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.

Maida J. Sewitch, PhD, Assistant Professor, Department of Medicine, McGill University, and the Divisions of Gastroenterology and Clinical Epidemiology, The Research Institute of the McGill University Health Centre, Montreal, QC.
Caroline Fournier MSc, Research Associate, Division of Clinical Epidemiology, The Research Institute of the McGill University Health Centre, Montreal, QC.

Colorectal cancer (CRC) is a commonly diagnosed cancer and a leading cause of cancer deaths in Canada and the industrialized world. According to cancer registries, incidence varies by age, geographical location, site, and time. CRC screening reduces both CRC incidence through removal of premalignant polyps and CRC deaths through early detection and treatment. Health Canada considers CRC an ideal target for mass screening of individuals 50 years of age and older. This article reviews the epidemiology of CRC and the reasoning behind the development of screening guidelines for persons 50 years of age and older. Various Canadian and U.S. guidelines are detailed. Routine screening of average-risk individuals is advocated. Finally, the review highlights trends in patient utilization of CRC screening as well as the role of screening in an aging population.
Keywords: aging, colorectal cancer, epidemiology, screening, adenomatous polyps.

Lodovico Balducci, MD, Professor of Oncology and Medicine, University of South Florida College of Medicine and H. Lee Moffitt Cancer Center and Research Institute; Director, Division of Geriatric Oncology, Department of Interdisciplinary Oncology; Tampa, FL, USA.

The need for physicians to manage cancer in older patients is increasingly common. Cytotoxic chemotherapy for lymphoma, cancers of the breast, of the colorectum, and of the lung may be as effective in older individuals as in younger adults provided that patient selection is individualized on the basis of life expectancy and functional reserve rather than chronologic ages; the doses of chemotherapy are adjusted to the Glomerular Filtration Rate (GFR); prophylactic filgrastim or pegfilgrastim are utilized to prevent neutropenic infections; and hemoglobin is maintained at 120gm/l.
Keywords: Cancer, aging, older adult, chemotherapy, toxicity.

Yosuke Wakutani, MD, Centre for Research in Neurodegenerative Diseases, Departments of Medicine, University of Toronto, and Toronto Western Hospital Research Institute, Toronto, ON.
Peter St. George-Hyslop, MD, Centre for Research in Neurodegenerative Diseases, Departments of Medicine, University of Toronto, and Toronto Western Hospital Research Institute, Toronto, ON.
Ekaterina Rogaeva, PhD, Centre for Research in Neurodegenerative Diseases, Departments of Medicine, University of Toronto, and Toronto Western Hospital Research Institute, Toronto, ON.

There are ~200 human diagnostic categories presenting as or accompanying dementia (interested readers may investigate the database Online Mendelian Inheritance in Man, a catalog of human genes and genetic disorders, at www.ncbi.nlm.nih.gov/ genome/guide/human/). Many forms of dementia are associated with deposition of different aberrant proteins in the brain. Familial aggregation in Alzheimer’s disease (AD), frontotemporal dementia (FTD), and other forms of dementia implies the presence of inherited susceptibility factors. Many forms of dementia remain genetically unexplained; however, linkage analyses suggest that most of them are complex disorders with several underlying genetic factors. Here we provide an update on known genes responsible for dementia with the strongest focus on AD and FTD, which are the most common forms of dementia.
Key words: dementia, Alzheimer’s disease, gene, APP, APOE, frontotemporal dementia.

Silja Majahalme, MD, PhD, FESC, Cardiologist and Clinical Hypertension Specialist, Appleton Heart Institute/Appleton Cardiology Associates, Appleton, WI, USA.

Heart failure (HF) is an increasing problem in the older adult population, specifically among women. The majority of health care expenses are generated in the last few years of life, and hospitalization for HF is one of the major medical conditions influencing the expenditure. The nature of women’s HF differs from men: coronary artery disease is the most common etiologic factor for HF in men while women more often suffer from hypertensive heart disease, which results in stiffness of the left ventricle with relaxation problems, and diastolic HF. Most commonly there is a long history of poorly controlled hypertension. In acute situations these patients often present with florid edema and congestion along with significantly elevated blood pressure levels, which are both challenging to treat. This short review covers issues related to gender differences in etiology and epidemiology of HF, and evaluates current evidence for drug therapies.
Key words: epidemiology, heart failure, gender, myocardial infarction, hypertension.