Male , Matrix Metalloproteinase 2 , Matrix Metalloproteinases , Metabolism , Models, Animal , Pneumonia , Pulmonary Fibrosis , Rats , Rats, Sprague-Dawley
13.
Article in Korean | WPRIM | ID: wpr-196526

ABSTRACT

Malignant hyperthermia is an inherited hypermetabolic syndrome, characterized by temperature elevation, muscle destruction, muscle rigidity, high oxygen consumption, and metabolic acidosis. It is usually triggered by anesthetic agents and neuromuscular relaxants. We present a case of malignant hyperthermia who developed rhabdomyolysis, acute renal failure, disseminated intravascular coagulopathy following an apparently uneventful general anesthesia. Anesthesia was induced with thiopental sodium and succinylcholine. He was successfully treated with dantrolene along with cardiopulmonary resuscitation and hemodialysis.


Subject(s)
Acidosis , Acute Kidney Injury , Anesthesia , Anesthesia, General , Anesthetics , Cardiopulmonary Resuscitation , Dantrolene , Malignant Hyperthermia , Muscle Rigidity , Oxygen Consumption , Renal Dialysis , Rhabdomyolysis , Succinylcholine , Thiopental
14.
Article in Korean | WPRIM | ID: wpr-50999

ABSTRACT

Although arthralgia with or without hyperuricemia commonly occurs in a patient receiving antituberculous treatment including pyrazinamide, acute gouty arthritis is rarely reported. Here we report a case of acute gouty arthritis presented after antituberculous treatment in a patient with asymptomatic hyperuricemia and mild renal insufficiency. A 76-year-old woman complained sudden onset of painful swelling in both first metatarsophalangeal joints 9 weeks after antituberculous treatment. She had hypertensive nephropathy with mild renal insufficiency and asymptomatic hyperuricemia for 8 years. Needle aspiration of the joint fluid demonstrated needle-shaped strongly negative birefringent monosodium urate crystal. The painful swelling improved with steroid and colchicine.


Subject(s)
Aged , Arthralgia , Arthritis, Gouty , Colchicine , Female , Humans , Hyperuricemia , Joints , Metatarsophalangeal Joint , Needles , Pyrazinamide , Renal Insufficiency , Renal Insufficiency, Chronic , Tuberculosis , Uric Acid
16.
Article in Korean | WPRIM | ID: wpr-47451

ABSTRACT

BACKGROUND: Excessive extracellular matrix (ECM) deposition by airway inflammation is presumed to play an important role in the pathogenesis of worsening airflow obstruction (Ed- acceptable three-word noun) seen during acute exacerbations of chronic bronchitis. Although many proteases can cleave ECM molecules, matrix metalloproteinases (MMPs) and their inhibitors are likely to be the physiologically relevant mediators of ECM degradation. OBJECTIVES: The purpose of this study was to demonstrate that antibiotic treatment can change airway MMPs and TIMP-1 concentrations/levels by controlling airway inflammation in acute exacerbation of chronic bronchitis. METHOD: We studied 40 patients, all of whom had an acute exacerbation of chronic bronchitis. The patients were treated with two different antibiotics, moxifloxacin and clarithromycin, in a double-blind manner for 7 days. Sputum samples were induced and collected before and after antibiotic therapy. We measured the sputum concentration of MMP-1,-9, TIMP-1, IL-8 and secretory leukocyte proteinase inhibitor (SLPI) in sputum supernatants by ELISA method. RESULTS: There was no difference after antibiotic treatment in the sputum concentrations of MMP-1,-9, TIMP-1, IL-8 and SLPI between the patients treated with moxifloxacin and those treated with clarithromycin. But the sputum concentrations of TIMP-1, and SLPI, and the TIMP-1/MMP-1 ratio were significantly reduced by the antibiotic therapy. There were significant positive correlations between sputum TIMP-1 levels and IL-8 levels (p<0.01, r=0.751), and between the sputum TIMP-1/MMP-1 ratio and IL-8 levels (p<0.01, r=0.752). The sputum SLPI levels were significantly elevated by antibiotic treatment and were negatively correlated with sputum TIMP-1 levels (p<0.01, r=-0.496) and TIMP-1/MMP-1 levels (p<0.01, r=-0.456). CONCLUSION: The study shows that the worsening of airway inflammation in acute exacerbation of chronic bronchitis is associated with an imbalance between the concentrations/levels of TIMP-1 and MMPs. Antibiotic treatment can prevent progression of airway narrowing in acute exacerbation of chronic bronchitis by modulation of the protease and anti-protease imbalance.


Subject(s)
Anti-Bacterial Agents , Bronchitis, Chronic , Clarithromycin , Enzyme-Linked Immunosorbent Assay , Extracellular Matrix , Humans , Inflammation , Interleukin-8 , Leukocytes , Matrix Metalloproteinase 1 , Matrix Metalloproteinases , Peptide Hydrolases , Sputum , Tissue Inhibitor of Metalloproteinase-1
17.
Article in Korean | WPRIM | ID: wpr-113079

ABSTRACT

Cryptococcosis is a systemic infection caused by the yeast-like fungus Cryptococcus neoformans. Respiratory tract is the usual portal of infection but relatively few cases of pulmonary cryptococcosis have been reported. Recently the incidence of the disease are increasing because the perception to seek the disease is increasing and immunocompromised hosts are more widespread with introduction of immune-suppressants, steroids and advent of AIDS. Because of nonspecific pattern of clinical manifestation, radiologic findings, differentiating the other diseases is essential and it needs fungal culture and biopsy. We describe a patient in the state of bilateral adrenalectomy due to bilateral ACTH-independent macronodular hyperplasia who developed pulmonary cryptococcosis and was later infected with pulmonary tuberculosis.


Subject(s)
Adrenalectomy , Biopsy , Cryptococcosis , Cryptococcus neoformans , Fungi , Humans , Hyperplasia , Immunocompromised Host , Incidence , Respiratory System , Steroids , Tuberculosis , Tuberculosis, Pulmonary
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