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The benefit of surgery interventional neuroradiologists had to pass a quality increases with the degree of stenosis between 70% control order 50 mg minocycline fast delivery. The primary endpoint discount 50mg minocycline with amex, ipsilateral stroke or death stenosis between 50 and 70%, in high-degree within 30 days, was 6. The reported medium-term Whether this translates into higher long-term outcomes were comparable and the restenosis rate event rates is not yet known. The intracranial stenosis and randomized them to either risk reduction is even higher in stenosis >90%. Predictors for a recurrent ischemic event should be given prior to, during and after carotid were the degree of stenosis, stenosis in the vertebro- surgery [70]. Most likely all antihypertensive in subtypes of ischemic stroke: the German stroke data drugs are effective in secondary stroke bank. Stroke: Pathophysiology, Diagnosis and targets (<140/90 mmHg in non-diabetics and Management. The high risk of stroke Statin therapy reduces the rate of recurrent immediately after transient ischemic attack: a stroke and vascular events. Early risk of recurrence Aggressive lowering of blood glucose does not by subtype of ischemic stroke in population-based reduce the risk of stroke and might even increase incidence studies. Complications following acute homocysteine with vitamin B6, B12 and folic ischemic stroke. An improved scoring system for identifying patients at high early not effective in the secondary prevention of risk of stroke and functional impairment after an acute stroke and may even increase the risk of fatal transient ischemic attack or minor stroke. N Engl J Med after endarterectomy or the combination of clo- 2008; 358(15):1547–59. Patel A, MacMahon S, Chalmers J, Neal B, Billot L, candesartan cilexetil therapy in stroke survivors. Lowering vascular events among 20,332 individuals with recent homocysteine in patients with ischemic stroke to stroke. A clinical trial of estrogen-replacement recent clinical trials for the National Cholesterol therapy after ischemic stroke. Heart meta-analysis of randomised trials of antiplatelet Protection Study Collaborative Group. Effects of therapy for prevention of death, myocardial infarction, cholesterol-lowering with simvastatin on stroke and and stroke in high risk patients. Effects of clopidogrel in addition to Chapter 19: Secondary prevention aspirin in patients with acute coronary syndromes 49. N Engl J Med 2001; stroke in patients with nonrheumatic atrial fibrillation 345:494–502. Diener H, Bogousslavsky J, Brass L, Cimminiello C, strokes in atrial fibrillation: Frequency and effect of Csiba L, Kaste M, et al. Acetylsalicylic acid on a antithrombotic agents in the stroke prevention in atrial background of clopidogrel in high-risk patients fibrillation studies. J Am Coll Cardiol on practice guidelines and the European Society of 2007; 49(19):1982–8. Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 guidelines for 41. Int J Clin Pract 2001; warfarin in the first year of therapy among elderly 55:162–3. Cerebrovasc Dis 2007; anticoagulants versus aspirin after cerebral ischemia of 23:368–80. Algra A, De Schryver E, van Gijn J, Kappelle L, atrial fibrillation after transient ischaemic attack or Koudstaal P. Benefit of carotid factors for stroke and death within 30 days after endarterectomy in patients with symptomatic carotid endarterectomy and stent-protected moderate or severe stenosis. Randomised trial of endarterectomy for Endarterectomy versus stenting in patients with recently symptomatic carotid stenosis: final results of symptomatic severe carotid stenosis. European Carotid Surgery Trialists’ Collaborative Stenting for carotid artery stenosis. Circulation 2006; Prediction of benefit from carotid endarterectomy in 113(4):555–63. Rothwell P, Eliasziw M, Gutnikov S, Warlow C, moderate intracranial atherosclerotic stenosis. It adds a social perspective with Although progress in the acute treatment of stroke emphasis on participation. While for many decades of the last century it was After the acute treatment, stroke patients with believed that, “once development is complete, the relevant neurological deficits should in general be sources of growth and regeneration of axons and treated by a specialized neurorehabilitation clinic or dendrites are irretrievably lost. The best timing for transferring a patient after nerve paths are fixed and immutable: everything can initial treatment (e. A few years later in 1936 it was reported cussion, but early initiation of rehabilitation is man- that therapeutic exercises influence the course of spon- datory for outcome optimization (whereas ultra-early taneous recovery of a brain affection [5]. It has been a high-intensity training in the first hours to few days long way, however, to what we now know, first by might be problematic). As an exception, in severe disorders recovery can others) with structured organization and processes and vary and these patients may even show onset of func- the stroke patient taking part in a multimodal, intense tional recovery after a longer period [7]. The the course of time after the onset of stroke is possible Section 4: Therapeutic strategies and neurorehabilitation due to a mechanism described as neuroplasticity, reorganization in the motor cortex adjacent to the which can be observed and investigated by different lesion. Hebb first deficits with damage to corticospinal tract, it is described neuroplasticity with regard to the function suggested that of synapses [8], and later this principle was also linked interruption of projections from the primary to the functioning of neurons in the wider context of motor cortex (M1) leads to increased neuronal networks. With functional imaging, however, it focused and efficient brain activity in a later could be demonstrated that vicariation takes place phase reflecting reorganization [17], and in cortical representation areas. Another clinical which are reminiscent of normal activation example is the change in lateralization of speech in patterns. Later such For better understanding of these mechanisms a enlargement of cortical representations was also main strategy for recovery in such patients seems to be demonstrated in humans. In an illustrative many different areas may also indicate a less successful longitudinal study [15], a small group of stroke or failed reorganization in chronic stroke patients: the patients with comparable circumscribed M1 higher the involvement of the ipsilesional motor net- lesions (similar to experimental lesions in animal work, the better the recovery.

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Authors often underline how plague’s unique terribility derives from its more direct correlation with divine wrath: “the plague is more immediately from God buy 50 mg minocycline overnight delivery, than any other Sicknesse or Disease for it is the immediate stroke of God” (Brooks 1666: A3v) minocycline 50mg discount. All texts invariably construct the discourse of human culpability and active agency in connection with God’s pestilential punishment by for example reiterating references to human ‘wilful consenting’ to 4 I have not modernized the spelling in my quotations from early texts or cor- rected any printing mistakes. The first is to further prayer and repentance: writings which elaborate on wilful sinning aim to stimulate energetic personal initiatives towards reformation. Indeed, great care is always taken to associate descriptions of plague as God’s scourge with accents on its quality as a just and deserved retribution, a pesti- lential visitation sent by a just God to his creatures who have ‘justly deserved’ it (Grindal 1563: 484). A text of exceptional persuasive cha- racter and capillary dissemination, the collection of plague prayers published in 1563 by the Bishop of London Edmund Grindal for use in each English church and household, includes this invocation: “turn away from us this his plague and punishment, most justly poured upon us for our sins and unthankfulness” (1563: 78). The discourse of divine clemency and fairness in association with open or implied references to human culpability is furthered by stress on divine patience: God has repeatedly forgiven sinners and has urged repentance; only “at length” has he begun “to stretch forth his v punishing hande” (Pullein 1608: D2 ). Other writings propose the same notion of a merciful God by presenting plague as the product of divine love: “God most mercifully chastiseth his Children for their sinnes […] that they might […] flee vnto him for help” (I. Semantic fields in the discourse of plague Within the discourse of plague as punishment, two semantic fields ‒ one concerning communication, the other law ‒ are worth noting. As regards the first, the disease is frequently presented as God’s means of communication with his disobedient creatures, as a sort of “messen- Ideological Uses of Medical Discourses in Early Modern English 53 ger” (Hooper 1553: A2). An evocative treatment of this function of pestilence is found in the first-hand account of the great London epi- demic of 1665 by the nonconforming preacher Thomas Vincent. In a passage characterized by a didactic and pedantic tone, the London minister points out that “God being a Spirit, hath no Mouth nor Tongue properly as men have, […] therefore his way of speaking is not like ours”; indeed, he speaks “by terrible things” and his voice is “loud and full of terrour”. As if reading a list of charges in court, authors compile long and detailed catalogues of sins which have occasioned an “awakening judgment” (Vincent 1667: 21), a “fearfull iudgement of the Lord” (Pullein 1608: E) in the form of a pestilential 5 visitation. Metaphors used to describe plague often include terms from the judicial area: plague is an “extra ordinary magistrate to v reforme and punish […] synne” (Hooper 1553: B3 ) and a “Nimble v executioner of the Diuine Iustice” (Dekker 1630: A4 ). While all texts, in connection with characterizations of plague as punishment, refer to some extent to divine wrath, some writings inflect this theme and depict the terrible image of a pitiless, blood- thirsty God at war with humanity. As with the discourse of human cul- pability discussed above, emphases on God’s fearfulness are generally more numerous and forceful in texts designed, by rousing terror, to convince people of the extreme virulence of the present epidemic requiring an extraordinary effort in terms of universal prayer and fasting, or in writings, especially by nonconformist ministers, which lay stress exclusively or predominantly on the supernatural origin of plague. I suggest that frequent and often particularly vehement refer- ences to God’s cruelty and fearfulness may also function as more or 5 Interesting lists are found in Vincent (1667: 51) and Church of England (1603: C3v). Drawing inspiration from and at the same time adding to a repertoire of scriptural images, numerous plague writings lay stress on God’s bellicose attitude. Hence, the epidemiolo- gical weaponry of the pestilential bacillus ─ the intensity of pain, the horror of signs, the rapid demise of victims ─ is transfigured in depic- tions of God’s weapons: sharp arrows, for a precise, mortal wound, a sword, a rod. The semantic field of military operations is evoked by frequent occurrences of expressions within the battle domain: thus God is cast as a “furious enemy” (Vincent 1667: 176) who negotiates “the retrait from the battell” (Pullein 1608: E) with his afflicted creatures. The terrifying sounds of the battlefield echo in plague writings which often include mentions of the “drum of God’s wrath” and the “Trumpet vnto the Lord’s battels” (Pullein 1608: E). This image of a bellicose God is a commonplace of all texts, including those by lay authors, like Kellwaye, a “Gentleman” writing for “the loue and benefit of his fellow countrymen”, who warns that God “hath determined to strike vs at the quicke” (1593: A3). Plague writings seem to document a general attempt to make sense of the enormity of the calamity in recognizable and acceptable terms as a no quarter war declared by God who typically destroys, smites, strikes, slaughters, slays and kills. He is an invincible enemy whose records on the battlefield include the annihilation of thousands in just three days with a pestilential visitation in response to David’s trespasses as Bishop Grindal reminds the English people (1563: 479). Military vocabulary and imagery extend to God’s ministers: since their vehement urgings to repent and hence parry the divine blow have fallen on deaf ears, they have joined the exterminating army: “now must you heare vs strike vp the drum of God’s wrath, and sound out the Trumpet vnto the Lords battels” (Pullein 1608: E). In addition to these volunteer drummers and trumpeters, God’s army in- Ideological Uses of Medical Discourses in Early Modern English 55 cludes redoubtable fighters like “venimous Aspes, and bloodie Lyons, Sathan and his wicked spirites” (Holland 1603: 53). The discourse of God’s enmity and bellicosity had universal currency, conveyed as it was not just through repeated elaborations in sermons and miscellaneous texts on Scriptural warnings that “the ar- rowes of the Lord are drunke with blood and his sword doth not cease deuoring of mans flesh” (Pullein 1608: E), but also in the iconogra- phical apparatus of widely circulated broadsheets and bills of morta- lity which was characterized by a version of the medieval danse macabre: God’s angel brandishes a sword and hovers from a pesti- lential cloud over cities and villages while a triumphant Death with his usual attributes, the hourglass and dart, is surrounded by coffins and corpses. As Sheils points out: “explanations of disease in terms of God’s will to punish and in terms of natural pheno- mena could be reconciled by theories of primary and secondary causa- tion” (1982: 89). Unsurprisingly, the balance between supernatural and natural explanations fluctuates in a remarkable way according to the characters and purposes of texts. Hence surgeon William Boras- ton, after a prefatory mention of sin as plague’s primary cause, first enlarges on the secondary means used by God to infect villages and cities, “astrall Impression”, “the coniunction of Saturne and Mars”, “Eclipses”, then alerts readers on the role of “the breath, heat, sweat, smell, habitation, and garments from the sicke” in contagion (1630: 1- 3). Bishop Hooper, on the other hand, while allowing for causes 56 Paola Baseotto v “naturall and consonaunte to reason” (1553: A3 ) like corrupt air which generates pestilential vapours from water or unbalance of the four humours, lays great stress on the supernatural origin of plague when he admonishes that “yuell humors” cannot be “engendered of any meates, were not the man that useth them corrupte and first infected with sinne; […] and soo altereth not by chaunce, nor by the influence of starres, the holesomnes of the ayer intoo pestylente and contagyouse infectyon” but because of “synne and contempte of v gooddes holye woorde” (1553: B3, B3 ). Some writings transcend the discourse of primary and seconda- ry causes by postulating the existence of two kinds of plague, one ut- terly supernatural, the other entirely natural. The first proceeds direct- ly from God’s blow and therefore is not infectious, the other is spread by natural means like corrupt air and contact with victims. Hence for in- stance Bradwell subtly distinguishes a “simple” kind of plague de- riving from the “immediate stroke of Gods punishing Angell” and en- tailing no “distemper of Blood, putrifaction of Humors, or influence of Starres” and a “putrid” kind (1636: 2). In their endorsements of this thesis some influential churchmen went as far as to argue that “wilfull sinners” catch the supernatural kind of plague, an “incurable […] pestilence” against which no medicine is effective (Hooper 1553: C1). Because the idea of a wholly supernatural type of the disease implied inefficacy of natural remedies, a compromise was found to allow for both supernatural and natural salves: the two kinds of plague, often occurring at the same time and in the same geographical area, were generally declared to be hardly distinguishable one from the other. While official writings like plague orders by the Privy Council and specific forms of prayers by Church of England authorities ac- commodate both natural and supernatural explanations allowing for natural and supernatural remedies ─ medicaments and quarantine, prayers and fasts respectively ─ other texts, especially by non- conforming preachers, are markedly biased in favour of the super- natural element and further a providential and predestinarian view of plague. This view encouraged fatalistic attitudes and presented medi- Ideological Uses of Medical Discourses in Early Modern English 57 cal and governmental measures as ineffective and ungodly: “they see many preserued in the midst of the plague, who haue vsed no phisicall meanes. Typical of such writings are general pronouncements which depict epidemics as a matter-of-fact divine initiative requiring godly submission, rather than resistance: “that so many thousands dies [sic] […] of pestilence, it is fore-ordained in heaven. The randomness of the disease, which wiped out whole households and spared their neighbours, devastated some geographical areas and was absent or hardly present in others, is also frequently re- ferred to as proof of its providential nature. Worth careful note are interpretations and descriptions of the physiological marks of plague in spiritual terms aimed at propagating the notion of the utterly supernatural quality of the disease requiring spiritual salves only. Recalling the etymology of plague from Latin plaga, a stroke or blow, and offering a literal reading of Scriptural metaphors, some passages describe buboes as marks left by God’s sword or arrows, as the visible tokens of sin which is the source of 6 infection. Clapham reports that many “so smitten, haue felt and heard the noyse of a blow and some of them haue upon such a blow found the plain print of a blew hand left behind upon the flesh”. His account closes with a telling cause-and-effect statement: “the Angels stroke so is the Cause, the plague-sores and marks arising and appearing are the v effect” (1603: B ). Drawing on the dominant metaphor used in connection with plague, that of war, he typifies it as a victorious “Captaine” or “Tyraunt” who “displayes his Ensignes on the Wals of our bodies” (1608: E4). Pullein goes on to describe with scientific accuracy the swift transformation of the buboes, the captain’s ensigns, from their 6 “Our word plague is derived from the Latin word plaga, which originally meant a blow or a stroke, but which acquired in late Latin the additional meaning of pestilence, because a pestilence – irrespective of its nature – was regarded by the pagan Romans as a blow from the gods and by the Christiani- zed Romans as a stroke expressive of the divine wrath” (Shrewsbury 1970: 1). Other expressive spiritual readings of the epide- miological realities of plague include transcriptions of public orders regarding burial of victims at night with “no neighbours nor friends […] to accompany the Coarse” (Royal College of Physicians 1636: H2) in order to prevent the spread of contagion, as retribution for sin. Capitalizing on well-established fears of anomalous and dishonour- able burial, some authors in their exhortations to repentance invite people to visualize their own funeral: “Which of your neighbors will accompany your corpes to the graue?

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It has also and arm is controversial; many authors consider been shown that simulator-based driving training it a form of reflex sympathetic dystrophy/complex improved driving ability buy 50 mg minocycline visa, especially for well-educated regional pain syndrome order 50 mg minocycline overnight delivery, probably initiated by and less disabled stroke patients [126]. Management includes Partnership and sexual functioning: partnership is positioning, orthotic management, physical therapy in many cases affected by the post-stroke condition, including steps for reduction of edema, and analgetics. Summarized in a review [127], observa- due to varying definitions, populations, exclusion cri- tional studies suggest that the frequency and range teria and the timing of assessments [123]. In underdiagnosed because of overlapping symptoms addition to the direct consequences of stroke, psycho- with the stroke itself. It manifests itself in subtle social issues and depression are likely to contribute to signs, such as refusal to participate in treatments. As the problems are often choice; in addition studies suggest adaptations of complex, treatment suggestions have to be compre- cognitive-behavioral therapy techniques and brief hensive. Erectile dysfunctioning can be treated with supportive therapy to be beneficial [3]. In a Cochrane phosphodiesterase type 5 inhibitors or intracaverno- review, however, there was no evidence for impro- sal prostaglandin E-1 injections. Social coun- (n ¼ 4448) the diagnosis “previous stroke” was only seling is therefore mandatory in the course of stroke a nearly significant risk [124]. There is no doubt that rehabilitation, which includes, for example, informa- driving ability in the post-stroke period needs assess- tion about social security systems, social services, self- ment, and a study [125] shows that patients are in help and stroke groups. As a first step there are certain Acknowledgement 300 medical and neurological conditions where clinical The authors would like to thank Serafin Beer for judgement will confirm stroke patients as being helpful discussion and comments on the manuscript. Chapter 20: Neurorehabilitation Chapter Summary and others were found to be beneficial for motor recovery, while others, e. Neuroplasticity is the dynamic potential of the brain to reorganize itself during ontogeny and learning, or Speech disorders need intense training because following damage. Newer adult human being has an astounding potential for studies with therapies taking place daily for several regeneration and adaptability, which can be select- hours correct the former uncertainty regarding the ively supported and used for rehabilitation. Brain stimulation Several mechanisms of neuronal plasticity can be techniques and medication might add additional identified: benefit. Vicariation describes the hypothesis that func- Dysphagia occurs in the acute state of stroke in tions of damaged areas can be taken over by more than 50% of patients, probably leading to different regions of the brain. In the central nervous system of the ventions, for example modification of bolus volume adult, however, this mechanism is reduced, but and viscosity, and rehabilitative techniques, such as not absent. Diaschisis describes the phenomenon that a focal Patients admitted with tracheostomy often also need lesion may also lead to changes in brain func- intense dysphagia management. Spasticity can be treated with physiotherapy, nursing care and occupational therapy. If physical Neuroplasticity can be supported by: treatment reaches a limit, oral agents, intrathecal A multidisciplinary team in a structured setting. Treatment in a stroke unit has been shown to For the treatment of spatial neglect, perception improve the outcome significantly (number via the affected side is enforced as much as possible needed to treat 7 for thrombolysis versus 9 for and additional alertness training as well as visual and stroke unit treatment). Only team of medical, nursing and therapy staff, opti- a few pilot studies have been published to evaluate mal timing and early initiation (i. Pharmacological interventions: in preliminary studies, some medications such as levodopa 5. Brain plasticity: from pathophysiological mechanism for recovery and rehabilitative training. Mechanisms for recovery of motor function interaction, and physical activity as determinants of following cortical damage. Curr Opin Neurobiol 2006; functional outcome after cerebral infarction in the rat. Noninvasive cortical representations in primary motor cortex following stimulation in neurorehabilitation: a review. Pattern-specific role of the current orientation used Use-dependent alterations of movement to deliver theta burst stimulation. Clin Neurophysiol representations in primary motor cortex of adult 2007; 118(8):1815–23. Influence of Training-induced changes of motor cortex somatosensory input on motor function in patients representations in stroke patients. Vicarious function within the human stroke survivors with severe motor loss of the upper primary motor cortex? Functional neuroimaging studies of motor recovery after stroke in adults: a review. Brain 2003; Inactive and alone: physical activity within the first 126(Pt 6):1430–48. The Immediate constraint-induced movement therapy Rivermead Mobility Index: a further development of causes local hyperthermia that exacerbates cerebral the Rivermead Motor Assessment. Balance in elderly exacerbate brain damage after focal brain ischemia in patients: the “get-up and go” test. Early ambulation training: a randomized controlled and long-term outcome of rehabilitation in stroke pilot study. Arch Phys Med Rehabil 2002; patients: the role of patient characteristics, time of 83(9):1258–65. Timing of initiation of rehabilitation after Neurorehabil Neural Repair 2000; 14(1):13–19. Retention of upper limb with body weight support: effect of treadmill speed and function in stroke survivors who have received practice paradigms on poststroke locomotor recovery. Repetitive task training for through body weight support and treadmill improving functional ability after stroke. Whole-body intensive rehabilitation on stroke outcomes: what is the rehabilitation is feasible and effective in chronic stroke evidence. In Barnes M, Dobkin B, Bougousslavsky J, survivors: a retrospective data analysis. Robot-assisted gait training in multiple exercise capacity and walking capacity in adult sclerosis: a pilot randomized trial.

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