November 2014 by Doctor's Review

1O depression

MEDICINE ON THE MOVE

points on P. 34

Photo contest

winners How the west got fit

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

NOVEMBER 2014

P. 44

WINTER REVERIES Ski to Canadian Paradise Holiday gift guide Festive food

Toast to Moravia Hand-carved temple in Thailand

A MATCH MADE FOR OA VIMOVO unites powerful OA efďŹ cacy with the reduction of NSAID-associated gastric ulcer risk VIMOVO (naproxen/esomeprazole) is indicated for the treatment of the signs and symptoms of osteoarthritis (OA), rheumatoid arthritis (RA) and BOLZMPTJOH TQPOEZMJUJT "4 BOE UP EFDSFBTF UIF SJTL PG EFWFMPQJOH HBTUSJD VMDFST JO QBUJFOUT BU SJTL GPS EFWFMPQJOH /4"*% BTTPDJBUFE HBTUSJD VMDFST

Clinical use: VIMOVO is not recommended for initial treatment of acute pain because the absorption of naproxen is delayed (as with other modiďŹ ed release formulations of naproxen). VIMOVO, as an NSAID, does NOT treat clinical disease or prevent its progression. VIMOVO, as an NSAID, only relieves symptoms and decreases inďŹ&#x201A;ammation for as long as the patient continues to take it. Evidence from naproxen clinical studies and postmarket experience suggest that use in the geriatric population is associated with differences in safety. For patients with an increased risk of developing cardiovascular (CV) and/or gastrointestinal (GI) adverse events, other management strategies that do NOT include the use of NSAIDs should be considered ďŹ rst. Use of VIMOVO should be limited to the lowest effective dose for the shortest possible duration of treatment in order to minimize the potential risk for cardiovascular or gastrointestinal adverse events. Contraindications: t 5IF QFSJ PQFSBUJWF TFUUJOH PG DPSPOBSZ BSUFSZ bypass graft surgery (CABG)

VIM252E

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VIMOVOÂŽ and the AstraZeneca logo are registered trademarks of the AstraZeneca group of companies. ÂŠ AstraZeneca 2014

t 8PNFO JO UIF UIJSE USJNFTUFS PG QSFHOBODZ PS who are breastfeeding t 1BUJFOUT XJUI TFWFSF VODPOUSPMMFE IFBSU GBJMVSF t 1BUJFOUT XJUI LOPXO IZQFSTFOTJUJWJUZ UP substituted benzimidazoles t 1BUJFOUT XJUI IJTUPSZ PG BTUINB VSUJDBSJB PS BMMFSHJD UZQF SFBDUJPOT BGUFS UBLJOH "4" PS other NSAIDs t 1BUJFOUT XJUI BDUJWF HBTUSJD EVPEFOBM QFQUJD ulcer or active gastrointestinal bleeding t 1BUJFOUT XJUI DFSFCSPWBTDVMBS CMFFEJOH PS other bleeding disorders t 1BUJFOUT XJUI JOnBNNBUPSZ CPXFM EJTFBTF t 1BUJFOUT XJUI TFWFSF MJWFS JNQBJSNFOU PS BDUJWF liver disease t 1BUJFOUT XJUI TFWFSF SFOBM JNQBJSNFOU PS deteriorating renal disease t 1BUJFOUT XJUI LOPXO IZQFSLBMFNJB t $IJMESFO BOE BEPMFTDFOUT MFTT UIBO 18 years of age Most serious warnings and precautions: Risk of cardiovascular (CV) adverse events: Naproxen, which is a component of VIMOVO, JT B OPO TUFSPJEBM BOUJ JOnBNNBUPSZ ESVH (NSAID). Use of some NSAIDs is associated

with an increased incidence of CV adverse events (such as myocardial infarction, stroke or thrombotic events), which can be fatal. This risk may increase with duration of use. 1BUJFOUT XJUI $7 EJTFBTF PS SJTL GBDUPST GPS $7 disease may be at greater risk. Caution should be exercised in prescribing NSAIDs such as naproxen to any patient with ischemic heart disease, cerebrovascular disease, congestive IFBSU GBJMVSF /:)" ** *7 BOE PS SFOBM EJTFBTF Use of NSAIDs such as naproxen can result in increased blood pressure and/or exacerbation of congestive heart failure. Randomized clinical trials with VIMOVO have not been designed to detect differences in CV events in a chronic setting. Therefore, caution should be exercised when prescribing VIMOVO. Risk of gastrointestinal (GI) adverse events: Use of NSAIDs such as naproxen is associated with an increased incidence of GI adverse events (such as ulceration, bleeding, perforation and obstruction of the upper and lower gastrointestinal tract). Special Populations: Caution should be exercised in prescribing VIMOVO during the ďŹ rst and second trimesters of pregnancy.

Other relevant warnings and precautions: t 1BUJFOUT XJUI IBFNPQIJMJB QMBUFMFU EJTPSEFST "4" JOUPMFSBODF PS XIP BSF GSBJM or debilitated t 8PNFO BUUFNQUJOH UP DPODFJWF t $PODPNJUBOU VTF XJUI PUIFS OPO "4" NSAIDs; NSAIDs containing naproxen; clopidogrel; anticoagulants; methotrexate; atazanavir; nelďŹ navir t )ZQPNBHOFTBFNJB IZQPLBMFNJB hypocalcemia, blood dyscrasias and antiplatelet effects t )FQBUJD SFOBM BOE HFOJUPVSJOBSZ JNQBJSNFOU t /FVSPMPHJD BEWFSTF FWFOUT JODMVEJOH CMVSSFE or diminished vision, decreased alertness or depression t *OGFDUJPO SJTL PG NBTLJOH TJHOT BOE symptoms of infection and skin reactions For more information: $POTVMU UIF 1SPEVDU .POPHSBQI BU XXX B[JOGP DB vimovo/pm846 for important information relating to adverse reactions, drug interactions BOE EPTJOH JOGPSNBUJPO 5IF 1SPEVDU .POPHSBQI is also available by calling AstraZeneca Canada *OD BU

Two cheers for the holidays

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I enjoy holidays when the family gets together and eats too much and also indulges in the kind of togetherness you can only get from spending time with your near and dear. No one has captured that homey holiday atmosphere better than poet Dylan Thomas in his 1952 remembering of A Child’s Christmas in Wales. “For dinner we had turkey and blazing pudding, after dinner the Uncles sat in front of the fire, loosened all buttons, put their large moist hands over their watch chains, groaned a little and slept. Mothers, aunts and sisters scuttled to and fro, bearing tureens. Auntie Bessie, who had already been frightened, twice, by a clock-work mouse, whimpered at the sideboard and had some elderberry wine. The dog was sick. Auntie Dosie had to have three aspirins, but Auntie Hannah, who liked port, stood in the middle of the snowbound back yard, singing like a big-bosomed thrush.” You can find the whole delightful piece at poemhunter. com/poem/a-child-s-christmas-in-wales. These family gatherings are not always the joyous occasions we hope they’ll be. Being with your relatives can also bring up past hurts and transgressions and these can engender considerable stress. Indeed, such feelings are sufficiently common that a small industry has grown up to offer advice on how to calm one’s nerves during this time of year. Research-supported antidotes include: don’t over schedule your time; get out of the house and exercise; go tech free; make time to do things you enjoy; stay away from cake and cookies and instead eat mangos, honey and spicy foods, each proven to reduce stress; or you could take heed of the advice of Cathy Frank, medical director of the Henry Ford Behavioural Health Services Outpatient Center, and abandon old customs entirely and start new ones! This issue offers other alternatives: cook up some festive food, peruse the gift guide and fantasize about life in the backcountry. Happy holidays,

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David Elkins, Publisher delkins@parkpub.com

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history of medicin e by

Tilke Elkins

Planet of the blues?

It seems to be human is to suffer from depression — and women suffer more

The Depression Series in Doctor’s Review  AUGUST: Depression demographics

“The fog is like a cage without a key.” — Elizabeth Wurtzel

epression in humans probably began shortly after Adam and Eve were cast out of the Garden of Eden

— reason enough to be depressed. By the time the Greeks showed up, withdrawal from social interaction, excessive sleeping, inadequate eating, suicidal thoughts and relentless despair were common. The condition was ascribed to an imbalance of the four humours — phlegm (water), blood (air), yellow bile (fire) and black bile (earth). An excess of black bile or malina chole — was blamed for a litany of woes, including anxiety and listless behaviour. Hippocrates, took it further by suggesting that in addition to black bile melancholia was a condition of the brain. Always early off the mark, he was also noted postpartum depression and speculated that lochial discharge — the fluid that comes from the uterus after a birth — if suppressed, could flow into the head and result in agitation.

SEPTEMBER: The history of depression  Virginia Woolf, now recognized as one of the greatest English writers of the 20th century, was overwhelmed by depression at age 59 and drowned herself in 1941.

 OCTOBER: Talking to patients about depression

THIS ISSUE: 10 things to know about depression P. 34

Some men were depressed because they claimed their penises had been stolen by witches

BOdY OR SOUL?

Whether to treat the body or the soul has been a central dilemma from the beginning. Current thinking has it that both can be significant. Hippocrates would have agreed. He recommended a diet of mandrake and hellebores to eliminate an excess of yellow and black bile, but also relied on the curative properties of advice and action — and put them into practice. He cured melancholic King Perdiccas II by advising him to marry the woman he loved which he did and, we’re told, his depression disappeared. Practitioners following in his footsteps were so astute. The post-Hippocratic Philotimus, observing that his depressive patients complained of “a light head, arid, as though nothing existed,” fitted them with heavy lead helmets. Chrysippus of Cnidus promoted cauliflower as a panacea for the blues. september 2014 • D

octor’s

review

FIND THEM ONLINE AT DOCTORSREVIEW.COM NOVEMBER 2014 • Doctor’s

Review

GLYCEMIC CONTROL WITH CONFIDENCE

GLYCEMIC CONTROL WITH

ONGLYZA

KOMBOGLYZE®

Demonstrated long-term HbA1c reduction vs placebo, both in combination with metformin over 102 weeks HbA1c mean change from baseline:1*



At week 24: -0.7% for ONGLYZA + metformin (n=186) vs 0.1% for placebo + metformin (n=175, 95% CI -1.0, -0.6, p≤0.0001)



At week 102: -0.7% for ONGLYZA + metformin (n=31 observed, n=184 LOCF) compared to placebo + metformin (n=15 observed, n=172 LOCF)

The convenience of a ﬁxed dose combination of saxagliptin with metformin2

KOMBOGLYZE is indicated for use: as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus who are already treated with saxagliptin and metformin or who are inadequately controlled on metformin alone. Consult the product monograph at www.azinfo.ca/ komboglyze/pm566 for important information about:  Contraindications in type 1 diabetes mellitus, metabolic acidosis including diabetic ketoacidosis, history of lactic acidosis, renal disease or impairment, excessive alcohol intake, moderate and severe hepatic impairment, hypoxic states, stress conditions, severe dehydration, pregnancy, breastfeeding and radiologic studies involving iodinated contrast materials  The most serious warnings and precautions regarding lactic acidosis  Other relevant warnings and precautions regarding pancreatitis, risk of hypersensitivity, patients with congestive heart failure, reduced vitamin B12, use during surgical procedures, CYP 3A4 inducers, immunocompromised patients, rash and renal function  Conditions of clinical use, adverse reactions, drug interactions and dosing instructions The product monograph is also available by calling us at 1-800-668-6000.

AstraZeneca Canada Inc. Mississauga, Ontario L4Y 1M4

There have been no clinical efﬁcacy studies conducted with KOMBOGLYZE tablets; however, bioequivalence of KOMBOGLYZE with coadministered saxagliptin and metformin hydrochloride immediate release tablets was demonstrated.

09/15

ONGLYZA is indicated in patients with type 2 diabetes mellitus to improve glycemic control in combination with: metformin when metformin used alone, with diet and exercise, does not provide adequate glycemic control. Refer to the page in the bottom right icon for additional safety information and a web link to the product monograph discussing:  Contraindications in diabetic ketoacidosis, diabetic coma/ precoma and type 1 diabetes mellitus  Relevant warnings and precautions regarding patients with congestive heart failure, exposure to stress, CYP 3A4 inducers, lactose, risk of hypersensitivity, pancreatitis, immunocompromised patients, rash, pregnant or nursing women, moderate to severe renal impairment and ESRD  Conditions of clinical use, adverse reactions, drug interactions and dosing instructions In addition, the page contains the reference list relating to this advertisement.

Seepage additional information on page XX See XX additional safety information 55 forsafety

contents

CANDYBOX IMAGES / SHUTTERSTOCK.COM

NOVEMBER 2014

features 26

Eat, drink and be in Moravia Four wineries, two wheels and none of the Czech Republic’s crowds by Gary Crallé

Party perfect Appetizers from the chefs of Neiman Marcus that are simple and sophisticated by Kevin Garvin

Made in Thailand

The massive Pattaya temple that’s being carved by hand by Will Aitken

Photo contest winners! The top picture plus the runners-up of the great Canadian cell phone photo contest

Backcountry paradise Far-flung lodges in the heart of the Canadian Rockies by David Elkins

December • We humans have had millennia to explore our sexuality and we’ve put the time to good use • A crash course in combining spices to develop tasty new flavours • Writer Jeremy Ferguson takes his camera and his appetite to Asian restaurants in Victoria, BC • A Moroccan adventure with one woman, a couple of German guys and two Mercedes • To this Mom, Disney meant the commercialization of childhood but her boys had a different idea

NOVEMBER 2014 • Doctor’s

Review

When managing pain and inflammation

SELECT CELEBREX be celective CELEBREX demonstrated: • Superior pain relief in OA vs. naproxen

The #1 dispensed NSAID in Canada1

Reduction in pain from baseline of -29.5% with CELEBREX 200 mg/day vs. -21.8% with naproxen 1000 mg/day on WOMAC* pain subscale at week 12 (p<0.001)

• Lower GI ulceration rate vs. naproxen

7.5% for CELEBREX 200 mg BID vs. 34.6% for naproxen 500 mg BID during 12 weeks of treatment (p<0.05)

• No significant difference in CV risk (up to 1 year) compared to naproxen, diclofenac and ibuprofen in a meta-analysis 3,4

The incidence of the composite endpoint of CV death, non-fatal myocardial infarction and non-fatal stroke was similar between CELEBREX (n=19,773) and non-selective NSAID (n=13,990) treatment (RR=0.86, 95% CI 0.59-1.26) Caution should be exercised in prescribing CELEBREX to any patient with ischemic heart disease, cerebrovascular disease and/or congestive heart failure (NYHA II-IV).

Indications and Clinical use: • For relief of symptoms associated with: o Osteoarthritis o Adult Rheumatoid Arthritis o Ankylosing Spondylitis • For the short-term (≤7 days) management of moderate to severe acute pain in adults in conditions such as: musculoskeletal and/ or soft tissue trauma including sprains; postoperative orthopaedic pain; pain following dental extraction In those with increased risk of cardiovascular (CV) or gastrointestinal (GI ) adverse events, consider ﬁrst other management strategies that do NOT include use of NSAIDs. Limit use to the lowest effective dose and the shortest possible duration to minimize potential risk for CV or GI adverse events. CELEBREX does NOT treat clinical disease or prevent its progression. Contraindications: • peri-operative setting of coronary artery bypass graft surgery • 3rd trimester of pregnancy • breastfeeding • severe uncontrolled heart failure • demonstrated allergic-type reactions to sulfonamides • history of asthma, urticaria, or allergic-type reactions after taking ASA or other NSAIDs • active gastric/duodenal/peptic ulcer, active GI bleeding • cerebrovascular bleedings • inﬂammatory bowel disease • severe liver impairment or active liver disease • severe renal impairment or deteriorating renal disease • known hyperkalemia • patients <18 years of age

Serious warnings and precautions: • Risk of CV adverse events: ischemic heart disease, cerebrovascular disease, congestive heart failure (NYHA II-IV) o Some NSAIDs are associated with increased incidence of CV adverse events which can be fatal o NSAIDs can promote sodium retention which can increase blood pressure and/or exacerbate congestive heart failure • Risk of GI adverse events: NSAIDs are associated with an increased incidence such as ulcers, perforation, obstruction and bleeding • Risk in pregnancy: caution in 1st and 2nd trimesters Other relevant warnings and precautions: • Not recommended for use with other NSAI Ds (except low-dose ASA) • Risk in patients who are renally compromised • Blood pressure, renal and ophthalmologic monitoring • Concomitant warfarin use • Blood dyscrasias • Abnormal liver tests • Increased risk of hyperkalemia • Hypersentivity reactions: anaphylactoid, ASA-intolerance, NSAID cross-sensitivity, serious skin reactions • Neurologic adverse reactions • Blurred and/or diminished vision • May impair fertility • CYP2C9 poor metabolizers • Some NSAIDs associated with persistent urinary symptoms, hematuria or cystitis • Rarely, with some NSAIDs, aseptic meningitis

For more information: Please consult the product monograph at http://www.pfizer.ca/en/ our_products/products/monograph/125 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. References: 1. IMS data, September 2012-December 2013. NSAID Market, monthly data, prescriptions. 2. Zhao SZ et al. Evaluation of the functional status aspects of health-related quality of life of patients with osteoarthritis treated with celecoxib. Pharmacother 1999;19:1269-78. Prospective, multicentre, randomized, double-blind, parallel-group, 12-week trial. Baseline measurements for CELEBREX, naproxen and placebo, respectively were: total composite: 50.5, 52.9, 51.6; pain: 10.5, 11.0, 10.8; stiffness: 4.7, 5.0, 4.9; physical function: 35.4, 36.6, 36.0. 3. CELEBREX Product Monograph. Pfizer Canada Inc., May 2013. 12-week, double-blind, parallel-group study in 523 patients with OA or rheumatoid arthritis (RA) in whom baseline endoscopies revealed no ulcers. Patients were randomized to CELEBREX 200 mg BID or naproxen 500 mg BID. No long-term, controlled, clinical study specifically designed to assess the CV safety of chronic CELEBREX dosing of any duration has been conducted. However, a meta-analysis of safety data from 41 completed CELEBREX clinical studies of up to 1 year in duration has been conducted, representing 44,308 patients (24,933 [56.3%] patients exposed to CELEBREX, 13,990 [31.6%] patients exposed to NSAIDs, 4,057 (9.2%) patients exposed to placebo, and 1,328 (3.0%) patients exposed to rofecoxib). The number of events for CELEBREX and NSAIDs was: composite CV endpoint (57 vs. 54), CV death (35 vs. 19), non-fatal MI (35 vs. 19) and non-fatal stroke (7 vs. 16). 4. Data on file. Pfizer Canada Inc.

OA = osteoarthritis * WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), consisting of 3 subscales: pain, stiffness, and physical function.

contents NOVEMBER 2014

regulars 7 LETTERS In your own words

PRACTICAL TRAVELLER An Islamic art museum in Toronto, a 10-day Highlights of Haiti tour, unlimited date changes for skiers and snowboarders via Liftopia and more! by Camille Chin

GADGETS 10 gifts you may want to keep for yourself by Roger White

BEST MD APPS Highly rated Calculate just keeps getting better by Theo Sands

TOP 25 The best medical meetings happening next April

HISTORY OF MEDICINE The evolution of exercise from Sparta to today by Rose Foster

KEY POINTS 10 things you should know about treating depression by Dr Valerie Taylor

PHOTO FINISH A cold sweat by Dr Dennis Lee

For body * and scalp psoriasis Indicated for the topical treatment of: - moderate to severe scalp psoriasis vulgaris in patients 18 years and older for up to 4 weeks - mild to moderate plaque psoriasis vulgaris on the body in patients 18 years and older for up to 8 weeks

warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The product monograph is also available by contacting LEO Pharma Medical Information at 1-800-263-4218. *Should not be used on the face, axillae, flexures, groin, or genitals ® Registered trademark of LEO Pharma A/S used under license and distributed by LEO Pharma Inc., 123 Commerce Valley Dr. E., Suite 400, Thornhill,Ontario L3T 7W8 www. leo-pharma.ca

Please consult the product monograph at www. leo-pharma.ca/dovobetgel_pm for contraindications,

NOVEMBER 2014 • Doctor’s DOV_Gel_DocRev.indd 1

Review

14-08-12 9:33 A

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

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

Pfizer Strive Payment Assistance Card Available in all provinces except Quebec

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

My Pfizer Card Only available in Quebec

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

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

LETTERS

In your own words

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Guests can take fitness classes like yoga and pilates aboard the Holistic Holiday at Sea cruise.

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

Vegans at sea

SENIOR ART DIRECTOR

Pierre Marc Pelletier

all photos courtesy christine homsy unless otherwise noted

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

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David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

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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.

A LIGHT READ? Quote: “I am eating… less meat, fish and dairy and I believe it’s good for me and my family” and “…dairy products and fish could trigger cancer cells” [Vegans at sea, September 2014, page 41]. Please! If I need anecdotal and nonevidence based medical advice like that I will read the latest Cosmo. Doctor’s Review articles should be held to a more rigorous standard.

A doctor and his daughters cruise the Caribbean on the way to healthier living by Christine Homsy

hen my father first proposed that my sister and I join him for a week on a vegan cruise, I’m sure he could feel my eyebrows rise as he clicked “send” on the email. A what? A vegan cruise?!

In 2009 my mother was diagnosed with stage four ovarian cancer. She beat the odds and survived four more years. I credit those years in part to my father. The truth is, they did it together. He’s a pediatric urologist and my mother continued to work part-time as a pediatric ophthalmologist almost until her death. Their ability to listen, see solutions rather than problems and to continually question the status quo, allowed the family — including my sister and I — to find ways to tackle the disease one day at a time. During this demanding period, my dad read a book that changed his perspective on nutrition and disease. The China Study by T. Colin Campbell PhD and Thomas M.

Campbell PhD was published in 2005. It’s loosely based on the China-Cornell-Oxford Project, a 20-year study, and became a new York Times bestseller. The book puts the case that a plant-based diet can reduce the risk of heart disease and various cancers. It speaks in the language of science, one with which my father is most comfortable, and he clearly found it convincing. In 2011, to our great surprise, my father became a vegan. The author (right) The next year, 2012, was a tragwith her sister ic one for our family. It saw the Marianne. death of my uncle, my grandmother and, in the end, my mother. The idea of my sister and I sharing a holiday with my dad, just the three of us, seemed like the breath of fresh air we all needed. september 2014 • Doctor’s

review

you attribute to Israel Spach. However, Dr Jan Bondeson, in his article about the lithopedion of Sens attributes that poem to Jean d’Ailleboust. Here is the link: ncbi.nlm.nih. gov/pmc/articles/PMC1295635/?page=6. The Jean d’Ailleboust citation (1582) predates the Spachs citation. Perhaps Spachs was quoting d’Ailleboust? Lyz Lenz Via email

Dr H. Numair Via email

ART ESPECIALLY FOR MDS The article on Philadelphia didn’t include the Mütter Museum, which I’d love to check out [Creative thinking, October 2014, page 30]. It grew out of Dr Mütter’s own collection and dates from the 1860s. Any physician visiting Philadelphia should go and it would also be of interest to anyone in the sciences. Dr G. Lad Via email

OUT OF LINE I recently read your article titled “Fetal Rock” [History of Medicine, September 2008, page 99 and online at doctorsreview.com] and came across some lines of a poem that

Correction: The Docphin medical data retrieval app does not include UpToDate search features or links to UpToDate as described in July/August’s Best MD Apps on page 25. You can, however, search other clinical guidelines.

Help your patients take control of their psoriasis A new patient support site is here

www.qualitycarebyleo.ca Your patients can join now! It’s free Registered trademark of LEO Pharma A/S used license and distributed by LEO Pharma Inc., 123 Commerce Valley Dr. E., Suite 400, Thornhill, Ontario L3T 7W8 www.leo-pharma.ca

NOVEMBER 2014 • Doctor’s

Review

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 beneďŹ ts of Telemedicine to your practice.

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

C a mi lle C hi n

GARY OTTE / © THE AGA KHAN MUSEUM

A 15th-century marble and sandstone fountain from Egypt.

TO’s guiding light North America’s first museum for Islamic art just opened in Toronto — the second choice for the Aga Khan Museum’s location after planning permissions quashed ideas to build it across from London’s Palace of Westminster. Of course, a museum dedicated to Muslim civilizations with no single, simple experience now seems right at home in a city — and country — that embraces diversity. Designed by Pritzker prize-winning architect Fumihiko Maki, the museum, north of Eglinton off Don Mills Road, was founded by its namesake, the Imam of the Shia Ismaili Muslims. The Aga Khan wanted the museum to be designed around the concept of light so Maki’s building is positioned 45 degrees to solar north to ensure that all exterior surfaces receive natural light throughout the day. Its angular walls of white Brazilian granite were chosen for its resilience and luminosity. The museum’s permanent collection includes 1000 objects — portraits, textiles, ceramics, tiles, musical instruments and manuscripts — from the 8th to 19th centuries stretching from the Iberian Peninsula to China. Adults $20; students and kids 3 to 14 $15. Closed Mondays. tel: (416) 646-4677; agakhanmuseum.org.

NOVEMBER 2014 • Doctor’s

A 14th-century bronze planispheric astrolabe from Spain.

Review

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

Local artist Oana Dragan from Croix Des Bouquets.

A power trip

Doctor’s Review • NOVEMBER 2014

Flex appeal

IM_PHOTO / SHUTTERSTOCK.COM

Liftopia just introduced a tiered pricing system that’ll give skiers and snowboarders more flexibility beginning this winter. The online lift-ticket-sales aggregator now lets customers choose Value, Value Plus and Flexible options. Value lift tickets are date-specific, non-changeable and non-refundable, but they offer the biggest discounts off window rates (up to 80 percent) when purchased in advance. Value Plus tickets allow customers a one-time date change during the season; Flexible tickets allow unlimited date changes during the season. If Value Plus and Flexible tickets are changed to dates that are more expensive, customers will have to pay the difference, but they won’t be charged separate change fees. There are over 130 Canadian resorts on Liftopia’s website. Liftopia’s tiered pricing system is also being introduced on some park websites using their cloud-based platform. tel: (800) 349-0870; liftopia.com.

Toronto-based G Adventures is launching a Highlights of Haiti tour beginning in February 2015, five years after a 7.0-magnitude earthquake struck the Creole island. The 10-day tour will start and end in Port-au-Prince, and will include stops at artists’ studios in the capital, Cap-Haïtien and the UNESCO-designated Citadelle Laferrière, and the cobalt-blue Bassins Bleu pools and waterfalls. Each group of no more than 16 travellers will also visit the Art Creation Foundation for Children, which provides food and teaches at-risk kids traditional art. They’ll also learn to make flat bread called kasav and meet a voodoo priest. G Adventures and its non-profit Planeterra work with the Inter-American Development Bank on community-based projects that will support local economies in Central and South America. G Adventures uses local suppliers so money spent in Haiti will stay in the country. $2499 per person for accommodations, nine breakfasts, eight lunches and five dinners. tel: (888) 800-4100; gadventures.com.

A cut above the rest Henri Matisse: The Cut-Outs was the most popular exhibit in the Tate Modern’s history — the London show received 562,622 visitors — and it’s now at NYC’s MoMA until February 8, 2015. The deceptively simple, coloured-paper cut-outs were made between 1937 and 1954 when the French artist turned almost exclusively to painted sheets and a big pair of scissors as his primary medium. Matisse would cut the paper into different shapes and sizes — from the vegetal to the abstract — and then arrange them into fun compositions. Eventually they evolved into mural and room-sized works. The centerpiece of the MoMA show is The Swimming Pool, the only cut-out ever created for a specific room: Matisse’s dining room in his apartment in Nice, France. The MoMA acquired the piece in 1975; it’ll be joined Masciotra by 100 other cut-outs making this exhibit the most extensive such show of its kind. Timed tickets: adults US$25, students US$14, kids under 16 free. tel: (212) 708-9400; moma.org.

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Review

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

MARC BERTRAND / © PARIS TOURIST OFFICE

Clear the floor The first floor of the Eiffel Tower is the least visited, but the city of Paris has spent more than $40 million in the last two years to try to change that. Architects Moatti-Rivière have replaced part of its opaque floor with glass, transforming it into a viewing platform that’s 57 metres above the ground. The surrounding balustrade is also glass so it doesn’t obstruct the views of the tower’s ironwork or city beyond. Gustave Eiffel’s 125-year-old tower also has new restaurants and shops, a museum and seven screens that chart its history. Solar panels and wind turbines have been installed to help with its energy requirements and some toilets use rain water. Adults from €5, ages 12 to 24 from €4, kids and disabled people from €3. toureiffel.paris.

Four of the spaces at the Alcatraz island penitentiary that are usually off limits to visitors will be open to the public through April 26, 2015 for @Large: Ai Weiwei on Alcatraz. The exhibit features large-scale sculpture, sound and mixed-media works that explore human rights. The pieces have been installed in the New Industries Building where privileged inmates were allowed to work; the main and psychiatric wards of the hospital; the A-block cells, the only remaining section of the early 20th-century prison that was never remodelled; and the dining hall. The penitentiary, just offshore from San Francisco, has never hosted anything of the sort and because Weiwei isn’t allowed to leave Beijing, the contemporary artist and activist had to entrust the exhibit’s installation to collaborators. Tickets include the general Alcatraz audio tour. Ages 12 and up US$30; kids 5 to 11 US$18.25. Tickets to Alcatraz usually sell out weeks in advance; early-bird packages are available. nps.gov/goga/planyourvisit/aiweiwei.htm.

Doctor’s Review • NOVEMBER 2014

PHOTO BY RYAN CURRAN WHITE, PARKS CONSERVANCY

Ai Weiwei in Alcatraz

With Wind (2014) in the New Industries Building.

ethinyl estradiol 10 mcg/ norethindrone acetate 1 mg and ethinyl estradiol 10 mcg

Introducing Lolo ™

A new low-dose combined oral contraceptive with 10 mcg of ethinyl estradiol * 1

*Any benefits from the lower estrogen exposure provided by Lolo have not been evaluated. 1

Lolo offers the lowest ethinyl estradiol dose of any combined oral contraceptive in Canada * 2

Indication and clinical use: Lolo is indicated for the prevention of pregnancy. The safety and efficacy of Lolo have not been evaluated in women with a body mass index >35 kg/m2 or in women <18 years of age. Lolo is not indicated for use before menarche or postmenopause. Any benefits from the lower estrogen exposure provided by Lolo have not been evaluated. Contraindications: Women with: • History of (or actual) thrombophlebitis or thromboembolic disorders • History of (or actual) cerebrovascular disorders • History of (or actual) myocardial infarction or coronary artery disease • Valvular heart disease with complications • History of (or actual) prodromi of a thrombosis • Active liver disease, or history of (or actual) benign or malignant liver tumours • Known or suspected carcinoma of the breast • Carcinoma of the endometrium or other known or suspected estrogen-dependent neoplasia • Undiagnosed abnormal vaginal bleeding • Steroid-dependent jaundice, cholestatic jaundice, history of jaundice of pregnancy • Any ocular lesion arising from ophthalmic vascular disease • Known or suspected pregnancy • Current (or history of) migraine with focal aura • History of (or actual) pancreatitis if associated with severe hypertriglyceridaemia • Presence of severe/multiple risk factor(s) for arterial or venous thrombosis

™

08/15

Most serious warnings and precautions: Smoking: Cigarette smoking increases the risk of serious cardiovascular events associated with the use of hormonal contraceptives. This risk increases with age, particularly in women over 35 years of age, and with the number of cigarettes smoked. For this reason, Lolo should not be used by women over the age of 35 who smoke. Sexually Transmitted Infections (STIs): Patients should be counselled that birth control pills DO NOT PROTECT against sexually transmitted infections (STIs) including HIV/AIDS. For protection against STIs, it is advisable to use latex or polyurethane condoms IN COMBINATION WITH birth control pills. General: Patients should discontinue medication at the earliest manifestation of thromboembolic and cardiovascular disorders, conditions which predispose to venous stasis and vascular thrombosis, visual defects (partial or complete), papilledema or ophthalmic vascular lesions, severe headache of unknown etiology or worsening of pre-existing migraine headache, or increase in epileptic seizures. Other relevant warnings and precautions: • Potential increased risk of breast cancer, cervical cancer, hepatocellular carcinoma • Predisposing factors for coronary artery disease • Hypertension • Diabetes • Adverse lipid changes • Crohn’s disease, ulcerative colitis • Vaginal bleeding • Fibroids • Jaundice, gallbladder disease, hepatic nodules • Angioedema, ﬂuid retention • Risk of thromboembolic complications after major surgery

• History of emotional disturbances • Amenorrhea • Reduced efﬁcacy (due to missed dose, gastrointestinal disturbances or concomitant medication) • Chloasma • Pregnant women • Physical examination and follow-up For more information: Consult the Product Monograph at www.lolocanada.ca/ lolo/pm for important information regarding adverse reactions, drug interactions and dosing information (particularly in regards to dose intervals not exceeding 24 hours) not discussed in this piece. The Product Monograph is also available by calling Actavis Specialty Pharmaceuticals Co. at 1-855-892-8766. References: 1. Lolo™ Product Monograph. Warner Chilcott Canada Co. December 10, 2013. 2. 2012 Hormonal Contraception Available in Canada. The Society of Obstetricians and Gynaecologists of Canada. Available from: http://sogc.org/news_items/hormonal-contraceptioncomparative-chart-now-available-2/. Accessed May 13, 2014.

ethinyl estradiol 10 mcg/ norethindrone acetate 1 mg and ethinyl estradiol 10 mcg

GA D GE T S by

R og e r W hi t e

’Tis the season of giving One cool warm shirt Duckworth Maverick Crew: One of the best wool shirts out there. Extremely thin yet remarkably warm, it’s fashioned from the wool of cold-weather merino sheep raised in Montana. Perfect for layering in winter and yet the unique weave keeps the wearer cool in summer. $80 (all prices in US dollars) for men and women; duckworthco.com.

A hot snowshoe

A better ride Priority Bike: This may just be one of niftiest bikes you’ve seen at any price. The aluminum frame is decked out with three gears and a rubber and glass fibre belt drive that never needs grease. The knobby tires mean you can run it on muddy mountain trails in summer and on slushy winter streets. $399; prioritybicycles.com.

Louis Garneau Black Everest: Snowshoeing is a hot new way to get around when it’s cold thanks to the new breed of lightweight shoes. The molded polymer deck keeps you on top of the snow even when carrying a heavy pack. Crampons in the centre aid backcountry climbs. $185; louisgarneau.com.

Wrap it up Miggo Strap & Wrap: Go light. The Miggo starts as a cushioned camera strap that morphs into a protective case. This model works only with mirrorless and small DSLRs, but there’s a bigger one coming. $50; mymiggo.com.

Heads up K2 Route: Weighs less than 340 grams (12 oz.), so light you may forget you’re wearing it even as it protects your noggin. The fashionable look and multi-vents make it ideal for the alpine skier on your list. $150 for men; K2skis.com.

Doctor’s Review • NOVEMBER 2014

Long, long lived light Nanoleaf One: Pricey perhaps but you get something remarkable for your money. Patented circuitry and carefully positioned diodes help avoid heat sinks and make this the most efficient 100-watt-equivalent bulb ever: lights up for over 25 years. $50; nanoleaf.me.

A drone for your home A watch that watches you

Swann QuadForce Video Drone: Take aerial shots of your property or whatever else you fancy. The Swann’s controls fly the bird up to 100 metres away. Comes with a 2GB microSD camera that shoots 720p HD videos or still shots. Works well indoors where the replacement blades may come in handy. Flight time: 8 minutes. $90; swann.com

Soleus GO!: Connects to a smartphone by Bluetooth 4.0 and displays everything from fitness stats to the weather, phone call alerts and incoming text messages. $129; soleusrunning.com.

Cheap streamer Chromecast: Stream any video from your Android mobile device to your TV. Works with Netflix and Google Play apps. Streams smoothly. At the price it has to be one of the best electronic deals out there. $39; google.com/chromecast.

Bedbugs be gone ThermalStrike Heated Luggage: Bedbugs are something to avoid at all costs on your travels — and you certainly don’t want to bring them home with you. This rollercase heats up just enough to kill the insects. Caution: don’t keep chocolate in it. $199 for a 20-inch carry-on; thermalstrike.com.

Please consult the product monograph at www. leo-pharma.ca/dovobetgel_pm for contraindications,

NOVEMBER 2014 • Doctor’s DOV_Gel_DocRev.indd 1

Review

14-08-12 9:33 A

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. Marketed with sanofi-aventis Canada Inc. Copyright © 2014 Actavis Specialty Pharmaceuticals Co., Mississauga, ON. All rights reserved.

TAKE WITH BREAKFAST *

BEST MD APPS by

T he o S a n d s

The latest update of a highly useful app Calculate by QxMD is not the newest app in the medical arsenal, but it is one of the most popular. It consistently ranks in the top five. The latest upgrade on October 3, 2014 was intended to fix bugs and enhance performance. It did not include changes to take advantage of the iPhone 6 and 6 plus or the new iOS8 operating system. That’s to come later this year. Fair warning: some users report frequent crashes when they try to run it on the newest Apple iPhones. That said, iMedicalApps, the popular review site, has called it “the best free medical calculator app…” pure and simple. The elegant design and intuitive interface makes it easy to use the more than 150 calculators. The emphasis is on diagnosis, treatment and prognosis using point-of-care tools in cardiology, internal medicine, nephrology, general practice, hematology, gastroenterology, emergency medicine, oncology, orthopedics, respirology, neurology, neurosurgery, general surgery and obstetrics. Calculate also provides automatic updates based on answers to questions you’ve provided about your clinical practice, while unique “question flow technology”

quickly finds the info you need. One comment from a user: “I use it multiple times every workday. It is my most used app by far!” Calculate (Medical Calculator) by QxMD  Devices: iOS, Android Cost: free

history of medicin e by

Tilke Elkins

Planet of the blues?

It seems to be human is to suffer from depression — and women suffer more

The Depression Series in Doctor’s Review  AUGUST: Depression demographics

“The fog is like a cage without a key.” — Elizabeth Wurtzel

epression in humans probably began shortly after Adam and Eve were cast out of the Garden of Eden

 OCTOBER: Talking to patients about depression

THIS ISSUE: 10 things to know about depression P. 34

Some men were depressed because they claimed their penises had been stolen by witches

BOdY OR SOUL?

octor’s

review

FIND THEM ONLINE AT DOCTORSREVIEW.COM NOVEMBER 2014 • Doctor’s

Review

Merck Respiratory A PATIENT-BY-PATIENT APPROACH TO RESPIRATORY CARE

ZENHALE® and ASMANEX® Twisthaler® are registered trademarks of MSD International Holdings GmbH. Used under license. GRASTEK™ and RAGWITEK™ are trademarks of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. Used under license. NASONEX® is a registered trademark of Schering-Plough Canada Inc. Used under license. SINGULAIR® is a registered trademark of Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc. Used under license. © 2014 Merck Canada Inc., a subsidiary of Merck & Co., Inc. All rights reserved. © 2014 Schering-Plough Canada Inc., a subsidiary of Merck & Co., Inc. All rights reserved.

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings compiled by Camille Chin

Canada Calgary, AB April 10-11 2015 Annual Scientific Meeting and Conference of the Trauma Association of Canada traumacanada.org

Montreal, QC April 16-18 35th Annual General Meeting of the Canadian Geriatric Society canadiangeriatrics.ca

April 22-26 2015 Annual Scientific Meeting of the Canadian Society of Nephrology csnscn.ca

April 23-26

Ottawa’s Canada Aviation and Space Museum.

3rd World Congress on Controversies, Debates and Consensus in Bone, Muscle and Joint Diseases congressmed.com/bmjd

Ottawa, ON April 23-25 2015 Canadian Respiratory Conference lung.ca/crc/home-accueil_e.php

Toronto, ON April 22-25 38th Annual Meeting of the Society of General Internal Medicine sgim.org/meetings/future-meetings

Vancouver, BC April 24-25 A western-wear store in Calgary.

2015 Canadian Conference on Physician Leadership ccpl2015.com

April 25-28 2015 Canadian Conference on Medical Education mededconference.ca/ccme2015/index.php

Around the world Austin, TX April 23-26 46th Annual Conference of the American Society of Addiction Medicine asam.org/education/the-asam-annual-conference

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

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

Go to doctorsreview.com/meetings for conferences in these cities... and many more! NOVEMBER 2014 • Doctor’s

Review

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings Berlin, Germany March 26-29 6th International Conference on Fixed Combination in the Treatment of Hypertension, Dyslipidemia and Diabetes Mellitus 2015.fixedcombination.com

2015 International Conference of Eating Disorders aedweb.org

Cape Town, South Africa March 13-17 2015 World Congress of Nephrology wcn2015.org

April 21-24 19th World Congress on Disaster and Emergency Medicine wcdem2015.org

Chicago, IL April 23-26 100th Annual Meeting of the American Medical Women’s Association amwa-doc.org

MKRBERLIN / SHUTTERSTOCK.COM

Boston, MA April 23-25

Berlin’s Christmas market.

Glasgow, Scotland April 17-19

San Diego, CA April 15-17

2015 Conference of the European Stroke Organisation eso.kenes.com

World Cornea Congress VII corneasociety.org

Marrakesh, Morocco March 19-22

2015 Meeting of the American Society of Pediatric Nephrology and the Pediatric Academic Societies pas-meeting.org

4th Global Congress for Consensus in Pediatrics and Child Health cipediatrics.org

Seoul, South Korea March 21-25

Miami, FL March 5-7 16th World Congress of Pain Clinicians wspc.kenes.com

April 9-12 2015 Anxiety and Depression Conference adaa.org/resources-professionals/anxiety-anddepression-conference-2015

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Salt Lake City, UT April 18-21 40th Annual Conference of the American Society of Andrology andrologysociety.org A red hot poker plant in Cape Town.

Doctor’s Review • NOVEMBER 2014

April 25-28

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

6th World Congress on Sleep Medicine wasmcongress.com

Tokyo, Japan March 22-25 6th World Congress on Women’s Mental Health iawmh.org/congress.html

April 15-18 8th International DIP Symposium on Diabetes, Hypertension, Metabolic Syndrome & Pregnancy comtecmed.com/dip/2015

Vienna, Austria April 22-26 50th International Liver Congress easl.eu/_the-international-liver-congress/ general-information

S E I R E S T R A P E E R H T

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

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

R os e F os t e r

How the west got fit It took almost 6000 years for exercise to become respectable

RIGHT: Muscular male bodies are a common feature on ancient Greek pottery. BELOW: Friedrich Jahn invented most of the equipment still used in gymnastics and encouraged their use in international competition.

efore Agriculture (BA) it never occurred to anyone to think about fitness at all. People were too busy

foraging and hunting and celebrating their success in finding good things to eat by vigorous dances and other physical manifestations of joy. Humanity existed in a state of fitness grace. Agriculture took a lot of work to get going. The endless removal of large stones from places one wished to plant initially kept people fit, but once the crops were in then things could go to pot quickly doing little but waiting for nutritious grasses to grow. Something else was needed to keep the race physically fit and it didn’t take long before someone came up with an idea: war. Once the concept took hold it became clear that the human body was the keenest, most crucial instrument of war we humans had — and it was so close at hand. With a little extra physical training you could trounce your neighbours a few fields over and take whatever you wanted. It was soon apparent to everyone that the path to victory came through exercise. Compulsory physical training to make hard men out of soft boys became the battle cry of every would-be conqueror from around 4000 BCE to the fall of the Roman Empire. Truth be told, long before the Spartans cottoned on to a good thing Assyrians, Babylonians, Egyptians and Persians learned to bulk up before they even picked up a weapon. By the time the Greeks and Romans got into the act, training regimes had become so grueling that actually going to war offered a respite from the rigours of the exercise field.

The flesh that lay under the armour and chain mail was more SPARTAN EXERCISE often fat than muscle

In the West, the citizens of the Greek city-state of Sparta were early adapters. They quickly learned that by getting into shape you could scare your opponents and, if necessary, beat them into submission. A brutal and relentless fitness regime made Spartan soldiers so invincible their army was feared in the Peloponnese and beyond. That Spartan reputation for toughness lingers to this day. Training began when boys were just seven years old. Snatched from their mothers’ arms, they were enrolled in a program of heavy exertion the results of which are familiar to the modern eye, thanks to the remarkably well-built naked male bodies whose splendid muscles grace so much of ancient NOVEMBER 2014 • Doctor’s

Review

Greek pottery and sculpture. Indeed, “gymnastics” comes from the common Greek adjective “gymnos,” meaning naked. Well muscled but scantily clothed, Spartan soldiers-intraining are thought to have been responsible for the tradition of nudity at the Olympic games. Fortunately, working yourself into stupendous condition did have a more positive aspect. The first Olympic games, believed to have taken place in 765 BCE, glorified the body in the name of peace. An Olympic truce was enacted to allow participants to travel to the games in safety, and the games themselves served to reinforce spiritual and religious beliefs and to emphasize the benefits of harmony instead of war. Behind the scenes, the games became a political tool, an opportunity for city-states to glory it over their rivals. Whether in the service of Ares, the god of war, or Irene, the goddess of peace, the Olympic competitions infused the culture with the ideal of a “sound mind in a sound body.” A very good thing.

It didn’t take long before someone came up with an idea of how to keep physically fit: war ROMAN SLOTH Contemporary historians who liken modern decadence and laziness to that of Roman citizens in the last centuries before the fall of the empire may be onto something. Whether the decline and fall of Rome can be attributed to flabby abs or not, it’s safe to say that the Dark Ages that followed them were not a golden period for the human form. Jousting and archery tournaments were an important way to climb the feudal social ladder but body building was not a medieval sport. In England for a period of time both upper and lower class men between the ages of 15 and 60 were required by law to practice archery in readiness for battle. But that didn’t mean they were up to the fight. Only farmers and soldiers, who went to the trouble to work out, were in decent shape. The flesh that lay under the armour and chain mail was more often fat than muscle. Christianity showed a marked distaste for the body and suggested the population ignore it entirely in favour of saving their souls. After a long decline, fitness as an activity for personal gain and health bloomed once more during the Renaissance. In 1553, the Spaniard Cristobal Mendez published The Book of Exercise and Its Benefits to the Body. The work analyzed games and exercises from a medical point of view and suggested specific activities for all citizens, including women, children and the elderly. An Italian physician, Mercurialis, who wrote about the benefits of exercise and outlined physical therapy for the first time, resurrected techniques from Classical times.

Doctor’s Review • NOVEMBER 2014

The coal-spewing factories of the Industrial Revolution mark the real origin of fitness as we know it. It was clear to anyone who cared to look that being slave to a machine for all of your waking hours had a deleterious effect on one’s health. The idea that exercise might be a good thing began to take hold in Europe, albeit slowly. The Philanthropinium, a school based on the ideas of the progressive Frenchman JeanJacques Rousseau, opened in 1774 in Dessau, Germany and emphasized physical exercise and games. Thirty-seven years later, in 1811, Friedrich Jahn, a pioneer of physical education, opened the first open-air gymnasium which he called a “turnplatz.” Jahn also invented most of the equipment still associated with elite gymnastics. Olympic watchers who thrill to the remarkable feats of 14-year-old girls have Jahn to thank for the pommel horse and parallel bars. The first health club or “physical culture centre” was opened in Lille, France in 1885 by Edmond Desbonnet who, by-the-by, is also credited with formulating the first rules for the sport of weight lifting. Another Frenchman, Georges Herbert, strongly disapproved of the physical inactivity imposed on women of the day and wrote that by following his natural method of exercise, females could “develop self-confidence, will-power and athletic ability just as well as their male counterparts.” Herbert also actively promoted “natural” training in “non-designed” environments. His ideas gave rise to woodland rope courses and other obstacle training. Their most recent evolution is parkour, developed in France, primarily by Raymond Belle, David Belle, and Sébastien Foucan during the late 1980s. It consists in getting from point A to point B any way you can including running, climbing, swinging, vaulting, jumping, rolling and crawling on all fours, tasks that work the entire body. Complex indoor courses such as Toronto’s The Monkey Vault Movement Training Centre, a 929-square-metre facility, exist in cities across the country and are especially popular with hip urban youth.

FITTEST COUNTRY? Fitness historians call such developments the latest manifestation of “The Battle of the Systems” which began in Europe in the late 1890s and has led to a proliferation of ideas about exercise. Various national allegiances soon led to disagreements about which was best. German tumbling? Czech plyometrics? Swedish calisthenics? Scottish and Irish hurling? Take your pick. At the time, this was so much Greek to most North Americans, who were, perhaps, “plumb tuckered” from all the physical labour and hardship they’d put into beating back nature on the continent. Many Canadians settled into a nonchalance about their physical capacities. In the US, Thomas Jefferson had insisted, “ Not less than two hours a day should be devoted to exercise, and the weather shall be little regarded. If the body is feeble, the mind will not be strong.” But that was long ago and far away. North America’s first Young Men’s Christian Association, “the Y,” opened in Montreal in 1851. Fifteen years later, the Canadian YMCA Physical Director, James Naismith, sparked a craze that has ignited indoor fitness ever since. He

Canadian John Naismith invented basketball by hanging two peach baskets at either end of a gym invented basketball by hanging two peach baskets from the railing of the gymnasium’s second level while at a training school in Springfield, Massachusetts. Post-World War I, the public caught wind of a shameful secret: one third of the draftees had been unfit for combat. Governments passed legislation requiring the improvement of physical education programs in the schools. But the Great Depression and the Roaring 20s again dropped physical fitness to the bottom of most priority lists, so that by the time World War II rolled around, nearly half of draftees were rejected for service and given office jobs. Children became the centre of attention in the 1950s, when it was discovered they were even more out of shape than their parents. The wee baby boomers were subjected to a variety of tests, measuring muscular strength and core flexibility. They failed miserably about 60 percent of the time compared to a failure rate of only 9 percent for European children. In the 1970s Canada launched ParticipACTION and promoted the program with that now famous commercial that announced the average 60-year-old Swede was in better shape than most 30-year-old Canadians. It was a message many took to heart. Making exercise fast, fun and quantifiable has been the focus of fitness ever since. Cross-cultural fusion workouts like “jazzercise” and others that mix and match jazz dance, resistance training, Pilates, yoga, kickboxing and Latin-style movements set to pop music have proliferated. All this emphasis on the out-of-the ordinary has lead to some bizarre fitness fads, perhaps none odder than backwards running. Proponents claim it’s easier on your knees and uses 25 percent more energy. Not surprisingly given the current national obsession with pets, “doga” classes devoted to getting Fido fit are now offered in most Canadian cities.

The first YMCA in North America opened in Montreal on December 9, 1851.

THE DEBUNKERS Massive quantities of fresh scientific data have also made this the era of debunking. What was good for you yesterday may be something to avoid today. For example, recent research papers have suggested that touching your toes is something you should never do; that belly crunches do not help you lose belly fat; and that sprinting in one minute bursts over ten minutes is more beneficial than jogging for an hour. Even the catch phrase “No Pain, No Gain” has come under negative scrutiny. These days no true fitness buff takes a step without tracking and recording their times, distance and vital functions on a wearable device and smartphone. And the robots are coming. Joggobot is a flying disk that zips ahead of you encouraging you to keep pace. Its Australian makers call it “robotic technology as a social companion.” It’s almost like going for a jog with a friend. Watch for the next techno-exercise revolution: machines that will get you fit without requiring any sweat equity at all. You can be sure someone is already hard at work on it.

ABOVE: John Naismith of Almonte, ON studied in Montreal before moving to Springfield, MA where he invented basketball. LEFT: Joggobot might be your next running companion.

NOVEMBER 2014 • Doctor’s

Review

history of castles and kings has led to wine and wonderful things in Moravia. Here,

history, architecture, gastronomy and fantasy are inextricably entwined. Czech wine glasses would be more than nine-tenths empty if not for this chunk of terrain bordering the southern neighbours of Austria and Slovakia. It’s the oenological epicenter of the Czech Republic. History flows from every glass of Moravian wine and has deep roots stretching from early third-century plantings of the 10th Roman Legion to the Czech National Wine Centre and Salon in Valtice Castle. Cyclists on wine tours now crisscross a region of prehistoric human beginnings dating back some

Eat, drink and 600,000 years. This is the same region in which a 1925 discovery unearthed the oldest ceramic statue ever found: a 25- to 29,000-year-old, small, nude female known as Venus of Dolní Veˇstonice. With beauty and taste in the eye of the beholder, Moravia unabashedly holds appeal for mind, body and spirit. Perhaps best of all, compared to crowded Prague, it’s undiscovered. Few nations can trace a modern wine industry to a magnificent high gothic castle. Founded in 1348, Castle Karlštejn (172 Karlštejn, Karlštejn; hradkarlstejn. cz; guided tours adults $8, kids 6 and up $5) was both residence and storehouse for the royal treasures of King and Holy Roman Emperor Charles IV, often called the father of Czech wine for his early promotion of viticulture. Only 28 kilometres from Prague, the castle lies on the touristic Castle Road stretching 1200 kilometres from the Czech capital to Mannheim, Germany. Karlštejn is actually two villages on both sides of the Berounka River, with the castle looming above the Crop Research Institute (507/73 Drnovská, Prague; www.vurv.cz) on the north side. Both castle and institute

Doctor’s Review • NOVEMBER 2014

Lunch at the Jánˇu˚v Dvu˚r includes dumplings and local cider or wine, and the pension offers farmhouse accommodations.

be in Moravia Bike through the Czech Republic’s wine country and escape the crowds of Prague text and photos by Gary Crallé

There are many 14th-century panel paintings inside the Castle Karlštejn, the residence of King and Roman Emperor Charles IV, the father of Czech wine.

You can rent a bike and pedal the paved paths linking several villages, which are part of the EuroVelo cycle network.

This is the region in which a 1925 discovery unearthed the oldest ceramic statue ever found can be visited, though the institute is basically a research station studying cold-hardy grape varieties. It produces wines bearing the emblem of the castle which is, after all, the major tourist draw. In ruins by the 19th century, the once mighty fortress required extensive renovations to its floors and roof, which, ironically, have excluded it from being listed as a UNESCO site. However, a genuine medieval atmosphere remains, especially on a misty day. Restaurants and gift shops form a gauntlet up the hill to the castle, which receives 300,000 visitors annually, but not so many the rainy day I visited. U Adama Restaurant (61 Karlštejn, Karlštejn; restauraceuadama.cz, website in Czech only) provides fine cuisine at its main street address just a five-minute walk from the castle — unless you stop for photos.

2½-hour drive southward from Prague along highway D1/E50/E65 to Brno, then E451 to Mikulov (mikulov.cz) brings visitors to a part of Moravia very near the Austrian border. Here, fabled King Wenceslas tended his vineyards. The bond between these precious liquids and religion is still nominally strong, with vineyards traditionally anchored by a statue of the Madonna or a saint at the end of a row of grapes.

Doctor’s Review • NOVEMBER 2014

The medieval village of Mikulov is a good place to begin a local tour. Bikes can be rented to traverse the paved paths linking several villages. It’s an easy ride over flat terrain and the path is well signposted as part of the EuroVelo network (eurovelo.org). Within Mikulov, Romanesque and Baroque architecture rubs shoulders with unpretentious dwellings and wine cellars that look like garages open to visitors. In a flourish, the entire region has awakened from boring, communist-era dormancy and is rapidly modernizing. During the grape harvest, partially fermented young wine a mere few days old called burcˇák is offered for sale at farm stalls, including the central square of Mikulov. The sweet-sour, yellow-orange (sometimes pink) beverage has an alcohol content of 5 to 8 percent, so beware: if you treat it lightly, it will return the favour. Historically, the quality of Czech wines was a personal decision made by the winemakers. That’s the way it was and largely remains in South Moravia — and the standard is high. European Union regulations are continuing that guarantee. Three kilometers along the bike trail from Mikulov brings us to the modest, but well-stocked cellar of Kern Winery (546 Sklepní, Brˇe zí; vinarstvikern.cz, website in Czech only; daily tastings, but reservations required on weekends). It’s a family enterprise with David Kern and

The limestone Pálava Hills impart a chalky minerality to the wines, including those produced at the Mikrosvin Winery.

The Crop Research Institute studies cold-hardy grape varieties and produces wine bearing the emblem of the Castle Karlštejn.

his son Peter plus a small staff producing mostly whites with “care and love” on 20 hectares of vineyards. Chardonnay, Müller-Thurgau, Riesling, Sauvignon and Traminer are some of the plantings. David grows several types of grapes due to varying soil conditions

even within the same vineyard. And the locals want variety. Vintners are free to plant whatever they wish, but almost no Czech wine is exported; instead, it’s absorbed, so to speak, by the local markets. Pension Jánˇu˚v Dvu˚r (43 Nový Prˇerov, Brˇezí; januvdvur.cz, website in Czech only) sits conveniently at kilometre seven, where one can enjoy a lunch of dumplings and beer, fresh-pressed cider or local wines in the open courtyard. Horseback-riding tours of the vineyard start at $13 per person (reservations by email required). The pension is a BIOfarm that offers restored and tidy farmhouse accommodations from $27 per person a night. Kovacs Winery (293 Novosedly; vinarstvi-kovacs.cz, website in Czech only; email vinoteka@vinarstvi-kovacs.cz for tastings) is at kilometre 11 in the village of Novosedly. As at Kern, the sheer variety of wines is surprising: 26 whites and 20 reds — more balanced than the national production ratio of 70/30 white to red. Tastings at Kovacs might include Muscat, Grüner Veltliner, Riesling, Zweigeltrebe rosé and Regentské cuvée red. Rieslings are typical of the region, exhibiting flavours of apricot with a slightly salty aftertaste. When asked why Czech wines are so subtle and delicate in contrast to Czech politics, the gentleman serving the wines replied without hesitation: “It’s a good climate for wines, but not politics.” NOVEMBER 2014 • Doctor’s

Review

Mikulovâ&#x20AC;&#x2122;s historic town square was originally built in the 13th century and was reconstructed after a fire in 1584.

Each year, 100 wines are chosen for tastings at the Wine Salon inside the Baroque Château Valtice.

Plan your visit for September or October if you want to attend a grape harvest festival.

Vintners are free to plant whatever they wish, but almost no Czech wine is exported; it’s absorbed, so to speak, by local markets Our final stop that day was at Mikrosvin Winery (29 Nádrazˇ ní, Mikulov; mikrosvin.cz, website in Czech only; email david.chrapek@mikrosvin.cz for tastings) with its grand views of the limestone Pálava Hills, which impart a chalky minerality characteristic to all the wines of this region. Young winemaker Vojteˇch Vít applies modern techniques to a century of family tradition for premium wines. His ambition is to produce the finest wines in the world, concentrating on Italian Riesling as the best fit for local soil and climate. The result is wines with a delicate, distinct and sophisticated structure. As we left the cellars, a full moon rising over vineyards and villages couldn’t have been more perfect to complete this Moravian fairytale scene.

ithout doubt, the Wine Salon of the Czech Republic (1 Zámek; salonvin.cz; closed in February) in Valtice (valtice.eu) is the single best place to sample the nation’s wines. Each year the top 100 selections from Moravia and Bohemia to the north are chosen for display, tasting

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and purchase inside the prestigious Baroque Valtice Château. Its four wings consist of 100 rooms. For less than $30 visitors can taste as many wines as they want within a 90-minute time period, but they must remain standing. Our sommelier guide, a retired policeman, informed us that both driving and cycling while inebriated is illegal. Cyclists are generally not targeted by police, however, unless involved in an accident. A sobering thought. The closest hotel to the salon is literally steps away — at the end of the palace steps, actually. Hotel Salety (239 Zámecká, Valtice; hotelsalety.cz; from $72 a night, double occupancy) is modern, clean and convenient. For those who time their visit with Valtices’ annual wine festival at the end of September, the hotel is a few minutes from the historic labyrinth of Valtické Underground wine cellars. A public walk through the vineyards also takes place at that time of year. Na zdraví! For info on the region, visit the Tourism Authority of South Moravia (ccrjm.cz) or Czech Tourism (czech tourism.com).

Five Canadian wines that will sparkle at your holiday get-togethers. doctorsreview.com/wine/seasons-sippings NOVEMBER 2014 • Doctor’s

Review

“I felt down and

overwhelmed nearly every day.” Nicole*, 37

SNRI = serotonin norepinephrine reuptake inhibitor. * Fictitious case. May not represent all patients. † Results of the ﬁnal on-therapy assessment in the 6-month, double-blind, placebo-controlled phase of a long-term trial in patients who had responded to PRISTIQ during an initial 12-week, open-label phase. ‡ Men only. § Women only.

For patients like Nicole...

Indication and clinical use

Trust PRISTIQ

for powerful

symptom relief

• PRISTIQ is indicated for the symptomatic relief of major depressive disorder • PRISTIQ is not indicated for use in children under the age of 18 • The short-term eﬃcacy of PRISTIQ has been demonstrated in placebo-controlled trials of up to 8 weeks • The eﬃcacy of PRISTIQ in maintaining an antidepressant response for up to 26 weeks, following response during 20 weeks of acute, open-label treatment, was demonstrated in a placebo-controlled trial

Contraindications • Concomitant use with monoamine oxidase inhibitors (MAOIs) or within the preceding 14 days • Hypersensitivity to venlafaxine hydrochloride

Most serious warnings and precautions

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

due to adverse events comparable to placebo

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

• No statistical diﬀerence in mean weight change

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

• Low incidence of sexual function adverse events

demonstrated at 8 weeks

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

• Behavioural and emotional changes, including self-harm: SSRIs and other newer antidepressants may be associated with: - Behavioural and emotional changes including an increased risk of suicidal ideation and behaviour - Severe agitation-type adverse events coupled with self-harm or harm to others - Suicidal ideation and behaviour; rigorous monitoring advised • Discontinuation symptoms: should not be discontinued abruptly. Gradual dose reduction is recommended

Other relevant warnings and precautions • Concomitant use with venlafaxine not recommended • Allergic reactions such as rash, hives or a related allergic phenomenon • Bone fracture risk with SSRI/SNRI • Increases in blood pressure and heart rate (measurement prior to and regularly during treatment) • Increases cholesterol and triglycerides (consider measurement during treatment) • Hyponatremia or Syndrome of Inappropriate Antidiuretic Hormone (SIADH) with SSRI/SNRI • Potential for GI obstruction • Abnormal bleeding with SSRI/SNRI • Interstitial lung disease and eosinophilic pneumonia with venlafaxine • Seizures • Narrow angle glaucoma • Mania/hypomania • Serotonin syndrome or neuroleptic malignant syndrome-like reactions

For more information Please consult the product monograph at http://www.pﬁzer.ca/en/our_products/products/ monograph/226 for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-463-6001.

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

for powerful symptom relief

D EP RE SSIO N K EY PO I NT S b y bValerie Taylor, MD, FRCPC, PhD y Valerie Taylor, MD, FRCPC, PhD

things you should know about treating depression 1. Careful differential diagnosis is crucial Before starting treatment, it is important to distinguish depression from bipolar disorder (which requires very different treatment) and to screen for co-morbid psychiatric conditions, especially anxiety (which may not alter pharmacotherapy but can affect response and need for additional treatments) and attention deficit hyperactivity disorder (which should be treated concurrently).1

2. Treatment takes time to produce maximum effect The time from clinical response to first-line treatment with antidepressants can vary from one to eight weeks. Patients who show some improvement after six weeks should continue on the same treatment for up to another four weeks before considering additional strategies. Dosage can be increased within this time frame.

3. The goal is remission The aim of acute treatment is to eliminate symptoms of depression and restore psychosocial functioning, with depression score in the normal range.

4. Inadequate response requires further action If a patient does not show improvement on antidepressants after 8 to 12 weeks, the first steps should be to re-evaluate the diagnosis, especially to rule out bipolar disorder and substance abuse, and verify adherence. Additional strategies can include adding psychotherapy or another agent, switching to neurostimulation treatment, or switching pharmacologic agents either within or outside the class.

5. Emphasize sleep, exercise and diet It is important to emphasize positive health behaviors as these can be important to maintaining wellness. Sleep hygiene is important to focus on, and may require active planning and goal setting to achieve. Exercise can also be as helpful as medication for mild to moderate depression. It should be discussed in a structured way, however, with a focus on at least three 20-minute blocks of activity per week that increases the heart rate and breathing.2

Valerie Taylor, MD, FRCPC, PhD, is Psychiatrist-in-Chief, Head of Women’s Mental Health and Co-Director of the Equity, Gender and Population Division at Women’s College Hospital. She is an Associate Professor in Psychiatry at the University of Toronto, and holds a part-time appointment as Associate Clinical Professor of Psychiatry at McMaster, where she heads the bariatric surgery psychiatry program.

Doctor’s Review • NOVEMBER 2014

6. Discontinuation rates are high Weight gain is one of the top reasons people stop taking their medications. It is valuable to weigh patients at every visit and treat weight gain seriously as an adverse effect. It may be the perception of weight gain associated with improvement that is an issue for example, and monitoring weight changes over time can help ensure adherence, and prevent the development of weight-related illnesses. Gastrointestinal side effects are common and, in patients who are responding well, efforts should be made to manage these side effects and enable them to continue on treatment.3,4

7. Patients have difficulty accessing psychotherapy Psychotherapy (cognitive behavioural therapy or interpersonal therapy) is recommended for both acute treatment of depression and maintenance treatment. Familiarize yourself with resources available to your patients. Computer-based and telephone-delivered psychotherapy are effective alternatives when in-person therapy is not available.

8. Weigh risks and benefits during pregnancy The risks and benefits of initiating or continuing antidepressant medications during pregnancy and breastfeeding must be carefully weighed. Pregnancy can be a risk factor for depression and screening should be undertaken periodically. Antidepressants do not appear to be major teratogens and are excreted in small quantities in breast milk, though a few studies have found associations with (usually transient) neonatal complications.

9. Use a collaborative approach Medical illness and depression need to be treated with a collaborative comprehensive approach. Co-morbid depression is a risk factor for poor prognosis and outcomes in patients with existing medical illnesses. Treatment of the depression should be accompanied by measures to reduce the medical illness’ contribution to depression. It is important to consistently monitor for drug interactions that may increase side effects or reduce efficacy, especially given that treatment is often long term.

10. Don’t assume that all symptoms your patient reports are due to depression This is especially true if there is a change in presentation. Investigate to ensure a comorbid physical illness is not missed!

References Except where other references are provided, this information is based on: Canadian Network for Mood and Anxiety Treatments (CANMAT) Clinical guidelines for the management of major depressive disorder in adults. Kennedy SH, Lam RW, Parikh SV, Patten SB, Ravindran AV. Journal of Affective Disorders 117 (2009) S1–S2 1. Ramasubbu R, Taylor V, Samaan Z, et al. The Canadian Network for Mood and Anxiety Treatments (CANMAT) task force recommendations for the management of patients with mood disorders and select comorbid medical conditions. Annals of Clinical Psychiatry 2012;24(1): 91-109. 2. Mammen G, Faulkner G. Physical activity and the prevention of depression: a systematic review of prospective studies. Am J Prev Med 2013;45(5):649-57. 3. Lett, TAP, Wallace TJM, Chowdhury NI et al. Pharmacogenetics of antipsychotic-induced weight gain: review and clinical implications. Molecular Psychiatry 2012;17:242-66 4. Blumenthal SR et al. An Electronic Health Records Study of Long-Term Weight Gain Following Antidepressant Use. AMA Psychiatry 2014;71(8): 889-96.

NOVEMBER 2014 • 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.

WILL AITKEN

Made in Construction of the Sanctuary of Truth began in 1981, but it’s still a work in progress that’s expected to be completed in 2015.

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The temple is 20 storeys tall and features the high-gabled roofs that are traditional in Thai architecture.

Thailand A

Discover the 20-storey teak temple that’s being carved by hand by Will Aitken

s any visitor can tell you, Buddhist temples, or wats, as they’re known locally, lie thick on the ground across Thailand. They’ll tuck one in anywhere: behind a supermarket, looming above a

superhighway, half-hidden behind the Happy Shoes Bowling Alley, perched high on a mountaintop. They are beyond lavish — gold leaf run amok, glittering crystals that outshine the sun, azure, pink and chartreuse enameled walls and columns, tiny mirrors flung like confetti over spires, arches and chedis (hemispherical domes, also known as stupa, where sacred relics are stored). Gargantuan carved Buddhas stand, recline or sit in lotus position at the centre of most wats, their finely sculpted hands semaphoring messages of peace and enlightenment. (I once asked a Thai guide why the Buddha we were standing before drooped down to touch the earth and he said it was because “Buddha’s telling the evil spirits to cool it.”) But sometimes, after visiting the White Wat, the Mirror Wat, the Silver Wat and the Red Swing Wat

(seriously), the mind tires of excess as from a surfeit of sequins. All those serenely smug Buddhas with their heavy-duty expectations: Are you sitting right? Are you breathing right? Have you rid yourself of all desire? It was at a moment like this that my Thai friend Ice suggested I visit the Sanctuary of Truth (206/2 Naklua Road; sanctuaryoftruth.com; adults $17, kids $9) located in the seaside city of Pattaya, a 90-minute drive from Bangkok. “It’s all carved out of teak,” Ice said. “Very old school.” Pattaya itself is a 24/7 carnival by way of Hieronymus Bosch, a flamboyant charivari of LGBT revelers, sun-scalded sex tourists, bewildered families who didn’t realize their all-inclusive holidays would include all this, and hard-eyed Russian expats (store signage in Pattaya is trilingual now: Thai, English and Russian). NOVEMBER 2014 • Doctor’s

Review

WILL AITKEN

All of the major and many minor Buddhist and Hindu deities are depicted on the multi-faith temple.

PUWANAI / SHUTTERSTOCK.COM

Pattaya itself is like a 24/7 carnival, but the temple is on an isolated promontory that overlooks the Gulf of Thailand.

But the Sanctuary of Truth is well away from all that, on an isolated promontory overlooking the Gulf of Thailand. Seen from above, where my driver let me off, it was hard to get a sense of the scale of the thing. As Ice promised, it’s gilt-free, an all-teakall-the-time fantasia featuring a multitude of the high-gabled roofs of traditional Thai architecture sprouting in all directions, but they are the least of it. Every possible surface is encrusted with hand-carved teak sculpture. Pantheons of not immediately recognizable gods riot handsomely, huge-tusked elephants with heads as big as houses trumpet from on high. Not a balustrade is left uncurlicued nor a column unembraced by a Brobdingnagian bare-breasted goddess. Snakes swirl, dragons scowl, tigers snarl and strange bird-like creatures, also bare-breasted, spread their wings. Because sun and salt have weathered the exterior teak to shades of silver and grey, there’s an oddly gothic air about the place, as if Tim Burton was in on the original design. It looks like it’s been there forever, but soft-voiced Sanctuary guide Mao, handing me a yellow hardhat at the structure’s rococo-inoverdrive entrance, explained that construction began in 1981 and, as the ladders, scaffolding, clouds of sawdust and workmen tapping with their chisels high up in the eaves attest, it’s still very much a work in progress. “It will be finished in 2015,” she added. “Perhaps.” But dates, statistics, even place names, are relative things for Thais, untrammeled as they are by nagging certainties. The Sanctuary of Truth, aka the

Wooden Temple, aka the Wooden Palace, aka Prasat Satchatham, aka Prasat Sut Ja-Tum, stands, according to Mao, 150 metres tall, although other sources claim, variously, 100 metres and 205 metres, while Lonely Planet neatly sidesteps the issue by saying “20 storeys tall.”

he interior is oddly cave-like with serried ranks of huge carved columns that are evocative of stalagmites, wafting veils of incense, wide-plank flooring that gives as you walk and sudden knockout views of the corrugated sea. As we strolled along, passing saffron-coloured robed Buddhist monks carrying video cameras and a young man from Goa who spontaneously struck a Lord Shiva pose, Mao attempted to explain the dense iconography of the interior carvings. The Sanctuary of Truth is utopian and multi-faith, with all the Asian gods and goddesses multi-tasking up and down the steep walls. It’s a mash-up really of all the major and many of the minor Buddhist and Hindu deities, as well as figures from Thai, Khmer, Indian and Chinese legend. All this is the visionary project of Thai millionaire (some say billionaire) Lek Viriyaphant (1914-2000), who opened the first Mercedes-Benz dealership in Thailand not long after the end of the Second World War. Viriyaphant, who is inevitably described as “eccentric,” was keen to represent the power of Eastern spirituality and philosophy while at the same time preserving Thailand’s culture and history, architecture NOVEMBER 2014 • Doctor’s

Review

The interior is oddly cave-like and the wide-plank flooring gives as you walk.

Indications and clinical use • Cymbalta® (duloxetine hydrochloride) is indicated for: • the symptomatic relief of major depressive disorder (MDD) • the symptomatic relief of anxiety causing clinically significant distress in patients with generalized anxiety disorder (GAD) • The efficacy of Cymbalta® in maintaining anxiolytic response for up to 6 months in patients with GAD was demonstrated in a long-term placebo-controlled trial in patients who had initially responded to Cymbalta® during a 6-month open-label phase. • Cymbalta® is not indicated for use in children under 18 years of age. Contraindications • Patients concomitantly taking any of the following medications: monoamine oxidase inhibitors (MAOI), including linezolid and methylene blue, or within at least 14 days of discontinuing treatment with an MAOI; potent CYP1A2 inhibitors (e.g. fluvoxamine) and some quinolone antibiotics (e.g. ciprofloxacin or enoxacin); and thioridazine • Any liver disease resulting in hepatic impairment • Uncontrolled narrow-angle glaucoma • End-stage renal disease (requiring dialysis) or patients with severe renal impairment (estimated creatinine clearance <30 mL/min)

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Most serious warnings and precautions • Behavioural and emotional changes, including self-harm: SSRIs and other newer antidepressants may be associated with: • Behavioural and emotional changes, including an increased risk of suicidal ideation and behaviour in patients <18 years • Severe agitation-type adverse events coupled with self-harm or harm to others in patients of all ages • Rigorous clinical monitoring for suicidal ideation and behaviour and agitation-type emotional and behavioural changes is advised in patients of all ages • Increased risk of suicidal behaviour in patients ages 18 to 24 years with psychiatric disorder • Discontinuation symptoms: Cymbalta® should not be discontinued abruptly. A gradual dose reduction is recommended.

and traditional crafts. Ironically, most of the men and women who carve exclusively for the Sanctuary are Burmese refugees who have been specially trained for this unending task. Even as they carve new figures for the interior, they are also restoring great swaths of the exterior that have been sanded down by time and weather. What’s perhaps most remarkable about this chimerical structure — it appears to metamorphose as you circumnavigate it — is that there’s not a metal nail in it. Everything is done by old-fashioned joinery: wooden pegs instead of nails as well as dovetail, tongue-and-groove and mortise-and-tendon joints, the way it was done for centuries in the Kingdom of Siam. As I was about to leave, Mao led me over to a varnished wooden information panel. Previous ones we looked at featured Buddhist or Hindu moral precepts mixed in with Confucian teachings about filial duties and ancestor worship. But this particular panel counsels against all excess, a long list that runs from alcohol and drugs down to licentious thoughts and lustful activities. Mao kept giving me long fervid looks as she pointed out each misdeed in turn. She suggested it would be a good idea for me to memorize the worst of them. I explained I already have them by heart. For more info on the temple and region, visit the Tourism Authority of Thailand (tourismthailand.org).

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The coolest, high-end hotels in Thailand, Singapore and Vietnam. doctorsreview.com/features/beauty-sleeps-luxury-asian-hotels Doctor’s Review • NOVEMBER 2014

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

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

Major Depressive Disorder (MDD) 1

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

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

Sunday afternoon on Moose Factory Island. This is a local feast preparation of goose and bannock (in the traditional fashion). by Dominika Jegen, a rural FP from Moose Factory Island, ON Taken with an iPhone 5S

FIRST PLACE

Neighbourhood watch

ST CONTER S! E N N I W

Your colleagues use their cell phones to show their world outside the office

ell phone selfies are ubiquitous and we didn’t receive a single one for the Canadian cell phone photo contest that we launched in our August issue. Yay! What we did get was pretty much what we

asked for: shots taken around your neighbourhood. What shots! What neighbourhoods! Entries included a gigantic bubble and a giant rutabaga; a canola field near Drumheller, Alberta and an island in Ontario’s Georgian Bay. There were sunsets — every contest needs sunsets — and a fish with a model car, likely a first for any contest. Frost on rose hips in Langley, BC, and a goose and

Doctor’s Review • NOVEMBER 2014

bannock roast on Moose Factory Island. We’re a diverse nation indeed. But how to decide on a winner? The judges went back and forth, and back and forth, and argued for their favourites. In the end, content ruled. The winner receives a $50 gift certificate from a choice of Mountain Equipment Co-op, Lee Valley Tools or Canadian Tire, second a $35 certificate, third $25.

“Mummy this rutabaga is as big as me!”

THIRD PLACE

SECOND PLACE

by Kate Brown, a GP from Whitehorse, YT Taken with an iPhone 5

Children and adults alike were dazzled by the giant bubbles drifting and morphing down the street during the annual flamenco dance festival on rue Bernard in Montreal. by Lynne Peters, a psychiatrist from Montreal, QC Taken with an iPhone 5S

HONORABLE MENTION A July morning on Beckwith Island in Georgian Bay taken from my cottage deck. by John Wyatt Crosby, an FP from Cambridge, ON Taken with an iPhone 4

NOVEMBER 2014 • Doctor’s

Review

HONORABLE MENTION November frost on rosa rugosa hips. by Richard Waiz, a GP from Langley, BC Taken with an iPhone 4S

HONORABLE MENTION “It’s been one of those days.”

by Laurie Rotman, an FP from Scarborough, ON Taken with an iPhone 5S

HONORABLE MENTION The joys of fall.

by Cameron Morhaliek, a psychiatrist from Edmonton, AB Taken with an Android HTC phone from 2011

HONORABLE MENTION

The Google bikes in Technicolor captured by a Google fan on the Google campus.

by John Vu, a family practice and palliative care physician from Oshawa, ON Taken with a Samsung S3 (running Google Android obviously!)

Doctor’s Review • NOVEMBER 2014

HONORABLE MENTION

A hot summer and the resultant forest fires in BC made for some dramatic skies and sunsets. by Paul Mackey, a GP anesthetist from Fort St. John, BC Taken with and iPhone 5 (using Snapseed)

HONORABLE MENTION A canola field in July near Drumheller, AB. by Dubravka Rakic, an FP from Calgary, AB Taken with a Samsung Galaxy Note II NOVEMBER 2014 • Doctor’s

Review

“There is a lot to be excited about with the new cma.ca. You’ll be able to search more effectively, save time and see relevant resources used most often by your colleagues.” dr. andrea Kermack internist, montréal, Que. Cma member

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

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Backcountry paradise

Ski or heli in to these stunning gems in the heart of the Rockies by David Elkins

PAUL ZIZKA

Skoki’s main lodge and three surrounding cabins can accommodate 22 guests.

s a rule, I prefer summer to winter. I ski, but hesitate to call myself a skier. I skate and try to get in a couple of pick-up games of hockey at the local rink between the holidays and Spring Break, but seldom manage it. I’ve made peace with those annual few weeks of very cold weather when daytime temperatures plunge below -25ºC and I even delight in those few black, icy nights with their great sprays of stars. I’m a Canadian afterall. Some taste for cold weather is bred in the bone. And there’s one thing I like about winter that I wouldn’t care to give up for all the beaches in Florida and Phuket combined: the chance to spend a few days and nights at a ski-in lodge that feels far enough from civilization that you might have skied or snowshoed right into the 19th century. You only get that true wildernessthe-way-it-was feeling in the West. Here are four such places where you can experience just that.

SKOKI Skoki Lodge sits at an elevation of 2164 metres in the heart of Banff National Park. You reach it by skiing cross-country over an 11-kilometre trail out of Lake Louise. The rustic log cabin was built in 1931 and has been a National Historic Site for more than 20 years. It’s a place you owe it to yourself to see at least once before you pass on to your great reward. Speaking of passing on, seeing it is not entirely a cakewalk. That’s as it should be. The work equity you build up getting there makes the arrival all the more satisfying. The trail through the Ptarmigan Valley goes over two steep passes. The second, Deception Pass,

NOVEMBER 2014 • Doctor’s

Review

requires skins on your skis to make the climb. Don’t let that discourage you. Anyone who is reasonably fit can manage it, no worries. Now the rewards. Most guests arrive in the late afternoon, not long before dinner and that’s a good thing. There will be as many 22 of you at the table — the lodge and nearby cabins are usually fully booked — and what a table it is. Chef Katie Mitzel has com-

PAUL ZIZKA

Breakfast and dinner at Skoki are served buffet style; lunch is build-it-yourself.

manded the kitchen for 16 years. Her meals have earned her a certain reputation and the guest list is all the proof needed. The Duke and Duchess of Cambridge, Will and Kate, visited in July 2011 as part of their cross-country tour. The heir to the British throne chose the beef tenderloin, butternut squash, roasted potatoes with candied pecans and the Amazon chocolate cake for dessert. If those particular items are not on the menu don’t despair; all Skoki meals are quite wonderful. After dinner, guests usually linger in the main lodge to socialize. If there’s someone who can play piano, there may be a group sing. Board games usually come out as well. Given the exercise expended each day, most make it early to bed. After a night tucked under a duvet and a big breakfast in the morning you’ll be ready to explore the lakes and trails around the lodge before skiing out toward the end of the afternoon. Or if you’re one of the lucky ones, stay another day to enjoy the beauty, silence and that irreplaceable feeling of being in the great outdoors. tel: (888) 9975654; skoki.com; opens December 21; from $169 a night, including meals.

Her meals have earned her a certain reputation and the guest list is all the proof needed: Will and Kate visited in 2011

NOEL ROGERS

Assiniboine Lodge is 28 kilometres from the nearest road. RIGHT: A three-course dinner is served in their historic dining room.

ASSINIBOINE Built in 1928, Assiniboine Lodge in Mount Assiniboine Provincial Park near Canmore, BC was the first backcountry ski lodge in the Rockies. The property now accommodates 30 guests with five rooms in the lodge and seven private cabins. You ski in over a 28 kilometre trail or take a short helicopter ride ($175). You can also arrange to ski in and fly out.

Doctor’s Review • NOVEMBER 2014

Stunning mountain views embrace the visitor — the sheer grandeur of the place can take your breath away. Mount Assiniboine (3618 metres) is considered Canada’s Matterhorn. Visitors have called it one of the most beautiful places on the planet, others simply describe it as “paradise.” Spectacular as the wilderness setting is, guests need not want for anything. Go off exploring on your own or take part in one of the many guided tours on offer. When you get back, relax in the sauna before launching into a gourmet meal in the warmth of the fire-lit main dining room. tel: (403) 6782883; assiniboinelodge.com; February 13 to April 6; $250 per person, per night for a double-occupancy room, $310 for a private cabin, including meals.

BREWSTER’S SHADOW LAKE The trailhead for the ski in is on the Trans-Canada Highway 19 kilometres west of Banff, AB. Park your car in the free lot, strap on your skis or snowshoes and set out for the lodge a relatively easy 14 kilometres away — no daunting mountain passes to climb. That doesn’t mean you won’t be hungry when you get there and that’s a good thing. Shadow Lake is famous for food and comfort. Homemade bread and afternoon tea will be waiting for you. Save room for dinner. Alison Brewster serves a fantastic familystyle meal. Guests rave about the leg of lamb, the beef tenderloin, roast chicken, baked salmon, herbed potatoes, buttered squash etc. etc. etc. Enjoy

wine or beer with dinner. For some, the desserts alone are worth the trek in. But it’s not all about the food. This is one “ski in” that includes many of the creature comforts found in hotels close to Banff Avenue. Private cabins offer a choice of king, queen and double beds, and there is a central shower, and a sauna. After a tasty breakfast, build your own lunch in the kitchen and head out to enjoy the many trails to lakes and passes in the surrounding area. You won’t want to tear yourself away. tel: (866) 762-0114; shadowlakelodge.com; January 29 to March 22, Thursday to Saturday only; $260 per person, per night for a double-occupancy cabin, including meals.

SHELLEY PEACHELL

HEATHER SMITH

Th wood-frame lodge has six bedrooms. LEFT: There are no power lines, roads or snowmobilers in the area around Powder Creek.

POWDER CREEK Power Creek is an entirely different beast. As the name suggests, it’s all about downhill skiing in powder and on most days through February there’s good powder thanks to the elevation. The lodge is in the Purcell Wilderness Conservancy in southeastern BC, an 11 minute helicopter ride from Kaslo on Kootenay Lake. Fly in and spend a week skiing your heart out. The stunning area is home to several peaks over 2700 metres and a plethora of small lakes. The newish lodge was built in 1998 and it’s a big, rough-hewn place with six, two- to three-person private rooms; no dorm sleeping here. There’s an open

area that houses a generous kitchen (guests have the option of preparing their own meals or having them catered), dining and living room. Other comforts: inside liquid toilets, a spacious sauna and showers. You’re here for the outside, not the inside, and it’s here Powder Creek comes into its own. Over 7000 hectares and a huge number of wonderful touring possibilities await your pleasure right on the doorstep. This is skiing many only dream about. The lodge is functional and tucked away enough to give you a strong sense of adventure. For a solid idea of the Powder Creek experience watch the seven-minute “Powder Creek Lodge” video on the Backcountry Skiing Canada channel on YouTube. Like what you see? Group bookings are the norm. Call the lodge to find out if they can fit you into an existing group. tel: (250) 359-5916; powdercreeklodge. com; Christmas through April for seven days starting on Saturdays only; $1400 per person, self-guided and self-catered; $2450 guided and catered. NOVEMBER 2014 • Doctor’s

Review

Party perfect Easy, elegant holiday food from the chefs of Neiman Marcus recipes by

Endive spears with ricotta and lemon zest.

Kevin Garvin

with

John Harrisson

photos by

Jody Horton

hen Herbert Marcus Sr. became frustrated with the dining options in downtown Dallas, home of the flagship Neiman Marcus department store he co-founded in the early 1900s, his son Stanley hired a cook to make lunch for his dad in a

small room on the building’s top floor. It was the late 1940s and Marcus Sr. would invite vendors and other guests to join him. When he died in 1950, Stanley, now president and CEO of the store, expanded the business and opened a full-service restaurant for customers. It was the first of 43 across the US to come and led to 2003’s Neiman Marcus Cooks, which was recently revised and rereleased by Rizzoli. Compiled by the vice president of Neiman Marcus Restaurants, chef Kevin Garvin, it contains all the classics, but also debuts new delights your own guests will love. Here are our picks for the season.

spear, using another teaspoon to help push off the ricotta onto the spear. Using a microplane or fine grater, grate zest from the lemons over the ricotta and endive spears. Top each with a watercress leaf. Serve chilled. This appetizer can be prepared up to 3 hours in advance and kept loosely covered in the refrigerator. Makes 24 spears or serves 8.

Chef’s notes: You’ll find fresh ricotta in finer cheese sections and it’s worth the investment if you really want to make an impression with this recipe. Belgian endive is a form of chicory and one of the most flavourful. When buying heads of endive, prepare by cutting the core from the spears about ½ inch (1.25 cm) from the bottom then carefully pull the leaves apart.

Chicken charmoula skewers.

ENDIVE SPEARS WITH RICOTTA AND LEMON ZEST This is such a simple recipe, and so pretty and delicious. Any dinner party or gathering can use a nice platter of fresh endive spears with a good ricotta cheese and lemon zest. It’s always a winner. Ricotta is made from the whey after the curds are strained in the cheesemaking process and it’s being increasingly made locally in many parts of the continent. Its attractively soft, smooth texture and flavour make ricotta a favourite ingredient for desserts in Italy, such as cannoli and cheesecake. 12 oz. (375 g) ricotta (see chef’s notes) pinch of salt pinch of freshly ground black pepper 24 red or white Belgian endive spears, about 2½ inches (6.25 cm) long (3 or 4 heads endive) 2 lemons baby watercress leaves, for garnish

In a mixing bowl, combine the ricotta, salt and pepper, and keep chilled. Gently rinse the endive spears under cold running water and then wipe them dry with a paper towel. Lay the endive spears on a clean platter. Scoop the ricotta with a teaspoon and place in the middle of each NOVEMBER 2014 • Doctor’s

Review

To prepare the chicken skewers, cut the chicken into 32 strips, about 1 ounce (30 g) each and place in a glass or ceramic mixing bowl. In a separate bowl, mix the olive oil, lemon juice, garlic, cumin, paprika, cayenne, salt, allspice, cilantro and parsley. Pour the marinade over the chicken, making sure the chicken is covered. Cover tightly with plastic wrap and let marinate in the refrigerator for at least 4 hours or overnight. Soak the skewers in water so they don’t burn when cooking. Prepare the grill (or use a good grill pan or your broiler for high-heat cooking as a substitute). Remove the bamboo skewers from the water and thread 2 chicken strips lengthwise on each. Set the threaded skewers on a clean platter as you work. Place the skewers on the grill and cook over medium heat for 3 or 4 minutes on each side or until completely cooked through. Serve the chicken skewers with the tzatziki. Makes 16 skewers or serves 4.

Mahi-mahi fish tacos with cilantro-lime vinaigrette.

CHICKEN CHARMOULA SKEWERS This is an adaptation of a method for flavouring chicken with a classic marinade from northern Africa. Feel free to make plenty: it works great on all types of seafood as well as red meat. Serve the skewers with classic Greek tzatziki. For the tzatziki 1 c. (250 ml) plain Greek yogurt 1 large cucumber, peeled, seeded and finely diced 1 tbsp. (15 ml) olive oil ½ tsp. (2.5 ml) minced garlic ¼ c. (60 ml) minced fresh dill juice from ½ lemon ¹⁄8 tsp. (0.5 ml) salt ¹⁄8 tsp. (0.5 ml) freshly ground white pepper

Doctor’s Review • NOVEMBER 2014

For the skewers 2 lbs. (1 kg) boneless, skinless chicken breast 1½ c. (375 ml) olive oil ¼ c. (60 ml) fresh lemon juice (about 2 lemons) 2 tbsp. (30 ml) minced garlic 2 tsp. (10 ml) ground cumin 2 tbsp. (30 ml) paprika ¼ tsp. (1.25 ml) cayenne 1½ tsp. (7.5 ml) salt 1 tsp. (5 ml) ground allspice ¹⁄3 c. (80 ml) chopped fresh cilantro leaves ¹⁄3 c. (80 ml) chopped fresh Italian parsley 16 bamboo skewers, 6 to 8 in. (15 to 20 cm) long

To prepare the tzatziki, place all the ingredients in a bowl and mix thoroughly. Cover and set aside in the refrigerator.

Chef’s notes: Charmoula (sometimes also written and pronounced as “chermoula”) is a marinade used in North African cooking. It typically contains olive oil, herbs, garlic, lemon and cumin or coriander. It’s most commonly used with fish and seafood, but as this recipe shows, it makes a fine marinade for chicken, too.

MAHI-MAHI TACOS WITH CILANTROLIME VINAIGRETTE Who would have thought that the trendy food-truck fish taco would find its way onto Neiman Marcus restaurant menus? Well, they have — and in a big way. On a whim, this recipe was introduced to the Dallas NorthPark Mermaid Bar restaurant and it quickly became one of the top sellers. Putting into practice the principle that whatever’s good for one Neiman Marcus restaurant must be good for others, the tacos soon found their way onto the menus of many of the chain’s biggest and fanciest restaurants. From “white tablecloth” to “grab-and-go” concepts, this dish sells.

For the fish 4 mahi-mahi fillets, about 1 inch (2.5 cm) thick and 5 oz. (150 g) each 1 tbsp. (15 ml) Cajun blackening spice 3 tbsp. (45 ml) olive oil 1 lime, cut into 8 wedges For the chipotle mayonnaise 1 c. (250 ml) light mayonnaise juice of 1 lime 2 tbsp. (30 ml) pureed canned chipotle chile and adobo sauce For the cabbage slaw 2 c. (500 ml) shredded white cabbage 3 tbsp. (45 ml) cilantro-lime vinaigrette (recipe follows) 2 tbsp. (30 ml) roughly chopped fresh cilantro leaves

To assemble the tacos, place two tortillas, side by side, on each serving plate. With a fork, gently flake each mahi-mahi fillet into four smaller pieces and place two pieces on each tortilla. Top the fish with the cabbage slaw and then two slices of avocado. Drizzle with the chipotle mayonnaise and garnish with jalapeño slices. To serve, fold the tacos over or serve open-face. Serves 4. Chef’s notes: The blackening spice is the key to this recipe. If mahi-mahi is unavailable, use another firm-fleshed fish such as snapper, Gulf redfish or even fresh tuna.

CILANTRO-LIME VINAIGRETTE

For the tacos 8 small (5-in./12.5 cm) white corn tortillas 1 avocado, pitted, peeled and cut into 16 slices 1 jalapeño, thinly sliced

We use this vinaigrette exclusively for our Asian-style salads. It also works really well as a coleslaw dressing with shaved cabbage, and in Tex-Mex cuisine because it packs a punch and marries well with spicy flavours.

To marinate the fish, place the mahimahi fillets in a large dish and sprinkle with the blackening spice and olive oil. Squeeze the lime juice from the wedges over the fish, then toss with the squeezed wedges. Transfer to the refrigerator and let sit for 1 hour. Meanwhile, prepare the chipotle mayonnaise. Place the mayonnaise in a small mixing bowl, add the lime juice and chipotle puree, and mix thoroughly. Cover and keep refrigerated. To prepare the slaw, place the cabbage in a mixing bowl and add the vinaigrette and cilantro. Toss together and mix thoroughly. Cover and keep refrigerated. Prepare the grill and spray the grill rack with non-stick spray so the fish does not stick. (Use a good grill pan or your broiler for high-heat cooking as a substitute.) Place the fillets on the grill and cook over medium-high heat on the first side for 3 to 4 minutes. Turn the fish over and grill for 3 to 4 minutes longer. Remove the fish and reserve. Heat the tortillas on the grill for about 15 seconds on each side to heat through; a little browning is fine and they should still be pliable.

1 c. (250 ml) olive oil ½ c. (125 ml) fresh lime juice ¼ c. (60 ml) Japanese rice vinegar 2 tbsp. (30 ml) honey 3 tbsp. (45 ml) chopped fresh cilantro ½ tbsp. (7.5 ml) salt 1 tsp. (5 ml) freshly ground black pepper

Place all the ingredients in a blender and blend for 1 minute or until completely smooth. Keep in an airtight container in the refrigerator for up to 1 week. Makes 2 cups (500 ml).

ONGLYZA Contraindications:  Diabetic ketoacidosis  Diabetic coma/precoma  Type 1 diabetes mellitus Relevant warnings and precautions:  Not recommended for patients with congestive heart failure  Exposure to stress (e.g. surgery)  Interactions with potent CYP 3A4 inducers  Contains lactose  Risk of hypersensitivity  Discontinue if pancreatitis is suspected  Immunocompromised patients (consider monitoring lymphocyte count)  Rash (monitoring recommended)  Not recommended for pregnancy, should not be used by nursing women  Not recommended for patients with moderate to severe hepatic impairment (not recommended for patients with ESRD requiring hemodialysis)  Monitor renal function For more information: Please consult the product monograph at www.azinfo.ca/onglyza/pm664 for more information relating to adverse reactions, drug interactions, and dosing information not discussed in this piece. The product monograph is also available by calling us at 1-800-668-6000. * Randomized, double-blind, placebo-controlled study of 24 weeks’ duration in patients with inadequate glycemic control (HbA1c ≥7.0% and ≤10.0%) on metformin alone. Saxagliptin baseline HbA1c 8.1% (n=186), FPG 9.9 mmol/L (n=187), PPG 16.4 mmol/L (n=155). Placebo baseline HbA1c 8.1% (n=175), FPG 9.7 mmol/L (n=176), PPG 16.4 mmol/L (n=135). Patients were required to be on a stable dose of metformin (1500 mg to 2550 mg daily) for at least 8 weeks to be enrolled in the trial. Patients who completed all visits during the initial 24-week study period without need for hyperglycemia rescue therapy were eligible to enter a controlled, double-blind, long-term study extension. Patients who received saxagliptin in the initial 24-week study period maintained the same dose in the long-term extension. References: 1. Onglyza® Product Monograph. AstraZeneca Canada Inc., June 30, 2014. 2. Komboglyze® Product Monograph. AstraZeneca Canada Inc., June 30, 2014.

09/15

Recipes and photos © Neiman Marcus Cooks by Kevin Garvin with John Harrison (Rizzoli International Publications, Inc., 2014).

AstraZeneca Canada Inc. Mississauga, Ontario L4Y 1M4

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Dr Den n i s L e e

A cold sweat

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

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