Geoffrey F. Dervin, MD, MSc, FRCS(C), Associate Professor, University of Ottawa and the Ottawa Hospital, Orthopaedic Division, Department of Surgery, Ottawa, ON.

Understanding the options for treatment of osteoarthritis of the knee will allow physicians to help their patients realize the physical and social demands of healthy life. Weight loss, physical therapy and unloading braces are clinically proven strategies in the early stages of the disease. Acetaminophen remains the analgesic of choice, while COX-2 NSAIDs are reserved for flare-ups and short-term use. Oral glucosamine and chondroitin sulfate also may be helpful. Persistently swollen knees may respond to aspiration and corticosteroid injection or viscosupplementation with hyaluronic acid derivatives. Those with acute onset of mechanical symptoms may respond to arthroscopic débridement and resection of unstable meniscal tears. Osteotomy of the tibia or femur are options for isolated unicompartmental disease in younger and more active patients. Arthroplasty of one or all compartments of the knee is the definitive procedure for end-stage arthrosis with very dependable results in most clinical settings.
Key words: osteoarthritis, knee, arthroplasty, acetaminophen, older people.

Part 1: Introduction, Head and Neck, and Cranial Nerves

David J. Gladstone, BSc, MD, Fellow, Cognitive Neurology and Stroke Research Unit, Sunnybrook and Women's College Health Sciences Centre and Division of Neurology, University of Toronto, Toronto, ON.

Sandra E. Black, MD, FRCPC, Professor of Medicine (Neurology), University of Toronto; Head, Division of Neurology and Director, Cognitive Neurology Unit, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON.

Abstract
This four-part series of articles provides an overview of the neurological examination of the elderly patient, particularly as it applies to patients with cognitive impairment, dementia or cerebrovascular disease. The focus is on the method and interpretation of the bedside physical examination; the mental state and cognitive examinations are not covered in this review. Part 1 begins with an approach to the neurological examination in normal aging and in disease, and reviews components of the general physical, head and neck, neurovascular and cranial nerve examinations relevant to aging and dementia. Part 2 covers the motor examination with an emphasis on upper motor neuron signs and movement disorders. Part 3 reviews the assessment of coordination, balance and gait. Part 4 discusses the muscle stretch reflexes, pathological and primitive reflexes, sensory examination and concluding remarks.

91st annual meeting of the American Association for Cancer Research

While a number of analgesics are shown to inhibit tumour growth, anti-cancer properties of acetaminophen appear to work earlier during the neoplastic process. According to the recent research at the New York Medical College in Valhalla, acetaminophen can prevent the beginning of colon cancer by blocking the action of food mutagens. Treatment of rats with acetaminophen prior to the administration of 3,2'dimethyl-4-aminobiphenyl (a carcinogen, similar to the one formed during cooking) "produced a marked cytoprotective effect," Dr. Gary Williams, principal investigator of the study, said at the 91st annual meeting of the American Association for Cancer Research. While these results are very exciting, clinical trials with people at risk for colon cancer are necessary to determine whether administration of acetaminophen would reduce this risk in humans.

Neil P. Fam, BSc

Arthritis has been called the sleeping giant of Canadian health care. According to Statistics Canada, over 3 million Canadians suffer from osteo-arthritis (OA), with another 300,000 affected by rheumatoid arthritis (RA).¹ Together, these diseases represent one of the leading causes of chronic disability, lost productivity and worker absenteeism in Canada.² As our population ages, more patients are presenting to physicians with musculoskeletal complaints, most of which center around chronic joint pain.

Treatment of the pain of arthritis involves both pharmacologic and non-pharmacologic approaches. Traditionally, treatment of OA and RA has revolved around the use of non-steroidal anti-inflammatory drugs (NSAIDs). Although these medications are often effective in relieving pain, they are associated with significant gastrointestinal and renal complications. Elderly patients are particularly prone to life-threatening complications such as GI bleeding and perforation. For these reasons, other treatment modalities are often utilized. This article presents an overview of pain management strategies, with a focus on OA, the single most common cause of arthritis in seniors.

OA pain

In the management of osteoarthritic pain in the elderly, the best approach is to begin with therapies that are inexpensive and have a low risk of side effects. The following is a stepwise approach, summarized in Table 1.

Lilia Malkin, BSc

According to a study conducted by Dr. Elaine Hyle and associates at the Massachusetts General Hospital and Harvard Medical School in Boston and reported in the March 4, 1998 issue of the Journal of the American Medical Association (JAMA), acetaminophen significantly increases the level of anticoagulation, measured and commonly reported as the international normalized ratio (INR). Other important risk factors for increased anticoagulation identified in the study included decreased food intake, diarrhea, and increased warfarin dosage, as well as a recently initiated course of antibiotics or other medications previously known to augment the response to warfarin. Hylek and associates also identified factors that inversely affected the INR, such as alcohol and increased dietary intake of Vitamin K.