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Owda F, Mallah S, Ayyad M, Albandak M, Yousef S, Hmeedan A, Odeh M, Reid AM, Sleibi W, Azar J. A Very Uncommon Case of Transudative Chylothorax: A Case Report and Literature Review. Cureus 2023; 15:e38320. [PMID: 37261168 PMCID: PMC10227672 DOI: 10.7759/cureus.38320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/29/2023] [Indexed: 06/02/2023] Open
Abstract
The presence of chyle in the pleural cavity is referred to as chylothorax. Exudative chylothorax is usually related to damage or obstruction of the lymphatic vasculature with subsequent leakage into the pleural space. In contrast, transudative chylothorax is related to increased hydrostatic pressure caused by elevated intra-abdominal pressure, which leads to the translocation of chylous fluid into the pleural space. Cirrhosis is the most common cause of transudative chylothorax, commonly presenting with ascites and portal hypertension. To the best of our knowledge, isolated transudative chylothorax as a consequence of cirrhosis is exceptionally rare and has been scarcely reported in the literature. We herein report a female patient in her fifties who presented to our hospital with isolated unilateral transudative hepatic chylothorax, with no clinical evidence of cirrhosis or any stigmata of portal hypertension at the time of presentation.
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Affiliation(s)
- Fahed Owda
- Internal Medicine, An-Najah National University, Nablus, PSE
| | - Shatha Mallah
- Internal Medicine, An-Najah National University, Nablus, PSE
| | | | | | - Shahed Yousef
- School of Medicine, Al-Quds University, Jerusalem, PSE
| | - Alaa Hmeedan
- Internal Medicine, An-Najah National University, Nablus, PSE
| | - Mahmoud Odeh
- Internal Medicine, An-Najah National University, Nablus, PSE
| | - Adam M Reid
- Research, University of California Los Angeles, California, USA
| | - Wadi Sleibi
- Internal Medicine, Al-Quds University, Jerusalem, PSE
| | - Jehad Azar
- Respiratory Institute, Cleveland Clinic, Cleveland, USA
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Lu HL, Xuan FF, Luo YC, Qin X. Efficacy and safety of transjugular intrahepatic portosystemic shunt combined with transcatheter embolization/chemoembolization in hepatocellular carcinoma with portal hypertension and arterioportal shunt. Abdom Radiol (NY) 2021; 46:5417-5427. [PMID: 34302511 DOI: 10.1007/s00261-021-03214-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/11/2021] [Accepted: 07/12/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVES This study seeks to assess the efficacy and safety of transjugular intrahepatic portosystemic shunt (TIPS) combined with transarterial embolization/transarterial chemoembolization (TAE/TACE) in hepatocellular carcinoma (HCC) with portal hypertension and arterioportal shunt (APS). METHODS Consecutive hospitalized patients having HCC accompanied by portal hypertension and APS were retrospectively analyzed. A total of 103 patients were enrolled. Of them, 26 patients were in Group A and 77 patients were in Group B according to the treatment protocol (Group A: TIPS plus TAE/TACE; Group B: TAE/TACE alone). The clinical outcomes and survival rate were compared between the two groups. RESULTS The mean survival time in Group A and Group B were 14 mo and 9.9 mo, respectively, with statistical difference (p = 0.043). The immediate APS improvement rate was 95.2% in Group A and 91.9% in Group B, respectively, with no signficant difference (p = 1.000). However, the first follow-up consultation revealed that APS improvement rate in Group A was more obvious (66.7% vs 27.4%, p = 0.001). Objective response rate of HCC tended to be greater in Group A compared with Group B (65.4% vs 38.7%, p = 0.019). Liver function parameters significantly increased in Group A than those in Group B. After TIPS placement, the mean portal pressure gradient decreased from 32.61 ± 8.87 mmHg to 15.61 ± 8.15 mmHg, with significant difference (p = 0.000). The rate of absorption of ascites and control of variceal bleeding were statistically different between the two groups (p = 0.045 and 0.039, respectively). CONCLUSION Our research suggests that TIPS combined with TAE/TACE seems to be safe and efficacious in patients with HCC accompanied by portal hypertension and APS, albeit may be accompanied by liver function damage.
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Rajesh S, George T, Philips CA, Ahamed R, Kumbar S, Mohan N, Mohanan M, Augustine P. Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update. World J Gastroenterol 2020; 26:5561-5596. [PMID: 33088154 PMCID: PMC7545393 DOI: 10.3748/wjg.v26.i37.5561] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 07/31/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.
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Affiliation(s)
- Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sandeep Kumbar
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Narain Mohan
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced GI Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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Migaou A, Ben Saad A, Baili H, Mhamed SC, Achour A, Bouhlel W, Fahem N, Abdelaaly M, Rouatbi N, Joobeur S. Transudative chylothorax in liver cirrhosis; an underappreciated entity. Respir Med Case Rep 2020; 31:101151. [PMID: 32714824 PMCID: PMC7369586 DOI: 10.1016/j.rmcr.2020.101151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 07/03/2020] [Indexed: 02/07/2023] Open
Abstract
Chylothorax is a rare pathology with potentially severe consequences. Transudative chylothorax remain an extremely rare entity. Cirrhosis is often an underappreciated cause. We report a case of transudative chylothorax in 62-year-old woman with cirrhosis due to hepatitis C.
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Affiliation(s)
- Asma Migaou
- Pulmonology Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
| | - Ahmed Ben Saad
- Pulmonology Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
| | - Hassene Baili
- Pulmonology Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
| | | | - Asma Achour
- Radiology Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
| | - Wided Bouhlel
- Gastrology Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
| | - Nesrine Fahem
- Pulmonology Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
| | - Mabrouk Abdelaaly
- Radiology Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
| | - Naceur Rouatbi
- Pulmonology Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
| | - Samah Joobeur
- Pulmonology Department, Fattouma Bourguiba Hospital, Monastir, Tunisia
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Cocomazzi F, Castellaneta NM, Castellaneta A, Fucilli F, Ierardi E, Di Leo A. Transjugular intrahepatic portosystemic shunt for a patient with chylothorax in cryptogenic/metabolic cirrhosis. Hepatobiliary Pancreat Dis Int 2020; 19:303-304. [PMID: 32284259 DOI: 10.1016/j.hbpd.2020.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 03/10/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Francesco Cocomazzi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | | | - Antonino Castellaneta
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Fabio Fucilli
- Radiology Unit, IRCCS De Bellis, Castellana Grotte, Bari, Italy
| | - Enzo Ierardi
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Alfredo Di Leo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy.
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Transjugular Intrahepatic Portosystemic Shunt (TIPS) in Refractory Transudative Chylothorax due to Liver Cirrhosis. Case Rep Med 2020; 2020:2581040. [PMID: 32089702 PMCID: PMC7029287 DOI: 10.1155/2020/2581040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 09/20/2019] [Accepted: 10/29/2019] [Indexed: 12/11/2022] Open
Abstract
Chylothorax is an infrequent type of pleural effusion, typically exudative, caused by obstruction or laceration of the thoracic duct by malignancy, trauma, or thoracic surgery. Transudative chylous pleural effusions are extremely rare. We report a case of a 63-year-old male with recurrent transudative chylothorax secondary to cirrhosis that completely resolved with transjugular intrahepatic portosystemic shunting (TIPS). Transudative chylous pleural effusion is an extremely rare entity with only a few cases reported in the literature to date. Transudative chylothorax can occur in patients with liver cirrhosis. Recognizing this association will prevent unnecessary testing and procedures. Timely diagnosis and early initiation of treatment are pivotal in preventing complications from malnutrition and infection by preventing loss of electrolytes, immunoglobulins, and T-lymphocytes.
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Proton Pump Inhibitor Therapy and Hepatic Encephalopathy Risk in Cirrhotic Patients: A Systematic Review with Meta-analysis. Clin Drug Investig 2019; 39:847-856. [DOI: 10.1007/s40261-019-00810-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Koshima Y, Miyazaki S, Ninomiya J, Kuno Y, Ikeda T. Transudative chylothorax associated with alcoholic cirrhosis. Oxf Med Case Reports 2019; 2019:omz019. [PMID: 30949356 PMCID: PMC6440272 DOI: 10.1093/omcr/omz019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/10/2019] [Accepted: 02/23/2019] [Indexed: 02/07/2023] Open
Abstract
We present the case of a 53-year-old man with decompensated alcoholic cirrhosis who was referred for right pleural effusion. After investigation, the patient was ultimately diagnosed with cirrhotic chylothorax. Chylothorax is a rare manifestation of cirrhosis, which results from the trans-diaphragmatic passage of chylous ascites. While chylothorax generally results in an exudative pleural effusion, cirrhotic chylothorax is always a transudative effusion. Biochemical characteristics are useful for diagnosis, avoiding potentially harmful diagnostic and therapeutic procedures.
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Affiliation(s)
- Yusuke Koshima
- Junior Resident, Yokkaichi Municipal Hospital, Sibata2-2-37, Shibata, Yokkaichi-shi, Mie, Japan
| | - Shinichi Miyazaki
- Department of Respiratory Medicine, Yokkaichi Municipal Hospital, Sibata2-2-37, Shibata, Yokkaichi-shi, Mie, Japan
| | - Jun Ninomiya
- Department of Gastroenterology, Yokkaichi Municipal Hospital, Sibata2-2-37, Shibata, Yokkaichi-shi, Mie, Japan
| | - Yasumasa Kuno
- Department of Respiratory Medicine, Yokkaichi Municipal Hospital, Sibata2-2-37, Shibata, Yokkaichi-shi, Mie, Japan
| | - Takuya Ikeda
- Department of Respiratory Medicine, Yokkaichi Municipal Hospital, Sibata2-2-37, Shibata, Yokkaichi-shi, Mie, Japan
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Lizaola B, Bonder A, Trivedi HD, Tapper EB, Cardenas A. Review article: the diagnostic approach and current management of chylous ascites. Aliment Pharmacol Ther 2017; 46:816-824. [PMID: 28892178 DOI: 10.1111/apt.14284] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 07/15/2017] [Accepted: 08/11/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND Chylous ascites is rare, accounting for less than 1% of cases. An appropriate and stepwise approach to its diagnosis and management is of key importance. AIM To review the current diagnostic approach and management of chylous ascites. METHODS A literature search was conducted using PubMed using the key words 'chylous', 'ascites', 'cirrhosis', 'pathophysiology', 'nutritional therapy', 'paracentesis", "transjugular intrahepatic portosystemic shunt" and "TIPSS'. Only articles in English were included. RESULTS Chylous ascites is caused by the traumatic or obstructive disruption of the lymphatic system that leads to extravasation of thoracic or intestinal lymph into the abdominal space and the accumulation of a milky fluid rich in triglycerides. The most common causes are malignancy, cirrhosis and trauma after abdominal surgery. This condition can lead to chyle depletion, which results in nutritional, immunologic and metabolic deficiencies. An ascitic triglyceride concentration above 200 mg/dL is consistent with chylous ascites. Treatment is based on management of the underlying cause and nutritional support. CONCLUSIONS Chylous ascites is mostly due to malignancy and cirrhosis in adults, and congenital lymphatic disorders in children. Treatment with nutritional optimization and management of the underlying etiology are the cornerstones of therapy. When conservative measures fail, other interventions such as octreotide/somatostatin analogues, surgical ligation, embolization and transjugular intrahepatic portosystemic shunt in patients with cirrhosis can be considered.
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Affiliation(s)
- B Lizaola
- Department of Medicine, St. Elizabeth Medical Center, Brighton, MA, USA
| | - A Bonder
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - H D Trivedi
- Liver Center, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - E B Tapper
- Department of Gastroenterology, University of Michigan, Ann Arbor, MI, USA
| | - A Cardenas
- GI/Liver Unit, Institute of Digestive Diseases and Metabolism, University of Barcelona, Hospital Clinic and Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS), Barcelona, Spain
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Tsauo J, Shin JH, Han K, Yoon HK, Ko GY, Ko HK, Gwon DI. Transjugular Intrahepatic Portosystemic Shunt for the Treatment of Chylothorax and Chylous Ascites in Cirrhosis: A Case Report and Systematic Review of the Literature. J Vasc Interv Radiol 2016; 27:112-6. [PMID: 26723922 DOI: 10.1016/j.jvir.2015.09.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/25/2015] [Accepted: 09/26/2015] [Indexed: 02/07/2023] Open
Abstract
Cirrhosis-related chylothorax and chylous ascites are rare conditions. The pathophysiologic mechanism of cirrhosis-related chylous fluid collections is believed to be excessive lymph flow resulting from portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) creation is a well-established method for reducing portal hypertension. The case of a 61-year-old man with cirrhosis-related chylothorax treated successfully with a TIPS is described. A systematic review of the literature revealed nine additional cases of chylothorax or chylous ascites treated successfully with a TIPS. These cases showed that TIPS creation may be effective and safe for the treatment of chylous fluid collections in patients with cirrhosis.
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Affiliation(s)
- Jiaywei Tsauo
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea.
| | - Kichang Han
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Hyun-Ki Yoon
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Gi-Young Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Heung-Kyu Ko
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
| | - Dong-Il Gwon
- Department of Radiology and Research Institute of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, 86, Asanbyeongwon-gil, Songpa-gu, Seoul 138-736, Korea
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Bhardwaj H, Bhardwaj B, Awab A. Transudative chylothorax in a patient with liver cirrhosis: A rare association. Heart Lung 2015; 44:363-5. [PMID: 25941072 DOI: 10.1016/j.hrtlng.2015.03.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 03/13/2015] [Accepted: 03/13/2015] [Indexed: 02/07/2023]
Abstract
Chylothorax is an unusual type of pleural effusion which results from the accumulation of chyle in the pleural cavity. High triglyceride content and presence of chylomicrons in the chyle give this fluid a characteristic milky appearance. Chylothorax most commonly results from the obstruction of the thoracic duct by a malignant lesion or from its traumatic disruption. Liver cirrhosis is an uncommon and frequently underappreciated cause of chylothorax. Pleural effusion in chylothorax is typically described as a lymphocytic predominant, exudative type and it is exceedingly rare to encounter a transudative type of chylothorax. To date, very few cases of transudative chylothoraces have been described in the literature, most commonly in association with liver cirrhosis. Only a limited range of other clinical settings have been linked to transudative chylothorax and timely recognition of these associations can prevent unnecessary, expensive and sometimes invasive workup in this patient population.
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Affiliation(s)
- Himanshu Bhardwaj
- Pulmonary Medicine & Critical Care, Internal Medicine, University of Oklahoma Health Sciences Center, P.O. Box 26901, WP1310, Oklahoma City, OK 73190, USA.
| | - Bhaskar Bhardwaj
- Internal Medicine, University of Missouri Kansas City, 2411 Holmes Street, Kansas City, MO 64108, USA
| | - Ahmed Awab
- Pulmonary Medicine & Critical Care, Internal Medicine, University of Oklahoma Health Sciences Center, P.O. Box 26901, WP1310, Oklahoma City, OK 73190, USA
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