BACKGROUNDDual antiplatelet therapy with clopidogrel plus low-dose aspirin has not been studied in a broad population of patients at high risk for atherothrombotic events.METHODSWe randomly assigned 15,603 patients with either clinically evident cardiovascular disease or multiple risk factors to receive clopidogrel (75 mg per day) plus low-dose aspirin (75 to 162 mg per day) or placebo plus low-dose aspirin and followed them for a median of 28 months. The primary efficacy end point was a composite of myocardial infarction, stroke, or death from cardiovascular causes.RESULTSThe rate of the primary efficacy end point was 6.8 percent with clopidogrel plus aspirin and 7.3 percent with placebo plus aspirin (relative risk, 0.93; 95 percent confidence interval, 0.83 to 1.05; P=0.22). The respective rate of the principal secondary efficacy end point, which included hospitalizations for ischemic events, was 16.7 percent and 17.9 percent (relative risk, 0.92; 95 percent confidence interval, 0.86 to 0.995; P=0.04), and the rate of severe bleeding was 1.7 percent and 1.3 percent (relative risk, 1.25; 95 percent confidence interval, 0.97 to 1.61 percent; P=0.09). The rate of the primary end point among patients with multiple risk factors was 6.6 percent with clopidogrel and 5.5 percent with placebo (relative risk, 1.2; 95 percent confidence interval, 0.91 to 1.59; P=0.20) and the rate of death from cardiovascular causes also was higher with clopidogrel (3.9 percent vs. 2.2 percent, P=0.01). In the subgroup with clinically evident atherothrombosis, the rate was 6.9 percent with clopidogrel and 7.9 percent with placebo (relative risk, 0.88; 95 percent confidence interval, 0.77 to 0.998; P=0.046).CONCLUSIONSIn this trial, there was a suggestion of benefit with clopidogrel treatment in patients with symptomatic atherothrombosis and a suggestion of harm in patients with multiple risk factors. Overall, clopidogrel plus aspirin was not significantly more effective than aspirin alone in reducing the rate of myocardial infarction, stroke, or death from cardiovascular causes. (ClinicalTrials.gov number, NCT00050817.).

The settlement intention of migrants is an important factor for urban development. Through examination of existing research we found that the influencing factors on settlement intention differed by region; however, little attention was paid to the factors affecting settlement intention based on regional differences in China. Using data from the National Health and Family Planning Commission of the People's Republic of China, this study chose 282 cities as study areas, First, this was performed through the statistic and spatial analysis of GIS, which explains the effect of the city level variable on settlement intention; then, it introduced a hierarchical linear regression model, combining macro statistics with micro-survey data to explain the factors influencing settlement intention as well as the relationship between the city-level variable and the individual-level variable. The results showed three things: First, the characteristic of city had an impact on the settlement intention. Second, the regional difference of settlement intention was significant, it was interesting insofar as Eastern China attracted the most migrants but the settlement willingness of migrants in the east was the most insignificant. Thirdly considering the characteristic of city, education, age, income, employment status and occupation type had a significant effect on urban settlement intention.

Paradoxical embolism through right-to-left shunts is widely accepted as a potential cause of cerebral ischemia. Contrast echocardiography is an excellent tool for detection of these shunts. The timing of the appearance of bubbles in the left atrium (ie, early vs late) allows differentiation of foramen ovale patency from intrapulmonary shunting as a result of arteriovenous malformations. We report a patient with recurrent neurologic deficit after surgical closure of a patent foramen ovale. Transesophageal echocardiography demonstrated residual right-to-left shunting from previously unrecognized pulmonary arteriovenous malformations associated with hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu). This case illustrates the fact that contrast echocardiography may fail to identify intrapulmonary shunts when a resting patent foramen ovale coexists.

Stroke is a major cause of death and disability. The resulting burden on society continues to grow, despite recent advances in acute stroke therapy. Acute stroke units, which allow for the greatest overall improvement in outcome, provide the best facilities for acute intervention. Despite recent advances in acute management, such as endarterectomy and anticoagulation, primary and secondary preventive measures to control stroke risk factors, along with appropriate specific interventions, are the keys to reducing the overall burden of stroke. Thrombolysis reduces stroke morbidity but is only applicable to a small percentage of stroke patients. Intravenous tissue-plasminogen activator (tPA) was the first treatment demonstrated in a randomized controlled trial to improve outcome if given within the first 3 hours of stroke onset. Subsequent trials failed to extend the time window for intravenous therapy beyond 3 hours. For the millions of stroke survivors, investigations are now underway into the possibility of improvement of function through neuronal transplantation.

L'activite du Service de Neurologie est consacree au diagnostic et au traitement medical des affections organiques touchant le systeme nerveux central (cerveau et moelle epiniere) et peripherique (nerfs et appareil musculaire). La recherche clinique et fondamentale en sciences neurologiques constitue une des activites essentielles qui caracterisent la mission academique du service. Au fil des annees, le Service de Neurologie a evolue de l'offre de competences en neurologie generale a la mise en place d'une unite comportant les diverses facettes des sous-specialites des neurosciences cliniques. Les principaux themes de recherche ont ete de longue date la neuro-oncologie, la neurophysiologie, la neuropsychologie, les affections cerebro-vasculaires, l'epilepsie infantile et les affections retentissant sur le developpement psychomoteur de l'enfant. La neurogenetique constitue un nouveau theme de recherche du service. La recherche en neurogenetique du service est a la fois fondamentale et clinique et l'accent est mis sur les ataxies hereditaires et les epilepsies d'origine genetique.

The department of neurology is devoted to the diagnosis and medical treatment of organic diseases of central nervous system (brain and spinal cord) and peripheral nervous system (peripheral nerves and muscles). Basic and clinical research in neuroscience constitute an essential activity of the department that defines its academic character. Over the years, the department of neurology has evolved from providing general neurology services to a multifaceted unit that has developed the several subspecialties of clinical neuroscience. Main research areas have included neurooncology, neurophysiology, neuropsychology, cerebrovascular diseases, childhood epilepsy and conditions affecting the psychomotor development of children. Neurogenetics is a recent addition to the areas of the interest of the department; research in neurogenetics includes basic investigations as well as clinical studies and focuses on inherited ataxias and genetic epilepsies.

Background and Purpose-Abciximab is a potent parenterally administered platelet glycoprotein IIb/IIIa antagonist, Because:this agent has been shown to improve outcomes in coronary artery disease, there is interest to evaluate whether it could improve cerebral perfusion and outcomes after ischemic stroke. This study was designed to evaluate the safety of abciximab in acute ischemic stroke and to obtain pilot efficacy data.Methods-We conducted a randomized, double-blind, placebo-controlled, dose-escalation trial. Seventy-four eligible and consenting patients presenting within 24 hours after ischemic stroke onset at 38 study sites were randomly allocated to receive either an escalating dose of abciximab (54 patients)or placebo (20 patients) in a ratio of 3:1, We studied 4 escalating doses of abciximab. Patients underwent a scheduled follow-up head CT scan 24 to 36 hours after the completion:of study agent administration to monitor for bleeding complications and were evaluated through 3 months.Results-There were no cases of major intracranial hemorrhage, Asymptomatic parenchymal hemorrhages were detected on post-study agent CT in 4 of 54 abciximab patients (7%) and in 1 of 20 placebo patients (5%). Six additional abciximab patients had asymptomatic hemorrhagic lesions detected by unscheduled brain imaging during their follow-up period. Nine of 1 1 patients with asymptomatic hemorrhage had a:baseline National Institutes of Health Stroke Scale-score > 14. At 3 months, there was a trend toward a higher rate of minimal residual disability (Barthel Index greater than or equal to 95 or modified Rankin scale less than or equal to 1) among abciximab patients compared with those who received placebo.Conclusions-Abciximab appears to be safe when administered up-to 24 hours after stroke onset, and it might improve functional outcome.

Background and Purpose-Tirilazad is a nonglucocorticoid, 21-aminosteroid that inhibits lipid peroxidation. Studies in experimental models of ischemic stroke had suggested that tirilazad had neuroprotective properties. As a result, clinical studies were undertaken to assess the safety and efficacy of tirilazad in the treatment of acute ischemic stroke. We performed a systematic review of randomized, controlled trials that assessed the safety and efficacy of tirilazad in patients with acute ischemic stroke.Methods-Trials of tirilazad were identified from searches of the Cochrane Library and communication with the Pharmacia & Upjohn company, the manufacturer of tirilazad. Data relating to early and end-of-trial case fatality, disability (Barthel Index and Glasgow Outcome Scale), phlebitis, and corrected QT interval were extracted by treatment group from published data and company reports and analyzed by using the Cochrane Collaboration meta-analysis software REVMAN.Results-Six trials (4 published, 2 unpublished) assessing tirilazad in 1757 patients with presumed acute ischemic stroke were identified; ail were double-blind and placebo controlled in design. Tirilazad did not alter early case fatality (odds ratio [OR] 1.11, 95% confidence interval [CI] 0.79 to 1.56) or end-of-trial case fatality (OR 1.12, 95% CI 0.88 to 1.44). A just-significant increase in death and disability, assessed as either the expanded Barthel Index (OR 1.23, 95% CI 1.01 to 1.51) or Glasgow Outcome Scale (OR 1.23, 95% CI 1.01 to 1.50) was observed. Tirilazad significantly increased the rate of infusion site phlebitis (OR 2.81, 95% CI 2.14 to 3.69). Functional outcome (expanded Barthel Index) was significantly worse in prespecified subgroups of patients: females (OR 1.46, 95% CI 1.08 to 1.98) and subjects receiving low-dose tirilazad (OR 1.31, 95% CI 1.03 to 1.67); a nonsignificant worse outcome was also seen in patients with mild to moderate stroke (OR 1.40, 95% CI 0.99 to 1.98).Conclusions-Tirilazad mesylate increases death and disability by about one fifth when given to patients with acute ischemic stroke. Although further trials of tirilazad are now unwarranted, analysis of individual patient data from the trials may help elucidate why tirilazad appears to worsen outcome in acute ischemic stroke.

We report the case of a 21 year old man who has severe headache and blurred vision since 2 weeks. Ophthalmologic examination discloses typical lesions of acute posterior multifocal placoid pigment epitheliopathy and an homonymous right inferior quadrantanopsia. An inflammatory syndrome and a cerebrospinal fluid lymphocytosis are found. Cerebral imagery is normal. Headache improves only with corticotherapy. We conclude that the neurological attack associated with this acute posterior multifocal placoid pigment epitheliopathy is most likely due to a cerebral vasculitis.

The generators of the audiogenic startle reflex (ASR) are located in the bulbopontine reticular formation. We studied the influence of acute vascular supratentorial lesions on ASR. Ten patients with hemiplegia due to hemispheric cerebral infarct were studied within 5 days of stroke onset. ASR and magnetic cortical stimulation were performed the same day. A muscle response to magnetic stimulation was not elicited over the plegic side in any patient. In four of seven patients, ASR was enhanced over the plegic side. We suggest that enhanced ASR is due to the loss of a predominantly inhibitory hemispheric drive on ASR generators.