A newly developed wireless application that allows health care providers to transmit patient data and digital photos to consulting physicians at major medical centres and clinics may change the way home-care services are provided.

Pixalere ("pix" for pixel and "alere" meaning "to tend to") is a web-based wireless application designed to manage home-care patients on-site, reducing or eliminating the need for costly and time-consuming trips to their GP or the emergency department. Physicians and home-care nurses in British Columbia are being outfitted with pocket PCs equipped with Pixalere to securely transmit patient reports and compressed digital photographs to consulting nurses or doctors at a central facility.

Remote management of patients with the Pixalere device would be particularly beneficial for nursing home residents for whom it can be difficult or expensive to travel to a clinic to be seen for a few minutes and for relatively routine ailments, such as minor wounds, bedsores and burns, that could be treated locally by nurses on-site. Instead, using a handheld device or laptop computer, a home-care nurse in rural Northern B.C., for instance, will be able to transmit patient data and colour photos for immediate review by consulting specialists in Vancouver efficiently, easily and inexpensively.

Physicians in Hamilton and North Bay, ON. collaborated to perform two successful laparoscopic fundoplication surgeries using remotely controlled robotic arms, making them the world's first hospital-to-hospital telerobotic-assisted surgeries. Though still in early stages of development, the success of these telesurgeries shows promise for a procedure that could bring specialized surgical techniques to rural areas in which specialists are not available.

Using voice commands and his hands to operate the robotic arm 300km away, Dr. Mehran Anvari from St. Joseph's Healthcare Hamilton performed the microsurgery while Dr. Craig McKinley in North Bay assisted on-site. Dr. Anvari was impressed at the ease with which he was able to direct the remotely operated surgical instruments, and was pleased with the duration of the operations. With network backup systems in place, the one in 10,000 chance of a network failure becomes even less of a risk. Both patients are reported to be recovering well.

Despite the Canadian physicians' optimism, telesurgery has not yet been accepted as a commercially viable means of surgery in the U.S., where doctors are considerably more skeptical of its benefits. They claim it is still safer, more practical and less expensive to fly the surgeon into the rural area to perform the surgery. Obviously still in a nascent stage, telesurgery may have potential as a tool that can bring surgical expertise into underserved, remote rural communities in Canada.

Innovative applications of the mobile phone are quickly emerging in clinical practice as a time- and money-saving tool for physicians and patients alike. Physicians from Graz's University Medical School in Austria have successfully monitored from afar the blood pressures and heart rates of 25 people with hypertension using mobile phones. In the comfort of their own homes, patients entered key values, including blood pressure, pulse and body weight, on a regular basis into their mobiles using a specially developed software program. Immediately, physicians were informed of a patient's vitals, while the software alerted them to intervene if a patient's values became too high or too low. Patients, in turn, were able to receive almost instant remote advice from their physicians.

Meanwhile, researchers in the U.K. are preparing a pilot study of remote monitoring of asthmatics via mobile phone. A newly developed device hooks a peak flow meter up to a mobile phone that gathers, records and submits accurate asthma data in real-time to physicians. Furthermore, an electronic diary enables patients to describe, and then transmit, their symptoms on a daily basis. At any time, GPs or nurses have access to their patients' data stored on the server, allowing them to monitor their patients' conditions with up-to-date, accurate and reliable data. Initially, 100 asthmatics will receive the mobile device for the duration of the trial. Researchers hope the innovation will provide a more efficient, proactive management of asthma and perhaps help understand the relationships between symptoms and a patient's environment, by analysing whether symptoms are exacerbated at home or at work.

Durhane Wong-Rieger, PhD, President, Anemia Institute for Research & Education.

Anemia affects tens of thousands of Canadians, including many older people. While some types of anemia are relatively easy to diagnose and treat, complications such as chronic disease or complex medication regimes can often interfere with diagnosis and management of this condition.

The Anemia Institute for Research & Education (AIRE) is the first and only nonprofit organization in the world committed entirely to generating and sharing knowledge about anemia. AIRE supports patients in understanding anemia, its causes, effects and the available treatment options. The Institute partners with numerous patient and professional groups to facilitate patient education on anemia and blood safety and supply. Furthermore, through a yearly research grant competition, AIRE sponsors numerous anemia research studies. All in all, the Anemia Institute is working hard to ensure that anemia is treated seriously.

For Physicians: Anemia Guidelines for Primary Care
In a 2001 survey of family physicians across Canada, 90% of doctors indicated their interest in clinical practice guidelines on anemia for family practice. The Anemia Institute responded, initiating the development of Anemia Guidelines for Primary Care with MUMS Guidelines Clearinghouse (Medication Use Management Services), to be published in May 2003. The Anemia Guidelines is the fifth book in the Orange Book guideline series published by MUMS. This easy to use, peer-reviewed and fully-referenced book provides diagnostic and treatment guidelines for the full range of anemia conditions (see Table 1 for a selection of topics covered).

A limited number of complimentary copies of the Anemia Guidelines is available from AIRE. To order, please visit www.anemiainstitute.org and go to the Healthcare Professionals section.

For Your Patient: Anemia Educational Tools
The Anemia Institute's series of patient leaflets covers the most common types of anemia. Patient Educational Leaflets include:

• What is Anemia?
• What is Hemoglobin?
• Anemia & Nutrition
• Anemia & Iron Deficiency
• Anemia & Cancer
• Anemia & Kidney Disease
• Anemia & Surgery
• Anemia & Hepatitis C
• Anemia & HIV/AIDS
• Anemia & Children and Teens.

Anemia Awareness Week is the Institute's yearly campaign to raise awareness of anemia among the general public. This takes place each year during the last week of March. In March 2003, the public were invited to visit numerous hemoglobin screening clinics and anemia display booths in pharmacies and hospitals across Canada. Similar events are planned for Anemia Awareness Week next year, March 22&endash;26, 2004.

Research & Development Fund
The Anemia Institute Research & Development Fund supports research initiatives through a yearly, peer-reviewed grant competition. Projects currently funded include:

• the role of anemia and red blood cell substitutes in traumatic brain injury;
• new strategies to treat post-transplant anemia;
• anemia among the inner city homeless.

More information on the AIRE research grant process, including funding priorities and application procedures, can be found on the Internet at www.anemia-institute.org.

Wilbert S. Aronow, MD, Divisions of Cardiology and Geriatrics, New York Medical College, Valhalla, NY.

Patients with unstable angina pectoris/non-ST-segment elevation myocardial infarction should be treated with nitrates, beta-blockers, Aspirin plus clopidogrel and angiotensin-converting enzyme inhibitors, as well as with diet plus statins if the serum low-density lipoprotein cholesterol is = 100mg/dL. Intravenous unfractionated heparin or preferably low-molecular-weight heparin should be given to high-risk or intermediate-risk patients. A platelet glycoprotein IIb/IIIa inhibitor should be administered if percutaneous coronary intervention is planned. Eptifibatide or tirofiban should be given to patients with continuous myocardial ischemia, an elevated troponin T or I level, or other high-risk features, and in whom an invasive strategy is not planned. High-risk patients should have early invasive management.
Key words: acute coronary syndromes, unstable angina pectoris, non-ST-segment elevation myocardial infarction, percutaneous coronary intervention.

Anne Grand'Maison, MD, FRCPC, Hematologist, Research Fellow, Thromboembolism Department, Sunnybrook and Women's College Health Sciences Centre; University of Toronto, Toronto, ON.
William Geerts, MD, FRCPC, Consultant in Clinical Thromboembolism, Sunnybrook and Women's College Health Sciences Centre; University of Toronto, Toronto, ON.

The elderly population is at risk of arterial and venous thromboembolic diseases. Traditional anticoagulants have demonstrated their benefits for prevention and treatment of these conditions and are accepted as standard practice. Despite this evidence, anticoagulants are still underused in older people. Practitioners often hesitate to consider anticoagulation in the elderly because of comorbidities, potential drug interactions and increased risk of bleeding. Careful assessment of bleeding risk and close monitoring of anticoagulant level are essential strategies to optimize the use of anticoagulants in the elderly. Many recently developed antithrombotics that have completed late stage of testing are presented in this review, although further studies are needed to determine their exact role, particularly in the elderly.
Key words: factor Xa inhibitor, antithrombin, renal insufficiency, drug interactions, bleeding risk index.

Guillermo Paradiso, MD and Robert Chen, MBBChir, MSc, FRCPC, Division of Neurology and Krembil Neuroscience Centre, Toronto Western Research Institute, University Health Network; University of Toronto, Toronto, ON.

Restless legs syndrome (RLS) is a common disorder and its prevalence in the elderly is about 10%. It is characterised by unpleasant, difficult-to-describe sensations in the lower limbs and an irresistible desire to move the legs. The symptoms typically worsen in the evening and at night and often result in sleep disturbance. Idiopathic RLS is often familial. Secondary RLS may occur in several medical conditions, such as uremia and iron deficiency. Most patients with RLS also have periodic limb movements in sleep (PLMS), characterised by repetitive flexion of the lower extremities. RLS and PLMS may be the result of a dopaminergic dysfunction and PLMS may be due to release of spinal flexor reflex pathways. Dopaminergic agents, benzodiazepine and opioids are effective in treating RLS.
Key words: restless legs, periodic leg movement, sleep disorder, dopamine.

Chris MacKnight, MD, MSc, FRCPC, Division of Geriatric Medicine, Dalhousie University, Halifax. NS.

Creutzfeldt-Jakob disease (CJD) is rare, occurring in one per million people. It is difficult to eradicate from contaminated instruments, and so is important to recognise for infection control reasons. As well, there is much interest in possible changes in the epidemiology of this disease, and so familiarity is necessary among all physicians. Sporadic CJD presents in the young-old with a rapidly progressive dementia, while variant CJD presents in younger patients, initially with psychiatric symptoms. Electroencephalography, MRI and 14-3-3 protein testing are all helpful in the diagnostic process. There is no recognised therapy as yet.
Key words: Creutzfeldt-Jakob disease, variant Creutzfeldt-Jakob disease, prion, dementia.

G. Daniel Schachter, MD, FRCPC, DABD, Consultant Dermatologist, Sunnybrook & Women's College Health Sciences Centre and St. John's Rehabilitation Hospital; Lecturer, University of Toronto, Toronto, ON.

During the past century, the amount of time spent at leisure and exposed to the sun has increased, yet we have also become increasingly aware of the detrimental effects of the sun. The skin ages slowly (intrinsic, chronologic aging), but this process is enhanced or accelerated by sun exposure (extrinsic aging, photoaging). The features of photoaging will be presented, followed by the importance of the prevention of sun damage by sun avoidance and use of sunscreens. Methods of treating or reversing photodamage will be reviewed, including topical agents, chemical peels and use of lasers and other light sources.
Key words: photoaging, ultraviolet radiation, prevention, sunscreen, skin rejuvenation.

Anne G. McLeod, MD, FRCPC, Assistant Professor, Department of Medicine, University of Toronto; Staff Physician, Department of Medical Oncology and Hematology, University Health Network, Toronto, ON.

Bleeding in the elderly is a common problem. Careful assessment of a patient's bleeding history and physical examination is essential to try to establish if a clinically significant bleeding disorder is present. Initial laboratory testing should include a complete blood count, blood film review, PT/INR and PTT. Common etiologies of bleeding in the elderly include thrombocytopenia and medications such as Aspirin, non-steroidal anti-inflammatory agents and anti-coagulants. Unfortunately, no single approach to the treatment of coagulopathy exists; rather, a clear understanding of the cause of the bleeding disorder is needed to direct management.
Key words: coagulopathy, elderly, bleeding, hemostasis, clotting.