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Bruxism secondary to brain injury treated with Botulinum toxin-A: a case report
Mohammed El Maaytah, Waseem Jerjes, Tahwinder Upile, Brian Swinson, Colin Hopper, Peter Ayliffe
Head & Face Medicine , 2006, DOI: 10.1186/1746-160x-2-41
Abstract: The term bruxism is derived from the Greek work "brychein", which means "to grind or gnash the teeth". The reported prevalence is 5 to 96% in adult populations [1-5] and 15% in children [6]. Bruxism is often noted in patients with altered states of consciousness, but its occurrence after brain injury is still unknown. Resolution of bruxism is often associated with improvement in the level of consciousness.The appearance of bruxism has been closely linked to the return of sleep-wake cycles and improvement of level of consciousness in patients who were initially comatose [7]. To prevent dental wear, mouth guards, spasmolytic medications and relaxation therapy have been used with variable success.In this report, we describe a successful treatment of bruxism in a patient with anoxic brain injury using botulinum toxin-A (BTX-A).A 26-year-old male suffering global ischemic/hypoxic brain injury after attempted suicide by hanging was admitted to University College London Hospitals (UCLH) intensive care unit for resuscitation following respiratory arrest. The patient remained in coma for 12 days with Glasgow Coma Scale (GCS) of 3–6. Gradual improvement was noticed and the patient started showing signs of alertness and increasing muscle tone of the upper and lower limbs, however they were still in spasm (flexion of upper limbs and extension of lowers). CT scans revealed diffuse low attenuation change in the supratentorial compartment, loss of grey-white matter differentiation and loss of sulcus pattern due to cerebral swelling; a diagnosis of global ischemic/hypoxic brain injury was then reached.After one month, the patient responsiveness to touch and voice increased, he responded to eye contact and answered questions by yes/no and his GCS reached 15. However, he continued to suffer muscle spasm, have no control over his bladder or bowels and had difficulty in speaking as well as feeding problems; he is currently under multidisciplinary care.The patient was then referred to t
Direct microvascular monitoring of a free autologous jejunal flap using microendoscopy: a case report
Tahwinder Upile, Waseem Jerjes, Mohammed El Maaytah, Colin Hopper, Adam Searle, Anthony Wright
BMC Ear, Nose and Throat Disorders , 2006, DOI: 10.1186/1472-6815-6-14
Abstract: We used microendoscopic technique for microvascular monitoring of free autologous jejunal flap by the direct visualisation of the flow of erythrocytes through the capillary vasculature on both the mucosal and serosal surfaces.Blood flow was seen to be pulsatile, with individual erythrocytes visible in the capillaries. The best view was obtained when the scope was focussed directly on the capillary rather than the graft surface. The view of the unstained mucosal surface was bland apart from the fine capillary loops which were seen to fill with each pulsatile event. The microendoscopic examination of the serosal surface revealed much larger calibre vessels with obvious blood flow.The microendoscopic monitoring technique is simple and safe with direct visualisation of blood flow. The technique may also be useful for the monitoring of other free bowel transplants.Tissue oxygenation and maintenance of microvascular blood flow in grafted tissues are crucial for flap viability. Early identification of flap failure is a precondition of flap salvage and therefore important for flap prognosis [1]. Although many technical developments of free flap monitoring have now reached clinical application, very few are considered to be reliable and non-invasive for early recognition of flap failure [2]. Therefore, reliable monitoring of free microvascular tissue flaps would be a valuable new tool for clinicians [3,4].Non-invasive monitoring techniques are procedures of little or no morbidity that may be repeated frequently to assess tissue viability. The ideal non-invasive technique would be safe, sensitive, reliable, reproducible, simple to use and inexpensive [5]. Furthermore, postoperative monitoring of the perfusion of a free flap used in head and neck reconstruction is vitally important in achieving a favourable outcome [6].Several techniques have now an established place in free flap monitoring, some of them being technically demanding (Microdialysis, pH-measurement, Green light p
Reversible atrial fibrillation secondary to a mega-oesophagus
Tahwinder Upile, Waseem Jerjes, Mohammed El Maaytah, Sandeep Singh, Colin Hopper, Jaspal Mahil
BMC Ear, Nose and Throat Disorders , 2006, DOI: 10.1186/1472-6815-6-15
Abstract: We present a rare case of atrial fibrillation secondary to a mega-oesophagus occurring in an 84-years-old Caucasian woman. The patient had a history of progressive dysphagia and the accumulation of food debris lead to mega-oesophagus.The diagnosis was made by barium swallow and electrocardiogram; evacuations of 300 ml of the food debris lead to complete resolution of the arrhythmia. The possible aetiology leading to this AF is discussed.Atrial fibrillation (AF) is the most common cardiac arrhythmia, and it increases in prevalence with advancing age to about 5% in people older than 65 years (Table 1). The chance of developing atrial fibrillation at age 40 years or older is about 25% in men and women. This arrhythmia accounts for about one-third of all strokes, and 30% of all patients with atrial fibrillation have a family history of the disease [1].When the atria are in fibrillation, contraction occurs at rates of 350–900 per minute. The AV node may conduct these impulses to the ventricles at 90–170 beats per minute, and often higher. There are several complementary and competing theories regarding the pathophysiology of AF initiation and propagation. The occasional impulses conducted by the atrio-ventricular node results in a totally irregular ventricular rhythm which is a characteristic of the condition which can be either continuous (acute or chronic) or paroxysmal [2].Achalasia is primarily associated with a degeneration of ganglion cells of Auerbach's plexus resulting in an absence of oesophageal peristalsis and failure of lower oesophageal sphincter relaxation. This results in oesophageal dilatation or mega-oesophagus [3].We present a rare case of a patient with achalasia in which accumulation of undigested food lead to mega-oesophagus and atrial fibrillation.An 84-year-old Caucasian women referred by her General Practitioner complaining of dysphagia and dyspnoea exacerbated by swallowing. She reported a 3 week history of progressive dysphagia, initially for so
Third molar surgery: the patient's and the clinician's perspective
Waseem Jerjes, Tahwinder Upile, Panagiotis Kafas, Syedda Abbas, Jubli Rob, Eileen McCarthy, Peter McCarthy, Colin Hopper
International Archives of Medicine , 2009, DOI: 10.1186/1755-7682-2-32
Abstract: Specifically, three main areas of interest were investigated: the prediction of surgical difficulty and potential complications; the assessment of stress and anxiety and finally the assessment of postoperative complications and the surgeon's experience.In the first study, the prediction of surgical difficulty and potential injury to the inferior alveolar nerve was assessed. This was achieved by examining the patient's orthopantomograms and by using the Pederson Difficulty Index (PDI). Several radiological signs were identified and a classification tree was created to help predict the incidence of such event.In the second study, a prospective assessment addressing the patient's stress and anxiety pre-, intra- and postoperatively was employed. Midazolam was the active drug used against placebo. Objective and subjective parameters were assessed, including measuring the cortisol level in saliva. Midazolam was found to significantly reduce anxiety levels and salivary cortisol was identified as an accurate anxiety marker.In the third study, postoperative complications and the surgeon's experience were examined. Few patients in this study suffered permanent nerve dysfunction. Junior surgeons reported a higher complication rate particularly in trismus, alveolar osteitis, infection and paraesthesia over the distributions of the inferior alveolar and lingual nerves. In apparent contrast, senior surgeons reported higher incidence of postoperative bleeding.These studies if well employed can lead to favourable alteration in patient management and might have a positive impact on future healthcare service.The removal of third molars is the most common surgical procedure practiced in oral & maxillofacial surgery (OMFS). The procedure can be implemented under anaesthesia (either local or general) or intravenous sedation.The patient's journey starts when they present with pain, recurrent swelling or recurrent infection in the third molar area. The patient is usually referred for asse
Rheumatoid nodule of the thyrohyoid membrane: a case report
Tahwinder Upile, Waseem Jerjes, Fabian Sipaul, Sandeep Singh, Colin Hopper, Anthony Wright, Ann Sandison
Journal of Medical Case Reports , 2007, DOI: 10.1186/1752-1947-1-123
Abstract: We present the case of a 62-year-old male who presented with a midline neck mass. Clinically it moved on swallowing and tongue protrusion-suggesting attachment to the thyrohyoid membrane. Ultrasound examination revealed a cystic lesion in the absence of cervical lymphadenopathy in a non-smoker. The neck was explored and histological examination of the excised lesion which was attached to the thyrohyoid membrane revealed a rheumatoid nodule.A rheumatoid nodule of the thyrohyoid membrane is very rare. The triple diagnostic scheme of clinical examination supplemented with ultrasound and guided fine needle aspiration for neck lumps remains valid in most cases. If excision is indicated we feel it should be performed in such a manner that the scar tract could easily be encompassed in a neck dissection excision should definitive histological examination be adverse. We suggest that when dealing with patients with established rheumatoid arthritis one should consider a rheumatoid nodule as a differential diagnosis for any swelling on the patient whether it be subcutaneous or deep.Rheumatoid nodules commonly occur on the extensor surface of the forearms, in the olecranon bursa, over joints and over pressure points [1]. In almost all cases, they occur in patients with established rheumatoid arthritis and occasionally systemic lupus erythematosus.Benign rheumatoid nodules however, can occur usually in healthy young people with no evidence of rheumatoid arthritis or systemic lupus erythematosus [2].Cases have been reported of rheumatoid nodules discovered at unusual sites which include upper eyelid, distal region of soles, vulva and internally in the gallbladder, lung, heart valves, larynx and spine. In some patients rheumatoid nodules were first detected in these sites [3].We report a case of rheumatoid nodule found in another unusual site namely attached to the body of the hyoid bone.A 62-year-old man with known rheumatoid arthritis on gold injection and indomethacin presented
The role of surgical audit in improving patient management; nasal haemorrhage: an audit study
Tahwinder Upile, Waseem Jerjes, Fabian Sipaul, Mohammed El Maaytah, Seyed Ahmad Reza Nouraei, Sandeep Singh, Colin Hopper, Anthony Wright
BMC Surgery , 2007, DOI: 10.1186/1471-2482-7-19
Abstract: The aim of this audit was to determine if routine nasal haemorrhage (epistaxis) can be managed at home with simple nasal packing; a retrospective and prospective audit.Ethical committee approval was obtained. Similar practice was identified in other UK accident and emergency centres. Literature was reviewed and best practice identified. Regional consultation and feedback with regard to prospective changes and local applicability of areas of improved practice mutually agreed upon with involved providers of care.Retrospective: The Epistaxis admissions for the previous four years during the same seven months (September to March).Prospective: 60consecutive patients referred with a diagnosis of Nasal bleeding over a seven month time course (September to March). All patients were over 16, not pregnant and gave fully informed counselled consent.New Guidelines for the management of nosebleeds, nasal packing protocols (with Netcel?) and discharge policy were developed at the Hospital. Training of accident and emergency and emergency ENT staff was provided together with access to adequate examination and treatment resources. Detailed patient information leaflets were piloted and developed for use.Previously all patients requiring nasal packing were admitted. The type of nasal packing included Gauge impregnated Bismuth Iodoform Paraffin Paste, Nasal Tampon, and Vaseline gauge. Over the previous four year period (September to March) a mean of 28 patients were admitted per month, with a mean duration of in patient stay of 2.67 days.In the prospective audit the total number of admissions was significantly reduced, by over 70%, (χ2 = 25.05, df = 6, P < 0.0001), despite no significant change in the number of monthly epistaxis referrals (χ2 = 4.99, df = 6, P < 0.0001). There was also a significant increase in the mean age of admitted patients with epistaxis (χ2 = 22.71, df = 5, P < 0.0001), the admitted patients had a mean length of stay of 2.53 days. This policy results is an estim
Laryngocele: a rare complication of surgical tracheostomy
Tahwinder Upile, Waseem Jerjes, Fabian Sipaul, Mohammed El Maaytah, Sandeep Singh, David Howard, Colin Hopper, Anthony Wright
BMC Surgery , 2006, DOI: 10.1186/1471-2482-6-14
Abstract: We present a rare case of laryngocele occurring in a 77-year-old Caucasian woman. The patient presented with one month history of altered voice, no other associated symptoms were reported. The medical history of the patient included respiratory failure secondary to childhood polio at the age of ten; the airway management included a surgical tracheostomy.Flexible naso-laryngoscopy revealed a soft mass arising from the posterior pharyngeal wall obscuring the view of the posterior commissure and vocal folds. The shape of the mass altered with respiration and on performing valsalva maneuver. A plain lateral neck radiograph revealed a large air filled sac originating from the laryngeal cartilages and extending along the posterior pharyngeal wall. The patient was then treated by endoscopic laser marsupialization and reviewed annually.We discuss the complications of tracheostomy and the pathophysiology of laryngoceles and in particular the likely aetiological factors in this case.A laryngocele presenting in a female patient with tracheostomy is extremely rare and has not been to date reported in the world literature. A local mechanical condition may be the determinant factor in the pathogenesis of the disease.A laryngocele is usually a cystic dilatation of the laryngeal saccule. The etiology behind its occurrence is still unclear, but congenital and acquired factors have been implicated in its development [1,2].Laryngoceles appear to be an atavistic remnant from the higher apes, particularly those who use their arms with the thoracic cage fixed whilst swinging through the trees. In an excellent review of 139 laryngoceles, Stell and Maran showed that the sex incidence is 5:I in favor of men, and the maximum age incidence is in the sixth decade. The authors suggested that two out of three laryngoceles are unilateral and they may be combined, external or internal, with roughly equal frequency; about 8 per cent become infected and present as pyocele. Furthermore they reported
Ethical and technical considerations for the creation of cell lines in the head & neck and tissue harvesting for research and drug development (Part II): Ethical aspects of obtaining tissue specimens
Tahwinder Upile, Waseem Jerjes, Panagiotis Kafas, Sandeep U Singh, Jaspal Mahil, Ann Sandison, Colin Hopper, Holger Sudhoff
International Archives of Medicine , 2009, DOI: 10.1186/1755-7682-2-9
Abstract: We discuss the ethical implications of tissue retention and present a generic consent form (Part II). We also present a simple and successful protocol for the development of cell lines and tissue harvesting for the clinical scientist (Part I).Consent is also more proximate and assurance can be given of appropriate usage. Ethical questions concerning tissue ownership are in many institutions raised during the current consenting procedure. We provide a robust ethical framework, based on the current legislation, which allows clinicians to be directly involved in cell and tissue harvesting.In this molecular diagnostic age, we have a duty to our patients to try to advance and improve treatment. One of the main areas of research nowadays is related mainly to cell cultures [1-7] and their applications increases everyday.Advances are dependent upon and limited by the availability of sufficiently high quality tissue samples for analysis by DNA, mRNA and expressed protein assays [8-10]. The limitations may be caused by restrictions in the scope of patient consent [11], rarity of the disease, diversity of tumour types, method of storage and inadequate documentation [9,10,12].Although much has been published for the development of cell lines [1-7], these were lab based and developed for scientific technical staff. We, however, present a simple and successful protocol for the development of cell lines and tissue harvesting for the clinical scientist (see Part I). Our aim is to enhance the quality of translational research to the benefit of our future patients.In this section (Part II) we discuss the ethics implications of tissue retention and present a generic consent form, which maybe adapted to suit individual institutions. The Human Tissue Act 2004 [11,13,14] provides a detailed statutory framework for tissue use but does not resolve the issues of ownership and of how much information should be disclosed to those consenting and how specific the consent should be [11], we hope
Ethical and technical considerations for the creation of cell lines in the head & neck and tissue harvesting for research and drug development (Part I): Techniques of tissue harvesting and propagation
Tahwinder Upile, Waseem Jerjes, Panagiotis Kafas, Sandeep U Singh, Holger Sudhoff, Jaspal Mahil, Ann Sandison, Colin Hopper
International Archives of Medicine , 2009, DOI: 10.1186/1755-7682-2-8
Abstract: We present a simple and successful protocol for the development of cell lines and tissue harvesting for the clinical scientist. We also discuss the ethical implications of tissue retention and present a generic consent form.The advantages of hospital-based cell line creation are numerous. We can be more certain that cell lines are developed from the particular tissues of interest and accurate anatomical and appropriate clinico-pathological control tissues are also harvested. We can also be certain of less cell line cross contamination.In this molecular diagnostic age, we have a duty to our patients to try to advance and improve treatment. One of the main areas of research nowadays is related mainly to cell cultures and their applications increases everyday [1-7].Human cells will usually continue to grow if supplied with the appropriate nutrients and conditions. Cell culture or cell lines helps us to investigate the physiology and biochemistry of the cell (i.e. cell metabolism) and to test the effect of various chemicals or drugs on specific cell types, i.e. in vitro assays of the effect of chemotherapy, radiotherapy and gene therapy regimes to examine the possibility for resistance to optimise treatment. This procedure is very similar to microbiological sensitivities to assess bacterial susceptibility to antibiotics. Furthermore tissue or pathological samples taken at operation can be tested against protein chips or have their genetic material extracted and run against gene chips. This may provide direct prognostic information as to the likely clinical progression and response of the pathological process [1-7].Cell lines have been used in generating artificial tissues (tissue engineering), i.e. artificial skin, and to synthesize valuable biological compounds from large scale cell cultures, i.e. therapeutic proteins. One of the main advantages of cell lines is the consistency and reproducibility of results; however, cell characteristics can change after a period of c
Salivary VEGF: a non-invasive angiogenic and lymphangiogenic proxy in head and neck cancer prognostication
Tahwinder Upile, Waseem Jerjes, Panagiotis Kafas, Shash Hirani, Sandeep U Singh, Marcel Guyer, Melissa Bentley, Holger Sudhoff, Colin Hopper
International Archives of Medicine , 2009, DOI: 10.1186/1755-7682-2-12
Abstract: The aim of this study is to develop an independent normative database of values of salivary VEGF in a healthy population and to test the hypothesis that values would be raised in the saliva of patients with oral cancer.Twenty-one participants (12 males and 9 females) of whom 14 were healthy and 7 had oral squamous cell carcinoma took part in this study.An immunoassay was employed to quantify a range of specific vascular endothelial and lymphatic endothelial growth factors in various body fluid compartments (blood, saliva). This was correlated to tumour factors and patient outcomes.The mean salivary levels and serum VEGF A165 levels were significantly correlated in the sample as a whole. Additionally, both saliva and serum VEGF A165 levels were significantly correlated with age. There were significant differences in the salivary and serum levels of the control group and the cancer group.We present independent normative data on the levels of endothelial growth factor in the saliva of a healthy control population. We also suggest the use of simple non-invasive tests in helping to predict head and neck tumour biology and outcomes.Saliva is an enriched milieu containing biologically active proteins, including growth factors and cytokines [1]. The endothelial growth factor family of proteins is important for the development of blood and lymphatic vessels in a healthy individual but can also aide tumour growth. Head and neck cancers are known to secrete high levels of endothelial growth factors which may aid their growth (angiogenesis) and metastasis (lymphangiogensis).Vascular endothelial growth factor (VEGF or VEGF-A), also known as vascular permeability factor (VPF), is known for its important roles in regulating both physiological and pathological blood vessel growth. It is a member of the VEGF family that also includes VEGF-B, -C, -D, -E, and PlGF (placental growth factor). VEGF165 appears to be the most abundant isoform.VEGF transcription is potentiated in response t
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