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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 63-69

Clinico-etiological profile of lower respiratory tract infections in HIV-positive patients


Department of Medicine, AMCH, Dibrugarh, Assam, India

Date of Submission22-Jun-2022
Date of Acceptance16-Aug-2022
Date of Web Publication23-Nov-2022

Correspondence Address:
Dr. Malisetty Sreenivas Sai
Department of Medicine, AMCH, Dibrugarh, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ajoim.ajoim_8_22

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  Abstract 

Background: The type of pathogens responsible for opportunistic infections in human immunodeficiency virus (HIV)-infected persons varies from region to region. Till date, very few studies covering respiratory tract infections in HIV-positive patients have been conducted in this part of the country. This study was conducted in order to get better understanding of the clinical picture of lower respiratory tract infections (LRTIs) in HIV-positive patients in this region. Aim: The aim was to study the LRTIs in HIV-positive patients. Settings and Design: Eighty-one patients were diagnosed as HIV-positive with LRTIs, attending to Department of Medicine at Assam Medical College and Hospital, Dibrugarh, Assam, India. Materials and Methods: Personal and family history was collected with emphasis on the duration of HIV-positive status, any chronic illness, sexually transmitted diseases, history of blood transfusions, or any surgical procedures. A detailed general and systemic examination was done. Statistical Analysis Used: The data collected were tabulated in MS Excel and analyzed using SPSS 20.0. The categorical variables were summarized as frequency and percentages. Results: Mycobacterium tuberculosis was responsible for 18.52% of cases of LRTIs, whereas fungal etiology was found in 7.41% of the cases. The most common bacterial and fungal pathogens isolated were Streptococcus pneumoniae (23.46%) and Candida albicans (7.41%), respectively. Conclusion: Low CD4 cell count is an important indicator for the risk of pulmonary tuberculosis and fungal LRTIs, as shown in our study. Periodic CD cell count in HIV-positive patients is important in this regard.

Keywords: CD4, etiological agents, HIV, LRTI


How to cite this article:
Rajkhowa D, Kalita BC, Sai MS. Clinico-etiological profile of lower respiratory tract infections in HIV-positive patients. Assam J Intern Med 2022;12:63-9

How to cite this URL:
Rajkhowa D, Kalita BC, Sai MS. Clinico-etiological profile of lower respiratory tract infections in HIV-positive patients. Assam J Intern Med [serial online] 2022 [cited 2022 Nov 29];12:63-9. Available from: http://www.ajimedicine.com/text.asp?2022/12/2/63/361829


  Introduction Top


Human immunodeficiency virus (HIV) is a member of the human retrovirus family and the lentivirus subfamily. There are two types of HIVs: HIV-1 and HIV-2, with HIV-1 accounting for the vast majority of cases worldwide.[1]

Acquired immunodeficiency syndrome (AIDS) is a multi-system disorder that affects various organs of the body at various stages of the disease. Pulmonary disorders have been observed at all stages of HIV infection. According to reports, 70% of HIV-infected people will experience at least one episode of respiratory illness during the course of their disease. It affects people of all ages and genders. HIV affects nearly every organ system in the body. The pulmonary system is the most commonly involved system in HIV patients.[2]

Lower respiratory tract infections (LRTIs) are one of the leading causes of morbidity and mortality in the world.[3] Diseases of the respiratory tract are responsible for half of deaths from AIDS. Bacterial pneumonia and AIDS can lead to significant morbidity and mortality.[4] Tuberculosis (TB) is the leading cause of death among people living with HIV, responsible for around one in three AIDS-related deaths.[5]

LRTIs are the most frequent respiratory diseases among HIV-infected patients and are frequently the first clinical manifestations of the HIV infections.[6] When compared with general community, LRTI are 25 times more common in patients with HIV.[7]

The type of pathogens responsible for opportunistic infections in HIV-infected persons varies from region to region. So it is important to evaluate the causative agents for the management of such cases.[4] Moreover, prompt diagnosis and early management may hasten the clinical recovery. Also knowledge regarding the incidence and clinical manifestations may help in developing strategies regarding prophylactic therapy of various infections of the respiratory system.[8]

Till date, very few studies covering respiratory tract infections in HIV-positive patients have been conducted in this part of the country. This study was taken up in order to get some better understanding of the clinical picture of LRTIs in HIV-positive patients in this region.


  Materials and Methods Top


Objectives

  • To evaluate the clinical presentation of LRTIs in HIV-positive patients;
  • To find out the etiological agents of LRTIs in HIV-positive patients.


Study population

The study population included patients who were diagnosed as HIV-positive as per National HIV testing strategies with clinical features suggestive of LRTIs, attending ART Center and Medicine Outpatient Department or admitted in various wards of Department of Medicine at Assam Medical College and Hospital, Dibrugarh, Assam, India.

Inclusion criteria

The criteria included all diagnosed cases of HIV-positive, fulfilling the case definition of LRTIs attending ART Center and Medicine Outpatient Department or admitted in various wards of Department of Medicine at Assam Medical College and Hospital, Dibrugarh and willing to give written informed consent.

Exclusion criteria

  • Patients with age less than 13 years;


  • Patients taking anti-tubercular therapy;


  • Patients taking antibiotic therapy in the last 2 weeks;


  • Patients undergoing chemotherapy or radiotherapy;


  • Patients with history of organ transplantation;


  • Patients not willing to give written informed consent.


A detailed history was taken with special reference to complaints of the patient at the time of presentation. Past history was elaborated with emphasis on the duration of HIV-positive status, any chronic illness, sexually transmitted disease, history of blood transfusions, or any surgical procedures. In personal history, subjects were enquired about risk factors for acquisition of HIV, smoking and alcohol habit, or any use of intravenous drug. In family history, patients were enquired about the health status of their family members, especially regarding anyone in the family living with HIV-positive status. With regard to drug history, patients were asked regarding their history of antiretroviral therapy (ART). History of antibiotics, antitubercular therapy, and so on was also enquired and documented. In female patients, menstrual and obstetrical history was enquired. A detailed general and systemic examination was done in all the patients. Important relevant pathological, biochemical, radiological (chest X-ray, CT scan thorax) investigations, and so on were done and findings noted. Sputum examination with Gram stain, Ziehl–Neelsen stain, Geimsa stain, Crystal violet stain, cartridge-based nucleic acid amplification test (CBNAAT), fungal stain, bacterial culture, and fungal culture was done in all the cases.

Statistical analysis

The data collected were tabulated in Microsoft Excel Worksheet, and a computer-based analysis was performed using the Statistical Product and Service Solutions (SPSS) 20.0 software (SPSS, Chicago, IL, USA) and Microsoft Excel 2010. The categorical variables were summarized as frequencies and percentages.


  Results Top


This study was carried out in the Department of Medicine, Assam Medical College and Hospital, Dibrugarh for the period of 1 year from June 1, 2019 to May 31, 2020.

A total of 81 HIV-positive patients fulfilling clinical criteria of LRTIs were taken up for the study, and detailed clinical history, physical examination, and necessary laboratory and radiological investigations were done for the evaluation of the patients.

It is observed that majority of the cases (38.27%) were in the age group of 30–39 years, followed by 24.69% in the age group of 40–49 years. In the age group 13–19, 20–29, 50–59, and ≥ 60 years, the number of cases were 3 (3.70%), 16 (19.75%), 9 (11.11%), and 2 (2.47%), respectively. Mean age in our study was found to be 37.30 ± 10.89 years. The youngest patient in our study was a 13-year-old boy and the oldest patient was a 67-year-old male. Mean age of the HIV-positive patients with LRTIs was 37.30 ± 10.89 years, with the most common age group of 30–39 years [Table 1].
Table 1: Age-wise distribution

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Both males and females were affected, but males outnumbered females with a male–female ratio of 2.24:1.

Heterosexual route was the most common mode of acquisition in our study comprising 73 patients (90.12%). Male sex with male (MSM) accounted for four cases (4.94%). Mother-to-child route of transmission was found in three patients. One patient was intravenous drug user in the study. About 56.79% of the patients were newly diagnosed, whereas 43.21% were previously diagnosed and were on ART during the time of the study [Table 2].
Table 2: Mode of acquisition

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All the patients in our study had fever and cough during presentation. Generalized weakness, breathing difficulty, and weight loss were seen in 44.44%, 32.10%, and 27.16% of the patients, respectively. About 12.35% of the patients had hemoptysis. Smoking was the most common risk factor associated with 56.79% of the cases followed by past history of LRTIs in 24.69%. Diabetic patients were more prone for co-infection with both bacterial and fungal LRTIs. In our study, out of the five cases of LRTI with co-infection, four cases were diabetic [Table 3].
Table 3: Presenting complaints

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Out of the 81 cases of LRTIs, 48 (59.26%) cases were of bacterial etiology other than M. tuberculosis. Six LRTI cases (7.41%) were of fungal etiology. Pulmonary tuberculosis due to M. tuberculosis was found in 15 cases (18.52%). Out of the 15 cases, 7 (8.64%) cases had acid fast bacilli (AFB)-positive sputum smear and 4 cases were detected on sputum examination with CBNAAT. Four patients were having sputum smear-negative pulmonary tuberculosis. P. jiroveci was not detected in our study population [Table 4].
Table 4: Microbial etiology of LRTIs

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About 53.09% of the cases had only bacterial growth in sputum culture, whereas 6.17% of the cases had both bacterial and fungal growth in sputum culture. Approximately 39.51% of the cases did not show any significant growth in sputum culture. Co-infection was most common in HIV-positive people with CD4 cell count <200/mm3. The most common bacterial and fungal pathogens isolated from the patients in our study were Streptococcus pneumoniae (23.46%) and Candida albicans (7.41%), respectively [Table 4].

Out of the 81 LRTI cases of our study, majority (n = 45, 55.56%) were in the group with CD4 cell count in the range of 200–499/mm3, followed by 31 cases (38.27%) with CD4 cell count less than 200/mm3. Five cases (6.17%) had CD4 cell count above 500/mm3.

Majority of the LRTI cases of bacterial etiology (n = 28, 58.33%) were having CD4 cell count in the range of 200–499/mm3, whereas the majority of fungal LRTIs (n = 5, 83.33%) and LRTIs due to M. tuberculosis (n = 11, 73.33%) were having CD4 cell count less than 200/mm3.

Out of the 15 patients of LRTIs with M. tuberculosis as etiology, 11 patients did chest X-ray as shown in [Table 5]. Pulmonary infiltrates (n = 8, 72.73%), pleural effusion (n = 2, 18.18%), and fibrosis (n = 2, 18.18%) were the most common radiological findings in our study. Miliary pattern was seen in one case.
Table 5: Distribution of LRTI cases in relation to CD4 count

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Thirty-four patients with bacterial etiology of LRTIs other than M. tuberculosis underwent radiological investigations. Focal consolidation was the most common finding associated with 25 cases (73.53%), followed by nodular opacity in 4 cases (11.76%). Mediastinal lymphadenopathy and cavitary lesion were seen in one case each [Table 5].

Low CD4 cell count is an important indicator for the risk of pulmonary tuberculosis and fungal LRTIs, as shown in our study. Periodic CD cell count in HIV-positive patients is important in this regard. Effective implementation and integration of National health programs of HIV and TB are important in decreasing the mortality and morbidity of TB associated with HIV infection.

On the basis of these findings, it can be recommended that we should assess LRTIs in HIV-infected persons for the presence of these treatable pathogens as well as the need to consider recurrent LRTIs as a possible presentation of HIV infection which necessitates screening for HIV.

HIV is here to stay but we should aim that no one dies of AIDS and other opportunistic infections. We should invest our efforts into prevention and testing strategies to prevent HIV infection and save lives. Though the efforts to find a cure for this pandemic seem to be a herculean task, research in this field is highly welcomed to save mankind from the grip of this dreaded disease.


  Discussion Top


Age distribution

From the present study, it was seen that majority of the cases (38.27%) were in the age group of 30–39 years followed by 24.69% of the cases in the age group of 40–49 years with a mean age of 37.30 ± 10.89 years. Three cases were in the age group of 13–19 years, whereas two cases were above or equal to 60 years of age.

This finding was in accordance with Shah et al.[8] in their study of HIV-AIDS patients with respiratory manifestations at a tertiary care center, in which the maximum patients belonged to the 30–39 years of age. In their study, 76% patients belonged to the 15–39 age group.

Similar finding was noted by Dhadke et al.[2] in their study of pulmonary involvement in people living with HIV (PLHIV). Most patients were in the age group of 31–50 years of age.

Sex distribution

In our study, male patients accounted for 69.14% (n = 56) and females accounted for 30.86% (25). The male and female ratio was found to be 2.24:1.

Our finding was almost similar to that found by Shah et al.,[8] in their study of HIV-AIDS patients with respiratory manifestation at a tertiary care center. They found that 82% of the patients were male and 18% were female. The male-to-female sex ratio was 1.7:1 in the study of pulmonary involvement in PLHIV by Dhadke et al.[2]

Mane et al.[9] in their study of etiological spectrum of severe community-acquired pneumonia in HIV-positive patients from Pune, India found that bacterial community-acquired pneumonia patients were predominantly male (63.8%).

Marital status

Out of the 81 patients, 61 (75.31%) were married and 20 (24.69%) were not married.

Baruah et al.[10] also reported similar findings with 72.2% of married patients. In the study by Boorsu et al.,[11] 50% of the patients were married.

Mode of acquisition

In our study, the most common route of transmission was found to be the heterosexual route (n = 73, 90.12%) followed by MSM (n = 4, 4.94%). Following the recent legalization of homosexuality in India (decriminalization of section 377 IPC), there may be increase in the cases of MSM route of transmission.

The most common mode of infection of HIV is sexual route. In developing countries, heterosexual route of transmission is most common, although in many western countries male-to-male sexual transmission dominates.[1]

The most common route of transmission was found to be heterosexual (76.7%), followed by MSM (12.2%) in the study done by Baruah et al.[10] Shah et al.[8] found the sexual route as the commonest source of HIV infection. Unprotected heterosexual contact was the commonest mode of HIV transmission in the study by Boorsu et al.[11]

HIV disease status

Out of the 81 patients, 35 (43.21%) were previously diagnosed and were on ART, whereas 46 (56.79%) were newly diagnosed cases.

Khushbu and Satyam[4] in their study found that prevalence of LRTI was higher among cases not under ART (64.8%) compared with those under ART (41.8%).

Risk factors associated with LRTI

In our study, it was found that out of the 81 patients, 46 patients (56.79%) were either current smokers (n = 25, 30.86%) or had history of smoking in the past (n = 21, 25.93%).

It was found from our study that 20 patients (24.69%) had history of LRTIs in the past 1 year, 17 patients (20.99%) were taking alcohol on a regular basis, 11 patients (13.58%) were having diabetes mellitus, and 9 patients (11.11%) were suffering from chronic respiratory disease.

Smoking is an established risk factor for community-acquired pneumonia.[12],[13] In a cohort study of HIV-infected patients by Lamas et al.,[14] it was found that tobacco smoking was associated with increased risks of LRTIs. Davis et al.[15] have mentioned that there is an increased risk of bacterial pneumonia among the HIV-infected people with active cigarette use.

Alcoholism has been associated with defects in innate and adaptive immunity[16] and is a recognized risk factor for community-acquired pneumonia.[17]

Microbial etiology

In our study, out of the 81 cases of LRTIs, bacterial etiology (other than M. tuberculosis) was found in 48 cases (59.26%), fungal etiology in 6 cases (7.41%), and 15 cases (18.52%) had M. tuberculosis as the etiology of LRTIs.

Among the 48 cases of bacterial etiology, 5 cases were having both bacterial and fungal growth on sputum culture. Four out of these five cases were having CD4 cell count less than 200/mm3. Four of them were diabetic patients. All of these cases were either current or former smoker. Out of these five cases of co-infection with both bacteria and fungi, four patients were of more than 40 years of age.

In the study of LRTIs among HIV-positive and control groups in Nepal by Ojha et al.,[18] 85 out of 120 HIV-positive cases were co-infected with one or more microorganisms. HIV-seropositive patients were having higher rate of polymicrobial infection than the normal population. The patients with age more than 40 years had a higher rate of co-infection in their study. Twelve patients out of 120 HIV-positive groups were found to be infected by M. tuberculosis.

Relation to CD4 count

LRTI cases due to M. tuberculosis were most commonly seen in the group with CD cell count less than 200/mm3, accounting for 11 (73.33%) out of the 15 cases. Three cases had CD cell count in the range of 200–499/mm3 and one case had CD4 cell count ≥500/mm3.

Among the six cases with fungal etiology of LRTIs, 5 cases (83.33%) had CD4 cell count less than 200/mm3 and one case was having CD4 cell count in the range of 200–499/mm3.

In the study of 150 patients with HIV-TB co-infection by Boorsu et al.,[11] 126 (84%) patients had CD4 cell count less than 200/mm3 and the remaining 24 (14%) patients had CD4 cell count ≥200/mm3.

Khushbu and Satyam[4] found that LRTI was significantly higher in cases having CD4 count below 200 cells/mm3, followed by those within 200–500 cells/cumm and those with range above 500 cells/mm3.

Hirschtick et al.[19] have found that the rate of bacterial pneumonia was inversely related to the baseline CD4 lymphocyte count.

Radiological findings

Among the 15 cases of LRTIs with M. tuberculosis etiology, 11 cases had radiological investigations. Pulmonary infiltrates were seen in 8 cases (72.73%), pleural effusion, fibrosis, and miliary pattern were seen in 2 (18.18%), 2 (18.18%), and 1 (9.09%) case, respectively.

In the prospective cross-sectional study done by Boorsu et al.,[11] among the 120 patients with TB-HIV co-infection, pulmonary infiltrates were seen in 98 cases (65.33%) and pleural effusion was seen in 24 cases (16%).

In our study of 81 HIV-infected persons with LRTIs, it was revealed that the young productive age group was most commonly affected. Males, due to high-risk sexual activities, are at a higher risk of acquiring HIV infection rendering the housewives a hapless prey to the virus. Lack of proper education and prevailing social stigma among the general population are the most important causes of exponential spread of this dreaded disease. Providing education to our population is crucial in this regard. Practicing safe sexual behaviors will go a long way in reducing the disease burden.

Acknowledgments

It gives us immense pleasure to acknowledge our deep sense of gratitude and profound indebtedness to Prof. (Dr.) Sanjeeb Kakati, MD, Professor and Head, Department of Medicine, Assam Medical College and Hospital, Dibrugarh, Assam, for his valuable suggestions and inspiring guidance, along with his keen and continued interests all throughout the period of this work. It is also our privilege to acknowledge our heartfelt gratitude and indebtedness to Dr. Amrit Kumar Borah, MD, Assistant Professor, Department of Microbiology, Assam Medical College and Hospital, Dibrugarh, Assam, for his constant guidance and supervision during the course of the study. It would be pleasure on our part to express our grateful appreciation to all the patients for their active cooperation and good understanding, without which we could not have been able to conduct this study. We would also like to thank all the staffs of ART Center, AMCH, who were supporting us throughout the study.

Financial support and sponsorship

Self-sponsored.

Conflicts of interest

None.

Ethical policy and Institutional Review Board statement

IEC, Assam Medical College and Hospital, Dibrugarh.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Data availability statement

The data set used in the current study is available on request from Dr. Malisetty Sreenivas Sai ([email protected]).

 
  References Top

1.
Fauci AS. Human immunodeficiency virus disease: AIDS and related disease. Harrison’s Internal Medicine; 2008. p. 1137-204.  Back to cited text no. 1
    
2.
Dhadke SV, Dhadke V, Kshirsagar R, Dhadke M. Pulmonary involvement in peoples living with HIV (PLHIV). J Assoc Physicians India 2019;67:58-61.  Back to cited text no. 2
    
3.
Murray CJ, Lopez AD. Mortality by cause for eight regions of the world: Global burden of disease study. Lancet 1997;349:1269-76.  Back to cited text no. 3
    
4.
Khushbu Y, Satyam P. Bacteriological profile of lower respiratory tract infection (LRTI) among HIV seropositive cases in central terai of Nepal. Int J Curr Microbiol App Sci 2015;4:431-42.  Back to cited text no. 4
    
5.
Global HIV and AIDS statistics—2020 Fact Sheet | UNAIDS [Internet]. [cited Jun 25, 2020]. Available from: http://www.unaids.org/en/resources/fact-sheet. [Last accessed on 18 Dec 2021].  Back to cited text no. 5
    
6.
Mayaud C, Parrot A, Cadranel J. Pyogenic bacterial lower respiratory tract infection in human immunodeficiency virus infected patients. Eur Respir J 2002;20:28-39.  Back to cited text no. 6
    
7.
Feikin DR, Feldman C, Schuchat A, Janoff EN. Global strategies to prevent bacterial pneumonia in adults with HIV disease. Lancet Infect Dis 2004;4:445-55.  Back to cited text no. 7
    
8.
Shah H, Bhatt P, Vaghani B, Patel K. HIV-AIDS patients with respiratory manifestation: Study at tertiary care center. Int J Adv Med 2017;4:270-4.  Back to cited text no. 8
    
9.
Mane A, Gujar P, Gaikwad S, Bembalkar S, Gaikwad S, Dhamgaye T, et al. Aetiological spectrum of severe community-acquired pneumonia in HIV-positive patients from Pune, India. Indian J Med Res 2018;147:202-6.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
Baruah SM, Rajkakati R, Das JK, Barua T. Clinico-epidemiological patterns of HIV positive patients attending a tertiary care hospital. J Evid Based Med Healthc 2018;5:3008-11.  Back to cited text no. 10
    
11.
Boorsu SK, Myreddy VSN, Kandati J, Ponugoti ML, Nandam MR. Clinical and laboratory profile of TB-HIV co-infected patients with relation to CD4 counts in a tertiary care hospital. Int J Res Med Sci 2016;4:4618-23.  Back to cited text no. 11
    
12.
Almirall J, González CA, Balanzó X, Bolíbar I. Proportion of community-acquired pneumonia cases attributable to tobacco smoking. Chest 1999;116:375-9.  Back to cited text no. 12
    
13.
Baik I, Curhan GC, Rimm EB, Bendich A, Willett WC, Fawzi WW. A prospective study of age and lifestyle factors in relation to community-acquired pneumonia in US men and women. Arch Intern Med 2000;160:3082-8.  Back to cited text no. 13
    
14.
Lamas CC, Coelho LE, Grinsztejn BJ, Veloso VG. Community-acquired lower respiratory tract infections in HIV-infected patients on antiretroviral therapy: Predictors in a contemporary cohort study. Infection 2017;45:801-9.  Back to cited text no. 14
    
15.
Davis JL, Fei M, Huang L. Respiratory infection complicating HIV infection. Curr Opin Infect Dis 2008;21:184-90.  Back to cited text no. 15
    
16.
Nelson S, Kolls JK. Alcohol, host defence and society. Nat Rev Immunol 2002;2:205-9.  Back to cited text no. 16
    
17.
Koivula I, Sten M, Mäkelä PH. Risk factors for pneumonia in the elderly. Am J Med 1994;96:313-20.  Back to cited text no. 17
    
18.
Ojha CR, Rijal N, Khagendra KC, Palpasa K, Kansakar P, Gupta BP, et al. Lower respiratory tract infections among HIV positive and control group in Nepal. VirusDisease 2015;26:77-81.  Back to cited text no. 18
    
19.
Hirschtick RE, Glassroth J, Jordan MC, Wilcosky TC, Wallace JM, Kvale PA, et al. Bacterial pneumonia in persons infected with the human immunodeficiency virus. Pulmonary complications of HIV infection study group. N Engl J Med 1995;333:845-51.  Back to cited text no. 19
    



 
 
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