June 2014 by Doctor's Review

nd nt Co-op e p s 0 to Equipme 0 1 $ Win ountain at M TO PAGE 1

MEDICINE ON THE MOVE

TURN

More than wine in

the Okanagan Hiking Italyâ&#x20AC;&#x2122;s

Sabine Hills A bicycle built for you?

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

JUNE 2014

Become an urban

beekeeper

The gory golden age of

barber-surgeons

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Help fight

heartburn associated with GERD With the demonstrated power of DEXILANT™ Visit www.DEXILANT.ca 24 hours a day to learn more

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

99% of nights were heartburn-free vs 72% with placebo (median; p<0.00001)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.

The “which bike is best” dilemma When I was 12, my Dad bought me my first brand new bike. He picked it up after work at a local bicycle shop and rode it home. He was a kind man and this was a wonderful surprise. I appreciated the gift very, very much and worked hard to show it. Only trouble was, I hated the bike on first sight. The two-wheeler of choice among my friends was a three-gear model with hand brakes, thin tires and a faux-leather black bag thing that strapped on at the back of the seat. What we all really wanted was a top of the line British Raleigh in racing green. We were ready to settle for a “Made in Canada” CCM or other lesser manufacturer, but Raleigh set the standard. The bike my father so proudly presented me with was a single-gear model with back pedal brakes. There were two clunky upper bars instead of one with a fake gas tank welded between them. The whole catastrophe rested on fat, balloon tires with white walls. It was as heavy as a truck. I thanked him again — probably a little too enthusiastically and struggled to hide my disappointment. Two years later, I’d saved enough from my paper route to trade it in. Ten years after that, smaller, modified versions of the design were rebranded as BMX bikes, and they became an instant hit and have retained their popularity. Dad’s taste in bikes turned out to be way ahead of his time. These days, there are an astonishing number of different models out there, so many, in fact, it’s hard to know which one to pick. “Gear” on page 19 reviews some of the models: city, comfort, commuter — which one would you chose? Perhaps you’d prefer a fatbike, crossroad, touring or mountain model. No? Then try a pedal on a cyclo-cross or hybrid. A must-read for anyone in the market for a new ride. Elsewhere in the issue you’ll find a prediction of culinary things to come. Long-time contributor Jeremy Ferguson takes a foodie tour in BC’s Okanagan and foresees a wonderful dining future is in store for the valley. Staying close to home this summer? Alexandra Pimms suggests you try a hotel pool near you. Happy trails,

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Lolo

™

is now available

ethinyl estradiol 10 mcg norethindrone acetate 1 mg

NEW

The speed of 2 or 3 day dosing

in Actinic Keratosis is here

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

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

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

Once daily dosing: 3 days - face & scalp, 2 days - trunk & extremities For more information Please consult the product monograph at www.leo-pharma.ca/picato_pm for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by contacting LEO Pharma Medical Information at 1-800-263-4218. 1. Picato® product monograph, January 30 2013. *Two multi-centre, double-blind, randomized, parallel-group, vehicle-controlled, clinical studies of AK patients evaluating the efficacy and safety of Picato® Gel 0.015% applied once daily on the face or scalp to a 25cm2 area of skin for 3 consecutive days in adult patients. Efficacy measurements included

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

complete clearance rate and median percent reduction compared to vehicle control assessed at day 57 in Study 1 (PEP005-025) (Picato® Gel N=142, Placebo Gel N=136) and Study 2 (PEP005-016) (Picato® Gel N=135, Placebo Gel N=134) (8 weeks). †Two multi-centre, double-blind, randomized, parallel-group, vehiclecontrolled, clinical studies of AK patients evaluating the efficacy and safety of Picato® Gel 0.05% applied once daily on trunk and extremities to a 25cm2 area of skin for 2 consecutive days in adult patients. Efficacy measurements included complete clearance rate and median percent reduction compared to vehicle control assessed at day 57 in Study 3 (PEP005-028) (Picato® Gel N=100, Placebo Gel N=103) and Study 4 (PEP005-014) (Picato® Gel N=126, Placebo Gel N=129) (8 weeks).

www.leo-pharma.ca

contents JUNE 2014

YANLEV / SHUTTERSTOCK.COM

features 31

High on Italy Hike the mountains north of Rome through charming hilltop villages by Dr Philippe Erhard

Watering holes Seven hotel pools that’ll make you want to dive in by Alexandra Pimms

regulars

BC’s chef d’oeuvre The Okanagan Valley is about to be famous for its food by Jeremy Ferguson

9 LETTERS

Keep the Faita

Breakfast parfaits plus more dishes perfect for summer by Stefano Faita

And the MD going to Montreal is...

PRACTICAL TRAVELLER A three-wheeled, egg-shaped car, Air Canada’s first 787 Dreamliner plus is Paris banning PDAs? by Camille Chin

47 19

JUNE 2014 • Doctor’s

Review

In major depressive disorder

“I felt down and

overwhelmed nearly every day.” Nicole*, 37

For patients like Nicole...

Trust PRISTIQ

for powerful

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

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

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

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

CA0113PRI023E

Count on

for powerful symptom relief

contents JUNE 2014

regulars 17

FOOD

Why everyone is buzzing about home-harvested honey by Theo Sands

Should MDs put their appointment schedule online? by David Elkins

GEAR Find out which of these 13 bikes is built for you by Annarosa Sabbadini

PRACTICE MANAGEMENT

PHOTO FINISH From the bottom up by Dr Lorraine Sanfaçon

BEST MD APPS An eye app that you’ll love at first sight by David Elkins

HISTORY OF MEDICINE The birth of bloody barber-surgeons by Jackie Rosenhek

TOP 20 The medical meetings you have to attend this October

in the next issue •

The glory of Greece in autumn: an MD visits his favourite haunts in his favourite season

•

Old Florida lives! Flagler Beach retains the charm that made the Sunshine State popular in the first place

•

What makes Olga run? Aging with this 95-year-old track star is like not aging at all

•

The history of birth control: pregnancy prevention from the wacky to the sublime

•

Plus, hot travel news, the best MD apps, the world’s top med meetings and easy, end-of-summer recipes

JUNE 2014 • Doctor’s

Review

STRIVE FOR SUPPORT FOR YOUR LYRICA PATIENTS Your patients can save on their LYRICA with the Payment Assistance Card. The Pfizer Strive Payment Assistance Card (My Pfizer Card in Quebec)* allows your patients to save on their Pfizer Brand medication*.

Remind your patients to ask for LYRICA by name and direct them to Lyrica.ca to download their Payment Assistance Card and access other helpful resources. Your patients may also call 1-866-794-3574 to have a card sent to them by mail.

Pfizer Strive Payment Assistance Card Available in all provinces except Quebec

IF IT DOESNâ&#x20AC;&#x2122;T SAY PFIZER, LYRICA (pregabalin) is indicated for the management of neuropathic pain associated with diabetic peripheral neuropathy (DPN) and postherpetic neuralgia (PHN) in adults. LYRICA is indicated for the management of neuropathic pain associated with spinal cord injury (SCI) in adults.

My Pfizer Card Only available in Quebec

IT ISNâ&#x20AC;&#x2122;T LYRICA. LYRICA is indicated for the management of pain associated with fibromyalgia in adults. Please consult the Product Monograph at http://www.pfizer.ca/en/our_products/products/ monograph/141 for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph is also available by calling 1-866-463-6267.

*Availability and coverage varies by province and may vary based on patient plan. The My Pfizer Card program is only available in Quebec.

LETTERS

EDITOR

Annarosa Sabbadini

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

And the MD going to Montreal is...

TRAVEL EDITOR

Valmai Howe

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Pierre Marc Pelletier

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Pierre Marc Pelletier

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David Elkins

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AN APP OUT OF HELL? Are you kidding me? I’m flabbergasted that you think an app that shames people for their body weight is something to be lauded — and promoted [“Patient Perfect,” Best MD Apps, May 2014, page 19]! If body shaming worked as a weightloss device, I would have lost every extra ounce I ever had in sixth grade where the insults came at me like machine-gun fire. You have not only missed the Caribbean cruise on this one, you hopped on the Titanic headed to the icy north seas. I hope you get off before the thing sinks. Please rethink your support for this horrible app. Amy Dobek Via email

A FINE LINE Other readers might find it interesting to note that striped clothing keeps insects away [“Foods for mosquito magnets,” Food, May 2014, page 15]. A recent article in the National Post reported that zebras may be striped for precisely that reason. T-shirts with thin stripes are recommended — which will certainly make statement, but at least you won’t get bitten while on holiday! Dr J. Hughes Via email

THE NEW KID ON THE BLOCK The latest Legoland in Boston got a nice plug in April [“Boston goes blocky,” Practical Traveller, April 2014, page 12]. You gave

r te t! en tes n o c

Win two rom ant Suite at Hôtel ic nights in an Executive Le Crystal Montréal

A lucky phys ician and a guest will recei • Two night ve: s in an Exec utive (part of the Diamond Colle Suite • Continent ction) al breakfast at Restaurant • Valet park La Coupole ing for two night s This prize is value

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Fill out a con test ballot at doc drcme is the access cod torsreview.com/meet e to get to the ings contest sub mission form may 2014

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CONGRATULATIONS!

The winner of two nights at the Hôtel Le Crystal Montréal is Dr Paul Dubois, a surgeon from Moncton, New Brunswick. a line to Toronto’s version (at the Discovery Centre in Vaughan Mills) right at the end, but it deserves more. Our two boys six and nine prefer it to Disney World and it’s just down the road from where we live. Jon Bailey, Markham, ON

SUPPER SAVER Thank you for “The Tuesday Feed” [Tuesdays at doctorsreview.com]. Twice now I’ve found a simple meal I can throw together for the family. With a little creativity I’ve been able to use food in the ‘frig or pantry. R. Crites St. Boniface, MA

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

Treating chronic pain, our shared responsibility. JUNE 2014 • Doctor’s CLIENT: Purdue

DOCKET NUMBER: PQ9818

Review COLOURS

PRODUCER

DATE

Where can you turn for help in preventing

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

AMONG CHILDREN 1-4 years of age

AMONG ADOLESCENTS 15-19 years of age‡

Other serogroups 33%

B 80%

B 67%

Other serogroups 38%

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

Introducing

BEXSERO

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

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

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

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

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

References: 1. National Advisory Committee on Immunization. Update on the use of quadrivalent conjugate meningococcal vaccines. Can Commun Dis Rep. 2013; 39(ACS-1):1-40. 2. BEXSERO® Product Monograph. Novartis Pharmaceuticals Canada Inc. December 6, 2013.

Novartis Pharmaceuticals Canada Inc. Dorval, Québec H9S 1A9 www.novartis.ca T: 514.631.6775 F: 514.631.1867

BEXSERO is a registered trademark. Product Monograph available on request. Printed in Canada ©Novartis Pharmaceuticals Canada Inc. 2014 13BEX044E

Be informed. Be immunized. 45 See additional safety information on page xxxx

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

C a mi lle C hi n

Chrysler (Ghia) Streamline X “Gilda,” 1955.

Reinventing the wheels L’Oeuf électrique, 1942.

Bugatti Type 57S, 1935.

The 17 concept cars featured in Dream Cars: Innovative Design, Visionary Ideas at the High Museum of Art in Atlanta, GA weren’t ever intended for the real road; a threewheeled, Plexiglass, egg-shaped car would turn heads and cause accidents. Cars like these were experiments by automakers to showcase their forward-thinking ideas and test new technology. The 17 in Dream Cars, on now through September 7, were chosen from hundreds produced in Europe and the US between 1932 and today. Paul Arzens’ L’Oeuf électrique (1942) is included as is Harley J. Earl’s Firebird 1 XP-21 (1953), a needle-nosed, gas-turbine-powered “rocket” complete with bubble-top cockpit, and Marcello Gandini’s Lancia Stratos HF Zero (for Bertone, 1970), an 84-centimetretall, wedge-shaped car that doesn’t have doors. Adults US$19.50; kids 6 to 17 US$12. tel: (404) 733-4400; high.org. CHRYSLER: COURTESY OF SCOTT GRUNDFOR AND KATHLEEN REDMOND. PHOTO BY MICHAEL FURMAN. L’OEUF ÉLECTRIQUE: COURTESY MUSÉE DES ARTS ET MÉTIERS, PARIS, FRANCE. PHOTO BY MICHEL ZUMBRUNN AND URS SCHMID. BUGATTI: COURTESY OF CHRISTOPHER OHRSTROM. PHOTO BY JOE WIECHA.

JUNE 2014 • Doctor’s

Review

PR A CTICA L T RAVEL L ER

Air Canada’s dream machine Air Canada’s first Boeing 787 Dreamliner just landed. The airline will have 37 by the end of 2019. Fifty percent of the 787 is made of composite materials and just 20 percent aluminum. The 787 is 20 percent more fuel efficient than the 767 it’ll replace. That means less risk of metal fatigue so higher cabin pressure and humidity levels are possible, which’ll be comfier for flyers. Its International Business Class features 20 lie-flat Executive Pods and 18-inch personal entertainment screens. Its Premium Economy Cabin has 21, 19.5-inch seats with 38 inches of legroom. Economy has 210 seats — and not much else. The aircraft’s dimmer-switch-controlled windows are larger than average, and each seat has a universal power and USB outlet. The 787 will be previewed on some domestic and transatlantic flights. AC’s first new route with 787 service will be Toronto-Tokyo/Haneda in July. Its Toronto-Tel Aviv route will convert to 787 service this summer; its Vancouver routes to Tokyo and Shanghai over the 2014-2015 winter. 787.aircanada.com.

A welcome invasion A bronze key with Christian symbolism.

If the word “Viking” conjures up images of horned helmets, you should probably visit Vikings: Lives Beyond the Legends on now until November 11 at the Royal BC Museum in Victoria — apparently no self-respecting Norse seafarer ever wore one. Produced by the Swedish History Museum in Stockholm and MuseumsPartner in Innsbruck, Austria, the exhibit features 500 artifacts, pieces of jewellery and clothing, swords and axes. Night at the Museum: Vikings! includes more archeological discoveries for kids — with Viking yoga in the morning, whatever that is — while Saturday Night Alive will teach Viking craft techniques. Vikings: Journey to the New Worlds is a 40-minute IMAX documentary. Timed-tickets to the exhibit: adults $23.95, kids 6 to 18 $17.95. IMAX tickets: $11.95 and $9.75. tel: (888) 447-7977; royalbcmuseum.bc.ca. KEY: PHOTO COURTESY OF THE ROYAL BC MUSEUM, SHM 6819:535. PENDANT: PHOTO COURTESY OF THE ROYAL BC MUSEUM, SHM 16429.

Doctor’s Review • JUNE 2014

A silver pendant of the goddess Freyja.

You’ve been served

Riad Kheirredine, Marrakech, Morocco.

There should be an award for handing out awards and TripAdvisor should win. The travel website of 150 million traveller reviews has a Traveller’s Choice Award for everything: destinations, islands, beaches, top hotels, bargain hotels, small hotels, B&B and inns, and on and on. They also have one for hotels with exceptional service. Abigail’s Hotel in Victoria, BC is the winner in Canada for 2014; Riad Kheirredine in Marrakech, Morocco is the winner worldwide. The seven-room hotel welcomes guests with mint tea and pastries, and gives them a bottle of water every time they leave. They also get a cell phone to call the staff for help if they get lost. The top 10 worldwide follow. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Riad Kheirredine, Marrakech, Morocco Hamanasi Adventure and Dive Resort, Hopkins, Belize Akademie Street Boutique Hotel and Guesthouse, Franschhoek, South Africa Riad Noir d’Ivoire, Marrakech, Morocco Hotel Residence Agnes, Prague, Czech Republic Castlewood House, Dingle, Ireland The Dairy Private Luxury Hotel, Queenstown, New Zealand Desert Riviera Hotel, Palm Springs, CA, USA La Maison Arabe, Marrakech, Morocco Hotel Villa Steno, Monterosso al Mare, Italy

JUNE 2014 • Doctor’s

Review

P R A CTICA L TR AVEL L ER

MUSEUM OF FINE ARTS, BOSTON. GIFT OF JOHN T. SPAULDING / PHOTOGRAPH © MUSEUM OF FINE ARTS, BOSTON

The art of persuasion The WWI, US Army recruitment poster of a steely-eyed Uncle Sam was so popular that four million copies were printed in its first year (1916). It was used again in WWII and now, to commemorate the 100th anniversary of the Great War, the original lithograph by James Montgomery Flagg will be at the Museum of Fine Arts in Boston. Over There! Posters from World War I, July 26 to June 14, 2015, will feature 50 wartime posters from the US and Europe. Most are about enlisting in the US Army, Navy, Marines and Air Service; others about buying war bonds, conserving food and supporting the Red Cross. Many have not been seen since 1938. Adults US$25; kids 7 to 17 free. Wednesdays after 4pm by donation. tel: (617) 267-9300; mfa.org. Lithograph by Frederick J. Hoertz, 1917.

NIGEL SPIERS / SHUTTERSTOCK.COM

A ban on PDAs

Paris’ Pont des Arts.

Doctor’s Review • JUNE 2014

Lisa Anselmo and Lisa Taylor Huff, Americans who live in Paris, want to stop “love locks” from being attached to the French capital’s bridges — but they’re not bitter old ladies. Each meant to represent an “unbreakable” love, the estimated 700,000 padlocks on the Pont des Arts, Pont de l’Archevêché and other bridges across the Seine and throughout the 10th arrondissement are putting the structural integrity of the bridges at risk. The pressure placed on them is checked regularly, but Anselmo and Huff’s No Love Locks petition, launched in March, already had 7000 signatures at the beginning of June — 75 percent of them from people within France. nolovelocks.com.

NEW! NEW Centrum Prenatal multivitamins are specifically formulated to support the demands of pregnancy, with optimized daily levels of key nutrients including Vitamins D, C, B6, K, Iron and Folic Acid.

CENTRUM SCIENCE FOR PREGNANCY. Centrum Prenatal + DHA combo pack adds Omega3 in a small softgel, with no fishy repeat. 30+ years of Centrum science.

Prenatal Tablets : Helps prevent neural tube defects when taken daily prior to becoming pregnant and during early pregnancy. Helps to prevent iron deciency anaemia. Helps to maintain healthy skin. Helps to maintain immune function. Helps in the maintenance of bones. *DHA Capsules : Helps support cognitive health and brain function.

See warnings, cautions and directions of use for Tablets at - http://webprod5.hc-sc.gc.ca/lnhpd-bdpsnh/info. do?licence=80045822&lang=eng, Softgels at - http://webprod5.hc-sc.gc.ca/lnhpd-bdpsnh/info.do?licence=80042704&lang=eng for information to assist in benet-risk assessment. Always have your patients read and follow the label. The terms of market authorization are also available upon request through Pzer Consumer Healthcare, a division of Pzer Canada Inc. 1-888-275-9938.

You can win the fight against colon cancer Colon Cancer is the number two killer of all cancers â&#x20AC;&#x201C; and it can affect anyone. But with early detection the survival rate is estimated at 90%. And it all starts with a simple selfadministered test that you do in the privacy of your own home. Talk with your doctor and get the test. Not knowing is not the answer.

Adam van Koeverden,

Olympic medalist Father is a colon cancer survivor

Colon Cancer Canada Weâ&#x20AC;&#x2122;re behind your behind

For more information or to donate visit coloncancercanada.ca

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3/13/09 3:11:06 PM

F OOD by

T he o S a n d s

Beekeeping for more than just honey It’s hip to care for bees these days — and not just for the honey. Toronto architect Paul Dowsett of Sustainable.TO, recently designed a “bee condo” inspired by the city’s skyline. It now sits on the roof of the Fairmont Royal York hotel. The structure provides shelter for bees, the rest is up to the prolific pollinators — no one will tend the hive or collect the honey. John Fly of the Toronto District Beekeepers’ Association (torontobeekeepers.org) estimates there are over 300 other hives in the city in which the honey is most definitely collected. Indeed urban centres across the country are home to hundreds of beehives and millions of bees. The burgeoning interest in beekeeping is an outgrowth of the grow-your-own movement. Raised vegetable beds have proliferated in city backyards and rooftops, and beekeeping has followed. Bee tending devotees praise the hobby for it’s calming effects and compare it to doing yoga. Beekeeping, in many ways, is an ideal pursuit for physicians. It requires many of the skills you’ve already developed in looking after your patients. Attention to detail, regular checkups, the satisfaction of knowing you are doing something worthwhile. And there can be a lot honey in it. You can expect to harvest between 20 and 25 kilos a year from a single well-tended hive.

The bee condo at the Fairmont Royal York.

Beginners are strongly advised to join a local beekeeping club. Raising bees is not difficult — and it’s surprisingly inexpensive to get started — but you’ll have dozens of questions as you get underway and members will be more than glad to help. Another of the pluses is the people you’ll meet; beekeepers are interesting folk, a great community to get to know. There are dozens of sites on the Internet (beware of any that wants to sell you something) and libraries of books on the topic — people have been raising bees for over 5000 years. A recent title is Chronicle Books’ The Rooftop Beekeeper: A Scrappy Guide to Keeping Urban Honeybees by Megan Paska who started a hive in Brooklyn a few years back and got hooked. Another reason to read Ms. Paska’s informative work: she makes it all sound so cool.

JUNE 2014 • Doctor’s

Review

• 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

GE A R by

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

A bike built for you? Buyers brace yourselves: choosing what type of bike to buy is complicated business. You best know exactly where, when and how you plan to ride before you walk into that cycle shop. For example, city, comfort and commuter bikes may sound like one in the same, but they’re each quite different. Start with the city bike: the European version is a utility two-wheeler used in bike-sharing programs, while its US counterpart is an urban mountain bike. Ride a comfort bike, and you’ll be sitting on a wide seat with plenty of shock absorption. Comfort bikes are comfortable until you have to go up a hill or carry one up three flights of stairs. The commuter bike is well equipped for earlymorning and late-night travel to and from work in the city — with good lights and basket holders. Then there are cruiser bicycles, also called beach cruisers, that have balloon tires, just one speed, but are very stylish. Fatbikes, if you didn’t know, are made exclusively for snow and sand. So much for the utility and recreational twowheelers. What about sports bikes? Thinking of trying out for the Tour de France? Then you’ll want a road bike. Everything is light and narrow. Expect to bend down low riding one of these.

But it doesn’t stop there. There are performance road bikes with shorter top tubes and longer head tubes, which let you sit slightly more upright. Crossroad bikes have wider wheels for some off-roading. Touring bikes are built for long hauls and for the back trails. Some people confuse touring bikes with mountains bikes. Silly them! The mountain bike has a serious bobbing, front-shock system, different sized wheels and hand position. It’s not built for crosscountry trips. If you’re planning on entering a race in Flanders, chances are it’ll be a cyclo-cross race on trails, grass, steep hills and past various obstructions that’ll require you to dismount and carry your bike. You’ll obviously need to invest in a cyclo-cross bike. For those who aren’t sure what terrain they’ll be on, there’s none other than the hybrid bicycle, which blends characteristics from road bikes, touring and mountain bikes. Unsure where you’ll want to pedal this summer? You may want to stick with the humble stationary bike. At last count, there are still only two basic types to hem and haw over: upright and recumbent.

Ridley’s road and cyclo-cross bikes are now available at MEC. This one, the X Bow 10 Disc (unisex), is a cyclo-cross. JUNE 2014 • Doctor’s

Review

Actavis, a new name in Women’s Health. • We’re passionate about improving the lives of women • We’re committed to leadership in R&D, Quality and Customer Service • We have an exciting pipeline of new products

www.actavis.ca/specialty

BEST MD APPS by

D a v i d Elk i n s

Love at first sight Looking for a good eye app? Look no further. The Eyes Have It, from the University of Michigan’s Kellogg Eye Center, came out in April and it’s excellent. Family physicians who see patients with eye problems will find it most useful. It’s a must for med students. The opening screen lets you browse common eye symptoms, eye trauma, red eye, other eye conditions, systemic conditions, side effects of medications, screening exams, ophthalmoscopic abnormalities and anatomy. Touch the “Red Eye” icon and a list of 20 diagnoses appear. Touch “Gallery” at the top right of the screen and photos of each pop up. Convenient — and useful. Other categories list symptoms as well when appropriate. Tap on your choice and a pic comes up followed by a list of questions: How does it appear? What else looks like it? What to do? What will happen? The application shines on the answer screens. The clear, concise explanations often contain hyperlinks, a real plus and something many apps don’t offer.

For example, under “Common Eye Symptoms,” “Floaters” are listed and the “What is it screen?” features three hyperlinks that include a photograph illustrating “solid vitreous suspended within clear vitreous gel.” The “What to do?” screen cautions that if the floater is new or disturbing, the patient should immediately be referred to an ophthalmologist owing the possibility of a retinal tear and detachment, vitreous hemorrhage, vitreous inflammation or cancer. The mobile app does not offer a quiz function, which is a pity. The good news is that quizzes are offered on the full website version at kellogg.umich.edu/ theeyeshaveit. EyesHaveIt by Jonathan Trobe, University of Michigan Devices: iPhone and iPad (not available on Android) Cost: US$4.99

JUNE 2014 • Doctor’s

Review

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

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

See prescribing summary on page xxx 51

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

Ja c k i e R os e n he k

Mad men and barbershops

In medieval times, a bowl of blood advertised an unusual assortment of services

A medieval bleed at the village barber-surgeon’s shop.

Barbering was such a desirable and lucrative profession, failed surgeons often tried to join their ranks

s the butt of countless jokes, lawyers who advertise on TV may or may not belong in one of Dante’s

circles of hell, but ambulance-chasers of ill repute certainly weren’t the first professionals to, er, lower the bar by employing somewhat lurid methods to reel in clients. The history of medicine is, in fact, rife with snake-oil salesmen who used fear and trickery to play to the insecurities of potential patients. In some ways it was a necessary evil, and perhaps it still is. Before newspapers and pop-up ads, before junk mail and Madison Avenue, the service-providers, healers and merchants of the Middle Ages were forced to get creative when it came to advertising their skills and products. Nobody could read and with most forms of effective public communication centuries away, the options for getting the word out were extremely limited. Basically, there was word of mouth, the JUNE 2014 • Doctor’s

Review

town crier (if one could afford it) and that good old standby, the shop window. Barber-surgeons — those medieval hybrid healers with a penchant for slicing and dicing — had the most sensational, macabre window displays of all. But first, a little backstory...

OLD-SCHOOL PHLEBOTOMY Bloodletting was the Tylenol of times past: a panacea for virtually every ailment doctors could diagnose — and especially for those they couldn’t. Some 3000 years ago, in the cradle of civilization, the Mesopotamians were the first known people to drain blood therapeutically. The ancient Egyptians took up the tools too, as did the Greeks under Hippocrates. Ancient Ayurvedic texts describe bloodletting practices in great detail, as did Chinese and Islamic sources. Even the Talmud references the many wonderful, curative ways that blood could be drained from patients. But nobody was more enthusiastic about purgative phlebotomy than the Romans. Galen (circa 129-210 AD) — the humourobsessed darling of all things medicinal and philosophical — ensured that bloodletting became so deeply ensconced within the medical and lay communities that his influence in this matter endured for some 15 centuries after his demise. There was no questioning the value of phlebotomy; to argue against its usefulness was tantamount to apostasy. During the plague-infested centuries of the medieval era that stretched roughly between 400 and 1400, medicine was basically devoid of logic in all its forms. These Middle Ages, also more aptly referred to as the Dark Ages , were among the

You might go in for a shave and an enema, or to have a cyst lanced or a tooth extracted very worst times in human history that one could have had the misfortune of being born into. Disease, famine, war and the fallout of feudalism meant that people (including the one percent) lived short, painful lives filled with work for very little consideration except the hope of cosmic reward in the sweet hereafter. It was, however, the Golden Age of bloodletting. So while bloodletting was everywhere — vigorously employed to drain the body of the wrong humours, “excessive” blood, evil spirits and virtually anything a doctor or patient could imagine — not everyone was willing to do it. Many physicians, in fact, considered it beneath them to do the cutting themselves, and so referred their patients to the so-called barber-surgeons. The Ancient Egyptians viewed barbering as a noble art, one usually reserved to priests or doctors, since the pharaohs’

Doctor’s Review • JUNE 2014

FROM TOP: After the 12th century, barber-surgeons were taught basic anatomy. Barber poles were always mounted at an angle. The white stripe indicated that you could get a shave while the red advertised the barber’s bloody surgical skills. No respectable barbersurgeon ever left home without portable bloodletting tools for emergency house calls. The wealthy could afford to have their barbersurgeon make house calls.

hairstyle — shaved with only a ponytail on top — was intimately connected to their worship of the sun god, Ra. This likely derives from various tribes’ notions that the hair was a portal to bad spirits, a way for an imp or devil to sneak into the body and take hold of the mind. Proper haircuts ensured protection as well as kept the good spirits from leaving. Later the barbershops of Ancient Greece and Rome became social gathering places too, and the ceremony surrounding a young boy’s first shave was an important part of his coming of age.

SHAVE AND HAIRCUT: 10 FLORINS Fast-forward a few hundred years to after the fall of Rome, when the once-glorious public medical system was in ruins and there were no rock-star doctors to build healing temples or publish materias medicae. The responsibility of healing was about to fall into the hands of the barber, as akin in skills and responsibility to a physician as a hair stylist. This shift came about in large part because of the rise in monastic medicine. As focal points for education, religion and public care, monasteries were literally the centre of the action during the early Middle Ages. Only one problem: papal decrees prohibited monks from spilling blood, a rather inconvenient glitch since monks were usually the ones practicing medicine at the time. The solution? Barbers were enlisted; besides their actual hair-cutting duties, part of their job was to get their hands dirty cutting and stitching, bleeding and cupping. Medicine evolved slowly but surely, thanks in part to a sort of mini Renaissance during the 12th century when medical texts from the ancient Greeks, Romans and Arabs were translated into the languages of the day. Healing returned to the hands of trained physicians, at least in theory. Before too long, the guilds — powerful political associations of tradesmen with common tools and practices — were naturally lumping barbers and surgeons together. Not only did they use the same tools, but their history was intricately intertwined. It was the birth of the barber-surgeon — ready, willing and able to use his blade to free your blood from its veins for a few florins. There was no problem too intimate or too complicated for one’s barber-surgeon to attend to. On a good day, you might go in for a shave and an enema. On another, you might need to have a cyst lanced, a rotten tooth extracted, a fistula repaired or just a good old-fashioned vein drain, either by blade or by leech. There was no anesthesia, of course, but there was always that strap the barber used to hone his blade — a good choice for biting down on while the master practiced his craft. With no secretary to place calls to patients reminding them to come in for an annual draining, the barber-surgeon used the art of advertising to drum up business. The hallmark of his window display was a bowl of fresh blood, recently culled and glistening suggestively for all passersby to see. Londoners eventually recoiled from the sight and petitioned the city to take care of the problem. In 1307, the blood bowls were banned: “No barbers shall be so bold or so hardy as to put blood in their windows.”

POLE POSITIONED The pole was devised as a reinterpretation of the bloody and clean rags that were hung outside the barber’s shop to dry; the white stripe now would indicate the service of barbering, while the red denoted the master’s surgical skills. Alternately, some scholars believe the red and white simply represent bloody and clean bandages. On the tops of these first poles was a copper washbasin, of the kind that was used to hold leeches; on the bottom, another bowl of the sort used to collect blood. (Eventually the bowls were replaced with balls.) The pole itself was chosen as a fitting symbol since patients were traditionally handed a pole to squeeze against the pain — and to encourage veins to swell up — while they were being bled. As the centuries wore on and life retreated somewhat from the country to the burgeoning cities, livery companies took the place of many medieval guilds, though they had similar raisons d’être. The Worshipful Company of Barbers was formed in London in 1308, and governed the laws and rules surrounding barbering and surgery. Since barbering was such a desirable and often lucrative profession, failed surgeons often tried to join their ranks. But by 1368, everyone had had enough, so the surgeons were granted permission to form their own association, though barbers still had the authority to oversee them. An Act of Parliament saw the two guilds merge once again in 1540 into the Company of Barbers and Surgeons, though someone had the good sense to provide that barbers stick to hair while surgeons were to do all the slicing. Naturally, they were both allowed to pull teeth. It was the death knoll for the once-mighty barber-surgeon. Surgery was quickly evolving into a real medical discipline, and they broke away from their hair-cutting counterparts in 1745 to form what would soon become the Royal College of Surgeons. So what of the Worshipful Company of Barbers? It still exists, though no members cut hair. Most liverymen among its ranks are, in fact, medical professionals, and the historical guild’s modern mandate is now to raise money for surgical and medical charities. (It remains unknown whether, in turn, any trained barbers are members of the Royal College.) The next time you go to get a haircut, ask your barber or hairdresser if they might be willing to lance that boil while they’re at it, or get rid of a little extra yellow bile. Even better — assuming you’re not too worried about drumming up some competition — suggest they take down that silly redand-white spinner and put a nice fresh bowl of blood in the window instead. It would be sure to attract attention, though perhaps unlikely to garner them any new clients.

JUNE 2014 • Doctor’s

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FORMAT

3,5” x 1,2

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.

doctorsreview.com/meetings access code: drcme

the top 20 medical meetings compiled by Camille Chin

Canada Calgary, AB October 19-21

2014 Annual Conference of the Canadian Association of Paediatric Health Centres

Gatineau, QC October 16-19

4th Congress of the Annual Canadian Hypertension Congress

Toronto, ON October 17-19

10th Annual CADDRA ADHA Conference

October 29-November 1 Critical Care Canada Forum

October 30-November 2

Action 2014: Skin Health for Canada

Quebec City, QC November 13-15

Family Medicine Forum 2014

Vancouver, BC October 4-7

2014 Canadian Stroke Congress

October 25-28

2014 Canadian Cardiovascular Congress 43rd Global Congress on Minimally Invasive Gynecology

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CANADIAN TOURSIM COMMISSION

November 17-21

La Boca is Buenos Aires’ Quebec City’s Quartier most colourful barrio. du Petit Champlain.

43717 MER14ZH068_Banner-4E_Zenhale_E1.indd 1

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3:56 PM

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the top 20 medical meetings Around the world Birmingham, England November 30-December 2 2014 Osteoporosis Conference

Boston, MA November 2-7 ObesityWeek 2014

November 7-11 SEAN PAVONE / SHUTTERSTOCK.COM

Liver Meeting 2014

Los Angeles, CA November 20-22 12th Annual World Congress on Insulin Resistance Diabetes and Cardiovascular Disease

2014 Annual Meeting of the North American Spine Society

Miami, FL November 6-8

13th Annual Pain Medicine Meeting

30th Annual Meeting of the International Society for Traumatic Stress Studies

CDRIN / SHUTTERSTOCK.COM

November 20-23 Bliss Dance by Marco Cochrane on San Francisco’s Treasure Island. TOP: Philadelphia’s Suburban Station.

San Francisco, CA November 12-15

20th Annual Fall Scientific Meeting of the Sexual Medicine Society of North America

Philadelphia, PA November 11-16 Kidney Week 2014

November 13-16

Washington, DC November 5-9

67th Annual Scientific Meeting of the Gerontological Society of America

November 15-19

44th Annual Meeting of the Society of Neuroscience

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

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Doctor’s Review • JUNE 2014

P R AC T I C E MANAGEMENT by

D a v i d Elk i n s

An open book Montrealer Brian Morris is a urologist with a mission. He wants to put your appointment schedule online. DoctorDirect.com (DD) and the software he developed do just that. It’s an idea he first toyed with six years ago. “You can book an airline ticket, a hotel or a restaurant online, I saw no reason why a patient couldn’t book an appointment with a doctor in the same way.” His motivation? Better access to medical care. By providing the appointment schedules of a large number of physicians online, patients are better able to find the doctor and time slot they need. The best way to get a sense of how DD works is to have a look. The site is divided into two sections: one for patients and one for professionals. Videos guide you through. In a nutshell, once you sign up, patients can make appointments with you and other doctors by entering a physician’s name or using a dropdown menu to select a specialty. A single click brings up a profile, a photo, even a map. Request an appointment, and suggested dates and times appear. Most DD doctors have a system that sends them an e-mail reminder 48 hours before each appointment. Patients can get a reminder too via a phone call. They love the convenience and some wonder why every practice doesn’t offer the service. The benefits to you can be substantial. Physician users report an increase in patient visits. Some specialists report a boost of 25 percent, an 80 percent reduction in no-shows and lower admin costs (39 percent). The cost of joining DD is $125 a year. An e-mail reminder is $0.10; a phone call to a patient $0.15; $0.20 for both. There’s a one-time programming fee of $75 for the reminders, which are important part of reducing no-shows.

Urologist Brian Morris: better access to care.

Billing is sent to the health system almost automatically, with only a few clerical tasks necessary. DoctorDirect.com is a stand-alone program; you don’t need to have an EMR system to use it. Doctors are enthusiastic.

Patients love the convenience and some wonder why every practice doesn’t offer the service “We have encouraged all patients to use this very user-friendly appointment tool and the feedback has been highly favourable,” writes Brian Gore of the Ste. Catherine Medical Group in Westmount, QC. “Our previous web-based software was no match for DoctorDirect.” The Quebec-based DD isn’t the only online appointment system out there, but its big advantage is that it was developed by a Canadian physician with our unique health care system in mind.

JUNE 2014 • Doctor’s

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I P R E S C R I B E A TRIP TO... THE SABINE HILLS

High on Italy Hike the mountains north of Rome with an MD from Manitoba by Dr Philippe Erhard

PHOTOS COURTESY PHILIPPE ERHARD

limbing steadily under a menacing sky, Heather and I struggled among loose rocks on a steep trail along a deep valley. “Why is this called the Sabine Hills?” Heather asked. “I don’t see hills, I see mountains.”

The forest helped Dr Erhard stay dry on a rainy first day of a six-day trek.

Originally from France, Philippe Erhard is a family and sports medicine physician in Winnipeg. After many years of caring for his patients, he decided to follow his own advice by “doing” less and “being” more. This lead to a book called Being: A Hiking Guide Through Life. Hiking is the perfect way to slow down and explore the world. He and his wife just hiked the St. James Trail in France. Next year, they’ll continue where they finished off, slowly reaching the Spanish border.

At times we were at the edge of a cliff, the summit hiding in the darkening clouds. “At least it’s not raining,” I said. “It would be tricky if wet.” The Sabine Hills, just one hour north of Rome, is an undiscovered area of Italy, even for the Romans. We had left our beautiful bed and breakfast, Locanda Bellarmino (locandabellarmino.com), and the narrow cobblestone streets of Contigliano, our first hilltop village, that morning. White, yellow, blue, purple and pink flowers dotted the forest, brightening our progression. Our guidebook noted that the gate coming up was “a vicious barbed-wire, branch and string affair;” an intriguing description and a good introduction to the many Italian “gates” we encountered along the way. They were all unique, sometimes defying description. Posts pointed in all directions, and the fences were made of wires, strings and sometimes pieces of cloth. They all had an unusual opening system. This one was easy to figure out: the posts were almost horizontal so we climbed over. Not that vicious after all. The view at the top reminded us of Switzerland, with open pastures, grazing cows and fields of flowers. It was the perfect place to lie down on a sunny day, but we were forced to eat our lunch standing under the illusory protection of a tree while it rained. Suddenly, we saw two large white dogs running towards us. This is it; we escaped the barbed wire and long climb along a precipice only to be attacked by mean dogs. We had no idea where they came from and watched helplessly as they got closer. We quickly realized that they were more interested in our food. When the rain finally stopped, it got warmer quickly. The sun came out, dried everything, and we lay down in the grass to enjoy the view of forestcovered mountains dotted with farms overlooking open pastures and stone houses. We tried to finish our lunch. The size of it made me wonder if Viviana, JUNE 2014 • Doctor’s

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Cottanello is about 60 kilometres north of Rome and home to about 600 people.

the owner of our B&B, thought we might get lost and wander the countryside for days. Our descent was slow and gentle, but became steeper as the trail disappeared. The abundant and reassuring markings on the trees brought us down quickly. Suddenly, the dark forest opened to a sunny field, a fence and a stone house: Francesca’s place. We immediately felt like we were visiting a friend, a sentiment we experienced every night of the trip. Francesca welcomed us to the Casa d’Artista (casadartista.it) with a bottle of wine, and introduced us to her two dogs and some of her 12 cats. We sat outside, enjoying the sun and the company of a British couple hiking like us. In the evening, over a delightful meal, we listened to some of her life story in a mixture of Italian and English.

CLIMB TO THE TOP “Don’t forget to send me a postcard,” Francesca shouted at the gate. “For my collection!” “Of course we will,” we yelled back. We left our new friend and followed a path overgrown with knee-high grass full of dew. We hiked through the forest along a pleasant, but rocky trail and then suddenly, at a turn, Cottanello appeared in front of us. The hilltop village was so inspiring after the shade and monotony of the forest so we sat down to ad-

Doctor’s Review • JUNE 2014

The size of our lunch made me wonder if Viviana, the owner of our B&B, thought we might get lost for days mire it. It felt like we could jump across the valley to reach the village in one giant step. Rows of houses circled a church steeple, the highest point, with forests and hills in the background. It looked minuscule from our viewpoint, but Cottanello was bigger than expected. We bought our lunch at a small food store, said “Ciao!” to three elderly men seated on a bench who were watching us with interest and then left the village via a thigh-burning trail that used to be the town’s entranceway in Roman times. I had difficulty imagining loaded carts going up or down the steep road. When we reached the bottom of the valley, we spread out on the grass to eat our mortadella sandwiches. We didn’t see any more cows — but we did see horses disguised as Swiss cows with bells around their necks.

That day we learned a local hiking law: getting to a village required a steep, but rewarding, climb up. Casperia, our destination for the day, was no exception. We entered the flowery village through an arch and arrived at a sophisticated palazzotto called La Torretta (latorrettabandb.com). Our large room overlooked the village’s roofs and the valley. The village was a picture of paradise. Bright geraniums illuminated the austere façade of the stone houses. Cobblestone streets weaved under archways past vaulted wooden doors, colourful windowsills and flashy linen flapping in the wind. From the terrace, our eyes flew over the immensity of the scenery. A small road from the village connected lonely farms, passing flocks of sheep, slowly climbing a field dominated by forest-covered hills.

Some of the trees in Stefano’s 2000-year-old olive plantation are bent with age, but they’re still productive.

LOST IN THE WOODS Heather had been fighting a worsening cold and decided to take advantage of the available ride with the luggage and take a day of rest. When I left, she was waiting for the driver and trying to translate the front page of an exciting newspaper article: Berlusconi had been charged with fraud. But the world news and even Berlusconi don’t affect the fortified village of Roccantica. It seemed more animated than the previous ones and the usual three elders on a bench were watching my arrival. A frail, elderly woman walked slowly up a narrow twisting street, using a cane and holding a bag. Her presence conveyed a feeling of serenity and eternity — a melodious medieval adagio. Suddenly, the tempo changed. A young man walked up to her and started a joyful conversation in that lively Italian way. The trail followed a dirt road, and climbed gently and steadily up the Valle de Galantina. The village disappeared as I reached a pass and started my descent. According to my guidebook, I shouldn’t worry about the lack of signs in this part of the trail, and I didn’t — until I reached a paved road that didn’t fit the description in the guide. I was lost. Too confident, I must have missed a turn. I studied the map and it looked like I might be able to rejoin the trail by turning left. I was a bit nervous about adventuring in unmarked territory, but I eventually got back on track after passing a clear, babbling stream. The forest opened up to a flowery meadow, a perfect spot to eat my lunch — and lie down in the middle of white and yellow flowers to enjoy the peace, sun and scenery. I climbed again and past an attractive stone building called Osteria Faducchi before arriving at a pass where the next valley was visible. The trail dropped suddenly and was described as “an adventurous way down.” The challenge was not so much the precipitous slopes, but identifying the trail.

Le Mole sul Farfa serves a four-course vegetarian dinner made, in part, with homegrown organic produce.

The Sabine Hills feature lots of “fences” made of branches, string and sometimes cloth.

Cows had created their own path, one more travelled and obvious than ours, and the faded markings were not easy to find. Several times, I was unsure of where to go. I’d stop, look around and climb again to find the previous mark, then scout around until I finally spotted the next one. It was a time consuming exercise that I had to repeat several times. I wouldn’t want to be there in the evening — or rainy conditions. I arrived to see Heather sitting in the sun, reading and feeling much better. We were at Il Fienile di Orazio (fienilediorazio.it), an isolated biological farm. Even the small village of Misciani was invisible from here. Mauro made a fire in the dining room and proudly presented his homemade salami and wine. We were treated to another beautiful meal with pasta followed by pork and lamb chops. Mauro’s wife, who teaches at a university twice a week in Rome, came later to help.

A CULTURAL EXPERIENCE On day four, we were back to our old routine: going up and down. The day went so fast that we were almost surprised to arrive at Le Mole sul Farfa (lemolesulfarfa.com). “The swimming pool is open,” Elizabeth said, as she welcomed us to the B&B. Stefano, her husband, made arrangements for the next day; we had to visit his Villa Romana and his olive plantation. Our “cultural day” began like any other: a steep hill down then the usual climb up, this time to Castelnuovo di Farfa. A lady, who was watching us from a window at the entrance of the village, gestured for us to go up the street to an archway where she would meet us. Margharita was proud to take us to her apartment and her small family museum of farm tools used by her ancestors. When we arrived at the Benedictine Abbey of Farfa (abbaziadifarfa.com), our timing was perfect for a tour of its cloisters and archeological museum. Then we visited Stefano’s Villa Romana, a stone shepherd’s dwelling that changed his life. Under it, he discovered an arched opening, obstructed by centuries of refuse and manure. Intrigued, he started an 11-month cleaning with the help of volunteers from around the world. He discovered tunnels leading to multiple rooms, and a unique oil producing and storing system. His hard work was rewarded in a true Italian fashion. Elizabeth arrived as a volunteer from Belgium and they fell in love. They married and are now raising their first bambino. Stefano’s enthusiasm was contagious as he took us through his almost 2000-yearold olive plantation. Three donkeys, in charge of cutting the grass, welcomed us. We walked around olive trees bent by age and disease. Their trunks were sometimes hollow in the middle, the result of drastic “surgical resection” of fungus diseases over the years. Despite their geriatric appearance, they were still alive and productive. We climbed a chamomile field and saw Castelnuovo on the other side of the valley and further away the Abbey of Farfa. Sheep were grazing peacefully on isolated farms. The bucolic and harmonious view has likely remained the same for centuries. We were a bit nostalgic to leave such an enchanting place that felt like The seven-night Sabine Hills (Italy) tour home, but Rome and its intriguing with On Foot Holidays (tel: 011-44streets were waiting for us. On our last 1722-322-652; onfootholidays.co.uk; night in the beautiful B&B, we went £710 per person) includes stays at seven online to browse On Foot Holidays’ B&Bs, breakfast daily, four evening meals website, a British agency that organizes and two picnics, and luggage transfers. self-guiding treks in Europe. Expect 3½ to 6 hours of walking a day. “Where will we go next?”

WALK THIS WAY

MORE ONLINE

Explore the French portion of the St. James Trail with Dr Erhard. doctorsreview.com/features/i-prescribe-chemin-st-jacques Doctor’s Review • JUNE 2014

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 openlabel phase. • Cymbalta® is not indicated for use in children under 18 years of age. 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) 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 selfharm 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

Are symptoms of Generalized Anxiety Disorder holding your patients prisoner?

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., June 13, 2013. 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.

Covered as a general beneﬁt in AB, ON, SK and on NIHB formulary as well as many private plans.

Watering holes 7 hotel pools in the US and Canada that give new meaning to taking a dip by

Alexandra Pimms

The 107 rooms at this lodge are certainly comfortable — and have recently been renovated — but it’s the world’s largest hot springs pool that visitors come for. Every day, 13 litres of water from the nearby Yampah Springs flow into one of two bubbling mineral pools. If you’d rather a few laps, the larger pool is the length of two city blocks. The lodge’s website features some interesting package deals; one of the most popular for families is the Tidal Wave that includes doubleoccupancy accommodation, breakfast, access to two waterslides and the pool, as well as an 18-hole mini golf course for US$246. hotspringspool.com.

Doctor’s Review • JUNE 2014

GLENWOOD HOT SPRINGS LODGE, COLORADO

HILTON MONTREAL BONAVENTURE

Montreal’s first premier conference hotel opened to much fanfare for Expo ’67. It had, after all, the first heated outdoor pool in the city. More than two decades later, on November 7, 1990, the pool was the setting of Quebec’s most famous unsolved UFO sighting that lasted around three hours. It’s got history, a little bit of mystery and, lest we forget, a lot of class in terms of service in what’s one of the best downtown locations. The rooftop pool is open year-round and surrounded by a one-hectare garden. hilton.com.

ORLANDO WORLD CENTER MARRIOTT It’s the largest Marriott in the world — picture 2008 rooms over 28 floors with a nine-storey lobby atrium that has no less than 10 restaurants and lounges to ensure no one feels the slightest hunger pang. It’s about two kilometres from Disney World and minutes from SeaWorld Orlando, Universal Studios and Legoland. But the real reason people stay is the Falls Pool Oasis that features a new slide tower with two 366-metre winding waterslides and one 27-metre speed slide, a kid’s splash park and an interactive game room. The new slides are among the tallest and fastest resort slides in the state. bit.ly/1lL0SRX. JUNE 2014 • Doctor’s

Review

GRAND WAILEA, MAUI This Waldorf Astoria resort seems to have a pool for every developmental stage in life. While the romantic 450-square-metre Hibiscus pool — inlaid with a glass mosaic of a giant Hibiscus flower — is strictly for adults, the Wailea Canyon activity pool features nine pools on six levels connected by a slow-moving 186metre-long river and white-water rapids. There are four jungle pools, four connecting slides, a Tarzan pool with a rope swing, six waterfalls, caves, a white-waterrapids slide, something called the Lava slide, something else called the Ana Puka slide, an infant pool and the world’s first water elevator. Daredevils will love the Fishpipe, the world’s first rotating barrel ride. All this, well, not far from the beach. grandwailea.com.

The Four Seasons’ 12-metre infinity pool may be a little small for serious lap swimmers, but it remains one of the city’s choicest spots to take in the view of Elliott Bay. And no worries if you want to break a sweat: the gym is right next door. Use the machines, take a dip in the heated pool, snap a vista shot to email home and then sit next to the fire pit with a local newspaper — or just take in some early-morning sun before exploring the Emerald City. When you’re ready, Pike Place Market, one of the oldest public farmers’ markets in the US, is nearby. fourseasons.com/seattle.

Doctor’s Review • JUNE 2014

FOUR SEASONS HOTEL SEATTLE

This hotel gives new meaning to rest and relaxation: it comes with a healthy dose of fitness. Spend a morning soaking in the serenity at the infinity pool, then move over to the 23-metre lap pool and work your strokes. Looking to seriously improve your swimming? Take a lesson with the coach, Misty Hyman, gold medalist in the 200-metre butterfly at the 2000 Summer Olympics in Sydney. If that’s not enough of a workout, there’s also a fitness centre, a movement studio, five championship tennis courts as well as hiking and biking trails. sanctuaryoncamelback.com.

SANCTUARY ON CAMELBACK, SCOTTSDALE

WESTIN GRAND, VANCOUVER If you can’t stand chlorine pools, the Westin Grand has a soothing salt-water alternative. In 2011, the hotel’s third-floor outdoor heated pool was refitted with a new extraction system that guarantees the water remains 99.9 percent bacteria free without the use of harsh chemicals. Even in winter, the pool’s temperature is maintained at a comfortable 27°C. It’s surrounded by a spacious garden terrace — a nice spot for a break from pounding the pavement. Currently, it’s only one of three hotels in the city that uses the salt-water system. westingrandvancouver.com.

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See more stunning hotel pools around the world. doctorsreview.com/ architecture/worlds-most-spectacular-hotel-pools JUNE 2014 • Doctor’s

Review

BC’s chef d’oeuvre

The Okanagan Valley is known for its wine, but it’s about to be as famous for its food by

Ontario-born Jeff Van Geest is the executive chef at Miradoro, which overlooks the Valley and Tinhorn Creek’s vineyards.

Jeremy Ferguson

t God’s Mountain Estate, a sprawling guesthouse and vineyard perched high over BC’s Okanagan Valley, life unfolds according to an old Spanish proverb: “How beautiful it is to do nothing and

then rest afterwards.” The anonymous author would have been pleased that his thought survives and thrives here. A holiday about wine, food and scenic beauty is pretty much like that: sybaritic, indolent and deeply conducive to a rest in which even a mortician might have difficulty wiping the smile from your face. It goes without saying that there’s more than wine to wine country. The Okanagan’s transition began about a dozen years ago, part of a surge that

encompassed winery facilities from sophisticated wine emporia to scholarly tastings, winery blitzes by shuttle and helicopter, stylish resorts, spas, cooking classes, festivals and never least, restaurants. Since Doctor’s Review visited five years ago, wine country’s turned to dine country. So, with an update in mind, we’ve journeyed the valley again, exploring both wineries and free-standing restaurants unveiled since that last visit.

OLIVER

CAROL CLEMENS

We began in the south at Oliver — designated by Tourism BC as “Wine Capital of Canada” — a town of less than 5000 that produces 12 million bottles of wine a year and accounts for more than half the vineyard acreage in the province. Set on the Golden Mile Bench, Hester Creek (877 Road 8; tel: 866-498-4435; hestercreek.com) personifies the contemporary winery resort, combining vineyards, wine emporium, villa accommodations and a restaurant. Their decidedly luxe Villa suites boast, probably, the most beautiful panoramic view in the Okanagan — though you’ll be reminded to close the doors here because it’s rattlesnake country. Terrafina (terrafinarestaurant.com), its restaurant, looks to the Mediterranean for its sunny disposition. The room features a baronial rusticity with exposed beams, iron chandeliers, an open kitchen and a wood-fired oven. Its patio comes fronted with banks of lavender in early summer. Pizzas are not too humble for wine country, and Terrafina’s breakfast pizza with eggs and hollandaise is a hit. Yet there are more intriguing fancies. An amuse brings a lovely scallop playfully drizzled with bacon jam. Caprese salad is a finely balanced affair of heirloom tomatoes, fior di latte and basil.

Seared scallop and grilled garlic scape at Terrafina.

Chef Natasha Schooten’s evening stunner is panfried squid, something much more than the sparse words suggest. It’s a melange of tender squid tentacles, sun-dried tomato, artichoke, black olives, capers, garlic, arugula and focaccia crostini. Yes, an umami bomb, that savoury fifth taste that recently swept like brush fire across the foodie world. Wine to note: Pinot Blanc and Hester Creek Block 3 Reserve Cabernet Franc 2010, winner of the Lieutenant Governor’s Award for Excellence. JUNE 2014 • Doctor’s

Review

Like many Okanagan restaurateurs, Manuel Ferreira is a defector from the highest echelon of Vancouver dining; he owned Le Gavroche. His partnership with Tinhorn Creek Vineyards (537 Tinhorn Creek Road; tel: 888-484-6467; tinhorn.com) resulted in Miradoro, an easy contender for best winery resto in the valley.

CAROL CLEMENS

Miradoro’s octopus carpaccio with chorizo, Sicilian olive and ciabatta crostini.

From the alfresco terrace at Miradoro, the view of the valley, vineyards and hills rivals that of Hester Creek’s villas. Here, the Okanagan is the decor. Bring a panoramic camera. Chef Jeff Van Geest, who earned his reputation at Vancouver’s Aurora Bistro, sports the exec chef toque. Van Geest transplants his coaster’s perspective seamlessly with a dazzling octopus carpaccio. The underrated and overlooked cephalopod arrives raw, thinly sliced, tender and roaring with oceanic flavour. It’s garnished with chorizo, olive “pearls” and crackling focaccia croutons. Clams and chorizo recall the Chinese magic of pairing seafood and pork (poor pity those who turn away for religious reasons), here with tomato-saffron sauce. The stellar main is lamb shank, its flesh cascading from the bone, gone Moroccan as harira soup with orange peel, coriander and lentils. A few bites and you expect to see turbaned horsemen thundering across the valley below. Wine to note: Tinhorn Creek Chardonnay, Pinot Gris and Syrah.

God’s Mountain Estate is a sprawling manse in which one imagines the playing out of an Agatha Christie murder

Local Lounge Grille (12817 Lakeshore Drive South; tel: 250-494-8855; thelocalgroup.ca) occupies prime Summerland real estate overlooking Okanagan Lake. It pairs the postcard view with chef Lee Humphries’ playful cuisine. Humphries cut his teeth at three top Vancouver restaurants — West, Elixir and C — before departing the big city for Okanagan bounty. Originally from Cornwall, England, he grew up on a vegetable farm, but that doesn’t mean he’s content with run-of-the-mill pork belly. He transforms it into tempura, adding crrrunnnch, lime and red pepper gels cutting the unctuous pork. Fresh albacore tuna, BC’s most underrated fish, arrives as tartare, its delicate raw flesh spooned onto spiced potato chips and inventively sided with softly poached egg, coriander and red mustard seed. Among mains, lamb rump follows with three riffs on the tomato — fresh, dried and confit — and as if that’s insufficient, he adds crushed peas and crispy-creamy deep-fried polenta zapped with preserved lemon. Duck breast shows up properly pink,

Doctor’s Review • JUNE 2014

Pan-seared duck breast with potatoes, sautéed kale and orange honey gel at Local.

CAROL CLEMENS

SUMMERLAND

liberated from the icky sweetness of à l’orange, its accent orange-honey gel, its sidekick fingerling potatoes fried in duck fat. For dessert? How to improve on deep-fried apple beignet with raspberry coulis and ginger ice cream? Wine to note: Time Estate Meritage white and red, from restaurant partners Christa-Lee McWatters Bond and her dad, Harry, the wine legend behind Sumac Ridge.

NARAMATA

PENTICTON By any standards, God’s Mountain Estate (4898 Lakeside Road; tel: 250-490-4800; godsmountain.com), located high in the hills over Lake Skaha’s eastern shore, is a one-off. Feisty Sara Allen’s 14-room bedand-breakfast is a sprawling, unruly manse in which one easily imagines the playing out of an Agatha Christie murder (pssst: the saucier did it). One bedroom is actually roofless. Promoted entirely by wordof-mouth, the house is packed all summer long.

The owner’s lakeside manse at Lake Breeze Vineyards looks like it was flown in from Tuscany.

JEREMY FERGUSON

Wine to note: Lake Breeze Chardonnay.

JEREMY FERGUSON

On the Naramata Bench on Okanagan Lake’s southeast shore, the Patio at Lake Breeze (930 Sammet Road; tel: 250-496-5659; lakebreeze.ca) is indeed a breezy affair with the feel of lazy, sun-filled lunches in France’s Côte d’Azur (although the owner’s lakeside manse appears to have flown in from Tuscany). Chef Mark Ashton’s sharply conceived starters get underway with a grilled ‘n’ chilled portabella mushroom carpaccio served with arugula and crabmeat. For a championship main, he takes a hefty slab of halibut, pan sears it and drapes it over puff pastry filled with roasted cauliflower, leek and saffron. And to gild his gastro-lily, he caps the fish with frizzled leeks and surrounds everything with a moat of roasted tomatoes in Chardonnay cream. Is it over? Not if you’re a crème brûlée aficionado. The Patio’s chocolate crème brûlée brings a crackling sugar crust and a silken, creamy chocolate atop salted caramel. They don’t do it any better in France.

Sundays at God’s Mountain Estate feature four-course dinners and local wine for as many as 40 people.

KELOWNA

Greata Ranch, located between Peachland and Summerland, is CedarCreek’s sister winery.

The CedarCreek Estate Winery (5445 Lakeshore Road; tel: 778-738-1027; cedarcreek.bc.ca) was one of the first eight wineries in BC and has been twice recognized as Canadian Winery of the Year. Its Vineyard Terrace is plenty bold: it reinvents the spring roll, the crispy wrap stuffed with salmon, halibut and potato, and accompanied with a miso dipping sauce. Lingcod, BC’s unheralded Pacific jewel, is panfried and served with smoked tomato broth, wilted kale and crispy, addictive potato “hay.” The rampant carnivore, however, will leap for roasted rack of elk, a monumental chop of game meat.

RauDZ only serves sustainable West Coast seafood and meat from farms in BC and Alberta.

There’s poutine, only with chicken confit and pan gravy, and the “fries” are baked then drizzled with blackberry ketchup

CAROL CLEMENS

Rack of elk at CedarCreek’s the Terrace.

Doctor’s Review • JUNE 2014

Veteran restaurateurs Rod Butters and Audrey Surrao remain at the top of their game at RauDZ Regional Table (1560 Water Street; tel: 250-868-8805; raudz.com). Butters’ cooking has always been flamboyant (he created the first kitchen at the Tofino’s celebrated Wickaninnish Inn) and at RauDZ, he’s having as much fun as the faithful who pack the joint. Butters turns Dungeness crab into crab cappuccino. Caesar salad takes on umami with double-smoked bacon and sun-dried olives. Yes, there’s poutine, only with chicken confit and pan gravy. His “fries” are baked and drizzled with blackberry ketchup. The standout appetizer though is venison carpaccio, laid out on a palette like a Jackson Pollock painting, with apples, walnuts, mustard dressing and toasted baguette. Signature mains? He has the gall to reboot tuna casserole of yore — one of several reborn classics on the menu — as albacore tuna poached in olive oil and seared rare tuna paired with creamy pasta and a Parmesan crisp. Unsurprisingly, it works. Ditto his take on the steak sandwich, no humble dish here: draped across brioche is a fat-grilled beef tenderloin with bacon and crabmeat poached in butter, the lot sided with potatoes and duck-fat mayo. For each and everything, there’s a well-chosen Okanagan wine.

JEREMY FERGUSON

Wine to note: Platinum Reserve, CedarCreek’s top-of-the-line label, “Block 3” Riesling and Syrah.

Every Sunday, Allen invites the intrepid Joy Road Catering (tel: 250-493-8657; joyroadcatering.com) to whip up a multi-course fete, a Wine Maker dinner with labels provided by a stellar Okanagan winery. Guests are seated at one long table, sometimes more than 40 diners, under the stars and treetops. Joy Road’s dinner is a procession of flawless dishes. The opener may be salt cod fritters with Espelette chili mayo and fresh oysters with rhubarb and shallot mignonette. Mains include burrata with freshly shelled peas and prosciutto, halibut in beurre blanc and duck confit with cherries, olive oil-roasted cauliflower, roasted asparagus and black lentil salad. Run all the way.

CAROL CLEMENS

The author at one of Hester Creek’s six Mediterranean-style villas.

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A $25 Pinot Noir from Quails’ Gate, one of the Okanagan Valley’s most established estate wineries. doctorsreview.com/wine/quails-gate-winery-review

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

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

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

Be informed. Be immunized.

JUNE 2014 • Doctor’s BEX_7386_PI_DoctorsReview E01.indd 1

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14-02-25 1:52 PM

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California roll salmon burgers.

Keep the Faita Recipes from the CBC cooking series that convinces you dinner could be easy recipes by

Stefano Faita

photos by

Leila Ashtari

tefano Faita and his mom are fairly well-known in Montreal. They own a store called Dante’s in the city’s Little Italy that sells kitchenware and

hunting supplies — an eclectic mix that’s hard to forget. They also own the Mezza Luna cooking school and Stefano just opened his first restaurant, Impasto. Canada knows Stefano for his CBC cooking series. He got his big national TV break after he filled in for his mom,

Elena, on a local food show. Two seasons and 155 episodes later, In the Kitchen with Stefano Faita, published by Penguin Books, is his first English-language cookbook. It features 250 easy, fan-favourite recipes from his series, including the four that follow. JUNE 2014 • Doctor’s

Review

BREAKFAST YOGURT PARFAITS This pretty parfait has a little bit of everything — yogurt, fruit and an easy granola topping. Serve it in little jars for a grab-and-go breakfast. No kid can resist this morning treat when it looks so colourful and fun! For the granola topping ¼ c. (60 ml) chopped hazelnuts 2 tbsp. (30 ml) ground flaxseeds 2 tbsp. (30 ml) wheat germ 2 tbsp. (30 ml) unsweetened shredded coconut 2 tbsp. (30 ml) brown sugar, or to taste 2 tbsp. (30 ml) large-flake rolled oats 1 tsp. (5 ml) cinnamon 2 tbsp. (30 ml) flax oil 1 tsp. (5 ml) vanilla extract For the yogurt parfaits 4 c. (1 L) Greek-style or drained plain yogurt

1 c. (250 ml) blueberries ¼ c. (60 ml) honey 1 c. (250 ml) chopped mango 1 c. (250 ml) chopped kiwifruit 1 c. (250 ml) chopped strawberries

To make the granola topping: in a small bowl, combine hazelnuts, flax meal, wheat germ, coconut, brown sugar, oats and cinnamon. Sprinkle with flax oil and vanilla. Toss to combine. To make the yogurt parfaits: in 4 parfait glasses or 2 cup (500 ml) mason jars, layer blueberries, one-quarter of the yogurt, 1 teaspoon (5 ml) of honey, mango, one-quarter of the yogurt, a drizzle of honey, kiwi, one-quarter of the yogurt, a drizzle of honey, strawberries and remaining yogurt. Top with granola topping. Serves 4.

TIP: Get creative here. Shake up the selection of fruit or use different nuts in the granola. Serve the parfaits in a small mason jar: the screw-on lid makes it portable to take to work or school.

QUICK SHRIMP AND CORN CHOWDER A bag of shrimp in the freezer is the perfect dinner solution in a stir-fry, pasta or soup any night of the week. This creamy chowder, topped with a crumble of crispy bacon, is simple and fast, but be warned: you’ll probably be tempted to have a second bowl!

2 tbsp. (30 g) butter 1 tbsp. (15 ml) olive oil 1 small onion, chopped 2 celery stalks, diced 1 tsp. (5 ml) dried thyme (or leaves from 1 fresh sprig) 2 tbsp. (30 ml) all-purpose flour 2 c. (500 ml) diced unpeeled potatoes 1 can (19 oz./540 ml) creamed corn 4 c. (1 L) chicken or vegetable stock pinch of freshly grated nutmeg, or to taste salt and freshly ground pepper ½ lb. (225 g) small to medium shrimp

Breakfast yogurt parfaits.

Doctor’s Review • JUNE 2014

Quick shrimp and corn chowder.

(thawed if frozen), peeled and deveined 2 jars roasted red peppers, chopped 2 slices pancetta or bacon, coarsely chopped ¼ c. (60 ml) whipping cream (35 percent) (optional) 2 tbsp. (30 ml) chopped fresh cilantro or parsley (optional)

Melt butter with olive oil in a large saucepan over medium heat. Add onions, celery and thyme. Cook, stirring frequently, until veggies start to soften, 1 to 2 minutes. Add flour and cook, stirring, for 1 minute. Add potatoes, creamed corn, stock, nutmeg, and salt and pepper to taste. Bring to a boil. Cover and reduce to a simmer. Simmer chowder until potatoes are fork-tender, about 15 minutes. Add shrimp and roasted red peppers. Simmer until shrimp turn pink and curl, 3 to 5 minutes. Meanwhile, cook the pancetta in a small skillet over medium heat until golden and crispy. If desired, stir in cream for a rich chowder. Reheat if needed. Serve soup garnished with

pancetta and fresh herbs, if desired. Serves 4.

TIP: For a thicker, creamier soup, before adding the shrimp, whizz half of the soup in a blender. Stir it back into the remaining soup.

CALIFORNIA ROLL SALMON BURGERS Top these moist, flavourful salmon patties with whatever toppings you like, but, for a mind-blowing burger, try the “California roll” combo: avocado, cucumber, pickled ginger and a hint of wasabi mayo make this sushi-inspired burger an unforgettable meal. For the salmon burgers 1 side of salmon (about 2 lb./900 g), skin removed, coarsely cut into cubes 2 large eggs, lightly beaten 2 tbsp. (30 ml) mayonnaise 1 c. (250 ml) panko bread crumbs 3 green onions, finely chopped

1 tbsp. (15 ml) chopped fresh ginger 3 tbsp. (45 ml) soy sauce, or to taste 2 tbsp. (30 ml) sesame oil 1 tbsp. (15 ml) sugar 1 tbsp. (15 ml) rice wine vinegar pinch of salt 2 to 3 tbsp. (30 to 45 ml) vegetable oil To assemble mayonnaise wasabi paste, to taste 6 sesame burger buns, toasted if desired avocado slices, pickled ginger, sprouts, cucumber slices, red onion slices

To make the salmon burgers: working in batches, pulse cubed salmon in a food processor just until finely chopped. Be careful not to over-process. Transfer chopped salmon to a large bowl. Add eggs, mayonnaise, bread crumbs, green onions, ginger, soy sauce, sesame oil, sugar, rice wine vinegar and salt. Mix with your hands. Divide mixture into 6 even portions and shape each into a patty about 1 inch (2.5 cm) thick. Heat a large nonstick skillet over medium heat. Add vegetable oil. When JUNE 2014 • Doctor’s

Review

Stefano’s pasta puttanesca.

oil is hot, add burgers in batches, if needed, to avoid crowding the pan. Fry, turning once, until burgers are just cooked through, 2 to 4 minutes per side. Combine mayonnaise and wasabi paste to taste. Serve salmon burgers in buns and garnish with wasabi mayonnaise and desired toppings. Serves 6.

TIP: For another great flavour, make these burgers with lump crabmeat instead of salmon. If you cannot find panko crumbs, just use plain dry bread crumbs.

STEFANO’S PASTA PUTTANESCA If there is a pasta dish that exudes intense flavour, it is definitely this one. The best part is, you probably have all the ingredients in your fridge or pantry right now. Why not go make it? 1 lb. (450 g) tortiglioni, penne or spaghetti ½ c. (125 ml) extra-virgin olive oil

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4 to 5 anchovies 2 garlic cloves, minced 1 tbsp. (15 ml) chopped drained hot peppers packed in oil 1½ c. (375 ml) pitted black olives, whole or chopped 2 tbsp. (30 ml) capers 1 tsp. (5 ml) dried oregano 1 can (14 oz./398 ml) diced tomatoes, preferably San Marzano salt and freshly ground pepper ⅓ c. (80 ml) chopped baby arugula, parsley or basil

Bring a large pot of water to a boil. Generously salt. Add pasta and cook until al dente. Meanwhile, heat olive oil in a large skillet over medium heat. Add anchovies and mash into a paste with a fork. Add garlic and hot peppers and cook, stirring, for 1 minute. Add olives, capers and oregano. Cook for another 1 to 2 minutes. Add tomatoes. Bring to a boil, reduce heat and simmer until slightly thickened, 7 to 10 minutes. Drain pasta, reserving some of the water. Add pasta to sauce and toss to combine, adding a little pasta water, if

needed, to loosen the sauce. Season with salt and pepper, and stir in arugula. Serves 6.

TIP: A traditional puttanesca sauce does not include the arugula, so feel free to prepare it either way. It’s a good idea to make more than you need for dinner, because leftovers will make an even more delicious lunch the next day.

From In the Kitchen with Stefano Faita by Stefano Faita. Copyright © Canadian Broadcast Corporation/ Stefano Faita Inc., 2013. Reprinted by permission of Penguin Canada Books Inc. Photograohy credit: Leila Ashtari.

From MTL’s Stefano Faita to PEI’s Michael Smith. Recipes for salmon in a bag and sweet potato salad from the Food Network chef. doctorsreview.com/food/book/back-basics-100-simple-classic-recipes-twist Doctor’s Review • JUNE 2014

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

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

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

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

Safety Information WARNINGS AND PRECAUTIONS General: OxyNEO (oxycodone hydrochloride controlled release tablets) must be swallowed whole. Taking cut, broken, chewed, dissolved or crushed OxyNEO® tablets could lead to the rapid release and absorption of a potentially fatal dose of oxycodone. The tablets have been hardened, by a unique process, to reduce the risk of being broken, crushed or chewed. ®

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

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

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

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

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

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

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

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

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

Doctor’s Review • JUNE 2014

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

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

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

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

JUNE 2014 • Doctor’s

Review

P H OT O FI NI SH by

Dr L orr a i n e S a n f a ç on

From the bottom up advertisers index ACTAVIS SPECIALTY PHARMACEUTICALS

Corporate.....................................................20 LoLo..........................................................2, 3

ASTRAZENECA CANADA INC.

Vimovo....................................................OBC

BOEHRINGER INGELHEIM

Cymbalta................................................ 34, 35

BRISTOL-MYERS SQUIBB

Abilify.................................................... 18, 25

LEO PHARMA INC.

Picato.............................................................4

MEC GLOBAL

Centrum.......................................................15

When people think of the Eiffel Tower, they often think about its impressive height dominating Paris’ skyline. We’re inclined to look up at the massive structure, ignoring all the action at its feet. On a blazing hot day last July, my nine-month-old baby and I needed to escape the heat wave so we decided to take a boat ride down the Seine. We got to see another side of Paris and all of its hot spots. Under the city’s biggest tourist attraction, locals gathered to cool off by soaking their feet in the river. Children splashed about and couples had their first kiss as the Eiffel Tower’s carousel turned. It was as if this rumbling and crowded Métropole paused for a second and I got to see a glimpse of the romantic Paris we all dream about.

MERCK CANADA

Merck respiratory.........................................27

NOVARTIS PHARMACEUTICALS CANADA INC.

Bexsero.........................................................10 Seebri.............................................Front cover

PFIZER CANADA

Lyrica.............................................................8 Pristiq.............................................................6

PURDUE PHARMA CANADA

Analgesic Portfolio................................... 9, 26 OxyNeo................................................... 7, 22

SEA COURSES INC.

Corporate.....................................................13

TAKEDA CANADA INC.

Dexilant.................................................... IFC

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.

editors@doctorsreview.com

Doctor’s Review • JUNE 2014

PRESCRIBING INFORMATION Abilify............................................. 55 Bexsero............................................ 45 OxyNeo..................... 51, 52, 53, 54, 55

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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

• 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.