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It would minimize administrative and customs costs because Israeli customs o ces would continue to erectile dysfunction treatment medscape order generic cialis with dapoxetine online collect and reimburse tari s on Palestinian imports transiting Israeli ports erectile dysfunction young living purchase generic cialis with dapoxetine on line. It could also strengthen industrial supply relationships between the two countries erectile dysfunction future treatment buy 60mg cialis with dapoxetine with amex. It would leave Palestine highly vulnerable to impotence cure food order cialis with dapoxetine 30 mg line shocks in the Israeli economy and to politi cal relations with Israel. The tari structure of the union would likely re ect Israeli interests more than Palestinian interests, potentially impeding the development of competitive Palestinian sectors. A future Palestinian state could also lose tax revenues through leakage to Israel of import duties and value-added taxes as is currently the case. If continued close trade links with Israel come at the price of barriers to trade with other potential partners, a future Palestinian government might seek more open trade relations with other partners. Alternatively, a future Palestinian state may choose to negotiate free trade agree ments with a number of states, including Israel. Under such a trade regime, Palestine would impose no tari s on imported goods from all of its trading partners with which it has free trade agreements, including Israel. The di erence here is that Pales tine might set nonzero tari s for di erent goods. Given the economys small size and the need to generate as much economic activity as possible, nonzero tari s would not be recommended. Economics 125 portunity to strengthen ties with other countries in the Middle East, North America, Europe, and Asia, diversifying its exports markets and sources of supply. If Palestine were to eliminate all or most tari s, which act as a tax on commerce, it would reduce administrative costs since an extensive customs apparatus would not be needed. A completely free trade regime would help Palestine foster use of its comparative advan tage in labor, accelerating economic growth. If Israel were to decide not to provide a future Palestinian state duty-free access to the Israeli market, growth in Palestinian exports would be retarded by the additional costs imposed by Israeli tari s on Palestinian exports. The reduction in trade could adversely a ect Palestinian economic growth in light of Palestines underdeveloped economic relations with the rest of the world and its lack of transport infrastructure. For decades, relatively open Israeli labor mar kets have allowed Palestinian workers to commute to jobs in Israel and the settlements and return to their homes in the West Bank and Gaza at night. Easy Palestinian access to the Israeli labor market (in terms of legally sanctioned access either with or without permits) would provide signi cant employment oppor tunities for the Palestinian workforce. Wages in Israel tend to be substantially higher than those in the West Bank and Gaza, boosting Palestinian incomes. Higher Palestinian incomes translate into higher expenditures, which would fuel the domestic economy. The Israeli government wishes to ensure that no Palestinian workers in Israel engage in attacks on Israelis. In addition, the Israeli government has frequently used closure of borders or closure of Palestinian towns and cities as a means of combating attacks. Closures make it virtually impossible for Israeli rms to hire Palestinians because employers can never be sure that their employees will be able to make it to work. For Israeli rms to be will ing to hire a signi cant number of Palestinians, Palestinians would have to have rela tively unfettered access across Israeli borders. Future Israeli governments may conclude that the security risks of permitting large numbers of Palestinians to work in Israel are so large that the past practice of permitting Israeli rms to employ Palestinian labor is unacceptable. Also, it is currently illegal for Palestinian workers to remain overnight in Israel. Four critical issuestransaction costs, resources, the Palestinian trade regime, and Palestinian employment in Israel will shape the conditions under which economic activity occurs in an independent Palestine. In this section we use these issues to construct four scenarios of conditions that Palestine could face with respect to its economic development. A study by the World Bank (2002c) examines how the Palestinian economy might develop under di erent scenarios of economic and political relations with Israel, including various trade regimes and degrees of access of Palestinian labor to employment in Israel. The study uses a comprehensive macroeconomic model that incorporates foreign trade and labor markets in addition to growth accounting, provid ing projections for 20022010. Like the World Bank study, we de velop plausible scenarios based on the territory encompassed by a new Palestinian state (geographic contiguity) and its economic relations with Israel (economic integration). As the preceding sections suggest, many di erent policy and investment decisions will shape the future of Palestinian economic development. However, some simpli cation is necessary to focus on the major drivers of economic development in Palestine and to allow for clear inferences to be drawn. We, therefore, concentrate on the e ects of contiguity and integration in the following section but recognize that many other factors, such as the quality of governing institu tions, will play important roles also. Allocations of rights and institu tional arrangements can always be renegotiated in the future should parties deem it bene cial. Economics 127 Second, we implicitly assume that security is maintained throughout the 2005 to 2019 time frame. In other words, our scenarios are predicated on the notion that economic activity occurs in a safe and stable environment. Lack of security, and result ing responses to it, would inhibit all aspects of Palestinian economic development de scribed in this chapter. Consequently, our conclusions are correctly seen as what might happen in the best case. Geographic Contiguity A major determinant of transportation and transaction costs that a Palestinian state will face and the resources that will be available to it will be geographic contiguity. We de ne geographic contiguity broadly to include the amount of territory allocated to the Pales tinian state, special sites (such as East Jerusalem and the Jordan valley), the integrity or fragmentation of this territory (perhaps because of settlement roads), and control over elements associated with this territory such as water rights, airspace, and borders. The low contiguity case re ects conditions that are similar to but still an improvement over the period since the signing of the Oslo Accords. It assumes that for the most part, Israel retains control over East Jerusalem, the existing settlements, aquifers and surface water in the West Bank, external borders, and the customs apparatus. However, Israel would have less authority over the internal situation in the Palestinian state: It could not impose internal closures or curfews or prevent Palestinians from developing their own infrastructure. This case also assumes that most settlements are dismantled or exchanged for contiguous land elsewhere. Economic Integration We use an additional composite dimension called economic integration with Israel that encompasses the Palestinian trade regime and Palestinian access to Israeli labor mar kets. In the sense used here, economic integration is similar to border permeability or border openness used elsewhere in this book. Under high economic integration, cross-border commerce resembles that which existed under the Oslo Accords. This case assumes a customs union (or perhaps a free trade agreement) between Palestine and Israel, a large number of Palestinians are allowed to work in Israel (likely around the pre-intifada 23 Given that the low-contiguity case in our analysis re ects an improvement over the status quo (from the Palestin ian perspective), any nal agreement that encompasses less land or fewer resources than the low-contiguity caseor that entails limitations on movement of goods and people within Palestinian territory, via closure or curfewpre sumably would make it more di cult to sustain economic growth than our analysis suggests. Under low economic integration, cross-border commerce with Israel is impeded by a symbolic or physical wall. This case also assumes that the current customs union with Israel ends and Palestinian businesses do not have favorable access to Israeli markets; that barriers to labor mobility signi cantly reduce the number of Palestinians work ing in Israel; and that restrictions are imposed on tourists and others wishing to cross the border. Under both cases, Israel remains an important trading partner, but condi tions under high economic integration are more conducive to economic cooperation between Palestine and Israel, providing the possibility of higher trade volumes, more cross-border investment, and more collaboration in tourism and other sectors than in the low economic integration case. Four Scenarios The degree of geographic contiguity determines how much control Palestinians will have over resources and movements of people and goods within the new state. The de gree of economic integration captures future economic relations between the Palestin ian state and Israel. Together, these dimensions create a simple two-by-two framework describing initial conditions confronting the Palestinian state. The likelihood of ending up in any of the four quadrants will vary depending on negotiations to establish the new state and the strategic choices made. It is also possible that the new state could be in more than one quadrant in the rst ten years of its existence. This section presents these scenarios without delving into their likelihood, but these issues are discussed in some detail in Chapters Two and Tree. As is clear below, there are real consequences to the degree of contiguity and integration of the new state. Tese scenarios are (1) high contiguity/high integration, (2) high contiguity/low integration, (3) low contiguity/high integration, and (4) low contiguity/low integra tion. In the rst scenario, Palestine consists of a contiguous West Bank with an uninterrupted road and rail link to Gaza. Consequently, trans port and transaction costs for businesses and consumers are relatively low. Citizens can move freely within the state and travel to and from Jordan and Israel without much cost or delay.

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Gilbert (2008) tells us that it 16 is argued that 95 per cent of what is known about the brain has been discovered in the last 15 17 years erectile dysfunction wife proven 60 mg cialis with dapoxetine, which erectile dysfunction medicine in bangladesh buy 60mg cialis with dapoxetine amex, if true erectile dysfunction chicago purchase cialis with dapoxetine discount, is remarkable erectile dysfunction treatment bodybuilding purchase cheapest cialis with dapoxetine. As a relatively new area for research and classroom 18 application there is, understandably, some level of disagreement concerning the value of the 19 application of the findings of neuroscience research to classroom practice. However, there is 20 undoubtedly value in some of the claims of the brain learning advocates and for that reason it 1 is of value to spend time here investigating the claims and then some of the suggested approaches 2 to teaching with the brain in mind. Even the 4 uninitiated, if questioned, would consider that learning takes place in the brain. She continues 5 to say that:Advocates of brain-based teaching insist that there is a difference between brain 6 compatible education, and brain-antagonistic teaching practices and methods which can 7 actually prevent learning. As we will see, there are some principles that have developed out of the brain 1 based learning movement which, if applied, seem to have the potential to improve the learning 2 environment and to lead to improved learning. The important point about intelligence and the lowly 41 86 Brain-based learning neurone is not to do with how many an individual might have, but to do with the number of connections that have been made between them. His intelligence came from the number of connections he had between his brain cells. The ability of the brain to forge new links and to re-make links (akin to unlearning something that may be wrong) is referred to as plasticity. The brain is, in a sense, moulded by our experiences of everyday life in general and by specific learning situations. Every time learning takes place new links are made and every time the same learning is used or rehearsed the links become stronger and in doing so become more fixed. The patterns of links between neurones are referred to as templates and each individual item of learning has its own precise template. We have billions of templates and many more billions of individual links between cells. The more we learn, the greater number of links are made and the more complex the already complex patterns of connection become. This means that the young have a great potential for learning, but it does not mean that older dogs cannot learn new tricks. As long as new experience comes along and the will to engage with new ideas and skills exists the plasticity of the brain will continue. Two hemispheres Some brain research has pointed to the notion that the two hemispheres of the brain having different functions: The left brain specialises in academic aspects of learning language and mathematical processes, logical thoughts, sequences and analysis. The right brain is principally concerned with creative activities utilising rhyme, rhythm, music, visual impressions, colour and pictures (Rose and Nicholl 1997). Put simply, by this view, one hemisphere is predominantly concerned with the logical and the other with the more creative. It seems that one or other of the hemispheres is dominant in certain activities, but both are involved in almost all of our thinking. The problem of brain laterality and the difference in what is known as hemispheric dominance can be seen to relate to an individuals learning style. If an individual has a dominant hemisphere, which seems to be the case in most of us, then the approach taken to mental activity which of course includes learning will be affected. Left-brain dominance Those of us who are left-brained tend to favour a slow, step-by-step build up of information; learning proceeds in a linear fashion. Others, while recognising the importance of this supposed difference, and 7 considering it worthy of attention and investigation, are less dogmatic about it. The right-side hemisphere controls the motor movement of the left side of the body 10 and the right side of the body is controlled by the left hemisphere. As for the more intellectual 11 functions of the two hemispheres, we are told that it is important not to overemphasise the 12 different functions because the almost infinite complexity of the brain works holistically, with 13 both hemispheres engaged to lesser and greater degrees in all of our mental activity. However, 14 it is important to recognise that the two hemispheres operate and process information in very 15 different ways (Hannaford 1997). The name gestalt comes from the group of psychologists who described the working 17 of the human mind in a way that suggests that it is capable of working with very large whole 18 events and capable of filling in missing elements of large information sets. The gestalt hemisphere, 19 which in most, but not all, people is the right hemisphere, deals with the whole picture; it operates 20 intuitively and in a more random manner than the logic hemisphere. The logic hemisphere, which 1 is usually the left hemisphere, processes information piece by piece, in sequence and in fine detail. Each of us has a dominant hemisphere, and this will influence the ways in which we consider 2 the world around us and, naturally, the ways in which we approach learning. According to which 3 hemisphere dominates, we will either prefer to look at the whole picture and operate in an 4 intuitive, more random way, or we will prefer to concentrate on detail and work in a far more 5 ordered and logical way. The background to the left/right-brain account of the ways in which 6 mental activity unfolds actually tells us something which we notice as we interact with people 7 throughout our lives: that is, some people operate in a methodical way, paying great attention 8 to detail, and others are far less well-organised in this respect and operate quite differently. This view 2 also considers the two hemispheres of the brain, but describes them, and their functions and 3 relationship to each other, rather differently. This description is supported by research evidence 4 from the late twentieth and early twenty-first centuries (Gazzaniga 1998; Ivry and Robertson 5 1998; Gazzaniga 2002, for example) and in some ways can be said to supersede the leftright 6 split described above. A newer way of describing brain hemispheric function and speciality is 7 that the brain does have two separate hemispheres which operate both independently and in 8 tandem, and which appear to operate differently from each other (Curran 2008). It seems that 9 the split between hemispheres, previously considered as a dichotomy between linear, logical 40 and creative holistic, is perceived more along the lines of an intellectual versus emotional divide. To elaborate, the right hemisphere is described as the intellectual side and the left as the emotional one. We will see later that emotion, and the emotional structure of the mid brain or limbic system is an incredibly important evolutionary change in human brains which sets them apart the majority of the animal kingdom in terms of thought and action, and allows for a vast degree of conscious thought. Sometimes, in the case of language, for example, there are matched areas in both sides of the brain, but their functions are slightly different. This has been described as complementary hemispheric specialisation (Heilman and Gilmore 1998), and makes the rigid differentiation which is sometimes put forward as less than convincing. There are certain areas of the brain, however, that have specialist functions, in for example language, and damage to this area can lead to a loss of certain aspects of language, but other aspects may well be unaffected. Having said all of this, we should be asking what impact this knowledge can have on learning activities in the classroom. The precise location of intellectual or emotional centres of the brain do not affect what teachers plan and do. However, an understanding that these different systems are present is very important. We will see in the next section that emotion and appealing to emotion in learning situations can have a big influence on learning and on its longevity. There is another aspect of the structure and function of the brain which has a bearing on the theories surrounding brain-based learning. Paul MacLean developed the theory of the triune brain, which complements the description of the two hemispheres and their respectivefunctions. The triune brain (triune meaning a trinity or three in one) was first identified in the 1950s, and has been expanded upon in later work (for example, MacLean 1974; 1989). The notion of the triune brain offers a simplified model of the way that the brain functions. It should go without saying that the brain is a highly complex organ, having over 100 billion active nerve cells, each of which is capable of producing 20,000 to 50,000 branches. There are approximately another 900 billion cells which support and protect the nerve cells. The brain functions in a far more complex way than we currently understand and MacLeans model does not purport to do more than illustrate some key elements of the way that the brain operates. The three elements of the structure of the brain, according to MacLean, are: 1 the reptilian or instinctive brain. The reptilian brain controls muscles, balance and autonomic functions (such as breathing and heartbeat) and is always active, even when we are in deep sleep. This part of the brain has the same type of simplistic and instinctive behavioural programmes as snakes and lizards, which is where its name comes from. A learner does not respond when the instinctive brain is in control because this part of the brain operates in basic, ritualistic responses, such as flight or fight. We will consider the importance of this aspect of the brains function in learning situations later. The role of this part of the brain is to control emotions and it is thought to be the location of the long-term 89 Ways of learning memory. Sometimes referred to as the mammalian brain, this part of the brain corresponds 1 to the brain of most mammals. The mammalian brain is concerned with emotions and 2 instincts, feeding, fighting, fleeing and sexual behaviour, all at a higher level than the 3 instinctive brain.

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Since then long term erectile dysfunction treatment generic 20/60 mg cialis with dapoxetine overnight delivery, the advent of voice recorders paved the way for many creative implementations and inventions hard pills erectile dysfunction order cialis with dapoxetine 20/60 mg line. These were poems that consisted of a wide variety of vocalizations erectile dysfunction melanoma purchase discount cialis with dapoxetine on-line, cries erectile dysfunction high blood pressure buy 20/60 mg cialis with dapoxetine visa, shrieks, and ululations. Later, German scientists developed magnetic recording into a technique that involves tape cassettes. Tape recorders allowed for editing, cutting, arranging, rearranging, speeding up, slowing down, and adding effects to the vocal piece after the real-time performance [McCaffery, 1978]. Recording vocal effects such as canned laughter, cries, and other noises and reusing them would not have been possible without the advent of voice recording. Nowadays, digital recording has overtaken analog recording and made possible perfect copying of recordings. Digital technology has made it easier to edit, analyze, duplicate, loop, and perform various processing algorithms on the recorded voice. It has also made it possible to filter, manipulate and add various effects to the live voice input into a computers microphone. Voice Analysis the invention of the microphone by Emile Berliner in 1877 and the development of its commercial form later on by Thomas Edison was crucial to the development of various voice analysis mechanisms. Among these mechanisms is the spectrograph which captures sound waves and generates a spectrogram, a graphical representation of the sound signal that plots the frequency against time. The intensity at a particular time is represented by brightness in a colored spectrogram or darkness in a grey-scale spectrogram. One of the methods of calculating spectrograms from the voice signal involves the use of a Fourier Transform; an algorithm named after the French mathematician Jean Baptiste Joseph Fourier. A Fourier transform converts the signal from a time domain into a frequency domain displayed in terms of sinusoidal functions. It breaks up a complex signal into individual frequency components and their amplitudes. By using this conversion a variety of digital signal processing techniques can be applied to achieve different purposes. Unwanted frequency components, for example, can then be eliminated in order to decrease hissing or background noise. Many variants of the Fourier Transform exist including Fast Fourier Transform, Short-Time Fourier Transform, Continuous Fourier Transform, and Discrete Fourier Transform. Some of these algorithms, especially the Discrete and Fast Fourier Transforms play a major role in voice signal processing and the recognition, manipulation, synthesis, and compression of voice. The Fast Fourier Transform is the main technique underlying all my voice-controlled projects, which are presented in the third chapter. Voice Recognition It is important to highlight the difference between voice recognition and speech recognition. Although these two terms are often used synonymously, it is best to distinguish their meaning. Voice recognition is the computers ability to analyze the voice signal in order to identify a person from another. Speech recognition, which is further discussed in the next section, is the computers ability to analyze the speech signal in order to identify a word from another. Voice recognition software is biometric and is usually used to verify the voice of a certain speaker and prevent unauthenticated use of a system. Speech recognition software, which can usually be trained, can be used either by a certain speaker (speaker-dependent) or by any speaker (speaker-independent). Voice recognition systems are also referred to as voice authentication or voice verification systems. Often used for security purposes, they extract the acoustic parameters of the speakers voice or speech. They then compare the speakers voice print with one that has been previously enrolled and stored. Such systems have recently been improved to the extent that they cannot be tricked by the use of a pre-recorded response by the speaker in what is commonly referred to as spoofing. They have been equipped with anti-spoofing features that involve generating a number of random phrases that the speaker is required to say in order to be verified. Speech Recognition Speech recognition is the conversion of a speech signal captured by a microphone into words, which then potentially allow meaning to be inferred by a computer. Speech recognition programs are sometimes trained to match the voice input to a digitized voice sample and are programmed to then execute a certain command. Voice signals can also be processed using Fourier Transform algorithms which match the characteristics of the voice-input with the characteristics of the previously stored samples. These include background noise, the type of microphone used, and the type of software used to convert the voice signal into computer commands. The difficulty in speech recognition lies in the difference in the vocal characteristics, speaking rate, and the variety of pronunciations produced by different people. Other recognition difficulties may arise from changes in the type of microphone used and the relative position of the microphone to the speaker and to ambient noise. Speech recognition systems are differentiated based on a number of features including: speaking mode, enrolment, and vocabulary. The speaking mode is determined by whether the system recognizes continuous speech or discrete speech. Enrolment is determined by whether the system is speaker-dependent or speaker-independent. A speaker dependent application will only recognize a certain speakers speech after s/he enrols by providing some speech samples. A speaker-independent application will recognize any speakers speech signal without enrolment. The vocabulary list also differs from one system to another depending on the number of words the system is programmed to recognize. The larger the vocabulary, the more the chances of it containing similar-sounding words, and the greater the probability of confusion. Many other speech-related processing technologies exist, including speech synthesis, speech compression and decompression, and non-verbal speech recognition. Non-verbal speech recognition, on the other hand, involves the recognition of non-verbal speech features. Quast [2002] is exploring programs that can measure and recognize nonverbal content. His projects aim to train a pattern recognition system to recognize non-verbal speech by which he means the non-verbal information in the speech signal. According to Quast, word recognition, which is the conventional method of speech recognition, has been investigated for a while now and progress in improving the accuracy of this technique is slow. He suggests the employment of multiple communication channels in speech recognition, such as paralinguistic voice as well as speech. Recognition of Non-Speech Aspects of Voice There have been some efforts to incorporate more forms of non-verbal communication in user interfaces in order to make them more human-oriented. Nevertheless, research in affective computing and computer-based recognition of emotions through vocal expressions is still in its infancy. There have recently been some attempts to develop systems which recognize and respond to human emotional states. However, there are some studies which indicate that the human is better able to decode emotions from the voice than from the face [Kappas, 2003]. Although voice might be considered the neglected child of emotion research [Kappas, 2003], there is a growing body of research aimed at exploring the acoustic features that vary with the emotional state in human voice. These studies examine the relationship between the characteristics of vocal expression and emotional state. The following table (Table 3) illustrates the characteristics of voice that Xiaoqing believes generally to differentiate between the expression of anger, joy, and sadness [2003]. The table indicates the possible relationship between vocal characteristics and emotional state of the utterer. These characteristics can be detected and analyzed separately using various signal analysis mechanisms.

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Although previously attributed to erectile dysfunction kegel buy generic cialis with dapoxetine 60 mg on line hypotonia erectile dysfunction viagra cialis with dapoxetine 40/60 mg without a prescription, it is more likely a re ection of asynergia between agonist and antagonist muscles erectile dysfunction diabetes pathophysiology 30 mg cialis with dapoxetine for sale. Recruitment Recruitment erectile dysfunction over the counter purchase 20/60mg cialis with dapoxetine with amex, or loudness recruitment, is the phenomenon of abnormally rapid growth of loudness with increase in sound intensity, which is encountered in patients with sensorineural (especially cochlear sensory) hearing loss. Thus patients have dif culty with sounds of low-to-moderate intensity (Speak up, doctor) but intense sounds are uncomfortably loud (Theres no need to shout, doctor! Cross Reference Re exes Recurrent Utterances the recurrent utterances of global aphasia, sometimes known as verbal stereo typies, stereotyped aphasia, or monophasia, are reiterated words or syllables produced by patients with profound non uent aphasia. The poet Charles Baudelaire (18211867) may have been reduced to a similar state following a stroke. Red Ear Syndrome Irritation of the C3 nerve root may cause pain, burning, and redness of the pinna. This may also occur with temporomandibular joint dysfunction and thalamic lesions. Reduplicative Paramnesia Reduplicative paramnesia is a delusion in which patients believe familiar places, objects, individuals, or events to be duplicated. The syndrome is probably het erogeneous and bears some resemblance to the Capgras delusion as described by psychiatrists. Reduplicative paramnesia is more commonly seen with right (non dominant) hemisphere damage; frontal, temporal, and limbic system damage has been implicated. This may occur transiently as a consequence of cerebrovas cular disease, following head trauma, or even after migraine attacks, or more 307 R Re exes persistently in the context of neurodegenerative disorders such as Alzheimers disease. Cross References Capgras delusion; Delusion; Paramnesia Re exes Re ex action a sensory stimulus provoking an involuntary motor response is a useful way of assessing the integrity of neurological function, since disease in the afferent (sensory) limb, synapse, or efferent (motor) limb of the re ex arc may lead to dysfunction, as may changes in inputs from higher centres. Muscle tendon re exes (myotactic re exes) may be either tonic (in response to a static applied force: stretch re ex) or phasic (in response to a brief applied force, for example, a blow from a tendon hammer to the muscle tendon). The latter are of particular use in clinical work because of their localizing value (see Table). However, there are no re exes between T2 and T12, and thus for localization one is dependent on sensory ndings, or occasionally cutaneous (skin or super cial) re exes, such as the abdominal re exes. Re ex Root value Jaw jerk Trigeminal (V) nerve Supinator (brachioradialis, radial) C5, C6 Biceps C5, C6 Triceps C7 Finger exion (digital) C8, T1 Abdominal T7T12 Cremasteric L1, L2 Knee (Patellar) L3, L4 Hamstring L5, S1 Ankle (Achilles) (L5) S1 (S2) Bulbocavernosus S2, S3, S4 Anal S4, S5 Tendon re ex responses are usually graded on a ve-point scale: : absent (are exia; as in lower motor neurone syndromes, such as peripheral nerve or anterior horn cell disorders; or acute upper motor neurone syndromes. Re ex responses may vary according to the degree of patient relaxation or anxiety (precontraction). Moreover, there is interobserver variation in the assess ment of tendon re exes (as with all clinical signs): a biasing effect of prior knowledge upon re ex assessment has been recorded. There is also a class or primitive, developmental, or psychomotor signs, present in neonates but disappearing with maturity but which may re-emerge with ageing or cerebral (especially frontal lobe) disease, hence sometimes known as frontal release signs. Reliability of the clinical and electromyographic examina tion of tendon re exes. This may be particularly evident using the swinging ashlight test, in which the two pupils are alternately illuminated every 23 s in a darkened room. Quickly moving the light to the diseased side may produce pupillary dilata tion (Marcus Gunn pupil). Subjectively, patients may note that the light stimulus seems less bright in the affected eye. Although visual acuity may also be impaired in the affected eye, and the disc appears abnormal on fundoscopy, this is not necessarily the case. Isolated rel ative afferent pupillary defect secondary to contralateral midbrain compression. It is sometimes dif cult to see and may be more obvious in the recumbent position because of higher pressure within the retinal veins in that position. Venous pulsation is expected to be lost when intracranial pressure rises above venous pressure. This may be a sensitive marker of raised intracranial pressure and an early sign of impending papilloedema. However, venous pulsation may also be absent in pseudopapilloedema and sometimes in normal individuals. Cross References Papilloedema; Pseudopapilloedema Retinitis Pigmentosa Retinitis pigmentosa, or tapetoretinal degeneration, is a generic name for inher ited retinal degenerations characterized clinically by typical appearances on ophthalmoscopy, with peripheral pigmentation of bone-spicule type, arteriolar attenuation, and eventually unmasking of choroidal vessels and optic atrophy. Despite the name, there is no in ammation; the pathogenetic mechanism may be apoptotic death of photoreceptors. This process may be asymptomatic in its early stages, but may later be a cause of nyctalopia (night blindness), and produce a midperipheral ring scotoma on visual eld testing. A variety of genetic causes of isolated retinitis pigmentosa have been partially characterized: autosomal recessive: linked to chromosome 1q; X-linked: Xp11, Xp21; autosomal dominant:3q,6p,8. Looking at protein misfolding neurodegenerative disease through retinitis pigmentosa. Cross References Nyctalopia; Optic atrophy; Scotoma Retinopathy Retinopathy is a pathological process affecting the retina, with changes observ able on ophthalmoscopy; dilatation of the pupil aids observation of the periph eral retina. Laser treatment of new vessels is the treatment of choice Hypertension: hypertensive retinopathy may cause arteriolar constriction, with the development of cottonwool spots; and abnormal vascular per meability causing ame-shaped haemorrhages, retinal oedema, and hard exudates; around the fovea, the latter may produce a macular star. Systemic hypertension is associated with an increased risk of branch retinal vein and central retinal artery occlusion Drug-induced. Cross References Maculopathy; Retinitis pigmentosa; Scotoma Retrocollis Retrocollis is an extended posture of the neck. Retrocollis may also be a feature of cervical dystonia (torticollis) and of kernicterus. This phenomenon does not have partic ular localizing value, since it may occur with both occipital and anterior visual pathway lesions. Cross References Akinetopsia; Visual agnosia RightLeft Disorientation Rightleft disorientation is an inability to say whether a part of the body is on the right or left side or to use a named body part to command. This may occur in association with acalculia, agraphia, and nger agnosia, collectively known as the Gerstmann syndrome. Although all these features are dissociable, their concurrence indicates a posterior parietal dominant hemisphere lesion involving the angular and supramarginal gyri. Cross References Acalculia; Agraphia; Autotopagnosia; Finger agnosia; Gerstmann syndrome Rigidity Rigidity is an increased resistance to the passive movement of a joint which is constant throughout the range of joint displacement and not related to the speed of joint movement; resistance is present in both agonist and antagonist mus cles. Rigidity may be described as: consistent: leadpipe rigidity; or jerky: cogwheel rigidity or Negros sign, when a rhythmic uctuation. However, this may occur in some normal subjects; it is most helpful in the diagnosis of Parkinsons disease if unilateral. Rigidity is a feature of parkinsonism and may coexist with any of the other clinical features of extrapyramidal system disease, but particularly akinesia (akinetic-rigid syndrome); both are associated with loss of dopamine projections from the substantia nigra to the putamen. The pathophysiology of rigidity is thought to relate to overactivity of tonic stretch re exes in the spinal cord due to excessive supraspinal drive to spinal cord 313 R Rindblindheit motor neurones following loss of descending inhibition as a result of basal gan glia dysfunction. In other words, there is a change in the sensitivity of the spinal interneurones which control motor neurones due to defective supraspinal con trol. Hence rigidity is a positive or release symptom, re ecting the operation of intact suprasegmental centres. In support of this, pyramidotomy has in the past been shown to produce some relief of rigidity. Rigidity in Parkinsons disease may be lessened by treatment with levodopa preparations. The techniques of modern stereotactic neurosurgery may also be helpful, particularly stimulation of the subthalamic nucleus, although both thalamotomy and pallidotomy may also have an effect. The term rigidity may also be used to describe posturing associated with coma: decorticate or decerebrate, exor and extensor posturing, respectively; a lack of mental exibility, particularly evident in patients with frontal lobe dysfunction. Pathophysiology of Parkinsons disease rigidity: role of corticospinal motor projections. Neurophysiology of Parkinsons disease, levodopa-induced dyskinesias, dystonia, Huntingtons disease and myoclonus. Relationship between electromyographic activity and clin ically assessed rigidity studied at the wrist joint in Parkinsons disease. Risus sardonicus may also occur in the context of dystonia, more usually symptomatic (secondary) than idiopathic (primary) dystonia. Cross References Parkinsonism; Wheelchair sign Rogers Sign Rogers sign, or the numb chin syndrome, is an isolated neuropathy affecting the mental branch of the mandibular division of the trigeminal (V) nerve, causing pain, swelling, and numbness of the lower lip, chin, and mucous membrane inside the lip. Hypoaesthesia involving the cheek, upper lip, upper incisors, and gingiva, due to involvement of the infraorbital portion of the maxillary division of the trigeminal nerve (numb cheek syndrome), is also often an ominous sign, result ing from recurrence of squamous cell carcinoma of the face in ltrating the nerve.