hemorrahge due to leptospirosis

Jubran A[2] has elaborated upon why patients are ventilator-dependent. These factors require both clinical awareness as well as focused assessment. The search for underlying causes for ventilator dependency is pertinent if previously unrecognized but reversible conditions are discovered. Understanding the determinants of respiratory failure and ventilator dependence is a vital step in providing quality care. We could help prevent prolonged ICU stay and fi nancial burden in our patient by the use of our placebo technique.

He was put on similar placebo ventilation multiple times with incremental time duration. He remained calm and continued to breathe on his own. ABGs after 30 min of such ventilation were normal. After two days of observation, we gained his confi dence by revealing the truth and he was convinced that he could breathe on his own. Successful separation from the ventilator was achieved.
Jubran A [2] has elaborated upon why patients are ventilator-dependent. These factors require both clinical awareness as well as focused assessment. The search for underlying causes for ventilator dependency is pertinent if previously unrecognized but reversible conditions are discovered. Understanding the determinants of respiratory failure and ventilator dependence is a vital step in providing quality care. We could help prevent prolonged ICU stay and fi nancial burden in our patient by the use of our placebo technique.

Carbon monoxide poisoning
Dear Editor, We read the article "Accidental carbon monoxide poisoning in our homes" [1] with great interest. The authors have done a commendable job to draw attention of doctors to think of CO poisoning from gas geysers as a potential cause of unexplained neurological collapse in bathrooms. We would like to add our comments and present our view on this.
As the practice of using LPG geysers is gaining popularity, the Government needs to create public awareness by appropriate use of mass media regarding the health complications attributed to CO poisoning caused by LPG geysers. Also, statutory warning regarding the proper place and ventilatory requirements for installation, potential medical problems and immediate action needed in case of suspected poisoning, should be mentioned on the geyser itself. This will greatly help to reduce the number of cases as well as encourage immediate medical attention seeking behavior of the user. We again appreciate the efforts of authors.

H. Singh, S. Aggarwal 1
Intern, All India Institute of Medical Sciences,

Cyclophosphamide in alveolar hemorrahge due to leptospirosis
Dear Editor, We read with interest the research article Cyclophosphamide in pulmonary alveolar hemorrahage due to leptospirosis by Trivedi et al. [1] We would like to have some clarifi cation regarding the design and fi ndings of the study.
Regarding the methodology of the study, we have a comment and some questions. We disagree with the authors' statement, "in view of the lifethreatening nature of the disease, a randomized trial was not possible". We are unclear if this is a prospective observational series with historical controls or a non-randomized controlled trial with contemporary controls. As we understand it, a high mortality of 29/32 was noted in the initial group of patients, and cyclophosphamide was then used in the subsequent 33 patients (of whom 22 survived). Could the authors clarify if they submitted the protocol and got clearance from the Human Research Ethics Committee before the 32 control and 33 study patients, or after the 32 control but before the 33 study patients were enrolled.
We would like the authors to clarify if they used cyclophosphamide only if there was clear evidence of pulmonary alveolar hemorrhage, or if they used it for all patients with severe pulmonary involvement in leptospirosis. A Murray ALI score of ≥ 2.5 could be due to alveolar hemorrhage or due to non hemorrhagic conditions like ARDS, pulmonary edema, atelectasis and secondary bacterial pneumonia. Could the authors specify which criteria they used for identifying the subgroup of those with pulmonary alveolar hemorrhage from patients with other forms of pulmonary complications secondary to leptospirosis.
We would also like to authors to give us information regarding the severity of illness and the need of standard critical care in these patients. We note that NIV was used in all patients. We would like further information as to how may in each group got intubated, how many needed invasive hemodynamic monitoring and inotropes or pressors. We note that none received renal replacement therapy. Could the authors give more information about this considering that there was an 80% renal involvement in both groups, and the overall mortality was 40/65. We would also appreciate it if any of the authors could give us a more defi nite end point, like 28 day mortality, rather than the follow-up only till the counts returned to normal or the patient was discharged from hospital.
We feel that the concept of using cyclophosphamide for alveolar hemorrhage in leptospirosis has potential but would like more complete data before we start using this promising approach.