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Arctic mammals include polar bear, arctic fox, ermine, marten, arctic wolf, wolverine, walrus, seal, caribou, reindeer (domesticated caribou), musk-ox, lemming, arctic hare, and many species of whale.Birds are plentiful throughout the Arctic Regions. The guillemot and little auk nest by of puget, the thousands along cliffs. Ravens, snow buntings, and sandpipers have been seen in christopher success essay the remotest northern land regions, as have the snowy owl and of puget sound supplemental essay, the gyrfalcon. Various species of the lagoon, gull, including the jaeger, also range far t laska and northern Canada still follow a subsistence lifestyle. They live as their ancestors have, measuring their lives with the caribou.The Porcupine caribou herd sustains some 7,000 aboriginal people in northern Canada and Alaska.
They rely on caribou meat for university of puget, food and on the herd for learning the ways of their culture. For the beginning essay quote, Gwich'in, which means caribou people, this animal is the sound supplemental, spiritual center of life. Young men learn from their fathers and uncles how to essays hunt wisely and use all parts of the animal. Young women learn from their mothers and of puget supplemental, aunts how to preserve the meat and take care of the hides. Elders share their knowledge with their people, teaching them how to make valuable medicines and clothing from the caribou.Today the essentials of beginning, life, the values and social order of the Gwich'in depends upon nature's natural cycle, and the return of the caribou. For these people, the caribou must return each year forever.If the Porcupine caribou herd is disrupted, even for a few years, ding air currents bearing pollution from the industrial countries and the fact that most of the pollutants biomagnify in fat are threatening the very survival of humans and animals living in the Arctic.
Fat is packed with energy making it possible for marine animals and sound, humans to survive in the Arctic (meat and essay, sugar diets are not adequate in the frigid climate) but the fat diet magnifies pollution. University Sound Supplemental! The international fund for animal welfare recently found arctic seals to be polluted with 29 chemicals including pesticides, PCBs, arsenic, mercury, cadmium as well as hydrocarbons from petrol soot and tar. The seals milk contained radioactive caesium-137 and strontium 90 from reactor wastes. Polar bears, walruses and humans top the food chain and bear pollution loads that have begun to threaten their survival. When PCBs reach a critical level in fat, males loose the ability to christopher columbus failure produce sperm, the most efficient food gatherers are sterilized first leaving profound impacts on of puget sound, the evolution of the animals. T rmer Soviet Union, Eastern Europe and North America. DDT long banned in Canada and the United States is used extensively in Central and write, South America and is a threatening pollutant of the Arctic. A recent study traced DDT and PCBs from the Caribbean (including industrial Merida) up the Mississippi Valley to Southwestern Ontario and presumably beyond to the Arctic. Canadian and United States industries fleeing to Mexico for sound, cheap labour and oresteia clytemnestra analysis, lax environmental controls are clearly threatening the very existence of Canadians and polar animals. University Supplemental Essay! On Goodfriday 1987 the Exxon Valdez ran aground in the Prince William Sound, spilling 11 million gallons of crude oil into the surrounding ocean.
Prevailing winds and currents produced a slick on 1500km of pristine coastline. The damage caused by an oil tanker unlicensed to be so close to the coast caused the with, worst ecological damage in the area to date:980 dead Sea Otters146 dead Bald Eagles 33,126 other seabirds killed through suffocation, poisoning or exposur fe Range the Arctic National Wildlife Refuge, and enlarged the university sound supplemental essay, Refuge to 19 million acres, most of the essay with quote, former Range a part of the Wilderness Preservation System.There is of puget supplemental opposition towards this:- worldwide consumption of oil is growing. There is pressure on the US Governmetn from lobbyist groups from the oil industry to find new sites of extraction for oil and other raw materials to reduce it.s reliance on the OPEC countries and importance of unity world essay, also to continue the present day growth in it.s economy. The American Petroleum Institute claims the coastal plain of the Arctic National Wildlife Refuge might produce as much as 250 thousand barrels of crude oil per day, that is about 105 million barrels per year.In November, 1991, legislation that would have opened the Arctic Refuge to drilling reached the Senate floor, but was defeated on a procedural vote. A February, 1992, effort to add it to university sound supplemental essay a Senate energy bill was dropped due to limited support. However, the drilling proposal could be brought up again at outline, any time.. erica.
DDT long banned in Canada and the United States is used extensively in Central and South America and is a threatening pollutant of the Arctic. A recent study traced DDT and university of puget sound supplemental essay, PCBs from the Caribbean (including industrial Merida) up the importance muslim world, Mississippi Valley to Southwestern Ontario and presumably beyond to university of puget sound supplemental the Arctic. Canadian and United States industries fleeing to Mexico for columbus failure, cheap labour and lax environmental controls are clearly threatening the very existence of Canadians and polar animals. Cohen S (1994). Mackenzie Basin Impact Study (MBIS). Alaska.Crawford R (1990). Effects of Human Activity on High Latitude Biodiversity (HILBIO) - on behalf of UK NERC and ESRC. HMSO, London.Cummins J E(1992) Poisoning The Northern Environment University of Western Ontario, London, Ontario USA Goudie A (1994) The Human Impact on the Natural Environment, 4th Edition, Blackwell, Oxford. Goudie A (1993) The Nature of the Environment, 3rd Edition, Blackwell, Oxford. Kalland A Nord. Our writers are all Uni graduates able to work effectively on any level under time constraints.
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Patience Is a Writer’s Most Important Virtue. Patience is bitter, but its fruits are sweet. —Jean Jacques Rousseau. We live in a world of instant gratification. This is rarely a good thing, especially when it comes to creativity. Photo credit: Brandon Christopher Warren.
Think about it. There’s Twitter, text messages, and email (remember what it was like waiting for an actual piece of paper to arrive in your mailbox?). When you post an update on Facebook, you get that little red notification sign as soon as someone leaves a comment. If you want to know something, you don’t call your Mom or dust off an of puget sound supplemental, encyclopedia; instead, you simply type your request into a search box. How about today’s diet culture? Forget healthy eating and exercise — You must be thin now! Lose 10 inches off your waist in just 10 days! Impatience plagues our writing, too. When it comes to writing, most of outline, us writers spend a great deal of university supplemental essay, time talking about how important it is to us. It’s our calling.
We can’t survive without the written word. Yet, we’re plagued with an impatience to see our writing improve faster, to gain recognition for our work, and to get our words in print. Later isn’t soon enough. Waiting to christopher columbus success failure hear whether our writing has been accepted is university of puget supplemental, torturous—whether it be a guest post on someone else’s blog, an article for a magazine, a story for write thesis statement narrative essay a literary journal, or a book for an agent. We want immediate responses. I’ve even heard writers say they’d rather have a quick form rejection, as opposed to waiting months for sound supplemental a well-considered personal rejection. This type of mindset is counterproductive. Columbus Success Failure Essay! Here are three reasons why patience is the supplemental most important virtue for writers: Lesson 1: It takes time to with quote learn to write well. If your dream were to university supplemental be a concert pianist, you wouldn’t expect to sit down and just play. You’d take lessons for many years, practice every day, and sacrifice a great deal in oresteia clytemnestra, order to sound essay achieve that dream.
So, why do we expect ourselves to be able to write well without the same level of commitment and patience? Years ago, I remember thinking, “Hey, I’m a smart person. I read a lot, have a couple of degrees, and columbus essay, can string sentences together pretty well. University Of Puget Supplemental Essay! There’s no reason I shouldn’t be able to oresteia clytemnestra analysis get published.” Those qualities might be helpful, but they’re no substitute for sound supplemental plain hard work and patience. Quote! Very few writers have succeeded in getting published without years’ worth of practice behind them. Lesson 2: It takes time for your writing to get noticed. Even if you’re a great writer, getting to of puget a point where other people (especially editors and agents) know how great you are can take a lot of time. Building a portfolio of writing credits often takes a while to get rolling. Usually, you have to importance of unity 120 words start small and work your way up, which might mean writing for supplemental free for years before your passion actually earns you a dime.
But, if you’re impatient — if you give up before you’ve built that portfolio — you risk never getting past the status of hobbyist and write thesis narrative essay, having your talent go down the of puget toilet. Lesson 3: It takes time to build a writing career. One published book does not a writing career make. Unless you happen to skyrocket to the top of the bestseller list with your debut — and even if you do — you’ll still have to put in success essay, years of hard work to promote that book, write more books, speak at university conferences and/or teach writing courses, build a website and blog, and the lagoon essay, continue to improve your writing. If you just want to see your name on a book cover, self-publishing is becoming easier and more common. But if you want a long-term professional writing career, you’ll need patience and endurance to build it. When I talk about writers and impatience, I’m talking from of puget sound supplemental essay a long history of personal experience. In my early years of outline, university, after an unsuccessful experience with a creative writing degree, I quit writing. I saw it as being all just too hard and too competitive, but what I really lacked was life experience and of puget sound supplemental essay, patience to develop my talent. Nearly 10 years later, I tried again. Rejection after rejection continued to roll in columbus failure, because I was still too impatient to do the type of university supplemental, work necessary to improve my writing.
I still wanted it to toulmin essay outline happen immediately. It’s taken almost five more years of hard work, and university of puget supplemental, plenty of beginning with quote, rejection, to university of puget sound essay get to the point where I’m happy to let something mellow in a drawer for in the muslim world essay a while before sending it out, or where I can stand the (admittedly) long wait times it takes to hear back from literary journals. I’ve learned that patience makes a difference. It makes me a better writer. I know this, because—finally—I have some publishing credits under my belt. Patience is not passive; on the contrary, it is active; it is concentrated strength. Next time you feel tempted to complain about how slowly things are progressing in university of puget supplemental, your writing life, consider that piece of oresteia, wisdom.
Being patient doesn’t mean sitting around twiddling your thumbs. Supplemental! It takes strength and character. While you wait, you can be writing more, reading more, practicing, failing, dusting yourself off, and trying again. What aspects of writing do you need to be more patient about today? Share in the comments. I write books and essay with, help writers get their work out into the world. I am the best-selling author of of puget supplemental, four books, including The Art of Work . Each week, I send out a newsletter with free tips on writing and creativity. Ever Wonder If Your Blog Post Is Good Enough? We built a free tool so you don’t have to worry about that ever again.
1. Pick your goal of the post. 2. Answer 5 basic questions. 3. It tells you if it’s good enough and how to make it better. nicely put, patience is essay, so very hard, but it’s a virtue, right? I’m not a patient person, but i am quite cautious and essay, very much strategic. As such i’m forced to write thesis essay be patient, to sit on things and let the evolve, and take risk carefully. Think before i speak and act is something i have to of puget supplemental consciously act upon each day. Matt (Turndog Millionaire) Matt, I think we all need to essay outline work on thinking before we speak and act, in all realms of university of puget sound, life! Good advice #128578;
Thanks for the encouragement. I’ve been writing for 3just years. I’m just now getting to the point where I’m learning what I’m doing. It’s takes a while, doesn’t it? The good thing is how much satisfaction you get from knowing you’ve worked your way up. I needed this today, for more reasons than any writing/creativity goals I’m chasing. I needed it for more…
Glad this hit the spot, Mandy! This could be applied in so many areas of life. Thanks for sharing. I’m making it a goal to the lagoon essay write everyday for the next 30 days, even if it’s just 5 minutes. With newborn twins and a total of four children, I’ve been writing in VERY short bursts for the past while. A little goes a long way, just as long as you keep up with it! Patience is NOT one of my virtues… I tend to university of puget essay subscribe to the Blitz and Burn Out… Blitz and Burn Out… method of writing. Is that working for you? #128521; I certainly wouldn’t recommend it. Essay Outline! But when something hits me that I want to write about I can’t stop writing till it’s done.
I just typed up the Bulwer-Lytton quote in huge letters and pinned it up on the bulletin board that sits above my desk. It’s inspiring to think that in being patient, I’m building up my strength. Thanks for the great words! Great idea! I should probably do the same. “Waiting to hear whether our writing has been accepted is torturous—whether it be a guest post on university sound essay someone else’s blog, an article for write thesis narrative essay a magazine, a story for a literary journal, or a book for supplemental essay an agent.” Because I have e-mailed you “Why is no one commenting. Toulmin Outline! ” after I was a guest blogger on supplemental another blog this sentence made me laugh out success failure, loud. Again it is like you are in university of puget essay, my head! Weird! I know your pain #128578; It gets easier as time goes by, but I don’t know that it ever completely goes away! I think the most important thing is simply realizing it will be along journey. A lot of people understand that it is, but for the lagoon some reason think their talent or their drive or their luck will change that.
Sure, that happens for some. But before we even start, we need to prepare ourselves for the long haul. Agreed! It’s not easy, but it’s necessary. GREAT post! I, too, am constantly struck by university sound, the people who don’t believe that writing takes practice. Yes! It’s just like playing the piano or running. You need to LEARN techniques and the lagoon essay, you need to build MUSCLE and ENDURANCE.
I think I may ask my clients to read your pieces. Thanks for sharing your thoughts, Suzannah. I think most people feel they are pretty good writers until they’ve actually done it for a while. University Sound Essay! Then they realize just how far they need to go to become ‘pretty good,’ let alone ‘great’! This speaks directly to essay me today, Jeff. I’ve been mulling over the “what should I do next?” question for awhile now, and praying for a different job. I’ve been feeling pressured to figure out sound supplemental, where I’m going in the lagoon, order to of puget gain more financial stability, more credentials on my resume. Thanks for the reminder that it’s about patience and diligence in essay outline, my work.
All the best with finding the right job for essay you! Patience can be a real pain. No denying we are a nation of impatience, but hopefully writers can turn that into toulmin motivation. If you want to be a writer so bad you can hardly wait for it, then you better get started TODAY! That doesn’t mean all the pieces of the puzzle will magically fall into place, but at least leverage that jittery, itching ambition to start creating something beautiful right away. Whether it’s starting a blog, writing an article or diving into to chapter one of a book, don’t dwell in your impatience, use it. Thanks for of puget sound supplemental essay a great post. I’m already a fan of Write It Sideways and I’m interested in checking out a Busy Mom’s Guide. Awesome to see you on another of my favorite sites. Thanks for importance of unity in the muslim world essay your kind words, Christelle! Great post.
Thanks for university of puget sound sharing. I struggle with point number two, I want my writing to get noticed. That’s why I appreciate this meesage so much, we all need more patience. Excellent and needed post Suzannah. It takes time, but the wait is so worth it! I can’t tell you how glad I am to have put in in the, several years of practise before getting that first published story. I needed to hear this! Thanks for sharing! An important piece of advice I’ve recently come upon university, is not worrying about the quality of others work.
Don’t compare your writing to successful writers and your peers (who may well be successful writers). This can only lead to beginning impatience in seeing that your work isn’t up to the level that you wish it was (which is good, but impatience is the wrong response). Just try to make the piece you are working on the best it can be – it needs to live up to itself, nothing else. There are no expectations for a piece of writing than the full realization of the idea it contains. That’s what I try to remember when I think towards my future as a writer.
I’ve been guilty of the comparison thing, but now I stop myself and realize that I’m right where I’m supposed to be. Patience is one of the most difficult skills to cultivate. I can’t help but wish I were there already! Getting my book blurbs Just Right. “While you wait, you can be writing more, reading more, practicing, failing, dusting yourself off, and trying again.” That’s great advice. Thank you.
Hi Jeff. Of course thing article rings true. However, I feel that, at my age, (65), I may not have a lot of time left. Of Puget Supplemental! That’s what makes me so grumpy and impatient. Nor do I consider myself to be a “real” writer. Writers write. The Lagoon! It’s like a compulsion. They can’t help it.
They MUST write or they feel awful. University Sound! They start writing in childhood. I just had this idea for a sci/fi/supernatural story, that sprang out of a few near-muggings that happened to me, and my amazing (to me) responses to them, and that wonderful “what if?…” came to my mind, and novel details started tickling around the edges of the lagoon, my imagination. Finally, I sat down to brainstorm, and the characters came to me as though I were channeling them. I experienced the real relativety of university, time while I typed as fast as I could to write down the back stories of christopher essay, my principal characters, unaware that hours had passed. Of Puget Sound Supplemental Essay! It was the most fun I’ve ever had on essay a computer, LOL.
So, as with any skill, it takes time and university supplemental, patience to learn. Write Narrative! I understand that. I’m just stuck in the “Good grief, how much time do I REALLY have left?” mindset. You know, the time needed to refine and hone the prose and plot, etc. Which, BTW, is what I’m doing right now. And, good grief, I had no idea that copy editing could be such a chore! LOL #128512; THANKS FOR THIS ARTICLE, IN SPITE OF MY MUTTERING AND GRUMBLING! I’m just a late bloomer, or maybe a blooming idiot!
Sharon, you might like to read this guest post Debra Eve wrote for my blog, all about ‘late-blooming writers.’ You might be surprised and encouraged by it! https://writeitsideways.com/offbeat-lessons-from-three-late-blooming-writers/ Writing is a tough gig. Getting published is harder yet. I just returned from an author’s conference where one of the speakers talked about writing and self publishing a book in a month. While it is technically possible to university essay do this, I think it leads to frustration. As a blogger for over seven years, I can say that blogging is a great way to practice your writing and to explore subjects that will make a great book. Christopher Columbus Success Failure! When I wrote my first novel, I was constantly reading books on the craft of university sound supplemental essay, writing.
It was fun to apply what I was learning as I went through. Essay! My editor commented that my book got progressively better chapter by chapter. While I had to do considerable editing on that first draft, I realized how much I had learned in a short time. Books like Stein On Writing and William Zinsser’s On Writing Well , really helped me get up to speed quickly. I agree, writing and self-publishing a book in a month is technically possible, but is it really a good idea?
What kind of of puget supplemental, product are you going to end up with in this scenario? Thanks for importance of unity essay sharing your experience! The idea is to essay write a smaller 100 page book about a single subject and use it as an clytemnestra, expensive “business card.” While that idea has merit, if it’s your business card, it better be good. Thanks for the reminder! I’m trying to bask in the process. I am not sure whether it is the of puget most important one, but I am sure this quality is very important.
I am Chinese and I hope to write English well and I meet many problems in my writing when using English to write something nice and importance muslim world essay, meaningful down. I feel confused and impatient, but I must try my best to calm myself down because this is really a haul for me-a Chinese who understand English not enough. I love this anyway! Sounds like you’re a very patient person! Learning to write in another language is a difficult task.
Suzannah, you offer sound wisdom gleaned from experience. I know, after several years of of puget sound supplemental, trying to convince my tax man that “Yes, this is a legitimate deduction,” he believes I’m serious about toulmin essay, writing. Your time line of 5 years lines up well with my own journey. The mileage adds up and you eventually find yourself at a destination you’d never dreamed of, the place where authors gather. Thanks, Tom. Wow! Great minds must think alike. University Sound Supplemental! I’ve been chewing on a post like this for sometime.
Great to analysis see someone talking about it. The aspect I need to be patient about is of puget sound supplemental essay, my audience. It’s growing but not as fast as I would like it to. Essay Outline! It will come, I just need to keep pushing out the essay content. Hey Jeff, it’s been a while since I have been back here. Thanks for the kick in the ass here. Patience is something I know and christopher columbus failure essay, apply regularly in sound, my life except for essay with quote writing. Maybe because I am so passionate about it. Of Puget Sound Supplemental Essay! Passion is good but your advice here is statement, of great value especially the “patience is university sound, learned” piece.
I know this will take time but it’s the spaces between that make it most challenging. Everyday that I write is a good day–I am so very grateful I have reached a point in my life where this is happening again! Wonderful post–and extremely helpful to prod us writers into essay with quote the habit of of puget sound, PATIENCE, which we must have to analysis keep on keeping on! Send that gratitude my way. Great great attitude. #128578; Patience has always been one of my personal demons. Thanks to of puget supplemental God I’m learning to surrender to this valuable virtue. I love the idea that patience is the lagoon, “concentrated strength.” For me patience is hard when it comes to sound building my freelancing career. My first job was an unexpected explosion of fireworks, so now everything else seems rather drained of its color.
It’s hard to re-adjust expectations and remain joyful in the waiting. Thanks for this post! It’s a great reminder. Thanks for this piece of advise, I started blogging about 4 months ago and it’s discouraging when I don’t get comments. I have made the mistake of comparing myself to long time bloggers and their followers. But that’s a big mistake indeed. Building something like this takes a great deal of time, thanks for reminding me never to give up and keep writing:) Awesome write up.
Those who believe in the fast way of life are sure to reject your views. Only experience can teach the value of patience. When I’m at my worst, I can hardly get 1 paragraph on narrative essay a page before throwing it into university of puget sound the trash. Terrific post! Thanks. Everything.
I need to toulmin be patient about everything. University Sound Essay! I have great ideas and christopher success failure essay, then I go to write and I feel this wave of frustration, like a huge wave of dread/anxiety/stress and then I get discouraged and go into freak-out-mode about never living to my full potential. Then I eat something or hang out university of puget, with the fam and I feel better. I think what I might need is more writer friends (I have none) to share in the lagoon, our frustrations together and help encourage and build each other up. Agreed. Of Puget Sound Supplemental Essay! As a matter of fact, if you look at essay the lives of those who have been successful in the eyes of university of puget supplemental, society versus other who maybe aren’t as successful, one stark difference is that the ones that are successful just never quit.
They kept going, waited it out, and eventually hit upon something that gave them success. I’m Jeff Goins, the best-selling author of importance of unity muslim world essay, five books including The Art of Work and Real Artists Don’t Starve . Every week, I share new tips on sound supplemental essay creative work. Enter your email below and I’ll send you a free book.
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Clopidogrel with Aspirin in university of puget sound essay, Acute Minor Stroke or Transient Ischemic Attack. Yongjun Wang, M.D., Yilong Wang, M.D., Ph.D., Xingquan Zhao, M.D., Ph.D., Liping Liu, M.D., Ph.D., David Wang, D.O., F.A.H.A., F.A.A.N., Chunxue Wang, M.D., Ph.D., Chen Wang, M.D., Hao Li, Ph.D., Xia Meng, M.D., Ph.D., Liying Cui, M.D., Ph.D., Jianping Jia, M.D., Ph.D., Qiang Dong, M.D., Ph.D., Anding Xu, M.D., Ph.D., Jinsheng Zeng, M.D., Ph.D., Yansheng Li, M.D., Ph.D., Zhimin Wang, M.D., Haiqin Xia, M.D., and S. Claiborne Johnston, M.D., Ph.D., for write the CHANCE Investigators * N Engl J Med 2013; 369:11-19 July 4, 2013 DOI: 10.1056/NEJMoa1215340. Comments open through July 10, 2013. Stroke is common during the first few weeks after a transient ischemic attack (TIA) or minor ischemic stroke. Combination therapy with clopidogrel and aspirin may provide greater protection against university subsequent stroke than aspirin alone. In a randomized, double-blind, placebo-controlled trial conducted at 114 centers in China, we randomly assigned 5170 patients within 24 hours after the onset of minor ischemic stroke or high-risk TIA to combination therapy with clopidogrel and aspirin (clopidogrel at an initial dose of 300 mg, followed by 75 mg per day for 90 days, plus aspirin at a dose of 75 mg per day for the first 21 days) or to placebo plus aspirin (75 mg per day for 90 days).
All participants received open-label aspirin at a clinician-determined dose of 75 to 300 mg on day 1. Christopher Success Failure Essay! The primary outcome was stroke (ischemic or hemorrhagic) during 90 days of university of puget sound supplemental essay, follow-up in an intention-to-treat analysis. Treatment differences were assessed with the use of a Cox proportional-hazards model, with study center as a random effect. Stroke occurred in 8.2% of patients in essay, the clopidogrel–aspirin group, as compared with 11.7% of those in the aspirin group (hazard ratio, 0.68; 95% confidence interval, 0.57 to 0.81; P0.001). Of Puget Sound! Moderate or severe hemorrhage occurred in seven patients (0.3%) in the clopidogrel–aspirin group and in toulmin essay outline, eight (0.3%) in the aspirin group (P=0.73); the rate of hemorrhagic stroke was 0.3% in each group. Among patients with TIA or minor stroke who can be treated within 24 hours after the onset of symptoms, the university of puget essay, combination of clopidogrel and aspirin is superior to aspirin alone for reducing the risk of failure essay, stroke in university of puget essay, the first 90 days and essay, does not increase the risk of hemorrhage. (Funded by the Ministry of Science and Technology of the sound essay, People's Republic of China; CHANCE ClinicalTrials.gov number, NCT00979589.) Transient ischemic attack (TIA) and acute minor ischemic stroke are common and often lead to disabling events. In China, there are approximately 3 million new strokes every year, and approximately 30% of failure, them are minor ischemic strokes. 1,2 The incidence of TIA in China has not been determined, but on university of puget supplemental essay the basis of the incidence in other countries, there are probably more than 2 million TIAs annually in China. 3-5 The risk of thesis essay, another stroke occurring after a TIA or minor stroke is high, with approximately 10 to 20% of patients having a stroke within 3 months after the index event; most of these strokes occur within the university of puget, first 2 days. 5-8. The role of antiplatelet therapy for secondary stroke prevention has been well established.
However, aspirin is the only antiplatelet agent that has been studied in the acute phase of christopher columbus success, stroke, during which its benefit is modest. 9,10 Aspirin and clopidogrel synergistically inhibit platelet aggregation, 11,12 and such dual therapy reduces the risk of recurrent ischemic events in patients with the acute coronary syndrome. 13,14 Large-scale trials of secondary prevention of ischemic events after stroke have not shown a benefit of the combination of clopidogrel and aspirin. 15-17 However, these trials did not study the early, high-risk period after stroke, they included some patients with strokes of moderate severity, and they included few if any patients with TIA. Three small pilot trials have shown trends toward a benefit of the university sound essay, combination therapy and minimal safety concerns in patients with minor stroke or TIA. 18-20. We conducted the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial to test the hypothesis that 3 months of treatment with a combination of christopher columbus failure, clopidogrel and aspirin would reduce the risk of recurrent stroke, as compared with aspirin alone, among patients with acute high-risk TIA or minor ischemic stroke. We conducted this study according to the protocol and statistical analysis plan, which are available with the full text of this article at NEJM.org. The trial was designed by of puget essay, three of the christopher columbus essay, authors and was overseen by of puget sound, the executive committee, which had full access to the data. Essay With! Data collection and of puget essay, entry were performed by analysis, staff at the Tiantan Clinical Trial and Research Center for Stroke, where the data analysis was performed. One of the authors had full access to an independent database for any questions regarding the analyses.
All members of the writing committee contributed to and approved an university of puget, earlier draft of this manuscript, which was prepared without professional editorial assistance. The first and last authors made the decision to submit the manuscript for publication. All the authors assume responsibility for the accuracy and completeness of the data and the fidelity of this report to the study protocol. There was no confidentiality agreement between the study sponsor (the Ministry of the lagoon essay, Science and of puget sound supplemental essay, Technology of the People's Republic of China) and oresteia analysis, the investigators. There was no commercial support for this study. All the participants or their legal proxies provided written informed consent. University Sound! The CHANCE protocol was approved by the ethics committee at christopher columbus essay each study center. Clopidogrel and the matching placebo were purchased from university of puget supplemental, Sanofi-Aventis, which had no other role in the study. Patients who met the essay outline, following inclusion criteria were eligible: age of 40 years or older; diagnosis of an acute minor ischemic stroke or TIA; and university of puget supplemental essay, ability to start the study drug within 24 hours after symptom onset, which was defined as the point at which the patient reported no longer being in a normal condition. Acute minor stroke was defined by a score of 3 or less at the time of randomization on the National Institutes of Health Stroke Scale (NIHSS; scores range from write thesis statement narrative, 0 to 42, with higher scores indicating greater deficits). TIA was defined as focal brain ischemia with resolution of symptoms within 24 hours after onset plus a moderate-to-high risk of stroke recurrence (defined as a score of university of puget, ?4 at the time of randomization on the ABCD, 2 which assesses the risk of stroke on the basis of age, blood pressure, clinical features, duration of essay 120 words, TIA, and presence or absence of sound, diabetes; scores range from 0 to 7, with higher scores indicating greater short-term risk).
All patients with possible clinical neurologic events during the essay with quote, follow-up period underwent computed tomography (CT) or magnetic resonance imaging (MRI) of the of puget sound supplemental, head. Patients were excluded if they had any of the following: hemorrhage; other conditions, such as vascular malformation, tumor, abscess, or other major nonischemic brain disease; isolated sensory symptoms (e.g., numbness), isolated visual changes, or isolated dizziness or vertigo without evidence of acute infarction on baseline CT or MRI of the head; a score of more than 2 on the modified Rankin scale (scores range from 0 [no symptoms] to 6 [death]) immediately before the occurrence of the beginning essay, index ischemic stroke or TIA, indicating moderate disability or worse at baseline; an university of puget sound, NIHSS score of muslim world, 4 or more at supplemental randomization; a clear indication for anticoagulation therapy (presumed cardiac source of embolus, such as atrial fibrillation or prosthetic cardiac valve) or a contraindication to clopidogrel or aspirin; history of intracranial hemorrhage; anticipated requirement for long-term nonstudy antiplatelet drugs or for nonsteroidal antiinflammatory drugs affecting platelet function; heparin therapy or oral anticoagulation therapy within 10 days before randomization; gastrointestinal bleeding or major surgery within the statement essay, previous 3 months; planned or probable revascularization (any angioplasty or vascular surgery) within 3 months after screening (if clinically indicated, vascular imaging was to be performed before randomization, whenever possible); planned surgery or interventional treatment requiring cessation of the university sound essay, study drug; TIA or minor stroke caused by angiography or surgery; or severe noncardiovascular coexisting condition, with a life expectancy of less than 3 months. Women of childbearing age who were not practicing reliable contraception and did not have a documented negative pregnancy test and patients receiving other investigational drugs or devices were also excluded (see Table S1 in the Supplementary Appendix, available at NEJM.org). No patients included in the study were treated with thrombolysis around the time of randomization. CHANCE was a randomized, double-blind, placebo-controlled clinical trial conducted at 114 clinical centers in China; details of the rationale for the study and its design have been published previously. 21 Patients meeting the enrollment criteria were randomly assigned to one of the two treatment groups with the use of toulmin essay, a double-blind, double-dummy design. The site investigator called into an automated system that randomly assigned a number corresponding to a medication kit stored at the study site, and the medication in the kit was administered to the patient.
Both groups received open-label aspirin on day 1 (with the dose ranging from 75 to 300 mg, at the discretion of the treating physician). Patients randomly assigned to the clopidogrel–aspirin group received a loading dose of 300 mg of clopidogrel on day 1, followed by a dose of 75 mg per day on university sound supplemental days 2 through 90, aspirin at a dose of 75 mg per day on days 2 through 21, and placebo aspirin on days 22 through 90. Patients randomly assigned to the aspirin group received a placebo version of with, clopidogrel on days 1 through 90 and aspirin at a dose of 75 mg per of puget supplemental essay, day on days 2 through 90. Columbus Success Essay! Randomization was stratified according to clinical center and interval between symptom onset and enrollment (12 hours vs. 12 to university supplemental, 24 hours). The primary objective was to assess the effects of the beginning quote, two treatment regimens on the incidence of stroke in the first 90 days after acute minor stroke or high-risk TIA. The primary efficacy outcome was a new stroke event (ischemic or hemorrhagic) at 90 days. Ischemic stroke was defined as an university of puget sound, acute focal infarction of the brain or retina with one of the essay, following: sudden onset of a new focal neurologic deficit, with clinical or imaging evidence of infarction lasting 24 hours or more and not attributable to a nonischemic cause (i.e., not associated with brain infection, trauma, tumor, seizure, severe metabolic disease, or degenerative neurologic disease); a new focal neurologic deficit lasting for less than 24 hours and not attributable to a nonischemic cause but accompanied by sound supplemental, neuroimaging evidence of new brain infarction; or rapid worsening of an existing focal neurologic deficit lasting more than 24 hours and not attributable to a nonischemic cause, accompanied by new ischemic changes on MRI or CT of the brain and clearly distinct from the index ischemic event. Hemorrhagic stroke was defined as acute extravasation of blood into toulmin outline, the brain parenchyma or subarachnoid space with associated neurologic symptoms. Recurrent stroke was considered to be disabling if the score on the modified Rankin scale was 2 or more.
The primary safety outcome was a moderate-to-severe bleeding event, according to university, the Global Utilization of Streptokinase and Tissue Plasminogen Activator for narrative Occluded Coronary Arteries (GUSTO) definition. University Sound Essay! 22 Severe hemorrhage was defined as fatal or intracranial hemorrhage or other hemorrhage causing hemodynamic compromise that required blood or fluid replacement, inotropic support, or surgical intervention. Moderate hemorrhage was defined as bleeding that required transfusion of blood but did not lead to hemodynamic compromise requiring intervention. 22. Key secondary efficacy outcomes included a new clinical vascular event (ischemic stroke, hemorrhagic stroke, myocardial infarction, or vascular death), analyzed as a composite outcome and also as individual outcomes. Vascular death was defined as death due to stroke (ischemic or hemorrhagic), systemic hemorrhage, myocardial infarction, congestive heart failure, pulmonary embolism, sudden death, or arrhythmia.
Efficacy outcomes were also analyzed according to prespecified subgroups. All reported efficacy and importance muslim 120 words, safety outcomes were confirmed by a central adjudication committee that was unaware of the study-group assignments. The committee members classified ischemic-stroke subtypes on the basis of available diagnostic studies. A data and safety monitoring board whose members were selected by the sponsor was in place to ensure the safety of patients during the study, with predetermined periodic assessments of university of puget supplemental, safety and stopping rules. We calculated that a sample of 5100 patients would provide 90% power to detect a relative risk reduction of 22% in the clopidogrel–aspirin group, with a two-sided type I error of 0.05, assuming an essay, event rate of 14% in university of puget sound supplemental, the aspirin group and a 5% overall rate of withdrawal (defined as medication nonadherence). 21. No patient withdrew between the essay, time of randomization and the administration of the first dose of university sound, study medication; all analyses were based on the population of patients who underwent randomization. We compared the beginning, baseline characteristics of the patients in the two study groups.
Proportions were used for categorical variables, and medians with interquartile ranges were used for continuous variables. University Of Puget Sound Supplemental Essay! Time to randomization was calculated as a group mean. Differences between study groups in the rate of stroke (ischemic or hemorrhagic) during the 90-day follow-up period were assessed with the use of a Cox proportional-hazards model, with pooled study centers (?20 patients) as a random effect. Hazard ratios with 95% confidence intervals are reported. Christopher Columbus Success Failure! When there were multiple events of the university of puget, same type, the time to the first event was used in the lagoon essay, the model. Of Puget Supplemental Essay! Data from patients who had no events during the study were censored at the time of study termination or death. We used this approach to maximize the time-dependent information in the trial while maintaining the beginning, ease of interpretation of risks. For each model, the proportional-hazards assumption was assessed by testing the interaction between treatment and university sound supplemental essay, time. In addition, we assessed whether the treatment effect differed in certain prespecified subgroups by testing the treatment-by-subgroup interaction effect with the use of Cox models.
All tests were two-sided, and a P value of 0.05 was considered to indicate statistical significance. All statistical analyses were performed with the use of SAS software, version 9.0 (SAS Institute). Between October 2009 and July 2012, a total of 41,561 patients with stroke or TIA were screened at 114 clinical sites; 5170 patients were enrolled, with 2584 randomly assigned to the clopidogrel–aspirin group and 2586 to the aspirin group. The most common reasons for exclusion were delayed presentation (26.4% of screened patients); moderate or severe stroke (10.4%); intracranial hemorrhage (7.0%); low-risk TIA, defined as a score of oresteia clytemnestra analysis, 4 on university of puget essay the ABCD 2 (6.5%); or contraindication to clopidogrel or aspirin (6.0%) (Fig. S3 in the Supplementary Appendix). The two groups were well balanced regarding baseline characteristics ( Table 1 Table 1 Baseline Characteristics of the Patients. Christopher Columbus Success Essay! ). The median age was 62 years, and 33.8% of the of puget sound essay, patients were women. A total of 65.7% of the patients had a history of hypertension, 21.1% had diabetes, and 43.0% were current or former smokers. The median time from the onset of the columbus success, qualifying minor stroke or TIA to randomization was 13 hours. The index event was a TIA in 1445 patients (27.9%).
A total of 36 patients (0.7%) — 20 in the clopidogrel–aspirin group and 16 in the aspirin group — were lost to follow-up; 165 patients (6.4%) in the clopidogrel–aspirin group and university sound, 146 (5.6%) in the aspirin group discontinued the study medication before the end of the study (Fig. S3 in the Supplementary Appendix). Stroke occurred in 212 patients (8.2%) in the clopidogrel–aspirin group, as compared with 303 patients (11.7%) in the aspirin group (hazard ratio, 0.68; 95% confidence interval [CI], 0.57 to 0.81; P0.001) ( Table 2 Table 2 Efficacy and Safety Outcomes. and Figure 1 Figure 1 Probability of Survival Free of Stroke. The primary outcome was ischemic or hemorrhagic stroke. The inset shows the same data on an enlarged segment of the y axis. Thesis Essay! ). Fatal or disabling stroke occurred in 135 patients (5.2%) in the clopidogrel–aspirin group and in 177 (6.8%) in the aspirin group (hazard ratio, 0.75; 95% CI, 0.60 to 0.94; P=0.01). Of Puget Sound Supplemental! Ischemic stroke occurred in 204 patients (7.9%) in the clopidogrel–aspirin group and in 295 (11.4%) in the aspirin group (hazard ratio, 0.67; 95% CI, 0.56 to essay outline, 0.81; P0.001). Hemorrhagic stroke occurred in 8 patients in university of puget essay, each of the two study groups (0.3% of write narrative essay, each group). Key Secondary and Other Efficacy Outcomes. The composite outcome of vascular events occurred in 216 patients (8.4%) in university of puget, the clopidogrel–aspirin group, as compared with 307 patients (11.9%) in the aspirin group (hazard ratio, 0.69; 95% CI, 0.58 to 0.82; P0.001) ( Table 2 , and Fig. Christopher Columbus! S4 in the Supplementary Appendix).
Death from any cause occurred in 0.4% of the patients in each group. Vascular death (including death from hemorrhagic stroke) occurred in supplemental essay, 6 patients (0.2%) in the clopidogrel–aspirin group and in the lagoon essay, 5 (0.2%) in the aspirin group. University Of Puget Sound Essay! TIA occurred in 39 patients (1.5%) in the clopidogrel–aspirin group and in 47 (1.8%) in the aspirin group (P=0.36). Moderate or severe hemorrhage, as defined by means of the the lagoon, GUSTO criteria, occurred in seven patients (0.3%) in the clopidogrel–aspirin group and in eight (0.3%) in university of puget sound essay, the aspirin group (P=0.73) ( Table 2 ). Oresteia Essays! The rate of any bleeding event was 2.3% in the clopidogrel–aspirin group as compared with 1.6% in the aspirin group (hazard ratio, 1.41; 95% CI, 0.95 to 2.10; P=0.09) ( Table 2 ). The reduction in the rate of stroke and combined secondary vascular events with clopidogrel and aspirin was consistent across all major subgroups ( Figure 2 Figure 2 Hazard Ratio for university the Primary Outcome in clytemnestra analysis essays, Prespecified Subgroups. The reduction in the risk of stroke with clopidogrel and aspirin, as compared with aspirin alone, was consistent across all major subgroups. There were no significant interactions in any of the 11 predefined subgroups (P0.10 for university of puget sound essay all comparisons). Data on systolic blood pressure at baseline were missing for 4 patients. The ABCD 2 assesses the christopher, risk of stroke on the basis of age, blood pressure, clinical features, duration of transient ischemic attack (TIA), and university sound supplemental essay, presence or absence of diabetes, with scores ranging from oresteia clytemnestra analysis, 0 to 7 and higher scores indicating greater short-term risk. , and Fig. S5 in the Supplementary Appendix). University Sound! There were no significant interactions in any of the clytemnestra analysis essays, 11 predefined subgroups (P0.10 for all comparisons).
Adverse events occurred in similar proportions of university of puget essay, patients in essay, the two groups (5.8% in university of puget sound supplemental essay, the clopidogrel–aspirin group and 5.0% in the aspirin group). The proportions of patients with serious adverse events were also similar (1.0% and 0.8% in the clopidogrel–aspirin and outline, aspirin groups, respectively) (Table S4 in university supplemental essay, the Supplementary Appendix). In this large-scale trial involving patients with high-risk TIA or minor ischemic stroke, we found that the addition of clopidogrel to aspirin within 24 hours after symptom onset reduced the risk of subsequent stroke by 32.0%, as compared with aspirin alone. Event rates during this early period were very high, and clopidogrel was associated with an absolute risk reduction of the lagoon essay, 3.5 percentage points, equivalent to a number needed to treat of 29 patients to prevent one stroke over a period of 90 days. Combination therapy with clopidogrel and aspirin, as compared with aspirin alone, was not associated with an increased incidence of hemorrhage, although there was a worrisome trend in overall bleeding toward more events with the combination therapy.
The results of of puget supplemental, our trial differ from clytemnestra essays, those of other trials of university essay, combination therapy with clopidogrel and aspirin after cerebral ischemic events. 7,8,17 One possible explanation is essay that, unlike previous trials, our trial targeted a population at particularly high risk for university of puget sound essay recurrent ischemia and at low risk for clytemnestra analysis hemorrhage. Previous trials included patients with more severe strokes than our trial did, and they did not enroll patients in university of puget supplemental essay, the first hours after an index minor stroke or TIA, during which the write thesis, risk of recurrent ischemia is particularly high. University Sound Supplemental Essay! This may explain why other trials did not show a reduction in the risk of ischemic events but did show an increased risk of hemorrhage. In our study, the oresteia, curves for survival free of stroke were particularly steep in the first few days, during which the curves representing the sound supplemental essay, treatment groups diverged dramatically. Subsequently, the rates of stroke were similar. This suggests that the requirement for randomization within 24 hours after the onset of symptoms, with nearly half the patients enrolled within 12 hours (and treated shortly thereafter), was important.
Although we did not see a relative difference in the efficacy outcome between patients randomly assigned to columbus failure essay, a study group within 12 hours and university essay, those assigned after a longer interval, absolute event rates were higher among those who were enrolled within 12 hours. In clinical practice, treatment with clopidogrel and with quote, aspirin as soon as possible after symptom onset is likely to produce the greatest absolute benefit, since ischemic event rates are highest in the initial hours after symptoms appear. Our trial was conducted entirely in China, a country with approximately 150 to 250 deaths from stroke per of puget sound supplemental essay, 100,000 persons per oresteia clytemnestra, year, which is five times as high as the rate in the United States. 23 Although diagnostic tools and therapies commonly used in university essay, the United States and Europe are available in most hospitals in China, some patients cannot afford this level of care. 24,25 Secondary prevention practices are also less rigorous in thesis statement essay, China, where rates of treatment of hypertension, diabetes, and hyperlipidemia are low, as shown in our study population (Table S3 in university sound essay, the Supplementary Appendix). Furthermore, the distribution of stroke subtypes in China differs from that in more developed countries; China has a higher incidence of large-artery intracranial atherosclerosis 25 and a higher prevalence of columbus success essay, genetic polymorphisms that affect the metabolism of university supplemental, clopidogrel.
26 The Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) trial (ClinicalTrials.gov number, NCT00991029), sponsored by the National Institutes of Health, which is thesis narrative essay similar to supplemental, our trial, is now enrolling patients at sites primarily in columbus failure, the United States. 27 The POINT trial is assessing a higher loading dose of university, clopidogrel (600 mg) and of unity in the 120 words, a narrower time window (treatment within 12 hours after symptom onset) than were used in our study. Several common clinical conditions mimic TIA, including seizures, migraine, peripheral vertigo, syncope, and anxiety. Of Puget Sound! 28 To minimize the risk of enrolling patients with TIA mimics, we excluded all patients with isolated sensory symptoms, isolated visual changes, or isolated dizziness or vertigo without evidence of beginning quote, acute infarction on baseline CT or MRI of the head. In addition, enrollment of patients with TIA was limited to those with a high ABCD 2 score (?4) to university sound supplemental essay, increase the likelihood that spells were due to true TIAs and to ensure that we were enrolling patients who were at high risk for subsequent ischemic events. 29 The risk of subsequent stroke in the trial was high for of unity world 120 words this patient population, suggesting that our strategy was successful. Our findings may not apply to other populations of patients with ischemic events.
In conclusion, our study shows that among patients with high-risk TIA or minor ischemic stroke who are initially seen within 24 hours after symptom onset, treatment with clopidogrel plus aspirin for 21 days, followed by clopidogrel alone for of puget sound supplemental essay a total of 90 days, is superior to aspirin alone in reducing the risk of the lagoon, subsequent stroke events. The combination of clopidogrel with aspirin did not cause more hemorrhagic events in this patient population than aspirin alone. Supported by university sound supplemental essay, grants (2008ZX09312-008, 2011BAI08B02, 2012ZX09303, and 200902004) from the Ministry of Science and Technology of the columbus success failure, People's Republic of China. Disclosure forms provided by of puget sound supplemental, the authors are available with the full text of this article at NEJM.org. No potential conflict of interest relevant to this article was reported. This article was published on June 26, 2013, at the lagoon NEJM.org. From Beijing Tiantan Hospital (Yongjun Wang, Yilong Wang, X.Z., L.L., Chunxue Wang, Chen Wang, H.L., X.M.) and Xuan Wu Hospital (J.J.), Capital Medical University, and Peking Union Medical College Hospital (L.C.), Beijing; Huashan Hospital of Fudan University (Q.D.) and Renji Hospital of Shanghai Jiaotong University (Y.L.), Shanghai; First Affiliated Hospital of Jinan University (A.X.) and First Affiliated Hospital of Sun Yat-Sen University (J.Z.), Guangzhou; Taizhou First People's Hospital, Taizhou (Z.W.); and Taiyuan Iron and Steel Group, General Hospital, Taiyuan (H.X.) — all in of puget, China; Illinois Neurological Institute Stroke Network, Sisters of the Third Order of St. Francis Healthcare System, University of with quote, Illinois College of Medicine, Peoria (D.W.); and the Departments of Neurology and Epidemiology, University of California, San Francisco, San Francisco (S.C.J.).
Address reprint requests to Dr. Yongjun Wang at No. University Sound Supplemental Essay! 6 Tiantanxili, Dongcheng District, Beijing 100050, China, or at firstname.lastname@example.org; or to Dr. Johnston at the Departments of Neurology and Epidemiology, University of California, 505 Parnassus Ave., M-798, San Francisco, CA 94143-0114, or at email@example.com. A complete list of of unity in the muslim, investigators and institutions participating in the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial is provided in the Supplementary Appendix, available at NEJM.org. Zhao D , Liu J , Wang W , et al. Sound! Epidemiological transition of clytemnestra essays, stroke in China: twenty-one-year observational study from the sound essay, Sino-MONICA-Beijing Project. Stroke 2008;39:1668-1674. Wang YL , Wu D , Liao X , Zhang W , Zhao X , Wang YJ . Burden of stroke in China.
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David Abernethy. . 2018. Stroke in Old Age. Write Thesis! Geriatric Medicine, 193-235. Weiqi Chen, Yuesong Pan, Xingquan Zhao, Liping Liu, Hao Li, Xiaoling Liao, Chunjuan Wang, Yilong Wang, Yongjun Wang. . (2017) Intravenous Thrombolysis in Chinese Patients with Different Subtype of Mild Stroke: Thrombolysis in Patients with Mild Stroke. Scientific Reports 7 :1. Jie Xu, Yongli Tao, Hao Li, Hongqiu Gu, Xuewei Xie, Xia Meng, Yuming Xu, Yilong Wang, Yongjun Wang. Sound Supplemental Essay! . (2017) Different levels of blood pressure, different benefit from dual antiplatelet therapy in minor stroke or TIA patients. Scientific Reports 7 :1.
Christopher A. Stack, John W. Cole. . (2017) A Diagnostic Approach to Stroke in Young Adults. Current Treatment Options in Cardiovascular Medicine 19 :11. Zilong Rao, Huaguang Zheng, Fei Wang, Anxin Wang, Liping Liu, Kehui Dong, Xingquan Zhao, Yibin Cao, Yilong Wang. . (2017) High On-Treatment Platelet Reactivity to Adenosine Diphosphate Predicts Ischemic Events of Minor Stroke and Transient Ischemic Attack. Journal of Stroke and Cerebrovascular Diseases 26 :10, 2074-2081. K.E. Kjorstad, S.T. Baksaas, D. Bundgaard, E. Halbakken, T. Hasselgard, T. Essay! Jonung, G.T. Jorgensen, J.J. University Sound Supplemental! Jorgensen, A.H.
Krog, K. Krohg-Sorensen, E. Importance Of Unity 120 Words! Laxdal, S.R. Mathisen, G.V. Oskarsson, S. Of Puget! Seljeskog, I. Settemsdal, M. Beginning Essay With! Vetrhus, B.A. Viddal, J. Wesche, F. Aasgaard, E. Mattsson. . (2017) Editor's Choice – The National Norwegian Carotid Study: Time from Symptom Onset to Surgery is too Long, Resulting in university sound essay, Additional Neurological Events. European Journal of oresteia analysis essays, Vascular and Endovascular Surgery 54 :4, 415-422. Kuan H Ng, Mukul Sharma, Oscar Benavente, Laura Gioia, Thalia S Field, Michael D Hill, Shelagh B Coutts, Kenneth Butcher, . . University Sound Supplemental! (2017) Dabigatran following acute transient ischemic attack and write statement essay, minor stroke II (DATAS II). International Journal of Stroke 12 :8, 910-914. Zuowei Duan, Lihong Tao, Tieyu Tang, Changbiao Fu, Jiangbing Liu, Bin Chen, Zhensheng Liu, Haifeng Zhang, Yihui Liu, Xinjiang Zhang. . Of Puget! (2017) Effect of blood pressure variability on early neurological deterioration in write thesis narrative essay, single small subcortical infarction with parental arterial disease. eNeurologicalSci 8 , 22-27. Victor Aboyans, Jean-Baptiste Ricco, Marie-Louise E. L. Bartelink, Martin Bjorck, Marianne Brodmann, Tina Cohnert, Jean-Philippe Collet, Martin Czerny, Marco De Carlo, Sebastian Debus, Christine Espinola-Klein, Thomas Kahan, Serge Kownator, Lucia Mazzolai, A. Ross Naylor, Marco Roffi, Joachim Rother, Muriel Sprynger, Michal Tendera, Gunnar Tepe, Maarit Venermo, Charalambos Vlachopoulos, Ileana Desormais, . . (2017) 2017 ESC Guidelines on of puget supplemental essay the Diagnosis and with quote, Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS). European Heart Journal . Weiqing Zhang, Yanwei Yin, Yingqian Zhang, Fen Yang, Wenqian Shi, Dawei Chen, Chen Song, Huiping Shi, Xuanzhu Zhao, Jin Shi. . (2017) Influence of university sound supplemental essay, cerebrovascular reactivity on outcome of the patients with ?50% symptomatic unilateral middle cerebral artery stenosis. International Journal of Neuroscience 42 , 1-6.
Zilong Rao, Huaguang Zheng, Fei Wang, Anxin Wang, Liping Liu, Kehui Dong, Xingquan Zhao, Yilong Wang, Yibin Cao. . (2017) The association between high on-treatment platelet reactivity and early recurrence of ischemic events after minor stroke or TIA. Essay With! Neurological Research 39 :8, 719-726. Yasuko Ikeda-Sakai, Masahiro Sasaki, Taizen Nakase. . (2017) Effects With and of puget sound essay, Without Clopidogrel Loading Treatment for Acute Ischemic Cerebrovascular Disease Patients: A Retrospective Cohort Study. Journal of Stroke and essay, Cerebrovascular Diseases . Authors/Task Force Members, Victor Aboyans, Jean-Baptiste Ricco, Marie-Louise E.L. Bartelink, Martin Bjorck, Marianne Brodmann, Tina Cohnert, Jean-Philippe Collet, Martin Czerny, Marco De Carlo, Sebastian Debus, Christine Espinola-Klein, Thomas Kahan, Serge Kownator, Lucia Mazzolai, A. University Sound Supplemental Essay! Ross Naylor, Marco Roffi, Joachim Rother, Muriel Sprynger, Michal Tendera, Gunnar Tepe, Maarit Venermo, Charalambos Vlachopoulos, Ileana Desormais, Document Reviewers, Petr Widimsky, Philippe Kolh, Stefan Agewall, Hector Bueno, Antonio Coca, Gert J. Clytemnestra Essays! De Borst, Victoria Delgado, Florian Dick, Cetin Erol, Marc Ferrini, Stavros Kakkos, Hugo A. Katus, Juhani Knuuti, Jes Lindholt, Heinrich Mattle, Piotr Pieniazek, Massimo Francesco Piepoli, Dierk Scheinert, Horst Sievert, Iain Simpson, Jakub Sulzenko, Juan Tamargo, Lale Tokgozoglu, Adam Torbicki, Nikolaos Tsakountakis, Jose Tunon, Melina Vega de Ceniga, Stephan Windecker, Jose Luis Zamorano. . (2017) 2017 ESC Guidelines on sound supplemental essay the Diagnosis and Treatment of importance of unity muslim world 120 words, Peripheral Arterial Diseases, in sound supplemental essay, collaboration with the European Society for Vascular Surgery (ESVS). The Lagoon! European Journal of Vascular and Endovascular Surgery . Fawaz Al-Mufti, Elie Dancour, Krishna Amuluru, Charles Prestigiacomo, Stephan A. University Of Puget Supplemental Essay! Mayer, E. Sander Connolly, Jan Claassen, Joshua Z. Willey, Philip M. Meyers. . (2017) Neurocritical Care of Emergent Large-Vessel Occlusion: The Era of a New Standard of Care.
Journal of Intensive Care Medicine 32 :6, 373-386. Amy Y. X. Yu, M. Patrice Lindsay, Noreen Kamal, Jiming Fang, Shelagh B. Coutts, Michael D. Hill. Beginning Essay! . (2017) Shifting Trend of Transient Ischemic Attack Admission and Prognosis in Canada. Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques 44 :04, 391-396. H.-Z. Bei, S.-J. University Sound Supplemental Essay! You, D. Beginning! Zheng, C.-K. Zhong, H.-P.
Du, Y. Zhang, T.-S. Lu, L.-D. Cao, X.-F. Dong, Y.-J. Cao, C.-F. Liu. . (2017) Prognostic role of hypochloremia in acute ischemic stroke patients. Acta Neurologica Scandinavica 353 . Ying Tan, Yuesong Pan, Liping Liu, Yilong Wang, Xingquan Zhao, Yongjun Wang, . . (2017) One-year outcomes and secondary prevention in patients after acute minor stroke: results from the China National Stroke Registry. Neurological Research 39 :6, 484-491. Manli Qiao, Qi Bi, Paul Fu, Yixin Wang, Zhe Song, Fang Guo. . (2017) Previous hypertensive hemorrhage increases the risk for bleeding and ischemia for PCI patients on dual antiplatelet therapy.
Neurological Research 39 :6, 516-520. Matthew B. Bevers, W. Sound Essay! Taylor Kimberly. . (2017) Critical Care Management of Acute Ischemic Stroke. Thesis Narrative Essay! Current Treatment Options in Cardiovascular Medicine 19 :6. Jae Youn Moon, Francesco Franchi, Fabiana Rollini, Dominick J. Angiolillo. . (2017) Role for Thrombin Receptor Antagonism With Vorapaxar in of puget sound, Secondary Prevention of Atherothrombotic Events: From Bench to Bedside. Journal of Cardiovascular Pharmacology and outline, Therapeutics 10 , 107424841770861.
Xingjian Zhou, Jing Tian, Ming Zhu, Colin He. . (2017) A systematic review and university of puget supplemental essay, meta-analysis of published randomized controlled trials of combination of clopidogrel and aspirin in outline, transient ischemic attack or minor stroke. Experimental and Therapeutic Medicine . Salvador Cruz-Flores. . (2017) Acute Stroke and Transient Ischemic Attack in the Outpatient Clinic. Medical Clinics of North America 101 :3, 479-494. Aidonio Fiolaki, Aristeidis H Katsanos, Athanassios P Kyritsis, Styliani Papadaki, Maria Kosmidou, Iraklis C Moschonas, Alexandros D. Tselepis, Sotirios Giannopoulos. . (2017) High on treatment platelet reactivity to aspirin and clopidogrel in ischemic stroke: A systematic review and meta-analysis. Journal of the university of puget sound essay, Neurological Sciences 376 , 112-116. Yeongu Chung, Sung Ho Lee, Jiwook Ryu, Johnho Kim, Sang Bong Chung, Seok Keun Choi. . (2017) Tailored Double-Barrel Bypass Surgery Using an Occipital Artery Graft for Unstable Intracranial Vascular Occlusive Disease. World Neurosurgery 101 , 813.e5-813.e9. Nikhil Kapil, Yvonne H. Datta, Naila Alakbarova, Eric Bershad, Magdy Selim, David S. Liebeskind, Ornina Bachour, Gundu H. R. Rao, Afshin A. Divani. Analysis Essays! . (2017) Antiplatelet and Anticoagulant Therapies for Prevention of Ischemic Stroke.
Clinical and of puget sound essay, Applied Thrombosis/Hemostasis 23 :4, 301-318. Brandon R. Christophe, Shyle H. Mehta, Andrew L. A. Columbus Essay! Garton, Jonathan Sisti, E Sander Connolly. . (2017) Current and future perspectives on the treatment of cerebral ischemia. Expert Opinion on Pharmacotherapy 18 :6, 573-580. Nobuhiro Nakagawa, Norihito Fukawa, Kiyoshi Tsuji, Naoki Nakano, Saori Murakami, Kazuhiro Nagatsuka, Amami Kato. . (2017) Urgent Carotid Artery Stenting for Carotid-Related Stroke-in-Evolution. Operative Neurosurgery . Xingyang Yi, Qiang Zhou, Chun Wang, Jing Lin, Ping Liu, Cheng Fu. . (2017) Platelet receptor Gene (P2Y12, P2Y1) and platelet glycoprotein Gene (GPIIIa) polymorphisms are associated with antiplatelet drug responsiveness and clinical outcomes after acute minor ischemic stroke. European Journal of Clinical Pharmacology 73 :4, 437-443.
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Journal of Stroke and Cerebrovascular Diseases 25 :10, 2439-2447. Atsuhiro Sugidachi, Makoto Mizuno, Kousaku Ohno, Joseph A. Jakubowski, Atsuyuki Tomizawa. . (2016) The active metabolite of prasugrel, R-138727, improves cerebral blood flow and reduces cerebral infarction and neurologic deficits in a non-human primate model of acute ischaemic stroke. European Journal of Pharmacology 788 , 132-139. Penglian Wang, Yilong Wang, Xingquan Zhao, Wanliang Du, Anxin Wang, Gaifen Liu, Liping Liu, Ruijun Ji, Chunxue Wang, Kehui Dong, Yongjun Wang. Toulmin Outline! . (2016) In-hospital medical complications associated with stroke recurrence after initial ischemic stroke. Medicine 95 :37, e4929. Nicholas Losseff, Matthew Adams, Martin M. Brown, Joan Grieve, Robert Simister. . 2016.
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Ischemic stroke and beginning essay with quote, transient events, TIA. International Neurology, 3-6. Amarenco, Pierre, Lavallee, Philippa C., Labreuche, Julien, Albers, Gregory W., Bornstein, Natan M., Canhao, Patricia, Caplan, Louis R., Donnan, Geoffrey A., Ferro, Jose M., Hennerici, Michael G., Molina, Carlos, Rothwell, Peter M., Sissani, Leila, Skoloudik, David, Steg, Philippe Gabriel, Touboul, Pierre-Jean, Uchiyama, Shinichiro, Vicaut, Eric, Wong, Lawrence K.S., . . University Of Puget Sound! (2016) One-Year Risk of Stroke after Transient Ischemic Attack or Minor Stroke. New England Journal of Medicine 374 :16, 1533-1542. S. Yaghi, J. Z. Willey, P. Essay! Khatri. University Of Puget Supplemental! . (2016) Minor ischemic stroke: Triaging, disposition, and importance muslim world, outcome.
Neurology: Clinical Practice 6 :2, 157-163. Shailesh Male, Chris Nickele, Lucas Elijovich. . (2016) Critical Care of university of puget supplemental essay, Brain Reperfusion. Current Neurology and Neuroscience Reports 16 :3. Yasha Kayan, Josser E. Of Unity In The Muslim World Essay 120 Words! Delgado Almandoz, Jennifer L. Fease, Kira Tran, Anna M. Milner, Jill M. Scholz. . (2016) Incidence of delayed ipsilateral intraparenchymal hemorrhage after stent-assisted coiling of university essay, intracranial aneurysms in a high-volume single center. Neuroradiology 58 :3, 261-266. Shigeru Fujimoto, Masato Osaki, Makoto Kanazawa, Naoki Tagawa, Masaya Kumamoto, Yuichiro Ohya, Takanari Kitazono. . (2016) Effect of thesis statement narrative essay, oral cilostazol on acute neurological deterioration and outcome of noncardioembolic minor stroke. Journal of Clinical Gerontology and Geriatrics 7 :1, 21-26. Kyusik Kang, Tai Hwan Park, Nayoung Kim, Min Uk Jang, Sang-Soon Park, Jong-Moo Park, Youngchai Ko, SooJoo Lee, Kyung Bok Lee, Jun Lee, Dong-Eog Kim, Yong-Jin Cho, Joon-Tae Kim, Dae-Hyun Kim, Jae-Kwan Cha, Moon-Ku Han, Ji Sung Lee, Juneyoung Lee, Mi Sun Oh, Jay Chol Choi, Byung-Chul Lee, Keun-Sik Hong, Hee-Joon Bae. . (2016) Recurrent Stroke, Myocardial Infarction, and Major Vascular Events during the First Year after Acute Ischemic Stroke: The Multicenter Prospective Observational Study about Recurrence and Its Determinants after Acute Ischemic Stroke I. Journal of Stroke and university of puget, Cerebrovascular Diseases 25 :3, 656-664. E. Johansson, E. Toulmin Essay Outline! Cuadrado-Godia, D. Hayden, J. Bjellerup, A. Ois, J. University Sound Supplemental Essay! Roquer, P. Wester, P. Christopher Success Essay! J. Kelly. . (2016) Recurrent stroke in university sound supplemental essay, symptomatic carotid stenosis awaiting revascularization: A pooled analysis.
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Stroke, 849-867.e5. Juan Quiles, Monica Rodriguez-Manteca. . (2016) Indicaciones y duracion de las combinaciones de antiagregantes. FMC - Formacion Medica Continuada en Atencion Primaria 23 :1, 29-34. S Shahidi, A Owen-Falkenberg, B Gottschalksen, K Ellemann. Of Puget Supplemental! . (2016) Risk of early recurrent stroke in symptomatic carotid stenosis after best medical therapy and before endarterectomy. International Journal of Stroke 11 :1, 41-51. S. The Lagoon! B. Coutts, M. Goyal. . (2015) Emergent Neurovascular Imaging: A Necessity for the Work-Up of Minor Stroke and university supplemental, TIA. Beginning Essay With! American Journal of Neuroradiology 36 :12, 2194-2195. Fang Yang, Wenrui Jiang, Ya Bai, Junliang Han, Xuedong Liu, Guangyun Zhang, Gang Zhao. . (2015) Treatment of university of puget, Rivaroxaban versus Aspirin for Non-disabling Cerebrovascular Events (TRACE): study protocol for columbus failure a randomized controlled trial.
BMC Neurology 15 :1. Hernan Polo Friz, Mauro Molteni, Claudio Cimminiello. University Sound Supplemental Essay! . (2015) The dogma of aspirin: a critical review of evidence on importance in the muslim world the best monotherapy after dual antiplatelet therapy. Thrombosis Journal 13 :1. Tzu-Hsien Tsai, Cheng-Hsien Lu, Christopher Glenn Wallace, Wen-Neng Chang, Shu-Feng Chen, Chi-Ren Huang, Nai-Wen Tsai, Min-Yu Lan, Pei-Hsun Sung, Chu-Feng Liu, Hon-Kan Yip. . (2015) Erythropoietin improves long-term neurological outcome in acute ischemic stroke patients: a randomized, prospective, placebo-controlled clinical trial. Critical Care 19 :1.
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Guideline Antiplatelet Therapy in High-Risk Patients with Recent Ischemic Stroke or Transient Ischemic Attack: Rationale and university essay, Design of the Triple Antiplatelets for Reducing Dependency after Ischaemic Stroke (TARDIS) Trial (ISRCTN47823388). International Journal of Stroke 10 :7, 1159-1165. L. Liu, K. S. L. Columbus Success Failure Essay! Wong, X. Leng, Y. Pu, Y. Wang, J. University Of Puget Sound Supplemental Essay! Jing, X. Zou, Y. Pan, A. Toulmin Essay! Wang, X. Meng, C. Wang, X. Zhao, Y. Soo, S. C. Johnston, Y. Wang, . . (2015) Dual antiplatelet therapy in stroke and ICAS: Subgroup analysis of CHANCE. Neurology 85 :13, 1154-1162. S. Claiborne Johnston, Pierre Amarenco, Gregory W. Albers, Hans Denison, J. Donald Easton, Peter Held, Jenny Jonasson, Kazuo Minematsu, Carlos A. Supplemental Essay! Molina, Lawrence K. S. Wong. . Toulmin! (2015) Acute Stroke or Transient Ischemic Attack Treated with Aspirin or Ticagrelor and of puget, Patient Outcomes (SOCRATES) trial: rationale and design. International Journal of Stroke , n/a-n/a.
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