July-August 2015 by Doctor's Review

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JULY / AUGUST 2015

Czech beer Fabulous cranes Poet’s tower Tasty fish Flight attendant secrets

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Depression in the elderly

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Choose Alvesco first. Demonstrated effective symptom control with an excellent safety profile. ®

1,2

Indications and clinical use: Alvesco is indicated for the prophylactic management of steroid-responsive bronchial asthma in adults, adolescents, and children 6 years of age and older.

• Immunosuppressant drugs • May cause eosinophilic conditions • May cause candidiasis • As with other inhalation therapy, paradoxical bronchospasm may occur Contraindications: • Caution in systemic steroid replacement by inhaled steroid • Untreated fungal, bacterial or tuberculosis • Patients with hypoprothrombinemia in infections of the respiratory tract conjunction with acetylsalicyclic acid • Primary treatment of status asthmaticus or other acute episodes of asthma or in patients • Systemic effects of inhaled corticosteroids may occur, particularly at high doses for with moderate to severe bronchiectasis prolonged periods Relevant warnings and precautions: • Monitor HPA axis function and effects • Patients with hypothyroidism on the eye • Patients with cirrhosis and/or severe hepatic impairment ®

For more information: For important information on conditions of clinical use, contraindications, warnings, precautions, adverse reactions, drug interactions and dosing, please consult the product monograph at http://www.takedacanada.com/ca/alvescopm. The product monograph is also available by calling us at 1-866-295-4636. REFERENCES: 1. Alvesco (ciclesonide inhalation aerosol) Product Monograph. Takeda Canada Inc. December 17, 2012. 2. Lougheed MD et al. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults. Can Respir J 2012;19(2):127-164. ®

Flying joys and sorrows CANDYBOX IMAGES / SHUTTERSTOCK.COM

My first real job was with an airline. I liked it so much I stayed for five years. Twelve of us rotated through two shifts a day at what was then called Dorval International Airport in Montreal. We did everything. When we weren’t writing tickets and checking passengers in, or on the tarmac servicing flights and loading bags, we took reservations. An office behind the ticket counter was fitted out with six-line phones. There were no computers, reservations were written out in pencil on cards and filed in boxes by flight and date. To find out how many passengers there were on a given flight, you counted the cards. The airline flew to New England and Florida. Many of the passengers were regular travellers and we got to know some of them well. We talked to them on the phone, met them at the ticket counter and took their boarding passes at the gate. The wages were good, thanks to the Transport Workers Union of America, and the perks weren’t bad either. Generous inter-airline deals offered heavily discounted passes to employees and we could fly almost anywhere on any airline we chose for less than $50. There was no security, the planes were roomy and most flights served hot meals. That didn’t mean there weren’t glitches. Lost bags were a problem then as now. For example, the airline made connections over Boston to Lebanon, New Hampshire and, not surprisingly perhaps, baggage sometimes ended up in that other Lebanon, and took forever to locate and retrieve. New England-bound passengers occasionally boarded the wrong flight and ended up in Montreal. One day I was confronted in the baggage claim area by a gentleman who said he was surprised that Nantucket had its own customs and immigration officers! And, of course, there were inside jokes. Instructor to new recruit: “What do you do if you find out the flight is going to be two hours late?” Recruit: “I’m not sure, sir.” Instructor: “Announce a 20-minute delay.” The more things change, the more they stay the same. Then there was the agitated passenger who came up to the ticket counter and asked, “When’s your next flight to Washington?” Agent: “It’s at 5pm, sir.” Passenger: ”Give it to me at 4:30pm and I’ll take it!” Flying these days is, well, different. For an update, see Flying secrets, (page 42). Europe bound this fall? Read Czech please (page 46) — there’s no better time for a tour of the republic famous for its beer. On a more serious note, you’ll find an interview with Dr Derek Puddester on page 21, the Ottawa MD with an abiding interest in physician wellness, discussing the risks of suicide.

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JULY / AUGUST 2015 • Doctor’s

Review

Covered on RAMQ and most private plans

Help fight

heartburn associated with GERD With the demonstrated power of DEXILANT®

Visit www.DEXILANT.ca 24 hours a day to learn more

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

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

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

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

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

contents 30

features 26

KAPRIK / SHUTTERSTOCK.COM

PADDY PALLIN

JULY / AUGUST 2015

The thrill of sandhill cranes

A brewery tour in and around Prague where the beer, they say, is cheaper than water by Cinda Chavich

An MD from Ontario flies to Nebraska for North America’s most spectacular bird migration by Dr Mel Borins

Wild things 10 ways to take in Canada’s most iconic animals from coast to coast to coast by Katharine Fletcher

Czech please

Fish for compliments Three recipes for sustainable seafood from the new Ocean Wise cookbook by Jane Mundy

A man of his word

Flying secrets The ups and (surprising) downs of being a flight attendant by Roger White

Coming in

September

• Tour Israel by bike in the best season to do it • Dig for truffles in Croatia — and dine out on the story all winter

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• Sip a cup of Darjeeling tea with Swaraj Kumar Banerjee • Art collectors flock to Santa Fe in autumn, find out why • Fall travel offers some of the best weather — and deals — going

JULY / AUGUST 2015 • Doctor’s

Review

CHAMELEONSEYE / SHUTTERSTOCK.COM

The California house that was the inspiration behind Robinson Jeffers’ poem The Bed by the Window by Keith Skinner

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

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

contents JULY / AUGUST 2015

regulars 7 LETTERS Savants, soup and the state of Tennessee

PRACTICAL TRAVELLER How to book a night in one of England’s historic churches, Toronto’s exhibit on Pompeii, an elevated trail in Adirondack Park and more! by Camille Chin

9 25

BUDGET TRAVELLER Deals in LA, Maui and the Caribbean to help you stretch summer by Camille Chin

Mental illness in the elderly by Mairi MacKinnon

15 GADGETS

PHOTO FINISH Ship shape by Dr Réal Le Gouëff

Floodlights on home security by David Elkins

DEPRESSION KEYPOINTS

TOP 25 The biggest medical meetings happening this winter

HISTORY OF MEDICINE Dr Derek Puddester on physician suicide by Rose Foster

aWIN new contest!

a trip to Casa de Campo!

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We’re sending one lucky physician and a guest on a Caribbean holiday valued at $5800. Turn to page 8 for details.

JULY / AUGUST 2015 • Doctor’s

Review

Are your OAB patients on the verge of experiencing an accident? TURN TO

TOVIAZ 8 mg demonstrated SUPERIORITY to placebo in treating UUI episodes/24 hours at week 12 in OAB patients defined as sub-optimal responders to tolterodine ER 4 mg in a study1* • Mean change from baseline: -1.87 placebo and -2.37 TOVIAZ (p=0.0079) • Sub-optimal responders were defined by the study as those reporting a ≤50% reduction in mean UUI episodes/24 hrs with tolterodine ER 4 mg during the 2-week, open-label, run-in period

Demonstrated EFFICACY and AE profile in a study of ELDERLY OAB patients • In ELDERLY OAB patients (VES-13 score of ≥3): TOVIAZ significantly improved urgency urinary incontinence episodes/24 hrs vs. placebo at week 122†

Indication and Clinical Use: TOVIAZ is indicated for the treatment of patients with overactive bladder with symptoms of urinary frequency, urgency, or urge incontinence, or any combination of these symptoms.2 Safety and efficacy in pediatric populations have not been established. Contraindications: • Urinary retention • Gastric retention • Uncontrolled narrow-angle glaucoma • Hypersensitivity to tolterodine L-tartrate, soya, peanuts, lactose Relevant warnings and precautions: • Increase in heart rate; caution in patients with ischemic heart disease, congestive heart failure, cardiac arrhythmias or tachycardia • Interaction with potent CYP3A4 inhibitors (i.e., max of 4 mg) • Patients at risk of gastric retention • Patients at risk of urinary retention • Patients with impaired hepatic function • Angioedema • Patients with myasthenia gravis • Patients with controlled narrow-angle glaucoma • Patients with impaired renal function (i.e., max of 4 mg for severe impairment) • Contraception in women of childbearing potential • Not recommended during breastfeeding For more information: Please consult the product monograph at http://www.pfizer.ca/en/our_products/ products/monograph/317 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. * 12-week, double-blind, placebo-controlled, parallel-group trial of 990 patients with OAB (≥8 micturitions/24 hrs and ≥2 to <15 UUI episodes/24 hrs on a 3-day bladder diary). Before being randomized to the treatment study period, patients entered a 2-week, open-label, run-in period to identify subjects who the study defined as responding sub-optimally to tolterodine ER 4 mg/day. Patients were randomized to placebo (n=320) or TOVIAZ 8 mg/day (4 mg for 1 week then 8 mg for 11 weeks, n=322). Baseline means for UUI episodes/24 hrs were 3.93 for TOVIAZ and 3.83 for placebo. † 12-week, randomized, double-blind, flexible-dose, placebo-controlled, parallel-group, multicenter trial in patients aged ≥65 years with OAB symptoms (≥3 months, mean of 2-15 UUI episodes/24 hrs, mean of ≥8 micturitions/24 hrs reported in 3-day bladder diary). Patients were randomized to placebo (n=283) or TOVIAZ 4 mg/day (n=283), with the option to increase to 8 mg at Week 4 only. Baseline means for UUI episodes/24 hrs were 4.1 and 3.9, respectively. References: 1. Kaplan SA et al. Efficacy and safety of fesoterodine 8 mg in subjects with overactive bladder after a suboptimal response to tolterodine ER. Int J Clin Pract 2014;68:1065-73. 2. DuBeau CE et al. Effect of fesoterodine in vulnerable elderly subjects with urgency incontinence: a double-blind, placebo controlled trial. J Urol 2014; 191:395-404. 3. Pfizer Canada Inc. TOVIAZ Product Monograph. February 12, 2015.

– LS mean change from baseline: -2.20 placebo (n=250) and -2.84 TOVIAZ (n=256, p=0.002)

In pivotal trials, the most common adverse events ≥5% were dry mouth (18.8% 4 mg and 34.6% 8 mg) and constipation (4.2% 4 mg and 6.0% 8 mg).3 No overall differences in safety and efficacy were observed between patients <65 years and those ≥65 years in the pivotal studies; however, the incidence of antimuscarinic adverse events was higher in patients ≥75 years as compared to younger patients.3

CA0115TOV008E

• Most frequently reported adverse events (≥11%) were dry mouth (23.5% TOVIAZ) and constipation (11.1% TOVIAZ)2

LETTERS

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

Savants, soup and the state of Tennessee

CONTRIBUTING EDITOR

Katherine Tompkins

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

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Denise Bernier

CIRCULATION MANAGER

Claudia Masciotra

EDITORIAL BOARD

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

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

MADE IN TENNESSEE I read with amusement your editorial on Tennessee and Davy Crockett [The ballad of Davy E in Tennessee, April 2015, page 1]. The real eighth-generation David Crockett is an environmental activist for the City of Chattanooga in Tennessee where we used to live. We helped him campaign for city government before moving back to New Brunswick. He’s a very large, brilliant man who retired from IBM sales and has taken his heritage very seriously. Maybe worth doing an article on him sometime! He is quite the raconteur and, of course, is madly in love with Tennessee. In his presence one does not mention “coon skin cap” and one does not dare call him “Davy!” Heather Carter (Office manager for Dr Allister Carter) Miramichi, NB

FACT AND FICTION I just finished reading The Rosie Project about a professor who has Asperger’s Syndrome. It’s such an interesting condition so I looked it up. I wanted to know the difference between Asperger’s and autism, and stumbled on your article about autistic savants [“Autism at the start,” History of Medicine, June 2015, page 18]. It was very interesting and I learned a lot. I saw Rain Man many, many years ago, but didn’t know very much about Savant Syndrome so it was good to read about it. J. Orlean Via email

AU NATUREL — OR NOT? Why is that pretty little girl on your [June 2015] cover wearing lipstick?! Without getting into any deep discussions, I found it disturbing. Dr N. E. Antonenko Selkirk, MB

Niagara-on-the-Lake

MEDICINE ON THE MOVE

delights

Bolivian high desert

adventure

Los Cabos golf: two big new

courses

Modern Jewish cooking

JUNE 2015

Valmai Howe

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A NEW CONTEST WIN a luxurious Caribbean holiday at Casa de Campo! PAGE 33

SAGUENAY’S BEST IBS-C: a case study Depression in the workplace Autism’s early years

Editor’s note: We’re very sensitive to the use of photographs of children. Neither the staff, nor others who were asked since receiving your letter, were under the impression the child was wearing any cosmetics whatsoever.

SEEING GREEN It was great to see a recipe for sorrel soup [A modern nosh, June 2015, page 53] in your last issue. We eat organic, but had a hard time finding organic veggies when we went to visit my mom in St. Catharines in May. We found some organic sorrel though and I made a cream of sorrel soup. It was nice, but harissa and sour cream on top would have been better! Dr Deborah Zibell Via email

Correction: The photo of the black building on page 40 of the May 2015 issue was misidentified as Newfoundland’s Fogo Island Inn. It’s actually one of the artist studios, not the actual hotel. The picture below it isn’t a Norse boat at L’Anse aux Meadows, but rather a Basque whaling boat discovered at Red Bay. JULY / AUGUST 2015 • Doctor’s

Review

CO NE NT W ES T!

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: • 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.

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

C a mi lle C hi n

Pompeii comes to Toronto WITH PERMISSION OF THE SUPERINTENDENCE FOR THE ARCHAEOLOGICAL HERITAGE OF NAPLES

The Canadian premiere of Pompeii: In the Shadow of the Volcano is on now through January 3 at the Royal Ontario Museum in Toronto. The exhibit features 200 items from the ancient Roman city in southern Italy that was buried by ash and debris after the “dormant” Mount Vesuvius erupted in 79CE. The objects on show are arranged chronologically, from bustling city life before the eruption — Pompeii had an amphitheatre, a couple of theatres, and bars and businesses — to those dug out nearly 1700 years after the disaster. The city’s commercial life is seen through the coins and scales on view; domestic life through jewellery and dinnerware. There are even carbonized figs and olives on plates, and casts of those who perished. About 600,000 people live below Mount Vesuvius today; geologists and volcano logists agree that an explosion is overdue. Adults $28; students $25.50; kids 4-14 $20. tel: (416) 586-8000; rom.on.ca.

COURTESY OF THE TRUSTEES OF THE BRITISH MUSEUM WITH THE PERMISSION OF SAHN

A wall painting depicting the distribution of bread. RIGHT: A silver wine cup entwined with ivy leaves.

JULY / AUGUST 2015 • Doctor’s

Review

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

A walk in the park Hikers can now get a bird’s eye view of Adirondack Park in upstate New York — and they can do it from inside a giant bald eagle’s nest. Wild Walk opened in the park in July and it takes visitors up an elevated trail of bridges to the treetops of the 2.5-million-hectare forest, two hours south of Montreal. There’s a people-sized eagle’s nest at the trail’s highest point from which visitors can take in the park’s lofty white pines. The tallest pine is 49 metres; four of its neighbours are taller than the Statue of Liberty. The 4645-metre-long trail also includes a huge spider’s web that visitors can hang around in and a fourstorey twig tree house. Twenty-seven steel “tree” towers support the trail, which was designed by Charles “Chip” Reay. Reay worked on the 1964 World’s Fair in Queens, NY when he was with the Charles Eames studio and also on the National Air and Space Museum in Washington, DC. Adults US$20; kids 5–17 US$13. tel: (518) 359-7800; wildcenter.org/wildwalk.

Take the high road There’s a new shuttle that links downtown Toronto to Pearson International Airport. The Union Pearson Express was launched in June, a month ahead of the 2015 Pan Am and Parapan Am Games. It operates between Union (train) Station and the airport’s Terminal 1 with two stops (Weston and Bloor) in between. The shuttle runs on an elevated track to avoid traffic and the trip takes 25 minutes. There are departures from either end every 15 minutes during airport hours. Free Wi-Fi on board. A family of five (two adults, three kids) $55; adults $27.50; youth 13-19 $23.40; kids 6-12 $13.75. tel: (416) 874-5900; upexpress.com.

Doctor’s Review • JULY / AUGUST 2015

El Celler de Can Roca, Girona, Spain.

Feeding frenzy Being honoured as one of the World’s 50 Best Restaurants inevitably translates into big business so it’s little wonder there’s a bit of a brouhaha around how they’re selected. A recent New York Times article about the new 2015 list (see the Top 10 below) discussed how the scales are tipped when chefs and restaurateurs make up a third of the 950-plus voters and when some countries give journalists free meals and trips. What’s more, judges don’t have to prove that they’ve eaten in the restaurants they’re voting for in the last 18 months. The Occupy50Best petition calls on organizers to make the process more professional. By mid July, it had garnered 750-plus signatures including that of chef Joel Robuchon. theworlds50best.com/ list/1-50-winners.

For

1. El Celler de Can Roca, Girona, Spain 2. Osteria Francescana, Modena, Italy 3. Noma, Copenhagen, Denmark 4. Central, Lima, Peru 5. Eleven Madison Park, NYC 6. Mugartiz, Sab Sebastián, Spain 7. Dinner by Heston Blumenthal, London, England Claudia Masciotra 8. Narisawa, Tokyo, Japan 9. D.O.M., São Paulo, Brazil Doctor’s Review July 2015 issue 10. Gaggan, Bangkok, Thailand

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New: YUL to PEK

England’s Churches Conservation Trust is giving travellers the key to three of its historic buildings for overnight stays. The national charity takes care of 345 churches that are no longer used for regular worship. The new camping-in-churches or “champing” initiative is a way to raise money, help preserve the buildings and promote “slow tourism.” The All Saints’ Church in Aldwincle, Northamptonshire, the Church of St. Cyriac and St. Julitta at Swaffham Prior in Cambridgeshire and the Church of St. Mary the Virgin in Fordwich, Kent are taking two-day, onenight reservations for £60 ($118) per person through September. Guests get the entire church to themselves and breakfast is included. They have to bring their own bedding (inflatable or fold-out beds are provided). The buildings aren’t heated and don’t have shower facilities; the church in Aldwincle doesn’t have electricity. visitchurches.org.uk/champing.

Doctor’s Review • JULY / AUGUST 2015

Montreal

Sanctuary sleeps

All Saints’ Church at Aldwincle in Northamptonshire, England.

DAVID JOYNER

Beijing

Air China is launching direct flights between Montreal and Beijing beginning September 29. This will be the first direct link between Asia and Montreal. There will be three flights weekly on Air China’s Boeing 777-300ER aircraft. The flights are made possible through an agreement between Air China and Air Canada. Either airline will accept bookings. tel: (800) 882-8122; airchina.ca.

Dubai’s Miracle Garden.

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Angkor Wat, Siem Reap, Cambodia.

The world’s centres of attraction To

Claudia Masciotra

For

Doctor’s Review

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July 2015 issue

According to Trip Advisor’s Travellers’ Choice awards, tourists love the 12th-century Angkor Wat temple in northwestern Cambodia more than any other landmark in the world. The recently released list of the Top 25 Landmarks in the World also includes the Eiffel Tower (number 11), the Alhambra in Granada, Spain (14), the Hagia Sophia in Istanbul (15), the National September 11 Memorial and Museum (20) and Chichen Itza in Mexico’s Yucatan (22). TripAdvisor considered 700 landmarks and applied an algorithm to millions of user reviews over a 12-month period to determine the winners. The Top 10 are below; the full list is at tripadvisor.com/ travelerschoice-landmarks.

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JULY / AUGUST 2015 • Doctor’s

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BUDGET TRAVELLER

C a mi lle C hi n

great deals to help you stretch summer

Maui, HI The Honua Kai Resort and Spa on North Kaanapali Beach is making the best of a bad situation by offering a Hard Hat package while a new Westin — slated to open in 2017 — is being built next door. The rates for one-, two- and threebedroom suites that overlook the construction site have been cut by as much as 40 percent through the rest of 2015. One-bedroom suites feature a king-size bed and a queen-size sofa bed, and can accommodate a family of four. They include a full kitchen and even a washer and dryer. Rates started at US$230 (plus US$29 daily resort fee) when we searched online in mid-July for a mid-Aug vacation dates — US$65 per person. tel: (855) 718-5789; honuakai.com.

Honua Kai Resort and Spa, Maui.

Los Angeles, CA

Dallas, TX

A Mama Shelter just opened in Hollywood and accommodations start at US$149. The 70-room hotel on Selma Avenue is a few minutes walk from Hollywood Boulevard and is the European hotel chain’s first North American property. (There are four Mamas in France; one in Turkey). Medium Mama rooms are 20 to 21 square metres and the most affordable; Medium, Large and XXL Mama rooms all feature an iMac (to double as a TV), a mini fridge and free Wi-Fi. There’s a restaurant, coffee shop and bar on-site. Breakfast is not included; 12-kilo pets are welcome for an additional US$79 per stay. tel: (323) 7856666; mamashelter.com.

Dallas just joined the CityPass family. The Big D’s CityPass booklet costs US$44 for adults and US$33 for kids aged three to 12, and covers the admission to four of the city’s most popular attractions — a savings of 30 percent. The booklet includes the Reunion Tower GeO-Deck for 360-degree views of Dallas and the Perot Museum of Nature and Science. Travellers then get the choice of either the Dallas Zoo or the Sixth Floor Museum, and the choice of the George W. Bush Presidential Library and Museum or the Dallas Arboretum and Botanical Garden. The booklet is valid for nine consecutive days. For details: citypass.com/dallas.

Honua Kai Resort and Spa, Maui.

Caribbean

BOOK NOW!

Hilton Curaçao.

Doctor’s Review • JULY / AUGUST 2015

The Hilton Caribbean Summer Sale is on now through August 31. Accommodations at 18 of its properties — from Curaçao to Trinidad to Puerto Rico — start at US$96 a night with the fourth night free and a $100 resort credit per room per stay. When we searched online for rooms at the Dorado del Mar Beach Resort at the end of July, we found nightly rates of US$96 for stays between September 7 and 17. The Dorado del Mar is 32 kilometres west of San Juan in Puerto Rico. hiltoncaribbean.com/summer.

GA D GE T S by

Da vi d E l k i n s

Floodlights on security About a year ago there was a break-in at a neighbours down the street. I was tasked with putting up security lights. The plan was to put one over our garage, another near the front door and a couple on the rear corners of the house that would come on if anyone breeched the back garden. I found what I needed at the local hardware store. Conventional motion-detection lights sell for about $30, take two bulbs ($8) and are easily mounted except for one thing — wiring them up. I was able to run a line from the garage and another from the light at the front door, but the back lights were a challenge. I had to call an electrician who did the job in less than two hours for $166. How much easier it would have been had I known about Smart-Sensor Outdoor LED Lighting. The battery-operated units do not need wiring and — the best feature — they communicate with each other. If anything comes within nine metres of one, a radio transmitter turns on a bright 200-lumen floodlight in all of the others that are within a 46-metre range. You can add additional lights at any time up to a total of 50. A network of that many would illuminate an area of 697 square metres, says the manufacturer. It’s not clear to me why anyone would want to do this, but if you did, it would certainly alert anyone in the vicinity that something untoward was going on. Each unit runs for 3000 activations on three D batteries. To conserve power, they shut off if no motion is detected for 30 seconds. A sensor prevents them from coming on in daylight. The weatherproof fixtures stand about 17 centimetres tall. An easily screwed in mount allows the beam to be rotated to shine where it’s needed. The lights are sold in pairs and I’ve ordered a set to attach to the back fence as a kind of distant early-warning system. I’m hoping for better luck than my Australian father-in-law had when he installed outdoor lights and a burglar alarm at his townhouse outside Brisbane. The first night it was up, he and his wife were woken at 3am by a siren and a blaze of light only to find a kangaroo calmly grazing on the front lawn. Smart-Sensor LEDs, package of two, $89.50, batteries not included. leevalley.com. JULY / AUGUST 2015 • Doctor’s

Review

Introducing

Introducing Nesina ; a new DPP-4 inhibitor for patients with type 2 diabetes. ®

Nesina is reimbursed by RAMQ as a medicament d’exception and prescribing codes are available for all indications reimbursed. ®

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. ®

NES-2015-6E

THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Access 2500+ meeting listings at doctorsreview.com/meetings Code: drcme Canada Quebec City, QC January 21-22, 2016 24e Réunion Scientifique Annuelle de la Société Québécoise d’Hypertension Artérielle hypertension.qc.ca

Toronto, ON November 12-14 2015 Family Medicine Forum fmf.cfpc.ca Society of Obstetricians and Gynaecologists of Canada: Ontario CME sogc.org

December 4-5 2015 Heart and Stroke Clinical Update heartandstroke.ca/healthcareprofessionals

December 4-5 55th Annual Ophthalmology Update: Walter Wright Day cpd.utoronto.ca/walterwright

Vancouver, BC November 30-December 4

KIEV.VICTOR / SHUTTERSTOCK.COM

December 3-5

The historic Distillery District in downtown Toronto.

Around the world Cannes, France January 14-17, 2016

2015 World Diabetes Congress idf.org/worlddiabetescongress

2016 World Congress on Recurrent Pregnancy Loss wcrpl.com

January 28-30, 2016 Early Years Conference 2016 interprofessional.ubc.ca/EarlyYears2016/default.asp

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

Cape Town, South Africa December 2-6 46th Union World Conference on Lung Health capetown.worldlunghealth.org

Florence, Italy November 29-December 2 11th International Congress on Coronary Artery Disease iccad.kenes.com

Huntington Beach, CA December 3-5 26th Annual Meeting of the American Academy of Addiction Psychiatry aaap.org/annual-meeting

46425 MER15ZH096-Banner-3E-Merck_E2.indd 1

JULY / AUGUST 2015 • Doctor’s

R2015-05-25 eview

11:11 PM

THE TOP 25 MEDICAL MEETINGS

Access 2500+ meeting listings at doctorsreview.com/meetings Code: drcme Istanbul, Turkey October 31-November 3

Paris’ La Défense business district.

World Sleep 2015 congrex-switzerland.com/worldsleep2015/ worldsleep2015.html

November 5-7 5th World Congress on Controversies to Consensus in Diabetes, Obesity and Hypertension codhy.com/2015

F11PHOTO / SHUTTERSTOCK.COM

Kuala Lumpur, Malaysia December 10-13 18th Congress of the ASEAN Federation of Endocrine Societies afes2015.com

Las Vegas, NV November 19-22 21st Annual Fall Scientific Meeting of the Sexual Medicine Society of North America smsna.org

Miami, FL January 20-22, 2016 18th International Conference on Dialysis: Advances in Kidney Disease renalresearch.com

Milan, Italy December 6-9 XXI World Congress on Parkinson’s Disease and Related Disorders oic.it/iaprd2015

New Orleans, LA November 5-7

Paris, France December 17-18

31st Annual Meeting of the International Society for Traumatic Stress Studies istss.org/am15/home.aspx

35èmes Journées de l’Hypertension Artérielle jhta2015.fr

January 13-16, 2016

Orlando, FL November 7-11

26es Journées Européennes de la Société Française de Cardiologie sfcardio.fr/JESFC-2016

2015 Scientific Sessions of the American Heart Association scientificsessions.org

San Antonio, TX December 8-12

December 5-8 57th Annual Meeting and Exposition of the American Society of Hematology hematology.org/annual-meeting

London’s Natural History Museum.

38th Annual San Antonio Breast Cancer Symposium sabcs.org

San Diego, CA January 28-31, 2016 13th Annual Natural Supplements: An Evidence-Based Update scripps.org/events/13th-annual-naturalsupplements-january-28-2016

Santiago, Chile October 31-November 5 SERJIO74 / SHUTTERSTOCK.COM

XXII World Congress of Neurology wcn-neurology.com

The Universidad de Chile metro station in Santiago, Chile.

Doctor’s Review • JULY / AUGUST 2015

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

NEW TO DOCTORSREVIEW.COM BEST OF THE WEB Links to articles, deals and special opportunities of interest to Doctor’s Review readers selected by the editors

Updated on our website three times a week!

Includes selections from: Guardian Travel, The Travel Magazine, National Geographic Travel, NYT Travel, Globe & Mail Travel, Spas in Canada, Budget Travel, LA Times Travel, The Frugal Traveller, Smartertravel.com, Petergreenberg.com, The Travel Guys, Travelzoo.com, Triponadeal.com, Adventurouskate.com, Dave and Deb Travel, The World Wanderer, Boston Globe Travel, Chicago Tribune Travel, Savvy Traveller, The Gypsy Nester, WSJ Health & Travel, Wanderlust, Independent Traveler, Outpost Magazine, Travel+Leisure, Outside Magazine, Go Green Travel, Washington Post Travel, National Post Travel, Vancouver Sun Travel, Backpacker, Islands, Condé Nast Traveler, Coastal Living, Caribbean Living, Camping Life… and many, many more

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

R os e F os t e r

Physician wellness and suicide prevention An interview with Ottawa’s Derek Puddester

n the last year, a spate of articles have reported that 400 doctors commit suicide annually in the US — about he size of an entire medical school graduating class. The subject received wide coverage

here in Canada and with reason: rates in this country are also high. Interviewed by CTV, Dr Derek Puddester, associate medical director of the Ontario Medical Association’s Physician Health Program and associate professor at the University of Ottawa said: “The concerns here mirror those in the United States. We’ve known for a number of decades that physicians have a higher risk of attempted and completed suicide. One of the unique things about Canada is we have a lengthy history of trying to reach out and support doctors right from the very beginning of their careers to try to prevent such tragedies.” A medical graduate of Memorial University from Newfoundland, Dr Puddester completed his residency

in psychiatry at McMaster University. He’s devoted much of his career to physician wellness and co-authored the popular and useful CanMEDS Physician Health Guide with Leslie Flynn and Jordan Cohen. The chapter called “Physician Health Care Needs: Unique Issues” deals with mental issues and physician suicide. (A PDF of the guide is available at php.oma.org/ PDF%20files/Articles/CanMEDS%20PHG.pdf). Dr Puddester has been recognized for leadership in physician health by the Canadian Association of Interns and Residents through the creation of the Dr Derek Puddester Resident Wellbeing Award, given annually to a person or program that has made a significant contribution to the improvement of residential health and wellness. JULY / AUGUST 2015 • Doctor’s

Review

Suicide rates in the profession are hard to study, but the gender difference has been consistently noted WHAT IS “PHYSICIAN HEALTH?” Not so long ago “physician health” meant rehab for substance abuse when problems occurred on the job. The contemporary concept, Dr Puddester points out, is “a holistic and broad construct,” one that encompasses everything from physical and mental health to colleagues caring for one another. He reminds the profession that physicians receive care differently than other people. They are “physician patients” and do not behave like someone with no medical training. Yet to rely on his or her own medical knowledge or elicit off-hand advice “in the corridor” is a mistake, he says. Dr Puddester strongly believes that doctors must have a family physician that they see regularly since these periodic health examinations may provide physicians the only opportunity to have a consultation with a health professional. He calls on health economists who scoff at annual health exams to remember that, while the general population may visit a doctor’s office as many as four or five times a year, physicians often try to answer their own health related questions which leaves the annual exam as the only contact with another doctor who is actually responsible for their health.

UPS AND DOWNS Doctors have an uneven record when it comes to monitoring their own health. Among populations with hypertension, only 56 percent of physicians

have their blood pressure monitored, compared with 77 percent of those who are not doctors. On the other hand, physicians are more contentious about having regular colonoscopies though less diligent about fecal occult blood testing. Dr Puddester offers some helpful nuts-and-bolts advice on planning a primary care visit. He reminds you to treat yourself with the care and compassion with which you hope your patients treat themselves and to arrive at an appointment ready to be seen. He suggests bringing a family member with you, making a list of health concerns in advance, and bringing samples of all prescription and non-prescription medications just as you’d like your patients to do. He believes this kind of regular physician care and attention to stress management are crucial components to preventing physician suicide. In an effort to provide anonymous, free, easy-toaccess support for doctors, Dr Puddester teamed up with colleagues to create ePhysicianHealth.com, an online resource that provides information for doctors on subjects like burnout and depression, anxiety, relationship with self, boundaries and resilience. He believes firmly in doctor resilience and the lasting power that well-placed support can have to refresh that resilience when it’s been weakened by stress or trauma. An interview with Dr Puddester follows. Do you have an eye for spotting which medical students have what it takes to meet the demands of the profession and those who don’t? What do you look for?

Increasingly, the goal of admissions committees is to use a blend of qualitative and quantitative data to help them recruit learners who will be able to cope with the demands of training and many years of practice. But often, learners who have demonstrated resiliency will “catch our eye.” Those who have experienced life stressors appreciate what it means to be vulnerable, have insight into their own healthy and maladaptive coping strategies, and have managed real-life failure and/or challenge successfully tend to be resilient. Editor’s note: Dr Puddester cited an article which reports on the nine core personal competencies for medical students that have been endorsed by the Association of American Medical Colleges (AAMC): ethical responsibility to self and others, reliability and dependability, service orientation, social skills, capacity for improvement, resilience and adaptability, cultural competence, oral communication and teamwork.

Doctor’s Review • JULY / AUGUST 2015

SPARK BOEMI

Pamela Wible is a family physician in Eugene, Oregon and a pioneer of the Ideal Medical Care Movement (idealmedicalcare.org). She hosts physician retreats to help her colleagues reclaim their lives and careers. She has been named 2015 Woman Leader in Medicine.

Do you think that the old psychological profile of the doctor as an all-knowing authority still lingers? What professional image do you think would best serve doctors in the context of their own health and well-being?

It’s been a long time since I have seen that sort of psychological profile! Most physicians I trained and work with are highly collaborative, quite humble and very much in touch with their human side. I think the profile you describe may be more in keeping with outdated stereotypes from the 50s or perhaps a very small minority of practitioners. I see most physicians now as very genuine, compassionate, and engaged practitioners who approach care with a sense of partnership. This aligns well with Canada’s sense of social responsibility in medicine. Female doctors have a higher rate of suicide than their male colleagues. How can women physicians be best supported?

Suicide rates in the profession are very hard to study well due to methodological challenges (rates are already low, deaths are often not reported as suicides), but the gender difference has been consistently noted in the literature. I often see women physicians who are already working very hard professionally… and seem to have more than their share of the responsibility for child rearing, eldercare and homemaking. This does seems to be shifting, however, as more families have a more equitable approach to family/household duties. What issues do you think are the most challenging for colleagues to recognize in other doctors and how best can doctors support each other in these issues?

Litigation and complaint are serious issues and tap into the dreaded sense physicians have of real or perceived failure. After all, almost everything we do is for our patients and their families, and should we make an error it can resonate deeply… and painfully. Personal health issues are also challenging to face and often are minimized by physicians and the profession. It would be nice if we took other doctors as patients, provided them with the same care we offer to all patients, and bear in mind that they work in a hazardous profession. Besides that, going through normal life stressors, transitions and tragedies happen to physicians like everyone else. However, physicians tend to have precious little “wiggle room” in their lives to manage and process these issues. Without surge capacity, physicians’ schedules may contribute to these things not being processed in a healthy fashion. Whenever we see a colleague going through strain, stress or change we ought to simply reach out as friends and colleagues, and ask how are they doing… and can we help in any way. I’d like to end with a question about the value of play! How can doctors use play to invigorate their own mental health?

Play is an essential part of the human spirit and one we often lose touch with during intense training and practice. Keeping in touch with our playful selves keeps us real, open to wonder, curious and creative, and welcoming of growth. I think we’d all be better off with regular recess and nap time, even well into our senior years of practice! JULY / AUGUST 2015 • Doctor’s

Review

In major depressive disorder

“I felt down and

overwhelmed nearly every day.” Nicole*, 37

For patients like Nicole...

Trust PRISTIQ

for powerful

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

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

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

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

CA0113PRI023E

Count on

for powerful symptom relief

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

Mairi MacKinnon

Seniors’ mental health Recognize the signs of depression and how to help Reviewed by Corina Velehorschi, MD, FRCPC, DABPN, Adjunct Professor of Psychiatry, University of Western Ontario

D .

epression is a serious and prevalent mental health issue in today’s rising senior population. Canadian Coalition for Seniors’ Mental Health (CCSMH) guidelines indicate that over 100,000 older communitydwelling Canadians have some form of depression, and another 400,000 suffer from significant symptoms.1 Other research cited reports a depression rate of 21 percent (range 12–45 percent) in the hospitalized elderly, and up to 40 percent in seniors in long-term care (LTC).1 Among the dire consequences of later-life depression on individuals, families and society are poor recovery/rehabilitation after illness, hastened physical and mental deterioration, greater dependency, distress and heightened risk of untimely death, including by suicide.1,2 On the upside, depression is not an inevitable part of aging, and important functional, health and social benefits can be achieved with proper assessment and treatment.1,2

Detection can be difficult Risk factors for depression in older adults include history of depression, female sex, recent major illness or chronic disease, multiple medication use, diagnosis of dementia, stroke or Parkinson’s, bereavement or other stressful life event, sensory deprivation, social isolation/lack of stimulation, caregiving burden, and recent hospitalization or LTC placement.1,3 Symptoms include sadness, lack of pleasure in normal activities, low energy, appetite/weight loss, poor sleep quality, pain, memory problems, confusion, irritability, delusions and fixation on health issues. Some of these may overlap with symptoms of conditions such as dementia, arthritis, cancer, heart disease, Parkinson’s and stroke. Older patients often hesitate to discuss mood-related issues openly, and may instead focus on physical complaints. Hearing and/or cognitive impairments can also interfere with clear communication of depressive symptoms.1-3 Suspicion of depression based on observation and/or patient or family concerns should trigger fuller assessment. Understanding of the diagnostic criteria for depression (DSM-5) is essential. Evaluation should incorporate personal/family history, physical exam (with laboratory tests as needed to rule out medical conditions that may contribute to or mimic depression), review of medication/substance use, mental status exams, discussion of family/support situation, etc.1,3 All patients should be asked about suicidal thoughts and/ or intent, plan and means, and anyone considered high-risk referred to a mental health specialist.1

Treatment targets remission Remission (vs response) of depressive symptoms is a principal goal of therapy, aimed toward full functional recovery while reducing the risk of recurrence and promoting long-term health and quality of life.1,3 Treatment depends on severity of the depression, previous response to therapy, patient preference and available resources. Combined pharmacotherapy and psychotherapy (e.g. cognitive behavioural therapy or interpersonal therapy) has proven better than either intervention alone in some patient groups, including the elderly.4 Problem-solving, reminiscence and positive psychology therapies are also recommended.1 Electroconvulsive therapy (ECT) remains a safe and effective treatment for depression, especially in the frail elderly or patients who are on multiple medications, medically compromised (including cachexia), suffering with delusions or highly suicidal.1,5 Efficacy of antidepressant treatment and response rates in older people generally resemble those in younger individuals. Choose medications with the fewest side effects and least potential for drug interactions that might affect older patients with comorbid illnesses. Therapeutic doses are similar to ones used in younger patients: current evidence supports starting the antidepressant at half the recommended dose and increasing to the average dose within one month, with further gradual boosts if required up to the maximum dose. Frequent, ongoing monitoring is crucial.1,3

Resources for physicians and patients Physicians need to be increasingly knowledgeable of the complex issues involved in managing depression in older adults, and of when/where to refer them for additional support. A trusting relationship and the continuity of care offered in the primary care setting can be especially important.1 The full text of the CCSMH guidelines, along with a variety of tools for healthcare providers, can be downloaded at www. ccsmh.ca/en/projects/depression.cfm. Also available are user-friendly guides for seniors and families, and information aimed at enhancing advocacy and public awareness. References 1. Buchanan D, Tourigny-Rivard M-F, Cappeliez P et al. National guidelines for seniors’ mental health: The assessment and treatment of depression. Can J Geriatr 2006; 9(Suppl 2):S52-S58. 2. National Alliance on Mental Illness (NAMI). Depression in older persons: Fact sheet. www2.nami.org. Accessed June 12, 2015. 3. Wiese BS. Geriatric depression: The use of antidepressants in the elderly. BCMJ 2011;53:341-7. 4. Parikh SV, Segal ZV, Grigoriadis S et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. II. Psychotherapy alone or in combination with antidepressant medication. J Aff Disord 2009;117(Suppl 1):S15–S25. 5. American Psychiatric Association. Task Force on Electroconvulsive Therapy. The practice of ECT: Recommendations for treatment, training and privileging. Convuls Ther 1990;6:85-120.Wiese BS. Geriatric depression: The use of antidepressants in the elderly. BCMJ 2011;53:341-7. JULY / AUGUST 2015 • Doctor’s

Review

I P R E S C R I B E A TRIP TO... NEBRASKA

The thrill of sandhill cranes Plan now to witness the most spectacular bird migration in North America next March

ANN CANTELOW / SHUTTERSTOCK.COM

by Dr Mel Borins

Dawn and dusk are the best times to view the magnificent birds at the Rowe Sanctuary.

or 15 years I spent a couple weeks each summer in Ontario’s Algonquin Provincial Park. One of the highlights of my time there was to go on early morning bird walks hosted by a park ranger.

Dr Mel Borins is a family physician on active staff at St. Joseph’s Health Centre in Toronto and Associate Professor in the Department of Family and Community Medicine at the University of Toronto. He’s the author of three books and lectures, in a humorous vein, on health and stress management.

Doctor’s Review • JULY / AUGUST 2015

I learned about habitats and birdcalls and, when I was lucky, experienced the thrill of spotting a rare breed. The time spent with “birders” was both enjoyable and relaxing so when I heard of the spectacular sandhill crane migration in Nebraska I had to see it for myself. Last March I booked a flight to Omaha and drove three hours to Kearney (visitkearney. org), a small town near the Platte River where as many as a half a million of the large birds stop over on their annual migration.

The cranes gain 20 percent of their weight, then fly on to northern Canada, and even Alaska and Siberia Sandhill cranes use the sandbars in the shallow Platte River to discourage nighttime predators.

SUZANNE TUCKER / SHUTTERSTOCK.COM

Canadians don’t need any prompting to understand the wisdom of going south in the winter and like all good “snowbirds,” what goes south, must return north. Now picture a vast flock of cranes on the way to their northern home. For five weeks every March, as winter draws to a close, the banks of the Platte River become their resting and feeding place enroute to northern nesting grounds. Every year hundreds of birders, naturalists and the occasional curious Canadian doctor, flock there to experience America’s greatest migration. Imagine being a sandhill crane, one of the oldest bird species on earth. You are a big grey bird, 90 to 120 centimetres tall and weigh about 4.5 to 5.5 kilos with a spectacular wing span of 1.65 to 2.29 metres. You have a red patch of skin on your head that gets engorged and turns redder during sexual excitement or anger. At the end of each summer, you fly south to bask in the sun in Mexico, Texas, New Mexico, Arizona and Florida. On the way back north, you look forward to an early spring stay on the Platte River where you gorge on the big buffet of corn left over from the previous year’s harvest. You fatten yourself up, gain about 20 percent of your weight, then fly on to northern Canada, Hudson’s Bay, and possibly even Alaska and Siberia. At the end of your travels, as a couple you have 90 days to build a nest, copulate, hatch eggs and teach your chicks to fly before it’s time to head south again.

to discourage nighttime predators. Many stand knee deep in the water perhaps 20 metres from shore, thousands of them, a curious sight. Then, as the sun appears on the horizon, they rise on their massive wings in groups a dozen or two at a time lifting slowly into the dawn. It’s inspiring; you shiver with the wonder of it — and the early morning chill. They feed in the cornfields all day and then, as sunset gathers, they return to the protection of the river and bed down for the night. (Corn makes up about 90 percent of their diet. Their feeding does a service to local farmers by cleaning up any left over waste from the fall harvest.) We stayed until the last few had departed and then headed off with plans to come back before sunset to watch the cranes land on the river for the night.

EARLY BIRDS

The cranes rise on their massive wings and lift into the dawn.

LEAVES002 / SHUTTERSTOCK.COM

In Nebraska, on the northward journey, the crane stopover lasts about six weeks from the end of February to first week of April. The Rowe Sanctuary (rowe.audubon.org) managed by the Audubon Society is the place to see the cranes in their hundreds of thousands. The best time for viewing is dawn and dusk. At 5am, I bundled up to face the freezing morning air and headed to the 1000-hectare property. From the parking lot, the cacophony coming from the river tells you the birds are in residence. My group stood behind a wooden blind with viewing windows to wait for the sun. The whole show takes a couple of hours so make sure you bundle up as you would for a full-on Canadian winter. Down parkas, warm hats, gloves and scarves are de rigueur. And don’t forget your binoculars, a camera with a long lens and, if you’re smart, a thermos of your favourite hot beverage. You gaze out at the dark river and sandbars. The cranes use the sandbars of the shallow Platte River

JULY / AUGUST 2015 • Doctor’s

Review

The Great Platte River Road Archway at Kearney tells the story of early settlers.

PELICANS AND OTHER PAST TIMES Most of us drove an hour to the North Shore Marina at Harlan County Reservoir (harlantourism.org/activities_ trails/birding.php) in Republican City to see another wonderful birding site home to hundreds of pelicans. The American white pelican weighs about 4.5 to 9 kilos and have wingspans of about 1.75 metres. After breakfast we were taken out by boat onto the lake to see the large white birds in action, a wonderful sight. During our time on the water, we also spotted Canadian geese, bald eagles, gulls, cormorants and ducks. The next day, after seeing the cranes again at sunrise, we drove to Grand Island and visited the Crane Trust Nature and Visitor Center (cranetrust. org). The Crane Trust is a private non-profit established to protect and restore the cranes’ habitat. The biggest challenge is to preserve the fresh water, 70 percent of which gets diverted for farming and industry before it ever reaches the protected areas. Seeing the cranes and pelicans is reason enough to trek down to the River Platte, but it’s not the only reason. You’ll also want to call in at the Prairie Heritage Stuhr Museum (stuhrmuseum.org; adults US$4 fall through spring) in Grand Isle, an acclaimed living history museum. Their mission is to translate the past for the people of the future. Joe Black, the museum’s executive director, showed us around and vividly told the story of the towns, settlements and communities that populated rural Nebraska between 1860 and 1929. We learned of the roughly 10,000 members of the Pawnee Nation that were living in Nebraska before

Doctor’s Review • JULY / AUGUST 2015

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Every year birders, naturalists and curious Canadian doctors, flock to the Platte River to experience America’s greatest migration the Europeans arrived. With the settlers, came disease and the slaughter of millions of buffalo, which put an end to the Pawnee Nation’s primary food source and, with it, their way of life. In the end, the few hundred remaining Pawnee were force-marched to Kentucky where they were given land for a reservation. The Stuhr houses over 150,000 artifacts in more than 100 historic structures. There’s even a restored railroad town from the end of the 19th century complete with a flourmill, blacksmith shop and sheriff’s office. Crane watching is confined to a couple of hours at dawn and dusk so it’s best to plan some other activities. During the crane season, there are a lot of scheduled tourist goings-on in Kearney, Grand Island and Hastings. In addition to the Stuhr, I recommend a visit to the Great Platte River Road Archway (archway.org; adults US$12) at Kearney, an impressive structure that tells the story of early settlers in a very entertaining and educational way. The Museum of Nebraska Art (mona.unk.edu/mona) in Kearney and the Hastings Museum of Natural and Cultural History (hastingsmuseum.org) are also worth a visit. And if that’s not quite enough, you can also head over to the Heartland Public Shooting Park (see below).

DR MEL SHOOTS GUNS I am an anti-gun kind of guy. I believe that access to and the glorification of guns increases societal violence. Nevertheless, while at Grand Island, I visited the Heartland Public Shooting Park (grand-island. com/your-government/parks-and-recreation/heartlandpublic-shooting-park) and for the first time in my life not only touched a gun, but shot several of them. Heartland has different sections set aside for shotgun, rifle, handgun and archery. I warily picked up a shotgun and successfully hit a few of the airborne skeet targets. I also knocked down some range targets with a .22-calibre rifle. Now I can better understand the appeal and dopamine rush of shooting without condoning it. In Nebraska, anyone over the age of 21 can carry a legally purchased firearm and you can even get a permit to carry a concealed weapon. And what happens if you get caught carrying without a permit? The only consequence is a fine. Though fun, I confess, my experience at the shooting range was scary and ominous.

Donate a week at your cottage to a cancer survivor Choose a time you won’t be using your cottage in Quebec or Ontario

and Cottage Dreams will take care of the details Guests will bring their own groceries and stay from 2pm Sunday to noon Friday. Guests are fully insured and tax receipts are available. Cottage Dreams has, since 2003, found a week at a cottage in Ontario or Quebec for thousands of those recovering from cancer.

If you know of someone who could benefit, send them along — you’ll be glad you did! For full details visit cottagedreams.ca or e-mail program.info@cottagedreams.org.

North America’s largest subspecies of moose range through Kluane National Park.

Doctor’s Review • JULY / AUGUST 2015

Wild things 10 ways to take in animals big and small across the country

PADDY PALLIN

by Katharine Fletcher

Canada is famous worldwide for its amazing nature. Here are 10 spots from coast to coast to coast that offer fantastic views of whales, bears, moose, elks, eagles, snow geese and more during late summer and fall.

YUKON A drive along the Kluane Parkway in Kluane National Park (tel: 867-634-7207; pc.gc.ca/eng/pn-np/yt/kluane/ index.aspx) at dawn or dusk can reveal grizzlies, black (and cinnamon) bears, moose and their calves, white-tailed deer or a rarely seen lynx. The park, in the province’s southwest, is a UNESCO World Heritage Site and home to Canada’s highest peak — 5959-metre Mount Logan — and its largest ice field.

Whale watching is superb during August and September when orcas congregate in the Juan de Fuca Strait to coincide with the annual salmon migration as the fish spawn along the Fraser River. If you’re lucky, on a trip with Vancouver Whale Watch (tel: 604-274-9565; vancouverwhalewatch.com; adults from $130, until October 31), you’ll spy a super pod of 80 or more killer whales.

TOURISM VICTORIA/ALEXIA FOSTER

ALBERTA

Dall sheep are Kluane National Park’s most abundant large mammal.

SASKATCHEWAN Prince Albert National Park is home to one of Canada’s few wild, free-ranging herd of Plains bison. Ride with Sturgeon River Ranch (tel: 306-469-2356; sturgeonriver ranch.com) to view them from horseback, then spend the night in a tipi. Three-hour rides cost $100 per person; five-hour rides $125. Overnight trips cost $250 per person; tipis feature cots, sleeping bags and a little wood stove.

GOVERNMENT OF YUKON

Visit the Festival of Eagles (tel: 403-678-8939; canmore. ca/festivalofeagles), annually in October, in Canmore near Banff National Park during the annual Golden Eagle migration. View hundreds of these majestic birds of prey migrating south for winter with both amateur bird lovers and serious birdwatchers. Films, talks and guided walks will enhance your experience.

In Churchill, polar bears can be observed in the wild.

Hear male elks start “bugling” (their eerie mating cry) in Riding Mountain National Park in the fall. Frontiers North’s Big Five Safari (tel: 800-663-9832; frontiersnorth.com) tours the park every August, then flies you to Churchill, giving you a chance to see black bears, moose, bison, polar bears, belugas and more. Seven-night packages cost $5899 per person and include accommodations, meals, airfare and over-land transport, excursions and entrance fees.

Doctor’s Review • JULY / AUGUST 2015

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MANITOBA

TOURISM SASKATCHEWAN/GREG HUSZAR PHOTOGRAPHY

DAVEMHUNTPHOTOGRAPHY / SHUTTERSTOCK.COM

A whale-watching tour is a great day trip in BC.

The Canadian Rockies are home to bald and golden eagles (pictured).

Prince Albert National Park hosts overnight canoe excursions.

JULY / AUGUST 2015 • Doctor’s

Review

Doctor’s Review • JULY / AUGUST 2015

TOURISM PEI/CARRIE GREGORY

PEI National Park is best known for its broad, sandy beaches.

WAYNEDUGUAY / SHUTTERSTOCK.COM

NOVA SCOTIA TOURISM

Nova Scotia’s Cabot Trail makes a 297-kilometre loop around a chunk of the island.

ONTARIO

Each year, snow geese migrate south through Quebec where they rest for six to eight weeks.

Enjoy naturalist-led public wolf howls beneath a twinkling canopy of stars in iconic Algonquin Park (algonquinpark.on.ca/visit/programs/wolf-howls.php; $17 for a vehicle park permit). The expeditions take place on Thursdays throughout August and on the first Thursday of September. Alternatively, watch and listen for haunting cries of loons while paddling Algonquin’s or Bonnechere Provincial Park’s (ontarioparks.com/park/bonnechere) lakes.

QUEBEC In October, 800,000-plus snow geese as well as other migratory birds from the Great North congregate along the north shore of the St. Lawrence River before continuing on to their winter habitat on the Atlantic seaside — a journey of some 8000 kilometres. Large concentrations of the birds can usually be seen midmonth at Cap Tourmente and Montmagny, which hosts a Snow Goose Festival (tel: 418-248-3954; festival deloie.qc.ca) every October.

NOVA SCOTIA Drive along the renowned Cabot Trail, one third of which runs through Cape Breton Highlands National Park of Canada (pc.gc.ca/eng/pn-np/ns/cbreton/index. aspx), for a glimpse of black bears, moose and bald eagles. The park’s Skyline Sunset Hike (tel: 902-2242306; $14.70 per person) is a 7.5-kilometre guided tour, Mondays through Fridays until September 21. CANADIAN TOURISM COMMISSION

Wolf howling expeditions in Algonquin Park are three hours.

The Swallowtail Lighthouse sits on an isolated peninsula at the northern tip of Grand Manan Island.

NEW BRUNSWICK In July and August, observe the migration of three million or so shorebirds, including immense flocks of semipalmated sandpipers, at Mary’s Point Shorebird Reserve (fundy-biosphere.ca/en/amazing-places/mary-spoint.html). Or whale watch off Grand Manan Island with Sea Watch Tours (tel: 877-662-8552; seawatchtours. com; adults $65; kids 12 and under $45) looking for humpbacks, fin, minkes and more up until late fall.

EDCOREY / SHUTTERSTOCK.COM

PEI Wildlife abounds in PEI National Park (pc.gc.ca/eng/ pn-np/pe/pei-ipe/visit.aspx), from great blue herons and marine life in tidal pools to rare, endangered, piping plovers and woodland species such as pileated woodpeckers. The park also features Green Gables, part of L. M. Montgomery’s Cavendish National Historic Site, and Dalvay-by-the-Sea National Historic Site, once the 19th-century summer home of a wealthy oil tycoon. Courtesy of the Canadian Tourism Commission. This text has been modified from the original. JULY / AUGUST 2015 • Doctor’s

Review

Experience ANORO ELLIPTA ™

Indications and Clinical Use: ANORO™ ELLIPTA® (umeclidinium/vilanterol) is a combination of a long-acting muscarinic antagonist (LAMA) and a long-acting beta2-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. ANORO™ ELLIPTA® is not indicated for the relief of acute deterioration of COPD. ANORO™ ELLIPTA® is not indicated for the treatment of asthma. The safety and efficacy of ANORO™ ELLIPTA® in asthma have not been established. ANORO™ ELLIPTA® should not be used in patients under 18 years of age. Contraindications: • Patients with severe hypersensitivity to milk proteins. Most Serious Warnings and Precautions: • ASTHMA-RELATED DEATH: Long-acting beta2-adrenergic agonists (LABA) increase the risk of asthma-related death. Data from a large placebo-controlled US study that compared the safety of salmeterol (SEREVENT® Inhalation Aerosol) or placebo added to patients’ usual asthma therapy showed an increase in asthma-related deaths in patients receiving salmeterol. This finding with salmeterol is considered a class effect of LABA, including vilanterol, one of the active ingredients in ANORO™ ELLIPTA®. The safety and efficacy of ANORO™ ELLIPTA® in patients with asthma have not been established.

Other Relevant Warnings and Precautions: • ANORO™ ELLIPTA® is not indicated for the treatment of acute episodes of bronchospasm (i.e., as rescue therapy), relief of acute deterioration of COPD or for the treatment of asthma. • ANORO™ ELLIPTA® should not be initiated in patients during rapidly deteriorating or potentially life-threatening episodes of COPD. • Patients should be instructed to discontinue regular use of short-acting beta2-agonists and to use them only for acute respiratory symptoms. • Exacerbations may occur during treatment. Patients should be advised to continue treatment and seek medical advice if COPD symptoms remain uncontrolled or worsen after initiation of therapy. • ANORO™ ELLIPTA® should not be used more often or at higher doses than recommended. ANORO™ ELLIPTA® should not be used in conjunction with other medicines containing a LABA or LAMA. • Headache or blurred vision may influence the ability to drive or to use machinery. • Anticholinergic Effects: Use with caution in patients with narrow-angle glaucoma or urinary retention. • Cardiovascular effects: ANORO™ ELLIPTA® should be used with caution in patients with cardiovascular disorders, especially coronary insufficiency, acute myocardial infarction, cardiac arrhythmias, and hypertension. Cardiovascular effects such as cardiac arrhythmias, may be seen after administration. Treatment may need to be discontinued. ANORO™ ELLIPTA® was associated with a dose-dependent increase in heart rate and QTcF prolongation in healthy subjects receiving steady-state treatment. Caution is recommended in patients with a known history of QTc prolongation, risk factors for torsade de pointes (e.g., hypokalemia), or patients taking medications known to prolong the QTc interval.

A once-daily LAMA/LABA dual bronchodilator for COPD.* • Endocrine and Metabolism: Use with caution in patients with convulsive disorders, thyrotoxicosis and patients who are unusually responsive to sympathomimetic amines. Use with caution in patients predisposed to low levels of serum potassium or patients with ketoacidosis or diabetes. • Respiratory: Treatment should be discontinued if paradoxical bronchospasm occurs and alternative therapy instituted if necessary. • Hypersensitivity: As with all medications, immediate hypersensitivity reactions may occur after administration of ANORO™ ELLIPTA®. Patients with severe milk protein allergy should not take ANORO™ ELLIPTA®. • Use during pregnancy, labour and in breastfeeding women should only occur if the potential benefit justifies the potential risk. Adverse Events: Adverse reactions reported at a frequency of ≥1% and greater than placebo include: pharyngitis, sinusitis, lower respiratory tract infection, diarrhea, constipation, pain in extremity, muscle spasms, neck pain and chest pain.

Recommended Dose: • The recommended dose is one inhalation of ANORO™ ELLIPTA® 62.5/25 mcg once daily. Dosing Considerations: • No dosage adjustment is required in patients over 65 years of age, in patients with renal impairment, or in patients with mild or moderate hepatic impairment. ANORO™ ELLIPTA® has not been studied in patients with severe hepatic impairment. For More Information: Please consult the Product Monograph at http://gsk.ca/anoro/en for important information relating to adverse reactions, drug interactions, and dosing information, which have not been discussed in this piece. The Product Monograph is also available by calling 1-800-387-7374. To report an adverse event, please call 1-800-387-7374. *LAMA=Long-acting muscarinic antagonist [also known as a long-acting anticholinergic (LAAC)]; LABA=Long-acting beta2-agonist

ANORO and ELLIPTA are trademarks of Glaxo Group Limited, used under license by GlaxoSmithKline Inc. ANOROTM ELLIPTA® was developed in collaboration with Theravance, Inc. © 2015 GlaxoSmithKline Inc. All rights reserved. 00656 05/15

A man of his

The room that inspired poet Robinson Jeffersâ&#x20AC;&#x2122; The Bed by the Window in the Carmel house where he lived and died by Keith Skinner

Robinson Jeffers wrote almost all of his poetry at the Tor House in the morning and worked on building the Hawk Tower in the afternoon.

Robinson and Una had a covert love affair for a few years before she divorced her attorney-husband to marry the poet in 1913.

COURTESY OF TOR HOUSE FOUNDATION

word A

s we walked into the room, I first noticed the bed — broad, slightly concave,

uncomfortable-looking — covered with a thin, antique quilt. But it was the west-facing windows, unusually close to the floor, that caught my attention and brought back the words.

PHOTO COURTESY OF CARMELCALIFORNIA.COM

“I chose the bed downstairs by the sea-window for a good death-bed When we built the house; it is ready waiting, Unused unless by some guest in a twelvemonth, who hardly suspects Its latter purpose....” A chill rippled across my skin as I realized that we were standing in that very room and the bed before me was the subject of the poem — the deathbed in The Bed by the Window. Robinson Jeffers had written the poem as a young man shortly after building the house in Carmel, California. Many years later, he had indeed died in the room, thereby fulfilling its destiny. I had first read the poem while browsing a Jeffers anthology in a bookstore, a volume entitled The Wild God of the World. I knew little about the man but kept bumping into him in other writers’ work. Noted authors and bohemian celebrities were always dropping in on Jeffers when passing through Carmel. There was often some degree of awe or reverence ascribed to these occasions, but very little mentioned about the man himself. JULY / AUGUST 2015 • Doctor’s

Review

If Whitman was a Telemann concerto, Jeffers was a melancholy cello solo played mournfully in a dim, candlelit room knew little of its history. The article recounted how Jeffers had purchased an uninhabited plot of land on Carmel Point and had hired a stonemason to build a house for him. He apprenticed himself to the builder so he could learn how to set stone himself. Once the house was finished, Jeffers spent nearly four years building a 12-metre-high tower on the property, hauling boulders from a nearby beach and hoisting them into place by himself using only a block and tackle. The story about the tower was as provocative and unsettling as the deathbed poem. Who was this guy? He had rolled boulders, some weighing as much as 180 kilograms, several hundred yards uphill, through coastal scrub, and then had set each one by hand — alone. This only confirmed my suspicions that the man was obsessive and unpredictable if not outright stubborn. But he had somehow gotten under my skin. I decided to stop in Carmel on my way home to visit Tor House, to see his mad man’s tower, and to try to unravel the Jeffers riddle that kept resurfacing.

I picked up the book and, by chance, opened it to The Bed by the Window. It was an eerie poem. More than eerie, it was downright creepy. It wasn’t as though Jeffers had used death in a gratuitous manner; it wasn’t a cheap, dramatic device. The bed seemed to be a fetish of sorts for him as he worked through his feelings about his own mortality. I often regard it, “with neither dislike or desire; rather with both,...” Still, meditating on death in a poem was one thing; anticipating a lingering death in the distant future while still a young man and building a room in which to die was quite another. As I read through several more poems, the voice, at times, seemed almost feral. The ruggedness of the language, the starkness of the imagery — Jeffers prowled like a lone wolf or, more accurately, a rangy coyote skirting the edge of civilization: hungry, suspicious and angry. He seemed dark and self-absorbed. If Whitman was a Telemann concerto, full of trumpets and bright brass celebrating the world, it seemed to me that Jeffers was a melancholy cello solo played mournfully in a dim, candlelit room. For some unexplained reason, I felt compelled to buy the book, though it wasn’t long before it was abandoned on a bookshelf and I had put Jeffers out of my mind.

everal days before I found myself standing in Jeffers’ bedroom, and nearly a year after I had bought the anthology, I was staying in Big Sur and came across an article in a local magazine about the building of Tor House, Jeffers’ home. I knew the house was in Carmel, but

COURTESY OF TOR HOUSE FOUNDATION

Jeffers apprenticed himself to the contractor of the house so he could learn the art of making “stone love stone.”

Doctor’s Review • JULY / AUGUST 2015

ur small tour group was still huddled around Jeffers’ bed as if gathered to say our final goodbyes while the docent recited the deathbed poem. It was a sober moment for everyone. I looked out through the sea-window with its simple curtains and wooden window seat, across the grey-green mat of garden sprinkled with drifts of May flowers, to the gun metal surf churning in the distance. It was a stormy day and dark clouds were furrowed along the horizon. I wondered what had gone through Jeffers’ mind as he lay dying, his head turned toward the window, gazing at a similar scene. What I had expected to be an ordinary tour had become something more profound. As we filed into the living room, a latent energy seemed to linger in the house, as if the family had gone out for a walk together and, at any minute, the two boys would come bursting in through the door with a dog at their heels. This sensation was due, in part, to the way our docent had made the home come alive for us. He told stories about each room that portrayed the fierce love affair between Jeffers and his wife Una, and of a family life that was often insular, but very closely knit. If the house seemed infused with the warmth of family life, the world outside, at least on this day, was more typical of Jeffers’ flinty demeanor. I zipped up my jacket and cinched the hood tightly around my face as we crossed the small yard.

PHOTO COURTESY OF CARMELCALIFORNIA.COM

When Robinson and Una discovered Carmel-by-the-Sea in 1914, they called it their “inevitable place” and built Tor House on Carmel Point.

Hawk Tower was an odd structure, simultaneously squat and gangly. Una had long admired the medieval towers found throughout Ireland and Jeffers had tried to replicate the style. But the structure in front of me looked nothing like those I had seen in Ireland, other than ruins where the ramparts had either been breached or severely ravaged by time. There were two ways to move about within the structure: the wider, external staircase or the “secret” interior passageway that Jeffers had built for his sons. We were warned that the passageway was dark and extremely narrow in places and the steps, unusually steep. I chose the passageway because Jeffers often used it himself and I had a hunch the other members of my group would take the stairs. I would be alone with Jeffers and the dark, cold stone. “Old but still strong I climb the stone Climb the steep rough steps alone,” I climbed past the first landing that served as a play area for the two boys and up to Una’s stronghold. Over a small fireplace in the corner, Jeffers had carved a wooden mantle with a line of Latin from Virgil that roughly translated to “lovers fashion their own dreams.” It seemed to describe Tor House so precisely. The stone buildings, the keepsakes everywhere, the wildness of their surroundings — the Jeffers had carefully created a world, a dream, solely for themselves. Robin and Una required only each

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other’s company and the promontory overlooking the ocean; the rest of the world could be damned. I continued up to the outside parapet at the top of the tower, carefully navigating the steep, wet steps and pulling myself up by the hefty anchor chain that served as a handrail. The wind had picked up and gusts of rain stung my face the higher I climbed. I turned southward and scanned the jagged coast, the tree-lined shore that stretched into the distance and wrapped around the bay to join Point Lobos. “White-maned, wide-throated, the heavy-shouldered children of the wind leap at the sea-cliff.” I imagined Jeffers standing in this very spot in a squall, pensive and content as he took in the surrounding natural world that, at the time, laid claim to Carmel Point. Up on this perch, he would become hawk-like: calm, watchful and uncomplicated, comforted by the elements and the power of wind and ocean. Jeffers may have built the tower for Una, but it was more than a simple material gift he had given her. It was himself, his blustery spirit, his wild god heart embodied in granite, each stone placed as carefully as the words he arranged upon a page. Reprinted with permission. The article appears on TravelersTales. com and BestTravelWriting.com under the title Inside the Tower. It won the Grand Prize Bronze Award for Best Travel Story of 2014 in the Eighth Annual Solas Awards sponsored by Travelers’ Tales.

Why Big Sur is known as the US’s most spectacular drive. doctorsreview.com/features/big-sur-coast JULY / AUGUST 2015 • Doctor’s

Review

Flying secrets The real life of flight attendants

ALL ILLUSTRATIONS WIZDATA1 / SHUTTERSTOCK.COM

by Roger White

Doctor’s Review • JULY / AUGUST 2015

ir travel is not what it once was. In the Golden Age in the ’50s and ’60s flying was

a privileged way to get from A to B reserved largely for the business and leisure classes. In 1965 fewer than 20 percent of the population had ever flown. Routes and airfares were regulated. Whether you were flying to Toronto or to Tokyo the price was the same regardless of what airline you chose. Instead of competing on price, airlines used perks and service to entice customers on board. Consider this airline ad from back in the day. After touting the luxurious decor of the leather-lined walls of the “separate ladies lounge and men’s dressing room” it highlighted “memorable oven-fresh full-course meals and delicious between-meal snacks” and invited passengers to “step down the spiral staircase to a beautifully appointed built-in bar, horseshoe-shaped couch and circular table.” On board, the seats were wide, drinks were cold and meals were hot. Most flight attendants were female, many had nursing backgrounds and all were hired on the basis of weight — 54.4 kilos maximum — and good looks. Compulsory retirement came at age 32.

Deregulation works The big changes began with deregulation in 1978 when airlines were freed to compete on fares. The intention was to lower ticket prices and so increase passenger loads. It worked. By 2000 almost half the population took at least one flight a year. In 1974, it was illegal for an airline to charge less than US$1442 in inflation-adjusted dollars for a one-way flight between New York City and Los Angeles. Theses days you can fly from Toronto to Los Angeles return for less than $550. JULY / AUGUST 2015 • Doctor’s

Review

Of course, today’s flight experience is not quite what it was 40 years ago. Flying in 2015 is one of the more stressful public events in which you can take part. In most cities, the tension starts when you leave for the airport. Traffic snarls are so pervasive, you worry if you’ll make the flight. Once you’ve checked in, you face the physical and emotional stress of passing through security. Going up in the air to travel in excess of 700 kph in a large metal cylinder with a couple of hundred others is fear enough for many, add to it the possibility that the plane may be blown out of the sky by a terrorist bomb and it’s a wonder that anyone flies at all. Next comes the carry-on crisis. Will they allow you to take your bag on board or will you have to check the thing and risk loosing it? Once on board, with any luck, you’re seated in a window or aisle seat, if not you’re crowded into the centre with a stranger on either side. The struggle begins. Six elbows do quiet battle for three armrests, a skirmish

ALMOND ROCA You may have overheard dialogues like this one: Flight attendant (FA): Would you like the almond roca or the brownie, sir? Passenger (P): What? FA: Would you like the almond roca or the brownie, sir? P: What? FA: You’d probably hear me better if you took those headphones off, sir. Would you like the almond roca or the brownie? P: Do you have any peanuts? FA: No. P: Can I get a coke? FA: Yes, it’s on the beverage cart behind me, sir. P: What is that? FA: It’s a cart with drinks on it. P: No, that thing in your hand. What’s that? FA: That is the almond roca. P: I thought you said you had brownies. FA: Look pal! P: What is an almond roca anyway? FA: It’s a fine butter toffee elegantly wrapped in gold foil. Now would you like one or not? P: Nah, nothing. The passenger seated beside the gentleman who has been listening to the conversation. FA: Would you like the almond roca or the brownie? P: I’ll have the almond brownie. Excerpted with permission from Around the World in a Bad Mood: Confessions of a Flight Attendant by Rene Foss published by Hyperion, New York.

Doctor’s Review • JULY / AUGUST 2015

that often continues, on and off, until landing. There’s so little legroom you say a silent pray the person in front will not put their seat back.

Here comes the FA Cheer up, there’s inflight service. Before long someone will come down the aisle and offer you a beverage and, perhaps, a bag of peanuts, pretzels or cookies. Meet the flight attendant; she or he spends their entire working day breathing the recycled air, walking up and down those narrow aisles all in the cause of keeping you and your 200-odd seatmates happy, mostly by dispensing drinks, picking up trash and answering questions — many of which would test a Zen master. These include: Why are we delayed? What are we flying over? Am I going to make my connection? Will they hold the plane? Will my bag make it? Why would anyone do this for a living? “It’s the travel, stupid,” as frequent flyer Bill Clinton might put it. Working on airplanes is not at all like working in an office. You live out of a suitcase, and given flight schedules and the weather, you’re never quite sure where you’ll be sleeping next, but as you gain seniority and more control over your schedule, the world really does become your oyster. It’s addictive. Airline employees have a lower turnover than those in other jobs. “It’s a career, but it’s also a lifestyle. We have friends all over the world,” Glenn, a flight attendant with a major US airline told AFAR magazine recently. Many of those friends are fellow employees, but they’re not the same as those you might work with in an office. Says Curtis, one of Glenn’s colleagues: “…you fly with different people everyday. You have a different office and a different crew and different passengers every day.” And you get to travel both on the job and on holiday — and so does your family. Airline employees receive generous discounts not only on their

In-flight crew are often asked to answer questions — many of which would test a Zen master

“It’s a career, but it’s also a lifestyle. We have friends all over the world” own airline, but on most others too. Contra-deals between airlines means air travel at 80 percent off with special promotions that often include hotels in some of the most popular destinations on the globe.

The downside to living high On the flipside, the route to becoming a flight attendant can be an arduous one. For the first five years most are “on reserve” which means you are at the beck-and-call of the airline 24/7. You may live in Toronto or Vancouver and be told, on a few hours notice, to report for duty on a flight leaving from Halifax for Winnipeg at 6am. If you want to keep your job, says Glenn, “You adapt.” Pets, kids and marriage are a poor fit with this kind of demand. Even deciding on a place to call home can be a challenge. Many flight attendants share “crash pads” where roommates come and go at all hours depending on their flight schedules. You never know quite who you’ll find in your bed. And another thing, the pay’s not very good. Starting salaries are around $20,000 for 120 hours a month and can climb to around $40,000 after ten years. Not too shabby for a 30-hour week? Guess

again. The time clock only starts at take off and stops on landing. It’s not unusual to spend as much time getting to and from your flight and on layovers as you do in the air. Once everything is factored in, you can make a case that the pay is not much above minimum wage. And one more thing: the passengers. People are people and flying can put them through the wringer and leave them exhausted, hungry and angry. Even as passenger loads increase, in-flight staffing drops. Airline employee moral is low. “Air rage” is real. Flights are diverted to off-load inebriated passengers, personnel can be and are physically attacked, hot coffee is thrown, nasty things are said. The in-flight atmosphere is generally worsening as airlines try to wring every dollar out of flights from reducing legroom to cram in more seats to upcharging for everything from carry-ons to seats in exit rows. Despite low fuel costs and record profits, it emerged in July that the four major US airlines may be colluding to reduce the number of seats available on given routes in order to boost the percentage of seats filled. And yet… and yet… there remains something undeniably romantic about being an airline insider and the remarkable access it gives you to the entire world. After all, somebody has to do it. JULY / AUGUST 2015 • Doctor’s

Review

Young brewers are reinventing old breweries in small towns; Minipivovar Labut in LitomeË&#x2021; Ë&#x2021; rice is just one example.

Czech please

A beer pilgrimage from Prague to Pilsen via the home of Saaz hops by Cinda Chavich

CINDA CHAVICH

t’s been just hours since we landed in Prague and I’m sitting in one of the city’s historic cafés, a glass of golden lager in hand. We’ve walked the cobblestone streets, admiring the gothic architecture

among the crush of tourists, but I’m here to research another significant chapter in Czech history: the legacy of brewing the world’s first pilsner-style beer. The frothy glass of Pilsner Urquell before me in the elegant Café Imperial (cafeimperial.cz) is the iconic Czech brew, considered the world’s first pale lager and arguably the country’s most famous export. But there are so many other avenues to explore when it comes to Czech beer from the historic beer halls of Prague and the origins of lager to the famed Saaz hops or a pilgrimage to Pilsen. As Champagne is to Paris and vodka to Moscow, beer is to Prague, the beverage of choice for Czechs. They say pivo (beer) is cheaper than water here, which may be why Czechs are the biggest per capita beer drinkers on the planet. A pint of lager is still less than $2 and it’s certainly easy to find locals imbibing on a hot afternoon, whether you stop at a historic beergarten, a microbrewery, a farmer’s market or a posh café. Prague has more than its share of smoky historic beer halls. U Flek u˚ (en.ufleku.cz), 516 years old this year, lays claim to being the oldest brewpub and though you can do better for food elsewhere, it’s

worth a stop for their unique dark lager (served here exclusively) and medieval architecture. Tourists shouldn’t stop you from visiting the pub in Prague’s Municipal House (obecni-dum.cz). The stained glass and tile work in this Art Nouveau landmark is unmatched. Head down to the vaulted Plzenska Restaurant in the basement for classic Czech cuisine and big glasses of pilsner then have a nightcap in the cool little Americky cocktail bar, apparently the oldest bar in the city. There’s a beer hall around every corner here but for tradition in the Old Town there’s U Medvídk u˚ (umedvidku.cz) — which means At the Little Bears — an old-time pub that’s not totally overrun by tourists. It’s famous for its own double-hopped 1466 lager and ice cream made with its barrel-fermented Old Gott. Or look for Lokal (lokal-dlouha.ambi.cz), a modern interpretation of the vaulted taverns of old created by the popular Ambiente restaurant group. You’ll find young locals meeting here for the fresh, crisp Pils they keep in special tanks and for the locally-sourced menu, which features Prague ham served with creamy horseradish and all-you-can-eat dumplings. JULY / AUGUST 2015 • Doctor’s

Review

CINDA CHAVICH

The medieval centre of Žatec was built on the wealth of the region’s hop-growing heritage.

Doctor’s Review • JULY / AUGUST 2015

A tour of the Pilsner Urquell brewery includes a visit to its historic cellars.

famous for their St. Norbert lager. We take a seat in the vaulted pub to enjoy rustic platters of sausage and cheese alongside a frosty pint of their latest creation, a hoppy American APA, made with malted wheat and Bavarian mandarin and Polaris hops.

CINDA CHAVICH

hey’ve literally been brewing beer in this part of the world for more than 1000 years, the rights to brew passed down from monks and royal towns to noble families, malting guilds and professional brewers. The best place to taste anything is at the source so I head to Bˇrevnov Monastery Brewery, in the oldest monastery in Prague, where Benedictine monks began brewing in 993. The monks moved out when the Communists moved in during the 1950s, the monastery ironically taken over as the headquarters of the secret police. After the Velvet Revolution of 1989, the old convent became the Adalbert Hotel (hoteladalbert.cz), named for one of the founding bishops and the city’s first eco-hotel. Brewing resumed here, too, with an independent group turning the former stable into a microbrewery and now producing some 3000 hectolitres of light and dark lagers, Imperial Stout and hoppy, American-style IPA’s under the Bˇrevnov Benedictine label. From the monastery, it’s a 30-minute hike down to Prague Castle and the Strahov Monastic Brewery also called Klasterni Pivovar (klasterni-pivovar.cz). Brewing began on this site in the 13th century, and though monks no longer brew the beer, a new generation of brewers who opened Strahov in 2000 are

CINDA CHAVICH

BOCMAN1973 / SHUTTERSTOCK.COM

A pint of beer costs less than $2 in Prague and it’s even cheaper outside of the capital.

Pilsner Urquell has been brewed the same way since 1842.

Beer is cheaper than water here, which may be why Czechs are the biggest beer drinkers on the planet And speaking of hops, no Czech beer tour is ˇ complete without a trip to Zatec (or the German Saaz), the land of the famed noble Saaz hops, about 90 ˇ minutes northwest of Prague. The Zatec Basin, a sort of bowl surrounded by highlands, has the perfect warm and dry climate for growing hops and archeological evidence suggests it was in the 8th century that the people from this part of Bohemia discovered that bitter hops not only balanced sweet malts in beer, they helped preserve it. Saaz hops have long been an important commodity on the world market, added to famous brews from classic Czech pilsners to Belgium’s Stella Artois and Oregon’s Rogue Dead Guy Ale. In the 13th century, hops were such a significant part of the economy that King Wenceslas ordered the death penalty for anyone caught exporting the cuttings. Today this aromatic variety is recognized with EU “protected designation of origin” status, a guarantee that only this Czech region can produce Saaz hops. ˇ The pretty medieval centre of Zatec was built on the wealth of the region’s hop-growing heritage. Its central square, encircled in pastel houses and arcaded walkways, is lovely to wander at night when monuments and historic churches are illuminated. But you can also get a great view of the dozens of old hops warehouses, with their red tile roofs and tall chimneys,

from the glass and steel tower that’s part of the Temple of Hops Museum (beertemple.cz; $5). Take the elevator to the top, complete with a 3D film enroute, then visit the old hops storage room to learn about the history of hops. Our tour ends at the U Orloje restaurant with a Czech feast of beer-braised pork and dumplings, washed down with a refreshing Pils brewed on-site.

t was Bavarian brewer Josef Groll who originally developed the recipe for the golden lager the world now knows as Pilsner Urquell. His original Pilsner was an innovation in 1842, but today, nine out of 10 beers consumed in the world are Pilsner-style lagers. When we arrive in Pilsen, 90 kilometres west of Prague, our first stop is Pivovar Groll (pivovargroll.cz), a small brewery recently resurrected in Groll’s historic house with functioning replicas of his wood-fired tiled stoves and vats. Still made using the old methods, bottom fermented in oak barrels, the Groll pilsner in my glass is rich and flavourful with a dense, creamy head. The city of Pilsen, named the European Capital of Culture for 2015 (pilsen.eu), has plenty of monuments to visit, from the Gothic cathedral to museums devoted to art, puppetry and, of course, brewing, the latter offering a look at the labyrinth of medieval underground cellars beneath the old town. But the holy JULY / AUGUST 2015 • Doctor’s

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grail for lager lovers is the Pilsner Urquell Brewery (prazdrojvisit.cz) itself and we are soon lost in this veritable Disney world of beer. A bus whisks us around the sprawling property, through the massive bottling plant, past traditional copper mash kettles, and down into the chilly old lagering cellars for a chance to taste the beer as it was originally made, unfiltered and unpasteurized. While now owned by multinational SABMiller, along with 150 other brands, Pilsner Urquell remains a Czech favourite, still brewed according to its 171-year-old recipe. And having a pint pulled right from one of their historic oak barrels is worth every penny of the $10 admission.

The 109-room Hotel Josef is a chic, contemporary property in Prague’s Old Town.

HOP INTO BED You can plan your own beer tour through the Czech Republic or spend an afternoon visiting pubs on a walking tour with Prague Beer Tours (prague-beertours.com; $30). Every year Pilsner Urquell celebrates the date when the first batch was brewed, October 4 in Pilsen (pilsnerfest.cz). Public transport (trains and buses) is efficient in and around Prague, and very inexpensive. The hourly train from Prague to Pilsen, a 90-minute journey, is $7. Hotel Angelo (vi-hotels.com/en/angelo-prague; from $88) is a colourful, modern four-star in the Smíchov quarter of Prague 5, a bus or metro ride into the old city. The three-star Adalbert Eco-Hotel (hoteladalbert. cz; from $93) consists of spartan rooms, but with a microbrewery on-site, a classic Czech pub and beautiful gardens, it makes a quiet base for exploring the city. Hotel Josef (hoteljosef.com; from $157) is a chic boutique hotel in the heart of Prague’s old quarter. It features docking stations, free in-room fitness equipment and even offers a staff-led jogging tour — to help you work off all of that beer. Hotel Zlaty Lev (www.zlaty-lev.cz; from $88), or Golden Lion, is a comfortable hotel in the centre of Zˇatec near the Hop and Beer Temple. It makes a good base for exploring the hop-growing region and offers a beer bath in its spa. For more info on travel to the region, check out Prague City Tourism (prague.eu) and Czech Tourism (czech.cz).

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zechs ended 50 years of totalitarian rule in 1989 with the Velvet Revolution. By then, the communists had nearly destroyed the Czech beer industry, with only one remaining microbrewery in the country. Today, there are some 150 microbreweries in the Czech Republic, with many innovators now exploring the wide world of craft beer. Young brewers are breathing new life into old breweries in small towns, most with restaurants and innovative new beers to taste. At Minipivovar Labut (minipivovarlabut.cz) in Litomˇe rˇice, an hour from Prague, Sabina Zakova offers a pub lunch of spiced Camembert, pickled Moravian sausage and rustic bread alongside glasses of her unfiltered and unpasteurized pale and dark lagers and rye ale. She uses American Cascade hops for the fruity bitterness in her pale ale, the international style young Czech consumers want. The beer culture is alive and well whether you’re looking for special brewing trails to cycle or beer spas where you can literally immerse yourself in beer. There are beer-based shampoos and beer-based cosmetics. In Pilsen, The Pub is part of an innovative Czech-based chain of smoke-free pubs with self-serve beer taps and computers at every table to record each patron’s consumption. Back in Prague, there are new taprooms like U Kacíˇre and Pivní Tramvaj that serve a variety of local microbrews or the Prague Beer Museum with 30 taps. Good King Wenceslas, immortalized on horseback in a massive bronze statue in Prague’s main square, is considered the patron saint of beer. Avant-garde ˇ sculptor David Cerný literally turned the national monument on its head in his piece in nearby Lucerna Palace, Saint Wenceslas astride a dead steed hanging ˇ upside down. Cerný may be making a political statement about the challenges of the newly-independent republic, but thankfully, the good king’s legacy remains; in Prague, you’ll never want for a pint of Pils.

On two wheels through the Czech Republic’s wine country. doctorsreview.com/features/eat-drink-and-be-moravia

Doctor’s Review • JULY / AUGUST 2015

Seafood cioppino.

Fish for complim Three recipes for sustainable seafood that’ll win praise for the cook recipes edited by

Jane Mundy

he Vancouver Aquarium’s Ocean Wise program was founded in 2005 to make it easier for people to choose ocean-friendly seafood by looking for

the Ocean Wise symbol. Today, the 10th anniversary, there are thousands of locations across Canada committed to sourcing Ocean Wise seafood and to offering at least one Ocean Wise recommended item. The Ocean Wise Cookbook 2 was recently published by Whitecap Books; the

Doctor’s Review • JULY / AUGUST 2015

first cookbook came out in 2010. The fish and shellfish featured in its 350-plus pages are recommended by the Ocean Wise program and come from sustainable fisheries and farms; the recipes are from chefs across the country. The book is divided into four sections: fin fish (big guys such as halibut,

SEAFOOD CIOPPINO recipe by chef Wayne Sych This dish is available for lunch and dinner at the Joe Fortes Seafood and Chophouse restaurant in Vancouver — it’s so popular. Portioning the seafood into serving dishes can be tedious so for ease place the pot in the centre of the table and let everyone serve themselves! Substitutions: You can substitute halibut or salmon with any other firm-textured fish.

HAMID ATTIE

ents Chicken pot pies with golden cheddar crusts.

salmon, albacore tuna and sturgeon); shellfish; little fish (mackerel, anchovies, herring and sardines) and everything else that isn’t easily classifiable: fish eggs, squid, octopus and seaweeds. The fifth and final section describes the difference between a bouillabaisse — an authentic stew contains saffron and a variety of saltwater fish, but not shellfish — and a cioppino — more shellfish than fish in a rich tomato base. Our favorite cioppino follows along with a few other recipes that’ll make you happy as a clam.

3 tbsp. (45 ml) olive oil ¾ c. (180 ml) julienned white onions ¾ c. (180 ml) julienned carrots ¾ c. (180 ml) julienned leeks, white part only ¾ c. (180 ml) julienned celery ¾ c. (180 ml) julienned fennel bulb 1 garlic clove, minced 1 tsp. (5 ml) fennel seeds 1 tsp. (5 ml) fresh thyme leaves ½ c. (125 ml) tomato paste 8 c. (2 L) homemade or store-bought fish stock pinch of saffron 1 tsp. (5 ml) sambal olek 1½ tsp. (8 ml) salt 1 tsp. (5 ml) black pepper 10 oz. (300 g) fresh salmon, skinless, boneless, cut into 1-inch (2.5 cm) cubes 10 oz. (300 g) fresh Pacific halibut, skinless, boneless, cut into 1-inch (2.5 cm) cubes 2 lb. (900 g) fresh whole Dungeness crab, cooked and cleaned (instructions follow) cut into 6 sections 18 whole fresh spot prawns 1 lb. (450 g) fresh clams, rinsed 1 lb. (450 g) fresh mussels, cleaned and debearded 1 tbsp. (15 ml) chopped fresh parsley crusty bread

Heat the olive oil over medium heat in a large pot that will fit all the seafood. Add the onions, carrots, leeks, celery, fennel and garlic. Sauté for 2 to 3 minutes until softened. Add the fennel seeds, thyme and tomato paste, and simmer for 2 to 3 minutes. Add the fish stock, saffron, sambal olek, salt and pepper.

Bring the broth to a boil. Reduce the heat and let simmer for 10 to 12 minutes. Add the salmon, halibut, crab, spot prawns, clams and mussels. When first placing the fish and shellfish into the simmering broth, stir it gently to coat all the seafood in the broth. Cover and let it simmer for approximately 4 to 6 minutes, or cook until clams and mussels open and the seafood is cooked. Do not over stir the soup or the fish will break into little bits. Sprinkle with fresh chopped parsley and serve immediately with crusty bread on the side. Serves 6.

How to cook and prepare crab Adding vegetables to the water is a French technique — a court bouillon. It will add extra flavour to your crab.

1 c. (250 ml) carrots, peeled and diced 1 c. (250 ml) diced celery 1 c. (250 ml) diced onion 2 c. (500 ml) white wine 1 bay leaf 3 tbsp. (45 ml) whole black peppercorns ¾ c. (180 ml) salt ¼ c. (60 ml) vegetable oil

Heat the oil in a large stockpot set over medium-high heat. When the oil is hot, add the carrots, celery and onion. When the vegetables begin to sizzle, stir well and cover the pot; cook for 2 minutes. Deglaze the pan with white wine; add the bay leaf and peppercorns, and allow the liquid to reduce by half. Add enough water to boil the crabs (about 32 cups/8 L) and bring to JULY / AUGUST 2015 • Doctor’s

Review

a boil. Add the salt and crabs to the boiling water; return to a boil and cook 1½ to 2 ½ pounds (700 to 1150 g) crabs for 10 to 15 minutes; 3-pound (1400 g) crabs will take about 20 minutes. Plunge the crab into an ice bath consisting of equal parts ice and water. After 10 minutes, remove the crabs from the ice bath. Crack the shells and remove the meat (use a wooden skewer to help coax the meat out of the nooks and crannies). Chill the crabmeat completely in the refrigerator. Once thoroughly chilled, pick over the meat to check for any wayward bits of shell. Drain well. Tip: A single cooked, cleaned 1½ to 2 pound (700 to 900 g) Dungeness

crab (with back shell) yields 7½ to 8 ounces (1 to 1½ cups) of meat.

Substitutions: Scallops or shrimp for the squid. Try to get a Thai brand of fish sauce, it is not as strong-tasting.

SQUID SALAD WITH ROASTED RICE

For the dressing 1 medium hot pepper, thinly sliced into rings ¼ c. (60 ml) rice wine vinegar juice of 1 lime 2 tbsp. (30 ml) fish sauce 2 tbsp. (30 ml) water 1 tsp. (5 ml) sugar 1 lemongrass stalk, outer leaves removed and core minced 1 tbsp. (15 ml) sweet chili sauce

recipe by chef Jane Mundy Squid typically appeals to more adventurous eaters in North America. Besides pub-style calamari, this preparation is a gateway dish: forgo the tentacles if you think they look too intimidating in a salad. The roasted rice adds a nutty flavour and great texture — and will start a guessing game with your guests.

In a small bowl add the pepper slices to the vinegar and let steep for about half an hour. Combine the rest of the dressing ingredients in another small bowl and set aside. For the squid 1 lb. (250 g) Humboldt squid tubes, cleaned and sliced into rounds 3 tbsp. (45 ml) peanut oil ½ tsp. (2.5 ml) hot dried chili flakes salt black pepper

Pat the dry tubes. Cut along one side of the squid tubes and open them out flat. With the tip of a sharp paring knife, score the inner tubes in a diamond pattern, cut into 2-inch (5-cm) pieces. Heat the oil in a heavy pan over high heat. Add the squid and sauté, stirring, for 2 minutes. Transfer to a plate and sprinkle with dried chili flakes, salt and black pepper. Cool at room temperature. For the roasted rice 2 tbsp. (30 ml) long-grain rice

Squid salad with roasted rice.

Doctor’s Review • JULY / AUGUST 2015

TRACEY KUSIEWICZ

In a heavy (preferably cast-iron) small pan, add the rice and stir until golden brown. Transfer to a spice grinder and pulse — don’t grind into a powder. Or transfer the rice to a cutting board, cover with parchment paper and roll with a rolling pin until the rice is broken. For the salad 1 romaine heart, cut into 4 wedges 1 c. (250 ml) julienned daikon 1 long English cucumber, peeled, seeded and sliced into long strips

4 green onions, julienned ¼ c. (60 ml) mint leaves, whole ¼ c. (60 ml) cilantro leaves, whole

Remove and discard the red pepper from the vinegar and add the vinegar to the rest of the dressing. Divide the lettuce wedges, daikon and cucumber amongst plates, and sprinkle with green onion, mint and cilantro leaves. Add the squid, along with the remaining peanut oil in the pan. Drizzle the dressing over the squid and sprinkle with the roasted rice. Serves 4.

HOT SMOKED SALMON WITH ORANGES AND MAPLE SYRUP recipe by chef Quang Dang If you have a commercial smoker such as a Bradley, the wood “pucks” or “biscuits” are specifically made for it. If you don’t have a smoker, you can buy wood chips and use a charcoal barbecue. Experiment with wood flavours: a combination of apple and alder is popular.

2 oranges 1 c. (250 ml) salt 2 c. (500 ml) brown sugar 1 tbsp. (15 ml) black pepper 1 tsp. (5 ml) ground juniper berries 1 tsp. (5 ml) ground coriander seed 2 sockeye salmon fillets, about ½ lb. (230 g) each 1 c. (250 ml) maple syrup

With a fine grater, zest the oranges and set aside; they will be grilled later. Make the salmon cure by combining the salt, sugar, spices and orange zest, and mix well. Completely crust all sides of the salmon in the cure. Lay the fillets skin-side down on a parchment paper–lined baking sheet. Let sit in the fridge for 1½ hours.

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TRACEY KUSIEWICZ

Special equipment: Hardwood chips or pucks (alder, apple or cherry)

Hot smoked salmon with oranges and maple syrup.

Rinse off the cure under cold water and pat the fillets dry with paper towels. At this point, you will need to set up your smoker. Place the salmon into the smoker. Make sure that your smoker is hot: the internal temperature should be around 120 to 140°F (50 to 60°C) with full smoke. Brush the fillets with maple syrup and place into the smoker. Brush the salmon with maple syrup every 5 minutes or so. They will need to smoke for 45

minutes, until the salmon flakes when touched with a fork. Slice the oranges in half, place cutside up under a broiler and let roast until they are charred. Squeeze the juice from the broiled oranges onto the salmon just before serving. Serves 6. Recipes and photos from The Ocean Wise Cookbook 2 (Whitecap Books, 2014).

Everyday raw recipes — just chop, blend and/or toss and repeat. doctorsreview.com/food/book/everyday-raw-detox JULY / AUGUST 2015 • Doctor’s

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P H OT O FI NI S H by

Dr Réa l L e Gou ë f f

Ship shape

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I love colour photography, but black and white offers a perspective that’s particularly interesting in this era of advanced visual technology. When I worked near a fishing port in Lamèque, NB around 1990, I often saw the boats at the dock. One day, I encountered one that was reminiscent of a ghost ship. The sun was in the right place and I thought that with the right adjustments, I could create the desired effect. I took several pictures in black and white, and by playing with the development and using good film, I achieved the contrast that I wanted. The result wasn’t perfect, however, so (20 years later) I improved things with an image-processing program. The boat was in dry dock, but the intensity of the contrast gives the impression that it was in water.

Doctor’s Review • JULY / AUGUST 2015

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

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

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

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