The evaluation of evidence-informed changes to an internationally educated nurse registration process.

AIM: To evaluate effectiveness of specific policy and practice changes to the process of registration for internationally educated nurses. BACKGROUND: Little research exists to inform registration policy for internationally educated health professionals. INTRODUCTION: Internationally educated nurse employment can help address nursing shortages. Regulators assess competencies for equivalency to Canadian-educated nurses, but differences in health systems, education and practice create challenges. METHODS: The study setting was a Canadian province. We used a mixed methods approach, with a pre-post-quasi-experimental design and a qualitative evaluation. Previous analysis of relationships between applicant variables, registration outcomes and timelines informed changes to our registration process. Implementation of these changes composes the intervention. Comparisons between pre- and post-implementation exemplar subgroups and timeline analyses were conducted using descriptive statistics, univariate analysis and non-parametric tests. Data were collected from complete application files before (n = 426) and after (n = 287) implementation of the intervention. Interviews, focus groups and consultations were completed with various stakeholders. FINDINGS: The time between steps in the process was significantly reduced following implementation. Stakeholders reported an increase in perceived efficiency, transparency and use of evidence. DISCUSSION: Results indicated that initial impacts of the policy changes streamlined the process for applicants and staff. CONCLUSION: Maintaining a consistent and systematic review of an organization's data coupled with implementation of findings to effect policy and practice change may have an important impact on regulatory policy. IMPLICATIONS FOR NURSING POLICY: These findings represent the beginning of an international policy conversation. Policy changes based on organizational data can underlie major process improvement initiatives. Ongoing nursing shortages across the globe and increasing mobility of nurses make it important to have efficient and transparent regulatory policy informed by evidence.

Additive interfacial chiral interaction in multilayers for stabilization of small individual skyrmions at room temperature.

Facing the ever-growing demand for data storage will most probably require a new paradigm. Nanoscale magnetic skyrmions are anticipated to solve this issue as they are arguably the smallest spin textures in magnetic thin films in nature. We designed cobalt-based multilayered thin films in which the cobalt layer is sandwiched between two heavy metals and so provides additive interfacial Dzyaloshinskii-Moriya interactions (DMIs), which reach a value close to 2 mJ m(-2) in the case of the Ir|Co|Pt asymmetric multilayers. Using a magnetization-sensitive scanning X-ray transmission microscopy technique, we imaged small magnetic domains at very low fields in these multilayers. The study of their behaviour in a perpendicular magnetic field allows us to conclude that they are actually magnetic skyrmions stabilized by the large DMI. This discovery of stable sub-100 nm individual skyrmions at room temperature in a technologically relevant material opens the way for device applications in the near future.

Epidemiology of thoracolumbar spine injury in blunt trauma.

OBJECTIVE: To evaluate the prevalence, distribution, and demographics of thoracolumbar (TL) spine injuries following blunt trauma. METHODS: Prospective, cross-sectional study of a consecutive sample of all blunt trauma patients presenting initially to the emergency department (ED) of a Level 1 trauma center and undergoing thoracic and/or lumbar spine radiography from August 1997 to November 1998. The age, sex, and mechanism of injury of each patient as well as location and type of spine injury were recorded for those patients with vertebral fractures, dislocations, or subluxations. RESULTS: Two thousand four hundred four blunt trauma patients were enrolled. Vertebral injuries were identified in 152 individuals (6.3%, 95% CI = 5.4% to 7.4%). Two hundred sixty distinct anatomic levels of injury were identified in these 152 individuals. Of these 260 injuries, 42 (16.2%) occurred at L1, 38 (14.6%) at L2, 29 (11.1%) at L3, and 27 (10.4%) at T12, making these the most commonly injured vertebrae. Injuries were most common (34 patients) in those aged 30-39 years and were least common (12 patients) in those under 18 years. Compression fractures (52%) were the most common injury in the thoracic spine, while transverse process fractures (48%) were the most common injuries in the lumbar spine. CONCLUSIONS: The prevalence of TL injuries in ED blunt trauma patients undergoing TL radiographs is 6.3%. The most commonly injured area of the TL spine is the thoracolumbar junction.

The changing pattern of laryngeal tuberculosis.

Laryngeal tuberculosis is now an uncommon disease in the United Kingdom. A series of ten cases is reported. In contrast to the pre-chemotherapy era, when the disease was associated with advanced cavitated pulmonary tuberculosis and was highly infectious, it now presents in a manner similar to laryngeal carcinoma except that painful dysphagia is a prominent symptom. All such patients should have a chest X-ray carried out as part of their initial investigation. Sputum is almost always positive for tubercle bacilli on direct films. Direct laryngoscopy and biopsy are necessary if a carcinoma is suspected. The change of pattern of the disease may be due to the fact that the larynx now usually becomes involved by haematogenous spread rather than by direct spread along the airways. Laryngeal tuberculosis is now no more infectious than pulmonary tuberculosis, and responds well to antituberculous chemotherapy. Symptoms resolve completely within three weeks if corticosteroids are given in combination.

The role of the Nurse Specialist in the highly specialized field of Mental Health and Deafness.

This opinion paper considers the need for enhanced clinical skills and knowledge to fulfil the role of a Specialist Nurse in the field of Mental Health & Deafness and informs professionals of a new group called the Mental Health & Deafness National Nurse Specialist Forum. Their knowledge and skills enable therapeutic interventions to be accessible and meaningful for Deaf people. A case study illustrates the complex nature of assessment and treatment in Mental Health & Deafness and highlights the potential devastating consequences that may occur if a Deaf person is misdiagnosed and does not access appropriate services. An increased awareness of the field and forum aims to increase the interest of nurses outside of the field and support a developing evidence base for Deaf sensitive interventions and opportunities for further pioneering work.

Chlamydia testing in community pharmacies: evaluation of a feasibility pilot in south east London.

BACKGROUND AND OBJECTIVE: Chlamydia trachomatis infection is a common sexually transmitted infection with serious sequelae. Excellent access to testing, treatment and contact tracing are an essential part of strategies to control it. With traditional sexual health services over-stretched, community pharmacies are well placed to provide this service. They have the potential to improve access by offering chlamydia testing and treatment from high street venues with long opening hours. This study evaluated the feasibility and acceptability to users and pharmacists of this service in independent community pharmacies. METHOD: A chlamydia testing and treatment service was offered in three community pharmacies in two inner London boroughs for a 3-month pilot. Data on the feasibility and acceptability of the new service were collected via a survey of client experience, in-depth semistructured interviews with clients and pharmacists, and structured evaluation reports completed by professional patients paid to visit the pharmacies. RESULTS: 83 tests were taken with eight (9.5%) of these positive for C trachomatis. Of those tested, 94% (n = 73) were women and 71% (n = 56) were from ethnic minorities. 80 clients completed the questionnaires and 24 clients were interviewed. Most clients heard about the service from the pharmacist when requesting emergency contraception and 16% (n = 13) would not otherwise have been tested. Clients valued the speed and convenience of the service and the friendly, non-judgmental approach of the pharmacist. Confidentiality when asking for the service at the counter was suboptimal, and the pharmacist trained to deliver the service was not always available to provide it. CONCLUSIONS: Chlamydia testing and treatment in community pharmacies is feasible and acceptable to users. The service increases access among young women at high risk of sexually transmitted infection but not among young men.

Conservative management of renal tuberculosis.

The conservative management of 60 patients suffering from renal tuberculosis is reported. Following chemotherapy, bacteriological conversion to negative was obtained in all patients. 2 patients (3-3%) relapsed due to failure to take adequate treatment. Evidence of ureteric obstruction was obtained in 30 patients (50%)--23 at the time of diagnosis, 6 during treatment and 1 at the time of relapse. Following corticosteroid treatment relief of obstruction was obtained in 72%. Nephrectomy was carried out in 4 patients (6-7%) but in only 1 of these was the operation carried out for reasons which we now consider valid.

Tuberculosis in immunosuppressed patients.

11 patients who developed tuberculosis while on long-term immunosuppressive-drug therapy are described. The indications for immunosuppressive therapy were varied, but all patients received high doses of corticosteroids with azathioprine in addition in 2 cases and chlorambucil in a third. The diagnosis was delayed in all cases because of suppression of symptoms, so that 4 patients died, 3 directly as a result of tuberculosis. 3 of the remaining patients were critically ill at the time of diagnosis but recovered with antituberculosis chemotherapy; whereas the other 4, although not critically ill, had advanced cavitated pulmonary tuberculosis with miliary spread in one case. A clear policy of investigation and, if indicated, chemoprophylaxis is necessary for all patients in whom long-term immunosuppressive therapy, especially with prednisolone, is contemplated. A high index of suspicion for tuberculosis must be maintained with regular clinical and radiological review.

Betamethasone valerate in corticosteroid-dependent asthmatics. The integrity of the hypothalamic pituitary adrenal axis.

In a single-blind trial 29 patients with corticosteroid-dependent asthma reduced their daily dose of oral prednisolone by 1 mg/week while using a placebo inhaler until an unacceptable degree of asthma occurred. Betamethasone-17-vlaerate in a dose of 800 mug/day and if necessary 1600 mug/day was then substituted for the placebo inhaler and the reduction of oral prednisolone continued until the prednisolone was withdrawn completely or an unacceptable degree of asthma recurred. In 22 patients (76%) prednisolone was withdrawn completely, 11 on 800 mug and 11 on 1600 mug betamethasone-17-valerate. The mean reduction of prednisolone was 3-8 mg on placebo, 5-4 mg on 800 mug and a further 1-8 mg in patients requiring 1600 mug of betamethasone-17-valerate. The hypothalamic pituitary adrenal (HPA) axis was assessed by tetracosactrin and insulin stress tests at the start of the study and after withdrawal of oral prednisolone. The results indicate that an HPA axis which is completely suppressed by systemic corticosteroids can regain normal integrity when the systemic steroid is replaced by betamethasone-17-valerate in a dose of either 800 mug/day or 1600 mug/day. Candidiasis was observed, but will be reported later.

Intrapleural immunotherapy with Corynebacterium parvum in recurrent malignant pleural effusions.

Twenty-one patients with proven recurrent malignant pleural effusions were randomly allocated to treatment groups receiving either intrapleural Corynebacterium parvum in a dose of 7 mg or intrapleural mustine (20 mg). The designated intrapleural therapy was repeated on one occasion if further pleural aspiration was required. Corynebacterium parvum (nine patients) proved superior to mustine (12 patients) in suppressing the reaccumulation of pleural fluid, and was associated with only minimal side-effects of fever and nausea in two patients. Mustine caused marked nausea and vomiting in almost all patients. Three of the four patients who were deemed "failures" after mustine therapy had complete suppression of pleural fluid reaccumulation after a single dose of C parvum, the survival of the fourth being too short to assess a response adequately. There were no failures in the C parvum treated group. Corynebacterium parvum appears to be an effective, well-tolerated agent in the management of recurrent pleural effusions. The relative contribution of its potent immunological stimulant effect to its mode of action remains uncertain.

Intralesional injection of BCG using the fibreoptic bronchoscope in the treatment of bronchogenic carcinoma.

Current evidence suggests that the most effective administration of BCG immunotherapy is by the intralesional route. The new technique and complications of BCG intralesional injection of bronchogenic carcinomas via the fibreoptic bronchoscope is described. Seventeen patients with irresectable bronchogenic carcinoma have been treated with chemotherapy and BCG intralesional immunotherapy. Side-effects observed with intralesional BCG injection are: fever, hypotension and transient mild disturbances of liver function tests, and a single episode of granulomatous hepatitis. Early clinical improvement (nine patients) and radiological regression of the tumour (six patients) have been observed. Cavitation of the tumour has also been observed in three patients. Long term results are not yet available.

Five-year results of a controlled study of BCG immunotherapy after surgical resection in bronchogenic carcinoma.

Ninety-two patients with histologically confirmed bronchogenic carcinoma treated by surgical resection of the tumour were subsequently given immunotherapy with BCG (Glaxo). The patients were randomly allocated into three groups. Twenty-nine patients received multipuncture BCG (50 to 250 X 10(6) viable units), and twenty-six patients intradermal BCG (0.4 to 0.9 X 10(6) viable units), treatment being given at 1, 2, 6, 9, 13, 26, and 52 weeks after operation. Thirty-seven control patients did not receive any BCG immunotherapy; two patients in the control group were lost to follow-up. The overall five-year survival in all groups was 37%. Favourable prognostic features were squamous carcinoma (45% five-year survival), the absence of involved mediastinal nodes at operation (46%), and lobectomy (45%), but even the presence of involved mediastinal nodes was associated with a 19% five-year survival. There were no statistically significant differences between the survival of the control group and either group treated by immunotherapy considered individually or in combination. The influence of the presence of positive mediastinal lymph nodes and the extent of surgical resection on survival was not affected by immunotherapy. No serious side-effects of immunotherapy were encountered.

Further experience of Corynebacterium parvum in malignant pleural effusion.

The outcome of drug induced pleurodesis has been evaluated in a non-randomised retrospective study of 67 patients with recurrent malignant pleural effusions treated during 1976-83. Fourteen died within 30 days of treatment. Of the remaining 53 patients, 26 studied during 1976-80 were treated with intrapleural mustine hydrochloride, while 27 studied during 1978-83 were treated with intrapleural Corynebacterium parvum. There was no significant difference between the groups in age, sex, or tumour type, most tumours being secondary to bronchial neoplasms. Corynebacterium parvum successfully prevented reaccumulation of the effusion in 24 (92%) patients, while mustine was effective in only 17 (65%) (p less than 0.05). Data on survival were obtained on 47 cases where a single agent was used to induce pleurodesis. In 25 patients treated with C parvum the mean survival was 251 (range 31-1143) days, compared with 119 (range 31-380) days for the 22 patients in whom mustine was used. Survival of the C parvum group was significantly greater (p less than 0.01). The difference was principally due to the greater number of long term survivors in the C parvum group, nine of this group living for more than 180 days (mean 574, range 180-1143 days) compared with only four such survivors in the mustine group (mean 263, range 193-380 days). This study confirms our initial impression that C parvum is highly effective in controlling recurrent malignant pleural effusions. The finding of unexpected long term survivors with C parvum treatment suggests that this treatment may have an additional effect on the progression of disease, a finding that merits further investigation.

Miliary tuberculosis in adults.

Of 40 adults with miliary tuberculosis 24 had "overt" disease; in them miliary mottling was usually present on the chest radiograph, and tubercle bacilli were readily isolated from sputum, urine, or cerebrospinal fluid. In the remaining 16 patients the disease was termed "cryptic" because its usual clinical and radiographic features were absent. This cryptic type is as common as the overt type in patients over 60 years. In this series the peak age incidence was in the eighth decade, and possibly this increase in the incidence age is due to the breakdown of old tuberculous foci in patients with diminished immunological mechanisms.Cryptic miliary tuberculosis is a difficult diagnostic problem and should be suspected in any elderly patient, particularly a woman, who has an unexplained pyrexia, pancytopenia, or leukaemoid reaction. In 10 cases it was diagnosed by a therapeutic trial with para-aminosalicylic acid and isoniazid, a fall of temperature to normal (usually within a week), weight gain, a rise in haemoglobin, and increased well-being being the criteria of improvement The use of such a trial is strongly advocated as a specific method of diagnosing cryptic miliary tuberculosis.

Phytohemagglutinin-induced lymphocyte transformation in newly presenting patients with primary carcinoma of the lung.

The transformation of peripheral blood lymphocytes in response to PHA was studied in 37 newly presenting patients who were subsequently proven to have carcinoma of the lung. When compared with healthy age- and sex-matched normal controls, no differences were noted in the thymidine uptake of the unstimulated lymphocytes in culture or in the response to any of the three dose levels of PHA used. Neither the extent of the spread of the carcinoma nor the type of its histology showed any correlation with the PHA response, but the PHA response was significantly depressed within 14 days of death in 7 patients. No evidence for serum inhibitory factors was found.