October 2014 by Doctor's Review

Depression and your patients

MEDICINE ON THE MOVE

P. 26

The story of food Muscle trigger points NEW APP

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13 AUTUMN ESCAPES Canadian romance Philadelphia art Oregon soaks Desert golf Vermont colour ...and more

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What? Me worry? Time for a getaway

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Getaways are good for you. A host of studies over the years have identified a variety of benefits. Taking a vacation relieves stress, improves mental skills, bolsters physical health, and strengthens family ties. There are a few caveats. Getting away from your practice won’t do you much good if you worry about what you’ve left behind. I’m a worrier and I’ve searched for ways to reduce it. At different times, I’ve put my hope in exercise, meditation, long walks in nature, a library of “how-to” books, and playing with the dogs among other things. They all work at some level, but I hadn’t found the killer app — until recently. I’m grateful for the change it’s made in my inner landscape and I’m ready to share it. Here it is: don’t worry! I know it sounds simplistic, even silly, but once I made up my mind it was surprisingly easy to kick what can be a debilitating habit. The chance a holiday gives you to improve your mental skills and look after your health are a couple of benefits I can take or leave. They require work to accomplish and I’d just as soon not let them mess up my time off — I’d rather shoehorn them into my work-a-day life. The next two items, though, are important in my books. Vacations are the best possible time to put in some quality time with the family even if you are only a family of two. Breaks away from the usual routine provide an invaluable chance to simply be together and enjoy each other. And while you’re at it, don’t forget to enjoy yourself. Set aside some time to indulge your passions. Do something for you alone, you’ll be a better person for it. There are many suggestions in this issue on how you might while away a few happy days: romantic spa visits, touring fall colours, a day or two looking at art, a round of desert golf. Here’s another idea: simply take a few days off to hang around the house and do nothing more strenuous than read a book, surf the net at your leisure, watch a few videos or even take in a movie at the local theatre. And don’t think about your practice. And don’t worry! With any luck, you’ll return to the office refreshed and in just the right frame of mind to deal with a day full of patients.

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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 

 THIS ISSUE: Talking to patients about depression P. 26

COMING NOVEMBER: 10 things to know about 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.

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

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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)

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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

contents

features 30

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OCTOBER 2014

41 46

Creative thinking Art museums in Philadelphia for an impromptu long weekend by Will Aitken

A fair game

Golf in California’s Palm Springs where the architecture and food are also winners by Anita Draycott

World’s most unpretentious spa

Oregon’s Breitenbush Hot Springs is (almost) off the grid — and it might be your perfect escape by Tilke Elkins

Crowd pleasers One dish, two ways for kids and adults by Jane Kennedy

regulars 7 LETTERS From gadgets to grub

46 41

Fall for Vermont Circus figures, a steamboat and 25 historic structures on the family-friendly grounds of the Shelburne Museum by Portlin Cochise

PRACTICAL TRAVELLER A week-long bike trip through Adirondack Park, a mind-boggling Richard Estes’ exhibit in Washington, DC, new fees on Air Canada and WestJet, and more by Camille Chin

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OCTOBER 2014 • Doctor’s GRAPHIC

ART

CREATIVE

Review COPY-

3 STUDIO

CLIENT

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

contents OCTOBER 2014

regulars 13

BUDGET TRAVELLER Four spas for a romantic weekend near you by Ellery Vargas

GADGETS A handheld, water purification system that’ll change the way you travel by Theo Sands

BEST MD APPS

TOP 25 The best medical meetings happening next March

Eighty muscles,150 trigger points, one teeny tiny app by David Elkins

coming next issue

HISTORY OF MEDICINE A history of what we eat: to Paleo and back by Rose Foster

CLINICAL TALK Addressing depression in your family practice by Dr Valerie Taylor

PHOTO FINISH

The big picture by Dr Philip Ettin

• Visit Thailand’s little-known Sanctuary of Truth, a stupendous wooden temple devoted to Buddhist and Hindu culture • History of exercise from China’s Nine Treasures to the first Olympiad to CrossFit • This African adventure begins in Morocco with two white Mercedes heading south

Treating chronic pain, our shared responsibility.

• A mother wants to steer her boys away from Disney’s commercial excesses but… • Launch the winter season in style with a night or two at a ski-in lodge CLIENT: Purdue

OCTOBER 2014 • Doctor’s

DOCKET NUMBER: PQ9818

Review

COLOURS

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DATE

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

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

Pfizer Strive Payment Assistance Card Available in all provinces except Quebec

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

My Pfizer Card Only available in Quebec

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

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

LETTERS

EDITOR

David Elkins

From gadgets to grub

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

2014, page 52]. Since the recipe calls for only 7.5ml, you’d have to make about 45 to 50 batches of gumbo in six months so as not to waste the spice mix. Even halving the recipe, you’d have to make 20 to 25 batches (three to four per month!). I like gumbo, but not a big batch for six to eight people every week or two.

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Shrimp gumbo from the Brown Sugar Kitchen in West Oakland, CA.

KEY TO SUCCESS? Keyless doors are very clever [“Unlock your door with your smartphone,” Gadgets, September 2014, page 19], but if your kids don’t have a cell phone, they’ll have to use the key fob. My daughter wasn’t great at keeping things in a safe place when she was a younger and she would’ve lost it, which would’ve been a problem because anyone can use it to get inside. A fob also costs more to replace than a regular key. Something to think about if you have young kids. Dr D. Palusamy Via email

OLD SPICE It’s an awful lot of creole spice mix: 335 to 350ml, good for six months, if stored airtight [“Shrimp Gumbo,” Eats meets West, September

AN ABUSE OF POWER I think the park benches with USB ports in them are a clever idea, but I wonder how long they’ll last before someone vandalizes them [“Power Seat,” Practical Traveller, August 2014, page 9]? Dr JP Cronish Via email

Editor’s note: Both Famiglia and Co. by Marcy Gordon and Hiking Grizzly Country — Or Not by John Flinn on pages 38 and 50 of the September issue were extracts from the Travelers’ Tales series of books. The former appears in The Best Women’s Travel Writing: Volume Eight, the latter in The Best Travel Writing: Volume Nine, published by Solas House, Inc. Correction: The photo caption on page 41 of Vegans at Sea in the September issue identified the author as being on the right; she is on the left. On page 42, her sister, Marianne, appears with Dr Homsy.

The new cma.ca — see how personal a website can be.

cma.ca/new Optimized

mObilized

persOnalized

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7 14-08-28 9:39 AM

IES R E S T R A P THREE

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!

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P R AC T I C AL T R A V E L L E R C a mi lle C hi n

Reaching new rights

This is not a photograph

TOP: Double Self-Portrait, 1976. BOTTOM: Near Hunter’s Beach, Acadia National Park, 2008.

Richard Estes is one of the founders of photorealism, and the way he plays with light, reflection and perspective will trick you into thinking his cityscapes are real. Also, everything in the Illinoisborn artist’s paintings has equal visual weight — the background is as detailed and as focused as what’s in the foreground — which creates a sense of hyperreality. Through February 5, get lost in his world at the Smithsonian American Art Museum in Washington, DC. The Richard Estes’ Realism exhibit features 46 paintings from the late 1960s to 2013 making it the first complete overview of his work in the US since 1978. He’s known for urban scenes — NYC, London, Paris and Tokyo — but landscape paintings of Maine’s coast and the woods on Mount Desert Island, where he’s spent part of each year since the late 1970s, will also be on view. Admission is free. tel: (202) 633-7970; americanart.si.edu.

OCTOBER 2014 • Doctor’s

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

RÉJEAN BRANDT PHOTOGRAPHY

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Sophia Lee and Liang Xing in Swan Lake.

A case in point

Doctor’s Review • OCTOBER 2014

JULIEN HAUTCOEUR / SHUTTERSTOCK.COM

Manitoba might be one of the best places to see the Nutcracker this December. The 2014/15 season will be the Royal Winnipeg Ballet’s 75th anniversary so we’d assume that it’s extra important that all the dancers be on their toes. Founded in 1939, Canada’s premiere ballet company is also one of the oldest in North America. It received its royal title, the first granted under the reign of Queen Elizabeth II, in 1953. A native of Quebec, André Lewis has been the artistic director for 18 years. After the holidays, Swan Lake will take the stage in March followed by The Faerie Queen: A Ballet Based on A Midsummer Night’s Dream in April. The Royal Canadian Mint is commemorating the RWB’s anniversary milestone with a silver coin that features six ballerinas in colourful platter tutus. For RWB tickets: tel: (204) 956-2792; rwb.org.

High an

Airlines pack a punch

nd mighty The final leg of NYC’s High Line opened in mid-September and some have described it as the most “New York” stretch of the elevated park. Picking up from the northernmost end of section two (which opened in June 2011, two years after section one), it runs along 30th Street beginning at 10th Avenue, then curves up the West Side Highway before continuing on 34th. Part of the $35-million third leg features views of the Hudson River, but also of the behemoth construction site that is Hudson Yards. When that massive real estate project being built over the city’s busy railroad yards is fully completed within the next decade, a section of the High Line will connect to a plaza in the development, creating a mega pedestrian space. In the meantime, the five million people that visit the High Line every year have the third leg’s wider paths to promenade. There are also “peel-up” benches that seem to emerge from the path itself and an elevated catwalk at 11th Avenue for an even higher perspective. thehighline.org.

Passengers flying on Air Canada’s Economy Class Tango fare will now be charged $25 for a first checked bag. The new fee affects bookings made on September 18 onwards for travel on or after November 2 within Canada, and to and from the Caribbean and Mexico. Travellers flying on WestJet’s Econo fare will also be charged $25 for a first checked bag. The fee affects bookings made on September 15 onwards for travel on or after October 29 within Canada, and between Canada and the US. For more: aircanada.com/en/ travelinfo/airport/baggage/index.html and westjet.com/ guest/en/baggage.shtml.

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

A new course of action Cycle Adirondacks, hosted by the Wildlife Conservation Society, is already registering riders for next year’s August 23 debut. It’ll be the first-ever, weeklong, fully supported road-bike tour through Adirondack Park. Beginning and ending at Saranac Lake, NY, each of the 600 participants will bike 80 to 120 kilometres a day and have up to 12 hours to do it. There’ll be SAG (or support-and-gear) vans along the way, and mechanics, medical personnel, clear maps and signs, volunteers, and rest stops with food and drinks. You can overnight in your own gear at “tent city,” which’ll include showers, toilets and water bars, or rent an already-assembled tent and air mattress from Comfy Campers. Local lodging is another option. Registration is US$1495 for adults, which includes parking for the week, three meals a day, designated camping areas, daily baggage service, and support services in camp and en route. info@cycleadirondacks.com; cycleadirondacks.com.

A presidential welcome WHITE HOUSE HISTORICAL ASSOCIATION

Contrary to what some fence-jumpers might think, a request to tour the White House must be submitted “three weeks to six months” before the date of your visit. The newly revamped White House Visitor Center in President’s Park, which surrounds the White House, has more of an open-door policy, however, daily from 7:30am to 4pm. The US$12.5 million revamped space features an interactive touchscreen tour of the White House and a 14-minute film, White House: Reflections From Within. There are also 90 artifacts on view including the desk where President Roosevelt delivered his fireside chats and the telegraph key used by Ab Lincoln’s administration during the Civil War. Equally titillating: a display that reveals which president liked squirrel soup and who liked rice pudding for dessert. Admission is free. tel: (202) 208-1631; nps.gov/whho/planyourvisit/whitehouse-visitor-center.htm.

Doctor’s Review • OCTOBER 2014

BUDGET TRAVELLER

Elle r y V a r g a s

romantic spas Porto, Portugal.

British Columbia Victoria’s Magnolia Hotel and Spa, just two blocks from the city’s Inner Harbour, offers rarely matched luxury and intimacy. The award-winner was voted one of the top places to stay in Canada by Condé Nast readers. You won’t be disappointed with Flight Night Wine and Spa. The package includes a flight of three wines and two visits each to the spa. Choose from a 30-minute Swedish massage, 30-minute facial, 30-minute body scrub and hydrotherapy tub, 30-minute foot treatment. Pamper yourselves from $359 a night, double occupancy. tel: (877) 624-6654; magnoliahotel.com.

The countryside around The Falls Inn & Spa brings out the best of autumn.

Saskatchewan Manitou Springs Resort and Mineral Spa in Watrous, SK offers something you can’t find almost anywhere else in the world. The mineral-rich waters of Little Lake Manitou are as buoyant as those of Israel’s Dead Sea. Ranked as one of the top 50 spas in the country, the resort’s big European-style pools offer ample opportunities to soak. Float away on the Spa Romance two-night package for just $241 for two people. The package includes Champagne and chocolates, breakfast and two massages. tel: (800) 667-7672; manitousprings.ca.

Ontario To Claudia Masciotra

The Falls Inn & Spa in Walters Falls is about two thirds of the way from Toronto to Owen Sound. Its rooms are spacious For Doctor’s Review October 2014 issue and well appointed if a tad folksy. Dining is a nightly celebration. Generous and tasty dinners garner high praise from guests. Faxbucolic1-855-861-0790 The setting demands country strolls. Choose one of

the Cherry Suites with a view of the falls. It’s good value, priced at $180 midweek and $210 on weekends, double occupancy. tel: (519) 794-4388; thefallsinn.com.

Quebec Autumn in Quebec City is about as romantic as it gets. Hôtel Le Germain-Dominion in the Old Port is housed in a classic 19th-century limestone with an outer atmosphere that reflects the capital’s long and prosperous history. Inside it’s all about contemporary design and colour. The place exudes luxury and comfort in the heart of the Lower Town close to where Champlain first touched shore in 1608. Choose the romantic package, which includes champagne and roses, a breakfast buffet and late checkout. Starts at $319 a night, double occupancy. tel: (888) 833-5253; germaindominion.com.

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January 16 - 30, 2015 Australia Rheumatology Vanuatu Gastroenterology Fiji Infectious Diseases Chronic Pain New Caledonia

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more CME cruises at www.seacourses.com

OCTOBER 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.

GA D GE T S by

T he o S a n d s

Know the water is safe to drink Travel and safe drinking water go hand in hand. The water that flows from taps in most of North America and Europe is usually potable and that means we’re spoiled. Almost 80 percent of all travel disease comes from contaminated water and over 10 million travellers get sick every year. It’s a lesson hikers have always known: either carry water with you or have a way of purifying any source you come across in nature. The options to make sure your water is safe are limited and most have downsides. Boiling leaves you with hot water, chemicals add a bad taste and filtration systems demand a lot of pumping for a trickle of return. Enter my new favourite purifying companion: the SteriPEN Freedom. It uses UV light to purify a cup of water in 48 seconds while you stir and eliminates over 99.9 percent of bacteria, viruses and protozoa that cause water-borne illness. It weighs a scant 74 grams and fits in a shirt pocket. The rechargeable battery treats 40 liters before you need to plug it in again. Pack one in a travel bag so you know where to find it when you need it. Time magazine lists it as one of the 100 best gadgets and it won Outside magazine’s Editor’s Choice in 2013. $103 at Mountain Equipment Co-op. For more info: steripen.com.

OCTOBER 2014 • Doctor’s

Review

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

ON THE GO

TAKING IT SLOW

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

VERE O C BY MOST

PRIVATE DRUG PLANS‡, ODB and EDS in SK

Please consult the product monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp by searching for ACTONEL DR for additional important information including adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available on request through our medical department at 1-855-892-8766. * Breakfast may include high fat foods, coffee, tea, milk, orange juice, etc. A higher incidence of upper abdominal pain was seen when ACTONEL DR was taken in a fasted state before breakfast. ACTONEL DR tablet should be swallowed whole (not chewed, cut or crushed) while in an upright position and with sufficient plain water (≥120 mL). Patients should not lie down for at least 30 minutes after taking ACTONEL DR. † Comparative clinical significance not established. ‡ Based on a coverage survey conducted by Equilibrium Health, July 2012. ODB: Ontario Drug Benefit; EDS: Exception Drug Status; SK: Saskatchewan Consult formulary for full coverage information. Reference: 1. Warner Chilcott Canada Co. ACTONEL and ACTONEL DR Product Monograph, Toronto, July 3, 2013. ACTONEL DR® is a registered trademark of Warner Chilcott Company, LLC. Marketed with sanofi-aventis Canada Inc. Copyright © 2014 Actavis Specialty Pharmaceuticals Co., Mississauga, ON. All rights reserved.

TAKE WITH BREAKFAST *

BEST MD APPS by

D a v i d Elk i n s

An app that gets to the point Myofascial trigger points (TP) are places in muscles that produce pain elsewhere in the body. They are a common source of often-overlooked pain and can be a frustration for physician and patient alike. The app identifies more than 150 such points along with their corresponding referral patterns. Separate screens offer discrete searches by muscle, area of pain and symptoms using illustrations and alphabetical lists. There’s even a “sensitive interface” which allows you to tap the body and find the trigger points that way. If you prefer, you can tap on a virtual model on the screen, or search

by keyword, for example, “knee” or “elbow.” More than 40 conditions are covered. The app was launched in September and early users are enthusiastic. Commented one: “As far as the subject goes, there’s no better I’ve found on TP and understanding referral pain.” Any health-care worker who deals with muscular pain would find the app useful.” Myofascial Trigger Points — Guide & Reference by Body Culture Devices: iOS 7.1 or later, optimized for iPhone 5 Cost: US$2.99 A similar, well-reviewed, TP Android app: Muscle Trigger Point Anatomy by Real Bodywork Cost: US$3.30

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

SEPTEMBER: The history of depression 

 THIS ISSUE: Talking to patients about depression P. 26

COMING NOVEMBER: 10 things to know about 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.

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 OCTOBER 2014 • Doctor’s

Review

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

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

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings compiled by Camille Chin

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

Canada Banff, AB February 27-March 2, 2015

Halifax, NS February 19-21, 2015 2015 Scientific Meeting of the Canadian Pediatric Endocrine Group cpeg-gcep.net/content/cpeg-2015-annualscientific-meeting

Séminaire de Québec, Quebec City.

Quebec City, QC February 4-7, 2015 2015 Annual Scientific Meeting of the Canadian Rheumatology Association rheum.ca/en/events

Vancouver, BC March 4-5, 2015 6th International Conference on Fetal

CHIRSTIAN MUELLER / SHUTTERSTOCK.COM

Alcohol Spectrum Disorder interprofessional.ubc.ca

Around the world Berlin, Germany March 26-29, 2015 El Badi Palace, Marrakesh.

6th International Conference on Fixed Combination in the Treatment of Hypertension, Dyslipidemia and Diabetes Mellitus 2015.fixedcombination.com

CAMIRAND PHOTO

Canadian Digestive Disease Week 2015 cag-acg.org/annual-conference-cddw

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

Glasgow, Scotland March 22-25, 2015 83rd European Atherosclerosis Society Congress eas2015.kenes.com

Lake Buena Vista, FL March 25-28, 2015 26th Annual Meeting of the American Neuropsychiatric Association anpaonline.org

Marrakesh, Morocco March 19-22, 2015 4th Global Congress for Consensus in Pediatrics and Child Health cipediatrics.org

MERCK ASTHMA

Respiratory offerings for your asthma patients ® Registered trademarks of MSD International Holdings GmbH. Used under license. © 2014 Merck Canada Inc., a subsidiary of Merck & Co., Inc. All rights reserved.

44321 MER14ZH068-Banner-4E-MerckAsthma_E1.indd 1

OCTOBER 2014 • Doctor’s

2014-07-24 Review

8:43 PM

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings Miami, FL March 5-7, 2015 16th World Congress of Pain Clinicians wspc.kenes.com

Milan, Italy March 19-21, 2015 10th International Workshop on Interventional Pediatric and Adult Congenital Cardiology workshopipc.com

March 26-29, 2015 2015 World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases 2015.wco-Iof-esceo.org

Nashville, TN February 11-13, 2015 International Stroke Conference 2015 strokeconference.org Senso¯-ji Temple, Tokyo.

National Harbor, MD March 19-22, 2015

31st Annual Meeting of the American Academy of Pain Medicine painmed.org/annualmeeting

New Orleans, LA March 27-30, 2015

2015 Annual Meeting of the American Association for Geriatric Psychiatry aagponline.org

New York, NY March 18-22, 2015

19th Congress of the International Society for Psychological and Social Approaches to Psychosis isps2015nyc.org

For conference details: doctorsreview.com/meetings

Nice, France March 18-22, 2014 12th International Conference on Alzheimer’s and Parkinson’s Diseases kenes.com/adpd

San Francisco, CA March 18-19, 2015 18th Joint Meeting of the International Society of Dermatopathology intsocdermpath.org/meetings.asp

March 20-24, 2015 73rd Annual Meeting of the American Academy of Dermatology aad.org/meetings/2015-annual-meeting

Savannah, GA March 18-21, 2015 73rd Annual Scientific Meeting of the American Psychosomatic Society psychosomatic.org/ AnMeeting/2015annualmeeting.cfm

Seoul, South Korea March 21-25, 2015 6th World Congress on Sleep Medicine wasmcongress.com

Snowmass, CO March 1-6, 2015 Interventional Cardiology 2015: 30th Annual International Symposium promedicacme.com/meeting.htm

Sorrento, Italy March 12-14, 2015 Third International Congress on Controversies in Rheumatology and Autoimmunity cora.kenes.com

TUNGTOPGUUN / SHUTTERSTOCK.COM

Tokyo, Japan March 22-25, 2015 6th World Congress on Women’s Mental Health iawmh.org/congress.html

Vienna, Austria March 28-31, 2015 23rd European Congress of Psychiatry epa-congress.org

Doctor’s Review • OCTOBER 2014

“I am impressed by the level of physician input that has gone into the process. The result is a much more efficient and member-focused cma.ca site.“ dr. darren larsen Family physician, thornhill, Ont. Cma member

WE FOLLOWED OUR DOCTORS’ ADVICE

Now you can view the resources your colleagues access most 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.

The new cma.ca — see how personal a website can be.

cma.ca/new mObilized

persOnalized

2679

Optimized

For patients with type 2 diabetes

IT’S HERE. NEW JANUMET XR ®

(sitagliptin and metformin hydrochloride modified-release tablets)

The convenience of once-daily dosing

50/1000 mg

50/1000 mg Tablets are actual size.

JANUMET® XR (50 mg/1000 mg) should be taken as two tablets once daily with a meal, preferably in the evening. Please consult the JANUMET® XR Product Monograph for complete dosing information.

JANUMET® XR is indicated as an adjunct to diet and exercise to improve • Most serious warnings and precautions regarding lactic acidosis and excessive intake of alcohol. glycemic control in adult patients with type 2 diabetes mellitus inadequately controlled on metformin or in patients already being treated with the • Other relevant warnings and precautions regarding type 1 diabetes or diabetic ketoacidosis; patient selection and follow-up; pancreatitis, hypoglycemia; combination of sitagliptin and metformin. Consult the product monograph at http://www.merck.ca/assets/en/pdf/products/ JANUMET-PM_E.pdf for important information about: • Contraindications regarding Type 1 diabetes; metabolic acidosis; lactic acidosis; renal impairment; alcohol intake; hepatic dysfunction; cardiovascular collapse and hypoxemia; stress conditions; severe dehydration; hypersensitivity; pregnancy and breastfeeding; radiologic studies (iodinated contrast material) and any surgical procedure.

hypersensitivity reactions; congestive heart failure, hypoxic states; change in clinical status of previously controlled diabetes; loss of control of blood glucose; vitamin B12 levels; hepatic disease; immunocompromised patients; peri-operative consideration; renal disease; skin; caution in elderly patients; should not be used in patients <18 years of age; monitoring of glycemic and hematologic parameters and of renal function. • Conditions of clinical use, adverse reactions, drug interactions and dosing instructions.

References: 1. Data on file, Merck Canada Inc.: Product Monograph - JANUMET® XR, 27 November 2013.

® 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. FEB-15-DIAB-1103300-0001

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

Are we really what we eat? From Paleo to the Fertile Crescent to Grain Brain and back “Let your food be your medicine and medicine be your food.” —Hippocrates

Hippocrates prescribed a mixture of water and honey for patient health.

An agricultural scene of plowing with oxen found in the Tomb of Sennedjem in Deir el-Medina.

he media frequently associates atherosclerosis with our overindulgent eating habits. It’s an idea that’s

made the authors of countless diet books very rich. It’s also twisted government nutritionists into knots trying to come up with a food pyramid that, if followed, would keep citizens’ blood flowing smoothly and so save health care systems billions. Yet the Egyptian builders of the original pyramids also suffered from “hardening” of the arteries. Native people living on the high plains before the invention of the bow and arrow suffered from atherosclerosis. So did the Unangan-speaking hunter-gatherers of the Aleutian Islands. Science tells us that a high percentage of people who lived more than 4000 years ago had heart disease. CAT scans of mummies in locations across the globe have found blocked arteries in as much as 60 percent of the population. Experts estimate that most of our ancient ancestors’ children died before age 15 and life after 40 was rare. Still, we struggle to give up the idealized vision of an “original” human diet that might provide a magical solution to all our ills. In addition to not being terribly healthy, however, our predecessors ate whatever was at hand — and that varied tremendously depending on where they lived.

HIPPOCRATES FOR THOUGHT In warm, dry regions people were thought to mostly eat plants, augmented by the occasional animal protein from hunting. In contrast, people in artic areas ate little but meat, consuming all parts of the animal to ensure that they got their OCTOBER 2014 • Doctor’s

Review

necessary doses of the nutrients found in fruits and vegetables, seeds and nuts. That said, contrary to what modern paleos contend, meat is no panacea. Around 400 BCE, Hippocrates, ahead of his time as always, was onto this. In the Greece of his day, obesity was on the rise and he thought he knew why. Foie gras, referred to in Homer’s Odyssey, was a favoured delicacy and he fingered it as the culprit. His solution? Exercise and a moderate, heavily plant-based diet, much like the current strategies for curbing expanding waistlines. What to eat was his primary guide to patient health. Millet and lentils, and pumpkin and chard were some of his prescribed favourites. He also suggested melikreton, a mixture of water and honey. To build his patients up he prescribed raw, whole milk and buttermilk, and even treated fevers with infusions and fasting. Even earlier, moderation, with certain vegetables, was implied in the first recorded dietary advice. A stone tablet carved in Babylon around 2500 BCE suggests abstaining from onions for three days when suffering from internal pains.

THE CHINA STUDY A conservative use of meat is a familiar part of the Chinese diet to this day. Small quantities used to flavour large vegetable dishes are still common. The ancient Chinese were probably the first to develop a food system. As early as the 6th century BCE, they developed the concept of Qi or “wind,” the vitality of which was kept in check by taking in the correct balance of “hot” and “cold” foods. Traditional Chinese medicine (TCM) continues to practice this basic concept. Meat, blood, ginger and spices are considered “hot,” while green vegetables and other plant foods form the cool end of the spectrum. The use of herbs in teas and soups was also an early practice, one still followed by many contemporary Chinese who approach illness first and foremost by adding and eliminating foods and herbs. They consider Western medicine “too strong,” to be used only as a last resort. China’s scant use of meat, especially in rural populations, was highlighted in the 2005 publication of The China Study, a 20-year research project that examined the relationship between eating animal products and chronic illnesses. The researchers came to an emphatic and radical conclusion: moderate consumption of animal products, including eggs and dairy, is better than high consumption, but eliminating them altogether is best. The study claimed with no small certainty that eating animal products in any quantity, however small, reduces lifespan. The study sparked interest in vegan diets which continue to win adherents. Former US president Bill Clinton took the study to heart. He became a vegan and quickly dropped 11 kilograms to return to his college weight.

WHEAT IS KING When we think of China, we think rice, not wheat. Legend has it that rice was domesticated around 3000 BCE, but genetic evidence puts the crop’s domestication between 8200 and 13,500 years ago in the country’s Pearl River Delta region.

Doctor’s Review • OCTOBER 2014

FROM TOP: Wheat became more popular with the rise of Christianity. The book that made Bill Clinton a vegan. The medieval rich ate so extravagantly that laws were passed against overindulgence.

Science tells us that a high percentage of people who lived more than 4000 years ago had heart disease The use of wheat is far from new, having reached China from Western lands around 2000 BCE. While Chinese southerners grow and eat rice, northerners still consume more wheat. In fact, China is the second highest producer of wheat worldwide. In 2013, the 121.7 million metric tonnes it produced put it just behind the EU’s 143.3 million tonnes. Canada was a distant seventh at 37.5 million tonnes. Wheat is famous for jump-starting agrarian civilization and, to this day, grain remains the number-one global source of vegetable protein in human foods. Emmer, the forerunner of wheat, grew in the Fertile Crescent about 11,500 years ago. Large-scale cultivation and ease of long-term storage made it a key factor in the establishment of city-based cultures. Wheat’s popularity can also be attributed to its high protein content, which surpasses that of both corn and rice. In medieval times, wheat became the basic staple for much of the world’s population spreading northward with the rise of Christianity. Christians of the day emphasized the specialness of wheat by likening its harvesting process to the life of Christ. St. Augustine sermonized: “This bread retells your history… You were brought to the threshing floor of the Lord and were threshed… While awaiting catechism, you were like a grain kept in the granary... At the baptismal font you were kneaded into a single dough. In the oven of the Holy Ghost you were baked into God’s true bread.”

LET THEM EAT GRUEL While the holy and the poor subsisted on wheat gruel, the rich fancied extravagant feasts so over the top that sumptuary laws were passed in an effort to curb gross overindulgence. Roe deer, wild boars, kid goats, rabbits, hares, capons, goslings and herons graced the banquet tables of the wealthy. Coloured jellies of gilded swans, peacocks and pheasants adorned with their feathers formed the centerpieces. Complex soups became de rigueur with aristocrats, and the richer the flavour and the more expensive the ingredients the better. They were often served five or six at a sitting sprinkled with saffron, rose water and pomegranate seeds, and were enjoyed in the place of sweets. The church insisted that Christians eat fish on Fridays, not always a popular edict. Many got around the rules by stretching the definition of “fish” to include whales, barnacle geese, puffins and even beavers. Benedictine monasteries were known to out do even the lavishness of noble tables with 16-course meals. During the renaissance, cooks learned to prepare a barrage of strange and wonderful foods from the New World including potatoes, corn, carrots, tomatoes, asparagus and coffee. Those at table were advised to approach these new foods with caution, consuming small amounts at first.

SUGAR DEVIL Sugar cane originated in Southeast Asia. The process of granulated crystallization was discovered in India around 350 AD, and spread quickly to China and the Middle East. Crusaders brought the “sweet salt” home with them. William of Tyre, a crusade chronicler, described sugar as “a most precious product, very necessary for the use and health of mankind.” After 1500, plantations in the New World made it a popular commodity. Sugar had its shadow side, right from the start. Tooth decay aside, it was a highly labour-intensive crop to grow and harvest. The solution: slaves. By 1540, sugar plantations were being set up in Surinam, Brazil, Cuba and the Caribbean. Of the nearly four million slaves sent to the British West Indies, only 400,000 survived. White flour, another a labour-intensive process, could only be afforded by the rich until after the invention of the roller mill and large-scale production. Refined sugar and white flour are now regarded as the two greatest evils of the modern diet.

THE GRAIN DRAIN In his recent best-selling book, Grain Brain, paleo-diet advocate Dr David Perlmutter says that it’s not just wheat, but all grains that are to be avoided. He argues they cause a spike in blood sugar levels, which leads to inflammation and disease. He ascribes dementia and all other neurological disorders to the gluten in wheat, rye, barley and oats, which he calls a “modern poison.” His paleo diet is only one of the most recent ideas of how to achieve optimum health. Opponents point out that healthy groups like the Okinawans and the Kitava of the South Sea who dine largely on starchy tubers and honey are a remarkably lean and robust people. A March 2014 study entitled Low Protein Intake is Associated with a Major Reduction in IGF-1, Cancer and Overall Mortality in the 65 and Younger but Not Older Population published in Cell Metabolism examines the effects of animal protein. Lead by Morgan E. Levine and a host of other researchers, the title sums up the gist of it. Meat and other animal products were shown to cause disease in younger people, but to actually prevent disease in older people. Clearly, we’ve not heard the end of diet discussions which have gone on since humans first questioned what they put in their mouths. There seems to be only one thing that we can agree on these days: green leafy vegetables are good for you and so is exercise. So if you’re feeling lost and confused, go for a run or a game of tennis. When you get home, refuel with some lightly steamed kale or a side of bacon. Pick your poison. OCTOBER 2014 • Doctor’s

Review

D E PRESSIO N C L I NI C AL T A L K by

Valerie Taylor, MD, FRCPC, PhD

Touchy subject Talking about depression in the family practice setting

D .

espite the fact that two out of every 10 patients sitting in your waiting room will suffer from depression at some point, this illness remains severely under-diagnosed (≤ 50%) and under-treated by physicians.1 There is, as yet, no blood test available to establish a diagnosis and the illness presents in a variety of ways. Patients are often unable to articulate what is wrong with them, and may be hesitant to talk about it even if they suspect depression because of the stigma still associated with mental illness. So how then, as busy family physicians, can we initiate a dialogue that will help identify patients suffering from depression and steer those who need it towards treatment?

A foundation for trust and openness Educate all your patients about the signs and symptoms of depression, so that even if they have no concerns at the moment, they become aware of what to watch for in themselves and family members. This information can be shared quickly and will help reassure clients that if depression does become a concern, they can be comfortable talking about it with you. Despite public awareness campaigns, a lot of stigma and fear still surround mental illness and this may prevent some patients from acknowledging that they need help. It is important to normalize the diagnosis, explain its prevalence (20 percent of Canadians will personally experience a mental illness in their lifetime according to the Canadian Mental Health Association)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 • OCTOBER 2014

and the fact that it affects people of all ages, educational and income levels, and cultures. This is often eye-opening and reassuring. It may be important to dispel some urban myths about depression, reassuring patients that a diagnosis does not mean they will be “locked up,” lose their children, be unable to travel, or that their employer will automatically be informed. While these ideas may seem preposterous, there is a lot of misinformation regarding depression that can scare people into suffering in silence. Simple questionnaires that provide a quick screen for depression can be helpful in identifying behavioural changes, especially if used routinely. Three commonly used questionnaires include the Physical Health Questionnaire (PHQ-9), the Sheehan Disability Scale (SDS) and the Beck Depression Inventory (BDI). These types of questionnaires can help to initiate dialogue and highlight areas that require further exploration. It is important to use them to help with screening only, however, as they may lead to overdiagnosis if responses are not adequately followed up.

Life events We need to be especially vigilant for depression in patients who are undergoing physiologic changes and life events known to increase risk for depression, such as pregnancy, the post-partum period and menopause. Make sure to really investigate complaints that could signal depression during those periods. Medical illnesses also place people at increased risk. Patients with serious medical conditions such as heart disease and cancer may be encouraged to raise concerns if you point out that untreated depression can actually worsen physical outcomes (i.e. increase mortality post-heart attack). Be aware of how culture and migration issues can impact the presentation of depression. A diagnosis can be missed because of issues like somatization, or an inability to talk about suicide. Diagnosis can also be missed if depressive symptoms in bereavement or after migration are attributed solely to these experiences. In such cases, a longer evaluation of symptoms such as

appetite, sleep and energy changes may be required and the use of open-ended questions may be valuable.

Helpful questions Depression should not be ruled out simply because a patient answers “No” when asked “Are you depressed?” More productive dialogue might start by inquiring about when they last participated in favourite activities. The question “What do you think is happening?” can also initiate an exploration of possible mood disorders contributing to the ailment that brought them to your office. Recognize that complaints regarding headaches, digestive problems, fatigue, irritability or chronic pain can sometimes indicate depression and may be a patient’s way of saying they are in distress. Use these openings as a way to explore mood symptoms as well. Depression can look different in men than it does in women and may require other lines of questioning. It can be helpful to ask about changes in the use of unhealthy coping behaviours such as excessive alcohol consumption, reckless behavior such as speeding, escapist or solitarily behaviour through sports or work, and becoming quicker to anger.

Acceptance of treatment A conversation about the fact that depression is an illness that can be treated and that earlier recognition and diagnosis will help improve outcomes may increase a patient’s willingness to take action. You can describe that there are a number of options within the treatment armamentarium, as clients may have fears about electro-convulsive therapy, or not want to be required to take a medication without being given other options. In following up suspected depression, encourage patients to talk with family members, or even bring family members to an appointment. An individual may be unaware of how their behaviour has changed and a dialogue with those close to them in the somewhat formal context of a physician visit may give the patient (and you) greater insight. Brush up on your knowledge and skills! There is no doubt that we need to get better at this. Earlier diagnosis and treatment of depression will help improve outcomes and reduce suffering.

Take home messages

References: 1. Ronald Epstein et al. “I didn’t know what was wrong:” how people with undiagnosed depression recognize, name and explain their distress. J Gen Internal Med 2010;25(9):954-61 2. Fast facts about mental Illness. Canadian Mental Health Association. www.cmha.ca. Website accessed September 2014.

• Understand how culture can influence symptoms and the way information is presented.

• Stigma can affect disclosure and it is worth taking time to dispel myths that may make a patient less comfortable with sharing information. • Understand how screening tools can be of help, but remember they are NOT to be used for diagnosis. • Be aware of the multiple comorbid factors, both medical and psychological, that can increase the risk of depression and get in the way of a clear diagnosis. • Remember that gender may impact how depression presents and tailor questions to adequately get the information you need.

• Ensure you ask about both externalizing symptoms (crying, fatigue, sleep and appetite problems) and internalizing ones (hopelessness, guilt, suicidal thinking). OCTOBER 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...

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• 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

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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

The recently redesigned sculpture garden at Philadelphia’s Rodin Museum includes eight works including The Thinker.

Creative think Give NYC a pass. Philadelphia has all the art you want — minus the mobs of people

B. KRIST / VISIT PHILADELPHIA

by Will Aitken

Doctor’s Review • OCTOBER 2014

king he obvious choice for a run-yourself-ragged eastern seaboard weekend of art viewing is Manhattan — if you don’t mind looking at Guernica with 340 other museum-goers listening to canned Picasso lectures on their clattery little lavalier audio guides. For a far more spacious viewing option — and a far less expensive city — Philadelphia offers three world-class museums within walking distance of one another, the Philadelphia Museum of Art, the Barnes Foundation, and the elegant and recently refurbished Rodin Museum. The Philadelphia Museum of Art is the grand dowager of the three and it’s in the process of being radically transformed. Thanks to the original Sylvester Stallone Rocky movie, it boasts one of the most famous museum stone staircases and facades in the world. A Greek Revival,

U-shaped structure, the museum features an imposing ceremonial entrance that, with its eight dolomite Corinthian columns and the graceful pediment they support, echoes the Parthenon. A temple to art of the monolithic kind: large American cities of the late 19th and early 20th centuries threw them up with pecuniary abandon. It opened, in 1928, just in time for the Depression. But what is old school magnificent on the outside feels a bit poky and dimly lighted within, with cul-de-sac corridors and a lack of flow from gallery to gallery. Detractors call it the “Gothic Garage.” After long debate and a number of financial crises, the museum finally hired Frank Gehry to rethink

Doctor’s Review • OCTOBER 2014

M. FISCHETTI / VISIT PHILADELPHIA

the building. His plan will add considerable gallery space and create, in the Athenian mode, a Forum where visitors can meet, greet and people watch — and all for only half a billion dollars. What’s unusual, coming from an architect known for his swooping titanium fantasies like the Guggenheim Bilbao in Spain, is that the museum’s neoclassical exterior will scarcely be touched. Gehry’s expansion (7400 square meters) will be underground; he calls it his “rabbit in a hat trick.” The museum board hopes that his conjuring feat, when it opens in 2015, will raise the museum’s profile, and perhaps the city’s as well, the way the Guggenheim Bilbao changed a drab, industrial city into a major international art destination. Until then, visitors can still explore the original building and its manifold holdings (227,000 items and counting). At times, with its armour collection, Korean porcelains, rooms dedicated to lace or Persian and Turkish carpets, an English drawing room by Robert Adam and yes, Grace Kelly’s wedding dress, it feels like a very grand and slightly dotty granny’s attic, or an omnium-gatherum of all the things that exist in the art world. But this is also the place to see the work of the great American realist painter, photographer and sculptor Thomas Eakins (1844-1916) as well as one of the best collections of American painting and crafts of the last three centuries. Current and upcoming exhibitions include Patrick

B. KRIST / VISIT PHILADELPHIA

The Museum of Art’s armour gallery includes protection for a horse that belonged to Duke Ulrich of Wurttemberg. BELOW: The museum hired Frank Gehry for an underground expansion, but its neoclassical exterior will barely be touched.

Kelly: Runway of Love (through December 7), a retrospective presenting the brash and subversive fashion of the African American designer who was the toast of Paris in the 1980s, a dazzle ended by his death at the age of 36 in 1990. Paul Strand: Master of Modern Photography is on view October 21 through January 4. Strand explored street photography to portraiture to abstraction, and pioneered new forms of landscape photography in the American Southwest, Egypt and Morocco. Further along Benjamin Franklin Parkway, the Barnes Foundation raises its cool, cream-and-white modernist flanks, as much a symbol of early 21stcentury architecture — it opened in 2012 — as the Museum of Art is of early 20th-century style. Modernist bordering on minimalist austerity, the Barnes’ exterior is two great pale stone rectangles from which a luminous cantilevered light box extrudes. The big

The museum was built by Dr Barnes who made his money with an antigonorrhea treatment stacked blocks of stone from the Negev desert evoke the cyclopean stone masses used at ancient Mycenae, while the shining white box above, massive though it is, appears light and airy, like a huge Chinese lantern. The last time I visited the Barnes was in the early 1980s, when it was located in the Main Line, a suburban area south of Philadelphia popular with “oldmoney” families who built their mansions there in the late 19th century. The Barnes collection was in a mansion-esque museum purpose-built by Dr Albert C. Barnes who, up from poverty, made his new money, and scads of it, with an anti-gonorrhea treatment. Dr Barnes’ Foundation wasn’t easy to find; reservations had to be made in advance and the original galleries, 24 in all, were cramped to the point of claustrophobia, the lighting varying from murky to Stygian. But it’s doubtful anyone ever regretted making the trek to the plush suburb because Dr Barnes had a superb eye for art and over four decades assembled a collection of Impressionist, Post-Impressionist and Modernist French paintings valued at US$25 billion in 2010. Shoehorned into one room, an avalanche of Renoir’s luscious pink-bosomed ladies; in another, a whirling circus of Picassos; in a third, a whole countryside of Cézanne landscapes; and interspersed among them shining wonders by Modigliani, Soutine, Seurat, Degas and Van Gogh, along with a Barnes-commissioned mural, the stunning La Danse (II), surely one of Matisse’s greatest works. When the Barnes Foundation hired US architects Tod Williams and Billie Tsien to design a downtown “campus,” there was a great hue and cry, along with legal battles, art critics’ screeds against the move and complaints that Dr Barnes’ legacy was being destroyed. The biggest surprise for visitors to the new building is that the 24 original galleries are still there, minutely recreated and still hewing to Dr Barnes’ ideas about hanging art. The paintings, in their original chunky gold ormolu frames, hang chock-a-block. Barnes abhorred chronological display and often threw canvases together on the basis of colour, subject or form. Best of all, there are no loquacious wall tags telling you what to think. Instead, small printed booklets are available in each gallery with information on what’s on the walls. The architects have preserved the heavy wooden benches from the original building so that viewers, suffering from Stendhal Syndrome — an ecstatic vertigo brought on by too much beauty

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SEEBRI® BREEZHALER® (glycopyrronium bromide) is indicated as a long-term once-daily maintenance bronchodilator treatment in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema.1 Consult the Product Monograph at www.novartis.ca/ SeebriMonograph for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph is also available by calling 1.800.363.8883. 1. SEEBRI ® BREEZHALER® Product Monograph. Novartis Pharmaceuticals Canada Inc., August 7, 2014

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

OCTOBER 2014 • Doctor’s

Review

The architects of the new Barnes designed a “gallery within a garden and a garden within a gallery.”

The Barnes’ new building features the museum’s 24 original galleries with paintings in the same gold frames.

MORE ONLINE

— can safely sit and stare. Or they might ponder Dr Barnes’ fondness for Pennsylvania Dutch metalwork: hinges, bridles, saws and strange objects that look like instruments of torture hang between the ormolu frames. Emerging from this aesthetic bombardment, viewers can decompress in the building’s vast central atrium, the Light Court, its soaring ceiling a light canopy that diffuses soft light into the space. The scale is grand, from the 1000-kilogram, bronzeand-glass entry doors to the massive interlocking acoustic panels that soften sound, but the effect is intimate and warm, with long low seating, a perfect entrance and exit to the honeycomb of galleries. Just next door to the Barnes is the small, exquisite Rodin Museum, a stand-alone building that is technically part of the Philadelphia Museum of Art. Built in 1929, the Beaux Arts edifice, designed by French architect Paul Philippe Cret, originally housed the 227-piece Auguste Rodin collection amassed by a local movie-theatre mogul named Jules Mastbaum. Visiting the Musée Rodin in Paris in 1924, Mastbaum came away with a small bronze bust by Rodin and subsequently began purchasing other pieces.

The new Philly exhibit of a two-storey brain that your kids can climb through. doctorsreview.com/news/new-head-space

Doctor’s Review • OCTOBER 2014

In more recent years, Philadelphia’s Rodin Museum had fallen on hard times. The free-standing sculptures in its surrounding garden corroded by pollution, the garden itself untended and the original interior walls and woodwork painted over, frequently in odious colours. After a $9-million refitting of both building and garden, the museum reopened in 2012, and now stands as the sweetest spot outside of Paris to see the great master of modern sculpture’s works. In the intervening years since Rodin’s death in 1917, it’s become hard to see the artist’s modernity, thanks to the proliferation of bronze casts of dubious provenance and quality, and cities and corporations around the world using them as street furniture or hulking markers of good taste. The Rodin museum restores the shock of the new to the artist’s works by placing one of the three original castings of his Gates of Hell front and centre in the building’s entry portico. (Rodin didn’t live to see his masterpiece in bronze, having worked only on its plaster original, now housed in the Musée d’Orsay in Paris.) Six metres high and four metres wide, the Gates were inspired by early Renaissance sculptor Lorenzo Ghiberti’s Gates of Paradise commissioned for the Baptistery of Saint John in Florence. Ghiberti’s Gates were inspired by scenes from the Old Testament; tempestuous Rodin chose Dante’s Inferno. The Thinker sits atop the Gates and it’s downhill from there on: the lower the figures are positioned on the gates, the more they writhe in agony and despair. Those closest to The Thinker are, like him, classically formed and realistic, but as the eye traces down, the bodies become more abstract, with less anatomically correct detail, in order to arouse more primal emotions. Toward the foot, the figures seems scarcely human, more a terror-stricken mass than suffering individuals. The interior of the museum features pieces that are less alarming and more intimate. There are studies of hands in bronze and marble; busts and statues of the great and glorious (George Bernard Shaw, Gustav Mahler and Balzac) and intensely erotic male and female nudes, sometimes alone, sometimes intertwined that, because of their rough bases, seem to emerge from the earth itself.

STATE OF THE ART Access for two consecutive days to the Philadelphia Museum of Art (2600 Benjamin Franklin Parkway; tel: 215-763-8100; philamuseum.org; closed Mondays) and the Rodin Museum (2151 Benjamin Franklin Parkway; tel: 215-763-8100; rodinmuseum.org; closed Tuesdays) is US$20 for adults. Admission to the Rodin museum only is “pay what you wish;” the suggested donation is US$10. The Barnes Foundation (2025 Benjamin Franklin Parkway; tel: 215-278-7200; barnesfoundation.org; closed Tuesdays) is US$22 for adults.

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

OCTOBER 2014 • Doctor’s

Review

World’s most unpretenti Five reasons why Oregon’s Breitenbush Hot Springs might be your perfect retreat

ALL PHOTOS TILKE ELKINS UNLESS OTHERWISE NOTED

by Tilke Elkins

Breitenbush is so remote you can’t rely on your GPS to get you there.

A N E W A D D ITI O N TO TH E N OVA RTI S CO PD P O RTFO LI O

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YOU WANT A CAR-FREE HOLIDAY

Breitenbush Hot Springs is about 95 kilometres from Salem, the capital of Oregon, an hour south of Portland on the interstate — but you can’t rely on your GPS or MapQuest to get you there. Once you leave I-5, you’ll need detailed directions (see The Way to Relaxation on page 38). The last mile takes you down a US Forest Service dirt road and into a long gravel driveway. Park your vehicle, check in at the beautiful, hand-built wooden office, load your stuff into a twowheeled hauling cart and make your way down the pine-needle lined paths to your cabin, natural hot springs, great outdoor beauty and a whole lot more. It’s just walking paths from now on. Goodbye, cars!

YOU WANT A SPA EXPERIENCE WITHOUT THE HEFTY PRICE TAG Breitenbush has it all: soaking tubs, saunas, classes and workshops in the healing arts, miles of beautiful hikes, and delicious organic vegetarian meals. All of it, including three meals a day and lodging in a rustic cabin, is part of one all-inclusive rate. The seven, clothing-optional pools are open 24 hours a day, except during meal times, when they’re cleaned. Three of them, known as the Meadow Pools, dot the edge of a wild field that overlooks the rushing, turquoise Breitenbush River. Lined with smooth river stones, the pools progress in temperature from warm to invigoratingly hot.

ULTIBRO® BREEZHALER® (indacaterol maleate and glycopyrronium bromide) is a combination of a long-acting ß2 -agonist (LABA) and a long-acting muscarinic antagonist (LAMA), indicated for the long-term once-daily maintenance bronchodilator treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and emphysema.1 Consult the Product Monograph at www.novartis.ca/ UltibroMonograph for contraindications, warnings, precautions, adverse reactions, interactions, dosing, and conditions of clinical use. The Product Monograph is also available by calling 1.800.363.8883. 1. ULTIBRO ® BREEZHALER® Product Monograph. Novartis Pharmaceuticals Canada Inc., August 18, 2014.

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

OCTOBER 2014 • Doctor’s

Review

Four Spiral Hot Tubs make up the remaining pools. Arranged according to the four directions, the deep, round, concrete tubs vary in temperature and include a cold plunge, which elevates the soaking experience to a near-psychedelic realm. The sauna is more of a steam room, heated by a hot river that passes under the cedar floor of a quaint shack. Tiny diamond-shaped windows can be cracked open for a welcome rush of cool air. Daily well-being programs include yoga, meditation, drumming, ecstatic dance and Edgu, a “spinalmaintenance” program developed on-site by one of the staff.

YOU WANT TO RELAX AT YOUR OWN PACE, IN YOUR OWN TIME Wander in and out of class offerings at your whim (no need to sign up), show up for meals any time during mealtime, and soak when it pleases you. Relaxing is the goal here. Breitenbush has a distinctly timeless quality and not much has changed at the place since it opened in 1977. Slickness and sophistication are out; earnestness and sincerity are in. The tiny cabins are dark and a bit gloomy, but the thick mattresses covered in white flannel sheets are surprisingly sleep-inducing. (Bring your own bedding, or rent it for an extra US$17 single or US$23 couple.) The organic, vegetarian meals are served cafeteria-style with an option of a special diet that’s vegan and gluten-free. The meals are undeniably tasty: roasted potatoes with peach-smoked aioli and phyllo broccoli pie for dinner, peanut soup with rice balls and chard salad for lunch, and banana quinoa hot cereal for breakfast, to name a few. The salad bar is abundant, and lunch and dinner are accompanied by chilled herbal drinks with names like tamarind lemongrass cooler and hibiscus-mint-ade. Caffeine alert: bring you own coffee/tea and a way to brew it (hot water provided). But be warned: the soporific effect of the carb-heavy meals may inspire more napping than hiking.

YOU WANT TO BRING THE KIDS

Breitenbush loves kids. Unlike most soaking spas, which have a distinctly for-adults vibe, Breitenbush caters to families. The wide lawn in front of the main lodge is dotted with hula hoops, balls and a mini teepee to play in. Children are welcome in all the tubs, and while you may imagine that this could disrupt the aura of calm necessary for enjoying a good soak, parents

Doctor’s Review • OCTOBER 2014

tend to be watchful and considerate. The spa is run not by individuals, but by a community, which is itself very family-focused. Retreats like, “Shared Heart: Family Spirituality,” and “Beyond Mother’s Day: A Retreat for Moms,” are offered regularly. Specific retreats are an additional cost and a yearly schedule can be viewed online.

YOU WANT TO BE ALONE

In spite of the crowds that show up for the various workshops in tantra, yoga, homeopathy, medicinal wild plants and a host of other ’60s favourites, it is quite possible for a guest to have a quiet, inward experience at the spa. In fact, it’s a good place to be alone, because you can let your guard down in the company of respectful strangers. The network of gorgeous hiking trails that encircles the spa winds through ancient trees and ascends sunny cliffs. After a long leisurely hike where you’re unlikely to cross paths with more than a handful of other guests, retreat to the Silent Pool, the hottest of the three Meadow Pools. If you’re lucky, you’ll position yourself in what’s secretly understood to be the best seat in the house: an indentation on the pool’s side where you can lean back, nestle your head between two smooth stones and put your feet up on the edge. This torso-only immersion allows you to tolerate the heat for longer than usual, so you can sink into an otherworldly reverie to the sound of birds and the rushing river below. After a hearty dinner, retreat to the lodge’s cozy library, also a silent space, where you can peruse a collection of magazines, many of them from the 1980s. But what year is it, anyway? By then, you may have forgotten.

THE WAY TO RELAXATION One of the joys of Breitenbush Hot Springs (53000 Breitenbush Road, Detroit; tel: 503-8533320; reservations required; Monday to Saturday 9am-4pm) is that it’s tucked away off the beaten path. Full directions and a helpful map can be found at breitenbush.com/about/directions.html. Rates are most reasonable at this back-to-basics spa. At peak season, a private cabin with its own toilet costs US$124 per person. To share a cabin with one other “dorm” style, the cost is US$75 each. Children under four get in free, while kids under 16 pay US$39 per overnight stay. Day-use of the spa is also available, priced on a sliding-scale of US$15 to US$28, and includes all daily programs. Add an extra US$100 if you’d like a 90 minute massage during your stay.

The pools are lined with smooth river rocks and are open 24 hours a day.

WONDERLANE / FLICKR.COM

The seven clothing-optional pools progress from warm to invigoratingly hot.

ROBERT ASHWORTH / FLICKR.COM

Some of the year-round cabins have bathrooms.

The steam room is heated by a hot river that passes under the quaint shack.

Devilâ&#x20AC;&#x2122;s Peak is just one of the hiking trails that lead you to mountain vistas.

WONDERLANE / FLICKR.COM

Organic vegetarian meals are served buffet-style three times a day.

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The rare Round Barn, with a diameter of 24 metres, was moved here in 1986 and provides a unique gallery space that hosts a variety of exhibitions.

Fall for Vermont ALL PHOTOS COURTESY SHELBURNE MUSEUM

Add architecture and art to the autumn colours on the generous grounds of the Shelburne Museum by Portlin Cochise

he English romantic poet, John Keats, called autumn “the season of mists and mellow fruitfulness” and so it is, especially in Vermont. People flock here at this time of year to see the coloured hills and the piles of pumpkins at roadside stands, to get lost in cornfield mazes, drink cider and munch on cider donuts, and have supper in rustic inns after late afternoon walks on leaf-strewn mountain paths — to do the things fall urges our hearts to do by the simple cooling of the air.

I’m in Vermont and I could be doing any of those things, but I’m not. I’m in a small cottage at the Shelburne Museum just south of Burlington surrounded by gorgeous 18th-century American furniture. Most pieces emit the soft glow of polished wood generally associated with fine antiques, except this

OCTOBER 2014 • Doctor’s

Review

Shelburne’s folk collection is now recognized as the biggest and best in the US one. This chest is painted in garish pinks and whites and yellows. The curator explains that most furniture of the period was painted — and usually in the brightest colours the makers of the time could find. He compares the furniture with the sculptures of ancient Greece and reminds me that the clean white marble we so much admire now was also originally painted in garish colours. The cottage is near the first historic dwelling brought to museum, the Dutton House built in 1782, which the museum’s founder, Electra Webb, purchased and had transported to Shelburne in 1947. The site has grown considerably since and is more like a version of Colonial Williamsburg, Virginia than the museum moniker suggests. The lushly landscaped property spreads over 18 hectares and is now home to more than two dozen restored houses, barns, a general store, jail, stagecoach shed, lighthouse and the 67-metre paddlewheel steamer, Ticonderoga, that once plied the nearby waters of Lake Champlain. I began my day with the astonishing collection of impressionist paintings on display in the Pizzagalli Center. Yes, impressionist paintings by the masters — Manet, Degas, there are even five Monets — along with better-known American artists of the period. It’s one of the most diverse such collections in the US. Quite a surprise in rural Vermont. Many of the works were acquired in the early part of the last century by Louisine Havemeyer, the mother of the museum’s founder, on the advice of the noted

Doctor’s Review • OCTOBER 2014

American impressionist Mary Cassatt. Havemeyer’s daughter Electra, grew up in the three-storey family home on 5th Avenue in Manhattan and developed a deep appreciation for art and architecture from her parents. Sugar baron H.O. Havemeyer and Louisine were both avid art collectors. They bequeathed almost 2000 pieces to the Metropolitan Museum of Art, which are now in the MET’s permanent collection. As you stroll the grounds you can’t help but be impressed by the woman who had the vision to put it all together. I wanted to find out more about her and, as it happens, it was easily done. After her death in 1960, her children built a substantial columned Greek revival house patterned on one she’d admired in Orwell, VT. They then recreated six rooms of her 1930s Park Avenue apartment inside. No detail was spared right down to the large period photographs that show Central Park from the fifth floor windows. Looking at art and antiques is inspiring, but also tiring and, if you brought the kids, and you should, they’ll be getting restless by now. Check the map you received with your tickets and head over to the cafeteria housed in a building that’s appropriately painted barn-red. Wraps, good salads, passable coffee and a range of fruit are on offer. Afternoon and there’s still an awful lot to see. The Circus Building is a fun place to start. You’ll find it tucked behind the Ticonderoga steamer near the Round Barn. There’s a working merry-go-round too, but keep it a surprise or the kids will drag you there first thing and then be reluctant to leave.

Print Shop

SH ELB U R N E MU S E U M G R O U N D S TOP, LEFT TO RIGHT: Adopt a carousel horse for Shuttle Route restoration, name it, and be recognized on a Shuttle Stops plaque when your steed goes into service. Rest Rooms Info: conservation@shelburnemuseum.org. Food Kids jump for joy at Service the prospect of tearing Informationa 67-metre steamer around the Ticonderoga, Wifion Lake Champlain for that served ports decades. The Pizzagalli Center for Art and V Strollers and backpacks are Education isprohibited the newest additionidentified to the in buildings museum and hosts premier with a V to ensure exhibitions. the safety of

Shaker Shed

Jail

Toy Shop

Hat and Fragrance Textile Gallery V

Horseshoe Barn

Stone Cottage

Schoolhouse

Stagecoach Inn V Meeting House

Vermont House Gallery

Covered Bridge

Dutton House V

Blacksmith Shop

General Store V

School Group Cubbies

Dorset House

Apothecary Shop V

Owl Cottage

Settlers’ House and Barn

Stencil House V

Café

Pleissner Gallery

Variety Unit V

Smokehouse

Horseshoe Barn Annex

our collections.

Pick up a site map at the entrance, you’ll refer to it often as you find your way from building to building.

Weaving Shop

Prentis House V

Sawmill

Webb Gallery V

The Artisans Shop

Lighthouse

Ticonderoga

Locomotive 220

-Railroad Station

Electra Havemeyer Webb Memorial Building V

Rail Car Grand Isle V

Beach Lodge Beach Gallery

Railroad Freight Shed

Museum Exit

Carousel Round Barn Circus Building

Admissions and Museum Store

Center for Art and Education Opening August 18

The Roy Arnold Circus Parade is one of the most popular exhibits. The hand-carved wood circus runs 152 metres and has almost 4000 figures in it. Follow up with the 3500-piece Kirk Bros. Circus, a miniature three-ringer fashioned by Edgar Kirk between 1930 and 1956 using only a jigsaw and a penknife. Still not satisfied? Take a gander at the 500 circus posters touting events at the big top between 1870 and 1940. While you’re there, don’t miss the folk art. There’s even more of it at the Stagecoach Inn and the Brick House, including weathervanes, cigar store figures and scrimshaw, if you’re up for a bit of a trek across the grounds. Electra bought her first piece at age 19 and Shelburne’s folk collection is now recognized as the biggest and best in the US. Having fun? Don’t stop now. Take the short walk to the Toy Shop and take in the museum’s 400 dolls made between 1760 and 1930. And don’t miss the 30 automata: large and (usually) amusing windup toys that can be as tall as one metre and also play music. Boys, young and old, will likely hanker after the American Flyer electric train making it’s way around the tracks. It’s just like the ones that circled so many Christmas trees of lucky male children before 1960. There are dollhouses too, of course, including Ramshackle Inn, a rambling place with an artist’s studio in the attic, and an English Gothic Revival home complete with decorated gingerbread eaves. Hats, perfume or quilts your passion? Stroll through the exhibits in the attached building. The depth and history of the displays are stunning. Take a break now and return to the café for a snack. Pacing is critical at Shelburne. If the weather’s fine choose one of the many gardens and set a spell under a tree. The afternoon wears on and there’s still a lot to see. Now’s the time to regroup and check off any spots you’ve missed: the Blacksmith Shop, perhaps, or the Horseshoe Barn. Stencil House is certainly worth a peek to discover the full effect of wallpaper, without the paper, and a quick nip into the Apothecary Shop would clearly not be out of place. Save your strength, though, for a tour of the Ticonderoga, moored back near the entrance. The paddlewheel steamer is spit and polished and looking its very best. Tables are set in the elegant butternut-and-cherry panelled dining room with its proud goldstenciled ceiling. The ship was briefly a casino and it’s easy to imagine poker games going on here after dinner with whiskey and cigars. The massive engine sits amid ship where big windows reveal huge iron rods and gears powered by two coal-fired boilers that moved the ship up to 27 kilometres per hour. Climb the stairs to the top deck for a view of the entire museum property. I attended a summer camp near here and the highlight of the season was a cruise on the “Ti.” For three hours about a hundred boys roared around the boat getting into every nook and cranny — especially those forbidden to passengers — pursued by an exhausted and increasingly cranky crew. It was heaven! But time grows on, the maples cast long shadows across the lawns and the October breeze runs cold. Red and yellow and brown leaves accumulate in the dips and hollows. A good time to repair to a nook and share a glass. Shelburne town’s Village Wine and Coffee Shop is just such a place (see The Pleasures of Shelburne below).

THE PLEASURES OF SHELBURNE Shelburne is a charming town just 15 minutes south of Burlington on Route 7. The Shelburne Museum (6000 Shelburne Road; tel: 802-985-3346; shelburnemuseum.org) is open from 10am to 5pm daily. Winter admission after November 1 is US$8 for adults, US$5 kids 5 to 17. Open buildings include the Pizzagalli Center for Arts and Education, the Round Barn and the Webb Gallery. The Shelburne Country Store (29 Falls Road; tel: 800-660-3657; shelburne countrystore.com) is packed to the rafters and specializes in Vermont products. The website is a good place to visit before you take the plunge. The Village Wine and Coffee Shop (5288 Shelburne Road; tel: 802-985-8922; villagewineandcoffee.com) is inviting and the coffee is very fine. It’s owned and operated by Kevin Clayton who’s been in the wine business for 25 years. You’ll find many bottles by small, family-owned wineries on his shelves.

Doctor’s Review • OCTOBER 2014

Indications and clinical use • Cymbalta® (duloxetine hydrochloride) is indicated for: • the symptomatic relief of major depressive disorder (MDD) • the symptomatic relief of anxiety causing clinically significant distress in patients with generalized anxiety disorder (GAD) • The efficacy of Cymbalta® in maintaining anxiolytic response for up to 6 months in patients with GAD was demonstrated in a long-term placebo-controlled trial in patients who had initially responded to Cymbalta® during a 6-month 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) Most serious warnings and precautions • Behavioural and emotional changes, including self-harm: SSRIs and other newer antidepressants may be associated with: • Behavioural and emotional changes, including an increased risk of suicidal ideation and behaviour in patients <18 years • Severe agitation-type adverse events coupled with self-harm or harm to others in patients of all ages • Rigorous clinical monitoring for suicidal ideation and behaviour and agitation-type emotional and behavioural changes is advised in patients of all ages • Increased risk of suicidal behaviour in patients ages 18 to 24 years with psychiatric disorder • Discontinuation symptoms: Cymbalta® should not be discontinued abruptly. A gradual dose reduction is recommended. Other relevant warnings and precautions • Cymbalta® should not ordinarily be prescribed to patients with substantial alcohol use as it may be associated with severe liver injury. • Investigate symptoms of liver damage promptly. Discontinue and do not re-start in patients with jaundice. • Bone fracture risk with SSRIs/SNRIs • Risk of increases in blood pressure and heart rate. Monitor as necessary. • Risk of hypertensive crisis in uncontrolled hypertension • Abnormal bleeding risk with SSRIs/SNRIs • Caution of increased bleeding events with concomitant use of NSAIDs, ASA, or other drugs affecting coagulation • Risk of serotonin syndrome or neuroleptic malignant syndrome-like reactions • Risk of urinary hesitation and retention • Risk of serious skin reactions, including Stevens-Johnson syndrome and erythema multiforme • Akathisia/psychomotor restlessness • Caution is advisable when using Cymbalta® in patients with diseases or conditions that produce altered metabolism or hemodynamic responses (e.g. conditions that slow gastric emptying). • Patients with history of drug abuse • Worsened glycemic control in some diabetic patients • Hyponatremia associated with SSRIs and SNRIs • Patients with a history of seizure disorder • Patients with raised intraocular pressure or those with narrow-angle glaucoma • Patients with a history of mania • Effect on ability to drive and use machines • Patients with rare hereditary problems of fructose intolerance, glucose-galactose malabsorption or sucroseisomaltase insufficiency should not take this medicine. For more information Please consult the product monograph at www.lilly.ca/ cymbaltapm/en for important information relating to adverse reactions, drug interactions, dosing and administration which have not been discussed in this piece. The product monograph is also available by calling 1-866-364-4043.

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

Major Depressive Disorder (MDD) 1

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

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

A fair game

Golfers love Palm Springs, and the architecture, desert landscapes and food are also winners by Anita Draycott

Doctorâ&#x20AC;&#x2122;s Review â&#x20AC;˘ OCTOBER 2014

Golf Digest once ranked Pete Dye’s TPC Stadium Course at the La Quinta Resort as one of the toughest in the US.

ubbed the “golf capital of the world” and voted as 2012’s Top North American Golf Destination by the International Association of Golf Tour Operators, the Greater Palm Springs oasis in California is home to more than 100 lush courses and an average of 350 days of sunshine per year. This year I finally checked it off my bucket list. Beyond the fairways, I discovered that Palm Springs has a unique vibe. Think Jetsons architecture, Frank Sinatra clones crooning in piano bars and a laid-back lifestyle that seduces both retirees and younger folks alike.

Back in the 1930s and ‘40s Palm Springs became the playground for the Hollywood set. In those days actors were pretty much “owned” by movie moguls and most contracts stipulated that movie stars had to be within two hours of Hollywood. Palm Springs fit the geographical requirement. Liberace, Lucille Ball, Dinah Shore, Frank Sinatra and Bob Hope all partied in the Coachella Valley. As you drive

OCTOBER 2014 • Doctor’s

Review

PALM SPRINGS BUREAU OF TOURISM

Frank Sinatra paid architect E. Stewart Williams US$150,000 for a Desert Modern house with a piano-shaped pool.

WHERE TO GOLF

The Spanish-style Ingleside Inn is home to Melvyn’s Restaurant, which is popular with celebrities.

around, you’ll notice streets and landmarks named in their honour. Greater Palm Springs consists of nine cities (Palm Springs, Desert Hot Springs, Cathedral City, Rancho Mirage, Palm Desert, Indian Wells, La Quinta, Indio and Coachella) tucked into the folds of the San Jacinto Mountains, across the desert floor and into the foothills of Joshua Tree National Park. Although the region is surrounded by sand, rock and tumbleweed, it’s far from desert-like because most of its cities sit on a giant aquifer. What’s not to like? The ever-changing light on the Santa Rosa and San Jacinto Mountain chains is enchanting and there’s no lack of creature comforts from hot mineral springs to cool cuisine and funky hotels. Plus, you don’t need a movie-star income to enjoy it all.

Doctor’s Review • OCTOBER 2014

The Palms and Valley Courses at the JW Marriott Desert Springs Resort & Spa (tel: 888-538-9459; desertspringsresort.com) are set among 35 acres of rolling greens and fairways with sweeping views of the towering Santa Rosa Mountains. Both courses, originally designed by acclaimed architect Ted Robinson, were recently renovated by his son, Ted Jr., at a cost of US$3 million. There are sparkling streams, lagoons and waterfalls, and Ted Robinson, dubbed “King of the Waterscapes,” lives up to his reputation on the Palms’ signature par-three 17th. To reach the island green, your ball must carry a series of waterfalls and boulder-lined pools that black swans and pink flamingos call home. To augment the challenge, the green sports three “magnetic” bunkers. There’s so much going on here you’ll have to harness all of your powers of concentration to score par. Managed by Troon Golf and owned by the City of Indian Wells, the two courses at Indian Wells Golf Resort (tel: 760-346-4653; indianwellsgolfresort. com) may be the poshest “munis” you’ll ever play. Golfweek ranks both in the Top 20 Public Courses in California. I started on the Celebrity Course, reopened in 2006 after a complete redo by Clive Clark. In addition to spectacular mountain views, the course fea-

Palm Springs is home to some of the world’s best-preserved mid-century architecture tures split-level lakes connected by waterfalls. Exquisite gardens frame every tee deck. The Players Course, by designer John Fought, is a gem with sculpted bunkers reminiscent of Alister Mackenzie’s classics around Melbourne, Australia. Fought took advantage of the plentiful water supply, so bring lots of balls. Time your fight against Fought late in the afternoon so you can relax in the massive new clubhouse filled with memorabilia and signed photos of celebrities. Vue restaurant’s gourmet offerings, such as lamb loin, roasted baby beets and cherry wild rice, are several notches above basic clubhouse grub. Another “muni,” owned by the city of La Quinta, the Arnold Palmer Classic Course at SilverRock (tel: 760-777-8884; silverrock.org) was the former Bob Hope Classic home course from 2008 to 2011. From the tips at 7578 yards some forced carries look so long they might require a flight plan. Water and scrub areas will collect errant shots, as will numerous deep bunkers. The greens are massive, multitiered and were super quick on the day we played. This course demands respect and should be strategically managed from tees that are appropriate to your skill level. When you approach the ritzy clubhouse at Mission Hills Country Club (tel: 760-324-9400; missionhills. com) in Rancho Mirage, you know you’ve arrived at a place of legendary fame. It’s the home of the Dinah Shore Tournament Course and the site of the first Major every year: the LPGA’s Kraft Nabisco Championship. Mission Hills Country Club offers a unique experience with three diverse courses designed by some of the game’s greatest names. Diabolical Pete Dye’s Challenge Course opened in 1988. Arnold Palmer’s contribution is most members’ favourite. Desmond Muirhead designed the Dinah Shore Tournament Course in 1970. It holds the distinct honour of being rated the number one course in the Coachella Valley for many years and has hosted a major championship for more than four decades. A bronze statue of Dinah Shore presides over the 18th green. Ms. Shore, a top golfer herself, used to reside on the first fairway. In 1988 Amy Alcott started the tradition of the winner of the now Kraft Nabisco Championship jumping into the pond beside the 18th island green. In later years, Annika Sorenstam celebrated with a cannonball and Lorena Ochoa took the plunge with her whole family. La Quinta Resort & Club (tel: 760-564-4111; laquintaresort.com) boasts nine courses. Only members can play the private Arnold Palmer, Jack Nicklaus, Tom Weiskopf and Citrus tracts, while the rest of us

can take a swing at the PGA West’s Greg Norman, Nicklaus Tournament or Pete Dye’s TPC Stadium, Dunes and Mountain challenges. The newest at PGA West, the only one in the Coachella Valley to be designed by “Shark” Norman, sports 102 bunkers and water on nine holes of the 7200-yard gem that has been described as a truly “outback” experience. It was recently Audubon certified. If you think the Norman course is difficult, consider that the 17th island green hole at Dye’s TPC Stadium Course is known as Alcatraz and hosts PGA Tour “Q-School” finals every other year. As Dye has said, “Golf is not a fair game, so why build a course fair?”

WHERE TO DINE

Once you’ve said goodbye to yet another Titleist, remember that Palm Springs knows how to pamper your hedonistic side. At Arnold Palmer’s Restaurant (tel: 760-771-4653; arnoldpalmersrestaurant.com) in

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,

DOV_Gel_DocRev.indd 1

OCTOBER 2014 • Doctor’s

Review

14-08-12 9:33 A

PALM SPRINGS BUREAU OF TOURISM

ANITA DRAYCOTT

The Elrod House was built in 1968 for interior designer Arthur Elrod and features a domed, concrete roof with skylights.

La Quinta, try some of the “King’s” favourite comfort foods like meatloaf and pot roast. Cool off with a glass of his chilled Chardonnay and savour the good life under the palms. In 1976, Frank Sinatra and Barbara Blakeley had their pre-wedding dinner at Melvyn’s Restaurant (tel: 760-325-2323; inglesideinn.com) at the iconic Palm Springs Ingleside Inn. It’s been a celebrity hangout for years. There’s nothing hip about Melvyn’s and that’s the way his clientele like it. The restaurant specializes in chateaubriand and flambé desserts. In the evenings, a pianist plays old-time hits and folks take a spin around the Casablanca Lounge dance floor. Don’t miss Sunday brunch with eggs Benedict and an endless flute of Champagne. Melvyn’s is vintage Palm Springs at its best. Splurge at Rancho Mirage’s most awarded restaurant, Wally’s Desert Turtle (tel: 760-568-9321; wallys-desert-turtle.com) where Old Blue Eyes also dined. I recommend the filet mignon crusted with bone marrow and horseradish with a wine jus, celeriac mash and maybe the world’s best Brussels sprouts. However, Dover sole meunière or amandine,

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flown in from Belgium, is the most popular dish. You’ll probably never have a better crème brûlée. Chef/owner Andie Hubka’s unpretentious openkitchen Cork & Fork (tel: 760-777-7555; corkandfork winebar.com) in La Quinta packs folks in nightly. Her concept? A great wine list with many vinos available by the glass to accompany lots of tapas. Try the sesame ahi poke nachos, tequila/lime shrimp tacos and wild mushroom risotto for starters. Leave room for the butterscotch pot de crème with a bacon topping. At Workshop Kitchen + Bar (tel: 760-459-3451; workshoppalmsprings.com) begin with a cocktail. Workshop’s original martini uses a recipe dating back to 1911 concocted by the head bartender of New York’s Knickerbocker Hotel. The menu is meant for sharing. Try the oxtail shepherd’s pie and the duck fat fries with sea salt.

WHERE TO SLEEP

After buying a dilapidated motel in 2001, Bruce Abney and John Aguilar went on a shopping spree in Marrakesh. They filled huge containers with Oriental

Three resort communities in Maui with some of the best golf in the US. doctorsreview.com/features/hawaiis-hole-one

Doctor’s Review • OCTOBER 2014

ANITA DRAYCOTT

PALM SPRINGS BUREAU OF TOURISM

SilverRock’s Arnold Palmer Classic Course is owned by the city of La Quinta.

Built in 1946, the stone-and-steel Kaufmann House was commissioned by a businessman from Pittsburgh who wanted a winter retreat.

rugs, inlaid furniture and colourful lanterns, and transformed the dowdy motel into El Morocco Inn and Spa (tel: 888-288-9905; elmoroccoinn.com; doubles from US$179 per night). El Morocco is located in Desert Hot Springs, renowned for the mineral streams that feed more than 20 spa resorts. Billowing sheer fabrics tent a seductive mineral pool. Guests are welcome to help themselves to homemade cookies, dried figs, dates and Humphrey Bogart mint lemonade; breakfast includes avocados, yogurt, bagels and more. Or you can bring in some groceries and use the Kasbah kitchen. In the heart of Palm Springs’ hip Uptown Design District, the completely renovated Alcazar (tel: 866887-8733; alcazarpalmsprings.com; doubles from US$89 per night) features white rooms that wrap around a pool shaded by lime trees. Some have private patios, fireplaces and Jacuzzis. Espresso and pastries are complimentary each morning. Beside the Indian Wells golf courses, the Hyatt Regency Indian Wells Resort and Spa (tel: 760-3411000; indianwells.hyatt.com; doubles from US$159) makes a terrific base if you prefer a larger hotel. Soak those aching golf muscles in your choice of seven pools or get professional pampering at the Agua Serena Spa.

WHERE TO EXPLORE

Palm Springs is home to some of the world’s bestpreserved modernist architecture of the 1940s, 50s and 60s. You’ll learn more about the designers who shaped the houses of the time — from Richard Neutra to Albert Frey — on Robert Ember’s Modern Architecture Tour (tel: 760-318-6118; palmspringsmoderntours.com; US$85 per person). During the three-hour driving tour, he’ll point out the former homes of Howard Hughes, Jack Benny, Spencer Tracy, Elvis Presley, Liberace and Dinah Shore. On Thursday evenings, head to Villagefest (palmspringsvillagefest.com) on North Palm Canyon

Drive, the main drag in Palm Springs. The street becomes a bustling open-air pedestrian market. Food vendors cook up sizzling dishes, musicians entertain and artisans display their handiwork.

TEE TIME WestJet (tel: 888-937-8538; westjet.com) flies nonstop from Vancouver, Calgary, Edmonton, Winnipeg and Toronto to Palm Springs Airport.

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

OCTOBER 2014 • Doctor’s

Review

Crowd pleasers

Dishes both kids and grownups will love — double-duty not required recipes by

Jane Kennedy

Doctor’s Review • OCTOBER 2014

Mark Roper

ane Kennedy cooks for seven people every single night — and she used to do it in two shifts. Like most kids, her five little ones don’t like “green bits,”

“orange bits,” “hot bits,” and “weird bits,” and ground black pepper is too “hot” for them. To keep the “mealpeace,” she cooked one dish for them at 5:30pm and another for the adults to eat later. Then she realized that she needed to safeguard her sanity. Enter One Dish, Two Ways.

photos by

Published by Hardie Grant Books, her latest cookbook contains basic kidfriendly recipes that can easily be dressed up with spices and herbs for adults. You might have to use two bowls or two baking dishes, but none of the meals require overtime. Our favourites follow.

Vietnamese grilled pork meatballs.

3 tbsp. (45 ml) chopped flat-leaf Italian parsley salt

For adults ½ tsp. (2.5 ml) ground cumin ½ tsp. (2.5 ml) hot paprika ¼ c. (60 ml) Greek-style yogurt freshly snipped chives, to garnish freshly ground black pepper

Green soup.

GREEN SOUP This dish is simply called green soup. The simple addition of chopped chives and a dollop of yogurt is enough to jazz it up for the adults. ¼ c. (60 g) unsalted butter 1 onion, chopped 4 c. (1 L) low-salt vegetable stock 6 c. (1.5 L) shelled fresh peas or frozen peas, thawed 3 tbsp. (45 ml) chopped mint

Melt the butter in a heavy-based saucepan over a medium heat. Cook the onion until translucent, for around 6 to 8 minutes. Add half the stock and bring to a boil. Add the peas, lower the heat and simmer until the peas are tender, about 5 minutes for fresh peas or 2 to 3 minutes for frozen peas. Remove the saucepan from the heat and stir through the parsley, mint and remaining stock, and add salt to taste. Purée the soup in a blender and if it’s too thick, thin it with a little water. Bowl one Serve out the kids’ portions into serving bowls. Bowl two For the adults, return the remaining soup to the saucepan. Add the cumin and paprika, and simmer over a medium heat for 2 to 3 minutes. To serve, add a dollop of yogurt, some chives and lots of pepper. Serves 4.

VIETNAMESE GRILLED PORK MEATBALLS Kids can eat these meatballs straight from the skewer. Adults can slide them off and wrap them in lettuce leaves, along with slivers of cucumber, shredded carrots and fresh herbs. Serve them with a tangy dipping sauce.

1 tbsp. (15 ml) fish sauce 2 tsp. (10 ml) light soy sauce 1 large garlic clove, crushed 1 lb. 2 oz. (500 g) ground pork peanut or vegetable oil, for brushing steamed rice, to serve 8 bamboo skewers, soaked for 30 minutes

For adults 4 iceberg lettuce leaves ½ long cucumber, halved lengthways and sliced on the diagonal 1 carrot, shredded 1 scallion, sliced small handful cilantro leaves small handful Vietnamese mint For the nuoc cham dipping sauce 1½ tbsp. (22.5 ml) fish sauce OCTOBER 2014 • Doctor’s

Review

1 tbsp. (15 ml) lime juice 1 tbsp. (15 ml) rice vinegar ½ tsp. (2.5 ml) brown sugar 1-2 bird’s eye chilies, finely chopped 1 small garlic clove, crushed

Combine the fish sauce, soy sauce and garlic in a bowl. Add the ground pork and mix with your hands. Form the mixture into 28 balls, each about ¾ inch (2 cm) in diameter. Thread the meatballs onto eight presoaked skewers — 3 meatballs per skewer for the kids and 4 meatballs per skewer for adults. Refrigerate the skewers for 30 minutes to let them firm up.

Heat a barbecue grill or a frying pan to a medium-high heat. Brush the meatballs with a little oil and cook them, turning frequently for 6 to 8 minutes or until browned on all sides and cooked through. Dish one Serve the meatball sticks with plain rice for the kids. Dish two To make the nuoc cham sauce, combine the ingredients with 1½ tablespoons (22.5 ml) of water in a small bowl. Serve the meatballs with the lettuce cups, cucumber, carrot, scallion, cilantro and mint, as well as the dipping sauce. Serves 4.

PAD THAI WITH CHICKEN AND SHRIMP Not all kids are into shrimp and cilantro. Feel free to assemble as you’d like. 7 oz. (200 g) packet dry rice noodles 2 tbsp. (30 ml) brown sugar 2½ tbsp. (37.5 ml) fish sauce 1½ tbsp. (22.5 ml) ketchup 3 tsp. (15 ml) worcestershire sauce 2 tbsp. (30 ml) peanut oil 5 garlic cloves, crushed

1 lb. (450 g) boneless, skinless chicken breasts, cut into ¾-inch (2-cm) cubes 2 eggs 2 c. (500 ml) bean sprouts 4 scallions, sliced 3 tbsp. (45 ml) chopped roasted peanuts 2 limes, cut into wedges

For adults 1 tsp. (5 ml) sambal oelek 9 oz. (250 g) shrimp, shelled and deveined

Pad thai with chicken and shrimp.

½ c. (125 ml) chopped cilantro leaves, loosely packed

Prepare the noodles according to the packet instructions. Drain and set aside. Combine the sugar, fish sauce, ketchup and worcestershire sauce, then divide into two small bowls. Dish one Heat 1 tablespoon (15 ml) of peanut oil in a large frying pan or wok over a medium-high heat. Stir-fry half the garlic with half the chicken for 3 minutes. Add one bowl of the sauce mixture and cook for 2 minutes more. Lightly beat 1 egg then add it to the pan and stir constantly for 1 minute. Add half the noodles and toss until coated. Stir in half the bean sprouts and scallions, and toss for 1 minute, or until heated through. Scatter over half the chopped peanuts and serve with wedges of lime for the kids to squeeze over the noodles.

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Dish two Stir the sambal oelek through the remaining sauce mixture. Heat the remaining peanut oil in a frying pan or wok over a medium-high heat. Stir-fry the remaining garlic and chicken for 3 minutes. Add the shrimp and stir-fry for 2 minutes or until the shrimp turn pink. Pour in the sauce and cook for a further 2 minutes. Lightly beat the remaining egg then add it to the pan and cook for 1 minute, stirring constantly. Add the remaining noodles and toss to coat. Stir through the remaining bean sprouts, scallions and half the cilantro. Divide between the adults’ plates. Scatter over the remaining chopped peanuts and cilantro, and garnish with wedges of lime. Serves 4. Recipes and photos from One Dish, Two Ways: Feeding the Family, Without the Fuss (Hardie Grant Books, distributed by Rizzoli New York 2014).

Dishes your kids will love by busy Toronto moms. doctorsreview.com/food/book/how-feed-family

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

OCTOBER 2014 • Doctor’s DOV_Gel_DocRev.indd 1

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One of the most exciting vacations you can go on is a safari in Africa. Do research beforehand to make sure you see everything. Botswana makes the best first port of call. The Big Five — lion, leopard, elephant, buffalo and rhino — are magnificent, but you shouldn’t forget the other wildlife. Watch meerkats looking around to see if they’re safe, wild dogs walking around nonchalantly, not at all interested in you, kudus the size of moose that are constantly grazing, hyenas lying in the mud searching for a carcass that has not been fully devoured by cheetas. The list goes on and on. We came across this elephant and calf on their way to a lake for a cooling mud bath and to drink a few gallons of water. They too did not appear to be concerned about our presence, though I’m sure the mother would become very protective if she was worried that her calf might be injured. There is a phrase that is quite true: “You can get out of Africa, but you can’t get Africa out of you.” Organize a safari before it’s too late. This photo was taken with a Panasonic GH1 f 5.8 1/160 second ISO 125 and a 14-200 lens at 125mm.

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

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

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

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

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