Assessing attitudes and behaviours surrounding Alzheimer's disease in Europe: key findings of the Important Perspectives on Alzheimer's Care and Treatment (IMPACT) survey.

The Important Perspectives on Alzheimer's Care and Treatment (IMPACT) survey is an assessment in Europe of the attitudes of caregivers, physicians, the general public and payors towards Alzheimer's disease and dementia. This was an Internet-based questionnaire study, which sought to determine the opinion and perception of responders on issues relating to ageing and dementia. There were additional questions for caregivers on the impact of caregiving on their life. Responses were analysed from 949 members of the general public, 500 physicians (generalists and specialists), 250 caregivers and 50 payors from 5 countries--France, Germany, Italy, Spain and the United Kingdom. The survey highlighted the difficulty of diagnosing dementia, especially in the initial stages of the disease. The average time from first noticing symptoms to diagnosis varied from 36 to 63 weeks. Caregivers and the general public felt they had insufficient information about the benefits of treatment and care, although more than half the general public, caregiver and physician responders agreed that early treatment could delay the progression of the disease. The majority of respondents recognised the devastating effects of AD on caregivers and families, and a majority of caregivers, the general public and physicians agreed that their governments fail to view AD as a health care priority. This study occurs roughly 5 years after a similar survey, and provides a timely update. Despite some important differences between the methodologies used in these surveys, diagnosis of dementia is still a key issue, especially amongst generalists, as is the provision of information and support to caregivers. Despite the prevalence of AD in the ageing population of Europe, the perception within each of the 5 countries surveyed is that AD is not viewed as a health care priority.

Assessing physician attitudes and perceptions of Alzheimer's disease across Europe.

Given the important role that physicians play in clinical care, disease advocacy, national health policy making and clinical research, the IMPACT survey sought to assess the attitudes and perceptions of physicians in 3 general categories: diagnosis and treatment of Alzheimer's disease (AD); caregivers and families of patients with AD; and the role of government in dealing with this disease and its consequences. Survey respondents comprised a total of 250 generalists and 250 specialists (neurologists, geriatricians, neuro-psychiatrists, psychiatrists and psychogeriatricians) from France, Germany, Italy, Spain and the United Kingdom. Physicians were aged 25 to 69 years, in practice for between 5 and 30 years and currently spending more than 50% of their time in direct patient care. Results showed that a sizable majority of physicians throughout Europe, specialists and generalists alike, agree that: 1) AD is underdiagnosed and undertreated; 2) patients and families are not prepared to recognise the early symptoms of the disease; 3) early treatment can help to slow the progression of the disease; and 4) more effective treatments are needed. Attitudes were statistically significantly different between some groups of physicians regarding disclosure of the diagnosis of AD, the benefits of lifestyle modification, and the value of AD-specific medication in patients whose symptoms are worsening. Differences in attitudes and perceptions of AD between specialists and generalists were limited; differences between countries were more common and of greater magnitude, particularly with respect to barriers to the use of prescription medications.

Implications of the Impact Survey for payors across Europe.

People involved with development of health care policy must be appreciative of the social and economic challenges that will likely develop as a result of the rise in Alzheimer's disease (AD) as the 21st century progresses. Their attitudes, perceptions and understanding regarding AD were captured in the IMPACT survey, a 30-minute Web-based questionnaire. Fifty health policy managers and decision-makers (payors) were recruited, 10 each from 5 European countries--France, Germany, Italy, Spain and the United Kingdom. Most payors felt that AD was underdiagnosed and undertreated in their country (80% and 68%, respectively). Half of all payors felt that their government did not invest enough in treating AD, and 30% felt their government hindered access to drug therapy. Payors believed that treatment should be initiated as early as possible after a diagnosis of AD (82%), and that early treatment can delay progression of the disease (82%). Even more than caregivers, payors agreed that AD can have devastating effects on the family of the sufferer (90% vs 75%; P<0.05). Payors more often cited cancer, stroke and heart disease than AD as affecting their budgets, but cited AD more often than depression, diabetes, HIV/AIDs and arthritis. Cost savings were seen as the most important factor regarding policy decisions. These attitudes of the surveyed payors towards AD and the patients and caregivers affected by it suggest that they may advocate for national and international policies that will facilitate earlier diagnosis and improved access to treatment.

Gender differences in spontaneous cervical artery dissection.

We analyzed sex differences in 696 patients with spontaneous cervical artery dissection. There were more men (n = 399; p < 0.0001), and men showed a higher frequency of hypertension (31% vs 15%; p < 0.0001). Women were younger (42.5 +/- 9.9 vs 47.5 +/- 9.3 years; p < 0.0001), had more often multiple dissections (18 vs 10%; p = 0.001), migraine (47 vs 20%; p < 0.0001), and tinnitus (16 vs 8%; p = 0.001). Outcome and mortality were similar in both sexes.

Pain as the only symptom of cervical artery dissection.

BACKGROUND: Headache or neck pain is a frequent symptom of spontaneous cervical artery dissection (sCAD). PATIENTS AND METHODS: Patients were drawn from an ongoing hospital-based registry of consecutive cases diagnosed with sCAD. Only patients with isolated pain were included in this series. Pain topography, dynamics, severity and quality, imaging findings and outcome were analysed. RESULTS: 20 of 245 (8%) patients with sCAD presented with pain as the only symptom (mean (SD) age 39 (8) years; 14 (70%) women). Of them, 12 had vertebral artery dissection, 3 had internal carotid dissection and 5 had multiple dissections. The median delay from symptom onset to diagnosis was 7 days (range 4 h to 29 days). 6 patients presented with headache, 2 with neck pain and 12 with both. Onset of headache was progressive in 6, acute in 8 and thunderclap-type in 4 patients; neck pain was progressive in 7 and acute in 7. Headache was throbbing in 13 and constrictive in 5 patients; neck pain was throbbing in 4 and constrictive in 10. Pain was unilateral in 11 and bilateral in 9. Pain was different from earlier episodes in all but one case. All patients were pain free at 3 months. CONCLUSION: Pain may be the only symptom in sCAD, even when multiple arteries are dissected. Pain topography, dynamics, quality and intensity were heterogeneous. Data from this study lend support to recommendations favouring imaging studies of the cervical arteries in patients with new-onset unexplained headache or neck pain.

[Neuro-ophthalmologic initial presentation of sarcoidosis]. / Manifestations neuro-ophtalmologiques révélatrices d'une neuro-sarcoïdose.

PURPOSE: To describe different forms of neuro-ophthalmologic onset of sarcoidosis: clinical signs, means of diagnosis, treatment, and progression. PATIENTS AND METHODS: Retrospective study of 13 patients with neuro-ophthalmologic initial onset of sarcoidosis diagnosed in three departments between 1997 and 2003. RESULTS: There were ten women and three men, with a mean age of 36 years. Six patients suffered from diplopia. In three cases, the cavernous sinus was involved; the three other patients with diplopia had meningoradiculitis. Nine patients had infiltration of the anterior visual pathway: the optic nerve was involved in five cases, the chiasm in two cases, and two patients had papilledema. Two patients also had both symptoms. The dosage of the angiotensin-converting enzyme level was evaluated in 11 patients and was elevated in six cases. Nine patients underwent a lumbar puncture; the cerebrospinal fluid protein was high in seven cases. Chest radiography and CT were abnormal in nine cases of 11. Ten patients had histological proof of sarcoidosis; the three others had enough evidence to support this diagnosis. All of them were treated with systemic corticosteroids. The diplopia improved for the six patients. Among the seven patients with optic nerve or chiasmal infiltration, one recovered completely, two were partially improved, and four remained stable. CONCLUSIONS: Diplopia and anterior visual pathway abnormalities can be the manifestation of initial onset of sarcoidosis; therefore this diagnosis must be kept in mind when these frequent neuro-ophthalmologic signs are encountered. Complementary exams, mainly biopsy of the involved areas with histological analysis, are needed to confirm this diagnosis. Corticosteroid treatment is generally followed by improvement, but relapses may occur.

Migraine and the risk of cervical artery dissection: a case-control study.

The association between migraine and cervical artery dissection (CAD) was explored in a hospital-based case-control study. Migraine was present in 49.1% (23/47) of patients with CAD and in 21% (11/52) of patients hospitalized for a cerebral ischemic event not related to a CAD (adjusted odds ratio = 3.6; 1.5 to 8.6, p = 0.005). This result supports the hypothesis that an underlying arterial wall disease could be a predisposing condition for migraine.

[Infectious aneurysms of the cavernous carotid artery]. / Anévrisme infectieux de la carotide intracaverneuse.

We describe 3 patients who developed infectious aneurysms of the cavernous carotid artery. The aneurysms were due to sphenoidal sinusitis in two patients and due to endocarditis in one. The acute and septic onset of the cavernous sinus syndrome, suggested thrombophlebitis of the cavernous sinus in all 3 patients. The diagnosis was established by magnetic resonance imaging and magnetic resonance angiography. Therapeutic internal carotid artery occlusion was indicated for a fissuration of their aneurysm manifested (n=3) by an episode of epistaxis (n=2) and blood in sphenoid sinus (depicted by MRI) in one case. We discuss the pathophysiology and management of bacterial aneurysms of the cavernous carotid artery. Close clinical and imaging follow-up should be performed for patients under antibiotherapy. Selective angiography with therapeutic occlusion of the carotid artery is discussed in patients with persistence of symptoms or if clinical findings are suggestive of fissuration or if aneurysmal sac diameter increases on follow-up imaging studies.

Significant association of atrial vulnerability with atrial septal abnormalities in young patients with ischemic stroke of unknown cause.

BACKGROUND AND PURPOSE: Atrial septal abnormalities have been associated with cryptogenic ischemic stroke in young patients, but the causal link has not yet been established. Paradoxical embolism is considered the most likely mechanism but is rarely proven. It can be hypothesized that, in those patients, paroxysmal atrial arrhythmias, potentially favored by the anatomic abnormalities, can be another cause of thrombus formation and subsequent embolism to the brain. In this study we assessed the relationship between atrial vulnerability, reflecting arrhythmogenic properties of the atria, and atrial septal abnormalities in young patients with cryptogenic ischemic stroke. METHODS: We enrolled 62 consecutive patients aged <55 years who had ischemic stroke of unknown cause and transesophageal echocardiography to assess atrial septal aneurysm (ASA) or patent foramen ovale (PFO) (ie, atrial septal abnormalities). These patients underwent electrophysiological study to measure atrial refractoriness and conduction time defining a vulnerability index (ie, latent atrial vulnerability) and to assess the inducibility of sustained (lasting >60 seconds) atrial fibrillation with the use of programmed atrial stimulation. Actual atrial vulnerability was defined by the presence of both latent vulnerability and inducibility of sustained atrial fibrillation lasting >60 seconds. RESULTS: We found atrial vulnerability in 58% of patients with atrial septal abnormalities and in 25% of patients without (odds ratio=4.1 [95% CI, 1.3 to 12.7; P<0.02]). The difference between patients with and without PFO or between patients with both PFO and ASA and those without were also significant. Patients with inducible sustained atrial fibrillation had more frequent past history of palpitations and syncope than patients without (P<0.02). CONCLUSIONS: Atrial vulnerability is associated with atrial septal abnormalities in patients with cryptogenic stroke. This result raises the question of the potential role of transient atrial arrhythmias in thrombus formation in the presence of PFO or ASA.

[Brain imaging in AIDS]. / Imagerie encéphalique du SIDA.

Encephalic diseases remain an important problem in AIDS patients despite improvement in the rate of disease spread. We provide data on the current situation and describe the clinical, pathological and imaging features commonly observed in encephalic diseases in AIDS patients.