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Issues in the Treatment of Osteoarthritis

Issues in the Treatment of Osteoarthritis

Teaser: 

Dr. Shafiq Qaadri, MD, Family Physician and CME Lecturer, Toronto, ON.

Introduction
With the demographic shift in Canada--the "greying" of its population--arthritis is a growing health concern. A leading cause of long-term disability in Canada, arthritis and other musculoskeletal diseases result in $17.8 billion in lost productivity annually.1 Currently, four million Canadians are affected by arthritis, and the number of people afflicted is expected to double in the next 20 years.2 Already, 33% of Canada's seniors have osteoarthritis,2 the most common form of arthritis in older adults.

Effective osteoarthritis care requires a spectrum of approaches on the biopsychosocial model including: advice on carrying out daily activities (coping with fatigue, protecting joints, using orthotics); controlling pain through approaches such as relaxation therapy, massage therapy, hydrotherapy or acupuncture; using walking/assistive devices; and learning more about arthritis from organizations or websites. Self-help groups are a particularly valuable resource for arthritis patients.

Many patients ask about alternative remedies such as glucosamine or chondroitin, which have shown some effectiveness in studies. A full discussion of complementary therapies for arthritis is presented on the Arthritis Society website at www.arthritis.ca.

Medication remains the mainstay for controlling arthritis pain of all types.

Cholinesterase Inhibitors in the Treatment of Vascular Dementia

Cholinesterase Inhibitors in the Treatment of Vascular Dementia

Teaser: 

Chris MacKnight, MD, MSc, FRCPC, Division of Geriatric Medicine, Dalhousie University, Halifax, NS.

Introduction
Vascular dementia is common, and currently there is no accepted therapy aimed at the cognitive symptoms. Prevention of further strokes is, of course, well established.1 Evidence is accumulating that the cholinesterase inhibitors, proven therapy in Alzheimer disease (AD), may also be of use in vascular dementia (VaD). This paper will summarize that evidence.

Epidemiology of Vascular Dementia
Vascular dementia can be diagnosed when there is a high degree of suspicion that cognitive impairment and stroke are related. Various criteria exist, which unfortunately do not overlap to any great extent, but all share several features.2 These include: the presence of stroke, either clinical or found on neuroimaging; the presence of focal neurologic signs, such as asymmetric power or a positive Babinski response; and a characteristic course, with a sudden onset or stepwise progression. For the highest degree of confidence in the diagnosis, a temporal relationship between the stroke and the dementia is required.

In most surveys of older adults, vascular dementia is the second most common cause of dementia in the community, after AD. In Canada, the prevalence of VaD is 1.5% in people 65 and over, and 5.1% for AD.3 Other surveys have found similar values.

Aggressive Treatment for Prostate Cancer in the Elderly: When is it Appropriate?

Aggressive Treatment for Prostate Cancer in the Elderly: When is it Appropriate?

Teaser: 

James Brown, MD, Minimally Invasive Urologic Oncology Fellow
Department of Urology, Thomas Jefferson University, Assistant Professor of Urology
Medical College of Georgia, Augusta, GA, USA.

Leonard G. Gomella, MD, Bernard Godwin Associate Professor of Prostate Cancer
Director of Urologic Oncology, Department of Urology, Kimmel Cancer Center,
Thomas Jefferson University, Philadelphia, PA, USA.

Abstract
The treatment options for localized prostate cancer are extensive and highly controversial. Although there is general agreement that symptomatic metastatic disease should be treated by hormonal ablation, there is no consensus on how to treat patients with localized disease. While an argument can be made not to screen any patient for prostate cancer, many organizations, including the American Urological Association, support both screening and the treatment of prostate cancer in men with a life expectancy of greater than 10 years. In the asymptomatic, older man with localized, low-risk disease, characterized by a low Gleason score, low PSA and low clinical stage, observation may be the treatment of choice. However, in the older man with localized prostate cancer and high-risk features such as a high Gleason score, aggressive treatment is warranted since many of these men will progress and ultimately die of prostate cancer.

Parkinsonian Dementia: Diagnosis, Differentiation and Principles of Treatment

Parkinsonian Dementia: Diagnosis, Differentiation and Principles of Treatment

Teaser: 

Ali Rajput, MBBS, FRCPC and Alex Rajput, MD, FRCPC
Division of Neurology, University of Saskatchewan, Saskatoon, SK.

The terms parkinsonism and Parkinson syndrome (PS) are used interchangeably. Two of the three cardinal features--bradykinesia, rigidity and tremor--are necessary to make a diagnosis of PS. Several pathological entities and neuroleptic drugs may produce PS, the most common being Parkinson's disease or idiopathic Parkinson's disease (PD), which is characterized by marked neuronal loss in the substantia nigra and Lewy body (LB) inclusions (Figure 1 is not available online). The prevalence of PS in the Canadian general population is estimated at 300 per 100,000.1 The mean age of onset is 62 years, with both incidence and prevalence rates increasing with age. In a Canadian survey of a community population over age 65 years, 3% had PS.2

Alzheimer disease (AD) is the most common dementing illness in the industrialized countries. Marked cortical neuronal loss, plaques and intraneuronal neurofibrillary tangles are pathological features of AD (Figures 2A and 2B are not available online). More than 5% of the general population over 65 years of age have AD.

Because both PD and AD occur in old age, some individuals will have both. Pathological studies suggest that this overlap is higher than expected in unselected large autopsy series.

Catechol-O-methyltransferase Inhibition in Treatment of Parkinson’s Disease

Catechol-O-methyltransferase Inhibition in Treatment of Parkinson’s Disease

Teaser: 

Zhigao Huang, MD, PhD, Clinical Fellow,
Ajit Kumar, DM, Clinical Fellow,
Joseph Tsui, MD, FRCPC, Professor, Department of Medicine, University of British Columbia, Vancouver, BC.

Introduction
Long-term treatment with dopaminomimetic drugs is often complicated by the occurrence of motor complications in Parkinson's Disease (PD) patients. This is especially true with levodopa, which remains to date the mainstay of treatment of PD. These motor complications consist of fluctuations and dyskinesias. Fluctuations refer to predictable or unpredictable changes of motor response that occur in relation to levodopa administration. Dyskinesias refer to abnormal excessive movements. Motor fluctuations can affect up to 50% of PD patients after five years of levodopa treatment.1 The main categories of fluctuations are 'wearing-off' and 'on-off.' Clinically, 'wearing-off' is characterized by a shortened duration of motor response and a rapidly waning effect in response to each oral dose of levodopa. 'On-off' refers to random fluctuations in motor response seemingly unrelated to levodopa administration.2

In early PD, the motor response to levodopa administration lasts longer than would be inferred from the plasma half-life of levodopa. Presumably, this phenomenon is related to surviving nigrostriatal neurons being able to store dopamine (DA) synthesized from exogenous levodopa, thus serving a buffer-like function.

Parkinson’s Disease: An Update on Therapeutic Strategies

Parkinson’s Disease: An Update on Therapeutic Strategies

Teaser: 

Daniel S Sa, MD and Robert Chen, MBBChir, MSc, FRCPC
Division of Neurology and Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON.

The treatment of Parkinson's Disease (PD) has undergone major changes over the past decade with the introduction of new drugs and the development of more advanced and reliable surgical procedures. However, the role of each of these different treatment alternatives is not yet clearly defined. Frequently raised questions include the most appropriate treatment in early PD and determining which patients with more advanced PD are suitable for surgery. In this review, we will attempt to address some of these issues.

Initial Treatment
The first decision to make is when to begin treatment. Since there is no therapeutic strategy proven to halt or slow disease progression, treatment initiation should be related to the level of disability. Therefore, drug therapy should be initiated when symptoms are interfering with social or occupational functions. This is usually due to impaired motor function but sometimes is related to embarrassment.

The next question is which treatment to offer. There is a long-standing debate regarding whether to start with levodopa or dopamine agonists. The levodopa proponents argue that it is still the most effective therapy for PD, and early treatment (before postural instability) has been proven to reduce mortality.

Cardiac Tumours: Presentation and Treatment

Cardiac Tumours: Presentation and Treatment

Teaser: 

Nimesh D. Desai1, MD, Jagdish W . Butany, MBBS MS, FRCPC2
Departments of Cardiac Surgery
1 and Pathology2, Toronto General Hospital / University Health Network and University of Toronto, Toronto, ON.

Introduction
Cardiac tumours are uncommon,when compared to other tumours. A few of these are more frequently seen in the young (first and second decade of life),while most are more common in older individuals ( fourth decade of life and later). When they occur they are more likely to be metastatic than primary cardiac neoplasms, the latter more likely benign than malignant, and the former more common in older individuals.Their manifestations are varied and invariably pose a diagnostic challenge. The first pre-mortem diagnosis of an intracardiac myxoma was not made until 1952, using angiography.1 Today, the accurate clinical diagnosis of cardiac tumours is made with non-invasive techniques such as echocardiography.

Incidence
Autopsy studies have shown an incidence of between 0.0017 and 0.3 percent for primary cardiac tumours.2,3 In adults the mean age at diagnosis of tumours is: sarcoma 40 years; myxoma 50 years; mesothelioma, 57 years; papillary fibroelastoma, 59 years; and lipomatous hypertrophy, 64 years.4 The incidence of secondary or metastatic cardiac tumours is significantly greater than that of primary tumours and is approximately 1.23%.

Ovarian Cancer in Older Women: Management and Treatment Options

Ovarian Cancer in Older Women: Management and Treatment Options

Teaser: 

Natalie S. Gould MD, Fellow and Clinical Instructor
D. Scott McMeekin MD, Assistant Professor Section of Gynecologic Oncology,
Department of Obstetrics and Gynecology
University of Oklahoma Medical Center, Oklahoma City, OK, USA.

Ovarian cancer is a disease of older women, with 48% over the age of 65 at diagnosis.1 It is also the most deadly of gynecologic malignancies, accounting for more deaths than cervical and endometrial carcinoma combined in the US. An estimated 23,400 new cases of ovarian cancer will be diagnosed in 2001 with 13,900 deaths in the US.2 As our population ages, the number of women affected by ovarian cancer will increase. Cancer limited to an ovary is typically silent and discovered incidentally on exam or at surgical exploration for other reasons. Patients with disease that has spread beyond the ovaries may present with vague gastrointestinal symptoms, bloating, diarrhea, pain and changes in bowel or bladder habits. On physical exam, patients will have a pelvic mass and often ascites. Due to the absence of symptoms until the malignancy has spread beyond the ovaries, and the lack of good screening tests, approximately 70% of patients present with advanced disease and overall survival is poor.3 (Table 1).

Initial management involves cytoreductive surgery aimed at removal of the greatest volume of tumour (Table 2).

Role of Venlafaxine and Bupropion in the Treatment of Depression in the Elderly

Role of Venlafaxine and Bupropion in the Treatment of Depression in the Elderly

Teaser: 

Kiran Rabheru, MD, CCFP, FRCPC, Active Staff, Geriatrics Psychiatry,London Psychiatric Hospital, London, ON.

Depression is the most common psychiatric disease in the elderly, and is a problem of major public health importance; however, it is underrecognized and undertreated, particularly in primary care and long-term care settings.1 Major depression may affect up to 20% of hospitalized elderly while up to 30% of older persons in the community suffer from milder forms of depression. In many, the symptoms are persistent or recurrent, resulting in increased disability, worsening of symptoms caused by other medical illness, greater health care utilization, and higher mortality from suicide as well as other medical causes such as vascular diseases.

Antidepressant medication, although not adequate or sufficient on its own, is often an essential part of the treatment plan for an older person who suffers from a significant burden of depressive symptoms. A dysregulation of the central neurotransmitters, norepinephrine (NE), serotonin (5-HT) and dopamine (DA), has been suggested to be part of the underlying mechanism in major depression.

In recent years, newer compounds have been introduced that have similar efficacy but far fewer side effects than do tricyclic antidepressants (TCA).

The Role of Angiotensin Receptor Blockers in the Treatment of Congestive Heart Failure: An Evolving Controversy

The Role of Angiotensin Receptor Blockers in the Treatment of Congestive Heart Failure: An Evolving Controversy

Teaser: 

D'Arcy Little, MD, CCFP, Academic Fellow, Department of Family and Community Medicine, University of Toronto, and Director of Medical Education, York Community Services, Toronto, ON.

Introduction
Congestive heart failure (CHF) is a serious common, condition. It qualifies as one of the most important contributors to cardiovascular morbidity and mortality in the developed world. Due to the burgeoning elderly population, as well as to new treatments for acute myocardial infarction which are allowing more patients to survive with impaired ventricular function, the incidence of CHF will continue to increase dramatically.1 While significant improvements in CHF therapy have been made in the last few decades with the development of angiotensin-converting enzyme inhibitors (ACE inhibitors), as well as a clarification of the role of beta-blockers in therapy, additional strategies are still needed to further reduce progression of disease and consequent morbidity and mortality.1,2 Angiotensin receptor blockers (ARB) may represent an additional approach to the treatment of CHF with the possibility for improved outcomes. Despite physiological explanations that would make such an assertion sound, significant supporting clinical data are currently lacking.