Tara Snelgrove BSc, MSc, Faculty of Medicine, Memorial University of Newfoundland, St. John’s, NL.
Proton Rahman MD, MSc, FRCPC, Associate Professor of Medicine, Department of Medicine, Division of Rheumatology, Memorial University of Newfoundland, St. John’s, NL.

Rheumatoid arthritis is the most common etiology for inflammatory arthritis in the older population, with an estimated prevalence of 2%. An older individual with inflammatory polyarthritis usually falls into one of two categories. The first consists of patients with well-established long-standing disease, whose course is often confounded by end organ damage and toxicity related to antirheumatic drugs. The other category comprises patients with late-onset inflammatory polyarthritis, whose presentation is often nonspecific and, thus, more elusive to diagnose. Systemic lupus erythematous can also occur in the older adult; it is less prevalent than rheumatoid arthritis and is associated with multiple organ involvement, including musculoskeletal symptoms.
Key words: rheumatoid arthritis, systemic lupus erythematosus, inflammatory polyarthritis, late-onset disease.

Peter G. Passias, MD, 4th year resident, Tufts Affiliated Hospitals Orthopedic Surgery Residency Program, Medford, MA, USA.
James V. Bono, MD, Clinical Professor of Orthopedics, Tufts University School of Medicine; Director of Education, New England Baptist Hospital, Medford, MA, USA.

Total hip arthroplasty (THA) is one of the most commonly performed and successful operations in orthopedic surgery in terms of clinical outcome, implant survivorship, and cost-effectiveness. The average age for a patient undergoing a THA is 66 years. As life expectancy continues to increase in developed nations and the percentage of the population that is older than 65 years rises, THA surgery will be more frequently performed. This change in demographics is clinically relevant as the indications, risks involved, and outcomes are not identical to those of younger THA candidates. Osteoarthritis is by far the most common diagnosis among patients undergoing primary elective THA. Other common diagnoses include rheumatoid arthritis, other types of inflammatory arthritis, post-traumatic arthritis, and osteonecrosis of the femoral head. Patients that are candidates for THA have radiographic evidence of hip joint degeneration together with the clinical symptoms of disabling pain and functional limitation despite adequate nonsurgical management. The following article attempts to summarize some of the key issues regarding THA in an older population.
Key words: total hip arthroplasty, osteoarthritis, avascular necrosis, hip fracture, older population.

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

Kevin D. Gross PT, PhD, Boston University Clinical Epidemiology Research and Training Unit, and the Department of Medicine at Boston Medical Center, Boston, MA, U.S.A.
David J. Hunter MBBS, PhD, Boston University Clinical Epidemiology Research and Training Unit, and the Department of Medicine at Boston Medical Center, Boston, MA, U.S.A.

Despite the increasing prevalence of symptomatic knee osteoarthritis, many uncertainties exist pertaining to its management. Many putative risk factors are characterized by excessive loading of vulnerable joint structures. Clinical examination includes assessment of knee function and the influence of modifiable risks such as malalignment, muscle strength, and obesity. Knee braces, footwear, exercises, and dieting are prescribed for the purpose of improving the distribution of loads on the knee, and reducing the likelihood that osteoarthritis (OA) and its symptoms will worsen. In this conservative approach, pharmaceuticals of low toxicity are preferred and given only when other methods fail to achieve functional improvement.
Key words: knee osteoarthritis, mechanical risk factors, nonpharmacologic management, physiotherapy, joint replacement.

Timothy Daniels, MD, FRCSC, Associate Professor, University of Toronto, Toronto, ON.
Eran Tamir, MD, Department of Orthopaedic Rehabilitation, Sheba Medical Center, Tel-Hashomer, Israel.

Neuropathic foot complications are increasing in frequency, and surgery is becoming recognized as an important adjunct to their treatment and prevention.
The development of a diabetic foot ulcer is a multifactorial process; however, the presences of obvious and/or subtle foot deformities are being recognized as a significant contributing factor.
Off-loading of the affected area is the standard of care and commonly results in healing the noninfected neuropathic ulcer. Methods of off-loading can be broadly categorized as external (nonweightbearing, casting, braces, orthotics, and shoes) or internal (surgical intervention to correct the deformity).
Reconstructive surgery can prevent foot complications when conservative methods fail. By correcting the musculoskeletal deformity, the areas at risk are off-loaded so that the prevention of ulcer becomes less dependent on protective footwear and patient compliance.
Key words: Diabetic foot, ulceration, off-loading, surgery, reconstruction.

Joseph F. Coffey, BSc, MD, PGY4 Dermatology, University of Alberta, Edmonton, AB.
Gordon E. Searles, OD, MD, MSc, FRCPC, Assistant Clinical Professor; Program Director, University of Alberta, Edmonton, AB.

As the population ages, the corresponding rise in incidence of skin cancer and photodamaged skin necessitate skin assessments of older patients in the dermatology clinic. Sallowness, wrinkles, solar lentigos, and other benign conditions reflect extensive ultraviolet damage to the skin, and provide a background of mutagenesis for skin cancer formation. Some treatments available for photodamaged skin are cosmetic and only available in a dermatology or plastic surgery office setting. However, there are many treatments that improve sun-damaged skin as well as prevent progression to skin cancer formation; these tools are available in the primary care physician’s office. This article addresses ablative and nonablative treatment options for sun-damaged skin and encourages the promotion of sun-safe behaviours, including use of protective clothing and sunscreen.
Key words: photoaging, therapy, prevention, cosmetic, nonablative, ablative.

Patricia K. Long, FNP-C, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.
David W. Ollila, MD, Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, University of North Carolina, Chapel Hill, NC.

Proper management of patients with biopsy-proven melanoma is vitally important. Patients with melanoma in situ, invasive melanoma <1 mm thick, and invasive melanoma >1 mm thick should have surgical resection margins of 5 mm, 1 cm, and 2 cm, respectively. All patients with melanomas >1 mm should be offered a sentinel node procedure, the most important prognostic variable in this group of patients. All patients with metastatic melanoma in the sentinel node should undergo a complete therapeutic lymphadenectomy.
Key words: melanoma, margin of resection, sentinel node biopsy.

D. Larry Sparks, PhD, Senior Scientist and Head, Roberts Laboratory for Neurodegenerative Disease Research, Sun Health Research Institute, Sun City, AZ, USA.

The primary care physician is often pressed with first-line treatment of Alzheimer’s disease (AD). A number of FDA-approved therapies are available. Emerging data indicate that circulating cholesterol levels may influence progression of the dementing disorder. A recent pilot, proof-of-concept, placebo-controlled clinical trial suggests that the cholesterol-lowering medication atorva-statin provides benefit in treating mild-to-moderate AD. Although not approved for the treatment of AD, statin therapy might be considered in the setting of elevated cholesterol levels--even when LDL/HDL ratios are acceptable.
Key words: Alzheimer’s disease, cholesterol, statins, dementia, atorvastatin.

Anna J.M. van de Sande, BSc, Medical Student, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands. Visiting Medical Student, Canadian VIGOUR Center, University of Alberta, Edmonton, AB.
Paul W. Armstrong, MD, Professor, Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB.
Padma Kaul, PhD, Assistant Professor, Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, AB.

The burden of cardiovascular disease increases significantly with age. One of the most complex decisions facing clinicians is whether or not to perform coronary revascularization in an older patient. Our review of recent evidence on revascularization therapies for aging patients with non-ST-elevation acute coronary syndromes found an inverse relationship between age and the use of evidence-based medications as well as revascularization procedures. Older patients undergoing revascularization had a higher likelihood of adverse outcomes compared with younger patients undergoing revascularization. However, older patients who underwent revascularization had significantly better outcomes than their counterparts who did not undergo revascularization, suggesting that they deserve the same consideration as younger patients in the use of coronary interventions.
Key words: acute coronary syndromes, percutaneous coronary intervention, coronary artery bypass graft surgery, evidence-based medications, outcomes.

Patrice Bourée, MD, Head of the Department of Tropical Medicine, Bicetre Hospital (AP-HP); Paris-XI University, Paris, France.

The older population continues to increase; these individuals generally have substantial leisure time and are in good mental and physical health. As a result, they take the opportunity to travel. To avoid unnecessary risks, trips should be carefully planned with regard to updating immunizations according to the destination. Some older individuals suffer from chronic diseases which, though not a contraindication to travel, should be considered. Their medication should be reviewed with regard to the climate; there may be a need for specific travel medication such as chemoprophylaxis of malaria. It may be necessary to seek the advice of different specialists related to the patient’s medical problem. With careful planning, older adults shall remember only the pleasant moments of the trip.
Key words: immunization, travel, older adults, infectious disease, advice.

Michael A. Drebot, PhD, Chief, Viral Zoonoses, Zoonotic Diseases and Special Pathogens, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada.
Harvey Artsob, PhD, Director, Zoonotic Diseases and Special Pathogens, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada.

Since its introduction into North America in 1999, West Nile virus (WNV) has rapidly expanded its range across the continent. There is evidence that it has moved into the Caribbean and South and Central America. The virus has significantly affected public health, causing more than 20,000 cases of associated illness and resulting in the largest WNV epidemic ever recorded. Although neuroinvasive disease occurs in less than 1% of infections, the risk for encephalitis and other neurological illnesses increases with age. Currently there is no specific therapy for the treatment of WNV-associated disease and a vaccine is not yet available. Decreasing the risk of virus exposure requires seasonal preventative and control measures.
Key Words: West Nile virus, epidemiology, diagnosis, neurological illness, disease prevention.