Neurology Congress

Abstracts and lectures

L01 - Multiple sclerosis and its treatment: Lessons from history, literature, and science

McDonald I

Queen Square, London, United Kingdom

Abstract not received.

L02 - The prognosis after an optic neuritis

Fredriksen J

Dept. of Neurology, University Hospital Glostrup, Denmark

Abstract not received.

L03 - Prognostic Possibilities in Multiple Sclerosis (MS)

Fredrikson S

Division of Neurology, Neurotec, Karolinska Institutet, Huddinge University Hospital, Stockholm, Sweden

One major challenge to all clinical neurologists is to predict the course of multiple sclerosis (MS) in the individual patient. The course of MS in the individual patient has by many neurologists been considered as unpredictable. There are, however, several reasons why studies of prognostic "markers" and the natural course of MS are important, for example (1) to identify patients who are at risk of developing severe disability and to select patients possibly suitable for treatment attempts; (2) to establish what is the normal evolution of the disease as a comparison to what is found in patients using long term disease-modifying treatments; (3) to delineate the clinical heterogeneity of patients with MS into more homogenous categories which may increase our understanding of possible pathogenetic mechanisms operating in various clinical phenotypes; and (4) to improve our prognostic ability and thus improve medical advice in clinical practice. Studies of the natural course of the disease have been performed over many years and different patterns have appeared. This presentation will review some clinical characteristics possibly reflecting both the inflammatory and degenerative aspects of MS, as well as findings on magnetic resonance imaging (MRI) of the brain, that may improve our prognostic possibilities in MS.

L04 - Cognitive aspects in MS

Hämäläinen P

Masku Neurological Rehabilitation Centre, Masku, Finland

Cognitive problems are commonly reported by MS patients. Both temporary and more permanent cognitive deficits are known to be related to MS. Temporary deficits are possible as a consequence of relapses, depression or fatigue. Permanent changes are thought to be associated with both subcortical and cortical changes in the Central Nervous System. Different kinds of neuropathological alterations are supposed to affect cognition in approximately 50% of patients.

The most vulnerable cognitive areas are reported to be memory, complex attention and information processing as well as executive functions, whereas, for example, language problems are supposed to be more infrequent. It is also known that dementia typical for diseases with more widespread cortical pathology is relatively rare in MS. However, in MS, no single profile of cognitive impairments can be observed. Instead, cognitive problems are heterogeneous and highly individual. Therefore, cognitive problems associated with MS cannot be adequately described by the term subcortical dementia. In clinical practise, the profile of cognitive impairments can be determined only by an individual assessment.

As other MS symptoms, also cognitive deficits are difficult to predict. Cognitive problems can be among the first symptoms of the disease. No clear relationship between cognitive impairments and disease duration, course of disease or physical disability as measured with the EDSS exists. Instead, the correlation between the range of cognitive deficits and lesion burden measured with MRI techniques is at least moderate. Positive correlations have been reported also between cognitive impairments and metabolic changes observed in PET studies and electrical changes observed in event related potential studies. The natural history of cognitive impairments is not well understood - longitudinal studies are few in number and the results are partly contradictory. However, our three year follow-up study demonstrated that determined cognitive decline frequently predicts further deterioration. In line with these findings are also the results of a recent ten year follow-up study.

Even mild cognitive impairments affect patients' everyday life. Cognitive deficits have been observed to have an effect on personal competence and self-esteem as well as on employment and ability to take care of social relations. Cognitive problems have also been shown to affect rehabilitation outcome. Therefore, methods to alleviate the effects of cognitive impairments are needed. Experiments with medications and rehabilitation have shown both positive and negative results. Disease modifying drugs have shown promise in slowing down both the occurrence and further progress of cognitive decline. However, these effects have been demonstrated only in certain patient samples. Also well-planned rehabilitation programs have been shown to be effective in decreasing certain types of cognitive impairments or in alleviating the effects of cognitive problems in patients' everyday life. In the present presentation, the frequency, characteristics, heterogeneity, natural history and treatment methods of cognitive impairments in MS are discussed.

Key features of cognitive decline in MS

o about 50% of MS patients have cognitive problems

o many aspects of cognition are vulnerable

o no single pattern of cognitive deficits can be identified

o defined cognitive decline predicts further deterioration

o cognitive deficits can be the first symptom of MS

o severely physically handicapped MS patient can be cognitively normal

o cognitive problems call for individual diagnostics and rehabilitation

A model for alleviating the effects of cognitive problems in MS

o information about cognitive deficits in MS

o neuropsychological assessment

o evaluation of the characteristics of cognitive decline

o feedback of cognitive strengths and weaknesses

o ways to use individual strengths effectively

o possible compensatory strategies

o sharing experiences with other patients with cognitive problems

o supporting the nearest ones

L05 - Cortical pathology in multiple sclerosis

Bø L

Department of Neurology, Haukeland Hospital, Bergen, Norway

Previous studies indicate that cortical plaques may constitute a significant proportion of multiple sclerosis (MS) lesions in the brain. In a systematic immunohistochemical autopsy study of 4 different brain regions in MS we found that the percentage demyelinated area was significantly higher in the cerebral cortex than in subcortical white matter. Five of 20 MS brains contained extensive subpial demyelination in all areas studied, indicating a general subpial demyelination. Purely cortical lesions accounted for 85,6% of the total demyelinated area in cerebral cortex. We have found that the number of T cells detected in intracortical demyelinated lesions is low, and equal to in nondemyelinated cerebral cortex in MS patients and in controls. In a recent study transected neurites were detected in cortical lesions, although at lower density than in white matter lesions in the same MS patients. Apoptotic neurons were significantly increased in demyelinated cortex compared to in myelinated cortex. The data of these and previous studies indicate that the cerebral cortex is a predilection site for MS lesions, and that the pathogenesis of demyelination within different regions of the brain may be heterogeneous. Cortical lesions may contribute to the sensory and motor deficits of MS, as well as to cognitive impairment and epilepsy.

L06 - Scandinavian Co-Operation between Neurologic Nurses

Jämsä T

Nursing Officer, Oulu University Hospital, Finland

I am very happy that Iceland and Ingibjörk Kolbeins with her co-workers have arranged this Second Scandinavian Congress of Neurological Nursing.

I will first tell you briefly about the organization of public health care in Finland and then describe the questionnaire survey I carried out among the nursing officers and ward nurses in the clinics of neurology of Finnish university hospitals. The topic of the questionnaire was Scandinavian co-operation. Finally, I will suggest some ways in which we could promote Scandinavian co-operation in the future.

In Finland, public health has been organized at three levels - primary health care (health centres operated by municipalities or intermunicipal boards), regional and central hospitals and university hospitals. Only university hospitals have separate outpatient clinics and one or two inpatient wards for neurologic patients. The nurses working in central hospitals and health centres have to concentrate on many patient groups apart from neurologic patients.

Being a nursing officer in a university hospital, I also feel concern for the ability of nurses in primary health care to take care of neurologic patients. I hope that all nurses providing care to neurologic patients would be able, if they so wish, to participate in Scandinavian co-operation.

I presented a questionnaire to the nursing officers and head nurses (N=23) working in clinics of neurology in the Finnish university hospitals (5) concerning Scandinavian co-operation in February 2002. The respondents had a long experience as nursing officers. All of them considered Scandinavian co-operation either extremely important or important. Despite this, few are engaged in such co-operation at the present.

How would Scandinavian co-operation between neurologic nurses affect the quality of life of neurologic patients? Culture and living conditions are notably similar in the Scandinavian countries. The countries also share the public demand for cost efficiency and efficacy of health care. Exchange of knowledge concerning new and different nursing practices in Scandinavian educational programmes would improve the quality or neurologic nursing. Scandinavian research projects in nursing science would be both extensive and interesting. The results of research and development projects could be presented in Scandinavian educational programmes. We could even outline disease-specific nursing recommendations for Scandinavian nurses to facilitate their work.

Neurologic patient organizations are engaged in Scandinavian co-operation. The Parkinson Association, for example, arranges Scandinavian meetings and facilitates exchange of patient education materials.

What does Scandinavian co-operation mean for neurologic nurses? The following things were considered important: professional growth, exchange of information, increasing internationalization and improvement of language skills. The high cost of travelling to international congresses was considered a problem. The nurse associations specializing in certain neurologic diseases co-operate at the international level.

The First Scandinavian Congress of Neurological Nursing was arranged in Oulu, Finland, in June 1998. We had lecturers from Norway, Sweden and Finland in that congress. My aim was to recruit lecturers from each Scandinavian country. Altogether 122 nurses participated. The participants came from Sweden (12), Norway (15), Denmark (8) and Finland (87). They expressed their hope to have such congresses arranged at regular intervals.

It is obvious that we need Scandinavian co-operation. It should be systematic and organized rather than merely co-operation motivated by interpersonal contacts. I sincerely hope that Scandinavian Congresses of Neurological Nursing would continue to be arranged regularly and, whenever possible, concurrently with congresses of neurologists. This would help to enhance co-operation between nurses and medical specialists. The organization of a congress requires a lot of work. To facilitate this work, I suggest that a Scandinavian co-operative committee should be set up, which could decide about the topics of the each congress, help to invite the lecturers and co-ordinate the presentation of research papers. The organizing committee could also help to co-ordinate Scandinavian research in nursing science.

L07 - Quality of life in Parkinson's disease

Hagell P

Section of Restorative Neurology, Dept. of Clinical Neuroscience, University Hospital, Lund, Sweden

Quality of life (QoL) has a long history; it has been debated for centuries and under scientific scrutiny for decades. In terms of the impact of ill health on people's QoL, measurement attempts have typically been made using the health-related QoL (HRQoL) approach. The term HRQoL has largely come to substitute what earlier was described as health status, and the two are typically considered equivalent. Health status is, however, conceptually preferred and will be used here. Health status questionnaires can be divided into generic and disease-specific. Generic questionnaires have been developed for use among a wide range of patient populations, whereas disease-specific ones are targeted to particular disorders. In Parkinson's disease (PD), the PDQ-39 is the most widely used disease-specific questionnaire. The NHP, SIP, and SF-36 are the most commonly used generic questionnaires in PD.

Researchers have recently begun attempting to address what factors contribute to QoL in PD. Studies indicate that depression is a major contributor, whereas severity of the underlying parkinsonism contributes only to a minor extent. However, these studies have all operationalized QoL as health status and used very similar sets of independent variables. Other investigators, using patients' perceived overall QoL as the dependent variable and a broader set of independent variables, have presented different results. Thus, various personality characteristics have been found to be of importance for perceived QoL in PD patients, whereas depression only has contributed to a minor extent. In a recent cross-sectional Swedish study, generic and disease-specific health status questionnaires showed only modest to moderate correlations with patients' perceived overall QoL, similar to that of indices of PD severity, whereas illness-related distress correlated stronger. In an explorative re-analysis of these data, a forward stepwise multiple regression analysis was performed, with varying operationalizations (perceived overall QoL, PDQ-39 summary index, and illness-related distress) of the dependent variable (DV), i.e., QoL, and using indices of PD severity, PDQ-39 and NHP subscales, and perceived overall QoL (when not used as DV) as independent variables (IVs). Results show that the IVs making significant contributions to the models differ according to choice of DV, with the amount of variance explained ranging between 57% and 87%. Results illustrate that outcomes are related to study design and choice of variables. Investigators should provide clear definitions, rationales and conceptual theory when defining DVs and IVs in QoL studies. Furthermore, these data also illustrate that there is little support for the validity of using health status questionnaires to address QoL issues.

Nevertheless, health status questionnaires are valuable and important in gaining a better understanding of the impact of disease, as they yield information not obtained by clinical assessments. However, to allow for valid conclusions, questionnaires must meet certain criteria regarding, e.g., validity and reliability. We recently assessed various psychometric properties, several not addressed before, of the PDQ-39 and the NHP in a Swedish PD sample. Results indicate that both are in need of further evaluations and developmental work before they can be considered suitable for valid use in PD in their present formats. The PDQ-39 thus exhibited floor effects and suboptimal ability to separate subjects into distinct groups, as well as bias toward the severe end of the health continuum. Non-additivity of item scores and non-linearity of scale scores, along with questionable dimensionality, response category ambiguities, and signs of differential item functioning (DIF), were also observed. The NHP behaved similarly but had more floor effects and poorer ability to separate subjects. However, measurement bias toward the more severe end of the health continuum among patients with non-extreme scores was less pronounced, and there were fewer indications of suspect dimensionality and DIF than in the PDQ-39. These observations illustrate important measurement problems, and underscore the necessity of systematic evaluations of health status questionnaires prior to their use in clinical studies.

Until we have gained a better understanding of "QoL" and until better, more appropriate measurement tools have been devised, valid conclusions regarding the nature of QoL and how it is influenced by various personal, disease, and intervention related factors, are largely prohibited. Attention should be paid to nomenclature and investigators should avoid conclusions beyond what can be supported by scientific data. Furthermore, close attention must be paid to the psychometric properties of measurement tools in order to allow for valid measurement and conclusions. At a time when patient-reported outcomes and evidence-based health care are increasingly emphasized, it is of fundamental importance to emphasize also the need for evidence-based measurement, with demands on measures to meet appropriate psychometric standards.

L08 - Quality of MS-care in Sweden

Myr Å

Dept. of Neurology, Karolinska Hospital, Stockholm, Sweden

A group of neurologist and nurses with special interest in MS and the Swedish society for neurologically disabled decided to investigate important questions if persons with MS are getting the same care such as rehabilitation, immune modulator treatment, support from counsellor. Regardless where in Sweden they live.

A questionnaire with 47 items was constituted covering the most of the aspects of care quality. Nurses in the network where asked to Participate in the survey and 23 centres in for MS-patients in Sweden participated.

The survey was made and the Questionnaire was handed out to patients visiting the various Clinics. Large centres was limited to 100 patients, Smaller centres had one month to complete the survey. The data had been collected (602 Questionnaires) and is presently analysed and will be presented at the conference.

L09 - The Danish Interferon-beta experience

Sørensen PS

Dept. of Neurology, Copenhagen University Hospital, Rigshospitalet, Denmark

Abstract not received.

L10 - Genetics of MS in Iceland

Gulcher J

deCODE genetics, Reykjavík, Iceland

Abstract not received.

L11 - Follow-up on MS patients treated with interferon-beta and the importance of neutralising antibodies.

Myhr K-M

The National Multiple Sclerosis Competence Centre, Department of Neurology, Haukeland Hospital, University of Bergen, Norway

A potential problem with the prolonged clinical use of recombinant human proteins, including the interferons (IFN), is antibody induction. Antibodies have been shown to reduce the effects of IFN-a in viral hepatitis and cancers of the blood or blood-forming organs, in which recurrence of infection or malignant cells in the blood can be accurately measured. The antibodies bind to different epitopes of the interferons, and some of these binding antibodies are neutralising antibodies (NAB), as measured in antiviral neutralisation assays. The prevalence of NAB formation is most likely influenced by intrinsic properties of the IFN preparation, such as different IFN subtypes and their production, purification and storage conditions. The prevalence is also influenced by the treatment regimen, as a high dose gives a lower frequency of NAB than does low-dose injection, and short dose intervals may induce earlier and higher antibody response than long dose intervals. Further, the NAB response is lower after intravenous and intramuscular versus subcutaneous administration. The disease apparently also influences the formation of NAB, as the incidence is lower in cancer patients than in patients with infectious diseases or MS. Some studies have shown that the MHC types and race may be important for inducing IFN antibodies. The assays used for NAB analysis may influence the NAB prevalence, as different levels of sensitivity give different results. The timing of the blood sampling is also important. If blood samples are obtained shortly after the last injection of IFN, a false-negative value may be observed because antibodies may be complexed to the injected IFN. IFN-b is not detectable in serum 24-48 hours after the most recent injection, depending on the type of IFN-b, dosage, route and frequency of administration.

Antibodies to IFN are commonly encountered in IFN-treated MS, and it has been shown that the prevalence of NAB in MS depends on the type of IFN-b and treatment regimen. However, various prevalence rates have been reported from the trials, and the clinical significance is still debated. Nevertheless, the problem seems to be similar to that observed in hepatitis and cancer, as reduced bioavailability and reduced clinical and MRI efficacy has been demonstrated in NAB-positive MS patients.

In patients with treatment failure during IFN-b treatment should be analysed for NAB. Patients that are NAB positive should switch to another immunomodulatory drug like glatiramer acetate (Copaxone®).

L12 - MS in Iceland in the last century with particular emphasis on the natural history

Benedikz JEG

Dept. of Neurology, Landspítali University Hospital Hringbraut, Reykjavík, Iceland

Abstract not received.

L13 - Major Nursing Issues in the Rehabilitation of Stroke Patients

Kirkevold M

Institute of Nursing Science, University of Oslo, Norway

Objective: Summarise results from a series qualitative longitudinal studies focusing on adjustment and QoL following a stroke and discuss major implications for rehabilitation nursing.

Material and Methods: In-depth interviews were conducted with approximately 40 stroke patients during the first year. A field study focused on nursing care provided in a specialised acute stroke unit. Patients were interviewed 3 and 8 times by the same interviewer. The narrative interviews focused on how the stroke impacted on the lives of the patients over time and how the process of adjustment evolved.

Results: The process of adjustment following a stroke is lengthier and more complex than earlier supposed. It proceeds through different phases and varies greatly from patient to patient. It is influenced by age, gender, cultural background and earlier experiences. The adjustment process proceeds through several phases. The patient must adjust both in terms of bodily, existential or biographical and daily life issues. Successful adjustment in terms of these issues are essential for continued quality of life following a stroke.

The field study indicated that caring for stroke patients in the acute phase involves consoling patients and family, conserving energy and functions, interpreting the situation of the patients and the ramifications of the stroke as well as integrating new skills and functions into the daily structures of daily life of the patients and the caring efforts of the staff.

Conclusion: The process of adjusting following a stroke is far reaching. It requires systematic and tailored efforts from nurses and other health professionals in order to foster adjustment and quality of life following the stroke.

L14 - Surviving To Thriving. My Journey As A Stroke Survivor

Johnson J

Nurse consultant, Health Quest, Minneapolis, Minnesota, USA

For most of us who have experienced a stroke, regaining a life of quality is a long and arduous journey. First we have to simply survive the immediate dangers of the stroke. And for the two thirds of us who do remain alive find ourselves faced with perhaps the biggest challenge we have ever know in our lifetime. Surviving is a strong word. It literally means to remain alive, to struggle for existence and to claim life. It implies hard work, determination and strength to get beyond those first critical days when we are under the care of neurology. This concept of surviving carries over to rehabilitation efforts-a further need for hard work and sweat. The word thriving means to move beyond surviving to a life where you prosper, grow rigorously, and/or flourish. To move from surviving to thriving is a process. There is a blending and movement back and forth between these two concepts. It takes a conscious effort on the part of the stroke survivor and all of those who touch and influence their lives in order to move the mode of thriving. This process knows no end-it means that a stroke survivor must set out on a new life journey that requires them to be constantly seeking, persevering and working at living life to its fullest. It requires them to accept that "they cannot control what has happened to them, but they can control their attitude about what has happened".

The process, or formula, for thriving as a survivor can be viewed as analogous to the education process. In school we learn on two levels: in the classroom where we learn from books along with the guidance of teachers, and outside the classroom where we put to practice what we have learned. Teachers are a critical factor in our learning process - they inspire, motivate, and praise our accomplishments. Take this same process and apply it to stroke recovery. We soon discover that we have a lot to learn but are naïve as to how long it will take! We are enrolled in classes for retraining our bodies, rethinking with our minds, and reaffirming our spirit for living. Our teaching team includes all kinds of therapists, nurses, and doctors. Their are also family and friends who learn along with us. Later, we are sent out into the "real world" to practice what we have learned. Hopefully we find new teachers and fellow classmates who reinforce our efforts and value us for who we are.

This presentation will describe the learning process of surviving to thriving based on my perspective as a stroke survivor. My journey of recovery has been paved with years of therapy, retraining, and conquering what seem to be continuous small challenges. On my life's journey I am seeing new vistas, making new friends, and realizing many new opportunities that are enriching me.

L15 - Evidence Based Nursing: Setting out to measure the effects of NDT-nursing in stroke patients

Hafsteinsdóttir Þ, Kappelle LJ, Algra A, Grypdonck M

Division of Nursing Science, University Medical Centrum, Utrecht, The Netherlands

Objective: Neurodevelopmental Treatment (NDT) based on the Bobath principles has widely been implemented into nursing in the western world, while no conclusive s-cientific evidence exists on its effects on the stroke patient. Three outcome studies have been conducted on the subject, showing contradictory findings. NDT-nursing was also implemented on the neurological ward on the University Medical Centrum of Utrecht, thereby confronting the nurses with the question if NDT would lead to improved rehabilitation results for stroke patients. Therefore, in this study we address the question: Does NDT-nursing lead to better functional status and quality of life as compared to non NDT-nursing of hemiplegic stroke patients?

In the design of the study we paid special attention to issues which were covered unsatisfactorily in previous studies, in particular comparability of the two treatment groups and whether NDT-nursing was performed according to generally accepted standards.

Method: In the study a prospective, non-randomised, longitudinal design was used, comparing two groups of patients from 12 hospitals, i.e. six neurological wards using NDT-nursing and six neurological wards not using NDT.

Outcome measures and instruments measured were: Functional status measured with the Modified Barthel Index and the Rankin Scale; Quality of life measured with the MOS SF-36, the SA-SIP and the GSW; depression measured with the CES-D and shoulder-pain measured with a VAS. Measures were taken at admission, discharge, 6 and 12 months after the stroke.

The primary aim of the data analysis is to compare the percentage of patients with poor outcome (Modified Barthel Index<12) at 12 months between the two study groups. The results will be expressed as cumulative incidence ratios with corresponding 95% confidence intervals. Logistic regression will be employed to calculate odds ratios adjusted for incomparability of multiple baseline characteristics simultaneously.

In this study some of the limitations of previous studies were overcome by conducting an intervention check within nursing, measuring the nurses' competency in performing NDT-nursing, and within physiotherapy to find out if and to what extent physiotherapists use NDT in the treatment of stroke patients. Also, the general level of quality of nursing care was measured on the 12 participating wards, to determine if the general quality of nursing care, not related to NDT, would vary between the two groups of wards and if the two groups were comparable.

Results: A total of 326 patients was included in the study.

The intervention check, measuring the nurses' competency in performing NDT-nursing was conducted on the six NDT-wards, with 144 nurses participating, showed that the nurses have the adequate competency to conduct NDT-nursing according to the preset standards. The findings showed the mean score for the six neurological wards to be 195 (70%), varying from 206 (74%) to the lowest score of 181 (65%) of the 280 (100%) possible.

Also, an intervention check was conducted within physiotherapy in the 12 hospitals, consisting of a questionnaire and a case vignette. All physiotherapists (N=38) involved in the treatment of stroke patients took part in this part of the study. The findings showed that, the 79% of the physiotherapists working in the NDT-wards have followed adequate NDT-postgraduate education as opposed to the 21% of the physiotherapists working in non NDT-hospitals.

Measurement of quality of nursing care was conducted in the 12 wards through interviews of both nurses (N=125) and patients (N=71). Analysis of the data showed no differences between the two groups of wards in relation to the general level of quality of nursing care not related to the NDT.

Not all data from the main study have been received. Analysis of baseline data show that for most variables the two groups are comparable, but for a few variables, there are some differences between the groups, which will be adjusted for. The available findings of the analysis for the whole group will be presented.

Conclusion: We will describe the setting up of a study to find an evidence base for NDT-nursing and discuss the challenges of overcoming the limitations of previous studies and of not being able to randomise patients between the study groups. Data collection was not yet complete, hence treatment specific results are not yet available. The findings of the analysis of the available data for the whole group of patients will be presented.

L16 - Health care utilization and medication overuse in migraine

Zwart JA

St. Olav Hospital, Trondheim, Norway

Abstract not received.

L17 - Mechanisms of Migraine

Olesen J

Professor of Neurology, University of Copenhagen, Glostrup Hospital, Dept. of Neurology N01

The etiology of migraine is partly genetic, partly environmental. The genetics of migraine are being dealt with in another contribution at this symposium. Environmental factors can be divided into: a) those that cause the expression of a genetic disposition. b) Those that make migraine worse over a prolonged period of time also called exacerbating factors. c) Factors that precipitate an individual attack.

Recent years have brought at wealth of information about the pathophysiological mechanisms and about the pain sensing apparatus in the head on which these mechanisms play. In migraine with aura evidence continues to increase in favor of cortical spreading depression as the underlying mechanism. Thus, recent MR-BOLD studies have confirmed the previously observed slowly spreading oligemia and reversible, slowly spreading inhibition of cortical activation. Cortical spreading depression phenomenon probably triggers the painful migraine attack via leakage of neurotransmitters and ions from cortical cellular element and subsequent depolarization of perivascular sensory nerve terminals. In migraine without aura there is no evidence of blood flow changes or cortical spreading depression. Here it has been hypothesized that the attack may start in the brain stem where a so-called migraine generator area has been shown. Whether or not these findings hold up, there is little doubt that subsequent nociception (pain triggering) takes place in sensory nerve endings around cranial arteries. These nerve endings are sensitized and there may be sensitization also at higher levels of the neuraxis. The peripheral changes may lead to release of calcitonin gene-related peptide and other peptides and monoamines. CGRP occurs in increased quantity in the external jugular venous blood during a migraine attack. Other messenger molecules that are important include nitric oxide (NO) and 5-hydroxytryptamine (5-HT). The migraine attack can be induced by nitroglycerin, which is a prodrug for NO. Furthermore, an inhibitor of nitric oxide syntase is effective in reducing or curing pain during a spontaneous migraine attack. Infusion of CGRP can cause a migraine attack. The most efficient drugs for migraine are interacting with the 5-HT receptors. The triptans are 5-HT1b/d agonists and highly effective in the treatment of acute migraine attack, while certain prophylactic drugs are 5-HT antagonists probably mainly at the 5-HT2 receptor.

Further studies have clarified the neurobiology of the headache pain pathway. Thus, stimulation of vascular structures such as the superior saggital sinus induces activity in nucleus caudalis of the trigeminal nerve as reflected in C-fos expression. The pharmacology of this first synapse in the trigeminal vascular pain pathway has been extensively described. In recent years, it has also been clearly demonstrated that the sensory affective components of pain may be discriminated at a cortical level. Here PET studies and MR-activation studies have contributed significantly but a more detailed understanding of the role of the hemispheres in headache perception is still to come.

The neurobiological understanding of migraine has thus progressed tremendously. Even more exciting is that: this research has lead to the identification of several new targets for drug development for migraine. The likelihood is overwhelming that our already good therapeutic possibilities will be further enhanced in the near future.

18 - Genetics of migraine

Kallela M, Wessman M

Historical perspective: It has been known for centuries that migraine runs in families and many studies have addressed the inheritance of migraine. Still there is no consensus on the mode of inheritance of the common types of migraine, migraine with and without aura. There are various reasons for this. Firstly, migraine is so prevalent that it might easily occur in several family members just by chance. Secondly, variable definitions of migraine have been used and the diagnostic criteria have changed from time to time. In addition, the family studies are also demanding: all family members should be interviewed directly, migraine with and without aura should be accurately differentiated and population based cohorts should be used instead of clinical patients.

Family studies: Two population based studies have addressed the heredity of migraine using the IHS criteria and making a distinction between migraine with and without aura. Based on these studies, Russell and colleagues concluded that migraine is a hereditary disease, migraine with and without aura are distinct entities, and that migraine with aura is largely or exclusively determined by genetic factors while in migraine without aura also environmental factors are important. It is very likely that a syndrome as diverse as migraine is not inherited in any simple way, and, indeed, segregation studies of migraine have suggested for multifactorial inheritance.

Twin studies: Several twin studies have supported a strong genetic component for migraine. Merikangas reviewed twin studies comparing monozygotic (MZ) and dizygotic (DZ) twins and concluded that about 50% of the predisposition to migraine can be considered hereditary. Table 1 summarises probandwise concordance rates and heritability figures from seven large population based twin studies. In a recent twin study involving MZ and DZ twins raised together and apart Ziegler came up to an estimate of 52%, which is probably the best heritability estimate of migraine to date.

Molecular genetic studies: Recent molecular genetic studies have provided new and important information on migraine pathophysiology. Several chromosomal gene loci relevant to migraine have been identified. Mitochondrial DNA has also been studied.

In 1993 a gene for familial hemiplegic migraine (FHM) was linked to chromosome 19 and in 1996 the first gene for FHM was found. The gene, CACNA1A, codes for a subunit (alfa 1A subunit) of a calcium channel (P/Q type voltage sensitive Ca2+ channel) and this discovery has evolved theories of migraine as a "chanellopathy". Additional linkage of FHM to chromosome 1 has been found by two groups. The gene (or genes) has not yet been identified. There are FHM families not linked to either chromosome 19 or 1 and thus at least a third gene locus exists.

Heterogeneity is also very likely for the more common entities, migraine with and without aura. The female preponderance of migraine could suggest involvement of X-chromosome. Indeed, Nyholt and colleagues have found, in two large multigenerational migraine pedigrees, significant excess allele sharing of Xq in typical familial migraine. Peroutka and colleagues reported overrepresentation of DRD2 IC allele of the D2 dopamine receptor gene (in chromosome 11) among patients with migraine with aura. In Sardinia, Del Zompo and colleagues demonstrated a positive association between allele 1 of the same dopamine receptor gene in migraineurs with both jawning and nausea during attacks. Dopaminergic candidate genes have thus also been in the spotlight. The CACNA1A gene has been connected also to migraine with and without aura in association analyses. Further evidence was demonstrated by Terwindt and colleagues, who found increased allele sharing in the region in affected siblingpairs, especially in pairs with migraine with aura.

Recently even more genomic areas have been studied. Nyholt and colleagues linked typical migraine in an Australian family to chromosome 19p13 with evidence for genetic heterogeneity. An insuline receptor gene on 19p13.3/2 and an endothelin type A receptor gene are among the hot new topics. Lea and collegues have found linkage and association to 1q31 in 83 Australian pedigrees. Most recently, in 50 extensive Finnish migraine families, Wessman and collegues found susceptibility locus for nonhemiplegic migraine with aura on chromosome 4q24. These novel discoveries clearly underly the complexity and heterogeneity of migraine with and without aura.

L19 - Botulinum toxin treatment from the clinician's point of view

Jakobsson F

Dept. of Neurology, Landspítali University Hospital Grensás, Reykjavík, Iceland

Abstract not received.

L20 - Botulinum toxin and hyperhidrosis.

Naver H, Aquilonius S-M

Department of Neuroscience, Neurology, Uppsala University Hospital Sweden

In 1822 Justus Kerner described muscular paralysis as well as anhidrosis in botulism. (Kerners disease). In 1996 treatment of focal hyperhidrosis with botulinum toxin was developed in Uppsala, and since 1997 the therapy has replaced sympathectomy for severe palmar hyperhidrosis. The anhidrotic effect lasts long as compared to the effect on dystonia, side effects are minor and transient. For axillary hyperhidrosis the safety and efficacy of btx has been confirmed in two multicentre double blind placebo controlled studies. Frey syndrome and secondary and primary hyperhidrosis at other locations may be treated with similar good results

Our demonstration that the severely reduced quality of life of hyperhidrotic patients can be restored, that side effects are transient, that the therapy can be performed by nurses, motivates that the therapy should be offered these patients before sympathectomy.

L22 - Epidemiology of epilepsy in Iceland

Ólafsson E

Dept. of Neurology, Landspítali University Hospital Hringbraut, Reykjavík, Iceland

Abstract not received.

L23 - Risk factors for epilepsy

Hauser A

Dept. of Neurology, Columbia University, New York, USA

Abstract not received.

L24 - Living with eating difficulties after stroke. Nursing assessment and interventions.

Jacobsson C

Department of Nursing, Umeå University, Sweden

The need to eat and drink is something we all have in common and this makes food an important element in our lives. Food is consumed not only for the nourishment of the body, but it also nourishes the heart, mind and soul. Food and food habits are integral parts of the culture and an aspect of existence associated with for instance lifestyles. Eating special kinds of food and drinking special kinds of beverages reflect social and cultural identities and are intimately related to concepts of self and identity. Cultural food practices have symbolic meanings that people may use to express themselves and communicate. In general, food and eating are symbols of interpersonal acceptance, friendliness, sociability and communion. The meal is a time to unite in fellowship and create a sense of belonging and it is intimately connected with emotions.

Cultural rules and learnt habits are important for our experience of meaning in eating. When eating with other people, we are required to follow cultural rules about how to behave and to show table manners. Food can be treated as a code, meaning that the messages it encodes will be found in the social relations which are expressed in the social structure. The relationship between cultural pattern and nutrition is central to an understanding of human life. In nursing care, it is therefore important to pay more attention to cultural values and nutrition in recovery from illness as well as the promotion of wellbeing.

Literature about living with stroke indicates that recovery is closely related to activities that matter to the patients and that the patients' life situations are influenced primarily by their own way of dealing with their disabilities. The bodily breakdown may lead to identity confusion, the feeling of unreality and the awareness of a changed role in life. The bodily changes may result in both physical and psychological trauma, which could be best described as personal catastrophes.

Eating difficulty is described as related to chewing, swallowing, loss of lip control, drooling, and leakage of food from the mouth and is of special interest in nursing care. This may have serious physical as well as social consequences and is reported to be stressful and to result in anxiety, shame, loneliness, isolation and lack of appetite. Research findings show that these eating difficulties cause inadequate food intake, aspiration and malnutrition. Malnutrition may negatively affect the potential for functional outcome in the recovery process. In a recent article, the frequency of dysphagia was found to be 40 % among patients with an overall severe stroke. Among persons with stroke under rehabilitation, 80 % were subject to eating difficulties and 52,5% were unable to eat without assistance. It was also concluded that most patients with dysphagia could be identified through systematic interviews and observations of test swallowing. Dysphagia is considered to be only one type of eating difficulty, but also disturbed functions in one arm, perceptual problems, concentration problems as well as confusion and depression may have an impact on eating. These difficulties are of interest when considering the broader concept of 'eating difficulties', and are of importance for nurses in practice who have to make sure that patients eat.

Studies show that eating training can be successful if the training is individualised through an accurate diagnostic procedure. It has been indicated that the efficacy of a training program depends not only on the content of the training program but also on the relationship between patient and trainer. The use of dialogues is suggested as possible means of reaching mutual agreement, taking the patient's individuality and the complex disturbances in motor function into account in order to reach the point where different treatments can be successful in promoting recovery. In my presentation, I will further illuminate experiences of living with eating difficulties among persons with stroke, describe important aspects in assessment (interviews, observations, tests and dialogues), and present examples of individualised interventions based on research in the area.

L25 - To Love and Be Loved. Sexuality, Stroke, and Quality of Life

Johnson J

Nurse consultant, Health Quest, Minneapolis, Minnesota, USA

The majority of stroke survivors live with some form of permanent disability. They often struggle with the many ways their quality of life has been altered by the stroke event. There is difficulty in adjusting to changes in mobility, vocational and social roles. Even when physical recovery is good, psychological recovery is often guarded. Most stroke survivors experience some loss of self, loss of physical and mental functions, loss of work, loss of relationships and an overall sense of loss of control over life. Depression and anxiety are identified as common. There is always a lingering fear of a recurring stroke.

How do these changes affect a person's sexuality? Having a chronic illness, such as a stroke, does not take away a person's desire to love and to be loved. Sexuality involves many levels of activity and behavior starting with self-love (self-esteem and self-image) and expands to include loving others and acts of loving together (intimacy, sexual activity). It is a complex phenomenon, which pervades our biological being, our sense of self and the way in which we relate to each other. During the acute phase of survival, the stroke survivor's anxiety about the outcome of the stroke and fears about functional abilities may well supersede concerns of sexuality. However, once survival is assured, many questions and concerns arise about resuming life and living!!

In 1997 through 2000 an informal survey was conducted with nearly 100 community dwelling stroke survivors and their significant others. Questions were asked relating to changes in their sense of self, their need for intimacy, their sexual practices, etc. Most of the respondents indicated that they would have liked knowing more about potential sexual problems and would have welcomed the opportunity to discuss their personal concerns. Many reported having unanswered questions and yet were hesitant to ask them. Only 2 respondents remember the topic of sexuality ever being discussed by any health care provider at any time in their stroke recovery. It seems clear from these respondents that most health professionals do not discuss sexual concerns and yet it would be welcomed by the stroke survivors and their significant others.

This presentation will expand on the findings in this survey and present the PLISSIT model that is used for helping people express their sexual concerns. StrokeWise, a 16-hour patient education course taught to stroke survivors and family members includes a session on self-esteem and intimacy. The components of this session will be reviewed and participants be given opportunity to consider some of the teaching strategies.

Quality of life, the ultimate goal of stroke rehabilitation services should encompass the sexual concerns of stroke survivors and their significant others. These concerns need to be identified and dealt with through accurate information, counseling, and supportive programs. This domain of care should be embraced as an essential and integral component of rehabilitation.

Doctors platform session

26 - Topiramate treatment of epilepsy in five mentally retarded patients with unilateral mesial temporal sclerosis

Arvio M*, Sillanpää M**

*Pääjärvi Centre for Mentally Retarded, Lammi, Finland, **Departments of Child Neurology and Public Health, Turku University, Finland

Objective: To study the effectiveness of topiramate as an adjunctive drug in temporal lobe epilepsy (TLE), associated with unilateral mesial temporal sclerosis (MTS).

Subjects and methods: Five adults with nonspecific mental retardation, difficult-to-treat TLE since childhood and MTS. Effects of topiramate as an add-on drug on seizure frequency was retrospectively analysed.

Results: On topiramate treatment with clinical daily dosages, two patients became seizure-free. In one patient the seizure reduction was >75%, and in two >50%. A previous antiepileptic theray could be reduced. The patient data are presented in table 1.

Conclusion: Topiramate add-on therapy seems effective and allows reduction of polytherapy in mentally retarded patients with TLE associated with MTS.

27 - Cholinergic system modulates auditory processing in elderly subjects: a combined MEG/EEG-study

Pekkonen E1,2,3, Jääskeläinen IP2, Kaakkola S1, Ahveninen J1,3

1Department of Neurology, Helsinki University Central Hospital, Finland, 2BioMag Laboratory, Medical Engineering Centre, Helsinki University Central Hospital, Finland, 3Cognitive Brain Research Unit, Department of Psychology, University of Helsinki, Finland

Objective: Auditory event-related potential (ERP) components P50 and specifically N100 index preattentive auditory processing underlying stimulus detection. Our previous results indicate that preattentive auditory processing is delayed in aging and in Alzheimer's disease (AD), and that in young subjects it is modulated by scopolamine, a centrally acting cholinergic antagonist. Existing results also suggests that scopolamine administration gives rise to temporary cognitive dysfunction in aged subjects. It has remained unsettled, however, whether scopolamine effects on preattentive auditory processing underlying stimulus detection in elderly subjects.

Material and methods: We measured simultaneously electric and magnetic responses to monaurally presented tones with electroencephalogram and 122-channel whole-head magnetometer from nine non-demented elderly subjects after intravenous injection of scopolamine or glycopyrrolate, which served as a placebo drug being a peripherally acting cholinergic antagonist. A random, cross-over desing was employed and the drugs were administrated using a double blind protocol.

Results: Scopolamine significantly delayed both electric and magnetic P50 and N100 responses, and augmented electric and magnetic P50 responses. In contrast, following electric P200 response was not affected by scopolamine.

Conclusions: Our results indicate that the cholinergic system modulates auditory processing underlying stimulus detection in elderly subjects. Additionally, generators of separate ERP components appear to have different age-related sensitivities to scopolamine administration. Given that preattentive auditory processing is delayed in AD, the combined MEG/EEG measurements could be used to monitor cholinergic cortical activity in aging and in dementia.

28 - The variability of epidermal nerve fiber densities in healthy individuals

Mellgren SI, Göransson L, Omdal R, Skjesol A, Lindal S

Dept. of Neurology, University Hospital of North Norway, Tromsø, Norway

Background: Quantification of epidermal nerve fibers has proved to be a valuable tool in the investigation of small fiber neuropathies.

Objective. To establish epidermal nerve fiber densities in different age groups, search for possible changes with age and comparison of nerve fiber densities in females and males.

Methods: Two 3 mm skin biopsies were obtained with a punch needle ca. 10 cm superior to the lateral malleolus of the right leg of 106 healthy individuals (66 females and 40 males). Fifty micron frozen sections were immunostained with 0.8% rabbit polyclonal antibody to the human peptide protein gene product (PGP) and the number of nerve fibers were recorded as the mean of counts per mm in six sections, three from each of the two biopsies.

Results: The mean number of ENF was 12.4 per mm, median 11.5 (range 4.5-26.5). There was a modest, but signficant decrease of fiber density with age (r=-0.332, p=0.0005). In females the mean density was 13.6 and median 13.6 (5.9-26.5) and in males mean 10.5, median 9.8 (4.5-22.8) (p=0.0005).

Conclusion: There is a considerable variation of epidermal nerve fiber densities in healthy individuals, but we also showed a modest, but significant decrease with age, and that males had lower epidermal nerve fiber density than females. The latter observation may implicate that males are more subjected to factors known to cause peripheral neuropathy. Age and sex differences of normal ranges should be taken into consideration when cut off values of epidermal nerve fiber densities indicating neuropathy are determined.

30 - Olfactory Function in Neurodegenerative Disease

Hawkes C

Oldchurch Hospital, Essex Neuroscience Centre, Romford, United Kingdom

There has been a gradual increase of interest in olfactory dysfunction since it was realised that anosmia was a common feature of idiopathic Parkinson's disease [IPD] and Alzheimer-type dementia [AD]. It is an intriguing possibility that the first sign of a disorder hitherto regarded as one of movement or cognition may be that of disturbed smell sense. In this review of IPD, parkinsonian syndromes, essential tremor, AD, motor neurone disease [MND] and Huntington's chorea [HC] the following observations are made: 1) olfactory dysfunction is frequent and often severe in IPD and AD 2) normal smell sense in IPD is rare and should prompt review of diagnosis unless the patient is female with tremor dominant disease. 3) anosmia in progressive supranuclear palsy and corticobasal degeneration is rare and should likewise provoke diagnostic review. 4) hyposmia is an early feature of IPD and AD and may precede motor and cognitive signs respectively. 5) subjects with anosmia and one ApoE-4 allele have an approximate 5-fold increased risk of later AD. 6) impaired smell sense is seen in some patients at 50% risk of parkinsonism 7) smell testing in HC and MND are not likely to be of clinical value. 8) biopsy of olfactory nasal neurons reveals non-specific changes in IPD and AD and at present will not aid diagnosis.

31 - Epilepsy and driving licence

Brodtkorb E, Bråthen G, Helde G

Dept. of Neurology, St. Olavs Hospital, Trondheim, Norway

Objective: To find out how current regulations are applied in clinical practice in Norway.

Material and methods: A questionnaire was sent to all 344 members of the Norwegian Neurological Association.

Results: Fifty-six percent responded within 3 months. Most responders (152) worked in the field of clinical neurology and filled in the questionnaire. The majority (73%) did not regard reporting a "situation-related" seizure to the authorities as obligatory, but almost all of these responders (94%) would temporarily disallow driving. Sixty percent did not consider it obligatory to report the exclusive occurrence of simple partial seizures with retained consciousness and motor control. A surprisingly large number (36%) would never recommend dispensation from the 1 year driving ban rule. Thirty-nine % generally used EEG in the assessment of driving fitness, whereas 17% rarely did so. Almost all (93%) would withdraw AEDs after longstanding freedom from seizures in patients allowed to drive, but only 44% recalled having done so within the past year. Most responders (75%) considered a necessity to drive to weigh against drug withdrawal. Only 50% instructed the patients not to drive in relation to AED withdrawal. Forty-five % did not consider seizure recurrence resulting from consented withdrawal to activate the obligation to report.

Conclusion: There is poor consensus among neurologists about many aspects of driving and epilepsy, particularly in assessing the risk when stopping drug treatment. The regulations should be more specific and these issues should be focused during postgraduate teaching in clinical neurology.

32 - Could Multiple Sclerosis Be A Sexually Transmitted Illness?

Hawkes C

Oldchurch Hospital, Essex Neuroscience Centre, Romford, United Kingdom

Many aspects of Multiple Sclerosis (MS) are not explained by genetic mechanisms. Evidence supporting the theory includes: 1) age and gender pattern of MS is similar to many STI. 2) migration studies imply MS is acquired around puberty i.e. time of sexual debut 3) some MS clusters occur after influx of large numbers of males e.g. Faroes, Orkneys, Shetlands, Iceland. Space-time cluster analysis suggests MS is acquired in adolescence. 4) tropical spastic paraplegia, a known STI with low conjugal rate, has similarity to primary progressive MS. HTLV-1 infection is transmitted inefficiently from husband to wife and children are infected only if mother has disease - not father alone. This asymmetry of risk is similar to MS 5) twin studies give conflicting, support to the genetic component of MS 6) reanalysis of data on oral contraceptive use in the US-Nurse Health Survey suggests increased risk of MS after 6 years' use. 7) MS prevalence is high in permissive societies and low in strict or isolated cultures. Much of the world distribution of MS can be explained on the basis of sexual morality and racial separation. 8) during the sexual revolution of 1960s MS incidence increased particularly for females e.g. Denmark 9) conjugal studies from Sardinia but not Canada suggest elevated risk of transmission to spouse. 10) childhood MS may result from maternal infection or sexual abuse. It is proposed that: MS is an infection which is rarely symptomatic but widely present in Caucasians; it transmits to naïve populations especially female; adolescents are at particular risk from infected but not necessarily symptomatic males.

33 - A genome wide linkage disequilibrium screen in Scandinavian multiple sclerosis patients shows association to chromosome regions at 1q (D1S1601) and 11q (D11S1986)

Harbo HF*1, Datta P*2, Spurkland A1, Ryder LP2, Sawcer S3, Celius EG4, Modin H5, Åkesson E5, Sandberg-Wollheim M6, Myhr K-M7, Andersen O8, Hillert J5, Soerensen PS2, Svejgaard A2, Compston A3, Vartdal F1, Oturai A2

1The National Hospital, Oslo, Norway; 2Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; 3Addenbrookes Hospital, Cambridge, United Kingdom; 4Ullevål UniversityHospital, Oslo, Norway; 5Huddinge University Hospital, Huddinge, Sweden; 6Lund University Hospital, Lund, Sweden; 7Haukeland Hospital, Bergen, Norway; 8Gothenburg University Hospital, Gothenburg, Sweden. *These authors contributed equally.

Objective: This study attempts to identify gene regions encompassing putative susceptibility genes in multiple sclerosis (MS) in the genetically homogenous Scandinavian population.

Materials and methods: Linkage disequilibrium mapping of the genome was performed by analysing two pools of DNA from MS patients (n=199 and n=201) and two pools from healthy controls (both n=200). These pools which contain equal amounts of DNA from each individual were analysed in two separate screens using the same 6000 microsatellite markers evenly spaced throughout the genome. Differences in microsatellite allele image patterns between one MS pool and one control pool were identified in each screen. Furthermore, data from both screens (i.e. from 400 patients and 400 controls) were analysed together. A few selected markers which displayed significant deviations were reanalysed in both sets of pools.

Results: A total of 4212 markers were successfully analysed, when data from both screens were analysed together. The HLA markers D6S2447 and D6S2444 are among the markers displaying association in this analysis. Fourteen markers appeared to be significantly associated with MS in both screens when analysed separately. Among these the D1S1601 marker at 1q and the D11S1986 marker at 11q were confirmed to be associated with MS in a repeat experiment.

Conclusion: Two novel genetic regions (1q and 11q) which seem to contribute to the genetic susceptibility to MS were identified. More susceptibility gene regions are expected to be identified when this study is included in a European meta-analysis in the Genetic Analysis of Multiple sclerosis in EuropeanS study (GAMES).

34 - Is stroke in the young primarily of non-embolic origin? The Copenhagen Stroke Study

Jørgensen HS, Mosegaard D, Olsen TS

Dept. of Neurology, Gentofte Hospital, Copenhagen, Denmark

Purpose: It is our clinical observation that stroke in the young is often characterized by being mild, nonexplained, having a good prognosis, and recurrency is rare. We wanted to test the hypothesis that stroke in the young may often be of noncardioembolic origin.

Methods: The Study is community-based. We prospectively included 1,197 patients with acute stroke. Patients were stratified into two groups according to age (young<50 years). Stroke was considered likely if the patient had either atrial fibrillation (AF) or ischemic heart disease (IHD). Uni- and multivariate statistics were used.

Results: 45 (4%) patients were young. Compared to the elderly they were more often men (71% vs 45%, p<0.01;OR 2.7), and had less often AF or IHD (2% vs 35%, p<0.001;OR 0.04). No difference was found regarding diabetes or hypertension. Young patients had in general less severe strokes (Scandinavian Stroke Scale score 48 vs 35 points, p<0.001). Mortality was 2% vs 21%, p<0.001, and both neurological and functional outcomes were significantly better in the young. 5-year survival was 89% vs 35%, p<0.001. The better outcome was explained by less severe stroke and not by age. In survivors, 4% vs 16% had a recurrent stroke during the 5-year follow-up period, p=0.1.

Conclusion: In the young, cardioembolic risk factors are rare, stroke is less severe and often unexplained, and recurrent stroke is infrequent in comparison to in the elderly. Stroke in the young seems therefore often to be of non-cardioembolic origin. We suggest that stroke in the young is frequently due to a localized cerebrovascular abnormality such as malformation or vasospasm. Short- and longterm prognosis is exellent and recurrency rare.

35 - Cerebral embolization is reduced by carrying out coronary artery bypass surgery "at a beating heart"

Lund C1, Lundblad R2, Sundet K3, Tennøe B4, Fosse E5, Brucher R1,

Russell D1

Depts. of 1Neurology, 2Thoracic and cardiovascular surgery, 3Psychosomatic Medicine, 4Radiology, 5The Interventional Centre; Rikshospitalet, University of Oslo, Norway

Objective: Coronary artery bypass surgery (CABG) using cardiopulmonary bypass (on-pump surgery) carries a substantial risk for cerebral injury due to cerebral embolization. This is due to the whole-body inflammatory response which is induced by the heart-lung-machine, and the fact that cannulation and cross clamping of the ascending aorta produces atheromatous embolization. CABG performed without cardiopulmonary bypass (off-pump surgery) may therefore lead to a reduced risk of cerebral embolization and subsequent cerebral injury. In this prospective, randomised study we have assessed the rate of cerebral embolization during off-pump compared to on-pump surgery.

Material and methods: Transcranial Doppler (TCD) was used to determine the number of cerebral microemboli in the left middle cerebral artery during coronary artery bypass surgery in 52 patients, of which 29 were carried out off-pump. Clinical, neuroradiological and neuropsychological assessments were also performed one day prior to surgery and at three months later.

Results: There was significantly fewer cerebral microemboli in the off-pump group compared to the on-pump group (16 (range 0-131) versus 66 (range 15-274), p<0.0001). One ischemic stroke occurred in the on-pump group. There was no significant difference with regard to neuroradiological and neuropsychological findings.

Conclusion: Perioperative cerebral microembolization is significantly reduced using the off-pump technique. TCD monitoring allows identification of which surgical procedures that induces embolization. A larger patient population will be assessed to determine if off-pump surgery is better for neurocognitive functions.

36 - Spondylotic Cervical Myelopathy: Conservative vs Surgical Results in a Three-year Follow-up Study

Kadanka Z, Mares M, Bednaník J, Smrnka V, Krbec M, Stejskal L, Chaloupka R, Surelová D, Novotný O, Urbánek I, Dusek L

Departments of Neurology and Orthopaedic Surgery*, Faculty Hospital Brno

Study Design: A 3-year prospective randomised study. Objectives: To compare conservative and operative treatments of mild and moderate, non-progressive, or slowly progressive, forms of SCM.

Methods: Sixty-eight patients were randomised into two groups. Group A, treated conservatively, consisted of 35 subjects, while group B, treated surgically, was made up of 33 patients. The clinical outcome was evaluated by modified JOA score, timed 10-m walk, score of daily activities recorded by video and evaluated by two observers blinded to the type of therapy, and by subjective assessment by the patients themselves at months 6, 12, 24, and 36 of the follow-up.

Summary of Background Data: It is not known whether the results of decompressive surgery of the mild and moderate forms of spondylotic cervical myelopathy (SCM) are any better than those of the conservative approach.

Results: There was, on average, no significant deterioration in mJOA score within the two groups over 3 years of follow-up, but there was a slightly expressed decrease in the self-evaluation score in group B, and a slight deterioration of the score for daily activities in group A. Comparison of the two groups showed significant difference in the timed 10 m walk test in favour of group A, but no difference in mJOA score and self evaluation by patients themselves (with the exception of a better score at month 6 in favour of group B). Conclusions: The 3-year follow-up study did not show, on average, that the surgery is superior to the conservative treatment of mild and moderate forms of SCM.

Acknowledgments: This study was supported by the Internal Grant Agency of the Ministry of Health of the Czech Republic, grant number NF 6521-3.

37 - Does aerobic training improve endurance in mild MS?

Bjarnadóttir ÓH1, Konradsdóttir ÁD1, Reynsidóttir K1, Ólafsson E1

1Reykjalundur Rehabilitation Centre, Mosfellsbær, Iceland, 2Dept. of Neurology, Landspítali University Hospital Hringbraut, Reykjavík, Iceland

Objective: To determine the influence of intense physical training for five weeks on cardiorespiratory fitness of individuals with mild MS.

Material and methods: Twenty three patient with definitive MS, aged18-50 with EDSS < 3,5 were recruited. They were randomized to exercise group (EG) (n=11) and control group (CG) (n=12). Both groups were comparable with regard to age, sex, degree of diasbility, time from diagnosis. The EG was expected to train for 60 minutes three times a week for five weeks. The exercises included warming up for 5 minutes, endurance training for 20 minutes, range of motion for 25 min and streching/cooling down for 10 minutes. The CG agreed to lead their normal lives during the five weeks of the study and not to change their regular exercise pattern.

The degree of disability (EDSS), endurance (max watt/kg and max VO2 ml/kg/min), and balance (TUG) was determined at baseline and after 5 weeks. Five patients dropped out of the EG (unrelated illness (2), lack of modivation (1), IV steriod treatment (1) and MS relapse (1)). Two individuals in the CG dropped out (MS relapse (1), unrelated illness (1)).

Results: Six individuals completed the study in the Exercise Group and ten in the Control Group. The difference in cardirorespiratory fitness at baseline and at 5 weeks was compared. The change in maximum energy production (Wmax/kg) was 0.40 for the EG group and 0,07 for the CG group (T-test; p= 0,04). The change in maximal O2 uptake (ml/kg/min) was 4,03 for the EG group and -0,51 for the CG group (T-test; p=0,01). No difference was detected in degree of disability (EDSS) or balance (TUG) at baseline compared with 5 weeks later. The training was well tolerated by all.

Conclusion: Our results demonstrate that intentsive physical exercise for five weeks markedly improves cardiorespiratory fitness in a goup of individuals with mild MS, compared with a control group. The participants demonstrated poor fitness at baseline testing and the improvement observed is likely to signficantly improve their health and quality of life. The marked improvement seen after only five weeks of training may indicate that longer training programs would be even more beneficial.

L38 - Changes in blood pressure, temperature, and blood glucose within the first hours after stroke onset

Boysen G, Christensen H

Department of Neurology, Bispebjerg Hospital, University of Copenhagen, Copenhagen 2400 NV, Denmark

Body temperature, arterial blood pressure, and plasma glucose are almost always measured in acute stroke patients on admission to hospital. Much has been written about these variables, however, in most studies the measurements have been done fairly late, that is 12 to 24 hours after stroke onset. In our series patients were admitted and the variables measured within 6 hours of stroke onset.

We then did serial measurements every two hours the first 24 hours. All patients had their neurological deficit rated on the Scandinavian Stroke Scale (SSS), and all patients had a CT-scan. Neurological deterioration was defined as a drop in SSS of 2 points lasting more than 4 hours within the first 72 hours.

Temperature: The temperature was normal or subnormal in the very early hours after stroke onset. In severe stroke patients, defined as having SSS < 25, the temperature started to increase after 4 to 6 hours. At 8-10 hours after stroke onset increased body temperature was related to poor outcome at 3 months. In patients with mild strokes there was no change in temperature. In about 5% of the patients temperature was > 37.5°C on admission. Outcome in these patients was not significantly different from that of patients with normal temperature.

Blood pressure: In patients with mild ischemic stroke or with TIA, blood pressure declined significantly within the first 6 hours after admission. In patients with severe strokes the decrease in blood pressure was much less pronounced. In deteriorating stroke, which occurred in 20% of patients with ischemic stroke, blood pressure was slightly higher than in patients without deterioration.

Glucose: In 445 stroke patients without history of diabetes mellitus we measured blood glucose twice within 12 hours of stroke onset. An increase in blood glucose was observed in most patients. The increase was larger in severe stroke. In severe stroke patients blood glucose increased from a mean of 6.2 mmol/l to 6.7 mmol/l, p < 0.001. In patients with mild to moderate stroke patients blood glucose increased from 5.8 mmol/l to 6.1 mmol/l, p < 0.001. In patients who died within 7 days (N=38) blood glucose increased from 6.8 mmol/l to 7.1 mmol/l, p < 0.001.

Conclusion: Stroke is a dynamic process, giving rise to alterations in many systemic parameters. The new contributions of this study are that temperature increases in the early hours after stroke onset in patients with severe stroke. That blood pressure falls spontaneously to stable values within 6-8 hours in patients with mild stroke as contrasted to patients with severe stroke, where the adjustment of the blood pressure takes several days. The increase in blood glucose within 12 hours of stroke onset is more pronounced in patients with severe stroke than in mild stroke. The increase in temperature and blood glucose may potentially be harmful to the ischemic brain.

L39 - Stroke reduction: Impact of HMG-CoA reductase inhibitor therapy

Þorgeirsson G

Dept. of Medicine, Landspítali University Hospital Hringbraut, Reykjavík, Iceland

Abstract not received.

L40 - Optimal Therapy for Intracranial Arterial Stenosis: Antiplatelet agents, Anticoagulation or Angioplasty?

Chimowitz MI

Professor of Neurology, Emory University, Atlanta, USA

Atherosclerotic stenosis of the major intracranial arteries (carotid siphon, middle cerebral artery, vertebral artery, basilar artery) is an important cause of ischemic stroke, especially in Blacks, Asians, and Hispanics. In the USA, intracranial stenosis causes approximately 50,000 ischemic strokes annually. Moreover, the risk of recurrent stroke in these patients is 7%-15% per year.

Despite the importance of intracranial stenosis as a cause of ischemic stroke, the treatment of this disease remains empirical. Antiplatelet agents (aspirin, ticlopidine, clopidogrel, aspirin / dipyridamole combination) are frequently used in this setting based on studies that have shown a benefit of these agents for lowering the risk of stroke in patients with non-cardioembolic TIA or minor stroke. However, the efficacy of antiplatelet agents has not been established in patients with symptomatic intracranial large artery disease. Warfarin is also frequently used for the treatment of symptomatic intracranial large artery disease based on retrospective data that suggests warfarin may be more effective than aspirin in this setting.

Transluminal angioplasty/stenting is another therapeutic option for the treatment of intracranial stenosis. Early experience suggested that intracranial angioplasty was associated with an unacceptably high risk of stroke or death and the procedure was largely abandoned. However, recent advances in microcatheter and balloon technology have led to renewed interest in intracranial angioplasty and stenting. Several recent studies have shown that intracranial angioplasty and stenting are technically feasible and have been associated with stroke rates of 4%-40%. More data on safety, long-term outcome, and re-stenosis rates in patients undergoing intracranial angioplasty or stenting are needed before this therapy should be evaluated in a randomized, multi-center clinical trial. Moreover, best medical therapy for intracranial stenosis, which will serve as the proven control group in such a trial, has yet to be determined.

In this regards, the ongoing Warfarin-Aspirin Symptomatic Intracranial Disease (WASID) trial is an ongoing randomized, double blind clinical trial in which 806 patients with TIA or minor stroke related to angiographically proven stenosis (50 to 99%) of a major intracranial artery will be randomized to warfarin (INR 2-3) or aspirin (1300 mg per day). This study, which is funded by the National Institutes of Health (USA) will 1) determine whether warfarin or aspirin is more effective for preventing stroke and vascular death in these patients; and 2) identify subgroups of patients whose rate of ischemic stroke in the territory of the stenotic intracranial artery is sufficiently high to justify a subsequent trial comparing intracranial angioplasty/stenting with best medical therapy in these patients.

L41 - Vascular testing in patients with stroke and TIA

Feldmann E

Brown University, Rhode Island, USA

Abstract not received.

40 - Optimal Therapy for Intracranial Arterial Stenosis: 40 - 39 - 42 - Supporting People With Chronic Disesaes to Live With Their Disease

Jónsdóttir H

Associate Professor, Faculty of Nursing University of Iceland and Project Manager, National University Hospital

Life with a chronic disease may be the single biggest challenge in life for people living with a variety of diseases. The impact these diseases may have upon people and their loved ones are frequently underestimated by nurses and other health care professionals and health service is commonly limited to instrumental treatments of the patho-physiological manifestations of diseases.

Nursing practice is no exemption to this. Immediate physical needs have the priority: To take care of personal hygiene, mobility, communication, nutrition, elimination and physical comfort. Other needs, commonly phrased as psychological, social, spiritual, and existential, are not considered immediate and are frequently postponed-often indefinitely.

The limitations of focusing nursing care on meeting physical needs become clear when attention is paid to the turmoil that diseases may cause. The literature demonstrates vast changes that take place in relation to the chronic disease experience. Some of these amendments are alterations in relating to oneself and to others, inability to be employed, lack of meaningful social interactions, pain, fatigue, and uncertainty. The ways a disease creeps into people's lives are numerous, depending on the nature of the disease, prior life experiences, age, gender, social circumstances, and culture, to name a few.

The chronic illness experience is very personal and needs to be explored in the light of the uniqueness of each individual with his/her hopes, wishes, desires and goals in life. It is to this multifaceted picture, which a chronic disease creates in an individual's life that nursing practice needs to attend. Nursing practice should be concerned with what matters to people, and accordingly, support them in meeting their aims and aspirations life.

Fundamental to supporting people to live life with a chronic disease is to make efforts to understand what it is like to live in particular health circumstances; to relate to clients; and to attend to what is of importance in their life. Based on these premises a nursing practice named 'partnership' is being developed (Jonsdottir, Litchfield & Pharris, 2002; Litchfield, 1999). Partnership has been articulated as nursing practice as it unfolds. The nurse is present to clients in a "fully open caring attentiveness to whatever emerg[es]" in the nurse-client relationship (Litchfield, 1999 p. 65). The nurse focuses on that which is meaningful in the life of the client and embraces and responds to whatever emerges about that experience. This interaction is on a form of natural conversations. It is open and creative and a sense of a connection and mutual trust evolves. Through the conversations, insight into life may develop and possibilities for action may be identified. The nurse does not seek it. Rather, the nurse attempts to let go of controlling the clients' behaviours and thoughts and attempts to accept people's own capacity to find their way in life.

The benefits of participating in partnership can only be illuminated retrospectively. Litchfield (1999) described the benefits for families living with complex health circumstances from participating in partnership in terms of "insight as the potential for action", expanding horizon reflected in a movement from "being trapped in the present without vision to seeing the presence of past and future" and "increasing connectedness" reflected in "inclusion" with others, "interdependence in health care" and "transformation" of living.


Jonsdottir, H., Litchfield, M., & Pharris, M.D. (2002). Partnership as an expression of caring in the human health experience. Submitted for publication.

Litchfield, M. (1999). Practice wisdom. Adv Nurs Sci, 22(2), 62-73.

43 - A study on bowel and bladder management of spinal cord injured individuals in Iceland

Kjartansdóttir M

Department of Rehabilitation, Landspítali Grensás, University Hospital, Iceland

This is a report on a descriptive study on bowel and bladder management of spinal cord injured individuals in Iceland after discharge from hospital from 1973 to 1996.

Objective: The purpose of this study was to see what method spinal cord injured individuals (discharged from hospital 1973-96) are using regarding bowel- and bladder management in home environment. Is what we teach them in the rehabilitation unit relevant to home environment? Are spinal cord injured individuals satisfied with the method they are using as bladder and bowel management?

Problem: Spinal cord injury produces a wave of repercussions that affect many organ systems and subsequently the live activities of the affected person. What general population less appreciates is the effect of spinal cord injury on a person's ability to control the elimination of stool and urine.

Material and method: 117 spinal cord injured individuals were admitted to Reykjavík Hospital in the years 1973-96. Questionnaire regarding method, technique, equipment on bowel and bladder management and satisfaction was mailed to 57 spinal cord injured individuals who had been injured in the years 1973-96. Multiple-choice questions were developed by the investigator for data collection. Included in this study were 44 males and 13 females. Data was collected in mars- april 1997.

Results: 38 individuals replied, that is 66,7% of them who were included in the study. 14 could not been reached by telephone and 5 where not willing to participate.

Demographic variable: The individuals were divided by:

A) Gender: Included in the study were 28 males and 10 females.

B) Three age groups. The mean age was 43,6 years, S.D. 13,2 years and the range was 24-74 years.

C) Three groups a coring to length from the injury: mean 13,4 years, S.D. 7,2 years and the range were 1-24 years since injury.

D) Three groups according to American Spinal Injury Association impairment scale. 21 or 55,3% had A injury, 9 or 23,7% had B or C injury and 8 or 21,1% had D injury.

Satisfaction was measured on scale, 1 = very dissatisfied to 7 = very satisfied.

Bladder: The method of bladder emptying: Intermittent clean catheterisation (16), reflex stimulation (12, 3 of them used also clean intermittent catheterisation), normal micturition (6), indwelling catheters (3), condom catheter (1). Urinary tract infections that needed medication were reported as less than 4 times last year by 74,2% and over 5 times last year by 25,8%. Does bladder management interfere with any of what is listed below? Social life, school and work were reported by 17, home life by 4, body image by 9, sex life by 7 and 10 reported something else. Regarding choice of bladder management, hand movement was reported by 12, problem with transport by 7 and balance by 6.

Bowel: Those who have normal bowel function are eight. They did not answer any more questions. Method of bowel management was reported by those who answered all questions as: Manual removal of faeces (11). Manual stimulation (10). Transanal Irrigation (2). External massage (16). Valsalva (bearing down)(10). Stoma (1). Bowel medication (16). None use anal tampons. Only four need pad/diapers after bowel management. Bowel management frequency is mostly every other or every third day.

Conclusion: The conclusion is that those who use intermittent catheterisation and those who use reflex stimulation and/or abdominal pressure are satisfied with bladder management. Hand movement has a big impact on the choice of bladder management.

Findings indicate that having a neurogenic bowel has a big impact on life for those who have ASIA A and B or C classification, especially regarding social live, work and school. The fear for unplanned bowel movements and the amount of time involved in bowel management has the most significant effect on their lives after injury. Hand movement has a big impact on the choice of bowel management. Most individuals, special the younger, are satisfied with teaching methods and their choice of methods. That indicates that what we teach them in the rehabilitation unit is relevant to home environment.

This study corresponds to similar studies, which indicate that having neuroginic bowel and bladder affects life activities and lifestyle for spinal cord injured individuals.

A limitation of the study is that the sample is small and the questionnaire was in writing, a personal interview would probably have given a better result. However it shows that our patients have the same problems as others have reported and there is a lack of problem solving fore the group who has the most problems.

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44 - The Role of the Nurse Specialist in a Memory Clinic: Outreach home visits to referred patients

Jakobsen O, Hasselbalcj S, Hejl AM, Waldemar G

Rigshospitalet, Memory Disorders Research, Copenhagen, Denmark

The literature demonstrates that nurse-specialists with advanced knowledge and skills in dementia care can provide a higher quality of care and quality of life for the patient and the caregivers.

Objective: The aim of the study was to demonstrate the value of early contact between the nurse specialist and new referred patients in a memory clinic.

Methods: All patients, above 60 years, referred to the clinic were offered a home-visit prior to their first visit in the clinic. The home-visit included an interview about their expectations and attitude towards diagnostic evaluation, and towards the assistance of the nurse. The patients were evaluated by use of MMSE, GDS and DAD.

Results: 157 patients were included. 70% had a visit and were subsequently evaluated in the clinic (49 men and 61 female, mean age was 75.6 years. Mean MMSE 23.7. Mean GDS 5.5. Mean DAD 38.0. 30% declined to have a visit. Only 28% had already contact to the community care service and 12% had no help and were only able to manage themselves by help from a caregiver. 55% needed more help and support in their own home.

Conclusion: The home visit played an important role in the further evaluation program. The home-visit nurse report was very useful in relation to the clinic program and early contact. The patient and caregivers had increased confidence to the staff at the first visit. In many patients suggestions from the nurse report concerning the need for additional social measures were established and implemented by the first visit in the clinic.

45 - Voice therapy for patients with Parkinson´s disease

Arnardóttir E

Speech-Language Pathologist, Reykjalundur Rehabilitation Center, Mosfellsbær, Iceland

Objective: One of the most common speech problems in Parkinson´s disease (PD) is low volume. A group of patients with PD received voice therapy as a part of a group rehabilitation program. The objective of this study was to determine if this form of speech therapy was effective in increasing volume.

Material and methods: Thirty-four individuals with PD, mean age 65 years (49-84) received speech therapy as a part of a five-week multidisciplinary group therapy program, in November 1999 - September 2001. Therapy focused on intensive voice training. Vocal intensity in conversation and sustained phonation before and after therapy was compared. Twenty-three patients came for a 3 month follow-up.

Results: Significant differences (p=<,0001) were found in intensity in sustained phonation and conversation, before and after therapy, and differences between pre-treatment and follow-up values were significant in both parameters.

Conclusion: Voice therapy, provided in a group rehabilitation setting, is an effective way of improving speech function in Parkinson´s patients. Participants maintained a stronger voice 3 months post treatment.

46 - Developing multimedia and e-learning for teaching and learning the care of people with brain injury

Iggulden H

University of Salford, Manchester Greater Manchester M30 ONN United Kingdom

This paper describes an education project designed to explore how a structured e-learning environment can enhance the learning and practice of nursing brain injured people from the early stage through to rehabilitation. The paper describes the development of video, electronic classroom and CD ROM materials with an interdisciplinary team caring for people with brain injury. The project was funded by the University of Salford, with clinical input in acute care from Hope Hospital, Salford and Rehabilitation care from the Floyd Unit at Birch Hill Hospital, Rochdale. The project has been going for the three years and tries to make learning more flexible and accessible for nurses caring for people with brain injury. Evaluations have been carried out quantitatively using Likert scales, questionnaires and electonical data generated in the electronic classroom. The data has also been evaluated qualitatively using interviews. The samples that we have used are both students and qualified nurses and the evaluations have been very positive about the content , the interest and the availability of good learning resources. Students on the whole have enjoyed this style of learning. However sometimes there are technical problems and students would like materials to be more interactive. We are working on this with a new teaching CD ROM looking at the role of the nurse in mobilising patients through all the activities of daily living.

47 - Estimation of Glasgow verbal score from the Glasgow eye and motor scores in head trauma patients

Yousefi H

School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan, Iran

Background: The Glasgow coma scale (GCS) is a important tool for grading the level of consciousness. One of the most important problems of the GCS is the inability to assess the verbal response in special patients such as intubated and aphasic patients. According to the recent studies, there seems to be a correlation between the verbal response and motor and eye responses of the GCS.

Methods: This study is a descriptive analytic study. Data were obtained from 100 patients with decrease in level of consciousness (LOC) referring to hospitals of Isfahan university of medical sciences. The goal of this study is to estimate of verbal score from motor and eye scores in patients. Data were collected by checklists including demographic characteristics and LOC measured with GCS. Data were analyzed with chi-sqauere and multiple-Regression in SPSS software.

Results: There is a strong correlation between verbal score and motor and eye scores in head trauma patients(R= 0.785 ) as well as patients intubated after the trauma.(R= 0.685 )

Discussion: The present study confirms previous studies describing a strong correlation between verbal component and eye and motor components. This study was performed in patients with low GCS, and answers this question in previous studies: How can we test model in intubated patients? Therefore we can suggest this model for using in intubated patients.

L48 - Gabapentin, mechanism of action, do we know anything new?

Field M

Abstract not received.

L49 - New evidence for the role of Gabapentin in the treatment of chronic pain

Rice A

Imperial College, London, United Kingdom

Abstract not received.

L50 - Possible role of Gabapentin in the treatment of primary headaches

Bendtsen L

Bispebjerg Hospital, Denmark

Abstract not received.

L51 - Parkinson's disease

Larsen JP

Dept. of Neurology, University of Trondheim, Norway

Abstract not received.

L52 - Hereditary neuromuscular disorders

Edström L

Abstract not received.

L53 - Today´s medical treatment of Alzheimer´s disease and future perspectives

Jón Snædal

Memory Clinic, Geriatric Department, Landspitali University Hospital, Reykjavik, Iceland

Alzheimers disease (AD) is the major cause of dementia which affects at least 5% of individuals over age 65. Twice as many may be affected if the prodromal stages are included. Although the etiology of AD remains unknown many risk factors have been established with aging being the single most important one. With increasing proportion of the aged the consequence is a significant increase in incidence and prevalence of dementia and Alzheimer´s disease in particular during the next decades. Other risk factors include family history, female gender and low education level.

Current medical interventions for AD are mainly focused on one hand the cognitive impairment and on the other the psychiatric and behavioral symptoms of the disease (BPSD: Behavioral and Psychological Symptoms in Dementia). Among the psychiatric symptoms are depression, anxiety, paranoia and hallucinations and the behavioral symptoms may include agitation, irritability, restlessness, wandering and screaming. The symptoms of BPSD in AD are very important to recognize and treat as they often pose the greatest challenge to the caregivers and the health providers and can be the direct cause of institutionalization of the patients. The newer antidepressants and neuroleptics are the mainstay of medical treatment and the treatment is often effective. Caution and close monitoring of effects and side effects is warranted.

Acetylcholine deficit has been shown to be closely linked to the cognitive decline in AD. A significant progress in the management of the disease followed by the introduction of the Cholinesterase inhibitors. These drugs have now gained a wide acceptance as the cornerstone of medical treatment during the mild to moderate stages of the disease even though their overall effect is modest at best. Although the three drugs currently on the market all act by inhibiting the function of the acetylcholine degrading enzyme (AchE), they have different profile of action which will be discussed in more detail.

Other possible options of today´s treatment are Ginkgo biloba, vitamin-E, estrogens, statins and NSAIDs. None of these have been established yet as being effective for the treatment of Alzheimer´s disease.

Many new drugs directly aimed at AD are currently in the pipelines within the pharmaceutical industry. Some of them are acting on the cholinergic system as muscarinic or nicotinic agonists. Others are aiming towards more fundamental pathology such as the b- or g-secretase inhibitors. Yet another mode of action is promoting the release of nerve growth factors. The mechanisms of several of these potential future drugs will be discussed in more detail.

L54 - Sporadic vascular dementia subtypes - an update

Anders Wallin

Institute of Clinical Neuroscience, Sahlgrenska University Hospital/Mölndal, Sweden

Sporadic vascular dementia, now judged to be the second most common type of dementia, accounts for 10-50% of all dementia cases. It has become clear that vascular disease is a risk factor for cognitive impairment and dementia, not only vascular dementia but also AD. With the variation in prevalence figures, diagnostic criteria and pathophysiological mechanisms, vascular dementia must be considered a heterogeneous concept.

In subcortical vascular dementia, the primary types of brain lesions are lacunar infarcts and ischaemic white matter lesions, with demyelination and loss of axons, a decreased number of oligodendrocytes, reactive astrocytosis, and the primary lesion site is the subcortical region. Changes in the levels of structural proteins in the cerebrospinal fluid (CSF) may reflect pathophysiological mechanisms and may also serve as markers in the clinical differentiation between subcortical vascular dementia and "pure" Alzheimer's disease. Potential CSF biochemical markers for subcortical vascular dementia include the CSF/serum albumin ratio (for identification of blood-brain barrier damage related to disturbances in the small intracerebral vessels), CSF sulfatide (for identification of demyelination related to white-matter changes, CSF tau and CSF neurofilament light protein (NFL) (for identification of axonal degeneration), and CSF b amyloid protein (for identification of amyloid mismetabolism).

Subcortical vascular dementia fulfils what can be referred to as the basic criteria for a disease: the presence of a distinct pattern of clinical features, i.e., subcortical (or frontosubcortical) symptoms, that matches a distinct pathological picture. The opposite seems to be true in post-stroke dementia, which has symptomatological variation and relatively heterogeneous aetiology, i.e., thromboembolism or haemorrhage. AD + vascular dementia is also heterogeneous with regard to both clinical picture and (by definition) aetiology.

The large clinicopathological spectrum of 'arteriosclerotic dementia' has again become a focus of attention. There is as yet no approved pharmacological treatment for vascular dementia, but risk factor management may be beneficial. It seems clear that harmonisation of the criteria for vascular dementia and its subtypes would facilitate research in this field. International acceptance of the currently suggested criteria for subcortical vascular dementia would provide a good starting-point for comparisons of treatment responses across studies worldwide.

L55 - Genealogic approach to neurological diseases

Stefánsson K

deCODE genetics, Reykjavík, Iceland

Abstract not received.

L56 - Epidemiology And Genetics Of Parkinson's Disease In Iceland

Sveinbjörnsdóttir S

Dept. of Neurology, Landspítali University Hospital Grensás, Reykjavík, Iceland

Abstract not received.

L58 - Localization of a susceptibility gene for common forms of stroke

Gretarsdottir S1, Sveinbjörnsdottir S2, Jonsson HH1, Jakobsson F2, Einarsdottir E1, Agnarsson U3, Skholny D1, Einarsson G2, Gudjonsdottir HM1, Valdimarsson EM2, Einarsson ÓB1, Thorgeirsson G3, Hadzic R1, Jonsdottir S1, Reynisdottir ST1, Bjarnadottir SM1, Gudmundsdottir Þ1, Gudlaugsdottir GJ3, Gill R4, Lindpaintner K4, Sainz J1, Hannesson H1, Sigurdsson GT1, Frigge ML1, Kong A1, Gudnason V3, Stefansson K1, Gulcher JR1

1deCODE genetics, Sturlugata 8, IS 101-Reykjavik, Iceland, 2National University Hospital, IS 101-Reykjavik, Iceland, 3Icelandic Heart Association Heart Preventive Clinic, 108-Reykjavik, Iceland, 4F. Hoffmann La Roche, Grenzacher strasse, CH-4070 Basel, Switzerland

Stroke is one of the most complex diseases of man with several subtypes as well as secondary risk factors such as hypertension, hyperlipidemia, and diabetes, which in turn have genetic and environmental risk factors of their own.

We have mapped the first major locus for common forms of stroke. In our study we used a broad but rigorous definition of the stroke phenotype including hemorrhagic stroke, ischemic stroke and transient ischemic attack. We cross-matched a population-based list of stroke patients in Iceland with an extensive computerized genealogy database clustering 476 stroke patients within 179 extended pedigrees. Linkage to chromosome 5q12 was detected, and the lod score at this locus meets the criteria for genome-wide significance (multipoint allele sharing lodscore of 4.40, p-value of 3.9 X 10-6). By extensive fine-mapping we narrowed down the most promising region for harbouring a stroke susceptibility gene to a segment less than 6 cM. We have sequenced this segment and identified genes in the region. A candidate gene for stroke has been identified based on association analysis using a dense set of microsatellite markers and SNPs, typed for 800 patients and 500 controls.

L 59 - Electrophysiological monitoring

Rosén I

Division of Clinical Neurophysiology, Department of Clinical Neuroscience, Lund University Hospital.

Continuous EEG monitoring is a relatively new modality in intensive care. Whereas a number of physiological parameters such as ECG, heart rate, oxygen saturation, blood pressure and temperature since long have been integrated into ICU monitoring systems, monitoring of EEG, directly reflecting the functional state of the brain, has been used more rarely. There are probably a number of reasons for this.The EEG signal is of low amplitude and often contaminated by artefacts of biological and non-biological origin. Interpretation of the EEG requires a long and extensive experience with due consideration taken to a number of factors such as level of wakefulness and medication given. It is almost impossible for the attending clinician or nurse to extract useful trends in the development of the functional state of the brain during intensive care by inspecting the ongoing EEG activity only. Even for the professional EEG interpreter it is very difficult to discern trends of EEG development during hours and days of intensive care by repeated inspection of the ongoing raw EEG signal displayed on a time scale, which is usually in the order of 10-20 sec per page. Furthermore, the intensive care situation does not permit maintenance of impedance and position of multiple EEG recording electrodes on the scalp for any length of time exceeding a few hours.

These considerations have inspired a number of developments of monitoring devices, which provide simplified time compressed displays of EEG during intensive care. The two main physical features of the EEG signal, which are targeted, are, variations in the amplitude (amplitude integrated EEG, aEEG) and frequency content (compressed spectral arrays CSA, spectral edge SE).

Recently, digital EEG monitoring systems have been developed which allow raw EEG to be displayed and stored continuously with on line trend analysis of aEEG as well as the spectral content of the EEG signal. This is of special value for identification and monitoring of continuously ongoing epileptiform discharges in non-convulsive status epilepticus, which is a common reason for performing long term monitoring in neurological intensive care.

L60 - Bedside monitoring of cerebral energy metabolism

Ståhl N, Nordström C-H, Ungerstedt U

Department of Neurosurgery Lund University and Department of Physiology and Pharmacology, Karolinska Institute, Stockholm

The technique of microdialysis was introduced more than 25 years ago for monitoring the animal brain and has become a standard technique in neuroscience with well over 7.000 publications. The first studies of the human brain were published about 10 years ago and subsequent studies have shown that microdialysis might be a valuable tool for the supervision of patients during neuro intensive care.

In 1995, CMA Microdialysis (Stockholm, Sweden) introduced microdialysis instruments for clinical use (catheters for peripheral and brain tissue, a microdialysis pump, and a bedside chemical analyzer). We have used the technique since 1995 as routine in all patients with severe traumatic brain lesions in the Department of Neurosurgery, Lund University Hospital. The technique has also been used in patients with spontaneous subarachnoid or intracerebral hematoma, bacterial meningitis, brain tumor, and malignant infarcts of the middle cerebral artery. Since microdialysis is a regional technique the positioning of the catheter is essential. The intracerebral microdialysis catheters now have a radiopaque tip and they are visible on routine CT scans.

According to our routines an intracerebral microdialysis probe is inserted into cortical tissue via a separate burr hole when an intraventricular catheter is introduced for ICP monitoring ("better position"). During open brain surgery (i.e. evacuation of a focal brain contusion, hemicraniectomy etc.) one or two microdialysis probes are introduced into brain tissue close to the injured area ("worse position"; "biochemical penumbra zone"). In addition one subcutaneous microdialysis catheter is place in subcutaneous fat tissue.

The microdialysis probes are perfused (0,3 _l/min) and samples are collected in microvials every 30 or 60 min for bedside analyses of glucose, pyruvate, lactate, glutamate and glycerol. The analytes have been chosen to give information regarding cerebral energy metabolism and glycolysis (glucose, pyruvate, lactate), excitotoxicity (glutamate), and degradation of cell membranes (glycerol). The results of the analyses are shown on a monitor bedside. Information regarding physiological parameters, ventilation, drug infusion, blood biochemistry are also included and a new computer program (ICU-pilot, CMA Microdialysis) allows bedside comparison and evaluation of all modalities. After routine analyses the microvials are kept frozen for later scientific studies utilizing HPLC (amino acids, ions, transmitters, drugs).

Table I gives steady state levels of metabolites monitored bedside in normal human brain and in human brain with manifest ischemia (cerebral perfusion pressure close to 0). These data are used as reference values during routine biochemical monitoring in neuro intensive care (1,2) and microdialysis is presently used to guide our treatment. The biochemical data have also been used to evaluate the effect of treatment in a series of 50 patients with severe brain trauma (3).

In an ongoing study we are comparing physiological and cerebral biochemical variables in two groups of patients treated for malignant middle cerebral artery infarcts. From this study we will present preliminary data comparing the group treated with a combination of hemicraniectomy, hypothermia and inotropic support to the second group treated only with hemicraniectomy.

Table I

Glucose Lactate Pyruvate La/py Glycerol Glutamate

mM/L mM/L mM/L ratio mM/L mM/L

Normal Mean 1.7 2.9 166 23 82 16

brain S.D. 0.9 0.9 47 4 44 16

Manifest Mean 0.1 8.9 31 458 573 381

ischemia S.D. 0.2 6.5 47 563 427 236


1. Reinstrup P, Ståhl N, Hallström Å, Mellergård P, Uski T, Ungerstedt U, Nordström CH: Intracerebral microdialysis in clinical practice. Normal values and variations during anaesthesia and neurosurgical operations. Neurosurgery. 47:701-710,2000

2. Ståhl N, Mellergård P, Hallström Å, Ungerstedt U, Nordström CH: Intracerebral microdialysis and bedside biochemical analysis in patients with fatal traumatic brain lesions. Acta Anaesthesiol Scand. 45: 977-985, 2001

3. Ståhl N, Ungerstedt U, Nordström CH: Brain energy metabolism during controlled reduction of cerebral perfusion pressure in severe head injuries. Intensive Care Med 27:1215-1223, 2001

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61 - Identifying Nursing Sensitive Patient Outcomes (NOC) in neuro-rehabilitation at Landspitali - University Hospital in Iceland

Guðmundsdóttir E, Delaney C, Thoroddsen Á

Landspitali University Hospital, Reykjavík, Iceland

No data or information exists on the impact of nursing in Iceland on patient outcomes, as nursing sensitive patient outcomes have not been identified within nursing in Iceland. The purpose of this study was to describe patient outcomes perceived by nurses in clinical practice to be relevant to (a) the general patient population and (b) the patient population within each nursing specialty at LSH. This paper will focus on results from neuro-rehabilitation nursing.

A survey research design was used. The Nursing Outcomes Classification (NOC 2nd Ed.) who contains 260 nursing sensitive patient outcomes, organized into 29 classes, was used in this study. The NOC survey was translated to Icelandic and mailed to experienced clinical nurses at the hospital (LSH) in November 2001. Clinical nurses (N=560) from all nursing specialities received the survey. Responses came from a majority of units within each of the thirteen nursing specialties. The hospital is an acute-care hospital with 1260 beds, there were 35,700 inpatient visits, 197,799 outpatients visits and 2980 child births in the year 2000. It is estimated that nursing care representing more than 8000 inpatients and 750 child-births created the basis for the nurses' perception of relevant patient outcomes in this study.

Ninety percent of nursing units (n=54) in the sample were presented in this study. Respondents had more than one years experience within nursing, with 36% of respondents had over twenty years of experience in nursing. Experience within specialty was ever one year. Significant variance (p< 0.05) by nursing specialty was found for the perceived relevancy of twenty-five NOC classes. NOC outcomes perceived relevant to over 50% of patients within neuro-rehabilitation nursing and those rated relevant to less than 10% of patients will be described.

NOC was an effective tool to describe the perceived relevant patient outcomes for nursing in general and within specialty. Implications for clinical practice and further development will be addressed.

62 - Nurses role in the treatment of patients with hyperhidrosis

Wilhelmsson I-L, Eriksson S

Department of Neurology, Uppsala University Hospital

Since treatment of palmar and axillary hyperhidrosis with botulinum toxin was introduced in Uppsala 1996 the method has become increasingly popular and has replaced sympathectomy as the method of choice for severe cases. A hidrosis outpatient clinic has been established in collaboration between the dpts. of neurology and dermatology. Specialised nurses of department of neurology, familiar with the use of botulinum toxins, organises the clinic and are the primary contact persons for all patients. The clinic receives patients with generalised, regional and palmar, plantar, axillary, facial, inguinal and other focal hyperhidrosis. At the first visit all patients see a neurologist or a dermatologist to set the right diagnosis, exclude other diagnosis and ordination of therapy. Nurses perform injections of botulinum toxin. When needed, the physician does regional nerve blocks. Clinical control and repeated injections at remission as well as iodine starch tests to outline the area of injections are performed by the nurses. Five years experience of the clinical problems of the patients, quality of life, technique of injections with botulinum toxin, improvement and side effects will be discussed.

63 - Frequency of pressure ulcer on persons with spinal cord injury in Iceland

Kjartansdóttir M

Department of Rehabilitation, Landspítali Grensás, University Hospital, Iceland

Objective: The purpose of this retrospective research was to see the frequency of pressure ulcer in persons with spinal cord injury 1) after discharge from rehabilitation ward and 2) frequency of pressure ulcers when skin was inspected.

Material and methods: The sample was 47, of them 36 were men and 11 women, and the mean age was 49 years. At the time of the injury the participants were 15-77 years old and the mean age was 34,7 years. Time from injury was 2-32 years and the mean time was 14,8 years. The participants were graded by ASIA impairment scale, 47,9% had A or B classification. Number and characteristics of prior ulcers was self-reported, but recorded by the author. The participant's skin was inspected at the same time.

Results: Pressure ulcer frequency was 51,1% (n=24). When skin was inspected 40,4% had ulcer (n=19). Wheelchair bounded participants were 32 (68,1%), of them 22 had ulcer prior to inspection and 17 had ulcer when skin was inspected.

Conclusion: Pressure ulcers have many causes and in order to lower their frequency nurses must take actions. They have to record inspection of the skin and treatment in systematic order. That is the only way they can have quality control of their treatment of the skin. Inspection of the skin gives the nurse opportunity to discuss prevention techniques. Knowledge of prevention techniques will give the spinal cord injury person more control over their ulcer development and increase their responsibility for their skin care.

64 - Social situation of people who have been diagnosed with multiple sclerosis

Sigurdardóttir M

Dept. of Neurology, Landspítali University Hospital Grensás, Reykjavík, Iceland

Introduction: The research is a MA study in Social Work at the Iceland University in Reykjavík.

Research description: To study the impact of Multiple Sclerosis on social situation by a samle of factors in a representive Icelandic population by a variety of factors.

Main objectives:

1) To explore in what extent changes in participant´s situation are and the families' coping style, social support and adjustment to MS.

2) To evaluate if it is possible to improve peoples quality of life.

3) To explore if people have already had sufficient information about the disease. To look into if people with MS have had enough support form health professionals.

4) To examine how the individual and the family have adjusted to the changes the disease can bring to their lives, and which resources could be helpful.

5) To focus on families situation when one member has MS. What happens when parents can not take care of their role? Does the other parent take over the families duties and responsibilties?

6) Are those numerous who have been forced to quit their study or resign from work because of the disease.

The purpose of this research is to collect information and also to test hypotheses by correlation of variables. To look into the influence the disease has on the individual and his/her family relations. This research can give information about need for service, support, economic status and participant´s support net.

Material and methods: In Iceland are about 380 people (0.136 % of the population) diagnosed with Multiple Sclerosis. A questionnaire will be sent to all members of the Multiple Sclerosis Society in which are about 60% of those diagnosed with the disease in Iceland are members. Others will receive telephone calls and be invited to participate. The research is quantitive and the method is a postal study. Participants will be sent a questionnaires with a letter giving information about the research. The people who are not able to answear the questionnaire themselves will be interviewed, if they agree to attend. Included in the letter will be the permit for this study given by National Bioethics Committee and Data Protection Authority.

Results: Results of the study will be presented at the conference.

L65 - Results of 40 years surveillance for Creutzfeldt-Jakob disease in Iceland

Georgsson G

Institute for Experimental Pathology, Keldur. University of Iceland, Reykjavík, Iceland

Creutzfeldt-Jakob disease (CJD) belongs to a group of diseases of man and animals, which are either called Prion-diseases, a term derived from the name, that Stanley B. Prusiner gave the infectious agent, or Transmissible spongiform encephalopathies (TSE´s), which refers to the characteristic pathological lesions. Initially these diseases were classified as slow infections, a term introduced by Björn Sigurdsson, as they fulfil the main criteria for this class of infections. The sporadic form of Creutzfeldt-Jakob disease (spCJD) was first described some 80 years ago. Later studies have shown that CJD does also exist in familial forms due to mutations in the prion gene and iatrogen forms due to medical treatment including surgical procedures. Recently, i.e. in 1996, a variant form, vCJD, was described and there is considerable evidence that it is caused by consumption of products of cattle with Bovine spongiform encephalopathy (BSE). Cattle did apparently contract BSE through consumption of meat and bone meal containing carcasses of scrapie sheep, a natural Prion-disease, which has been known in sheep in the United Kingdom for approximately 250 years. Interestingly Kuru, a Prion-disease of people of the Fore-tribe living in New-Guinea, is also transmitted orally and has been traced to kannibalistic rituals. The cause of spCJD, however, is still not kown. The impetus for the initiation of the surveillance for CJD in Iceland, was a hypothesis published in Science in 1974 dealing with and trying to explain an unusually high incidence of CJD in Libyan Jews living in Israel. These Jews had 15-30fold higher incidence of CJD than Iraqui and other Jews living in Israel. The Libyan Jews were sheep farmers and the hypothesis was that they might have contracted CJD through the dietary habit of eating eyeballs of sheep. In Iceland sheep products have together with fish made up the bulk of the diet. Singed sheep heads including eyeballs and in some districts also brain have been considered a delicacy and have been an integral part of the Icelandic diet. As scrapie of sheep was apparently introduced to Iceland some 120 years ago and did spread to most parts of the country some 50 years ago the majority of the population has certainly been exposed to scrapie of sheep for several decades. Thus we expected to find either a high incidence and/or aberrant forms when we started this survey of CJD. The surveillance consisted of two parts: 1) Retrospective study 1960-1979; 2) Prospective study 1980-1999. The results were, that two cases of definite CJD were detected in each period, corresponding to an annual death rate 0.5 per million inhabitants in the earlier period and 0.4 in the latter period. The overall figure was 0.44 per million inhabitants, 2 females and 2 males. The age distribution was 56-73 years and the duration of illness 2-12 months. These parameters as well as the clinical symptoms and especially the character and pattern of the pathological lesions were consistent with the diagnosis spCJD, but not vCJD. This fact and the finding of a relatively low incidence of CJD in spite of a considerable exposure to scrapie of sheep allows us to conclude, that we have no reason to assume that scrapie of sheep can be transmitted to humans and cause CJD.

L66 - Hereditary Cystatin C Amyloid Angiopathy in Iceland.

Blöndal H

Departments of Anatomy and Pathology, University of Iceland, Faculty of Medicine

Introduction: In his doctoral thesis, Apoplexie und ihre Vererbung, published in 1935, an Icelandic district physician reported on his studies of several families in the Breidafjordur area that were known for sudden deaths of young people from stroke. He concluded that this was an autosomal dominant hereditary disease which was confirmed by later studies. In 1972 amyloid was identified in pathological blood vessels in the brain of family members and the condition then received the name Hereditary cerebral hæmorrhage with amyloidosis (HCHWA). In 1983 the amyloid protein was isolated and characterized as the proteinase inhibitor cystatin C in a mutated form (L68Q) and the disorder received its present name Hereditary cystatin C amyloid angiopathy (HCCAA). Later (1989) it was recognized that cystatin C amyloid was not restricted to the central nervous system but present in many internal organs. It would thus not be inappropriate to name the disease Hereditary cystatin C amyloidosis (HCCA).

Material and methods: This presentation is based on a study by conventional histological, immunohistological and transmission electron microscopic methods on material from 43 autopsied patients, 25 females and 18 males and cell culture of smooth muscle cells from leptomeningeal arteries of two patients. The average age at death of the female patients was 32.3 years (range 21-57 years) and for the males 32.0 years (range 15-62 years).

Pathology: The pathological changes observed in the central nervous system (CNS) fall into three principal categories: damage of medium and small arteries by amyloid deposits, hæmorrhagic lesions and ischæmic lesions. The pathology will be demonstrated and discussed. Experiments exposing cultured human cerebrovascular smooth muscle (HCSM) cells to amyloid extracted from leptomeningal arteries of patients and electrophoretically verified to be cystatin C have shown harmful effect on HCSM. This supports our notion that the damage of the vessel wall is due to toxic effect of the cystatin C amyloid on smooth muscle cells in the arterial media.

Cystatin C immunoreactive and Congo red positive material is found in internal organs primarily in three locations: in vascular smooth muscle and adventitia of arterioles and the perivascular tissue of lymphatic capillaries and blood capillaries including sinusoids; at the interface between surface epithelium, mesothelium and glandular epithelium and subjacent connective tissue; in peri- and endoneurial tissue of peripheral nerves.


o HCCAA is a widespread systemic disorder caused by a point mutation of the cystatin C gene with subclinical expression in many tissues of the body and clinical expression in the brain.

o HCCAA is characterized by vascular lesions common to other cerebral amyloid angiopathies (e.g. beta-amyloid) but is by far more widespread in the brain, and the cerebral vasculature is more severely damaged than in most of the amiloid angiopathies.

o The deposition of cystatin C amyloid in blood vessels outside the CNS does not have the catastrophic results it has in the brain.

o The actual source of the mutated amyloidogenic cystatin C is not known but circumstantial evidence points to the cerebrovascular smooth muscle cell as both an active participant in its formation and sufferer from its presence.

o The precise course of events that leads to hæmorrhage in the brain remains to be elucidated.

67 - Neurological nursing in the Nordic countries

Kirkevold M

Institute of Nursing Science, University of Oslo, Norway

Abstract not received.

68 - Neurology in the Nordic countries

Sigurðsson AP

Dept. of Neurology, Landspítali University Hospital Hringbraut, Reykjavík, Iceland

Abstract not received.

69 - The future of neurology

Hachinski V

London Health Sciences Centre, University Campus, Canada

Abstract not received.

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