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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.

Advances in Revascularization Procedures of the Lower Extremities in the Treatment of Peripheral Vascular Disease

Advances in Revascularization Procedures of the Lower Extremities in the Treatment of Peripheral Vascular Disease

Teaser: 

Ernane D. Reis, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.
Osvaldo J. Yano, MD, Attending Vascular & Endovascular Surgeon, Saint Francis Hospital, Roslyn, NY.

Introduction
Peripheral vascular [arterial] disease (PVD) of the lower extremities is a result of generalized atherosclerosis, and has the same risk factors as do stroke and myocardial infarction.1 PVD is associated with increased mortality even in asymptomatic patients,2 and is an important cause of complications and death after successful coronary revascularization.3,4 Twenty-five percent of patients with limb-threatening ischemia die within one year of diagnosis.2 In patients older than 60 years, the prevalence of clinically detectable PVD is approximately 15%, and claudication occurs in up to 5%.2 PVD also reduces ambulatory capacity and quality of life and, therefore, represents an enormous human and financial burden to individual patients and society.5

During the last decade, management of arterial disease of the lower extremities has undergone remarkable changes. A true medical revolution is ongoing, as a consequence of the successful introduction of new technologies that can be used alone or in conjunction with established surgical and radiological methods.

Influence of Age on the Outcomes of Percutaneous and Surgical Treatment of Multivessel Coronary Artery Disease Patients

Influence of Age on the Outcomes of Percutaneous and Surgical Treatment of Multivessel Coronary Artery Disease Patients

Teaser: 

Results from the Multicentre Randomized Arterial Revascularization Therapy Study

V. Legrand1 MD, PhD, FESC,
P. Serruys
2 MD, PhD, FACC, FESC,
WK Lindeboom
3 PhD,
M. Vrolix
4 MD,
G. Fransen
4 MD,
P. Materne
5 MD,
G. Dekoster
5 MD,
R. Seabra-Gomes
6 MD,FESC,
J. Queiroz E Melo
6 MD

1CHU Liege Belgium.
2Thoraxcenter, Rotterdam, The Netherlands.
3Cardialysis, Rotterdam, The Netherlands.
4St Jansziekenhuis, Genk, Belgium.
5CHR Citadelle, Liege, Belgium.
6Hosp Santa Cruz, Carnaxide, Portugal.

Key words : coronary angioplasty, stent, coronary bypass surgery, elderly.

Introduction
As the population ages, an increasing number of elderly patients are presenting with symptomatic multivessel coronary artery disease requiring revascularization. However, the most appropriate myocardial revascularization procedure for older patients with multivessel disease is still controversial. Indeed, it is well recognized that the procedure-related morbidity associated with either percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) increases dramatically with age.

The Efficacy and Safety of Tamsulosin for the Medical Treatment of Benign Prostate Hyperplasia

The Efficacy and Safety of Tamsulosin for the Medical Treatment of Benign Prostate Hyperplasia

Teaser: 

Levent Ozdal, MD, Research Fellow, Department of Urology, McGill University, Montreal, QC.
Simon Tanguay, MD, FRCS(C), Associate Professor, Department of Urology, McGill University, Montreal, QC.

Benign prostate hyperplasia (BPH) is the most common benign neoplasm in aging men. Although microscopic evidence of BPH occurs in 80% of men who are at least 80 years old, clinical enlargement of the gland only occurs in half of all men in this age group. Furthermore, symptomatic disease only develops in about half of men with clinically enlarged prostate glands.1

Lower urinary tract symptoms (LUTS) of BPH can be obstructive or irritative in nature. Most symptoms occur and progress slowly in aging men. The treatment of BPH is usually indicated once patients develop either moderate or severe symptoms, or in the presence of complications due to bladder obstruction. Complications of BPH due to chronic obstruction include recurrent urinary tract infection, bladder stones, incontinence, gross hematuria, urinary retention or renal failure.

The aim of BPH treatment should include improving or eradicating symptoms, reversing the complications of the disease and preventing additional sequelae. Treatment is typically based on the severity of symptoms and patient preference.

Treatment of Hypertension in the Elderly

Treatment of Hypertension in the Elderly

Teaser: 

Anne-Sophie Rigaud, Hôpital Broca, CHU Cochin-Port-Royal, Paris, France.
Bernard Forette, Centre Claude Bernard de Gérontologie, Hôpital Sainte Périne, Paris, France.

Abstract
Diastolic blood pressure is considered an important risk factor for the development of cerebrovascular disease, congestive heart failure and coronary heart disease. However, it is now clear that isolated systolic hypertension and elevated pulse pressure play an important role in the development of these diseases, which are the major causes of cardiovascular morbidity and mortality among subjects aged 65 years and older. The benefit of antihypertensive therapy in reducing the incidence of cardiovascular and cerebrovascular complications has been shown for systolic and systolo-diastolic hypertension in all age groups. Because of the higher risk of cardiovascular disease in the elderly, the effect of antihypertensive treatment appears greater in patients over 60 or 65 years when expressed as an absolute risk reduction.

Definition
Essential (i.e. primary) hypertension is the main cause of hypertension in the elderly population. However, secondary, especially renovascular hypertension is more common in older than in younger adults. The incidence of hypertension in the elderly is high. In an ambulatory population aged 65-74, the overall prevalence is 49.6 % for stage 1 hypertension (140-159/90-99 mmHg), 18.2% for stage 2 (160-179/100-109 mmHg), and 6.

A New Treatment for Patients with Alzheimer Disease

A New Treatment for Patients with Alzheimer Disease

Teaser: 

G. Tong, MD, PhD
Jody Corey-Bloom, MD, PhD
Department of Neurosciences,
University of California San Diego, CA, USA.

 

Introduction
Alzheimer disease (AD), the most common form of dementia in the elderly, is characterized clinically by multiple cognitive deficits, including memory loss, visuospatial impairment, disorientation and language dysfunction. These features are often accompanied by behavioural and mood changes. A definitive diagnosis of AD can only be made by biopsy or autopsy. The major neuropathological features of AD are neuritic plaques and neurofibrillary tangles.

Cholinergic neurotransmission in the central nervous system (CNS) plays a key role in memory, attention, learning and other cognitive processes. Although other neurotransmitter deficiencies (e.g., noradrenaline, dopamine, serotonin and glutamate) have been noted, the cognitive impairments seen in AD patients have been largely attributed to decreased cholinergic neurotransmission. AD, in part, is characterized by the loss of neurons in basal forebrain cholinergic cells, especially in the nucleus basalis of Meynert, which projects to the cerebral cortex and hippocampus.