February 2014 by Doctor's Review

MEDICINE ON THE MOVE

FEBRUARY 2014

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The plumage of Ploceidae males is typically brightly coloured, usually red or yellow and black. Some species show colour variation only during the mating season.

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Dogs in winter

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There’s an article in this issue about skiing with your dog: Marley and ski, page 44. I’ve never been skiing with my dogs though I did have a bulldog once who loved to toboggan. Elizabeth couldn’t get enough of winter and she enjoyed 14 of them to the max. Thomas Wolfe, our Borzoi, also adores the cold. “Polar vortex,” he says and cocks his long, long nose. “Bring it on.” He likes the snow and ice so much, it’s hard to get him in from the yard at night. “I think I will lie out here under the silver moon and dream of the Russian steppes of my homeland,” he implies with a stubborn glance. “Come in you silly fellow,” I call as I flash a handkerchief-sized piece of sirloin. “You’ll freeze your family jewels slumbering in that snowbank.” The other dogs, the Pug and the Pekingese, need no such persuasion. Quite the opposite. In the morning I have to stand outside the open backdoor and make a fuss unwrapping a fat chop to get them to come out to pee. No sooner is their business done than they’re barking through the letter box to be let back in. On cold days they then search out the warmest spot in the house and spend most of their time licking their paws, whispering “we’re never going to go out there again ’til April.” The Russian wolfhound would probably like nothing more than to try the moguls, but he’s told me many times that he can’t chance it, as he noses his delicate ankles as though they were the gams of a starlet insured for $1 million. It’s clear he won’t be strapping on the fiberglass boards anytime soon, so there’ll be no dogs and skiing in this house. That’s not to say they don’t love to travel. They do and they do an awful lot of it. Pull an old valise out from under the bed and they’re at the garage door scrambling to climb into the car and get going. They’re all excellent travellers. And they’ve learned a thing or two about motel etiquette. They know, for example, that Mum and Dad never tell the front desk they’ve got more than one dog so they never pay the slightest attention to their brothers, but pretend, instead, that those mongrels belong to the couple in 156; nothing to do with them. They also know that if they stay quiet in the morning they’ll get cereal with milk, waffles and, if they’re on their very best behavior, scrambled eggs and toast from the hot buffet off the lobby. Happy travels from icy February into warm April.

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FEBRUARY 2014 • Doctor’s

Review

The speed of 2 or 3 day dosing in Actinic Keratosis is here

Picato® Gel (ingenol mebutate) is indicated for topical treatment of non-hyperkeratotic, non-hypertrophic actinic keratosis (AK) in adults.

Demonstrated efficacy Median % reduction in lesion count at day 57:1 for face and scalp - 87% (study 1) and 83% (study 2)* for trunk and extremities - 75% (study 3) and 69% (study 4)†

Complete clearance at day 57:1 for face and scalp; 47% for Picato® Gel vs. 5% for placebo gel (study 1) and 37% for Picato® Gel vs. 2% for placebo gel (study 2) (p<0.001)* for trunk and extremities; 42% for Picato® Gel vs. 5% for placebo gel (study 3) and 28% for Picato® Gel vs. 5% for placebo gel (study 4) (p<0.001)†

®Registered trademark of LEO Pharma A/S used under license and distributed by LEO Pharma Inc., 123 Commerce Valley Dr. E., Suite 400, Thornhill, Ontario L3T 7W8

NEW

Once daily dosing: 3 days - face & scalp, 2 days - trunk & extremities Relevant Warnings & Precautions • Severe Local Skin Responses (LSRs) including erythema, flaking/scaling, crusting, swelling, vesiculation/pustulation, and erosion/ulceration can occur after topical application • Severe eye disorders, including periorbital edema, eyelid edema, eye edema, eye pain, and eyelid ptosis, occurred more frequently in patients treated with Picato® Gel than vehicle, and may result from spreading of application site edema • Administration of Picato® Gel is not recommended until the skin is healed from treatment with any previous medicinal product or surgical treatment • Contact with skin outside the treatment area should be avoided • Picato® Gel is for topical use only but should not be used near the eyes, on the inside of the nostrils, on the inside of the ears, or on the lips • Picato® Gel must not be ingested • Avoid the use of Picato® Gel during pregnancy • Nursing mothers should avoid physical contact between her newborn/infant and the treated area for 6 hours after application • The efficacy of Picato® Gel in the prevention of squamous cell carcinoma (SCC) associated with actinic keratosis (AK) has not been studied

• Clinical data on re-treatment and treatment of more than one area is not available • Clinical data on treatment in immunocompromised patients is not available For more information Please consult the product monograph at www.leo-pharma.ca/ picato_pm 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 contacting LEO Pharma Medical Information at 1-800-263-4218. 1. Picato® product monograph, January 30 2013. *Two multi-centre, double-blind, randomized, parallel-group, vehicle-controlled, clinical studies of AK patients evaluating the efficacy and safety of Picato® Gel 0.015% applied once daily on the face or scalp to a 25cm2 area of skin for 3 consecutive days in adult patients. Efficacy measurements included complete clearance rate and median percent reduction compared to vehicle control assessed at day 57 in Study 1 (PEP005-025) (Picato® Gel N=142, Placebo Gel N=136) and Study 2 (PEP005-016) (Picato® Gel N=135, Placebo Gel N=134) (8 weeks). †Two multi-centre, double-blind, randomized, parallel-group, vehicle-controlled, clinical studies of AK patients evaluating the efficacy and safety of Picato® Gel 0.05% applied once daily on trunk and extremities to a 25cm2 area of skin for 2 consecutive days in adult patients. Efficacy measurements included complete clearance rate and median percent reduction compared to vehicle control assessed at day 57 in Study 3 (PEP005-028) (Picato® Gel N=100, Placebo Gel N=103) and Study 4 (PEP005-014) (Picato® Gel N=126, Placebo Gel N=129) (8 weeks).

www.leo-pharma.ca

VIMOVO is indicated for the treatment of the signs and symptoms of osteoarthritis (OA), rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and to decrease the risk of developing gastric ulcers in patients at risk for developing NSAID-associated gastric ulcers.

Product Monograph is available upon request from AstraZeneca Canada Inc. AstraZeneca Canada Inc., 1004 Middlegate Road, Mississauga, Ontario L4Y 1M4 www.astrazeneca.ca

02/14

VIMOVOÂŽ and the AstraZeneca logo are registered trademarks of the AstraZeneca group of companies. ÂŠ AstraZeneca 2013

contents FEBRUARY 2014

COVER: KURHAN / SHUTTERSTOCK.COM

features 34

On the prowl One flat tire, a jeep in mud and chains hitched between vehicles in Kenya’s Maasai Mara National Reserve by Josephine Matyas

11 53

Spin doctors Who needs Orlando when Anaheim, California is home to the original Disney? by Robb Beattie

Marley and ski The eight questions you have to chew over before you pack up the pooch for Mont-Tremblant by Lora Perrone

Crowd pleasers Dishes your kids will love by busy Toronto moms by Laura Keogh and Ceri Marsh

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Size doesn’t matter Anchovies may be small, but the little powerhouses will leave you plenty satisfied by Pamela Cuthbert

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LETTERS Dogged disgust?

PRACTICAL TRAVELLER Seven hot places ideal for an impromptu escape by Tyson Lowrie

BUDGET TRAVELLER Jamaica, Costa Rica, Hawaii and more… six places to save on your spring break by Annarosa Sabbadini

FEBRUARY 2014 • Doctor’s

Review

THIS IS

NOT A GOOD TIME for

travellers’ diarrhea Why not help prevent travellers’ diarrhea? 1 DUKORAL® * is the oral vaccine that helps prevent travellers’ diarrhea caused by enterotoxigenic E. coli. It demonstrated 86% efficacy against severe heat-labile, toxin-producing enterotoxigenic E. coli and has an oral administration schedule.1§ As many as 50% of travellers experience travellers’ diarrhea during a two-week stay in a developing country. A study has shown that those who experienced travellers’ diarrhea were 5x more likely to develop new irritable bowel syndrome than those who didn’t .1,2†‡ Help protect your patients from travellers’ diarrhea. † DUKORAL® is not indicated to prevent IBS.

DUKORAL® (Oral, Inactivated Travellers’ Diarrhea and Cholera Vaccine) is indicated for the prevention of and protection against travellers’ diarrhea (TD) and/or cholera in adults and children 2 years of age and older who will be visiting areas where there is a risk of contracting TD caused by enterotoxigenic E. coli and/or cholera caused by V. cholerae. Immunocompromised persons may not obtain the expected immune response. DUKORAL® is not recommended for use in pregnancy but may be given to lactating women. Immunization should be deferred in the presence of acute illness though a minor illness such as mild upper respiratory infection is not a reason to defer immunization. Allergy to any component of DUKORAL® is a contraindication to vaccination. Most common adverse events: abdominal pain (16%), diarrhea (12%), subjective fever (4%), nausea (4%) and vomiting (3%). As with any vaccine, immunization with DUKORAL® may not protect 100% of susceptible individuals. Travellers should take all necessary precautions to avoid contaminated food and water. § Randomized, double blind study. 89,596 adults and children aged 2 and older in Bangladesh demonstrated 86% efficacy (p<0.05) against severe episodes of LT-ETEC over 3 months.1 ‡ Prospective study investigating the influence of travellers’ diarrhea in the development of IBS. After repatriation, a single episode of travellers’ diarrhea was associated with a five-fold increase in risk of developing IBS (13.6% vs 2.4%, p<0.0001). n=405.1,2 References: 1. Crucell Vaccines Inc. DUKORAL® Product Monograph, August 10, 2012. 2. Stermer E et al. Is travellers’ diarrhea a significant risk factor for the development of irritable bowel syndrome? A prospective study. Clin Infect Dis. 2006;43(7):898-901.

See prescribing summary on page 57

contents FEBRUARY 2014

regulars 18

VISUAL ARTS Forty paintings by an artist who can take years to complete one canvas by David Elkins

GADGETS A machine that has the publisher head over heels by David Elkins

23 25

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The surefire way to find out if your fruits and veggies have been genetically modified by Kim N. Arrey

The brothels of Paris were his muse, but medieval Albi was where artist Henri de Toulouse-Lautrec called home

•

Europe’s 10 best free museums

•

See Pompeii, Capri, Naples, the Amalfi Coast and the temples of Paestum in one unforgettable journey

•

The best medical apps

•

The Nest, Google and the new smarthome: it’s happening faster than we think

•

The world’s top 20 med meetings happening this summer

•

The irregular and electrifying history of the defibrillator

•

The dirty dozen: what fruits to absolutely eat organic

A NEW COLUMN! BEST MD APPS

TOP 20 The best med meetings happening this June and July, plus the 15 things you’ll want to do in Beantown

coming in March

FOOD

Meet the aggregators by David Elkins

HISTORY OF MEDICINE Mad with menopause?! by Jackie Rosenhek

ONE BOTTLE Santa Carolina’s red, red wine by James Nevison

PHOTO FINISH Banded together by Dr Hans Berkhout FEBRUARY 2014 • Doctor’s

Review

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Dogged disgust?

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HAIRY HOMONYMS By “axil” [Orient Yourself, January 2014, page 38] you were referring to horticultural anatomy, right? Or did you mean “axle?” MONTREAL HEAD OFFICE

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A DOG-EAT-DOG WORLD What a beautiful account concerning such a far away place, with people having a completely different mentality [Connect the pots, November 2013, page 29]. I have to underline though, that in my travels to China I was, not once and not only in the rural parts, witness to people choosing live dogs and cats, the vendor putting them in boiling water and skinning them alive. Different mentality or animal cruelty? Dr Radu Puscas Via email

Dr Lorne Walton Via DoctorsReview.com

LEAVE IT TO NEVIS My grandfather was born at Golden Rock Estate [Living in the Past, January 2014, page 44] when it was a working sugarcane plantation. The cane would then be shipped to St. Kitts aboard lighters. Dr Ron Evelyn Via DoctorsReview.com

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IN PRAISE OF PAPRIKASH Saw this recipe for chicken paprikash in Doctor’s Review years ago and have been making it ever since. I would venture to even say it’s become a bit of a staple in my family; it’s fast and easy to make — perfect for a winter weeknight. As I’m not a very experienced phone (or otherwise) photographer, my son took this picture for me before the family dug into a delicious meal. Thanks Doctor’s Review. Cara Karson Vie email

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StiStill sufferi ll sufferingnfrom g fromGERD? GERD? Roll over to page xx. Roll over to page xx. FEBRUARY 2014 • Doctor’s CHANGE #

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Open up to a new

LAAC option in COPD

IMPROVED PATIENTS’ QUALITY OF LIFE (LS mean change in SGRQ total score vs. placebo, -3.32; p<0.001)1,2†

Now co by the vered and RAODB MQ

NEW ONCE-DAILY

SEEBRI BREEZHALER

DEMONSTRATED 5-MINUTE ONSET AND 24-HOUR BRONCHODILATION FEV1 improvement shown 5 minutes after first dose (0.093 L vs. placebo, p<0.001, serial spirometry)1,3‡

Significantly greater LS mean FEV1 vs. placebo demonstrated at all time points over 24 hours (LS mean FEV1 [L] vs. placebo after first dose, p<0.001; time points were 5 min, 15 min, 30 min, 1 hr, 2 hrs, 3 hrs, 4 hrs, 6 hrs, 8 hrs, 10 hrs, 12 hrs, 23 hrs 15 min, 23 hrs 45 min)4§ Indication & clinical use: SEEBRI* BREEZHALER* (glycopyrronium bromide) is indicated as a long-term once-daily maintenance bronchodilator treatment in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema. Not indicated for the relief of an acute deterioration of COPD Can be used at the recommended dose in elderly patients 65 years of age and older Should not be used in patients under 18 years of age Contraindications: Hypersensitivity to glycopyrronium or to any other component of SEEBRI* BREEZHALER* Relevant warnings and precautions: Not indicated for treatment of acute episodes of bronchospasm Not indicated for treatment of acutely deteriorating COPD Caution in patients with narrow-angle glaucoma Caution in patients with urinary retention In severe renal impairment (estimated GFR <30 mL/min/1.73m2), use only if the expected benefit outweighs the potential risk Risk of paradoxical bronchospasm: discontinue immediately

* SEEBRI and BREEZHALER are registered trademarks. Product Monograph available on request. 13SEE029E © Novartis Pharmaceuticals Canada Inc. 2013

For more information: Please consult the Product Monograph at www.novartis.ca/SeebriMonograph for important information relating to adverse events, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling the Medical Information department at 1-800-363-8883. LAAC: long-acting anticholinergic; COPD: chronic obstructive pulmonary disease; LS: least square; SGRQ: St. George’s Respiratory Questionnaire; measures health-related quality of life in symptoms, activities and impact on daily life;5 FEV1: forced expiratory volume in 1 second. † GLOW2: A 52-week, randomized, double-blind, placebo-controlled parallel-group study of 1,060 patients with COPD. Patients received either SEEBRI* BREEZHALER* (glycopyrronium 50 mcg o.d.; n=525), placebo (n=268), or open-label tiotropium (18 mcg o.d.; n=267) as an active control. Primary endpoint was 24-hour post-dose (trough) FEV1 following 12 weeks of treatment. ‡ GLOW1: A 26-week, randomized, double-blind, placebo-controlled parallel-group study to assess the efficacy, safety and tolerability of once-daily SEEBRI* BREEZHALER* (50 mcg) in patients with COPD (n=550); placebo (n=267). § LS mean FEV1 (L) after first dose; SEEBRI* BREEZHALER* (n=169) vs. placebo (n=83), respectively: 5 min: 1.39 vs. 1.30; 15 min: 1.43 vs. 1.28; 30 min: 1.44 vs. 1.28; 1 hr: 1.47 vs. 1.28; 2 hrs: 1.53 vs. 1.34; 3 hrs: 1.53 vs. 1.35; 4 hrs: 1.52 vs. 1.35; 6 hrs: 1.48 vs. 1.33; 8 hrs: 1.47 vs. 1.33; 10 hrs: 1.47 vs. 1.32; 12 hrs: 1.45 vs. 1.31; 23 hrs 15 min: 1.37 vs. 1.27; 23 hrs 45 min: 1.39 vs. 1.31; p<0.001 for all time points. References: 1. SEEBRI* BREEZHALER* Product Monograph. Novartis Pharmaceuticals Canada Inc., October 12, 2012. 2. Kerwin E, Hébert J, Gallagher N et al. Efficacy and safety of NVA237 versus placebo and tiotropium in patients with COPD: the GLOW2 study. Eur Respir J 2012;40:1106-14. 3. D’Urzo A, Ferguson GT, van Noord JA et al. Efficacy and safety of once-daily NVA237 in patients with moderate-to-severe COPD: the GLOW1 trial. Respir Res 2011;12:156(1-13). 4. Data on file. Novartis Pharmaceuticals Canada Inc. 5. Jones P. St. George’s Respiratory Questionnaire Manual. Available from: www.healthstatus.sgul.ac.uk/SGRQ_download/SGRQ%20 Manual%20June%202009.pdf. Accessed December 5, 2011. 6. Ontario Drug Benefit Formulary, August 29, 2013. 7. RAMQ, June 1, 2013.

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

T y s on L ow r i e

hot spring escapes

VXLA / FLICKR.COM

A Mongol yurt in Central Asia’s Tian Shan range.

Havana, Cuba DIRECT FLIGHTS Air Canada: Toronto; Cubana Airlines: Toronto, Montreal (includes a technical stop). OVERVIEW You might think of Havana as a day trip from a nearby all-inclusive, but the city is well worth deeper exploring. Year-round warm water and pleasantly mild temperatures of just under 25°C in February and March will make your stay comfortable, while the (sometimes crumbling) 16th-century architecture and lively nightlife make it fascinating. HOTEL The Hotel Los Frailes (8 Teniente Rey; hotellosfrailescuba.com; doubles from $95) is an award-winning, 22-room converted mansion hotel in Old Havana with quaint decorations and good rates. If you prefer to rent your own casa, try cubaccommodation.com or havanacasaparticular.com. WITH KIDS The Playas del Este beaches are a quick taxi ride away, but within Old Havana there are colourful souvenir markets, pony rides and more. The Parque Zoológico Nacional (Avenida Zoo Lenin, south of downtown) was recently upgraded and restocked with a gift of 146 animals from Namibia.

FEBRUARY 2014 • Doctor’s

Review

Grand Bahama, Bahamas DIRECT FLIGHTS (to Freeport) Sunwing: Edmonton, Winnipeg, Toronto, Ottawa, Montreal, Halifax; WestJet: Toronto. OVERVIEW The Lucayan National Park (bnt.bs) contains six different ecosystems, caverns and, of course, beaches. The island is also home to wonderful scuba-diving opportunities and includes an impressive collection of sites with shipwreck dives (bahamas.com/rapture-wrecks). Bahamians are said to be some of the friendliest people on earth; take in local culture in the form of Afro-Caribbean music or a fish fry in Freeport on the beach. Sunwing just added direct flights from five Canadian cities (in addition to Toronto). HOTEL Freeport is the only real city of note on the island and will be your default base. The Pelican Bay Hotel (Seahorse Road at Port Lucaya; pelicanbayhotel.com; doubles from US$179) is well located in the port area, with clean, colourful rooms. WITH KIDS We think all of the above is all pretty kid-friendly, but a couple of guided options are Grand Bahama Nature Tours (grandbahamanaturetours.com; from US$89) which offers kayak tours of Lucayan National Park, and snorkelling lessons for the littl’uns with Grand Bahama Scuba (grandbahamascuba.com; lessons US$30).

Doctor’s Review • FEBRUARY 2014

TRAVELINGOTTER / FLICKR.COM

SHANE GROSS / SHUTTERSTOCK.COM

PR A CTICA L T RAVEL L ER

Orlando, FL DIRECT FLIGHTS Air Canada Rouge: Toronto, Montreal; Air Transat: Toronto, Montreal, Quebec City, Halifax, St. John’s; Sunwing: Toronto, Ottawa, Halifax; WestJet: Calgary, Edmonton, Winnipeg, Toronto; American Airlines: Toronto (WestJet code-share); Delta: Toronto (WestJet code-share). OVERVIEW There’s plenty of spring break options in the Sunshine State, but none quite so family-friendly as Orlando. Expect warm to hot temperatures, reasonable hotel rates and theme parks offering everything from Mickey Mouse to Jesus Christ to Harry Potter, often at discounted rates. There’s no city that’s quite so thoroughly engineered for entertainment. HOTEL Orlando sprawls and you’ll want to avoid downtown, so your best base will depend on which attractions you’re going to visit. A good place to start is Orlando’s Deals for Canadians (visitorlando.com/EN-CA/discounts-tickets/deals-made-for-canadians), which will give you discounts on a variety of hotels and theme-park accommodations. Otherwise, booking sites such as Hotwire.com are a good place to look for savings. WITH KIDS Universal Orlando’s Wizarding World of Harry Potter (universalorlando. com/harrypotter; adults US$128, kids 3 to 9 US$122) is, like the books, good for both kids and adults. If you’re sports-minded, check out the Atlanta Braves’ Grapefruit League (floridagrapefruitleague.com/teams/braves; tickets from US$12) with all games played in Orlando, or for hoops try to catch an Orlando Magic home game.

DIRECT FLIGHTS Air Canada: Toronto; WestJet: Toronto. OVERVIEW Bermuda is tiny, but there’s a surprisingly high concentration of both beach and history there. Weather is great year-round, the water is warm, the town of St. George is UNESCO-protected and there’s no end of activities. Trips to the island nation don’t come cheap though, as the remote location and currency at parity with the US dollar make this is splurge holiday.

Bermuda

HOTEL At the north end of the island, near Bailey’s Bay, is the Grotto Bay Resort (11 Blue Hole Hill, Bailey’s Bay; grottobay.com; doubles from US$209), which is good bargain by Bermudan standards. WITH KIDS Formerly a British naval base, the empire made sure to sprinkle a few forts (gotobermuda.com/blog/5-must-see-forts-in-bermuda) around the island, which are great for scampering about. Even more stunning are the Crystal Caves (caves.bm/crystalcave.html; adults US$22, kids 12 and under US$8).

FEBRUARY 2014 • Doctor’s

Review

DIRECT FLIGHTS Air Canada: Vancouver, Calgary, Toronto; Air Canada Rouge: Toronto; Air Transat: Victoria, Vancouver, Kelowna, Calgary, Edmonton, Regina, Saskatoon, Winnipeg; WestJet: Vancouver, Calgary, Edmonton, Toronto and occasionally from Victoria, Comox, Abbotsford, Kelowna, Prince George, Regina, Saskatoon, Winnipeg. OVERVIEW Cancun is where you’ll find most of the springbreak partying in Mexico, but if you’re looking for something with a bit more history and slightly more laid-back, Puerto Vallarta is a better bet. Walk through the Old Town where you can visit the stunning Church of Our Lady of Guadalupe, peruse the art galleries and, of course, like everyone else flock to the beach. Expect weather in the mid-to-high 20s. HOTEL There are many hotels and resorts in Puerto Vallarta, so keep your eyes on booking sites for deals, especially given that March and April aren’t high season. If you’re looking for something safe, the Marriott-run CasaMagna (435 Paseo La Marina Norte; marriott.com/hotels/travel/pvrmx-casamagnamarriott-puerto-vallarta-resort-and-spa; doubles from US$183) is modern, near the marina and highly-rated. WITH KIDS Puerto Vallarta’s hinterland is as beautiful as the beach, and horseback tours are a popular option. Rancho El Charro (Puerto Vallarta; ranchoelcharro.com; from US$61.50) is a popular way to get saddle-sore.

Doctor’s Review • FEBRUARY 2014

Napa, CA

CAN BALCIOGLU / SHUTTERSTOCK.COM

Puerto Vallarta, Mexico

BRYAN BRAZIL / SHUTTERSTOCK.COM

PR A CTICA L T RAVEL L ER

DIRECT FLIGHTS (to San Francisco) Air Canada: Vancouver, Toronto, Montreal; United Airlines: Vancouver; United Express: Victoria, Calgary, Edmonton (Air Canada code-shares). OVERVIEW No, spring in California isn’t quite beach weather, but aim for late March or early April for a trip to wine country. The weather is mild, the crowds are small and the valleys are painted yellow with spring mustard growth. You won’t see the harvest, but many locals will tell you that’s the worst time to go, and the wine’ll surely taste better when you can savour it in relative peace. For details and lists of places to visit, see visitnapavalley.com and sonomavalley.com. HOTEL Accommodation can be pricey, but if you stay outside a winery your bottom line improves. The Wine Country Inn (1152 Lodi Lane, St. Helena; tel: 888-465-4608; doubles from US$240) is an award-winning hotel with 50 wineries within eight kilometres of each other. WITH KIDS The vintages aren’t for the kids of course, but many wineries offer kidfriendly activities and prices too. Napa’s Sterling Vineyards (1111 Dunaweal Lane, Calistoga; tel: 800-726-6136; sterlingvineyards. com; adults US$28, under 21 US$10) includes a ride on its gondola with admission and nearby Sonoma’s Train Town (20264 Broadway, Sonoma; tel: 707-938-3912; traintown.com; US$6) is a favourite. There are plenty of hikes (napahiking.com or sonomohikingtrails.com) too.

68%

of adolescent invasive meningococcal disease in Canada was caused by meningococcal serogroup B in 2006 1,†

Don’t turn your back on the stats. Serogroup B invasive meningococcal disease affects all ages, particularly infants under 1 year of age, children 1-4 years of age and adolescents 15-19 years of age.1

Novartis Pharmaceuticals Canada Inc. is committed to research in Serogroup B Meningococcal Disease.

†In adolescents 15 -19 years of age, 21 out of 31 IMD cases were caused by serogroup B. Reference: 1. An Advisory Committee Statement (ACS), National Advisory CommitteeNovartis on Immunization (NACI): Pharamaceuticals Canada Inc. Update on the Invasive Meningococcal Dorval, QuébecDisease H9S 1A9 and Meningococcal Vaccine Conjugate Recommendations. www.novartis.ca CCDR, April 2009, vol. 35, (ACS-3):1-40. T: 514.631.6775 F: 514.631.1867

Printed in Canada ©Novartis Pharmaceuticals Canada Inc.

aware. informed. prepared.

Austin, TX DIRECT FLIGHTS Flights head to Dallas Fort-Worth, a couple hours away, but buses are frequent and because Dallas is a hub, you can sometimes find low prices. Air Canada: Toronto; American Airlines: Vancouver, Calgary, Edmonton (begins April 2), Toronto, Montreal. OVERVIEW It’s one of the fastest-growing major cities in the US and is known for somehow combining the concepts of being hip and Texan. The marquee South by Southwest (SXSW) film/music festival (sxsw.com), one of the biggest in the world, takes over from March 7 to 16, so target or avoid those dates as you like. Even without the fest, the city is always alive. HOTEL During SXSW’s dates, downtown hotels will be packed and expensive, but the city runs extended MetroRail service, so looking for accommodation along the line, in neighbourhoods like North Burnet and Crestview, is a better bet. Other times, the San Jose Hotel (1316 South Congress Avenue; tel: 512-444-7322; sanjosehotel.com; doubles from US$205), just near downtown, is a cool, retro-style property that also serves as a neighbourhood gathering point. WITH KIDS If you’re SXSW-ing, there’s free kiddie-friendly events and expos like the Renegade Craft Fair, Gamer’s Expo, SXSW Create (sxsw.com/free) and more. At any time, check out the massive Zilker Park (austintexas.gov/department/zilkermetropolitan-park) where you can let the little monsters tucker themselves out, and the brand-new Thinkery (1830 Simond Avenue; tel: 512-469-6200; thinkeryaustin.org; US$9) children’s science centre. *Some flights only operate seasonally until March or April. Check individual airline websites for details.

Doctor’s Review • FEBRUARY 2014

GSPHOTOGRAPHY / SHUTTERSTOCK.COM

P R A CTICA L TR AVEL L ER

BUDGET TRAVELLER by

An n a r os a S a b b a d i n i

spring break deals

Whistler Blackcomb Want to do some spring skiing without spending hours online ferreting out descent lodging? Try Whistler Blackcomb’s official site: its last-minute hotel deals match dates (up to two weeks in advance) with affiliated hotels. You see the price and a description of what you’ll get, but not the hotel’s name until you book. Given the number properties that make up the resort, this sight-unseen purchase may come without much risk. whistlerblackcomb.com.

Porto, Portugal.

Hawaii Don’t give up on Maui because of high hotel prices. Check out TripAdvisor’s top-rated B&Bs: Hale Huanani Bed and Breakfast (halehuananibandb.com) and Maui Ocean Breezes (mauivacationhideaway.com). Prices start at US$105 and US$155, respectively.

Tensing Pen in Negril, Jamaica.

Jamaica

New Mexico

Tensing Pen has a cluster of cliff-top cottages on a private cove on Negril’s quieter west-end side. Until March 31, a cottage that’s US$260 is US$208 or 20 percent off (mention Last Minute March when booking). The online-only Be Happy Promo gets you a fourth free night if you book by March 31 and stay between April 1 and June 30. Enter code BE HAPPY PROMO. tensingpen.com. Read more at doctorsreview.com/ features/jamaica-hot-properties.

The Nativo Lodge is a good base to explore Albuquerque and attractions like Balloon Fiesta Park and the Sandia Mountains. Plus, Santa Fe is an hour’s drive north. Rates start at US$79119; included are a historic walking tour (depending on the season) and a discount card for 15 percent off Albuquerque and Santa Fe shops and restos. nativolodge.com.

Claudia Masciotra

Costa Rica

For Dos Aguas Doctor’s Review Entre in Sámara has sevenFebruary rooms and a2014 treetop suite in a jungle setting, just off a main road. Some things are shared:1-855-861-0790 outdoor kitchenette, pool, bar, boogie boards and Fax books. Others not: stone and mosaic showers, colourful rooms. The calm Playa Sámara is a three-block walk along the main road. US$41-92. hoteldosaguas.com.

Grenada The 34-square-kilometre island of Carriacou (population 4595) is known for its quiet beaches and coral reefs. Green Roof Inn’s six rooms and two sea-facing cottages are fully equipped, but affordable. Rooms start at US$95 doubles (US$70 singles), cottages US$130. Breakfast included. greenroofinn.com.

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Review

V IS UA L A RT S by

Da vi d E lki ns

JOCHEN LITTKEMANN

Peter Doig’s many canvases a

100 Years Ago (Carrera), 2001 (229 X 359 cm). This painting was influenced by Matisse’s Bathers with a Turtle with its large flat planes that balance abstraction and figuration. Doig called it “one of the most extraordinary paintings” he had ever seen.

Doctor’s Review • FEBRUARY 2014

People and places engender impressions in the mind that time and memory alter. Unlike most of us, Peter Doig works with these accumulated images to create works on paper, canvas and linen. The hundreds of paintings he’s produced have made him very famous. White Canoe (1990) and The Architect’s Home in the Ravine (1991) sold at an auction in London last year for $10.5 million and $12.5 million, respectively. Both share Canadian roots but as he says, “I want it to be more of an imaginary place — a place that’s somehow a wilderness.” Doig chose Edinburgh and Montreal — two cities where he grew up — as the venues for the extraordinary No Foreign Lands exhibit. On now through May 4 at the Montreal Museum of Fine Arts (mbam.qc.ca), the show is housed in the original classical building on the north side of Sherbrooke Street. Doig insisted on the venue — it’s where his father took him to look at pictures when he was a kid. No Foreign Lands is a big, colourful show that covers the period 2002 to the present with over 40 works from large canvases to small sketches.

and countries COURTESY MICHAEL WERNER GALLERY, NEW YORK AND LONDON

The show’s title is taken from an observation made by novelist and travel writer Robert Louis Stevenson (Treasure Island, Strange Case of Dr Jekyll and Mr Hyde) that “there are no foreign lands. It is the traveller only who is foreign.” Like Stevenson, Doig is another Scot of huge imagination who’s spent much of his life in other places. Born in Edinburgh in 1959, the family moved to Trinidad when he was three and then came to Canada when he was seven. In 1979 he went to art school in London and rented a studio there. He made Montreal his base in the mid-’80s and travelled extensively. He kept the London studio from his student days and, in 1989, moved back to the UK. In 2002 he relocated to Trinidad where he currently lives.

MONTREAL

Walking Figure by Pool, 2011 (260 X 200 cm). The man in the bathing suit is based on a photograph of Francis Picabia (1879-1953), a French painter now best remembered for the exotic paintings of women he did after WWII. Note the legs of a swimmer in the bottom left corner.

Like most kids growing up in Quebec, Doig skied, skated and was a Canadiens hockey fan. He was thrilled when, a few days before No Foreign Lands opened, Guy Lafleur presented him with an Yvan Cournoyer sweater. You can feel a blowing wind in some of the work this country has inspired, among them Blizzard (’77); Ski Lift (’97); Ski Jacket (’94); Ski Hill (’97), an oil on two canvases based on a photo in a Japanese newspaper; and Alpiniste, a small blue drypoint done in 2007.

TORONTO A canoe floating on a northern lake hundreds of years ago; cold empty cottages abandoned at the end of summer; melting sheets of ice against a bank of trees; a multimillion dollar house in a ravine half hidden in a forest. The painter knows Ontario like a memory of itself.

Doig is a painter’s painter. His style is bold. He uses colour and brush strokes with the same confidence shown by the Impressionists. There are echoes in his work of Matisse, Edward Munch, Gauguin, Pierre Bonnard. When he arrived in Trinidad, the exotic landscape, the palm trees and thick undergrowth made him nervous. He feared he might be seen as a mere tourist. He need not have worried. Twelve years on, his work shows how easily he transcended those insecurities. He continues to paint from photographs as always and, here as elsewhere, the people and places emerge fresh, alive, as though he has knows them in his bones. The huge landscapes vibrate with colour and exuberance and become softer, the edges blur. The enormous leaves and vines, the shining water, the carnival goer with his gigantic bat wings draw the viewer in the way travel can.

GEORGE WHITESIDE

TRINIDAD

Peter Doig in his Trinidad studio.

FEBRUARY 2014 • Doctor’s

Review

GA D GE T S by

D a v i d Elk i n s

Hang time No doctor needs to be told that back pain is endemic in Canada. Estimates have it that as many as eight out of 10 people suffer from lower back pain at some point in their lives. Muscle strain, sciatica, herniated discs, compression fractures and spinal stenosis, the list goes on and on — and so does the pain. Sufferers will go to almost any lengths for relief. Massage, acupuncture, cortisone, spinal fusion — or learn to ignore it. Dr Jerome Groopman, a Harvard professor and a leading researcher in cancer and AIDS, did the latter and found that after hurting for 30 years, he was virtually pain free. (Go to npr.org and search “Groopman” to read more in a recent January 2014 article). Or you can try inversion therapy. Hanging upside down takes pressure off the discs in your spine and nerve roots, decompresses the joints and provides quick, if sometimes only temporary, relief. But it’s not for everybody. “Inversion therapy involves hanging upside down, and the head-down position could be risky for anyone with high blood pressure, heart disease or glaucoma,” writes the Mayo Clinic’s Dr Edward Laskowski. That said, legions of back sufferers swear by it. Google it and you’ll find hundreds of positive reviews. After a month using an inversion table, I’m ready to write one myself. I’m one of the lucky people who has never experienced back pain. A friend, an athletic guy who runs a gym, developed sciatica and bought a machine. When he told me it quickly became his favourite piece of equipment, I had to try it. And presto; love at first hang. There’s something exhilarating about being suspended by your ankles for a few minutes. Things that age and that gravity has caused to descend, feel like they’re slipping back up into their rightful place and you feel young(er) again. I’ve been hanging twice a day for a couple of weeks and my wife tells me I’m standing up straighter for it. There are dozens of machines on offer. I’ve tried a few and, hype not withstanding, the Hang Ups by Teeter (teeter-inversion. com) really are the best. I assembled and then tested the EP-560 (pictured), which sells for $379 on Amazon.ca. The instructions were clear — it took about an hour to put together — and the included video on how to use it was helpful. Another unit, the Exerpeutic 5503, offers one of the lowest prices at just US$104 (plus shipping and duties) on Amazon.com and it’s quite adequate. Both do the job, but their differences are akin to those between a Cadillac and a Chevy.

FEBRUARY 2014 • Doctor’s

Review

REG

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NS I

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Join us in Ottawa to be a part of

Capitalizing on Excellence at CAEP 2014

May 31 - June 4, 2014

Discover more at the CAEP Lounge located in the Foyer

Get more information w w w. cat: a ecaep.ca/Conference p.ca

F OOD by

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There is no such thing as genetically modified oats. But that didn’t stop General Mills from slapping “not made with GM ingredients” onto the label of its original-flavoured Cheerios. Now that General Mills has picked up on the marketing potential of being GMO-free, it may be time we understand more about the genetic background of fresh produce we eat — all those fruits and veggies that make up our weekly staples. What are GM foods? Health Canada defines genetic modification as the “intentional manipulation of the gene structure of a plant.”1 This could involve cross-breeding, mutagenesis and genetic engineering.2 Plant breeding vs. GM Traditional methods of plant breeding change genes through selection. The resulting genetic material was already present within a species. Modern lab methods allow us to insert foreign genes. Are they safe? Before a GM seed can be planted, it must undergo a rigorous approval process that can take up to 10 years. This is similar to the testing a drug undergoes before approval. The molecular structure of the new food is evaluated, then its nutritional composition is compared to that of its traditional counterpart. Finally, the possibility of it being toxic or allergenic is evaluated.3 These regulations are based on international standards that include recommendations by the WHO and the Codex Alimentarius. Does Health Canada require labelling? Companies currently make voluntary declarations regarding the presence or absence of GM ingredients in a food.3 It’s possible to tell if a fruit or veggie is GM by its UPC bar code. The bar code of conventionally grown produce starts with 3 or 4 and contains three other numbers, organic food starts with a 9, and GM produce starts with an 8 followed by four other numbers.4 Expect to see more voluntary labelling on store shelves. But in the same way that companies plaster the claim “contains no cholesterol” on foods that never contained cholesterol in the first place, this is likely to cause more confusion than actual better health.

KNOW YOUR BAR CODES

YU LAN / SHUTTERSTOCK.COM

Are you eating GM foods?

For footnote references, go to doctorsreview.com/ nutrition/GMfoods.

Conventionally grown: the code starts with 3 or 4 and contains three other numbers. Organic: the code starts with a 9. GM: the code starts with an 8 and is followed by four other numbers. FEBRUARY 2014 • Doctor’s

Review

NEW

! T S TE

N O C

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+ fill out a contest ballot Be one of the first 100 doctors to enter and you could win a $100 gift certificate from Lee Valley Tools doctorsreview.com/meetings Find a meeting. Win a prize. Search by destination â&#x20AC;˘ date â&#x20AC;˘ specialty

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The aggregators A notable trend in medical apps is to aggregate several useful resources in a single application. Two of the better ones are offered by Skyscape (skyscape.com). The new Omino app, currently only available on iPads, is billed as an electronic black bag to hold all of your “must haves.” The free app contains extensive drug information, a bank of medical calculators, a symptom checker, a recently updated reference checker as well as medical alerts as they’re announced. Keeping up with the latest medical news can be as fast or as leisurely as

you like with this app. When you first download Omino, you tailor your news feed to present summaries and links to your preferred journals and sources. After that, it’s easy to scroll and easy on the eyes. Omino is rated 4+ by users in the iTunes app store. Recent comments: “wonderful app that [keeps] me up-todate, keen for learning and gives me quick access to the answers I need in daily practice.” Another writes “the retrieved information is current, well organized and clinically relevant.” The app comes with an excellent demo set up for a cardiologist making for an easy learning curve. Available in English. Skyscape Medical Resources (SMR) is also free but more widely available on Apple, Android and BlackBerry devices. Plus, it comes with Archimedes: hundreds of definitions, charts, tables, tools and references from “A-a-gradient” to “X-ray rules (Ottawa knee).” Outlines in clinical medicine are well organized and comprehensive with drop-down menus to access what amounts to a medical encyclopedia of additional material. A complete A-Z drug list includes classes and a drug-interaction analyzer based on data from Hansten and Horn’s Top 100 Drug Interactions. SMR has a 4.5 rating from iTunes users. Says one: “I use this for most drug-related questions;” another recommends it for nurse practitioners as well as physicians. English only.

FEBRUARY 2014 • Doctor’s

Review

Act NOW Purdue Pharma has replaced OxyContin® with OxyNEO®.

OxyNEO® (oxycodone hydrochloride controlled release tablets) is indicated for the relief of moderate to severe pain requiring the continuous use of an opioid analgesic preparation for several days or more. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, concomitant disease or other drug therapy. The use of OxyNEO® is not recommended in patients under 18 years of age. Dosing requirements vary considerably between patients and limitations may be imposed by adverse effects. If they occur, refer to the prescribing information. The adverse effects associated with OxyNEO® are similar to those seen with other opioid analgesics. The most frequently observed are asthenia, constipation, dizziness, dry mouth, headache, nausea, pruritus, somnolence, sweating and vomiting. OxyNEO® is contraindicated in: patients hypersensitive to oxycodone or other opioid analgesics or to any ingredient in the formulation; patients with mechanical gastrointestinal obstruction or diseases/conditions that affect bowel transit; patients with suspected surgical abdomen; patients with mild, intermittent, short or acute pain; patients with acute asthma or other obstructive airway, status asthmaticus; patients with acute respiratory depression, elevated carbon dioxide levels in blood, cor pulmonale; patients with acute alcoholism, delirium tremens, convulsive disorders; patients with severe CNS depression, increased cerebrospinal or intracranial pressure, head injury; patients taking MAO inhibitors (or within 14 days of such therapy); women who are breastfeeding, pregnant, or during labour and delivery. Warning: Opioid analgesics should be prescribed and handled with a degree of caution appropriate to the use of a drug with abuse potential. Patients should be cautioned not to consume alcohol while taking OxyNEO®, as it may increase the chances of experiencing dangerous side effects. There have been post-marketing reports of difficulty swallowing OxyNEO®. If patients experience swallowing difficulties or pain after taking OxyNEO® tablets, they are advised to seek immediate medical attention. To avoid difficulty swallowing, OxyNEO® tablets should not be pre-soaked, licked or otherwise wetted prior to placing in the mouth and should be taken one tablet at a time with enough water to ensure complete swallowing immediately after placing it in the mouth. A single dose greater than 40 mg of oxycodone, or total daily doses greater than 80 mg of oxycodone, may cause fatal respiratory depression when administered to patients who are not tolerant to the respiratory depressant effects of opioids. OxyNEO® tablets must be swallowed whole as taking cut, broken, chewed, dissolved or crushed OxyNEO® tablets could lead to the rapid release and absorption of a potentially fatal dose of oxycodone. The tablets have been hardened, by a unique process, to reduce the risk of being broken, crushed or chewed, and consist of a matrix with hydrogelling properties. Patients should be instructed not to give OxyNEO® to anyone other than the patient for whom it was prescribed as such inappropriate use may have severe medical consequences, including death. Product monograph available on request.

See prescribing summary on page 59 xxx

doctorsreview.com/meetings access code: drcme

the top 20 medical meetings compiled by Camille Chin

Canada Blue Mountain, ON July 10-12 5th Annual CBT Blue Mountain

Montreal, QC June 18-21

June 25-28 91st Annual Conference of the Canadian Paediatric Society

July 27-August 1 2014 International Union of Microbiological Societies

Niagara Falls, ON June 10-13 70th Annual Clinical and Scientific Conference of the Society of Obstetricians and Gynaecologists of Canada The Montreal Jazz Fest runs from June 26 to July 6 this year.

CARLOS CAETANO / SHUTTERSTOCK.COM

2014 Combined Meeting of the Canadian Orthopaedic Association and American Orthopaedic Association

On a clear day you can see Pena National Palace in Sintra from Lisbon.

Ottawa, ON May 31-June 4 2014 Annual Conference of the Canadian Association of Emergency Physicians

For meetings around the world, turn to page 30. Vancouver, BC June 22-26 29th CINP World Congress of Neuropsychopharmacology

Whistler, BC July 28-30 CBT Whistler

For contact info on these and 2500+ more conferences, visit doctorsreview.com/meetings

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

Go to doctorsreview.com/meetings for a reason to visit these cities... and many more! FEBRUARY 2014 • Doctor’s

Review

Why Boston?

by Tyson Lowrie

KINDRA CLINEFF / MOTT

Boston is known for being compact and accessible on foot with plenty of pleasant paths on which to pound the pavement. Summer is perfect for the Rose F. Kennedy Greenway, named for JFK’s mother, in the heart of downtown, with its gardens, shrubs and even the occasional art installation.

Pavement pounder

The redbrick, four-kilometre Freedom Trail is where you go to take in Boston’s history in an hour. The trail features 16 sites, such as the Massachusetts Statehouse, historic churches and numerous statues.

Walk under the paifang at Beach Street and Surface Road to enter the city’s historic Chinatown. Long a destination for immigrants, the area is now a combination of historic buildings, gentrification and some of the highest-population density in Boston.

Seafood lover

ARNOLD INUYAKI / FLICKR.COM

Boston is a great city to get seafood. In the Fort Point neighbourhood, the recently-opened Row 34 has been drawing rave reviews. Despite the ultra-modern décor, it dubs itself the “workingman’s oyster bar” and has oysters starting at US$2, numerous craft brews on tap and more adventurous dishes like fish-head terrine. Dubbed the best seafood restaurant in the city by Zagat, Neptune Oyster is ironically more famous for its lobster roll. Check for daily specials; if you can make it on a Sunday, the fried fish tacos are recommended. The Hyatt Harborside Grill & Patio won 2013’s Chowderfest competition for the best version of the iconic New England dish. Better yet is the view; using public transit, cross the water and take a seat next to Boston Harbor. You’ll enjoy both your award-winning US$9 bowl of clam chowder and the city skyline.

Doctor’s Review • FEBRUARY 2014

SAM OGDEN / MIT MUSEUM

19th World Congress on Heart Disease cardiologyonline.com/wchd2014

From the Downtown Crossing station, take the red line five stops to Harvard Square and suddenly you’re in a university town. It’s so scholarly that in Cambridge, on Oxford Street, you can see the Harvard Museum of Natural History. Its fossils and skeletons are good for kids and adults alike. The 13-metre-long Kronosaurus skeleton is a highlight. Double back towards Boston on the red line and get off at Kendall/MIT station. Walk east to the gigantic Stata Center. Architectural marvel or monstrosity according to your tastes, it’s one of a dozen remarkable buildings on MIT’s campus. For a self-guided tour: web.mit.edu/institute-events/ events/privategrouptour/150WalkingTour.pdf.

A Boston meeting: July 25-28

For contact info on this and 2500+ more conferences, visit doctorsreview.com/meetings

Scholar

Also at MIT, pop into the MIT Museum. Showcasing the university’s research achievements, it has one of the coolest displays of robots you’ll see anywhere. Who knew scientific progress could be so creepy-looking?

SNOWPEA & BOKCHOI / FLICKR.COM

SHUTTERSTOCK.COM

Immigrants from the Middle East, Ireland, Canada’s Maritime provinces, a gay community and artists have all contributed to Boston’s most interesting neighbourhood. Take in Southie’s many Victorian brownstones and small gardens; it’s a bit like Brooklyn, though locals will tell you it’s better. For a self-guided tour: southendgardentour.org.

DIRECTORY Bristol Lounge 200 Boylston Street tel: 617-338-4400 fourseasons.com/boston/dining/ afternoon_tea

For fuel, try the original location of the Flour Bakery. It’s run by a Harvard graduate and sometimes dubbed the best bakery in Boston. There are sweet and savoury items at the growing chain, but make sure to try the famous sticky buns. A French-style restaurant, Hamersley’s Bistro is consistently ranked one of the best in the city. Visit in summer, when you can enjoy the signature roast chicken on the peaceful patio area.

Fire, Yamaguchi Ryu¯un.

Boston Public Library Central Branch 700 Boylston Street tel: 617-536-5400 bpl.org/central

Explorer

Boston is known for having some of the finest “high-art” institutions in North America. The Boston Museum of Fine Arts is always home to excellent exhibits; this summer catch Fired Earth, Woven Bamboo: Contemporary Japanese Ceramics and Bamboo Art.

SHUTTERSTOCK.COM

Tasteful tourist

ALEX JAFFE / MOTT

Boston Museum of Fine Arts 465 Huntington Avenue tel: 617-267-9300 mfa.org adults US$25, kids 7 to 17 US$10 and free weekends and weekdays after 3pm

Even if you don’t love books, you’ll appreciate the Boston Public Library’s Central Branch. The two buildings that make it up are works of art in their own right. A walk through the McKim building’s reading room is a must, where the silence and occasional page-flip only adds to the reverence. Shh! For a place known for its wanton destruction of tea in 1773, the city has quite a few places where you can enjoy the genteel tradition of an afternoon cuppa. The Four Seasons’ Bristol Lounge serves it weekends at 3pm, and overlooks the equallygenteel Boston Public Garden.

Flour Bakery 1595 Washington Street tel: 617-267-4300 flourbakery.com Freedom Trail thefreedomtrail.org Hamersley’s Bistro 553 Tremont Street tel: 617-423-2700 hamersleysbistro.com Harborside Grill & Patio 101 Harborside Drive tel: 617-568-1234 bostonharbor.hyatt.com Harvard Museum of Natural History 26 Oxford Street, Cambridge tel: 617-495-3045 hmnh.harvard.edu adults US$12, kids 3 to 18 US$8 MIT Museum 265 Massachusetts Avenue, Cambridge tel: 617-253-5927 web.mit.edu/museum adults US$10, kids 5 to 18 US$5 Neptune Oyster 63 Salem Street tel: 617-742-3474 neptuneoyster.com Rose F. Kennedy Greenway rosekennedygreenway.org

SHUTTERSTOCK.COM

Row 34 383 Congress Street tel: 617-553-5900 row34.com Stata Center 77 Massachusetts Avenue, Cambridge web.mit.edu/facilities/ construction/completed/stata.html FEBRUARY 2014 • Doctor’s

Review

doctorsreview.com/meetings access code: drcme

the top 20 medical meetings Around the world

Learn all about the city’s past at the Indiana History Center.

Copenhagen, Denmark June 7-11 2014 Congress of the European Academy of Allergy and Clinical Immunology

Edinburgh, Scotland June 14-18 PHOTO COURTESY OF VISITINDY.COM

14th World Congress of the World Association for Infant Mental Health

Indianapolis, IN June 20-22 2014 International Conference and Scientific Sessions of the Pulmonary Hypertension Association

Jerusalem, Israel June 9-12

Lisbon, Portugal July 2-5

47th Annual Meeting of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition

19th Europe WONCA Conference

Kiel, Germany June 12-14

19th Congress of the European Hematology Association

12th Congress of the European Society for Pediatric Dermatology Paris’ Jardin des Tuileries is popular with kids and adults alike.

Milan, Italy June 12-15 July 5-9 9th FENS Forum of Neuroscience

For meetings in Canada, turn to page 27. Nice, France July 5-10 XIII International Congress on Neuromuscular Diseases

Paris, France June 11-14 15th Annual European Congress of Rheumatology

San Diego, CA June 12-14 25th Scientific Sessions of the Society for Vascular Medicine

Washington, DC July 21-26 © PARIS TOURIST OFFICE - AMÉLIE DUPONT

2014 Annual Scientific Meeting of the American Urogynecologic Society and the International Urogynecology Association

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Doctor’s Review • FEBRUARY 2014

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Ja cki e Rosenhek

Mad with menopause

The way we look at The Change has certainly, well, changed

n 1692, 16 women falsely accused of witchcraft were executed or died while imprisoned in Salem, Massachusetts. At least 13 of them were menopausal. Today we see this infamous incident of mass hysteria as a seminal moment in women’s history, although to be fair, “seminal” may not be the most appropriate word. No matter how one chooses to describe what happened during this dark chapter in American history, it’s undeniably significant that those targeted were women past childbearing age, a group perceived as powerful, threatening and altogether ungodly. Gender politics aside, menopause has somewhat of a strange place in the story of medicine, despite it being a big part of the cycle of life. Prior to the last couple of centuries, not much thought had been given to the slew of physiological and psychological changes that accompany the female ageing process. Perhaps it was because life expectancy was shorter; after all, so many women died in childbirth, and the various plagues and diseases floating around meant that in some eras, making it to menopause was like hitting the jackpot. More likely, though, was the fact that nobody gave the medical aspects of ageing much thought. Aside from the storied fountain of youth, what defense could there possibly be against the onslaught of old age? Only the wealthy and the philosophical could afford to sit around contemplating their own mortality. For the average Medieval Joe, there were fields to sow, serfdoms to defend, work to be done! The tide turned in the 19th century, when life expectancy increased somewhat in the Western world as did the accompanying onslaught of medical conditions. It’s not that nobody knew about menopause — Aristotle himself noted that women couldn’t get pregnant after around age 50 and Hippocrates associated this with breast cancer — it’s just that nobody cared. Here and there, a physician attempted to apply logic to the situation. Most notably, perhaps, was the well-known English physician Thomas Sydenham (1624-1689). Sydenham — who revived Hippocratic values like detailed observation, careful case histories and the blessings of opium — was keen to point out that women were prone to “hysterick fits” between the ages of 45 and 50. It stood to reason, therefore, that restoring the menses in these hapless souls might be the solution. He advocated a hearty regimen of blood-letting as a cure; many of his middle-aged female patients likely dreamed of turning the scalpel on the gouty old man himself!

Doctor’s Review • FEBRUARY 2014

FROM TOP: The deck at the 1692 Salem Witch trials were stacked against women of a certain age. Thomas Sydenham astutely noted that women were prone to “hysterick fits” between the ages of 45 and 50. For this, he prescribed a full regimen of blood-letting. The matriarch of menopause herself, Queen Victoria. Kentucky physician Ephraim McDowell performed the first successful ovariotomy in 1809.

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DE LA MÉNÉPAUSIE

One 19th-century French physician spearheaded a new interest in the subject. Charles Pierre Louis De Gardanne studied at length the symptoms experienced by women as they aged. He coined the term itself in 1821, in the first-ever article on the subject: De la ménépausie, ou de l’âge critique des femmes (“Menopause: The Critical Age of Women”). It was to be a banner year for granny-bashing. Although De Gardanne may have been the first to give menopause some serious medical attention, it is also to him that we can attribute the first negative attitude towards this most natural of biological processes. He blamed an incredible slew of physical and emotional symptoms on the cessation of menstruation.

Having a working womb gave you hysteria, not having one pretty much did the same thing In 1845, De Gardanne’s countryman C. F. Menville de Ponsan took up the cause and devoted an entire book to menopause, which he liked to call “the death of the womb.” In his defense, he was somewhat of a romantic when it came to menopause: “When the vital forces cease to conspire over the uterus, they will increase those of the spirit…. The critical age passed, women have the hope of a longer life than men, and their thought acquires more precision, understanding and vivacity.” Nineteenth-century cures were mainly held over from earlier times — purgatives, bleeding and enemas fell into the category of “vicarious menstruations.” The forward-thinking London gynecologist Samuel Ashwell’s (1798-1857) treatments might have been standard, but his attitude was anything but. In his Practical Treatise on the Diseases Peculiar to Women (1844), he suggested abstinence from alcohol, exercise and vegetarianism, although he did not see menopause as a disease: “It has become too general an opinion that the decline of this function [menstruation] must be attended by illness; but this is surely an error, for there are healthy women who pass over this time without any inconvenience and many whose indisposition is both transient and slight.”

DELETERIOUS DOUCHES

Sadly, Ashwell’s influence was limited. It wasn’t long before the Victorian mind-set twisted menopause into a mental illness to be cured. Women couldn’t catch a break: it seems that having a working womb gave you hysteria, while not having one pretty much did the same thing. The doctors in England began prescribing deadly-sounding douches containing a cocktail of acetate of lead, morphine and chloroform.

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uu CONTINUED ON PAGE 63 FEBRUARY 2014 • Doctor’s

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On the prow Kenyaâ&#x20AC;&#x2122;s Maasai Mara National Reserve has the most savannah species in the world, but itâ&#x20AC;&#x2122;s the big cats that get the big looks by

Josephine Matyas

There are only 32,000 lions left in all of Africa due, in part, to hunting, the destruction of habitats and climate change.

alk about a civilized start to a day in a very wild place. Had I not been awake, dressed and ready to begin the morning, I might have missed the soft tapping on the canvas door of my tent. This is how they do wake up calls at the tented luxury resorts near Kenya’s Maasai Mara National Reserve: I chose the time, there was a knock followed by a tray with a steaming pot of hot chocolate and a fresh-baked muffin. Perfect. Starting early — before the sun has brightened the sky — is de rigueur safari etiquette in Africa. To do otherwise is to mess with a deeply entrenched natural order. The animals know enough to be up and about as the sun peeks over the horizon. Abdi, our driver, safari guide and wildlife expert, left no room for misinterpretation: this game drive was starting early. And so that is how day one began, with the rough grinding of gears and a panicked search for ways to keep coffee mugs from exploding hot liquid — plus chatter in the back seat about how neighbouring Botswana prefers women safari drivers because they are easier on the vehicles . Almost immediately after clearing the front gate of the resort, Abdi veered from the gravel road and onto a set of deeply rutted tracks that cut across the grassy plain. When you’re looking for wildlife, off road is best. “Warthogs,” he announced, bringing the jeep to a sudden stop. “Not too smart and they have a very short memory. We call them lion appetizers.” Coffee mugs were abandoned as we scrambled to fish cameras from backpacks. The warthog is the Danny DeVito of the savannah: short, squat and full of swagger. It may not be the sharpest creature in the wilds, but perhaps it is best to start near the bottom of the food chain and work upwards. Finding wildlife should be like climbing a ladder: one rung at a time. To do otherwise is toying with sensory overload.

ALA737 / SHUTTERSTOCK.COM

FEBRUARY 2014 • Doctor’s

Review

When looking for wildlife, off road is best so expect rough rides.

ANDRZEJ KUBIK / SHUTTERSTOCK.COM

JOSEPHINE MATYAS

The National Reserve is 1500 metres above sea level where temperatures are more moderate and water not so scarce.

One flat tire. A jeep in thick mud. Chains hitched between vehicles. A respectable amount of yelling, and we were off again

he landscape of the Maasai Mara is the quintessential image that comes to mind when you think of a safari expedition. Spotted with acacia trees — the thorny trademark symbol of Kenya — the open grasslands of the National Reserve are home to the largest number of savannah species in the world: 2.5 million herbivores like gazelles, zebras, giraffes and elephants plus the carnivores that prey on them, including lions and cheetahs. Our safari days were split between the Maasai Mara National Reserve (which is maintained by the local government) and the smaller community-owned and operated Ol Chorro Conservancy. At 1500 metres above sea level, temperatures are more moderate on the plains of the Maasai Mara region. Large animals like it there. Food is plentiful and water not so scarce. Abdi pointed our jeep away from the well-worn visitor hot spots. Instead, he zigzagged through Ol Chorro from one wildlife sighting to the next, following a map in his head, bouncing across riverbeds, spraying mud from rear tires and cutting through the grasslands in a sort of safari pinball.

Doctor’s Review • FEBRUARY 2014

A troop of several dozen baboons. Zebras, Cape buffalo and the ungainly wildebeest — “a creature designed by committee.” We worked our way up the wildlife ladder, one rung at a time. Later that morning (with camera cards precariously near full), we stumbled upon a family herd of several dozen elephants grazing in an area of especially succulent grasses. Abdi inched the jeep closer, closer. Poaching is illegal — although it exists — in Kenya, so the elephants showed no fear on their home turf. The babies followed the mamas. The adults ate, twisting their trunks to tear out clumps of greenery, all the while keeping an eye on the intruders. “Watch their ears,” warned Abdi. “If they go flat against their head they could be getting ready to charge.” As the Earth’s largest land animal, pound for pound an elephant clearly outranked our jeep. Charging was one thrill I could do without. The next morning — bleary-eyed but sufficiently caffeinated — we loaded into the jeep for the 90minute drive to the Maasai Mara National Reserve. To placate the group, we were aiming for the top of the food chain: lions. But, it was no straight line to

ANDRZEJ KUBIK / SHUTTERSTOCK.COM

To reduce conflicts between people and wildlife, some communities pay farmers for livestock killed by predators.

get there. We had to work to find this elusive member of Africa’s Big Five (the others are the African elephant, Cape buffalo, leopard and rhinoceros). One flat tire. A jeep up to its hubcaps in a pool of thick mud. Chains hitched between two vehicles. A respectable amount of yelling and encouragement, and we were off again, headed towards the reserve’s northern Musiara Gate. The breakdowns made our arrival at the sweeping plains of the National Reserve much later than planned; the sun was already breathing fire into midday. The landscape of the Mara was wide open with tall green and golden grasses riffling in the breeze as far as the eye could see. There was the occasional acacia tree, pruned to a characteristic muffin-top shape by hungry giraffes. But, even with binoculars, no wildlife of any kind was in sight. Where exactly does an elephant go to hide in the heat of the day? We felt deflated. The only life was a park janitor, sitting atop a chugging tractor. “Lions,” he snorted, anticipating our question. “Try under the tree.” He waved broadly in a westerly direction. Of the planet’s apex predators — a clique with tigers, crocodiles, wolves and grizzlies among the members — few are as sought after on game treks as the African lion. They are majestic hunters: one adult lion needs 40 kilos of meat every five days, the equivalent of about 20 unlucky zebras per year. Although Kenya instituted a ban on game hunting in 1977, the country’s lions are facing a threat to their

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FEBRUARY 2014 • Doctor’s

Review

population. According to the National Geographic Society’s Big Cats Initiative (animals.nationalgeographic. com/animals/big-cats-initiative), African lion numbers on that continent have plummeted from hundreds of thousands estimated in the 1960s to around 32,000 today. Hunting, the destruction of habitats, climate change, pesticides and disease have all contributed to the decline. Recognizing that lions are key to a vibrant tourism industry, communities and local governments are creating innovative programs to save the beasts by reducing the conflicts between people and wildlife. In southern Kenya, the Lion Guardians program (lionguardians.org) recruits young Maasai warriors to protect lions rather than kill them, as traditionally required for the transition into manhood. Instead, they monitor lion movements, and prevent clashes with herders and cattle. Communities in the crucial migration corridor connecting the national parks of Amboseli and Tsavo have developed a predator compensation fund, paying livestock owners for losses due to attacks by lions, leopards, cheetahs, jackals and hyenas. Contrary to every instinct in my brain, I wanted these big cats to find me. And Lady Luck appeared to be riding shotgun that afternoon. In a patch of scarce shade, we found a pride — three lionesses and nine cubs — sprawled beneath an acacia tree. These lions weren’t on the hunt. Lethargic, bellies full, fur smeared with dried blood, they’d enjoyed a recent kill and feeding. We parked a stone’s throw away to watch. Only then did I remember to breathe. After a decent snooze, a half dozen rolled over, got to their feet and walked single file between our two jeeps through the tall grass to a spot in the distance. “The kill,” announced our guide, pointing at the vultures circling overhead. We waited a respectable amount of time and then drove across the plain to get a better look. Splayed on the ground was a massive Cape buffalo, with a lineup of cubs, jostling to crawl inside its ripped belly. To my North American sensibilities this covered both ends of the spectrum, from raw to exotic. But to my Maasai host, the Mara is a familiar landscape that still beats with the slow, steady pulse of prehistory. “The lions will feed,” he reflected. “Tonight a pack of hyenas will come. And tomorrow, the vultures. It’s the food chain of nature.”

Doctor’s Review • FEBRUARY 2014

JOSEPHINE MATYAS

The Maasai are a semi-nomadic people who live in southern Kenya and northern Tanzania.

CREATE A GAME PLAN KLM flights (klm.com) depart from Toronto and Montreal to Nairobi, connecting through Paris and Amsterdam. There is a US$50 visa required upon entry to Kenya. Wildlife viewing is good year round, but June, July and August are the best months. During this dry season, animals tend to migrate to sources of water, making the chance of concentrated sightings much better. The Fairmont Mara Safari Club (fairmont.com/ masai-mara-safari; singles from US$569, doubles from US$749, including meals and daily games drives, but not park fees) provides tented luxury overlooking a hippo and crocodile-infested river. The 50 tents on the property are surrounded by the Mara River and the Maasai Mara. The Public Health Agency of Canada (phacaspc.gc.ca) warns of a risk of yellow fever and malaria at certain times of the year in certain parts of the country. For more info on travel to the region, visit the Kenya Tourist Board (magicalkenya.com).

All of the tents at the Fairmont Mara Safari Club feature four-poster beds and private bathrooms.

I M P O RTA N T N O T I C E

Health Canada/PAAB regulation change for prescribing information in journals Dear Doctor, Beginning in July 2013, important changes to regulations governing advertising of prescription, non-prescription, biological and natural health products will come into effect. The Canadian Association of Medical Publishers (CAMP) wants to inform our valued readers of these changes, as they will affect access to prescribing information that is currently published in our journals. The Pharmaceutical Advertising Advisory Board (PAAB), acting on behalf of Health Canada, reviews and approves all promotional materials directed at healthcare professionals in Canada. PAAB recently approved changes to their code of advertising acceptance that will allow advertisers to replace the current prescribing information pages with an electronic link to full product monographs. This link will be displayed prominently in all published print ads (a 1-800 number will also be provided). These changes will be phased in over the next twelve months, during which time you will see a mix of ads using the current print prescribing information and ads utilizing the new format. Medical journals play a vital role in educating physicians. Journal readership continues to grow. An annual national study (Print Measurement Bureau – Medical Media Study July 2012) shows readership of medical journals has risen 16% since 2007. Journals rank second only to live CME as a preferred communication channel. Canada will be breaking new ground with this “ePI” approach. If you have comments or concerns regarding these changes we encourage you to contact PAAB or Health Canada directly: Pharmaceutical Advertising Advisory Board (PAAB) 300-1305 Pickering Parkway Pickering, Ontario L1V 3P2 Canada Contact: Patrick Maasad Telephone: 905-509-2275 Email: Patrickm@paab.ca

Sincerely, Canadian Association of Medical Publishers

Health Canada Alain G. Musende, PhD Manager, Regulatory Advertising Section/ Gestionnaire de la section de la réglementation de la publicité Therapeutic Effectiveness and Policy Bureau/ Bureau de l’efficacité thérapeutique et des politiques Marketed Health Products Directorate/ Direction des produits de santé commercialisés Tel/Tél.: 613-954-6780 Fax/Téléc.: 613-948-7996

The Mad Tea Party cups have been in operation since 1955 but were modified in 2004 to reduce motion sickness.

Spin doctors The original Disney in California can still turn mere pixie dust into park magic by

Robb Beattie

he underground temple was vast and dark, its walls covered with mystic symbols and sculpted faces of idols. Centipedes scuttled over pillars and serpents slithered

PAUL HIFFMEYER/DISNEYLAND RESORT

through heaps of coins as our 12-person jeep shuddered down a steep track into a corridor guarded by statues of cobras. “It’s the Gates of Doom!” screamed a young archeology student as we accelerated across a bridge over a pit of bubbling magma. The jeep skidded abruptly into a pitch-black passageway. Looking up, I saw a colossal boulder rolling towards us. Closer and closer it rumbled; then, just as it was about to crush us, the floor collapsed and our jeep plunged downward. The smaller explorers among us shrieked exuberantly. Moments later, I was back in the California sunshine, relieved at my escape from the Temple of the Forbidden Eye, an Indiana Jones attraction at Disneyland in Anaheim, 42 kilometres south of Los Angeles. “Want to go again?” a young girl piped up behind me.

The Mickey’s Soundsational Parade features nine floats, each designed like a “pop-up” book.

FEBRUARY 2014 • Doctor’s

Review

THE WONDERFUL WORLD OF DISNEY The Monorail, Matterhorn Bobsleds and Submarine Voyage all debuted on June 14, 1959.

CALIFORNIA ADVENTURE AREAS

PAUL HIFFMEYER/DISNEYLAND

Buena Vista Street Grizzly Peak Pacific Wharf Bugs Land Gravity Falls

Paradise Pier Condor Flats Hollywood Land Cars Land

THE BEST RIDES

DISNEYLAND AREAS

Main Street USA New Orleans Square Critter Country Toon Town

Adventureland Frontierland Fantasyland Tomorrowland

Radiator Springs Racers (Cars Land) Tower of Terror (Hollywood Land) California Screamin’ roller coaster (Paradise Pier) PLUS, Pixar characters (from A Bug’s Life, Cars and the new Monster’s University)

SHOWS

World of Colour, 1200 fountains, lasers, lights and fire with projections on mist screens Alice in Wonderland-themed Mad T Party

THE BEST RIDES

Radiator Springs Racers is one of the most elaborate attractions ever created for a Disney park.

SHOWS

Mickey’s Sensational Parade Jedi Training Academy (audience participation) Fantasmic, a nightly multi-media show with projections on mist screens Mickey & the Magical Map, a stage show with plenty of computer-generated effects Nightly fireworks

PAUL HIFFMEYER/DISNEYLAND

Indiana Jones Adventure (Adventureland) Splash Mountain (Frontierland) The Finding Nemo submarines (Tomorrowland) Pirates of the Caribbean (Adventureland) Iron Man and Star Wars shows (Tomorrowland) PLUS, costumed characters are best seen around the Magic Castle and in Toon Town

One-day, one-park tickets cost US$92 for ages 10 and up; US$86 ages 3 to 9. Multi-day passes and twin-park admissions are available. Check disney.ca for deals.

Accommodations: Downtown Disney has two resort hotels (the Grand Californian and the Disneyland Hotel). Both are US$440 plus tax for one night, double occupancy. The Paradise Pier Hotel in the California Adventure Park is US$364 nightly. To book, go to disney.ca. The site also features a list of less expensive hotels in neighbouring Anaheim.

Doctor’s Review • FEBRUARY 2014

It’s amazing to think that Disney’s pantheon of talking animals and fairytale figures — now updated with the likes of Indiana, Iron Man and characters from Star Wars — has been a part of childhood ever since Snow White came out in 1937 (an event my mother recalled for the rest of her life). When the theme park opened in 1955, the Disney giddy sensibility immediately caught on — even the Shah of Iran and the Soviet Premier Khrushchev wanted to say hi to the oversized mouse (Khrushchev was denied the privilege; Mickey and his friends didn’t like playing Cold War politics). Day tickets were US$3.50, compared to US$92 now, and lineups became an occupational hazard from the moment the park first opened. From California, the Disney brand expanded to parks in Florida, Tokyo, France and Hong Kong, with a park in Shanghai slated to open in 2015. But Anaheim remains the original; the first and only one designed by Uncle Walt himself. When I visited in May I found that, despite 60 years of expanding and revamping, the park is still infused with Walt’s charm. The imagination and engineering that goes into shows like Fantasmic! (animation projected on clouds of mist in the sky), the fireworks over Sleeping Beauty’s castle, or the new Mickey and the Magical Map (a stage show with seamless interactive effects) are staggering. There’s a reason why Kevin Elder, Disney’s Head of Imagineering (the people who think up and build this stuff), has this to say about his crew: “We are obsessed storytellers and we are obsessed about detail. We want people to get lost.” While I never literally lost my way, I often found myself wheeling in circles, unabashedly gawking at the park’s 65-hectare assortment of attractions, many of which cost US$50 million apiece and look as if they were built with the help of alien technology. The most recent transformation occurred in 2012 to the adjacent California Adventure park; its attractions are loosely based on themes like Hollywood, surfing and dragsters. Besides a new 1920’s-styled entrance, Disney’s added Cars Land, a massive five-hectare expansion dedicated to Pixar’s Cars.

s one of the world’s few fully functional paradises for children, Disneyland is a very ecumenical place. While I never saw a cynical eight-year-old, I did see a veiled woman in a chador wearing mouse ears. Waiting in line for one ride, I began talking to the Keo family from Laos, who’d taken the trip of a lifetime to see relatives in San Diego before making a beeline for Disneyland. “No brainer,” smiled teenage son Phaivanh, using an expression he learned from satellite TV. The Keos’ favourite experience so far? The Tower of Terror, which drops you multiple stories in a haunted elevator.

Even the Shah of Iran and Soviet Premier Khrushchev wanted to say hi to the oversized mouse Wandering through attractions, I also noticed quite a few maple leafs on backpacks and T-shirts. More and more Canadians are visiting, lured by coastal California’s year-round mild, dry climate and Disneyland’s manageable size — at least compared to the overwhelming Disney World in Florida, which is as big as Ottawa and boasts 27 resorts. Manageable Disneyland may be, but at 206 hectares, the place is hardly small. When I first visited as child, it seemed planet-sized, and has continued growing since, though the resort is still circled by the elevated monorail installed in 1959 by Walt Disney. As futuristic today as it was back then, the monorail uu CONTINUED ON PAGE 56

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FEBRUARY 2014 • Doctor’s

Review

Marley Four pet-friendly properties in Mont-Tremblant plus everything you need to chew over before you pack up the pooch by

Lora Perrone

ebruary/March is the time of year when many families come together, load up the car and head out for their annual spring-break ski holiday. Quebec’s Mont-Tremblant hosts many of these families: its 95 ski trails were recently running at capacity when snow conditions were arguably at their best and the polar-frigid temperatures of December/January were but a distant memory. But before the SUV backs out of the driveway, some families have a decision to make: does Fido — the dog, not the phone — come too? The decision to bring your dog on a ski trip isn’t something you can decide spontaneously although it is becoming an easier decision to make as more hotels and other lodgings start to open their doors to people travelling with their pooch. Still, unless travelling with your pet is something you’re used to, there are a number of things you need to consider before you take your dog out of his/her comfort zone — not to mention your own. Sean Palardy, the front office manager of Tremblant’s Westin Resort & Spa, has seen a lot in terms of what checks in and out. He estimates that half of all Westin guests travelling with their dog for the first time are not familiar with house rules and regula-

Doctor’s Review • FEBRUARY 2014

tions, and are surprisingly unaware of the fastidious attention that having a dog on vacation demands. For example, a standard rule is that dogs generally cannot be left alone in hotel rooms. According to Palardy, owners who claim their dogs never bark or cause a ruckus don’t realize that taking their dogs out of their homes and leaving them in a strange place even for a short while might very well be like “the first day you brought your dog home from a shelter.” I remember the first time I travelled with my dog, Sambuca. It wasn’t so much a baptism-by-fire experience, but it was an adjustment. Suddenly, the places I could frequent without a moment’s notice were noticeably harder to get to. Even stepping out of my hotel room to get ice down the corridor proved to be problematic: I heard her whimpering the moment I left the room. Once the reality of “travelling with dog”

and ski set in, I was good to go — and far more prepared the next time. Now, like the famously coined credit-card slogan, I don’t leave home without her. Perhaps the most important thing you need to know about any ski destination including Tremblant is whether the resort is dog-friendly. It’s one thing if you can find a place at the ski hill that accepts dogs, but if you can’t take your dog anywhere once you’re at the resort, what’s the point? Tremblant, with its picturesque pedestrian village sitting at the mountain’s base, is actually quite conducive to having a dog by your side. You can take walks anywhere in the village as long as he or she is on a leash. Some boutique owners will even allow your dog to enter their store, especially on exceptionally cold days. Dogs are not allowed on either of the gondolas for security reasons (there’s the village

The pedestrian village in Quebec’s Mont-Tremblant welcomes dogs as long as your four-legged friend is on a leash.

gondola known as the Cabriolet and the main one that takes you up to the summit). The mountain, considered part of the National Park and incidentally home to wildlife, is naturally off limits to canines. There are, however, trails that you can take at the entrance of the village to walk, snowshoe or cross-country ski with your dog for miles. On a recent trip, I took Sambuca for a walk on one of Tremblant’s golf courses where she had her first ever encounter with some prancing deer. Tremblant also has a variety of options where staying with your dog is concerned. Many property owners who privately rent their units accept dogs, while some property managers don’t advertise that they do, but will if prompted by a potential guest. Here are four establishments that are forthright about their dog friendliness.

CLOCKWISE: The Fairmont Tremblant accepts dogs, but pooches are not allowed in the pool. Le Westin features 122 rooms, but only certain units are dog-friendly so families plus Fido must reserve in advance. The holidays floored three-year-old Umi, the Fairmont Tremblant’s canine ambassador. The Westin’s Heavenly Beds aren’t limited to humans; your pooch can sleep on one too. Rendez-Vous rents out private condos and homes with up to four bedrooms.

It’s one thing if you find a place that accepts dogs, but if you can’t take your dog anywhere at the resort, what’s the point? LE WESTIN RESORT AND SPA tel: 819-681-8000; westin.com/tremblant Suites start at $199 a night, double/quad occupancy, Sundays to Thursdays; $239 Fridays to Saturdays Dog fee $35 per night, cleaning fees may apply in case of damages

Le Westin, located in the pedestrian village at the base of the mountain, accepts dogs that weigh up to 18 kilograms. That means if you show up at the front desk with a Marmaduke, your Great Dane will likely spend the night in the hotel’s garage. Because only certain units on a particular floor are dog-friendly, it’s imperative that you reserve in advance. The units available to visitors with dogs are guest rooms and one-bedroom suites that sleep up to four people. The Westin’s world-renown Heavenly Beds aren’t limited to humans; your dog will have his own Heavenly Dog Bed too, plus other treats, including a Westin dog-tag, waiting for him in his room. Despite the hotel’s firm dog policy, Revenue Manager Rhakiya Taylor notes that demand is up. During a typical weekend stay, an average of six dogs is likely to check-in with their owners.

18 kilos are accepted at Rendez-Vous. Whether the dog is left alone in the unit while the family goes off to ski for the day or out for supper at night is left to the discretion of the guest. What’s more, RendezVous provides doggie beds, bowls, treats and toys in all dog-friendly units. “Families that travel with their dogs are usually responsible and their dogs are used to travelling,” said Lori. “They also appreciate the fact they’re able to bring their dogs with them on vacation, so they’re careful.” In the 12 years that Lori has been running Rendez-Vous, there’s only been two incidents in which a carpet or sofa had to be thoroughly cleaned at the end of a stay. It’s no surprise that many of her guests are repeat visitors.

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RENDEZ-VOUS MONT-TREMBLANT tel: 866-429-5111; rvmt.com One-bedroom units start at $139 a night during low season; $399 high season Dog fee $65 per stay, $1000 security deposit in case of damages

Looking for something a little more rustic, homey and further away from the village? Rendez-Vous is a lodging outfitter that manages the renting out of privately owned homes and condos of all sizes and categories in and around the resort. Rendez-Vous was one of the first, if not the first, property management companies in the area to offer pet-friendly units. Over the years, owner Lori Donaldson has seen this part of the business grow as “more and more guests want to bring their dogs with them on vacation.” Not surprisingly, Lori brings her dog, Rufus, to work everyday. Non-shedding dogs that weigh up to

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 For important information on contraindications, warnings, precautions,

adverse reactions, interactions, dosing, and conditions of clinical use, please consult the product monograph at www.DEXILANT.ca/PM. The product monograph is also available by calling us at 1.866.295.4636. * Comparative clinical significance has not been established. DEXILANT® and Dual Delayed Release® are registered trademarks of Takeda Pharmaceuticals U.S.A., Inc. and used under license by Takeda Canada Inc. ©2014 Takeda Canada Inc.

FEBRUARY 2014 • Doctor’s

Review

The Domaine Summum has rentable units spread out across 80 hectares of country land and offers dog-boarding services too.

FAIRMONT TREMBLANT tel: 819-681-7000; fairmont.com/tremblant Rooms start at $199 a night, double occupancy, during low season; $299 high season Dog fee $35 per night

The Fairmont, situated at the top of the pedestrian village, is the other resort hotel that accepts dogs. Its dog policy is similar to that of the Westin in that dog-specific units are on the same floor and you can’t leave your dog alone in a room or anywhere in the hotel for that matter. It goes without saying that dogs are not allowed in any of the restaurants or the swimming-pool area. The Fairmont doesn’t have a dog-size limit and advance booking isn’t required, but it’s always recommended. What makes the Fairmont Tremblant unique is their charismatic canine ambassador, Umi. Umi is a trained, three-year-old Guide Dog, who meets and greets guests as they arrive. Umi is so popular that his hours are roughly 9am to 5pm Mondays to Fridays. Guests who want to walk him

CANINE Q&A

Rendez-Vous Mont-Tremblant rents out private condos and homes with up to four bedrooms in and around the resort.

around the village can book his services, free of charge, for 30 minutes at a time at the concierge desk.

DOMAINE SUMMUM tel: 819-681-7539; domainesummum.com Four-person suites start at $163 a night, double occupany, during low season; $220 high season Dog fee for up to two pets included; kennel fee extra

For something even more off the beaten path and about a 15-minute drive from the mountain, there’s Domaine Summum. In addition to running a fullfledged kennel and breeding Bernese Mountain Dogs, owner Birgit Schulze has a handful of units she rents out to guests with dogs. She owns a lovely spread of land and lake, idyllic for walking, snowshoeing and cross-country skiing. If you’re staying at the hill with your dog, but want to take a day off from skiing to go to the city for shopping, leaving your dog at the Summum’s kennel is an option. For Spring Break deals and packages for the first three establishments, go to tremblant.ca.

What to ask when researching where to go n n n n n n n n

Does the ski resort welcome dogs? How many hotels/properties in the area are dog-friendly? Does your dog’s size, fur and overall disposition meet the standards of the hotel/property policies? What is the dog fee and security deposit, if any? Is the entire family skiing or will someone be able to stay with the dog during the day? If everyone is skiing, are you allowed to leave your dog alone in the unit? Are you allowed to leave the dog in a crate while the whole family goes out for, say, supper? If you’re going to leave your dog alone a lot, is it worth the extra cost and worry to bring him/her in the first place? Doctor’s Review • FEBRUARY 2014

C ac onf ce ere ss nc co e l de ist : d ing rc s m e

MEDICINE ON THE MOVE

We asked... How

many hours of sleep do Canadian MDs get a night? Survey says:

57.7%

more than 8 hours 8 hours 10.3%

28.7%

6â&#x20AC;&#x201C;7 hours less than 6 hours

3.3%

Are some of those hours spent dreaming of spring? Enter to win a $100 Lee Valley Tools gift card at doctorsreview.com/meetings. Once there, register or use access code drcme to get to the contest ballot, which will be at the top of the medical meetings page. Source: Doctorâ&#x20AC;&#x2122;s Review, January 2009.

Size doesn’t he next time you order a pizza, be sure to tell your server “don’t hold the anchovies.” Even if you have to hold your nose, the time is now to consume this rich, pungent fish before we lose it altogether. Never mind that hundreds of millions of tonnes of the critters are caught each year, fishmongers are finding it difficult, even impossible, to get any at all. “We get asked all the time for anchovies,” said Dylan McCulloch, co-owner of Vancouver’s Daily Catch (1418 Commercial Drive; tel: 604-253-3474; dailycatch.org). “I’ve called all my suppliers, but we can’t get them.” Instead of served up freshly grilled on toast or salted and cured in olive oil for making fragrant tomato sauce, the plentiful stocks of anchovies that are caught each year are turned into fishmeal to feed livestock and farmed fish or, given their high omega-3 content, processed for fish-oil supplements.

Majluf is ready to bring the anchoveta to North America — it could solve a problem for shops in Toronto It’s no wonder: in a world dominated by bland farmed salmon and ho-hum shrimp, most of us have forgotten to enjoy the anchovy in all its olfactory glory. But now a small group of fans is trying to resurrect a centuries-old tradition of dining on this oily and

Doctor’s Review • FEBRUARY 2014

nutritious seafood. Some, like chef Lee Humphries, have overcome a childhood hatred of the tinned fish. Raised in northern England, the former chef of Vancouver’s C Restaurant (2-1600 Howe Street; tel: 604681-1164; crestaurant.com), used to buy as much northern Pacific anchovies as he could from small BC fisheries during the brief midsummer season each year. He and his staff then cleaned, processed, cured and packed the year’s worth of stock as soon as the catch — mainly fished for bait — was in. “It’s a labour of love,” Humphries once said, “but the anchovy is the perfect seasoning. It’s not fishy, but clean tasting.” The northern Pacific anchovy is prized among some chefs for its superior flavour, but not all anchovies are created equal. There’s the European anchovy from Spain, Italy and Portugal. Usually packed in oil or salt, it’s a less odorous specimen, appreciated locally and abroad. When salt-cured and marinated in vinegar to produce a milder flavour, it becomes the so-called white anchovy, named for its colour. But by far the most common species is the lowly anchoveta from Peru, which, due to years of industrial fishing and cheap processing, gained a reputation as a foul-smelling turnoff. “It tasted bad, looked bad and was badly packed,” said marine conservationist and Peru native Patricia Majluf. Majluf directs the Centre for Environmental Sustainability at the Cayetano Heredia University in Lima and is leading a collaboration with the Fisheries Centre

matter at the University of British Columbia to bring the fish back to the table. Working with an international network of producers, environmentalists, fishmongers and chefs, the plan is to produce a premium product that will change public sentiment and rejuvenate small-scale fisheries in Peru. Processing is key; the fish are salted and put in a barrel to cure for six months. The result is far from malodorous. “They look and taste more like sardines, and a lot of people say when you open the can no one can tell they’re anchovies,” she said. Peru once had the world’s biggest fishery, the anchovy industry, but overfishing nearly destroyed it. Even today, quotas need constant assessment to ensure stocks replenish. “We need to fish less anchovy and send more just for us [instead of for feed],” said Majluf. It was impossible to get anchoveta in Peru for decades, however, because all of it went to fishmeal and supplements. But in the six years since bringing quality anchoveta to the public, Majluf has seen an increase in demand. Chef Gastón Acurio is an enthusiast. A culinary ambassador with dozens of Peruvian restaurants around the world — Astrid y Gastón in Lima made S. Pellegrino’s 2013 list of the top 50 restaurants in the world — he’s a vocal champion, serving it as tapas or in appetizers like olives stuffed with anchovy. Majluf estimates that about two percent or 200,000 tonnes of Peruvian anchovies are now reserved for human consumption. “It’s very little, but when you look at it in terms of global marine catches, we managed to make this change very quickly.” Majluf is ready to bring the anchoveta to North America — and it could solve a problem for Dan Donovan of the Hooked fish shop (two locations, 888 Queen Street East and Baldwin Street; tel: 416-8281861/551-2755; hookedinc.ca) in Toronto. Donovan loves anchovies but finds it difficult to get his hands on them, particularly because his shop, like C Restaurant and the Daily Catch, only sells

Anchovies may be small, but they’re leaving more and more people satisfied by

Pamela Cuthbert

As the founding restaurant of the Vancouver Aquarium’s Ocean Wise Program, C is committed to using sustainable seafood and local ingredients.

responsibly sourced seafood. European anchovies are often on “not recommended” lists by watchdogs like Ocean Wise (oceanwise.ca), a Vancouver Aquarium conservation program that educates consumers about sustainable seafood. (Donovan occasionally stocks European anchovies from sustainable supplies.) Although Donovan knows “it’s hard to have feelings for an anchovy,” he urges clients to challenge their taste buds and give it a try. Given that reports now show that farmed fish is on the brink of eclipsing wild-caught fish for human diets — and those cultivated species need unsustainable amounts of wild-caught fish to grow — it may be time we start eating closer to the source. Once you’ve tried it, you realize it’s crazy to eat the farmed flesh when you can simply relish the singular anchovy. FEBRUARY 2014 • Doctor’s

Review

ONE BOTTL E by

James Nevison

Seeing red Researchers from the University of Adelaide in South Australia recently launched the first searchable database of the world’s wine grape plantings.1 A quick browse reveals that Cabernet Sauvignon is now the most widely planted grape variety, and indeed since 1990 both Cabernet Sauvignon and Merlot have more than doubled their acreage under vine. This makes them the top two cultivated grape varieties in the world, and it goes to show that despite talk of quirky cultivars and happening indigenous grapes, the tried-and-true still rule the vineyards. The research — which spanned 521 wine regions across 44 countries and 1271 different grapes — also found that the balance of red versus white plantings continues to stack in red’s favour. At the turn of the millennium white grapes outnumbered red, but now red grapes represent 55 percent of the world’s total vineyard acreage. Grapes may be an agricultural product, but wine is still a luxury item and therefore subject to trends and fads just as any fashionable good. Growers have their ear to the tasting room, and more and more consumers have been clamouring for red wine. Whether it’s because of its associations with the height of wine sophistication or a quest to ingest more heart-healthy antioxidants, it’s hip to drink red. And Cabernet Sauvignon, thanks to its historical pedigree and naturally thick skins and hearty pips, hits all the right notes. Given the abundance of Cabernet Sauvignon planted around the wine world, it’s no stretch to say that there’s a Cab Sauv for all tastes — and budgets. If value is on the mind, check out Santa Carolina’s Reserva Estate Cabernet Sauvignon. Made predominantly from old vine fruit grown at the Chilean winery’s Miraflores Vineyard in the Colchagua Valley, it offers classic Cab cassis and herbaceous tones. It’s an easy style to get into: relatively rich and ripe yet with enough structure and a dry, almost savoury finish. For food matches, consider roast pork or a pot of chili.

Where to find it Santa Carolina Reserva Estate Cabernet Sauvignon is available across Canada, priced from $12.95–14.25.

James Nevison is a wine writer and educator based in Vancouver. The 2014 edition of his bestselling wine guide, Had a Glass: The top 100 wines under $20, is available at all major booksellers. Visit hadaglass.com to learn more.

1. Anderson, K. and N. Aryal. “Database of Regional, National and Global Winegrape Bearing Areas by Variety, 2000 and 2010.” Wine Economics Research Centre, University of Adelaide, December 2013.

Doctor’s Review • FEBRUARY 2014

Shakshuka.

Crowd pleasers Dishes your kids will love by busy Toronto moms recipes by

Laura Keogh

and

Ceri Marsh

photos by

Maya Visnyei

or years, dinner meant hors d’oeuvres and champagne for Laura Keogh and Ceri Marsh. Life as long-time fashion-magazine editors will do that to some folks. Both women had always reported on

health and nutrition, and when they had kids around the same time, their old casual relationship with cooking just wouldn’t do. The Toronto-based journalists dug into research, interviewed experts and gave birth of another kind to Sweet Potato Chronicles (sweetpotatochronicles.com), a website about families and food. Then, late last year, How to Feed a Family (Appetite by Random House) was born.

The cookbook’s design is clean yet playful; the food photography makes you want to lick the pages; and the 100 recipes are fast and unfussy, and use ingredients readily available at your grocery store. The book will easily become a go-to companion in the kitchen — but then we wouldn’t expect any less from authors with a background in, ahem, print magazines. Here’s what we plan to make in our own kitchens, kids or not. FEBRUARY 2014 • Doctor’s

Review

SHAKSHUKA Shakshuka is the kind of recipe that starts fights in the comments section of food blogs. It’s Tunisian. No, it’s Libyan! It’s absolutely Israeli. Never add feta. My mother always uses feta! Apologies in advance: this version of zesty tomato sauce topped with poached eggs is not traditional. But it’s so delicious, takes half an hour to make and you probably have all the ingredients in your kitchen right now. Prep time: 5 minutes Total time: 30-35 minutes 2 tbsp. (30 ml) olive oil 1 onion, diced quite fine 3 or 4 garlic cloves, minced 1 tsp. (5 ml) paprika ½ tsp. (2.5 ml) ground cumin chili flakes (optional) 1 can (28 oz./796 ml) whole tomatoes 1 tbsp. (15 ml) tomato paste salt and pepper

6 eggs ¼ c. (60 ml) crumbled feta handful of chopped basil or parsley

Shimmy a big serving spoon under each egg to scoop them out of the pan. Serve with crusty bread and steamed vegetables. Makes 4 servings.

Heat the olive oil in a large, high-sided frying pan over medium heat. Add the onion and garlic, and let them become really soft and begin to brown. Add the paprika, cumin and a pinch of chili flakes, and stir. Let the spices cook for about 3 minutes. Pour the tomatoes and tomato paste in, and use a potato masher to gently break them up. Allow the sauce to simmer for about 20 minutes, until it becomes quite thick. Taste, and add salt and pepper accordingly. Use the back of a wooden spoon to spread the sauce evenly across the frying pan. Gently crack the eggs, say, five in a circle around the pan and one in the centre, over the sauce. Cook the eggs for 6 to 7 minutes. Cover it all for the last minute if you like the tops of your eggs quite set. Crumble the feta and basil or parsley overtop.

from our dietitian Eggs offer one of the most biologically available proteins, and are rich in choline, lutein and zeaxanthin as well as vitamins A, D, E and B12. Their cholesterol content has been much maligned, but in recent years the cholesterol per yolk has dropped significantly to 195 grams. Studies suggest that eating one egg daily isn’t related to an increased risk of heart disease. Hens fed flax seeds produce eggs that are a good source of omega-3 fatty acids and contain more vitamin E. Still worried you’re consuming too many eggs? Instead of two whole eggs, eat one whole and one egg white, or replace one whole egg with two whites. Alternatively, choose a low-fat liquid egg that contains omega-3 fats. [Kim N. Arrey]

SHRIMP WITH BACON AND POLENTA If you keep polenta in the cupboard and shrimp in the freezer — and you should, on both counts — you can arrive home at the end of the day with no plan for dinner and still have something amazing on the table in less than half an hour. Prep time: 15 minutes Total time: 25 minutes

5 c. (1.25 L) water 1 c. (250 ml) instant polenta 2 tbsp. (30 ml) olive oil 6 slices of bacon, chopped into bite-size pieces 2 garlic cloves, minced 1 can (28 oz./796 ml) whole tomatoes 1 lb. (450 g) fresh or thawed frozen shrimp, peeled, deveined and washed small handful of parsley

Bring the water to a boil and slowly pour in the polenta. Bring the heat right down. Keep stirring and cook the poShrimp with bacon and polenta.

ZUCCHINI BREAD Prep time: 20 minutes Total time: 1 hour 20 minutes ½ c. (375 ml) all-purpose flour 1 ¾ c. (180 ml) whole-wheat flour ¼ c. (60 ml) wheat bran 1 tsp. (5 ml) salt 1 tsp. (5 ml) baking powder 1 tsp. (5 ml) baking soda 1 tsp. (5 ml) ground cinnamon ½ tsp. (2.5 ml) ground nutmeg 2 eggs ½ c. (125 ml) granulated sugar ½ c. (125 ml) Greek yogurt ¼ c. (60 ml) vegetable oil 2 tsp. (10 ml) vanilla extract 2 c. (500 ml) grated zucchini ½ c. (125 ml) grated carrot 1 c. (250 ml) raisins ½ c. (125 ml) chopped dried apricots ½ c. (125 ml) chopped pecans

Zucchini bread.

lenta for 3 to 5 minutes. Remove from the heat and cover the pot. Heat the olive oil in a large frying pan over medium heat, then add the bacon. Cook for a few minutes until the bacon is brown, but not crispy. Add the garlic and cook for minute or so. Add the tomatoes and gently break them up with a potato masher. Allow the sauce to simmer for 15 minutes, or until it begins to thicken. While the sauce is bubbling away, get your shrimp ready. Peel off the shells and tails (left on for the recipe photo since they make shrimp look more shrimpy). If they’re not already deveined, take a small, sharp knife and run it down the back of the shrimp. Make a very shallow cut and use the tip of your knife to pull out the vein. Rinse all the shrimp under cold water to be sure they’re clean. Drain well. Put the shrimp into the simmering sauce and stir. They’ll cook quickly, about 3 minutes. Give your polenta another stir. You may need to add a splash of warm wa-

ter to loosen it up. Create a nest of polenta on a plate and then ladle the saucy shrimp onto it. Sprinkle parsley on top. Makes 4 servings.

from our dietitian Shrimp are nutritious, but many people avoid them due to their reputed high cholesterol and link to heart disease; a 120-gram portion contains about 250 milligrams of cholesterol. But shrimp contain other sterols linked to lower levels of HDL cholesterol. They also contain the hard-to-find DHA and EPA as well as a great balance of omega-3 and omega-6 fats. Astaxanthin, which is a carotenoid, is also in shrimp. It works as an anti-inflammatory and has been associated with lower rates of colon cancer. The bad news in this recipe is the bacon (lots of sodium and saturated fat). Use back bacon or lean ham instead. [KNA]

Preheat the oven to 350°F (180°C). Lightly grease a 9- x 5-inch (23- x 13cm) loaf pan. In a large bowl, whisk together both flours, the wheat bran, salt, baking powder, baking soda, cinnamon and nutmeg. In another bowl, mix together the eggs, sugar, yogurt, oil and vanilla. Add the dry mixture to the wet and combine. Stir in the zucchini, carrot, raisins, apricots and pecans until everything is evenly distributed throughout the batter. Pour the batter into the prepared loaf pan. Bake for 50 to 60 minutes or until a toothpick inserted in the centre comes out clean. Cool in the pan for 15 minutes before turning the loaf out onto a rack to cool completely. Loaf will keep in an airtight container or wrapped in plastic wrap for 1 week. Makes 1 loaf or 6 mini loaves.

Recipes and photos from How to Feed a Family (Appetite by Random House). FEBRUARY 2014 • Doctor’s

Review

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Doctor’s Review • FEBRUARY 2014

Spin doctors uu CONTINUED FROM PAGE 43

provides quick, sleek transport to stops all over Disneyland, even running right through the lavish Grand Californian, the hotel I stayed at this time around. Officially called the Disneyland Resort these days, the theme park has three distinct sections. Downtown Disney is a large shopping, dining and entertainment district that runs down a multi-block pedestrian mall to the park entrance. Here I passed many stores devoted to princesses and pirates as well as the best Lego store I’ve ever seen (there’s a huge Lego dragon hanging over it). Along with 16 different eateries, the nightclubs, bars and cafes stay open late to assuage deprived grown-ups. The Grand Californian hotel faced the pedestrian mall on one side (where a harpist played “Hotel California” under my balcony), and the theme park on the other; the midcentury Mad Men-flavoured Disneyland Hotel was just down the street. In May, purple-flowered jacaranda trees were blooming and the sidewalks were lined with Bird of Paradise flowers. The two parks, the original Disneyland and California Adventure, make up the other two sections. A naturally indecisive person, I found choosing between the parks a little dizzying, a feeling that intensified when I realized they together contain 92 “attractions,” the catchall term for rides, shows and exhibits. Then there’s the not-so-small issue of crowds. In 2012, over 20 million people visited — a number which works out to around 55,000 people every day — with unbearably more on holidays and weekends. This is where a little advance planning comes in. You can try something I neglected to, which is to check the Internet before leaving home; as one can imagine, there are websites and online guides galore with tips on making the most of the House of Mickey. Once onsite, there are the handy Fast Passes (entry at a specific time, tickets are distributed via terminals near the entrance to each attraction that uses them), as well as single-rider entries (I got to skip line-ups because of my fifth-wheel status).

And the relatively new Disability Access Services (DAS) card has replaced the Guest Assistance card to weed out the disturbing all-too-common scams — like large families renting wheelchairs to jump the lines. If you don’t mind spending more, there are also reservation services for stage shows and events, along with fancy VIP services providing extras for additional cost. Over the three days I spent in the two theme parks, I learned to arrive within an hour of opening (usually 8am) and make the most of the late afternoon, when strollers carrying sleeping toddlers mass for the exits. Almost all the kids I saw wore expressions that ranged from ecstasy to glee, but if you’re taking a smaller child, it’s worth considering their reactions to the unexpected. While scarier, more intense attractions have height restrictions that put them off limits, a lanky five-year old can still clamber onto a surprising number of thrill-seeking rides. Even many of the more sedate attractions feature intervals of speed, darkness or unexpected noise, never mind the frights or sights that may be part of the attraction’s storyline. Disney posts advisories (they helped me avoid vertigo after lunch), and there are always gentler activities to choose from. I lounged on the Mississippi Queen (a paddleboat treading the Disneyland lagoon), hung out with Goofy in nearby Toontown (the home of many familiar Disney characters), and even revisited American literature at California Adventure park’s Pacific Wharf, a seafood-filled homage to Cannery Row, writer John Steinbeck’s 1945 novel on the sardine fishery. Walt Disney once said that he wanted to create a place of “unconditional fun,” an escape where “age relives fond memories of the past, and youth has the chance to savour the future.” I doubt he would have any trouble recognizing his creation today, as Disneyland in 2014 still adheres to his vision, mixing kid culture and folksy nostalgia with science and state-of-theart futurism, while making it look like child’s play — all of it conjured with the make-believe and magic only the mouse provides.

Oral, Inactivated Travellers’ Diarrhea and Cholera Vaccine Oral Suspension Recombinant cholera toxin B subunit (rCTB) 1 mg Active Immunizing Agent for the Prevention of Travellers’ Diarrhea Caused by Enterotoxigenic Escherichia coli and/or caused by Vibrio cholerae

PRESCRIBING SUMMARY IMPORTANT: Before making prescribing decisions, please refer to complete Product Monograph. Request a hard copy from Crucell Vaccines Canada, a division of Janssen Inc. at 1-800-567-3331 or 1-800-387-8781.

Patient Selection Criteria INDICATIONS AND CLINICAL USE DUKORAL® [Oral, Inactivated Travellers’ Diarrhea and Cholera Vaccine] is indicated for the prevention of and protection against travellers’ diarrhea (TD) and/or cholera in adults and children 2 years of age and older who will be visiting areas where there is a risk of contracting TD caused by enterotoxigenic Escherichia coli (ETEC) or cholera caused by V. cholerae. Onset of protection against ETEC diarrhea and cholera can be expected about one week after the primary immunization series is completed.

CONTRAINDICATIONS

Hypersensitivity to any component of DUKORAL® [Oral, Inactivated Travellers’ Diarrhea and Cholera Vaccine], or its container, to formaldehyde, or an anaphylactic or other hypersensitivity reaction to a previous dose of DUKORAL® is a contraindication to vaccination. Immunization with DUKORAL® should be deferred in the presence of acute gastrointestinal illness or acute febrile illness to avoid superimposing adverse effects from the vaccine on the underlying illness or mistakenly identifying a manifestation of the underlying illness as a complication of vaccine use. A minor illness such as mild upper respiratory infection is not reason to defer immunization.

Safety Information WARNINGS AND PRECAUTIONS

General: DO NOT ADMINISTER THIS VACCINE PARENTERALLY. THIS VACCINE MUST BE TAKEN ORALLY (BY MOUTH) AFTER MIXING IT WITH THE BUFFER SOLUTION. Before administration, take all appropriate precautions to prevent adverse reactions. This includes a review of the patient’s history concerning possible hypersensitivity to the vaccine or similar vaccines, previous immunization history, the presence of any contraindications to immunization and current health status. DUKORAL® contains approximately 1.1 g sodium per dose, which should be taken into consideration by patients on a controlled sodium diet. Before administration of the vaccine, health-care providers should inform the patient, parent or guardian of the benefits and risks of immunization, inquire about the recent health status of the patient and comply with any local requirements regarding information to be provided to the patient before immunization. Patients should be advised on the importance of taking the vaccine correctly (mixed with buffer and at dosing intervals of at least one week) and completing the immunization series at least one week before departure to achieve optimal protection. Gastrointestinal: As with any vaccine, immunization with DUKORAL® [Oral, Inactivated Travellers’ Diarrhea and Cholera Vaccine] may not protect 100% of susceptible persons. Thus, travellers should use care in the choice of food and water supply and use good hygienic measures. Immune: Immunocompromised

persons (whether from disease or treatment) may not obtain the expected immune response. If possible, consideration should be given to delaying vaccination until after the completion of any immunosuppressive treatment. DUKORAL® can be given to HIV-infected persons. Clinical trials have shown no vaccine-associated adverse events and no change in disease clinical progression. Limited data are available on immunogenicity and safety of the vaccine. Vaccine protective efficacy has not been studied among HIV-infected persons. However, in a field study in Mozambique the protective efficacy was 84% in a population with approximately 25% HIV prevalence. Formaldehyde is used during the manufacturing process and trace amounts may be present in the final product. Caution should be taken in subjects with known hypersensitivity to formaldehyde. As with all products, the possibility of hypersensitivity reactions in persons sensitive to components of the vaccine should be evaluated. DUKORAL® confers protection specific to Vibrio cholerae serogroup O1. DUKORAL® has not been demonstrated to protect against cholera caused by V. cholerae serogroup O139 or other species of Vibrio. Neurologic: Potential Effect on Cognitive and Motor Performance: There is no evidence of an effect on the ability to drive and use machines.

SPECIAL POPULATIONS

Pregnant Women: The effect of DUKORAL® [Oral, Inactivated Travellers’ Diarrhea and Cholera Vaccine] on embryo-fetal development has not been assessed and animal studies on reproductive toxicity have not been conducted. No specific clinical studies have been performed to address this issue. The vaccine is therefore not recommended for use in pregnancy. However, DUKORAL® is an inactivated vaccine that does not replicate. DUKORAL® is also given orally and acts locally in the intestine. Therefore, in theory, DUKORAL® should not pose any risk to the human fetus. Administration of DUKORAL® to pregnant women may be considered after careful evaluation of the benefits and risks. Nursing Women: DUKORAL® may be given to breast-feeding women. Pediatrics: DUKORAL® has been given to children between 1 and 2 years of age in safety and immunogenicity studies, but the protective efficacy has not been studied in this age group. Therefore, DUKORAL® is not recommended for children less than 2 years of age. Geriatrics: DUKORAL® has been given to persons over the age of 65 in clinical trials, but there are only very limited data on protective efficacy of the vaccine in this age group. However, this group can be expected to be at risk of more severe complications of disease if infected by ETEC or cholera and therefore may obtain greater benefit from vaccination.

ADVERSE REACTIONS

The following is a summary of the ADVERSE REACTIONS section. For additional information see Supplemental Product Information. Adverse Drug Reaction Overview In clinical trials conducted in Bangladesh, Peru and Sweden, gastrointestinal symptoms were reported with similar frequency in vaccine and placebo groups. No serious adverse reactions were reported. Clinical Trial Adverse Drug Reactions The safety of DUKORAL® [Oral, Inactivated Travellers’ Diarrhea and Cholera Vaccine] was assessed in clinical trials, including both adults and children from 2 years of age, conducted in endemic and nonendemic countries for cholera and ETEC producing heat-labile enterotoxin (LT). Over 94,000 doses of DUKORAL® were administered during the clinical trials. Evaluation of safety varied between trials with respect to mode of surveillance, definition of symptoms and time of follow-up. In the majority of studies adverse events were assessed by passive surveillance. The most frequently reported adverse reactions occurred at similar frequencies in vaccine and placebo groups. These included gastrointestinal symptoms including abdominal pain, diarrhea, loose stools, nausea and vomiting. Post-Market Adverse Drug Reactions To report an adverse event or a side effect, contact Crucell Vaccines Canada, a division of Janssen Inc. Tel: 1-800-567-3331 or 1-800-387-8781 Fax: 1-866-767-5865

DRUG INTERACTIONS

Overview There are obvious practical advantages to giving more than one vaccine at the same time, especially in preparation for foreign travel or when there is doubt that the patient will return for further doses of vaccine. Most of the commonly used antigens can safely be given simultaneously, except for those administered orally. No increase in the frequency or severity of clinically significant side effects has been observed. The immune response to each antigen is generally adequate and comparable to that found in patients receiving these vaccines at separate times. Drug-Drug Interactions The administration of an encapsulated oral typhoid vaccine and DUKORAL® [Oral, Inactivated Travellers’ Diarrhea and Cholera Vaccine] should be separated by at least 8 hours. Oral FEBRUARY 2014 • Doctor’s

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administration of other vaccines and medicinal products should take place at least 1 hour before or at least 1 hour after DUKORAL® administration. DUKORAL® has been administered concomitantly with yellow fever vaccine to 55 subjects. The yellow fever antibody response was similar to that seen in the 58 subjects who received the yellow fever vaccine alone. However, no results are available to evaluate the safety of concomitant administration of the two vaccines or to evaluate the immune response to DUKORAL® when administered with yellow fever vaccine. Drug-Food Interactions The vaccine is acid labile. Food and/or drink will increase acid production in the stomach and the effect of the vaccine may be impaired. Consequently, food and drink must be avoided for 1 hour before and for 1 hour after vaccination. To protect DUKORAL® from the acidic stomach environment, it has to be mixed with buffer solution (supplied effervescent buffer granules dissolved in water).

Administration

2. Shake the vaccine vial (1 vial = 1 dose).

3. Add the vaccine to the sodium hydrogen carbonate solution. Mix well and drink the mixture. If the mixture is not drunk immediately it should be consumed within 2 hours of mixing. Keep it at room temperature. Missed Dose: If the 2nd or 3rd dose is missed, it can be taken at any time within six weeks of the previous dose. Food and drink must be avoided for 1 hour before and 1 hour after.

Study References

DOSAGE AND ADMINISTRATION

TO PREVENT TRAVELLERS’ DIARRHEA CAUSED BY ETEC: Primary Immunization for adults and children 2 years and older: • 2 oral doses at least 1 week apart. • 1st dose at least 2 weeks before departure. • 2nd dose at least 1 week after the 1st dose and at least 1 week before departure. • Protection against traveller’s diarrhea caused by ETEC starts about 1 week after the 2nd dose and will last for about 3 months. • If more than 6 weeks elapse between the 1st and 2nd dose, the primary immunization should be re-started. Booster for adults and children 2 years and older: • If the patient received the last dose between 3 months and 5 years before, one booster dose will be sufficient to renew the protection. • If the patient received the last dose more than 5 years before, a complete primary immunization (2 doses) is recommended to renew the protection. TO PREVENT CHOLERA: Primary Immunization for adults and children 6 years and older: • 2 oral doses at least 1 week apart. • 1st dose at least 2 weeks before departure. • 2nd dose at least 1 week after the 1st dose and at least 1 week before departure. • Protection against cholera starts about 1 week after the second dose and will last for about 2 years. • If more than 6 weeks elapse between the 1st and 2nd dose, the primary immunization should be re-started. Booster for adults and children 6 years and older: • If the patient received the last dose between 2 and 5 years before, one booster dose will than 5 years before, a complete primary immunization (2 doses) is recommended to renew the protection. Primary Immunization for children 2 to 6 years: 3 oral doses at least 1 week apart and finishing at least 1 week before departure. • 1st dose at least 3 weeks before departure; 2nd dose at least 1 week later; 3rd dose at least 1 week later and at least 1 week before departure. • Protection against cholera starts about 1 week after the 3rd dose and will last for about 6 months for children 2 to 6 years. • If more than 6 weeks elapse between any of the doses, the primary immunization should be re-started. Booster for children 2 to 6 years: • If the patient received the last dose between 6 months and 5 years received the last dose more than 5 years ago, a complete primary immunization (3 doses) is recommended to renew the protection. Important Information about Taking DUKORAL®: Do not eat or drink for 1 hour before and 1 hour after taking the vaccine. Do not take any other medicine for 1 hour before and 1 hour after taking the vaccine. Use only cool water to prepare the buffer solution to which the vaccine is added (see ‘How to Prepare DUKORAL®.’ below). Do not use any other liquid. How to Prepare DUKORAL®: Prepare the buffer solution and add the vaccine according to the directions below. 1. Open the buffer sachet and dissolve the effervescent granules (sodium hydrogen carbonate) in 5 oz. (approx. 150 ml) of cool water. Children 2-6 years: pour away half of the solution.

SUPPLEMENTAL PRODUCT INFORMATION ADVERSE REACTIONS Clinical Trial Adverse Drug Reactions Frequency Classification: Very Common: ≥1/10 (≥10%) Common (Frequent): ≥1/100 and <1/10 (≥1% and <10%) Uncommon (Infrequent): ≥1/1,000 and <1/100 (≥0.1% and <1%) Rare: ≥1/10,000 and <1/1,000 (≥0.01% and <0.1%) Very Rare: <1/10,000 (<0.01%), including isolated reports Metabolism and Nutrition Disorders: Rare: Loss of or poor appetite Very Rare: Dehydration Nervous System Disorders: Uncommon: Headache Rare: Dizziness Very Rare: Drowsiness, insomnia, fainting, reduced sense of taste Respiratory, Thoracic and Mediastinal Disorders: Rare: Respiratory symptoms (including rhinitis and cough) Gastrointestinal Disorders: Uncommon: Diarrhea, abdominal cramps, abdominal pain, stomach/abdominal gurgling (gas), abdominal discomfort Rare: Vomiting, nausea Very Rare: Sore throat, dyspepsia Skin and Subcutaneous Tissue Disorders: Very Rare: Sweating, rash Musculoskeletal and Connective Tissue Disorders: Very Rare: Joint pain General Disorders and Administration Site Conditions: Rare: Fever, malaise Very Rare: Fatigue, shivers Post-Market Adverse Drug Reactions Additional adverse reactions reported during post-marketing surveillance are listed below. Blood and lymphatic system disorders: Lymphadenitis Gastrointestinal disorders: Flatulence General disorders and administration site conditions: Pain, flu-syndrome, asthenia, chills Infections and infestations: Gastroenteritis Nervous system disorders: Paraesthesia Respiratory thoracic and mediastinal disorders: Dyspnoea, increased sputum Skin and subcutaneous tissue disorders: Urticaria, angioedema, pruritus Vascular disorders: Hypertension

ACTION AND CLINICAL PHARMACOLOGY

Pharmacodynamics In clinical trials DUKORAL® has been shown to prevent TD caused by enterotoxigenic E. coli and cholera caused by V. cholerae O1 (classical and El Tor biotypes). Protection against ETEC diarrhea and cholera can be expected to start about one week after the primary immunization series is completed.

DURATION OF EFFECT

Effect on Cholera: Clinical results have revealed a protective efficacy against cholera of 80-85% for the first six months in all age categories. In adults and children over the age of 6, protective efficacy over a 3-year followup period averaged about 63% (without a booster dose). Children under the age of 2 were not examined, but protective efficacy in the 2-6 year age range was satisfactory for the first six months. Effect on ETEC: Protective efficacy with reference to all TD will vary depending on the prevalence of ETEC. There are considerable variations between different seasons and geographic areas. Protective efficacy against ETEC lasts about 3 months.

OVERDOSAGE Data on overdose are limited. Adverse reactions reported are consistent with those seen after the recommended dosing. For management of a suspected drug overdose, contact your regional Poison Control Centre. Product Monograph available from Crucell Vaccines Canada, a division of Janssen Inc. at 1-800-567-3331 or 1-800-387-8781.

Manufactured by: Crucell Sweden AB 105 21 Stockholm, Sweden Imported and Distributed by: Crucell Vaccines Canada, a division of Janssen Inc. Toronto, Ontario M3C 1L9

Doctor’s Review • FEBRUARY 2014

Oxycodone hydrochloride controlled release tablets 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, 60 mg, and 80 mg

Prescribing Summary IMPORTANT: Before making prescribing decisions, please refer to the complete Product Monograph at www.Purdue.ca or request a hard copy from Pharmacovigilance and Product Information Service of Purdue Pharma at 1-800-387-4501.

Patient Selection Criteria THERAPEUTIC CLASSIFICATION: Opioid Analgesic INDICATIONS AND CLINICAL USE Adults: OxyNEO (oxycodone hydrochloride controlled release tablets) is indicated for the relief of moderate to severe pain requiring the continuous use of an opioid analgesic preparation for several days or more. ®

Geriatrics (> 65 years of age): In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, concomitant disease or other drug therapy (see DOSAGE AND ADMINISTRATION). Pediatrics (< 18 years of age): The safety and efficacy of OxyNEO® has not been studied in the pediatric population. Therefore the use of OxyNEO® is not recommended in patients under 18 years of age. CONTRAINDICATIONS OxyNEO (oxycodone hydrochloride controlled release tablets) is contraindicated in: • Patients who are hypersensitive to the active substance (oxycodone) or other opioid analgesics or to any ingredient in the formulation. For a complete listing, see the DOSAGE FORMS, COMPOSITION AND PACKAGING section of the Product Monograph • In patients with known or suspected mechanical gastrointestinal obstruction (e.g, bowel obstruction, strictures) or any diseases/conditions that affect bowel transit (e.g., ileus of any type) • Patients with suspected surgical abdomen (e.g., acute appendicitis or pancreatitis) • Patients with mild, intermittent or short duration pain that can be managed with other pain medications • The management of acute pain ®

• Patients with acute asthma or other obstructive airway, and status asthmaticus • Patients with acute respiratory depression, elevated carbon dioxide levels in the blood, and cor pulmonale • Patients with acute alcoholism, delirium tremens, and convulsive disorders • Patients with severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury • Patients taking monoamine oxidase (MAO) inhibitors (or within 14 days of such therapy) • Women who are breast-feeding, pregnant, or during labour and delivery

Safety Information WARNINGS AND PRECAUTIONS General: OxyNEO® (oxycodone hydrochloride controlled release tablets) must be swallowed whole. Taking cut, broken, chewed, dissolved or crushed OxyNEO® tablets could lead to the rapid release and absorption of a potentially fatal dose of oxycodone. The tablets have been hardened, by a unique process, to reduce the risk of being broken, crushed or chewed. There have been post-marketing reports of difficulty swallowing OxyNEO® tablets. These reports include choking, gagging, regurgitation and tablets stuck in the throat. If patients experience such swallowing difficulties or pain after taking OxyNEO® tablets, they are advised to seek immediate medical attention. To avoid difficulty swallowing, OxyNEO® tablets should not be pre-soaked, licked or otherwise wetted prior to placing in the mouth and should be taken one tablet at a time with enough water to ensure complete swallowing immediately after placing it in the mouth. OxyNEO® should not be taken by patients with difficulty in swallowing or who have been diagnosed with narrowing of the esophagus. Do not administer OxyNEO® via nasogastric, gastric or other feeding tubes as it may cause obstruction of feeding tubes. OxyNEO® 60 mg and 80 mg tablets, or a single dose greater than 40 mg are for use in opioid tolerant patients only (see also DOSAGE AND ADMINISTRATION). A single dose greater than 40 mg of oxycodone, or total daily doses greater than 80 mg of oxycodone, may cause fatal respiratory depression when administered to patients who are not tolerant to the respiratory depressant effects of opioids (see WARNINGS AND PRECAUTIONS and DRUG INTERACTIONS). Patients should be instructed not to give OxyNEO® to anyone other than the patient for whom it was prescribed as such inappropriate use may have severe medical consequences, including death. Patients should be cautioned not to consume alcohol while taking OxyNEO®, as it may increase the chance of experiencing dangerous side effects.

Abuse of Opioid Formulations: OxyNEO® is intended for oral use only. Abuse of OxyNEO® can lead to overdose and death. This risk is increased when the tablets are cut, crushed, dissolved, broken or chewed, and with concurrent consumption of alcohol or other CNS depressants. With parenteral abuse, the tablet excipients, can be expected to result in local tissue necrosis, infection, pulmonary granulomas, and increased risk of endocarditis and valvular heart injury. Cardiovascular: Oxycodone administration may result in severe hypotension in patients whose ability to maintain adequate blood pressure is compromised by reduced blood volume, or concurrent administration of such drugs as phenothiazines or certain anesthetics. Dependence/Tolerance: As with other opioids, tolerance and physical dependence may develop upon repeated administration of oxycodone and there is a potential for development of psychological dependence. OxyNEO® tablets should therefore be prescribed and handled with the degree of caution appropriate to the use of a drug with abuse potential. Abuse and addiction are separate and distinct from physical dependence and tolerance. In addition, abuse of opioids can occur in the absence of true addiction and is characterized by misuse for non-medical purposes, often in combination with other psychoactive substances. Tolerance, as well as physical dependence, may develop upon repeated administration of opioids, and are not by themselves evidence of an addictive disorder or abuse. Concerns about abuse, addiction, and diversion should not prevent the proper management of pain. The development of addiction to opioid analgesics in properly managed patients with pain has been reported to be rare. However, data are not available to establish the true incidence of addiction in chronic pain patients. Opioids, such as oxycodone, should be used with particular care in patients with a history of alcohol and drug abuse. Withdrawal symptoms may occur following abrupt discontinuation of therapy or upon administration of an opioid antagonist. Patients on prolonged therapy should be withdrawn gradually from the drug if it is no longer required for pain control. Use in Drug and Alcohol Addiction: OxyNEO® is an opioid with no approved use in the management of addictive disorders. Its proper usage in individuals with drug or alcohol dependence, either active or in remission, is for the management of pain requiring opioid analgesia. Gastrointestinal Effects: There have been rare post-marketing cases of intestinal obstruction, and exacerbation of diverticulitis, some of which have required medical intervention to remove the tablet. Patients with underlying GI disorders such as esophageal cancer or colon cancer with a small gastrointestinal lumen are at greater risk of developing these complications.

FEBRUARY 2014 • Doctor’s

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Use caution when prescribing OxyNEO® for patients who have any underlying GI disorders that may predispose them to obstruction. Oxycodone and other morphine-like opioids have been shown to decrease bowel motility. Oxycodone may obscure the diagnosis or clinical course of patients with acute abdominal conditions. Neurologic: CNS Depression: Oxycodone should be used with caution and in a reduced dosage during concomitant administration of other opioid analgesics, general anesthetics, phenothiazines and other tranquilizers, sedative-hypnotics, tricyclic antidepressants, antipsychotics, antihistamines, benzodiazepines, centrally-active anti-emetics and other CNS depressants including alcohol. Respiratory depression, hypotension and profound sedation, coma or death may result. When such combination therapy is contemplated, a substantial reduction in the dose of one or both agents should be considered and patients should be carefully monitored (see DRUG INTERACTIONS). Severe pain antagonizes the subjective and respiratory depressant actions of opioid analgesics. Should pain suddenly subside, these effects may rapidly become manifest. Head Injury: The respiratory depressant effects of oxycodone and the capacity to elevate cerebrospinal fluid pressure, may be greatly increased in the presence of an already elevated intracranial pressure produced by trauma. Also, oxycodone may produce confusion, miosis, vomiting and other side effects which obscure the clinical course of patients with head injury. In such patients, oxycodone must be used with extreme caution and only if it is judged essential. Peri-Operative Considerations: OxyNEO® is not indicated for pre-emptive analgesia (administration pre-operatively for the management of post-operative pain). In the case of planned chordotomy or other pain-relieving operations, patients should not be treated with OxyNEO® for at least 24 hours before the operation and OxyNEO® should not be used in the immediate post-operative period. Physicians should individualize treatment, moving from parenteral to oral analgesics as appropriate. Thereafter, if OxyNEO® is to be continued after the patient recovers from the post-operative period, a new dosage should be administered in accordance with the changed need for pain relief. The risk of withdrawal in opioid-tolerant patients should be addressed as clinically indicated. The administration of analgesics in the perioperative period should be managed by healthcare providers with adequate training and experience (e.g., by an anesthesiologist). Oxycodone and other morphine-like opioids have been shown to decrease bowel motility. Ileus is a common post-operative complication, especially after intra-abdominal surgery with opioid analgesia. Caution should be taken to monitor for decreased bowel motility in post-

Doctor’s Review • FEBRUARY 2014

operative patients receiving opioids. Standard supportive therapy should be implemented. OxyNEO® should not be used in the early post-operative period (12 to 24 hours postsurgery) unless the patient is ambulatory and gastrointestinal function is normal. Psychomotor Impairment: Oxycodone may impair the mental and/or physical abilities needed for certain potentially hazardous activities such as driving a car or operating machinery. Patients should be cautioned accordingly. Patients should also be cautioned about the combined effects of oxycodone with other CNS depressants, including other opioids, phenothiazine, sedative/hypnotics and alcohol. Respiratory: Respiratory Depression: Oxycodone should be used with extreme caution in patients with substantially decreased respiratory reserve, pre-existing respiratory depression, hypoxia or hypercapnia. Such patients are often less sensitive to the stimulatory effects of carbon dioxide (CO2) on the respiratory centre and the respiratory depressant effects of oxycodone may reduce respiratory drive to the point of apnea. Patient Counselling Information: A patient information sheet should be provided when OxyNEO® tablets are dispensed to the patient. Patients receiving OxyNEO® should be given the following instructions by the physician: 1. Patients should be informed that accidental ingestion or use by individuals (including children) other than the patient for whom it was originally prescribed, may lead to severe, even fatal consequences. 2. Patients should be advised that OxyNEO® contains oxycodone, an opioid pain medicine. 3. Patients should be advised that OxyNEO® should only be taken as directed. The dose of OxyNEO® should not be adjusted without consulting with a physician. 4. OxyNEO® must be swallowed whole (not cut, broken, chewed, dissolved or crushed) due to the risk of fatal oxycodone overdose. 5. To avoid difficulty swallowing, patients should be advised to take OxyNEO® tablets one at a time. Tablets should not be pre-soaked, licked or otherwise wetted prior to placing in the mouth. Each tablet should be taken with enough water to ensure complete swallowing immediately after placing in the mouth. If patients experience difficulty in swallowing or pain after taking OxyNEO®, they should seek immediate medical attention. 6. Patients should be advised to report episodes of pain and adverse experiences occurring during therapy. Individualization of dosage is essential to make optimal use of this medication. 7. Patients should not combine OxyNEO® with alcohol or other central nervous system depressants (sleep aids, tranquilizers) because dangerous additive effects may occur, resulting in serious injury or death. 8. Patients should be advised to consult their physician or pharmacist if other medications are being used or will be used with OxyNEO®.

9. Patients should be advised that if they have been receiving treatment with OxyNEO® and cessation of therapy is indicated, it may be appropriate to taper OxyNEO® dose, rather than abruptly discontinue it, due to the risk of precipitating withdrawal symptoms. 10. Patients should be advised that the most common adverse reactions that may occur while taking OxyNEO® are asthenic conditions, constipation, dizziness, dry mouth, headache, nausea, pruritus, somnolence, sweating and vomiting. 11. Patients should be advised that OxyNEO® may cause drowsiness, dizziness or lightheadedness and may impair mental and/ or physical ability required for the performance of potentially hazardous tasks (e.g., driving, operating machinery). Patients started on OxyNEO® or patients whose dose has been adjusted should be advised not to drive a car or operate machinery unless they are tolerant to the effects of OxyNEO®. 12. Patients should be advised that OxyNEO® is a potential drug of abuse. They should protect it from theft or misuse. 13. Patients should be advised that OxyNEO® should never be given to anyone other than the individual for whom it was prescribed. 14. Patients should be advised that OxyNEO® 60 mg and 80 mg tablets or a single dose greater than 40 mg are for use only in individuals tolerant to the effect of opioids. 15. Women of childbearing potential who become or are planning to become pregnant should be advised to consult a physician prior to initiating or continuing therapy with OxyNEO®. Women who are breast-feeding or pregnant should not use OxyNEO®. Special Populations: Special Risk Groups: Oxycodone should be administered with caution and in a reduced dosage to debilitated patients, to patients with severely reduced hepatic or renal function or severely impaired pulmonary function, and in patients with Addison’s disease, hypothyroidism, toxic psychosis, pancreatitis, prostatic hypertrophy or urethral stricture. Pregnant Women: Animal reproduction studies have revealed no evidence of harm to the fetus due to oxycodone, however, as studies in humans have not been conducted, OxyNEO® is contraindicated in patients who are pregnant. Labour, Delivery and Nursing Women: In view of the potential for opioids to cross the placental barrier and to be excreted in breast milk, oxycodone is contraindicated during labour or in nursing mothers. Physical dependence or respiratory depression may occur in the infant if opioids are administered during labour. Pediatrics (< 18 years of age): The safety and efficacy of OxyNEO® have not been studied in the pediatric population. Therefore, use of OxyNEO® is not recommended in patients under 18 years of age. Geriatrics (> 65 years of age): In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency

of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy (see DOSAGE AND ADMINISTRATION). “In Vitro” Dissolution Studies of Interaction with Alcohol: Among readily available drugs with the established potential to pharmacologically augment the CNS depressant effect of opioids, ethanol also has the potential to chemically interact with the pharmaceutical formulation to accelerate the release of opioids from the dosage form. Given the larger doses of opioids in controlled release opioid formulations on average, the occurrence of such a formulation effect can further augment the risk of serious and unintended respiratory depression. A method to assess the potential for ethanol to accelerate the release of opioids from a pharmaceutical formulation requires the use of in vitro dissolution studies using simulated gastric fluid and 40% ethanol. With OxyNEO®, increasing concentrations of alcohol in the dissolution medium (from 0% to 40% v/v), resulted in a slight decrease in the rate of release of oxycodone from intact tablets. Additional in vitro dissolution testing in ethanol (40% v/v), conducted with OxyNEO® tablet fragments over a range of particles sizes, showed that dose dumping did not occur with the particle sizes tested. Other “In Vitro” Testing: The physical properties of the tablet were examined following an extensive battery of physical manipulations. Beyond demonstrating that OxyNEO® was harder to crush than another controlled release oxycodone formulation, testing over the range of OxyNEO® tablet fragment sizes showed that some of the controlled release properties were still retained. Hydrogelling properties continued to be demonstrated and dose dumping was not associated with OxyNEO®. ADVERSE REACTIONS Adverse Drug Reaction Overview: Adverse effects of OxyNEO® (oxycodone hydrochloride controlled release tablets) are similar to those of other opioid analgesics, and represent an extension of pharmacological effects of the drug class. The major hazards of opioids include respiratory and central nervous system depression and to a lesser degree, circulatory depression, respiratory arrest, shock and cardiac arrest. The most frequently observed adverse effects of OxyNEO® are asthenia, constipation, dizziness, dry mouth, headache, nausea, pruritus, somnolence, sweating and vomiting. Sedation: Sedation is a common side effect of opioid analgesics, especially in opioid naïve individuals. Sedation may also occur partly because patients often recuperate from prolonged fatigue after the relief of persistent pain. Most patients develop tolerance to the sedative effects of opioids within three to five days and, if the sedation is not severe, will not require any treatment except reassurance. If excessive sedation persists beyond a few days, the dose of the opioid should be reduced and alternate causes investigated. Some of these are: concurrent CNS depressant medication, hepatic

or renal dysfunction, brain metastases, hypercalcemia and respiratory failure. If it is necessary to reduce the dose, it can be carefully increased again after three or four days if it is obvious that the pain is not being well controlled. Dizziness and unsteadiness may be caused by postural hypotension, particularly in elderly or debilitated patients, and may be alleviated if the patient lies down. Nausea and Vomiting: Nausea is a common side effect on initiation of therapy with opioid analgesics and is thought to occur by activation of the chemoreceptor trigger zone, stimulation of the vestibular apparatus and through delayed gastric emptying. The prevalence of nausea declines following continued treatment with opioid analgesics. When instituting therapy with an opioid for chronic pain, the routine prescription of an antiemetic should be considered. In the cancer patient, investigation of nausea should include such causes as constipation, bowel obstruction, uremia, hypercalcemia, hepatomegaly, tumour invasion of celiac plexus and concurrent use of drugs with emetogenic properties. Persistent nausea which does not respond to dosage reduction may be caused by opioidinduced gastric stasis and may be accompanied by other symptoms including anorexia, early satiety, vomiting and abdominal fullness. These symptoms respond to chronic treatment with gastrointestinal prokinetic agents. Constipation: Practically all patients become constipated while taking opioids on a persistent basis. In some patients, particularly the elderly or bedridden, fecal impaction may result. It is essential to caution the patients in this regard and to institute an appropriate regimen of bowel management at the start of prolonged opioid therapy. Stimulant laxatives, stool softeners, and other appropriate measures should be used as required. The following adverse effects occur less frequently with opioid analgesics and include those reported in OxyNEO® clinical trials, whether related or not to oxycodone. General and CNS: abnormal dreams, abnormal gait, agitation, amnesia, anaphylactic reaction, anaphylactoid reaction, anxiety, confusional state, convulsion, delirium, depersonalization, depression, disorientation, drug dependence, drug tolerance, drug withdrawal syndrome, dysphoria, emotional lability, euphoria, hallucinations,headache, hypertonia, hypoaesthesia, hypotonia, insomnia, miosis, muscle contractions involuntary, nervousness, paresthesia, speech disorder, thought abnormalities, tinnitus, tremor, twitching, vertigo and vision abnormalities Cardiovascular: chest pain, faintness, hypotension, migraine, palpitation, ST depression, syncope, tachycardia and vasodilation Respiratory: bronchitis, bronchospasm, cough, dyspnea, pharyngitis, pneumonia, respiratory depression, sinusitis and yawning Gastrointestinal: abdominal pain, anorexia, biliary spasm, dental caries, diarrhea, dyspepsia, dysphagia, eructation, flatulence, gastritis,

gastrointestinal disorder, hiccups, ileus, increased appetite, stomatitis and taste perversion Genitourinary: amenorrhea, antidiuretic effects, libido decreased, dysuria, hematuria, impotence, polyuria, urinary retention or hesitancy Dermatologic: dry skin, exfoliative dermatitis, edema, other skin rashes and urticaria Other: allergic reaction, asthenia, chills, dehydration, fever, hypoglycemia, increased hepatic enzymes, lymphadenopathy, malaise, thirst and weight loss Post-marketing Experience: The following have been reported during post-marketing experience with OxyNEO®, potentially due to the swelling and hydrogelling property of the tablet: choking, gagging, regurgitation, tablets stuck in the throat and difficulty swallowing the tablet. To report any suspected adverse event associated with this drug, you may notify: • The Canada Vigilance Program at 1-866-234-2345 or • Purdue Pharma at 1-800-387-4501 or productinfo@purdue.ca For complete information on options when Reporting Suspected Side Effects, please see “Part III: Consumer Information” of the Product Monograph. DRUG INTERACTIONS Overview: Interaction with Central Nervous System (CNS) Depressants: OxyNEO® (oxycodone hydrochloride controlled release tablets) should be dosed with caution and started in a reduced dosage (1/3 to 1/2 of the usual dosage) in patients who are currently taking other central nervous system depressants (e.g., alcohol, other opioids, sedatives, hypnotics, anti-depressants, sleeping aids, phenothiazines, neuroleptics, anti-histamines and anti-emetics), pyrazolidone and beta-blockers, as they may enhance the CNS-depressant effect (e.g., respiratory depression) of OxyNEO®. Drug-Drug Interactions: Drugs Metabolized by Cytochrome P450 Isozymes: Oxycodone is metabolized in part by cytochrome P450 2D6 and cytochrome P450 3A4 pathways. The activities of these metabolic pathways may be inhibited or induced by various co-administered drugs, which may alter plasma oxycodone concentrations. Oxycodone doses may need to be adjusted accordingly. Inhibitors of CYP3A4: Since the CYP3A4 isoenzyme plays a major role in the metabolism of OxyNEO®, drugs that inhibit CYP3A4 activity, such as macrolide antibiotics (e.g., erythromycin), azole-antifungal agents (e.g., ketoconazole), and protease inhibitors (e.g., ritonavir), may cause decreased clearance of oxycodone which could lead to an increase in oxycodone plasma concentrations. A published study showed that the co-administration of the antifungal drug, voriconazole, increased oxycodone AUC and Cmax by 3.6- and 1.7-fold, respectively. Although clinical studies have not been conducted with other CYP3A4 inhibitors, the expected clinical results would be increased or prolonged

FEBRUARY 2014 • Doctor’s

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opioid effects. If co-administration with OxyNEO® is necessary, caution is advised when initiating therapy with, currently taking, or discontinuing CYP450 inhibitors. Evaluate these patients at frequent intervals and consider dose adjustments until stable drug effects are achieved. Inducers of CYP3A4: CYP450 inducers, such as rifampin, carbamazepine and phenytoin, may induce the metabolism of oxycodone and, therefore, may cause increased clearance of the drug which could lead to a decrease in oxycodone plasma concentrations, lack of efficacy or possibly the development of an abstinence syndrome in a patient who had developed physical dependence to oxycodone. A published study showed that the co-administration of rifampin, a drug metabolizing enzyme inducer, decreased oxycodone (oral) AUC and Cmax by 86% and 63% respectively. If co-administration with OxyNEO® is necessary, caution is advised when initiating therapy with, currently taking or discontinuing CYP3A4 inducers. Evaluate these patients at frequent intervals and consider dose adjustments until stable drug effects are achieved. Inhibitors of CYP2D6: Oxycodone is metabolized in part to oxymorphone via cytochrome CYP2D6. While this pathway may be blocked by a variety of drugs (e.g., certain cardiovascular drugs including amiodarone and quinidine as well as polycyclic antidepressants), such blockade has not been shown to be of clinical significance during oxycodone treatment. Administration with Mixed Activity Agonist/ Antagonist Opioids: Mixed agonist/antagonist opioid analgesics (i.e., pentazocine, nalbuphine, butorphanol, and buprenorphine) should be administered with caution to a patient who has received or is receiving a course of therapy with a pure opioid agonist analgesic such as oxycodone. In this situation, mixed agonist/ antagonist analgesics may reduce the analgesic effect of oxycodone and/or may precipitate withdrawal symptoms in these patients. MAO Inhibitors: MAO Inhibitors intensify the effects of opioid drugs which can cause anxiety, confusion and decreased respiration. OxyNEO® is contraindicated in patients receiving MAO Inhibitors or who have used them within the previous 14 days (see CONTRAINDICATIONS). Warfarin and Other Coumarin Anticoagulants: Clinically relevant changes in International Normalized Ratio (INR or Quick-value) in both directions have been observed in individuals when oxycodone and coumarin anticoagulants are co-administered. Drug-Food Interactions: Administration of OxyNEO® with food results in an increase in peak plasma oxycodone concentration of up to 1.5-fold but has no significant effect on the extent of absorption of oxycodone. Drug-Herb Interactions: Interactions with herbal products have not been established. Drug-Laboratory Interactions: Interactions with laboratory tests have not been established.

Doctor’s Review • FEBRUARY 2014

Administration DOSAGE AND ADMINISTRATION Dosing Considerations: OxyNEO® tablets must be swallowed whole and should not be cut, broken, chewed, dissolved or crushed since this can lead to rapid release and absorption of a potentially fatal dose of oxycodone. The tablets have been hardened by a unique process to reduce the risk of being broken, chewed or crushed. There have been post-marketing reports of difficulty swallowing OxyNEO® tablets. These reports include choking, gagging, regurgitation and tablets stuck in the throat. If patients experience such swallowing difficulties or pain after taking OxyNEO® tablets, they are advised to seek immediate medical attention. To avoid difficulty swallowing, OxyNEO® tablets should not be pre-soaked, licked or otherwise wetted prior to placing in the mouth and should be taken one tablet at a time with enough water to ensure complete swallowing immediately after placing it in the mouth (see Patient Counselling Information). OxyNEO® should not be taken by patients with difficulty in swallowing or who have been diagnosed with narrowing of the esophagus. Do not administer OxyNEO® via nasogastric, gastric or other feeding tubes as it may cause obstruction of feeding tubes. OxyNEO® 60 mg and 80 mg tablets, or a single dose greater than 40 mg, are for use in opioid tolerant patients only. A single dose greater than 40 mg, or total daily doses greater than 80 mg, may cause fatal respiratory depression when administered to patients who are not tolerant to the respiratory depressant effects of opioids. OxyNEO® should not be used in the early post-operative period (12 to 24 hours postsurgery) unless the patient is ambulatory and gastrointestinal function is normal. OxyNEO® is not indicated for rectal administration. The controlled release tablets may be taken with or without food, with a glass of water. Recommended Dose and Dosage Adjustment: Adults: Individual dosing requirements vary considerably based on each patient’s age, weight, severity and cause of pain, and medical and analgesic history. Patients Not Receiving Opioids at the Time of Initiation of Oxycodone Treatment: The usual initial adult dose of OxyNEO® for patients who have not previously received opioid analgesics is 10 mg or 20 mg every 12 hours. Patients Currently Receiving Opioids: Patients currently receiving other oral oxycodone formulations may be transferred to OxyNEO® tablets at the same total daily oxycodone dosage, equally divided into two 12 hourly OxyNEO® doses. For patients who are receiving an alternate

opioid, the “oral oxycodone equivalent” of the analgesic presently being used should be determined. Having determined the total daily dosage of the present analgesic, TABLE 1 in the product monograph can be used to calculate the approximate daily oral oxycodone dosage that should provide equivalent analgesia. This total daily oral oxycodone dose should then be equally divided into two 12 hourly OxyNEO® doses. It is usually appropriate to treat a patient with only one opioid at a time. Patients who are receiving 1 to 5 tablets/capsules per day of a fixed-dose combination opioid/ non-opioid containing 5 mg of oxycodone or 30 mg codeine should be started on 10 mg to 20 mg OxyNEO® q12h. For patients receiving 6 to 9 tablets/capsules per day of a fixed-dose combination opioid/non-opioid containing 5 mg of oxycodone or 30 mg codeine, a starting dose of 20 mg to 30 mg q12h should be used and for patients receiving 10 to 12 tablets/capsules per day of a fixed-dose combination opioid/nonopioid containing 5 mg of oxycodone or 30 mg codeine, a starting dose of 30 mg to 40 mg q12h is suggested. For those receiving > 12 tablets/ capsules per day of a fixed-dose combination opioid/non-opioid containing 5 mg of oxycodone or 30 mg codeine, conversions should be based on the total daily opioid dose. Use with Non-Opioid Medications: If a non-opioid analgesic is being provided, it may be continued. If the non-opioid is discontinued, consideration should be given to increasing the opioid dose to compensate for the non-opioid analgesic. OxyNEO® can be safely used concomitantly with usual doses of other non-opioid analgesics. Dose Titration: Dose titration is the key to success with opioid analgesic therapy. Proper optimization of doses scaled to the relief of the individual’s pain should aim at regular administration of the lowest dose of controlled release oxycodone (OxyNEO®) which will achieve the overall treatment goal of satisfactory pain relief with acceptable side effects. Dosage adjustments should be based on the patient’s clinical response. In patients receiving OxyNEO®, the dose may be titrated at intervals of 24 to 36 hours to that which provides satisfactory pain relief without unmanageable side effects. OxyNEO® is designed to allow 12 hourly dosing. If pain repeatedly occurs at the end of the dosing interval it is generally an indication for a dosage increase rather than more frequent administration of controlled release oxycodone (OxyNEO®). Adjustment or Reduction of Dosage: Following successful relief of pain, periodic attempts to re-assess the opioid analgesic requirements should be made. If treatment discontinuation is required, the dose of opioid may be decreased as follows: one-half of the previous daily dose given q12h (OxyNEO®) for the first two days, followed thereafter by a 25% reduction every two days. Withdrawal symptoms may occur following abrupt discontinuation of therapy. These symptoms may include body aches, diarrhea, gooseflesh, loss of appetite, nausea, nervousness

or restlessness, runny nose, sneezing, tremors or shivering, stomach cramps, tachycardia, trouble with sleeping, unusual increase in sweating, palpitations, unexplained fever, weakness and yawning. Patients on prolonged therapy should be withdrawn gradually from the drug if it is no longer required for pain control. In patients who are appropriately treated with opioid analgesics and who undergo gradual withdrawal for the drug, these symptoms are usually mild. Opioid analgesics may only be partially effective in relieving dysesthetic pain, stabbing pains, activity-related pain and some forms of headache. That is not to say that patients with these types of pain should not be given an adequate trial of opioid analgesics, but it may be necessary to refer such patients at an early time to other forms of pain therapy. Missed Dose: If the patient forgets to take a dose, it should be taken as soon as possible, however, if it is almost time for the next scheduled dose, they should skip the missed dose and take their next dose at the scheduled time and in the normal amount. OVERDOSAGE For management of a suspected drug overdose, contact your Regional Poison Control Centre. Symptoms: Serious overdosage with oxycodone may be characterized by respiratory depression (a decrease in respiratory rate and/or tidal volume, Cheyne-Stokes respiration, cyanosis), extreme somnolence progressing to stupor or coma, miotic pupils, skeletal muscle flaccidity, cold and clammy skin, and sometimes bradycardia and hypotension. Severe overdosage may result in apnea, circulatory collapse, cardiac arrest and death. Treatment: Primary attention should be given to the establishment of adequate respiratory exchange through the provision of a patent airway and controlled or assisted ventilation. The opioid antagonist naloxone hydrochloride is a specific antidote against respiratory depression due to overdosage or as a result of unusual sensitivity to oxycodone. An appropriate dose of an opioid antagonist should therefore be administered, preferably by the intravenous route. The usual initial i.v. adult dose of naloxone is 0.4 mg or higher. Concomitant efforts at respiratory resuscitation should be carried out. Since the duration of action of oxycodone, particularly sustained release formulations, may exceed that of the antagonist, the patient should be under continued surveillance and doses of the antagonist should be repeated as needed to maintain adequate respiration. An antagonist should not be administered in the absence of clinically significant respiratory or cardiovascular depression. Oxygen, intravenous fluids, vasopressors and other supportive measures should be used as indicated. In individuals physically dependent on opioids, the administration of the usual dose of narcotic antagonist will precipitate an acute withdrawal syndrome. The severity of this syndrome will depend on the degree of physical dependence and the dose of antagonist administered. The use of narcotic antagonists in such individuals should be avoided if possible. If a narcotic antagonist must be used to treat serious respiratory depression in the physically dependent patient, the antagonist should be administered with extreme care by using dosage titration, commencing with 10% to 20% of the usual recommended initial dose. Evacuation of gastric contents may be useful in removing unabsorbed drug, particularly when a sustained release formulation has been taken. Product Monograph available on request. Purdue Pharma Canada, 575 Granite Court, Pickering, Ontario, L1W 3W8, 1-800-387-4501, http://www.purdue.ca

Mad with menopause uu CONTINUED FROM PAGE 33

In the North American land of opportunity, the growing perception on a woman’s change of life as a disease to be cured meant a boon for snake-oil salesmen. Industrious quacks jumped on the menopause bandwagon and touted all manner of miraculous cures for hot flashes, insomnia and night sweats. Surgery was option too, it seemed. In 1809, Kentucky physician Ephraim McDowell (1771-1830) performed the first successful ovariotomy in 1809, removing a 10.2-kilogram tumour from a woman believed by her previous physician to be 11 months pregnant. He performed several similar surgeries over the next decade or so, eventually publishing his work in 1817. News of his successful ovariotomies travelled back to Britain, where Scottish surgeon and laudanum addict John Lizars (1787-1860) saw new potential in the surgery. He reasoned that if a woman’s ovaries — the wellspring of her goodness and virtue, according to Victorian mores — weren’t in working order, it seriously compromised her mental and physical integrity. The solution? Remove them! Lizars performed 200 ovariotomies between 1825 and 1854, killing 89 women in the process. Sounds abominable, of course. Yet as gruesome as the ovariotomy may seem today — remember that surgical anesthesia wasn’t commonplace until the mid1800s — the menopausal madam faced a far worse option, thanks to the megalomaniacal medical mind of one Dr Isaac Baker Brown (1811-1873). Baker Brown, an English gynecologist and surgeon, enjoyed an illustrious career until he decided to take the ovariotomy a few inches south and began experimenting with clitorodectomies as a cure for menopause and that old stand-by, hysteria. In 1866, he published his results, claiming that clitoris removal was successful even in treating epilepsy (caused by masturbation) upwards of 70 percent of the time. Soon it was revealed that Baker Brown was performing these surgeries without his patients’ consent. This was too much even for the cadre of clitoris-fearing old fogies at the Obstetrical Society of London, and Baker Brown was summarily dismissed.

LAWSON LOCKS ’EM UP

The 1870s saw a trend toward the institutionalization of menopausal women behaving badly. The popular obstetrician and general champion of women’s health Lawson Tait (1845-1899) felt that menopause-induced hysteria and general noncompliance — especially if the woman in question liked to enjoy a glass of wine on occasion — were good enough reasons to put her away for a spell. He prescribed violent purgatives and random commitment to the asylum as prophelatic measures to be taken against the threat of menopausal “dementia.” One of Tait’s most accepted ideas was his belief that Jack the Ripper was actually a woman, and a midwife to boot. Where institutions and surgery failed, surely pharmacology would succeed! The late 19th-century menopausal scene was flooded with medicinal treatments for hot flashes, moodiness, vaginal dryness and the like. Some treatments for menopause, often referred to as “climacteric insanity” — like opium, wine and cannabis — promised a good time, if not a complete remission. Others big sellers in the lateVictorian pharmacopeia were powdered ovaries and testicles — of what or whom, we can never know for sure, though some labels boasted powerful pig parts. The 20th century would hold many breakthroughs in the understanding of menopause and its treatment. Estrogen was isolated at St. Louis University in 1929 by Nobel-Prize winning biochemist Edward Doisy (1893-1986). German-Israeli gynecologist Bernhard Zondek (1891-1966) not only developed the first pregnancy test in 1928, but also discovered water-soluble estrogen in the urine of pregnant mares in 1930. The war against cold sweats heated up and an entire industry was born in hormonereplacement therapy. While medicine may never be able to technically turn back the clock for women experiencing menopause, it certainly can make things a little easier as the next generation of drugs is poised to offer better, safer treatment than ever before. FEBRUARY 2014 • Doctor’s

Review

PHOTO FINISH by

D r H a n s B e r k hou t

Banded together

A visit to San Miguel de Allende, Mexico offers many visual and acoustic delights. Every day brings a new celebration with parades, concerts, dances and fireworks. In between the organized events, you’ll find people who are making their living on the streets, offering for sale their flowers, balloons, dolls and roasted corn. There’s live music almost everywhere, in and out of doors. Naturally, there are mariachis, but also, for instance, this couple — an excellent combination of instruments and voice — who we met several times. They were very pleased when I gave them a copy of this picture on the following year’s visit. This photo was taken with Leica M6 with Summicron 5-cm lens. I processed the Tri-X film in D23.

MDs, submit a photo! If it’s printed, you’ll receive $50. Please send photos (black and white only) along with a 150- to 300-word article to: Doctor’s Review, Photo Finish, 400 McGill Street, 4th Floor, Montreal, QC H2Y 2G1.

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av No ai w la bl e

Introducing NEW Levemir FlexTouch ®

An easy to use, easy to teach, pre-filled insulin pen

Insulin delivery at the touch of a button A pre-filled insulin pen with a light-touch button requiring up to 5X less thumb pressure* 62%–82% lower injection force demonstrated with FlexTouch® than other pre-filled insulin pens*§ (Mean Injection Forces: FlexTouch® 5.1N. At 4, 6 and 8 mm/s respectively; SoloStar® 13.5N, 19.1N and 26.9N, KwikPenTM 14.5N, 20.9N and 28.2N)

Light-touch button does not extend at any dose

End-of-dose click to confirm dose delivery

Indications and clinical use: Levemir® (insulin detemir) is indicated for the treatment of: • adult patients with type 1 or type 2 diabetes mellitus who require a long-acting (basal) insulin for the control of hyperglycemia • pediatric patients with type 1 diabetes mellitus who require a long-acting (basal) insulin for the control of hyperglycemia. The safety and efficacy of Levemir® has not been studied in children below the age of 6 years • type 2 diabetes mellitus in combination with oral anti-diabetic agents (OADs) [metformin or sulfonylureas] in adult patients who are not in adequate metabolic control on OADs alone. For safety reasons, the use of insulin in combination with thiazolidinedione is not indicated • type 2 diabetes mellitus in combination with Victoza® (liraglutide) and metformin when Victoza® and metformin do not achieve adequate glycemic control Levemir® is also recommended in combination with short- or rapid-acting mealtime insulin. Please consult the product monograph at http://novonordisk.ca/PDF_Files/our_products/ Levemir/LevemirPM.pdf for important information on contraindications, warnings and precautions, adverse reactions, drug interactions and dosing. The product monograph is also available by calling us at 1 (800) 465-4334. * Comparative clinical significance has not been established § Injection Force = the force required to press the pushbutton on pens to inject insulin Adapted from Hemmingsen H et al., 2011. This study compared the injection force of FlexTouch® with that of SoloStar® and KwikPenTM. Injection force was measured at 3 constant push-button speeds delivering 80 units with SoloStar® and 60 units with KwikPenTM. FlexTouch® was not tested at 3 speeds because the spring-loaded mechanism has no influence on the rate of insulin delivery. Instead, injection force was measured as the spring activation force at 80 units. The manufacturers’ recommended needles were used; NovoFine® (Novo Nordisk) 32-gauge tip extra thin wall (etw) 6 mm needle for FlexTouch® and BD (Franklin Lakes, NJ) MicroFineTM 31-gauge 5 mm needle for SoloStar® and KwikPenTM. Only one needle of each type was used for all injection force tests to avoid variation in measured injection force caused by the flow stress of different needles. REFERENCES: 1. Levemir® Product Monograph, Novo Nordisk Canada Inc., September 2013. 2. Hemmingsen H, Niemeyer M, Hansen MR, Busher D, Thomsen NB. A prefilled insulin pen with a novel injection mechanism and a lower injection force than other prefilled insulin pens. Diabetes Technol Ther 2011;13(12):1-5. All trademarks owned by Novo Nordisk A/S and used by Novo Nordisk Canada Inc. Novo Nordisk Canada Inc., 300-2680 Skymark Avenue, Mississauga, Ontario L4W 5L6. Tel: (905) 629-4222 or 1-800-465-4334. www.novonordisk.ca

CA/LM/0813/00147-E