Christina M. Canil, MD, FRCPC, Clinical Research Fellow and Jennifer J. Knox, MD, MSc, FRCPC, Staff Medical Oncologist; Department of Medical Oncology and Hematology, Princess Margaret Hospital, University Health Network, Toronto, ON.

Renal cell carcinoma is more prevalent in older people. The incidence of this cancer is rising secondary to incidental detection on routine imaging. In localized disease, radical nephrectomy is standard therapy; however, options of laparoscopic procedures or surveillance may be appropriate for small tumours. Treatment of advanced or metastatic renal cell carcinoma is limited and the main goal of therapy is palliation of symptoms. Nephrectomy and surgical removal of metastases have been shown to improve survival in patients with good performance status. Results with chemotherapy have been disappointing, but clinical trials of novel systemic agents are underway.
Key words: renal cell carcinoma, kidney cancer, older person, nephrectomy, interferon.

Milita Crisby, MD, PhD, Neurotec Department, Division of Geriatric Medicine, Stockholm, Sweden.

The interaction of genetic and multiple environmental factors contributes to the development of Alzheimer disease (AD). Hypertension and hypercholesterolemia have been identified as risk factors for ischemic heart disease (IHD). Recent epidemiological data also have revealed an association between hypercholesterolemia and AD. Experimental models of AD and in vitro studies have shown that cholesterol modulates the amyloidogenic pathway in favour of production and deposition of amyloid in the brain. Dysregulation of the lipid metabolism in the brain due to apolipoprotein E4 or 24-hydroxylase polymorphisms has been observed in patients with AD and related dementias. Furthermore, observational studies have revealed that statin use could have a potential role in the prevention of AD.
Key words: cholesterol, statins, lipid-lowering, Alzheimer disease, neurodegeneration.

A Review of the Literature

Alan K. Berger, MD, Sections of Cardiology and Epidemiology, University of Minnesota, Minneapolis, MN, USA.

While elderly patients (aged = 75 years) represent a small segment of the general population, they account for disproportionate morbidity and mortality associated with acute myocardial infarction. Consequently, the efficacy and utilization of reperfusion therapy--thrombolysis and primary coronary angioplasty/stenting--remain highly relevant. A randomized clinical trial of thrombolysis in the elderly has never been performed, although subgroup analyses have suggested a benefit. The effectiveness of thrombolysis in the elderly has been challenged by observational studies documenting unexpectedly high mortality. The efficacy of primary coronary angioplasty/stenting is now well established and growing evidence suggests this approach is superior to thrombolysis in the elderly.
Key words: geriatrics, thrombolysis, primary coronary angioplasty, acute myocardial infarction, guidelines.

Charles D. Ray, MD, FACS, FRSH (Lond.), President, American College of Spine Surgery; President, International Spine Arthroplasty Society; Past President, North American Spine Society, Yorktown, VA, USA.

Stenoses, or nerve entrapment, can occur at several sites. The focus here is on lumbar spine segments. Compression by stenosis can exist wherever nerve tissue is protectively covered by bone or where thick ligaments are located adjacent to nerve. Overgrowth of bone by spurs is the most common cause of compression producing disability and pain. Neurologic changes are rare. Diagnostic radiological imaging is needed, sometimes aided by selective injections of medications. Due to the limitations of non-surgical treatment, surgical decompression is common with generally good results.
Key words: spinal stenosis, vertebral bone spurs, claudication, surgical decompression, nerve injections.

Benjamin R. Davis, BSc, DDS, FRCD(C), Department of Oral and Maxillofacial Surgery, Queen Elizabeth II Health Sciences Centre, Halifax, NS.

Temporomandibular disorders (TMDs) are common and can be divided into either muscular or intra-joint conditions. With advancing age, the craniomandibular complex undergoes changes that are similar to other musculoskeletal structures. Many of these changes may explain the decrease in incidence of TMDs seen in the older population. Conservative treatment is usually effective at decreasing TMD pain and improving function. A small percentage of patients will benefit from surgery when appropriate conservative measures have failed, and an intra-joint etiology has been definitively established.
Key words: temporomandibular disorders, aging, facial pain, temporomandibular joint surgery.

Oksana Davidovich, BSc, DCh (Chiropodist), Private Practice, Davisville Foot Clinic; President, Ontario Society of Chiropodists, Toronto, ON.

The incidence of foot problems increases with age, and may impair mobility and interfere with independent living. Although most podiatric conditions may be treated effectively with conservative measures by a chiropodist or podiatrist, older patients are often reluctant to report foot problems to their physician. Common structural foot ailments in the older population include digital deformities, metatarsalgia and heel pain. Skin and nail conditions also are prevalent, such as fungal or ingrown toenails, as well as corns and calluses. Given that osteoarthritic joint changes in the lower extremities may compromise gait and stability, foot orthoses and footwear have the potential to improve foot function.
Key words: chiropodist, podiatric, footwear, foot problems, gait.

Geoffrey F. Dervin, MD, MSc, FRCS(C), Associate Professor, University of Ottawa and the Ottawa Hospital, Orthopaedic Division, Department of Surgery, Ottawa, ON.

Understanding the options for treatment of osteoarthritis of the knee will allow physicians to help their patients realize the physical and social demands of healthy life. Weight loss, physical therapy and unloading braces are clinically proven strategies in the early stages of the disease. Acetaminophen remains the analgesic of choice, while COX-2 NSAIDs are reserved for flare-ups and short-term use. Oral glucosamine and chondroitin sulfate also may be helpful. Persistently swollen knees may respond to aspiration and corticosteroid injection or viscosupplementation with hyaluronic acid derivatives. Those with acute onset of mechanical symptoms may respond to arthroscopic débridement and resection of unstable meniscal tears. Osteotomy of the tibia or femur are options for isolated unicompartmental disease in younger and more active patients. Arthroplasty of one or all compartments of the knee is the definitive procedure for end-stage arthrosis with very dependable results in most clinical settings.
Key words: osteoarthritis, knee, arthroplasty, acetaminophen, older people.

Herbert P. von Schroeder, MD, MSc, FRCSC, University of Toronto Hand Program and Toronto Western Hospital, University Health Network, Toronto, ON.

Osteoarthritis is a highly prevalent and disabling condition of the hand in the geriatric population. It is commonly and effectively managed by surgical means. The interphalangeal joints and base of the thumb are most frequently involved, particularly in women, whereas post-traumatic osteoarthritis of the wrist is more common in men. Surgical procedures include simple debridement, soft tissue stabilization or osteotomies for milder cases. Joint arthroplasty, including excision procedures, and joint arthrodesis (fusion) are indicated for more severe arthritis. The type of procedure used depends on the location of the affected joint, patient age and physical demands placed on the hand. Surgery can effectively alleviate pain and improve hand function to improve an individual's quality of life.
Key words: osteoarthritis, hand, arthrodesis, arthroplasty, surgery.

Feisal A. Adatia, MD, MSc, First Year Ophthalmology Resident, University of Toronto, Toronto, ON.

The Internet has become the world's greatest information resource. Physicians have come to depend on sites such as MD Consult (www.mdconsult.com) and PubMed (www.pubmedcentral.org) for their clinical queries, and family physicians have found Family Practice Notebook (www.fpnotebook.com) to be a valuable resource. As well, journals such as the Canadian Medical Association Journal (www.ecmaj.ca) and Geriatrics & Aging (www.geriatricsandaging.ca) are available online to allow physicians to keep up with new developments in medicine.

With the SARS outbreak, the international community has used the Internet to share knowledge and information. The World Health Organization has responded to the threat of SARS by using its website to publish daily updates about the number of worldwide cases, thus allowing analysts to monitor the progress of this outbreak. In the U.S., the Centers for Disease Control and Prevention has posted dozens of fact sheets, travel advisories and a breakdown of domestic cases by state on its site.

Moreover, the Internet has become a trusted way to communicate, with e-mail having supplanted the use of the telephone in many regards. Given these changes, there is a great deal of excitement over new technologies that allow physicians to have the power of the Internet in a wireless device. Wireless systems also provide ways to share Internet connections and information between computers.

Bluetooth™ Wireless Technology
Bluetooth and Wireless Fidelity, or Wi-Fi, technologies are reshaping the way the Internet can be accessed. Bluetooth provides a means for devices to communicate with one another. This short-range technology allows for a wireless voice and data link between a broad range of devices, including desktops, notebooks, handheld computers, printers, mobile phones and digital cameras. Bluetooth creates a Wireless Personal Area Network (WPAN) consisting of all the Bluetooth-enabled electronic devices immediately surrounding a user, allowing these devices to communicate with one another. With this technology, desktop computers can send files to a printer, handhelds can synchronize with a notebook computer, one can surf the web via a mobile phone, and a wireless headset can be used to talk on a cell phone while driving. Physicians can use a Bluetooth-enabled notebook or handheld computer, such as the Palm Tungsten T, Sony TG50, iPAQ h5455 or Toshiba e740, to connect to the Internet via a Bluetooth-enabled cell phone, from companies such as Nokia, Motorola, Samsung and Sony Ericsson. However, to communicate, these devices need to be in close proximity, usually less than 10 metres.

Wireless Fidelity Technology
Wi-Fi technology allows one to develop a network, linking enabled devices through radio waves transmitted from a base station or access point. With this technology files can be shared between computers, and a single Internet connection can be shared by many computers. A larger range of approximately 100 metres allows this technology to become more feasible for broad access in public places.

It seems likely that many of us will adopt this technology, with mainstream pushes from suppliers such as Intel whose Pentium M chip, branded Centrino, includes Intel's Pro Wireless 2100 802.11b (Wi-Fi) module, expected to be included in 125 models of notebook computers by the end of this year. Palm's Tungsten C and certain HP iPAQ and Toshiba handhelds are currently Wi-Fi enabled. Intel is also teaming with Hilton Hotels and Resorts, Borders Group and McDonald's restaurants to offer wireless access to customers in certain areas. Mainstream Wi-Fi access is even available at Starbucks locations in the U.S., with 2,000 cafes expected to be wired for Wi-Fi by this year's end. AT&T and IBM have formed a company called Cometa Networks Inc. and plan to blanket the 50 largest U.S. metropolitan areas with public wireless access points, or "hot spots". Toshiba and Accenture also plan to have 10,000 hot spots across North America by the end of the year. In Canada, Toshiba has announced plans for a nationwide pay-per-use network of hot spots in more than 1,000 locations, including coffee chains, hotels and travel terminals. Bell Canada, Toronto-based Rogers Cable Inc. and Calgary's Shaw Cable Inc. also are expected to provide Wi-Fi access points, with Bell Canada having recently run a pilot project offering free wireless access at 19 public places in Montreal, Toronto, Kingston and Calgary.

In the health care setting, U.S. hospitals are using this technology to help provide working environments that will attract nursing staff. Internet Protocol (IP) wireless headset phones can use a Wi-Fi network to make and receive telephone calls. This allows nurses to answer doctors' pages on the spot, rather than having to hustle to a nursing station telephone. They can also use laptops or phones to update medical charts at bedsides. In fact, even north of Toronto at the Markham-Stouffville hospital, nurses use Wi-Fi-enabled laptops to feed information into the hospital's electronic documentation system from a patient's bedside. Although the employment of this technology is just beginning in the hospital environment, it is likely to become increasingly important in health care.

Technologies such as Wi-Fi are going mainstream and, perhaps more intriguingly, may revolutionize the accessibility of hospital staff and data access in our hospitals. In the future, wireless networks and everywhere access to the Internet may be a standard in clinical practice and in our homes.

Robert S. Sheldon, MD, PhD, FRCP(C) and Satish R. Raj, MD, FRCP(C), Cardiovascular Research Group, University of Calgary, Calgary, AB.

Implantable cardioverter-defibrillators are pacemaker-like devices that sense and treat ventricular tachycardia and ventricular fibrillation, and are generally used in an aging population. They have been proven in large randomized clinical trials to prevent death in patients who have already survived a life-threatening episode of ventricular arrhythmias. Recent studies have expanded their indications to the prevention of arrhythmic death in patients who have risk factors for this disorder. How widely they will be used, and at what cost, is unknown.
Key words: implanted defibrillator, arrhythmia, sudden death, anti-arrhythmic therapy, heart disease.