A Cross-Sectional Study of the Impact of the COVID-19 Pandemic and Lockdown Orders on Injury Prevalence in National Collegiate Athletic Association (NCAA) Division I Athletes.

Objective The purpose of this study was to analyze the effect of the coronavirus disease 2019 (COVID-19) on injury prevalence in National Collegiate Athletic Association (NCAA) varsity athletes following mandatory state-issued stay-at-home orders in March 2020. A secondary objective was to evaluate the relationship between COVID-19 infection and injury prevalence. Methods The respondents were recruited during pre-participation evaluations held at a Division I university in California in the summer of 2021, as well as via emails shared by athletic trainers at the institution. Data was collected using the Qualtrics Survey Platform (Qualtrics, Provo, UT). For all questions regarding the effects of the COVID-19 pandemic, the participants were asked to compare March 2020-March 2021 ("post-pandemic") to March 2019-March 2020 ("pre-pandemic"). Injury was defined as a physical complaint or condition sustained by an athlete during participation in training or competition that resulted in at least one missed day of practice or competition. The study participants were also asked to disclose their history of laboratory-confirmed COVID-19 infection. Results One hundred forty-six respondents completed the survey, with a 72.3% response rate. Of the respondents, 33.6% (n=49) reported sustaining at least one injury in the year preceding the pandemic, whereas 45.2% (n=66) of respondents reported sustaining at least one injury within the first year of the pandemic, a 34.5% relative increase in injuries (RR=1.35; 95% CI=1.01, 1.80). There was no significant difference in the number of upper body (RR=1.64; 95% CI=0.8, 3.34; p=0.177) versus lower body (RR=1.31; 95% CI=0.94, 1.82; p=0.11) injuries before and after the pandemic onset. Thirty-two respondents reported a history of COVID-19 infection. The athletes who reported a prior COVID-19 diagnosis were no more likely than the athletes with no prior COVID-19 diagnosis to obtain an injury from March 2020 to February 2021 (p=0.85). Conclusion This study indicates that the COVID-19 pandemic and stay-at-home orders were associated with a greater risk of injury in this cohort of collegiate athletes. Interestingly, a history of laboratory-confirmed COVID-19 infection was not associated with increased risk of injury.

Not as simple as it seems: extensive facility and training gaps in nursing home bathing.

Standardized observation of bed baths and showers for 100 residents in 8 nursing homes revealed inadequate cleansing of body sites (88%-100% failure) and >90% process failure involving lather, firm massage, changing dirty wipes or cloths, and following clean-to-dirty sequence. Insufficient water warmth affected 86% of bathing opportunities. Bathing training and adequate resources are needed.

Exploration of California School Nurse perspectives on the impact of COVID-19.

OBJECTIVE: To explore in a sample of school nurses (SN) in California the impact of the COVID-19 pandemic on school nurse health services, how school nurses mitigated the impact of COVID-19, and moral distress levels among school nurses. DESIGN AND METHODS: Nineteen (N = 19) school nurses who work in K-12 schools in California, USA participated in a mixed-methods approach involving qualitative descriptive design, inductive content analysis, and descriptive statistics. Interviews were conducted in August and September 2021. RESULTS: Five themes emerged: (1) role of the SN during the COVID-19 pandemic, (2) coordination with school administration, (3) COVID-19 related challenges and disruptions to care, (4) moral distress, and (5) coping during the pandemic. CONCLUSION: The pandemic had a profound impact on school nurses. This study provides school nurse perspectives of the impact of COVID-19 on services they delivered, the unique skills of school nurses essential to mitigation strategies, and moral distress school nurses encountered during the pandemic. Understanding the important role school nurses had during the pandemic is paramount to fully contextualize the contributions they made within public health nursing practice and inform preparedness for future pandemics.

Food Insecurity and Type 2 Diabetes Among Latinos: Examining Neighborhood Cohesion as a Protective Factor.

Qualitative work has found that Latino food pantry recipients share food and reciprocally provide social support to their food-insecure neighbors. These findings suggest that neighborhood cohesion (NC) may serve as an important community-level resource that Latinos utilize as a coping mechanism when food-insecure. High levels of NC may be a proxy for instrumental support outside the household and act as a buffer against the adverse health effects of food insecurity including type 2 diabetes (T2D), which is highly sensitive to food insecurity. The purpose of this study was to quantitatively test this theory by examining whether NC moderated the association between T2D and food security (FS) status among Latino adults nationwide. We used data from the 2013-2018 National Health Interview Survey (n = 23,478). We found that FS status was associated with T2D prevalence, with Latino adults having a higher odds of T2D if they had low FS or very low FS compared to their FS counterparts. We also found Latinos adults who reported high NC had a lower odds of T2D compared to those who reported low NC. However, we did not find there was significant interaction between FS status and NC on T2D. NC may instead be a precursor to FS status, rather than a buffer of food insecurity on T2D. Low NC may lead to less instrumental support and tangible benefits that determine FS. Additionally, perceived NC might not align with objective NC and T2D may be too distal of a health outcome to test the protective effect of NC.

Mental Health and Substance Use in NCAA Athletes in the Context of the COVID-19 Pandemic and Lockdown.

Background Although the coronavirus disease 2019 (COVID-19) pandemic had pervasive effects on the lives of individuals, its influence on the mental health of collegiate athletes remains unknown. This study aimed to assess changes in mental health and substance use in National Collegiate Athlete Association (NCAA) Division I athletes in Southern California during the COVID-19 pandemic. Methodology An online survey was created using the Qualtrics software (Qualtrics, Provo, Utah). NCAA Division I athletes in Southern California completed preseason surveys querying indices of mental health, substance use, and injury in the year before the COVID-19 pandemic (March 2019 to March 2020) and during the pandemic (March 2020 to March 2021). The athletes filled out the survey from June 2021 to September 2021. Participants were asked how likely they were to agree with the following statements: I have felt physically prepared for athletic competitions, I have been satisfied with my mental health, and I have had adequate sleep. Participants were also asked to compare their substance use between the two time periods. Sociodemographic information regarding participants' age, gender, sports team, as well as year in sport and school was also collected. Group comparison analyses were performed using Fisher's exact test. Correlations between mental health measures and other variables were examined using Spearman's correlation coefficients. Results A total of 189 athletes completed the survey (out of the 259 surveys that were started). Females were significantly less likely to feel satisfied with mental health (p < 0.01) and physically prepared for sport (p < 0.01). Across all respondents, satisfaction with mental health was positively correlated with adequate sleep (p < 0.01) and physical preparedness for sport (p < 0.01) and negatively correlated with injury (p < 0.05). There was no significant correlation between mental health status and history of COVID-19 infection (p = 0.84). The vast majority of athletes reported no significant change in substance use pre- to post-pandemic, with no differences according to sex. Conclusions The COVID-19 pandemic had a differential impact on the mental health of female versus male NCAA athletes. Mental health was correlated with sleep, physical preparedness, and being injury-free but not with a history of COVID-19 infection. Despite reports indicating increased substance use in the general population, athletes in this group reported no change in licit and illicit substance use.

Encouraging Mental Health Care in Family Medicine Residents.

Introduction: Residency training is associated with stress and burnout that can contribute to poor mental health. However, residents are less likely to utilize mental health services due to perceived barriers such as lack of time and concerns about confidentiality, among others.1 There is a need to promote help-seeking behavior and improve access to mental health services during residency training. Methods: In order to decrease barriers to seeking mental health care and promote well-being among residents, the University of California Irvine Family Medicine Residency Program (UCI FMRP) implemented a program that included confidential, regular, mental health check-ins between residents and a psychiatrist. We gathered data on help-seeking behavior from an internally conducted electronic survey of 29 residents regarding perceived barriers to seeking mental health care in June, 2020. Results: The internal survey results from 24 respondents out of 29 residents demonstrated that the program supported help-seeking behavior among the residents, with 33% of the residents requesting additional sessions with the psychiatrist and another 13% seeking external mental health resources. Conclusion: Providing additional, confidential, on-site support may be one method of decreasing stigma, increasing access to care, and normalizing conversations around mental health in residency.

Breathing Room: Industrial Zoning and Asthma Incidence Using School District Health Records in the City of Santa Ana, California.

Background: Traffic and industrial emissions are associated with increased pediatric asthma morbidity. However, few studies have examined the influence of city industrial zoning on pediatric asthma outcomes among minoritized communities with limited access to air monitoring. Methods: In this cross-sectional analysis of 39,974 school-aged students in Santa Ana, CA, we investigated the effect of proximity to areas zoned for industrial use on pediatric asthma prevalence, physical fitness, school attendance, and standardized test scores. Results: The study population was 80.6% Hispanic, with 88.2% qualifying for free/reduced lunch. Compared to students living more than 1 km away from industrial zones, those living within 0.5 km had greater odds of having asthma (adjusted OR 1.21, 95% CI 1.09 to 1.34, p < 0.001). Among children with asthma, those living between 0.5−1.0 km had greater odds of being overweight or obese (aOR 1.47, 95% CI 1.00, 2.15, p = 0.047). Industrial zone proximity was not significantly associated with worse fitness and academic outcomes for students with asthma. Conclusion: These findings suggest that industrial zone proximity is associated with increased pediatric asthma in a predominantly Latino community in Southern California.

Adoptive T-Cell Therapy in Advanced Colorectal Cancer: A Systematic Review.

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths in the US. For the vast majority of patients with advanced CRC (ie, for those in whom metastatic tumors are unresectable), treatment is palliative and typically involves chemotherapy, biologic therapy, and/or immune checkpoint inhibition. In recent years, the use of adoptive T-cell therapy (ACT), leveraging the body's own immune system to recognize and target cancer, has become increasingly popular. Unfortunately, while ACT has been successful in the treatment of hematological malignancies, it is less efficacious in advanced CRC due in part to a lack of productive immune infiltrate. This systematic review was conducted to summarize the current data for the efficacy and safety of ACT in advanced CRC. We report that ACT is well tolerated in patients with advanced CRC. Favorable survival estimates among patients with advanced CRC receiving ACT demonstrate promise for this novel treatment paradigm. However, additional stage I/II clinical trials are needed to establish the efficacy and safety of ACT in patients with CRC.

Frequency of Social Media and Digital Scholarship Keywords in U.S. Medical Schools' Promotion and Tenure Guidelines.

PURPOSE: Medical schools must have clear policies and procedures for promotion and tenure (P&T) of faculty. Social media and digital scholarship (SMDS) is an emerging form of scholarship capable of reaching audiences quickly, conveniently, and in a wide variety of formats. It is unclear how frequently SMDS is considered during P&T reviews. The authors sought to determine whether current P&T guidelines at medical schools consider SMDS. METHOD: The authors acquired P&T guidelines from any U.S. Liaison Committee on Medical Education-accredited medical school (or their governing university) that were available online between October and December 2020. Using an iterative process, they developed a bank of keywords that were specific to SMDS or that could include SMDS between October and December 2020. The authors searched each school's guidelines for each keyword and determined whether the word was being used in relation to crediting faculty for SMDS in the context of P&T procedures. The primary outcome measure was the dichotomous presence or absence of SMDS-specific keywords in each school's P&T guidelines. RESULTS: The authors acquired P&T guidelines from 145/154 (94%) medical schools. After removing duplicate documents, the authors considered 139 guidelines. The keyword bank included 59 terms, of which 49 were specific to SMDS and 10 were umbrella terms that could be inclusive of SMDS. Of the 139 guidelines, 121 (87%) contained at least 1 SMDS-specific keyword. Schools had a median of 3 SMDS-specific keywords in their P&T guidelines. CONCLUSIONS: As the presence and impact of SMDS increase, schools should provide guidance on its role in the P&T process. Faculty should receive clear guidance on how to document quality SMDS for their promotion file.

Latino Health Access: Comparative Effectiveness of a Community-Initiated Promotor/a-Led Diabetes Self-management Education Program.

Community-initiated health interventions fill important gaps in access to health services. This study examines the effectiveness of a community-initiated health intervention to improve diabetes management in an underserved community of color using a retrospective observational study, comparing a study intervention, the Latino Health Access Diabetes Self-Management Program (LHA-DSMP), with usual care. The LHA-DSMP is a 12-session community health worker (promotor/a) intervention developed and implemented by a community-based organization in a medically underserved area. Usual care was delivered at a federally qualified health center in the same geographic area. Participants were 688 predominantly Spanish-speaking Latinx adults with type 2 diabetes. The main outcome was change in glycemic control (glycosylated hemoglobin [HbA1c]) from baseline to follow-up. At 14-week follow-up, mean (95% CI) HbA1c decrease was -1.1 (-1.3 to -0.9; P < .001) in the LHA-DSMP cohort compared with -0.3 (-0.4 to -0.2; P < .001) in the comparison cohort. Controlling for baseline differences between cohorts, the adjusted difference-in-differences value in HbA1c was -0.6 (-0.8 to -0.3; P < .001) favoring the LHA-DSMP. A community-initiated promotor/a-led educational program for diabetes self-management is associated with clinically significant improvement in blood sugar control, superior to what was observed with usual medical care.

Increased Mortality in Underinsured Penetrating Trauma Patients.

INTRODUCTION: It remains unclear whether an increased mortality risk in uninsured patients exists across Injury Severity Score (ISS) classifications. We hypothesized that penetrating trauma self-pay patients would have a similarly increased mortality risk across all ISS categories. METHODS: The National Trauma Data Bank (2013-2015) was queried for patients presenting with penetrating firearm, explosive, or stab wound injuries. 115 651 patients were identified and a stratified multivariable logistic regression model was used. RESULTS: In the >15 ISS group, self-pay patients had a lower median total hospital Length of Stay (LOS) (3 vs 8, P < .001), lower median Intensive Care Unit LOS (1 vs 3, P < .001), and lower median ventilator days (0 vs 1, P < .001). Self-pay patients had an increased risk for mortality compared to patients with private insurance in both the ≤15 ISS group (OR 2.68, P < .001) and >15 ISS group (OR 1.56, P < .001). CONCLUSION: Uninsured patients have an increased mortality risk in both low and high ISS groups. A higher mortality risk among uninsured patients in the high ISS group can be explained by decreased resource availability and lower ICU days and ventilator time. However, more studies are needed to determine why there is an even greater mortality risk among uninsured patients with mild ISS.

Professional development in integrative health through an interprofessional online course in clinical settings.

BACKGROUND: Although there is mounting clinical and cost-effectiveness evidence supporting integrative healthcare (IH), a significant knowledge gap hinders widespread adoption by health professionals. INTERVENTION: Foundations in Integrative Health (FIH), a 32-h online competency-based interprofessional course to address this knowledge gap. METHODS: The course was pilot-tested by an interprofessional sample of providers in various clinical settings as professional and staff development. OUTCOME MEASURES: Prior to and following the course, participants completed an IH knowledge test, an IH self-efficacy self-assessment, and validated measures of burnout, wellness behaviors, and attitudes toward IH, interprofessional teams, and patient involvement. Evaluation surveys were administered following each unit and the course. RESULTS: Thirty-one percent of the participants (n = 214/690) completed the course. Pre/post course improvements were found in IH knowledge, IH self-efficacy, attitudes towards IH and interprofessional teams, and several wellness behaviors. The course was positively evaluated with 81% of the participants indicating interest in applying IH principles in their practice and 92% reported that the course enhanced their clinical experience. CONCLUSION: This study demonstrates the outcomes of a multi-site, online IH curriculum offered to a diverse group of health professionals in various clinical settings. This course may allow clinical settings to offer an interprofessional, IH curriculum even with limited on-site faculty expertise.

Injury incidence and characteristics for elite, male, artistic USA gymnastics competitions from 2008 to 2018.

OBJECTIVES: To determine the injury incidence and characteristics for elite, male, artistic USA gymnasts during gymnastics competitions, held in the USA, from 2008 to 2018. METHODS: Injury documentation performed by lead physician and certified athletic trainers at elite junior and senior USA Gymnastics competitions from 2008 to 2018 were reviewed and compiled into an excel database. Injury incidence was computed per 1000 registered gymnasts by competition setting as well as injury location, type, cause, severity, and setting. RESULTS: From 2008 to 2018, 180 injuries were reported in a total of 2102 gymnasts with injury incidence of 85.6 per 1000 gymnasts (95% CI 73.4 to 97.8). The most common injury site was at the ankle (16.7 per 1000 gymnasts, 95% CI 10.9 to 22.4), and muscle strain/rupture/tear was the most common type of injury (28.5 per 1000 gymnasts, 95% CI 21.2 to 35.9). The most common cause was contact with surface (56.1 per 1000 gymnasts, 95% CI 46.1 to 66.2), and the event where most injuries were sustained was the vault (21.9 per 1000 gymnasts, 95% CI 15.4 to 28.4). Incidence of time loss injuries was 38.5 per 1000 gymnasts (95% CI 30.1 to 47.0). Injury incidence was higher during competition (58.5 per 1000 gymnasts, 95% CI 48.2 to 68.8) than during training (27.1 per 1000 RG, 95% CI 19.9 to 34.3; RR 2.16, 95% CI 1.59 to 2.94, p<0.001); injury incidence was greater at Olympic Trials (RR 3.23, 95% CI 1.24 to 8.47, p=0.017) than at National Qualifier meets. We report concussion incidence in gymnastics (5.7 per 1000 gymnasts, 95% CI 2.3 to 9.2). CONCLUSIONS: This is the largest injury study to date for male artistic gymnasts (180 injuries, 2102 gymnasts, 11 years).

A Retrospective Interventional Cohort Study to Assess the Safety and Efficacy of Sandostatin LAR for Treatment of Recurrent and/or Refractory Meningiomas.

Background: Meningiomas are the most common adult primary intracranial tumors in the United States. Despite high recurrence rate of atypical and malignant subtypes, there is no approved drug indicated specifically for meningioma. Since the majority of meningiomas exhibit high density of somatostatin receptors subtypes, somatostatin analogs have been under close investigation. The aim of this study was to evaluate efficacy and safety of Sandostatin LAR (octreotide) in patients with progressive, and/or recurrent meningioma, and identify subset of patients who were more likely to benefit from this treatment. Methods: A total of 43 patients ≥ 18 years old were included in the retrospective chart review. The patients underwent treatment with Sandostatin LAR (octreotide) from 01.01.2010 to 06.01.2017 at the University of California, Irvine after confirmation of the diagnosis. Six months progression free survival (PFS6) was defined as a primary endpoint, and the overall survival (OS), safety, and toxicity were identified as secondary endpoints. Results: The OS for 6 months, 1, and 3 years for all WHO grades was 94.8, 88.1, and 67.0%, respectively. The PFS6 for WHO I, II, III, and all was 89.4, 89, 33.3, and 80% respectively. For patients with no prior surgeries, chemotherapy or radiation, the PFS6 was 88.9, 84.8, and 94.8%, respectively. Interestingly, the PFS6 was 90.5% for skull-based and 80% for 3-6 cm tumors. Patients with tumors in parasagittal location had PFS6 of 83.3% compared to PFS6 of 50.0% for patients with convexity tumors. Evaluation of PFS6 based on the effect of estrogen and progesterone on meningioma identified that ER-PR+ tumors had PFS6 of 87.8% while patients with ER-PR- meningiomas had PFS6 of 62.5%. Median TTP for WHO grade I, II, and III was 3.1, 2.40, and 0.26 years, respectively. Subgroup analysis showed that median TTP was 3.1 years for <3 cm tumors, 3.22 years for skull-based tumors, 2.37 years for patients with prior surgeries and 3.10 years for patients with no history of chemotherapy. History of radiation had no effect on median TTP. Sandostatin LAR (octreotide) was well-tolerated. Conclusions:This is one of the largest retrospective analysis of meningioma patients treated with Sandostatin LAR (octreotide) suggesting that this treatment has minimal to no adverse events and could prolong overall survival, and progression free survival especially for patients with ER-PR+ tumors who underwent surgeries for small skull-based tumors.

Development and validation of a bladder trabeculation grading system in pediatric neurogenic bladder.

Bladder trabeculation (BT) is commonly noted on cystogram images of patients with neurogenic bladder (NB). BT is associated with a hostile bladder often requiring prompt, more aggressive management. We aimed to define and validate a reliable grading system for BT severity. The proposed grading system will improve clinicians and radiologist's communication and serve as a foundation for future studies in the field of NB. The study was conducted in two phases: 1) Development of a grading system for BT and 2) testing of the proposed grading system for reliability and validity. Agreement between raters was assessed using Cohen's Kappa. Inter-rater reliability and intra-rater reliability was assessed using intra-class correlation coefficients (ICC) and Spearman's p (rho) correlation coefficient. The content of the grading system was assessed for face validity by senior pediatric urology and radiology experts. We observed inter-rater reliability with ICC of 0.998 (95%CI 0.996-0.999, p < 0.001), and a Cohen's Kappa ranging from 0.795 to 1.0, p < 0.001 and Spearman's p (rho) correlation coefficient ranging from 0.910 to 1.0, p < 0.001 between raters on the decided grades of BT. In conclusion, we established a defined grading system for BT severity that has substantial inter/intra-rater reliability and validity. This grading system could be useful for improving clinician and radiologist's communication about the status of a child's bladder wall and serve as a foundation for future studies assessing severity of NB.

Does Applicant Gender Have an Effect on Standardized Letters of Evaluation Obtained During Medical Student Emergency Medicine Rotations?

BACKGROUND: The standardized letter of evaluation (SLOE) in emergency medicine (EM) is one of the most important items in a student's application to EM residency and replaces narrative letters of recommendation. The SLOE ranks students into quantile categories in comparison to their peers for overall performance during an EM clerkship and for their expected rank list position. Gender differences exist in several assessment methods in undergraduate and graduate medical education. No authors have recently studied whether there are differences in the global assessment of men and women on the SLOE. OBJECTIVES: The objective of this study was to determine if there is an effect of student gender on the outcome of a SLOE. METHODS: This was a retrospective observational study examining SLOEs from applications to a large urban, academic EM residency program from 2015 to 2016. Composite scores (CSs), comparative rank scores (CRSs), and rank list position scores (RLPSs) on the SLOE were compared for female and male applicants using Mann-Whitney U-test. RESULTS: From a total 1,408 applications, 1,038 applicants met inclusion criteria (74%). We analyzed 2,092 SLOEs from these applications. Female applicants were found to have slightly lower and thus better CRSs, RLPSs, and CSs than men. The mean CRS for women was 2.27 and 2.45 for men (p < 0.001); RLPS for women was 2.32 and 2.52 for men (p < 0.001) and CS was 4.59 for women and 4.97 for men (p < 0.001). CONCLUSIONS: Female applicants have somewhat better performance on the EM SLOE than their male counterparts.

Effect of diabetes self-management education on glycemic control in Latino adults with type 2 diabetes: A systematic review and meta-analysis.

PURPOSE: This systematic review and meta-analysis evaluated the effectiveness of diabetes self-management education (DSME) in reducing glycosylated hemoglobin (A1C) levels in adult Latinos with type 2 diabetes (T2DM). METHODS: Five databases were searched for DSME randomized controlled trials or quasi-experimental trials published between January 1997 and March 2019. A random effects model was utilized to calculate combined effect sizes. Subgroup analyses were performed to explore possible sources of heterogeneity between studies. RESULTS: Twenty-three unique studies met criteria for this systematic review and of these, 18 were included in the meta-analysis. Pooled estimate effect of DSME on A1C from the random effect model was -0.240 (95% confidence interval = -0.345, -0.135, p <  0.001). There was moderate heterogeneity (Cochrane Q=30.977, P=0.020, I^2 = 45.121) between the studies. Subgroup analyses demonstrated greater A1C reductions in studies with intervention duration ≤6 months, initial A1C baseline values >8.0 [69 mmol/mol], and team-based approach. CONCLUSIONS: Meta-analysis results showed that culturally tailored DSME interventions significantly reduce AIC in Latinos with T2DM despite the heterogeneity across the studies. IMPLICATIONS: The heterogeneity in the study methodologies reinforce the need for additional studies to better understand DSME interventions to reduce disparities in Latino adults with T2DM.

A Retrospective Cohort Study of the Effect of Home Institution on Emergency Medicine Standardized Letters of Evaluation.

BACKGROUND: The standardized letter of evaluation (SLOE) was developed to make letters of recommendation in emergency medicine (EM) more objective and discerning. Typically, students obtain one SLOE from a home EM rotation and at least one more SLOE from an away clerkship. It is unclear if students perform better on their home or away EM rotations. OBJECTIVE: The purpose of this study was to determine if students perform better on the group SLOE at their home institution compared to an away institution. METHODS: The authors performed a retrospective application review of all allopathic applicants to an urban, academic EM residency program. The authors calculated a composite score (CS) for each group SLOE, using the global assessment scores for comparative rank and rank list position. A lower CS indicates better performance. The authors compared mean CS for students' first home rotations with first away rotations. For students in the study who had a third (second away or second home site) SLOE available, the authors compared mean CS on the students' first SLOEs with mean CS on the students' third SLOEs. RESULTS: A total of 624 records were included in the primary analysis. There was a small, but significant difference between mean CS for students' home rotations when compared to away rotations (4.67 vs. 4.85, p = 0.024). Students performed better on their home rotations. Students who had three SLOEs available performed worse on their third rotation (first = 4.40, second = 4.63, third = 4.77, p = 0.012 for first vs. third). For all available SLOEs, more than 50% of students fell into the top 10% or top one-third categories. CONCLUSION: Students perform slightly better on their home EM rotations. Students' mean SLOE CS is slightly worse for a third rotation when compared to a first rotation.