Hayden Barry Bosworth, PhD

• Professor in Population Health Sciences
• Professor in Psychiatry and Behavioral Sciences
• Professor in Medicine
• Associate of the Duke Initiative for Science & Society
• Core Faculty in Innovation & Entrepreneurship
• Affiliate Faculty Member, Duke-Margolis Center for Health Policy
• Senior Fellow in the Center for Study of Aging
• Member of the Duke Cancer Institute

https://medicine.duke.edu/faculty/hayden-barry-bosworth-phd

Paraneoplastic syndromes can affect many organ systems symptoms 7 days after ovulation purchase generic hydrea on-line, with the nervous system often being severely affected symptoms magnesium deficiency cheap 500 mg hydrea visa. Commonly associated malignancies include small-cell lung cancer medications ok for pregnancy hydrea 500 mg purchase without prescription, breast cancer medications zyprexa cheap hydrea 500 mg buy, gynecologic tumors medications without doctors prescription order hydrea 500 mg with visa, and hematologic malignancies. Diagnosis of a paraneoplastic syndrome is based on clinical presentation, exclusion of other causes. Treatment of paraneoplastic disorders can involve immunotherapy and identification and 1reatment of the underlying malignancy. Neurofibromin is a major negative regulator of Ras, which is a Irey protein involved in signaling for cell growth and division. Vestibular schwannomas can cause significant hearing loss, and management often involves surgical resection and/or radiation therapy. Other findings include cutaneous manifestations, such as cafe-aulait spots and subcutaneous schwannomas, cataracts, gliomas, meningiomas, and spinal intramedullary ependymomas. However, there are some syndromes that predispose affected individuals to cancers ofboth the nervous and other systems. Clinically, the nervous system is most often affected, and clinical manifestations can include seizures, developmental delay, intellectual disability, and behavioral problems. Treatment of patients with tuberous sclerosis is primarily symptomatic and involves seizure control and tumor surveillance. It is linked to germline mutations of the p53 tumor suppressor gene, which plays an important role in regulating cell cycles. Treatment options largely consist of surgery, radiation therapy, and chemotherapy, and management often involves a multidisciplinary team ofphysicians. Which of the following is the most likely cause of malignant brain tumors in this age group A 9-year-old girl presents with headache and is found by imaging to have a cystic lesion with a protruding nodule in the cerebellum. On biopsy, the tumor is glial in origin, does not have brisk mitotic activity, and has eosinophilic granular droplets. Mitoses Cellular density Necrosis Marked anaplasia Sturge-Weber Syndrome Sturge-Weber syndrome (also known as encephalotrigeminal angiomatosis) is a congenital, noninherited disorder that is characterized by a port-wine nevus affecting the skin in the ophthalmic (Vl) or maxillary(V2) distributions of the trigeminal nerve, leptomeningeal angiomas on the side of the brain ipsilateral to the port-wine stain (usually occipital). Sturge-Weber syndrome is not associated with the development of either central or peripheral nervous system tumors. The I-year prevalence of migraine in the United States is 12%, with a female predominance. Migraine prevalence is highest during some of the peak productive years of life (age 30 to 39 years). Migraine is among the top 10 causes of disability worldwide and accounts for the most years lived with disability of any neurologic disorder. There are a number of potential "red flags" in the history that may suggest the need for further workup (Table 26-1). The pathophysiology of migraine is likely secondary to genetic predisposition and environmental. The more common primary headache disorders, namely migraine and tension-type headache, are diagnosed based on a thorough history and physical exam. Auras are most commonly visual but can involve motor or other sensory changes as well. Nluromedlldon:Also known as neuromodulators, chemical substances released In the central nervous system or In the periphery that can regulate a broad population of neurons. Primaryhe1dachu:lhose in which headache is the primary problem, such as tension or migraine headaches. Secondary headaches: Those due to another condition, such as sinusitis or intracerebral hemorrhage. Trigger: Astlmulus that can set off a migraine, for example, stress or a particular food. It is thought that patients with migraine have cortical neuronal hyperexcitability and likely abnonn. The aura spreads at a similar speed, and therefore, it has been attributed to cortical spreading depression. When the cortical spreading depression initiates in the occipital lobes, a visual aura ensues. Migraine without aura may result from cortical spreading depression in a clinically silent area of cortex. Cortical spreading depression (via an unknown mechanism) is thought to activate the trigeminal vascular system and release of substances involved in pain pathways including calcitonin gene-related peptide and glutamate. A migraine attack can be divided into 4 phases: (1) the premonitory phase, which occurs hours to days before the onset of head pain and includes various symptoms ranging from euphoria to fatigue; (2) the aura phase, when neurologic symptoms occur just before or during the headache onset; (3) the headache phase. Neuroimaging is not indicated unless historical warning signs (see Table 26-1) are present or the neurologic exam is abnormal, but may reveal small subcortical hyperintensities that are not periventricular or in the corpus callosum. Migraine headache can be episodic or chronic, and chronic migraine is defined as a headache on at least 15 days per month with a minimum of 8 days meeting criteria for migraine. Based on diagnostic criteria, an untreated migraine attack lasts 4 to 72 hours in adults but can be of shorter duration in children. During the headache, the patient must have 1 of the following features: (1) nausea and/or vomiting or (2) phonophobia and photophobia. Each individual aura can last up to 1 hour, so if a patient has multiple aura symptoms in succession, the total aura time will be longer than 60 minutes. Migraine with aura has several different variants; these include migraine with typical aura, migraine with brainstem aura, hemiplegic migraine, and retinal migraine. In migraine with typical aura, the aura consists of visual, sensory, and/or spee<:h and language symptoms. Migraine with brainstem aura requires at least 2 of the following brainstem symptoms: (1) dysarthria, (2) vertigo, (3) tinnitus, (4) hypoacusis (hearing impairment). Hemiplegic migraine is a subtype of migraine with aura in which the aura is a syndrome of fully reversible motor weakness and fully reversible visual, sensory. Retinal aura is distinguished from the typical visual aura because it is a monocular positive or negative visual phenomenon. All patients who suffer from migraine headaches should be counseled on lifestyle modifications, such as regular sleep and meals, healthy diet and exercise. Migraine patients should be offered prescription preventive migraine therapy ifthey have >3 migraine days without disability per month or >2 migraine days with disability per month. For optimal prevention of migraine headaches, it is important to involve patients in their care. Consider comorbidities, and when possible, choose a single medication to treat multiple diseases. With women of childbearing age, discuss contraception and the potential risk of medication use during pregnancy. Each preventive medication should be started at a low dose and slowly titrated up. The use of headache calendars before and after initiation of migraine preventive therapy can give objective data on the efficacy of the drug in that patient. Medications with established efficacy (level A evidence) for the prevention of migraine include anti. Divalproe:i: sodium should be considered in someone with concomitant mood disorders and requires monitoring for weight gain, hyponatremia. Topiramate might be helpful in an overweight patient, as it can cause weight loss. Patients need to be monitored for cognitive complaints and should be warned about tingling and changes in taste (carbonated drinks taste "flat"), which are common side effects. Other antiepileptics that can be beneficial in the treatment of headaches include gabapentin. Propranolol should be considered in someone with concomitant hypertension or anxiety. Medications that are probably effective (level B evidence) for the prophylaxis of migraine headaches include antidepressants (amitriptyline, venlafaxine). It should be used with caution in patients with cardiovas<:ular disease because it can lead to arrhythmia. Cortical spreading depression is a wave of increased cortical neuronal activity, followed by neuronal suppression that propagates at a velocity of 2 to 3 mm per minute. Central sensitization and allodynla can occur In patients with refractory headache. The pain pattern In migraine Is most often severe unilateral frontal and/or temporal throbbing that can radiate to involve the relTo- or supraorbital region. Alternative tricyclic antidepressants that can be used for the prevention of migraine include nortriptyline and protriptyline. Venlafaxine might be useful in a migraine patient who suffers from moderate depression. Patients should also be monitored for hypertension and, as with many of the antidepressants, suicidal ideation. If medications in the anticonvulsant, antihypertensive, and antidepressant categories are ineffective or contraindicated, memantine (category Bin pregnancy) should be considered in the prevention of migraine headaches. Supraorbital nerve stimulation has also been shown to be an effective preventive therapy. The typical visual aura associated with migraine headache is described ClS a scintillating scotoma, which spreads at about 2 to 3 mm per minute. There is evidence for the use of herbal supplements such coenzyme QlO, magnesium, riboflavin, and feverfew. Although Petasites hybridus extract has strong evidence in the preventive treatment of migraine, its use is currently not recommended because of safety concerns given potential liver toxicity and carcinogenic/teratogenic properties of formulations that are not free of pyrrolizine alkaloids. If a patient has predictable migraine headaches during menses, she may qualify for a "mini-prophylaxis:" Instead of taking a daily preventive medication, she would use therapy the week of her expected migraine headache. Although the traditional preventive migraine medications can be used during the week of prophylaxis, using frovatriptan has been found to be effective OevelA evidence) for this purpose. Aside from this setting, medications in the triptan category are traditionally used for migraine abortive treatment. Because triptans induce vasoconstriction, migraine with brainstem aura was excluded from triptan clinical trials due to concerns of increasing the risk of brain infarction and is thus not a formal indication for triptan therapy. However, it is now clearer that aura is primarily a neuronal process related to cortical spreading depression, and more recent literature suggests that treating these patients with triptans may actually be beneficial without increased risk for ischemic vascular events. Sumatriptan was the first triptan introduced for acute migraine treatment It has the fastest time to peak levels but also the shortest half-life. Triptans are the abortive treatment of choice in migraine headache (level A evidence). Because of a variation In chemical structure, frovatrlptan has a slower onset and lower potency, but also the longest half-life of this class of medications. Almotriptan, eletriptan, frovatriptan, and naratriptan ue only available in an oral tablet formulation. Provatriptan and naratriptan have a slower onset and lower potency but also a lower headache reoccurrence rate because they are longer lasting. When choosing a triptan, it is important to amsider how quickly the headache climau3, as well as associated symptoms of nausea and vomiting. Although a patient might be able to tolerate oral mediations without symptoms of nausea, vomiting. Therefore, nonoral triptans should be considered early, especially ifgastrointestinal. Ifa lmre- dose formulation ill partially effective, the patient should be instructed to redoee, and the practitioner should prescnbe the equivalent higher dose formulation in the future. Cydobenzaprine has a similar chemical structure to amitriptyline and can also be used as an adjunct for symptomatic headache therapy. Adding antiemetics, especially in the setting ofgas-trointestinal symptoms, may alao be beneficial. In patients with migraine with aura, transcranial magnetic stimulation at the occipitalis is another option. The patient should also be counseled on how to use symptomatic medication effectively, using migraine-specific medications when possible at headache onset. Waiting until the headache has built up in intensity may render the symptomatic medication less effective. The patient should limit all pain medications to 9 da)15 or less per month to avoid medication overuse headache. Note that it is the number of da)15, not the total number of times during a day, that puts the patient at risk. Therefore, if within prescribing range, the patient should redose or use multiple medications from different categories in an effort to completely abort the headache. Medlc:atfon ovenue headache only occurs in patients with primary headache disorders. However, any symptomatic pain medication or decongestant, whether used for headache or another condition, has the potential to cause medication overuse headache in a patient with a primary headache disorder. The headaches have become more frequent and more Intense over the years but have not changed In character. They begin with visual distortion that Is described as a sclntlllatlng scotoma that slowly enlarges over 10 minutes to involve the right hemifield and then dissipates over 30 minutes. This is accompanied by a dul ache and followed by severe hemicranial pain that builds up over an hour and is pounding in character. Associated symptoms induc:le severe photophobia and phonophobia but no nausea or vomiting. The patient can sometimes have nasal congestion, but there are no unilateral autonomic symptoms. She is on oral contraceptive piUs and takes ibuprofen (which only minimally decreases the intensity) for her headaches 3 days per month.

Inside that Is the choroid containing blood vessels dlat nourish the retina and pigment epfthellum medicine lookup 500 mg hydrea purchase otc. The vitreous (from the Latin for glass) Is a get-like substance that fills the inside of the eye medications drugs prescription drugs buy 500 mg hydrea with amex. There are no photoreceptors there medicine for runny nose discount 500 mg hydrea fast delivery, so it constitutes theblind spot" in the retina medicine upset stomach order 500 mg hydrea otc. Pupil size is controlled by the dllary muscle treatment 4th metatarsal stress fracture purchase generic hydrea on line, which Is driven by the dllary nerve. How accommodation, the control of focus, works: the lens fine-tunes the focusing of light entering the eye. Light from a distance Is refracted a small amount by the stretched, flat lens to strike the retina In focus. Light from a source nearby Is refracted more by the refaxed, more convex lens to be focused on the retina. Meridional astigmatism is characterized by a corneal surface that is slightly cylindrical rather than spherical. If, for example, the cornea/lens optical system is set for proper vertical but not horizontal focus, vertical lines can be resolved, but horizontal lines would be blurry. Nonmeridional astigmatism, in contrast, occurs when the corneal surface is irregular in a complex way such that there is not even a single axis of good focus. The eye is said to be emmetropic if the match between the focusing power of the cornea and lens and the length of the eye is such that light from distant objects is correctly focused on the retina when the lens is in its flattest, lowest power state. In myopia, the power of the cornea/lens system is too high for the length of the eyeball, so that myopes cannot focus on distant objects. However, myopes can focus on objects closer to the eyes than those with normal emmetropic eyes. In hyperopia, the cornea/lens system has insufficient power for the length of the eye. In mild cases, lens accommodation may allow distant objects to be focused, but then there is no remaining accommodative power to focus near objects. If one is emmetropic prior to the onset of presbyopia, then distance vision, where the le. Someone who is not emmetrcpic prior to presbyopia onset may require different compensation lenses for distant versus close vision, such as bifocals. In normal sight (top) the optics of the eye match its length, so that when the lens ls at Its flattest. Close objects may be In focus, however, because their diverging rays require more power in the lens. Eye movements can be voluntary or involuntary and are essential for acquiring, fixating, and tracking visual stimuli. About 3 to 4 times a second, the eyes make large movements, called saccades, that shift the fovea to anew area of attention. In between saccades, during fixation, our eyes make several types of small movements, called microsaccades, drift, and tremor, which are necessary for vision. The oculomotor nerve controls the majority of eye muscles, with the exception of the superior oblique, which is controlled by the trochlear nerve, and the lateral rectus, controlled by the abducens nerve. The brain takes into account the eye movements it commands with the associated image movements so that when you are tracking a bird moving across the sky and the image on the retina is relatively stationary, your brain knows that the bird is moving be<:ause it knows your eyes are moving with it. This signal is combined with visual information so that we perceive movement of ourselves rather than that of things around us. The first of these is the central retinal artery and vein, which enter through the optic nerve. These blood vessels ramify a capillary bed across the retinal surface everywhere except in the macular area of highest visual acuity. Eye movements are characterized by a sequence offlxatfons lasting about one-quarter ofa second followed by rapid eye movements called saccades to new locatlon. Across-section 1hrough the eye at the optic nerve head and fovea shows important structures of the eye. The central retinal artery and vein enter the eye from the optic nerve and produce the blood cln::ulatlon In the choroid, located just distal to the retlnal pigment eplthellum. Below the opttc nerve head Is the central region of high acuity, the macula lutea. Across-section through the retina showing the 5 major cell types and their relationship to the surrounding ttssues. The fovea, in the center of the macula, has an ultra-high density of cones and is rod free. The fovea receives input from the central one-half degree of visual angle, which is about the size of the moon. Because the retina more or less lines the inside of the spherical eyeball, vision scientists use the center of the eye as the main reference point and the terms proximal and distal to refer to cell and synaptic layers closer to and farther from, respectively. The most proximal illustrated structure is a capillary on the proximal surface of the retina (next to the vitreous) from the central retinal artery. Layers with cell bodies include the outer nuclear layer containing photoreceptor somas, the inner nuclear layer containing the somas of horizontal, bipolar and amaaine cells, and the ganglion cell layer with somas of ganglion cells and some amacrine cells. The two major synaptic layers are the outer plexlform layer where photoreceptor terminals contact bipolar and horizontal cell dendrites. The result of this process is the conversion of the optical image to several neural images represented in the firing of different ganglion cell classes whose axons form the optic nerve and project to visual processing centers in the brain. The initial process of seeing, as mediated by the retina, starts with the capture of light photons by photoreceptor cells, which are specific types of sensory neurons. This glutamate modulates the activity of bipolar and horizontal cells to which they are coMected in the outer plexiform layer. Starting from the most proximal layer at the vitreal surface (where light enters) is the optic nerve fiber layer. This layer contains the axons of retinal ganglion cells that will gather at the optic nerve head and exit the retina on their way to the optic chiasm and retinal recipient zones in the bra. Distal to that is the ganglion cell layer that contains the cell bodies of the retinal ganglion cells (2 types are shown: midget and diffuse). Distal to the inner plexiform layer is the inner nuclear layer that contains the cell bodies ofbipolar (midget, rod, and flat bipolar). Distal to that is the outer plexiform layer, which contains the photoreceptor terminals that synapse onto bipolar cell and horizontal cell dendrites. Beyond that is the outer nuclear layer containing the photoreceptor cell bodies (rod and cone). The 5 major neuronal cell classes in the retina are photore<:eptors, bipolar cells, horizontal cells, amacrine cells, and ganglion cells. The main pathway through the retina is the sequence of photoreceptor to bipolar cell to ganglion cell. Horizontal cells modulate the signals from photoreceptors to bipolar cells, and amacrine cells modulate the output of bipolar cells to ganglion cells. The 2 major types of photoreceptors, rods and cones, function in dim and bright light, respectively. A major structural difference between rods and cones is that, in rods, the photopigme:nt is contained in disks that are completely internal to the outer segment of the receptors, whereas in cones, the cell membrane itselfis folded into a comb-like membrane process that contains the photopigment. This view shows the retinal cells In the orientation they occupy In the superior retina. Light passes through the inner retina (ganglion cell axons, then ganglion cells, and so forth, reaching the photo~ptDr outer segments last. Photons not captured by photopigment molecules in the photoreceptors are absorbed by the pigment epithelium to prevent scattering and Image blurring. Gangllon cells are the output of the retina via their axons that exit at the optic disk and make up the optic nerve. These axons are unmyellnated within the retina to a110ld light scattering because llght passes through the axon layer before reaching the photoreceptor outer segments. There are 3 main cell soma layers: the outer nuclear layer photoreceptor somas, the inner nuclear layer (somas of horizontal, bipolar. There are 2 major synaptic layers: the outer plexlform and Inner plextform layers. The outer segment contains the photon-absorbing photopigment in an array of disk-like membrane structures. The plasma membrane of the outer segment has a high concentration of cyclic nucleotide-gated sodium/calcium. The Inner segment contains mitochondria and biochemical machinery for transporting the photopigment, such as rhodopsin, to the outer segment from its sites of synthesis in the cell body. Within the inner segment is the cell body that contains the nucleus and protein-manufacturing machinery. The synaptic: terminal is where glutamate is released to regulate second-order cells (bipolar and horizontal cells). What this refers to is the projection of the visual world onto the retina along a horizontal line that runs through the fovea and extends from the periphery of the retina closest to the nose (nasal retina) to the periphery closest to the cheek (temporal retina). The rod photoplgment Is contained In disks that are completely internal to the outer segment of the receptors, whereas in cones, the photopigment lies in the cell membrane that is folded into a comblike membrane process. Both rods and cones have 3 main structural elements: the outer segment contains the photon-absorbing photoplgrnent In an array of dlsk·llke membrane structures. The Inner segment contains mitochondria and blochemlcal machinery for transporting the photopigment. Within the inner segment is the cell body that ccntains the nucleus and protein· manufacturing machinery. The synaptic termlnal Is where glutamate Is released to regulate second·order cells (bipolar and horlzontal cells). Cones are concentrated In the fovea and parafovea and then have a relatively conslilnt distribution throughout the rest of the retina. Rods are absent from the fovea and parafovea, but peak in density just outside this region. The blind spot at the optic nerve head where the ganglion cell axons leave the eye has no cones or rods. Blue cone density relative to green and red cones peaks slightly just outside the fovea in the parafovea, and then constitutes a relatively constant percentage ofall cones throughout the rest of the retina, where the relative percentages are about 64% red, 32% green, and 2% blue. Rod density peaks just outside this region, and then gradually declines out to the retinal periphery. Because rods mediate vision in dim light, it has long been known that in trying to locate a very dim object, such as a faint star, one should not look directly at the assumed location but just to the side of that location. Rods greatly outnumber cones across the retina except in the central foveal region. The vertical density function follows a similar, but not identical, eccentricity profile for both rods and cones. The blind spot is the retinal area where the ganglion cell axons become myelinated and exit the retina to form the optic nerve. Human vision operates based an absorption of photons from just below 400 to nearly 700 nm. For the cones, the peaks are at 420, 534, and 564 nm for the blue, green, and red cones, respectively. Because of this, color vision depends on having multiple receptor types with different spectral sensitivity curves whose ratio ofactillfty codes fer wavelength. In dim light, only rods are active, so there Is no colar vision, but during the day, the 3 canes give us what is called trichromatic vision. In bright light, however, retinal cells are sensitive to the ratio of activity of different cones, which varies with wavelength, and vision is photopic. Photons of any wavelength of light produce a unique ratio of activity of the 3 cones, allowing color to be identified independently oflight intensity level. There is a regime at middle light levels in which both cones and rods operate to some extent. Under ideal circumstances, a brief flash can usually be detected if approximately 5 to 7 rods each capture a single photon of light at about the same time. Individual rod cells are more sensitive to light because they express more photopigment and have higher amplification in the phototransduction cascade. The photopigment is formed by the protein opsin, which is Cones & Color Vision Humans, like many primates, have 3 types of cones, called short-wavelength (blue), middle-wavelength (green). When photoreceptors capture a photon of visible light, their response is the same regardless of its wavelength, because the molecular cascade that modulates glutamate release is the same regardless of the wavelength of the photon that is absorbed. In rods, as shown, the photoplgment Is fanned by the protein opsln, bound to a molecule of retinal. When the photoplgment molecule absorbs a photon, the retinal unit changes Its stereolsomerform from the kinked structure called 11-ds retinal to a straighter form called alltrans retinal. All-trans retinal separates from the protein opsln to which It was bound, allowing the opsln to be active. The hyperpolarization of the photoreceptor causes its synaptic terminal to release less glutamate, the photoreceptor neurotransmitter. When the photopigment molecule, such as rhodopsin in rods (or photopsins in cones), absorbs a photon, the retinal changes its stereoisomer form from the kinked structure called 11-cis retinal to a straighter form called all-trans retinal. All-trans retinal separates from the protein opsin to which it was bound, allowing the opsin to be active. The sodium-potassium transporter pump works to counteract the effect ofthe dark current and maintain the normal cell low sodium-high potassium concentration gradients. Specifically, the outputs of photoreceptors drive 2 main types of cells, called bipolar and horizontal cells. Photoreceptor Adaptation the visual system has evolved to function from light levels at which single rods absorb a few photons per second, to levels where cones absorb millions. This dynamic range is mediated by 3 types of adaptation: (1) the use of rods in dim light and cones in bright light; (2) light and dark adaptation by rods and cones themselves within their operating range; and (3) adaptation by other retinal neurons. Cones function in light levels from daylight shadows to reflection off snow, which constitutes a range of about 8 log units oflight intensity. Rods adapt over a range from a few photons per second to hundreds, or about 2 log units of background intensity.

Most interneu· rons and motor neurons have a single axon and multiple den· drites and are called multipolar neurons medicine plies effective 500 mg hydrea. L Blpclar ceUs have a slngle dendrite that receives electrlcal signals and an axon that transmits signals to other cells medicine cabinets with lights buy discount hydrea on-line. They contain one axon branch that extends to the skin or muscle georges marvellous medicine cheap 500 mg hydrea, and another axon branch extends to the spinal cord medicine zoloft hydrea 500 mg for sale. Pyramidal cells are found In the cerebral cortex symptoms 6 days past ovulation best buy for hydrea, and have a roughly triangular cell body; apical dendrites emerge from the apex and the basal dendrites from the base. Purkinje cells of the cerebellum are characterized by an extensive dendrltlc tree that accommodates enormous synaptic Inputs. Unipolar neurons, which contain only 1 process, are common in insects but are found in only a few brain regions in mammals. Sensory neurons do not have typical dendrites because they do not receive information from synapses, but rather have specialized sensory receptor regions to detect signals from the environment Some sensory neurons (eg. Roman and Arabic numerals lndkate the layers of the neocortex; 4, external llne of Balllarger (llne of Gennarl In the occipital lobe); Sb, internal line of Baillarger. Their name derives from the basket-like nest that their axons form around their target cells. Underneath the cerebellar Purkinje neurons are a population of neurons called Lugaro cells. These spindle-shaped neurons have 2 dendrites that emerge from opposite poles of the cell body and provide information to many cells in the cerebellum. Also located in the cerebellum are the Golgi cells, discovered by Camillo Golgi, which are located in the granule cell layer and provide inputs to the granule cells. Discovered by Birdsey Renshaw, Renshaw cells are intemeurons found in the spinal cord gray matter that provide and receive inputs to and from lower motor neurons. Constantin von Economo first identified and named the spindle neurons described earlier, which are found in only hominids, whales. Other criteria by which neurons can be classified are by their neurotransmitter and the response they produce in their targets, which can be excitatory, inhibitory, or modulatory. Although glutamate can act on several types of postsynaptic receptors, the majority (in terms of numbers) of glutamate receptors are ionotrop:l. An important class of glutamaterglc neurons are the pyramidal neurons in the hippocampus and cerebral. Inhibitory intemeurons are found throughout most regions of the brain and are abundant in the cerebral. Other brain neurons release acetylcholine (called cholinergic neurons) or one of the monoamines. In the brain, many cholinergic neuron cells bodies are located in the basal forebrain and project to many areas of the cerebrum. Neurons that release biogenic amines, called noradrenergic, adrenergic, dopaminergic, or serotonergic neurons, have cell bodies located in the brainstem. Because these neurons produce a variety of excitatory, inhibitory, and modulatory effects on their targets, they are usually named for their neurotransmitter. The cell body of the neuron, also called the cell soma, can vary in diameter from approximately 100 pm to approximately 10 pm. Neurons contain a robust cytoskeleton with typical filaments and cytoskeletal motor proteins, which are important in the development, structure, and function of axons and dendrites. However, in the mammalian dentate gyrus of the hippocampus and striatum and the olfactory bulb in rodents, adult neurogenesis can lead to the generation of new neurons. The precursors for adult neurogenesis in the hippocampus have been identified as neural precursor cells that lie in the subgranular zone. The newly produced neurons migrate, differentiate into mature neurons, and form connections with existing neurons. Shown to be stimulated by exercise and activity, adult neurogenesis has been implicated in learning and memory, and errors in neurogenesis have been proposed to contribute to depression and schizophrenia. Proteins that are entirely water soluble, called cytoplasmic or cytosolic proteins, are synthesized on free ribosomes that. It is estimated that the human genome contains approximately 20,000 protein-coding genes. Gene expression and control of protein expression determine the morphologic and functional phenotype ofa cell. Neurons express approximately 14,000 protein-coding genes, with approximately 8000 ofthese expressed in other cells and involved in fundamental cellular processes and metabolism. Approximately 6000 protein-coding genes are neuronal specific genes that are only expressed in neurons and include types of transporters, channels, neurotransmitter synthetic enzymes. Proteins and lipids move between membrane compartments by a process called membrane trafficking. Plasma membrane lipids and transmembrane proteins undergo endocytosis, where a small patch of the membrane folds inward into the cytoplasm and pinches off to form a small endocytic vesicle. This vesicle then traffics to and fuses with the early endosome, where the proteins are sorted into small vesicles that bud off and are trafficked to different compartments. Transmembrane proteins can travel by recycling vesicles back to the plasma membrane. A specific type of endocytosis, called receptor-mediated endocytosis, is used to bring key nutrients such as cholesterol and iron into the cell. In this process, the receptors bind and deliver their nutrients to endosomal compartments and can recycle back to the plasma membrane. Transmembrane proteins that have been damaged will traffic to the late endosome and then fuse with the lysosome. A lysosome is a membrane-bound compartment with an acidic pH that contains a variety of degradative enzymes inside, which can degrade proteins, nucleic acids, and lipids. Lysosomes can also function to degrade cytoplasmic proteins or damaged organelles, such as mitochondria, by fusing with compartments in the autophagy pathway. Another intracellular compartment, called the proteasome, is involved in degrading mainly cytoplasmic proteins. Located in the cytoplasm or nucleus, proteasomes are large complexes of proteins that lack membranes. Proteasomes bind damaged proteins, unravel them, and then cleave them with proteases to produce small peptides that can be further degraded to amino acids. The fluid mosaic model of membrane structure emphasittS that the phospholipid bilayer of a membrane contains proteins inserted in it or associated with its surface (perlpheral proteins) and that many of these proteins move within the fluld. When cells are frozen and fractured (cryofracture), the llpld bllayer of membranes Is often deaved along the hydrophobic center. Electron microscopy of ayofracture preparation replicas provides a useful method for studying membrane structures. Most of the protruding membrane parades seen (1) are proteins or aggregates of proteins that remain attached to the halfof the membrane adjacent to the cytoplasm (P or protoplasmic face). Fewer particles are found attached to the outer half of the membrane (E or extracellular face). Each protein bulging on one surface has a corresponding depression (2) on the opposite surface. Neurons do not contain large stores of glucose in glycogen, and therefore, they depend on nearby astrocytes to take up glucose from capillaries and release glucose and its glycolytic product lactate into the extracellular space. It is a process that is specialized for the generation and conduction of electrical signals called action potentials. Axons can be long or short and unmyelinated or myelinated Projection neurons and sensory neurons extend the longest axons, which are usually myelinated and can be centimeters to a meter in length. Local circuit neurons are usually unmyelinated and only a few millimeters in length. A neuron is composed of a cell body (soma) with a nudeus, several processes called dendrites, and an axon that originates from the axon hillock. The axon hillock also blocks diffusion of plasma membrane proteins from the cell body membrane to the axonal membrane. The initial segment is adjacent to the axon hillock and is the region where the action potential is generated. Even in myelinated axons, the initial segment is unmyelinated and is the regions where voltage-gated sodium channels are highly concentrated. The end of the axon is called the axon terminal, presynaptic terminus, or synaptic bouton. If the axon is myelinated, the myelin membrane does not cover the presynaptic terminus. Axons contain cytoskeletal proteins that provide structure and important functions. Vesicles provide lipids and transmembrane proteins destined for the amnal plasma membrane, synaptic vesicle components, and peptides destined for secretion by the presynaptic terminus. Many soluble proteins and cytoskeletal components use slow axonal transport to travel along the axon. Two other cytoskeletal filaments, an intermediate filament called neurofilament and the microfilaments composed of actin, are expressed in neurons. Mechanically strong, neurofilaments serve a mainly structural role and ensure the diameter of the axon does not diminish along its length. Actln microfilaments are found associated with the plasma membrane, along with dozens of actin-binding proteins that regulate the assembly, disassembly, and bundling ofthe actin filaments and binding to the plasma membrane. In mature axons, actin is localized in a mesh that underlies the axonal plasma membrane and at the presynaptic terminus. Presynaptic axon terminals form synapses on dendrites, which then produce postsynaptic signals that are passively transmitted to the cell body. The number of inputs that a neuron receives is proportional to its dendritic area. Unlike axons, which have a constant diameter, dendrites taper as they extend from the cell body. Dendrites are usually shorter than axons and may be studded with dendritic spines. Anterograde (orthograde) transport occurs along microtubules from the cell body to the presynaptic region, while retrograde transport occurs from the presynaptic terminus to the cell body. Note the spines on the main dendrite and on its smaller branches, and note that spines have different lengths and shapes. Dendritic spines are actin-rich small protrusions that can have a bulbous head and are the regions where the majority of excitatory glutamate synapses occur on the dendrite. Spines are dynamic structures that can undergo changes in shape, size, and number, and this morphologic spine plasticity (and the functional plasticity of the synapses they contain) has been implicated in learning and memory. The axon terminal is the part of the axon that forms a synapse with another neuron, muscle, or gland. When a neuron makes a synaptic connection with another cell, it is said to innervate that cell. The connections between an axon and a muscle or gland are also referred to as junctions. In neurons, synapses occur between an axon and a dendrite (axodendritic synapses). If the axons form short branches at their ends and synapse on dendrites or cell bodies, these branches are called the terminal arbor. Some axons form bulbous presynaptic swellings and synapse on a dendrite without terminating there, but continue on to form additional synapses. Two different types of synapses, named electrical and chemical synapses, mediate transmission. The synaptic cleft (20 to 40 nm wide) separates the pre- and postsynaptic membrane, although synaptic adhesion molecules from the presynaptic and postsynaptic membrane hind across the synaptic cleft to help produce the stability and specificity of the synapse. The postsynaptic membrane contains neurotransmitter receptors that are tethered at the synapse by scaffolding and cytoskeletal proteins, forming a region called the postsynaptic density in excitatory/glutamatergic synapses. Diagram showing a synapse releaslng neurotransmitter <Nn by exoc:ytosls from the termlnal bouton. The postsynaptic membrane on the right is part of a dendrite (0), associated with fewer vesicles of any kind, showing this to be an axodendrilic synapse. Less numerous axoaxonic synapses occur between a presynaptic axon and a postsynaptic axon and. Electron micrograph ofa synapse showing the presynaptic knob (S) ending en the shaft of a dendrite (0) in the central nervous system. Originally thought to develop from mesoderm, microglia are likely derived from the embryonic yolk sac and are distinguished by their small cell bodies and short processes. As phagocytic cells, microglia have also been implicated in dendritic spine removal underlying spine plasticity. Transporter proteins on the end feet allow astrocytes to take up important molecules such as glucose, lactate, amino acids, and other metabolites from the blood and release them into the extracellular fluid around neurons. Through this mechanism, astrocytes provide key nutrients to nearby neurons, axons, and oligodendrocytes. Astrocytes also express ion channels and ion transporters, which enable them to regulate the ionic: concentration of the extracellular fluid. The lnterrelatlonshlps and major functions of these cells are shown diagrammatically here. Pericytes (which are not shown) are involved in regulating the blood-brain barrier. Glutamine is imported into the presynaptic glutamatergic neuron (A) and ainverted into glutamate by glutamlnase. The glutamate Is then transported In vesicles by the vesicular glutamate transporter. It Is converted Into glutamlne by glutamlne synthetase and transported back into the extrac:ellular fluid where it can be taken up by the presynaptic axon.

The decussation of nerve fibers in the chiasm results in the right optic tract conveying impulses from the left visual field and vice versa treatment 4 sore throat hydrea 500 mg buy fast delivery. The visual field is what is seen by a person with both eyes wide open and looking straight ahead medicine quiz order hydrea uk. Most fibers in the optic tracts terminate in the lateral geniculate bodies (nuclei) of the thalamus symptoms 4 days post ovulation buy hydrea 500 mg cheap. From these nuclei medications peripheral neuropathy order hydrea master card, axons are relayed to the visual cortices of the occipital lobes of the brain medicine for high blood pressure safe 500 mg hydrea. Right visual field representation on retinas, left lateral geniculate body, and left visual cortex. Bitemporal hemianopsia: loss of vision in the temporal fields of both eyes (tunnel vision). It emerges from the midbrain, pierces the dura, and runs through the roof and lateral wall of the cavernous sinus. The inferior division also carries presynaptic parasympathetic (visceral efferent) fibers to the ciliary ganglion, where they synapse. The trochlear nerve, the smallest cranial nerve, arises from the nucleus of the trochlear nerve and crosses the midline prior to emerging inferior to the inferior colliculus of the posterior surface of the midbrain. It then passes anteriorly around the brainstem and pierces the dura mater at the margin of the tentorium cerebelli to course anteriorly in the lateral wall of the cavernous sinus. The abducent nerve emerges from the brainstem between the pons and the medulla and traverses the pontine cistern of the subarachnoid space. It then pierces the dura and runs the longest intracranial course within the cranial cavity of all the cranial nerves. During its intracranial course, it bends sharply over the crest of the petrous part of the temporal bone and then courses through the cavernous sinus, surrounded by venous blood such as the internal carotid artery. External ophthalmoplegia results from selective damage of the somatic motor fibers. The characteristic sign of trochlear nerve injury is diplopia (double vision) when looking down. Diplopia occurs because the superior oblique normally assists the inferior rectus in depressing the pupil (directing the gaze downward) and is the only muscle to do so when the pupil is adducted. It also supplies the posterior bellies of the digastric, stylohyoid, and stapedius muscles. The main features of parasympathetic ganglia associated with the facial nerve and other cranial nerves are summarized at the end of the chapter in Table 9. Parasympathetic fibers synapse in these ganglia, whereas sympathetic and other fibers pass through them without synapse. After traversing the internal acoustic meatus, the nerve proceeds a short distance anteriorly within the temporal bone and then turns abruptly posteriorly to course along the medial wall of the tympanic cavity. The motor paralysis of facial muscles involves upper and lower parts of the face on the ipsilateral (same) side (Bell palsy). However, forehead wrinkling is not visibly impaired because it is innervated bilaterally. Lesions between the geniculate ganglion and the origin of the chorda tympani produce the same effects as that resulting from injury near the ganglion, except that lacrimal secretion is not affected. Greater petrosal nerve joins deep petrosal nerve (sympathetic) at foramen lacerum to form nerve of pterygoid canal. Nerve of pterygoid canal travels through pterygoid canal and enters pterygopalatine fossa. Parasympathetic fibers from nerve of pterygoid canal synapse in pterygopalatine ganglion in pterygopalatine fossa Parasympathetic fibers of chorda tympani synapse in submandibular ganglion; postsynaptic fibers follow arteries to glands. It is composed of the central processes of bipolar neurons in the vestibular ganglion; the peripheral processes of the neurons extend to the maculae of the utricle and saccule (sensitive to linear acceleration relative to the position of the head) and to the ampullae of semicircular ducts (sensitive to rotational acceleration). It is composed of the central processes of bipolar neurons in the spiral ganglion; the peripheral processes of the neurons extend to the spiral organ. Acoustic Neuroma An acoustic neuroma is a benign tumor of the neurolemma (Schwann cells). The tumor begins in the vestibular nerve while it is in the internal acoustic meatus. Deafness There are two kinds of deafness: conductive deafness, involving the external or middle ear. The glossopharyngeal nerve is afferent from the tongue and pharynx (hence its name) and efferent to the stylopharyngeus and parotid gland. Somatic (General) Sensory the pharyngeal, tonsillar, and lingual branches supply the mucosa of the oropharynx and isthmus of the fauces (L. Stimuli determined to be unusual or unpleasant here may evoke the gag reflex or even vomiting. Somatic sensory Somatic (Branchial) Motor Motor fibers pass to one muscle, the stylopharyngeus, derived from the third pharyngeal arch. Special Sensory (Taste) Taste fibers are conveyed from the posterior third of the tongue to the sensory ganglia. Special sensory (taste) Visceral sensory Carotid body Carotid sinus and the carotid body, a chemoreceptor sensitive to blood gas (oxygen and carbon dioxide) levels. Inferior to the foramen is an inferior ganglion (nodose ganglion) concerned with the visceral sensory components of the nerve. Uvula centered Oropharynx Uvula off center Tongue (A) Palatine tonsil Anterior view through widely opened mouth. In B, note that the palate and posterior wall of the pharynx deviate to the left side when the gag reflex is elicited. The vagi join the esophageal plexus surrounding the esophagus, which is formed by branches of the vagi and sympathetic trunks. Somatic (Branchial) Motor Fibers from the nucleus ambiguus supply · Pharyngeal muscles, except stylopharyngeus, via the pharyngeal plexus (with sensory fibers of the glossopharyngeal nerve) · Muscles of the soft palate · All muscles of the larynx Jugular foramen Internal jugular vein Superior ganglion of vagus nerve* Carotid sheath Pharyngeal nerve Visceral (Parasympathetic) Motor Fibers from the posterior (dorsal) nucleus of the vagus nerve supply the thoracic and abdominal viscera to the left colic (splenic) flexure. Mastoid process Pharyngotympanic tube Tympanic nerve Parotid gland Soft palate Palatine tonsil Stylohyoid ligament Tonsillar branches Tympanic nerve enters middle ear via the tympanic canaliculus in petrous part of temporal bone. Lingual branches Carotid sinus Pharyngeal branches on middle pharyngeal constrictor Hyoid 3 Lesser petrosal nerve arises as a branch of tympanic plexus. Mastoid cells Tympanic nerve Auriculotemporal nerve Parotid branch of auriculotemporal nerve 6 Parotid gland 5 Parasympathetic fibers synapse in otic ganglion. Lesions of the superior laryngeal nerve produce anesthesia of the superior part of the larynx and paralysis of the cricothyroid muscle. Injury of a recurrent laryngeal nerve may be caused by aneurysms of the arch of the aorta and may occur during neck operations. Injury of the recurrent laryngeal nerve causes hoarseness and dysphonia (difficulty in speaking) because of paralysis of the vocal folds (cords). Paralysis of both recurrent laryngeal nerves causes aphonia (loss of voice) and inspiratory stridor (a harsh, high-pitched respiratory sound). Because of its longer course, lesions of the left recurrent laryngeal nerve are more common than those of the right. Tachycardia (accelerated heartbeat) and cardiac arrhythmia (irregular heartbeat) may occur. It crosses the posterior cervical region and passes deep to the superior border of the trapezius to innervate it. Branches of the cervical plexus conveying sensory fibers from spinal nerves C2­C4 join the spinal accessory nerve in the posterior cervical region, providing these muscles with pain and proprioceptive fibers. This branch actually conveys only fibers from the cervical plexus (loop between the anterior rami of C1 and C2) that joined the nerve outside the cranial cavity. A Abdominal aorta, 102, 106, 186, 187, 222 Abdominal aortic aneurysm, 189 Abdominal autonomic plexus, 177 Abdominal cavity, 112 Abdominal nodes, 54 Abdominal paracentesis, 135 Abdominal protrusion, 118 Abdominal quadrants, 113 Abdominal regions, 113 Abdominal surgical incisions, 117­118 Abdominal viscera, 135­179 Abdominal wall anterolateral, 112­130 fascia of, 113 internal surface of, 115­116, 120 layers of, 124t muscles of, 113­115 nerves of, 120 palpation of, 118 surface anatomy of, 119, 119 vasculature of, 120, 120­121, 121, 121t posterior, 183­188 fascia of, 183, 183­184 lymphatics of, 187­188, 188 muscles of, 184, 184, 185 nerves of, 184­185, 185 vasculature of, 186­187 Abdominopelvic cavity, 112, 112 Abdominopelvic splanchnic nerves, 158, 172, 172, 175, 176t, 178 Abducent nerve, 497, 501, 505, 528, 532, 532, 533, 628, 630, 631t, 632t, 638, 640, 641 Abducent nerve nucleus, 633 Abducent nerve palsy, 536, 641 Abduction, 6, 7 Abductor digiti minimi, 364, 365t, 454, 455, 455t Abductor hallucis, 364, 365t Abductor pollicis brevis, 453, 454, 455, 455t Abductor pollicis longus, 443, 445t, 453, 453, 464, 483 Abscess ischio-anal, 249, 249 perinephric, 174 psoas, 189 subphrenic, 160 Accessory bones, 13 Accessory hemi-azygos vein, 60, 69, 73, 100 Accessory meningeal artery, 540 Accessory obturator artery, 338 Accessory pancreatic duct, 143, 157, 157, 165 Accessory phrenic nerve, 590 Accessory process, 273 Accessory renal vessels, 174 Accessory thyroid tissue, 607 Accommodation, in eye, 526 Acetabular fossa, 314 Acetabular notch, 314 Acetabulum, 122, 196, 197, 199, 311, 314 labrum of, 369, 370 lunate surface of, 369, 370 Acoustic neuroma, 648 Acromioclavicular joint, 16t, 398, 402, 465, 466, 466­468, 469t, 484 Acromioclavicular joint dislocation, 470­471 Acromioclavicular ligament, 465 Acromion, 399, 484, 588 Actin, 20 Adduction, 6, 7 Adductor brevis, 330, 332, 332t, 394 Adductor canal, 331­335 Adductor compartment, 453 Adductor group, 330, 332 Adductor hallucis, 364, 365t Adductor hiatus, 330, 331, 344 Adductor longus, 18, 330, 332, 332t, 334, 394 Adductor magnus, 330, 332, 332t, 341, 394 Adductor muscles, 262 Adductor pollicis, 443, 452, 453, 454, 455, 455t Adductor tubercle, 312, 321, 355 Adenoiditis, 623 Adhesiotomy, 135 Aditus, 568, 569 Adrenal glands. Neurons (also called nerve cells or neuronal cells) are the main signaling cells that communicate with other neurons, muscles, or glands. Glial cells (also called neuroglia or glia) are the support cells in the nervous system. Neurons have a cell body where the nucleus and majority of cellular organelles are located and many biochemical activities occur. Neurons also contain specialized processes and regions that allow them to send and receive signals rapidly and precisely: the axon is a process by which electrical signals are conducted and where signals are sent to other neurons or target cells. Neurons can receive thousands of synaptic inputs, can form neural circuits, and function in networks that underlie sensations, cognitive functions, and the generation of responses and behavior. The meninges are a 3-membrane system that covers, protects, and nourishes the brain and spinal cord. The outer dura mater is a thick tough membrane that is connected to the cranium and protects the brain. The innermost layer, the pia mater, is a thin layer that adheres to the surface of the brain and follows its contours, forming a barrier but with many capillaries that nourish the brain and spinal cord. The internal carotid arteries, which are branches from the common carotid artery, supply the anterior brain, whereas the vertebral arteries, which are branches from the subclavian artery. The cerebrum is formed by the large left and right cerebral hemispheres, which are separated by the medial longitudinal fissure, and contains the outer cerebral cortex. The cerebrum encloses the lateral ventricles and overlies the diencephalon, a structure that contains the thalamus and hypothalamus and that surrounds the third ventricle. The oldest part ofthe brain, the brainstem, is composed of the midbrain, pons, and medulla and serves to relay information from the spinal cord and cerebellum to the forebrain and vice versa. In addition, the brainstem regulates vital functions, such as breathing, consciousness, and control of body temperature. Connected to the pons, the cerebellum forms the posterior-most region of the brain and is involved in control and coordination of movement and some cognitive tasks. Examination of postmortem fixed brain tissue reveals that each of these brain regions contains gray and white matter areas (Flgu. Gray matter contains mainly neuronal cell bodies, their dendrites, and associated glial cells. In the brain, 2 types of gray matter are present Cortical gray matter forms the outer regions of the cerebrum and cerebellum and is distinguished by its layered organization of neurons. The other type of gray matter is called a nucleus, an aggregate of cell bodies with similar morphology and function found below the cortex (subcortical nuclei) and in the brainstem and cerebellum. White matter contains predominantly myelinated axons (which, because of their fatty rich myelin membrane, produce the white appearance) and white matter glial cells. In the brain, the white matter tracts include projection tracts that connect neurons in the forebrain to neurons in the brainstem or spinal cord, association tracts that connect one cortical region to another, and commissural tracts, which connect areas from one side of the brain to the other. The exterior surface of the cerebrum is distinguished by many gyri (singular: gyrus) and sulci (singular: sulcus) that produce the characteristic folded appearance of the human and many mammalian brains. The folding created by gyri and sulci facilitates a larger surface area of cerebral cortex to:fit inside the skull Deep sulci separate the cortex into 4 cortical lobes on each side, called the frontal. The parieto-ocdpital sulcus forms the boundary between the parietal and occipital lobes. Use of a hematoxylln stain with gold chloride shows the neuropll (Np), which Is the dense network of axons and dendrites. A typical projectlon/pr1ndpal lnterneuron has a cell body (or soma), multiple dendrites, which receive synaptic responses, and an axon, which sends electrical signals and Is Insulated by a myelln sheath dertved from specialized membrane processes ofollgodendrocytes. Along their length, the vertebral column and spinal cord inside are separated into 5 regions, called cervical. Similar to the brain, the spinal cord is composed of gray and white matter regions but with an opposite organi7. Spinal gray matter is separated anatomically and functionally into dorsal (posterior) and ventral (anterior) horns on each side. Sensory information is carried by afferent axons of spinal nerves, which enter the cord via the dorsal roots. These sensory axons branch, and one branch can synapse on intemeurons in the dorsal horn, whereas the other branch can ascend to the brain. Descending tracts in the white matter provide outgoing motor information from the cerebrum or brainstem. The axons in the descending tracts synapse on motor neuron cell bodies in the ventral/anterior horns. The ventral horn motor neurons extend their axons out of the cord via the ventral root, and their axons form the motor components of the spinal nerves. The anatomy of the brain and spinal cord is described in greater detail in Chapter 3. Composed of the dura mater, arachnoid mater, and pla mater, the meninges form a membrane system that surrounds the brain and the spinal cord. The somatic nervous sy5tem mediates conscious/voluntary movement via regulation ofskeletal muscle contraction and provides sensory information from the skin. The autonomic nervous system involves unconscious/involuntary control of cardiac muscle, smooth muscle, and glands. Arterial blood for the brain enters the cranial cavity by way of two pairs of large vessels. The pair of internal carotid arteries supplies arterial blood to most of the forebraln while the pair of vertebral arteries supplies the bralnstem, cerebellum, occipital lobe, and parts of the thalamus. The autonomic motor system is divided into the sympathetic and parasympathetic nervous systems. Tates the left cerebral hemisphere with its major sulci and gyri, cortical areas, and several subcortical structures. The sympathetic ganglia lie outside of but close to the spinal cord and communicate to form. The neuronal cell bodies that give rise to nerves do not lie within the nerves themselves. Afferent and efferent amns are protected by several layers ofconnective tissue, which together with glia and blood vessels form nerves.

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