Psychogenic coma after dental surgery under general anaesthesia.

Delayed awakening after general anaesthesia due to psychogenic coma is a phenomenon that rarely presents to the oral and maxillofacial surgeon. A case of psychogenic coma following general anaesthesia for dental extractions is presented here. It is recommended that patients at risk of conversion disorder should be counselled about the risks of psychogenic coma. Early diagnosis of this condition could lead to better patient management.

Enhanced recovery in patients having free tissue transfer for head and neck cancer: does it make a difference?

Programmes for Enhanced Recovery after Surgery (ERAS) accelerate recovery, reduce morbidity, and shorten hospital stay in a wide range of surgical specialties. We established a standardised multimodal ERAS pathway for patients who were being treated by free tissue transfer for head and neck cancer to evaluate its benefit. Our primary outcome was duration of hospital stay, and secondary outcomes included complications, number of days to first mobilisation, and readmission rates. We compared 100 consecutive patients who followed the ERAS programme with a control group of 40 consecutive patients who had free tissue transfer before the ERAS programme was introduced. There was a significantly reduced median duration of stay from 14days in the control group to 10days in the ERAS group. Patients in the ERAS group who were aged over 60 years, or had tracheostomies, or who required bone resection also had a significantly reduced duration of stay. There was no difference between morbidity and readmission rates, although patients in the ERAS group were mobilised significantly earlier. The ERAS programme is safe and effective for patients who are treated by free tissue transfer for head and neck cancer, and potentially reduces their duration of stay in hospital.

Biotechnological Applications of Marine Enzymes From Algae, Bacteria, Fungi, and Sponges.

Diversity is the hallmark of all life forms that inhabit the soil, air, water, and land. All these habitats pose their unique inherent challenges so as to breed the "fittest" creatures. Similarly, the biodiversity from the marine ecosystem has evolved unique properties due to challenging environment. These challenges include permafrost regions to hydrothermal vents, oceanic trenches to abyssal plains, fluctuating saline conditions, pH, temperature, light, atmospheric pressure, and the availability of nutrients. Oceans occupy 75% of the earth's surface and harbor most ancient and diverse forms of organisms (algae, bacteria, fungi, sponges, etc.), serving as an excellent source of natural bioactive molecules, novel therapeutic compounds, and enzymes. In this chapter, we introduce enzyme technology, its current state of the art, unique enzyme properties, and the biocatalytic potential of marine algal, bacterial, fungal, and sponge enzymes that have indeed boosted the Marine Biotechnology Industry. Researchers began exploring marine enzymes, and today they are preferred over the chemical catalysts for biotechnological applications and functions, encompassing various sectors, namely, domestic, industrial, commercial, and healthcare. Next, we summarize the plausible pros and cons: the challenges encountered in the process of discovery of the potent compounds and bioactive metabolites such as biocatalysts/enzymes of biomedical, therapeutic, biotechnological, and industrial significance. The field of Marine Enzyme Technology has recently assumed importance, and if it receives further boost, it could successfully substitute other chemical sources of enzymes useful for industrial and commercial purposes and may prove as a beneficial and ecofriendly option. With appropriate directions and encouragement, marine enzyme technology can sustain the rising demand for enzyme production while maintaining the ecological balance, provided any undesired exploitation of the marine ecosystem is avoided.

Optical control of filamentation-induced damage to DNA by intense, ultrashort, near-infrared laser pulses.

We report on damage to DNA in an aqueous medium induced by ultrashort pulses of intense laser light of 800 nm wavelength. Focusing of such pulses, using lenses of various focal lengths, induces plasma formation within the aqueous medium. Such plasma can have a spatial extent that is far in excess of the Rayleigh range. In the case of water, the resulting ionization and dissociation gives rise to in situ generation of low-energy electrons and OH-radicals. Interactions of these with plasmid DNA produce nicks in the DNA backbone: single strand breaks (SSBs) are induced as are, at higher laser intensities, double strand breaks (DSBs). Under physiological conditions, the latter are not readily amenable to repair. Systematic quantification of SSBs and DSBs at different values of incident laser energy and under different external focusing conditions reveals that damage occurs in two distinct regimes. Numerical aperture is the experimental handle that delineates the two regimes, permitting simple optical control over the extent of DNA damage.

Serum and salivary sialic acid as a biomarker in oral potentially malignant disorders and oral cancer.

Background: Aberrant glycosylation is the universal feature of cancer and components of various glycoconjugates, such as sialic acid is found to rise in various malignancies. The objective of this study was to evaluate the serum and salivary sialic acid in oral potentially malignant disorders (OPMD) and oral cancer (OC) to investigate the possibility of using this as a diagnostic marker. Materials and Methods: The study included 85 subjects, who were grouped as control (30), OPMD patients (25), and oral cancer patients (30). Serum and unstimulated whole saliva was collected from subjects of all groups and sialic acid estimation was done using spectrophotometry. The results were tabulated and analyzed statistically. Results: The mean serum sialic acid levels in normal, OPMD, and oral cancer group were 7.515, 19.620, and 55.235 mg/dL, respectively, whereas the levels of salivary sialic acid were 1.5113, 2.3302, and 9.0304 mg/dL, respectively. A very highly significant rise (P < 0.005) in serum and salivary sialic acid was observed in the study subjects compared with that of the control. Conclusions: The present study showed a significant and gradual increase in serum and salivary sialic acid from control to oral potentially malignant disorders to oral cancer. From this study we can suggest that sialic acid can be used as a reliable biomarker. As this monosaccharide is observed in saliva in detectable quantity, saliva can be used as a diagnostic medium for screening and early detection of oral cancer.

DNA damage by OH radicals produced using intense, ultrashort, long wavelength laser pulses.

We probe femtosecond laser induced damage to aqueous DNA, relying on strong-field interaction with water wherein electrons and free radicals are generated in situ; these, in turn, interact with DNA plasmids under physiological conditions, producing nicks. Exposure to intense femtosecond pulses of 1350 and 2200 nm light induces single strand breaks and double strand breaks (DSBs) in DNA. At the longer wavelength (and at higher intensities), rotationally hot OH radicals induce DSBs, producing linear DNA. Strand breaks occur due to single or multiple OH hits on DNA. With 2200 nm light, DSBs are formed mostly by the action of two OH radicals; use of OH scavengers establishes that the probability of a two-hit event reduces much faster than a one-hit event as scavenger concentration is increased. Thermal effects do not induce DSBs with 2200 nm light.

Changing trends and the role of medical management on the outcome of patients treated for osteoradionecrosis of the mandible: experience from a regional head and neck unit.

This study is a retrospective review of treatment outcomes of osteoradionecrosis (ORN) of the mandible with specific reference to the evolving role of medical management with pentoxifylline, tocopherol, and doxycycline. We reviewed the presentation and management of 71 patients treated for ORN of the mandible at the regional head and neck unit during a 15-year period to January 2011, and categorised them into three grades using the Notani classification: grade I (n=28), grade II (n=16), and grade III (n=27). Twelve patients with grade I ORN, 3 with grade II, and 10 with grade III, were prescribed medical treatment. Of these, three with grade I, and two with grade II ORN were cured, and progression of the disease had halted and there was satisfactory control of symptoms in eight with grade I and four with grade III disease. Patients who failed to respond to conservative treatment were further analysed for the need for free flap reconstruction. Medical management was introduced as a standard treatment in January 2006. Of the 39 patients diagnosed before this, 20 (51%) required resection and free flap reconstruction compared with only 8/32 (25%) after it had been introduced.

Surgical management of osteochondritis dissecans of the knee in the paediatric population: a systematic review addressing surgical techniques.

PURPOSE: Several case series have been published exploring a variety of surgical treatments for osteochondritis dissecans (OCD) in patients 18 years and younger, but a systematic review is currently lacking. This systemic review identifies the various surgical techniques reported in the literature for treating OCD and assesses the effectiveness of these treatments based on functional outcomes and radiographic healing. METHODS: A search of the EMBASE and MEDLINE databases was performed to identify clinical studies reporting outcomes of surgical management of OCD in the knee. A quality assessment of the included articles was conducted independently by 2 reviewers using a quality assessment tool developed by Yang et al. RESULTS: A total of 25 papers including 470 patients aged ≤18 years (516 lesions) met the eligibility criteria and were reviewed. Surgical techniques for stable lesions included (arthroscopic and open) transarticular drilling, either alone (41%) or with bioabsorbable pin fixation (3%), extra-articular drilling (29%) and fixation with bioabsorbable screws (4%) or bone pegs (4%). For unstable lesions, surgical techniques included (arthroscopic and open) fixation with bioabsorbable pins (9%), metal screws (4%), bone pegs (4 %), osteochondral plugs (3%) or bioabsorbable screws (2%), as well as transarticular drilling with bioabsorbable pin fixation (3%) and drilling with metal screw fixation (2%). CONCLUSION: The most common techniques were transarticular drilling for stable lesions and bioabsorbable pin fixation for unstable lesions. The key findings were that the vast majority of lesions healed postoperatively, regardless of technique, and that high-quality trials are required to more appropriately compare the effectiveness of techniques. LEVEL OF EVIDENCE: Systematic review, Level IV.

Effect of intense, ultrashort laser pulses on DNA plasmids in their native state: strand breakages induced by in situ electrons and radicals.

Single strand breaks are induced in DNA plasmids, pBR322 and pUC19, in aqueous media exposed to strong fields generated using ultrashort laser pulses (820 nm wavelength, 45 fs pulse duration, 1 kHz repetition rate) at intensities of 1-12 TW cm(-2). The strong fields generate, in situ, electrons and radicals that induce transformation of supercoiled DNA into relaxed DNA, the extent of which is quantified. Introduction of electron and radical scavengers inhibits DNA damage; results indicate that OH radicals are the primary (but not sole) cause of DNA damage.

Longitudinal evaluation of restricted mouth opening (trismus) in patients following primary surgery for oral and oropharyngeal squamous cell carcinoma.

Trismus is a serious problem for some patients after oral and oropharyngeal cancer, and it has a detrimental impact on quality of life and function. We know of few published papers that include preoperative assessment in reports on the longitudinal outcomes of mouth opening after oral and oropharyngeal surgery. We prospectively measured mouth opening in patients who had primary surgery for oral and oropharyngeal cancer from baseline to six months to find out the characteristics at baseline and at discharge of those who develop trismus at six months. Ninety-eight patients were eligible between February 2007 and March 2008, and 64 (65%) were recruited into the study. The range of mouth opening was measured on three occasions: before operation, on the ward before discharge from hospital, and at follow-up six months after operation. Using a criterion of 35 mm or less as an indication of trismus, 30% (19/63) had trismus before operation, 65% (37/57) at hospital discharge, and 54% (26/48) at six month follow-up. Patients at high risk of trismus were those with T stage 3 or 4 cancers who required free flap reconstruction and adjuvant radiotherapy; radiotherapy was the most significant factor at six months. Trismus at discharge was a prediction of trismus at six months. Interventions such as spatulas or a passive jaw mobiliser should be targeted at patients at high risk early in the postoperative phase. The efficacy of such interventions needs further research.

Update experience of surgery for acute limb ischaemia in a district general hospital - are we getting any better?

INTRODUCTION: The aims of this study were to audit results of a 10-year experience of surgery for acute limb ischaemia (ALI) in terms of limb salvage and mortality rates, and to compare results with a historical published series from our unit. PATIENTS AND METHODS: All emergency operations performed during the period 1993-2003 were identified from theatre registers and patient notes reviewed to determine indications for, and outcome of, surgery. Data were compared to a similar cohort who underwent surgery from 1980 to 1990. RESULTS: There was a 33% increase in workload from 87 to 116 patients between the two time periods. The number of patients with idiopathic ALI reduced (24% versus 4%; P < 0.05), and there were fewer smokers (71% versus 39%; P < 0.05) and a greater number of claudicants (17% versus 35%; P < 0.05) in those treated from 1993-2003. Latterly, more patients underwent pre-operative heparinisation (33% versus 80%; P < 0.05), received prophylactic antibiotics (14% versus 63%; P < 0.05), and had anaesthetic presence in theatre (46% versus 88%; P < 0.05). There was also a reduction in local anaesthetic procedures (80% versus 41%; P < 0.05). Despite increased pre-operative (15% versus 47%; P < 0.05) and on-table imaging (0% versus 16%; P < 0.05) technical success did not improve. Whilst complication rates were identical at 62%, there were fewer cardiovascular complications in the recent cohort. The 30-day mortality rate for embolectomy fell from 45% to 33%. Multivariate analysis revealed age > 70 years, prolonged symptom duration, ASA score > or = III, lack of prophylactic antibiotics, absence of an anaesthetist, and operations performed under local anaesthetic to be associated with increased risk of mortality. Factors adversely affecting limb salvage included prolonged duration from symptom onset to operation, and a history of claudication or smoking. CONCLUSIONS: Despite improvements in pre- and peri-operative management, arterial embolectomy/thrombectomy remains a procedure with a high morbidity and mortality. Further attempts to improve outcome must be directed at early diagnosis and referral as delay from symptom onset to surgery is a major determinant of outcome.

Prioritisation of vascular outpatient appointments cannot be based on referral letters alone.

BACKGROUND: Vascular referrals include patients with conditions varying from varicose veins of cosmetic nuisance to patients with critical ischaemia, transient ischaemic attacks and abdominal aortic aneurysms. A large number of such referrals are received each week from general practitioners. It is important to prioritise patients with conditions that need to be dealt with quickly. OBJECTIVE: We prospectively reviewed referral letters to two vascular units, one in South Wales and one in the Oxford region to assess whether prioritisation can be made on the basis of referral letters. MATERIAL AND METHODS: All GP referral letters were studied for four months. Only patients with lower limb ischaemic symptoms were included. Degree of urgency requested by the GP was also noted. RESULTS: Of 174 referrals for potential lower limb ischaemia analysed, 145 (83%) proved to be due to peripheral vascular disease. Of these 145 referrals, 72% were referred for claudication. Only 37% and 13% respectively mentioned claudication distance and/or rest pain. Risk factors with reference to diabetes, hypertension, hyperlipidaemia, ischaemic heart disease, atrial fibrillation, cerebrovascular disease and smoking were made in 19%, 43%, 23%, 23%, 10%, 14%, 31% of letters respectively. Clinical signs were poorly documented, with 90% of referrals failing to mention presence or absence of critical ischaemic signs. The GP's own assessment of urgency was not stated in 66% of letters, without which only 3% of patients were seen in the clinic within four weeks, compared with 22% in those in whom urgency was stated. Six per cent of patients when reviewed in outpatients were found to have sufficiently severe symptoms to warrant immediate admission. Regional variation was observed with 57% of Royal Glamorgan Hospital referral letters documenting degree of urgency compared with only 23% of Royal Berkshire Hospital letters (p = < 0.0001). CONCLUSION: Most referral letters were poorly documented with regard to key symptoms, risk factors and clinical signs. The degree of urgency was often not stated. The creation of referral protocols is now being considered.

Management of cardiovascular risk factors by primary care physicians in patients with peripheral arterial disease.

BACKGROUND: Patients with significant coronary artery disease (CAD) are now intensively treated by primary care physicians predominantly because of government pressure and remuneration to prescribe anti-platelet and anti-hyperlipidaemic drugs. Peripheral arterial disease (PAD) with the identical risk factors appeared to us to be less intensively investigated and treated by primary care physicians. OBJECTIVE: To review the treatment of risk factors in all patients referred to two vascular clinics with a diagnosis of suspected PAD. DESIGN: Cross-sectional survey. SETTING: Vascular outpatient clinic in two district general hospitals. PARTICIPANTS: 124 consecutive new patients were studied to determine risk factors and appropriate treatment. RESULTS: Of the 124 patients, 85 (68%) were confirmed to have PAD without evidence of symptomatic CAD. In the PAD alone group, less than 25% received anti-smoking advice (p < 0.0001) and only 36% were prescribed anti-platelet drugs (p = 0.016). Seventy-three per cent of the overall referred patients with hypertension had been treated for this condition and the blood pressure was normal in 71% of the patients with PAD. In patients with hyperlipidaemia, statins had been prescribed in 92% of patients with coexistent symptomatic CAD, but only in 64% of patients with PAD alone (p = 0.009). In the patients with diabetes, only 66% of the PAD alone group had adequate control of their blood sugar (p = 0.185). CONCLUSIONS: It would appear that patients with CAD and PAD are being treated successfully for their risk factors, but patients with PAD alone, sharing the same common risk factors, are being less than optimally treated.

Oxcarbazepine in migraine headache: a double-blind, randomized, placebo-controlled study.

OBJECTIVE: To evaluate the efficacy, safety, and tolerability of oxcarbazepine (1,200 mg/day) vs placebo as prophylactic therapy for patients with migraine headaches. METHODS: This multicenter, double-blind, randomized, placebo-controlled, parallel-group trial consisted of a 4-week single-blind baseline phase and a 15-week double-blind phase consisting of a 6-week titration period, an 8-week maintenance period, and a 1-week down-titration period, after which patients could enter a 13-week open-label extension phase. During the 6-week titration period, oxcarbazepine was initiated at 150 mg/day and increased by 150 mg/day every 5 days to a maximum tolerated dose of 1,200 mg/day. The primary outcome measure was change from baseline in the number of migraine attacks during the last 28-day period of the double-blind phase. RESULTS: Eighty-five patients were randomized to receive oxcarbazepine and 85 to receive placebo. There was no difference between the oxcarbazepine (-1.30) and placebo groups in mean change in number of migraine attacks from baseline during the last 28 days of double-blind phase (-1.74; p = 0.2274). Adverse events were reported for 68 oxcarbazepine-treated patients (80%) and 55 placebo-treated patients (65%). The majority of adverse events were mild or moderate in severity. The most common adverse events (>or=15% of patients) in the oxcarbazepine-treated group were fatigue (20.0%), dizziness (17.6%), and nausea (16.5%); no adverse event occurred in more than 15% of the placebo-treated patients. CONCLUSIONS: Overall, oxcarbazepine was safe and well tolerated; however, oxcarbazepine did not show efficacy in the prophylactic treatment of migraine headaches.

The influence of hyperbaric oxygen on the outcome of patients treated for osteoradionecrosis: 8 year study.

This study was a retrospective review of treatment outcomes of osteoradionecrosis (ORN) of the mandible over an 8-year period, with specific reference to the role of hyperbaric oxygen therapy (HBOT). The presentation and management of 23 patients treated for ORN was studied by categorising them into three grades according to the severity of clinical and radiographic involvement. At presentation there were 13 patients with grade I ORN, six patients with grade II ORN and four patients with grade III ORN. HBOT was given to 10 patients in the grade I group, four patients in the grade II group and two patients in the grade III group. Overall eight patients (62%) with grade I, three patients (50%) with grade II and two patients (50%) with grade III were cured. In the patients who received HBOT the cure rate was 12.5% whilst in those without HBOT it was 86%. Although the cohort was small it seems that HBOT was of little benefit. HBOT is demanding for patients and has cost implications for the NHS; hence further clinical outcome data are urgently required with regard to its role in the management of ORN.

Non Surgical Management of Pseudoaneurysms.

BACKGROUND: The incidence of pseudoaneurysm has increased due to the large number of vascular procedures performed and the widespread use of anticoagulation therapy during procedures. Non-invasive methods for management of pseudoaneurysms comprise of ultrasound guided compression (USGC), thrombin therapy, arterial embolisation and endovascular stent graft insertion. We discuss our experience in the management of fourteen cases of pseudoaneurysms using non surgical techniques. METHODS: During a two year period, fourteen patients presenting with pseudoaneurysms of different regions were treated. RESULT: Of the fourteen patients, eleven were iatrogenic and three were attributable to trauma. There were six cases of pseudoaneurysms of the femoral artery following coronary angiography studies. One patient developed pseudoaneurysm of right popliteal artery after external fixation of fracture right tibia and fibula. Three cases of renal artery pseudoaneurysms occurred following percutaneous nephrolithotomy (PCNL). The cases were evaluated using a varying combination of color doppler, multidetector computerised tomography (CT) and angiography. These cases were treated with ultrasound guided compression (USGC), stent graft and coil embolisation. The selection of method was based on the location and size of pseudoaneurysms besides the efficacy of the technique. USGC was performed in seven, of which six were in the femoral artery and one supraorbital. The technique was unsuccessful in three of the seven, wherein stent graft was deployed in the femoral artery. Coil embolisation was utilised in three cases of renal artery pseudoaneurysms following PCNL. CONCLUSION: Follow up with color doppler and CT angiography within a week, 6 and 12 months period showed successful regression of pseudoaneurysms in all cases.