June 2015

Niagara-on-the-Lake

MEDICINE ON THE MOVE

delights

Bolivian high desert

adventure

Los Cabos golf: two big new

courses

CANADIAN PUBLICATIONS MAIL SALES PRODUCT AGREEMENT No. 40063504

JUNE 2015

Modern Jewish cooking

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

PAGE 33

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

F O R B O DY * A N D S C A L P PS O R I A SI S , CO N SI D E R D OVO B E T ® G E L

A Corticosteroid plus Vitamin D Analogue in one formulation.

Providing a dual mechanism of action†: anti-inflammatory properties and suppresses keratinocyte proliferation Dovobet® Gel (calcipotriol + betamethasone dipropionate) is indicated for the topical treatment of:1 • moderate to severe scalp psoriasis vulgaris in patients 18 years and older for up to 4 weeks • mild to moderate plaque psoriasis vulgaris on the body in patients 18 years and older for up to 8 weeks Contraindications • Disorders of calcium metabolism • Viral skin lesions; fungal, bacterial, parasitic skin infections; skin manifestations related to tuberculosis or syphilis • Perioral dermatitis • Skin atrophy or striae • Fragility of skin veins • Ichthyosis • Acne vulgaris, acne rosacea or rosacea • Ulcers and wounds • Perianal and genital pruritus • Guttate, erythrodermic, exfoliative and pustular psoriasis • Severe renal insufficiency • Severe hepatic disorders • Ophthalmic use

Relevant Warnings & Precautions • Should not be used on the face, axillae, flexures, groin or genitals • Skin AE risk: Application on large areas of damaged skin, in skin folds, or under occlusive dressings should be avoided • Prolonged use of corticosteroid containing preparations may produce striae or atrophy of the skin or subcutaneous tissues

• Post-treatment medical supervision recommended related to the risk of pustular psoriasis or rebound psoriasis when discontinuing corticosteroids after prolonged periods of use • Hypercalcaemia and hypercalciuria may occur if the maximum daily dose (15 g), maximum weekly dose (100 g), or maximum treated body surface area (30%) is exceeded • Monitoring recommendation: baseline and at other suitable intervals for serum calcium levels • Calcipotriol when used in combination with ultraviolet radiation (UVR) may enhance the known skin carcinogenic effect of UVR • Risk of enhanced skin carcinogenic effect with exposure to ultraviolet radiation. Excessive exposure to both natural and artificial sunlight should be avoided.

• May cause eye irritation. Avoid contact with the eyes or conjunctiva • Avoid concomitant treatment with other corticosteroids • Monitoring recommendation for HPA axis suppression related to the systemic absorption of topical corticosteroids • AE risks with systemic absorption of topical corticosteroids: Manifestations of Cushing’s syndrome, effects on the metabolic control of diabetes mellitus and unmasking of latent diabetes mellitus • Dermatitis AE risk • Not recommended for use in pregnant and nursing women

*Should not be used on the face, axillae, flexures, groin or genitals. †Clinical significance unknown.

Adverse Reactions • Most common was pruritus (0.6% body and 2.3% scalp) • Others, occurring in ≥ 1% of patients Body: application site pain (0.4%) • Others, occurring in ≥ 1% of patients Scalp: headache (0.5%), skin irritation (0.5%), alopecia (0.4%), and erythema (0.4%)

For More Information Please consult the product monograph at www.leopharma.ca/dovobetgel_pm 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 contacting LEO Pharma Medical Information at 1-800-263-4218.

®Registered trademark of LEO Pharma A/S used under license and distributed by LEO Pharma Inc., 123 Commerce Valley Dr. E., Suite 400, Thornhill, Ontario L3T 7W8 1. Dovobet® Gel product monograph. LEO Pharma Inc. July 3, 2013.

www.leo-pharma.ca

DOV-007-15E

My Saguenay roots “My mother taught school in a small town in the Saguenay.”

DENIS ROGER / SHUTTERSTOCK.COM

My father grew up in Quebec City. He put himself through school working weekends at the reception desk at the Château Frontenac, but when he graduated, he couldn’t find full-time work.

As an enterprising young man who liked to read, he established a door-todoor lending library. He started with books he’d begged and borrowed, put them in a cart and went up one street and down the next offering his wares. It cost a nickel a book for a week. As a member, you could request specific titles and offer books you’d read to other patrons.

The service was popular and he ran it for 18 months before he found a job at paper maker Price Brothers in Riverbend, a company town in the Saguenay-LacSaint-Jean region of the province. There was only one way to get there: a 200-kilometre bus ride over a rough road through what is now Parc des Laurentides. He didn’t care for the commute but he recognized the grandeur and beauty of the landscape and, to cap it off, he met a nice woman who taught school in the small town. He embraced life in the area, so to speak. They married a few years later so, in some sense, I owe my origins to the romance of the Saguenay region. It’s celebrated in this issue in Hidden glories of the Saguenay by writer and photographer Gary Crallé, which starts on page 26.

Gary is an Ontarian and he brings a fresh eye to this part of Quebec that is very popular within the province but less visited by outsiders. The centerpiece is the magnificent Saguenay fjord, a 105-kilometre-long waterway with an average depth of 210 metres bordered by 150-metre cliffs. Spectacular! As is the kayaking, whale watching, hiking and food and drink in the many watering holes along the way.

Give it a read, you may have found the perfect place for your next travel adventure.

This issue isn’t lacking in adventure. Another must-read is Bolivia’s Outback, page 34. Until recently the high desert that runs all the way into Chile was only accessible to those who trekked in carrying their supplies. An enterprising local firm now offers an easier way: a five-day minibus tour with hot meals and comfortable if rudimentary accommodation along the way.

If a golfing adventure is more your style, you’ll want to read about the new Tiger Woods and Jack Nicklaus’s courses in Los Cabos, Mexico, page 42.

Summertime! Whatever you do, get out and enjoy it as much as you can.

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JUNE 2015 • Doctor’s

Review

1

For your adult patients with type 2 diabetes

Equipped for glycemic control.

Trajenta® is indicated in adult patients with type 2 diabetes mellitus (T2DM) to improve glycemic control.

• Monotherapy: In conjunction with diet and exercise in patients for whom metformin is inappropriate due to contraindications or intolerance.

• Combination therapy: • With metformin when diet and exercise plus metformin alone do not provide adequate glycemic control.

• With a sulfonylurea when diet and exercise plus a sulfonylurea alone do not provide adequate glycemic control.

• With metformin and a sulfonylurea when diet and exercise plus metformin and a sulfonylurea do not provide adequate glycemic control.

Please refer to the product monograph at www.TrajentaPM.ca for important information relating to contraindications, warnings, precautions, adverse events, drug interactions, dosing and conditions of clinical use. The product monograph is also available by calling 1-800-263-5103 ext. 84633.

Jentadueto™ (linagliptin/metformin hydrochloride) is indicated as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus when treatment with both linagliptin and metformin is appropriate, in patients inadequately controlled on metformin alone or in patients already being treated and well controlled with the free combination of linagliptin and metformin.

Jentadueto™ is also indicated in combination with a sulfonylurea (i.e., triple combination therapy) as an adjunct to diet and exercise to improve glycemic control in adult patients with type 2 diabetes mellitus inadequately controlled on metformin and a sulfonylurea.

Please refer to the product monograph at www.JentaduetoPM.ca for contraindications, warnings, precautions, adverse reactions, drug interactions, dosing and conditions of clinical use. The product monograph is also available by calling 1-800-263-5103 ext. 84633.

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

BITRJ00110 CATRJ00110

GORILLAIMAGES / SHUTTERSTOCK.COM

JUNE 2015

26 38 34

features 26

Hidden glories of the Saguenay 12 things to see and do along Quebec’s spectacular fjord

by Gary Crallé

30

Niagara-on-the-Lake’s flowers and other joys Why Ontario’s wine country is a little Garden of Eden

by David Elkins

34

49

In search of The Scream A family trip through Oslo on Edvard Munch’s trail

by Chris Epting

53

A modern Jewish nosh Spinach-matzo lasagna and more veggie recipes for a kosher kitchen

by Leah Koenig

Bolivia’s outback Five days of sun and survival in the desert on the road to Chile

by Margo Pfeiff

42

Two big new Los Cabos courses Jack Nicklaus and Tiger Woods go head-to-head in Mexico’s Baja

by Anita Draycott

Coming in

July/August

• Indulge in Santa Fe’s Indian Market, the annual blowout celebrating Southwest culture • Birding in Nebraska: sandhill cranes, white pelicans and a whole lot more • Meet Swaraj Kumar Banerjee, the “Rajah of Darjeeling Tea” • Hit the Pilsner Trail in the Czech Republic • Physician suicide: a history and the road to wellness

42

JUNE 2015 • Doctor’s

Review

3

THE VALUE OF OUR SIGNATURE At Pfizer we are committed to providing patients with medication that always meets our high standards.

Only CELEBREX is

Signed by Pfizer

Now your patients can save on original CELEBREX — the #1 prescribed NSAID in Canada.1 It’s easy! First, direct them to www.Celebrex.ca (or to call 1-866-794-3574) for information on how to save with Pfizer’s payment assistance program.

And then remind them to ask for CELEBREX by name!

Get your CELEBREX patients to sign up for savings

CELEBREX is indicated for relief of symptoms associated with Osteoarthritis, adult Rheumatoid Arthritis, and Ankylosing Spondylitis.

CELEBREX is also indicated for the short-term (≤7 days) management of moderate to severe acute pain in adults in conditions such as the following: musculoskeletal and/or soft tissue trauma including sprains; post-operative orthopaedic; pain following dental extraction.

Please consult the product monograph at http://www.pfizer.ca/en/our_products/products/monograph/125 for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece. The product monograph is also available by calling 1-800-463-6001.

1. IMS data, January 2014 – December 2014, NSAID Market, monthly data, prescriptions

contents JUNE 2015

9

regulars 7

15

LETTERS Wellness therapies

9

PRACTICAL TRAVELLER Mexico’s clothing and culture at the ROM in Toronto, NYC’s new One World Observatory plus why airplane seats are about to get smaller

by Camille Chin

13

GADGETS Canon’s new smartphone-friendly PowerShot SX600 HS

by Roger White

15

TOP 25 The biggest medical meetings happening in November

18 18

HISTORY OF MEDICINE The autistic savants’ role in early diagnosis

by Rose Foster

22

IBS KEYPOINTS Stressed out and stuffed up: a case study

by Dr Gabor Kandel

25

DEPRESSION KEYPOINTS Managing mental illness in the workplace

by Mairi MacKinnon

13

56

PHOTO FINISH Buried treasure

by Dr Daniel Ngui

JUNE 2015 • Doctor’s

Review

5

Covered in 9 out of 10 provinces with Special Authorization† Are your OAB patients on the verge of experiencing an accident?

TURN TO

Demonstrated EFFICACY in OAB • Demonstrated superiority in treating UUI episodes/24 hours with TOVIAZ 8 mg vs. tolterodine ER 4 mg in 2 head-to-head trials at Week 121,2‡§ – Winsorized mean changes from baseline • Study 1: -1.6 placebo, -1.7 tolterodine ER, and -2.0 TOVIAZ (p=0.0072 TOVIAZ vs. tolterodine ER)1‡ • Study 2: -1.5 placebo, -1.6 tolterodine ER, and -1.7 TOVIAZ (p=0.017 TOVIAZ vs. tolterodine ER)2§

Demonstrated EFFICACY and study AE profile in ELDERLY OAB patients • In ELDERLY OAB patients (VES-13 score of ≥3): TOVIAZ significantly improved urge urinary incontinence episodes/24 hrs vs. placebo at Week 123¶ – LS mean change from baseline: -2.20 placebo (n=250) and -2.84 TOVIAZ (n=256, p=0.002)

• Most frequently reported adverse events were dry mouth (23.5% TOVIAZ) and constipation (11.1% TOVIAZ)3

Demonstrated SAFETY profile • In pivotal trials, the most common adverse events ≥5% were dry mouth (18.8% 4 mg and 34.6% 8 mg) and constipation (4.2% 4 mg and 6.0% 8 mg)4 ® Pfizer Inc., used under license.

TOVIAZ ® C.P. Pharmaceuticals International C.V., owner/ Pfizer Canada Inc., Licensee © 2014 Pfizer Canada Inc., Kirkland, Quebec H9J 2M5

No overall differences in safety and efficacy were observed between patients <65 years and those ≥65 years in the pivotal studies; however, the incidence of antimuscarinic adverse events was higher in patients ≥75 years as compared to younger patients.2 Indication and Clinical Use: TOVIAZ is indicated for the treatment of patients with overactive bladder with symptoms of urinary frequency, urgency, or urge incontinence, or any combination of these symptoms.

Safety and efficacy in pediatric populations have not been established.

Contraindications: • Urinary retention • Gastric retention • Uncontrolled narrow-angle glaucoma • Hypersensitivity to tolterodine L-tartrate, soya, peanuts, lactose Relevant warnings and precautions: • increase in heart rate • interaction with potent CYP3A4 inhibitors (i.e., max of 4 mg) • patients at risk of gastric retention • patients at risk of urinary retention • patients with impaired hepatic function • angioedema • patients with myasthenia gravis • patients with controlled narrow-angle glaucoma • patients with impaired renal function (i.e., max of 4 mg for severe impairment) • contraception in women of childbearing potential • not recommended during breastfeeding For more information: Please consult the product monograph at http://www.pfizer.ca/en/our_products/ products/monograph/317 for important information relating to adverse reactions, drug interactions, and dosing information which have not been discussed in this piece.

The Product Monograph is also available by calling 1-800-463-6001.

LS = least square † TOVIAZ is covered on formulary with special authorization in Alberta, Saskatchewan, Manitoba, Ontario, Quebec, New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland and Labrador. ‡ 12-week, double-blind, double-dummy, placebo-controlled, parallel-group, randomized clinical trial of patients with OAB (≥8 voids/24 hrs and ≥1 UUI episodes/24 hrs on a 3-day bladder diary). Patients were randomized to placebo (n=478); maximum dose of tolterodine ER 4 mg (n=973); or maximum dose of TOVIAZ (4 mg for 1 week then 8 mg for 11 weeks; n=960). Number of patients evaluated for UUI episodes/24 hrs was 448, 926, and 908, respectively. Baseline means for UUI episodes/24 hrs were 2.4, 2.6, and 2.6, respectively. § 12-week, double-blind, double-dummy, placebo-controlled, parallel-group, randomized clinical trial of patients with OAB (≥8 voids/24 hrs and ≥1 UUI episodes/ 24 hrs on a 3-day bladder diary). Patients were randomized to placebo (n=334); maximum dose of tolterodine ER 4 mg (n=684); or maximum dose of TOVIAZ (4 mg for 1 week then 8 mg for 11 weeks; n=679). Number of patients evaluated for UUI episodes/24 hrs was 307, 626, and 619, respectively. Baseline means for UUI episodes/24 hrs were 2.6, 2.5, and 2.4, respectively. ¶ 12-week, randomized, double-blind, flexible-dose, placebo-controlled, parallel-group, multicenter trial in patients aged ≥65 years with OAB symptoms (≥3 months, mean of 2-15 UUI episodes/24 hrs, mean of ≥8 micturitions/24 hrs reported in 3-day bladder diary). Patients were randomized to placebo (n=283) or TOVIAZ 4 mg/day (n=283), with the option to increase to 8 mg at Week 4 only. Baseline means for UUI episodes/24 hours were 4.1 and 3.9, respectively.

References: 1. Kaplan SA et al. Superior efficacy of fesoterodine over tolterodine extended release with rapid onset: a prospective, head-to-head placebo-controlled trial. BJU Int 2011;107:1432-1440. 2. Herschorn S et al. Comparison of fesoterodine and tolterodine extended release for the treatment of overactive bladder: a head-to-head placebo-controlled trial. BJU Int 2010;105:58-66. 3. DuBeau CE et al. Effect of fesoterodine in vulnerable elderly subjects with urgency incontinence: a double-blind, placebo controlled trial. J Urol 2014;191:395-404.

4. Pfizer Canada Inc. TOVIAZ Product Monograph. March 2014.

LETTERS

Wellness therapies EDITOR

David Elkins

MANAGING EDITOR

Camille Chin

CONTRIBUTING EDITOR

Katherine Tompkins

TRAVEL EDITOR

Valmai Howe

SENIOR ART DIRECTOR

Pierre Marc Pelletier

DOCTORSREVIEW.COM WEBMASTER

Pierre Marc Pelletier

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David Elkins

DIRECTOR, SALES & MARKETING

Stephanie Gazo / Toronto

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Denise Bernier

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EDITORIAL BOARD

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

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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.

SHORE THINGS Pirates of the Carolinas [April 2015, page 34] bought back memories. When I was a kid, my family would drive the 20-something hours to Kill Devil Hills in North Carolina’s Outer Banks. My parents would rent a beach house on stilts and we’d spend late mornings to early evenings at the seashore. I remember collecting seashells, and corn on the cob and seafood dinners on the screened-in patio. The road trip was always so, so long, but the summers memorable.

Amelia Via email

AN ADD-ON STRATEGY IN DEPRESSION Selecting the antidepressant that is most effective initially often yields the best results but, that said, pharmacologic strategies include switching to another first-line agent (this can be in the same class) or adding another antidepressant [“Strategies for depression,” Depression Keypoints, April 2015, page 25].

I would strongly recommend adding an atypical antipsychotic to an antidepressant. In fact, there is more evidence for atypical antipsychotics in depression as an add-on to an antidepressant than two antidepressants. CANMAT guidelines recommend this treatment choice as first-line based on level I evidence (reference is LAM RW et al Canadian Network for Mood and Anxiety Treatments/CANMAT clinical guidance for the management of major depressive disorder in adults. III. Pharmacotherapy. Journal of Affective Disorders 2009;117 Suppl 1:S26-43).

Dr Ruth Baruch Via DoctorsReview.com

CREATING A STIR Great to see this article [“Art for Therapy’s Sake,” History of Medicine, April 2015, page 29]. It was well-balanced and insightful. I started my training 16 years ago and still wonder why we haven’t embraced art therapy into the more conventional practices of healthcare.

Hopefully, after reading this article, more interests will be peaked!

Laura Via DoctorsReview.com

GET TECHNICAL I appreciate you writing about the Kidspeak application [“Winning ways with kids,” Best MD Apps, May 2015, page 17].

Kids love electronics and using technology to help them understand what’s wrong with their bodies is very smart.

Including the sounds of different medical procedures is impressive.

Dr G. Ratti Via email

We want to hear from you!

Send your comments and questions to: Doctor’s Review, Letters, 400 McGill Street, 4th Floor, Montreal, QC H2Y 2G1.

Or email us at editors@doctorsreview.com.

JUNE 2015 • Doctor’s

Review

7

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

1,2

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

Contraindications: Untreated fungal, bacterial or tuberculosis infections of the respiratory tract • Primary treatment of status asthmaticus or other acute episodes of asthma or in patients with moderate to severe bronchiectasis •

Relevant warnings and precautions: Patients with hypothyroidism • Patients with cirrhosis and/or severe hepatic impairment • Immunosuppressant drugs • May cause eosinophilic conditions • May cause candidiasis •

• As with other inhalation therapy, paradoxical bronchospasm

may occur Caution in systemic steroid replacement by inhaled steroid • Patients with hypoprothrombinemia in conjunction with acetylsalicyclic acid • Systemic effects of inhaled corticosteroids may occur, particularly at high doses for prolonged periods • Monitor HPA axis function and effects on the eye •

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

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

REFERENCES: 1. Alvesco (ciclesonide inhalation aerosol) Product Monograph. Takeda Canada Inc. December 17, 2012. 2. Lougheed MD et al. Canadian Thoracic Society 2012 guideline update: Diagnosis and management of asthma in preschoolers, children and adults. Can Respir J 2012;19(2):127-164. 3. IMS CompuScript, November 2014. ®

† Metered dose inhaler © 2015 Takeda Canada Inc. All rights reserved. ® Registered trademark of Takeda GmbH. Used under licence.

1 ICS MDI dispensed in Canada with respirologists #

†

3

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

C a mi lle C hi n

© CHLOË SAYER, 2004

© ROYAL ONTARIO MUSEUM

The fabric of Mexico

FROM TOP: A Huichol man’s ensemble from the states of Jalisco and Nayarit, 1944-1969.

Women dressed in richly embroidered clothing for the Feast of the Assumption in Santa María Reoloteca, Tehuantepec, Oaxaca.

Toronto’s Royal Ontario Museum has a collection of Mexican textiles that span 300 years and for the first time ever 150 pieces are on display through May 23, 2016. ¡Viva México! Clothing & Culture celebrates the best, brightest and rarest garments, and explores the evolution of the country’s clothing styles.

In pre-Conquest times, the elite’s splendid ensembles were symbols of high status.

When the Spanish conquistadores arrived in 1519, they were impressed by the work of the spinners, dyers, weavers, embroiderers and feather artisans.

Later European materials, techniques and styles were merged with those of indigenous societies. Beautifully woven rebozos (women’s shawls) and patterned sarapes (men’s wool overgarments) from the 18th and 19th centuries are on view as are ceremonial outfits and lace headdresses that are evocative of grand fiestas. Adults $17; students $15.50; kids 4 to 14 $14. Discount admissions on Best Value Fridays start at 4:30pm. tel: (416) 586-8000; rom.on.ca.

JUNE 2015 • Doctor’s

Review

9

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

Size matters

Italy after dark 10

S. BORISOV / SHUTTERSTOCK.COM

Air Canada has added staff to check-in counters and security checkpoints at Toronto’s Pearson International Airport to make sure that carry-ons conform to size and weight limits.

Approved bags will get a tag. Those that don’t measure up will be checked and charged $25. The stricter checks started at Pearson on May 25; they’ll begin at other airports in June.

Carry-ons cannot be larger than 23 x 40 x 55 centimetres and can’t weigh more than 10 kilograms. For a baggage guide: aircanada.com/en/travelinfo/airport/baggage/index.html.

Last year’s inaugural La luna sul Colosseo — Moon over the Colosseum — was so popular that the Rome landmark will offer night tours again this summer. Lead by an archeologist, the 75-minute group tours are available Mondays, Thursdays, Fridays and Saturdays through October 10.

Groups are made up of a maximum of 25 people. Tours are available in English and Italian. Adults €26. For tickets: rome-museum.com/bookingcolosseum-special-night-opening.php.

Doctor’s Review • JUNE 2015

Pillar of strength

For

New York City’s One World Trade Centre skyscraper is the tallest building in the Western Hemisphere. Its observatory on the 100th floor opened on May 29. Located on the northwest corner of the 6.5-hectare World Trade Center site, the 541-metre-tall tower consists of 104 floors and 70 elevators.

Five Sky Pod elevators bring guests to the top in less than one minute; they feature floor-to-ceiling LED technology that depicts the development of city’s skyline from the 1600s to today.

In addition to 360-degree views, the One World Observatory features the Sky Portal, a four-metre wide circular disc that guests can stand on to see real-time, high-def footage of the streets below. At City Pulse, ambassadors trained in gesturerecognition technology can help guests with info on landmarks and neighbourhoods using a ring of HD monitors. There are Claudia Masciotra three restaurants on the 101st floor, a theatre on the 102nd floor.

Tickets are date and time specific. Adults US$32; kids US$26.

Doctor’s Review June 2015 issue tel: (844) 696-1776; oneworldobservatory.com.

Fax

1-855-861-0790

To

PANAMA CANAL + CARIBBEAN and COSTA RICA

November 20 - 30, 2015

Bringing Best Evidence

Dermatology Psychiatry Infectious Dsx. MORE CME CRUISE DESTINATIONS

ALASKA CARIBBEAN

ASIA TAHITI

ICELAND & NORWAY CME CRUISES July 16 - 28, 2016

Essential Topics in Primary Care MEDITERRANEAN NEW ZEALAND

QUEBEC & ST. LAWRENCE EUROPE RIVERS

www.seacourses.com 1-888-647-7327 JUNE 2015 • Doctor’s

Review

11

P R AC T I C AL T R A V E L L E R Dubai’s Miracle Garden.

The main squeeze If you find flying uncomfortable now, it’s going to get worse. Airbus has debuted a new seat configuration for its A380 double-decker jets. Instead of 10 seats per row (in a three-four-three pattern) on the main deck; it has 11 (three-five-three).

The airplane manufacturer is also offering airlines an extra seat on its more regular-sized A330 up from eight to nine per row. Its competitor, Boeing, is adding more seats too.

Demand is down for its long-haul 777 models with nine seats per row; airlines increasingly want the newer 10-seat version. Along with seat size, legroom is also shrinking. The industry standard for the distance between coach seats used to be 33 inches (84 cm); on the new Airbus A380 and Boeing 777, seat pitch could be between 27 and 29 inches (69 and 74 cm). What’s more, Boeing has designed new luggage bins for 737s. The “Space Bins” can hold six standard carry-ons, two more than the current pivot bins; passengers will have less headroom.

A new ball game

ANDREA IZZOTTI / SHUTTERSTOCK.COM

A recent New York Times article has revealed that “brown is the new green” in California’s golf industry.

The Golden State is in its fourth consecutive year of drought and golf resorts are faced with huge cuts in water allocation and potentially higher water rates.

To cope, some resorts are letting their turf turn brown and ripping up grass in places that won’t affect the game. They’re planting drought-resistant desert vegetation instead and installing smart watering systems. To help, some water agencies are running turf reduction rebate programs that offer $2 to $3 for every square foot of ground cover removed.

According to Mike Huck, a water management consultant who works with golf courses statewide, an average 18-hole course in California uses almost 90 million gallons (340 million litres) of water per year, enough to fill 136 Olympic-size swimming pools.

12

Doctor’s Review • JUNE 2015

GA D GE T S by

R o g er W h i t e

A digital camera/ smartphone match On a recent stroll along the harbour in Old Montreal, I noticed that many of the visitors taking photographs used both smartphones and digital cameras. For group shots and selfies, smartphones (often using Bluetooth selfie sticks) were the clear choice. The cameras came out for boats on the water and longer shots back toward the city.

A couple of years ago, as smartphone cameras grew more and more sophisticated, packing in megapixels and features, it looked as though they might replace cameras entirely.

That’s clearly not the case.

Here are five reasons why cameras are not going the way of the dodo anytime soon: optical zoom lens; superior and faster auto focus; better photos in low light; more megapixels; longer battery life.

On the downside, cameras are more expensive and heavier, and mean that you have yet another item to lug around with you. With these things in mind, a lot of thought has gone into Canon’s new 16-megapixel PowerShot SX600 HS. It may be just the ticket to pair with your smartphone.

Don’t be put off by the “advanced” tag: it’s as easy to use as any point-and-shoot camera. Reviewers give it good ratings for photos and 1080p HD video quality is excellent. The big plus is its 18x f3.8–6.9 25–450 mm optical lens that gets you in close even at full range. The 16.0-megapixel high-sensitivity CMOS sensor combined with the DIGIC 4+ image processor means solid performance in low light. It also has built-in Wi-Fi that makes sharing easy. You can even set the camera up on a tripod and program your smartphone to take the shot, eliminating the need to use a timer. The slim, lightweight body has a large 76.2 mm LCD with a resolution of 461,000 dots.

Priced at less than $275, the camera is widely available.

JUNE 2015 • Doctor’s

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doctorsreview.com/meetings access code: drcme

the top 25 medical meetings compiled by Camille Chin

Canada Banff, AB November 12-14 XXV Annual Meeting and Scientific Conference of the Canadian Society of Addiction Medicine csam-smca.org/events/xxv-annual-meetingscientific-conference-2015

Charlottetown, PEI October 14-17

Montreal, QC October 24-28 CHEST 2015 chestnet.org/education/chest-meetings/chest-2015

Toronto, ON November 12-14 2015 Family Medicine Forum fmf.cfpc.ca

LISSANDRA MELO / SHUTTERSTOCK.COM

2015 Annual Meeting of the Canadian Society of Internal Medicine csim.ca/en/meetings-cme-2/annualmeetings/191-2015-national-meeting

Sulphur Mountain, Banff National Park, AB.

Vancouver, BC October 1-3

October 22-24 5th Annual Canadian Hypertension Congress hypertension.ca/en/chc

October 24-27 2015 Canadian Cardiovascular Congress cardiocongress.org

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

65th Annual Conference of the Canadian Psychiatric Association cpa-apc.org

October 4-9 XXI FIGO World Congress of Gynecology and Obstetrics figo2015.com

Around the world Baltimore, MD October 17-21 71st Annual Meeting of the American Society for Reproductive Medicine asrm.org/ASRM2015

November 30-December 4

Boston, MA October 21-24

2015 World Diabetes Congress idf.org/worlddiabetescongress

10th Annual Cardiometabolic Health Congress cardiometabolichealth.org

® MSD International Holdings GmbH. Used under license. © 2014, 2015 Merck Canada Inc. All rights reserved.

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

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R2015-05-25 eview

11:11 PM

doctorsreview.com/meetings access code: drcme

the top 25 medical meetings Florence, Italy November 29-December 2 11th International Congress on Coronary Artery Disease iccad.kenes.com

Istanbul, Turkey October 31-November 3 JEFFERSON BERNARDES / SHUTTERSTOCK.COM

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

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

Lake Buena Vista, FL October 18-23

Ipanema Beach, Rio de Janeiro, Brazil.

15th International Thyroid Congress thyroid.org/itc2015

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

National Harbor, MD October 7-10

Phoenix, AZ October 8-10

44th Annual Meeting of the Child Neurology Society childneurologysociety.org/meetings/2015-cnsannual-meeting

29th Annual North American Cystic Fibrosis Conference nacfconference.org

New Delhi, India November 19-21 XXXVI Symposium of the International Society of Dermatopathology dermpathindia.org/isdp2015.html

New Orleans, LA November 5-7

London’s Natural History Museum.

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Doctor’s Review • JUNE 2015

VIACHESLAV LOPATIN / SHUTTERSTOCK.COM

Galata Tower, Istanbul, Turkey.

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

Orlando, FL November 7-11 2015 Scientific Sessions of the American Heart Association scientificsessions.org

November 18-22 68th Annual Scientific Meeting of the Gerontological Society of America geron.org/meetings-events/gsa-annual-scientificmeeting

San Diego, CA November 3-8 Kidney Week 2015 asn-online.org/education/kidneyweek/archives/ future.aspx

Santiago, Chile October 31-November 5 XXII World Congress of Neurology wcn-neurology.com

Rio de Janeiro, Brazil November 18-21 9th World Congress on Pediatric Infectious Diseases wspid.kenes.com

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

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

R os e F os t e r

Austism at the start How “autistic savants” moved science from mystery to insight

J

edediah Buxton, born in Derbyshire, England in 1707, measured everything. He accurately measured the area of the town he was born in

simply by walking around it. He counted the number of steps that dancers took at town dances and the number of words uttered by actors at plays. He couldn’t write, but when the Royal Society tested his mathematical abilities in 1754, they found that he could calculate numbers up to 39 figures.

Buxton may be the earliest recorded example of an autistic savant. These days, savants with autism perform feats with a modern flair. Stephen Wiltshire, for instance, known as “the human camera,” can create ink drawings of city skylines in perfect detail after a single helicopter Jedediah Buxton is believed to be one of the earliest autistic savants.

fly-over. What hasn’t changed much is the mystery that surrounds both autism and the savants the condition sometimes produces.

Recent discoveries suggest that autism may result from a combination of genetic and environmental factors.

Some scientists even believe they have figured out how to manipulate the brain to make temporary savants of us all. Still, autism remains a puzzle yet to be cracked. The attempt to do so, however, has yielded some curious insights into how our brains work.

SPECTRUM STRUGGLES The Diagnostic and Statistical Manual of Mental Disorders’ (DSM-5) 2013 conflation of multiple terms used to describe various autistic disorders into a single term — autism spectrum disorder or ASD — can be bewildering. Rett syndrome, childhood disintegrative disorder and Asperger syndrome, while they are considered autism spectrum disorders, are distinct from autism, though boundaries between diagnostic categories on the spectrum can seem arbitrary.

A person who is “on the spectrum” can be without language or motor skills and require lifelong care, exhibiting a fanatical need for sameness, relentlessly repetitive behaviours and even bouts of violence.

These “low-functioning” individuals require an enormous amount of energy, an exhausting journey for parents who

18

Doctor’s Review • JUNE 2015

In 1943, Donald Gray Triplett of Mississippi was the first person identified as having a condition called “autism.” The diagnosis was made by Boston’s Dr Leo Kanner who coined the term.

seek the best treatments for their children. A case in point is that of Kim Peek, the real person on whom Dustin Hoffman’s character in the film Rain Man was based. Peek relies entirely on his father, now in his 80s. “It’s a 30-houra-day, 10-day-a-week job,” says dad.

While some autistic savants — like celebrity professor Temple Grandin, who has made dramatic improvements to slaughter house design and lectures widely on “thinking in pictures” — can be very high-functioning, having savant capacity often appears in people with low-functioning autism.

The thread that holds the diagnosis together across the spectrum is a triad of symptoms: impairments in verbal and non-verbal communication; persistent deficits in social interaction; and restricted, repetitive behaviours, interests or activities. This preoccupation with details and the uncanny ability to perceive governing patterns or systems is what fuels the autistic savant mind.

AUTISM’S FIRST CASE The first person ever to be diagnosed with autism — “Case 1… Donald T” — was a savant, so named in 1943 by Johns Hopkins professor Dr Leo Kanner.

At a young age, Donald Gray Triplett of Forest, Mississippi spent most of his time engaged in what are now considered typical autistic behaviours: spinning blocks and plates, and repeating strings of unrelated words. But as an older child, his fixation with math acquired savant proportions.

When a visiting hypnotist spent a night with the family and discovered their son’s genius for multiplying num-

bers in his head and his perfect musical pitch, the performer wanted young Donald to join his act. His parents would have none of it. They had made a supreme effort to integrate him into normal life, including getting him to attend classes at the local school where he was a celebrity for his reputed ability to count the number of bricks in a building just by glancing at it. Truth be told, it later came out that he just made up the number, an unusual feat for someone with autism since people with autism don’t tend to lie. He was a special case on so many levels.

When the family travelled to Boston to see Dr Kanner, Donald, age three, displayed all the characteristics of autism that are well-recognized today. He showed “no apparent affection” for human beings and had several obsessions including pictures of the US presidents and the letters of the alphabet, which he enjoyed reciting in reverse order. To all intents and purposes, he appeared to have withdrawn “into his shell,” to

“live within himself,” as his father described in a detailed letter to Dr Kanner.

The term autism refers to this apparent retreat into self, coming from the Greek word “autos” meaning “self.”

“Autistic” was first used in 1911 to describe a symptom of schizophrenia wherein patients seemed averse to social interaction. Dr Kanner applied the term to the new set of behaviours he observed in Donald.

Part of what makes social interaction so challenging for those on the autism spectrum is their acute ability to track individual details in a hyper-literal way combined with their inability to grasp generalized concepts, such as those required to initiate and nurture relationships. Rather than not perceiving enough in the world around them, they perceive too much to be able to sort through it.

Retreating into their obsessions gives them the peace they need to focus and function. Only by breaking down niceties into distinct, formalized steps are they able to function in a social context.

Savant Stephen Wiltshire can accurately reproduce city skylines after a single helicopter fly-over.

JUNE 2015 • Doctor’s

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Derek Amato smashed his head on the bottom of a swimming pool and thereafter found he could play piano THE BRAINS BEHIND IT What makes it possible for the brain to remember songs after hearing them once, learn a language in a week, or name the day of the week of any date from any time in history at the drop of a hat? Some scientists suggest it is this supreme, obsessive focus, which is unmitigated by “the tyranny of the prefrontal cortex.”

The prefrontal cortex, which has recently been shown to exhibit consistent damage in the brains of autistic children, is the region of the brain in charge of executive functions like predicting consequences, focusing attention and examining emotions. The prefrontal cortex brings together the data gathered by the various disparate parts of the brain and configures it to form a cohesive picture. It looks at the big picture and ignores details like counting fallen toothpicks, as Dustin Hoffman’s autistic savant character in Rain Man does.

When the prefrontal cortex is damaged, however, the brain is free to obsess.

“Acquired savants” offer evidence that

this theory may be true. Like characters in a bad daytime TV drama, a blow to the head really has turned some individuals into overnight artistic geniuses or prodigious musicians.

Painter Jon Sarkin was a chiropractor who dabbled in art. After suffering a brain hemorrhage and a stroke, he suddenly became obsessed with painting and even found that he needed to paint to stave off debilitating nervous tension.

Derek Amato, a 39-year-old failed businessman who had dabbled in music in high school, smashed his head on the bottom of a swimming pool while diving for a football and thereafter found himself with a surprising ability to play piano.

In 2003, an Australian scientist named Allan Snyder raised eyebrows by suggesting that he could recreate the conditions that led to acquired savantism by suppressing the activity of the prefrontal lobes using a non-invasive machine called a transcranial magnetic stimulator (TMS). The device employs a magnetic field generating coil to stimulate small regions of the brain. Snyder had read that certain people undergoing treatment with a TMS to slow down specific regions of the brain during brain Kim Peek is the source of Dustin Hoffman’s character in Rain Man.

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Doctor’s Review • JUNE 2015

A nine-dot puzzle to test subjects before and after receiving transcranial direct current stimulation.

surgery suddenly exhibited isolated pockets of genius-like mental ability. He was familiar with acquired savantism and was intrigued.

Snyder set up a test in which subjects were asked to draw a cat from memory before, during and after having their prefrontal lobes stimulated by the TMS machine. He claimed that the cat drawings showed much more detail and realism post-TMS, suggesting that dimming down the prefrontal cortex freed up the part of the brain used in drawing to access the wealth of remembered details that were stored there.

Experts were skeptical about Allan’s assertion that the drawings improved, but were more convinced by another test. Using transcranial direct current stimulation (TDCS), subjects were asked to connect a set of nine dots by drawing three lines without lifting the pen. Before treatment, none of the participants could complete the test; afterwards, 40 percent could.

The sci-fi minded will perhaps envision a time when we can selectively amplify sections of our brains to increase our mental powers at will. But for those on the spectrum, a more significant advance would be that the insights about savantism provide better ways for those affected to be understood by “neuro-typicals” — that’s the rest of us.

For the Treatment of IBS-C and CIC in Adults CONSTELLA ® (linaclotide) is indicated for the treatment of: • irritable bowel syndrome with constipation (IBS-C) in adults • chronic idiopathic constipation (CIC) in adults Pr

CONSTELLA showed significant improvement in abdominal discomfort vs. placebo (secondary endpoints, mean change from baseline at Week 12)

IBS-C

CIC

IBS-C: -2.0 vs. -1.2 (Trial 1); -1.9 vs. -1.1 (Trial 2) (p<0.0001)* CIC: -0.5 vs. -0.3 (p<0.001)†

Study parameters are available at www.frx.ca/_products/constella.htm

Clinical use: 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 Actavis Specialty Pharmaceuticals at 1-855-892-8766.

* 11-point ordinal scale; Trial 1, Trial 2. † 5-point ordinal scale; Trials 3 and 4.

CONSTELLA® is a registered trademark of Ironwood Pharmaceuticals, Inc. used under license by Actavis Specialty Pharmaceuticals Co. or its affiliates. ©2015 Actavis Specialty Pharmaceuticals Co., Mississauga ON. All rights reserved.

REFERENCE 1. CONSTELLA® (linaclotide) Product Monograph, Forest Laboratories Canada Inc., May 12, 2014.

I B S K E Y P OI N T S by

Dr Gabor Kandel

Case study: irritable bowel syndrome

Confident diagnosis and an integrated approach ensure long-term Brent, a 44-year-old small-business owner, visits his family physician because his business is suffering a downturn and it’s causing him to be “stressed out.” His symptoms include muscle and joint aches, insomnia, palpitations and sweating, as well as constipation with bloating and gas. Brent’s family and friends constantly tell him he has to learn to relax and that things will get better. The family physician prescribes lorazepam (2 mg qhs, 4 weeks) to help him sleep.

At follow up one month later, Brent reports his sleep has improved, but he’s still suffering from other symptoms. His major concern is the ongoing gastrointestinal (GI) symptoms: bloating, gas, abdominal pain and decreased bowel frequency, from “once daily like clockwork,” to once every four days. He’s had bouts of these problems since his teens, but never told a doctor before, due to embarrassment.

Over the years, Brent tried numerous home treatments without success. First, he raised his fibre intake through both diet and psyllium powder, which increased his bowel movements slightly but made his bloating, gas and pain worse. He tried over-the-counter polyethylene glycol, but found it worked too well — after his second dose, he woke up at 4am with soiled pyjamas. He self-medicated with bisacodyl which relieved his constipation, but caused cramping severe enough that his wife made him go to the emergency room thinking he might have a bowel obstruction.

Frustrated, Brent recently consulted a naturopath for colonic irrigation, after hearing a relative’s glowing testimonial. The naturopath, however, suggested he get a colonoscopy first, to rule out colon cancer, which Brent is also worried about.

G .

uidelines insist that IBS-C can be confidently diagnosed solely by the presence of symptoms meeting diagnostic criteria (Table 1) and absence of alarm features (Table 2), based on the history and physical.1 The history should also include questions about foods that seem to trigger IBS symptoms. Studies have shown a higher prevalence of celiac disease and lactose intolerance in IBS vs healthy patients.1 Small carbohydrates known as FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols), found in wheat and dairy foods, and many fruits, vegetables and legumes, may cause bloating and gas due to osmotic effects and fermentation in the bowel.2 Finally, assessing the patient’s emotional state is important, since anxiety and depression are common comorbidities, and stress is a known trigger of IBS symptoms.3 Routine diagnostic testing isn’t recommended — the yield is generally low and similar to that in healthy patients. Like Brent, many IBS patients are concerned about colon cancer, yet, in some studies, the prevalence of bowel malignancy is lower in IBS than in age-matched controls, probably because such patients are health-conscious and follow screening guidelines. Alarm features do require appropriate investigations to rule out organic causes, but even then, positive findings are unlikely.1

Gabor Kandel, MD, FRCPC, is a gastroenterologist on staff at St Michael’s Hospital and Associate Professor of Medicine at the University of Toronto.

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Doctor’s Review • JUNE 2015

That said, selected diagnostic tests can be useful in IBS-C without alarm features (Table 3). Their main value lies in boosting your confidence in the diagnosis of IBS-C.2 I see nothing wrong in doing tests to convince patients no sinister disease has been overlooked, since their buy-in to the diagnosis of IBS is so important for successful therapy.

No need for alarm Brent’s recurrent GI symptoms, especially abdominal pain and constipation, are consistent with IBS-C. His family physician confirms the diagnosis using the Rome III symptom criteria and rules out organic disease based on Brent’s lack of alarm features, and normal/negative results on the above diagnostic tests. Brent also reports that onions and legumes cause severe bloating, gas and abdominal pain, suggesting FODMAP sensitivity.

Weighing the treatment options The overall goal of treatment in IBS is to help patients feel qualitatively better, with no specific targets. Patients need to know that, although IBS is usually a chronic, lifelong condition, their best chance of long-term benefits is to work with their physicians to implement a combination of lifestyle, diet, behavioural and/or medical interventions.2 Exercise increases colon transit speed and stool frequency, and a randomized controlled trial of an exercise program showed

with constipation success

benefits over usual care in improving overall IBS symptoms.2 Fibre, particularly psyllium, can provide overall symptom relief, but may worsen bloating and abdominal discomfort, and adherence may be difficult. Low-FODMAP diets are promising, but more research is needed to define their role. Referral to a dietitian is recommended. Psychological therapies, including cognitive behavioural therapy, hypnosis and dynamic psychotherapy, can effectively improve IBS symptoms, but evidence quality is low.3 We know laxatives can improve constipation, but few studies have looked at their effects in IBS-C. In reviewing trials of polyethylene glycol in IBS-C, the ACG concluded that it doesn’t improve overall symptoms or pain. Tricyclic antidepressants and selective serotonin reuptake inhibitors effectively relieve global symptoms and abdominal pain in IBS-C, but side effects and patients’ reluctance to take psychotropics may limit their use.3 Linaclotide is a prosecretory agent with visceral analgesic effects. High-quality trials show that it is an effective option for IBS-C, improving both abdominal symptoms (pain, discomfort, cramping, bloating) and bowel habits (frequency, consistency, straining). Stool frequency typically increases within the first week, while abdominal symptoms may take several weeks to improve.

The main side effect of linaclotide is diarrhea, which tends to occur in the first few days, if at all. Patients who get diarrhea should decide with their physician whether to stop the drug.2,3

Table 1. Diagnostic criteria for irritable bowel syndrome (IBS)3 Rome III • Recurrent abdominal pain or discomfort ≥3 days/month in past 3 months • Symptom onset ≥6 months before diagnosis • Associated with ≥2 of the following: —— Improvement after defecation —— Change in stool frequency —— Change in stool form/appearance • Subtyped according to predominant bowel habit: —— Constipation (IBS-C) —— Diarrhea (IBS-D) —— Mixed (IBS-M) —— Unclassified (IBS-U) American College of Gastroenterology • Abdominal discomfort associated with altered bowel habits ≥3 months

Table 2. Alarm features1 Many happy endings Relieved to hear that he doesn’t have a serious illness, Brent resolves to take charge of his health. He sees a dietitian to try a low-FODMAP diet, based on his sensitivity to onions and legumes, and agrees to takelinaclotide, which reduces his abdominal pain and constipation dramatically. Within a few months, his IBS has improved overall, and his bowel symptoms have stabilized, but not resolved completely. However, his muscle aches are now more bothersome than ever.

The family doctor realizes that Brent probably has an underlying generalized anxiety disorder, and recommends cognitive behavioural therapy.

References 1. Brandt LJ, Chey WD, Foxx-Orenstein AE, et al. An evidence-based position statement on the management of irritable bowel syndrome. Am J Gastroenterol 2009; 104 Suppl:S1-S35. doi:10.1038/ajg.2008.122.

2. Chey WD, Kurlander J, Eswaran S. Irritable Bowel Syndrome. JAMA 2015; 313(9):949. doi:10.1001/jama.2015.0954.

3. Ford AC, Moayyedi P, Lacy BE, et al. American College of Gastroenterology Monograph on the Management of Irritable Bowel Syndrome and Chronic Idiopathic Constipation. Am J Gastroenterol 2014;109(S1):S2-S26. doi:10.1038/ajg.2014.187.

• • • • • • •

Onset after age 50 Blood in stools Severe or progressively worsening symptoms Weight loss Iron-deficiency anemia Nocturnal symptoms Family history of colorectal cancer, inflammatory bowel disease or celiac disease

Table 3. Selected diagnostic tests in IBS-C • Celiac disease screening, lactose intolerance testing (higher prevalence of these conditions in IBS) • Complete blood count (anemia) • Colonoscopy (colon cancer) • Blood glucose (diabetes) • Serum calcium (hypercalcemia) • Thyroid function (hypothyroidism) • Abdominal ultrasound (bloating due to ascites) JUNE 2015 • Doctor’s

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23

In major depressive disorder

“I felt down and

overwhelmed nearly every day.”

Nicole*, 37

For patients like Nicole...

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

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

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

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

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

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

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

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

Mairi MacKinnon

Managing work-related depression Collaboration and communication are key

D .

epression is a leading cause of disability worldwide and a burgeoning source of disability costs to Canadian employers. It takes its toll in high rates of work absence or sick leave, short- and long-term disability, unemployment and lost productivity by workers who remain on the job (presenteeism).1,2 It raises the risk of other medical or psychiatric illnesses, as well as injuries and accidents in the workplace.3,4 Recovery of full normal function and quality of life is a primary goal of therapy for depression.1 Primary care physicians (PCPs) have an important role in facilitating patients’ safe and timely return to productive work after an illness or injury.3-5 Severe cases of depression and/or those necessitating long-term disability benefits may also require the involvement of a psychiatrist.3

Individual and social costs Data from a 2002 Canadian Community Health Survey revealed that 79 percent of workers with depression had experienced some degree of interference with work, and 19 percent reported severe hindrance; on average, they lost 32 days a year in which they were unable to work due to symptoms.2 A recent Ipsos MORI global survey of workers and managers reported that about half of Canadians diagnosed with depression have taken time off work because of their condition; roughly one quarter had to stop work during their last episode, for an average of 49 days (compared to the global average of 32 lost working days); and 40 percent of those off work did not disclose the reason for their absence to their employer (higher than the global average of 33 percent).6 Symptoms reported by Canadian employees in the survey included low mood/sadness, difficulty concentrating, forgetfulness and withdrawal from colleagues.6 Fatigue, very common in people with clinical depression, may also be a key symptom or a contributing cause of workplace depression.7

Sharing vital information PCP’s expertise lies in evaluating impairment (diagnosis, assessment of symptoms/functional deficits) vs disability (the realm of employers/insurers). In establishing a diagnosis (best following DSM-5 criteria), it is helpful to give precise details on the frequency, severity and duration of symptoms and on how/to what degree the impairments might affect the individual’s work performance.3,4 Physicians may require information from employers to help understand patients’ work situation (job requirements, ability to meet those demands, etc.) and the effect of symptoms on occupational functioning.3-5 Extra paperwork may be involved to provide employers and/or insurers with information (with the

knowledge/consent of the patient) to help them make accommodations in the workplace or process benefits claims. While time-consuming, interaction with employers/insurers is an important part of the physician’s role.

Acknowledging the patient’s central role Empowering patients to participate in their own care can improve adherence and enhance their return to productive work.

Work together to define problems, establish priorities and decide on the best course of action (in terms of treatment and work).

Discuss the pros and cons/optimal duration of work leaves.

Prolonged work absence often has a negative effect (leading to inactivity, isolation, anxiety, difficulty ever returning to work).

Encourage patients to ask their employer about possible modifications in the workplace.4 Counselling services may also be available through confidential Employee Assistance Programs.4 Educational and self-help materials can assist individuals in understanding their diagnosis, improving their condition and preventing recurrence (for example, see comh.ca/antidepressantskills/work).

Pharmacotherapy can lead to significant improvement of depressive symptoms; where available, psychotherapy (e.g. cognitive behavioural therapy) has been shown to provide additional specific benefits in fostering return to full functioning.3,4 With usual treatment, many depressed employees continue to have some residual impairment, so ongoing monitoring and preventive strategies are essential.3 If no progress is seen within a few months of treatment, consider a different approach or referral to another mental health professional.4 References 1. Patten SB, Kennedy SH, Lam RW et al. CANMAT Clinical guidelines for the management of major depressive disorder in adults. I. Classification, burden and principles of management. J Aff Disord 2009;117(Suppl 1):S5–S14.

2. Gilmour H, Patten SB. Depression and work impairment. Health Reports (82003-X). 2007;18(1). www.statcan.gc.ca/pub/82-003-x/2006001/article/ depress/4060597-eng.htm. Accessed May 22, 2015.

3. Bilsker D, Wiseman S, Gilbert M. Managing depression-related occupational disability: A pragmatic approach. Can J Psychiatry 2006;51:76-83.

4. Bilsker D, Gilbert M, Samra J. Managing workplace mental health & occupational disability: Guidelines for physicians. Centre for Applied Research in Mental Health and Addiction and BC Mental Health & Addiction, 2009. www.comh.ca/antidepressant-skills/work/resources/physicianguidelines/. Accessed May 18, 2015.

5. Canadian Medical Association. CMA Policy: The physician’s role in helping patients return to work after an illness or injury (2010 Update). Ottawa: CMA, 2010.

6. Mood Disorders Society of Canada launches Mental Health in the Workplace handbook. Health News Network. Jaguar Media, 2015. chrgonline.com. Accessed May 18, 2015.

7. Lam RW, Malhi GS, McIntyre RS eta l. Fatigue and occupational functioning in major depressive disorder. Aust NZ J Psychiatry 2013;47:989-91.

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The â&#x20AC;&#x153;company townâ&#x20AC;? of Val-Jalbert features 40 period buildings evocative of the 1920s including a general store, convent school and pulp mill.

Hidden glories

12 reasons you’ll want to spend your summer along Quebec’s spectacular fjord text and photos by Gary Crallé

of the Saguenay T

here’s a little corner of Quebec that’s a world unto itself; a community of villages that celebrates isolation by its devotion to its forest and farms, lakes and rivers. Iconic Quebec painter Clarence Gagnon (1881-1942) would have been right at home among the small farmhouses set on winding hilly roads edged by conifers.

The region defines itself through geography, dominated as it is by LacSaint-Jean and the Saguenay Fjord on the north shore of the St. Lawrence.

Water and woods are never far.

Appreciation of terrain is evident in the paintings many residents do en plein air. There’s also a gastronomy based on local produce. Blueberries are particularly abundant, so much so that residents are known throughout the province as Bleuets, a proud point of distinction. And the blueberry pies?

Superior!

JUNE 2015 • Doctor’s

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THINGS TO DO In late spring, summer and early fall, whale watching, hiking, biking, canoeing and kayaking are almost rabid activities for locals and visitors alike.

Rent a bike and hit the Véloroute des Bleuets (veloroute-bleuets.qc.ca).

The website provides all the information you’ll need to join the paved cycling trail at a variety of locations through the region.

Rock climbers, kayakers and zipliners will find it all at Parc Adventures Cap Jaseux (capjaseux.com) near SainteFulgence. Exhausted after a day in the open? Sleep in a dome in the woods overlooking the fjord.

Ready for a quieter pace? Explore the historical village Val-Jalbert (valjalbert.com), a pretty and partly restored 1920s company town that was ahead of its time.

Here’s a surprise: the “wild” zoo at Saint-Félicien (zoosauvage.org) is home to 77 species, which make it one of the most comprehensive in North America. Here, the visitors are enclosed while the animals roam free.

For one of the best kayaking experiences anywhere, dip your paddle in the fjord at L’Anse-Saint-Jean with Fjord en Kayak (fjordenkayak.ca).

The town and surrounding hills and the river are a treat in every way.

Recuperate from your day on the water at Édouard-les-Bains (edouard lesbains.com/fr/spas-nordiques-edouardles-bains.html), an outdoor Nordic spa in the village of L’Anse-Saint-Jean. The next day consider taking a Saguenay Fjord cruise with Croisières du Fjord (croisieresdufjord.com). Tours leave from a dock just down the hill.

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CLOCKWISE FROM TOP LEFT: There are 75 animal species at Saint-Félicien Wild Zoo. Saguenay is Quebec’s blueberry capital.

The Véloroute des Bleuets skirts Lac-Saint-Jean. Auberge des Cévennes is a 15-room B&B. Bergerie de la Vieille Ferme is known for its locally raised lamb. The dome at Cap Jaseux sleeps four people. Auberges des Berges consists of an on-site restaurant that serves classics like tourtière. The region is home to many farm scenes à la Clarence Gagnon. L’Anse-Saint-Jean is one of the province’s Plus Beaux Villages du Québec. The Parc national du Fjord-du-Saguenay stretches for 320 square kilometres.

WHERE TO STAY AND EAT Get back to the land at the Parc National du Fjord-du-Saguenay (sepaq.com/pq), a wilderness park with campsites, self-contained chalets and some good hiking trails.

On your visit to L’Anse-Saint-Jean, consider spending a night or two at Auberge des Cévennes (aubergedes-cevennes.qc.ca), an older inn with rooms that have fine views.

The breakfast is pretty good too.

If you find yourself in Saint-Félicien, plan to dine at Auberges des Berges (auberge-des-berges.qc.ca, website in French only), a hotel with a fine menu.

Cap au Leste (capauleste.com, website in French only) in Ste-Rosedu-Nord is a cute country bistro restaurant. The view from the deck is worth a stop all by itself.

Bergerie de la Vieille Ferme (agneaudufjord.com) in Saint-Fulgence has a P’tit Marché where they sell products from their farm. There’s also a restaurant that serves lunch and dinner.

Best choice? Locally raised lamb.

Quebec microbrews are known for their strength and character. A good selection of Quebec wine from the Eastern Townships is available at the local Société des alcools du Québec (SAQ) (saq.com).

The charming town of Tadoussac hosts a popular painting festival every September.

NOTL’s flowers Niagara-on-the-Lake makes a specialty of summer’s delights text and photos by David Elkins

Irises add a dash of purple to a garden on the “prettiest street in Canada.”

and other joys N

iagara-on-the-Lake thrives on theatre, wine and golf.

A stroll down Queen Street

ogling all the other visitors is also high on the list.

And that goes double if you’re scooping the best gelato in Ontario out of a dainty cup with an artful little spoon.

The Shaw Festival’s three stages offer playgoers unmatched entertainment; upwards of 75 wineries in the region offer tours and tastings of white wines and ice wines to rival those anywhere; and the gorgeous golf course along the lake proclaims itself to be “the ninth best small course in the world outside the US.” It is a good course and offers clear proof that we are not a boastful people.

The setting for all these activities is close to perfect.

Located where the Niagara River joins Lake Ontario, the area enjoys a much ballyhooed mini-climate famous for nurturing things that grow. In spring cherry, peach and apple orchards burst into bloom along side the rapacious vineyards. Flowers flourish everywhere.

Niagara-on-the-Lake (NOTL) owes its good vibes entirely to spring and summer. Autumn is tolerable as long as you wear your woolies — the Shaw runs through October — but after Labour Day the bloom is off the gardens as they begin their descent into December. Winter can be brutal, as the last couple

Over 200 varieties of lilac bloom in Centennial Park on the way to the Falls.

years have proven. Great banks of ice as high as garden sheds pile up along the shore, the hundreds of sailboats that adventure on the blue water in July and August doze in their dry docks. All that grows in the earth lies swathed in duvets of snow.

But this is June and the flowers are in their full glory. The first shoots appear in May and, after their long sleep, the race is on. Purple and white crocuses waft their spring perfume across lawns and along sidewalks only to be replaced in a twinkling by fragrant hyacinths and daffodils. Daffodils are a specialty of the region, worthy of Wordsworth’s famous poem: “I wandered lonely as a cloud That floats on high o’ver vales and hills, When all at once I saw a crowd, A host, of golden daffodils; Beside the lake, beneath the trees, Fluttering and dancing in the breeze.”

An early summer poppy “pops out” along Regent Street.

A single garden on Prideau Street hosts 10,000 of the beauties. Tens of thousands more grace lawns and open spaces, and along the Niagara Parkway, which runs south above the river, 27 kilometres to Niagara Falls. Sir Winston Churchill called it “the prettiest Sunday afternoon drive in the world.” He likely made the trip in late May or early June when JUNE 2015 • Doctor’s

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Simcoe Park, opposite the Prince of Wales Hotel, has fresh blooms all summer long.

Late May tulips flair in front of the iconic Clock Tower on Queen.

Sir Winston Churchill called it “the prettiest Sunday afternoon drive in the world” the 1200 trees and 200 varieties of lilac bloomed in the Centennial Garden.

After the daffodils it’s the tulips’ turn. They appear almost overnight in many beds on Queen Street, most notably the long one in front of the iconic Clock Tower.

Soon they’re waving their outrageously coloured heads above skinny green stems. It’s in the residential streets, though, that the show really takes off.

Pinks, whites, blues, oranges and a hundred shades of purple from violet to almost black reveal themselves in pots and window boxes. Private gardens flash their colours against a hundred white picket fences to the delight of passersby.

S

omething even more exciting is happening in the trees. Clouds of magnolia blossoms are springing out of leafless branches, a spectacular display has materialized down every road and lane.

In Simcoe Park, opposite the Prince of Wales Hotel, by mid-May the magnolias’ gently falling petals have blanketed the ground in pale pinks and whites, and

A cherry tree in Queen’s Royal Park looks across to Fort Niagara on the US side.

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the crab apples are beginning to flower in a show of delicate snow white. You see them everywhere on front lawns and backyards and along medians.

And now there’s another wondrous spectacle unfolding. The cherry trees are dense with ravishing blossoms. So tightly do they grow, they could be pink clouds that have fallen to earth and are intent on breaking free and rising into the sky once more.

They tower over cottages and call to picnickers in Queen’s Royal Park along the lake. Blankets are spread, food baskets opened, and icy bottles of Chardonnay and Riesling from wineries a short bike ride away uncorked. The air has turned warm and down on the shore brave kids wade in still cold water and practice skipping stones.

On the edge of town orchards of colour-drenched peach trees preen among the still barren rows of vines that stretch off as far as you can see, broken here and there by gleaming stands of paper-white pear and plum trees.

Back in town, the gardens and terraces are putting on their June best. Outside small boutiques, huge pots of summery blooms welcome shoppers to come in and browse. The gardens and lawns around painter Trisha Romance’s big pink Victorian house, just off the main street on the way to the lake, are festooned with flowers. Even the horses waiting patiently with their buggies outside the hotel across the street are wearing flowers in their hair.

Summer is truly here. Choose someone you love and take a quiet ride at dusk along streets that many other than Churchill call “the prettiest in Canada.”

Or rent a bike, see a play and visit the wineries, shoot a round or two of golf, or simply walk Queen Street, up one side and back down on the other, window shopping and eating ice cream. You can’t go wrong.

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

When the salt lake called Lago MinchĂ­n dried up under the hot Andean sun, it left saltpans like the Salar de Uyuni.

Boliviaâ&#x20AC;&#x2122;s outback

Salt, sun and survival in the most remote regions of the Altiplano on the road to Chile text and photos by Margo Pfeiff

I

’m on a psychedelic Hunter S. Thompson-esque road trip. Over the past four days I’ve watched vicuñas trot across a Day Glo-orange lagoon and bunnies with long fluffy tails hop through towering

cactus forests. I’ve seen blinding-white salt plains that look like ice, extra-terrestrial-looking lime green blobs of vegetation flourishing on stark desert, and pink flamingos strutting shallow magenta ponds.

But unlike the gonzo author of Fear and Loathing in Las Vegas whose encounters with giant attack-bats were drug and alcohol induced, the only thing I’ve guzzled as we bump across the surreal technicolor foothills of the Bolivian Andes is bottled water.

Years ago, on my first trip to Bolivia, I spotted travel posters for this unique region where the world’s biggest salt plain, the Salar de Uyuni, stretches towards a bizarre landscape of mineral pools, exotic critters and all things actively volcanic from geysers to boiling mud pools. But traversing the Altiplano high desert of the Andean Plateau in the country’s southwest meant travelling on rough tracks through a remote region with just a handful of

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We plunk ourselves in the middle of the salt at sunset to watch low pink rays glitter across the crystallized plain basic hotels. I read posts about overcrowded vehicles breaking down in the middle of nowhere without spares or satellite phones, about altitude and food sickness, and running out of drinking water en route. I put Bolivia’s Outback on the backburner.

Then, recently, I learned that a few international outfitters were offering cushier options for small groups. They include certified guides, communications and oxygen on board reliable vehicles, and clean food and water. One of them, Santiago-based Explora, started five-day, four-night Travesias — traverses — from Uyuni through the Andes to their luxury Hotel de Larache in San Pedro de Atacama in Northern Chile (and vice-versa). So far they have been the only outfitter to tackle the Bolivian one-star accommodation issue by crafting their own unique outposts en route.

T

hree clients and I meet up with Explora’s Chilean guide Luis Guzman in the old silver mining town of Potosí before zooming three smooth highway hours to Uyuni (elevation 3500 metres), a wild west salt mining town on the edge of the 19,270-square-kilometre dry salt lake.

We literally hit the salt, driving straight onto the wide-open plain in our hefty adapted mini-bus, the hard textured surface shuddering beneath our wheels. We pass tiny clusters of stone houses and whitewashed churches before veering off an hour later at the last village. We meet Felix Urrelio, our Bolivian driver and trip logistics whiz, in front of our home for two nights, a trio of centuries-old woodand-stone cottages with mud and thatch roofs like those in the rest of Tahua (population: 20). Ours have been insulated and renovated traditional/rustic-style.

Three small double bedrooms make up one house, each with puffy down expedition sleeping bags and alpaca blankets atop deluxe cots. Across a courtyard we each have our own spacious bathroom complete with a hot rain shower, robes and goodie bags of amenities.

In the kitchen and dining cottage, Felix’s wife, Hortencia, has laid out fresh coffee, and crackers with avocado and morsels of homemade llama jerky. The multi-course dinner includes hearty local quinoa and vegetable soup with a grilled lamb-chop “popsicle” to pick up and munch with the hand that is not holding a glass of Chilean wine. Under a full moon that has the salt plain glowing, I slip into my

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sleeping bag’s silk liner, the last thing I remember being the chocolate left on my pillow melting in my mouth.

A

llama stampede starts the morning as farmers herd their animals through town to pasture. Partway up the slope of the dormant 5430-metre Tunupa Volcano, we visit a cave where a family of 1800year-old mummies have been preserved by the hyperdry air. They’ve remained untouched since the last eruption.

In nearby Chantani (population: 4), we drop in at an intriguing little museum and outdoor sculpture garden. We then stroll along the shoreline back to our refuge communing with grazing llamas, local farmers and women dressed in full Bolivian skirts

The llareta plant is a high-altitude relative of parsley that lives for more than 3000 years.

Isla del Pesacado or “Fish Island” is home to an astounding number of cacti, some of which are 10 metres tall.

Laguna Colorada is tinted red due to a variety of algae that thrive in the shallow salt water.

There are beautiful cactus flowers at Coqueza near the Tunupa Volcano.

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The accommodations in the Bolivian Altiplano includes five shipping containers near the Cañapa saltpan.

and bowler hats before plunking ourselves in the middle of the salt at sunset to watch low pink rays glitter across the polygon-patterned crystallized plain while sipping champagne.

We leave Tahua the next morning for Isla Pescada, the biggest island in this plain that becomes a shallow, half-a-metre-deep lake during the December-to-March rainy season. An easy hike to its summit takes us through cacti 10 metres tall as viscachas, cute, longtailed rodents similar to chinchillas, scurry into burrows at their feet.

A posse of viscachas doing the cha-cha on the rooftop of our next vamped-up stone cottage abruptly awakens us at dawn the following morning. We leave the salt behind with a breathtaking climb towards 4100 metres where we’re surrounded by glacier and snow-capped peaks topping out over 6100 metres.

Felix navigates stretches of “road” that are mere boulder-strewn ruts: wide-open plains look like plowed landscapes with hundreds of dusty routes.

We come across a magical desert cave, a wizard’s lair with delicate stalactites alongside a pre-Incan cave cemetery. Mini-tornados twirl across the desert as we hike past wind-sculpted stone hoodoos. That’s where I first spot The Blob. Luis identifies the bizarre green, moss-like mounds as “llareta,’” a highaltitude relative of parsley. “The plant lives over 3000 years and exudes a highly flammable resin,” he explains.

As the air gets thinner, things get weirder so I’m barely surprised that our guesthouse for the night is a series of 12-metre, re-jigged shipping containers with a killer view. Outside, after Hortencia’s dinner of fork-tender wild duck, the stars across the night sky look like an exercise in pointillism.

O .

ur last Travesia day is a surreal parade of multi-coloured mineral ponds, most crowded with three species of flamingos combing the waters for brine shrimp.

Laguna Colorada shimmers from burgundy to orange to pink at the puff of a breeze as vicuñas trot by our shore-side picnic spot.

We top out at 4700 metres amid geysers and plopping mud ponds, then reach the Chilean bordercrossing. After almost 965 hard-core kilometres we say goodbye to Felix and hop into a waiting SUV that drops us 2130 metres in 47 blissfully paved highway kilometres. By the time we reach San Pedro de Atacama, a mellow desert outpost of adventure travel

shops, boutique hotels, bars and restaurants at 2500 metres, my lungs are drunk on oxygen.

After almost a week of eyeball-stinging dust and lunar landscapes, the trees and lush gardens around Hotel de Larache are as much a shock as the sudden luxury. Known for its desert expeditions from hiking and mountain biking to horseback riding — especially for advanced riders — and lounging in its own cascade of hot springs pools, Explora has also taken advantage of Atacama’s clear skies and built an onsite observatory for guests.

On the hour-long shuttle downhill to Calama airport, we pass an entourage of experimental solar cars racing in the 1300-kilometre Atacama Solar Challenge. As the shiny, insect-like vehicles whiz across the driest desert in the world, I can’t help wondering what Hunter S. Thompson would have thought he was seeing.

They’re the only outfitter to tackle the one-star accommodation issue by crafting their own unique outposts 38

Doctor’s Review • JUNE 2015

The Hotel de Larache in Atacama consists of 50 rooms, four pools and a private observatory.

SOUTHERN MOVEMENTS The time to visit the Salar de Uyuni region is April through November. Although it’s possible to travel during the rainy season from December to March, many sites are inaccessible due to mud. It’s wise to spend a few days working your way up to altitude before heading to Uyuni.

Amaszonas Airlines (www.amaszonas.com; US$177 one way) has regular service from La Paz to Uyuni. Buses are quite comfortable, with bed-like reclining seats for overnight trips from La Paz and Sucre. Trans Copacabana (transcopacabanasa. com; about US$10) is recommended. Buy tickets several hours before departure.

If you’re spending a night in Uyuni, the 49-room Luna Salada Hotel (lunasaladahotel.com; doubles from US$116) is just outside of the town centre and entirely made of salt blocks. There’s a restaurant on-site.

Explora’s Uyuni Travesia (tel: 866-750- 6699; explora.com) starts in Potosí (200 kilometres north of Uyuni; 150 kilometres south of Sucre). The tour includes four nights in Bolivia — accommodations are in Explora’s own camps — and three nights at Explora’s Hotel de Larache in San Pedro de Atacama, Chile. The trip is also offered with a similar reverse itinerary from Chile to Bolivia.

Tour groups are small: six people max with Wilderness First Responder certified guides. There’s a satellite phone, medical kit and oxygen tanks on board. The trip is all-inclusive including meals, open bar throughout, park fees and hotel excursions.

Contact Claudia Pardo (cpardo@explora.com) for rates depending on routing.

For more info on travel the region, check out Bolivia Tourism (www.bolivia.travel).

Bolivian clothing differs by region; the pollera or pleated skirt is worn to the ankles in some areas, to the knees in others.

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NES-2015-5E

The 13th green at Jack Nicklaus’s Quivira is 105 feet above sea level and calls for a do-or-die shot over an abyss.

On cours L

ured by the legendary sportfishing, Hollywood stars such as Bing Crosby and John Wayne put Los Cabos on the tourist map in the 1950s. While fishing still draws avid anglers to what’s called

“Marlin Alley,” Los Cabos, at the southern tip of Baja California where the desert meets the Sea of Cortez, has become one of the world’s top golf destinations.

Home to four of the top five courses in Mexico according to Golf Digest’s current “Planet Golf” rankings, Los Cabos raised the stakes last year when the two best-known figures in the sport, Jack Nicklaus and Tiger Woods, unveiled their newest designs just a few kilometres apart from each other.

Jack Nicklaus officially opened his epic layout, Quivira (quiviragolfclub.com) in Cabo San Lucas, last December, arguably his most daring design to date.

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It has the fewest bunkers and the smallest greens.

The front nine is par-34; the back nine is par-38 — another departure from the norm.

Quivira, Jack’s sixth course in Los Cabos, is Nicklaus Design’s 23rd in Mexico. Golf Magazine named him “architect of the year” for 2015.

Nicklaus recalls his early days in Los Cabos: “We used to come here in the ’60s with a tee shirt, swimming suit, a pair of sandals and 20 bucks, and stay for a week. Then all of a sudden we started doing golf down here and it just exploded — the real estate values, the golf courses and the developments.

se in Los Cabos How Tiger Woods and Jack Nicklaus made Mexico’s Baja Peninsula one of the best places to play golf

by Anita Draycott

When we came in ’86 to do Palmilla, there was nothing here. My friends say I’m the guy who ruined Cabo. But what we really did was introduce the game of golf to Cabo.”

Quivira boasts more oceanfront exposure than any other course in Los Cabos. All 18 fairways feature views of the Pacific. From December to March you’ll likely spot whales leaping in the wild blue yonder.

The layout with four tee placements, ranging from 7139 to 4326 yards, starts at sea level, scales cliffs more than 275 feet above the surf, spans canyons and arroyos, meanders through dunes and desert, and returns to the sea at the finish.

There isn’t a weak hole at Quivira; many are spectacular. For example, the 10-minute drive to the fifth traces a switchback route up the side of a mountain. The fairway, slanted below a dune on the right, El Cardonal is the first golf course that Tiger Woods has ever designed.

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All of the holes at El Cardonal have views of the Pacific Ocean, including the par-four fourth.

Cabo San Lucas was a sportfishing mecca in the 1950s and is now home to expensive resorts.

Quivira’s Clubhouse consists of a bar with fire pit and a steakhouse restaurant with indoor/outdoor seating.

“Some people will say it’s the best golf course they have ever seen and others will say, ‘You have got to be kidding’” traces the edge of sheer granite cliffs to the left as it tumbles downhill to a transition zone before dropping to a rock-walled, cliff-hanging green 106 feet below the tee.

When asked to predict how Quivira will impact his legacy, Nicklaus says, “I think some people will say it’s the most spectacular and best golf course they have ever seen and others will say, ‘You have got to be kidding.’ I don’t think there will be a lot of middle ground. If you look at the game of golf as having a fun experience, and playing in an exciting and beautiful place, you will absolutely love it. From start to finish, I’d say Quivira has as much pace, variety and spectacular beauty as any course I’ve ever designed.”

To play Quivira you must be a resident or guest of one of four Pueblo Bonito Oceanfront Resorts and Spas (pueblobonito.com) in Los Cabos: the adultsonly Pueblo Bonito Pacifica; the family-friendly Pueblo Bonito Sunset Beach (both share property with Quivira); Pueblo Bonito Rosé; or Pueblo Bonito Los Cabos (the latter two are located on El Médano beach). Stay-and-play packages are available.

A golf day at Quivira Golf Club starts with a complimentary shuttle to the club. Warm up on the range. Perhaps you’d like to relax your swing with a Bloody Maria? Snacks, such as tuna sliders and fish tacos, and drinks are included in your green fee.

After the fourth hole, golfers maneuver their carts to the first comfort station, perched 200 feet above the ocean where they can help themselves to more refreshments. The Oasis halfway house offers inventive takes on classic Baja cuisine and has a tequila bar. Players may indulge again at the 16th.

A

rguably the hottest news in golf course architecture was the December 2014 opening of El Cardonal at Diamante (diamantecabosanlucas.com) in Los Cabos.

Why? Because it’s the very first track in the world to be designed by Tiger Woods.

Just six miles from Cabo San Lucas’ city centre, Diamante is a master-planned luxury community with two 18-hole courses: the Dunes by Davis Love III (opened in 2008) and now El Cardonal by Woods.

El Cardonal takes its name from the cactus that thrives in this region; it was also the name of the cattle ranch upon which this property was developed.

Tiger’s design career has had a tumultuous start.

His first three commissions — in the Dubai desert (2006), in the mountains of Asheville, North Carolina (2007) and on Mexico’s Baja Coast (2008) — were all either postponed or abandoned because of the economy. El Cardonal also had a stormy start due to damage in September 2014 from Hurricane Odile.

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The fairway at Quivira’s fifth traces the edge of a granite cliff before dropping to a rock-walled green 106 feet below the tee.

The Ocean Course at Cabo del Sol is framed by natural desert landscape.

GOLF GALORE While avid swingers will want to put Quivira and El Cardonal on their bucket lists, Los Cabos boasts several more terrific tracks. Jack Nicklaus’s Ocean Course at Cabo del Sol (cabodelsol.com) is a must. Puerto Los Cabos (puertoloscabos.com) offers the unique chance to play a composite 18 holes by both Nicklaus and Greg Norman.

Nicklaus’s 27-hole Palmilla (palmillagc.com) was the first Jack Nicklaus Signature golf course in Mexico and home to the Senior PGA Tour’s 1997 Senior Slam. The Ocean, Desert and Mountain nines are brilliantly routed layouts over ponds and around desert scrub. You might find yourself teeing it up there with celebrity swingers Michael Douglas and Billy Crystal.

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While the neighbouring Dunes course is reminiscent of seaside links in Ireland or Scotland, El Cardonal has the feeling of old-style California courses like Riviera and Bel-Air, the types of tracks that Tiger played while growing up. Tiger, who owns a home at Diamante, just off the driving range, was given an interior parcel of land set well back from the Dunes Course, which is routed in towering sand dunes above the Pacific. Scenery-wise, Tiger’s track will never compete with the Dunes, though it offers an ocean view from every hole. What the 7363-yard, par-72 course presents is a superb strategic test.

The front nine, routed on the lower, flatter portion of the property, plays to and from the sea along fairways framed by rolling, man-made dunes. One of the best holes is the short par-four third, which skirts a pond and brings a menacing central bunker into play off the tee. You have to make a choice: lay up short of the bunker on the tee shot; carry the bunker to set up a short approach from a good angle; or boldly try to carry a second bunker and drive the green. It invites fun risk/reward options.

The back nine is on higher ground with more interesting contours than the front. Tiger and his team have brilliantly incorporated cactus-studded arroyos into the layout.

According to Diamante’s owner Ken Jowdy, Tiger’s goal was to create different ways to negotiate each hole.

“He [Woods] focused more on the people he plays with on Wednesdays [amateurs] than on the weekend.”

Many players-turned-designers have been criticized for being too hands-off, but that wasn’t the case with Woods, assures Jowdy. “Tiger’s level of passion for this design has been evident since day one…. He’s

There are four “Oasis” comfort stations dotted throughout Quivira’s course.

El Cardonal has the feeling of old-style California courses, the types of tracks Tiger played while growing up made multiple visits and spent many hours in the field.” Woods even got involved in the quality of the grains of sand used in the bunkers and, because he has a house here, he also had input on the kind of exercise equipment installed in the gym.

W

hile the course measures almost 7400 daunting yards from the tips, Woods is adamant that his design will reflect a “playable-for-all” philosophy, inspired by North Carolina’s Pinehurst No. 2 and the Old Course at St. Andrews.

“I don’t want people to lose a dozen balls when they play our course,” Woods comments. “Pinehurst is a great example of a course that’s tough for us [pros], but playable for everybody else. It gets players thinking, with options around the greens. We want lots of variety. The Old Course at St. Andrews, Scotland is the world’s greatest course. There are so many different ways to play it, to get the ball on the green.”

The El Cardonal track will not only be hard-pressed to stack up against Pinehurst and St. Andrews, it will have to be good just to match Diamante’s existing Dunes course, which is ranked Number 52 in GOLF Magazine’s Top 100 Courses in the World. Golf at Diamante

does share some similarities with the classic links courses in Scotland and Ireland. But here, the weather is warmer. The sand is whiter. And the sea is bluer.

“I’ve started off El Cardonal with a slightly downhill par-five measuring just over 550 yards,” Tiger says.

“The idea was to ease the golfer into the round. The 18th is just the opposite. I like strong finishing holes where par is a good score. With the downhill parfour 18th measuring just over 500 yards, it will be a true test. And with the Pacific Ocean as the backdrop, it should be a memorable conclusion.”

El Cardonal is private, however, tee times for prospective property buyers are available. If you rent a house, golf villa, beach estate or two-bedroom condo unit at Diamante, you can also play the course.

Green fees are approximately US$275, comparable to Dunes course rates.

At both El Cardonal and the Dunes courses, golfers are in for the royal treatment: your caddy will take you to a private hitting station at the driving range, complete with sunscreen and lawn chairs, and there are several comfort stations on the courses that provide cocktails and a full range of snacks, including bean and tortilla soup, tamales and more.

For more info on travel to the region, go to Los Cabos Tourism website (visitloscabos.travel).

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IN SEARCH OF

The Scream A father and son hike through Oslo to find the site of Edvard Munch’s hysterical portrait

by Chris Epting

I

n my mind, travellers are hunters.

What do you hunt for when you travel? Experiences, people, souvenirs?

We all hunt for something. I hunt for places.

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VISITOSLO / MUNCHMUSEET

The Munch Museum in Oslo is home to two of the four original versions of The Scream.

exhausted, and leaned on the fence — there was blood and tongues of fire above the blue-black fjord and the city — my friends walked on and I stood there trembling with anxiety — and I sensed an infinite scream passing through nature.”

But where was the spot? Where is the exact site that inspired that painting? Did it really even exist?

Also called The Scream of Nature, The Shriek and The Cry, there are actually four versions of the painting in existence. There’s the one in the National Gallery, a pastel version owned by a Norwegian businessman, and two versions are held at the Munch Museum located on the outskirts of Oslo.

The Scream, as you may know, has been the target of several high-profile art thefts. Back in 1994, the National Gallery piece was swiped, but recovered several months later. In 2004, a Munch Museum piece (along with another Munch piece, The Madonna) were stolen, but later recovered.

And here we stood before one of them. It was surreal, as it always is, to stand close enough to touch a piece of art you have dreamed about. To see the textures of the paint, the wear and tear; the life it has lived.

I’ve written a number of books on locating the exact places in pop culture history in North America. My son shares my passion and between us, we knew what mission lay ahead: we simply had to locate the path where Munch was when the moment consumed him, the birthplace of The Scream.

Oslo’s main street for shopping and strolling, Karl Johans Gate, begins at the Central (train) Station.

VISITOSLO / ROBERTO MEAZZA

W

e were in Oslo, Norway, my teenaged son and I, spending a few days before hopping a ship with Quark Expeditions to explore around the Arctic archipelago called Svalbard.

Our first day, we stopped at the National Gallery, not for the Van Goghs or Gaugins or Cezannes. We wanted to see the most famous local painting: Edvard Munch’s The Scream. Pop culture artifact that it was, is and will probably always be, we have long been fascinated by this masterpiece, born of a tortured moment on what appeared to be a bridge.

In his diary, Munch wrote: “I was walking along a path with two friends — the sun was setting — suddenly the sky turned blood red — I paused, feeling

WIKIMEDIA COMMONS / HELGE HØIFØDT

The original Ekeberg restaurant was built in 1916; it was redesigned in 1927 by Oslo architect Lars Backer.

T

he sun-drenched postcard of Oslo Day One was replaced on Day Two by a grey, bone-chilling, wet blanket sky. Getting off the train at Oslo Central Station, we were treated to Oslo’s grittiness as the locals, all steel-eyed and stoic, marched off to work.

Charlie and I soon hopped another train, which took us just outside the soggy city to visit the Munch Museum. Rare is the reliquary dedicated to a single artist; it’s a good opportunity to get fully immersed in one person’s vision(s).

We found the modest, but sleek and industriallooking building easily enough. As soon as we entered, we were immersed in many of Munch’s classic works.

I interviewed the curator of the museum and we discussed many of Munch’s daring, seductive works, but, of course, it all came back to The Scream, that phantasmagorical, tortured portrait of a howling being.

Gently, I asked about the actual location that inspired the mad portrait, what appeared to be bridge (that is actually featured in other works by Munch, as well). He was curious as to why we wanted to find it and I explained our fascination with cultural geography; the need and longing to enter a space that, due to planning, luck or just coincidence, had been brushed by something hallowed.

With a bit of mysterious glee in his eye, he gave us a cryptic clue. “Take the train outside the city to Ekeberg. Near the stop, there is a restaurant, a large white building. Ask in there. They will help you.”

And so in the rain, on this steel-blue day, we set off. Little did we know that what lay ahead was a daylong adventure; a rigorous, comical, frustrating, ultimately thrilling treasure hunt. So you know, we’re used to playing detective in the US in search of special places. But this was another story.

With a broad, knowing smile, she nodded.

“Ah, you have arrived,” she said. “But there is no bridge. There never was a bridge” JUNE 2015 • Doctor’s

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52

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When Munch died in 1944, 1000 paintings were found behind locked doors in his house.

part had sent us to the rock path. With a raised eyebrow, Catherine Deneuve smile and a coy shake of the head as if to say “you people are crazy,” she took up our cause. She called the curator at the Munch Museum and obtained a new version of where we should go.

So we set off on a new path, through more miles of fields and muddy paths. But no bridge. Charlie wanted to press on, but it was getting dark and so I told him, sadly, that we best call it a day.

Heading down the original path, we finally got to the restaurant where the adventure started. The head chef was out back, having another smoke and jawing with some of the servers when he saw us, chilled and a bit demoralized. He called out, “Did you find it?” I explained everything and he was concerned. “It’s up there, guys. Even a little sign as I recall.” He repeated his original directions once more and Charlie said, “Dad, that’s the last spot where we just were, where I wanted to continue.”

What to do, but head back up the hill, right?

This time though, it all clicked. Charlie was right.

Rounding a bend that we had almost reached before, there it was. The bridge. Overlooking the city.

Precisely where Munch stood. And we lined it up with the original. “… I stood there trembling with anxiety — and I sensed an infinite scream passing through nature,” Munch wrote. Right here where we stood, in the geographic pocket of his creation, connected to his muse.

Though a few may have initially found us to be as crazed as the person in Munch’s Expressionist masterpiece, we made some lovely acquaintances that day. Adventure, mystery and “the hunt” seem to be universal magnets.

The lesson for us is something we experienced many times before. We can’t be afraid to explore, to dig deep and to connect. You never know where it may lead. Perhaps to a bend in the road high in the Oslo hills, overlooking a fjord, to a place where an artist met a ghost.

Reprinted with permission. The article appears on TravelersTales.com and BestTravelWriting.com under the title In Search of The Scream in Norway. It won a gold award in the Destination category of the Seventh Annual Solas Awards for Best Travel Writing sponsored

by Travelers’ Tales.

JEAN-PIERRE DALBÉRA / FLICKR.COM

W

e found the restaurant after exiting the train at Ekeberg. It sat atop a steep hill that overlooked the city and we must have looked like two tired, waterlogged scarecrows as we approached the hostess in what turned out to be quite an elegant little spot.

Beautiful, but aloof, she seemed hardly interested in helping two wayward tourists at the peak of a busy lunch service. I explained to her what the curator had told me, but she knew of no Munch location in the heavily wooded area above the restaurant. I tried several times to engage her, but each time was shot down with a more terse denial. “I know nothing about a painting.” Then, something happened. I must have seemed just pathetic enough that she offered, “Let me ask the chef.”

Moments later, he emerged from the kitchen. I could see in his eyes, he knew.

Leading my son and I outside, he lit a cigarette and good-naturedly diagrammed our journey, which involved about a mile hike up a deeply wooded path, several twists and turns until, he told us, we would be standing right at the site, precisely where Munch had been. “Good luck, my friends!”

Excitedly reaching the top of the path, the good chef’s directions stopped making sense. We couldn’t locate the paths he described. But we did find a RV park in a clearing. So we asked a woman who worked at the office desk for help. With a broad, knowing smile, she nodded. She knew where the bridge was located? “Ah, you have arrived,” she said. “But there is no bridge. There never was a bridge.” Huh? She explained that Munch had imagined the bridge, but that in reality it was merely a footpath where they walked, a walkway outlined in prehistoric stone. She added that we were a mere 100 metres or so from the path and that the stones were still there.

Was this it?

We rushed across the field in the rain and spotted the rocks embedded in the ground. There was a plaque on one of them. Had someone commemorated the Munch landmark? Breathlessly, we examined the plaque, which read, “Skalgroper fra bronsealdren. 1800 f.Krf, - 500 f.Krf.” Some strange Munch code reserved for history detectives such as ourselves?

Nearby, a male groundskeeper was working. We brought him over to translate. He read it. The plaque marked the remains of an ancient, Ice Age glacier.

Pleading our case to him he lit up. “Ah, Munch!

Shriek! Yes! I will direct you!”

So he sent us down yet another path. Charlie discovered the local equivalent of poison oak, but no Munch. I approached a woman walking her dog to ask.

She appeared to develop a toothache due to my presence. “What?” she grimaced. “No Munch, no Munch!”

Undaunted, we retreated to the office, where a new woman was at the helm. I explained how her counter-

Creamy sorrel soup with harissa.

A modern nosh Vegetable-forward Jewish dishes for today’s kosher kitchens recipes by

G

Leah Koenig

photos by

Sang An

randma Bessie was an intuitive, shoot-from-the hip Jewish cook who used a juice glass to measure sugar. In Modern Jewish Cooking (Chronicle Books),

author Leah “Bessie” Koenig explains that her bubbe passed away before she was born, but that she inherited her first name as her middle name and regrets that she didn’t also get her recipe for gefilte fish. Koenig’s own mom turned out “a superbly juicy brisket,” but as a teenager, it never occurred to

her to ask mom how. In college, she looked online for recipes and started to build a repertoire of classics. Because they weren’t “family recipes” that she had to copy, she felt free to improvise in her Brooklyn kitchen, and incorporated lots of seasonal ingredients from farmer’s markets and global flavours.

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About 175 of her fun, vegetable-forward concoctions appear in Modern Jewish Cooking; all, including the three dishes featured here, are kosher.

zle of harissa (a North African hot chili sauce popular in Israel) adds a spicy, Middle Eastern counter note to this Ashkenazi-inspired dish.

CREAMY SORREL SOUP WITH HARISSA

Eastern European Jews love sorrel — a green that resembles spinach, but tastes sour like rhubarb — as the base for a summery soup called schav. Big pots of the green get simmered down with water and thickened with beaten egg yolk, then served chilled with sour cream, boiled potato, and chopped fresh radishes and scallions. But its distinctly old-world taste is not everyone’s cup of tea. This adaptation whirs the tangy greens and silky cooked potato into a creamy, full-flavoured soup that can be served either warm or chilled. A driz-

4 tbsp. (60 g) unsalted butter 2 yellow onions, finely chopped 5 c. (1.25 L) vegetable broth 2 medium russet potatoes, peeled and cut into 1-inch (2.5-cm) chunks 12 oz. (340 g) sorrel, stemmed and roughly chopped (about 10.5 c./ 2.5 L) 1 c. (250 ml) heavy cream kosher salt and freshly ground black pepper sour cream or labneh for serving harissa for drizzling

Melt the butter until foaming in a large saucepan set over medium heat. Add the onions and cook, stirring occasionally, until softened and lightly browned, 8 to 10 minutes. Add the broth, pota-

Carrot salad with mint and dates.

toes and sorrel, stirring to help the sorrel begin to wilt. (It will seem like too much sorrel at first, but will cook down significantly).

Raise the heat to medium-high and bring to a boil. Then turn the heat to low, cover and simmer until the potatoes are tender, about 15 minutes. Remove from the heat and let cool slightly.

Purée the soup until smooth using an immersion blender or working in batches in a standard blender. Return the soup to the pan, set over low heat and whisk in the heavy cream. Taste and season with salt and pepper.

To serve warm, divide into bowls, dollop with sour cream and drizzle with harissa. To serve cold, let the soup cool slightly, then cover and refrigerate for at least 3 hours or up to 1 day. Divide into bowls, dollop with sour cream and drizzle with harissa. Serves 6.

CARROT SALAD WITH MINT AND DATES Moroccan carrot salads flavoured with cumin and coriander have become a staple of the Jewish table. This dish is an alternative. Grated carrots get paired with Mediterranean ingredients like dates, fresh mint and hazelnuts for a sweet, crunchy, lemon-kissed salad that might become your new favourite. ½ c. (125 ml) raw hazelnuts 2 tbsp. (30 ml) fresh lemon juice, plus more as needed 2 tbsp. (30 ml) finely chopped shallot 2 tbsp. (30 ml) extra-virgin olive oil kosher salt and freshly ground black pepper 1 lb. (455 g) carrots, peeled (about 7 medium carrots) ¹⁄³ c. (80 ml) finely chopped pitted deglet noor dates ¼ c. (60 ml) roughly chopped fresh mint leaves 2.5 oz. (75 g) baby arugula (about 3 c./ 750 ml)

Place the hazelnuts in a small pan set over medium-low heat. Cook, stirring occasionally, until fragrant and lightly browned, 5 to 7 minutes. Remove from the heat and transfer to a small bowl to

Spinach-matzo lasagna.

cool completely, then peel off the skins with your fingers and roughly chop.

Whisk together the lemon juice, shallot and olive oil in a small bowl, and season with salt and pepper.

Grate the carrots on the large holes of a box grater or with a food processor fit with a shredding blade. Combine the grated carrots, toasted hazelnuts, dates, mint and arugula in a large bowl.

Drizzle with the dressing and gently toss to combine. Taste and add more lemon juice, if desired.

Divide the salad among plates and serve immediately. (If not serving right away, keep the dressing and salad in separate containers; combine and toss just before serving.) Serves 4 to 6.

SPINACH-MATZO LASAGNA

Over the last decade, matzo lasagna has quickly and emphatically entered the Passover mainstream. Its rise has partly to do with the need it fills for a substantive main dish to serve during the holiday’s weeklong bread ban. The other reason for its popularity? It’s delicious. Softened matzo provides a convincingly noodle-like base for the rich ricotta and mozzarella, tangy marinara and tender spinach threaded throughout the layers.

3 tbsp. (45 ml) extra-virgin olive oil 2 large yellow onions, finely chopped 4 garlic cloves, finely chopped 5 oz. (140 g) baby spinach (about 4½ c./1.25 L) 4 c. (1 L) full-fat or low-fat ricotta cheese 2 eggs, lightly beaten 2 c. (500 ml) grated mozzarella ¼ c. (60 ml) roughly chopped fresh flat-leaf parsley kosher salt and freshly ground black pepper 9 sheets matzo 4 c. (1 L) good-quality marinara ¼ c. (60 ml) grated Parmesan

Preheat the oven to 350°F (180°C).

Heat the olive oil in a medium pan set over medium heat. Add the onions and

MORE ONLINE

cook, stirring occasionally, until softened and lightly browned, 5 to 7 minutes. Add the garlic and spinach, and cook, tossing with tongs, until the garlic is fragrant and the spinach wilts, about 2 minutes.

Remove from the heat and set aside.

In a medium bowl, stir together the ricotta, eggs, ½ cup (125 ml) of the mozzarella and the parsley. Season generously with salt and pepper, and set aside.

Fill a shallow baking dish with water.

Dip 3 sheets of the matzo in the water and let soften for 1 to 2 minutes. (Not longer — you want the pieces to feel soft, but not mushy or soggy. They should still hold their shape.)

Spoon half of the marinara into the bottom of a 9-by-13-inch (23-by-33-cm) baking dish. Shake the excess water off of the softened matzo pieces and arrange in the baking dish, breaking the sheets

as necessary to fit. Top with about half of the ricotta mixture, followed by half of the spinach mixture. Repeat with half of the remaining marinara, another 3 softened sheets of matzo, and the remaining ricotta and spinach mixtures.

Soften the remaining 3 sheets of matzo and arrange on top. Spoon the remaining marinara over the top, then sprinkle evenly with the remaining 1½ cups (375 ml) mozzarella and the Parmesan.

Cover with aluminum foil and bake until heated through, about 45 minutes. Uncover and continue baking until the cheese is lightly browned, 10 to 15 minutes more. Let stand for a few minutes. Serve hot. Serves 8 to 10.

Recipes and photos from Modern Jewish Cooking: Recipes and Customs for Today’s Kitchen (Chronicle Books, 2015).

Dishes from Jerusalem, the International Association of Culinary Professional’s Cookbook of the Year in 2013. doctorsreview.com/food/book/jerusalem-cookbook JUNE 2015 • Doctor’s

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PHOTO FINISH by

D r D a n i e l Ng u i

Buried treasure

Located in Angkor, Cambodia, Ta Prohm has been swallowed up by the jungle. Built in the 12th century as a Buddhist Temple, it features many towers, courtyards and corridors. This photo was taken at sunrise on a cool, mystical morning before the heat of the day.

MDs, submit a photo!

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

editors@doctorsreview.com

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Indications: SPIRIVA RESPIMAT (tiotropium bromide monohydrate) is indicated as a long-term once-daily maintenance bronchodilator treatment of airflow obstruction in patients with chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema, and for the reduction of exacerbations.

SPIRIVA RESPIMAT is not indicated as rescue medication for the relief of acute bronchospasm in COPD. Clinical use: Safety and effectiveness in patients less than 18 years of age have not been established.

Contraindications: Patients with a history of hypersensitivity to atropine or its derivatives (e.g. ipratropium).

Relevant warnings and precautions: - Should not be used for initial treatment of acute episodes of bronchospasm or for the relief of acute symptoms - Immediate hypersensitivity reactions may occur - Should not be used more frequently than two inhalations once daily

References: 1. O’Donnell DE, Aaron S, Bourbeau J, et al. Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2008 Update. Can Respir J 2008;15(Suppl A):1A-8A. 2. SPIRIVA® RESPIMAT® Product Monograph. Boehringer Ingelheim (Canada) Ltd., Dec 12, 2014. 3. COMBIVENT® RESPIMAT® Product Monograph.

Boehringer Ingelheim (Canada) Ltd., Jan 8, 2014. 4. Decramer M, Vestbo J, Bourbeau J, et al. Global strategy for the diagnosis, management, and prevention of COPD (updated 2014). Global Initiative for Chronic Obstructive Lung Disease, Inc. 2014. 5. Data on file. Boehringer Ingelheim (Canada) Ltd., 2015.

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

The product monograph is also available by calling us at 1 (800) 263-5103 Ext. 84633.

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* See Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease (2008) for complete recommendations.

Spiriva® and Respimat® are registered trademarks used under license by Boehringer Ingelheim (Canada) Ltd.