Hypertonic packs to reverse blindness caused by facial lymphoedema in the setting of head and neck cancer - A case report.

BACKGROUND: Severe, cancer-related facial oedema can impair vision. It can result from lymphatic and/or venous obstruction due to disease and/or treatment related fibrosis. There is very limited data on the use of directly applied hypertonic packs for the relief of periorbital oedema. CASE: A 63 year old man with recurrent laryngeal squamous cell carcinoma developed functional blindness secondary to periorbital oedema in the setting of severe facial swelling. This was refractory to maximal facial lymphatic massage available in the community setting. POSSIBLE COURSES OF ACTION: Management dilemmas included what non-medical interventions may relieve his periorbital oedema and thereby restore his vision outside of daily lymphatic massage from a qualified physiotherapist. FORMULATION OF MANAGEMENT PLAN: The patient agreed to an initial dry hypertonic pack with a great functional improvement of his vision. He was taught how to do this so that he could repeat ad libitum. OUTCOME: The patient had previously expressed that his most distressing thought was the prospect of becoming functionally blind prior to dying. The provision of an easy additional therapy to relieve his visual obstruction provided him with much comfort. He passed away peacefully a few weeks later. LESSONS: The case demonstrates that application of a dry hypertonic pack can relieve periorbital oedema in the setting of facial oedema in cases which are refractory to the combination of self-massage, cold-compress application, and daily lymphatic massage by a certified physiotherapist. RESEARCH AVENUES: A case series to define incidence of adverse effects and duration of treatment effectiveness.

Research and advice giving: a functional view of evidence-informed policy advice in a Canadian Ministry of Health.

CONTEXT: As evidence-based medicine grows in influence and scope, its applicability to health policy prompts two questions: Can the principles and, more specifically, the tools used to bring research into the clinical world apply to civil servants offering advice to politicians? If not, what approach should the evidence-oriented health policy organization take to improve the use of research? METHODS: This article reviews evidence-based medicine and models of research use in policy. Then it reports the results of interviews with civil servants in the Ontario Ministry of Health, which recently adopted a stewardship rather than an operational role, incorporating many evidence-oriented strategies. The interviews focused on functional roles for research-based evidence in policy advice. FINDINGS: The clinical context and tools for evidence-based medicine can rarely be generalized to policy. Most current models of research use offer lessons to researchers wishing to apply their work to policy but little help for civil servants wishing to become more evidence oriented. The interviews revealed functional roles for research in setting agendas (noting upcoming issues and screening interest groups' claims), developing new policies (reducing uncertainty, helping speak truth to power, and preventing repetition and duplication), and monitoring or modifying existing policies (continuously improving programs and creating a culture of inquiry). Each area requires different tools to help filter the push of evidence from researchers and set agendas, to facilitate the urgent pull on relevant research by civil servants developing new policy, and to support ongoing linkage and exchange between civil servants and researchers for monitoring and modifying existing policy. CONCLUSIONS: A functional framework for evidence-informed policy advice is useful for distinguishing the activity from evidence-based medicine and "auditing" the balance of efforts across the different functional roles of research in policy.

Temporomandibular dysfunction

BACKGROUND: Orofacial pain is a common presentation in the primary healthcare setting and temporomandibular dysfunction represents one of the major causes. Its aetiology is multifactorial, caused by both masticatory muscle dysfunction and derangement within the temporomandibular joint. OBJECTIVE: The aim of this article is to provide an overview of temporomandibular dysfunction, its management and referral considerations for general practioners. DISCUSSION: Temporomandibular joint dysfunction affects a large number of adults. Conservative management involving non-pharmacological and pharmacological therapies is effective in the majority of cases.

Surgical management of plunging ranulas: a 10-year case series in South East Queensland.

BACKGROUND: Plunging ranulas are rare mucous extravasation pseudocysts that arise in the floor of the mouth and pass into the submandibular space of the neck. The aim of this study was to investigate the diagnosis, surgical management and outcomes of patients with a plunging ranula at our institution in South East Queensland over a 10-year period. METHODS: A retrospective analysis of adult patients diagnosed with and treated for plunging ranula between 2006 and 2016 at Logan Hospital was conducted. Patient demographics, preoperative investigations, surgical management and post-operative outcomes were collected from medical records. RESULTS: A total of 18 adult patients were treated for plunging ranula. Of the 18 cases, 17 were treated via transoral excision of the sublingual gland. The mean age at presentation was 28.8 years with a 3:1 female to male predominance. Fifty-six percent of patients were of Polynesian descent. The success rate was 94% with only one patient experiencing recurrence and requiring re-excision of remnant sublingual gland tissue. Three patients (17%) developed complications related to post-operative bleeding. There was a slight predominance for right-sided disease (56%) compared with left and one case of bilateral plunging ranulas in this series. CONCLUSION: This study demonstrates that excision of the sublingual gland is an effective and safe treatment for plunging ranula. The majority of plunging ranulas occur in patients aged <30 years with a higher incidence in patients of Polynesian heritage, which is consistent with previous studies suggesting a possible underlying genetic predisposition for this condition.

Research use in children's mental health policy in Canada: maintaining vigilance amid ambiguity.

Many researchers hope to see the best available research evidence used in policy-making to address important public problems. However, policy often appears to be based on anything but the research evidence, as the problem of conduct disorder (or severe antisocial behaviour in children) shows. In Canada, few children receive effective prevention or treatment programs, and incarceration is overused, despite evidence that it is ineffective and potentially harmful. Using the example of conduct disorder, we investigated why policy-making has not reflected the research evidence, examining research use in the context of competing influences on the policy process. Qualitative methods were used to analyze data from interviews with thirty-two politicians and senior civil servants. Our allegiance to rationality wavered as we listened to policy-makers who contended with the inherent ambiguity in the policy process. They told us that they managed institutional constraints including fragmentation across levels and sectors of government, and the long-term effects of fiscal restraint. They also reconciled the competing interests of stakeholders' priorities, the public's response to negative events involving children and the media's role in shaping this response. Ideas about youth violence were morally charged, but policy-makers remained committed to improving children's lives. Day-to-day, policy-makers obtained most of their information internally and informally. Research evidence was valued and used, but as just one source of ideas and information among many. In this environment of ambiguity, creative civil servants formed partnerships with trusted researchers in order to change policy. Our findings suggest that the use of research evidence in policy-making could be enhanced if researchers learned about the competing influences on the policy process, formed research-policy partnerships, challenged the incentives within research institutions, and engaged in public debates about important problems, such as child antisocial behaviour.

What new knowledge would help policymakers better balance investments for optimal health outcomes?

OBJECTIVE: Review the limitations in cross-sectoral health outcomes research and suggest a future research agenda. DATA SOURCES, STUDY DESIGN, DATA COLLECTION: Literature review and workshop discussion. PRINCIPAL FINDINGS: The research evidence that would aid public and private policy makers in answering the question the title poses is quite limited. CONCLUSIONS: Much more evidence from diverse disciplines is needed, and key areas are suggested. Criteria for progress by 2010 are proposed.

Commentary: whose views count in evidence synthesis? And when do they count?

Four recent pieces in Healthcare Policy reveal some disagreement on when and how to involve decision-makers in the process of evidence synthesis. This commentary proposes varying roles for researchers versus managers or policy makers at each of three different stages of synthesis and at the actual point of decision. It also raises the issue of how poorly current processes accommodate the broader conception of evidence held by most managers and policy makers.

Assessing country-level efforts to link research to action.

We developed a framework for assessing country-level efforts to link research to action. The framework has four elements. The first element assesses the general climate (how those who fund research, universities, researchers and users of research support or place value on efforts to link research to action). The second element addresses the production of research (how priority setting ensures that users' needs are identified and how scoping reviews, systematic reviews and single studies are undertaken to address these needs). The third element addresses the mix of four clusters of activities used to link research to action. These include push efforts (how strategies are used to support action based on the messages arising from research), efforts to facilitate "user pull" (how "one-stop shopping" is provided for optimally packaged high-quality reviews either alone or as part of a national electronic library for health, how these reviews are profiled during "teachable moments" such as intense media coverage, and how rapid-response units meet users' needs for the best research), "user pull" efforts undertaken by those who use research (how users assess their capacity to use research and how structures and processes are changed to support the use of research) and exchange efforts (how meaningful partnerships between researchers and users help them to jointly ask and answer relevant questions). The fourth element addresses approaches to evaluation (how support is provided for rigorous evaluations of efforts to link research to action).

Using research to inform healthcare managers' and policy makers' questions: from summative to interpretive synthesis.

This paper highlights the importance of research synthesis for healthcare managers' and policy makers' questions and the difficulty of generalizing from the methods used to answer clinicians' questions. Social science research has a central role in such syntheses because of the context-dependent nature of managers' and policy makers' questions, which generally encompass a far broader spectrum than the circumscribed "what works?" questions of clinically oriented reviews. A major challenge is in moving from purely researcher-driven processes, which summarize research, to co-production processes, which allow managers and policy makers to join with researchers in interpreting implications for the healthcare system. Additional challenges lie in clearly defining the function, role and objective of the synthesis; handling flexibility around finalizing the question; harnessing a manageable scope of literature to review; adopting rules to select the final sample of research; creating useful messages; and developing a format that is responsive to the needs and preferences of the audience. One inevitable conclusion is that research synthesis for managers and policy makers will, compared to that for clinicians, leave much discretion in the hands of the synthesiser(s). This raises the interesting issue of how to engender, in the absence of "methodological checklists," trust and credibility in both the people doing the synthesis and the processes they use.

Joining the conversation: newspaper journalists' views on working with researchers.

For health researchers who seek more research use in policy making to improve health and healthcare, working with the news media may represent an opportunity, given the media's pivotal role in public policy agenda-setting. Much literature on science and health journalism assumes a normative stance, focusing on improving the accuracy of news coverage. In this study, we investigated journalists' perspectives and experiences. We were particularly interested in learning how health researchers could work constructively with journalists as a means to increase research use in policy making. Qualitative methods were used to conduct and analyze interviews with experienced newspaper journalists across Canada, with children's mental health as a content example. In response, study participants emphasized journalistic processes more than the content of news coverage, whether children's mental health or other topics. Instead, they focused on what they thought researchers needed to know about journalists' roles, practices and views on working with researchers. Newspaper journalists balance business and social responsibilities according to their respective roles as editors, columnists and reporters. In practice, journalists must ensure newsworthiness, relevance to readers and access to sources in a context of daily deadlines. As generalists, journalists rely on researchers to be expert interpreters, although they find many researchers unavailable or unable to communicate with public audiences. While journalists are skeptical about such common organizational communications tools as news releases, they welcome the uncommon contributions of those researchers who cultivate relationships and invest time to synthesize and communicate research evidence on an ongoing basis. Some appealed for more researchers to join them in participating in public conversations. We conclude that there are opportunities for policy-oriented health researchers to work constructively with newspaper journalists--by appreciating journalists' perspectives and by taking seriously some of their suggestions for engaging in public conversations--and that such engagement can be a means to increase the use of research evidence in policy making and thereby improve health and healthcare.

On being a good listener: Setting priorities for applied health services research

It describes how the lessons learned from and the approaches to setting priorities for funding health services are translated into setting priorities for funding health services research, in which the paymasters want to use the finite human and financial resources for those areas most likely to improve health services delivery. (Au) (Volume 81, Number 3, 2003)