Discontinuation of contact precautions in patients with hospital-acquired MRSA and VRE infections during the COVID-19 pandemic: A multi-center experience

Variations in the literature support the benefit of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) infections in the hospital setting. During personal protective equipment shortages throughout the COVID-19 pandemic, contact precautions were discontinued for MRSA and VRE-infected patients. Rates of hospital-acquired MRSA and VRE infections were compared before and after this intervention, along with hand hygiene proportions. Contact precaution discontinuation did not lead to an increase in hospital-acquired MRSA or VRE infections.

Comparison of the efficacy of macrocyclic lactone anthelmintics, either singly or in combination with other anthelmintic(s), in nine beef herds in southern NSW

Anthelmintic resistance (AR) is a well-recognized challenge in farmed ruminants. The use of anthelmintics in combination is one of the strategies recommended to slow the rate of AR development. Two studies were undertaken in 2017 and 2019 to assess the efficacy of single-dose macrocyclic lactone (ML) anthelmintic and ML combination drenches. In total, 11 Faecal Egg Count Reduction Trials (FECRTs) were set up in 10 different beef herds, with results available from 10 of those FECRTs (9 herds). AR to a single ML anthelmintic was detected in all 9 herds, with resistance to Cooperia and Haemonchus spp on 9 farms, and resistance to Ostertagia and Trichostrongylus spp on 2 farms. In contrast, for the ML combination anthelmintics, all FECRTs resulted in efficacies of 99%-100%. The results suggest that cattle producers should strongly consider using combination drenches in their herds in preference to single actives.

185. Implementation of Multiplex Polymerase Chain Reaction in Clinical Practice: Impact on Antimicrobial Management In Infectious Diarrhea

Background

Stool culture and stool polymerase chain reaction (PCR) panels are both used to evaluate patients with suspected infectious diarrhea. Stool PCR panels are especially advantageous because of their ability to detect a broad array of infectious pathogens in less than one hour. Our study assessed how the use of stool PCR panels instead of stool culture impacted antibiotic days of therapy (DOT) and length of therapy (LOT) in hospitalized patients with suspected infectious diarrhea.

Methods

In December 2021, an intervention was implemented in our hospital in which all electronic orders for stool cultures were automatically switched to stool PCR testing. The pre-intervention group was comprised of 75 hospitalized adult patients who had a stool culture obtained from September to November 2021. The post-intervention group was comprised of 81 adult patients who had a stool PCR obtained from December 2021 to February 2022. The DOT and LOT for antibiotics prescribed specifically for infectious diarrhea were determined for each patient; DOT and LOT were compared between the pre- and post- intervention groups.

Results

The median DOT in the pre- and post-intervention groups was 0 with a range of 0-10 and 0-8, respectively. The median LOT in the pre- and post-intervention groups was 0 (range 0-5 for both groups). No significant difference in the median DOT (Wilcoxon rank sum test, p-value = 0.967) or LOT (Wilcoxon rank sum test, p-value = 0.993) was found between the pre- and post-intervention groups (Figure 1). After adjusting for patient days present, no significant change in DOT or LOT incidence rate was found between the pre- and post-intervention groups. The DOT incidence rate ratio (RR) was 0.71 (95% CI 0.42, 1.22), and the LOT incidence RR was 0.67 (95% CI 0.36, 1.24). Figure 1.

Anthelmintic resistance of gastrointestinal nematodes in dairy calves within a pasture-based production system of south West Western Australia

The objective of this study was to determine the prevalence of gastrointestinal nematodes among post‐weaned calves aged between 4 and 12 months old within a pasture‐based system of south west Australia and quantify the level of anthelmintic resistance. Pre‐treatment FECs were monitored on 14 dairy farms. Anthelmintic resistance was assessed on 11 of the farms. Control FECs were compared with anthelmintic FECs at 14 days post‐treatment with doramectin (injectable), levamisole (oral), fenbendazole (oral) and a levamisole/abamectin combination (pour‐on). Results demonstrate a strong level of anthelmintic resistance, with at least one class of anthelmintic failing to achieve a 95% reduction in FEC in one or more gastrointestinal nematode species. Doramectin was fully effective against Ostertagia, but C. oncophora displayed resistance in 91% of the farms. Conversely, levamisole was fully effective against C. oncophora, but Ostertagia displayed resistance in 80% of the farms. Fenbendazole resistance was present in both C. onocphora and Ostertagia in 64% and 70% of the farms, respectively. Trichostrongylus showed low resistance, occurring in doramectin (14%) and levamisole/abamectin combination (14%). This study confirms that anthelmintic resistance is common. Regular FEC reduction testing is recommended to monitor and guide decision‐making for appropriate anthelmintic usage.

The migratory pathways of the cells that form the endocardium, dorsal aortae, and head vasculature in the mouse embryo

Background

Vasculogenesis in amniotes is often viewed as two spatially and temporally distinct processes, occurring in the yolk sac and in the embryo. However, the spatial origins of the cells that form the primary intra-embryonic vasculature remain uncertain. In particular, do they obtain their haemato-endothelial cell fate in situ, or do they migrate from elsewhere? Recently developed imaging techniques, together with new Tal1 and existing Flk1 reporter mouse lines, have allowed us to investigate this question directly, by visualising cell trajectories live and in three dimensions.

Results

We describe the pathways that cells follow to form the primary embryonic circulatory system in the mouse embryo. In particular, we show that Tal1-positive cells migrate from within the yolk sac, at its distal border, to contribute to the endocardium, dorsal aortae and head vasculature. Other Tal1 positive cells, similarly activated within the yolk sac, contribute to the yolk sac vasculature. Using single-cell transcriptomics and our imaging, we identify VEGF and Apela as potential chemo-attractants that may regulate the migration into the embryo. The dorsal aortae and head vasculature are known sites of secondary haematopoiesis; given the common origins that we observe, we investigate whether this is also the case for the endocardium. We discover cells budding from the wall of the endocardium with high Tal1 expression and diminished Flk1 expression, indicative of an endothelial to haematopoietic transition.

Conclusions

In contrast to the view that the yolk sac and embryonic circulatory systems form by two separate processes, our results indicate that Tal1-positive cells from the yolk sac contribute to both vascular systems. It may be that initial Tal1 activation in these cells is through a common mechanism.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12861-021-00239-3.

Performance comparison of 159 Thoroughbred racehorses and matched cohorts before and after desmotomy of the interspinous ligament

Racehorses may perform poorly because of impinging dorsal spinous processes (DSPs) of the thoracolumbar vertebrae. No study has looked objectively at the long-term outcome of racehorses undergoing desmotomy of the interspinous ligament as a treatment for horses with poor performance caused by impinging DSPs. The aim of this study was to examine objectively, by using pre-operative and post-operative racing records, the effectiveness of desmotomy of the interspinous ligament (DISL) in improving the performance of racehorses with impinging DSPs. Medical records of all horses undergoing desmotomy of one or more interspinous ligaments at a referral equine hospital, between February 2015 and September 2016, were reviewed. The study was confined to Thoroughbred racehorses with sufficient historical information and racetrack data to allow their racing performances be compared to that of matched controls. Matched controls were of the same age, sex, and racing type and were trained at the same time by the same trainer as those undergoing desmotomy. The time to follow-up was at least 12 months. Of the 6545 horses presented for poor performance or lameness during the study period, 236 horses (3.6%) underwent desmotomy of one or more interspinous ligaments, and of these, 159 met the inclusion criteria. Horses undergoing desmotomy had significantly better improvement in racing performance than did matched controls. Eight horses developed unilateral neurogenic atrophy of epaxial musculature. DISL between impinging DSPs can improve the performance of racehorses experiencing from poor performance caused by pain resulting from the impinging processes.

Population levels of wellbeing and the association with social capital

Background

This research investigates wellbeing at the population level across demographic, social and health indicators and assesses the association between wellbeing and social capital.

Method

Data from a South Australian monthly chronic disease/risk factor surveillance system of randomly selected adults (mean age 48.7 years; range 16–99) from 2014/5 (n = 5551) were used. Univariable analyses compared wellbeing/social capital indicators, socio-demographic, risk factors and chronic conditions. Multi-nominal logistic regression modelling, adjusting for multiple covariates was used to simultaneously estimate odds ratios for good wellbeing (reference category) versus neither good nor poor, and good wellbeing versus poor wellbeing.

Results

48.6% were male, mean age 48.7 (sd 18.3), 54.3% scored well on all four of the wellbeing indicators, and positive social capital indicators ranged from 93.1% for safety to 50.8% for control over decisions. The higher level of social capital corresponded with the good wellbeing category. Modeling showed higher odds ratios for all social capital variables for the lowest level of wellbeing. These higher odds ratios remained after adjusting for confounders.

Conclusions

The relationship between wellbeing, resilience and social capital highlights areas for increased policy focus.

The Frostig Test: A Review

Within the last few years, more and more occupational therapists practising in Great Britain have been using standardised assessments in their work. Mostly they rely on popular tests which have gained respectability and acceptance in psychology and related professions. However, it is of utmost importance that occupational therapists are fully aware of how the tests they are using are thought of by a wide variety of people. The purpose of this article was to search the literature and discover what had been said about the Marianne Frostig Developmental Test of Visual Perception. The Frostig Programme for Individual Training and Remediation in Visual Perception is also examined briefly. It is hoped that this review will be of use in helping occupational therapists who are either using the test or thinking about using it to decide whether it is appropriate for their purpose.

Inflammatory Mechanisms in Hidradenitis Suppurativa

Hidradenitis suppurativa (HS) is a chronic relapsing disease of follicular occlusion that causes immense clinical and psychosocial morbidity when refractory to treatment. HS is no longer considered a disease of primary infectious etiology, although bacteria play a role. There is increasing evidence that HS is associated with immune dysregulation, based on its clinical association with other immune-mediated disorders, by its response to biologic therapy in the clinical arena, and from molecular research. This article summarizes what is known in relation to the inflammatory pathways in HS.

Comparison of treatment outcomes for superficial digital flexor tendonitis in National Hunt racehorses

Superficial digital flexor (SDF) tendonitis is a common injury in Thoroughbred racehorses. Injuries require prolonged rehabilitation, with unpredictable outcomes and a high incidence of re-injury. This observational case-control study aimed to compare race outcomes after commonly advocated treatments for tendon healing. Clinical and racing records were evaluated for 127 National Hunt racehorses treated between 2007 and 2011 for an SDF tendon injury. Two age- and sex-matched control horses were selected for each case horse to analyse the effect on post-injury racing outcomes of pre-injury data, lesion severity and treatment group [controlled exercise alone, bar firing, intralesional platelet-rich plasma (PRP), tendon splitting, tendon splitting combined with bar firing]. Control horses raced more often than case horses, with higher maximum racing post rating (RPRmax) and longer racing distances. Pre-injury racing performance was not associated with treatment group. Rate of return to racing was not associated with lesion severity or treatment group. Number of races, total distance raced post-injury and RPRmax were not associated with lesion severity or treatment group. Controlled exercise alone offered similar post-injury racing outcomes in National Hunt racehorses with SDF tendonitis to the other treatment options examined. Bar firing, either alone or in conjunction with tendon splitting, provided no additional benefit in rate of return to racing and race performance.

Tumour-suppression function of KLF12 through regulation of anoikis

Suppression of detachment-induced cell death, known as anoikis, is an essential step for cancer metastasis to occur. We report here that expression of KLF12, a member of the Kruppel-like family of transcription factors, is downregulated in lung cancer cell lines that have been selected to grow in the absence of cell adhesion. Knockdown of KLF12 in parental cells results in decreased apoptosis following cell detachment from matrix. KLF12 regulates anoikis by promoting the cell cycle transition through S phase and therefore cell proliferation. Reduced expression levels of KLF12 results in increased ability of lung cancer cells to form tumours in vivo and is associated with poorer survival in lung cancer patients. We therefore identify KLF12 as a novel metastasis-suppressor gene whose loss of function is associated with anoikis resistance through control of the cell cycle.

Correspondence

To the editor The election debrief published in the July issue of Nursing Management ( Aziz 2001 )stated that a report into public private partnerships carried out by the Institute for Public Policy Research was 'likely to recommend that the government pushed ahead with privatisation'. The clear implication of this article was that IPPR's conclusions were inevitable, given the financial support that the project received from private sector companies.

Dysregulated cytokine expression in lesional and nonlesional skin in hidradenitis suppurativa

BACKGROUND

There is a dearth of information on the precise pathogenesis of hidradenitis suppurativa (HS), but immune dysregulation is implicated.

OBJECTIVES

To determine the nature of the immune response in HS.

METHODS

Skin biopsies - lesional, perilesional (2 cm away) and uninvolved (10 cm away) - were obtained from patients with HS and healthy controls. The expression of various cytokines was determined by enzyme-linked immunosorbent assay, flow cytometry and real-time polymerase chain reaction.

RESULTS

The expression of the inflammatory cytokines interleukin (IL)-17, IL-1β and tumour necrosis factor-α was enhanced in lesional skin of patients with HS. In addition, IL17A and IL1B mRNA were enhanced in clinically normal perilesional skin. CD4(+) T cells produced IL-17 in HS, while CD11c(+) CD1a(-) CD14(+) cells were sources of IL-1β. Activated caspase-1 was detected in HS skin and was associated with enhanced expression of NLRP3 and IL18. Inhibition of caspase-1 decreased IL-1β and IL-18 production, suggesting that the caspase-1 pathway participates in IL-1β and IL-18 expression in HS. Abnormal cytokine expression was detected in perilesional and uninvolved skin, which may suggest that subclinical inflammation is present in HS skin prior to the formation of an active lesion.

CONCLUSIONS

This study demonstrates that CD4(+) T cells produce IL-17 in HS and that the IL-17 pathway may be important in HS pathogenesis. CD11c(+) CD1a(-) CD14(+) cells are a source of IL-1β in HS, the production of which was shown to be mediated, in part, via a caspase-1-dependent pathway. These results suggest that IL-17 and the caspase-1-associated cytokines IL-1β and IL-18 may play a role in the pathogenesis of HS.

Natural killer cells from psoriasis vulgaris patients have reduced levels of cytotoxicity associated degranulation and cytokine production

Psoriasis vulgaris is a chronic inflammatory disease of the skin with a strong genetic component and immune system involvement. Although some evidence suggests that Natural Killer (NK) cells may play a part in psoriasis, their role is relatively unstudied and results are controversial. In this current study, NK cells from psoriasis patients exhibited reduced degranulation and produced lower levels of the pro-inflammatory cytokines IFN-γ and TNF-α. Further investigation found that NK cells from psoriasis patients and healthy controls expressed similar levels of activation markers, NK cell receptors and apoptosis-inducing molecules. In addition, comparable levels of several cytokines important in NK cell biology were found in the serum of psoriasis patients and healthy controls. Genotyping analysis revealed that HLA-C2, which provides a ligand for killer-cell immunoglobulin-like receptors (KIR) expressed by NK cells, was strongly associated with psoriasis susceptibility. However, no link between the KIR genes themselves and disease was found.

MicroRNAs as biomarkers of resilience or vulnerability to stress

Identifying novel biomarkers of resilience or vulnerability to stress could provide valuable information for the prevention and treatment of stress-related psychiatric disorders. To investigate the utility of blood microRNAs as biomarkers of resilience or vulnerability to stress, microRNAs were assessed before and after 7days of chronic social defeat in rats. Additionally, microRNA profiles of two important stress-regulatory brain regions, the medial prefrontal cortex (mPFC) and basolateral amygdala (BLA), were assessed. Rats that displayed vulnerability to subsequent chronic stress exhibited reductions in circulating miR-24-2-5p, miR-27a-3p, miR-30e-5p, miR-3590-3p, miR-362-3p, and miR-532-5p levels. In contrast, rats that became resilient to stress displayed reduced levels of miR-139-5p, miR-28-3p, miR-326-3p, and miR-99b-5p compared to controls. In the mPFC, miR-126a-3p and miR-708-5p levels were higher in vulnerability compared to resilient rats. In the BLA, 77 microRNAs were significantly altered by stress but none were significantly different between resilient and vulnerable animals. These results provide proof-of-principle that assessment of circulating microRNAs is useful in identifying individuals who are vulnerable to the effects of future stress or individuals who have become resilient to the effects of stress. Furthermore, these data suggest that microRNAs in the mPFC but not in the BLA are regulators of resilience/vulnerability to stress.

Extreme chromosomal instability forecasts improved outcome in ER-negative breast cancer: a prospective validation cohort study from the TACT trial

BACKGROUND

Chromosomal instability (CIN) has been shown to be associated with drug resistance and poor clinical outcome in several cancer types. However, in oestrogen receptor (ER)-negative breast cancer we have previously demonstrated that extreme CIN is associated with improved clinical outcome, consistent with a negative impact of CIN on tumour fitness and growth. The aim of this current study was to validate this finding using previously defined CIN thresholds in a much larger prospective cohort from a randomised, controlled, clinical trial.

PATIENTS AND METHODS

As a surrogate measurement of CIN, dual centromeric fluorescence in situ hybridisation was performed for both chromosomes 2 and 15 on 1173 tumours from the breast cancer TACT trial (CRUK01/001). Each tumour was scored manually and the mean percentage of cells deviating from the modal centromere number was used to define four CIN groups (MCD1-4), where tumours in the MCD4 group were defined as having extreme CIN.

RESULTS

In a multivariate analysis of disease-free survival, with a median follow-up of 91 months, increasing CIN was associated with improved outcome in patients with ER-negative cancer (P trend = 0.03). A similar pattern was seen in ER-negative/HER2-negative cancers (Ptrend = 0.007).

CONCLUSIONS

This prospective validation cohort study further substantiated the association between extreme CIN and improved outcome in ER-negative breast cancers. Identifying such patients with extreme CIN may help distinguish good from poor prognostic groups, and therefore support treatment and risk stratification in this aggressive breast cancer subtype.

Alcohol-Related Fracture Admissions: A Retrospective Observational Study

INTRODUCTION

In April 2011 the NI public health agency estimated that alcohol misuse generates overall annual healthcare costs of £122.2m. There is currently a paucity of data regarding the burden of alcohol-related fractures on the provinces Trauma and Orthopaedic service.

PATIENTS AND METHODS

A retrospective review of 104 patients over a 12 month period was performed. Data collected using the Fractures Outcomes and Research Database included: age, gender, smoking status, weekly alcohol intake, mechanism of injury and subsequent treatment.

RESULTS

Alcohol related fractures accounted for 6.1% of all acute fractures admissions in the 12 month period. 73% were male, with a bimodal age distribution. The majority of patients were classed as social drinkers; however a significant proportion (23.1%) were alcohol dependent. 62.5% of patients were smokers at the time of admission. 95% of patients suffered a single injury which was commonly secondary to a simple mechanical fall (53.8%). The majority of patients sustained lower limb injuries, with 30.8% of these being ankle fractures.

CONCLUSION

In conclusion, our study has identified that alcohol-related trauma creates a significant financial burden on the NHS. It is likely that the incidence of alcohol related fracture is higher than documented in this study. We advocate the assessment of patients using the AUDIT-C score to assess for at risk drinking behaviour in those presenting with an alcohol related fracture.

Abstract P1-01-01: The value of isosulphan blue dye in addition to isotope scanning in the identification of the sentinel lymph node in breast cancer patients with a positive lymphoscintigraphy: A randomised controlled trial (ISRCTN 98849733)

Introduction

The advent of multimodal and targeted breast cancer treatment has seen a radical shift from aggressive surgical intervention to a more minimalist approach, both within the breast and axilla. Primary among these changes is the utilisation of the sentinel lymph node biopsy (SLNB) to detect disease within the axilla and a move away from an obligatory axillary clearance when the sentinel node is positive. This depends on the accurate identification of the SLN and initial studies describe a higher identification rate and a lower false negative rate with a dual tracer identification technique. This encompasses a combination of a blue / green dye and radio-labelled isotope. The use of blue dye has been, of itself, associated with significant morbidity and therefore many clinicians may opt for single tracer identification.

Aims

The aim of the current study was to determine whether the addition of blue dye to radio-isotope increased the positive SLN detection rate, where the SLN was identified pre-operatively on a lymphoscintigram.

Methods

A prospective randomised controlled trial comparing the combined techniques of isosulphan blue dye and isotope scanning versus isotope scanning alone was performed at a single tertiary referral centre. Ethical approval was obtained prior to commencing the study from the hospital ethics committee. Enrolment commenced in March 2010 and ceased in September 2012. The study design was a randomised open label controlled parallel group trial. The primary outcome measure was the effect of the omission of the blue dye on the identification of SLN if the lymphoscintigram was positive (1 -3 nodes identified).

Results

A total of 673 patients were included in the final analysis with 344 patients receiving the combination (blue dye and radio-isotope) and 329 patients who received radio-isotope scanning alone. The groups were evenly matched both demographically and pathologically. The mean age was 48 years (48.3 versus 47.7 years; P = 0.47), the mean tumour size was 23.1mm (23.2mm versus 23.0mm; p = 0.89) and there was no statistically significant difference in the grade of the tumours between the two groups (p = 0.58). Overall, there was no difference in the number of nodes retrieved between the two groups (563 versus 523; p = 0.30). Similarly, there was no difference in the number of positive lymph nodes that were identified between the two groups (107 versus 98; 23.8% versus 22%; p = 0.65).

Conclusions

The addition of isosulphan blue dye does not aid in the identification of the SLN in patients who have a positive lymphoscintigram when radioisotope colloid is used.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-01.

Short-term and long-term effects of repeated social defeat during adolescence or adulthood in female rats

Accumulating evidence suggests that adolescence represents a sensitive period during which social stressors influence adult behavior and stress reactivity. However, relatively little is known about the impact of social stress in adolescence on behaviors or stress reactivity in females. In this study, we exposed adolescent or adult female rats to the repeated social stress of defeat for seven consecutive days. Repeated defeat resulted in distinctly different behavioral repertoires during defeat in adolescent compared to adult female rats. Adolescent females exhibited more play and avoidant behaviors and adult females exhibited more active and aggressive behaviors toward the resident female. Examination of the short-term effects of social defeat using the Porsolt forced swim test (FST) indicated that adolescents, regardless of their exposure to social defeat, showed increased time immobile and decreased time swimming compared to adults. Adolescent rats exposed to defeat also exhibited increased climbing compared to their age-matched naïve counterparts. These effects dissipated with age. Interestingly, no effects of defeat were observed in adult females, however, when these females were re-assessed in the FST 30 days after the end of defeat, we observed increased swimming at the expense of climbing. Using exposure to a novel restraint to assess stress reactivity, we found that stress during adolescence and adulthood led to lower basal adrenocorticotropic hormone concentrations and that both stressed and control adolescent groups exhibited a delay in recovery in adulthood compared to stressed and control adult groups. Fos protein analysis further suggested that cortical/thalamic structures serve as potential substrates that mediate these long-term impacts of stress during adolescence. Thus, repeated social stress during adolescence produces different patterns of effects as compared with repeated social stress during adulthood.

Tracking microbial transport through four onsite wastewater treatment systems to receiving waters in eastern North Carolina

AIMS

To examine microbial transport through properly functioning and failing onsite wastewater treatment systems (OWTS) and its implication in surrounding water quality.

METHODS AND RESULTS

Water samples were collected from monitoring wells near leach lines of OWTS and nearby ditches and receiving surface waters to analyse for Escherichia coli and enterococci. Tracer studies with Rhodamine WT (RWT) and coliphage MS2 were also carried out to understand the fate and transport of contaminants through each OWTS. Escherichia coli and enterococci concentrations were higher around failing than properly functioning OWTS by as much as 85-fold. A storm event resulting in 9·5 cm of rainfall increased E. coli and enterococci concentrations by averages of 4·1 × 10³ and 7·9 × 10³ MPN per 100 ml, respectively, in wells close to the OWTS. MS2 persisted in the wastewater distribution boxes of the OWTS for several months and was detected in some outer perimeter wells.

CONCLUSIONS

Properly functioning OWTS in eastern North Carolina were effective in treating wastewater, whereas the failing OWTS affected the groundwater quality more adversely, especially after a rain storm, but had minor impact on the nearby coastal surface water.

SIGNIFICANCE AND IMPACT OF THE STUDY

The study is the first description of the microbial contaminant signature stemming from properly functioning and failing systems under regular use in a high-priority coastal area.

Are medical student results affected by allocation to different sites in a dispersed rural medical school?

INTRODUCTION

As medical education becomes more decentralised, and greater use is made of rural clinical schools and other dispersed sites, attention is being paid to the quality of the learning experiences across these sites. This article explores this issue by analysing the performance data of 4 cohorts of students in a dispersed clinical school model across 4 sites. The study is set in a newly established medical school in a regional area with a model of dispersed education, using data from the second to fifth cohorts to graduate from this school.

METHODS

Summative assessment results of 4 graduating cohorts were examined over the final 2 years of the course. Two analyses were conducted: an analysis of variance of mean scores in both years across the 4 sites; and an analysis of the effect of moving to different clinical schools on the students' rank order of performance by use of the Kruskal-Wallis test.

RESULTS

Analysis revealed no significant difference in the mean scores of the students studying at each site, and no significant differences overall in the median ranking across the years. Some small changes in the relative ranking of students were noticed, and workplace-based assessment scores in the final year were higher than the examination-based scores in the previous year.

CONCLUSIONS

The choice of clinical school site for the final 2 years of an undergraduate rural medical school appears to have no effect on mean assessment scores and only a minor effect on the rank order of student scores. Workplace-based assessment produces higher scores but also has little effect on student rank order. Further studies are necessary to replicate these findings in other settings and demonstrate that student learning experiences in rural sites, while popular with students, translate into required learning outcomes, as measured by summative assessments.