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Introdução: Certificado como Hospital de Ensino, o IIERibas recebia anualmente, pré-pandemia, cerca de 400 alunos de graduação para estagiar em suas enfermarias. Verificarmos o estado vacinal de todos eles é procedimento de rotina antes do início do estágio, tarefa que, por princípio, cabe às faculdades. A pandemia facilitou essa nossa prática ao adotarmos um formulário para autopreenchimento online. Objetivo: Avaliar a situação vacinal dos alunos de Internato Médico que estagiaram no IIERibas de fevereiro de 2021 a abril de 2022. Método: Análise retrospectiva dos formulários preenchidos às vésperas do início de cada grupo de estágio, os quais estão disponíveis numa página específica do site do hospital (emilioribas.org/internato-medico-pre) com informações básicas sobre as vacinas recomendadas. Para cada uma destas vacinas o aluno precisa assinalar se o seu esquema está (ou não) atualizado, “com” ou “sem comprovante”, se já teve alguma destas doenças ou se simplesmente “não sei”. Resultados: De um total de 264 internos que estagiaram no IIERibas neste período, temos o registro de 214 questionários respondidos, dos quais a respectiva carteira vacinal foi relatada como adequada e completa em 165 (77,1%). As inconsistências mais comuns (vacinação “não atualizada” ou “não sei”) foram relacionadas à vacinação para influenza (relatadas por 41 alunos - 19,2%), mas as outras doenças imunopreviníveis (com exceção da covid-19, foco das atenções midiáticas deste período) também apresentaram falhas: varicela (7 casos), tríplice viral (5), dupla bacteriana adulta (5), hepatite B (3) e BCG (2). Os principais fatores de confusão nesta casuística são o fato das informações vacinais serem espontâneas e não documentais, além da sazonalidade da vacinação para influenza em função do ano letivo. Todas as dúvidas e pendências foram abordadas individualmente pela chefia do Setor com a finalidade de saná-las ao longo do estágio. Conclusão: Nossa responsabilidade com a biossegurança ocupacional dos estagiários no IIERibas transformou-se numa bem-sucedida metodologia ativa de ensino-aprendizagem sobre o tema “imunização” (parte integrante do conteúdo programático do estágio). Além de identificar um percentual alto de não conformidade, esta estratégia promoveu uma automotivação ímpar (para além da nossa intervenção ativa) no sentido dos alunos se conscientizarem e desejarem adequar sua própria situação vacinal.

Introdução: O IIERibas é um Hospital de Ensino de administração direta da Secretaria Estadual da Saúde e, por conseguinte, não tem nenhuma Liga Acadêmica. Desde 2015, no entanto, o IIERibas organiza o “Encontro das Ligas de Infectologia”, iniciativa de uma residente e da Coordenação da COREME na época, hoje conduzida pelo setor de Internato Médico. O evento conta desde o início com o apoio da Sociedade Paulista de Infectologia. Objetivo: Descrever e avaliar esta experiência educacional no seu formato virtual do período pós-pandemia (GoogleMeet) em comparação ao registro histórico das reuniões presenciais pré-pandemia. Método: A divulgação dos Encontros é feita por email e por mídias sociais, sendo a inscrição dos interessados gratuita (www.emilioribas.org/encontro-de-ligas), porém obrigatória. Cada Encontro com cerca de 90 minutos consiste num Relato de Caso Clínico na área de Infectologia apresentado pelos próprios acadêmicos, devidamente orientados pelo professor assistente da respectiva Liga. A discussão dos temas inerentes ao caso envolve médicos assistentes do IIERibas e os professores das outras Ligas participantes. Resultados: Desde a sua criação, já aconteceram 49 Encontros da “liga das Ligas” (como é carinhosamente apelidada), sendo 35 presenciais (interrompidos pela pandemia) e 14 virtuais de outubro de 2020 a abril de 2022. O número de participantes nos encontros presenciais variou de 54 a 136 (mediana de 72,3), enquanto a mediana nos virtuais foi mais que o dobro: 156,5 (entre 85 e 208). Estes números correspondem a mais de 15 Ligas de Infectologia participantes (e alguns visitantes independentes), das quais 12 foram responsáveis pelas apresentações dos Casos Clínicos (rodízio definido no início do ano letivo). Além de mais alunos, outro ganho do modelo virtual foi possibilitar a participação de Ligas Acadêmicas do interior de SP e, mais recentemente, de outros estados: PR, MG e PE. Algumas intempéries relacionadas à transmissão pela internet são as únicas críticas reincidentes apontadas no feedback do evento. Conclusão: As Ligas Acadêmicas são atividade extracurricular de extensão universitária que despertam, dentre outros, o interesse dos futuros médicos por determinada especialidade - no caso, a Infectologia. O expressivo alcance (facilitado pela tecnologia online) destes Encontros reforça a vocação e a responsabilidade do IIERibas neste contexto, motivando-nos a continuar com esta iniciativa que carrega um potencial de abrangência ainda maior – estejam todos convidados a participar!

Introdução: A estratégia de aplicar uma avaliação do nível de conhecimento pré e pós-estágio dos internos no IIERibas é procedimento de rotina há tempos, porém as restrições sanitárias impostas pela covid-19 têm se apresentado como um potencial agravo da qualidade do ensino médico. Objetivo: Rever os resultados obtidos com este teste pré e pós-estágio dos internos que atuaram no IIERibas de fevereiro de 2021 a abril de 2022, com a retomada dos estágios pós-pandemia. Método: Uma avaliação com 10 questões de múltipla escolha (quatro alternativas) sobre conceitos básicos da Infectologia (temas fixos) foi aplicada no 1° dia de cada estágio (presencial), questões estas repetidas de forma aleatória em meio a outras tantas perguntas na prova final. Ao término do estágio acontece sempre a correção da prova final (com presença facultativa) conduzida pela chefia do Setor, mas a frequência dos internos nesta “revisão do conteúdo” costuma ser pequena. Resultados: Foram 262 internos que estagiaram no IIERibas neste período e completaram as duas etapas do teste (pré e pós-estágio). O percentual de acerto de todas as questões ANTES do estágio foi de 75,4%, aumentando para 83,2% DEPOIS do estágio (p = 0,037 pelo test t de Student para amostras pareadas). Os temas com maior porcentagem de acerto no pré e pós-estágio foram, respectivamente, sífilis (97,7 e 100,0%), transmissão e prevenção de doenças infecciosas (84,10 e 94,6%), antropozoonoses (79,4 e 93,1%), conceitos básicos de biossegurança (77,5 e 87,7%) e hepatites virais (77,5 e 91,6%). Os temas com menor porcentagem foram meningites (38,2 e 63,0%) e antibioticoterapia (63,4 e 65,6%). “Urgências em Infectologia” foi o resultado mais conflitante, com um índice de acerto de 68,7% no pré-estágio que reduziu para 47,7% no pós. Tomando como referencial as notas individuais, a média da nota de todos os alunos no pré foi de 7,51 e aumentou para 8,20 no pós, mas a mediana nas duas etapas foi a mesma: nota 8. Das 597 respostas erradas na fase pré, 406 foram corrigidas (68,0% de “inversão positiva”) na prova final, no entanto 222 das 2.006 respostas certas da fase pré viraram erradas (11,1% de “inversão negativa”) no final do estágio. Conclusão: A comparação entre os resultados de uma mesma prova ANTES e DEPOIS é útil para o direcionamento do conteúdo teórico-prático a ser abordado durante o estágio e nos permite identificar várias oportunidades de melhorias.

Foi estudada a reatividade tuberculínica e a resposta imunológica celular e humoral "in vitro", em 50 doentes de ambos os sexos, de 20 a 80 anos de idade, com tuberculose pulmonar ativa, internados no Parque Hospitalar do Mandaqui da Secretaria de Estado da Saúde, São Paulo (Brasil), no período de maio a agosto de 1980. Para o estudo da reatividade tuberculínica foi utilizado o PPD, Rt-23, 2 UT, tendo havido 14,0% de não-reatores, 12,0% de reatores fracos e 74,0% de reatores fortes. O estudo da imunidade celular e humoral "in vitro" foi realizado pela quantificação de linfócitos T e B, transformação blástica de linfócitos, liberação do fator inibidor da migração de leucócitos (LIF) e reação de hemaglutinação passiva. Os resultados mostraram a validade do cálculo do número absoluto dos linfócitos T e B. A cultura de linfócitos e a técnica do LIF, foram capazes de detectar a sensibilização dos linfócitos ao PPD, mesmo nos doentes não reatores, e a reação de hemaglutinação passiva revelou a presença de anticorpos específicos na população estudada em títulos superiores aos encontrados em pessoas normais, independentemente da reatividade tuberculínica.This paper presents the results of delayed-type skin reaction to tuberculin and the cellular and humoral immune responses "in vitro" in 50 patients with active pulmonary tuberculosis admitted to the "Parque Hospitalar do Mandaqui", São Paulo, Brazil, in the period from May to August 1980, matched for sex and ranging in age from 20 to 80 years old. In order to study the delayed-type skin reaction to tuberculin, the PPD, Rt-23, 2 TU (Purified protein derivative) was used and the result obtained was of 14.0% of nonreactors, 12.0% of weak reactors and 74.0% of strong reactors. The "in vitro" study of cellular and humoral immune responses was carried out by determining the number of T and B lymphocytes, the lymphocyte transformation, the liberation of the leucocyte inhibitor factor (LIF) and by the passive hemaglutination test. The results showed the importance of calculation of the absolute number of T and B lymphocytes. The culture of lymphocytes and the LIF experiment were able to detect the lymphocyte sensitivity to PPD even in the nonreactor patients and the passive hemaglutination test showed the presence of specific antibodies in the population studied demonstrated by the highest titers when compared with normal subjects, independently of the skin reactivity to tuberculin.

In humans, inability to stand and walk is the most limiting of motor disabilities. In humans, upright stance and gait is the most sensitive indicator of cerebellar disease. From animal and human studies, much has been learned about how the cerebellum coordinates normal movement, and how it may play roles in normal motor adaptation and learning. Much of this work suggests that different parts of the cerebellum control stance and gait in different ways, and differently located lesions cause different deficits. What is not known is whether the cerebellum can compensate for stance and gait disorders caused by lesions in other parts of the nervous system, or whether one part of the cerebellum can compensate for deficits caused by lesion of another part. These issues have become increasingly important in rehabilitation research and practice.

1. We studied seven subjects with cerebellar lesions and seven control subjects as they made reaching movements in the sagittal plane to a target directly in front of them. Reaches were made under three different conditions: 1) "slow-accurate," 2) "fast-accurate," and 3) "fast as possible." All subjects were videotaped moving in a sagittal plane with markers on the index finger, wrist, elbow, and shoulder. Marker positions were digitized and then used to calculate joint angles. For each of the shoulder, elbow and wrist joints, inverse dynamics equations based on a three-segment limb model were used to estimate the net torque (sum of components) and each of the component torques. The component torques consisted of the torque due to gravity, the dynamic interaction torques induced passively by the movement of the adjacent joint, and the torque produced by the muscles and passive tissue elements (sometimes called "residual" torque). 2. A kinematic analysis of the movement trajectory and the change in joint angles showed that the reaches of subjects with cerebellar lesions were abnormal compared with reaches of control subjects. In both the slow-accurate and fast-accurate conditions the cerebellar subjects made abnormally curved wrist paths; the curvature was greater in the slow-accurate condition. During the slow-accurate condition, cerebellar subjects showed target undershoot and tended to move one joint at a time (decomposition). During the fast-accurate reaches, the cerebellar subjects showed target overshoot. Additionally, in the fast-accurate condition, cerebellar subjects moved the joints at abnormal rates relative to one another, but the movements were less decomposed. Only three subjects were tested in the fast as possible condition; this condition was analyzed only to determine maximal reaching speeds of subjects with cerebellar lesions. Cerebellar subjects moved more slowly than controls in all three conditions. 3. A kinetic analysis of torques generated at each joint during the slow-accurate reaches and the fast-accurate reaches revealed that subjects with cerebellar lesions produced very different torque profiles compared with control subjects. In the slow-accurate condition, the cerebellar subjects produced abnormal elbow muscle torques that prevented the normal elbow extension early in the reach. In the fast-accurate condition, the cerebellar subjects produced inappropriate levels of shoulder muscle torque and also produced elbow muscle torques that did not very appropriately with the dynamic interaction torques that occurred at the elbow. Lack of appropriate muscle torque resulted in excessive contributions of the dynamic interaction torque during the fast-accurate reaches. 4. The inability to produce muscle torques that predict, accommodate, and compensate for the dynamic interaction torques appears to be an important cause of the classic kinematic deficits shown by cerebellar subjects during attempted reaching. These kinematic deficits include incoordination of the shoulder and the elbow joints, a curved trajectory, and overshoot. In the fast-accurate condition, cerebellar subjects often made inappropriate muscle torques relative to the dynamic interaction torques. Because of this, interaction torques often determined the pattern of incoordination of the elbow and shoulder that produced the curved trajectory and target overshoot. In the slow-accurate condition, we reason that the cerebellar subjects may use a decomposition strategy so as to simplify the movement and not have to control both joints simultaneously. From these results, we suggest that a major role of the cerebellum is in generating muscle torques at a joint that will predict the interaction torques being generated by other moving joints and compensate for them as they occur.

Background and Purpose: Electrical stimulation has been used to assess skeletal muscle resistance to fatigue. The purpose of this study was to test the hypothesis that 12 weeks of intense endurance exercise training on a bicycle ergometer would reduce the percentage of decline in quadriceps femoris muscle torque during an electrically elicited fatigue test., Subjects and Methods: Eleven nondisabled subjects performed 12 weeks of high-intensity endurance exercise training, and 6 subjects served as controls and did not exercise. Two electrically elicited fatigue tests, one with and one without prior voluntary fatiguing exercise, were administered to each subject before and after the 12-week training period., Results: The percentage of decline in peak torque of the quadriceps femoris muscle over 50 electrically elicited muscle contractions did not change as a result of endurance exercise training, despite significant improvements in maximal oxygen consumption and quadriceps femoris muscle endurance. The recovery of maximal isometric torque immediately after exhausting voluntary exercise followed by electrical stimulation was significantly greater after 12 weeks of intense exercise training., Conclusion and Discussion: The percentage of decline in peak torque during an electrically elicited fatigue test does not detect improvements in quadriceps femoris muscle endurance induced by endurance exercise training. The percentage of initial torque recovered immediately after fatiguing exercise, however, is improved by endurance training. [Sinacore Dr, Jacobson RB, Delitto A. Quadriceps femoris muscle resistance to fatigue using an electrically elicited fatigue test following intense endurance exercise training.

Background and Purpose: The purposes of this study were (1) to describe the characteristics of recovery of peak torque after a 1-minute bout of isokinetic exercise of the quadriceps femoris muscle, (2) to determine the short-term reliability of the recovery of peak torque, and (3) to determine whether the recovery of peak torque more closely associates with maximal endurance exercise capacity than does the decline in peak torque at the end of the fatigue test., Subjects: Thirty-three nondisabled subjects, ranging in age from 23 to 34 years (X = 27, SD = 3.4), participated in the reliability portion (phase 1) of the study. A different group of 21 nondisabled subjects, ranging in age from 21 to 47 years (X = 27.5, SD = 5.2), participated in the correlational portion (phase 2) of the study., Methods: The short-term reliability of percentage of decline in peak torque and recovery of peak torque was assessed in phase 1. Each subject performed two quadriceps femoris muscle fatigue tests (test-retest) on an isokinetic dynamometer. In phase 2, each subject performed a single fatigue test and a test of maximal oxygen uptake (VO2max) to examine the relationships between VO2max and percentage of decline in peak torque at the end of the fatigue test and recovery of peak torque., Results: Intraclass correlation coefficient values at every 30-second interval during recovery were acceptable (ICC = .67-.87), indicating recovery of peak torque is a consistent measure of quadriceps femoris muscle performance. A high negative correlation (r = -.84) was found between the percentage of decline at 30 seconds of recovery and VO2max, but a lower negative correlation (r = -.48) was found between the percentage of decline in torque at the end of the fatigue test and VO2max., Conclusion and Discussion: These results suggest recovery of peak torque is a reliable measure of muscle performance and closely associates with maximal aerobic exercise capacity.

Background and Purpose: The primary purpose of this study was to evaluate the effects of endurance training and detraining on the development of and recovery from fatigue induced by isokinetic exercise. It was our hypothesis that the rate of recovery from fatigue would correlate with maximal oxygen uptake (VO2max). A secondary purpose was to determine whether changes in the development of fatigue and in the time course of recovery that occur with alterations in training status correlate with shifts in the proportions of type IIa and type IIb muscle fibers., Subjects and Methods: Four subjects with no regular endurance exercise training participated in a 12-week program of intense endurance exercise training, and 6 endurance-trained subjects stopped all exercise training for 12 weeks. In addition, 11 subjects performed a single isokinetic fatigue test with recovery and a graded treadmill or bicycle ergometer test to determine VO2max., Results: Maximal oxygen uptake increased 24% (SD = 10%) in response to the exercise training program and decreased 17% (SD = 6%) with detraining. The percentage of type IIa and type IIb muscle fibers changed with endurance training and detraining. The percentage of decline in torque during a 60-second isokinetic exercise test was unaffected by endurance training or detraining; however, there was a significant change in recovery of torque., Conclusion and Discussion: The results demonstrate a positive correlation (r = .75) between the percentage of reduction in torque at 30 seconds of recovery and the change in the proportion of type IIb fibers with both training and detraining. The results also demonstrate a high, negative correlation (r = -.84) between the percentage of reduction in torque at 30 seconds of recovery and VO2max. These results suggest the recovery of muscle torque reflects both the training- and detraining-induced changes in the proportion of type IIa and type IIb muscle fibers and maximal aerobic exercise capacity.

Although thyroid hormone excess results in increased beta-adrenergic receptor density or agonist responses in some cells of experimental animals, the role of these effects in contributing to clinical manifestations of hyperthyroidism in human subjects is unclear. To shed further light on this issue, we characterized the effect of 2 weeks of excess triiodothyronine administration on cardiac and metabolic responses to graded-dose isoproterenol infusion, skeletal muscle beta-adrenergic receptor density, and physiologic determinants of exercise capacity in young healthy subjects. The slope of the heart rate response to isoproterenol was 36% greater (p < 0.05) after triiodothyronine administration. In addition, beta-adrenergic receptor density was increased (p < 0.01) in all types of skeletal muscle fibers. Maximal oxygen uptake during treadmill exercise declined 5% (p < 0.001) after triiodothyronine administration because of a decrease in the arteriovenous oxygen difference (p < 0.05). The plasma lactate response to submaximal exercise was 25% greater (p < 0.01) in the hyperthyroid state. These effects were paralleled by a decrement in skeletal muscle oxidative capacity and a decrease in cross-sectional area of type 2A skeletal myocytes. Thus, thyroid hormone excess enhances cardiac beta-adrenergic sensitivity under in vivo conditions in human subjects. Nevertheless, exercise capacity is diminished in the hyperthyroid state, an effect that may be related to reduced skeletal muscle oxidative capacity and type 2A fiber atrophy.

Background and Purpose: The purpose of this study was to determine the effect of total contact casting (TCC) on dorsiflexion at the talocrural joint (TCJ) and motion (inversion/eversion) at the subtalar joint (STJ)., Subjects: Thirty-seven patients (29 men, 8 women), ranging in age from 32 to 79 years (mean = 54, SD = 11), with diabetes mellitus and a unilateral plantar ulceration participated in the study., Methods: The subjects were measured with a goniometer for dorsiflexion and STJ range of motion (ROM). The ROMs for each subject's casted and noncasted legs were compared before and after treatment with TCC for neuropathic plantar ulcers by use of a 2 x 2 repeated-measures analysis of variance design., Results: Mean time of immobilization in TCC (healing time) was 42 days (SD = 43, range = 8-119). The results indicated (1) ROM was unchanged at the STJ, but dorsiflexion decreased slightly (1 degree) on both the casted and noncasted sides following the last cast removal, and (2) ROM was less on the ulcerated side prior to casting compared with the nonulcerated side., Conclusion and Discussion: We believe the beneficial effects (healing of wounds) outweigh the minimal detrimental effects (decreased dorsiflexion) of treatment with TCC.

A patient with an infarct in the distribution of the right superior cerebellar artery was studied with regard to his ability to make simple movements (visually triggered, self-terminated ballistic wrist movements), and compound movements (reaching to a visual target and precision pinch of a seen object). Movements on the right side of the body alone were affected. Control movements were made by the normal left upper extremity. Wrist movement on the right side was normal in reaction time, direction, peak velocity, and end-point position control as compared to the left. By contrast, both reaching and pinching movements on the right were impaired. Reaching movements showed marked decomposition of the compound elbow-shoulder movement into seriatim simple movements made alternately at elbow and shoulder. Pinching movements were not made, and instead winkling movements (a movement of index alone) were substituted. These results are compared to similar results of controlled inactivation of the cerebellar dentate nucleus in monkeys. We conclude that one function of the cerebellum may be to combine elements in the movement repertoires of downstream movement generators. When that ability is lost, a strategy may be voluntarily adopted of using the preserved simple movements in place of the impaired compound movements.

Management of the cognitively impaired elderly person in the community is presumed to be cost-efficient and the American way. Although this is what should be done, most would agree that paying for the services that make it possible to do so is not currently within the means of the median income of the family ($25,986) or of the female head of household ($15,350) in this country. This paper reviews the changes in the family, current family policies, and practices of our businesses and government and proposes the services that could be used to support both the impaired person and the family in the management of this evolving societal issue. Strategies for development of payment mechanisms for the proposed services are presented.

The purpose of this study was to determine the relationship between direction of lateral lumbar shift (LLS) and 1) the occurrence of symptoms during the side-bending movement test and 2) the location of symptoms in patients with low back pain syndrome (LBS). Twenty-four patients with LBS (17 male, 7 female) with an observable LLS were studied. Side-bending movement tests were performed bilaterally, and the results were recorded as positive if symptoms occurred during the movement. The location of symptoms (right side or left side) was obtained from the patient history. Use of the chi-square statistic revealed a statistically significant relationship between the direction of the LLS and the direction of the positive side-bending movement test. Seventeen tests (71%) were positive to the contralateral side of the LLS, and 5 (21%) were positive to the ipsilateral side. Two tests (8%) were negative in both directions. There was no significant relationship between the side of symptoms and the direction of the LLS. The determination of presence and direction of an LLS is necessary in certain physical therapy management approaches. Pain or restricted side-bending movement has been used to confirm the presence of an LLS. This study confirms the clinical usefulness of the side-bending movement test for determining the presence and direction of an LLS.

Placement of accurate arthroscopic portals is crucial in arthroscopic knee surgery. Unlike the inferolateral portal that is usually used initially in arthroscopic surgery, the utility medial portal allows excellent visualization of both the medial and lateral compartments as well as the patellofemoral articulation and suprapatellar pouch. Other diagnostic advantages include visualization of the anterior horn of the lateral meniscus, access into the posterior compartment of the knee, and visualization of the intercondylar notch. Surgically, this portal is invaluable in lateral meniscal procedures. Specifically, placement of the arthroscope in the utility medial portal allows access to the complete lateral meniscus, including the anterior and posterior horns, for both visualization and instrumentation. This portal is also outstanding for use in patellofemoral surgical procedures. This portal has been used with great success as a standard arthroscopic portal without difficulty, primarily in 550 arthroscopic procedures and secondarily in 240 procedures. This portal is recommended for examination of the knee in all cases except those in which there is a high suspicion of an isolated medial meniscus tear. Also, the portal may be used routinely for surgical visualization and instrumentation due to its flexibility.

The purpose of this study was to determine whether a relationship existed between type of foot deformity and the location of ulcers in patients with diabetes and insensitive feet. Forty-two ulcerated feet were examined in 40 patients. All patients had severely decreased or absent sensation. Foot deformities were classified according to operational definitions as 1) Charcot's foot, 2) a compensated forefoot varus, or 3) an uncompensated forefoot varus or forefoot valgus. The plantar surface of the midfoot and forefoot was divided into three regions. Six of the 7 patients with a Charcot's foot showed ulceration at the midfoot. Nine of 18 patients with a compensated forefoot varus showed ulceration at the second, third, or fourth metatarsal head. Fifteen of 17 patients with an uncompensated forefoot varus or forefoot valgus showed ulceration at the first or fifth metatarsal. A significant relationship was found between foot deformity and location of ulcer. These results support the hypotheses 1) that insensitivity, coupled with increased, repetitive pressure, is a primary cause of plantar ulcers and 2) that certain foot types are associated with characteristic patterns of pressure distribution and callus formation.

Home health is by definition intermittent treatment. The voluntary participation of the patient and family in working toward goal achievement, especially in the absence of the practitioner, greatly affects the effectiveness of the occupational therpist. Improving that participation requires a thoughtful understanding of the value system of the patient and creative, flexible programming. The unique effects that the sociocultural experiences of patients have on the treatment process in home health care are discussed according to a set of facotrs that influence his compliance with care. Research findings and a brief case study shall illustrate some of the factors.

Crosson (1985) proposed a model for language production which integrated cortical with subcortical functions. The implications of this model for schizophrenia are explored. One conclusion is that neural systems, as opposed to a single neural focus, account for schizophrenic symptoms. In this light, data regarding dysfunction in the limbic system, nucleus accumbens, globus pallidus, and prefrontal cortex, which are often seen as contradictory, can be viewed as complementary. Another conclusion is that Crosson's model may have implications specific to schizophrenic thought disorder. Random triggering of semantic segments and inability to maintain contextual referents are discussed in the context of the language production theory.

We investigated swallowing abnormalities in patients with Parkinson's disease, the relationship between these abnormalities and general parkinsonian signs, as well as the response to therapy. Twenty patients and 13 controls were evaluated with clinical rating scales and modified barium swallows before and after oral levodopa (in combination with carbidopa). Fifteen patients, but only 1 control, had abnormal swallows (chi 2 = 11.722, df = 1, p less than 0.001). Abnormalities included disturbances of oral and pharyngeal phases of swallowing. Patients without dysphagia frequently had abnormal swallows, including silent aspiration. Seven patients had improved swallowing after levodopa, whereas 1 worsened. Improvement in general parkinsonian signs was not a reliable indicator of improved swallowing.

Ankle sprains occur as a result of many factors. The initial treatment of all sprains, controlling further damage and edema, is the same. Recovery rates vary depending on the severity of injury and chronicity of the problem. Because there are no established criteria correlating objective measures (for example, torque production, range of motion, swelling) and function, the clinician should not allow the athlete to participate in their respective activity until the ankle feels stable when stressed.

The certification program has undergone an exciting change. The AOTA leadership and AOTA members are to be applauded for making this important step. The AOTCB is still a fledgling organization; nonetheless, it has already made great strides in carrying out its mission. The AOTCB will continue to build on the very excellent foundation AOTA has laid for the certification program. The AOTCB welcomes questions, comments, and suggestions concerning the certification program. To contact AOTCB, write to AOTCB, 1383 Piccard Drive, Rockville, MD 20850-4375 or call (301) 948-9626.

The purpose of this case report is to document the successful healing of a chronic neuropathic plantar ulcer with the molded double-rocker plaster shoe (MDRPS) in a lower extremity that also had stasis changes and poor blood flow. The patient was a 67-year-old woman with insulin-dependent diabetes mellitus, insensitive feet, a right ankle-arm index of 0.48, and an ulcer beneath the right cuneonavicular joint measuring 0.94 cm2 in area and 2 mm deep. Reported onset of the ulcer was 10 months before referral for physical therapy. The MDRPS was chosen as an alternative treatment to conventional below-knee total contact casting (TCC) because of the stasis changes and fragile skin in the patient's lower extremities. The ulcer healed in 39 days after initiating treatment with the MDRPS. We consider the MDRPS the preferred treatment with those patients with neuropathic plantar ulcers who cannot tolerate the below-knee TCC.

California Verbal Learning Test (CVLT) performance was compared for 33 head-injured and 33 neurologically normal adult males. On learning trials, head-injured persons recalled fewer items than controls in general, though the percent of improvement between trials did not differ for these groups. Head-injured patients also demonstrated more intrusions and used semantic groupings less than did normal controls during learning trials. On delayed recall trials, head-injured persons remembered a smaller percentage of items they had learned earlier than did controls. Semantic cues aided recall for head-injured but not normal persons. Head-injured persons were less able to discriminate list from nonlist items during the recognition trial. Results indicated both retrieval and storage (i.e., encoding or retention) deficits for the head-injured group. The CVLT is a useful instrument for defining memory deficits in a head-injured population.

This study compared the treatment of total contact casting (TCC) with traditional dressing treatment (TDT) in the management of diabetic plantar ulcers. Forty patients with diabetes mellitus and a plantar ulcer but with no gross infection, osteomyelitis, or gangrene were randomly assigned to the TCC group (n = 21) or TDT group (n = 19). Age, sex, ratio of insulin-dependent diabetes mellitus to non-insulin-dependent diabetes mellitus, duration of diabetes mellitus, vascular status, size and duration of ulcer, and sensation were not significantly different between groups (P greater than .05). In the experimental group, TCC was applied on the initial visit, and subjects were instructed to limit ambulation to approximately 33% of their usual activity. Subjects in the control group were prescribed dressing changes and accommodative footwear and were instructed to avoid bearing weight on the involved extremity. Ulcers were considered healed if they showed complete skin closure with no drainage. Ulcers were considered not healed if they showed no decrease in size by 6 wk or if infection developed that required hospitalization. In the TCC group, 19 of 21 ulcers healed in 42 +/- 29 days; in the TDT group, 6 of 19 ulcers healed in 65 +/- 29 days. Significantly more ulcers healed (chi 2 = 12.4, P less than .05) and fewer infections developed (chi 2 = 4.1, P less than .05) in the TCC group. We conclude TCC is a successful method of treating diabetic plantar ulcers but requires careful application, close follow-up, and patient compliance with scheduled appointments to minimize complications.