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Hypereosinophilic syndrome (HES) is a rare hematological disease that causes organ damage by eosinophil infiltration in the tissue with increased eosinophil production in the bone marrow. HES is a rare but important cause of stroke. Central nervous system involvement findings can be serious and life-threatening. Eosinophil values should be examined as the cause of stroke, and hypereosinophilia should be suspected, especially in young patients with no etiology. Reported herein is a case of a 47-year-old female patient who was followed up with the diagnosis of acute cerebrovascular disease due to idiopathic HES.

Valproic acid (VPA) is a anticonvulsant and mood-stabilizing agent used to treat epilepsy in patients of all ages. However, it can cause hepatotoxicity with increased oxidative stress. Melatonin (MEL) is known as antioxidant and antiinflammatory agent. Therefore, the present study designed to investigate the probable protective role of melatonin against VPA-induced liver toxicity. For that purpose, 28 Wistar rats were randomly selected and divided into four groups, namely the Group C (vehicle), VPA (500 mg/kg/day VPA), MEL + VPA (10 mg/kg/day melatonin + 500 mg/kg/day VPA) and MEL (10 mg/kg/day melatonin). The agents were given by oral gavage for 14 days. Blood and liver tissue samples from all the rats were harvested on the 15th day of experiment. Biochemical analyses were conducted on the blood samples. The levels of malondialdehyde (MDA), superoxide dismutase (SOD), alpha glutathione S-transferases (α-GST), nuclear factor-κB (NF-κB), myeloperoxidase (MPO) and changes in gene expression were examined in the liver tissues. Also, liver histopathological analyses were conducted. VPA administration significantly increased the levels of α-GST, MDA, NF-κB and of IL-1β, TNF-α gene expression in the liver compared to Group C. Moreover, vacuolization, hydropic degeneration, inflammatory cell infiltration, and sinusoidal congestion were commonly detected in the VPA-treated group along with the highest apoptotic index (TUNEL staining) values. Melatonin administration was revealed to exhibit powerful protective properties at cellular, inflammatory and oxidative level activities against VPA-induced liver toxicity. Therefore, melatonin administration may be used as an adjuvant therapy against to VPA-induced liver toxicity.

Medical errors are a serious public health problem and the third-leading cause of death after heart disease and cancer. Every day, the health care professionals (HCPs) practice their skill and knowledge within excessively complex situations and meet unexpected patient outcomes. These unexpected complications and unintentional errors will always be a part of the medical system due to the universal nature of human fallibility and technology. While not all errors are life-threatening, they can significantly compromise a patient's quality of life. However, the victims of medical error reach far beyond the patient. The second victim (SV), which defined for the first time by Albert Wu in his description of the impact of errors on HCPs by both personally and professionally, is a medical emergency equivalent to post-traumatic stress disorder. When the errors occur, it causes a domino effect including the four groups: the patient and family (first victim), the HCP [SV], the hospital reputation (third victim), and patients who are harmed subsequently (fourth victims). The rights of our patients to safe, reliable, and patient-centered care are critical and most important as a primary and utmost aim of medicine. However, we also have to take care of our own (SVs), especially when we have good people who mean to do well and then find themselves in an emotionally complex situation. There is a need to articulate to the public, politicians, and media how system failure leads to medical error even in hand of well-educated and competent HCPs are given an increasing clinical workload. Furthermore, despite several leading institutions in western countries have developed formal support programs that allow HCPs to cope with their emotional distress by obtaining timely support in an emphatic, confidential, non-judgmental environment, we need to raise awareness of this phenomenon and appropriate institutional responses both to harmed patients and their families and HCPs.

PRIOR ABSTRACT PUBLICATION: 2(nd) Medical Rehabilitation Congress; Nov 4–7, 2010; Ankara, Turkey OBJECTIVE: This study aims to investigate the process of breaking bad news from the perspective of spinal cord injury survivors. DESIGN: A cross sectional, qualitative study. SETTING: Community. PARTICIPANTS: Fourteen spinal cord injury survivors. INTERVENTIONS: Subjects participated in a semi-structured interview about ‘when’, ‘where’ ‘by whom’ and ‘how’ they received and ‘would’ prefer to receive bad news. OUTCOME MEASURES: Answers to ‘how’ questions were coded according to SPIKES protocol (Setting, Perception, Invitation, Knowledge, Empathizing, Summary). RESULTS: Eight participants (57%) reported that they received bad news from a physician, mostly during rehabilitation. All would prefer to be informed by a physician and majority preferred to be gradually informed during rehabilitation. Half were not satisfied with the content of information. Only half felt that his/her physiatrist understood his/her emotional distress. Majority of participants who received bad news from physicians reported that the setting was private and their family members accompanied them. CONCLUSION: Most spinal cord injury survivors were unsatisfied with knowledge and emotional support provided by rehabilitation physicians. Participants would prefer to receive bad news by a senior physiatrist in a planned meeting during rehabilitation.

Objective: Trigeminal autonomic cephalalgias (TACs) are a group of primary headache syndromes. Although hemicrania continua (HC)is not included among the TACs according to the International Classification of Headache Disorders (ICHD-II), it also shows autonomic symptoms. In the literature, some authors suggest that TACs can be related with pituitary lesions. In this study, we have compared the pituitary lesions observed in the TAC, HC and migraine-type headache patientsMethods The cranial magnetic resonance images (MRI) of the patients with TAC, HC and migraine without aura (MWOA) unaccompanied by autonomic symptoms were retrospectively evaluated. The 33 TAC and HC patients were compared with the 30 migraine without aura (MWOA) patients. Results: The mean age of the TAC and HC patients was 43. 36±10. 72 years, whereas the mean age of the MWOA patients was 39.0±6.92 years. No statistically significant difference in terms of age was observed between the groups (p˃0.05). The MRI of the TACs and HC patients indicated that 62.5% (n:20) were normal, while 12.5% (n:4) had pituitary microadenomas, 6.3 % (n:2) had macroadenomas, 12.5% (n:4) had suspected pituitary microadenomas, and 6. 3% (n:2) had suspected heterogeneity. The MRI results of the MWOA patients were normal in 46.7% (n:14), whereas 23.3% (n:7) had pituitary microadenomas, 23.3% (n:7) had suspected pituitary microadenomas, and 6. 2% (n:2) had suspected pituitary heterogeneity. No statistically significant difference was observed between both groups (p>0. 05).Conclusion: In this study, no correlation was observed between the TACs, HC and pituitary abnormalities. In conclusion, the use of pituitary MRI has not been supported as a routine method in patients with this type of headache

Objective: To develop and validate a scale to measure fear of activity in patients with coronary artery disease. Design: Psychometric study. Setting: Outpatient cardiology clinics. Participants: The scale was applied to patients who had myocardial infarction, coronary artery bypass grafting, or percutaneous coronary intervention within the last 12 months (N=250). Interventions: A scale for fear of activity in patients with coronary artery disease (Fact-CAD) was created through semistructured focus group interviews with patients. Face and content validity of Fact-CAD was verified. Main Outcome Measures: Psychometric analysis included model fit, unidimensionality, reliability, local dependency, differential item functioning, and external construct validity. Analyses were performed using the Rasch Analysis Model. Results: Fact-CAD scale was a reliable (high Person Separation Index of 0.89) and valid (unidimensional, no misfit, local independency supported, no residual correlations) measure of fear of activity. Three items showed differential item functioning according to employment status, marital status, and angina pectoris, which were not assigned as real item bias by experts and remained in the model. Conclusion: Fact-CAD was supported by Rasch analysis as a psychometrically valid scale to evaluate fear of activity in patients with coronary artery disease. (C) 2019 by the American Congress of Rehabilitation Medicine WOS:000520949900011 2-s2.0-85073748647 PubMed: 31562874

To explore Turkish physiatrists' experiences and opinions about breaking bad news (BBN) to patients with spinal cord injury (SCI).A cross sectional study.Turkey.Sixty-nine physiatrists completed a questionnaire about experiences and opinions regarding BBN and self-assessment of communication skills (CS).Eleven percent of specialists and 53% of residents were trained on basic CS. All participants believed that physiatrists should play a role in BBN and the majority reported that they delivered the bad news in their clinic. Sixty-seven percent believed that the primary responsibility belongs to physiatrists. Sixty-eight percent reported that the most appropriate time for BBN is during rehabilitation. Self-assessments of CS were considered satisfactory in most steps of SPIKES protocol. Twenty percent told absolute truth to patients while 80% stated that they did so sometimes or partially. Only 41% confirmed that they do not use unrealistic statements to comfort patients. Fewer than 60% stated that they performed the most appropriate and excellent behaviors for items in "empathy" section.Physiatrists had different opinions about the style of BBN. Self-assessments of CS were optimistic, however physiatrists were not fully satisfied with their empathy skills.

Background and objective Somatosensory temporal discrimination was recently reported as prolonged during migraine attacks, which is consistent with disrupted sensorial perception in migraine. However, knowledge about central sensory processing in tension-type headache is still lacking. This prospective, controlled study aimed to investigate somatosensory temporal discrimination thresholds in tension-type headache. Methods The study included 10 tension-type headache patients, 10 migraine patients and 10 healthy volunteers without headache. Somatosensory temporal discrimination thresholds were evaluated during the headache attacks of tension-type headache and migraine patients. Results Somatosensory temporal discrimination thresholds of tension-type headache patients (39.0 ± 5.5 ms for the right hand and 40.6 ± 4.6 ms for the left hand) were significantly lower than those of episodic migraine patients (137.1 ± 35.8 ms for the right hand and 118.4 ± 34.3 ms for the left hand, p Conclusion Central sensory processing, as tested by somatosensory temporal discrimination, was remarkably disrupted during the headache attacks in migraineurs, whereas it remained intact in the tension-type headache patients.

Migraine is a kind of headache accompanied by neurologic, gastrointestinal, and autonomous variations. The roles of factors that trigger migraine, especially nutrition triggers, have become much more questionable with the increase in the rate of migraine occurrence. Some patients with migraine have stated that their headache attacks start without any reason. However, inner triggers such as hormonal changes or external triggers such as air exchange, some smells or the association of both triggers can start the headache. Each patient may not have same sensitivity to these triggers. A single factor might become prominent in some patients, but more than one factor may need to be required in other patients. Although the connection between migraine and the factors such as stress, environmental factors, chronic diseases, and nutritional and sleep status has been known, their mechanisms are still not clear. Nutritional status and the effects of nutrition play an important role being pain triggers in everybody, especially children and young people who suffer from migraine headache. Considering the migraine triggers generally, it has been suggested in studies that there is at least one nutrition-related trigger and hunger is the most frequently reported trigger in terms of diet. Moreover it is known that chocolate, tea, coffee, cheese, and alcohol may trigger migraine because of some specific elements within them. In recently conducted studies, using some functional foods have raised on the treatment of migraine. For this reason, the relationship between migraine and triggering factors as food and nutrition are examined in this study.

Cytokines are multifunctional polypeptides synthesized by different body cells. They have clinical significance in terms of disease diagnosis, treatment and prevention. Cytokines TNF-α and IL-6 play an important role in the growth and differentiation of cells.Vascular Endothelial Growth Factor (VEGF) is excessively produced in epithelial, mesenchymal, and particularly in tumor cells. Studies have shown that the increased serum concentrations of IL-6, TNF-α, VEGF are strongly associated with colorectal cancer and directly with the clinical stage of the disease. This can be used to diagnose cancer and to identify patients with a bad prognosis who can avail themselves of a more aggressive treatment. The present study investigated the role of cytokines in the development of cancer by comparing preoperative serum cytokine levels of patients suffering from colorectal cancer with those of the healthy control group. The prognostic significance of the data obtained has also been evaluated. For this purpose, IL-6, TNF-α and VEGF levels in 60 serums, 30 preoperatively taken from patients with colorectal cancer and 30 from a healthy control group at í‡anakkale Onsekiz Mart University General Surgery Clinic, were determined by ELISA kits. The statistical analyses of the obtained data were evaluated on SPSS, a statistical package program. In this study, no significant difference was obtained between the mean scores concerning the IL-6 and VEGF serums of the colorectal cancer and healthy group (p>.05). But a statistically significant decrease was observed in the TNF-α serum level of the colorectal cancer group in comparison with the control group (p= .016; p < .05).

Background Short-lasting unilateral neuralgiform headache attack with conjunctival injection and tearing (SUNCT) is one of the trigeminal autonomic cephalalgias where neurovascular compression was detected in neuroimaging in recent years. Case We report two cases, a 52-year-old adult and a 69-year-old elderly patient with short-lasting and recurrent headache combined with cranial autonomic features. Diffusion tensor imaging (DTI) and magnetic resonance (MR) tractography of both patients outlined structural changes of the trigeminal nerve revealing neurovascular compression. Pain and autonomic symptoms were completely relieved in the 52-year-old patient who underwent microvascular decompression surgery. Conclusion To our knowledge, this is the first time in the literature where MR tractography revealed structural changes in the trigeminal nerve secondary to neurovascular compression in SUNCT patients. We suggest that in SUNCT patients high-resolution magnetic resonance imaging (MRI) and/or DTI-MR tractography should be performed to exclude neurovascular compression. We propose that the compression of the trigeminal nerve could generate SUNCT symptoms and the posterior hypothalamus could be activated secondarily. With this point of view, trigeminal neuralgia and SUNCT could represent the different features of the neurovascular compression spectrum.

The objective of this study was to evaluate the clinical significance of serum ADP-ribosylation and NAD glycohydrolase activity in patients with colorectal cancer (CRC). A total of 108 patients with CRC who underwent curative surgery and 20 healthy volunteers were enrolled in this study. ADP-ribosylation and NAD glycohydrolase activ- ity levels were determined. The association of ADP- ribosylation and NAD glycohydrolase with clinical and labo- ratory factors and their impact on overall survival (OS) and disease free survival (DFS) were shown. The preoperative ADP-ribosylation and NAD glycohydrolase activity levels were significantly higher in patients with CRC than in the control group (p

OBJECTIVE Complementary and alternative medicine (CAM) is increasingly being used as adjunctive treatment in primary headache syndromes in many countries. In the Turkish population, no epidemiologic data have been reported about awareness and usage of these treatments in patients with headache. METHODS One hundred and ten primary headache patients attending three headache clinics completed a questionnaire regarding their headaches, the known modalities and the use and effect of CAM procedures for their headaches. RESULTS The mean age of the patients was 34.7±9.6 years (32.8-36.5). Almost two-thirds of patients had completed high school and university, and one-third of patients were housewives. Migraine without aura (45.5%) was the most frequently diagnosed type of headache followed by migraine with aura (19.1%) and tension-type headache (18.2%). In 43.6% of the patients, headache frequency was 5-10 per month. The most frequently known CAM modalities were massage (74.5%), acupuncture (44.5%), yoga (31.8%), exercise (28.2%), psychotherapy (25.5%), and rosemary (23.6%). The most frequently used CAM treatments were massage (51%) and exercise (11%). Only massage was reported to be beneficial in one-third of the primary headache patients; the other modalities were not. CONCLUSION Our findings suggest that the subgroup of primary headache patients in Turkey seek and use alternative treatments, frequently in combination with standard treatments. Neurologists should become more knowledgeable regarding CAM therapies; further randomized and controlled clinical researches with large sample sizes are needed.

Peripheral nerve blocks have been used in primary headache treatment since a long time. In this study, we aimed to examine the efficiency of greater occipital nerve (GON) block in migraine prophylaxis.Data from migraine without aura patients who had GON block were collected and divided into two groups: Group PGON (n=25), which included patients who were under medical prophylaxis and had GON block, and Group GON (n=53), which included patients who had only GON blocks. Migraine was diagnosed using International Headache Society (IHS) classification. Data of 78 patients were analyzed. Headache attack frequency, headache duration, and severity were compared between and within groups in a 3-month follow-up period.The decrease in headache parameters after GON block in both groups was significantly similar. Headache attack frequency decreased from 15.73±7.21 (pretreatment) to 4.52±3.61 (3rd month) in Group GON and from 13.76±8.07 to 3.28±2.15 in Group PGON (p0.05). Headache duration decreased from 18.51±9.43 to 8.02±5.58 at 3rd month in Group GON and from 15.20±9.16 to 7.20±4.16 in Group PGON (p0.05). Headache severity decreased from 8.26±1.32 to 5.16±2.64 in Group GON and from 8.08±0.90 to 5.96±1.20 in Group PGON (p0.05). There was no statistically significant difference between the groups in 3rd month after treatment (p0.05).This study showed significant decreases in headache parameters in both groups. As GON blocks were performed in patients unresponsive to medical prophylaxis, a decrease in the headache parameters in Group PGON similar to that in Group GON can be attributed to GON blocks. Consequently, these results show that repeated GON blocks with local anesthetic can be an effective alternative treatment in migraine patients who are unresponsive to medical prophylaxis or who do not prefer to use medical prophylaxis.

Objective: To determine whether two types of exercise — breathing retraining (BRT) and inspiratory muscle training (IMT) — improve on cardiopulmonary functions and exercise tolerance in patients with stroke.Design: A randomized controlled trial.Setting: Education and research hospital.Subjects: Forty-five inpatients with stroke (24 men, 21 women) were recruited for the study. The subjects were randomized into three groups: 15 assigned to receive inspiratory muscle training (IMT); 15 assigned to received breathing retraining, diaphragmatic breathing and pursed-lips breathing (BRT); 15 assigned to a control group.Interventions: All study groups participated in a conventional stroke rehabilitation programme. For the same period, the IMT and BRT groups trained daily, six times a week, with each session consisting of one half-hour of training for six weeks.Main measures: Each subject underwent pulmonary function and cardiopulmonary exercise tests. Subjects were also assessed for exertional dyspnoea, stages of motor recovery, ambulation status, activity of daily living and quality of life.Results: After the training programme, the IMT group had significantly improved forced expiratory volume at 1 second (FEV1), forced vital capacity (FVC), vital capacity (VC), forced expiratory flow rate 25—75% (FEF 25—75%) and maximum voluntary ventilation (MVV) values compared with the BRT and control groups, although there were no significant differences between the BRT and control groups (P2peak) than the BRT and control groups, although there were no significant differences between the BRT and control groups (Pmax) and maximum inspiratory and expiratory pressure (PEmax) in the BRT group and, PImaxin the IMT group compared with baseline and the control group. In the IMT group, this was associated with improvements in exercise capacity, sensation of dyspnoea and quality of life.Conclusions: Significant short-term effects of the respiratory muscle training programme on respiratory muscle function, exercise capacity and quality of life were recorded in this study.

Brucellosis is a common infectious disease in Mediterranean countries. We evaluated the peripheral nerve involvement in patients with brucellosis. Thirty-eight patients with brucellosis were examined. Four of them were excluded because of B12 deficiency and diabetes mellitus. Thirty-four patients were included. The average age was 43.08 ± 15.3 years. Patients were divided into two groups according to the abnormality in their peripheral nervous system (PNS) examination. All patients underwent nerve conduction and needle electromyography EMG studies. Twenty normal healthy subjects were used as a control group. Axonal sensorimotor neuropathy was determined in 12 patients who also had abnormality in PNS examination. After 6 months of treatment, nerve conduction studies were nearly normal in these patients. The EMG findings of the remaining 22 patients were normal, as well as the clinical examination. However, the motor conduction velocities of median (p < 0.001), peroneal (p < 0.001), and ulnar (p < 0.05) nerves were decreased, F wave latencies were prolonged in the posterior tibial and peroneal nerve, and distal latency was also prolonged in the posterior tibial nerve (p < 0.05) when compared to healthy subjects. Sensory conduction velocities of the median (p < 0.001), ulnar and sural (p < 0.05) nerve were also decreased. Brucellosis may be considered as a cause of clinical or subclinical peripheral neuropathy and should be evaluated especially in endemic areas.

Background: Increased nitric oxide (NO) production may result in further brain damage via nitric oxide synthase uncoupling in patients with acute ischaemic stroke by increasing free radical formation and oxidative stress. In this connection, we measured nitrite and nitrate (NO metabolites), ischaemia-modified albumin (IMA) and thiobarbituric acid-reactive substances (TBARS) in patients with ischaemic stroke. Methods: We studied 41 patients with ischaemic stroke (22 men and 19 women, aged 65-13 years) and 37 age- and sex-matched controls (22 men and 15 women, aged 65-8 years). Blood samples were drawn within the first 24 h from the onset of symptoms in the patient group. Fasting morning samples were used in the control group. Concentrations of nitrite and nitrate were determined by Griess reagent; concentrations of IMA were determined by the albumin cobalt-binding test; and concentrations of TBARS were determined colorimetrically by thiobarbituric acid. Results: Nitrate, IMA and TBARS concentrations were significantly increased compared with controls ( P Conclusions: Patients with acute ischaemic stroke exhibit abnormalities in a range of markers of increased nitrosative and oxidative stress. These abnormalities may contribute to greater brain damage in patients with acute ischaemic stress.

Some patients with headache report that they have frequently used physical therapies such as application of cold to relieve their headache. There are only a few reported studies related to cold therapies in patients with migraine. In this study, we investigated the effect of cold application on migraine patients. Twenty-eight migraine patients were included. Cold therapy was administered to them by gel cap. Patients used this cap during their two migraine attacks. Before and after the cold therapy, headache severity was recorded by using visual analogue scale (VAS). Patients used this cap for 25 min in each application. They recorded their VAS score just after the therapy and 25 min, 1 h, 2 h and 3 h later. Two patients could not use this therapy due to side effects (one due to cold intolerance and one due to vertigo) in both applications. Therefore, therapeutic efficacy was evaluated in 26 patients. Twenty-five minutes after treatment of the first attack, VAS score was decreased from 7.89 ± 1.93 to 5.54 ± 2.96 (P< 0.01). Twenty-five minutes after treatment of the second attack, VAS score was decreased from 7.7 ± 1.8 to 5.4 ± 3.55 (P< 0.01). Cold application alone may be effective in some patients suffering from migraine attacks. Its combination with conventional drugs should be investigated in future studies.

Pathogenesis of leukoaraiosis (LA) is not clearly understood and its significance in patients with stroke remains undetermined. In the Neurol­ogy Department of Ankara Hospital, computed tomography (CT) examination of brain was performed for various reasons in 288 patients. LA was detected in 178 patients by the use of brain CT. Patients with LA had a higher incidence of hypertension history (70.8%) when compared with the non-LA group (57.3%; p

Hemicrania continua (HC) is a rare primary headache disorder. It presents some autonomic features (including conjunctival injection, ptosis, eyelid edema, lacrimation, nasal congestion, and rhinorrhea). Response to indomethacin treatment is the mandatory criteria for the diagnosis of HC. However, previously reported literature indicates that there are some reported cases that did not respond to indomethacin. In this case report, we present a patient who had indomethacin resistance with an associated pregabalin response. Pregabalin may be an effective treatment for hemicrania continua in some patients with indomethacin resistance.

Objective: Headache is a health problem which is a prevalent, disabling condition affecting people in all age groups. In this study, we evaluated headache characteristics and associated factors of patients in our headache center. Method: In this study,we retrospectively investigated the file records of 500 patients followed up between 1994-1997 in our headache center. Demographical data and other information about headache of all patients were evaluated in the file records. Results: .Mean age was 33,5±10,1 years in patients.47,4% of patients had migraine type headache. Other primary headache types were tension type headache, drug overuse headache and trigeminal autonomic cephalalgias, retrospectively. We investigated characteristics of pain, treatment schedules and their responses in all headache types. Conclusion: Headache is one of the most frequent health problem in the general population and it may cause disability. Among patients submitted to the our headache center, half of them had migraine type headache. However, we found that some patients had a wrong diagnosis in their initial assessments. This results, suggest that special headache centers are required for headache patients.

Migraine patients have an increased risk to develop deep white matter hyperintensities (WMH) than the general population. Oxidative stress is believed to play a role in the pathogenesis of migraine. The present study was undertaken to assess oxidant/antioxidant balance of migraineurs with and without WMH. We hypothesized that increased oxidative stress and decreased antioxidant response may play a role in the pathophysiology of WMH in migraineurs. The study included 32 patients in the migraine group and 17 age- and sex-matched healthy subjects without headache in the control group. The migraine group comprised 18 with WMH and 14 without WMH. We evaluated oxidative status with malondialdehyde (MDA) and to determine the activities of antioxidant enzymes: superoxide dismutase, glutathione peroxidase and catalase (CAT) in serum of migraineurs and controls. Comparison of the patient and control groups for oxidative parameters revealed significantly lower level of CAT and higher level of MDA in the patient group. Two-way comparison for CAT and MDA of the migraine with and without WMH and the controls revealed that CAT serum level significantly decreased in migraine patients with WMH than migraine patients without WMH and controls. In this preliminary study, we demonstrated that the levels of CAT were decreased in migraine patients with WMH compared to patients without WMH and controls. These findings suggest that decreased antioxidant response may play a role in the pathophysiology of WMH in migraineurs. Besides, our results encourage the new treatment and follow-up options based on antioxidant systems.

Objective: Systemic lupus erythematosus (SLE) with leptomeningeal involvement is a rare condition. We report a case in a 17-year-old woman. Clinical Presentation and Intervention: The patient was admitted to hospital with the complaints of vertigo, nausea, vomiting, headache, diplopia, ptosis on the left and weakness of the left leg. A diagnosis of SLE was established, with diffuse leptomeningeal involvement demonstrated by cranial magnetic resonance imaging. When treated with steroids, the clinical problems resolved almost completely. Conclusions: Although rare, leptomeningeal involvement can complicate SLE. Cranial magnetic imaging can demonstrate tissue involvement. The condition responds to steroid therapy.

Background Anxiety disorders are common and are frequently not diagnosed accurately in primary care. Our aim was to determine the knowledge gaps of general practitioners (GPs) in the diagnosis and treatment of anxiety disorders by using vignettes. Methods A cross-sectional survey was completed with 255 primary care physicians (response rate 59.4%) in Manisa, a city in western Turkey. From the postal questionnaire, information on working experience, postgraduate education in psychiatry, the interests of the physicians in psychiatry were obtained. The physicians' diagnosis and treatment preferences for generalized anxiety disorder (GAD), social phobia (SP), and obsessive compulsive disorder (OCD) were determined through clinical vignettes prepared for data collection. Results Two hundred and twenty-seven (89.0%) out of 255 GPs included the diagnosis of obsessive compulsive disorder in their differential diagnosis; however, the rates for social phobia and generalized anxiety disorder were 69.4% (n = 177) and 22.3% (n = 57), respectively. GPs with a post-graduate education on psychiatry diagnosed vignettes more accurately for OCD (p = 0.04). For all three cases, GPs mostly preferred a combination therapy including psychotherapy and psycho-pharmacotherapy. The referral rate to a psychiatrist was between 23.1 and 30.6%. The percentages of the prescription of selective serotonin reuptake inhibitors (SSRI) in accurate diagnosis were 59.3 for social phobia, 33.3 for GAD, and 55.5 for OCD. Conclusions There is a gap of knowledge in GPs, which leads to poor recognition and management of anxiety disorders in primary care. Effective interventions including post-graduate education and updated guidelines on anxiety disorders should be planned and implemented with their assessments by vignettes.

Primary headaches are known to be associated with multiple sclerosis. We aimed to determine headaches using ICHD-II in different phases of relapsing-remitting multiple sclerosis, and the correlation between headaches and several features of the disease.Migraine (41.2%) and tension-type headaches (20.6%) were the most common headaches in remission, and primary stabbing headache (PSH) (27.8%) was common in the relapsing phase. Although headaches seemed to occur independently of disease duration, extended disability status scale, beck depression inventory scores, and treatments, the total number of headaches was correlated with periventricular lesions (P = 0.03) and tension-type headaches were correlated with spinal lesions in remission (P = 0.02). Total number of headaches was correlated with brain stem lesions in the relapsing phase (P = 0.05).The high frequency of PSHs in relapse was notable, and, to the best of our knowledge, PSH was not reported in relapsing-remitting multiple sclerosis before. Further studies with larger samples are recommended.

Objectives Vitamin B-12 and folate deficiency are common, especially in people aged 55 or over, and accompanied by elevated methylmalonic acid (MMA) and homocysteine concentrations. The aims of the study were to investigate the relationship between serum vitamin B-12, homocysteine, folate, erythrocyte folate and urinary MMA in patients with ischemic stroke, and to develop a simple screening HPLC method for the measurement of urinary MMA. Design and methods Twenty-eight patients aged 55 years and over with ischemic stroke and 23 age- and sex- matched healthy controls were included in the study. Serum vitamin B-12 and folate were measured by immunoassay; serum total homocysteine and urinary MMA concentrations by HPLC. Results There was no significant difference in vitamin B-12, folate and homocysteine concentrations between the patient and control groups. Urinary MMA concentrations and erythrocyte folate levels were significantly higher in patients than controls. There was a significantly negative correlation between vitamin B-12 and MMA. Conclusions Increased urinary MMA excretion is associated with ischemic stroke and it may more robustly reflect vitamin B-12 deficiency in patients with ischemic stroke. The method used in this study is eligible for routine urinary MMA measurements.

This study was performed to investigate the differences in response to botulinum toxin treatment between patients with idiopathic versus neurovascular hemifacial spasm. A total of 69 patients with hemifacial spasm were investigated prospectively with cranial magnetic resonance imaging and magnetic resonance angiography. Neurovascular contact was found in 23 patients. All patients were assessed with a severity scale and a disease awareness scale. After treatment, the patients with idiopathic hemifacial spasm improved significantly in terms of both severity and awareness scores, but the patients with neurovascular hemifacial spasm improved only in the awareness scores. In conclusion, patients with idiopathic hemifacial spasm experienced a greater improvement after treatment with botulinum toxin than did patients with neurovascular hemifacial spasm.

We have tested Turkish version of the Migraine Disability Assessment (MIDAS) questionnaire in patients with tension type headache. Thirty-two patients who had a tension type headache were included. Turkish version of the MIDAS questionnaire was applied to all patients. Additionally, the patients were asked to keep a 90-day diary. The day diary and the MIDAS questionnaire were compared at the end of the study period. We found that cronbach's alpha 0.82 and had good reliability. Our findings suggest that the MIDAS questionnaire that was originally designed for patients with migraine may be used in patients with chronic tension type headache.

Discontinuation of medication is the treatment of choice for patients with chronic daily headache (CDH) who overuse their medications. This treatment may be difficult due to increased headache severity observed in patients immediately after withdrawal. We retrospectively evaluated the efficacy of valproic acid therapy in 66 patients with overuse of CDH medication during withdrawal therapy. Patients were all withdrawn from medications and valproic acid started at 250 mg or 500 mg daily. Forty-two (63.6%) patients had decreased headache severity, including 27.3% objective responses in the first week. At the last visit in the 12th week, 50 patients were headache-free and only one patient had persistent headache. Fifteen patients withdrew from therapy due to side effects and lost to follow-up within this timeframe. Thus, low dose valproic acid appears to be safe and effective in the management of withdrawal therapy.

The Migraine Disability Assessment (MIDAS) questionnaire is a brief, self-administered questionnaire which is designed to quantify headache-related disability in a 3-month period. We have tested a Turkish version of the MIDAS questionnaire in 60 migraine patients. Sixty of the clinically diagnosed migraine headache sufferers were enrolled in a 90-day diary study and completed the MIDAS questionnaire in the first, 21st and the last day of the 90-day study. The scores taken from the diary and the scores of the MIDAS taken at different times were evaluated by the correlation tests of both Pearson and Spearman for each question and total scores. Cronbach's scores taken from the diary and taken from the test of the MIDAS which was applied at different times were evaluated. Pearson's correlation on the responses in the initial MIDAS questions was between 0.44 (reduced productivity in household chores) and 0.78 (missed work or school days). The correlation of the Spearman was similar to the Pearson values. As a result, we found that the overall score of the MIDAS has a good reliability and its internal consistency is also good (Cronbach's α 0.87). These findings support the use of the MIDAS questionnaire as a clinical and research tool on Turkish patients.

This study investigated the changes in brainstem auditory evoked potentials (BAEPs) in acute phase of brucellosis. Twenty-two patients with brucellosis without neurologic involvement and seven patients with neurobrucellosis were included. BAEPs were evaluated before treatment. No patient had a symptom of hearing loss. Patients who had neurologic involvement did not show any abnormalities in their BAEPs recording. This study suggests that patients with brucellosis who are in the acute phase of the disease with or without neurological involvement may have normal BAEPs. BAEPs do not seem to be a sensitive method for central nervous system involvement of brucella patients in the acute phase of the disease.

Cervicogenic headache (CH) is a syndrome which is postulated to originate from nociceptive structures in the neck or head. The anatomical neck or head structures that are responsible for the pain in CH have not been clearly identified, but the pain in these patients probably originates from the structures of the cervical spine. In this study, cervical MRI were studied in 22 patients with cervicogenic headache and 20 control patients who did not have any disease which may effect the bone and muscle structures of cervical region. MRI imaging of cervical vertebra showed a disc bulging in 10 (45.4%) out of 22 patients with CH and in 9 (45.0%) of 20 controls ( P > 0.05). The distribution of pathological lesions in patients and controls were not significantly different ( P > 0.05). As a result, MRI may not be an adequate method to detect pathological findings underlying the aetiology of CH such as nerve roots, intervertebral joints and periosteum.

Treatment of malignant gliomas has changed substantially over the last few years. An oral alkylating agent, temozolomide, has become the standard agent for glioma management. Although it is generally well tolerated, it can cause lymphopenia and may lead to opportunistic infections. We report on a patient with malignant glioma who developed opportunistic cytomegalovirus (CMV) pneumonia following the termination of temozolomide therapy. The patient was admitted with acute dyspnea, fever and hypoxia, and she was diagnosed with CMV pneumonitis using a PCR-based CMV-DNA analysis. After treatment with ganciclovir, she recovered dramatically. To our knowledge, although there have been reported cases of Pneumocystis carinii infection associated with temozolomide therapy, there has only been one other case of CMV infection. We also review this report.