Chris Chan, MD, FRCPC
Fellow in Nephrology,
University of Toronto

Over the past two decades, the main strategies that have been used to protect patients against the loss of renal function include lowering their blood pressure and restricting the intake of dietary protein. The efficacy of the above treatments has been limited and a novel therapeutic target is required. In the past decade, landmark clinical trials with pharmaceutical agents that inhibit the renin-angiotensin system (RAS) have demonstrated a dramatic attenuation of the decline in renal function that is associated with diabetic and non-diabetic nephropathies. It is now recommended that inhibition of the RAS should be standard care for patients with proteinuric nephropathies.

Theoretical Basis of Renoprotective Benefits of RAS inhibition
Several authors have reviewed this topic in detail and interested readers should review the articles cited in the references.¹ The seminal studies were performed by Brenner et al. using the 5/6 nephrectomy animal model.^2,3 In these rats, extensive renal parenchyma is destroyed, which results in a compensatory increase in single nephron glomerular filtration rate and in the elevation of glomerular capillary hydraulic pressure. Pathologically, the rats developed focal glomerulosclerosis and proteinuria. This proteinuria was prevented, following treatment with enalapril.

Dimitrios G. Oreopoulos
Nada Dimkovic
Toronto Western Hospital,
University Health Network

Introduction
The elderly (>65 years) are the fastest growing group of patients who require dialysis. In 1988, of the more than four thousand new dialysis patients, one thousand nine hundred and fifty eight were 65 years or older, giving an approximate rate of 515 new patients per million members of the population.

Once an elderly patient has developed end-stage renal disease (ESRD), his/her therapeutic options become limited to the various modes of dialysis that are available and, to a lesser degree, to renal transplantation.

Here we should mention a word of caution with regards to using serum creatinine as a guide for the point at which to begin dialysis. Because of the decrease in muscle mass that is associated with age, serum creatinine is disproportionately low for the degree of renal failure. Rather than relying on serum creatinine, either a creatinine clearance, or the Cockroft-Gault formula should be used to assess the severity of renal failure.

Although renal transplantation may be successful in the elderly person with ESRD, and they may have renal graft and patient survival rates comparable to those of younger recipients, only a small percentage (0.5-3%) of these patients are undergoing transplant procedures. The main reason for this is the shortage of donor kidneys.

Medications May be of Limited Use for Treatment of Sexual Aggression in Dementia

Kiran Rabheru, MD, CCFP, FRCP(C)
Active Staff, Geriatrics
Psychiatry, London Psychiatric Hospital, London, ON

Until recently, most studies in dementia have focussed almost exclusively on cognitive dysfunction, rather than on the behavioural and psychological disturbances that occur in dementia (BPSD), which are often far more disturbing to the patient's caregivers. Specifically, there is very little published literature on inappropriate sexual behaviour in dementia (ISBsD). A stereotypic view of older adults as sexless, as well as relative disinterest in studying their patterns of sexual behaviour, have probably contributed to this lack of research into this important area.

From the neurologic viewpoint, the limbic system is the source of libido. Illnesses that damage the limbic system, with few exceptions, reduce the libido. Hence, in up to one third of patients with dementia, the change in sexual behaviour is one of sexual apathy. However, in patients with Alzheimer's dementia, hypersexuality and inappropriate sexual expression can also occur, and has been reported in 2 to 7% of these patients. Changes in the frontal lobe can cause alterations in personality such as disinhibition. Damage to the bilateral temporal lobe as a result of trauma, Herpes simplex, encephalitis, infarctions, and rarely, Alzheimer's or frontal lobe dementia (FLD) (e.g.

Dr. Michael J. Taylor

"Apocalyptic demography", "bankruptcy hypothesis of aging", "population aging crisis scenario"--these are only three of the many catch phrases currently being used to describe the impact that an aging population will have on our limited health care resources as we enter the first decade of the new millennium. Almost daily the news media reports stories of emergency departments filled to capacity, lengthy waiting lists for elective surgery and diagnostic imaging, and nation-wide shortages of long-term care beds. Public opinion polls consistently reveal that concerns about the future of health care are uppermost for many Canadians. Whether and how our national health care system, apparently already faltering, will survive the increase in demand that an aging population will impose is already the subject of intense national debate. Some form of health care reform over the upcoming years seems inevitable, but instituting reforms that will ensure the survival of our universally accessible health care system, the pride of many Canadians since its inception in the 1960s, will no doubt prove to be a great challenge to policy makers. This article will attempt to shed light on the complex issue of just how an aging population will affect our health care system; it will also present various perspectives regarding the directions that health care reform could take.

Special commentaries by:
Pierre Larochelle¹,
Ellen P. Burgess²,
Ernesto L. Schiffrin³,
Simon Kouz⁴, and
Michael Adams⁵

¹Assistant Director, Clinical Research Centre,
Centre Hospitalier de l'Université de Montréal-Campus Hôtel-Dieu,
Professor of Pharmacology,
Université de Montréal, Montreal, Quebec.

²Active Staff & Director, Foothills Medical Centre,
Associate Professor of Medicine,
University of Calgary, Calgary, Alberta.

³Director, Multidisciplinary Hypertension Group,
Hypertension & Lipid Clinic and Clinical Research Institute of Montreal, and
Professor of Medicine, Université de Montréal, Montreal, Quebec.

⁴Chief, Cardiology Service & Director,
Clinical Research Unit in Cardiology,
Centre Hospitalier Régional de Lanaudière, Joliette, Quebec.

⁵Head, Department of Pharmacology and Toxicology,
Queen's University, Kingston, Ontario.

Did the Results of the HOPE Trial Come as a Surprise?
Dr. Ernesto L. Schiffrin. Not at all. Our research group has been conducting numerous studies on ACE inhibitors for a number of years.

Introduction
The publication of the landmark Heart Outcomes Prevention Evaluation (HOPE) Study¹ in the New England Journal of Medicine in January 2000 was greeted by a great deal of excitement in the medical community. In essence, the trial confirmed beyond a doubt the cardiac and renal protective benefit of ACE inhibition and extended the patient base in whom ACE inhibition has been proven effective. Our understanding of the cardioprotective nature of ACE inhibitors has been built over the years by the various mega-studies that have been conducted, dating back to the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS),² published in 1987, which showed a 31% survival advantage for ACE inhibition in New York Heart Association (NYHA) class IV heart failure patients. Thirteen years and more than a dozen large trials later, the HOPE study has confirmed that patients need not be so sick--indeed, need only be considered at risk for cardiovascular events--for ACE inhibition to show similar benefits. Looking down the list, from CONSENSUS to HOPE and several landmark trials in between, one would be hard pressed to find a class of agents with a wealth of compelling evidence comparable to that accumulated for ACE inhibitors.

Main Results and Significance
The HOPE study investigators found that 17.

Is it Ethical to Use Foetal Tissue for the Treatment of PD?

David Kaplan, MSc(HA)
Joint Centre for Bioethics
Faculty of Medicine,
University of Toronto

Surgical transplantation of foetal brain cells has been reported to substantially improve the symptoms associated with Parkinson's Disease. Parkinson's disease, which is characterized by tremors, muscular rigidity, and akinesia, is believed to result from the deterioration of the brain's dopamine producing cells in the substantia nigra (the neural centre for the initiation and control of movement). This disease afflicts 70,000 Canadians, and unfortunately, approximately ten percent of these patients are refractory to conventional medical therapy. Clearly, new methods to control the disease would be of substantial benefit to these patients. In 1995, the Canadian government introduced legislation that would have made it difficult, if not illegal, to conduct research into foetal tissue transplant. Although this Bill died on the parliamentary order desk, there remains the prospect of reintroducing such legislation. The purpose of this article is to examine the murky ethical waters that surround the topic of research and therapy involving foetal tissue. However, I will not attempt to validate the merits of this therapy in this brief analysis.

Procurement
Obviously, a source of foetal tissue is required, in order to perform foetal tissue transplantation surgery. There are three potential sources for this tissue.

In 1869, french neurologist Jean-Martin Charcot first described a rapidly progressive, fatal neuromuscular disease. This disease, amyotrophic lateral sclerosis, or Lou-Gehrig's disease, is a neurodegenerative disorder that affects the patient's motor neurons; typically the patient is paralyzed or deceased within 2 to 5 years of the initial diagnosis. Currently, approximately 3000 Canadians suffer from this tragic disease.

Andrew Eisen MD, FRCPC
Professor and Head, Division of
Neurology, University of British Columbia,
Head of the Neuromuscular Diseases Unit,
Vancouver General Hospital

Amyotrophic lateral sclerosis (ALS) is a prototypic neurodegeneration of the aging nervous system. It has a worldwide incidence of about 2 per 100,000 members of the population and a prevalence of 4&endash;7 per 100,000. As is true of both Parkinson's and Alzheimer's disease, the incidence of ALS is increasing proportional to the increasing longevity of the population. Information regarding the specific incidence of ALS in the elderly (aged 75 years and older) is sparse. The apparent decrease in incidence of this disease in patients older than 70 years reflects mortality from competing diseases in later life.

The etiopathogenesis of ALS is complex and multi-factorial.

Alejandro Floh, BSc
Medical student,
University of Toronto

Co-authored by:
D'Arcy L. Little, MD, CCFP
Director of Medical Education and Research
York Community Services, Toronto, ON

Introduction
Family physicians are frequently faced with patients who complain of the swelling of one or both of their legs. Although many cases of leg swelling are benign, a systematic approach is necessary in order to avoid overlooking a potentially serious condition.

The principle cause of leg swelling is edema.² Edema is a general term that refers to a "clinically apparent increase in interstitial volume"¹, which arises from capillary filtration that exceeds lymphatic drainage.

History
A comprehensive history is the first step in making a diagnosis of leg swelling. Initially, leg swelling should be classified into two broad categories: unilateral versus bilateral, and acute versus subacute or chronic. In general, this classification should allow one to differentiate between local diseases, which are usually unilateral, and manifestations of systemic conditions, that present as unilateral or bilateral swelling. Major local conditions include deep vein thrombosis (DVT), superficial thrombophlebitis, and cellulitis. Systemic illnesses such as congestive heart failure (CHF), cirrhosis, nephrotic syndrome, and malnutrition usually present with bilateral swelling of the lower extremities.

How to Deliver a Riveting Lecture

As I write these lines, I am sitting through a long, exceedingly dry, and from my own perspective, mostly irrelevant, medical lecture. If this were a rare event, or one that only occurred when I was in the audience, there would be no reason to continue with this piece. In fact, just as I began to pen the end of the previous sentence, the chin belonging to the person seated next to me dropped precipitously to his chest.

There is much evidence (albeit anecdotal) to suggest that this process, oft repeated around the world, is one of the greatest wastes of time known to professional people.

One must first consider the origin and history of "the lecture", to fully comprehend how such a profligate dissipation of professional person-hours has been allowed. Before Herr Guthenberg's timely invention, books were both exceedingly rare and restrictively expensive; as a result, they were not available to the majority of the populace, which in any case, was mostly illiterate.

In medieval universities, the art of teaching involved a professor reading aloud to his students from the one available book. (Thus the word lecture: through Middle English, via Middle French, originating from Latin: lectura, from lectus [past participle of legere: to gather, select, read.])

Books, and the knowledge that lies therein, have always represented power.