Supporting international medical graduates’ transition to their host-country: realist synthesis

Context Many health services and systems rely on the contribution of international medical graduates (IMGs) to the workforce. However, concern has grown around their regulation and professional practice. There is a need, in the absence of strong evidence and a robust theoretical base, for a deeper understanding of the efficacy of interventions used to support IMGs’ transition to their host countries. This study seeks to explore and synthesise evidence relating to interventions developed for IMGs. It aims to provide educators and policy makers with an understanding of how interventions should be developed to support IMGs in their transition to the workplace, particularly looking to identify how and why they are effective. Methods The realist synthesis involved an initial systematic search of the literature for the period January 1990 to April 2015. Secondary searches were conducted throughout the review in order to inform and test the developing programme theory. The context, mechanism and outcome data were extracted from all sources meeting the inclusion criteria. Fourteen case studies were included to further aid theory refinement. Results Sixty-two articles were identified, describing diverse interventions of varying intensity. A further 26 articles were identified through a secondary search. The findings illustrate that, alongside a developed programme, ongoing support and cultural awareness at organisational and training levels are crucial. Individual differences must also be taken into consideration. This will ensure that IMGs engage in transformative learning, increase their levels of self-efficacy and cultural health capital, and reduce feelings of stress and anxiety. These factors will have an impact on work, interactions and cultural adjustment. Conclusions Organisational, training and individual contexts all play a role in IMGs’ adjustment during the transition process. Establishing ongoing support is critical. A list of recommendations for implementation is given

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

Background Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. Methods FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762. Findings Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839–1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26–6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38–2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months. Interpretation Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function. Funding UK Stroke Association and NIHR Health Technology Assessment Programme

Variations in the geochemistry of magmatism on the East Pacific Rise at 10?30'N since 800 ka

Samples of volcanic rock, collected from the flanks of the East Pacific Rise at 10°30'N, were used to investigate changes in the geochemistry of magmatism at the ridge axis, over the past 800 ka at this location. We show that there have been large variations in the major element chemistry of the lavas erupted at the spreading axis on this ridge segment over this period. For example, the average MgO content of lavas erupted at the ridge axis increased from about 3.0% at 600 ka, to about 7.0% at 300 ka. Since 300 ka the average MgO content has systematically decreased, and the average MgO content of lavas collected from within the neovolcanic zone at 10°30'N is 6.0%. These temporal changes in major element chemistry are not accompanied by systematic changes in isotope composition or incompatible trace element ratios, and are interpreted to reflect changes in the average rate of supply of melt to the ridge axis during this period. The data support previous arguments that changes in melt supply rate over periods of 100-1000 ka have an important influence on the major element chemistry of the lavas erupted at fast spreading ridges. At 10°30'N, the melt supply rate appears to have been relatively low for much of the past 800 ka. Samples younger than 50 ka, collected from within 3 km of the ridge axis at 10°30'N (inside the neovolcanic zone), have a smaller range in major element chemistry compared to the samples dredged from the ridge flanks. Variations in the chemistry of lavas erupted over periods of less than about 100 ka may be controlled by the geometry of the magma plumbing system beneath the ridge axis