A Durward

Guy's and St Thomas' NHS Foundation Trust, Londinium, England, United Kingdom

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Publications (80)365.66 Total impact

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    ABSTRACT: A total of 8 infants presenting with sepsis-like illness were diagnosed to have human parechovirus (HPeV) infection; of which, 5 had abdominal distension and 6 had an erythematous rash. A combination of abdominal distension and erythematous rash was observed in 4 infants. The abdominal symptoms can be very prominent and signs could be confused with acute surgical conditions. Although fever and central nervous symptoms are important features, a red rash with abdominal distension and a low C-reactive protein value and lymphocyte count can be clues to recognize this infection.
    No preview · Article · Mar 2011 · The Pediatric Infectious Disease Journal
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    ABSTRACT: Mutations in the αB-crystallin (CRYAB) gene, encoding a small heat shock protein with chaperone function, are a rare cause of myofibrillar myopathy with autosomal-dominant inheritance, late-onset and moderate severity. We report a female infant presenting from 4 months with profound muscle stiffness, persistent creatine kinase elevation and electromyography characterized by spontaneous electrical activity and pseudomyotonic discharges. Muscle biopsy suggested a myofibrillar myopathy and genetic testing revealed homozygosity for the CRYAB mutation c.343delT (p.Ser115ProfsX14). These findings suggest a severe, recessively inherited form of CRYAB-related myofibrillar myopathy. Profound muscle stiffness as the main presenting feature indicates αB-crystallin as a potent modifier of muscle contractility.
    No preview · Article · Jan 2011 · Neuromuscular Disorders
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    D Knight · A Durward · I Thruston · K Larmour · S Tibby
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    ABSTRACT: Objective: To determine whether introduction a new feeding guideline based upon individual gastric emptying times provides a higher proportion of enteral feeding.Methods: A prospective audit in a 20-bed PICU was conducted one year before (March 2007) and after (March 2009) introduction of the new guideline (March 2008). Data were collected over 4 days per patient on 76 patients in 2007 (37 cardiac, 39 general), and 78 patients in 2009 (39 cardiac, 39 general), comprising 9339 PICU hours. In 2009, the feeding interval was based upon individualised gastric emptying time, calculated after a test feed.Results: The proportion of potential enteral calories given to cardiac patients increased from 39.8% in 2007 to 60.7% in 2009, p < 0.001). A smaller increase was seen for general patients (62.1% to 66.6%, p < 0.001). The median (interquartile) time from admission to establishing full feeds reduced from 23 (12 - 49) to 13 (8 - 24) hours for cardiac (p = 0.007) and from 17 (8 - 32) to 8 (5 - 20) hours (p = 0.05) for general patients. The impact of the feeding guideline on time to establish full feeds remained significant (p < 0.001) after multivariable adjustment for mortality risk (PIM2), diagnosis, weight and gender. By 2009, the major reasons for not feeding were largely unavoidable (including nil by mouth peri-procedure, gut pathology).Conclusions: Introduction of a new feed in guideline appeared to result in earlier and more effective establishment of enteral feeding.
    Preview · Article · Nov 2010 · Pediatric Research
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    ABSTRACT: Cerebral oedema is a potentially devastating complication of diabetic ketoacidosis (DKA). The relationship between osmolar changes, acid-base changes and development of cerebral oedema during therapy is unclear. Retrospective cohort study on 53 children with severe DKA (mean pH at presentation 6.92±0.08). Cerebral oedema was diagnosed using neurological status, response to osmotherapy, and neuroimaging, and classified as: early (occurring ≤1 h after presentation, n=15), late (1-48 h, n=17) or absent (controls, n=21). The temporal profiles for various osmolar and acid-base profiles were examined using a random coefficients fractional polynomial mixed model, adjusted for known risk factors. The three groups could not be differentiated by demographic, osmolar or acid-base variables at presentation. All osmolar and acid-base variables showed non-linear temporal trajectories. Children who developed late onset oedema showed dramatically different temporal profiles for effective osmolality and glucose-corrected serum sodium (both p<0.001). Glucose-corrected sodium provided better qualitative discrimination, in that it typically fell in children who developed late oedema and rose in controls. The maximum between-group difference for both variables approximated the median time of clinical cerebral oedema onset. Blood glucose and acid-base temporal profiles did not differ between the groups. Late onset oedema patients received more fluid in the first 4 h, but this did not influence the osmolar or glucose-corrected sodium trajectories in a predictable fashion. Glucose-corrected serum sodium may prove a useful early warning for the development of cerebral oedema in DKA.
    Preview · Article · Oct 2010 · Archives of Disease in Childhood
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    ABSTRACT: Mediastinal bleeding is common after pediatric cardiopulmonary bypass (CPB) surgery. Thromboelastography (TEG) may predict bleeding and provide insight into likely mechanisms. We aimed to (a) compare perioperative temporal profiles of TEG and laboratory hemostatic variables between patients with significant hemorrhage (BLEED) and those without (CONTROL), (b) investigate the relationship between TEG variables and routine hemostatic variables, and (c) develop a model for prediction of bleeding. TEG and laboratory hemostatic variables were measured prospectively at 8 predefined times for 50 children weighing <20 kg undergoing CPB. Patients who bled demonstrated different TEG profiles than those who did not. This was most apparent after protamine administration and was partly attributable to inadequate heparin reversal, but was also associated with a significantly lower nadir in mean (sd) fibrinogen for the BLEED group compared with CONTROL group: 0.44 (0.18) and 0.71 (0.40) g/L, respectively (P = 0.01). Significant nonlinear relationships were found between the majority of TEG and laboratory hemostatic variables. The strongest relationship was between the maximal amplitude and the platelet-fibrinogen product (logarithmic r(2) = 0.71). Clot strength decreased rapidly when (a) fibrinogen concentration was <1 g/L, (b) platelets were <120 x 10(9)/L, and (c) platelet-fibrinogen product was <100. A 2-variable model including the activated partial thromboplastin time at induction of anesthesia and TEG mean amplitude postprotamine discriminated well for subsequent bleeding (C statistic 0.859). Hypofibrinogenemia and inadequate heparin reversal are 2 important factors contributing to clot strength and perioperative hemorrhage after pediatric CPB. TEG may be a useful tool for predicting and guiding early treatment of mediastinal bleeding in this group.
    No preview · Article · Feb 2010 · Anesthesia and analgesia
  • S Arenas Lopez · H Mulla · A Durward · S M Tibby
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    ABSTRACT: Objectives Once-daily gentamicin therapy is becoming increasingly common in paediatric practice; however, little is known about pharmacokinetics in critical illness. Gentamicin exhibits concentration dependent killing; thus, peak serum concentrations at least eight times higher than minimum inhibition concentration of the target organism have been recommended. We wanted to derive pharmacokinetic parameters for gentamicin in critical illness and to evaluate whether a dose of 8 mg/kg provides an adequate peak serum concentration (>16 mg/l).Methods Population-based pharmacokinetic analyses were undertaken using therapeutic drug monitoring data collected prospectively in an intensive care unit over 6 months (n=50 children). Monte Carlo simulations were used to estimate the probability of achieving (1) peak concentrations >16 mg/l; and (2) trough concentrations 16 mg/l in critically ill children. A considerable proportion will require dose intervals >24 h; thus, therapeutic drug monitoring is essential.
    No preview · Article · Jan 2010 · Archives of Disease in Childhood
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    Full-text · Article · Sep 2009 · Neuromuscular Disorders
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    ABSTRACT: Once-daily gentamicin therapy is becoming increasingly common in pediatric practice; however, little is known about pharmacokinetics in critical illness. Gentamicin exhibits concentration dependant killing; thus, peak serum concentrations at least eight times higher than minimum inhibition concentration of the target organism have been recommended. We wanted to derive pharmacokinetic parameters for gentamicin in critical illness and to evaluate whether a dose of 8 mg/kg provides an adequate peak serum concentration (>16 mg/L). Population-based pharmacokinetic analyses were undertaken using therapeutic drug monitoring data collected prospectively in an intensive care unit over 6 months (n = 50 children). Monte Carlo simulations were used to estimate the probability of achieving 1) peak concentrations >16 mg/L; and 2) trough concentrations <2 mg/L at 24 and 36 hrs. The optimal pharmacokinetic model was of two-compartment disposition with zero order input and additive residual error. Weight was associated nonlinearly with clearance and linearly with volume, and age was a significant covariate for clearance. An 8-mg/kg dose provided near 100% probability of achieving adequate peak concentrations at all ages. However this probability decreased rapidly at doses <7 mg/kg with neonates being the most susceptible. Approximately 50% of nonpremature neonates within the first week of life, 25% of infants, and 10% of children are likely to need a dose interval >24 hrs. A gentamicin dose of 8 mg/kg is highly likely to achieve peak concentrations >16 mg/L in critically ill children. A considerable proportion will require dose intervals >24 hrs; thus, therapeutic drug monitoring is essential.
    No preview · Article · Sep 2009 · Pediatric Critical Care Medicine
  • Miriam R Fine-Goulden · Soumendu Manna · Andrew Durward
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    ABSTRACT: To report the first case of congenital central hypoventilation syndrome (CCHS) presenting with severe cor pulmonale in an adolescent. Case report and literature review. Our Institutional Review Board waived the need for consent. Pediatric intensive care unit in a tertiary care children's hospital. A 12-year-old girl who developed profound hypoxia following routine dental extraction under intravenous opiate sedation and became progressively obtunded due to marked hypoventilation without hypoxic arousal, requiring mechanical ventilation. She had evidence of severe right heart failure, but no cardiac, pulmonary, neurologic, or neuromuscular cause was identified. The diagnosis of CCHS was suspected and subsequently confirmed by blood polymerase chain reaction analysis that revealed a heterozygous polyalanine expansion mutation of the PHOX2B gene (five polyalanine repeats). This report describes the unusual presentation of severe cor pulmonale in an adolescent with so-called "late-onset" CCHS. CCHS was previously thought to be a disease affecting only neonates, but the late-onset phenotype has now been well described in adults. It should be considered in any child presenting with unexplained right heart failure without an identifiable cause, particularly if central sleep apnea is present, because early initiation of ventilatory support can prevent cardiac and neurologic sequelae and improve outcome.
    No preview · Article · Aug 2009 · Pediatric Critical Care Medicine
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    S Tibby · A Durward · L Ferguson · H Bangalore · I Murdoch

    Preview · Article · Mar 2009 · Critical Care
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    S Tibby · A Durward

    Preview · Article · Mar 2008 · Critical Care
  • Shane M Tibby · Andrew Durward
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    ABSTRACT: Pulmonary artery (PA) banding has been established as a palliative surgical technique for congenital heart defects for over 50 years [1]. With the advent of earlier corrective surgery, the indications for PA banding have changed over time [2, 3]. Currently these include: (a) limitation of pulmonary blood flow in the setting of an excessive left-toright shunt; (b) regulation of pulmonary blood flow in the univentricular circulation; and (c) a training procedure for the left ventricle prior to conversion to the systemic pumping chamber (late presentation of D-transposition of the great arteries, or prior to a double-switch procedure with L-transposition).
    No preview · Article · Feb 2008 · Intensive Care Medicine
  • Ellen O'Dell · Shane M Tibby · Andrew Durward · Ian A Murdoch
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    ABSTRACT: Metabolic acidosis is common in septic shock, yet few data exist on its etiological temporal profile during resuscitation; this is partly due to limitations in bedside monitoring tools (base excess, anion gap). Accurate identification of the type of acidosis is vital, as many therapies used in resuscitation can themselves produce metabolic acidosis. Retrospective, cohort study. Multidisciplinary pediatric intensive care unit with 20 beds. A total of 81 children with meningococcal septic shock. None. Acid-base data were collected retrospectively on 81 children with meningococcal septic shock (mortality, 7.4%) for the 48 hrs after presentation to the hospital. Base excess was partitioned using abridged Stewart equations, thereby quantifying the three predominant influences on acid-base balance: sodium chloride, albumin, and unmeasured anions (including lactate). Metabolic acidosis was common at presentation (mean base excess, -9.7 mmol/L) and persisted for 48 hrs. However, the pathophysiology changed dramatically from one of unmeasured anions at admission (mean unmeasured anion base excess, -9.2 mmol/L) to predominant hyperchloremia by 8-12 hrs (mean sodium-chloride base excess, -10.0 mmol/L). Development of hyperchloremic acidosis was associated with the amount of chloride received during intravenous fluid resuscitation (r = .44), with the base excess changing, on average, by -0.4 mmol/L for each millimole per kilogram of chloride administered. Hyperchloremic acidosis resolved faster in patients who 1) manifested larger (more negative) sodium chloride-partitioned base excess, 2) maintained a greater urine output, and 3) received furosemide; and slower in those with high blood concentrations of unmeasured anions (all, p < .05). Hyperchloremic acidosis is common and substantial after resuscitation for meningococcal septic shock. Recognition of this entity may prevent unnecessary and potentially harmful prolonged resuscitation.
    No preview · Article · Oct 2007 · Critical Care Medicine
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    Preview · Article · Mar 2007 · Critical Care
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    ABSTRACT: To demonstrate the diagnostic yield, therapeutic role and safety of flexible bronchoscopy via an intensivist-led service in critically ill children. Retrospective chart review. Regional paediatric intensive care unit. One hundred forty-eight flexible bronchoscopies were performed by two intensivists on 134 patients (median age 16.5 months) over a 2.5-year period. Eighty-eight percent of patients required mechanical ventilation, and 22% were receiving inotropes. Case mix included general (n = 77), cardiac surgery (n = 18), cardiology (n = 13), ear-nose-and-throat surgery (n = 17), oncology (n = 8) and renal (n = 1). The indication for bronchoscopy was defined a priori according to one of four categories: suspected upper airway disease (n = 32); lower airway disease (n = 70); investigation of pulmonary disease (n = 25); and extubation failure (n = 21). Bronchoscopy was generally performed soon after PICU admission, at a median time of 1.5 days for the former three categories, and 4 days for extubation failure group. A positive yield from bronchoscopy (diagnosis that explained the clinical condition or influenced patient management) was present in 113 of 148 (76%) procedures, varying within groups from 44% (pulmonary disease) to 90% (extubation failure). Ten percent of patients developed a fall in oxygen saturations > 20% during the procedure and 17% required a bolus of at least 10 ml/kg of 0.9% saline for hypotension. Critically ill patients with respiratory problems may benefit from a PICU-led bronchoscopy service as the yield for positive bronchoscopic finding is high, particularly for upper airway problems or extubation failure.
    No preview · Article · Jan 2007 · Intensive Care Medicine
  • Shane Tibby · Andrew Durward
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    ABSTRACT: Without Abstract
    No preview · Article · Sep 2006 · Intensive Care Medicine
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    O'Dell E · Tibby SM · Durward A · Murdoch IA
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    ABSTRACT: An abstract is unavailable. This article is available as HTML full text and PDF.
    Preview · Article · Jun 2006 · Pediatric Critical Care Medicine
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    M McDougall · S Colhurst · S Tibby · A Durward · I Murdoch

    Preview · Article · Mar 2006 · Critical Care
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    A Durward · D Taylor · S Tibby · I Murdoch

    Preview · Article · Mar 2006 · Critical Care
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    M McDougall · A Durward · S Tibby · I Murdoch

    Preview · Article · Mar 2006 · Critical Care

Publication Stats

1k Citations
365.66 Total Impact Points

Institutions

  • 2005-2013
    • Guy's and St Thomas' NHS Foundation Trust
      • Paediatric Intensive Care Unit (PICU)
      Londinium, England, United Kingdom
  • 2011
    • London School of Hygiene and Tropical Medicine
      Londinium, England, United Kingdom
  • 2002
    • The Bracton Centre, Oxleas NHS Trust
      Дартфорде, England, United Kingdom