·         May 20, a total of 1500 political prisoners, from 41 different prisons of various provinces of the country started the HS.

·         July 3, on the 45^th day, the strike was terminated, excluding 220 of them, who remained to carry it on as a “death fasting” (Group 1). 

·         HS is ingesting water, salt and lemonade (or linden tea), “death fasting” is limiting daily intake to only 4 glasses of water and salt. 

·         July  16 and 23, a further 111 people, who were from the original 1500, joined the death fasters (Groups 2 and 3).  

·         July 27, on the 69^th day, an agreement was reached and the strike was ended for the entire participants.

·         The first death occurred on the 61^st and the last one on the last day, making up a total of 12 deaths (11M, 1F), all from the Group 1.

Hunger strikers (n=1500)

®

DEATH

Group I: Starts death fasting on the 45^th day of HS, up until 69^th day.

(n=220)

¯

First phase as HS  ends after 45 days

(n=1169)

FAST

ING

Groups II & III: Terminate HS on 45^th day and after an interval of 13 days for Group II and 20 days for Group III, start death fasting for an additional 12 and 5 days, respectively.

(n=111)

¯

All the groups terminate death fasting on the 69^th day.  Group I sufferred 12 deaths

(n=331-12)

·         We have admitted a total of 18 patients (3F, 15M) within the first four weeks, starting right after the termination of the HS.

·         16 were from Group 1, one from Group 2, and one had only 39-day history of HS, who upon becoming comatose, had been refed with I.V. glucose, and had become severely amnestic after regaining consciousness.

·         14 of the referrals were from Istanbul Bayrampaşa Prison (IBP) which hosted the largest number of strikers (30.9% of Group 1 and 33.3% of the deaths).  One had already been released and the remaining 3 were from the other two prisons in Istanbul.

·         17 of 18 admitted patients returned to prison, after 3 to 6 week-hospital stay. One more was released later.

·         Via a special access privilege into IBP, we were able to follow up our patients in the prison and had the opportunity to examine the rest of the 60 remaining Group 1 strikers.

TABLE 1 : CONSTITUTIONAL PARAMETERS (n=18)

Range (Mean)

Age

23 - 50 (29.9)

Height (cm)

158 - 186 (171.5)

Pre-HS weight (kg)

50 - 105 (69.6)

Post-HS weight (kg)

36 -74 (47.7)

Weight loss (kg)

11 - 31 (21.8)

Post-HS BMI[1](kg/m²)

11.8 - 18.4 (16.5)[2]

Deaths

4 (6.25%)

Wernicke-Korsakoff’s

6 (9.37%)

Pure Wernicke’s

33 (51.5%)

Unaffected by W-K

21 (32.8%)

Total

64 (100%)

Main symptoms during the period of starvation

·         Fatigue, weakness, being bedridden mostly after 60th day.

·         Clouding of consciousness

·         Paresthesiae, ‘loss of sensation’, pains and cramps throughout the body.

·         Faintness and syncope in the upright posture.

·         Vomiting, persistent hiccup.

·         Hypersensitivity to light, sound and odors.

·         Decreased vision, double vision.

·         Nocturnal blindness.

·         Tinnitus, hearing loss.

·         Occipital neuralgia-like headache.

SYMPTOMS & SIGNS

INITIAL

# patients

(n=18)

1^ST YEAR

# patients

(n=18)

Altered consciousness (mild confusion to somnolence-stupor)

12

0

Korsakoff-like amnesia

10

10

Apathy

Euphoria, childish behavior

Depression and psychotic behavior

Anxiety Disorder

5

3

2

1

6

0

2

0

Nutritional amblyopia

Decreased vision, pale or blurred optic discs

Retinal hemorrhages

Xerophtalmia

Nocturnal blindness

Conjunctivitis

9

2

3

2

0

0

0

0

Hypersensitivity to environmental noise

Tinnitus, decreased hearing

Positional vertigo

16

3

2

0

0

0

Horizontal nystagmus

Vertical nystagmus

18

8

18

2

Ophthalmoparesis

12

0

Trunkal ataxia

Limb ataxia

18

4

10

5

Muscle wasting

Muscle weakness

10

5

0

0

Decreased tendon reflexes

5

0

Decreased vibration sensation

Altered position sensation

6

1

0

0

·         Thiamin replacement was started immediately, along with A, E and B complex vitamins.  Initial refeeding was done via total parental nutrition (TPN), for those whose BMI's were lower than 16.

·         Primary sensory problems cleared rapidly, from days to weeks;  although, they were as severe as virtual blindness in some.  Vestibular symptoms were rarer, but most resistant among them.

·         Muscle  bulk returned to normal, as the patients started to gain weight.

·         All of them showed trunkal ataxia and horizontal nystagmus; accompanied by conjugate gaze or ocular palsies in 12/18. 

?Wernicke's Encephalopathy

·         9/10 patients who were stuporous initially, developed a recent memory deficit accompanied by a varying degrees of retrograde amnesia, as their consciousness cleared within days to weeks.

?Wernicke-Korsakoff's Disease

·         Remaining 8 patients, 2 of whom were confused initially, did not become amnestic and were classified as Pure Wernicke's.

·         Two from the W-K group had psychotic depression initially, and were treated with anti-depressives and one with neuroleptics and ECT.  They improved into an apathetic and amnestic state within 3 months.  Another two, who were pure amnestic initially, developed severe psychiatric pictures after 3 months.  One had a resistant psychotic depression with bipolar features; the other had a delusional disorder.

·         Two from the pure W group and another pure W, not included in the group from the prison, after considerable improvement, showed worsening between 3 to 6^th months post-HS.  Trunkal ataxia became more marked (mild to moderate) in all, dysarthria and limb ataxia were added in two.  They resumed improvement after 9th month, but with a somewhat slower pace.