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Gupta L, Raj R, Agarwal S. Theory of Planned Behavior – The Need of the Hour? INDIAN JOURNAL OF RHEUMATOLOGY 2022. [DOI: 10.4103/injr.injr_252_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Xiang L, Low AHL, Leung YY, Fong W, Gandhi M, Yoon S, Lau TC, Koh DR, Thumboo J. Interval between symptom onset and diagnosis among patients with autoimmune rheumatic diseases in a multi-ethnic Asian population. Int J Rheum Dis 2021; 24:1061-1070. [PMID: 34232556 DOI: 10.1111/1756-185x.14165] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/22/2021] [Accepted: 06/13/2021] [Indexed: 12/19/2022]
Abstract
AIM The interval between symptom onset and diagnosis (pre-diagnosis interval) can at times be longer than is ideal in patients with autoimmune rheumatic diseases (ARDs). In this study, we aimed to characterize this interval and to identify its associated factors. METHOD We characterized pre-diagnosis interval into 4 intervals: Interval #1 between symptom onset and first visit to healthcare professionals; Interval #2 between first visit to healthcare professionals and rheumatology referral; Interval #3 between rheumatology referral and first rheumatology assessment; and Interval #4 between first rheumatology assessment and diagnosis. Median regression models were used to identify factors associated with longer pre-diagnosis interval and Interval #1. RESULTS Among 259 patients (median age = 52.0 [41.6-61.9] years, 71% female, rheumatoid arthritis [n = 75], axial spondyloarthritis [axSpA] [n = 40] and psoriatic arthritis [n = 35]), median pre-diagnosis interval was 11.5 (4.7-36.0) months. Interval #1 (median = 4.9 months) was significantly longer than Intervals #2-#4 (median = 0.3, 1.5, and 0.0 months, respectively). Patients with axSpA had significantly longer pre-diagnosis interval (median = 38.7 months) and Interval #1 (median = 26.6 months) than patients with the other ARDs. Median regression suggested that patients referred from specialty care had significantly longer pre-diagnosis interval (median difference = 7.7 months) and Interval #1 (median difference = 6.4 months) compared to those referred from primary care. CONCLUSION A long pre-diagnosis interval was observed among patients with ARDs (especially axSpA), due largely to a long interval between symptom onset and the first visit to healthcare professionals. This highlights the importance of interventions targeting patients prior to their first visit to healthcare professionals in reducing pre-diagnosis interval.
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Affiliation(s)
- Ling Xiang
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andrea Hsiu Ling Low
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Ying Ying Leung
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Warren Fong
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
| | - Mihir Gandhi
- Health Services and Systems Research, Duke-NUS Medical School, Singapore.,Biostatistics, Singapore Clinical Research Institute.,Tampere Center for Child Health Research, Tampere University, Tampere, Finland
| | - Sungwon Yoon
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Tang Ching Lau
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Medicine, National University Hospital, Singapore
| | - Dow Rhoon Koh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Department of Medicine, National University Hospital, Singapore
| | - Julian Thumboo
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore.,Duke-NUS Medical School, Singapore
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Jain S, Dhir V, Aggarwal A, Gupta R, Leishangthem B, Naidu S, Khullar A, Maurya S, Dhawan V, Sharma SK, Sharma A, Jain S. Comparison of two dose escalation strategies of methotrexate in active rheumatoid arthritis: a multicentre, parallel group, randomised controlled trial. Ann Rheum Dis 2021; 80:1376-1384. [PMID: 34112656 DOI: 10.1136/annrheumdis-2021-220512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/25/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES There are no head-to-head trials of different dose escalation strategies of methotrexate (MTX) in RA. We compared the efficacy, safety and tolerability of 'usual' (5 mg every 4 weeks) versus 'fast' (5 mg every 2 weeks) escalation of oral MTX. METHODS This multicentre, open-label (assessor blinded) RCT included patients 18-55 years of age having active RA with disease duration <5 years, and not on DMARDs. Patients were randomized 1:1 into usual or fast escalation groups, both groups starting MTX at 15 mg/week till a maximum of 25 mg/week. Primary outcome was EULAR good response at 16 weeks, secondary outcomes were ΔDAS28 and adverse effects (AE). Analyses were intention-to-treat. RESULTS 178 patients with mean DAS28-CRP of 5.4(1.1) were randomized to usual (n=89) or fast escalation groups (n=89). At 16 weeks, there was no difference in good EULAR response in the usual (28.1%) or fast escalation (22.5%) groups (p=0.8). There was no difference in mean ΔDAS28-CRP at 8 weeks (-0.9, -0.8, p=0.72) or 16 weeks (-1.3, -1.3, p=0.98). Even at 24 weeks (extended follow-up), responses were similar. There were no inter-group differences in ΔHAQ, or MTX-polyglutamates 1-3 levels at 8 or 16 weeks. Gastrointestinal AE were higher in the fast escalation group over initial 8 weeks (27%, 40%, p=0.048), but not over 16 weeks. There was no difference in cytopenias, transaminitis, or drug discontinuation/dose reduction between the groups. No serious AE were seen. CONCLUSION A faster MTX escalation strategy in RA was not more efficacious over 16-24 weeks, and did not significantly increase AE, except higher gastrointestinal AE initially. TRIAL REGISTRATION NUMBER CTRI/2018/12/016549.
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Affiliation(s)
- Siddharth Jain
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Varun Dhir
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ranjan Gupta
- Department of Rheumatology, All India Institute of Medical Sciences, New Delhi, India
| | - Bidyalaxmi Leishangthem
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shankar Naidu
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aastha Khullar
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Supriya Maurya
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Veena Dhawan
- Department of Experimental Medicine and Biotechnology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shefali Khanna Sharma
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Aman Sharma
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sanjay Jain
- Division of Clinical Immunology and Rheumatology, Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Ahmed S, Zimba O, Gasparyan AY. Moving towards online rheumatology education in the era of COVID-19. Clin Rheumatol 2020; 39:3215-3222. [PMID: 32939569 PMCID: PMC7494363 DOI: 10.1007/s10067-020-05405-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 09/06/2020] [Accepted: 09/12/2020] [Indexed: 12/28/2022]
Abstract
The coronavirus disease-2019 (COVID-19) pandemic has unsettled conventional medical education, hastening a switch to digital platforms and open-access publishing. Rheumatology is a fast evolving academic discipline that stands to gain by this switch. Most rheumatology textbooks are now available in digital formats, and these are complemented with live updating educational hubs such as UpToDate and ClinicalKey. Emerging topics of COVID-19 on these proprietary platforms are now freely available to all specialists. Social media channels, particularly Twitter, are becoming major players in the era of COVID-19 by offering online journal clubs, enabling fast dissemination of influential articles, and facilitating interactive education. Indexed rheumatology journals, in turn, aid online education by opening access to recommendations and other materials that are rapidly changing research and practice worldwide. Research peer review additionally offers learning experience to novice and seasoned researchers and authors. Global rheumatology societies have online learning resources, which are changing their format and geographic reach to meet the changing needs in the times of pandemic. While online teaching lacks emotional connections between mentors and mentees, switch to a more interactive format of education and regular contacts may partly solve the issue. Rheumatologists can take the lead in these challenging times and contribute more to online scholarly activities which are aimed to maintain and enrich education. Key Points • Disparities in rheumatology education are likely to be widened during the COVID-19 pandemic. • Barriers to rheumatology education include limited number of instructors and their limited experience in online teaching. • Online textbooks, didactic materials of indexed rheumatology journals, and frequently updated online educational hubs such as UpToDate serve as a foundation of online rheumatology education. • Online rheumatology education is enriched by peer review and social media activities, which are becoming major players in the time of the COVID-19 pandemic.
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Affiliation(s)
- Sakir Ahmed
- Department of Clinical Immunology & Rheumatology, Kalinga Institute of Medical Sciences (KIMS), KIIT University, Bhubaneswar, 751024, India
| | - Olena Zimba
- Department of Internal Medicine No. 2, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Armen Yuri Gasparyan
- Departments of Rheumatology and Research and Development, Russells Hall Hospital, Dudley Group NHS Foundation Trust (Teaching Trust of the University of Birmingham, UK), Pensnett Road, Dudley, West Midlands, DY1 2HQ, UK.
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Rastogi S. Emanating the specialty clinical practices in Ayurveda: Preliminary observations from an arthritis clinic and its implications. J Ayurveda Integr Med 2020; 12:52-57. [PMID: 32247569 PMCID: PMC8039344 DOI: 10.1016/j.jaim.2019.09.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 09/21/2019] [Accepted: 09/26/2019] [Indexed: 02/07/2023] Open
Abstract
Despite their historical praise, specialty studies and practices are not generally seen in current Ayurvedic education and practice. Current Ayurvedic education by and large is devoid of training programs focusing upon specialty based health care delivery. This makes many disappointed who look at Ayurveda for a focused and specialized health care. The consequences of this gap in demand and supply are alarmingly obvious. With its unfocused health care approach, the Ayurvedic health care remains generic for large section of its delivery. There are no referral settings in Ayurveda to get a higher level of care better than the one offered at a primary health care setting. This apparent lack of expertise care in Ayurveda shifts it as an alternative health care used only on the instances of failure of other trusted options. Specialty clinical practices in Ayurveda seem highly important in order to build the trust and to enhance its quality of health care delivery. Our preliminary observations from a deemed arthritis clinic at an Ayurveda teaching hospital, visited by a diverse joint disease population carves a path in this direction and proposes the possibilities of using it as a template for the qualitative improvements in Ayurvedic health care delivery in the country in various clinical areas.
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Affiliation(s)
- Sanjeev Rastogi
- State Ayurvedic College and Hospital, Tulsi Das Marg, Lucknow, 226003, India.
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Aggarwal A, Haq SA. Rheumatology workforce issues in South Asia: Challenges and solutions. Int J Rheum Dis 2020; 23:443-447. [PMID: 31960604 DOI: 10.1111/1756-185x.13793] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/27/2019] [Accepted: 12/29/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
| | - Syed Atiqul Haq
- Department of Rheumatology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh
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Rocha FAC, Landim JIVD, da Rocha LN. Advances in rheumatology practice in Brazil. Rheumatol Int 2018; 39:1125-1134. [PMID: 30506466 DOI: 10.1007/s00296-018-4211-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 11/21/2018] [Indexed: 02/07/2023]
Abstract
Despite resilient inequities, Brazil has seen progressive improvement in health care in the last 25 years. Infectious diseases rendered place to chronic non-communicable diseases as a major cause of death. Existence of traditional schools of medicine and training services in rheumatology helped form a reasonable number of specialists, though irregular distribution due to the economic issues favoring their clustering in major cities. The Brazilian Society of Rheumatology provides continued medical education, helps training rheumatologists, family physicians and other health professionals and has worked to publish national recommendations for the diagnosis and treatment of major rheumatic diseases. Access to medications and health care facilities is provided for most patients, free of direct charge, including biologics. Specialized services for autoimmune and rare diseases, including pediatric rheumatology and autoinflammatory diseases, have improved, particularly in developed centers of the southern best developed parts of the country. A major unmet need is the lack of access to non-pharmacological treatment modalities. In this article, we will summarize some of the strengths and points that need improvement to enhance access to the rheumatological health care in Brazil.
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Affiliation(s)
- Francisco Airton Castro Rocha
- Laboratório de Investigação em Osteoartropatias, Department of Internal Medicine, Liga de Reumatologia e Doenças Autoimunes, Instituto de Biomedicina, Faculdade de Medicina, Federal University of Ceará, Rua Cel. Nunes de Melo, 1315, 1°. Andar, Rodolfo Teófilo, Fortaleza, CE, 60430-270, Brazil.
| | - Joaquim Ivo Vasques Dantas Landim
- Laboratório de Investigação em Osteoartropatias, Department of Internal Medicine, Liga de Reumatologia e Doenças Autoimunes, Instituto de Biomedicina, Faculdade de Medicina, Federal University of Ceará, Rua Cel. Nunes de Melo, 1315, 1°. Andar, Rodolfo Teófilo, Fortaleza, CE, 60430-270, Brazil
| | - Leila Nascimento da Rocha
- Laboratório de Investigação em Osteoartropatias, Department of Internal Medicine, Liga de Reumatologia e Doenças Autoimunes, Instituto de Biomedicina, Faculdade de Medicina, Federal University of Ceará, Rua Cel. Nunes de Melo, 1315, 1°. Andar, Rodolfo Teófilo, Fortaleza, CE, 60430-270, Brazil
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Abstract
The practice of rheumatology in a country like India presents its own unique challenges, including the need to manage patients in a cost-constrained setting, where the lack of uniform government funding for healthcare merits the need to optimize the use of cheaper medicines, as well as devise innovative strategies to minimize the use of costlier drugs such as biologic disease-modifying agents. Use of immunosuppressive agents is also associated with increased risks of infectious complications, such as the reactivation of tuberculosis. In this narrative review, we provide a flavor of such challenges unique to Rheumatology practice in India, and review the published literature on the management of common rheumatic diseases from India. In addition, we critically review existing guidelines for the management of rheumatic diseases from this part of the world. We also discuss infectious etiologies of rheumatic complaints, such as leprosy, tuberculosis, and Chikungunya arthritis, which are often encountered here, and pose a diagnostic as well as therapeutic challenge for clinicians. There remains a need to identify and test more cost-effective strategies for Indian patients with rheumatic diseases, as well as the requirement for more government participation to enhance scant facilities for the treatment of such diseases as well as foster the development of healthcare services such as specialist nurses, occupational therapists and physiotherapists to enable better management of these conditions.
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Handa R, Upadhyaya S, Kapoor S, Jois R, Pandey BD, Bhatnagar AK, Khanna A, Goyal V, Kumar K. Tuberculosis and biologics in rheumatology: A special situation. Int J Rheum Dis 2017; 20:1313-1325. [PMID: 28730751 DOI: 10.1111/1756-185x.13129] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
India has a huge patient burden of rheumatic diseases (RDs) including rheumatoid arthritis. The use of biologics has transformed the treatment paradigm for RD; however, biologic treatment-related infections (especially tuberculosis [TB]) are an area of potential concern for TB-endemic nations like India. Anti-tumor necrosis factor (TNF) therapy impairs the physiological TNF-mediated signaling and may cause reactivation and dissemination of latent TB infection (LTBI). Careful screening is, thus, crucial in RD patients who are about to commence anti-TNF treatment. To date, there is no consensus available for the screening, evaluation and treatment of LTBI as well as on the drug dosage and duration regimen (monotherapy or combination therapy) in the Indian population. An evidence-based algorithm for LTBI screening and management in RD patients undergoing biologic disease-modifying anti-rheumatic drug therapy is suggested in this review for Indian rheumatologists. The proposed algorithm guides physicians through a step-wise screening approach, including medical history, tuberculin skin test, interferon gamma release assay, chest radiograph and management of LTBI with isoniazid therapy or its combination with rifampicin. Further, the provided algorithm can aid the national bodies (such as National TB Control Program) in formulating recommendations for LTBI in this high-risk population.
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Affiliation(s)
- Rohini Handa
- Department of Rheumatology, Indraprastha Apollo Hospital, New Delhi, India
| | - Sundeep Upadhyaya
- Department of Rheumatology, Indraprastha Apollo Hospital, New Delhi, India
| | - Sanjiv Kapoor
- Department of Rheumatology, Indian Spinal Injuries Center, New Delhi, India
| | - Ramesh Jois
- Department of Rheumatology, Fortis Hospital, Bangalore, India
| | | | - Anuj K Bhatnagar
- Rajan Babu Institute of Pulmonary Medicine and Tuberculosis, New Delhi, India
| | | | - Vishal Goyal
- Medical Affairs Department, Janssen India, Johnson & Johnson Pvt. Ltd., Mumbai, India
| | - Kamal Kumar
- Medical Affairs Department, Janssen India, Johnson & Johnson Pvt. Ltd., Mumbai, India
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Misra DP, Agarwal V, Negi VS. Rheumatology in India: a Bird's Eye View on Organization, Epidemiology, Training Programs and Publications. J Korean Med Sci 2016; 31:1013-9. [PMID: 27365996 PMCID: PMC4900990 DOI: 10.3346/jkms.2016.31.7.1013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 04/04/2016] [Indexed: 11/20/2022] Open
Abstract
India is home to the world's second largest population. Rheumatology is an emerging specialty in India. We reviewed organization, epidemiology and training facilities for Rheumatology in India. Also, we also looked at publications in the field of rheumatology from India from over the past six years using Scopus and Medline databases. Despite rheumatologic disorders affecting 6%-24% of the population, rheumatology in India is still in its infancy. Till recently, there were as few as two centers in the country training less than five fellows per year. However, acute shortage of specialists and increasing patient numbers led to heightened awareness regarding the need to train rheumatologists. Subsequently, six new centers have now started 3-year training programs in rheumatology. The epidemiology of rheumatic diseases in India is being actively studies under the Community Oriented Programme for Control of Rheumatic Diseases (COPCORD) initiative. The most number of publications on rheumatic diseases from India are on rheumatoid arthritis, lupus and osteoporosis, many of which have been widely cited. Major collaborators worldwide are USA, UK and France, whereas those from Asia are Japan, Saudi Arabia and Singapore. The Indian Rheumatology Association (IRA) is the national organization of rheumatologists. The flagship publication of the IRA, the Indian Journal of Rheumatology, is indexed in Scopus and Embase. To conclude, rheumatology in India is an actively expanding and productive field with significant contributions to world literature. There is a need to train more personnel in the subject in India.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
| | - Vikas Agarwal
- Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Vir Singh Negi
- Department of Clinical Immunology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
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Affiliation(s)
- Bharat Kumar
- Division of Immunology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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