Ernane D. Reis, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.
Nicholas Morrissey, MD, Assistant Professor, Department of Surgery, Mount Sinai School of Medicine, New York, NY.

Prevalence of peripheral arterial disease (PAD) increases with age. PAD is not only associated with disability (e.g., claudication, limb loss), but also with increased mortality from cardiac and cerebrovascular events. A thorough assessment of symptoms, risk factors and physical signs--including ankle-brachial indices--can be sufficient to determine whether PAD is present. Further testing--such as Duplex examination, magnetic resonance imaging and conventional arteriography--is often required to determine progression and accurate localization of lesions, as well as to direct therapeutic intervention. Early detection of PAD can help prevent functional impairment and death in the elderly.
Key words: atherosclerosis, peripheral arterial disease, ankle-brachial index, diabetes, claudication.

E. Rand Simpson, MD, Associate Professor of Ophthalmology, University of Toronto; Director, Ocular Oncology, Princess Margaret Hospital, Toronto, ON.
Larry Ulanski II, MD, Ocular Oncology Fellow, University of Toronto, Princess Margaret Hospital, Toronto, ON.

Ocular malignancies in the elderly are often difficult to diagnose and manage. The five main cancers found in association with the eye are basal, squamous and sebaceous cell carcinomas, uveal melanoma and malignant cancers to the orbit. These include malignancies from breast, lung, GI, prostate and myelogenous proliferations. This article briefly reviews the most common forms of ocular cancer and brings the general practitioner up to date on the most current data from the Collaborative Ocular Melanoma Study (COMS). We use clinical photos to demonstrate specific clinical signs of cancerous disease. By maintaining a high level of suspicion when treating patients with acute visual symptoms, unnecessary morbidity and mortality may be avoided.
Key words: ophthalmology, cancer, radiotherapy, malignancy.

David Stell, PhD, FRCS(Gen) and William J. Wall, MD, FRCS(C), Department of Surgery and Multi-Organ Transplant Program, London Health Sciences Centre, London, ON.

The process of aging does not produce changes in the liver that can be described as pathological. The major age-related alterations are a reduction in liver mass and a reduction in total blood flow, neither of which interferes with the liver's normal homeostatic functions. In spite of the liver's resilience, however, the aged liver is more vulnerable to injury from toxins, viruses and ischemia, and its capacity to regenerate is slowed. There also is a decline in liver enzymes with aging that affects metabolic clearance of drugs, a finding that has implications for drug dosing in the elderly.
Key words: liver, aging, function, metabolism, injury.

Dr. Faisal M. Sanai, MD, ABIM, Hepatology Fellow, London Health Sciences Centre, University of Western Ontario, London, ON.
Dr. Cameron N. Ghent, MD, FRCP(C), Consultant Hepatologist, Adjunct Professor, University of Western Ontario, London Health Sciences Centre, London, ON.

Cirrhosis of the liver is highlighted essentially by its portal hypertensive complications. The incidence of these complications in elderly cirrhotic individuals has been rising due to better management of this disease in the younger population. Moreover, improved diagnostic techniques have further contributed to this rising incidence. Early recognition of the cirrhotic complications coupled with aggressive intervention has led to reductions in mortality. Special consideration is given to elderly patients in view of the higher incidence of comorbidity and the variability in disease presentation. We present here a review of cirrhosis and its sequelae in this distinct population group with emphasis on recent trends towards diagnosis and management.
Key words: cirrhosis, portal hypertension, ascites, liver.

Douglas Thorburn, MD, MRCP and Paul J. Marotta, MD, FRCPC, Multi-Organ Transplant Unit, London Health Sciences Centre, University of Western Ontario, London, ON.

Liver transplantation improves survival for selected patients with chronic liver disease, fulminant hepatic failure and hepatocellular carcinoma. There is no absolute upper age limit for liver transplantation and the proportion of patients undergoing liver transplantation who are older than 60 years is increasing. Although the indications for liver transplantation in elderly patients do not differ from those in younger patients, the prevalence of comorbidities that are contraindications to liver transplantation are higher among the elderly. Outcomes after transplantation for selected patients over 60 years of age with Child-Pugh class B cirrhosis who are well nourished and at home are comparable to those for younger patients.
Key words: liver transplantation, fulminant hepatic failure, hepatocellular carcinoma, indications.

Don Rodgers, National Director of Communications, Canadian Liver Foundation.

What few laypeople realize is that the liver plays a crucial role in maintaining overall health. It performs numerous vital functions including the processing of dietary nutrients and vitamins, maintaining blood sugar levels, activating or detoxifying medications and manufacturing proteins. People may also be surprised to learn that liver disease is the fourth leading cause of death by disease in Canada. More than two million Canadians, regardless of age, sex, ethnic origin or lifestyle, will be affected by a liver or biliary tract disease in their lifetime. With improvements in diagnostic testing and a growing awareness of risk factors, more Canadians are finding out they have liver disease. Many liver diseases can be prevented, quite a few can be treated and early diagnosis is very important. The outlook is hopeful and research is continuing to improve the lives of people living with these disorders.

When a person is diagnosed with a liver disease, it can be a very stressful time for all concerned--patients, families and friends. Unanswered questions create anxiety, and doctors and other health care providers often are too busy to discuss every detail. Pamphlets and websites can provide a wealth of information but cannot possibly answer all of a patient's questions. Hence the role of the Canadian Liver Foundation's Living with Liver Disease Program, which provides a wide range of information about all aspects of liver disease, as well as a forum in which people can ask questions about their individual concerns.

The program provides emotional and social support through the participants' interaction with others in the same situation. Facilitated group sessions feature qualified speakers who cover issues such as nutrition, exercise, diagnosis, treatment, liver transplantation and social assistance. During each session, patients can hear valuable information from a physician or another knowledgeable health care provider caring for liver disease patients. In the course of the session, patients will have the opportunity to ask questions and chat with other people who are experiencing the same or similar challenges. The Canadian Liver Foundation offers Living with Liver Disease Programs in communities across the country. Depending upon local needs, sessions may cover one topic per month or may be compacted into an all-day seminar format.

The Canadian Liver Foundation's National 1-800 Help Line offers a confidential bilingual service to all people affected by liver disease. When people are first diagnosed with liver disease, they have many questions about their prognosis, how it will impact their lifestyle and what treatments or other interventions might be available to them. The Foundation's National 1-800 Help Line gives patients and their family members somewhere to turn for answers. For more information about a program in your area, please call the National Help Line at 1-800-563-5483 or visit our website at www.liver.ca.

Bao Q. Tang, MD, FRCS(C), Clinical Fellow, Minimally Invasive Surgery Program, Division of General Surgery, University Health Network, Toronto, ON.
David R. Urbach, MD, MSc, FRCS(C), Assistant Professor of Surgery and Health Policy, Management and Evaluation, University of Toronto; Staff Surgeon, Division of General Surgery, University Health Network, Toronto, ON.

Gallstone disease is common in elderly persons. The clinical syndromes caused by symptomatic gallstones include biliary colic, acute cholecystitis, acute gallstone pancreatitis, choledocholithiasis, cholangitis and gallstone ileus. In most cases, an accurate diagnosis can be made on the basis of the history, physical examination, basic blood tests and abdominal ultrasonography. Cholecystectomy is the appropriate treatment for most patients with symptomatic gallstones, and can be done safely in the elderly. Because the risk of complications of gallstone diseases is higher in the elderly than in younger patients, symptomatic gallstone disease should be identified and treated promptly in elderly persons.
Key words: gallstones, cholecystitis, pancreatitis, cholangitis, cholecystectomy.

D'Arcy Little, MD, CCFP, Lecturer and Academic Fellow, Department of Family and Community Medicine, University of Toronto; Director of Medical Education, York Community Services; 2002 Royal Canadian Legion Scholar in Care of the Elderly, Toronto, ON.

Viral hepatitis is a major cause of acute and chronic liver disease worldwide. This article will review the epidemiology, etiology, presentation, diagnosis, management and prevention of acute viral hepatitis (Types A, B and C), with specific reference to the elderly population. Both similarities and differences between management in the elderly and the general population will be detailed. A cost-effective approach to diagnosis will also be formulated.
Key words: hepatitis A, hepatitis B, hepatitis C, acute viral hepatitis, elderly.

Robert J. Fingerote, MD, MSc, FRCPC, Consultant in Gastroenterology and Internal Medicine, Queensway Carlton Hospital, Ottawa, ON.

Primary biliary cirrhosis (PBC) is a disease of unknown origin that causes chronic liver injury. It has an insidious onset, is associated with slow progression and ultimately leads to liver failure and either death or liver transplantation. It is presumed to be of autoimmune origin, is frequently associated with other autoimmune disorders and typically affects middle-aged and elderly women. Patients may be asymptomatic at diagnosis or present with typical symptoms of fatigue, pruritus and jaundice. Although current therapy may slow the progression of disease, no therapy has yet been proven to arrest or reverse the disease process.
Key words: cirrhosis, fatigue, autoimmune, cholestasis, antimitochondrial antibodies.

Pat Agnew, Executive Director, Pulmonary Hypertension Society.

I sympathize with doctors, particularly general practitioners. They are "frontline" diagnosticians who are expected to know every symptom and, even more challenging, every disease. When the patient comes in with generalized yet valid symptoms of exhaustion, breathlessness, dizziness, pain and edema, the detective work begins. We all know that in most instances these symptoms can be broken down and analysed and some common disease or syndrome can be diagnosed. However, there also are the few who show no evidence of abnormality in the testing process yet continue to come back with the same, sometimes worsening symptoms. These patients are usually sent to many specialists until a diagnosis is made or it is assumed, after appropriate work-up, that stress, obesity or an existing primary problem is the culprit.

Often, it is not until the patient is in serious trouble, possibly near death, that it is discovered that one of the rare, unusual afflictions is the cause of their often two- or more-year-old complaints. The goal of this article is to make clinicians aware of one of these diseases that, although not especially difficult to diagnose, is often missed because it is considered so rare--pulmonary hypertension. Presented are the modified contents of the brochure distributed by the Pulmonary Hypertension Society that is intended for patients and their families.