September 2014

Évian’s

MEDICINE ON THE MOVE

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

SEPTEMBER 2014

heavenly waters

LIFE AT SEA How I learned to love cruises Sea time for vegans San Francisco

soul food

History of depression CONTEST! SEE YOUR CELL PHONE PHOTOS IN PRINT PAGE 25

Hike with grizzly bears — or not T H E N O VA R T I S C O P D P O R T F O L I O

SEEBRI, ONBREZ, ULTIBRO and BREEZHALER are registered trademarks.

Product Monographs available on request.

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Cruise to the best

MICHELE SCHWINGBOTH / SHUTTERSTOCK.COM

My first cruise was down the St. Lawrence River out of Montreal to Quebec City and then on to the mouth of the Saguenay. The trip was a reward for a summer of work pedalling tickets on the line to tourists from a booth in a downtown hotel.

The three days and two nights I was on the boat were among the most boring of my life up to then. Pseudo intellectual that I was, the only entertainment I brought on board was Proust’s Remembrance of Things Past. By page six, I realized I’d made a dreadful mistake. Now, many decades later, I’ve progressed to page 52, so a yellowed bookmark placed there years ago tells me.

These days I look at cruises quite differently, a change that is nicely reflected in an article in this issue. How I learned to love cruises, by Mark Bittman, page 47, hits all the positive notes of life on the open waves, albeit aboard luxury liners.

What he likes best is the chance of downtime with nothing to do other than eat and sleep, and nowhere more pressing to go than the pool deck. No Internet, no phone, no one can get you.

What in my youth seemed boring, today feels like the ultimate escape — time to one’s self to do whatever you like.

Vegans at Sea by Christine Homsy, page 41, offers another reason many doctors take to the waves: to relax and earn CME credits in the bargain. And on this particular cruise there is yet another bonus: a plethora of courses on how to live a healthier life. Ms. Homsy’s doctor father, a vegan himself, invited his daughters to join him on the voyage, in part so they could enjoy the benefits of this way of dining. Many physicians were among the participants on the annual holistic cruise, which sails out of Miami every March. The times they are indeed changing.

Best of the best Also in this issue, you’ll find two examples of the best travel writing anywhere. Famiglia and Co. and Hiking Grizzly Country – Or Not are excerpts from a series of the best travel stories in the world. They are a delight. Watch for other “bests” in future issues.

With summer gone, it’s time to plan a quick autumn getaway. The next issue — October — is devoted to that proposition. Happy times at work and play.

Visit

doctorsreview.com David Elkins, Publisher delkins@parkpub.com

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@doctorsreview

SEPTEMBER 2014 • Doctor’s

Review

1

Lolo

™

is now available

LOLO™ and its design are trademarks of Warner Chilcott Company, LLC. © 2014 Actavis Specialty Pharmaceuticals Co., Mississauga, Ont. All rights reserved.

ethinyl estradiol 10 mcg norethindrone acetate 1 mg

Your banking should be as personalized as your patient care.

Specialized banking advice for your practice.

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TD Business Banking Specialists work with you to help keep your business just as healthy with product expertise and specialized banking advice. And because we’re open earlier, open later and even on Sundays,* you can get the advice you need, on your time.

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Visit tdcanadatrust.com/doctors or call 1-888-679-4808 *Individual branch hours vary. 400 branches are open Sundays. ÂŽ The TD logo and other trade-marks are the property of The Toronto-Dominion Bank.

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contents SEPTEMBER 2014

41

features 32

32 52

The ripple effect Dive into France’s Haute-Savoie where the landscape is all about water

by Josephine Matyas

38

Eats from West Waffles, gumbo and more from the Brown Sugar Kitchen in Oakland, CA

by Tanya Holland

Famiglia and Co. Find your roots in Sicily.

Not Italian? Don’t worry about it

by Marcy Gordon

41

Vegans at sea Cruise the Caribbean on the way to healthier living — and CME credits, too

by Christine Homsy

47

How I learned to love cruises Common complaints about holidaying at sea — and why you should ship out anyway

by Mark Bittman

50

Hiking grizzly country — or not Attack Jasper’s backcountry alone, but don’t think about it beforehand

by John Flinn

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,

SEPTEMBER 2014 • Doctor’s DOV_Gel_DocRev.indd 1

Review

5 14-08-12 9:33 AM

When managing pain and inflammation

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

®

The #1 dispensed NSAID in Canada1

2

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

3

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

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

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

Indications and Clinical use: • For relief of symptoms associated with: o Osteoarthritis o Adult Rheumatoid Arthritis o Ankylosing Spondylitis • For the short-term (≤7 days) management of moderate to severe acute pain in adults in conditions such as: musculoskeletal and/ or soft tissue trauma including sprains; postoperative orthopaedic pain; pain following dental extraction In those with increased risk of cardiovascular (CV) or gastrointestinal (GI ) adverse events, consider first other management strategies that do NOT include use of NSAIDs. Limit use to the lowest effective dose and the shortest possible duration to minimize potential risk for CV or GI adverse events.

CELEBREX does NOT treat clinical disease or prevent its progression.

Contraindications: • peri-operative setting of coronary artery bypass graft surgery • 3rd trimester of pregnancy • breastfeeding • severe uncontrolled heart failure • demonstrated allergic-type reactions to sulfonamides • history of asthma, urticaria, or allergic-type reactions after taking ASA or other NSAIDs • active gastric/duodenal/peptic ulcer, active GI bleeding • cerebrovascular bleedings • inflammatory bowel disease • severe liver impairment or active liver disease • severe renal impairment or deteriorating renal disease • known hyperkalemia • patients <18 years of age

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

For more information: Please consult the product monograph at http://www.pfizer.ca/en/ our_products/products/monograph/125 for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece.

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

References: 1. IMS data, September 2012-December 2013. NSAID Market, monthly data, prescriptions.

2. Zhao SZ et al. Evaluation of the functional status aspects of health-related quality of life of patients with osteoarthritis treated with celecoxib. Pharmacother 1999;19:1269-78.

Prospective, multicentre, randomized, double-blind, parallel-group, 12-week trial.

Baseline measurements for CELEBREX, naproxen and placebo, respectively were: total composite: 50.5, 52.9, 51.6; pain: 10.5, 11.0, 10.8; stiffness: 4.7, 5.0, 4.9; physical function: 35.4, 36.6, 36.0.

3. CELEBREX Product Monograph. Pfizer Canada Inc., May 2013.

12-week, double-blind, parallel-group study in 523 patients with OA or rheumatoid arthritis (RA) in whom baseline endoscopies revealed no ulcers. Patients were randomized to CELEBREX 200 mg BID or naproxen 500 mg BID. No long-term, controlled, clinical study specifically designed to assess the CV safety of chronic CELEBREX dosing of any duration has been conducted. However, a meta-analysis of safety data from 41 completed CELEBREX clinical studies of up to 1 year in duration has been conducted, representing 44,308 patients (24,933 [56.3%] patients exposed to CELEBREX, 13,990 [31.6%] patients exposed to NSAIDs, 4,057 (9.2%) patients exposed to placebo, and 1,328 (3.0%) patients exposed to rofecoxib). The number of events for CELEBREX and NSAIDs was: composite CV endpoint (57 vs. 54), CV death (35 vs. 19), non-fatal MI (35 vs. 19) and non-fatal stroke (7 vs. 16).

4. Data on file. Pfizer Canada Inc.

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

contents SEPTEMBER 2014

19

regulars 9 LETTERS Feeling sheepish?

11

PRACTICAL TRAVELLER Canada’s new Museum for Human Rights, the first luxury ship to cruise the Northwest Passage, The Paris of ToulouseLautrec in NYC and more!

by Camille Chin

16

BEST MD APPS A big classic dermatology text that you can now carry in your pocket

by Theo Sands

19

GADGETS The new smartphone technology that’s replacing house keys

by David Elkins

coming next issue • Three truly great — and often overlooked — museums in Philadelphia

11 21

HISTORY OF MEDICINE The depression treatments of yesteryear

by Tilke Elkins

29

TOP 25 The best medical conferences to kick off 2015

56

PHOTO FINISH Call of nature

by Dr Camille B. Forest

contest

YOUR CELL PHONE PHOTOS IN PRINT! Plus, winners will receive a $50 gift card from MEC, Lee Valley Tools or Canadian Tire.

Details on page 25.

• Golf the way they did in the 1950s plus the funk of Palm Springs • Vermont’s Shelburne Museum makes a perfect family day trip especially in fall • Oregon’s Breitenbush Hot Springs celebrates natural living in all its glory • How to talk to patients about depression …and much more

Oxycodone hydrochloride controlled release tablets SEPTEMBER 2014 • Doctor’s

Review

7

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

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

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*

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

LETTERS

EDITOR

David Elkins

Feeling sheepish?

MANAGING EDITOR

Camille Chin

BEACH BOUND I never realized [Flagler Beach] was so close to St. Augustine [Yesterday, FLA, August 2014, page 41]. I have a very good friend who lives there. I swore to her I would make it down one day. After your article, I just may do that. It sounds heavenly!

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

Susan E. Shea Via doctorsreview.com

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

OFFICE MANAGER

Denise Bernier

CIRCULATION MANAGER

Claudia Masciotra

EDITORIAL BOARD

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

MONTREAL HEAD OFFICE

400 McGill Street, 4th Floor Montreal, QC H2Y 2G1 Tel: (514) 397-8833 Fax: (514) 397-0228 Email: editors@doctorsreview.com www.doctorsreview.com

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None of the contents of this publication may be reproduced, stored in a retrieval system or transmitted in any form by any means, without prior permission of the publishers. ISSN 0821-5758 Canadian Publications Mail Sales Product Agreement No. 40063504 Post-paid at St. Laurent, QC. Return undeliverable Canadian addresses to: Circulation Department, 400 McGill Street, 3rd Floor, Montreal, QC, H2Y 2G1.

Subscription rates: One year (12 issues) – $17.95 Two years (24 issues) – $27.95* One year U.S. residents – $48.00 *Quebec residents add PST. All prescription drug advertisements appearing in this publication have been precleared by the Pharmaceutical Advertising Advisory Board.

TO SERVE AND PROTECT Was interested in the illustration of the animalbladder condoms [“Contraception: Silly to Sensational,” History of Medicine, August 2014, page 31]. I’ve been using “lambskin” condoms for years. They are made from a thin layer of sheep cecum, part of the intestine membrane. They provide heightened sensitivity and I recommend them to anyone who has a latex allergy. One major concern is that they do not protect against STDs and so are best used in a relationship where fidelity is not an issue.

Congrats to writer Josephine Matyas on her win at the CTC’s GoMedia Canada Marketplace Awards! Her article Pitch-Black, Picture-Perfect, published in our June 2013 issue and online at doctorsreview.com, took the top place in the Blogging (Canadian media) category.

Y. Paxton Via email

FOR THE RECORD I heard Sri Chinmoy in concert in Toronto some years ago and was quite moved [“Jewels of Happiness,” Review, August 2014, page 17]. Looking forward to receiving a copy of the CD. L. Chatterley Mississauga, ON

Editor’s note: The CD can be ordered at jewelsof happiness.com/book.

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

SEPTEMBER 2014 • Doctor’s

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9

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

Get started at otn.ca/gothedistance.

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

C a mi lle C hi n

Reaching new rights

Winnipeg’s Canadian Museum for Human Rights (CMHR) is this country’s first new national museum since 1967 and the first one to be located outside the Ottawa region.

The $351-million project is on Treaty One land at The Forks where the Red and Assiniboine rivers meet which has been a gathering place for trade and to resolve disputes for over 6000 years. It’s the only museum in the world that’s entirely devoted to human rights issues, explored, in part, through stories about aboriginals, women, children, persons with disabilities and the LGBTTQ community. Designed by Antoine Predock, an American architect based in Albuquerque, New Mexico, the CMHR combines Tyndall stone and glass in four sections.

There’s the “roots” at the base of the museum; the “mountain” for permanent exhibits; the glass “cloud” and the 23-storey “Tower of Hope.” Inside, there are 11 galleries, and theatre and performing arts spaces. Adults $15; kids 7 to 17 $8.

Closed Mondays. tel: (877) 877-6037; humanrights.ca.

SEPTEMBER 2014 • Doctor’s

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

Orange is the new track The August 18 opening of the Dallas Area Rapid Transit’s last Orange Line segment means that the longest light rail system in the US is now linked to one of the world’s busiest airports. The new eight-kilometre segment links the Belt Line Station to Dallas/Fort Worth International Airport’s newly renovated Terminal A, which now makes the entire Orange Line 22.5 kilometres long.

It provides access to landmarks like the Mustangs of Las Colinas, Irving Convention Center, Dallas Museum of Art, Perot Museum, Klyde Warren Park, the famous West End, American Airlines Center and Downtown Plano. The first Orange Line train departing downtown Dallas arrives at the airport at 3:50am; the last departing the airport for downtown at 1:12am weekdays, 12:12am weekends. A two-hour pass costs US$2.50; a day pass US$5. dart.org/ riding/dfwairport.asp.

By the end of 2014, Hilton HHonors members will be able to check-in and choose any room they want at 4000 Hilton Worldwide properties in 80-plus countries without mumbling so much as a peep to hotel staff. At 6am the day before a booked stay, members will be able to sign into their account online or via HHonors’ mobile app to choose their room through floor plans or lists showing the hotel’s available inventory, which is updated in real-time. There’ll also be photos of the rooms to help guests make their selection. Digital check-out and technology that’ll let smartphones replace room keys will be rolled out through 2015/16 at the majority of Hilton Worldwide properties.

12

Doctor’s Review • SEPTEMBER 2014

PHOTOS COURTESY HILTON HOTELS AND RESORTS

Suite yourself

The Elegant Elbe river cruise.

A longship runs through it According to a November 2013 article on CruiseCritic, “river cruising is still the fastest-growing sector in the cruise industry.” The entrepreneurial minds behind Viking Cruises would probably agree. The company christened 16 longships in 24 hours this past March, which, according to a Guinness World Records adjudicator, was “the most ships [ever] inaugurated in one day by one company.” Viking also christened two other river vessels that month.

Fast forward to April and May for more expansion; Viking has ordered 12 additional longships for 2015 and two unique river vessels designed specifically for their Elegant Elbe itinerary. All of Viking’s river vessels are designed for a few hundred guests at most and are purpose-built for the waters they sail.

They feature all-outside staterooms, many of which include full verandas or French balconies. Its longships are known for their indoor/outdoor Aquavit Terraces with retractable floor-to-ceiling glass doors. tel: (800) 207-7286; vikingcruisescanada.com.

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,

SEPTEMBER 2014 • Doctor’s DOV_Gel_DocRev.indd 1

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

Paris in NYC

Jane Avril, 1899.

The Paris of Toulouse-Lautrec: Prints and Posters, on through March 22, 2015 at NYC’s Museum of Modern Art, is the first MoMA exhibit devoted to the French painter in 30 years. It consists of 100 prints and posters of the Belle Époque that celebrate Parisian life in the late 19th-century.

The exhibit features five themes: the café-concerts and dance halls section depicts nighttime venues like the Moulin Rouge. A second focuses on the singers and dancers that were Toulouse-Lautrec’s muses among them can-can dancer Jane Avril. A third offers a more intimate portrayal of women and includes Toulouse-Lautrec’s Elles portfolio of prostitutes during nonworking hours; they’re seen in rumpled sheets just before waking or sipping coffee in boudoirs. Designs for song sheets and theatre productions are also on view as are Parisian pastimes like strolling the Bois de Boulogne and horse racing at Longchamp. Adults US$25; kids under 16 free. tel: (212) 708-9400; moma.org.

PHOTOS THIS PAGE COURTESY THE MUSEUM OF MODERN ART, NEW YORK

The Box with the Gilded Mask, 1894.

Queen of Joy, 1892.

MORE ONLINE

14

Divan Japonais, 1893.

All about Albi: the quiet, medieval city in the French southwest that Toulouse-Lautrec called home. doctorsreview.com/features/lautrec-legacy

Doctor’s Review • SEPTEMBER 2014

Cruise to the top

To

Claudia Masciotra

For

Doctor’s Review

Fax

1-855-861-0790

HAWAIIAN I SLANDS

Sep 2015

Crystal Cruises has been exploring the idea of sailing the Northwest Passage for the last two years. Beginning August 16, 2016, it’ll be the first large, luxury line to do just that on a trip that will last 32 days. The Northwest Passage is a series of waterways north of the Arctic Circle that link the Atlantic and Pacific Oceans, from Greenland through the Canadian Arctic Archipelago and onwards into the Beaufort Sea. It was originally conceived of as a shorter trade route between Europe and Asia, and it captured the imaginations of ambitious royalty and adventurers for centuries. Fourteen expedition experts will join the Anchorage, AK-to-NYC sailing aboard Crystal’s Serenity. Its itinerary is flexible and will include unscheduled “expedition days” — wildlife viewing of polar bears, caribou, musk oxen and narwhals, trekking the tundra, kayaking in protected bays, zodiac landings — when the weather permits. Under the approval of locals, it will visit remote communities. (There will be more people aboard the 1070-passenger Serenity than in some communities, but only 100 to 200 guests will be issue allowed onshore at a time.) An escort vessel with a platform for wilderness landings and a helicopter will accompany the voyage. From US$19,755 per person. For more on how the cruise line intends to protect the environment and the locals: crystalcruises.com/NWP-FAQ.

CME CRUISES

TAHITI AND TUAMOTUS IS.

Apr 20 - May 1, 2015 Charting a new course in patient care

Mar 18 - 28, 2015 Tahitian CME pearls 2015

BRITISH ISLES

FIJI, TONGA, COOK IS. TAHITI

Jul 15 - 27, 2015 10th annual Update in Medicine with 2 days in Edinburgh for British Open

call today

1-888-647-7327

Nov 10 - 20, 2015 Endocrinology, Diabetes, Obesity

HOT DEAL: New CME. New ship. Only 40 rooms available Jun 15-24/15 Singapore, Vietnam, Hong Kong, Shanghai

voted WORLD’s BEST small ship cruise line

www.seacourses.com for more CME cruises

SEPTEMBER 2014 • Doctor’s

Review

15

BEST MD APPS by

T he o S a n d s

A derm classic goes electronic Many of the apps featured in this column are free or cost only a few dollars. This is emphatically not the case with Lookingbill and Marks’ Principles of Dermatology

by Elsevier.

The classic introductory text is now available in an app that’s priced at US$89.99 — you can get the newest edition (June 2013) in paperback on Amazon for US$79.65.

The key advantage to having it on an iPad or iPhone (there’s no Android app yet) is portability; a second is the search function.

The opening screen shows full-content pages, and any and all of your bookmarks: another plus. Each chapter

also has links to sections within it (very handy) and a note-taking page.

Thumbnails of images appear at the top of the screen, another search timesaver. Click on an image and it opens on full screen, which also includes a clearly written caption.

The search tab works well and allows users to search by either word or image. There are also 17 case-based self-assessment features that begin with an image of a condition, and ask for a diagnosis and workup.

Overall assessment: the app is easy to use, and the search function and ability to enlarge photos makes it a better bet than the hard copy.

Lookingbill and Marks’ Principles of Dermatology

by Usatine Media LLC Devices: iPad and iPhone only Cost: US$89.99

MORE ONLINE

16

Put this acclaimed UBC-developed drug formulary in your pocket. doctorsreview.com/gadgets/formulary-finds-it-fast/ Doctor’s Review • SEPTEMBER 2014

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

THE NEW cma.ca

OPTIMIZED. MOBILIZED. PERSONALIZED.

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

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

cma.ca/new mObilized

persOnalized

2588

Optimized

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.

GA D GE T S by

D a v i d Elk i n s

Unlock your door with your smartphone

The Goji (above) features a camera.

The August (right) is available in four colours.

Front-door locks that you can operate with a smartphone have been around for a few years, but now the bugs have been worked out and there are a couple of spiffy new models on the market.

The big advantage: your phone can unlock the door as you approach — no more fumbling for keys.

They’re easy to install often right over your existing deadbolt so you may not have to replace your existing lock. Most operate using a key as well, just in case. Still, it’s buyer beware. Not all locks work the same way or have the same features.

All models do work, however, by opening the lock when it receives a signal from a smartphone.

Duplicate electronic “keys” can be programmed into the phones of family, friends and service people.

For the latter, you can limit the times in which the keys will work.

One important question: how secure are they?

The answer: not very. They can be hacked, but there are some work arounds. One model — the Goji — takes photos of anyone who comes to the door and sends it to your phone. Others will send a message telling you the door has been unlocked.

Here’s a quick look at three models. Research the model you want carefully before you buy.

August The newest entry is designed by noted Swiss designer, Yves Béhar. A 9-centimetre disk fits on the inside of the door and comes in four different colours. It operates on Bluetooth using two AA batteries. Comes with a key fob and can be programmed for extra electronic “keys.” US$199. august.com.

Kwikset Kevo Compatible with all popular Kwikset deadbolts. Easy to install inside, it can detect whether your phone is inside or outside the house, a security feature worth considering.

Bluetooth 4 and iPhone only. Four AA batteries.

Key fob and multiple electronic keys. US$220. kwikset.com.

Goji Introduced earlier this year, it attaches to the outside of the door. It includes a replacement for your current deadbolt and features a camera (a small hole has to be drilled through the door for a wire). Bluetooth and Wi-Fi. Four AA batteries.

Key fob and multiple electronic keys. US$278. gojiaccess.com.

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

cma.ca/new Optimized

mObilized

persOnalized

SEPTEMBER 2014 • Doctor’s

Review

19

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

T i lk e Elk i n s

Planet of the blues?

It seems to be human is to suffer from depression — and women suffer more “The fog is like a cage without a key.” — Elizabeth Wurtzel

D

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.

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 • Doctor’s

Review

21

NOT ALL BAD?

The Renaissance saw a return to the Greek idea of melancholy as a sign of philosophic depth. Those with depression were seen as victims of possession by demons rather than as sinners.

In northern Europe, men who were depressed because their penises had been stolen by witches were found to be delusional — since the stolen organs could easily be confirmed to be right where they always had been. This introduced the idea that the ones who had “stolen” the penises were also delusional.

Witches were merely depressed and foolish old women, said the Englishman Reginald Scott in 1584. Gradually, this idea of illness rather than possession became commonplace.

Plato and Aristotle introduced the notion that divine madness was associated with melancholia. While Aristotle sought ways to treat the condition, he also thought a certain amount of black bile was necessary to genius. “All those who have attained excellence in philosophy, in poetry, in art and in politics, even Socrates and Plato, had a melancholic habitus; indeed, even some suffering from melancholic disease,” he wrote.

This view was vigorously suppressed by the rise of Christianity, a dangerous time to be depressed. Saint It was once thought that an imbalance of the four humours caused depression.

Augustine’s assertion that reason separated men from beasts invited the conclusion that the loss of reason was a sign of God’s disfavour.

Melancholics themselves were to blame for their lack of joy in God’s love and mercy.

By the time of the Inquisition, depressives were fined or imprisoned for their sin. The medieval Church defined acedia, or The French were the first to effectively treat depression-relatsloth, with its depression-like symptoms, as one of the deadly sins. ed symptoms. Montaigne, himself a depressive, created a sort of anti-melancholic theatre of illusion. He cured one woman suffering from terror associated with the thought of having swallowed a needle by having her vomit and introducing a needle into the vomit by slight of hand.

Melancholy was a common affliction by the 17th century, one that could be as pleasurable as it was unpleasant. Writers all over Europe were swept up in romantic Aristotelian notions of melancholy. Brilliant men suffered and lesser pretended to suffer.

The dark-eyed, taciturn, disheveled, surly upper-class malcontent became a social prototype and fodder for a cast of Shakespearean characters, Hamlet being the most famous.

In 1621, Robert Burton’s The Anatomy of Melancholy emphasized the real ties between medicine and philosophy, and introduced the modern principle that everyone has a different level of tolerance for trauma. His cures for depression included addressing the “passions and perturbations of the mind” by “opening up” to friends and family and seeking out “mirth, music, and merry company.”

Despite his insights, he continued to recommend eating certain foods including marigold, dandelion, ash, willow, tamarisk, violets, sweet apples, wine, tobacco, syrup of poppy, and St. John’s wort, “if gathered on a Friday in the hour of Jupiter.” Wearing a ring made from the right forefoot of an ass would also be a help.

FIRST EFFECTIVE TREATMENTS

NEW BAD IDEAS The upper-class malcontent became fodder for Shakespearean characters like Hamlet.

22

Doctor’s Review • SEPTEMBER 2014

The idea that depression changes the physical makeup of the brain was introduced in 1672 by the English physician Thomas Willis, who declared in his Two Discourses Concerning the Soul of Brutes that melancholic blood can “cut new Porosites in the neighbouring bodies.”

Wilhelm Griesinger, born in Germany in 1817, can be credited as the first to fully medicalize depression Further scientific advances came when Nicholas Robinson proposed the fibrous model of the body in 1729, calling for “the most violent vomits, the most purging medicins, and large bleedings, […] to be often repeated.” He wasn’t so big on talk therapy, saying, “You may as soon attempt to council a man out of the most violent fever.”

As the Age of Reason ramped up, the social position of the depressive once again entered a slump. The association of depression with religious waywardness faded, replaced by reason’s triumph over faith. In mental asylums one could hope the depressed would attract less attention than the noisy ranting and raving of many of their fellow inmates, and so escape the hideous treatments that passed for cures. It was not so; places like Bedlam, the famous British asylum, were equal opportunity torturers. Most prominent was the continued idea that great physical pain would distract the depressed patients, so all manner of grotesque devices were invented to simulate drowning or cause melancholics to swoon and vomit.

Women, who also suffered from such treatments, began to voice their malaise more audibly. The Marquise du Deffand wrote to a friend in England, “You cannot possibly have any conception of what it is like to think and yet have no occupation.” In America, Cotton Mather, known in the early part of his life for extreme moral judgment, found himself sympathizing with his wife’s depression which, he thought, was “little short of a proper satanical possession.” Still, he focused on treatments rather than causes, recommending the dubious cure of the application of “two living swallows, cut in two, and laid hott reeking onto the shaved head.”

GETTING MODERN The 19th century marked the beginning of a more humane treatment of mental illness. Wilhelm Griesinger, born in Germany in 1817, can be credited as the first to fully medicalize depression. He agreed with Hippocrates, and declared that all “mental diseases are brain diseases” and was the first to suggest that some mental illnesses are only treatable, while others are curable. Brain autopsies became common on the basis of his work, especially in the case of suicides.

Sigmund Freud’s Mourning and Melancholia contributed significantly to the contemporary understanding of depression.

“In grief,” he wrote, “the world becomes poor and empty; in melancholia, it is the ego itself [which becomes poor and empty].” If Freud was the father of psychoanalysis, then Emil Kraepelin was the father of psychobiology. His work birthed the idea that depression is caused by internal chemical processes that are somehow beyond the control of the afflicted.

He opened the door which eventually led to the discovery of antidepressants in the early 1950s.

Depression increasingly came to be associated with women.

Charlotte Perkins Gilman captured the social backwardness

This book, published in 1621, introduced the idea that everyone has a different level of tolerance for trauma. BELOW: Burton’s cures for depression included St. John’s wort “gathered on a Friday” and “hung about the neck.”

SEPTEMBER 2014 • Doctor’s

Review

23

Premenstrual symptoms and postpartum depression are conditions that can benefit from treatment of her time in her tale of a mother with postpartum today by the World Health Organization. The first depression who is misguidedly confined to a garuseable serotonin drug, citalopram (Celexa) was ret room and gradually loses her sanity. Virmarketed in 1986. gina Woolf and Sylvia Plath were literary Two kinds of talk therapy have evolved geniuses driven to suicide by depression. as having the best record for healing Today, one in eight women will expethrough insight. Cognitive-behavioural rience a major depressive episode in her therapy (CBT), pioneered by Arthur T. lifetime. While men are more likely to Beck in the 1960s, works to transform die during suicide attempts, women reunhelpful thought patterns or “automatport attempting suicide twice as often as ic thoughts.” Interpersonal therapy men. One in four depressed women are (IPT), developed at Yale University dispensed medication while only 15 peraround the same time, encourages incent of men treated for depression are presights into past experiences to find a stratscribed drugs. The difference in the statisegy for moving forward in life.

Emil Kraepelin was the first to tics is thought to reflect both female More than 2500 years have passed since suggest that an internal hormonal fluctuations as well as social presHippocrates had that heart-to-heart with sad chemical process causes depression. sures that women face, particularly the modern King Perdiccas who was cured by marrying his pressures to balance motherhood and career. Presweetheart. Today, the father of western medicine, menstrual symptom and postpartum depression have would doubtless follow up the chat with a prescription. gradually become recognized as medical conditions that can He might also offer his new wife a little marital advice and benefit from treatment. suggest that she come back to see him if family life became more than she could bear.

ANTIDEPRESSANTS ARRIVE

The story of the origin of antidepressants describes a group of patients with tuberculosis who, when treated with a new compound called iproniazid, became curiously exultant. But the discovery popped up in a number of places: Nathan Kline, in the US, discovered the substance and may have been aware of its function as a MAO inhibitor. Lurie and Salzer showed good results with isoniazid, and Roland Kuhn in Germany discovered the tricyclic imipramine, still in use

Wilhelm Griesinger agreed with Hippocrates and declared that “all mental diseases are brain diseases.”

24

Doctor’s Review • SEPTEMBER 2014

Sylvia Plath suffered from depression and it led to her suicide at the age of 30.

OW N R

E T N E

Canadian cell phone photo contest!

Snap a few shots with your mobile phone around your neighbourhood and e-mail them to us.

No restrictions on subject: pets and/or kids, your neighbours, the corner store, clouds, rainbows, the moon at midnightâ&#x20AC;Ś originality counts!

Winners will receive a $50 gift card for a choice of Mountain Equipment Co-op, Lee Valley Tools or Canadian Tire.

The winning photos will appear in print and online.

TO ENTER Email photos and a caption to editors@doctorsreview.com Deadline: October 15. doctorsreview.com

“I felt down and

overwhelmed nearly every day.”

Nicole*, 37

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

For patients like Nicole...

Indication and clinical use

Trust PRISTIQ

for powerful

symptom relief

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

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

Most serious warnings and precautions

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

due to adverse events comparable to placebo

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

• No statistical difference in mean weight change

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

• Low incidence of sexual function adverse events

demonstrated at 8 weeks

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

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

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

For more information Please consult the product monograph at http://www.pfizer.ca/en/our_products/products/ monograph/226 for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece.

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

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

for powerful symptom relief

®

PRISTIQ Wyeth LLC, owner/ Pfizer Canada Inc., Licensee © 2013 Pfizer Canada Inc. Kirkland, Quebec H9J 2M5 CA0113PRI024E

®

FORMULATED WITH INACTIVE INGREDIENTS INTENDED TO MAKE THE TABLET MORE DIFFICULT TO MANIPULATE FOR MISUSE AND ABUSE.*

HTR TECHNOLOGY TM HARDENS THE TABLETS TO REDUCE THE RISK OF BEING BROKEN, CHEWED OR CRUSHED.*

OxyNEO® (oxycodone hydrochloride controlled release tablets) is indicated for the management of pain severe enough to require daily, continuous, long-term opioid treatment, and: • that is opioid-responsive; and • for which alternative options are inadequate.

OxyNEO is not indicated as an as-needed (prn) analgesic.

Consult the Product Monograph at http://www.purdue.ca/files/OxyNEO%20PM%20EN.pdf for important information on: • Contraindications in patients who are hypersensitive to the active substance (oxycodone) or other opioid analgesics or to any ingredient in the formulation, patients with known or suspected mechanical gastrointestinal obstruction or any diseases/conditions that affect bowel transit, patients with suspected surgical abdomen, patients with mild, intermittent or short duration pain that can be managed with other pain medications, the management of acute pain, patients with acute

A MATRIX WITH HYDROGELLING PROPERTIES: PARTICLES OR WHOLE TABLETS BECOME HIGHLY VISCOUS (GEL-LIKE) IN WATER.*

asthma or other obstructive airway, and status asthmaticus, patients with acute respiratory depression, elevated carbon dioxide levels in the blood, and cor pulmonale, patients with acute alcoholism, delirium tremens, and convulsive disorders, patients with severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury, patients taking monoamine oxidase (MAO) inhibitors (or within 14 days of such therapy), and women who are breast-feeding, pregnant, or during labour and delivery • Most serious warnings and precautions regarding swallowing tablets whole, potential difficulties swallowing tablets, administration via nasogastric, gastric or other feeding tubes, fatal respiratory depression, and inappropriate use • Other relevant warnings and precautions regarding alcohol consumption, hyperalgesia at high doses, abuse, severe hypotension in patients whose ability to maintain adequate blood pressure is compromised, tolerance, physical dependence, and psychological dependence, patients with a

history of alcohol and drug abuse, abrupt discontinuation, patients who have any underlying GI disorders, decreased bowel motility, concomitant administration of CNS depressants, patients with a head injury, use for pre-emptive analgesia or in the early post-operative period, impairment of mental and/or physical abilities, patients with substantially decreased respiratory reserve, pre-existing respiratory depression, hypoxia or hypercapnia, debilitated patients, patients with severely reduced hepatic or renal function or severely impaired pulmonary function, patients with Addison’s disease, hypothyroidism, myxedema, toxic psychosis, prostatic hypertrophy or urethral stricture, and dose selection in geriatrics (> 65 years of age) • Conditions of clinical use, adverse reactions, drug interactions and dosing/administration instructions The Product Monograph is also available by calling Purdue Pharma at 1-800-387-4501.

HTR Technology™ is a unique recrystallization process. *Comparative clinical significance has not been established.

OxyNEO® and HTR TechnologyTM are trademarks of Purdue Pharma. © 2014 Purdue Pharma. All rights reserved.

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings compiled by Camille Chin

The Halifax Citadel.

© CTC

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

Canada Banff, AB 60th Annual Scientific Assembly of the Alberta College of Family Physicians acfp.ca/what-we-do/annual-scientific-assembly

February 27-March 2, 2015 Canadian Digestive Disease Week 2015 cag-acg.org/annual-conference-cddw

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

Banff National Park.

© CTC

February 26-28, 2015

Quebec City, QC February 4-7, 2015

Around the world

2015 Annual Scientific Meeting of the Canadian Rheumatology Association rheum.ca/en/events

Cancún, Mexico February 16-20, 2015

Vancouver, BC March 4-5, 2015

February 23-27, 2015

6th International Conference on Fetal Alcohol Spectrum Disorder interprofessional.ubc.ca

18th Annual Mayo Clinic Endocrine Update mayo.edu/cme/find-a-course 20th Annual Cardiology at Cancún: Topics in Clinical Cardiology mayo.edu/cme/find-a-course

™ Trademark 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-Grastek_E1.indd 1

SEPTEMBER 2014 • Doctor’s

29

2014-07-07 Review

6:18 PM

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings Music City in Nashville.

Honolulu, HI February 3-6, 2015 11th International Kawasaki Disease Symposium my.americanheart.org/ikds

Houston, TX February 20-24, 2015 2015 Annual Meeting of the American Academy of Allergy, Asthma and Immunology annualmeeting.aaaai.org

Kauai, HI February 2-6, 2015 F11PHOTO / SHUTTERSTOCK.COM

Arrhythmias and the Heart: a Cardiovascular Update mayo.edu/cme/find-a-course

Lake Tahoe, CA February 23-27, 2015 Emergency Medicine 2015: 38th Annual Winter Conference ucdmc.ucdavis.edu/cme

Long Beach, CA February 14-17, 2015 Clinical Nutrition Week 2015 nutritioncare.org/CNW

Miami Beach, FL February 19-22, 2015 13th Annual Cardiovascular Disease Prevention International Symposium cme.baptisthealth.net/cvdprevention

Maui, HI February 7-13, 2015 Pediatric Potpourri: State of the Art 2015 childrenshospitallamedicalgroup.org

February 23-27, 2015 Mayo Clinic Gastroenterology and Hepatology 2015 mayo.edu/cme/find-a-course

Nashville, TN February 11-13, 2015 International Stroke Conference 2015 strokeconference.org

30

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

Paris, France February 18-21, 2015

Sacramento, CA February 6-7, 2015

Philadelphia, PA February 25-28, 2015

San Diego, CA February 2-7, 2015

8th International Conference on Advanced Technologies and Treatments for Diabetes attd.kenes.com

2015 Annual Assembly of the American Academy of Hospice and Palliative Medicine aahpm.org/meetings/assembly

Oahu, HI February 11-14, 2015 Advancements in Urology 2015: AUA/JUA Symposium auanet.org/education/education-calendar.cfm

February 15-19, 2015

9th Annual Vascular Care: Best Practices and Innovative Approaches and 14th Biennial Strandness Symposium ucdmc.ucdavis.edu/cme

For conference details: doctorsreview.com/meetings

33rd Annual UC Davis Infectious Diseases Conference ucdmc.ucdavis.edu/cme

35th Annual Pregnancy Meeting smfm.org/the-pregnancy-meeting

February 26-March 1, 2015 25th Annual Meeting of the American Glaucoma Society americanglaucomasociety.net/meeting

Snowbird, UT February 13-16, 2015 40th Annual Cardiovascular Conference at Snowbird mayo.edu/cme/find-a-course

St. Petersburg, FL February 6-9, 2015 15th Annual International Symposium on Congenital Heart Disease allkids.org/conferences

SEPTEMBER 2014 • Doctor’s

Review

31

The

ripple effect JOHN LUMB / SHUTTERSTOCK.COM

Discover the Haute-Savoie in France’s Rhône-Alpes where the landscape is all about water

by Josephine Matyas

32

Doctor’s Review • SEPTEMBER 2014

After Napoleon and Josephine’s visit to Annecy in 1860, people flocked to the town to see the blue-green lake and surrounding hillsides.

hances are you know the water of the Haute-Savoie, even if you would be hard pressed to flip open an atlas and pinpoint its exact location. This is the landscape that produces Evian — the ubiquitous bottle gracing the tables of bistros worldwide — and a landscape of water frozen in time and space in the country’s largest glacier and the Alps’ tallest mountain. The geography is blanketed with lakes and rivers and springs and canals.

At its heart, the Haute-Savoie is about water.

Built in the 14th century, this château was acquired by the d’Yvoire family in 1655 and has since been a private residence.

© OT EVIAN

The same Evian water sold at shops worldwide flows nonstop from two springs in Évian-les-Bains.

JOSEPHINE MATYAS

The wild, ice-capped peaks of the French, Swiss and Italian Alps are just two hours from Évian’s spas and springs.

JOSEPHINE MATYAS

LUKASZ JANYST / SHUTTERSTOCK.COM

Two cable cars take about 600 people up to the Aiguille du Midi every hour for a visit that’s 2½ hours long.

The Aiguille du Midi was outside of my comfort zone, but the 430 steps down to the ice grotto had my name all over it The Rhône River and the towering French Alps give the region its name. The valleys are a collage of small villages and farms with a culinary pedigree that produces one-quarter of the country’s 400 varieties of cheese. There are white wines, pressed from the Chasselas grapes and poured when indulging in mountain specialties like fondue and raclette, and fresh-caught, pan-fried perch from Lake Léman.

ÉVIAN-LES-BAINS “Évian is definitely the water city,” said guide Evelyne Hurtaud in a tone leaving no room for debate.

Turning 360-degrees I spotted signs of water in every direction. On the shoreline of Lake Léman, the northerly view across the lake is of Lausanne and the Swiss Alps. To the south of Évian-les-Bains (evian-tourisme.com), the countryside soars into the snow-capped peaks of the French Alps. Surrounded by so much geological action, it’s no surprise that at Évian, thermal springs would be spouting from fissures in the rock.

“All year long the water is 11-degrees Celsius,” she continued. “It’s rainwater that falls onto the hills and naturally filters through the stone. After 20 years of filtering it arrives at the two open spring heads in the village.”

At La Source Cachat, one of the springs in the centre of town, people were lined up waiting to fill empty bottles and jugs. What flows nonstop from the spout is unadulterated Evian, the same water sold at restaurants and shops worldwide. In the 19th century when the spring water was labelled with health properties, the resort town of Évian-les-Bains quickly grew around the water source.

“The water was very pure and they discovered it was very good for kidney problems. In the 1830s the first bottling factory was established, although the amount they are allowed to use is strictly controlled.

By the 1860s, an agreement was made to also use the water for therapeutic purposes.”

Thermal spa centres soon popped up with health regimes hinging on drinking the water and bobbing in swimming pools sloshing to the brim with pure Evian. At the city’s thermal spas, it’s a popular pastime for visitors to sip from a glass, swim in the pools, then stroll along the waterfront pathway, or while away the afternoon at an outdoor café.

This is the kind of tranquil setting where I found myself gazing out over a glassy lake, but after a few days I was pining for a break from sipping water and

wanted to find a way to get out onto the water. The perfect quick fix was to hop aboard one of the passenger ferries shuttling between Évian and the neighbouring medieval village of Yvoire (yvoiretourism.com).

Named one of “Les Plus Beaux Villages de France,” the narrow cobblestone streets of Yvoire are dwarfed by the waterside stone castle that has been home to the family d’Yvoire for 3½ centuries. Visitors from Évian make the day cruise to walk among the flowers of Yvoire’s Jardin des Cinq Sens (Rue du Lac; jardin5sens.net; adults €12, kids 6 and up €7) and to linger on a patio while enjoying a glass of Le Jacquère, an elegant vintage and one of the Savoie region’s most renowned wines.

CHAMONIX Nature’s finely tuned sense of balance is on display in the Haute-Savoie. In a mere two hours it’s possible to travel from an elegant lakeside town awash with spas and thermal springs to wild, ice-capped peaks where humanity hangs on by its fingernails.

Omnaris is covetreed by most priva s. insurance plan ®

was What did you think I going to say? Baah?

OMNARIS (ciclesonide nasal spray) is indicated for the treatment of seasonal allergic rhinitis, including hay fever, and perennial allergic rhinitis in adults and adolescents 12 years of age and older.

For important information on conditions of clinical use, contraindications, warnings, precautions, adverse reactions, interactions and dosing, please consult the product monograph at http://www.takedacanada.com/ca/omnarispm.

The product monograph is also available by calling us at 1-866-295-4636. ®

® Registered Trademark of Takeda GmbH. Used under licence.

Powerful AR relief.

SAMUEL BORGES PHOTOGRAPHY / SHUTTERSTOCK.COM

Annecy’s 12th-century Palais de l’Isle was once a courthouse and prison before becoming a museum.

36

Doctor’s Review • SEPTEMBER 2014

MIRA ARNAUDOVA / SHUTTERSTOCK.COM

Air France (tel: 800-667-2747; airfrance.ca) flies into Geneva from Montreal. Air Canada (tel: 888-247-2262; aircanada.com) flies into Geneva from Toronto and Montreal. Évian-les-Bains is 30 minutes away by car.

The Hilton Évian-les-Bains (Quay Paul Léger; placeshilton. com/evian-les-bains; doubles from €105) is right on the lake with immediate access to the waterfront pathway popular with walkers and bicyclists. Rentals available at the hotel.

The five-star Hôtel Royal (Avenue des Mateirons; evianresort.com; doubles from €248) includes spectacular views over the city of Évian-les-Bains. The century-old, Belle Époque resort property was recently renovated and reopened this past July.

At the lakefront Hôtel-Restaurant du Port (Rue du Port; hotelrestaurantduport-yvoire.com) in Yvoire almost everyone was ordering the specialty of the house: traditional platters of French fries and pan-fried lake perch served with lemon sauce.

The family-run Restaurant La Calèche (18 rue du Docteur Paccard; restaurant-caleche.com) in Chamonix serves regional specialties like Tartiflette, Savoy cheese fondue and raclette.

The ambience is “mountain chalet” and the portions are hearty.

A lunchtime or dinner cruise (adults from €55.30; kids up to 12 €20.90; annecy-croisieres.com) offers a different perspective of Annecy — one from the water — circling the lake with views of the mountains and small villages.

For more info on the region, visit the Rhône-Alpes tourism website (rhonealpes-tourisme.com).

Annecy’s medieval Old Town is nicknamed the “Venice of the Alps” because of its many canals and streams.

The Montenvers train starts at Chamonix and reaches the Mer de Glace, France’s largest glacier, in 20 minutes.

JULIA KUZNETSOVA / SHUTTERSTOCK.COM

SAVOIE FAIRE

At the mountain resort town of Chamonix (chamonix.com), my voyage into the region’s wilder side began to take shape. It’s here that tourists and serious climbers are shuttled 20 minutes by whisper-quiet cable car to the Aiguille du Midi’s summit terraces where the air is thin, but the views are rich. At a height of 3842 metres, feeling light-headed comes with the elevation.

Mountaineers were strapping on their crampons and testing their safety ropes before stepping away from civilization, quickly becoming small coloured dots against a dazzling white background. Most people make the cable-car trip to get their camera shutters closer to Mont Blanc, the Alps’ highest mountain, but it’s the visual buffet of all the peaks — French, Swiss and Italian Alps — that steals the thunder.

The full mountaineering experience at the top of the Aiguille du Midi cable car was outside of my ability and comfort zone, but the 430 steps down to the ice grotto bored into the living glacier had my name all over it. A wide metal staircase was cantilevered onto the side of a sheer rock face for the climb down — and the more onerous return hike up. At the bottom, a large hole was drilled into the clear, compacted ice. Once inside the tunnel, people spoke in hushed tones; the blue ice was a chapel of nature.

Back in the green valley, Chamonix was also the starting point for our trip by cog railcar to Montenvers where the big attraction is the sweeping Mer de Glace.

At seven kilometres long, it’s the largest glacier in France. We spilled out of the red cogwheel train and ogled the peaks of Les Drus and Les Grandes Jorasses, their sharp and pointed tops divulging their young age.

Wind and water have not yet softened their craggy profile.

I’ve always found there is something about glaciers that makes me feel more alive, and Montenvers’ Mer de Glace had the same effect. The tongue of the 200-metre-thick ice flow moved so slowly under the weight of its own ice; it’s been witness to — and a victim of — shifting climate cycles.

“If these climate cycles continue, the Mer de Glace will recede four to five kilometres over the next 200 years,” explained a scientist manning the Glaciorium exhibit just a stone’s throw from where visitors spill out from the cogwheel train. “This would take it back to its minimal state before the last glaciation 125,000 years ago. The valley would have no ice, just vegetation.”

Most visitors head for the city’s atmospheric Old Town with its châteaux, canals and medieval bridges.

“The canals of Annecy are like Venice,” remarked local tour guide Catherine Mercier-Guyon. “We have water everywhere. The Old Town developed in the Middle Ages at the foot of the castle. At the time, the Thiou River played an important role as the transportation route for small boats servicing the tanneries of the town.

Houses were built right on the river and the canals.”

“The landmark of Annecy’s Old Town is the large fortified house on a small limestone island in the middle of the river,” continued Mercier-Guyon as we lingered on one bridge with an especially scenic view of the Palais de l’Isle.

During the Middle Ages, the Palais de l’Isle fortress was a prison and then a court of justice. During both the French Revolution and the Second World War, resistance fighters were imprisoned within the building’s twometre-thick stone walls. Now restored as a museum, it houses displays on the unique architecture of Annecy.

This seemed like the natural spot to bring my watery exploration of the Haute-Savoie to a close. I settled into a small café with a view over the fortress.

“Water?” suggested my waiter. “Evian?”

Could there be any other choice?

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When it comes to Omnaris , I don’t keriadll.. ®

I’m a lamb aft

ANNECY Annecy sits on the banks of Lac d’Annecy (en.lacannecy.com), a startlingly turquoise body of water some claim is the purest in Europe. In 1860, Emperor Napoleon and his wife Josephine graced the lakeside town with a royal visit, kicking off an era of intense tourism. Visitors flocked to Annecy to see the bluegreen lake and the beauty of the surrounding hillsides.

OMNARIS (ciclesonide nasal spray) is indicated for the treatment of seasonal allergic rhinitis, including hay fever, and perennial allergic rhinitis in adults and adolescents 12 years of age and older.

For important information on conditions of clinical use, contraindications, warnings, precautions, adverse reactions, interactions and dosing, please consult the product monograph at http://www.takedacanada.com/ca/omnarispm.

The product monograph is also available by calling us at 1-866-295-4636. ®

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Powerful AR relief.

This may or may not be the author’s cousin Mario.

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Famiglia and Co. Italian hospitality can be so overwhelming it’s almost unbelievable

by Marcy Gordon

M

y first visit to Sicily was with my mother, when I was 14 — we were there to look up her Sicilian relatives on the outskirts of Palazzolo Acreide. Although my mother was born in New York,

her older brother had lived in Sicily until he was 16, so it was through his recollections that she pieced together the location of her ancestral home and the distant cousins who still lived there.

Palazzolo, located well off the tourist track southeast of Siracusa, did not lend itself to casual visitors. At the time of our visit there were no tourist offices or large hotels, just a small square surrounded by a crumbling baroque church, a bakery and a few cafés. Women in black sat on benches, and groups of men wearing vests and Borsalino hats strolled around the square’s perimeter. It appeared no one under the age of 55 lived there.

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Up to that point, everything I knew about Sicily I learned from reading The Godfather. The book was making the rounds at my junior high school — not for its literary merits of course, but for the violence and raunchy sex scenes. An ambitious reader before me had created a Cliff’s Notes version of the book by highlighting all the graphic sections, such as the one in which Sonny Corleone bangs Lucy Mancini (a bridesmaid) on his wedding day. The Godfather was set mostly in New York, but the Sicily scenes shaped my expectations of what I might find there.

Standing in the square, it felt like we were living a page right out the book.

My mother was a travel writer for our local paper back home and this wasn’t the first time I’d been dragged along on one of her crazy international escapades. As a 10-year-old, I’d been smuggled into a nightclub in the Bahamas while she interviewed Peanuts Taylor, the famous bongo drummer, for an article about the maiden voyage of Carnival’s first cruise ship, “the Mardi Gras” (although the real story was that shortly after pulling away from the dock, the ship ran aground on a sandbar just outside the Port of Miami).

I’d been with her to Haiti, where we visited the Centre d’Art in Port-au-Prince and learned about Voodoo symbolism in the colorful paintings. And when I was 12, I accompanied her to Cartagena, Colombia, where we toured a plantation that made “vitamins” from coca leaves.

Now it was the 1970s and Alex Haley’s miniseries Roots had turned everyone into amateur genealogists.

“We will go to the old country,” she declared, “and find our Sicilian roots.” She pitched the story to her editor and off we went in search of — as she put it — “our Italian Kunta Kinte.”

“Mi scusi,” she said, trying to ask one of the men if he knew the location of the Rizza family farm outside of town. He refused to talk to her and the women uniformly glared at us. For once, my mother’s reporter charm wasn’t getting us very far. It seemed we were up against a deeply ingrained suspicion of strangers and might not possess the linguistic skills to bridge the gap. Finally, a woman came out of a bakery and looked at the documents we held. As she drew a crude map and gave it to my mother, I felt like the whole town was watching.

“Should we stay here for lunch?” my mother asked.

“Are you kidding? Let’s get going before they shoot us or something.” I was half expecting a black sedan to come screeching around the corner and start firing bullets into the square.

She rolled her eyes and we got back in the car.

The directions led us out of town down several miles of unmaintained roads, past acres of cactus and then olive trees. After about 20 minutes, the road petered out and my mother stopped the car in front of a modest stone farmhouse. She knocked on the door, clutching the yellowed family photos and the map. A slender young man about 19 opened the door and my mother thrust the documents into his face as if he were a customs agent.

“We’re here from America!” she shouted.

GUIDO BRAMANTE / FLICKR.COM

As a teenager, it was my job to be sullen, but their hospitality had pierced me and I was close to tears

St. Sebastian’s Church in Palazzolo Acreide is a nice place for Sunday mass with people you think you’re related to.

He immediately shut the door. A minute later, a much older man in a threadbare undershirt who looked like he’d just woken from a nap emerged from the house along with a woman wearing rubber gloves and an apron splotched with red stains. They looked like Italian hillbillies, the Ma and Pa Kettle of Sicily, only more frightening. I imagined dueling banjos playing the theme from Deliverance in the background. uu CONTINUED ON PAGE 55

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

ALL PHOTOS COURTESY CHRISTINE HOMSY UNLESS OTHERWISE NOTED

Vegans at sea A doctor and his daughters cruise the Caribbean on the way to healthier living

by Christine Homsy

W

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

In 2009 my mother was diagnosed with stage four ovarian cancer. She beat the odds and survived four more years. I credit those years in part to my father.

The truth is, they did it together. He’s a pediatric urologist and my mother continued to work part-time as a pediatric ophthalmologist almost until her death.

Their ability to listen, see solutions rather than problems and to continually question the status quo, allowed the family — including my sister and I — to find ways to tackle the disease one day at a time.

During this demanding period, my dad read a book that changed his perspective on nutrition and disease. The China Study by T. Colin Campbell PhD and Thomas M.

Campbell PhD was published in 2005. It’s loosely based on the China-Cornell-Oxford Project, a 20-year study, and became a New York Times bestseller. The book puts the case that a plant-based diet can reduce the risk of heart disease and various cancers. It speaks in the language of science, one with which my father is most comfortable, and he clearly found it convincing.

In 2011, to our great surprise, my father became a vegan.

The author (right) The next year, 2012, was a tragwith her sister ic one for our family. It saw the Marianne. death of my uncle, my grandmother and, in the end, my mother. The idea of my sister and I sharing a holiday with my dad, just the three of us, seemed like the breath of fresh air we all needed.

SEPTEMBER 2014 • Doctor’s

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HOLISTIC HOLIDAY AT SEA

Participants learn relaxation techniques on the upper deck.

Vegan meals are as toothsome as they look.

HOLISTIC HOLIDAY AT SEA

Christine reading The China Study, the book that started it all.

The author of this article with her father, Dr Yves Homsy.

HI-HO FOR LIFE ON THE WAVES This past March we set sail on the MSC Divina from Miami for a week-long cruise with stops in StMartin, Puerto Rico and the Bahamas. We would be part of The Holistic Holiday at Sea, a program that would include daily lectures and workshops on nutrition and other “healthy” topics, and the menu would be entirely vegan. It’s a luxurious ship with 18 decks, pools, bars, restaurants and lounges in every corner, a floating Las Vegas of sorts, not quite what I’d imagined given the nature of the conference.

The man behind these healthy offerings at sea is Sandy Pukel, who, in 1970, opened Oak Feed in Coconut Grove, now the best-known health food store in South Florida. Eleven years ago he came up with the idea of offering lectures and vegan meals on a cruise ship where participants shared the boat with regular holidayers. He remembers the early days when doctors would not even identify themselves as being part of such gathering for fear of damage to their reputations among their colleagues if word got out.

Five years later, in 2008, National Geographic named the cruise one of “the best 100 worldwide vacations to enrich your life.”

One of the presenters on our trip, Dr Janet Jonefal, Director of Integrative and Complementary Academic Medicine Programs (iCAMP) at the University of Miami’s Miller School of Medicine, describes the cruise as “a mixture of high-level training in an atmosphere where it’s a living experience. The fact that non-vegan options are available elsewhere on the ship is a plus as it replicates real life, where social pressures and food choices are part of the challenges we face every day.”

She’s right about the pressures. Every morning as I passed the eggs and cheese in the regular buffet, I had to remind myself of the choices I’d made for the next seven days: to give a vegan way of eating a chance and to keep an open mind. After all, it was only a week.

On this, its 11th voyage, The China Study author himself, T. Colin Campbell at age 80, was clearly the vegan rock star of the cruise. In a nutshell, his research suggests that plant-based protein reduces tumour development and is good for the heart, but his suggestion that dairy products and fish could trigger cancer cells or raise my cholesterol levels gave me something new to chew on.

AN OCEAN OF EXPERIENCES Over the seven days, there were 120 classes to choose from, 35 speakers, and a whole ocean of people with whom to discuss and share experiences.

The dialogue and engagement between participants and speakers created a powerful learning environment

based on mutual respect. It mixed science, personal experience and beliefs into absorbing conversations that often began with “how long have you been a vegan?” Most people said between two and five years. They weren’t at all critical of my non-vegan status, most complimented me for giving it a try.

Presenting scientific research to a more secular audience enlarged the scope of “healthy” conversations — we were all open to new perspectives. The benefits of a plant-based diet certainly took centre stage, but there were talks on meditation, skincare, the healing power of the mind, and vegan cooking boot-camp classes to name just a few. Many participants also brought along family members and friends for a crash course. Though most people were over 50, I was surprised at the number of people in their early 30s with kids. How often in a CME setting, do doctors engage with both their peers and the general public at the same time?

OUTCOMES BACK ON SHORE My sister and I doubted that submerging ourselves in a vegan “culture” for a week could teach us more than we would have learned from reading a book.

“From the moment I decided to keep an openmind, the experience became fully enriching,” my sister said of the cruise. As for my dad, who had spent the last two years debating the topic with us, “I couldn’t be happier with the outcome of our trip, everyone is more inquisitive and a lot less defensive.

Isn’t this a step in the right direction?”

HOLISTIC BOOKING The 2015 Holistic Holiday at Sea (tel: 877-8447977; atasteofhealth.org) is March 14 to 21.

The Italian liner MSC Divina leaves from Miami with ports of call in Jamaica, Cayman Islands, Cozumel, Mexico and Great Stirrup Cay in the Bahamas. Prices, based on double occupancy, start at US$1375 for an inside cabin and go up to US$3175 for a Yacht Club suite with a balcony.

Conference registration and vegan meals are included. Their website is excellent and will give you a pretty good idea of what the cruise is like.

CME credits: The University of Miami, Miller School of Medicine reviewed and provided the endorsement for the American Academy of Family Physicians’ CME/CE Program. Canadian doctors receive CME credits through the reciprocal certification agreement between the AAFP and the College of Family Physicians.

SEPTEMBER 2014 • Doctor’s

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So, do I now solely eat a plant-based diet? Well, one thing is clear. I’m eating more fruit, vegetables, nuts, legumes and grains and less meat, fish and dairy, and I believe it’s good for me and my family.

While there are never any absolutes in life, the prospect that a plant-based diet may reduce the chances of a cardiovascular event or cancer is now firmly in my mind.

I learned a lot more on this cruise about nutrition and disease than I anticipated when I got that telephone call from Dad. I’ll never look at the food on my plate in quite the same way again.

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)

HOLISTIC HOLIDAY AT SEA

“Boot camp” cooking classes expand delegates’ vegan cuisine repertory.

SEITAN PAELLA Vegan cooking requires creativity so delegates look forward to meals because they want to see what the chef has whipped up. Here’s a recipe for seitan paella.

Seitan is made from the protein portion of wheat and it has meat-like texture.

You can find recipes for other vegan dishes served on the cruise — including kasha cabbage rolls and shitake mushroom pâté — at atasteofhealth.org/ events/cuisine.htm.

Cooking time: 1 hour 2 c. (500 ml) short grain brown rice, washed and soaked for 2 hours 12 c. (3 L) vegetable stock with kombu ¼ c. (60 ml) olive oil 1 c. (250 ml) onions, medium dice 2 tbsp. (30 ml) garlic, minced 1 tsp. (5 ml) saffron ¼ c. (60 ml) carrots, medium dice ½ c. (125 ml) seitan, cut into ¼-in.

(0.62-mm) cubes ¼ c. (60 ml) celery, medium dice ¼ c. (60 ml) burdock, small dice 1 c. (250 ml) mushrooms, medium slice

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Doctor’s Review • SEPTEMBER 2014

¼ c. (60 ml) summer squash, medium dice 1 bunch parsley, minced 2 lemons, quartered salt and pepper to taste

Wash and soak rice, and prepare vegetable stock by using veggie scraps and kombu (a seaweed used in Asian cooking).

Sauté onions and garlic in olive oil while stirring for 10 minutes. Add the rice and saffron while constantly stirring, cook 10 more minutes.

Slowly add vegetable stock while stirring, adding more stock as the rice absorbs it, and continue for 30 minutes on reduced heat.

Add carrots, seitan, celery and burdock. Continue to stir, adding more stock as needed, and cook approximately 20 minutes or until tender.

Still stirring and adding stock, add mushrooms and squash.

Season with salt and pepper, and cook 10 more minutes.

Serve on a plate garnished with chopped parsley and lemon wedges.

Serves 6 to 8.

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.

© Eli Lilly Inc., Toronto, Ontario, M1N 2E8 ® Licensed user of trademark owned by Eli Lilly and Company.

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There are lots of things to do on a cruise like admiring passing islands or shorelines.

How I learned to love cruises You only have to unpack once, the food is better than most hotels and you never have to do anything you don’t want to do

by Mark Bittman

I

have an embarrassing admission to make: I like cruises. This is, of course, among the least hip things one can say. My friends look at me with incredulity. I feel the glare of the late David Foster

Wallace, who in his 1996 Harper’s essay Shipping Out, later retitled A Supposedly Fun Thing I’ll Never Do Again, exposed cruises for the torturous, un-fun things they can be. So be it.

There is a qualification here: I have worked on cruises, as part of the “entertainment staff.” (Though I’m not very entertaining, I may actually be funnier than the so-called comedian.) This comes with the very real benefit of not paying, although there is the downside of having to work, and being bossed around a bit. So I may miss a few hours of time to myself in order to give a lecture or prep ingredients or demonstrate recipes. Or even get cornered by curious fellow passengers, asking things like “Oh, you’re the celebrity chef?” (Which I’m not, but close

enough.) In short, I’m less busy than the servers, but more obligated than the average passenger.

I’ve taken five of these cruises in the last eight years, to destinations as varied as the North Sea, the Greek Islands and Antarctica, and each one seems to whet my appetite for the next. Admittedly, these trips have not been on shabby operations nor have they gone to common destinations. That is part of the point.

Nevertheless, my first journey took some gearing up to, because cruising is so easy to put down. I was like that: too sophisticated to consider it. You know: I’ll take Paris. Until you try it, it’s far easier to accept that cruises are gauche and for “others” than to explore the ecosystem.

Many of the common complaints about cruise ships SEPTEMBER 2014 • Doctor’s

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47

There’s so much food it might be hard to refuse seconds.

I simply went for a run or a walk and retreated to the ship, which was sublimely peaceful when in port es for the highest-paying passengers. Much of the food, too, is the same for everyone.

There is, of course, the cabin, where you get what you pay for, and that’s a big differential. Unless you’re photophobic, an interior cabin is not anyone’s first choice, and an upper-deck suite may be nicer than your normal abode. Not much can be done about this.

UNPACK, STAY PUT ring true: the best of the entertainment is boring.

Most of the food is mediocre and it’s usually about as opposite of “local” as you can find. (Indeed most of the food is shipped in containers from the States or other central locations to ports of call.) The excursions are rushed, timid, overpriced. Many of the ports have nothing in them worth seeing. The companionship is limited. (The best cruise joke I know: “This cruise has the oldest passengers I’ve ever seen. And most of them brought their parents.”) There are the risks of illness, although my experience is that the industry has become germophobic and ships seem safer than most workplaces, contagion-wise. Then there’s the issue of safety, although there’s not much to worry about.

You might hit rough seas, and even become seasick.

EQUALITY AND GOOD FOOD Some other things I have found: in general, the prices are not unreasonable, especially since they’re often discounted. The service is usually excellent, especially compared with hotels and restaurants on land, at least most of the places I frequent. The food is as abundant as you’ve heard, generally better than that in most hotels; furthermore, after a few days, you can probably strike a deal with a friendly cook to customize it as you like. (For the most part, the ingredients are typical food-service quality, and there’s no getting around that. Sometimes you get lucky and a bold chef does his shopping in a good port.)

There’s also an odd level of equality: everyone spends time in the public spaces, and those are shared, although there are no doubt exclusive loung-

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But there are two other factors that make cruising not only unusual but uniquely satisfying, at least to me. The first is completely obvious and yet it tends to be overlooked with all the talk of booze, food, partying and entertainment. It is simply that the “floating hotel” means that your vacation is structured like this: you get onboard; you unpack; you never change rooms again; and yet you go different places. Effortlessly.

At a time when many of us are travelling greater distances with greater frequency and more stress than ever, it’s an incomparable luxury to put your suitcase under the bed and not think of it for days or, if you’re lucky, weeks. To keep your toothbrush parked in the same place; to not search for your cellphone charger among your belongings; to leave your magazines in a stack; to recover from jet lag once, at most — all while actually travelling — this feels inconceivable.

It is even better if you take the approach that fewer ports may be better. I was once on a “crossing” from London to New York, with stops in the Faroe Islands, Reykjavik and Nuuk (Greenland), places whose charms are not revealed in six hours. In those

It’s a luxury to unpack and then put your suitcase away for days or weeks.

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ports, and many others, I simply went for a run or a walk and retreated to the ship, which was sublimely peaceful when in port. On a trip from Santiago to Buenos Aires via Antarctica, I did not set foot on land for seven days.

At the beginning of those seven days, we — I was travelling with my wife — were cautious. Seven days at sea? With these people? And yet, these days were fantastic. Almost needless to say, the scenery, the glimpse of the world’s most remote place, is astonishing. You are in a harsh, terrifyingly beautiful environment, eating not-bad pea soup being brought to you in steaming bowls on deck.

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Then there is the ability to carve out your own space in the vastness of the sea and in the impersonal, weird nature of the floating hotel. After all, the only thing you have in common with the people you encounter daily is that you’re all in the same boat (ship, technically). This is not much more to have in common than being in the same nonfloating hotel.

But because the ship offers many options — you can play bridge, you can eat (almost always), work (if your work can be done independently), read, watch movies, dance, go to the gym, be alone with your partner (or not), drink (at 7am, if you choose), sleep, gamble, even shop, for crying out loud, and on and on — there is a way in which you can craft your life the way you want to. And it’s a life that is free of life’s normal chores: cooking, cleaning, commuting (can you imagine not driving or taking the subway, for a week or two on end?), working (unless you work independently), even talking on the phone — because at $3 per minute you’re not going to be taking calls from your mother. In my life, this feels like an extra five hours a day.

These are hours spent staring at passing islands or shorelines, wildlife, the sky and sea. These are hours spent not doing these things: catching up on long-term projects or binge-watching shows that everyone else watched two years ago. You may enter a lost zone and become caught up in the strangeness of the environment. You may even treat the ship like the social club it is. (Many passengers are frequent cruisers, and many sign up for 60 and even 120 days at a time — hence the “nursing home at sea” jokes.)

Time slows, warps. One sits inside looking out, the banality of the ship framing the sublime nature of the landscape. Often, the ship’s roll is soothing, as if you were placed in the hand of a walking giant.

The sound of the ocean is constant; the salt air breezes through every opening. The “culture” is so middleAmerica (even on non-American cruise ships, it seems), and demands so little that you can actually think.

What a change.

And then you go eat dinner.

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There are about 20,000 grizzly bears in the Yukon, Northwest Territories, BC and Alberta; 109 live in Jasper National Park.

JEAN-EDOUARD ROZEY / SHUTTERSTOCK.COM

Hiking grizzly count Would you hike Jasper’s backcountry alone? One man attacks the idea and other existential questions

by John Flinn

I

s it possible to be scared out of your wits and profoundly grateful at the same time? Those competing emotions were racing through my brain, although “scared out of my wits” was out to a commanding lead.

It was nearly dawn and in two hours I was supposed to be hoisting my backpack onto my shoulders and setting off on a 23-kilometre hike to a backcountry lodge in the Canadian Rockies.

Alone.

Through country teeming with grizzly bears.

A guide was supposed to have accompanied me, but he cancelled and no backup could be found.

“Ah, there’s nothing to be a’scared of,” said the lodge owner. “I’ve been around those bears my whole life. I’ve been this close to them” — he held his hands one metre apart — “and I’ve never had any trouble. None at all.”

I couldn’t help thinking that he sounded just like Timothy Treadwell, star of the documentary Grizzly Man, right before he began his journey through the gastrointestinal system of a lip-smacking ursus horribilis.

It had been shaping up as a bad summer for grizzly encounters. At the time, four teenagers from an Outward Bound course were recovering in an Alaska hospital after being attacked by a mama grizzly. A

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couple of weeks earlier, a man had been killed in Yellowstone National Park — to go along with the two killed just outside the park the year prior — and a few days after I got home from my trip a hiker was mauled in Glacier National Park.

Everyone I talked to in Jasper agreed that the trail I would be walking was one of the most reliable places around for coming face-to-face with a grizzly.

Someone pointed me to a YouTube video, shot two weeks earlier, of an enormous mother and two cubs lumbering alongside the path.

My courage needed some serious bucking-up, so the night before the hike I went to a lecture on bear safety. The naturalist began with a scary story about a close call she’d once had with a grizzly — on the very same trail I’d be walking, naturally — and stressed that the safest thing hikers could do was travel in a group of four or more. Hiking alone, it occurred to me, deprived me even of solace in the old joke that ends, “I don’t have to outrun the bear; I just have to outrun you.”

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The naturalist didn’t think much of my two main lines of defense: some jingly bear bells designed to prevent surprise encounters — they’re not even remotely loud enough to do any good, she said, but they make great souvenirs — and a canister of “bear spray,” a weapons-grade version of the Mace women carry to fend off muggers.

“Sometime it deters the bears,” she said, “and sometimes it just makes them mad. And sometimes the wind blows it right back in your face while the bear is charging.”

So I think I’ve got the “scared out of my wits” part of my dilemma covered pretty well. What about the “profoundly grateful” part? That’s a little trickier, but hear me out.

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Everyone has his own personal definition of wilderness, and this is mine: a place where humans are not at the top of the food chain. Or, to put a finer point on it: a place where there are creatures who can, and will, without even giving it a second thought, eat you.

I’m grateful such places exist and I wish we had more of them. I’ve walked through grizzly country before, always in the company of other people, and it’s a profoundly humbling and energizing experience. Instead of swaggering like the lord and master of your domain, you walk lightly and modestly: you’re just one insignificant creature among many.

You’re part of nature — part of the food chain — not aloof and apart from it.

The potential danger, no matter how statistically slight (and it is slight), triggers a gusher in your adrenal glands that puts your senses on high alert. Your eyesight grows sharper, your hearing more acute.

You feel an extra, nervous, spring in your step.

Normally we are so accustomed to being unchallenged as apex predators that we barely give it a thought. To see things from the other side, to become potential prey, however temporarily, forces us to rethink our place in the world. Which, I suppose, is one of the reasons we travel.

The sky outside was growing light and my alarm clock had just gone off — quite unnecessary, because I hadn’t closed my eyes all night. I’d been too scared.

I’d made a decision or, rather, admitted to a decision I realized I’d made hours prior: I wasn’t going.

I vowed to come back and do the hike another day, when I’d lined up some partners and wouldn’t have to run the grizzly gauntlet alone. But at that moment I was just grateful that the bears have a place that is theirs, not ours.

A truly wild place.

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Cornmeal waffles with apple cider syrup.

Eats from West Recipes from California’s Brown Sugar Kitchen for food with soul recipes by

Tanya Holland

with

T

Jan Newberry

photos by

anya Holland isn’t a morning person, but in Brown Sugar Kitchen, published by Chronicle Books, she explains that she’s seen the sunrise almost

everyday since January 15, 2008.

Holland’s days at her soul-food restaurant in West Oakland, CA start at 5:30am with the removal of the heavy-duty locks on the window grates and doors. Then, for the next 90 minutes, she steeps pots of chai, puts sticky buns in the oven, heats up waffle irons, fries buttermilkand-herb-soaked chicken, fills pie shells with sweet potatoes, add grits to boiling water, dumps potatoes on the flat-top

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Jody Horton

grill and paints the tops of biscuits with cream before baking them. She even fires up one of the playlists that her husband, Phil, has made all before slipping her on chef’s coat at 7am and opening the doors. The Brown Sugar Kitchen served 37 people the day it opened in 2008; today, it serves as many as 400 on a Saturday. Three of our favourite recipes from the resto’s new cookbook follow; you’ll want to serve all of them at home.

In a large pot, combine the brown sugar, vinegar, cider, cinnamon and butter. Bring to a boil, reduce to a simmer and let cook until reduced to 1½ cups (375 ml), 45 minutes.

Discard the cinnamon and keep warm over very low heat. (To make ahead, refrigerate in an airtight container for up to 1 month.)

In a small bowl, combine the yeast and warm water. Let stand until foamy, 10 minutes. In a large bowl, whisk together the eggs and milk. In another large bowl, sift together the cornmeal, flour, salt and granulated sugar.

Add the yeast mixture to the eggs and milk, then whisk in the flour mixture until thoroughly combined. Whisk in the melted butter until just combined.

Cover the bowl with plastic wrap and refrigerate for at least 4 hours or up to overnight.

STUDIO

CLIENT

Holland’s mother and her three sisters all grew up in the same household in Louisiana, but they all cook different versions of gumbo. Her version is slightly different from the one her mom makes, a tomato and okra combination with lots of shrimp and chicken. She leaves out the tomatoes and adds a dark roux like her aunt Maxine.

COPY-

For the waffles 2 tsp. (10 ml) active dry yeast ¾ c. (180 ml) warm water 3 eggs 3 c. (750 ml) whole milk 1 c. (250 ml) cornmeal 2 c. (500 ml) all-purpose flour 1½ tsp. (7.5 ml) salt 1½ tsp. (7.5 ml) granulated sugar ¾ c. (180 g) unsalted butter, melted vegetable oil for the waffle iron ½ tsp. (2.5 ml) baking soda

SHRIMP AND CHICKEN GUMBO

CREATIVE

For the syrup 1½ c. (375 ml) firmly packed brown sugar 1½ tsp. (7.5 ml) apple cider vinegar 4 c. (1 L) apple cider 2 cinnamon sticks ½ c. (125 g) unsalted butter

NOW AVAILABLE

1 head garlic ½ tsp. (2.5 ml) olive oil salt and freshly ground pepper 1 c. (250 ml) vegetable oil, plus 1 tbsp. (15 ml) 1 c. (250 ml) all-purpose flour 2 celery stalks, diced 1 green bell pepper, diced 1 large yellow onion, diced 8 c. (2 L) chicken stock 1½ tsp. (7.5 ml) Creole spice mix (recipe follows) 1½ tsp. (7.5 ml) gumbo filé powder 1 lb. (455 g) okra, trimmed and cut into ½-in (12-mm) rounds 2 lbs. (910 g) cooked chicken, shredded 2 lbs. (910 g) medium shrimp, peeled and deveined cooked rice for serving (optional)

Preheat the oven to 300°F (150°C). Cut the garlic in half widthwise and put both halves on a sheet of aluminum foil.

Drizzle with the olive oil, and season with salt and pepper. Wrap tightly in foil and

ART

These waffles are based on the riseovernight, yeasted version made famous by the late cookbook author Marion Cunningham, but they include cornmeal, which gives them a distinctive Southern flavour. They’re one of Brown Sugar Kitchen’s signature dishes. The apple cider syrup is an homage to Holland’s grandmother, who fried apples for breakfast.

Preheat the oven to 250°F (120°C).

Preheat the waffle iron and brush lightly with oil. Set a wire rack over a baking sheet.

Remove the waffle batter from the refrigerator and stir in the baking soda.

Ladle some of the batter into the waffle iron, close the lid and cook the waffles until golden and cooked through, 3 minutes or according to the manufacturer’s instructions.

Transfer the waffle to the rack to keep warm in the oven. Repeat with the remaining batter, placing the waffles in a single layer on the rack. Serve warm with warm apple cider syrup.

Makes 1½ cups (375 ml) syrup and 8 to 10 waffles.

GRAPHIC

CORNMEAL WAFFLES WITH APPLE CIDER SYRUP

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½ tsp. (2.5 ml) salt 4 eggs 1 c. (250 g) unsalted butter, melted and slightly cooled 2 c. (500 ml) chocolate chips

In a small bowl, stir together the salt, herbes de Provence, cumin, cayenne, black pepper and paprika until thoroughly combined. Makes about 1½ cups (375 ml). (To make ahead, store in an airtight container for up to 6 months.)

Preheat the oven to 350°F (180°C). Butter and flour a 12-cup (2.8-L) Bundt pan.

In a medium pot, cover the sweet potatoes with water. Bring to a boil and cook until the potatoes are soft, 15 minutes. Drain.

In a medium bowl, whisk together the flour, sugar, baking soda, cinnamon, allspice, nutmeg, ginger and salt.

Using a stand mixer fitted with the paddle attachment, beat the cooked sweet potatoes and eggs on medium speed until smooth. Add the melted butter and beat until combined. Reduce to low, add the flour mixture and mix just until combined. Remove the workbowl from the mixer and, with a wooden spoon, stir in the chocolate chips.

Spoon the batter into the prepared Bundt pan. Bake until a toothpick or skewer inserted into the centre comes out clean, 40 to 50 minutes. Transfer to a wire rack to let cool completely in the pan, 1 hour. Loosen the cake from the pan using the tip of a dinner knife, then invert a rack over the pan and turn the cake out onto the rack.

Serve at room temperature. Serves 12. (To make ahead, cover with plastic wrap and store at room temperature for up to 3 days.)

SWEET POTATO BUNDT CAKE

Recipes and photos from Brown Sugar Kitchen: New-Style, Down-Home Recipes from Sweet West Oakland (Chronicle Books, 2014).

Shrimp and chicken gumbo.

roast until the garlic is tender, 1 hour.

In a heavy-bottomed pot, heat the 1 cup (250 ml) vegetable oil over mediumhigh heat until very hot and almost smoking. Add the flour and cook, stirring constantly, until the roux is a deep caramel color, 5 minutes. Set aside.

In a large soup pot, heat the remaining 1 tablespoon (15 ml) oil over mediumlow heat. Add the celery, bell pepper and onion, and cook until quite soft, 20 minutes.

Squeeze the roasted garlic cloves out of their skins and add to the pot, along with the stock. Bring to a boil, reduce to a simmer and whisk in the roux. Cook until the gumbo base begins to thicken, 10 minutes.

Stir in the Creole spice mix and the gumbo filé powder. Add the okra and cook until tender, 10 minutes. Add the chicken and the shrimp, and cook just until the shrimp is opaque in the centre, 5 minutes. Taste and season with salt and pepper. Serve immediately over rice, if desired. Serves 6 to 8. (To make ahead, refrigerate the gumbo in an airtight container for up to 3 days. Reheat in a saucepan over medium heat.)

Creole spice mix 3 tbsp. (45 ml) salt 3 tbsp. (45 ml) herbes de Provence

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Doctor’s Review • SEPTEMBER 2014

3 tbsp. (45 ml) ground cumin ¹⁄³ c. (80 ml) cayenne pepper ¼ c. (60 ml) freshly ground black pepper ¼ c. (60 ml) sweet paprika

Sweet potatoes and chocolate chips seem like an unlikely combination, but they work really well together. If you like baking cakes, it’s worth investing in a nice Bundt pan. They’re a simple way to make pretty cakes.

1½ lb. (680 g) orange-fleshed sweet potatoes, peeled and cut into large pieces 3¹⁄³ c. (830 ml) all-purpose flour 2 c. (500 ml) sugar 1 tbsp. (15 ml) baking soda 1 tbsp. (15 ml) ground cinnamon 1 tbsp. (15 ml) ground allspice 1 tbsp. (15 ml) grated nutmeg 1 tbsp. (15 ml) ground ginger

Sweet potato bundt cake.

Famiglia and Co. uu CONTINUED FROM PAGE 39

For a few anxious moments we just stared at each other. Then my mother pointed out the house in the photo she held. Aside from the trees, which had grown considerably, the house was unchanged. That clinched the deal.

We were ushered into the house and despite our unexpected arrival, put up for three days. Their son was banished to the couch, “Ma and Pa” took his room, and we were given their bedroom.

Although my mother knew some Italian, the relatives spoke only in Sicilian dialect. I sat by silently as they struggled to communicate with each other, feeling as if I was watching a foreign film without subtitles.

When we arrived, “Ma” had been in the middle of roasting and canning tomatoes, and the house smelled sweet and savoury. I couldn’t understand her

On Saturday morning I helped Ma finish putting up the tomatoes and later, in the fading afternoon light, we gathered lemons and she showed us how to make limoncello. My mother shadowed Ma in the kitchen and took careful notes, thrilled that our trip would yield not just a travel story, but a few food articles, too.

On Sunday we all drove to town for Mass at the crumbling church off the square where we’d asked for directions. Just days before we were outsiders — strangers — but now we were celebrities. Famiglia! From America!

After Mass I walked in the olive groves with the son. He showed me how they spread out nets to gather the olives and, in broken English, asked if he could “scratch my beautiful hair.” I figured he meant touch, not scratch, but my mother and Ma were following close behind, leaving us little opportunity for further cultural exchange.

Just days before we were outsiders — strangers — but now we were celebrities.

Famiglia! From America! words, but I could interpret that rich wonderful scent in any language.

I still remember the food we ate that weekend. In addition to being a travel writer, my mother also wrote a weekly food column, so I grew up eating what would have been considered exotic at the time — borscht, tagines and curries. Our family dinners were often results of research for her food column, straight out of the test kitchen and onto our plates. Admittedly, the majority of the tests proved unsuccessful.

But here, there was pasta with sardines, fennel and pine nuts; fried eggplant with ricotta and basil; and arancini, the deep-fried rice balls stuffed with tomato ragu, ground beef, mozzarella and peas — exactly the way my grandmother made them. There was wine drawn from a big glass jug that looked like an office water cooler, and I had my very first taste of grappa.

On the day of our departure, we stood outside the stone house, loaded down with jars of blood orange marmalade, tomato sauce and bottles of olive oil. As a teenager, it was my job to be sullen and maintain an air of detached boredom, but as we hugged goodbye, my carefully constructed posture of aloofness began to crumble.

Their hospitality had pierced me and I was close to tears.

M

y mother started writing her “Roots” article immediately after we returned home, but it took two weeks before the film from her camera was developed and we could share our photos with my uncle. When the prints arrived, my uncle studied them carefully. He reached the last one, then slowly flipped through them again.

“Mary,” he finally said to my mother, “Who are these people?”

“That’s Maria and her husband and son.”

“Who?” “Cousin Maria!”

“This is not Maria,” he said, shaking his head.

“But this is the house,” said my mother. “Don’t you recognize it?”

“I remember this house, I played there as a boy. But our house was farther down the road, past a creek.”

The colour drained out of my mother’s face. Had we stayed with complete strangers? As she tried to recall the exact conversation with “Cousin Maria” at the door, she realized we’d never really exchanged names. Ma and Pa called each other Mario and Mama, and since she never revealed her real name, we called her Mama too. We’d just been swept up into their home and their lives, no questions asked. Our status as blood relatives was based solely on a dog-eared photo.

I found all of this completely hilarious, but my mother was horrified that the roots she thought were hers belonged to some other tree. We later discovered that cousin Maria and her family had moved to Catania 12 years earlier. Even if we had found the right house, our real relatives would have been long gone.

Thirty years later, when my mother was in her 70s, we returned to Sicily to connect with our genuine blood relations in Catania. This time, we were veramente la famiglia. True family. Once again we were plied with copious amounts of food and drink, and once again we were given the master bedroom. The experience varied little from our first trip.

Maybe I hadn’t been so far off, learning about Sicily by reading The Godfather. If only I’d paid more attention to the plot, I would have realized it was actually a story about the enduring bonds of family — regardless of whether you were related by blood. If you presented yourself as loyal to the family, you were accepted as family. Our first trip to Sicily was evidence of that.

This time we were connected by blood, but I would always be connected to Ma and Pa by love.

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P H OT O FI NI SH by

Dr Ca m i lle B . F or e s t

Call of nature

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The truth is this place represents everything to me.

This is where I spent my summers, escaping Montreal for two weeks, going to La Malbaie with my friends, looking forward to the Centre écologique de Port-auSaumon summer camp.

We had the privilege of seeing this incredible view everyday, of exploring this beautiful bay during low tide and finding mollusks, anemones, fish, marine worms, seaweed, starfish. We realized how strong life is, how it resists the St. Lawrence River’s assaults.

After lunch, I used to sit on a bench behind the cafeteria to take in nature and simply observe the birds and listen to the forest. I learned to look outside of myself and it helped me to know myself better, and to develop who I wanted to be and discover what I wanted in life.

It made me feel what life is, the importance of it, and how the balance of nature is fragile. It also taught me that we have a responsibility to protect it.

I would not be the same person if I didn’t experience Port-au-Saumon. This is why I can’t help but go through the area at least one day every summer.

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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