Bristol Royal Childrens Hospital

Bristol, United Kingdom

Bristol Royal Childrens Hospital

Bristol, United Kingdom
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Stoica S.,Bristol Royal Childrens Hospital | Goldsmith K.,Medical Research Council | Demiris N.,Medical Research Council | Punjabi P.,Hammersmith Hospital | And 3 more authors.
Heart | Year: 2010

Objective: To characterise contemporary results of aortic valve replacement in relation to type of prosthesis and subsequent competing hazards. Methods: 5470 procedures in 5433 consecutive patients with aortic valve replacement ± coronary artery bypass grafting (CABG) were studied. Microsimulation of survival and valve-related outcomes was performed based on meta-analysis and patient data inputs, with separate models for age, gender and CABG. Survival was validated against the UK Heart Valve Registry. Results: Patient survival at 1, 5 and 10 years was 90%, 78% and 57%, respectively. The crossover points at which bioprostheses and mechanical prostheses conferred similar life expectancy (LE) was 59 years for men and women (no significant difference between prosthesis types between the ages of 56 and 69 for men, and 58 an 63 for women). The improvement in event-free LE for mechanical valves was greater at younger ages with a crossover point of 66 years for men and 67 years for women. Long-term survival was independently influenced by age, male gender and concomitant CABG, but not by type of prosthesis. In bioprostheses the most common long-term occurrence was structural deterioration. For men aged 55, 65 and 75 at initial operation it had a lifetime incidence of 50%, 30% and 13%, respectively. The simulation output showed excellent agreement with registry data. Conclusion: Bioprostheses can be implanted selectively in patients as young as 56 without significant adverse effects on life expectancy, although event-free life expectancy remains significantly lower with bioprostheses up to age of implant of 63.


Shalaby M.S.,Bristol Royal Childrens Hospital | Shalaby M.S.,Ain Shams University
Archives of Disease in Childhood | Year: 2015

During the last decade, there has been a significant increase in the number of magnetic toys available for children. Two or more magnets separate from each other along the gastrointestinal course can attract each other across bowel walls, resulting in pressure necrosis, bowel perforations and fistulas formation. This has led to an increasing number of case reports describing serious complications from ingesting more than one magnet. We report the ingestion of a large number of magnets from one toy (>60 pieces). Our patient presented with generalised peritonitis and shock. During emergency laparotomy, she was found to have gross abdominal contamination with multiple bowel perforations and fistulae. This report emphasises the danger of such toys and how important that parents, physicians and manufacturers are aware of such fatal hazards that can arise from 'unsupervised' ingestion of these 'nice-looking' toys.


Cravero J.,Boston Childrens Hospital | Anderson B.,Starship Childrens Hospital | Wolf A.,Bristol Royal Childrens Hospital
Paediatric Anaesthesia | Year: 2015

Dexmedetomidine has established a firm position in the armamentarium of anesthesia pharmacology. However, it is still a relatively new drug and its application is based on early evidence that is intriguing but far from conclusive. Based on experience with previous cure-alls, anesthesia clinicians and researchers must insist on more information and formulate appropriate science that will allow us to truly understand the role of this dexmedetomidine in our specialty-as wonder drug or also-ran. © 2015 John Wiley & Sons Ltd.


Bosenberg A.T.,University of Washington | Bosenberg A.T.,Seattle Childrens Hospital | Johr M.,Kantonsspital | Wolf A.R.,Bristol Royal Childrens Hospital
Paediatric Anaesthesia | Year: 2011

In recent years the inclusion of regional techniques to pediatric anesthesia has transformed practice. Simple procedures such as caudal anesthesia with local anaesthetics can reduce the amounts of general anesthesia required and provide complete analgesia in the postoperative period while avoiding large amounts of opioid analgesia with potential side effects that can impair recovery. However, the application of central blocks (epidural and spinal local anesthesia) via catheters in the younger infant, neonate and even preterm neonate remains more controversial. The potential for such invasive maneuvers themselves to augment risk, can be argued to outweigh the benefits, others would argue that epidural analgesia can reduce the need for postoperative ventilation and that this not only facilitates surgery when intensive care facilities are limited, but also reduces cost in terms of PICU stay and recovery profile. Currently, opinions are divided and strongly held with some major units adopting this approach widely and others maintaining a more conservative stance to anesthesia for major neonatal surgery. In this pro-con debate the evidence base is examined, supplemented with expert opinion to try to provide a balanced overall view. © 2011 Blackwell Publishing Ltd.


Gamble C.,University of Liverpool | Wolf A.,Bristol Royal Childrens Hospital | Sinha I.,Respiratory Unit | Spowart C.,University of Liverpool | Williamson P.,University of Liverpool
PLoS ONE | Year: 2013

Background: Adequate sedation is crucial to the management of children requiring assisted ventilation on Paediatric Intensive Care Units (PICU). The evidence-base of randomised controlled trials (RCTs) in this area is small and a trial was planned to compare midazolam and clonidine, two sedatives widely used within PICUs neither of which being licensed for that use. The application to obtain a Clinical Trials Authorisation from the Medicines and Healthcare products Regulatory Agency (MHRA) required a dossier summarising the safety profiles of each drug and the pharmacovigilance plan for the trial needed to be determined by this information. A systematic review was undertaken to identify reports relating to the safety of each drug. Methodology/Principal Findings: The Summary of Product Characteristics (SmPC) were obtained for each sedative. The MHRA were requested to provide reports relating to the use of each drug as a sedative in children under the age of 16. Medline was searched to identify RCTs, controlled clinical trials, observational studies, case reports and series. 288 abstracts were identified for midazolam and 16 for clonidine with full texts obtained for 80 and 6 articles respectively. Thirty-three studies provided data for midazolam and two for clonidine. The majority of data has come from observational studies and case reports. The MHRA provided details of 10 and 3 reports of suspected adverse drug reactions. Conclusions/Significance: No adverse reactions were identified in addition to those specified within the SmPC for the licensed use of the drugs. Based on this information and the wide spread use of both sedatives in routine practice the pharmacovigilance plan was restricted to adverse reactions. The Clinical Trials Authorisation was granted based on the data presented in the SmPC and the pharmacovigilance plan within the clinical trial protocol restricting collection and reporting to adverse reactions. © 2013 Gamble et al.


White L.E.,Queen Margaret University | Merrick V.M.,Royal Hospital for Sick Children | Bannerman E.,Queen Margaret University | Russell R.K.,Royal Hospital for Sick Children | And 4 more authors.
Pediatrics | Year: 2013

Background and objectives: Although the incidence of pediatric celiac disease (CD) is increasing globally, it is uncertain whether this is attributed to improved case ascertainment or signifies a true rise. We aimed to identify all incident cases of childhood CD in southeast Scotland over the period 1990 to 2009 to assess trends in totalincidence and cases diagnosed as a result of (1) a classic presentation, (2) a nonclassic presentation, or (3) targeted screening. Methods: Twenty-year retrospective cohortstudy of case notes, pathology databases, endoscopy, and patient records for all children (<16 years of age) diagnosed with CD on biopsy in southeast Scotland (at-riskpopulation of 225 000-233 000). Data were age-gender standardized and Poisson regression models used to calculate changes in incidence over time. Results: A total of 266 children were diagnosed from 1990 to 2009 with an increase in incidence from 1.8/100 000(95% confidence interval [CI] 1.1-2.7) to 11.7/100 000 (95% CI 9.8-13.9) between the epochs 1990 to 1994 and 2005 to 2009, respectively (P < .0001). The incidence of nonclassic presentation (children with a monosymptomatic presentation and those with extraintestinal symptoms) and actively screened cases increased by 1566% (P < .05) and 1170% (P < .001) from 1990 to 1999 to 2000 to 2009, respectively. However, a rise in the incidence of Oslo classic cases from 1.51/100 000 (95% CI 0.91-2.38) in 1990 to 1994 to 5.22/100 000 (95% CI 3.98-6.75) in 2005 to 2009 (P < .01) remained evident. Conclusions: The incidence of pediatric CD increased 6.4-fold over the 20 years. This study demonstrates that this rise is significant for classic CD, indicating a true rise in the incidence of pediatric CD. © 2013 by the American Academy of Pediatrics.


Wolf A.R.,Bristol Royal Childrens Hospital | Humphry A.T.,Bristol Royal Childrens Hospital
Paediatric Anaesthesia | Year: 2014

Summary Development of the cardiovascular system through the last trimester of pregnancy and the subsequent neonatal period is profound. Morphological changes within the myocardium make the heart vulnerable to challenges such as fluid shifts and anesthetic drugs. The sensitivity of the myocardium to metabolic challenges and potential harm of drugs needed to maintain adequate blood pressure and cardiac output are highlighted. Traditional monitoring under anesthesia has focussed on maintaining oxygenation and heart rate in the neonate with less attention paid to blood pressure, cardiac output, and more importantly organ well-being. There is now a better understanding of the limitations of blood pressure homeostasis in the neonate and the potential consequences of marginal hypoperfusion. This article highlights some of these vulnerabilities particularly as they relate to anesthesia and surgery in the very young. © 2013 John Wiley & Sons Ltd.


Nolan J.A.,Bristol Royal Childrens Hospital
Anaesthesia and Intensive Care Medicine | Year: 2016

This article provides an overview of the practical aspects of paediatric anaesthesia, with particular emphasis on airway and fluid management. Common dilemmas that may be encountered during preoperative assessment are highlighted, including the child with asthma, obstructive sleep apnoea and the particularly anxious child. In light of the findings of the fourth National Audit Project (NAP4), strategies for managing the child with the difficult airway are discussed. The rationale for the use of isotonic perioperative fluids is outlined, along with the management of intraoperative blood loss. The increasingly recognized problem of emergence delirium is also discussed. © 2016


Pickard A.,Bristol Royal Childrens Hospital | Davies P.,University of Bristol | Birnie K.,University of Bristol | Beringer R.,Bristol Royal Childrens Hospital
British Journal of Anaesthesia | Year: 2014

Undergoing general anaesthesia is distressing for children, with up to two-thirds demonstrating abnormal behaviours after their procedure, such as emergence delirium (ED) and post-hospitalization behaviour change. The aim of this systematic review was to determine the effect of intraoperative i.v. α2-adrenergic agonists on postoperative behaviour in children. We included published full-text reports of randomized controlled trials involving children who received i.v. clonidine or dexmedetomidine after induction of general anaesthesia, who were assessed for postoperative behavioural disturbance. After screening of references identified by the search strategy, a data collection form was developed and piloted. Data extraction was performed by one reviewer and checked by a second. Twelve randomized trials met the inclusion criteria. Ten studies (n=669) reported dichotomous data that were included in the pooled analysis of α2-adrenergic agonists vs placebo. There was strong evidence that i.v. α2-adrenergic agonists reduced postoperative ED (overall summary odds ratio 0.28, 95% confidence interval 0.19-0.40, P<0.001). No studies examined post-hospitalization negative behaviour changes. There was evidence that α2-adrenergic agonists prolonged time in the recovery room. No adverse haemodynamic events were reported in any arm of any study. This meta-analysis provides evidence that intraoperative i.v. α2- adrenergic agonists reduce the incidence of emergency delirium in children. The prolongation of time in recovery is unlikely to be clinically relevant. The absence of data regarding the effect on post-hospitalization behavioural changes provides an opportunity for future research. © 2014 The Author.


Wolf A.R.,Bristol Royal Childrens Hospital
Paediatric Anaesthesia | Year: 2012

Management of the very low-birth weight infant in the neonatal intensive care unit (NICU) is geared to provide optimal outcome not only in term of survival but increasingly with a goal of limitation of long-term neurological and pulmonary morbidities. Careful follow-up studies have demonstrated that relatively small variations in oxygenation and gas exchange, ventilator management, and other management modalities can have long-term consequences. Within this context, there are good data that closure of a clinically significant patent ductus arteriosus has outcome benefit, but little data on the idealized anesthetic to manage such fragile patients. Does the anesthetic management matter? Given the attention to detail within the NICU, it would seem prudent to try to choose techniques that limit changes in hemodynamics, gas exchange, and ventilation within the context of the surgery. Anesthesia for ductal ligation in the very low-birth weight infant may need to be judged by more than simple survival and brings into question the current techniques and monitoring used. © 2012 Blackwell Publishing Ltd.

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