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The white matter of the cerebrum consists spinal cord and contains nuclei for several cerebrospinal fluid in the CNS; and of association buy viagra super active 50 mg with visa, commissural viagra super active 25mg mastercard, and autonomic functions. Basal nuclei are specialized masses of gray reticular activating system in arousing the (a) The neuroglia that surround an axon matter located within the white matter of cerebrum. The diencephalon is a major autonomic outer periosteal layer and an inner 4. The thalamus is an ovoid mass of gray a single layer surrounded by the vascular (a) Sensory (afferent) neurons are matter that functions as a relay center for epidural space. The hypothalamus is an aggregation of surrounding the subarachnoid space, multipolar. The epithalamus contains the pineal smooth muscle, cardiac muscle, gland and the vascular choroid plexus and glands. Nervous Tissue and the © The McGraw−Hill Anatomy, Sixth Edition Coordination Central Nervous System Companies, 2001 398 Unit 5 Integration and Coordination Ventricles and Cerebrospinal Fluid 4. The blood-brain barrier determines which (b) The conus medullaris is the terminal (pp. The lateral (first and second), third, and the extracellular fluid of the brain. Ascending and descending spinal cord continuous with the central canal of the 1. Cerebrospinal fluid is continuously formed and two longitudinal grooves that decussate (cross over) in the spinal by the choroid plexuses from blood plasma partially divide it into right and left cord or in the medulla oblongata of and is returned to the blood at the halves. Beside each Match the following structures of the brain to (d) the vermis. The structure of the brain that is most basic functional units of the nervous system? List the six principal types of neuroglia (c) mesencephalon (c) the medulla oblongata. Why is it called an all-or-none sheaths in the peripheral nervous system are (a) They are located within the response? A collection of neuron cell bodies located (d) They indirectly exert an inhibitory 8. The corpora quadrigemina, red nucleus, major part of the autonomic nervous (b) a nerve. List the nuclei located (a) sensory neurons in the midbrain and state the function (b) somatic motor neurons (c) the mesencephalon. Describe the location and structure of the (d) autonomic motor neurons 12. Describe the formation of the neural crest CT scan, MS, DSR, and CVA stand for? Nervous Tissue and the © The McGraw−Hill Anatomy, Sixth Edition Coordination Central Nervous System Companies, 2001 Chapter 11 Nervous Tissue and the Central Nervous System 399 14. What causes it and how complains of loss of sensation from the specific irritable tissue, such as a tumorous is it controlled? Electrical stimulation of the cerebellum or before a focal seizure, the sufferer these conditions differ? How would damage to these called an aura, that suggests the origin of Critical-Thinking Questions two regions of the brain affect skeletal the electrical burst. If an entire cerebral hemisphere is origin of a seizure that was preceded by of body structures are reported. A flash of brief case study of a patient who has suffered damage to the medulla oblongata, a much light. A seizure occurs when abnormal electrical nose may be detected from a spinal tap legs over the course of several days, which activity overwhelms the brain’s normal performed in the lumbar region. A focal seizure originates from a also loses urinary bladder control and Visit our Online Learning Center at http://www. Peripheral Nervous © The McGraw−Hill Anatomy, Sixth Edition Coordination System Companies, 2001 Peripheral Nervous System 12 Introduction to the Peripheral Nervous System 401 Cranial Nerves 403 Spinal Nerves 413 Nerve Plexuses 415 Developmental Exposition: The Peripheral Nervous System 426 Reflex Arc and Reflexes 427 Clinical Case Study Answer 430 Chapter Summary 432 Review Activities 433 Clinical Case Study Following an auto accident, a 23-year-old male was brought to the emergency room for treat- ment of a fractured right humerus. Although the skin was not broken, there was an obvious de- formity caused by an angulated fracture at the midshaft. While conducting an examination on the patient’s injured arm, the attending orthopedist noticed that the patient was unable to ex- tend the joints of his wrist and hand. What structure could be injured in the brachial region of this patient that would ac- count for his inability to extend his hand?

Phase I questions: Do patients with the target disorder have different test results from normal individuals? Question 1 often can be answered with a minimum of effort discount 25mg viagra super active with amex, time buy viagra super active 50mg line, and expense, and its architecture is displayed in Table 2. For example, a group of investigators at a British university hospital measured BNP precursor in convenience samples of “normal controls” and in patients who had various combinations of hypertension, ventricular hypertrophy, and LVD. It was not surprising, therefore, that they concluded that BNP was “a useful diagnostic aid for LVD”. Note, however, that the direction of interpretation here is from known diagnosis back to diagnostic test. Answers to Phase I questions cannot be applied directly to patients because they are presented as overall (usually average) test results. They are not analysed in terms of the diagnostic test’s sensitivity, specificity, or likelihood ratios. Moreover, Phase I studies are typically conducted among patients known to have the disease and people known not to have the disease (rather than among patients who are suspected of having, but not known to have, the disease). As a result, this phase of diagnostic test evaluation cannot be translated into diagnostic action. First, such studies add to our biologic insights about the mechanisms of disease, and may serve later research into therapy as well as diagnosis. Second, such studies are quick and relatively cheap, and a negative answer to their question removes the need to ask the tougher, more time-consuming, and costlier questions of Phases II–IV. Patients known to have the target disorder (LVD) Normal controls Average diagnostic test (BNP 493. Phase II questions: Are patients with certain test results more likely to have the target disorder than patients with other test results? Following a positive answer to a Phase I question, it is logical to ask a Phase II question, this time changing the direction of interpretation so that it runs from diagnostic test result forward to diagnosis. Although the Phase II questions often can be asked in the same dataset that generated the Phase I answer, the architecture of asking and answering them differs. For example, a second group of investigators at a Belgian university hospital measured BNP in “normal subjects” and 3 groups of patients with coronary artery disease and varying degrees of LVD. Whether it is used to “rule out” LVD on the basis of its high sensitivity (SnNout)8 or to “rule in” LVD with its high specificity (SpPin),9 BNP looks useful, so it is no wonder that the authors concluded: “BNP concentrations are good indicators of the severity and prognosis of Table 2. Patients known to have the target disorder (LVD) Normal controls High BNP 39 2 Normal BNP 1 25 Test characteristics and their 95% confidence intervals Lower Upper Sensitivity 98% 87% 100% Specificity 92% 77% 98% Positive predictive value 95% 84% 99% Negative predictive value 96% 81% 100% Likelihood ratio for an abnormal 3. It compares test results between groups of patients who already have established diag- noses (rather than those who are merely suspected of the target disorder), and contrasts extreme groups of normals and those with severe disease. Thus, it tells us whether the test shows diagnostic promise under ideal conditions. Promising diagnostic test Promising treatment Feature Explanatory Pragmatic Explanatory Pragmatic (Phase II study) (Phase III study) Question Can this test Does this test Efficacy: Can this Effectiveness: discriminate discriminate in treatment work Does this under ideal routine practice? Selection of Preselected Consecutive Highly compliant, All comers, patients groups of normal patients in whom high-risk, high- regardless of individuals and it is clinically response compliance, risk of those who sensible to patients or responsiveness clearly have the suspect the target disorder target disorder Application Carried out by Carried out by Administered by Administered by of manoeuvre expert clinician usual clinician or experts with usual clinicians or operator on operator on great attention to under usual best equipment usual equipment compliance circumstances Definition of Same reference Often different May focus on “Hard” clinical outcomes standard for standards for pathophysiology, events or death those with and patients with and surrogate (often all-cause without the without the target outcomes, or mortality) target disorder disorder; may cause-specific invoke good mortality treatment-free prognosis as proof of absence of target disorder Exclusion Often exclude Include all May exclude Includes all of patients patients with lost patients, events before or events after or events results and regardless of lost after treatment is randomisation indeterminate results or applied diagnoses indeterminate diagnoses Results Usually not Ideally yes confirmed in a second, independent (“test”) sample of patients Incorporation Usually not Ideally yes Sometimes Ideal into systematic review 27 THE EVIDENCE BASE OF CLINICAL DIAGNOSIS and Phase III studies is by analogy with randomised clinical trials, which range from addressing explanatory (efficacy) issues of therapy (can the new treatment work under ideal circumstances? No attempt is made to validate these initial (“training set”) results (especially the cut-off used to set the upper limit of normal BNP) in a second, independent “test” set of ducks and yaks. On the other hand, and as with the Phase I study, this relatively easy Phase II investigation tells us whether the promising diagnostic test is worth further, costlier evaluation; as we have said elsewhere,10 if the test cannot tell the difference between a duck and a yak it is worthless in diagnosing either one. As long as the writers and readers of a Phase II explanatory study report make no pragmatic claims about its usefulness in routine clinical practice, no harm is done. Furthermore, criticisms of Phase II explanatory studies for their failure to satisfy the methodological standards employed in Phase III pragmatic studies do not make sense. Phase III questions: Among patients in whom it is clinically sensible to suspect the target disorder, does the level of the test result distinguish those with and without the target disorder? Given its promise in Phase I and II studies, it is understandable that BNP would be tested in the much costlier and more time-consuming Phase III study, in order to determine whether it was really useful among patients in whom it is clinically sensible to suspect LVD. As we were writing this chapter, an Oxfordshire group of clinical investigators reported that they did just that by inviting area general practitioners “to refer patients with suspected heart failure to our clinic”. About one third of the patients referred by their general practitioners had LVD on echocardiography. These investigators documented that BNP measurements did not look nearly as promising when tested in a Phase III study in the pragmatic real-world setting of routine clinical practice, and concluded that “introducing routine measurement [of BNP] would be unlikely to improve the diagnosis of symptomatic [LVD] in the 28 ARCHITECTURE OF DIAGNOSTIC RESEARCH Table 2.

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IV C olor tlas and Textbook of m an natom y in 3 volumes Volume 1: Locomotor System by Werner Platzer Volume 2: Internal Organs by Helmut Leonhardt Kahle trusted 100 mg viagra super active, Color Atlas of Human Anatomy cheap 25 mg viagra super active with mastercard, Vol. Professor Emeritus Institute of Neurology University of Frankfurt/Main Frankfurt/Main, Germany Michael Frotscher, M. Professor Anatomical Institute I University of Freiburg Freiburg, Germany 5th revised edition 179 color plates Illustrations by Gerhard Spitzer Thieme Stuttgart · New York Kahle, Color Atlas of Human Anatomy, Vol. VI Library of Congress Cataloging-in-Publication Some of the product names, patents and regis- Data tered designs referred to in this book are in fact is available from the publischer registered trademarks or proprietary names even though specific reference to this fact is not always made in the text. Therefore, the appear- 1st German edition 1976 ance of a name without designation as pro- 2nd German edition 1978 prietary is not to be construed as a representa- 3rd German edition 1979 tion by the publisher that it is in the public 4th German edition 1982 domain. Any use, exploita- 7th German edition 2001 tion or commercialization outside the narrow limits set by copyright legislation, without the 1st English edition 1978 publisher’s consent, is illegal and liable to pros- 2nd English edition 1984 ecution. This applies in particular to photostat 3rd English edition 1986 reproduction, copying, mimeographing or du- 4th English edition 1993 plicationofanykind,translating,preparationof 1st Dutch edition 1978 microfilms, and electronic data processing and 2nd Dutch edition 1981 storage. Thieme New York, 333 Seventh Avenue, Title of the German edition: Taschenatlas der New York, N. VII Preface to the 5th Edition of Volume 3 Thenumberofstudentsaswellascolleaguesinthefieldwhohavelearnedneuroanatomyac- cording to volume 3 of the color atlas has been steadily increasing. What should one do after taking on the job of carrying on with this text book, other than leaving as much as possible as it is? However, the rapid growth in our knowledge of neuroscience does not permit this. In just the last few years many new dis- coveries have been made that have shaped the way we view the structure and function of the nervous system. Hence, new sections have been added; for example, a section on modern methods of neuroanatomy, a section on neurotransmitter receptors, and an introduction to modern imaging procedures frequently used in the hospital. The Clinical Notes have been preserved and supplemented in ordertoprovide alink totheclinical setting. Thepurposewas toprovidethestudent not only withasolidknowledgeofneuroanatomybutalsowithanimportantfoundationofinterdisci- plinary neurocience. Furthermore, the student is introduced to the clinical aspects of those fields in which neuroanatomy plays an important role. I sincerely hope that the use of mod- ernmulticolorprintinghasmadeitpossibletopresentthingsmoreclearlyandinamoreuni- form way. Thus, sensory pathways are now always presented in blue, motor pathways in red, paraympathetic fibers in green, and sympathetic fibers in yellow. I wish to thank first and foremost Professor Gerhard Spitzer and Stephan Spitzer who took chargeofthegrapicdesignofthecoloratlasandprovidedtheirenormousexperiencealsofor the present edition. I thank Professor Jürgen Hennig and his co-workers at the radiodiagnos- tic division of the Medical School of the Albert Ludwig University of Freiburg, Germany, for their help with the new section on imaging procedures. André Diesel who took great care in screening the text for lack of clarity and who contributed significantly to the color scheme of the figures, al well as my secretary, Mrs. Jürgen Lüthje at Thieme Verlag, Stuttgart, for their generous advice and their patience. The Nervous Introduction System The Nervous System—An Overall View 2 Development and Structure of the Brain 6 Kahle, Color Atlas of Human Anatomy, Vol. The neural tube finally differentiates into the spinal cord (D7) and Overall View the brain (D8). Development and Subdivision (A–D) Functional Circuits (E, F) The nervous system serves information The nervous system, the remaining or- processing. In the most primitive forms of ganism, and the environment are function- organization (A), this function is assumed ally linked with each other. The simplest the CNS via motor (efferent) nerves (E13) response to environmental stimuli is to the muscles (E14). This afferent tract does not transmit ditional cell is interposed between the environmental stimuli but stimuli from sensory cell and the muscle cell – the nerve within the body (proprioceptive stimuli).

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Maximum and minimum urine osmolalities in humans are about 1 purchase 25 mg viagra super active amex,200 V receptor Aquaporin-2 Vesicle with 2 to 1 cheap viagra super active 25 mg with mastercard,400 mOsm/kg H2O and 30 to 40 mOsm/kg H2O. We aquaporin-2 next consider the mechanisms involved in producing os- motically concentrated or dilute urine. AVP PKA G s cAMP The Ability to Concentrate Urine Osmotically Is an Important Adaptation to Life on Land Adenylyl ATP cyclase When the kidneys form osmotically concentrated urine, Nucleus they save water for the body. The kidneys have the task of ( gene transcription) getting rid of excess solutes (e. Suppose, for ex- aquaporin-2 synthesis ample, we excrete 600 mOsm of solutes per day. If we were only capable of excreting urine that is isosmotic to plasma (approximately 300 mOsm/kg H2O), we would need to ex- FIGURE 23. The second that is 4 times more concentrated than plasma (1,200 messenger for AVP is cyclic AMP (cAMP). CHAPTER 23 Kidney Function 397 2 genes and produces an increase in the total number of recta help maintain the gradient in the medulla. Multipliers, and the Vasa Recta Are Countercurrent multiplication is the process in which a Countercurrent Exchangers small gradient established at any level of the loop of Henle is It has been known for longer than 50 years that there is a increased (multiplied) into a much larger gradient along the gradient of osmolality in the kidney medulla, with the high- axis of the loop. The osmotic gradient established at any level est osmolality present at the tips of the renal papillae. The single effect involves move- gradient is explained by the countercurrent hypothesis. The term countercurrent indicates a flow of fluid in entering the next, deeper level of the loop is now more con- opposite directions in adjacent structures (Fig. The centrated, repetition of the same process leads to an axial gra- loops of Henle are countercurrent multipliers. The extent to which coun- toward the tip of the papilla along the descending limb of tercurrent multiplication can establish a large gradient along the loop and toward the cortex along the ascending limb of the axis of the loop depends on several factors, including the the loop. The loops of Henle set up the osmotic gradient in magnitude of the single effect, the rate of fluid flow, and the the medulla. Establishing a gradient requires work; the en- length of the loop of Henle. The larger the single effect, the ergy source is metabolism, which powers the active trans- larger the axial gradient. Impaired solute removal, as from the inhibition of active transport by thick ascending limb cells, port of Na out of the thick ascending limb. If flow rate through the loop rections along juxtaposed descending (arterial) and ascend- is too high, not enough time is allowed for establishing a sig- ing (venous) vasa recta, and solutes and water are exchanged nificant single effect, and consequently, the axial gradient is passively between these capillary blood vessels. Finally, if the loops are long, there is more opportu- nity for multiplication and a larger axial gradient can be es- tablished. Countercurrent exchange is a common process in the Vasa Loop of Collecting vascular system. In many vascular beds, arterial and venous recta Henle duct vessels lie close to each other, and exchanges of heat or ma- terials can occur between these vessels. For example, be- cause of the countercurrent exchange of heat between blood flowing toward and away from its feet, a penguin can stand on ice and yet maintain a warm body (core) temper- Outer ature. Countercurrent exchange between descending and medulla ascending vasa recta in the kidney reduces dissipation of the solute gradient in the medulla. The descending vasa recta tend to give up water to the more concentrated inter- stitial fluid; this water is taken up by the ascending vasa recta, which come from more concentrated regions of the medulla. In effect, much of the water in the blood short-cir- Inner cuits across the tops of the vasa recta and does not flow medulla deep into the medulla, where it would tend to dilute the ac- cumulated solute. The ascending vasa recta tend to give up solute as the blood moves toward the cortex. Solute enters the descending vasa recta and, therefore, tends to be trapped in the medulla. Countercurrent exchange is a purely passive process; it helps maintain a gradient estab- lished by some other means.

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