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.

William A. Banks, GRECC, Veterans Affairs Medical Center and Saint Louis University School of Medicine, Division of Geriatrics, Department of Internal Medicine, St. Louis, MO.
Marian R. Banks, Center for Human Nutrition, Washington University School of Medicine, St. Louis, MO.

The term "nursing home" is often a misnomer. The typical nursing home is more institution than home and run more like a hospital than a household. Indeed, the American Heritage dictionary defines "nursing home" as "a hospital for convalescent or aged people" (emphasis ours). Yet many of us will spend a good portion of the last part of our lives in these institutions. How can these last years be made as enjoyable and meaningful as possible? We recently published a study examining the effects of animal-assisted therapy (AAT) on loneliness among nursing home residents. The statistical aspect of that study has been published elsewhere and it showed, among other things, that AAT can reduce loneliness.¹ However, during the course of that study we learned several lessons that couldn't be reduced to statistics. Here, we review some of the things we learned about making long-term care facilities more comfortable and enjoyable for residents.

There are many movements afoot to improve life in long-term care facilities. Pet therapy, music therapy, activities and holiday events are all assumed to be progressive programs. Since these programs are considered to be good, they are assumed to be good for all.

J. David Spence, MD, FRCPC, Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, London, ON.

Effective treatment of hypertension is even more beneficial in the elderly than in younger patients because the elderly have a higher absolute risk of vascular events. Treating hypertension not only prevents stroke, but also reduces risk of dementia. Effective blood pressure control is based on identifying and treating its physiological cause. Renal hypertension, primary hyperaldosteronism and renal tubular abnormalities such as Liddle's syndrome can be identified by measuring the plasma renin and aldosterone. Most elderly patients require diuretic therapy for control, but most will require additional drugs to achieve the lower targets now supported by evidence.
Key words: hypertension, elderly, adrenocortical, renovascular.

Roy C. Ziegelstein, MD, Department of Medicine, Division of Cardiology, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD.

Depressed mood is common after a myocardial infarction and is associated with increased mortality risk. Although mild forms of depression often resolve without specific treatment, moderate to severe depression is typically longer lasting. Depression is particularly unlikely to resolve spontaneously in those who are socially isolated, a common problem in older individuals. Patients may be screened for depression using one of several short and valid instruments. If antidepressant treatment is indicated, a selective serotonin reuptake inhibitor is preferred and should be combined with efforts to improve social support, to address medication adherence issues and to encourage participation in a cardiac rehabilitation program.
Key words: depression, myocardial infarction, screening, social support, antidepressants.

Kunin-Lunenfeld Applied Research Unit 2nd Annual Conference at Baycrest Centre for Geriatric Care, October 18, 2002

Joanna Goldberg, MSc, Associate Editor, Geriatrics & Aging.

Speakers

1. The Role of Anti-inflammatories and the Inflammatory Hypothesis in the Prevention of Alzheimer Disease
   Presented by Patrick McGeer, MD, Vancouver, BC.
2. Decreasing Dementia Risk and Minimizing Cognitive Decline with Participation in Engaging Activities and Memory Rehabilitation
   Presented by Angela Troyer, PhD, CPsych, Baycrest Centre for Geriatric Care, Toronto, ON.
3. Pharmacological Strategies for Prevention of Alzheimer Disease
   Presented by Serge Gauthier, MD, FRCPC, McGill Centre for Studies in Aging, Montreal, QC.

The goal of research at the Baycrest Centre for Geriatric Care is to provide a scientifically based understanding of diseases and disorders of the elderly. Through various educational methods, staff are trained to implement new practices in assessment, management and rehabilitation. The ultimate goal is to find preventative measures to delay or eliminate the onset of disease. Three of the eight lectures at this conference that touched on how future research, clinicians and care providers may help to achieve these goals in patients with dementia are presented in this report.

I.

Karen Beattie, BSc, PhD Candidate and Dr. A. Papaioannou, MSc, MD, FRCP(C), Associate Professor of Medicine; Department of Geriatrics, McMaster University, Hamilton, ON.
Dr. P. Boulos, MD, FRCP(C) and Dr. J.D. Adachi, MD, FRCP(C), Professors of Medicine; Department of Rheumatology, McMaster University, Hamilton, ON.

Osteoporosis is a major health concern in Canada, affecting 25% of women and 12% of men. Vertebral compression fractures, the most common of all osteoporotic fractures, are clinically diagnosed only 30% of the time. Treatment for such fractures is primarily pharmacological. However, newer, non-invasive methods of treatment, namely vertebroplasty and kyphoplasty, stabilize compression fractures, provide pain relief and even improve posture and functional ability. While vertebroplasty involves the injection of a cement product into one or more compressed vertebrae, kyphoplasty adds another step of inserting a balloon into the vertebra to re-establish original vertebral height. Clinical studies of these procedures suggest kyphoplasty provides better symptomatic relief and is associated with fewer complications than vertebroplasty. However, further randomized, controlled evidence comparing these procedures is required.
Key words: kyphoplasty, vertebroplasty, osteoporosis, vertebral fracture, compression fracture.