in the study by de Freitas et al was the timing of targeted neonatal echocardiography (ie, between days 7 and 30 of life), because the decision when to treat a hemodynamically relevant PDA must usually be taken much earlier. 1 Although we did perform serial echocardiography in the first week of life and thereafter, it must also be stated that our study identified other important nonhemodynamic parameters that were at play with regard to the occurrence of AKI. 2 We conclude that it is important to collect data on both the size of the PDA with correction for birth weight, possibly birth length, and its effect on flow patterns in the cerebral, mesenteric/ celiac, and renal arteries. In doing so, an individualized approach can be realized to determine whether subsequent therapeutic interventions (eg, use of cyclo-oxygenase inhibitors or surgery) are warranted for PDA closure. 3 We agree with de Freitas et al that isolated parameters (ductal diameter) should not be used as a surrogate indicator of the magnitude of shunt volume to inform treatment decisions. 1 We also suggest that the findings gathered at the bedside may be complemented by the use of biomarkers (brain natriuretic peptide and N-terminal pro-brain natriuretic peptide) for the assessment of the significance of PDA. 4 Finally, it is important to correlate clinical findings (bounding pulses, wide pulse pressure, increase in oxygen requirements, oliguria, and feeding intolerance) with these important, repetitively performed echocardiographic parameters, to assess changes over time. 3 When putting all these information pieces together, the assessment of a PDA with regard to its hemodynamic relevance may become less puzzling.
Objectives-To characterize the relationship of echocardiographic markers of left heart overload and flow in peripheral major end-organ vessels (eg, celiac artery) with the presence of reversed holodiastolic flow in the descending aorta, considered a surrogate marker of an increased transductal shunt volume, in preterm patients with a patent ductus arteriosus (PDA).Methods-This work was a retrospective study of data from echocardiography performed to investigate the hemodynamic significance of a PDA in preterm patients. We studied differences in echocardiographic markers of the PDA shunt volume according to patterns of flow in the postductal descending aorta (no PDA, PDA with antegrade diastolic flow, and PDA with reversed diastolic flow). The strength of the association between each echocardiographic marker and the presence of aortic holodiastolic flow reversal was investigated.Results-We studied 137 patients with a median (interquartile range) birth weight of 850 (694-1030) g and a median gestational age of 25 (24-27) weeks. Among patients with a PDA (113), those with diastolic flow reversal in the descending aorta (44) presented had increased echocardiographic markers representative of the shunt volume (increased left ventricular output, left atrial-to-aortic ratio, pulmonary vein D wave, and shorter isovolumic relaxation time) compared to those with aortic antegrade diastolic flow. A positive, albeit weak, correlation between diastolic flow reversal and shunt volume echocardiographic markers was found. Abnormal diastolic flow in the celiac artery had the strongest correlation (R 2 = 0.24).Conclusions-In preterm patients with a PDA, echocardiographic markers of the shunt volume were more abnormal in patients with reversed diastolic flow in the descending aorta. These data support the assumption that variance in these markers are related to the shunt volume, which needs consideration when adjudicating hemodynamic significance.
Diabetes Mellitus is a metabolic disease that is chronic and requires ongoing medical care in a variety of ways that can reduce the risk of multi-factors beyond glycemic control. Uncontrolled diabetes mellitus will cause an increase in complications, one of which is diabetic ulcers. Achieving better wound healing is the main goal of diabetic ulcer management. Moisturizing dressings can provide a supportive environment for cells to carry out the wound healing process and prevent further damage or trauma. This study was to determine the effect of modern dressing with moist healing on diabetic ulcers. This type of research is a quantitative research with a quasi-experimental research design with an accidental sampling approach. Data was collected using demographic data and the Wocare For Indonesian Nurses (WINNERS) Scale assessment sheet which is a modified Bates-Jasen score to predict and evaluate the average score of wound healing. WINNERS scale consists of 10 assessments. The results of the intervention that have been carried out have shown a significant improvement in diabetic ulcers as assessed using the Bates Jensen Wound Assessment Tools. Based on the results and discussion, it was concluded that there was a significant effect of modern wound care using the moist wound healing method on the healing process of diabetic ulcers.
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