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By C. Seruk. Mercy College.

Functionally generic 100 mcg entocort mastercard, the thalamus has three different types of nuclei: These nuclei are reciprocally connected to association • Specific relay nuclei generic entocort 100mcg on line. Included with these are the medial and Pul — pulvinar <---> visual cortex lateral geniculate bodies buy generic entocort 100 mcg online, relay nuclei for the LP — lateral posterior <---> parietal lobe auditory and visual systems. In addition, LD — lateral dorsal <---> parietal lobe motor regulatory information from the basal ganglia and cerebellum is also relayed in the Nonspecific Nuclei (to Widespread Areas of the thalamus as part of this set of nuclei. These Cerebral Cortex) nuclei are located in the lateral nuclear mass. These are connected to IL — intralaminar broad areas of the cerebral cortex known as CM — centromedian the association areas. One of the most impor- Ret — reticular tant nuclei of this group is the dorsomedial ADDITIONAL DETAIL nucleus, located in the medial mass of the thalamus. For schematic purposes, this presentation of the thalamic • Nonspecific nuclei. These scattered nuclei nuclei, which is similar to that shown in a number of have other or multiple connections. Histological sections through these nuclei are located within the internal the thalamus are challenging and beyond the scope of an medullary lamina and are often referred to as introductory course. This functional Note to the Learner: The thalamus is being introduced group of nuclei does not have the strong recip- at this point because it is involved throughout the study of rocal connections with the cortex like the the brain. The learner should learn the names and under- other nuclei. Some of these nuclei form part stand the general organization of the various nuclei at this of the ascending reticular activating system, point. It is advised to consult this diagram, as the cerebral which is involved in the regulation of our state cortex is described in the following illustrations. Each of of consciousness and arousal (discussed with the specific relay nuclei involved in one of the pathways Figure 42A). The reticular nucleus, which lies will be introduced again with the functional systems (in on the outside of the thalamus is also part of Section B) and, at that point, the student should return to this functional system. A summary diagram showing the thalamus and the cortex with the detailed connections will be pre- The following detailed classification system is given sented in Section C (see Figure 63). Various nuclei are also at this point but will only be understood as the func- involved with the limbic system (see Section D). These ridges CEREBRAL HEMISPHERES 1 are called gyri (singular gyrus), and the intervening crev- ices are called sulci (singular sulcus). This arrangement allows for a greater surface area to be accommodated CEREBRAL CORTEX: DORSAL within the same space (i. A very deep (PHOTOGRAPHIC) VIEW sulcus is called a fissure; two of these are indicated, the central fissure and the parieto -occiptal fissure. These tend When people talk about “the brain,” they are generally to be constant in all human brains. The brain of higher apes and humans is dominated Some parts have a predominantly motor function, whereas by the cerebral hemispheres. The outer layer, the cerebral other parts are receiving areas for one of the major sensory cortex, with its billions of neurons and its vast intercon- systems. Most of the cerebral cortex in humans has an nections, is responsible for sensory perception, movement, “association function,” a term that can perhaps be language, thinking, memory, consciousness, and certain explained functionally as interrelating the various activi- aspects of emotion. In short, we need the intact cerebral ties in the different parts of the brain. Two The neurons of the cerebral cortex are organized in prominent fissures allow this subdivision to be made — layers and generally there are six layers; this highly the central fissure and the lateral fissure. Neurons in each of fissure divides the area anteriorly, the frontal lobe, from the layers differ in their functional contribution to cortical the area posteriorly, the parietal lobe. The brain area behind that fissure is the occip- ish appearance and is often referred to as the gray matter ital lobe. The temporal lobe and the lateral fissure cannot (see Figure 27 and Figure 29). The cerebral hemispheres occupy the interior of the The surface of the cerebral hemispheres can be visu- skull, the cranial cavity.

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If a metastatic site is identified entocort 100mcg mastercard, the patient should be offered the least invasive technique for diagnosis generic entocort 100 mcg with visa. Staging should include CT of the chest with visuali- zation of the adrenals discount entocort 100mcg on line; CT of the head; and bone scanning. PET scanning is a promising technology and is being used in many centers; most data involve studies with lesions larg- er than 1 cm. The stage of the cancer is more important for prognosis than type or grade. A 65-year-old Chinese man comes to your indigent care clinic for routine health maintenance. He immi- grated to the United States 35 years ago and works as a grocer. Physical exami- nation reveals poor dentition but is otherwise normal. Prostate examination reveals a smooth, normal- sized, symmetrical prostate. A lipid panel shows the LDL cholesterol level to be 95 mg/dl and the HDL cholesterol level to be 50 mg/dl. Which of the following statements regarding this patient’s risk of prostate cancer is true? Advanced age is the most important risk factor for prostate cancer; most clinically detected prostate cancers are detected in the fifth and sixth decades of life B. Chinese men have a moderate risk of prostate cancer C. A diet high in red meat increases the risk of prostate cancer D. Men with low testosterone levels who develop prostate cancer are more likely to develop lower-grade prostate cancer Key Concept/Objective: To know that age, race, family history, diet, and hormone levels are important risk factors in the development of prostate cancer Advancing age is the most obvious risk factor for prostate cancer; perhaps no other cancer is as age dependent. Most clinically detected prostate cancers are detected in the seventh and eighth decades of life. African Americans have the highest incidence of prostate can- cer. The dramatic differences between the Asian and Western diets possibly contribute to the significant difference in risk. Data from large cohort studies and case-control studies support the contentions that red meat, animal fat, and total fat consumption increase the risk of prostate cancer. In the Health Professionals Follow-up Study, men with lower testosterone levels who subsequently devel- oped prostate cancer were more likely to develop higher-grade prostate cancer. A 58-year-old white man presents to your clinic with a chief complaint of frequent urination. Other results of the physical examination are normal. For this patient, which of the following statements regarding screening for prostate cancer is true? Most cancers detected by DRE are confined to the prostate and are usu- ally curable 12 ONCOLOGY 21 B. PSA is a glycoprotein with serine protease activity; it is a member of the kallikrein family and is produced only by malignant prostatic epithelial cells C. Biopsy of the prostate in men who have moderately elevated PSA levels (i. Prostate cancer is more likely when the total PSA level is high and the percentage of free PSA is low Key Concept/Objective: To understand that the goal of screening for prostate cancer is to detect organ-confined prostate cancer that is potentially curable Optimal screening for prostate cancer combines use of the PSA test and the DRE. Historically, DRE was used to screen for prostate cancer.

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The nucleus gigantocellularis of the medulla cheap 100mcg entocort with visa, The cerebral cortex sends fibers to the RF nuclei cheap entocort 100 mcg with mastercard, and the pontine reticular nuclei 100 mcg entocort with mastercard, caudal, and including the periaqueductal gray, forming part of the oral portions, give rise to the descending tracts cortico-bulbar system of fibers (see Figure 46). The nuclei that emanate from these nuclei — the medial that receive this input and then give off the pathways to and lateral reticulo-spinal pathways, part of the the spinal cord form part of an indirect voluntary motor indirect voluntary and nonvoluntary motor sys- system — the cortico-reticulo-spinal pathways (discussed tem (see Figure 49A and Figure 49B). In addition, this system is known to play an and project to all parts of the CNS. Recent extremely important role in the control of muscle tone studies indicate that serotonin plays a signifi- (discussed with Figure 49B). One special nucleus CLINICAL ASPECT of this group, the nucleus raphe magnus, Lesions of the cortical input to the reticular formation in located in the upper part of the medulla, plays particular have a very significant impact on muscle tone. This is the physiological basis nervous system at multiple levels. In this model, the same circuit knowing which parts of the limbs and body wall are is activated at a segmental level. We know that mental states and cognitive cussed with Figure 36). There is good evidence that some processes can affect, positively and negatively, the expe- “conscious” perception of pain occurs at the thalamic rience of pain and our reaction to pain. This system apparently func- CLINICAL ASPECT tions in the following way: The neurons of the periaque- In our daily experience with local pain, such as a bump ductal gray can be activated in a number of ways. It is or small cut, the common response is to vigorously rub known that many ascending fibers from the anterolateral and/or shake the limb or the affected region. What we may system and trigeminal system activate neurons in this area be doing is activating the local segmental circuits via the (only the anterolateral fibers are being shown in this illus- touch- and mechano-receptors to decrease the pain sensa- tration), either as collaterals or direct endings of these tion. This area is also known to be rich Some of the current treatments for pain are based upon in opiate receptors, and it seems that neurons of this region the structures and neurotransmitters being discussed here. Experimen- The gate theory underlies the use of transcutaneous stim- tally, one can activate these neurons by direct stimulation ulation, one of the current therapies offered for the relief or by a local injection of morphine. More controversial and certainly less certain is ing cortical fibers (cortico-bulbar) may activate these neu- the postulated mechanism(s) for the use of acupuncture rons (see Figure 46). The axons of some of the neurons of the periaqueduc- Most discussions concerning pain refer to ACUTE tal gray descend and terminate in one of the serotonin- pain, or short-term pain caused by an injury or dental containing raphe nuclei in the upper medulla, the nucleus procedure. CHRONIC pain should be regarded from a raphe magnus. From here, there is a descending, crossed, somewhat different perspective. Living with pain on a pathway, which is located in the dorsolateral white matter daily basis, caused, for example, by arthritis, cancer, or (funiculus) of the spinal cord. The serotonergic fibers ter- diabetic neuropathy, is an unfortunately tragic state of minate in the substantia gelatinosa of the spinal cord, a being for many people. Those involved with pain therapy nuclear area of the dorsal horn of the spinal cord where and research on pain have proposed that the CNS actually the pain afferents synapse (see Figure 32). The descending rewires itself in reaction to chronic pain and may in fact serotonergic fibers are thought to terminate on small inter- become more sensitized to pain the longer the pain path- neurons, which contain enkephalin. There is evidence that ways remain active; some of this may occur at the receptor these enkephalin-containing spinal neurons inhibit the level. Many of these people are now being referred to transmission of the pain afferents entering the spinal cord “pain clinics,” where a team of physicians and other health from peripheral pain receptors. The large neurons of the motor strip (in the deeper cortical layers) send their axons as INTRODUCTION projection fibers to form the cortico- bulbar and There are multiple areas involved in motor control, which cortico-spinal tracts. It is this cortical strip that is the reason for the title Motor Systems (plural). This cortical nucleus), the cerebellum (with its functional subdivisions), area sends its axons to the motor cortex as well nuclei of the brainstem including portions of the reticular as to the cortico-spinal tract, and its function formation, and finally the output motor neurons of the likely has more to do with proximal joint con- cranial nerve motor nuclei and the spinal cord (the anterior trol and postural adjustments needed for move- horn cells, also known as the lower motor neurons). One way of approaching this complexity is to separate • The supplementary motor cortex is located motor activity into a voluntary system and a nonvoluntary on the dorsolateral surface and mostly on the system. This is an organizing area for • Voluntary motor control involves both direct movements and its axons are sent to the premo- and indirect pathways: tor and motor cortex. These two important large areas of the brain are continuation in the spinal cord, the lateral “working behind the scenes” to adjust and calibrate the cortico-spinal tract. All these areas also receive input from other parts system for the control of proximal joint of the cerebral cortex, particularly from the sensory post- movements and axial musculature, involves central gyrus, as well as from the parietal lobe.

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In developed market economies order entocort 100 mcg otc, these injuries have been markedly reduced by occupational safety laws purchase entocort 100mcg with visa, which are administrated by national agencies generic 100 mcg entocort otc. After many years of implementation, these laws have led to important safety features being incorporated into machines and the work setting. Restrictions on child labour have also helped to reduce this type of injury. These laws and their oversight agencies do not exist in most developing countries. Globalisation of markets and the development of many international corporations have been associated with shifting of manufacturing to developing countries, where low labour costs, favourable tax structure, and limited environmental and safety regulations reduce overheads and enhance profit margin. Growing manufacturing centres have caused the migration of farm workers from the countryside to growing mega-cities in search of better employment. Long hours, dangerous working conditions and abusive labour practices produce the ideal setting for frequent work related injuries. Although these countries benefit from the economic growth associated with importation of manufacturing, governments must be encouraged to adopt environmental protection and workers’ safety regulations. Standards found in developed market economies must be implemented in developing countries to protect the environment and ensure human rights. These regulations will avoid many serious injuries, which would otherwise require expensive medical care. Together with road traffic injuries, work related injuries consume health resources. A recent emphasis has been placed on the health and safety of child labourers. While much media attention has focussed on deplorable working conditions for children in regions of the developing world, the United States Centers for Disease Control has showed that the workplace can be hazardous for children in the USA. These numbers do not reflect younger workers often employed in agriculture. Data from a survey of Iowa farms showed that 40% of children operated machinery unsupervised and the average age at which they started operation was 12. Nearly 50% of the victims of fatal injuries die prior to reaching a physician, re-emphasising the continued shortcomings present in rural trauma care. Only one third of tractors on US farms are equipped with seat belts and antirollover devices and the rates are much lower in the developing world. Sports injuries In developed market economies, participation in competition and recreational athletics results in a large number of ligament sprains, muscle strains and fractures. While most of these problems would be classified as minor, they often require medical care and do result in some limited loss of work time and interference with other activities. By sheer numbers, they become significant in their social and economic impact. A number of current trends will expand over the next two decades to make these problems even more significant. The combination of genetic evolution and physical conditioning is producing athletes that are larger, stronger and faster. Despite improvements in protective equipment, these factors will produce larger numbers of severe injuries, particularly in contact sports. While the types of sports related injuries are numerous and nearly every portion of the musculoskeletal system can be affected, focussing on anterior cruciate ligament injuries may highlight some key issues and demographics. The incidence of acute anterior cruciate ligament injuries in the USA is estimated at between 80000 and 100000 per year and the cost of related treatment is estimated at 1 billion dollars (US$). The highest incidence of injury occurs in young men aged 15–25 involved in pivoting sports. The majority of anterior cruciate ligament injuries occur in men and result from non- contact mechanisms. Current research is actively investigating the rate of these anterior cruciate ligament injuries specifically, and musculoskeletal injuries in general in female athletes in comparison to their male counterparts.

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