July-August 2014 by Doctor's Review

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Wright in Buffalo New edges

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July / august 2014

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History of the

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Vegan summer Track star at 95!

A MATCH MADE FOR OA VIMOVO unites powerful OA efficacy with the reduction of NSAID-associated gastric ulcer risk VIMOVO (naproxen/esomeprazole) is indicated for the treatment of the signs and symptoms of osteoarthritis (OA), rheumatoid arthritis (RA) and ankylosing spondylitis (AS) and to decrease the risk of developing gastric ulcers in patients at risk for developing NSAID-associated gastric ulcers.

Clinical use: VIMOVO is not recommended for initial treatment of acute pain because the absorption of naproxen is delayed (as with other modified release formulations of naproxen). VIMOVO, as an NSAID, does NOT treat clinical disease or prevent its progression. VIMOVO, as an NSAID, only relieves symptoms and decreases inflammation for as long as the patient continues to take it. Evidence from naproxen clinical studies and postmarket experience suggest that use in the geriatric population is associated with differences in safety. For patients with an increased risk of developing cardiovascular (CV) and/or gastrointestinal (GI) adverse events, other management strategies that do NOT include the use of NSAIDs should be considered first. Use of VIMOVO should be limited to the lowest effective dose for the shortest possible duration of treatment in order to minimize the potential risk for cardiovascular or gastrointestinal adverse events. Contraindications: • The peri-operative setting of coronary artery bypass graft surgery (CABG) • Women in the third trimester of pregnancy or who are breastfeeding

VIM252E

02/15

VIMOVO® and the AstraZeneca logo are registered trademarks of the AstraZeneca group of companies. © AstraZeneca 2014

• Patients with severe uncontrolled heart failure • Patients with known hypersensitivity to substituted benzimidazoles • Patients with history of asthma, urticaria, or allergic-type reactions after taking ASA or other NSAIDs • Patients with active gastric/duodenal/peptic ulcer or active gastrointestinal bleeding • Patients with cerebrovascular bleeding or other bleeding disorders • Patients with inﬂammatory bowel disease • Patients with severe liver impairment or active liver disease • Patients with severe renal impairment or deteriorating renal disease • Patients with known hyperkalemia • Children and adolescents less than 18 years of age Most serious warnings and precautions: Risk of cardiovascular (CV) adverse events: Naproxen, which is a component of VIMOVO, is a non-steroidal anti-inﬂammatory drug (NSAID). Use of some NSAIDs is associated with an increased incidence of CV adverse events (such as myocardial infarction, stroke or thrombotic events), which

can be fatal. This risk may increase with duration of use. Patients with CV disease or risk factors for CV disease may be at greater risk. Caution should be exercised in prescribing NSAIDs such as naproxen to any patient with ischemic heart disease, cerebrovascular disease, congestive heart failure (NYHA II-IV) and/or renal disease. Use of NSAIDs such as naproxen can result in increased blood pressure and/or exacerbation of congestive heart failure. Randomized clinical trials with VIMOVO have not been designed to detect differences in CV events in a chronic setting. Therefore, caution should be exercised when prescribing VIMOVO. Risk of gastrointestinal (GI) adverse events: Use of NSAIDs such as naproxen is associated with an increased incidence of GI adverse events (such as ulceration, bleeding, perforation and obstruction of the upper and lower gastrointestinal tract). Special Populations: Caution should be exercised in prescribing VIMOVO during the first and second trimesters of pregnancy.

Other relevant warnings and precautions: • Patients with haemophilia, platelet disorders, ASA-intolerance, or who are frail or debilitated • Women attempting to conceive • Concomitant use with: other non-ASA NSAIDs; NSAIDs containing naproxen; clopidogrel; anticoagulants; methotrexate; atazanavir; nelfinavir • Hypomagnesaemia, hypokalemia, hypocalcemia, blood dyscrasias and antiplatelet effects • Hepatic, renal and genitourinary impairment • Neurologic adverse events, including blurred or diminished vision, decreased alertness or depression • Infection, risk of masking signs and symptoms of infection and skin reactions For more information: Consult the Product Monograph at www.azinfo.ca/ vimovo/pm846 for important information relating to adverse reactions, drug interactions and dosing information. The Product Monograph is also available by calling AstraZeneca Canada Inc. at 1-800-668-6000.

September escapes

solovyova lyudmyla / shutterstock.com

Summer 2014 is ebbing. Fall is on the horizon and I’m not anxious to embrace it. I like to stay as close to warm days as white on rice. That’s why I enjoy going south in September. Why fly off to a hot spot in July and August when the weather is as good as it gets in Canada? After Labour Day, though, the weather usually deteriorates quickly. You wake of a morning to find grey skies, driving rain and a wind that brings back the horrors of February. It’s not like that in Florida. There — barring a hurricane or two — it’s still full on beach weather and will be well into November. Also, the prices are lower. That said, two words: Flagler Beach. Never heard of it? I know the state pretty well, but I hadn’t either until I read Alastair Sutherland’s beguiling article, which begins on page 40. Turns out Flagler hasn’t changed much in the last 20 years. There’s still a fishing pier you can walk out on at dawn to watch the sunrise, mom-andpop shops that sell saltwater taffy and motels where every unit has its own door. I try to stay as close to places like that as two coats of paint. But, you may prefer something more exotic. How about Greece? Remember the slogan of a few years back: “When it’s fall everywhere else, it’s still summer in Greece?” I rest my case. Turn to A Greek revival by Dr D. James Sahlas, which begins on page 34. You’ll be glad you did. The doctor takes the family back to his hometown in Laconia, a seldom-visited part of the country, and gives you the inside dope. A home closer to home, perhaps? Turn to Wright in Buffalo on page 48 for a delightful read about one of the first homes the famous architect designed. It’s been fully restored and is open to visitors. On a considerably less delightful note, Annarosa Sabbadini is leaving the magazine after 16 years as editor. Her sharp eye for a good story, precise editing skills and fine writing will be missed. In the latter case, I hold out hope that her byline will continue to appear from time to time.

Visit David Elkins, Publisher delkins@parkpub.com

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contents july / august 2014

cover Photo courtesy Kinsterna Hotel F ‘n M Photography / Thodoris Laliotis & Evangelia Lazou

features 34

46 46

A Greek revival A family vacation to the Laconia region lets an MD rediscover his roots by Dr D. James Sahlas

Wright in Buffalo One of Frank Lloyd’s first commissions is finally restored to its former glory by Gerald Fitzpatrick

Olga: track star at 95

Yesterday, FLA Cheap motels and seafood shacks by the Flagler seashore by Alastair Sutherland

She racked up world records until her death in June. An excerpt from What makes Olga run? by Bruce Grierson

coming next issue

Natural winners An easy, end-of-summer supper that doesn’t include meat by Myra Goodman and Marea Goodman

• A history of women & depression & its cures • A vegan cruise with kids and CME credits • The unhip, unexpected joys of cruising • Hike Jasper’s grizzly country — if you dare • How to find your roots in Italy

Treating chronic pain, our shared responsibility.

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contents july / august 2014

regulars

7 Letters Food for thought

9 Practical Traveller

ada 17

Legend

Fall foliage with Crystal Cruises, park benches of population over age 12 reporting diagnosis with USB ports, plus% byVancouver-based a health professional as having a mood disorder BikeHike turns 20 (depression, bipolar disorder, mania, dysthymia) in 20131 by Camille Chin Innovative mental health programs across Canada

A new way to sharpen dull blades by Theo Sands

review

Canadian cases by the numbers by Susan Usher

ported by the n of Canada ome/Chez Soi e first step th for people g with mental pants who ble apartment ntal health elationships lies.4

3.9%

Best MD Apps Put 5000 journals in your pocket by David Elkins

An audiobook of Sri Chinmoyâ&#x20AC;&#x2122;s inspirational

Between 80% and 90% of words by David Elkins people with major depression can be treated successfully, depression snapshot yet only about a third seek help.2

gadgets

27 Top 25 Great medical meetings on tap this winter

History of Medicine Contraception just keeps on getting better by Jackie Rosenhek

56 Photo Finish Life in Paris by Dr Greg Iverson

5.1%

6.5%

contest!

8.4%

Newfoundland and Labrador 6.8%

Quebec 5.2% 7.3% 6.6%

9.2%

New Brunswick 7.9% 8.4%

13.1%

Prince Edward Island 10.3% 12.0%

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Chew on this RauDZ in Kelowna [BC’s chef d’oeuvre, June 2014, page 40] has the best gnocchi that I have ever tasted anywhere in the world — including Italy. Dr David Smith Via doctorsreview.com

I tried a recipe on your website — Stefano’s pasta puttanesca [Keep the Faita, June 2014, page 47] — and it was possibly one of the best things I’ve ever made! Josephine Matyas Vie email

Soak it in The rooftop pool at the Thompson Hotel in Toronto is kind of small [Watering holes, June 2014, page 36], but it has the best skyline view in the city. You can even see the CN Tower. There are a lot of cool comfortable couches for relaxing on, and there’s a bar. The weekend I was there, it was packed with a lot of young, fashionable people at night. The crowd was a little too young and fashionable for me though, so I left after an hour, but it seems to be a nice place for a night out. Dr A. Mehta Via email

All the buzz I had no idea that people had started beekeeping [“Bee keeping for more than just honey,” Food, June 2014, page 17]. What a riot! I read an article about declining bee populations because of pesticides, which affect bees’ navigation abilities and memory, so they can’t find the entrance to their hives! It’s amazing that people and hotels like the Royal York in Toronto have started their own hives. What a great initiative! D. Halliday Via email

best of the web Just had a look at “Best of the Web” [doctorsreview.com] for the first time. Of the 10 articles listed, I found many useful, informative and fun to read. My favourites were the items on renting a family villa in Tuscany (Heaven in Tuscany) and the one about how hard you workout (Check your workout intensity). I would never have come across them surfing on my own. Thanks for a helpful new service. Dr R. James Cameron Via email

Correction: The caption in All Eyes on Italy (March 2014) should have read “Sorrento’s Marina Grande has lots of dinghies and fishermen, but few souvenir shops and fewer tourists.” Thanks to Dr Howard Taynen for pointing out the error.

All prescription drug advertisements appearing in this publication have been precleared by the Pharmaceutical Advertising Advisory Board.

The new cma.ca — see how easy “on-the-go” can be.

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“Like most physicians, time is a critical factor in almost every decision I make. The new cma.ca allows me to search quickly across multiple tools for the most relevant clinical information.” dr. naheed dosani palliative care physician, toronto, Ont. Cma member

Access relevant evidence-based information with a single search Working closely with CMA members, we’ve rebuilt our website to better serve physicians’ needs. The new cma.ca delivers enhanced clinical search capabilities and personalized content. Accessible on any mobile device, it’s your go-to source for knowledge resources, national advocacy on health and health care, and the CMAJ. Questions? Comments? Email cmamsc@cma.ca, call 888-855-2555 or @CMA_Members. We’re listening.

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p r ac t i c al t r a v e l l e r C a mi lle C hi n

Double Dutch

Carel Fabritius’ The Goldfinch, 1654.

Mauritshuis, The Hague

The Girl with the Pearl Earring is home. Vermeer’s most famous canvas — a “tronie” or painting of an imaginary figure — was welcomed back to the newly expanded Mauritshuis in The Hague in June. After a two-year, €30-million renovation, the 17th-century mansion-turned-museum is now connected to a new art deco Royal Dutch Shell Wing via a light-filled below-ground atrium, doubling the Mauritshuis in size. The museum’s collection is small — 800 paintings with just 250 on display — but of high quality. It includes Rembrandt’s The Anatomy Lesson of Dr Nicolaes Tulp, the Golden Age’s best-known landscape, Vermeer’s View of Delft and Fabritius’ The Goldfinch, recently made more famous by Donna Tartt’s Pulitzer Prize-winning novel. Adults €14. mauritshuis.nl.

july / august 2014 • Doctor’s

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Canadian cell phone photo contest! Snap a few shots with your mobile phone around your neighbourhood and e-mail them to us. No restrictions on subject: pets and/or kids, your neighbours, the corner store, clouds, rainbows, the moon at midnight… originality counts! Winners will receive a $50 gift card for a choice of Mountain Equipment Co-op, Lee Valley Tools or Canadian Tire.

The winning photos will appear in print and online.

TO enter Email photos and a caption to editors@doctorsreview.com Deadline: September 30. doctorsreview.com 10

Doctor’s Review • july / august 2014

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Ancient treasure

Claudia Masciotra

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The Rani Ki Vav stepwell in Patan in Gujarat, India.

Twenty-six new sites were inscribed on the UNESCO World Heritage List this past June. The brick, walled and moated Pyu cities of Halin, Beikthano and Sri Ksetra are Burma’s (Myanmar’s) first, joining 1007 other sites in 161 countries. Below are a handful of the 2014 inductees. For all 26: whc.unesco.org/en/newproperties. • The earliest-known and best-preserved figurative drawings in the world dating from the Aurignacian period (30,000-32,000 years ago). Over 1000 have been inventoried in a cave that was discovered in 1994 near the Ardèche River in southern France. • The Rani Ki Vav stepwell in Gujarat, India that was built as a memorial to a king in the 11th century. The subterranean water systems evolved into multistorey works architecture over time. • A silk mill complex established in 1872 in the Gunma prefecture north-west of Tokyo. It consists of an experimental farm that produced cocoons as well as a cold-storage facility for silkworm eggs. The spinning of raw silk was done here, too. • The vineyard landscape of Piedmont, Italy, which covers five distinct wine-growing areas and where vine pollen dating from the 5th century BCE has been found. The region was once a point of trade between the Etruscans and the Celts. • The Stevns Klint geological site in Denmark that’s comprised of a 15 kilometre-long, fossil-rich coastal cliff that offers evidence of the impact of the Chicxulub meteorite that crashed into the planet 65 million years ago. Researchers think it was responsible for the disappearance of 50 percent of all life on earth.

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p r a ctica l t ravel l er Crystal Cruises new sailing may be its most colourful. The 10-day Autumn’s Palette cruise, September 19 to 29 from Boston to Quebec City, includes six stops centred around seeing fall foliage. The 1070-passenger, 535-room Serenity will stop first in Bar Harbor on Mount Desert Island in Maine, where millionaires used to spend their summer and where you can drive up Mount Cadillac to take in the forests and shoreline. The ship stops next in Saint John, NB before continuing on to Halifax, NS, Quebec’s Magdalen Islands, HavreSaint-Pierre and then Baie-Comeau before arriving for an overnight in the French capital. Cruise-only fares through August 29 start at US$3540 per person, double occupancy. tel: (888) 722-0021; crystalcruises.com.

Quebec City’s Fairmont Le Château Frontenac.

All the buzz 12

Doctor’s Review • july / august 2014

gvictoria / shutterstock.com

Peep this

Chikungunya, the mosquito-borne disease that’s been buzzing around the Caribbean since late 2013, has arrived in the US. The first locally acquired case was reported in Florida in mid-July. The virus is spread by the bite of an asian tiger or yellow fever mosquito. The word chikungunya is derived from the Kimakonde word meaning “that which bends up” (as in pain). Symptoms typically include fever and joint pain as well as headaches, muscle aches, joint swelling and rashes. For more: cdc.gov/chikungunya.

On active duty

Vancouver-based BikeHike Adventures is celebrating its 20th year. In an interview with Where.ca, Trish Sare said she founded the travel company in 1994 after a five-year, around-the-world trip she took at age 20 following her mom’s death. Today, BikeHike consists of 50 easy-to-strenuous, hiking, biking, kayaking and multi-sport trips in more than 30 countries. Four of the trips have appeared in National Geographic Traveler’s annual 50 Tours of a Lifetime. Each guided tour is designed for a max of 12 travellers; nights are spent in small, family-run guesthouses, mountain-top lodges, and inns. Adventures like the week-long Walking Safari with the Nomads (from US$2299 per person) brings you even closer to the locals: you camp with a semi-nomadic Berber family and their herd of 200 animals, and Masciotra trek south with them from the High Atlas Mountains into the Jebel Saghro in Morocco. tel: (888) 805-0061; bikehike.com.

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pr a ctica l tr avel l er

Power seat

“Your cell phone doesn’t just make phone calls,” Boston’s Mayor Marty Walsh recently said. “Why should our benches just be seats?” Soofas are solar-powered benches with USB ports that’ll charge electronic devices for free. Developed by a three-woman team at Changing Environments, a MIT Media Lab spinoff, the benches have already been installed in three Boston parks. The “smart urban furniture” also tracks how many people have visited each bench in a single day, how many hours of solar charging it’s provided, and the park’s air quality and noise level. The info is viewable at soofa.co.

Tom Crane

A new head space

Doctor’s Review • july / august 2014

The Franklin Institute’s new US$41-million-dollar Nicholas and Athena Karabots Pavilion in Philadelphia is hard to miss. Its façade is an ever-changing Shimmer Wall by internationally renowned artist Ned Kahn. It’s comprised of 10,824 clear anodized aluminum squares that are hinged on one side only so they move freely in the wind. The Squares look like waves during the day; they reflect a subtle light at night. The three-storey, 5000-square-metre pavilion includes a climate-controlled gallery that’ll allow the institute to attract larger, more complex travelling exhibits, but its centerpiece is the permanent Your Brain exhibit, the largest of its kind in the US. Seventy interactive experiences cover 790 square metres; in one visitors climb through a twostorey structure simulating a neural network with lighting and sound effects that are triggered by footsteps. Adults US$18.50; kids 3 to 11 US$14.50. tel: (215) 448-1200; fi.edu.

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new to doctorsreview.com BEST OF THE WEB Links to articles, deals and special opportunities of interest to Doctor’s Review readers selected by the editors

Updated on our website three times a week!

Includes selections from: Guardian Travel, The Travel Magazine, National Geographic Travel, NYT Travel, Globe & Mail Travel, Spas in Canada, Budget Travel, LA Times Travel, The Frugal Traveller, Smartertravel.com, Petergreenberg.com, The Travel Guys, Travelzoo.com, Triponadeal.com, Adventurouskate.com, Dave and Deb Travel, The World Wanderer, Boston Globe Travel, Chicago Tribune Travel, Savvy Traveller, The Gypsy Nester, WSJ Health & Travel, Wanderlust, Independent Traveler, Outpost Magazine, Travel+Leisure, Outside Magazine, Go Green Travel, Washington Post Travel, National Post Travel, Vancouver Sun Travel, Backpacker, Islands, Condé Nast Traveler, Coastal Living, Caribbean Living, Camping Life… and many, many more

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Jewels of happiness The power of words to inspire and transcend

Sri Chinmoy.

ranjana

Consider a few words with the power to make your life better: peace, love, joy, hope, wisdom, patience, enthusiasm, sincerity, humility and gratitude. They don’t need much explanation. Most of us recognize that if we lived by even two or three of them there would be benefits — for ourselves and those around us. These particular words were chosen by Sri Chinmoy (1931-2007), who, for many years led the twice-weekly Peace Meditation at the United Nations. He believed strongly in self-transcendence and encouraged everyone to go beyond even their best selves. He practiced what he preached. He composed thousands of songs and gave almost 800 concerts in all parts of the world, including in Montreal, Toronto and Vancouver. His art has been shown in galleries in London, New York and Ottawa among many other locations. Every two years runners in more than 100 countries take part in the World Harmony Run he founded; 500 races are presented every year by the Sri Chinmoy Marathon Team including the world’s longest running race of 3100 miles (5000 kilometres), which takes place in Queens, NY each June. Now a group of people who have been inspired by his writings and his life have recorded selections for an audiobook titled: The Jewels of Happiness: Practical Inspiration and Wisdom for your Life’s Journey to be released at the end of August. In the forward Desmond Tutu emphasizes the theme: “our spirit tells us that we are made for transcendence. We are not small. We are not helpless. We are vast, and we have everything we need to succeed…. Come let us make a better and happier life for ourselves and for all our brothers and sisters.” The performers on Jewels include Archbishop Tutu (PEACE); singer Roberta Flack (LOVE); Tony-award-winner Judith Light (SINCERITY); Russian singer-songwriter Boris Grebenshikov (SIMPLICITY); Ashrita Furman, holder of the most Guinness World Records (ENTHUSIASM); and Olympian Carl Lewis (SELF-TRANSCENDENCE). You can find selections from the audiobook at jewelsofhappiness.com/book.

“We are not helpless. We are vast…” —Archbishop Desmond Tutu

july / august 2014 • Doctor’s

Review

de p r e s s i on s nap s h ot by

S us a n Us he r

Depression across In 2013, 2,264,640 Canadians over age 12 suffered from depression and related mood disorders; 60% were women.1

3.5%

13.0%

Yukon 8.2% E-mental health The Online Therapy Unit at the University of Regina supports mental health providers in Saskatchewan deliver Internet Cognitive Behaviour Therapy (ICBT) to people suffering from depression and anxiety. The Unit has brought wider access to treatment and large improvements in symptoms. It is just one example of how technology is transforming the mental health system.5

9.6%

Northwest Territories 7.4%

5.1%

9.0%

British Columbia 9.3%

References: 1. Statistics Canada. 2014. Health Trends. Statistics Canada Catalogue No. 82-213-XWE. Ottawa. Released June 12, 2014. www12.statcan.gc.ca/health-sante/82-213/index. cfm?Lang=ENG (accessed July 24, 2014) 2. Mood Disorders Society of Canada Depression: Community and Family Support Document; mooddisorderscanada.ca 3. Mental Health Commission of Canada “Mental Health First Aid Canada launches new training course for northern peoples” News Release June 25, 2014. 4. Mental Health Commission of Canada “New research results show that the Housing First approach contributes to ending homelessness.” News Release June 12, 2014. 5. Online Therapy Unit. Online Therapy User Update June 2014; onlinetherapyuser.ca 6. College of Family Physicians of Canada cfcp.ca 7. Hamilton Family Health Team; hamiltonfht.ca

Doctor’s Review • july / august 2014

Mental Health First Aid This three-day training course provides the skills and knowledge to help people better manage mental health problems in themselves or someone close to them until treatment is found or the crisis is resolved. The course has been rolled out across Canada since 2008, training over 100,000 Canadians in its first two years. A version of the course specifically for Northern Peoples was launched in June 2014.3

Nunavut 4.7%

9.1%

Alberta 7.1%

4.0% 6.5%

9.0%

10.3%

Manitoba 7.2%

Saskatchewan 7.8%

Shared Mental Health Care The Hamilton Family Health Team (FHT) aims to provide timely access to high-quality mental health care through well-integrated primary care and mental health teams. Dr Nick Kates set up the model in 1994 and is the pioneer of shared mental health care in Canada. In June 2014, the Hamilton FHT was awarded the first ever College of Family Physicians of Canada/Canadian Psychiatric Association Collaborative Mental Health Care award.6,7

Canada

Legend % of population over age 12 reporting diagnosis by a health professional as having a mood disorder (depression, bipolar disorder, mania, dysthymia) in 20131 Innovative mental health programs across Canada

Between 80% and 90% of people with major depression can be treated successfully, yet only about a third seek help.2 At Home/Chez Soi Supported by the Mental Health Commission of Canada in several major cities, At Home/Chez Soi treats stable housing as the first step towards better mental health for people who are homeless and living with mental illness. In Montreal, participants who received help to find a suitable apartment had less stress, better mental health and were able to restore relationships with members of their families.4

3.9%

5.1%

6.5%

8.4%

Newfoundland and Labrador 6.8%

Quebec 5.2% 7.3% 6.6%

10.2%

Ontario 8.4%

6.6%

9.2%

New Brunswick 7.9% 8.4%

13.1%

Prince Edward Island 10.3% 12.0%

Nova Scotia 10.3%

15% of people suffering from depression will take their lives by suicide.2 july / august 2014 â&#x20AC;˘ Doctorâ&#x20AC;&#x2122;s

Review

“I felt down and

overwhelmed nearly every day.” Nicole*, 37

SNRI = serotonin norepinephrine reuptake inhibitor. * 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. ‡ Men only. § Women only.

For patients like Nicole...

Indication and clinical use

Trust PRISTIQ

for powerful

symptom relief

• 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

In major depressive disorder, choose PRISTIQ • An SNRI therapy with a discontinuation rate

due to adverse events comparable to placebo

Discontinuation rate in 8-week clinical trials: 4.1% PRISTIQ 50 mg vs. 3.8% placebo

• No statistical diﬀerence in mean weight change

vs. placebo was seen at 6 months (p=ns)†

• Low incidence of sexual function adverse events

demonstrated at 8 weeks

Incidence ≥1% at 8 weeks (PRISTIQ 50 mg vs. placebo): erectile dysfunction‡ 3% vs. 1%; libido decreased‡ 4% vs. 1%; ejaculation delay‡ 1% vs. <1%; ejaculation failure‡ 1% vs. 0%; sexual dysfunction‡ 1% vs. 0%; anorgasmia§ 1% vs. 0%

• 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.

Count on Reference: PRISTIQ Product Monograph, Pﬁzer Canada Inc., July 3, 2013.

for powerful symptom relief

• Recommended starting dose: 2-5 mg/day 1

Is MDD treatment at a standstill for your patients?

• Therapeutic dosing range: 2-15 mg/day 1 • Dose adjustments of up to 5 mg/day should occur gradually, at intervals of no less than 1 week 1

CONSIDER ADDING ABILIFY. Start with 2 mg.

Demonstrated 68% greater symptom improvement as early as week 1 vs. placebo Demonstrated 58% greater improvement

by week 6 vs. placebo

Change in mean MADRS total score with adjunctive ABILIFY vs. adjunctive placebo plus antidepressant: 2,3*

Demonstrated 88% greater improvement in quality of life vs. placebo • Secondary endpoint: Signiﬁcant improvement in score on the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), Short Form, demonstrated with adjunctive ABILIFY (9.8) vs. antidepressant therapy (5.2; p=0.004) 2*

• Week 1: -3.67 vs. -2.19; p=0.015 • Week 6: -10.12 vs. -6.39; p<0.001

ABILIFY® is indicated for use as an adjunct to antidepressants for the treatment of major depressive disorder (MDD) in adult patients who had an inadequate response to prior antidepressant treatments during the current episode. Refer to the page in the bottom-right icon for additional safety information and for a web link to the Product Monograph discussing: • Most serious warnings and precautions regarding elderly patients. • Other relevant warnings and precautions regarding: body temperature regulation; orthostatic hypotension; glucose abnormalities; rare risk of priapism; agranulocytosis and temporally-related leukopenia/neutropenia; venous thromboembolism; potentially-fatal

neuroleptic malignant syndrome; tardive dyskinesia; use in patients with a history of seizures; potential for cognitive and motor impairment; possibility of suicide inherent in psychiatric illness; use in pregnant and nursing women; QT interval prolongation, dependence/tolerance; use in patients with rare hereditary problems of galactose intolerance or glucose-galactose malabsorption. • Conditions of clinical use and dosing instructions. In addition, the page contains the reference list and study parameters relating to this advertisement.

ABILIFY is a registered trademark of Otsuka Pharmaceutical Co., Ltd. used under licence by Bristol-Myers Squibb Canada. Montréal, QC, Canada

See additional safety information on page XX 55

ga d ge t s by

T he o S a n d s

A couple of years ago, a friend of our daughter’s and her boyfriend arrived for the weekend. He was an amateur cook of some talent and claimed to have studied with Julia Child, author of the famous cookbook. His freezer, he said, was full of reductions of various kinds: several pounds of premium meat reduced to 500 millilitres, that sort of thing. He talked a great meal. I like to mess around in the kitchen too, if perhaps not at that level. I’d planned a tasty Indian meal for them, but was deflated when he came into the kitchen and proceeded to go through my utensil drawer. He extracted my chef’s knife holding the blade up with two fingers, and said, “Oh Theo, you should be ashamed.” The knife, a Henckels from Germany, was as dull as the left bank of the Rhine. I was indeed ashamed. A sharp knife is one of the essential tools in any kitchen. I aspired to always having one in mine — and I had the knife sharpeners to prove it: from sharpening stones, to sharpening rods, to several models with ceramic or steel wheels that you draw the blade through. I have an electric model too, and a diamondsurfaced block of stainless steel that comes in a small leather travel case.

More online

photos this page © lee valley tools ltd.

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The Universal Sharpener even works on blades with a curve in them.

And I have dull knives. Sadly, I’ve never quite mastered the art of knife sharpening — until now. Enter the Universal Sharpener. It uses “a very different concept in sharpening” boasts the Lee Valley catalogue. A sub-micron tungsten carbide blade shaves the steel rather than abrades it. It actually peels away a tiny thread of steel leaving a blade that is as sharp as it was when new — maybe sharper. It takes very little force and it works on all kinds of blades: axes, scissors and even those with a curve in them. The sharpener resembles a chunky penknife with the working part folding into a handsome red anodized aluminum handle. There’s even a belt clip. It’s simple to use and comes with a clearly illustrated instruction booklet. Your liberation from dull knives could be less than a week away. $18.50. leevalley.com.

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july / august 2014 • Doctor’s

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Treating chronic pain, our shared responsibility. As one of the leading pharmaceutical companies in Canada, Purdue Pharma is dedicated to ongoing research and development in the field of drug delivery and the use of pain medications. However, we also recognize that prescription drug abuse is a public health issue. A recent survey conducted by CAMH showed that 81% of students who use medicines non-medically obtain them from family or friends.1 Purdue Pharma, together with health authorities and the medical community, is actively working to reverse this trend so that the right medications get to the right patients. Through our educational programs and strong community partnerships, we are confident that we can continue to make great strides in addressing the use, abuse and diversion of pain medications. For more information on our products and our role within the community, please contact your Purdue Health Solutions Manager or visit www.purdue.ca.

1. Boak, A., Hamilton, H. A., Adlaf, E. M., & Mann, R. E. (2013). Drug use among Ontario students, 1977-2013: Detailed OSDUHS findings (CAMH Research Document Series No. 36). Toronto, ON: Centre for Addiction and Mental Health.

h i s t o r y o f m e di c i n e by

Ja c k i e R os e n he k

Contraception: silly to sensational

The long evolution from lemon-soaked pessaries to the Pill Vintage postcards amply illustrate the emotions with which a pregnancy was sometimes greeted.

part from survival, the biological drive to procreate is the strongest instinct in the animal kingdom

— fueled by everything from spectacular flauntings of feathers and antlers to awe-inspiring displays of red Porsches and pushup bras. But what sets us humans apart from the rest of our furry and feathered friends is the ability — and perhaps more tellingly, the desire — to manipulate so many aspects of our reproduction. Of course, the desire to mess with Mother Nature was there long before we had the science to back it up. The oldest method of birth control of all, the withdrawal method, is right there in the pages of Genesis. Onan, who was slain by God for his crime of coitus interruptus, at least survived in the sense that he gave the act — and its partner in seed-spilling, masturbation — his name. Judging by the large family sizes also recounted in the Bible, onanism was about as effective then as it is now.

SWEET AND SOUR Birth control forced lovers of the past to get creative. The Talmud, the ancient Jewish how-to guide to life, recommended lemonjuice soaked sponges inserted just prior to intercourse. Speaking

of citrus and sex, Giacomo Casanova (1725-1798), that notorious Italian lover and leaver of legend, was known to use a half-lemon as a cervical cap to prevent pregnancy in his many partners. The always crafty ancient Egyptians had methods of their own. The Ebers Papyrus (circa 1550 BCE) describes a virtual plethora of pessaries, with ingredients as varied and sweet-sounding as acacia root and honey, to more stomachchurning inserts soaked in donkey’s milk or crocodile dung. Onion juice applied to the foreskin was also recommended. These last few were likely quite effective forms of birth control in that they also served to repel one’s partner so completely that sex was nearly impossible. The lovers in ancient China fared even worse — women sometimes drank hot mercury as their birth control method of choice. Presumably, this worked well too — if maternal death can be considered a way to prevent pregnancy.

CRAZY CONDOMS The centuries marched on but time did little to solve the problem of family planning. The Japanese devised a glans cover made of animal horn as early as the 1400s. European methods were even more creative and equally ineffective. In medieval times, drinking sheep’s urine or rabbit’s blood was celebrated as a sure-fire way to prevent conception; alternately, weasel testicles could be strapped to one’s thigh during sex to achieve the same effect. Nettle-leaf pessaries were favoured in Elizabethan England, while around the same time in Africa, women were advised to collect and drink the frothy spittle from camels’ mouths. Some strides were made around 1500 when Italian anatomist Gabriele Falloppio (1523-1562) contributed the first academic description of the condom to the literature. Inspired by a nasty syphilis epidemic in Italy at the time, this condom was unlikely very effective seeing as how it was made of very fine july / august 2014 • Doctor’s

Review

linen and tied on the base of the penis with a pretty ribbon. Slightly less porous were the leather condoms to come out of Denmark, and those made from animals’ intestines. Ones made from fish entrails were found in the cesspit of an English castle in Dudley, dating from the mid 1600s. It wasn’t until Charles Goodyear came up with the vulcanization of rubber in 1839 that condoms actually became a viable form of birth control, with rubber remaining the shield material of choice until latex came along a century or so later.

THOSE VIRILE VICTORIANS During Victorian times, freedom from the corset was at least one reason to look forward to pregnancy, but that didn’t stop women from trying to fend off the stork on their own. Aside from condoms, the delightfully named “womb veils” — mail-order cervical caps made of rubber — were originally devised to correct prolapsed uteri, though their effectiveness as birth control was questionable. Stateside, the Comstock Laws of 1873 made the dissemination of immoral material (i.e., pornography and contraception) illegal, so women ordering douches and clysters and caps from adverts in the backs of magazines were once again left to their own devices — the US Postal Service refused to deliver any orders. The beginning of the 20th century saw definite improvement in fertility awareness and family planning, although there were still some pretty big gaps in terms of both the understanding and the execution. One low point for women during the 1920s and ’30s was the inexplicably popular Lysol douche; despite its miserable and often quite serious side effects, there seemed to be a common belief that chemical disinfectants could be used pre- or post-coitally as an effective form of birth control. Many of these so-called “feminine hygiene” products contained poisonous ingredients, often causing burns and other irreparable damage. Alternately, women willing to endure the embarrassment could get diaphragms from their doctors, but condoms still remained the most popular form of birth control during the first half of the 20th century.

RHYTHM METHOD More good news was that the rhythm method was finally up and running in more or less the right way by the 1930s. Previously, physicians from the first century, like Greek doctor Soranus of Ephesus (one of the first physicians to really specialize in gynecology) and the Roman-Christian MD Augustine of Hippo, a.k.a. Saint Augustin (354-430), wrote that the days immediately preceding and following a woman’s menstrual flow were when she was most fertile. It was an erroneous notion held until well into the 20th century, when gynecologists Kyusaku Ogino of Japan (18821975) and Hermann Knaus of Austria (1892-1970) pinpointed ovulation. The discovery quickly led to the development of manuals, handheld devices and even an entire clinic devoted to spreading the word. The eponymously named “O.K.” method was great in theory but — as legions of “surprise” babies can attest — just because a woman knows about the rhythm method doesn’t mean she can keep a beat.

Doctor’s Review • july / august 2014

A 1934 version of the “Rythmeter” for physician use. The device was developed by engineer Gilmore “Tilly” Tilbrook.

The instructions included with these circa 1900 animal-bladder condoms recommend that they only be used 10 times each.

Margaret Sanger (shown in 1917), founder of Planned Parenthood of America, worked for 40 years to turn the Pill into a reality.

Europeans were even more creative: weasel testicles were strapped to one’s thigh during sex to prevent conception MOTHER OF THE PILL It was the Comstock Laws that inspired one New York nurse, Margaret Sanger (1879-1966) to fight for women’s right to birth control. Repulsed by the reproductive misery she witnessed in her work in the slums of the city, from the perils of frequent childbirth and miscarriage to the dangers of STDs and self-induced abortions, she began to advocate for women’s right to good birth control. In 1915, both she and her husband, the architect William Sanger, were charged with the crime of disseminating information about birth control and sending diaphragms by post, but they ultimately won their appeal on the grounds that it could also prevent disease. In 1921, Ms Sanger founded what would one day become Planned Parenthood of America. Her dream — a magical little pill that could prevent pregnancy — was 40 years in the making but eventually, after plenty of legal battles and scientific research, she found a team who made it happen. The road from idea to drugstore shelves was a rocky one. Sanger enlisted the medical genius of reproductive biologist Gregory Pincus (1903-1967) and as much as $2 million in funding from her friend, International Harvester heiress Katharine McCormick (1875-1967). A key piece in the puzzle was the ability to create synthetic progesterone, a feat accomplished in the early ’50s by chemists Frank Colton and Carl Djerassi. At last, the holy grail of family planning — approved by the FDA following extensive testing and marketed by Searle under the name Enovid — hit the North American scene in 1960. The world would really never be the same.

FERTILITY FALL-OUT Yes, the year 1960 was a seminal one (in more ways than one). Socially, the impact of the Pill was enormous. Although social mores of the time dictated that the Pill be prescribed and marketed only to married women, it didn’t take long before it was widely available. Almost overnight, single women everywhere were free from fear of unwanted pregnancies something that undoubtedly helped engender the “free-love” movement in the latter half of the decade. The freedom of being able to plan one’s family was equally thrilling for married women, and provided mothers the chance to not only limit their number of children, but also to space their kids out and plan their careers freely. Of course, there were unanticipated social side effects as well. Almost instantly, the skyrocketing birth rates in North America courtesy of the post-WWII baby boom came to a screeching halt. As the 1960s unfolded, the debate over who controlled women’s fertility came to the fore. Margaret Sanger

and other women’s health advocates insisted that since the burden of childbirth and child-rearing fell almost exclusively to women, that they alone had the right to control this extremely important domain. And yet men were the ones in control of the Pill in many ways.

banned by the pope A backlash against the Pill came in the form of safety hearings before the US Senate in 1970. For a brief moment, religious interests — and there were many groups who opposed use of the Pill, especially after the Pope “banned” it and all forms of artificial family planning in 1968 — suddenly aligned with a new generation of feminists who asked if perhaps the Pill might not be the greatest thing since sliced bread. Was it safe? Could it be safer? Was it yet another way to control women’s bodies? Shouldn’t birth control be equally the man’s responsibility as well? In what was seen as a patients’-rights victory for Pill users — as well as the radical feminists who disrupted the meetings — the FDA approved its continued sale provided each packet contained patient information outlining the risks associated with its use. In addition, the renewed interest in the Pill’s safety resulted in better formulations with lower doses of hormones to lessen the risk of blood clots. After a brief decline in sales, the Pill became more popular than ever, with more than 10 million women in North America counted among its loyal fans by 1973. The debate surrounding this and indeed all forms of family planning rages on. But today, some 55 years after the Pill first hit the market, women who want to be in charge of the ifs and whens of having babies turn to the Pill more than any other kind of birth control, it being the method of choice among close to half of North American women of childbearing age. Internationally, the number is quite astounding: roughly 100 million women around the globe use the Pill regularly. Unlike the first- or even second-generation formulations, today’s Pill delivers highly effective birth control and cycle regulation at the lowest hormonal doses possible. This translates into a level of safety and efficacy that our ancient ancestors — and even our mothers — could really only dream of.

july / august 2014 • Doctor’s

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i p r e s c r i b e a trip to... greece

A Greek revival A family vacation to the Laconia region lets an Ontario MD revisit his roots

all photos courtesy d. james sahlas unless otherwise noted

by Dr D. James Sahlas

Dr Chiavaras and Dr Sahlas with their twins, Eleni and Sophia, and their son, Ioannes, in Monemvasia.

he Laconia region in the southern Peloponnese is a crucible of human drama. Rugged mountainsides cradle a broad, fertile river valley, birthplace to Helen of Troy and centuries later, the warrior

culture of ancient Sparta. Remnants of bygone empires — Roman, Byzantine, Ottoman — lie scattered everywhere, stacked one atop the other. My family is from here, and my siblings and I have kept returning since the summers of our youth, nowadays with our own young families in tow.

D. James Sahlas is a stroke neurologist at Hamilton General Hospital in Ontario, where his wife Meg Chiavaras is a musculoskeletal radiologist. They both also have academic appointments at McMaster University. They enjoy staying with members of their extended family on their periodic trips to Greece, where life in a traditional village offers a welcome and restorative change of pace.

Doctor’s Review • july / august 2014

This is a corner of Greece well worth visiting, not only during the summer months, but also in spring or the warm afterglow of a Mediterranean autumn. Last October witnessed a record-breaking spike in tourists, welcoming the highest numbers for that month ever as Greek tourism continues to rebound. Ancient Sparta was comprised of a cluster of settlements. Its kings didn’t construct any monumental architecture, so little evidence remains of its past glory. By the late Roman era, the city of Lacedaemonia had emerged at the centre of the Spartan plain, although it fell beneath the onslaught of barbarian invasions after the collapse of the Roman Empire. The ruined city was repopulated during the Middle Ages, but diminished in importance when the nearby settlement of Mystras became the new capital of the Peloponnese during subsequent periods of Byzantine and Ottoman rule.

nick k. / shutterstock.com

The ruins of ancient Sparta are near the modern city of Sparti, founded in 1834 and home to 20,000 people.

The modern town of Sparti was founded in 1834, following the Greek War of Independence. Today, its population numbers around 20,000 and it serves as the economic hub of the Laconian plain. There is a weekly farmer’s market on Wednesdays, but in the summertime everything shuts down by midafternoon for the requisite siesta. This is followed hours later by a surprisingly active nightlife, as families emerge for an after-dinner stroll, and young people from the surrounding villages converge upon the trendy bars and dance clubs. Driving in Sparti can be a hair-raising experience: there are two frenetic roundabouts in place of any traffic lights. My wife is from Boston and even she has never seen anything like it. But, despite the madness, there’s a sleepy charm in its broad central square surrounded by coffeehouses. This is the place we come to enjoy a frappé — Greek iced coffee, whipped up like a milkshake and best enjoyed glyco me gala, with milk and sugar — while lounging under the shady umbrella of a cushioned patio chair. The Archeological Museum of Sparta (71 Osiou Nikonos Street; admission €2) is one of the oldest mu-

seums in modern Greece. Established in 1876, most of the exhibits date from the Hellenistic and Roman periods. Its tranquil grounds are the perfect escape from the noise and confusion of the busy town, and are a favourite spot for an ice cream break. If you can survive the traffic, head for the small hillside covered in olive trees behind the impressive statue of King Leonidas. This is the acropolis of the ancient Roman city, where you’ll likely find yourself wandering alone among the half-excavated ruins. From here, one is better able to appreciate the grandeur of the surrounding mountains, dominated by the summit Taygetus to the southwest, lumbering 2407 metres into the heavens. Squint and you can make out a distant foothill covered with ruins. This is Mystras.

high on Mystras For years now, I’ve been fascinated with the story of the Frankish noblemen who briefly ruled in medieval Greece. Born in Kalamata, Guillaume de Villehardouin was the son of a crusader from the Champagne region july / august 2014 • Doctor’s

Review

panos karas / shutterstock.com

The town of Mystras, a UNESCO World Heritage Site, includes a hilltop fortress that dates from the 13th century.

in Northern France. His father became the ruler of the Peloponnese and established a short-lived Frankish dynasty. When Guillaume succeeded his older brother, he chose the craggy summit of Mystras for an impressive fortress to subdue the warlike Slavic tribes dwelling within the Taygetus range. After the Byzantine Greeks won back the Peloponnese, they expanded the Frankish fortress, and constructed a palace and impressive churches, making Mystras the administrative centre of the region. It was here, at the dawn of the 15th century, that the final cultural flowering of Byzantium took place and where Constantine XI Palaiologos was hastily crowned as his millennium-old empire crumbled. In Western Europe, the Byzantine diaspora contributed significantly to the Italian Renaissance. Back in the Peloponnese, four centuries of Ottoman rule followed. Mystras was one of the first towns to revolt in the Greek War of Independence of 1821. It

On warm evenings, many locals sit around the little square as the floodlit walls of the castle float in the night sky 36

Doctorâ&#x20AC;&#x2122;s Review â&#x20AC;˘ july / august 2014

was destroyed in the crushing reprisals that came after, rendering it a ghost town. Repopulation in the years that followed centred mainly in the newly established city of Sparti on the previous site of Roman Lacedaemonia. Designated a UNESCO World Heritage Site in 1989, Mystras is one of our favourite places to explore. Most visitors enter using the upper fortress gate, from where the strenuous hike to the Frankish castle is best completed prior to the intense heat of late morning. The views of the Laconian plain from the summit are vertiginous, but exhilarating. My son and I made the ascent when he was only six years old and he has never forgotten it. There are numerous Byzantineera churches to discover as one makes the circuitous descent, and a small monastic community of nuns welcome the penitent with refreshments. Bring enough water and a small picnic lunch, and itâ&#x20AC;&#x2122;s quite possible to spend much of the day among the sprawling, maze-like ruins. My feisty nonagenarian grandmother still resides in the small, modern town of New Mystras located on the outskirts of the archeological site. One of my uncles converted an old guard tower that had been in the family for generations into a summer residence. It stands across the street from where the imposing statue of Constantine XI Palaiologos looms, brandishing a sword. On warm summer evenings, many of the locals sit around the little square near the statue, as the floodlit walls of the Frankish castle float

serenely in the night sky, couched upon the blackness of the craggy summit. We often join them to discuss matters ranging far and wide, as bats swirl around the lamplights, drawn to their nightly feast of insects. For those without relatives in the village, there’s Pyrgos Mystra (3 Manousaki; pyrgosmystra.gr); previous guests include British actor Ralph Fiennes. Alternatively, Guesthouse Mazaraki (Pikoulianika; xenonasmazaraki.gr; doubles from €85) in the nearby village of Pikoulianika is a truly memorable place to stay. The hotel is situated along a high ridge adjacent to the summit of the archeological site, the whole of the Spartan plain spread beneath it. The Veil Café Bistro and Chromata Restaurant are two of the finest nearby dining options.

The crystal waters of the Bay of Diro lead to the entrance of a half-submerged cave network.

Coasting through Laconia As everyone knows, Greece is intimately linked to the sea. The southern coastal town of Gytheion served as the port of ancient Sparta. Today, the modern town of Gytheio features a broad promenade fronted by pastel-coloured neoclassical buildings. Rows of octopus hang drying in the sun, and the restaurants along the shore overlook the islet of Marathonisi, said to represent Homeric Cranae where Paris fled with Helen on their passage to Troy. There are several excellent beaches both north and south of town, and a variety of accommoda-

tions like Castello Antico Hotel (Mavrovouni Beach; castelloantico.com; April to October; doubles €80) along famed Mavrovouni Beach. Gytheio is considered the gateway to the wild and remote Mani peninsula. Travelling westwards through a winding, hilly pass across the southern extension Dr Chiavaras strikes a pose in front of Monemvasia, which became an island after an earthquake in 375 CE.

july / august 2014 • Doctor’s

Review

The Kinsterna Hotel in Monemvasia is housed in a 17th-century mansion on an eight-hectare estate.

Indications and clinical use • Cymbalta® (duloxetine hydrochloride) is indicated for: • the symptomatic relief of major depressive disorder (MDD) • the symptomatic relief of anxiety causing clinically significant distress in patients with generalized anxiety disorder (GAD) • The efficacy of Cymbalta® in maintaining anxiolytic response for up to 6 months in patients with GAD was demonstrated in a long-term placebo-controlled trial in patients who had initially responded to Cymbalta® during a 6-month open-label phase. • Cymbalta® is not indicated for use in children under 18 years of age.

kinsterna hotel

Contraindications • Patients concomitantly taking any of the following medications: monoamine oxidase inhibitors (MAOI), including linezolid and methylene blue, or within at least 14 days of discontinuing treatment with an MAOI; potent CYP1A2 inhibitors (e.g. fluvoxamine) and some quinolone antibiotics (e.g. ciprofloxacin or enoxacin); and thioridazine • Any liver disease resulting in hepatic impairment • Uncontrolled narrow-angle glaucoma • End-stage renal disease (requiring dialysis) or patients with severe renal impairment (estimated creatinine clearance <30 mL/min)

of the Taygetus range, you’ll reach the small mountain town of Areopoli on the other side. Continuing north is the stunning Bay of Itilo, where our favourite place to stay is Limeni Village (Limeni Areopolis; limenivillage.gr; doubles from €80). From there, one can travel north to Kalamata, even returning to Sparti eastward back across the mountains through the spectacular Langada Gorge. To the south of Areopoli is a region called the Deep Mani, home to the halfsubmerged cave network of Diros. Gondoliers pole boatloads of visitors through the narrow, water-filled tunnels and subterranean chambers festooned with stalactites. One must eventually disembark and ascend back into the sunlight on foot. My wife and I have visited the caves before, but we experienced them anew on our trip last year with our son Ioannes, aged nine, and twin daughters Eleni and Sophia, aged seven, who were thoroughly fascinated. There is something otherworldly about floating upon the cool waters of an underground lake, and one cannot help but converse in hushed, reverential tones. Far to the east, the Parnon mountain range descends towards another peninsula. Built on the seaward side of a monolithic rock, the well-preserved medieval town of Monemvasia lies ensconced, almost invisible from the mainland. Its rocky promontory was rendered an island after a huge earthquake in 375 CE. One’s first arrival to the town is always a magical experience. The single entrance does not permit automobiles on the narrow, sloping, cobblestone streets. My wife, Meg, learned on our last trip that wearing heels is not an option. Fortunately, we were able to find a pair of stylish Tsavalas sandals, handmade in Laconia, at one of the little shops a short distance from the main entrance. There are accommodations in Monemvasia itself, but, on our last trip, we spent a couple of days at the remote yet luxurious Kinsterna Hotel (Agios Stefanos; kinsterna hotel.gr; March to December; doubles from €135), a restored, centuries-old Ottoman mansion that opened just a few years ago. The Malea peninsula also boasts many first-rate beaches, like the white shores of Elafonisos, just over an hour away by car. While there are many places worth visiting in Greece, Laconia beckons with its natural beauty and historical sites, not to mention the warmth and hospitality of its locals. In recent years, luxury accommodations and improved tourism infrastructure have emerged. This southern region of the mainland is less well known than the Greek islands, yet there’s the promise of plenty of new discoveries to entice any traveller.

More online

Discover Mount Desert Island in Maine where Dr Chiavaras spent the summers of her youth. doctorsreview.com/features/ i-prescribe-trip-mount-desert-island Doctor’s Review • july / august 2014

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 in patients <18 years • Severe agitation-type adverse events coupled with self-harm or harm to others in patients of all ages • Rigorous clinical monitoring for suicidal ideation and behaviour and agitation-type emotional and behavioural changes is advised in patients of all ages • Increased risk of suicidal behaviour in patients ages 18 to 24 years with psychiatric disorder • Discontinuation symptoms: Cymbalta® should not be discontinued abruptly. A gradual dose reduction is recommended. Other relevant warnings and precautions • Cymbalta® should not ordinarily be prescribed to patients with substantial alcohol use as it may be associated with severe liver injury. • Investigate symptoms of liver damage promptly. Discontinue and do not re-start in patients with jaundice. • Bone fracture risk with SSRIs/SNRIs • Risk of increases in blood pressure and heart rate. Monitor as necessary. • Risk of hypertensive crisis in uncontrolled hypertension • Abnormal bleeding risk with SSRIs/SNRIs • Caution of increased bleeding events with concomitant use of NSAIDs, ASA, or other drugs affecting coagulation • Risk of serotonin syndrome or neuroleptic malignant syndrome-like reactions • Risk of urinary hesitation and retention • Risk of serious skin reactions, including Stevens-Johnson syndrome and erythema multiforme • Akathisia/psychomotor restlessness • Caution is advisable when using Cymbalta® in patients with diseases or conditions that produce altered metabolism or hemodynamic responses (e.g. conditions that slow gastric emptying). • Patients with history of drug abuse • Worsened glycemic control in some diabetic patients • Hyponatremia associated with SSRIs and SNRIs • Patients with a history of seizure disorder • Patients with raised intraocular pressure or those with narrow-angle glaucoma • Patients with a history of mania • Effect on ability to drive and use machines • Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucroseisomaltase insufficiency should not take this medicine. For more information Please consult the product monograph at www.lilly.ca/ cymbaltapm/en for important information relating to adverse reactions, drug interactions, dosing and administration which have not been discussed in this piece. The product monograph is also available by calling 1-866-364-4043.

A serotonin-norepinephrine reuptake inhibitor (SNRI) also indicated for the symptomatic relief of

Major Depressive Disorder (MDD) 1

Do your patients feel like prisoners to their symptoms of Generalized Anxiety Disorder?

At Week 9, Cymbalta® 60 mg once daily:1 • Significantly improved HAMA total score vs. placebo (mean treatment difference -4.4 vs. placebo, p<0.001);* • Significantly improved the Sheehan Disability Scale (SDS) work/school score vs. placebo (mean change from baseline -2.62 vs. -1.08 placebo; least squares mean treatment difference -1.48 vs. placebo, p≤0.001, secondary endpoint).2,3 * A 9-week, multicenter, randomized, double-blind, fixed-dose, placebo-controlled study involving patients at least 18 years of age, meeting DSM-IV criteria for GAD. Patients were randomized to receive placebo (n=175), duloxetine 60 mg QD (n=168) or duloxetine 120 mg QD (n=170). The primary efficacy measure was mean change from baseline in HAMA total score vs. placebo. Treatment difference was determined by calculating the difference between mean change in anxiety scores at endpoint between Cymbalta® and placebo arms. Baseline mean HAMA total score = 25.3.1,3 1. Cymbalta® Product Monograph, Eli Lilly Canada Inc., May 7, 2014. 2. Data on file, Eli Lilly Canada. 3. Koponen H, Allgulander C, Erickson J, et al. Efficacy of duloxetine for the treatment of generalized anxiety disorder: implications for the primary care physicians. Primary Care Companion J Clin Psychiatry 2007;9:100–107.

Lena Grottling / Shutterstock.com

Flagler Beach’s centerpiece is an old wooden pier where you can rent a pole for US$6 and fish with the locals.

Doctor’s Review • july / august 2014

Yesterday, FLA At Flagler Beach, Old Florida isn’t a thing of the past by Alastair Sutherland

ocated 40 kilometres north of the roar of Daytona, Flagler Beach markets itself as laid-back and quiet, a seaside community that offers a taste of the “Old Florida.” America’s oldest city, St. Augustine, is actually 50 kilometres north, but it’s old in terms of history: forts, monuments, relics from the British and Spanish past. At Flagler Beach, old means cheap motels and seafood shacks, no condos and strip malls, and 10

kilometres of orange-sand beach. There isn’t a chain restaurant in sight, and the town’s centerpiece is an old wooden pier, where you can rent a pole and fish with the locals or, if the waves are good, which they often are, stand and watch the surfers.

All photos by Alastair Sutherland unless otherwise noted

You’re more likely to see dolphins and turtles than crazy spring breakers on the 30-kilometre-long beach.

The Princess Place Preserve is home to Florida’s first inground swimming pool, which flows into Pellicer Creek.

In 2012, Flagler Beach was named one of the Top Retirement Destinations in Florida.

Sometimes, you can watch the fishermen and surfers fight. The pier has a 45-metre No Surf Zone, and rogue surfers enter it to get closer to the swells, tangling themselves in the lines and disturbing the fish. It’s one of the longest running controversies at Flagler Beach, with the most recent flare-up being in 2011, when a proposal to extend the zone to 90 metres was voted down after protesting surfers took to the streets with signs saying “Don’t take our break.” The normal mood at Flagler is calm. Most of the small town (pop. 4484) is built on the west side of the A1A Ocean Shore Scenic Highway that runs along the coast. On the east side, there isn’t much but beach. You can park your car (for free) on the grass shoulder and go for a swim or a walk on the sand, which gets its distinctive orange-cinnamon colour from coquina shell fragments. The beach has pet-friendly zones for dogs and, further up, coquina rock formations that give children a place to climb. There are two restaurants on the beach side: the Funky Pelican, beside the pier, and High Tides at Snack Jack, where you can eat fish tacos and crab cakes in the open-air. Back on the other side of the street, you can watch the sunset from the upper patio at the Golden Lion Café, a regular finalist in best Florida beach bar contests, or Finn’s, a divey but comfortable pub with a large wooden rooftop deck that is a Flagler landmark, the town’s equivalent of a Hard Rock Café. If you think it all sounds cool, you’re not alone. Last year, Flagler was a finalist in Budget Travel magazine’s Coolest Small Towns Contest. “The area seems to attract more sea turtles and right whales than spring breakers,” the magazine wrote, noting

I did a kayak tour through an ecosystem that has never been developed and looks the same as it did 10,000 years ago that the “thin strip of a beach town has remained significantly less-developed than its neighbours.” And not only is Flagler Beach cool, it’s also a cool place to be old, at least according to Where to Retire magazine, which in 2012 named it one of the Top Retirement Destinations in Florida.

o what does one do in a place that is both cool and old-age friendly? I spent three days in Flagler Beach to find out, armed with a full itinerary of places to go and sites to see. The number one site would, of course, be the beach, long and unspoiled, with enough wind and waves to keep things interesting. Then there is the “downtown,” which exists in name only, and again is most notable for the lack of chain restaurants and stores. No McDonalds, no Subway, no Walmart or Best Buy (though mind you, it’s a sort of illusion, as all can be found further inland in the planned community of Palm Coast). Instead, there are surf shops, taco stands and galleries with local crafts and art, and odd stores like Toes in the Sand, which has a large sign outside announcing its specialties: ukuleles and flip flops. The main downtown attraction is the Flagler Beach Historical Museum and Visitor Center (207 South Central Avenue; tel: 386-517-2025; flaglerbeachmuseum.com), which is a long name for a small place. Seeking refuge from the beating noonday heat, I did a full perusal of the museum, which was cool due to both the air conditioning and the friendly senior citizen who was on volunteer duty. In press materials, the museum proudly describes itself as “quaint,” and so it is, with an ongoing display that tells the history of Flagler Beach “from the Stone Age to the Space Age,” starting with dinosaur bones all the way up to dehydrated astronaut food. Jam-packed with photos, newspaper clippings, maps and curios, it also has vintage brochures (“You do not need to be a millionaire to live in Flagler Beach!”), a classic surfboard and early promotional material from Marineland, which was one of the first theme/sea-life parks in the world. It was a few miles up the road, and still in business. On the day it opened in 1938, Marineland caused a sensation, with over 20,000 tourists jamming the A1A Highway hoping to see what was billed as the largest aquarium in the world. Partially owned by the grandson of Leo Tolstoy, the park had its heyday in the ’50s, and was famous for its film studio (parts of Creature from the Black Lagoon were filmed there) and

dolphin show. It was hit hard in the ’70s by the arrival of Orlando’s SeaWorld and a long period of financial trouble ensued, with the park’s reputation falling into shabby disrepute. In the last decade, demolishment, donations and renovations have pulled it back to life, and it is now trying to reinvent itself as Marineland Dolphin Adventure (9600 N. Ocean Shore Blvd., St. Augustine; tel: 904-471-1111; marineland.net; ages 13 and up US$12, kids US$7), with an emphasis on educational and interactive programs for kids. On the day I went, a highlight of the short tour was Nellie, the world’s oldest dolphin. Born in 1953, Nellie, an Atlantic bottlenose, had been a star of Marineland for most of her life, but was now on her last legs, or rather flippers, and was only able to bob up and down, over and over again, in her tank. Her doting guardians assured me she was happy, and enjoying her retirement, but at any rate she died a few months later at the age of 61 — not bad considering the life expectancy for most dolphins is 45 to 50.

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There are plenty of freshly painted retro-style motels in lieu of big chain hotels and condos. The Kinsterna Hotel in Monemvasia is housed in a 17th-century mansion on an eight-hectare estate.

From seafood to sleeps

The meat at Captain’s BBQ is slow cooked in a wood-burning smoker.

High Tides at Snack Jack has been in business since 1947.

The one big hotel is the oceanfront Hammock Beach Resort (200 Ocean Crest Drive, Palm Coast; tel: 866-841-0287; hammockbeach.com; doubles from US$160) with 320 accommodations, including two- and three-bedroom villas. Part of the charm of Flagler Beach lies in its retro-style motels, most of which are freshly painted and shine in the sun like beacons of old. The Flagler Beach Motel (820 S. Ocean Shore Blvd., Flagler Beach; tel: 386-5176700; flaglerbeachmotelandvacationrentals.com) has excellent ratings on TripAdvisor. A small studio for four, with a kitchen and rooms decorated by a local artist, goes for US$65 a night in November, or US$390 a week. The two seafood restaurants on the beach will be the first to catch your eye: High Tides at Snack Jack (2805 S. Ocean Shore Blvd., Flagler Beach; tel: 386-439-3344; snackjack.com), in business since 1947, and the Funky Pelican (215 S. Ocean Shore Blvd., Flagler Beach; tel: 386-439-0011; funkypelican.com) next to the pier. Further north, in an area called The Hammock, is JT’s Seafood Shack (5224 N. Ocean Shore Blvd., Palm Coast; tel: 386-446-4337 jtseafoodshack. com), while Captain’s BBQ at Bing’s Landing (5862 N. Ocean Shore Blvd. Palm Coast; tel: 386-597-2888; captainsbbqbaittackle.com) is next to the Intracoastal Waterway. It serves meat cooked in a wood-burning smoker and the owner, Mike Goodman, was a former pastry chef in New York. Somewhat fancier fare — crabmeat stuffed portabella mushroom, wasabi salmon — can be found at Blue at the Topaz (1224 S. Ocean Shore Blvd., Flagler Beach; tel: 386-439-4322; blueatthetopaz.com), on the A1A next to the Topaz Motel.

arineland is north of Flagler Beach, and while still in Flagler County, it is actually its own small town, with a population of 16. Across the street, on the Matanzas River, which is part of the Intracoastal Waterway that separates Flagler Beach from the mainland, is Ripple Effect Ecotours (101 Tolstoy Lane, St. Augustine; tel: 904-347-1565; rippleeffectecotours.com), which runs kayak tours guided by naturalists from the University of Florida. They also have jet boat tours on a boat that runs on vegetable oil and that doesn’t have a propeller that’ll harm dolphins and manatees. I did a three-hour, 5.5-kilometre kayak tour through the Pellicer Flats lagoon, a peaceful paddle through an ecosystem that has never been logged or developed in any way, and looks pretty much the same as it did 10,000 years ago. The price was US$55, which also includes entrance to Marineland Dolphin Adventure. In keeping with my Old Florida theme, the next place I visited was Princess Place Preserve (2500 Princess Place Road; Palm Coast; tel: 386-313-4020), a 605-hectare park on the north side of the Matanzas River. It’s great for hiking, canoeing and kayaking, and has campgrounds as well as Flagler County’s oldest intact structure, an Adirondack-style lodge that was built in 1887 by a rich New England sportsman, Henry Cutting, who was then 24. Cutting used tree trunks and coquina rock for the lodge, and it’s still an impressive site. Unfortunately, after entertaining guests for four years, Cutting died on a boat near St. Augustine, from an overdose of codeine. His wife Angela inherited the lodge and years later married an exiled Russian prince named Boris, thus becoming a princess and giving the lodge its name. Of keen interest, though, is what’s outside: Florida’s first inground pool. Fed by an artesian well, the pool is still full of water that flows into Pellicer Creek, and is almost inviting enough to take a dip, were it not in a state of crumbling disrepair with a big sign that says “No swimming.” The old bathhouses and changing rooms are nearby, and apparently there are plans to fix everything one day, if money can be raised. As exciting as the first pool was, there’s more Old Florida history to discover at the Florida Agricultural Museum (7900 Old Kings Road, Palm Coast; tel: 386-446-7630; myagmuseum.com; adults US$9, kids 6 to 12 US$7), which has fully restored pioneer homesteads from the 1890s, and the Washington Oaks Gardens State Park (6400 N. Ocean Shore Blvd., Palm Coast; tel: 386-446-6780; washingtonoaks.org) which preserves the original habitat of a Florida Barrier island, with award-winning gardens and the second largest outcropping of coquina rock on the Atlantic Coast.

Flagler was a finalist in Budget Travel magazine’s Coolest Small Towns Contest The Gamble Rogers Memorial State Recreation Area (3100 S. Ocean Shore Blvd., Flagler Beach; tel: 386517-2086; floridastateparks.org/gamblerogers; US$5 per car) is a good place to visit for the hiking trails, camping and seaside picnicking, and has a poignant history of its own. Gamble Rogers was a Florida storyteller, folksinger and guitar-picker — he appeared on the Ed Sullivan and Johnny Carson shows, and was a big influence on Jimmy Buffett — who died a hero’s death on Flagler Beach in 1991, at the age of 54, trying to save a Canadian tourist who was caught in a rip tide. Someone to raise a toast to — and a reminder to be careful in the water, as there are only lifeguards in certain areas — as you watch the sun go down on Flagler Beach.

More online

Find out how St. Augustine, Florida’s oldest city, woos its littlest visitors. doctorsreview.com/features/st-augustine

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Wright in Buffalo The 1903 Darwin Martin House, one of Frank Lloyd’s first commissions, is finally restored to its former glory

biff henrich / img_ink, courtesy of the martin House restoration corporation

by Gerald Fitzpatrick

hances are the house you’re living in today was influenced by Frank Lloyd Wright, arguably the greatest architectural visionary of the 20th century. Born in 1869, Wright had an ego to match his genius.

His mother decorated his nursery with drawings of European cathedrals — and something must have rubbed off as the precocious child became fascinated with architecture. With no formal training, Wright found a position with Louis Sullivan, Chicago’s best known architect. After seven years, Wright left Sullivan and opened his own office. With his first commission, the Winslow House in the Chicago suburb of River Forest, completed in 1893, Wright changed the course of American domestic architecture.

Doctor’s Review • july / august 2014

Unlike most houses of the time, which Wright called “vertical boxes with holes cut in them for doors and windows,” the Winslow house had horizontal lines with a low pitched roof and broad overhanging eaves. This new style came to be known as the “prairie school” because the low horizontal lines seemed to reflect the form of the prairie. Of the 80 or so prairie houses Wright designed between 1900 and 1917, one of the finest is the Darwin Martin House in Buffalo, New York, completed in 1906. Long neglected, the house has now been

The roof of the Darwin Martin House seems to float on a series of second storey windows.

superbly restored to close to its original state and is a National Historic Landmark. As guide, Richard Beatty says: “This is Wright at his audacious best.” In 1903, Darwin Martin, a wealthy executive with the Larkin mail-order company in Buffalo, invited Wright to look at a property on which he wanted to build two houses, one for himself and a smaller one for his sister. Having seen Wright’s work in Chicago, Martin gave the architect remarkably free rein. The George Barton House, for Martin’s sister, was built as a compact prairie house with a two-storey living area intersected at right angles by a singlestorey section with an entrance porch and kitchen. The roof seems to float on a series of windows that enclose the second storey, a feature repeated on the main house.

Upon completion the complex consisted of the main house, a 30-metre pergola linking the main house to the Conservatory and Coach House, the George Barton House and a small gardener’s cottage. From all accounts, the Martin family lived happily in the house until Darwin Martin died in 1935. Then the family suffered financial setbacks. The house was abandoned two years later and stood derelict for sixteen years. Somehow surviving the weather and vandalism, the house was purchased by a Buffalo architect in 1954. During the next phase of its life, major parts of the building including the pergola, conservatory and carriage house were destroyed and eventually the house passed to the State University of New York at Buffalo. When I first visited the house in the mid 1980s, july / august 2014 • Doctor’s

Review

biff henrich / keystone, university at buffalo anderson gallery

The Barton House was built for Martin’s sister and brother-in-law.

Doctor’s Review • july / august 2014

gerald fitzpatrick

looking around the empty rooms, I had to imagine what it might have been like when it was still home to the Martin family. Fortunately, one doesn’t have to imagine any more. In 1992 the non-profit Martin House Restoration Corporation was formed. By that time, as Mary F. Roberts, Executive Director of the Corporation, said: “Wright’s masterpiece was down on its luck: abandoned for decades, partly demolished, a neglected eyesore in a residential section of a city beset by hard times.” Through a partnership of federal state and county governments, matched almost equally by private donors, the corporation embarked on an ambitious plan to remove non-historical buildings and recreate parts of the original structure that had been destroyed. The project, said Mary Roberts: “captured the hearts and minds of the community,” and now, following Wright’s original plans, the pergola, conservatory and carriage house have been recreated. Work on the interior of the house proceeds slowly. The upstairs has mostly been stripped back to the bare walls awaiting funds to continue restoration. But most of the downstairs, other than some wood finishing, has been returned to its original state, Windows and details have been replicated and it’s hard to tell the difference between Wright’s original Tree of Life art-glass from the reproductions. Amazingly, about 40 percent of the original furniture has found its way back to the house. In one case a visitor remarked: “Those kitchen cabinets look very much like ours,” and returned them to the house. One fin-

This Tree of Life reproduction is hard to distinguish from the original.

ishing touch yet to be completed is the stunning “Sunburst” fireplace. For a visitor who last saw the house in the 1980s the most memorable interior view is the statue of Victory at the end of the recreated pergola. The original cast of the statue was tracked down and reformed in poly-resins. The pergola leads to the conservatory and carriage house, which now serves as a gift shop.

Getting to Wright

gerald fitzpatrick

The Graycliff summer house on Lake Erie was a gift to Martin’s wife, Isabelle.

Tours are conducted at the Darwin Martin House (125 Jewett Parkway, Buffalo; tel: 716-856-3858; darwinmartinhouse.org) year-round. The basic, one-hour tour costs US$17; an in-depth two-hour tour is US$35. Reservations strongly recommended. There are complimentary tours at 10:30am on the second Wednesday of every month (reservations mandatory). One-hour tours at Lake Erie’s Graycliff (6472 Old Lake Shore Road, Derby; tel: 716-947-9217; graycliffestate.org) cost US$16 year-round. In-depth two-hour tours are US$30. Reservations essential due to limited space. The Roycroft Inn (40 South Grove Street, East Aurora; tel: 877-652-5552; roycroftinn.com; doubles from US$145) is a National Historic Landmark with some suites that have up to five rooms.

A National Historic Landmark, it has been said: “This is Wright at his audacious best” Twenty minutes from downtown Buffalo, on the shore of Lake Erie, is Graycliff, the Martins’ summer home, also designed by Frank Lloyd Wright. Darwin Martin told a somewhat reluctant Wright: “Isabelle is the client. This house is my gift to her.” The Martin’s first summer in the house was 1928. Isabelle was legally blind from an early age and the house is flooded with light from scores of windows. From outside you can look through glass walls of the house to the lake beyond. The hand dipped cedar shakes are Cherokee Red, Wright’s favourite colour. Spacious cantilevered balconies and broad terraces emphasize the architect’s typical horizontal lines and tie the house to the surrounding landscaping, also designed by Wright. Entrance to the house is through a small foyer with Wright’s characteristic low ceiling to give a sense of compression before entering the light-filled living room with its views over Lake Erie. At one end is an unusual fireplace that takes vertical logs. While the Martins abandoned their city home in 1937, they returned annually to Graycliff until 1943. In 1951 the Martins sold the house to an order of Hungarian priests who established a boarding school on the grounds and stayed for 45 years. Although they left most Wright-designed buildings intact, at one point the priests moved windows under an overhang to an outside wall to make a small chapel. One day in 1958 Wright drove up to the house unannounced and immediately saw what had been done. When one of the brothers appeared he began

yelling, pointing with his cane to the offending addition. The brother shrugged: “We needed a chapel,” to which Wright snapped “You needed me!” He left his card and promptly drove off. Graycliff was likely one of the last of his designs that Wright visited. He died the following year. By 1997 the priests could no longer afford to maintain the property and put it up for sale. Threatened with demolition and redevelopment of the prime on-the-lake site, a grass-roots group managed to buy the property in order to restore it to its original condition. Most of the restoration is being done by volunteers unless professional skills are clearly called for. To visit both houses comfortably really requires a stay-over in the area and one place to keep you in the century-old mood is the Roycroft Inn in East Aurora. Once at the heart of one of the most successful Arts and Crafts communities in the United States, the inn was restored and reopened in 1995. Founded by Elbert Hubbard, a sort of 19th century Bill Gates, the Roycroft campus in its heyday was home to over 500 artisans and crafts people. The main business of the campus was printing, originally for Hubbard to publish his own work. In 1938 the campus was divided and sold off to different owners and the artisans left. Today some of the buildings have been restored and a few artisans have begun to trickle back, but it is the inn that makes a trip to East Aurora worthwhile. And all this in Buffalo, New York. Who would have thought it? july / august 2014 • Doctor’s

Review

Olga: track star at 95 Ms Kotelko racked up world records until her death in June. An except from What makes Olga run? published earlier this year follows by Bruce Grierson

ver since she was 90, Olga Kotelko has presented a problem for organizers of the track meets she enters: whom does she compete against? The issue surfaced prominently in the 60-metre-dash final

at the World Masters Indoor Athletics Championships, in Kamloops, BC, in 2010. Olga found herself, well, in a class by herself. There just aren’t many nonagenarian sprinters — even when you draw from the whole planet. The next-oldest woman in this meet, Californian Johnnye Vallien, was 84. So there Olga was, 91, bespandexed and elfin, lumped in with the men. In lane one stood Orville Rogers, 91, a longstriding retired Braniff Airways pilot and the worldrecord holder in the mile for men over 90. Next to him:

The most curious thing is her extraordinary power for her size Belgian Emiel Pauwels, 90, another world-record middle-distance man (1500-metre), in bright orange track spikes, who would later make everyone nervous as he ran most of the 3000-metre final with his left shoelace untied. Front and centre: Ugo Sansonetti, 92, a former frozen-food magnate from Rome, in a blue sleeveless skinsuit, his tanned biceps bulging like small baked potatoes. Olga drew the inside lane, rounding out the field. She wore black tights and a long-sleeved white shirt — the modest uniform she wears no matter the weather. She’d been worried about her start. She’s not a good starter. She can get rattled. Sometimes, when the gun sounds or even a fraction of a second before, she takes a step backward. But today she started clean and mechanically strong, piston-pumping her arms, generating enough wind to pin her hair back a bit.

Doctor’s Review • july / august 2014

It’s no longer strange to see geriatric runners: every big-city marathon has its share of valiant, white-haired competitors who spark bursts of applause as they shuffle past. Kids and dogs and young adults run full-out. But old folks? The incongruity of that image inspired a television commercial that Ugo Sansonetti shot for Bertolli margarine not long ago. A runaway baby carriage is seen careening through the streets of Rome, until a fissure-faced old bystander — Ugo — springs into action and chases it down. Sansonetti crossed the first line at Kamloops, in a world-record time of 11.57 seconds. He bounced around in the run-off area, arms overhead in triumph, as Rogers glided in behind him at 12.82. Olga came in third, at just over 15 seconds. She looked concerned for Pauwels, the Belgian, who had caught a spike and crashed down hard, then picked himself up and limped in last. She was cool with running against the guys. “That one fellow was pretty fast,” she said, on the way to the changing area. She had gotten used to this. When you’re the fastest 91-year-old woman on the planet, either you compete against younger women or you run against the guys. Just how good is Olga? There are a couple of ways to put her in perspective. She currently holds 26 world records. She set 20 world records in a single year, 2009. She hits these totals in part by entering more events than everyone else, including a couple that nobody else in the world her age attempts. She will often do six throwing events, three sprints and three jumps. (At age 88, she considered adding the pole vault, but was deterred by practical considerations. “What do you do with the pole — strap it to the roof of the car? Check it on a plane?”) Track records, at the elite level, tend to fall by fingernail pairings of time and distance: fractions of seconds, portions of inches. At the 2009 World

FROM LEFT TO RIGHT: The book that made Olga Kotelko famous in the last few years of her life. Her autobiography was published this past April, two months before she died of a cranial hemorrhage.

Masters Athletics Competitions in Lahti, Finland, Olga threw a javelin almost six metres farther than her nearest rival. At the World Masters Games in Sydney, Australia, in 2009, Olga’s time in the 100-metre dash — 23.95 seconds — would have won the women’s 80-84 division — two age brackets down. Olga stands five feet and a half an inch. She weighs 130 pounds. For her size — and this may be the most curious thing about her — she has extraordinary power. It can be surprising, after her slo-mo windup, to see how far the things she throws go. On the hammer throw pitch in Kamloops, she took her place with the other competitors. Big guys with leather gloves paced around, shaking their hands out. Olga removed her glasses. There was a sudden and brief sense of menace; when a little old lady starts swinging a three-pound cannonball around her head, a good outcome is not guaranteed. But the thing sailed, straight and true. “If I spun I could throw it farther,” Olga says, but after watching somebody very old fall that way she has decided not to risk it. Olga got more leg into the second throw. But the trajectory wasn’t what she liked. She made a little swan’s head gesture with her hand, to remind herself. Routinely, Olga performs better on every subsequent attempt as she recalibrates and tries again. It’s like watching a marksman bracket the bull’s-eye and then draw in: 12.72 metres. 13.37. 13.92. In 10 minutes she added four feet of distance. “New world record,” a disembodied voice said over the loudspeaker. There is a formula called “age-grading” that’s used to put the performances of older athletes in perspective. Age-graded scores tell us how impressed we should be by what a masters athlete — placed in

categories from ages 35 to 105 — just did. A set of tables plots a given performance against the expected decline of the human body, and expresses it as a percentage. So, theoretically, 100 percent is the high-water mark for a human being of that age. But a number of Olga’s marks — in shot put, high jump, 100-metre dash — top 100 percent. In Sydney she threw the shot put 5.6 metres — which age-grades out at 119 percent. If you plug Olga’s 23.95 100-metre dash time from Sydney into the tables, you’ll find it’s exactly equivalent to American Olympian Florence Griffith Joyner’s prevailing, suspicious, and thought-to-be untouchable world record of 10.49 seconds. Remarkably, when you age-grade, you find Olga is not only holding her own but in some cases getting better — which suggests that either the tables are wonky or Olga is. Most likely both are true. “She throws off the curve, because she’s doing things nobody’s ever done,” says Ken Stone, editor of Masters Track, the watering hole of the masters track community. (Motto: “Older, Slower, Lower.”) But at the same time, some recent performances speak for themselves. “I threw the hammer farther this year than I did two years ago,” she mentioned recently, offhandedly. “How do you explain that?” No two ways about it: Olga is defying, or rewriting, our understanding of the retention of human physical capability. When people hear how old she is, they seem to look at her more deeply, at her face. To be blunt: She is not aging normally. “How old do you feel?” I asked her on her 91st birthday. She thought about that. “Fifty?” She gave a half shrug. “I still have the energy I had at 50,” she said. “More. Where is it coming from? Honestly I don’t know. I wish I knew. It’s a mystery even to me.” (Note: Olga turned 95 on March 2, 2014 and competed in the 95-99 age category until the week before she died on June 25, 2014.) Excerpted from What Makes Olga Run? Copyright © 2014 Bruce Grierson. Published by Random House Canada. Reproduced by arrangement with the publisher. All rights reserved. july / august 2014 • Doctor’s

Review

Wheat berry and baby kale salad.

Natural winners Three delicious vegan dishes that make it easy to lose the meat

recipes by

Myra Goodman

and

Marea Goodman

photos by

n Straight from the Earth, published by Chronicle Books, Myra Goodman and her daughter Marea explain that “vegan” means no animal products

at all; no meat, fish, dairy, eggs and even honey. Serious business, but oh the benefits: eating more fruits, veggies, legumes and grains, while cutting back on animal products, can lower your risk of developing hypertension, diabetes, heart disease and more; beans and grains generally cost less per calorie than meat and dairy; and choosing

Doctor’s Review • july / august 2014

Sara Remington

plant foods over animal ones helps to reduce the global warming gases and water pollution generated by livestock production. Of course, there’s also discovering new foods — like agave nectar and coconut oil — and their flavours. The recipes featured here are full of taste, and they’re perfect for the last weeks of summer.

Wheat berry and baby kale salad Baby kale is mild and convenient to use because the whole leaf is edible. You can substitute full-size kale by removing the stem and slicing the leaf very thinly. The wheat berries take an hour to cook, and 20 minutes to cool, but they can be cooked a day ahead of time. 2 c. (500 ml) wheat berries 1 tsp. (5 ml) salt For the curry-orange vinaigrette ²⁄³ c. (160 ml) extra-virgin olive oil ¼ c. (60 ml) golden balsamic vinegar zest of 1 orange 2 tbsp. (30 ml) fresh orange juice 2 tsp. (10 ml) agave nectar 1½ tsp. (7.5 ml) Dijon mustard 1 tsp. (5 ml) salt ¾ tsp. (3.75 ml) curry powder pinch of cayenne pepper pinch of ground ginger freshly ground black pepper

½ cup (125 ml) of the dressing. Add the grapes and orange segments and another ¼ cup (60 ml) of the dressing and toss again. Add more dressing if desired, and season with salt and pepper. Toss in the walnuts before serving. Serves 8.

Three-colour hummus This recipe is a standout at gatherings thanks to the varied flavours and three colours. Canned beans are convenient, and they work fine for hummus. Homemade pita chips are a great accompaniment — tastier as well as healthier than store-bought versions.

4½ c. (1 L) cooked garbanzo beans (rinsed and drained if canned) ²⁄³ c. (160 ml) tahini ¹⁄³ c. (80 ml) plus 2 tbsp. (30 ml) extra virgin olive oil ¹⁄³ c. (80 ml) plus 1 tbsp. (15 ml) fresh lemon juice 3 large garlic cloves, coarsely chopped 2 tsp. (10 ml) salt freshly ground black pepper ¼ c. (60 ml) plus 1 tsp. (5 ml) oilpacked, sun-dried tomatoes, drained and chopped 1¼ c. (310 ml) packed baby spinach ½ c. (125 ml) packed fresh flat-leaf parsley garlic pita chips (recipe follows)

Combine the beans, tahini, ¹∕³ cup

For the salad 5 oz. (140 g) baby kale 1 c. (250 ml) seedless red grapes, halved 1 c. (250 ml) seedless green grapes, halved 2 oranges, segmented salt freshly ground black pepper 1 c. (250 ml) raw, unsalted walnuts, toasted and coarsely chopped

Rinse the wheat berries and put them in a medium pot with 6 cups (1.5 L) water and the salt. Bring to a boil, and then reduce to a simmer. Cook, covered, for 1 hour, until the wheat berries are just tender. Add a few cups of cold water to the pot, stir and then strain. Place the wheat berries in a large bowl to cool, stirring occasionally to help them along. Combine the oil, vinegar, zest, juice, agave, mustard, salt, curry powder, cayenne, ginger and pepper in a small jar. Seal the lid tightly and shake vigorously to combine. Set aside at room temperature. Combine the cooled wheat berries with the kale in a large bowl. Toss with

Three-colour hummus.

july / august 2014 • Doctor’s

Review

Seared polenta with tomato sauce.

Garlic pita chips ¼ c. (60 ml) extra-virgin olive oil 2 tbsp. (30 ml) pressed garlic ¼ tsp. (1.25 ml) salt 4 whole-wheat pitas, split in half

Position a rack in the lower third of the oven and preheat it to 350°F (180°C). Whisk together the oil, garlic and salt. With a pastry brush, brush the split side surfaces of the pita with the oil and garlic mixture. Cut each round in half, and then cut each half into 3 or 4 pieshaped wedges. Arrange the chips in a single layer on a rimmed baking sheet (you may need two sheets). Bake for 10 minutes, or until the pitas are fragrant and begin to crisp. Remove from the oven and let cool before serving. (The chips will get soggy after a few hours, especially when the weather is humid.) Serves 8.

Seared polenta with tomato sauce A plate of crispy pan-fried polenta cakes topped with heirloom tomato sauce will satisfy even the pickiest eater. The polenta cooks quickly, but needs an hour or two to cool in the fridge, so make it ahead of time or let it cool while you cook the tomato sauce.

(80 ml) of the oil, ¹∕³ cup (80 ml) of the lemon juice, the garlic, ½ cup (125 ml) water, 2 tsp. (10 ml) salt, and a few grinds of pepper in a food processor fitted with a steel blade. Process until the mixture is smooth, stopping at least once to scrape down the sides of the bowl. If the hummus is thicker than desired, add 2 tablespoons (30 ml) at a time of cold water. Remove 1²∕³ cups (410 ml) of the puree and transfer to a serving bowl. Season with salt and pepper. This is the classic hummus. Remove an additional 1²∕³ cups (410 ml) of the hummus and set aside (this will become the green hummus).

More online

Add the sun-dried tomatoes and 2 tablespoons (30 ml) water to the hummus remaining in the food processor. Process until smooth. Season with salt and pepper. Transfer the red hummus to a serving bowl. Rinse the food processor bowl and blade. Place the spinach and parsley in the bowl and pulse until the mixture is finely chopped. Add the reserved plain hummus, and the remaining 2 tablespoons (30 ml) oil and 1 tablespoon (15 ml) lemon juice. Process until smooth, and season with salt and pepper. Transfer the green hummus to a serving bowl. Serve with pita chips. Serves 8 to 12.

2 c. (500 ml) plain unsweetened soymilk 2 tbsp. (30 ml) extra-virgin olive oil 1 tsp. (5 ml) dried oregano 1 tsp. (5 ml) salt ½ tsp. (2.5 ml) freshly ground black pepper ½ tsp. (2.5 ml) garlic powder ¼ tsp. (1.25 ml) red pepper flakes 1 c. (250 ml) corn grits/polenta ¼ c. (60 ml) whole-wheat pastry flour or corn flour canola oil for frying spicy heirloom tomato sauce (recipe online at doctorsreview.com) or good-quality jarred marinara sauce, heated

A bread pudding with roasted cherry tomatoes and corn, plus more veggie mains. doctorsreview.com/food/book/fresh-and-green-table Doctor’s Review • july / august 2014

1 c. (250 ml) chopped fresh flat-leaf parsley ½ c. (125 ml) pine nuts, toasted

Grease a 9-x-9-inch (23-x-23-cm) baking pan with olive oil. Set aside. Combine the soymilk, olive oil, oregano, salt, pepper, garlic powder, pepper flakes and 2 cups (500 ml) water in a medium saucepan, and bring to a simmer over medium heat. At the same time, bring a second pot of water to a boil. Slowly whisk the polenta into the soymilk-olive oil mixture in the medium saucepan. Continue whisking until the mixture is smooth, reducing the heat to low to avoid spattering. Cook until the polenta grains are tender, about 15 minutes, whisking regularly (it should have the consistency of cream of wheat). If it gets thick before fully cooked, add more boiling water, ¼ cup (60 ml) at a time. Immediately pour the polenta into the prepared baking pan. Cool for about 20 minutes, then refrigerate until cold, 1 to 2 hours. To cut the cold polenta into eight equal triangles, first cut a vertical line down the middle, followed by a horizontal line that divides the polenta into four equal squares. Then make two diagonal cuts from corner to corner to create eight triangles. Sprinkle the flour on a flat plate and dredge each polenta triangle in flour. Ready a plate lined with several layers of paper towels. Place a large skillet (preferably cast iron) over medium-high heat and film it with a thin layer of canola oil. Sear the triangles on each side until they are crispy and golden brown, about 5 minutes. Add more oil as needed between batches. Transfer the seared polenta to the paper towel-lined plate to absorb excess oil. To assemble the dish, place two polenta triangles on each plate. Top with hot tomato sauce. Sprinkle with parsley and pine nuts, and serve immediately. Serves 4 as an appetizer or 8 as a side dish. Recipes and photos from Straight from the Earth: Irresistible Vegan Recipes for Everyone (Chronicle Books, 2014).

CLINICAL USE: • Clinicians must take into account the safety concerns associated with antipsychotic drugs, a class of drugs to which ABILIFY belongs. ABILIFY should be used for the shortest period of time that is clinically indicated. ABILIFY is not indicated in patients with MDD <18 years of age and in elderly patients with dementia. The safety and efﬁcacy of ABILIFY in patients 65 years of age or older has not been established. Caution should be used when treating geriatric patients. MOST SERIOUS WARNINGS AND PRECAUTIONS: Elderly patients: Increased mortality in elderly patients with dementia. OTHER RELEVANT WARNINGS AND PRECAUTIONS: • Body temperature disruption with antipsychotic use • Orthostatic hypotension • Glucose abnormalities associated with atypical antipsychotics • Rare risk of priapism with antipsychotic use • Agranulocytosis and temporally-related leukopenia/neutropenia associated with antipsychotics, including ABILIFY • Venous thromboembolism (VTE) with antipsychotic drugs, including ABILIFY • Potentially-fatal neuroleptic malignant syndrome (NMS) with antipsychotics, including ABILIFY • Tardive dyskinesia associated with antipsychotic use • Use in patients with a history of seizures • Potential for cognitive and motor impairment • Possibility of suicide inherent in psychiatric illness • Use in pregnant and nursing women • QT interval prolongation • Dependence/tolerance • Use in patients with rare hereditary problems of galactose intolerance or glucose-galactose malabsorption DOSING INSTRUCTIONS: ABILIFY can be taken without regard to meals. Patients should be treated with the lowest effective dose that provides optimal clinical response and tolerability. FOR MORE INFORMATION: Please consult the Product Monograph at http://www.bmscanada.ca/ static/products/en/pm_pdf/ABILIFY_EN_PM.pdf for important information relating to adverse reactions, and drug interactions, and for dosing information which have not been presented elsewhere in the APS. The product monograph is also available through our medical department at 1-866-463-6267. * A 3-phase, randomized, placebo-controlled study in patients 18-65 years of age experiencing a major depressive episode for ≥8 weeks and reported inadequate response to previous antidepressant therapy. Patients were discontinued from their psychotropic medications during an initial screening phase (n=1147) and entered an 8-week, single-blind, prospective treatment phase to conﬁrm inadequate response to antidepressants, during which they received a standard antidepressant and an adjunctive placebo (n=827); 349 patients with inadequate response were randomized to continue antidepressant treatment in the double-blind phase of the study, and receive adjunctive ABILIFY 2-20 mg/day (n=177) or adjunctive placebo (n=172) for 6 weeks. Results are LOCF. References: 1. ABILIFY Product Monograph. Bristol-Myers Squibb Canada, May 27, 2013. 2. Berman RM, Fava M, Thase ME, et al. Aripiprazole augmentation in major depressive disorder: a double-blind, placebo-controlled study in patients with inadequate response to antidepressants. CNS Spectr 2009;14(4):197-206. 3. Data on File. Bristol-Myers Squibb Canada, Clinical Study Report CN138165. April 30, 2008. ABILIFY is a registered trademark of Otsuka Pharmaceutical Co., Ltd. used under licence by Bristol-Myers Squibb Canada. Montréal, QC, Canada

july / august 2014 • Doctor’s

Review

photo finish by

D r Gr e g I v e r s on

Life in Paris I was stationed in Germany with the Armed Forces in the late ’70s, and in the summer of 1980 my future wife and I went to Paris for the weekend — one of the many perks of that posting. I had the vague notion that Paris should be photographed in black and white so that’s what I did (with Tri-X, of course). When I came upon this scene, I was struck by the incongruity of the location and the destitute state of this homeless woman. I remember wrestling with the dilemma of actually taking the picture and recording her misfortune. In the end, the image was just too powerful to ignore, and my Canon A-1 with 35mm f/2 lens captured the poignant scene. Curiously, my wife and I returned to Paris this past New Year’s Eve and we came upon a similar scene on the Champs-Elysées. Some things will never change.

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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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)1* 96% of 24-hour periods were heartburn-free vs 29% with placebo (median; p<0.00001)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 conditions of clinical use, 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 Reference: 1. DEXILANT (dexlansoprazole) Product Monograph, Takeda Canada Inc. ™DEXILANT is a trademark of Takeda Pharmaceuticals U.S.A., Inc. and used under license by Takeda Canada Inc. ©2013 Takeda Canada Inc.