June M. Chan, ScD, Assistant Adjunct Professor, Departments of Epidemiology & Biostatistics and Urology, University of California, San Francisco, CA, USA.

Prostate cancer is the most commonly diagnosed cancer and is second only to lung as the most fatal cancer among men in the United States. It is the ninth most common cancer in the world, with higher rates predominating in North America, Europe and Australia, and lower rates reported in Hong Kong, Japan, India and China. The main non-modifiable risk factors include age, race and family history.

The incidence of prostate cancer increases exponentially with age, with men age 75-79 experiencing an incidence rate more than 100-times greater than that of men age 45-49 (age-specific prostate cancer incidence rate for men age 75-79 = 1400/100,000 person-years; for men age 45-49 = 11/100,000 person-years).¹

African Americans have the highest recorded age-standardized rates in the world, estimated at 137 cases per 100,000 persons in 1997 according to Surveillance, Epidemiology, and End Results (SEER) data.² In contrast, the rate among Caucasians in the U.S. was 101/100,000. Europeans tended to have rates in the range of 20-50 cases/100,000.

It has been an exciting year at Geriatrics & Aging, with the formation of new alliances and major changes to the publication, including the move to a journal size format and the new indexing on the AgeLine database.

Last year, we conducted our first ever readership survey to determine how you felt about the quality and content of the publication. Thanks to last year's respondents, we were able to make big improvements to the publication for the current year.

This year, we asked how you felt about the changes that have been made. I am happy to report that the feedback was very positive, with many people particularly pleased with the change to a more 'user-friendly' journal size format. We were also excited to see that the majority of respondents regularly use our publication for making clinical decisions and consider the quality of the content as Very Good or Excellent. Feedback like this makes our jobs that much easier!

However, we were disappointed to find out that many of you were not aware that all of our clinical content is available on our website at www.geriatricsandaging.ca. Articles are indexed by topic, author and keyword, and content goes back to our first year of publication. We have also recently added a new Message Boards section, where visitors can ask questions, or participate in discussions. Drop by the site and take a look!

As promised, all respondents to the survey were entered into a draw for prizes and the winners have been selected. Insert drum-roll here please! The lucky Grand-prize winner of $1000 for the 2002 Geriatrics & Aging Reader's Survey is Dr. Roger Bunn, of Brampton, Ontario. Dr. Bunn's administrative professional Irene Theodoropolous will also walk away with $100. In close second is Dr. Jeff Tschirhart of Simcoe, Ontario, who wins $500, with $100 in prize money going to Vicki McKnight. Last, but certainly not least, is Dr. Christena Côté of Halifax, Nova Scotia and her administrative professional Marilyn Healey, who win $200 and $100, respectively. Congratulations to all of our winners!

We would also like to take this opportunity to thank everyone who participated in the readership survey. We also encourage you to contact us on a regular basis with any comments or suggestions you may have. To those of you who responded but didn't win …don't despair, you'll have another shot at the big money next year!

Nabeel AlAteeqi MD, FRCPC and Johane Allard MD, FRCPC
University of Toronto, Toronto, ON.

Introduction
Zinc is one of the essential micronutrients, and plays an important role in human nutrition and health. In 1961, Prasad first recognized zinc deficiency as the cause of dwarfism and hypogonadism among iron-deficient adolescent Iranian village boys.^1,2

Zinc deficiency occurs in individuals and populations with diets low in sources of readily bioavailable zinc, such as red meat, and high in unrefined cereals that are rich in phytate. The elderly population is potentially vulnerable to zinc deficiency because of decreased intake of food energy, protein, vitamins and minerals, and increased intake of carbohydrates.^3,4

In this review, we discuss the importance of zinc to humans, as well as the causes, clinical features and management of zinc deficiency in the elderly population.

Importance of Zinc
Zinc is an essential mineral, present in most systems of the human body, and plays a role in stabilization of cell membranes, tissue regeneration and protein synthesis. It also serves as a structural component of at least 70 metalloenzymes. Examples of zinc metalloenzymes are carbonic anhydrase, alkaline phosphatase, alcohol dehydrogenase and zinc-copper superoxide dismutase.

In addition, zinc is needed for growth, normal development, DNA synthesis, RNA conformation, immunity, neurosensory function and other important cellular processes.

Jenny F.S. Basran, BSc, MD, and David B. Hogan MD, FACP, FRCPC
Division of Geriatric Medicine, University of Calgary, Calgary, AB.

Introduction
Recently, there has been growing interest in the use of vitamins for the treatment of various health conditions. One study has estimated that 35-54% of older Canadians take some form of vitamin or mineral supplement.¹ Oxidative stress has been theorized to be an important contributor to select conditions, particularly those involving the cardiovascular and central nervous systems. Vitamin E is the only fat-soluble, chain-breaking antioxidant found in biological membranes⁴ and, therefore, has been investigated for its use in the treatment of ischemic cardiovascular disease in recent landmark studies such as the Heart Outcome Evaluation Study (HOPE)² and Heart Protection Study (HPS).³

How Does Vitamin E Work?
Vitamin E is a generic term for chemical derivatives of tocopherol and tocotrienol.⁵ There are eight naturally occurring forms, but only a-tocopherol is found in human plasma, has the highest bioactivity and is the form used for medicinal purposes. a-tocopherol is found naturally in vegetable oils, almonds, sunflower seeds, walnuts, sweet potato, liver, wheat germ and egg yolk.⁶ Synthetic forms are available as vitamin capsules and in fortified foods.

Rory Fisher, MB, FRCP(Ed)(C), Director, Regional Geriatric Program of Toronto and Interdepartmental Division of Geriatrics, Faculty of Medicine, University of Toronto, Toronto, ON.

In Canada, the sustainability of the health care system is a major issue. Two commissions have been established to address the future of health care.^1,2 Improvements in technology and changes in the delivery of health care have led to major restructuring of the system. Acute hospital beds and the length of hospital stays have decreased with the concomitant expansion of ambulatory services. The aging population, which is increasing dramatically in Canada, particularly with regard to the oldest old, is a major priority policy issue in these discussions.³ However, the current management of the elderly in acute hospitals is of concern. In the United Kingdom, an enquiry into the care of older people in acute wards in general hospitals entitled "Not because they are old" found that problems existed with older patient and relatives' dissatisfaction with the care, numerous deficiencies in physical environments, clear evidence of staff shortages and concerns about nutrition.⁴ Problems were also identified with preserving dignity, interactions with staff, insufficient training, discharge planning and the accessibility of services in the community. In addition, a recent study by Health Canada on unmet needs for health care reported, an estimated 7% of Canadians, or about 1.

• Office-based risk factor evaluation is mandatory in people with diabetes, and aggressive risk factor modification should be based on those results.
• The metabolic syndrome commonly precedes the onset of diabetes by several years. Insulin resistance apparently predates the risk factors associated with metabolic syndrome, thus detection of insulin resistance relatively early in life offers the opportunity to identify, at an early stage, those people likely to develop blood fat abnormalities, high blood pressure (HBP) and, ultimately, diabetes.
• A person with diabetes who smokes is at double the risk for cardiovascular disease (CVD). Therefore, every effort must be made to convince the patient to stop smoking.
• HBP increases a diabetic patient's risk of coronary heart disease (CHD), stroke, kidney failure and heart failure. Treatment of HBP in people with diabetes should be intensive enough to reach blood pressure goals.
• The common drugs to treat high blood pressure--diuretics, beta-blockers, angiotensin converting enzyme (ACE) inhibitors and calcium channel blockers--are generally effective in treating patients with diabetes.
• Assiduous treatment of high blood pressure in people with diabetes can delay the progression of diabetic nephropathy and retinopathy, as well as CVD.

James Brown, MD, Minimally Invasive Urologic Oncology Fellow
Department of Urology, Thomas Jefferson University, Assistant Professor of Urology
Medical College of Georgia, Augusta, GA, USA.

Leonard G. Gomella, MD, Bernard Godwin Associate Professor of Prostate Cancer
Director of Urologic Oncology, Department of Urology, Kimmel Cancer Center,
Thomas Jefferson University, Philadelphia, PA, USA.

Abstract
The treatment options for localized prostate cancer are extensive and highly controversial. Although there is general agreement that symptomatic metastatic disease should be treated by hormonal ablation, there is no consensus on how to treat patients with localized disease. While an argument can be made not to screen any patient for prostate cancer, many organizations, including the American Urological Association, support both screening and the treatment of prostate cancer in men with a life expectancy of greater than 10 years. In the asymptomatic, older man with localized, low-risk disease, characterized by a low Gleason score, low PSA and low clinical stage, observation may be the treatment of choice. However, in the older man with localized prostate cancer and high-risk features such as a high Gleason score, aggressive treatment is warranted since many of these men will progress and ultimately die of prostate cancer.

Cynthia M. Westerhout, MSc and Eric Boersma, PhD
From the Department of Cardiology, Erasmus Medical Centre,
Rotterdam, The Netherlands and the University of Alberta, Edmonton, AB, Canada.

Introduction
The introduction of balloon angioplasty in the early 1980s and stents in the mid-1990s has revolutionized mechanical reperfusion therapy in patients with stenotic coronary arteries.^1,2 In fact, percutaneous coronary interventions (PCI) are one of most frequently performed procedures, with more than 1.3 million performed worldwide in 1999.³ However, an important limitation of PCI is the risk of inducing platelet aggregation. As a result of the disruption of the culprit plaque and injury to the coronary vessel during the procedure, the periprocedural risk of reocclusion of the vessel and myocardial infarction (MI) is high, and there is a 20-40% incidence of restenosis at 6-12 months after the index procedure.³

In an attempt to reduce the risk of these complications, several new strategies have been explored. Glycoprotein IIb/IIIa receptor inhibitors (GPIs), for example, have been enthusiastically tested in over 25,000 patients undergoing PCI over the last decade (Table 1). Gp IIb/IIIa receptors are found in great abundance on the surface of platelets and blocking these receptors obstructs the final common pathway leading to platelet aggregation.

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

Introduction
Lewy body disease is one of the many conditions causing dementia. As it is relatively common, and has an effective management distinct from that of Alzheimer disease,¹ all physicians who see older adults should have some familiarity with Lewy body disease.

Diagnosis
Lewy body disease is underdiagnosed.² It should be suspected in an older adult who presents with cognitive impairment (even if quite mild) in addition to hallucinations or parkinsonism. Clinical criteria are presented in Table 1.^3,4 The criteria of fluctuation have proven difficult to apply at the bedside, but clinical tools are now available.⁵ The parkinsonism is often mild and subtle, and is more often rigidity than tremor. An important feature is neuroleptic sensitivity. Up to 80% of these patients can, even with low doses, develop reactions to neuroleptics or atypical agents, which are often severe.⁶ Extrapyramidal symptoms and cognitive decline are the most common manifestations. The decline can be permanent, and neuroleptic malignant syndrome can occur. This likelihood of reaction to neuroleptics is one of the chief reasons to be familiar with the disorder and to have a low threshold to at least suspect its presence.

It can sometimes be difficult to distinguish Lewy body disease from Alzheimer disease, Parkinson's disease or delirium.

Madhuri Reddy, MD, Dermatology Day Care (Wound Healing Clinic), Sunnybrook and Women's College Health Care Centre, Toronto, ON, Associate Editor, Geriatrics & Aging.

R. Gary Sibbald, BSc, MD, FRCPC (Med), FRCPC (Derm), MACP, DABD, Associate Professor and Director of Continuing Education, Department of Medicine, University of Toronto, Toronto, ON.

Introduction
Pressure ulcers are areas of localized damage to the skin and underlying tissue caused by pressure, shear, friction, excess moisture, incontinence or abrasion. They usually occur over bony prominences such as the sacrum, heels, hips and elbows (Figure 1).

Pressure ulcers are associated with a significant burden of illness in the elderly and a significant financial burden to the health care system. In a recent study of a geriatric unit in Glasgow, the prevalence of pressure ulcers was 41%.¹ The incidence in acute care² has been estimated at 10%, and up to 60% of patients develop ulcers while in acute care hospitals.³ In one study, the prevalence of stage I-IV pressure ulcers in 1,960 acute care facilities in Canada from 1995-1998 was 11.2%.⁴ The incidence rate for home care is 15.4%.⁵ Approximately 45% of all pressure ulcers are probably preventable.

Annually, 1.7 million patients in the U.