January 2016 by Doctor's Review

s p i u q ical

e M W NE

MEDICINE ON THE MOVE

Unforgettable

Rome

Hand transplants

Depression JANUARY 2016

charted

Make Obama’s chili

WIN

THIS MONTH’S

GADGET PAGE 17

ISLAND ESCAPES Caribbean

Cuba

Florida Keys

INTRODUCING FORXIGA FORXIGA is a reversible inhibitor of sodiumglucose co-transporter 2 (SGLT2) that improves glycemic control by reducing renal glucose reabsorption leading to urinary excretion of excess glucose1*† Over 193,000 patients have been prescribed FORXIGA worldwide combined across all indications

CONVENIENT, ONCE-DAILY DOSING1‡§¶ RECOMMENDED STARTING DOSE: 5 mg

In patients tolerating 5 mg and who require additional glycemic control, dose can be increased to 10 mg

CAN BE TAKEN ANY TIME OF DAY

WITH OR WITHOUT FOOD

FORXIGA is indicated in monotherapy as an adjunct to diet and exercise to improve glycemic control in patients with type 2 diabetes mellitus for whom metformin is inappropriate due to contraindications or intolerance.1 FORXIGA is also indicated in patients with type 2 diabetes mellitus to improve glycemic control in add-on combination with metformin, a sulfonylurea, or insulin (alone or with metformin), when the existing therapy, along with diet and exercise, does not provide adequate glycemic control.1

Clinical use: Not for use in pediatrics (<18 years). In patients ≥65 years of age, a higher proportion had adverse events related to volume depletion and renal impairment or failure compared to placebo. Contraindications: • Patients with moderate to severe renal impairment, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, or end-stage renal disease Relevant warnings and precautions: • Not for use in type 1 diabetes or for the treatment of diabetic ketoacidosis • Not for use in patients with active bladder cancer and use with caution in patients with a prior history of bladder cancer • Not for use in patients concomitantly treated with pioglitazone • Not recommended for use in patients who are volume depleted; caution in patients for whom a FORXIGA-induced drop in blood pressure could pose a risk, or in case of intercurrent conditions that may lead to volume

depletion; careful monitoring of volume status is recommended and temporary interruption of FORXIGA should be considered for patients who develop volume depletion until the depletion is corrected • Risk of hypoglycemia when used in combination with insulin or insulin secretagogues • Dose-related LDL-C increases; monitor LDL-C levels • Increased mean hemoglobin/hematocrit and frequency of patients with abnormally elevated values of hemoglobin/hematocrit • Increased risk of genital mycotic infections • Renal function should be assessed prior to initiation of FORXIGA and regularly thereafter • Not for use in pregnant or nursing women For more information: Please consult the Product Monograph at www.azinfo.ca/forxiga/pm367 for important information relating to adverse reactions, drug interactions and dosing. The Product Monograph is also available by calling 1-800-668-6000.

* Clinical significance unknown. † The amount of glucose removed by the kidney through this mechanism is dependent upon the blood glucose concentration and GFR. ‡ In patients with evidence of volume depletion, this condition should be corrected prior to initiation of FORXIGA. § The efficacy of FORXIGA is dependent on renal function. Assessment of renal function is recommended prior to initiation of FORXIGA therapy and periodically thereafter. ¶ Please see Product Monograph for complete dosing and administration information. Reference: 1. FORXIGA Product Monograph. AstraZeneca Canada Inc., December 10, 2014.

02/16

Sunny dream time The other day I happened to hear a CBC rebroadcast of an Eleanor Wachtel interview with Martha Gellhorn. Born in St. Louis in 1909, Gellhorn was the most intrepid of intrepid reporters. One example will suffice: she was the first reporter, male or female, into Auschwitz. She also covered the Spanish Civil War out of a hotel room she shared with Ernest Hemingway. The couple took a taxi to the front everyday and were married briefly. He admired her, but she was too much competition for him and they soon parted. What she wanted to talk about in the interview was how the world has changed, often not for the better. She died in 1998 at age 89. She was for the underdog, the ordinary people of the world. Her views weren’t always popular and she couldn’t have cared less. She preferred Cuba after the revolution and praised the country for its high rate of literacy, and would still appreciate Trinidad, Cuba where life continues largely as it has for the past several decades. Read about it in The Road to Trinidad on page 28. The Rome of today might not win a nod from Gellhorn, but the article Divine Roman Encounters, page 48, would. It describes the powerful women who made the Imperial City what it is and whose statues still adorn the capital. She admired Gorbachev for setting his country on a path to democracy for the first time in its history and she adored St. Petersburg for its continued authenticity. She would have appreciated Nevis, the sister island of St. Kitts in the Caribbean’s Leewards. It too has changed — Josephine Matyas describes the super luxe hotel Nisbet Plantation Beach Club in her article on page 42 — but the island still retains patches of the old Caribbean that delighted me on my first visit. I arrived on the ferry from St. Kitts along with locals on their animals. I remember one affectionate goat who delighted in picking peoples’ pockets. We arrived at a sturdy wooden dock and clambered out. Clouds swathed the extinct volcano at the centre of the round island. The place had a piratical feel and I imagined I was young Jim Hawkins setting foot on Treasure Island. Speaking of treasure, be sure to enter our first-ever Gadget of the Month contest. The prize is an Atomic bedside radio that not only keeps perfect time, but also projects it on the ceiling at the touch of a button. There will be a different prize every month all year. Plan to enter them all; you have a good chance of winning. Something else new for 2016: you’ll find medical jokes and quips scattered throughout the issue. Contributions welcome. See your name in print and be rewarded with a $25 gift certificate from Chapters. It’s winter; do take a few minutes to dream of sunny places on and off the beaten track. Martha Gellhorn would approve.

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David Elkins, Publisher and editor delkins@parkpub.com

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JANUARY 2016 • Doctor’s

Review

heartburn

Because doesn’t give a hoot what time it is

DEXILANT : Demonstrated 24-hour heartburn relief 96% of 24-hour periods were heartburn-free ®

vs. 29% with placebo in patients maintaining healed erosive esophagitis (EE) with DEXILANT® 30 mg (median; p<0.00001, secondary endpoint)1,2†

99% of nights were heartburn-free vs. 72% with placebo in patients maintaining healed EE with DEXILANT® 30 mg (median; p<0.00001, secondary endpoint)1,2†

DEXILANT® and Dual Delayed Release® are registered trademarks of Takeda Pharmaceuticals U.S.A., Inc. and used under licence by Takeda Canada Inc. Product Monograph available on request. Printed in Canada © 2015 Takeda Canada Inc.

Indications and clinical use: In adults 18 years and older, DEXILANT® is indicated for: • Healing of all grades of erosive esophagitis for up to 8 weeks • Maintenance of healed erosive esophagitis for up to 6 months • Treatment of heartburn associated with symptomatic non-erosive gastroesophageal reflux disease (GERD) for 4 weeks Other relevant warnings and precautions: • Symptomatic response does not preclude the presence of gastric malignancy • May slightly increase the risk of gastrointestinal infections such as Salmonella and Campylobacter and possibly Clostridium difficile • Concomitant methotrexate use may elevate and prolong serum levels of methotrexate and/or its metabolites • May increase risk of osteoporosis-related fractures of the hip, wrist, or spine. Use lowest dose and shortest duration appropriate • Patients >71 years of age may already be at high risk for osteoporosis-related fractures and should be managed carefully according to established treatment guidelines • Chronic use may lead to hypomagnesemia. For patients expected to be on prolonged treatment or concurrent treatment with digoxin or drugs that may cause hypomagnesemia (e.g., diuretics), initial and periodic monitoring of magnesium levels may be considered • May interfere with absorption of drugs for which gastric pH is important for bioavailability • Co-administration of HIV protease inhibitors for which gastric pH is important for bioavailability (e.g., atazanavir, nelfinavir) is not recommended • Prolonged use may impair absorption of protein-bound Vitamin B12 and may contribute to development of cyanocobalamin deficiency • Should not be administered to pregnant women unless the expected benefits outweigh the potential risks • Should not be given to nursing mothers unless its use is considered essential. In this case nursing should be avoided

Dual Delayed Release (DDR ) technology in a PPI: Unique to DEXILANT ®

®1‡§

• Two types of enteric-coated granules deliver 2 distinct releases of drug: • The first type of granule is designed to release drug early in the proximal small intestine • The second type of granule is designed to release drug several hours later in the distal small intestine

For more information: For more information on Contraindications, Warnings, Precautions, Adverse Reactions, Interactions, and Dosing, please consult the Product Monograph at www.takedacanada.com/dexilantpm. The Product Monograph is also available by calling us at 1-866-295-4636. † Results of a 6-month, multicenter, double-blind, placebo-controlled, randomized study of patients who dosed DEXILANT® 30 mg (n=140) or placebo (n=147) once daily and had successfully completed an EE study and showed endoscopically-confirmed healed EE.2 ‡ Clinical significance has not been established. § Comparative clinical significance unknown. References: 1. DEXILANT® Product Monograph, Takeda Canada Inc., April 22, 2015. 2. Metz DC, Howden CW, Perez MC et al. Clinical trial: dexlansoprazole MR, a proton pump inhibitor with dual delayed-release technology, effectively controls symptoms and prevents relapse in patients with healed erosive oesophagitis. Aliment Pharmacol Ther 2009;29(7);742-54.

For your adult patients with type 2 diabetes

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

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

BITRJ00110 CATRJ00110

contents JANUARY 2016

COVER: EKATERINA RAINBOW / SHUTTERSTOCK.COM

features

The road to Trinidad Cuba beyond Havana in the small city known for its casas particulares and the best sand in the south by Margo Pfeiff

Keys to fun, food and films A roadtrip through the islands south of Miami for a little bohemian kitsch and a lot of fresh fish by Cherie DeLory with David Elkins

Fantasy islands

Ian Fleming’s Jamaica, a beachfront plantation home in Nevis, and a resort in Anguilla that celebrities love by Josephine Matyas

Divine Roman encounters The goddesses of ancient Rome — from Venus to the Vestal Virgins — that still grace the Eternal City by Susan Van Allen

In the bowl The best vegetarian chili ever, plus the beef chili that President Obama has been making since college by Robb Walsh

36 48 JANUARY 2016 • Doctor’s

Review

JANUMET ® Help get your patients toward their A1C goal The clinical efficacy study described below was not conducted with JANUMET® tablets; however, bioequivalence of JANUMET® with coadministered sitagliptin and immediate-release metformin hydrochloride tablets has been demonstrated.

-0.9%: the demonstrated A1C difference from placebo in patients receiving sitagliptin 100 mg + metformin ≥1500 mg + glimepiride (≥4 mg/day) (n=115) vs. those receiving placebo + metformin ≥1500 mg + glimepiride (≥4 mg/day) (n=105) at 24 weeks (p<0.001). Mean baseline A1C was 8.3% for both treatment arms†‡

JANUMET® (sitagliptin/metformin) is indicated as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus inadequately controlled on metformin or in patients already being treated with the combination of sitagliptin and metformin. Refer to the page in the bottom-right corner for additional safety information and for a web link to the product monograph discussing: • 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. • Most serious warnings and precautions regarding lactic acidosis and excessive intake of alcohol. • Other relevant warnings and precautions regarding type 1 diabetes or diabetic ketoacidosis; patient selection and follow-up; pancreatitis; hypoglycemia; 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.

† 24-week, randomized, double-blind, placebo-controlled study designed to assess the efficacy of sitagliptin 100 mg once daily (n=116) compared to placebo (n=113), 229 patients were on the combination of glimepiride (≥4 mg per day) and metformin (≥1500 mg per day). ‡ Adjusted mean A1C change from baseline in: -0.6 for sitagliptin vs. 0.3 for placebo.

When efficacy matters to you, choose JANUMET® See additional safety information on page xx 55

contents JANUARY 2016

regulars 9

LETTERS And the winner is…

Montreal’s musical aviary, the US National Park Service turns 100, Vikings in Ottawa, plus the making of the world’s largest hotel company by Camille Chin

PRACTICAL TRAVELLER

GADGETS An atomic bedside clock that never gains or loses a single second by David Elkins

TOP 25 The biggest medical meetings scheduled for the start of summer

HISTORY OF MEDICINE Hand transplants from 1964 to today by Rose Foster

DEPRESSION KEYPOINTS An infographic highlights the need for treatment by Mairi MacKinnon

PHOTO FINISH The show on the road by Dr Errol Billinkoff

Coming in

February • Spring is on the way: you deserve a break — and a deal on the dollar • Waiting for the sun: winter lingers in the Yukon and so does the fun • How do anchovies get into those little bottles and other Italian mysteries solved • Zen and now: what a difference 30 years and a trip to Japan can make • New feature: family practice now — goings-on inside and outside the office

17 JANUARY 2016 • Doctor’s

Review

NO PARENT WANTS TO HEAR THEY PASSED ALONG A DEADLY GENE TO THEIR CHILD.

Thatâ&#x20AC;&#x2122;s what April Kawaguchi learned, that her son Andrew inherited her heart condition that causes sudden cardiac arrest and death. Family history can double your risk of heart disease and stroke, yet many of these genes are unknowingly passed along. Doctors predict the remaining 80% of this genetic mystery could be discovered in the next 5 years. Thatâ&#x20AC;&#x2122;s why we fund the best medical minds in the world for genetic research. Start by knowing your family history and personal risks by getting a FREE ASSESSMENT at heartandstroke.ca.

Thanks to our visionary partner CP for helping move research forward.

LETTERS

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

And the winner is...

CONTRIBUTING EDITOR

Katherine Tompkins Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

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David Elkins

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EDITORIAL BOARD

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

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ACCESS TO EDUCATION Being interested in CME trips in 2016, I find that since I don’t receive the hard copy of the magazine — I’m over 70, still in active practice — I cannot get the code that allows me to register and to look over the offerings. Dr Andris Lielmanis Via email

Editor’s note: The code to access the medical meetings database at doctorsreview.com/ meetings is drcme. To request the electronic “flip-through” version of the magazine, please email editors@doctorsreview.com.

CONGRATULATIONS!

The winner of an all-inclusive trip to Casa de Campo is Dr Steve Choi, a GP from Oakville, Ontario.

ch la a en nc st te e t r! o

TRAVEL EDITOR

Win an all-inclusive trip to Casa de Campo, one of the most luxurious resorts in the Caribbean Doctor’s Review and Casa de Campo will send one lucky physician and a guest for a holiday at this renowned Dominican Republic venue.

The winning MD receives airfare for two aboard Air Transat and four nights “Elite” accommodation. A $5800 value! Enjoy “The Sporting Life” set on 2833 hectares:

FLORIDA THEN My father was an excellent GP (physician, surgeon, inventor of the Brook Airway) in Saskatoon. We used to flee the Prairies at Christmas for holidays. One year, December 1965, Dad took us to Florida, which he loved. We visited all the highlights (his highlights): Hialeah, Nettleton Shoes, the jai alai fronton, Greyhounds, and, of course, Wolfie’s, which was memorable. I remember ordering a half-chicken dinner — I was a growing boy! It arrived with some fanfare in a huge shiny covered pot that opened with a sliding retractable handled-top to reveal la pièce de résistance: 32 ounces of matzah ball soup, maybe half a dozen big matzah balls, the aforesaid chicken and whoknows-what-else crammed-in — the whole spiel. Quite a lot for a 12-year-old. It was there that I really learned to fress American-style. I’m still full. Thanks for the memories and for the very cool photo on page 1 of the December edition. Dr David R. Brook Victoria, BC

• golf the Teeth of the Dog, 90 holes designed by Pete Dye • play tennis on championship courts • ride horseback • shoot skeet • swim, dive, sail, kayak and paddle board at Minitas Beach • spin, work on your abs and glutes at the fitness centre • please your palate — six restaurants in a variety of fascinating venues And so much more. Whet your appetite at casadecampo.com.do

Enter at doctorsreview.com. Click on the contest box in the top right. Use access code drcme to participate. The winner will be announced in the October issue, just in time for a glorious winter vacation. This prize is valid from October 1, 2015 to October 1, 2016, subject to availability. Not valid for the period of December 20, 2015 to January 4, 2016; other blackout dates may apply. Absolutely no date extension will be made to redeem prize after expiration. Prize is not redeemable for cash and estimated package value may not be applied as credit to an existing reservation.

READ IT AND WEEP I have a quick question regarding your article on page 19 of the December 2015 edition (“Tablet Wars,” Gadgets). You state that iPads will only load the first 30 pages of a Kindle book. I certainly couldn’t find a peep about this on the Internet, on any site, and you’d think there would be blogs from upset iPad Kindle users. When did this situation start? I haven’t downloaded a book from Kindle in a few months and haven’t had any problems so far with my “old” downloaded books. Dr Joanne Lorraine Toronto, ON

Editor’s note: There are many comments on this situation on the net including a few workarounds. Here’s one of them: business insider.com/why-you-cant-buy-kindle-bookson-iphone-2014-4. JANUARY 2016 • Doctor’s

Review

CL I CKI NG

SO O N

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

PHOTO © FLORIAN KLEINEFENN 2015

Montreal’s live music In addition to the one million people that pass through the Montreal Museum of Fine Arts (MMFA) every year, 70 live zebra finches are visiting now through March 27 for from here to ear v.19 by French artist Céleste Boursier-Mougenot (pictured). The Canadian premiere of the installation has transformed the MMFA’s Contemporary Art Square into a gigantic musical aviary featuring 14 electric guitars and cymbals as well as songbirds native to central Australia. When the finches flitter on the strings and perch on the guitars, pre-recorded blues, rock and heavymetal chords play through amplifiers. Twenty-five visitors can tour the space at a time. Vets will check the birds regularly. The exhibit has been presented more than a dozen times — New York, Paris and Brisbane — but the Montreal show is one of the largest versions created by the Nice-born artist. Ages 31 and up $20; ages 13 to 30 $12. tel: (514) 258-2000; mbam.qc.ca.

JANUARY 2016 • Doctor’s

Review

PHOTOS © THE SWEDISH HISTORY MUSEUM

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

Vikings in Ottawa

Vikings are Scandinavian celebrities and a new exhibit at the Canadian Museum of History in Gatineau, QC features 500 artifacts from The Swedish History Museum that will challenge your notion of the Viking Age. Located immediately across from Ottawa, the museum’s Vikings show covers the period between 750 and 1100CE. It confronts the stereotype of Vikings as bearded barbarians with horns on their helmets and examines the prominent role of women with insights into family life and settlements. Areas covered also include death rituals, conquest and trade journeys as well as the power of mythology and the symbolism of their ships. The exhibit is on now through April 17. Adults $15; students (with ID) $10; kids three to 12 $8. tel: (800) 555-5621; historymuseum.ca.

TOP: The mouth of this drinking horn is decorated with silver-plated fittings. RIGHT: The key was a symbol of power for a Viking woman.

Doctor’s Review • JANUARY 2016

A first in the US

F11 PHOTO / SHUTTERSTOCK.COM

Philadelphia has been named the US’s first World Heritage City by UNESCO. The distinction is awarded to cities that have made notable contributions to the world; they also must already be home to a UNESCO World Heritage site — Independence Hall (pictured) in Philly’s case, where the Declaration of Independence was adopted in 1776, the design of the American flag was agreed upon in 1777 and the US Constitution was drafted in 1787. There are 266 World Heritage Cities, including Lunenburg, NS and Quebec City in Canada. Italy and Spain have the most with more than 15 designations each. According to a study done by Global Philadelphia, the distinction has the potential to increase foreign tourism by at least 10 percent and revenue by US$150 million annually. For a list of all the World Heritage Cities: ovpm.org.

PUNG / SHUTTERSTOCK.COM

Glacier National Park in Montana’s Rocky Mountains.

100 days of parks and recreation The US’s National Park Service turns 100 in 2016. To celebrate, the tour operator Globus will visit 34 of the country’s national parks on a 103-day tour. It begins on July 7 in Honolulu, HI at Pearl Harbor and the USS Arizona Memorial and Museum, and ends on October 17 in Las Vegas. In between, travellers will discover volcanic landscapes in Hawai’i Volcanoes and Haleakala National Parks; the giant General Sherman and General Grant trees in Sequoia and Kings Canyon National Parks (California); alpine scenery and wildlife in Denali (Alaska), Mount Rainier (Washington), Glacier (Montana), Grand Teton (Wyoming), Rocky Mountain (Colorado) and Acadia (Maine) National Parks. Most of the trip will be done overland, with flights between regions; one week will be spent aboard a cruise ship in Alaska. The price is hefty — US$26,988 per person — and airfare isn’t included. tel: (866) 755-8581; globusjourneys.com.

JANUARY 2016 • Doctor’s

Review

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

The 1.3 million-hectare Sierra del Divisor is the world’s newest national park. Located along the Peru-Brazil border in the heart of the Amazon Basin, it’s bigger than Yosemite and Yellowstone National Parks combined. The final link in the Andes-Amazon Conservation Corridor — now 27 million hectares, larger than the total land and sea area of the United Kingdom — the park’s waterfalls, rivers and jungles have some of the highest levels of biodiversity recorded on the planet. Over 550 bird species, 120 mammals and nearly 80 amphibians have been documented within the borders of the reserve as have several rare or endemic species including Red uakari monkeys, South American tapirs and jaguars. Described by the Rainforest Trust as one of the Amazon’s “last true wildernesses,” the park is largely unexplored and may contain unrecorded or undiscovered species. Dozens of indigenous communities live

DIRK ERCKEN / SHUTTERSTOCK.COM

Peru’s vast new park

in the park too, including the Iskonawa, a tribe of 300 to 400 who reside in voluntary isolation. rainforesttrust.org/news/ sierra-del-divisor-created.

When more might mean less

Sheraton Grand Hotel & Spa, Edinburgh.

Marriott International is acquiring Starwood Hotels and Resorts in a US$12.2 billion deal that’s expected to take effect in mid-2016. The merger will create the world’s largest hotel company; the combined business will have 1.1 million rooms in more than 5500 hotels worldwide. The two companies have different business models, however, and that has some of Starwood’s 21 million Preferred Guest members concerned. Starwood has nearly 1300 hotels worldwide — it owns the Sheraton, Westin, W, Le Méridien and St. Regis hotel chains — and its loyalty program really pampers frequent customers. Staying 25 nights a year, for example, gets members 4pm checkout at most hotels; those staying at least 100 nights get a personal travel ambassador to handle their bookings and arrange customized perks. Marriott has over 4200 hotels, with 54 million Marriott Rewards members — and not a lot of frills. Stay tuned to find out if Starwood perks go the way of the dodo, just as upgrades and free flights became harder to get under frequent flier programs after recent airline mergers.

St. Regis Florence.

Doctor’s Review • JANUARY 2016

Binge Eating Disorder (BED) BED has recently been defined by the American Psychiatric Association as a distinct entity from other eating disorders such as bulimia Valerie Taylor, MD, PhD nervosa (BN) and anorexia nervosa (AN).1 BED is a serious disorder characterized by recurrent episodes of excessive eating accompanied by a sense of lack of control, guilt, shame and distress. Unlike BN, binge-eating episodes are not associated with compensatory behaviour such as purging, excessive exercise or fasting. As a result, people with BED are often (although not always) overweight or obese.1,2

Individuals with BED must meet all of the following criteria1: At least once per week for 3 months, they experience a loss of control over eating and consume an abnormally large amount of food in a short period of time compared with what others might eat in the same amount of time.1 These episodes feature at least 3 of the following: consuming food faster than normal; consuming food until uncomfortably full; consuming large amounts of food when not hungry; consuming food alone due to embarrassment; and/or feeling disgusted, depressed, or guilty after eating a large amount of food.1 Overall, individuals with BED feel significant distress about their binge eating.1 They do not show regular compensatory behavior associated with bulimia nervosa, nor do they binge eat solely during an episode of bulimia nervosa or anorexia nervosa.1 Diagnosis should be based upon a complete evaluation of the patient.1

BED – The most common eating disorder BED is four times more prevalent than AN or BN, and actually impacts more individuals than the other eating disorders combined. According to a survey, the lifetime prevalence of BED is 2.8% compared with 1.0% for BN or 0.6% for AN.2 BED is slightly more common in women than in men (3.5% vs. 2.0%, respectively).1,2 Prevalence rates of BED are also comparable across ethnicities.2-4

How does BED differ from other eating disorders? Bulimia nervosa BED is similar to BN in that patients exhibit recurrent episodes of binge eating. However, unlike BN, patients with BED do not compensate with purging, excessive exercising or fasting. In addition, those with BED do not generally practice marked or sustained dietary restriction between binging episodes.1 Obesity and other comorbidities Binge-eating disorder occurs in normalweight/overweight and obese individuals. As per DSM-5, it is associated with individuals presenting as overweight or obese. Nevertheless, binge-eating disorder is distinct from obesity. Most obese individuals do not engage in recurrent binge eating.1 Individuals with BED tend to overvalue body weight and shape compared with obese individuals without the condition.1 In addition, rates of psychiatric comorbidity are high among those with BED.1,2 For instance, 32.3% of adults with lifetime BED have been found to have comorbid major depressive disorder.2 This illness is about more than food intake and weight control. It is also often associated with other psychiatric comorbidities that need to be addressed.

Causes of BED While the exact causes of BED are unknown, research suggests that it may have a neurobiological basis in addition to genetic and environmental influences.5-7 Nearly half of individuals diagnosed with BED have a history of mood disorders.2 Impulsive behaviour also seems to be more common in people with BED.2 Per DSM-5, the psychiatric comorbidity is linked to the severity of the binge eating and not the degree of obesity.1

Could it be BED? Simple questions to ask your patients Individuals with BED may be unaware they have this diagnosis, or they may not seek help because of the stigma and bias associated with binge eating behaviour. It is important that physicians are able to recognize this illness and start a dialogue with clients with a few simple questions: • Do you often eat, within a 2-hour period, what most people would regard an unusual amount of food? • Do you sense a lack of control over eating during the episode? • During these periods, did you eat: – Much more rapidly than normal? – Until you felt uncomfortably full? – Large amounts of food when you didn’t feel physically hungry? – Alone because you were embarrassed by how much you were eating? • After eating, did you feel guilt, shame or distress? BED is a serious disorder that can significantly impact both psychological and physical health.1 It is distinct from other eating disorders. However, very few individuals with BED are ever diagnosed.8 This highlights the importance of querying patients about eating problems, even if they do not include them among their presenting complaints.2 Improved diagnosis is important to begin helping the patient.

References: 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013. 2. Hudson JI, et al. The prevalence and correlates of eating disorders in the national comorbidity survey replication. Biol Psychiatry 2007;61(3):348-58. 3. Franko DL, et al. Racial/ethnic differences in adults in randomized clinical trials of binge eating disorder. J Consult Clin Psychol 2012;80(2):186-95. 4. Marques L, et al. Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: implications for reducing ethnic disparities in health care access for eating disorders. Int J Eat Dis 2011;44(5):412-20. 5. Balodis IM, et al. Divergent neural substrates of inhibitory control in binge eating disorder relative to other manifestations of obesity. Obesity 2013;21(2):367-77. 6. Davis C, et al. Binge eating disorder and the dopamine D2 receptor: Genotypes and sub-phenotypes. Prog Neuropsychopharmacol Biol Psychiatry 2012;38(2):328-35. 7. Mitchell KS, et al. Binge eating disorder: a symptom-level investigation of genetic and environmental influences on liability. Psychol Med 2010;40(11):1899-1906. 8. Data on file, Shire. September 27, 2014.

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

Some people only do it on Sunday afternoon.

09/16 The AstraZeneca logo is a registered trademark of AstraZeneca AB, used under license by AstraZeneca Canada Inc. ÂŠ 2015 AstraZeneca Canada Inc.

GA D GE T S by

D a v i d Elk i n s

Atomic time Time remains one of the more puzzling aspects of the universe. Truth is, we haven’t yet figured out what it is. Since Einstein, we’ve come to believe it’s closely connected to speed and distance and that it’s, well, relative. When it comes down to it, the only thing on which this planet’s time is based is the duration it takes for the earth to do one revolution on its axis, a day, and the duration it takes for the earth to do one revolution around the sun, a year. People had been gazing at the sky for tens of thousands of years before Copernicus suggested, in the 15th century, that the earth even went around the sun. It wasn’t until 100 years after that that Galileo, with the help of the newly invented telescope, put the other planets in place and came up with the solar system, as we know it today. The church didn’t care for his ideas and he spent the last few years of his life under house arrest. By then, we’d been trying to measure time for more than 6000 years. The Chinese used sundials, as did the Egyptians. Water clocks that measure the inflow or outflow of water into a vessel were also popular. The Romans came up with mechanical devices to more accurately measure the flow and they continued to be used in Europe until the early 14th century when clocks driven by weights first appeared. One such clock is still in existence. It was a gift from an admirer to Philip the Good, the Duke of Burgundy, around 1430. He kept it in his bedroom. Bedrooms are where people still like to have a clock — witness the digital clock radios that grace bedside tables in virtually every hotel, motel and B&B room in Canada. The red LED lights are irritating, the controls are tiny, setting the alarm can be a challenge as can finding a radio station in a strange city that you can tolerate first thing in the morning. Enter the atomic clock that automatically sets itself to the US Atomic Clock, which is accurate to one second in 30 million years, more or less. The model shown here comes from Oregon Scientific and has discrete black numbers on a grey screen, which include time, date and room temperature. It also has the amusing and useful benefit of projecting the time in large red digits on the ceiling above your bed either all the time or at the touch of a button. I’ve been using one for a month and still wake up with a smile when I see those numbers above my head even if they read 5:45am, and that’s saying something. The clock runs on two AA batteries or an included AC adapter and measures 10.8 centimetres long by 6.35 centimetres wide by 11.3 centimetres high. The RM313PNA model is $29.95; radioworld.ca/oregonscientific-m-74.html.

You can win one for your own bedroom by entering our new Win the Gadget of the Month contest online at doctorsreview.com.

JANUARY 2016 • Doctor’s

Review

COVERSYL® reduces blood pressure in patients with mild to moderate essential hypertension. COVERSYL® is indicated for the treatment of mild to moderate essential hypertension. It may be used alone or in association with other drugs, particularly thiazide diuretics. The safety and efficacy of COVERSYL® in renovascular hypertension have not been established and therefore, its use in this condition is not recommended. The safety and efficacy of concurrent use of COVERSYL® with antihypertensive agents other than thiazide diuretics have not been established. Use in children is not recommended.

COVERSYL® reduces CV risk in hypertensive and/or post-MI patients with stable CAD. COVERSYL® is indicated for the reduction of cardiovascular (CV) risk in patients with hypertension or post-myocardial infarction (MI) and stable coronary artery disease (CAD). COVERSYL® has been demonstrated to reduce the risk of CV death, non-fatal MI and cardiac arrest in mild or moderately hypertensive patients with stable CAD, or in patients with a previous (> 3 months ago) MI and stable CAD, including patients with previous revascularization when administered as an add-on to conventional treatment, such as platelet inhibitors, beta blockers, lipid-lowering agents, nitrates, calcium channel blockers or diuretics. Use in children is not recommended.

Please consult the product monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for contraindications, warnings, precautions, adverse reactions, interactions, dosing and conditions of clinical use. The product monograph is also available by calling us at 1-800-363-6093. ACEI = Angiotensin converting enzyme inhibitor CV = Cardiovascular MI = Myocardial infarction CAD = Coronary artery disease *Data on file, IMS Brogan, Servier Canada Inc., April 2014–March 2015.

COVERSYL® is a registered trademark of Servier Canada Inc. Servier Canada Inc. 235, boulevard Armand-Frappier, Laval, QC H7V 4A7 www.servier.ca | 1-888-902-9700

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Canada Charlottetown, PEI June 22-25 93rd Annual Conference of the Canadian Paediatric Society www.cps.ca

Kelowna, BC June 16-18 17th Canadian Collaborative Mental Health Care Conference ubccpd.ca/course/ccmhcc2016

Ottawa, ON June 6-7 2016 National Health Leadership Conference cchl-ccls.ca/site/nhlc

June 17-20 2016 Annual Meeting and Exhibition of the Canadian Ophthalmological Society cos-sco.ca/cpd/annual-meeting

Quebec City, QC June 4-8 2016 Annual Meeting of the Canadian Association of Emergency Physicians caep.ca

June 16-19 71st Annual Meeting of the Canadian Orthopaedic Association coa-aco.org/annual-meetings/meeting-archives/ future-meetings.html

June 21-24 51st Congress of the Canadian Neurological Sciences Federation congress.cnsfederation.org

Balzac’s Coffee Roasters in Toronto’s Distillery District.

Saskatoon, SK June 22-25

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

91st Annual Conference of the Canadian Dermatology Association dermatology.ca

Around the world

Toronto, ON June 5-8

Boston, MA April 1-4

8th World Congress on Pediatric Intensive and Critical Care picc2016.com

Vancouver, BC June 24-27 2016 Annual Meeting of the Canadian Anesthesiologists’ Society cas.ca

June 25-28 71st Annual Meeting of the Canadian Urological Association cuameeting.org

ENDO 2016 endocrine.org/endo-2016

Chicago, IL April 14-16

2016 Summit of the Thrombosis and Hemostasis Societies of North America thsna.org/web/index.php

Dallas, TX April 15-17

18th Annual Meeting of the American Society of Interventional Pain Physicians asipp.org/meetings.htm

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

Go to doctorsreview.com/meetings for conferences in these cities... and many more! JANUARY 2016 • Doctor’s

Review

THE TOP 25 MEDICAL MEETINGS

Access 2500+ conferences at doctorsreview.com/meetings Code: drcme Glasgow, Scotland June 26-30

London, England June 8-11 2016 Annual Congress of the European League Against Rheumatism congress.eular.org

The Ferry Building in San Francisco.

Los Angeles, CA June 23-26 58th Annual Scientific Meeting of the American Headache Society americanheadachesociety.org/events/ 58th_annual_scientific_meeting

Prague, Czech Republic June 19-22

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

Málaga, Spain April 4-7

New Orleans, LA June 10-14

2016 World Congress on Osteoporosis, Osteoarthritis and Musculoskeletal Diseases wco-iof-esceo.org

76th Scientific Sessions of the American Diabetes Association professional.diabetes.org

Mexico City, Mexico June 4-7

Paris, France June 10-13

2016 World Congress of Cardiology and Cardiovascular Health world-heart-federation.org/wcc-2016

26th Annual Meeting of the European Society

OSCITY / SHUTTERSTOCK.COM

10th International Symposium on Pneumococci and Pneumococcal Diseases isppd2016.kenes.com

10th Congress of the European Glaucoma Society egs2016.org

San Francisco, CA April 6-10 Obesity Medicine 2016 asbp.org/education/obesitymedicine.html

Seattle, WA June 10-14 27th Annual Scientific Sessions of the American Society of Echocardiography asescientificsessions.org

of Hypertension esh2016.org

Vienna, Austria June 11-15

Mexico City’s Auditorio Nacional.

2016 Annual Congress of the European Academy of Allergy and Clinical Immunology eaaci2016.org

MEDICAL QUIPS

Doctor’s Review • JANUARY 2016

RAFAEL RAMIREZ LEE / SHUTTERSTOCK.COM

By any other name Who ever thought up the word “mammogram?” Every time I hear it, I think I’m supposed to put my breast in an envelope and send it to someone. — Jan Kin

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

R os e F os t e r

Hand transplants push science forward Gratifying results for recipients and surgeons

Dr Kodi Azari talks about his hand transplant program at UCLA on NPR’s “The Moth.”

he first moderately successful hand transplant quickly became an embarrassment for the surgeons not long after they performed it. The procedure

was attempted in Ecuador in 1964, but due to the primitive nature of antirejection medication, the hand failed after only two weeks. Almost 25 years went by before the next attempt. In 1998, an international team led by French surgeon Dr JeanMichel Dubernard in Lyon, France, seemed to be going better with the hand showing promising results. The glory of the operation, though, was soon tainted by reports that the recipient, Clint Hallam, had a criminal record and had lost his hand in prison during an accident with a circular saw. Before the operation, he’d said he lost it in “an industrial accident” which, to give him the benefit of the doubt, was not far off the mark considering that he was serving time for fraud. But things soon went from bad to worse. Hallam seemed put off by the new hand, even uncomfortable with the idea of transplantation. Rumours had it that he refused to take the prescribed drugs to prevent rejection of the graft and failed to do regular exercises to train his new appendage.

About 85 transplants have been performed around the world and some surgeons have doubts about continuing 22

Doctor’s Review • JANUARY 2016

In late 2000, Hallam claimed that the hand, which had belonged to a motorcyclist who was killed in a crash, had stopped functioning after the first 12 months. Then, he said, it began to break out in scabrous “pockets of rejection,” and he tired of its presence, admitting that he had stopped taking the medication. All he wanted now — “enough is enough,” he said — was to have the hand amputated. In February 2001, Dr Nadey Hakim of St. Mary’s Hospital in London obliged him, saying that his life was in danger due to rejection. Dr Dubernard did not wish to comment.

A TEAM APPROACH The disappointing outcome of the Hallam transplant provided an important lesson: the success of the next transplant would depend on a committed team of caregivers, including psychologists who could help the patient adjust to the eeriness of adopting such a personal part of another person’s body. In addition, it would be necessary to be more straightforward about what transplanted hands could be expected to do. While generally capable of slight movement soon after being attached, the new hands only become capable of doing the things one expects hands to do after months, even years, of hard, focused work. Transplantation, as with most medical innovations, begins with trial and error. A case in point is that of Dr Kodi

Zion Harvey, 8-year-old Baltimore resident, is the first child to receive a double hand transplant.

Azari who recently launched the first hand transplant program in California at the UCLA Medical Center. He found inspiration from the considerable advances made in liver transplantation since its early days. When he was in high school, a family friend sent him an article about young liver transplant pioneer Dr Thomas Starzl. Up to then, the lad who considered himself a risk taker had hoped to become a fighter pilot. After reading Dr Starzl’s profile, he did an about-face and from that time on he tried to learn everything he could about transplants. The first operations he read about were so bloody that blankets had to be placed on the floor by the doors of the operating room so that the blood wouldn’t seep out into the hospital hallway. In Pittsburgh, where Dr Starzl practiced, liver transplants required so much blood that all elective surgeries had to be cancelled that day for lack of blood. Moreover, many of the early patients died, either on the table or in the ensuing weeks. Now, Dr Azari notes, the hospital where he interned routinely performs three liver transplants a day.

BUILDING ON THE PAST Hand transplantation may be on a similar trajectory. After the botched 1998 transplant, a team at the Jewish Hospital in Louisville, Kentucky became the first to achieve prolonged success. Pre-

paring for years in advance with extensive basic science research and feasibility studies, they took great care in selecting their donor. The recipient of the hand was Matthew Scott, from New Jersey, who lost his dominant left hand in 1984 at age 24 in a blast from an M-80 firecracker. He received the new hand in 1999 and now, 16 years later, Mr Scott is considered the most successful hand transplant patient in the world. “His range of motion can touch things, he can almost read braille, which is down to four millimetres apart,” says Dr Joseph Kutz, a surgeon at the Kleinert Kutz Hand Care Center where Scott’s transplant was performed. “We’ve had patients who’ve had their own hands put on who haven’t even reached that point.” Dr Jean-Michel Dubernard, however, was not to be outdone. In January 2000, he and a 50-member surgical team performed the world’s first double hand transplant, again in Lyon, France. This time, the operation was a success. Two single hand transplants were also performed the same month in Guangxi, China. Two months after that, an 18-member Austrian surgical team performed the world’s second double hand transplant. Theo Kelz, a 45-yearold policeman who lost both of his hands in a pipe bomb explosion in

1994, was adamant about wanting new hands. “I was, from the beginning, absolutely convinced about getting new hands. So it’s not been a problem at all to accept these beautiful new hands. I will learn to seize life again,” he explained passionately to Austrian reporters.

ICY HANDS Hand transplantation is a long, slow operation; it can take anywhere from 13 to 50 hours. By contrast, a heart transplant takes six to eight hours. First, the bones of the recipient’s arm are joined to the bones of the donor’s hand, followed by the tendons, arteries, nerve veins and skin. If the arteries are poorly attached, a clot will form and the graft will fail. What’s more, all of this is done on ice to preserve the hand. Dr Azari recalls desperately wishing someone could pour warm water on his hands during his first operating session.

Theo Kelz, the Austrian policeman who lost both his hands while disarming a bomb. The transplants were performed by an Austrian crew of surgeons. JANUARY 2016 • Doctor’s

Review

New hands only become capable of doing things after months, even years, of hard, focused work It takes about six months for new nerves to grow all the way to the tips of the fingers — and that’s the easy part. The hard part is regrowing the neural connections that allow the hand and the brain to work together. This is where Clint Hallam, the recipient of the first hand transplant, made such a bad candidate. Kelz, the Austrian policeman, called the 1700 hours of cognitive therapy that were required of him a “huge task of concentration.” Kelz spent 1700 hours with his eyes closed, patiently absorbing tactile information while a cognitive therapist moved his thumb and fingers across a variety of textured surfaces and asked him questions about his sensations. Therapy isn’t the only challenge faced by a hand transplant recipient, of course. While new immunosuppressive drugs are better tolerated these days, they still carry an increased risk of infection and some cancers. In 2000, surgeons in Malaysia had a rare opportunity to perform a transplant without immunosuppressant drugs. The recipient was Lih Ying, a one-month-old baby girl born with a missing arm whose identical twin sister died moments after birth of brain damage. Despite their confidence that the drugs would not be necessary, the microsurgeons at Kuala Lumpur’s Selayang Hospital breathed a sigh of relief when the arm showed clear signs of taking.

EASY CHOICE? Getting a new pair of hands isn’t a matter of survival — it’s a choice, not a necessity. So far only about 85 of the transplants have been performed around the world and some surgeons have expressed doubts about continuing. But to many, especially those who have lost their hands and gained them back, the choice is obvious. Dr Azari, speaking on NPR’s show “The Moth,” said he considers the work he does restoring hands to servicemen and women who

Doctor’s Review • JANUARY 2016

Dr Steven McCabe, director of the University of Toronto Hand and Upper Extremity Program, is the first surgeon set to perform a hand transplant in Canada.

have lost them in action to be an experience beyond compare. He recalls meeting his first transplant patient, a young marine, later at the Pentagon for a photo-op. “Outside of family events, this was one of the really most incredible events of my life,” he says. “I looked at his face and I shook his hand. And the hand was warm. It was strong. And it was sweaty. Human hands are sweaty if they have nerve function.” The most recent recipient of a new set of hands in the limelight is Zion Harvey, an eight-year-old from Baltimore, MD who lost his hands and feet to an infection at age two. He’s the first child

MEDICAL QUIPS Coming to terms... Why do they call it proctology? Is it because analogy was already taken?

in the world to get two new hands. He was, it would seem, the perfect candidate. Not only was he already taking immunosuppressants for a kidney transplant he received from his mother when he was four, but he has the attitude consistent with other hand transplant recipients who have met with success. He’s relentlessly positive and unstoppable in his determination to function with ease — and he’s not afraid. “When I get these hands,” he’s said, “I will be proud of what hands I get. And if it gets messed up, I don’t care because I have my family.” Hand transplants have yet to be performed in Canada, in spite of the nearly 18,000 citizens living with amputations. Dr Steven McCabe, director of the University of Toronto hand and upper extremity program, was one of the team of surgeons who performed the first hand transplant in Lyons, and he’s determined to bring the operation to Canada. Ethical concerns, he says, have kept the health care system from approving the procedure, such as the need to take the immunosuppressive medication for life. But for some, says McCabe, the transplant is the right choice, because, he says, “it recreates a sense of wholeness for the person.”

Count on

for powerful symptom relief

PRISTIQ is indicated for the symptomatic relief of major depressive disorder.

In major depressive disorder, her doctor calls it

“demonstrated improved functional outcomes” She calls it “helping her at work”*

Choose PRISTIQ:

demonstrated improvements in functional outcomes: work, family life and social life (secondary endpoints).

PRISTIQ 50 mg demonstrated signiﬁcant improvements in functional outcomes from baseline vs. placebo, as measured by the Sheehan Disability Scale (SDS).1* Work score: PRISTIQ -2.9 (n=156), placebo -2.2 (n=148), p=0.01. Family life score: PRISTIQ -3.0 (n=163), placebo -2.2 (n=160), p=0.002. Social life score: PRISTIQ -3.2 (n=163), placebo -2.3 (n=160), p=0.003. *The SDS measures the functional impairment that depressive symptoms have on a patient’s family life, social life and work.1 A decrease in SDS score represents improved functional outcomes.2

References: 1. Boyer P, et al. Efficacy, safety, and tolerability of fixed-dose desvenlafaxine 50 and 100 mg/day for major depressive disorder in a placebo-controlled trial. Int Clin Psychopharm 2008;23:243–253. 2. Sheehan DV, Rush AJ, et al., editors. Handbook of psychiatric measures. 2000.

• 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://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.

CA0115PRI005E

Clinical Use: − Severe agitation-type adverse events coupled with self-harm or harm to others • PRISTIQ is not indicated for use in children under the age of 18 − Suicidal ideation and behavior; rigorous monitoring • 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 • Discontinuation symptoms: should not be discontinued abruptly. Gradual dose reduction is response for up to 26 weeks, following response during recommended 20 weeks of acute, open-label treatment, was demonstrated in a placebo-controlled trial Other Relevant Warnings and Precautions: Contraindications: • Concomitant use with venlafaxine not recommended • Concomitant use with monoamine oxidase inhibitors • Allergic reactions such as rash, hives or a related (MAOIs) allergic phenomenon or within the preceeding 14 days • Bone fracture risk with SSRI/SNRI • Hypersensitivity to venlafaxine hydrochloride • Increases in blood pressure and heart rate (measurement prior to and regularly during treatment) Most Serious Warnings and Precautions: • Increases cholesterol and triglycerides • Behavioural and emotional changes, (consider measurement during treatment) including self-harm: SSRIs and other newer • Hyponatremia or Syndrome of Inappropriate antidepressants may be associated with: Antidiuretic Hormone (SIADH) with SSRI/SNRI − Behavioural and emotional changes including an • Potential for GI obstruction increased risk of suicidal ideation and behaviour • Abnormal bleeding SSRI/SNRI

DE PRE SSIO N S NAPS H O T

The high cost of untreated The Toronto-based Centre for Addiction and Mental Health suggests that mental illness costs the Canadian economy about $51 billion a year. Research by the Canadian Mental Health Association estimates that employees who take a leave of absence owing to depression cost employers an average of $18,000. It further points out that only 43% of sufferers from depression seek help, and most people who do, go on to lead fulfilling, productive lives.

11.3% 13.8%

Yukon 8.7%

10.2% 12.5%

6.2% 7.6%

Refers to Canadians ≥ age 12 diagnosed by a health professional as having a mood disorder.

Urban dwellers* are more prone to depression as are individuals in the lowest socioeconomic groups. Recent immigrants report considerably less depression. Population group Urban dwellers* Recent immigrants Low-income individuals

Total Females Males 9.17% 11.44% 6.82% 5.24% 6.64% 3.87% 14.52% 17.07% 10.79%

* 81% of the population. 2011 Census

11.6% 14.2%

Doctor’s Review • JANUARY 2016

6.0% 7.4%

6.2% 7.6%

Alberta 8.9%

In 2014, a total of 2,346,244 Canadians (7.8% of the population) aged 12 and older reported that they were diagnosed with depression or a related mood disorder, depression being the most prevalent.1,2 Mental Health Commission of Canada estimates the numbers will rise by 22.5% by 2041.

Depression is highest in low-income city dwellers3,4,5

9.6% 11.8%

Canada 7.8%

7.4% 9.1%

Map legend 2014 2041

6.8% 8.3%

Northwest Territories 7.7%

British Columbia 8.8%

2014 2041

8.7% 10.7%

11.6% 14.2%

4.6% 5.6%

Saskatchewan 8.1%

9.3% 11.4%

5.7% 7.0%

Manitoba 7.5%

References 1. Statistics Canada. Mental Health and Well-Being. CANSIM table 105-0501 and Catalogue no. 82-221-X. www.statcan.gc.ca/tables-tableaux/sum-som/index-eng.htm. 2. Public Health Agency of Canada. Mental Illness. What is Depression? Government of Canada, 2014. www.phac-aspc.gc.ca/cd-mc/mi-mm/ depression-eng.php. 3. AS@ W. Facts about Depression. Centre for Applied Research in Mental Health and Addiction (CARMHA) and BC Mental Health & Addiction Services (BCMHAS) 2009. www.comh.ca/ antidepressant-skills/work/resources/factsaboutdepression. 4. Smith K, Matheson F, Moineddin R, Glazier RH. Gender, income and immigration differences in depression in Canadian urban centres. Can J Public Health 2007;98:149-53. 5. Romans S, Cohen M, Forte T. Rates of depression and anxiety in urban and rural Canada. Soc Psychiatry Psychiatr Epidemiol 2011;46:567-75). 6. Statistics Canada, 2011 Census of Population. www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/demo62a-eng.htm. 7. Statistics Canada. Aboriginal Peoples in Canada: First Nations People, Métis and Inuit. 2015. www12.statcan.gc.ca/nhs-enm/2011/as-sa/99-011-x/99-011-x2011001-eng.cfm. 8. Bellamy S, Hardy C. Understanding Depression in Aboriginal Communities and Families. Prince George: National Collaborating Centre for Aboriginal Health, 2015. 9. Health Canada. First Nations and Inuit Health: Mental Health and Wellness. Government of Canada, 2015. www.hc-sc.gc.ca/fniah-spnia/promotion/ mental/index-eng.php. 10. Cavanagh JT, Carson AJ, Sharpe M. Psychological autopsy studies of suicide: A systematic review. Psychological Medicine 2003;33:395-405. 11. Lesage AD, Boyer R, Grunberg F. Suicide and mental disorders: a case-control study of young men. Americal Journal of Psychiatry 1994;151:1063-8. 12. statcan.gc.ca/pub/82-003-x/2006001/article/depress/4060597-eng.htm. 13. wsps.ca/Information-Resources/Articles/Depressions-prolonged-effects-CBOC-recommends-wor.aspx. 14. healthcentral.com/depression/cf/slideshows/10-signs-depression-relapse#slide=11

depression

High cost of suicide Depression is the most common illness among those who die from suicide, with approximately 60% suffering from this condition. The estimated cost of a suicidal death ranges from $433,000 to $4,131,000 per individual depending on potential years of life lost, income level and effects on survivors.9,10

Depression sufferers use of negative coping12 85%

Wishing situations away

70%

Use of smoking, drinking, sleep, drugs to get through the day

80% 55%

High cost of absenteeism

70%

Self blaming

45%

Absenteeism and presenteeism due to depression, chronic depression, bipolar disorder, social anxiety disorder, panic disorder, and agoraphobia costs the Canadian economy $20.7 billion a year. By 2030, these costs are expected to reach $29.1 billion. Two out of three employees who return to work after an absence due to depression have trouble concentrating, remembering things, making decisions, and performing tasks — even though they may no longer be depressed.13

65%

Avoiding people

25% Depressed Not depressed

Depression doubles the risk of alcohol abuse Harmful alcohol use and alcohol dependence in persons with a 12-month diagnosis of MDD were 12.3% as opposed to 6.9% in the general population.10

Depression affects abilities 4.8

4.5 0

Work at a job

Maintain close relationships

5 0

8.5% 10.4%

Newfoundland and Labrador 6.6%

6 10

Home responsibilities

Social life

13.5% 16.5%

10.2% 12.5%

6.6% 8.1%

Ontario 8.4%

7.2% 8.8%

New Brunswick 10.4%

Scale range: 0 (no inteference) to 10 (very severe interference)13

6.1% 7.5%

4.7% 5.8%

4.1% 5.0%

Quebec 5.1%

14.8% 18.1%

13.0% 15.9%

5.3% 6.5%

Prince Edward Island 9.3%

6.9% 8.5%

Nova Scotia 11.0%

Signs of relapse14 • Social withdrawl • Loss of interest • General gloominess • Sleep disruptions • Self-loathing • Irritability • Weight changes • Fatigue • Brain fog • Aches & pains JANUARY 2016 • Doctor’s

Review

The road to Trini Cuba beyond Havana in the UNESCO city known for its casas particulares text and photos by Margo Pfeiff

int from my mojito mingled with the pleasant whiff of cigars. Horsesâ&#x20AC;&#x2122; hooves clattered along lantern-lit cobblestone lanes, barely audible above the salsa beat pulsing from restaurants

idad

Climb the 119 stairs to the top of Trinidad’s yellow and white bell tower for views all the way to the beaches.

JANUARY 2016 • Doctor’s

Review

Havana

Varadero Santa Clara

CUB A Trinidad

and bars. There were no cars and not a single person was looking at a smartphone. This is the mind-messing time-travel that Cuba is famous for. Even among the country’s many well-preserved, lived-in historic quarters, the small city of Trinidad is special. Perched overlooking the Caribbean on the south coast halfway across the island, it was one of the first cities founded in Cuba by the Spaniards in 1514, a colonial gem with an old town that completely immerses you into another century. An added bonus is a nearby uncrowded crescent of white beach, the best on this coast, with warm turquoise waters — and icy cocktails. With all the recent news about Americans soon being able to visit Cuba, there’s a sense that this entire authentic, Starbucks-free country will change quickly. In fact, only a tiny fraction of Cuba’s 3-4 million annual visitors today venture outside Havana and the beach resort of Varadero, about 3½ hours north, with its string of all-inclusive behemoths. Trinidad, with its sparse tourist traffic and low prices, has plenty of unique Cuban culture that isn’t as likely as the capital to change its nature as diplomatic relations normalize, making it worth travelling the 317 kilometres southeast, beyond Havana, to the province of Sancti Spíritus. Our bus driver sang a mournful love song on the scenic three-hour drive to Trinidad from Santa Clara airport on a nearly-deserted, four-lane highway with only the occasional ’50s-era vintage car, Russian Lada, or 1940s Russian motorcycle complete with a sidecar for the wife and chickens. Cars out of precious gasoline or undergoing repairs were tinkered with on the shoulders. The landscape was rolling hills and rural with Cuban cowboys herding goats and skinny cows, fields being readied for sugar cane planting by ox-drawn plough, a giant step backwards from the tractors that once worked this land until the Soviet Union’s fall. My friend Michel and I were there for a week, booked into one of three government-owned, all-inclusive hotels occupying the long stretch of beach on the Ancón Peninsula just 13 kilometres from Trinidad. Ours was the three-star Hotel Ancón (Carretera Maria Aguiar, Playa Ancón; hotelancon-cuba.com), a sturdy relic of the concrete-loving Soviet-era, retrocool 1985 angular architecture festooned with a rainbow of kitschy Latin colours. Yet it was a sur-

Doctor’s Review • JANUARY 2016

Trinidad has rows of colourful colonial buildings and more than 350 family residences in this town of 74,000 make it Cuba’s “casa capital” prising and relaxing welcome from the band and dancers who greeted every bus to the cheery bowtied bartender who unhurriedly mashed mint leaves into a fragrant pulp at the bottom of my mojito. The quality of Cuba’s three- or four-star hotels would not live up to their North American counterparts in this country’s cash-strapped economy, but the rooms were clean and comfortable, and the buffet spread surprisingly good. And, after all, the largely European, South American and Canadian vacationers were here for sun and sand, snorkeling, tennis, cheesy nightly entertainment extravaganzas and the all-inclusive rum-drenched drinks… and for the crepe guy who serenaded with songs at breakfast.

fter unwinding on the beach for three days, we tossed our overnight bags into a 1959 German Opel Kapitän taxi and headed out on the 15-minute drive into Trinidad for a couple of nights in a casa particular, a trip that would also make a nice bike ride. For the past 15 years or so, the government has allowed residents to rent rooms in their houses on a homestay/B&B basis. Trinidad, with its remarkable rows of colourful colonial buildings from the days when this region boomed with the sugar cane trade,

CLOCKWISE FROM TOP LEFT: Souvenirs feature a standard trio of themes: the Cuban flag, portraits of Che Guevara and men smoking cigars. The cathedral in Plaza Mayor was built between 1817 and 1892 on the site of a previous church from the 17th century. Playa Ancón is 13 kilometres south of Trinidad and widely recognized as the best beach on Cuba’s south coast. A sturdy, retro-cool relic of the Soviet era, the Hotel Ancón is a budget-friendly all-inclusive.

TOP TO BOTTOM: Built in 1745, the Casa Colonial el Patio was recently restored and has three rooms for rent. There are still thousands of American cars from the 1940s and ’50s on Cuba’s roads. Museo 1514 is a paladar, which is a privately owned and operated restaurant.

HOT SPOTS There are regular flights from Havana to Trinidad’s nearest airports. Cienfuegos is about 1½ hours away from Trinidad and Santa Clara is a three-hour drive. You can take the bus or easily hire a taxi to get to your accommodation. The airport shuttle is included if you book an all-inclusive hotel with a flight. Many establishments have no websites and the Internet is very slow. Vinales B&B (bbinnvinales.com) is an excellent, reliable, free booking site for casa particulares — homestays/B&Bs — throughout Cuba. Payment is made to the host after your stay in convertible pesos (CUC). There are many restaurants throughout town, particularly around the Plaza Major and along Simon Bolivar Street beside the cathedral, but your best meal will likely be at your own casa. Quince Catorze (1514) (515 Simon Bolivar; trulycuba.com/restaurant-quince-catorce-1514) is decorated with furniture and antiques from the 18th and 19th centuries. Like dining in an antique shop, it offers a unique experience with good Cuban food. At La Ceiba (263 Pablo Pichs Giron), you’ll dine on a lovely patio under a huge ceiba tree. Traditional Cuban chicken, pork, lobster. For more info on travel to the region, visit Cuba Tourism (gocuba.ca).

allows you to sleep in the 18th or 19th century: more than 350 families in this town of 74,000 make Trinidad Cuba’s “casa capital.” There was no car traffic in the hilly old town which became a UNESCO World Heritage Site in 1988, just tricycle cabs, horse-drawn carts and the occasional horseback cowboy, Texas-style boots, hat ’n all. The taxi dropped us outside the zone and we walked narrow cobblestone streets past the grand cathedral where a band was jamming on the sidewalk amid the aroma of roasting chicken. Manuel Castillo swung open his house’s massive, bright blue, ancient timber doors and welcomed us into Casa Colonial el Patio (274 Ciro Redondo Street; elpatio.trinidadhostales.com; doubles from $25; breakfast from $3, dinner from $7) where he and his wife, Lisbeth, rent three rooms. As we registered, he brought out the deed to the house his grandfather bought in 1910 for “400 pesos in Spanish gold.” He pointed out an old wooden plank on the wall with the date “1745” etched into it that he discovered when renovating. The ceilings were tall, the walls adorned with handpainted frescoes. A breeze blew in from the highwalled patio out back that gives the inn its name, also home to a tropical garden with the occasional gecko and hummingbird. We made ourselves at home in hammocks with a cold cerveza Cristal. One of the perks of staying at a casa is having access to a legendary Cuban home-cooked dinner, likely the best meal you’ll have in the country. Lisbeth created a classic langoustine (lobster) feast that we enjoyed with a cold bottle of Chilean wine beneath the twinkling lights, dangling mangoes and Tarzan-calibre vines of the patio. Breakfast, too, was in the bird-chirping shade of the garden, a wonderful spread of high-octane Cuban coffee, homemade bread and jam, in-season papaya, and fresh eggs supplied by nearby chickens whose mate woke us up earlier that morning.

e spent the day prowling a hilly maze of streets where shops and colonial row houses in cotton-candy colours featured windows barred with wrought-iron grills, regas, instead of glass. Often, bird cages hung outside. We poked into rows of tiny art shops, most featuring paintings with the standard trio of themes: the Cuban flag, portraits of Che Guevara, old men puffing massive cigars. The layers of ornate old frescoes on the peeling walls of the Galeria de Arte were even more intriguing than the exhibits. The main square, Plaza Mayor, has a towering cathedral and the town’s best museum, Museo Romantico, where aristocratic antique furnishings —

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including a 1.4-tonne marble bathtub — gathered from surrounding sugar estates are on display in the lavishly restored 1808 mansion of a former sugar baron. Just down the cobbled road, a former convent is now the Museo de la Lucha Contra Bandidos honoring the heroic Cubans who fought off counterrevolutionary “bandits” in the surrounding Sierra del Escambray after Castro took power in 1959. Those mountains are now part of Topes de Collantes National Park, popular for hiking and horseback riding. The highlight of the museum visit, though, was the climb up 119 rickety wooden stairs to the top of the yellow and white bell tower that is Trinidad’s trademark for a stunning panorama all the way to the beaches. Humming, strumming and drumming are everywhere. Trombones, trumpets, guitars and drums in the hands of small street bands belted out tunes on sidewalks, in squares and urban parks. Some of the best jamming took place outside the UNESCO zone in Parque Cépedes amid a no-frills, unrestored neighbourhood with a cigar factory and tiny markets where Trinitarios hand over ration cards in exchange for meat and vegetables. It’s a great place to take a seat under a tree, chat with locals and peoplewatch with a salsa beat. Transportation-watching too is a popular Cuban entertainment as legions of 1950s American cars streamed by. I chatted with a taxi driver alongside his red and white 1957 Ford Fairlane. “Original upholstery and original engine,” he pointed out proudly. “It has done over one million kilometres.” When the dim, flickering lanterns switch on at sunset, the volume in this sleepy town cranks up. Many of the lively restaurants with dining patios along Simon Bolivar Street — colonial homes-turnedeateries — featured live music. But the epicentre was the alfresco Casa de la Musica at the top of a broad stone staircase alongside the cathedral where top bands had everyone sweating on a dance floor under the stars. (Live outdoor performances begin at about 10pm nightly). Change is coming to Cuba, but very slowly, which is a good thing. As we checked out of our casa, I commented to Miguel how refreshing it is not to have cell phone or data access. He explained excitedly that the Cuban communications division had just announced a partnership with AT&T to upgrade the island’s notoriously sluggish Internet. “But they are advocating smart Internet use for its citizens,” he said. Good luck with that. Personally, I was happy to linger just a little longer in the past. I slipped into the back seat of a 1956 Ford Customline for the retro ride — pre-seatbelts — back to the beach.

The Dominican Republic beyond the all-inclusives. doctorsreview.com/features/galeras-dominican-republic JANUARY 2016 • Doctor’s

Review

AndroGel速 is indicated for testosterone replacement therapy in adult males for conditions associated with a deficiency or absence of endogenous testosterone (hypogonadism). 1

AndroGel

速

TESTOSTERONE REPLACEMENT THERAPY (TRT) FOR MEN WITH HYPOGONADISM 1

Consult the Product Monograph at http://webprod5.hc-sc.gc.ca/dpd-bdpp/index-eng.jsp for important information on contraindications, warnings, precautions, adverse reactions, drug interactions, dosing and conditions of clinical use. The Product Monograph is also available by calling Mylan EPD at 1-844-596-9526.

References: 1. AndroGel速 Product Monograph. BGP Pharma ULC. January 28, 2015. 2. IMS Brogan, CompuScript, Testosterone Replacement Therapy, Molecular Level, National Data, MAT July 2015. Data on file, BGP Pharma ULC. 息 Mylan 2015. All rights reserved. 速 Registered Trademark Abbott Laboratories (USA), Licensed use by BGP Pharma ULC, Saint-Laurent, Quebec, H4S 1Z1

Keys to fun,

Smathers Beach is one of the biggest and best public beaches in Key West.

food and films A frolic along the string of islands south of Miami by Cherie DeLory with David Elkins

ANDY NEWMAN/FLORIDA KEYS NEWS BUREAU

ey Largo, home to the restored African Queen steamboat, is the largest island in the Keys and a place where fans of classic films and laid-back island lifestyles alike come to fall in love.

Hopeless classic film nut that I am, I’d always longed to visit Humphrey Bogart’s Key Largo, and I finally had my chance. One sunny January day last year, I climbed aboard the restored African Queen steamboat (keylargoprincess. com/queen; from US$49), and prepared to fall in love as Bogey and Katharine Hepburn’s characters did in the 1951 film named for it. There are more than 1700 mostly very small coral islands with a total landmass of 356 square kilometres strung along the Florida Straits between the Atlantic and Gulf of Mexico. Key West (pop. 25,000), near the southwest end of the chain, is the southernmost destination in the US just 145 kilometres from Cuba. From cigar kiosks to spicy Cubaninspired fish dishes, the town has a welcoming Cuban vibe with a heavy overlay of American tourist. It’s long been a B&B mecca and these days Airbnb lists 246 rental units with a surprisingly high average rental rate of $365 a night. Why so high? Because

the Keys, and especially Key West, can be a lot of fun. It’s more of a party town than a place to hit the beaches, though there are bits of sand to lie on throughout the Keys. Another caveat: unless you do a lot of careful planning, it might be wiser to leave the kids at home. One indication: the best deals on food in the Conch Republic, as the town is sometimes called, come with drinks during happy hour. Getting there is an essential part of the Keys experience. The drive south from Miami is along 240 kilometres of US Highway 1, a two-lane stretch, which threads its way through the bright blue water of the Atlantic on the right and the Gulf of Mexico on the left. It’s an iconic route that was once home to the Overseas Railroad, the spine and lifeline that connected the Keys to the mainland along 42 bridges. The trip can be done in about three hours, but leave plenty of time to meander. There are lots of places to swim and picnic as you wind your way JANUARY 2016 • Doctor’s

Review

ANDY NEWMAN/FLORIDA KEYS NEWS BUREAU/HO

GO FISH

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he unpretentious Keys are a little bit of bohemian kitsch and a whole lot of diving, fishing, arts and adventure. It’s a place where Key Lime Pie is on every menu, and “cook your catch” means there’s a chef in the kitchen just waiting to prepare your filleted fresh fish (see “Go Fish” below). If all things quirky and unique are up your alley, the Florida Keys delivers. Check out the funky music festival, view the underwater pumpkin carving

scene, sleep in Jules’ Undersea Lodge and plunge into wreck diving, a hugely popular local sport. The Keys have a long history of shipwrecks so there’s always the glittering possibility of treasure still to be found. Even if you don’t discover gold on the ocean floor, you’ll find treasure in the Shipwreck Museum (keywestshipwreck.com; adults US$15, kids four to 12 US$9) in Key West and the History of Diving Museum (divingmuseum.org; adults US$12, kids five to 11 US$6) in Islamorada, which boasts the world’s largest collection of vintage diving masks. Ride the tour trolley (trolley tours.com/key-west; adults from US$30, kids under 12 free) through the Old Town in Key West and keep your eyes peeled for the former homes of president Harry Truman,

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south. Eighty kilometres out of Miami, you’ll come to Key Largo, proud to call itself the dive capital of the world and the aforementioned spot made famous by Bogart and his wife, Lauren Bacall. Next in the necklace is Islamorada, which bills itself the sports fishing capital of the globe, then on to Marathon and into the Lower Keys before coming to Big Pine Key just 47 kilometers north of Key West.

LEFT TO RIGHT: Built in 1912, the African Queen once carried Humphrey Bogart and Katharine Hepburn. There are many famous restaurants and bars along downtown’s Duval Street. Old Town Trolley tickets are valid all day so riders can hop on and off.

Ask any fisherman worth his bait to name a few famous fishing destinations and the Florida Keys will be close to the top of the list. At Lazy Days Restaurant (keysdining.com/lazydaysrestaurant) in Islamorada, Chef Lupe Ledesma cooks up king fish, wahoo, yellowtail snapper, mangrove snapper and mahi mahi. Diners choose how they’d like it prepared — fried, blackened, grilled, jalapeño encrusted, sautéed or their signature dish. “Our Lazy Days Style is extremely popular,” says manager Lisa Harris. “We encrust the fish with Japanese breadcrumbs, sauté it and top with fresh shredded Parmesan cheese, diced tomatoes, scallions and key lime butter sauce.” Half Shell Raw Bar (halfshellrawbar.com), in the heart of Key West’s historic seaport, lets diners watch as the fishermen unload the catch of the day into Half Shell’s Fish Market or you can turn in your catch to the chef to do what he/she does best. “We will cook any fish customers bring in, whether they caught it themselves or bought it from our fish market,” says Chef Sebastian Pilch. He sees a lot of snapper and grouper, and customers ask for their fish to be fried, blackened or grilled, usually in that order of preference. Chef John Mirabella at the Castaway Waterfront Restaurant & Sushi Bar (facebook.com/castaway restaurant) in Marathon says, “The truth is, [customers] will bring anything they catch even if it may not be one of the most popular eating fish around. They bring in snapper, grouper, mackerel, lionfish, lobster, hogfish and mahi. We have also had them bring in kingfish, bluerunners, toro and grunts. We really don’t mind what kind they bring.” Preparation styles run the gamut from broiled, grilled, blackened, fried, lemon caper, wreck diver style and Mazatlán style. His recipe for wreck diver-style lionfish, with capers, tomato, lime and scotch bonnet peppers, is featured on the National Geographic website.

Doctor’s Review • JANUARY 2016

The Seven Mile Bridge is open to vehicular traffic, but the old bridge next to it is only for pedestrians and cyclists.

The Shipwreck Museum gives guests a glimpse at 19th century life and the wrecking’s influence on the islands.

ANDY LIDSTONE / SHUTTERSTOCK.COM

Mallory Square is home to a sunset celebration that’s a daily ritual for visitors.

BOB KRIST/FLORIDA KEYS NEWS BUREAU

FUN AMONG THE KEYS Every day hundreds of sunset seekers gather at Key West’s Mallory Square (mallorysquare.com) to watch the fiery orb sink into the sea. It’s a spectacle that seldom disappoints. The party kicks off two hours before sunset, with jugglers, fire eaters, conch fritter kiosks and a host of other festivities. Train fanatics are invited to visit historic Pigeon Key Island up the road in Marathon and stay overnight in an intimate cottage. It’s the two-hectare property where the Florida East Coast railway workers and their families lived between 1905 and 1912 during construction of the Old Seven Mile Bridge and the laying of the tracks. At the museum, you’ll learn about Standard Oil founder Henry Flagler’s dream of building a railway that would connect mainland Florida with the Keys, and the hurricane in 1935 that destroyed it. A small ferry from the Pigeon Key Visitor Center (pigeonkey. net) transports visitors under both new and old bridges. A section of the old bridge is open for sightseeing. There are daily historical tours; a Marine Science Summer Camp; and the annual Pigeon Key Art Festival in February. Customized programs include visits to the Turtle Hospital and mangrove kayaking. JANUARY 2016 • Doctor’s

Review

playwright Tennessee Williams — the film adaptation of his play “The Rose Tattoo” was shot on the island in the 1950s — and writer Ernest Hemingway. Visit the Nobel Prize winning author’s two-storey Spanish colonial villa, now a registered National Historic Landmark and museum, and take a close look at the cats you’ll find meandering around. Do a quick toe-count and you’ll spy more than a few sixtoed felines lolling in the garden and reclining on Hemingway’s chaise lounge. Legend has it that a ship’s captain gave Hemingway a white six-toed cat named Snowball, the start of a long line of furry descendants. The prolific American novelist and war correspondent lived in Key West for 10 years beginning in 1929 and penned many of his novels on the island. He wrote about depression-era Key West in “To Have and Have Not.” Bogart and Bacall fell in love on set of the movie in 1944 which contains the famous Bacall line, “You know how to whistle,

Doctor’s Review • JANUARY 2016

There are hundreds of places to stay in the Keys from the many offerings on Airbnb.com to four-star resorts. Here are just three. Postcard Inn Beach Resort and Marina (holidayisle.com; doubles from US$289) at Holiday Isle in Islamorada offers a relaxed nautical vibe with tropical beach and pool area, a variety of water sports, boating and bonfires. Hawks Cay Resort (hawkscay.com; doubles from US$294) is in Duck Key, midway between Miami and Key West. It boasts five swimming pools, an impressive range of accommodations and a fine tennis centre. Charter fishing boats and guides are available for hire at Hawks Cay Marina. Casa Marina Waldorf Astoria Resort (casamarinaresort.com; doubles from US$399) is a historic luxury hotel with connections to the Overseas Railroad. There’s a private beach and it’s minutes from the excitement of the Old Town in Key West.

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Ernest Hemingway lived and wrote in this house in the heart of the Old Town for more than 10 years.

WHERE TO STAY

ANDY NEWMAN/FLORIDA KEYS NEWS BUREAU/HO

The Hemingway Days Festival features a “Running of the Bulls” and Look-Alikes contest.

don’t you? Just put your lips together and blow.” The Humphrey Bogart Film Festival (bogartfilmfestival. com) is scheduled for October 12 to 16 this year. African Queen canal and dinner cruises run daily all year. As I climbed aboard that famous boat, I could imagine Bogart and Hepburn standing on deck, and when the magic moment came for me to take the helm and steer her along the canal, I hoped I made Bogey’s Captain Allnut proud.

Introducing

Introducing Nesina (alogliptin): a new DPP-4 inhibitor for patients with type 2 diabetes. Pr

Reimbursed by RAMQ as a médicament d’exception (prescribing codes available) Treatment of type 2 diabetic patients:

CODE

As monotherapy, where metformin and sulfonylurea are contraindicated or not tolerated

EN167

In association with metformin, where sulfonylurea is contraindicated, not tolerated or ineffective

EN148

In association with sulfonylurea, where metformin is contraindicated, not tolerated or ineffective

EN149

DPP-4 = Dipeptidyl peptidase-4

As per RAMQ List of Medications and Codes des médicaments d’exception (Updated July 24, 2015).

Nesina is indicated to improve glycemic control in adult patients with type 2 diabetes mellitus • as monotherapy as an adjunct to diet and exercise in patients for whom metformin is inappropriate due to contraindications or intolerance • in combination with metformin when diet and exercise plus metformin alone do not provide adequate glycemic control • in combination with a sulfonylurea (SU) when diet and exercise plus a SU alone do not provide adequate glycemic control • in combination with pioglitazone when diet and exercise plus pioglitazone alone do not provide adequate glycemic control ®

• in combination with pioglitazone and metformin when diet and exercise plus dual therapy with these agents do not provide adequate glycemic control • in combination with insulin (with or without metformin) when diet and exercise plus a stable dose of insulin (with or without metformin) do not provide adequate glycemic control Consult the product monograph at http://www.takedacanada.com/ ca/nesinapm for contraindications, warnings, precautions, adverse reactions, drug interactions, dosing and conditions of clinical use. The product monograph is also available by calling us at 1-866-295-4636.

REFERENCE: 1. NESINA Product Monograph, Takeda Canada Inc., November 7, 2014. ®

See Product Monograph for complete dosing and administration information including dosage adjustment in renal impairment.

Fantasy islands Yes, these Caribbean resorts are expensive, but whatâ&#x20AC;&#x2122;s life without dreams? text and photos by Josephine Matyas

At Viceroy Anguilla, guests are pampered with private infinity pools and the services of a 24/7 lifestyle assistant.

here’s no heat quite like Caribbean beach heat. Warm and moist with a prevailing breeze, it’s a temperature and humidity made for relaxing. As snowflakes begin to fall on our world north of the 49th parallel, we fantasize about turquoise waters lapping a palm-fringed shoreline. There are resorts aplenty vying for the business of winter-weary Canadians and sometimes schedules, bank balances and vacation days align. Other times, that “trip” only happens in the world of dreams. So, when my travels are confined to fantasy, I like to think big.

Not necessarily sprawling destinations, but big on the scale of romantic settings that ooze laidback luxury. With that in mind, the Caribbean as a canvas, allow your mind to wander to the shores of these three island resorts. Only one rule: you’re not allowed to think of your bank account, instead take off for a few minutes on a “what if…” holiday.

The beach at GoldenEye was part of what Fleming called “the most healthy life I could wish to live.”

Guests are welcome at GoldenEye House, the Jamaican home where Ian Fleming wrote all 14 James Bond books.

At the centre of the estate is the five-bedroom Ian Fleming villa that can be rented for the ultimate “guess-where-I-stayed?” GOLDENEYE Jamaica’s GoldenEye offers even the most paparazzifearing celebs a place to drop out of sight. A gravel driveway snakes through lush tropical greenery. The front gardens are dotted with trees planted by jetsetters. The tropical shrubs planted throughout the grounds are a botanical guest book. For years, visitors have been encouraged to plant trees to support sport and physical education as a catalyst for social change in Jamaica. Pierce Brosnan, Gwyneth Paltrow, Harrison Ford, Willie Nelson, Jim Carrey and Martha Stewart are among the alums. Indeed, thanks to the tantalizing harmony between community and nature, GoldenEye possesses a special mojo for artists, musicians, authors and actors. Singer/songwriter Sting wrote “Every Breath You Take” while staying at GoldenEye. From the 1940s, GoldenEye was the Caribbean home of 007 author Ian Fleming. Commander Fleming — a former British intelligence officer — drew from his military experience and his fascination with techno-gadgets and penned all 14 James Bond novels while at GoldenEye. He famously closed the windows to keep from being distracted by the birds and the flowers, and pushed his desk

Doctor’s Review • JANUARY 2016

against the bare wall so he wouldn’t be diverted from the task at hand. At the centre of the historic estate is the original five-bedroom Ian Fleming villa that can be rented for the ultimate “guess-where-I-stayed?” getaway. There are also cliffside, lagoon and beachfront cottages with open-air dining, jalousie shutters, wide verandas and irresistible outdoor showers. Many units have full kitchens and everything you’d need to shake or stir at Happy Hour. The GoldenEye design mantra is to meld the outdoors and indoors as seamlessly as possible. Soon after Fleming’s death in 1964, the estate was acquired by default by record producer Chris Blackwell, the man responsible for introducing the world to the sounds of Bob Marley, Steve Winwood, U2 and others. “In 1976 I talked Bob Marley, to whom I’d just paid $70,000 in royalties, into buying GoldenEye,” Blackwell recounted. “But then he got cold feet, said it was too posh, so the next year, when I was flush again, I bought it myself. The original For Sale document said Bob Marley and we crossed that out and wrote in Chris Blackwell.” Lucky Chris. On my first twilight at the resort, I took out one of the blue kayaks tied to the dock of my commodious villa

The cottages at Nisbet Plantation reflect a long British tradition at the Nevis resort.

and paddled out on the lagoon to look back at GoldenEye and soak up what Fleming called his “wonderful annual escape… into blazing sunshine, natural beauty and the most healthy life I could wish to live.” As dusk fell, I sat on the dock dangling my toes in the water and listening to the rhythmic chirpings of Caribbean tree frogs — little frogs with big voices. Torch lit pathways wound through the palms and quiet waves lapped at a beach the colour of a buttery croissant. At the resort’s tree-house-style restaurant, The Gazebo, the bartender whirled together a mixture of pineapple and orange juices, crushed ice and rum to make tumblers of the signature libation, The GoldenEye. True to Blackwell’s “roots philosophy,” the rum of choice is Blackwell’s Well Black, made at GoldenEye and based on an old family recipe from when his ancestors traded in rum, sugar and coconuts — the perfect finale to a day of sun, sand and the sweetness of doing nothing. GoldenEye (islandoutpost.com; winter rates for a fully equipped villa complete with kitchen start at US$925, half and full board plans available on request) is located on Oracabessa Bay, 20 minutes east of Ocho Rios, Jamaica.

NISBET PLANTATION BEACH CLUB Nevis, a Leeward Island and sister to St. Kitts, today is something of a West Indian secret. In early 1607, English explorer John Smith and his flotilla of three ships stopped on the small island for six days before venturing north to settle Jamestown in Virginia, the first permanent English settlement in the New World. In the era of colonization, the British and French waged war over the prosperous soil on Nevis; the British eventually took the power. They quickly created plantations for cotton, sugarcane, tobacco and indigo, creating an economic engine that was larger than the 13 American colonies put together. It was then that Nevis was nicknamed the Queen of the Caribbees. In the early days of the plantation era, sugar was so lucrative that it was known as “white gold,” but after the 20th-century downturn of the sugarcane market, the compact island was forced to reinvent itself and turned to tourism. Several of the island’s historic plantation homes saw new life as restored, elegant resorts. Nisbet Plantation Beach Club is the only one of the original plantation homes that boasts a beachfront JANUARY 2016 • Doctor’s

Review

Nevis has some lovely beaches yet Nesbit Plantation is the only resort on the island that’s right on the water. RIGHT: Celebrities like Paul McCartney enjoy the seclusion of the Viceroy Anguilla as well as the copious amenities.

location. The heritage property was the ancestral home of Fanny Nisbet, wife of famed British naval hero Admiral Horatio Nelson, and has been turned into an intimate getaway where the emphasis is on preserving the authentic flavours and hospitality of the Caribbean. Long rows of coconut palms lead from the Great House across an expansive lawn dotted with cottage-style villas. In the distance — three kilometers across The Narrows — the hills of its sister island St. Kitts create a screensaver view. With its deep English pedigree come certain traditions. Nisbet Beach is known for its ritual of afternoon tea, with a menu choice spanning both sides of the ocean, from English Breakfast to ginger and honey bush tea, a Nevisian staple steeped from herbs gathered locally. Later, from my cottage beneath the palms, the sound of guitar and steel pans drifted from the beachfront bar. The only sound competing was the rhythmic shush of the waves on shore. I wandered down, grabbed a tropical drink and wiggled my bare feet into the sand. “It’s the perfect night for just grabbing someone special and cruising on the dance floor,” explained dining room maître d’ Patterson Fleming. It is easy to be seduced by a spot like Nisbet Plantation. The setting, the people and the sense of family create the perfect mélange of nature, culture and hospitality.

Doctor’s Review • JANUARY 2016

Nisbet Plantation Beach Club (nisbetplantation.com; winter rates start at US$739 for two, including all meals and most amenities) is on Nevis, the sister island of St. Kitts, in the Leeward Islands.

VICEROY ANGUILLA On an island known for its discerning clientele, Viceroy Anguilla is a place to see and discreetly be seen. From a lobby that looks like a page torn from Architectural Digest, the property is a design-driven village of luxe rooms, suites and villas set on prime beachfront and bluff-tops. Anguilla is a small island, standing apart from many other Caribbean sun spots. There are no bargain chain resorts, and the small airport only services private jets and a select few regional aircraft (most guests arrive by small ferry from neighbouring St. Martin). The Viceroy Anguilla was quick to establish its niche as a celebrity haven; Alec Baldwin, Paul Simon, Paul McCartney and Sandra Bullock have signed the guest register. Away from unwanted glare, the gracefully landscaped resort is a true getaway for the Manhattan and Los Angeles crowd. They come for the seclusion, copious amenities and attention to detail. There are more than 200 pools on the property and almost all rooms, suites and villas have at least one private one.

There are more four- and five-bedroom villas than entry-level units at the Viceroy Anguilla.

There are 200 pools on the Viceroy property and almost all rooms, suites and villas have one private one With more four and five bedroom villas than professional gas stoves and grills, 24-bottle wine entry-level units, the resort’s room mix is flip-flopped fridges, and outdoor cooking areas furnished with from the norm. Impressive four-bedroom oceanfront gas grills, fridges and sinks. villas feature separate living areas where each bedroom Cobà, the resort’s signature restaurant (and one is separated into its own pod with a dressing room of five), is clean and uncomplicated, letting the and boundless bathroom. Some are accessed by ingredients speak for themselves. Neighbouring separate outside entrances — intended as a nanny or St. Martin is Viceroy’s culinary pipeline to the best pilot suite. A butler, housekeeper and chef are a phone of European ingredients: oysters from Brittany, butcall away. At a very minimum, each villa comes ter from Normandy, Heineken from Holland and with a lifestyle assistant (graduates of the Internawines from France. tional Institute of Modern Butlers) accessible 24/7 on Three sides of Cobà overlook the ocean, the pera dedicated cell-phone line, to arrange room service, fect wakeup vista for a morning espresso. An extensive act as a personal concierge and keep the villa humming breakfast buffet places an emphasis on “healthy,” along (doing laundry, stocking the kitchen and bar). including tropical fruits, an omelette station (yes to Some villas’ design pièce de “egg whites only”), coconut résistance are floor-to-ceiling glass French toast, imported cheesdoors that slide open to a spaes, hot and cold cereals, and cious, private terrace view of yogurts. In the evening, the turquoise ocean, a saline infinity Sunset Lounge is positioned pool and Jacuzzi, not to mento ensure that it’s the island’s tion a covered patio nook with best place to watch the sun Overheard in a clinic, as a outdoor sofas and a dining table drop below the horizon. receptionist spoke to an that seats eight. obviously hard-of-hearing client, Cooking in suite is serious Viceroy Anguilla (viceroyhotel “No Mrs. Jones, not the HEARSE, business, whether you choose sandresorts.com/anguilla; winter rates I’m sending the NURSE.” to cook yourself or arrange for start at US$737 for two, including all a private chef. Fully-equipped meals and most amenities) is locatkitchens include six-burner ed on Barnes Bay, Anguilla.

MEDICAL QUIPS What’s that again?

JANUARY 2016 • Doctor’s

Review

Divine Roman The goddesses of ancient Rome that still grace the Eternal City by Susan Van Allen

The Roman Goddess Minerva was worshipped with Jupiter and Juno as a powerful triad of gods on Capitoline Hill.

n encounters Y

ou’ll never forget your first time. You’ll be walking along or speeding in a cab from the

airport and then they will appear… the Colosseum… the Arco di Tito… the whole glorious spread of jawdropping triumph and ruin. Rome is a place to let your imagination run wild. Picture women rattling tambourines in torch-lit processions, chariots carrying tanned muscular men in togas to the baths. Goddesses’ temples, empresses’ tombs and churches dedicated to the Virgin Mary are all to be discovered in the 1000-plus years of history that surround you. It’s impossible to absorb it all in one shot. Hiring a good guide is best since hardly any of the sculptures and ruins are marked. Or just stroll around and surrender to your fantasies.

DOUG SCHNURR / SHUTTERSTOCK.COM

THE CAMPIDOGLIO The Michelangelo-designed piazza is a perfect place to begin, where Minerva, Goddess of Wisdom, Rome, and War, sits on a throne holding her mighty spear — just behind Marcus Aurelius on his horse. To either side of Minerva are the Capitoline Museums (Piazza del Campidoglio; en.museicapitolini.org; €15), packed with sculptures of characters who once roamed the area surrounding you. In the Palazzo Nuovo, the museum to the left of Minerva, head to the first-floor hallway to see the Capitoline Venus. The Goddess of Love and Beauty is featured in a sunlit niche, posed as Venus Pudica (modest Venus), with one hand over her breast, the other covering her Cupid’s cloister. Yes, she’s modest, but also teasing, as if to say: “Look what I’m hiding....” Venus was the deity who flitted from passion to passion. She was married to Vulcan, God of Fire, but even the best couple’s counsellor couldn’t have kept this beauty tied to that angry, crippled god. Venus had hot affairs with Mars (God of War), the devastatingly

JANUARY 2016 • Doctor’s

Review

The vessel next to Modest Venus in the Palazzo Nuovo may allude to bathing in the sea to renew her virginity.

XUAN CHE / FLICKR

The House of Augustus was discovered in 1961, but only opened to the public in 2008 after decades of restoration.

Walking up from the Forum, you come to this serene place, where Romulus chose to begin the city handsome Adonis, and disguised herself as a mortal for trysts with men she found attractive. Every year she bathed herself in the sea from which she was born to renew her virginity. In the same hallway, you’ll see a statue of a Roman Woman Dressed as Venus (hardly dressed), proving how closely Romans associated themselves with the goddess. The Roman woman breaks out of the Modest Venus pose, standing proud and naked with one hand on her hip. For a laugh farther down the hall, check out the Drunken Old Woman, who’s crouched, laughing and guzzling a jug of wine.

SANTA MARIA D’ARACOELI Up steep steps from the Palazzo Nuovo is this red brick church, dedicated to Mary. It was built over a temple that was dedicated to Juno, Goddess of Marriage. The legend goes that in ancient times a sibyl (wise woman prophet) appeared here to Emperor Augustus and foretold the coming of Christ. The stairs were called the Stairway to Heaven in medieval times, when women wanting a child or husband would climb them on their knees.

THE ROMAN FORUM Here in the ongoing archeological excavation, you’ll see ancient Rome’s largest temple, dedicated to Venus and Rome. The Forum (coopculture.it; €12 for two-day access to the Colosseum, Forum and Palatine Hill area) was built during Emperor Hadrian’s time, now

Doctor’s Review • JANUARY 2016

distinguished by its large curved half roof. It once held two humongous statues of those beloved deities, sitting on thrones, back to back. Roman priests would sacrifice female animals to these goddesses to bring good fortune in war and business. Nearby is the Temple of the Vestal Virgins, now rows of pillars with remains of female statues. The Cult of Vesta, Goddess of Hearth and Home, was the oldest of the ancient world. Some say this cult still exists in modern Italy, where la famiglia remains the country’s core. Back then, girls from the ages of six to 10 were chosen from patrician families to become Vestals, taking vows of chastity and service for 30 years. They tended the temple flames, made salt cakes and were the only women presiding at rituals. The upside for the Vestals, in a time when women didn’t have that much freedom, was that they could come and go as they pleased and got perks all over town like special seats at games and festivals. The downside was gruesome: if they let Vesta’s flame go out, they’d be flogged, and if they had sex with anyone, they’d be buried alive. Tip: Don’t go to the Forum between 10am and 2pm, the heaviest tourist times.

THE PALATINE HILL Walking up from the Forum, you come to this pretty and serene place, where Romulus, great grandson of Venus, chose to begin the city. It went on to become the Beverly Hills of Ancient Rome, where noble palaces

IRISPHOTO1 / SHUTTERSTOCK.COM

BOJAN PAVLUKOVIC / SHUTTERSTOCK.COM

The House of the Vestal Virgins features a courtyard with statues of the head vestals and inscriptions of their virtues on the pedestals.

were built. In the 16th century, the Farnese family created gardens here, so you can wander through rows of boxwood shrubs, cypress trees, laurel and rose bushes, and enjoy lovely views of the Forum below. As for the palaces, the Home of Augustus is now open to the public, but be prepared to wait in a long line to see the emperor’s frescoes unless you get there when the site opens. His wife Livia’s house was recently restored so you’ll be treated to a vast arched space with frescoes of vibrant garlands, symbols of Augustus’s victories. The Palatine is a great place to fantasize about the grand days of Livia and Augustus, who ruled Rome for 45 years, bringing the city into its Golden Age. Back in 39 BCE, just after Julius Caesar’s assassination, Livia was a beautiful 19-year-old, married to the much older Tiberius Claudius Nero and pregnant with their second child. Along came handsome, young Octavius (soon to be Augustus), a rising star on the military scene, married with a pregnant wife. Octavius fell in love with Livia, divorced his wife the day she gave birth, and married the pregnant Livia. Livia’s old husband gave her away at the ceremony, even throwing in a dowry. It turned out to be a good political move for all involved and in those days the citizenry didn’t even blink over it. Octavius became Emperor Caesar Augustus and ruled Rome with his perfect mate Livia, who took charge of everything at home when he set off to conquer distant lands. Livia was an exemplary Roman wife. She was famously chaste, “worked wool” (made her husband’s togas) and never showed off

with fancy jewellery or dress. The couple lived simply here throughout their 51 years of marriage, with Livia putting up with philandering Augustus, who was known for his S&M exploits. Together they revived Rome, restoring monuments in the Forum and building new ones throughout the city. Livia has become famous in fiction, particularly through Robert Graves’s I Claudius, where she’s portrayed as a conniving woman who poisoned potential heirs to make sure her family line would inherit the throne. Whatever version of the story you believe, Livia’s descendants did end up ruling Rome. She died at the ripe old age of 86 and was honoured as Diva Augusta. Her image was revered in the streets of Rome, carried by elephant-drawn carriages in celebrations. To get a more vivid experience of Livia’s lifestyle, head to the Palazzo Massimo alle Terme (1 Largo di Villa Peretti; archeoroma.beniculturali.it; adults €7; closed Mondays), near Roma Termini. The entire garden room of her suburban villa has been moved to the top floor of this museum, so you can stand in the midst of amazing frescoes that feature a harmonious, abundant landscape of trees, flowers, and birds. Tip: Time your visit so you’ll be on the Palatine Hill at sunset, then head to Enoteca Provincia Romana (82 Via Foro Traiano; closed Sundays) for an aperitivo. This is an excellent wine bar that features wines and cuisine of the Lazio region, facing Trajan’s column. Excerpted from 50 Places in Rome, Florence, and Venice Every Woman Should Go (Travelers’ Tales, 2014). JANUARY 2016 • Doctor’s

Review

Lentil, sweet potato and ancho chili.

In the bowl Chili times three — with chicken, lentils and turkey recipes by

Robb Walsh

photos by

Eva Kolenko

exicans, Texans, New Mexicans and Midwesterners have been arguing about chili for over a century. In The Chili Cookbook, food writer and

three-time James Beard Award winner Robb Walsh writes that they’re still debating what it is and even how to spell it. Tomatoes or no tomatoes? Ground meat or hand chopped? An “I” or an “E” at the end? The cookbook’s contents will likely add to the controversy. It fea-

Doctor’s Review • JANUARY 2016

tures 60-plus recipes — including “modern” ones that call for chicken and turkey, lamb, pork and shrimp. Purists will go wild. A vegetarian version is included here as is the chili that President Barack Obama makes for his family.

LENTIL, SWEET POTATO AND ANCHO CHILI One of the hardest things about vegetarian chili is getting the consistency right; it’s hard to achieve the ideal gravy-tochunk ratio. This lentil and sweet potato version gets very close. The secret is pureeing half the stew and adding it back in as a thickener. Fresh ginger, garlic and basil sautéed in butter, and a pinch of cinnamon and allspice give it some zing. 1 lb. (455 g) dried green lentils, soaked for 4 to 6 hours then drained (about 2½ c. / 625 ml) 1 large sweet potato, chopped (do not peel) 1 lb. (455 g) tomatoes, chopped (about 2½ c. / 625 ml) 1 tbsp. (15 ml) sea salt 1 tbsp. (15 ml) sweet paprika ½ tsp. (2.5 ml) cayenne pepper ½ tsp. (2.5 ml) ground cinnamon ¼ tsp. (1.25 ml) ground cloves 4 c. (1 L) vegetable broth 3 dried ancho chillies ½ tbsp. (7.5 g) butter 2 large or 4 small garlic cloves, chopped 1-inch (2.5-cm) piece fresh ginger, peeled and chopped (about 1 tsp./5 ml) 6 leaves fresh basil

Put the lentils, sweet potato, tomatoes, salt, paprika, cayenne, cinnamon, and cloves into a Dutch oven. Cover with the broth, cover the Dutch oven and bring to a boil over medium-high heat, stirring occasionally. Reduce the heat to a simmer and cook until the sweet potatoes are tender, about 1½ hours. Tear the anchos in half and discard the stem and easily removed seeds. Toast the anchos in a dry skillet over medium heat until warm and aromatic, 2 to 3 minutes each side. Turn off the heat and transfer the chillies to a small saucepan and cover with water. Press them down into the water so that they’re mostly submerged. Heat the water over medium heat for a few minutes, then turn off the burner. Do not boil. In a small frying pan, melt the butter over medium heat. Add the garlic and

ginger and cook until fragrant, about 1 minute. Stir in fresh basil leaves and wilt for about another minute. Remove from the heat. Once the sweet potatoes are tender, ladle about half of the solid ingredients (about 4 cups/1L) into a high-powered blender or food processor, allowing most of the liquid to drain back into the pot before transferring. Drain the softened anchos. Chop coarsely and add to the blender along with ginger and garlic mixture. Puree until very smooth and thickened; the mixture should be a thick paste. Use a rubber spatula to return the paste to the pot and stir well to integrate completely. Continue simmering over low heat for about 15 minutes to combine flavours. Taste and adjust seasoning. Serve in a bowl, family style. Serves 10 to12.

WHITE CHICKEN POBLANO CHILI Here’s a more satisfying version of white chicken chili in which you cook a whole chicken instead of using boneless breasts and create your own chicken stock in the process. Poblano chillies can vary in heat intensity from very mild to medium-hot. This recipe calls for seeded and stemmed fresh chillies, but if you like more heat, just remove the stem and leave the seeds and the white membranes intact. 1 whole chicken, cut into 8 pieces 10 c. (2.5 L) water 2 tbsp. (30 g) butter 2 tbsp. (30 ml) olive or vegetable oil 1 white onion, chopped

White chicken poblano chili.

JANUARY 2016 • Doctor’s

Review

4 large garlic cloves, minced 6 to 8 poblano chillies, roasted (see instructions) 1 jalapeño chili, seeded, stemmed and thinly sliced 1 lb. (455 g) dried great northern beans, rinsed and soaked in water for 2 to 3 hours (about 2½ c. / 625 ml) ½ tsp. (2.5 ml) chili powder ½ tsp. (2.5 ml) cayenne pepper 1½ tbsp. (22.5 ml) ground cumin 2 tbsp. (30 ml) masa harina 1 c. (250 ml) whole milk ½ tsp. (2.5 ml) salt, or to taste white pepper sour cream, to garnish

Put the chicken in a stockpot over medium heat and add the water. Bring to a boil, then lower the heat and simmer until the chicken is cooked through, 20 to 30 minutes. Remove the chicken with a slotted spoon, set aside and allow to cool. Reserve the broth and add water, if necessary, to yield 8 cups (2 L). Remove the skin from the chicken and

discard. Then remove the meat from the bones — you should have about 3 cups (750 ml) of cooked chicken. In a Dutch oven over medium heat, heat the butter and oil. Add the onion and garlic, and cook until softened, about 8 minutes, being careful not to brown the vegetables. Reserve 1 poblano for the garnish and cut it into long, thin strips. Chop the remaining poblanos and add to the pot along with the sliced jalapeños and drained soaked beans. Add the chili powder, cayenne and cumin. Add the chicken broth and cook for 1 hour. Add the chicken and continue cooking for another hour, until the beans are fully cooked. Alternatively, transfer the chili to a slow-cooker set on low and cook for at least 6 and up to 8 hours. When the beans are thoroughly cooked, dissolve the masa harina in the milk and add to the pot. Cook for an additional 15 minutes on high, and add salt and white pepper to taste.

Serve garnished with sour cream and the reserved roasted poblano chili strips. Serves 6 to 8.

Roasted green chillies Poblanos, Anaheims and the long green chili of New Mexico have tough skins, so these chillies are usually roasted and the charred skins removed. Whatever you don’t use right away can be frozen easily for longer storage. 12 fresh New Mexican long green chillies, Anaheim chillies or green poblano chillies

Rinse the fresh peppers and allow to dry. Set the oven to broil. Line a broiling pan or baking sheet with aluminum foil, place the chillies on top and place the pan under the broiler. When the skin is well blistered and charred, after about 5 minutes, rotate the chillies to expose more green skin to the flame. Don’t overdo it — if they turn completely black, there won’t be any flesh left to cook with. When the peppers are blistered all over, wrap them in wet paper towels, place them inside a plastic bag and set it aside to steam gently for 10 to 15 minutes or until the skins are very loose. When you remove the towels, most of the skins should come off easily. Scrape off the rest with a butter knife. Cut off the stem and remove the seeds with the side of a butter knife. (Don’t rinse with water or you’ll lose the flavour.) Keep the roasted chillies in the refrigerator for up to 1 week or freeze for several months in packages containing four or five chillies each — enough for an average recipe. Makes 1 dozen.

OBAMA FAMILY’S CHILI

Obama family’s chili.

MORE ONLINE

Bean recipes for February’s Heart Month. doctorsreview.com/food/ book/spilling-beans-cooking-and-baking-beans-and-grains Doctor’s Review • JANUARY 2016

President Barack Obama is an avid chili maker — it’s about the only thing he cooks. When the president gave this recipe to Good Morning America, he noted: “I’ve been using this chili recipe since college and would bring it to any potluck. I can’t reveal all the secrets, but if you make it right, it’s just got the right amount of bite, the right amount of oomph in it, and it will clear your sinuses.”

1 large onion, chopped 1 green pepper, chopped several garlic cloves, chopped 1 tbsp. (15 ml) olive oil 1 lb. (455 g) ground turkey or beef ¼ tsp. (1.25 ml) ground cumin ¼ tsp. (1.25 ml) ground oregano ¼ tsp. (1.25 ml) ground turmeric ¼ tsp. (1.25 ml) ground basil 1 tbsp. (15 ml) chili powder 3 tbsp. (45 ml) red wine vinegar several tomatoes, depending on size, chopped 1 (15-oz./425 g) can red kidney beans white or brown rice, to serve accompaniments: shredded cheddar cheese, chopped onions and sour cream

Heat the olive oil in a large pot over medium-high heat and sauté the onion, green pepper and garlic in the olive oil until soft. Add the ground meat and cook until browned. Combine the cumin, oregano, turmeric, basil, chili powder; add to the ground meat. Add the vinegar and tomatoes. Let simmer until the tomatoes cook down, about 1 hour. Alternatively, transfer the chili to a slow-cooker set on low and cook for at least 6 and up to 8 hours. Add the kidney beans and cook for a few more minutes. Serve over white or brown rice. Garnish with shredded cheddar cheese, onions and sour cream. Serves 4. Excerpted from The Chili Cookbook by Robb Walsh. Copyright © 2015 by Robb Walsh. Photographs copyright © 2015 by Eva Kolenko. Published in the United States by Ten Speed Press, an imprint of the Crown Publishing Group, a division of Penguin Random House LLC, New York. All rights reserved.

MEDICAL QUIPS

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FAIR BALANCE INFORMATION Janumet................................................... 55

Indications and clinical use: • As an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus inadequately controlled on metformin or in patients already being treated with the combination of sitagliptin and metformin. • In combination with a sulfonylurea as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus inadequately controlled on metformin and a sulfonylurea. • In combination with pioglitazone in adult patients with type 2 diabetes mellitus to improve glycemic control when diet and exercise, and dual therapy with metformin and pioglitazone do not provide adequate glycemic control. • In combination with premixed or long-/intermediate-acting insulin as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus inadequately controlled on metformin, and premixed or long-/intermediate-acting insulin. Use with caution as age increases. Contraindications: • Unstable and/or insulin-dependent (type 1) diabetes mellitus • Acute or chronic metabolic acidosis, including diabetic ketoacidosis, with or without coma, history of ketoacidosis with or without coma • History of lactic acidosis, irrespective of precipitating factors • Renal impairment or when renal function is not known and in patients with serum creatinine levels above the upper limit of normal range • Excessive alcohol intake, acute or chronic • Severe hepatic dysfunction • Cardiovascular collapse and in disease states associated with hypoxemia • During stress conditions • Severe dehydration • Pregnancy and breastfeeding • Temporary discontinuation in patients undergoing radiologic studies involving intravascular administration of iodinated contrast materials and in patients undergoing any surgical procedure necessitating restricted intake of food and fluids Serious warnings and precautions: • Lactic acidosis: rare, but serious, metabolic complication that can occur due to metformin accumulation • Alcohol: caution against excessive intake, either acute or chronic, since alcohol intake potentiates the effect of metformin on lactate metabolism Other relevant warnings and precautions: • Not for use in type 1 diabetes or for the treatment of diabetic ketoacidosis • Careful patient selection and follow-up • Pancreatitis • Hypoglycemia • Hypersensitivity reactions, including anaphylaxis, angioedema and exfoliative skin conditions including Stevens-Johnson syndrome • Not recommended in patients with congestive heart failure • Hypoxic states • Change in clinical status of previously controlled diabetes: should be evaluated promptly • Loss of blood glucose control • Consider therapeutic alternatives in secondary failure • Impairment of vitamin B12 absorption • Avoid in patients with hepatic disease • Efficacy and safety not established in immunocompromised patients • Temporary suspension for any surgical procedures • Renal adverse events • Caution in concomitant use with medications that may affect renal function or metformin disposition • Monitoring for skin disorders recommended • Monitoring of glycemic parameters, hematologic parameters and renal function For more information: Please consult the product monograph at http://www.merck.ca/assets/ en/pdf/products/JANUMET-PM_E.pdf 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 1-800-567-2594. References: 1. JANUMET® and JANUMET XR® Product Monograph. Merck Canada Inc. August 21, 2015. 2. IMS Brogan data, May 2015.

Martin diagnosis “First the doctor gave me the good news, I was going to have a disease named after me.” — Steve Martin ® Merck Sharp & Dohme Corp. Used under license. © 2015 Merck Canada Inc. All rights reserved.

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JMKJAN 17755 E_1_3 Jrnl_Ad_DR.indd 1

12/15/15 11:37 AM

PHOTO FINISH by

D r Er r ol B i lli n k of f

The show on the road

I decided to drive my Audi A5 convertible from Winnipeg, MB to Phoenix, AZ where I could extend my top-down experience over the winter months. As I drove west from Lincoln, NE on Highway 80, I saw an unusual “white wall” in the distance that stretched across the entire horizon. I couldn’t imagine what this was, but it reminded me of the Mendenhall Glacier in Alaska. With my Canon PowerShot G7 X, I managed to take this shot through the windshield.

MDs, submit a photo! Please send photos along with a 150- to 300-word article to: Doctor’s Review, Photo Finish, 400 McGill Street, 4th Floor, Montreal, QC H2Y 2G1.

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tiotropium + olodaterol inside Delivered by RESPIMAT 速 SMI (soft mist inhaler)1-3

INSPIOLTO RESPIMAT (tiotropium bromide monohydrate and olodaterol hydrochloride) is a combination of a long-acting muscarinic antagonist (LAMA) and a long-acting beta2-adrenergic agonist (LABA) indicated for the long-term, once-daily maintenance bronchodilator treatment of airflow obstruction in patients with Chronic Obstructive Pulmonary Disease (COPD), including chronic bronchitis and emphysema. References: 1. INSPIOLTOTM RESPIMAT速 Product Monograph. Boehringer Ingelheim (Canada) Ltd., May 28, 2015. 2. Data on file. Boehringer Ingelheim (Canada) Ltd., 2015. 3. Decramer M, Vestbo J, Bourbeau J et al. Global strategy for the diagnosis, management, and prevention of COPD (updated 2015). Global Initiative for Chronic Obstructive Lung Disease, Inc. 2015.

Please consult the product monograph at www.boehringer-ingelheim.ca/content/ dam/internet/opu/ca_EN/documents/humanhealth/product_monograph/ InspioltoRespimatPMEN.pdf for conditions of clinical use, contraindications, warnings, precautions, adverse reactions, interactions and dosing. The product monograph is also available by calling us at 1 (800) 263-5103 Ext. 84633. NEW tiotropium bromide monohydrate & olodaterol hydrochloride

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