Etiology, Risk Factors and Outcome of Spontaneous Intracerebral Hemorrhage in Young Adults Admitted to Tertiary Care Hospital in Mogadishu, Somalia.

Introduction: Spontaneous Intracerebral hemorrhage (ICH) in young patients is less common and not well studied compared to ICH in older patients. The etiology, risk factors and outcome of ICH in young patients may have regional and ethnic differences. The study aims to investigate the clinical characteristics, risk factors, etiology and outcome of spontaneous intracerebral hemorrhage in young adults in Somalia. Methods: The study enrolled 168 young patients with ICH (16-50 years) admitted to the neurology department of a tertiary hospital from 2019 to 2022. The information about the demographic details, documented ICH risk factors, etiology and patients' clinical status were retrieved. The etiology of ICH was determined based on clinical, laboratory and radiological findings. Intra-hospital survival status and associated factors were assessed. Results: The mean age of the patients was 35±8.6 years. 99 (59%) of patients were male while 69 (41%) were females. Hypertension 48 (29%) was the most common risk factor, followed by substance abuse. Hypertensive hemorrhage was the most common etiology of ICH 60 (35.7%), followed by cerebral venous thrombosis (CVT) 5(15%), substance abuse 23 (13.7%) and arteriovenous malformation (AVM) in 10 (6%). AVM, CVT, cavernoma, eclampsia, substance abuse and cryptogenic etiology were more common in the 2nd and 3rd decades whereas hypertension was more common in the 4th and 5th decade. Intrahospital mortality was 28% in this study. Factors predicting intrahospital mortality were hematoma volume of greater than 30mL, thrombolytic etiology, brainstem ICH location, substance abuse related etiology, presence of associated mass effect, low GCS score on admission, high systolic blood pressure on admission, and the presence of chronic renal failure. Conclusion: In this study, hypertension, substance abuse, CVT and vascular malformation are the leading causes of ICH in young adults. Intracerebral hemorrhage in the young has different spectrum of etiologies and factors associated with short-term mortality compared to older patients.

Todd Paralysis in a Pregnant Mother Presenting as Acute Stroke: Case Report.

Todd's paralysis (TP) is relatively uncommon condition that can occur immediately after an epileptic seizure. It is a heterogeneous clinical syndrome that presents with acute-onset neurological findings, such as paralysis, paresthesia, aphasia, hemianopsia, and an altered state of consciousness. This may be accompanied by cytotoxic edema on diffusion MRI. This case illustrates a 28-week pregnant patient with TP who presented with acute stroke-like clinical and radiological findings. The patient was presented to the emergency room with left side weakness following focal onset generalized seizure. Magnetic resonance imaging demonstrated diffusion restriction which led to the initial consideration of acute stroke. However, after the disappearance of the neurologic deficit and the resolution of the diffusion restriction in the control MRI, the diagnosis shifted away from acute stroke to the postictal TP. It is important to keep in mind that TP may mimic acute stroke even in the presence of an acute brain lesion in the brain MRI. The differentiation is necessary as each of them has completely different treatment and etiology.

Cerebellopontine angle meningioma in a patient presented as acute cerebrovascular accident.

Cerebellopontine angle (CPA) meningioma is a slowly growing benign tumor of the brain that may compress adjacent neural structures. It has variable clinical presentations that progress very slowly depending on its growth pattern and associated mass effect. A sudden onset clinical presentation is unusual and should prompt consideration of other potential etiologies. Case presentation: Here, the authors present a 66-year-old male patient with diabetes, hypertension, and hyperlipidemia who presented to the emergency department of our hospital with sudden onset walking difficulty (ataxia). On examination, the patient was fully conscious. There was no associated cranial nerve deficit, hearing loss, or focal/lateralizing weakness. All sensory modalities were intact. However, the patient had a gait impairment. Romberg and tandem gait tests were positive with the tendency to sway to the left. The patient was admitted with suspicion of acute cerebrovascular disease. The initial noncontrast brain computed tomography and subsequent diffusion MRI were inconclusive. A later brain MRI with contrast revealed a homogeneously contrast enhancing meningioma in the left CPA. Clinical discussion: The differential diagnosis of sudden onset ataxia is broad and should include the assessment of a possible CPA lesion. Sudden onset ataxia by a CPA meningioma is very rare as meningiomas grow very slowly. A brain MRI with contrast is essential for its diagnosis. Conclusion: Although stroke is the main cause of sudden onset ataxia in a patient with cerebrovascular risk factors, yet other less common causes may be found as in this case of CPA meningioma.

The inflammatory markers and prognosis of cervicocephalic artery dissection: a stroke center study from a tertiary hospital.

OBJECTIVE: Cervicocephalic artery dissection (CeAD) is the most common cause of ischemic stroke in young adults. Although the exact cause is unknown, inflammation is thought to have a role. Here, we investigated the relationship between CeAD and inflammation. METHODS: Patients diagnosed with CeAD in our stroke center were evaluated retrospectively, and their demographic and clinical features were recorded. The C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), white blood cell, neutrophil and lymphocyte counts, platelet/lymphocyte ratio (PLR), and neutrophil/lymphocyte ratio (NLR) were recorded on admission. Modified Rankin scores (mRS) were noted on admission and at 6 months to evaluate the dependency status and functional outcome of each patient. RESULTS: Of the 95 patients in the study, 70 (73.7%) were male, and the mean age was 44.4 ± 9.8 years. Patients with high WBC count, ESR, PLR, and NLR frequently had mRS scores of 3-6 at admission; these differences were significant (p = 0.04, p = 0.02, p = 0.04, and p = 0.02, respectively). At 6 months, patients with high CRP and ESR at admission also had significantly poorer prognoses (p < 0.001, p = 0.002, respectively). PLR and NLR values were higher in patients with mRS of 3-6. But there were no significant differences between the good and poor prognosis groups regarding PLR and NLR (p = 0.22, p = 0.05, respectively). CONCLUSION: Inflammation may have a role in the prognosis of CeAD, and inflammatory markers can be evaluated as auxiliary tests for determining prognosis.

The Review of Transient Ischemic Attack Patients: An Experience of a Clinic about Diagnosis and Follow-up.

OBJECTIVES: Transient Ischemic Attack (TIA) is due to a temporary lack of adequate blood and oxygen to the brain. TIAs typically last less than 24 hours. 10-15% of ischemic stroke patients have a history of TIA. 18% of them experience an ischemic stroke within 90 days, and the ABCD2 scoring system is used to estimate the risk. Our study aims to investigate the risk factors, the etiology, the lesion occurrence on MRI and the near-term risk of stroke of patients on whom TIA was diagnosed. METHODS: In this study, 124 patients were included between January 2012 and January 2018. Sixty-eight of the 124 patients were male. The history of patients was questioned; systemic and neurological examinations were made. The stroke risk factors and TIA duration were noted and ABCD2 scores were calculated. All the patients' blood samples, including glucose and lipid profile, were studied. They received CT, DWI MRI, electrocardiography, transthoracic echocardiography, ultrasound and/or MR angiography of the cervical arteries. RESULTS: One hundred twenty-four patients were included in this study, and 56 patients were female. The mean age was 63.04±16.77. Hypertension was the most common risk factor (50.8%). Twenty-seven patients were on antithrombotic; six patients were on anticoagulant therapy, while 91 patients were not receiving any antiaggregan therapy. ABCD2 scores were significantly higher on the antithrombotic therapy group (p=0.019). In 52 patients ABCD2 score was below 4, and in 72 patients, the score was greater than 4. In 67.7% of patients, no etiology was found. An ischemic lesion was detected in 16.9% of the patients. 58 % of the patients were discharged on anticoagulant therapy. Five patients developed ischemic stroke. CONCLUSION: The risk factors of ischemic stroke and TIAs are similar factors. The etiology of TIAs cannot be found out in most of the patients. Thus, the patients are discharged with oral anticoagulant treatment.

The Relationship Between Serum Uric Acid Levels and Clinical Features in Essential Tremor.

INTRODUCTION: In this study, we aimed to investigate the effect of uric acid on the disease, its severity and progression in ET patients with partially co-clinical features with Parkinson's disease (PD). METHODS: Serum UA levels of 87 consecutive ET patients were measured and were matched according to age and sex with 87 healthy controls. Fahn-Tolosa-Marin scale was used for the severity of tremor. Sociodemographic characteristics, type of ET, duration of disease, and treatment modalities were evaluated. RESULTS: The mean uric acid level was calculated as 4.986±2.1458 mg/dL and 6.004±1.523 mg/dL in the patient and control groups, respectively (p≤0.005). The blood UA level of patients with sporadic (n: 61) ET was found to be lower than the familial ET (n: 26) (p≤0.005). The tremor severity of the family ET patients was lower than the sporadic ET. (n: 61) (p≤0.005). The mean blood UA level (4.429±1.216 mg/dL) in the patients with high total tremor severity scores (n: 48) was found lower than in the patients with low total tremor severity scores (n: 39) (5.673±2.106 mg/dL) (P=0.000). The serum UA level was significantly lower in the patients whose disease duration longer than 5 years than in patients whose duration of the disease was shorter than 5 years. 5.732±1.240 for ≥5 years; 6.438±0.286≤5 years) (P=0.001). CONCLUSION: We hypothesize that as a result of high antioxidant properties of high serum uric acid levels, it is a biomarker that can show disease risk and progression in patients with ET as well as PD.

Does restricted diffusion in the splenium indicate an acute infarct?

OBJECTIVE: Although splenial lesions are rare, they are frequently associated with ischemic infarcts, antiepileptic drug toxicity or abrupt discontinuation, viral encephalitis, and metabolic disturbances. In this study, we evaluated clinical and imaging findings and aetiology in 16 patients with splenium lesions. METHODS: Between 2013 and 2017, patients with splenium lesions were examined. Magnetic resonance imaging (MRI) was performed using a 1.5-T unit with fluid attenuation inversion recovery sequences. Additionally, diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) maps were examined. RESULTS: The patients were 11 males and 5 females; the mean age was 52.3 ± 20.3 (22-87) years. The patients were admitted with the following conditions: consciousness disorder (n = 7, 43.7%), headache (n = 3, 18.7%), seizure (n = 3, 18.7%), ataxia (n = 3, 18.7%), hemiparesis (n = 4, 25%), meaningless speech (n = 2, 12.5%), fever (n = 3, 18.7%), perioral numbness (n = 1, 6.2%), and diplopia (n = 1, 6.2%). Hyperintensity in the splenium was observed in DWI sequences in all patients on MRI. Fourteen patients (87.5%) showed hypointensity in the same region on ADC. In patients with ischemic infarcts, the splenium lesions were most commonly observed in the area of the posterior cerebral artery (n = 4, 25%). MRI showed splenial signal changes in DWI sequences in all patients. Hyperintensity in the splenium was observed in DWI sequences in all patients on MRI. Fourteen patients (87.5%) showed hypointensity in the same region on ADC. The aetiologies were defined as multiple sclerosis (n = 1, 6.2%), ischemic infarction (n = 4, 25%), tuberculous meningitis (n = 3, 18.7%), viral encephalitis (n = 2, 12.5%), hypernatremia (n = 1, 6.2%), brain tumour (n = 1, 6.2%), Marchiafava-Bignami syndrome (n = 1, 6.2%), head trauma (n = 1, 6.2%), substance use (n = 1, 6.2%), and epilepsy (n = 1, 6.2%). CONCLUSION: Not every diffuse restriction observed on MRI indicates an ischemic stroke. Although radiologic images of the splenium may suggest acute ischemic infarction, the actual cause may be another pathology. Therefore, the symptoms and aetiologies of patients with splenium lesions should be considered and investigated from a wide range of perspectives.

Acute bilateral drop foot as a complication of prolonged squatting due to haemorrhoid.

Drop foot is defined as difficulty of dorsiflexion of the foot and ankle due to weak anterior tibial, extensor hallucis longus and extensor digitorum longus muscles. Cauda equina syndrome, local peroneal nerve damage due to trauma, nerve entrapment, compartment syndrome and tumors are common etiologies. A 32-year-old male patient was applied with difficulty in dorsiflexion of both of his toes, feet and ankles after he had squatted in toilette for 6-7 hours (because of his haemorrhoid) after intense alcohol intake 2 weeks before. Acute, partial, demyelinating lesion in head of fibula segment of peroneal nerves was diagnosed by electromyography. This case was reported since prolonged squatting is an extremely rare cause of acute bilateral peroneal neuropathy. This type of neuropathy is mostly demyelination and has good prognosis with physical therapy and mechanical devices, but surgical intervention may be required due to axonal damage. People such as workers and farmers working in the squatting position for long hours should be advised to change their position as soon as the compression symptoms (numbness, tingling) appear.

Cognitive Functioning and Silent Neurological Manifestations in Behçet's Disease with Ocular Involvement.

INTRODUCTION: Various reports have revealed a cognitive dysfunction in Behçet's disease (BD). In this study, we aimed to assess the silent neurological manifestations, behavioral and neuropsychiological impairments of Behçet's disease patients with ocular involvement. METHODS: Thirty BD patients with ocular involvement in the nonactive phase of their illness were applied detailed neurological examination and magnetic resonance imagining (MRI). Neuropsychological tests were performed. Patients' neuropsychological performances were compared to those of healthy, demographically matched twenty subjects. RESULTS: Neurological manifestations of patients were headache (56.6%), pyramidal signs (13.3%), behavioral changes (3.3%) and sensory symptoms (3.3%). Four patients (13.3%) had white matter hyperintensities lesions on T2/FLAIR brain MRI. Fourteen patients (46%) had impaired cognitive performances on the following tasks: verbal memory (immediate memory p=0.000, maximal learning capacity p=0.009, number of repetitions p=0.000, total learning capacity p=0.001, recall p=0.033), nonverbal memory (immediate memory p=0.029, recall p=0.001), logical memory (immediate memory p=0.001, recall p=0.001), executive (frontal) functions (clock-drawing test p=0.000, Stroop test p=0.001, verbal fluency tests p=0.000). Patients' MMSE and clock drawing test scores were significantly lower than controls (p=0.03). Attention deficit was not detected. Behçet's disease patients showed higher scores on depression scales than healthy subjects but there was no statistically significant difference between anxiety scores. CONCLUSION: Neuropsychological deficits, involving mainly memory and executive functioning, subcortical MRI lesions, and non-structural headache may be present in Behçet's disease patients with ocular involvement without overt neurological manifestations.

A Case of Acute Intermittent Porphyria Mimicking Guillain-Barré Syndrome.

Patients with acute intermittent porphyria attacks present with severe abdominal pain, neuropathy and psychiatric disturbances. Porphyric neuropathy mostly causes confusion in clinical practice, and patients with porphyria are rarely correctly diagnosed early in the course of the illness. We report a patient with acute intermittent porphyria mimicking Guillain-Barré syndrome with acute onset weakness that rapidly progressed to severe quadriplegia.

Can we predict the compensatory hyperhidrosis following a thoracic sympathectomy?

BACKGROUND: Primary hyperhidrosis is a functionally and socially disabling condition resulting in social embarrassment and low quality of life. Thoracic sympathectomy is a definitive choice of treatment with favorable results. However, patients may face another embarrassing condition following surgery as compensatory hyperhidrosis which has no definitive treatment. The predictors of compensatory hyperhidrosis are controversial and remain unclear. PATIENTS AND METHODS: A total of 74 patients underwent a videothoracoscopic sympathectomy for primary hyperhidrosis. We statistically analyzed our patients with correlations and uni-multivariate logistic regression models to outline the possible predictors of compensatory hyperhidrosis. RESULTS: A total of 45 (60.8%) patients had compensatory hyperhidrosis. The correlations showed that patients, with age greater than 21 years (P = 0.018), with body mass index (BMI) greater than 22 kg / m2 (P = 0.045), with isolated facial hyperhidrosis (P = 0.044), and with smoking status (P = 0.015), had significantly greater rates of compensatory hyperhidrosis. Similarly, the significant univariate predictors of compensatory hyperhidrosis were age > 21 (P = 0.020), BMI > 22 kg / m2 (P = 0.048), and the presence of smoking status (P = 0.015). Multivariate analysis revealed only smoking as a predictor within the threshold of significance (P = 0.078). CONCLUSION: The clinical predictors of compensatory hyperhidrosis following a thoracic sympathectomy appear as older age, greater body mass index, and smoking.

A case with angiographic demonstration of isolated anterior spinal artery occlusion.

Anterior spinal artery syndrome (ASAS) is a rare syndrome which occurs due to thrombosis of anterior spinal artery (ASA) which supplies anterior two thirds of the spinal cord. A 27-year-old female patient was admitted to emergency clinic with sudden onset neck pain, sensory loss and weakness in proximal upper extremities which occurred at rest. Thrombophilia assessment tests were negative. Echocardiography was normal. Serum viral markers were negative. In cerebrospinal fluid (CSF) examination, cell count and biochemistry was normal, oligoclonal band was negative, viral markers for herpes simplex virus (HSV) type-1 and type-2, Brucella, Borrellia, Treponema pallidum, Tuberculosis were negative. Diffusion restriction which reveals acute ischemia was detected in Diffusion weighted MRI. Digital subtraction angiography (DSA) was performed. Medical treatment was 300mg/day acetilsalycilic acid. Patient was discharged from neurology clinics to receive rehabilitation against spasticity.

Profile of Syrian Asylum-Seekers from Neurological Clinic in a Tertiary Center.

BACKGROUND: The humanitarian response for Syria has been largely managed either from within Syria or from neighboring countries, particularly Turkey. This study was aimed at determining the sociodemographic and clinical profiles of Syrian asylum-seekers admitted to our clinic, changes in patient number across years, and the percentage of patients on follow-ups. METHODS: Syrian patients who were admitted to the neurology outpatient clinics, neurology emergency department (ED), and hospitalized in the neurology clinics were included in the study. Age, gender, number of admissions, year of admissions, chief complaints, diagnoses, and follow-up percentages of patients were recorded. RESULTS: The total number of Syrian patients who were first admitted to our hospital and consulted from other clinics, were found to be 763 (ED: 609 [79.8%], outpatient: 134 [17.6%] consultation: 20 [2.6%]). A total of 543 (96.1%) of the patients with a neurological disorder did not come to the follow-ups even though their conditions required regular follow-ups. The most common complaints were headache (24.2%), fainting (16.1%), weakness (11.9%), and dizziness (10%). CONCLUSION: Most of the patients admitted to our hospital did not come to the follow-ups and information regarding their treatments could not be obtained. Even though the Republic of Turkey provided the Syrian asylum-seekers with free medical care, utilization of these resources may be limited because of socioeconomic issues.

The relation of serum uric acid levels with L-Dopa treatment and progression in patients with Parkinson's disease.

In this study, we aimed to investigate the association of the serum uric acid (UA) level with disease progression and L-Dopa treatment in PD (Parkinson's disease) patients. Serum UA levels of 80 consecutive PD patients were measured and were matched according to age and sex with 80 healthy controls. The patients were divided into two subgroups according to the pharmaceutical treatment received. First group consisted of patients treated with L-Dopa and a dopamine agonist and the second group consisted of patients treated only with a dopamine agonist. The patients were divided into two other subgroups according to Hoehn and Yahr scale. First group consisted of patients at the first two stages and the second group included patients at the third and upper stages. PD patients were found to have significantly lower levels of serum UA than controls (p = 0.000). Serum UA levels were lower in the group under L-Dopa + dopamine agonist treatment and in patients at third and upper Hoehn and Yahr stages than the patients under only dopamine agonist treatment and in the patients at the first two stages (p = 0.000 and p = 0.000). Multivariate logistic regression showed that advanced stages (OR 0.65, CI 0.50-0.79, p = 0.000) and L-Dopa treatment (OR 1.08, CI 1.03-1.16, p = 0.001) were independently associated with low UA levels. Our study supports that there is an inverse relation between UA levels and L-Dopa treatment and PD stages, and high serum UA levels may decrease the oxidative stress taking part in the pathogenesis of PD.

Evaluation of interictal autonomic function during attack and remission periods in cluster headaches.

OBJECTIVE: To investigate which part of the autonomic system is mainly involved and assess the sensitivity of face sympathetic skin response in cluster headache. MATERIAL AND METHODS: The study sample consisted of 19 drug-free cluster headache patients (16 males, three females) and 19 healthy volunteers. Demographic features and pain characteristics were thoroughly identified. Dysautonomic symptoms were evaluated during attack and remission periods of cluster headache patients. Orthostatic hypotension, R-R interval variation and sympathetic skin responses obtained from the face and four extremities were evaluated and the sensitivity of face sympathetic skin responses was assessed in contrast to extremity sympathetic skin responses. RESULTS: All sympathetic skin responses of face and extremities could be obtained during attack and remission periods. On the symptomatic side, mean latency of face sympathetic skin responses was longer compared to the asymptomatic side and controls (p = 0.02, p = 0.004). There were no differences in latency or amplitude of extremity sympathetic skin responses between symptomatic and asymptomatic sides and controls. No significant relationship was determined between sympathetic skin responses, R-R interval variation, orthostatic hypotension and cluster headache clinical features. CONCLUSION: Sympathetic hypoactivity of the face seems to predominate the pathophysiology of cluster headache. Face sympathetic skin responses might be more sensitive compared to extremity sympathetic skin response in demonstrating dysautonomic symptoms in cluster headache patients.

Evaluation of cognitive functions of juvenile myoclonic epileptic patients by magnetic resonance spectroscopy and neuropsychiatric cognitive tests concurrently.

Our aim in this research is investigating the hypothesis of biochemical changes in frontal cortex and thalamocortical pathways in juvenile myoclonic epilepsy (JME) and the interaction between the biochemical changes and cortical functions. Magnetic resonance spectroscopy (MRS) was applied to 20 JME patients and 20 controls for measuring N-acetyl aspartate (NAA), N-acetyl aspartate to creatine ratio (NAA/Cr), Glutamine and Glutamate (GLX), Glutamine-Glutamate to creatine (GLX/Cr), Choline containing compounds (Cho) and Choline to creatine (Cho/Cr) levels. Neuropsychological cognitive tests for linguistic and visual attention, linguistic and visual memory, visuospatial and executive functions were applied to all participants. NAA and NAA/Cr concentrations were found lower in bilateral frontal and thalamic regions in JME group as compared with the control group (p < 0.05). There was no difference in frontal and thalamic GLX, GLX/Cr, Cho, Cho/Cr levels in between JME patients and controls (p > 0.05). JME patients were found more unsuccessful than the controls in attention, memory, visuospatial function, verbal fluency, Trail B test and executive functions, stroop test, clock drawing test and Trail A test (p < 0.05). Prefrontal NAA/Cr level was positively related to visual attention, memory, stroop test and thalamic NAA/Cr level was positively related to linguistic memory and Wisconsin card sorting test in JME patients. This research highlights regional brain changes and cognitive decline in JME patients and suggests that MRS may be a sensitive technique for showing subclinical cognitive changes.

Evaluation of Glutamic Acid Decarboxylase Antibody Levels in Patients with Juvenile Myoclonic Epilepsy and Mesial Temporal Lobe Epilepsy with Hippocampal Sclerosis.

INTRODUCTION: Several clinical studies have been conducted to investigate the role of autoantibodies and immunological mechanisms in the etiology of treatment-resistant epilepsy in recent years. Some immunological treatments have been suggested as a result of these studies. In this study, we aimed to investigate the role of autoimmunity in partial and idiopathic generalized epilepsy and determine the relationship between drug resistance and autoimmune antibodies. METHODS: Twenty-eight patients (24 treatment-responsive and 4 treatment-resistant) with juvenile myoclonic epilepsy (JME), 26 patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLEHS) resistant to antiepileptic drug treatment, and 26 age-matched healthy control subjects were included in a two-year cross sectional study. Glutamic acid decarboxylase antibody (GADA) levels were measured with a radioimmunoassay method in the serum of the included subjects. RESULTS: High GADA titers were detected in 2 patients with JME (7.1%), 1 patient with MTLEHS (3.8%), and 1 healthy subject (3.8%). There was no statistically significant difference among the groups regarding the serum GADA level. Although a limited number of drug-resistant patients with JME our study did not show relationships among anti-GADAs, both epileptic syndromes and drug resistance. CONCLUSION: Because we did not determine any significant relationship between GADA levels and JME or MTLEHS, we do not recommend analysis of serum GADA levels in routine examinations where there is no evidence to suggest risk factors for autoimmunity.

Independent effect of fatigue on health-related quality of life in patients with idiopathic Parkinson's disease.

Nonmotor symptoms (NMS) of idiopathic Parkinson's disease (IPD), specifically fatigue, depression and sleep disturbances, are important contributors for worse quality of life and poor patient outcomes. The aim of this research is to determine the relationship between fatigue and other NMS and the independent effect of fatigue on health-related quality of life (HRQoL) in patients with IPD. 86 IPD patients and 85 healthy individuals were included in our study. Participants were evaluated by their answers to the Beck Depression Inventory, Fatigue Severity Scale, Epworth Sleepiness Scale and Parkinson's Disease Questionnaire-39. Hoehn-Yahr stage, disease duration, medications and demographical characteristics were also noted. ROC analysis was used to determine the cutoff point for HRQoL. Nonparametric Spearman correlation analysis was used for determining the relationship between variables. Independent factors which affect HRQoL were detected by multiple forward stepwise logistic regression analysis. NMS were associated with each other and with HRQoL when they act concomitantly (p < 0.001). Of these three frequent NMS, depression (p < 0.05) and fatigue (p < 0.001) had independent worsening effect on HRQoL, whereas sleep disturbances did not (p > 0.05). The stage of IPD and levodopa-entacapone treatment had independent effects on HRQoL too (p < 0.05). Fatigue was found as the most important factor which affects HRQoL among all investigated NMS. So, it is important to ask about fatigue in routine controls of IPD patients and try to treat it for improving life quality.

Parallel imports and a mandatory substitution reform: a kick or a muff for price competition in pharmaceuticals?

What has been the effect of competition from parallel imports on prices of locally sourced on-patent drugs? Did the 2002 Swedish mandatory substitution reform increase this competition? To answer these questions, we carried out difference-in-differences estimation on monthly data for a panel of all locally sourced on-patent prescription drugs sold in Sweden during the 40 months from January 2001 to April 2004. On average, facing competition from parallel imports caused a 15-17% fall in price. While the reform increased the effect of competition from parallel imports, it was only by 0.9%. The reform, however, did increase the effect of therapeutic competition by 1.6%.