February 2015 by Doctor's Review

7car gadgets

MEDICINE ON THE MOVE

MD depression collaborations

FEBRUARY 2015

Two short sleeps a night

BEYOND

ADELAIDE IN AND AROUND THE

EYRE PENINSULA

Last Antarctic cruise? Spring savings

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Rock’s Dixie roots

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

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

NOW AVAILABLE

salbutamol plus ipratropium

Performing

TOGETHER delivered in an SMI (Soft Mist Inhaler) 1-4

1 PUFF

4X A DAY

Take additional inhalations as required. Total number of inhalations should not exceed 6 in 24 hours.

COMBIVENT RESPIMAT (ipratropium bromide and salbutamol sulfate) inhalation solution is indicated for treatment of bronchospasm associated with chronic obstructive pulmonary disease (COPD). Consult the Product Monograph at www.boehringer-ingelheim.ca/content/ dam/internet/opu/ca_EN/documents/humanhealth/product_monograph/ CombiventRespimatPMEN.pdf for important information about: - Contraindications in patients with cardiac tachyarrhythmias, hypertrophic obstructive cardiomyopathy and patients with hypersensitivity to atropine or its derivatives - Relevant warnings and precautions regarding patients with uncontrolled diabetes mellitus, recent myocardial infarction, severe organic heart or vascular disorders, hyperthyroidism, pheochromocytoma, prostatic hypertrophy, urinary retention,

cardiovascular disorders, risk of deleterious cardiovascular effects with concomitant use with other sympathomimetic agents or epinephrine which is not recommended, monitoring for AE risk of acute and worsening of dyspnea, chest pain and reduced response to treatment, idiopathic hypertrophic subvalvular aortic stenosis, metabolic changes, gastric mobility issues in patients with cystic fibrosis, hypersensitivity reactions, ocular complications, paradoxical bronchospasm or being treated with other anticholinergic and/or beta-agonist containing drugs, monoamine oxidase inhibitors or tricyclic antidepressants, pregnant or nursing women, elderly patients and ability to operate vehicle or machinery - Conditions of clinical use, adverse reactions, interactions and dosing instructions The product monograph is also available by calling us at 1 (800) 263-5103 Ext. 84633.

NEW References: 1. COMBIVENT® RESPIMAT® Product Monograph. Boehringer Ingelheim (Canada) Ltd., Jan 8, 2014. 2. STRIVERDI® RESPIMAT® Product Monograph. Boehringer Ingelheim (Canada) Ltd., May 7, 2014. 3. Decramer M, Vestbo J, Bourbeau J, et al. Global strategy for the diagnosis, management, and prevention of COPD (updated 2014). Global Initiative for Chronic Obstructive Lung Disease, Inc. 2014. 4. Data on file. Boehringer Ingelheim (Canada) Ltd., 2014.

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

Together in a mist

Things we like about the South Winter is here and yet signs of spring will begin to appear in a very few weeks in some lucky parts of the country — try BC and southern Ontario. In the meantime, we have an issue for you that looks south, very far south in the case of Seventh Heaven? by writer Pamela Mandel who makes her first appearance in these pages. She had a dream: to visit each of the seven continents, the final one being Antarctica. The trip went well enough on the surface, but the feelings it produced in her were another matter. It wasn’t so much a case of “be careful what you dream for” as “dreams are evanescent,” perhaps travel dreams most of all. Another writer went looking for mystery, romance and adventure in the south, Australia in this case. Margo Pfeiff has been going to Oz for 35 years and had never been to the Eyre Peninsula. What she found there was a seldom-visited part of the country that’s a microcosm of the whole. Mobs of kangaroos, flocks of exotic birds, trees of koalas, oceans of sea life to swim with, white-sand beaches to the horizon, long reaches of the outback, phenomenal seafood, stunning white wines, all within a couple of hundred kilometres. Her voyage of discovery begins on page 33. Fancy something closer to home? If you love rock ‘n’ roll music, you’ll adore Josephine Matyas and Craig Jones’ piece, Soul survivors, page 40. Macon, Memphis and Muscle Shoals may bring up American country and western images, but that’s not a tenth of it. This is blues country and during the ’60s and early ’70s it was responsible for some of the most popular music on the planet. To local boy made good, Elvis Presley, add Aretha Franklin, The Beatles, The Rolling Stones, Tom Waits, Wilson Pickett, Otis Redding, Paul Simon and Bob Dylan, who recorded both his Christian albums in The Shoals, to just skim the surface. Spoiler alert: after reading you may want to buy, beg or steal a 1969 Cadillac and start driving south with the radio blaring. If all of this leaves you just too excited to sleep, turn to page 25 where you’ll find a fascinating piece on taking two short Gawler Ranges National Park, naps a night instead of a single long doze. When you wake, Eyre Peninsula, Australia. spring will be even closer.

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FEBRUARY 2015 • Doctor’s

Review

NEW

The rst

SMI

Soft Mist Inhaler

1-4

Ask for a demo of Placebo Respimat today ®

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

† Comparative clinical signiﬁcance unknown

* Solution is dispensed through mechanical energy4

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

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

contents JIM HUTCHISON

FEBRUARY 2015

features 33

46 51

Plunge into secret Australia

German recipes that are familiar, but far from traditional by Jeremy and Jessica Nolen

Escape to the Eyre Peninsula, it’s the entire country in microcosm by Margo Pfeiff

Beyond bratwurst

Soul survivors

Three towns in the US southeast that changed the history of Rock ‘n’ Roll by Josephine Matyas and Craig Jones

Seventh heaven? A bittersweet ending to the final destination on one traveller’s bucket list by Pamela Mandel

Coming in

March • A British visit with poets Lennon, McCartney and William — Shakespeare, that is • Take a stroll through some of the most beautiful villages in France • The search for the origins of Norway’s most famous painting, The Scream • Seven of Europe’s small hotels and what makes them memorable stays

51 FEBRUARY 2015 • Doctor’s

Review

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contents FEBRUARY 2015

regulars 21

7 LETTERS What’s cooking?

PRACTICAL TRAVELLER An around-the-world solar flight, the best sky events of 2015, the first Virgin Hotel opens in Chicago and more by Camille Chin

Are two short sleeps better than one? by Rose Foster

BUDGET TRAVELLER

GADGETS Make your car ride a safer, nicer place to be by Theo Sands

DEPRESSION POINTS Can Canadian GPs and psychiatrists collaborate to help patients? by Susan Usher

Spring comfort in Florida, Arizona and California from US$129 a night by Roger White

HISTORY OF MEDICINE

PHOTO FINISH Caught off guard by Dr Wayne Campbell

TOP 25 The best medical meetings scheduled for this summer

9 FEBRUARY 2015 • Doctor’s

Review

Today he will think more about Rebecca than his diabetes.

Imagine a world where life with diabetes is a

little easier. We believe that with dedication, research and a never-quit attitude, that day will come. Itâ&#x20AC;&#x2122;s your day.

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David Elkins

What’s cooking?

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EASY AS PIE? I am always interested in recipes for my family and “easy casseroles” [eNewsletter, January 19, 2015] caught my eye so I checked it out. I am wondering who at Doctor’s Review considers a chicken pot pie recipe that requires you to make pie crust and a white sauce and a filling “easy.” It certainly does not fit my definition of “easy.” I didn’t bother reading the other two recipes — I’m a decent cook and I don’t stock saffron in my kitchen. I hope you’ll reconsider what constitutes an “easy” recipe.

Dr David Wood and his wife, Nina.

Dr Jennifer Brasch Hamilton, ON

Editor’s note: The chicken pot pie is a threestage recipe, to be sure. A white sauce is not terribly demanding, but any recipe for a pie will require a crust and making one from scratch is time consuming. The suggestion that a store-bought one could be substituted would have been helpful. Saffron is not in every kitchen, but easy to find.

A REAL SOUTHERN BELLE Josephine Matyas’s article [Where ancient cultures thrive, January 2015, page 40] provided a tantalizing glimpse at the splendid archeology of the Southwest. Mix in the endless blue skies, the hot days and crisp nights, the art of today and the past, and you have a sense of how exciting this destination is. I can’t wait to see the next article. Morley Burwash Via doctorsreview.com

DOCTORS DO MOROCCO We had a similarly good experience in Morocco [“Head for the hills,” I Prescribe a Trip to… Morocco, January 2015, page 28] with Insight Tours last November. We circled the country from Casablanca/ Rabat/Meknes/Fez/Erfoud/Todra Gorge/Ouarzazate/Marrakesh with an excellent guide. Security is judged by visitors to be

better in Morocco than Egypt — 25 people on our tour in Morocco versus nine in Egypt in October. Guided tours have pluses and minuses, but with passing years, we find it preferable to going it alone. The merging cultures and languages of Morocco (Arabic/ French/English) demonstrate that harmony can be achieved. We exercised our French, which is their second language, when we couldn’t communicate in Arabic — which was most of the time! Dr Ken Wilson Via doctorsreview.com

FOOD FIGHT Regarding “...that insidious disease caused by ‘grain brain’” [8 small “cures” for post-holiday depression, December 2014, page 25]. This is supposed to be medical advice? Please provide your peerreviewed sources. Dr Lorne Walton Via doctorsreview.com

Editor’s note: In Grain Brain (Little, Brown and Company, 2013), neurologist David Perlmutter argues that carbs can cause dementia, ADHD, anxiety, chronic headaches, depression and more. His best-selling book is worth a read, even if you disagree with his research. FEBRUARY 2015 • Doctor’s

Review

PA R T O F T H E N O VA R T I S C O P D P O R T F O L I O

Open up to a

LAMA option in COPD

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

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® 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 Relevant warnings and precautions: Not indicated for treatment of acute episodes of bronchospasm Not indicated for treatment of acutely deteriorating COPD Worsening of narrow-angle glaucoma Worsening of urinary retention In severe renal impairment, use only if the expected benefit outweighs the potential risk Paradoxical bronchospasm

SEEBRI and BREEZHALER are registered trademarks. Product Monograph available on request. 14SEE033E © Novartis Pharmaceuticals Canada Inc. 2014

For more information: Please consult the Product Monograph at www.novartis.ca/asknovartispharma/download. htm?res=seebri%20breezhaler_scrip_e.pdf&resTitleId=665 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. LAMA: long-acting muscarinic antagonist; 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 life5; 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., December 3, 2013. 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 May 16, 2014.

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

Untitled, 1982. BELOW: A Panel of Experts, 1982.

C a mi lle C hi n

PHOTOS THIS PAGE © ESTATE OF JEAN-MICHEL BASQUIAT. LICENSED BY ARTESTAR, NEW YORK

A man of the world An NYC graffiti artist whose tag was “SAMO” or “same old shit” in the 1980s is being featured in a major show through May 10 at the Art Gallery of Ontario in Toronto. Jean-Michel Basquiat: Now’s the Time will feature close to 85 large-scale pieces by the street-artist-turned-Neo-Expressionistpainter who used words, symbols, stick figures and animals in his work. Born to a Haitian-American father and Puerto Rican mother, Basquiat, who died of a heroin overdose in 1988 at age 27, explored identity and racism in his paintings, and also the dichotomies between integration and segregation, and rich and poor. He was inspired by abstract expressionism and conceptualism as well as by graffiti, remix culture, jazz and comics, and created visual works that encouraged us to think critically about the world. He once said, “I don’t think about art when I’m working. I try to think about life.” To learn more about his art go to basquiatnow.com. Timed tickets; adults $25. tel: (877) 225-4246; ago.net.

FEBRUARY 2015 • Doctor’s

Review

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

Heads up

Five of the best sky events of 2015

KPG PAYLESS / SHUTTERSTOCK.COM

LUNAR ECLIPSES A total eclipse of the moon is way better than one of the heart. On Saturday, April 4, the earth will pass between the sun and the moon, obscuring the sun’s light and casting a shadow on the moon’s surface. When the earth’s shadow completely covers the moon, the latter will appear reddishbrown. The entire event will be visible from start to end in Alaska, the South Pacific, eastern Australia and Japan. A second eclipse of the moon will cross the Americas, Europe and Africa on Sunday, September 27. CONJUNCTIONS On Canada Day, Wednesday, July 1, super bright Venus — named for the Roman goddess of love and beauty, and the only planet named after a female — will snuggle up next to Jupiter, the largest planet in the solar system; it’s named after the king of the gods in Roman mythology. Venus and Jupiter will be separated by only 0.3 degrees of distance in the sky. On Thursday, October 8, the Moon and Venus will make a close approach only to rendez-vous again on Saturday, November 7.

Southern comfort

Slow-moving koala bears in Southern Australia need cotton mittens. They’ve been hurt by the out-of-control bushfires that swept through the region at the beginning of January. Burnt paws caused by contact with burning trees or by fleeing across burning ground are treated with creams and then covered. The dressings are changed daily and some koalas need up to a year to fully recover. The Australian branch of the International Fund for Animal Welfare has asked locals to make and donate mitts made from clean, 100-percent, old cotton sheets or tea towels. They recently reported receiving mitts from Canada, the US and Europe, and are now also appealing for pouches to keep orphaned baby marsupials warm. Up to six pouches can be used per animal a day. For mitt and pouch patterns or to donate (shipping is expensive), go to ifaw.org/australia.

Doctor’s Review • FEBRUARY 2015

The first attempted around-the-world solar flight will depart from Abu Dhabi on March 1. The Solar Impulse 2 won’t have any fuel onboard. It’ll make 12 stops in Asia, North America and Europe over the five-month, 35,000-kilometre trip before returning to the UAE capital at the beginning of August. Two pilots will take turns flying the airplane of “perpetual endurance” for five to six days and nights in a row logging a total of 500 flying hours each. The single-seat cockpit is unheated and unpressurized, but don’t worry. Bertrand Piccard and André Borschberg will be protected by high-density thermal insulation, and their seat includes a parachute and life raft. When fully reclined, it is intended to allow the pilot to perform some physical exercise. Oh — and it’s also a toilet. The aircraft is made of carbon fibre and has a 72 metre wingspan. The four electric engines operate on 17,000 solar cells which also recharge lithium batteries for night flying. solarimpulse.com.

Spin your wheels There are now 500 bikes on Seattle’s streets that are available for rent 24/7, 365 days a year. Travellers can buy a 24-hour pass for US$8 or a three-day pass for US$16 at one of the 50 Pronto stations throughout the city. The first 30 minutes of every ride is free; usage fees apply after that. Helmets are mandatory and can be borrowed at any station based on the honour system. The protective gear is cleaned and inspected after every use, rewrapped and restocked in nearby bins. prontocycleshare.com.

Flying on empty

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

MINNEAPOLIS CVB

Art for free The Minneapolis Institute of Arts is a free museum and this year it’s celebrating its centennial so a big party is in order. Its neoclassical building opened in 1915, and expanded in 1974 and 2006 to accommodate its permanent collection of 83,000 pieces. Masterpieces in Focus, until May 3, is one of 52 events planned for the MIA’s100th anniversary. The exhibit will feature three surprise works that will be revealed one at a time in the weeks to come. Vermeer’s Woman Reading a Letter from the Rijksmuseum in Amsterdam is the first piece on view. The MIA is also showing The Habsburgs: Rarely Seen Masterpieces from Europe’s Greatest Dynasty through May 10. It follows the royal house’s rise in the late Middle Ages through strategic marriages, political alliances and conquests to its decline at the end of WWI. Many of the show’s 93 pieces have never travelled outside of Austria and include armour, carriages, and court uniforms and dresses. Closed Mondays. tel: (888) 642-2787; new.artsmia.org.

KUNSTHISTORISCHES MUSEUM, VIENNA

Carousel sleigh, circa 1740-1750.

Doctor’s Review • FEBRUARY 2015

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

SY1180E

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

12/15 ®

BREATHE IT IN

Explore the possibilities.

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

Stay in The Loop Richard Branson’s new four-star hotel brand first caught our attention in 2011, the year Virgin Hotels bought the old Dearborn Bank Building in downtown Chicago for US$15 million in an all-cash transaction. Built between 1926 and 1928, the 27-storey Art Deco building in “The Loop,” the city’s business core, reopened as a hotel in January and now features 250 rooms or “chambers.” Each consists of a dressing room — hallway, closet, bathroom — and sleeping lounge separated by a sliding door complete with a peephole. The added privacy lets guests loaf in bed while, say, hotel services delivers that tube of toothpaste someone forgot to pack. All of the beds have ergonomic headboards and adjustable footboards, the minibars are stocked at “street prices” and Wi-Fi is free. You can ask the hotel app “Lucy” for extra pillows or a spa reservation, or to adjust the room temperature. Double-occupancy rooms start at US$209. Hotels in Nashville and NYC are up next. tel: (855) 946-6600; virginhotels.com.

Doctor’s Review • FEBRUARY 2015

IES R E S ING O G N O

Rise & Shine! Start the day right with a delightful breakfast recipe It is well known that breakfast is the most important meal of the day. It can provide an excellent chance for you to take in foods rich in bone-strengthening calcium, such as cereals, milk and yogurt. Add a glass of orange juice, fortified with vitamin D, to support the absorption of calcium, and improve muscle function, especially important if youâ&#x20AC;&#x2122;ve been diagnosed with osteoporosis. This three-part recipe series puts breakfast in the spotlight bringing you tasty, bone-healthy recipes.

New recipes every month!

doctorsreview.com

BUDGET TRAVELLER by

R og e r W hi t e

Spring comfort from $129 a night A spring break in the warmer parts of the US doesn’t have to be predictable or expensive — the current exchange rate notwithstanding. Here are three spots that break the conventional mold. Porto, Portugal.

Arizona Sedona is fun at any time of year, but it’s at its peak in spring. Warm days, cool nights, dry mountain air, some of the best day hikes on the planet and all those inspiring red-rock cliffs, buttes and mesas, it’s no wonder many feel closer to heaven here. The best views are to be had from the Sky Ranch Lodge on Airport Mesa right in the centre of all the beauty. Perhaps even more remarkable, one of the better places to eat, much favoured by locals, is at your doorstep. Mesa Grill’s American menu features tasty treats for breakfast, lunch or dinner. Make sure you dine at least once during sunset — spectacular! All the pleasures of the town are just down the hill, from the funky new age shops to pink jeep tours into them thar hills. From US$129. tel: (888) 708-6400; skyranchlodge.com.

California

Sky Ranch Lodge, Sedona, AZ.

California as it used to be is waiting for you. The village of Ojai sits in a deep valley about 100 kilometres northeast of LA just in from the coast. The 1937 film Lost Horizon, the story of Shangri-La, was shot here and it has the feel of somewhere you might like to live. Hike in the hills, drive the narrow roads through miles of citrus groves, dine on farm-fresh produce. Tension drops away naturally in this community long the home to many spiritual groups including the Krishnamurti Centre. To Claudia Masciotra Celebrities favour the valley for a serene place for second homes. Make your home at the Capri Hotel, a 1960s hotel that’s For reborn Doctor’s Review 2015 issue been as a hip new place to stay.February Ask for a room with a private patio. They open onto a lush garden where date palms Fax a pool 1-855-861-0790 shelter and Jacuzzi. Dogs welcome. Book early for weekends. From US$149. tel: (877) 589-5860; hotelojai.com.

EUROPE

Italy & Dalmatian Coast May 28 - Jun 9, 2015

British Isles Jul 15 - 27, 2015

Florida Sarasota is a wonderful place to be in spring. Soft, mild sea air, flowers everywhere, a good public library, museums, concerts and plays galore, good coffee shops, loads of restaurants, interesting stores, and the beach a short drive away. Stay downtown in one of nine studios at the renovated and stylish Hotel Ranola where you can spend a happy weekend or a week soaking up some of the best culture in the state. Enjoy a sitting room and fully equipped kitchen, which includes a Keurig coffeemaker. Take a drink up to the rooftop deck one evening. From US$179 for a queen room. Adults only; no pets. tel: (941) 951-0111; hotelranola.com.

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1-888-647-7327 FEBRUARY 2015 • Doctor’s

Review

For your adult patients with type 2 diabetes

Equipped for glycemic control. Trajenta® is indicated in adult patients with type 2 diabetes mellitus (T2DM) to improve glycemic control. • Monotherapy: In conjunction with diet and exercise in patients for whom metformin is inappropriate due to contraindications or intolerance. • Combination therapy: • With metformin when diet and exercise plus metformin alone do not provide adequate glycemic control. • With a sulfonylurea when diet and exercise plus a sulfonylurea alone do not provide adequate glycemic control. • With metformin and a sulfonylurea when diet and exercise plus metformin and a sulfonylurea do not provide adequate glycemic control. Please refer to the product monograph at www.TrajentaPM.ca for important information relating to contraindications, warnings, precautions, adverse events, drug interactions, dosing and conditions of clinical use. The product monograph is also available by calling 1-800-263-5103 ext. 84633. Jentadueto™ (linagliptin/metformin hydrochloride) is indicated as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus when treatment with both linagliptin and metformin is appropriate, in patients inadequately controlled on metformin alone or in patients already being treated and well controlled with the free combination of linagliptin and metformin. Jentadueto™ is also indicated in combination with a sulfonylurea (i.e., triple combination therapy) as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus inadequately controlled on metformin and a sulfonylurea. Please refer to the product monograph at www.JentaduetoPM.ca for contraindications, warnings, precautions, adverse reactions, drug interactions, dosing and conditions of clinical use. The product monograph is also available by calling 1-800-263-5103 ext. 84633.

Trajenta® is a registered trademark used under license by Boehringer Ingelheim (Canada) Ltd. Jentadueto™ is a trademark used under license by Boehringer Ingelheim (Canada) Ltd.

BITRJ00110 CATRJ00110

GA D GE T S by

T he o S a n d s

Along for the ride Most of us spend far more time in our cars than we care to admit. Why not, then, make your driving environment as convenient, comfortable — and safe — as you can. Here are a few after-market enhancements designed to boost the pleasure you take in your vehicle. All are available at amazon.ca. When you’re driving it’s essential that all of your cell-phone calls, incoming and outgoing, be hands-free. Most new vehicles come equipped with a hands-free system, but there are some out there that don’t have the feature. If yours is one of them, don’t hesitate: this is something every car you own must have. The Signstek Portable Multipoint Wireless Hands-Free Bluetooth Sun Visor In-Car Speakerphone Car Kit ($23), pictured right, is a basic system at an excellent price. Why stop with just your cell phone? Take it up a level with the GOgroove FlexSMART X2 ($63), pictured bottom right, which adds music controls and also has connections to charge your smartphone and MP3 player. If your in-car navigation system is more than a couple of years old you can almost certainly benefit from a newer, standalone model. Highly detailed voice prompts and enhanced traffic advice are hallmarks of the Garmin nüvi 2597LMT 5-Inch Bluetooth Portable Vehicle GPS ($206), which comes with with lifetime maps and traffic. Not ready to layout quite so much money? A good alternative is the free Google Maps app for iOS and Android. Something to hold your cell while you drive is another necessity. The one-piece Flexible Air Vent Cushioned Cradle Car Mount ($13) does the trick. Jump-starts are synonymous with Canadian winters and they can be hard to find when you need them. The BESTEK 13600mAh Multi-function Portable Car Jump Starter ($76), pictured left, gets solid reviews and also comes with cables for most electronic equipment as well as a powerful flashlight. While you’re at it, prepare yourself for most summer or winter road emergencies with the versatile Superex SAFE TO GO 97-127 Winter Roadside Kit ($34), which includes an escape tool and a roadside flasher as part of a complete package that should see you through most roadside mishaps.

FEBRUARY 2015 • Doctor’s

Review

FOR THE TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS ACTONEL DR SHOULD BE TAKEN IN THE MORNING WITH BREAKFAST

ON THE GO

TAKING IT SLOW

EITHER WAY, IT’S BREAKFAST AS USUAL.* Actonel DR® is the only oral bisphosphonate designed to be taken with breakfast.1†

VERE O C BY MOST

PRIVATE DRUG PLANS‡, ODB and EDS in SK

Please consult the product monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp by searching for ACTONEL DR for additional important information including adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available on request through our medical department at 1-855-892-8766. * Breakfast may include high fat foods, coffee, tea, milk, orange juice, etc. A higher incidence of upper abdominal pain was seen when ACTONEL DR was taken in a fasted state before breakfast. ACTONEL DR tablet should be swallowed whole (not chewed, cut or crushed) while in an upright position and with sufficient plain water (≥120 mL). Patients should not lie down for at least 30 minutes after taking ACTONEL DR. † Comparative clinical significance not established. ‡ Based on a coverage survey conducted by Equilibrium Health, July 2012. ODB: Ontario Drug Benefit; EDS: Exception Drug Status; SK: Saskatchewan Consult formulary for full coverage information. Reference: 1. Warner Chilcott Canada Co. ACTONEL and ACTONEL DR Product Monograph, Toronto, July 3, 2013. ACTONEL DR® is a registered trademark of Warner Chilcott Company, LLC. © 2015 Actavis Specialty Pharmaceuticals Co., Mississauga, ON. All rights reserved.

TAKE WITH BREAKFAST *

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings compiled by Camille Chin

Canada Toronto, ON June 3-6 17th Annual Conference of the International Society for Bipolar Disorders isbd2015.com

June 20-25

June 24-27 92nd Annual Conference of the Canadian Paediatric Society annualconference.cps.ca

Vancouver, BC June 8-13 23rd World Congress of Dermatology derm2015.org

CLAUDIO ZACCHERINI / SHUTTERSTOCK.COM

XXV Congress of the International Society on Thrombosis and Haemostasis isth2015.com

Hong Kong’s Cat Street.

Boston, MA June 5-9

Hong Kong, China June 6-9

Around the world

75th Scientific Sessions of the American Diabetes Association professional.diabetes.org

6th World Glaucoma Congress worldglaucoma.org

Athens, Greece June 14-18

Budapest, Hungary June 23-25

12th World Congress of Biological Psychiatry

2015 International Scientific Conference on Probiotics and Prebiotics probiotic-conference.net

July 25-27 20th World Congress on Heart Disease cardiologyonline.com/wchd2015/index.html

wfsbp-congress.org

Barcelona, Spain June 6-10 2015 Annual Congress of the European Academy of Allergy and Clinical Immunology eaaci2015.com

Crete, Greece June 21-25 14th World Congress in Fetal Medicine fetalmedicine.org/fmf-world-congress

Krakow, Poland June 25-28 14th International Congress on Pediatric Pulmonology cipp-meeting.org

To register and to search 2500+ 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 conferences in these cities... and many more! FEBRUARY 2015 • Doctor’s

Review

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings Kuching, Malaysia June 3-6 24th Asian and Oceanic Congress of Obstetrics and Gynaecology aocog2015.com

Miami, FL June 22-25 2015 Annual Meeting of the American Society of Clinical Psychopharmacology ascpp.org/ascp-meetings/ascp-annual-meeting

25th European Meeting on Hypertension and Cardiovascular Protection esh2015.org

June 21-24 EHRA Europace – Cardiostim 2015 escardio.org/congresses/ehra-europace-2015

Hohensalzburg Fortress in Austria.

Nice, France June 9-13

Prague, Czech Republic June 21-24

San Francisco, CA June 8-12

40th Annual Meeting of the International Urogynecological Association iugameeting.org

16th International Coeliac Disease Symposium icds2015prague.com

42nd Annual Meeting of the International Society for the Study of the Lumbar Spine issls.org/meetings

Rome, Italy June 10-13 16th Annual Congress of the European League Against Rheumatism congress.eular.org

Salzburg, Austria June 27-30 7th International Conference on Children’s Bone Health www.iccbh.org

San Diego, CA June 24-27 EMI CRISTEA / SHUTTERSTOCK.COM

2015 Annual Meeting of the Federation of Clinical Immunology Societies focisnet.org

Rome’s Basilica of St. John Lateran.

Doctor’s Review • FEBRUARY 2015

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

Vienna, Austria June 6-9 2015 Congress of the European Society of Ophthalmology soe2015.org

Vilnius, Lithuania June 10-13 26th Annual Meeting of the European Society of Paediatric and Neonatal Intensive Care espnic.kenes.com

Washington, DC June 18-21 57th Annual Scientific Meeting of the American Headache Society americanheadachesociety.org

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Milan, Italy June 12-15

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Where can you turn for help in preventing

* MENB? Serogroup B has become the most common invasive meningococcal disease (IMD) serogroup to affect Canadians (2007).1 Percentage of reported IMD cases by age and serogroup, Canada (2007)1,† AMONG INFANTS <1 year of age Other serogroups 20%

AMONG CHILDREN 1-4 years of age

AMONG ADOLESCENTS 15-19 years of age‡

Other serogroups 33%

B 80%

B 67%

Other serogroups 38%

B 62% ‡BEXSERO® is used in individuals 2 months through 17 years of age.

Introducing

BEXSERO

BEXSERO® is indicated for active immunization of individuals from 2 months through 17 years old against invasive disease caused by N. meningitidis serogroup B strains. Refer to the page in the bottom right icon for additional safety information and for a web link to the Product Monograph discussing t $POUSBJOEJDBUJPOT JO JOEJWJEVBMT XIP BSF IZQFSTFOTJUJWF to the BEXSERO® vaccine or to any ingredient in the formulation or components of the container closure.

The ﬁrst and only vaccine indicated for active immunization against invasive meningococcal disease caused by serogroup B strains.1,2,§

t 3FMFWBOU XBSOJOHT BOE QSFDBVUJPOT SFHBSEJOH temperature elevation following vaccination of infants and children (less than 2 years of age), postponement of the administration of BEXSERO ® in subjects suffering from an acute severe febrile illness, thrombocytopenia, hemophilia or any coagulation disorder that would contraindicate intramuscular injection, impaired immune responsiveness, not administering by intravascular, intravenous, subcutaneous or intradermal injection, not mixing with other vaccines in the same syringe, availability of appropriate medical treatment and supervision in

case of an anaphylactic event following administration of the vaccine, risk of apnoea in premature infants and need for respiratory monitoring, known history of hypersensitivity to latex, hypersensitivity to kanamycin, that protection against invasive meningococcal disease caused by serogroups other than serogroup B should not be assumed and that as with any vaccine, BEXSERO® may not fully protect all of those who are vaccinated. t $POEJUJPOT PG DMJOJDBM VTF BEWFSTF SFBDUJPOT ESVH interactions and dosing instructions.

*MenB: meningococcal disease caused by serogroup B. †In 2007, in infants <1 year old, 20 out of 25 reported IMD cases were caused by serogroup B, in children 1-4 years old, 18 out of 27 reported IMD cases were caused by serogroup B and in 15-19-year-olds, 18 out of 29 reported IMD cases were caused by serogroup B. §Comparative clinical signiﬁcance is unknown.

References: 1. National Advisory Committee on Immunization. Update on the use of quadrivalent conjugate meningococcal vaccines. Can Commun Dis Rep. 2013; 39(ACS-1):1-40. 2. BEXSERO ® Product Monograph. Novartis Pharmaceuticals Canada Inc. December 6, 2013. Novartis Pharmaceuticals Canada Inc. Dorval, Québec H9S 1A9 www.novartis.ca T: 514.631.6775 F: 514.631.1867

BEXSERO is a registered trademark. Product Monograph available on request. Printed in Canada ©Novartis Pharmaceuticals Canada Inc. 2014 13BEX017E

Be informed. Be immunized.

See additional safety information on page xxxx 55

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

R os e F os t e r

The long and short of bimodal sleep Lying down for eight straight hours used to be a bad thing

ur not-so-distant ancestors had no trouble getting to sleep at night. In fact, they

did it more than once. “Bimodal sleep,” as it’s called now, may have been their answer to not only sweet dreams, but to a deeper overall sense of peace. How did we sleep before we began to sleep the way most of us do today? What can we learn from sleeps past? Sleep historian Roger Ekrich knew he was onto something when he started keeping track of references to “two sleeps” in old books, diaries, medical papers and hundreds of other documents, including the Bible. Sixteen years of research led him on a journey through countless mentions of “first sleep” and “second” or “morning” sleep. A character in Chaucer’s Canterbury Tales sleeps “hire fyrste sleep & thanne a-wok.” A 16th century French physician concludes that the working class produces more offspring due to their practice of waiting until after their “premier sommeil” to conceive. In Homer’s Odyssey, book four, Proteus’s daughter Eidothea tells Menelaus to seize her father “in his first sleep.” And in Latin texts, there are multiple references to primo somno or concubine nocte. Ekrich published his findings in a 2009 book entitled At Day’s Close: Night in Times Past. First or “deep” or “dead” sleep, as it was sometimes called, often seems to have taken place shortly after sunset, or at least before 10 in the evening. After two to four hours of the night’s deepest rest, people would wake up for an hour or two, then resume sleep for another stretch before rising with the light. Ekrich was struck by the ordinariness of the mention of first and second sleeps, as though it were a practice so commonplace as to be truly unworthy of explanation. And while he suspected that sleeping twice in a single night might have been healthier than the unbroken eight-hour sleep that today is considered the epitome of a good night’s rest, what

Night prayers have long been practiced by many faiths and often took place between two short sleeps.

really impressed him was what people got up to in that deep dark hour of wakefulness between sleeps. One thing was clear: the absolute darkness and silence of the hour made it a perfect time for prayer. In fact, further evidence of the naturalness of sleeping twice can be found in Islam, which strongly suggests that its devotees include a prayer, called the Tahajjud, between sleep in the final third of the night. Some Christian churches hold regular midnight masses and historically members of oppressed religions found the so-called witching hour the perfect time to gather and pray. Monks of all traditions have considered the time of absolute stillness as ideal for meditation. Dream analysis, love-making and creative ruminations were also favourite activities during “the FEBRUARY 2015 • Doctor’s

Review

Did waiting to make love until the second sleep produce more offspring? watch,” another name given to midnight wakings. Thomas Jefferson, the third president of the United States, was in the habit of taking up books on moral philosophy before bed with the intention of waking after his first sleep to “ruminate” over them. A century earlier, poet Francis Quarles (1592-1644) praised the hour between sleeps, saying, “Let the end of thy first sleep raise thee from thy repose: then hath thy body the best temper, then hath thy soul the least encumbrance; then no noise shall disturb thine ear; no object shall divert thine eye.” An odd handful of modern creatives have extolled the virtues of what is today considered an eccentric practice. Architect Frank Lloyd Wright woke at four, worked for several hours, and then resumed sleep. Psychologist B.F. Skinner kept paper and pen at his bedside for night wakefulness, and Nobel-Prize-winning Norwegian novelist Knut Hamsun regularly woke in the dead of night to write.

LOSS OF WATCHFULNESS? When the majority of us lost the practice of sleeping twice, we not only meddled with our circadian rhythms, we lost our connection to the serenity of the watchful but somnolent state, an oceanic consciousness that honoured our right-brain capacities. Could the loss of this nighttime immersion in dreamy pontifications and meditative merging with the divine be at least partly responsible for the current proliferation of anxiety and mood disorders which often lead to sleeplessness?

Doctor’s Review • FEBRUARY 2015

Eye-opening studies of shut-eye made in the ’90s support the concept of bimodal sleep as a natural human tendency, and also suggest that there’s a hormonal component to the peace we feel in the middle of the night. Thomas Wehr, now a scientist emeritus at the National Institute of Mental Health, has done some interesting work in photoperiodicity, or how exposure to light affects sleep. In the early 1990s, he placed 14 volunteers in total darkness for 14 hours a day every day for a month. After a period where they slept in the dark an average of 11 hours, the subjects settled into a pattern of sleeping for an average of eight hours a night in two segments, separated by an hour or two of contemplative wakefulness. Wehr hypothesized that this was a return to a more primitive pattern of sleep. Other studies have shown that during the period of wakefulness, the pituitary gland excretes high levels of prolactin, the hormone associated with the surreal hallucinatory pre-sleep state. Prolactin is also the hormone produced when nursing mothers lactate, as well as during orgasm. So how exactly were we robbed of the pleasures of segmented sleep? The first demons to disrupt our ancient sleep patterns were artificial lighting and clocks. That old saying about burning the candle at both ends is evidence that as soon as people had the means to eat away at the night, they did. But time, or rather, the keeping track of it, was the more powerful enemy. Before mechanical clocks replaced sundials, the night was a mysterious realm which could not be subdivided into minutes and seconds. Clocks and personal time pieces went hand in hand with industrialization and quickly became the instru-

PROPERTY OF THE REZA-YE ABBASI MUSEUM IN TEHRAN

LEFT: Detail of a 16th-century Persian miniature showing a Sufi meditating in the dark trunk of a çinar tree. ABOVE: The nightmare (1796) by John Henry Fuseli was painted during a period when bimodal sleep was common and is said to depict both the dreamer and the dream. OPPOSITE PAGE: Hypnos, the Greek depiction of sleep, is shown in this Roman relief protecting a sleeping woman.

ments which undid sleep as it has been practiced for millennium. Clock-time introduced the concept of “wasting time” and what could be more wasteful than lying in the dark doing nothing with no explicable reason to do so? Tiredness and the need for sleep increasingly became a sign of moral lassitude. As the popularity of street lighting grew, the night retreated. Paris was the first to light its streets, using wax candles in glass lanterns in 1667, followed closely by Lille, Amsterdam and eventually London. By the time the candles were replaced with gas, people had lost most of their associations of night with thieves, fierce animals and witches. As bedtimes grew later and later, references to “two sleeps” began to fade and to be seen as a bad thing. Parents were even encouraged to purge their children of any night-waking tendencies. An article in an 1829 British medical journal instructs parents that, “If no disease or accident there intervene, they will need no further repose than that obtained in their first sleep, which custom will have caused to terminate by itself just at the usual hour. And then, if they turn upon their ear to take a second nap, they will be taught to look upon it as an intemperance not at all redounding to their credit.”

SLEEPLESS DISASTERS What do the Exxon Valdez oil spill, the nuclear incidents at Chernobyl and Three Mile Island, and the explosion of the space shuttle Challenger have in common? They are all the casualties of sleep deprivation. In recent years, the whittling away of sleep has been blamed, in the literature, for everything from accelerated aging, obesity, heart attacks, cancer and neurodegenerative disease. The 24-hour garbage cycle takes a heavy toll on the environment. So should we all revert to our primitive ways? One online group, the Polyphasic Society, encourages the establishment of broken sleep schedules and hosts forums on “sleep hygiene” and the exploration of personal sleep patterns. But some sleep experts express caution at the idea of reverting to bimodal sleep. Considering today’s busy schedules, they fear people would grab the first sleep but skip the second, leaving many more exhausted than they already are. The current thinking is that it’s best to stick to the old stalwart — seven to eight hours — a night, maintain regular bedtimes and pay off “sleep debts” as soon as possible. FEBRUARY 2015 • Doctor’s

Review

Contraindications: • Patients with severe hypersensitivity to milk proteins. Most Serious Warnings and Precautions: Precautions • ASTHMA-RELATED DEATH: Long-acting beta2-adrenergic agonists (LABA) increase the risk of asthma-related death. Data from a large, placebo-controlled US study that compared the safety of another long-acting beta2-adrenergic agonist (salmeterol) to placebo added to usual asthma therapy, showed an increase in asthma-related deaths in patients receiving salmeterol. This finding with salmeterol is considered a class effect of LABA, including vilanterol, the active ingredient in BREO® ELLIPTA®. • BREO® ELLIPTA® is only indicated for COPD. • The safety and efficacy of BREO® ELLIPTA® in patients with asthma have not been established. BREO® ELLIPTA® is not indicated for the treatment of asthma. Other Relevant Warnings and Precaution: Precaution • BREO® ELLIPTA® should not be used to treat acute symptoms of COPD (i.e., as rescue therapy for the treatment of acute episodes of bronchospasm) and should not be initiated in patients with acutely deteriorating COPD. • Patients who have been taking a rapid onset, short duration, inhaled bronchodilator on a regular basis (e.g., q.i.d) should be instructed to discontinue the regular use of these drugs and use them only for symptomatic relief if they develop acute symptoms while taking BREO® ELLIPTA®. • Exacerbations may occur during treatment. Patients should be advised to continue treatment and seek medical advice if COPD symptoms remain uncontrolled or worsen after initiation of therapy. • BREO® ELLIPTA® should not be used more often than recommended, at higher doses than recommended, or in conjunction with other medicines containing a LABA, as an overdose may result. • Caution in patients with cardiovascular disease: vilanterol can produce clinically significant cardiovascular effects in some patients as measured by an increase in pulse rate, systolic or diastolic blood pressure, or cardiac arrhythmias such as supraventricular tachycardia and extrasystoles. In healthy subjects receiving steady-state treatment of up to 4 times the recommended dose of vilanterol (representing a 12-fold higher systemic exposure than seen in patients with COPD) inhaled fluticasone furoate/vilanterol was associated with dosedependent increases in heart rate and QTcF prolongation. Use with caution in patients with severe cardiovascular disease, especially coronary insufficiency, cardiac arrhythmias, hypertension, a known history of QTc prolongation, risk factors for torsade de pointes (e.g., hypokalemia), or patients taking medications known to prolong the QTc interval. • Effects on Ear/Nose/Throat: Localized infections of the mouth and pharynx with Candida albicans. • Endocrine and Metabolic effects: possible systemic effects include Cushing’s syndrome; Cushingoid features; and HPA axis suppression. • Hypercorticism and adrenal suppression (including adrenal crisis) may appear in a small number of patients who are sensitive to these effects. Doses of the rapid onset, short duration, beta2 adrenoceptor agonist salbutamol, when administered intravenously, have been reported to aggravate pre-existing diabetes mellitus and ketoacidosis. • Adrenal insufficiency: particular care should be taken in patients transferred from systemically active corticosteroids because deaths due to adrenal insufficiency have occurred during and after transfer to less systemically available inhaled corticosteroids. • Bone Effects: An increase in the incidence of bone fracture has been observed in COPD patients. Decreases in BMD have been observed with long-term administration of products containing inhaled corticosteroids. • Monitoring recommendations: Serum potassium levels should be monitored in patients predisposed to low levels of serum potassium. Due to the hyperglycemic effect observed with other beta-agonists, additional blood glucose monitoring is recommended in diabetic patients. Patients with hepatic impairment should be monitored for corticosteroid effects due to potentially increased systemic exposure of fluticasone furoate. • Use with caution in patients with convulsive disorders or thyrotoxicosis and in those who are unusually responsive to sympathomimetic amines.

BREO and ELLIPTA are registered trademarks, used under license by GlaxoSmithKline Inc. BREO® ELLIPTA® was developed in collaboration with Theravance, Inc. © 2014 GlaxoSmithKline Inc. All rights reserved. ®

• Hematologic effects: may present with systemic eosinophilic conditions, with some patients presenting clinical features of vasculitis consistent with Churg-Strauss syndrome. Physicians should be alerted to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients. • Hypersensitivity effects: immediate hypersensitivity reactions have occurred after administration, and patients should not be re-challenged with BREO® ELLIPTA® if it is identified as the cause of the hypersensitivity reaction. There have been reports of anaphylactic reactions in patients with severe milk protein allergy with other inhaled dry powder drug products containing lactose. • Immune effects: greater susceptibility to infections. Administer with caution and only if necessary in patients with active or quiescent tuberculosis infections of the respiratory tract; chronic or untreated infections such as systemic fungal, bacterial, viral, or parasitic; or ocular herpes simplex. Chickenpox and measles can have a more serious or even fatal course in susceptible patients using corticosteroids. In such patients who have not had these diseases or been properly immunized, particular care should be taken to avoid exposure. • Ophthalmologic effects: Glaucoma, increased intraocular pressure, and cataracts. Close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma, and/or cataracts. • Respiratory effects: paradoxical bronchospasm may occur with an immediate increase in wheezing after dosing. This should be treated immediately with a rapid onset, short duration inhaled bronchodilator. BREO® ELLIPTA® should also be discontinued immediately, the patient assessed, and alternative therapy instituted if necessary. An increase incidence of pneumonia, and pneumonias resulting in hospitalization, has been observed with inhaled fluticasone furoate/vilanterol in COPD patients. In some incidences these pneumonia events were fatal. Physicians should remain vigilant for the possible development of pneumonia in patients with COPD as the clinical features of such infections overlap with the symptoms of COPD exacerbations. COPD exacerbations may occur during treatment. Patients should be advised to continue treatment and seek medical advice if symptoms remain uncontrolled or worsen after initiation of therapy. Patients should not stop therapy without physician supervision since symptoms may recur after discontinuation. • Drug interactions: caution should be exercised when considering coadministration with inhibitors of cytochrome P450 3A4; inhibitors of P-glycoprotein (P-gp); sympathomimetic agents; beta-adrenergic receptor blocking agents; non potassium sparing diuretics (i.e. loop or thiazide diuretics); drugs that prolong the QTc interval (e.g. monoamine oxidase inhibitors and tricyclic antidepressants); xanthine derivatives; and acetylsalicylic acid. Adverse Events: Adverse reactions reported at a frequency of ≥1% 1% from two 6-month placebo-controlled clinical studies of BREO® ELLIPTA® 100/25 mcg included: nasopharyngitis (9%); upper respiratory tract infection (7%); oropharyngeal candidiasis (5%); sinusitis (2%); bronchitis (1%); pharyngitis (1%); headache (7%); back pain (2%); COPD (2%); cough (2%); nausea (1%); ventricular extrasystoles (1%); and pyrexia (1%). Dosage and Method of Administration: Administration The recommended dose of BREO® ELLIPTA® 100/25 mcg is one oral inhalation once daily, administered at the same time every day (morning or evening). After inhalation, patients should rinse their mouth with water (without swallowing). If a dose is missed, the patient should be instructed not to take an extra dose, and to take the next dose when it is due. Dosing Considerations • For optimum benefit, advise patients that BREO® ELLIPTA® must be used regularly, even when asymptomatic. • No dosage adjustment is required in patients over 65 years of age, or in patients with renal or hepatic impairment. For More Information: Please consult the Product Monograph at http://gsk.ca/breo/en for important information relating to adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374.

ONC e ve r

24 h y

BREO ELLIPTA ®

The first and only once-daily ICS/LABA combination for COPD.* BREO® ELLIPTA® (fluticasone furoate/ vilanterol) is indicated for the long-term oncedaily maintenance treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema, and to reduce exacerbations of COPD in patients with a history of exacerbations. BREO® ELLIPTA® is not indicated for the relief of acute bronchospasm in COPD. BREO® ELLIPTA® is not indicated for the treatment of asthma. BREO® ELLIPTA® is not indicated for use in children and should not be used in patients <18 years of age. *Comparative clinical significance is unknown.

fluticasone furoate / vilanterol

Practical once-daily dosing.

00416 12/14

D E P R E S S I O N COL L A B OR A T I V E CA R E b y bSusan Usher y Valerie Taylor,

MD, FRCPC, PhD

Who treats depression? How do Canadians suffering from depression find their way to treatment? The short answer is: with great difficulty. Access to mental health care remains a spot on Canada’s record despite attention from national and provincial governments. Psychiatrists are increasingly difficult to access, hospitalizations are shorter and family physicians are expected to make up the difference. Some are succeeding better than others, however only 28% of Canadians agree they are getting the best treatment possible for their depression.1

Hospitals Hospitalization rates for mood disorders remain a considerable 34%.2 Those who are admitted spend only half as long in hospital as they would have a decade ago (16.7 days in 2008 vs. 36.2 days in 2000).3 In the 30 days following discharge, fewer than half manage to see a psychiatrist; almost 20% visit the ER and around 7% are readmitted to hospital.4

Psychiatrists There are currently about 4400 psychiatrists in Canada. Over half are over age 55. Psychiatrists per 100,000 people range from a low of 2 in the NWT to a high of 15 in Nova Scotia.5 Among psychiatrists themselves, 40% rate access as fair or poor.5 Shortages are especially acute in rural and northern areas.6 In a study conducted in Vancouver to shed light on wait times, an enterprising researcher called 230 psychiatrists to take a referral from a family physician for an adult male patient with depression; 70% stated they were unable to accept the referral and only 9% of those who said they could consider accepting the referral provided wait time estimates (between 4 and 55 days).7 The Canadian Medical Association’s 2010 supply estimates see the total number of psychiatrists increasing, but the number per 100,000 population continues to drop, from a Canadian average of about 13.9 to 11.9 by 2013.5

Family physicians Over 80% of those with mental health problems receive care exclusively within the primary care system.8 Ideally, family physicians provide their patients with a medical home and can see them quickly when help is needed. In reality, 4.4 million Canadians do not have a family physician9 and practitioners continue to struggle to align their practices and training to meet the mental health needs of their populations.

Doctor’s Review • FEBRUARY 2015

Dr Jeffrey Habert is a family physician in Thornhill, Ontario. Like most busy family physicians, mental health issues constitute a significant part of his practice. He is also involved in educating family physicians about depression in primary care and gives lectures about this topic. He has seen significant improvement over his 25 years in practice. “The biggest change is that family doctors have gotten better at treating depression. They’re much more knowledgeable and comfortable than they were 10 or 15 years ago. The availability of more drugs, drugs that are better tolerated and more education has contributed to this.” The main concerns he hears from colleagues are about the management of patients who do not respond to first-line treatment, especially given the difficulty of referrals to psychiatrists. “We’re trying to focus (educational efforts) on enabling family doctors to go down the treatment tree on their own,” says Dr Habert. Other challenges are screening for depression, which is still not done regularly; arranging prompt (i.e. within one to three weeks) follow-up visits for patients who screen positive; and learning how to promote adherence to therapy to counter high discontinuation rates in antidepressant treatment. Improvement on all fronts requires education. “In British Columbia,” says Dr Habert, “they provide funding to the GPs for further education. Ontario doesn’t have that.” The BC program stands out as exemplary. The province’s General Practice Services Committee (GPSC) started offering supplemental training to improve GPs ability to diagnose and treat mental health problems in 2009. GPs were compensated for taking the course and almost 1000 participated in the first year. In an article in The Globe and Mail, BC GP Dr Bruce Hobson of Powell River, BC, said it was the biggest improvement in his 28 years of practice. He estimated that he used his new skills every day with more than 50% of his patients.10 BC also adjusted its fee schedule to encourage family physicians to take on the management of community-dwelling patients with mental health problems.11

Collaborative mental health care The shared care, or collaborative care model, has been proposed as a means of providing family physicians the support they need. Dr Habert points to the McMaster Collaborative Mental Health Care program as an ideal model. “At McMaster there are nurse practitioners and psychiatrists available to help the family physician. The patient can be triaged or assessed by the nurse practitioner, the family physician will give an opinion and, if more expertise is needed, the family physician has easy access to a psychiatrist. That

model, where you have one psychiatrist helping 10 or 20 family physicians, is beautiful.” Evidence from Canadian programs over the last five years suggests that shared care leads to better access, decreased wait times, decreased hospitalizations and outpatient visits, decreased prescriptions and more efficient use of secondary resources.12 A position paper was developed by the Canadian Psychiatric Association and the College of Family Physicians of Canada Collaborative Working Group on Shared Mental Health Care in 2010 to outline the features and advantages of collaborative practice. It emphasized shared goals, regular communication and equitable decision-making as what define collaboration.13 However, collaborative models require the availability of psychiatrists and that, for the time being, remains elusive. Numbers are part of the problem, but Dr Habert sees a need to change practice models as well. “After they’re sent for referral (to a psychiatrist), patients are hesitant to leave, as opposed to a model where the psychiatrist sees a patient a few times to resolve an immediate issue and then sends them back to the family physician. In that model, we’d have more psychiatrists available.” Research in Ontario bears that out, showing that urban psychiatrists see fewer patients more often, while rural psychiatrists see a greater number of patients less frequently. Psychiatrists in Ottawa and Toronto were found to see half as many different and new patients a year as psychiatrists practicing elsewhere in the province.4 Whether psychiatrists or family physicians assume responsibility, treatment of mood disorders often requires more and longer visits over an extended period of time. Collaborative care holds promise for improving access to care for depression and other mental health conditions, but the road ahead includes some important hurdles. For the moment, Dr Habert states very frankly, “there’s isn’t a lot of it around.”

Interested in broadening your mental health care practice? According to the OMA, out of the 10,641 family physicians in Ontario (2005 numbers), fewer than 500 conduct psychotherapy as a major part of their practice.12 The General Practice Psychotherapy Association supports medical psychotherapy by physicians in Canada and provides ongoing education and training. See www.gppaonline.ca for programs near you.

Look for action in your region on the following gaps13: 1. Support for the restructuring of primary care practices, the introduction of information technology 2. Models of remuneration to compensate physicians for participation in collaborative activities 3. Time constraints faced by providers in primary care and psychiatry 4. Lack of clarity regarding medico-legal standards and documentation requirements 5. Lack of preparation of medical students to work collaboratively with other specialties and disciplines 6. Lack of access to family physicians They will make all the difference. References 1. Mood Disorders Society of Canada. Quick Facts: Mental Illness and Addiction in Canada November 2009, 3rd Edition, page 8. Retrieved from http://www. mooddisorderscanada.ca/documents/Media%20Room/Quick%20Facts%203rd% 20Edition%20Referenced%20Plain%20Text.pdf. Accessed January 18, 2015. 2. Mood Disorders Society of Canada (2009), page 28. 3. Canadian Institute for Health Information (CIHI). Hospital Mental Health Services in Canada 2005–2006. Ottawa, 2008, page 3. 4. Kurdyak P. A Study of Psychiatrist Supply and Practice Patterns in Ontario. Presented at the 2011 Ontario Psychiatric Outreach Program conference. Retrieved from http://www.opop.ca/CMFiles/Publications/Annual%20Retreats/ 2011/Psychiatrist%20Supply_15_9_11.pdf. Accessed January 18, 2015. 5. Canadian Collaborative Centre for Physician Resources. 2010 National Physician Survey. Retrieved from https://www.cma.ca/Assets/assets-library/document/en/ advocacy/25-Psychiatry-e.pdf. Accessed January 18, 2015. 6. Canadian Psychiatric Association. FAQ. Retrieved from http://www.cpa-apc.org/ browse/documents/19. Accessed January 18, 2015. 7. Goldner EM1, Jones W, Fang ML. Access to and waiting time for psychiatrist services in a Canadian urban area: a study in real time. Can J Psychiatry 2011. 8. Canadian Mental Health Association – BC Division. Improving Primary Care Mental Health Services. 2012. Retrieved from http://www.cmha.bc.ca/get-informed/ public-issues/primarycare. Accessed January 18, 2015. 9. Wait Times Alliance. Time to Close the Gap: Report Card on Wait Times in Canada 2014. Retrieved from http://www.waittimealliance.ca/wp-content/uploads/2014/ 06/FINAL-EN-WTA-Report-Card.pdf. 10. Globe and Mail, March 17, 2011. 11. GP Services Committee. Mental Health Incentives 2011. Retrieved from http:// www.gpscbc.ca/system/files/GPSC_Mental_Health_Initiative_Billing_GuideRevised_May_2011_0.pdf. Accessed January 18, 2015. 12. Centre for Applied Research in Mental Health and Addiction. Family Physician Guide for Depression, Anxiety Disorders, Early Psychosis, and Substance Use Disorders. BC Ministry of Health 2008. Retrieved from http://www.health.gov. bc.ca/library/publications/year/2008/fpg_full.pdf. Accessed January 18, 2015. 13. Kates N et al. The Evolution of collaborative mental health care in Canada: A shared vision for the future. Can J Psychiatry, 2008; 56(5-insert). FEBRUARY 2015 • Doctor’s

Review

In major depressive disorder

“I felt down and

overwhelmed nearly every day.” Nicole*, 37

For patients like Nicole...

Trust PRISTIQ

for powerful

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

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

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

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

CA0113PRI023E

Count on

for powerful symptom relief

Some tours with Gawler Ranges Wilderness Safaris include a visit to Sturt Lake.

Plunge into

secret Australia

A swim with tuna, dolphins and sea lions is only the start of the adventure on the Eyre Peninsula by Margo Pfeiff

ALL PHOTOS JIM HUTCHISON

roperly wet-suited, I pulled on my mask and slipped into the chilly water of a huge netted open ocean pen and found myself face-to-face with great mob of bluefin tuna. I’ve been up close and personal with a lot of sea life in my time, but this was the first time I ever swam with sushi. Two hours later, my next bluefin encounter was just that — hyper-fresh, melt-in-your-mouth sashimi served at Del Giorno’s café overlooking the Southern Hemisphere’s largest commercial fishing fleet at Port Lincoln, South Australia, west of Adelaide. Located at the very tip of the shark tooth-shaped Eyre Peninsula that bites into the nippy Southern Ocean, it’s a diverse, rugged, pristine and little-known tourism gem, even for Australians.

I’ve spent years in this part of the country with my buddy Jim who grew up here, but neither of us had ever hopped the 35-minute flight west from Adelaide to Port Lincoln. A rural hub of 14,000, we expected a sleepy fishing outpost. Boy, were we wrong. Instead we found chic hotels and bistro menus that listed free range everything and a roll call of abalone, oysters, kingfish, prawns, rock lobster, snapper, and much loved and sought after King George whiting. All that marine bounty adds up to a most profitable local trade. “Between the tuna barons, abalone

FEBRUARY 2015 • Doctor’s

Review

There are lots of opportunities to swim with dolphins and sea lions in Baird Bay.

The Coffin Bay oyster is known for its flavour and size.

The coastal landscape of Coffin Bay National Park includes windswept cliffs and massive dunes.

license holders and aquaculture folks there’s more millionaires per capita here than anywhere in Australia,” explained our guide, Dave Doudle, a chipper former wheat farmer. We first considered exploring the Eyre on our own with a rental car, but all but the main roads — including those wild, intriguing routes in the national parks — are sandy or unpaved tracks. So we left the driving to Dave, a chipper former wheat farmer who enthusiastically introduced us to his vast backyard. As we drove the coastline, the wheat fields on our right were straight out of Saskatchewan while on our left stretched endless Caribbean-calibre whitesand beaches. We started the tour with Port Lincoln’s handful of award-winning wineries. Lincoln Estate’s owner explained he pays the bills with a wild abalone operation, but spends days doing what he really loves, not only making wine that troupes of visiting Chinese and Japanese tuna buyers pair with sashimi, but running an animal park that offers close contact with Aussie creatures from kangaroos, dingos and hairy-nosed wombats to a rockin’ cockatoo who dances to anything by the Foo Fighters. At the next vineyard, Boston Bay Estate, host winemaker/master chef Tony Ford quipped, “We’re so close to the ocean we have to prune at low tide,” pouring his Great White sauvignon blanc, he went on to explain, “we have a Bordeaux climate with the ocean so close on both sides of the peninsula that temperatures are perfect for grapes”. So perfect, in fact, that Penfolds is looking to plant a vineyard for Australia’s iconic Grange Hermitage. How iconic? Prices for the 2010 vintage start at US$650 and top out north of US$2200.

he next day was all about tuna. We began with the aforementioned swim and sashimi then stopped in at the sleek new Fresh Fish Place, a seafood store/ cooking school/restaurant that’s also a processing facility where fisherman drop off their daily catches. The town holds an annual Tunarama Festival that once featured a tuna tossing competition (politically correct plastic ones now substitute) and crowns a Miss Tuna. The lucrative, often cutthroat local enterprises have even spawned two Discovery Channel reality shows, Tuna Wranglers and Abalone Wars. Heading to the west coast we walked dramatic beaches and scrambled up silky white dunes in Coffin Bay National Park. We picked up a dozen nationally coveted Coffin Bay oysters and relaxed on the waterfront with chilled wine watching pelicans glide past, kids fishing off jetties and cyclists pedalling the Oyster Trail. Soon it was time to go koala hunting. At the 245-hectare Mikkira sheep station, Bett de la Perelle and her husband restored an historic 1842 homestead and imported four koalas from Tasmania years ago.

PA RT O F T H E N OVA RTI S CO PD P O RT FO LI O

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.1 Consult the Product Monograph at www.novartis.ca/ SeebriMonograph for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph is also available by calling 1.800.363.8883. 1. SEEBRI ® BREEZHALER® Product Monograph. Novartis Pharmaceuticals Canada Inc., August 7, 2014

SEEBRI and BREEZHALER are registered trademarks. Product Monograph available on request. 14ULT040E © Novartis Pharmaceuticals Canada Inc. 2014

FEBRUARY 2015 • Doctor’s

Review

The bush environment around Mikkira Station is ideal for bird and koala watching, and picnics.

Some roads in Gawler Ranges National Park can only be accessed via four-wheel drive vehicles.

The author communed with a mob of roos (right) and a band of lorikeets at Glen Forest Tourist Park.

Dozens now lounge photogenically in the big gum trees, dreamily munching on eucalyptus leaves. Except for the occasional flock of screeching Granny Smith-green Port Lincoln parrots, it was a serene experience as we sipped tea and ate Lamingtons, that popular Ozzie confection made of sponge cake, chocolate syrup, desiccated coconut, strawberry jam and/or cream. After tea we headed out for our own Outback immersion. Kangaroos hopped by, emus strutted past and a koala “ran” slow motion across the road proving that those koala-crossing signs are not just for funning the tourists. A couple of hours later, we pulled into tiny Wudinna, 200 kilometres north of Port Lincoln, where Dave introduced us to “a crackin’ bloke,” Geoff Scholz, who piled us into his Land Cruiser and drove us further into “whoop-whoop,” Aussie for “the middle of nowhere.”

PA RT O F TH E N OVA RTI S CO PD P O RTFO LI O

Roos to the left of us, emus and cockatoos to the right, and masses of gilded lorikeets in every tree At the corner of two sign-posted, red-sand tracks, Rowley and Bartley Roads, he stopped. “The Outback officially starts right here,” he announced. In 1868 Goyder’s Line was drawn across South Australia to mark the limits of sustainable agriculture due to rainfall; the “Outer Regions” morphed into “Outback” which is exactly where Geoff, another ex-wheat farmer, and his wife run Gawler Ranges Wilderness Safaris, an African-style bush camp. After sipping sundowners overlooking a salt lake in the far flung Gawler Ranges, then lingering under a hot rainwater shower, I crashed in my spacious luxury canvas tent beneath a duvet and dreamt of Zambia.

chewing sound woke me in early morning. Half asleep, I peeked through the mesh window expecting a zebra or giraffe, but a chomping kangaroo startled me back to Australia. More roos sipped at the trough outside the dining tent as we ate breakfast. Then we were off for the day, skidding through white sand, bumping over hard red pan and pebbles. We poked around giant piles of baked dirt marking the entrances to labyrinthine wombat tunnels, a bane to farmers and sheep herders. Geoff spotted a shingleback skink lizard on the track and stopped to

ONBREZ® BREEZHALER® (indacaterol maleate) is a long-acting ß2 -agonist (LABA) indicated for long-term once-daily maintenance bronchodilator treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema.1 Consult the Product Monograph at www.novartis.ca/ OnbrezMonograph for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph is also available by calling 1.800.363.8883. 1. ONBREZ® BREEZHALER® Product Monograph. Novartis Pharmaceuticals Canada Inc., December 3, 2013.

ONBREZ and BREEZHALER are registered trademarks. Product Monograph available on request. 14ULT040E © Novartis Pharmaceuticals Canada Inc. 2014

FEBRUARY 2015 • Doctor’s

Review

Guests overnight in spacious luxury tents at Kangaluna Camp. BELOW: The Port Lincoln Seafood Cooking School offers up delicious seafood and teaches you how to cook it.

GOOD LIFE ON THE PENINSULA Port Lincoln is a 35-minute flight from Adelaide with service by RexJet (rexjet.com) and Qantas (qantas.com.au); both have high baggage rates. Port Lincoln Hotel (1 Lincoln Highway; portlincolnhotel.com.au; doubles from US$130) offers well-appointed rooms on the downtown waterfront. For a stylish boutique hotel with kitchens just out of town try Tanonga Luxury Eco-Lodges (Pope Drive, Charlton Gully; tanonga.com.au; doubles from US$250 with a two-night minimum stay). For the best local seafood, take a window seat at Del Giorno’s Café & Restaurant (80 Tasman Terrace; delgiornos.com.au). The Fresh Fish Place (20 Proper Bay Road; portlincolnseafood.com.au) offers seafood processing tours, tastings included. The onsite café serves fresh seafood lunches. Port Lincoln is also home to fantastic wineries including Lincoln Estate Wines (22 Lincoln Highway; lincolnestatewines.com.au) and Boston Bay Wines (Lincoln Highway; bostonbaywines.com.au). Delacolline Estate Wines (31 Whillas Road; delacollinewines.com.au) offers both food and drink served on a deck overlooking the ocean. Mikkira Station (Fishery Bay Road; mikkirakoalas.com) is 30 kilometres southwest of Port Lincoln and is a great place for picnics, koala spotting and camping. The Kangaluna Camp in the Gawler Ranges (gawlerranges safaris.com; from US$1650 per person for two nights, all meals and activities included) outside Wudinna offers guided Outback wilderness safaris living in luxury tents. For more info on travel to the region, go to the South Australia Tourism Commission (southaustralia.com/regions/eyre-peninsula.aspx) or Eyre Peninsula Tourism (exploreeyrepeninsula.com.au).

Doctor’s Review • FEBRUARY 2015

Who knew? It turns out sharks have a particular penchant for the beat of AC/DC pick him up. “We had a yard-long goanna come right into the camp kitchen every day for months,” he said. “We used to call him ‘The Captain’.” And then there were the mobs of wildlife — the universal Aussie measurement of anything in great numbers. In 35 years of visiting Outback Australia I’ve never seen anything like it, roos to the left of us, emus and brilliant cockatoos to the right, gilded lorikeets and shimmering splendid wrens perched like multi-coloured candles in the gum trees. “It’s unusual that we’ve got three kinds of roos in one area, big Reds, Greys and the less common Euros,” said Geoff. “The EU wanted to call their new currency European Monetary Units, but realized the acronym EMU is an Australian bird. So they named it EURO and learned later it was an Australian kangaroo!” We arrived just after noon at Lake Gairdner, a blindingly white 160-by-50-kilometre dry lake whose bed is a metre-deep slab of salt stretching to the horizon. Geoff spread a tailgate lunch and we watched wedge-tailed eagles ride thermals as teams of stokedup vehicles and motorcycles prepared for a weekend of remote madness, salt-lake racing. For three dry, warm days we awoke to the sounds of magpies and parrots, hiked amid strange rock formations in Gawler Ranges National Park, lingered over picnic lunches, dropped in at sheep stations and strolled through countless small salt pans filled with ankle deep water. Sunset signalled time for a cold beer before darkness set sky ablaze with stars. That’s when Geoff’s hefty telescope came out. We left early on our last day, heading straight to the west coast, dramatic and rugged cliffs that continued westward towards the stark Nullabor Plain. The trip had started with a critter swim and that’s how it ended at Baird’s Bay, a sheltered natural lagoon where a boat took us out to cavort with playful sea lions and pods of dolphins. As we slipped into wetsuits, our guide strapped on an ankle gadget that emitted electronic noise to keep sharks away, the same as local abalone divers wear. These are not to be confused with the electronic gadgets that chum the waters of Port Lincoln with music to attract Great White sharks towards cages bobbing like wire-mesh teabags and filled with adrenalin-charged divers (we weren’t surprised to learn the sharks have a particular penchant for the beat of AC/DC). We decided against visiting “whities” on their turf, however. If only to avoid becoming someone else’s sushi.

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FEBRUARY 2015 • Doctor’s

Review

Soul survivors The artists that emerged out of Macon, Memphis and Muscle Shoals, and the music that still moves us

by Josephine Matyas and Craig Jones

ou can tell a lot about a town by the music that spools from its borders. This is the story of a journey through three Southern centres, meccas for some of the 20th-century’s musical giants. Two of these

musical hubs are small — barely dots on a map — and one is a sprawling city, but all loom large on the stage of soul, R&B and rock, set in a time of America’s unfolding civil rights movement. Macon, Memphis and Muscle Shoals were like a melodious constellation.

Doctor’s Review • FEBRUARY 2015

In the 1950s, ’60s and ’70s, artists were constantly circling these three, dipping into the well of inspiration and coming away with hit after hit after hit. Consider the adage “there’s something in the water,” as they claim in Macon, Georgia. It seems

There’s a life-sized statue of Elvis on Beale Street in Memphis where he began his singing career with Sun Records.

as good an account as any other. What else could explain a town of 90,000 producing musical giants like Otis Redding, Little Richard and The Allman Brothers Band? There’s talk of Macon as “the cradle of American music.” It’s a sentiment echoed by Karla Redding, daughter of soul singer Otis Redding, who was just five years old when her father passed away, just as his career was rocketing to greatness. His first million seller, “(Sittin’ on) the Dock of the Bay,” was

recorded three days before the singer died in a plane crash at age 26. “‘(Sittin’ on) the Dock of the Bay’ was something he never got to experience,” said Karla. “He knew that it was a great song; he knew he was going to be different after he came back and finished Dock of the Bay, but he never got to finish it. I often wonder if that song would have been as big as it is now if he had lived ‘cause it’s so different from everything he did.” “His songs are so passionate,” Karla said about the way her father’s music transcends generations. “All the feelings you and I have, people around the world have, I think you put on any Otis Redding song and it touches some part of your heart, or some similarity to something that’s going on in your life. All these things just kind of calm your soul.” The Redding family continues to protect Otis’ legacy, just as they have for the past four decades. “The Otis Redding Foundation provides scholarships for young dreamers who, just like Otis Redding, have a dream but don’t know how to get there. You’ve got to be able to succeed in education and then go ahead and tie all of those successes to your music passion. We can’t touch them all, but the ones we touch will be successful.” It was the music of Redding that transfixed another Macon-area great, Gregg Allman of The Allman Brothers Band, the foundational group of what became known as Southern rock. Macon was the home of Capricorn Records, the springboard for the band that relocated from northern Florida to this small city. One of the South’s first racially-integrated bands, these five white guys — with their black drummer — would gather together all the music of the Deep South, including the power of black gospel, Delta and Chicago blues, and fuse it into a juggernaut of jamming and grooving that would, and still does, inspire imitators to this day. When they played their farewell concert in 2014 at New York’s Beacon Theatre, no one in that audience, or on that stage, could have believed that for all the turbulence and celebration the band would survive for 45 years. Die-hard fans of ABB songs like “Midnight Rider” and “Ramblin’ Man” get more than their fill by dipping into the well at The Big House (2321 Vineville Avenue; tel: 478-741-5551; thebighousemuseum.com; US$7; closed Mondays), which has room after room of lovinglycurated instruments, clothing, hand-written lyrics, concert posters and ticket stubs. The Big House is the spiritual and actual home of the original Allman Brothers Band; the members lived and worked there communally in the early 1970s. FEBRUARY 2015 • Doctor’s

Review

The old dining room in The Big House now features clothing and instruments that once belonged to members of ABB.

Some have even declared Muscle Shoals as “a holy place in the evolution of rock ’n’ roll”

hoose one city that embodies all styles of Southern music and it would be Memphis, the home of the legendary Stax Records studio, Graceland and Sun Studio, where, according to legend, Bob Dylan fell to his knees and kissed the mark on the floor where Elvis charted musical history with “That’s Alright Mama.” The magic that burst from Sam Phillips’ Sun Studio (706 Union Avenue; tel: 800-441-6249; sunstudio.com; adults US$12) was the perfect intersection of talent and entrepreneurship. In the 1950s — at the height of segregation — Phillips recorded greats like Ike Turner, Johnny Cash, Carl Perkins, Jerry Lee Lewis, Roy Orbison and, of course, Elvis Presley. The young Presley was discovered when he sidled up to the microphone to record a song for his mother’s birthday. After that, the face of modern music changed forever. Across town, in the heart of the neighbourhood once known as Soulsville USA, is Stax (926 East McLemore Avenue; tel: 901-942-SOUL; staxmuseum.com; adults US$12, kids 9 to 12 US$9; closed Mondays), now the only full-fledged soul music museum in the world. They say soul music was born in the church and in the cotton fields; in the 1950s it described a style of jazz blending elements of hard bop, gospel and the blues. Musical giants like James Brown, Sam Cooke and Ray Charles were instrumental in

Doctor’s Review • FEBRUARY 2015

bridging the worlds of gospel and R&B, setting the stage for the transition to soul. By the 1960s, soul was named for a niche of gospel music with a heavy dose of secular lyrics and the torch was picked up by singers like Otis Redding who famously said: “If you listen to the song and your shoulders don’t move, there’s no groove to it.” Groove was big. It stirred your insides and shook your outsides. At the heart of the hard-hitting, percussive Stax sound was house band Booker T. & the MGs, whose tight-but-loose, Hammond organ-infused groove was behind almost every of the label’s recordings through the 1960s. It was an era dominated by A-list soul artists including Isaac Hayes, Wilson Pickett, Sam and Dave, Aretha Franklin, The Staple Singers and numerous others, but without a doubt the biggest star to emerge from Stax was Otis Redding. Although Macon was home base, Redding did most of his enduring work at Stax. It was lightening in a bottle. Memphis was still a segregated city, rife with racial and class tensions but none of that mattered inside the Stax studios — or in the bars on Beale Street (bealestreet.com) — where white and black musicians socialized and cowrote music that would sell in the millions and make them stars as far away as Europe. The songs poured forth from Stax and artists travelled from all parts of the lower 48 to be part of that sound.

JOSEPHINE MATYAS

The Big House in Macon, GA was where members of The Allman Brothers Band, their roadies and families lived until 1973.

The original site of Memphis’ Stax Records is now home to the only soul music museum in the world.

n the early 1970s, many artists moved from Stax to the small town of Muscle Shoals 200 kilometres away, home of the equally renowned FAME recording studios and the “Muscle Shoals sound.” They say this is not only where music was made, it was also where musical history was made. Here, in the northwest corner of Alabama, another rhythm section, known as The Swampers, was

drawing the stars and cranking out the hits. Paul Simon, Bob Dylan, Bob Seger, Rod Stewart, Aretha Franklin, Willie Nelson, Elton John, Cat Stevens, Boz Scaggs, The Rolling Stones and countless other musical giants vied to be backed by The Swampers, a collection of white players who managed to channel black rhythms and sensibilities, a soulful sound that captured a particular quality audiences craved. Ben Tanner, keyboardist with the Grammynominated Alabama Shakes and studio tech at

The Alabama Music Hall of Fame in Muscle Shoals features instruments and stage costumes donated by inductees.

FEBRUARY 2015 • Doctor’s

Review

JOSEPHINE MATYAS

When it was too hot to work inside the Stax studio, musicians and singers would unwind at the nearby Lorraine Motel, one of the only places in Memphis where different races could share the swimming pool, drink beer, hang out in the rooms and write songs. Black and white collaborated in an integrated organization existing within a city where segregation was the rule of law. No one could have foreseen how all that would change with the assassination — at that same Lorraine Motel — of Dr Martin Luther King Jr. in April 1968. Sadly, his death heightened a racial sensitivity between the musicians, part of the story told at both the Stax Museum of American Soul Music and at the National Civil Rights Museum (450 Mulberry Street; tel: 901-521-9699; civilrightsmuseum.org; adults US$15, kids 4 to 17 US$12; closed Tuesdays), on the grounds of the former motel.

There are three blocks of blues clubs and restaurants on Beale Street in downtown Memphis.

The Sun Studio in Memphis was founded by Sam Phillips and it’s where Elvis recorded more than 20 songs.

Memphis was still a segregated city, rife with racial and class tensions, but none of that mattered inside the Stax studios

Memphis’s National Civil Rights Museum is on the grounds of the former Lorraine Motel where Martin Luther King Jr. was killed.

FAME, knows about the magic transcending generations. “It’s about the way the parts are interlocked. There’s a feel to the way these guys played together that translated into hits. They were musicians who really put the song first, so people wanted to be a part of that experience.” FAME was built from the ground up by accomplished producer Rick Hall, who still runs the studio. His story is chronicled in the recent documentary, Muscle Shoals. “He had an ear for a song, for a feel,” explained Tanner. “Rick would handpick his musicians and create a particular sound. After that he could bring in any soloist and match the music.” It was Percy Sledge’s 1966 hit “When a Man Loves a Woman” that went No. 1 that planted Shoals on the musical map. In 1967, a recording session backed by the FAME rhythm section launched the mainstream career of a young Aretha Franklin with the blues ballad “I Never Loved a Man (the Way I Love You).” What followed was a bumper crop of hits. After a business split in 1969, several of the FAME musicians left to set up their own recording studio, Muscle Shoals Sound Studios, nicknamed 3614 Jackson Highway and made famous by a Cher album of the same name. The songs rolled out from 3614 and from FAME: everything from the Stones’ “Brown Sugar” to Paul Simon’s “Kodachrome” was laid down in these recording studios. Muscle Shoals is home to the Alabama Music Hall of Fame (617 Highway 72, Tuscumbia; tel: 800239-2643; alamhof.org; adults US$10, kids under 12 US$7; closed Mondays), a collection of the wide ranging music

styles of Alabama, from the blues of W.C. Handy to the country twang of Hank Williams to the soul of Lionel Ritchie. Some have noted that the talent pool is wide and deep in this part of the country, even declaring Muscle Shoals as “a holy place in the evolution of rock ’n’ roll.” It’s the rich cross-pollination that is most striking about this musical triumvirate. From Macon to Memphis to Muscle Shoals, criss-crossing and hop scotching from one to the other to the next. What a time it was. What a wealth of music. As Karla Redding reminds us, “There is such a rich music history and the up-and-coming musicians are following in the footsteps of all of these legends.” For more info on travel to these regions, visit the Macon-Bibb County CVB (maconga.org), Memphis CVB (memphistravel.com) and Alabama’s Florence/ Lauderdale Tourism Board (visitflorenceal.com).

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FEBRUARY 2015 • Doctor’s

Review

Seventh heaven? A bittersweet finale to one travellerâ&#x20AC;&#x2122;s wish to visit all the continents in the world by Pamela Mandel

About 35,000 people visit Antarctica every year.

Jean-Baptiste Charcot led two expeditions to the Antarctic in 1903 and 1908.

STEPHEN LEW / SHUTTERSTOCK.COM

slumped back into my chair, overwhelmed. My seat at the window faced the stern,

we were sliding past giant blue glaciers, their cracked faces a wall above the blue black mirror of the Lemaire Channel. I felt oddly sad, all of a sudden, like I might cry, though sad isn’t the right word at all. “What’s the matter?” asked my breakfast companion. She must have seen the shift of emotion on my face, in my body. “This is the last continent,” I said. “I’ve been to all seven now.” “Charcot was an idiot,” said the doctor. We walked the icy slopes of Petermann Island. French explorer Charcot anchored on the wrong side of the island — the prevailing winds blew ice into the cove, forcing him to winter over. The other side of the island, where the Plancius — “my” ship — was anchored while we were ashore, was free and clear. I looked south at Charcot’s cove. A block of blue ice, vaguely reminiscent of a cowboy hat and the size of a modest house was shifting, gradually, towards the shore. The weather was bad that day, it was raining, hard. The island was a worn down slide of algae covered snow and muddy penguin guano, every now and

FEBRUARY 2015 • Doctor’s

Review

then my boots would punch through the surface into a puddle of icy water. In two hours, I would be back on the ship. I would be wearing slippers and eating butternut squash soup, I would be uploading photos from my camera to my laptop. Charcot would probably have been listening to the ice crunch up against his ship (a sound I know now) and worrying. Charcot survived the winter; he died later in a shipwreck off the coast of Iceland, something I have no plans to do.

ately, I consider my travels in historical context. It’s not that I am a great explorer, it’s that I like to put the significance of my travels in the context of those brave humans, those madmen — and in some cases women — who went off the map so they could find out what was there. I like to be taken down a notch or twelve when I think I’m doing something special and I like to keep in mind the absolute privilege I have in being able to — can you believe this — take a ship to Antarctica to see penguins and seals and the wild raw places where nature makes lunch out of all of us, should she be so inclined. Iced in with his crew, Charcot probably had hard tack and seal meat while on the other side of the island; I ate steamed rock cod with asparagus in a delicate mustard sauce followed by a baked fruit tart and coffee with milk and sugar.

A trip to Antarctica is achievable, for those with some means and the will to plan I live in modern times, for that I am grateful. Anyone who has the financial means can go to Antarctica, you need not be all that sturdy, even — many travellers to Antarctica are retirees, gripping the handrails as they wander about the halls of the ship, moving carefully up and down the gangplanks. Not all travellers to Antarctica are wealthy, either. For example, an Australian couple I met told me how they’d saved for years in order to do this adventure, a lifetime ambition. This was their once in a lifetime experience. But once in a lifetime or no, a trip to Antarctica is achievable, for those with some means and the will to plan. If, instead of being born to modern times when a

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bookish, slightly odd female can step foot on all seven continents without raising an eyebrow, I’d been born in, say, the age of exploration, my world would collapse upon me. To complete my travels, I’d require a past life as the child of missionaries or diplomats. Or a father involved in obscure botanical research for some institute, probably British, and later, back in London or Cambridge, there would be presentations in which I was not involved in any way. I am much luckier to be born curious and to a somewhat open globe, a time when the infrastructure exists in such a way that I can stand looking at Charcot’s badly chosen anchorage and a week or so later, sit on my couch in Seattle writing about it.

t was this sense of historical, geographical whiplash that had me gazing into the middle distance. In the collected lives of travellers, my existence, my adventures, are insignificant. I walked a mountain pass in the Himalayas. I rode a bicycle to see the Valley of the Kings in Egypt. I drove a car to Ayers Rock. I took a tour bus to see the temples of Angkor. I boarded a cruise ship to stand on the frozen ground of the seventh continent, Antarctica. I have accomplished so little — probably you know many people who have done exactly what I’ve done. But now, I hold this unique honour of having visited all seven continents. What times we live in that someone like me, with weak upper body strength and perpetually cold hands, can stand on all seven continents! I travel in the footsteps of all the great explorers. Sitting on the ship, while my coffee got cold, I again imagined the long blue lines of the planet between where I sat and my home back in Seattle. I wrapped the lines the horizontal way, too, around the belt of the planet to Honolulu, Alice Springs, Saigon, Delhi. There are many places in the world I have not been. I would like to see the churches of Ethiopia, I would like to see elephants in the wild. But as I looked out the window at this last place, I imagined the great blue globe stretching away from our tiny ship floating at the bottom of the planet in the icy still water. I could picture the whole great planet in my mind, for just a moment, I thought I could sense the weight of us all, floating in space. I pushed my toast away, I wasn’t hungry anymore. “I’ve been to all seven continents,” I said. And I looked out the window and tried not to cry. Reprinted with permission. The article appears on TravelersTales. com and BestTravelWriting.com under the title Seven. It won a silver award in the Cruise category of the Seventh Annual Solas Awards for Best Travel Writing sponsored by Travelers’ Tales.

Whales and walruses on a weeklong Arctic cruise with Manitoba-based Frontiers North Adventures. doctorsreview.com/features/arctic-safari-igloolik

Doctor’s Review • FEBRUARY 2015

The Plancius sailed for the Dutch Navy until 2004.

Gentoo parents form long-lasting bonds with their offspring and are highly nurturing.

VOLODYMYR GOINYK / SHUTTERSTOCK.COM

KNUMINA STUDIOS / SHUTTERSTOCK.COM

Antarctica is the coldest continent in the world and the only one that’s uninhabited.

Duck, barley and mushroom soup (Entensuppe).

Beyond bratwurst

Modern German recipes that’ll change what you think about the country’s cuisine recipes by

Jeremy

and

Jessica Nolen

with

Drew Lazor

photos by

Jason Varney

t’s hard not to think of weisswurst (and lederhosen… and oompah bands… and beer steins…) when you hear the words “German food,” but there’s more to the country’s cuisine than white Bavarian

sausages. The north, along the border with Denmark, is dominated by seafood from the Baltic Sea and the North Atlantic. Westphalia, or northwest-central, is known for its acorn-fed hogs used in making junipercured hams. The area around the Black Forest in the southwest is influenced by French cooking and the east by that of the Czech Republic and Poland. New German

Cooking, published by Chronicle Books, is a beautiful intro to this delicious diversity. Compiled by chef Jeremy Nolen of Philly’s Brauhaus Schmitz, where his wife, Jessica, is the pastry chef, it features more than 100 recipes from bread and spreads to noodles and dumplings to desserts. Some of our favourites to help your through February are included here. FEBRUARY 2015 • Doctor’s

Review

DUCK, BARLEY AND MUSHROOM SOUP Beef and barley are a classic German soup combination, but here the beef has been swapped out in favour of duck, giving this cool-weather dish a bolder personality. Start with a whole bird, using its meat for the soup and its carcass for the rich, beery duck broth backdrop. If you’re feeling under the weather, this soup will definitely put you on the road to recovery. It’s chicken noodle soup, new German style. For the stock 2 carrots, peeled and cut into 1-in (2.5-cm) pieces 1 yellow onion, cut into 1-in (2.5-cm) pieces 4 stalks celery, cut into 1-in (2.5-cm) pieces 1 leek, white and green parts, cut into 1-in (2.5-cm) pieces 1 5-to-6-lb (2.3-to-2.7-kg) Long Island duck 4 fresh bay leaves or 2 dried bay leaves 6 sprigs fresh thyme ¼ c. (560 ml) pearl barley 2 1 yellow onion, diced 1 carrot, peeled and diced 2 stalks celery, diced 4 garlic cloves, minced 1 fresh bay leaf or dried bay leaf 1 lb. (455 g) wild (chanterelle or porcini) and/or cultivated (portobello, cremini, or shiitake) mushrooms, trimmed and cut into thin slices 4 c. (1 L) Spaten Optimator, Ayinger Celebrator, or other double-bock beer 2 tbsp. (30 ml) finely chopped fresh curly-leaf parsley

To make the broth, preheat the oven to 375°F (190°C). Put the carrots, onion, celery and leek in the centre of a roasting pan, forming a vegetable “rack” for the duck. Place the duck, breast-side up, on top of the vegetables and place in the oven. Roast until an instant-read thermometer inserted into a leg away from bone registers 150°F (65°C), about 1½ hours. Transfer the duck to a large plate and set aside to cool until it can be handled. Place the roasting pan on the stove top

Doctor’s Review • FEBRUARY 2015

over two burners. Turn on the heat to medium and pour enough water into the pan to come about 1 inch (2.5 cm) up the sides. Using a wooden spoon or spatula, scrape the bottom of the pan to loosen any browned bits. When the water reaches a boil, remove the pan from the heat and strain the liquid through a fine-mesh sieve into a large stockpot. Discard the solids. When the duck is cool enough to handle, pull the meat with the skin intact off the carcass. Shred the meat and skin into pieces, put into a bowl, cover and set aside for adding to the soup. Break up the carcass into a few big pieces, add to the stockpot with the deglazed pan liquid and then add water to cover, the bay leaves and thyme. Place over medium-high heat, bring to a boil, turn the heat to medium and simmer, uncovered, for about 1 hour. Remove the stockpot from the heat, strain the broth through the fine-mesh sieve into a heatproof container and discard the solids. You should have about 8 cups (2 L) for the soup. (Reserve the remainder for another use.) Using a large metal spoon, skim off the fat from the surface. (Alternatively, let the broth cool, cover, and refrigerate the broth and the reserved duck meat separately overnight. The next day, skim off the solidified fat from surface of the broth and finish the soup.) Rinse out the stockpot, pour the broth back into it and bring to a boil over high heat. Add the barley, onion, carrot, celery, garlic and bay leaf. Lower the heat to a simmer and cook, uncovered, for 30 minutes. Add the mushrooms, beer and the reserved duck meat, and continue to simmer until the barley is tender, about 15 minutes longer. Ladle into individual bowls and garnish with the parsley. Serve immediately. Serves 6 to 8.

COD-STUFFED CABBAGE ROLLS The classic northern German pairing of cabbage with fish gets a literal twist here: we are wrapping a seasoned cod cake in cabbage leaves, baking the parcels and then topping them with a mustardand-cream-thickened pan sauce bright-

ened by fresh dill. This recipe was the result of a line cook accidentally chopped an entire night’s worth of cod into bitesize pieces that was supposed to remain whole! 1 head Savoy cabbage 1½ lb. (600 g) cod fillets 1 tbsp. (15 ml) canola oil 1 yellow onion, chopped 1 garlic clove, minced 1 c. (250 ml) fine dried bread crumbs 1 egg, lightly beaten 2 tbsp. (30 ml) finely chopped fresh curly-leaf parsley 2 tbsp. (30 ml) finely chopped fresh dill salt and freshly ground white pepper 4 tbsp. (60 ml) mild German mustard 2 c. (500 ml) dry white wine 1 c. (250 ml) heavy cream

Fill a large pot half full with water and bring to a boil over high heat. Immerse the cabbage in the boiling water and cook until the outer leaves have loosened and can be peeled off, about 5 minutes. To test, using a wire skimmer, carefully lift out the cabbage head and try to peel away the outer leaves; if they do not come away, return the head to the water for a couple minutes more, then test again. Peel off as many whole leaves as you can easily remove without tearing them. Return the cabbage head to the boiling water and repeat the process until you have six whole leaves. Arrange the leaves, interior-side up, in a single layer on a work surface and let cool completely. Reserve the remaining cabbage for another use. Preheat the oven to 350°F (180°C). Finely chop the cod fillets, discarding any errant bones. Put the fish in a medium bowl, cover and refrigerate until ready to use. In a medium sauté pan, heat the canola oil over medium-high heat. Add the onion and garlic and cook, stirring occasionally, until the onion is translucent, about 4 minutes. Remove from the heat and let cool completely. Add the cooled onion mixture, bread crumbs, egg, parsley, dill, 1 teaspoon (5 ml) salt, ½ teaspoon (2.5 ml) white pepper and 2 tablespoons (30 ml) of the mustard to the cod and mix well. Divide the cod mixture into six equal portions and shape each into a

Cod-stuffed cabbage rolls with dill cream sauce (Fischrouladen).

Green bean salad with white beans, tomatoes and pine nuts (Bohnensalat ).

For the salad salt 8 oz. (225 g) green beans, ends trimmed 1 15-oz. (430-g) can cannellini or navy beans, rinsed and well drained 6 cherry tomatoes, quartered lengthwise 1 shallot, sliced ½ c. (125 ml) diced roasted red pepper ½ c. (125 ml) pine nuts, toasted

rough log shape. Put a portion about 1 inch (2.5 cm) from the bottom edge of a cabbage leaf, where the stem is the thickest. Lift the edge of the leaf over the filling and then roll up the filling in the leaf, folding in the sides as you roll. Place the roll, seam-side down, in a baking dish just large enough to accommodate all the rolls. Repeat with the remaining cabbage leaves and filling portions. Pour the wine into the dish. Bake the rolls until a thermometer inserted into the centre of a roll registers 145°F (63°C). Remove the dish from the oven, pour off the liquid into a medium saucepan and cover the rolls in the dish to keep them warm. Place the saucepan over mediumhigh heat and bring the liquid to a boil. Whisk in the cream until heated through and lightly thickened, then whisk in the remaining 2 tablespoons (30 ml) mustard. Season with salt and white pepper. Arrange the cabbage rolls on a platter and pour the sauce over the top. Serve immediately. Serves 6.

Doctor’s Review • FEBRUARY 2015

GREEN AND WHITE BEAN SALAD In Germany, bean salads are often made with a jarred mixed-bean mixture, but the combination of fresh green beans and high-quality canned white beans yields a more satisfying flavour and crunch. What also sets this recipe apart is its bold dressing. Its key ingredient is sweet smoked Spanish paprika. For the dressing 1 small shallot, minced ¼ c. (60 ml) cider vinegar 1 tsp. (5 ml) honey 1 tbsp. (15 ml) finely chopped fresh tarragon 2 tsp. (10 ml) sweet smoked Spanish paprika 1 tsp. (5 ml) salt ½ c. (125 ml) grapeseed or canola oil

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To make the dressing, in a small bowl, whisk together the shallot, vinegar, honey, tarragon, paprika and salt. Slowly whisk in the grapeseed oil until emulsified. Set aside. Fill a medium saucepan two-thirds full with water, bring to a boil over high heat and season with salt. It should not be too salty; instead it should be seasoned just enough to resemble a good chicken stock. While the water is heating, ready an ice-water bath in a large bowl and line a plate with paper towels. Place both near the stove. Plunge the green beans into the boiling water and cook until very tender, about 7 minutes. Using a wire skimmer or slotted spoon, transfer to the icewater bath, immersing them completely. Leave them in until chilled, about 5 minutes. Remove and drain well on the towel-lined plate. In a large bowl, combine the green beans, cannellini beans, tomatoes, shallot and red pepper. Pour in the dressing and toss to coat all of the ingredients evenly. Garnish with the pine nuts and serve immediately. Serves 4 to 6.

Recipes and photos from New German Cooking (Chronicle Books, 2014).

The new Old Town in Dresden, the capital of Saxony in Germany. doctorsreview.com/features/turning-back-clock

Indications and clinical use: BEXSERO ® is indicated for active immunization of individuals from 2 months through 17 years old against invasive disease caused by N. meningitidis serogroup B strains. As the expression of antigens included in the vaccine is epidemiologically variable in circulating group B strains, meningococci that express them at sufficient levels are predicted to be susceptible to killing by vaccine-elicited antibodies. Contraindications: • Hypersensitivity to the BEXSERO ® vaccine or to any ingredient in the formulation or components of the container closure. Relevant warnings and precautions: • Temperature elevation following vaccination of infants and children (less than 2 years of age) • Administration of BEXSERO® should be postponed in subjects suffering from an acute severe febrile illness • Individuals with thrombocytopenia, hemophilia or any coagulation disorder that would contraindicate intramuscular injection • Subjects with impaired immune responsiveness • Do not inject intravascularly, intravenously, subcutaneously or intradermally

• Do not mix with other vaccines in the same syringe • Availability of appropriate medical treatment and supervision in case of an anaphylactic event following administration of the vaccine • Risk of apnoea in premature infants; need for 48-72 hours respiratory monitoring • Caution in subjects with known history of hypersensitivity to latex • Hypersensitivity to kanamycin • Protection against invasive meningococcal disease caused by serogroups other than serogroup B should not be assumed • As with any vaccine, BEXSERO® may not fully protect all of those who are vaccinated For more information: Please consult the Product Monograph at www.novar tis.ca / BexseroMonograph for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling Medical Information at 1-800-363-8883.

BEXSERO is a registered trademark. Product Monograph available on request. Printed in Canada ©Novartis Pharmaceuticals Canada Inc. 2014 13BEX017E Novartis Pharmaceuticals Canada Inc. Dorval, Québec H9S 1A9 www.novartis.ca T: 514.631.6775 F: 514.631.1867

Be informed. Be immunized.

BEX_7386_PI_DoctorsReview E01.indd 1

14-02-25 1:52 PM

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Bexsero........................................................................................ 55 Symbicort.................................................................................... 12 FEBRUARY 2015 • Doctor’s

Review

PHOTO FINISH by

D r Wa y n e C a mp b e ll

Caught off guard

While on vacation in Rome, we were fortunate to observe the changing of the guard ceremony in front of the Quirinale Palace, the official residence of the President of Italy. Many units from different branches of the Italian forces participated, along with bands playing martial music. At the conclusion of the ceremony, the forces dispersed, heading away in various directions from the large plaza. I was standing near a balustrade overlooking a staircase leading down from the plaza to the street below. A group of sailors appeared at the top of the stairs lead by a soldier in fatigues. Anticipating a nice photo of the men in uniform, I got my camera ready for the sailors to pass in front of me. As soon as I started to focus, the lead soldier turned his head and smiled broadly. The sailor next in line stopped, turned towards me and actually posed for the shot, causing his fellow sailors to stop marching and wait for me to take my photo. The camera: a Canon EOS Rebel Digital SLR.

MDs, submit a photo! Please send photos 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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Doctor’s Review • FEBRUARY 2015

GO WITH THE FLOW

The AstraZeneca logo is a registered trademark of AstraZeneca AB, used under license by AstraZeneca Canada Inc. ÂŠ 2014 AstraZeneca Canada Inc.

Covered on RAMQ and most private plans

Help fight

heartburn associated with GERD With the demonstrated power of DEXILANT®

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

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

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

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

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

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