Jagdish Butany, MBBS, MS, FRCPC and Manmeet S. Ahluwalia, MBBS, Department of Pathology, Toronto General Hospital, University Health Network, Toronto, ON.

With advancing age, the cardiovascular system undergoes subtle but progressive changes that result in altered function. The endocardium becomes thicker and opaque, left ventricular (LV) wall thickness increases and there is increased interstitial fibrosis in the myocardium. Although myocyte size increases, the number of myocytes decreases, as does the number of cells in the conduction system. The decrease in the filling rate of LV in early diastole is accompanied by a greater rate of filling in late diastole augmented by atrial contraction. Maximum achievable heart rate and ejection fraction (with exercise) decreases. All these changes make increasing age a significant independent risk factor for heart failure, the most common reason for hospitalisation in patients older than 65 years.
Key words: aging, cardiovascular disease, myocardium, fibrosis, heart failure.

Kiran Rabheru, MD, CCFP, FRCP, ABPN, Physician Leader, Geriatric Psychiatry Program, Regional Mental Health Care; Chair, Division of Geriatric Psychiatry, University of Western Ontario, London, ON.

Electroconvulsive therapy (ECT) is an effective and relatively safe procedure for treating severe, treatment-refractory mood disorders in special populations, particularly in the elderly. The frail elderly are especially good candidates for ECT because they are often unresponsive to, or intolerant of, psychotropic medications. The central nervous, cardiovascular and respiratory systems require special attention during the course of ECT. With modern anesthesia techniques and careful medical management of each high-risk patient, most elderly can successfully complete a course of ECT. Obtaining informed consent for ECT from incapable patients is a challenging issue with few concrete guidelines.
Key words: electroconvulsive therapy, elderly, depression, special patient population.

Christopher J. Danner, MD, Fellow Otology/Neurotology/Skull Base Surgery and Jeffery P. Harris, MD, PhD, Departmental Chairman, Department of Otolaryngology, Head and Neck Surgery, University of California--San Diego, San Diego, CA, USA.

Multiple factors lead to the cause and progression of presbycusis or hearing loss secondary to increased age. Noise trauma, genetic predisposition and oxidative damage all have been implicated in its development. Tinnitus, a frequent side effect of hearing loss, often has its origin within the central auditory system. A classification scheme for hearing loss and treatment options for tinnitus are discussed.
Key words: hearing loss, presbycusis, tinnitus, free radicals, central auditory system.

Lorne Bellan, MD, FRCSC, Acting Department Head, Department of Ophthalmology, Misericordia Health Centre, Winnipeg, MB.

In addition to the clinical presentation and diagnosis of cataracts, a summary of the development of cataract surgery is presented. Indications for cataract surgery are now based on subjective visual impairment rather than measured visual acuity. Cataract surgery can now be done safely through 3mm self-sealing incisions with excellent results and rapid recovery.
Key words: cataract, lens, phacoemulsification, visual acuity, red reflex.

Catherine M. Birt, MD, FRCSC, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, ON.

Primary open angle glaucoma (POAG) is a disease of the optic nerve head, frequently but not always associated with elevated intraocular pressure. This article discusses the presentation and risk factors associated with POAG, how the diagnosis is made by the ophthalmologist, and the current medical management of the disease.
Key words: primary open angle glaucoma, risk factors, anti-glaucoma medications.

Robert J. Campbell MD, MSc and William G. Hodge MD, PhD, FRCSC, University of Ottawa Eye Institute, Ottawa, ON.

The differential diagnosis of the red eye involves structures ranging from the periorbita, lids and conjunctiva, to the surface sclera and episclera, to the cornea and uvea and to acute angle closure glaucoma. The history and physical examination can usually differentiate these entities from one another. The most important part of the examination is the visual acuity, which can usually distinguish the serious red eye from more benign causes.
Key words: orbital cellulites, conjunctivitis, blepharitis, keratitis, acute glaucoma, red eye.

Doron Milstein, PhD, Hofstra University, Long Island, NY, USA.
Barbara E. Weinstein, PhD, Graduate School and University Center, CUNY, New York, NY, USA.

Hearing loss diminishes quality of life. The elderly rely on auditory input to maintain social contact and awareness of their environment, such that hearing loss in this age group can lead to isolation and withdrawal from the community. Most elderly individuals do not take advantage of available audiological services nor do they use hearing aids (HAs), the treatment of choice for their hearing loss. Modern HAs utilise digital technology and computer software to improve speech intelligibility. Current research reveals that HAs are effective in minimising the negative consequences of hearing loss in the daily functioning of the elderly. The availability of sophisticated technology allows for more efficient HA fitting, and allows the audiologist to spend more time counseling.
Key words: presbycusis, hearing aid technologies, rehabilitation, assistive listening devices.

Sohel Somani, MD, Senior Resident, Department of Ophthalmology, University of Toronto, Toronto, ON.

Age-related macular degeneration (ARMD) is a progressive disease affecting the central vision of patients older than 55 years. Typically, ARMD patients are classified into dry and wet forms based on clinical characteristics. This has important implications with respect to their clinical presentation, prognosis and management options. Important risk factors in the progression of disease include age, smoking and drusen characteristics. The promising results of a new study on vitamin supplementation provide direction for treatment and prevention, as well as the understanding of the role of antioxidants in ARMD pathogenesis. High-dose vitamins (beta- carotene, vitamins C and E and zinc) should be considered in certain patients with ARMD.
Key words: macular degeneration, vitamins, low vision, supplementation, Amsler grid.

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.