The article "SPECT May Help Resolve Dementia Diagnosis," in the January/February issue fails to mention EEG in diagnosis of dementia, a test cheaper than SPECT and CT. EEG is quite sensitive, correlates with prognosis, and is specific withing a given clinical context.

Your title "May Help Resolve" may generate unnecessary referrals for SPECT scanning in this situation. At a time of rigorous health care funding, we need to utilise only those tests which are clearly going to benefit the patient in a cost-effective manner. This article does not advance that goal.

Sincerely,

Warren T. Blume, MD, FRCPC,
Professor,
Department of Clinical Neurological Sciences,
Epilepsy and Clinical Neurological Sciences,
London Health Sciences Centre,
London, Ontario

P.S. The cost of EEG versus SPECT scanning is $51.20 and $162.50 respectively.

Use of oral contraceptives may lower the risk of hip fracture later in reproductive life, according to a report in the May 1st issue of the Lancet. Previous studies have shown a protective effect of postmenopausal oestrogen therapy on the risk of having a fracture. However, whether or not oral contraceptives, which also contain the hormone oestrogen, can confer a similar risk is not clear.

Dr Karl Michaëlsson and colleagues, from Sweden and the USA, collected data on all cases of hip fracture that occurred between October 1993, and February 1995, among women in Sweden. Questionnaires were then posted to these women who had had a hip fracture (the cases), and to a group of women who had not had a hip fracture (the control group) to ascertain details about the women's previous use of oral contraceptives.

Of the 1327 cases, 130 (11.6%) had used oral contraceptives. Of the 3312 controls, 562 (19.1%) reported previous use of oral contraceptives. The use of oral contraceptives was associated with a 25% reduction in risk of having a hip fracture later in life. Women who had previously taken an oral contraceptive containing a high dose of oestrogen had a 44% reduced risk of hip fracture.

Oestrogen in the oral contraceptive pill acts on bone, via a mechanism that is as yet unclear, making bones denser and stronger. After a woman has gone through menopause, her bone mass decreases naturally. The researchers postulatee that by increasing the bone mass before menopause, the mass will decrease by less overall, and state that oral contraceptive users appear to reach the menopause with a bone density 2 to 3% higher than that of non-users.

*Provided by The Lancet.

Contact: Dr Karl Michaëlsson, University Hospital, S 75185 Uppsala, Sweden
tel +46 18 663000; fax +46 18 509427; e-mail: Karl.Michaelsson@ortopedi.uu.se

Valerie Ha, BSc

In the past ten years, public campaigning on behalf of breast cancer has raised awareness to new heights. Despite an increase in the incidence of breast cancer over the past twenty years (most likely due to better detection of disease), we have seen a plateau and even more recently a decline in the mortality rates in both Canada and the United States. This is likely due to our ability to diagnose disease earlier through breast screening and our improvements in treatment.

Breast Screening is indeed a major player in our fight against breast cancer. It is estimated that a significant reduction in breast cancer mortality can be achieved in Ontario if 70% of women between the ages of 50-69 were to participate in a program of early detection.

Breast cancer screening involves participation in biennial mammograms, monthly self-examination and regular breast examination by a trained professional; a regimen that should be followed during the years that the woman is most likely to be affected.

Shechar Dworski, BSc

Osteoarthritis (OA) is common in the elderly, affecting as many as 80% of people aged 55 and over. It is the most common form of arthritis, occurring mostly, but not exclusively, in the elderly. It is also the most common musculoskeletal disease in the elderly. It affects mostly the hands, as well as the major weight bearing joints of the body which are primarily the hips and knees. Please refer to the article on Osteoarthritis: Early Diagnosis Improves Prognosis in the May/June 1999 issue of Geriatrics & Aging for more information on the symptoms and specific aspects of OA. There are several routes one may take to treat OA, as well as many preventive measures. Joint replacement is usually the last step, when all other treatments have been unsuccessful. At this stage of disease, people often have difficulty walking and climbing stairs, and have joint pain at rest and at night. In this case, joint replacement therapy is extremely effective at relieving pain and improving function.

Joyce So, BSc

Benign prostatic hyperplasia (BPH) is a non-malignant condition of nodular but symmetrical enlargement of the prostate in the peri-urethral region, likely due to androgen imbalances associated with aging. It is common in men over the age of 40, regardless of ethnic background. The incidence of BPH can be as high as 50% by the age of 60, and 90% by age 85.¹ This makes BPH a condition of increasing importance as the population ages.

Because of its proximity to the urogenital tract, prostatic enlargement most commonly presents as obstructive lower urinary tract symptoms, although some are asymptomatic (see Figure 1). Bladder outlet obstruction, causing incomplete emptying and subsequent rapid filling, results in urgency, frequency, and nocturia as the primary presenting complaints. The weak and reduced urinary stream in BPH produces hesitancy, intermittency and post-void dribbling. Urinary retention and stasis predispose BPH patients to infection, which can cause bladder and upper urinary tract inflammation, as well as calculus formation. In severe, prolonged obstruction, there is a risk of hydronephrosis and progressive renal failure and azotemia.

Figure 1. Location of the prostate gland in relations to the urogenital tract

Anna Liachenko, BSc, MSc

Despite potentially serious side effects, non-steroidal anti-inflammatory drugs (NSAIDs) are currently one of the very few options available for alleviating chronic pain and inflammation. Over the past 30 years, scientists searched for safer NSAIDs and managed to create the 20 different drugs and 40 dosing options currently available in Canada. While some of the newer drugs turned out to be safer than others, their design was based largely on trial-and-error. A recent major breakthrough in the understanding of the molecular mechanisms of NSAID action allowed researchers to methodically design a new class of NSAIDs. These new drugs, the Cox-2 Inhibitors or C-2SIs, are not only comparable to the older NSAIDs in efficacy but are also (at least in theory) devoid of some of the most serious side effects. One of these drugs, celecoxib (Celebrex) has just become available in the US and Canada. Another, rofecoxib (Vioxx) is under review by the Food and Drug Administration (FDA) in the US and the Health Protection Branch (HPB) in Canada. Moreover, increased safety of some of the previously approved NSAIDs is now thought to be attributed to the same molecular mechanism. Newly arriving NSAIDs as well as the best NSAID options currently available in Canada are discussed below.

Lilia Malkin, BSc

Heart disease is a major cause of morbidity and mortality in the geriatric population. According to Health Canada, myocardial infarction (MI) and ischemic heart disease (IHD) accounted for over one-third of deaths in men and women aged 65 and older in 1995, once again firmly establishing coronary artery disease (CAD) as the leading cause of mortality in Canada. In Ontario, 23 percent of patients die within one year of experiencing MI and one-third of congestive heart failure (CHF) patients succumb within one year of being hospitalized for CHF. Importantly, as Dr. David Naylor, co-editor of the 1999 Institute for Clinical Evaluative Sciences (ICES) Cardiovascular Atlas points out, the Canadian demographic profile is shifting toward a larger geriatric population, potentially greatly increasing the number of Canadians vulnerable to heart disease. Therefore, it is imperative that both primary and secondary prevention methods be used as extensively as possible to reduce the morbidity and mortality due to CAD.

Rhonda L Witte, BSc

The immune system is an elegant example of nature's work. When functioning properly, it protects us against what is "foreign" and does not attack the "self". Throughout an individual's life, changes occur within the immune system which make defense mechanisms less effective. Immunogerontology--the study of the aging immune system--is an up and coming field of research that will help build our knowledge, not only about the aging immune system, but also about the immune system in general.

The Immune System

Our immune system can be broken down into two interacting components: innate (natural) immunity and acquired (specific) immunity.¹ Innate and acquired immunity differ regarding the effector cells and molecules that carry out their specific and essential functions. Natural immunity is composed of defense systems that are present before exposure to foreign macromolecules and infectious microbes. Physical barriers (i.e. the skin) phagocytic cells and eosinophils, a specific class of lymphocytes called natural killer cells, and a range of blood-borne molecules (i.e. soluble proteins of the complement cascade) make up the natural immune system.² Acquired immunity requires stimulation by exposure to foreign molecules and includes sub-types of lymphocytes (e.g. B- and T-cells), cutaneous and mucosal immune responses and antibodies which circulate to find their target.

Thomas Tsirakis, BA

Bipolar disorder is a recurrent and potentially incapacitating illness affecting a person's mood and behaviour, which manifests itself in different ways throughout its course (Table 1). The first episode of bipolar disorder may be manic, hypomanic (milder form of mania with elevated mood), mixed (both mania and depression), or depressive. Due to the extremely variable nature of the illness, it may present itself differently from patient to patient in terms of the severity and duration of episodes. Often, the type of episode an individual experiences may also follow a seasonal pattern (e.g. hypomanic in the summer and depressed in the winter.) With proper intervention, some people recover completely between episodes and may experience years of symptom-free relief, while others may experience continuous low-grade depression and mild mood swings throughout the course of their lives.

Bipolar disorder is classified according to the symptoms that an individual experiences. In Bipolar I Disorder, an individual will have one or more manic episodes, or mixed episodes, lasting at least one week. Many also experience at least one major depressive episode. In Bipolar II Disorder, a person will have one or more major depressive episodes accompanied by at least one hypomanic episode but no manic episodes.