Seneca and the First Description of Anton Syndrome.

Seneca was a Roman philosopher, politician, and mentor to the young Nero. He later fell in disgrace and was sentenced to death by the Emperor. Seneca left many texts, one of the most influential being his Moral Letters to Lucilius (63 CE). In Letter 50, he describes the case of Harpaste, his wife's foolish slave who acutely became blind. She denied her illness and argued irrationally about room darkness, constantly asking attendants to change her quarters. Harpaste's case, consisting of acutely acquired blindness and anosognosia in the presence of relatively well-preserved cognition, fulfills the clinical criteria for the diagnosis of Anton syndrome, and probably constitutes its first description.

Trauma related to falls from trees treated in a specialized trauma centre in Burkina-Faso-one hundred and six cases treated in one year.

PURPOSE: Falls from trees related traumas are rarely reported in literature. They are public health problems in developing countries where their frequency is still important. The aim of the study is to describe falls from trees related trauma patterns and to present preventative measures. METHODS: An annual ongoing prospective study was held in our trauma emergency department (ED) about all the patients who sustained an injury after a recent fall from tree. A questionnaire related to the patient and to the trauma was established. The data were encoded and analysed by a statistical software. RESULTS: One hundred six patients who sustained a fall from tree trauma, out of a total of 139, were studied. Most patients were under 15 years old (76.4 %); they were injured in fruits season (33 %) after a fall from a fruit tree (mango trees, Shea trees, Néré, etc.) and were received late (86 %). Injuries were polymorphic from traumatic brain injuries (51.8 %) and spine injuries (13.2 %) to thoraco-abdominal (21.6 %) and limbs injuries (46.2 %). Three housewives were pregnant at the time of the trauma with secondary abortions. Patients were managed medically (33.9 %), surgically (19.8 %) or by casting (34.9 %) with good outcome in 59 cases. Twelve patients refused medical care and two died. CONCLUSION: Education programs must focus on picking fruits and leaves in order to make them safe and prevent injuries related to these traditional or professional activities.

Salvage intracerebrospinal fluid thiotepa in breast cancer-related leptomeningeal metastases: a retrospective case series.

There is currently a paucity of data on salvage intracerebrospinal fluid (intra-CSF) chemotherapy in leptomeningeal metastases (LM). This report is a single-institution experience with salvage treatment in patients with breast cancer (BC) and LM. This retrospective cohort describes 24 consecutive patients with BC selected for a second-line of treatment for LM. The first line of LM treatment consisted of intra-CSF liposomal cytarabine in all patients combined with systemic therapy in 18 cases and radiotherapy in four cases. Second-line (salvage) treatment utilized intra-CSF thiotepa in all and systemic chemotherapy in nine patients. No patient received CNS-directed radiotherapy. The median Eastern Cooperative Oncology Group performance status at initiation of intra-CSF thiotepa treatment was 3 (range 1-4). The median progression-free survival and median survival following intra-CSF thiotepa was 3.1 months (range 3 days-2 years) and 4.0 months (range 6 days-2.5 years), respectively. The median overall survival from LM diagnosis was 9.5 months (range 1.3 months-2.7 years). No grade 3 or higher toxicity was observed. Recognizing the limits of a retrospective study, intra-CSF thiotepa has an acceptable toxicity profile and appears to be a reasonable option for selected BC patients.

Is poststroke depression a major depression?

BACKGROUND: Poststroke depression (PSD) is the most common neuropsychiatric consequence of stroke. A large number of studies have focused on the pathogenesis of PSD, but only a few aimed to characterize its psychopathology; these studies yielded results that are difficult to compare because of the different methods utilized. The current study aimed to characterize the symptom profile of PSD in an attempt to better understand the disease and allow a more accurate diagnosis. METHODS: The study sample comprised 64 patients divided into three groups: stroke patients without diagnosis of depression (n = 33), stroke patients diagnosed with PSD (PSD group, n = 14) and patients diagnosed with major depression (MD) but with no clinical comorbidity (MD group, n = 17). All patients were diagnosed using the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). The initial diagnostic interview was complemented by the Mini Mental State Examination (MMSE), the Rankin Scale, and four scales for the assessment of the intensity of symptoms of anxiety and depression: the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression General Scale (HADS), the Hamilton Depression Rating Scale (HAM-D) and the Hamilton Rating Scale for Anxiety (HAM-A). The Star Plot, a graphical method of data visualization, was used to analyze the results. The t test was used for independent samples (two-tailed analysis). RESULTS: As measured by the BDI, HAM-D and HAM-A scales and HADS depression subscale, the average total scores of symptoms for the sample of patients diagnosed with MD without clinical comorbidity was significantly higher than that of the PSD patients (p < 0.05). Similar results were obtained by plotting the BDI data on Star Plot. The PSD patients showed mild typical depressive symptoms such as less depressed mood, anhedonia, disinterest, guilt, negative thoughts, depreciation, suicidal ideation and anxiety, when evaluated by the HAM-A scale. Moreover, the somatic symptoms of depression did not lead to increased diagnosis of major depression in stroke patients. CONCLUSIONS: The results indicate that the PSD clinical picture comprised, in general, symptoms of mild/moderate intensity, especially those considered as pillars for the diagnosis of depression: depressed mood, loss of pleasure and lack of interest. Given the imprecision of boundaries that separate the clinical forms of depression from subclinical and nonpathological forms, or even from the concepts of demoralization and adjustment disorders, we situate PSD in a complex biopsychosocial context in which a better understanding of its psychopathological profile could provide diagnostic and therapeutic alternatives best suited to the difficult reality experienced by stroke patients.

Paul Bouts and the Short Life of Psychognomy in Brazil.

Paul Bouts (1900-1999) was a Belgian pedagogue, a Roman Catholic priest, and the founder of Psychognomy, which is a personality diagnostic system combining phrenology and several related practices - typology, craniofacial measurements, physiognomy, graphology etc. Bouts had a fragile health; therefore, it is unlikely that he travelled to Brazil. Despite this, his most famous book, rich in conservative and religious thoughts, was translated to Portuguese and published with ecclesiastic support in 1943, and the doctrine acquired good reputation among Brazilian members of the clergy, politicians, teachers, and military personnel. Lay scholars and medical doctors founded a Brazilian institute devoted to the study and diffusion of psychognomy in 1949. They published two volumes of a psychognomy treatise, and the institute was active until the early 1960s, when social interest in the subject rapidly vanished.

Paul Bouts (1900­1999) foi um pedagogo e padre católico belga que criou a psicognomia, um sistema de análise caracterológica que combinava elementos da frenologia, tipologia, medições craniofaciais, fisionomia, grafologia etc. Suas teorias influenciaram acadêmicos, religiosos, políticos e militares brasileiros. Bouts tinha uma saúde frágil, e não há evidências de que tenha estado no Brasil. Seu livro mais famoso, Psicognomia, foi publicado no país em 1943 com aval da censura eclesiástica e com apêndices especiais. A doutrina levou, ainda, à criação, em 1949, de um instituto privado de divulgação e estudos de psicognomia com sede no Rio de Janeiro, que publicou dois volumes de um tratado sobre o tema e permaneceu ativo até o início da década de 1960, quando o interesse pelo assunto rapidamente desapareceu na sociedade.

Prevalence of mouth breathing, with or without nasal obstruction, in children with moderate to severe obstructive sleep apnea.

BACKGROUND: Mouth breathing (MB) is a symptom of obstructive sleep apnea (OSA) in children, but its diagnosis remains challenging. The main objectives of our study were to evaluate whether parents' and physician's diagnose of MB were concordant and to evaluate the prevalence of nasal obstruction in children with OSA and MB. METHODS: Ninety-three children (median age: 10.6 years, range 3-18) with moderate to severe OSA prospectively underwent otorhinolaryngologist (endoscopy, acoustic rhinometry and pharyngometry allowing calculation of pharyngeal compliance) and orthodontist (clinical exam and cephalometry) assessments together with parental interview (daytime MB: never, sometimes, often, always). MB was also assessed by the otorhinolaryngologist (nasal obstruction on endoscopy) and the orthodontist (incompetent lips or anterior open bite or low tongue position). RESULTS: Thirty-eight children (41%) were mouth (parental criterion: MB often or always, median age 8.2 years) and 55 nasal (11.4 years, p = 0.016) breathers. The agreement of parental and physician diagnosis of MB was slight (orthodontist) to moderate (otorhinolaryngologist). Parental diagnosis of MB was associated with nasal obstruction on acoustic rhinometry and endoscopy (hypertrophy of inferior turbinate, n = 18 or adenoids, n = 15) and with an adenoid facies (increased Frankfort's mandibular plane angle on cephalometry). Eleven children had MB by habit and were characterized by more severe OSA and higher pharyngeal compliance than mouth breathers with nasal obstruction. CONCLUSION: MB diagnosis by parents is acceptable and is mainly related to nasal obstruction. A subset of children had MB by habit associated with worst OSA and increased pharyngeal compliance that could benefit from myofunctional therapy.

Effectiveness of nutritional interventions to prevent nonprogressive congenital and perinatal brain injuries: a systematic review and meta-analysis of randomized trials.

CONTEXT: Nutritional interventions for newborns with brain injury are scarce, and there are gaps in the knowledge of their mechanisms of action in preventing the occurrence of cerebral palsy (CP) or the incidence of other developmental disabilities. OBJECTIVE: The objective of this review was to assess the effect of nutritional interventions in preventing nonprogressive congenital or perinatal brain injuries, or in improving outcomes related to neurological development. DATA SOURCES: Randomized trials on any nutritional intervention for pregnant women at risk of preterm delivery, or for children with low birth weight, preterm, or with confirmed or suspected microcephaly, CP, or fetal alcohol syndrome disorders (FASDs) were retrieved from MEDLINE, Embase, Scopus, Web of Science, LILACS, and CENTRAL databases from inception to September 17, 2020. DATA EXTRACTION: Data extraction, risk of bias (Cochrane Risk of Bias tool 2), and quality of evidence (GRADE approach) were assessed by 2 authors. DATA ANALYSIS: Pooled risk ratios (RRs) with 95% confidence intervals were calculated using a random-effects meta-analysis. Seventeen studies were included on intravenous interventions (magnesium sulfate [n = 5], amino acids [n = 4], vitamin A [n = 1], and N-acetylcysteine [n = 1]); enteral interventions (vitamin D [n = 1], prebiotic [n = 1], nutrient-enriched formula [n = 1], and speed of increasing milk feeds [n = 1]); and oral interventions (choline [n = 1] and docosahexaenoic acid, choline, and uridine monophosphate [n = 1]). All studies assessed CP, except 1 on FASDs. Eight studies were judged as having high risk of bias. Five studies (7413 babies) with high-quality evidence demonstrated decreased risk of childhood CP (RR = 0.68, 95% CI: 0.52-0.88) with magnesium sulfate. Interventions with amino acids had no effect on CP prevention or other outcomes. Except for 1 study, no other intervention decreased the risk of CP or FASDs. CONCLUSION: Although different types of nutritional interventions were found, only those with antenatal magnesium sulfate were effective in decreasing CP risk in preterm infants. Well-designed, adequately powered randomized clinical trials are required.

Is visual scanning better than mental practice in hemispatial neglect? Results from a pilot study.

OBJECTIVE: We compared visual scanning and mental practice and explored the effects of these techniques on specific hemispatial neglect tests and activities of daily living in chronic hemispatial neglect patients. METHODS: Ten right-handed patients with hemispatial neglect caused by right hemisphere ischemic strokes were randomly allocated to 1 of 2 study groups: visual scanning (n = 5), mental practice (n = 5). Five additional patients were included in a control group. Three evaluations for hemispatial neglect and the FIM were carried out in the intervention groups: pretreatment, at the end of the intervention period, and 3 months after that intervention period. Control patients were evaluated twice within a 2-month interval. RESULTS: There was a significant difference among the 3 groups in Behavioral Inattention Test (BIT) score changes (P = .047) and in FIM self-care item score changes (P = .035), the visual scanning protocol being responsible for these differences both in BIT (P = .008) and in FIM self-care item scores (P = .016). The positive functional effects of visual scanning were partially retained at the end of the follow-up period. CONCLUSIONS: Visual scanning should probably be considered preferable to mental practice protocols in the treatment of hemispatial neglect patients.

Detection of genetic variation and base modifications at base-pair resolution on both DNA and RNA.

Accurate decoding of nucleic acid variation is critical to understand the complexity and regulation of genome function. Here we use a single-molecule magnetic tweezer (MT) platform to identify sequence variation and map a range of important epigenetic base modifications with high sensitivity, specificity, and precision in the same single molecules of DNA or RNA. We have also developed a highly specific amplification-free CRISPR-Cas enrichment strategy to isolate genomic regions from native DNA. We demonstrate enrichment of DNA from both E. coli and the FMR1 5'UTR coming from cells derived from a Fragile X carrier. From these kilobase-length enriched molecules we could characterize the differential levels of adenine and cytosine base modifications on E. coli, and the repeat expansion length and methylation status of FMR1. Together these results demonstrate that our platform can detect a variety of genetic, epigenetic, and base modification changes concomitantly within the same single molecules.

Endovascular closure of patent foramen ovale: a critical appraisal of published trials.

OBJECTIVE: The treatment of cryptogenic stroke patients with a patent foramen ovale (PFO) is controversial. A critical review of these studies is presented. METHODS: A description of all trials comparing medical and endovascular treatment with closing devices is given. Additional pertinent studies are discussed to help construct a rational basis for treatment decisions. RESULTS: Initial negative trials evaluating PFO closure were followed by positive studies published in 2017 and 2018. All trials evaluated young patients (up to 60 years). Methodological problems are present in all trials including their open label construction. Most positive trials developed strategies to increase the percentage of patients with interatrial septal aneurysms or hypermobility and large right-to-left shunts. Even in these positive trials, large numbers of patients need to be treated to avoid one stroke. Atrial fibrillation occurred in 2-6% and other adverse effects related to the procedure and to the devices occurred in a substantial number of patients. Incomplete occlusion of the PFO is also frequent. Anticoagulant treatment has not been adequately studied as a therapeutic option. CONCLUSION: Young patients with cryptogenic strokes seem to benefit from endovascular closure of a PFO in the presence of a large right-to-left shunt or an associated atrial septum aneurysm. For most other patients, a highly-individualized decision must be made, taking into account the low risk of recurrence in patients with a cryptogenic stroke attributable to a PFO, the high numbers needed to treat and the risks related to the procedure.

Lampião, Lages, Lombroso: the autopsy of the bandit king of the Brazilian backlands.

Lampião, the most infamous Brazilian brigand leader, was killed and decapitated during an ambush in 1938. The Alagoas police coroner, Dr. José Lages Filho, performed an autopsy of his head. Strongly biased toward the anthropologic ideas of the famous Italian psychiatrist and criminalist Cesare Lombroso, the examination found only a few of the so-called criminal inborn traits. The Lombrosian doctrine and a number of related theories strongly influenced medical and political reasoning in the first half of the 20th century. Modern genetic and neuroscientific studies are still looking for the potential biological roots of misbehavior and criminality.

New surgical method of tongue reduction for macroglossia: technical note.

OBJECTIVE: We describe here a new surgical technique, which allows for efficient tongue reduction with satisfactory appearance and avoids the complications of tip excision. STUDY DESIGN: This is a retrospective case review that includes 6 patients who had macroglossia and underwent tongue reduction using our new central V-shaped excision technique. Three patients were operated on at an early age because of significant macroglossia with permanent tongue protrusion, cosmetic disorder, and speech delay. The other 3 patients underwent surgery performed in their teenage years because medical treatment had been unsuccessful. We assessed tongue shape, mobility, taste, and sensitivity. RESULTS: The postoperative follow-up period ranged from 2 months to 16 years (average 7 years). On subjective evaluation, all patients were satisfied with the appearance of the tongue and reported no sensitive or sensory difficulties. The patients reported normal food progression in the oral cavity. Objective evaluation showed that the tongue had normal mobility, taste, and sensitivity. Postoperatively, there was no residual tongue protrusion, cosmetic disorder, or speech delay. None of the patients needed revision surgery. CONCLUSIONS: This central V-shaped excision offers good surgical results, with efficient tongue reduction and none of the complications of other tongue reduction techniques, such as tip amputation or anterior wedge resection.

Bedside assessment of swallowing in stroke: water tests are not enough.

OBJECTIVE: The clinical functional evaluation is the usual method for dysphagia screening in patients with acute stroke. This study compared two methods of evaluation--with liquid and semisolid viscosities. METHOD: Twenty-six patients with stroke onset within 7 days--with a mean age of 63.5 +/- 12.4 years--were prospectively evaluated for deficit severity, swallowing mechanisms, chest X-ray studies, and late (30 days after discharge) assessment of disability with the modified Rankin Scale. RESULTS: Tests using water and pudding correlated poorly (p < .001). The water test exhibited higher sensitivity for detection of problems in laryngeal protection, and the test with pudding was more sensitive for the functional analysis of dysphagia itself. Abnormalities in the water test were associated with weak spontaneous cough, while a normal pudding test correlated well with oral feeding 30 days after hospital discharge. The initial neurological severity correlated with results from both tests. No patient had pulmonary infiltrates 72 hours after testing or pneumonia up to 30 days after hospital discharge. CONCLUSION: The two evaluation methods should be used to both decrease the risk of aspiration and increase the likelihood of a safe and early reintroduction of oral feeding.

Phrenology and the Rwandan Genocide.

Belgian colonizers used phrenology to create an irreducible division between the two major groups living for centuries in Rwanda-Urundi. This formed the basis for the implementation of systematic efforts to subdue the large Hutu population. Both the Hutus and the smaller, and initially privileged, Tutsi group soon incorporated the racist discourse, which was pivotal to the gradual increase in violence before and after Rwandan independence in 1962. The Rwandan genocide in 1994 culminated in the horrible pinnacle of this process, involving recurrent episodes of slaughtering. Doctors should not underestimate the racist potential of pseudoscientific misconceptions.

807C/T polymorphism in the platelet glycoprotein Ia gene in young patients with ischemic stroke of undetermined etiology.

Platelet membrane glycoprotein receptors mediate key reactions in arterial thrombosis. The relationship between glycoprotein Ia polymorphisms and the risk of ischemic stroke, however, remains controversial. A matched case-control study was conducted to evaluate this question in young patients. Seventy patients with ischemic stroke of undetermined etiology, with ages ranging from 15 to 50 years, and 70 healthy control individuals, matched by age, gender and ethnicity, were tested for the 807C/T genotypes. Patients were excluded if they had systemic diseases known to predispose to thrombosis or any defined etiology of ischemic stroke. The frequencies of the 807T glycoprotein Ia variant and of conventional risk factors for arterial thrombosis (hypertension, smoking, diabetes mellitus, use of oral contraceptives, levels of serum cholesterol and body mass index) were compared in stroke patients and control individuals. The 807T allele was found in 61% of patients and 53% of control individuals (matched-pair odds ratio, 1.38; 95% confidence interval, 0.69-2.74; P = 0.42). Arterial hypertension and smoking were more frequent in patients than control individuals (matched-pair odds ratio, 2.83; 95% confidence interval, 1.05-8.02; P = 0.04; and odds ratio, 3.20; 95% confidence interval, 1.10-9.97, P = 0.03, respectively). In conclusion, our results do not support an independent association between the 807C/T polymorphism and stroke of undetermined etiology. The interplay of this polymorphism with arterial hypertension in the causation of ischemic stroke requires further evaluation.

[How is Sydenham's chorea treated in Rio de Janeiro?]. / Como a coréia de Sydenham é tratada no Rio de Janeiro?

BACKGROUND: Sydenham's chorea is the most common cause of acquired childhood chorea in Brazil. Thus it is relevant to know how physicians treat those patients. OBJECTIVE: To describe the practice patterns of Sydenham's chorea among pediatricians. METHOD: A descriptive study was undertaken using a questionnaire among specialists and emergency pediatricians who work in public hospitals of Rio de Janeiro district. RESULTS: 74% of the physicians informed not to use any severity scale; 81% informed to always prescribe benzathine penicillin; 64% informed to begin pharmacological treatment for all patients; and Haloperidol was the most remembered drug among all physicians. CONCLUSION: Physicians do not routinely use severity scales in follow-up of choreic patients; there is a tendency of irregular prescription of benzathine penicillin by younger doctors; and 28.3% prescribe only haloperidol.

Screening tests are not enough to detect hemineglect.

OBJECTIVE: To verify the sensitivity of the conventional subtests of the Behavioral Inattention Test (BIT) in the diagnosis of hemineglect after stroke. METHOD: One hundred and two patients with cerebral infarct or hemorrhage were prospectively evaluated. In 22, hemineglect was diagnosed using standard BIT criteria. The frequency of hemineglect using 6 commonly used screening subtests of this battery was assessed. RESULTS: Hemineglect would not be recognized in 10 patients if they were only screened using the line crossing test; this would be the case in 2 patients with the letter cancellation test; and in 4 patient with the line bisection test. Three patients would not be diagnosed even if both line crossing and line bisection tests were used. CONCLUSION: Hemineglect may not be recognized with single screening tests commonly used. The use of a standard battery is recommended to improve diagnostic sensitivity in individuals with various subtypes of hemineglect.

Evolving story: trepanation and self-trepanation to enhance brain function.

Trepanation has been performed by people interested in enhancing mental power and well-being since the early 1960s. The pioneers and main proponents of the procedure are described here. The phenomenon appeared in Europe after a Dutch former medical student published a psychoactive drug-friendly scroll suggesting trepanation as a form of permanently increasing cerebral blood volume and function. He trepanned himself in 1965. Three of his friends became enthusiasts. They also submitted themselves to the procedure and published films and books describing their experiences. Two of them coauthored papers, in collaboration with Russian researchers, and created institutions to promote discussion on trepanation. One of these institutions organized trips to Central and South America to get the operation done. Dozens of people nowadays look for trepanation as a method of spiritualization and increasing well-being and mental power. The phenomenon has an uncertain future, however, as the main proponents and supporters are aging.

Paul Bouts and the Short Life of Psychognomy in Brazil / Paul Bouts e a curta vida da psicognomia no Brasil

Abstract Paul Bouts (1900-1999) was a Belgian pedagogue, a Roman Catholic priest, and the founder of Psychognomy, which is a personality diagnostic system combining phrenology and several related practices - typology, craniofacial measurements, physiognomy, graphology etc. Bouts had a fragile health; therefore, it is unlikely that he travelled to Brazil. Despite this, his most famous book, rich in conservative and religious thoughts, was translated to Portuguese and published with ecclesiastic support in 1943, and the doctrine acquired good reputation among Brazilian members of the clergy, politicians, teachers, and military personnel. Lay scholars and medical doctors founded a Brazilian institute devoted to the study and diffusion of psychognomy in 1949. They published two volumes of a psychognomy treatise, and the institute was active until the early 1960s, when social interest in the subject rapidly vanished.

Resumo Paul Bouts (1900-1999) foi um pedagogo e padre católico belga que criou a psicognomia, um sistema de análise caracterológica que combinava elementos da frenologia, tipologia, medições craniofaciais, fisionomia, grafologia etc. Suas teorias influenciaram acadêmicos, religiosos, políticos e militares brasileiros. Bouts tinha uma saúde frágil, e não há evidências de que tenha estado no Brasil. Seu livro mais famoso, Psicognomia, foi publicado no país em 1943 com aval da censura eclesiástica e com apêndices especiais. A doutrina levou, ainda, à criação, em 1949, de um instituto privado de divulgação e estudos de psicognomia com sede no Rio de Janeiro, que publicou dois volumes de um tratado sobre o tema e permaneceu ativo até o início da década de 1960, quando o interesse pelo assunto rapidamente desapareceu na sociedade.

Progressive decline in stroke mortality in Brazil from 1980 to 1982, 1990 to 1992, and 2000 to 2002.

BACKGROUND AND PURPOSE: We describe the trends in stroke mortality in Brazil during 3 decades and investigate their differences according to regional disparities, sex, and age distributions. METHODS: Official data on mortality and population estimates were retrieved to calculate standardized mortality rates (with the 1980 Brazilian population as a reference) in 6 age strata and in the 5 political regions for the initial period (3 first years) of the 1980, 1990, and 2000 decades. Data were corrected for undefined causes of death. The Poisson model was used to estimate risk reduction during the 3 decades and to study the interaction between those rates and sex, age strata, and regions. RESULTS: The stroke standardized mortality rate decreased consistently in the last 20 years, from 68.2 to 40.9 per 100,000 habitants. This reduction paralleled a decrease in total cardiovascular mortality rates in the same period, from 208.2 to 126.1 per 100,000 habitants. The reduction in stroke standardized mortality rate was detected in men and women and in all age strata. The reduction was evident in all geopolitical regions of the country, with the wealthiest regions' exhibiting higher initial rates and more marked standardized mortality rate reductions. The risk of dying of stroke in the period 2000 to 2002 was 0.45 (95% CI, 0.44 to 0.45) of that found in the period 1980 to 1982. CONCLUSIONS: The risk of dying of stroke in Brazil declined dramatically between the initial period in the early 1980s and the early 2000s. The decline was especially marked in the most developed regions and may reflect an improvement in general health conditions during the study period.