Innovation and Missed Opportunities in Internal Medicine Undergraduate Education During COVID-19: Results from a National Survey

BACKGROUND

COVID-19 disrupted undergraduate clinical education when medical schools removed students from clinical rotations following AAMC recommendations. Clerkship directors (CDs) had to adapt rapidly and modify clerkship curricula. However, the scope and effects of these modifications are unknown.

OBJECTIVE

To examine the effects of the initial phase of COVID-19 on the internal medicine (IM) undergraduate clinical education.

DESIGN

A nationally representative web survey.

PARTICIPANTS

IM CDs from 137 LCME-accredited US medical schools in 2020.

MAIN MEASURES

Items (80) assessed clerkship structure and curriculum, assessment in clerkships, post-clerkship IM clinical experiences, and CD roles and support. The framework of Understanding Crisis Response (Royal Society for Encouragement of Arts, Manufactures, and Commerce) was used to determine whether curricular modifications were "amplified," "restarted," "let go," or "ended."

KEY RESULTS

Response rate was 74%. In response to COVID-19, 32% (32/101) of clerkships suspended all clinical activities and 66% (67/101) only in-person. Prior to clinical disruption, students spent a median of 8.0 weeks (IQR: 2) on inpatient and 2.0 weeks (IQR: 4) on ambulatory rotations; during clinical re-entry, students were spending 5.0 (IQR: 3) and 1.0 (IQR: 2) weeks, respectively. Bedside teaching and physical exam instruction were "let go" during the early phase. Students were removed from direct patient care for a median of 85.5 days. The sub-internship curriculum remained largely unaffected. Before the pandemic, 11% of schools were using a pass/fail grading system; at clinical re-entry 47% and during the survey period 23% were using it. Due to the pandemic, 78.2% of CDs assumed new roles or had expanded responsibilities; 51% reported decreased scholarly productivity.

CONCLUSIONS

Curricular adaptations occurred in IM clerkships across US medical schools as a result of COVID-19. More research is needed to explore the long-term implications of these changes on medical student education and clinical learning environments.

Fine-regolith production on asteroids controlled by rock porosity

Spacecraft missions have observed regolith blankets of unconsolidated subcentimetre particles on stony asteroids^1-3. Telescopic data have suggested the presence of regolith blankets also on carbonaceous asteroids, including (101955) Bennu⁴ and (162173) Ryugu⁵. However, despite observations of processes that are capable of comminuting boulders into unconsolidated materials, such as meteoroid bombardment^6,7 and thermal cracking⁸, Bennu and Ryugu lack extensive areas covered in subcentimetre particles^7,9. Here we report an inverse correlation between the local abundance of subcentimetre particles and the porosity of rocks on Bennu. We interpret this finding to mean that accumulation of unconsolidated subcentimetre particles is frustrated where the rocks are highly porous, which appears to be most of the surface¹⁰. The highly porous rocks are compressed rather than fragmented by meteoroid impacts, consistent with laboratory experiments^11,12, and thermal cracking proceeds more slowly than in denser rocks. We infer that regolith blankets are uncommon on carbonaceous asteroids, which are the most numerous type of asteroid¹³. By contrast, these terrains should be common on stony asteroids, which have less porous rocks and are the second-most populous group by composition¹³. The higher porosity of carbonaceous asteroid materials may have aided in their compaction and cementation to form breccias, which dominate the carbonaceous chondrite meteorites¹⁴.

A phase I study of lenalidomide plus chemotherapy with idarubicin and cytarabine in patients with relapsed or refractory acute myeloid leukemia and high-risk myelodysplastic syndrome

Patients with relapsed/refractory (R/R) acute myeloid leukemia (AML) have poor outcomes and hematopoietic cell transplantation (HCT) is the only curative treatment. New targeted therapies improved survival in select patients with specific mutations, however management of patients without these molecular alterations is an unmet need. We conducted a phase one study of lenalidomide in combination with cytarabine/idarubicin salvage chemotherapy in patients with R/R AML and high‐risk myelodysplastic syndromes. A total of 33 patients were enrolled in the study (30 AML, 3 MDS), and treated at three dose levels with 3 + 3 design. Dose‐limiting toxicity (DLT) was seen in eight patients, including four hematologic DLTs. The most commonly observed non‐hematologic serious adverse events were febrile neutropenia, rash, sepsis and renal injury. Dose level −1, consisting of 25 mg/d lenalidomide D1‐21, 1 g/m² cytarabine D5‐8, and 8 mg/m² idarubicin D5‐7 was determined to be the maximum tolerated dose. Note, 15/33 (45%) of patients were able to receive pre‐planned 21 days of lenalidomide. Overall, 18 patients achieved complete remission (CR) (n = 14) or CR with incomplete count recovery (CRi) (n = 4) with total CR/CRi rate of 56%. The 1‐year and 2‐year overall survival (OS) were 24% and 10%, respectively. Among responders, 10/18 underwent allogeneic HCT and had a 1‐year OS of 40%. There was no molecular pattern associated with response. These data demonstrate that the combination had clinical activity in R/R AML. This regimen should be further investigated for patients who relapsed after HCT, and as a bridge therapy to HCT. (ClinicalTrials.gov identifier: NCT01132586).

Variations in color and reflectance on the surface of asteroid (101955) Bennu

Visible-wavelength color and reflectance provide information about the geologic history of planetary surfaces. Here we present multispectral images (0.44 to 0.89 micrometers) of near-Earth asteroid (101955) Bennu. The surface has variable colors overlain on a moderately blue global terrain. Two primary boulder types are distinguishable by their reflectance and texture. Space weathering of Bennu surface materials does not simply progress from red to blue (or vice versa). Instead, freshly exposed, redder surfaces initially brighten in the near-ultraviolet region (i.e., become bluer at shorter wavelengths), then brighten in the visible to near-infrared region, leading to Bennu's moderately blue average color. Craters indicate that the time scale of these color changes is ~10⁵ years. We attribute the reflectance and color variation to a combination of primordial heterogeneity and varying exposure ages.

Asteroid (101955) Bennu's weak boulders and thermally anomalous equator

Thermal inertia and surface roughness are proxies for the physical characteristics of planetary surfaces. Global maps of these two properties distinguish the boulder population on near-Earth asteroid (NEA) (101955) Bennu into two types that differ in strength, and both have lower thermal inertia than expected for boulders and meteorites. Neither has strongly temperature-dependent thermal properties. The weaker boulder type probably would not survive atmospheric entry and thus may not be represented in the meteorite collection. The maps also show a high-thermal inertia band at Bennu's equator, which might be explained by processes such as compaction or strength sorting during mass movement, but these explanations are not wholly consistent with other data. Our findings imply that other C-complex NEAs likely have boulders similar to those on Bennu rather than finer-particulate regoliths. A tentative correlation between albedo and thermal inertia of C-complex NEAs may be due to relative abundances of boulder types.

Heterogeneous mass distribution of the rubble-pile asteroid (101955) Bennu

The gravity field of a small body provides insight into its internal mass distribution. We used two approaches to measure the gravity field of the rubble-pile asteroid (101955) Bennu: (i) tracking and modeling the spacecraft in orbit about the asteroid and (ii) tracking and modeling pebble-sized particles naturally ejected from Bennu's surface into sustained orbits. These approaches yield statistically consistent results up to degree and order 3, with the particle-based field being statistically significant up to degree and order 9. Comparisons with a constant-density shape model show that Bennu has a heterogeneous mass distribution. These deviations can be modeled with lower densities at Bennu's equatorial bulge and center. The lower-density equator is consistent with recent migration and redistribution of material. The lower-density center is consistent with a past period of rapid rotation, either from a previous Yarkovsky-O'Keefe-Radzievskii-Paddack cycle or arising during Bennu's accretion following the disruption of its parent body.

Hemispherical differences in the shape and topography of asteroid (101955) Bennu

We investigate the shape of near-Earth asteroid (101955) Bennu by constructing a high-resolution (20 cm) global digital terrain model from laser altimeter data. By modeling the northern and southern hemispheres separately, we find that longitudinal ridges previously identified in the north extend into the south but are obscured there by surface material. In the south, more numerous large boulders effectively retain surface materials and imply a higher average strength at depth to support them. The north has fewer large boulders and more evidence of boulder dynamics (toppling and downslope movement) and surface flow. These factors result in Bennu's southern hemisphere being rounder and smoother, whereas its northern hemisphere has higher slopes and a less regular shape. We infer an originally asymmetric distribution of large boulders followed by a partial disruption, leading to wedge formation in Bennu's history.

In situ evidence of thermally induced rock breakdown widespread on Bennu's surface

Rock breakdown due to diurnal thermal cycling has been hypothesized to drive boulder degradation and regolith production on airless bodies. Numerous studies have invoked its importance in driving landscape evolution, yet morphological features produced by thermal fracture processes have never been definitively observed on an airless body, or any surface where other weathering mechanisms may be ruled out. The Origins, Spectral Interpretation, Resource Identification, and Security–Regolith Explorer (OSIRIS-REx) mission provides an opportunity to search for evidence of thermal breakdown and assess its significance on asteroid surfaces. Here we show boulder morphologies observed on Bennu that are consistent with terrestrial observations and models of fatigue-driven exfoliation and demonstrate how crack propagation via thermal stress can lead to their development. The rate and expression of this process will vary with asteroid composition and location, influencing how different bodies evolve and their apparent relative surface ages from space weathering and cratering records.

In their study, the authors discuss the potential of thermal weathering on airless bodies. As a case study, they use boulder and fracture morphologies on asteroid Bennu.

Collisional formation of top-shaped asteroids and implications for the origins of Ryugu and Bennu

Asteroid shapes and hydration levels can serve as tracers of their history and origin. For instance, the asteroids (162173) Ryugu and (101955) Bennu have an oblate spheroidal shape with a pronounced equator, but contain different surface hydration levels. Here we show, through numerical simulations of large asteroid disruptions, that oblate spheroids, some of which have a pronounced equator defining a spinning top shape, can form directly through gravitational reaccumulation. We further show that rubble piles formed in a single disruption can have similar porosities but variable degrees of hydration. The direct formation of top shapes from single disruption alone can explain the relatively old crater-retention ages of the equatorial features of Ryugu and Bennu. Two separate parent-body disruptions are not necessarily required to explain their different hydration levels.

The unexpected surface of asteroid (101955) Bennu

NASA'S Origins, Spectral Interpretation, Resource Identification and Security-Regolith Explorer (OSIRIS-REx) spacecraft recently arrived at the near-Earth asteroid (101955) Bennu, a primitive body that represents the objects that may have brought prebiotic molecules and volatiles such as water to Earth1. Bennu is a low-albedo B-type asteroid2 that has been linked to organic-rich hydrated carbonaceous chondrites3. Such meteorites are altered by ejection from their parent body and contaminated by atmospheric entry and terrestrial microbes. Therefore, the primary mission objective is to return a sample of Bennu to Earth that is pristine-that is, not affected by these processes4. The OSIRIS-REx spacecraft carries a sophisticated suite of instruments to characterize Bennu's global properties, support the selection of a sampling site and document that site at a sub-centimetre scale5-11. Here we consider early OSIRIS-REx observations of Bennu to understand how the asteroid's properties compare to pre-encounter expectations and to assess the prospects for sample return. The bulk composition of Bennu appears to be hydrated and volatile-rich, as expected. However, in contrast to pre-encounter modelling of Bennu's thermal inertia12 and radar polarization ratios13-which indicated a generally smooth surface covered by centimetre-scale particles-resolved imaging reveals an unexpected surficial diversity. The albedo, texture, particle size and roughness are beyond the spacecraft design specifications. On the basis of our pre-encounter knowledge, we developed a sampling strategy to target 50-metre-diameter patches of loose regolith with grain sizes smaller than two centimetres4. We observe only a small number of apparently hazard-free regions, of the order of 5 to 20 metres in extent, the sampling of which poses a substantial challenge to mission success.

The dynamic geophysical environment of (101955) Bennu based on OSIRIS-REx measurements

The top-shape morphology of asteroid (101955) Bennu is commonly found among fast-spinning asteroids and binary asteroid primaries, and might have contributed significantly to binary asteroid formation. Yet a detailed geophysical analysis of this morphology for a fast-spinning asteroid has not been possible prior to the Origins, Spectral Interpretation, Resource Identification, and Security-Regolith Explorer (OSIRIS-REx) mission. Combining the measured Bennu mass and shape obtained during the Preliminary Survey phase of OSIRIS-REx, we find a significant transition in Bennu's surface slopes within its rotational Roche lobe, defined as the region where material is energetically trapped to the surface. As the intersection of the rotational Roche lobe with Bennu's surface has been most recently migrating towards its equator (given Bennu's increasing spin rate), we infer that Bennu's surface slopes have been changing across its surface within the last million years. We also find evidence for substantial density heterogeneity within this body, suggesting that its interior has a distribution of voids and boulders. The presence of such heterogeneity and Bennu's top-shape is consistent with spin-induced failure at some point in its past, although the manner of its failure cannot be determined yet. Future measurements by the OSIRIS-REx spacecraft will give additional insights and may resolve questions regarding the formation and evolution of Bennu's top-shape morphology and its link to the formation of binary asteroids.

Shape of (101955) Bennu indicative of a rubble pile with internal stiffness

The shapes of asteroids reflect interplay between their interior properties and the processes responsible for their formation and evolution as they journey through the Solar System. Prior to the OSIRIS-REx (Origins, Spectral Interpretation, Resource Identification, and Security-Regolith Explorer) mission, Earth-based radar imaging gave an overview of (101955) Bennu's shape. Here, we construct a high-resolution shape model from OSIRIS-REx images. We find that Bennu's top-like shape, considerable macroporosity, and prominent surface boulders suggest that it is a rubble pile. High-standing, north-south ridges that extend from pole to pole, many long grooves, and surface mass wasting indicate some low levels of internal friction and/or cohesion. Our shape model indicates that, similar to other top-shaped asteroids, Bennu formed by reaccumulation and underwent past periods of fast spin leading to its current shape. Today, Bennu might follow a different evolutionary pathway, with interior stiffness permitting surface cracking and mass wasting.

A novel regimen for relapsed/refractory adult acute myeloid leukemia using a KMT2A partial tandem duplication targeted therapy: results of phase 1 study NCI 8485

KMT2A partial tandem duplication occurs in approximately 5–10% of patients with acute myeloid leukemia and is associated with adverse prognosis. KMT2A wild type is epigenetically silenced in KMT2A partial tandem duplication; re-expression can be induced with DNA methyltransferase and/or histone deacetylase inhibitors in vitro, sensitizing myeloid blasts to chemotherapy. We hypothesized that epigenetic silencing of KMT2A wildtype contributes to KMT2A partial tandem duplication-associated leukemogenesis and pharmacologic re-expression activates apoptotic mechanisms important for chemoresponse. We developed a regimen for this unique molecular subset, but due to relatively low frequency of KMT2A partial tandem duplication, this dose finding study was conducted in relapsed/refractory disease regardless of molecular subtype. Seventeen adults (< age 60) with relapsed/refractory acute myeloid leukemia were treated on study. Patients received decitabine 20 milligrams/meter² daily on days 1–10 and vorinostat 400 milligrams daily on days 5–10. Cytarabine was dose-escalated from 1.5 grams/meter² every 12 hours to 3 grams/meter² every 12 hours on days 12, 14 and 16. Two patients experienced dose limiting toxicities at dose level 1 due to prolonged myelosuppression. However, as both patients achieved complete remission after Day 42, the protocol was amended to adjust the definition of hematologic dose limiting toxicity. No further dose limiting toxicities were found. Six of 17 patients achieved complete remission including 2 of 4 patients with KMT2A partial tandem duplication. Combination therapy with decitabine, vorinostat and cytarabine was tolerated in younger relapsed/refractory acute myeloid leukemia and should be explored further focusing on the KMT2A partial tandem duplication subset. (clinicaltrials.gov identifier 01130506).

Dose, schedule, safety, and efficacy of guadecitabine in relapsed or refractory acute myeloid leukemia

BACKGROUND

Outcomes for patients with relapsed or refractory acute myeloid leukemia (AML) are poor. Guadecitabine, a next‐generation hypomethylating agent, could be useful in treating such patients.

METHODS

In this multicenter, open‐label, phase 2 dose‐expansion study, AML patients from 10 North American medical centers were first randomized (1:1) to receive subcutaneous guadecitabine at 60 or 90 mg/m² on 5 consecutive days in each 28‐day cycle (5‐day regimen). Subsequently, another cohort was treated for 10 days with 60 mg/m² (10‐day regimen).

RESULTS

Between June 15, 2012, and August 19, 2013, 108 patients with previously treated AML consented to enroll in the study, and 103 of these patients were treated; 5 patients did not receive the study treatment. A total of 103 patients were included in the safety and efficacy analyses (24 and 26 patients who were randomly assigned to 60 and 90 mg/m²/d, respectively [5‐day regimen] and 53 patients who were assigned to 60 mg/m²/d [10‐day regimen]). The 90 mg/m² dose showed no benefit in clinical outcomes in comparison with 60 mg/m² in the randomized cohort. Composite complete response (CRc) and complete response (CR) rates were higher with the 10‐day regimen versus the 5‐day regimen (CRc, 30.2% vs 16.0%; P = .1061; CR, 18.9% vs 8%; P = .15). Adverse events (grade ≥ 3) were mainly hematologic, with a higher incidence on the 10‐day regimen. Early all‐cause mortality was low and similar between regimens. Twenty patients (8 on the 5‐day regimen and 12 on the 10‐day regimen) were bridged to hematopoietic cell transplantation.

CONCLUSIONS

Guadecitabine has promising clinical activity and an acceptable safety profile and thus warrants further development in this population. Cancer 2018;124:325‐34. © 2017 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Outcomes for patients with relapsed or refractory acute myeloid leukemia are poor. Guadecitabine, a next‐generation hypomethylating agent, has promising clinical activity and an acceptable safety profile and warrants further development in this population.

See also pages 242‐4.

Discordant Expression of CD20 by Flow Cytometry and Immunohistochemistry in a Patient Responding to Rituximab: An Unusual Mechanism

Immunohistochemistry using the L26 antibody recognizes an intracellular domain of CD20, whereas the L27 antibody used for surface CD20 staining by flow cytometry (FC) recognizes an extracellular domain and would be expected to be a better predictor of response to rituximab. We present a 75-year-old man who was initially treated for CD20- diffuse large B-cell lymphoma based on FC and, at relapse, still had CD20- disease by FC but CD20+ disease by immunohistochemistry. The patient responded to rituximab alone. On further study, it was shown that the malignant B cells, but not normal B cells, expressed the L27 surface binding site only within the intracellular domain. Therefore, it appears that the rituximab binding site is distinct from the surface binding site, and when there is a disparity between the methods to detect CD20 expression, consideration should be given to include rituximab in the treatment plan.

Regional variations in sulfate and nitrate on annual, seasonal, and synoptic time scales

Ambient data from Interagency Monitoring of Protected Visual Environments (IMPROVE) monitors are analyzed to evaluate the spatial structure of SO4 and NO3 aerosols in the mid-Atlantic region. Sub-weekly, seasonal, and annual data values are compared between the IMPROVE Washington, DC, site and three rural sites. Synoptic perturbations are compared between sites to quantify similarities in short-term temporal perturbations of SO4 and NO3. Based on these comparisons between the rural and urban IMPROVE monitors, the spatial structure of SO4 shows broad regional homogeneity that is recognizable from both the long-term average values and the short-term variations. NO3 data on a seasonal and annual basis show much larger spatial gradients between the urban Washington monitor and the three rural monitors than do SO4 data. Short-term NO3 perturbations at the three rural monitors also differ significantly from those at the Washington site. These dissimilarities in NO3 levels between the rural and urban IMPROVE monitors on both short-term and longer-term time scales indicate little homogeneity of NO3 aerosols in the mid-Atlantic region considered here. The volatility of NO3 aerosols and the removal rate of HNO3 via dry deposition could contribute to the spatial variability differences shown here between SO4 and NO3.

Transmitted proliferation disadvantage from mouse oocytes labeled in vivo with [3H]thymidine: radiosensitive target considerations

This study was conducted to test the hypothesis that a nuclear target is involved in the embryonic cell proliferation disadvantage transmitted by irradiated mouse oocytes and detected by the chimera assay. In this assay, the cells from the irradiated embryo exhibit a competitive cell proliferation disadvantage when they are challenged by direct cell-cell contact with cells from a normal embryo in an aggregation chimera. Here, six pregnant CD-1 mice received a total of 1.85 TBq tritiated thymidine (TdR) delivered by multiple intraperitoneal injections during days 13-15 postconception. Six more pregnant mice were sham-injected to provide control embryos. Sixty randomly selected female progeny were mated at 47 days of age and their 4-cell embryos tested in the chimera assay. The mean proliferation ratio (PR, number of cells from the experimental embryo divided by total cell number of the chimera) for experimental chimeras was 0.45 +/- 0.02 SE (n = 43), which was significantly less than the mean PR of 0.49 +/- 0.01 SE (n = 47; p = 0.02) for control chimeras. This entire experiment was repeated, with similar results. A comparison for TdR confined to the nucleus (i.e., mean beta-ray range is only 0.7 microm) with the relationship for uniform irradiation by 137Cs gamma-rays demonstrates that these two very different modes of dose delivery produce essentially identical PRs. These results in vivo suggest a nuclear DNA target for embryonic cell proliferation disadvantage consistent with our previous findings in vitro.

Mouse immature oocytes irradiated in vivo at 14-days of age and evaluated for transmitted effects using the aggregation embryo chimera assay

A previous study using the mouse-preimplantation-embryo-chimera assay demonstrated a reproducible transmitted effect (proliferation disadvantage observed in early embryos) from females irradiated as 49-day-old adults using 0.15 Gy of gamma rays and then mated seven weeks later, i.e., embryos were from oocytes that were immature at time of irradiation. Because mouse immature oocytes are known to be much more radiosensitive to cell killing in juveniles than in adults, a follow-on study was performed here using 14-day-old juvenile mice. In contrast to adults, the exposure of juveniles to 0.15 Gy of gamma rays did not result in a detectable transmitted proliferation disadvantage when animals were mated 7 or 12 weeks later. This observation is discussed in light of previous studies on mouse immature oocytes and embryo chimeras.

Inherited effects from irradiated mouse immature oocytes detected in aggregation embryo chimeras

Data obtained using the mouse-preimplantation-embryo-chimera assay are presented that show a transmitted effect following low-dose irradiation of immature oocytes in vivo. Six-week-old female mice were irradiated using 137Cs-gamma-rays (0.05 Gy, 0.15 Gy, and unexposed controls). At 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12 weeks post exposure, the mice were mated and aggregation chimeras made from the 4-cell embryos. Three independent experiments have now been carried out, all showing a significant embryonic cell-proliferation disadvantage of the embryos obtained from the females treated 7 weeks previously, i.e., embryos from oocytes that were immature at the time of radiation exposure. No effect was detected at 1-6 weeks when embryos were obtained from maturing oocytes. Also, the effect was not seen at 8, 9, 10, 11, and 12 weeks post exposure. The implications of these results are discussed in the light of previous studies on mouse oocytes.

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) accelerates differentiation of murine preimplantation embryos in vitro

2,3,7,8-Tetrachlorodibenzo-p-dioxin (TCDD) is a potent teratogen in several animal species, especially during the period of organogenesis. The purpose of this study was to test the hypothesis that TCDD has direct effects on the earliest stages of murine embryonic development, namely the preimplantation stages. Three endpoints were measured: 1) embryo cell number, a measure of embryo viability, 2) competitive embryonic cell proliferation utilizing chimeric embryos, another measure of embryo viability, and 3) cavitation rate, a functional measure of trophectoderm differentiation. Neither embryo cell numbers nor competitive embryonic cell proliferation (chimera assay) were affected by TCDD, either when the mother was dosed in vivo (prior to fertilization), or when 2-cell embryos were dosed in vitro. However, cavitation rates of in vitro-dosed embryos, in the presence of 10% fetal bovine serum, were significantly higher for TCDD than controls, suggesting that TCDD accelerated differentiation of murine preimplantation embryos. Taken together, these results demonstrate that: 1) TCDD can act directly on the murine preimplantation embryo, and 2) TCDD's actions are primarily on accelerated differentiation and not on embryo viability. To our knowledge, this is the earliest stage of mammalian development during which TCDD has been shown to exert an effect.

A rehabilitation ward in a district general hospital: first three years' experience

The experience of the first three years' work on a ward for the rehabilitation of patients was reviewed. Adults with physical disabilities or mixed physical and psychological disabilities, including unstable or deteriorating conditions, were accepted for intensive rehabilitation. Most patients had neurological disorders. The ward policy was that each patient had considerable time with the therapist, maximum personal independence was encouraged, and multidisciplinary staff meetings were held to agree the goals of treatment. Much effort was spent helping patients and relatives to adapt to conditions of progressive disability, but the response to questionnaires suggested that these patients as well as those who did improve received some benefit from being on the ward. Overall the benefits of the intensive rehabilitation that was offered on this ward outweighed those from short stays on medical wards.