Europos Socialinis Fondas

EUROPOS SJUNGA

The Program of Medicine studies

Module NEURAL AND ENDOCRINE REGULATION Third course Fifth semester

Faculty of Medicine Kaunas University of Medicine

Contents
1. 2. 3. 4. GENERAL INFORMATION .................................................................................................. 4 GENERAL CONTENT OF THE MODULE ........................................................................... 4 AIM AND OBJECTIVES OF THE MODULE ....................................................................... 4 TUTORIALS .......................................................................................................................... 5 4.1. Case 1. Difficulty to move without having muscular strength. ......................................... 5 4.2. Case 2. Healthy people do not fall out of bed. .................................................................. 8 4.3. Case 3. Walking disorder. .............................................................................................. 12 4.4. Case 4. The concern of the manager. ............................................................................. 14 4.5. Case 5. The concern of the teacher. ................................................................................ 17 5. Lectures ................................................................................................................................ 20 5.1. Histology of the nervous system its formation ............................................................... 20 5.2. Histophysiology of endocrine glands and skin .................................................................... 20 5.3. Functional anatomy of spinal cord and brain stem .............................................................. 20 5.4. Structural organization of the somatomotor neurofunctional system ................................... 20 5.5. Functional anatomy of the autonomic nervous system ........................................................ 20 5.6. The neuroendocrine regulation ........................................................................................... 22 5.7. Hypothalamus the thyroid neuroendocrine axis ................................................................ 22 5.8. Signal transmission in the nervous system .......................................................................... 22 5.9. Spinal cord and the brain stem motor functions. Efferent control of the motor functions. Disorder of the motor functions of the central nervous system ................................................... 22 5.10. Fundamental activity of the autonomic nervous system. Stress and the pathophysiology of general adaptation syndrome ..................................................................................................... 23 5.11. Pathological physiology of the endocrine system (2 hours) ............................................... 23 5.12. Pathological anatomy of the nervous and endocrine regulation disorders .......................... 23 5.13. Methods of the nervous system radiological analysis. Radiological diagnostics of the demyelinating pathology. Radiological diagnostics of the degenerative brain change ................ 23 5.14. Spinal cord and the brain regional anatomy. Radiological diagnostics of CNS blood circulation and CSF pathology .................................................................................................. 23 5.15. Radiological diagnostics of the brain congenital abnormalities ......................................... 24 5.16. Radiological diagnostics of pituitary and adrenal glands pathology................................... 24 5.17. Cholinoreceptor- blocking drugs and other antiparkinson drugs (2 hours) ......................... 24 5.18. Cholinomimetics, cholinoreceptor-blocking drugs, adrenomimetics, adrenoreceptor-bloking drugs and antisympathicotonic drugs ......................................................................................... 24 5.19. Fundamental of the nervous system clinical examination .................................................. 24 5.20. Clinical evaluation of the endocrine system ...................................................................... 24 6. PRACTICALS ...................................................................................................................... 25 6.1. Principles of the histological structure of the peripheral and central nervous system components histological structure ............................................................................................. 25 6.2. Histological structure of the endocrine glands and skin ....................................................... 26 6.3. Regional anatomy of effector structures of the spinal cord and brain stem .......................... 28 6.4. Anatomy of effector structures of diencephalon and telencephalon ..................................... 29 6.5. Anatomy of the peripheral nervous system ......................................................................... 30 6.6. Potential of action and the spread in the nerves ................................................................... 31 6.7. Motor spinal cord reflexes .................................................................................................. 31 6.8. Pathology of the neural and endocrine regulation disorders (3 hours) ................................. 31 6.9. Cholinomimetics, cholinoreceptor-blocking drugs, adrenomimetics, antiadrenergic agents . 33 6.10. Outline of the motor system (upper and lower motor neuron) examination and assessment33

6.11. Clinical examination and assessment of gait, coordination, smooth movements ................ 33 6.12. Clinical analysis of the endocrine system .......................................................................... 34 7. Seminars ............................................................................................................................... 34 7.1. Cytology of nervous tissue, the structural principles of the interneuronal chemical relations34 7.2. Functional anatomy of blood supply of the brain and CSF circulation................................. 34 7.3. Anatomy of the endocrine glands ....................................................................................... 35 7.4. Features of biochemical structure and metabolism of nervous tissue ................................... 35 7.5. Disorders of the endocrine glands functions ....................................................................... 35 7.6. Antiparkinson drugs ........................................................................................................... 36 7.7. Thyroid hormones, antithyroid drugs and iodine ................................................................. 36 8. EXAMINATION QUESTIONS OF THE MODULE ............................................................ 37 8.1. Histology ........................................................................................................................... 37 8.2. Anatomy ............................................................................................................................ 38 8.3. Biochemistry ...................................................................................................................... 38 8.4. Physiology ......................................................................................................................... 39 8.5. Pathological physiology ..................................................................................................... 39 8.6. Pathological anatomy ......................................................................................................... 40 8.7. Pharmacology .................................................................................................................... 40 8.8. Radiology........................................................................................................................... 41 8.9. Essentials of medical diagnosis .......................................................................................... 41

1. GENERAL INFORMATION
Supervisor of the module: Prof. habil. dr. Rimvydas Stropus, Institute of anatomy (anatom@med.kmu.lt ) Coordinator of the module: lect. Igor Korotkich, Department of physiology (igor@med.kmu.lt) Divisions: 1. 2. 3. 4. 5. 6. 7. 8. Institute of anatomy Department of histology and embryology Department of physiology Department of biochemistry Department of theoretical and clinical pharmacology Clinic of pathological anatomy Clinic of internal diseases Clinic of radiology

2. GENERAL CONTENT OF THE MODULE

While analysing the problem of the module, a student obtains new information and embodies it into these spheres: Nervous tissue structural and functional organization in cellular neurobiologys level and the application value of neuroscience achievements; Anatomy and histology of the nervous and endocrine system effector functions (somatomotor and autonomic); Functional organization of the nervous and endocrine system effector working; Pathogenesis of the disorders of the neuroendocrine functions, symptoms and syndromes and essentials of their origin; Fundamentals of clinic analysis of the impared effector functions of the nervous system and the endocrine gland functions; Principles of pharmacological correction of the impared neuroendocrine effector functions.

3. AIM AND OBJECTIVES OF THE MODULE

To establish students with conditions under which they obtain knowledge about structural and functional organization of the nervous and the endocrine system effector regulation, the pathogenesis of the repeated disorders, clinical expression and pharmacology correction. To acquire ability to apply knowledge while analysing and annotating the symptoms of clinical situations, pathological phenomena and their origin ground, terminology and treatment principles. While pursuing this goal, a student must acquire new knowledge about: Principles of the nervous system structural and functional organization at cellular neurobiologys level and their application value in pathology;

Structure and function of the motor system of spinal cord and brain stem, the pathogenesis and clinical expression of this system lesions; Structural and functional organization of central motor system (cortex, basal ganglia and cerebellum), the pathogenesis of central motor disorders, their clinical expression principles of pharmacological correction; Structural and functional organization of the interactions between neural and endocrine regulation; Morphology and physiology of autonomic regulation of the organs functions, its disorders, symptoms, syndromes, principles of pharmacological correction; Hierarchy of the endocrine regulation, the clinical expression of its disorders and principles of pharmacological correction.

4. TUTORIALS
4.1. Case 1. Difficulty to move without having muscular strength.

Mrs. Mielina, a 37-year-old woman, having a committal of the family doctor applied for a neurologist for the left arm and leg weakness that suddenly appeared. However, she felt alright till this moment: did not have a temperature, did not experience any injury. Having the results of anamneses, it is known that woman had an optical disorder within the right eye two and a half year ago she saw as if through the mist, however, optical acuity recovered fully in two weeks. Furthermore, the right leg was numb and had weakened at the same time but the symptoms passed away in few weeks and later on the woman did not consult doctors. Having a general medical examination done, no changes were found. Having neurological inspection done, it was determined that perception and orientation were unchanged, no cephalic nerve function changes found. Muscle strength in the left side of arms and legs was lesser 3-4 points (due to the system of 5 points), when the stretching arms forward the left one droops down. Tendon and periosteum reflexes are much stronger on the left side rather than on the right. There is no abdomen and normal right foot metatarsus reflex. Both arms have pathological flexor reflexes; however, the left leg has pathological Babinski reflex. Superficial and deep senses are weak on the left side of the body. Performance of coordination samples: coordination of fingernose and heel-knee is well done. She can walk 500 metres on her own though the left leg gets tired, she walks with a limp. Urinates and evacuates normally. Performed analysis: Oculist examination: optical acuity 1.0 within both eyes, visual nerve discs were of pink colour, with clear margins in the fundus of eyeballs. Neurophysiologic analysis: Acoustic induced potentials examination: aural lateral loop capacity is not disordered. Optical induced potentials examination: optical lateral loop capacity is not disordered. MRI: in both cerebral hemispheres periventricular white matter, in the corpus callosum there are apparent several, small, having oval form small, hyperintense foci on T2W/FLAIR images. Several similar focuses are apparent in the mesencephalon and pons basis and in tegmentum part. Changes are typical to demyelinization case.

On what purpose was the examination of optical and aural induced potentials performed? What pathomorphological cerebrum tissue variation could determine MRI findings? How can one explain whether to associate MRI findings in the brain stem within the disorders of an arm, leg and abdomen reflexes and senses? Does the left side leg weakness and melting as well as optical disorder two years ago relate to the present Mielinas ailment?

Concept of the problem: structural and functional mechanisms of the neurons and neuroglia interaction as well as their disorder consequences. Clinical symptoms: repeated muscle strength weakness for a young woman, temporal optical disorder.

Objective To obtain knowledge and know how to apply it while analysing neuroglia significance and myelinisation and demyelinisation processes, biochemical structure peculiarities of myelin sheath, the significance of the morphological structure for nerve fibre conduction. With reference to the pathomorphological peculiarities of this disease, a student has to know how to explain and annotate clinical studies purposes, their findings, the relation of disease progress peculiarities within the demyelinisation and myelinisation processes and neurological symptomatics connection within the pathological focuses localisation.

Learning objectives and content Completed with the problem analysis, a student must know: Microstructure of nerve tissue; the function and distribution of structural elements of the nerve tissue. Subject histology and embryology Department of Histology and Embryology References: 1. Junquiera L.C., Carneiro J. Basic histology. Text & atlas. McGraw-Hill, 2005, p. 153-181. Histological structure of nerve tissue; function and distribution of structural elements of the nerve tissue. Subject anatomy Institute of Anatomy References: 1. FitzGerald M.J.T, Folan-Curan J. Clinical Neuroanatomy and Related Neuroscience. Saunders; 2002. p. 55-71. Supplementary readings: 1. Nadeau S.E., Ferguson T.S., Valenstein E. et al. Medical Neuroscience. Saunders, 2004. p. 117-136. 2. Poritsky R. Neuroanatomy To Color and Study. Hanley&Belfus, 2004. p. 2, 5-9. 3. Grays anatomy.Elsevier Churchill Livingstone, 39th ed., 2005. p. 43-55.

Action potential, its origin and phases. Al-or-None law. Phases of the action potential and their ionic mechanisms Changes of excitability during the action potential. Refractory, its physiological importance. Spread of electrotonic potential. Local response. Membrane length and time constants. Propagation of action potential along nerve fibers. Factors affecting conduction velocity of the action potential. Compound action potentials, measurement of their propagation velocity. Classification of nerve fibers. Synaptic signal transfer in the central nervous system and regulation of secretion of neurotransmitters. Ionotropic and metabotropic receptors. Excitatory and inhibitory postsynaptic potentials, their ionic mechanisms. Inhibition in the CNS. Signal transmission in the neurons. Temporal and spatial summation. Subject physiology Department of Physiology References: 1. Ganong WF. Review of medical physiology. 23rd ed. New York: Lange Medical Books / McGraw-Hill; 2010. Ch.2 (p. 54-61), Ch. 4 (p. 79-89, 115-124, 140-142). 2. Guyton AC, Hall JE. Textbook of medical physiology. 11th ed. Philadelphia: Elsevier Saunders; 2006, Ch. 5 (p. 57-71), Ch. 45 (p. 555-571). Supplementary readings: 1. Zxc Ganong WF. Review of medical physiology. 22nd ed. New York: Lange Medical Books / McGraw-Hill; 2005. Ch.2 (p. 54-61), Ch. 4 (p. 85-98, 107-111, 116). Features of nervous tissue biochemical structure and metabolism Subject biochemistry Department of Biochemistry References 1. Smith C., Marks A., Lieberman M. Marks Basic Medical Biochemistry. A Clinical Approach. 2nd ed. Lippincott Williams&Wilkins, 2005, p. 881-904. Pathological anatomy of nervous system demyelinised and degenerated diseases and consequences Subject pathological anatomy Clinic of Pathological Anatomy References: 1. Pathologic basis of Disease. Eds I.L. Robbins, R.S. Cotran. 7 th ed. 2005, p. 1177-1280; 13261333. Methods of the nervous system radiological analysis Radiological diagnostics of demyelinised pathology Subject radiology Clinic of Radiology References: 1. Lectures 2. Grossman R.I., Yousem D. M., Neuroradiology. The Requisites, Mosby, 2003, p. 331-369. 3. Osborn A. G. Diagnostic neuroradiology, Mosby; 1994, p.716-747. 4. Osborn A. G. et all. Diagnostic imaging. Brain. Vol. I, Amirsys; 2004, section 8, p. 74-83. Supplementary readings:

1. Osborn A. G,. Blaser S. I, Salzman K. L. Pocket radiologist Brain Top 100 diagnoses, Amyrsis, 2003, p. 255-257 Neurological evaluation of motor reflexes and movement disorders Subject Essentials of medical diagnosis Clinic of Internal Diseases References: 1. Epstein P. et al. Clinical examination. London: Mosby; 1997, p. 348-356. Supplementary readings: 1. Tomas J, Monaghan T. Oxford Handbook of Clinical Examination and Practical Skills. Oxford: University Press; 2007, p.330-334, 346-349. 2. Bickley L. S. Bates Guide to Physical Examination and History Taking. Philadephia: Lippincott Williams & Wilkins; 2007, p. 633-641.

4.2.

Case 2. Healthy people do not fall out of bed.

A 56-year-old Mr. Kraujalis liked to confine himself to a regular daily routine. Every morning he used to get up at 6 oclock, to have breakfast with family at 6:45 and then go to work. One Wednesday morning this daily routine was disturbed he did not get up at 7 oclock. Mr. Kraujalis had myocardial infarction 5 years ago and was operated the coronary revascularisation performed. After myocardial infarction the man had a heart rhythm disorder, therefore, he constantly took Digoxin and Orpharin. Having fear of another heart attack, family members went to see why Kraujalis did not get up. They found him fallen out of bed, unable to move his left hand and leg. He had diplopia, felt the left side of the body melting. A careful glance to his face told about the right cheek side being set. Family members called for an ambulance immediately and took Mr. Kraujalis to an emergency room. Duty doctor that worked at the emergency room called a neurologist for an immediate consultation. A medical examination was performed on Kraujalis in the emergency room until the neurologist came: Electrocardiogram: atrial fibrillation, tachisistolic form. Scar changes in myocardium heart anteroseptal part. Extracranial neck arterial echoscopy: lumens of carotid arteries are within the norm, in the left carotid artery cerebral part there is an atherosclerotic plate, narrowing the lumen to 50% but which is insignificant hemodynamically. The consultant performed neurological analysis, concisely drew up the analysis results and the patient was told to do a CT of brain. Neurological screening findings: conscious, able to orient, able to understand and execute commands, speaks intelligibly, symmetric pupils, does not pull the right eye to the lateral side, have diplopia when takes a look to the right, does not contract the right forehead, closes the right eye incompletely, the wright nose-lips corner is set, tongue in the middle line as well, other cranial nerve function is not disordered, determines superficial and deep sense disorders on the left side of the body, does not move the left arm and leg, tendons reflexes on the left side strengthened, muscle tonicity was increased in the left limbs, pathological flexor reflex in the left arm, pathological extensor symptom in the left leg, no meningitis symptoms found, pelvic organ functions are not disordered. What structures and how do they participate in the examined (motor) functions execution

performed by the neurologist? What are the mechanisms of the examined reflexes? What neurophysiologic mechanisms do determine tendons reflexes and muscle tonicity changes? After half an hour computer-based tomography findings were received. The neurologist looked through the photos carefully and just took a glance to the description. Well, lets take him to the hospital unit - he said and put an appropriate record down to the case-record. Arranging the documentary of the patient taken to the neurologic unit, the emergency room doctor read the record of a radiologist. CT: on the right cerebral pedunculi, pons and the right cerebellar hemisphere there is a hypodense zone, with a slight perifocal oedema, the fourth ventricle is narrower, however, the system of lateral ventricles is not dislocated. What affection could cause such CT changes? What functions can this violation disorder? Referring to CT, give neuroanatomic basis on motor disorders on the right side of the patient face and on the left side limbs. Concept of the problem: structural and functional mechanisms of the spinal cord and brain stem reflex and motor function, their disorder correlation with brain stem blood supply pathology. Clinical symptoms: the peculiarities of disease anamnesis, neurological features of motor disorders, findings of CT analysis.

AIM To obtain knowledge about structural and functional organization of the spinal cord and brain stem reflex and motor function, the peculiarities of brain stem regional blood supply, pathogenesis of motor functioning disorders and radiological diagnostics. To know how to apply information while analysing and annotating the pathogenesis of patient Kraujalis, neurological symptoms and echoscopic and CT findings. Learning objectives and content Completed with the problem analysis, a student must know: Structural peculiarities of the spinal cord and the brain stem (the medulla oblongata, pons, the mesencephalon. Subject histology and embryology Department of Histology and Embryology References: 1. Junquiera L.C., Carneiro J. Basic histology. Text & atlas. McGraw-Hill, 11th ed. 2005, p. 153-181. Grey matter of spinal cord: topography and functions of nuclei and laminae (in longitudinal and transverse sections). White matter of spinal cord: topography and function of propriospinal fibers, funiculs and tracts. Segmental structure of spinal cord and pathways of motor fibres to periphery. Blood supply of spinal cord. Internal structure of rhombencephalon and mesencephalon (in longitudinal and transverse sections). Motor and autonomic nuclei of the brain stem and pathways of their fibers to innerved regions. Structure and location of inferior and superior olivary complexes, reticular formation nuclei, substantia nigra and red nucleus, their connections with other efferent system structures. Topography and function of descending motor tracts and association fibers in brain stem; Blood supply of the brain stem; Neuroanatomy of the tendon reflex arches frequently used in neurology; Subject anatomy Institute of Anatomy References: 1. Drake R. L, Vogl W, Mitchel A.W.M. Grays Anatomy for Students. Philadelphia: Elsevier, Churchil Livingstone; 2005, p. 62-67, 787-799. Supplementary readings: 1. FitzGerald M.J.T, Folan-Curran J. Clinical Neuroanatomy and Related Neuroscience. Edinburgh: Saunders; 2002, p. 123-134; 135-154, 296. 2. Nadeau St.E, Ferguson T.S, Valenstein E. et al. Medical Neuroscience. Saunders; 2004, p. 245-263; 155-186. 3. Poritsky R. Neuroanatomy To Color and Study. Hanley&Belfus, 2004. p. 52. 4. Grays anatomy.Elsevier Churchill Livingstone, 39th ed., 2005. p.307-314, 320-323, 327-345, 295-305. Role of spinal cord in motor control. Mechanisms of stretch and Golgi tendon reflexes. Polysynaptic reflexes; Role of spinal cord in locomotion and other stereotypic movements;

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Associative (Renshaw) neuron and descending tractus correlation with motor neuron mechanisms; Control mechanisms of stereotypic movements operated by the brain stem (swallowing, chewing, respiration, locomotion etc.); The role of the brain stem descending pathways in the spinal cord motor functions. Subject physiology Department of Physiology References: 1. Ganong WF. Review of medical physiology. 23rd ed. New York: Lange Medical Books / McGraw-Hill; 2010. Ch.9 (p. 157-165), Ch. 16 (p. 241-242, 247-250). 2. Guyton AC, Hall JE. Textbook of medical physiology. 11th ed. Philadelphia: Elsevier Saunders; 2006, Ch. 54 (p. 673-684), Ch. 55 (p. 691-692, 697). Supplementary readings: 3. Ganong WF. Review of medical physiology. 22nd ed. New York: Lange Medical Books / McGraw-Hill; 2005. Ch.6 (p. 129-137), Ch. 12 (p. 202-203, 206-212). Radiological diagnostics of the spinal cord and brain stem pathology Subject radiology Clinic of Radiology References: 1. Lectures 2. Grossman R. I, Yousem D. M.. Neuroradiology, The Requisites, Mosby, 2003, p.183-197. 3. Baseviius A., Lukoeviius S., Kiudelis J.ir kt. Radiologijos pagrindai, Kaunas, 2005, p. 108-116; 141-162. 4. Osborn A. G. Diagnostic Neuroradiology. Brain, Mosby, 1994, p. 333-367, 834-836. 5. Osborn A. G. et all. Diagnostic imaging. Brain. Amirsys, 2004, I, section 4, p. 4-107. Supplementary readings: 1. Osborn A. G., Blaser S. I., Salzman K. L., Pocket radiologist Brain Top 100diagnoses, Amyrsis, 2003, p. 84-90. Pathogenesis of the motor disorders of the central origin; Subject pathological physiology Department of Physiology References: 1. Stephen J. McPhee, William F. Ganong. Pathophysiology of Disease. An introduction to clinical medicine. 5th ed. Lange 2006.p. 181-186. 2. Kathryn L. Mccance Sue E. Huether. Pathophysiology. The Biologic Basis for Disease in Adults and Children. 5th ed. Elsevier Mosby; 2006. p. 527-533. The analysis methods of motor functions disorder. Clinical diagnostics of central origin motor functions disorders. Subject Essentials of medical diagnosis Clinic of Internal Diseases References: 1. Epstein P. et al. Clinical examination. London: Mosby; 1997, p. 356-363. Supplementary readings: 1. Tomas J, Monaghan T. Oxford Handbook of Clinical Examination and Practical Skills. Oxford: University Press; 2007, p. 324-329, 344-345, 350-351. 2. Bickley L.S. Bates Guide to Physical Examination and History Taking. Philadephia: Lippincott Williams & Wilkins; 2007, p. 616-629.

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4.3.

Case 3. Walking disorder.

A 53-year-old Parkinnas having a committal of the family doctor applied for a neurologist for the left shoulder joint pain, movement limitation and the disorder of left leg movement he feels the left leg constraint and quicker tiredness while walking. All these ailments have troubled him for around half a year. He took anaesthetics, muscle relaxing medicine but did not notice improvement. He as well noted that he has to walk more carefully, he can not stop when starting to move, falls forward and can not change movement direction quickly. Doctor neurologist examined Parkinnas: Neurological examination findings: orientated, critical, hypomimic face expression, symmetric pupils, eye movements to either side are not disordered, symmetric face, the tongue in the middle line. Rigid muscle tonicity is increased in the left hand, movement softness and threading gear phenomenon while flexing elbow joint, moderation of the left leg movement amplitude and softness while walking, threading gear phenomenon is noticed while flexing tarsus joint. The manner of patient walking is different as he now walks in small steps. No other changes are noticed. Performed analysis: General analysis of blood: without pathological changes. Rheumatoid factor, C-reactive protein and ESR (the erythrocyte sedimentation rate) are within the norm. CT: clear foci changes of brain density were not noticed; a slight increase of brain ventricles and subarachnoidal space enlargement. MRI: bilaterally in frontotemporal white matter there are some hyperintense non-specific lesions. Diminution of black matter layer is seen in the mesencephalon. Why does the walking of Parkinnas got disordered, why does he fall? What does the performed radiological analysis determine? What is the correlation between the changes of determined analysis and the health disorders of Parkinnas? What are the principles of treatment of these disorders? Concept of the problem: Higher motor centres participating in movement control, structural and functional mechanisms and the consequences of their activity disorder. Clinical symptoms: slow disease progress, hypomimic face, constraint of limbs, slow motions, gait changes, echoscopy, findings of CT and MRI. AIM To obtain knowledge about structural and functional organization of somatomotor system higher centres (motor and premotor cortex, basal ganglia, subthalamus, cerebellum) and know how to apply while analysing the reason of Parkinnas disease, its neurological symptomatics, MRI findings and treatment principles. Learning objectives and content Completed with the problem analysis, a student must know: Structure of the cerebellar cortex; Cyto- and myeloarchitectonics of the cerebral cortex; Histophysiological peculiarities of substantia nigra of mesencephalon.

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Subject histology and embryology Department of Histology and Embryology References: 1. Junquiera L.C., Carneiro J. Basic histology. Text & atlas. McGraw-Hill, 11th ed. 2005, p. 153-181. Anatomy of motor cortex (projection and association centres); Basal nuclei: location, structure and functional organization; Location of thalamus, subthalamus and their nuclei related to motor functions Grey and white matter of cerebellum, anatomy of its afferent and efferent pathways; Structure of descending pathways from higher somatomotor centres to the brain stem and spinal cord. Subject anatomy Institute of Anatomy References: 1. Fitz Gerald M.J.T., Folan-Curran J. Clinical Neuroanatomy and Related Neuroscience. Edinburgh: Saunders; 2002, p. 207-215, 225-228, 250-253; 265-273. Supplementary readings: 1. Nadeau St.E, Ferguson T.S, Valenstein E. et al. Medical Neuroscience. Saunders; 2004, p. 267-297. 2. Poritsky R. Neuroanatomy To Color and Study. Hanley&Belfus, 2004, p. 37, 38, 45, 106116, 131-134. 3. Grays anatomy. Elsevier Churchill Livingstone, 39th ed., 2005. p. 396-398, 419-427, 371, 372, 383, 353-356, 363-366. Somatotopic organization of the cortical motor functions; Functional organization of the pyramidal pathway; Role of motor cortex in voluntary movements; Functional organization of the basal ganglia and related structures; Neurotransmitters of the basal ganglia; Neuronal circuit and microphysiology of the cerebellum; Functional organization of the cerebellar connections;

Subject physiology Department of Physiology References: 1. Ganong WF. Review of medical physiology. 23rd ed. New York: Lange Medical Books / McGraw-Hill; 2010. Ch. 16 (p. 242-247, 250-259). 2. Guyton AC, Hall JE. Textbook of medical physiology. 11th ed. Philadelphia: Elsevier Saunders; 2006, Ch. 55 (p. 685-691), Ch. 56 (p. 698-713). Supplementary readings: 1. Ganong WF. Review of medical physiology. 22nd ed. New York: Lange Medical Books / McGraw-Hill; 2005. Ch. 12 (p. 203-207, 211-222). Pharmacological correction of central origin motor disorders Subject pharmacology Department of Theoretical and Clinical pharmacology References: 1. Bertram G. Katzung. Bendroji ir klinikin farmakologija (Basic and Clinical Pharmacology). (Vertimas lietuvi kalb.) Charibd, 2007, p. 443-457.

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2. Mycek M. J. Champe P.C. et al. Lippincott's Illustrated Reviews: Pharmacology, 3rd ed. Philaelphia: Lippincott Williams & Wilkins; 2006. p. 91-102. 3. Rang H.P. Dale M.M. et al. Pharmacology. 5th ed. Edinburgh: Churchil Livingstone; 2003. p. 490-502. Supplementary readings: 1. Basic & Clinical Pharmacology, 9th ed/ ed. by B.G.Katzung, 2004, p. 447-461; 109-121.

4.4.

Case 4. The concern of the manager.

Mr. Stresunas, a 32-year-old head manager of a middle-sized trade network, applied to health care centre for impairment of general health state, insomnia, heartbeat and anxiety attacks. After a consultation with his doctor the fact appeared that the mentioned symptoms have bothered him for about 2-3 months, however, he did not pay attention to that due to his great occupation. The patient also mentioned frequent headaches and disordered activity of the digestive tract: lack of appetite, frequent constipations, heartburn, pain in the upper part of abdomen appearing after having not eaten food for a long time or in the morning. The patient does not smoke, consumes alcohol rarely and his ailments connect to job matter. He has been managing to a high-level project during last 6 months. He often has to take complex decisions, to go on business trips and work overtime. During medical screening of the patient, there were eruptions of herpes type noticed on the lip corners. Palpating the abdomen, the pain appeared in the upper part. HB (rate of heartbeat) 85 bpm, ABP (arterial blood pressure) 160/100 mmHg. General analysis of blood: Erythrocytes, Hb, erythrocyte sedimentation rate within the norm. Leucocytes 5.0 x109 l (norm 4.0-10.0 x109 l). Lymphocytes 0.9x109/l (norm 1.2-3.0 9 x10 /l). Findings of fibrogastroduodenoscopic analysis: inflammation of stomach and duodenum. Duodenal ulcer. What organs and organ system activity do cause the origin of the determined symptoms and disorders? Explain pathogenesis of these disorders. Concept of the problem: The significance of autonomic nervous system, hypothalamuspituitary gland and adrenal gland combined activity in adaptive function regulation of the organism. Clinical symptoms: stress-related changes of internal organ functions. AIM To obtain knowledge about morphology and function of autonomic nervous system, hypothalamus, pituitary and suprarenal gland, their correlation mechanisms and to understand an appearance of neurohumoral regulation disorders and principles of their pharmacological correction. Learning objectives and content Completed with the problem analysis, a student must know: Histological structure of autonomic part of the PNS; Histological structure of hypothalamus, the pituitary and adrenal gland.

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Subject histology and embryology Department of Histology and Embryology References: 1. Junquiera L. C., Carneiro J. Basic histology. Text & atlas. McGraw-Hill, 2005, p. 153-181; 392-407. Anatomy of sympathetic, parasympathetic nuclei, amygdaloid nuclear complex, nuclei of mesolimbic system their functions and neural connections; Hypothalamus, parts, functions and neural connections; Anatomy of pituitary gland, neural connections and peculiarities of blood supply; Regional anatomy of sympathetic trunk, pathways of fibers to organs; Regional anatomy of parasympathetic ganglia, pathways of fibers to organs Regional anatomy and structure of autonomic plexuses and ganglia of internal organs; Anatomy of sympathoadrenal system; Principles of innervation of internal organs. Subject anatomy Institute of Anatomy References: 1. Drake R, Vogl W, Mitchell A.W.M. Grays Anatomy for Student. Philadelphia: Churchill Livingstone; 2005. p. 197-199; 308-314. 2. Fitz Gerald M.J.T., Folan-Curran J. Clinical Neuroanatomy and Related Neuroscience. Edinburgh: Saunders; 2002, p. 85-100, 217- 221, 285-288. 3. Nadeau St.E., Ferguson T.S., Valenstein E. et al. Medical Neuroscience. Saunders, 2004, p. 496-506. Supplementary readings: 1. Poritsky R. Neuroanatomy To Color and Study. Hanley&Belfus, 2004. p. 125- 128. 2. Grays anatomy.Elsevier Churchill Livingstone, 39th ed., 2005. p. 375-379, 380-383, 235239, 409-411. Functional organization of the autonomic nervous system; Neuromediators and neuropeptides of the autonomic nervous system and their effects on target organs; Functional organization of the autonomic reflexes; Control of autonomic functions by hypothalamus, brain stem, cerebral cortex; The basic peculiarities of the endocrine regulation: hormone concept, common mechanisms of hormone action and secretion regulation; Significance of the hypothalamicpituitary axis to the activity of the endocrine glands; Subject physiology Department of Physiology References: 1. Ganong WF. Review of medical physiology. 23rd ed. New York: Lange Medical Books / McGraw-Hill; 2010. Ch. 17 (p. 261-272), Ch. 18 (p. 273-276, 279-282). 2. Guyton AC, Hall JE. Textbook of medical physiology. 11th ed. Philadelphia: Elsevier Saunders; 2006, Ch. 45 (p. 556, 748-760), Ch. 74 (p. 905-930). Supplementary readings:

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1. Ganong WF. Review of medical physiology. 22nd ed. New York: Lange Medical Books / McGraw-Hill; 2005. Ch. 13 (p. 223-231), Ch. 14 (p. 232-238, 248-249). Hierarchy of the neuroendocrine regulation; Structure of the hypothalamus hormones, their secretion peculiarities, target cells and biochemical significance; Structure of the pituitary gland hormones, their secretion, target cells and biochemical significance; Hormones of adrenal cortex, their types, synthesis, secretion, target cells, molecular mechanisms of action; Subject biochemistry Department of Biochemistry References: 1. R.Murray, D.K. Granner, P.Mayes, V.Rodwell. Harpers Biochemistry, 23 rd ed. Prentice-Hall International, Inc. 1996, p. 509-533; 547-560. Physiological basics of stress-related and general adaptation syndrome Subject pathological physiology Department of Physiology References: 1. Lee-Ellen C. Copstead, Jacquelyn L. Banasik. Pathophysiology. 3rd ed. Elsevier Saunders. 2005, p. 23-45. 2. Kathryn L. Mccance Sue E. Huether. Pathophysiology. The Biologic Basis for Disease in Adults and Children. 5th ed. Elsevier Mosby. 2006, p. 311-332. Supplementary literature: 1. Lee-Ellen Copstead. Perspectives on Pathophysiology. W.B. Saunders Company. 1995, p.136-142. Pathomorphology of the pituitary and adrenal gland and causes their disorders Subject pathological anatomy Clinic of Pathological Anatomy References: 1. Kumar V, Abbas A.K., Fausto K.N. Robbins and Cotran Pathologic Basis of Disease, 7th ed. Elsevier Saunders, 2005, p.1156-1164; 1207-1221. Radiological diagnostics of the pituitary and the adrenal glands pathology Subject radiology Clinic of Radiology References: 1. Lectures 2. Grossman R. I., Yousem D. M., Neuroradiology. The Requisites, Mosby, 2003, p. 517-541 3. Osborn A. G. Diagnostic neuroradiology, Mosby; 1994, p. 461-484. 4. Prokop A. A., Galanski M. Spiral and multislice computed tomography of the body, Thieme, 2003, p. 625-637. 5. Osborn A. G. et all. Diagnostic imaging. Brain. Vol. I, Amirsys; 2004, section 8, p. 2-41. Supplementary readings: 1. Federle M. P., Jeffrey R. Br. Diagnostic imaging of abdomen, Amirsys, 2004, III section 2, p. 2-38.

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2. Osborn A. G., Blaser S. I., Salzman K. L. Pocket radiologist Brain Top 100 diagnoses, Amyrsis, 2003, p. 174-177, 210-213. Vegetotropic medicine and its operating mechanisms; The principles of disordered neurohumoral regulation pharmacological correction Subject pharmacology Department of Theoretical and Clinical Pharmacology References: 1. Mycek M. J. Champe P.C. et al. Lippincott's Illustrated Reviews: Pharmacology, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 35-90; 271-280. 2. Rang H.P. Dale M.M. et al. Pharmacology. 5th ed. Edinburgh: Churchil Livingstone; 2003. p. 136-183; 404-420. Supplementary readings: 1. Basic & Clinical Pharmacology, 9th ed,/ ed. by B.G.Katzung, 2004, p. 75-159; 604624. Symptoms and syndromes of disordered neurohumoral regulation and chronic stress; Subject Essentials of medical diagnosis Clinic of Internal Diseases References: 1. Naudinas A., Leiyt P., Petkeviien R.T. ir kt. Vidaus lig diagnostikos pagrindai (Basic diagnostics of Internal Medicine), Kaunas: Vitae Litera, 2007, p. 204-220.

4.5.

Case 5. The concern of the teacher.

Mrs. altyt works as a teacher in a gymnasium. Constant feelings of weakness and energy lack have bothered her for a long time. Often these feelings are followed by an unpleasant sense of cold which becomes unbearable sometimes and forces her to dress up in warmer clothes than usually. She slept for 8 hours; no difficulties in falling asleep were noticed. Constipations bothered her she evacuates no more than 1-2 times a week. Work with schoolchildren is not easy and I am already 48 years old, - she used to think and never took her ailment more seriously. However, Mrs. altyt felt anxious when she found it hard to concentrate, her memory failed, she could not perform work on time as usual and finally her professional reputation got worse. Furthermore, she noticed that she had gained 8 kg during the last 6 months, though her appetite and ration had not changed. Eventually, she made time and visited the family doctor. The doctor noted that Mrs. altyt seemed sad, apathetic and her voice was deep-chested and of low tone. The doctor examined the patient and paid attention to her tumid face, his coarsened features. Her skin had pale yellowish skin colour. It was cold, dry, reminded of dough consistency while touching. Stiffening of deep tissues is found in the region of the neck and throat. Body temperature 35.8 0 C, the rate of heartbeat (HR) 50 bpm, arterial blood pressure (BP) 130/80 mmHg. Why could these health disorders appear? What functions of organs or organ system did get disturbed? Thinking of thyroid activity disorder, the doctor told to do blood analysis. Its results: General analysis of blood is without changes. Thyroid self-reactive antibody test affirmative. Thyroid hormone amount in blood:

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T4 5.3 pmol/l (norm 9-26 pmol/l); T3 0.7 nmol/l (norm 0.9-2.6 nmol/l). Hypothalamus thyroid-stimulating hormone (TSH) amount in blood 9.0 mU/l (norm 0.55.0 mU/l). What is the correlation between these results and the health state and the health disorders? What is the mechanism of these disorders? Concept of the problem: the significance of the thyroid hormone to the metabolic functions of organism and thermoregulation. Clinical symptoms: goitre, obesity, rapidly developing tiredness, indolence, the increased sensibility to cold. AIM To obtain knowledge about the structure of thyroid gland, its hormone synthesis, secretion, physiological and biochemical bases of activity, to understand possible disorders of thyroid activity and principles of their pharmacological correction, to understand the fundamental processes of heat production and loss as well as the neurohumoral regulation mechanisms of thermoregulation Learning objectives and content Completed with the problem analysis, a student must know: Histophysiology of thyroid gland.; Histological structure of skin and sweat glands. Subject histology and embryology Department of Histology and Embryology References: 1. Junquiera L. C., Carneiro J. Basic histology. Text & atlas. McGraw-Hill, 2005, p. 411-415; 360-372. Regional anatomy of thyroid gland, external and internal structure of thyroid gland and peculiarities of blood supply; Regional peculiarities of the sweat glands, blood supply and autonomic innervation of skin. Subject anatomy Institute of Anatomy References: 1. Fitz Gerald M.J.T., Folan-Curran J. Clinical Neuroanatomy and Related Neuroscience. Edinburgh: Saunders; 2002, p.79-83. 2. Drake R, Vogl W, Mitchell A.W.M. Grays Anatomy for Student. Philadelphia: Churchill Livingstone; 2005. p. 915-919. 3. Grays anatomy. Elsevier Churchill Livingstone, 39th ed., 2005. p. 157-163, 169-170, 560565. Regulation of the thyroid hormone secretion; Mechanisms of body temperature regulation, heat production and loss Subject physiology Department of Physiology References:

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1. Ganong WF. Review of medical physiology. 23rd ed. New York: Lange Medical Books / McGraw-Hill; 2010. Ch. 18 (p. 282-287), Ch. 20 (p. 301-313). 2. Guyton AC, Hall JE. Textbook of medical physiology. 11th ed. Philadelphia: Elsevier Saunders; 2006, Ch. 73 (p. 889-901), Ch. 76 (p. 931-943). Supplementary readings: 1. Ganong WF. Review of medical physiology. 22nd ed. New York: Lange Medical Books / McGraw-Hill; 2005. Ch. 14 (p. 251-255), Ch. 18 (p. 317-332). Thyroid hormones (iodothyronines), synthesis, secretion, target cells, mechanism of molecular working and effect on metabolism. Changes of metabolism in organism during hypo- and hyperfunction activity of thyroid. Subject biochemistry Department of Biochemistry References: Etiology of the thyroid hormone secretion disorders and pathogenesis of related functional disorders. Subject pathological physiology Department of Physiology References: 1. Stephen J. McPhee, William F. Ganong. Pathophysiology of Disease. An introduction to clinical medicine. 5th ed. Lange 2006.p. 572-586 2. Kumar V., Abbas A.K., Fausto K.N. Robbins and Cotran Pathologic Basis of Disease, 7th ed. Elsevier Saunders, 2005, p. 1164-1183. 3. Porth CM. Pathophysiology: Concepts of Altered Health States. Lippincott Williams & Wilkins, 7th ed, 2005, p. 970-976. Pathological anatomy of thyroid hyper- and hypofunctions and complications. Subject pathological anatomy Clinic of Pathological Anatomy References: 1. Pathologic basis of Disease. Eds. Robbins I.L., Cotran R.S. 7 th ed., 2005, pp. 1122-1125. Pharmacological correction of disordered thyroid function. Subject pharmacology Department of Theoretical and Clinical pharmacology References: 1. Bertram G. Katzung. Bendroji ir klinikin farmakologija (Basic and Clinical Pharmacology). (Vertimas lietuvi kalb.) Charibd, 2007, p. 620-635. 2. Mycek M. J. Champe P.C. et al. Lippincott's Illustrated Reviews: Pharmacology, 3rd ed. elphia: Lippincott Williams & Wilkins; 2006. p. 277-280. 3. Rang H.P. Dale M.M. et al. Pharmacology. 5th ed. Edinburgh: Churchil Livingstone; 2003. p. 421-428. Supplementary readings: 1. Basic & Clinical Pharmacology, 9th ed,/ ed. by B.G.Katzung, 2004, p. 625-640. Symptoms and syndromes of the thyroid pathology Subject essentials of medical diagnosis Clinic of Internal Diseases References:

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1. Naudinas A., Leiyt P., Petkeviien R.T. ir kt. Vidaus lig diagnostikos pagrindai (Basic diagnostics of Internal Medicine), Kaunas: Vitae Litera, 2007, p. 216-217.

5. Lectures
5.1. Histology of the nervous system its formation
Department of Histology and Embryology Peculiarities of the development of the central and peripheral nervous system. General principles of the structure of brain white and grey matter. Distinctive histological features of the structure of spinal cord, the brain stem, the diencephalon. Histological structure of the cerebellar cortex and telencephalon. The histostructure of PNS derivations (nerves, spinal and autonomic ganglia)..

5.2. Histophysiology of endocrine glands and skin

Department of Histology and Embryology Histophysiology of the hypothalamus, and hypophysis, thyroid, parathyroid and suprarenal glands; their origin. Microstructure of the skin.

5.3. Functional anatomy of spinal cord and brain stem

Institute of Anatomy Grey and white matter of spinal cord (in longitudinal and transverse sections), the structures of motor function. Peculiarities of regional anatomy and structure of somatic motor, autonomic and reticular formation nuclei and efferent pathways of brain stem.

5.4. Structural organization of the somatomotor neurofunctional system

Institute of Anatomy Location of motor neurons and their pathways in the PNS. Structural organization of motor control. Morphofunctional characteristics of components of somatomotor system: cortical motor areas, extrapyramidal system, reticular formation, cerebellum and tracts.

5.5. Functional anatomy of the autonomic nervous system

Institute of Anatomy Structural peculiarities of efferent part of autonomic reflex arch, correlation to autonomic innervation. Anatomy of the sympathetic trunk, connections between sympathetic ganglia and sympathetic nuclei, pathways of postganglionic fibres to organs. Prevertebral ganglia and autonomic plexuses. Parasympathetic ganglia, their correlation with parasympathetic nuclei, pathways of postganglionic fibres. Structural organisation of intraorganic (metasympathetic) nervous system.

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21

5.6. The neuroendocrine regulation

Department of Biochemistry Hierarchy of the neuroendocrine regulation. Hypothalamic hormones, their structure, secretion control, target cells and biochemical function. Hormones of anterior pituitary hormones (growth hormone, tropic hormones), their structure, secretion control, target cells and biochemical meaning. Hormones of adrenal gland (glucocorticoids and adrenalin): synthesis, secretion and its control, target cells, molecular working mechanisms and inactivation.

5.7. Hypothalamus the thyroid neuroendocrine axis

Department of Biochemistry Thyroid hormones (iodthyronine), their synthesis and secretion, secretion control, transfer. Iodthyronine target cells, mechanisms of action and effect to metabolism. Metabolism changes in organism during thyroid hypo- and hyperfunctions process.

5.8. Signal transmission in the nervous system

Department of Physiology Action potential (AP), its,origin. AP phases, their ionic mechanisms and registration. Excitability changes during AP. Physiological significance of refractory. Spread of electronic potential. Propogaion of action potential along the nerve fibres. Classification and characteristics of the nerve fibres. Measurement of the nerve impulse velocity. Synaptic signal transfer in the central nervous system (CNS). Types of neurotransmitters in the CNS, their activity, regulation of release. Ionotropic and metabotropic receptors. Excitatory and inhibitory postsynaptic potentials. Inhibition in the CNS, its types and mechanisms. Signal transfer in neurons, spatial and temporal summation.

5.9. Spinal cord and the brain stem motor functions. Efferent control of the motor functions. Disorders of the motor functions of the central nervous system
Department of Physiology General characteristics of the somatic motor system. Spinal control of movement. Proprioceptors in muscles and tendons and their innervation. The simplest reflexes: the stretch reflex and Golgi tendon reflex. Reciprocal inhibition. Polysynaptic reflexes (flexor, cross-extensor). Locomotion. Effects of spinal cord lesions on the motor functions. Motor control by brain stem (midbrain, pons and medulla). The function of the motor cortex in voluntary movement. Effects of lesions of corticospinal (pyramidal) tract. Cerebellar subdivisions and their functions. Neuronal circuit of the cerebellar cortex. The role of cerebellum in learning of movements. Effects of cerebellar lesions on motor performance. Basal ganglia connections and neurotransmitters. Comparison of functional motor loops through basal ganglia and cerebellum. Effects of basal ganglia lesions on motor performance. Etiology and pathogenesis of nervous system motor functions disorders. Hyperkinesis, hypokinesis, paresis and paralysis: etiology and pathogenesis. Differences of central and peripheral paralysis.

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5.10. Fundamental activity of the autonomic nervous system. Stress and the pathophysiology of general adaptation syndrome
Department of Physiology Comparison of somatic and autonomic nervous system. Charactreistics of sympathetic and parasympathetic systems. Effects on internal organs. Transmitters and receptors in autonomic nervous system. Synaptic transmission in the autonomic nervous system: direct-gating channels or indirect action via G-proteins and second messengers. Enteric nervous system. Autonomic reflexes. Control of autonomic functions by hypothalamus and other higher centers (brain stem, cerebral cortex). Stress and stressors. General adaptation syndrome (GAS) conception. Disorders of organism functions. Diseases of adaptation.

5.11. Pathological physiology of the endocrine system (2 hours)

Department of Physiology General etiology and pathogenesis of endocrine glands function disorders. Hyperfunction and hypofunction of hypophysis, suprarenal gland, parathyroid gland, disorders of organism functions.

5.12. Pathological anatomy of the nervous and endocrine regulation disorders

Clinic of Pathological Anatomy Morphological bases of demyelinating and degenerative nervous system disorders. Morphology and complications of the thyroid and parathyroid glands sustained and weakened function, definition of the goitre. Morphological peculiarities and possible complications of the hypophysis and suprarenal gland disorders, its frequent clinical syndromes.

5.13. Methods of the nervous system radiological analysis. Radiological diagnostics of the congenital brain disorders, degenerative changes and demyelinating pathology.
Clinic of Radiology Brief history of radiology, computed tomography (CT), magnetic resonance (MRI), Transcranial Doplerography (TCD), positron emission tomography (PET) and single photon emission computed tomography (SPET), angiography, their working principles, indications, contraindications, contrast media. Congenital disorders: CT and MR diagnostics of the ventral, dorsal induction, neuronal migration. Demyelinating and degenerative diseases: white and grey matter diseases, congenital and acquired diseases.

5.14. Spinal cord and the brain regional anatomy. Radiological diagnostics of CNS blood circulation and CSF pathology

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Clinic of Radiology Radiological topographical anatomy of the brain and the spinal cord, radiological topographical anatomy of the blood vessels, CT and MRI diagnostics of the ischemic stroke due to time and localisation. Radiological diagnostics of the CSF circulation disorders (occlusive and communicative hydrocephaly).

5.15. Radiological diagnostics of hypothalamus, pituitary and adrenal glands pathology Clinic of Radiology Radiological anatomy of the sella, hypothalamus, normal variants, diagnostics (CT, MRI, ultrasonic) of pathology (dysplasia, traumatic injuries, infections, tumours). Radiological anatomy of the adrenal gland, normal variation, diagnostics (CT, MRI, ultrasonic) of pathology (hyperplasia, adenomas, metastases, feochromocytomas, carcinomas).

5.16. Cholinoreceptor- blocking drugs and other antiparkinson drugs (2 hours)

Department of theoretical and clinical pharmacology Cholinoreceptor-bloking drugs: classification, agents, pharmacokinetics, pharmacodynamics, indications, contraindications, undesirable effect. Other antiparkinson medicines: agents, pharmacokinetics, pharmacodynamics, contraindications, undesirable effect.

5.17. Cholinomimetics, cholinoreceptor-blocking adrenomimetics, adrenoreceptor-bloking drugs antisympathicotonic drugs

drugs, and

Department of theoretical and clinical pharmacology Cholinomimetics: classification, agents, pharmacokinetics, pharmacodynamics, indications, contraindications, undesirable effect. Adrenomimetics: classification, agents, pharmacokinetics, pharmacodynamics, indications, contraindications, undesirable effect. Adrenoreceptor-blocking drugs and antisympathicotonic medicines: classification, agents, pharmacokinetics, pharmacodynamics, indications, contraindications, undesirable effect.

5.18. Fundamental of the nervous system clinical examination

Clinic of Internal Diseases The purpose of neurological clinical examination. Evaluation of consciousness, mental activity and meningitic symptoms. Evaluation and assessment principles of movements, senses, coordination and gait. A brief scheme of neurological patient examination and description of the noticed changes.

5.19. Clinical evaluation of the endocrine system

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Clinic of Internal Diseases Clinical methods of patients examination in endocrinology. Clinical symptoms and syndromes: acromegaly, Cushings syndrome, thyrotoxicosis, myxedema, suprarenal insufficiency.

6. PRACTICALS
6.1. Principles of the histological structure of the peripheral and central nervous system components histological structure
Department of Histology and Embryology While analysing the microscopic preparations, a student must know the features of the spinal cord, the brain stem, the cortex of cerebellum, the diencephalon and the cortex of telencephalon, ganglions and peripheral nerve histological structure. Description of slides 1. Neural tube, tubus neuralis and brain vesicles, vesiculae cerebrales (H-E). N. 1A. In the transversal section of the embryo, find and note the canal of the neural tube. Pay your attention to the thickness of the neural tube wall and location of the cells. Draw three layers of the cells in the neural tube wall: inner or ependyma, middle layer with neuroblasts and outer layer. During the fourth week, the neural folds expand and fuse to form three primary brain vesicles: the forebrain, or prosencephalon, the midbrain, or mesencephalon and the hindbrain, or rhombencephalon. During the fifth week, the telecephalon, and hindbrain partly divides into the metencephalon and myelencephalon. As a result, there are five secondary brain vesicles. By means of a small objective lens in the transversal section of the embryo, find and draw three primary of five secondary brain vesicles. 2. Spinal ganglion, ganglion spinale (azanas arba H-E). N. 2A, 98. By means of a small objective lens find and draw the connective tissue capsule which covers the ganglion in the transversal section of the spinal ganglion. Neurons of the sensory ganglia are seen to be large and arranged in groups at the periphery of the ganglion. The groups of cells are separated by groups of myelinated nerve fibers. Fibers are mostly located in the center of the ganglion. By means of a large objective lens find pseudounipolar neurons with large, bright nuclei. Each neuron body is surrounded by glial cells (satellite cells). It is necessary to separate glial cells with round nuclei and the cells of the connective tissue capsule (with oval nuclei). 3. Spinal cord, medulla spinalis (impregnation). N. 95. By means of a small objective lens find the central canal of the spinal cord, gray and white matter (it looks as a butterfly) in the transversal section of spinal cord. Find the anterior (broader and shorter) and posterior horns. In the thoracic and the first two or three lumbar segments of the cord, a lateral horn of gray matter is also to be seen on each side of the cord. Note posterior lateral and anterior funiculi of the white matter. By means of a large objective lens find elements of gray and white matter: neurons and glial cells. Pay attention to the neurons in anterior, posterior and lateral horns. Note the zona spongiosa, substantia gelatinosa and formatio reticularis in the posterior horns. 4. Cross section of the nerve, nervus (Azan). N. 99. Draw the whole view of the nerve. Find the sheths of the nerve: the sheath of connective tissue which surrounds the one nerve fibre is called endoneurium, the fibres surrounds the perineurium and the whole nerve is surround by epineurium.

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5. Parasympathetic ganglion, ganglion autonomicum (H-E). N. 3A. By means of a small objective lens find muscle layers in the wall of the small intestine. Find the autonomic ganglion between the inner circular and outer longitudinal layer. Cells of the parasympathetic ganglion are brighter than muscle cells. 6. Cerebellar cortex, cortex cerebellaris (impregnation). N. 96. By means of a small objective lens find a superficial layer of gray matter (cortex) and the core of white matter. Draw three layers of the gray matter of the cerebellar cortex. From the surface the layers are: 1) an outer molecular layer, 2) a central layer of Purkinje cells and 3) an inner granular layer. Pay attention to the Purkinje cells. They are quite large and their dendrites divide repeatedly in one plane, forming a sort of fan. 7. Cerebral cortex, cortex cerebralis (impregnation). N. 4A or 5A. The cerebrum, like cerebellum, also the surface has a cortex of gray matter and a central area of white matter. Draw six layers of the cerebral cortex. From the layers are: 1) the molecular layer consisting largely of fibers, most of which travel parallel to the surface, and relatively few cells, 2) the outer granular layer consisting mainly of small cells, 3) the outer layer of pyramidal cells consisting only of a typical pyramidal shape, 4) the inner granular layer characterized by the presence of many small stellate cells (granule cells), 5) the inner layer of pyramidal cells containig large pyramidal cells, but in the motor area there are extremely large pyramidal cells called Betz cells, 6) the layer of polymorphic cells containig cells with diverse shapes, many of which have a spindle or fusiform shape. 8. Choriod plexus, plexus choroideus (Aazan). N. 96. By means of a small obejective lens find and draw blood vessels with loose connective tissue, covered by ependymal cells in the transversal section of the choroid plexus. Pay attention to the ependymal cells. Ependymal cells compose the simple cuboidal or low columnar epihelium. 9. The midbrain, substantia nigra. (Luxol/Blue). N. 7. Find the area in the midbrain substantia nigra, where are a lot of neurons with melanine granules inside. References: 1. Junquiera L. C., Carneiro J. Basic histology. Text & atlas. McGraw-Hill, 2005, p. 153-181.

6.2. Histological structure of the endocrine glands and skin

Department of Histology and Embryology While studying the microscopic preparations, a student must know the features of histological structure of the hypophysis, thyroid, parathyroid glands and skin. Description of slides 1. Hypothysis, hypophysis (Aazan). N. 21A. By means of a small objective lens find adenohypophysis, neurohypophysis and pars intermedia. Find the capsule of the hypophysis and septa of the loose connective tissue. In adenohypophysis by means of a small objective lens find the following cells: 1) Chromophobe cells. These cells are small, their cytoplasm stains slightly. 2) Chromophilic cells. Chromophilic cells are larger than chromophobe cells, their cytoplasm stains intensively. There are 2 kinds of the chromophilic cells: acidophils and basophils. The cytoplasm of the acidophilic cells is granular, it stains with acid dyes (it stains pink with eosin). The cytoplasm of

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the basophilic cells stains with basic dyes (it stains blue with hematoxylin ). Basophilic cells are most frequent in the posterior and medial parts of the adenohypophysis. PARS INTERMEDIA is located between the adenohypophysis and neurohypophysis. You can find a thin layer of cells in the pars intermedia. NEUROHYPOPHYSIS consists of glial cells, pituicytes and nerve fibers. Pituicytes are highly branched cells. Between them you can see endothelial cells of capillaries. 2. Epiphysis cerebri (pineal gland), epiphysis cerebri, (H-E). 22 A. By means of small objective find the pia mater that covers the surface of epiphysis and septa that extend into the gland and forme the lobules. By means of large objective within the lobule find pinealocytes chief cells of the gland. The cells are big with large nucleus in cytoplasm contain lipid droplets. At the periphery of the lobule find smaller cells with oval compact nuclei glial cells. In addition to these parenchymal and glial cells, in the human pineal gland you can find calcified concretions, called brain sand or corpora arenacea. 3. Thyroid gland, glandula thyreoidea (HBp). 23 A. By means of a small objective lens find connective tissue capsule and septa of loose connective tissue capsule. Find follicles of the gland. Walls of the follicles are composed of the follicular cells. Lumen of the follicle contains colloid (a gelatinous substance). Another type of cells, the parafollicular cells, are found as part of the follicular epitheliumIn the connective tissue between follicles there is a great number of capillaries. 4. Parathyroid gland, glandula parathyroidea (HBp). N. 24 A. By means of a small

objective lens find the capsule of the loose connective tissue. The perenchyma of the parathyroid gland consists of 2 types of cells: the chief cells and the oxyphil cells. Chief cells are small, polygonal with a vesicular nucleus and a pale staining, slightly acidophilic cytoplasm. They contain secretory granules, which secrete parathyroid hormone. Oxyphil cells are polygonal also, but larger than chief cells, nuclei are smaller and stain more densely. The cytoplasm of these cells contains acidophilic granules. The function of the oxyphil cell is uncertain. 5. Adrenal gland, glandula suprarenalis (Azan or H-E). N. 24 A, 25 A. By means of a small objective lens find the capsule of dense connective tissue. Find the cortical and medullar parts of the adrenal gland. Adrenal cortex can be subdivided into 3 concentric layers: the zona glomerulosa, zona fasciculata and the zona reticularis. Beneath the capsule is the zona glamerulosa in which the cells are arranged in rounded or arched clusters surrounded by capillaries. In zona fasciculata the cells are arranged in straight cords 1 and 2 cells thick. The cells are polyhedral with a great number of lipid droplets in their cytoplasm. The zona reticularis contains cells arranged in irregular cords that form an anastomosing network. The adrenal medulla is composed of polyhedral parenchymal cells

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arranged in cords or clumps and supported by a reticular fiber network. Between cells there is a great number of capillaries. 6. Skin of the palm, cutis (H-Kernechtrot). N. 21. By means of a small objective lens find epidermis, dermis and hypodermis. By means of a larger objective lens find and draw layers of the epidermis: stratum basale, stratum spinosum, stratum granulosum, stratum lucidum and stratum corneum. The junction between the dermis and epidermis is an uneven boundary. Dermis consists of two layers: papillary and reticular. The papillary layer is constituted of numerous finger like connective tissue protrusions into the dermis. The papillary layer consists of loose connective tissue. It is located immediately under the epidermis and is separated from it by the basal lamina. The reticular layer is deep to the papillary layer and consists of dense connective tissue. It considerably thicker than the papillary layer. Hypodermis contains a variable amount of adipose tissue. In the dermal papillae you can find Meissners corpuscles (they are touch receptors) and in deeper dermis and hypodermis Pacinian corpuscles (they are composed of a myelinated nerve ending surrounded by a capsule and they respond to pressure and vibration). 6. Skin of the head, cutis (HBp/H-E). N. 23. By means of a small objective lens find layers of the skin. Stratum corneum is much thinner, papillary layer is thin, reticular thick. Find longitudinal sections of hair follicles in the dermis and hypodermis. The outermost part of the hair follicles is a downgrowth of the epidermis external root sheeth, at deepest point there is invagination of the connective tissue papilla. External root sheet is several cells thick, other cells are called the matrix. Internal root sheet is a multilayered cellular covering that surrounds the deep part of the hair. The hair consists of the medulla, cortex and cuticle. Near hair follicle find sebaceous glands, musculus errector pili and sweat glands. References: 1. Junquiera L. C., Carneiro J. Basic histology. Text & atlas. McGraw-Hill, 2005, p. 411-415; 360-372.

6.3. Regional anatomy of spinal cord and brain stem effector structures. Anatomy of cerebellum
Institute of Anatomy Students must repeat external anatomy and regional location of spinal cord, brain stem and cerebellum effector structures (somatic, autonomic nuclei and tracts). For neuroanatomical reasoning of first (4.1) and second (4.2) study problems student should be able to explain:

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Segments of spinal cord: definition, number, sceletotopy, internal structure (gray and white matter, proper fasciculi*, roots*, spinal nerve*), origin and structure of horse tail, segmental distribution of sensory and motor fibers to dermatome, sclerotome, and myotome, their neurological significance. Gray matter of spinal cord in horizontal and longitudinal sections: anterior, intermediate, posterior columns*, anterior, lateral, posterior horns*- their segmental functional peculiarities (sensory, motor, autonomic) at different levels. Effector nuclei of gray matter: somatic motor, autonomic (sympathetic, parasympathetic): location, pathway of their fibers to periphery and lesions. White matter of spinal cord: funiculs*, descending tracts (corticospinal*, rubrospinal*, reticulospinal*, vestibulospinal*, tectospinal*) origin, location and function. Brain stem*: parts, internal structure (basis* and tegmentum*), location of descending tracts. Effector nuclei of brain stem: topography of motor somatic nuclei*, pathway of fibers, innervated muscle groups, lesions; topography of parasympathetic nuclei*, pathway of preganglionic fibers. Cerebellum*: parts, structure and function of gray matter (cortex and nuclei), peduncles, their main afferentic and efferentic tracts related to somatomotor function. Blood supply of brain stem and cerebellum. Note. At the end of practical work the assessment of students knowledge is carried out. Students must answer to 3, 4, 5, 6, 7, 8, 9, and 10 exams questions. Additional information about these questions will be given in the lecture 5.3. References: 1. Fitz Gerald M.J.T., Folan-Curran J. Clinical Neuroanatomy and Related Neuroscience. Edinburgh: Saunders; 2002, p. 23-32, 123-154. 2. Grays anatomy. Elsevier Churchill Livingstone, 39th ed., p. 307-322, 327-350.

6.4. Anatomy of effector structures of diencephalon and telencephalon

Institute of Anatomy Students must repeat peculiarities of diencephalon and telencephalon anatomy. For neuroanatomical reasoning of second (4.2), third (4.3), and fourth (4.4) study problems student should be able to explain: location, structure of effectors and connections with functionally related other parts of brain. Diencephalon: lateral group of thalamus nuclei, nucleus of subthalamus, location, connections with basal nuclei and motor cortex; structures of hypothalamus involved in autonomic and neuroendocrine regulation, location, structure, neuronal and humoral interaction with hypophysis. Basal nuclei: location of caudate and lentiform nuclei, corpus striatum and globus pallidum, connections with substantia nigra, thalamus, motor cortex, neurochemical features.

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Motor cortex: primary, premotor, and associate cortex, connections and functions. Somatomotor tracts: corticospinal, corticonuclear: origin, location in capsule interna, brain stem, spinal cord, lesions; rubrospinal, reticulospinal tracts: origin, location in spinal cord, functions. Note. At the end of practical work the assessment of students knowledge is carried out. Students must answer to 11, 12, 13, 14, and 22 exams questions. Additional information about these questions will be given in the lecture 5.4. References: 1. Fitz Gerald M.J.T., Folan-Curran J. Clinical Neuroanatomy and Related Neuroscience. Edinburgh: Saunders; 2002, p. 217-219, 250-252, 265-272. 2. Grays anatomy. Elsevier Churchill Livingstone, 39th ed., 2005. p.369, 372, 387-398, 412414.

6.5. Anatomy of the peripheral nervous system

Institute of Anatomy Students must repeat anatomy of somatic part (plexuses and peripheral nerves) and autonomic part (sympathetic trunk, prevertebral ganglia, autonomic nerves, plexuses) of peripheral nervous system. While studying the anatomical preparations, models, charts, students should be able to explain: distribution of sensory, somatic and visceral motor fibers to organs, anatomy of spinal and brain stem somatic and autonomic reflexes. Spinal nerves: distribution of dorsal branch fibers to myotomes (short and long deep muscles), sclerotomes (vertebra and joints), and dermatomes (skin of back). Ventral branch, Cervical plexus: structure, location, innervation regions, phrenic nerve; Brachial plexus: structure, location, long thoracic, suprascapular, axillary, radial, ulnar, medianus, musculocutaneus nerves, innervated muscle groups and lesions. Intercostal nerves: distribution to myotomes, sklerotomes, and dermatomes. Lumbar plexus: structure, location, distribution to dermatomes, myotomes; obturator and femoral nerves, innervated muscle groups and lesions. Sacral plexus: structure, location, distribution, sciatic nerve- location, innervated muscle groups, lesions. Cranial motor (III, IV, VI, XI, XII) and mixed (V, VII, IX, X) nerves: rootlets on brain stem, pathway through cranial basis, innervated muscle groups, lesions, pathway of preganglionic parasympathetic fibers to postganglionic neurons, regional anatomy of vagus nerve. Sympathetic nervous system: sympathetic trunk, structure, location, gray and white communicating branches, interganglionic branches, origin, structure, pathway to organs, celiac, abdominal aortic, superior and inferior hypogastric plexuses- location, structure, distribution to organs. Anatomy of somatic and autonomic reflexes: receptors, afferentic pathway, center, efferentic pathway. Muscle stretch reflex: biceps jerk, knee jerk, Achilles reflex, jaw jerk- chin reflex, skin reflexes: abdominal, cremasteric, foot; autonomic blink, salivation, tear reflexes. Note. At the end of practical work the assessment of students knowledge is carried out. Students must answer to 15, 16, 18, 19, and 20 exams questions. Additional information about these questions will be given in the lecture 5.5. References:

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1. Drake R, Vogl W, Mitchell A.W.M. Grays Anatomy for Student. Philadelphia: Churchill Livingstone; 2005. p. 69-71, 87-88; 110-112; 340-343; 420-425; 494-497; 617- 621, 656-665, 800-807. 2. Grays anatomy. Elsevier Churchill Livingstone, 39th ed., 2005. p.554-559, 966-968, 11241126, 1364, 1365. Supplementary readings; 1. Poritsky R. Neuroanatomy To Color and Study. Hanley&Belfus, 2004. p. 17, 27, 28, 53, 56, 57, 60, 61, 79.

6.6. Action potentials in nerves

Department of Physiology Please print Appendix 9.1 for laboratory exercise Registration of monophasic and diphasic summated (compound) action potentials (SAP), measurement of their propagation velocity. Refractory periods during the action potential of separate nerve fibre and during the SAP. Inhibition of the SAP by local anaesthetic drug. References: 1. Ganong WF. Review of medical physiology. 22nd ed. New York: Lange Medical Books / McGraw-Hill; 2005. Ch.2 (p. 54-61). Supplementary readings: 1. Guyton AC, Hall JE. Textbook of medical physiology. 11th ed. Philadelphia: Elsevier Saunders; 2006, Ch. 5 (p. 65-71).

6.7. Motor spinal cord reflexes

Department of Physiology Please print Appendix 9.2 for laboratory exercise Recording of the strech reflex and reflex induced by electrical impulses (Hoffmanns reflex), excitability changes in their reflex arch, their similarities and differences. Recruitment curve of the Hoffmanns reflex. References: 1. Ganong WF. Review of medical physiology. 22nd ed. New York: Lange Medical Books / McGraw-Hill; 2005. Ch.6 (p. 129-134). Supplementary readings: 2. Guyton AC, Hall JE. Textbook of medical physiology. 11th ed. Philadelphia: Elsevier Saunders; 2006, Ch. 54 (p. 673-680).

6.8. Pathology of the neural and endocrine regulation disorders (3 hours)

Clinic of pathological anatomy

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While studying macro- and micro preparations and electrograms, a student has to pick up the images illustrating nervous system and hypophysis, thyroid, parathyroid gland, suprarenal gland diseases and the causes of syndromes development, morphological variations, complications and possible death reason. A student has to find and draw typical changes in histological preparations and to solve the designed macroscopic morphological tasks. Description of slides Struma basedovica. Graves disease. Histological preparation (H+E). To pay attention to the fact that most of thyroid follicles are middle-sized or small, do not contain colloid or is fluid, containing many resorptive vacuoles of various size. Epithelium of follicle is tall, cuboidal and columnar, proliferated in some places. Distinct specific immune reactions are noticed in stroma lymphocyte infiltrates, formatting secondary lymphatic follicles with the bright centres. Struma colloides (partem proliferans). Histological preparation (H+E). To pay attention to the fact that thyroid tissue consists of middle-sized and huge follicles, full of consistent colloid; the epithelium of follicle is turned flat, single and low-level proliferators of follicle epithelium in some places. References: 1. Pathologic basis of Disease /Eds. I.L. Robins, R.S. Cotran, 7th ed., 2005, p. 1382-1396, 1330-1335, 1156-1174, 1184- 1186, 1207-1220.

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6.9. Cholinomimetics, cholinoreceptor-blocking drugs, adrenomimetics, antiadrenergic agents

Department of Theoretical and Clinical Pharmacology While performing the practical work, a student must obtain knowledge about the pharmacokinetic, pharmacodynamic characteristics and usage of this kind of medicines, contrindications, undesirable effect. References: 1. Bertram G. Katzung. Bendroji ir klinikin farmakologija (Basic and Clinical Pharmacology) (Vertimas lietuvi kalb). Charibd, 2007, p. 74-120; 121-158. 2. Mycek M. J., Champe P.C., et al. Lippincott's Illustrated Reviews: Pharmacology, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2006, p. 35-65; 66-90. 3. Rang H.P., Dale M.M. et al. Pharmacology. 5th ed. Edinburgh: Churchil Livingstone; 2003, p. 136-160; 161-183. Supplementary readings: 1. Basic & Clinical Pharmacology, 9th ed./ ed. by B.G.Katzung, 2004, p. 75-121; 122-159.

6.10. Outline of the motor system (upper and lower motor neuron) examination and assessment
Clinic of Internal Diseases Muscle strength examination and evaluation. More often in neurological practice used reflexes: examination and their response evaluation within the standard and in pathology. The search and evaluation of the pathological reflexes. The examination and evaluation of muscle tonicity. The symptoms of upper and lower motor neuron lesions. References: 1. Epstein P. et al. Clinical Examination. London: Mosby; 1997; pp. 348-356. Supplementary readings: 1. Thomas J, Monaghan T. Oxford Handbook of Clinical Examination and Practical Skills. Oxford: University Press; 2007, p. 330-334; 346-349. 2. Bickley L.S. BatesGuide to Physical Examination and History Taking. Philadelphia: Lippincott Williams & Wilkins; 2007, p. 633-641.

6.11. Clinical examination and assessment of gait, coordination, smooth movements

Clinic of Internal Diseases Examination and assessment of extrapyramidal system. Examination and assessment of coordination. Examination and evaluation of gait and posture. References: 1. Epstein P. et al. Clinical Examination. London: Mosby: 1997, p. 356-363.

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Supplementary readings: 1. Thomas J., Monaghan T. Oxford Handbook of Clinical Examination and Practical Skills. Oxford: University Press; 2007; p. 324-329; 344-345; 350-351. 2. Bickley L.S., BatesGuide to Physical Examination and History Taking. Philadelphia: Lippincott Williams & Wilkins; 2007; p. 616-629.

6.12. Clinical analysis of the endocrine system

Clinic of Internal Diseases To get acquainted with the clinical, laboratory and instrumental analyses of the endocrine disease diagnostics. To learn how to interpret the symptoms of glucose tolerance test, the results of thyroid ultrasonic scanning, to recognise the symptoms of some syndromes (Cushings, acromegaly thyrotoxicosis, myxedema, adrenal insufficiency). References: 1. Epstein P. et al. Clinical examination. London: Mosby; 1997, p. 297-310.

7. Seminars
7.1. Cytology of nervous tissue, the structural principles of the interneuronal chemical relations
Institute of Anatomy Structural elements of neuron functions, their morphological and functional groups. Structural components of neuron information reception and transfer. Structure and types of synapses. The structure of neuroglia (astrocytes, oligodendrocytes, microglia, neurolemocytes), their biological and medical significance. The structure of myelin sheath and its importance. Neuron degeneration and regeneration. Nerve growth factors and neurotrophic substances. References: 1. Fitzgerald M.J.T., Folan-Curran J. Clinical Neuroanatomy and Related Neuroscience. Saunders, 2002, p. 55-63. 2. Haines D.E. Fundamental Neuroscience, 2nd ed. Churchill Livingstone, 2002, p. 16-36.

7.2. Structural and functional organization of autonomic part of peripheral nervous system.
Institute of Anatomy Structural and functional pecularities of sympathetic trunk. Regional anatomy of sympathetic trunk ganglia (cervical, thoracic, lumbar, sacral). Pathways of preganglionic (cholinergic) sympathetic fibers from sympathetic nuclei to sympathetic trunk ganglia, to plexus of internal organs and ganglia. Pathways of postganglionic (adrenergic) fibers from ganglia of sympathetic trunk (cervical, thoracic, lumbar, and sacral) to organs. Pathways of preganglionic parasympathetic fibers from nuclei of brain stem to parasympathetic ganglia. Regional anatomy of parasympathetic ganglia (ciliary, pterygopalatine, otic, and submandibular) and pathways of postganglionic fibers to organs. Regional anatomy of vagus nerve and pathways of its parasympathetic and sensory fibers to organs.

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Regional anatomy of internal organs innervation (coeliac, abdominal aortic, superior and inferior hypogastric plexuses and ganglia), their structure and innervated organs. Anatomy of heart autonomic regulation. References: 1. Drake R, Vogl W, Mitchell A.W.M. Grays Anatomy for Student. Philadelphia: Churchill Livingstone, 2005, p. 307-314, 179-180, 835, 998-999. 2. Grays anatomy. Elsevier Churchill Livingstone, 39th ed., 2005. p. 3. FitzGerald M.J.T, Folan-Curan J. Clinical Neuroanatomy and Related Neuroscience. Saunders; 2002, p. 85-100. Supplementary readings: 1. Poritsky R. Neuroanatomy To Color and Study. Hanley&Belfus, 2004. p. 17, 27, 28,

7.3. Anatomy of the endocrine glands

Institute of Anatomy Functional anatomy of hypothalamus nuclei, their humoral and neural connections with pituitary gland. Peculiarities of the regional and aging anatomy of pituitary, pineal, thyroid, parathyroid, adrenal glands. Dispersed neuroendocrine system. Anatomy of the sympathoadrenal system. References: 1. Drake R., Vogl W, Mitchell A.W.M. Grays Anatomy for Student. Philadelphia: Churchill Livingstone, 2005, p. 327-328; 915-919. 2. Grays anatomy. Elsevier Churchill Livingstone, 39th ed., 2005. p. 179- 182, 380-385, 560565, 1245-1249. Supplementary readings: 1. Nadeau St.E., Ferguson T.S., Valenstein E. et al. Medical Neuroscience. Saunders, 2004, p. 507- 522.

7.4. Features of biochemical structure and metabolism of nervous tissue

Department of Biochemistry Peculiarities of nervous tissue biochemical structure. Metabolism of carbohydrates and energy in the nervous tissue. Metabolism of amino acids and lipids. References: 1. Devlin T.M. Textbook of biochemistry with clinical correlation. Wiley-Liss, 6th ed. 2006, p. 892-947.

7.5. Disorders of endocrine glands functions (2 hours)

Department of Physiology Description: Slides of patients with endocrine diseases (disfunction of thyroid, adrenal, parathyroid gland, adenohypophysis etc.), schemes of pathogenesis of endocrine glands function disorders are analysed during the seminar. Literature: 1. Stephen J. McPhee, William F. Ganong. Pathophysiology of Disease. An introduction to clinical medicine. 5th ed. Lange 2006. p. 493-502, 554-564, 572-584, 598-620.

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2. Porth C.M. Pathophysiology: Concepts of altered Health States. 7th ed. Lippincott Williams & Wilkins; 2005. p. 951-984. 3. Kumar V., Abbas A. K., Fausto N. Robbins and Cotran Pathologic Basis of Disease. 7th ed. Elsevier Saunders; 2005, p. 1155-1226.

7.6. Antiparkinson drugs

Department of Theoretical and Clinical Pharmacology Antiparkinson drugs, classification, agents, pharmacokinetics, mechanism of action, indications, contraindications, undesirable effect. References: 1. Bertram G. Katzung. Basic and Clinical Pharmacology. Charibde, 2007, p. 443-457. 2. Mycek M. J. Champe P.C. et al. Lippincott's Illustrated Reviews: Pharmacology, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 2006, p. 91-102. 3. Rang H.P. Dale M.M. et al. Pharmacology. 5th ed. Edinburgh: Churchil Livingstone; 2003, p. 490-502. Supplementary readings: 1. Basic & Clinical Pharmacology, 9th ed/ ed. by B.G. Katzung, 2004, p. 447-461; 109-121.

7.7. Thyroid hormones, antithyroid drugs and iodine

Department of Theoretical and Clinical Pharmacology Preparations of thyroid hormones: agents, pharmacokinetics, pharmacodynamics, indications, contraindications, undesirable effect. Antithyroid drugs: agents, pharmacokinetics, pharmacodynamics, indications, contraindications, undesirable effect. Iodine products: agents, pharmacokinetics, pharmacodynamics, indications, contraindications, undesirable effect. References: 1. Bertram G. Katzung. Bendroji ir klinikin farmakologija (Basic and Clinical Pharmacology). (Vertimas lietuvi kalb). Charibd, 2007, p. 621-635. 2. Mycek M. J. Champe P.C. et al. Lippincott's Illustrated Reviews: Pharmacology, 3rd ed. Philadelphia; Lippincott Williams & Wilkins; 2006. p. 277-280. 3. Rang H.P. Dale M.M. et al. Pharmacology. 5th ed. Edinburgh: Churchill Livingstone; 2003, p. 421-428. Supplementary readings: 1. Basic & Clinical Pharmacology, 9th ed./ ed. by B.G. Katzung, 2004; p. 625-640.

7.8 The importance of CT and MR methods in neuroradiology. The analysis of CT and MR imaging.
Department of Radiology Evaluation of CT and MR tomograms: MR different sequences, topographical anatomy of the brain in CT and MR slices, congenital disorders, demyelinating diseases, degenerative disorders, pathology of the hipophysis and adrenal glands. References: 1. Lectures 2. Grossman R. I., Yousem D. M. Neuroradiology. The Requisites, Mosby, 2003, p. 183-197 , 331-369, 517-541 3. Osborn G. Diagnostic neuroradiology, Mosby, 1994, 3-113, 330-398, 461-484, 716-747, 834836
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4. Prokop A. A., Galanski M. Spiral and multislice computed tomography of the body, Thieme, 2003 5. Baseviius A., Lukoeviius S., Kiudelis J., Dobrovolskien L. Radiologijos pagrindai, Kaunas, 2005 6. Osborn A. G. et al. Diagnostic imaging. Brain. Vol. I, Amirsys; 2004, section 8, p. 74-83, vol. II, section 2, p. 2-41. Supplementary readings: 1. Burgener F. A., Meyers St. P., Tan R. K., Zaunbauer W. Differential diagnosis in magnetic resonance imaging, Thieme, 2002. 2. Federle M. P., Jeffrey R. Br. Diagnostic imaging of abdomen, Amyrsys, 2004 3. Osborn A. G., Blaser S. I., Salzman K. L., Pocket radiologist Brain Top 100 diagnoses, Amyrsis, 2003, p. 84-90, 174-177, 210-213, 255-257

8. EXAMINATION QUESTIONS OF THE MODULE

8.1. Histology
1. Histological structure and distribution of grey matter of the brain and spinal cord. 2. Histological structure and distribution of white matter of the brain and spinal cord. 3. Histological structure of the peripheral nerve, spinal and autonomic ganglia. 4. Histological structure and peculiarities of the development of spinal cord. 5. Structural peculiarities of brain stem (the medulla oblongata, pons, the mesencephalon). 6. Histological structure of the cerebellum (structural peculiarities and distribution of the grey and white matter). 7. Histological structure and origin of the cortex of the telencephalon. Histological characteristics of the module of the brain cortex.

8. Connective tissue derivates in the central and peripheral nervous system. 9. Basic principles of the histostructure of endocrine gland. Histophysiology of parathyroid glands. 10. Histological structure and origin of the adenohypophysis. Functional relations between hypothalamus and hypophysis. 11. Histological structure and origin of the neurohypophysis. Functional relation between hypothalamus and hypophysis. 12. Histophysiology and origin of the thyroid gland. 13. Histophysiology and the origin of the suprarenal gland. 14. Histological structure of hairy skin. 15. Histological structure of nonhairy (glabrous) skin. Differences between the histological structure of the hairy and glabrous skin.

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8.2. Anatomy
1. Components of neuron internal structure and their functional significance. Axoplasmic flow structure, its biological and medical significance. Structural organization of neuron interaction: chemical synapses, their types due to the structure and neuromediators. 2. Structural organization of neuroglia and neuron interaction: astrocytes, oligodendrocytes, neurolemocytes (Schwann cells). Biological and medical significance of neuroglia. Influence of nerve fibre sheath structure to nerve impulse speed. Neuron degeneration and regeneration. 3. Anatomy of spinal gray matter in transverse and longitudinal sections, regional (segmental) functional peculiarities of the gray matter. 4. Somatic motor neurons of the spinal cord: location, pathways of fibers to muscles and outcome of their lesions. 5. Sympathetic and parasympathetic nuclei of the spinal cord: location and pathways of preganglionic fibres to postganglionic neurons. 6. Descending tractus of spinal white matter (propriospinal fascicles, funicules): origin, location in funiculs and function. 7. Somatic motor nuclei of brain stem: location, their controlled muscles and outcome of lesions. 8. Parasympathetic nuclei of brain stem: location and pathway of preganglionic fibers to postganglionic neurons. 9. Location of mixed and motor cranial nerve rootlets in the brain stem and in the base of skull. 10. Cerebellum: external and internal structure. Afferents and efferents of cerebellum. 11. Diencephalon: parts, location. Thalamus and subthalamus nuclei: interconnections with basal nuclei and motor cortex. 12. Motor cortex: primary motor, premotor, and prefrontal: location in pallium, interneuronal connections (tracts) with other cortical areas, basal nuclei, diencephalon and cerebellum. 13. Descending motor tracts (corticonuclear, corticospinal): location in the internal capsule, brain stem, and spinal cord. Functional significance of tracts and outcome of lesions. 14. Caudate and lentiform basal nuclei: parts and location. Corpus striatum. Basal nuclei interconnections with substantia nigra, subthalamus and motor cortex. 15. Somatic nerve plexuses: formation, location and peripheral nerves. 16. Regional anatomy of cervical, thoracic, lumbar, and sacral sympathetic trunk ganglia. 17. Pathways of preganglionic (adrenergic) fibers from cervical, thoracic, lumbar and sacral sympathetic trunk ganglia to organs. 18. Regional anatomy of ciliary, pterygopalatine, otic, and submandibular parasympathetic ganglia, pathway of fibers to organs. 19. Regional anatomy of vagus nerve, pathways of parasympathetic and sensory fibers. 20. Innervation of internal organs: coeliac, abdominal aortic, superior and inferior hypogastric plexuses and ganglia, regional anatomy, formation and innervated organs. 21. Anatomy of heart autonomic regulation. 22. Hypothalamus: parts, location, internal structure, humoral and neural connections with hypophysis. 23. Regional anatomy of hypophysis, parts and blood supply. 24. Regional anatomy of thyroid gland, external structure, and blood supply. 25. Regional anatomy of suprarenal glands, blood supply and innervation. 1.

8.3. Biochemistry
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1. Hormones of hypothalamus and tropic hormones of the adenohypophysis, their structure, secretion control, target cells and biochemical function. 2. Somatostatine (the growth hormone), its structure, secretion control, target cells and biochemical significance. 3. Glucocorticoids of adrenal cortex: synthesis, secretion and its control, target cells, mechanisms of action. 4. Adrenalin: synthesis, secretion and its control, target cells, molecular mechanisms of action and inactivation. 5. Thyroid hormones (iodthyronines): synthesis, secretion, target cells, effect to metabolism. Metabolism changes in organism during thyroid hypo- and hyperfunction.

8.4. Physiology
1. Action potential, its phases and their origin. 2. Excitability phases and their connection with action potential. Physiological significance of refractory period. 3. Electrotonic potential and local response. Spread of electrotonic potential, membrane time and length constants. 4. Propagation of action potential along nerve fibres. Factors affecting conduction velocity of the action potential. Classification of nerve fibres and their characteristics. 5. Synaptic signal transfer in central nervous system (CNS). Types of CNS neurotransmitters, their activity, regulation of release. 6. Ionotropic and metabotropic receptors. Excitatory and inhibitory neurotransmitters. 7. Excitatory and inhibitory postsynaptic potentials. Types of inhibition in tne central nervous system. 8. Signal transfer in neurons, spatial and temporal summation. 9. Mechanisms of exteroreceptive reflexes: flexor, cross-extensor and cutaneous reflexes. 10. Mechanisms of proprioreceptive reflexes: stretch (spindle) reflex and Golgi tendon organ reflex. 11. The role of descending brain stem pathways in spinal motor functions. 12. Microphysiology of cerebellar cortex. Functional structure of cerebellar connections. 13. Functional organization and interactions of the basal ganglia, substantia nigra and thalamus. Neurotransmitters of the basal ganglia. 14. Somatotopic organization of the motor cortex. Control of voluntary movements by the motor cortex. 15. Functional organization of the autonomic nervous system: centers, ganglia, preganglionic and postganglionic fibers, neurotransmitters, receptors and mechanisms of their action. 16. Effects of sympathetic and parasympathetic nervous systems on internal organs. Enteric nervous system. 17. Central regulation of autonomic functions (feedback circuits, spinal cord, hypothalamic functions and cortical influences). 18. Processes of heat production and heat loss in the organism. 19. Nervous and humoral regulation of the body temperature.

8.5. Pathological physiology

1. Hyperfunction of thyroid gland. Graves (Basedows) disease: etiology, pathogenesis, disorders of body functions.

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2. Hypofunction of thyroid gland. Congenital and acquired hypothyroidism: etiology, pathogenesis, disorders of body functions. 3. Hyperfunction of suprarenal gland. Cushings syndrome: etiology, disorders of body functions. 4. Hypofunction of suprarenal gland. Addisons disease: etiology, disorders of body functions. 5. Hyperfunction of anterior hypophysis. Gigantism, acromegaly: etiology, disorders of body functions. 6. Hypofunction of anterior hypophysis: etiology, disorders of body functions. Simmonds syndrome. 7. Hyperfunction and hypofunction of parathyroid gland: etiology, disorders of body functions. 8. General etiology of nervous system disorders and pathogenesis. 9. Disorders of motor functioning of nervous system: hypokineses: conception, causes, types. 10. Disorders of motor functioning of nervous system: hyperkineses: conception, causes, types. 11. Disorders of movement coordination: conception, causes, types. 12. Stress conception. General adaptation syndrome (GAS): etiology, stages, disorders of organism functions. Diseases of adaptation.

8.6. Pathological anatomy

1. Pathological anatomy of nervous system demyelinatind and degenerated diseases and consequences. 2. Pathological anatomy and complications of syndromes induced by hypophysis disturbance. 3. Pathology and complications of endemic and thyrotoxic goitre. 4. Morphology of syndromes induced by suprarenal gland pathology, complications and death causes. 5. Pathological anatomy of parathyroid gland diseases and syndromes.

8.7. Pharmacology
1. Antiparkinson medicines: classification, agents, mechanism of action of each drug group. 2. What antiparkinson drugs and why is it necessary to take them during the treatment of parkinsonism that was induced by neuroleptics? 3. Directly acting cholinomimetics: classification, agents, peculiarities of pharmacokinetics, mechanism of action, pharmacodynamic effect, indications, undesirable effect. 4. Indirectly acting cholinomimetics: classification, agents, peculiarities of pharmacokinetics, mechanism of action, pharmacodynamic effect, indications, undesirable effect. 5. M cholinoreceptor-blocking drugs: classification, agents, peculiarities of pharmacokinetics, mechanism of action, pharmacodynamic effect, indications, undesirable effect. 6. Peripheral myorelaxants: classification, agents, peculiarities of pharmacokinetics, mechanism of action, pharmacodynamic effect, indications, undesirable effect. 7. Classification of adrenomimetics. Indirectly acting and mixed acting andrenomimetics: agents, peculiarities of pharmacokinetics, mechanism of action, pharmacodynamic effect, indications, undesirable effect. 8. Classification of adrenomimetics. Directly acting adrenomimetics: agents, peculiarities of pharmacokinetics, mechanism of action, pharmacodynamic effect, indications, undesirable effect. 9. Classification of adrenoreceptor-blocking drugs. Alpha adrenoreceptor-blocking drugs: agents, peculiarities of pharmacokinetics, mechanism of action, pharmacodynamic effect, indications, undesirable effect.

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10. Classification of adrenoreceptor-blocking drugs. Beta adrenoreceptor-blocking drugs: agents, peculiarities of pharmacokinetics, mechanism of action, pharmacodynamic effect, indications, undesirable effect. 11. Antisympathicotonic drugs: agents, peculiarities of pharmacokinetics, mechanism of action, pharmacodynamic effect, indications, undesirable effect. 12. Medicine products of thyroid hormones: agents, pharmacokinetics, pharmacodynamics, indications, contraindications, undesirable effect. 13. Antithyroid drugs: agents, pharmacokinetics, pharmacodynamics, indications, contraindications, undesirable effect. 14. Iodine products: agents, pharmacokinetics, pharmacodynamics, indications, contraindications, undesirable effect.

8.8. Radiology
1. CT and MRI working principle. Indications and contraindications of the investigations. 2. CT and MRI used contrast media. Basic sequences of MRI. 3. Features of multiple sclerosis CT and MRI, differential diagnostics. 4. CT and MRI diagnostics of acquired degenerative CNS diseases (Alzheimers disease, Pick, Fahr disease). 5. Sectional anatomy of the posterior skull fossa (at the level of the fourth ventricle) and o the cerebrum (at the level of the third ventricle), vessels at the same levels. 6. Liquor production, flow in the system of ventricles. Communicative and occlusive hydrocephaly. 7. CT and MRI diagnostics of acute insult in the middle cerebral artery. 8. Disorders of the neuronal migration. CT and MRI diagnostics. 9. CT and MRI diagnostics of the acquired degenerative disorders of the grey matter (Alzheimer, Pick, Parkinson, Fahr diseases). 10. Methodology of pituitary gland analysis. CT and MRI diagnostics of adenomas. 11. CT and MRI diagnostics of the anterior pituitary diseases (inflammation, dismetabolic changes, hyperplasia, tumours). 12. Anatomy, localisation, size of adrenal gland in CT tomogram. Methodology of analysis. The CT and MRI diagnostics of the adrenal adenomas and metastases.

8.9. Essentials of medical diagnosis

1. Evaluation of consciousness and mental activity and meningitic symptoms. 2. Evaluation of movements and senses. 3. Evaluation of coordination and gait. 4. Reflexes: their response evaluation within the standard and in pathology. 5. Symptoms of central and peripheral paralysis. 6. Examination and assessment of extrapyramidal system. 7. Clinical analyses used in endocrinology. 8. Thyrotoxicosis: clinical symptoms, diagnostics. 9. Myxedema: clinical symptoms, diagnostics. 10. Acromegaly and Cushings syndrome: clinical symptoms and diagnostics. 11. Acute adrenal insufficiency: clinical symptoms, diagnostics.

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Name .... Group ... Date ... 9. Appendix 9.1. ACTION POTENTIAL IN NERVES (NEMESIS)

Direction: Make measurements on the computer screen and fill in the tables. Table 1. Exercise Fl. Comparison of mono- and diphasic sumated action potentials (SAP). SAP Diphasic I phase II phase Monophasic Amplitude (mV) Duration (ms)

Table 2. Exercise F2. Stimulation strength and amplitude of SAP. Measur. No. Strength of stimulus (V) Amplitude of SAP (mV)

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Exercise 3. Conduction velocity of SAP. Direction: Calculate conduction velocity of SAP from data of exercise F2 (rough calculation) and exercise F3 (exact calculation) in the space below.

Table 3. Exercise F4. Refractory period of a single nerve fibre. Measur. No. Interval between stimuli (ms) Strength of the second stimulus (mV) Amplitude of the second AP (mV)

Conclusions:

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Name .... Group ... Date ... 9.2. MOTOR SPINAL CORD REFLEXES (HOFFMANN REFLEX)

Direction: Make on-line measurements using a computer and fill in the tables. Table 1. Effect of excitability changes on reflex responses. Amplitudes of responses (mV) T-reflex Exercise F3.1: Exercise F3.2: passive dorsal active plantar flexion flexion

State

Control Light weight Heavy weight State H-reflex Exercise F7.1: Exercise F7.2: passive dorsal active plantar flexion flexion

Control Light weight Heavy weight

Table 2. Effect of Jendrassik maneuver on reflex responses. Amplitudes of responses (mV) State Control Jendrassik maneuver T-reflex Exercise F3.3 H-reflex Exercise F7.3

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Table 3. Exercise F4: Evoking M-wave and H-reflex. (finding stimulus steps for exercise F5) Intensity of stimulus (mA) For maximal M-wave Threshold for H-reflex Difference: Stimulus step (difference/20)

Table 4. Comparison of parameters of responses. Exercise F6. M-wave Latency (ms) Duration (ms) Amplitude (mV) Note. Do not fill the shaded cells! T-reflex H-reflex

Conclusions:

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