July August 2016

MEDICINE ON THE MOVE

WIN

THIS MONTH’S

GADGET

JULY / AUGUST 2016

PAGE 13

COAST into FALL Sicily’s Southeast Southern US parks NB covered bridges Hats off to Panama Cooking lessons

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Award winners take a bow Three Doctor’s Review writers and photographers received Travel Media Association of Canada awards for work that appeared in the magazine in 2015.

Winners were announced at the end of June.

Cinda Chavich was honoured for her May 2015 article The Rock of Ages (doctorsreview.com/features/rock-ages) about a thrilling cruise around Newfoundland’s craggy shores. Two photographers received prizes: Gary Crallé for Best People Photo for the June 2015 article Hidden glories of the Saguenay (doctorsreview.com/ features/hidden-glories-saguenay), which he also penned; Dave Finn won for Best Photo Series for the September 2015 article Casa de Campo Reverie (doctorsreview. com/features/casa-de-campo-reverie).

Watch for their work in upcoming issues. Cinda has a rollicking piece about a cruise she took at the opposite end of the country. Sails and Ales, coming in September, describes the comings and goings in the seas off Vancouver Island.

We have an eclectic mix in this issue to celebrate the last days of summer and to get you started on the cooler season to come. A good way to begin might be to enroll in a cooking course as writer Lin Stranberg did over the summer: Going cooking in Canada, page 37. Teacher-chefs can be found in most towns. One of the perks is, of course, you get a chance to sample whatever is prepared. Yum. Fancy a road trip instead? New Brunswick has the back roads and scenery to calm the troubled heart and soothe the seething mind. How about a spin though The [covered] Bridges of Kings County, page 30.

Something longer in mind? Head south and call in at a US National Park or two in this, the Service’s 100th year. You’ll find six of these lesser-known beauties in Josephine Matyas’s Centennial views, page 22.

And don’t forget Europe. My best trips there have always been in shoulder seasons and nowhere does good weather linger quite so well as it does in Sicily. The article, Sicily’s superlative Southeast, page 42, proposes a trip that’s long on beaches, eating and visiting ancient sites, and short on time spent getting from place to place. Consider it a tasting menu of what may well be the most fascinating island in the world.

On the other hand, if you’re determined to hang on to summer for as long as you possibly can, grab your hat and head to Panama. Speaking in hats, page 48, gives an intimate look at the culture of a part of the world with stunning diversity that is starting to show up on many a visitor’s itinerary.

As they say, travel broadens.

Gary Crallé’s photo of Mrs. Sylvie Fortin playing the role of Mother Superior at the school-convent in Val-Jalbert in Quebec’s Saguenay region.

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JULY / AUGUST 2016 • Doctor’s

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contents JULY / AUGUST 2016

42 COVER: ROMROD PHOTO / SHUTTERSTOCK.COM

features

22

Centennial views

22

48

The US National Park Service turns 100 this year: six lesser-known parks for one breathtaking celebration

by Josephine Matyas

30

The bridges of Kings County New Brunswick’s beautiful Salmon Bridge and more covered passageways for old-fashioned romance this fall

by Cherie DeLory

37 Going cooking in Canada

Speaking in hats How Panama’s bus drivers and fruit salesmen may be communicating their temperament through their sombrero’s brim

by Darrin DuFord

52

Pucker up A lemony pesto-goat cheese dip plus more sweet and savoury recipes featuring your favourite citrus fruits

by Carla Snyder

From BBQ in Prince Edward County to French pastry in Old Montreal — classes to sharpen your culinary skills

by Lin Stranberg

42 Sicily’s superlative Southeast

37

A short tour of the Italian island’s antiquities and beaches inspired by the BBC series Inspector Montalbano

by Roger White

48 2

Doctor’s Review • JULY / AUGUST 2016

Help your OAB patients fight the urge

MYRBETRIQÂŽ (mirabegron) is indicated for the treatment of overactive bladder (OAB) with symptoms of urgency, urgency incontinence and urinary frequency.

contents JULY / AUGUST 2016

13

regulars

5

LETTERS

7

13

The best zoom binoculars ever

by David Elkins

Addiction, memories of Ontario plus Dr Heimlich the hero

7

PRACTICAL TRAVELLER Montreal gets a sky-high observatory, the Tate’s big new Switch House, Google Translate is now available offline and much more

by Camille Chin

GADGETS

14

TOP 25 The biggest medical meetings scheduled for this winter

16

MEDICINE AND THE ARTS Poetry and medicine: William Carlos Williams’ inspiring life and work

by Tilke Elkins

20

DEPRESSION KEYPOINTS Three fascinating case studies

by Eva Chanda

Coming in

September

• Sails and ales: take a trip on a sailing ship around BC’s Salish Sea • Venice starting from the inside of a gourmet chef’s kitchen • Victoria’s venerable Empress Hotel: does the remodel work?

• For a unique taste of luxury, stay and dine at a Relais & Châteaux

4

Doctor’s Review • JULY / AUGUST 2016

It is difficult to get the news from poems yet men die miserably every for lack of what is found

16

Covered in 8 out of 10 provinces with special authorization*

Proven efficacy in OAB with symptoms of urgency, urgency incontinence and urinary frequency.1

Consider MYRBETRIQ (mirabegron): A potent and selective β-3 adrenoceptor agonist for OAB ®

Indication and clinical use: MYRBETRIQ® (mirabegron) is indicated for the treatment of overactive bladder (OAB) with symptoms of urgency, urgency incontinence and urinary frequency.

• Safety and efficacy in pediatric patients have not been established.

•

Contraindications: Severe uncontrolled hypertension (SBP ≥180 mm Hg and/or DBP ≥110 mm Hg) • Pregnancy •

Relevant warnings and precautions: Serious adverse events of neoplasm • Serum ALT/AST increase with/without bilirubin increase and Stevens-Johnson syndrome • Dose dependent QTc prolongation, elevated blood pressure, elevated heart rate • Caution in patients with risk factors for torsade de pointes or patients taking medications known to prolong the QT interval • Interaction with CYP2D6 substrates • Caution in patients with clinically significant bladder outlet obstruction or taking antimuscarinics for OAB •

y day

d there.

1†

Caution in patients with moderate hepatic impairment; not recommended in severe hepatic impairment • In patients with glaucoma, ophthalmological examinations should be performed regularly • Angioedema of the face, lips, tongue and/or larynx has been reported. If involvement of tongue, hypopharynx or larynx occurs, discontinue MYRBETRIQ® and initiate appropriate therapy and/or measures • Caution in patients with severe renal impairment; not recommended in end stage renal disease • Should not be used during nursing •

For more information: Please consult the Product Monograph at http://www.cmsastellas.ca/uploads/pdf/2015-12-17%20 Myrbetriq%20English.pdf for more 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 us at 1-888-338-1824.

Reference: 1. Astellas Pharma Canada, Inc. MYRBETRIQ® Product Monograph, 2015.

* MYR B ETR IQ ® is eligible for formulary coverage with special authorization in Alberta, Saskatchewan, Manitoba, Ontario, Quebec, New Brunswick, Newfoundland and Labrador, and Nova Scotia. Please refer to the respective formularies for coverage information. †Clinical significance is unknown.

MYR B ETR IQ ® is a trademark of Astellas Pharma Canada, Inc.

LETTERS

Dr Heimlich the hero

EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

Dr Heimlich and Johnny Carson.

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

Dr Michael Golbey Via DoctorsReview.com

PUBLISHER

David Elkins

DIRECTOR, SALES & MARKETING

HEIMLICH THEN AND NOW In the May issue, Rose Foster profiled, in the History of Medicine section, Dr Henry Heimlich and his manoeuvre [“A man and his manoeuvre,” page 22].

As if to remind us that he is still active at 96 years of age, Dr Heimlich used his manoeuvre to save a woman choking on a hamburger in May 2016.

This happened at a senior community residence where he now lives. It was reported by CNN and a few local newspapers. As an aside, I wonder what would have created such bad blood between the two, father and son, Heimlich doctors.

Stephanie Gazo / Toronto

OFFICE MANAGER

Denise Bernier

CIRCULATION MANAGER

Claudia Masciotra

EDITORIAL BOARD

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

MONTREAL HEAD OFFICE

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

Dr Muri B. Abdurrahman Via email

TORONTO SALES OFFICE

553 Prestwick Oshawa, ON L1J 7P4 Tel: (905) 571-7667 Fax: (905) 571-9051

LIGHTS OUT Great looking prize, would really be fun to have [“Smartphone light control,” Gadgets, June 2016, page 14]. The pack of 60-watt incandescent bulbs for $4 is no longer available — at least in BC. Incandescent bulbs have been phased out.

Kawartha Highlands Provincial Park.

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.

THE ROAD TO RECOVERY Addiction is often looked poorly upon in our society [“The beauty of recovery,” Viewpoint on Addiction, June 2016, page 25]. Many never speak about recovery and it is such a beautiful thing and we notice this in the article. Well written!

Jason Stalls Via DoctorsReview.com

LAKESIDE IN ONTARIO My old stomping grounds as a child and teenager [Bright water, happy days, June 2016, page 26]. Haven’t been back [to Peterborough and the Kawartha Lakes] in many years, but would do it if time and finances would allow. Love reading articles of my homeland!

Gwen Six Via DoctorsReview.com

GRANOLA YOUR WAY I was excited to see the apricot-granola recipe in your magazine [The whole truth, March 2016, page 26]. My kids love parfaits in the morning and healthy, store-bought granola — the kind without chocolate pieces and candied fruit — can add up when you use as much as we do. I love the idea of making it at home and controlling exactly what goes in it.

C. Tal Via email

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Doctor’s Review • JULY / AUGUST 2016

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

© 2016 ESTATE OF LAWREN S. HARRIS

by

Seventh heaven © 2016 ESTATE OF LAWREN S. HARRIS

On now through September 18, The Idea of North: The Paintings of Lawren Harris at Toronto’s Art Gallery of Ontario is curated, in part, by actor and comedian Steve Martin.

Ontario-born Lawren Harris (1885–1970) is a founding member of the Group of Seven. His paintings evolved from decorative Impressionist-influenced landscapes to stark portraits of the North to geometric abstractions. The show opens with some of Harris’ early paintings from the 1910s, including many of Toronto’s working-class Ward neighbourhood where Harris spent his formative years. It then continues with more than 30 of Harris’ most significant and rare northern landscapes from the 1920s and 1930s. Over 80 works are on view. Timed tickets: adults $25, kids six to 17 $16.50. tel: (877) 225-4246; ago.net.

TOP TO BOTTOM: Mount Thule, Bylot Island, 1930.

Ice House, Coldwell, Lake Superior, 1923.

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P R AC T I C AL T R A V E L L E R Houston’s Buffalo Bayou Park Cistern

guided tours of the old underground water reservoir are offered for only US$2.

Built in 1926, the 8000-square-metre industrial space served as the city’s main source of drinking water for decades — until it sprung an irreparable leak.

Today, there are five to eight centimetres of water on the cistern’s floor, which create sight and sound effects among the 221 concrete columns that support the eight-metre-high ceilings. An art installation called Down Periscope (houstonperiscope.com) by Donald Lipski gives people above ground a glimpse and there’s also a web option.

Tickets can be reserved online within 60 days of your visit. buffalobayou.org/ visit/destination/the-cistern.

NASH BAKER

Underground art

KATYA HORNER

Mosque – Cathedral of Córdoba the public in May and half-hour in Spain’sopened Andalusiatoregion.

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Decked out © AU SOMMET PLACE VILLE MARIE

Montreal’s newest attraction is 185 metres above ground on the 46th floor of Place Ville Marie, a building that was designed, in 1962, by I.M. Pei, the creator of the Louvre Pyramid, in collaboration with Henry N. Cobb. Au Sommet Place Ville Marie opened in June and features an observation deck with all-around views that take in the Saint Lawrence River, Jacques-Cartier Bridge, Mount Royal, Old Montreal and the Olympic Stadium.

It features high-resolution digital telescopes that promoters have likened to those atop the Burj Khalifa in Dubai. There’s a multimedia exhibit on the 45th floor that explores popular city themes — hockey, performing arts, gastronomy, neighbourhoods — through 55 videos and 500 photos. The brasserie on the 44th floor has a four-season terrasse with tall bay windows and an urban garden. Adults $19; youth 13 to 17 $15; kids 6 to 12 $13. ausommetpvm.com.

Flower power BORNA MIRAHMADIAN / SHUTTERSTOCK.COM

It takes 100 volunteers four hours to install the 600,000 begonias that become the 75-metre-long Flower Carpet in Brussels every two years in August. Begonias are resistant to intense sunshine, rain and even cold, and the flowers are tightly packed together so the petals don’t blow away.

The inspiration of landscape architect Etienne Stautemas, the first Flower Carpet of Brussels was created in 1971.

The 20th edition will be on view this August 12 to 15 in the Grand-Place, a UNESCO World Heritage Site that’s home to buildings that date from the 15th century. Each edition of the Flower Carpet has a different musical theme; a concert and sound-and-light show is held every evening. flowercarpet.be/en.

Free speech The Google Translate app received a major update in May and can now be used offline — that is, with no data or Wi-Fi connection — on both iOS and Android devices.

Travellers can now translate 52 of the app’s 103 languages without having to worry about roaming data charges. Also new: the addition of both simplified and traditional Chinese, which can be translated through the app’s Word Lens feature along with 29 other languages including Arabic, Italian, Spanish and Thai. Users can simply hold their smartphone camera over a word and instantly get a translation. Via the iTunes or Google Play stores.

JULY / AUGUST 2016 • Doctor’s

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

THE TANKS © TATE PHOTOGRAPHY

London’s SWITCH HOUSE, TATE MODERN © IWAN BAAN

big Switch

TOP TO BOTTOM: The Switch House sits on top of the Tanks, former oil tanks turned underground gallery.

The perforated lattice of bricks allows light to filter in during the day and to glow out at night.

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Doctor’s Review • JULY / AUGUST 2016

The Tate Modern receives five million visitors a year, but when it was built 16 years ago in 2000, it was designed for only two million. The museum opened a new 10-storey extension in June and the pyramidshaped Switch House increases the gallery’s space by 60 percent. Its façade is a lattice of bricks; inside concrete columns and high ceilings evoke the site’s industrial past as an old power station. The Switch House features art from the 1960s onwards with a focus on work by women and artists from outside of North America and Western Europe. There’ll be more installations and performance art, more cafés and social spaces. The 10th-floor roof terrace has 360-degree views of London’s skyline as well as the River Thames and St Paul’s Cathedral. Admission is free, except for special shows. tate.org.uk/visit/tate-modern.

Picture yourself in Edinburgh.

Doctor’s Review makes planning your personal and professional travel easier.

Go to doctorsreview.com/meetings to search 2500+ top world conferences.

Access code: drcme

GA DGE T S by

D a v i d Elk i n s

Here’s lookin’ at you, kid Few products provide such instant delight as a good pair of binoculars.

Pick them up and gaze down the street, across the lake, at that bird in the far bushes, at the quarterback going back to pass, at the actors on a distant stage and you’re immediately part of the action.

Quality counts here. You want a crystal clear view with little or no focus fiddling. The legendary Hammacher Schlemmer Institute that does research for the New York store of the same name has found just such a pair of compact binoculars, which they describe simply as “The Best Zoom Binoculars.”

Their test: how many of 10 rows on an eye chart can you spot at 200 feet (61 metres)? The best of the competition could see six rows; the winner allowed researchers to read line seven clearly.

Also noted was the ease with which the diopter could be adjusted. To test durability, the units were repeatedly dropped from three feet (one metre) with no damage, thanks to the protection given by the rubberized coating.

The binoculars’ 21-millimetre lenses produce up to a 261 foot field of view at

1000 yards. The BAK4 Porro prism system zooms from 8x to 16x with little loss to image quality, regardless of distance. They’re compact and light at 11 ounces (309 grams) and birdwatchers, especially, will appreciate that they can be tripod mounted.

Users are enthusiastic: “We live on a102-acre lake. These are just what we needed to see what’s going on on the opposite shore.”

“We went to a bird sanctuary and the instant focusing was exceptional and the clarity was the best I’ve encountered.”

“I find the object — usually a bird — first with the 8x mag, then can zoom to the 16x. It’s amazing and lots of fun!

They also focus very well on close objects.

I definitely recommend them to bird and wildlife watchers.”

“Ordered [a pair] for my football loving husband. He watches from the upper deck and he LOVES them!”

These ballyhooed binoculars are, in fact, the UP 8-16x21 Zoom Green Binoculars from Pentax. You can find them at a local supplier or order them at Binoculars Canada. $99.95; binocularscanada.com.

Win these zoom binoculars by entering the Win the Gadget of the Month contest online at doctorsreview.com

CONGRATULATIONS! The winner of a car locator and Hori Hori knife

is Dr Gilda Bowdridge,

a GP from Halifax.

JULY / AUGUST 2016 • Doctor’s

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THE TOP 25 MEDICAL MEETINGS compiled by Camille Chin

Canada Toronto, ON December 1-3 2016 Ontario CME Program of the Society of Obstetricians and Gynaecologists of Canada sogc.org/events Challenging Cases in Opioid Use and Misuse cpd.utoronto.ca/opioidprescribing/developing-skills

December 9-10 Heart and Stroke Clinical Update 2016 heartandstroke.on.ca

Vancouver, BC November 9-12 Family Medicine Forum fmf.cfpc.ca

November 17-18 5th Health and Wellbeing in Children, Youth and Adults with Developmental Disabilities Conference interprofessional.ubc.ca/healthandwellbeing2016/ default.asp

MARISA ESTIVILL / SHUTTERSTOCK.COM

December 7

Cape Town’s Camps Bay Beach against the Twelve Apostles.

Amsterdam, Netherlands November 10-13 24th World Congress on Controversies in Obstetrics, Gynecology and Infertility congressmed.com/cogi

December 11-13

Around the world

8th European Multidisciplinary Colorectal Cancer Congress emccc2016.org

Abu Dhabi, UAE November 17-19

Atlanta, GA December 2-4

Gastro 2016: EGHS-WGO International Congress gastro2016.com

9th World Congress on Prevention of Diabetes and its Complications wcpd9.com

Berlin, Germany November 30-December 1 2016 World Congress on Clinical Trials in Diabetes wctd2016.com

Big Island, HI January 23-27, 2017

Arrhythmias and the Heart: A Cardiovascular Update cveducation.mayo.edu/marketing/arrhythmiasand-the-heart-a-cardiovascular-update--2

Bonita Springs, FL December 8-11

2016 Annual Meeting of the American Academy of Addiction Psychiatry aaap.org/annual-meeting

Boston, MA December 4-10

2016 Annual Update in Internal Medicine updateinternalmedicine.com

RADIOKAFKA / SHUTTERSTOCK.COM

Cape Town, South Africa November 18-22

2016 World Psychiatry Association International Congress wpacapetown2016.org.za

To register and to search 2500+ conferences, visit doctorsreview.com/meetings A restaurant courtyard in Berlin’s Prenzlauer Berg neighbourhood.

Access 2500+ conferences at doctorsreview.com/meetings

Code: drcme The Pier Café in Seaport Village, San Diego.

Chicago, IL November 15-20 Kidney Week 2016 asn-online.org/education/kidneyweek

Dubai, UAE December 7-10

2016 Scientific Conference of the Emirates Society of Emergency Medicine esem.ae/esem-activities

December 15-17 SIERRALARA / SHUTTERSTOCK.COM

5th Emirates International Urological Conference eusc2016.com

Houston, TX December 2-6 70th Annual Meeting of the American Epilepsy Society aesnet.org/annual_meeting

Miami Beach, FL January 30-February 3, 2017 20th Annual Mayo Clinic Endocrine Update 2017 ce.mayo.edu/endocrinology/content/20th-annualmayo-clinic-endocrine-update-2017

Orlando, FL December 4-7

28th Annual National Forum on Quality

Improvement in Health Care ihi.org/education/conferences/forum2016/ pages/default.aspx

December 8-10

2016 Clinical and Research Conference of the Crohn’s and Colitis Foundation of America: Advances in Inflammatory Bowel Diseases advancesinibd.com

New Orleans, LA November 12-16

2016 Scientific Sessions of the American Heart Association professional.heart.org/professional/index.jsp

San Antonio, TX December 6-10 39th San Antonio Breast Cancer Symposium sabcs.org

San Diego, CA December 3-6 58th Annual Meeting and Exposition of the American Society of Hematology hematology.org/annual-meeting

Vienna, Austria December 4-7 17th IASLC World Conference on Lung Cancer iaslc.org/events/iaslc-17th-world-conferencelung-cancer

MEDICAL QUIPS After 12 years of therapy, my psychiatrist said something that brought tears to my eyes.

He said: “No hablo inglés.”

— Ronnie Shakes

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

Go to doctorsreview.com/meetings for conferences in these cities... and many more!

JULY / AUGUST 2016 • Doctor’s

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ME D ICINE AND T H E AR T S by

Ti lke Elki ns

Poetry and medicine: two William Carlos Williams’ inspiring life and work

so much depends upon a red wheel barrow glazed with rain water beside the white chickens.

Dr Williams often wrote poetry on the back of his prescription pads and found it provided an immense release.

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Doctor’s Review • JULY / AUGUST 2016

I

n the 80 years of his life, renowned modernist poet William Carlos Williams (1883-1963) known for his assertions of “no ideas but in things” — such as

wheel barrows and chickens — published 21 books of poetry and 28 books of prose including four novels, an opera libretto, essays and criticism, his autobiography, a biography of his mother, and the translation of a medieval Spanish novel. His work has been credited with reshaping American poetry. Two months after his death, he was awarded the Pulitzer Prize.

Had Williams had any time to spare, it might have been said that the products of his literary genius came of such time. By his description, the time was stolen, not spare. In the course of his 40 year career as a small-town physician and the chief of pediatrics at the Passaic General Hospital in Passaic, New Jersey, he delivered more than 2000 babies and, by his estimate, saw over half a million patients. His days as a physician began at 7am and ended at 9pm when his night office hours ended.

How was he capable of such output? He addresses the question himself in a chapter of his autobiography entitled The Practice: “They naively ask him, ‘How do you do it? How can you carry on an active business like that and at the same time find time to write? You must be superhuman. You must have at the very least the energy of two men.’ But they do not grasp that one occupation complements the other, that they are two parts of a whole, that it is not two jobs at all, that one rests the man when the other fatigues him.”

Williams came to neither career by choice. As a teen, he fancied he’d be-

come a forester “to get away from human beings, out where I could be alone and clean.” His dreams of an active lifestyle were dashed when he pushed himself too hard during a high school track meet and was diagnosed with what was then called adolescent heart strain.

The athletic boy who participated in sports of all kinds was told that the most he could look forward to in life was long walks in the country. Passing a special medical entrance exam at the end of high school, he was able to skip pre-med and go directly to medical school at the University of Pennsylvania, where he befriended poets Ezra Pound and H.D. (Hilda Doolittle).

POETIC RELEASE The suppression of his physical energies became a great boon to him, he discovered, sparking a search for a passion that could relieve some of what he called his pent up “frustration.” His mother had studied painting until she was driven off course by the birth of her children, and so he dabbled with her old paint set, and was not without talent.

Ultimately, though, he seized the tools of his trade. He found that “with the back of a prescription blank and a good pencil in my hand,” he could write anything. A few simple words — such as would fit on a small sheet — had the power to bring him an immense satisfaction, a release.

Williams half-joked that he worried that he might be “found out” for plumbing the depths of his patients’

parts of a whole lives for material, and for receiving such a wealth of inspiration from their stories and their bodies of all shapes and sizes. Medicine was, he said, “my very food and drink, the very thing which made it possible for me to write.”

Profoundly influenced by Walt Whitman, America’s great humanist poet who was “mad for contact,” Williams was similarly preoccupied with contact with humanity, but focused on the body as an object of suffering and simple existence rather than of sexuality, as this excerpt from his autobiography shows.

“Was I not interested in man?

There the thing was, right in front of me. I could touch it, smell it. It was myself, naked, just as it was, without a lie telling itself to me in its own terms.

Oh, I knew it wasn’t for the most part giving me anything very profound, but it was giving me terms, basic terms with which I could spell out matters as profound as I cared to think of.”

A first-generation American — his father was a British citizen and his mother a Puerto Rican woman of French Basque and Dutch Jewish de-

scent — Williams sought to immerse himself in and promulgate an authentic American culture. While friends and contemporaries like Pound and Eliot rooted their poetry in the European intellectual tradition, Williams immersed himself in the lives of Passaic’s immigrant factory workers, absorbing their dialects and aiming to capture a uniquely American language. Pound

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teased his friend saying, “America?

What the hell do you, a bloomin’ foreigner, know about the place?”

Paterson, the industrial New Jersey city that gave Williams’ great epic poem its name, was a rich cauldron of human joys and struggles, especially during the Depression when Williams was gathering speed as a poet. At this convergence of race, culture and Old World languages, Williams balanced being a lyric observer and prophet with his role as obstetrician and general practitioner.

SCRUPLES TAKE THE DAY His was not, as he says “a money practice.” Early on, he could have found himself with a well-oiled career as a “New York Specialist,” but he was a

MEDICAL QUIPS General anesthesia is so weird.

You go to sleep in one room, then wake up four hours later in a totally different room. Just like in college.

— Ross Shafer

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Doctor’s Review • JULY / AUGUST 2016

man of principle and his adherence to scruples got in the way. In 1909, he was enjoying a residency at the Nursery and Child’s Hospital in New York when he was asked to sign papers that would falsify the hospital’s monthly report to the state government on admissions, discharges, births and deaths.

When he refused and none of the senior doctors backed him up, he quit and returned to his parents’ home in Rutherford, New Jersey, where he would end up living and practicing for many years. There he met and married, in 1912, Florence Herman.

“Floss,” as he called her, made Williams’ dual career possible by tending to all the housework as well as the administrative details of his practice.

A slice of life of Williams’ daily rounds can be glimpsed through his particular poetic lens in his posthumously published collection of short stories called The Doctor Stories. The collection was compiled and introduced in 1984 by Dr Robert Coles, a well-known writer and child psychologist, whose own career path was chosen based on advice from Dr Williams, whom he met while interviewing the poet for his senior honours thesis at Harvard.

The stories are at once terse and quietly riveting. Like Williams’ poems, they feel open-ended, finishing abruptly but with an inherent meaning that settles in slowly. Dr Cole points to their value as admissions of fallibility, calling them “stories that tell of mistakes, of errors in judgment” as well as admissions of small successes, not in the field of research, but in “that most important of all situations, the would-be healer face-to-face with the sufferer who half desires, half dreads the stranger’s medical help.”

Williams’ son, Dr William Eric Williams, puts his father’s perspective on his career more bluntly, concluding in the book’s afterward that medicine came to his father’s rescue as a writer, allowing him to put food on the table while qualifying him to explore what he himself called “the ischio-rectal abscesses of mankind.”

Williams never wavered in his loyalty to his twin passions. He saw poetry, and in fact all art, as a crucial anodyne

for doctors, a relief not only from the misery, suffering and death that all doctors must navigate, but from the sort of frustration that threatened to subvert him as a young man. In a 1950 interview on the Mary McBride show, Williams points to the vital importance of art. The artist, he explains, has the power to “bring… relief to others quite unsentimentally by presenting to them, putting before them, something which they may not understand, but gives them a secret satisfaction.”

The meaning inherent in William’s brief poem about a wheelbarrow and some chickens may seem obtuse. But an examination of his dual careers makes it plain: without this beauty, and without the attuned nature needed to behold it, a person’s very zest for life can be lost. Williams puts it best himself when he observes in his much-admired poem, Asphodel, That Greeny Flower:

It is difficult to get the news from poems yet men die miserably every day for lack of what is found there.

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

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

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

• Interstitial lung disease and eosinophilic pneumonia with venlafaxine • Seizures • Narrow angle glaucoma • Mania/hypomania • Serotonin syndrome or neuroleptic malignant syndrome-like reactions For More Information: Please consult the product monograph at http://pfizer.ca/ en/our_products/products/monograph/226 for important information relating to adverse reactions, drug interactions and dosing information which have not been discussed in this piece.

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PRISTIQ ® Wyeth LLC, owner/ Pfizer Canada Inc, Licensee © 2016 Pfizer Canada Inc. Kirkland, Quebec H9J 2M5

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DE PRESSIO N K EY PO I NT S by

Eva Chanda

with

Dr Toba Oluboka

The faces of depression

Three case studies confirm that every patient is different

Case 1:

Anxious about side effects

A .

nnik is a 39-year-old woman, married for four years with no children. She’s medically well and isn’t taking any medication. She tells her doctor she’s teary and irritable, worries constantly, lacks concentration at work and avoids social activities. She’s nauseated “all the time” and has noncardiac chest pain a few times a day.

She says she felt like this when she was diagnosed with depression in the past. At the time, she was prescribed paroxetine. Treatment was discontinued about two years ago.

Now Annik is refusing any medication. She says paroxetine caused emotional numbness, a 10-kg weight gain and loss of interest in sex. She stopped taking it after a few months, but didn’t tell her doctor.

Her doctor now suggests trying an antidepressant outside the SSRI class and she’s given information on serotoninnorepinephrine inhibitors (SNRIs) and bupropion to research and discuss with her husband.

At her next visit, Annik says she’s not doing very well. She says no to venlafaxine because of potential sexual dysfunction, no to bupropion because it might cause seizures, and she read online that both drugs can increase anxiety. She reemphasizes fear of weight gain. Finally, Annik and her doctor decide on desvenlafaxine. She is prescribed 50 mg/day with a return visit in two weeks. Three days later, she calls to say she’s feeling “really edgy” and wonders if she should discontinue the medication. The doctor reassures her it’s a common side effect when starting any antidepressant that should resolve within a few days.

At the next appointment, Annik reports the edginess is gone.

She still feels down at times, but things that used to bother her aren’t bothering her now. She’s willing to continue the desvenlafaxine, but says her husband wants her to stop taking it as soon as she’s back to her “old self.” She asks her doctor to speak to him, and he wisely agrees — family support is important for adherence.

20

Doctor’s Review • JULY / AUGUST 2016

Case 2:

Recurrence risk versus pregnancy plans

M .

aria is a 35-year-old teacher, married with no children, who presents with a probable third episode of major depression. She is medically well, has no known allergies and drinks alcohol only occasionally. She has a positive family history for unipolar depression and anxiety.

Her first episode of major depression was at age 20 while at university, characterized by loss of interest, crying, insomnia, anxiety, weight loss, poor appetite, lethargy and suicidal ideation, but no attempts. She opted for psychotherapy for six months, rather than medication, and continued her studies, although with great difficulty.

Maria’s second episode was at age 27, after the end of a long-term relationship, with similar, but more severe, symptoms.

She was unable to work for six months, had suicidal ideation with plans, and attempted to cut her wrists while intoxicated.

She was treated with pharmacotherapy (sertraline 150 mg daily for one year) and psychotherapy.

Maria only consulted her family physician six months after the current depressive symptoms began. She was feeling more anxious, especially at night, and had difficulty falling asleep. Her food intake increased as she ate for comfort, and she gained about 7 kg. Low energy, poor concentration, difficulty at work, especially because of uncontrollable crying spells, and ultimately the resurgence of suicidal thoughts convinced her to seek help. She was started on sertraline, rapidly titrated to 200 mg/day, but showed no improvement.

Maria has been depressed for 10 months and off work for four months. She feels discouraged, admits to suicidal plans, but denies any intentions to act on these thoughts. Her husband is supportive, but she wonders if depression will hamper their relationship, especially since they’d like to have children.

Maria’s doctor suggests switching her to another anti­ depressant, extended-release bupropion. She’s started on 150 mg/day and brought back in two weeks. There’s a 30 percent improvement in symptoms, especially of crying spells, appetite and anxiety. Suicidal thoughts have decreased, and Maria has no significant side effects. Her dose is raised to 300 mg/day, and she’s referred to a psychologist for cognitivebehavioural therapy (CBT) and an occupational therapist for return-to-work assessment.

At her next visit, Maria reports significant improvement in concentration, energy and motivation. After another two weeks, she improves further, with no more suicidal thoughts.

OLLYY / SHUTTERSTOCK.COM

Reviewer: Toba Oluboka, MD, FRCPC, is Site Chief, Addiction and Mental Health Services, South Health Campus, Alberta Health Services, Calgary, and Assistant Clinical Professor, Department of Psychiatry, University of Calgary.

When Maria is told she should stay on this medication for at least three years, she objects because she wants to become pregnant soon. Maria agrees to continue therapy for now and to let her doctor know when she plans to get pregnant.

Case 3:

Sleepless and sexless

M .

ichael is a 52-year-old divorced man working at a major bank. He has an active lifestyle that includes a busy professional life, regular exercise, a full social calendar, and a monogamous relationship for the past two years.

Michael is distressed about changes in the past two months: he can’t concentrate, feels very nervous, has stopped going to the gym, rarely sees his friends, has difficulty both initiating and maintaining sleep, and feels “down and out” most of the time.

He’s been going through a particularly stressful time at the office and his partner has left him — she feels rejected because his sexual interest is poor. He recalls that when he was 21 at university, he felt like this during final examinations, but it went away after several months. His medical history is unremarkable, other than a drop of 10 kg from his previous baseline weight.

Michael isn’t aware of psychiatric issues in his family, says he doesn’t use illicit drugs and drinks alcohol socially.

He’s started on mirtazapine 15 mg/day and advised to seek help with stress management. At a two-week followup, he has no major side effects, doesn’t have trouble sleeping anymore, and his appetite has returned. He hasn’t noticed any improvement in mood, but is less worried.

His mirtazapine dose is increased to 30 mg/day and he’s asked to return in another two weeks. He reports a noticeable improvement in mood, interest in social activities and concentration, his libido is back and his partner has given him a second chance. However, although he has no trouble falling or staying asleep, he feels sluggish in the morning, which is affecting his work. He is experiencing some constipation and has put on 3.5 kg since the initial visit.

The doctor tells Michael the drug is working, but may be causing his side effects. She advises him to keep taking the mirtazapine and to get back to his workouts and healthy eating to manage his weight.

He cancelled his third followup, declaring himself better.

But four months later, he returned to the office, admitting he stopped the medication due to the sluggishness and weight gain.

His depressed mood and insomnia are back. Before his doctor could address these concerns, Michael says he restarted mirtazapine 15 mg last night, and it was his first night of “good sleep” in a while. He’d like to continue the medication.

He is titrated to 45 mg mirtazapine at night, and after four weeks is started on an add-on agent, aripiprazole 2 mg in the morning.

At his eight-week appointment, Michael reports remarkable improvement in work, mood and social life. He and his partner have decided to get married. Michael promises to keep taking his medications as long as recommended.

MORE ONLINE

For famous Canadian faces of depression, see the sidebar online at doctorsreview.com/ articles/faces-depression.

JULY / AUGUST 2016 • Doctor’s

Review

21

Centennial view Six lesser-known US National Park destinations that make a big impression

by Josephine Matyas

CHRIS CURTIS / SHUTTERSTOCK.COM

T

n the world of North American travel, “centennial� always grabs headlines. In other parts of the planet, a century barely registers on the timeline. But here, in the New World, 10 decades is a great big deal.

Chiricahua National Monument consists of volcanic rock that has eroded into dramatic pinnacles, many balancing on a small base.

ews

JULY / AUGUST 2016 • Doctor’s

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23

For the US National Park Service, 2016 marks the 100th anniversary of the first Act of Congress that preserved the nation’s pristine landscapes.

There are now more than 400 sites protecting historic and prehistoric structures, threatened and endangered species, and fragile environments.

The service is offering 16 days of free admission (nps.gov/planyourvisit/fee-free-parks.htm) to celebrate so the big ones — Grand Canyon, Yellowstone, Monument Valley — will be even more packed than usual.

For Canadians travelling south when the weather cools, there are plenty of lesser-known gems that deserve a visit. Unfold your map, start on the left and follow west to east across the US with a sampling of destinations that may have evaded your radar.

Haleakala– National Park HAWAI‘I

It’s like another planet. In the Hawaiian language they call it kua mauna: “the land above the clouds.”

There is one main roadway to the dramatic crater summit of the world’s largest dormant volcano. According to Hawaiian mythology, the demigod Maui climbed the peak with a special net to catch the sun and slow its track across the sky, prolonging daylight.

The thin air is heady, but that doesn’t deter a smattering of bicycling enthusiasts who tackled the brutal grind to the top (many more opt to whiz down the mountain with uphill transport provided

by local outfitters). They come to gape into a crater so expansive it could swallow all of Manhattan and to snap Instagram shots with arms slung over the 3055-metre elevation marker.

The summit of Haleakala–, which means House of the Sun, is a cinder desert: an otherworldly landscape of muted rust and ink-black volcanic lava and ash well above the tree line. Much of the park’s protected fragile flora and fauna is found nowhere else on earth.

For astronomers, Haleakala–’s clean air gives it the fourth best viewing conditions on the planet.

There is a cluster of observatories on the peak, including a NASA telescope that can track basketballsize objects more than 32,000 kilometres away.

The summit weather changes quickly. Sun one minute, a blanket of clouds below the next. The mountain’s microclimate traps moisture, feeding the valley’s streams and waterfalls while nourishing the windward side rainforest.

Joshua Tree National Park CALIFORNIA

What makes Joshua Tree National Park distinct is not that it formed the photo backdrop for the first album by the Eagles (although there is that), but that it’s the point where the high Mojave and low Colorado deserts converge.

PIERRE LECLERC / SHUTTERSTOCK.COM

Haleakala National Park covers 13,500 hectares and features a lush, tropical landscape as well as a moonlike terrain near the volcano’s crater.

24

Doctor’s Review • JULY / AUGUST 2016

The towering boulders in Joshua Tree National Park were once hideouts for cattle and horse rustlers.

JOSEPHINE MATYAS

In desert ecosystems, elevation is everything.

Desert plants and critters are extremely sensitive to the slightest change. The park’s upper half — the Mojave Desert section — is a jumble of boulders beloved by rock climbers and an arid “forest” of wildarmed Joshua trees, which are not trees at all but enormous yucca. The towering boulder piles — formed through volcanic activity and erosion — were once hideouts for cattle and horse rustlers. The park is encircled by rugged mountain ranges.

On the park’s north-south road, elevation drops with the transition to the lower Colorado Desert.

The park’s namesake disappears, replaced by creosote bushes, palo verde, spindly ocotillo and prickly jumping cholla cacti. In springtime, it’s a blast of colourful wildflowers.

Joshua Tree is perfect for a little driving tour, a few hiking stops, a picnic in the shade or a ranger-guided talk. An eight-kilometre side trip leads to the outlook at Keys View, with a panorama over the Coachella Valley, including the menacing San Andreas Fault.

Camping at Joshua Tree is especially sweet; when darkness falls the stars pop out, tumbling right to the horizon. The rustic campgrounds offer a true desert experience, complete with seven species of rattlers, coyote, bighorn sheep, and the elusive and endangered desert tortoise. Load up your iPhone with the Eagles album and listen to Glenn Frey and Don Henley Take It Easy.

Cholla cacti are nicknamed “jumping cacti” because of the ease with which the stems detach and stick to hikers when brushed.

JOSEPHINE MATYAS

Organ Pipe Cactus National Monument The first thing you notice about Organ Pipe Cactus National Monument is how out of the way it is.

Halfway between Yuma and Tucson, turn south at Gila Bend and continue through 95 kilometres of Sonoran Desert until almost to Mexico. The park abuts the borderline.

Organ Pipe Cactus fulfills a lot of wish lists. For birding enthusiasts, more than 270 species make it a stunning display of Sonoran Desert birdlife. The Sonoran Desert is known for its biodiversity (the park is also a UNESCO Biosphere Reserve), home to some 30 types of cacti including saguaro, cholla, ocotillo and the rare organ pipe. It’s the only place in the US where you can see large stands of organ pipe cacti growing in the wild.

More than 95 percent of the park is wilderness.

Desert hiking is best in the cooler morning or evening, and there are even ranger-led full moon hikes and night sky talks. Camping at the park’s Twin Peaks Campground means constellations at night and the calmness of the desert after sundown. The

JOSEPHINE MATYAS

ARIZONA

Organ Pipe Cactus National Monument is the only place in the US where you can see large stands of organ pipe cacti growing in the wild.

The author’s husband poses in front of a “balanced rock,” which is just one rock that has eroded away.

Tohono O’odham people, whose lands border the park, view the stars as cornmeal strewn across the dark fabric of the night sky.

The land is a mix of craggy mountains and arid, cacti-dotted scrublands. A 34-kilometre graded dirt road along the scenic Ajo Mountain Loop crosses the Diablo and Ajo Mountains through dense “forests” of thorny ocotillo, giant saguaro and organ pipe cactus. The road is narrow at points and there are stretches of teeth-chattering washboard, but the two-hour trip is a plunge into the diverse life community of the Sonoran Desert. There are picnic pull outs along the way, marked hiking trails and… peace and quiet.

Chiricahua National Monument

JOSEPHINE MATYAS

ARIZONA

ANNA ABRAMSKAYA / SHUTTERSTOCK.COM

The Spanish designed Castillo de San Marcos in 1672 to withstand the impact of a cannonball.

To park ranger Suzanne Moody, Chiricahua is a secluded park of “significant natural and cultural significance.” Tucked into the southeast corner of Arizona, the mountains and fantastic rock formations rising above the surrounding grasslands seem to attract nicknames: “island in the desert” and “wonderland of rocks.” The Chiricahua Apache and their ferocious leader Geronimo found ample hiding places in “the land of standing-up rocks” during their conflicts with the US Army.

“It’s a wonderful pioneer story as well as a natural story,” explains Moody. “Out here you either made do, made it up or did without.” That pioneering spirit is frozen in time at the park’s log cabins and large homestead Faraway Ranch.

Chiricahua’s landforms were created millions of years ago when gigantic volcanic eruptions left the area covered in compacted ash, which was lifted by geologic forces and sculpted by wind and water.

The result is an unearthly scene of balanced rocks, columns and pinnacles that stand as monuments to the power of nature.

Although the area holds an important place in the history of expanding frontiers, it’s Chiricahua’s natural crossroads that place it under National Park Service protection. The straw-coloured grasslands meet the upland forests of Douglas fir, aspen and endemic Arizona cypress. The Sonoran Desert meets the Chiricahuan Desert, creating a wide range of habitats, flora and fauna.

The park has trails for everyone, from a wheelchairaccessible nature trail to all-day hikes through complicated rock formations. This is one park where getting into the car is a must: the 13-kilometre scenic drive to Massai Point is a days-end favourite, when the setting sun leaves an afterglow on the rocks of the sky island.

Natchez Trace Parkway The Natchez Trace Parkway is a journey along a historical timeline. The blissfully commercial-free, 715-kilometre roadway links Tennessee, Alabama and Mississippi, honouring the storied Native American and pioneer trail stretching from Natchez to Nashville. It’s a no-pressure way for travellers to experience history and nature at a leisurely pace.

This natural travel corridor once bisected the traditional homelands of the Natchez, Chickasaw and Choctaw tribes. In the early 1800s, northern farmers floated crops and livestock on wooden flatboats down the Mississippi River to the ports of Natchez and New Orleans, sold their goods and then travelled the land route homeward to the north. The paved route is also a National Scenic Byway and an All-American Road.

The landscape continuously changes, from forest to meadows. It crosses through distinct ecosystems — bayous and swamps, limestone caves, deciduous woodlands — providing protection as a “habitat corridor” for animal life. In the south, it’s alligators and armadillos; in the north, fox and white-tailed deer.

There are hiking, biking and opportunities for history buffs all along The Trace. Soldiers in the War of 1812 marched along the route. There are Confederate gravesites and national battlefields dating to the American Civil War. Restored plantation homes and old mine sites are glimpses into the era of the Old Southwest. One of the most visited stops is the gravesite of trailblazer Meriwether Lewis — of Lewis and Clark fame — whose explorations opened the west. Lewis died on and is buried along the Tennessee portion of The Trace.

Castillo de San Marcos National Monument FLORIDA

It has stood a long time. Longer than the United States has been a country. The massive stone fort in St. Augustine was built in 1672 by the Spanish to strengthen their place in the New World and to defend Spanish “treasure fleets” returning home.

JAMES R. MARTIN / SHUTTERSTOCK.COM

TENNESSEE / ALABAMA / MISSISSIPPI

The restored plantation homes along the Natchez Trace Parkway are glimpses into the era of the Old Southwest.

When Christopher Columbus found new lands in 1492, it sparked four centuries of European rule in parts of the Americas. The Spanish, Portuguese, English, French, Danes and Dutch wrestled for territorial control, often attacking and looting each other’s vessels. The Castillo de San Marcos was crucial to early Spanish endeavours, serving as a base to patrol the shoreline, looking for pirates and salvaging wrecks.

For 235 years, St. Augustine was the centre of Spanish power and control over a vast geographical territory.

As a monument, the Castillo tells a story. It has never been conquered, but changed hands through treaties — from the Spanish to the British, back to the Spanish and then, in 1821, ceding Florida to the United States. The fort holds re-enactments and visitors can tour vaulted powder magazines, guardrooms, storage areas, a chapel and gundecks. It is the nation’s oldest (and best preserved) example of a Spanish colonial fortification.

A wooden fort first stood on the spot, but was replaced by a masonry fortress made from coquina, a porous, naturally occurring stone that would not shatter when hit by a cannonball. The walls are four metres thick at the base, with ramparts at the top lined with cannons pointed out to sea. From this fort, troops and their armaments faithfully stood watch over the land Ponce de León named “La Florida.”

The America the Beautiful Pass (nps.gov/planyourvisit/passes.htm) is US$80 and valid for entries into any of the National Park Service properties for a 12-month period. Single park entries range from $15 to $30.

JULY / AUGUST 2016 • Doctor’s

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27

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See additional safety information on page 36 xx

Point Wolfe Bridge in Fundy National Park is the only painted bridge in the province.

The bridges of Revive old-fashioned romance this fall on a tour of New Brunswick’s beautiful covered passageways

GREG AND JAN RITCHIE / SHUTTERSTOCK.COM

by Cherie DeLory

W

hile the Bay of Fundy’s record-breaking high tides and Fundy National Park’s

waterfalls and scenic trails attract nature enthusiasts worldwide, scattered about New Brunswick are relics of history that locals hold dear to their hearts.

Covered bridges that resemble small barns offer an enchanting connection to the past, when horse and buggies were the mode of transportation, and romance and secret wishes swirled amidst the timber trusses.

Kings County, in central New Brunswick, is the covered-bridge capital of Atlantic Canada. The province once boasted 320 covered bridges, some dating back to 1900. The latest bridge to go was lost in a flood in 2014, but 60 are still standing today. In Kings County, 16 bridges hover over rivers and dot the rolling rural road landscape in the towns of Sussex, Hampton, Rothesay, Quispamsis and Norton.

Kings County Bob Alston was raised on the family farm in Newtown, where he and his wife live today, not far from the Oldfield Covered Bridge. When he was a youngster, he often travelled through three covered bridges on his way into Sussex to shop. Many years later, Alston would find those same bridges threatened.

In 1975, the Department of Transportation tore down the Windgap Bridge, deeming it unsafe. In 1978, the Malone Bridge was burnt in a Halloween prank. In 1982, when the Department of Transportation announced that it would replace the Salmon Bridge, Alston said enough is enough.

Recognizing that part of the area’s heritage was being destroyed, he and a small group of locals formed the Salmon River Covered Bridge Park Association and successfully lobbied the government for two years to keep the bridge standing.

Preserving the bridges and showcasing them to the world is Alston’s passion. He became president of the province’s now defunct Covered Bridge Preservation Association and spearheaded the development of the Covered Bridge Visitor Information Centre, which opened in 2003 and was built to look like a covered bridge. He also launched the annual Kings County Covered Bridge Festival that year, which had a successful run but is no longer taking place.

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JERRY WHALEY / SHUTTERSTOCK.COM

The Department of Transport wanted to replace the Salmon Bridge in 1992; today it’s closed to traffic and a popular picnic spot.

32

Doctor’s Review • JULY / AUGUST 2016

Smith Creek was featured on a 25-cent coin in 1992 to mark the 125th anniversary of Confederation.

covered one was estimated to last 80 to 100 years.

One couple who enjoyed a romantic evening inside the Salmon Covered Bridge is Arleen and Clyde Bradley of Pittsburgh, PA. Their first trip to New Brunswick was in 1997 and they returned in 2003 for the first annual Kings County Covered Bridge Festival. A highlight of the festival was dinner and dancing in Salmon Bridge. It was the first and only time the globetrotting “bridgers” had eaten or danced in a covered bridge, making it a very special and memorable occasion.

“Our heritage is important...

People come from all over to look at the Salmon Bridge and other bridges in our province”

CHERIE DELORY

“Our heritage is important,” Alston says. “I know a lot of people don’t understand that. In today’s world, it’s got to be new and it’s got to be flashy. But people come from all over the world to look at the Salmon Bridge and other bridges in our province. You take all the bridges away and you’re going to take away thousands of people who are interested in covered bridges.”

Salmon’s convenient location, at Exit 195 on Highway 1, one kilometre west of the exit on route 890, means that tourists can find the bridge easily.

Also, because this bridge is closed to traffic and designated as a park, it’s a popular picnic spot, with canoeing and fishing on the Kennebecasis River.

And it shouldn’t come as a surprise to see weddings in the covered bridges since romance and covered bridges — fondly nicknamed “kissing bridges” — go hand in hand.

In the days of the horse and buggy, men would train their horses to stop while inside the bridge so they could snatch a private moment for romance. Of course, the bridges weren’t built as they were with romance in mind. It was to protect the raw lumber from rotting. An uncovered bridge, exposed to the elements, would last only 10 to 15 years, whereas a

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Spanning 391 metres over the Saint John River, Hartland Bridge is the longest covered bridge in the world.

I

CHERIE DELORY

f you’re ambitious, it’s possible to see all 16 covered bridges in the Kings County area in one day by car. Or, for a more leisurely route, self-guided cycling tours of the bridges are recommended.

Eight of the bridges are within a 10-minute drive from downtown Sussex: Salmon (located at Four Corners), Plumweseep (at Plumweseep Road), Tranton (at Rockville Road), Urney and Moores Mill (both in Waterford near Poley Mountain, a popular ski hill), Oldfield (in Newtown; Oldfield Bridge appears on a 1992 commemorative quarter), Centreville (Berwick area, west of Sussex) and McFarlane (Wards Creek, south of Sussex).

The covered bridges will often have more than one name. Officially, a bridge is named after the river it crosses or the owner of the land on which it was built.

If several bridges cross the same river, they’re numbered. For instance, the Kennebecasis River No. 9 was

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Doctor’s Review • JULY / AUGUST 2016

the ninth covered bridge from the mouth of the river, but it’s also known as Plumweseep Bridge, named after the Mi’kmaq and Maliseet First Nations people who blazed the portage trails in the area. Tranton and Oldfield Bridge are named after their original landowners, but they’re also known as Smith Creek No. 1 and Smith Creek No. 5 respectively.

Point Wolfe Bridge in Fundy National Park, an hour’s drive southeast of Sussex, is New Brunswick’s only painted bridge. Its beautiful red colour is in sharp contrast to all the weathered board bridges in the province.

It’s been said that covered bridges have the power to grant wishes. Horse-and-buggy passengers would shut their eyes, raise their feet, and hold their breath for the length of the bridge. It would have been a challenging journey when crossing New Brunswick’s Hartland Bridge, the longest covered bridge in the world. It spans 391 breathless metres over the Saint John River in Hartland, located off Route 2 / Trans Canada Highway, between routes 103 and 105. (As an aside, the longest bridge in the world is Confederation Bridge, which is also in New Brunswick and connects the mainland to PEI.) Two other bridges worth seeing are Hardscrabble and Vaughn Creek in the coastal village of St. Martins in Saint John County, about a 45-minute drive southwest of Sussex. Look for the picture-postcard red house perched between the bridges, and say hello to the owner. He doesn’t mind chatting with tourists and wouldn’t dream of moving. “No money in the world can get me to move away from here,” says Donald Brian McIntyre. “I see the changing tides every day.”

Plumweseep Bridge is named after the First Nations people who blazed the portage trails in the area.

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.

Clinical Use BuTrans® is not indicated as an as-needed (prn) analgesic. Elderly patients should be dosed cautiously and initiated on the lowest available BuTrans® strength. Use of BuTrans® is not indicated in patients <18 years old.

Contraindications: • Ileus • Suspected surgical abdomen • Mild, intermittent or short duration pain that can otherwise be managed • Management of acute pain • Management of peri-operative pain • Acute asthma or other obstructive airway and status asthmaticus • Acute respiratory depression

• Alcoholism, delirium tremens and convulsive disorders • Severe CNS depression, increased cerebrospinal or intracranial pressure, and head injury • MAO use • Pregnancy, labour and delivery or breast-feeding • Opioid-dependent patients and for narcotic withdrawal treatment • Myasthenia gravis • Severe hepatic insufficiency

Most Serious Warnings And Precautions: Limitations of use: Should only be used in patients for whom alternative treatment options are ineffective, not tolerated, or would be otherwise inadequate to provide appropriate management of pain.

Addiction, abuse, and misuse: Assess patient risk prior to prescribing; monitor all patients regularly; store BuTrans® securely.

Life-threatening respiratory depression: May occur with BuTrans® use. Monitor patients for respiratory depression, especially during initiation or following dose increases. Placing the patch in the mouth, chewing it, swallowing it or using it in any way other than indicated may cause choking or overdose that could result in death.

Accidental exposure: Serious medical consequences, including death, may occur, especially in children.

Neonatal opioid withdrawal syndrome: Can result from prolonged maternal use during pregnancy.

Dosage: Initiation: Doses higher than 5 mcg/h should not be used in opioid-naïve patients; Maximum: 20 mcg/h every 7 days.

Serum concentrations: Decline gradually. Patients who experienced serious adverse events should be monitored for at least 24 hours after BuTrans® removal or until the adverse reaction has subsided.

Depot: Formation of a subcutaneous depot of buprenorphine results in continued exposure after patch removal. If the patch is removed prior to peak buprenorphine exposure, buprenorphine plasma levels may continue to increase after patch removal.

Transdermal: BuTrans® patches are intended for transdermal use on intact skin only; use on compromised skin can lead to increased exposure to buprenorphine.

Dependence/Tolerance: BuTrans® has potential for abuse, dependence of the opiate type, and diversion.

Overdose: Primary management should be reestablishment of adequate ventilation with mechanical assistance of respiration, if required. Naloxone may not be effective in reversing any respiratory depression produced by buprenorphine. starting BuTrans®, when the dose has been adjusted, and Other Relevant Warnings And Precautions: when receiving other CNS-active drugs. Patients should be • Unintentional increase in drug exposure including application advised not to drive a car or operate machinery unless they of external heat are tolerant to the effects of BuTrans® • Acute abdominal conditions • Chronic pulmonary disease • Hypotensive effects • Special risk groups: Adrenocortical insufficiency; CNS • Concomitant use of CYP3A4 inhibitors or inducers depression or coma; high-risk debilitated patients; • Not approved for managing addictive disorders myxedema or hypothyroidism; prostatic hypertrophy or • Hepatic, biliary and pancreatic disease urethral stricture; and toxic psychosis • Application site skin reactions • Disposal and security: After use, fold patch in half. Never • Neurologic considerations throw BuTrans® into household trash, where children and • Psychomotor impairment: Advise patients that BuTrans® pets may find it. Return to pharmacy for proper disposal. may impair mental and/or physical ability required for the Should be kept under lock and out of sight and reach of performance of potentially hazardous tasks especially when children and pets Adverse Events: The most common adverse effects in six randomized titration-to-effect placebo-controlled clinical trials with BuTrans® were anorexia, application site erythema, application site reactions, asthenia, constipation, dizziness, dry mouth, headache, hyperhidrosis, insomnia, nausea, somnolence and vomiting.

For more information: Please consult the Product Monograph at http://www.purdue.ca/files/2014-08-05-butrans-pm-eng-final-tpd-clean..pdf for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The Product Monograph is also available by calling us at 1-800-387-5349.

References: 1. NBuTrans® Product Monograph, Purdue Pharma, August 2014. 2. Purdue Pharma, letter on file, August 9, 2011.

BuTrans® is a registered trademark of Purdue Pharma. © 2014 Purdue Pharma. All rights reserved.

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Doctor’s Review • JULY / AUGUST 2016

KEVIN CLARK

Chef David Robertson from Vancouver’s Dirty Apron and (below) his plate of BC spot prawns on halibut cheeks.

Going cooking in Canada Classes across the country to sharpen your culinary skills

LIN STRANBERG

by Lin Stranberg

T

fabulous new dining experience can be as close as your kitchen.

Take a cooking course this fall, dazzle your taste buds then invite family and friends to join you for a meal and dazzle theirs. Writer Lin Stranberg shares some tips and tasty bites she picked up in Vancouver, Prince Edward County near Toronto and also in Montreal. Similar courses in towns big and small across the country are only a web search away.

JULY / AUGUST 2016 • Doctor’s

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37

BLAKE ALLAN

The writer and her new grandchild, Raya, in Vancouver.

FOOD AND WINE IN VANCOUVER My daughter added excitement and depth to the summer by giving birth to her first child on the West Coast. My cooking extravaganza began while visiting mother and baby. Vancouver, with its vibrant food and craft beer culture, has lots of different

JOEY ARMSTRONG

The Dirty Apron also consists of a delicatessen where Chef Robertson (pictured) sells gourmet sandwiches, deli meats and local BC cheeses.

cooking classes. I zeroed in on “Friday Night Bites,” a new demo-and-dine class at The Dirty Apron (dirtyapron.com), a gourmet deli known for its cooking school and best-selling cookbook. David Robertson, owner, author and chef, teaches the class himself.

The hands-on cooking classes — many themed for couples, singles, kids or teens — accommodate more than a thousand people a month and are usually waitlisted. In response, “Friday Night Bites” was launched this spring.

“It’s got a smaller price point and is more relaxed,” Chef David says. “It’s a great night out for people who don’t want to cook, but would like to enjoy a few glasses of wine and a good dinner.

There’s no intimidation factor.”

After seeing the excellent Picasso: The Artist and His Muses exhibit, on now through October 2 at the Vancouver Art Gallery (vanartgallery.bc.ca), I walked over to the Crosstown area and took a seat at one of The Dirty Apron’s communal tables. I was ready to taste some of BC’s finest regional cuisine — halibut cheeks, spot prawns, the Peking breed of duck from the Fraser Valley — and learn how it’s done.

It was a little like watching a professional magician at a private party. Chef David talked, waved his hands, asked questions and answered them.

“How do you tell prawns are fresh? When the meat sticks to the shell.”

“How do you tell fish is cooked? Flaking and opaquing!” “Score and marinate duck breast, then cook it low, slow and in control. You want to render the fat in the pan.”

Our group took on his chatty vibe, fortified with flights of wine paired with each course. Chef David kept us interested and on track throughout. Enjoying each course was a fleeting pleasure, but the experience stayed with me well after my flight back home.

Two-hour Friday Night Bites Dine and Demo classes cost $95.

At the Waring House Inn, Chef Jordon McGinnis (right) focuses on making everyday dishes better. Case in point: warm asparagus and maple glazed salmon salad (bottom).

LIN STRANBERG

LIN STRANBERG

During a weekend in Prince Edward County, a foodie hotspot and favourite Ontario getaway, I chose a “Sunday Morning Grilling Techniques” class with Chef Jordon McGinnis, part of a package deal at The Waring House Inn (waringhouse.com).

The historic property outside Picton seemed like a good spot to whisk up my skills for summer entertaining.

The cookery school and guest lodges are clustered near the old inn, a limestone farmhouse built around 1860. We had a lodge room with a balcony and environmentally-friendly features, including an energy-efficient electric fireplace with a snazzy faux flame. At dinner, we snagged a window table at the main restaurant, Amelia’s Garden, and went back for breakfast before the class.

There were eight of us. We were all ages, genders and backgrounds yet it was as relaxed and enjoyable as a weekend house party coming together to cook Sunday lunch. We tied on our black aprons, chef’s helper Kayleigh Anne passed around the menu sheets and Chef Jordon ran down our action plan for cooking a barbecue spread.

“We’ll focus on ways you can look at average dishes and really improve them,” he said. “The simpler a dish is, the harder it is. You don’t have a lot of ingredients to hide behind.”

We worked in teams, two to a workstation, making buttermilk cornbread; warm asparagus with pancetta, pine nuts and leek; potato salad and a sweet chili barbecue sauce. Most of us had time to cook two or three dishes. Chef Jordon, a food sciences buff, demystified sous vide, the vacuum-bag-in-a-waterbath cooking method popularized by high-end chefs, as he demonstrated techniques for grilling maple-glazed salmon, sous-vide-prepped steak, and chicken with the sweet chili sauce.

LIN STRANBERG

BBQ IN PRINCE EDWARD COUNTY

We enjoyed it all together over lunch then left with recipes and helpful tips. “Brine chicken then grill over low heat to make it moist and tender.”

“Add a few drops of vinegar to the water when you boil potatoes. It keeps them from crumbling.”

Classes are approximately three hours long and cost $115.

JULY / AUGUST 2016 • Doctor’s

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39

“It clicked when my doctor and I discussed Trulicity .” ™

• • •

*

Once-weekly dosing Ready-to-use pen† Preattached, hidden needle†

*Fictitious patient. May not be representative of all patients.

Trulicity 1.5 mg demonstrated A1c reduction comparable to liraglutide in a non-inferiority, open-label study. ‡§

Change from baseline in A1c at 26 weeks: Trulicity 1.5 mg + metformin, -1.4, liraglutide + metformin, -1.4; p<0.001 for non-inferiority.

Trulicity is indicated for the once-weekly treatment of patients with type 2 diabetes mellitus to improve glycemic control, in combination with: • diet and exercise in patients for whom metformin is inappropriate due to contraindication or intolerance.

• metformin, when diet and exercise plus maximal tolerated dose of metformin do not achieve adequate glycemic control.

• metformin and a sulfonylurea, when diet and exercise plus dual therapy with metformin and a sulfonylurea do not achieve adequate glycemic control.

• prandial insulin with metformin, when diet and exercise plus basal or basal-bolus insulin therapy (up to two injections of basal or basal plus prandial insulin per day) with or without oral antihyperglycemic medications, do not achieve adequate glycemic control.

CADUA00013

TRULICITY is a trademark owned by or licensed to Eli Lilly and Company, its subsidiaries or affiliates. © 2016, Eli Lilly and Company. All rights reserved.

Clinical use: Trulicity has not been studied in combination with basal insulin.

Trulicity is not a substitute for insulin. Trulicity should not be used in patients with type 1 diabetes mellitus or for the treatment of diabetic ketoacidosis.

Contraindications: Patients with a personal or family history of medullary thyroid carcinoma or in patients with Multiple Endocrine Neoplasia syndrome type 2 (MEN 2) • Pregnant and nursing women LIN STRANBERG

•

Most serious warnings and precautions:

Risk of thyroid C-cell tumours: In male and female rats, dulaglutide causes dose-dependent and treatment duration-dependent thyroid C-cell tumors after lifetime exposure. Patients should be counseled regarding the risk and symptoms of thyroid tumors.

PASTRY IN OLD MONTREAL

Other relevant warnings and precautions: • Heart rate increase • Prolongation of PR interval • Hypoglycemia (in combination with a secretagogue or prandial insulin) • Severe gastrointestinal disease • Pancreatitis • Systematic hypersensitivity • Not studied in pediatric patients • No dose adjustment required in patients over 65 years of age • Hepatic or renal impairment • Recent myocardial infarction, unstable angina and congestive heart failure

Wander into La Maison Christian Faure (maisonchristianfaure.ca) in Old Montreal and you’ll get a flash of somewhere far away. It’s all thick stone walls, cozy tables and an out-of-this-world display of elegant desserts.

It’s French pastry art and quelle surprise! It’s all made in the downstairs atelier of the 300-year-old building at 355 Place Royale, across from the Pointe-à-Callière Museum (pacmusee.qc.ca). The discreet little elevator has a trick up its sleeve: it takes you to a state-of-the-art international pastry school as well. There’s a sixmonth curriculum, the brainchild of elite pastry chefs who, like Lyon-born Chef Faure, are Meilleurs Ouvriers de France, the crème de la crème of French gastronomy.

For those of us whose day jobs are far from the kitchen, “Serious Amateurs” classes are offered on Saturday afternoons. Six hours of demos and hands-on creation of things like macaroons, sorbets, even the towering triumph of a croquembouche — it’s the real deal.

Prices range from $250 for a single class to $950 for five and $1800 for a 10-class package.

For more information: Please consult the product monograph at www.lilly.ca/TrulicityPM/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 us at 1-888-545-5972.

Reference: 1. Trulicity Product Monograph. Eli Lilly Canada Inc., November 10, 2015.

Clinical significance has not been established.

‡

The recommended starting dose for Trulicity is 0.75 mg once-weekly.

§

26-week, randomized, open-label, parallel group, multicentre, active-controlled, phase III non-inferiority study. Patients received either 1.5 mg Trulicity once weekly (n=299; baseline A1c 8.1%) or 1.8 mg liraglutide once daily (n=300; baseline A1c 8.1%). Treatment was added to background therapy with metformin (≥1500 mg/day).

All n-values refer to intent-to-treat population. Primary endpoint was change in A1c from baseline to week 26 between once-weekly Trulicity and once-daily liraglutide.

PIERRE MARC PELLETIER

†

Chef Christian Faure’s pastry school has classes for “serious amateurs” — those who can’t bake can sample his strawberry shortcake (above) in the pastry shop.

JULY / AUGUST 2016 • Doctor’s

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41

Take in a view of the southeastern mountain town of Ragusa Ibla from the Church of Santa Maria delle Scale.

Sicily’s superlative Southeast A short tour of antiquities and beaches on Italy’s largest island

ALVARO GERMAN VILELA / SHUTTERSTOCK.COM

by Roger White

taly is one of my favourite countries, but Sicily wasn’t on my horizon until recently. About 18 months ago, I came across the BBC series Inspector Montalbano. Based on books by Andrea Camilleri, the show stars Luca Zingaretti as a brusque, shavenhead detective who keeps an eye out for the less fortunate. It feels very authentic, helped enormously by the fact that it’s in Italian with English subtitles.

The show is filmed in Punta Secca, a village on the beach on the island’s southeast coast. I was a fan the instant I saw the inspector enjoying breakfast on the terrace of his villa with its balustrade on the sand only metres from the Mediterranean. The plots are terrific too, of course, giving an intimate glimpse of life among

Sicily’s classes, high and low, not forgetting the staggering history of the place or the power of the church and its mafia friends. You can get a taste of the drama on YouTube (youtube.com/user/mhzmystery).

Sicily’s location on the major trade route between Europe and the Middle East has made the island one of the most fascinating places on the planet.

There’s history hidden under every rock. The Greeks were here over 3000 years ago and Syracuse, on the Ionian Coast, famously defeated Athens in 413 BCE. JULY / AUGUST 2016 • Doctor’s

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43

The third-century Greek theatre in Taormina has distant views of Mount Etna to the north and is a “must visit.”

Sample a pasta and shrimp dish on the rooftop terrace at the Villa Carlotta in Taormina.

Punta Secca offers another chance to combine history with beach life.

LUIGI NIFOSI / SHUTTERSTOCK.COM

For simple local fare head down the hill to Ragusa’s La Capinera.

K. ROY ZERLOCH / SHUTTERSTOCK.COM

Under the Romans, the island was an important source of resources for the empire and a gateway to eastern conquest, and they too left many villas, temples and amphitheatres. During the Crusades, northern Europeans, on their way to liberate the Holy Land, occupied Sicily. The city of Messina was held briefly by England’s Richard the Lionheart and, over the next century, became an important exporter of products to markets in northern Italy, the Byzantine Empire and Egypt, only to decline.

The new millennium finds Sicily on a cultural upswing, this time fed by tourism. There are recently opened boutique hotels all over the island, a cornucopia of hip new restaurants and the most promising up-and-coming wine region in Italy. What’s more, Sicilians know how to eat. Fruits and vegetables, olive oil, cheeses and seafood are outstanding and bountiful. The mushrooms, the sauces, the pasta, the pastry! Oh my! It’s hard to get a bad meal anywhere in Italy and that goes double for Sicily.

To great dining, and important Greek, Roman, Arab and Christian sites, add the rugged beauty of the large island, three-quarters the size of Vancouver Island, including 3300-metre-high Mount Etna, one of the most active volcanoes on earth. Toss in fabulous beaches and a climate that’s more North African than European with balmy temperatures from March through November, and the question becomes: where to begin?

For these purposes, perhaps not where you’d expect — not Palermo. Instead, consider a meander down the east coast and either take in the island’s capital at the end or leave it for another visit. You’ll almost certainly want to return. The trip outlined here, down the Ionian Coast, requires only short drives and combines visiting key sites with beach time.

B.

egin your visit by flying to Catania. Stay more or less where you are by booking into a hotel overlooking the sea and slopes of Mount Etna. Antico Borgo Petralia (anticoborgopetralia.it; from €100 a night) is one of many boutique hotels in the area. There’s a pool, the food comes highly recommended, and the views of both sea and volcano are everything you could want. Spend a day exploring Etna on one of the many tours offered by Etnaround (etnaround. com; from €60) including trips by jeep, donkey and shank’s mare.

With Etna under your belt — and after sampling a glass or two of Etna Rosso, the region’s highly considered red — you’ll be ready to move on to the island’s best-known resort town, delightful Taormina, a 53 kilometre drive up the coast. With its medieval, twisting streets and sudden sea vistas, it’s long been popular with the English, including author D. H. Lawrence who penned his naughty novel Lady Chatterley’s Lover here.

JULY / AUGUST 2016 • Doctor’s

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TOM ROCHE / SHUTTERSTOCK.COM

ANDREAS ZERNDL / SHUTTERSTOCK.COM

Book a train ticket to busy Modica, Ragusa’s sister city, just 16 kilometres away.

In Roman times, Cicero called Syracuse “the greatest Greek city and the most beautiful” Get the lay of the land by visiting the spectacular third-century Greek amphitheatre with sea vistas to distant Mount Etna. Seriously consider a stay at the Villa Carlotta (hotelvillacarlottataormina.com; from €179 a night), which has been the home away from home for the better classes for eons. Elegant yet friendly, the service and food are among the best you’ll find anywhere. Rates vary widely depending on the season and are higher in September and October when you can pay around €250 a night. Given the loveliness of the setting though, you might even want to splurge to a terrace room. Explore the town, shop, eat, enjoy the cafés and take the cable car down to the beach at least once.

W

hen it’s time to leave Taormina, retrace your way down the coast through Catania and continue south for 60 kilometres to Syracuse.

In Roman times, Cicero called it “the greatest Greek city and the most beautiful.”

At its height, Syracuse was home to 300,000, including Archimedes and many other luminaries.

The Parco Archeologico features the dazzlingly white, 15,000-seat, fifth-century BCE Teatro Greco,

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Doctor’s Review • JULY / AUGUST 2016

an amphitheatre where Aeschylus staged his last tragedies including The Persians, his most renowned.

Over the ridge, the old stone quarries are beautiful, replete with lemon and orange trees. It was not always so. They housed over 7000 prisoners during the Athenian War. The Ear of Dionysius, a 23-metrehigh grotto, has such good acoustics that the tyrant was said to use them to eavesdrop on prisoners.

For a contrast of Roman and Greek styles, call in at the nearby third-century CE Anfiteatro Romano, a 140-metre-long amphitheatre where countless gladiators and wild beasts once fought and died. Leave time to take the bridge to the island of Ortigia where restaurants and cafés ribbon the waterfront.

With over 2500 years of history, there’s a lot to see, but start with the abundant market at the entrance to the island. You’ll be tempted to stock up on goodies you can cook yourself. If you have access to kitchen facilities offered in many rental apartments and Airbnbs great; if not, look for Burgio (fratelliburgio.com) on the edge of the market, a sort of upscale, open-air grocery store and restaurant in one.

Burgio serves sandwiches, craft beer and local wine, and features flavourful small plates of cheese, fish, sausages and salamis with accompanying sauces.

Dessert on the Villa Carlotta hotel terrace in Taormina makes for a perfect, sweet ending any day.

Inspector Montalbano slept here in this very villa on the beach in Punta Secca and you can too.

Come to Syracuse’s Piazza del Duomo in the evening when the Doric columns of the cathedral are illuminated.

Or try restaurant DiVino Mare (divinomare.it) for grilled fish at affordable prices.

By now it’s likely getting dark so go back to town to the beautifully lit Piazza del Duomo and its Cathedral with its Doric columns once part of the Temple of Athena. After that, let your instincts be your guide.

Combining history and beaches is easy in Syracuse. The Musciara Siracusa Resort (siracusaresort. it; from €140 a night) is near the pier and has a small private beach inside the breakwater. The rooms are small, but elegant. The waterside terrace restaurant has an excellent menu. One thing to note: no kids under age 14.

T

ime to move deeper into the south and to the adjoining mountain towns of Ragusa and Modica, a short 129 kilometres away. The whole area was rebuilt under the Spanish in honey-coloured sandstone after the destruction of the 1693 earthquake. Ragusa and Modica offer visitors yet another helping of history. A train links the towns and, if you have time, plan to visit both.

Ragusa Ibla is a compact city with fully 14 UNESCO World Heritage buildings in less than one square kilometre. Visit the Cathedral of St. George, climb the stairs to the new town and take in the architecture at sunset from the terrace of the Church of Santa Lucia. As twilight falls, if you feel like splurging, dine at the superlative Duomo (cicciosultano.it), celebrated for its wine pairings. If you’re looking for simpler fare and are ready for a bit of adventure, set out down the hill to La Capinera

(ristorantelacapineraragusa.it) near the old train station.

The food, the view and the other diners will give you a sense of the real Sicily.

Modica, just 16 kilometres away, continues the theme. Set between steep hills, it’s a busy Sicilian city. Head for the tourist office on Corso Umberto.

Elegant buildings line the street and the museum is here as are dozens of cafés and shops selling Modica’s famous chocolate. Visitors typically use this as a starting point for exploring. Put on your walking shoes, the narrow streets climbing above are full of surprises, but steep.

To continue the sea and history combo, stay in the nearby village of Marina di Ragusa which has gorgeous beaches and lots of night life. The Miramare (hotelmiramareragusa.com; from €130 a night) is one of dozens of offerings. With 23 modern rooms, six with sea views, and an excellent restaurant, you won’t be disappointed, but book early — it’s a popular place especially in the warmer months which extend well into October.

But wait, why stay in Marina di Ragusa when you can sleep where Inspector Montalbano slept just a few kilometres farther down the coast in Punta Secca? La Casa Di Montalbano (bed-and-breakfast.it/ en/sicily/bb-la-casa-di-montalbano-la-dimora-delcommissario-punta-secca/628; from €90 a night, including breakfast) is right on the beach with wonderful water views and a breakfast that gets applause.

For more info on Sicily’s southeast, visit the Italian Tourist Board (italia.it/en/discover-italy/sicily.html) or the excellent site Italy Heaven (italyheaven.co.uk).

JULY / AUGUST 2016 • Doctor’s

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How the flip of a sombrero’s brim reveals if a Panamanian is looking for a fight — or a girlfriend

by Darrin DuFord

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Doctor’s Review • JULY / AUGUST 2016

GOLLIDAY STEVENS / FLICKR

Speaking

The Panamanian sombrero pintado features a round crown and slightly slanted brim that have the ability to change the hat’s shape.

— and since Panamanians tend to be partial to landmark navigation as opposed to being reliant on street names — the town was named after the house and the hats after the town.

Like any self-respecting Panamanian town, La Pintada is easily navigable owing to its central plaza, complete with requisite gazebo, benches and manicured grassy area. Fellow passengers on the bus had told me to look for the store run by Reinaldo Quiróz, La Pintada’s most famous hat maker.

The living-room-sized store faced the central plaza and was covered with a corrugated aluminum roof. Rows of sombreros — some with dyed black rings, others with dashed weaves, others simply the natural sandy colour of dried palm leaves — were attached to cords strung across the walls with clothespins.

“Hats are part of our culture,” Quiróz began when I asked him about the uses of the various hats he offered. Farmers usually buy two hats: a basic sombrero with a coarse weave and a large brim for work in the field; and another, the finer and more costly sombrero pintado for daily use.

“Sombreros were made in Panama over 200 years ago, before the arrival of Ecuadorian Panama

Hats,” Quiróz explained. He unclipped a hat and held it up, spinning it slowly, as if it were a jewel. “A Panamanian sombrero does not have indentations on the crown like an Ecuadorian Panama Hat. It is made of woven rings sewn together in a spiral,” he said as his finger followed the outline of the brim.

He explained that the materials are purely Panamanian: the black rings within the weave get their colour from natural dyes used by the Emberá and Wounaan Amerindians of Panama’s easternmost jungle provinces.

Ecuadorian Panama Hats have indentations in the crown that Panamanian sombreros do not.

RAFAL CICHAWA / SHUTTERSTOCK.COM

T

he Panamanian sombrero pintado took its name from the town of La Pintada, which used to boast the only painted (pintado) house in the area a century ago. Since the hats were woven here

JULY / AUGUST 2016 • Doctor’s

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Since human heads are oval, wearing the round hat distorts the crown, which in turn distorts the brim

P

anamanians have also discovered that their sombreros offer a versatility that most molded Ecuadorian Panama Hats do not, thanks to basic geometry.

The sombrero pintado’s round crown and slightly slanted brim have given Panamanians the ability to change the hat’s shape. Since human heads are oval, not round, the act of wearing the round hat distorts the crown, which in turn distorts the brim into a front and back flap. Each flap can be toggled up independently.

And not just for vanity. According to Quiróz, the bus drivers and fruit salesmen may be attempting to communicate their current temperament through their sombrero’s brim. He began decoding the head-bound language of El Interior by sliding on a sombrero pintado in a well-practiced motion and flipping up the front brim. He shook his fists and, while holding back a chuckle at his overemphasis, he said, “This style means that he is looking for a fight.” The angled-up accessory did not immediately register with me as an extension of angry posture, but I made a mental note to give such wearers a wide berth.

Both brims up? An economically-successful man. The front up and the entire hat tilted back?

You would be facing a strong worker since the extra tilt allows the wearer to wipe the sweat off his forehead.

And, like any language, this too has its regionalisms.

“There are several interpretations from different parts of the country,” Quiróz said, flipping up only the front flap. In Coclé, unlike other areas, this wearer may not be ready to throw punches, but instead may be keeping secrets and cannot be trusted.

A ladies’ man, for example. I surmised that both etymologies could share a common ancestor, one of manly overconfidence.

Any aspiring hat-flap interpreter must also consider that wearing only the back flap up holds its own ambiguous pitfall. “In the Azuero Peninsula, this style means that the wearer is looking for a girlfriend.” In Coclé, however, the same style indicates that the wearer is an intellectual. I wondered what confusion might occur if a proudly educated lad from Coclé travels south to the neighboring Azuero Peninsula. How would the women know whether he was displaying the sartorial equivalent of a Facebook relationship status update or harmlessly preparing to bombard them with boring literary references?

Hat flap etymology has also been known to evolve over time. Many years ago, Quiróz explained, when a man wanted to kiss his girlfriend, he would use his hat to conceal the tender moment. When both flaps were down, more of the action was hidden.

Today, wearing both flaps down currently holds a meaning that has morphed from the joy of a sneaky smoocher into a general mood of calmness and agreeability.

BLANKE VLA / WIKIMEDIA COMMONS

N Sombreros have been made in Panama for over 200 years and consist of woven rings that are sewn together in a spiral.

ear the end of the 19th century, the popularity of the Ecuadorian Panama Hat threatened to topple the actual Panamanian sombrero industry.

“Because of the great demand for Ecuadorian Panama Hats,” Quiróz explained, “the Panamanian government, around the year 1890, brought in artisans from Ecuador to teach Panamanians how to make the Ecuadorian Panama Hat.” It was a one-two punch: a foreign product had hijacked Panama’s cultural identity and local artisans were being told to manufacture foreign Ecuadorian hats as a replacement to their own sombreros.

At that time, Panama was still a far-flung and rebellious province of Colombia. But when Panama gained sovereignty in 1903, the artisans, vitalized by

Near the end of the 19th century, the popularity of the Ecuadorian Panama Hat threatened to topple the Panamanian sombrero industry.

FOTOS593 / SHUTTERSTOCK.COM

their independence, began to teach their pupils how to make sombreros pintados instead of Ecuadorian Panama Hats. “Thirty years later,” Quiróz added, a glowing smirk growing across his face, “classes on the fabrication of sombreros pintados were obligatory in the primary schools of the Coclé province.”

In 2011, the Panamanian National Assembly formally recognized the cultural and economic importance of the hat by declaring October 19 the Day of the Sombrero Pintado. An annual festival takes place in the town of La Pintada and includes the participation of weavers from the surrounding area of Coclé.

While Panamanian hat makers have confidently reinstated their sartorial heritage in their own country, the misleading name of the Ecuadorian-made Panama Hat is still causing trouble in Ecuador.

In a 2012 article in the Miami Herald International Edition, Alba Cabrera of the Ecuadorian Institute of Intellectual Property remarked, “In Ecuador it is prohibited to say ‘Panama Hat.’ Here, it is the Montecristi,” referring to the coastal town that produces many of the finest hats in the country. When I visited Ecuador in 2006, however, the hat vendors I’d spoken with still casually referred to their products as Panama Hats without any signs of unease.

Several tourism websites and online clothing retailers have also thrust themselves into the arena of thorny nomenclature by diplomatically referring to the accessory as the Ecuador Panama Hat. No matter what the hat is named, however, its popularity is on the rise. Ecuador’s hat makers reported that sales were up 25 percent in 2014 compared to the previous year. The trend would have been even steeper if it weren’t for the competition from cheaper, Chinese-made imitations, which some Ecuadorians refer to as “false Panamas” — a term the Panamanian sombrero weavers just might relish as fitting justice.

The weave on his hat was fine and smooth. Twelve, maybe fifteen vueltas. Both front and back flaps were up. He could have been alerting the bakery of his acute business sense. But I was more interested in how the hat stayed on his head, as my scientific side assured me that the upward flaps should provide lift.

I complimented him on his sombrero and asked him if he has had problems with Penonomé’s wind, a non-stop gusher of a breeze that gleefully joyrides down the slopes of the nearby mountains and into town. He nodded dismissively. How did he manage to keep it on his head? He probed me for a moment, freezing his pensive eyes on me, and then answered, “It’s the correct size.” had taken three steps out of Quiróz’s store when By that logic, I have never owned a hat of the the wind made off with my new sombrero pintacorrect size. I did not let that prevent me from wando. It didn’t matter how I adjusted the brim — as dering past the town’s quiet rows of colonial-era houses, the intellectual, the agreeable chap or the belligadmiring their stained and varnished doors that aperent hothead — the gusts tore it off just the peared as if they had just been constructed. The same and sent it rolling across La Pintada’s manihouses were lined up neatly, creating a wind tunnel. cured square again and again.

I kept one hand on my new Arroz con piña, or rice with hat and I was mildly disappineapple, was the drink of the pointed that there was no way day at the bakery near the to communicate frustration square. I was now in Penonoby means of brim manipulamé, the capital of the Coclé tion.

I was going to have cosmetic province, about 16 kilometres surgery until I noticed that the from La Pintada. I had just reExtract reprinted with permission. The doctor’s office was full of portraits turned to the counter for anothentire article appears on TravelersTales.

by Picasso. er $0.40 Styrofoam cup of arroz com and BestTravelWriting.com under — Rita Rudner con piña when a man in a light the title Speaking in Hats. It won the yellow guayabera and a sombreGold Award in the Travel and Shopping ro pintado sat down at an outCategory of the 10th Annual Solas Awards door table with his daughter. sponsored by Travelers’ Tales.

I

MEDICAL QUIPS

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Lemon scones with blackberries.

Pucker up Sweet and savoury recipes featuring your favourite citrus fruits recipes by

Carla Snyder

I

photos by

Nicole Franzen

t was a simple lemon bar that kick-started cookbook author Carla Snyder’s love affair with citrus fruits. Her obsession is easy to understand. When

it comes to dessert, the sweet-tart flavour is hard to beat, and all it takes is a quick zest and squeeze to achieve. Add the fact that lemons, and limes, oranges and grapefruits for that matter, are kitchen staples and one begins to wonder why we

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Doctor’s Review • JULY / AUGUST 2016

aren’t all eating a little sunshine in every meal, particularly when citrus juices can be added to savoury recipes too. One savoury snack from Snyder’s latest, Sweet and Tart (Chronicle Books), follows here as do a couple of her sweet treats.

LEMON SCONES WITH BLACKBERRIES You won’t feel guilty about making and eating these buttery, flaky scones.

They’re light and airy, and full of juicy blackberries with an addictively tart glaze — so good that you can’t eat only one.

2 c. (500 ml) unbleached all-purpose flour ¹⁄³ c. (80 ml) granulated sugar 2 tsp. (10 ml) baking powder 1 tsp. (5 ml) baking soda ¼ tsp. (1.25 ml) salt zest of 1 lemon, plus 1 tbsp. (15 ml) fresh lemon juice ½ c. (125 g) plus 2 tbsp. (30 g) unsalted butter, softened and cubed ²⁄³ c. (160 ml) buttermilk, plus 2 tbsp.

(30 ml) 3½ c. (875 ml) fresh blackberries 1 c. (250 ml) powdered sugar

Preheat the oven to 400°F (200°C). Line a baking sheet with parchment paper.

Combine the flour, granulated sugar, baking powder, baking soda, salt and lemon zest in a large bowl. Add the butter and rub it in with your fingers until the mixture resembles fine meal. Stir in the ²∕³ cup (160 ml) buttermilk and the blackberries just until combined.

Turn the dough out onto a lightly floured work surface and divide into two equal mounds. Sprinkle the top of each mound with a little flour and gently pat each into a disk about 6 inches (15 cm) in diameter. Cut each mound into six wedges.

Transfer the scones to the prepared baking sheet and brush the tops with the 2 tablespoons (30 ml) buttermilk.

Bake for 25 to 30 minutes or until golden brown and firm to the touch. Let cool slightly on the baking sheet on a wire rack.

Combine the powdered sugar and lemon juice in a small bowl and blend with a fork to make a glaze. Drizzle the glaze over the warm scones. (If the glaze is too thick to drizzle, add a few drops of lemon juice or water.)

Serve warm or at room temperature within a few hours after baking for the best flavour and texture. If you must make them ahead, let cool to room

temperature, transfer to freezer bags and store in the freezer for up to 2 months. Thaw at room temperature and rewarm in a 300°F (150°C) oven for 10 minutes. Makes 12 scones.

Tips: The trick to making light, flaky scones is to not overwork the dough. Rub the butter into the flour and then stir in the buttermilk just until the mixture is moistened fairly evenly.

If you keep stirring until uniformly wet, the scones will be dense, heavy and not nearly as delightful.

Freeze unbaked scones on parchment-lined baking sheets, then transfer the scones to freezer bags or wrap tightly in plastic wrap and freeze for up to 3 months. Thaw on parchment-lined baking sheets and bake as directed.

CHOCOLATEDIPPED CANDIED CITRUS PEEL Sure, candied citrus is delicious, but candied citrus with chocolate… now you’re talking.

And sure, you can buy candied citrus peel. But it will never be as good as the ones you can make at home. These little citrus strips make a perfect ending to a meal when served with shortbread cookies and strong coffee. But they are just as good diced into biscotti or used as a garnish on a simple lemon cake.

3 lemons, 2 oranges or 1 grapefruit 2 c. (500 ml) sugar

Chocolate-dipped candied citrus peel.

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½ c. (375 ml) water 1 6 oz. (170 g) high-quality white or dark chocolate, chopped into small pieces

Coat a wire rack with nonstick cooking spray and place it on a baking sheet.

Line another baking sheet with parchment paper.

Make four slits along the length of each citrus fruit from end to end, cutting through the peel, but not the flesh.

Using your fingers, gently peel the skin from the fruit and reserve the fruit for another use. Cut the peel into thin strips, about a ¼ inch (6 mm) wide.

Put the peel in a medium saucepan and add water to cover. Bring to a boil over medium-high heat, turn the heat to low and simmer for 15 minutes.

Drain, cover with fresh water and repeat.

Drain and rinse the peel.

Combine 1½ cups (375 ml) of the sugar and the 1½ cups (375 ml) water in the same pan over medium-high heat and bring to a boil, stirring occasionally. Once the sugar is dissolved, add the drained peel, turn the heat to low and simmer for about 40 minutes or until the peel is very tender and looks translucent.

Scoop the peel from the syrup with a fork and arrange in a single layer on the prepared rack. Let dry for about 30 minutes then dredge the peel in the remaining ½ cup (125 ml) sugar in a shallow bowl (this helps to prevent the peel strips from sticking to each other).

Place the peel in a single layer on the parchment-lined baking sheet and let dry overnight.

Melt 5 oz. (150 g) of the chocolate in a stainless-steel bowl set over a pan of simmering water. Be sure that the bottom of the bowl doesn’t touch the water and don’t walk away from it; just stand there and stir. When the chocolate is half melted, remove the bowl from the pan of water and continue to stir on the countertop. It will begin to cool but the chocolate will continue to melt. Once com­pletely melted, stir in the remaining 1 ounce (30 g) chocolate, then continue stirring gently until the chocolate is cool and no longer melts. Remove any unmelted pieces.

Line another baking sheet with parchment paper. Dip the peel strips halfway into the chocolate and arrange

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Lemony pesto-goat cheese dip.

in a single layer on the second prepared baking sheet. Let stand for about 1 hour or until the chocolate is firm.

Store in an airtight container, separating the layers with parch­ment paper, at room temperature for up to 3 weeks.

Makes about 60 pieces.

LEMONY PESTOGOAT CHEESE DIP Tangy goat cheese is a natural with lemon and pesto. And who doesn’t love goat cheese? You’ll come to rely on this creamy dip more often than you’ll care to admit. ¹⁄³ c. (80 ml) pine nuts 8 oz. (230 g) goat cheese, softened ½ c. (125 ml) plain whole milk Greek yogurt 2 tbsp. (30 ml) lemony basil pesto (recipe follows) zest and juice of 1 lemon ½ c. (125 ml) diced roasted red bell pepper assorted raw vegetables for serving,

such as carrots, celery, fennel, broccoli, and red and yellow bell pepper strips lemon, pepper and asiago crackers (recipe follows) or your favorite store-bought crackers for serving

In a microwave-safe bowl, toast the pine nuts for 30 sec­onds. Stir and microwave for another 30 seconds. Stir again and if the nuts aren’t oily and fragrant, microwave for another 30 seconds. Let cool. Alternatively, toast the nuts in a skillet over medium heat, tossing them every now and then, about 3 minutes.

Combine the goat cheese, yogurt, pesto, lemon zest and lemon juice in the bowl of a food processor and process until well blended. Alternatively, combine the ingredients in a large bowl and stir with a fork. (Add more yogurt to thin the dip, if desired.) Store, covered, in the refrigerator for up to 2 days.

Transfer the dip to a serving bowl, and top with the roasted red bell pepper and toasted pine nuts. Serve with the vegetables and crackers.

Makes about 1½ cups (375 ml).

Lemony basil pesto Pesto is “summer in a jar.” This lemony version just shouts “party!” It’s delicious spread on crostini for an easy appetizer or added to soups and stews.

2 garlic cloves 1 c. (250 ml) walnuts salt zest of 2 lemons, plus 2 tbsp. (30 ml) fresh lemon juice 3 c. (750 ml) fresh basil leaves, stemmed ½ c. (125 ml) extra-virgin olive oil, plus more for drizzling 1 c. (250 ml) grated Parmesan cheese freshly ground pepper

Drop the garlic into the bowl of a food processor while the processor is running. Turn off the machine, add the walnuts and 1 teaspoon (5 ml) salt, and pulse until finely ground. Add the lemon zest and basil, and pulse until still a little chunky. Add the olive oil, lemon juice and Parmesan, and season with pepper. Pulse again until the desired texture is reached.

Taste and adjust the seasoning if necessary with salt and pepper.

Transfer to storage containers and drizzle a little olive oil on top to keep the pesto green. Store in the refrigerator for up to 2 weeks or freeze for up to 3 months.

Makes about 1½ cups (375 ml).

Lemon, pepper, and Asiago crackers It might seem crazy to make your own crackers, but these crispy shingles are incredibly beguiling with their rustic, homemade charm. Pair them with local goat cheese and olives or serve them with a dip, but nothing firmer than hummus because the crackers are fragile.

1¾ c. (430 ml) unbleached all-purpose flour ¹⁄³ c. (80 ml) sugar 1 tsp. (5 ml) freshly ground pepper ½ tsp. (2.5 ml) salt ½ tsp. (2.5 ml) baking powder ½ c. (125 g) cold unsalted butter, cubed

½ c. (125 ml) grated Asiago cheese 1 large egg zest of 2 lemons, plus 1 tbsp. (15 ml) fresh lemon juice 1 tbsp. (15 ml) whole milk specialty sea salt such as Maldon, pink Himalayan or black Hawaiian 3 tbsp. (45 ml) black sesame seeds (optional)

Preheat the oven to 350°F (180°C).

Line four baking sheets with parchment paper.

Combine the flour, sugar, pepper, salt and baking powder in the bowl of a food processor, and pulse to com­bine.

Add the butter and Asiago, and process until they are cut into the flour and the mixture resembles coarse meal, about 20 pulses. Add the egg, lemon zest and lemon juice, and process until the dough comes together in a ball.

Turn the dough out onto a lightly floured work surface and shape into a log 12 inches (30.5 cm) long. Cut into 12 pieces. Keep the dough covered with plastic wrap so it doesn’t dry out.

Flatten out one piece of dough on the work surface. Using a pasta roller, feed the dough through the rollers set on the widest setting (the dough will become very long). Place on one of the prepared baking sheets. Repeat to roll out the remaining dough, refrigerating each baking sheet as it fills up. (You can also roll out the dough using a rolling pin, but the crackers won’t be quite as thin and crispy.)

Brush the milk over the tops of the dough and sprinkle lightly with sea salt and the sesame seeds (if using). Bake for 20 minutes or until the crackers are firm and brown. If you are baking more than one sheet at a time, rotate them

MEDICAL QUIPS I went to the doctor and he said I had acute appendicitis, and I said compared to who?

— Jay London

180 degrees about halfway through the baking time. Let cool on the baking sheets on wire racks. The crackers will crisp up as they cool. Break the crackers into the desired size. Store in sealable plastic bags at room temperature for up to 1 day. Makes 12 4-by-12-inch (10-by-30.5-cm) crackers.

Recipes and photos from Sweet and Tart: 70 Irresistible Recipes with Citrus (Chronicle Books, 2015).

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Contraindications: • Patients with severe hypersensitivity to milk proteins.

• In the primary treatment of status asthmaticus or other acute episodes of asthma.

Most Serious Warnings and Precautions: • ASTHMA-RELATED DEATH: Long-acting beta2-adrenergic agonists (LABA), such as vilanterol, increase the risk of asthma-related death. Physicians should only prescribe BREO® ELLIPTA® for patients not adequately controlled on a long-term asthma control medication, such as an inhaled corticosteroid, or whose disease severity clearly warrants initiation of treatment with both an inhaled corticosteroid and a LABA. Once asthma control is achieved and maintained, assess the patient at regular intervals and do not use BREO® ELLIPTA® for patients whose asthma can be adequately controlled on low- or medium-dose inhaled corticosteroids.

Other Relevant Warnings and Precautions: • BREO® ELLIPTA® should not be used for the relief of acute symptoms of asthma (i.e., as rescue therapy for the treatment of acute episodes of bronchospasm).

• Patients who have been taking a rapid onset, short duration, inhaled bronchodilator on a regular basis (e.g., q.i.d) should be instructed to discontinue the regular use of these drugs and use them only for symptomatic relief if they develop acute symptoms while taking BREO® ELLIPTA®.

• BREO® ELLIPTA® should not be initiated in patients with acutely deteriorating asthma, which may be a life-threatening condition.

• Exacerbations may occur during treatment. Patients should be advised to continue treatment and seek medical advice if symptoms remain uncontrolled or worsen after initiation of therapy.

• BREO® ELLIPTA® should not be used more often than recommended, at higher doses than recommended, or in conjunction with other medicines containing a LABA, as an overdose may result.

• Caution in patients with cardiovascular disease: vilanterol can produce clinically significant cardiovascular effects in some patients as measured by an increase in pulse rate, systolic or diastolic blood pressure, or cardiac arrhythmias such as supraventricular tachycardia and extrasystoles. In healthy subjects receiving steady-state treatment of up to 4 times the recommended dose of vilanterol (representing a 10-fold higher systemic exposure than seen in patients with asthma) inhaled fluticasone furoate/vilanterol was associated with dose-dependent increases in heart rate and QTcF prolongation. Use with caution in patients with severe cardiovascular disease, especially coronary insufficiency, cardiac arrhythmias (including tachyarrhythmias), hypertension, 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.

• Effects on Ear/Nose/Throat: localized infections of the mouth and pharynx with Candida albicans have occurred.

• Endocrine and Metabolic effects: possible systemic effects include Cushing’s syndrome; Cushingoid features; HPA axis suppression; growth retardation in children and adolescents; decrease in bone mineral density.

• Hypercorticism and adrenal suppression (including adrenal crisis) may appear in a small number of patients who are sensitive to these effects.

• Adrenal insufficiency: particular care should be taken in patients transferred from systemically active corticosteroids because deaths due to adrenal insufficiency have occurred during and after transfer to less systemically available inhaled corticosteroids.

• Bone Effects: decreases in BMD have been observed with long-term administration of products containing inhaled corticosteroids.

• Effect on Growth: orally inhaled corticosteroids may cause a reduction in growth velocity when administered to children and adolescents.

• Monitoring recommendations: serum potassium levels should be monitored in patients predisposed to low levels of serum potassium. Due to the hyperglycemic effect observed with other beta-agonists, additional blood glucose monitoring is recommended in diabetic patients. Monitoring of bone and ocular effects (cataract and glaucoma) should be considered in patients receiving maintenance therapy.

Patients with hepatic impairment should be monitored for corticosteroid effects due to potentially increased systemic exposure of fluticasone furoate.

• Use with caution in patients with convulsive disorders or thyrotoxicosis and in those who are unusually responsive to sympathomimetic amines.

• Hematologic effects: may present with systemic eosinophilic conditions, with some patients presenting clinical features of vasculitis consistent with Churg-Strauss syndrome.

Physicians should be alerted to eosinophilia, vasculitic rash, worsening pulmonary symptoms, cardiac complications, and/or neuropathy presenting in their patients.

• Hypersensitivity effects: immediate hypersensitivity reactions have occurred after administration, and patients should not be re-challenged with BREO® ELLIPTA® if it is identified as the cause of the reaction. There have been reports of anaphylactic reactions in patients with severe milk protein allergy with other inhaled dry powder drug products containing lactose.

• Immune effects: greater susceptibility to infections. Administer with caution and only if necessary in patients with active or quiescent tuberculosis infections of the respiratory tract; chronic or untreated infections such as systemic fungal, bacterial, viral, or parasitic; or ocular herpes simplex. Chickenpox and measles can have a more serious or even fatal course in susceptible patients using corticosteroids. In such patients who have not had these diseases or been properly immunized, particular care should be taken to avoid exposure.

• Ophthalmologic effects: glaucoma, increased intraocular pressure, and cataracts.

Close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma, and/or cataracts.

• Respiratory effects: paradoxical bronchospasm may occur with an immediate increase in wheezing after dosing. This should be treated immediately with a rapid onset, short duration inhaled bronchodilator. BREO® ELLIPTA® should also be discontinued immediately, the patient assessed, and alternative therapy instituted if necessary. The incidence of pneumonia in patients with asthma was uncommon. Patients with asthma taking BREO® ELLIPTA® 200/25 mcg may be at an increased risk of pneumonia compared with those receiving BREO® ELLIPTA® 100/25 mcg or placebo.

• Drug interactions: caution should be exercised when considering coadministration with inhibitors of cytochrome P450 3A4; inhibitors of P-glycoprotein (P-gp); sympathomimetic agents; beta-adrenergic receptor blocking agents; non-potassium sparing diuretics (i.e., loop or thiazide diuretics); drugs that prolong the QTc interval (e.g., monoamine oxidase inhibitors and tricyclic antidepressants); xanthine derivatives; and acetylsalicylic acid.

Adverse Events: Adverse reactions reported at a frequency of ≥1% and more common than placebo in one clinical study of BREO® ELLIPTA® 100/25 mcg included: nasopharyngitis, oral candidiasis, upper respiratory tract infection, headache, dysphonia, oropharyngeal pain, epistaxis. Adverse reactions reported at a frequency of ≥1% in another clinical study of BREO® ELLIPTA® 200/25 mcg and BREO® ELLIPTA® 100/25 mcg also included the following additional adverse reactions: influenza, bronchitis, sinusitis, respiratory tract infection, pharyngitis, cough, rhinitis allergic, abdominal pain upper, diarrhea, toothache, back pain, pyrexia, muscle strain.

Dosage and Method of Administration: The recommended dose of BREO® ELLIPTA® 100/25 mcg or 200/25 mcg is one oral inhalation once daily, administered at the same time every day (morning or evening).

Do not use more than once every 24 hours. The starting dose is based on patients’ asthma severity. For patients previously treated with low- to mid-dose corticosteroid-containing treatment, BREO® ELLIPTA® 100/25 mcg should be considered. For patients previously treated with mid- to high-dose corticosteroid-containing treatment, BREO® ELLIPTA® 200/25 mcg should be considered. After inhalation, patients should rinse their mouth with water (without swallowing). If a dose is missed, the patient should be instructed not to take an extra dose, and to take the next dose when it is due.

Dosing Considerations: • For optimum benefit, advise patients that BREO® ELLIPTA® must be used regularly, even when asymptomatic.

• Once asthma control is achieved and maintained, assess the patient at regular intervals and do not use BREO® ELLIPTA® for patients whose asthma can be adequately controlled on low-or medium-dose inhaled corticosteroids.

• No dosage adjustment is required in patients over 65 years of age, or in patients with renal or mild hepatic impairment.

• Caution should be exercised when dosing patients with hepatic impairment as they may be more at risk of systemic adverse reactions associated with corticosteroids.

Patients should be monitored for corticosteroid-related side effect. For patients with moderate to severe hepatic impairment, the maximum daily dose is 100/25 mcg.

For More Information: Please consult the Product Monograph at http://gsk.ca/breo/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.

References: 1. BREO® ELLIPTA® Product Monograph, GlaxoSmithKline Inc., August 26, 2015. 2. Data on file HZA106827.

3. Data on file HZA106829.

Member of Innovative Medicines Canada BREO and ELLIPTA are registered trademarks of Glaxo Group Limited, used under license by GlaxoSmithKline Inc. BREO® ELLIPTA® was developed in collaboration with Theravance, Inc. © 2016 GlaxoSmithKline Inc. All rights reserved.

01258 01/16

AN ICS/LABA COMBINATION

INTRODUCING AN ASTHMA TREATMENT SHOWN TO IMPROVE LUNG FUNCTION (FEV1)

DAY & NIGHT

BREO® ELLIPTA® 100/25 mcg provided improvements in FEV1 vs. placebo that were sustained over 24 hours at week 12, as demonstrated by serial FEV1 measurements taken at 5, 15, and 30 minutes and 1, 2, 3, 4, 5, 12, 16, 20, 23, and 24 hours.1,2*†

BREO® ELLIPTA® 200/25 mcg demonstrated improvements in FEV1 vs. an ICS (fluticasone furoate 200 mcg) that were sustained over 24 hours at week 24, as demonstrated by serial FEV1 measurements taken at 5, 15, and 30 minutes and 1, 2, 3, 4, 5, 12, 16, 20, 23, and 24 hours.1,3‡§

BREO® ELLIPTA® (fluticasone furoate/vilanterol) 100/25 mcg and BREO® ELLIPTA® 200/25 mcg are indicated for the once-daily maintenance treatment of asthma in patients aged 18 years and older with reversible obstructive airways disease.

BREO® ELLIPTA® is not indicated for patients whose asthma can be managed by occasional use of a rapid onset, short duration, inhaled beta2-agonist or for patients whose asthma can be successfully managed by inhaled corticosteroids along with occasional use of a rapid onset, short duration, inhaled beta2-agonist.

BREO® ELLIPTA® is not indicated for the relief of acute bronchospasm. BREO® ELLIPTA® 200/25 mcg is not indicated for COPD. ICS=inhaled corticosteroid; LABA=long-acting beta2-adrenergic agonist * A 12-week treatment, multicenter, randomized, double-blind, placebo-controlled, parallel group study to compare the efficacy and safety of BREO® ELLIPTA® 100/25 mcg, fluticasone furoate (FF) 100 mcg, and placebo administered once daily in the evening in subjects with persistent bronchial asthma (N=609). † ITT population, FEV1 data (mL) of BREO® ELLIPTA® vs. placebo, respectively: 5min: 495 vs. 224, 15min: 516 vs. 267, 30min: 530 vs. 252, 1hr: 546 vs. 271, 2hr: 561 vs. 264, 3hr: 538 vs. 216, 4hr: 537 vs. 212, 5hr: 536 vs. 222, 12hr: 494 vs. 126, 16hr: 502 vs. 245, 20hr: 525 vs. 228, 23hr: 517 vs. 237, 24hr: 508 vs. 260. ‡ A 24-week treatment, multicenter, randomized, double-blind, parallel group study to compare the efficacy and safety of BREO® ELLIPTA® 200/25 mcg administered once daily each evening with FF 200 mcg administered once daily each evening and fluticasone propionate (FP) 500 mcg administered twice daily in subjects with persistent asthma (N=586). § ITT population, FEV1 data (mL) of BREO® ELLIPTA® vs. FF 200 mcg, respectively: 5min: 465 vs. 326, 15min: 466 vs. 338, 30min: 472 vs. 348, 1hr: 478 vs. 343, 2hr: 505 vs. 343, 3hr: 483 vs. 340, 4hr: 478 vs. 343, 5hr: 487 vs. 351, 12hr: 441 vs. 274, 16hr: 470 vs. 322, 20hr: 454 vs. 335, 23hr: 431 vs. 371, 24hr: 446 vs. 372.

Treating IBS-C? Consider CONSTELLA® CONSTELLA® patients showed significant improvement in:

• Abdominal pain

• Bloating • Constipation2

Abdominal pain2 AT WEEK 12 38.9% had ≥30% reduction in abdominal pain for at least 9/first 12 weeks vs. 19.6% placebo (p<0.0001)

(Trial 2, abdominal pain responder, ≥30% reduction from baseline)

Bloating2,3† AT WEEK 12 29% improvement in abdominal bloating from baseline vs. 15% placebo (p<0.0001)

(Trial 2, secondary endpoint, mean change vs. baseline) Baseline: CONSTELLA® 6.6, placebo 6.5. Mean weeks 1-12: CONSTELLA® 4.7, placebo 5.4, 11-point scale.

Spontaneous bowel movements (SBMs)2 67% had an SBM within 24 hours of their first dose vs. 42% placebo (p<0.0001) (Trials 1 and 2, pooled results, secondary endpoint)

Study parameters are available at http://www.actavis.ca/specialty/products/constella

The only prescription medication indicated in Canada for IBS-C in adults1* Visit ConstellaMD.ca to learn more Indications and clinical use: CONSTELLA® (linaclotide) is indicated for the treatment of irritable bowel syndrome with constipation (IBS-C) and chronic idiopathic constipation (CIC) in adults.

Clinical studies of CONSTELLA® did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.

CONSTELLA® is contraindicated in children under 6 years of age and is not recommended for use in children between 6 and 18 years of age as the safety and efficacy of CONSTELLA® in pediatric patients have not been established.

Contraindications: • Pediatric patients under 6 years of age • Patients with known or suspected mechanical gastrointestinal obstruction Most serious warnings and precautions: Children: Not recommended in children between 6 and 18 years of age

Other relevant warnings and precautions: • Diarrhea most common adverse reaction; may cause serious diarrhea • Use in pregnant women only if the potential benefit justifies the potential risk to the fetus • Caution should be exercised when CONSTELLA® is administered to nursing women For more information: Please consult the Product Monograph at www.actavis.ca/NR/ rdonlyres/94008767-D103-460E-B854-766C324A3CE8/0/CONSTELLA_ ProductMonograph.pdf for important information relating to adverse reactions, food interactions and dosing information not discussed in this piece.

The Product Monograph is also available by calling 1-855-892-8766.

IBS-C=irritable bowel syndrome with constipation * Comparative clinical significance has not been established. † Scores self-evaluated on an 11-point numerical rating scale (0=none, 10=very severe).3 References: 1. Data on file, Allergan Inc., August 26, 2015. 2. CONSTELLA® (linaclotide) Product Monograph, Forest Laboratories Canada Inc., May 12, 2014. 3. Data on file, Forest Laboratories Canada Inc.

CONSTELLA® is a registered trademark of Ironwood Pharmaceuticals, Inc., used under license by Actavis Specialty Pharmaceuticals Co. © 2016 Allergan. All rights reserved.

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