April 2015 by Doctor's Review

APRIL 2015

Palm Springs’ many charms beyond golf Tennessee’s natural and not-so-natural amusements A “ride ’em cowboy” holiday on the Prairies Wheelie bag makeover

MEDICINE ON THE MOVE

art as therapy

The origins of

COASTING THE CAROLINAS

3 CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

ways to cook a rotisserie chicken PLUS:

Talking to patients about IBS AND

Depression treatment strategies T H E N O VA R T I S C O P D P O R T F O L I O

SEEBRI, ONBREZ, ULTIBRO and BREEZHALER are registered trademarks. Product Monographs available on request. 14SEE034E © Novartis Pharmaceuticals Canada Inc. 2014

INTRODUCING FORXIGA FORXIGA is a reversible inhibitor of sodium-glucose co-transporter 2 (SGLT2) that improves glycemic control by reducing renal glucose reabsorption leading to urinary excretion of excess glucose1*† Over 193,000 patients have been prescribed FORXIGA worldwide combined across all indications

CONVENIENT, ONCE-DAILY DOSING1‡§¶ RECOMMENDED STARTING DOSE: 5 mg

In patients tolerating 5 mg and who require additional glycemic control, dose can be increased to 10 mg

CAN BE TAKEN ANY TIME OF DAY

WITH OR WITHOUT FOOD

FORXIGA is indicated in monotherapy as an adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance.1 FORXIGA is also indicated in patients with type 2 diabetes mellitus to improve glycemic control in add-on combination with metformin, a sulfonylurea, or insulin (alone or with metformin), when the existing therapy, along with diet and exercise, does not provide adequate glycemic control.1

Doctor’s Review •

DECEMBER 2013

In add-on combination with metformin, FORXIGA demonstrated signiﬁcant reductions in A1c vs. placebo + metformin at weeks 24 and 1021,2** Adjusted mean change from baseline at week 24 (LOCF): -0.70% with FORXIGA 5 mg + metformin and -0.84% with FORXIGA 10 mg + metformin vs. -0.30% with placebo + metformin (p<0.0001) Adjusted mean change from baseline at week 102 (extension study): -0.58% with FORXIGA 5 mg + metformin and -0.78% with FORXIGA 10 mg + metformin vs. 0.02% with placebo + metformin (p<0.0001) In add-on combination with metformin, body weight results demonstrated with FORXIGA vs. placebo + metformin at weeks 24 and 102 (secondary endpoint)1,2** Adjusted mean change from baseline at week 24 (LOCF): -3.04 kg with FORXIGA 5 mg and -2.86 kg with FORXIGA 10 mg vs. -0.89 kg with placebo + metformin (p<0.0001) Adjusted mean change from baseline at week 102 (extension study): -3.38 kg with FORXIGA 5 mg + metformin and -2.81 kg with FORXIGA 10 mg + metformin vs. -0.67 kg with placebo + metformin FORXIGA is not indicated for weight reduction.

Clinical use: Not for use in pediatrics (<18 years).

temporary interruption of FORXIGA should be considered for patients who develop volume depletion until the depletion is corrected

In patients ≥65 years of age, a higher proportion had adverse events related to volume depletion and renal impairment or failure compared to placebo.

• Risk of hypoglycemia when used in combination with insulin or insulin secretagogues

Contraindications:

• Dose-related LDL-C increases; monitor LDL-C levels

• Patients with moderate to severe renal impairment, deﬁned as an estimated glomerular ﬁltration rate (eGFR) <60 mL/min/1.73 m2, or end-stage renal disease

• Increased mean hemoglobin/hematocrit and frequency of patients with abnormally elevated values of hemoglobin/hematocrit

Relevant warnings and precautions:

• Increased risk of genital mycotic infections

• Not for use in type 1 diabetes or for the treatment of diabetic ketoacidosis

• Renal function should be assessed prior to initiation of FORXIGA and regularly thereafter

• Not for use in patients with active bladder cancer and use with caution in patients with a prior history of bladder cancer

• Not for use in pregnant or nursing women

• Not for use in patients concomitantly treated with pioglitazone

For more information:

• Not recommended for use in patients who are volume depleted; caution in patients for whom a FORXIGA-induced drop in blood pressure could pose a risk, or in case of intercurrent conditions that may lead to volume depletion; careful monitoring of volume status is recommended and

Please consult the Product Monograph at www.azinfo.ca/ forxiga/pm367 for important information relating to adverse reactions, drug interactions and dosing. The Product Monograph is also available by calling 1-800-668-6000.

* Clinical significance unknown. † The amount of glucose removed by the kidney through this mechanism is dependent upon the blood glucose concentration and GFR. ‡ The efficacy of FORXIGA is dependent on renal function. Assessment of renal function is recommended prior to initiation of FORXIGA therapy and periodically thereafter. § In patients with evidence of volume depletion, this condition should be corrected prior to initiation of FORXIGA. ¶ Please see Product Monograph for complete dosing and administration information. ** Double-blind, placebo-controlled, 24-week study, with a 78-week, controlled, blinded extension period, of 546 patients with type 2 diabetes and A1c ≥7% and ≤10% and who were on a dose of metformin of ≥1500 mg/day. After a 2-week lead-in period, patients were randomized to dapagliflozin 2.5 mg, FORXIGA 5 mg, or 10 mg once daily or placebo. Mean baseline A1c values: FORXIGA 5 mg + metformin 8.17%, FORXIGA 10 mg + metformin 7.92% and placebo + metformin 8.11%. Mean baseline body weight: FORXIGA 5 mg + metformin 84.73 kg, FORXIGA 10 mg + metformin 86.28 kg and placebo + metformin 87.74 kg. LOCF: last observation (prior to rescue for rescued patients) carried forward. References: 1. FORXIGA Product Monograph. AstraZeneca Canada Inc., December 10, 2014. 2. Bailey C et al. Dapagliflozin add-on to metformin in type 2 diabetes inadequately controlled with metformin: a randomized, double-blind, placebo-controlled 102-week trial. BMC Medicine 2013;11:43.

02/16

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TRINTELLIXTM is a trademark of Lundbeck Canada Inc.

The ballad of Davy E in Tennessee

DAVE ALLEN PHOTOGRAPHY / SHUTTERSTOCK.COM

When I was a kid I had tremendous visions of Tennessee. Mind you, they were largely fuelled by “The Ballad of Davy Crockett” who, pop music aficionados will recall, “kilt him a b’ar when he was only three.” I badgered my parents for a coonskin cap and when they refused to get me one, I badgered my uncle to give me the coon tail he had waving from the antenna of his 1954 Ford. He obliged and, with considerable difficulty, I sewed it onto the back of my Montreal Canadiens tuque. That summer flew by as I hunted “injuns” from the vacant lot behind our place all the way uptown to the big Rexall drugstore and back again. Davy wasn’t politically correct, but then neither was Elvis Presley, another Tennessean who exploded onto the pop charts a few years later. I worked a daily paper route and scooped ice cream at the local dairy so I could buy all his LPs. My idea of a good time was to put on my blue suede shoes and hit the Friday night sock hop in the church basement. If I failed to meet a girl who would let me walk her home and maybe even give me a goodnight peck on the cheek, I’d take myself musically down to “Heartbreak Hotel” where I’d be so lonely, “so lonely I could die.” I finally made it to Tennessee in my 40s and was as taken with the place as I’d expected to be. The trees, the mountains were everything I could have hoped for — magnificent, nature at its most fecund. We stayed at the Scottish Inn in McMinnville, Great Smoky Mountains TN. I’ll never forget the place because our threeNational Park, Tennessee. year-old Russian Wolfhound escaped and ran two miles down the highway with me in tepid pursuit. A nice guy caught him outside a Wendy’s and gave him half his burger. Ah, the kindness of strangers. A final note: one steamy July day we tried to visit Graceland, Elvis’s home in Memphis, but got hopelessly lost in traffic, found ourselves on a freeway heading south and, as yet, have never returned. There is, of course, an article on the great state in this issue, page 32. Dr Mel Borins prescribes a family trip there and everyone has a smashing time. While you’re in the region, have a look at the cover story, Pirates of the Carolinas, page 34. Then come north again for an entirely different kind of holiday on a working ranch near Saskatoon, page 48, well worth the read. Happy trails,

Visit

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facebook.com/doctorsreview

David Elkins, Publisher delkins@parkpub.com

@doctorsreview

APRIL 2015 • Doctor’s

Review

GLYCEMIC CONTROL WITH CONFIDENCE

GLYCEMIC CONTROL WITH

ONGLYZA

KOMBOGLYZE®

Demonstrated long-term HbA1c reduction vs placebo, both in combination with metformin over 102 weeks HbA1c mean change from baseline:1*



At week 24: -0.7% for ONGLYZA + metformin (n=186) vs 0.1% for placebo + metformin (n=175, 95% CI -1.0, -0.6, p≤0.0001)



At week 102: -0.7% for ONGLYZA + metformin (n=31 observed, n=184 LOCF) compared to placebo + metformin (n=15 observed, n=172 LOCF)

The convenience of a ﬁxed dose combination of saxagliptin with metformin2

KOMBOGLYZE is indicated for use: as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are already treated with saxagliptin and metformin or who are inadequately controlled on metformin alone. Consult the product monograph at www.azinfo.ca/ komboglyze/pm566 for important information about:  Contraindications in type 1 diabetes mellitus, metabolic acidosis including diabetic ketoacidosis, history of lactic acidosis, renal disease or impairment, excessive alcohol intake, moderate and severe hepatic impairment, hypoxic states, stress conditions, severe dehydration, pregnancy, breastfeeding and radiologic studies involving iodinated contrast materials  The most serious warnings and precautions regarding lactic acidosis  Other relevant warnings and precautions regarding pancreatitis, risk of hypersensitivity, patients with congestive heart failure, reduced vitamin B12, use during surgical procedures, CYP 3A4 inducers, immunocompromised patients, rash and renal function  Conditions of clinical use, adverse reactions, drug interactions and dosing instructions The product monograph is also available by calling us at 1-800-668-6000.

AstraZeneca Canada Inc. Mississauga, Ontario L4Y 1M4

There have been no clinical efﬁcacy studies conducted with KOMBOGLYZE tablets; however, bioequivalence of KOMBOGLYZE with coadministered saxagliptin and metformin hydrochloride immediate release tablets was demonstrated.

09/15

ONGLYZA is indicated in patients with type 2 diabetes mellitus to improve glycemic control in combination with: metformin when metformin used alone, with diet and exercise, does not provide adequate glycemic control. Refer to the page in the bottom right icon for additional safety information and a web link to the product monograph discussing:  Contraindications in diabetic ketoacidosis, diabetic coma/ precoma and type 1 diabetes mellitus  Relevant warnings and precautions regarding patients with congestive heart failure, exposure to stress, CYP 3A4 inducers, lactose, risk of hypersensitivity, pancreatitis, immunocompromised patients, rash, pregnant or nursing women, moderate to severe renal impairment and ESRD  Conditions of clinical use, adverse reactions, drug interactions and dosing instructions In addition, the page contains the reference list relating to this advertisement.

Seepage additional information on page XX See XX additional safety information 55 forsafety

contents

SEBASTIEN BUREL / SHUTTERSTOCK.COM

APRIL 2015

features 32

Family fun in Tennessee Five kid-friendly things to do way down around the Old Smokies by Dr Mel Borins

Pirates of the Carolinas Dunes, lighthouses and shipwrecks: touring south from the Outer Banks to Beaufort, SC by Josephine Matyas

Sizing up Palm Springs The city that celebrities love has architecture and museums that you’ll fall for too by Jeremy Ferguson

Little ranch on the Prairie A working cattle spread near Saskatoon that’s guaranteed to please the dude or dudette in you by Gary Crallé

Spring chicken A rotisserie bird three ways by Eric Akis

52 APRIL 2015 • Doctor’s

Review

THE VALUE OF OUR SIGNATURE At Pfizer we are committed to providing patients with medication that always meets our high standards.

Only CELEBREX is

Signed by Pfizer

Now your patients can save on original CELEBREX — the #1 prescribed NSAID in Canada.1 It’s easy! First, direct them to www.Celebrex.ca (or to call 1-866-794-3574) for information on how to save with Pfizer’s payment assistance program. And then remind them to ask for CELEBREX by name!

Get your CELEBREX patients to sign up for savings

CELEBREX is indicated for relief of symptoms associated with Osteoarthritis, adult Rheumatoid Arthritis, and Ankylosing Spondylitis. CELEBREX is also indicated for the short-term (≤7 days) management of moderate to severe acute pain in adults in conditions such as the following: musculoskeletal and/or soft tissue trauma including sprains; post-operative orthopaedic; pain following dental extraction. Please consult the product monograph at http://www.pfizer.ca/en/our_products/products/monograph/125 for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-463-6001. 1. IMS data, January 2014 – December 2014, NSAID Market, monthly data, prescriptions

contents APRIL 2015

regulars 9 LETTERS “Beeting” out the competition

PRACTICAL TRAVELLER A huge Alexander McQueen exhibit in London, the best cruises ever, Haiti’s shiny new hotel plus is Expedia taking over the travel world? by Camille Chin

17 GADGETS Convertible luggage that hides away under your bed when you’re at home by Roger White

TOP 25 The biggest medical meetings happening this September

IBS: PATIENT APPROACHES Distinguishing IBS-C and CIC from other gastrointestinal disorders by Dr Gabor Kandel

DEPRESSION: TREATMENT STRATEGIES Finding the combination of behavioural, talk and pharmacologic therapies that works best for your patients by Mairi MacKinnon

Coming in

• A writer rediscovers her home province — and herself — driving Vancouver Island’s coastal route

HISTORY OF MEDICINE Art therapy: diagnostic and treatment gifts from the newest kid on the block by Rose Foster

May

• Newfoundland isn’t much like anything except itself, as we discover on this cruise around “The Rock”

PHOTO FINISH

• The ancient villages, giant pandas and mineral pools in and around Chengdu

Right as rain by Dr Daniel Kapeluto

and much more…

17 APRIL 2015 • Doctor’s

Review

MAY 6 - 9 | 2015 13

A N N U A L

THE INTERNATIONAL CENTRE HALL 2 - 6900 AIRPORT RD. TORONTO | ON

FAMILY PHYSICIANS, GENERAL PRACTITIONERS, PHARMACISTS

AND NURSE PRACTITIONERS

WORKING TOWARDS BETTER PATIENT OUTCOMES

MAINPRO-M1 SESSIONS 15 Hours of Mainpro-M1

KEYNOTE SPEAKERS Top physicians in their field of practice delivering information on the most relevant topics.

MAINPRO-C SESSIONS 36 Mainpro-C Seminars Useful Tools for Your Practice

Relevant CME Peer to Peer Collaboration

LETTERS

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

“Beeting” out the competition

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

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Denise Bernier

CIRCULATION MANAGER

Claudia Masciotra

EDITORIAL BOARD

R. Bothern, MD R. O. Canning, MD M. W. Enkin, MD L. Gillies, MD M. Martin, MD C. G. Rowlands, MD C. A. Steele, MD L. Tenby, MD L. Weiner, MD

MONTREAL HEAD OFFICE

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None of the contents of this publication may be reproduced, stored in a retrieval system or transmitted in any form by any means, without prior permission of the publishers. ISSN 0821-5758 Canadian Publications Mail Sales Product Agreement No. 40063504 Post-paid at St. Laurent, QC. Return undeliverable Canadian addresses to: Circulation Department, 400 McGill Street, 3rd Floor, Montreal, QC, H2Y 2G1. Subscription rates: One year (12 issues) – $17.95 Two years (24 issues) – $27.95* One year U.S. residents – $48.00 *Quebec residents add PST. All prescription drug advertisements appearing in this publication have been precleared by the Pharmaceutical Advertising Advisory Board.

SOUPED UP I tasted borscht [From Russia with love, March 2015, page 54] in Krakow’s famous Jewish quarter when the “Popsi” was visiting years ago. No desserts were allowed to be served that day. Can someone explain why? The borscht had no meat, just red cabbage. I next tasted borscht, again without meat, in Moscow last year and it tasted bland. I then tasted it in St. Petersburg in a Georgian restaurant. It had garlic and cheese and meat… the best I’ve ever tasted. I didn’t realize that there were so many different kinds of borscht. Dr Sleem Feroze Via DoctorsReview.com

Unfortunately people are often mistaken and mix up Russian and Ukrainian cuisine. Borscht has never been a Russian dish, only Ukrainian, especially the recipe [featured in the magazine]. Russian cuisine has a similar meatless soup called shchi. If you want to try really good borscht, you have to do it in Ukraine only. Olena Via DoctorsReview.com

BEDTIME STORIES There is so much written about sleep — how to fall asleep faster, how to get a good night’s rest, what kind of pillow and mattress and room temperature is best — but your article on two short sleeps a night [“The long and short of bimodal sleep,” History of Medicine, February 2015, page 25] was a first for me and it was an interesting read. I read a headline recently that said that eight hours of sleep a night decreases the length of a person’s life. Soon research may tell us that segmented sleep is what we should have stuck to all along! Dr Miranda Ezell Via email

MDs DO MOROCCO Enjoyed [Dr David Wood’s] commentary on Morocco [“Head for the Hills,” I Prescribe a Trip to…, January 2015, page 28]. My wife, Cynthia (MD, McGill ’72), will be touring there in January 2016. First visited with Max Ward (remember Wardair many years ago?). We did a self-drive in Slovenia several years ago. Be sure to rent a “skiff” and row out to the church on the island (and back). The caves and the coast are a “must” too. Don’t forget the sticker on the windscreen to avoid road tolls. Good travels! Graeme Litteljohn Via DoctorsReview.com

Editor’s note: Vehicles must carry a vignette in order to drive on the motorways and expressways managed by the DARS in Slovenia. Weekly vignettes cost €15 for most cars. For details: slovenia.info and dars.si. APRIL 2015 • Doctor’s

Review

Omnaris : Powerful allergic rhinitis relief with an excellent tolerability profile. ®

Common adverse reactions (1%–10%) in 2 to 6 week clinical trials with SAR or PAR patients (≥12 years) for Omnaris and placebo include epistaxis (2.7% vs. 2.1%), nasal passage irritation (2.4% vs. 2.2%) and headache (1.3% vs. 0.7%). Most common adverse reactions reported in a 52-week clinical trial of PAR in patients ≥12 years, OMNARIS vs. placebo, were epistaxis (8.4% vs. 6.3%), nasal passage irritation (4.3% vs. 3.6%) and headache (1.6% vs. 0.5%).

Indications and clinical use: OMNARIS (ciclesonide nasal spray) is indicated for the treatment of seasonal allergic rhinitis, including hay fever, and perennial allergic rhinitis in adults and adolescents 12 years of age and older. ®

Contraindications: • Patients with tuberculosis Relevant warnings and precautions: • Patients who are on drugs that suppress the immune system are more susceptible to infections than healthy individuals • Patients should be examined periodically for changes or signs of adverse effects on the nasal mucosa (e.g. Candida albicans)

• Do not use in patients with recent nasal ulcers, nasal surgery, or nasal trauma until healing has occurred • Monitor for growth suppression in children and adolescents • Signs of adrenal insufficiency and withdrawal can accompany the replacement of a systemic corticosteroid with a topical corticosteroid; patients should be carefully monitored. Rapid decreases in systemic corticosteroid dosages following long-term treatment may cause a severe exacerbation of symptoms • Monitor for hypoadrenalism in infants born to mothers taking corticosteroids • Use with caution, if at all, in patients with untreated local or systemic fungal or bacterial infections, viral or parasitic infections, or ocular herpes simplex

• Rare instances of wheezing, nasal septum perforation, cataracts, glaucoma, increased intraocular pressure have been reported with intranasal corticosteroid use For more information: For important information on conditions of clinical use, contraindications, warnings, precautions, adverse reactions, interactions and dosing information, please consult the product monograph at http://www. takedacanada.com /ca /omnarispm. The product monograph is also available by calling us at 1-866-295-4636.

REFERENCE: 1. OMNARIS (ciclesonide nasal spray) Product Monograph. Takeda Canada Inc., January 2, 2013. ®

COVERED BY MOST PRIVATE INSURANCE PLANS. ® Registered trademark of Takeda GmbH. Used under licence.

OMN14104E

Powerful AR relief. Excellent tolerability profile.

P R AC T I C AL T R A V E L L E R by

C a mi lle C hi n

The Victoria and Albert Museum in London is hosting a huge show on Alexander McQueen’s work until August 2. The British designer committed suicide in February 2010 following the death of his mother from cancer. The exhibit comes from the Costume Institute at the Met in NYC, which presented the show in 2011. It was extremely popular and one of the Met’s top 10 most visited exhibits. Savage Beauty has been expanded for the V&A and features 66 additional items for a total of 240 ensembles and accessories on view. It spans McQueen’s 1992 postgraduate collection to his A/W 2010 collection, which was completed after his death. London is, of course, the perfect place for such a gigantic retrospective. “London’s where I was brought up. It’s where my heart is and where I get my inspiration,” the designer once said. And later, “The collections at the V&A never fail to intrigue and inspire me. The nation is privileged to have access to such a resource…. It’s the sort of place I’d like to be shut in overnight.” Admission £16. vam.ac.uk.

VICTORIA AND ALBERT MUSEUM, LONDON

Designed to impress

FROM TOP: The VOSS (Spring/Summer 2001) collection. Alexander McQueen, 1997.

APRIL 2015 • Doctor’s

Review

Expedia’s big buy Expedia bought Travelocity at the end of January for US$280 million; three weeks later, the online travel booking site acquired Orbitz for US$1.3 billion. Expedia and Priceline are now the biggest airline/hotel booking sites on the web — to the chagrin of hotel owners who don’t like having even bigger companies between them and their customers. Hotels pay these sites about 15 percent commission per booking and mergers like this mean they have less leverage in negotiations. To try to get travellers to their own sites, hotels are offering free breakfasts, Wi-Fi and loyalty points if they book directly. For customers, acquisitions like this generally mean less competition and choice. Also, booking sites make deals with large hotel chains to get more properties in their listings. B&Bs, inns and hidden gems, which can be more affordable (and memorable), aren’t always represented. OWNED BY EXPEDIA CarRentals.com Hotels.com Hotwire Travelocity Trivago Venere Wotif

OWNED BY PRICELINE Agoda.com Booking.com Kayak (an aggregator) OpenTable RentalCars.com

Plus the Orbitz brands: CheapTickets.com eBookers HotelClub RatestoGo

China opens up GARY YIM / SHUTTERSTOCK.COM

Canadians can now get a 10-year, multiple-entry visa for travel to China, and vice versa. China’s foreign Minister Wang Yi made the announcement at the beginning of March. The agreement applies to both business and leisure travellers. for stays of up to 180 days. Last year, China issued 230,000 visas to Canadian citizens. The US and China made a mutual, 10-year-visa arrangement last November. china-embassy.org.

Doctor’s Review • APRIL 2015

P R AC T I C AL T R A V E L L E R

A new hotel in Haiti The Marriott Port-au-Prince in the island’s Haut Turgeau region opened in February, five years after a 7.0-magnitude earthquake killed more than 160,000 people and displaced 1.5 million. The 175-room hotel was an initiative between Marriott International and the Clinton Foundation with a US$45-million investment from the phonenetwork provider Digicel Group. About 1100 jobs were created throughout the construction phase; 200 afterwards at the hotel itself. There’s Haitian art — from papier-mâché masks and voodoo flags to stone-and-wood sculptures and metalwork — throughout. Fair-trade soaps are from local producer Ayiti Natives, which uses island herbs, fruits and nuts, and employs Haitian woman, often from the poorest villages. All of its coffee is from the Haitian company Rebo Coffee; produce is from Claudia Masciotra Afe Neg Combite, a Kenscoff-based co-op made up of 5500 farmers. The Marriott is also collaborating with the country’s Ministry of Tourism and World Central Kitchen Doctor’s Review April 2015 issue on a hospitality curriculum for culinary students. Construction of the École Hotelière should be completed this year. Rooms start at US$149. marriott.com/hotels/travel/ 1-855-861-0790 papmc-marriott-port-au-prince-hotel.

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voted “Best Overall Cruise Value” (21 consecutive years) by Ocean & Cruise News

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www.seacourses.com 1-888-647-7327 APRIL 2015 • Doctor’s

Review

P RA CT I CA L T RAVE L L E R

MARK STROSHANE

Star Wars characters will join Disney Cruise Line guests in 2016.

Sailings that are shipshape Cruise Critic has named the Best Ships for 2015 in its 5th Annual Cruisers’ Choice Awards. Awards are based on member reviews submitted to the TripAdvisor-affiliated website for sailings taken in 2014. (You have to register — free of charge — to become a member.) The site features more than 100,000 reviews and gets four million visitors every month. Disney was the winner of seven of the 11 award categories. For the full list: cruisecritic.com/memberreviews/cruiserschoice_index.cfm. BEST OVERALL: Disney Dream (large ship) Disney Wonder (mid-size ship) Pacific Princess (small ship)

BEST FOR ENTERTAINMENT: Disney Dream (large) Disney Magic (mid-size) Pacific Princess (small)

BEST FOR CABINS: Disney Fantasy (large) Oceania Riviera (mid-size) Regent Seven Seas Voyager (small)

BEST FOR SERVICE: Disney Fantasy (large) Disney Wonder (mid-size) Regent Seven Seven Seas Voyageur (small)

BEST FOR DINING: Holland America Nieuw Amsterdam (large) Oceania Riviera (mid-size) Azamara Quest (small)

BEST FOR VALUE: Carnival Liberty (large) Holland America Zuiderdam (mid-size) Pacific Princess (small) BEST FOR FAMILIES: Disney Fantasy

Doctor’s Review • APRIL 2015

Indication and clinical use: Symbicort® is indicated for the treatment of asthma in patients 12 years and older with reversible obstructive airways disease. In patients with asthma, there are two treatment approaches: Symbicort ® Maintenance Therapy, where Symbicort® is taken as regular maintenance treatment with a separate rapid-acting bronchodilator as rescue, and Symbicort Maintenance and Reliever Therapy (SMART®), where Symbicort® is taken as regular maintenance treatment and as needed in response to symptoms. Symbicort® should not be used in patients whose asthma can be managed by occasional use of a rapid onset, short duration, inhaled beta 2 -agonist or in patients whose asthma can be managed by inhaled corticosteroids along with occasional use of a rapid onset, short duration, inhaled beta 2 -agonist. Contraindications: • Hypersensitivity to inhaled lactose Most serious warnings and precautions: Risk of asthma-related death: Long-acting beta 2 -agonists (LABA), such as formoterol, one of the active ingredients in Symbicort ®, may increase the risk of asthma-related death. This was found with salmeterol and is considered a LABA class effect. LABA may increase the risk of asthma-related hospitalization in pediatric and adolescent patients. It has not been established whether concurrent use of inhaled corticosteroids or other long-term asthma control drugs mitigates the increased risk of asthmarelated death from LABA. Therefore, when treating patients with asthma, Symbicort ® should only be used for patients not adequately controlled on a long-term asthma control medication, such as an inhaled corticosteroid, or whose disease severity clearly warrants the initiation of treatment with both an inhaled corticosteroid and LABA. Once asthma control is achieved and maintained, assess the patient at regular intervals, and do not use Symbicort ® for patients whose asthma is adequately controlled on low- to medium-dose inhaled corticosteroids. Rescue medication: Inform patients to have rescue medication available at all times. Recommended dosage: Do not exceed. Use in adolescents: Periodic reassessment should be considered as severity of asthma may vary with age. Other relevant warnings and precautions: • Treatment should not be stopped abruptly • Cardiovascular effects • Candidiasis • Hyperglycemia, hypokalemia • Enhanced effect of corticosteroids on patients with hypothyroidism and cirrhosis • Adrenal insufficiency in patients transferred from systemic steroid • Susceptibility or decreased resistance to infection • Paradoxical bronchospasm • Potential risk during pregnancy, labour, delivery or nursing • Control of asthma should be monitored For more information: Consult the Product Monograph at azinfo.ca/symbicort/pm796 for important information regarding adverse reactions, drug interactions and dosing. The Product Monograph is also available by calling AstraZeneca Canada at 1-800-668-6000.

SY1180E

SYMBICORT , SYMBICORT SMART , TURBUHALER and the AstraZeneca logo are registered trademarks of the AstraZeneca group of companies. © AstraZeneca Canada Inc. 2014 ®

12/15 ®

BREATHE IT IN

Explore the possibilities.

Covered on RAMQ and most private plans

Help fight

heartburn associated with GERD With the demonstrated power of DEXILANT®

Visit www.DEXILANT.ca 24 hours a day to learn more

In patients maintaining healed erosive esophagitis (EE) with DEXILANT® 30 mg:

99% of nights were heartburn-free vs 72% with placebo (median; p<0.00001 secondary endpoint)1* 96% of 24-hour periods were heartburn-free vs 29% with placebo (median; p<0.00001 secondary endpoint)1*

Indications and clinical use: In adults 18 years and older, DEXILANT® is indicated for: • Healing of all grades of erosive esophagitis for up to 8 weeks • Maintenance of healed erosive esophagitis for up to 6 months • Treatment of heartburn associated with symptomatic non-erosive gastroesophageal reflux disease (GERD) for 4 weeks Contraindication: • Should not be concomitantly administered with atazanavir Other relevant warnings and precautions: • Symptomatic response does not preclude the presence of gastric malignancy • May slightly increase the risk of gastrointestinal infections such as Salmonella and Campylobacter and possibly Clostridium difficile • Concomitant methotrexate use may elevate and prolong serum levels of methotrexate and/or its metabolites

• May increase risk of osteoporosis-related fractures of the hip, wrist, or spine. Use lowest dose and shortest duration appropriate • Patients >71 years of age may already be at high risk for osteoporosisrelated fractures and should be managed carefully according to established treatment guidelines • Chronic use may lead to hypomagnesemia. For patients expected to be on prolonged treatment or concurrent treatment with digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), initial and periodic monitoring of magnesium levels may be considered • May interfere with absorption of drugs for which gastric pH is important for bioavailability For more information: For important information on Contraindications, Warnings, Precautions, Adverse Reactions, Interactions, and Dosing, please consult the Product Monograph at www.DEXILANT.ca/PM. The Product Monograph is also available by calling us at 1.866.295.4636.

*Results of a 6-month, multicenter, double-blind, placebo-controlled, randomized study of patients who dosed DEXILANT® 30 mg (n=140) or placebo (n=147) once daily and had successfully completed an EE study and showed endoscopically confirmed healed EE.1,2 References: 1. DEXILANT® (dexlansoprazole) Product Monograph, Takeda Canada Inc. 2. Metz DC, et al. Clinical trial: dexlansoprazole MR, a proton pump inhibitor with dual delayed-release technology, effectively controls symptoms and prevents relapse in patients with healed erosive oesophagitis. Aliment Pharmacol Ther 2009;29:742-754. DEXILANT® is a registered trademark of Takeda Pharmaceuticals U.S.A., Inc. and used under licence by Takeda Canada Inc. ©2014 Takeda Canada Inc.

GA D GE T S by

R og e r W hi t e

Wheelie bags that pack convenience Air travel has become almost as much about bags as it is about passengers. Truth is your luggage is now an important source of revenue. Many airlines require basic, economy-fare passengers to pay for any and all checked luggage, starting with bag one. Air Canada tacks on $28.74 to Montreal-Vancouver economy fares to check a single bag; a second will set you back a staggering $104.97. The baggage boondoggle has introduced a whole new level of inconvenience. Passengers, understandably, pack their carry-ons to the hilt. On a recent Atlanta-Montreal flight, the boarding lineup resembled a gypsy caravan. Passengers were tugging wheelie-bags with an assortment of other carrying devices slung about their person: backpacks, duffels, reusable shopping bags, plastic numbers from big-box stores, all of them stuffed with “personal effects.” Gate agents were on the lookout for anything that might not fit in the overhead bins. Several were wrestled out of the owner’s hands and tagged but most of the heavily burdened were allowed to clamber onto the plane with all goods and chattels in hand. Now the race was on to stow them. Swift and frequent travellers hefted theirs — “wheels out please” — into the first available slot regardless of where they were seated. The slow and weak were left largely on their own though, to be fair, white-haired women under 1.5 metres were offered help by the flight attendants. A mother with two kids herded her offspring into their seats and then got a finger jammed in a stroller as she tried to fold it. Oh my! Chaos reigned up and down the plane. Is there a solution? Not yet, but they’re working on it. The new EC Lync System from Eagle Creek offers a modicum of relief. The bags easily convert from a wheeled bag to a backpack or a duffel thanks to a completely removable frame with wheels. When you get to your destination, store the heavy part and you’ve got a light backpack to tote around. When you get home, it stores flat in its own small stuff sack and easily fits under a bed. The bag comes in four sizes: 20, 22, 26 and 29 inches. The three smaller bags weigh less than five pounds (2.25 kilos) with the frame, about two pounds (less than a kilo) without it. The smaller sizes convert to backpacks; the 29-inch turns into a duffel. The over-sized treaded wheels, self-repairing zippers and abrasion-resistant fabric comes with a “No-Matter-What” damage guarantee. Graphite, blue and orange. US$254.95 to US$299.95. shop.eaglecreek.com or your local luggage retailer.

APRIL 2015 • Doctor’s

Review

LEADERSHIP lives here

— Dr. Caroline Gerin-Lajoie Psychiatrist Ottawa, Ont.

Complement your clinical expertise with effective leadership skills PMI physician leadership courses Developed by the CMA specifically for physicians Accredited by the RCPSC and the CFPC Set you on a path to achieve the Canadian Certified Physician Executive (CCPE) designation Upcoming open-enrolment courses Developing and Leading System Improvement — June 1–2, 2015, Halifax, NS Leadership Strategies for Sustainable Physician Engagement — June 3–4, 2015, Halifax, NS Online courses (facilitated) New! Effective Communication Skills for Physician Leaders — April 27–June 7, 2015 Leadership Begins with Self-awareness — October 19–November 29, 2015 In-house courses Bring customized PMI physician leadership courses to your workplace, conference or annual meeting.

For more information or to register, visit:

cma.ca/pmi

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“PMI physician leadership courses are important ways for physicians to remain engaged and resilient in today’s complex health care system.”

Registered trademarks of the Canadian Medical Association used under licence

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings compiled by Camille Chin

Canada Niagara Falls, ON September 24-27 13th Annual Conference of the Canadian Society of Hospital Medicine fhs.mcmaster.ca/conted/calendar.html

Quebec City, QC September 17-20 2015 Annual Meeting of the Canadian Heart Rhythm Society chrsonline.ca/index.php/annual-meeting

Toronto, ON September 25-27

Around the world Brisbane, Australia September 13-16 2015 World STI and HIV Congress worldsti2015.com

Brussels, Belgium September 3-5 48th Annual Scientific Meeting of the European Society of Paediatric Nephrology espn-2015.org

To register and to search 2500+ conferences, visit doctorsreview.com/meetings

A tour of the falls with Niagara Helicopters.

©CTC

7th Congress of the Canadian Sleep Society css-scs.ca/conference

Budapest, Hungary September 17-20

Copenhagen, Denmark August 31 – September 1

22nd World Congress on Controversies in Obstetrics, Gynecology and Infertility congressmed.com/cogi

5th International Symposium on Critical Bleeding iscb2015.dk

Chennai, India September 6-9 17th Congress of the Asia Pacific League of Associations for Rheumatology aplar2015.com

Chicago, IL September 27-29 2015 Annual Meeting of the American Neurological Association myana.org/events/ana-2015-annual-meeting

Istanbul, Turkey September 5-9 31st International Epilepsy Congress epilepsyistanbul2015.org

Kuala Lumpur, Malaysia September 13-16 9th Congress of the International Society for Hemodialysis ishd2015.org.my

Amsterdam, Brasilia, Florence, Hamburg, Honolulu, Istanbul, Madrid, Milan, Paris, Quebec City, San Diego, Seoul, Shanghai, Sydney, Toronto

Go to doctorsreview.com/meetings for conferences in these cities... and many more! APRIL 2015 • Doctor’s

Review

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings The Fisherman’s Wharf District in San Francisco.

Las Vegas, NV September 30 – October 3 2015 Annual Meeting of the North American Menopause Society menopause.org/annual-meetings/2015-meeting/ general-information

Lisbon, Portugal September 17-21 JEFF WHYTE / SHUTTERSTOCK.COM

30th International Papillomavirus Conference and Clinical and Public Health Workshops hpv2015.org

London, England August 29 – September 2 European Society of Cardiology Congress escardio.org/congresses

September 28-30 3rd World Congress on Interventional Therapies for Type 2 Diabetes wcitt2d.org

Monaco August 31 – September 3 13th World Conference “The Esophagiome” oeso.org/monaco_conference2015

National Harbor, MD September 26-29 19th Annual Scientific Meeting of the Heart Failure Society of America hfsa.org/hfsa-wp/wp/upcoming-meetings London’s Natural History Museum.

Prague, Czech Republic September 3-6 2nd World Congress on NeuroTherapeutics: Dilemmas, Debates, Discussions congressmed.com/neurology

San Diego, CA September 10-13 US Psychiatric and Mental Health Congress psychcongress.com/psychcongress

San Francisco, CA September 7-11 25th World Congress of Lymphology lymphology2015.com

Seoul, South Korea August 29 – September 1 12th Congress of the World Federation of Societies of Intensive and Critical Care Medicine wfsiccm2015.com

Stockholm, Sweden September 14-18 2015 Annual Meeting of the European Association for the Study of Diabetes easd.org

Tokyo, Japan September 16-19 7th World Congress of the International Society for Vascular Behavioural and Cognitive Disorders http://www2.convention.co.jp/vas-cog-world2015/ index.html

Vienna, Austria September 2-5

IACOPO GUIDI / SHUTTERSTOCK.COM

9th Congress of the European Pain Federation, EFIC efic.kenes.com

Washington, DC September 10-13 19th Annual United States Conference on AIDS nmac.org/2015usca

Doctor’s Review • APRIL 2015

NEW

for the Treatment of IBS-C and CIC in Adults CONSTELLA ® (linaclotide) is indicated for the treatment of: • irritable bowel syndrome with constipation (IBS-C) in adults • chronic idiopathic constipation (CIC) in adults Pr

CONSTELLA showed significant improvement in abdominal discomfort vs. placebo (secondary endpoints, mean change from baseline at Week 12)1

IBS-C

CIC

IBS-C: -2.0 vs. -1.2 (Trial 1); -1.9 vs. -1.1 (Trial 2) (p<0.0001)* CIC: -0.5 vs. -0.3 (p<0.001)†

Study parameters are available at www.frx.ca/_products/constella.htm

Clinical use: Safety and efficacy in geriatric patients (≥65 years of age) have not been established. CONSTELLA is contraindicated in children under 6 years of age and is not recommended for use in children between 6 and 18 years of age as the safety and efficacy of CONSTELLA in pediatric patients have not been established. Contraindications: • Pediatric patients under 6 years of age • Patients with known or suspected mechanical gastrointestinal obstruction Most serious warnings and precautions: Children: Not recommended in children between 6 and 18 years of age

Other relevant warnings and precautions: • Diarrhea most common adverse reaction; may cause serious diarrhea • Use in pregnant women only if the potential benefit justifies the potential risk to the fetus • Caution should be exercised when CONSTELLA is administered to nursing women For more information: Please consult the Product Monograph at www. actavis.ca/NR/rdonlyres/94008767-D103-460E-B854766C324A3CE8/0/CONSTELLA_ProductMonograph.pdf for important information relating to adverse reactions, food interactions and dosing information not discussed in this piece. The Product Monograph is also available by calling Actavis Specialty Pharmaceuticals at 1-855-892-8766.

* 11-point ordinal scale; Trial 1, Trial 2.1 † 5-point ordinal scale; Trials 3 and 4.1 CONSTELLA® is a registered trademark of Ironwood Pharmaceuticals, Inc. used under license by Actavis Specialty Pharmaceuticals Co. or its affiliates. ©2015 Actavis Specialty Pharmaceuticals Co., Mississauga ON. All rights reserved. REFERENCE 1. CONSTELLA® (linaclotide) Product Monograph, Forest Laboratories Canada Inc., May 12, 2014.

IB S K EY POI NTS by

Dr Gabor Kandel

Getting comfortable with bowel Talking to patients about irritable bowel syndrome with constipation

D .

iagnosis and management of irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) can be challenging in busy primary care settings. IBS-C and CIC are among the most common functional gastrointestinal disorders worldwide. The prevalence of all types of IBS is 11%, with roughly one-third being constipation-predominant, while CIC occurs in about 14% of the population. There’s some overlap between IBS-C and CIC in symptoms, but the hallmark of IBS-C is abdominal pain or discomfort that improves upon defecation. Although IBS-C and CIC are not life-threatening conditions, don’t underestimate their impact on patients’ lives. From mildly annoying to debilitating, symptoms can interfere with work, daily activities and socializing, and lead to lower health-related quality of life. The lack of biologic markers and curative treatments can lead to a vicious cycle of ineffective management: repeated visits, tests, referrals and drugs feed negative perceptions on both sides and, ultimately, prolong suffering by the patient. Breaking this cycle requires a strong, positive therapeutic alliance.

Ask and ye shall receive Some patients actively seek health care for bowel symptoms and aren’t shy about discussing them, while others only mention problems as an afterthought. But many people — perhaps most — never report symptoms to their doctor, no matter how distressing. Asking patients about their bowel movements may be a tough sell for overworked family physicians, but it’s worthwhile because effective treatments are indeed available for IBS-C and CIC, and it’s a real opportunity to improve someone’s quality of life. The first step is to ensure patients feel comfortable discussing their symptoms. For patients who are embarrassed to describe their bowel movements, a little humour can really help. My go-to icebreaker is: “It may be poop to you, but it’s bread and butter to me!” Questions about bowel symptoms not only demonstrate your concern, but also are crucial to establish the diagnosis and help rule out organic causes. The classic medical definition

Gabor Kandel, MD, FRCPC, is a gastroenterologist on staff at St Michael’s Hospital and Associate Professor of Medicine at the University of Toronto.

Doctor’s Review • APRIL 2015

of constipation is fewer than three bowel movements a week, but there are many different definitions among patients, including straining, pain, bloating, a sensation of retained stool, or not having as many bowel movements as they think they should. The type, intensity and frequency of pain and discomfort also vary. “How are your bowel movements?” and “What exactly is unsatisfactory about your bowel movements?” are good questions to get them to be more specific. But it’s not just about bowel movements. Anxiety and depression are frequent comorbidities with IBS, and stress can exacerbate symptoms, so it’s important to find out how patients are feeling generally. Sometimes such emotional issues require tact to elicit. Simply listening to patients may be our most important intervention; it can be both diagnostic and therapeutic.

Knowledge is power The cornerstones of IBS-C and CIC management are reassurance, explanation and support. This is a situation where you have to be a “talk-doc” rather than a “do-doc.” If you’re short on time, it may be more practical to schedule follow-up visits. Patients need to feel that you’re not in a rush and that their concerns are tantamount. The key to reassuring patients lies in how confident you are in the diagnosis. Do as many tests as you need to be sure — if you’re still worried about organic disease, your concerns will be sensed by the patient. For some patients, just hearing that they don’t have something serious like cancer is all the relief they need. You may also need to explain to patients that constipation itself is not harmful, despite what their mothers and the Internet told them. Many people think that if their stools are retained, poisons that the body is trying to get rid of will leach out into the blood and make them sick. This notion dates as far back as the ancient Egyptians and peaked in the early 20th century with the “autointoxication” theory that blamed constipation for a host of diseases from skin disorders to cancer. Although the autointoxication theory was thoroughly debunked decades ago, colonic cleansing and “detoxification” remain popular among laypeople and are a lucrative industry. Another element of reassurance for patients is to validate that their pain is real. Explaining the mechanisms of IBS-C and CIC will help them understand what’s causing their symptoms and shows that you take their suffering seriously.

health

I explain colonic dysmotility as bowel muscle contractions that aren’t well-coordinated, and emphasize that “It’s the bowel’s fault, not yours.” I compare it to a toothpaste tube: the upper part of bowel should contract to squeeze the stool downward, while the lower part should relax to release the stool from the body. Using a tube of lubricant, I show them what happens in IBS, squeezing it at top and bottom to cause a bulge in the middle. On seeing this, many patients exclaim that their abdomen is visibly distended during an episode, and they can understand why that might cause discomfort. To understand why IBS-C is painful, and how certain drugs and psychologic interventions can help, a simple explanation of the gut-brain connection is in order. When the bowel is stretched, gut nerves send signals to the brain, where they may be interpreted as pain. In people with IBS, the gut may be oversensitive and send more signals than in healthy people. The brain, in turn, may misinterpret normal gut messages as pain, or may even trigger gut dysmotility or hypersensitivity in response to stress, certain hormones, and brain chemicals.

Keeping it real There’s no one-size-fits-all treatment for IBS-C and CIC. Work with patients to establish realistic treatment expectations. Be clear that there’s no cure — these are chronic, often lifelong conditions, and coping is key. It’s a good idea to ask which symptoms are the most troublesome. Actively involve patients in management. For example, instead of saying “I think you should try this drug,” you could say: “Changing diet is hard and tends to be of only minimal benefit, whereas drugs are more potent but less ‘natural.’ Which would you prefer?” Most patients have tried various dietary changes and over-thecounter products remedies before coming to you. Find out what they’ve used, to make sure their trials were appropriate and to avoid duplication. The goal in the treatment of constipation is to make the patient feel comfortable. Explain that there’s no magic number of bowel movements, so people shouldn’t panic if they don’t go once a day — if a patient has one bowel movement a month

and feels well, that’s okay. For pain and bloating, the aim is to reduce severity and/or frequency of episodes. Suggested reading: Müller-Lissner SA, Kamm MA, Scarpignato C, Wald A. Myths and misconceptions about chronic constipation. Am J Gastroenterol 2005;100(1):232-242. Ford AC, Moayyedi P, Lacy BE, et al. American College of Gastroenterology Monograph on the Management of Irritable Bowel Syndrome and Chronic Idiopathic Constipation. Am J Gastroenterol 2014;109(S1):S2-S26.

Take-home messages Most physicians find management of IBS-C and CIC just as challenging as you do, but the effort is worthwhile because these conditions can so severely impact quality of life, and patients may become trapped in a vicious cycle of ineffective management. • Breaking this vicious cycle requires a strong, positive therapeutic alliance. • Listening is key, often more therapeutic than drugs. • Asking patients about bowel movements is worthwhile because effective treatments are available. • Ensure patients feel comfortable discussing their symptoms. • Ask specific questions about bowel movements to establish diagnosis and help rule out organic causes. • Actively look for precipitants such as anxiety, depression and stress. • Do as many tests as you need to be confident in the diagnosis. • Explain that constipation itself is not harmful, and educate patients on the mechanisms of IBS-C and CIC. • Establish realistic treatment expectations, emphasize the role of coping, and actively involve patients in management.

In major depressive disorder

“I felt down and

overwhelmed nearly every day.” Nicole*, 37

For patients like Nicole...

Trust PRISTIQ

for powerful

symptom relief No statistical difference in mean weight change vs. placebo was seen at 6 months (p=ns)†

* Fictitious case. May not represent all patients. † Results of the final on-therapy assessment in the 6-month, double-blind, placebo-controlled phase of a long-term trial in patients who had responded to PRISTIQ during an initial 12-week, open-label phase.

Indication and clinical use • PRISTIQ is indicated for the symptomatic relief of major depressive disorder • PRISTIQ is not indicated for use in children under the age of 18 • The short-term efficacy of PRISTIQ has been demonstrated in placebo-controlled trials of up to 8 weeks • The efficacy of PRISTIQ in maintaining an antidepressant response for up to 26 weeks, following response during 20 weeks of acute, open-label treatment, was demonstrated in a placebo-controlled trial Contraindications • Concomitant use with monoamine oxidase inhibitors (MAOIs) or within the preceding 14 days • Hypersensitivity to venlafaxine hydrochloride Most serious warnings and precautions • Behavioural and emotional changes, including self-harm: SSRIs and other newer antidepressants may be associated with: - Behavioural and emotional changes including an increased risk of suicidal ideation and behaviour - Severe agitation-type adverse events coupled with self-harm or harm to others - Suicidal ideation and behaviour; rigorous monitoring advised • Discontinuation symptoms: should not be discontinued abruptly. Gradual dose reduction is recommended Other relevant warnings and precautions • Concomitant use with venlafaxine not recommended • Allergic reactions such as rash, hives or a related allergic phenomenon • Bone fracture risk with SSRI/SNRI • Increases in blood pressure and heart rate (measurement prior to and regularly during treatment)

• Increases cholesterol and triglycerides (consider measurement during treatment) • Hyponatremia or Syndrome of Inappropriate Antidiuretic Hormone (SIADH) with SSRI/SNRI • Potential for GI obstruction • Abnormal bleeding with SSRI/SNRI • Interstitial lung disease and eosinophilic pneumonia with venlafaxine • Seizures • Narrow angle glaucoma • Mania/hypomania • Serotonin syndrome or neuroleptic malignant syndrome-like reactions For more information Please consult the product monograph at http://www.pfizer.ca/en/our_products/ products/monograph/226 for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-463-6001. Reference: PRISTIQ Product Monograph, Pfizer Canada Inc., July 3, 2013.

CA0113PRI023E

Count on

for powerful symptom relief

D E P R E S S I O N K E Y P OI N T S by

Mairi MacKinnon

Strategies for depression The right treatment can help patients get well and stay well

M .

ajor depressive disorder (MDD) is a serious and often recurring condition, and the risk of recurrence rises with each episode a person experiences. Early assessment and timely, effective intervention can help to reduce the burden.1,2 The Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines offer clinicians evidence-based recommendations on managing adults with MDD. Where resources are available, a combination of psychosocial and pharmacologic therapies — tailored to the individual — is suggested.3

who show ≥ 20% improvement on depression rating scales after four to six weeks should continue the medication for another two to four weeks before another strategy is tried. If response is inadequate (< 50% reduction in score on patient rating scales) after a reasonable trial at the maximum dose, explore possible reasons including depression subtype, bipolarity, side effects and adherence. Selecting the antidepressant that is most effective initially often yields the best results but, that said, pharmacologic strategies include switching to another first-line agent (this can be in the same class) or adding another antidepressant.4

Talking helps

Use alternative remedies with caution

Psychotherapies, or “talk” therapies, can be effective for mild to moderate depression. Cognitive behavioural therapy (CBT) involves recognizing and learning to modify negative thinking and behaviour patterns that may be causing depression. CBT is recommended as a first-line treatment and to reduce relapse in the maintenance phase. Interpersonal therapy (IPT) uses problem-solving, dispute resolution and social skills training to help individuals deal with relationships that may be either the cause or result of depression. IPT is a recommended first-line treatment for acute MDD and second-line maintenance therapy. Internet-assisted CBT and telephone-delivered CBT and IPT can be other useful second-line interventions, along with bibliotherapy (reading self-help materials).3

Complementary and alternative medicine (CAM) therapies are not regulated like mainstream therapies and data is limited on their safety and effectiveness. However, substantial evidence exists to recommend light therapy as a first-line treatment for seasonal MDD and a second-line option for non-seasonal mild to moderate MDD. St. John’s wort is considered a first-line treatment for mild to moderate MDD and can be used as adjunctive treatment for more severe depression.5

Antidepressants boost neurotransmitters that affect mood For moderate to severe depression, pharmacotherapy and psychotherapy can be more effective than psychotherapy alone.3 Since most first-line medications have equivalent efficacy, the choice is based on factors such as the patient’s symptoms, comorbidity, safety and tolerability, potential for drug interactions, individual preference and cost.4 First-line therapies — selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs) and norepinephrine dopamine reuptake inhibitors (NDRIs) — are usually prescribed first. These newer antidepressants have good evidence for safety and tolerability, with reduced side effects compared to first-generation tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOs). Second-line therapies can be tried when first-line medications are not tolerated or have not worked.4 Patients should understand that antidepressants can take time to work. According to the CANMAT guidelines, patients

Patient engagement The goals of therapy are to eliminate the depressive symptoms and facilitate the return to full normal function and quality of life. Involving patients in their treatment plan and in self-management can improve adherence and help prevent recurrence. Emphasize the importance of maintaining a healthy lifestyle — eating and sleeping well, exercising regularly, avoiding substance abuse — as well as managing their stress levels and monitoring their moods.1 References 1. Patten SB, Kennedy SH, Lam RW et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management. J Aff Disord 2009;117(Suppl 1):S5–S14. 2. Canadian Psychological Association. “Psychology Works” Fact Sheet: Depression. Ottawa, 2014. www.cpa.ca/docs/File/Publications/FactSheets/PsychologyWorksFact Sheet_Depression.pdf. Accessed March 13, 2015. 3. Parikh SV, Segal ZV, Grigoriadis S et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Aff Disord 2009;117(Suppl 1):S15–S25. 4. Lam RW, Kennedy SH, Grigoriadis S et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. III. Pharmacotherapy. J Aff Disord 2009;117(Suppl 1):S26–S43. 5. Ravindran AV, Lam RW, Filteau MJ et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. V. Complementary and alternative medicine treatments. J Aff Disord 2009;117(Suppl 1):S54–S64. APRIL 2015 • Doctor’s

Review

Trust in a name that has been available for 16 years: PrEFFEXOR® XR EFFEXOR XR (venlafaxine hydrochloride) is indicated for the symptomatic relief of: Major Depressive Disorder, Anxiety causing clinically significant distress in patients with Generalized Anxiety Disorder Social Anxiety Disorder (Social Phobia), Panic Disorder, with or without agoraphobia, as defined in DSM-IV

Recommended as a first-line agent for:1-3* •

Depression

•

General Anxiety Disorder

•

Social Anxiety Disorder

•

Panic Disorder

Help your patients taking EFFEXOR XR by offering payment assistance with Pfizer Strive Payment Assistance† * See respective guidelines for complete recommendations. † Pfizer Strive Payment Assistance is available in all provinces except Quebec. Availability and coverage vary by province.

Clinical use:

• Caution in patients operating machinery or engaging in tasks requiring alertness

Depression: Short-term efficacy has been demonstrated in placebo-controlled trials of up to 12 weeks. Efficacy in maintaining an antidepressant response for up to 26 weeks, following response to 8 weeks of acute treatment, was demonstrated in a placebo-controlled trial.

• Caution in patients with a history of myocardial infarction or unstable heart disease

Generalized Anxiety Disorder: Anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic. The effectiveness in long-term use has been evaluated for up to 6 months in controlled clinical trials.

• Risk of QTc prolongation, Torsade de Pointes (TdP)

Social Anxiety Disorder (Social Phobia): Efficacy was demonstrated in four 12-week, multi-centre, placebo-controlled, flexible-dose studies and one 6-month, fixed/flexible-dose study in adult outpatients. Panic Disorder: Efficacy was established in two 12-week, placebo-controlled trials in adult outpatients. The efficacy in prolonging time to relapse for up to 6 months, in responders of a 12-week acute treatment, was demonstrated in a placebo-controlled trial. The physician who elects to use EFFEXOR XR for extended periods should periodicallyre-evaluate the long-term usefulness of the drug. Caution should be exercised in the elderly.

• Increases in heart rate may occur; caution in patients whose underlying conditions may be compromised – Caution in patients with cardiovascular disease or family history of QT prolongation, or in patients taking medicines known to increase QT interval, especially for patients with increased risk of QT prolongation • Caution in patients with diseases or conditions that could affect hemodynamic responses or metabolism • Risk of serum cholesterol elevations; monitor levels, especially during long-term treatment • Potential for changes in appetite and weight • Risk of hyponatremia and syndrome of inappropriate antidiuretic hormone (SIADH) secretion, usually in volume-depleted or dehydrated patients • Risk of bleeding; concomitant use with NSAIDs, ASA or other drugs affecting coagulation may add to the risk; caution in patients with a history of bleeding disorder or predisposing conditions

Contraindications: • In combination with Monoamine Oxidase Inhibitors (MAOIs) or within two weeks of terminating treatment with MAOIs. Most serious warnings and precautions: • Risk of potential association with behavioural and emotional changes, including self-harm: – Rigorous clinical monitoring for suicidal ideation or other indicator of potential for suicidal behaviour is advised in patients of all ages. This includes monitoring for agitation-type emotional and behavioural changes. – Patients, families, and caregivers should watch for the emergence of unusual behavioural changes, depression worsening and suicidal ideation, especially during treatment initiation or change in dose/dose regimen. • Discontinuation symptoms: dosage should be tapered gradually and the patient monitored. • Bone fractures: increased risk of bone fractures have been shown with some antidepressants, including selective serotonin reuptake inhibitors/serotonin norepinephrine reuptake inhibitors (SSRIs/SNRIs).

• Caution in patients with a history of seizures; promptly discontinue if seizure develops • Risk of serotonin syndrome or neuroleptic malignant syndrome (NMS) – Careful observation if concomitant treatment with other agents affecting serotonergic and/or dopaminergic neurotransmitter systems is clinically warranted – Concomitant use with serotonin precursors is not recommended • Can cause mydriasis; caution in patients with raised intraocular pressure or narrow angle glaucoma • Treatment-emergent insomnia and nervousness • Mania/hypomania: caution in patients with a history or family history of bipolar disorder • Lactating women should not nurse their infants For more information:

Other relevant warnings and precautions:

Please consult the product monograph at www.pfizer.ca/en/our_products/ products/monograph/258 for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece.

• Risk of allergic reaction

The product monograph is also available by calling 1-800-463-6001.

• Hepatic and renal impairment: Dosage adjustments required.

• Risk of hypertension, including acute severe and sustained hypertension; monitor blood pressure regularly in all patients • Caution in the treatment of pregnant women, especially during the third trimester – Exposure late in the third trimester may result in discontinuation symptoms and complications requiring prolonged hospitalization, respiratory support and tube feeding

References: 1. EFFEXOR XR Product Monograph, Pfizer Canada Inc., August 2013. 2. Lam R, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical Guidelines for the management of major depressive disorder in adults. J Affec Disord 2009;117:S26-S43. 3. Swinson R, et al. Clinical Practice Guidelines Management of Anxiety Disorders.Can J Psychiatry 2006;51(suppl 2):S1-92S.

® Pfizer Inc, used under license Effexor ® Wyeth LLC., owner/ Pfizer Canada Inc., Licensee

CA0114EFX007E

Not indicated for use in children under 18 years of age.

R E CO M M E N D E D F I R S T- L I N E

IN CHILDREN, ADOLESCENTS AND ADULTS 1*

ANYONE IN THE FAMILY CAN HAVE ADHD BIPHENTIN ®: FOR ADHD PATIENTS FROM 6-65 YEARS OLD 2

IN ADULTS: 3 Fast onset – similar to IR methylphenidate2† IN CHILDREN ≥6 YEARS OF AGE AND ADOLESCENTS: 3 Demonstrated improvements within one hour2‡ 3 Efficacy shown to last for 10 to 12 hours2§ Biphentin® is indicated for treatment of Attention-Deficit Hyperactivity Disorder (ADHD) in children 6-11, adolescents 12-18 and adults >18 years of age. Refer to the page in the bottom-right icon for additional safety information and a web link to the Product Monograph discussing: • contraindications in patients with anxiety, tension, agitation, thyrotoxicosis, advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension, glaucoma, motor tics or with family history or diagnosis of Tourette’s syndrome or concomitant use of an MAO or within a minimum of 14 days following discontinuation of an MAO;

Flexible dosing – available in 8 strengths for dose optimization2¶

May be sprinkled on these soft foods: apple sauce, yogurt or ice cream2

• the most serious warnings and precautions regarding drug dependence/tolerance; • other relevant warnings and precautions regarding the risk of sudden cardiac death, patients who are involved in strenuous exercise or activities; are using other stimulants or medications for ADHD; have a family history of sudden cardiac death, cardiovascular effects, pre-existing cardiovascular and cerebral vascular conditions, hypertension, long-term suppression of growth, normal fatigue states, psychiatric effects, neurologic effects, ophthalmologic effects; pregnancy and lactation, an element of agitation, driving and heavy machinery, drug interactions; • conditions of clinical use, adverse reactions, drug interactions and dosing instructions.

* Recommended first-line for uncomplicated ADHD in children, adolescents and adults by CADDRA (Canadian Attention Deficit Hyperactivity Disorder Resource Alliance).1 † Rapidly and extensively absorbed with peak blood levels obtained in 1 to 3 hours. The initial peak plasma concentration at 1.7 hours post-dose was similar to 1.8 hours for the immediaterelease formulation when fasting.2 ‡ Improvements relative to placebo were noted within 1 hour on Biphentin® and persisted into the early evening in a doubleblind, placebo-controlled, crossover comparison of Biphentin® and IR methylphenidate in ADHD children and adolescents 6-15 years of age (n=17).2 § IOWA Conners’ Rating Scale and Conners’ Parent Rating Scale performed at approximately 10 and 12 hours, respectively, post-morning dose in two separate randomized, double-blind crossover studies vs. IR methylphenidate and placebo and vs. IR methylphenidate in children and adolescents ≥6 years of age.2 ¶ Biphentin® should be initiated at the lowest possible dose and titrated in weekly increments of 10 mg/day. Maximum daily dose of 1 mg/kg (not exceeding 60 mg/day) in children 6-12 years of age and adolescents. Maximum dose of 80 mg/day for adults.2 Biphentin® is a registered trademark of Purdue Pharma. © 2014 Purdue Pharma. All rights reserved.

See additional safety information on page 47 XX

H I S T O R Y O F M E DI CI N E by

R os e F os t e r

Art for therapy’s sake Creativity that soothes and heals the troubled soul

H The house-tree-person test is used in the diagnosis of personality, general mental function and brain damage.

ave you ever glanced down at a paper on your desk covered in doodles after a

lengthy and perhaps emotionally draining phone call and wondered what all the interlocking shapes and cross-hatchings might mean? What about that funny character with the big nose? Or the strange lady with the long, long arms? If you’re a doodler, you’ve been dabbling in a little art-therapy-self-diagnosis and chances are it’s brought some relief from the tension or the tedium of the call. Art therapy is a young field, having only been officially recognized in the 1960s, but its roots lie in the work of Sigmund Freud. The Austrian neurologist popularized the notion that images have a power that words do not with his suggestion that dreams are messengers from the unconscious mind which come bearing insights about a person’s inner world. Although Freud noted that patients frequently expressed their certainty that they could draw dreams that they could not otherwise describe to him, it was not until the 1940s that psychiatrists took his observations one step farther by actually inviting patients to draw in a psychiatric context. American psychologist, educator, author and artist Margaret Naumburg is considered to have been one of the first major theoreticians of art therapy, which she introduced as a therapeutic modality in the 1940s in New York City. Her “Dynamically Oriented Art Therapy” was based primarily on Freudian psychoanalysis and she viewed it as a form distinct from psychotherapy. Her method — and many forms of art therapy that were to follow — uses the transference process between the therapist and the patient who makes the art. The therapist both elicits the patient’s own interpretation of the work and provides additional interpretation of the self-expression. The patient’s own participation in the interpretation process makes art therapy an active and engaging act, and can distill a sense of self-determination. An 1895 illustration by artist Adolf Wölfli, one of the first to appear in Hans Prinzhorn’s 1922 book, Artistry of the Mentally Ill. APRIL 2015 • Doctor’s

Review

An example of a diagnostic drawing test in which the patient is asked to do three drawings: anything you want; a tree; lines that convey how you feel.

THE ARTIST WITHIN Margaret’s sister, Florence Cane, herself an art educator, provided Margaret with the therapeutic technique that she used with her patients, which was essentially doodling with their eyes closed and then elaborating on the resulting scribbles with eyes open. Florence was a powerhouse of inspiration to the generations of young art students who came through the Walden School, founded by Margaret in the early 1920s. Florence had undergone psychoanalysis as a child and was a firm believer that the method brought deep inner thoughts, memories, emotions and catharsis to the patient. In

1952, she published a book called The Artist In Each of Us, which became the bible for early art therapies. Florence was also inspired by Eastern philosophy and the work of Carl Jung, who spent the years between 1915 and 1930 invoking a voluntary confrontation with the unconscious through the active engagement of what he called his “mythopoetic imagination.” The results of this exploration can be seen in The Red Book, a manuscript containing rich images and calligraphic notes which chart his visionary journeys. It was published posthumously in 2009. Rather than regarding art products as information packets which contain insights to healing, some therapists have focused on the creative process itself as the vehicle for transformation. This duel potential is referred to by art therapists today as “art as therapy vs. art in therapy.” The two perspectives can be observed arising in parallel waves throughout the development of art therapy.

It wasn’t until the 1940s that psychiatrists invited patients to draw as part of their treatment A LIFTING OF SPIRITS

Between 1876 and 1888, Paul-Max Simon, a French psychiatrist known as “the father of art and psychology,” amassed a large collection of artwork by mentally ill patients and found that those with specific illnesses could be associated with recurring themes and visual elements in their drawings. He also noted that the act of making the images seemed to lift the spirits of their creators. This amassing of art by mentally ill patients, most of them untrained as artists, became a cultural craze of sorts that had a lasting influence on the art world. Hans Prinzhorn, a German art historian turned psychiatrist, gathered his own collection, soliciting patients’ drawings from other doctors and hospitals nationwide, and publishing them in 1922 in his influential book, Artistry of the Mentally Ill, which was richly illustrated with examples from his collection. French painter and sculptor Jean Dubuffet was An advertisement for the product Cylert showing drawings before taking the medication and after.

Doctor’s Review • APRIL 2015

Patients with specific illnesses could be associated with recurring visual elements in their drawings inspired by the artworks, and coined the term “Art Brut,” known in the English-speaking world as “Outsider Art.” Rather than attempt to apply critical analysis to the works in his collection, Prinzhorn believed that art-making was a “universal creative urge” that brought solace and healing. European therapists who emerged around the same time as those in the US and Canada have also been credited with establishing the practice of art therapy. In England, artist and educator Adrian Hill used the term “art therapy” in his 1945 book, Art Versus Illness, and in his case, it referred primarily to the health benefits to be gained by the practice, rather than the analysis of art. He discovered the positive effects of the creative process while convalescing from tuberculosis in 1938 and observed that drawing objects from his hospital bed aided in his recovery. Soon afterwards he was invited to teach drawing and painting to other patients. Art appreciation also furthered recovery, Hill thought, and arranged to have reproductions of famous artists’ works lent to hospital wards all over England, where speakers were engaged to discuss the art with patients. This evolved into programs for both art instruction and appreciation in long-stay mental asylums, which became a major influence on the British development of art therapy. In 1964, Hill became president of the British Association of Art Therapists.

MENNINGER & SONS On this side of the pond, art therapy was catching on at a hospital in Topeka, Kansas, founded by Charles Menninger and his two sons in 1925. The Menninger clinic promoted “activity therapies” as a recovery tactic for mental illness and employed Mary Huntoon, an artist, not a therapist, to teach classes at the hospital. She coined the term “art-synthesis” to describe the process of self-discovery that many of the participants experienced after completing an artwork. In 1969, artists Don Jones and Robert Ault, who worked at the hospital, formed the American Art Therapy Association, which formally established art therapy as a professional field in North America.

DRAWING THAT HEALS One of the many tools to emerge from the profession is art-based assessments, diagnostic tests which can provide insights into mental functioning. The classic test is the “Draw-A-Man” test, developed by Florence Goodenough in 1926. It initially ascribed

A 1910 illustration titled Proof by artist Jakob Mohr from Artistry of the Mentally Ill.

levels of intelligence based on the number of details in a drawing, but was later discovered to convey just as much information about personality as it did about smarts. The “house-tree-person” test and the “road drawing” test follow similar guidelines, in which therapists consider everything in the drawing from line length, space usage, placement on the page, and the number of colours used to gain insights about the patients. A newer exercise called “body tracing” is used to show patients with eating disorders the difference between their perceived and actual weights. The panoply of uses for art therapy is ever-growing. Studies have shown that art-making — or even simply being in the presence of soothing landscape paintings in a hospital room — effectively reduces stress. Cancer patients’ symptoms have been shown to be alleviated when they draw and paint, children with autism spectrum disorder are able to increase their social skills through art making, and at-risk teens can be averted from self-destructive behaviours when they engage in the creative process. Prison inmates, disaster victims, bereaved children and depressed retirees have all benefitted from art therapy. The separation of art and mental health has been narrowed considerably in the last 50 years. The power of personal creativity to heal now has a central place in treatment. Its influence continues to grow to the benefit of both the profession and patients. APRIL 2015 • Doctor’s

Review

I P RE SCRIBE A TRIP TO... TENNESSEE

Family fun in Tennessee From nature parks to lavish shows, five kid-friendly things to do in the eastern part of the state by Dr Mel Borins

PARK IT HERE The most visited National Park in the US is Tennessee’s Great Smoky Mountains (nps.gov/grsm; free) and that’s where we began our trip through the state. The park is vast, over 2000 square kilometres, so we started with a bus tour.

The Cades Cove loop departs from the Sugarlands Visitor Center and included time for a three-kilometre stroll along the Fighting Creek Nature Trail through a small portion of the park’s magnificent forest. Afterwards, back at the visitor center, we learned that the park is home to over 120 species of trees, 66 types of mammals, over 1500 flowering plant species, 39 varieties of reptiles and over 200 species of birds. That first evening, on our way back to our big log cabin at Dollywood Cabins in Pigeon Forge near the north entrance of the park, we were lucky enough to spot a black bear from a safe vantage point by the road. It was the first of three sightings; a treat and a privilege. Over 1600 bears inhabit the area.

WELL, HELLO DOLLY There are more than 23 rides at Dollywood Splash Country.

Doctor’s Review • JANUARY 2015

Dolly Parton, of country and western fame, was born in Pigeon Forge. She was the daughter of an illiterate miner and grew up in poverty. After her career took off,

ALL PHOTOS TENNESSEE DEPARTMENT OF TOURIST DEVELOPMENT

An aerial tram takes guests up Mount Harrison to the Ober Gatlinburg resort.

Dr Mel Borins is a family physician on active staff at St. Joseph’s Health Centre in Toronto and Associate Professor in the Department of Family and Community Medicine at the University of Toronto. He’s the author of three books and lectures, in a humorous vein, on health and stress management.

The Dixie Stampede Dinner and Show has been revamped for 2015.

she came back home and built Dollywood (dollywood. com; adults from US$47, kids 4-11 from US$42), a 119-hectare theme park that includes a water park. The Dixie Stampede Dinner Attraction (dixiestampede. com; adults US$55, kids 4-11 US$28) is a nightly show that lays on horseback riding, clowns, games and a chance to eat a Southern-style meal with your hands. There are also impressive musical shows staring top entertainers that are performed at four indoor and three outdoor stages. There are sometimes 40 live performances a day! The 307-room Dollywood’s DreamMore Resort opens in mid-August. There’s more to Ms. Parton than meets the eye. The Dollywood Foundation promotes literacy at home and around the world. The Imagination Library program has sent more than 75 million books to children and is the largest purchaser of kids’ books in the world.

GATLINBURG, THE TINY GIANT There was more music waiting for us down the road in the small, mountain town of Gatlinburg (gatlinburg. com). Though the population is just over 4000, the tourist town has more than 80 restaurants serving southern-style cooking and there’s also lots of choice when it comes to night life. The biggest entertainment venue is the 1200-seat Grand Majestic Theater (thegrandmajestic.com), which runs five shows a day. We went to the Sounds of Soul and The Hit Parade. I love old music and hearing many of the songs again lifted my spirits. Ripley’s Aquarium of the Smokies (ripleyaquariums. com/gatlinburg; adults US$25, kids US$14) was something unexpected: it has four-metre sharks, giant sea turtles, thousands of exotic sea creatures and an excellent penguin exhibit.

The statue of Dolly in Sevierville is sometimes rubbed for good luck.

And another surprise: you can take the 120-passenger aerial tramway 823 metres up Mount Harrison to the Ober Gatlinburg resort (obergatlinburg.com; adults US$12, kids US$9.50 roundtrip). In winter, you can cross-country or downhill ski on one of 10 ski runs. There’s even a year-round skating rink and river rides in the summer.

PARTY ON IN SEVIERVILLE Our adventure continued a few miles north in Sevierville (visitsevierville.com), a kind of Las Vegas without gambling for families. We stayed at The Wilderness at the Smokies Hotel and Waterpark Resort (wildernessatthesmokies.com; from US$149 during high season), which has rides, laser tag, a forest treetop walk, a climbing wall and even jet boats to ride. I played the Sevierville Golf Course while the others shopped — they have that, too. The Highlands Course winds through rolling hills and mountain ponds along the Little Pigeon River. Lovely.

STOP, EAT BAR-B-QUE Throughout the trip we delighted in Appalachian mountain cooking. Some highlights: the Pancake Pantry in Gatlinburg; Smokin’ Joe’s Bar-B-Que and Miss Lily’s Café in Townsend; and Carver’s Applehouse Restaurant in Cosby. If you have a hankering for some Southern hospitality, want to explore an outstanding US National Park and have a family that loves history, adventure, rides and world-class entertainment, consider a visit to Great Smoky Mountains National Park, and the towns and communities in the vicinity. It’s just what this doctor orders. APRIL 2015 • Doctor’s

Review

Built in 1872, the Bodie Island Lighthouse is 48 metres tall and is climbable.

Doctor’s Review • APRIL 2015

Pirates of the Carolinas

Four days of history, beauty and adventure touring south from the Outer Banks to Beaufort, SC text and photos by Josephine Matyas

he view from the sand dunes at Jockey’s Ridge State Park is one you don’t want to miss. A vast panorama spreads out from the top of the tallest natural dune on the east coast. The long arc of shifting sand that is the Outer Banks of North Carolina are laid out in a living map — small costal villages, lighthouses, the long beaches, the glittering Atlantic. The adventure begins with a turn off a busy interstate and onto the smaller routes tracing the coastline of the Carolinas. We have four days with nothing to do but slow down and touch the history, food, landmarks and people of small community life along the shoreline. There’s easy beach access across the dunes at Jockey’s Ridge State Park.

Climb every lighthouse you can; the views make it well worth the effort.

In 1999, the Cape Hatteras Light Station was relocated from the spot on which it had stood since 1870.

â&#x20AC;&#x153;Colonial Spanish Mustangsâ&#x20AC;? were brought to the Outer Banks nearly 500 years ago.

DAY 1 Outer Banks Nicknamed the Graveyard of the Atlantic, the waters off the Outer Banks are littered with hundreds of shipwrecks, and the curved barrier islands are pinpointed with dozens of lifesaving stations and lighthouses. It was not always so. In villages like early 19th century Nags Head the local shipwrecks could be a lucrative business. They tied lanterns to the necks of nags and walked them up and down the beach. The ship captains would see the moving lights and think the way was clear. Crashing into the treacherous shoals sealed the fate of many a vessel. In the 1870s, a series of towering lighthouses was built to warn of the coastline’s danger. In the village of Corolla, the red brick Currituck Beach Light Station (currituckbeachlight.com; late March through November; free) emits a reliable flash, piercing the darkness at the northern reach of the Outer Banks. A 220-step climb to the observation

The Wright brothers launched the first powered aircraft at Kitty Hawk in 1903.

platform gives sweeping views over marshland, dunes, the sound and the Atlantic coastline. To the north, a 20-kilometre stretch of beach and dune is protected as part of the Currituck National Wildlife Refuge. To the south, the black-and-white striped Bodie Island Lighthouse and Cape Hatteras Lighthouse (nps.gov/caha; late April through early October; adults US$8) still blink as beacons of protection along the shoreline. Both are historic parts of the Cape Hatteras National Seashore. The spiral staircase that winds inside the Cape Hatteras station is a breathtaking 12-storey climb up the nation’s tallest brick lighthouse, with views to match. The Outer Banks — Kitty Hawk in particular — claims bragging rights as the Birthplace of Aviation. “In 1900 the brothers wrote the weather bureau asking for the windiest spot in the country,” explained Josh

Boles, a park ranger at the Wright Brothers National Memorial (nps.gov/wrbr; adults US$4). “They were looking for wind but they were also looking for privacy — they were developing proprietary material.” Inside the visitor centre are reproductions of the Wright Brothers’ flying machines, the wind tunnel used to measure lift, and grainy archival video and photos. Orville and Wilbur were bicycle builders and understood the mechanics of moving parts and forces like propulsion. “A soaking wet Wright Brother weighed about 150 pounds,” Boles said. “They broke out the slide rule and calculated that if they made the wing four inches longer, the craft would be stable.” On December 17, 1903 their calculations struck aviation gold. The world’s first successful heavierthan-air powered flight along a remote, sandy beach changed world history.

DAY 2 Ocracoke Island The ferry from Hatteras Inlet to Ocracoke Island gently slipped into the dock after an hour’s sail effectively snapping our connection to the north and nudging the relaxation dial up a notch. In describing the remote nature of their home, Ocracoke islanders like to say, “If the world ended tomorrow, Ocracoke wouldn’t know for a week.” What is now out-of-the-way haven for seekers of fishing, beachcombing, birding and solitude with a thriving art community was once a revolutionaryera route to the rich, major inland ports. “It’s never been a fishing village although people think of it that way,” explained Al Scarborough, a volunteer at the Ocracoke Preservation Society Museum (site.ocracokepreservation.org; open seasonally). “The first settlers in the 1700s were the pilots who guided schooners through the inlet. They were the lifeblood of this community.” When modern amenities like electricity, a reverse osmosis water system and regular ferry service came along, the tourists followed to find their little slice of nirvana. Perhaps the island’s most infamous visitor was the pirate Blackbeard. Ocracoke is where he met his demise in 1718 while anchored at nearby Teach’s Hole. Local guide and captain of the schooner Windfall II (schoonerwindfall.com; April to October; sunset cruise US$40) Rob Temple is an authority on the buccaneer. “Nobody’s sure what his real name was or where he came from. The colonists of North Carolina were concerned that Blackbeard was comfortable hanging out at the outlet.” When the pirate was finally cornered by the Royal Navy, he led them on a chase through shallow waters before being killed by five bullet and 20 sword wounds. Legend has it that the pirate’s APRIL 2015 • Doctor’s

Review

headless body swam seven times around the ship. Locals doubt it could have managed more than two!

DAY 3 Beaufort, North Carolina and the Down East communities To this day, Blackbeard’s tales of piracy echo up and down the North Carolina coastline. For pirates and privateers, the merchant ships following the northsouth current of the Gulf Stream were easy pickings, creating a golden opportunity for looting. In the historic mainland town of Beaufort, the North Carolina Maritime Museum (ncmaritimemuseums. com; free) shows how coastal villages provided a demand for the types of black market goods the pirates could supply. The passing merchant ships and needs of the colonists created the perfect storm for an era marked by piracy.

Legend has it that the pirate’s headless body swam seven times around the ship In colonial times, there was a push to attract residents to new communities up and down the coastline. “Hungry Town is a historic name for Beaufort,” explained David Cartier who operates Hungry Town Tours (hungrytowntours.com; from US$20). “They were not hungry for food but hungry for settlers.” David and his wife Betsy lead pedalling and walking tours through the Beaufort Historic District, a part of town liberally peppered with sweet 18thcentury coastal cottages and grand West Indian-style homes built by shipbuilders to withstand punishing storms. “Beaufort has been isolated, so it’s kept its charm,” David said. The main thoroughfare — Front Street — is lined with independent shops, small eateries and artisan studios. A half-hour drive east of town, staying true to the coastline, is the region called Down East — a collection of small maritime villages tied to the history and traditions of the seafaring life: boat building, whaling, fishing and the craft of decoy carving. On Harkers Island, at the Core Sound Waterfowl Museum & Heritage Center (coresound.com; US$5),

Doctor’s Review • APRIL 2015

a local group of skilled carvers partner with the museum to revive the art of carving duck decoys. They work in a wood shop on the main floor of the museum — a building designed to resemble a hybrid between a hunting lodge and a traditional coastal lifesaving station. World-renowned carver Walter “Brother” Gaskill sat surrounded by blocks of tupelo, cork and juniper as well as an arsenal of tools for chopping, carving and shaping. “We start out with a square block and make patterns,” he explained in the brogue characteristic of Down East. “Then, what don’t look like a duck, you whittle off.”

DAY 4 Beaufort, South Carolina and Gullah culture Into South Carolina, the oceanfront roadways seem swallowed by the saltwater marshes, dunes and tidal creeks known as the Low Country. Before the building of causeways, some 150 tiny sea islands were isolated, insulating the unique Gullah culture along with the traditions and linguistic patterns rooted in the rich African heritage of slave communities. By 1810, plantation slaves made up almost 90 percent of the parish population, leaving a cultural mark that is still survives. Their history is preserved at the Penn Center (penncenter.com), the first school in the nation to teach freed African slaves. Now a National Historic Landmark District, the school celebrates a place of transition — freedom from slavery and the 20th-century fight for civil rights and social justice. Standing sentinel to the Sea Islands, the Beaufort is known for its antebellum homes (it escaped the shelling of the Civil War), art galleries, boutiques and well-preserved waterfront. It’s a smaller, more walkable version of its big sister city, Charleston. The architecture of the 300-year-old town has been irresistible bait for film scouts; its laneways, gracious mansions and oceanfront are the backdrop for many well known Hollywood films including Forrest Gump, The Big Chill and The Prince of Tides. Named Best Small Southern Town by Southern Living, a Top 25 Small City Arts Destination by American Style, and a Top 50 Adventure Town by National Geographic Adventure, South Carolina’s secondoldest city is custom made for strolling. The streets of The Point neighbourhood are lined with opulent architecture sheltered among Spanish moss-draped oaks — some so large and old that thick branches bend to touch the ground. In Beaufort, the coastline journey came to an end. Sometimes, like this time, a turn off the busy highway is well worth taking.

TOP ROW: Laid-back Ocracoke Island is the perfect place to do as the natives do: fish and bird-watch.

The Carolina coast is one of the best regions on the Atlantic for â&#x20AC;&#x153;just-caughtâ&#x20AC;? seafood.

A ferry takes passengers across Hatteras Inlet to Ocracoke Island.

Expect opulent architecture sheltered among Spanish mossdraped oaks in Beaufort, SC.

Local artists have revived the art of carving duck decoys on Harkers Island.

Introducing

Introducing Nesina ; a new DPP-4 inhibitor for patients with type 2 diabetes. ®

Reimbursed by RAMQ as a medicament d’exception (prescribing codes available) Single entity DPP-4 inhibitors RAMQ reimbursement comparison*

Nesina

$2.10 UNIT PRICE

Treatment of type 2 diabetic patients:

Januvia

® †

REIMBURSED / CODE

$2.62 UNIT PRICE REIMBURSED / CODE

As monotherapy, where metformin and sulfonylurea are contraindicated or not tolerated

EN167

N/A

In association with metformin, where sulfonylurea is contraindicated, not tolerated or ineffective

EN148

In association with sulfonylurea, where metformin is contraindicated, not tolerated or ineffective

EN149

N/A

Onglyza

® †

Trajenta

$2.30 UNIT PRICE

†

REIMBURSED / CODE

N/A

$2.25 UNIT PRICE

†

REIMBURSED / CODE

N/A

EN148

N/A

EN149

N/A

* Comparative clinical significance has not been established. As per RAMQ List of Medications (Updated December 11, 2014). † Actual acquisition cost; prices do not include mark-up or dispensing fees. N/A = Not Applicable.

Nesina is indicated to improve glycemic control in adult patients with type 2 diabetes mellitus: • as monotherapy as an adjunct to diet and exercise in patients for whom metformin is inappropriate due to contraindications or intolerance • in combination with metformin when diet and exercise plus metformin alone do not provide adequate glycemic control • in combination with a sulfonylurea (SU) when diet and exercise plus a SU alone do not provide adequate glycemic control • in combination with pioglitazone when diet and exercise plus pioglitazone alone do not provide adequate glycemic control ®

• in combination with pioglitazone and metformin when diet and exercise plus dual therapy with these agents do not provide adequate glycemic control • in combination with insulin (with or without metformin) when diet and exercise plus a stable dose of insulin (with or without metformin) do not provide adequate glycemic control Consult the product monograph at http://www.takedacanada. com /ca/nesinapm for contraindications, warnings, precautions, adverse reactions, drug interactions, dosing and conditions of clinical use. The product monograph is also available by calling us at 1-866-295-4636.

Please see Product Monograph for complete dosing and administration information including dosage adjustment in renal impairment.

Nesi ® na 2

5 Once mg Dail y

REFERENCE: 1. Nesina Product Monograph, Takeda Canada Inc. ®

© 2015 Takeda Canada Inc. All rights reserved. Nesina is a registered trademark of Takeda Pharmaceutical Company Limited and used under license by Takeda Canada Inc. JANUVIA Registered trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. Used under license. ONGLYZA Registered trademark of AstraZeneca AB, used under license by AstraZeneca Canada Inc. TRAJENTA Registered trademark used under license by Boehringer Ingelheim (Canada) Ltd. ®

NES-2015-5E

Sizing up Palm Springs Six reasons Hollywoodâ&#x20AC;&#x2122;s playground will give you a natural high

ALL PHOTOS JEREMY FERGUSON UNLESS OTHERWISE NOTED

by Jeremy Ferguson

Expect to see a lot of yucca trees and granite monoliths in Joshua Tree National Park.

he face of the San Jacinto range that looms over Palm Springs is deeply pocked, a brooding pile of jagged shards and boulders as if flung by some raging deity who’s confused this placid resort with Sodom and Gomorrah. In mid-afternoon, the mountain swallows the sun, and the shadow that engulfs the city is the beginning of night. This town appears to cherish its darkness. Because its rich and powerful prefer their view of the starry sky free of “light pollution,” city ordinances call for “minimal” street lighting. Welcome to la ville noire. As night falls, people are seen bumbling around with flashlights. Unlit intersections are lethal; pedestrians die. This urban blackness recalls Calcutta or

Addis Ababa: everyone needs a seeing-eye dog. The Palm Springs night is made for muggers, and vampires in capes and golf hats. If night can be downright creepy, the day seems a happy postcard of brilliant sunshine, Kodachrome skies, towering palms, lemons raining from trees, and wine and whisky prices to leave a Canadian bawling on a street corner. Even without its touted golf courses — 150, according to one resident — Palm Springs offers an armload of treats for us passers-through.

APRIL 2015 • Doctor’s

Review

MODERN ARCHITECTURAL TOUR

Desert architect William Cody hid door frames within walls, elongated the span of steel roofs and reduced steel beams to slivers.

The Palm Springs Art Museum is modest in size, but it features 28 galleries and two sculpture gardens.

CELEBRITY HOMES AND BONES The 1940s and 1950s were Palm Springs’ glory period, the Hollywood years. Maps of celebrity homes are available at the local tourist office. At any of these manses, you’ll see Fords and Chevys disgorging star-struck tourists snapping away with smartphones. Well, maybe the celebrity era isn’t quite over. Last year, Leonardo DiCaprio purchased Dinah Shore’s former home for $5.3 million. Such is the near-eternal nature of celebrity that maps also include the realm of the dead. The commoners’

COURTESY OF PALM SPRINGS BUREAU OF TOURISM

Every city should have a tour like the one offered by lifelong architecture buff Robert Imber. Imber’s affectionate two-hour spin around the city’s residential neighbourhoods focuses on mid-century modern, the architectural force that defined the Palm Springs look from the 1930s into the 1960s. This was the era when Palm Springs aristocrats — people like 20th Century-Fox boss Darryl F. Zanuck — commissioned the finest architects of their era to interpret a style influenced by the Bauhaus and hallmarked by clean and simple lines, natural materials, the artful use of light and a respect for desert ecology. Seen in passing are Copley’s, an upscale restaurant occupying Cary Grant’s old guesthouse, the urban nudist resort once owned by Errol Flynn and the Palm Springs Parker Hotel where, in a drug bust, Robert Downey Jr. was found with a prostitute clad in a Wonder Woman suit. Unfortunately, it’s impossible to get a decent view of Bob Hope’s 1900-square-metre “Flying Saucer” home, currently on sale for a mere $25 million. tel: (760) 318-6118; palmspringsmoderntours.com; US$85 per person.

COURTESY PALM SPRINGS AERIAL TRAMWAY

The tram climbs four kilometres in 10 minutes and boasts views of Salton Sea.

Palm Springs Desert Memorial, with its simple tablets laid flat in a parkland setting, is where legions of fans find Francis Albert Sinatra’s resting place, beside the graves of his parents. Others might gravitate to the nearby grave of Frederick Loewe. Loewe was one of the titans, along with George Gershwin, Richard Rodgers and Irving Berlin, of the American musical theatre. He composed the music for My Fair Lady, Camelot and the film Gigi. One of the wonderful songs from Gigi was “Thank heaven for little girls.” Loewe’s tombstone reads: “Thank heavens for Frederick Loewe.”

PALM SPRINGS ART MUSEUM It may be a midget next to the Louvre, but the Palm Springs’ Art Museum is all about quality, and you don’t have to be a gallery hound to fall for it. Its emotional core, the western art gallery, showcases evocative works from a posse of outstanding artists including Frederic Remington and Thomas Moran. Actor George Montgomery, remembered most for 1940s and 1950s westerns, had a more interesting private life. He married TV-star Dinah Shore, and was an accomplished artist and sculptor in his own right. When he left his art and sculpture, along with his collection of movie posters, to the museum, it was its single most important acquisition. The museum’s overall collection includes works from Chagall, Picasso, Andy Warhol, Alexander Calder, Henry Moore and Ansel Adams. Galleries incorporate art glass, photography, architecture, ar-

cheology and sculpture, all of a commanding caliber. 101 Museum Drive; tel: (760) 322-4828; psmuseum.org; adults US$12.50, free Thursdays after 4pm.

PALM SPRINGS AERIAL TRAMWAY Look way, way up: this cable car — the largest rotating aerial tram in the world — sweeps you up the sheerest mountain face on this continent to an altitude of 2590 metres. The view of the Coachella Valley and Sonoran Desert goes on forever, of course. Equally intriguing is the tramway’s engineering history. In the early 1960s, helicopters flew 23,000 missions to erect four of five supporting towers, and transport men and construction materials to perilous locations. 1 Tram Way; tel: (888) 515-8726; pstramway.com; adults US$23.95.

JOSHUA TREE NATIONAL PARK This geological wonderland, part Mohave Desert, part Sonora Desert, is more than an hour’s drive, but it’s Palm Springs’ most important experience, at least for photographers, desert junkies and travellers who like to exercise their sense of wonder. This eye-popping landscape of boulders the size of office buildings and Joshua Trees — yucca plants with limbs like outstretched arms — might as well be another planet. For any first-timer, the ideal introduction is the Hidden Valley trail, an easy 1.5-kilometre loop that APRIL 2015 • Doctor’s

Review

Leonard Knight used local adobe clay and donated paint to make Salvation Mountain.

leads through a mysterious cleft in the boulders to a completely enclosed valley. It was discovered by 19th-century rustlers who stole cattle in Arizona, rebranded them here and sold them on the California coast. US$5 per person or US$15 per vehicle for seven consecutive days; nps.gov/jotr/index.htm.

SALTON SEA An hour’s drive brings you to California’s great inland sea. It’s a critical stop for 400 species of wintering birds, and for bird-watchers. It boasts great beauty and Bombay Beach sunsets are legend, but appearances are deceptive.

In the 1960s, it was hailed as California’s new resort frontier, a glamour spot with vacation homes and yacht clubs. It welcomed more visitors than Yosemite National Park. All of this turned to rot as salt levels soared. Today, it contains 50 percent more salt content than the oceans themselves and is almost certainly fated to turn completely saline as its fresh water sources dwindle. A principle source of fresh water is the New River, which flows north out of Mexico and isn’t very fresh: it’s the most polluted body of water in North America. The Salton Sea contains 400 million tilapia, the only fish that can survive in this toxic saline soup. Fishing, anyone? Many observers predict a catastrophic future after the dry-up. They envision a dust cloud of salt, chemical toxins and sewage lifted out of the seabed by the region’s powerful winds. If this is allowed to happen — and no level of government is ready to finance the massive rescue effort so far — it could blow like an airborne tsunami over the land and smother Palm Springs as surely as Vesuvius did Pompeii. Drive through a hardscrabble neck of the woods east of the Salton Sea and you’ll discover Salvation Mountain, a man-made adobe alp painted in madcap colours and completely inscribed with biblical quotes and religious slogans. This is the work of the late Leonard Knight and the Folk Art Society of America found it “worthy of preservation and protection.” What fun for the camera. parks.ca.gov; salvationmountain.us.

The author made the 2130-kilometre journey from Victoria, BC to Palm Springs by car, crossing the Salish Sea on the Coho ferry and motoring through the misty Washington State farm country, Oregon’s Grants Pass, northern California’s drought-imperiled Central Valley and southern California’s desert country; a most scenic journey. Everyone who eats at Bill’s Pizza (119 S. Indian Canyon Drive; tel: 760-325-5571; billspizzapalmsprings.com) claims it’s the best pizza ever and, surprisingly, they’re right. These pizzas with crispy sourdough crusts and topnotch toppings are simply luscious. The superstar at Lulu California Bistro (200 S. Palm Canyon Drive; tel: 760-327-5858; lulupalmsprings.com) is the tower of fresh ahi tuna enmeshed with avocado and landscaped on the plate with wasabi, pickled ginger, seaweed salad and, for crunch, tortilla chips. Overheard from a Canadian customer: “Yeah, we’d get this in Canada, but it’d be half the size and twice the price.” China 8 (31855 Date Palm Drive, Cathedral City) is one of those mediocre-looking Chinese eateries that surprises with flashes of excellence. Velvety eggplant roars with garlic and chilies, and kung pao chicken tickles the palate without blowing off the top of your head. Our advice: order takeout, bring it back to your digs and pair it with California chardonnay or New Zealand sauvignon blanc. There are accommodations galore including Del Marcos (225 West Baristo Road; tel: 800-676-1214; delmarcoshotel.com; from US$139 during high season), designed in 1947 by William F. Cody. It has 17 rooms and complimentary Wi-Fi. Adults only; pets welcome. The Rendezvous B&B (1420 N. Indian Canyon Drive; tel: 760-320-1178; palmsprings rendezvous.com; US$230 during high season) has 10 retro-styled rooms. It was formerly the Mira Loma where Marilyn Monroe’s favourite room is now called Pretty in Pink. Kids over 14 only. For more info, visit the Greater Palm Springs CVB (visitgreaterpalmsprings.com).

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Five courses you have to golf in Palm Springs. doctorsreview.com/features/fair-game Doctor’s Review • APRIL 2015

LULU CALIFORNIA BISTRO

DEL MARCOS HOTEL

CHEW ON THIS

ONCE DAILY Controlled release methylphenidate hydrochloride capsules

ONCE DAILY

Controlled release methylphenidate hydrochloride capsules

PRODUCT OF CANADIAN RESEARCH

10 mg 10 mg

1515 mg mg 20 mg2030mg mg

40 mg 30mg mg 50 40

60 mg 5080 mg mg mg

60 mg

80 mg

Indications & Clinical Use: Biphentin® is indicated for treatment of Attention-Deficit Hyperactivity Disorder (ADHD) in children 6-11, adolescents 12-18 and adults >18 years of age. Biphentin® is indicated as an integral part of a total treatment program for ADHD that may include other measures (psychological, educational, social) for patients with this syndrome. Drug treatment may not be indicated for all patients with this syndrome. Effectiveness for more than 4 weeks has not been systematically evaluated in placebo-controlled trials. Physicians electing to use Biphentin® for extended periods should periodically re-evaluate the long-term usefulness of the drug for the individual patient. Should not be taken by children under 6 years of age. No data is available for patients >65 years of age. Contraindications: • Anxiety, tension, agitation, thyrotoxicosis, advanced arteriosclerosis, symptomatic cardiovascular disease, moderate to severe hypertension or glaucoma • Motor tics or with family history or diagnosis of Tourette’s syndrome • Concomitant use of an MAO or within a minimum of 14 days following discontinuation of an MAO Most Serious Warnings And Precautions: • Drug dependence/tolerance. Careful supervision is required during drug withdrawal Other Relevant Warnings And Precautions: • The risk of sudden cardiac death should be considered although incremental risk of adverse cardiac events has not been confirmed • Patients who are involved in strenuous exercise or activities; are using other stimulants or medications for ADHD; or have a family history of sudden cardiac death • Cardiovascular – sudden death and pre-existing structural cardiac abnormalities or other serious heart problems • Screen for cardiovascular and cerebral vascular conditions before initiating treatment and monitor for new conditions during treatment • Monitor blood pressure at appropriate intervals especially in patients with pre-existing conditions that may result in hypertension • Long-term suppression of growth: Carefully monitor patients requiring long-term therapy. Interrupt treatment in patients not growing or gaining weight as expected • Psychiatric effects: Screen for risk of bipolar disorder in patients with comorbid depressive symptoms • Not for use in treatment or prevention of normal fatigue states • Neurologic effects: Discontinue if seizure frequency rises • Ophthalmologic effects • Not for use in pregnant women unless the potential benefit outweighs the risk to the fetus. A risk to the suckling child cannot be excluded • Patients with an element of agitation may react adversely; discontinue therapy if necessary • Patients should be cautious when driving or operating machinery • Drug interactions For more information: Please consult the Product Monograph at http://www.purdue.ca/files/2012-11-23%20Biphentin%20PM_ENG%20Final.pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-387-5349. References: 1. Canadian Attention Deficit Hyperactivity Disorder Resource Alliance (CADDRA): Canadian ADHD Practice Guidelines, Third Edition, Toronto ON; CADDRA, 2011. http://www.caddra.ca/pdfs/caddraGuidelines2011.pdf. Accessed September 26, 2013. 2. Biphentin® Product Monograph, Purdue Pharma, November 23, 2012 or such later date as posted at www.purdue.ca.

Little ranch on

The landscape at La Reata is a mix of open range, rolling prairies, river hills as well as beaches at Lake Diefenbaker.

n the Prairie

A working cattle farm near Saskatoon where wannabe cowboys and cowgirls are welcome text and photos by Gary Crallé

After breakfast, guests head outside to saddle the horses.

“T

his ain’t no pony ride in the park,” La Reata Ranch’s website warns. I gulped as visions of stampeding

cattle raced through my overactive mind. I saw myself jumping from back to back over horns and hide through a swirl of dust and pounding hooves until I finally reached the lead cow and wrestled it to a halt. La Reata is a working cattle ranch, but I was prepared to concede that my imagination was carrying me away. In reality, La Reata turned out to be great fun and nowhere near as demanding as I had envisioned. The 2000-hectare property has plenty of space to roam — runaway herds or not. It sits two hours southwest of Saskatoon on the shores of Lake Diefenbaker, a 225-kilometre-long man-made reservoir that was created in 1967. Fed by the South Saskatchewan River and named after the native son who became prime minister, it certainly adds another dimension to the dude-ranch experience. APRIL 2015 • Doctor’s

Review

The 2000-hectare property sits on the shores of Lake Diefenbaker.

It’s a place to lose yourself, or find yourself, as the sun and clouds paint patterns on the terrain

“I

’ve heard all about you,” cowboss and owner George Gaber said with a smile as we shook hands. My mouth opened wide enough to catch a country fly. George winked. Evidently a friend who had stayed at the ranch a week earlier had told some devilish stories. None of them true, of course. George’s friendly, casual demeanor was as open and genuine as the rolling Saskatchewan hills on which he built his ranch. It puts everyone at ease — and keeps ‘em coming back. One guest has faithfully returned for the past nine years. Originally from Germany, George realized a dream when he created La Reata in 1996. He’s been sharing it with others ever since. I stowed my bag in my bunkhouse cabin and moseyed over to the saloon. Wilton, a big Rhodesian ridgeback and a real sweetheart, followed along. An old-fashioned saloon sign warned cowboys to leave their guns at the bar. After a beer it was time for lunch served family-style at long tables in the cookhouse.

Doctor’s Review • APRIL 2015

Conversation flowed as plates of home cooking were passed around. Five large bowls came heaped with summer salads. Baked beans weighed down another. Grilled hamburgers were the main that day with cheese slices, onion rings, relishes, mustard and ketchup to slather on according to taste. There were pickles, too. It was an indoor picnic down on the range, nothing fancy — unless you count the dog-bone-shaped cookies with good wishes from Wilton and his sister Ginger to “Dad” (George) as part of the Father’s Day dessert. Diets are for city slickers. Lasso practice was taking place outside and some Swiss visitors were trying their hands at roping a tree stump. Other guests hiked in the hills surrounding the property. Soon they were a dot on the horizon. This is big sky country, coulee grasslands, not as pancake flat as parts of the province where, they say, you can see your dog run away for three days. La Reata sits on the eastern shore of Lake Diefenbaker and it’s an ideal spot for watching a sunset.

The surrounding landscape has remained pretty much unchanged for millennia. It’s a place to lose yourself, or maybe find yourself, as the sun and clouds paint moving patterns on the terrain.

epending on the season, your time at La Reata might also include some ranch chores. Early in the season, there are daily horseback trips to the pastures to check the cattle, and treat or ear tag newborns, if necessary. Fences also need fixing. Horseback riding is the big draw, of course, and it’s generally a soothing trot or gallop across wideopen grassland separated by coulees (small gullies). With no defined path, riders tend to form a loose group, riding at their own pace when on a trail ride. It’s easy to relax amid the vast silence of the prairies. When the breeze blows, your thoughts float carefree as the clouds and nothing matters except to delight in the moment. The gentle squeak of the leather saddle blends with the clip clop of hooves in a mesmerizing cadence that carries you far from daily concerns — until your horse breaks into a run to reach the top of a knoll, interrupting your reverie with a jolt. I learned that photographing from a moving horse can be a challenge of balance and judgment. There were more than a few instances when my mount broke into a trot just as I raised camera to eye. With arms, legs, camera vest and hat each heading in a different direction. More than once a more experienced colleague retrieved my hat for me. Part way through the ride, we dismounted for a break. George put a coffeepot on a campfire, riders found spots in the sun or shade to kick back for a snooze in the grass, hats tilted over their eyes, grass stems in their mouths, cowboy style. By late afternoon we arrived at a steep hill overlooking the ranch house, the green hills rolled into the distance with the lake stretched out to the right, it felt like part of a movie scene. George urged his mount slowly down the path to the corral and we followed. The horses knew the way and they were anxious for their oats. At trail’s end we unsaddled and headed to the saloon for a cool one. We played cards for pennies and had a tabletop football match. There was music — country, of course. The lake was always available for a myriad of activities from swimming to fishing. Some guests preferred to drain any residual cares in the hot tub. George and staff “ranch hands” prepared chow at the cookhouse that evening for a dozen hungry dudes and dudettes. Barbecued steak never tasted so good. Communal dining without pretence. And not a cell phone, radio or TV in sight.

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La Reata’s ranch hands include dogs Ginger and Wilton.

Evenings at the saloon include games of pool, foosball and darts.

German-born George Gaber opened the ranch in 1996.

BUY THE FARM — KIND OF The La Reata Ranch (tel: 306-375-2291; george@ lareata.com; lareataranch.com) is a two-hour drive from Saskatoon Airport. The nearest town, Kyle, is 20 minutes away. The ranch’s season starts on May 18 and runs through October 12. The daily rate for adults is $199 (two-night minimum required); Friday-toSunday stays cost $475; one-week stays $1393. (There’s special pricing for pre-teens aged 8 to 12 and kids 4 to 7. Check the website for details.) Rates include accommodation, all meals, horseback riding and the activities on offer, depending on the season.

Five farms on the Vermont Cheese Trail. doctorsreview.com/features/vermont-cheese-trail APRIL 2015 • Doctor’s

Review

Vietnamese-style chicken and rice noodle bowl.

Spring chicken Three ways to serve a homemade or store-bought rotisserie bird recipes by

Eric Akis

photos by

Jo-Ann Richards

mericans bought 650 million rotisserie chickens in 2013 according to the US National Chicken Council. Applying the 10-percent rule, Canadians gobbled up about 65 million birds. The juicy, orangey red-hued chickens are a staple in

supermarkets and they’re inexpensive. After dinner, leftovers can be used in lunch sandwiches and the bones often go to make soup stock. Bang for your buck or what? Eric Akis’ The Great Rotisserie Chicken Cookbook, from Appetite by Random House, has 60 ideas of how you can plate your poultry. It’s full of great suggestions including 10 rubs for roasting your own bird when you have more time to cluck around in the kitchen; there’s a jerk to a tandoori to the red Thai curry included here.

VIETNAMESE-STYLE CHICKEN AND RICE NOODLE BOWL This is a version of the cold, rice noodle bowls offered on menus at some Vietnamese restaurants. Those noodles are often topped with slices of grilled pork and fried spring rolls. In this take, a colourful mix of raw vegetables and hot pieces of rotisserie chicken take their place. Drizzle the noodles with nuoc cham, a hot, salty and sour Vietnamese-style sauce, just before serving. Prep time: 30 minutes Cooking time: 15 minutes For the nuoc cham 1 c. (250 ml) hot water ¹⁄³ c. (80 ml) granulated sugar ½ tsp. (2.5 ml) dried, crushed chili flakes 1 large garlic clove, minced ¼ c. (60 ml) fish sauce

¼ c. (60 ml) lime juice ½ c. (125 ml) grated carrots For the noodle bowl ½ lb. (250 g) thin dried rice noodles (see note) 2 c. (500 ml) shredded head or romaine lettuce 2 c. (500 ml) bean sprouts ¼ English cucumber, cut in matchstick- size slices 24 small sprigs of fresh cilantro or mint or basil 1 rotisserie chicken, hot, cut into portions ¼ c. (60 ml) unsalted roasted peanuts, coarsely chopped, for garnish

To make the nuoc cham, place the hot water and sugar in a medium bowl and stir until the sugar is dissolved. Stir in the chili flakes, garlic, fish sauce, lime juice and carrots. Allow the sauce to steep for at least 15 minutes before serving. The sauce can be made a cou-

ple of hours ahead, then covered and refrigerated until needed. Bring a large pot of water to a boil over medium-high heat. Add the noodles and cook for 1 minute, until just tender. Drain the noodles well, and then run cold water into the pot to cool the noodles. Drain the noodles again and divide them among 4 large, shallow bowls. Placing each of the ingredients in separate mounds, top the noodles with lettuce, bean sprouts, cucumber, and cilantro (or mint or basil), leaving a space on one side of the bowl for the chicken. Arrange the chicken portions in that space. Sprinkle each serving with peanuts. Serve the nuoc cham in individual bowls for drizzling. Serves 4. Note: Look for the thicker fettuccinetype of noodle rather than the thin rice stick or vermicelli varieties.

POLENTA PIZZA WITH CHICKEN, OLIVES, FENNEL AND ASIAGO Polenta is a cooked, thick cornmeal mixture that, when spread on a pizza pan and baked, provides a dense, wheat-free crust. Prep time: 25 minutes, plus cooling and setting Cooking time: 32 to 37 minutes 1 tbsp. (15 ml) olive oil 3½ c. (875 ml) water 1 tsp. (5 ml) salt APRIL 2015 • Doctor’s

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1 c. (250 ml) cornmeal ½ c. (125 ml) tomato sauce 1 c. (250 ml) grated asiago cheese 1 c. (250 ml) shredded rotisserie chicken meat, or to taste 8 to 12 pitted black olives, halved ¼ tsp. (1 ml) fennel seeds, coarsely crushed 8 to 12 fresh basil leaves

Brush a 12-inch (30-cm) non-stick pizza pan with the olive oil and set aside. Pour the water into a medium, heavybottomed pot and bring to a boil over medium-high heat. Add the salt and then reduce the heat to medium. While whisking steadily, slowly pour in the cornmeal. Reduce the heat to medium-low and cook for 5 minutes, whisking frequently. Using a sturdy wooden spoon to stir the polenta, cook, stirring frequently, for

15 minutes more. At this point the polenta will be quite thick, but spreadable. Spoon the polenta onto the prepared pizza pan and quickly spread into a circle ¼ to ½ inch (6 mm to 1.25 cm) thick. Allow to cool to room temperature and set, about 20 minutes. (Polenta pizza can be made to this point several hours in advance; cover and refrigerate until ready to top and bake.) Preheat the oven to 450˚F (230˚C). Spread the tomato sauce evenly over the polenta. Top with the cheese, chicken and olives. Sprinkle with the fennel seeds. Bake for 12 to 15 minutes, until the polenta is hot and a little crispy on the bottom. Remove from the oven and allow to cool for 3 to 4 minutes. Top with fresh basil, cut in 8 wedges and serve. Serves 4 (2 wedges each).

Polenta pizza with chicken, olives, fennel and asiago.

Doctor’s Review • APRIL 2015

RED THAI CURRY CHICKEN Thai-style curry pastes come in three colours: red, green and yellow. The type of hot chili and other seasonings, such as garlic, spices and herbs, determine the colour. This recipe calls for a modest amount of red curry paste to spice up rotisserie chicken. If you like “the heat,” you could add more. Look for curry pastes in the Asian food aisle of your grocery store. Prep time: 20 minutes, plus marinating time Cooking time: 75 to 90 minutes 2 tbsp. (30 ml) orange juice 1 tbsp. (15 ml) lime juice 1 tbsp. (15 ml) vegetable oil 1 tbsp. (15 ml) soy sauce 1½ tsp. (7.5 ml) honey 1 tbsp. (15 ml) Thai red curry paste 2 tsp. (10 ml) freshly grated ginger ¼ c. (60 ml) chopped fresh mint or cilantro 1 whole chicken (3 lb./1.5 kg) salt and freshly ground black pepper to taste

In a small bowl, combine the orange and lime juices, vegetable oil, soy sauce, honey, curry paste, ginger and mint (or cilantro). Set aside. Truss the chicken with twine and set it in a shallow-sided glass or ceramic dish. Brush and coat the outside of the chicken with the curry mixture, ensuring it reaches deep into the areas between the breasts and legs and the tucked parts of each wing. Cover the chicken with plastic wrap and refrigerate for 4 hours, turning the bird occasionally. When ready to cook, let the chicken sit at room temperature for 30 minutes to take the chill from the meat and allow it to cook more evenly on the spit. Preheat the barbecue to 400˚F (200˚C). While the barbecue heats up, season the chicken with salt and pepper, then slide it onto one end of the rotisserie spit and secure it. Brush the chicken with any leftover marinade. Place the spit on the barbecue and set a heat-proof pan under the chicken to catch the juices seeping from the bird. Add a little water to the pan so the first

ONGLYZA Contraindications:  Diabetic ketoacidosis  Diabetic coma/precoma  Type 1 diabetes mellitus Relevant warnings and precautions:  Not recommended for patients with congestive heart failure  Exposure to stress (e.g. surgery)  Interactions with potent CYP 3A4 inducers  Contains lactose  Risk of hypersensitivity  Discontinue if pancreatitis is suspected  Immunocompromised patients (consider monitoring lymphocyte count)  Rash (monitoring recommended)  Not recommended for pregnancy, should not be used by nursing women  Not recommended for patients with moderate to severe hepatic impairment (not recommended for patients with ESRD requiring hemodialysis)  Monitor renal function For more information: Please consult the product monograph at www.azinfo.ca/onglyza/pm664 for more information relating to adverse reactions, drug interactions, and dosing information not discussed in this piece. The product monograph is also available by calling us at 1-800-668-6000.

Red Thai curry chicken.

drips don’t scorch it. Turn the rotisserie motor on. Close the lid on the barbecue and turn off the heat directly under the chicken. Leave the other side of the barbecue between medium and medium-high. Cook the chicken, brushing it occasionally with the pan juices, for 75 to 90 minutes, or until an instant read thermometer inserted into the deepest part of the thigh, not touching the bone, registers 170˚F (77˚C). As the chicken cooks, adjust the flame as needed to maintain a constant temperature of 400˚F (200˚C). Remove the chicken from the spit, set it on a plate, loosely tent it with the aluminum foil, and allow it to rest for 10 minutes before carving and serving. Serves 4. Note: If you don’t have a barbecue fitted with a spit, after trussing and fla-

vouring the chicken, set it in a cast-iron skillet or another pan suitable for the barbecue. Set the skillet on one side of the barbecue, close the lid, and turn the heat off underneath the chicken, but leave the other side on. Cook, brushing occasionally with the pan juices, for 75 to 90 minutes. Alternatively, preheat your conventional oven to 375˚F (190˚C). After trussing and flavouring the chicken, set it in a shallow-sided roasting pan. Roast in the oven, brushing occasionally with the pan juices, for 90 minutes. Excerpted from The Great Rotisserie Chicken Cookbook. Copyright © 2015 Eric Akis. Published by Appetite by Random House, a division of Random House of Canada Limited a Penguin Random House Company. Reproduced by arrangement with the Publisher. All rights reserved.

* Randomized, double-blind, placebo-controlled study of 24 weeks’ duration in patients with inadequate glycemic control (HbA1c ≥7.0% and ≤10.0%) on metformin alone. Saxagliptin baseline HbA1c 8.1% (n=186), FPG 9.9 mmol/L (n=187), PPG 16.4 mmol/L (n=155). Placebo baseline HbA1c 8.1% (n=175), FPG 9.7 mmol/L (n=176), PPG 16.4 mmol/L (n=135). Patients were required to be on a stable dose of metformin (1500 mg to 2550 mg daily) for at least 8 weeks to be enrolled in the trial. Patients who completed all visits during the initial 24-week study period without need for hyperglycemia rescue therapy were eligible to enter a controlled, double-blind, long-term study extension. Patients who received saxagliptin in the initial 24-week study period maintained the same dose in the long-term extension. References: 1. Onglyza® Product Monograph. AstraZeneca Canada Inc., June 30, 2014. 2. Komboglyze® Product Monograph. AstraZeneca Canada Inc., June 30, 2014.

09/15

AstraZeneca Canada Inc. Mississauga, Ontario L4Y 1M4 APRIL 2015 • Doctor’s

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P H OT O FI NI SH by

Dr Da ni e l K a p e lu t o

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This is an older photo of mine, but one of my favourites. I was having a drink at an outdoor café in Bern, Switzerland when the skies opened up and everyone ran for cover. The previously congested street had become empty. I took out my umbrella, began to stroll and snapped this nice shot of the tranquility. The photo was taken on my first digital camera, an Olympus D-540 at 1/640 sec, f/5, ISO 50.

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FAIR BALANCE INFORMATION Biphentin................................................. 47 Komboglyze............................................ 55 Symbicort................................................ 14

Doctor’s Review • APRIL 2015

Your banking should be as personalized as your patient care.

Specialized banking advice for your practice. Your expert advice helps your patients stay healthy. TD Business Banking Specialists work with you to help keep your business just as healthy with product expertise and specialized banking advice. And because weâ&#x20AC;&#x2122;re open earlier, open later and even on Sundays,* you can get the advice you need, on your time. Because a healthy practice deserves specialized care.

Visit tdcanadatrust.com/doctors or call 1-888-679-4808 *Individual branch hours vary. 400 branches are open Sundays. ÂŽ The TD logo and other trade-marks are the property of The Toronto-Dominion Bank.

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Ask for a demo of Placebo Respimat today ®

STRIVERDI® RESPIMAT® (olodaterol hydrochloride solution for inhalation) is a long-acting beta2-adrenergic agonist (LABA) indicated for the long term, once daily maintenance bronchodilator treatment of airﬂow obstruction in patients with Chronic Obstructive Pulmonary Disease or COPD (including chronic bronchitis and emphysema). Consult the Product Monograph at www.boehringer-ingelheim.ca/content/dam/internet/opu/ca_EN/documents/humanhealth/product_monograph/StriverdiPMEN.pdf for important information about contraindications, warnings, precautions, conditions of clinical use, adverse reactions, interactions and dosing. The Product Monograph is also available by calling us at 1 (800) 263-5103 Ext. 84633. Pr

† Comparative clinical signiﬁcance unknown

* Solution is dispensed through mechanical energy4

References: 1. STRIVERDI® RESPIMAT® Product Monograph. Boehringer Ingelheim (Canada) Ltd., May 7, 2014. 2. Decramer M, Vestbo J, Bourbeau J, et al. Global strategy for the diagnosis, management, and prevention of COPD (updated 2014). Global Initiative for Chronic Obstructive Lung Disease, Inc. 2014. 3. COMBIVENT® RESPIMAT® Product Monograph. Boehringer Ingelheim (Canada) Ltd., Jan 8, 2014. 4. Data on ﬁle. Boehringer Ingelheim (Canada) Ltd., 2014. 5. ATROVENT® HFA Product Monograph. Boehringer Ingelheim (Canada) Ltd., Oct 29, 2010. 6. VENTOLIN® HFA Product Monograph. GlaxoSmithKline Inc., Dec 18, 2013. 7. ADVAIR® and ADVAIR® DISKUS® Product Monograph. GlaxoSmithKline Inc., Sep 24, 2013. 8. SPIRIVA® Product Monograph. Boehringer Ingelheim (Canada) Ltd., Aug 21, 2012.9. SEREVENT® DISKHALER® and SEREVENT® DISKUS® Product Monograph. GlaxosmithKline Inc., Oct 16, 2013. 10. FORADIL® Product Monograph. Novartis Pharmaceuticals Canada Inc., May 9, 2013. 11. ONBREZ® BREEZHALER® Product Monograph. Novartis Pharmaceuticals Canada Inc., Oct 24, 2012. 12. SEEBRI® BREEZHALER® Product Monograph. Novartis Pharmaceuticals Canada Inc., Oct 12, 2012. 13. SYMBICORT® TURBUHALER® Product Monograph. AstraZeneca Canada Inc., Jun 21, 2012. 14. TUDORZA™ GENUAIR™ Product Monograph. Almirall Ltd., Jul 26, 2013.

Striverdi® and Respimat® are registered trademarks used under license by Boehringer Ingelheim (Canada) Ltd.