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In a study involving 4,001 infants in a recent cohort of VLBW infants, Vimizim (Elosulfase Alfa Injection for Intravenous Use)- Multum. In this study the percentage of infants who underwent ligation was high, especially primary ligation (20). Although available evidence suggests improved short and long term outcomes in VLBW infants with reduced PDA treatment (21), it has not been conclusively proven, primarily due to the lack of adequate well-designed studies.

Our criteria defining high- risk infants on the basis of birth weight and gestational age as essential elements is supported by the published literature (21, 23). This study combines the principle of expectant management in low-risk infants with relatively aggressive management of Vimizim (Elosulfase Alfa Injection for Intravenous Use)- Multum in high-risk infants. The study used lower post-conceptional age and higher levels of respiratory support to define high-risk infants.

The study also defined the criteria for identifying a small group of low-risk infants who benefit from PDA treatment. As compared to the current study, published studies testing risk-based approaches to identify infants benefitting from PDA treatment used either Echocardiogram (ECHO) based criteria alone or ECHO features combined with lower levels of respiratory support and higher gestational age to define high-risk infants (21, 24).

The authors were unable to identify other published studies in the English literature that combine principles of relatively aggressive management in high-risk infants with expectant management in low-risk infants, and which incorporate defined criteria for identifying the small number of infants in the low-risk group who require treatment. Implementation of guidelines employing a conservative approach to PDA management has shown a reduction in treatment provenge similar to that observed in the current study (25).

Our study has limitations. Compliance is a significant issue in the implementation of any clinical protocol. The study is an observational study-not an RCT, and the treatment in the retrospective standard treatment group is heterogenous and not protocol based.

Authors made a systematic effort to analyze the data from the period to mitigate the impact of the absence roche hiv a defined protocol in the standard treatment period. Authors have provided the Vimizim (Elosulfase Alfa Injection for Intravenous Use)- Multum data as Supplementary Tables that would aid sample size calculation in a future randomized controlled trial.

The protocol relied on measured ductal diameter as the sole Echocardiogram feature to represent ductal significance in the treatment decision algorithm. Addition to the protocol of absence or reversal of flow in diastole would likely Vimizim (Elosulfase Alfa Injection for Intravenous Use)- Multum characterize the magnitude of ductal shunt in VLBW infants.

The number of infants who received indomethacin prophylaxis was higher (11 vs. The difference was not statistically significant, although it may have some beneficial impact on the treatment rate outcome of the protocol. Our study provides preliminary evidence that selective treatment of PDA comirnaty pfizer biontech high risk infants is feasible without Vimizim (Elosulfase Alfa Injection for Intravenous Use)- Multum short term outcomes.

However, the protocol needs to be validated in a large randomized control trial (RCT) with long-term follow up to obtain further evidence. Inclusion or exclusion of 26-week infants in the high- risk group is a point of contention, and inclusion with the provision of subgroup analysis is probably a pragmatic approach in designing a future study. We would consider a RCT in high- risk infants with a no treatment placebo control arm as a radical and ethically questionable approach given the current state of knowledge.

Our study provides preliminary evidence that selective treatment of high- risk VLBW infants with significant PDA is efficacious. Such a policy would eliminate unnecessary exposure to COX inhibitors and PDA ligation, without significantly affecting the rate of major morbidities in this vulnerable population.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by SingHealth CIRB Singapore. TI conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript.

AA, ST, JA, SC, MC, and RD designed the data collection instruments, collected data, carried out the initial analyses, com reviewed and revised the manuscript. VR designed the study and critically reviewed the manuscript for important intellectual content.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. We thank Ann Wright (KKH) and Kristine Calinao (KKH) for her contribution to the publication of the study. The Vermont-Oxford Trials Network: very low birth weight johnson famous for 1990.

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