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Reciprocally inhibitory modules that form half-center oscillators require mechanisms for escaping or being released from inhibition. The central pattern generator underlying swimming by the nudibranch mollusc, Dendronotus iris, is composed of only four neurons that are organized into two competing modules of a half-center oscillator. In this system, bursting activity in left-right alternation is an emergent property of the network as a whole; none of the neurons produces bursts on its own. We found that the unique synaptic actions and membrane properties of the two neurons in each module (Si2 and the contralateral Si3) play complementary roles in generating stable bursting in this network oscillator. Although Si2 and Si3 each inhibits its contralateral counterpart, Si2 plays a dominant role in evoking fast and strong inhibition of the other module, the termination of which initiates postinhibitory rebound in the Si3 of that module by activating a hyperpolarization-activated inward current. Within each module, the synaptic actions and membrane properties of the two neurons complement each other: Si3 excites Si2, which then feeds back slow inhibition to Si3, terminating the burst. Using dynamic clamp, we showed that the magnitude of the slow inhibition sets the period of the oscillator. Thus, the synaptic actions of Si2 provide the hyperpolarization needed for the other module to rebound stably, whereas the membrane properties of Si3 in each module cause it to rebound first and excite Si2 to maintain the burst until terminated by the slow inhibition from Si2, which releases the other module to become active. NEW & NOTEWORTHY Half-center oscillators composed of reciprocally inhibitory neurons have been posited for over a century to underlie the production of rhythmic movements. The Dendronotus swim central pattern generator may be the simplest such circuit with only two pairs of bilaterally represented neurons. This study completes the description of the mechanism by which this network oscillator functions, showing how stable rhythmic activity arises from the complementary membrane and synaptic properties of the two neurons in the competing modules.

Background: As the population is aging and medical advancements enable people to live longer, advance care planning (ACP) becomes increasingly important in guiding future care decisions; however, they are often incomplete or absent from the patient chart. This study describes the development and implementation of an ACP policy in a post-acute care and long-term care setting using a systematic implementation framework. Methods: A process evaluation that parallels the Replicating Effective Programs (REP) framework was used to understand stakeholder experiences with ACP and identify gaps in practice. Physicians, multidisciplinary staff, patients, and substitute decision makers engaged in focus groups and interviews, and completed surveys. A retrospective chart review determined Plan for Life Sustaining Treatment (PLST) form completion rates. Results: Stakeholder feedback identified barriers and facilitators to ACP including a need for staff training, user-friendly resources, and standardization of ACP practice. The PLST form was developed and embedded in the electronic medical record, and had a 92% and an 87% PLST completion rate on 2 pilot units. Conclusion: The study showed the usefulness of the REP model in guiding the evaluation as an effective tool to enhance implementation practices and inform ACP policy development that can be replicated in other organizations.

Assisted living (AL) has existed in the United States for decades, evolving in response to older adults' need for supportive care and distaste for nursing homes and older models of congregate care. AL is state-regulated, provides at least 2 meals a day, around-the-clock supervision, and help with personal care, but is not licensed as a nursing home. The key constructs of AL as originally conceived were to provide person-centered care and promote quality of life through supportive and responsive services to meet scheduled and unscheduled needs for assistance, an operating philosophy emphasizing resident choice, and a residential environment with homelike features. As AL has expanded to constitute half of all long-term care beds, the increasing involvement of the real estate, hospitality, and health care sectors has raised concerns about the variability of AL, the quality of AL, and standards for AL. Although the intent to promote person-centered care and quality of life has remained, those key constructs have become mired under tensions related to models of AL, regulation, financing, resident acuity, and the workforce. These tensions have resulted in a model of care that is not as intended, and which must be reimagined if it is to be an affordable care option truly providing quality, person-centered care in a suitable environment. Toward that end, 25 stakeholders representing diverse perspectives conferred during 2 half-day retreats to identify the key tensions in AL and discuss potential solutions. This article presents the background regarding those tensions, as well as potential solutions that have been borne out, paving the path to a better future of assisted living.

ImportanceAssisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents’ medical and mental health needs. No guidance exists to inform this care.ObjectiveTo identify consensus recommendations for medical and mental health care in AL and determine whether they are pragmatic.Evidence ReviewA Delphi consensus statement study was conducted in 2021; as a separate effort, the extent to which the recommendations are reflected in practice was examined in data obtained from 2016 to 2021 (prepandemic). In the separate effort, data were from a 7-state study (Arkansas, Louisiana, New Jersey, New York, Oklahoma, Pennsylvania, Texas). The 19 Delphi panelists constituted nationally recognized experts in medical, nursing, and mental health needs of and care for older adults; dementia care; and AL and long-term care management, advocacy, regulation, and education. One invitee was unavailable and nominated an alternate. The primary outcome was identification of recommended practices based on consensus ratings of importance. Panelists rated 183 items regarding importance to care quality and feasibility.FindingsConsensus identified 43 recommendations in the areas of staff and staff training, nursing and related services, resident assessment and care planning, policies and practices, and medical and mental health clinicians and care. To determine the pragmatism of the recommendations, their prevalence was examined in the 7-state study and found that most were in practice. The items reflected the tenets of AL, the role of AL in providing dementia care, the need for pragmatism due to the diversity of AL, and workforce needs.Conclusions and RelevanceIn this consensus statement, 43 recommendations important to medical and mental health care in AL were delineated that are highly pragmatic as a guide for practice and policy.

Although acute intracranial hemorrhage (ICH) is a rare complication of catheter-directed thrombolysis (CDT), it remains a major concern associated with the use of CDT. The incidence and clinical predictors of developing ICH in the setting of CDT are not known.The National Inpatient Sample database was used to identify all patients with proximal lower extremity or caval deep vein thrombosis (DVT) from January 2005 to December 2013 in the United States. Multivariate logistic regression was performed to identify the clinical predictors of ICH between patients with DVT who had received anticoagulation therapy alone and those who had been treated with CDT plus anticoagulation therapy.Of 138,049 patients with proximal lower extremity or caval DVT, 7119 (5.2%) had received anticoagulation therapy and CDT. Of the patients treated with anticoagulation alone, ICH had occurred in 0.2% compared with 0.7% for those treated with CDT (P .01). The independent predictors of ICH in the CDT cohort were a history of stroke (odds ratio [OR], 19.4; 95% confidence interval [CI], 8.8-42.8; P .01), chronic kidney disease (OR, 2.2; 95% CI, 1.1-4.7; P = .03), age74 years (OR, 2.2; 95% CI, 1.2-4.3; P = .02), male sex (OR, 1.8; 95% CI, 1.01-3.3; P = .048). Of those patients treated with anticoagulation alone, the risk factors for the development of ICH were a history of stroke, hospital teaching status, and age74 years.The results from the present nationwide observational study showed that of patients with DVT treated with CDT, the independent predictors for developing ICH were a history of stroke, chronic kidney disease, male sex, and age 74 years.

Telepsychiatry via video conferencing is not new to mental health but has been expanding at a rapid rate over recent years. Initially it was introduced for treatment in remote and rural communities...

Objectives: Borderline personality disorder (BPD) is associated with frequent self-harm and suicidal behaviours. This study compared physician-assessed self-harm risk and intervention choice according to a (i) standard risk assessment and (ii) BPD-specific risk assessment methods. Methods: Forty-five junior and senior mental health physicians were assigned to standard or BPD-specific risk training groups. The assessment utilized a BPD case vignette containing four scenarios describing high/low lethality self-harm and chronic/new patterns of self-harm behaviour. Participants chose from among four interventions, each corresponding to a risk category. Results: Standard and BPD-specific groups were alike in their assessment of self-harm risk. Divergence occurred on intervention choice for assessments of low lethality, chronic risk ( pConclusions: Although standard and BPD-specific methods are well aligned for assessing self harm-associated risk, BPD-specific training raised awareness of BPD-appropriate interventions, particularly in the context of chronic patterns of self-harm behaviour. Wider dissemination of BPD-specific risk training may enhance the confidence of mental health clinicians in identifying the nature of self-harm risk as well as the most clinically appropriate interventions for clients with BPD.

This paper aimed to test the hypothesis that intraventricular extension of spontaneous intracerebral hemorrhage (ICH) in the absence of hydrocephalus is not associated with increased mortality or severe disability. We performed a retrospective consecutive cohort study of patients with primary spontaneous ICH who were admitted to a single institution. Multivariate logistic regression analysis was used to assess the association of each variable with functional outcome as measured by the modified Rankin Scale (mRS). A total of 164 patients met our inclusion criteria and were included in the study. Only hydrocephalus (p = 0.002) and hematoma volume (p = 0.006) were significantly associated with mortality or poor functional outcome (mRS of 3 to 6). In contrast, the presence of intraventricular hematoma was not independently associated with poor functional outcome. The presence of intraventricular extension of ICH in the absence of hydrocephalus may not increase mortality or disability.

Neurologic sequelae of synthetic cannabinoids are not well understood. We report a case of a woman who developed hyperreflexia, paratonia and cogwheel rigidity after consumption of synthetic cannabinoids. MR imaging demonstrated T2/FLAIR signal enhancement in the supratentorial white matter and globus pallidus internus.

Temple University Hospital (TUH) is a large, urban tertiary care hospital that cares for more than 700 patients with strokes annually. TUH has received the American Heart Association’s Get With The Guidelines-Stroke Gold Plus Quality Achievement Award and is certified as a primary stroke center by

Background: Stroke is the 5th leading cause of death in the United States .Every year, more than 795,000 people in the United States have a stroke. Ischemic Stroke in young adults age ≤50 years old has a prevalence of 3-5%. Many young patients with Ischemic Stroke don’t have common stroke risk factors such as high blood pressure, diabetes or hyperlipidemia and in general 33% of infarcts in this age group are cryptogenous. Methods: Retrospective review of prospectively collected data from the Temple University Hospital stroke database. Patients were selected based on age ≤50, clinical presentation and primary diagnosis of Ischemic Stroke. Characteristics including hypercoagulability work up, vessel imaging, heart studies and risk factors were reviewed. IRB approval was obtained. Results: From January 2011 through December 2014, we enrolled 1924 registered patients with Ischemic Stroke. 198 patients were ≤50 years old (10.2%). Baseline characteristics are Male (54%), NIHSS 0-16 (Median 6), Hypertension (48%), Diabetes (30%), Smoking (60%), Hyperlipidemia (20%), Positive drug screen (22%), Abnormal cardiac studies (42%). Despite 42% abnormal cardiac echocardiograms, there were no cardiac arrhythmias diagnosed. Abnormal brain or vessel imaging including brain MRI/MRA, CTH or CTA (36%). Hypercoagulability tests were checked in 68% of patients. Abnormalities showed factor-V Leiden (100% Normal), Prothrombin Mutation (100% Normal), Protein-C (80% Normal), Protein-S (84% Normal), Antithrombin-III (89% Normal), Antiphospholipid antibody (80% Normal), Lupus Anticoagulant (79% Normal), ANA (80% Normal) Conclusions: The incidence of Ischemic Stroke in this cohort is much higher than that reported in other observational studies. Despite an extensive work up, a cause was not found in the majority of patients. These data support the need for a more in depth investigation of the causes of stroke in the young in urban, underserved communities. Standard of care diagnostic tests fail to explain the unusually high incidence of Ischemic Stroke in the young in this cohort.

The military regime that controlled Argentina between 1976 and 1983 sought to radically depoliticize Argentine society through a violent campaign of social exclusion. Although this campaign required the active participation of the country’s major civil institutions, scholars of Argentina’s dictatorship and subsequent democratic transition have largely neglected the behavior of these key groups. This article examines the conduct of one such institution, the Delegation of Argentine Jewish Associations (DAIA), the Jewish community’s official political representative. DAIA’s drive for normality in the face of disorienting violence led the group, like many civil institutions, to cooperate with an abhorrent regime. DAIA’s cooperation entailed no obvious crimes, but it did contribute markedly to the climate of fear and isolation central to the military’s repressive social project. Rather than continue to ignore the critical role played by groups like DAIA, transitional justice mechanisms must be developed to account for this ‘political’ sort of complicity.

OBJECTIVES: To evaluate older adult emergency department (ED) patients for depression and cognitive impairment and to re-evaluate those findings 2 weeks later. DESIGN: Prospective cohort study. SETTING: ED. PARTICIPANTS: One thousand two hundred six older community-dwelling ED patients consented to participate; 811 (67%) completed the 2-week follow-up. MEASUREMENTS: Screening for depression (9-item Patient Health Questionnaire) and cognitive impairment (Six-Item Screener) was performed. Changes were evaluated through paired comparisons. RESULTS: At 2-week follow-up, for depression, 27 of 97 (28%) with baseline positive tests remained positive, and 22 of 706 (3%) with baseline negative tests were positive. At 2-week follow-up, for cognitive impairment, five of 43 (12%) with baseline positive tests remained positive, and 11 of 765 (1%) with baseline negative tests were positive. CONCLUSION: Significant variability exists for depression and cognitive impairment testing completed during and after the ED visit, with markedly fewer subjects testing positive at follow-up. The variability may reflect changes in clinical state, confounding from other conditions, or poor validity of the instruments in the ED setting. Further studies are needed to explain these findings before case-finding for these conditions is implemented in the ED setting.

Background Brain glutathione levels are decreased in schizophrenia, a disorder that often is chronic and refractory to treatment. N-acetyl cysteine (NAC) increases brain glutathione in rodents. This study was conducted to evaluate the safety and effectiveness of oral NAC (1 g orally twice daily [b.i.d.]) as an add-on to maintenance medication for the treatment of chronic schizophrenia over a 24-week period. Methods A randomized, multicenter, double-blind, placebo-controlled study. The primary readout was change from baseline on the Positive and Negative Symptoms Scale (PANSS) and its components. Secondary readouts included the Clinical Global Impression (CGI) Severity and Improvement scales, as well as general functioning and extrapyramidal rating scales. Changes following a 4-week treatment discontinuation were evaluated. One hundred forty people with chronic schizophrenia on maintenance antipsychotic medication were randomized; 84 completed treatment. Results Intent-to-treat analysis revealed that subjects treated with NAC improved more than placebo-treated subjects over the study period in PANSS total [−5.97 (−10.44, −1.51), p = .009], PANSS negative [mean difference −1.83 (95% confidence interval: −3.33, −.32), p = .018], and PANSS general [−2.79 (−5.38, −.20), p = .035], CGI-Severity (CGI-S) [−.26 (−.44, −.08), p = .004], and CGI-Improvement (CGI-I) [−.22 (−.41, −.03), p = .025] scores. No significant change on the PANSS positive subscale was seen. N-acetyl cysteine treatment also was associated with an improvement in akathisia ( p = .022). Effect sizes at end point were consistent with moderate benefits. Conclusions These data suggest that adjunctive NAC has potential as a safe and moderately effective augmentation strategy for chronic schizophrenia.

The physician can play an important role in managing high-risk nursing home residents without restraints and working with interdisciplinary care teams in comprehensive fall evaluations. A reduction or elimination of physical restraints can be measured for a facility over time, and it represents a relevant quality indicator of physician and facility interactions during the process of care. We discuss how the physician's role fits into this quality of care equation for nursing homes and its implications for new clinical, research, and policy directions for long-term care.

The US is currently experiencing a serious epidemic of methamphetamine (Meth) use entangled with HIV-1 infection. Blood monocyte derived dendritic cells (DC ) are the first line of defense against HIV-1 infection and are the initial target of HIV-1 in injection drug users. Chemokines are known to be HIV-1 suppressing molecules and are positively associated with non- progression of HIV disease. Co-stimulatory molecules are necessary for DC maturation, effective antigen presentation, cell migration, and T cell proliferation. Although previous studies suggest that Meth deregulates various immune responses, the role of Meth on gene expression and production of β-chemokines and co-stimulatory molecules by DC has not been studied. We hypothesize that Meth induced immune defects may be mediated by dysregulation of β-chemokines (MIP-1α/CCL3, MIP-1β/CCL4 and RANTES/CCL5), co-stimulatory and maturation molecules (CD83 and CCR7) by DC. Our results show that Meth significantly downregulates the gene expression and production of β-chemokines and co stimulatory molecule by DC from normal subjects. In HIV-1 infected subjects, RANTES variant In1.1c that has been associated with accelerated HIV-1 disease progression was significantly higher compared to normal controls. Further, Meth significantly inhibited total RANTES gene expression with a reciprocal upregulation of RANTES variant In1.1c in a dose dependent manner by both immature DC (IDC) and mature DC (MDC) from normal subjects. These studies report for the first time that Meth deregulates β-chemokines and co-stimulatory molecule expression by DC. The results emanating from these studies may help to support the therapeutic application of chemokines to restore anti-HIV-1 immune responses to prevent or control HIV-1 infection in meth using populations.

Background: Although acute intracranial hemorrhage (ICH) is a rare complication of catheter directed thrombolysis (CDT), it remains a major concern associated with the use of this therapy. The incidence and clinical predictors of developing ICH in the setting of CDT are not known. Methods: The

OBJECTIVE: There is considerable debate regarding whether pressure ulcers can truly be prevented in nursing homes. New pressure ulcers are often taken as a sign of negligence that can lead to a lawsuit. This study sought to determine expert opinion regarding the preventability of pressure ulcers, the resources available to nursing homes for prevention, and the role of negligence lawsuits in pressure ulcer care. DESIGN: Survey mailed to a convenience sample of 98 experts in the field of pressure ulcer care. The survey contained 36 questions, most based on a 5-point Likert scale from "strongly agree" to "strongly disagree." Several questions asked respondents to rank items. RESULTS: Sixty-five of 92 surveys were completed (6 were returned but not completed) for a response rate of 71%. Sixty-two percent of respondents disagreed with the statement that all pressure ulcers are preventable. Only 5% said that nursing homes have adequate resources to prevent all pressure ulcers. Although most respondents disagreed that pressure ulcers are necessarily a sign of neglect and that nursing homes should be sued when a resident develops a pressure ulcer, 38% agreed with the concept that lawsuits are an appropriate way to stimulate improvement in nursing home care. CONCLUSION: The results of this survey demonstrated divergent expert opinion on whether pressure ulcers are preventable. The role of regulations and litigation in pressure ulcer prevention needs to be further defined.

We describe a case of thymoma and pemphigus erythematosus developing in a 68-year-old woman 8 years after an initial diagnosis of systemic lupus erythematosus. Although numerous reports describe associations between any two of these entities, this case represents the first clearcut report of all three diseases in the same patient. The case description outlines the diagnostic approach to these diseases and reveals the importance of adhering to specific diagnostic criteria. Furthermore, by highlighting the potential role of thymic pathology in autoimmune disease, the case raises questions concerning pathogenesis of these disorders.

EUKARYOTIC cells respond to different extracellular stimuli by recruiting homologous signalling pathways that use members of the MEKK, MEK and ERK families of protein kinases. The MEKK→ MEK→ ERK core pathways of Saccharomyces cere-visiae may themselves be regulated by members of the STE20 family of protein kinases1,2. Here we report specific activation of the mammalian stress-activated protein kinase (SAPK) pathway by germinal centre kinase (GCK; ref. 3), a human STE20 homologue3,4. SAPKs, members of the ERK family, are activated in situ by inflammatory stimuli, including tumour-necrosis factor (TNF) and interleukin-1, and phosphorylate and probably stimulate the transactivation function of c-Jun5-7. Although GCK is found in many tissues, its expression in lymphoid follicles is restricted to the cells of the germinal centre, where it may participate in B-cell differentiation3. Activation of the SAPK pathway by GCK illustrates further the striking conservation of eukaryotic signalling mechanisms and defines the first physiological function of a mammalian Ste20.

Objectives: To determine if the perceived high incidence of hypersensitivity to various substance in firomyalgia, including medications, due to abnormal P450 xenobiotic metabolism. Methods: The metabolism via two genetically polymorphic P450 pathways was determined for 33 fibromyalgia patients, and matched controls. Results: There was no statistical difference between the genotypic frequency of the CYP2D6 gene or phenotypic expression of CYP2C19 between patients and contorls. Conclusion: Xenobiotic metabolism by the two pathways studied is normal in fibromyalgia. Although other P450 pathways could conceivably be abnormal in fibromyalgia, we speculate that such hypersensitivity to multiple substances in these conditions is unlikely to be due to abnormal metabolism, and postulate instead that these symptoms are mediated by neural mechanisms.

To evaluate older adult emergency department (ED) patients for depression and cognitive impairment and to re-evaluate those findings 2 weeks later.Prospective cohort study.ED.One thousand two hundred six older community-dwelling ED patients consented to participate; 811 (67%) completed the 2-week follow-up.Screening for depression (9-item Patient Health Questionnaire) and cognitive impairment (Six-Item Screener) was performed. Changes were evaluated through paired comparisons.At 2-week follow-up, for depression, 27 of 97 (28%) with baseline positive tests remained positive, and 22 of 706 (3%) with baseline negative tests were positive. At 2-week follow-up, for cognitive impairment, five of 43 (12%) with baseline positive tests remained positive, and 11 of 765 (1%) with baseline negative tests were positive.Significant variability exists for depression and cognitive impairment testing completed during and after the ED visit, with markedly fewer subjects testing positive at follow-up. The variability may reflect changes in clinical state, confounding from other conditions, or poor validity of the instruments in the ED setting. Further studies are needed to explain these findings before case-finding for these conditions is implemented in the ED setting.

Bronchiolitis obliterans organizing pneumonia (BOOP) is an uncommon and underrecognized pathologic finding observed in a variety of syndromes including connective tissue diseases. Although lung involvement in essential mixed cryoglobulinemia (EMC) has been reported, there are no previous reports of BOOP in EMC. We report herein a case of longstanding EMC associated with interstitial and cavitary lung disease histologically consistent with BOOP. A theory of a possible etiologic basis for the development of BOOP in patients with connective tissue diseases is discussed.

Rural-dwelling older adults experience unique challenges related to accessing medical and social services. This article describes the development, implementation, and experience of a novel, community-based program to identify rural-dwelling older adults with unmet medical and social needs that leveraged the existing emergency medical services (EMS) system. The program specifically included geriatrics training for EMS providers; screening of older adult EMS patients for falls, depression, and medication management strategies by EMS providers; communication of EMS findings to community-based case managers; in-home evaluation by case managers; and referral to community resources for medical and social interventions. Measures used to evaluate the program included patient needs identified by EMS or the in-home assessment, referrals provided to patients, and patient satisfaction. EMS screened 1,231 of 1,444 visits to older patients (85%). Of those receiving specific screens, 45% had fall-related, 69% medication management-related, and 20% depression-related needs identified. One hundred and seventy-one eligible EMS patients who could be contacted accepted the in-home assessment. Of the 153 individuals completing the assessment, 91% had identified needs and received referrals or interventions. This project demonstrated that screening by EMS during emergency care for common geriatric syndromes and linkage to case managers is feasible in this rural community, although many will refuse the services. Further patient evaluations by case managers, with subsequent interventions by existing service providers as required, can facilitate the needed linkages between vulnerable rural-dwelling older adults and needed community-based social and medical services.

To characterize the proportion of older adult emergency department (ED) patients with depression or cognitive impairment. To compare the prevalences of depression or cognitive impairment among ED patients arriving via emergency medical services (EMS) and those arriving via other modes.Community-dwelling older adults (age ≥60 years) presenting to an academic medical center ED were interviewed. Participants provided demographic and clinical information, and were evaluated for depression and cognitive impairment. Subjects arriving via EMS were compared with those arriving via other modes using the chi-square test, t-test, and the Wilcoxon rank sum test, where appropriate.Consent was obtained from 1,342 eligible older adults; 695 (52%) arrived via EMS. The median age for those arriving via EMS was 74 years (interquartile range 65, 82), 52% were female, and 81% were white. Fifteen percent of EMS patients had moderate or greater depression, as compared with 14% of patients arriving via other modes (p = 0.52). Thirteen percent of the EMS patients had cognitive impairment, as compared with 8% of those arriving via other modes (p0.01). The depressed EMS patients frequently reported a history of depression (47%) and taking antidepressants (51%). The cognitively impaired EMS patients infrequently reported a history of dementia (16%) and taking medications for dementia (14%). Conclusions. In this cohort of community-dwelling older adult ED patients, depression and cognitive impairment were common. As compared with ED patients arriving by other transport means, patients arriving via EMS had a similar prevalence of depression but an increased prevalence of cognitive impairment. Screening for depression and cognitive impairment by EMS providers may have value, but needs further investigation.

In response to the Association of American Medical Colleges' call for increases in medical school enrollment, several new MD-granting schools have opened in recent years. This article chronicles the development of one of these new schools, The Commonwealth Medical College (TCMC), a private, not-for-profit, independent medical college with a distributive model of education and regional campuses in Scranton, Wilkes-Barre, and Williamsport, Pennsylvania. TCMC is unique among new medical schools because it is not affiliated with a parent university. The authors outline the process of identifying a need for a new regional medical school in northeastern Pennsylvania, the financial planning process, the recruitment of faculty and staff, the educational and research missions of TCMC, and details of the infrastructure of the new school. TCMC's purpose is to increase the number of physicians in northeastern Pennsylvania, and in the next 20 years it is expected to add 425 practicing physicians to this part of the state. TCMC is characterized by autonomy, private and public support, assured resources in good supply, a relatively secure clinical base, strong cultural ties to the northeast, recruiting practices that reflect the dean's convictions, and strong support from its board of directors. TCMC has invested heavily in social and community medicine in its educational programs while still developing a strong research emphasis. Major challenges have centered on TCMC's lack of a parent university in areas of accreditation, infrastructure development, faculty recruitment, and graduate medical education programs. These challenges, as well as solutions and benefits, are discussed.

Fibromyalgia is a common condition that affects 2-4% of the population and is characterized by widespread pain, fatigue, and a number of other symptoms. There is evidence to suggest that fibromyalgia occurs much more frequently than expected in individuals with inflammatory rheumatic disorders. At present, it is not clear whether the inflammatory disorder leads to fibromyalgia or vice versa, but plausible mechanisms exist for either scenario. The coexistence of fibromyalgia and inflammatory disorders can lead to considerable difficulty in both diagnosis and treatment. In this article, the reasons that these two types of disorders can coexist are reviewed, and an approach to the diagnosis and management of individuals with components of both fibromyalgia and an inflammatory disorder is suggested.

Survival in systemic lupus erythamatosus (SLE) continues to improve because of better ancillary care, earlier diagnosis, and earlier treatment. However, infection remains a leading cause of morbidity and mortality in this disease Although corticosteroids and immunosuppressives increase the risk of opportunistic infection, the SLE patient is still most at risk from common bacterial pathogens. As the prototypic immune-complex disease, patients with active SLE have low circulating complement as well as a reticuloendothelial system (RES) saturated with immune complexes. It seems intuitive that SLE patients should be most at risk for organisms dependent for their removal on the RES or complement for opsonization or bacteriolysis. The current series presents four patients with SLE and disseminated neisseria infection and brings to 14 the number of patients in the literature with disseminated neisserial infection. They are typically young, female, with renal disease, and either congenital or acquired hypocomplementemia, and may present with all features of a lupus flare. Surprisingly, they are not all on corticosteroids or immunosuppressives and have some features that are unusual for non-SLE patients with these infections. There seems to be an over-representation of Nisseria meningitidis (despite potential reporting bias), and there ironically may be better tolerance with fewer fulminant complications in patients who have complement deficiencies. The best approach for the physician treating SLE is to immunize all SLE patients with available bacterial vaccines to N meningitidis and Streptococcus pneumonia , have a low threshold of suspicion for the diagnosis of disseminated neisserial or other encapsulated bacterial infection in the SLE patient who is sick, and to treat empirically with third generation cephalosporins after appropriate cultures.

Objective To perform a systematic review of the published literature on disease management of rheumatoid arthritis (RA) and to use metaanalysis to estimate the magnitude of benefit these programs have on functional status in patients with RA. Methods Computerized databases for English articles from 1966 to September 2001 were searched. Two reviewers evaluated 1,029 published titles, identified 11 studies meeting explicit inclusion criteria, and extracted data about study characteristics, interventions used, and outcomes measured. Pooled effect sizes for functional status were calculated using a random-effects model. Results Four out of 8 disease management programs showed significant improvements in functional status; however, the pooled effect size (ES) was small and statistically non-significant (ES 0.27; 95% confidence interval [95% CI] −0.01, 0.54). Studies with longer intervention durations (>5 weeks) had significantly improved patient functional status (ES 0.49; 95% CI 0.12, 0.86), compared with studies with shorter intervention durations (≤5 weeks, ES 0.13; 95% CI −0.25, 0.52). Conclusions There were limited data to support or refute the effectiveness of disease management programs in improving functional status in patients with RA. Additional studies are needed to confirm if a more intensive intervention may be of benefit to patients with RA, as suggested by our study.

Medical research programs are under significant pressure both from declines in the growth rates of government funding as well as from increases in government oversight of the privacy and safety of human research subjects. To cope, forward-thinking healthcare institutions are applying the same no-nonsense business rules to their research programs that they apply to other programs and departments. Modern Healthcare and PricewaterhouseCoopers present Straight Talk. In the session on medical research, we discuss how and why the world of medical research is changing, and what health systems should do to manage research programs successfully. The session was held on March 4, 2003 at Modern Healthcare's Chicago headquarters. Charles S. Lauer, publisher of Modern Healthcare, was the moderator.