Recent advances in the understanding of the aetiology and therapeutic strategies in burning mouth syndrome: Focus on the actions of cannabinoids.

Burning mouth syndrome (BMS) is a neuropathic pain disorder associated with a burning sensation on oral mucosal surfaces with frequently reported xerostomia, dysgeusia and tingling or paraesthetic sensations. However, patients present no clinically evident causative lesions. The poor classification of the disorder has resulted in a diagnostic challenge, particularly for the clinician/dentist evaluating these individuals. Major research developments have been made in the BMS field in recent years to address this concern, principally in terms of the pathophysiological mechanisms underlying the disorder, in addition to therapeutic advancements. For the purpose of this review, an update on the pathophysiological mechanisms will be discussed from a neuropathic, immunological, hormonal and psychological perspective. This review will also focus on the many therapeutic strategies that have been explored for BMS, including antidepressants/antipsychotics, non-steroidal anti-inflammatories, hormone replacement therapies, phytotherapeutic compounds and non-pharmacological interventions, overall highlighting the lack of controlled clinical studies to support the effectiveness of such therapeutic avenues. Particular focus is given to the cannabinoid system and the potential of cannabis-based therapeutics in managing BMS patients.

Reduction in Pediatric Ambulatory Adenotonsillectomy Length of Stay Using Clinical Care Guidelines.

OBJECTIVE: Standardization of postoperative care using clinical care guidelines (CCG) improves quality by minimizing unwarranted variation. It is unknown whether CCGs impact patient throughput in outpatient adenotonsillectomy (T&A). We hypothesize that CCG implementation is associated with decreased postoperative length of stay (LOS) in outpatient T&A. METHODS: A multidisciplinary team was assembled to design and implement a T&A CCG. Standardized discharge criteria were established, including goal fluid intake and parental demonstration of medication administration. An order set was created that included a hard stop for discharge timeframe with choices "meets criteria," "4-hour observation," and "overnight stay." Consensus was achieved in June 2018, and the CCG was implemented in October 2018. Postoperative LOS for patients discharged the same day was tracked using control chart analysis with standard definitions for centerline shift being utilized. Trends in discharge timeframe selection were also followed. RESULTS: Between July 2015 and August 2017, the average LOS was 4.82 hours. This decreased to 4.39 hours in September 2017 despite no known interventions and remained stable for 17 months. After CCG implementation, an initial trend toward increased LOS was followed by centerline shifts to 3.83 and 3.53 hours in March and October 2019, respectively. Selection of the "meets criteria" discharge timeframe increased over time after CCG implementation (R2  = 0.38 P = .003). CONCLUSIONS: Implementation of a CCG with standardized discharge criteria was associated with shortened postoperative LOS in outpatient T&A. Concurrently, surgeons shifted practice to discharge patients upon meeting criteria rather than after a designated timeframe. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2610-2615, 2021.

Standardized Order Set Exhibits Surgeon Adherence to Pain Protocol in Pediatric Adenotonsillectomy.

OBJECTIVES/HYPOTHESIS: To produce a sustained reduction in opioid prescriptions in patients <5 years of age undergoing T&A through utilization of standardized algorithms and electronic health record (EHR) automation tools. STUDY DESIGN: Prospective quality improvement initiative. METHODS: Plan-do-study-act (PDSA) methodology was used to design an age-based postoperative pain regimen in which children <5 years of age received a non-opioid pain regimen, and option to prescribe oxycodone for additional pain relief was given for children >5 years of age. Standardized discharge instructions and automated, age-specific order sets were created to facilitate adherence. Rate of discharge opioid prescription was monitored and balanced against post-discharge opioid prescriptions and returns to the emergency department (ED). RESULTS: In children <5 years of age undergoing T&A, reduction in opioid prescription rates from 65.9% to 30.9% after initial implementation of the order set was noted. Ultimately, reduction of opioid prescribing rates to 3.7% of patients was noted after pain-regimen consensus and EHR order set implementation. Opioid prescriptions in patients >5 years of age decreased from 90.6% to 58.1% initially, and then down 35.9% by the last time point analyzed. Requests for outpatient opioid prescriptions did not increase. There was no significant change in returns to the emergency ED for pain management, or in the number opioids prescribed when patients returned to the ED. CONCLUSIONS: Iterative cycles of improvement utilizing standardized pain management algorithms and EHR tools were effective means of producing a sustained reduction in opioid prescriptions in postoperative T&A patients. Such findings suggest a framework for similar interventions in other pediatric otolaryngology settings. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2337-E2343, 2021.

How do patients experience caring? Scoping review.

OBJECTIVE: Summarise empirical research into patients' experiences of caring in order to promote this as a core condition for the work of health professionals. METHODS: A review team: carried out a scoping review with a phenomenological orientation that did not privilege any profession or context of care; comprehensively searched six databases from inception to the present, including all English language articles that report patients' lived experiences of caring; and identified and contrasted uncaring experiences. RESULTS: 43 articles straddled nursing, medicine, and physiotherapy, and a wide range of care settings. Patients experienced caring when competent professionals displayed positive attitudes, communicated effectively, formed relationships, helped them navigate clinical services, and engaged emotionally. CONCLUSION: This research provides a rich description of caring, which was derived from patients', rather than professionals', experiences. PRACTICE IMPLICATIONS: Whilst publications and basic professional curricula are dominated by the perspectives of single professions, this research describes patients' experiences that can prepare all health professionals to be caring in collaborative, interprofessional practice.

Thiolated polymers as mucoadhesive drug delivery systems.

Mucoadhesion is the process of binding a material to the mucosal layer of the body. Utilising both natural and synthetic polymers, mucoadhesive drug delivery is a method of controlled drug release which allows for intimate contact between the polymer and a target tissue. It has the potential to increase bioavailability, decrease potential side effects and offer protection to more sensitive drugs such as proteins and peptide based drugs. The thiolation of polymers has, in the last number of years, come to the fore of mucoadhesive drug delivery, markedly improving mucoadhesion due to the introduction of free thiol groups onto the polymer backbone while also offering a more cohesive polymeric matrix for the slower and more controlled release of drug. This review explores the concept of mucoadhesion and the recent advances in both the polymers and the methods of thiolation used in the synthesis of mucoadhesive drug delivery devices.

Synthesis and characterisation of mucoadhesive thiolated polyallylamine.

The thiolation of polyallylamine (PAAm) for use in mucoadhesive drug delivery has been achieved. PAAm was reacted with different ratios of Traut's reagent, yielding products with thiol contents ranging from 134-487µmol/g. Full mucoadhesive characterisation of the thiolated PAAm samples was conducted using swelling studies, mucoadhesive testing on porcine intestinal tissue and rheology. Both swelling and cohesive properties of the thiolated PAAm products were vastly improved in comparison to an unmodified PAAm control. The swelling abilities of the thiolated samples were high and the degree of thiolation of the products affected the initial rate of swelling. High levels of mucoadhesion were demonstrated by the thiolated PAAm samples, with adhesion times of greater than 24h measured for all three samples and, thus, thiol content did not appear to influence mucoadhesion. Rheological studies of the thiolated PAAm samples showed an increase in G' and G″ values upon the addition of a mucin solution which was not observed in the unmodified control, again highlighting the mucoadhesive interactions between these thiolated polymers and mucin. The synthesis of thiolated PAAm by reaction with Traut's reagent and resulting mucoadhesive properties demonstrates its potential for use a mucoadhesive drug delivery device.

Comparison of the mucoadhesive properties of thiolated polyacrylic acid to thiolated polyallylamine.

Synthetic polymers, polyacrylic acid (PAA) and polyallylamine (PAAm), were thiolated using different methods of thiolation. Both polymers resulted in comparable thiol contents, thus allowing for the direct comparison of mucoadhesive and cohesive properties between the well-established thiolated PAA and the more novel thiolated PAAm. Thiolation of both polymers improved the swelling ability and the cohesive and mucoadhesive properties in comparison to unmodified control samples. In this study, it was shown that the swelling abilities of the thiolated PAAm sample were far greater than that of the thiolated PAA sample which, in turn, affected the drug release profile of the thiolated PAAm sample. Importantly, however, the mucoadhesive properties of thiolated PAAm were equivalent to that of the thiolated PAA sample as demonstrated by both the adhesion times on porcine intestinal tissue as measured by the rotating cylinder method and by rheological studies with a mucin solution. This study demonstrates the potential thiolated polyallylamine has as a mucoadhesive drug delivery device.

Synthesis of mucoadhesive thiolated gelatin using a two-step reaction process.

Using a novel two-step approach, the thiolation of gelatin for mucoadhesive drug delivery has been achieved. The initial step involved the amination of native gelatin via an amine to carboxylic acid coupling reaction with ethylene diamine, followed by thiolation with Traut's reagent. The resulting thiolated product showed an increase in thiol content of up to 10-fold in comparison with control gelatin samples. Improved cohesion and mucoadhesion in comparison with unmodified and control gelatin samples was also observed. This reaction process was observed to be influenced by both the temperature and the pH of the amination reaction, affecting both amine content and product yield. Swelling ability, cohesion and mucoadhesion were all observed to be strongly dependent on the thiol content of the samples but also, importantly, the molecular weight (MW) of the gelatin used. Gelatin with a MW of 20-25 kDa proved to be optimal in creating this novel mucoadhesive gelatin material.