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Symptomatic vertebral artery stenosis is associated with a high risk of recurrent stroke, with higher risks for intracranial than for extracranial stenosis. Vertebral artery stenosis can be treated with stenting with good technical results, but whether it results in improved clinical outcome is uncertain. We aimed to compare vertebral stenting with medical treatment for symptomatic vertebral stenosis. We did a preplanned pooled individual patient data analysis of three completed randomised controlled trials comparing stenting with medical treatment in patients with symptomatic vertebral stenosis. The primary outcome was any fatal or non-fatal stroke. Analyses were performed for vertebral stenosis at any location and separately for extracranial and intracranial stenoses. Data from the intention-to-treat analysis were used for all studies. We estimated hazard ratios (HRs) with 95% CIs using Cox proportional-hazards regression models stratified by trial. Data were from 354 individuals from three trials, including 179 patients from VIST (148 with extracranial stenosis and 31 with intracranial stenosis), 115 patients from VAST (96 with extracranial stenosis and 19 with intracranial stenosis), and 60 patients with intracranial stenosis from SAMMPRIS (no patients had extracranial stenosis). Across all trials, 168 participants (46 with intracranial stenosis and 122 with extracranial stenosis) were randomly assigned to medical treatment and 186 to stenting (64 with intracranial stenosis and 122 with extracranial stenosis). In the stenting group, the frequency of periprocedural stroke or death was higher for intracranial stenosis than for extracranial stenosis (ten (16%) of 64 patients vs one (1%) of 121 patients; p<0·0001). During 1036 person-years of follow-up, the hazard ratio (HR) for any stroke in the stenting group compared with the medical treatment group was 0·81% CI 0·45–1·44; p=0·47). For extracranial stenosis alone the HR was 0·63 (95% CI 0·27–1·46) and for intracranial stenosis alone it was 1·06 (0·46–2·42; pinteraction=0·395). Stenting for vertebral stenosis has a much higher risk for intracranial, compared with extracranial, stenosis. This pooled analysis did not show evidence of a benefit for stroke prevention for either treatment. There was no evidence of benefit of stenting for intracranial stenosis. Stenting for extracranial stenosis might be beneficial, but further larger trials are required to determine the treatment effect in this subgroup. None.

Historians of early modern Europe have long stressed how new practices of diplomacy that emerged during the period transformed European politics. Fictions of Embassy is the first book to examine the cultural implications of the rise of modern diplomacy. Ranging across two and a half centuries and half a dozen languages, Timothy Hampton opens a new perspective on the intersection of literature and politics at the dawn of modernity. Hampton argues that literary texts-tragedies, epics, essays-use scenes of diplomatic negotiation to explore the relationship between politics and aesthetics, between the world of political rhetoric and the dynamics of literary form. The diplomatic encounter is a scene of cultural exchange and linguistic negotiation. Literary depictions of diplomacy offer occasions for reflection on the definition of genre, on the power of representation, on the limits of rhetoric, on the nature of fiction making itself. Conversely, discussions of diplomacy by jurists, political philosophers, and ambassadors deploy the tools of literary tradition to articulate new theories of political action. Hampton addresses these topics through a discussion of the major diplomatic writers between 1450 and 1700-Machiavelli, Grotius, Gentili, Guicciardini-and through detailed readings of literary works that address the same topics-works by Shakespeare, More, Rabelais, Montaigne, Tasso, Corneille, Racine, and Camoens. He demonstrates that the issues raised by diplomatic theorists helped shape the emergence of new literary forms, and that literature provides a lens through which we can learn to read the languages of diplomacy.

At the close of the 1960s two developments changed the shape of mainstream rock and roll music. The first was a new focus, on the part of a number of influential artists, on music about domestic life—kids, spouses, home. The second was a new interest in blending rock rhythms with instrumentation and themes taken from country music. This essay explores the ways in which these two concerns overlap in the work of Bob Dylan. I argue that Dylan's work at the turn of the decade offers insights into our own current moment, when the relationship between the public world and the private world is being renegotiated. I show how Dylan's \"country\" songs are, in fact, models of self-conscious experimentation that push against the conventions of popular song and highlight the conditions of their own production.

Hampton narrates his experience as research assistant of Michel Foucault at the University of Toronto's Summer Semiotics Institute. Foucault was involved in his work on the techniques of self-construal in late antiquity and the early Christian period. He had just published The Care of the Self. With Jacques Derrida, he was one of the figure heads of a strangely named invention called \"French Theory,\" a fantasy in the American imaginary that there was a club of French guys who sat around in Paris and cooked up new concepts to animate the careers of ambitious American academics. Of the various French theoreticians, Foucault was the most appealing, because of his interest in history.

As David Quint's work has shown, one of the principal thematic concerns of Cervantes's Don Quixote involves the clash between traditional chivalric values and the values of an emerging \"money\" economy. This essay explores Sancho Panza's entry into that new economy. It shows how Sancho's dealings with money consistently raise issues about truth and lying, and about the veracity of narrative. And it traces Sancho's increasing awareness of how literature itself can become a form of capital, both monetary and symbolic.

Bob Dylan’s turn from “folk music” to “electric music” in the 1960s involves the development of a new visionary poetics. Through a consideration of his affinity with the French Symbolist poet Arthur Rimbaud, this essay traces Dylan’s recasting of himself as a visionary and studies the pressures placed by this process on lyric form, on poetic diction, and on the representation of the self in popular music.

Beyond the difficult personal consequences of Bob Dylan, his description raises two related but distinct problems in cultural history. The first is what happens when an artist is overcome or threatened by his or her own popularity. Dylan's fans called for him to return to public life because he had been pigeonholed as a particular kind of antiestablishment artist. Second is his association with the so-called 1960s generation (evoked above by his canny characterization of the fans outside his house as \"demonstrators\") poses the problem of what people might call a generational poetics and of how figures associated with particular generational moments in artistic history may break free from those moments. Here, Hampton observes that a critical engagement with the resources of literary form helped free him, at least momentarily, in song, from the smoky visions of his contemporaries.

We present a case of adhesive spinal arachnoiditis, as a complication of a fall with traumatic subarach- noid haemorrhage, in a patient with progressive multiple sclerosis (MS).A 68 year-old woman with MS and spasticity, on Baclofen, Pregabalin and Nabiximols, was admitted following a fall. CT scanning demonstrated traumatic subarachnoid haemorrhage. She was admitted to the ITU initially and managed conservatively. Four months later, while undergoing inpatient rehabilitation, her condition deteriorated over six weeks with worsening paraparesis, neurogenic bladder and bowel dys- function with a C5–6 sensory level. She received steroids and underwent MRI of her neuroaxis. Imaging of her brain showed unchanged demyelinating lesions. Spinal imaging identified distortion with considerable T2 signal change in the cervical and thoracic regions, extending from the C5/6 to the T8/9 level, radiologi- cally consistent with a syrinx and myelopathy. It was felt her deterioration was not due to demyelination but secondary to cervicothoracic adhesions ventral to the cord as sequelae of cerebral haemorrhage. Following neurosurgical review, the patient underwent C4-T1 laminoplasty, adhesionolysis and expansion duraplasty with histopathology showing calcified connective tissue but the clinical outcome has thus far been poor. It is important to consider all the causes of deterioration in patients with progressive MS.menafarag@doctors.org.uk