Roger E.Thomas,MD, Ph.D., CCFP, MRCGP, Professor, Department of Family Medicine, University of Calgary, and Cochrane Coordinator, University of Calgary, Calgary, AB.

Recent evidence has shown that vaccination against influenza is effective in reducing the complications of influenza (pneumonia, hospitalization for influenza or pneumonia, and deaths due to influenza or pneumonia) for those 60 years and over living in long-term care facilities (LTCs) during periods of high viral circulation if the vaccine has a good match to the circulating strain. Vaccination was found to be similarly effective for those 60 and over living in the community. There is further evidence that health care workers should be vaccinated for their own benefit, as vaccination is demonstrably effective for healthy adults under 60, and most health professionals are under 60.There is some evidence that vaccination of these workers may provide additional protection for residents of LTCs from the complications of influenza. Influenza can be detected by rapid office-based tests and should be used when the pretest probability of influenza is less than 30%. The evidence suggests that oseltamivir and zanamivir are effective in reducing the symptoms of cases and reducing infections in households and contacts of cases.
Keywords: influenza, older adults, vaccination, prevention of influenza, antivirals.

Edward Etchells,MD, MSc, FRCP, Division of General Internal Medicine and Patient Safety Service, Sunnybrook & Women’s College Health Sciences Centre; Associate Professor, Department of Medicine, University of Toronto,Toronto, ON.
Tasnim Vira, BScPhm, Medical Student, Faculty of Medicine,University of Toronto, Toronto, ON.
Vincent C.Tam,MD, BSc(Hon), Internal Medicine Resident, Department of Medicine, McMaster University, Hamilton, ON; Thunder Bay, ON.

Medication errors at the time of acute care transition (admission, transfer, and discharge) are common. Health care providers can reduce these errors by obtaining an insightful medication history, documenting medication changes in medication orders and on discharge prescriptions, and promoting close teamwork among physicians, nurses, and pharmacists. The patient and family can also play an active role in reducing these errors. Medication reconciliation is a method for identifying and rectifying medication errors at transition. Reconciliation is a safe medication practice promoted by the Safer Healthcare Now campaign and is an accreditation requirement by the Canadian Council on Health Services Accreditation (CCHSA). Debates about the need for better studies examining the impact of reconciliation are ongoing.
Keywords: medication error, patient safety, hospital admission, discharge, transfer.

Meera George, JD, Postgraduate Fellow, Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VA Medical Center, Houston,TX, USA.
Aanand D. Naik,MD, Assistant Professor, Health Services Research and Geriatrics, Baylor College of Medicine; Houston Center for Quality of Care and Utilization Studies, Michael E. DeBakey VA Medical Center, Houston,TX, USA.

Many older adults have difficulty bathing.Those unable to bathe are more likely to need formal home care and to be admitted to long-term care than those who can bathe without help. Disability with bathing function is complex, involving multiple subtasks; inability to perform those subtasks has many attributable causes. Bathing disability can be remediated through timely diagnosis and prescription of appropriate assistive devices and adaptations to the home bathing environment. Clinicians have an important role in the diagnosis of bathing disability, and collaborative planning of bathing remediation with patients, caregivers, and allied health providers is key.
Keywords: activities of daily living, assessment, disability, assistive devices.

Kristine E. Pringle, Ph.D., Health Care Consultant, First Health Services Corporation/PAPACE, Harrisburg, PA, USA.
Frank M. Ahern, Ph.D., Senior Research Associate, Department of Biobehavioral Health, Pennsylvania State University, University Park, PA, USA.
Debra A. Heller, Ph.D., Senior Health Care Consultant, First Health Services Corporation/PA-PACE, Harrisburg, PA, USA.

Many medications have the potential to interact with alcohol, and older patients may be at greater risk of experiencing adverse effects due to issues of comorbidity and polypharmacy. Even small amounts of alcohol consumed by an older person who is taking multiple medications can have serious consequences. A retrospective analysis linked prescription claim records with self-reported alcohol use. Results showed that 77% of older adults used at least one alcohol-interactive medication, and 19% of alcohol-interactive drug users reported concomitant alcohol use. Because many individuals are unaware of the risks posed by alcohol and medications, it is important for clinicians to warn patients about potential interactions.
Keywords: older adults, alcohol, prescription drug use, alcohol-drug interactions, concomitant use of alcohol and prescription drugs.

Marie D.Westby, BSc(PT), PhD Candidate, Mary Pack Arthritis Program,Vancouver Coastal Health, School of Rehabilitation Sciences, University of British Columbia,Vancouver, BC.
Linda Li, BSc(PT), PhD, Harold Robinson/Arthritis Society Chair, Assistant Professor, School of Rehabilitation Sciences, University of British Columbia,Vancouver, BC.

Physiotherapy aims to prevent physical impairment and restore functional ability through the use of exercise, education, and physical modalities. While there is solid evidence supporting physical activities in the management of arthritis, inactivity continues to be a problem among both younger and older patients with arthritis as compared to the general population. Current evidence supports the effectiveness and safety of moderate- to highintensity aerobic and strengthening exercises for osteoarthritis and stable rheumatoid arthritis. Participation in recreational activities does not replace the need for therapeutic exercises. Physicians and health professionals should be equipped with strategies to overcome barriers and facilitate treatment adherence when prescribing exercise.
Keywords: osteoarthritis, rheumatoid arthritis, physical therapy, exercise, physical activity.

Patrick Couture,MD, FRCP(C), PhD, Lipid Research Center, Laval University Medical Center, Laval,QC.
Nancy Gilbert, RN, Lipid Research Center, Laval University Medical Center, Laval,QC.

Several lines of evidence suggest that triglyceride-rich lipoproteins contribute significantly to the development of atherosclerosis. However, the relationship between cardiovascular disease and plasma levels of triglyceride remains complex due to the presence of two major confounders: (1) the inverse relationship between plasma triglyceride levels and highdensity lipoprotein-cholesterol and (2) the heterogeneity in triglyceriderich lipoprotein size, number, and composition between individuals. Plasma apo-B measurement is recommended for patients with high triglyceride levels to identify their risk category.The goals of lipidmodifying therapy for these patients are to reduce the atherogenic lipoprotein number and to increase HDL particle number.
Keywords: triglyceride, lipoprotein, atherosclerosis, coronary heart disease, cholesterol.

Lynne T. Shuster, MD, Women’s Health Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
Sharonne N. Hayes, MD, Women’s Heart Clinic, Department of Internal Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
Mary L. Marnach, MD, Women’s Heart Clinic, Department of Gynecology, Mayo Clinic College of Medicine, Rochester, MN, USA.
Virginia M. Miller, PhD, Departments of Surgery and Physiology and Biomedical Enginering and Office of Women’s Health, Mayo Clinic College of Medicine, Rochester,MN,USA.

Women in the Western world may expect to spend a significant portion of their lives in postmenopause. After menopause, women are at increasing risk for several conditions associated with aging that may or may not be related to declining hormone levels. Caring for women seeking advice and treatment for menopausal concerns presents a golden opportunity to not only identify individuals at risk for early intervention but also to address prevention and screening strategies important to sustaining health.
Keywords: cancer, cardiovascular disease, menopause, osteoporosis, screening.

Margaret Fitch, RN, PhD, Head, Oncology Nursing and Supportive Care; Director, Psychosocial and Behavioural Research Unit,Toronto Sunnybrook Regional Cancer Centre, Toronto, ON.

Ovarian cancer has more than a physical impact.There are also emotional, psychosocial, spiritual, and practical consequences for those women diagnosed with the disease. These women face many challenges— lives are changed irrevocably with the diagnosis, and life becomes a series of transitions. In caring for women with ovarian cancer, health care providers must be sensitive to myriad concerns these patients may have and try to understand the issues from the perspective of those experiencing them.
Structures and processes need to be established within care facilities that allow patients to have regular comprehensive assessment, good symptom management, effective communication, and individually tailored support.The availability of timely and relevant referral to other experts when needed is of key importance at moments of care transition.
Keywords: supportive care, ovarian cancer, older women, psychosocial concerns, emotion.

The accredited CME learning activity based on this article is offered under the auspices of the CE department of the University of Toronto. Participating physicians are entitled to one (1) MAINPRO-M1 credit by completing this program, found online at www.geriatricsandaging.ca/cme.htm

Nehmat Houssami, MBBS, MPH, MEd, FASBP, FAFPHM, PhD, Screening & Test Evaluation Program, School of Public Health, University of Sydney, Sydney, Australia.
J. Michael Dixon, MBChB,MD, FRCS, FRCSEd, FRCP, Edinburgh Breast Unit,Western General Hospital, Edinburgh, Scotland.

The incidence of breast cancer increases with advancing age, and the relative frequency of benign breast disease (BBD) decreases. Therefore, all breast symptoms or abnormalities should be assessed with triple testing (clinical examination, imaging, +/-percutaneous needle biopsy if a localized lesion is identified) to establish a diagnosis.The spectrum of BBD changes substantially from about age 45 onwards.We review some of the benign conditions that occur in older women, such as cysts and duct ectasia, and describe clinical features and management.We also discuss specific BBDs that may be encountered more frequently and in a much older population of women than was previously identified, a consequence of both increased incidence of BBD due to past use of hormone replacement therapy and improved detection.
Key words: benign breast disease, triple test, breast neoplasms, breast cyst, duct ectasia.

To the Editor:
The omission of Dukoral™* (oral, inactivated traveller’s diarrhoea and cholera vaccine) from Dr. Patrice Bourée’s article “Safe Foreign Travel” (Geriatrics & Aging 2006;7:472-8) was surprising, especially since the author comments that “traveller’s diarrhea occurs in up to 50% of travellers in tropical areas.”
Could the author comment?

K.M. Laycock

Dr. Patrice Bourée responds:
The reader’s question is not surprising for me. I have not forgotten the matter of vaccination with Dukoral™. I am familiar with this vaccine, manufactured by SBL Vaccin AB (Stockholm) with Vibrio cholerae 01, killed by heat or formol and B-subunit choleric toxin. But, according to the French Health Ministry, the official recommendations are “such a vaccination is not justified for travellers who wash their hands and practice adequate personal hygiene. It is only justified for health teams who are working in a cholera-infected area or in a refugee’s camp.”¹ This does not apply to the typical older traveller. Travellers should be attentive to the risk of acquiring cholera, but the risk is very low for most travellers who do not encounter conditions of severe poverty. The fear of this disease is used to promote food safety.² Besides, “the effectiveness of such a vaccine is not proved in people of 65 years old and more.”¹ So, my failure to mention it is not an omission but my estimation that this vaccine is not recommended for older adults.

However, the indications for this drug pose an interesting problem that is not yet satisfactorily resolved. Opinions differ markedly in Europe, Canada, and in the United States on the matter of this and other agents, and it is difficult to say which perspective is best. There is a similar conflict regarding agents used to treat traveller’s diarrhea: in the U.S., bismuth subsalicylate is used as first-line therapy, while this agent is strictly forbidden in France and is not available.

Sincerely yours,
Dr. Patrice Bourée

*Note: Dukoral was approved for use in Canada in 2003. It is indicated for active immunization against disease caused by Vibrio cholerae serogroup O1 in adults and children from two years of age who will be visiting endemic/epidemic areas.

1. Comité Technique des Vaccinations. Guide des vaccinations. INPES, Paris, 2006, 125-9.
2. DuPont HL, Steffen R. Textbook of Travel Medicine. BC Decker: Hamilton, Ontario, 1997: 86-91.