Local drug delivery for oral mucosal diseases: challenges and opportunities

There are few topical formulations used for oral medicine applications most of which have been developed for the management of dermatological conditions. As such, numerous obstacles are faced when utilizing these preparations in the oral cavity, namely enzymatic degradation, taste, limited surface area, poor tissue penetration and accidental swallowing. In this review, we discuss common mucosal diseases such as oral cancer, mucositis, vesiculo-erosive conditions, infections, neuropathic pain and salivary dysfunction, which could benefit from topical delivery systems designed specifically for the oral mucosa, which are capable of sustained release. Each condition requires distinct penetration and drug retention profiles in order to optimize treatment and minimize side effects. Local drug delivery may provide a more targeted and efficient drug-delivery option than systemic delivery for diseases of the oral mucosa. We identify those mucosal diseases currently being treated, the challenges that must be overcome and the potential of novel therapies. Novel biological therapies such as macromolecular biological drugs, peptides and gene therapy may be of value in the treatment of many chronic oral conditions and thus in oral medicine if their delivery can be optimized.

Evidence based practice and its critics: what is a nurse manager to do?

AIM(S)

The purpose is to discuss the arguments against the evidence based practice (EBP) movement and suggest how nursing management might respond.

BACKGROUND

EBP is a pervasive approach to directing and regulating nursing care. There are, however, fierce critics who argue that it is fundamentally flawed and detrimental to patient care.

EVALUATION

We consider some of the more radical criticisms of EBP, weighing the arguments and reflecting on the extent to which alleged short-comings are supported in the literature. Postmodernist critics are amongst the most vocal and are therefore our principal focus.

KEY ISSUE(S)

'Best evidence' implies a hierarchical approach to knowledge which excludes other forms of evidence that are needed to understand the complexity of care. Evidence based guidelines tend to stifle critical thinking amongst nurses.

CONCLUSION(S)

While EBP is increasingly open to a range of research methodologies, it still largely subscribes to a hierarchy of evidence, even though this approach to addressing the complexities of healthcare is limiting. Although the EBP approach can be shown to stifle critical thinking, this is not inherent to the approach, which can lend itself to supporting professional nursing practice.

IMPLICATIONS FOR NURSING MANAGEMENT

Nursing managers should neither abandon EBP nor accept it uncritically.

Primary adenoid cystic carcinoma of the bronchus in a female teenager

Primary adenoid cystic carcinoma (ACC) of the lung is an extremely rare malignant lung neoplasm. ACC of salivary glands of the head and neck, lachrymal glands, breast, skin, vulva and trachea have been frequently reported disease patterns in the literature, but it is unique to see this rare lung tumour in a patient as young as 14 years old. No double blind placebo, multicentre treatment data are available. Surgery is considered as the cornerstone of the treatment. Prognosis is variable and adjuvant radiotherapy has been found beneficial for prolonged survival. Our report of primary lung ACC in a young girl is a complex case due to young age, a different way of presentation and staging on diagnosis. It has been a quite challenging clinical scenario for the multidisciplinary lung cancer treating team involved in the clinical care. Prognosis remains unpredictable and uncertain despite the best present day evidence-based treatment.

On the problems of mixing RCTs with qualitative research: the case of the MRC framework for the evaluation of complex healthcare interventions

In the perceived hierarchy of research designs, the results from randomised controlled trials are considered to provide the highest level of evidence. Indeed, these trials have been upheld as the gold standard in research. The benefits and limitations of the randomised controlled trial as a method of evaluating the effectiveness of healthcare interventions are presented. The paper then examines the different levels of complexity within healthcare interventions and the problems this poses in determining effectiveness. In an effort to provide a solution to this problem, the Medical Research Council produced a framework to assist investigators to develop and evaluate complex healthcare interventions. The framework is described with reference to an example of implementing and evaluating protocols for weaning patients in the intensive care unit. The framework is critiqued on the basis that it involves an ambiguous or contradictory ontology, which fails to articulate the relationship between the positivism of randomised controlled trials with the relativism of qualitative approaches. It is concluded that the use of realist strategies in combination with randomised controlled trials provides the most coherent solution to this quandary.

Characteristics of myxobacteria isolated from the surface of freshwater fish

A study was made of 32 nonpathogenic myxobacterial isolates obtained from a variety of fish taken in the Pacific Northwest. Morphological, cultural, biochemical, and serological studies were carried out on these strains. All were found to be members of the genus Cytophaga. Two myxobacterial strains pathogenic to fish were also included in this study for comparative purposes. These pathogenic organisms were found to be culturally and physiologically similar to some of the nonpathogenic strains. Antiserum against the pathogenic species, however, showed no cross agglutination when tested against the other myxobacterial isolates. As a result, serological procedures appear promising as a rapid means for distinguishing pathogenic myxobacteria from one another and from saprophytic myxobacteria commonly found on fish.

Bronzino's 'Allegory of Venus and Cupid': an exemplary image for contemporary sexual health promotion?

Recent sexual health promotion strategies have veered between a negative emphasis on the deleterious consequences of sexually transmitted infections, and a more positive, eroticized approach to safer sex. The differences in approach are starkly reflected in the images chosen to illustrate them. We note that there are problems with both approaches. The main purpose of this review is to demonstrate how this dichotomy was transcended by the sixteenth century Florentine Mannerist painter, Agnolo Bronzino, in his allegory on syphilis.

Dental management of patients at risk of osteochemonecrosis of the jaws: a critical review

Osteonecrosis of the jaw bones is a complication of bisphosphonate (BP) drug usage characterised by trans-mucosal exposure of necrotic bone, often followed by infection and pain. Osteonecrosis is observed in cancer patients on high-potency intravenous BP more frequently than in osteoporotic individuals using low-potency oral BP. The management of osteonecrosis caused by BP is often unsatisfactory and control of risk factors is considered the most effective means of prevention. Surgical manipulation and dental infection of the jawbone are the major risk factors, hence it is suggested that careful management of oral health and relevant dental procedures may decrease the risk of osteonecrosis in individuals on BP. Recommendations for dentists and oral surgeons have been suggested by different groups of clinicians but they are often controversial and there is no clear evidence for their efficacy in reducing the likelihood of osteonecrosis development. This report critically reviews current dental recommendations for individuals using BP with the aim of helping the reader to transfer them into practice as part of pragmatic and non-detrimental clinical decisions making.

[An electro-stimulating oral splint for dry mouth treatment]

Dentists encounter regularly patients with xerostomia, which is the accepted term for dry mouth complaint. Left untreated, xerostomia can lead to psychosocial distress and to impaired quality of life. Oral complications of the most frequent cause of xerostomia, salivary gland hypofunction, include dental caries and candidiasis. In addition, quality of life is significantly hampered. The etiology of xerostomia is multiple, but the most common conditions are Sjögren's syndrome, radiotherapy to the head and neck and use of medications. Current therapies offered by dentists rely on saliva substitutes and stimulants such as chewing gum, and are somewhat limited by their short-term efficacy. Oral mucosal electro-stimulation increases salivary secretion and relieves symptoms of dry mouth in patients with xerostomia. Therefore, intra-oral electronic devices have been developed aimed at stimulating salivary gland function. They offer promise as an optional safe and non-chemical treatment of xerostomia.

Validity, trustworthiness and rigour: reasserting realism in qualitative research

AIM

This paper challenges recent sceptical approaches to the possibility of validating qualitative research and underlines the benefits of adopting a realist approach to validity.

BACKGROUND

In recent discussion about the methodological bases for qualitative research it has been argued that, because different methodologies take different approaches to validity, attempts to develop a common set of validation criteria are futile. On the basis of this sceptical view, a number of strategies for judging qualitative research have been proposed. These include suggestions that: it should be judged according to aesthetic or rhetorical criteria, rather than epistemological validity; responsibility for appraisal should move from researchers to readers; each methodology should be assessed individually according to its own merits.

DISCUSSION

None of these suggestions provide a viable alternative to validity, defined as the extent to which research reflects accurately that to which it refers. Because the form of research does not determine its content, replacement of epistemology by aesthetics is unsustainable. Because research reports mediate between writer and reader, a one-sided approach to this relationship constitutes a false dichotomy. If we accept the criterion of practitioner confidence as a means of judging methodological approaches, this involves rejection of judgement according to a methodology's own merits.

CONCLUSION

If qualitative research is actually about something, and if it is required to provide beneficial information, then a realist approach to validity holds out greatest promise.