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Because of such differences erectile dysfunction doctors fort lauderdale purchase viagra soft online now, the teachers viewed the African-American children as having deficits in their language and literacy abilities erectile dysfunction medications in india order genuine viagra soft, for example impotence quotes cheap viagra soft 100 mg fast delivery, and were not able to best erectile dysfunction doctors nyc order discount viagra soft on line engage them in effective literacy instruction. Valdes (1996) reported similar findings for immigrant Mexican children and their teachers. In their homes, the children were taught to respect others by not engaging in displays of knowledge, whereas the teachers expected the children to demonstrate what they knew. This discrepancy between home and school expectations often worked to the children’s disadvantage because the teachers misperceived them as being less capable and placed them in lower reading groups. Although the researchers took into ac- count one or two sociocultural variables, such as ethnicity/race or socioeco- nomic status, they sometimes ignored other sociocultural variables, such as di- alect or second-language status, that might have influenced their assessment of the students’ performance or the interpretation of the data. For example, in a comparison of grades 1 and 2 European-American, African-American, and Latino students, Juel et al. However, they did not take into account the variation in students’ oral pronunciation of standard English that was due to dialect or second-language status. Other researchers have focused on the reading performance and instruction of dialect speakers. They con- cluded that teachers’ negative reactions to students’ use of dialect adversely af- fected the type of instruction that the students received. Teachers’ negative reactions were determined to have more of an effect on students’ reading com- prehension development than the students’ use of dialect features. They also receive ac- cess to a different set of reading activities because they are disproportionately placed in the lowest reading groups or lowest tracks where isolated-skill in- struction dominates. These examples clearly show that membership in different groups defined, in part, by factors that may appreciably affect proficiency in reading and reading comprehension per se—factors such as social class, ethnicity, and native lan- guage—can, indeed, have a significant effect on early reading development. Thus, research evaluating the relative contribution of such factors to early read- ing development as well as their interaction with other factors contributing to variability in such development (capacity differences) is an important area of inquiry in need of further study. Social cultures offer a wealth of posi- tions that readers can assume, and each position requires certain attributes. For example, to assume the position of “good reader,” an individual must possess certain abilities that are verifiable and recognizable to others who occupy that same position (McDermott & Varenne, 1995). But how students end up inhabit- ing some positions and not others in their classroom environments is some- times a matter of their being placed into those positions because of differential instruction, teacher attitudes, and certain expectations. Researchers working within a sociocultural framework recognize the possibility that youth who are routinely described in school as resistant readers may actually be readers who use alternative literacy practices, such as predicting the next episode in the Japanese anime Dragonball-Z (Alvermann, 2001) and using football statistics to structure an essay about the economic connections between athletes and commercial enterprises. A productive research focus would highlight situa- tional contexts that promote reading comprehension both in and out of school for all adolescents. Researchers who investigated older students’ reading comprehension from a sociocultural perspective focused primarily on cultural schemata. They reported that when students read culturally familiar material, they read it faster, recalled it more accurately, and made fewer comprehension er- rors. However, the researchers did not develop profiles of expert and novice readers from various backgrounds. As a result, no information is available on how students from these backgrounds resolved dialect or language problems or varied in their strategy use or motivation. An Expanded Review of the Research on Variability in Reading Comprehension 79 Group Differences We include group differences as a focus of our interest, even though they are to some extent coterminous with sociocultural sources of variability, because a fairly large body of work has considered group membership. We are not concluding that membership in any of these groups can itself cause particular comprehension outcomes; rather, we are suggesting that documenting the differences may generate hy- potheses about causal connections. In research conducted with young children, Sonnenschein and colleagues (Sonnenschein, Baker, Serpell, Scher, Truitt, & Munsterman, 1997) found that children from lower-income brackets had fewer opportunities to interact with print and play with words than did children from higher-income brackets. Similarly, Whitehurst and Lonigan (1998) reported that children from low-income homes had less experience with books, writing, rhymes, and other literacy-promoting activities than did children from higher- income homes. In contrast, children from higher-income homes tended to en- ter kindergarten with more of such experience, as evidenced in greater alphabetic knowledge, greater ability to generate invented spellings, greater knowledge of print concepts, and so forth. Thus, in general, children from low- income families are less well prepared to engage in formal literacy learning than are those from higher-income families. However, as Goldenberg (2001) points out: “Family socioeconomic effects on achievement are in fact quite modest; and. Another example of a group membership factor that significantly affects early literacy development is second-language learning. Tabors and Snow (2001) re- cently reviewed research on language and literacy development in second- language learners from birth to age 8. They generally concluded that second- language learning differentially affects literacy development depending on such factors as the age at which second-language learning is initiated, the language in which exposure to print and early literacy instruction is initiated, the child’s degree of proficiency in a first or second language, the child’s proficiency in the language in which print exposure and literacy instruction begins, and the de- gree of support for first- and second-language learning and literacy develop- ment in both the home and school environments (see also Snow et al. Similarly, disruption of first-language learning by virtue of total immersion in second- language learning may impede language and literacy development in both. Thus, variability in both language and literacy development is greatly affected by the second-language learner’s home and school environments. Two indicators of the reading perfor- mance and academic engagement of older students (grades 4–12) in U. In 1992, 1994, and 1998, high percentages of African-American, Latino, and Native-American students scored below the basic level, or the lowest achievement level, for grades 4, 8, and 12 (Campbell, Hombo, & Mazzeo, 2000). According to the National Center for Education Statistics, dropout rates for African-American, Latino, and Native-American students are consider- ably higher than those of European-American students. Clearly, if we want to improve the literacy performance of all students, we must pay more attention to the literacy instruction and performance of those groups of students who have historically been poorly served by U. More research has focused on the reading processes of older English language learners (grades 3–7) than on younger children (Garcia, 2000). English language learners, when compared with monolingual English speakers, typically have less background knowledge relevant to topics in English texts or tests, know less English vocabulary, and have some difficulty with questions that rely on back- ground knowledge. Researchers who explored how English language learners were making sense of reading in both of their languages re- ported that it was important to differentiate students who were successful English readers from those who were less successful. The successful English readers had a unitary view of reading and used strategies and knowledge that they had acquired in one language to An Expanded Review of the Research on Variability in Reading Comprehension 81 approach reading in the other language. They also used bilingual strategies, such as cognates, paraphrased translating, code-mixing, and code-switching. The less-successful English readers did not use cross-linguistic transfer strate- gies and thought that they had to keep their two languages separate or they would become confused. English language learners, regardless of the program in which they were en- rolled, tended to receive passive, teacher-directed instruction of the sort that does not promote higher-order thinking or language development (Padron, 1994; Ramirez, Yuen, & Ramey, 1991). Metacognitive and cognitive strategy in- struction, such as reciprocal teaching and question-answer relationships, has shown promise with both English language learners and monolingual English speakers (see. We reiterate that when discussing group differences associated with race, second-language learning, and similar factors, research that emphasizes literacy processes at the level of the individual is not very illuminating unless we situate the individual’s experience within the larger sociocultural and historical context (Buenning & Tollefson, 1987). Yet, the trend within literacy research has been to focus on the structural and formal properties of literacy, often seeing it as a technical problem that can be investigated without taking into account power relations and social practices (Wiley, 1996). When ethnic/racial and linguistic minorities are included in large-scale research, they often are part of a random sample, and specific information related to their actual literacy performance and improvement is not included in the data interpretation (Garcia et al. At other times, projects have excluded these populations (Willis & Harris, 2000), erroneously generalizing to them the findings based on the experiences and in- struction of European-American, middle-class, monolingual students. Given the discrepancy in literacy performance between the default monolingual European-American reader and readers from other ethnic/racial and linguistic groups, research efforts that specifically examine the literacy processes, per- formance, and engagement of students from diverse ethnic/racial and linguistic groups, and that take into account the larger sociocultural and historical con- texts, are warranted. Inter-Individual Differences Describing and attempting to explain inter-individual differences in reading outcomes have been by far the most common undertakings of reading re- searchers. Indeed, many of the advances in our understanding of early reading development have emerged from studies that took an individual differences perspective. A systematic analysis of individual differences in the capabilities 82 Reading for Understanding that relate to comprehension is a potential source of considerable insight about the process of comprehension. Some of this variability, no doubt, reflects the procedures used to assess reading comprehension. However, variability in reader characteristics may also partially account for these differences. Thus, the differential development of a variety of capabilities and dispositions supporting reading comprehension may lead to patterns of relative strengths and weak- nesses that are directly related to variations in reading comprehension abilities. Moreover, we have reason to believe that the relative contributions that differ- ent learner characteristics make to variability in reading comprehension ability change significantly during the course of reading development.

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In animal reproduction studies what do erectile dysfunction pills look like purchase viagra soft 100mg without a prescription, oral administration of riociguat to erectile dysfunction drugs and melanoma 100mg viagra soft overnight delivery pregnant rats during organogenesis was teratogenic and embryotoxic at exposures approximately 8 times and 2 times erectile dysfunction causes uk purchase line viagra soft, respectively erectile dysfunction due to diabetes icd 9 generic viagra soft 100mg on-line, the human exposure. All pregnancies have a background risk of birth defect, loss, or other adverse outcomes. Data Animal Data In rats administered riociguat orally (1, 5, and 25 mg/kg/day) throughout organogenesis, an increased rate of cardiac ventricular-septal defect was observed at the highest dose tested. Post-implantation loss was statistically significantly increased from the mid-dose of 5 mg/kg/day. Plasma exposure at the lowest dose in which no adverse effects were observed is approximately 0. Advise patients to contact their healthcare provider if they become pregnant or suspect they may be pregnant. Counsel patients on the risk to the fetus [see Boxed Warning, Dosage and Administration (2. Contraception Females Female patients of reproductive potential must use acceptable methods of contraception during treatment with Adempas and for 1 month after treatment with Adempas. If a partner’s vasectomy is the chosen method of contraception, a hormone or barrier method must be used along with this method. Counsel patients on pregnancy planning and prevention, including emergency contraception, or designate counseling by another healthcare provider trained in contraceptive counseling [see Boxed Warning]. No overall differences in safety or effectiveness were observed between these subjects and younger subjects, and other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. Elderly patients showed a higher exposure to Adempas [see Clinical Pharmacology (12. Based on extensive plasma protein binding, riociguat is not expected to be dialyzable. The inactive ingredients are cellulose microcrystalline, crospovidone, hypromellose 5cP, lactose monohydrate, magnesium stearate, sodium laurylsulfate, hydroxypropylcellulose, hypromellose 3cP, propylene glycol, and titanium dioxide. Right heart catheterization was performed at the beginning and the end of the study period in 233 patients. Improvements in other hemodynamic parameters (not pre-specified as endpoints) are displayed in Table 2 below. Right heart catheterization was performed at the beginning and the end of the study period in 339 patients. Improvement in other relevant hemodynamic parameters (not pre-specified as endpoints) for the individual dose titration group versus placebo are displayed in Table 3. Acetylsalicylic Acid: Concomitant use of riociguat and aspirin did not affect bleeding time or platelet aggregation. Absorption and distribution the absolute bioavailability of riociguat is about 94%. Plasma protein binding in humans is approximately 95%, with serum albumin and fi1–acidic glycoprotein being the main binding components. Following oral administration of radiolabeled riociguat in healthy individuals, about 40 and 53% of the total radioactivity was recovered in urine and feces, respectively. There appears to be considerable variability in the proportion of metabolites and unchanged riociguat excreted, but metabolites were the major components of the dose excreted in most individuals. The terminal elimination half-life is about 12 hours in patients and 7 hours in healthy subjects. Specific Populations: the effect of intrinsic factors on riociguat and M1 are shown below in Figure 1. There are no clinically relevant effects of age, sex, weight, or race/ethnicity on the pharmacokinetics of riociguat or M1. Effects of Riociguat on other Drugs: Riociguat did not affect the pharmacokinetics of midazolam, warfarin, or sildenafil [see Contraindications (4. In mice, oral administration of riociguat (up to 25 mg/kg/day in males and 32 mg/kg/day in females) for up to two years did not demonstrate evidence of carcinogenesis. In rats, oral administration of riociguat (up to 20 mg/kg/day) for up to two years did not demonstrate evidence of carcinogenesis. Impairment of fertility: In rats, no effects on male or female fertility were observed. In male rats, oral administration of riociguat (up to 30 mg/kg/day) prior to and throughout the mating period had no effect on fertility. The no-effect dose for adverse effects is 37 times the human exposure when based on body surface area. In female rats, oral administration of riociguat (up to 30 mg/kg/day) prior to and during mating and continuing to gestation Day 7 had no effect on fertility. The dose of riociguat was titrated every 2 weeks based on the patient’s systolic blood pressure and signs or symptoms of hypotension. The imputation for missing values included last observed value, not including follow-up for patients who completed the study or withdrew. For deaths or clinical worsening without a termination visit or a measurement at that visit, the imputed worst value (zero) was used. Overall this figure shows that patients treated with Adempas benefit compared to those treated with placebo. The dose of Adempas was up-titrated every 2 weeks based on the patient’s systolic blood pressure and signs or symptoms of hypotension. Oral anticoagulants, diuretics, digitalis, calcium channel blockers, and oxygen were allowed. In case of death or clinical worsening without a termination visit or a measurement at that termination visit, the imputed worst value (zero) was used. Adempas-treated patients experienced a significant delay in time to clinical worsening versus placebo-treated patients (p=0. Significantly fewer events of clinical worsening up to week 12 (last visit) were observed in patients treated with Adempas (1. Embryo-Fetal Toxicity Instruct patients on the risk of fetal harm when Adempas is used during pregnancy [see Warnings and Precautions (5. Instruct females of reproductive potential to use effective contraception and to contact her healthcare provider immediately if they suspect they may be pregnant. Inform female patients (and their guardians, if applicable) of the following important requirements: fi All female patients must sign an enrollment form. Instruct patients to report all current medications and new medications to their physician. Advise patients to be aware of how they react to Adempas before driving or operating machinery, and if needed, consult their physician. This Medication Guide does not take the place of talking to your doctor about your medical condition or your treatment. Your doctor will decide when to do the tests, and order the tests for you depending on your menstrual cycle. See the chart below for Acceptable Birth Control Options during treatment with Adempas. Talk to your doctor or pharmacist right away if you have unprotected sex or if you think your birth control has failed. If you are the parent or caregiver of a female child who started taking Adempas before reaching puberty, you should check your child regularly to see if she is developing signs of puberty. Tell your doctor right away if you notice that she is developing breast buds or any pubic hair. Adempas can improve your ability to exercise and can help to improve some of your symptoms. Adempas can improve your ability to exercise, improve some of your symptoms, and help slow down the worsening of your physical condition. Do not take Adempas if: fi you are pregnant, plan to become pregnant, or become pregnant during treatment with Adempas. Ask your doctor or pharmacist if you are not sure if you take any of the medicines listed above. It is important to tell your doctor if you have any symptoms of low blood pressure during this time, such as dizziness, lightheadedness, or fainting. Do not drive, operate machinery, or do other activities that require mental alertness or coordination until you know how Adempas affects you. Talk with your doctor if you are concerned about when it is safe for you to do these activities. Tell your doctor if you stop smoking or start smoking during treatment with Adempas, because your dose of Adempas may need to be changed. This may cause symptoms of low blood pressure, such as lightheadedness, chest pain, and dizziness especially in people who are dehydrated, or have a severe blockage of blood flow out of the heart, or have certain other medical problems.

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Furthermore erectile dysfunction young discount viagra soft 50 mg without a prescription, there are no other signs of organic disease of the corticospinal system impotence clinic buy discount viagra soft on-line. In lesions of the extrapyramidal system impotence law chennai generic 50 mg viagra soft with amex, there are no consistent reflex changes (Table 38 impotence bike riding purchase viagra soft 50mg overnight delivery. The activity of the response depends on the level of muscle tone and the amount of rigidity that is present. Usually, the reflexes are slightly exaggerated, owing to increased muscle tone, but this is not a consistent finding. The increased swinging may result from hypotonia of the extensor and flexorPthomegroup muscles and a lack of the restraining influence they normally exert on each other. The pendular response may also be observed in chorea, but there is more frequently a “hung” reflex: If the patellar tendon is tapped while the foot is hanging free, the knee may be held in extension for a few seconds before relaxing because of prolonged contraction of the quadriceps. In chorea, the response may not be obtained until the stimulus has been applied a number of times. Inverted and Perverted Reflexes Occasionally, percussion of a tendon produces unexpected results. In the presence of hyperreflexia, there may be spread to other muscles, as in the crossed adductor response. With an inverted triceps or patellar reflex, there is elbow or knee flexion instead of extension. Under these circumstances, the segmental reflex is absent, but there is an underlying hyperreflexia lowering the threshold for activation of the antagonist muscle, perhaps because of transmitted vibration. With the triceps jerk, care must be taken not to strike the arm too distally; a blow delivered over the olecranon may cause the elbow to flex because of the biomechanics and force vectors involved, simulating an inverted reflex. An inverted brachioradialis (often referred to as an inverted radial periosteal) reflex does not result in true inversion. When the brachioradialis reflex is present, this finger flexion is simply referred to as spread; when the brachioradialis reflex is absent and the only response is finger flexion, the reflex is commonly said to be inverted. An investigation into mechanisms of reflex reinforcement by the Jendrassik manoeuvre. Hyperactive pectoralis reflex as an indicator of upper cervical spinal cord compression. Pthomegroup C H A P T E R 39 the Superficial (Cutaneous) Reflexes Superficial reflexes are responses to stimulation of either the skin or mucous membrane. Cutaneous reflexes are elicited by a superficial skin stimulus, such as a light touch or scratch. The response occurs in the same general area where the stimulus is applied (local sign). Too painful a stimulus may call forth a defensive reaction rather than the desired reflex. Superficial reflexes are polysynaptic, in contrast to the stretch reflexes, which are monosynaptic. The superficial reflexes respond more slowly to the stimulus than do the stretch reflexes; their latency is longer, they fatigue more easily, and they are not as consistently present as tendon reflexes. The primary utility of superficial reflexes is that they are abolished by pyramidal tract lesions, which characteristically produce the combination of increased deep tendon reflexes and decreased or absent superficial reflexes. Unilateral absence of the superficial abdominal reflexes may be an early and sensitive indicator of a corticospinal tract lesion. Many of the superficial reflexes are arcane, of minor clinical significance, and primarily of historical interest. The response is minimal or absent in normal individuals beyond the first few months of life. When exaggerated, this response is referred to as a grasp reflex; it is discussed in more detail in Chapter 40. The Scapular or Interscapular Reflex Scratching the skin over the scapula or in the interscapular space causes contraction of the scapular muscles with retraction and sometimes elevation of the scapula; there may be associated adduction and external rotation of the arm. The reflex is related to the deep scapulohumeral reflex (see Chapter 38), and the innervation is similar. The response can be divided into the upper abdominal and lower abdominal reflexes. The anterior abdominal wall can be divided into four quadrants by vertical and horizontal lines through the umbilicus. Light stroking or scratching in each quadrant elicits the response, pulling the umbilicus in the direction of the stimulus. The stimulus may bePthomegroup directed toward, away, or parallel to the umbilicus; stimuli directed toward the umbilicus seem more effective. The response is mediated in the upper quadrants (supraumbilical reflexes) by the intercostal nerves (T7-T10) and in the lower quadrants (infraumbilical or suprapubic reflexes) by the intercostal, iliohypogastric, and ilioinguinal nerves (T10 to upper lumbar segments). In Bechterew’s hypogastric reflex, stroking the skin on the inner surface of the thigh causes contraction of the homolateral lower abdominal muscles. The responses are typically brisk and active in young individuals with good anterior abdominal tone. They may be sluggish or absent in normal individuals with lax abdominal tone, in those who are obese, or in women who have borne children. The epigastric reflex is similar, but elicited by a stimulus moving from the xiphoid toward the umbilicus; there is usually no retraction or movement of the umbilicus. The superficial abdominal reflexes may be difficult to obtain or evaluate in ticklish individuals. They may be absent in acute abdominal disorders (Rosenbach’s sign) and with abdominal or bladder distension. They may be absent on the side of an incision from abdominal surgery or posterolateral thoracotomy. The latency is longer and the responses slower in children and the elderly than in young adults. In a study of 65 adolescents and young adults, 14% of the subjects had asymmetric abdominal reflexes, in 15% responses were absent in all quadrants, and 11% had no reflex in at least one quadrant; no subjects had reflexes present on one side and absent on the other. Dissociation of the abdominal reflexes, with absent superficial and exaggerated deep reflexes, suggests a corticospinal tract lesion. If the superficial abdominal reflexes are physiologically diminished or absent, the lower quadrant reflexes are usually affected first. In unilateral abdominal paralysis, there may be inversion of the reflex, with deviation of the umbilicus to the opposite side. Absence of superficial abdominal reflexes in patients with scoliosis has been suggested as an indicator of underlying syringomyelia. An abdominal reflex can be elicited electrophysiologically; its characteristics resemble the blink reflex. The response consists of a contraction of the cremasteric muscle with a quick elevation of the homolateral testicle. The cremasteric reflex must not be confused with the scrotal, or dartos, reflex, which produces a slow, writhing, vermicular contraction of the scrotal skin on stroking the perineum or thigh or applying a cold object to the scrotum. The cremasteric reflex may be absent in elderly males, in individuals who have a hydrocele or varicocele, in those with torsion of the testicle, and in those who have had orchitis or epididymitis. The Gluteal Reflex A contraction of the gluteal muscles may follow stroking the skin over the buttocks. The gluteus maximus is innervated by the inferior gluteal nerve (L4–S2), and the skin of this area is innervated by the cutaneous branches of the posterior rami of the lumbar and sacral nerves. The Plantar Reflex Stroking the plantar surface of the foot from the heel forward is normally followed by plantar flexion of the foot and toes (Figure 39. There is individual variation in the response and some variability dependent upon the site of maximal stimulation. The pathologic variation of the plantar reflex is the Babinski sign (see Chapter 40). The normal plantar response may be difficult to obtain in individuals with plantar callosities. In ticklish patients, there may be voluntary withdrawal with flexion of the hip and knee, but in every normal individual, there is a certain amount of plantar flexion of the toes on stimulation of the sole of the foot. A tonic plantar reflex with slow, prolonged contraction has been described as a sign of frontal lobe and extrapy-ramidal disease. The Superficial Anal Reflex the cutaneous anal reflex (anal wink) consists of contraction of the external sphincter in response to stroking or pricking the skin or mucous membrane in the perianal region. Assessment of the superficial anal reflex is particularly important when a cauda equina or conus medullaris lesion is suspected.

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The cerebral mantle is intricately folded and traversed by fissures and sulci (Figures 6 erectile dysfunction vacuum pump medicare discount 100 mg viagra soft with visa. Differences in the anatomy of the layers form the basis for cytoarchitectonic maps of the brain diabetes and erectile dysfunction health order cheap viagra soft on line. The best-known and most widely used map is that of Brodmann kidney disease erectile dysfunction treatment buy generic viagra soft 100mg, which divides the brain into 52 identifiable areas (Figure 6 erectile dysfunction treatment options injections purchase generic viagra soft on line. In primates, especially humans, a huge number of neurons are able to occupy the relatively small intracranial space because of layering of the cortex and the folding that vastly increases the surface area of the brain. The more important fissures divide the hemispheres into lobes, and these in turn are subdivided by the sulci into gyri, or convolutions. Lissencephaly is a congenital malformation in which the normal pattern of sulci fails to develop. Separation of the parts of the brain by surface landmarks is practical anatomically, but the divisions are morphologic; the individual lobes are not necessarily functional units. The hemispheres are incompletely separated by the median longitudinal (interhemispheric) fissure, within which lies the falx cerebri (Figure 6. Two major surface landmarks are visible on the lateral hemispheric surface: the lateral (sylvian) fissure and the central (rolandic) sulcus (Figure 6. The sylvian fissure begins at the vallecula on the basal surface between the frontal and temporal lobes, and runs laterally, posteriorly, and superiorly. In the depths of the sylvian fissure lies the insula (island of Reil), surrounded by the limiting, or circular, sulcus. The frontal, parietal, and temporal opercula are overhanging aprons of cerebrum that cover the insula. More superficially in the sylvian fissure run branches of the middle cerebral artery. The central sulcus runs obliquely from posterior to anterior, at an angle of about 70 degrees, from about the midpoint of the dorsal surface of the hemisphere nearly to the sylvian fissure, separating the frontal lobe from the parietal. The term basal ganglia includes these plus other related structures such as the subthalamic nucleus and substantia nigra. The caudate and putamen are actually two parts of a single nucleus connected by gray matter strands and separated from each other by fibers of the anterior limb of the internal capsule. The heavily myelinated capsular fibers passing between and intermingling with the gray matter bridges cause the caudate-putamen junction to look striped, hence the term corpus striatum or striatum (L. The claustrum, amygdala, and substantia innominata are sometimes included as basal ganglia; they are indeed gray matter masses lying at the base of the hemispheres, but bear little functional relationship to the other basal ganglia. The body and progressively thinner tail extend backwards from the head and arch along just outside the wall of the lateral ventricle,Pthomegroup ultimately following the curve of the temporal horn and ending in the medial temporal lobe in close approximation to the amygdala. The substantia nigra lies in the midbrain just posterior to the cerebral peduncle. In the pars compacta lie the prominent melanin-containing neurons that give the region its dark color and its name. Fahr’s disease is a rare inherited disorder causing calcification and cell loss in the basal ganglia. The basal ganglia generally serve to suppress activity in thalamocortical motor neurons. Hypokinetic movement disorders are characterized by reduced motor function due to higher than normal basal ganglia output, for example, Parkinson’s disease. Hyperkinetic movement disorders are characterized by excessive motor activity due to lower than normal basal ganglia output, for example, Huntington’s disease. Dysfunction of nonmotor circuits of the basal ganglia has been implicated in Tourette’s syndrome and obsessive compulsive disorder. The third ventricle lies between the two thalami, which are joined together by the massa intermedia. The dorsal aspect of the thalamus forms the floor of the lateral ventricle, and its medial aspect forms the wall of the third ventricle. It is bounded laterally by the internal capsule and basal ganglia; ventrally it is continuous with the subthalamus. The anterior thalamic peduncle consists of frontothalamic, thalamofrontal, striothalamic, and thalamostriatal fibers that run in the anterior limb of the internal capsule. The superior thalamic peduncle consists of thalamoparietal sensory fibers from the thalamus to the cortex; these fibers run in the posterior limb of the internal capsule. The posterior thalamic peduncle contains the optic radiations from the lateral geniculate body to the occipital cortex, and the inferior thalamic peduncle carries auditory radiations from the medial geniculate body to the temporal cortex. The thalamic syndrome (Dejerine-Roussy) is characterized by contralateral hemianesthesia and pain due to infarction of the thalamus. Rostrally, the midbrain is continuous with the subthalamus and thalamus; caudally, the medulla is continuous with the spinal cord. The rostral limit of the midbrain is an imaginary line between the posterior commissure and mammillary bodies; the caudal limit is defined by a line between the pontomesencephalic sulcus and the inferior colliculi. The pons extends from this point caudally to the pontomedullary sulcus, and the medulla from that point to the cervicomedullary junction at the foramen magnum. The dominant feature of the ventral midbrain is the paired crus cerebri, which contain the cerebralPthomegroup peduncles. Dorsally, the dominant feature is the quadrigeminal plate, made up of the superior and inferior colliculi. The superior colliculus is connected to the lateral geniculate body by the brachium of the superior colliculus; the inferior colliculus is connected to the medial geniculate body in similar fashion. The pulvinar, the most caudal portion of the thalamus, overlies the rostral midbrain laterally. The superior cerebellar peduncle (brachium conjunctivum) connects the midbrain to the cerebellum behind. The ventral pons is a massive, bulging structure due to the underlying transverse pontocerebellar fibers. The pons is connected to the cerebellum posteriorly by the middle cerebellar peduncle (brachium pontis). Posteriorly, the cerebellum overlies the pons, separated from it by the fourth ventricle. The cerebellopontine angle is the space formed by the junction of the pons, medulla, and overlying cerebellar hemisphere. The dorsal aspect of the pons consists of the structures that make up the floor of the ventricular cavity. The medulla oblongata is the most caudal segment of the brainstem, lying just above the foramen magnum, continuous with the pons above and spinal cord below. The transition to spinal cord is marked by three features: the foramen magnum, the decussation of the pyramids, and the appearance of the anterior rootlets of C1. Posteriorly, the cerebellum overlies the medulla, connected to it by the inferior cerebellar peduncle (restiform body). The gracile and cuneate tubercles are prominences on the posterior aspect of the medulla at the cervicomedullary junction. The third nerve exits through the interpeduncular fossa, the fourth nerve through the tectal plate posteriorly. In addition, the brainstem reticular formation controls vital visceral functions, such as cardiovascular and respiratory function and consciousness. A mnemonic called the “rule of 4” helps recall the anatomy and the brainstem syndromes. The cortex is densely packed with neurons, primarily granule cells; in fact, the cerebellum contains more neurons than the cerebral cortex. The branching of the white matter into the cortical mantle and the structure of the folia lends a treelike appearance (arbor vitae). The cerebellum lies in the posterior part of the posterior fossa, behind the brainstem and connected to it by the three cerebellar peduncles (Figure 2. It forms the roof of the fourth ventricle, and is separated from the occipital lobe above by the tentorium cerebelli. The cerebellar tonsils are small, rounded masses of tissue on the mostPthomegroup inferior part of each cerebellar hemisphere, just above the foramen magnum.

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