James M. Wright, MD, PhD, CRCP(C), Professor, Departments of Anesthesiology, Pharmacology & Therapeutics and Medicine, University of BC, Coordinating Editor, Cochrane Hypertension Review Group, Vancouver, BC.

Abstract
Choosing the optimal first-line drug for patients with hypertension must address a hierarchy of treatment goals: reduction in mortality and morbidity, efficacy in lowering blood pressure, ensuring tolerability, and minimizing cost. This article examines the evidence for the different classes of first-line antihypertensive drugs in light of these four goals. The evidence indicates that first-line low-dose thiazides are better than or equivalent to other antihypertensive drug classes for each of the goals of therapy in both people with hypertension in general and in older adults ≥ 60 years of age.
Keywords: hypertension, thiazide, first-line, older adults, evidence-based.

Andrew M. Johnson, PhD, Associate Professor, School of Health Studies, Faculty of Health Sciences, The University of Western Ontario,
London, ON.
H. Christopher Hyson, MD, FRCPC, Assistant Professor of Neurology, Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, ON.
Kaitlyn P. Roland, MSc, Research Assistant, Interdisciplinary Graduate Studies, The University of British Columbia Okanagan, Kelowna, BC.

Abstract
Although Parkinson’s disease is primarily considered to be a motor disorder, it has inarguable effects on cognition and personality. The cluster of neuropsychiatric sequelae known as impulse-control disorders has been of particular interest in recent years, perhaps owing to the potentially disastrous effects that such behaviors can have on individuals and families. Research has suggested that impulse control disorders are significantly more prevalent among individuals with Parkinson’s disease, particularly with regards to pathological gambling and hypersexuality, and has further suggested that these disorders are significantly and substantively affected by the use of dopamine agonists. Treatment options for impulse control disorders tend to revolve around dopamine agonist dose reduction or cessation. The use of psychosocial strategies, or deep-brain stimulation of the subthalamic nucleus may also be considered in the management of patients with impulse control disorders.
Keywords: Impulse control disorders, Parkinson’s disease, dopamine agonists service use.

Shabbir M.H. Alibhai, MD, MSc, FRCP(C), Staff Physician, University Health Network, Toronto, ON, Canada, Assistant Professor, Departments of Medicine and Health Policy, Management, and Evaluation, University of Toronto, Research Scientist, Canadian Cancer Society

Abstract
More than one-half of new cancers and over 70% of cancer deaths occur in adults age 65 or older. Systematic screening has been associated with reductions in cancer- related mortality for a variety of cancers, including breast, cervical, and colorectal cancer. Prostate cancer screening remains more controversial despite the recent publication of two large randomized trials of screening. Although guidelines are beginning to address cancer screening specifically among the growing group of seniors age 70 or older, there is virtually no guidance on estimating remaining life expectancy or considering competing causes of mortality (e.g. comorbid medical illness) in this age group. In this article, I review evidence-based guidelines for cancer screening in adults and discuss the limitations of screening studies with respect to older adults. I have also highlighted new evidence and substantive updates to guidelines since the last publication on cancer screening in Geriatrics & Aging five years ago.

Keywords: cancer screening, aged, mass screening.

Publication of THE LATEST IN ACNE CARE supplement was made possible by an unrestricted educational grant from Galderma Canada Inc.

Maha Theresa Dutil, MD, M.Ed, FRCPC, Assistant Professor of Medicine, Division of Dermatology, University of Toronto, Toronto, ON.

One of the marked changes in the practice of dermatology over the past thirty years has been the increased focus on acne. What was once considered a universal rite of passage that occasionally caused deeply disturbing scars is now considered—by patients and doctors alike—an insufferable condition that must be treated. Perhaps as a sign that available treatments are increasingly successful, acne is showing signs of affecting popular culture. Kid Acne, a British artist (not his real name!), decided to make his affliction his signature so as to stand out in the crowded hip-hop scene. The Uruguayan movie Acné (as you would have guessed, about a thirteen-year-old boy coming of age while enduring acne outbreaks) was a hit of Spanish-speaking cinema in 2008. Acne for Dummies by Dr. Herbert P. Goodheart (a remarkably good book!) ranks a respectable 76th in skin care/ beauty books on Amazon.ca.

Success has bred the desire for even more success. This supplemental publication to Dermatology Times on "Innovations in Acne Care: The Latest Guidelines and Treatment Options" sheds light on new approaches that will be helpful to specialists and GPs alike. Dr. Neil Shear's "Newest Guidelines for the Treatment of Acne" discusses the acne guidelines...

Neil H. Shear, MD, FRCPC, FACP,

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Abstract: This article summarizes key statements from the 2009 Global Alliance to Improve Outcomes in Acne Group's therapeutic guidelines, published as a supplement in the Journal of the American Academy of Dermatology (JAAD). It offers an algorithm for acne treatment, as well as addresses important statements from the committee on acne pathophysiology, epidemiology, and the latest research findings, as they pertain to the guidelines.

Key Words: acne, treatment guidelines, adherence, antibiotic resistance, maintenance.

Dermatologists should be actively contributing to educating other clinicians that acne is a chronic disease.

Despite many extensive educational programs, the committee sees an ongoing need to urgently reduce the use of antimicrobial therapies, especially as single agents.

A combination of a topical retinoid plus an antimicrobial agent is first-line therapy for most patients with acne (a finding based on clinical trials with over 16,000 total subject participants in studies of Level I evidence quality), as it targets multiple pathogenic features and both inflammatory and noninflammatory acne lesions.

The Global Alliance 2009 update affirms that topical retinoids should be fundamentally a core component of an acne therapy regimen for stages I to III. The committee's consensus is that early and appropriate treatment, continued for as long as necessary, is the best approach to mitigating scarring for acne patients.

Implement strategies to improve adherence to therapy (e.g., medication reminders, self-monitoring with diaries, support groups, telephone follow-up) to ensure success.

Treat acne as quickly and as efficiently as possible to achieve the best therapeutic outcomes, and to improve patient satisfaction, limit treatment expenses, and mitigate scarring.

To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.

Dr. Shannon Humphrey,¹ Dr. Joseph Brioux,² Dr. D'Arcy Little,³

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Abstract: Do dermatologists and GPs approach acne care differently? How do these two groups of clinicians approach acne treatment, keep abreast of the latest guidelines, and manage maintenance therapy? How will the availability of a new retinoid combination product in Canada for acne change the way acne is currently treated? To address these questions, a roundtable discussion was convened, featuring clinicians with a significant number of acne patients in their practices. Dr. Shannon Humphrey, a dermatologist, and Dr. Joseph Brioux, a family physician, and moderator Dr. D'Arcy Little, himself a family physician and radiologist, offered a candid take on guideline-based acne treatment and the effort to improve treatment outcomes among patients. The discussants addressed how each professional has tended to view acne, pursues acne care differently, and why. They also discussed the latest acne treatment guidelines as well as the depth of the gap between the generalist's versus the specialist's treatment approach.

Key Words: acne, treatment gap, antibiotic resistance, treatment adherence.

Antiobiotic resistance is a key factor to consider when establishing maintenance and treatment regimens.

Combination retinoid-based therapies are first-line treatments for acne; evidence suggests that such regimens achieve faster and more complete clearance, while addressing multiple pathogenic factors simultaneously.

Patients are often prescribed legitimate, evidence-based therapies but may abandon them after a short trial because of lack of perceived, efficacy or side effects. Address patient expectations and advise on the necessity of pursuing a sufficient course of topical therapy (e.g., 12 weeks) before drawing conclusions.

It is advisable to see patients on maintenance therapy for follow-up—attempt at least two office visits per year, and more if there is an increase in flares.

Convey to patients that acne is a chronic condition and that a sound treatment maintenance regimen is essential.

Do not give samples to patients unless supply is sufficient to pursue a 12-week trial of medication.

To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.

Publication of THE LATEST IN ACNE CARE supplement was made possible by an unrestricted educational grant from Galderma Canada Inc.

Jerry Tan, MD, FRCPC,

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Abstract: Adapalene 0.1%/BPO 2.5% (adapalene/BPO) gel is a novel agent for acne therapy that has recently become available in Canada. This fixed-dose combination of a topical retinoid and benzoyl peroxide is efficacious in mild-moderate inflammatory acne and as an adjunct to oral antibiotics for severe acne. Adapalene 0.1%/BPO 2.5% (adapalene/BPO) gel provides synergistic efficacy, whereby efficacy of the combination exceeds the summed efficacy of individual components. Furthermore, adapalene/BPO with oral doxycycline for severe acne increases the rate of global treatment success four-fold beyond that with doxycycline alone. Practical means to abrogate the development of local intolerability have been shown to be effective.

Key Words: acne, adapalene, benzoyl peroxide, fixed-dose gel, combination, topical acne medication, retinoids.

Three of five pathogenic factors involved in acne can be addressed by topical medications: follicular hyperkeratinization, Proprionibacterium acnes proliferation, and inflammation.

The combination of retinoid and BPO in the form of adapalene 0.1%/BPO 2.5% has recently been approved in Canada, and has been advocated by an international acne expert group as a rational standard for treating mild-moderate acne as it offers complementary mechanisms of action.

An adapalene/BPO formulation provides greater proportions of global success and reduction in acne lesion counts compared to the vehicle or either agent alone.

As topical retinoids and benzoyl peroxide can be irritating, their combination may potentiate this factor. Measures to minimize intolerability include every other night application and daily moisturizer use.

For the treatment of mild-moderate acne, the fixed-dose adapalene and BPO gel combination may enhance treatment efficacy and adherence through improved ease of use.

Benzoyl peroxide does not induce bacterial resistance.

To have access to full article that these tools were developed for, please subscribe. The cost to subscribe is $80 USD per year and you will gain full access to all the premium content on www.healthplexus.net, an educational portal, that hosts 1000s of clinical reviews, case studies, educational visual aids and more as well as within the mobile app.

Guylaine Ferland, PhD,Département de Nutrition, Université de Montréal; Centre de recherche, Institut universitaire de gériatrie de Montréal, Montréal, QC.
Carol E. Greenwood, PhD,Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, and Kunin-Lunenfeld Applied Research Unit, Baycrest, Toronto, ON.
Bryna Shatenstein, PhD, PDt, Département de Nutrition, Université de Montréal; Centre de recherche, Institut universitaire de gériatrie de Montréal, Montréal, QC.

Abstract
While prospective epidemiologic studies have provided strong evidence linking higher intakes of many nutrients with slower rates of cognitive decline and reduced dementia risk, randomized controlled trials on supplementation with individual nutrients have largely been disappointing. In contrast, recent research points to substantial benefits for brain aging and cognition from consumption of a varied diet centred on plant-source foods, whole grains and fish, and avoidance of foods rich in saturated and trans fats. An unhealthy dietary pattern, in conjunction with obesity, low physical activity, and smoking, could contribute to a pro-inflammatory state and oxidative stress which could exacerbate risk for development of cognitive decline the metabolic syndrome, diabetes, and cardiovascular disease.
Keywords: nutrition, dementia, Alzheimer's disease, nutrients, dietary patterns.

Gill Lewin, BSc Hons Psych, MSc Clin Psych, MPH, PhD, FAAG, Professor, Centre for Research on Ageing, Curtin Health Innovation Research Institute, Curtin University of Technology; Research Director, Silver Chain, Perth, Western Australia.

Abstract
Restorative home care services are being developed around the world. While having somewhat different origins and structures, these services share a capacity building paradigm and are designed to assist older people to maximize their functioning and reduce their need for ongoing assistance to complete everyday tasks. The evidence for the effectiveness of these services is positive though limited. In comparison to usual home care, they have been shown to increase individuals' functional abilities, their self-rated health, and their confidence and well-being, and to decrease individuals' need for ongoing care. More research is needed to address a range of unanswered questions about these services.
Keywords: home care, restorative, older adults, functional improvement, service use.