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Open the lung with high-frequency oscillation ventilation or conventional mechanical ventilation? It may not matter!
Vito Fanelli, Sangeeta Mehta
Critical Care , 2010, DOI: 10.1186/cc9343
Abstract: Dispute regarding the optimal levels of PEEP in ARDS patients represents the substrate for a translational research effort from the bedside to the bench, driving animal studies aimed at elucidating which ventilation strategies reduce biotrauma, considered one of the most important driving forces of VILI and ARDS-related multi-organ failure and mortality. Inappropriate values for end-inspiratory or end-expiratory pressure have clear potential to damage a lung predisposed to VILI. In the heterogeneous environment of the ARDS 'baby lung', lung recruitment and the avoidance of tidal overstretch with high-frequency oscillation ventilation or conventional mechanical ventilation, guided by respiratory mechanics, appears to reduce VILI.In the previous issue of Critical Care, Krebs and colleagues [1] elegantly demonstrated that an 'open lung' ventilation strategy using high-frequency oscillation ventilation (HFOV) or conventional mechanical ventilation (CMV) has the potential to mitigate ventilator-induced lung injury (VILI) compared to low positive end-expiratory pressure (PEEP) CMV. Using two animal models of lung injury (saline-lavage and lipopolysac-charide (LPS)), they randomized rats to three ventilation strategies: CMV and low PEEP, CMV and high PEEP (pursuing an 'open lung' strategy), and HFOV. In both CMV groups protective ventilation was ensured by limiting tidal volume to 6 ml/kg. Compared to the low PEEP group, the open lung approach, whether applied with CMV or HFOV, was able to reduce VILI, as demonstrated by improvements in the respiratory system elastance, oxygenation, and histological lung injury score, as well as reduced expression of inflammatory cytokines. Moreover, comparing rats randomized to the two open lung approaches, HFOV resulted in better oxygenation than CMV with high PEEP, but elastance, lung injury and cytokine levels did not differ between the two groups.Pivotal animal studies have eloquently demonstrated the deleterious effects of mechanical
Bench-to-bedside review: High-frequency oscillatory ventilation in adults with acute respiratory distress syndrome
James Downar, Sangeeta Mehta
Critical Care , 2006, DOI: 10.1186/cc5096
Abstract: Mechanical ventilation remains the cornerstone of therapy for patients with acute respiratory distress syndrome (ARDS) and acute lung injury. Paradoxically, mechanical ventilation has the potential to cause further lung injury in patients with ARDS and acute lung injury – a phenomenon known as ventilator-induced lung injury, which occurs when alveolar overdistension due to high ventilator pressures or volumes disrupts the alveolar epithelial membrane (volutrauma) [1]. Lung injury can also occur in the setting of repeated opening and closing of alveoli due to inadequate end-expiratory alveolar recruitment, which can disrupt both the alveolar epithelial and capillary endothelial membranes (atelectrauma). These mechanical insults lead to the release of inflammatory cytokines that further exacerbate lung injury and may contribute to the development of multiple organ failure [1-3].Lung-protective conventional ventilation (CV) strategies are structured to limit alveolar overdistension, with the use of small tidal volumes and low end-inspiratory pressures, and to avoid repeated end-expiratory alveolar collapse with adequate positive end-expiratory pressure. Such a strategy was evaluated in the ARDS Network trial, and was associated with a 9% absolute reduction in mortality compared with a strategy that employed a higher tidal volume [4]. Notwithstanding, mortality in the low tidal volume group remained high at 31%, spurring investigators to develop alternative lung-protective mechanical ventilation strategies that could further reduce mortality in patients with ARDS.High-frequency oscillatory ventilation (HFOV) theoretically satisfies all of the goals of a lung-protective strategy, and offers several potential advantages over CV. Utilizing a piston pump, HFOV achieves gas exchange by delivering very small tidal volumes at frequencies ranging from 3 to 15 Hz. The potential advantages of HFOV over CV include: the delivery of smaller tidal volumes, limiting alveolar over-dist
Evaluation of topical 0.1% tazarotene cream in the treatment of palmoplantar psoriasis: An observer-blinded randomized controlled study
Mehta Bijal,Amladi Sangeeta
Indian Journal of Dermatology , 2011,
Abstract: Background : Palmoplantar psoriasis is a frequently encountered variant of psoriasis. It is difficult to treat and even more difficult to maintain remission as it is exacerbated by friction and trauma of the patient′s daily activities. Existing topical modalities of treatment are often inadequate and show unpredictable response. Aim : To study the efficacy and safety of a newer retinoid, tazarotene, as 0.1% cream in the treatment of palmoplantar psoriasis. Materials and Methods : Thirty adult patients with palmo-plantar psoriasis were randomized to therapy with once daily application of topical tazarotene cream (0.1%) or once daily application of clobetasol propionate cream (0.05%) for 12 weeks. The patients were assessed every 2 weeks for improvement in Erythema, Scaling, Fissures and Induration (ESFI) score and Physicians Global Assessment Scale. Results : At 12 weeks, the tazarotene group showed mean ESFI reduction to 1.12 (83.2%) from 6.65 at baseline. Complete clearance was noted in 52.9% of the patients. Clobetasol propionate group showed mean ESFI reduction to 0.62 (89.1%) from 5.69 at baseline, with complete clearance in 61.5% of the patients. Differences between the two groups were statistically insignificant. Side effects observed were initial irritation (41%) in the tazarotene group and hypopigmentation (53.8%) in the steroid-treated patients. Conclusion : Tazarotene is as effective as clobetasol propionate and provides a good alternative for the treatment of palmo-plantar psoriasis where hypopigmentation limits the use of clobetasol propionate cream.
Bench-to-bedside review: Recruitment and recruiting maneuvers
Stephen E Lapinsky, Sangeeta Mehta
Critical Care , 2004, DOI: 10.1186/cc2934
Abstract: Ventilatory management protocols for acute respiratory distress syndrome (ARDS) are continually evolving and improving. Strategies have changed from optimizing convenient physiologic variables, such as oxygen and carbon dioxide levels, to protecting the lung from injury. Nevertheless, much remains unknown and some controversy persists [1,2]. One of the more recent areas of research and clinical interest involves lung volume recruitment. This refers to the dynamic process of opening previously collapsed lung units by increasing transpulmonary pressure. The concept of opening the injured lung is not new [3,4], but recent experimental data suggest that this intervention may play an important role in preventing ventilator-induced lung injury [5], although this has not been uniformly supported by clinical studies. This review describes the pathophysiologic basis and clinical role for lung recruitment maneuvers. Several recent publications have reviewed this topic in some detail [6,7]; the present review aims to describe these concepts in a format that may be useful to the practicing intensivist, bringing laboratory and clinical research to bedside practice.The acutely injured lung comprises a heterogeneous environment of aerated and nonaerated lung (Fig. 1) [8], the nonaerated lung consisting of collapsed or consolidated alveoli. Positive pressure ventilation generates tensions at the boundaries between aerated and nonaerated lung, and repeated high-pressure inflations may cause damaging shearing forces at these junctional interfaces [9]. Another stress induced by positive pressure ventilation is the cyclic opening and closing of alveoli, in the presence of inadequate positive end-expiratory pressure (PEEP) to maintain alveolar patency through the respiratory cycle [10]. These mechanical stresses may have a number of effects, including epithelial and endothelial damage, cellular inflammatory damage, and release of cytokines [5,11].Pressure-limited ventilatory strategies
Pro/con clinical debate: Is high-frequency oscillatory ventilation useful in the management of adult patients with respiratory failure?
Jeffrey M Singh, Sangeeta Mehta, Robert M Kacmarek
Critical Care , 2002, DOI: 10.1186/cc1483
Abstract: You have been asked to assist in the organization of and equipment purchases for a new large, state of the art, adult intensive care unit. You are encouraged to obtain leading edge equipment that offers the patients the best hope of survival. While ordering mechanical ventilators, you wonder whether it would be useful to have some high-frequency oscillators.Jeffrey M Singh and Sangeeta MehtaConventional mechanical ventilation (CMV) may contribute to lung injury through a number of mechanisms, including alveolar overdistension and shear-force injury from end-expiratory collapse [1]. Lung-protective ventilation techniques have been successfully applied in clinical trials demonstrating the efficacy of CMV-based strategies limiting overdistension [2] and preventing end-expiratory collapse [3]. Although successful, these CMV-based strategies each addressed only one aspect of lung protection.HFOV, applied using an open lung approach, may accomplish all the objectives of lung-protective ventilation. During HFOV, a constant mean airway pressure (Paw) is applied during inspiration and expiration, thus avoiding end-inspiratory overdistension, while maintaining end-expiratory alveolar recruitment. By optimizing alveolar recruitment, and thus ventilation perfusion matching, HFOV improves gas exchange and allows reductions in inspired oxygen concentration (FiO2) to safer levels. In saline-lavaged rabbits, HFOV attenuated the physiological and pathological changes observed to occur with a lung-protective CMV strategy [4].The majority of clinical trials evaluating HFOV have been conducted in the neonatal population. Published experience with HFOV in adults with acute respiratory distress syndrome (ARDS) is limited to observational studies [5,6,7,8] and one randomized, controlled trial (Derdak et al., manuscript submitted).Two prospective observational studies assessed HFOV as rescue therapy in patients with ARDS and severe oxygenation failure [5,6]. Fort et al. evaluated the safet
An unusual periumbilical plaque
Mehta Bijal,Amladi Sangeeta,Nayak Chitra,Savant Shankar
Indian Journal of Dermatology, Venereology and Leprology , 2008,
Goldenhar syndrome with unusual features
Mehta Bijal,Nayak Chitra,Savant Shankar,Amladi Sangeeta
Indian Journal of Dermatology, Venereology and Leprology , 2008,
Abstract: We report here the case of a 17 year-old girl with the classic signs of Goldenhar syndrome in the form of multiple accessory tragi, bilateral ocular dermoids, mandibular hypoplasia (micrognathia) and cervical lordosis. She also had a high arched palate, gingival hypertrophy and malaligned teeth, features which are as yet unreported.
Leprosy in the era of integration
Mehta Bijal,Nayak Chitra,Savant Shankar,Amladi Sangeeta
Indian Journal of Dermatology, Venereology and Leprology , 2009,
Technical Note: MRI-guided breast biopsy - our preliminary experience
Taneja Sangeeta,Jena Amarnath,Kumar Kapil,Mehta Anurag
Indian Journal of Radiology and Imaging , 2010,
Abstract: The diagnostic potential of breast MRI can be fully utilized only when it is possible to biopsy lesions detected on MRI, especially when they are not visible on mammography or USG. We would like to describe our experience with MRI-guided wire localization and biopsy.
Prenatal Diagnosis of Meckel-Gruber Syndrome with Dandy Walker Malformation
Madhu Gupta, Anil Mehta, Renu Gupta, Rajni Gupta, Sangeeta Singh
JK Science : Journal of Medical Education & Research , 2005,
Abstract: We report a 38 week old female fetus affected by Meckel-Gruber syndrome. Polycystic dysplastickidneys, oligohydroamnios, symmetrical IUGR, hydrocephalus with Dandy-Walker cyst was observedon ultrasonographic (USG) examination. Small occipital encephalocele with polydactly was notedafter delivery of child.
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