Robert B. Devlin, PhD

• Senior Scientist
• Human Studies Division
• National Health and Environmental Effects Research Laboratory
• U.S. Environmental Protection Agency
• Research Triangle Park, North Carolina

However erectile dysfunction what age does it start discount sildenafil uk, Freeman eventually came to believe that once psychological problems got to a certain level of severity erectile dysfunction beat buy discount sildenafil 25 mg on-line, patients became unresponsive to other treatments erectile dysfunction treatment germany purchase sildenafil 50 mg with amex. Following this belief erectile dysfunction self treatment 75 mg sildenafil otc, he shifted his position to using the frontal lobotomy as a more general treatment to be applied earlier to a range of problems erectile dysfunction treatment in india buy discount sildenafil 100mg on line, including depression impotence at 16 discount sildenafil, criminality, schizophrenia, alcoholism, obsessivecompulsive disorder, and hysteria, among others (Acharya, 2004; Kucharski, 1984). To perform this treatment as often and as efficiently as necessary to meet his new criteria, Freeman abandoned the surgical suite, the surgical team, and general anesthesia. Thousands and thousands of individuals were lobotomized in this manner during the 1940s and 1950s in assembly-linelike procedures. Eventually, Freeman abandoned the use of ice picks, which occasionally broke off in the skulls of his patients, and had custom instruments made that were far stronger than the average ice pick. Despite grossly inconsistent results from the procedure-varying from improvement of conditions to extreme worsening of conditions and severe side effects-Freeman continued advocating for the procedure well after pharmaceutical treatments in the mid-1950s had been successfully developed to target the same psychological conditions (Acharya, 2004). The frontal lobotomy was a product of its time and part of the scientific zeitgeist of the 1940s and 1950s. In retrospect, it is seen as being accepted too enthusiastically and blindly as an effective procedure by not only the scientific community but also the public at large who were willing to subject their loved ones to the procedure. He was known to those around him to be moderate in his habits and in possession of selfrestraint, and he was rarely known to be profane (MacMillan, 2000). It is generally accepted that he might not have lost consciousness from the injury. He is said to have sat upright in the cart that drove him to see a doctor (MacMillan, 2000). However, it was noted by friends and relatives that his personality changed dramatically after his accident. He was reported to have become very uninhibited and had difficulties not indulging in all his desires. His employers found that he could no longer complete his previous duties in railway construction. Years after his death, his skull was exhumed, and it was determined that the areas of Mr. More cortical tissue within the primary sensory cortex is dedicated to body parts that have higher numbers of sensory receptors than those that have fewer. Accordingly, very large sections of the primary sensory cortex are dedicated to receiving and processing sensory information coming from the mouth and lips. In contrast, the skin on the back has far fewer sensory receptors and therefore has very little representation in the primary sensory cortex. As in the primary motor cortex, the topographical arrangement of cortical tissue representing the associated body parts creates an illustration that is referred to as the sensory homunculus. Extending the previous example, the mouth and lips on the sensory homunculus are quite large, while the trunk of the sensory homunculus is very small. Most of the memory ability of the temporal lobes can be attributed to the hippocampi (plural). The hippocampi of the temporal lobes are so named because of their curled shape, which early anatomists thought resembled a seahorse. The hippocampal region takes new experiences and turns them into memories that can be stored and accessed later. Individuals who have damage to the hippocampal regions in both temporal lobes display severe to profound deficits in short-term memory because they cannot create new memories (Scoville & Milner, 1957), and long-term memory abilities might be destroyed as well. The primary auditory cortex is the section of the temporal lobes that first receives neural impulses of sound from the ears. Hence, the left hemisphere is responsible for auditory comprehension of verbal language while the right hemisphere is responsible for comprehension of the meaning of environmental sounds, such as a car starting or tree falling, as well as our appreciation of music. The role of the hippocampus in creating new memories was brought to the attention of the medical community in the 1950s. Medications were ineffective in controlling his seizures (Scoville & Milner, 1957). This operation was performed in 1953 and was successful in relieving the patient of most of his seizures. Although his memory of events prior to the surgery was mostly intact, Scoville and Milner (1957) report that 2 years after his surgery H. He also arranged for his brain to be extracted for examination upon his death so that his case could continue to help others (Corkin, 2002). The primary visual cortex is located on the most posterior section of each occipital lobe. The right and left divisions of the primary visual cortex receive and process information from the contralateral visual field. This is the section of the brain that processes and interprets visual information received from the primary visual cortex, allowing for appropriate visual perception. Subcortical Structures Beneath the cortex is the subcortex, its name literally meaning "below the cortex. The following subsections discuss five primary structures, or groups of structures, of the subcortex: the brain stem, cerebellum, thalamus, basal ganglia, and limbic system. The Brain Stem In evolutionary terms, the brain stem is the oldest part of the brain. As a species, we were sleeping, breathing, and mating long before we were enjoying Shakespeare or learning the Pythagorean theorem. Higher levels of cognition came only with the more recent evolution of the huge cerebrum that sits on top of our brain stems. In a basic sense, the brain stem is the structure that connects the spinal cord to the brain. The medulla is the inferior-most section of the brain stem that connects the spinal cord to the pons. Because of the decussation of these tracts of motor neuron fibers, the left side of the body is controlled by the right cerebral hemisphere and vice versa. Because of the decussation of these tracts of motor neurons, a lesion to descending motor tracts above the medulla creates a hemiplegia (one-sided paralysis) or a hemiparesis (onesided weakness) on the side of the body contralateral (opposite) the lesion. If a lesion occurs below the level of decussation (such as within the spinal cord), the resulting hemiplegia or hemiparesis is on the side of the body ipsilateral to (same as) the lesion. The substantia nigra is where the brain produces a neurotransmitter known as dopamine. Stretching between the midbrain, pons, and medulla is a series of nuclei called the reticular formation or the reticular activating system. The cerebellum is known as the "little brain" because of its resemblance to the cerebral hemispheres. Students must be sure not to confuse the cerebellar hemispheres with the cerebral hemispheres. This plant-shaped structure is known as the arbor vitae (Latin for "tree of life"). The right and left cerebellar hemispheres are connected to each other at midline by the unpaired vermis. The vermis is the midline gray matter that connects the cerebellar hemispheres and receives somatosensory information about the body through projections coursing through the pons. After motor plans are assembled in the primary motor cortex, they are sent to the cerebellum to be checked for errors. The cerebellum monitors the intended movements of the motor plan and compares those plans with what the body is actually doing (Duffy, 2005). It does this by altering force, timing, and sequencing of muscle contractions (Diener & Dichgans, 1992). The word peduncle is used primarily to refer to the stalk that a piece of fruit hangs from. The word is used here because early anatomists perceived that the cerebellum resembled a piece of fruit hanging off the pons under the cerebrum. In order from top to bottom, there are three cerebellar peduncles: the superior, middle, and inferior cerebellar peduncles. Each cerebellar hemisphere receives and monitors motor plans from the contralateral cerebral hemisphere (Duffy, 2005). This means that motor signals from the left cerebral hemisphere are checked for errors in the right cerebellar hemisphere and that motor signals from the right cerebral hemisphere are checked for errors in the left cerebellar hemisphere. Because of this arrangement each cerebellar hemisphere is responsible for monitoring movement occurring on the ipsilateral side of the body (Duffy, 2005). The more rapid and precise a body movement is, the greater the likelihood that an error in the execution of motor plans will occur and the harder the cerebellum will work to minimize that risk. For example, as a professional pianist performs a complicated piece, the cerebellum works much harder to monitor the motor plans of finger movements for errors than it does if the pianist simply waved an arm in the air. A far more common activity that also requires a great deal of rapidity and precision in motor execution and that is used by almost everyone every single day is speech. Because the act of producing smoothly articulated speech requires a great deal of cerebellar input, difficulties in articulation can be a first indicator of cerebellar pathology. Pathology of the cerebellum often produces a speech problem known as ataxic dysarthria. This is a perfect location for the thalamus because the thalamus is responsible for taking sensory signals from one part of the nervous system and directing them to another part of the nervous system. Specifically, all afferent (sensory) information (excluding olfaction) passes through the thalamus before arriving at the correct portion of the cerebral cortex for processing. For example, the optic nerve from the eyes passes through the thalamus on its way to the occipital lobes. Afferent impulses of proprioception and taction coming up from the body pass up the spinal cord, through the brain stem, and through the thalamus to the primary sensory cortex in the parietal lobes. The thalamus also takes the motor plans that the cerebellum has checked for errors and sends those motor plans to the appropriate places for execution (Duffy, 2005). The structures of the basal ganglia include the caudate nucleus, the putamen, and the globus pallidus (Duffy, 2005). The basal ganglia and its connections and circuitry are far from being perfectly understood. Lesions to the basal ganglia create problems with initiation of movement, muscle tone, and involuntary movements. The Limbic System A collection of subcortical structures situated primarily on either side of the thalamus makes up the limbic system. This system of subcortical structures is responsible for such things as sense of pleasure, mating and feeding behaviors, fight-or-flight response, as well as the generation of emotions, emotional memory, and sense of motivation. Disturbances of the limbic system can create difficulties such as emotional imbalances, anxiety disorders, and panic attacks, among other problems. The Spinal Cord the spinal cord is a bundle of white matter tracts and gray matter housed within the bony vertebral column. It allows afferent (sensory) impulses coming from the body to be transmitted to the brain and efferent (motor) impulses from the brain to be transmitted to the body. The spinal cord then passes inferiorly through the vertebral column until it narrows at a section known as the conus medullaris. The spinal cord terminates inferiorly at the conus medullaris in the lumbar region of the lower back. The grayness of the butterfly shape stands out in contrast to the whiteness of the surrounding tissue. This gray tissue is spinal nerve matter and is the location where the spinal nerves enter and leave the spinal cord. The nerve cells of the dorsal horns deliver the sensory (afferent) information from the spinal nerves to the surrounding white matter tracts to be transmitted to the brain. The nerve cells of the ventral horns deliver motor (efferent) information from the associated white matter tracts in the spinal cord to the spinal nerves to be delivered to the organs and muscles. In the usual orientation of the spinal cord within the vertebral column, the dorsal horns point posteriorly, and the ventral horns point anteriorly. In addition to being a major highway between the brain and body for afferent and efferent signals, the spinal cord is also involved in basic reflexes. A reflex is the production of a physical movement that occurs automatically in response to a stimulus and is initiated below the level of awareness. In fact, the person began pulling the hand away before he realized his hand was being burned or that he was even in pain. One very important reflex of concern to speech-language pathologists is the stretch reflex. The most well-known example of this is the kick a leg makes unintentionally after the knee is tapped, the patellar reflex. A sensory receptor in that muscle called a muscle spindle is stretched as well and sends an afferent signal to the spinal cord indicating that the muscle has moved. The spinal cord receives this signal and recognizes that the leg muscle has been moved and yet no instructions came down from the brain telling that muscle in the leg to do so. The spinal cord reacts accordingly to the problem of a body part moving with no commands from the brain to do so. The spinal cord here can be thought of as a mediator between the body and the brain. The spinal cord monitors the motor plans for the muscles as they come down from the brain, and then it sends those motor plans out along the cranial and spinal nerves to the muscles for execution. When a muscle behaves in a way contradictory to the motor plans sent down from the brain, the spinal cord is the first to react. In evolutionary terms, this could mean the difference between an escape from a saber-toothed tiger and a saber-toothed tiger tearing off an arm. It recognizes the situation as an emergency and takes immediate action without consulting the brain.

Syndromes

• Salty-tasting skin
• Abscess (collection of pus around the urethra)
• Stroke
• Rapid pulse and cold sweats immediately after eating
• Parathyroid
• Liver biopsy

The spectrum of endometrial pathology induced by progesterone receptor modulators disease that causes erectile dysfunction order sildenafil 50mg free shipping. Endometrial morphology after treatment of uterine fibroids with the selective progesterone receptor modulator impotence 25 years old sildenafil 75 mg fast delivery, ulipristal acetate erectile dysfunction dr mercola cheap sildenafil 100mg amex. Endometrial polyps: prevalence erectile dysfunction pump for sale sildenafil 100mg without a prescription, detection and malignant potential in women with abnormal uterine bleeding erectile dysfunction treatment sydney discount sildenafil 25 mg fast delivery. Transvaginal ultrasound and hysteroscopy as predictors of endometrial polyps in postmenopause erectile dysfunction pills canada buy sildenafil 100mg low cost. Clonal 6p21 rearrangement is restricted to the mesenchymal component of an endometrial polyp. Limitations of the criteria used to diagnose histologic endometritis in epidemiologic pelvic inflammatory disease research. Reproducibility of biopsy diagnoses of endometrial hyperplasia: evidence supporting a simplified classification. Histopathological findings of the endometrium in patients with dysfunctional uterine bleeding. Ciliated carcinoma-a variant of endometrial adenocarcinoma: a report of ten cases. Endometrial epithelial metaplasias: proliferations frequently misdiagnosed as adenocarcinoma. Papillary proliferation of the endometrium: a clinicopathologic study of 59 cases of simple and complex papillae without cytologic atypia. Simple and complex hyperplastic papillary proliferations of the endometrium: a clinicopathologic study of nine cases of apparently localized papillary lesions with fibrovascular stromal cores and epithelial metaplasia. Mucinous endometrial epithelial proliferations: a morphologic spectrum of changes with diverse clinical significance. Comparison of morphologic and immunohistochemical features of cervical microglandular hyperplasia with low grade mucinous adenocarcinoma of the endometrium. Proliferative mucinous lesions of the endometrium: analysis of existing criteria for diagnosing carcinoma in biopsies and curettings. In this article, the rationale for the new classification of precursors of endometrial carcinoma and the main types of endometrial carcinoma are discussed. Common problems in the differential diagnosis, and the role of immunohistochemistry and molecular categorization of endometrial carcinoma, are also covered. The term has served historically to identify a spectrum of endometrial changes, some of them related to cancer. A new classification was proposed in 1994 and accepted in 2003 dividing endometrial hyperplasia into four groups based on architectural complexity and cytologic atypia: (1) simple hyperplasia without atypia, (2) complex hyperplasia without atypia, (3) simple hyperplasia with atypia, and (4) complex hyperplasia with atypia. This scheme was since challenged due to its lack of reproducibility, particularly concerning criteria for nuclear atypia. Consequently, to improve interobserver reproducibility, it was proposed to collapse the four-tier scheme into two categories: nonatypical and atypical. Notice the presence of irregular white to yellow tissue protruding into the endometrial cavity. Although it typically occurs in perimenopause, it can be also seen in reproductive-age and postmenopausal women. It is part of the spectrum of endometrial changes secondary to continuous unopposed estrogen stimulation, which may result from (1) successive prolonged periods of anovulation, (2) estrogen administration, (3) peripheral conversion of androgens to estrone in adipose tissue in obese women or patients with polycystic ovarian syndrome, or (4) estrogen-secreting ovarian neoplasms. Patients typically present with abnormal uterine bleeding (hypermenorrhea, dysmenorrhea, intermenstrual bleeding). The epithelial lining is pseudostratified, with cells being similar to those seen in mid to late proliferative phase. The cells display elongated nuclei with evenly dispersed chromatin and inconspicuous nucleoli. Importantly, crowded (hyperplastic) glands imperceptibly blend with noncrowded glands, and there are no significant cytologic differences between the two populations. In the event of superimposed ovulation or exogenous progestin administration, superimposed secretory changes will be observed; in this scenario, changes will be similar to the normal secretory endometrium, but glands remain somewhat disorganized and lack the perpendicular arrangement of the normal secretory phase. However, with practice these artifacts are easy to recognize, and importantly, the diagnosis of hyperplasia must be made in intact pieces of endometrium without significant fragmentation. During the secretory phase, glands increase in volume, exceeding 50% of the surface area. However, unlike nonatypical hyperplasia, secretory endometrium retains organization and orderly glandular distribution perpendicular to the endometrial surface. The distinction between nonatypical hyperplasia and disordered proliferative endometrium is often difficult but anovulatory cycles including disordered proliferative endometrium, postmenopausal cystic atrophy, polyps, and metaplasias. Of note, endometrial hyperplasia usually generates abundant material in curettage specimens, which is a helpful clue in the distinction from atrophy. Nonatypical hyperplasia is usually a diffuse process whereas polyps and metaplastic changes are discrete lesions. There is an increase in the number of endometrial glands, with surface area exceeding that of the surrounding stroma (A). The glands show cytologic features similar to those seen in proliferative endometrium (C). Disordered proliferative endometrium commonly occurs in perimenopausal women, frequently in the setting of anovulatory cycles. The defining feature of hyperplasia is the increased glandular density; although disordered proliferative endometrium has gland irregularity, the glands do not exceed 50% of the surface area, unlike hyperplasia. Cystic atrophy occasionally may be confused with nonatypical hyperplasia that shows prominent gland dilation; however, the glands in the former are lined by a single nonstratified layer of low cuboidal cells with no mitotic activity in contrast to the pseudostratified appearance of the nuclei associated with mitoses seen in nonatypical hyperplasia. Endometrial polyp differs from nonatypical hyperplasia in its polypoid configuration, presence of dilated thick-walled blood vessels, stromal fibrosis or compact appearance of the stroma, and glandular irregularity with arrangement parallel to surface endometrial epithelium. In this distinction, it is important to keep in mind that polyps can have glandular crowding; in other words, polyps can contain areas of "hyperplasia. If the crowded areas are not significantly different from the background polyp glands, then it is nonatypical, and the lesion should be classified as endometrial polyp. Finally, the absence of plasma cells, granulomata, and reactive changes in the stroma helps in the distinction between endometrial hyperplasia and chronic endometritis. Any type of endometrial metaplasia (ciliated eosinophilic, mucinous) may occur as part of endometrial hyperplasia. If the low-power architecture is that of a normal endometrium, the diagnosis of hyperplasia can be excluded. Patients present with abnormal uterine bleeding (postmenopausal bleeding, hypermenorrhea, dysmenorrhea, intermenstrual bleeding); others may be found to have an abnormal endometrium on ultrasound during work-up for infertility, pain, or other complaints. A minority is identified after an abnormal Papanicolaou smear showing atypical glandular cells or endometrial cells after the age of 45 years prompting endometrial sampling. Pathologic assessment in this setting requires adequate clinical information, including time since initial diagnosis and duration of progestin treatment. Ideally, the first diagnostic sample should be compared with the follow-up specimen. Architectural changes include decrease in volume of disease and number of involved fragments, diminution of the glandular crowding, effacement of the nuclear stratification, and decreased cellularity. In most cases, the altered cytomorphology of the crowded area is seen as large round nuclei with inconspicuous nucleoli, increased nuclear-to-cytoplasmic ratio and loss of axial polarity. The distinction relies on the presence of altered cellular differentiation in the crowded glands that is significantly different from the background endometrium. The area of glandular crowding measures more than 1 mm in greatest dimension (A) and is composed of closely packed individual glands with a gland-tostroma ratio exceeding 1:1 (B). At high power, the cells demonstrate cytomorphology significantly different from the background endometrium (see inactive glands in upper right aspect); neoplastic cells have large, round nuclei with pseudostratification and inconspicuous nucleoli (C). As in the nonpolypoid endometrium, comparison between crowded and noncrowded glands within the polyp is imperative. This exercise may be challenging in curettage specimens, in which it may be difficult to determine whether the fragments involved by gland crowding represent a polyp or not. Comparative analysis of the gland populations within the same tissue fragment suffices in most cases. Endocervical tissue with reactive changes, particularly florid squamous metaplasia and microglandular hyperplasia may be observed in endometrial samplings. In the continuum of endometrioid neoplasia, carcinoma is defined by the presence of invasion and/or effacement of the endometrial stroma by the glandular proliferation. Extensive papillary and villoglandular architecture with absence of stroma in between the definition of the minimum amount (size of span, surface area, or number of fragments) of these patterns needed to diagnose low-grade endometrioid adenocarcinoma is not resolved and remains a subjective interpretation by the individual pathologist. However, some authors recommend that the last three findings are required to occupy at least half of a low power field, roughly corresponding to an area >2 mm in maximum dimension. Spectrum of metaplasias includes squamous morular (A), mucinous (B), secretory (C), and papillary (D, also notice mucinous differentiation). Notice the background pseudodecidualized stroma, absence of conventional epithelial "atypia," and the rather bland nuclear features. Unlike endometrial intraepithelial neoplasia, this lesion is characterized by a visible basal reserve cell layer underneath the columnar epithelium. Additional findings suggestive of carcinoma include necrosis and foamy macrophages. This can be safely recommended to peri- and postmenopausal patients and those who do not want to preserve fertility. As outlined earlier in this chapter, a significant subset of patients with this condition will have endometrial carcinoma on hysterectomy. While stroma can still be appreciated around most of the neoplastic glands, there is focal cribriform architecture and confluence bordering on early well-differentiated carcinoma. However, this is not an ideal pathologic classification, as there is morphologic overlap between the two types, particularly in the setting of a high-grade tumor. Furthermore, recently the potential importance of incorporating the molecular profile in the classification of endometrial cancer has been shown. In these situations, hormonal treatment with high-dose progestins is a valid temporary alternative. Progestin treatment is recommended for at least 6 continuous months, at which point a follow-up biopsy is required; biopsies earlier in the treatment may be indicated if new symptoms or complications occur. In terms of pregnancy-related outcomes, the live birth rate after progestin treatment is up to 73% for those who actively attempted pregnancy. In biopsy and curettage specimens, the tissue may appear normal or quite abundant, depending on tumor volume. In the latter case, tumoral tissue is usually soft, fleshy, and tan with variable hemorrhage and necrosis. In hysterectomy specimens, the uterus may be normal in size or enlarged (due to massive cavitary growth and/or extensive myometrial invasion). It also may be seen as discrete nodules or variably thickened plaques with a white to pale tan and soft cut surface. Tumor may not be grossly evident or may only involve an endometrial polyp (a finding more commonly seen in serous carcinoma). Rarely, carcinomas may arise in the cornual region or within intramural adenomyotic foci; in these situations, proper visualization of the tumor and proper sectioning in relationship to the uterine wall thickness may be difficult. Adenomyosis involvement by the tumor appears as islands of fleshy and soft tan tissue dispersed throughout the wall. In contrast, myometrial invasion often appears as a firm confluent mass extending into the wall with a pushing or infiltrative border. There is, however, macroscopic overlap between adenomyosis and myoinvasive carcinoma, and in some instances, invasion may not even be evident on gross examination. Extension to the cervix may be seen with the naked eye and should be noted as it affects stage and prognosis. If complicated by cervical stenosis, endometrial carcinoma may be associated with pyometra or hematometra. Carcinomas with exuberant squamous differentiation may appear flaky, whereas mucinous carcinomas may display a gelatinous or mucoid appearance. Necrosis and hemorrhage are usually seen in the context of high-grade or large, deeply myoinvasive tumors. Whenever possible, sections of the tumor and underlying uterine wall should be full-thickness (from endometrial cavity to uterine serosa); if the uterine wall is too thick to fit in a single block, a composite section should be provided. The deepest point of gross penetration into the wall should always be sampled as a full-thickness section. In addition, adjacent normal-appearing endometrium (if present) should be included. If the tumor grossly involves the cervix or is close to it, a composite section from the distal aspect of the tumor to the ectocervix is required. Pathologic staging requires careful macroscopic and microscopic assessment of the tumor extent. Challenging situations in the staging exercise are discussed in the following paragraphs. Notice the mucinous differentiation of the abnormal glands and the significant nuclear atypia. Extensive squamous differentiation within a low-grade endometrioid carcinoma has a pearly glistening appearance. The tumor shows an undulating interface but appears to be confined to the endometrium (B).

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An expressive language deficit is a difficulty in formulation and production of language to communicate an intended meaning erectile dysfunction treatment with diabetes buy sildenafil 100 mg overnight delivery. However erectile dysfunction in a young male buy sildenafil australia, lesions almost anywhere in the anterior portion of the left hemisphere are likely to produce some expressive deficits impotence treatments natural purchase sildenafil 100mg fast delivery. A receptive language deficit is a deficit in the ability to derive meaning from language top erectile dysfunction doctors new york buy sildenafil in india. These small lesions can produce aphasia with few or no discernable concomitant cognitive or physical deficits erectile dysfunction new zealand 100mg sildenafil mastercard. A similar isolated deficit profile of limited deficits can be produced by tumor or focal surgical trauma erectile dysfunction caused by neuropathy sildenafil 100mg low price. In contrast, a large stroke in the left hemisphere is capable of producing profound aphasia and utterly debilitating cognitive and physical deficits. However, aphasia can also be associated with more generalized damage to the brain such as that often produced by traumatic brain injury or degenerative disease. Etiologies that produce general damage or degeneration of the brain can often produce a broader spectrum of cognitive and physical deficits alongside aphasia-like language deficits. Signs and Symptoms of Aphasia Anomia the most pervasive deficit in the aphasias is anomia. A person with anomia knows the meaning he wants to communicate but cannot find the appropriate word or words to do so. Individuals with aphasia who display anomia can often describe an object in detail and maybe even use hand gestures to demonstrate how the object is used but cannot find the appropriate word to name the object. Verbal Comprehension Deficits Whereas the term receptive language deficit can refer to a deficit in any modality of language interpretation (verbal language, written language, etc. In aphasia, verbal comprehension deficits are assumed to be acquired deficits resulting from neurologic damage. It is common for most individuals with aphasia to display some level of difficulty understanding verbal language. Therefore, individuals with mild verbal comprehension deficits usually have no difficulty interacting socially and understanding or correctly guessing the meaning of most language presented to them. It might be only when presented with a lengthy or detail-heavy utterance that the verbal comprehension deficits of a person with aphasia begin to show. Individuals with more severe levels of aphasia display far more dramatic verbal comprehension deficits and might lack the ability to understand even a single word. This is illustrated anecdotally by individuals who have recovered from a stroke that produced moderate or severe receptive language deficits when they state that directly after the stroke the speech of others and even their own speech suddenly sounded like a foreign language. For example, let us say I cannot think of the name of the guy who played Neo in the Matrix. I probably remember that he has an unconventional first name and maybe even that it starts with a K. Individuals experiencing expressive deficits such as anomia often state that they know exactly what they want to say, but they just cannot find the words. Paraphasias Even if individuals with aphasia can get around their anomia and find the words they want to say, they might have difficulties producing these words error free. Paraphasias are errors in expressive language unrelated to motor deficits but linked to higher language-level deficits associated with aphasia. Goodglass, Kaplan, and Barresi (2001a) define paraphasias as syllables, words, or phrases produced unintentionally by an individual with aphasia. A phonemic paraphasia, also known as a literal paraphasia, is when the word produced is discernable, mostly correct, and yet there are phoneme-level mistakes. Phonemic paraphasias are phoneme "substitutions, omissions, or transpositions" (Goodglass et al. An example of a phonemic paraphasia is when an individual with aphasia intends to produce the word staple but transposes the initial /s/ phoneme to the final position and produces "taples. Goodglass and associates (2001a) define a neologism as when 50% or more of the intended word or utterance is indiscernible. An example of a neologism is when an individual with aphasia intends to produce the word pencil but instead produces "dowfler. A substitution of a word that is unrelated in meaning to the intended word is categorized as an unrelated verbal paraphasia (Goodglass et al. For example, substituting the word lunch for the word bicycle is an unrelated verbal paraphasia. For examples of many different types of paraphasias, see the video interview Recovering from Mixed Fluent Aphasia. Perseveration To perseverate is to do something repeatedly, redundantly, and, more often than not, inappropriately. Although the word perseverate is commonly used in child language literature to refer to repetitive and obsessive behaviors of children with autism, it is also used in adult language disorders. In adult language disorders, such as the aphasias, a perseveration is a word that is said repeatedly and inappropriately. A perseverative paraphasia occurs when a word produced earlier is repeatedly and inadvertently produced by an individual instead of the intended word (Goodglass et al. An example of this is when an individual with aphasia correctly names a hammer as a "hammer" but then involuntarily continues to produce "hammer" when presented with other items, despite knowing the correct names of the other items (see the Clinical Note on perseverative paraphasia). Often, speechlanguage pathologists can learn which words individual patients get stuck on and can avoid using those words in therapy. This is often seen in individuals with aphasia who lack the ability to use language with appropriate grammatical construction. This most often arises because individuals with many kinds of aphasia systematically omit function words in their utterances. Function words, or functor words, are the inbetween words used to frame the major content words in a sentence. As a result of the omission of function words, the speech of individuals with aphasia might be grammatically incorrect while still conveying a great deal of meaning. The speech output of these individuals is often referred to as sounding telegraphic, which indicates that few words are used, but the words that are used are generally used with some degree of efficiency. For examples of agrammatic speech of individuals with aphasia, see the videos Recovering from Mixed Fluent Aphasia, Living with Chronic Nonfluent Aphasia, and Recovering from Stroke and Nonfluent Aphasia. In fact, babies begin mimicking verbalizations of their parents at the point in their brain development when their arcuate fasciculus has matured enough to begin to function. However, just because a person cannot repeat a word does not necessarily mean that she cannot understand the meaning of the word she has been asked to repeat. Dyslexia is commonly used to refer to congenital or developmental reading deficits. Lesions to the language-dominant hemisphere at the angular gyrus often result in alexia and agraphia. Often but not always, individuals with deficits in auditory comprehension of language also display deficits in comprehension of written language. Similarly, individuals with anomia usually cannot find words for the production of verbal language or written language. However, there are exceptions, and speechlanguage pathologists should always thoroughly test all language modalities. The most curious example that comes to mind from my own experience has to do with an older woman I saw years ago. She was about 75 years old and had experienced one left hemisphere stroke many years earlier that had left her mildly anomic. However, a more recent and severe left hemisphere stroke had transformed this mild anomia into a far more significant expressive language deficit consisting of severe anomia and a greatly reduced average length of utterance. We generally began each therapy session with her attempting, with my help, to name common objects. I quickly discovered in therapy that if she was presented with a hammer, a picture of a hammer, the word hammer written on a card, or even the gesture of how to use a hammer to drive a nail, the only word this woman would be able to produce verbally for the rest of the session was hammer, despite the fact that she knew very well that every other object presented to her was not a hammer. When she attempted to produce the target word to name any other objects, her brain would foil all attempts at success, and to her amazement her mouth would produce the word hammer. The perseveration on the word hammer was devastatingly frustrating and usually lasted about 3 hours before she was able to produce any other words. Once I learned this, therapy progressed smoothly, and this woman made great improvements, but we certainly avoided the word hammer. Later, this young man discovered that the letters were not written in a foreign language but that he had lost the ability to visually interpret writing in his native language. More recently, the Canadian novelist Howard Engel experienced a stroke in the same part of his brain and stated that he had no idea he had experienced a stroke until he picked up his morning paper and was surprised to see it written in a foreign language, possibly "Serbo- Croatian or Korean" (Krulwich, 2010). Despite losing the ability to read, his ability to write was preserved, and eventually Engel produced the memoir the Man Who Forgot How to Read. An intact ability to write despite losing the ability to read occurs because writing abilities are preserved in motor memory, which is stored in anterior portions of the brain entirely different from the damaged language decoding and reading centers, which are located more posteriorly in the brain. Related Behaviors Self-Repairs A self-repair occurs when a speaker restates or revises a word or phrase in an attempt to produce it in an error-free fashion or refine it to better reflect the intended meaning (Levelt, 1983). Unimpaired speakers produce speech errors and repair them easily by restating words or revising phrases. Most unimpaired speakers are highly successful at correcting speech errors on their first attempt (Farmer, 1977; Levelt, 1983). Individuals with nonfluent aphasia make far more errors and therefore produce proportionately far more self-repairs and attempts at self-repairs to correct for these errors (Farmer, 1977; Liss, 1998). However, speakers with aphasia are far less successful at selfrepairing errors in their speech than unimpaired speakers are (Farmer, 1977; Marshall & Tomkins, 1982). Farmer (1977) found that fewer than half of the selfrepair attempts of her participants with nonfluent aphasia were successful. These perseverative and unsuccessful attempts to selfrepair semantic and phonetic errors can further compromise the ability of speakers with aphasia to communicate by decreasing their fluency of speech. Marshall and Tomkins (1982) and Whitney and Goldstein (1989) also observed that multiple attempts to self-repair an error within an utterance can slow the rate of speech and increase speaker frustration. More recently, it has also been suggested that recurring attempts at self-repair by speakers with aphasia might actually contribute to maintenance of their long-term deficits. Fillingham, Hodgson, Sage, and Lambon Ralph (2003) studied the effects of errorless learning and errorless therapy on individuals with aphasia. These researchers suggest that the repetitive unsuccessful attempts of people with nonfluent aphasias to self-correct speech errors could function as a practicing and habituation of the production of speech errors. Speech Disfluencies Certain kinds of speech disfluencies can inhibit the fluency of individuals with nonfluent aphasia (Brown & Cullinan, 1981, p. These behaviors consist of sound, word, part-word, or phrase repetitions, prolongations, and interjections (Brown & Cullinan, 1981). It should be noted that the disfluency types associated with stuttering such as phoneme repetitions, syllable repetitions, or part-word repetitions are usually rare in aphasia. Individuals with aphasia most often produce the normal disfluencies, such as interjections and self-repairs but at pathologic levels of frequency. Struggle in Nonfluent Aphasias Most unimpaired individuals need not put forth any effort to express themselves verbally. Verbal expression is usually produced quite automatically and is, therefore, taken for granted almost universally by unimpaired speakers. However, when individuals acquire expressive language deficits, this automaticity of speech is lost to some degree. Most often, individuals respond to this loss by becoming frustrated and angry at suddenly having to expend incredible amounts of effort to produce and use language that formerly was effortless. For instance, as individuals with anomia attempt to overcome their word finding difficulties and find the target word, they struggle visibly. Individuals with these deficits will struggle with their deficits and their frustration in different ways. Some clench their fists, grit their teeth, sigh, stare into space, or swear and curse, whereas others simply acknowledge their difficulties verbally and quietly persevere. Preserved and Automatic Language It is a long established curiosity that even in severe cases of aphasia, it is common for some production of rote and overlearned language to be preserved. This can take the form of an intact ability to sing songs that the individual often heard or sang premorbidly. In fact, attempting to elicit a well-known song such as the "Happy Birthday" song is a fixture of aphasia evaluations. Preserved language skills might also take the form of intact abilities to recite rote language such as the days of the week, the months of the year, and the count from 1 to 10. Often, individuals with aphasia might be unable to begin the rote language task by themselves, but they can take over production of the task when provided with the first few words. Language that is produced very automatically or that is associated closely with some stimulus might also be preserved. For instance, many individuals with aphasia who cannot produce any volitional expressive language might still be able to produce curse and swear words perfectly to express their pain and frustration when a nurse stabs them with a needle or a speech-language pathologist asks them to complete a task they are having difficulty with. Another example is when a speech-language pathologist asks the person with aphasia to say the word hello, the individual might not be able to do so but can promptly utter "Hello! The presence of preserved and automatic language often is used as a prognostic tool. Speechlanguage pathologists test for the presence of preserved or automatic language by simply asking the individual to produce the desired language. Automatic and preserved language is also useful clinically because, when a person cannot produce any other verbal output, it can provide a useful starting point in therapy to begin rebuilding expressive language skills. Associated Deficits In the classroom, aphasia is usually spoken of as being a pure language disorder with no associated cognitive deficits. Theoretically and academically, aphasia is only a language disorder, and students must first understand aphasia and how it affects communication before layering concomitant disorders and their potential effects on top of this definition. Most individuals with aphasia also have deficits in cognition and motor skills that can affect speech, swallowing, or both. For example, in a highly Protestant and religious community in the Deep South where most residents attended church, I found that I could elicit the recitation of the Bible verse John 3:16 from many, if not all, individuals with aphasia. To a religious individual who has lost all other language and expression, the intrinsic value of being able to recite a Bible verse should not be overlooked.

Diseases

• Myopathy tubular aggregates
• Enolase deficiency
• Pontoneocerebellar Hypoplasia
• Vasquez Hurst Sotos syndrome
• Peripheral T-cell lymphoma
• Optic atrophy, autosomal dominant
• Presbycusis
• Neurofibrillary tangles
• Brachydactyly long thumb type
• Ergophobia