Can Videourodynamics shape management in refractory pediatric lower urinary tract dysfunction?

INTRODUCTION: Bladder dysfunction, or more specifically lower urinary tract dysfunction (LUTD), remains a common reason for pediatric urology consultation, and the management of these patients is time consuming and frustrating for patients, families and providers alike. But what happens when the patient proves refractory to current treatment modalities? Is there a role for the use of videourodynamics (VUDS) to help guide therapy in the patient with refractory voiding dysfunction, and if so how might we select patients for this invasive study in order to increase the yield of useful information? OBJECTIVES: To determine the role, if any, for VUDS in the evaluation of pediatric patients with refractory LUTD and to identify parameters that might be used to select patients for this invasive study in order to increase the yield of useful information. STUDY DESIGN: Through our IRB-approved prospectively maintained urodynamics database, we retrospectively identified 110 patients with non-neurogenic LUTD over a period from 2015 to 2022 who underwent VUDS. We excluded patients with known neurologic or anatomic lesions and developmental delay. RESULTS: There were 76 females and 34 males (69%/31%) and their average age at the time of the study was 10.5 years ± 4 with a median age of 7.3 years. Patients had been followed for a mean of 5.9 ± 3.5 office visits prior to obtaining the VUDS and reported a mean Dysfunction Voiding and Incontinence Symptom Score (DVISS) of 15.6 ± 6.7 before the VUDS. VUDS resulted in a change in management in 86 of these 110 patients (78%). Management changes included a change in medication (53/110), consideration of CIC (11/110), PTENS (1/110) and surgery (14/110). As shown in the Figure, the DVISS score was significantly higher and the number of office visits prior to VUDS was significantly higher in the 86 patients whose management was changed versus the 24 patients in whom management did not change (P < 0.02). CONCLUSION: This retrospective analysis suggests that criteria for selecting these patients include: 1) long standing urinary incontinence that is refractory to biofeedback and medications, 2) ≥6 visits to LUTD clinic with no improvement, and 3) LUT symptom score of ≥16. Our findings suggest these criteria identify a cohort of patients in which a VUDS evaluation for the child with refractory LUTD can offer a more exact diagnosis that can shape management.

Australian rural service learning student placements: a national survey.

This preliminary national study is the first of its kind to investigate how service learning placements are implemented in real world settings in rural Australia and what factors enable or hinder their implementation. An anonymous survey was distributed to 17 University Departments of Rural Health (UDRH) in Australia. Numerical data were analysed descriptively. Textual data were analysed using a hybrid content analysis approach. Thirty seven respondents provided data representing 12 UDRHs. Responding UDRHs reported facilitating service learning programs, with experience in this context ranging from 3 months to 21 years. Service learning placements predominantly occurred in schools and aged care facilities. Occupational therapy, physiotherapy, and speech pathology were the most frequently involved professions in service learning. Enablers and barriers identified were categorised into: People, Partnerships, and Place and Space. This national-scale study provides a springboard for more in-depth investigation and implementation research focused on development of a conceptual model to support service learning across rural and remote Australia.

Changing conversations about family violence in regional Western Australia: A primary prevention communication case study.

OBJECTIVE: To illuminate the enablers and challenges of implementing a communication strategy designed to support Community, Respect, Equality (CRE) and a family and domestic violence (FDV) primary prevention plan in a regional Western Australian town. METHOD: This research draws on documentation and interviews with members of Leading Lights, an advocacy group arising from a collaboration of local organisations to communicate the goals and priorities of the CRE action plan. Interviews explored how primary prevention messages were promoted to foster supportive community attitudes toward addressing the drivers of FDV. RESULTS: The initiative fostered a learning community that coordinated public messaging about the drivers of FDV for organisations pledged to the CRE values. The diffusion of messaging was affected over time by inconsistent staffing, discontinuities in resourcing and individual organisational commitment, and concerns about gender equality messaging. CONCLUSION: The communications strategy increased awareness of the drivers of FDV among the members of the Leading Lights. In turn, this group produced media content that made visible each organisation's commitment to addressing the attitudes and behaviours that enable FDV. IMPLICATIONS FOR PUBLIC HEALTH: Community collaborations need time, resourcing, and coordination to sustainably prompt changes in social norms that underpin violence.

Measuring for primary prevention: An online survey of local community perspectives on family and domestic violence in regional Australia.

BACKGROUND: Family and domestic violence, encompassing diverse behaviours including physical, sexual, emotional and financial abuse, is endemic worldwide and has multiple adverse health and social consequences. Principal drivers include traditional gender values that disempower women. Changing these is a key prevention strategy. In Australia, high-quality national surveys provide data on public perspectives concerning family and domestic violence but may not capture community-level diversity. As part of a project for primary prevention family and domestic violence in outer regional Australia, our aims were to develop and administer a questionnaire-based survey suitable for the local community encompassing knowledge about, attitudes towards, and personal experiences of family and domestic violence, to describe and to investigate the theoretical (factor) structure and local socio-demographic predictors of responses, and to determine the extent to which the survey findings are locally distinctive. METHODS: The online community survey for local residents (≥15 years), comprised items on respondents' sociodemographic characteristics plus questions abridged from pre-existing national instruments on knowledge about, attitudes towards, and personal experiences of family and domestic violence. Responses were rake-weighted to correct census-ascertained sample imbalance and investigated using exploratory factor analysis, with sociodemographic predictors determined using multiple linear regression and dominance analysis. RESULTS: Among 914 respondents, males (27.0%), those from age-group extremes, and less-educated persons were underrepresented. Familiarity with diverse family and domestic violence behaviours was high among all subgroups. Poorer knowledge of the FDV behaviour continuum and attitudes supporting traditional gender roles and FDV were disproportionately evident among males, older respondents and those with lower education levels. Both the factor structure of extracted composite measures reflecting community perspectives and sociodemographic predictors of responses generally aligned with patterns evident in national data. CONCLUSIONS: Local reinforcement of existing nationwide findings on community understanding of and attitudes towards family and domestic violence provides salience for targeted interventions.

Metabolite profiling and cytotoxic activity of Andean potatoes: Polyamines and glycoalkaloids as potential anticancer agents in human neuroblastoma cells in vitro.

Andean potatoes (Solanum tuberosum L. ssp. andigena) are a good source of dietary antioxidant polyphenols. We have previously demonstrated that polyphenol extracts from Andean potato tubers exerted a dose-dependent cytotoxic effect in human neuroblastoma SH-SY5Y cells, being skin extracts more potent than flesh ones. In order to gain insight into the bioactivities of potato phenolics, we investigated the composition and the in vitro cytotoxic activity of total extracts and fractions of skin and flesh tubers of three Andean potato cultivars (Santa María, Waicha, and Moradita). Potato total extracts were subjected to liquid-liquid fractionation using ethyl acetate solvent in organic and aqueous fractions. We analyzed both fractions by HPLC-DAD, HPLC-ESI-MS/MS, and HPLC-HRMS. Results corroborated the expected composition of each fraction. Organic fractions were rich in hydroxycinnamic acids (principally chlorogenic acid isomers), whereas aqueous fractions contained mainly polyamines conjugated with phenolic acids, glycoalkaloids, and flavonoids. Aqueous fractions were cytotoxic against SH-SY5Y cells and even more potent than their respective total extracts. Treatment with a combination of both fractions showed a similar cytotoxic response to the corresponding extract. According to correlation studies, it is tempting to speculate that polyamines and glycoalkaloids are crucial in inducing cell death. Our findings indicate that the activity of Andean potato extracts is a combination of various compounds and contribute to the revalorization of potato as a functional food.

The Kawa Model: A Self-Reflection Tool for Occupational Therapy Student Development in Practice Placements in Australia.

Introduction: The Kawa Model is a conceptual occupational therapy model of practice that uses the metaphor of a river as a medium to support the exploration of self, life events, and environment. In this study, the Kawa Model was used by occupational therapy students during a practice placement in a remote community setting as a tool to support learning, build self-awareness, and promote reflection on personal and professional development. Method: The study used an exploratory qualitative research design. Six student participants were purposively recruited and orientated to the use of the Kawa Model at the beginning and throughout their remote community practice placement. Semistructured interviews were used to collect data which were analysed thematically using interpretative phenomenological analysis (IPA). Findings. Analysis of the student transcripts revealed three overarching themes: self-awareness, the development of personal and professional skills, and working with metaphor. All students identified the model as a reflective tool that enhanced their understanding of their student selves in a remote setting. The students described the growth of various professional skills including communication, goal planning, and confidence. Whilst initially students found the metaphor challenging to fathom, throughout their placement, they found it impactful for comprehending their development of self. Conclusion: This study revealed that the students' self-awareness and personal and professional development were influenced by their engagement with and application of the Kawa Model. Repeated engagement with the Kawa Model enhanced the students' journey of personal and professional skill development.

Experiences of primary health care nurses advancing their careers in a remote Western Australian location.

OBJECTIVE: The objective of the study was to explore the experiences of primary health care (PHC) nurses advancing their careers in a remote location in Western Australia. SETTING: The study was conducted in PHC organisations in one remote location in northern Western Australia. PARTICIPANTS: Six registered nurses working in four PHC organisations participated in the study. All were registered with the Nursing and Midwifery Board of Australia. Participants were all female, and five had child carer responsibilities. They had worked in the region for between 8 months and 10 years. DESIGN: The design was based on a qualitative, interpretative phenomenological analysis methodology involving in-depth, semi-structured, face-to-face interviews. RESULTS: Participants faced challenges advancing their careers given the limited employment opportunities and need to balance their professional ambitions with family needs. Participants had limited capacity to support each other's learning and felt poorly supported by employers to undertake professional development not directly related to their role. Participants were not well engaged with professional associations beyond undertaking online professional development activities provided with membership. Accessing professional development was difficult given a lack of time, limited access to local learning activities and a consequent need to travel, which was challenging. Despite the challenges they faced, most nurses remained passionate about their remote nursing roles and enjoyed the lifestyle. CONCLUSION: Remote PHC nurses face a range of challenges, some of which can be overcome by improved availability of local professional development and better support from employers and professional associations.

Contribution of Dysregulated B-Cells and IgE Antibody Responses to Multiple Sclerosis.

Multiple sclerosis (MS), a debilitating autoimmune inflammatory disease that affects the brain and spinal cord, causes demyelination of neurons, axonal damage, and neurodegeneration. MS and the murine experimental autoimmune encephalomyelitis (EAE) model have been viewed mainly as T-cell-mediated diseases. Emerging data have suggested the contribution of B-cells and autoantibodies to the disease progression. However, the underlying mechanisms by which dysregulated B-cells and antibody response promote MS and EAE remain largely unclear. Here, we provide an updated review of this specific subject by including B-cell biology and the role of B-cells in triggering autoimmune neuroinflammation with a focus on the regulation of antibody-producing B-cells. We will then discuss the role of a specific type of antibody, IgE, as it relates to the potential regulation of microglia and macrophage activation, autoimmunity and MS/EAE development. This knowledge can be utilized to develop new and effective therapeutic approaches to MS, which fits the scope of the Research Topic "Immune Mechanism in White Matter Lesions: Clinical and Pathophysiological Implications".

Analysis of reporting of family violence reporting in print media in regional Western Australia.

OBJECTIVES: This research aimed to gain insights into the reporting of family violence (FV) and to explore any changes in FV reporting associated with a FV primary prevention initiative in Geraldton, Western Australia. METHODS: An in-depth analysis of articles published by the Geraldton Guardian in 2019 examined the nature of FV reporting. Analysis was based on deductive coding from existing literature and inductive identification of new themes. A comparative analysis examined articles from the Geraldton Guardian and Albany Advertiser over the same three-month period in 2015, 2017 and 2019 to analyse trends in FV reporting. RESULTS: Of 135 articles analysed, there was alignment with five previously reported themes and two new themes were identified: FV as a public health issue; and community responses to reduce FV. Episodic framing was overwhelmingly associated with court reporting. There was more reporting of efforts at primary prevention of FV over time in both newspapers. CONCLUSIONS: Local media can contribute to the promotion of community and public health issues related to FV. Efforts are needed to improve court reporting to situate FV in a broader context. IMPLICATIONS FOR PUBLIC HEALTH: Concerted efforts to educate the public and journalists can support FV being recognised as a public health issue.

RORγt Promotes Foxp3 Expression by Antagonizing the Effector Program in Colonic Regulatory T Cells.

RORγt is the master transcription factor for the Th17 cells. Paradoxically, in the intestine, RORγt is coexpressed in peripherally induced regulatory T cells (pTregs) together with Foxp3, the master transcription factor for Tregs. Unexpectedly, by an unknown mechanism, colonic RORγt+ Tregs show an enhanced suppressor function and prevent intestinal inflammation more efficiently than RORγt-nonexpressing pTregs. Although studies have elucidated the function of RORγt in Th17 cells, how RORγt regulates pTreg function is not understood. In our attempt to understand the role of RORγt in controlling Treg function, we discovered a RORγt-driven pathway that modulates the regulatory (suppressor) function of colonic Tregs. We found that RORγt plays an essential role in maintaining Foxp3 expression. RORγt-deficient Tregs failed to sustain Foxp3 expression with concomitant upregulation of T-bet and IFN-γ expressions. During colitis induced by adoptive transfer of CD45RBhi cells in Rag1 -/- mice, RORγt-deficient colonic Tregs transitioned to a Th1-like effector phenotype and lost their suppressor function, leading to severe colitis with significant mortality. Accordingly, Foxp3-expressing, RORγt-deficient Tregs showed impaired therapeutic efficacy in ameliorating colitis that is not due to their reduced survival. Moreover, using the Treg-specific RORγt and T-bet double-deficient gene knockout mouse, we demonstrate that deletion of T-bet from RORγt-deficient Tregs restored Foxp3 expression and suppression function as well as prevented onset of severe colitis. Mechanistically, our study suggests that RORγt-mediated repression of T-bet is critical to regulating the immunosuppressive function of colonic Tregs during the inflammatory condition.

PLUS Framework: guidance for practice educators.

BACKGROUND: The practice educator role is complex and becoming more so with changes in placement configurations since the COVID-19 pandemic. The role requires practitioners to manage clinical activities while providing learning opportunities and supervision for students. This can be time-consuming in often stretched clinical settings. This research investigated how experienced practice educators in occupational therapy tailored their approach to supporting student learning to make the most of limited supervision time. The results were developed into the Professional Learning through Useful Support (PLUS) Framework, which revealed how experienced practice educators focused their supervisory approach with students to maximise learning. METHODS: An Action Research methodology was used across four cycles. Semi-structured interviews and naturally occurring placement documentation were gathered to determine the critical features of practice educator supervision. Template analysis was used to explore the approaches employed by practice educators to support student learning. Key focal points were linked and situated within educational theory to create the PLUS Framework. FINDINGS: Three key focal points for practice educators were identified: (1) guiding learning, (2) making the theory-to-practice links explicit and (3) supportively challenging students. DISCUSSION: The PLUS Framework is an educational tool that describes a set of guidance strategies used by skilled practice educators, whilst acknowledging the critical influences of workplace and university contexts. The proposed key features could be useful target areas for busy practice educators to help make the most of limited supervision time. Future research will explore the PLUS Framework in different countries and professions' practice education environments.

The Integral Role of Organisational Governance in Promoting Interprofessional Education in Rural Settings.

One of the key challenges with implementing and sustaining interprofessional education initiatives is the lack of governance structures and processes to guide them. This case study presents a process evaluation of an intersectoral advisory group that facilitated a novel interprofessional clinical education model in rural health settings in the state of Queensland, Australia. The group consisted of health and academic partners to guide the implementation and promote sustainability of this new model. The advisory group process was evaluated mid-way and at conclusion of the group functions, using focus group discussions. The focus group audio recordings were transcribed verbatim and subjected to inductive content analysis. Categories were developed for reporting. Three broad categories were identified: Characteristics of the group, functions of the group and multifaceted communication within the group and between sectors. By identifying and mapping the processes used by a strategic, high-level intersectoral advisory group consisting of members from the health and academic fields, key recommendations have been formulated to guide similar work in the future.

Understanding the elements of a quality rural/remote interprofessional education activity: A rough guide.

AIMS: To offer a rough guide to a quality rural/remote interprofessional educational activity. CONTEXT: Australian remote and rural interprofessional undergraduate placements offered in Modified Monash Model 3-6 locations. APPROACH: Biggs' triple P framework from the interprofessional educational literature and Allport's contact hypothesis are used to describe map, and explore the educational dimensions and positive elements, of a quality rural/remote interprofessional educational activity. CONCLUSION: Delivery of a quality interprofessional educational activity requires attention to all dimensions of the activity with acknowledgement of the value of the remote or rural contexts. Interprofessional learning requires constructive alignment and positive contact conditions to ensure a quality and sustained experience.

Twelve tips for teaching the International Classification of Functioning, Disability and Health with a view to enhancing a biopsychosocial approach to care.

The World Health Organization International Classification of Functioning, Disability and Health has the power to shape professional behaviour and positively influence all aspects of health and social care practice. The visual depiction of the ICF framework belies the complexity of this multifaceted classification and coding system which students and practitioners can find challenging to grasp. This guide offers twelve integrated practical tips to help health and social care educators embed the ICF throughout the curriculum with a view to supporting student learning and ultimately interprofessional and inclusive practice.

Embedding the International Classification of Functioning, Disability and Health in Health Professions Curricula to Enable Interprofessional Education and Collaborative Practice.

The World Health Organization's International Classification of Functioning, Disability and Health (WHO-ICF) is a comprehensive and highly adaptable framework that provides a universal language and shared health concepts to articulate human functioning across the lifespan and from individual to population health settings. It provides a global, biopsychosocial, and holistic structure for conceptualising the human experience of health and health service provision. Consequently, the ICF framework offers hope for a universal map for health service providers that bridges professional, cultural, economic, and geographical variations. While the use of the ICF is typically mandated by health professions accreditation bodies, integration of the ICF in medical and health professional education programmes has been slow. In addition, its potential for scaffolding interprofessional education for collaborative practice has not been maximised. In this Perspective paper, we draw on our extensive experience in developing curricula and teaching within a range of health professions programmes (medicine, occupational therapy, physiotherapy, and speech-language pathology) to provide advice on conceptual, theoretical, and practical dimensions of embedding the ICF framework within curricula to support interprofessional education and collaborative practice.

Governance options for effective interprofessional education: Exposing the gap between education and healthcare services.

CONTEXT: The increase in interprofessional models of collaborative practice and identification of health services as interprofessional organisations, sits somewhat awkwardly with traditional governance systems for both health services and educational institutions. Whereas health services have a primary focus on assuring competence and safety for health care practice, educational institutions have a primary focus on assuring academic standards within specific qualifications. Bridging the gap between these two systems with a workable option has proven challenging, especially in relation to interprofessional education (IPE). OBJECTIVES: Given the need to ensure 'work ready' graduates within a more interprofessional and collaborative workforce, it is important to review the quality assurance governance models that are in place and to consider which of these existing governance systems, if either, is the more appropriate model for enabling and supporting IPE. METHODS: This paper describes current issues in relation to governance for quality assurance, summarises the current state of research in the field and discusses potential governance options moving forward. CONCLUSION: Given that existing governance models are not meeting the challenges of IPE, there is a need to achieve greater alignment between the academic and health service governing systems.

One "chemsex" or many? Types of chemsex sessions among gay and other men who have sex with men in Madrid, Spain: findings from a qualitative study.

BACKGROUND: Understanding 'chemsex' has become one of the key issues in LGBT health and HIV prevention in high-income countries, since it has been shown that this form of sexualised drug use correlates with higher risks to the physical and mental health of gay and other men who have sex with men (GMSM) who participate in chemsex sessions. Numerous studies have analysed sociodemographic characteristics, drug-use patterns or consequences of chemsex, but less research has been carried out to describe possible variations in the ways chemsex is practised. In the context of a broader qualitative study about chemsex in Madrid (Spain), we sought to explore differences among types of chemsex sessions. METHODS: 11 in-depth interviews and two triangular focus groups (N = 7) were conducted with self-identifying GMSM between the ages of 22-46 who lived in Madrid and claimed to have engaged in chemsex during the last two years. Interviews and focus groups were recorded, transcribed and subjected to thematic analysis and sociological discourse analysis. RESULTS: We identified four different types of chemsex sessions - "anonymous sessions", "chill-sex", "semi-closed parties among networks of friends" and "chemsex in saunas or other sex on premise venues (SPVs)" - which present differences in how they are arranged, in the way they develop and in the meanings their participants ascribe to them. They also involve different degrees and forms of exposure to risk, as well as other peculiarities that, in some cases, may even function as factors of protection. CONCLUSION: This study highlights the need to elaborate a more detailed description of chemsex, since not all forms of practicing chemsex are equivalent or involve equal forms of risk. Risk reduction strategies and other HIV prevention activities would benefit from considering internal variations among forms of chemsex practice.

How early is early? Effect of oxybutynin on bladder dynamics within the first year of life in patients with spina bifida.

INTRODUCTION: Early proactive treatment of patients with high-risk neurogenic bladder from spina bifida (SB) may preserve renal function and decrease the need for bladder augmentation later in life. Timing of initiation of anticholinergic therapy (AC) medication and clean intermittent catheterization (CIC) is variable and based on imprecise studies. The authors hypothesized that initiation of AC after the initial video-urodynamic study (VUDS) may benefit bladder capacity even in children who do not meet the standard hostile criteria for starting AC. STUDY DESIGN: A retrospective review of a prospectively maintained VUDS database from August 2015 to March 2019 was performed. Patients with SB who had undergone initial VUDS between 1 and 7 months of age and had a subsequent follow-up study between 9 and 18 months of age were included. Multiple VUDS and clinical parameters including expected bladder capacity, actual capacity reached, pressure at actual capacity, presence of detrusor overactivity, presence of urinary tract dilation and reflux, and whether or not AC was started were extracted and compared. P-value of <0.05 was considered statistically significant. RESULTS: A total of 69 patients completed an initial study at median age of 2 months, and follow-up study at median age of 13 months. Anticholinergic therapy was started in 21 patients (10 F, 11 M). Decision to initiate AC was at discretion of the attending pediatric urologist performing the VUDS in real time. Changes between the initial and repeat VUDS are listed in the summary table below. Adverse effects of AC were reported in 25% (5/21) patients: urinary retention/UTIs (3), allergic reaction (1), and fatigue (1). DISCUSSION: The authors findings suggest that AC stabilizes storage pressure for those who initially have a higher storage pressure, while in those with initial low storage pressures, storage pressures worsened over time in the absence of AC. Patients started on AC experienced a faster rate of increase in bladder capacity. Limitations to this study included the unknown long term and sustainability of the improvement in bladder parameters, the lack of uniform criteria for the initiation of AC or CIC, and an unknown long-term degree of upper tract protection. CONCLUSION: This study found early initiation of AC in SB at 2 months of age had significant positive effects on growth of bladder capacity and stabilization of storage pressure. However, long-term effects of AC are still undetermined, and thus, longitudinal studies are needed to understand the precise indications for initiation of early AC treatment.

Factors associated with rural work for nursing and allied health graduates 15-17 years after an undergraduate rural placement through the University Department of Rural Health program.

INTRODUCTION: Very little is known about the long term workforce outcomes, or factors relating to these outcomes, for nursing and allied health rural placement programs. The positive evidence that does exist is based on short term (1-3 year) evaluations, which suggest that undergraduate rural placements are associated with substantial immediate rural practice of 25-30% graduates practising rurally. These positive data suggest the value of examining long term practice outcomes, since such data are necessary to providing an evidence base for future workforce strategies. The objective was to measure long term (15-17 year) rural practice outcomes for nursing and allied health graduates who had completed an undergraduate rural placement of 2-18 weeks through a university department of rural health (UDRH). METHODS: This was a longitudinal cohort study, with measures taken at the end of the placement, at one year and at 15-17 years post-graduation. Participants were all nursing and allied health students who had taken part in a UDRH rural placement, who consented to be followed up, and whose practice location was able to be identified. The main outcome measure was factors associated with location of practice as being either urban (RA 1) or rural (RA 2-5). RESULTS: Of 776 graduates initially surveyed, 474 (61%) were able to be contacted in the year after their graduation, and 244 (31%) were identified through the Australian Health Practitioner Regulation Agency, 15-17 years later. In univariate analysis at the first graduate year, previously lived rural, weeks in placement, discipline and considering future rural practice all had significant relationships with initial rural practice. In multivariate analysis, only rural background retained significance (odds ratio (OR) 3.19, confidence interval (CI) 1.71-5.60). In univariate analysis 15-17 years later, previously lived rural and first job being rural were significantly related to current rural practice. In multivariate analysis, only first job being rural retained significance (OR 11.57, CI 2.77-48.97). CONCLUSION: The most significant long term practice factor identified in this study was initial rural practice. This suggests that funding to facilitate a rural pathway to not just train but also support careers in rural nursing and allied health rural training, similar to that already established for pharmacy and medicine, is likely to have beneficial long term workforce outcomes. This result adds to the evidence base of strategies that could be implemented for the successful development of a long term rural health workforce.