March 2015 by Doctor's Review

Biking lighting Fearsome medical devices Best pre-op advice app Depression: differential diagnosis

MEDICINE ON THE MOVE

8 7 EUROPEAN DELIGHTS 4 8

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

MARCH 2015

French villages

boutique hotels

nights in Camargue

days a week in Liverpool

PLUS:

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

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

GO WITH THE FLOW

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

Why we travel

SOKOLOVSKY / SHUTTERSTOCK.COM

We travel for a lot of reasons: to attend conferences, to visit famous places, to sample tasty foods, to visit cultures that have a different view of what’s important than our own. To do good, to do business, to shop and go to concerts and museums, to lie on a beach, to have adventures, to pursue our hobbies, to meet new people, to broaden our horizons, to gain insight into what the world is really like away from our small corner, to get away from it all. There are other reasons too, of course. I had a friend who travelled to reinforce his prejudices and another, similarly inclined, who travelled to freshen his love of the town he grew up in: Toronto. Paul Theroux, a man whose métier is travel and writing about it, has made a point of visiting places others warn against: Ireland during the troubles; the Congo in the ’60s; East Germany in the ’70s, Egypt during the “peaceful mob” period a few years ago. His thoughts on travel appeared in The New York Times on the publication of his book The Tao of Travel. “The earth is often perceived as a foolproof Google map — not very large, easily accessible and knowable by any finger-drumming geek with a computer. In some respects this is true. Distance is no longer a problem. You can nip over to Hong Kong or spend a weekend in Dubai, or Rio. But as some countries open up, others shut down… travel maps have always been provisional and penciled in, continually updated. Travel, especially of the old laborious kind, has never seemed to me of greater importance, more essential, more enlightening.” I’m with him on the travel of “the old laborious” kind — albeit without his penchant for trouble spots. My idea of great travel is to find myself in an unfamiliar city on a Tuesday with the whole day spread before me. It’s a pleasure that can be enhanced, I’ll admit, if at the end of the day, you can return to pleasing accommodations. Each of the seven boutique hotels described in this issue (page 42) would fill the bill nicely, so would the Hard Days Night Hotel in Liverpool (page 48). If adventuring with a certain je ne sais quoi is more your style consider exploring the Camargue in Provence (page 32). This issue is devoted to Europe; may you find many delights here that set you dreaming — or calling a travel agent. Keep on travellin’,

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MARCH 2015 • Doctor’s

Review

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

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

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

ONC e ve r

24 h y

BREO ELLIPTA ®

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

fluticasone furoate / vilanterol

Practical once-daily dosing.

00416 12/14

For your adult patients with type 2 diabetes

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

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

BITRJ00110 CATRJ00110

contents

SEBASTIEN BUREL / SHUTTERSTOCK.COM

MARCH 2015

features

42 53

Provence’s astonishing Camargue

Classic recipes from the biggest country in the world by Maria Depenweiller

A land of green pastures, white horses, black bulls and pink flamingos by Dr Andrew Farquhar

From Russia with love

The abiding beauty of old stones Stroll through eight towns designated as “Les plus beaux villages de France” by Jeremy Ferguson

Europe’s boutique hotels Seven special places to stay that promise a night to remember by Roger White

Coming in

Eight days a week in Liverpool A bus tour through the city that gave the world the Fab Four by Josephine Matyas

April

• The Carolina coasts, both north and south, are perfect for a pre-summer vacation • Dudes and dudettes, plan now for a week at Saskatchewan’s real-time La Reata Ranch • Palm Springs! Forget the golf; the town and desert around it have so much to offer • Discover the joys of hidden Tennessee with this medical family on an adventure • Join the search for the origins of Norway’s painting The Scream

MARCH 2015 • Doctor’s

Review

contents MARCH 2015

regulars 9 LETTERS Doctors talk depression

PRACTICAL TRAVELLER Big portraits in Amsterdam, a glacier that you can get inside, Cunard recreates its first-ever cruise and more! by Camille Chin

17 GADGETS

Lighting the way to better biking by P.G. Ryerson

BEST MD APPS PreopEval14 may be all you need to talk to patients pre and post op by Theo Sands

Mechanical devices patients feared — with reason by Rose Foster

TOP 25

HISTORY OF MEDICINE

The biggest medical meetings scheduled for this summer

DEPRESSION POINTS Differential diagnosis by Mairi MacKinnon

PHOTO FINISH An artsy move? by Dr Peter Quelch

24 21

MARCH 2015 • Doctor’s

Review

NEW

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

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

IBS-C

CIC

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

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

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

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

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

LETTERS

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

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David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

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Denise Bernier

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Claudia Masciotra

EDITORIAL BOARD

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

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

Doctors talk depression MENTAL NOTES The current Ontario provincial government has been fiscally irresponsible and are in full assault mode in decreasing health-care funding. Thus any additional funding to improve mental health initiatives will not be forthcoming for several years [“Who treats depression?” February 2015, page 30]. I do know that we physicians will continue to offer the best care possible given the debt hole this current and previous Liberal Ontario provincial governments have created. Dr Brian Shamess Via doctorsreview.com

For the past 30 years, I have developed a practice based on a strong belief in the ability of any human being to manage himself appropriately, a capability that is not innate, but must be developed. So when I see someone who is not managing appropriately, whether it is through a criminal act, the abuse of a chemical, or depression, I see someone who needs to be educated in developing personal maturity, even if that is not global, but confined to one area of life. This I see as the level of mental/ emotional development, not just the result of an anatomical or physiologi-

cal abnormality (though that can also happen). I want to retrain these people and set them on their road, responsible for themselves. This is not how the medical or legal community sees it. They see only that such a person needs to be managed by an authority — doctor or jailer. This act of reaching deeply inside the person, discovering where and why there is a deficit, and re-educating them to overcome it is both extremely time consuming and energy depleting. But the end result is so fulfilling that I cannot let go of it. I am aware that this is not easy for either the psychiatrist or family physician in a busy office. I have had the privilege of restricting my practice to only this area of medicine. I really want to share this with other practitioners. There is an article I have posted on my website, and I would ask readers to read and comment: understandingchange. org/Essays_and_Articles_public/post/ depression_facts. Dr Albert de Goias Via doctorsreview.com

MARCH 2015 • Doctor’s

Review

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

ON THE GO

TAKING IT SLOW

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

VERE O C BY MOST

PRIVATE DRUG PLANS‡, ODB and EDS in SK

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

TAKE WITH BREAKFAST *

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

C a mi lle C hi n

COLLECTION AMSTERDAM MUSEUM

The distribution of bread in the almshouse, painter unknown, 1627.

Saving face

You’ve got until the end of 2016 to see Portrait Gallery of the Golden Age on now at the Hermitage Amsterdam. The exhibit features 30 big paintings dating from the 17th century that are rarely seen. The largest canvas measures three by six metres. Drawn from the Amsterdam Museum and Rijksmuseum, the pieces are the “brothers and sisters” of Rembrandt’s The Night Watch. The rest of Europe was governed by rulers and church officials then, but the Republic of the Seven United Netherlands was run by the bourgeoisie who are the civic guards, regents and regentesses in the paintings. They managed the city and country, trade, defence and even developments in science making the Republic one of the most powerful and prosperous at the time. The administration of some care and disciplinary institutions even included (gasp!) women. Adults €15; kids 6 to 16 €5. hermitage.nl.

MARCH 2015 • Doctor’s

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

A clean break The Vatican has new bathrooms, but they’re not where or for whom you might think. The public restrooms near Bernini’s Colonnade in St. Peter’s Square are for “homeless pilgrims.” The restrooms include motion-activated sinks and showers with hot water, soap dispensers and even a barbershop. The showers are open every day except Wednesdays; haircuts are done on Mondays when Rome’s local barbers have the day off so they can volunteer their time. Kits with a towel, change of underwear, soap, deodorant, toothpaste, razor and shaving cream will be supplied; the Vatican will use the proceeds from offerings to purchase what hasn’t been donated.

JOHANN HELGASON / SHUTTERSTOCK.COM

Tunnel vision

Doctor’s Review • MARCH 2015

Beginning June 1, you’ll be able to go 200 metres inside Europe’s second largest glacier to see the “blue ice” that’s beneath its surface. Iceland’s Langjökull features a circular tunnel to a depth of 30 metres that’ll bring visitors to a large, naturally-formed crevasse — and a manmade ice chapel. There are three sub-glacial Langjökull adventures visitors can choose from June through October. The shortest is 2½ to 3½ hours long (adults $170); the 14-hour package includes pit stops at geothermal hot springs, waterfalls and a geyser ($370). Each begins in either the island’s capital of Reykjavik or the small town of Húsafell where an eight-wheel-drive, 40-passenger monster truck will take participants through the 5770-metre Hvalfjörður (whale) Tunnel under the Hvalfjörður fjord before climbing to the top of the 950-square-kilometre glacier, which is 1400 metres above sea level at its highest point. icecave.is.

A royal celebration

Claudia Masciotra

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Doctor’s Review

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Cunard’s first transatlantic crossing from Liverpool to Boston was 175 years ago on July 4, 1840. The British cruise line’s first ship, Britannia, was a little wooden paddle steamer that carried 115 first-class passengers, 89 crew, the Atlantic mail, chickens, a cow for milk and three cats to keep the rats down. Halifax-born Samuel Cunard and his daughter Britannia joined the 14-day trip. This summer, the Queen Mary 2 will leave Southampton on July 2 and then Liverpool on that same date for that same Halifax and Boston voyage, but it’ll continue to NYC as a bonus. The 12-day trip starts at $2858 per person (plus taxes and fees). Cunard’s anniversary celebrations begin on May 3 when the cruise line’s three ships, the Queen Elizabeth, Queen Mary 2 and Queen Victoria, will be in their home port in Southampton. On May 25, they’ll meet on the Mersey in Liverpool for a choreographed show. tel: (800) 728-6273; March 2015 issue cunard.com/cruise-types/anniversary-cruises-2015.

EUROPE ALASKA CME CRUISES British Isles Jul 15 - 27 Clinical Care Jul 12 - 19 Update in Medicine

ER, Neurology, Chronic Pain

Mediterranean Sep 19 - Oct 2 Primary Care Challenges in Medicine

Aug 2 - 9

Cardiology & Respirology

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

Review

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

Moscow’s Tretyakov Gallery.

POPOVA VALERIYA / SHUTTERSTOCK.COM

An artful gesture Admission to Russia’s 62 federal museums is now free to youth under 18. This includes the State Hermitage in Saint Petersburg, and the Tretyakov Gallery and Pushkin Museum of Fine Arts in Moscow. The new 2015 initiative applies to both locals and foreign travellers. The country’s federal museums are said to have received 30 million visitors last year and the Culture Ministry has agreed to compensate them for lost revenue.

The track record Santorini, Greece.

LEOKS / SHUTTERSTOCK.COM

As of January 1, you can now travel by train to Krakow and Warsaw with Eurail’s Global Pass. Poland, Serbia, Montenegro, and Bosnia and Herzegovina are now among the 28 countries covered. If you bought your Global Pass in 2014, but are travelling this year, you’ll be able to visit the four latest countries added. Also new in 2015 is Eurail’s One Country Attica Pass. It includes four domestic ferry trips in Greece, giving you access to 26 islands including Crete, Kos, Lesvos, Rhodes and Santorini, and two international ferry trips between Italy and Greece. Finally, kids under 11 now ride free when accompanied by anyone over 18 travelling on any of Eurail’s adult passes. For more 2015 news: eurail.com/ news/new-announcements-traveling-2015.

Doctor’s Review • MARCH 2015

Telemedicine is an efficient and effective way for Ontarioâ&#x20AC;&#x2122;s specialists to connect with patients anywhere in the province â&#x20AC;&#x201C; not because you need more patients, but because more patients need you. Join the thousands of specialists, family physicians, nurses and allied health professionals who are already going the distance for better patient care. Let OTN help you add all the benefits of Telemedicine to your practice.

Get started at otnhub.ca/gothedistance.

es i r e s g n i o g on

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

New recipes every month!

doctorsreview.com

GA D GE T S P .G. R y e r s on

Lighting the way to better biking The idea of wearable technology was introduced about two years ago, but it’s never really taken off. Sure there’s been a modest market for electronic wristbands that track and record heart rate, exercise intensity and other functions, and some buzz has been generated around the imminent release of the Apple Watch, but here are some wearables that’ll make you think “what took them so long.” The Visijax Commuter Jacket, introduced at the Las Vegas Consumer The Visijax Commuter Jacket. Electronic Show this past December, BELOW: the turn signal vest. simply makes it much easier for cyclists to be seen at night. It’s festooned with 23 high-intensity LEDs — white in front and red in the back — that can be adjusted to blink slow or fast or emit a steady light. A rechargeable battery runs for 30 hours. The jackets come in florescent yellow or black, are waterproof and washable. And one more thing: there are turn signals in the sleeves that are activated when you raise your arms and go off once you’ve completed the turn. The lights are so bright they can be seen in daylight. This is a garment that could save your life. They’re not cheap and, equally discouraging, they’re not yet available in Canada though they should be soon, hopefully later in the spring before the cycling season gets fully underway. In the meantime, you can order them through amazon.com if you have access to a US shipping address. amazon.com; US$160. Sticking with wearables, here’s an idea: Novomarket’s turn signal vest. Highly visible LED left and right arrows on the back are operated wirelessly by controls mounted on bike handlebars. Uses two “button” batteries. It has the advantage of flexibility. It can be attached to a backpack, for example, obviating the need to wear cycle clothing. amazon.ca. $73. Even less obtrusive is the Docooler 3-in-1 bicycle turn signal brake and horn. In this case the turn signals are mounted on the back of your bike’s seat and are operated by controls mounted on the handlebars or frame or wherever you find a convenient spot. Bonus: the units include an eight-tune horn. Sound a little over the top? Still, why not give it a try. You have very little to lose and it could very well add to your biking safety. amazon.ca. $9.

MARCH 2015 • Doctor’s

Review

May 30 â&#x20AC;&#x201C; June 3, 2015

Annual Conference

Shaw Conference Centre | #CAEP15

Event Speakers

Dr. Thomas Kerr

Prof. Timothy Caulfield

Dr. Wendy Levinson

Dr. Peter A. Burke

Knowledge in Action: The Insite Program

From Celebrities to Science Spin: Debunking Medical Myths

Choosing Wisely Canada: The Present and The Future

Boston Marathon Bombing: Lessons Learned

May 31, 2015

June 1, 2015

June 2, 2015

June 3, 2015

Early Bird Registration Deadline April 9th 2015 Visit CAEP.ca for more event details and to sign up today!

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A preoperative evaluation must If you evaluate preoperative patients you’re likely already familiar with PreopEval and if you’re not, you should be. Created by Dr Joshua Steinberg, it’s just been updated with PreopEval14 and continues to provide high-quality, evidence-based guidelines for the preoperative evaluation of patients undergoing non-cardiac surgery and perioperative medication management. The app, based on the American College of Cardiology’s (ACC) algorithm, covers surgery urgency and risk, cardiac conditions or lack of them, and a spate other clinical factors, including: • blood-work before surgery • common perioperative medications

• the timing of non-cardiac surgery after an M.I. • indications for preoperative electrocardiography, chest radiography and blood tests • patients on warfarin, aspirin, and clopidogrel • perioperative use of B-blockers or statins Writes the app’s creator: “This app is written and intended for practicing physicians like internists, family physicians and hospitalists; for resident physician trainees; and for medical students. In addition to being a reference, the algorithm is written to be a teaching tool by not just delivering an answer, but instead walking a physician through the evaluation process so that one learns that process along the way.” Reviewers are enthusiastic, finding it carefully researched yet concise, highly readable and easy-to-use — a significant achievement given the complexity of the original sources which include guidelines from the aforementioned ACC, the American Heart Association (AHA), the Institute for Clinical Systems Improvement, and the American College of Chest Physicians. Indeed, the information on which the app is based is so comprehensive and clearly written that more than one reviewer has recommended it as a model for anyone engaged in building medical apps. PreopEval14 by Dr Joshua Steinberg Devices: iPhone only Cost: Free

MARCH 2015 • Doctor’s

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Canada Edmonton, AB May 30-June 3 2015 Annual Conference of the Canadian Association of Emergency Physicians caep.ca/conference

Halifax, NS August 26

Vancouver, BC July 25-27

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2015 Annual Meeting of the Canadian Medical Protective Association cmpa-acpm.ca/annual-meeting

20th World Congress on Heart Disease cardiologyonline.com/wchd2015/index.html

Around the world Big Island, HI July 5-10

Big Island’s Pu’uhonua o Honaunau National Historical Park.

Essentials of Women’s Health: An Integrated Approach to Primary Care and Office Gynecology ucsfcme.com

Chicago, IL July 16-18

Dallas, TX August 13-15

Boston, MA July 9-12

67th Annual Meeting of the National Hemophilia Foundation hemophilia.org/events-meetings/annual-meeting

41st Annual Meeting of the Society for Pediatric Dermatology pedsderm.net

Edinburgh, Scotland July 8-10

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11th Summer Academy of Dermatopathology intsocdermpath.org/meetings.asp

Las Vegas, NV July 28-August 1 23rd Annual Scientific Meeting of the International Spine Intervention Society spinalinjection.org/annual-scientific-meeting.php

Long Beach, CA July 16-18 2015 Annual Meeting of the American Orthopaedic Foot and Ankle Society aofas.org/education/annual-meeting/Pages/ home.aspx

Mackinac Island, MI July 31-August 2 33rd Annual Internal Medicine Update ocpd.med.umich.edu/cme/course-calendar

August 14-16 28th Annual Cardiology Update ocpd.med.umich.edu/cme/course-calendar

Manezhnaya Square, Moscow.

Maui, HI July 4-10

Portland, OR August 6-8

Pediatrics in the Islands: Clinical Pearls 2015 childrenshospitallamedicalgroup.org

2015 Annual Meeting of the Infectious Diseases Society for Obstetrics and Gynecology idsog.org/annual-meeting/annual-meetingoverview/2015-annual-meeting

Moscow, Russia July 9-10 International Forum “New Horizons in Reproductive Health” reproduction2015.com

New York, NY July 27-29 XXIII World Congress of the International Society for the Study of Vulvovaginal Disease newyork.issvd.org

August 19-23 2015 Summer Academy Meeting of the American Academy of Dermatology aad.org/meetings/2015-summer-academy-meeting

Orlando, FL July 9-12 SUE STOKES / SHUTTERSTOCK.COM

2015 Annual Meeting of the American Orthopaedic Society for Sports Medicine sportsmed.org

July 23-26 Sedona’s Slide Rock State Park.

Doctor’s Review • MARCH 2015

2015 Annual Scientific Meeting of the American Podiatric Medical Association www.apma.org/events/thenational.cfm

Rochester, MN August 14-15 Mayo Clinic Updates in Urology and Case Conference 2015 ce.mayo.edu

San Francisco, CA July 23-24 Osteoporosis: New Insights in Research, Diagnosis and Clinical Care ucsfcme.com

August 7-9 Mayo Clinic Headache Symposium 2015 ce.mayo.edu

Sedona, AZ August 6-9 Cardiology Update 2015: The Heart of the Matter ce.mayo.edu

Vail, CO July 20-23 29th Annual Echocardiographic Symposium at Vail ce.mayo.edu

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

R os e F os t e r

Fear of medical mech

Bloodletting in Naples, Italy circa 1671.

Circa 1900 French hypodermic syringe set with sterling silver fittings and, in the lid, two wire cleanouts.

Doctor’s Review • MARCH 2015

physician’s white coat may be enough to send some patients’ blood pressure

soaring, but at least it can be said that medical instruments these days are no longer the stuff of nightmares. Not so long ago though, even the most soothing bedside manner was not enough to put a patient at ease once they glimpsed the horrific-looking implements that would be put to use on them. Trypanophobia, fear of needles, was certainly more justified back in the 1660s than it is today. In the 1660s experimenters J.D. Major of Kiel and J.S. Elsholtz of Berlin were the first to attempt injections in humans. They used a forerunner of the syringe put together by the renowned English architect Sir Christopher Wren, who probably should have stuck to buildings. Fashioned using animal bladders as the syringe and goose quills for the needle, Wren used the primitive device to deliver opium intravenously to a dog, likely to see if orally administered medicines could be delivered in this way. Major and Elsholtz boldly went where they should not have gone and used the device on humans with often deadly results. Their failed experiments were enough to turn the medical establishment away from injections for nearly two centuries.

anics

It wasn’t doctors that patients minded so much as the tools they used

This brass scarificator used in bloodletting has 13 blades and dates between 1833 and 1855.

“feeders.” When the lice had had their fill of blood, they were infected with typhus, dissected, and used to create a vaccine for the terrible disease which until then could not be stopped. No catalogue of horrific medical instruments would be complete without a respectable collection of bloodletting devices. Spring lancets, fleams and blood bowls can still send a chill through the hearts of both patients and practitioners, especially the latter, who can fully appreciate how harmful the gory practice was. In an era when there is never enough blood to go around no matter how generously donors may give, the idea of hacking into a patient’s leg with a twelve-bladed scarificator and dumping the resulting blood down the drain is almost as disturbing as the effect on the victim.

CUT IT OUT When they were taken up again in the latter half of the 19th century, they were still not for the faint of heart. Early models were made entirely of metal. Only later did a version with glass make it possible for the user to better estimate dosages. Today’s anti-vaxxers might have even more support than they do now were vaccines still administered as they were back in the day — with a mechanical scarificator. Even a good-sized needle pales in comparison to these hulking metal objects. Manufactured between 1874 and 1900 and thoughtfully curved to fit the arm of a child, they usually housed four rows of double blades, or sometimes, gilded steel teeth, reminiscent of the “steel leeches” from the time when bloodletting was a common practice. The instruments were prepared for a small pox vaccination by dipping the working end in lymph material from the pustule of a person who had received the vaccine five to eight days before and was showing skin blisters as proof. A similar delivery method, greatly refined, is still used today for small pox vaccinations.

Other instruments were used somewhat higher up on a patient’s body. Hemorrhoid forceps ruled the day before quilted toilet paper and Preparation H, banding and cauterization with lasers. Generations of physicians who proceeded you simply mustered all the gumption they could, grasped the hemorrhoid tightly with the instrument and crushed it to restrict blood supply. Eventually, the damaged hemorrhoid tissue would wither and fall off.

A LOUSY SYSTEM Vaccines bring to mind another distasteful tool-ofthe-trade, this one invented in the 1920s: louse cages. About the size and shape of a match box minus the protective sleeve, these were filled with live lice and strapped by the half-dozen to the legs of human

An ad for the leucotomy instrument invented by Canadian neurosurgeon Dr Kenneth G. McKenzie in the 1940s. It was used to perform lobotomies by inserting the narrow shaft into the brain though a hole in the skull, extending a wire and then rotating it to cut a core of brain tissue. MARCH 2015 • Doctor’s

Review

The tonsil guillotine was gruesome, but it saved doctors from having their fingers A HOLE IN THE HEAD bitten by patients

having their fingers bitten by terrified patients. After piercing the tonsil with a fork and severing it with the guillotine’s blade, their work was done. More fortunate patients received a mild anesthetic in the form of a cocaine solution.

A similar concept was at work with the once common physician’s tool, the eraser or “crusher.” A loop at the end of a long hook made it possible to lasso all manner of growths, cysts, polyps and tumours, and strangle and crush the offending matter by turning a screw to apply pressure and restrict blood supply like a tourniquet. Speaking of tourniquets, a helpful mechanism to be sure in some cases, we can be thankful that Lister-type tourniquets, invented by Joseph Lister, father of antiseptic surgery, are a thing of the past. Designed to compress the abdominal aorta during surgery, the Lister often damaged internal organs in the process and was doubtless the cause of some deaths. The doctor’s safety was occasionally taken into consideration in the manufacture of medical tools whose barbaric purposes were obvious to the patient from the start. The tonsil guillotine was a long, wickedlooking device with a loop and a moveable blade on the end. Gruesome as it sounds, doctors of the 19th century were glad to have it, as it saved them from

This 1829 tongue ecraseur was used to remove parts affected by cancer in an attempt to curb its spread.

Doctor’s Review • MARCH 2015

Not so lucky were the patients who underwent trepanning, the well-intended though misguided operation designed to relieve pressure on the brain by drilling a hole in the skull. The osteotome was a kind of hand-cranked chainsaw with a spike on the end meant to be jabbed into the patient’s skull to stabilize the rotating blade chains. The practice has never entirely died out. As recently as 1965, Dr Bart Hughes, a librarian, not a physician, drilled a hole in his own head with a dentist drill. He was not alone in believing that trepanation increased “brain blood volume” and enhanced cerebral metabolism, and claimed that it had benefits similar to that of natural vasodilators such as ginkgo biloba. Finally, there are certain medical instruments that should be banished from our collective memory. The fetal destructor comes to mind, a tool which delivered a killing blow to a baby when the mother’s health was failing and a caesarean was deemed too risky. The fetal perforator and extractor would be used to puncture the baby’s skull and empty its contents, rendering the head collapsible and easier to extract. One of the most challenging instruments to reconcile in the history of medicine is one from our recent past. The leucotome, invented by Canadian neurosurgeon Dr Kenneth G. McKenzie in the 1940s, has a narrow shaft which is inserted into the brain through a hole in the skull. Depressing a plunger on the back of the instrument extends a wire loop into the brain, cutting brain tissue and so performing a lobotomy. Another version of the leucotome was introduced by American Walter Freeman for use in the transorbital lobotomy. It was only too easy to insert the pointed shaft, modelled after an icepick, into the tear duct of a misbehaving teenager or wayward patient at a mental hospital, and give a quick tap with a mallet. The results were abominable, causing death in 5 percent of cases and a range of often hideous personality alterations in the rest. Freeman performed more than 3500 such lobotomies until 1967 when his license was revoked. The practice was eventually banned but not before over 40,000 lobotomies had been performed worldwide. The present-day patient fears associated with a physician’s white coat would seem to pale in comparison to what’s gone before. Not so fast. The once ubiquitous garment has been banned in Britain, due to the propensity of the long sleeves to spread infection.

In major depressive disorder

“I felt down and

overwhelmed nearly every day.” Nicole*, 37

For patients like Nicole...

Trust PRISTIQ

for powerful

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

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

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

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

CA0113PRI023E

Count on

for powerful symptom relief

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

Mairi MacKinnon

Differential diagnosis of depression Pinpointing the primary problem is key before deciding on treatment Ms. M, a 47-year-old married woman with two children, missed her last annual check-up but comes to see you because she has been feeling extremely low. She has not been sleeping well and lacks her usual enthusiasm and “get up and go.” She has been gaining weight even though she watches her diet. Her mother died of cancer a few months ago, but she feels she has adjusted well to her loss. Things are going well with her job and her family; she has a good life and feels she “has no reason to complain.” She feels guilty that she cannot seem to pull herself together. One of her sisters has been treated for depression but she never thought something like that could hit her. Is depression Ms. M’s problem or could something else be behind her state?

D .

epression can have a major impact on quality of life, affecting work, family, social relationships and financial status. Further, it can damage physical health outcomes by worsening pain, lowering motivation in terms of self-care and decreasing adherence to treatment.1,2 Symptoms of many psychiatric and medical conditions can overlap with or hide those of depression, and sometimes more than one disorder may be present, making diagnosis challenging.3,4 The rate of depression in individuals with chronic illness is between 25% and 50% (compared to 5% in otherwise healthy adults), and at least half of these may go undiagnosed.3

DSM-5 diagnostic criteria for major depression6 Patients who express frequent feelings of sadness or depression, or loss of interest or pleasure in normal daily activities, should undergo further investigation. A diagnosis of major depressive disorder (MDD; also called unipolar depression or clinical depression) must also include at least four of the following criteria: • unexplained changes in weight or appetite • sleep problems (sleeping too much or too little) • feeling of restlessness or slowness • fatigue, lack of energy • inappropriate guilt, self-blame • lack of focus or concentration • recurrent suicidal thoughts or attempts Distressing symptoms should have been present during most of the day on most days for a consecutive two-week period and have resulted in considerable functional impairment. Symptoms are not substance-related (drug abuse or medication) or due to the effects of a medical condition.

Doctor’s Review • MARCH 2015

Since the diagnosis of depression occurs most often in primary care settings,1,5 it is important for family physicians to understand the link between depression and other disorders. Effective treatment for depression can improve both mood and medical health.2,3

Rooting out the causes Many factors can coincide to contribute to depression, including genetics, life stress or trauma, a previous episode of depression or the presence of another illness. Steps in establishing a differential diagnosis of depression include distinguishing it from other mood disorders and ruling out possible medical causes. Where appropriate, prescribe laboratory tests such as complete blood count, thyroid stimulating hormone (TSH), vitamin B12, neurologic exam.7,8

Is depression related to another mood disorder or ADHD? Dysthmia is a chronic disorder characterized by low mood; symptoms persist for at least two years, but do not meet DSM criteria for major depressive disorder (MDD).4,6,9 Dysthmia is a risk factor for the development of MDD.10 Anxiety disorders share symptoms with MDD such as fatigue, poor concentration and restlessness.4,9 People with obsessivecompulsive disorder, panic disorder, social anxiety, etc are at high risk for developing comorbid depression; specific disorders should be identified as they require different treatment approaches.7,10 Bipolar disorder presents with depressive symptoms interspersed with episodes of mania or “highs” (racing thoughts, hyperactivity, grandiosity, compulsive behaviour). A missed diagnosis of bipolar disorder (e.g. as recurrent unipolar depression) and failure to treat it can trigger a hypomanic, manic or mixed episode.4,10

It is also worth considering whether attention deficit hyperactivity disorder (ADHD) might be the problem in patients who complain of difficulties with inattention, inactivity/hyperactivity, restlessness, forgetfulness, or that affect everyday functioning.6

Is substance abuse or a medication side effect to blame? Alcohol or drug abuse (cocaine, amphetamines, cannabis, sedatives, narcotics) can cause fatigue, memory deficits, insomnia and nervousness.4,9,10 Depression can also lead to substance abuse as a form of self-medication.4 Also ask patients about their use of any of the following prescription medications: central nervous system drugs used to treat seizures, Parkinson’s, migraine; cardiovascular drugs including some beta-blockers, antihypertensives, vasodilators, antiarrhythmics; steroids and other hormonal agents; anti-infectives such as antiretrovirals, interferon, antimalarials; chemotherapy drugs; sedatives; appetite suppressants; isotretinoin (for skin problems); clomiphene citrate (fertility drug).7,9,10

Could there be a medical cause? Neurologic disorders: Changes in affect and mood occur with Alzheimer’s, stroke, Parkinson’s, multiple sclerosis (MS) and seizures. Changes in cognitive function and behaviour due to MDD can sometimes be confused with dementia; this is called dementia of depression, and benefits from treatment of the depressive episode.9,10 Consider TSH or vitamin B12 testing for modifiable causes of dementia. Endocrine diseases: Elevated serum TSH indicates hypothyroidism, characterized by slowed mental/physical functioning, fatigue, lethargy, sleep disturbances and weight gain; decreased TSH signals hyperthyroidism, which presents with symptoms such as weight loss, fatigue, weakness and irritability. Cushing’s disease, caused by a tumour or excess growth of the pituitary gland, is linked to obesity, back pain and mental changes among other symptoms, and can be detected by a 24-hour urine cortisol test.2,9,10 Sleep disorders: Sleep apnea, especially common in obese individuals, is known to cause significant symptoms that mimic

depression, and should be investigated and treated.10 Vitamin B12: Deficiency in vitamin B12, associated with long-standing anemia, can also be the source of altered mood, confusion, impaired memory and/or insomnia.9 Infections and autoimmune diseases: Infection triggers an inflammatory response that produces cytokines, which affect how brain cells communicate and are elevated in depression. In autoimmune disease, the body’s defence system attacks healthy tissues and may sometimes target brain and nerve cells.10 Mood disorders and behavioural changes are often associated with conditions involving inflammatory processes, including infections (Lyme disease, mononucleosis, HIV/AIDS etc), autoimmune disorders (celiac disease, MS, lupus, rheumatoid arthritis and others), cardiovascular disease, diabetes and some cancers.1,10

Watch for clinical clues Every effort should be made toward better assessment and diagnosis of depression. While current Canadian guidelines do not recommend routine screening of people who may be at higher risk, they advise clinicians to be aware of the possibility of depression in patients who present with signs such as insomnia, low mood, loss of interest/pleasure and suicidal thoughts.11 References 1. Patten SB, Kennedy SH, Lam RW et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. Jof Aff Disord 2009;117(Suppl 1):S5–S14. 2. Simon GE. Treating depression in patients with chronic disease. West J Med 2001; 175:292–3. 3. Canadian Mental Health Association British Columbia Division (CMHA BC). Depression and co-existing conditions. www.cmha-bc.org. Accessed Feb. 13, 2015. 4. Centre for Applied Research in Mental Health and Addiction (CARMHA), Faculty of Health Sciences, Simon Fraser University. Family physician guide for depression, anxiety disorders, early psychosis and substance use disorders. British Columbia Ministry of Health, 2008. 5. Wong ST, Manca D, Barber D et al. The diagnosis of depression and its treatment in Canadian primary care practices: an epidemiological study. CMAJ Open 2014; 2:E337-E342. 6. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition. Washington, DC: American Psychiatric Association, 2013. 7. BCGuidelines.ca. Major depressive disorder in adults: Diagnosis & management. British Columbia Ministry of Health, 2013. 8. Merck Manual. Depressive disorders. Merck, Sharpe & Dohme Corp, 2013. www.merckmanuals.com/professional/index.html. Accessed Feb. 13, 2015 9. BMJ Best Practice. Depression in adults: Differential diagnosis. http://bestpractice. bmj.com/best-practice/monograph/55/diagnosis/differential.html. Accessed Feb. 13, 2015. 10. Halverson JL. Depression differential diagnoses. http://emedicine.medscape.com/ article/286759-differential. Accessed Feb. 13, 2015. 11. Canadian Task Force on Preventive Health Care. Recommendations on screening for depression in adults. CMAJ 2013:185:775-82. MARCH 2015 • Doctor’s

Review

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

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

Depression

•

General Anxiety Disorder

•

Social Anxiety Disorder

•

Panic Disorder

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

Clinical use:

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

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

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

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

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

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

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

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

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

Other relevant warnings and precautions:

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

• Risk of allergic reaction

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

• Hepatic and renal impairment: Dosage adjustments required.

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

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

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

CA0114EFX007E

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

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

Greener pastures The Biosphere Reserve in Provence where the wildlife outnumbers the visitors text and photos by Dr Andrew Farquhar

Camargue horses are born with a dark coat that turns white when they’re four or five years old.

Dr Andrew Farquhar is a retired family physician, but he still gives lectures and teaches in Kelowna, BC. His most recent trip was to Bucerias and Sayulita in Mexico to do a project on pelicans. Next up: China this spring and maybe a walking tour of Northern Italy this summer. To see more of his photography, go to afarfotos.com.

Doctor’s Review • MARCH 2015

or most people, the South of France means the sparkling Mediterranean with trendy

resorts like St. Tropez and Cannes, and beautiful beaches packed with beautiful people. Not far from these glittering resorts is a gem of a different kind though, a gentle wilderness, unknown even to many seasoned travellers.

Bulls from Camargue have slender heads and bodies, and they are never more than 1.2 metres in height.

This is the fascinating Camargue region of Provence, a photo destination with unique landscapes and wildlife, exhilarating light and bloodless bullfights. An article in National Geographic featuring the Camargue inspired my wife and I to check it out in July 2013. We flew to Nice, rented a tiny red Citroën, figured out the complicated and expensive French motorway tolls, braved European drivers, survived a terrifying thunderstorm, and finally, four hours later, were welcomed to Van Gogh country with fields of glowing sunflowers. Arles, at the north edge of the Camargue, is the region’s largest town with about 55,000 inhabitants. Inspired by the unique light, Van Gogh produced much of his best work here. Our destination was 38 kilometres further south — we were in search of the region’s famous white horses, black fighting bulls and pink flamingos. The Camargue lies between the Rhône delta and the Mediterranean Sea. At the centre of the delta is a huge brackish lake, the Étang de Vaccarès, which is surrounded by an intricate pattern of lagoons, wetlands and salt flats. Prior to the 19th century, recurrent flooding created an estuary in a constant state of flux with an ever-changing landscape. Extensive engineering with pumps, drains and dykes was undertaken to stabilize it. The outcome has been an incredible mosaic of such rich biodiversity that the area has been designated a UNESCO Biosphere Reserve. Raptors soar in the blue skies, horses and bulls roam freely, and pink flamingos, the symbol of the Camargue, can be seen just about anywhere there is water. This is a paradise for birders, not to mention hikers, bikers, photographers and artistes. It’s easy to understand why Van Gogh loved this area.

THE MANE ATTRACTIONS Saintes-Maries de la Mer (saintesmaries.com), a vibrant little town popular with French vacationers, is the capital of the Camargue. Its name comes from the biblical legend of Mary Jacobe and Mary Salome, who, evicted from Palestine and shipwrecked here, introduced Christianity to France.

Most mornings we would pull off the deserted road and marvel at the stunning dawn light We spent four nights at a small hotel on the outskirts of town. The Mas des Salicornes (13460 SaintesMaries de la Mer; hotel-salicornes.com; double rooms from €99) is a charming, converted farmstead. Each of the 24 rooms has a private patio surrounded by oleander and bougainvillea. The Parc Ornithologique (parcornithologique. com; adults €7.50) was nearby. It’s a large wilderness area with over 300 species of birds. We spent one morning exploring seven kilometres of trails, winding around the park’s marshes, enjoying flamingos, herons, egrets, swans and various raptors along with MARCH 2015 • Doctor’s

Review

I was confronted by the very large head of an angry black bull peering at me about a metre away the occasional curious horse that poked its head up through the reeds. Most mornings we would drive a short distance from our hotel, pull off the practically deserted road and marvel at the stunning dawn light, placid white horses munching and shuffling through the reeds, sometimes huddled together, their manes blowing in the early mistral wind. Birds of all descriptions were in the air, on the water and even on the backs of horses, their birdsong welcoming the sun. We saw few other people. Occasionally a motorist would slow to see what they might be missing. Sometimes we saw other early morning photographers, or riders on horseback heading into the brush, or a jogger, or a group of cyclists. But mostly it seemed we were alone in this paradise.

FROM BIRDS TO BULLS

Our days typically started at predawn to catch the rising sun and waking birdlife. After a while, we’d return to our hotel for breakfast on the patio: warm croissants and baguettes, ham, cheese, fruit and great coffee. Then we’d set off to explore the town’s beaches, cafés and history. Late one afternoon we

visited the town’s famous ninth-century fortified church, the Notre-Dame-de-la-Mer, where we enjoyed an impressive rendering of Vivaldi’s Four Seasons. The following day we embarked on a short river tour of the Petit Rhône, which provided different views of the estuary. From the boat we were treated to memorable images of a gardian (Camargue cowboy) herding horses and bulls down a dusty track to the river. Photo ops were countless. While enjoying a lunch of calamari and wine at a seafront café, we noticed people lining up across the street. Something special was unfolding. Then came the horses and riders — lots of them — from white Camargue horses with brownish foals to large Arab horses and stately Belgiums. Our random restaurant stop gave us the perfect ringside seat to this feria, a colourful festival of local horses. Serendipity would also play a role in the most memorable event of our entire trip. A meandering drive on our third day brought us to the small town of Salin-de-Giraud in the southeast corner of the Camargue. By sheer chance we stumbled on a bullfight known locally as the Course Camarguaise. A bloodless sport — at least for the

The pink flamingo is one of the 340 species of birds in the Camargue.

Doctor’s Review • MARCH 2015

Dr Farquhar’s lunch at a café in Les Saintes-Mariesde-la-Mer came complete with a festival of horses.

bulls — it’s a mesmerizing spectator event and a photographic feast. I’d started shooting when my viewfinder suddenly went dark. I cursed, thinking my camera had a problem. As I pulled the camera from my face, I was confronted by the very large head of an angry black bull peering at me from over the barrier about a metre away. I gasped and jumped back to the amusement of onlookers. Young men (raseteurs) compete to outrun the bulls while at the same time attempting to snatch a rosette from the beast’s head. Scoring is determined by the number of rosettes retrieved. To avoid serious injury, they must run, dodge, twist and ultimately leap onto a high ledge to evade the furious snorting bull. It’s completely riveting to watch. Although the bulls’ horns were capped on this occasion, they could still inflict serious injury; I saw raseteurs with arm slings and crutches in the audience. Four days was only time enough to whet our appetites for this unique place called the Camargue, but we were obliged to move on. We had a rendezvous with a tour group in Arles to explore the rest of Provence.

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The majority of Van Gogh’s sunflowers in vases were created in Arles between 1888 and 1889.

For more info on the region, check out Le Parc Naturel Régional de Camargue (parc-camargue.fr) and the Bouches-du-Rhône Tourist Board (visit provence.com).

In and around Arles, Avignon and Aix-en-Provence. doctorsreview.com/features/tourism-provence-france MARCH 2015 • Doctor’s

Review

There are lots of ochre-hued restaurants in Cucuron’s Place de L’Étang.

Sitting pretty Eight villages that may be the most beautiful in France text and photos by Jeremy Ferguson

happily confess to being a French village junkie, although I’ll never get to see them all because they number 32,000. Worlds apart, they remove me from the unrelieved buzz of the Internet age, our desecration of the blue planet and the barely suppressed hysteria that forms the day-to-day connection among us. These villages, where time moves like a speeding escargot, proffer the rich and gentle pleasures of discovery and nuance. There is history and civilization to be felt here, and cuisine that pleasures us so mightily, and the French culture which is like no other.

My wife, who knows how to hit a nail square on the head faster than anyone I know, says: “In a village, you can do better than visit, you can live there. You sit on your balcony listening to the sounds of the neighbourhood. You get to know your neighbours and you learn about the village from their perspective. This brings a certain intimacy to travel, something beyond what you get when you’re confined to hotels and restaurants.”

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Oppède-le-Vieux’s lower village is a popular stop for hikers and cyclists.

Ansouis’s 1000-year-old castle overlooks vine-covered stone houses.

Orange lactelle mushrooms are a delicacy you can find in the markets around Ansouis.

There are many plane-tree lined avenues between the villages.

Doctor’s Review • MARCH 2015

“In a village, you can do better than visit, you can live there” You won’t find the Vaucluse village of Ansouis on the hipster’s map of France. It doesn’t have many tourists. It’s a working village whose inhabitants crawl out of bed and go to their jobs at the local vineyards and olive groves or offices in Aix or Marseilles. We rented a house and made it our base in Provence. Ansouis has a thousand inhabitants and a thousand years. Its character springs from ancient walls, cobblestone streets, twisting lanes, vine-covered stone houses and the patina of time. All of the French countryside seems to have one foot in the Middle Ages: step into a public square and you wouldn’t be astonished to find a beheading or dwarftossing in progress. And cuisine? The village has a couple of cafés and a Michelin-starred restaurant calling for reservations two months in advance. A van arrives weekly to purvey perfectly fresh fish, so we could eat fat Atlantic scallops and glowingly pink swordfish dressed with black olive tapenade. From markets in neighbouring villages, we found orange lactelle mushrooms, a delicacy from the fungi universe, and duck confit wrapped in crinolines of its own fat, and Rhône wines at six bucks a bottle. Our walks transported us steeply up towards the Château d’Ansouis and the 12th-century church of Saint-Martin (which showed up in the film classics Jean de Florette and Manon des Sources). We paused at L’Atelier d’Art de France, a gallery showcasing the outstanding oeuvre of bronze sculptor Maria Catuogno and her jewellery-designer husband, Juan. Our reward for the climb was a sweeping panorama of the green-gold Luberon countryside. And the château: one of its owners had been Elzéar de Sabran, whose family had acquired it in the 13th century. He was so bent on virtue that both he and his bride swore a lifetime vow of chastity on their wedding night. The Vatican made saints of both of them.

nsouis is one of Les Plus Beaux Villages de France, the association of 161 villages promoting the French countryside to the more than 80 million tourists who make France one of the most popular destinations in the world. The designation — the Canadian counterpart is Les Plus Beaux Villages du Québec — is signposted at each village. Maps and a guidebook are available. To be a Plus Beaux Villages, you must have a population of fewer than 2000. You must have two protected areas: picturesque or legendary sites, or sites of artistic, historic or scientific interest. Our journey took us from Lyon to the town of

Nyons in northern Provence and then further south to Ansouis. We visited and photographed 18 villages. Welcome to eight of the best.

O .

ut of Lyon, our first stop was the 12th-to14th-century village of Pérouges. A postcard from the Middle Ages, its cobblestones, vaulted passageways and narrow streets make it a prêt-à-porter movie set, as it was for the 1961 French version of The Three Musketeers. Pérouges recalls medieval Carcassonne, but with fewer tourist restaurants and shops. Its bakeries are famed for the local galette, a cake resembling a pizza crust topped with butter and sugar. Negotiate the narrow staircases to the top of the museum watch tower to peek into hidden courtyards and tiny gardens planted with centuries of secrets. Also from Lyon, we motored north to the southern Beaujolais village of Oingt, amusingly pronounced “wah.” Its scrubbed yellow-ochre buildings, and refined shops and restaurants render this a luxe stop, but even more impressive is its exquisite setting among the rolling hills, where it sits like an amber bauble on a swatch of emerald silk. Find yourself a restaurant with a terrace and celebrate

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The Beaujolais village of Oingt is a luxe stop set among rolling vineyards.

A caged bust of Marquis de Sade stands by the ruin of his castle in Lacoste.

The unassuming Le Petite Maison in Cucuron is a Michelin-starred restaurant.

the view with a glass of Beaujolais or a headier Côtes du Rhône from the south. Châtillon-sur-Chalaronne isn’t a Plus Beaux, but has much to boast about in its old quarter, half-timbered walls, flower-festooned bridges and a 15th-century covered market. The local tourist office publishes a smart little walking-tour brochure, the stroll culminating at the ramparts of a long-destroyed, 1000-year-old castle. A slip of a village, Brantes is an artists’ retreat perched 600 metres up on a mountain outcrop overlooking the lush Toulourenc Valley. With a population of just 80 and a huddle of renovated medieval buildings separated by steep, ungainly steps, it’s a natural for any aspiring recluse with a set of paints. The switchback road up provides yet another scenic high for the camera.

inally, we travelled south to Ansouis. Hopping Lourmarin is where Albert Camus lived and is buried, and where bestselling author Peter Mayle has his house. Remarkable chef Édouard Loubet got his start many years ago (he still owns the lovely hotel Moulin de Lourmarin) and Reine Sammut, one of France’s top female chefs, currently presides on the village outskirts. The once-charming village has pedigree and also a Renaissance castle, but nowadays seems more dedicated to its gauntlet of overpriced restaurants and boutiques much favoured by conspicuously affluent American tourists. Farmers from neighbouring villages joke that the price doubles when they sell their vegetables in Lourmarin. Oppède-le-Vieux is a comely, contrary village. Pilgrims like us rush through the charming lower village to make the steep climb up the Luberon heights to the upper village and what’s left of its château. But when we arrive, huffing and puffing, we found not much at all: the 12th century ruin is privately owned and off-limits. The village of Lacoste isn’t Plus Beaux, but it has better qualifications than many that are: this is one of the most picturesque of perched villages. Its old château was the home of the Marquis de Sade. It was here that he lived, wrote and conducted fastidiously orchestrated orgies involving himself, his wife and a troupe of nuns and servant girls. The château, which was destroyed during the French Revolution, is the now the second home of celebrity couturier Pierre Cardin (imagine ghosts in leisure suits). Cardin slyly bought up as many as 46 buildings and turned them into swank hotels, restaurants and galleries. The villagers were unamused. He later planned a golf course, but the peasants revolted at this excess — just as they had at De Sade’s licentious behavior in the 1770s — with a battalion of tractors and a successful threat to shut down Cardin’s splashy annual Festival de Lacoste. Today the tourist can access De Sades’s old haunt

by a steep climb through the village or by road. The restored section of the ruin is Cardin’s private residence. A striking-looking caged bust of the young Marquis de Sade sits in the outer courtyard, welcoming guests to the rogue’s quarters, which are open in summer. Set among vineyards and olive groves, Cucuron is the perfect pause for a walk through the old town and a bounteous lunch at one of the restaurants on the Place de L’Étang. The place, with its ochre-hued buildings and 14th-century reservoir shaded by plane trees, is a delight to behold. Terrace lunches from the Bar de L’Étang might floor Goliath: a carafe of house red and a colossal platter of beef carpaccio with green salad and a load of fat frites makes for a deeply contented tourist. The pretty house at the end of the square, La Petite Maison, is a Michelin-starred restaurant owned by portly, food-loving chef Eric Sapet. Will that be the veal grenadin in a parmesan pastry crust or ris de veau (yes, the way you can find sweetbreads only in France) with morels? Book a table, take a snooze between restaurants and bon appétit. For more info, visit the Les Plus Beaux Villages website (les-plus-beaux-villages-of-france.org) and France Tourism (ca.rendezvousenfrance.com).

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How to find a holiday rental in France. doctorsreview.com/features/inside-story

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Palazzo Tolomei, Florence.

Suite dreams Small hotels in Europe for romance and luxury one night at a time by Roger White

urope is home to some of the most enchanting small hotels in the world. They’re the kind of places that dwell in memory for decades. You’ll find seven such places here. First, a word about prices. Rates for most, though not all, are toward the higher end and, perhaps surprisingly, the highest rates are the ones quoted by the hotel directly. The rates shown here are for mid-April and were found on a variety of booking sites. A caveat: rates vary widely from site to site so before you book, search for the best you can find on the web; it could save you hundreds of dollars. That said, always visit the hotel website for a full appreciation of what’s offered.

Doctor’s Review • MARCH 2015

FLORENCE Located in the heart of Florence, Palazzo Tolomei is housed in a captivating palace that dates from the 16th century and is only a short walk from all the sites that make the city famous: the Duomo, the Ponte Vecchio, the Uffizi Gallery, the Basilica of Santa Croce. The Palazzo offers 15 Italianate rooms with many of the ceilings decorated with original frescoes. Spacious rooms and common spaces carefully furnished with a blend of antique and modern pieces foster a feeling of luxury that would have been appreciated by a Medici. Expect gold and white rooms, mirrors, fine china, crystal, marble and exquisite flooring. You will also find all the modern amenities: Wi-Fi, television, and luxurious bathrobes and fine toiletries. Some rooms contain Nespresso machines, and coffee and complimentary pastries are offered in the elegant lounge. From $255 (ca.hotels.com); palazzotolomei.it.

PRAGUE

PHOTOS STEFAN SCHUETZ

Prague, like Vienna, is a walking town. Go for the Baroque buildings, the stone bridges, the lovely green river, and all the mad people who have been attracted here for centuries and still are. You might start your tromp in the old town’s Malá Strana quarter, home to painters, poets, musicians and others of that ilk, with a stop at the Kampa Museum, which features Bohemian artists past and present. Take a break at the tobacco-infused Franz Kafka Café where you can debate the virtues of the choices you’ve made in life or, if you’re in more of an up mood, head for the chandeliers and cakes of Café Café. Visit the Castle and go up the tower, but mostly hang out, eat and drink, and allow yourself to have a very good time. Those good times could well start at the Hotel Josef. The unfailingly bright and upbeat architecture and decor set a positive mood, the breakfasts are outstanding and can be enjoyed on the rooftop terrace in fair weather. The staff are friendly and helpful. There’s fruit, coffee and pastries in the lobby, bottled water and fine cosmetics in the generously sized rooms, Wi-Fi and a fitness centre with sauna. From $169 (expedia.ca); hoteljosef.com.

Hotel Josef, Prague.

COPENHAGEN Denmark has, for the last 40 years, topped international polls as the happiest place in the world to live. That doesn’t mean that Danes go around leaping for joy and clicking their heels in the air. It’s more a contentment index and Danes really do get many small pleasures out of life. So what about visitors? If you enjoy biking, parks, city lakes, open-face seafood sandwiches, swimming in harbours, lots of cafés with superior food and drink, good design and even better looking people you probably would enjoy a visit to Copenhagen. That goes double if you fancy living on a canal. The CPHLiving boat hotel, docked across from the city centre, offers 12 rooms with full front glass walls that look out on passing ships and the harbour beyond; even the showers come with water views. There’s a pleasing rooftop sundeck where you can enjoy a Carlsberg at the end of the day. The decor is upscale Danish modern with lots of wood and steel. Heated floors enhance the pleasure of pad-

ding around barefoot. It’s an informal place that’s bound to add to your happiness quotient. TV and Wi-Fi equipped, of course. From $164 (expedia.ca); cphliving.com.

The CPHLiving’s glass walls look out on passing ships and the harbour beyond VIENNA

Hotel Das Tyrol, Vienna.

Doctor’s Review • MARCH 2015

Why Vienna? The Kunsthistorisches Museum, Viennese State Opera and Spanish Riding School for starters. The museum has a stunning collection of European paintings thanks to the Hapsburgs penchant for conquer and art; the opera offers standing room tickets for less than $10; and you owe it to yourself to see those horses perform “airs about the ground” at least once. Then there’s Freud’s home, the Third Man Museum based on the 1949 Orson Welles movie filmed in post-war Vienna, and the Narrenturm, which houses a Pathology and Anatomy Museum, worth a glimpse if only to see how far the profession has come since the 19th century. And on to the food. Take frequent stops for the iconic pastries and don’t balk at the idea of a daily Wiener schnitzel — you’d never do that at home, but this is a holiday. Sleep it off at the Hotel Das Tyrol on the Mariahilfer Strasse, the longest shopping street in the city and close to the historic quarter, the Spittelberg. The decor blends the past with the modern. Contemporary Viennese art is featured in most of the commodious rooms. The breakfast buffet gets you off to a running start toward a high-calorie day. Leave it to the hotel’s sauna, steam room and light therapy facility to coax you back into shape. Wi-Fi. From $209 (ca.hotels.com); das-tyrol.at.

CPHLiving, Copenhagen.

EDINBURGH The Scottish capital is the most popular city in the UK with overseas visitors — outside of London — and why not? It’s poetry in stone and masonry. The High Street tucked below the rock on which Edinburgh Castle sits makes the city centre one of the most arresting anywhere. More than 500 years old, it’s home to dozens of ancient pubs in which to sip a wee dram. The sightseeing is spectacular from the Castle to Holyrood Park with its stunning views to Arthur’s Seat. Culture abounds from bookstores to theatre, not forgetting the famous summertime Fringe Festival. You can even take tea on the Royal Yacht Britannia, now in dry dock and open to visitors. You will feel like royalty when you stay at Prestonfield, once home

Prestonfield, Edinburgh.

to the Lord Provosts of Edinburgh. Located on an estate a five-minute ride from the town centre, its 18 rooms and five suites offer both history and sensuality, a combination that is perhaps the reason this is often called the finest place to stay in the capital. Expect impeccable service. From $266 (trivago.ca); prestonfield.com.

LISBON The capital of Portugal is sometimes overlooked by visitors to Europe and that is a mistake. It offers the best beach/city combination on the continent, the weather is consistently mild from March through November, the architecture is a marvel, old wooden trams rumble up the hills, there’s a Medieval/Moorish castle and a lavish monastery that celebrates the country’s vast colonial empire. The seafood is beautiful, the wine soft and highly drinkable, the porto the best on the globe. The Hotel Britania, on a quiet street off the main Avenida da Liberdade, is a stunning Art Deco masterpiece designed by Cassiano Branco in the 1940s and maintained in pristine condition. Hotel Britania, Lisbon.

MARCH 2015 • Doctor’s

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Hotel Britania, Lisbon.

It’s a gem. The 30 rooms are large, yet intimate and comfortable, the beautiful bar with its original wall paintings and cork floors invites lingering. Service throughout is impeccable, indeed it’s a winner of a Condé Nast award for “most outstanding service” among a host of other honours. From $231 (expedia.ca); hotel-britania.com.

ROME If you need an excuse to go to Rome, perhaps you should stay home. After over 2600 years since it was founded by those twins, the place still has a lot to offer. If this is a first trip, get the tourist sites out of the way early on and spend the rest of your stay absorbing the city — the restaurants, cafés, shopping, people watching and nearly everything else reaches its zenith in the Imperial City. You’ll find yourself in the heart of it all at Hotel Campo de’ Fiori near the plaza of the same name. The astonishingly romantic looking place covered with ivy is right out of the movies. Inside you’ll find 23 elaborately decorated rooms in the Roman style — that is to say over the top with heavy draperies, frescos and gilt. The rooms are on the small side, but don’t let that stand in the way; there’s a rooftop garden where you’re invited to bring your own wine. If space is a necessity, the deluxe accommodations are larger and some have balconies. The service is friendly and the breakfast buffet generous. Wi-Fi. Families should ask about the 12 apartments connected to the hotel. From $288 (priceline.ca); campodefiori.com.

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

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Hotel Campo de’ Fiori, Rome.

Doctor’s Review • MARCH 2015

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BREATHE IT IN

Explore the possibilities.

Eight days a w Hereâ&#x20AC;&#x2122;s your ticket to ride back to The Fab Fourâ&#x20AC;&#x2122;s glory days by Josephine Matyas

Liverpool was a European Capital of Culture in 2008 and even buses commemorated The Beatles.

eek in Liverpool A

eld guide to the heartbeat pop music capital of the world might read like this:

KENNY 1 / SHUTTERSTOCK.COM

“In an industrial city in the British midlands some young men meet by chance on a school bus, talk about their mutual love of music, form a band, hone their craft at a local club, take the world by storm and change the history of popular music.” It’s a story familiar to every fan of The Beatles. It’s also a tale deeply baked into present day Liverpool, a port city that has weathered hard times in the past but is repackaging itself as ground zero for Beatles fans. One of the best ways to become immersed in that musical past is by climbing aboard the hallucinogenic Magical Mystery Tour bus (cavernclub.org/themagical-mystery-tour; £17 per person), one of the city’s Beatles-themed tours, for a trip down Penny Lane. “It’s without a shadow of a doubt the most important house in rock ’n’ roll history,” says tour guide Neil Brannan, nodding toward the reddish brick terrace house at 20 Forthlin Road. It’s a modest home with utilitarian trim and a small front yard. There’s little hint that anything of historical note ever happened inside. The giveaway is the steady stream of the faithful who come on foot, by van and on tour busses to stand outside and gaze respectfully at what has become a shine. “This is the home Paul McCartney moved into in 1955 and it’s where he was living when he met John Lennon,” explains Brannan. “Paul’s father was a musician himself and he encouraged the lads to come to the house to rehearse. More than 100 songs were written here — the majority in the bathroom, where the acoustics were better.”

MARCH 2015 • Doctor’s

Review

John Lennon grew up in this 1930s semi-detached on Menlove Avenue.

More than 100 songs were written here — the majority in the bathroom, where the acoustics were better McCartney spent his formative teenage years living on Forthlin Road, a decade during which the world’s most famous song-writing duo penned hits that defined a generation, including “From Me To You,” “I Saw Her Standing There,” “I’ll Follow the

LIVERPOOL SANS JOHN, PAUL, GEORGE OR RINGO The city’s deep historic and cultural roots were recognized in 2004 with UNESCO World Heritage Status and in 2008 when it was named European Capital of Culture. When you’ve had you fill of Beatlemania, head for these spots: The Gothic architecture at the Liverpool Cathedral, the largest Anglican cathedral in the UK and the fifth largest in the world. The view from the 101-metre tower is spectacular. Take a stroll through St. George’s Hall, one of the finest examples of neoclassical architecture in Europe. For 130 years the renowned Walker Gallery has housed Liverpool’s most outstanding art collection, which includes works by Rembrandt, David Hockney, Claude Monet and Rossetti. Hope Street, anchored with a magnificent cathedral at both ends, was recently voted the best street in the UK. It’s also home to the Royal Liverpool Philharmonic Orchestra, performing in the Art Deco surroundings of the Royal Philharmonic Hall. Liverpool’s long theatre history is on display at venues like the Playhouse, Royal Court and Empire. The newlyrenovated Everyman Theatre combines a trademark wrap-around auditorium, basement bistro and workshop facility.

Doctor’s Review • MARCH 2015

Sun” and their debut single “Love Me Do.” It was here that 14-year-old McCartney wrote “When I’m Sixty Four.” The house is now a protected National Trust site and Beatles aficionados can take an inside look at rooms frozen in time circa 1960 or just soak in the greatness vibe from the sidewalk. Much of what made it to the page and mesmerized listeners was actually the mundane detail of the songwriters’ daily lives. “Paul and George were both at the Liverpool Institute; they’d travel from home on a bus, change buses here and then travel by bus into the city,” Brannan tells his riders at an intersection in the same neighbourhood as the small roadway, Penny Lane. “The song ‘Penny Lane’ was written about what was going round while waiting for a bus to school. What is now Sgt. Peppers Bistro in the middle of the roundabout was formerly the bus- and tram-waiting shelter where those pretty nurses sold poppies from a tray. What is now the Penny Lane Surgery was the bank on the corner where the banker never wore a mac in the pouring rain… very strange.” The bus also stops at the boyhood home of John Lennon where he lived with his beloved Aunt Mimi. “When the band came around to rehearse they weren’t allowed in the house with the guitars,” claims Brannan. “They were only allowed on the porch because Mimi insisted ‘the guitar’s all very well and good, John, but you’ll never make a living at it’.” It was the sound of a brass band emanating from nearby Strawberry Field — a Salvation Army Children’s Home — that caught the attention of preschool-age John Lennon, who could hear the music coming from over the garden wall. According to popular legend, it was these tunes that planted a love of music in the lad.

CHRIS DORNEY / SHUTTERSTOCK.COM

The McCartney family moved to 20 Forthlin Road in 1955.

TUPUNGATO / SHUTTERSTOCK.COM

CHRIS DORNEY / SHUTTERSTOCK.COM

Lennon and his Aunt Mimi used to go to summer garden parties at Strawberry Field.

The Beatles performed at the Cavern Club a staggering 292 times.

EGG AND VEGGIES PLAY

The Beatles Story is the world’s largest permanent exhibit devoted to the Fab Four.

1960s; Lennon’s eyeglasses; and archival photos and video footage including their arrival in America and their famous stint on the Ed Sullivan Show. It was a sad day for Beatles fans when the group formally disbanded on April 10, 1970. A lucky few, including thousands of office workers on their lunch break, had been on hand on the street in central London for the band’s last performance on January 30, 1969 on the roof of the five-storey Apple Records headquarters at 3 Savile Row. The 42-minute concert ended with John Lennon quipping, “I’d like to say thank you. I hope we passed the audition.” Indeed.

JOSEPHINE MATYAS

The Cavern Club (10 Mathew Street; cavernclub.org) in the heart of working-class Liverpool is arguably the most famous bar of the 20th century. Fans still line up for performances of The Beatles tribute band, but mainly they come on a pilgrimage to what is the place where the band’s gig history began. At the time the group first started to play there, the club was in the basement of a fruit and vegetable warehouse packed to the rafters with crates of eggs and veggies. It opened its doors as the Cavern in early 1957 and within a very short space of time had transitioned through several music styles of the day — jazz and skiffle — before settling into rock ’n’ roll. “Anyone who’s anyone in rock ’n’ roll played the Cavern over the years,” says Brannan. “The reason it became synonymous with The Beatles rather than any other band is because of how many times they played there. From the first Cavern gig as The Beatles in February 1961 to their last gig in August 1963, The Beatles performed at the Cavern a staggering 292 times.” What would history be without a proper museum? The Beatles Story (Britannia Vaults, Albert Dock; beatlesstory.com; adults £15) situated in a renovated warehouse at the historic Albert Dock, now a UNESCO World Heritage Site on the waterfront, is just such a place. And for fans, it’s a treasure trove of Beatles memorabilia: George Harrison’s first guitar; props from the original Casbah Coffee Club; a reconstruction of the famous Abbey Road Studio including the original tape deck used for recording through the

MRMICHAELANGELO / SHUTTERSTOCK.COM

The Magical Mystery Tour pulls up to the brightlypainted Strawberry Field front gates, another spot where the faithful pause to remember the tunes of the 1960s. The original, century-old, wrought-iron gates were removed by the city for safekeeping, replaced by handcrafted replicas able to stand up to the wear and tear of thousands of musical pilgrims. Lennon’s childhood memories were, immortalized in the band’s song “Strawberry Fields Forever.”

There’s only one place to stay for Beatles’ buffs and that’s the Hard Days Night Hotel (Central Buildings, North John Street; harddaysnighthotel. com; from £95, but check the website, prices vary widely according to dates). MARCH 2015 • Doctor’s

Review

Make your travel dreams come true Go to doctorsreview.com/meetings to search 2500+ top world conferences Access code: drcme

Salad Olivier.

From Russia with love Classic recipes that demand white tablecloth treatment

recipes by

Maria Depenweiller

photos by

Tracy Kusiewicz

eets, cabbage, onions, oats and buckwheat are the main ingredients in Russian cuisine, and they have been for 2000 years. Cooking methods have evolved, however, with influences from Europe in

the west part of the country and Asia in the east. After the Revolution and civil war that finally ended in 1923, the new government determined what kind of produce was sold in stores and this lead to changes in what was available. Families moved from large houses with traditional ovens into small apartments with kerosene burners, and then gas and electric stoves. Poorer households relied on food preservation techniques like drying, pickling, fermentation and smoking; the

wealthy followed European trends, particularly those of the French. The middle (merchant) class could afford a variety of ingredients and cooking tools, but they had a strong attachment to their roots, and helped develop classic Russian cuisine as we understand it today. Maria Depenweiller, who was born in Moscow, but now lives in Milton, Ontario, has assembled those classics in Russian Cuisine, published by Whitecap Books. Three traditional recipes follow. MARCH 2015 â&#x20AC;˘ Doctorâ&#x20AC;&#x2122;s

Review

BORSCHT WITH BEEF Prep time: 30 minutes Cooking time: 1½ hours This lovely soup of Ukrainian origin was eaten in Russia well before Soviet times, but gained wide appeal during this period. Popularized by public eateries and restaurants, this colourful and thrifty dish became one of the most recognized symbols of Russian and Slavic cuisine.

Borscht with beef.

SALAD OLIVIER Prep time: 1 hour This is definitely the most popular of all Russian salads. No special occasion is celebrated without it.

3 medium potatoes, unpeeled 2 medium carrots, unpeeled 3 hard-boiled eggs, finely chopped 1 c. (250 ml) cooked ham (or boiled chicken breast), diced 2 green onions, finely chopped 2 dill pickles, finely chopped

Ham it up

½ c. (125 ml) chopped fresh dill or parsley ½ c. (125 ml) canned green peas 1½ c. (375 ml) mayonnaise ½ tsp. (2.5 ml) salt ½ tsp. (2.5 ml) black pepper

Cook the potatoes and carrots until tender and then let cool. Peel and dice them and place in a large salad bowl. Add hard-boiled eggs, ham, onions, pickles, dill and peas. Mix well. Add the mayonnaise, salt and pepper, making sure that the mayonnaise evenly coats all the ingredients. Makes 6 servings.

1 lb. (500 g) beef (brisket) or pork (brisket or ribs) 1 tsp. (5 ml) salt 1 bay leaf 3 whole black peppercorns 2 c. (500 ml) julienned beets 2 tbsp. (30 ml) sunflower oil 1 small onion, finely diced 1 c. (250 ml) julienned carrots ¼ c. (60 ml) tomato paste ¼ c. (60 ml) water 2 tbsp. (30 ml) sugar 1 tbsp. (15 ml) lemon juice 2 c. (500 ml) diced potatoes 3 c. (750 ml) finely sliced cabbage 6 tbsp. (90 ml) sour cream ¼ c. (60 ml) finely chopped parsley ¼ c. (60 ml) finely chopped dill

Place the meat in a large stockpot, cover with cold water and bring to a boil. Remove any foam that forms with a slotted spoon, then add salt, bay leaf, peppercorns and beets. Reduce the heat to medium and once the stock boils again remove the foam. Further reduce heat to medium-low and continue cooking for another 20 to 30 minutes. Meanwhile, in a deep frying pan, heat sunflower oil and sauté the onion

The original recipe for Salad Olivier, or Zakuska Olivier as it was once called, was made popular by a Russian chef of French origin, Lucien Olivier. He worked in Restaurant Hermitage in Moscow at the end of 19th century. The exact ingredients of the original recipe are still the subject of much discussion and speculation. It’s believed they were kept secret by the master himself and that Olivier never disclosed the recipe to anyone. The first-ever recorded recipe for Zakuska Olivier dates back to the late 1890s. This recipe included quail, fresh cucumbers, olives, crayfish, potatoes, lettuce and a composite sauce made with a mayonnaise base. The salad was well known and always in demand. It’s not surprising that attempts were made to recreate the masterpiece at home. Even the political and social turmoil of the revolution and early Soviet period did not diminish people’s love for this salad. Due to the absence of many ingredients and the adaptation to the new Soviet lifestyle, the recipe for Salad Olivier evolved over time. Quails and olives were gone, and replaced with simpler ingredients. The current version of the classic Salad Olivier includes ham or chicken, potatoes, eggs and other vegetables.

Doctor’s Review • MARCH 2015

and carrots until onion is golden, about 5 to 10 minutes. Add tomato paste diluted in a ¼ cup (60 ml) water, sugar and lemon juice, and reduce the heat to low. Sauté until most of the liquid evaporates and the mixture has the consistency of a thick pasta sauce. Add potatoes and cabbage to the stockpot with the meat. Bring to a boil, then reduce heat and add the sautéed tomato and carrot mixture. Stir and let the borscht simmer on low heat until potatoes and cabbage are tender, about 10 to 20 minutes. Once all the vegetables are tender, remove the pot from heat; take out the meat and cut it into bite-sized pieces before returning it to the pot. Cover and let sit for 20 to 30 minutes to let all the flavours blend. To serve, ladle the hot borscht into bowls or plates, garnish with a dollop of sour cream, and finely chopped parsley and dill. Makes 6 servings.

In a deep bowl, dissolve yeast in warm milk; add sugar, salt and egg, and mix well. Gradually add flour and butter, and knead the dough until it stops sticking to fingers. Cover dough with a clean tea towel and put in a warm place to let rise for 1 hour. Then, knead it again to let the gas bubbles escape, cover with the tea towel and let rise for another 30 to 40 minutes. Sauté the diced onions in butter until lightly golden, about 10 minutes. Add diced salmon fillets, season with salt and pepper, and mix well. Sauté until the salmon is seared on all sides. Divide the dough into 10 small portions, rolling each into ½-inch (1-cm) thick rounds, approximately the size of a saucer. Place about 2 to 3 tablespoons (30 to 45 ml) filling in the middle of each dough round. Bring the edges together and seal (leave a ¾-inch/2 cm) opening in the middle) making the rasstegai boat shape.

Place rasstegai on a well-greased baking sheet and let them rest for 20 to 30 minutes. Glaze with beaten egg white and bake in preheated 400°F (200°C) oven for about 15 minutes, until golden brown. Remove from oven, glaze with melted butter and pour 1 to 2 tablespoons (15 to 30 ml) fish broth into each of the openings. Serve hot. Makes 10 servings.

Recipes excerpted from Russian Cuisine: Traditional and Contemporary Home Cooking (Whitecap Books, 2014).

SALMON-FILLED RASSTEGAI Prep time: 2½ hours Cooking time: 30 minutes Rasstegai are savoury boat-shaped pirogi with an elegant opening on top, exposing the filling. Typically they are served as a side with soup. For the dough 2 tsp. (10 ml) yeast 1 c. (250 ml) milk or water at room temperature 2 tbsp. (30 ml) sugar 1 tsp. (5 ml) salt 1 egg 2 c. (500 ml) all-purpose flour 2 tbsp. (30 ml) butter or vegetable oil For the filling 2 onions, diced ¼ c. (60 ml) butter or vegetable oil ½ lb. (250 g) salmon fillets, boiled and diced 1 tsp. (5 ml) salt 1 tsp. (5 ml) black pepper 1 c. (250 ml) fish broth For the glaze 1 egg white, beaten 3 tbsp. (45 ml) melted butter

Salmon-filled rasstegai.

MARCH 2015 • Doctor’s

Review

P H OT O FI NI SH by

Dr Peter Qu e lc h

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Last year, my wife and I spent five days in the former East Berlin. We stayed at the Brilliant Apartments, highly recommended on TripAdvisor. Our apartment was on the second floor of a four-storey building, and the rooms were large with high ceilings and plenty of windows. The building and apartment reminded me of scenes from the movie The Lives of Others, which is about life under the Stasi in pre-1989 East Berlin. In the morning, one could enjoy coffee in the Café Krone, located at street level in our building, where we watched people coming and going on the Oderberger Strasse. Many of the streets in the area have very wide sidewalks; the width on both sides of the street is greater than the roadway. This makes for great morning traffic with pedestrians, cyclists, parents pushing prams and the odd motor vehicle. The neighbourhood was delightful with many interesting restaurants, eclectic clothing stores, ice cream parlours and the occasional beer garden. There was a great street market on the weekend with plenty of entertainment for adults and children. Berlin has become a popular destination, not only for tourists, but also for many young people because of its affordability and art scene. Graffiti seems to have become commonplace, at least in the area where we were staying. People are divided in their opinions about graffiti, some think it’s art while others feel it defiles the beauty of the neighbourhood. This photo, taken with my iPhone 5, shows a postman’s bicycle left on the sidewalk while he entered the apartment to make his deliveries. It seems to blend in well with the graffiti on the wall of the building. Art or ugly? You be the judge.

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 • MARCH 2015

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

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

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

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

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

Indications: SPIRIVA RESPIMAT (tiotropium bromide monohydrate) is indicated as a long-term once-daily maintenance bronchodilator treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema, and for the reduction of exacerbations. SPIRIVA RESPIMAT is not indicated as rescue medication for the relief of acute bronchospasm in COPD. Clinical use: Safety and effectiveness in patients less than 18 years of age have not been established. Contraindications: Patients with a history of hypersensitivity to atropine or its derivatives (e.g. ipratropium). Relevant warnings and precautions: - Should not be used for initial treatment of acute episodes of bronchospasm or for the relief of acute symptoms - Immediate hypersensitivity reactions may occur - Should not be used more frequently than two inhalations once daily

References: 1. O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2008 Update. Can Respir J 2008;15(Suppl A):1A-8A. 2. SPIRIVA® RESPIMAT® Product Monograph. Boehringer Ingelheim (Canada) Ltd., Dec 12, 2014. 3. COMBIVENT® RESPIMAT® Product Monograph. Boehringer Ingelheim (Canada) Ltd., Jan 8, 2014. 4. Decramer M, Vestbo J, Bourbeau J, et al. Global strategy for the diagnosis, management, and prevention of COPD (updated 2014). Global Initiative for Chronic Obstructive Lung Disease, Inc. 2014. 5. Data on file. Boehringer Ingelheim (Canada) Ltd., 2015.

- Patients with narrow-angle glaucoma, urinary retention (prostatic hyperplasia or bladder-neck obstruction) - Avoid getting mist into eyes - Should not be used with other medicine containing a long-acting muscarinic antagonist - Occurrence of dizziness or blurred vision may influence ability to drive and use machinery - Cardiovascular effects, such as cardiac arrhythmias (e.g. atrial fibrillation and tachycardia), may be seen after the administration of muscarinic receptor antagonists - Moderate to severe renal impairment - Inhalation-induced bronchospasm - Pregnant and nursing women For more information: Please consult the product monograph at www.boehringer-ingelheim.ca/content/dam/ internet/opu/ca_EN/documents/humanhealth/product_monograph/SpirivaRespimatPMEN.pdf for important information relating to adverse reactions, interactions, and dosing information not discussed in this piece. The product monograph is also available by calling us at 1 (800) 263-5103 Ext. 84633.

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* See Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease (2008) for complete recommendations. Spiriva® and Respimat® are registered trademarks used under license by Boehringer Ingelheim (Canada) Ltd.